editorial 1 editorial letter from the editor jeri dunkin, phd, rn editor it has become very evident that the issues, struggles, and stories of rural nurses are similar around the world. as the official journal of the rural nurse organization, this journal presents these rural nurses’ efforts to our readers in hope of providing a forum for rural nurses to share their stories, both from practice and research, as a way to build the body of knowledge that is rural nursing. during this month in taipei, taiwan, the international counsel of nursing (icn) will meet and for the first time the agenda will include a program for the new international council of nurses rural and remote nurses network. this network developed through the work of rural nurses from around the world that began discussions of a need for such a network at the 2nd international congress of rural nurses held in toowoomba, queensland, australia, in 2000. the discussions and development culminated in the incorporation of the group as a network within icn. this network will provide a global forum for rural nurses and rural nursing science, issues, and practice. the network can be accessed through the icn website at http://www.icn.ch it is my hope that between the formal organizations for rural nurses and the forum provided by the journal that the voice of rural nurses will grow strong. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.icn.ch/ editorial 2 editorial more similarities than differences kathy crooks editorial board member bushy (2000) points out that “nursing practice in rural environments are very similar in canada, the united states, and australia” (p. 236). i think we can now add japan to that list of countries in which rural nursing has similar characteristics. i recently returned from the island of honshu in japan and had the good fortune to meet and discuss rural nursing with a large group of nurses who work at the nursing school attached to jichi medical school. they recently received a mandate from the japanese government to create the academy of rural and remote nursing at jichi and are planning on becoming involved in the icn rural and remote network that is being established. if you are anything like me, before i went to japan i found it hard to believe that there would even be areas that are considered rural let alone remote in a country as densely populated as japan. much to my surprise i found out that because much of the country is very mountainous there are communities that are as isolated as any remote area in canada. interestingly, many of these locations have a similar demographic structure to areas in rural canada, with the majority of residents being either very young or very old. it never ceases to amaze me that despite language differences, cultural differences and differences in health care systems that rural nurses from various parts of the world have so much in common. during my stay in japan i was asked to be part of a panel discussion with nurses who work in a variety of rural areas throughout the country. i heard stories about lack of anonymity and familiarity in the community, something that could have happened anywhere in a rural community in canada. i must say that this identification with other rural nurses regardless of culture or language bodes well for the establishment of an international network that will foster the sharing of ideas and concerns. i also think that it is comforting to know there will be a network of like-minded individuals that share many of the concerns and issues of nurses working in isolation, so ultimately no rural nurses need to feel that they are alone. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 editorial 4 editorial report from australia desley hegney editorial board member we have just held the association for australian rural nurses inc conference. the conference was attended by about 90 rural nurses from around australia. a major highlight of the conference is that we are now known as the australian rural nurses and midwives (arnm). the governor of queensland – ms quentin bryce opened the conference. speakers included dr. kim walker who provided some suggestions on how we might address the nursing workforce shortages (other than recruiting from developing countries or taking advantage of the retrenchments in the uk). on the last day of the conference we had a great debate around current issues facing rural nurses and midwives. we noted that our nurse practitioners were still limited by their lack of ability to provide prescriptions that are subsidized by the australian government. all nurses have been working to try to have this addressed without much success (mainly due to the medical lobby). they can write a private prescription (once they have a relationship with a pharmacy), but this costs the client much more than they would get it if the prescription was written by a doctor. we also looked at the move in australia for a national registration. at present, we are registered in individual states/territories, and each time we move we have to reregister. of course, we do have mutual recognition for most things – though there are differences between the states/territories. in 2008 we will go to a national registration system – so there is a lot to be worked out before this happens. we also discussed the need for mandatory continuing professional education. at present, none of our nursing registering bodies require this. victoria has been undertaking some research into whether this would be worthwhile, but their consensus seems to be that a mandatory system is not the way to go. in queensland our rural nurses are experiencing a lot of change. for example, our state government is transferring mental health and community health to the department of communities from the department of health. this means the department of health will focus on acute care only. at the same time, there has been a reduction in the number of districts, and we have several senior nurses who have gone to being the director of nursing of a district, to being something (not sure yet) else within a larger district. so, an enormous amount of change is happening in our state. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 online journal of rural nursing and health care, 2(2) 5 editorial rural practice forum: communicating with rural people bette ide, phd, rn, editorial board member helene kahlstorf, m.s., rn is a graduate of the university of north dakota rural health nursing graduate option. she is a parish nurse and the regional coordinator for colleagues in caring in western minnesota. she speaks from having lived in a rural culture for over 40 years and from vast experience with rural people. she states that rural people tend to be rugged individuals, very independent. early in her career, as the only public health nurse in a large county where there had not been a nursing service for two years, she found advice from the district nursing consultant from the minnesota department of health to be invaluable. during the same period, she met a farmer who showed her his healing varicose ulcer. the medication he used was “bag balm,” a treatment for his cows’ udders. he also used terminology that was new to her at the time – “bound up” meant constipated. some of the deterrents to seeking health care she notes are high insurance costs (resulting in many rural persons without insurance or underinsured), escalating health care costs combined with lower incomes, distance to travel for health care plus the time it takes away from work, and values related to health. because health care professionals speak in a “code” known only to them, she says that they need to listen carefully to what is being said, listen respectfully, and learn to speak the language of the people and identify their values. for example, a rural mother brought her child in regularly for immunizations but was noted to have significant body odor. the mother described their water supply as being from a source some distance from their farm. they valued car racing, and their money was used for building a car rather than for more easily accessible pure water. another online journal of rural nursing and health care, 2(2) 6 example was an 85+ woman who described her endoscopy as “looking for a splinter (rather than sphincter) in my throat.” in addition, she misinterpreted the instructions for the cholestyramine as six times a day because the label said you may take up to six doses a day. the doctor’s instructions said “take one scoop a day.” she strongly recommends that nurses in rural areas use community health workers for follow-up care. this practice has been very successful in many places for many years. indian reservations have successful programs using tribal diabetes educators, the mississippi delta luke society has had almost zero unplanned pregnancies because of community health workers, and oncology nurses have discovered their patients did better when trained lay persons assisted the patients. for questions or comments, e-mail me at bette_ide@mail.und.nodak.edu. the australian perspective 2 editorial online learning marietta stanton editorial board member learning online is all the rage today and with good reason. it provides a level of access and convenience that is not possible with traditional forms of education. this is especially true for rural nurses who may be miles away from academic centers and wish to pursue a degree. it also may be a convenient source of continuing education and staff development for working nurses who need an update on information in their area of practice. as an educator who provides a graduate program on line, i am often surprised at how nurses who are usually very cautious about products and services are not always cautious when it comes to their own education. i have students who attempt to transfer in credit from institutions that are not properly accredited and they are totally unaware that they probably will not be able to use that transfer credit towards their degree. if you are considering an online degree, there are certain questions you should ask to make sure that this is the best choice for you. first and foremost, make sure the nursing program is properly accredited by the commission of collegiate nursing education (ccne) or the national league for nursing (nln). do not attend programs that do not have one of these accreditations. other issues you should examine before enrolling in online nursing programs is to: 1. ask about the support services for online students. how will you access the library, student services, and financial aid and how will you purchase books? you will need to use these services and the program should have these available to you. 2. who are the faculty and what are their credentials? are they doctorally prepared? are they faculty employed by the academic program or are they contracted from outside the institution? faculty for online programs should be as well credentialed as faculty that teach in more traditional settings. 3. will you have an advisor and good access to your instructors? you want to be able to ask questions if you do not understand material or contact the instructor if you have a crisis and can’t complete an assignment. 4. make sure that your computer and equipment is up-to-date and compatible with programs and software the program may utilize. they should be able to provide you with requirements before you enroll. 5. what kind of financial aide or scholarships are available to you? online learning is a great approach for nurses who live and work in rural areas. shop around and find accredited and quality programs. be wary of programs that are not properly accredited and faculty not that are not suitably credentialed. always make sure that you will be able to get the support and services you need to be a success with your program. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 editorial 5 editorial report from australia desley hegney, phd editorial board member g’day to you all from australia. in queensland we have had some good rain; however, unfortunately many of our communities missed out and remain in severe drought. of course, the usual australian weather continues with a large amount of places that were in drought now experiencing floods!! as one new arrival to australia from england commented--it is certainly not easy to predict the weather in australia. we are in the midst of a state government election in queensland with the incumbent government promising to focus on health if re-elected. most of us are not quite sure why they could not have already implemented what they are promising (more nursing places, decrease in nursing workloads) regardless of an election--but i suppose that is politics. the australian government also comes up for election again this year, and we expect that they too will make lots of offers in the areas of health and education. in rural health, one would almost say that things are very quiet. certainly there are still major nursing shortages in australia, regardless of geographic location. the nurse practitioner movement in australia, is also moving ahead (with the exception of queensland--another election promise) albeit slower than any of us thought it would. research studies are being undertaken to develop nurse practitioner competency standards for australia and new zealand. it will be very interesting to see what eventuates from this research. one of the big changes occurring in australia is the change in focus on the role of nurse employed in general practice (or practice nurses as they are called). not to be confused with nurse practitioners, the australian government has recently made available to general practitioners (gps) funds to employ practice nurses. the funds were originally only available to rurally located gps, but this funding has now been extended. at the university of southern queensland, we have just completed a study on consumer perceptions of practice nurses. for example: will rural communities be happy to have their routine chronic care managed by a nurse rather than a gp?; is there a role for nurses to spend more time in health education and promotion within general practice? one of the major findings of our study (confirmed by another study undertaken by cheek et al. at much the same time) is that the average australian does not really know what nurses can do--let alone different levels of nurses! it was also apparent that most consumers were willing to consult with a nurse as long as their right to see a gp was not compromised. we have just applied for more funding to undertake some trials to establish the economic viability of practice nurses working in different models within the australian health care environment. at present the gp who employs the practice nurse is only able to claim a rebate from the australian government if the nurse is carrying out wound management or immunization. the rebate is much lower than the same rebate if the gp undertook this role. it is, therefore, interesting times in australia as we see if nurses are allowed to obtain similar rebates for their care if delivered in a primary care context. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 6 one of the best links for people outside australia who wish to see what is happening in medicine, nursing and allied health is that of the national rural health alliance – http://www.ruralhealth.org.au. for those seeking to come to australia to deliver papers, the next national rural health conference will be held in alice springs, northern territory, in 2005. the conference is usually held in early march. i expect that a call for papers would come out sometime within the next six months. and of course, not to be missed will be the international rural nursing conference to be held in sudbury, canada, later this year. i wish all of you a happy 2004 and look forward to meeting you all in person at some time of my professional life. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ruralhealth.org.au/nrhapublic/ editorial 7 editorial terri schiavo and five wishes kay rosenthal editorial board member my call to rno members as executive director of rno is to get active in your community. my challenge to all of you is to educate your community members about health and health care issues. here's a great way to take a national event and bring it to the local level. terri schiavo was in the news when a federal judge refused to order the reinsertion of her feeding tube march 22, 2005. the parents of this woman with braindamage filed a notice of appeal. to me, this is what five wishes is all about. what did terri want when she was able to speak for herself? what do you want when you can no longer speak for yourself and who will speak for you? five wishes began after jim towey was inspired by mother teresa to seek a way for patients and their families to cope with the decisions that must be faced due to serious illness by planning ahead. five wishes living will is a tool provided by aging with dignity to help persons communicate what they want done if they become seriously ill. if you were seriously ill and couldn't speak for yourself, who would make decisions about your health care for you? would the person making the decisions know and fulfill your wishes? have you had these discussions with your parents, your spouse, and your children? with the news of terri schiavo's battle and recent death in our thoughts i recommend taking time to have these discussions and reaffirming your wishes. this tool talks not only about your medical wishes but your personal, emotional, and spiritual wishes. it's a user-friendly tool. you can discuss it with your family and health care provider. five wishes helps you determine five areas of decision making that arise with serious illness. 1) the person i want to make health care decisions for me when i can't, 2) the kind of medical treatment i want or don't want, 3) how comfortable i want to be, 4) how i want people to treat me, and 5) what i want my loved ones to know. you may want your parent, spouse, sibling, or friend to speak on your behalf and make your decisions. (note in colorado, the person must be 21 years of age.) you decide. you may want life support treatment to include full resuscitation such as a breathing tube, feeding tube, cardiopulmonary resuscitation, antibiotics, or not. you decide. you may want to have specific comfort needs addressed such as keeping your lips and mouth moist, being pain free even though it makes you drowsy, having your hair and teeth brushed, having music played, or not. you decide. you may want lots of visitors, church members to stop by, photos of loved ones within your sight, to die in your own home if possible, or not. you decide. you may want to share thoughts with your friends and family that you haven't addressed before you were sick. asking for forgiveness, peace making, sharing your love, online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 8 determining that you want to be buried or cremated, noting what songs or readings you'd like at your memorial service, or not. you decide. your making the decision will relieve the burden on the person called upon to make these decisions for you. it is a difficult task for them and they are dealing with their own grief and loss issues. making your decisions known will help them make these difficult decisions much easier. the form can be ordered on line at www.agingwithdignity.org or by calling 1888-594-7437. the form is $5.00 for an individual copy and may be photocopied after being filled out for your health care provider and loved ones. here's an example of what you can do locally to help your community learn more about with health issues. as a parish nurse i held a community presentation that included the five wishes form, as well as other offerings. women from the newcomer's club and three of the churches brought soups and salads to entice people to come. i also submitted this information to the local newspapers and radio stations. the form was offered at the parish nursing fund raiser on sunday, april 10, 2005. in addition to five wishes, cliff stuart, estes park medical center pharmacist, was available to review medications for drug-to-drug interactions called a "brown bag" session because you bring all your meds (prescriptions and nonprescription) in a brown bag for review. the surgeon general's family medical history portrait was also provided along with information about parish nursing what it is. a good will offering to benefit the ep parish nursing program was matched by thrivent financial. the ep interfaith council endorses the ep parish nursing program. i hope you'll get active in your community and spread your nursing knowledge to help laypersons gain a better understanding of health and healthcare. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 as a member of the rural nurses organization (rn) we are concerned about moving rural health care and rural nursing forward through advocacy 9 editorial rno advocacy: tips for calling an elected official at local, state or federal levels angeline bushy, phd, rn, faan editorial board member members of the rural nurses organization (rn) are concerned about moving rural health care forward by advocating for our clients and relevant policies. advocating for clients varies depending on individual needs and cultural preferences. advocating politically at the local, state and federal level for most nurses is seemingly more complicated. when a nurse is put on the spot to respond to an issue that one knows only peripherally can be especially frightening. without having the time to seek out the best answer one can easily be tripped up and not give the most appropriate response –especially when responding to a representative or senator at the state or federal level. yet, these elected officials need and are seeking input from nurses, in particular those in rural practice. along with face-to-face meetings, nurses can interact with local officials, state legislators and congressional members by writing a letter sent by snail mail, using electronic mail (e-mail) or calling by telephone. picking up the phone and calling an elected official is quick and relatively easy. however, for most people the idea of making a phone call is more intimidating than writing a letter or sending an e-mail to your congress person. a short focused phone conversation can have a significant and timely impact in getting the attention of a staff member in the congressional office. in turn, that staff member often recalls a constituent’s verbal pitch from phone call or face-to-face conversations when reporting to the elected official. a phone call also presents an immediate opportunity for staff members to ask follow-up questions about the issue and its direct impact at the local level that is useful to policy makers. in other words, staff members are a conduit for elected officials to directly hear about constituent’ concerns. a phone call to the office of an elected official can be effective with a small investment of time for the nurse. while a letter or an e-mail may take at least 20 or more minutes to write, a phone call should take no longer than a few minutes using the following guidelines. when calling the office of an elected official, a receptionist (low-level staff person) generally answers all phone calls. even though the receptionist may have little, if any, direct contact with the elected official this individual serves in a gate keeper role. he or she has the ability to either quickly dismiss your call or get you connected with the appropriate individual who is interested in what you have to say about a particular issue. be courteous and polite when speaking with the receptionist. in the midst of other tasks, a rude phone call makes it is easy for this gatekeeper to respond; ‘thank you for your message. i will make sure to let the senator (representative) know your thoughts.” consequently, with the hundreds of calls that arrive each day it is highly unlikely that your message will get to the intended person. below are additional tips for making effective advocacy phone calls to elected officials. • when placing the call, ask the receptionist to speak with the health staff member in the office. (do not leave a message with the receptionist.) if possible learn the name of this individual and ask for that person. ask if it is possible to leave a online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 10 message on a voice mail of the health staff person. leaving a phone message is routine and to be expected until you have developed a relationship with a particular staff person. congressional staff members check their phone mail throughout the day in order to have timely input from constituents with contact information should he/she wish to follow up on a message. • before placing the call, carefully plan what you are going to say. it is prudent to write out the script; then, practice what you are planning to say. when focusing on legislation, specify the bill number about which you are calling. focus on one thing and give brief information as to why the issue is important. if you belong to a particular professional organization, mention one or two of the group’s talking points; or, provide anecdotal or local fact about the issue or program and how it will help or harm the community or constituency. your message should be no longer than two minutes. longer voice mail messages could be cut off or deleted. • when placing the call, introduce yourself to the receptionist. indicate the organization you are representing and, how you serve constituents in the elected official’s district or state. • ask if it is possible to speak to or leave a message with the staff person who is assigned to health affairs. if that is an option, do so. if not, leave your message with the receptionist. • keep your message short and simple. (use the script you developed prior to making the call.) if you have other supporting materials or evidence that you wish to share with the staff person indicate that this will be sent by e-mail. (be sure to follow through on this promise!) • close the conversation by thanking the staff member for his or her support for rural nursing. provide your contact information should the congressional office wish to follow up at a later time. • after the call, it is prudent to immediately follow up with an e-mail message restating key points. if the staff person on the call promised to send you information, sending a follow-up e-mail reminder is appropriate. it is important for rno members to be aware of current legislative and policy issues that impact rural health care systems and providers. the national rural health association (nrha) website includes comprehensive information on current rural health legislative at the following website: http://www.nrharural.org/go/left/policy-and-advocacy/government-affairs-news another nrha website provides contact information for your elected officials: http://www.capwiz.com/nrha/dbq/officials/ in sum, activism and advocacy entails contacting and working with elected officials at the local, state and federal levels. to that end, snail mail can be slow and easily misplaced while an e-mail message can be quickly deleted. most nurses do not have the time or financial resources to travel to washington dc to speak on every issue that impacts rural nurses or their clients. for this reason, a short but carefully planned phone call to an elected official is a low cost, efficient and effective strategy for nurses who are interested in affecting policy that can impact health care delivery and advocating on in clients’ behalf. references fry, t. (2008). now do something: the do-call list. rural crossroads, 6(1), 28-29. http://www.nrharural.org/go/left/policy-and-advocacy/government-affairs-news http://www.capwiz.com/nrha/dbq/officials/ editorial   3 editorial spirituality and nursing: personal responsibility linda dunn, dsn, rn, cce, cnl editorial board member my life has been blessed with six precious grandchildren. this spring, i have been going to their softball games or practices numerous times each week. i have noticed that each player is expected to be a team member, to attend practice, to be punctual, to play by the rules, and to cheer each other from the dugout. spectators watch players as they bat …some swing and miss; others connect for a single, double, triple, or home run. we cheer even more enthusiastically when the ball player is “ours” particularly if it was a grand slam!! if a player is called out, we rush to offer a pat on the back or words of encouragement. nursing is much like a ball team. within any health care agency, day in and day out, amidst offensive odors, cries of pain/disappointment, or the echo of a dreaded diagnosis, nurses must stay the course with patients and their families. nursing is a calling and we must keep “swinging and running” – the team is counting on us. perhaps just as importantly, “spectators” are watching. may, 2008, will be a time of national and international recognition for our nursing profession. the national nurses day 2008 (may 6th) theme is “caring hearts & healing hands” while the international nurses day 2008 (may 12th) theme is “ delivering quality, serving communities: nurses leading primary health care“. these themes offer each nurse a personal challenge to be instruments of caring, healing, and service. as we celebrate our profession, let us also focus on both the art and science of nursing in a team effort to mobilize our leadership in the multiple arenas of health care, to be passionate about our calling, and to be visionary in patient care innovations. one means of combining our efforts is through individual professional responsibility. whether in academia or clinical practice, nurses adhere to a holistic model where human beings are viewed as biopsychosocial-spiritual-cultural individuals. nurses must be aware of the professional and regulatory guidelines (i.e. ana, carf international, icn, jcaho) that mandate that this model be addressed with every patient to whom care is provided. sadly, the literature documents that patients’ report they are not being adequately addressed in the area of spirituality. failure to obtain a spiritual history/assessment or provide spiritual care may add to the patient’s suffering (grant, 2004). nurses spend more time with patients than does any other health care provider. since the nurse’s own personal spirituality will permeate individual nursing practice (reed, 1987), it will behoove each nurse to critically evaluate his/her own spirituality. becoming aware of one’s spiritual perspectives will enhance personal awareness and, thereby, contribute to the provision of spiritual care to patients (ross, 2006). i adhere to stoll’s (1989) conceptual model which may guide you in gaining an increased personal awareness of your spirituality. on a piece of paper draw a horizontal line. from the center of this line draw an upward vertical line perpendicular to the horizontal line. where the lines join, draw a small circle. the circle represents you. the vertical line represents your connection to the sacred (god/gods) and the horizontal line represents your connection to self, others and nature. there is a continuous interrelationship between these two dimensions which may be impacted by life experiences (i.e. illness, disappointment, grief/loss). threaded throughout each line are spiritual online journal of rural nursing and health care, vol. 8, no. 1, spring 2008   online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 4 needs: to love and be loved, to forgive and be forgiven, to hope, to trust, to be strengthened, to have relationships, to have meaning and purpose in life, and to transcend (lemmer, 2005). from this model, a person who has intrinsic (vertical) spiritual well-being will more likely have extrinsic (horizontal) spiritual well-being. while all humans are spiritual, all are not religious. for many, religion is a way to express their spirituality, to cope, or to transcend. research has shown a positive relationship between spirituality, religion, and health – religious attendance is enhances health (koenig, 2007). studies have also shown that nurses with a religious affiliation have a stronger spiritual base and are more likely to provide spiritual care in practice (cavendish, luise, russo, mitzeliotis, bauer, bajo, et al., 2004). even though a nurse has a spiritual base, it cannot be assumed that a nurse will provide spiritual care (cavendish, et al., 2004). health care administrators and nurse managers must create an environment that ensures the nurse’s own spirituality is cultivated and at the same time promotes the systematic provision of spiritual care to patients. likewise, nurse educators must include spiritual assessment/care within nursing curricula. including spiritual content will help ensure that nursing graduates have a basic understanding of the relationship between spirituality and health, and will have been afforded opportunities for personal spiritual awareness. so, as “team members”, let’s step up to the plate and swing into action by assuming personal responsibility for assessing our own spirituality as well as evaluating how well we are addressing spirituality in clinical practice or academia . if i may offer assistance in the area of spirituality, please contact me at ldunn@bama.ua.edu. i hope to continue our game plan in my next editorial. references american nurses association. (2002). code for nurses. kansas city, mo: american nurses. carf international. (2004). standards manual. tuscon, az: commission on accreditation of rehabilitation facilities. cavendish, r., luise, b., russo, d., mitzeliotis, c., bauer, m., & bajo, m.a.m., (2004). spiritual perspectives of nurses in the united states relevant for education and practice. western journal of nursing research, 26, 196-212. grant, d. (2004). spiritual interventions: how, when, and why nurses use them. holistic nursing practice, 18(1), 36-41. [medline] international council of nurses. (2006). the icn code of ethics for nurses. retrieved october 26, 2007, from www.icn.ch/icncode.pdf joint commission on the accreditation of healthcare organizations. (2004). spiritual assessment. retrieved october 26, 2007 from www.jointcommission.org/accreditationprograms/hospitals/standards/faqs koenig, h.g. (2007). spirituality in patient care (2nd edition). philadelphia: templeton foundation. lemmer, c.m. (2005). recognizing and caring for spiritual needs of clients. journal of holistic nursing, 23, 310-322. [medline] reed, p.g. (1987). spirituality and well-being in terminally ill hospitalized adults. research in nursing and health, 10, 335-344. [medline] ross, l.a. (2006). spiritual care in nursing: an overview of the research to date. journal of clinical nursing, 15, 852-862. [medline] stoll, r.l. (1989). the essence of spirituality. in v.b. carson (ed.), spiritual dimensions of nursing practice. philadelphia: w.b. saunders. mailto:ldunn@bama.ua.edu http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14765691%5buid%5d http://www.icn.ch/icncode.pdf http://www.jointcommission.org/accreditationprograms/hospitals/standards/faqs http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16049120%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=3671781%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16879378%5buid%5d 2 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 editorial rural healthcare access: issues for consideration in rural health research barbara ann graves, phd, rn editorial board member important differences in health outcomes across populations and geographical regions may reflect differences in access to healthcare services. many studies have shown the effect of low access on health outcomes. studies that look at access and disparate health outcomes are important in understanding and changing how and where healthcare services are located. physicians in the united states most often practice in urban communities rather than rural communities. in 1997, only one out of ten physicians provided healthcare services in rural areas. this statistic means that only eleven percent of this nation’s physicians provide healthcare to 20% of its population (usda, 2002). rural areas also have lower proportions of all healthcare professionals (ricketts, 1999). rural health services often experience diseconomies of scale in that their long run average cost increases as output increases (folland et al. 2001). providing care becomes too expensive; the providers lose money, and close or merge with other services thereby decreasing access. rural populations then experience an increase in distance and travel time to access necessary healthcare services. central to the study of rural health is how “rural” is defined. merriam-webster (2004) defines rural theoretically as “open land” or “relating to the country, country people or life, or agriculture”. but there are many operational definitions of rural. the u.s. department of agriculture economic research service (ers) created the rural-urban continuum codes (ruccs) as a measure of rurality of u.s. counties (usda, 2002). this common designation of rurality is based on the office of management and budget (omb) classification by a simple metropolitan (metro) versus non-metropolitan (non-metro) dichotomy. based on the central place theory, this method of classification takes into consideration adjacency factors as an indicator of urban influence and economic dependence. the code further distinguishes metro and non-metro counties by the degree of urbanization and adjacency to metro areas. codes 1 through 3 distinguish levels of metro counties by degrees of urbanization (or population size), while codes 4 through 9 distinguish varying degrees of rurality and metro proximity. ruccs provide a means for the study of the location, distribution and accessibility of healthcare facilities for rural populations. rural populations differ in many ways from their urban counterparts. many features of the rural environment create barriers to healthcare access. it is important for rural health research to include these differences. dunkin (2000) provides a framework for the development of health interventions for rural people. this model takes into account the financial, sociocultural (or personal), and structural factors that are a part of the complex web of causation in rural health. these factors affect health-seeking behaviors, health service utilization, and ultimately health outcomes in rural areas. sociocultural factors include cultural and spiritual beliefs, language, education, selfreliance, and concern about confidentiality. financial factors include a lack of health insurance, adequate health insurance, or income or financial resources to personally pay for needed health 3 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 services. structural factors are those factors that have to do with physical accessibility to healthcare resources. they include availability of primary care providers, medical specialist, or other healthcare professionals, and health care facilities. structural factors are measured in terms of availability and configuration of healthcare services, transportation to them, and distance and travel time to them. over the past fifty years sociocultural and financial factors that influence healthcare services have received extensive attention (bushy, 2000; eberhardt, et al., 2001; folland, goodman, & stano, 2001; usdhhs, 2000), while the geographical factors of healthcare access have received minimal consideration. healthcare policy changes over the past decade have drastically decreased access to healthcare services. the rural health environment has felt the impact of these changes in many ways (bushy, 2000; folland, et al., 2001). significant decreases in healthcare services to the already vulnerable, at-risk rural populations have compounded the existing problem of resource disparities. of noted importance are the drastic cuts in health services created by the balanced budget act (bba) of 1997 and the medicare prospective payment system (pps). loss of community health services, healthcare professional shortages, rapidly rising cost, hospital closures, homecare cut backs, and tighter government payment schedules are just a few of the changes that have led to greater resource disparities for rural populations (usdhhs, 2000; eberhardt, et al., 2001). healthcare resources and healthcare use vary considerably by level of urbanization (eberhardt et al, 2001). because of structural, financial and sociocultural barriers in rural populations, they have fewer healthcare resources than urban populations. rural resource disparities often lead to adverse health outcomes and rural health status disparities (fryer, drisco, et al., 1999; lovett, haynes, sunnenberg, & gale, 2002; lin, allen, & penning, 2002). in recent years changes in the kinds of health problems in rural populations have been noted. vulnerable populations (persons with hiv-aids, the aging, those with chronic illness, those mentally ill, and/or abused persons) living within rural areas have compounded issues and added challenges associated with resource disparities and access to care (bushy, 2000; ricketts, 1999; eberhardt, et al., 2001; aday, 2001). many issues of supply-and-demand are evident in rural populations. because healthcare is a highly competitive industry in the u.s., supply-and-demand analysis can provide valuable insight into the relevance of rural health issues. variables that affect the demand for health care are income, insurance, and taste (or preferences) (folland, et al., 2001). because rural areas have a lower population density and rural residents generally have lower levels of income, a lack of health insurance, and prefer informal care to formal care, the demand for health care is often lower (bushy, 2000). at the same time an increase in demand caused by a “sicker” population due to greater health status disparities could increase the demand for healthcare services. the supply of healthcare is affected by variables such as technological change, the size of the healthcare industry, and most importantly by demand (folland, et al., 2001). healthcare is a very large industry driven in part by economic incentives and technological change. progressive industry would not seek to supply services in an area resistive to change and utilization of services and without the means to pay for services. as rural residents consume fewer healthcare services, less is supplied. these changes in supply and demand in healthcare perpetuate problems with access to care in rural areas. the effect of supply and demand is easily seen in the fact that rural people have a lower level of access to both primary care providers and specialized services. over the past decade a decline in community hospital occupancy has led to the closure of many rural hospitals (eberhardt et al. 2001). between 1980 and 1998 approximately 1,072 hospital closures, mergers, 4 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 or conversions led to an 11.8% decline in the total number of community, general hospitals (from 5,842 to 5,153) (ricketts, 1999, p. 104). furthermore, ricketts notes that community hospital closures have had a profound effect on local communities in terms of changes in utilization of health services and health status. references aday, l.a. (2001). at risk in america. california: jossey-bass. bushy, a. (2000). special and at-risk populations. in bushy, a. (ed.), orientation to nursing in the rural community (pp. 73-85.). thousand oaks, ca: sage publications, inc. dunkin, j.w. (2000). a framework for rural nursing interventions. in bushy, a. (ed.), orientation to nursing in the rural community (pp.61-72). thousand oaks, ca: sage publications, inc. eberhardt, m.s., ingram, d.d., & makus, d.m., et al. (2001). urban and rural health chartbook. health, united states, 2001. hyattsville, md: national center for health statistics. folland, s., goodman, a.c., & stano, m. (2001). the economics of health and health care. upper saddle river, n.j: prentice-hall, inc. fryer, g.e., drisko, j., krugman, r.d., vojir, c.p., prochazka, a., miyoshi, t.j. et al. (1999). multi-method assessment of access to primary medical care in rural colorado. the journal of rural health, 15(1), 113-121. [medline] lin, g., allan, e.d., & penning, j.m. (2002). examining distance effects on hospitalization using gis: a study of three health regions in british columbia, canada. environment and planning, 34, 2037-2053. lovett, a., haynes, r., sunnenberg, g., & gale, s. (2002). car travel time and accessibility by bus to general practitioner services: a study using patient registers and gis. social science & medicine, 55, 97-111. merriam-webster online dictionary (2004). retrieved june 16, 2004 from http://mw.com/dictionary/rural ricketts, t.c. (1999). rural health in the united states. new york: oxford university press. u.s. department of agriculture. what is rural? (2002, july). rural information center. national agricultural library, beltsville, md. from http://www.nal.usda.gov/ric/faqs/ruralfaq.htm u.s. department of health and human services (usdhhs) (2000). healthy people 2010: national health promotion and disease prevention objectives. washington, dc: january 2000. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10437338%5buid%5d http://m-w.com/dictionary/rural http://m-w.com/dictionary/rural http://www.nal.usda.gov/ric/faqs/ruralfaq.htm microsoft word 19-337-2-ed_duran1.docx online journal of rural nursing and health care, 12(1), spring 2012 49 rural hispanic health care utilization marilyn duran, rn, phd. 1 1 assistant professor, department of nursing, taleton state university, duran@tarleton.edu abstract background and research objective: minority populations living in rural areas are often disadvantaged in their abilities to access healthcare in their community. to further understand the scope of this problem a sample of adult hispanics residing in three north central texas rural counties was studied. sample and method: a convenience sample of 386 adult hispanic residents of three rural counties in north central texas completed surveys about their utilization of health care services in their communities. results and conclusions: 74.4 % were uninsured, 72.3% did not have a primary care physician and 63.6% reported they needed access to more health care. over the past year 23.3 % reported 1-3 visits to the hospital emergency room for health care. over half (51.3%) reported the need for a translator when going to the doctor. my conclusion is, rural hispanics are disadvantaged to health care utilization by a lack of health insurance, language barriers and access to a primary care physician. keywords: rural, access to health care, hispanic rural hispanic health care utilization there is a well-documented problem with health care access for rural minorities (united states department of health and human services [usdhhs], 2010). without proper access to primary, secondary and tertiary levels of care poor minority populations are medically vulnerable (perez-escamilla, 2010). rural hispanics are at risk of suffering from chronic health conditions that could be medically managed with an early diagnosis. hispanics suffer from diabetes at a much higher rate than other ethnicities (center for disease control and prevention [cdc], 2011). between five and seven and a half million hispanics may have adult onset diabetes, but less than half of these cases are diagnosed (idrogo & mazze, 2004). key barriers for health care access are lack of medical insurance and not having a usual source of care (durden & hummer, 2006). lack of health insurance coverage is an important indicator of healthcare access. in 2007 health insurance access for hispanics was lower (68.2% compared with 87.4%) for non-hispanic whites (usdhhs, 2008). between 2008 and 2009 the percentage of uninsured hispanics increased from 30.7 percent to 32.4 percent (denavas-walt, proctor & smith, 2010). according to the national health interview survey, hispanics under age 65 years were about twice as likely as non-hispanic persons under age 65 years to be uninsured (cdc, 2010). in a study of racial differences in access to health insurance, 45 percent of rural adult hispanics were uninsured compared to 18 percent of rural adult whites (glover, moore, probst & samuels, 2004). another study of texas latino immigrant’s access to healthcare insurance reveals that only 26 percent of online journal of rural nursing and health care, 12(1), spring 2012 50 the total study population reported having some form of health insurance (rojas, marshal, trevino, lurie & bayona, 2006). the gap in health care access for minorities is expected to broaden with projected increases in the hispanic population. there were 9.1 million hispanics residing in texas in 2009 and the median age was 27.4 years. (united states census bureau, 2010). in 2000, racial/ethnic minorities accounted for one of every four united states (u.s.) residents (cdc, 2000). in 2009 the hispanic population was the largest minority population in the u.s. and accounted for 16 % of the total population (united states census bureau, 2010). further, geographical location complicates access to healthcare. rural minorities have a more difficult time accessing healthcare as compared to urban minorities (berdahl, kirby& stone, 2007). common barriers to healthcare access, are low wages, fewer work opportunities that provide healthcare insurance and less discretionary income. rural hispanic minorities earn less income and are three times more likely to live in poverty compared to whites. (ziller, coburn, loux, hoffman & mcbride, 2003). in addition to lack of healthcare insurance, language barriers compound the problem. english speaking hispanics are more likely to have health insurance and access to a doctor when needed for a medical condition (dubard & gizlice, 2008). design and methods the purpose of this study was to explore the healthcare access and utilization among rural adult hispanics. a descriptive design was used to explore healthcare utilization and identify barriers to healthcare access among three rural texas counties with a growing hispanic population. the instrument used to gather information was a modified version of a proven instrument obtained from a questionnaire developed by duke university in collaboration with the u.s. department of health, education and welfare. eric pfeiffer was the originator in 1975 of the multidimensional functional assessment scale that measured multiple areas at the same time to provide a profile of an individual (pfeiffer, 1976). this instrument has been used multiple times with noted reliability and validity. the study data were collected among adult hispanics residing in three rural counties (counties with fewer than 50,000 persons) of north central texas. participants were recruited from local hispanic churches. with the help of a translator i explained the purpose of the study and gained permission from the clergy to recruit participants from their churches. spanish speaking surveyors were recruited and received training on use of the survey tool. prior to data collection the purpose of the survey was explained to the participants. those who agreed to participate were enrolled in the study after completing an informed consent form. the participants were given the option of answering the survey questions in the language of their choice. most of the participants responded to the interview in spanish. questionnaires were administered through a facetoface interview. in order to maintain confidentiality no names or identifiers were included in the interview. the questionnaire consisted of 34 structured questions in english and spanish. the questions assessed participants’ demographic characteristics, health status, access to health insurance, access to health care, health problems or conditions. questions used to indicate healthcare barriers include; do you have health insurance? do you have a primary care physician? do you need someone to translate for you when you visit the doctor? sample approval for this study was obtained from the human subjects research review board at tarleton state university. a convenience sample of 110 men and 276 women aged 18 years and online journal of rural nursing and health care, 12(1), spring 2012 51 older constituted the subjects of this study. the participants were recruited from hispanic churches in 3 rural counties in north central texas. analysis statistical analysis was computed using spss version 17 (chicago, il.). descriptive statistics of frequencies, means and standard deviation were computed using analyze descriptive. surveys with missing data about race, age, gender, primary care physician and access to health insurance were excluded from analysis. findings a total of 386 surveys were included in the data processing and analysis. the mean age of respondents was 34.1 years with a range of 18-78 yrs. average monthly income was $1261.00 with a range of $100.00 $6000.00 monthly. the majority of the participants in this study are living in poverty or near poverty depending on the size of their family. table 1 lists the findings related to demographic variables including age, gender, marital status, ethnicity, country of origin and education. the sample was predominately (n = 276) female. all respondents were of hispanic ethnicity (n = 386). the education level was predominately (n = 250) high school and below a small number (n = 20) had a college education. small percentages (15%) were born in the united states. many of the respondents (n = 309) did not answer the question about origin of birth. most (n = 308) responded to the interview in spanish. table 1 demographic finding table 2 lists the findings related to health care access. findings show that the majority of respondents are disadvantaged in their ability to access healthcare. a large number (n= 287) did not have medical insurance. over seventy percent (72.8%) did not have access to a primary care physician. when seeking medical care (n= 193) needed help with translation. the majority (n=319) did not have enough money for their health needs. a small percent (26.2%) used the emergency room for health care. online journal of rural nursing and health care, 12(1), spring 2012 52 table 2 barriers to healthcare access diabetes (n = 29) and hypertension (n = 45) were the most common reported chronic illnesses. table 3 lists reported chronic health problems. table 3 self-reported chronic health problems discussion these results support what is documented in the research literature regarding lack of health insurance among poor rural minorities. this study shows that rural hispanics are disadvantaged online journal of rural nursing and health care, 12(1), spring 2012 53 in their abilities to access healthcare by a lack of income, health insurance and access to a primary care physician. self-report of emergency room usage in this sample was lower than has been previously portrayed in the literature. tracking of hispanic emergency room use in this three county area could assist in developing healthcare policy. as for chronic conditions, the participants did not have a high incidence of diabetes and hypertension. this could be related to the young age of the respondents or lack of access to health screenings to identify chronic diseases. in the early stages of chronic diseases such as diabetes and hypertension it is not uncommon to be asymptomatic. this study is limited in its ability to show direct causation or relationship. however, it is important to provide descriptive data on this population to help rural nurses have a better understanding on the scope of the problem. several questions arise from this study. how do poor, uninsured rural hispanics access healthcare? since the participants in this study were predominately female, do rural male hispanics access healthcare differently than females? how do rural communities provide healthcare for poor minority residents? many respondents reported they needed translation when seeking healthcare. if no translation is available how are healthcare needs conveyed to the healthcare provider? more research is needed to answer these questions. recommendations even though this was about hispanics, the health of the whole community is affected. minorities in rural communities are working in restaurants, farming, construction and child care. the rural economy is heavily dependent upon their wellbeing. rural nurses face the challenges of caring for this population and understand the associated issues of poverty and lack of health care. the rural nurse, like all nurses have a responsibility to serve as an advocate for the whole community. to improve the health of minorities such as those in this study, the whole community will need to be involved. rural nurses will need to work collaboratively with county and city leaders, health care providers, community employers, clergy and others to improve health outcomes for this population. references berdahl, t.a., kirby, j.b., & stone, r.a.t. (2007). access to health care for nonmetro and metro latinos of mexican origin in the united states. medical care 45(7), 647-654. [medline] center for disease control and prevention (2011) national diabetes fact sheet 2011. retrieved from http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf center for disease control and prevention (2010). summary health statistics for the u. s. population: national health interview survey, 2009. retrieved from http://www.cdc.gov/ nchs/data/series/sr_10/sr10_248.pdf center for disease control and prevention (2000). the hispanic population. census 2000 brief. retrieved from http://www.census.gov/prod/2001pubs/c2kbr01-3.pdf denavas-walt, c., proctor, b.d., & smith, j.c. (2010). u.s. census bureau current population reports, p60-238., income, poverty, and health insurance coverage in the united states: 2009. washington, dc: u.s. government printing office. retrieved from http://www.census.gov/prod/2010pubs/p60-238.pdf dubard, c. a., & gizlice, z. (2008). language spoken and differences in health status, access to care, and receipt of preventive services among us hispanics. american journal of public health, 98(11), 2021-2028. [medline] http://www.ncbi.nlm.nih.gov/pubmed/17571013 http://www.ncbi.nlm.nih.gov/pubmed/18799780 online journal of rural nursing and health care, 12(1), spring 2012 54 durden, t. e., & hummer, r.a. (2006). access to healthcare among working-aged hispanic adults in the united states. social science quarterly, 87, 1319-1343. glover, s., moore, c., probst, j., & samuels, m. (2004) disparities in access to care among rural working-age adults. journal of rural health 20(3), 193-205. [medline] idrogo, m., & mazze, r. (2004). diabetes in the hispanic population. postgraduate medicine, 116(6), 26-35. perez-escamilla, r. (2010). health care access among latinos: implications for social and health care reforms. journal of hispanic higher education, 9, 43-60. pfeiffer, e. (ed.). (1975). multidimensional functional assessment: the oars methodology. durham, nc: center for the study of aging and human development. united states census bureau (2010). facts and figures, hispanic heritage month 2010. retrieved october 7, 2010 from http://www.census.gov/newsroom/releases/archives/facts_for_ features_special_editions/cb10-ff17.html united states department of health and human services (2010) national healthcare disparities report. retrieved from http://www.ahrq.gov/qual/nhdr10/chap10.htm#racial united states department of health and human services (2008). national healthcare disparities report. retrieved from http://www.ahrq.gov/qual/nhdr08/chap3.htm#barriers urrutia-rojas, x., marshall, k., trevino, e., lurie, s., & bayona, g. (2006). disparities in access to health care and health status between documented and undocumented mexican immigrants in north texas. hispanic health care international, 4(1), 7-14. ziller, c., coburn, a., loux, s., hoffman, c. & mcbride, t. (2003) health insurance coverage in rural america. retrieved from http://www.kff.org/uninsured/upload/ health-insurance-coverage-in-rural-america-pdf.pdf http://www.ncbi.nlm.nih.gov/pubmed/15298093 21 building community capacity in southwest virginia tauna gulley, rn, msn, fnp1 1 instructor, department of nursing, university of virginia’s college at wise, tnmike@adelphia.net keywords: community building, partnerships, nursing education abstract asset based community development (abcd), a guide for building healthier communities, was used to promote positive change in a rural southwest virginia community. this paper illustrates how community assets were recognized and social capital increased as children painted a mural depicting the history of the community. a literature review of successful community building partnership models is provided and implications for nursing education are discussed, including suggestions for teaching collaboration skills for effective community partnering. introduction asset based community development is a valuable means for strengthening communities and promoting the health of the children and families who live within the communities. asset-based community development (abcd) is a partnership model that increases social capital by using the assets found within the community. social capital is defined as “the power of social networks and relationships which constitute the social environment” (pan, littlefield, valladolid, tapping & west, 2005). effective healthcare leaders should make a commitment to use their knowledge and skill in increasing social capacity and building community, because a strong community is home to healthier children and families. (pan et al. 2005). this paper will provide a literature review and illustrate the application of the abcd process within a rural community in southwest virginia. suggestions for using partnership models in nursing education are presented. partnership models creating partnerships is the foundation for building community capacity. successful partnerships require consideration of community diversity. culturally competent partnerships accurately represent the needs and problems of the community. involving community leaders and members in building community capacity promotes trust and results in effective working relationships between culturally diverse partners. culturally diverse partnerships hawkins, cummins & marlatt (2004) discussed three community-oriented partnership programs: the target community partnership project, the parent, school and community partnership program and pride (positive reinforcement in drug education). these partnerships were created to develop intervention strategies aimed at online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.wise.virginia.edu/nursing/index.html mailto:tnmike@adelphia.net 22 preventing substance abuse in native american adolescents living on or near a reservation in the united states. a common strategy used by these three models was the formation of partnerships among tribal leaders. tribal leaders are role models and decision makers within the native american community. the success of community empowerment interventions is dependent upon establishing partnerships among tribal leaders as well as community members, school administration and professional services staff. these community based programs were successful in preventing substance abuse among native american youth by identifying factors associated with increased substance use. without the partnerships, the success of these programs would not have been possible. community-academic partnerships meyer, armstrong-coben and batista (2005) described a model of communityacademic partnership in new york city. the partnership included pediatric residents and alianza dominicana, inc., a community based social service organization. the goal of the partnership was to promote child health and development in the community. according to the 2000 census, 72% of the community served described themselves as dominican. the community was located in a rural area with economically disadvantaged working class residents. meyer et al. (2005) reflectively described four principles that lead to the success of this culturally diverse partnership. first, a trusting relationship was established among university faculty, pediatric residents and community residents. the relationship took years to develop because of misconceptions between the pediatric residents and the community. the community perceived university faculty as the “ivory tower” and the pediatric residents as “arrogant and all-knowing”. the pediatric residents perceived the community as impoverished and lacking assets. initially, the pediatric residents did not see the assets within the community. therefore, the message was to abandon biases in order to have a positive working relationship. this was achieved through training sessions led by community leaders and faculty members. community leaders gradually gained leadership roles within the medical residency program. next, the establishment of specific defined goals was determined. the formation of the board of directors, consisting of representatives from the community, faculty and residents, was the third principle and the last principle leading to the success of the partnership was open communication using a common language. the creation of a common language was developed through “narrative lunches”, an activity for residents and community members to talk about cultural differences in an open dialogue (meyer et al. 2005). the abcd model the abcd model, a partnership model, brings together community assets including community members, organizations and institutions to build a strong community which will, hopefully, assure a promising future for the families and children within the community (pan et al. 2005). pan, littlefield, valladolid, tapping and west (2005) described five community assets within the abcd framework that have the potential to bring about positive changes. the five assets include: online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 23 • skills and capabilities of individuals within the community. everyone has something to offer; ideas are sometimes lost when individuals do not share. an effective leader encourages ideas from community members. community members are knowledgeable about needs within the community and the required improvements. • the association capacity within a community. capacity includes individuals who exercise or attend church together. associations are valuable social support systems within communities that provide networking opportunities. • institutions established within the community. schools, churches, businesses and government agencies are potential partners when building a stronger community. • potential development sites are used in creative ways. empty buildings found within the community can be used for meetings or recreation areas. • unused pieces of land are converted to playgrounds or parks. america’s promise america’s promise (2003), a partnership model founded by colin powell, former secretary of state, is similar to the “abcd” model. america’s promise is an example of a partnership model that focuses on providing a promising future for america’s youth by fulfilling five promises. the five promises for every child include: • a caring adult to take an interest in a child’s well being. teachers, coaches, neighbors or family members develop relationships with children that promote positive experiences and guidance. • a safe place to go after school. children should feel physically and emotionally safe from negative influences. adult led after school activities provide opportunities for children to interact with peer groups. • a healthy start. every child deserves adequate nutrition and access to health and dental care. • effective education. marketable skills provided by educational experiences and career development are necessary in order to become successful adults. • opportunities to give back to the community. allowing young people to serve the community enhances self-esteem and provides an opportunity for growth. many communities, schools, and businesses have pledged to fulfill these five promises to america’s youth in order to ensure a better future for america (america’s promise, 2003). research has shown these partnership models (meyer et al. 2005; pan et al. 2005; siegrist, 2004; and hall-long, 2004) have been successful in bringing about positive change within communities but the most successful models of community building originate within the community by individuals wanting to make a positive change for themselves and their families as this case study will illustrate. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 24 painting the wall within a small community in southwest virginia, one woman, ms. g, shared a vision. she wanted to do something for children and beautify the neighborhood. however, the project she envisioned, “painting the wall”, accomplished much more than those two objectives. the idea evolved into a community project that resulted in successful partnerships and numerous positive outcomes including enhanced self-esteem, feelings of competence, and increased activity level among the participants. ms. g asked children to paint a mural depicting the history of the community on a rock wall located at the community entrance. after securing permission from the landowner, ms. g began contacting parents of children living in and around the community to determine their interest in painting the wall. the response was optimistic and planning began. miss amy, a rural college student, had experience with painting murals, offered enthusiasm as well as her artistic ability, and used the project for her six week internship. this region is plagued by unemployment, substance abuse, illiteracy and geographic isolation. travel through the community is restricted to one primary road. abandoned ramshackle houses are unattended. the inhabitants of the area are caucasian, african american or multiracial. the town once flourished when men worked in the coal mines with children playing everywhere, especially playing basketball on the corner. today, children are inactive, staying inside, closer to the television and video games. only occasionally are children seen walking down the street. the abcd process as the project evolved, relationships between parents and ms. g. developed. a mutual commitment to the project became apparent with offers of financial support from parents to buy paint and brushes. the goals of the project were discussed in the initial contact and everyone agreed the mural would be a valuable piece of art history for the community. a specific partnership model was not used for the collaborative efforts of the individuals within the community. however, many characteristics of the abcd model are apparent within this collaboration. the first step was utilizing the association capacity and institutions within the community, an asset within the abcd framework. the fire department pressure washed the wall before painting began. parents provided drinks and snacks. the town council donated $300.00 to finance the project and the county board of supervisors agreed to help. ms. g exhibited strong leadership skills in planning and organization, a reflection of the skills and capabilities asset within the abcd model. she bought brushes, paint, sealer, cups, drinks, snacks and insect repellent but left the design and painting to miss amy. zukowski and shortell (2001) believe that partnerships progress best with a clear focus. the clear goal in this project was to allow community children to paint the wall despite cost and weather. the children, ages four to seventeen, were told about the project during vacation bible school and asked if they wanted to participate. ms. g also phoned the children’s parents. every child expressed a desire to paint. the parents brought the children to the online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 25 wall and left them in the care of ms. g. some parents stayed and painted with the children. children and parents painted for ten non-consecutive days. the history of the community was obtained from interviewing elderly community members. after the wall was pressure washed, it was painted white (picture 1). picture 1 the taller kids offered to paint the upper wall where the smaller children could not reach (picture 2). picture 2 online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 26 next, each child chose a square along the wall and the child’s name was marked in the square. then, the children had to plan what they wanted to paint in the square. after telling ms. g they were ready to paint, she helped the child find the necessary colors for the square based on the child’s vision. it was critically important for everyone to realize that each child was essential to the project. children were praised often for their choices of design and color. the children were passionate about painting “the wall” and their excitement was contagious. parents became enthusiastic and many chose to paint their own square of history. despite the summer heat, everyone kept a positive attitude (picture 3). picture 3 located directly in the center of the wall is the handprint tree containing the hands that contributed to the community project (picture 4). the children, parents and community members were invited to dip their hands in the paint and place their handprints at the edges of the painted limbs to imprint a “leaf”. the individual printed their name at the bottom of the “leaf”. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 27 picture 4 one child painted a cardinal (picture 5). another child painted the world surrounded by children of different races (picture 6). online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 28 picture 5 picture 6 her mother commented on the fact that this child got up at six-thirty every morning to paint the wall. “i’m going to show the wall to my grandchildren one day,” said the child to her mother. “it has showed me that i can do hard work and that it’s very time consuming. when i get older i can show my kids what i did,” a comment from a thirteen year old. “painting the wall” began as a simple idea that progressed to a partnership between residents of a small, rural community, local organizations and political representatives. the wall is a depiction of the community, a coal mining town. replicas of the company houses were painted on the wall and the train that traveled across the top of the wall fifty years ago carrying coal was also painted. the principles of abcd brought individuals within a rural community together for a common goal, paint a mural depicting the history of the town. the children and online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 29 community members were motivated to complete a task and with the completion of that task there was a sense of accomplishment, a job well done. the community will continue to enjoy the rewards of the completed project, an historical representation of the community. america’s promise was recognizable throughout this project. children formed relationships with caring, compassionate adults; adequate nutrition and hydration was provided, children interacted positively with peer groups in a safe place and children were given the opportunity to serve the community. implications for education developing partnerships within the community is an excellent way to teach team building skills and increase clinical experiences for undergraduate nursing students. partnership models between community health programs and schools of nursing currently exist at the university of delaware, newark; and western kentucky university, bowling green (siegrist, 2004 and hall-long, 2004). these partnership models benefit communities, students and faculty. siegrist (2004) noted that students, as a result of the “partnering” experience, developed interdisciplinary teamwork, program planning skills and cultural competency. in the project described by hall-long (2004), students developed public health skills and received academic credit. curricular competencies were met and new clinical sites were formed. most baccalaureate nursing programs require community health nursing content including partnership principles and community building. experience in asset based community development can be offered by allowing students to choose a partner community and complete a community assessment. students identify problems and assets within the community, create possible interventions to address the problems and validate both with community residents. for example, students may find a playground located directly beside a creek with water four feet deep. obviously, the playground needs a fenced enclosure for safety reasons. the goal is to develop a partnership specific to the community that will result in acquiring a fence around the playground. nursing students, with guidance from faculty, may want to speak to parents, using this opportunity to teach parents and children the dangers associated with playing near creeks and streams. empowered parents are valuable partners who can create positive change. it is necessary for nursing students to learn collaboration skills in order to provide quality patient care (van ess coeling & cukr, 2000). nursing faculty should take the opportunity to teach these skills out of the classroom setting using a “hands on” approach. implementing partnership programs within the community is an effective way to teach team building and collaboration skills necessary for successful partnerships. effective partnerships must include all community stakeholders. students need to look to business and government leaders, teachers, community activists and health care providers as potential partners. time and planning are essential for building successful partnerships. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 30 conclusions the residents of a rural community in southwest virginia were successful in achieving their goal. the mural will be a constant reminder of a positive experience for the residents of the community (picture 7). picture 7 through community partnering, nursing students can merge their roles as community residents and professional nurses. giving back to the community is the responsibility of every citizen. if all residents take this obligation seriously, communities will be healthier places for children and families. acknowledgement the author would like to thank joy e. wachs, phd, aprn, bc, faaohn, professor, family/community nursing, east tennessee state university for her support in preparing this manuscript. references america’s promise-the alliance for youth. (2003). retrieved september 18, 2005, from http://www.americaspromise.org hall-long, b. (2004). partners in action: a public health program for baccalaureate nursing students. family & community health, 27, 338-345. [medline] hawkins, e., cummins, l.h., & marlatt, g.a. (2004). preventing substance abuse in american indian and alaska native youth: promising strategies for healthier communities. psychological bulletin, 130(2), 304-323. [medline] online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.americaspromise.org/ http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15602324%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14979774%5buid%5d 31 meyer, d., armstrong-coben, a., & batista, m. (2005). how a community-based organization and an academic health center are creating an effective partnership for training and service. academic medicine, 80, 327-333. [medline] pan, r.j., littlefield, d., valladolid, s.g., tapping, p.j., & west, d.c. (2005). building healthier communities for children and families: applying asset-based community development to community pediatrics. pediatrics, 115, 1185-1188. [medline] siegrist, b.c. (2004). partnering with public health. family & community health, 27, 316-325. [medline] van ess coeling, h., & cukr, p. (2000). communication styles that promote perceptions of collaboration, quality, and nurse satisfaction. journal of nursing care quality, 14(2), 63-74. [medline] zukowski, a.p., & shortell, s.m. (2001, september/october). keys to building effective community partnerships. health forum journal, 22-25. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15793014%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15821307%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15602322%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10646302%5buid%5d editorial 2 editorial exciting times kathy crooks editorial board member the past year has been an exciting time for nurses working in rural and remote parts of canada. while 95 percent of this immense country is considered to be rural or remote, only 18 percent of all nurses in canada are employed in these areas. because of distance and lack of technology in some areas, until very recently it has been impossible for this small number of nurses to organize and band together to advance the cause of rural nursing in canada. this all changed at the canadian nurses association biennium in st. john’s newfoundland in june, 2004. at that time, a group of about 30 nurses from across canada with an interest in rural/remote nursing met to discuss the organization of the canadian association of rural and remote nurses (carrn). carrn is in the process of electing its first slate of officers. the emergence of an organization such as carrn is a monumental undertaking. its inception is the result of the hard work of dr. dana edge and meg mcdonoagh of the university of calgary, as well as barb shellian, a former president of the alberta association of registered nurses. these three individuals, along with dr. elizabeth thomlinson, met in binghamton, new york, for the third international congress. from that meeting, the idea for caarn was born. the desire for canadian nurses to establish an organization like carrn is in part the result of the formation of the icn remote and rural nurses network. the concept for the network grew from an initial meeting that took place in toowoomba, queensland, australia at the second international congress in 2000. spearheaded by dr. sally reel, the group of nurses who met in australia have been corresponding via e-mail over the past several years. thanks to dr. reel’s diligence and persistence, the group will meet again in sudbury, ontario, at the 4th international congress, at which time the network will become recognized officially by icn. rural nursing research has also assumed a more prominent position in canada during the past two years. a nation-wide study on the nature of rural nursing practice in canada is just reaching completion. this study, which involves researchers from several universities across the country, began about three years ago and has provided us with the only snapshot of the demographics of rural nurses to date. those of us that are interested in improving the cause of rural nursing in canada are eagerly anticipating the final results of this venture. recently, medicine hat college had the opportunity to host a delegation of educators from japan interested in rural and remote nursing. it was very interesting to me that there are areas in japan that are considered to be rural and remote. i will be visiting japan in april and look forward to seeing some of those areas for myself. it is so nice to see that many other countries are beginning to embrace the fact that nursing in these areas is quite different. sadly, canadian rural nursing lost one of its greatest supporters in march, 2004, when dr. elizabeth thomlinson passed away. dr. thomlinson, associate dean of online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 3 undergraduate studies at the university of calgary, had worked extensively as a rural nurse prior to transferring her expertise to the university. dr. thomlinson was instrumental in establishing the rural and remote health research group at the university and chaired the first two biennial conferences. a rural nursing student scholarship has been established in her name at the university of calgary. this scholarship will be awarded to a student who demonstrates a keen interest in rural nursing and health care. it is intended to assist students in offsetting costs when on a rural practicum experience and to help in promoting rural nursing as a practice choice. sometimes it seems that change moves very slowly, but sometimes that sense is only an illusion. as i reflect over the events of the past few months, i realize that rural nursing in canada is advancing more quickly than it sometimes appears. until a few years ago, rural nurses were often considered to be in a subordinate position to their urban counterparts. this is changing. canadian rural nursing is in a renaissance stage with many advances, some false starts but clearly with the best yet to come. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 editorial 3 editorial report from australia desley hegney editorial board member the major bi-annual rural health conference has just been completed in alice springs, northern territory, australia. this multi-disciplinary conference is the key rural conference and organised by the national rural health alliance. approximately 900 people attend these conferences, making it a very large conference by australian standards. this conference, like many others, had many meetings of many interest groups and associations organized around the three days. importantly the national health and medical research council (nhmrc), the peak research body for health and medical research in australia, ran a workshop to gather information on how rural health research could be improved. the majority of the attendees noted that while the nhmrc has broadened its research interests in the past, that there is still a focus on rcts and that the research outcomes that could be achieved by methods that build capacity (like action research) within communities should have a higher priority. there is always a good mix of people attending the conference. this year, similar to previous conferences, there were clinicians, academics, bureaucrats and very importantly, students. it is at these conferences that recommendations are made by the delegates that then drive the work of the national rural health conference for the next two years. many policy changes have come from the floor of this conference. i urge you to think about coming to this conference in 2007. dr. martha mcleod was a welcome visitor to the conference. prior to her leaving for alice springs she visited me here in toowoomba and then spent some time at ipswich hospital. after the conference she spent some time with professor karen francis at monash university in victoria. it is wonderful meeting with our international nursing colleagues there. often we are so isolated in australia – it is a long way to come to north america to talk, face-to-face, with our colleagues. it is always interesting to visit other health services in other countries and see how health care is delivered. there is some concern in australia at present that the current university training system may be under threat. in australia we have two tiers of higher education providers – the universities and the technical and further education providers (know as tafe). the latter provide education for the enrolled nurses (ens) and the former is where all the registered nurses (rns) are now educated. tafe programs are usually competency focused and most of what we call “trades” (electricians, plumbers, hairdressers and so on) people are educated through tafe programs. tafe’s are beginning to explore ways of articulating their en program to an rn program without nurses leaving the tafe system. if this went ahead the outcome could be that universities would offer only postgraduate programs. it would put us back 20 years to a system where nurses are educated in a lesser system than other health professionals. as you can imagine, it is unlikely that australian nurses will quietly let rn education be lost from the university to the tafe sector. it is a model, however, that would be very attractive to rural people, especially if the en to rn online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 4 conversion program were offered through a flexible delivery platform, thus allowing the student to remain in their community whilst they upgraded their qualifications. in my wanderings around australian rural communities, i often hear how rural people would like to revert to a program where nurses can be “trained” in the local hospital. as they acknowledge, once people leave rural communities it is very hard to attract them back. i have just returned from a visit to ireland where i attended the royal college of nursing’s international research conference in belfast. i found it very interesting to visit the irish countryside (it was so like i expected it to be) and to talk to irish nurses about health service delivery in rural ireland. of course, being an australian it was almost like being at home. all of the irish people i met knew as soon as i spoke i was australian, and many knew of toowoomba and most had been to australia or had relatives in australia. the irish, of course, made up a large proportion of australia’s early white settlers and they have largely influenced what we think of as the “australian culture.” i envied the irish their four-year nursing preparation program. we have tried so hard in australia to have a four-year degree and have never been able to convince the australian government, who believe that three years is sufficient. as we come into winter again, we hope that our international colleagues will pray for rain here in the areas of drought-stricken australia. in toowoomba our dams are down to 35% of their capacity and the town of 100,000 people is experiencing severe water restrictions. however we are not alone – much of rural australia is again in the grip of drought. it is really distressing to see trees dying for lack of rain. many rural people have had no crops for the last three years. i was talking to a friend who manages a large property in new south wales and he said that he cannot imagine how they will go through a third year of drought. no crops – no stock and very little drinking water. this is now the most urgent of issues facing us all here in australia – how we live on the driest continent in the world and how we have, until recently, not focused on preparing for the hard times. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 editorial 7 editorial communicating with mexican-american clients bette ide, phd, rn editorial board member this is the first of a series of three columns on communication and care in regard to mexican-american clients. dr. loretta heuer, associate professor at the university of north dakota, works and does research with migrant mexican-american farm workers. she offers some suggestions to help rural nurses in their communication with those clients. out of respect, mexican americans frequently avoid direct eye contact with authority figures such as health care providers, particularly if they may perceive the provider to differ in class from themselves. communication is strongly influenced by "respecto" (respect), which family members may demonstrate by standing when the provider enters the room. mexican americans are usually very warm and expressive with family and close friends, and embracing is common. touch by strangers is generally unappreciated and can be very stressful or perceived as disrespectful. silence sometimes shows lack of agreement with the plan of care. nevertheless, handshaking is considered polite and usually welcome. tone of voice should be respectful and polite, although it is usually reserved in the formal setting. phrases used are frequently complimentary. it is considered respectful to address individuals formally; the formal spanish "usted" should be used, especially with elders and married women. children should be included in introductions. with the establishment of rapport over time, providers may be permitted to be less formal. mexican americans are traditionally present-oriented, with social time more present-oriented than business time. in fact, time is viewed as relative to the situation (which allows for their feeling of punctuality even when 15-20 minutes late). the most sensitive issues, including health issues, are kept within the family, and immediate family members may serve as referents for individual concerns. males disclose less often, and self-disclosure to the same gender individuals is usually more comfortable. the next issue’s column will focus on the various issues involved in using or not using an interpreter. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 rural boundariesstudent perspective 36 the relationship between nurse to population ratio and population density: a pilot study in a rural/frontier state jeri l. bigbee, phd, aprn, bc, faan1 1jody demeyer endowed professor, department of nursing, boise state university, jeribigbee@boisestate.edu key words: rural, frontier, nurse-to-population ratio, population density abstract the purpose of this study was to evaluate the relationship between nurse to population ratio and population density. a secondary analysis was conducted, correlating nurse to population data with county-based population density data. the sample consisted of all 17 counties in the state of nevada (3 urban, 4 rural and 10 frontier). county nurse to population ratios ranged from 178 to 861 per 100,000 population and population density ranged from 0.3 to 173.9 people per square mile (mean of 39.3). correlational analysis indicated a significant positive relationship between nurse to population ratio and population density (r = .65 (p <.005). mean nurse to population ratios were found to be significantly different between frontier (356/100,000), rural (682/100,000), and urban (587/100,000) counties (f = 7.53, p =.006). not surprisingly, the results indicated that the lowest nurse to population ratios occur in areas with the lowest population density. these findings provide rural and frontier nurses with support in advocating for aggressive strategies to address the nurse to population disparity affecting rural and frontier communities. introduction the current global nursing shortage represents one of the most serious challenges facing health care today. since 2002, the nursing shortage has been identified as a “global crisis” (oulton, 2006). nursing shortages have been an ongoing challenge in rural and frontier communities, however limited research to date has explored the unique characteristics, consequences and implications of rural nursing shortages. review of the literature a predominant variable in nursing workforce research and policy discussions is nurse to population ratio. international research addressing nurse to population ratios has demonstrated a wide variance across countries. in 1993, the world bank recommended a minimum recommended ratio of nurses to population at .2/1000 population (20/100,000). robinson and wharrad’s research (wharrad & robinson, 1999; robinson & wharrad, 2000) using a global data set derived from united nations sources, including 147 countries, indicated that nurse to population ranged from a low of .03/1000 population in chad and rwanda to 16.4/1000 in angola and norway (us = 7/1000). globally, 40% of the variance in the nurse to population ratio was explained by the gnp per capita and the distribution of nurses was strongly correlated with the distribution of physicians (r =.84, p <.0001). international studies such as these, however, are limited by the fact that there is no global standard definition of “registered” nurse (robinson & wharrad, 2000). the online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 http://nursing.boisestate.edu/home.asp mailto:jeribigbee@boisestate.edu 37 international studies have also not addressed nurse to population ratio in relation population density or rural/urban differences. recent research, however, in canada has addressed rural/urban considerations related to the canadian nursing workforce. pitblado (2005) and his associates report that 17.9% of canadian nurses work in rural areas, but 21.7% of the total population are rural residents. the canadian nurse to population ratio in 2000 in rural areas was 62.3 per 10,000 compared with the urban ratio of 78.0. geographically, the canadian nurse-topopulation ratios decrease from east to west. this study also indicted that rural canadian nurses had lower levels of education both at practice entry and throughout their careers as compared with their urban colleagues, which is consistent with studies in other countries (kulig, 2005). they also found that rural canadian nurses are more likely to have multiple employers and work in non-hospital settings than urban nurses. nurse to population ratio in the u.s. in the united states, according to the most recent national sample survey of registered nurses, conducted in march 2004, there were an estimated 2.9 million registered nurses. the national ratio of employed nurses per 100,000 population (the nurse to population ratio) as of march 2004 was 825, increased from 782 in 2000. historically, the nurse to population ratio in the us has increased from 436/100,000 in the 1970’s to 638 in the 1980’s and 720 between 1990 and 1996 (shih, 1999). new england and the middle atlantic regions consistently have the highest nurse to population ratios, while the pacific, west north central, and south atlantic regions have historically had the lowest nurse to population ratios (shih, 1999). according to the national center for health workforce analysis (2004), in 2000 the national supply of full time equivalent registered nurses was estimated at 1.89 million while the demand was estimated at 2 million, a shortage of 110,800 (6%). by 2010 that shortage is estimated to reach 17%, 27% by 2015, and an alarming 36% by 2020. in rural and frontier areas of the u.s., the current nursing shortage is particularly acute, because it has just exacerbated long standing nursing shortages that have plagued those communities for decades (lasala, 2000; stratton, dunkin, & juhl, 1995). movassaghi and his associates (movassaghi, kindig, juhl, & geller, 1992) examined the 1988 national sample survey of registered nurses and found the nurse to population ratio (using work location) to be 726/100,000 in metropolitan areas, compared to 385 in rural areas. when rural areas were examined in more depth, the nurse to population ratio was found to be 448 in counties with populations of 25,000 to 50,000, 319 in counties with 10,000 to 25,000 and 349 in counties with less than 10,000. thus, the nurse to population ratio in the most rural areas (counties with less than 25,000 residents) was less than half of the ratio in metropolitan areas. this stratification of rural areas failed to take into account the geographic size of counties, thus did not truly reflect population density, only population size. additional findings from this study indicated that rural nurses had lower educational levels than urban nurses and a higher percentage of rural nurses worked outside of hospitals, especially public health and nursing homes. more recently, skillman, palazzo, keepnews and hart’s (2006) research using the 2000 national sample survey of registered nurses found that 20.8% of rns in the us lived in rural areas, including 9.2% in large rural, 6.7% in small rural, and 4.9% in online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 38 isolated rural areas, which approximated the general population distribution. the nurse to population ratios in urban and large rural areas (by residence) were similar (830 and 794/100,000), but declined significantly in small rural and isolated small rural areas (723 and 719/100,000), similar to movassaghi’s earlier findings. these disparities in nurse to population ratios based on population size were found to be even more pronounced when location of employment rather than location of residence was considered. the nurse to population ratio per 100,000 population (by location of employment) was 836 in large rural, 679 in small rural and 411 in isolated small rural areas as compared with 839 in urban areas. these findings indicated that a significant proportion of nurses living particularly in the most rural areas commute to jobs in urban areas. the average age for rural nurses was 43.1 years, which was similar to urban nurses (43.4 years), however the average age increased slightly as rurality increased. this study also indicated that rural nurses had significantly lower levels of education, with 32.2% of rural nurses holding a baccalaureate or higher degree versus 46.6% of urban nurses. the more rural the nurses were, the lower their educational levels. this study also found that rural nurses earned 14 to 18% less than urban nurses, with salary declining with increasing rurality. rural nurses were also more likely to work full-time and in non-hospital settings, particularly public/community health settings, a trend again that increased with increasing rurality. unlike previous studies, this study used zip code (ruca) coding in designating rurality, rather than the more traditional county-based designations. this method is advantageous in that it provides more precise differentiation of rural areas, especially in counties with a mixture of rural and urban areas. the use of the national sample survey data has the advantage of providing nationwide data that can be compared with previous survey results. however the data are based on sample data, and underrepresentation of nurses located in very rural areas may occur (bigbee & lind, 2007). the variable of population density again was not addressed directly in this study, but was somewhat reflected in the ruca coding of rurality. purpose and conceptual framework thus, no research to date has specifically addressed nurse to population ratio in relation to the specific variable of population density. it may be argued that comparing rural/urban differences indirectly addresses population density, however, this is a relatively rough measure at a categorical level that fails to capture the unique challenges of populations living in very sparsely populated areas. thus, the purpose of this study was to evaluate the relationship between nurse to population ratio and population density using counties as the unit of analysis. the concept of “nurse dose” served as the theoretical framework for the study. brooten and youngblut (2006) recently proposed this concept, which includes three components: dose, nurse, and host response. they define “dose” as the number of nurses or amount of care given by nurses; “nurse” as the education, expertise, and experience of the nurse; and “host response” as the response of the patient or organization to the nurse’s care. current research, most of which is hospital-based, has demonstrated that “differing nurse doses have been associated with both increases and decreases in patient mortality, morbidity, and health costs” (p.94). brooten and youngblut contend that in the macro view, nurse to population ratios related to geographic areas are consistent with their conceptual model. (in the macro view, online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 39 “dose” is the number of nurses per capita, and “host” could be a community, a hospital, or another health care organization.) however, community-oriented population-based studies addressing the concept of nurse dose are extremely limited and no studies have specifically addressed the nurse dose concept in relation to rurality. two research questions were addressed in this pilot study: 1. what is the relationship between nurse to population ratio and county population density? 2. are there significant differences in nurse to population ratios between urban, rural and frontier counties? methodology a correlational secondary analysis was conducted, examining nurse to population data in relation to county-based population density in the state of nevada, which is an ideal setting to study nurse to population ratios, particularly in relation to rural and frontier areas. between 1990 and 2000 the population of the state increased 69% to approximately 2 million, and the explosive growth has continued since then, making it one of the fastest growing states in the nation. not surprisingly, nevada is currently experiencing one of the most critical nursing shortages in the u.s. according to the 2000 national sample survey of registered nurses, there were an estimated 12,940 registered nurses in nevada in 2000 (increasing to 16,206 in 2004). as a result, nevada held the dubious distinction of having the worst nurse-to-population ratio in the nation, 520/100,000, as compared with the national average of 782 in 2000. nevada’s nurse to population ratio increased to 604/100,000, compared with the national ratio of 825/100,000 in 2004, which made it second worst in the nation above california at 590/100,000. the national center for health workforce analysis (2004) predicted a nevada nursing shortage of 12% in 2000, 23% in 2005, 31% in 2010, 41% in 2015, and 50% in 2020. the sample consisted of all 17 counties in the state of nevada, including three urban, four rural and ten frontier counties. rural counties were defined as counties with no metropolitan statistical area, and frontier counties were defined as those counties with population densities of less than seven persons/square mile. nevada ranks second only to alaska among u.s. states for having the highest percentage of frontier counties. the nurse-to-population ratios by county were drawn from the nursing workforce and nursing education in nevada report (packham, 2003) based on 1999 data from the nevada state board of nursing and population estimates from the nevada state demographer's office. thus the complete dataset (not a sample) of nevada nurses was used, ensuring a more accurate count particularly of nurses in rural and frontier areas. the location of the nurses was classified by residence only (not location of employment). the county population density data were calculated using county land area data and population estimates from the same time period obtained from the nevada state demographer’s office. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 40 results descriptive analysis revealed that county-level nurse to population ratios ranged from 178 to 861 per 100,000 population with a mean of 473. fifteen of the state’s 17 counties (89%) had nurse to population ratios below the national average of 782 per 100,000 population. looking specifically at the 14 rural and frontier counties, the nurse to population ratio was below the national average in all but one county. all of the frontier counties were also below the overall state average. county population density ranged from 0.3 to 173.9 persons/square mile with a mean of 39.3 and a median of 1.8 persons/square mile. this skewed distribution is consistent with the predominance of rural and frontier counties in the state. in addressing the first research question regarding the relationship between county-based nurse to population ratio and population density, a two-tailed pearson’s correlational analysis was conducted. the results indicated a significant positive relationship between nurse to population ratio and population density (r = .65, p <.005). in light of the international data that has demonstrated a strong link between nurse and physician distribution, a follow-up correlational analysis including physician to population ratio was performed. these results indicated that neither the relationship between population density and physician to population ratio (r = .33, p > .05), nor the relationship between nurse to population ratio and physician to population ratio (r = .33, p > .05), were statistically significant, which is in contrast to some previous international findings. to compare the nurse to population ratios in the urban, rural and frontier counties (research question two), an analysis of variance was conducted. the results revealed significant differences in the mean nurse to population ratios between the frontier (356/100,000), rural (682/100,000), and urban (587/100,000) (f = 7.53, p =.006) counties. the slightly higher rural ratio can be explained by the relatively few rural counties included (4) and the recent rapid growth of the state’s urban counties. in light of the small number of counties and the unequal distribution between the urban, rural, and frontier categories, a non-parametric kruskal wallis test of difference was conducted and the results again indicated a significant difference between the three groups (chi2 7.043, p=.030). discussion in light of the current global nursing shortage the results of this pilot study are highly relevant in assessing the distribution of nursing professionals, particularly in rural and frontier areas. the findings indicate that nurse to population ratio is positively related to population density and that frontier counties have significantly lower nurse to population ratios than rural or urban counties, which is not surprising given the chronic nursing shortages that plague many rural and frontier areas. these findings, based on a relatively small state population, suggest that the nursing shortage is most acute in those areas with the lowest population densities. these results provide additional evidence related to the chronic rural nursing shortage which can be used in advocacy efforts addressing nurse recruitment and retention efforts, particularly in areas with the lowest population density. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 41 limitations and research implications this study was limited by the small sample of counties drawn from only one unique state. in addition, nurse to population ratios in counties with very small populations must be interpreted cautiously due to the effect of small numbers. for example, if 10 nurses live in a rural county with a population of 3,000, the nurse to population ratio is 333/100,000. if only three additional nurses move into this county, the nurse to population ratio jumps to 433/100,000. calculating the nurse to population ratio based on 1000 population rather than 100,000 is arguably more appropriate in this setting but limits the comparability with national data. the fact that data related to nurses’ location of employment was not included also represents a significant limitation. further research is indicated using more current data with larger samples, addressing both location of nurse residence and employment, to elucidate the relationship between nurse to population ratio and population density in greater depth. it is essential, however, that the variable of nurse to population ratio be viewed within the larger context. this perspective is emphasized by the canadian nursing workforce researchers who stress that geographic factors, such as distance and isolation, as well as unique practice patterns must also be considered when assessing the rural nursing workforce (pitblado, 2005). further international research is also indicated, examining nurse to population ratios in relation to population density and rural/urban differences, within and between developed and developing nations. the results of this pilot study also support the “nurse dose” concept as a useful theoretical approach for the study of nurse to population ratios and nursing workforce dynamics in general. this study primarily addressed the “dose” aspect of the concept. further research addressing the entire concept, including the “nurse” and “host response” aspects, in relation to nurse to population ratio is indicated to fully assess the theoretical utility of the concept at the macro level. specifically assessing community health outcomes as related to nurse to population ratios would be particularly relevant to building the empirical basis for this newly developed conceptual approach. practice, education and policy implications implications for rural practice and policy include the need for increased emphasis on nurse recruitment and retention in rural and frontier areas. aggressive strategies to address the chronic disparities in nurse to population ratios affecting frontier and some rural communities are particularly needed, including creative incentives to attract and retain professional nurses to live and work in the most remote communities. greater emphasis on creative approaches to educating nurses specifically for rural and frontier practice is also indicated. it is critical that these strategies be shared among the international nursing community to address the rural nursing shortage from a truly global perspective. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 42 references bigbee, j.l., & lind, b. (2007). methodological challenges in rural and frontier nursing research. applied nursing research, 20, 104-106. [medline] brooten, d., & youngblut, j.m. (2006). nurse dose as a concept. journal of nursing scholarship, 38(1), 94-99. [medline] department of health and human services health resources and services administration. (2006). preliminary findings: 2004 national sample survey of registered nurses. accessed october 6, 2007 at http://bhpr.hrsa.gov/healthworkforcereports/rnpopulation/preliminaryfindings.htm department of health and human services, health resources and services administration, bureau of health professions, national center for health workforce analysis. (2004). what is behind hrsa’s projected supply, demand, and shortage of registered nurses? washington, d.c. accessed october 6, 2007 at ftp://ftp.hrsa.gov/bhpr/workforce/behindshortage.pdf department of health and human services health resources and services administration. (2002). 2000 national sample survey of registered nurses. accessed october 6, 2007 at http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/rnss1.htm kulig, j. (2005, may). what educational preparation do nurses need for practice in rural and remote canada? the nature of rural and remote nursing, 2. accessed october 6, 2007 at http://www.ruralnursing.unbc.ca/factsheet2.pdf lasala, k.b. (2000). nursing workforce issues in rural and urban settings – looking at the difference in recruitment, retention, and distribution. online journal of rural nursing and health care, 1(1), 8-17. accessed october 6, 2007 at http://www.rno.org/journal/index.php/online-journal/article/viewfile/63/62 movassaghi, h., kindig, d.a., juhl, n.j., & geller, j.m. (1992). nursing supply and characteristics in the nonmetroplitan areas of the united states: findings from the 1988 national sample survey of registered nurses. journal of rural health, 8(4), 276-282. [medline] oulton, j.a. (2006). the global nursing shortage: an overview of issues and actions. policy, politics & nursing practice, 7(3), 34s-39s. [medline] packham, j.f. (2003). the nursing workforce supply and demand in nevada 2000 to 2020. reno, nv: high sierra ahec. (hs ahec report no. 03-01). pitblado, j.r. (2005, april). how many registered nurses are there in rural and remote canada? the nature of rural and remote nursing, 1. accessed october 6, 2007 at http://www.ruralnursing.unbc.ca/factsheet1.pdf robinson, j., & wharrad, h. (2000). invisible nursing: exploring health outcomes at a global level: relationships between infant and under-5 mortality rates and the distribution of health professionals, gnp per capita, and female literacy. journal of advanced nursing, 32(1), 28-40. [medline] shih, y.t. (1999). growth and geographic distribution of selected health professions, 1971-1996. journal of allied health, 28(2), 61-70. [medline] online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=17481476%5buid%5d&webenv=0h3hagsgsrjasemnuvha9plvptd8qtstra3orn46vhw1-luas_utwj1gxzms7jugd7am9hxl85hapb%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16579330%5buid%5d&webenv=00v1wtd5bsrqlyleve2simzwuypkjw43ibu77gktgcicxoayoskk9rixgkhgjcmd3uc0zfzizo-moq%4026424f0f76980320_0050sid&webenvrq=1 http://bhpr.hrsa.gov/healthworkforcereports/rnpopulation/preliminaryfindings.htm ftp://ftp.hrsa.gov/bhpr/workforce/behindshortage.pdf http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/rnss1.htm http://www.ruralnursing.unbc.ca/factsheet2.pdf http://www.rno.org/journal/index.php/online-journal/article/viewfile/63/62 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10122982%5buid%5d&webenv=0fkda-9fvzol4-gwete9lljejb9xyvbc2d1udb77v0r0ykl-c4v0ln2_pvhgaikx2lntqc-fzohbzw%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=17071693%5buid%5d&webenv=0kx4p85a25qcj6bcdtt8dxcftplw4jvo7bv_xucqsf1dyhij1s-xiedsyq5my8-q7jb60popsm6yxv%4026424f0f76980320_0050sid&webenvrq=1 http://www.ruralnursing.unbc.ca/factsheet1.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10886432%5buid%5d&webenv=0mzncb8_x9mmoiqtyq7lx6uuqlssog8d-aj5hw_5dllng9ornlwbitac0gla-shchhqo1k6hp1see1%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10389049%5buid%5d&webenv=0go7goypzjrdxbi_-scf3tobwmbixnnrayincu7tiikul03tzpb6lxm3kl0bcmwdzf8ns-svpovzun%4026424f0f76980320_0050sid&webenvrq=1 online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 43 skillman, s.m., palazzo, l., keepnews, d., & hart, l.g. (2006). characteristics of registered nurses in rural versus urban areas: implications for strategies to alleviate nursing shortages in the united states. journal of rural health, 22(2), 151-157. [medline] stratton, t.d., dunkin, j.w., & juhl, n. (1995). redefining the nursing shortage: a rural perspective. nursing outlook, 43(2), 71-77. [medline] wharrad, h., & robinson, j. (1999). the global distribution of physicians and nurses. journal of advanced nursing, 30(1), 109-120. [medline] world bank. (1993). world development report 1993: investing in health. new york: oxford university press. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16606427%5buid%5d&webenv=0myml5lhvtnxrdxhoj5i7zf6jbqo8htwmqxfa2-i8d1xo0hwfb_erluxzrhz0woclmjk0qwty5rmlq%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7753645%5buid%5d&webenv=0ywu3zosromf6osh5rkdcaactpaxyu0hpvq7b_mxomucbjtupztqujf4uu1ogvvavpqs1jiqqufqfz%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10403987%5buid%5d&webenv=0om1ndk6sbm13y7mel8ddqqbdhxvxwuuk9gxbvav5tsklgq8h9gur26iciknfa__q9e6blbvlycc9e%4026424f0f76980320_0050sid&webenvrq=1 editorial 5 editorial nursing care of rural children with special health care needs (cshcn) mary m. wright, ph.d., rn guest columnist assistant professor, college of nursing university of north dakota va national survey of children with special health care needs conducted in 2001 estimated that there are 9.4 million children who have special health care needs. this represents an estimated 12.8 percent of the children in the united states. the definition of children with special health care needs (cschn) was developed by the federal maternal child health bureau and states that children with special health care needs are those who have, or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required generally (van dyck, p,, kogan, m., mcpherson, m., wessman, g., & newacheck, p., 2004). in providing nursing care, rural nurses can identify and classify cshcn by the impact on the child’s condition or functional ability. in this classification, nurses can look at whether the special needs a) sometimes affect the child’s functional abilities and activities, b) usually or always affect the cshcn, or c) never affect functional abilities and activities. nearly 40% of cshcn never have their activities affected by their special needs – however, 60% of cshcn have their functional ability affected and as a result are in need of adaptations and services in their community or by referral to a specialty site. there are specific challenges for nurses who care for these children in rural settings. the first challenge or barrier to care is access to care. accessibility is a great concern, for both primary care and specialty care. the use of a “medical home” for coordinated, comprehensive care is highly recommended and endorsed both by the american academy of pediatrics (http://www.aap.org/advocacy/archives/julymedhome.htm) and also within the objectives of health people 2010 (keefe, 2001). in the medical home model, the nurse helps to coordinate visit scheduling and communication between families and providers as they use services in primary and specialty care. another aspect of the medical home concept is the use of a portable care plan that lists patient history, treatment plan and goals. updating and assisting the family as they communicate the care plan to other providers and caregivers is also an aspect of nursing care in the medical home model. transportation issues and availability of services are barriers linked to access to care as the nurse tries to locate and schedule several services. another major barrier for the family is the financial and personal demands when caring for a cshcn. poverty is common in rural areas and the child with special needs adds financial cost and may also lessen the amount of time available for employment. awareness and acknowledgement of these issues by the nurse is the first step to accessing online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://www.aap.org/advocacy/archives/julymedhome.htm 6 and coordinating available services and dealing with the frustration of the family members. another setting for nursing care of the cshcn is the school system as they progress in their education and make the transition from school to employment and/or residential living. again, the nurse is essential for helping the young adult to navigate and use medical and community services. this includes the team meetings, such as the 504 or iep (individual educational plan) within the school setting. the rural nurse needs to educate and advocate for the child and have a good understanding of which community services may provide health care support as the student and teachers work toward meeting educational goals. rural nursing provides the opportunity for a close, professional relationship between the nurse, child and the family. the model of familycentered care is the result of a productive, close, professional relationship. the federal maternal and child health bureau division of services for children with special health needs defines family centered care as: family-centered care assures the health and well-being of children and their families through a respectful family-professional partnership. it honors the strengths, cultures, traditions and expertise that everyone brings to the relationship. family-centered care is the standard of practice which results in high quality services. each stage of the cshcn life presents challenges that the rural nurse can help the family navigate, building their decision making ability and their awareness and utilization of services (national center for family-centered care, 1989). the nurse assists the providers and families to recognize and provide for the developmental, emotional and recreational needs of the child, rather than focusing only on the episodic difficulties or illnesses. the partnership of family-centered care helps all to work in the child’s best interest and foster optimal health and development despite any disability. the future of rural nursing of cshcn and their families will include more technology and questions about adult and elder care. equally important is the need to gather and share information that can be developed into health care policy and evidence based practices so that rural nurses can advocate for cshcn and work with providers and families to promote family centered-care. references national center for family-centered care. (1989). family-centered care for children with special health care needs. bethesda, md: association for the care of children’s health. o’keefe, l., (2001). healthy people 2010 helping special needs kids. aap news, 19, 93100. van dyck, p.c., kogan, m.d., mcpherson, m.g., wessman, g.r., & newacheck, p.w. (2004). prevalence and characteristics of children with special health care needs. archives of pediatrics and adolescent medicine, 158, 884-890. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 47 screening for violence against women in a rural health care clinic sharon m. coyer, phd, cpnp, apn1 donna j. plonczynski, phd, fnp, apn2 karen b. baldwin, phd, rn3 patricia g. fox, phd, faan4 1 assistant professor, school of nursing, northern illinois university, norahsmedc@aol.com 2 assistant professor, school of nursing, northern illinois university, djplonz@niu.edu 3 assistant professor, school of nursing, northern illinois university, kbbatniu@aol.com 4 associate professor, school of nursing, northern illinois university, pfox@niu.edu keywords: women’s health, domestic violence, family violence, intimate partner violence, primary care screening abstract the purpose of this study was to compare the incidence of violence against women served at a rural health care center after introducing a violence screening protocol. all women 18-years and older who were served in the clinic in a one-year period (n=1690) were asked about episodes of violence. the number of positives responses was assessed in a retrospective chart review of all women’s charts seen in the clinic before and after an educational intervention and screening protocol were added to the intake procedures. previous to the intervention, no charts of women were identified who reported current violent against them. a second retrospective chart review was conducted after the intervention. six women were identified and referred to support agencies for violence against them. the investigators concluded that education of staff and adding the screening protocol about violence against women visits can increase the ability to identify violence against women. introduction violence against women is the most common source of injury to women. violence against women affects 1 to 4 million women in the united states each year (asher, crespo & sugg, 2001). however, the true incidence of violence may be low because most violence does not come to the attention of health care providers or the legal system (zust, 2000). the problem of violence against women occurs among women of all racial and ethnic groups, educational backgrounds and income levels. the issues of violence against women are receiving increased attention by government services and researchers (tjaden & thoennes, 2000). healthy people 2010 goals include reduction of the rates of physical violence between intimate partners, sexual assault without rape, rape and attempted rape (united states department of health and human services, 2000). yet, there is little research describing the issues of violence against women living in rural areas (ulbrich & stockdale, 2002). in violence against women physical abuse is often accompanied by sexual and psychological abuse. although physical violence may be more readily identified, women who have experienced physical violence often report that the psychological and emotional abuse were far more damaging (zust, 2000). many women in violent online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.chhs.niu.edu/nursing/ mailto:norahsmedc@aol.com http://www.chhs.niu.edu/nursing/ mailto:djplonz@niu.edu http://www.chhs.niu.edu/nursing/ mailto:kbbatniu@aol.com http://www.chhs.niu.edu/nursing/ mailto:pfox@niu.edu 48 situations do not want to be seen by health care providers to avoid the shame of their physical, psychological or sexual abuse. often they use several different emergency rooms, miss office visits and move among health care providers. vague, chronic symptoms, somatic complaints, depression and anxiety may be the symptoms a woman will most often discuss with her health care provider, rather than admitting to violence in her home (asher et al. 2001; dienemann, boyle, baker, resnick, wiederhorn & campbell, 2000). health providers may be aware of the obvious signs and symptoms of physical violence. multiple injuries are usually present and often appear on the upper extremities when women are trying to defend themselves. other sites of frequent injuries are on the abdomen, back, head, neck, face, breast, or genitals, but physical signs may not be apparent (asher et al. 2001). health care providers need to recognize that women may not be ready to report the problem so the abuser may not easily be identified. developing methods for screening all women for violence is essential to address the needs of abused women, yet most primary health care clinics do not screen for violence against women (asher et al. 2001; campbell, 1998). the purpose of this study was to identify the incidence of violence against women before and after the introduction of a screening protocol on a health intake form in a nurse managed rural health care clinic. violence against women was defined as intimate partner violence or domestic violence. review of the literature issues of violence against women in rural communities there are few studies of violence against women in rural communities (ulbrich & stockdale, 2002). websdale (1998) conducted an ethnographic study through interviewing battered women (n=50) living in rural kentucky. he also interviewed other service providers for battered women (n=46) including police officers, judges, social workers and domestic violence shelter personnel. although the types of violence women reported in this study were not different than the violence experienced by women living in urban areas, there were issues of physical isolation, social isolation, and the use of guns and knives that were unique to violence against women living in rural areas. physical isolation is the most significant difference between women living in urban rather than rural areas (ulbrich & stockdale, 2002). women living in rural communities are often isolated from neighbors and friends. sources of immediate help in a crisis are not readily available. rural areas lack public transportation and taxis, forcing the woman to depend on a car to leave the abusive environment. yet to leave the abuser may be difficult when a car is not available, or the car keys are lost, or hidden by the abuser. physical isolation may mean that the distances to health facilities may be as far as 20 to 30 minutes away by car. telephones are present in most homes in urban areas, but telephone service may be limited in a rural area. domestic violence abuse centers may not be readily available. treatment programs and services for psychological counseling are limited in rural areas (adler, 1996; websdale, 1998). the second issue impacting violence for women living in rural areas is social isolation. women hesitate to contact hot line numbers because a relative or friend of the abuser may be staffing the hot line. humiliation and fear are concerns for women who are online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 49 in violent situations, but the fear of contacting sources of help and not having an assurance of safety, makes it very difficult for the woman to seek help. social isolation can keep her away from church and community centers that could provide assistance. abusers may prevent women from having friends and close relationships with family members or access to agents of the state such as police officers, social workers and health care providers (adler, 1996). in industries that are seasonal, an abuser may be out of work for long periods of time allowing him/or her to watch every activity in the home making it difficult to have privacy or to contact help (websdale, 1998; ulbrich & stockdale, 2002). the third issue of violence against women living in rural areas is that firearms are often present in the home (adler, 1996; websdale, 1998). the rate of homicide is lower in rural communities, but the use of guns and knives in threatening exchanges toward women is higher. physical isolation, social isolation, and the increase use of guns and knives in violence against women contribute to unique issues for women living in rural communities. research is needed to determine the ways to identify and support women living in rural areas who are threatened by violence (websdale, 1998; ulbrich & stockdale, 2002). screening for violence against women the violence against women act in 1994 increased the level of screening for violence toward women in emergency rooms, primary care services and clinics (dienemann et al. 2000; ulbrich & stockdale, 2002). multiple health care settings should also screen women for violence. general practice offices, prenatal services and pediatric health care services all have the ability to screen for violence (amiel & health, 2003). in a retrospective chart audit of community health centers, magnussen et al. (2004) found that 31 (9%) of 337 charts had documentation of intimate partner violence. screening for violence has been suggested by many professional organizations. the american medical society and the american academy of pediatrics have supported using screening methods to detect violence (borowsky & ireland, 2002; calonge, 2004). clinical guidelines for nurse practitioners recommend screening for violence through health assessment questions and physical examination of the patient (uphold & graham, 2003). screening tools have been used to identify violence against women but at present no consistency exists regarding which tools to use for screening. most tools do not have established reliability and validity (furbee, sikora, william & derek, 1998; nelson, nygen, mcinerney & klein, 2004). though professional organizations and clinical guidelines suggest screening for violence against women, analysis of studies have indicated that screening does not routinely occur in most pediatric and family physician’s practices, primary care clinics and health care facilities (borowsky & ireland, 2002). the most common reasons stated by health professional for not screening is that they lack education and skills for addressing violence against women (mccarney & mckibbon, 2003). not all health professionals have received education regarding violence against women (heinzer & krim, 2002). understanding physical and sexual abusive outcomes are obvious to most practitioners, but the psychological components of this relationship are not immediately evident (wingood, diclemente & raj, 2000). online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 50 research questions and purpose this study was conducted to determine if adding a screening protocol into a primary health care clinic would increase the identification of violence against women. the purpose of this study was to compare the incidence rates of violence against women for women 18-years or older served at a nurse managed rural health care clinic. institutional review board (irb) approval was obtained for the pretest and posttest procedures of the study. anonymity was essential since calling women who were at risk for family violence at their homes to obtain consent for the chart review may put them in greater danger of physical or emotional harm. design and methods the investigators used a quasi-experimental pretest-posttest intervention design. a pre-test was conducted using a retrospective chart audit. the chart audit (n=1690) was conducted through a computer search of the medical records of all women seen at the clinic from january 1, 2000 to december 31, 2000. a second retrospective chart audit (n= 859) evaluated the incidence of violence against women identified after introducing an educational program in 2001 to the staff and adding a screening question to the intake procedures. the pretest study was conducted to determine the incidence of violence against women encountered in a rural community health care clinic. the clinic was located in a rural midwest county and serves women through both scheduled and same-day appointments. the clinic was staffed by nurse practitioners that served families in three rural counties. the computerized medical record database allowed the investigators to complete a text word search to identify women over 18-years-of age that had been seen at the clinic. charts of women served during 2000 were reviewed for patient characteristics documented in the progress notes. the search words were: abuse, rape, assault, battery, altercation, fight, argument and domestic violence. no charts were located in this search that identified women who were treated or referred for episodes of violence directed toward them. a further informal inquiry of the nurse practitioners was done to determine if they remembered any client they had referred to violence counseling in the year. no clients were identified for abuse during the time of the assessment by the nurse practitioners. the investigators discussed the results of the study with the clinic staff to begin the intervention phase of the study. after determining that no women with violence episodes were identified in the medical records for the previous year, the staff at the clinic discussed the need for appropriate care for these patients, starting with identification. after repeated discussions, the staff members identified a need for improving their knowledge of local community resources. due to staff interest, two local agencies that support women in violent situations in-serviced the members of the clinic in order to provide background information, local statistics, resources available and the processes for referrals. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 51 procedures the history form given to all patients seen at the clinic was modified to include ‘abuse’ in the list with other identified health risks, such as hypertension. in addition, all women over the age of 18 years of age were personally asked, ‘is anyone hurting you?’ during the intake process of every visit. policies on how to manage patients responding ‘yes’ to the question were developed and all the staff members were in-serviced accordingly. the question was added to the paper form as well as to the electronic medical record. in order to create an environment in which violence against women identification would be fostered, a kiosk was placed in the front lobby with health information, including identification and referrals for violence. in addition, posters were placed in every exam room describing the unacceptability of domestic violence and local referral numbers were visible. a re-evaluation process occurred after 6 months of implementation in several phases. first, records were evaluated randomly for charts missing the screening question response. none were identified. in addition to vigilance and commitment by the nursing staff, this 100% adherence is likely due to the electronic medical record characteristic that demands input at the specified site during data entry. the clinic staff members were further encouraged by the positive feedback received from the staff and representatives from the community agencies regarding the program. the procedure for screening included mechanisms for referring women to agencies dealing with violence. the women were provided support at the time of the initial positive response to the question. women received further evaluation of physical, sexual and psychological conditions related to violence. once the evaluation was completed in the clinic, women received referrals to community organizations that could provide a shelter, counseling or other services. the post-test consisted of a second retrospective (n=859) chart review to determine the incidence of violence against women after the intervention program and screening protocol was instituted. when the charts of the women were identified, two investigators examined the progress notes, the history forms and the problem list of the visit in which the abuse was identified and the visit after the initial identification of the violence. the charts were reviewed for further information regarding the age, race/ethnicity, presenting complain, past medical history, current medical history, referral and any follow-up information. two investigators reviewed the charts together and independently to accurately identify the data derived from the chart. findings a computer search determined which women had answered ‘yes’ to the question ‘is anyone hurting you?’. the computer search also identified any notation of abuse in the progress notes, history form or problem list over a one year period 2002. six women were identified in the computer search of the women seen in the clinic that year. the women ranged in age from 27 to 57 years (mean 45.5). two women were hispanic and four women were caucasian. the presenting complaints were: flank pain (1), headache (2), hypertension (2), and a work physical (1). the past medical history of the women included: vaginal infection and pelvic inflammatory disorder (4), myocardial infarction online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 52 (1), hepatitis (1), surgery (1), asthma (1), suicide potential (1), headaches/migraines (2), obesity (1), learning disability (1). five women had symptoms of depression in their current medical history. other problems identified in the current medical history of the women were: headaches (3), hypertension (1), chest pain (1), and alcohol/drug abuse (1). no woman identified a presenting complaint that was specifically associated with violence. only two women answered ‘yes’ on the history form to the question about abuse. the other four women discussed abuse with the nurse practitioner during the routine physical exam. one woman admitted that she could hurt herself. she was immediately referred to the local hotline and the national hotline number. further, immediate treatment consisted of providing medication for depression. the past and current medical history for the six women demonstrated some similarities. four women (66%) had treatment for vaginal infections or sexually transmitted diseases. four women (66%) had a current or past history of depression. one woman had a cholecystectomy, a hysterectomy, a myocardial infarction, and hypertension. two women had a history of headaches and migraines. the high level of pathology in the past and current medical history of these women suggests that women had been seen in the health care system frequently and may not have discussed the episodes of violence in their lives. follow-up procedures five women were referred to violence shelters, local and national hotline numbers, or local drug treatment facility. a psychiatrist was currently treating one woman for depression. another woman had left the abusive relationship and felt she had managed to remove herself from harm. one woman was treated for depression and returned to the clinic after removing the abusive relative from her home and achieving a therapeutic response from depression medication. this woman no longer feared self-harm and she was continuing counseling with the abusive relative. one woman lived in the local area and was often in another state so the national hotline number was also given to her. she was also given medication for depression. another woman was referred to the violence center in the area or the drug rehabilitation program. one woman was under treatment for depression and she was encouraged to discuss the abuse with her psychiatrist. one woman was abused by her daughter; and one woman was abused by a mother. four women were abused by their male partners. no stranger abuse was identified by the women in the clinic. conclusions and nursing recommendations asher et al. (2001) estimated that one in four women experience violence directed against them in their lifetime. the number of women identified in this clinic over a oneyear period was lower than that than one in four. magnussen et al. (2004) also reported a lower incidence of intimate partner violence (9%) in a retrospective chart audit. since the screening protocol had been initiated in the previous year, and women may not immediately report violent episodes directed at them, the nurse practitioner and nursing online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 53 staff were confident that an increased the number of women would be identified in the future. the limitation in this study is that there was no comparison or control group. there is no way to identify the number of violence against women episodes that occurred during 2002 in the community served by the clinic. yet the number of women identified with the screening protocol was similar to other studies using retrospective chart audits. the findings of this study supported previous research findings that education and providing specific tools to health providers increased the potential for identifying domestic violence in families (gadomski, wolff, tripp, lewis & short, 2001). the study also adds to the limited research on violence against women in rural communities. the nursing staff became advocates for introducing screening when they quickly found women were receptive to being asked about abuse. women were able to discuss the issues and seek support from the nursing staff. nurses can provide intervention services by sending women to a domestic violence shelter, referring them to counseling services, and scheduling health care visits for support and counseling. hopefully, the results of this study will offer health providers in health centers the support to overcome uneasiness they feel regarding screening women in all areas of health care for violence. screening methods should be introduced into all primary health care services to increase the identification and service to women exposed to violence in their home (amiel & heath, 2003). health providers can make an impact on women, children and men by providing preventive care to decrease the incidence of violence against women. references adler, c. (1996). unheard and unseen: rural women and domestic violence. journal of nurse-midwifery, 41, 463-466. [medline] amiel, s., & health, i. (eds). (2003). family violence in primary care. oxford: oxford university press. asher, j., crespo, e.i., & sugg, n.k. (2001). detection and treatment of domestic violence. contemporary ob/gyn, 46, 61-2, 65-6, 68. borowsky, i.w., & ireland, m. (2002). parental screening for intimate partner violence by pediatricians and family physicians. pediatrics, 110, 509-516. [medline] calonge, n. (2004). screening for family and intimate partner violence: recommendation statement. american family physician, 70, 747-751. campbell, j. (ed). (1998). empowering survivors of abuse: health care for battered women and their children. thousand oaks, ca: sage. dienemann, j., boyle, e., baker, d., resnick, w., weidhorm, n., & campbell, j. (2000). intimate partner abuse among women diagnosed with depression. issues in mental health nursing, 21, 499-513. [medline] furbee, p.m., sikora, r., williams, j.m., & derk, s. j. (1998). comparison of domestic violence screening methods: a pilot study. annals of emergency medicine, 31, 495-501. [medline] gadomski, a.m., wolff, d., tripp, m., lewis, c., & short, l.m. (2001). changes in health care providers’ knowledge, attitudes, beliefs and behaviors regarding online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8990718%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12205252%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11261074%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9546020%5buid%5d 54 domestic violence, following a multifaceted intervention. academic medicine, 76, 1045-1052. [medline] heinzer, m.m., & krimm, j. (2002). barriers to screening for domestic violence in an emergency room. holistic nursing practice, 16, 24-34. [medline] magnussen, l., schultx, j., oneha, m.f., brees-saunders, z., akamine, m., talisayan, b. & wong, e. (2004). intimate-partner violence: a retrospective review of records in primary care settings. journal of the american academy of nurse practitioners, 16, 502-512. [medline] mccarney, d.m., & mckibbin, l. (2003). screening for domestic violence: follow the initiative of one health care system. nursing management, 34(9), 35-36. [medline] nelson, h.d., nygren, p., mcinerney, y., & klein, j. (2004). screening women and elderly adults for family and intimate partner violence: a review of the evidence for the u. s., preventive services task force. annals of internal medicine, 140, 387-396. [medline] tjaden, p., & thoennes, n. (2000). extent, nature and consequences of intimate partner violence: finding from the national violence against women survey, research report. washington, d.c. retrieved april 2, 2002, from http://www.ojp.usdoj.gov/nij/pubs-sum/181867 ulbrich, p.m., & stockdale, j. (2002). making family clinics an empowerment zone for rural battered women. women and health, 35, 83-99. [medline] uphold, c.r., & graham. m. (2003). clinical guidelines in family practice. (4th ed.). gainesville, fl: barrymarrae books. united states department of health and human services. (2000). health people 2010. washington, dc: u. s. department of health and human services. websdale, n. (1998). rural women battering and the justice system: an ethnography. thousand oaks: sage. wingood, g.m., diclemente, r.j., & raj, a. (2000). adverse consequences of intimate partner abuse among women in non-urban domestic violence shelters. american journal of preventive medicine, 19, 270-278. [medline] zust, b.l. (2000). effect of cognitive therapy on depression in rural, battered women. archives of psychiatric nursing, 14, 51-63. [medline] online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11597847%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11913225%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15617364%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14501530%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14996681%5buid%5d http://www.ojp.usdoj.gov/nij/pubs-sum/181867 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12201512%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11064231%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10783523%5buid%5d the australian perspective 3 editorial report from australia desley hegney editorial board member in the last few weeks, we have changed our federal government and now prime minister kevin rudd from the labour party is our new leader. labour have been out of power for about 11 years. the swing against the government was greatest in queensland (where kevin rudd lives). in his first week, the prime minister (pm) has been busy. on the first friday after he was sworn in as pm, he visited a property at roma in western queensland. the transcript from his talk at this visit reads: ‘no matter which rural community i visit in new south wales, victoria, in the west or here in queensland, there is a problem of supply of rural doctors and nurses. that’s why, this morning, i discussed this with the shadow, not the shadow health minister. this morning i discussed this with the health and ageing minister, nicola roxon. and what we propose to do is this: we will conduct now an immediate audit of the shortage of doctors and nurses and other health professionals in rural australia, number one. number two: we will examine the reasons for these shortages. and three: we’ll be asking the department of health and ageing to provide us with a range of options for attracting and retaining health professionals in rural australia. you see, you can’t expect people to come out and farm these parts of australia unless you’ve got basic health services. the commonwealth is uniquely responsible for the adequate training of doctors and nurses but the commonwealth is responsible for allocating enough university places were that to be the case. therefore, i want to get to grips with this within the first week of us forming this government by commissioning that work through the federal department of health and ageing. and the federal minister, nicola roxon, we’ll be announcing our intention to do this at a meeting of state and territory health ministers, which is being held today in hobart.’ this is good news for the rural health care workforce. it is good news in that it does not focus solely on doctors. rather, it focuses on nurses and allied health professionals as well. certainly there are plenty of data of why there is a shortage of health professionals in ‘the bush’. one of the causes is the national and international shortage of health professionals, which has impacted on rural towns as well as metropolitan ones. however, rural nurses in particular are disadvantaged in many ways. in the past the australian government has provided a large amount of support (most financial) for rural doctors. in what the labour government called the ‘blame game’, online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 4 the then federal government always stated that nurses and allied health professionals were state/territory government responsibilities (and therefore they would ‘blame’ these governments or say it was the responsibilities of these governments to fix the situation not theirs). this is despite the fact that the federal government provides considerable funding via what is known as our ‘health care agreement’, to the states/territories from the taxation system. these funds are used as per the agreement, and are not just handed over to the state/territory governments to spend as they will. this new government has had other focuses on nursing. for example, they are making an incentive payment to nurses of $a6,000 if they return to the nursing workforce. we will look at the outcome of this incentive, as previous research suggests that remuneration is not a major reason for nurses to leave their employment. the other good news is that the australian rural nurses and midwives association, has had a major recruitment drive and now has over 1,000 members. i wish you all a very happy christmas and an excellent 2008. preceptorship rural boundariespreceptor perspective 15 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 meaning of boundaries to rural preceptors olive yonge, phd, rn 1 1 professor & vice-provost academic programs, faculty of nursing, university of alberta, olive.yonge@ualberta.ca key words: nursing education, preceptorship, boundaries and teaching, rural nursing. abstract preceptorship is widely used as a cost-effective clinical non-traditional teaching method. however, insufficient research has been done in this area, particularly as to how a successful student-preceptor relationship is formed. the rural setting poses additional challenges as the nursing instructor is not physically present to monitor the course of the student-preceptor relationship or to resolve arising boundary issues. this is part one of a grounded theory project whereby eleven rural preceptors were asked ‗what kinds of professional boundaries do you create in the rural preceptorship experience‘ and ‗how they created and maintained professional boundaries while precepting nursing students‘. the research project consisted of two parts: each examining the perspectives of preceptors and students. however, this study will focus on the perceptions of preceptors and is the first to examine perceptions of preceptors in the area of teaching and boundaries in rural settings. the resulting core variable was: trusting the student to be safe and the psychosocial process was the relationship they developed with the student. introduction the preceptorship experience is widely used by a number of professional faculties, including nursing, as a cost-effective method of providing quality field experience. students are individually assigned to preceptors in a formal, one to one teaching/learning relationship which allows them to experience the reality of the nursing staff role with the support of a role model and a resource person immediately available to them (kaviani & stillwell, 2000; öhlring & hallberg, 2000). preceptorship is comprised of a triad the student, preceptor and faculty member that work together to achieve a student‘s transition to the role of graduate nurse. preceptorship has come to represent the process of ―pairing new graduates with an experienced nurse to facilitate role transition to that of a staff nurse‖ (mccarty & higgins, 2003, p. 91). as part of the socialization process, students come to develop professional relationships and implicit in this, begin to recognize and resolve boundary issues. an effective preceptorship experience is dependent on the development and maintenance of this kind of professional relationship and so an important question that needs asking is: how are these professional boundaries created and maintained? a setting that is particularly vulnerable to professional boundary challenges is the rural setting due to the existence of dual and multiple role relationships that nurses have within small communities. the rural setting is also vulnerable due to nursing shortages which have had devastating effects. research has shown that preceptorship is an important tool for recruitment of new graduates to rural areas (neill & taylor, 2002) thus challenges for rural preceptorships such as boundary issues need to be identified and resolved. the focus of this article is how rural preceptors address boundaries within the preceptorship relationship. http://www.uofaweb.ualberta.ca/nursing/ mailto:olive.yonge@ualberta.ca 16 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 significance of the research despite the widespread use of the preceptorship program as a method of clinical teaching, the challenges of such a program for students, preceptors and faculty are not well understood. this is especially true for rural placements where the physical presence of a faculty instructor is an impossibility and thus an understanding of the effectiveness of rural placements is entirely dependent on the effectiveness of communication channels between the faculty and the preceptorship site. a negative experience with a student can influence the willingness of a staff nurse and their colleagues to preceptor at later points in time. faculty, students and preceptors need to understand boundary issues in the student-teaching relationship, avoiding harsh consequences should boundaries be crossed inadvertently. since positive preceptorship experiences can serve as recruitment of students, preceptors need to be diligent about professional relationships with students. review of the literature long and weinert (1989) define rural nursing as the provision of health care by professional nurses to persons living in sparsely populated areas. bushey (2000) stipulates the issues of defining rural nursing are significant because it affects nursing care, preparation of nurses, and nursing work-life issues. bushey (2000) notes the ability to function autonomously and the ability to adapt nursing interventions to a low-tech environment is historically characteristic of rural nursing practice in canada and rural nurses need to be expert generalists (2001). paradoxically, this setting is a rich learning opportunity for student clinical placements as they are faced with a wide variety of experiences and are forced to act at a greater level of independence and competence (van hofwegen, kirkham, & harwood, 2005). beatty (2001) declares that little has been done to investigate the rural nurses‘ learning needs or the context of their practice setting. in addition, she notes professional isolation prevents these providers from networking with colleagues to discuss new treatments and evaluate effectiveness (beatty, 2001). weinert and long (1991) surveyed rural nurses and found they had to travel between thirty and sixty miles to reach a college or university. however, in the medical literature, a review of the impact of students on rural practitioners found reduced professional isolation, increased identification with precepting peers and increased interaction with the medical school to be positive impacts of rural preceptorships on preceptors (walters, worley, prideaux, rolfe & keaney, 2005). ullian, shore & first (2001) stress the importance of two-way communication between medical preceptors and the faculty in dealing with problematic interactions between students and preceptors. however, in rural settings the physical presence of a faculty member is often an impossibility. unprofessional behaviours such as inability to demonstrate knowledge and skills, attitude problems, dishonesty or poor work ethic, and poor communication skills may serve as red flags to unsafe practice (luhanga, in press). thus, unprofessional behaviour on part of either the student or preceptor must be even more diligently monitored. as hargrove (1986) stipulates, there are a number of critical ethical issues for rural mental health practitioners specific to the rural setting and challenging for the student-preceptor relationship including: the confidentiality of and within the professional relationship with a consumer of professional services; limits of practice; and multiple levels of relationships between persons who live and work in small communities. roberts, battaglia, smithpeter, and 17 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 epstein (1991) later affirm that ethical dilemmas encountered in small communities derive from several highly interwoven attributes of health care in these settings: overlapping relationships and conflicting roles among caregivers, patients, and families; challenges in preserving patient confidentiality; heightened cultural dimensions of health care; limited resources access to health care services and related issues of clinical competence; and exceptional stresses on caregivers in these settings. thus, there is a greater possibility for boundary crossings in the form of confidentiality violations, unprofessional conduct, vague role definitions and interpersonal conflict in the rural setting. it is the preceptor who will be responsible for facilitating the student‘s learning experience and role socialization (kaviani & stillwell, 2000), including surmounting the added challenges facing the rural practitioner. thus the researchers set out to explore the questions: ―what are the professional boundaries created during the preceptorship experience?‖ and "how do rural-based nursing preceptors create and maintain professional boundaries when teaching undergraduate nursing students?" in order to better support and facilitate rural preceptorships. methods fourth year baccalaureate nursing students and their rural based preceptors were recruited for the study. the students had 340 hours of direct clinical preceptorship. students were recruited through in-class visitation and were requested to sign a consent form before participating. their preceptors where then contacted and recruited. no attempt was made to pair the students and preceptors to avoid coercion. the study received ethical approval by the host university review board. this article will only focus on the findings from the preceptors. data collection data was collected through a series of semi-structured interviews, participant observation in the placement setting and review of course materials. the interviews were based on an interview guide consisting of open-ended questions. this helped to facilitate participants‘ freedom of response and allowed for the researcher to clarify responses. framework to reveal ―what is actually going on rather than what ought to be going on‖, the researcher chose a grounded theory method (glaser, 1978, p. 14). grounded theory was chosen as the framework for this study as there is a general lack of research in the area of preceptorship and boundary creation, and there is a need for more middle-range theories in nursing education that can be empirically tested (streubert & carpenter, 1999). grounded theory recognizes that individual shape meaning through experience and although experience is unique to an individual, commonalities in experience occur with those sharing circumstances (mccann & clark, 2003). data analysis analysis of the data began almost as soon as collection using open codes (glaser, 1978). categories and dimensions emerged that were clustered together. these were compared among each other to determine how they connected. the researcher was guided by several questions 18 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 (glaser, 1992). first, precisely what do these data reflect? while allowing for complete emergence of the data, this question reminded the researcher that what might have originally aimed to study might not be what emerges. second, which category does an incident indicate? as the theory increasingly conceptualized, this question became easier to answer. third, what were the basic social/psychological problems faced by the participants, and what was the basic social/psychological process or social structural process that made the preceptor-learner relationship workable? this process yielded a core variable. to maintain rigor, four specific criteria were used: credibility, fittingness, auditability and confirmability (guba & lincoln, 1989). preceptors reviewed transcripts, two independent external researchers reviewed the transcripts for themes, participant observation was used and field notes captured when saturation was achieved. the limitation for grounded theory is the inability to generalize to other settings. the data captures the experience of these nursing students at a particular moment in their program. sample eleven rural nurse preceptors volunteered and were interviewed in the rural setting. ten had a diploma level of education while one preceptor had completed a baccalaureate degree in nursing; the average number of total years of nursing education was 3.06 years. all but one preceptor had been engaged in some form of continuing nursing education. there was a wide range of the number of years as a preceptor ranging from two preceptors who had a student for the first time to a nurse preceptor that had had 23 years of experience. slightly over half had previously precepted 4 th year baccalaureate students, and had also precepting experience with licensed practical nurses, two year nursing diploma students, and paramedic students. five preceptors indicated that they had had no preparation for the preceptor role. four nurses indicated that their experience was founded on the information packages provided by the university. one preceptor indicated that her years of precepting experience had prepared her for her role. results the core variable was: trusting the student to be safe. the preceptee was a student and needed the chance to learn, however patient safety was still the most critical issues for the preceptors. the preceptors skillfully outlined the process they used to ensure the student had the knowledge to practice. the psychosocial process was the relationship the preceptor developed with the student. six dominant themes emerged from the data. the first three theme described directly refer to teaching and learning. first, preceptors (n=6) viewed their role as furnishing their students with the skills needed for a successful transition from student to staff nurse. they felt it necessary to introduce students to the ―reality of nursing‖ and facilitating this transition as a role-model, supervisor and friend. the capacity for independent work was the primary objective of the clinical experience. three nurses viewed the clinical experience as complimentary to the university training and saw it as their role to reinforce their students‘ classroom knowledge. one nurse expressed ―[my role is] to make sure that the girls coming out into the nursing field are fully prepared for a work situation.‖ in terms of boundaries, their first concern was knowledge. essentially they needed to trust that the student had the knowledge to be safe. 19 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the second theme that emerged pertained to the process by which preceptors teach their students. the majority of preceptors outlined a process of three steps: the student observes the task performed by the preceptor, and then the student performs the task under the supervision of the preceptor, and then goes on to perform the task independently without the supervision of the preceptor. preceptors saw their role in the final stages of this process transform from a more direct form of guidance to that of a resource person, available for questions and encouragement. linked to this process was the mechanism by which feedback was delivered. preceptors demonstrated a respect for student reasoning and emotions and generally took great pains to deliver constructive encouragement in a private setting. criticism was never delivered in front of patients and rarely in front of other staff. they stressed the need to be open and deliver criticism or correct a task in a timely manner, however, the approach generally left the evaluation and final decision up to the student. one preceptor stated ―the only times i‘ve corrected is normally to say that . . . ‗i was taught that you should always do this,‘ or ‗you should do this in this manner; i don‘t know if that‘s good or not.‘ but i leave it up to her.‖ the third major theme was the nearly unanimous response to the interview question: ―how long does it take to know whether the student-preceptor relationship is going to be a positive one?‖ nine preceptors felt, ―the first day...you kind of know by the end of the first shift with them‖. factors influencing this relationship were very much based on personality and attitude rather than skill levels, thus most preceptors felt within the first shift, or at most after a couple of days, they had a sense of the student‘s willingness to learn and their enthusiasm for the experience. the fourth theme reflected further on the student-preceptor relationship. most preceptors felt honesty and respect are major factors promoting a positive student-preceptor relationship. when asked what promotes a good relationship one preceptor responded, ―i felt that i could trust her to do her best effort as well, and not have to be totally stand over her shoulder.‖ a mutual respect for the wealth of experience of the preceptor and the post-secondary education of the student contributed to a positive relationship. a preceptor qualified this, saying, ―i think respect from both. my respect for her, wanting to learn skills she knows, information she has‖. in contrast to these factors, the fifth theme detailed factors that were inhibitors for a positive student-preceptor relationship. the majority of preceptors felt a lack of motivation was the greatest inhibitor to a positive relationship. one preceptor explained, ―i think with the student, if they don‘t have the initiation to go and try to do things and want to do thing and want to be there. i find it‘s sometimes hard to get them motivated to jump in.‖ some preceptors explained that an unmotivated student contributed to their workload rather than lightening it as was the case with eager and motivated students. lastly, when exploring the boundaries of the student-preceptor relationship, the question of the degree of personal disclosure was posed in the interview. preceptors had mixed feelings when it came to sharing confidences with students. about half didn‘t have a problem sharing personal information, although it had seldom occurred in their experience. the other half maintained a strictly professional relationship saying, ―i don‘t think i‘ve been that close with a student. i won‘t talk about personal or intimate things. certain things aren‘t up for discussion.‖ many preceptors set professional boundaries with a student along the same lines as they would with other nurses or health care colleagues. they recognized the need to ‗take a break‘ from constantly discussing work while on a break, however the boundaries remained clear with disclosure limited to ―anything extra curricular, like sports or gym that sort of thing, but nothing personal‖. 20 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 other boundary issues that were explored were gift-giving, touching, and keeping in touch with the student after the placement has finished. nearly all preceptors with whom the question was raised (n=6) stated that gifts were by no means expected; however, that a little something or even a thank-you card or verbal appreciation provided the feedback and closure that was needed. many found a sense of closure in a special last-shift coffee, sharing baking or having a ‗reminiscent time‘. pertaining to the question of touching, many said that friendly or encouraging ‗pats on the back‘ did occur, and were often positively perceived. this occurred with preceptors who perceived themselves as ‗touchy‘ people and who interacted with patients in a similar manner. however, whether they themselves were comfortable with touching or not, most preceptors had an awareness of whether another individual was comfortable with touching or not. lastly, the majority of preceptors (n=6) had kept in touch with students or wished to following the placement. they expressed interest in the students‘ future endeavours and working experiences. this was often facilitated by the rural environment with students returning to work in the rural area or having relatives that also worked and lived in the area. the nurse preceptors reflected on the experience as specifically rural and the implications of this for both preceptors and students. the majority of nurses had not considered the goal of recruitment to rural areas when they had agreed to take on students and for many this possibility had not yet crossed their minds. one preceptor encouraged each of her students ―to work in a rural hospital for 2 years before working elsewhere, so that you can learn a little bit of everything.‖ secondly, they felt that a rural experience was particularly beneficial to students due to the generalist nature of a nurses‘ workload at a rural hospital. one nurse depicted the rural experience as compared to the urban as, ―in the big city hospital they got it easy, because they don‘t have to know everything and they‘ve got doctors right there. in the small hospital you have to use your brain a little; you have to think things out. although in the city, they think everybody in the country is born with a potato in their head‖. they felt students received a broader experience rather than being restricted to a single specialist facility or area. they had the opportunity to work with patients of all ages and were able to prioritize their experiences according to where ―the action was‖ on a particular shift. challenges of this environment included having to be exceptionally organized and requiring the ability to prioritize under pressure. discussion when directly confronted with the question of how a professional relationship was established with a student, many preceptors could not articulate the elements of this process. however, when questioned about aspects of the student-preceptor relationship such as giftgiving, touching, self-disclosure, closure and factors contributing to a positive experience, these preceptors maintained professionalism, keeping objectives and boundaries at the forefront. this was demonstrated through behaviour such as keeping personal matters outside of the working relationship, restricting gift-giving to small tokens of appreciation and touching to what would be appropriate with patients or colleagues. though faced with ethical challenges unique to the rural setting (students as children of friends and colleagues, heightened visibility in the community, confidentiality issues etc.) these preceptors set clear professional boundaries (hargrove, 1986; roberts et al., 1991). 21 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the delivery of criticism in a constructive and respectful manner also contributes to the development of professional boundaries. preceptors recognized students were not to be reprimanded as children, but as adults with their own learning, experience and decision-making processes. criticism was always delivered in a private space and never in front of patients or colleagues. they found that students responded very well to encouragement alongside criticism and were forced to develop critical thinking in evaluating their own skills. the development of mutual respect and learning was fostered through this method of feedback. the nurses were aware of the uniqueness of a rural placement in comparison to the urban clinical placement experience. they seemed to value the challenges of being a ‗generalist‘ in such a setting (hegney et al., 2002). preceptors felt the role of a rural nurse gave students an opportunity to put into practice a wide range of skills, forced them to function more autonomously and exposed them to a variety of challenges (bushey, 2000). although they did not have recruitment goals in mind, they recognized the potential of rural placements as a recruitment strategy. conclusion rural nurse preceptors seem to have an implicit understanding of professional boundaries necessary for life and work in a rural community. however, with the introduction of students with urban backgrounds into these settings it may become more important to articulate these boundaries more clearly and definitely. it was noteworthy that a central conception of boundaries was trust in the area of the student's knowledge development. additionally, as rural placements have been recognized as a successful recruitment strategy for health care professionals to rural areas, a greater number of students may enter these placements without having had previous experience in a rural area. if recruitment potentials are to be maximized it is important that a proper introduction to rural health care challenges and benefits be developed for these students and preceptors. acknowledgments the author would like to acknowledge the following for their assistance: the university teaching and research fund, and quinn grundy, research assistant. references beatty, r.m. (2001). continuing professional education, organizational support, and professional competence: dilemmas of rural nurses. journal of continuing education in nursing, 32(5), 203-209. [medline] bushey, a. (2000). orientation to nursing in the rural community. thousand oaks: sage. bushey, a., & bushey, a. (2001). critical access hospitals: rural nursing issues. journal of nursing administration, 31(6), 301-310. canadian institute for health information. (2002). supply and distribution of registered nurses in rural and small town canada. ottawa, ontario: author. champion, j.d., artnak, k., shain, r., & piper, j. (2002). rural woman abuse and sexually transmitted disease: an ethical analysis of clinical dilemmas. issues in mental health nursing, 23(3), 305-326. 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(2002). retaining rural and remote area nurses: the queensland, australia experience. journal of nursing administration, 32(3), 128-135. [medline] kaviani, n., & stillwell, y. (2000). an evaluating study of clinical preceptorship. nurse education today, 20(3), 218-226. [medline] long, k.a., & weinert, c. (1989). rural nursing: developing the theory base. scholarly inquiry for nursing practice, 3(2), 113-127. [medline] luhanga, f., yonge, o., & myrick, f. (2008) hallmarks of unsafe practice: what preceptors know. journal for nurses in staff development, 24(6), 257-264. [medline] mccann, t., & clark, e. (2003). grounded theory in nursing research: part 1—methodology. nurse researcher, 11(2), 7–14. [medline] mccarty, m., & higgins, a. (2003). preparing preceptors for their role. nurse education today, 23(2), 89-95. [medline] morgan, d.g., semchuk, k.m., stewart, n.j., & d‘arcy, c. (2002). job strain among staff of rural nursing homes: a comparison of nurses, aides, and activity workers. journal of nursing administration, 32(3), 152-161. [medline] neill, j., & taylor, k. (2002). undergraduate nursing students‘ clinical experiences in rural and remote areas: recruitment implications. australian journal of rural health, 10, 239-243. [medline] nichols, e. (1989). response to ―rural nursing: developing the theory base.‖ scholarly inquiry for nursing practice, 3(2), 129-132. [medline] öhrling, k.h., & hallberg, i.r. (2001). nurses‘ lived experience of being a preceptor. journal of psychosocial nursing, 33(4), 530-540. [medline] roberts, l.w., battaglia, j., smithpeter, m., & epstein, r.s. (1999). an office on main street: health care dilemmas in small communities. hastings center report, 29(4), 28-37. [medline] streubert, h.j., & carpenter, d.r. (1999). qualitative research in nursing. advancing the humanistic imperative (2 nd ed.). new york: lippincott. walters, l., worley, p., prideaux, d., rolfe, h., & keaney, c. (2005). the impact of medical students on rural general practitioner preceptors. education for health, 18(3), 338-355. [medline] van hofwegen, l., kirkham, s., & harwood, c. (2005). the strength of rural nursing: implications for undergraduate nursing education. international journal of nursing education scholarship, 2(1). [medline] yura, h., & torres, g. (1975). today‘s conceptual frameworks with the baccalaureate nursing programs. (nln pub. no. 15-1558, pp. 17-75). new york: nln. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11984243%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10820576%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=2772454%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=19060655%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14708425%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12593823%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11984246%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12230431%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=2772455%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11251741%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10451837%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16236582%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16646922%5buid%5d mexican american parents’ perceptions 33 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 mexican american parent’s perceptions of culturally congruent interpersonal processes of care during childhood immunization episodesa pilot study teresa keller rn, phd 1 1 assistant professor, school of nursing, new mexico state university, tkeller@nmsu.edu key words: mexican-americans, nurse-patient relationships, qualitative research, health disparities abstract one of the goals of health people 2010 is to eliminate health disparities among minority populations by 2010, including improved childhood immunization rates among mexican-american children. prior research has identified the importance of interpersonal process-related factors as significant components of care sought by mexican-americans, but more knowledge is needed about what mexican-american parents view as a beneficial relationship with the nurse during the immunization encounter. the purpose of this qualitative, descriptive pilot study was to explore and describe the perceptions of mexicanamerican parents‟ regarding their relationships with clinic nurses in a rural, primarily agricultural community. thematic analysis of data describes a beneficial relationship between mexican american women, their children, and nurses during immunization encounters as consisting of 1) trust in the nurse, 2) building confidence in the mother and child, and 3) language concordance. introduction one of the goals of health people 2010 is to eliminate health disparities among minority populations by 2010, including achieving a national immunization rate for children of 90% (centers for disease control [cdc], 2006a). for hispanic minority populations, including mexican americans, one of the barriers that leads to health disparities is a lack of access to preventive care (cdc, 2006b) this challenges all nurses working with minority populations to examine their practice for ways to improve the use of this important preventive service by mexican americans. prior research has identified the importance of interpersonal processrelated factors as significant components of care sought by mexican americans (fongwa, stewart, & pérez-stable, 2002; warda, 2000; zoucha, 1998). furthermore, interpersonal factors, including interactions with health care providers, are identified as explaining and predicting health behaviors in pender et al‟s (2002) health promotion model for nursing practice. since nurses are often involved in the delivery of immunization services to mexican americans, more knowledge is needed about the nurse-client relationship as a part of the interpersonal process of care experienced by mexican american families seeking childhood immunizations. the purpose of this qualitative, descriptive pilot study was to explore the nature of a meaningful and beneficial relationship between the clinic nurse and mexican-american parents and their children. specifically, this research examines the nurse‟s role in the interpersonal process of care while providing immunization services to mexican americans at a community health services center in a low-income, rural section of southern new mexico. the research aims were to: http://www.nmsu.edu/~nursing/ tkeller@nmsu.edu 34 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 1. describe how mexican american parents perceive their relationship with nurses as they seek immunization services for their children. 2. understand what these mexican american parents perceive as a helpful relationship with nurses. 3. contribute to the theoretical understanding of culturally congruent nursing care for mexican americans. relevant literature the u.s hispanic population grew by 57.9% between 1990 and 2000. the mexican american subset accounts 58% of the estimated 35.5 million hispanics currently residing in the united states (u.s. census bureau, 2001). the group‟s historical, cultural, and demographic characteristics present unique challenges for health care professionals working with this population in rural and urban settings. significant health disparities exist for hispanics, including mexican americans, in categories such as cancer, cardiovascular disease, type ii diabetes, when compared to non-hispanic whites (cdc, 2006b). health care disparities for hispanics are also a reflection of their use of primary preventive services, especially childhood immunizations. the rate of childhood immunizations in mexico is 95% compared to the u.s childhood immunization rate of 82% (paso del norte health foundation [pdnhf], 2004). the childhood immunization rate for hispanic children living in the united states is 79% (federal interagency forum on child and family statistics, 2005) for hispanic children living in the u.s. border region of el paso and dona ana county, new mexico, the rate of childhood immunizations is 77% and 79% respectively (pdnhf, 2004). while the gap in immunization rates between hispanic children and white, non-hispanic children living in the united states is closing, it is still a significant drop from the much higher childhood immunization rates in mexico. research has identified multiple barriers imposed by the health care system to utilization of services by mexican-americans and other hispanics, including financial constraints (zambrana, all, dorrington, wachsman, & hodge, 1994), discrimination (cornelius & altman, 1995; zambrana et al., 1994), lack of availability of non-emergency room and primary care services (shaffer, 2002), long waiting periods and lack of transportation (byrd, mullen, selwyn, & lorimor, 1996). timmins‟ (2002) analysis of research literature concluded that while language is probably a significant barrier to access for latino populations, it is not the most significant barrier for this population group. cultural congruence between health care professionals (including nurses) and hispanics is assumed to be a significant factor in the population‟s utilization of health care services. although some variation exists in the terms and definitions used to describe culturally congruent care (e.g., culturally competent or culturally sensitive care), all share the attributes and spirit of leininger‟s definition (1991). according to this cultural theorist, culturally congruent care: refers to those cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are tailor made to fit with the individual and group cultural values, beliefs, and lifeways in order to provide or support meaningful, beneficial, and satisfying health care, or well being services (p. 49) 35 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 the relationship between patient and nurse has been articulated as nursing‟s essence (benner & wrubel, 1989; gadow, 1980; newman 1999; paterson & zderad, 1976/1988; travelbee, 1966). although the importance of culturally congruent care is not an issue of debate for the nursing profession, the most fundamental component of this carethe nurse/ client relationshiphas not been empirically explored as it applies to mexican american parents and their children. the assumption that underlies the purpose is that culturally congruent care cannot occur without some knowledge of what mexican american clients are seeking in their relationships with nurses. shaffer (2002) explored factors influencing access to prenatal care among pregnant hispanic women and found health care providers‟ cultural knowledge of customs, expectations, and norms was an important influence on the women‟s decisions to access care. however, another study revealed an equivocal response by mexican-american, high-functioning, chronically mentally ill clients to having a health professional from their own culture care for them in a clinic setting: 39% thought it was better, 38% thought it was not better, and 23% stated, “it really doesn‟t matter” (lantican, 1998, p. 132). flaskerud‟s (1986) study of culturally congruent components such as language match and ethnic or racial match between provider and client in a mental health setting did not demonstrate a significant relationship between these barriers; some other factor or factors must exist for such care to occur. several studies point to the patient/client-health care professional relationship or something within the relationship as a potentially essential component to culturally congruent care. warda‟s (2000) qualitative inquiry into mexican-american perspectives identified their preferences for culturally congruent nursing care. warda describes culturally congruent care as including 1) valuingseeking to incorporate the client‟s knowledge, beliefs and values into the plan of care, 2) cultural comprehensionacknowledging and integrating the individual‟s cultural context into the plan of care, 3) system supports such as harmonious verbal and nonverbal communication, including language concordance, and 4) personalismo, an identified subset of provider behaviors that include showing respect, building confidence, taking time, and displaying generosity, caring and kindness to clients. an ethnographic nursing study of the experience and cultural values of mexican americans receiving nursing care identified the importance of nurse behaviors that build the client‟s confidence in the relationship (zoucha, 1998). according to zoucha, this confidence is essential for the client to experience a satisfactory episode of care. the nurse earns the client‟s confidence through the display of behaviors such as showing respect, paying attention, taking time and attempting to communicate in spanish during the care encounter. another study of the health seeking process of mexican american migrant farm workers found efficacy of treatment directly related to the rapport established with the nurses. (stasiak, 1991). although smith‟s (1994) study focused on white nurse practitioners working with african american families on health promotion, it is notable that nurses‟ knowledge or lack of knowledge about differences in cultural health beliefs and practices was in the background, whereas the nurse-client relationship was central to their care. no research was identified that specifically addresses the interpersonal processes of care that might affect the use of immunization services among mexican americans. however, one study identified that relationships developed between nurse practitioners and families exerted a strong positive influence for the use of immunization services in a rural primary care setting serving a predominantly white population (wilson, 2000). 36 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 methods a qualitative research design was selected because of the lack of research specifically addressing mexican american viewpoints about the interpersonal process of care that occurs during immunization episodes. a semi-structured interview format was selected and open-ended interview questions developed based on the research purpose. these questions asked the participants to describe their encounters with nurses while seeking immunizations for their children and what they thought were positive or helpful behaviors by the nurse during these encounters. the participants were also asked to describe negative or unhelpful behaviors displayed by nurses. the interviews took place in a community health center in a rural, agricultural town in southern new mexico. all participants were regular clientele of this health center and were identified for participation by the center‟s social worker. participants were eligible if they were mexican americans with children of immunization age. twelve participants were interviewed for this pilot study. all participants were women between the ages of 17 and 35 with children between the ages of six months and 11 years. socioeconomic status and education of the participants was varied. six of the women were immigrants from mexico with less than five years of residency in the united states, five were first generation mexican americans who had graduated from a u.s. high school in the region, and one participant was a 4 th generation mexican-american with a college education obtained in the united states. all participants were informed of their rights as research subjects and were provided with consent documents in their preferred language. after obtaining informed consent, the interviews were conducted in spanish or english, according to the research participant‟s preference. a certified spanish language interpreter was used to simultaneously interpret for interviews conducted in spanish. interviews were recorded and then transcribed by a bilingual transcriptionist prior to analysis. all participants received a monetary incentive for the time they spent participating in this study. interview transcripts were analyzed for emergent themes, using a grounded theory approach. three common themes that emerged were trust, confidence, and language concordance. data was then organized according to these themes and cross-checked with the supporting literature. findings data saturation was achieved very quickly in these interviews and the themes identified support the findings of warda (2000) and zoucha (1998). these themes describe a beneficial interpersonal process of care between mexican american women, their children and nurses during immunization encounters as consisting of 1) trust in the nurse, 2) building confidence in the mother and child, and 3) language concordance. trust every participant described the need for the nurse to be trustworthy. further, the nurse must not only be trusted by the mother but also by the child. nurses gained the trust of mothers and children best by adopting behaviors that helped put the mother and child at ease during the immunization encounter. displaying a friendly, sociable attitude was identified as essential to 37 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 decrease the anxieties surrounding immunizations for both parent and child. as one participant explained: to earn a child‟s trust, they need to be friendly with them, talk to them-so they can have trust. that‟s one thing about my children, if they don‟t know someone, they won‟t go near them and they won‟t talk to them. from all the interviews it is evident that these mothers placed great value on nurses who were able to engage their children and establish a trusting relationship. participants deplored the practice of entering a room and beginning the immunization procedure without an attempt to establish rapport with both the mother and child through friendly, social interaction. closely related to this was the need to appear unhurried and attentive to the mother and child during the visit. the nurse should not appear “rushed”, “mad‟, or “frustrated”. participants described positive experiences as those in which the nurse took the time to explain the procedure to the mother, inquire about questions she might have and engage the child in a way that lessens their fear and /or anxiety. for older children, the nurse should explain the reason for the vaccination, acknowledge their fear, and describe the benefits: …if they aren‟t patient he sees them, he can tell and he‟s afraid. and others talk to him and tell him „look this medicine is going to help you so that your bones will be strong so you can run and you can help your mom and it will hurt for just a little bit but then the pain will go away. for infants and younger children, trust and rapport is best established by gentle handling and friendly, soothing verbal communication by the nurse. asking the mother to help restrain a young child during the procedure provoked some anxiety in the sense that the mothers felt they would be perceived by their children as contributing to the pain of the procedure. being asked to hold young children in their laps for examinations and vaccinations were more acceptable practices for these participants. the participants all described being able to hold and hug their young children after the procedure as a routine expectation. friendliness and an unhurried attitude were not the only methods for establishing trust among children. several participants mentioned that the common pediatric strategy of rewarding children with candy, stickers or verbal praise was a helpful comfort measure that served to increase the child‟s willingness to receive immunizations. these small rewards were appreciated as comfort measures that reflected kindness and caring by nurses. when questioned about their responses to situations in which the nurse appeared unfriendly, hurried or inattentive, the participants all described reluctance on their own part to ask questions. in addition, a nurse who projects this kind of attitude also increases a child‟s anxiety about receiving the vaccination. participants felt that nurses who took the time to talk and attend to the concerns of both mother and child were more trustworthy: building confidence trust is the foundation for building the client‟s confidence in the care provided by the nurse. for these mothers, confidence in the care provided increased their comfort with the services they received and contributed to a satisfactory episode of care. the participants 38 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 described the role of confidence in the interpersonal process of care along two dimensions. first, the mother needs to have confidence in the nurse‟s professional competence. these participants described actions taken by the nurse that communicate professional competence such as wearing gloves, cleaning the injection site with alcohol, and the skillful administration of vaccines. they specifically mentioned practice inefficiencies, such as not having all required supplies assembled before beginning the procedure, as a sign to them that the nurse was inexperienced or inattentive. practice inefficiencies result in a loss of confidence in the nurse and less satisfaction with the care received. related to the issue of professional competence is the nurse‟s communication competence. conducting the encounter in the mother‟s preferred language will be discussed later, but other aspects of communication were also identified by these participants as important to promoting confidence in nurses and other staff as well. during the encounter, nurses should again adopt an unhurried attitude and provide accurate information conveyed in a friendly manner. participants also reported greater confidence with nurses and other clinic staff if they could easily call and get answers for their questions about appointments, medicines or after-care. the participants reported discomfort with having their personal health information discussed in places where other people might overhear, such as the waiting room or in hallways. the same holds true when the client hears nurses and staff discussing other clients in public places. these breaches of confidentiality are interpreted as a lack of respect and result in a loss of confidence in the nurse. the second dimension of confidence is related to how the nurse contributes to the mother‟s confidence in her own ability to adequately care for her child after the procedure. participants valued nurses who took the time to carefully explain the vaccines, their benefits and potential side effects. ensuring that the mother received adequate information, either through verbal instructions or printed education materials and in an unhurried manner is an essential aspect of satisfactory care, as one participant explained: …if i don‟t feel confident or i am nervous of the vaccine (sic) the children are going to be nervous as well. if i am comfortable, the children are going to be more relaxed. language concordance for these mothers, the importance of being able to make informed choices for their children and to adequately care for them after immunization was of paramount importance. every participant expressed the view that the immunization encounter should be conducted in the language with which the mother was most comfortable. the reason for this view is that the mothers wanted and needed to know why the vaccinations were important, what is appropriate after-care, and what adverse outcomes were possible. it was also important that printed educational materials or consent forms are in the preferred language of the mother. the six participants who were recent immigrants from mexico wanted their nurses and providers to speak spanish during encounters, while the participants who attended school in the united states were comfortable with either english or spanish. the participants also described the race and ethnicity of the provider or nurse as unimportant as long as there was language concordance. these participants felt that it was more important to speak in the mother‟s 39 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 preferred language rather than the child, perhaps as a reflection of the mother‟s primary caregiving responsibilities. discussion the findings in this pilot study support the prior work of warda (2002) and zoucha (1998). the components of a culturally congruent interpersonal care process as perceived by the mexican-american participants in this study are consistent with warda‟s descriptions of care delivered with respect for the client‟s cultural background (including their language preferences), the behaviors associated with personalismo, and system supports such as harmonious verbal and non-verbal communication. these participants described a beneficial relationship as one in which the nurse was “formally friendly” (warda, 2002), is attentive to the needs of both mother and child, is able to take time to answer questions and comfort the child, and demonstrates competence in professional skill and communication. nurses who demonstrate these behaviors within the interpersonal process of care are more likely to be viewed as trustworthy and obtain the confidence of their mexican-american clients. according to zoucha (1998) confidence in their health care providers is essential before mexican-americans will adopt the health promotion behaviors that will enhance their use of primary preventive services such as routine childhood immunizations. this pilot study sought to examine the perceptions of mexican-american parents regarding culturally acceptable interactions with nurses during clinic visits for childhood immunizations. as with any research, there are limitations in this study. first, all the participants were regular clientele of the community health center and their childrens‟ vaccination status was current. from the interviews, it was evident that participants were mostly satisfied with the care provided by the nurses at this particular center. however, this rural health center was also the only provider of preventive services in this community, so participants had little choice in where they obtained preventive careespecially the recent immigrants with questionable legal status within the united states. future research should be conducted among parents who have no regular source of preventive services. a confounding factor for this study is a state requirement for immunization of children prior to beginning public school. this provides an added inducement for parents to access the health care system regardless of their view of the personal and professional attributes of the clinic nurse. future research could be developed that involved participants requiring preventive services with no exclusionary government mandate, such as immunizations for influenza among adults. this research has benefited from the prior work of others 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(1966). interpersonal aspects of nursing. philadelphia: f. a. davis. warda, m. (2000). mexican-americans‟ perceptions of culturally competent care. western journal of nursing research, 22(2), 203-224. [medline] wilson, t. (2000). factors influencing the immunization status of children in a rural setting. journal of pediatric health care, 14(3), 117-121. [medline] zambrana, r., all, d., dorrington, c., wachsman, l., & hodge, d. (1994). the relationship between psychosocial status of immigrant latino mothers and use of emergency pediatric services. health & social work, 19(2), 93-102. [medline] zoucha, r. (1998). the experiences of mexican-americans receiving professional nursing care: an ethnonursing study. journal of transcultural nursing, 9(2), 34-44. [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10743411%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10823970%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8045452%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9856012%5buid%5d microsoft word marshall_172-1388-1-ed.docx online journal of rural nursing and health care, 13(1) physical activity and muscular strengthening in pregnancy: a rural urban comparison elaine s. marshall, phd, rn 1 bridget melton, edd, cscs 2 helen bland, phd 3 jacquelyn nagle, m.s 4 1 professor & bulloch healthcare endowed chair, co-director, rural health research institute elainemarshall@georgiasouthern.edu 2 associate professor, georgia southern university, bmelton@georgiasouthern.edu 3 professor, georgia southern university, hwbland@georgaisouthern.edu 3 university of pittsburgh, jan53@pitt.edu abstract though known to improve pregnancy outcomes, physical activity generally decreases through pregnancy. though some research has shown rural american women to be less active than urban dwellers, little is known regarding differences in such specific activities between rural and urban pregnant women. purpose: the purpose of this study was to compare self-reported physical activity patterns and muscular strength training activities between rural and urban pregnant women. sample: sample included 88 rural and urban pregnant women, mean age 25.83, in the southeastern region of the united states. method: women were recruited from the waiting rooms of regional obstetrician offices. following consent, physical activity was assessed by the short-form of the international physical online journal of rural nursing and health care, 13(1) physical activity and muscular strengthening in pregnancy: a rural urban comparison national guidelines for physical activity in adults are provided by two leading public health organizations. the 2008 physical activity guidelines were made available by the us department of health and human services (usdhhs, 2008) and in 2007 by the american college of sports medicine (2011; haskell, et al., 2007). these recommendations include: (a) physical activity of moderate intensity, 30 minutes for 5 days per week or 150 minutes per week; (b) vigorous intensity, 20 minutes for 3 days per week or 75 minutes per week, and (c) 6 to 10 musclestrengthening exercises with 8 to 12 repetitions of each exercise twice a week. the same levels of moderate intensity physical activity are specifically recommended for pregnant women. the american college of obstetricians and gynecologists (acog) encourages pre-pregnancy activity questionnaire (ipaq), and muscular strengthening activity was measured by an adapted self-report questionnaire. findings: several significant differences between rural and urban women included total number of minutes of moderate intensity physical activity, number of days per week of moderate activity, and time spent in resistance training. there was also a difference in total activity between participants with a high school education or lower and those with a college or higher education. there was no significant difference in total physical activity among trimesters for the entire group or between groups, showing no change across pregnancy. conclusions: rural pregnant women are less likely to engage in some levels of physical activity than urban counterparts. further investigation is recommended to understand specific factors influencing health and activity patterns of rural pregnant women. keywords: physical activity, muscle strengthening, pregnancy and rural online journal of rural nursing and health care, 13(1) maintenance of vigorous intensity and muscular-strengthening exercises with only slight modifications (acog, 2007; artal & o’toole, 2003). for the general population, health benefits of physical activity include weight control, reduced risk of hypertension, cardiovascular disease, and type ii diabetes http://www.cdc.gov/physicalactivity/everyone/health/index.html (cdc, n.d.a). there are additional benefits for pregnant women, including increased energy; enhanced mood; improved posture, muscle tone, strength, and endurance; reduction of back pain, constipation, bloating, and swelling; improved sleep, and prevention or treatment of gestational diabetes (acog, 2007; artal & o’toole, 2003). many studies have demonstrated declining physical activity patterns in pregnancy from the first to third trimester (borodulin, evenson, wen, herring, & benson, 2008; evenson & wen, 2010; fell & dobbs, 2009; schmidt, pekow, freedson, markenson, & chasantaber, 2006), leading to reduced known benefits from exercise. growing research on physical activity during pregnancy continues, but there is little information that includes women living in rural communities, even though it is increasingly evident that rural residents are least likely to meet national recommendations for physical activity (parks, housemann, & brownson, 2003). parks et al. (2003) demonstrated that both income level and rural or urban status are important predictors of adults' likelihood to meet physical activity recommendations. another study examined the perceptions of low-income rural mothers regarding their need for nutrition and physical activity education (atkinson, billing, desmond, gold, & tournas-hardt, 2007). participants indicated little knowledge about physical activity recommendations, and reported activity patterns that were likely inflated from perceptions of general housework chores and child care as exercise. online journal of rural nursing and health care, 13(1) beyond simple exercise, muscular strength training is currently recommended as part of the recommendations for physical activity for healthy adults. cdc reported, “research has shown that strengthening exercises are both safe and effective for women and men of all ages, including those who are not in perfect health. in fact, people with health concerns—including heart disease or arthritis—often benefit the most from an exercise program that includes lifting weights a few times each week” www.cdc.gov/physicalactivity/growingstronger/why/index.html (cdc, n.d. b para. 1). a gap in the literature continues concerning women’s participation in muscular-strengthening exercises. one recent study revealed that only 18.3% of women actually engage in muscle strengthening activities two or more times per week (carlson, fulton, schoenborn, & loustalot, 2010). long recognized benefits of muscular-strengthening exercises during pregnancy include improving posture to reduce low back pain, strengthening weightbearing muscles for mobility as weight gain continues, and easing labor and recovery. barakat and associates (barakat, lucia, & ruiz, 2009; barakat, ruiz, stirling, zakynthinaki, & lucia, 2009; barakat, stirling, & lucia, 2008) investigated safety concerns, time and type of delivery, and newborn outcomes related to light resistance exercise training in the second and third trimesters and found no negative health effects on mother or child. though such studies continue to confirm the value of activity and strength training in pregnancy, and public health nurses in rural and urban settings continue to promote healthy exercise, there is little research on actual activity patterns or muscular strengthening activities among women, particularly in rural settings. most research in this area has been performed by research teams within a specific discipline, such as physical education, public health, health education, sports medicine, or nursing. there is a need for continued study by inter-professional teams. the purpose of this study was to investigate the exercise patterns of rural and urban pregnant women residing in the southeastern region of the united states. the specific aims of online journal of rural nursing and health care, 13(1) this preliminary study were to compare the self-reported physical activity patterns and muscular strengthening or resistance training activities of rural and urban pregnant women. method design and sample the research method was a cross-sectional design. a convenience sample of 88 reportedly healthy pregnant women (53 rural residents and 30 urban residents; mean age 25.83 years, 4.99 sd sample) was recruited from three regional obstetrical practices in the southeastern united states. participants were excluded if they were under 18 years of age or did not completely respond to research questionnaires. completion of tools was voluntary following written informed consent, and data were recorded without identifying information. the study was approved by the human subject committee of the sponsoring university’s institutional review board. rural was defined as residence 1) outside census places with a population less than 25,000 and 2) within an area designated as non-metro based of definitions of the federal office of management and budget, united states department of agriculture[usda] (2010). urban was defined as residence inside a metro-based town or city with a population greater than 25,000 (usda, 2010). there were no significant differences in general demographic characteristics between the rural and urban groups. participants were primarily in the second or third trimester, (n = 24 and n = 43, respectively). racial background was comparable to that in the geographical area with majority being white (n = 50, 60.2%) and african american (n = 28, 33.7%). basic demographic characteristics of the women in this study are shown in table 1. online journal of rural nursing and health care, 13(1) instruments this version of the ipaq has been found to be valid and reliable (spearman’s p = -.76) (craig, et al., 2003; hagströmer, oja, & sjöström, 2006). the ipaq scoring protocol assigns the following metabolic equivalent (met) energy expenditure values to walking, moderate, and vigorous intensity activity: 3.3 mets, 4.0 mets, and 8.0 mets, respectively. table 1 frequencies and percentiles of demographic characteristics of participants (n = 88) variable n (%) variable n (%) racial / ethnic background (n = 83) age (n = 82) white 50 60.2 18 25 40 48.8 black 28 33.7 26 35 40 48.8 hispanic 2 2.4 ≥36 2 2.4 asian 0 0. gestational status (n = 79) multi-racial 1 1.2 1 st trimester 12 15.2 other 2 2.4 2 nd trimester 24 30.4 3 rd trimester 43 54.4 education (n = 82) residence (n = 83) <h.s. diploma or ged 28 34.1 urban 30 36.1 >college 54 65.9 rural 53 63.9 income ipaq physical activity score (n= 88) < $25,000 29 37.2 low 27 30.7 $ 25,001-50,000 28 35.9 moderate 33 37.5 $ 50,001-75,000 13 16.7 high 28 31.8 $ 75,001-100,000 8 10.3 smoking status (n = 82) >$ 100,000 0 0. yes 7 8.5 bmi classification, pre-pregnancy (n= 88) no 75 91.5 underweight 3 4.2 normal 34 47.2 overweight 18 25. obese 17 23.6 n = number of subjects in category muscular strengthening activity. activity in muscularly strengthening, or resistance, exercises was assessed by a questionnaire adapted from questions in the ipaq, seeking the typical number of days per week that participants engage in resistance training and the average number of minutes per day for such muscle strengthening exercises. following an explanation of online journal of rural nursing and health care, 13(1) resistance training, sample questions included, “resistance training activities refer to activities that strengthen or tone muscle such as push-ups, sit-ups or weight training. think about all the resistance training activity that you did in the last seven days. during the last 7 days, how much time did you spend resistance training on a week day? ___hours per day, ___minutes per day, ___ don’t know/not sure.” analyses all data were submitted to spss 14.0. descriptive statistics were calculated for all variables and demographics. to assess differences between groups, independent samples t test, chi-square analyses, and one-way analysis of variance were used. results physical activity the total mets for both groups, reported in minutes per week averaged 597.2, or nearly 10 hours per week. though the urban group averaged higher in overall activity, the difference was not statistically significant at the p = .05 level or less (see table 2). table 2 total metabolic equivalent (met/min/week) by trimester (n = 79) and by location overall mets rural mets urban mets trimester n x (sd) n x (sd) n x (sd) 1 st 12 739.6 (256.2) 7 844.5 (368.0) 5 592.8 (377.2) 2 nd 24 716.3 (179.9) 16 585.8 (168.7) 8 977.3 (427.5) 3 rd 43 490.9 (160.9 26 341.6 (157.9) 17 719.3 (326.9) total 79 597.6 (109.9) 49 493.2 (165.3) 30 767.0 (221.5) there was no significant difference in total mets among trimesters of pregnancy for the entire sample. additionally, no differences were found in the physical activity score (low, medium, high) among trimesters for the entire group (see table 3). online journal of rural nursing and health care, 13(1) no difference was detected comparing rural and urban residents by trimester, although there appeared to be a greater trend in declining activity by trimester among rural women. the ipaq gives a cumulative met scoring for overall physical activity, derived from the sum of high, moderate, and low physical activity. table 3 descriptive n (%) of physical score by trimester and location trimester/ pa scores 1 st 2 nd 3 rd rural urban low 1 (4.5) 5 (22.7) 16 (72.7) 17 (32.1) 8 (26.7) medium 5 (16.1) 8 (25.8) 18 (58.1) 20 (37.7) 11 (36.7) high 6 (23.1) 11 (42.3) 9 (34.6) 16 (30.2) 11 (36.7) total 12 (15.2) 24 (30.4) 43 (54.4) n = 79 trimester data breaking out moderate activity, a significant difference was revealed, with urban women reportedly engaging in nearly twice the amount of time overall (rural m = 52.17, sd = 17.9; urban m = 100.00, sd = 31.78), as shown in table 4. table 4 descriptive international physical activity questionnaire (ipaq) raw data by rural and urban (n = 88) activity level rural x (sd) urban x (sd) t-value p vigorous activity, days per week .81 (0.21) .93 (1.32) 0.41 .52 vigorous activity, minutes per day 33.32 (15.1) 27.17 (16.7) 0.26 .62 moderate activity, days per week 1.87 (0.29) 2.17 (0.47) 2.58 .11 moderate activity, minutes per day 52.17 (17.9) 100. (31.78) 4.63 .03* walking, days per week 5.32 (0.28) 5.2 (.35) 0.13 .72 walking, minutes per day 92.45 (19.48) 128. (31.66) 2.10 .15 sitting, minutes per day 277.89 (43.16) 334. (61.88) 0.65 .42 statistically significant (p ≤ .05), marked with * subsequent analysis revealed a significant difference between the number of days per week of moderate activity between those with a high school education or lower (m = 1.32, sd = .32) and those with college or higher education (m = 2.40, sd = .35) (p < .05). online journal of rural nursing and health care, 13(1) muscular strengthening activity there was a significant difference in reports of time spent in resistance training between urban and rural pregnant women. rural women reported a mean of 4.94 (sd 1.87) minutes of muscular strengthening exercises, while urban women participated in 20.67 (sd 13.16) minutes, resulting in a statistically significant difference between the two groups on an independent t-test (t = 11.18, p < .001*). discussion physical activity though results of this study show an apparent clinical difference in the total overall mets, or degree of physical activity (see table 1), between rural and urban pregnant mothers the difference was not statistically significant. neither did results indicate a significant difference in amount of time in total physical activity per week. however, data did indicate a significant difference between groups in regard to the number of minutes per week of moderate physical activity (see table 4). thus, urban women appeared to engage more often in moderate activities like bicycling, exercising, and carrying light loads. this finding is consistent with previous research of rural adults whom were less likely to achieve the recommended level of physical activity (parks, et al., 2003). factors associated with this decreased level of physical activity among rural women might include issues of access to physical activity outlets, such as walking paths, safe neighborhoods, community fitness centers, or malls (brownson, boehmer, & luke, 2005); or to cultural and social patterns of activity engagement. other researchers have found similar environmental factors among rural populations (deshpande, baker, lovegreen, & brownson, 2005; kaczynski, potwarka, & saelens, 2009). this study also confirmed other research showing level of online journal of rural nursing and health care, 13(1) education, which is often higher among urban residents, to be related to physical activity patterns, especially among women (chichlowska, et al., 2008; frank, schmid, sallis, chapman, & saelens, 2005; seeman, et al., 2008). muscular strengthening activity the participation in muscular strengthening exercise was significantly related to geographical place of residence; with urban pregnant women (m = 20.67, sd = 13.16) engaging in more minutes per day of muscular strengthen exercises compared to rural women (m = 4.94, sd = 1.87). muscular strengthening, or resistance training, has been shown to be related to numerous health benefits (hass, feigenbaum, & franklin, 2001). a recent report found that 18% of adult women are not achieving the recommended level of muscular strengthening (carlson, et al., 2010). prevalence of participation in muscular strengthening activities among pregnant women is currently largely unknown, since research has focused on clinical trials among other populations (hunter, mccarthy, & bamman, 2004). further investigations, including clinical trials, among pregnant women, especially in rural communities, are warranted. limitations of the study the limitations of the study underscore the need for more research in this area. first, the sample is relatively small and drawn from one southeastern region of the united states. second, measurements relied on self-report, and thus it is not known the extent to which participants were inclined to provide socially desirable responses. further, because of the preliminary nature of the study, the short form of the ipaq was used. the long form may have elicited responses that may have related better to strength training in rural living, such as chopping wood or gardening. many existing tools may not capture unique aspects of rural living. third, recruitment of the sample from participants’ own physicians’ offices may have had some effect on sample bias due online journal of rural nursing and health care, 13(1) to the focused recruitment site. finally, the cross-sectional design only provides a snapshot of current status or perceptions, and does not allow a longitudinal view of exercise patterns or reports of the past or future. conclusions and implications for rural nurses this study represents a beginning effort to discover issues related to physical activity and muscular strength training in order to improve the health of rural pregnant women, and subsequently, their children. to date, few studies have examined both patterns of physical activity and muscular strengthening exercises in pregnant women across residential areas. this work also shows the importance of an interdisciplinary approach to research on aspects of health promotion. the research team included experts in public health nursing, rural health, exercise science, and kinesiology. this approach opened a broad view of current research literature, appropriate measures for data collection, and clinical experience with the population. rural nurses are on the front lines to promote and monitor physical activity and other health promotion measures for women in pregnancy. working with practitioners from a broad variety of health professions, even by distance, can enhance the effectiveness of health care. our data suggest some differences that may exist in physical activity patterns, specifically in the amount of daily moderate physical activity and muscular strengthening activities. further study is needed related to factors that may affect physical activity and strength exercise, including exposure to cultural choices, means of transportation, and the spectrum of choices in commercial, environmental, and social interactions in rural communities. we recommend further investigations into these areas with other expanded means of data collection including the use of accelerometers, qualitative data from the women regarding factors related to physical activity and environment, larger sampling, and randomized controlled trials to determine most effective online journal of rural nursing and health care, 13(1) interventions. further research that targets the value of strength training in the daily life of pregnant women and for studies that lead to effective interventions to promote health among women and children is needed. prospective studies might investigate the effects of such interventions beyond health of mothers to include infants, child fitness, and ultimate prevention of obesity among all family members. certainly, data indicate a need for special focus on such factors among rural populations. nurses who practice in rural settings are well aware of challenges related to social isolation, distance from services, cultural patterns, socio-economic 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/16925881 http://www.ncbi.nlm.nih.gov/pubmed/17762377 http://www.ncbi.nlm.nih.gov/pubmed/11735680 http://www.ncbi.nlm.nih.gov/pubmed/11735680 http://www.ncbi.nlm.nih.gov/pubmed/18556600 http://www.ncbi.nlm.nih.gov/pubmed/18053188 http://www.ncbi.nlm.nih.gov/pubmed/12490645 online journal of rural nursing and health care, 13(1) schmidt, m. d., pekow, p., freedson, p. s. markenson, g., & chasan-taber, l. (2006). physical activity patterns during pregnancy in a diverse population of women. journal of women’s health, 15, 909-918. [medline] seeman, t., merkin, s. s., crimmins, e., koretz, b., charette, s., & karlamangla, a. (2008). education, income and ethnic differences in cumulative biological risk profiles in a national sample of us adults: nhanesiii (1988-1994). social science & medicine, 66(1), 72-87. [medline] united states department of agriculture (usda) (2010). rural definitions: georgia. retrieved from http://www.ers.usda.gov/data/ruraldefinitions/ga.pdf. united stated department of health and human services (2008). physical activity guidelines advisory committee. physical activity guidelines advisory committee report, 2008. washington, dc: author. http://www.ncbi.nlm.nih.gov/pubmed/17087614 http://www.ncbi.nlm.nih.gov/pubmed/17920177 5 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 editorial spiritual assessment: a nursing responsibility linda dunn, dsn, rn, cnl editorial board member on my way to work this morning, i noticed a church marquee that had this message posted: “procrastinators suffer from hardening of the oughteries” (author unknown). i immediately thought about this editorial…nurses must not procrastinate – meeting the spiritual needs of patients will reduce patient suffering (grant, 2004). not having been taught spiritual assessment in one’s nursing program of studies is not an excuse. we have a mandate, as well as a professional responsibility – procrastinate no more! in the last issue of ojrhhc, we focused on the personal responsibility of each nurse in assessing one’s own spirituality as well as evaluating how nursing is addressing spirituality in clinical practice or academia. remember that joint commission requires that nurses provide a spiritual assessment of every patient (jcaho, 2004); however, patient’s are reporting that their spiritual needs are not being adequately addressed by healthcare providers (grant, 2004; ross, 2006). this might be a concurrent problem within nursing curriculums and the healthcare environment. nursing students must be taught how to conduct a spiritual screening/assessment and how to provide spiritual interventions into the patient’s plan of care. likewise, the healthcare environment must continue to promote the systematic provision of spiritual care of patients (cavendish, et al., 2004). one strategy i have used is to investigate where spirituality is addressed within the nursing curriculum at the institution where i teach as well as to investigate how/when nurses assess a patient’s spiritually in the clinical area where i practice. within the clinical practice arena, i was saddened to learn that spiritual assessment is most often done with two questions: “do you have a religious preference?” and “do you need to see a chaplain?” while this is done primarily only on admission, we need to remember that spiritual assessment/care is a continuous process much like physical assessment. recently, i conducted a review of the literature on spiritual assessment and learned that it may be conducted in multiple ways with numerous tools. there are many resources available…for example, go to www.professionalchaplains.org then at the bottom left, click on “new spiritual history tool”. a page will come up “pastoral care – standard of practice” – underneath here you will find several helpful resources for both you and your agency. another site is www.spiritualcompetency.com/recovery/lesson7.html this publication provides a spiritual assessment interview and two instruments: fica and hope. perhaps these materials could provide opportunities for staff development on your clinical unit or within your nursing curriculum. so, stop procrastinating!! let’s not be guilty of the “ougtheries” http://www.professionalchaplains.org/ http://www.spiritualcompetency.com/recovery/lesson7.html 6 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 references cavendish, r., luise, b., russo, d., mitzeliotis, c., bauer, m., & bajo, m.a.m., et al. (2004). spiritual perspectives of nurses in the united states relevant for education and practice. western journal of nursing research, 26(2), 196-212. [medline] grant, d. (2004). spiritual interventions: how, when, and why nurses use them. holistic nursing practice, 18(1), 36-41. [medline] joint commission on the accreditation of healthcare organizations. (2004). spiritual assessment. retrieved october 26, 2007 from www.jointcommission.org/accreditationprograms/hospitals/standards/faqs ross, l.a. (2006). spiritual care in nursing: an overview of the research to date. journal of clinical nursing, 15(7), 852-862. [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15005986%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14765691%5buid%5d http://www.jointcommission.org/accreditationprograms/hospitals/standards/faqs http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16879378%5buid%5d 53 web-based graduate education in rural nursing case management marietta stanton, phd, rn, cmac1 carolyn crow, phd, rn2 ruby morrison, dsn, rn3 diane j. skiba, phd, faan4 todd monroe, msn, rn5 gina nix, msn, rn6 valeria gooner, msis7 1 professor and graduate program coordinator, capstone college of nursing, university of alabama, mstanton@bama.ua.edu 2 faculty emeritus, capstone college of nursing, university of alabama, ccrow@bama.ua.edu 3 associate professor, capstone college of nursing, university of alabama, rmorriso@bama.ua.edu 4 associate professor, university of colorado health sciences center, diane.skiba@uchsc.edu 5 graduate student, capstone college of nursing, university of alabama 6 graduate mentoring coordinator, capstone college of nursing, university of alabama keywords: graduate nursing education, web-based distance education, rural nursing case management abstract the decreasing supply of advanced practice nurses continues to be a problem that plagues america, especially in rural regions. it has been suggested that nurse educators aggressively recruit potential graduate students and provide "easy access" for nurses presently living and practicing in rural areas. web-based or on-line courses not only improve access to graduate education for rural nurses but also provide for high quality teaching and learning experience for both students and faculty. the purpose of this study was to examine what students in a web-based graduate program in rural nursing case management and faculty perceive are the advantages and disadvantages of web-based learning. in this descriptive study, interviews and a written survey were used for data collection. the sample included six faculty teaching in the graduate nursing program at the time of data collection and 29 former students enrolled or graduated from the program. findings revealed by students included difficulties with computer technology, unclear expectations for coursework, and lack of socialization as disadvantages. students identified teacher advocacy and accessibility through distance education as advantages of the program. faculty identified access as the major advantage. disadvantages identified by faculty included lack of socialization for students, faculty workload, and a need for ongoing faculty development. introduction the shortage of advanced practice nurses plagues american health care (hrsa, 1999; hrsa, 2000; johnson, 2000; moses, 1997; o’neal, 1999; sigma theta tau, 2001). according to coffman, blick and wong, 1998, the biggest challenge facing nursing is educating rns for their emerging roles. further, coffman et al. state that partnerships among educators, employers, and communities are needed to develop effective approaches to bridge the gap between the competencies of rns and employers expectations. o’neil and coffman (1998) argue that the challenges confronting nursing online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://nursing.ua.edu/home.htm mailto:mstanton@bama.ua.edu http://nursing.ua.edu/home.htm mailto:ccrow@bama.ua.edu http://nursing.ua.edu/home.htm mailto:rmorriso@bama.ua.edu http://www.uchsc.edu/ mailto:diane.skiba@uchsc.edu http://nursing.ua.edu/home.htm http://nursing.ua.edu/home.htm 54 emerge from the changing health care environment. the formation of health care systems in the future will focus on more managed, integrated, evidence based and ambulatory settings than the current system. nurse educators should provide accessible quality education for advanced practice nursing especially in rural areas (o’neal, 1999). because alabama is primarily a rural state, the capstone college of nursing (ccn) converted its graduate program in rural nursing case management to a web-based format. innovative web-based or on-line courses not only improve access to graduate education for rural nurses but also provide a high quality teaching and learning experiences for students and faculty (billings, connors, & skiba, 2001; o’neal, 1999; paulson, 2002; reavis & brykzcynski, 2002). the majority of the students chose this program because of the rural focus in nurse case management. background bushy (2000) argues for the advanced practice nurse to fill the professional void in rural communities where medical services are limited or non-existent. changes in the health care delivery system have led to the implementation of more university-based educational programs that prepare nurses in advanced practice roles. increased access to graduate nursing education is desirable for rural nurses (bushy, 2000; o’neal, 1999; waddell & hayes, 2000) but not at the expense of a quality educational experience. reviews of the research on distance learning (billings & bachmeier, 1994; daley, mcclelland, & yang, 1994; shomaker & fairbands, 1997) have extolled the benefits of distance-based programs in terms of quality learning outcomes. recent studies have focused specifically on web-based learning (billings et al. 2001; reavis & brykzcynski, 2002; ryan, hodson-carlton, & ali, 1999; waddell & hayes, 2000; woo & kimmick, 2000) outcomes. woo & kimmick, (2000) compared the learning outcomes for students who undertook the web-based or traditional on site versions of the course. they found no significant differences on test scores or student satisfaction. however, waddell and hayes (2000) found that distance-based technologies, especially the web-based courses, may produce a marginalization of minority and rural-based students. concerns raised about distance education included skills with technology, frustration and workload, isolation, fragmented communication, and lack of professional socialization. rural students may be at an even greater disadvantage because of limited technology skills (waddell and hayes, 2000). however, shomaker and fairbands (1997) found that bringing advanced nursing education to rural students increased retention rates of the state’s smaller hospitals and rural health clinics. they concluded that distance education is an innovative and successful method to provide education to rural nurses. hara and kling (2001) state that many advocates of computer-mediated distance education emphasize the positive aspects and understate the workload required and the frustration produced for both faculty and students. this frustration may contribute to increased attrition from a program. although finding grades equivalent between traditional and distance-based students; daly, mcclelland and yang (1994) raised the issue that professional socialization may be significantly hampered by distance education strategies. nurses practicing in a rural environment are already professionally isolated (bushy, 2000) and may not be exposed to role models (waddell & hayes, 2000). in online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 55 another study, ryan, hodson-carlton, and ali (1999) found that students felt disconnected from other faculty and students with internet instruction. the interrupted communication that is natural to web-based learning produced anxiety and frustration for some students. distance education also produced an increased workload for faculty in terms of preparation time and modification of teaching as well as evaluation strategies (billings & bachmier, 1994). a benchmarking study conducted by three schools of nursing and the flashlight project pilot tested a survey instrument used to assess three categories of best practices in web-based courses (billings et al. 2001). the first was use of technology, including student perceptions of the technology infrastructure and the productive use of time. the second assessed students’ perceptions of the seven principles of good practice in education (chickering & gamson, 1987). the last assessed outcomes including access, convenience, connectedness (isolated and missed face-to-face), socialization to the profession, preparation for real world work, proficiency with technology and satisfaction. in this pilot study, billings et al. (2001) found students were satisfied with web-based courses and highly rated convenience and accessibility as outcomes. the students reported missing face-to-face contact and indicated that computer proficiency improved over time. although others frequently mentioned the lack of ability to socialize students as a disadvantage of web-based learning, this study found that students reported socialization positively as an outcome of web-based courses. a study conducted by reavis and brykczynski (2002) described many advantages and disadvantages from both the faculty and nurse practitioner students’ perceptions in regard to distance learning. they found that students liked distance learning for its convenience, accessibility, instant feedback, freedom, opportunity, excitement, networking and flexibility. on the other hand, students felt it detracted from spontaneity and communication. unanticipated deficiencies in personal computer equipment often interfered with effective learning. although faculty objected to the increased workload and felt they needed additional time to learn technology, they enjoyed the creativity and innovation fostered by the use of this technology. methodology for the purposes of this study a descriptive design (polit, beck & hungler, 2002) was used to assess the experiences of faculty and students involved in the ccn webbased graduate nursing program in rural nursing case management. structured interviews were used to collect data from faculty and a survey was mailed to students to ascertain their perceptions. participation in this program evaluation study was voluntary. following an explanation of the study faculty were invited to participate. interviews were conducted privately in the faculty member’s office. return of the questionnaire implied student consent to participate and responses were anonymous. confidentiality of all data was maintained by retaining the data in a locked file drawer in a research member’s office. data was grouped for analysis and no identifying information has been reported. data will be shredded five years from publication of the study. minimal or no risks to participants were identified. interview questions for faculty were constructed based on those questions used by reavis and brykczynski (2002) in their study on web-based learning. content validity online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 56 was obtained by asking a panel of graduate faculty to review the questions for appropriateness. following the review, all questions were either retained or revised as recommended. the faculty interview tool contained specific questions about personal experiences with web-based coursework. faculty responses were transcribed and analyzed by the research team to determine common themes. faculty interviews were approximately 30 minutes each and conducted by the same member of the research team. the faculty population for this sample consisted of the six faculty teaching in the webbased graduate program at the time of the study. the questions for faculty interviews are presented in table 1. table 1 faculty interview questions 1. what are the advantages of distance-based education for our graduate students? 2. what are the disadvantages of distance-based education for our graduate students? 3. can all educational needs of the student be met with on-line learning? 4. what strategies can minimize the disadvantages of distance-based checkpoint? 5. describe your worst experience with distance-based education as a professor. 6. describe your best experience with distance-based education as a professor. the questionnaire to collect data from students contained two components. the first part included specific questions formatted as a likert-type scale whereas the second part of the instrument included narrative responses to provide feedback about participating in distance education (see table 2). the instrument for students was adapted from the flashlight program csi tool kit (ehrmann & zuniga, 1977) and consisted of six items eliciting student perceptions of specific outcomes, educational practices, and use of technology. two open-ended questions asked students what they found to be best and worst experiences with the distance-based master’s program. a third open-ended item asked for any additional comments. content validity of the items for the instrument was established previously by reviewing the nursing literature about web courses and using a national consensus panel of experts in distance education to review the items (ehrmann & zuniga, 1977). the student population for this study consisted of 29 former students of this program. data were collected over a six-month period. a statistician assisted with the analysis of quantitative data and the research team collaboratively analyzed the qualitative data. an exhaustive list of themes was identified and major themes emerged from the data. consensus on major themes was achieved. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 57 research findings qualitative finding-faculty the entire faculty (n = 6) teaching in the distance-based graduate program were interviewed at the time of data collection. each of the faculty interviewed had over 15 years of teaching experience in nursing. the entire faculty sample had some previous table 2 student questions instructions: circle the response that reflects your experience. 1 = not true; 2 = somewhat true; 3 = not sure; 4 = true; 5 = very true 1. if it were not for distance-based learning, you would not have been able to complete a graduate nursing degree. 1 2 3 4 5 2 you felt that your outcome, successful or unsuccessful, in this program was influenced by the use of distance-based learning? 1 2 3 4 5 3. you felt you were able to become a part of your “graduate student class” through on-line conversation on the bulletin board, e-mail, or discussion? 1 2 3 4 5 4. you believe that the education you have received is comparable to that of a traditional onsite program (where you attend classes on campus)? 1 2 3 4 5 5. you would recommend this program to a co-worker or friend? 1 2 3 4 5 6. you were able to communicate your questions or concerns with the faculty and receive timely or prompt responses? 1 2 3 4 5 open-ended questions for students 1. what is the worst experience you have had with this distance-based masters program? 2. what is the best experience you have had with this distance-based masters program? please provide any additional comments. experience with teaching web-based or distance education courses, and four of the six had previous experience teaching graduate courses. data saturation occurred with the fifth interview. all major themes were identified by at least 60 % of the faculty interviewed. faculty identified access to graduate nursing education as the major advantage of the web-based program. the major disadvantages identified by faculty included lack of student socialization, and an increased workload. most faculty felt that distance education could meet student learning needs but that it took a great deal of time and knowledge of technology to make that happen. another major theme identified in faculty responses was that of the need for faculty development prior to implementing distance-based teaching and for ongoing faculty development as technology changes. the major themes identified for each of the questions with illustrative comments appear in table 3. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 58 table 3 faculty common themes and illustrative comments for each themes question theme * illustrative comments # 1 -advantages of distance-based education 1. accessibility to graduate education “convenience”, “accessibility”, “availability and flexibility for students” # 2 -disadvantages of distance-based education 1. decreased socialization of students and faculty 2. increased faculty workload “lack of face-to-face contact” “lack of socialization in an academic environment” “lack of group experience” “faculty virtually available to students any time of day” “faculty need time to learn about technology” “additional workload not recognized by administration in terms of salary” # 3 -educational needs of students can be met with distance education 1. faculty development required “continuous skill development required” “keep on top of technology” # 4 -strategies that minimize disadvantages of distance education 1. use enhanced technology skills “use email to communicate with students on an ongoing basis” “use assignments which encourage online communication with students" # 5 -worst experience with distance education 1. technology difficulties interfere with teaching “distraught students because of timed-testing” “technology problems with power outages, quality of technology” “differences between faculty and student equipment” # 6 -best experience with distance education 1. accessibility and flexibility for students “dealing with students from three states” “observing the commonalities and nursing issues across states” “appreciation of students for this experience and opportunity” * more than 50% of respondents made comments or provided responses associated with the theme. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 59 quantitative findings-students twenty-nine of the 55 students surveyed returned usable questionnaires for a response rate of 55%. the typical respondent was a caucasian female in her thirties. of the 29 respondents 10% were male (n = 3) while 90% were female (n = 26). twenty-four percent of the respondents were african american (n = 7) while 76% were caucasian (n = 22). seventeen of the respondents took the program by distance education (59%) while twelve took the program on site (41%). the majority of the students chose this graduate program because of its focus in rural nurse case management. descriptive statistics were computed on all scale items. there were no differences in responses to survey questions based on demographic variables. comparisons of the demographic variable responses to likert scale items were made based on age, gender and ethnic background using the wilcoxon/mann whitney test. the majority of students (80%) indicated that if it were not for distancebased learning, they would not have been able to obtain their degree. the majority of students (80%) also reported that their educational outcomes were directly influenced by the use of distance-based modalities. less than half of the respondents (40%) felt they became part of the group through conversations on the web-based bulletin board, e-mail, and or discussion groups. all of the students indicated that the education they had received in the distance-based graduate program was comparable to that of an on-site traditional program and that they were able to communicate their questions or concerns to faculty in a timely manner. all of the respondents indicated that they would recommend the program to a co-worker or friend. (table 4). qualitative research findings-students major themes and illustrative comments for each of the narrative questions are delineated. one major theme identified by the students’ as “worst experiences” related to computer competencies or their lack of the requisite skills. a second theme was “unclear expectations for coursework.” “best experiences” included faculty and administration advocacy for them. students said that faculty and administration were very eager to help and support them in pursuit of a graduate degree. an additional comment from one student stated that “extensive research time on the computer was required.” several students commented that they would not have attained their degree without distance based learning. however, the major theme for the responses to this question centered on the student’s perceived lack of interaction with both faculty and their peers. student responses illustrative of major themes are listed in table 4. limitations the small convenience sample limits the generalizability of the findings of this study. however, for those who are interested in implementing a web-based graduate nursing education program in rural areas the findings of this study are relevant. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 60 table 4 common themes for students narrative questions with illustrative comments for each theme question theme * illustrative comments # 1 -worst experience of your masters program 1. computer competencies necessary to complete coursework 2. unclear expectations for coursework theme i “difficulty learning to compose messages” “difficulty posting papers to the bulletin board” “trying to become computer literate and work on graduate studies” “use of software limited paper submission” theme ii “expectations not made clear by professor” “assignments were not clear” # 2 -best experience with distance education 1. teacher advocacy for students “teachers were there for me” “professor bent over backward to help with problems” “faculty were available to help” “program director eager to help with problems # 3 -additional comments 1. lack of social interaction ”i missed face-to-face contact with my instructors” “need to attach a name to a face” “felt strange trying to complete assignments with strangers” “do not know my classmates” “wanted to know someone well enough to talk to them about problems with school and my personal situation” *more than 50% of respondents made comments or provided responses associated with this theme conclusions and recommendations the findings for both faculty and students in this study were consistent with findings of reavis and brykczyski (2002) and paulson (2002). in addition to the themes identified in those studies, faculty identified a major concern as a need for ongoing faculty development especially in web-based teaching technology. the findings of this study are congruent with paulson’s (2002) assertion that “projects continually online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 61 rediscovered the need to educate faculty, administrators, and students not only about the technologies used in distance education but about pedagogical approaches that work in distance education and the special needs of students learning at a distance” (p. 41). review of faculty and student responses led to several recommendations and conclusions for web-based graduate nursing education: 1. accessibility of the program to nurses, especially in rural, areas outweighs the disadvantages of distance-based education. therefore, the web-based format should continue to be an option of choice. 2. the web-based approach to graduate education provides a unique opportunity for increasing the supply of advanced practice nurses in rural area. 3. an aggressive faculty development program needs to be implemented and ongoing in order to integrate the latest technology into coursework and enhance student learning experiences. 4. on-going student and faculty course evaluations must be both formative and summative in order to ameliorate difficulties promptly. 5. clear specifications of computer requirements and testing of student personal computers prior to starting courses is needed to ensure the student has the proper equipment to effectively navigate the program and complete coursework requirements. 6. an on-line orientation to the web-based program should be provided prior to entry into the program. 7. further exploration of socialization strategies via the internet is needed. 8. analysis of faculty workload and best practices is needed for policy and guidelines. 9. development of policies and guidelines reflecting best practices in web-based courses is vital to future success. findings are congruent with conclusions of previous studies involved in distance education or web-based programs. the challenge to develop and practice creative strategies to increase socialization is imperative. web-based courses clearly improve access to quality graduate nursing education. the potential to improve the health of people in rural communities by advanced practice nurses is limitless. a decade ago, the american association of colleges of nursing (aacn, 1994) and the american nurses association (ana, 1996) recommended that congress pass legislation to support initiatives that would help improve rural consumers access to health care. the recommendations included: a) provision for direct reimbursement to advance practice nurses in rural and underserved areas, b) allocate federal and state funds for telecommunication infrastructures to educate and recruit nurses, and c) encourage collaboration among hospitals, professional nursing schools, and communities to create rural practice (bushy, 2000). online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 62 the ccn web-based graduate education in rural nursing case management is a federally funded initiative that meets the recommendations for improving access to health care for rural consumers. references american association of colleges of nursing. 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[medline] online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12422842&query_hl=110 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10512468&query_hl=117 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9309568&query_hl=120 http://www.nursesource.org/facts_shortage.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10860311&query_hl=127 open-ended questions for students 1. what is the worst experience you have had with this distance-based masters program? microsoft word yonge_article 47 preceptorship placements in western rural canadian settings: perceptions of nursing students and preceptors olive yonge, rn, phd1 linda ferguson, rn, phd(c)2 florence myrick, rn phd3 1 professor, faculty of nursing, university of alberta, olive.yonge@ualberta.ca 2 professor, college of nursing, university of saskatchewan, linda.ferguson@usask.ca 3 associate professor, faculty of nursing, university of alberta, florence.myrick@ualberta.ca keywords: nursing education, preceptorship, grounded theory, nursing students, nursing preceptors abstract this article reports on one theme from a grounded theory study examining the experiences of fourth year nursing undergraduate students and their rural-based preceptors. the preceptors reported issues concerning orientation and communication with faculty, integration of students into care, severe weather conditions, and lack of resources whereas the students reported issues with relocation to rural centers, accessing information, faculty contact, travel and accommodation. addressing these issues as well as increasing theoretical content related to rural nursing practice may be effective in recruiting younger nurses via positive preceptorship experiences to rural practice, thus ensuring rural residents continue to have access to limited health services in rural settings. the findings have implications for the role of faculty in preparing, orienting, and supporting both preceptors and students. introduction daily, nurse educators face the challenge of providing students with opportunities to learn how to cope with an escalating body of knowledge, rapid advances in science and technology, and ongoing health care changes and reform (jacobs, ott, sullivan, ulrich & short, 1997; laschinger & macmaster, 1992). in any professional discipline, the acquisition of knowledge is embodied by its application in the practice or field setting and particularly so in nursing (myrick, 2002; scanlan, 1996). preceptorship, in the final year of the undergraduate nursing program, is the primary approach to the promotion of knowledge through application (myrick & yonge, 2003). specifically, preceptorship experiences for nursing students in the rural setting expose them to the knowledge and expertise of nurses working in a complex practice environment. the unique characteristics of rural practice include: more independent practice in smaller centers; intricacy of work; distance from the educational institution and supervising faculty; limited access to educational experiences and resources; and difficulty in recruiting nurses to the setting (macleod, kulig, stewart, pitblado & knock, 2004). the purpose of this article is to describe one theme emerging from a grounded theory study, whereby the authors studied preceptors and students in rural settings. the primary methods of data collection were guided interviews with rural-based preceptors and students, augmented with written field notes, and available documents such as course outlines. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://www.nursing.ualberta.ca/ mailto:olive.yonge@ualberta.ca http://www.usask.ca/nursing/ mailto:linda.ferguson@usask.ca http://www.nursing.ualberta.ca/ mailto:florence.myrick@ualberta.ca 48 background the setting for this project is rural alberta and saskatchewan. statistics canada (1993) defines a rural area as a place having a population of less than 1000 and a density of less than 400 persons per square kilometer. in canada, the term rural might be perceived as referring to areas in which access to health care services is limited by distance and lack of qualified care providers, particularly physicians (alberta physicians resources planning group, 1997). in 2000, 41,502 registered nurses (rns) worked in rural canada, more than half of them in part-time positions, and consisted of 17.9% of the total number of rns employed in nursing nationwide. as well, as with the nursing profession generally, the rural nursing workforce is aging, with an average age of 42.9 years, an increase of 2.3 years since 1994 (canadian institute for health information (cihi), 2002). recruitment of new graduates to rural areas therefore can only be enhanced by the provision of high quality precepted student learning experiences. review of the literature nurses working in rural areas are described as having the ability to function autonomously, adapt nursing interventions to low-tech environments, to be expert generalists (bushy 2001), and frequently extend their practice into the domain of other health professionals (weinert & long, 1989). rural nurses have higher than average turnover rates, while those who stay in the setting cite job satisfaction and team work as reasons for continuing to practice in the setting (hegney, mccarthy, rogers-clark, & gormann, 2002). beatty (2001) noted little has been done to investigate rural nurses’ learning needs or the context of their practice setting. in addition, professional isolation prevents these nurses from networking with colleagues. rural nursing is recognized as a practice setting that requires nurses to be flexible, able to engage in more autonomous practice, and be able to expand the nursing role into the scope of practice of other health care professions as appropriate (kenny & duckett, 2003; lauder, reynolds, reilly & angus, 2001; long & weinert, 1999). rural nursing requires nurses who are generalists with strong assessment and case management skills (bushy, 2001; kenny & duckett, 2003; long & weinert, 1999). kenny and duckett (2003) suggest the complexity of rural nursing practice necessitates masters-prepared advanced practice nurses; however, most new nurses in canadian rural settings are recruited from undergraduate or diploma nursing programs. nurses in rural practice in canada are aging and are on average 42.9 years of age. in alberta and saskatchewan, rural nurses on average are even older (43.9 and 44.2 years respectively) (cihi, 2002). combined with national and worldwide nursing shortages, this demographic trend creates the imperative to recruit new nurses to rural practice settings. according to nichols (1999) and baird-crooks, graham and bushy (1998), an effective means of achieving this end is to address rural nursing issues in undergraduate curricula and expose students to rural nursing during their educational programs. preceptorships in rural practice settings during students’ senior years provide an ideal means of providing rural nursing experience under the supervision of experienced rural nurses. at this time, little is known about rural-based preceptorship experiences. since all students in western canada are offered and often encouraged to accept a rural online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 49 preceptorship experience, it was timely to begin to research this type of teaching. as educators, the authors are strongly committed to developing research evidence for teaching and learning. furthermore, the authors selected this setting recognizing the challenges of rural nursing and appreciating the uniqueness of the setting for nursing students, and recognizing rural preceptors too held unique views about their participation in the preceptorship process. methods the study design is a grounded theory with the intent of developing a middle-range theory that can be empirically tested (streubert & carpenter, 1999). as well, this method affords the researchers an opportunity to deal directly with what is actually going on in the preceptorship experience. “the grounded theory method tells it like it is” (glaser, 1978, p. 14). fourth year students were invited to participate via classroom presentations and a written information letter. their assigned rural preceptors were invited through a written information letter followed by a telephone call. all participants meet the criteria: to speak and understand english; be involved in a structured rural clinical preceptorship of 340 hours; and sign a consent form agreeing to participate in the study. prior to commencement of the study, the researchers sought permission from the deans of their respective faculties/colleges of nursing, and the clinical agencies in which the preceptorship experiences took place, and ethical approval from the appropriate ethics review committees. to ensure credibility of the data, participants were asked to review transcripts of their interviews, make any desired changes or deletions and sign a transcript release form indicating their willingness to release the data to the researchers. to ensure confidentiality, names of the participants were removed from the tape recordings, written transcripts and field notes, and replaced with randomly assigned code numbers. data collection data were collected, including demographic data, in nurses’ respective work settings through interviews, field notes and document analysis. initial interviews followed an interview guide and contained open-ended questions to help facilitate participants’ freedom of response (strauss & corbin, 1990). subsequent interviews were guided by the emerging categories. twenty six preceptors and twenty three students were interviewed. see tables 1 to 3 for description of the sample. the authors had hoped to engage in participant observation but both the preceptors and students expressed unease at being observed. data analysis as with any grounded theory method, analysis of the data began with the first interview. this immediate analysis was used to direct the study by using theoretical sampling to fully explore issues and patterns (glaser, 1978). the authors were able to generate inductively substantive categories and their attributes (mullen, 1975). these categories were coded and clustered, and relationships among the clusters emerged (stern, 1980). next, data were organized around the interrelation of the substantive codes (glaser, online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 50 1978) and dimensions of the categories were established. saturation of the data occurred and major recurring themes emerged. more incidents confirmed but did not further develop the emergent theory. rigor to maintain rigor, the following criteria were used: credibility; fittingness; and auditability (guba & lincoln, 1989). credibility was addressed by developing rapport, establishing trust and working collaboratively with the preceptors and students. findings were validated with the participants via member checks and structured feedback (guba & lincoln, 1989). fittingness, the recognition that findings can fit into contexts beyond the study (kirk & miller, 1986) and be meaningful to individuals outside of the study was augmented by collection of data from two different programs and multiple rural settings. auditability, the ability of other researchers to follow the thinking, decisions and methods used by the original researchers and, if strong, allows other researchers to arrive at similar, not contradictory, results and conclusions (yonge & stewin, 1988) was established through a comprehensive audit trail. results students’ perceptions of rural placements the majority of students in the study had requested a rural placement for their final preceptored practicum experience. typically, these students originated from or grew up in smaller towns, had accommodation, family support, previous positive experiences in small towns, or they did not like ‘big cities’. several stated directly they were more comfortable in the rural setting. some of the students expressed their enjoyment of the ‘family feel’ that coincides with a rural hospital. the reasons they cited for requesting rural placements included: the variety of experiences, challenges, and areas in which they would be working. they use the words ‘floating around’ as a positive attribute of the practice setting, a perspective expressed in the following quote, it’s been challenging because i’m going to so many different areas, but it’s a welcome challenge. i’m happy to be having the wide range of experiences i am having. the experiences i’m getting are so diverse, you know. you go from working with pediatrics to working with the elderly, from emergency to labor and delivery and it’s just that there’s some variety. students selected rural placements as part of their career planning and several expressed interest in returning to the rural setting to work once they had finished school, as captured in the following quote, i’m going back to the rural setting. absolutely. i’m a farm girl. i was born and raised in a small community and i'm headed back to a small community. not the same one i was born and raised in, but absolutely, i’m going to be a rural nurse. another student countered the perceptions of this student by commenting on the dynamics that could occur in a small hospital. she states, i don’t want to be stuck in a small town. because i grew up in a small town and i don’t want to be in a small town. in small towns, there are not a lot of opportunities for positions. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 51 it’s all seniority and these people have been here for years and years and years, so right now i don’t want to be in a hospital…not because i don’t like it... really, i like the variety of everything….i just don’t want to be in a small town. a few students who had not requested a rural placement but were placed there, were pleasantly surprised to find their rural experiences were proving to be both challenging and fulfilling. in fact, some students discovered their negative assumptions about rural nursing practice were unfounded once they were in the practice setting. most commented on the challenging nature of client care in acute care environments and holistic nature of community nursing practice, both unexpected findings for them. the disadvantage of being in rural placements was the lack of technology in the rural hospitals particularly in terms of computer use. if there are computers, the students’ knowledge of use often surpassed that of the hospital staff. as well, many students commented on the fact that contact with their university instructors had been limited and often only one short site visit occurred. one student mentioned a sense of isolation and believed students in rural placements did not have academic support. their sense of isolation was heightened by lack of peer contact and support. there was also unpredictability with patient numbers, ranging from a demanding patient assignment to too few patients whereas in urban centers, the patient census did not vary as widely. students were often pleasantly surprised by the complexity of some rural client needs and care, having assumed that more complex clients would be admitted to urban centres. preceptors perceptions of rural placements preceptors and students shared many similar perceptions. preceptors believed students had more exposure to different clinical areas in a rural setting. they believed their practice was unique and demanding, and not every nurse could work in a rural area. numerous times, they commented they were generalists who had to be alert in patient care, as noted in the following quote, ‘working in a rural hospital you can have so many things going on. you can have a really sick patient on the unit; you can have someone in labor; you can have something major going on in emergency and you kind of have to stay on top of things.’ like the students, they used the words ‘variety of experiences’, ‘doing everything’ and ‘challenging’ when describing the nature of their work. preceptors often referred to the differences between a rural and urban setting. in a rural setting there was increased opportunity for intersectorial networking, time to spend with patients, and time for the preceptor and student to spend with each other, particularly if they were driving together. preceptors also identified more opportunities to effect change and be involved in front line work. as well, they noted staff role modeled positive working group dynamics given they live in the same geographic area. lastly, as a limitation, rural settings did not have the resources of the urban centers, in terms of other health care professionals, specialists, or computers. just as they sent patients to the urban area for specialist care, the urban centers sent certain types of patients back to them. if the latter occurred, the health care agency had no choice but to accept them because the patient was ‘at the end of the line and has nowhere else to go’, resulting in unpredictable workloads and more long-term care and palliative clients. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 52 all in all, preceptors believed students obtained a better education in a rural setting given the ease by which student experiences could be arranged and rearranged and the way the staff worked together to facilitate student learning. the following quote captures this sentiment, ‘our unit is a combined unit – it’s a very bizarre combination of geriatrics, medical, psychiatry, icu and pediatrics. we have this vast arrangement of patients. now if i’m pulled into icu one day and it’s maybe not the best experience for the student, then one of my co workers will take the student under his or her wing that day and so the ward functions very nicely.’ rural preceptors often commented they received the ‘best students’ in rural placements, often evaluating their practice as excellent or exceptional. they assumed students who were experiencing difficulties in their nursing practice and thus requiring more observation were assigned to urban centers so faculty instructors could give support to students and staff. they too recognized the rural setting was not for every student particularly if they had rigid expectations for practice and were unable to be flexible. like the students, they too recognized the unpredictability of the workflow in acute or long-term care settings as reflected in the following quote, ‘i would have liked her to have a bit more experience with some things, but we just had some shifts where nothing happened. and that’s just the chance you take in a rural setting. you can end up with crazy stuff or you can have nothing. we kind of had a bit of a slow spell while she was here. this is unusual, because we’re usually full. sometimes you just have a lull.’ community-based preceptors also commented on the effect of the weather on their practice, indicating at times, severe winter weather could affect clinical experiences in communities to which they traveled. although they could arrange experiences for students with greater ease than their urban counterparts, they couldn’t control the impact of poor conditions on their own traveling or on client attendance at the pre arranged appointments or clinics. unlike the students, preceptors commented they often personally knew the patients or the patients’ family in this setting whereas urban nurses were less likely to know their patients. this could be a disadvantage if the patient did not want to be nursed by the student, someone they did not know. often the patients wanted the nurse they knew personally to be assigned to them and were wary of someone new and not primarily because it was student assigned to them. the following quotes capture this relationship, ‘it’s a small community. we know a lot of the clients that we are working with and their family circumstances. what she was telling me sounded reasonable for the situation… it’s different that in the city where your nurses wouldn’t know those families so well. i think that’s another plus of the rural areas, you know you see the babies in the baby clinic, you see their grandparents at the flu clinic. you know the whole family so you live in the community you know so and so and not in a, you know, in a gossipy way but you know.’ the nurses used their knowledge of the community to enhance their nursing care and derived personal satisfaction from these relationships. like the students, preceptors also noted they did not have the contact with the faculty instructor when in the rural setting as opposed to what they imagined happens in the urban setting. many indicated they would like more contact even if it were just in the form of telephone calls. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 53 discussion in this study, approximately 60% of preceptors were over the age of 40 years and most were diploma-prepared. all students were in their fourth year of baccalaureate nursing programs and the vast majority (95.7%) were in their twenties. several students commented on the ‘diploma-degree’ controversy that may have affected the willingness of rural nurses to preceptor, as did several preceptors who indicated a lack of confidence in the currency of their nursing knowledge. because most rural nurses in canada are diplomaprepared (82%) (cihi, 2002), nursing faculty may need to address the importance of a preceptor’s practice or experiential knowledge when endeavoring to recruit rural nurses as preceptors. as well, over half of the rural nurses in canada (50.3%) (cihi, 2002) are employed part-time, frequently resulting in preceptorships where two nurses function as joint preceptors for a single student. this arrangement may have some beneficial aspects for student learning but can also result in orientation and communication difficulties for students and supervising faculty. considering these employment demographics, faculty may need to reconsider their orientation and communication strategies to involve both nurses in their discussions of student progress. if faculty are not flexible in accepting this arrangement, they may be limiting the number of preceptorships rural agencies are willing to host. preceptors in this study were proud of their practice in rural settings and believed they had unique and challenging experiences to offer nursing students. they were enthusiastic in their selection of clinical experiences for students, believed they had more control over the learning experiences and had greater opportunity to offer students intersectorial networking, holistic care, and autonomous nursing practice. they also indicated greater opportunity to address mental health issues in their client populations, a vastly underserved issue in rural settings (lauder, reynolds, reilly & angus, 2001). they perceived the preceptored experience as a means of recruiting new nurses to the setting and willingly supported offers of employment to graduating students. several believed their preceptored students who experienced positive nursing practice in the rural setting may consider rural practice later in their careers. they supported students in their desire to work in urban settings upon graduation to increase their skills and confidence levels prior to rural practice. preceptors acknowledged some limitations in rural placements for students, not the least of which was the lack of resources for nursing practice. long and weinert (1999) suggested rural nurses need to be orientated to techniques for accessing diverse sources of current information especially when access to journals and current textbooks may be limited. unfortunately, some rural settings did not have computerized documentation systems or access to the internet. in many instances, because student skills in internet and computer use exceeded that of their preceptors, they were involved in retrieving information that was useful to both student and preceptor. although this arrangement may have limited student learning in various ways, it also allowed for mutuality in the precepted relationships; students could assist their preceptors in information retrieval or presentation preparation, often completed on a secretarial computer after hours. preceptors also expressed concern about lack of immediate access to faculty, assuming that urban-based preceptors met with supervising faculty on a regular basis. they expressed the need for more frequent contact with faculty, acknowledging the telephone online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 54 would be the most useful means of maintaining this contact. it may be advantageous for faculty to formally establish a communication contact system with preceptors whereby exact times and dates for contact are established prior to the rotation. even though preceptors recognized it is not realistic to expect faculty to travel great distances to meet with them, they still wanted frequent contact. in several instances, preceptors viewed the preceptoring experience as a means of continuing their professional education in part from the stimulus of student questions and through interactions with faculty. this aspect of preceptoring may be an important recruitment strategy if nursing programs are to increase the rural nursing experience in their programs. students who requested rural placements often did so because they had prior experience in rural settings. considering the needs of rural residents for more accessible health care, all students would benefit from greater knowledge of rural nursing practice. such a strategy could also facilitate recruitment of new graduates to rural practice settings. providing rural experiences for all students necessitates addressing rural nursing issues in theoretical content throughout the program and encouraging practical experiences in senior years of programs (baird-crooks, graham & bushy, 1998; bushy, 2003). in doing so, faculty may be able to address erroneous assumptions about rural nursing. students in rural placements consistently commented on the complex nature of the practice, opportunities for autonomous nursing practice, the need for strong assessment skills, and provision for holistic nursing care. contrary to some expectations, they were challenged. student issues about rural placements often related to personal difficulties with finances, locating accommodation, or maintaining current residences and jobs while out of the city. student support regarding these personal issues could facilitate more students in rural preceptorships. in addition, students often found by requesting rural placements, they obtained experience in desired practice areas that were severely over-subscribed in urban centers. students are entering an established culture whereby long term relationships are formed in the rural community (moran & reel, 2003). essentially the student is a stranger and one that wants to learn intimate health and illness details of the patient’s life and then leaves the setting. preceptors have long term relationships with the patients and not the students, know the patients and are respectful of their privacy and assess what information is appropriate to be disclosed to the student. they may ask the patient’s permission to include a student in the delivery of care or decide a prior that it would not be appropriate for a student to work with a particular patient. lee and winters (2004) discuss the concepts of anonymity and familiarity when describing rural nursing theory whereby everyone knows who others are and what they are doing. in this study, preceptors were acutely aware of these concepts and ensured students were introduced to others but this did not mean they could automatically care for all patients. conclusions countries such as canada with a large rural population and distant health services throughout rural regions must address issues of preparing health care professionals to provide health services in these settings. a positive preceptorship experience for both the student and the preceptor could significantly impact recruitment. as nurse educators we must understand the perceptions of the students and preceptors to better prepare, support online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 55 and guide them through the experience. this study highlights the importance of preparing student to learn in rural 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http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=2772454%5buid%5d abstract 47 perspectives of registered nurse cultural competence in a rural state part i teresa j. seright, msn, rn1 1 instructor, department of nursing, minot state university, teresa.seright@minotstateu.edu abstract inferences have been made from recent research that there is a correlation between lack of cultural competence and the incidence of health disparity. as our society becomes more global and more diverse, it is apparent that culture can no longer be considered as solely associated with ethnic/racial/cultural groups. nurses permeate all areas of health care and are therefore in a position to have positive impact on cultural competency. this paper describes the 5 constructs of cultural competence as described by dr. josepha campinha-bacote: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. she emphasizes, as do others in the literature, that cultural desire and awareness are antecedents to knowledge acquisition and skill. is mere cultural awareness enough? how do healthcare providers in homogenous rural states attain cultural competence when cultural encounters and cultural knowledge may not be readily accessible? this is the first in a series of two articles which explores cultural competence of health care providers in a rural state. the first article in the series provides literature review and definitions related to cultural competence as well as the impact of cultural competence. the second article reveal results of a cultural competence self-assessment survey of registered nurses in north dakota, a sprawling rural state described as 9th in the union for percentage of caucasions and 5th in rank for the most american indians. overview of cultural competence in march of 2002, the institute of medicine (iom) released the report, unequal treatment: confronting racial disparities in health care. the iom report concluded that evidence suggests that bias, prejudice, and stereotyping on the part of health care providers may contribute to differences in health care (institute of medicine, march 2002). while the iom’s report focused on racial and ethnical diversity, the american psychological association (apa) defined ten groups of persons in their ethics code. these included persons of differing age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language and socioeconomic status (apa code of ethics, 2002). logically, nurses can expect to care for patients that identify with the disenfranchised segment of one or more of these groups. culture can no longer be seen as solely associated with distinct ethnic/racial/cultural groups. nurses who are able to operate from a perspective of cultural competence will rapidly learn that culture is a component of all human life, including health and illness, and not something that mainly affects persons who are ethnically, racially or socio-economically different from them (desantis, 1994). diversity in north dakota us census data from 2003 revealed, not surprisingly, that the majority of the state of north dakota is caucasian (north dakota fact sheet, 2005). north dakota ranked as the 9th most white, or caucasian state in our union. it was fifth in rank for the state with the most american indians or alaskan indians (ai/ai). american indians and hispanics made up the online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.minotstateu.edu/nursing/ mailto:teresa.seright@minotstateu.edu 48 largest population of diverse cultures in our state of 609,691 (north dakota fact sheet, 2005). of the american indians living in north dakota, 40.2% of them did not live on reservations (north dakota indian affairs commission, 2005). census demographic data may not have included some groups living in our state, for example the data did not accurately account for the number of migrant workers in our state. the numbers of non-white races residing in our state may have been under represented on u.s. census polls as this data was limited to household populations and excluded those living in institutions, college dormitories, and other group quarters. it has been reported that over 22 languages are spoken in the north eastern part of the state where there has been a steady influx of refugees over the past 2 decades. they come from several international hot spots: kurdistan, haiti, russia, bosnia, zaire, vietnam, somalia, sudan, cuba, armenia, and iraq. cultural competency and nursing care in north dakota health care providers have received criticism about an overall lack of cultural competence, which may be linked to health disparities, decreased patient satisfaction, and decreased patient compliance. as research begins to tie health disparities to cultural diversity, the mandate for professional cultural competency strengthens. the commission on collegiate nursing education, the national league for nursing, most state boards of nursing, and other accrediting and certification bodies required or strongly encouraged the inclusion of the aspects of cultural care in nursing curricula and health care provider competencies (andrews and boyle, 2002). diversity training and cultural competency educational courses have been included in university and hospital educational programs around the country. the impact of these programs remains to be seen. the national mental health association made a strong statement that supports this thought: “many health systems simply pay lip service to this concept. some organizations claim to be culturally competent, but don’t have appropriate procedures in place to address diversity” (as quoted in meadows, 2000). there were not standard guidelines in place to help educators effectively design, evaluate, or report the interventions used to increase cultural competence (price et al. 2005). although the majority of our state’s population is white, nurses cannot be excused from accountability in providing culturally safe and congruent care. the process of becoming culturally competent takes time and commitment. an ongoing nursing education program must focus on developing the knowledge and skill required to evolve along the continuum of cultural competence (salimbene, 1999). an informal telephone survey of the staff education coordinators of 6 urban hospitals in north dakota on june 28, 2005 revealed that all six facilities had training on cultural competency/diversity in place. the types of training and the frequency with which the programs were held varied from facility to facility. none of the hospitals surveyed reported a mechanism for evaluating the effect of these programs. cultural competence: a review of the literature the concept of cultural competence has become a dominant force not only in health care, but also in business (hampden and tropenaars, 1997; trompenaars and wooliams, 2004), social work (patti, 2000), education (silverman, 2005),and psychiatry (green, 1997). the united states department of health recognized the impact of cultural competency as it related to online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 49 health disparity as outlined in their publication, the problem of accessing health care, (meadows, 1999). the web site for the bureau of primary health care (bphc) (2005) described cultural competence as a journey. the bphc has partnered with the national center for cultural competence (nccc) as a part of a strategic plan to enhance culturally competent services. leininger claimed to be the first to have coined the term cultural competence (burcham, 2002). a search of her books through 2002, elicited a definition of culturally competent nursing care as “the explicit use of culturally based care and health knowledge in sensitive, creative, and meaningful ways to fit the general lifeways and needs of individuals or groups for beneficial and meaningful health and well-being or to face illness, disabilities, or death” (2002, p. 84). leininger other wise used the term cultural congruence when describing culture specific care that is safe and appropriate. spector (2004) defined cultural competence as an ability by health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought to the health care experience; a complex combination of knowledge, attributes and skill. paulanka and purnell (1998) emphasized the importance of self-awareness, respect and conscientious thought processes in their definition. andrews and boyle (1999) qualified cultural competence as a process as opposed to an end point. campinha-bacote (2003) also de-emphasized the idea of an end point in reaching cultural competence. she defined cultural competence as a process in which the nurse continuously strives to achieve the availability to effectively work within the cultural context of a client, individual, family or community. bell and evans, as quoted in campinha-bacote (2003), caution against cultural blindness when one is progressing through the stages of cultural competence: “in this interacting style, the health care professional has made a decision that he/she is committed to equality for all people and therefore treats all people alike, regardless of cultural background” (p. 23). this type of interacting style lends to misinterpretation of verbal and physical cues made by the patient and ignores the fact that there are variations within cultural groups. attributes and antecedents of cultural competence a literature search of nursing publications yielded a fair amount of consistency in definitions and attributes of cultural competency (table 1). awareness can be counted not only as an attribute, but also as an antecedent. the health care provider must first be aware of the need for knowledge and of one’s own competency level pre-education before a quest for competency can begin. burcham (2002) mentioned cultural awareness as an attribute and as an antecedent. leininger (2002), purnell (1998), and spector (2004) all described awareness of one’s own beliefs and values as one of the first steps in achieving cultural competency. the nccc conducted a number of activities to meet its goal of assuring high quality healthcare that is culturally and linguistically competent (nccc, 2005). some of those activities included provisions for self-assessment for both individual providers and organizations (nccc). in this way, health care providers can gauge their needs and plan pertinent educational activities. in order to meet the attribute of cultural respect/sensitivity, the nurse must operate from an attitude of respect. there is no room for ethnocentricity on the part of health care providers. galanti (1991) supported this thought, stating that viewing the health behavior of others from a perspective that is culturally relativistic can only help us achieve our goals of providing safe, meaningful and appropriate care. while some in health care may argue that “they should learn online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 50 table 1 attributes of cultural competence cultural awareness the ability to analyze one’s own biases and prejudices towards other groups andrews and boyle (1999) awareness of one's own existence, sensations, thoughts, and environment without letting it has undue influence on those other backgrounds. self examination and in-depth exploration of one’s own cultural and professional back ground paulanka and purnell (1998, p. 2) campinha-bacote (2003) understanding of one's own cultural values, biases, and traditional health/belief practices spector (2004, p. 325) cultural knowledge acquiring knowledge of cultures other than one's own andrews and boyle (1999) achieving sound educational foundation regarding a variety of cultural races/world views campinha-bacote (2003) demonstration of understanding of the client's culture paulanka and purnell the nurse remains alert to using nursing, medical, and humanistic knowledge to understand the client leininger (2002, p. 123) cultural skill process that is greater than just fact gathering-it is focused, systematic, reflective and evaluative smith (1998) sensitive, creative and meaningful care practices [adapted to] fit with the general values, beliefs, lifeways of clients for beneficial health care. the ability to collect relevant cultural data regarding the client’s presenting problem as well as accurately performing a culturally based physical assessment leininger (2002, p. 12) campinha-bacote (2003) cultural encounters culture care is focused on discovery and learning about the meanings, patterns and uses of care within cultures leininger (2002, p. 57) the process that encourages the health care provider to directly engage in cross-cultural interactions with clients from culturally diverse backgrounds. campinha-bacote (2003) development of mutually satisfying relationships with diverse cultural groups involves good interpersonal skills and the application of knowledge spector (2004) if all cultures could study each other's techniques with a culturally relativistic perspective, the cause of modern medicine would be greatly advanced galanti (1991, p. 9) when individuals of dissimilar cultural orientations meet, the likelihood for developing a mutually satisfying relationship is improved if both parties attempt to learn about each other's culture paulanka and purnell (1998, p. 2) cultural respect/sensitivity it is imperative for those of us who deliver health care to be understanding/sensitive to cultural differences…" spector (2004, p.30) cultural respect implies that the provider possesses some basic knowledge of and constructive attitudes toward the traditions observed among the diverse cultural groups found in the setting in which they practice spector (2004, p. 8) cultural proficiency/development represents a commitment to change and is evidenced by demonstration of new knowledge and cultural skill and information sharing. cultural competency is a process. burcham (2002, p. 10) campinha-bacote (2003) to be even minimally effective, culturally competent care must have the assurance of continuation after the original impetus is withdrawn paulanka and purnell the nurse assesses his/her competencies and areas that need to be strengthened or modified. leininger (2002, p.28) online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 51 our ways”, this attitude is not helpful. what better way to advocate for a patient than to exhibit an understanding of where he/she is coming from? this truly is patient advocacy and is key to effective nursing (devries, 1999). acquisition of knowledge and skills pertinent to the culture or cultures for which the nurse is caring is an essential antecedent as well. there were many texts, web sites, videos and journal publications found on the topic of cultural competency. most of these described not only the concept of cultural care and or competency, but also described cultural characteristics and health habits of specific cultural and ethnic groups. texts utilized for this literature search included those by spector, campinha-bacote, leininger, purnell, andrews & boyle, and galanti. as these authors note within their texts, the nurse/health care provider must be alert to stereotyping and must understand that within cultures, variations do exist. these authors defined cultural competency as being on a continuum with emphasis on the need for constant reevaluation. consequences of cultural competence if cultural competency is on a continuum, then proficiency could be considered an outcome or consequence of cultural competency. burcham (2002), purnell (1998), campinhabacote (2003), and leininger (2002) supported this concept. the bphc (2005) measures the following outcomes: • improved diagnoses and treatment plans • development of treatment plans that are followed by the patient and supported by the family • reduction in delays seeking care • enhanced overall communication • enhanced compatibility between western and traditional cultural health practices the quality and culture website (2005) contained commentary on the research to date which, summarized, explains that culturally competent health care practices could have an impact on disparities. for example, spanish-speaking emergency department patients who spoke through an interpreter were more satisfied than those who said an interpreter should have been used. patient satisfaction, then, is a consequence of culturally competent care. practitioner satisfaction, logically, would also increase as patient compliance with plans of treatment increased. this could mean fewer return visits by the patient and hopefully attainment of optimal health. leininger made mention of safe and appropriate care as a consequence of culturally congruent care. indeed, regulatory agencies such as the office of minority health (omh) and the joint commission on accreditation of health care organizations (jcaho) promoted cultural competency as a means of providing safe patient care. jcaho supported hospitals, language, and culture: a snapshot of the nation, which was a 30 month project designed to gather data on a sample of hospitals to assess their capacity to address language and culture issues as they impact the quality and safety of patient care (jcaho, 2005). in december of 2000, the omh published the final recommendations on national standards for culturally and online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 52 linguistically appropriate services in health care (clas) (ross, 2001). the first standard listed was a mandate that health care organizations should ensure that all staff members are providing care that is compatible with the cultural health beliefs, practices, and language of their customers (ross, 2001). jcaho required hospitals to assess patient’s learning needs. part of this assessment involved evaluating cultural beliefs as they might impact learning. during informal discussions with health care providers in one north dakota acute care facility, it was revealed that some nurses were not sure what to do if cultural barriers were defined in the assessment. some of these nurses offered up the idea that they would use an interpretation service that was offered through a phone company, or would draw from a list of local interpreters if there were a language barrier, but none were able to list other possible interventions or assessment techniques. conceptual definition of cultural competence cultural competency can be conceptually defined as a referent to an individual who demonstrates cultural awareness, knowledge and skill and applies these components as he/she interacts with patients, co-workers, and customers. further, the culturally competent individual operates from a platform of respect for others. he/she continuously self-assesses and adjusts to the dynamic and challenging opportunities in remaining culturally aware and effective. review of related studies a review of scholarly publications revealed that there are few published correlational studies on cultural competence specific to nurses in health care settings. in june of 2005, price, et al published a review of the published studies that evaluate cultural competence training of health care professionals. under their eligibility criteria, only 64 articles were suitable for review. of those, most all measured provider outcomes (price, et al., 2005). a study published by narayanasamy (2003) explored qualitatively how nurses respond to their patients’ cultural needs. the findings from this study reveal that while this sample of 126 nurses were able to give accounts of ways in which they responded to their patients’ cultural needs, the nurses may have been operating from assumptions and stereotypes rather than from a culturally competent platform. narayanasamy (2003) also noted that the study might have implications for nurse education in that the participants expressed a need for further professional development in cultural knowledge and skills. coffman, shellman, and bernal (2004) reviewed the use of the cultural self-efficacy scale (cses) that had been developed by bernal and froman in 1987. they analyzed the use of the cses from 1987 to 2002. their method of survey and literature search revealed 26 known uses of the scale (coffman et al. 2004). the authors eliminated 11 studies and reduced the pool of eligible studies to 15. these authors reported that the cultural self-efficacy literature indicated that the “samples of american nurses and students perceived a lack of self-efficacy in caring for culturally diverse populations” (coffman et al. 2004). their findings also showed that ethnicity, previous coursework and educational experiences can increase nurses’ self-efficacy in delivering culturally competent care. doutrich and storey (2004) reported on a collaborative project designed to improve the cultural competence and public health skills of registered nurses who are baccalaureate students. the students studied in this project completed preand post-tests on the inventory for assessing the process of cultural competence among healthcare professionalsrevised (iapcc-r) online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 53 (doutrich & storey, 2004). a repeated measures analysis using spss software found that the students’ iapcc-r scores improved significantly after workshop interventions and student experiences with public health nurse mentors (doutrich & storey, 2004). from this project came changes in the academic practices related to links between nursing students and public health nurses. among these changes was the inclusion of campinha-bacote’s model of the process of cultural competence (doutrich & storey, 2004). campinha-bacote field-tested her first tool, the iapcc, for construct validity on 200 registered nurses who participated in an all-day workshop on cultural competence in health care (campinha-bacote, 1999). it should be explained here that the iapcc-r version was developed in 2002 when campinha-bacote added the fifth construct of cultural desire to the tool (campinha-bacote, april, 2005). each subject’s pretest score on the iapcc served as the control. post-test scores revealed an increase in the level of cultural competence after attending the workshop on cultural competence (campinha-bacote, 1999). smith (2001) reported on a quasi-experimental design in a two-group repeated measure format in which 94 registered nurses participated. forty eight of the nurses participated in a “culture school” while the other forty six received cultural training via nursing informatics (smith, 2001). the cses was used in pre-testing/post-testing. both groups benefited from education, however, the nurses who participated in the 8.5 hour culture school rated themselves higher post education on the cses than did the nurses who participated in the informatics course (smith, 2001). smith (2001) reports that a nursing education intervention could significantly increase cultural competence, as measured on the cses and on knowledge based questions. perez (2005) described a study that assessed the level of cultural competence among professional health educators using the iapcc-r. a review of the abstract of this study reveals that a series of analysis of a variance showed significant difference on cultural competency mean scores between health education setting and number of cultural/diversity education programs attended in the last 3 years. the research articles described here had one theme in common in the summation of findings: education impacted self-reported cultural competency. some of the authors discussed qualitative data in which study participants revealed a desire to learn more about other cultures in order to increase their cultural competency. the research for these articles was conducted in mainly urban areas where there would be an increased opportunity for cultural encounters. is cultural competence important in a rural state? rural states, especially those in the midwest and north central areas of the united states, do not contain particularly diverse populations at first glance. culture and cultural diversity, however, encompass much more than one’s ethnicity. culture is integral to each of our identities. it is our political affiliations; our gender; our occupation; socio-economic status; disabilities and abilities. even within ethnic groups there are cultural variations which, until explored further may not be apparent. if we as health care providers harbor preconceived notions and prejudices about other groups of persons, even if those assumptions seem harmless, we may poison the opportunity to effectively and safely care for our patients. inhabitants of rural states are often described by visitors as friendly; willing to help a stranger. communities in the state of north dakota have become home to immigrants who have come from diverse countries; speaking no english at times. more american indians are living in the communities surrounding their reservations rather then on the reservations. health care online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 54 providers may recognize the ethical obligations to treat these patients regardless of race, creed, religious or political affiliations. these providers must recognize the dangers of approaching care as though all persons should be treated equally, however. the outcomes of care should be equal. that is, all patients should be able to hold the expectation that their care will follow recognized and accepted standards of care. the approach to the care, however, may vary based on the patient’s needs. cultural variations will impact those needs. in states where ethnic diversity is minimal, the cultural assessment tools available to nursing staff, may be sparse in content. for example, a single-question assessment such as, “are there any cultural or religious preferences you would like to discuss with me” may seem like a very pertinent open-ended question. this question may be met with a “no” from the patient who is not sure what this question means or who feels that his/her desires might really not be important to the nurse. this can put nurses in an awkward position when attempting to assess for cultural variations that would impact care. it also may place patients at risk for suboptimal care and discharge planning. the iom report revealed several health care disparities amongst minorities which included: • inappropriate cardiac care, including medication prescriptions and surgical procedures • decreased incidence of appropriate cancer diagnosis and treatments • increased incidence of amputations for diabetic and peripheral vascular disease conditions a thorough cultural assessment may not only reveal patient beliefs that would impact the approach to care, but would also be important to establishing a trusting relationship with the patient. in order to avoid cultural blindness, health care providers should provide patients with a cultural assessment whether they look like they need one or not (campinha-bacote, 2003). this becomes particularly important for health care providers who practice in geographical areas which are not ethnically and culturally diverse. the first step toward achieving cultural competence is to assess one’s own awareness, feelings, skills, and knowledge. in the next article in this series, the author will share results of a cultural competency self-assessment survey completed by north dakota registered nurses. references adams, d. 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(2000). social welfare management. thousand oaks, ca: sage. purnell, l., & paulanka, b. (1998). transcultural health care: a culturally competent approach. philadelphia: f. a. davis. perez, m (n.d.). cultural competency among health educators. retrieved june 28, 2005, from http://www.aaahperd.org/2005/preliminaryprogram/abstract pollit, d., & beck, c. (2004). nursing research: principles and methods (7th ed.). philadelphia: lippincott williams & wilkins. price, e.g., beach, m.c., gary, t.l., robinson, k.a., gozu, a., palacio, a., et al. (2005). a systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals. academic medicine, 80, 578-586. [medline] quality and culture. (n.d.). [website.]. retrieved april 2, 2005, from http://www.erc.msh.org ross, h. (2001, february/march). office of minority health publishes final standards for cultural and linguistic competence. closing the gap. retrieved april 17, 2005, from http://www.omhrc.gov/assets/pdf/checked/final%20standards%20for%20cultural%20an d%20linguistic%20competence.pdf salimbene, s. (1999). cultural competence: a priority for performance improvement action. journal of nursing care quality, 13(3), 23-35. [medline] silverman, j. (2005, march 31). house republicans may scuttle state’s cultural competency efforts. retrieved april 2, 2005, from http://www.oregonlive.com/printer smith, l. (2001). evaluation of an educational intervention to increase cultural competence among registered nurses. journal of cultural diversity, 8(2), 50-63. [medline] spector, r. (2004). cultural diversity in health and illness. upper saddle river, nj: pearson prentice hall. trompenaars, f., & wooliams, p. (2004) business across cultures. chichester, uk: capstone. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.aaahperd.org/2005/preliminaryprogram/abstract http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15917363%5buid%5d http://www.erc.msh.org/ http://www.omhrc.gov/assets/pdf/checked/final%20standards%20for%20cultural%20and%20linguistic%20competence.pdf http://www.omhrc.gov/assets/pdf/checked/final%20standards%20for%20cultural%20and%20linguistic%20competence.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9926676%5buid%5d http://www.oregonlive.com/printer http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11855050%5buid%5d conceptual definition of cultural competence editorial 11 editorial geographical information systems and the analysis of health for rural populations barbara ann graves, phd, rn editorial board member a myriad of economic, political and demographic factors continue to propel the “social transformation” of health in america. the healthcare industry has undergone drastic restructuring in the united states (folland et al, 2001; mclafferty, 2003). during the 1980’s and 1990’s hospital closures, mergers, and reorganizations greatly impacted spatial organization and availability of healthcare services. geographical restructuring to date has followed a pattern of hospital closures in rural and lower socio-economic (ses) areas and expansions of larger hospitals located in higher ses areas (folland et al, 2001; ginter et al, 1998; mclafferty, 2003). subsequently, rural-to-urban restructuring has resulted in overall greater concentration of healthcare services in large tertiary hospitals thereby decreasing access by increasing the distance and travel time to healthcare services. this geographical restructuring of health services has most notably impacted rural populations. significant decreases in healthcare services to the already vulnerable, at-risk rural populations have compounded the existing problem of healthcare disparities. geographic information systems (gis) is an emerging new technology in healthcare. historically, it has been used in the past for the management of land and natural resources. this growing technology and new research methodology is simply an information system that can be used to efficiently capture, organize, store, manipulate and analyze spatial data. gis can link and join geographical and attribute databases as well as query these databases to identify patterns of health outcomes. its ability to link geographical features on a map with attribute data is proving more and more useful in the analysis of health data and planning of healthcare services. gis has demonstrated its value in the integration of statistical and geographic data and the visualization of spatial relationships. gis is efficient for analyzing health data, revealing trends and determining relationships that might be missed in a strictly tabular format. mapping and visualization of health disparities and their relationship to the geographical location of healthcare services allow for better planning and resource allocations to vulnerable populations. the literature is replete with reports of regional, locational, and small-area analysis of health disparities. studies of medical geography and epidemiology well document significant variations in health over even small geographical areas. disparities in access to healthcare services have been associated with barriers to access such as age, sex, race, ethnicity, income, insurance status, and geography. geographical proximity to healthcare services has been shown to be a strong predictor many health outcomes and various health disparities. according to the agency for healthcare research and quality, geographical disparities continue to exist. more research is needed to evaluate the impact of geographical access and important healthcare outcome measures. this innovative technology is becoming instrumental in the synthesis of information to foster awareness of specific health concerns, facilitate development of intervention strategies, and enhance utilization of resources. gis technology can be of value for future health planning, online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 12 the development of health policies and the allocation of healthcare resources. gis is effective in the management and analysis of health data. geographical analysis is important for the identification of patterns of healthcare outcomes and the association or linkage to political processes and policy makers (cromely, 2002; gatrell, 2002; elliott, wakefield, best, & briggs, 2000; meade & earickson, 2000). the world health organization (who) has recognized the value of public health mapping and gis. according to the who: geographical information systems (gis) provide ideal platforms for the convergence of disease-specific information and their analyses in relation to population settlements, surrounding social and health services and the natural environment. they are highly suitable for analyzing epidemiological data, revealing trends and interrelationships that would be difficult to discover in tabular format. moreover gis allows policy makers to easily visualize problems in relation to existing health and social services and the natural environment and so more effectively target resources (who, 2003, p.1). references cromley, e.k. (2003). gis and disease. annual review of public health, 24, 7-24. [medline] elliot, p., wakefield, j., best, n., & briggs, d. (2000). spatial epidemiology. new york: oxford university press. folland, s., goodman, a.c., & stano, m. (2001). the economics of health and health care. upper saddle river, nj: prentice-hall. gatrell, a. (2002). geographies of health. malden, ma: blackwell. ginter, p.m., swayne, l.m., & duncan, w.j. (1998). strategic management of health care organizations. malden, ma: blackwell. mclafferty, l.s. (2003). gis and healthcare. annual review of public health, 24, 25-42. [medline] meade, m.s., & earickson, r.j. (2000). medical geography. new york: guilford press. world health organization (who). (2003). public health mapping. retrieved april, 2, 2004, from http://www.who.int/csr/mapping/en/ http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12668753%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12668754%5buid%5d http://www.who.int/csr/mapping/en/ 37 what rural nursing stories are you living? kay rosenthal, phd, rn1 1 executive director, estes park medical center, co, epltr@aol.com keywords: rural, generalist, nurse, stories, narrative, river, theme, metatheme abstract this article illuminates the lived experience of rural generalist nurses who work in an acute care hospital with less than twenty-five beds located in a mountain setting. interviews of eight nurses were analyzed to develop a metatheme "rural nursing: flowing like a river" and four themes, which emerged from the data. the themes included: going with the flow: fluid role; fish out of water: expert to novice; still waters run deep: self reliance; and life in a fish bowl: contextual knowledge of patients. stories were co-created by the researcher; one, "code blue boots," is included. code blue boots "code blue" i stand to help. "i'll go to ed to help. i'll be back later. i'm just going to leave all my stuff here." "ok. we'll move 'em if they get in the way, but we won't toss 'em." they love to tease me, always joking that they're going to throw my statistics away! i hear my boots clomp, clomp, down the hallway all the way to the ed. as i enter the room everyone stops momentarily, turns and looks at me! "i can't believe it! you've got those ----boots on!" paula says and glares at me. paula gives me a sketchy report and it hits me! not only do i have on my code blue boots but also we are doing one of the mock cor scenarios i wrote last night, except this is the real thing. my mind drifts to think of the scenarios i've recently written: sids (sudden infant death syndrome), yes, we've just done one. hypothermia, yes, that car accident where the kids walked in to tell us there had been an accident; they were really hypothermic when the ambulance got to the scene. motor vehicle accident (mva), yes we had done the mva scenario, the car had even been kept from falling off the highway by a tree as i had imagined. you know, i think i've written eight scenarios, and we've done them all! i'm not writing any more. the code has ended, it has not been successful. alice asks if she should give the last of the epinephrine (epi). "there's a little left in the ampule. should i give it?" "i don't care." the doctor replies. alice says, "well, i hate to throw it away, i'll just give it." she pushes the rest of the epi. a minute later she says, "doctor, there's a heart beat! oh my god! there's a heart beat!" online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 mailto:epltr@aol.com 38 he runs back over. steve, the paramedic, starts bagging again and we call for the helicopter. alice can't believe it. "i'm just so frugal! i just couldn't stand to throw it away!" inside she is terrified, will there be brain damage? has she done something really, really good or really, really bad? was this a miracle? she wonders. the code continues, the patient is stabilized. the code blue is finished, we've succeeded again. we have a computed tomography (ct) scan but this guy, now that the code blue is over and we have stabilized him, really needs a magnetic resonance image (mri); we have a surgeon but this guy needs a neurosurgeon so it's off to metro for him. helicopter is here so i head back to the floor. i hear the familiar clomp, clomp, clomp of my boots and think to myself, i'm not wearing these boots again either! (rosenthal, 1996, p. 92-94). introduction in the modern world of specialty nursing, rural nursing offers many unique challenges to the nurse who functions as a generalist. nurses share stories of shifts where they were acting in the role of physician until he/she arrived in the emergency department, then changed to hospice nurse at the bedside of a dying patient, and ended their day in the role of neonatal nurse during the delivery of a baby. these typical rural nursing shifts create struggles, opportunities, and threats to generalist nurses that are specific to the practice of rural nursing. this article will review research available in the literature and report supporting and unique findings of the author's study (rosenthal, 1996). review of the literature long & weinert (1992) define rural nursing as “the provision of health care by professional nurses to persons living in sparsely populated areas” (p.390). characteristics of rural nursing described in the literature include: the need for the rural nurses to assume the role of generalist and function as jack-of-all-trades; lack of anonymity; flexibility; versatility; adaptability; working in a broad spectrum of clinical settings; performing many unrelated and diverse tasks; resourcefulness; culture consciousness; self-reliance; and skills in obstetrics, maternity, intensive care, and emergency room nursing; filling professional as well as nonprofessional roles; professional isolation; insider-outsider status based on the length of time in the community; all of the above descriptions (cozziburr, 1992; biegel, 1983; bond et al. 1984; thobaden & weingard, 1983, ross 1979; long & weinert, 1992; scharff, 1987; hamel-bissell, 1992). there is limited literature (rosenthal, 1996, 2000) from the rural nurses’ perspective regarding the rewards, threats, and/or challenges of rural nursing. this perspective is important in order to recruit students and experienced nurses in the rural setting, enhance the esteem of rural nurses, and elevate rural nursing to a specialty within the practice of professional nursing. through the use of narrative (stories) these issues are explicated. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 39 method there is much discussion in the nursing and education literature regarding the use of stories (heinrich, 1992; boykin & schoenhofer, 1991; van manen, 1990; benner, 1991; connelly and clandinin, 1990; vezeau, 1992; and witherell & noddings, 1991). storytelling is everywhere. people are keeping journals, writing family histories and their own biographies (witherell & noddings, 1991). stories are being used to help people make sense of their lives (greene-hernandez, 1992). people are finding their voice through narrative (belenky, clinchy, goldberger, & tarule, 1986). narrative provides a form through which matters that would remain untold about our daily lives are shared. stories engage readers and prod us to think in new ways. the use of narrative in research is demonstrating the usefulness of findings within a context instead of as sterile, detached findings. subject-object separation is no longer the only method valued. because people use narrative to organize their lives into meaningful units, researchers are able to identify the patterns embedded in the narrative (polkinghorne, 1988). qualitative researchers who are interested in "lived experiences" elicit nurses' stories and have explicated the complexity of nursing by recording nurses' stories of their professional experiences (boykin & schoenhofer, 1991). stories are powerful tools that may be used to convey deep feelings and meanings (heinrich, 1992). stories provide rich texts for interpretive phenomenological research studies (benner 1984, 1991). stories are being used in the classroom to link theoretical and clinical practice by reconnecting with our subjective feelings. counselors and educators are using story and narrative as professional tools; educators are recognizing that the quest for meaning is an important aspect of education; and narrative is being used as a multidisciplinary and multicultural model for teaching (connolley & clandinin, 1990; witherell & noddings, 1991). nursing's ways of being (ontology) are gleaned from studying nursing situations. story grounds nursing's ways of knowing (epistemology) within the ontology of relationship, meanings and context. thus story's major contribution to the profession of nursing is the meaning of our own practice gained from the insight and deepened understanding of practicing nurses (boykin & schoenhofer, 1991). aim the aim of this study was to describe the lived experience of rural nurses through their stories. the design, exploratory descriptive, encouraged nurses to tell stories of their experiences working in a rural acute care hospital. an exploratory descriptive design was chosen to explore the little-studied situation of the rural nurse generalist. this design is appropriate to study topics about which little is known (brink & wood, 1989). the use of narrative, with its emphasis on life-like, understandable, plausible stories, offers the best method to discover and describe the lived experiences of rural nurses. research question what are the stories told of the lived experience of rural generalist nurses who work in an acute care hospital, with less than twenty-five beds, located in a mountain setting? (rosenthal, 1996). online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 40 setting/sample after obtaining permission from the university review board two rural hospitals with less than twenty-five beds were selected. these hospitals are located in western mountain communities, in the united states. the study sample was composed of eight nurses (seven registered nurses and one licensed practical nurse), recruited by the director of nurses of the hospital, who agreed to participate in the study. see table 1. table 1 demographics hospital nurse age sex ethnic education rural/ clinical a 1 44 f c dipl n/n a 2 66 f c dipl n/n a 3 52 f c assoc n/n a 4 39 f c lpn y/y b 5 44 f c bsn n/n b 6 51 f c dipl n/n b 7 36 m c assoc n/n b 8 56 f c dipl n/n work status total years rural nursing % career in rural nursing ft 23 20 86 ft 40 28 70 ft 4.5 4.5 100 ft 19 19 100 pt 22 18 81 ft 20 26 86 ft 3 2 66 ft 34 34 100 key: female (f) male (m); caucasian (c); no (n) yes (y) full time (ft) part time (pt) rural nursing clinical offered in nursing program /participated in rural clinical the nurses were assured confidentiality of the research findings. signed consents were obtained from all participants and verbal consents were obtained prior to tape recording all interviews. staff nurse names and specifics of situations were changed to assure confidentiality. interviews were tape recorded and transcribed by the researcher. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 41 data analysis data analysis for this study had two distinct aspects that were based on taperecorded and transcribed interviews with rural generalist nurses. one was the identification of themes with supporting subthemes and exemplar transcripts (rosenthal, 1996, 2005). four themes emerged from the data based on the transcripts from the nurses’ interviews. these themes were: going with the flow: fluid role; fish out of water: expert to novice; still waters run deep: self reliance; and life in a fish bowl: contextual knowledge of patients. the second aspect of data analysis was the creation of a poem which illuminates the metatheme that emerged from the study findings, titled “rural nursing: flowing like a river,” as well as narratives that are stories rewritten by the researcher (rosenthal, 1996, 2005). see rosenthal (1996) for a full description of the metatheme, themes and subthemes with supporting transcript excerpts. stories the stories were written after reflection on the transcripts and the creative process of writing by the researcher. these stories are original creative outcomes written by the researcher, which came out of material from the transcripts. the unique rendering of the stories came from the data. this process used the researcher-as-instrument and refers not only to the researcher’s own influence on what was studied, but also refers to the limitations and creative possibilities of how the researcher decided to study the phenomenon and her/his ability to make sense of the data during analysis (oiler boyd & munhall, 1993). rigor rigor was established through the use of sandelowski’s (1986) four criteria for rigor in qualitative research studies. truth value was established through credibility defined as a faithful description or interpretation of the data, which was confirmed by the nurses involved in the study and two nurses from a third rural hospital. sandelowski's second criterion, applicability, was demonstrated by a review of the literature, which confirmed "fittingness." the third criterion, consistency, defines the auditability of the findings. the study should have consistent findings, in terms of themes. noting that the details interwoven from the interviews in the form of stories would vary even if the same data were used by a different researcher following the decision trail of the initial researcher. the fourth criterion, neutrality, addressed confirmability of the study’s findings. this final criterion pulled together the initial three: auditability, truth value and applicability and acknowledges the bias built into the study. sandelowski notes that in qualitative studies bias, acknowledged and accounted for, it is not controlled for or eliminated. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 42 ethical considerations ethical considerations center around beneficence and fidelity. beneficence, or the obligation to do no harm, was of importance in the protection of the participant. fidelity regarding the promise of confidentiality is paramount. study limitations one limitation of this study may be the issue of face-to-face interviewing. informing the nurses that the researcher worked in a rural setting could be a limitation. a third limitation of this study was that the researcher and the storyteller are the same person, therefore only the researcher’s perception of the nurses' stories was represented. another limitation of this study may be that the researcher's showing of empathy may have broadened the story as the nurse felt encouraged to proceed by my obvious interest and encouragement. perhaps the active sharing of stories between researcher and participant would have triggered other stories in the mind of the participant. however, there is a danger of leading or manipulating the participant if the researcher is too involved in the conversation (tochon, 1992). finally, some of the nurses were on duty and may have felt rushed during the interview process or may have felt time pressures from tasks left undone that they sensed a need to complete. this may have limited the length of participation. stories of rural nursing the creative outcomes of the interviews of rural nurses are a compilation of stories explicating the lived experience of rural nurses written by the researcher (rosenthal, 1996, 2005). the stories are written in the first person so that emotions can be expressed; however the stories are not the researcher's personal stories. the stories were based on the data but were adapted. therefore, certain aspects of the stories are fictionalized, i.e., names of participants, date, time, place, quoted dialogue. however, the gist of the stories' situations and events are true to the transcripted interviews of the participating nurses. the stories were created as a literary device. six stories (rosenthal, 1996) were written, titled: "injured? dying? this can't be happening!"; "man, am i a good metro nurse! i'll show those rural nurses a thing or two"; "code blue boots"; "we're all in this together"; "western slant"; and "orientation, you call this orientation?" one of the co-created stories from the perspective of rural nurses as rewritten by the researcher, “code blue boots,” was presented at the opening of this article. findings from the interviews with rural nurses several themes recurred in the review of the rural nursing literature, such as the need for rural nurses to assume the role of generalist and function as "jack-of-all-trades" (long & weinert, 1992; cozzi-burr, 1992; ross, 1979). the generalist nurses must be prepared with a broad scope of nursing skills in order to function independently and to respond appropriately to the unique challenges online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 43 presented in the clinical arena (ginsberg, 1982). the need for the rural nurse to have a broad experiential background as well as a broad spectrum of clinical settings (ross, 1979; long & weinert, 1992) was consistent with the theme fluid role (rosenthal, 1996, 2005). a third theme appearing in the literature indicates that rural nurses are expected to fill non-professional roles as well as roles of other professionals. the nurse may be required to draw blood, and spin the hematocrit, until the lab technologist arrives to further process the sample. the nurse frequently performs twelve-lead electrocardiograms (ekg) and assists patients with pulmonary function tests, incentive spirometry, percussion and postural drainage, since rural hospitals typically do not have ekg technicians and/or respiratory therapists on staff. the nurse may also function as dietician, pharmacist and even "runner" (long & weinert, 1992; ross, 1979; scharff, 1987). fluid role (rosenthal, 1996, 2005) in this study described these same issues. the fourth theme, lack of anonymity and what sociologists call "role conflict," is described in the rural nursing literature because in small towns everyone knows everyone's name. in the small rural hospital this means that you recognize the address of the patient being brought into the emergency department when you get the call from the dispatcher. the rural nurse also sees the look of relief when the patient recognizes her. lack of anonymity speaks to the difficulty of maintaining private areas of nurse’s lives. rural nurses occupy multiple identifiable role positions in small towns and are well known as neighbors, church members and family members. rural patients are also known by the rural nurses in several personal as well as social role relationships. in a small town the nurses’ roles as parent, spouse, and church member are all related to their effectiveness as nurses (long & weinert, 1992). these issues are described in the theme contextual knowledge of patients in this study (rosenthal, 1996, 2005) the fifth theme, the concept of "insider/outsider," is identified in the rural nursing literature. rural nurses are aware of the long period of residency in the community before the community members will consider the nurse an "insider." nurses recognize the importance of belonging and of participating in community events, being members of organizations being on committees of the service organization, and volunteering time with a local agency. nurses who prefer to keep their lives private will not be well accepted in the rural community (long & weinert, 1992; hamel-bissell, 1992). the theme contextual knowledge of patients (rosenthal, 1996, 2005) identified how nurses must be actively involved in their community. the final theme, professional isolation, is also addressed in the nursing literature. rural nurses must frequently travel long distances to participate in professional organizational meetings and to attend professional inservices. nurses who do not attend these meetings may feel isolated in the rural setting. also the rural nurse may be the only registered nurse on duty in the hospital during her shift and thus may feel isolated (long & weinert, 1992). rural nurses may not feel properly oriented, may not be offered inservices on a regularly preplanned basis and may be limited in their involvement with professional organizations (boekelheide, 1958). the theme self reliance (rosenthal, 1996, 2005) described the nurses commitment to life long learning. unique to this study were the findings related to fluid role (rosenthal, 1996, 2005) that included the feelings of team support, rapport, give and take; the implicit trust that develops between team members; and the role transcendence where nurses do tasks online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 44 of physicians and physicians do tasks of nurses. expert to novice has not been identified in the literature previously. subthemes related to the urban nurse transitioning into rural nursing and the surprises they are in for; the feelings of never having enough knowledge; learning things in the midst of the situation, "trial by fire"; knowing that you may be the most qualified in a situation; knowing that if you were caught not knowing something that you'll know it next time; and the feelings of confidence gained through certifications such as advanced cardiac life support and neonatal resuscitation courses. in the theme self reliance, the nurses' feelings of staying calm; using humor to gain confidence and the feelings associated with being alone, "you're it," are further unique findings. the feelings associated with caring for a known person and how that touches the nurses' heart and soul are the final aspects of this study that are unique in comparison with the literature. discussion through stories unique aspects of rural nursing were identified in this study. stories offer more of a lived experience than do the themes alone. stories are an important contribution to nursing education and nursing practice. the stories are what the researcher wanted to share with potential new rural nurses. the stories speak to different styles of learners. some nurses may get more out of themes and subthemes. others may get more out of the stories. some readers may need a combination of both to fully understand and appreciate the lived experience of rural nurses. these stories are but one explanation, of course, there may be others. implications for practice stories are a way of presenting data that facilitate understanding within the practice setting, and the transcripts revealed a number of implications for nursing practice. rural nurses involved in this study shared their personal recommendations for urban nurses making the decision to "go rural." the nurses described characteristics of successful rural nurses. fears and incidents of rule breaking were revealed that have implications for nursing practice. the need for strong teams and allowing for role reversal were explicated. the rewards and benefits of rural nursing were discussed by the rural nurses in the interviews. support systems were identified that have implications for rural nurse administrators and hospital administrators. other implications include the introduction of urban nurses to the rewards, complexities and challenges of rural nursing; heightening the sense of choice and decision making regarding moving to and/or working in rural settings; provision of images of rural nursing realities and possibilities; providing an historical context and the formulation of connections with the past; exposing urban nurses to new ideas and perspectives; and reducing urban nursing prejudices and misconceptions regarding rural nursing. finally, the study's illumination of the uniqueness of rural challenges and rewards may assist with health care reform decision making. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 45 recommendations for future research implications of the study for future research include support for further narrative inquiries and for expansion of the stories to develop rural nursing theory. gadow (1990) suggests that "the cultivation of personal knowing as a form of inquiry may be the most important contribution of nursing to the human sciences" (p.167). perhaps this study will encourage others to expand their inquiry into personal knowing and further ask, "what is it like?" regarding other aspects of nursing. the stories (rosenthal, 1996) may encourage another researcher to study rural nurses using ethnography, phenomenology or grounded theory. this study may encourage others to explore the esthetic pattern of knowing, which allows a greater level of understanding of nursing experiences that are not accessible through other means. the art of nursing can be illustrated best through an esthetic inquiry such as a descriptive narrative, since writing is expressive as well as descriptive. narrative reflects a special knowing that is from the senses rather than from the intellect. therefore, some of nursing's most profound experiences can be known only through the sharing of stories, the expression of emotion, and empathy without the restrictions of "scientific" inquiry (carper, 1978; sorrell, 1994). further research into the uncertainty and unpredictability of rural nursing would be helpful to establish a structure that would produce predictability in such an ambiguous set of situations. perhaps another researcher would be able to determine patterns within the ambiguity-subtle nuances that could actually be forecasted into future events. in future studies another style of interview and/or research methodology could be used. the researcher in this study worked very hard not to tell her own stories in response to the nurse-interviewee stories. it would be an interesting comparison to repeat the study with the researcher engaging in the interviews instead of staying passive. being more openly empathic might encourage the nurse-participant to share a more threatening story, to further expand on a story, or to offer insight into why treating a patient she knew was difficult for her. another possibility would be a focus group of rural nurses sharing their stories with the researcher both facilitating the group and actively participating in sharing his or her own stories with the participants. this technique might reveal other stories that are evoked by the researcher's participation. conclusion what stories are you living? rural nursing offers many unique challenges to the nurse who functions as a generalist in a world of specialist nurses. rural nurses share stories of shifts where they were providing preoperative care to a patient, then were called in to the operating room to assist with the patient and ended up as the nurse recovering the same patient hours later. these typical rural nursing shifts create struggles, opportunities, and threats to generalist nurses that are specific to the practice of rural nursing. this article compared research in the literature and reported the supporting and unique findings of the author's study (rosenthal, 1996). one story, “code blue boots,” was shared as an exemplar of rural nursing stories as shared by the interviewees and recreated into stories by the researcher (rosenthal, 1996). online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 46 references belenky, m.f., clinchy, b.m., goldberger, n.r., & tarule, j.m. (1986). women's ways of knowing. the development of self, voice, and mind. new york: basic books. benner, p. (1984). from novice to expert: excellence and power in clinical nursing practice. menlo park, ca: addison-wesley. benner, p. (1991). the role of experience, narrative, and community in skilled ethical comportment. advances in nursing science, 14(2), 1-21. [medline] biegel, a. (1983). toward a definition of rural nursing. home healthcare nurse, 1(1), 45-46. [medline] boekelheide, b. (1958). inservice education for professional staff nurses in rural hospitals in south dakota. unpublished master's thesis, university of colorado, denver, co. bond, l., bailey, s., dommer, j., hansen, m., & weirda, l. (1984). rural nursing: unique practice opportunity. michigan nurse, 57(3), 4-6. [medline] boykin, a., schoenhofer, s. (1991). story as link between nursing practice, ontology, epistemology. image, 23(4), 245-248. [medline] brink, p., & wood, m. (1989). advanced design in nursing research. newbury park, ca: sage. connelly, f., & clandinin, d. (1990). stories of experience and narrative inquiry. educational researcher, 19(5), 2-14. cozzi-burr, h. (1992). nursing on swans island, maine, 1938-1975. in p. winstead-fry, j. tiffany, & r. shippee-rice (eds.). rural health nursing. new york: nln. ginsberg, l.h. (1982). social work in rural communities with an emphasis on mental health practice. in p.a. keller, & j.d. murray (eds.). handbook of rural community mental health. new york: human science press. green-hernandez, c. (1992). being there and caring: a philosophical analysis and theoretical model of professional nurse caring in rural environments. in p. winstead-fry, j. tiffany, & r. shippee-rice (eds.), rural health nursing. new york: nln. hamel-bissel, b.p. (1992). mental health and illness nursing in rural vermont: case illustration of a farm family. in p. winstead-fry, j. tiffany, & r. shippee-rice (eds.), rural health nursing. new york: nln. heinrich, k.t. (1992). create a tradition: teach nurses to share stories. journal of nursing education, 31 (3), 141-143. [medline] long, k.a., & weinert, c. (1992). rural nursing: developing the theory base. in p. winstead-fry, j. tiffany, & r. shippee-rice (eds.), rural health nursing. new york: nln. oiler boyd, c., & munhall, p. (1993). qualitative research proposals and reports. in p. munhall & oiler boyd (eds.), nursing research. new york: nln. polkinghorne, d. (1988). narrative knowing and the human sciences. albany: state university of new york press. rosenthal, k. (1996). rural nursing: an exploratory narrative description. unpublished doctoral dissertation, university of colorado, denver, co. rosenthal, k. (2000). rural nursing: is it the right choice for you? american journal of nursing, 100 (4), 24-24b. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=1759806 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=6557107 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=6564345%5buid%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=1937524 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=1313092 47 rosenthal, k. (in press). the rural nursing generalist in the acute care setting: flowing like a river. in h. lee & c. winters (eds.), rural nursing: concepts, theory, practice. new york: springer. ross, w. (1979). the demands on nursing in a rural hospital setting. in nursing service in a specialty, a rural, and an urban hospital. new york: nln. sandelowski, m. (1986). the problem of rigor in qualitative research. advances in nursing science, 8(3), 27-37. [medline] scharff, j. (1987). the nature and scope of rural nursing: distinctive characteristics. unpublished master's thesis, montana state university, bozeman, mt. thobaden, m., & weingard, m. (1983). rural nursing. home healthcare nurse, 1(2), 913. [medline] tochon, f. (1992). presence beyond the narrative: semiotic tools for deconstructing the personal story. paper presented at the annual meeting of the american educational research association, san francisco, ca. van manen, m. (1990). researching lived experience: human science for an action sensitive pedagogy. new york: state university of new york press. vezeau, t. (1992). narrative inquiry and nursing: issues and original works. unpublished doctoral dissertation, university of colorado, denver, co. witherell, c., & noddings, n. (1991). stories lives tell. new york: teachers college, columbia university. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=3083765 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=6558059 10 psychosocial impact of cancer in low-income rural/urban women: phase i margaret a. lyons, phd, rncs1 1 assistant professor, capstone college of nursing, university of alabama, mlyons@bama.ua.edu keywords: breast cancer, cervical cancer, rural health, disparity, psychosocial effects, cancer burden abstract data reported here are from phase one of a larger ongoing study of depression and cancer-related quality of life in low-income rural and urban southern women who have been diagnosed with breast or cervical cancer. this phase of the pilot project examined the psychosocial impact of a new diagnosis of breast or cervical cancer and identified personal issues and concerns of those diagnosed. a telephone survey design was used to solicit information from 28 low-income rural and urban southern women regarding diagnosis, treatment, side-effects, available support systems, coping techniques, barriers to treatment, and the significance of god or spirituality during the course of their illnesses. content analysis indicated that many similarities exist in the experiences of rural and urban women regardless of race, socioeconomic status, or residence. however, many differences exist that negatively impact and contribute to health disparity and an unequal distribution of cancer burden. introduction the american cancer society (acs) estimates that, in the united states, 211,300 new cases of breast cancer and 13,000 cases of cervical cancer will be diagnosed in 2003 (acs, 2003). 3,400 cases of breast cancer are expected to occur in alabama (acs, 2003) and 2,400 cases will be in mississippi (acs, 2003). although incidence of cervical cancer is dropping, 200 new cases are expected in both alabama and mississippi (acs, 2003). if recent trends continue (acs, 2003), a majority of these women will be black and/or from high poverty areas (national cancer institute, 2003). data reported here are from phase one of a larger ongoing study of depression and cancer-related quality of life in low-income rural and urban southern women who have been diagnosed with breast or cervical cancer. this phase of the pilot project examined the psychosocial impact of a new diagnosis of breast or cervical cancer in rural and urban low-income women in the deep south and identified personal issues and concerns of those diagnosed. the resulting information facilitated development of the telephone survey instrument used in phase two of the study which investigated depression and cancer-related quality of life issues in a larger sample of women diagnosed with breast or cervical cancer. this research fills a significant gap in the existing literature. little information is available concerning the emotional status of african-american women newly diagnosed with cancer and residing in rural, low-income areas of the deep south or the impact of the diagnosis on low-income white women. questions prompting this research were the following: what are the issues and concerns of low income rural and urban women as online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://nursing.ua.edu/home.htm mailto:mlyons@bama.ua.edu 11 they manage their illnesses? are there health disparities related to race, socioeconomic status, or residence affecting these women and if so how do they cope? information gathered from this study will be used to further knowledge about how these women cope with cancer, ultimately leading to interventions that will reduce health disparity in this population. the problem the national cancer institute considers reducing health disparities to be a special challenge (nci, 2003). defined by a national institutes of health working group, health disparities are differences in incidence, prevalence, mortality, and cancer burden among select population groups. gender, age, ethnicity, education, income, social class, disability, geographic location, and sexual orientation characterize these groups (nih, 2002). it is known that minority women are more likely to be diagnosed at later stages of disease, are less educated, and more likely to die from breast cancer. they are younger, less likely to have insurance or are underinsured, live in poverty, and have more difficulty accessing health care (nci, 2003). disparities such as these result in unequal distribution of cancer burden (miller et al. 1996). before the problem of health care disparity can be fully addressed it is important to know what issues confront low-income rural and urban women with breast cancer or cervical cancer. are they similar to the issues of women who do not live in poverty and who have insurance? background a diagnosis of cancer produces more apprehension and worry than any other form of illness; the literature is replete with descriptions of the negative psychological sequelae experienced by women with breast or cervical cancer (arman, rehnsfeld, lindholm, & hamrin, 2002; shapiro et al. 2001; vicksberg et al. 2000). lackey, gates, and brown (2001) described the experience of finding a lump in the breast as a “dual experience trajectory” where the woman is catapulted into a physical trajectory through the healthcare system and an emotional trajectory characterized by deep feelings, emotions, and fears. prediagnostic anxiety is a clinically significant issue for women anticipating diagnosis and forced to participate in the “waiting game.” most women report moderate to high levels of anxiety with consequent reduced effectiveness in attentional functioning while waiting for diagnosis (lehto & cimprich, 1999; poole, 1997). intrusive thinking and avoidance have been found to be powerful precipitants of psychological distress (baider & de-nour, 1997; epping-jordan et al. 1999; lyons, jacobson, prescott, and oswalt, 2002; primo et al. 2000). although the time prior to diagnosis is the most difficult for some, some researchers report that the most anxiety provoking period is from diagnosis to treatment (loveys & klaich, 1991; pelusi, 1997; seckel & birney, 1996). uncertainty concerning what will happen if tests are positive, individual interpretation of the cancer diagnosis, and the consequences of the event are important issues that a woman faces regardless of stage of illness. management of the uncertainty may be a fundamental concern if adjustment is to occur (mishel, 1988). online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 12 there are different responses to the diagnosis and treatment of cancer. suffering is apparent for most women and can be metaphorically described as a “field of force” affecting all aspects of a woman’s life (arman, rehnsfeldt, lindholm, & hamrin, 2002). previous research by this author (lyons et al. 2002) described the lived-experience of women during the first year following diagnosis as one in which an initial trauma is recognized, retraumatization occurs in the form of treatment effects, and all energies are directed at resolution/healing. however, after an initial period of traumatization distinguished by feelings of hopelessness and helplessness, it is not uncommon for a woman to undergo a transformational process, viewing her ordeal as a “challenge” with inherent “value,” with resultant attribution of positive meaning (degner, hack, o’neil, & kristjanson, 2003; koopman et al. 2001; taylor, 2000). cultural background may affect the process of adaptation. african-american women are more likely to view a diagnosis of cancer as a death sentence, suggesting that convictions related to outcome may influence diagnostic delay or treatment refusal (lackey, 2001). issues relevant to african-american women not affecting caucasian women are keloid formation and the inability to find a prosthesis that matches skin tone (wilmoth & sanders, 2001). african-american women are more likely to have mastectomies, less likely to have breast reconstruction, less likely to be given a rationale for treatment decisions, and often do not ask questions about their illnesses (aziz & rowland, 2002; lackey, 2001). positive reappraisal and seeking social support are primary coping strategies used by african-american women with breast cancer and differences in survival rates between african-american women and caucasian women may partially depend on variations in coping strategies (bourjolly & hirschman, 2001). critical quality of life issues associated with a diagnosis of breast or cervical cancer include the physical and psychosocial effects of surgery, radiation, and/or chemotherapy. research consistently points to the devastating effects of side-effects such as fatigue, hair loss, pain and swelling and insomnia (ferrell et al. 1996; kissane et al. 1998; longman, braden & mishel, 1996). women receiving adjuvant chemotherapy often cope with the associated suffering by the use of normalizing strategies, such as concealing emotions, keeping previous routines intact, looking for humor, and restructuring time to meet their own needs (cowley et al. 2000). mediating factors may foretell distress in women with breast cancer. consistent predictors of distress are avoidant coping (mccaul et al. 1999), uncertainty (mishel, 1988), depression, and side-effect burden (badger, braden & mishel, 2001), whereas emotionally expressive coping, humor, spirituality, social support, and a fighting spirit are associated with adjustment to the cancer experience (ebright & lyon, 2002; gall, miquez-de-renart, & boonstra, 2000; henderson, fogel & edwards, 2003; stanton et al. 2000). rural/urban residence may impact psychosocial response to a diagnosis of breast or cervical cancer. hospital closures, homecare cutbacks, deficits in community health service funding, decreases in numbers of physicians, inadequate transportation coupled with lengthy distances, and lack of insurance create unnecessary hardship for many rural women (bushy, 2000). additionally, women residing in rural areas report that they do not receive enough emotional or educational support from their caregivers and express more negativity about their medical care (koopman et al. 2001). online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 13 although morbidity and mortality rates for cervical cancer victims continue to decline, issues similar to the woman with breast cancer affect cervical cancer survivors and are not to be forgotten. surgical morbidity, chemotherapy toxicity, loss of fertility, body image concerns, sexual concerns, and altered relationships embody the experience of the woman with cervical cancer (tabano, condosta & coons, 2002). methods sample twenty-eight low-income rural and urban southern women diagnosed with breast or cervical cancer comprised the sample for this study. participants were recruited from cancer treatment centers and health departments in mississippi and alabama, the mississippi breast and cervical cancer early detection program, support groups, the american cancer society, and word of mouth. potential participants were given flyers announcing the study and asked to call a toll-free number at the researcher’s office if they were interested. sixteen of the women were from urban areas of alabama and mississippi and twelve were from rural areas in these states. sixteen women were african-american and twelve were caucasian. twenty six were diagnosed with breast cancer, two with cervical cancer. of those diagnosed with breast cancer, twenty one had undergone a mastectomy and radiation and/or chemotherapy. the remaining four had lumpectomies with followup radiation and/or chemotherapy. the two women diagnosed with cervical cancer had undergone hysterectomies. participants ranged in age from 30 to 76 years. twenty-three were over the age of 50. about half were married and lived with their spouses. the remaining women were divorced, widowed, never married and/or lived alone or with children. only one woman was employed, part-time. all had incomes of less than $30,000, with the majority having incomes of less than $10,000. twenty-three women were medicaid recipients and were diagnosed through their respective state’s breast and cervical cancer early detection programs. two respondents had some type of private insurance; three were medicare patients. participants met sample criteria of having been diagnosed with breast or cervical cancer during the previous 12 months, having access to a telephone, and willingness to respond to questions posed by the researcher. respondents received $50 for their participation and were asked to sign a consent form that described the purpose and confidential nature of the study. assurances were given regarding the participant’s right to withdraw from the study until such time as all data were analyzed. data collection following institutional review board (irb) approval, participants who had expressed interest in the study were contacted via telephone and given a brief overview of the process and the purpose of the study. telephone interviews were convenient for accessing women from many different areas of mississippi and alabama and are more economical than in person interviewing for data collection (lavrakas, 1990). a semistructured open-ended questionnaire elicited information regarding diagnosis, treatment, online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 14 side-effects, available support systems, coping techniques, barriers to treatment, and the significance of god or spirituality during the course of the breast cancer experience. a large portion of the interview centered on psychosocial aspects of the breast or cervical cancer experience. the following questions were asked of each respondent: 1) how was your cancer first found? 2) how were you told about your cancer? 3) what were your thoughts and feelings when you first learned that you had cancer? 4) what kind of treatment did you receive? 5) did you experience side-effects to treatment and, if so, what were they? 5) how did you manage? 6) what kinds of things do you do to prevent illness that you didn’t do before? 7) did you have to take time off from work to manage your illness? 8) did you have difficulty obtaining or paying for your treatment? 9) what kind of support (family, friends, church, etc) do you have as you go through this illness? 10) what role does god or religion play in your life as you go through the cancer experience? open-ended questions facilitated the process of dialogue and helping participants to describe their experiences. since many of the women received radiation or chemotherapy during daytime hours, telephone interviews were usually conducted in the evenings. interviews generally lasted 45 minutes to an hour and were punctuated by health-related questions that the respondent asked of the researcher. data analysis both manifest and latent content analyses (wilson, 1989) were used to analyze data obtained from telephone interviews. content analysis (boyle, 1994) involves categorizing words and phrases from text data as well as using labels to illustrate concepts. word counts are useful in enabling the researcher to determine differences in the frequency of the concepts. results twenty-eight low-income, rural and urban women participated in this study. results indicated that primary issues for the women in this sample included: finding out, concerns about how they would cope, knowledge deficits and participation in treatment decisions, treatment issues, social support, health promotion, and the role of god or spirituality in their lives. finding out the women in this study learned of their breast or cervical cancer diagnosis in a variety of ways. six women were diagnosed with breast cancer following clinical breast exams. eight women found lumps during breast self-exam and ten women had suspicious lesions on routine mammograms. two were diagnosed with cervical cancer following pap smears. all of the women experienced fear and anxiety while waiting for diagnostic confirmation. many women described being in a state of shock. some representative comments were the following: online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 15 one night i was lying in bed and something told me "you’d better check your breasts." i found a big knot in there. i cried at first because i was scared. then i called my sister and she told me to "just go to the doctor and find out. i found it through breast exam. at first i was scared but everyone told me ‘don’t worry.’ once i found out it was positive all i could do was cry and i thought, 'i have to fight for my life and now i have to fight for my mind.’ guess i’m still in a state of shock. those who had to wait for mammogram results expressed a great deal of apprehension. one woman stated: they made me wait out in this little room and then they called me back to do another mammogram. then they wanted to do an ultrasound but nobody would tell me anything. three of the women seemed to suppress feelings and developed a business-like approach to dealing with their illnesses. one stated: i didn’t cry—still haven’t. i just felt like well now you have it. god will take care of you, no matter what happens. now we just have to do what we need to do to take care of it. several of the women were informed that they had cancer through phone calls from their physicians. one woman stated: “he told me on the telephone. on the telephone! that to me was a big no-no.” the majority of women were informed, in person, by their physicians. coping strategies many of the women expressed little confidence in their ability to cope immediately after diagnosis. however, after the diagnostic phase most women used normalization and sought to keep their routines from being disrupted. the majority of women in this study used family, friends, a fighting spirit, and a deep and abiding faith in god to cope with the initial diagnosis and treatment: i learned to rely on others for help. my sister took me to the doctor. my church family brought us food and my kids helped with the house work. one woman, diagnosed with cervical cancer, stated that she had “absolutely no support” even though she was temporarily living with her brother. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 16 knowledge deficit and participation in treatment decisions most of the women were undergoing treatment, relative to type of tumor and stage of disease, at the time of the interview. women with cervical cancer underwent hysterectomies and those with breast cancer had biopsies, lumpectomies, mastectomies, radiation and/or chemotherapy as deemed necessary by their physicians. both caucasian and africanamerican women listened intently to what their physicians recommended. however, african-american women were less likely to ask questions, ask for additional information, use other resources, e.g. internet, or challenge decisions made by their physicians regarding treatment. they were also more likely to have had a mastectomy. one african-american woman stated: “i didn’t ask questions. i just did what he told me.” in contrast, one caucasian woman with breast cancer refused treatment stating: i went to an herbal healer. she took me off all sugar and caffeine. i can’t have any pork and i’m supposed to eat 6 oz. red meat each day—lots of fruit, eggs, and butter. i’ve lost five pounds. in three months, if i’m not cured or if i’m not dead i will find another doctor and will probably have the surgery. treatment issues the majority of women cited being emotionally prepared prior to surgery. “i was as prepared as you could be for a thing like that.” the most difficult aspects of treatment were disfigurement after mastectomy, issues related to sexuality and feelings of unattractiveness, accompanying feelings of loss, and the appearance of side-effects related to chemotherapy. those who had undergone radiation alone complained of fatigue but were generally able to go about their daily routines. they managed their fatigue by enlisting the help of others and by taking frequent rest periods. for those who received chemotherapy, side-effects that were most disturbing were nausea and vomiting, feeling ill, fatigue, pain, and hair loss. the following statements are illustrative of the above concepts: “every night when i take a bath i’m not prepared for what i’m gonna see. i think about being disfigured and i start to cry. a part of me is gone." you ask about sex. what sex? i don’t feel like having it and i don’t want him to see me this way. but i told him, “if you can’t handle it then you need to go. cause i don’t need nobody like that.” i have swelling in the upper part of my chest and my arm. and i have trouble doing all kinds of things. things i used to do. it gives me fits. i try not to let it bother me. i can’t even lift a skillet. putting on my clothes—i have to have help. i can’t tie my shoes. i knew that my hair would probably fall out but i didn’t expect it to fall out in big clumps when i washed it. i cried and cried even though they said it would grow back in. i never go out without my turban. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 17 health promotion participants approached health promotion in several different ways. some cited engaging in limited exercise, “eating better,” and, being more appreciative of the “little things”. only a few cited taking vitamins or using herbal remedies. many stated that they had made no lifestyle changes. barriers to treatment five of the women in this study cited financial difficulties in terms of paying for treatment. those women who were covered under private insurance or medicare had substantial out of pocket costs. one woman stated: “i had to pay $5 every time i went to the office. i’m up to $30 and i can’t even pay that.” those women on medicaid had no out-of-pocket costs. “i got sent to the social worker and she got me on medicaid.” women living in rural areas often traveled great distances for treatment. however, they did not complain. “sometimes i’d be so sick. but that’s just the way it is.” spirituality spirituality was a dimension that permeated each woman’s experience. frequent references to god were evident in statements made by participants. “oh, god, please don’t let it be positive” or “please god help me through this.” one woman’s comments summarized sample sentiment: god has always bailed me out. i believe he’s there for me and that he loves me. i hope it’s his will that i will live. i ask for help everyday and every night before i go to bed. he’s the first place i’ve always turned. discussion when compared to results of the author’s previous research with women of means (lyons et al., 2002), findings from this study indicate similarities in the traumatic nature of the experiences of breast and cervical cancer survivors. fear and anxiety were experienced during diagnosis and treatment regardless of race, urban/rural residence, or differences in socioeconomic status. these women denied fear of dying. they did fear future reoccurrence of their cancers and were concerned about the possibility that their mothers, daughters, and/or siblings would develop cancer. again, this finding did not differ by race, rural/urban residence, or diagnosis. all of the women interviewed were determined to be survivors. all had days when they were depressed but they were able to implement strategies that kept them focused on the task of getting well again. congruent with the findings of cowley et al. (2000) and henderson et al. (2003) the women coped with diagnosis and treatment through the use of normalizing strategies, the use of social support, positive reappraisal, seeking and using social support, and relying on spiritual beliefs as a source of strength. the majority of women said that they had received adequate information prior to surgery and fully understood what type of surgery was to be performed. however, online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 18 congruent with the findings of lackey (2001), rural african-american women were less likely to seek information or ask questions and more likely to accept their physician’s decisions. they were also less likely to have access to the internet for information regarding their illnesses and could have benefited from additional pre-operative education and counseling. the need to mobilize resources after diagnosis was a universal reaction without regard for race or urban/rural residence but accessing resources was more cumbersome for rural women. rural residents traveled greater distances for appointments and felt more isolated. they were less likely to know what services were available to them and were less confident about taking the necessary steps to access those that they did know about. community education or support groups sponsored by local health departments or churches could be useful in meeting the need not only for support but also for education concerning available services in rural areas. a surprising finding was that the majority of women in this study were receiving medicaid services after referral by their state’s breast and cervical cancer early detection programs. participation in this program enabled these women to receive health care that they would otherwise be unable to afford. this fact indicates that the system is working and is a major step in the reduction of health disparity. acknowledgments this study was funded by the national cancer institute and the deep south network for cancer control, grant # 531863. references american cancer society. 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(2000) intrusive thoughts and psychological distress among breast cancer survivors: global meaning as a possible protective factor. behavioral medicine, 25, 152159. wilmoth, m.c., & sanders, l.d. (2001). accept me for myself: african-american women’s issues after breast cancer. oncology nursing forum, 28, 875-879. [medline] wilson, h.s. (1989). the craft of qualitative analysis. in h.s. wilson (ed.), research in nursing (2nd ed, pp. 394-428). menlo park, ca: addison-wesley. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11421147 18 lessons learned from a very small pilot study sharol jacobson, phd, rn, faan1 felecia g. wood, dsn, rn2 1 professor and director of nursing research, capstone college of nursing, university of alabama, sjacobson@fa.ua.edu 2 associate professor, capstone college of nursing, university of alabama, fwood@bama.ua.edu keywords: rural, pilot studies, feasibility studies, diabetes interventions, african americans abstract this report describes the lessons learned from a very small (three-family, nine-person) pilot study of the feasibility of in-home educational intervention for persons with diabetes in rural african american families. lessons learned included the need to liberalize sample criteria, appreciation of the difficulties of scheduling visits with working rural families and maintaining standard intervals between visits, documentation of the learning needs of people with prior diabetes education, realizing that caucasian nurses were accepted into african american homes and gaining insights into communication styles, finding that children were enthusiastic participants, and that even small studies produced some diffusion beyond the participants. the families all exhibited the self-reliance considered characteristic of rural families. investigators without experience in rural nursing or research are urged to seek consultation and to pilot their study for feasibility and logistics. introduction researchers agree that few research endeavors are more useful than pilot studies— small scale studies that enable researchers to test ideas; evaluate and refine methods of recruitment, intervention, measurement, and analysis; assess participant and investigator burden and benefit; refine project timelines; and identify unanticipated problems or benefits, all with minimal expenditure compared to the final full-scale project (fox & ventura, 1983; prescott & soeken, 1989; dallas, norr, dancy, kavanaugh, & cassata, 2005; van teijlingen, rennie, hundley, & graham, 2001; perry, 2001; jairath, hogerney, & parsons, 2000; carfoot, williamson, & dickson, 2004; hundley & van teijlingen, 2002; hinds & gattuso, 1991; richardson, selby-harrington, & sorenson, 1993). what is less apparent from research reports of a single study is the progression of pilot studies from very small ones directed at the most basic question of “is this idea at all feasible?” to test runs of a complete intervention based on several preliminary studies (melnyk, 2003). the purpose of this report is to describe the lessons learned from a very small (three-family, nine-person) pilot study directed at the basic feasibility of an in-home educational intervention for persons with diabetes in rural african american families. assessing feasibility for this idea involved not only the details of the intervention but working within the characteristics of rural environments and in a culturally competent way with african americans. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://nursing.ua.edu/home.htm mailto:sjacobson@fa.ua.edu http://nursing.ua.edu/home.htm mailto:fwood@bama.ua.edu 19 background type 2 diabetes is a major health problem for african americans in whom the disease is approximately 1.6 times as common as in caucasians. the prevalence and rate of complications are increasing and the age of onset is decreasing (anderson-loftin & moneyham, 2000; hughes, love, peabody, & kardong-edgren, 2001). the difficulties of self-management may be even greater for rural than for urban residents. besides the usual demands of living with diabetes, rural dwellers disproportionately experience such barriers to care as a lack of providers; lack of education; poverty that limits the purchase of care, medication, and diabetes supplies; lack of transportation to providers of care and diabetes education; lack of insurance; and low literacy and health literacy. african americans may hold cultural beliefs such as “sugar” is not serious, large bodies are attractive, disease is the will of god, and reliance on folk medicine that may hinder adherence to medical advice and diabetes control (anderson-loftin & moneyham, 2000); hughes et al. 2001; schorling & saunders, 2000; keyserling et al. 2000). distrust of research and healthcare professionals resulting from the well-publicized tuskegee syphilis study may also negatively affect care seeking and use of self-management information (jones, 1993). the literature on diabetes education supports incorporation of the family and multiple generations to increase support for the person with diabetes and address primary prevention; humanand relationship-oriented rather than knowledge-focused education; assessment of social support, environment, socioeconomic status, gender roles, and values of the patient and family; and a focus on participation, demonstration, and empowerment rather than on mere “telling” (norris, engelgau, & narayan, 2001; agency for healthcare research and quality, 2002; fisher, et al., 1998; hanson, et al., 1995; bailey & lherissoncedeno, 1997; & celano & kaslow, 2000). research on diabetes education with african americans is highly consistent with those recommendations. they desire professional assistance in linking their behavior with diabetic consequences, managing symptoms and practicing self-management skills, making healthy choices, discussion of the value of folk remedies, increasing family and community social support, and culturally sensitive education (anderson-loftin & moneyham, 2000; hughes et al. 2001; schorling & saunders, 2000; and keyserling et al. 2000). in a previous study the authors were the first to document that children aged 3 to 18 were active caregivers to adults with diabetes (jacobson & wood, 2004). we found no studies that actively included each member of an inter-generational family in the intervention or that included young children as potential caregivers of adults with diabetes or as participants in diabetes education for their own future welfare. home visits have been used successfully in many studies to educate parents about child development (brooten et al.1986; brooten, youngblut, deatrick, naylor, & york, 2003; kearney, m.h., york, r., & deatrick, j., 2000; kitzman et al. 1997) and to improve patients’ self-management of chronic disease, including asthma and diabetes (butz et al. 2005; catov, marsh, youk, & huffman, 2005; huang, wu, jeng, & lin, 2004). home visits offer the advantages of privacy, convenience, and participant comfort free from the distractions and pace of a more public environment. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 20 study background the study, approved by the university irb as low-risk, high-benefit, tested the feasibility of an in-home educational intervention for persons with type 2 diabetes in rural african american families. the study was conceptually based in the idea that a chronic disease like diabetes is truly a family affair with both the persons with diabetes and the family benefiting from increased knowledge of diabetes self-management, the literature on the extended family common among many african americans (celano & kaslow, 2000) and the strong african american cultural tradition of caregiving for relatives (hughes, love, peabody, & kardong-edgren, 2001). a family was defined as an adult with type 2 diabetes age 21-55 (we wished to focus on the age group with young children in the home), an adult support person (spouse, partner, or significant other), and a child between the ages of 9 and 18. previous diabetes education was not a study restriction, as we reasoned that the education received by most rural african americans may very well have been brief, not understood, or a long time ago and that the realities of living with the disease would have evoked more specific questions about disease management. children were included in the belief that their possible roles as caregivers and their proximity to an adult with diabetes comprised not only a benefit for the adult but a teachable moment for the child as well. building on 20 years of experience in diabetes education and research in clinical agencies, minority communities, and worksites, the investigators carefully planned the intervention to ensure that the volume of content was manageable for each visit and permitted time for interaction among the participants. the intervention consisted of seven home visits: one for screening, consent, and baseline assessment; four for teaching (daily self-care, nutrition and activity, medications, and prevention of complications); and two for immediate and delayed follow-up. the visits were planned to occur over seven to nine months. the teaching plans, based on social cognitive theory (baranowski, perry, & parcel, 1997) included content for each member of the family triad, brief didactic information about the visit's focus, much use of pictorial materials and materials needing only low levels of literacy, assessments of the family's experiences with the topic, and demonstration and return demonstration of one or more skills such as reading food labels or performing foot inspections. all diabetes content was based on the american diabetes association (ada) standards of care (ada, 2002). the chief outcome measure for the adult with diabetes was the hemoglobin alc. measures for all study participants included diabetes knowledge, general health, body mass index, activity levels, family functioning, dietary intake, and program satisfaction. standardized data collection tools were used whenever possible. specifically, the diabetes knowledge test (villagomez, 1989), the godin physical activity questionnaire (godin & shephard, 1985), revisions of the godin scale to measure occupational and household activity, 24-hour diet recall, 3-day food history, sf-12 (ware, kosinski, & keller, 1996), and objective activity measures using pedometers were used in all data collection. program satisfaction and family functioning in regard to disease management were measured using investigator-developed tools. questions and answers were exchanged throughout the sessions. children were included in all aspects of the teaching sessions; however, age-appropriate handouts and online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 21 time-limited active participation by the children helped ensure that the children focused on the teaching content and were stimulated but not fatigued. visits were not tape-recorded as both investigators attended all visits and made detailed field notes jointly immediately after each visit. we noted recruitment and retention success, preparation and travel time, scheduling changes and missed appointments, questions asked, effective explanations, participant activity and affect, and questions to discuss as possible refinement. participants were recruited through area diabetes educators. quantitative data analysis for this very small sample was minimal and done by hand. preand post-knowledge of diabetes scores increased and performance of self-management skills improved for all. the intervention was highly rated, and all participants indicated they would recommend the intervention to friends. the lessons learned were generated by three methods. we discussed each visit immediately afterward, reviewed our field notes, and examined the comments made on the study evaluations completed by the participants. lessons learned recruitment despite careful explanation to diabetes educator recruiters, all of whom we knew well, recruitment did not go smoothly or rapidly. the requirements for younger people with type 2 diabetes with children in the home and a willing, available adult support person ruled out the large share of many diabetes educators' case loads, who were older people. people were referred to us who did not meet the criteria. eleven families were contacted for eligibility and interest in participation to obtain three eligible families. five were qualified, five families consented, and three families completed the study. the reasons for attrition of the two eligible families were varied. one young mother smilingly consented, completed the baseline data, and could never, despite many calls from us, identify a good time for a subsequent visit. according to the referring diabetes educator, she was highly resistant to acknowledging her diabetes. we believe that she consented only to please her mother and grandmother who were highly concerned about her. this provided a cultural insight into the power of african american mothers and grandmothers over their daughters and the ability of an unenthusiastic participant to avoid not only participation but angering her elders by using a socially plausible excuse. another woman with diabetes was very interested in participating but her adult support person (her daughter) stayed for only a few minutes of the first two sessions and announced that she was moving and could not continue. we also realized, after several months of trying to recruit families with a nondiabetic adult support person, that this exclusion criterion was inappropriate given the high incidence of diabetes among spouses and family members in the african american culture. we relaxed this criterion and recruited one more family. the total time to acquire three eligible families who completed the study was nine months. the families the three families recruited were very different. the first consisted of a middle-aged man with diabetes who worked as a schoolteacher and minister, a neighbor and parishioner online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 22 as the adult support person, and the man’s 17-year-old daughter. the wife, also diabetic, attended but was not a subject. both were college educated. they were extremely close and affectionate and regarded the adult support person as a member of the family. they accepted us into their home as though we were old friends, and we never sensed any barriers to communication or rapport. the second family consisted of an adult female (grandmother) with diabetes, her adult daughter, and a ten-year-old grandson. this family had no telephone, intermittent electricity and gas, and no transportation. income (and sometimes, food) came solely from the grandmother’s part-time employment at a local fast food restaurant. the grandmother had never learned to read or write, and the grandson helped her with all written communication. the home was extremely dilapidated and in a dangerous neighborhood. this family posed the challenge of delivering education to an illiterate person, a person who would not "accept charity" from a local clinic where some help with medications was available, the concern of personal danger for us, and the "heartstring tug" of wanting to do more but realizing that our discomfort was not shared by the family as this was the way life was and, likely, always would be for them. the third family consisted of an adult male with diabetes, his wife with diabetes as the adult support person, and their 13 year old daughter. the man was employed in a physically demanding job and rotated shifts—another challenge to diabetes selfmanagement. the wife was employed full-time as a teacher’s aide in a local school. they lived in a very rural area, and traveled 75 miles for health care. although always very pleasant, they eventually admitted to us that they had started out "trying to put on a good front for you white professors" but had decided we really were good people. the families who completed the study were not what we had expected to find in that two of them were solidly middle-class and had access to the internet. although we had intentionally not defined "family" as a husband, wife, and child because of the prevalence of single parents and fictive (honorary) kin in african american families, two of the three families fit a nuclear pattern. in two of the families, the person with diabetes was the adult male, and both female spouses, one who served as the adult support person and one who did not, also had diabetes. we included the spouse who was not the adult support person in all the teaching but did not collect outcome data from her. travel the one-way distance to the homes of participants ranged from 5-150 miles. like community health and home health nurses, we quickly learned the importance of obtaining good directions and that neither compass points (north, west, etc.) nor miles were used. typical directions were “turn right by the big magnolia tree and go about 10 minutes.” we learned to leave early for initial visits to allow time for getting lost and to call prior to embarking on the trips to ensure that the families were available as planned. cellular phone communication was not always possible in many of the remote areas. the timing of visits for late afternoon or evening meant that we often drove back in the dark on unlit winding rural roads. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 23 the home visits all visits were held in the late afternoon and evening to accommodate the school and work schedules of participants. to facilitate the intervention and for safety reasons, both investigators traveled to all visits. coordinating travel times was especially challenging considering the teaching schedules of both investigators and the work, recreational, and church schedules of the families. the family that was closest geographically was the most difficult to contact because of the need to make arrangements through the adult support person and accounted for the only missed appointments we experienced. seven visits lasting 2-2 ½ hours were planned. we encountered no initial objection to the length of the visits, as participants were grateful for the help and their questions accounted for one hour of each visit. in keeping with southern views about politeness and african american views about caring and respect, each visit began with social pleasantries and inquiries about the family reunion or the daughter's basketball game. we then reviewed the "homework" or application of learning from the previous visit, presented about 15 minutes worth of information about the visit's main topic, practiced skills such as glucose testing and foot care, and contracted with participants about activities before the next meeting. all three families indicated they enjoyed the learning meetings, but by the conclusion of the study, the investigators recognized that the families were tiring of the visits and the difficulties in scheduling. maintaining an environment conducive to learning was sometimes difficult. ringing telephones, visitors who walked in and stayed for parts of the sessions, other children and pets running around, dinner time conflicts, and televisions were distractions. diabetes knowledge although all three adults with diabetes had participated in diabetes education from one to ten hours within the past year, none of them truly understood the mechanisms of diabetes development, medications, the daily tasks required for self-management such as foot care, and implications for development of related chronic health problems such as heart disease. as we had anticipated, they were either unable to remember what they had been told, had not understood it when they were taught, or had many more questions to ask as a result of the passage of time. reading food labels proved to be a revelation for all participants (except for the woman who could not read). one teenage girl revealed that she had been eating a can of lite spam® every noon, believing it to be low fat and one serving. the link between diabetes and heart disease was also new and of concern to the participants. activity is a critical component of diabetes self-management as well as a strategy to delay or prevent the development of diabetes. each participant wore a pedometer for several days during the study. the teenage girls found the pedometers to be “cool” and liked wearing them at school. all participants were surprised at the limited steps they walked per day and eagerly discussed strategies for incorporating more activity into a typical day. given the rural environments and family economic circumstances, gyms and exercise facilities were unavailable or unaffordable. blood sugar testing was problematic for all of the adults with diabetes. they didn’t like to “stick” themselves, were unsure of the desired frequency of testing, and wanted to online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 24 know the minimum number and timing of testing to allow adequate control. the woman with limited resources certainly could not afford test strips. although we provided a meter and 50 strips, we realized that all she had learned about testing would not be practiced once the strips ran out. buying food and paying the rent and electric bill took priority over selfcare. the children although the inclusion of children in the family intervention was the chief innovation of this study idea, it also provided us with the most initial concerns for feasibility. would children participate? would their attention wander? would they be willing to practice the skills of glucose testing and footchecks? would their adult relatives with diabetes welcome their assistance? to our delight, the children (aged 9, 13, and 17) were enthusiastic active participants. they stayed for each session, asked good questions, shared learning about health from school, did their between-sessions homework, and learned the skills, with only a minimum of tickling their relatives’ feet for fun during footchecks. the youngest child, the grandchild of the illiterate participant, told us, “i am so happy that i have learned all this. now i could save my gran’s life because i know about too much and too little sugar and i can test her.” the parents told us that it was comforting to know their children understood their problems and had learned how to help them and that they would encourage the children to eat healthier and be more active. the investigators organization and flexibility when working with families were of paramount importance. a day planned around a scheduled visit that was cancelled just prior to leaving town was one of the frustrations encountered several times. because the visits were in the late afternoon or evening, the investigators frequently worked all day, then left near the end of the work day to begin the trip for a family visit and returned near midnight. although the visits were always inspiring to the researchers, the demanding logistics of visiting rural families became apparent very early and raised the issue of whether we could hire interveners willing to work such erratic schedules and travel the rural areas at odd hours for a future trial. we were genuinely amazed to see the volumes of data collected from only the three families and how challenging managing the data was. in retrospect project management software or at least a spreadsheet should have been used from the beginning, even for this 9participant study. monitoring unexpected outcomes a very positive outcome of the feasibility study was the evidence of diffusion of the intervention beyond the participants. the adult support person for the minister with diabetes was also the church “kitchen lady.” she wanted to alter the menus for church meals to improve the health of the minister and the congregation and started preparing a heartor diabetes-friendly main dish and dessert each sunday. the minister’s spouse was alarmed at online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 25 how few steps she walked in a day and formed a group at work who walked around the parking lot for 15 minutes at lunchtime each day. when we learned that she had never tested her own blood sugar because of fear about piercing her skin, we contracted with her to do it herself. after several weeks of not accomplishing the goal, she finally tested herself and was delighted with her improved self-sufficiency. the teenage daughter of the heavy equipment operator with diabetes reported that her friends at school were intrigued with her pedometer, bought their own, and resolved to walk more. her diabetic mother, a teacher’s aide with responsibility for visiting classrooms with the snack cart every morning, decided to support the principal’s proposal for replacing chips and soda with fruit, baked chips, juice, and water. we also learned that the people who quietly drifted in and out during home visits were friends or relatives with diabetes who had been invited to hear “the talk” on food or medications. discussion despite the small sample size this very small pilot study was helpful to us in planning future work. on the positive side we learned that a family is an appropriate unit for diabetes education, that people with prior diabetes education still had major learning needs, that children were enthusiastic participants, and that caucasian nurses were welcomed into african american homes. the sample criteria need to allow a spouse with diabetes to be the adult support person to obtain adequate numbers of families with young children. we realized that having two investigators make each visit facilitated simultaneous activities for the participants and that the different personalities and communication styles of the investigators were complementary. very importantly, even this small study produced some diffusion of results beyond the participants. negative—or at least thought-provoking- insights included the logistics of visiting scattered rural families, maintaining suitable control over the spacing and duration of visits for a larger study, determining an optimal number of visits, and resisting the urge to try to teach everything instead of what is most necessary. an important process in our study was observation of family dynamics. although our families appeared to have excellent relationships, investigators in a family intervention must exercise caution not to become a part of negative family communications and actions. we were also struck by the family pride and spirit of self-reliance that all families exhibited and that is considered characteristic of rural families (dunkin, 2000). we approached families with the idea and the statement that “we do not know as much about cultural differences in ideas about disease and disease management as we would like to know”. we were encouraged to find that participants would spontaneously make remarks like, “i’d understand that better if you said thus and so” or assured us when we asked if our communication was clear and respectful. implications this very small pilot functioned as intended to “guide the development of the research plan rather than being a test of the already-developed plan” (prescott & soeken, 1989, p. 60). we encourage other investigators to conduct feasibility studies. those without online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 26 experience in rural areas should definitely obtain consultation about the characteristics of rural people and locales in general and the target population in particular. references agency for healthcare research and quality. 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[medline] online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10868860%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11328433%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8628042%5buid%5d microsoft word yonge.docx online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 3 the challenge of evaluation in rural preceptorship olive yonge, phd, rn 1 florence myrick, phd, rn 2 linda ferguson, phd, rn 3 1 professor & vice-provost, academics, university of alberta, olive.yonge@ualberta.ca 2 professor& associate dean, teaching, faculty of nursing, university of alberta, flo.myrick@ualberta.ca 3 professor, university of saskatchewan, linda.ferguson@usask.ca acknowledgements: the authors would like to acknowledge quinn grundy, research assistant for her assistance in preparation of this manuscript. irb approval number: university of alberta, health research ethics board, file number #b081008 funding: the authors would like to acknowledge the social sciences and humanities research council (sshrc) of canada for funding this research project. keywords: preceptorship, rural nursing, student evaluation, preceptors abstract the purpose of this article is to report preceptor perceptions of the process of evaluating nursing students in a rural setting. a grounded theory methodology was used to carry out this study to ascertain what is actually going on in the rural preceptorship experience. twenty-six preceptors from rural areas in two western canadian provinces participated in the study. these preceptors worked with fourth year nursing students in the final year of their baccalaureate programs. the core variable that emerged in this study was identified as “the challenge of the formal evaluation process”. the implications of the findings are that: evaluation should be characterized as the responsibility of the preceptor, student and faculty triad; the scope of each role should be clearly defined and; that preceptors require preparation for the evaluation process, which is specifically ‘rural’ in content. introduction today, nursing student placements in rural facilities are increasingly encouraged on the understanding that graduates are more likely to work in rural settings if they have had satisfying student experiences in those settings. in the year 2001, only 18% of the total number of registered nurses (rns) employed in nursing in canada worked in rural or small-town areas, compared with 21% of the general population (canadian institute for health information, 2007). the potential for rural preceptorship as a vehicle for the recruitment of nurses to underserved rural areas serves as a motivation for faculty and practitioners alike to create and maintain preceptorship programs at these sites (sedgwick & yonge, 2008; shannon et al., 2006). owing to distance and the wide geographic dispersion of students, preceptors are often subject to professional isolation and are not provided physical onsite faculty support with the exception of infrequent visitation (if at all), email contact and telephone calls. complex behaviours in the preceptorship experience such as performance evaluation can thus be a key challenge for these preceptors. one of the most demanding teaching expectations for any professional is performance evaluation. while this role is daunting for educators, it is even more so for practitioners. preceptors are expected to formally evaluate students according to specified online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 4 guidelines. while many preceptors are comfortable in their role, many are unprepared for student performance evaluation and find the process quite challenging (dolan, 2003; mccarthy & murphy, 2008; seldomridge & walsh, 2006; yonge, krahn, trojan & reid, 1997). the purpose of the study was to discern the process involved in preceptor evaluation of students in the rural setting and included how both preceptors and students perceive this process. in this article the authors report on preceptor perceptions of the process of evaluation in a rural setting. the student perspective is reflected in a second article (yonge, myrick & ferguson, 2011). both articles emanate from the first phase of a study entitled, “developing an evaluation model with rural preceptors”, funded by the social sciences and humanities research council (sshrc) in canada. background nurses who work in rural areas are described as having the ability to function autonomously, adapt nursing interventions to low-tech environments, be expert generalists (bushy, 2001; 2005), and frequently be able to extend their practice into the domain of other health professionals (weinert & long, 1989). rural nurses have higher than average turnover rates, while those who stay in the setting cite job satisfaction and team work as reasons for continuing in practice (hegney, mccarthey, rogers-clark, & gormann, 2002). beatty (2001) noted that little has been done to investigate rural nurses’ learning needs or the context of their practice setting. in addition, professional isolation prevents these nurses from networking with colleagues. the researchers thus selected this setting recognizing the challenges of rural nursing and appreciating the uniqueness of the setting for the preceptorship of nursing students, while recognizing the need to enhance rural preceptors’ development as educators. furthermore, in preceptorships, nursing faculties rely heavily on clinical preceptors to provide accurate evaluations of student performance (dibert & goldenberg, 1995). to be effective, preceptors must have an evaluation framework and appropriate tools that include formative and summative evaluation. evaluation kemper, rainey, sherrill, and mayo (2004) describe a three-part process of student evaluation: the process; the impact; and the outcome. prior to the evaluation process, it is essential that learning objectives be delineated (glover, 2000; kemper et al., 2004). evaluation must be future and not past-oriented as the goal of evaluation is to: improve future behaviour, not to change the past; ameliorate poor performance; replicate good performance; and improve overall performance thus affording recipients a clear understanding of what is and is not working (lee, 2005). yonge et al. (1997) differentiated between informal, ongoing evaluation and formal, documented evaluation. informal or formative evaluation is a process of tracking, monitoring, adjusting and regulating through ongoing feedback. daily, informal, immediate, ‘on-the-spot’ feedback is most effective for student learning and least challenging for the preceptor (clynes & raftery, 2008; glover, 2000; lee, 2005; qualters, 1999; yonge et al., 1997). ongoing feedback should be informative, specific, and focused on behaviour the student can change (glover, 2000; lee, 2005). the ‘feedback sandwich’ is recommended as a successful feedback approach and it comprises a positive comment, followed by ideas for improvement, followed by another positive comment (glover, 2000). summative evaluation involves measuring, ranking and formal grading. preceptors report great difficulty with summative evaluation owing to: unwieldy evaluation forms, the challenge of online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 5 objectivity, time pressures, student challenges and the need for additional data (yonge et al., 1997). according to lee (2005), grading is an ineffective evaluation strategy because grades generally evoke an emotional response rendering the recipient less receptive to constructive feedback. instead, what is suggested is the integration of self-evaluations into summative evaluation to encourage two-way dialogue that is more similar to the process of feedback (lee, 2005). preceptor challenges with evaluation despite the literature on evaluating students, preceptors are often ill-prepared to assume the evaluative role. evaluations can be inconsistent, inaccurate, and superficial, and preceptors continue to view them as onerous. in one of the first studies exploring the evaluation process in preceptorship, researchers examined the basis of preceptor evaluations and whether performance criteria were valued differently between preceptors and faculty (ferguson & calder, 1993). ferguson and calder (1993, p. 31) note that if faculty who have preparation in educational theory and practice have difficulties with the evaluation process, this problem must be even greater for nurse preceptors, many of whom have little or no preparation in clinical teaching and evaluation of students. lack of consistency of ratings, instructor bias, concern about the reliability and validity of evaluation tools and a general reluctance to document poor performance were noted (ferguson & calder, 1993). in 1997, yonge et al. discovered the discrepancy between how little preceptors are prepared for the evaluative role and yet how frequently they are expected to fulfill that role. preceptors often feel unprepared to use strategies such as reflection-on-practice and evaluation taxonomies and instead rely on assessment of skills rather than on competencies, and lack the time for the evaluation process (dolan, 2003; mccarthy & murphy, 2008; seldomridge & walsh, 2006). the need for faculty support of preceptors has been well documented (dolan, 2003; mccarthy & murphy, 2008; seldomridge & walsh, 2006; yonge et al., 1997). possible solutions to preceptor challenges regarding evaluation include preceptor selection criteria such as level of education, willingness to teach, student and preceptor matching of personality and learning styles, quality orientation to the preceptor role, ongoing faculty support, and opportunities for role recognition such as continuing education opportunities (seldomridge & walsh, 2006). rural preceptorship and evaluation owing to long distances from urban centres and a small number of students dispersed over a wide geographical area, faculty presence onsite during rural preceptorship is not often feasible. yet, rural clinical placements are recognized as rich learning settings for students owing to the nature of the practice, the breadth of learning opportunities, and the leadership skills required in such a setting (schoenfelder & valde, 2009; sedgwick & yonge, 2008). throughout the evaluation process, rural preceptors face unique challenges specific to the rural setting. significant gaps exist in the literature regarding the evaluation process in the rural setting and the challenges specific to rural preceptorship. thus the research question was, “what is the process of evaluation used by preceptors and how was it perceived by students in the rural setting?” online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 6 method owing to the lack of research in the area of preceptorship and evaluation, and viewing evaluation as a process, the researchers began with a grounded theory methodology as it afforded the researchers a firsthand opportunity to deal directly with what was actually going on in the preceptorship experience; “the grounded theory method tells it like it is” (glaser, 1978, p. 14). setting the settings for this project were rural areas in two western canadian provinces. statistics canada (2009) defines a rural area as a place having a population of less than 1000 and a density of less than 400 persons per square kilometre. in canada, the term rural might be perceived as referring to areas where access to health care services is limited by distance and lack of qualified care providers, particularly physicians (alberta physicians resources planning group, 1997). rural placements were located from 1 to approximately 16 hours driving distance from the urban centres where the universities were located. students and preceptors were recruited from two nursing programs at two western-canadian universities. both programs require students to complete a structured preceptorship (one-to-one pairing of a student with a registered nurse) in the final semester of their four year program. one program is a nine week, fulltime preceptorship in a setting of the student’s choice during which the preceptor and student are visited theoretically twice (distance permitting): at midterm and at the culmination of the preceptorship by a faculty member. if problems arise during the preceptorship, faculty may visit more frequently. evaluation takes place at midterm and at the end of the rotation. the preceptor and student each complete a student evaluation using a tool provided by the university which is based on the professional competencies outlined by the regulatory body. the faculty member takes these into account and assigns a pass/fail rating on the clinical component. a letter grade is derived from written assignments. the second program is a six week preceptorship, three weeks in a community setting (with one preceptor) and three weeks in an acute care setting (with a second preceptor). for this program, faculty do not visit preceptors at all during the preceptorship. the formal evaluation is completed at the end of the rotation. preceptors in both programs are prepared for the experience through optional preceptor courses, a preceptor manual and are guided by the course outline and final evaluation form provided them. interactions with faculty via telephone or email are also available at the student, preceptor and/or faculty member’s initiative. sample the sample for this study consisted of 26 rural-based preceptors in two provinces in western canada. recruitment of the preceptors was facilitated by clinical placement coordinators who provided the names of fourth year nursing students assigned rural placements. students were approached in class, provided an information letter, asked to provide their preceptor a letter of invitation and the research team followed up with an introductory phone call. preceptors worked in rural hospitals (including medical, surgical, and obstetrical nursing), public health clinics and community health centres. two preceptors were male and 24 preceptors were female. preceptors ranged in age from 27.5 years to 58.5 years, with a mean age of 42.3 years. fourteen (53.8%) preceptors were baccalaureate-prepared, and 12 (46.1%) preceptors were diploma-prepared practitioners. the preceptors ranged in experience from first time precepting to having precepted over 10 students in a rural setting. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 7 data collection researchers collected data, including demographic data, in their respective settings primarily through individual interviews, and supplemented data from field notes. an interview guide consisting of open-ended questions such as “how would you describe the process that you go through in guiding nursing students during their preceptorship experience”? was used for initial interviews (90 minutes) with follow-up interviews guided by emerging categories (strauss & corbin, 1990). nearly all interviews were completed face-to-face, though a few were done via telephone due to distance constraints. all interviews took place near the end of the structured clinical preceptorship. data analysis data analysis began concurrently with data collection. open coding, the first stage of analysis, began with the generation of substantive categories and their attributes which were coded, clustered and compared to determine relationships (stern, 1980). dimensions of categories were determined by organizing data around the interrelation of substantive codes (glaser, 1978). data saturation transpired when only recurring themes emerged and further incidents did not help explain the emerging theory. the core variable that resulted from the study was “the challenge of formal evaluation”. for preceptors, their lack of role clarity as evaluators, absence of a framework to conceptualize evaluation, and the need for greater support in this role function made the formal, or summative, evaluation an onerous task. rigour rigour was addressed by establishing creditability, fittingness, auditability and confirmability (guba & lincoln, 1989). after the interviews were completed, the interviewees were sent a summary of the transcripts asking participants to validate the findings as their own experience (streubert & carpenter, 1999). fittingness or transferability was built into the design of the project. two universities collected data so all the interviews were done by two people. the audit trail can be accessed and provided guidance to the researchers when they moved to the second stage of the research project which involved establishing a framework for evaluation. when all of the previous three criteria were ensured, then confirmability was also achieved. ethics ethical approval was obtained from the universities’ health research ethics boards in the two provinces in which the research took place. to ensure confidentiality, the names of the participants were replaced with randomly assigned code numbers and data were retained in a locked cabinet. upon completion of the study, code sheets containing participants’ demographic information were destroyed. findings the challenge of the formal evaluation process preceptors found the process of evaluation, culminating in the formal evaluation, onerous and challenging. one preceptor explained: “the hardest thing i find is evaluating a student, and putting it down on paper and communicating it to them. i don’t want to ever hurt somebody’s feelings”. the core variable was found to encompass seven key aspects: preceptor role perception; the necessity of clear learning goals and objectives; the variety of evaluation criteria; online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 8 the ease of formative evaluation and strategies used; the challenge of summative evaluation; adaptation of the evaluation process when dealing with an unsafe student; and the student role in evaluation. perceived role of the preceptor. preceptors described their role as a teacher who: provides information and knowledge; facilitates learning needs; supports the student; gives encouragement; acts as a supervisor who monitors learning; serves as a guide; orients the student; provides the student with positive learning experiences; helps students reach their goals; acts as a role model; and provides students with alternate perspectives on nursing practice. as one preceptor summarized: “i view my role as a preceptor as to provide an encouraging and safe environment for a student to engage in advanced nursing student level practice, to provide optimum learning experiences and positive learning experiences for students — my student”. learning objectives. preceptors acknowledged the necessity of setting out specific learning goals and objectives for the preceptorship experience. most preceptors, however, did not do so and were unclear about the purpose of the placement and what had to be accomplished to constitute a ‘pass’. preceptors who were successful in setting out clear goals and objectives did so by familiarizing themselves with the formal evaluation tool prior to commencement of the preceptorship. some used student self-evaluations to set individualized learning goals and to gauge “where we’re starting from”, creating learning plans and outlining expectations collaboratively with the student. criteria for evaluation. preceptors listed a variety of criteria upon which they based their student evaluations. each preceptor had a different set of behaviours that were used as indicators for how a student would be rated at the final evaluation. one preceptor stated: “i do have in my mind definite things that i would like to see”, yet for each preceptor these “definite things” were criteria based on behaviours they personally valued. the following criteria were reported as being “the most important” a student must display during a rural preceptorship: ability to work as a colleague; attitude; critical thinking; enthusiasm for learning; medication knowledge; awareness; organizational abilities; proficiency; safety; adaptability; basic knowledge; caring; patient interactions; professionalism; confidence; and punctuality. use of formative evaluation. preceptors were able to outline various strategies they used to evaluate students. the most commonly cited was the use of immediate, daily, honest, verbal feedback. as one preceptor described: “i’m honest and straightforward. . . i try and be specific”. preceptors described feedback as an informal, ongoing evaluation strategy that occurred spontaneously, in a variety of settings (anywhere from the bedside to in the car to during coffee breaks). feedback was much easier to deliver than the formal written evaluation and was most successful when delivered as close in time to the event as possible. in reference to a student who had performed poorly, one preceptor explained: “you don’t want to hear about it in two weeks. you want to hear about it now”. opportunities for feedback had to be actively created and, not surprisingly, feedback was more prevalent in community settings where preceptors and students had built-in debriefing sessions in the car between appointments. preceptors admitted that it was difficult to deliver negative feedback in a constructive manner and gauged the success of their feedback on the students’ reactions. one preceptor emphasized the importance of constructive feedback saying: “but occasionally you have to be critical and constructive, cause ultimately, you have to imagine that this person could easily be your teammate. . . what kind of nurse do you want to work with”? other nursing staff and members of the health care team were used as online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 9 sources of feedback during the rotation and for the final evaluation. lastly, preceptors acknowledged the importance of documenting feedback along the way in order to create a basis for the final, formal evaluation. successful evaluation strategies also included questioning and supervision. many preceptors employed questioning to determine the student’s level of knowledge but most importantly to determine the student’s perception of their own abilities. preceptors were alert to the types of questions students posed, affording them insight into the student’s critical thinking, attitudes towards learning and the extent of their knowledge. one preceptor expressed that “a mixture of confidence/knowledge and questioning behaviours is the best” because it displays proficiency and yet a willingness to continue learning. it is a strategy that is described as helping students to “guide themselves”. such supervision ensured for accurate evaluation in which preceptors observed students intently, evaluating their level of practice, gradually allowing for greater independence. two unsuccessful strategies were found to include the use of quizzes and written assignments to test a student’s knowledge. use of summative evaluation. the final step in the evaluation process was the completion of the formal, written evaluation at the culmination of the preceptorship to be submitted to the nursing faculty. preceptors were divided on their reactions to the evaluation tool, however, there was general consensus that the tool was the most difficult aspect of their preceptorship experience and they concurred as to why it may not work very well. one preceptor summarized several viewpoints in saying: “at first, i guess, [the evaluation form is] a bit overwhelming; i mean, they’re your standard professional jargon-type, nursing-type things. but if you read through the criteria that they give you, it becomes clearer. . . but i think their real evaluation is just what i’m writing in-between. like, the feedback i’m writing, i think that’s where the real evaluation is”. preceptors who had few challenges with the formal evaluation process had documented their feedback throughout the experience and had familiarized themselves with the student’s learning objectives at the start. specific challenges preceptors cited regarding the formal tool were found to be: too much work, tedious and wordy; too vague, lacking in guidelines as to what kinds of behaviour constituted standards such as “acceptable”, “exceeds acceptable” etc.; too constraining without enough room for writing comments; and inappropriate for community nursing, but better applied to acute care. in one case the nature of the rural setting prevented an objective evaluation because the student was related to one of the preceptor’s superiors. conversely, one preceptor felt it was effective in, “that they actually get you to sit down with the person, like once a month we sit down with them”. evaluation of the unsafe student. preceptors described the need to significantly adapt their evaluation strategies when faced with an unsafe student, a process described as a very difficult and the most challenging type of student to evaluate. the term unsafe student refers to those students whose level of practice is questionable in the areas of safety or to students with marked deficits in knowledge and psychomotor skills, motivation, or interpersonal skills (scanlan, care & gessler, 2001). the feedback strategy continued to be employed however, it became time-consuming and did not guarantee positive results. feedback that was “gentle, but firm”, immediate, positive and ongoing remained consistent. it was described as “unfair” if a online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 10 student did not have the benefit of receiving quality feedback regarding poor performance. preceptors had to rely much more heavily on teaching rather than evaluating. the role of the faculty rose to a much higher level of importance. one preceptor explained: “as a preceptor, i’m a guide and i’m an assistant, but i’m not a professor. . . personally, i would be in contact with their clinical instructor, identify the problem, and go from there”. many preceptors abandoned their typical evaluation strategies to rely heavily on faculty support for management of unsafe student behaviours which in turn created serious dilemmas for preceptors at rural sites where faculty presence is typically diminished, if not absent. role of the student. data revealed students play an integral part in the evaluation process. preceptors stated that typically ‘strong’ students are generally sent to rural placements and this impacted the time and effort they spent on evaluation. they described the evaluation of strong students as being “easy”. because the formal evaluation was difficult for many preceptors, however, it was often the student to whom they turned to guide them through the process, the student being familiar with the university’s expectations and evaluation tools. alternatively, preceptors used student self-evaluations to help with their final evaluation and viewed this approach as a more appropriate way of involving students in the evaluation process. student selfevaluations were helpful in setting learning goals, ensuring accuracy of the preceptor’s final evaluation and in providing the preceptor with feedback on the experience. summary. in the process that emerged in this study, preceptors clearly outlined the functions of their role, yet did not include the role of evaluator. they described in detail the evaluation process, commenting on successful strategies as well as what they would do differently in the future, such as the delineation of learning objectives at the beginning of the rotation. preceptors described the evaluation process as self-directed, and identified areas in which they required greater support such as completing summative evaluation and evaluating the student with unsafe behaviours. discussion rural preceptors revealed strategies that were effective (informal feedback, ongoing documentation, and development of learning objectives) and areas where they required a great deal more support (formal evaluation, evaluation of a student with unsafe behaviour, and need for a framework for evaluation). there is considerable inconsistency reflected in the evaluation process undertaken by rural preceptors. this inconsistency is apparent in how the role of the preceptor is defined, the variety of criteria upon which evaluation is based, steps taken (or not) in the evaluation process, evaluation strategies employed, and the variable role of the student and instructor in the evaluation process. first, not a single preceptor in this study acknowledged the function of preceptor as ‘evaluator’ on behalf of the university or profession, although the others roles reported were consistent with those described in the literature for urban preceptors (dibert & goldenberg, 1995; usher, nolan, reser, owens & tollefson, 1999). the majority of preceptors in this sample were, at the very least, expected to give their student a pass or fail recommendation at the culmination of the preceptorship. blum (2009) developed a preceptorship model derived from a participatory action research project that emphasizes the contributions of all stakeholders in student evaluation and in particular greater preceptor participation in evaluation. implications for nurse educators include incorporating formal recognition of the preceptor role and specifically, online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 11 the evaluator role in preceptor recruitment, preparation and development, in order to raise awareness of the responsibilities inherent in this role and preparation required to execute it. preceptors assume multiple role relationships in that they are related to their employer as recruiter, to the student as a mentor and guide, and to the faculty as an evaluator. these multiple roles may conflict and without recognition of this conflict, preceptors have little support with which to navigate such roles and responsibilities (seldomridge & walsh, 2006). in a rural setting, such conflict could be compounded by multiple role relationships and high visibility within the community (yonge, 2007). thus, it is important to characterize the evaluation process as the responsibility of the preceptorship triad: preceptor, student and faculty member, and to clearly define the scope of each role throughout the preceptorship. the evaluation process must include both a framework (to determine what is being observed) and a tool (a method to record what has been observed) (qualters, 1999). in this study it became apparent that preceptors lacked an evaluation framework and thus inconsistencies exist in “what is being observed”. preceptors recognized, in retrospect, the need for delineating learning objectives at the beginning of the placement (glover, 2000; kemper, et al. 2004). in the process of developing learning objectives students can identify their learning needs and their strengths and limitations, preceptors can begin to identify learning activities at the clinical site, and faculty can help to link learning objectives with outcome competencies. seldomridge and walsh (2006) discuss the faculty’s role in translating broadly stated course objectives into meaningful learning experiences and student-centered learning goals. preceptors in this study who perceived themselves successful in the evaluation process had familiarized themselves with the formal evaluation tool at the beginning of the preceptorship. a ‘working backwards’ approach could be encouraged to make the preceptorship more comprehensive from initial learning goals through to evaluation. the lack of a framework for evaluation in rural preceptorship has caused preceptors to be especially self-directed, especially given their professional isolation and decreased access to faculty support and professional development as compared to their urban counterparts (beatty, 2001; yonge, 2007). preceptors explained that they had devised personal criteria for evaluation, and sought guidance from students and colleagues when navigating the evaluation process. this process, however, resulted in a lack of reliability in student evaluation. it also points to a lack of preceptor preparation for the evaluation role (mccarthy & murphy, 2008; yonge, et al. 1997). face-to-face workshops and other forms of preceptor preparation have been used successfully to encourage preceptor-faculty dialogue, to orient preceptors to the evaluation role and to furnish preceptors with strategies for evaluation (hallin & danielson, 2009; riley-doucet, 2008; walsh, seldomridge & badros, 2008). based on the findings from this grounded theory, the authors developed a framework to guide rural preceptors through the evaluation process. this model may prove useful to rural preceptors in other settings (yonge, myrick & ferguson, 2011). as described, daily, informal, immediate, ‘on-the-spot’ feedback is most effective for student learning and also least problematic for the preceptor (clynes & raftery, 2008; glover, 2000; lee, 2005; yonge et al., 1997). preceptors also reported the use of observation and questioning as successful strategies for evaluation. however, they were described as being more intuitive than conscious– activities that occurred automatically. myrick and yonge (2002), in an article on preceptor questioning and its impact on student critical thinking explain, preceptors are in a prime position to challenge the way preceptees think, encourage them to justify or clarify their assertions, promote the generation of original ideas, online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 12 explanations, or solutions to patient problems, provide mental and emotional tools to help resolve dilemmas, and provide a more personal environment with the one-to-one relationship (p. 176). the theory underlying questioning and the skill itself could be promoted through preceptor education and workshops. effective questioning can help determine a student’s knowledge base, the process involved in their clinical decision making, and their critical thinking skills, ultimately providing the grounds for evaluation (myrick & yonge, 2002). the finding that the use of quizzes and written assignments was unsuccessful as a teaching strategy could be attributed to the fact they are ostensibly designed for a more didactic approach to teaching and learning and would not be particularly appropriate or useful in their application to the practical realm of teaching in preceptorship. the challenges preceptors reported regarding formal evaluation are consistent with those reported by urban preceptors in other studies (seldomridge & walsh, 2006; yonge et al., 1997). strategies that ensured success included documentation of feedback throughout the preceptorship together with delineation of learning objectives at the outset. interestingly, the rural setting itself created additional challenges as the multiple role relationships preceptors had within the rural community occasionally interfered with the objectivity of the final evaluation. thus, nurse educators should consider preceptor preparation for the evaluation process that is specifically ‘rural’ in content. this could be very beneficial for rural-based preceptors in dealing with the unique challenges of this setting. it was interesting to note that strategies for evaluation and teaching were dramatically adapted when preceptors had to work with a student who had unsafe behaviours. in a study by luhanga, yonge and myrick (2008), preceptors reported that it is much easier to make critical decisions about a student’s performance when ensured the support and guidance of a faculty member. rural preceptors could greatly benefit from the integration of strategies to work with such students during preceptor orientation as they may not have the benefit of the physical presence of a faculty member during the experience. additionally, faculty presence in the form of phone calls, e-mails and site visits greatly influenced preceptor perception of faculty support (luhanga et al., 2008), thus faculty need to be encouraged to maintain an ongoing presence at the rural site through phone calls, skype and emails. from another perspective, preceptors perceived that rural placements were generally the recipients of “strong” students and perceived the evaluation of such students to be “easy”. this perception may be misguided inasmuch as the placements in these two particular programs are coordinated through a modified lottery system whereby students’ choice of placement, home address, and grades are sometimes taken into account. this perception could lead to inflated evaluations if students are perceived as naturally “strong,” or students may miss out on the benefits of feedback for growth in clinical practice if they are perceived as such. even strong students need to be challenged in their practice, thus preceptors could be taught strategies such as the questioning as previously discussed (myrick & yonge, 2002). lastly, although preceptors perceived the evaluation of “strong” students to be easy, they often still relied on the student for guidance during the evaluation process. this approach suggests that the respective roles and responsibilities of the preceptorship triad may be poorly defined and require clarification so that appropriate teaching-learning boundaries can be maintained. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 13 limitations since the participants of this study were recruited from two large western canadian universities and their affiliated nursing programs, the findings may be unique to these nursing programs and the geographical regions which they span. conclusion rural-based preceptors require greater role clarification and recognition to support their responsibility as evaluators on behalf of an educational institution. this process includes the need to emphasize evaluation as an important component of the preceptors’ roles and responsibilities, including the provision of a framework for evaluation, and finally increasing faculty support for the functions of this 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[medline] yonge, o. (2007). preceptorship rural boundaries: student perspective. online journal of rural nursing and health care, 7(1). retrieved from http://www.rno.org/journal/index.php/online-journal/article/view/7 yonge, o., myrick, f. & ferguson, l. (2011). preceptored students in rural settings want feedback. international journal of nursing education scholarship, 8(1), article 12. http://www.ncbi.nlm.nih.gov/pubmed/9384017 editorial 1 editorial letter from the editor: online journal of rural nursing and healthcare readership data jeri dunkin, phd, rn editor the rural nurse organization has been very attentive to the needs of the online journal of rural nursing and health care. in 2005, software was installed that records information every time someone accesses the journal. these recordings include time and date, specific pages accessed, and the location of the person accessing the journal. as the editor, i am very excited to report that the journal was accessed 528,780 times in 2006. one of the benefits to those whose articles are published in the journal is the ability of rno to report how many times in a given period readers have accessed a particular contributor’s article. i have included a couple of pieces of information from the report for 2006. these reports are available each month on the website. your rno membership dues support this reporting function, as well as other information, including the digital library found on the web site. please consider joining the rural nurse organization if you haven’t already, or renew your membership if you are currently a member. go to http://www.rno.org/downloads/rno_membership_application.pdf to access the membership form. the form should be printed, filled out, and mailed to rno. thank you as always for your support of rno and the online journal of rural nursing and healthcare. online journal of rural nursing most active countries online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.rno.org/downloads/rno_membership_application.pdf 2 number of times select members’ articles were accessed 0 5000 10000 15000 20000 25000 williams volume 2 article adams volume 1 article barrett volume 1 article online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 abstract 34 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 rural nurses’ research use chad o’lynn, phd, rn 1 susan luparell, phd, cns-bc, cne 2 charlene a. winters, dnsc, cns-bc 3 jean shreffler-grant, phd, rn 4 helen j. lee, phd, rn 5 lori hendrickx, edd, rn, ccrn 6 1 assistant professor, school of nursing, university of portland, olynn@up.edu 2 assistant professor, college of nursing, montana state university-bozeman, luparell@montana.edu 3 associate professor, college of nursing, montana state university-bozeman, winters@montana.edu 4 associate professor, college of nursing, montana state university-bozeman, jeansh@montana.edu 5 professor emeritus, college of nursing, montana state university-bozeman 6 associate professor, college of nursing, south dakota state university abstract this descriptive study explored the availability of research findings to rural nurses and how they use those findings in clinical practice. surveys were completed by 200 registered nurses located in the rural northern united states. the results indicate that research findings were available to most participants. the majority (82.9%) of participants agreed that changing practice based on research was beneficial; however, less than 40% of the respondents indicated that they would change their practice based on research findings if those findings contradicted previously-held knowledge, beliefs, intuition, or common sense. this study identifies a need for greater emphasis in the practice setting and in generic nursing education programs on the value and implementation of evidence based-practice. introduction it is widely acknowledged that nursing practice should be based on research and other appropriate evidence. new knowledge is generated with increasing frequency and the need to update or reinvent practice to maintain currency is a constant challenge for clinicians. failure to update practice in light of new evidence suggestive of change may serve as a detriment to clients (melnyk & fineout-overholt, 2005). compounding this challenge is the large time lapse between awareness of new knowledge and resulting changes in clinical practice. balas and boren (2000) noted that it may take up to 17 years to translate evidence into practice. although a body of knowledge is developing about how nurses use research, very little is known specifically about how nurses in rural settings access and use evidence to influence their practice. this gap is significant because 21% of all americans live in rural areas (united states department of agriculture [usda], 2007). a solid understanding of the factors that influence rural nurses’ use of research is needed if research utilization is to be facilitated in rural health care settings. background seeking the most current evidence, appraising it for validity and relevance to the practice setting, and integrating evidence into practice are essential components of evidence-based http://nursing.up.edu/ mailto:olynn@up.edu http://www.montana.edu/wwwnu/ mailto:luparell@montana.edu http://www.montana.edu/wwwnu/ mailto:winters@montana.edu http://www.montana.edu/wwwnu/ mailto:jeansh@montana.edu http://www.montana.edu/wwwnu/ http://www3.sdstate.edu/academics/collegeofnursing/ 35 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 practice (agency for healthcare research & quality [ahrq], 2003; institute of medicine [iom], 2003; melnyk & fineout-overholt, 2005; van mullem et al., 2001). although various levels of evidence (such as experience, expert opinion, consensus panels, and qualitative studies) are necessary to fully inform practice (hicks & hennessy, 1997; melnyk & fineout-overholt, 2005), rigorous quantitative studies and meta-analyses and reviews remain the strongest information on which to base most practice decisions. however, the ability to understand and evaluate research reports and ultimately incorporate evidence into daily practice is variable among nurses. general barriers to effective utilization or translation of research evidence into practice include the complexity associated with the process of changing practice, lack of authority to change practice, lack of administrative support and mentoring, insufficient time to access and evaluate evidence, lack of education on the research utilization process, lack of ability to understand research reports, lack of money, lack of resources/equipment needed to search for evidence, and lack of interest (fink, thompson, & bonnes, 2005; funk, tornquist, & champagne, 1995; hutchinson & johnston, 2004; maljanian, 2000; mckenna, ashton, & keeney, 2004; parahoo, 2000; restas & nolan, 1999.) the realities of rural nursing may create additional obstacles in accessing and using research-based evidence in practice. rural facilities must provide a wide-range of services with fewer clinicians than larger, non-rural facilities. nurses in rural settings are required to be multiskilled generalists with additional expertise in more than one traditional clinical specialty (macleod, browne, & leipert, 1998; o’lynn, 2006; scharff, 1998; wellard & bethune, 2000). this clinical role diffusion requires access to and familiarity with a larger number of clinical topics than is required for many non-rural nurses with more focused clinical specialties. complicating this increased need for diverse information, many rural nurses experience professional isolation with fewer accessible colleagues, mentors, and educational opportunities in which to increase knowledge and skill sets (macleod et al., 1998; newhouse, 2005; olade, 2004; shreffler, 1998). in addition, due to smaller economies of scale, rural health care facilities often are less able to provide accessible technology and finance resources to assist clinicians with accessing appropriate evidence databases and sources than are non-rural facilities, and also are often less able to employ adequate staff with research and literature searching skills to assist and mentor clinicians. few studies have examined the possible combined effect of general and rural specific research utilization barriers for evidence-based practice. olade (2004) found only 20.8% (n = 22) of 106 rural nurses were involved with research utilization (defined as the “translation of research findings in practice” [p. 221]). in addition to the general barriers identified by non-rural nurse samples, participants in the olade study noted that isolation from nurses involved in research and from nurses with experience in research utilization as primary reasons for not utilizing research findings. newhouse (2005) noted that evidence-based practice was perceived by rural nurse executives to be at the “low end of the infusion curve” (p. 355). ouzts (2005) reported that 90% of rural nurses in wyoming did not have access to evidence-based information at the point of care, had limited access to nursing journals, and relied mostly upon colleagues for information. winters et al. (2007) interviewed 29 rural nurses and reported that primary barriers in using research in practice were insufficient skills in accessing and interpreting research findings. although these nurses reported that having supervisors who were supportive of activities associated with evidence-based practice was helpful, geographical isolation from educational opportunities and knowledgeable peers hampered the use of research in practice. in 36 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 addition, many of these nurses stated that little research was relevant to the unique characteristics of rural practice. no study was located which comprehensively examined research utilization for evidencebased practice among rural nurses. a comprehensive understanding is necessary in designing appropriate interventions that will support and increase the use of evidence-based practice (estabrooks, floyd, scott-findlay, o’leary, & gushta, 2003; funk, tornquist, & champagne, 1995). issues in need of exploration include investigation of rural nurses’ beliefs and attitudes regarding research, past experiences with research, professional characteristics and demographic factors, and structural constraints to accessing and implementing evidence into practice. exploration of these factors provides the needed information in order to guide the adoption of evidence-based practice into the daily activities of rural nurses. the specific aims of the study presented here were to broadly examine how rural nurses access and use research findings in their practice. specific research questions were: 1. to what extent are research findings available to rural nurses? 2. what resources do rural nurses use to obtain research findings? 3. to what extent do rural nurses find research relevant to their practice? 4. how do rural nurses use research findings in their practice? methods sample and setting after receiving approval from institutional review boards at the academic institutions affiliated with the authors, a descriptive, cross-sectional survey design was used to explore availability of research and its utilization with a sample of nurses practicing in rural settings in south dakota, montana, and oregon. these states were selected for convenience. none of these states have current continuing education requirements for licensure renewal. mailing lists of all registered nurses holding licenses in these three states were obtained from the respective boards of nursing. the lists were separated into rural and non-rural subsets based on county of residence using the county classification system developed by the economic research service (ers) of the united states department of agriculture (usda, 2007). the ers county classification system expands the often used three-tiered county classification system (metropolitan, and the non-metropolitan categories of micropolitan and non-core counties) of the federal office of management and budget into nine categories of counties (codes 1-9). counties meeting the criteria of ers continuum codes 6-9 were identified as rural. as such, rural nurses were those living in non-metropolitan counties containing urban populations of less than 20,000 residents. from this population, 800 nurses were randomly selected: 300 from oregon, 300 from montana, and 200 from south dakota. sample size was determined by budget resources. the desired study sample was nurses working in rural facilities. none of the mailing lists, however, indicated the employment location of the registered nurses. it was recognized that some nurses reside in rural areas and commute to employment settings in urban areas. in order to capture the desired population, the data for zip codes for residence and for primary place of employment were collected. with this information, it was possible to exclude registered nurses who commuted to urban settings from the data analysis. surveys and return envelopes 37 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 were mailed to each of the 800 nurses, accompanied by cover letters that included an explanation of the study and measures to assure confidentiality. instrument the survey tool, titled “rural nurses’ access to and use of research in practice”, was developed collaboratively by the research team and researchers from the university of calgary. the survey was adapted with permission from tools created by other researchers (estabrooks, 1996; funk, tornquist, & champagne, 1995; mckenna, ashton, & keeney, 2004). the adapted tool served primarily as an accumulation of items from the previous tools with the addition of demographic information and more detailed exploration of information from the previous tools (for example, more detailed exploration of internet connectivity). the adapted tool was pilot tested with 100 registered nurses from eastern montana, with a return rate of 52% (n = 52). the names of these 100 registered nurses were removed from the sample of the current study in order to prevent duplication of study participation. from the data of the pilot study, reliability of individual likert-scale items ranged from a cronbach’s alpha of 0.643 and 0.863. the adapted tool was originally designed to be distributed to physicians, nurses and social workers; therefore, items not relevant to nurses (e.g. identification of self as a social worker) were removed for the current study in order to better accommodate a nursing sample. to provide common context for the study participants, research utilization was defined on the survey as the use of any kind of research, in any kind of way, in any aspect of work as a health practitioner. even though clinical practices learned in school may be well-supported by research, participants were instructed not to consider information that was learned in their basic professional education as research because the aims of the study were to explore on-going posteducation research utilization behaviors in the practice setting. the tool contained a total of 115 items distributed among six sections: availability of resources, sources of information, internet access and use, use of research findings, attitudes toward research-based practice, and demographics. these sections primarily contained research utilization variables attributable to the individual nurse, congruent with the aims of the current study. nevertheless, effective research utilization is dependent upon individual variables as well as variables attributable to healthcare organizations and financial systems. data from systemic/ organizational variables were explored indirectly via the perspectives of individual nurses (for example, perceived availability of continuing education opportunities in the work setting). each section on the survey contained multiple items using likert-type or yes/no response questions. respondents were also afforded the opportunity to provide qualitative comments. procedure and data analysis school of nursing research office staff mailed surveys and return envelopes numerically coded to each of the 800 nurses, accompanied by cover letters that included an explanation of the study and measures to assure confidentiality. participants returned surveys via mail to the research office. office staff verified completed surveys and sent thank-you cards and certificates of participation to those who returned a completed survey. surveys were separated from envelopes in order to maintain confidentiality of the participants. data from completed surveys were entered into a database and displayed using the statistical package for social sciences (spss version 15®) software and analyzed by the research team using descriptive statistics to 38 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 determine item frequencies and measures of central tendency. content analysis (patton, 2002) was used to discern themes in the qualitative data. results sample in total, 263 surveys were returned representing a return rate of 35.3%. respondents who declined to participate by returning blank surveys were removed from the sample. also, nurses working in urban counties (identified by zip code of place of employment) were removed from the sample, leaving 200 surveys for analysis. overall response rates from the three states were similar. demographic data are detailed in table 1. no demographic data were available for nonresponders. of particular note is that the majority of the participants possess a baccalaureate degree or higher and work full-time in an acute care facility in a staff nurse position. variability in the amount of time spent in rural practice is evident. most participants reside close to their place of employment. availability of research findings fourteen items on the survey related to the availability of resources that would contain findings from research studies. just over half, some 51.3% (n = 100 of 195 responses) of the respondents, reported that professional journals were accessible at their workplaces; 59.5% (n = 116) noted that the journals available were current and 61.8% (n = 121) noted that the journals were appropriate to the specific clinical setting. a number of respondents provided qualitative comments that further explained or clarified their responses. some respondents noted that the journals available in the workplace were journals from their personal subscriptions that they had brought to the clinical setting from home. whether at work or at home, 38.8% (n = 76 of 196 responses) of the respondents reported reading general nursing journals (such as american journal of nursing) less than five times per year; 71.9% (n = 141) reported reading specialty nursing journals less than five time per year; and 82% (n = 161) reported reading nursing research journals less than five times per year. a small majority of the nurses (57.7%, n = 194) indicated that published clinical guidelines were available to them. a minority of rural nurses (29.9%, n = 58) reported that libraries were present at their workplace. over half (n = 120 of 193 responses) reported that regularly accessing the nearest library of any type, whether in their workplace or in their communities was difficult. educational opportunities were available to nurses through conferences and inservices. although the content of these opportunities was not explored by the survey items, 66.3% (n = 130 of 196 responses) of the respondents reported that education was provided at the workplace and 58.7% (n = 115) of the respondents noted that education was provided regularly. although 67.0% (n = 131) of the respondents stated that monies were available from their employers to attend educational conferences, some respondents indicated that these monies were limited to charge nurses or managers only. the internet has greatly expanded nurses’ ability to obtain research findings from the literature. a large majority (86.6%, n = 168 of 194 responses) of respondents reported internet availability in their workplace. most of the nurses (n = 156) used the internet at work. the internet connection at work was reliable for 90.5% (n = 176) of the respondents, but only 54.4% 39 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 table 1 select demographic data of study respondents 1. gender (n = 196) a. female 91.8% b. male 8.2% 2. age (n = 193) a. < 30 years 7.8% b. 31-40 years 18.1% c. 41-50 years 34.7% d. 51-60 years 29.5% e. > 60 years 9.8% 3. level of highest educational preparation (n = 194) a. diploma 9.8% b. associate degree 32.5% c. baccalaureate degree 45.4% d. master’s degree 12.4% e. doctorate 0.0% 4. level of employment (full/part) (n = 195) a. full time 67.0% b. part time/ per diem 32.9% c. not currently employed 6.7% 5. employment setting (n = 162) a. hospital 63.0% b. long-term care facility 9.9% d. public/ community health 11.1% e. other 16.0% 6. primary position (n = 169) a. staff nurse 55.0% b. charge nurse 18.9% c. manager/ administrator 14.8% d. nurse practitioner 9.5% e. educator/ instructor 1.8% 7. total years of nursing practice (n = 198) mean = 20.5 years range = 1-50 years sd = 11.8 years 8. total years of rural nursing practice (n = 196) mean = 15.1 years range = 1-46 years sd = 10.2 years 9. location of employment (n = 180) works in same community as residence 75.6% if not, one-way commuting distance (in miles) mean = 27.6 miles range = 3-130 miles sd = 20.4 miles if not, one-way commuting time (in minutes) mean = 34.2 minutes range = 10-120 minutes sd = 21.6 minutes 40 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 (n = 106) noted that the computers were adequate for searching for research information. the few nurses who did not use the internet cited a lack of time at work or that computers with internet access were only available in the offices of managers as the reasons they did not use it. nearly all of the respondents (94.6% n = 184) reported using the internet at home. for those few nurses (n = 10 ) who reported never using the internet, seven reported lacking computer skills and five reported not having time to use the computer. sources of knowledge table 2 details the knowledge sources used always or frequently by the respondents. the majority of respondents reported frequent use of self-knowledge (experience, intuition, basic education) or knowledge sources internal to the organization (procedure manuals, co-workers) as primary knowledge sources for professional practice. although 2/3 of the respondents reported frequent use of knowledge gained from inservices and conferences, other formal sources of knowledge external to the employment setting (post-education academic courses, clinical consultants from other settings) were used by a minority of the nurses. table 2 sources of knowledge used always or frequently in professional practice respondents knowledge source n % personal experience 197 89.3% content learned in school 197 72.1% inservices/ conferences 193 66.8% policy/ procedure manuals 196 58.7% intuition 195 56.4% consultations with co-workers 195 52.8% consultations with external experts 195 33.3% general nursing journals 196 31.6% routine habit 192 28.6% nursing research journals 196 18.9% general medical journals 196 13.3% drug representatives 196 11.7% lay literature/ media 195 5.6% relevance and use of research findings although 82.9% (n = 161 of 194 responses) of the nurses “agreed” or “strongly agreed” that changing practice based on research was beneficial and 73.7% (n = 143) of the nurses “agreed” or “strongly agreed” that implementing research-based practice would benefit their personal professional development, only 39.2% (n = 76) reported confidence that research findings were relevant to their rural practices and only 26.7% (n = 53) believed the results of research studies that they read. additionally, 15.4% (n = 30) of the nurses reported that the research specific to their clinical areas was of poor quality. in addition to the lack of perceived relevance of research to rural nursing, a number of additional barriers to using research in 41 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 table 3 “agreeing/ strongly agreeing” that barrier to using research in practice is present respondents barrier n % research literature reports conflicting results 194 79.9% lack of time to implement research effectively 194 61.9% lack of incentives to develop research skills for use in practice 195 59.0% amount of research is overwhelming 194 54.1% difficulty to influence change in the workplace 195 50.3% research articles not easily understood 195 49.2% isolated from knowledgeable colleagues 194 48.5% research findings not easily transferred to practice 194 44.8% lack of management support for using research in practice 195 29.3% lack of support from colleagues for using research in practice 194 23.7% lack of confidence in ability to evaluate quality of research 194 19.1% lack of knowledge of how to search research-based information 195 15.4% lack of confidence in personal skills with computers 195 14.4% practice were identified (see table 3). most of these barriers are consistent with those identified by previous researchers. in terms of actual use of research findings in practice, 27.1% (n = 54 of 199 responses) of the respondents reported using research “often” or “very often” in the past year; whereas 30.0% (n = 60) reported using research “rarely” or “never” in the past year. while the structural and educational barriers identified by the respondents may have limited the use of research in practice, attitudes and values regarding research may have affected the use of research as well. only 37.0% (n = 73) of the respondents would be willing to adopt research findings if those findings contradicted the information they had learned in the workplace. furthermore, only 34.8% (n = 68) of the respondents would be willing to adopt findings that contradicted the information they had learned in their basic nursing preparation and only 22.8% (n = 44) of the respondents would be willing to use research findings if the results contradicted their intuition or common sense. interestingly, 63.4% (n = 123) of the respondents stated that they would be more comfortable using research if a research-experienced individual was available to supply them information and 37.0% (n = 66) of the nurses felt that they should take a course to help them use research more effectively. finally, respondents were asked to estimate the percentage of their practice that was based on research. responses ranged from 0-100% with a mean score of 35.1% of practice that was perceived as research-based. discussion the results of this study provide useful insights about research utilization in rural nursing practice that are both encouraging and discouraging. for example, this rural nurse sample reported internet availability that exceeded previous reports in the literature (estabrooks, o’leary, ricker, & humphrey, 2003). additionally, the vast majority of the respondents 42 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 indicated that changing practice based on research would be beneficial. less encouraging, however, is that only about one in four nurses actually reported using research routinely in practice. there also appears to be a general lack of skill in interpreting research in a meaningful way based on the self-report of the participants. the results reveal some seemingly contradictory findings. for example, about half of the participants reported difficulty in understanding research articles, yet the majority of participants denied a lack of confidence in evaluating the quality of the research. although this study did not explore participant ability to understand specific components of a research article, some possible explanations for this contradiction could be considered. it is possible that participants had trouble understanding the methodology and data analysis aspects of research articles. yet if the discussion of the research findings were perceived to be too abstract or non-applicable to rural practice, participants may have judged these articles to be of poor quality. in other words, it is possible that the quality of a research article may have been determined by the applicability of its findings by some of the participants. such an explanation should be considered since nearly 40% of the participants felt that research findings were relevant to rural nursing and nearly 45% of the participants felt that research findings were poorly transferred to practice. another contradiction is that despite the general agreement among the nurses that incorporating research into practice is beneficial, few nurses in this study indicated that they would change their practice if the evidence contradicted pre-existing knowledge or beliefs. on the one hand, blind acceptance of research findings is not the goal of evidence-based practice. nonetheless, this disconnect between recognizing the possible benefits of evidence based practice and actual changes in practice needs to be addressed. perhaps more emphasis and support is needed in the practice setting and generic nursing education on the value and implementation of evidence based practice. nurses in this study reported reliance on general nursing journals more than nursing research journals and more so than non-nursing professional journals. this finding should not be surprising based on the generalist focus of most nurses in rural practice. given the extent to which general nursing journals are utilized, they could be useful vehicles for the dissemination of evidence. editors of these journals should consider incorporating more multidisciplinary content as well as manuscripts focusing on user-ready syntheses of current evidence. in addition, rural health care organizations should consider increasing nurses’ access to rural-focused health journals. access to these journals would facilitate availability of research articles that nurses would find relevant to rural practice. the nurses in this study from south dakota, montana, and oregon were consistent with their wyoming counterparts (ouzts, 2005) in acknowledging reliance on information from colleagues to inform their practice. however, it is unknown if or how information from colleagues is validated. these considerations suggest that there are essential personnel in rural agencies for whom it would be incumbent to send to continuing education venues to keep current in practice. given the barriers associated with geographic isolation from knowledgeable peers (macleod et al, 1998; newhouse, 2005; olade, 2004; shreffler, 1998; winters et al., 2007), the importance of professional practice networks for rural nurses is paramount. this sample also acknowledged that continuing education programs at the worksite are valuable in terms of dissemination of current information, making it imperative that administrators continue to allocate funds for such opportunities. the findings from this study suggest that rural nurses need much assistance interpreting research findings. given that the sample is likely more educated than the nurses in many rural 43 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 settings, with almost 58% of this sample educated at the baccalaureate or master’s level, the relative self-reported lack of skill in using research is troubling. although some of these nurses may have attended school at a time when research utilization was a rare topic in nursing curricula, the perceived lack of skill among the participants may be more indicative of a lack of database searching skills, as noted by the majority of participants who stated that a research mentor would be beneficial. if the culture of nursing is truly shifting to evidence-based practice, nursing programs need to shift their curricula accordingly, adding much more attention to critique of evidence as a fundamental competency of generic nursing education at all levels. specifically, education programs need to have a stronger focus on nursing informatics and evidence-based practice, actively helping students develop the skills to locate evidence in databases, interpret evidence, and perhaps more importantly, instilling the values and expectations that practice is ever dynamic and should always be changing to reflect the most current evidence. these goals could be realized by student assignments in which practices seen in the clinical setting are critiqued using evidence obtained from databases, analysis of quality improvement efforts, or the use of case studies to illustrate improved client outcomes resulting from changes in practice consistent with new evidence from research. opportunities exist for creativity in planning interventions to bolster the skills of rural nurses in critiquing evidence. for example, with the burgeoning of online academic programs, it may be possible for rural health agencies to partner with academic institutions to help their nurses obtain skills for accessing and critiquing evidence. other possibilities exist for the development of online learning modules that could be completed by rural nurses onsite or at home. such possibilities require organization support and collaboration among rural facilities, health networks, and academic institutions. finally, these results further suggest that rural health care agencies are ripe for clinical nurse specialists (cns) and clinical nurse leaders (cnl) who are specially prepared to identify practice questions, seek out pertinent evidence, and critique it for relevance to practice. clinical nurse specialists are well known for their ability to “influence care outcomes by providing expert consultation for nursing staffs and by implementing improvements in health care delivery systems’ (national association of clinical nurse specialists, 2007). the cnl “puts evidencebased practice into action to ensure that patients benefit from the latest innovations in care delivery” (aacn, 2005). given the general lack of resources at many rural agencies, a cns or cnl shared among several facilities would potentially provide for significant economic impact in terms of improved patient outcomes as a result of increased use of evidence-based practice. use of telecommunications for cns/ cnl consultations could overcome collaboration barriers related to geographical distance. further research will be needed to evaluate the efficacy of shared cns/ cnl personnel in improving the implementation of evidence-based practice in rural facilities. although the findings provide helpful insights into rural nurses’ access to and use of research to inform practice, the findings cannot be generalized to all rural nurses and rural health facilities. the small sample size does not afford the ability for inferential or predictive conclusions. in addition, financial, technology, and personnel resources are highly variable among rural facilities. rural areas distant from the geographical setting in this study may present with different sociocultural, educational, and industry networking variables which could yield different findings. also, this study did not evaluate whether or not nurses possessed specialty certification. requirements for maintaining certification may affect continuing education efforts of individual nurses. further research is needed exploring relationships among demographic 44 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 variables and attitudes, knowledge, and skills accessing research findings and implementing evidence into clinical practice. importantly, further research exploring how rural nurses resolve dissonance between new evidence and previously held clinical knowledge and beliefs is essential as clinical mentors, educators, and administrators develop strategies designed to increase the implementation of evidence based practice in rural health facilities. conclusion the findings from this study provide useful insights about the role of research in rural nursing practice. while a large majority of nurses considered it beneficial to incorporate research into practice, relatively few nurses actually routinely incorporated research into practice. reasons for this are likely due to a combination of individual and systemic barriers. additionally, nurses were inconsistent in their sources of knowledge, most often relying on selfknowledge or professional colleagues. although access to the internet, nursing journals, and other library resources was available, self-reported lack of skill in interpreting research as well as inconsistencies regarding the value of research appeared to be significant barriers to evidencebased practice in rural settings. references agency for healthcare 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(2004). evidence-based practice and research utilization activities among rural nurses. journal of nursing scholarship, 36(3), 220-225. [medline] o’lynn, c. (2006). men working as rural nurses: land of opportunity. in h.j. lee & c.a. winters (eds.) rural nursing: concepts, theory, and practice (2 nd ed., pp. 232-247). new york: springer. ouzts, k. (2005). evidence-based practice and information literacy skills in rural nurses. [abstract] communicating nursing research, 38(13), 287. parahoo, k. (2000). barriers to, and facilitators of, research utilization among nurses in northern ireland. journal of advanced nursing, 31(1), 89-98. [medline] patton, m.q. (2002). qualitative research & evaluation methods. thousand oaks, ca: sage. restas, a., & nolan, m. (1999). barriers to nurses’ use of research: an australian hospital study. international journal of nursing studies, 36, 335-343. scharff, j. (1998). the distinctive nature and scope of rural nursing: philosophical bases. in h.j. lee (ed.) conceptual basis for rural nursing (pp. 19-38). new york: springer. shreffler, m.j. (1998). professional isolation: a concept analysis. in h.j. lee (ed.) conceptual basis for rural nursing (pp. 420-432). new york: springer. us department of agriculture [usda], economic research service. (2007). measuring rurality: what is rural? retrieved on october 8, 2007, from http://www.ers.usda.gov/briefing/rurality/whatisrural . van mullem, c., burke, l.j., dohmeyer, k., farrell, m., harvey, s., et al. (2001 integrating research into practice. american journal of nursing, 101(4), 24a-24h. wellard, s., & bethune, e. (2000). learning issues for nurses in renal satellite centres. australian journal of rural health, 8(6), 322-326. [medline] winters, c.a., lee, h.j., besel, j., strand, a., echeverri, r., jorgenson, k.p., & dea, j.e. (2007). access to and use of research by rural nurses. rural and remote health (online), 7(758). [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9708085%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11898241%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14706003%5buid%5d http://www.nacns.org/faqs.shtml http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16077277%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15495490%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10632797%5buid%5d http://www.ers.usda.gov/briefing/rurality/whatisrural http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11894792%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=17892348%5buid%5d editorial 1 editorial letter from the managing editor steven l. maccall, phd managing editor greetings from the school of library and information studies (slis) here at the university of alabama. it has been my honor to contribute to the creation and ongoing management of the online journal of rural nursing and health care as the managing editor since its inception. as a faculty member at slis, i teach a variety of courses, including those in health information and librarianship. my research has been focused in the area of clinical digital libraries. our research group is responsible for the creation and ongoing maintenance of the rno digital library, which is linked to from the homepage of the rno website. you may also use the following url: http://ruralnurseorganizationdl.slis.ua.edu/. this work is in conjunction with dr. ana d. cleveland at the school of library and information sciences at the university of north texas. the purpose of this column twofold: to announce a significant milestone for the online journal of rural nursing and health care and to solicit feedback concerning the features of the journal. first, the milestone: since our last issue of the journal in spring 2004 (volume 4, no. 1), we have been accepted for inclusion into the cumulative index to nursing and allied health literature (cinahl). cinahl, which is the premier database covering nursing and allied health, currently indexes more than 1700 journals, of which 536 are classified as nursing journals. the availability of our articles through this highly used bibliographic tool will enhance the visibility of our authors’ work. our next step will be to examine possibilities for other bibliographic databases. second, i would like to personally invite emails from the readership of the online journal of rural nursing and health care concerning its features. we have made an attempt to provide a high quality product, including providing convenient access to article abstracts and links to medline abstracts in the bibliographies of each article. we are constantly seeking to provide a better reading environment, so all suggestions are welcome! my e-mail is smaccall@bama.ua.edu. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://ruralnurseorganization-dl.slis.ua.edu/ http://ruralnurseorganization-dl.slis.ua.edu/ http://www.cinahl.com/cgi-bin/jlookup?cdbysset.dat+nursing mailto:smaccall@bama.ua.edu running head: rural nurse retention 82 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 who stays in rural nursing practice? an international review of the literature on factors influencing rural nurse retention candice manahan roberge, msc 1 1 community health sciences program, university of northern british columbia, manac000@unbc.ca keywords: rural, nurse, retention, job satisfaction, international abstract this paper explores factors that influence rural nurse retention. a comprehensive literature review was used to highlight, examine and evaluate studies that identify factors, including personal characteristics and experiences, in relation to rural nurse retention and job satisfaction. the findings from the literature review suggest rural nurse retention is influenced by level of job satisfaction. the findings also suggest factors, including personal characteristics and experiences, influence job satisfaction. the literature review findings further indicate factors, including personal characteristics and experiences, affect the duration of rural nurse practice. the current rural nursing retention strategies in british columbia are explored. based on the findings from the literature review, detailed recommendations for future research and recommendations for rural nursing retention strategies are made. the concepts identified inform health human resources retention strategies, specifically nursing retention in rural areas. introduction understanding health human resources is essential to sustaining health care services. the world health organization (who) states the need for health care professionals has grown world-wide, and the quality of health care services heavily depends on the ability to meet that need (poz, kinfu, dräger & kunjumen, 2006). the health council of canada publicly announced the most pressing challenge now facing canada’s health care system is the health human resources requirement (decter, 2005). the canadian institutes of health research’s institute of health services and policy research stated in one of their latest national consultation reports, that one of canada’s top nationwide research priorities is to learn more about the country’s health human resources, and to develop effective recruitment and retention strategies (gagnon & ménard, 2001). the need to understand health human resources has become increasingly evident at the international, national and provincial levels. nurses are the largest health human resource group working in canada, with over 232, 000 registered nurses working throughout the nation (pong & russel, 2003). nurses are often considered the foundation of the canadian health care system, and understanding nurse retention is necessary to the analysis of health care service quality, efficiency and sustainability. the unequal distribution of the nursing workforce between rural and urban areas is well documented (macleod et al., 2004). the who states over 60% of the world’s nurses work in urban areas, suggesting a significantly unequal distribution of nursing service in rural areas (poz et al., 2006). assessments of canada’s nursing workforce show only 18% of registered nurses are serving the 22% of canadians who live in rural areas (macleod et al., 2004). it is also more difficult to recruit nurses in rural regions. a study at the university of colorado suggests it takes nearly 60% longer to recruit nurses to rural facilities than to urban facilities (macphee & scott, 2002). http://www.unbc.ca/communityhealth/ mailto:manac000@unbc.ca 83 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 despite the importance of rural nurses to the health care system and the evident disparities, there has still been little research that explores the retention of rural nurses (macleod et al., 2004). research question & objectives this paper explores factors that influence rural nurse retention. the current study poses the following research question: what personal factors, such as personal characteristics and experiences, are related to rural nursing retention and job satisfaction? this paper hypothesizes rural nurse retention is influenced by level of job satisfaction. this paper also hypothesizes factors, including personal characteristics and experiences, influence job satisfaction. furthermore, it is hypothesized that factors, including personal characteristics and experiences, affect the duration of rural nurse practice. the current rural nursing retention strategies in british columbia could be improved by addressing the factors that influence job satisfaction and retention. this paper will highlight, examine and evaluate the literature that identifies factors, including personal characteristics and experiences, in relation to rural nurse retention and job satisfaction. based on the findings, detailed recommendations for future research and recommendations for rural nursing retention strategies will be made. the concepts identified will inform health human resources retention strategies, specifically nursing retention in rural british columbia. methods to explore the hypotheses, a literature search using google scholar, pub med and ovid was conducted using the search terms: rural, nurse*, retention, health, job satisfaction. a search using the canadian nursing association and center for rural and northern health research websites search engines were also completed using similar keywords. additional relevant studies were identified using the bibliographies of those articles found in the literature searches. the studies included in this review were conducted between 1996 and 2006; the majority of studies are rural with a focus on canadian research. current literature: rural nursing practice rural nursing practice is characterized by a variety of challenges influencing nurse retention. researchers, pong and russel (2003) at the centre for rural and northern health research, found rural health professionals generally have difficulty obtaining full-time, permanent positions because rural areas often do not have the population base to fund full-time employees. pong and russel (2003) note nurses experience an increased scope of practice in rural areas because they are sometimes one of the only health care professionals in the area. the researchers note the shortage of other health professionals in rural areas make it hard for nurses to get the tools they need, like diagnostic tests (pong & russel, 2003). according to the researchers, nurses can not always deal with the increased variety and responsibility of rural practice, affecting their decision to stay in rural sites (pong & russel, 2003). according to pong and russel (2003), further pressures on the rural nursing workforce arise with the looming loss of “baby boomer” nurses to retirement, the dwindling number of canadian nursing graduates, and the increasing educational requirements for registered nurses. the information from this 84 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 study suggests nursing practice in rural canada has added complexities to consider in assessing job satisfaction and duration of practice. bushy (2002) assessed rural nursing workforces in canada, australia and the united states. bushy (2002) found similar challenges for rural nursing workforces despite regional differences. rural nurses in all three countries are concerned about the recruitment, education and retention of rural nurses. they express concerns about the growing population of elderly in rural areas, while the younger generation move away to find work in urban areas (bushy, 2002). nurses from all countries are concerned with the growing number of rural nurses retiring. other global trends, such as the shift to community care and increasing equitable health care access for rural people, also amplify the need for rural nurses (bushy, 2002). bushy notes “rural lifestyle” affects nurses in all three countries. bushy (2002) explains rural nursing blurs the boundaries between personal and professional life. rural nurses in each country express concern about decreased anonymity and confidentiality in small towns. bushy (2002) suggests nurses who work in rural areas are in high public visibility, and this often extends to their family members. for example, many of the study participants feel they are professionally evaluated by the community, based on how their children behave or what their yards look like. because the boundaries between personal and professional life are broken down in rural nursing, both professional and personal factors need to be addressed when assessing rural nurse retention (macleod et al., 2004). job satisfaction and rural nurse retention the relationship between job satisfaction and the decision to stay in rural nursing is well documented in the literature (stratton, dunkin, juhl, & geller, 1995). when rural nurses are not satisfied with their job, they are more likely to leave their position. using the data from a nationwide survey of canadian rural nurses, macleod and her colleagues (2004) found higher perceived stress and lower job satisfaction are central in the decision to leave rural practice. understanding the relationship between job satisfaction and duration of practice is essential to the successful creation of effective rural nurse retention strategies. pan, dunkin, muus, harris and geller (1995) used a logit analysis of international survey data of 2, 509 rural registered nurses. results suggest job satisfaction is the most influential predictor of staying in rural practice (pan et al., 1995). meanwhile, other studies show rural nurses have lower levels of job satisfaction than their urban counterparts. ndiwane (2003) surveyed 150 rural and urban american nurses. according to the results, rural nurses are less satisfied with their jobs, their pay and their opportunities for promotion. similarly, ndiwane (1999) surveyed nurses in cameroon, africa and found nurses who are less satisfied with their job are working in rural settings. overall, the current body of literature suggests features of rural practice influence job satisfaction, while job satisfaction influences duration of rural practice. factors that influence job satisfaction researchers compared rural and urban nurses in new york regions, and also found rural nurses have lower job satisfaction (ingersoll, olsan, drew-cates, devinney & davies, 2002). ingersoll and his colleagues (2002) used a random-sample survey to ask both rural and urban nurses (n=1,853) about job satisfaction, organizational commitment, demographics, and future career plans. when compared to urban nurses, rural nurses were more likely to be planning to 85 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 leave their practice within the next year, and less satisfied with their job (ingersoll et al., 2002). however, urban nurses were more likely than rural nurses to be planning to leave their job in five years, and more likely to have lower organizational commitment (ingersoll et al., 2002). these findings suggest once nurses have spent a significant amount of time in a rural community, other factors can overcome the influences of job satisfaction on retention. ingersoll and colleagues (2002) explored the factors interrelated with job satisfaction and retention by conducting a correlational analysis on the demographic and job satisfaction data. the researchers found nurses’ with higher levels of education are more satisfied with their job (ingersoll et al., 2002). nurses who are in educator roles or management roles are more satisfied with their job, while part-time and per diem nurses are less satisfied (ingersoll et al., 2002). there is a strong positive correlation between job satisfaction and professional autonomy, organizational commitment, pay scale and task requirements (ingersoll et al., 2002). furthermore, the researchers found nurses who are over 50 years of age reported higher levels of job satisfaction, and intent to stay in comparison to younger nurses (ingersoll et al., 2002). ingersoll and colleagues (2002) suggest the reasons for older nurses reporting higher levels of job satisfaction are still unknown. based on other findings from this study, one may suggest continued education, management roles, educator roles, professional autonomy, higher pay scale and variation in task requirements could be more accessible to experienced nurses, who in turn are more likely to be older. ingersoll and colleagues (2002) acknowledged the limitations of a 46% response rate and that the sample only included registered nurses, limiting the generalizability of the study. future research needs to aim for higher response rates, and use a variety of nursing professions to increase generalizability. nonetheless, this study lends valuable insight to rural nurse job satisfaction and retention. based on the findings from this study, retention strategies need to support nurses in professional development, specialty training, and provide opportunities for nurses to take on educator roles. an example of increasing access to professional development or specialty training could be increasing distance education courses in nursing programs. the findings from this study could also suggest retention strategies need to consider supplementing part-time employment, especially in rural areas. for example, if a rural community does not have the population base to support a full-time nurse, salaries need to increase and/or other part-time employment needs to be arranged. an interpretation of the findings could suggest increasing professional autonomy, and giving nurses a variety of tasks would increase job satisfaction and duration of rural practice. furthermore, although the reasons for older nurses reporting higher rates of job satisfaction are unknown (ingersoll et al., 2002), the results suggest decision makers need to recognize what retention strategies may be suitable for one age group, may not be as suitable for another (pan et al., 1995). chaboyer and colleagues (1999) surveyed 135 rural nurses in central australia to ask about influences on job satisfaction. chaboyer, williams, corkill, and creamer (1999) found higher job satisfaction if nurses have a variety of tasks in their job, peer feedback, and collaborative teamwork. the authors suggest the effects of making nurses part of a health care team are often underestimated (chaboyer et al., 1999). an interpretation of these findings could suggest retention strategies for rural nurses need to include team building initiatives, and plans for rural peer support networks. including rural nurses in an interdisciplinary health care team, or creating an on-line support group for rural nurses, could be considered to improve job satisfaction and lengthen duration of rural practice. 86 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 an earlier study at the university of kentucky used a multi-state survey of registered nurses serving three different rural populations (stratton et al., 1995). like ingersoll et al. (2002), the researchers surveyed registered nurses only (n=1,647), and had less than half of the target sample respond (40.3%). the analysis shows a positive relationship between tuition reimbursement and job satisfaction (stratton et al., 1995). researchers found rural nurses are more satisfied with their job if daycare facilities are provided by the employer (stratton et al., 1995). the findings highlight the need for retention strategies to continue tuition reimbursement, and other education incentives for rural nurses. the findings also suggest decision makers need to consider family life when creating retention strategies, and include supports for rural nurses with children. factors influencing duration of rural practice hegney, mccarthy, rogers-clark and gorman (2002) conducted a cross-sectional survey of 146 registered and enrolled nurses in rural australia. the survey asked nurses to rank 91 separate items on level of importance in relation to the decision to remain in rural practice. the results suggest job satisfaction and being part of a professional team are the most important predictors of remaining in rural practice (hegney et al., 2002). the nurses who remain in rural practice generally appreciate “rural lifestyle”, feel a sense of belonging in the community, and work in a family friendly environment (hegney et al., 2002). like other past studies, the findings suggest professional support networks, managerial support, professional autonomy, maintenance of clinical skills and peer recognition are very important in the decision to stay (hegney et al., 2002). this study provides further evidence of specific influences on both job satisfaction and retention already discussed in this paper. the results of this study raise questions about what constitutes “rural lifestyle”, and identifies a significant gap in the literature. in addition, the study introduces the importance of community satisfaction in the decision to stay in rural practice. researchers, henderson-betkus and macleod (2004) recently surveyed 124 public health nurses in rural, northern british columbia. the survey analysis indicates job satisfaction is most influenced by professional status, professional interactions and autonomy (henderson-betkus & macleod, 2004). however, the researchers note job satisfaction for rural nurses occurs within the context of community satisfaction (see figure 1). henderson-betkus and macleod (2004) suggest rural nurses can only be satisfied with their job if they are satisfied with their community. rural nurses in the study suggest the level of friendliness in the community, number of friends in the community, and level of trust they feel toward the community, all influence community satisfaction (henderson-betkus & macleod, 2004). similar to hegney, mccarthy, rogers-clark, and gorman (2002a), this study indicates having friends living in rural communities, a sense of belonging in the community, and having access to social networks are important predictors of retention. henderson-betkus and macleod (2004) note rural nurses report social/recreational opportunities, safety, and quality of schools increases community satisfaction as well (henderson-betkus & macleod, 2004). the findings suggest loss of anonymity, and work-related questions outside of work, decrease community satisfaction (henderson-betkus & macleod, 2004). small sample size and only using public health nurses in the sample limited the generalizability of this study. a similar study using a larger sample and a variety of nursing professions is recommended. however, these findings could have major implications for rural nurse retention strategies, specifically in british columbia. if job satisfaction occurs within 87 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 figure 1. the decision to stay or leave from “retaining public health nurses in rural british columbia: the influence of job and community satisfaction” by m. henderson-betkus and m. l. p. macleod, 2004, canadian journal of public health, 95(1), p. 54. decision to stay or leave community satisfaction filter factor: demographics filter factor: personal circumstances filter factor: opportunities job satisfaction 88 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 community satisfaction, retention strategies need to pay more attention to community integration. to help nurses become more satisfied with rural communities, retention strategies could promote community events and recreational activities. getting rural nurses more involved in community activities could help nurses find friends, build trust in the community, and increase their community satisfaction. furthermore, retention initiatives need to involve community members, especially other health care professionals, to help create both social and professional support networks. community development, including quality education opportunities and community safety initiatives, could also have a positive effect on rural nurse retention. personal characteristics and experiences henderson-betkus and macleod (2004) found the relationship between job satisfaction, community satisfaction, and the decision to leave or stay is interrupted by a number of “filter factors”. the researchers found that even if rural nurses are satisfied with their job and their community, a collection of personal characteristics and experiences, or “filter factors”, still dictate the decision to remain in rural practice (see figure 1). personal circumstances act as “filter factors”, and include retirement, financial needs, family needs, family commitments, and professional growth (henderson-betkus & macleod, 2004). nearing retirement influences nurses to stay in their current position for security; however, if their spouse is retiring, the nurse is more likely to leave (henderson-betkus & macleod, 2004). financial needs influence nurses to stay, but also influences nurses to leave if their spouse cannot find employment (hendersonbetkus & macleod, 2004). family needs and commitments can influence nurses to stay, but sometimes influence them to leave if their family lives somewhere else (henderson-betkus & macleod, 2004). henderson-betkus and macleod (2004) noted nurses who have children or spouses, who wanted post-secondary education not available in the community, are more likely to leave. this has important implications for rural nursing retention strategies. retention strategies need to increase professional development and educational opportunities for the rural nurses and their families. an example of this could be to improve access to post-secondary education by introducing more distance learning options, or offer scholarships for rural nurses’ family members. furthermore, if rural nurses have family living somewhere else, retention strategies may include videoconferencing for family visits. opportunities, like shifts in the economy, real-estate, job availability for self and spouse, as well as loss of benefits, act as “filter factors” (henderson-betkus & macleod, 2004). researchers note rural nurses are more likely to leave the community if there are drops in realestate prices, or other economic misfortunes. henderson-betkus and macleod (2004) show rural nurses are more likely to leave a community if the primary industry is suffering. the researchers found spouses’ employment is a major predictor of retention, and suggest retention may be more dependent on spousal employment than on personal job or community satisfaction (hendersonbetkus & macleod, 2004). based on these findings, future retention strategies should include job match initiatives or professional development programs for spouses. loss of benefits, another opportunistic factor, describes the loss of seniority and other employment benefits if a nurse transfers to another community. henderson-betkus and macleod (2004) found nurses stay in rural communities, even if they are not satisfied with the job or the community, because they do not want to lose employment benefits (henderson-betkus & macleod, 2004). in british columbia, the nurses’ union provincial collective agreement (2006) does not allow nurses to carry their seniority or benefits from one community to another, unless 89 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 they have been displaced or transferred. although nurses’ pension contributions can usually remain in the same pension plan, each change of employment that incurs triggers a break in service or a change in salary, which can affect the nurse’s pension in some way (m. hendersonbetkus, personal communication, march 28, 2007). changes in pension and loss of benefits deter nurses from moving (m. henderson-betkus, personal communication, march 28, 2007). threatening nurses with loss of benefits for moving from one community to another, may it be an urban facility to a rural facility or vice versa, could create negative feelings and limit experiences. furthermore, loss of benefits could deter new, young nurses from staying more than a couple of years in a rural community because of the commitment. nurses could be more inclined to try rural practice if they knew they could carry their benefits to another community. based on this interpretation, retention strategies need to address the portability of benefits outlined in the provincial collective agreement (2006). retention strategies could create an employment network between provincial hospitals, giving nurses the opportunity to transfer their employment status and benefits among communities. demographic factors, including place of nursing education, spouses’ occupation, and age act as “filter factors” (henderson-betkus & macleod, 2004). the majority of nurses who participated in this study were married, and were working in a small town because of their spouses’ job (henderson-betkus & macleod, 2004). the findings from the study suggest rural nurses, who are satisfied with their job and community, would leave a rural community if their spouse could not find employment in the area (henderson-betkus & macleod, 2004). similar to the ingersoll et al. (2002) study, henderson-betkus and macleod (2004) note older nurses are more likely to remain in rural practice, regardless of their level of job satisfaction. like the study by ingersoll and colleagues (2002), the relationship between age and retention was not determined by henderson-betkus and macleod (2004). however, one may suggest age has indirect influences on other “filter factors” identified in this study. age could have an effect on the number of family commitments made in a rural community, as older nurses could have more time to find a spouse, settle down, and have children. age could also have an effect on financial need, as older nurses may have more time to accumulate financial commitments. furthermore, age could have an influence on loss of benefits, as older nurses may have had more time invested with one employer; therefore, having more seniority and benefits at stake. going back to the australian survey of rural nurses in queensland, hegney et al. (2002a) found very specific personal characteristics and experiences that influence the decision to stay in rural practice. according to their survey, the most powerful predictor of retention is previous positive exposure to rural living and/or positive work experiences in rural areas (hegney et al., 2002a). the majority of participants agreed growing up in a rural community is a predictor of rural practice (hegney et al., 2002a). this finding is supported in rural physician literature, which suggests physicians are over two times more likely to practice in a rural area if they were raised in a rural community (easterbrook et al., 1999). however, henderson-betkus and macleod (2004) found education or training placements in rural areas are unlikely to predict similar long-term practice. the second most powerful predictor of rural practice, according to henderson-betkus and macleod (2004), is having family living in a rural area. also, personal feelings about wanting to raise a family in a rural area are considered predictors of rural practice (henderson-betkus & macleod, 2004). revisiting the comparison of canada, u.s.a. and australia, bushy (2002) found rural background and family connection to community are predictors of rural retention in all three 90 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 countries. earlier work by hegney, pearson & mccarthy (1997) echoed this discovery in an effort to identify the role and function of rural nurses in australia. based on this research, hegney and colleagues (1997) suggest rural nurses are generally from a rural background and trained in urban education facilities. they become rural nurses because go back to work in rural areas for family or lifestyle reasons (hegney et al., 1997). these findings, along with findings from henderson-betkus and macleod (2004), go beyond retention strategies into the recruitment phase. these studies suggest, in order to retain nurses in rural areas, recruitment and training initiatives need to focus on people from small communities, and/or who want to raise families in rural areas. retention strategies in british columbia in rural communities, where recruitment is increasingly complex, the first step in surviving the nursing shortage is to prevent existing rural nurses from leaving practice (muus, stratton, dunkin & juhl, 1993). the ministry of health (2006) in b.c. created a variety of rural nursing retention strategies, which address some influences outlined in this paper. professional development and making nursing education more accessible is one of the major focuses for the ministry’s rural nursing retention strategies (ministry of health, 2006). professional development, up-grading, specialty workshops, tele-health education and tuition reimbursement for nurses who want to work in rural areas, are all part of the ministry of health strategies (2006). the ministry has also dedicated funding to rural nursing research, and has provided research conference opportunities for nurses in rural communities (ministry of health, 2006). the ministry of health (2006) has also funded health authorities to increase management opportunities for nurses, include mentorship programs for new rural nurses, and improve shift scheduling. additionally, the ministry (2006) has funded initiatives aimed to increase the number of nurses in the workplace. special initiatives, including marketing and monetary incentives, have been established to recruit aboriginal students to nursing programs (ministry of health, 2007). more recently, the interprofessional rural program of b.c. was introduced, giving health care students the chance to do their practicum as part of an interdisciplinary team in a rural community (ministry of health, 2007). many of these retention strategies address influential factors identified in the literature, such as the need for professional development, maintenance of clinical skills, resources and professional support. the strategies deal with some of the factors that influence job satisfaction and retention, such as opportunities for management roles, tuition reimbursement, and mentorship. however, there are several factors identified in the literature, especially personal characteristics and experiences, that have not been addressed by these strategies, or that need to be further developed. recommendations based on the research findings, retention strategies need to include creating a more positive work environment for rural nurses. to improve the work environment, the ministry of health, as well as international policy makers, need to promote opportunities for professional interactions, team-based programmes, and professional support (chaboyer et al., 1999). work environments should encourage professional autonomy, job variety, counselling to deal with stress, and peer-feedback. furthermore, international decision-makers and policy-makers need to recognize different groups of rural nurses need different strategies (pan et al., 1995). for 91 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 example, retention strategies need to address both younger and older nurses in different ways. retention strategies for married nurses need to address spousal employment, possibly creating professional development or training opportunities for spouses. international policies and retention strategies need to consider rural nurses’ family lives. if nurses have children, retention strategies should include recreation and education opportunities for children. retention strategies need to make post-secondary education more accessible to rural families. strategies should support family-friendly work environments, make work schedules more flexible, and provide daycare facilities (stratton et al., 1995; hegney et al., 2002). furthermore, retention strategies need to incorporate less on-call shifts for rural nurses (shader, broome, broome, west, & nash, 2001). international policies and retention strategies need to address both job satisfaction and community satisfaction (pan et al., 1995; henderson-betkus & macleod, 2004). the national and provincial governments need to fund initiatives to help create social support networks for new rural nurses, such as sponsoring community integration activities and getting community members involved in retention strategies. furthermore, international policies and retention strategies should incorporate community development, making the rural community attractive to health care professionals (pan et. al., 1995). making rural communities more attractive could include improving schools, encouraging community events, and increasing community safety programs. international policies and retention strategies are the first step in dealing with the nursing shortage; however, recruiting nurses who will stay in rural areas is critical. local recruitment strategies need to target people who already have family and friends in the targeted rural areas, or people who have grown up in similar rural areas (hegney et al., 2002a). the ministry of health (2007) has recognized the need to recruit aboriginal nursing students, but increasing the number of rural residents who become health care professionals needs to be a focal point, as well. this could include further marketing campaigns, like nurses visiting rural high schools to promote the profession, and increasing the number of rural specific seats in nursing programs. retention and recruitment strategies should target nurses who have had positive past experiences in rural areas, and expand the interprofessional rural program of b.c. to allow for longer work terms. the ministry of health and other provincial governments need to identify nurses who are more likely to stay in rural practice, to inform recruitment. for example, research is needed to identify common characteristics and experiences shared by long term, rural nurses. the findings could inform recruitment initiatives. gaps in the literature although the research specific to rural nursing is growing, it is still very limited (macleod et al., 2004). research specific to rural nurses, job satisfaction and retention needs to be replicated and elaborated. further comparative studies between rural and urban nurses need to assess how retention strategies for rural and urban nurses may differ. meanwhile, more attention should be made to how different types of nurses (for example registered nurses versus public health nurses) differ in terms of job satisfaction, community satisfaction and retention in rural areas. many of the studies using surveys had poor response rates; therefore recommendations for future research would include larger sample sizes to improve validity. furthermore, qualitative research is needed to inform concepts identified in the literature, like “rural lifestyle” and how this may differ across regions (johnson, fyfe & snadden, 2006). 92 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 conclusion in summary, this paper explores challenges facing the canadian rural nursing workforce. this paper describes the relationship between job satisfaction and retention, and briefly assesses the differences in job satisfaction and retention for rural and urban nurses. in addition, this paper discusses how both professional and personal factors influence job satisfaction and retention of rural nurses. the ministry of health (2006) retention strategies are examined and specific recommendations to improve british columbia’s retention strategies and international policies are made. this term paper highlights the need for nursing research to further investigate the inter-relationship between professional and personal factors in both retention and recruitment. acknowledgement thank you to dr. josee lavoie and dr. cindy hardy at the university of northern british columbia for all of their guidance and editorial support. thank you also to mary hendersonbetkus for taking the time to talk to me about this issue. references bushy, a. 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(2004). retaining public health nurses in rural british columbia: the influence of job and community satisfaction. canadian journal of public health, 95(1), 54-58. [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12047505%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11094931%5buid%5d http://www.info-hcc-ccs.ca/20050614/story1.html http://www.chsrf.ca/other_documents/listening/pdf/eslistfordir_e.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12081512%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11984243%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14768743%5buid%5d 93 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 ingersoll, g. olsan, t., drew-cates, j. devinney, b., & davies, j. (2002). nurses’ job satisfaction, organizational commitment, and career intent. journal of nursing administration, 32(5), 250-263. [medline] johnson, a., fyfe, t., & snadden, d. (2006). rural and remote suitability score: a review. available from the university of northern british columbia/ university of british columbia northern medical program, 3333 university way, prince george, b.c. v2n 4z9) macleod, m., kulig, j., stewart, n., pitblado, j., banks, k., d’arcy, c., et al. (2004). the nature of nursing practice in rural and remote canada. ottawa, ontario: canadian health services research foundation. retrieved on february 13, 2007, from http://www.chrsf.ca macphee, m., & scott, j. (2002). the role of social support networks for rural hospital nurses: supporting and sustaining the rural nursing work force. journal of nursing administration, 32(5), 264-272. [medline] ministry of health (2006). b.c nursing strategy for 2005/2006updated. government of british columbia: nursing directorate. retrieved on february 15, 2007, from https://www.healthservices.gov.bc.ca/ndirect/nstrategies/ns_summary_0506.html ministry of health (2007). rural and remote health initiative. government of british columbia: rural health. retrieved on april 4, 2007, from http://www.healthservices.gov.bc.ca/rural/initiative.html muus, k., stratton, t., dunkin, j., & juhl, n. (1993). retaining registered nurses in rural community hospitals. journal of nursing administration, 23(3), 38-43. [medline] ndiwane, a. (1999). factors that influence job satisfaction of nurses in urban and rural community health centers in cameroon: implications for policy. clinical excellent nurse practice, 3(3), 172-180. [medline] ndiwane, a. (2003). the effects of practice location and work setting on job satisfaction of nurses. clinical excellence for nurse practitioners, 7(1-2), 27-33. pan, s., dunkin, j. muus, k.j., harris, r., & gellar, j. m. (1995). a logit analysis of the likelihood of leaving rural settings for registered nurses. journal of rural health, 11(2), 106-113. [medline] pong, r., & russel, n. (2003). a review and synthesis of strategies and policy recommendations on the rural health workforce. sudbury, ontario: centre for rural and northern health research, laurentian university. retreived feb. 13, 2007, from http://www.crnhr.ca poz, m.r.d., kinfu, y., dräger, s., & kunjumen, t. (2006). counting health workers: definitions, data, methods and global results. geneva, switzerland: world health organization, department of human resources for health evidence and information for policy. provincial collective agreement (april 4, 2004 to march 31, 2006). provincial collective agreement between health employers association of british columbia and nurses’ bargaining association. retrieved on march 30, 2007, from http://www.bcnu.org/contracts_services/provincial_contract/pdf/bcnu_ca_060331.pdf shader, k., broome, m.e., broome, c.d., west, m.e., & nash, m. (2001). factors influencing satisfaction and anticipated turnover for nurses in an academic medical center. journal of nursing administration, 31(4), 210-216. [medline] stratton, t., dunkin, j., juhl, n., & geller, j. (1995). retainment incentives in three rural practice settings: variations in job satisfaction among staff registered nurses. applied nursing research, 8(2), 73-80. [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12021566%5buid%5d http://www.chrsf.ca/ http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12021567%5buid%5d https://www.healthservices.gov.bc.ca/ndirect/nstrategies/ns_summary_0506.html http://www.healthservices.gov.bc.ca/rural/initiative.html http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8473927%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10646412%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10143271%5buid%5d http://www.crnhr.ca/ http://www.bcnu.org/contracts_services/provincial_contract/pdf/bcnu_ca_060331.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11324334%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7598520%5buid%5d editorial 5 editorial caring for mexican-american clients bette ide editorial board member there are growing mexican-american populations in rural areas. this editorial is a continuation of the previous column on communicating with those clients. dr. loretta heuer, associate professor at the university of north dakota, again offers suggestions to help rural nurses in caring for them. one major issue is the use of an interpreter. there are two styles of interpreting, line-by-line and summarizing. line-by-line interpretation ensures accuracy but takes more time; one can only speak few sentences at a time and must use simple language, no medical jargon. summarizing is faster and useful in teaching relatively simple health techniques with which the interpreter is already familiar. who should the nurse use as interpreter? family and friends may be readily available and anxious to help. unfortunately, their use violates confidentiality for the client, who may not want personal information shared. also, they may be fluent in ordinary language usage but unfamiliar with medical terminology, hospital or clinic procedures, and medical ethics. medically trained interpreters are ideal; they know interpreting techniques and are knowledgeable about the cultural beliefs and health practices. the nurse needs to be aware of certain differences between client and interpreter – sex/gender, age, and socioeconomic differences. the interpreter needs to be asked to translate as closely to verbatim as possible. the nurse should also be aware that a non-relative interpreter may seek compensation for services rendered. it helps to maintain a computerized list of interpreters who may be contacted as needed, to network with area hospitals, colleges, universities, and other organizations that may serve as resources, and to even use translation services provided by telephone companies. what does the nurse do when there is no interpreter? be polite and formal, greeting the person using the last or complete name. say your name, gesturing to yourself. offer a handshake or nod. proceed in an unhurried manner and speak in a low, moderate voice, using any words known in the patient’s language. use simple words, such as pain instead of discomfort. pantomime words and simple actions while saying them. be careful to give instructions in proper sequence, to discuss only one topic at a time, and to validate whether the client understands by having him/her repeat the instructions, demonstrate the procedure, or act out the meaning. you can also obtain phrase books from a library or bookstore or even make flash cards. overall, it is important for the nurse to remember that, under stress, clients may revert back to their first language and you should avoid responding to a client in a joking manner. assessment of their ability to communicate and understand is especially important when teaching is involved. for more information concerning the above points, see the following: andrews, m.m., & boyle, j.s. (1999). transcultural concepts in nursing care (3rd ed.). new york: lippincott. purnel, l.d., & paulanka, b.j. (1998). transcultural health care, a culturally competent approach. philadelphia: f.a. davis. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 editorial 8 editorial rx for health kay rosenthal, phd, rn editorial board member there is an obesity epidemic in this nation. as a rural nurse, what are you doing personally and professionally to reverse this trend? it’s time for nurses to step forward and make a difference in our own health and in the health of others. here’s a beginning prescription for health that can be applied personally and professionally. there are three factors that people need to incorporate into their fitness routine: 1). intensity (how hard you exercise); 2). frequency (how often you exercise); 3. duration (how long you exercise). achieving a balance between these three factors will give the best results (healthwise, 2001). bryon holmes, ms, an exercise physiologist, offered a prescription for health much as a health care provider would prescribe a medication. when you are given a prescription you are told what medication to take, what the dose is (intensity), how often to take it (frequency) and how long to take it (duration). a prescription for otitis media (infection of the inner ear) for an adult might include: • medication: amoxycillin • dose: 500 mg • frequency: twice a day • duration: ten days for cardiovascular health, the prescription recommended by bryon was: medication: exercise. anything that gets your heart rate up, e.g., walk, hike, bike, snowshoe, cross country ski, etc. dose: intensity. “talk test” or 60-70% of your maximum heart rate. what’s the talk test? ” if you can’t talk and exercise at the same time, you are going too fast; if you can talk while you exercise, you are doing fine (not that you’ll want to carry on a full conversation). what’s maximum heart rate? maximum heart rate = 200 minus your age. frequency: three to four times a week. duration: thirty minutes. for muscular-skeletal health the prescription recommended by bryon was: medication: exercise. anything at home or in a gym that works your bones and muscles to push, pull and squat. dose: intensity: on a scale of 1=10 with 10 being the highest you want to reach an intensity of 6 on the last repetition. frequency: two times a week. duration: twelve to 20 repetitions with enough resistance to reach the desired intensity. benefits of such a prescription for health include: • lowers your risk of premature death and death caused by heart disease. • reduces your risk of developing diabetes, high blood pressure, colon cancer, and osteoporosis. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 9 • helps lower high cholesterol and blood pressure levels. • improves your mood, relieves stress, and promotes a sense of well-being. • helps build and maintain healthy bones, muscles, and joints. • helps you maintain a healthy body weight (healthwise, 2001, p.22-23). want to make some improvements in your physical fitness? take one step at a time. pick an activity you enjoy. set a one-week goal that you can reach. start today. when you reach your goal, reward yourself. then set a new goal. for only an hour to an hour and a half a week, you can have a healthier body. so get up and get active! remember to consult your healthcare provider before beginning any new fitness routine. take good care of yourself. need help setting and maintaining your goals? contact kay rosenthal, ph.d., r.n., director, options for healthy living, inc., for online coaching today, and start on your journey to healthy living with your personal passport for health. join healthoptions4u listserv to receive health information that can be used in your community. share your knowledge and speak up to make a difference in your communities’ health. references bryon holmes, ms, exercise physiologist. magee, k. (ed.). (2001). healthwise handbook. boise, id: healthwise incorporated. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 microsoft word eisenhauer_397-2396-1-ed.docx online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 195 partnering with rural farm women for community-based participatory action and ethnography christine marie eisenhauer, phd, cne, aprn-cns 1 carol h. pullen, edd, rn 2 terry nelson, phd 3 sarah a. kumm 4 jennifer l. hunter, phd, rn 5 1 assistant professor of nursing and clinical researcher, university of nebraska medical center-northern division, ceisenhauer@unmc.edu 2 professor, college of nursing, university of nebraska medical center, omaha, chpullen@unmc.edu 3 professor, division of social sciences, mount marty college, yankton, sd, tnelson@mtmc.edu 4 rural community stakeholder, sarahannekumm@gmail.com 5associate professor, school of nursing, university of missouri-kansas city, hunterj@umkc.edu abstract background: u.s. farm women experience poor access to health care and high rates of health disparities. demographic shifts are increasing isolation and decreasing social capital for these women. providing locally meaningful health care requires cultural-historical understanding gained through community partnership. yet, rural farming communities present challenges to establish local-buy-in and participation for research collaboration. purpose: this article describes the steps taken to establish an action partnership between rural, farm women and a online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 196 local researcher, and outlines lessons learned from using participatory approaches to inform ethnographic research. sample: based in an agrarian county in the northern great plains, a partnership between two farm women developed into a research study inclusive of 24 female informants (ages 22-92). methods: ethnographic data (key informant interviews, focus groups, participant observation, artifact review, analytic memos, and reflective field notes) was analyzed thematically and the findings were examined reflexively to discern partnership building and participatory approaches that supported local community engagement with research. findings: promoters of relationship building included: 1) identifying the community gatekeepers, 2) using locally familiar language, 3) using a culturally congruent approach to recruitment, 4) accommodating seasonal farm demands, and 5) capitalizing on enthusiasm and community resolve to build partnerships for action planning. conclusion: local knowledge and sustained community presence are essential for rural nurses to engage in participatory action partnerships with rural farm women. keywords: partnership, engagement, rural farm women, participatory action, ethnography partnering with rural farm women for community-based participatory action and ethnography rural older farm women experience a high degree of health disparities when compared with their urban counterparts (florence, southerland, pack, & wykoff, 2012). the health conditions of these individuals is exacerbated by recent demographic shifts, which include the movement of increasing numbers of aging baby-boomers to rural farming states upon retirement, and the mass exoduses of young people who are moving out of the rural counties toward more urban settings (beyer, comstock, seagren, & rushton, 2011; jack, 2012; ramos, fullerton, online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 197 sapien, greenberg, & bauer-creegan, 2014). as the northern great plains states experience an influx of retirees, additional burdens are placed on an already over-taxed health care system. this exodus of young families results in school consolidations and school closings (tieken, 2014), increasing farm size (adamopoulus & restuccia, 2014; nelson, arwood, meendering, & sanner, 2004), and decreasing social capital for the remaining and returning older adults (eisenhauer, pullen, hunter, & nelson, 2015). the population that resides the longest in the rural northern great plains states are older women (congdon & magilvy, 2001). much can be learned from rural older women, including what they consider to be health priority and what actions they consider key to addressing them. community-based participatory research (cbpr) is an approach where the researcher engages as a facilitator with community members to collaboratively identify issues of local concern and apply socially acceptable solutions to alleviate those issues (reason & bradbury, 2006). this article describes the relationship stages between a local researcher and farm women residing in a rural county before and during an ethnographic study. our lessons learned exemplify the strengths of using ethnographic and participatory action approaches simultaneously to build capacity for cbpr. building the community partnership the stages of partnership building and research that are described were partially planned as part of an a-priori research design, but also unfolded naturalistically (lincoln & guba, 1985). much of the “naturalism” had much to do with the first author’s (hereby referred to as “the researcher”) “insider” status in the community as a 20-year resident in the county. she was known to most residents as a farmwife and home health nurse. while not every researcher has this insider connection, the challenges that persisted, despite being an insider, highlight the trust online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 198 and local understanding that must be gained in order to obtain deep entrée for a rural-based study. time and physical presence were fundamental for partnership initiation. community partnership building over time neighbor to neighbor. the first stage began with an “individual partnership” that occurred weekly between two neighbors over coffee. an 83 year-old farm woman and the researcher (although not functioning in a research role during these visits) began an informal, yet ongoing conversation. research opportunities started to unfold when this older woman said she wanted to change the way rural healthcare was provided to farm women because “they don’t understand how things are for us.” the researcher had previously noted that this was a recurring concern expressed by other older farm women during her home health visits and conversations in the community (eisenhauer, hunter, & pullen, 2010). these two neighbors decided to see if other local farm women shared the same concerns. the older woman telephoned other friends and neighbors, and eight farm women (ages 70-91) willingly responded to a group meeting. thus, the next stage, an exploratory partnership with a small group of community stakeholders began with the aim of improving rural health. neighbor to neighborhood. the first decision of this small group was to identify which health problem(s) would be the focus of the discussion. the group began this process by exploring each woman’s experiences through their telling of health-illness stories. story telling around the kitchen table, created a shared understanding among the partners, and began to affirm and clarify perceived clashes between the health care system and rural norms. the group decided to query other women through a similar process of comparing and contrasting health-illness stories in order to document a broader range of experiences. this action moved the women’s discussion from a small-neighborhood group partnership to a broader county level scope. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 199 neighborhood to university. as a part of this larger venture, the researcher, who was just beginning her doctor of philosophy studies, asked the women if she could help advance their issue by using their aim as the focus for her research. however, the aim would need to be specified to select a health issue pertinent to them. the farm women agreed. they identified cognitive decline, or fear of “losing my mind” as they defined it culturally, as their priority problem. thus, cognitive decline became the topic of the researcher’s doctoral dissertation. usual to ethnographic research, the socially constructed meaning of cognitive decline as interpreted through the rural farming context was sought. the perspective of communitydwelling farm women with self-identified intact memory was sought because they could articulate how the co-construction of fear surrounding cognitive decline was reinforced within the local context. engaging the community and examining relationship development through ethnography applying a constructivist paradigm (schwandt, 1994), the researcher sought to determine how the meaning of cognitive decline was co-created over time and across social interactions with the local community to create fear among mentally intact, older farm women (age 65 and older). ethnography uses multiple data collection approaches to holistically identify the elements and internal processes of social organization. analysis of ethnographic data reveals patterns of behavior, which distinguish unique cultural norms such as life customs, the meanings created from shared knowledge and social relationships, and the challenges experienced while living in the cultural context (agar, 1996; emerson, fretz, & shaw, 1995). institutional review board (irb) approval (protocol #ss10-95e) was obtained for this study. in-depth life history interviews, focus groups, participant observation, and review of local artifacts and documents were collected over one year by the researcher to obtain detailed online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 200 contextual data surrounding the day-to-day interactions of the older women. this provided a contextual background and understanding of the local constructions of reality within which to situate the women’s views, particularly their fears, of cognitive decline. interviews were held in either the women’s homes or the researcher’s farm house at a time and hour that was convenient for them. a total sample of 24 women, ranging from 22-92 years of age, participated in the study. the study was set in a u.s. county with a designated rural-urban community area code (ruca) of 10a rural area whose primary flow was outside an urban area health resources and service administration, federal office of rural health policy (orhp), and u.s. department of agriculture, economic research service (n.d.). the sample was recruited through reputational case selection by community leaders and neighborhood partners. reputational case selection is a common sampling technique in ethnography that seeks out participants based upon desired case characteristics that are reported by community leaders (lecompte, 1982). key informants four women were recruited to serve as key informants to share their detailed life history. inclusion criteria included being a resident of farming based county, aged 65 or older, selfidentified as having an intact memory. in-depth life history interviews were conducted over a series of 3-5 consecutive visits, until a richly detailed life history was obtained. the goal of these interviews was to elicit a pattern of learned behaviors and social interactions that persisted across their life course. the life course patterns were then compared using focus groups with four crossgenerational cohorts of younger women to examine how the rural, farm context had changed over time, and how this change may influence the older women’s beliefs and behaviors surrounding cognitive decline. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 201 focus groups twenty women were recruited to participate in one of four focus groups, each representing a separate generational cohort. inclusion criteria for the focus group included: 1) resident of the county under study, 2) at least 18 years of age and representative of one of four different historical cohorts: generation y (born 1983-2001), generation x (born 1965-1982), baby boomers (1946-1964), and the greatest generation (born 1926-1945) (carlson, 2009). the women were interviewed about their health and illness behaviors and the social-cultural practices they employed to deal with them. the women were asked detailed questions about their views of cognitive decline, specifically its cultural impact and the outcomes they saw result for older farm women who developed it. observation participant observation was conducted across the entire year, during morning, afternoon, and evening hours, across different communities, and amid the context of formal/informal events. some of these included ladies aid meetings, cattlemen’s ball, home canning-preserving, farm chores, birthday parties, baking, and hunting wild animals. observational and interactional notes were recorded in the field using emerson and colleagues’ (1995) approach. cultural artifacts local artifacts that were valued and displayed by the women were noted to richly detail the farm context. such items included polka music, extension club cookbooks and manuals, community centennial books, pictures of severe weather from years past, farm animals, family albums, church directories, and cemetery registries. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 202 reflexive journaling the researcher kept a detailed, typed journal, which was documented across each day of the study, which noted changing reflexive stances. reflexivity, often used synonymously with reflection, is defined as the “constant movement between being in the phenomenon and stepping outside of it” (p. 578). items documented pertained to the: 1) perceived/observed changing social stance as an insider-outsider with the participants across the study, 2) self-conscious reflections of communication, recruitment, engagement, and retention issues, and 3) perceptions regarding what was evolving across each stage of the study (enosh & ben-ari, 2016). analysis the reflexive notes made throughout the study detailed the researcher’s initial analysis of effects of interactive and contextual influences, including her changing positions between an “insider” (farmwife) and “outsider” (researcher) among the women (naples, 1996). analytic memos of methodologic-analytic decisions surrounding changes in coding schemes and conceptual reasoning were made at the close of each day (saldana, 2009). all interviews were audio recorded, transcribed verbatim, and checked against the digital file for accuracy. data was iteratively coded and analyzed until themes were discerned that were “internally coherent, consistent, and distinctive” (braun & clark, 2006, p.36). the local artifacts and observations enriched interpretation during thematic analysis by detailing material aspects of the women’s lives that shape their beliefs and behaviors (sandelowski, 2002). a second researcher audited research procedures weekly and the research team’s discussion surrounding the findings, interpretations and consensus was documented ongoing. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 203 neighborhood involvement in the research process the neighborhood partners were involved in select aspects of the research process. while these women did not serve as participants in the actual study, they influenced the iterative design and implementation of the study by: (a) guiding the selection of the research questions, (b) offering recruitment and retention strategies, (c) suggesting data collection sites, (d) developing and testing interview guides, (e) offering their interpretation of the findings presented during community dissemination, and (f) identifying a plan for subsequent action. during the year of the study, three of these neighborhood women were lost, due to death or worsening health. analysis of the challenges and lessons learned in performing a community-based ethnography provide insight into approaches for engaging farm women into community-based participatory action research. lessons learned building trusting relationships that were required to recruit farm women into the study was not easy, despite the early local involvement of the neighborhood partners and the insider status of the researcher. cultural clashes between the social norms of farm women and irb restraints were immediately evident. agrarian work seasons also challenged local engagement. reflections below, on these challenges, provide lessons for development of novel strategies needed in researching with rural farm communities. lesson 1: identify the gate keepers initial attempts to recruit the farm women for the ethnographic interviews were through females who were active leaders in their community, as determined by reviewing local newspapers, community flyers, and by word-of-mouth. these women were leaders in their ladies’ aid groups at church, business owners, or members of community-interest groups. as online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 204 they were socially “visible”, it was assumed (wrongly) that these women would best represent the interests of the other women. however, many of these individuals were not willing to join the partnership nor willing to recommend other women who might be interested in the study. the polite indifference left the researcher and neighborhood partners baffled and frustrated. while it was understood that establishing trust in the community was important in the identification of potential participants, merely having a shared history with other women who are active in community affairs did not guarantee study engagement. in contrast to the indifference that was expressed by some of the females of the community, when the researcher stopped at local businesses to run daily errands, men would initiate conversations and ask eagerly about the upcoming study. as time went by, the researcher observed a recurring pattern of men’s versus women’s willingness to engage in conversation about the research and to recommend potential study participants. that is, after the men of the community became engaged in the study, they were able to bring women aboard. this indicated that males were acting as “gatekeepers”, or those who are able to encourage women to take part in the study. once recruitment targeted the males as referral agents, a list of over 50 farm women was generated in less than a month, as these men “volunteered” their wives, mothers and neighbors. as the research unfolded, it became clear that the building of trust was also a process which was often dependent upon the males of the community. in fact, several study participants cited the approval of their sons and husbands as pivotal in their decision-making process when it came to health care. this insight then, led the researcher to seek out conversations with the men. trust regarding the research study was built directly with the men and indirectly with the women, following the norms and expectations around social connections and personal interactions within the farming community. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 205 lesson 2: keep the conversation local entrée into this county was largely due to the researcher’s trusted position as a local home health nurse and farmwife. however, increased social distance between the researcher and the local women was observed once recruitment commenced. negotiating trust with the farm women was a continual process. in the farmwife role, talking about health concerns or personal ailments among the partners was as common as discussing the weather. however, when the researcher spoke of the finer points of research or of political advocacy during study recruitment, social distance increased. once the study was underway, recurring questions and phone calls from local women wanting to know who was in the study became problematic. the inquiries were consistent with the local cultural norms for communication and information, a finding that had been documented in the field notes. when the researcher explained she could not divulge the names of other study participants, this also increased social distance between herself and her research subjects. the ever changing social position between farmwife and researcher during the study was specifically differentiated by the “language” being spoken. the norms for “farmwife” conversation included use of local slang and discussion of agrarian seasonal work related issues such as crop yields, grain market prices, and farm cooking. conversations which took place in the “researcher role” addressed the research goals through the use of farm-normed language and relevant farm-related topics the women were willing to discuss as part of the partnership. using too much “research language” would result in puzzled looks on the faces of the women, or would result in their changing the topic of conversation. continually maintaining a workable social distance in both roles required constant attention and fluent translation and negotiation across the “academic and farm culture divide”. as a farmwife, the researcher had the advantage of knowing online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 206 the local language, yet she was viewed as an “outsider” as a researcher. mastering the skills which were required to negotiate the ever changing social positioning with the women took time and experience, but doing so promoted trusting interactions with them. another innovative approach that successfully decreased social distancing from partners and research participants was holding the focus groups at the researcher’s farmhouse. the farmhouse setting enhanced the women’s comfort and confidentiality by providing a private, yet culturally familiar space. the women’s mannerisms, conversation style, and body language relaxed once the informed consent was obtained, coffee was served, and the interview proceeded around the kitchen table. an unplanned interruption happened during one of the focus groups, when a set of baby calves walked up to the kitchen window and peered in at the participants, then darted across the lawn with their tails in the air. while considered an interview interruption by most researchers and participants, in this situation, it served to further familiarity, relaxation, and increased participation in discussion. after the focus group interview was complete, pie was served to the women. many of the women expressed their level of comfort by walking into the kitchen and staying after the conclusion of the focus group discussion to visit informally with other participants. upon leaving, two of the women expressed they were glad the focus group was held in the country as opposed to in town at the community hall. “i felt like this was a more private setting where i didn’t have to worry about who saw my vehicle, and was going to ask what i was doing there and why.” holding discussions around the kitchen table, over a cup of coffee, decreased social distancing and strengthened the women’s bonds with the researcher by creating a “locally familiar” context, within which they could discuss what for many of them was an unfamiliar topicthe research study. the procedures used in rural research are thus kept culturally congruent with local norms. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 207 lesson 3: emphasize the importance of cultural congruity the university institutional review board (irb) prohibited the researcher from directly recruiting study participants because of the risk for coercion due to her close relationship with the locals in the county. to comply with this directive, a female research assistant was hired to contact potential participants using a pre-approved recruitment script. the research assistant was trained in the recruitment protocol by the researcher and she recited the recruitment script during the calls. the research assistant also took detailed notes regarding the women’s replies, as well as their tone to the call, and she documented each call attempt and conversation duration in a time log. rather than being a help, the irb-mandated script became a hindrance. the indirect approach, being contacted by the research assistant versus researcher, created a sense of suspicion among many of the women contacted. although the research assistant was also a lifelong resident (she worked at the farmer’s co-op), women vocalized concerns for their privacy, when she requested that they take part in the study. some of the women’s replies were: “why didn’t she (the researcher) contact me herself?” “what is she selling?” or “what’s the catch?” some community women even responded, “i doubt my name was really brought up by the men.” in total, five women declined to participate. whether the women’s replies were in part to the indirect nature of the recruitment call by research assistant is unclear. however, the experience informs critical discussion surrounding the best way to recruit rural farm women for research. researchers need to explain the cultural significance of direct recruitment and retention strategies to irbs, especially when it is imperative that they be congruent with rural norms for communication. our experiences suggest that indirect recruitment approaches, meant to protect rural participants from coercion, instead may have evoked suspicion and fears over possible violation of privacy. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 208 lesson 4: accommodate seasonal farm demands the livelihood of the farm is dependent upon seasonal fluctuations that affect the growth of crops and livestock. farm women have adapted coping mechanisms for dealing with seasonal uncertainty, both short-term and long-term, including weather-related storms, farm equipment malfunctions, predator animal invasions, and livestock illness and loss. these seasonal demands require close attention and flexibility during research activities. one woman phoned the researcher the day after missing her focus group to report that her absence was because “the cattle were out (of pasture and on the road) and i had to drop everything to put them back in”. another of the key informants refused to start the interview at her home until she had removed a predator raccoon who was menacing her canning cellar. work-intensive seasons (planting, harvesting, canning, calving) nearly halted the research activities due to heightened demands on the research participant’s time. twelve to eighteen hour work days aren’t unusual for rural women as they extend their presence in the fields and become couriers of farm supplies that are needed to maintain seasonal farm operations. communicating with actual and potential participants via their home land-lines became difficult because they were rarely near their phones. cell phone contact with potential participants was also difficult due to poor reception and the fact that cell phone numbers are not published for public access. in strategizing a successful partnership development and research design, one must be cognizant of heavy work seasons, their related demands and risks, and plan activities respectfully around them. in this study, the majority of the recruitment and interview process took place during times which least interfered with planting and harvest. the interviews that occurred after the women had completed peak-season activities yielded the richest data. it is surmised that the online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 209 women were more recently in touch with these farm experiences and better able to relate them. they were also eager for socialization after their hectic work seasons had ended. lesson 5: capitalize on enthusiasm and resolve to build participatory action plans while there were several challenges when engaging research participants, there were also many positive outcomes. the study generated a great degree of local interest and trust. in fact, two women bypassed the male gatekeepers and joined the research on their own. also, since the study concluded, there has been a growing number of community members expressing a desire to partner in future research studies, which has resulted from a broader and deeper discussion regarding other local problems. at the conclusion of the study, a celebratory event was sponsored by the researcher as a way to gather the local residents, research participants, and the neighborhood partners. the goals of this event were twofold: to share the findings with the community and to learn what sorts of actions community members wanted to see take place in response to the findings. the event was held at a local bar/café and was attended by over 56 community members and partners. gourmet cupcakes were displayed throughout the room along with a summary sheet of study results to encourage informal mingling and discussion. in addition, the researcher’s bound copy of her dissertation was displayed to allow the community to see the impact they had on the education of one of their own. discussion lasted for over five hours, a testament to the engagement of the community. since the ethnographic study has ended, there has been a growing number of community members expressing a desire to partner in future research studies, which has resulted from a broader and deeper discussion regarding other local problems. for instance, the problem of farm specific barriers to maintaining a heart healthy diet and physical activity, specifically among online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 210 men, was identified as a local concern. because farm-raised food, activity, and well water were believed to prevent cognitive decline (eisenhauer et al., 2015), culturally-tailored weight loss and weight maintenance strategies were identified as a new priority action area for intervention. women and men discussed environmental and social barriers for maintaining or losing weight across peak farm seasons, and expressed a new found trust in the power of a communityresearcher partnership to meaningfully address their problems. discussion farm-specific recruitment and partnership-building lessons based on this study provide valuable insight for future action partnerships between farming communities and rural nurse researchers. the neighborhood women identified as a clear concern the problem of cognitive decline, which allowed them to partner with the researcher as consultants-stakeholders. the researcher also observed, documented and analyzed the relational aspects of her social positioning as an “insider-outsider” with the women and the local communities throughout the study, which allowed her to clarify the processes that encourage involvement in this sort of study. the findings of our study also hold significance for future research in both the process and content of rural engagement by demonstrating how trust with rural farm women may be achieved over time and through multiple interactions. in our study, the women’s trust in the researcher and research study was enhanced by first establishing a trusting relationship with the local men. continual reflexive journaling across the study permitted examination of this otherwise “invisible” insider-outsider dynamic in terms of the meaning of the men’s relationship to engagement with larger local community of women. the researcher’s relationship with the men was not only influential on study recruitment, but also on sustained community engagement across time, including opportunities for future studies. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 211 the importance of the nurse researcher’s presence in the rural community before, during, and after initiating research partnerships led to a network of relationships and a strong degree of negotiated trust within the community. the findings illustrate that the optimum group structure for participatory action in this rural farming community was small, informal, and with researchers who have become locally familiar. becoming locally familiar required a physical presence as well as a time commitment; though, the researcher can expedite the process by engaging in informal discussions during normal daily activities. these findings are consistent with participatory action studies reported on other rural populations (averill, 2005; bish, kenny, & nay, 2012; richter, hall, & deere, 2007). implications for recruitment of rural women rural nurses who are planning research with farm women can enhance study recruitment plans in several ways. first, writing flexibility into their study in such a way so that their work will occur around peak farm seasons. by doing so, partnership building, recruitment and data collection will be more easily managed. second, rural nurses can identify community gatekeepers through repeated informal social interactions. other research findings have mirrored the importance of involving men as community partners when locating the “contextual, cultural experts” in rural communities (averill, 2005). third, adhere to the local social norms when developing recruitment plans to enhance feasibility. fourth, document reflexive notes of the ever changing social positioning that is observed as the researcher proceeds through the study, as it serves as an indicator of local norms and it indicates the researcher’s skill in negotiating her position as both “insider” and “outsider”. in addition, the findings from this study emphasize that direct correspondence with the researcher decreases concerns over encroachment on personal privacy and heightens study interest and participation. nurse researchers who can share online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 212 personal histories connecting them to the rural region, rural occupation, or local ancestors can also provide cultural connections that enhance their social position as an “insider”, thus decreasing suspicion and fear on the part of the study participants. in the end it was found that establishing broad, trusting relationships inside and outside the community through a small initial partnership, and by conforming to local norms, recruitment, retention, and results were able to exceed study expectations. the ethnography produced outcomes that strengthened partnership-building efforts, which are critical for future participatory action aimed at informing rural health policy. the partnership process enhanced solidarity and ongoing local engagement among men and women in this farming county to promote actions which improve the health of rural adults. conclusion this is a story that has moved through three stages, and it is one that continues to the present day. the first stage involved the development of a rather spontaneous researchercommunity partnership, spawned among eight older farm women. these initial conversations led to a community assessment and a prioritization of health problems. this partnership was unique in that is did not originate from formal community structures (county extension, medical providers, or centers for rural health) (guin et al., 2012; may et al., 2003). rather, the building blocks of this rural study were provided by neighborhood farm women who wanted to affect change for themselves and those like them. the commitment to this partnership ran deep, even to the point where a widower, along with his children and grandchildren, maintained their dedication to this study even after the neighborhood partner had died. this stage serves as an exemplar of initiating a community partnership with the most vulnerable rural residentsolder farm womento work toward common participatory action goals. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.397 213 the second stage involved the process of rolling an action priority into an extensive traditional ethnography, whose focus and progress was informed by the community-partners. although the researcher was a farmwife in the community, the process of looking from a researcher’s perspective at rural life across generations provided far more insight and understanding than had her farmwife role, which involved far less questioning and scrutiny of rural culture. the third stage exemplifies how community-based participation motivates action in response to ethnographic findings for research. support has grown beyond applying the ethnographic findings toward improving issues related to cognitive decline, to other locallyidentified problems, such as the need for enhanced healthy eating and physical activity among farm men and women. the blossoming of partnership support for these new areas emerged from conversations that were part of the ethnography. the mere existence of stage three is a testimony to the power of prolonged researcher presence in the local community to inform approaches for successful community partnering with farm women for action research. funding funding: gamma pi-at-large and lambda phi chapters of sigma theta tau international references adamopoulus, t. & restuccia, d. 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(2014). why rural schools matter. chapel hill: unc press. editorial 3 editorial is rural nursing a specialty? kathy crooks editorial board member like many other nurses who work in rural and remote areas, i never considered myself a specialist. that is until several years ago when i started to teach an undergraduate course in rural nursing. as i immersed myself in the little bit of rural literature that was available at the time, i recognized that i was becoming increasingly convinced that indeed rural nursing is a specialty. i remember feeling really pleased that finally someone somewhere understood that nursing in rural sites was not merely the poor relation of urban nursing, but something that required special knowledge and skill. from that time to the present, i have proudly pointed out this fact to students. in canada, however, rural nursing is still struggling to become recognized as a distinct entity. this caused me to consider the obstacles that we still face on the road to specialty status. historically, rural nurses believed they were not doing anything particularly important. mckinnon (1997) suggests that because these early nurses believed they were “just doing what is necessary” (p. 799) for their rural communities, they failed to analyze or write about their practice. this may be one of the primary reasons that rural nursing has failed to establish itself as a distinct entity. it is also possible that the reasons are more insidious. nursing has historically been considered an extension of the work that women do (crowe, 2000). therefore, its contribution to health care has been undervalued. further, rural nursing has always been considered to be just like any other type of nursing practice, only on a smaller scale. it stands to reason that if nursing itself is not considered worthy of notice, by extension, rural nursing is considered even less worthy. peplau (1965/2003) suggests that specialties in any discipline emerge as public need brings attention to a previously unnoticed situation or problem. this circumstance is exactly what has happened in rural canada over the past several years. as technology has increased, the needs and concerns of rural residents have become known. the rural population has pushed to indicate their particular concerns regarding health. it is interesting to consider if the health concerns of rural canada might have been noticed earlier if rural nurses had written about their practice. peplau (1965/2003) points out that any big increase in the amount of knowledge in a field of study tends to lead to specialization. an increase in the amount of knowledge regarding rural nursing practice in canada is very small. on a wider scale even the amount of knowledge worldwide is not particularly large. obviously to gain any amount of movement toward being recognized as a specialty requires more research and an increase in rural nursing knowledge. other influences may also be implicated in keeping rural nurses from gaining specialty status. nurses make up the largest single group of health care workers in canada. this is particularly true in rural areas where health care facilities are frequently the largest local employer. in canada, if rural nurses organized and became a cohesive group, they would be able to influence health care policy to a much greater extent than at online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 4 present. the ability to influence those in political power could be of grave concern to other stakeholders who remain the gatekeepers of the canadian health care system. this could be particularly threatening to some groups as this country undergoes a shift in the way health care is visualized. ironically, role diversification, one of the hallmarks of rural nursing practice, is also one of the reasons that rural nurses are not considered specialists, “…as nursing specialists, like medical specialists are known to work in one discrete area, for example, diabetes, pediatrics, midwifery, or intensive care” (hegney et al. 1997, p. 83). this paradox would appear to have no resolution in that the rural nurse is expected to be proficient in multiple areas but cannot be considered a specialist because of the multiplicity. additionally, the rural nurse is expected to acquire a broad range of advanced practice skills from other specialties but cannot be considered a specialist in her own area. it is likely that the relational concepts such as multiple personal associations and lack of anonymity are the elements that make rural nursing practice truly unique. these relational concepts, which assist the rural nurse in developing a deep therapeutic association, require the presence of so called “soft-skills” such as warmth, empathy, genuineness and respect (balzer-riley, 1998). these “soft-skills” are generally undervalued in present day “male-as-norm” western society which continues to value detachment and disconnection (crooks, 2001, p. 19). moreover, the “soft-skills” do not lend themselves to study in a society that continues to value quantifiable “hard” evidence. the “soft-skills” ultimately are relegated to a subordinate position. the nurse’s ability to navigate relational concepts insures the success or failure of a rural nursing practice. failure to recognize the importance of these elements to successful rural nursing practice is a critical reason that in canada rural nursing is not understood to be a specialty. i am not sure that nursing in rural and remote canada will ever receive the distinction it deserves. i am sure that the nurses who work in those areas deserve to be recognized; if not for their generalist practice then for the unique relational knowledge they possess. for questions or comments, e-mail me at kcrooks@acd.mhc.ab.ca. references balzer-riley, j. (2000). communication in nursing (4th ed.). toronto, on: mosby. crooks, d. (2001). the importance of symbolic interaction in grounded theory research on women’s health. health care for women international, 22, 11-27. [medline] crowe, m. (2000). the nurse-patient relationship: a consideration of its discursive context. journal of advanced nursing, 31(4), 962-967. [medline] hegney, d., pearson, a., & mccarthy, a. (1997). the role and function of the rural nurse in australia. sydney, au: royal college of nursing. mckinnon, k. (1997). historiography: what a difference a nurse makes—then and now. western journal of nursing research, 19(6), 795-801. peplau, h. (1965/2003). specialization in professional nursing. clinical nurse specialist, 17(1), 3-9. [medline] online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 mailto:kcrooks@acd.mhc.ab.ca http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11813790&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10759993&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12544112&dopt=abstract 74 human papillomavirus (hpv) in rural adolescent females: knowledge, protected sex, and sexual risk behaviors janet f. wang, phd, rn, faan1 patricia s. simoni, edd, rn2 ying wu, phd3 1 professor, school of nursing, west virginia university, jwang@hsc.wvu.edu 2 associate professor, school of nursing, west virginia university, psimoni@hsc.wvu.edu 3 assistant professor, school of nursing, west virginia university, ywu@hsc.wvu.edu keywords: female adolescents’ hpv knowledge, protected sex, sexual risk behaviors abstract reduction of cervical cancer morbidity/mortality relies on prevention and early detection of human papillomavirus (hpv). this study examined hpv knowledge, attitudes toward protected sex, and sexual risk behaviors among rural female adolescents, through cross-sectional survey of a convenience sample (n = 159). data analysis, via the statistical package for social studies (spss), identified a sexually active sample (64%) with limited knowledge regarding effective sexual protection or hpv. subjects living with both parents were (a) less knowledgeable about hpv than those living with single parents (b = -2.05, p = 0.035), as well as (b) less likely to be sexually active than those in other living arrangements (55% vs 77%, p = .0082). these findings suggest that the adolescent-parent relationship warrants further exploration in increasing knowledge regarding risk and reducing exposure to hpv. introduction cervical cancer is a leading cause of morbidity and mortality worldwide and, in 99.7% of all cases, the etiological agent is human papillomavirus (walboomers et al., 1999). of the many types of hpv, over 30 are transmitted from one person to another through sexual contact and are carried by an estimated 80% of sexually active adults (national cancer institute, 2004; rosenfeld, 2004). despite the prevalence of relatively harmless hpvs that clear within two years, various epidemiological studies have established that at least half of the 30 types of sexually transmitted hpvs are high-risk viruses, constituting the major cause of invasive cervical cancer (bosch & de sanjose, 2003; clifford, 2003; einstein & goldberg, 2002; ho et al., 2004; national cancer institute, 2004; and thompson, 2004). cervical cancer without hpv is exceedingly rare (walboomers et al., 1999). human papillomavirus (hpv) is the most prevalent sexually transmitted disease (std) in the united states (us), and is significantly associated with morbidity and cost (burk, 1999; ho et al., 2004; moscicki, 1999). the prevalence of hpv infection in young women has been estimated to range from 20% to 46%. studies conducted in the us suggest that, at a given time, 60% of collegeaged women are infec ted with hpv (ho et al., 2004). an early study estimated that 38% of adolescent females in a population of predominantly inner-city females were hpv-positive (rosenfeld et al., 1989). “high-risk” hpv infection is asymptomatic, invisible, and may not be expressed in cervical tissue dysplasia for years (american social health association, 2002). it will not be detected, except when cervical tissue is examined by microscope in routine pelvic examination, online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.hsc.wvu.edu/son/ mailto:jwang@hsc.wvu.edu http://www.hsc.wvu.edu/son/ mailto:psimoni@hsc.wvu.edu http://www.hsc.wvu.edu/son/ mailto:ywu@hsc.wvu.edu 75 employing papanicolaou (pap) testing; when viral dna is identified in cervical cells (national cancer institute, 2004); or when invasive cancer produces symptoms. theoretical framework fishbein’s theory of reasoned action (tra), the theoretical framework for this study (fishbein & ajzen, 1975) defines a certain behavior as a function of intention to engage in that behavior. in this study, intention to engage in sexual behavior is a function of attitudes toward an individual’s sexual behavior, as well as the subjective norms about sexual behavior held by reference groups; for adolescents, reference groups are primarily the family and peer group. essential to research aimed at understanding adolescent exposure to hpv and other std’s is the need to explore knowledge, attitudes, and reported practices of sexual risk behaviors related to hpv and stds. hpv knowledge in the adult population, 70% of us women, aged 18 and older, have reportedly never heard of hpv, and 89% have never discussed hpv with health care providers (kaiser family foundation, 2004). significant knowledge deficits regarding hpv have been identified among college/university students, as well. knowledge deficits, regarding the link between hpv and cervical cancer, are reported in studies by vail-smith et al. (1994) and biro et al. (1991). canadian researchers found that 87% of 523 inner-city high school students had not heard of hpv, and only 39% of sexually experienced female students knew they should receive pap testing (dell et al., 2000). one study reported subjects were unaware that hpv was asymptomatic, also finding that subjects reporting high-risk behaviors were more knowledgeable about hpv (anderson-ellstorm, 1996). thus, the authors concluded, educational hpv information was received by those who were currently involved in sexual behaviors. it becomes clear that even women who may adhere to a regular pattern of pap testing are likely to be ignorant of the most basic rationale for the testing: to determine whether or not sexually transmitted hpv infection has caused cervical dysplasia or cancer. and the gravest truth is that, without this essential information, sexually active females of all ages lack, and have lacked, the foundational rationale for preventing or screening for hpv. risk-taking behavior and related factors in eco-developmental theory (szapocznik & coatsworth, 1999), risk-taking is characteristic of normal adolescence. this theory is supported by a literature review (harvard mental health letter, 2005), recognizing continued development of the brain during adolescence, a time when the desire for novel experiences is strong and results in high risk taking. several studies have found a higher incidence of risk-taking behaviors among adolescents where there were low levels of parental monitoring (diclement et al., 2001; donenberg et al., 2002; rai et al., 2003). in addition, more sexual activity is reported among adolescents whose parents have not completed high school than among those of college graduates (santelli et al., 2000). family connectedness was found to be related to fewer sexual risk-taking behaviors, even when adolescents were otherwise identified as high-risk (markham et al., 2003). a study online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 76 exploring living arrangements found fewer behavioral problems, in general, among children living with married, biological parents, than among those living with cohabiting or blended families (nelson et al., 2004). purpose of study this study was designed to examine knowledge levels about hpv, other stds, and protected sex; attitudes toward protected sex; use of protection and level of sexual risk behaviors among adolescent females in a rural appalachian population. traditional knowledge, attitudes and behavior (kab) studies, effective in identifying important relationships among key variables in social research, are not reported in current hpv literature. the purpose of this study was to identify relationships (a) among demographic variables, (b) knowledge about hpv, other stds, and protected sex; and attitudes toward protected sex, (c) sexual risk behaviors, and (d) use of sexual protection in adolescent females living in two, rural, medically-underserved, appalachian counties. method the design of this study is non-probability survey. the study was conducted in 2002, focusing on students in three high schools in two counties in a rural, medically-underserved, appalachian state. a total of 159 female adolescents, enrolled in high school academic programs, participated in the study. institutional review board (irb) for protection of human subjects approved the study, and required written subject and parental consenting was completed prior to the adolescents’ participation in the study. the subjects completed a questionnaire addressing knowledge about hpv, other stds, and protected sex; attitudes toward sexual protection; and sexual risk behaviors and use of sexual protection. the questionnaire included demographic items. measures instruments. a three-part instrument with subscales by kirby (kirby and associates, 1998) was used in this study to measure knowledge, attitudes, and behaviors regarding sexual risk and sexual protection among adolescent females. the original kirby questions were used in a questionnaire that, additionally, included items specific to hpv knowledge. reliability for each of the kirby subscales is identified in the following description of each subscale. stds/hpv related knowledge scale. subjects were asked to answer questions about stds/ hpv; adolescent physical development, relationships, sexual activity, and pregnancy; and the use of sexual protection and probability of pregnancy and stds. correct answers for each question were coded as 1 (correct) and 0 (incorrect). a total score was obtained by summing the correct answers to all items (x = .77). protected sex attitude scale. this kirby subscale (alpha = .66) was included in the questionnaire to measure attitudes toward protected sex. the subscale contained five items asking responses to statements, such as, "more people should be aware of the importance of protected sex". response options ranged from 1 (strongly disagree) to 5 (strongly agree). a summary score was used in the analysis, with the highest score indicting a highly positive attitude toward the importance of protected sex. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 77 sexual risk behaviors. using kirby’s (1998) tool, respondents were asked whether (a) they had ever had sexual intercourse, (b) their age at first intercourse, and (c) whether they had sex during the past month, test-retest reliability coefficients for the behavior questions was .84. protected sex. respondents were asked whether or not they had used protection the first time they had sex. if they had engaged in protected sex, they were asked to identify the method used. demographic. standard demographic variables constructed by the authors were included as control variables for data analysis: age, ethnic background, living arrangements, religion, parental educational level and occupation, and household income. survey procedures after obtaining permission from the high school principals, the investigators described the study’s purpose and offered a $10 gift-certificate to each student who would participate in the study. the data were collected on a school day in a health class, in which stds had been discussed earlier in the semester, as part of the prescribed curriculum. students who agreed to participate in the study stayed in the classroom, and those who refused to participate in the study went to the library. the investigators distributed a self-administered questionnaire to the participants, who were told the survey was anonymous and no identification should be written on the questionnaire. except for 5% (n = 9), all eligible students in three high schools agreed to participate in the study, providing a subject sample of 159 students that represented freshman through senior classes. students who did not participate in the study were not measured for differences from those who participated. rational for non-participation was not gathered. data were reviewed for missing and obviously inconsistent data by the researcher and, except for the question regarding family income, all items were used in analysis. the statistical analysis of social science (spss) was used for data analysis. analysis the level of hpv knowledge. frequencies of correct answers to each of the hpv knowledge questions were calculated and compared by sexual status (1 = ever had sexual experience, 0 = otherwise). percent difference in correct answers for each item was examined by chi-square test. mean difference of the overall hpv knowledge scores between groups was examined by t-test. associations with hpv knowledge. to identify significant demographic factors contributing to higher level of hpv knowledge among youths having sexual experience, a multiple regression analysis was conducted, using the overall hpv knowledge score as the dependent variable. the independent variables simultaneously entered into the model included age, living arrangement, father's occupation, mother's occupation, age onset of sexual intercourse, and frequently sexual activity (defined by having sex last month). associations with protected sex attitude. multiple regression analysis was conducted to identify knowledge deficits, significantly related to attitudes toward protected sex , that may have implications for the design of health promotion intervention strategies. independent variables entered into the model were the items selected by stepwise regression among 30 hpv online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 78 knowledge items and 34 sexual knowledge items. age and sexual status were added into the multiple regression models as control variables. results this study identified deficits in knowledge related to hpv, as well as attitudes toward protected sex, that may contribute to behaviors placing adolescent females at risk for contracting hpv. predictive variables were identified, as were statistically significant differences in knowledge between subjects with sexual experience and those without. characteristics of subjects age and race. a total of 159 female adolescents, ages 14 20, participated in the study (mean = 16.8 years). the subjects were almost racially homogeneous, with only 2% (n = 3) reporting that they were non-caucasian. the majority of the subjects (82%, n = 130) were born in the rural state where the study was conducted. parents’ education, occupation, and income. most participants reported higher maternal than paternal educational level. the mean years for paternal education was 11.3 years, and, maternal, 12.7 years, with mothers completing 1.4 more years of education than fathers. seventy-one percent (71%) of fathers and 51% of mothers held jobs. relatively few mothers or fathers held highly skilled professional positions. one father was a physician; a few parents worked as public school teachers, post-secondary educators, or managers; and many mothers were identified as homemakers. only 34% of the participants responded to the question asking the amount of family income, with others saying that they did not know their household incomes. most employed mothers were non-professional, a fact related to lower reported household income. twenty-eight percent of the families had combined incomes of more than $50,000; income tended to be higher for those participants living with both parents. those reporting lower family incomes were from non-traditional family living arrangements, such as living with step-family, mother’s fiancé, or other relatives (see table 1). living arrangements. sixty-one (61%, n = 96) percent of participants were living with both biological parents, and 25% were living with their mothers (n = 40); about six (n = 10) percent were with their fathers; and 7.6% (n = 12) with other relatives. adolescents living with biological parents reported less sexual activity than those not living with both parents (55% vs 77%, p > .008). sexual experience and protection. sixty-four percent (n = 94) of subjects reported having had sexual intercourse, and of this group, 71% (n = 67) stated that they had sex during the past month. when asked their age at first intercourse, 80% (n = 87) said between age 10 and 15 years; 10% (n = 11) said between 16 and 17 years; and only two (n = 2) said that they did not have sex until they were 18 years of age. the mean age at first sexual intercourse in this group of rural adolescents was 15 years. when asked whether they had used protection the first and the last time they had sex, 80% (n = 85) indicated that they had used protection. the methods used were pills with condoms (36%); condoms, alone (30%), and pills, alone (24%) (see table 1). online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 79 table 1 characteristics of 159 women participating in the study. characteristic n % age 14 15 54 34 16 17 45 28 18 20 60 38 race white 153 98 others 3 2 did not answer 3 living with both parents 96 61 father 10 6 mother 40 25 other relatives 12 8 did not answer 1 religion 122 84 ever had sexual intercourse yes 94 64 no 52 36 did not answer 13 sexual behaviors (among n = 94) had sex during the past month 67 71 age onset of sexual intercourse 10 16 80 87 17 10 11 18 2 2 did not answer 2 used contraceptive methods/the first time having sex yes 80 85 no 14 15 contraceptives methods/the last time having sex (among n = 80) birth control pills with a condom 29 36 birth control pills alone 19 24 condom alone 24 30 had sex during the safe time of the month 0 0 withdrawal 7 9 other 1 1 online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 80 hpv knowledge and related factors knowledge about hpv transmission and prevention was low in this sexually active sample of adolescent females. with or without sexual experience, there was limited knowledge about hpv or about behaviors that would afford protection from hpv, as indicated in table 2 and table 3. items most accurately answered by the 159 subjects were three that dealt with symptoms of hpv, garnering 147 correct responses (92.5%), 139 correct responses (87.4%) and 138 correct responses (86.8%), respectively. the fourth item, "not having sex would prevent hpv," was answered correctly by 144 (90.6%). few participants correctly answered questions regarding hpv transmission. at least 20% of respondents were not aware that withdrawal is the least effective protective method among the choices given. table 2 numbers (%) of correct responses to the 34 knowledge questions among the 159 women and comparisons of those by sexual status. overall sexual status had sex no sex questions (n = 159) (n = 94) (n = 54) pb adolescent physical development the physical changes of puberty happen to different teenagers at different ages. 136 (86) (88) (83) most teenagers feel awkward and jealous, develop “crushes”, and sometimes worry about their appearance. 145 (91) (91) (92) girls have a monthly release of blood from the uterus during menstrual periods. 152 (96) (95) (98) girls usually mature earlier than boys physically. 149 (94) (95) (92) male testes produce millions of sperm for each ejaculation when they are physically mature. 91 (57) (61) (54) nocturnal emissions are a normal part of growing up for a boy. 143 (90) (93) (85) in puberty, boys become slimmer, their penises grow larger, they produce sperm, and voices become lower. 143 (90) (86) (94) adolescent sexuality half of teenagers graduate from high schools in us have had sex. 54 (34) (28) (44) * about one-third of american girls become pregnant before aged 20. 55 (35) (41) (25) * potential consequences of adolescent sexual intercourse are pregnancy, guilty feelings, and becoming more or less close to their sexual partners. 118 (74) (74) (73) for most teenagers, emotions seem to change frequently. 150 (94) (96) (94) for a close relationship be important that sexual partners trust each other, date each other only, and think of the other person first. 150 (94) (97) (90) teenagers become more interested in sex because of influences by hormones, media, and peer pressure. 123 (77) (73) (83) online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 81 adolescent pregnancy pregnancy is possible the first time she has sex, during the menstrual period, standing up or if there is ejaculation near the vagina, but no penetration. 129 (81) (83) (73) most unmarried teenage girls would decide to have an abortion when they are pregnant. 61 (38) (41) (31) girls might get pregnant when having sex without protection any time during the month. 113 (71) (82) (50) **** children born to teenage parents have a greater change of being abused by their parents. 43 (27) (32) (21) most unmarried high school girls who have children depend upon their parents for support. 151 (95) (97) (92) adolescent marriage identifies potential consequences of teenage marriage. 74 (47) (48) (50) identifies problems of teenage marriage. 107 (67) (71) (65) sexually transmitted disease hpv is a dangerous std, can lead to cancer, and has no initial symptoms. 105 (66) (64) (73) hpv is impossible to cure. 53 (33) (41) (17) *** it is harmful for a woman to have sex with partner having hpv. 138 (87) (90) (83) std treatment is best if both partners are treated at the same time. 149 (94) (94) (92) gonorrhea is 10 times more common than syphilis, a disease that can be transmitted from mothers to babies, difficult to detect in women, and make both men and women unable to have babies. 107 (67) (69) (63) protected sex condoms can be the best prevention of getting stds/hpv. 143 (90) (95) (81) ** withdrawal is a least effective method of protection. 127 (80) (85) (77) knows correct way to use condom effectively. 134 (84) (84) (85) knows the advantages of using a condom. 136 (86) (88) (81) birth control pills must be taken for 21 or 28 days to be effective. 75 (47) (53) (44) one should learn about all protective methods before choosing. 151 (95) (97) (96) some protective methods can be obtained by people under 18 without parents’ permission. 49 (31) (34) (25) knows the rhythm method (“natural” family planning). 70 (44) (50) (37) believes that 90% will get pregnant if having sex regularly without any protection by the end of 1 year. 47 (30) (34) (25) a. 1=has ever had sexual experience, 0=no. b.* p < .05, ** p < .01, *** p < .001, **** p < .0001 by chi-square test. there was 48.2% accuracy for all 159 students’ answers to 30 questions addressing hpv. chi square demonstrated statistically significant difference (p < 0.05) in knowledge between 94 students who indicated a history of sexual intercourse and 54 who did not, with those who had sexual experience providing more accurate answers, overall (see table 2). a statistically significant knowledge difference (p < 0.05) between the groups was identified for two separate items: (a) length of hpv incubation period and (b) condoms as a protective measure against hpv. students with a sexual intercourse history scored more accurately on both items than online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 82 table 3 numbers (%) of correct responses to the hpv knowledge among the 159 women and comparisons of those by sexual status. sexual status overall 1 0 (n = 159) (n = 94)(n = 54)pb concepts of hpv a test detecting hpv is now available 113 (71) (76) (62) there is no known cure for hpv 91 (57) (62) (50) women with hpv are at higher risk for cancer 91 (57) (61) (54) hpv infection may not appear for years after exposure to the virus 84 (53) (60) (42) * a vaccine of hpv is now available 66 (42) (45) (31) women with hpv are at higher risk for aids 32 (20) (15) (25) hpv can spread hpv even if the infection is not visible 6 (4) (2) (6) symptoms of hpv a sore on the sex organs 147 (92) (96) (88) pain while urinating 139 (87) (87) (87) discharge of pus from the sex organs 138 (87) (90) (79) a bad cough 107 (68) (73) (63) lower abdominal (below the stomach) pain in females 100 (63) (66) (56) a headache 82 (52) (53) (50) transmissions sharing drug needles 106 (67) (69) (65) a female having sex with another female 28 (18) (22) (12) donating blood 27 (17) (19) (15) a male having sex with another male 23 (15) (17) (12) hugging someone who has hpv 6 (4) (4) (2) shaking hands with someone who has hpv 2 (1) (2) (0) having more than one sex partner 2 (1) (0) (2) having sex with someone who has had several sex partners 2 (1) (1) (2) being in the same classroom with someone who has hpv 1 (1) (0) (2) having intercourse (sex) with someone who has hpv 1 (1) (0) (2) protective behaviors from being infected with hpv not having sex 144 (91) (94) (85) using condoms (rubbers) during sex 134 (84) (89) (71) * making sure that a partner looks healthy 116 (73) (74) (73) not taking illegal drugs with a needle 106 (67) (69) (63) urinating after having sex 102 (65) (69 (54) washing after having sex 96 (61) (62) (56) eating a healthy diet and staying physically fit 95 (60) (63) (52) over all score (mean) 24.5 22.7 * 1 = has ever had sexual experience, 0 = no. *p < .05, chi-square p value for testing proportion difference and t-test p value for testing mean difference. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 83 students without a history. hpv knowledge significantly predicted endorsement of the importance of protected sex (r = .34, p < .001). multiple regression analysis indicated that there was a statistically significant relationship between hpv knowledge and subject’s living arrangements. those who lived with both parents tended to have lower hpv knowledge. other variables, such as age, father’s or mother’s occupation, age at first sexual intercourse, or having had sex during the past month, were not related to hpv knowledge (see table 4). table 4 multiple regression for hpv knowledge score (n = 78). t p age -0.427 -0.89 .38 living with both parents -2.048 -2.15 .035 father's occupation (professional) 1.042 1.05 .3 mother's occupation (professional) -0.792 -0.83 .41 age onset of sexual intercourse -0.257 -0.61 .54 had sex during the past month -0.499 -1.52 .13 attitudes toward protected sex and related factors preliminary analysis, using stepwise regression, identified seven (7) of the 65 knowledge questions that demonstrated a p < .01 correlation with the protected sex attitude score. these items were then entered as independent variables into the multiple regression model, controlling for the variance due to age and sexual status. seven knowledge items remained in the final model, with r 2 = .28. table 5 presents the results of the stepwise regression for attitude toward protective measures. seven knowledge items remained in the final model, with r 2 = .28, controlling for age and sexual status. data from 145 data observations were available for multivariate regression analysis. the results indicate that adolescents who correctly answer the following questions are more likely to endorse the use of protected measures: “people who have hpv can spread hpv, even if the infection is not visible”, (b = 2.45, p < .007); “std treatment is best if both partners are treated at the same time”, (b = 2.5, p < .008)”; “condoms can best prevent getting stds, (b = 2.02, p < .01)”; “using condoms during sex reduces the chance of hpv infection”, (b = 1.58, p < .01); “having sex with someone who has multiple sex partners increases the chance of hpv infection”, (b = 4.66, p < .02); “for most teenagers, emotions seem to change frequently”, (b = 2,17, p < .05); “women with hpv are at higher risk for cancer”, (b = .93, p < .05) (see table 5). high scores on these seven knowledge items are predictive of a positive attitude toward protected sex. calculated by sas, the power of the regression analysis was 71%. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 84 table 5 the final model of stepwise regression for birth control attitude score (n = 145). t p age 0.02 0.13 .9 had sexual experience 0.24 0.48 .63 people who have hpv can spread hpv even if the infection is not visible. 2.45 2.75 .007 std treatment is best if both partners are treated at the same time. 2.50 2.69 .008 condoms can best prevent getting a std. 2.02 2.57 .01 using condoms during sex reduces the change of hpv infection.. 1.58 2.52 .01 having sex with someone who has multiple sex partners increases the chance of hpv infection. 4.66 2.30 .02 for most teenagers, emotions seem to change frequently. 2.17 1.98 .05 women with hpv are at higher risk for cancer. 0.93 1.98 .05 discussion the expectation that it would be difficult to acquire parental consent for underage student was met, instead, with high participation. the investigators’ speculations about the high level of participation in the study, overall, are that few opportunities are offered in rural settings to serve as research subjects; the subject of the study was interesting to adolescents, as may have been the $10 inducement; and families in these rural counties tend to be traditional and are, perhaps, concerned about prevalent expressions of adolescent sexuality. this study is unique in its exploration of adolescent females’ knowledge about hpv. most studies on hpv have focused primarily on sexually experienced young women (kaiser family foundation, 2004; yocobi, 1999; vail-smith et al., 1994; biro et al., 1991; leonardo & chrisler, 1992; gerhardt et al., 2000) and few have been conducted in appalachian rural areas among adolescents. the data from the present study show that those adolescents who know hpv may not show visible symptoms are more likely to favor protective measures. if they answered correctly about the hpv transmission, they were more likely to endorse protected sex. those adolescent females who believe std treatment is important for both partners also favor sexual protection (p < .008). the data demonstrated high use of condoms among subjects who feared pregnancy or stds, in general (b = 2.02, p <.01). those who recognized the increased risk for hpv and other stds in sex with multiple partners, or with a partner who has multiple partners (b = 4.66, p < . 02), was also higher than for those who did not recognize the risk. subjects who had endorsed protected sex scored higher in awareness of the emotional changes during puberty (b = 2.17, p < .05); std treatment knowledge (b = 2.50, p < .008) ; and knowledge of the link between hpv and cervical cancer (b = .93, p < .05) (see table 5). these seven questions have potential for use in assessment, serving to identify those who have positive or negative attitudes toward protected sex. demographic findings descriptive of the rural appalachian region in which this study was conducted were that (a) educational levels reported for many of the subjects’ fathers were online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 85 lower than the levels reported for subjects’ mothers, and (b) parents were typically employed in service or labor jobs, rather than in professions. in this study, despite having been presented facts and figures in earlier scholastic curricula, the majority of subjects from this sexually active population are not knowledgeable about hpv transmission and prevention. deficits in knowledge, beliefs, and high level risk behavior persist in a population vulnerable to hpv and cervical cancer. furthermore, knowledge represented by responses to items in this study, although related to accepting attitudes regarding protected sex, appeared not to have reduced sexual risk behaviors. hpv knowledge was identified as a predictive variable, with higher levels predicting endorsement of contraceptive methods. the study suggests, however, that information about hpv may not be reaching adolescent females. although subjects responded to questions aimed at determining their knowledge about stds/hpv, the level of their knowledge was low. for example, only 31% of the subjects did not know that they could obtain protective measures without parental consent. a finding that invites further investigation is that girls who report living with both parents are more likely to know less about hpv than girls in other living arrangements. this study suggests that living with both biological parents appears to have a protective influence against early sexual activities. adolescents living with biological parents reported less sexual activity than those not living with both parents (55% vs 77%, p > .008). these findings support santelli’s (2000) conclusion that family structure plays a role in adolescents’ sexual behavior and provide evidence that changing adolescent attitudes and behaviors is more complex that simply educational design and implementation. the data also supports markham’s (2003) findings that family connectedness may be a protective factor related to sexual risk-taking. it is likely that connectedness to family, as well as parental expectation of adolescent success in school and later in life, may be important factors in delaying the onset of sexual activity. it is also possible that when adolescents have high aspirations and life goals, they are more likely to delay sexual activity. therefore, it can be concluded that efforts to reduce adolescent stds/hpv infection should focus, not only on health professionals and school systems, but also on (a) increasing parental stds/hpv knowledge; (b) enhancing parenting skills; and (c) offering community venues, for parents and adolescents, that foster emotional and physical health for this vulnerable age group. this study supports the findings of anderson-ellstorm (1996) that educational hpv information was best received by those who were currently involved in sexual behaviors, with those who had sexual experience providing more accurate answers to the questionnaire, overall. subjects living with both parents were less knowledgeable about hpv. results suggest that living with both biological parents can have a protective influence against early sexual activities. the data encountered in this study support santelli’s (2000) conclusion that family structures play a role in adolescents’ sexual behavior, as well as findings in earlier studies of higher incidence of risk-taking behaviors among adolescents where there were low levels of parental monitoring (diclement et al., 2001; donenberg et al., 2002; markham et al., 2003; nelson et al., 2004; rai et al., 2003). parental educational preparation is not high, especially among fathers, in this subject sample of highly sexually active adolescents, supportive of santelli et al’s finding of higher sexual activity among adolescents whose parents have not completed high school. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 86 limitations the homogeneity of the subjects is a limitation that precludes generalization of its findings to all populations. an additional preclusion to generalizing the results of this study to the larger population is the use of a convenience sample. implications for rural adolescent health the findings of this study add emphasis to the complexity of understanding the variables that contribute to high incidence of hpv risk behaviors. identification of low levels of knowledge, despite exposure to information, challenges researchers and school health educators to identify factors that would motivate subjects to learn and to apply learning to behaviors. the finding that living arrangements predict students’ awareness of hpv should inspire examination of factors within the home environment that may influence primary prevention. involvement of parents with adolescent females in school-based programs may lead to increased communication and effective education concerning sexual risk behaviors; however, research related to the education of adolescents regarding sexuality, stds, and hpv prevention must be continued. acknowledgement this study was supported by a west virginia university senate grant for research. references american social health association. 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[medline] online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=2556023%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11029992%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15914222%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1315349%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10451482%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10404550%5buid%5d microsoft word weierbach_159-1361-1-ed1.docx online journal of rural nursing and health care, 13(1) 26 differences and similarities in rural residents’ health and cardiac risk factors florence m. weierbach, rn, mph, phd 1 bernice yates, rn, faha, phd 2 melody hertzog, phd 3 bunny pozehl, aprn-np, phd, faha 4 1 assistant professor, college of nursing, east tennessee state university, weierbach@etsu.edu 2 professor, college of nursing, university of nebraska medical center, bcyates@unmc.edu 3 assistant professor, college of nursing, university of nebraska medical center, mhertzog@unmc.edu 4 professor, college of nursing, university of nebraska medical center, bpozehl@unmc.edu abstract purpose: the current u.s. population exceeds three hundred million with approximately 20% living in non-urban rural areas. a higher percentage of rural residents have diagnosed heart disease and report poorer health compared to non-rural residents; however, it is not known whether risk factor modification for heart disease and health status differ based on degree of rurality. the purposes of this study were: 1) to compare differences in health status and cardiac risk factors between cardiac patients living in large and small/isolated rural areas, and 2) to compare the health status of rural cardiac patients with a national sample. method: a secondary analysis using data from three separate studies was completed using a comparative descriptive design. the cardiac rehabilitation participant sample (n=191) included individuals 3 to 12 months post-cardiac event. the arizona heart institute and foundation heart test measured risk factors and the eight subscales of the short-form, medical outcomes study measured health status. online journal of rural nursing and health care, 13(1) 27 findings: no significant differences in health status were found; all participants rated their health moderately high. however, individuals in large rural areas reported significantly better general health than those in the normative sample. no differences in smoking, blood pressure, diabetes, or overweight/obese bmi were found between the two rural groups. differences in exercise, and anger were present between the two groups. significant differences were identified in waist circumference between the genders placing women at higher risk for heart disease. conclusions: identifying health status and cardiovascular risk factors of rural individuals informs interventions to be tested for rural residents. keywords: cardiac risk factors, rural, cardiac rehabilitation differences and similarities in rural residents’ health and cardiac risk factors the current united states (us) population exceeds three hundred million with approximately 20% living in rural, non-urban areas (“american fact”, n.d.). a higher percentage of rural residents have diagnosed heart disease and report poorer health compared to non-rural residents (jones & goza, 2008). though a higher percentage of rural residents have heart disease, they have lower hospitalization rates due in part to distances to health care facilities (harris, aboueissa, & hartley, 2008). rural residents with heart disease encounter challenges accessing specialized cardiac care from primary care providers or cardiac rehabilitation (cr) programs. however, residents of small rural and frontier/isolated areas may have less opportunity to develop healthy lifestyles and have less access to programs, such as cr, to assist them with lifestyle changes after a cardiac event than those living in larger rural, suburban and urban areas. the specific objective for this research was to examine the differences and similarities in self-reported health status and secondary prevention of cardiac risk factors between cardiac patients living in larger rural areas and those living in smaller/isolated rural online journal of rural nursing and health care, 13(1) 28 areas; and further, to compare the health status of cardiac patients living in both types of rural areas with a national normative sample of cardiac patients. the normative sample classifies rural as non-urban, which is consistent with the terms used to refer to rural (non-urban) and urban individuals in prior literature. a beginning knowledge of specific differences in health status and secondary prevention efforts of cardiac patients may assist nurses and other health care professionals to inform health care policy in rural america. overview rural has been defined in various ways; one method is to classify non-urban areas using the rural urban commuting codes (ruca) designation (wwami rural health research center, n.d.). ruca designations take into account geographic location based on access to metropolitan or micropolitan statistical areas where it is likely health care services, e.g., hospitals, cr programs, and physicians, will be available. using the ruca codes, rural-designated areas can be combined to form rural categories, such as large or small rural and isolated areas. disparities in preventive health care exist between rural and urban individuals, including, routine physical exams (83.8% vs. 86%, respectively), screening tests including pap smears (84.3% vs. 86.6%), mammograms (77.9% vs. 82.2%) and colorectal screening (46.3% vs. 49.2%), with individuals living in isolated areas having even lower percentages than their counterparts in large rural areas (south carolina rural health research center, n.d.). coronary heart disease (chd) consistently accounts for more deaths in the us than other diseases and is the primary cause of death (lloyd-jones et al., 2009). mortality rates attributed to chd differ among individuals residing in rural and urban areas. estimates show one of three individuals has at least one type of cardiovascular disease (lloyd-jones et al., 2009). men living in rural, non-metropolitan counties (eberhardt et al., 2001) have an ischemic heart disease online journal of rural nursing and health care, 13(1) 29 mortality rates of 20%, which exceeds metropolitan county rates by 12%. according to the american heart association (lloyd-jones et al., 2009) the estimated direct and indirect costs of cvd in the u.s. is $475.3 billion. costs directly linked to health care delivery, hospital care, medications and provider visits are direct costs which may or may not be covered by health insurance; indirect costs, lost wages due to illness or death are not covered. when comparing individuals in urban and any type of rural area, differences exist in their insurance status with the greatest number of uninsured individuals living in isolated areas (lenardson, ziller, coburn & anderson, 2009). regardless of rural-urban designation, characteristics of the uninsured include low income, fair to poor health, and low educational attainment. however, uninsured rural residents earn significantly lower family incomes; 1) 50% of urban residents compared to 59% of rural residents earn incomes at 200% of the federal poverty level (p < .05), 2) 28% of urban residents compared to 31% of rural residents have no family members employed full time, (p <.05), and 3) 31% of urban residents compared to 36% of rural residents earn less than $10 per hour (p <.05) (lenardson et al., 2009). furthermore, individuals who live in rural areas are less likely to receive recommended cardiac treatment such as fibrinolytic or percutaneous coronary interventions (pci), compared to individuals living in urban areas (baldwin et al., 2004). health status individual health status varies based on geographic location. few studies were found which examined the health status of individuals with coronary disease who live in rural areas. in a study that compared frontier and urban individuals with chronic heart failure, minimal differences were found between the two groups in terms of depression, quality of life, new york heart association classification and socio-demographic information (wagnild, rowland, dimmler, & peters, 2004). in both groups, participants had on average of 2.5 to 2.65 chronic conditions. online journal of rural nursing and health care, 13(1) 30 although it was suggested that frontier participants reported more depression (m = 10.01, sd = 6.7) than urban participants (m = 8.26, sd = 6.5) and may be an important clinical finding, it is not statistically significance. using the minnesota living with heart failure questionnaire, frontier participants reported more symptoms then their urban counterparts (wagnild et al., 2004) (t = 2.0, p<0.05). ruralliving residents, compared to urban residents, have limited connections with a family health care provider, have more financial restrictions and less opportunities to engage in a heart healthy lifestyle, such as buying fresh produce, exercise equipment, or gym memberships, with additional barriers to keeping fit, including less time, and fewer alternatives to exercise (king, thomlinson, sanguins, & leblanc, 2006). risk factors the main modifiable risk factors for chd include tobacco use, physical inactivity, obesity, elevated blood pressure, and lipid levels (balady, et al., 2007). the majority of studies which investigated cardiovascular risk factors among rural residents examined rural versus urban comparisons. differences in risk factors were found between urban and any type of rural area with rural residents more likely to smoke, be obese, and be physically inactive than their urban counterparts (jones & goza, 2008; eberhardt et al., 2001). a comparison of rural appalachia and national data revealed higher scores for cardiac risk factors, hypertension, body mass index (bmi), and tobacco use, among rural residents (schwartz et al., 2009). however, in comparing all types of rural and urban medically underserved areas (muas), urban residents in muas had significantly higher percentages of individuals who either smoked or were diabetic (homko et al., 2008). online journal of rural nursing and health care, 13(1) 31 few studies were found that examined secondary prevention of cardiac risk factors in rural populations. using a pretest-posttest design, individuals living in rural areas who participated in a cr program demonstrated improvement with cardiac risk factors, including weight, activity levels, quality of life, cholesterol levels, and dietary fat intake (aounm & rosenberg, 2004). prior studies have found disparities in access to health care services such as cr programs between rural and urban individuals with rural persons being more disadvantaged (gavic, 2005). nebraska ranks first in the country in the number of cr programs per population; with approximately 90 cr programs scattered throughout the state, many of which are in small rural communities (curnier, savage, & ades, 2005). this finding suggests that regardless of where they live individuals living in nebraska, even though they may be 30 to 60 miles away, have access to a cr program. however, it is not known if nebraska cardiac patients who live in small rural/isolated areas have poorer health and are less successful in cardiac risk reduction after a cardiac event compared to those who live in large rural areas with easier access to cr services. to reduce cardiovascular disease risks in rural populations, researchers and practitioners need to know more about secondary prevention issues that cardiac patients face in managing their disease. individuals living in small/isolated rural areas may have less opportunity to engage in physical activity, dietary choices, and access to health care. these factors may contribute to their health status and their increase risks over those living in larger rural, and non-rural areas. however, because so few studies have been reported comparing individuals who have experienced a cardiac event and are living in small rural and isolated areas, more comparison studies with these groups are needed. large versus small rural/isolated environments offer unique challenges, encompassing health care access, travel distances and population density, that must be considered when planning interventions focused on secondary prevention; more research online journal of rural nursing and health care, 13(1) 32 is needed that includes individuals living in different rural environments. this study addresses whether differences in health status and risk factors exist between cardiac patients living in large rural versus small rural/isolated areas. method a secondary analysis using data from three separate studies was completed using a comparative descriptive design. the three studies were combined to form a cr participant sample (n = 191), referred to as the cr participant data sample. the subjects for all three studies which were used in the cr data sample were recruited using non-probability sampling methods from three separate midwestern health care systems in rural nebraska communities. the entire cr participant data sample (n = 191) included individuals 3 to 12 months post-cardiac event who lived in a rural area. rural categories were defined using the rural urban commuting codes (ruca) designation (wwami rural health research center, n.d.). postal zip codes were used to assign each study participant to the corresponding ruca classification. consistent with ruca categorization b, which designates 2 rural groups, participants were placed in one of the two rural groups, large rural core or small rural/isolated. the first data source (n = 64) included in the cr participant sample were patients who had been hospitalized 6-12 months earlier with coronary artery bypass graft (cabg) surgery or myocardial infarction (mi). a letter explaining the study, consent forms, questionnaires, and a return envelope were sent to 112 potential subjects, who were identified by cardiac case managers. sixty-six returned the questionnaires for a response rate of 59%, 2 patients were not included due to significant amounts of missing data (yates et al., 2007). the second data source (n=64) included in the cr participant sample were patients who had recently completed a rural based cr program. all participants who completed the cr online journal of rural nursing and health care, 13(1) 33 program and met study criteria were invited to participate in a randomized clinical trial involving booster sessions to maintain the positive gains they had made in cr. the patients’ baseline scores were used in the current analysis. of the 74 eligible, 9 declined due to scheduling problems or lack of interest (88%). of the 65 who were initially enrolled, 1 person withdrew (2% attrition rate) (yates, anderson, hertzog, ott, & williams, 2005). the third data source (n = 62) included in the cr participant sample were patients who participated in a clinical trial testing two methods of delivering cr: a traditional outpatient program vs. a home-based program. approximately 100 patients were approached to participate, 74 initially enrolled (74%), 13 persons withdrew (18%) during the course of the study (yates, price-fowlkes, & agrawal, 2003). measures all study instruments in the three studies which contributed to the cr participant data sample were completed via mail surveys. cardiac risk factors were measured by using selected items from the arizona heart institute and foundation heart test for men and women (dietrich, 1981). participants were asked about: 1) blood pressure,<140/90 vs. > 140/90; 2) whether or not they engaged in a regular exercise program; 3) recent cholesterol level, < 200 mg/dl vs. > 200 mg/dl; 4) amount of fat in diet, low fat vs. moderate/high fat; 5) how often they were easily angered and frustrated, rarely vs. some/most of the time; 6) whether or not they were trying to lose weight; 7) whether or not they smoked; and 8) whether or not they had diabetes. the arizona heart institute questions have face validity and the literature supports the relevance of measuring these variables as outcomes of risk reduction for cardiovascular patients. for those who exercised regularly, participants were asked what activities they did, how many times per week, and for how many minutes per session. weekly activity expenditure (kcals online journal of rural nursing and health care, 13(1) 34 / week) was calculated as the product of the duration and frequency of the primary activity (hrs / week), weighted by an estimate of the metabolic equivalent (met) of that activity (ainsworth et al., 2000) and multiplied by body weight (kg). the recommended weekly activity expenditure is 1000 – 1500 kcals/week, with a minimal goal of 150 minutes moderate to intensive exercise per week (american heart association, 2003; “acsm issues new,” 2011). participants were also asked to self-report their height and weight and waist circumference (in inches) by measuring their waist at the umbilicus. bmi was calculated using the standard formula from self-report of height and weight (centers for disease control, 2010). normal bmi is < 25.0 kg/m 2 . overweight is defined as a bmi of 25.0 to 29.9 kg/m 2 and obesity as a bmi > 30.0 kg/m 2 . women with a waist measurement greater than 35 inches or men with a waist measurement greater than 40 inches may have a higher chd disease risk american association of cardiovascular and pulmonary rehabilitation [aacvpr] 2003). health status was measured by the eight subscales of the short form-36 (sf-36) from the medical outcomes study (ware, snow, kosinski, & gandek, 1993). the eight categories of the survey includes: physical functioning, role-physical, role-emotional, social, bodily pain, vitality, mental health, and general health. scores on all eight subscales can range from 0 – 100 with 100 denoting the person’s ability to perform normal activities i.e. social, physical, etc. without interference due to health problems. estimates of internal consistency reliability (cronbach’s alpha) of these subscales ranged from 0.78 for general health to .93 for physical functioning (ware et al., 1993). the sf-36 also has established validity evidence (mchorney, ware, & raczek, 1993). in the current study, all cronbach alpha internal consistency reliabilities of the 8 subscales were > 0.70. online journal of rural nursing and health care, 13(1) 35 all three of the studies which contributed to the cr participant data sample were approved by an institutional review board (irb) at the university and the clinical sites where the studies were conducted. informed consent was obtained from each participant in the three separate studies. the cr participant data sample received exempt status from the university irb where the original three studies were conducted. data analysis the cr participant sample data was used to compare differences between the two groups (large vs. small/isolated rural), t-tests were used for continuous variables and chi-square statistics for categorical data. data were examined for outliers and violations of normality using spss v.19. all of the variables demonstrated low univariate skew and kurtosis. t-tests were used to examine whether there were differences between the two cr participant sample data rural groups and the mi normative group in the subscales of the sf36. the level of significance designated for all analyses was alpha ≤ 0.05. results the cr participant data sample was 97% caucasian and 77% male, with ages ranging from 40 to 86 years (see table 1). the majority of participants in both rural groups were married, well educated (> 80% completing high school), and had incomes greater than $20,000 a year. no differences were found between persons living in large rural and small/isolated areas in age, race, marital status, education, and income. in contrast, individuals from the large rural areas (m = 7 miles) lived significantly closer to the cr site than those living in small rural/isolated areas (m = 17.2 miles). fewer men lived in small rural/isolated areas (78%) compared to large rural areas (61%) and online journal of rural nursing and health care, 13(1) 36 more patients in the small rural/isolated areas had coronary artery bypass graft (cabg) surgery (79%) compared to large rural areas (62%). table 1 socio-demographic and illness comparisons between large vs. small rural/isolated areas variable large rural (n = 99) mean (sd) small rural (n = 80) mean (sd) test statistic t-test df = 177 age 64 (10.4) 65.9 (8.9) 2.32 miles from home to crp a 7 (9.7) 17.2 (17.3) 5.08* % % chi square (df = 1) men 78% 61% 5.80* married 82% 86% .58 hs diploma or higher 81% 83% .18 income >$20,000 61% 50% 2.63 cardiac event cabg surgery b medical intervention c 62% 38% 79% 21% 6.18* a crp = cardiac rehabilitation program, b cabg surgery = coronary artery bypass graft surgery c medical intervention = status post myocardial infarction or percutaneous coronary intervention *p < .05 of the 93 counties in nebraska, 85 (91.3%) are considered rural, with 32 (37.6%) of the rural counties designated as frontier areas, which loosely correlates with the ruca isolated category. the participants lived in 27 different rural counties, representing 29% of the state’s counties. even with the majority (74%) of the rural counties in the state having a hospital and cr program, many of the participants lived 2-5 counties away and traveled approximately 50 250 miles one way from the cr site. health status measured by the sf-36, showed no significant differences between participants living in large rural vs. the small rural/isolated areas (see table 2). participants in both rural areas rated their levels of functioning moderately high. the only significant difference found in health status revealed individuals living in large rural areas reported significantly better online journal of rural nursing and health care, 13(1) 37 general health than individuals experiencing an mi who were included in the normative sample (f = 2.81, df = 200, p < .006). table 2 comparisons between large rural, small rural/isolated areas and sf-36 normative data sf 36 subscale large rural (n = 95) mean sd small rural/isolated (n = 78) mean sd sf-36 normsa (n = 107) mean sd physical function 69.15 25.69 70.0 25.13 69.68 26.12 role physical 54.21 42.31 56.41 42.14 51.41 39.35 role emotional 72.98 38.98 71.36 37.11 73.49 38.01 social 79.73 25.53 79.96 24.78 84.65 21.23 pain 74.11 24.55 70.93 21.95 72.75 25.25 mental 76.33 16.80 77.69 15.12 76.33 16.80 vitality 59.47 21.35 56.41 20.49 57.68 18.97 general health 66.77b 19.02 63.35 19.31 59.17b 19.34 a normative data were from patients diagnosed with mi 27 b significant differences between groups at p< .05 cardiac risk factors, measured by the arizona heart institute questionnaire, showed mostly non-significant differences (see table 3). the majority of individuals were overweight or obese by bmi (74% in large rural group and 69% in small rural group) with no differences found between participants in the two groups. the majority of individuals in both groups were trying to lose weight using a combination of exercise and diet with the majority reporting a low-fat diet. while not significant the results demonstrate a trend toward more individuals living in the large rural areas to have a serum cholesterol level < 200 mg/dl (71%) compared small rural/isolated participants (55%, p = .056). compared to individuals living in small rural/isolated areas, those in large rural areas were significantly more likely to be engaged in a regular exercise program and to be more easily angered in their daily lives. no differences were found between the groups in smoking status, few were smokers, blood pressure status, most had normal bp < 140/90, or presence of diabetes (approximately 39%). online journal of rural nursing and health care, 13(1) 38 table 3 comparisons between participants in large vs. small rural areas in cardiac risk factors risk factor large rural areas (n = 99) % small rural/ isolated areas (n = 80) % test statistic chi-square df = 1 body mass index (kg/m2) normal weight overweight obese 26% 49% 25% 30% 42% 27% 0.82 trying to lose weight 67% 70% 0.09 eat low-fat diet 77% 82% 0.70 serum cholesterol < 200 mg/dl 71% 55% 3.64† frequency of anger and frustration (some or most of the time) 56% 37% 5.95* still smoking 10% 6% 0.88 normal blood pressure (<140/90) 93% 89% 0.49 has diabetes 39% 38% 0.02 regular exercise program 82% 68% 5.06* m (sd) m (sd) t-statistic (df) exercise # times/week minutes/session kcals/week 5.1 (1.7) 30.8 (10.1) 771 (474) 4.7 (2) 40.2 (40) 844 (611) 1.26 (df = 137) 2.02 (df = 131)* 5.31 (df = 115) * body mass index 27.7 (4.6) 27.4 (4.6) 0.327 (df = 170) waist circumference men (>40inches) women (>35 inches) 38.5 (3.9) 35.4 (6.4) 38.5 (4.0) 36.6 (5.4) -0.08 (df = 118) -0.71 (df = 46) *p < .05 †p = .056 exercise which was measured using self-report, showed significantly more persons living in large rural areas engaged in a regular exercise program (82%) compared to those living in small rural/isolated areas (68%). however, persons living in small rural/isolated areas who were exercising did significantly more minutes/week and expended more kcals/week than those in large rural areas (see table 3). the majority of individuals in both groups reported their aerobic exercise of choice as walking (92%), followed by bicycling (3%), and running/jogging (2%). finally, no differences were found between groups in waist circumference. however, online journal of rural nursing and health care, 13(1) 39 significantly more women (52%) than men (25%) had a waist circumference that placed them in a higher risk category (χ2 = 11.42, df = 1, p = .001) for heart disease. discussion the comparison of individuals by geographic location is unique; few studies examining cardiac risk factors and health status were found examining similarities and differences between individuals living in large rural vs. small/isolated rural areas. one of the reasons for examining these two groups is because individuals with reduced access to health care often have less access to care, poorer health, and more health problems. examining individual risk factors by geographic location allows a closer look at community level factors which contributes to the overall health of the population. differences were found for residents in their rating of general health status and in risk factors based on where they live. the main difference found in sociodemographic characteristics of the sample was that individuals living in small/isolated rural areas had farther to drive to access cr programs than those living in large rural areas. prior investigators have reported similar findings between large and small/isolated rural areas for mileage and travel time required to access cardiac and other types of health care in rural areas (chan, hart, & goodman, 2005). few differences in risk factors were identified between the two rural groups. the majority of individuals in both groups were overweight or obese, ate a low-fat diet, were non-smokers, had normal blood pressure, and engaged in a regular exercise program. differences that were found indicated that individuals living in large rural areas were more likely to engage in a regular exercise program compared to individuals living in small rural/isolated areas. in contrast, when individuals living in small/isolated rural areas did exercise, their exercise program was significantly greater in intensity than those living in large rural areas. however, on average, neither group was meeting the recommended level of 1000 to 1500 kcals of energy expenditure per week in physical activity (“acsm issues new,” 2011). although the data in the online journal of rural nursing and health care, 13(1) 40 current study are limited by self-report, other investigators (ayabe et al., 2004; savage, brochu, scott, & ades, 2000; schairer, keteyian, ehrman, brawner, & berkebilem, 2003; schairer et al., 1998) have demonstrated that cr participants do not consistently meet targeted kcals/week for physical activity. another difference in risk factors show that individuals living in large rural areas reported more anger and frustration in their daily lives than those in small/isolated rural areas. the differences in risk factors may be linked with problems associated with where they live. in this study, the large rural areas consisted of two communities of about 25,000 populations that face a common set of challenges such as traffic congestion, outdated roads, and shortages of affordable housing. these issues may serve as sources of frustration for individuals living in large rural areas. similarly, those individuals living in small/isolated rural areas need to spend more time driving to access everyday necessities i.e. groceries, health care, etc. and thus have less time for an exercise program. the finding in the current study that more persons in small rural/isolated areas had surgery (79%) compared to those in large areas (62%) may be because of access issues. persons living in small rural areas have farther to drive for care, or may delay longer in seeking care and, thus, were unable to get to the hospital soon enough for medical treatment of their cardiac event. however, baldwin et al. (2004) found that individuals who live in rural areas are less likely to receive recommended cardiac treatments, such as fibrinolytic or percutaneous coronary intervention (pci) procedures, compared with persons who live in urban areas. in contrast, a rural study conducted in a state that is considered predominantly frontier, found individuals seek health care based on their interpretation of symptom severity and delay health care based on the ability to adapt their life styles to the symptoms (buehler, malone, & majeruswegerhoff, 2006). future research is needed that reaches beyond individual reasons and online journal of rural nursing and health care, 13(1) 41 examines community level factors within rural environments that delay individuals in accessing care. in this study, a significantly higher proportion of women than men had a waist circumference placing them at increased risk for heart disease. body fat that accumulates around the stomach area poses a greater health risk than fat stored in the lower half of the body (“waist circumference health,” n.d.). other researchers have found that overweight or obesity was a problem for 67% to 73% of women living in rural areas (chikani, reding gunderson, & mccarty, 2004; feresu, zhang, puumala, ullrich, & anderson, 2008). weight-reduction strategies may need to take a more prominent role in cr programs to assist individuals with weight loss while they are actively enrolled in cr. no differences were found between individuals living in large vs. small/isolated rural areas in their ratings of health. sf-36 scores indicated moderately high levels of physical and psychological functioning. mean scores were slightly higher on the mental subscales, ranging from 71.4 to 80, compared to the physical subscales, ranging from 54.2 to 74.1. other investigators also found that sf-36 subscale scores ranged from 70 to 86 three months post cabg surgery (zimmerman et al., 2007). similarly, sf-36 subscale scores ranged from 47 to 80 six weeks post-pci (barnason, zimmerman, brey, catlin, & nieveen, 2006). the only significant difference found in health status was that individuals living in large rural areas reported significantly better general health than individuals experiencing an mi who were included in the normative sample. the majority of the patients in the current study had cabg surgery, perhaps they view their heart condition as “fixed” after surgery, while patients who are medically treated, pci or mi patients, do not consider themselves fixed. online journal of rural nursing and health care, 13(1) 42 the results of the study need to take into account limitations; 1) merging of three separate studies, 2) using existing data for secondary analysis, 3) using self-report instruments, and 4) the rural environmental context. the lack of clinician generated objective data such as blood pressure and lipid profiles are additional limitations. future studies could benefit from broadening the environmental context of the study by measuring county level data in addition to individual data, therefore an analysis would include participants place of residence, health status and county resources. the generalizability of the findings is limited to primarily caucasian men and women who reside in rural areas similar to those in this study. practice and policy implications based on the findings in this study, it appears that two of the main individual risk factors that continue to need modification for individuals in this rural population are lack of physical activity and being overweight or obese. thus, it is important to note that reducing or eliminating risk factors should remain on the agenda for healthcare providers. according to the national institutes of health (nih), obesity is now considered an epidemic (lucey, 2008). the proportion of nebraska adults who are overweight or obese has increased by 33% and 75% respectively since 1992; and is higher in nebraska than the nation (nebraska health & human services system, 2003), as well as higher in rural areas of nebraska than urban areas (wang, mueller, & liyan, 2008). it is also important to keep in mind that many of the modifiable risk factors, such as overweight/obesity, sedentary lifestyle, smoking, hypercholestermia, elevated blood pressure, and diabetes are interrelated (balady et al., 2007). having programs which focus on multiple risk factors should assist in decreasing all of the modifiable cardiovascular risk factors. the ability to identify information about the health status and cardiovascular risk factors of individuals in rural areas provides health care providers and program planners with data that can online journal of rural nursing and health care, 13(1) 43 assist them in developing health care resources for residents in large rural, small rural and isolated areas. while interventions aimed at improving the health status of individuals has included rural residents, understanding the health status of rural residents will assist in developing interventions that take into account the characteristics of the rural community. government, private for profit and non-profit health care systems in rural communities need to pool their resources to assess community level risk factors, such as access to health care, food and physical activity opportunities which may make rural residents vulnerable for developing cv disease. after the assessments are complete the group should then focus their energies on developing community level programs and initiatives aimed at individuals to improve their health status and modify their cv risk factors. supporting agencies this research was supported, in part, by the post-doctoral position to dr. weierbach; 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(2003). barriers and facilitators of self reported physical activity in cardiac patients. research in nursing and health, 26, 459-469. [medline] zimmerman, l., barnason, s., schulz, p., nieveen, j., miller, c., hertzog, m, rasmussen, d., tu, c. (2007). the effects of a symptom management intervention on symptom evaluation, physical functioning, and physical activity for women after coronary artery bypass surgery. journal of cardiovascular nursing, 22, 493-500. [medline] http://www.ncbi.nlm.nih.gov/pubmed/17225370 http://www.ncbi.nlm.nih.gov/pubmed/15812738 http://www.ncbi.nlm.nih.gov/pubmed/14689462 http://www.ncbi.nlm.nih.gov/pubmed/18090191 differences in autonomy and nurse-physician interaction among 39 differences in autonomy and nurse-physician interaction among rural and small urban acute care registered nurses in canada kelly l. penz mn, rn1 norma j. stewart ph.d., rn2 1doctoral student, college of nursing, university of saskatchewan, klp946@mail.usask.ca 2professor and associate dean, college of nursing, university of saskatchewan, norma.stewart@usask.ca key words: rural/remote nursing, autonomy, nurse-physician interaction, work satisfaction, recruitment, retention, acute care, kanter’s theory abstract in a secondary analysis of a national survey of registered nurses (rns) working in rural and remote canada, two groups of acute care nurses were compared on the work satisfaction variables of autonomy and nurse-physician interaction based on whether their workplace community population was rural (10,000 or less) or small urban (>10,000 but <100,000). for this analysis, the variable “size of community” served as a proxy indicator for hospital size. kanter’s (1993) theory on the structure of power in organizations was the basis of the hypotheses. as predicted, the rural rns (n=811) working in the smaller hospital organizations had significantly higher levels of autonomy [f(1, 1229)= 5.602, p<0.05] and higher levels of nurse-physician interaction [f(1, 1229)=27.78, p<0.001] than the small urban rns (n=427). the findings suggest that the size of an organization or hospital setting does have an influence on the level of autonomous practice and interaction between nurses and physicians. introduction health reform in the 1990’s in canada created many challenges for nursing practice, the most important being the nursing shortage that is projected to increase over the next decade (advisory committee on health human resources [achhr], 2002; baumann et al., 2001). nursing practice settings that may be the most affected by this projected shortage are hospitals, specifically those within rural and remote areas of canada. registration data shows that the majority of rural rns in canada (54%) practice within general hospital settings (canadian institute for health information [cihi], 2002). in addition, the rural rn workforce is aging; the average age of rns increased from approximately 40.6 years in 1994 to 43 years in 2000 (cihi, 2002). as a result, one of the main challenges facing the canadian health care system is the recruitment and retention of professional rns in rural and remote hospital settings. in a summary report on health human resource planning in canada, it was stressed that the propensity for nurses to leave the profession appears to be related to nurses’ job satisfaction and the quality of their work environments (fooks et al., 2002). higher levels of rns’ job satisfaction as well as recruitment and retention have been directly linked to practice environments that encourage professional nurse autonomy, and collaboration between nurses and physicians (keuter et al., 2000; rafferty et al., 2001; rosenstein, 2002). this research involves an examination of the work satisfaction variables of professional nurse autonomy and nursephysician interaction from the perspective of rural and small urban rns in canada. the data for this study were drawn from a large national survey of rns in rural and remote canada (stewart et al., 2005). online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 http://www.usask.ca/nursing/ mailto:klp946@mail.usask.ca http://www.usask.ca/nursing/ mailto:norma.stewart@usask.ca 40 background magnet hospital characteristics with a recent rise in community opportunities for rns, hospitals are increasingly illequipped to compete for the recruitment and retention of the most qualified professional rns (aiken et al., 2001). the increased job dissatisfaction of rns related to inadequate collaboration, lack of respect from physicians, and lack of a strong professional practice environment can be seen as a threat to the retention of rns (mee & robinson, 2003; upenieks, 2003a). during the 1980’s, a group of american hospitals were labeled “magnet hospitals” due to their ability to attract and retain professional nurses during a national nursing shortage (havens & aiken, 1999; mcclure et al., 1983; scott et al., 1999). the organization of nursing within magnet hospital settings has consistently demonstrated three core features that are key to professional nursing practice. these include professional nurse autonomy, nursing control over the practice environment, and collaborative nurse-physician relationships (aiken et al., 1994; havens & aiken, 1999; scott et al., 1999; upenieks, 2002). it has been found that within magnet hospital environments that support these core features, nurses have higher levels of job satisfaction and are attracted to, and stay within, these environments (havens & aiken, 1999; scott et al., 1999, upenieks, 2003b). unfortunately, the majority of studies on magnet hospitals have been conducted within urban environments and little is known about magnet hospital characteristics within rural hospital settings. characteristics of quality workplaces a review of the literature has identified that professional nurse autonomy, and collaborative interactions between nurses and physicians, have a significant influence on the quality of the work environment for rns (mcgillis hall, 2005). within the canadian context, attributes that enhance rn worklife have been identified that are similar to the characteristics of magnet hospitals. increased nurse autonomy in patient care as well as collaboration with other professionals, particularly physicians, has been shown to improve canadian nurses’ job satisfaction (freeman & o’brien-pallas, 1998; laschinger et al., 2003; o’brien-pallas & baumann, 2000). it has also been suggested that dedication to improving aspects of nursing worklife such as increasing professional nurse autonomy and nurse-physician collaboration, leads to success in recruiting and retaining nurses over time (fooks et al., 2002). baumann et al. (2001) pointed out that nurses are more satisfied with their jobs and more loyal to their employers when they are respected for their expertise and are able to provide input within their full scope of practice. regrettably, the bulk of canadian research on characteristics of healthy workplaces has been conducted within mainly urban settings (blythe et al., 2001; burke & greenglass, 2000; o’brien-pallas & baumann, 1992). as a result, little is known about healthy workplace characteristics of autonomy and nurse-physician collaborative interaction in rural and small urban hospitals from a national perspective. comparisons based on size of hospital or nursing unit coward et al. (1992) found that of 731 nurses working in rural florida, those working in smaller hospitals (i.e., 1-49 beds) were shown to have significantly higher scores for autonomy online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 41 than those working in medium sized hospitals (i.e., 50-100 beds) and large hospitals (i.e., 100+ beds). although not statistically significant, the trend in the research also suggests that the rns working in the smallest hospitals may have more collaborative interactions between nurses and physicians when compared to the rns working in the medium and large hospitals. however, the results were not conclusive and therefore further comparative study is necessary to substantiate the research evidence. mark et al. (2003) conceptualized professional nursing practice as a hidden construct that is defined by decentralization, enhanced nursing autonomy, and collaborative relationships between nurses and physicians. they compared results between size of hospital units and found that acute care rns from smaller units were more satisfied and reported enhanced levels of professional nursing practice, and that larger unit size was associated with lower levels of satisfaction for both nurses and patients. unfortunately, the researchers did not report the actual differences in the level of autonomy and nurse-physician interaction based upon size of hospital unit. shamian et al. (2002) aggregated 6,188 individual responses of ontario acute care rns, and used this to generate hospital-level measures of magnet hospital characteristics. although not statistically significant the pattern in the research suggests that the smaller hospitals may have better nurse-physician relationships than community hospitals (i.e., medium sized hospitals) and teaching hospitals (larger sized hospitals), and higher levels of autonomy than community hospitals. while differences were modest, stronger differences in favor of smaller hospital settings may have been observed if 19 of the smallest hospitals, accounting for close to 500 rns had not been excluded from the final analysis. in general, there appears to be limited comparative research available on the job satisfaction attributes of autonomy and nurse-physician interaction of rural and small urban hospital rns in canada. the few canadian studies that included rural hospital rns in their study (laschinger et al., 2001; shamian et al., 2002) were conducted at a provincial level and therefore do not provide a broad understanding of canadian rns who practice within rural and small urban hospital settings. even though increased satisfaction with professional autonomy and more positive interactions between nurses and physicians have been linked to nurse recruitment and retention, there is a paucity of literature available on these variables within rural hospital settings in canada. although it may appear that rns working within smaller hospitals or smaller nursing units have higher levels of autonomy and more collaborative relationships with physicians, the research evidence to support this trend is limited. further study of canadian hospital rns working in rural and small urban communities are necessary to determine if there are differences in their perceived autonomy and nurse-physician interaction. theoretical framework kanter’s (1977, 1993) theory on the structure of power in organizations was the basis of hypotheses for the present study. kanter (1977, 1993) emphasized that when people have more power and control over the conditions of their work environment, under these conditions, people will experience higher levels of autonomy and will have more participation in organizational decisions. kanter (1977. 1993) made reference to the importance of the size of an organization and stressed that in larger, more complex hierarchical environments people become dependent on those who control important contingencies and have more personal power (i.e., more personal influence within organizations). physicians within larger hospital organizations may have higher levels of personal power related to contingencies controlled, and may experience dependency behavior from rns. physicians who have more personal power in larger organizations may also online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 42 be less inclined to develop more collaborative interactions with their rn colleagues. the opposite is also true that dependency is reduced in smaller organizations where people can work more autonomously and have greater decision making latitude (kanter, 1977, 1993). the study aim the aim of this analysis was to determine if there are differences in the level of autonomy and nurse-physician interaction between rns working in rural and small urban hospitals. based on kanter’s (1977, 1993) structure of power in organizations, it was hypothesized that (1) rns working in rural communities within smaller hospital organizations would have higher levels of autonomy than rns working in small urban communities within larger hospital organizations; and (2) rns working in rural communities within smaller hospital organizations would have more positive interactions with physicians, than rns working in small urban communities within larger hospital organizations. design the data examined in this paper were drawn from a cross-sectional survey of rural and remote rns in canada. the survey method and questionnaire design used to collect the data were based on a modified version of dillman’s (2000) tailored design method. the survey was part of a multi-method study (macleod et al., 2004) examining the nature of nursing practice in rural and remote canada (also see cihi, 2002; kulig et al., 2003). detailed information regarding the survey methods, procedures, and data collection can be found in stewart et al. (2005). the present study is a secondary analysis of the national survey of rural and remote rns (penz, 2006). in this analysis, two groups of acute care rns were compared based on whether their workplace community population was rural (10,000 or less) or small urban (>10,000 but < 100,000), which served as a proxy indicator for size of hospital. in the rural study conducted by stratton et al., (1998), it was supported that hospital size is a valid proxy for community size. therefore, it was inferred that rural size of community (population 10,000 or less), would have smaller hospital organizations than small urban size of community (population >10,000 but <100,000). participants the national survey included a stratified random sample of rns living in rural areas in all the canadian provinces, as well as the total population of rns who worked in the yukon, nunavut, and northwest territories, and nursing station/outpost settings. a total of 3933 usable questionnaires were returned between october 2001 and july 2002, resulting in a 68% response rate (stewart et al., 2005). the acute care hospital rn sample for this analysis included the 1238 rns who defined their work setting as a “general hospital” and their primary area of practice as “acute care”. this provided a homogeneous sample based on practice area and represented rns from this work setting in all the provinces and territories in canada. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 43 to provide for appropriate comparisons between smaller communities, “rural communities” were defined using the statistics canada definition of “rural and small town” as those communities outside of the commuting zone of centers with a population of 10,000 or more (du plessis et al., 2001). the “small urban” communities were defined using the statistics canada “census agglomeration area”, which includes communities with populations greater than 10,000 but less than 100,000 (cihi, 2002; du plessis et al., 2001). based on these designations, the acute care rn sample was categorized according to those who work in communities with a population of 10,000 or less, which represented rural hospital acute care rns (n=811), and those working in communities with a population greater than 10,000 which represented small urban hospital acute care rns (n=427). measures stamps’ (1997) index of work satisfaction (iws) is a 30-item scale, with each item scored on a 7-point likert scale. the iws includes seven subscales of work satisfaction, as well as measurement of the perceived importance of each subscale. the national survey adapted a version of the iws by reducing each subscale to five items, which was then embedded into the questionnaire (stewart et al., 2005). the autonomy subscale and the nurse-physician interaction subscale from the index of work satisfaction (stamps, 1997) were used to test the hypotheses that were proposed for this analysis. each subscale contained five items and was summated to give a possible range of scores from 5 to 35, with a higher score representing higher autonomy or higher nurse-physician interaction. validity and reliability content validity for the original survey was determined through pilot testing of the overall survey and embedded scales, as well as through consultation with expert researchers, advisors and rns who practice in rural and remote areas of canada (stewart et al., 2005). the internal consistency reliability was replicated for the adapted iws embedded within the survey questionnaire and achieved adequate reliability compared to previous studies reported in stamps (1997). considering the national survey administered the modified iws to rns in many different practice areas (e.g., public and community health, home care, hospitals, long term care), it was originally thought that this may have lowered estimates of internal consistency. for this reason the internal consistency reliability was also replicated for the present acute care sample. as anticipated the nurse-physician interaction subscale for the acute care sample achieved a higher alpha of 0.88, which is comparable to other studies ranging from 0.77-0.84 (stamps, 1997; stewart et al., 2005). in contrast, reliability results were substantially lower for the autonomy subscale for the present acute care sample with an alpha of 0.58, compared to other studies ranging from 0.66-0.76 (stamps, 1997; stewart et al., 2005). ethical considerations approval for the national survey was obtained from the behavioral research ethics board of the educational institution that conducted the study. participation was voluntary and potential participants were given an information letter explaining the study. the return of a completed questionnaire after reading the letter constituted implied consent for this study. the online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 44 letter requested participation in the study, explained how participants were selected, the value of participating in the study, as well as confidentiality of responses and guarantee of anonymity. anonymity was also maintained by requesting each provincial/territorial nursing association to select all outpost nurses and a random sample of rns, using postal codes to identify rural residence (stewart et al, 2005). in the 4 out of 10 instances where the provincial/territorial nursing associations (newfoundland, nova scotia, british columbia, and ontario) did release the names and addresses of members to the research team, a contract to protect confidentiality was implemented (stewart et al., 2005). data analysis descriptive statistics were used to describe the region of residence, demographic, and employment characteristics for the rural and small urban rn participants. since selection bias could be a threat to the internal validity of the proposed research design (burns & grove, 2005; cook & campbell, 1979), groups were also compared on participant characteristics. analysis of variance (anova) was used to test the hypotheses that were proposed for the present study. this analysis was accomplished using the statistical package for social sciences (spss) 13. results sample characteristics as can be seen in table 1, the sample of acute care hospital rns represented nurses from all of the provincial and territorial regions in canada. table 2 describes the demographic and employment characteristics of the 811 rural and the 427 small urban hospital acute care rn participants from the national survey. in general, the rural and small urban rns represented an aging population and when compared, were similar on most sample characteristics including gender, years licensed to practice, marital status, dependent children or relatives, and employment status. the majorities of both rural and small urban rns were women (97% and 95.6%), reported being married or common law (84.3% and 86.4%), and had dependent children or relatives (61.5% and 64.9%). some significant differences were observed when comparisons were made between the two groups. there were a greater proportion of rural rns (12.0%) aged 55 years and over, when compared to the small urban rns (6.8%). an independent sample t-test conducted for age revealed that the rural rns (m = 42.9, sd = 9.3) were significantly older [ t(1225)=2.52, p < 0.05] than the small urban rns (m = 41.4 , sd = 8.9). although the majority of both rural and small urban rns had attained a diploma as their highest level of nursing education, there were a significantly greater proportion of small urban rns who had attained a higher level of nursing education. specifically, almost 22% of the small urban rns had attained a degree in nursing (i.e., baccalaureate, master or ph.d.), with only 15% of rural rns attaining the same level of education. groups were also compared on type of shifts worked (this analysis included those rns that worked either strictly 8-hour or 12-hour shifts). there were a significantly greater proportion of rural rns (34.9%) that worked 8-hour shifts exclusively when compared to the small urban rns (29.0%) that worked the same length of shift. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 45 table 1 region of residence of rural and small urban acute care rns in canada rural small urban total acute care sample (n=811) (n=427) (n=1238) region of residence n (%) n (%) n (%) atlantic provinces 284 (35.0) 138 (32.3) 422 (34.1) quebec/ ontario 102 (12.6) 82 (19.2) 184 (14.9) manitoba/ saskatchewan 181 (22.3) 46 (10.8) 227 (18.3) alberta/ british columbia 203 (25.0) 58 (13.6) 261 (21.1) northern territories and nunavut 41 ( 5.1) 102 (23.9) 143 (11.5) missing --------- 1 ( 0.2) 1 ( 0.1) total 811 (100) 427 (100) 1238 (100) autonomy and nurse-physician interaction comparisons a total of 1231 acute care hospital rns provided responses for both the autonomy subscale and the nurse-physician interaction subscale. the mean score of the autonomy subscale for the acute care sample was 23.2 (sd=4.9) with a range in scores from 6 to 35. the nursephysician interaction subscale showed similar results with a mean score of 23.9 (sd=6.6) and a range in score from 5 to 35 for all acute care participants. in order to make comparisons between groups, two one-way anovas were conducted using community size (rural vs. small urban) as the between-subjects factor. in the first anova, the dependent variable was the participants’ scores on the autonomy subscale of the index of work satisfaction (stamps, 1997). in the second anova, the dependent variable was the participants’ scores on the nurse-physician interaction subscale of the index of work satisfaction (stamps). the assumptions of anova were met for both analyses. as predicted in the first hypothesis, the mean scores for the autonomy subscale were statistically significantly higher [f(1, 1229)= 5.602, p<0.05] for the rural acute care rns who worked in the smaller hospitals (n= 807, m=23.44, sd=4.86) than for the small urban rns who worked in the larger hospitals (n= 424, m=22.74, sd=5.04). as predicted in the second hypothesis, the mean scores for the nurse-physician interaction subscale were also significantly higher [f(1, 1229)=27.78, p<0.001] for the rural acute care rns who worked in the smaller hospitals (n=807, m=24.57, sd=6.38) than for the small urban rns who worked in the larger hospitals (n=424, m=22.5, sd=6.61) (see table 3). the hypotheses that were proposed for this study were both supported by the above statistical analyses. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 46 table 2 sample characteristics of rural and small urban rns characteristic rural rns small urban rns (n=811) (n=427) n (%) n (%) χ² p age (years) < 25 16 ( 2.0) 9 ( 2.1) 25-34 154 (19.0) 94 (22.0) 35-44 270 (33.3) 160 (37.5) 45-54 267 (33.0) 130 (30.4) 55 and over 98 (12.0) 29 ( 6.8) 10.89 .028 missing 6 ( 0.7) 5 ( 1.2) gender female 787 (97.0) 408 (95.6) male 24 ( 3.0) 18 ( 4.2) 1.36 .243 missing ------ 1 ( 0.2) highest attained nursing education diploma 680 (83.8) 330 (77.3) baccalaureate/master or phd 124 (15.3) 91 (21.3) 7.32 .007 missing 7 ( 0.9) 6 ( 1.4) years practiced (years) 1-10 192 (23.7) 106 (24.8) 11-20 253 (31.2) 156 (36.5) 21-30 249 (30.7) 121 (28.3) 31 and over 111 (13.7) 42 ( 9.8) 6.43 .092 missing 6 ( 0.7) 2 ( 0.5) marital status married/common law 684 (84.3) 369 (86.4) single/divorced/widowed 125 (15.4) 57 (13.4) 0.952 .329 missing 2 ( 0.3) 1 ( 0.2) dependents (children or relatives) yes 499 (61.5) 277 (64.9) no 309 (38.1) 147 (34.4) 1.52 .217 missing 3 ( 0.4) 3 ( 0.7) nursing employment status (those that chose one employment status) full-time permanent 376 (46.4) 192 (45.0) part-time permanent 237 (29.2) 139 (32.6) job share/ casual/ contract/ term 98 (12.1) 54 (12.6) 1.007 .604 missing 100 (12.3) 42 ( 9.8) type of shifts worked (those who work 8-hr vs. 12-hr shifts) 8-hour shifts 283 (34.9) 124 (29.0) 12-hour shifts 390 (48.1) 237 (55.5) 5.839 .016 missing 138 (17.0) 66 (15.5) online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 47 table 3 differences in autonomy and nurse-physician interaction between rural and small urban hospital settings size of hospital rural small urban (n=807) (n=424) f p index of work satisfaction (iws) autonomy subscale m 23.44 22.74 sd 4.86 5.04 5.60 .018 nurse-physician interaction subscale m 24.57 22.50 sd 6.38 6.85 27.78 .000 discussion the aging workforce of rural and small urban rns presents a multidisciplinary challenge for the recruitment and retention of rural and small urban hospital nursing professionals. it has been suggested that the issue of early retirement of the first wave of baby boomers is already affecting the supply of members from many professional groups including nurses (o’brienpallas et al., 2004). the matter of early retirement in rural and small urban areas may be more of an issue due to the fact that an adequate supply of younger rn replacements may not exist in these isolated areas. it has been estimated that by 2006, canada is projected to lose the equivalent of 13% of the 2001 nursing workforce through retirement at age 65 (o’brien-pallas et al., 2003). due to the fact that many health professional retire before the age of 65, these losses are projected to increase to 28% of the 2001 nursing workforce if nurses choose to retire at the age of 55 (cihi, 2005). this projected nursing shortage is predicted to have a potentially dramatic effect in the rural regions of canada (kulig et al., 2003). it is difficult to predict what impact these losses to the nursing workforce may have on the provision of quality healthcare in the rural areas of canada. however, it can only be assumed that the significant decreases in the supply of these rns would negatively affect the rural access to quality care and therefore this issue must be addressed at a national level. studies that have focused on rural samples of hospital rns have consistently found that aspects of work satisfaction such as higher autonomy and collaborative interaction between nurses and physicians are important for the retention of rural rns (hanson et al., 1990; hegney et al., 2002; pan et al., 1995). national recognition and support of these aspects related to quality work environments may actually help retain those rns who are in the higher age categories. o’brien-pallas et al. (2004) emphasized that the factors that foster job enrichment and increase challenges in a nursing position may be significant in the retention of nurses who are closer to retirement age. the increased challenge that autonomous nursing practice and more collaborative online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 48 nurse-physician interaction can provide to the aging nursing workforce, is a retention strategy that should be focused on within rural and small urban acute care environments. another challenge that exists at a national level is the need for a new generation of rural and small urban acute care rns to replace the nurses that will be lost due to retirement and migration to other practice areas. increasing the enrollment in nursing schools is one strategy that is being used to ensure that an adequate supply of qualified rns are available to counteract the present nursing shortage in canada (achhr, 2002). unfortunately, an increase in the number of rns who have been educated mainly within urban areas may not improve the supply of rns who are prepared to work in the rural and small urban areas of canada. policy development at a national level could ensure that nursing students have adequate opportunities to enhance their nursing education with rural and small urban acute care experiences. in an australian study, it was found that the students who had rural clinical placements rated themselves as more confident, competent and organized than the students that had strictly urban placements (edwards et al., 2004). the choice of rural and small urban acute care practicum placements would introduce nursing students to the autonomous and collaborative type of practice that rural nursing has to offer as well as enhance their level of nursing competence and organizational skill. recruitment efforts may be more successful with the new nursing graduates who have already experienced the higher levels of autonomy and improved working relationships between nurses and physicians that are present in rural acute care settings. the findings of the present study suggests that size of an organization or hospital setting may have an influence on the level of autonomous practice that is perceived by the rns and also has an influence on the level of interaction between nurses and physicians. kanter (1977, 1993) stressed that greater independence and access to power structures (i.e., autonomy) are present in smaller organizations that have less hierarchical organizational structures. kramer et al. (2003) emphasized that nursing autonomy must have something to do with bureaucracy and hospital size. many of the nurses in their qualitative study emphasized that as their organizations merged and became bigger, they perceived that they lost their autonomy (kramer et al., 2003). it would be expected that smaller hospital organizations located in rural communities would have fewer rns on staff and fewer physicians on-site than larger urban settings. this would likely mean that there would be a flatter hierarchical structure present in smaller hospital settings, which would result in more independent, and autonomous practice opportunities for rns working within these smaller organizational settings. kanter (1977, 1993) pointed out that having the chance to engage in non-routine work, to show independent judgment, to take risks and become well known within the work environment are all less available in larger organizations. for the present study, rural rns from the smaller hospital settings may have had less routine work, more opportunities to make independent judgments, and increased participation in risk taking behavior than their small urban counterparts. all of these factors may account for the higher satisfaction with autonomy that was found for the rural rns from the smaller organizations when compared with the small urban rns from the larger organizations. kanter (1977, 1993) also emphasized that in larger, more hierarchical organizations; individuals can become dependent on those who have more personal power and who control important contingencies (i.e., have more personal influence within organizations). in many larger, more complex hospital organizations, physicians may still maintain high levels of personal power and therefore rns within the small urban settings may be more dependent on physicians to make the important decisions within the practice environment. this does not mean that small urban rns have no access to power structures, but they may have to contend with online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 49 greater hierarchical levels then rural rns, as well as the resulting dependency problems that tend to occur within a larger organizational structure. it may be that rns in the smaller hospital settings have decreased levels of organizational dependency on physicians, which they might obtain by accessing their own levels of personal power and by bypassing the hierarchy present in larger hospital settings. these factors may account for the higher satisfaction with collaborative interaction between nurses and physicians that was found for the rns in the smaller rural hospital settings when compared to the rns working in the larger, small urban hospital settings. related to organizational size, it may be possible that the nature of nursing practice may be different in the smaller rural hospitals when compared to the larger hospitals in the small urban communities. coward et al. (1992) suggested that nurses in smaller hospitals do things differently than their counterparts in larger hospitals; that their hospital nursing positions are organized differently, time is spent on different tasks and interpersonal relationships with coworkers are also different. hansen et al. (1990) suggested that rural nursing settings are culturally unique and are characterized by an approach to practice requiring a generalist perspective. the nursing culture and generalist perspective that are unique to rural nursing practice may have played a role in the higher satisfaction with autonomy and nurse-physician interaction that was observed for the rns working in the smaller rural hospital settings. it is evident in the literature that nurses in small rural hospitals must have a broad knowledge base and that they must practice as expert generalists (bushy & bushy, 2001; rosenthal, 1996). kanter (1977, 1993) stressed that although the accumulation of power in an organization is closely tied to the formal position that an individual attains within a hierarchy; having competence within this position is also imperative. provision of care in smaller rural hospital settings would require that rns practice with use of advanced assessment and judgment skills. rural rns working in these environments would have the responsibility to ensure that they maintain high levels of nursing competency. in the study of rural rns by bushy and banik (1991), it was found that the nurses who had the most variety in their nursing roles (generalist practice) had higher levels of work satisfaction than the nurses who worked in less diverse roles. although it is not possible to assess possible differences in the routine nature of the work between rural and small urban hospital settings, there may be differences in the nature of practice between the different sizes of hospitals. the small rural hospitals may require that individual rns take on more leadership roles, and fulfill a diversity of practice roles that may not be expected of an rn that works in a larger hospital in a small urban setting. these additional roles that are performed may not only give rural rns the opportunity to practice with a higher level of autonomy, but may also make them more visible to other health care professionals. these autonomous nursing roles may have a positive effect on the level of recognition and respect that rural rns are given, and may improve the interactions that occur between nurses and physicians. these factors may have had an influence on the higher satisfaction with autonomy and nursephysician interaction that was observed for the rural acute care hospital rns. conclusion the results of this study have added to the limited knowledge on the nature of acute care nursing practice in rural and small urban hospital settings in canada. similar to the total population of canadian rns, it has been established that the rural and small urban acute care rns of canada are an aging nursing workforce. the reality of this aging workforce raises many concerns related to the ongoing recruitment and retention of qualified rns, as well as the online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 50 sustainability of quality health care in the rural and small urban regions of canada. the quality of nurses’ work environments must be addressed if rural and small urban hospital settings are to maintain their nursing workforce in the future. as outlined previously, quality nursing work environments have been consistently linked to having more autonomous practice and more positive interactions between nurses and physicians. as well, these characteristics have been linked to rns’ work satisfaction and nursing recruitment and retention. the results of this study suggest that rns who practice in smaller, rural hospital organizations have higher levels of nursing autonomy and more interactive relationships with physicians. this higher rn satisfaction with autonomy and nurse-physician interaction that was found in the rural acute care settings must be acknowledged in canada, and possible reasons for these differences must be explored further. organizational size may not only have an influence on the structure of power that is present within hospital settings, but may also have an effect on the nature of nursing practice that is integrated by hospital organizations that differ in size. the commitment to the recognition and development of the advanced nursing skills necessary for rural and small urban acute care practice will ensure that future rns have continued access to quality nursing environments. references advisory committee on health human resources (achhr) (2002). our health, our futurecreating quality workplaces for canadian nurses: final report of the canadian nursing advisory committee. ottawa, on: author. aiken, l.h., clarke, s.p., sloane, d.m., sochalski, j.a., busse, r., clarke, h., et al. 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(1997). nurses and work satisfaction: an index for measurement (2nd ed.). chicago: health administration press. stewart, n.j., d’arcy, c., pitblado, j.r., morgan, d.g., forbes, d., remus, g., et al. (2005). a profile of registered nurses in rural and remote canada. canadian journal of nursing research, 37, 122-145. [medline] stratton, t.d., dunkin, j.w., szigeti, e., & muus, k.j. (1998). recruitment barriers in rural community hospitals: a comparison of nursing and nonnursing factors. applied nursing research, 11, 183-189. [medline] online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12690254%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12544565%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15190225%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10143271%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11700377%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12394075%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9921144%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11998196%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15887769%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9852661%5buid%5d online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 53 upenieks, v. (2002). assessing differences in job satisfaction of nurses in magnet and nonmagnet hospitals. journal of nursing administration, 32, 564-576. [medline] upenieks, v. (2003a). recruitment and retention strategies: a magnet hospital prevention model. nursing economics, 21(1), 7-13, 23. [medline] upenieks, v. (2003b). the interrelationship of organizational characteristics of magnet hospitals, nursing leadership, and nursing job satisfaction. health care manager, 22(2), 83-98. medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12464774%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12632712%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12785545%5buid%5d abstract background magnet hospital characteristics characteristics of quality workplaces comparisons based on size of hospital or nursing unit the study aim design participants measures validity and reliability ethical considerations data analysis results sample characteristics table 1 region of residence of rural and small urban acute care rns in canada table 2 sample characteristics of rural and small urban rns table 3 differences in autonomy and nurse-physician interaction between rural and small urban hospital settings editorial 1 editorial from the desk of kay rosenthal, phd, rn kay rosenthal executive director rural nurse organization according to the institute of medicine report, rural america is a vital component of american society. representing nearly 20 percent of the population, rural communities, like urban landscapes, are rich in cultural diversity. however, the smaller, poorer, and more isolated a rural community is, the more difficult it is to ensure the availability of high-quality health services. the institute of medicine report, quality through collaboration: the future of rural health examines the quality of health care in rural america. in the report, the committee offers a five-pronged strategy to address the quality challenges in rural communities: 1. adopting an integrated approach to addressing both personal and population health needs; 2. establishing a stronger health care quality improvement support structure to assist rural health systems and professionals; 3. enhancing the human resource capacity of health care professionals in rural communities, and the preparedness of rural residents to actively engage in improving their health and health care; 4. assuring that rural health care systems are financially stable; and 5. investing in an information and communications technology (ict) infrastructure, which has enormous potential to enhance health and health care over the coming decade; (http://www.iom.edu/report.asp?id=23359). rural nursing is patient-centered, especially since we are caring for our neighbors and community members. we strive to be safe and efficient in the care we deliver. with technology we can ensure that we are giving effective and timely healthcare and that our treatments are equitable to all those we deliver care to. what are you or your facility doing to ensure quality care? this is the time to become active on the local level. the rural nurse organization (rno) encourages you to read the reports, give your input and become actively involved in the pursuit of quality. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.iom.edu/report.asp?id=23359 rural nursing in africa: acts of mercy 7 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 editorial rural nursing in africa: acts of mercy angela collins, rn, dsn, aprn-bc, ccns editorial board member this summer provided a chance to go to uganda to serve a community by providing screening and simple interventional care. community service is not an unfamiliar experience of this acute care nurse because colleagues at the university of alabama, church fellowship, and greater birmingham nursing chapter are active in efforts to address healthcare disparity in the united states. however, this journey into international community needs engaged not only nursing expertise, but also misconceptions about global health needs. working alongside nineteen colleagues was a moment to make a difference. friends have asked “how were you changed by this time in another part of the world?” the following paragraphs are three stories that explain some of the paradigm shifts that occurred. presence the first day reminded this nurse of the time soloing off orientation on night shift in a progressive care unit. this author’s gut was tight, throat dry, anxiety filled all organ systems. there were about a hundred persons waiting for us to set up clinic. about forty were school age children who were singing and huddled under a tent set up as a respite from the equator’s sun. looking out over the group and our eighteen suitcases of medical supplies, the emotions could be best described as hope and fear. hope that our presence would be an act of mercy to the persons needing our help. fear that without electricity, a laboratory, and running water our assessment skills might be inadequate to the task. triage was the author’s assignment of service. lesson one was not to be overwhelmed by the mass of persons in one’s visual field. by turning our back to the crowd, each person was an individual to be seen, heard, and resources dispensed. presence is activity best accomplished one person to one care giver. each of us in triage covered each other in affirmation. our true collaboration was attention not to numbers, but to individuals. does it hurt? as the day progressed tasks were accomplished with confidence. vital signs were taken. chief complaints recorded. children sat close enough to pick the stickers off the table that signified that they had been triaged. one little girl who was about four had not been in contact with someone of caucasian ethnicity prior to this time. she enjoyed running her fingers gently up and down my arm. she touched the numerous freckles and looked up with a puzzled expression. “do they hurt?” she asked. looking down at this small human who had only eaten but once today, had a home without a window or floor, no access to running water, or malaria preventive agents, and a caregiver who was hiv positive. her question reminded this nurse that 8 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 compassion is an option for each person. it is a misconception that service is a unilateral experience. gratitude and compassion are options no matter how much or little of the world’s assets one has at any moment. her question of compassion reminds this author that we should all care first; to see if the other person hurts. “i want to see” pronouncing the name of the young man in front of me was a great challenge with my southern accent. with the help of a translator we were able to come to some compromise. he described me as white person who is round in a hat, a truly fitting description. once we had gotten the name agreement and vital signs recorded, the next question was what assistance he desired at the clinic. he said “i want to see the chalk board”. because there was no facility for custom fitting glasses all that we had were magnifying glasses. there were no distance vision glasses. his eyes were so hopeful and excited. urban air pollution and cooking fires produced eye irritation near where he lived; knowing this i pondered what options could the clinic offer. suddenly a thought occurred, perhaps my sunglasses and some lubricating eye drops could at least acknowledge his need and our concern. taking the sunglasses off my face and placing them on his the explanation was given that they would not solve his problem but our team wanted to assist him in some way. he dropped to his knees to thank me. getting down on my own knees to hug him, i lifted him up. i told him he was welcome but he was why i came over half way around the world. not all days as a nurse does one believe that our work makes an impact. past american association of critical care nurses president, debbie brinker (2006) said in an aacn news editorial that nurses should be able to bring our soul to work. at that moment, i did bring my soul with confidence into the work at hand. this encounter transformed my world view. a small act of mercy could change lives. it did mine. references brinker d. engage and transform: find the right match. president’s address. aacn news. 2006; 23: 2. 6 psychosocial impact of cancer in low-income rural/urban women: phase ii margaret a. lyons, phd, rncs1 m. mitchell shelton, phd, rn2 1 assistant professor, capstone college of nursing, university of alabama, mlyons@bama.ua.edu 2 assistant professor, capstone college of nursing, university of alabama, mshelton@bama.ua.edu keywords: breast cancer, cervical cancer, disparity, psychosocial effects, cancer burden abstract purpose: the goal of this study was to understand the emotional impact of diagnoses of breast or cervical cancer on low-income rural southern women by exploring depression and cancer-related quality of life in women who have been diagnosed with one of these cancers. method: the design for this descriptive study was a one-time cross-sectional telephone survey. this study reports the findings from phase ii of the project. in phase ii, results from phase i, as well as established measures of depression (ces-d) and cancer-related quality of life (fact-b) were used to develop a telephone survey instrument that measured the impact of cancer on the lives of an additional 60 women from the designated areas. findings: results from phase ii indicate that both african american and caucasian women, irregardless of rural or urban residence, who are diagnosed with breast or cervical cancer, experience significant anxiety, rely heavily on support systems that are already in place, are very knowledgeable about their diagnosis and treatment, have difficulty in the management of sideeffects during treatment, use spirituality as a mechanism for coping with the illness, would utilize counseling services from a nurse after diagnosis, and generally do not meet criteria for clinical depression. african american breast cancer patients were found to have a significantly (f=8.11) higher quality of life score than caucasian breast cancer patients. breast cancer patients who had a lumpectomy were found to have a significantly (f=5.91) higher quality of life score than those breast cancer patients who had undergone a mastectomy. living in a rural area, experiencing side-effects such as nausea, vomiting, hair loss, and swelling was predictive of a significantly lower quality of life. examination of cancer patients’ depression scores found a higher incidence of depressive symptoms if they did not receive adequate information prior to surgery. patients diagnosed with cervical cancer were significantly more depressed than patients with breast cancer. limitations: the use of convenience sampling and a small sample size in this study limits generalizability. implications: this study provides valuable information for practitioners to use in caring for breast or cervical cancer patients. introduction estimates from the american cancer society (acs) for the year 2003 are that 211,300 women will be diagnosed with breast cancer and that 13,000 women will be diagnosed with cervical cancer (american cancer society [acs], 2003). of those, 3,400 cases will be documented in alabama and 2,400 cases in mississippi. in addition, 200 cases of cervical cancer are expected to occur in both alabama and mississippi (acs, 2003). many of these women will be african american or impoverished and/or live in online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://nursing.ua.edu/home.htm mailto:mlyons@bama.ua.edu http://nursing.ua.edu/home.htm mailto:mshelton@bama.ua.edu 7 rural areas (national cancer institute, 2003). in order to meet the healthcare needs of low-income women, programs such as the national breast and cervical cancer early detection program (nbccedp) have been instituted, and provide access to lifesaving cancer screening, diagnostic services, and treatment centers to millions of uninsured and underinsured women (cdc, 2003). additionally, early detection and advances in cancer treatment have decreased mortality rates, raising concern for the well-being and quality of life of breast and cervical cancer survivors. data reported here are from phase ii of a larger study of depression and cancerrelated quality of life in low-income rural and urban southern women who have been diagnosed with breast or cervical cancer (lyons, in press). results from phase i indicated that primary issues for women with breast or cervical cancer include: fear and anxiety; coping strategies that were, for the most part, sufficient; and support systems that were adequate. the study revealed that the majority of women voiced a need for more in depth knowledge about the type of treatment to be received, felt that they were emotionally prepared prior to surgery, managed side-effects during treatment with some difficulty, used health promotion strategies, and consistently utilized spirituality in their quest for healing. qualitative analysis identified few differences in the cancer experience between rural and urban women, race, ethnicity, or socioeconomic status. the current study examines some of the same concerns, depression, and quality of life in a larger sample of rural and urban low-income southern women. background quality of life there is considerable agreement that quality of life is multifaceted and multidimensional (ferrell et al. 1997; ferrell et al. 1998). the world health organization quality of life group (1995) recognized that physical/health status, psychological status and social functioning are essential components that must be considered when examining quality of life. however, a number of specific variables such as the meaning of the new diagnosis to the individual, the type of intervention that is required, treatment side-effects, the type of support that is available, body image and sexual functioning, financial resources and socioeconomic status affect outcomes and quality of life in breast and cervical cancer patients (ganz, rowland, desmond, meyerowitz, & wyatt, 1998; nissen, swenson, ritz, farrell, sladek, & lally, 2001). additionally, logistical issues such as taking time off from work, transportation, and childcare, impact quality of life and are possible mediators of positive outcomes for women with breast or cervical cancer (swanson, 1996). other factors impact quality of life. social support from spouses, family members, and friends, as well as support from health care professionals are important factors in adjustment to breast cancer (hoskins et al. 1996; lackey, gates, & brown, 2001; loveys & klaich, 1991; street and voight 1997) found that quality of life was higher for women who perceived greater responsibility and choice for treatment decisions than for those who perceived limited input or control over these decisions. however, informationseeking behaviors that enable women to make informed choices are highly individualistic. rees and bath (2001) found that some women actively seek information and others avoid online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 8 information. still others vacillate between seeking and avoidance. but, those who sought information used it to cope with their cancers, regain a sense of control and assist in the decision making process. the investigators found that those women who avoided information did so to escape from anxiety, feelings of negativity, and depression. spirituality is an important aspect of cancer care (sephton, koopman, schaal, thoresen, & spiegel, 2001). fernsler, klemm, and miller (1999) investigated the relationship between spiritual well-being and the demands of illness imposed by a cancer diagnosis. the authors concluded that subjects who reported higher levels of spiritual well-being experienced significantly lower demands of illness related to physical symptoms, monitoring symptoms, and treatment issues. disparity low-income minority women may face disparity in health care. some authors contend that disparity in health care is primarily related to race but sufficient evidence exists to suggest that differences in diagnosis, treatment, and survival may be attributable to low socioeconomic status and a lack of insurance coverage rather than to race (bradley, given, & roberts, 2001; shinagawa, 2000). low-income women with breast or cervical cancer face problems of inadequate housing, along with fear, anger, and grief that is intensified by negative provider attitudes and stereotypes about socioeconomic status (levine, levenberg, wardlaw, & moyer, 2001). depleted financial resources may magnify the impact of a diagnosis of breast cancer or cervical cancer for some lowincome women. out-of-pocket costs such as prescriptions, transportation, co-pays, and lack of paid leave from jobs may result in an insurmountable burden for many women and thereby contribute to healthcare disparity (levine et al. 2001). rural versus urban residence other factors may contribute to disparity. living in a rural area may mean that individuals must travel long distances to the nearest hospital or treatment facility. it is known that, on average, women in rural areas travel twice the distance to treatment centers as those in urban areas (swanson, 1996; wilson, anderson, & meischke, 2000). consequently, people who become ill and live in rural areas often learn to filter out what symptoms are manageable by the individual, versus what may become problematic if left untreated. family members, friends, and acquaintances often assume roles of “inside,” albeit informal, diagnosticians and therapists (long, 1993). according to wilson et al. (2000), rural women need more education about breast cancer and more emotional support after diagnosis than urban women. angell et al. (2003) concluded that women in rural areas need immediate psychosocial intervention that is affordable, accessible despite distance, culturally appropriate, and designed for women with little education. depression psychological sequelae experienced by the woman with breast or cervical cancer directly affects how she copes with her illness and has been found to include intrusive online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 9 thoughts, avoidance, anxiety, depression, and impaired relationships (baider & de-nour, 1997; epping-jordan et al. 1999; lyons, jacobson, prescott, & oswalt, 2002; primo et al. 2000; vickberg, bovbjerg, & duhamel, 2000) women who attribute a negative connotation to the illness experience have been found to have significantly higher levels of depression, anxiety, and poorer quality of life than those with positive attribution (degner, hack, o’neil, & kristjanson, 2003). women who are able to transform negative aspects of the breast or cervical cancer experience into ones with positive meaning and who assist in making choices regarding treatment decisions fare better than those who do not (degner et al. 2003; koopman et al. 2001; lyons et al. 2002; taylor, 2000). previous research by this author (lyons et al. 2002) indicated that, after the initial diagnostic trauma and the retraumatization of treatment, many women are able to attribute inherent value to the illness experience and see themselves as stronger for having dealt with the illness. pascreta (1997) found that 9% of her sample (n=79) met criteria for major depressive disorder or dysthymia. 24% had elevated depressive symptoms, physical symptom distress, and impaired functioning in daily life. self-reported depression burden was found to influence severity of side-effects (badger, braden, & mishel, 2001). depression scores and psychological distress in early stage cervical cancer patients have also been reported to be higher than those in the general population. cull et al. (1993) reported that patients feared reoccurrence of their cancers, experienced sexual problems, and were unable to communicate their needs to their partners. purpose the goal of this study was to understand the emotional impact of diagnoses of breast or cervical cancer on low-income rural and urban southern women by exploring depression and cancer-related quality of life in women who have been diagnosed with one of these cancers. this research fills a significant gap in the existing literature. little information is available concerning the emotional status of african-american women newly diagnosed with cancer and residing in rural, low-income areas of the “deep south” or the impact of the diagnosis on low-income white women. questions prompting this research were the following: what are the issues and concerns of low-income rural and urban women as they manage their illnesses? are there health disparities related to race, socioeconomic status, or residence affecting these women and if so how do they cope? information obtained from this study will be used to further knowledge about how these women cope with cancer, ultimately leading to interventions that will aid in reducing health disparity in this population. method sample sixty low-income rural and urban southern women diagnosed with breast or cervical cancer comprised the sample for this study. participants were recruited from cancer treatment centers and health departments in mississippi and alabama, the mississippi breast and cervical cancer early detection program, support groups, the online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 10 american cancer society, and word of mouth. following institutional review board (irb) approval potential participants were given flyers announcing the study and asked to call a toll free number at the researcher’s office if they were interested. participants met inclusion criteria of having been diagnosed with breast or cervical cancer during the previous 6 months, having access to a telephone, and willingness to respond to questions posed by the researcher. respondents were asked to sign a consent form which described the purpose and confidential nature of the study. they received $50 for their participation. assurances were given regarding the participant’s right to withdraw from the study until such time as all data were analyzed. design the design for this descriptive study was a one-time cross-sectional telephone survey. a telephone survey is a rapid, cost-efficient strategy for data collection from a large sample and geographic area (lavrakas, 1990). sixty newly diagnosed women were surveyed about the impact of breast or cervical cancer on their lives, depression, cancerrelated quality of life, and other issues identified from the literature and from phase i of the study. instruments depression, a common response to a cancer diagnosis, was measured with the center for epidemiological studies depression scale (ces-d) (radloff, 1977). this well-established 20-item scale measures the major symptoms of clinical depression. alpha coefficients are .84 for the general population and .90 for a patient sample. testretest correlations of .48 (n=378) were moderate but appropriate as the ces-d was designed to measure the current level of depression. cancer-related quality of life was measured by the functional assessment of therapy for patients with breast cancer (fact-b) which contains the fact-general plus the breast cancer subscale (bcs) (cella, 1996). the fact was developed with an emphasis on patients’ values and instrument brevity. it contains 36 items and 5 subscales measuring physical well-being, functional well-being, emotional well-being, social well-being, and additional concerns about breast cancer. coefficient alpha for the total score was .90, with subscale coefficients ranging from .63 to .86. the fact-b is considered appropriate for use in oncology clinical trials and clinical practice. evidence supports high (.88) test-retest reliability for the bcs, as convergent, divergent, and known groups construct validity. all but three bcs items (self-consciousness about dress, shortness of breath, and swollen arms) are also suitable for cervical cancer patients. these three items were deleted for those patients. additional questions developed from phase i data were asked of each respondent (table 1). online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 11 table 1 cancer interview guide questions questions number percentage cancer 1st found mammogram breast self-exam doctor’s exam other 30 18 12 0 50 30 20 0 told about your cancer call from doctor call from nurse in person by doctor by your spouse or other family member 5 3 51 1 8.3 5 85 1.7 feeling upon notification shock fear anxiety calm anger other 48 51 52 8 5 1 80 85 86.7 13.3 8.3 1.7 * type of cancer treatment lumpectomy mastectomy hysterectomy radiation chemotherapy other medication other no treatment 19 35 3 19 33 4 4 0 31.7 58.3 5 31.7 55 6.7 6.7 0 * treatment side effects nausea/vomiting pain weakness fatigue hair loss swelling infection burns numbness hot flashes other no problems 34 39 42 52 34 2 2 4 11 3 0 1 57.6 66.1 71.2 88.1 57.6 3.4 3.4 6.8 18.6 5.1 0 1.7* quit/take off work yes no 14 6 70 30 employer support financial time off without pay 0 9 0 64.3 online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 12 sick leave other 4 2 28.6 14.3 personal support spouse children friends other no support 27 43 35 7 1 45 71.7 58.3 11.7 1.7 obstacles to treatment yes no 57 2 96.6 3.4 types of obstacles transportation childcare long waiting times financial other 3 0 1 57 0 5.3 0 1.8 100 0 * difficulty paying for tx yes no 51 8 86.4 13.6 emotionally prepared prior to surgery yes no 34 25 57.6 42.4 adequate information prior to surgery yes no 55 5 91.7 8.3 understand surgery prior yes no 58 2 96.7 3.3 participate in tx decisions yes no 53 7 88.3 11.7 used counseling if available yes no 60 0 100 0 promote health since dx eat better exercise rest spend more time w/ family appreciate life more vitamins herbal medicines 19 5 37 47 52 7 0 32.2 8.5 62.7 79.7 88.1 11.9 0 role of spirituality since dx strength consolation closer to god go to church more pray more no affect 47 46 47 2 16 4 88.7 86.8 88.7 3.8 30.2 7.5 * online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 13 sample fifty-three women who had been diagnosed with breast cancer and seven women diagnosed with cervical cancer comprised the sample for this study. all had been diagnosed within the previous six months and ranged in age from 27-72 years (mean of 49.8). about half of the women resided in alabama and half in mississippi; 46% (n= 28 ) resided in rural areas with the remaining 54% (n=32) residing in urban areas of those states. 57% (n=34) of the women were african american and 43% (n=26) were caucasian. all had incomes of less than $30,000 with the majority declaring incomes of approximately $10,000 or less. 78% (n=47) received financial assistance from medicaid, 11.9% (n=7) were medicare patients, and the remaining 10% (n=6) had some type of private insurance. complete demographic data is provided in table 2. table 2 sample demographics items count percentage type of medical insurance blue cross/blue shield champus medicare medicaid other 3 0 7 46 3 5.1 0 11.9 78 5.1 marital status married widowed divorced separated never married 30 2 14 5 9 50 3.3 23.3 8.3 15 education less than 8th grade almost completed hs completed hs/ged some college/trade baccalaureate degree master’s degree post graduate 1 19 27 13 0 0 0 1.7 31.7 45 21.7 0 0 0 household status live alone live with spouse live with children live with extended family live with friend 9 30 16 4 1 15 50 26.7 6.7 1.7 place of residence house apartment mobile other 42 10 8 0 70 16.7 13.3 0 online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 14 family income less than $10,000 $10,000-$20,000 $20,000-$30,000 $30,000-$40,000 $40,000-$50,000 $50,000-$70,000 $70,000-$90,000 $90,000+ don’t know 21 24 11 3 0 0 0 0 0 35.6 40.7 18.6 5.1 0 0 0 0 0 race caucasian african american 26 34 43.3 56.7 religion protestant catholic jewish other 55 0 0 4 93.2 0 0 6.8 type of cancer breast cervical 53 7 88.3 11.7 data analysis research questions were divided into two categories. the first category: “is there a significant difference between breast cancer patients’ quality of life and their race, type of surgery, chemotherapy, educational level, patient participation in decision making in treatment, patient treatment side effects, social support systems, rural/urban residence, and emotional preparedness? the second category: “is there a significant difference between cancer patients’ depression scores and their race, type of surgery, chemotherapy, educational level, patient participation in decision making in treatment, patient treatment side effects, social support systems, rural/urban residence, and emotional preparedness?” these questions were tested by means of the chi square statistic (fact b) and analysis of variance (ces-d). findings sixty low-income, african american and caucasian women, who resided in rural and urban areas of the deep south participated in this study. all had been diagnosed with breast or cervical cancer. the women in this study found out that they had cancer through mammograms (n=30), breast self-exam (n=18), or physician exam (n=12). the majority of women were informed of their cancers in person, by their physicians. however, eight women described finding out during phone calls from their physician or a nurse. the majority of the women expressed shock, fear, and anxiety upon notification. some experienced anger and still others stated that they were “very calm”. the type of cancer treatment varied depending on type and severity of cancer. three individuals had hysterectomies, the remainder had lumpectomies (n=19), mastectomies (n=35), radiation (n=19), and/or chemotherapy (n=33). treatment side effects included nausea and online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 15 vomiting, pain, weakness, fatigue, hair loss, swelling, and numbness. the majority had what they considered to be excellent support from spouses, children, friends, and church family. participants (n=53) overwhelmingly felt that they had experienced obstacles to treatment particularly in terms of financial difficulty and would not have been able to afford treatment without medicaid or medicare. more than half of the women felt that they were emotionally prepared prior to surgery, understood what surgery was to be performed and felt that they had participated in treatment decisions. however, 100% of the women stated that they would take advantage of additional education and counseling by a nurse if it were available. the women in this study engaged in a variety of health promoting behaviors such as “eating better”, exercise, rest, spending more time with family, appreciating life more, and taking vitamins. none of the participants admitted to taking herbal medications. when asked about the impact of spirituality on their experiences the most prevalent answers were strength, consolation, and feeling closer to god. table 2 depicts participant responses to survey questions. in examining the research questions (n=52) related to quality of life (fact-b) only race, type of surgery, rural/urban residence, and treatment side effects were found significant (p< 0.05). african american breast cancer patients were found to have a significantly (f=8.11) higher quality of life score than caucasian breast cancer patients. breast cancer patients who had a lumpectomy were found to have a significantly (f=5.91) higher quality of life score than those breast cancer patients who did not. patients who had a mastectomy were found to have a significantly (f=4.73) lower quality of life score when compared to those patients who did not. breast cancer patients living in rural areas were found to have a significantly (f=5.13) lower quality of life score as opposed to patients living in urban areas. patients were found to have a significantly lower quality of life score if they experienced nausea and vomiting (f=5.51), hair loss (f=7.62), and swelling (f=16.13). examination of cancer patients’ depression questions (ces-d) (n=60) found only two questions (emotional preparedness and type of cancer) to be significant (p<0.05). results indicated that patients who felt that they did not receive adequate information about their surgery prior to surgery were significantly (x 2 = 7.97) more depressed than patients who felt they received adequate information. those patients with cervical cancer were found to be significantly (x 2 = 11.58) more depressed than patients with breast cancer. however, making any inference based on these findings may be suspect, due to the small number of patients with depressive symptoms for both questions (emotional preparedness=5, type of cancer=7). discussion the goal of this study was to understand the emotional impact of diagnoses of breast or cervical cancer on low-income rural and urban southern women by exploring depression and cancer-related quality of life in women who have been diagnosed with one of these cancers. despite differences in race or rural/urban residence and congruent with phase i of this research (lyons, 2004) the women in this study experienced similar responses to the diagnosis of breast or cervical cancer. they acknowledged shock, fear, and anxiety related to the diagnosis, surgery, and treatment. they had good support systems in place and relied on family and friends for help in meeting their psychosocial online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 16 needs pre and post surgery and during treatment. however, 100% of the women indicated that they would welcome the opportunity to discuss their concerns with a nurse counselor. inadequate financial resources and lack of insurance were significant barriers to access to care for many of the women. however, all were screened for their cancers by their state’s breast and cervical cancer early detection program. once they received a positive diagnosis they were referred to medicaid to receive financial assistance, thereby leveling the playing field in some respects with women who have insurance. the women in this study who had insurance were burdened by a limited ability to pay for out-ofpocket expenses such as co-pays, medication, and transportation to treatment facilities. nursing assessment of financial resources/needs and subsequent referral to appropriate social services could be beneficial to these patients. consistent with current literature (henderson, fogel, & edwards, 2003) african american women in this study were found to have a higher quality of life than caucasian women. perhaps as other research has shown (bourjolly, 1998), this difference is related to differences in religious coping. mastectomy patients were found to have a lower quality of life than those who had undergone lumpectomy. congruent with other research findings (rustoen, moum, wiklund, & hanestad, 1999) this difference may be attributed to body image concerns, pain, sexual concerns, and self-esteem issues. women with breast cancer who lived in rural areas had poorer quality of life scores than those living in urban areas. distance to treatment, perceived lack of physician support, and isolation may have been contributing factors to this finding. lower quality of life scores were apparent in women who experienced treatment side-effects such as nausea and vomiting, hair loss, and swelling. contrary to the findings of other researchers (badger, braden, & mishel, 1999; pascreta, 1997) none of the women in this study met criteria for clinical depression. however, women who felt that they did not receive adequate information prior to surgery had more symptoms of depression. this finding may be attributed to feelings of helplessness, not knowing what to expect, an inability to ask questions, or feeling a lack of control over the outcome. assessment of depression symptoms by the clinician is key to treatment and successful outcomes. the differences in depression scores related to preoperative preparation and teaching support the findings of the phase i study (lyons, 2004) and suggest that a more comprehensive approach to education before surgery would have a positive impact in the reduction of depressive symptoms that these women experience. this one-time cross sectional telephone survey is limited by several important methodological limitations that restrict confidence in the interpretation of results. the cross-sectional nature of the data prohibits any claims of causality and the small sample size limits generalizability of results. data were collected through self-report responses to interviews which may lead to methodological shortfalls because validation of subject responses was not performed. however, this study clearly highlights the fact that nurses have unique opportunities to to answer pertinent questions for patients and to intervene as deemed appropriate for breast and cervical cancer patients. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 17 results twenty-eight low-income, rural and urban women participated in this study. results indicated that primary issues for the women in this sample included: finding out, concerns about how they would cope, knowledge deficits and participation in treatment decisions, treatment issues, social support, health promotion, and the role of god or spirituality in their lives. finding out the women in this study learned of their breast or cervical cancer diagnosis in a variety of ways. six women were diagnosed with breast cancer following clinical breast exams. eight women found lumps during breast self-exam and ten women had suspicious lesions on routine mammograms. two were diagnosed with cervical cancer following pap smears. all of the women experienced fear and anxiety while waiting for diagnostic confirmation. many women described being in a state of shock. some representative comments were the following: one night i was lying in bed and something told me "you’d better check your breasts." i found a big knot in there. i cried at first because i was scared. then i called my sister and she told me to "just go to the doctor and find out. i found it through breast exam. at first i was scared but everyone told me ‘don’t worry.’ once i found out it was positive all i could do was cry and i thought, 'i have to fight for my life and now i have to fight for my mind.’ guess i’m still in a state of shock. those who had to wait for mammogram results expressed a great deal of apprehension. one woman stated: “they made me wait out in this little room and then they called me back to do another mammogram. then they wanted to do an ultrasound but nobody would tell me anything.” three of the women seemed to suppress feelings and developed a business-like approach to dealing with their illnesses. one stated: i didn’t cry—still haven’t. i just felt like well now you have it. god will take care of you, no matter what happens. now we just have to do what we need to do to take care of it. several of the women were informed that they had cancer through phone calls from their physicians. one woman stated: he told me on the telephone. on the telephone! that to me was a big nono. the majority of women were informed, in person, by their physicians. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 18 coping strategies many of the women expressed little confidence in their ability to cope immediately after diagnosis. however, after the diagnostic phase most women used normalization and sought to keep their routines from being disrupted. the majority of women in this study used family, friends, a fighting spirit, and a deep and abiding faith in god to cope with the initial diagnosis and treatment. “i learned to rely on others for help. my sister took me to the doctor. my church family brought us food and my kids helped with the house work.” one woman, diagnosed with cervical cancer, stated that she had “absolutely no support” even though she was temporarily living with her brother. knowledge deficit and participation in treatment decisions most of the women were undergoing treatment, relative to type of tumor and stage of disease, at the time of the interview. women with cervical cancer underwent hysterectomies and those with breast cancer had biopsies, lumpectomies, mastectomies, radiation and/or chemotherapy as deemed necessary by their physicians. both caucasian and africanamerican women listened intently to what their physicians recommended. however, african-american women were less likely to ask questions, ask for additional information, use other resources, e.g. internet, or challenge decisions made by their physicians regarding treatment. they were also more likely to have had a mastectomy. one african-american woman stated: “i didn’t ask questions. i just did what he told me.” in contrast, one caucasian woman with breast cancer refused treatment stating: i went to an herbal healer. she took me off all sugar and caffeine. i can’t have any pork and i’m supposed to eat 6 oz. red meat each day—lots of fruit, eggs, and butter. i’ve lost five pounds. in three months, if i’m not cured or if i’m not dead i will find another doctor and will probably have the surgery. treatment issues the majority of women cited being emotionally prepared prior to surgery. “i was as prepared as you could be for a thing like that.” the most difficult aspects of treatment were disfigurement after mastectomy, issues related to sexuality and feelings of unattractiveness, accompanying feelings of loss, and the appearance of side-effects related to chemotherapy. those who had undergone radiation alone complained of fatigue but were generally able to go about their daily routines. they managed their fatigue by enlisting the help of others and by taking frequent rest periods. for those who received chemotherapy, side-effects that were most disturbing were nausea and vomiting, feeling ill, fatigue, pain, and hair loss. the following statements are illustrative of the above concepts: every night when i take a bath i’m not prepared for what i’m gonna see. i think about being disfigured and i start to cry. a part of me is gone online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 19 you ask about sex. what sex? i don’t feel like having it and i don’t want him to see me this way. but i told him, “if you can’t handle it then you need to go. cause i don’t need nobody like that. i have swelling in the upper part of my chest and my arm. and i have trouble doing all kinds of things. things i used to do. it gives me fits. i try not to let it bother me. i can’t even lift a skillet. putting on my clothes—i have to have help. i can’t tie my shoes. i knew that my hair would probably fall out but i didn’t expect it to fall out in big clumps when i washed it. i cried and cried even though they said it would grow back in. i never go out without my turban. health promotion participants approached health promotion in several different ways. some cited engaging in limited exercise, “eating better,” and, being more appreciative of the “little things.” only a few cited taking vitamins or using herbal remedies. many stated that they had made no lifestyle changes. barriers to treatment five of the women in this study cited financial difficulties in terms of paying for treatment. those women who were covered under private insurance or medicare had substantial out of pocket costs. one woman stated: i had to pay $5 every time i went to the office. i’m up to $30 and i can’t even pay that. those women on medicaid had no out-of-pocket costs. i got sent to the social worker and she got me on medicaid. women living in rural areas often traveled great distances for treatment. however, they did not complain. sometimes i’d be so sick. but that’s just the way it is. spirituality spirituality was a dimension that permeated each woman’s experience. frequent references to god were evident in statements made by participants. “oh, god, please don’t let it be positive” or “please god help me through this.” one woman’s comments summarized sample sentiment: online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 20 god has always bailed me out. i believe he’s there for me and that he loves me. i hope it’s his will that i will live. i ask for help everyday and every night before i go to bed. he’s the first place i’ve always turned. discussion when compared to results of the author’s previous research with women of means (lyons et al. 2002), findings from this study indicate similarities in the traumatic nature of the experiences of breast and cervical cancer survivors. fear and anxiety were experienced during diagnosis and treatment regardless of race, urban/rural residence, or differences in socioeconomic status. these women denied fear of dying. they did fear future reoccurrence of their cancers and were concerned about the possibility that their mothers, daughters, and/or siblings would develop cancer. again, this finding did not differ by race, rural/urban residence, or diagnosis. all of the women interviewed were determined to be survivors. all had days when they were depressed but they were able to implement strategies that kept them focused on the task of getting well again. congruent with the findings of cowley et al. (2000) and henderson et al. (2003) the women coped with diagnosis and treatment through the use of normalizing strategies, the use of social support, positive reappraisal, seeking and using social support, and relying on spiritual beliefs as a source of strength. the majority of women said that they had received adequate information prior to surgery and fully understood what type of surgery was to be performed. however, congruent with the findings of lackey (2001), rural african-american women were less likely to seek information or ask questions and more likely to accept their physician’s decisions. they were also less likely to have access to the internet for information regarding their illnesses and could have benefited from additional pre-operative education and counseling. the need to mobilize resources after diagnosis was a universal reaction without regard for race or urban/rural residence but accessing resources was more cumbersome for rural women. rural residents traveled greater distances for appointments and felt more isolated. they were less likely to know what services were available to them and were less confident about taking the necessary steps to access those that they did know about. community education or support groups sponsored by local health departments or churches could be useful in meeting the need not only for support but also for education concerning available services in rural areas. a surprising finding was that the majority of women in this study were receiving medicaid services after referral by their state’s breast and cervical cancer early detection programs. participation in this program enabled these women to receive health care that they would otherwise be unable to afford. this fact indicates that the system is working and is a major step in the reduction of health disparity. acknowledgments this study was funded by the national cancer institute and the deep south network for cancer control grant # 531863psychosocial impact of cancer in lowincome rural/urban women: phase ii online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 21 references american cancer society. 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[medline] online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11283922 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9261295 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11421149 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10197951 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11906445 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10705358 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9219190 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10868390 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10789021 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10957755 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8560308 microsoft word wiese_469-3152-2-ce.docx online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 180 an appalachian perspective of alzheimer’s disease: a rural health nurse opportunity lisa k. wiese, phd, rn, phna-bc, cne1 christine l. williams, dnsc, pmhcns-bc2 1 assistant professor, christine e. lynn college of nursing, florida atlantic university, lwiese@health.fau.edu 2 professor, christine e. lynn college of nursing, florida atlantic university, cwill154@health.fau.edu abstract predictions of the devastating impact of alzheimer’s disease (ad) are heightened in disadvantaged rural populations, yet studies investigating ad in this population are limited. other researchers have shown that when rural appalachian people are aware of their risk for a chronic illness, they are more willing to adopt healthy behaviors (della, 2011; schoenberg et al. 2011), suggesting that educational programs to increase knowledge and perception of risk are needed. the purpose of this article was to report findings from exploring knowledge of alzheimer’s disease in a southern rural west virginia community of residents (n = 193) and a sample of caregivers (n = 20) using cognitive interview techniques of “think-aloud” and “laddering”. the cultural fit and relevance of the “knowledge of alzheimer’s disease scale or kad (jang, kim, hansen, & chiriboga, 2010) was also examined. findings from the kad included that an updated ad measure appropriate for use in rural settings is needed. findings from the cognitive interview included that instead of fatalistic attitudes toward alzheimer’s disease, residents often viewed ad as something potentially preventable through healthier living, use of herbs as children, and eventual discovery of more online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 181 effective treatment regimens. the themes that emerged were “preventing ad” and “personal knowing of ad”. considering cultural perceptions and determining knowledge gaps in the communities by rural providers is an important component of changing stigma regarding routine cognitive screening for rural older adults at increased risk for alzheimer’s disease. keywords: appalachia think-aloud technique, cognitive interview, alzheimer's disease knowledge, rural older adults an appalachian perspective of alzheimer’s disease: a rural health nurse opportunity every 66 seconds, someone in the united states develops alzheimer’s disease (ad) (alzheimer's association [aa], 2017). since the year 2000, deaths from ad have increased by 89%, with more persons being diagnosed with ad than breast and prostate cancer combined. the estimated cost of care for ad is $259 billion for the year 2017 and projected to be $1.1 trillion by 2050 (aa, 2017). the threat of ad is heightened in rural communities (mattos, et al., 2017) due to multiple health determinants such as decreased health care access for a high percentage of older adult residents who are at risk for the age-related disease (russ, batty, hearnshaw, fenton, & starr, 2012). rural communities also have less access to social services and health education than urban residents (rural health information hub, 2017). they have less health insurance and are more economically stressed (borak, salipante-zaidel, slade, & fields, 2012). rural residents experience a greater incidence of the chronic diseases of diabetes and hypertension (crosby, wendel, vanderpool, & casey 2012) which is now linked to higher ad risk (li, song, & leng, 2015). this increased ad risk could have an impact on residents in appalachia, where over 2.6 million residents are classified as rural (pollard & jacobsen, 2011). furthermore, appalachian residents are known to care for their “own” (behringer & friedell, 2007), which heightens the online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 182 burden of dementia-related caregiving, and increases their own risk for chronic illness. thirtyfive percent of ad caregivers (providing 18.2 billion hours in unpaid care in 2016) reported that their health worsened because of care responsibilities (aa, 2017). although research regarding perceptions and practices related to other chronic illnesses such as cancer (bardach, schoenberg, fleming, & hatcher, 2012; hatcher, studts, dignan, turner, & schoenberg 2011; schoenberg, howell, & fields, 2012) cardiovascular disease (fahs, et al., 2013) and diabetes (della, 2011; huang, et al., 2014; sherzai, sherzai, & lui, 2016) in the rural area of appalachia is available, there have been no equivalent studies regarding ad. schoenberg and colleagues (2009; 2012) demonstrated that appalachian residents were more willing to pursue cancer screening after being informed of their disease risk, and researchers demonstrated similar findings related to dementia in underserved groups (williams, tappen, rosselli, keane, & newlin, 2010). the question of whether rural populations are knowledgeable about ad and would be receptive to screening has not been answered. to develop relevant interventions to decrease risk of cognitive impairment in rural residents, research is needed to determine current knowledge about ad and attitudes toward screening. the purpose of this study was to explore a rural appalachian cohort’s perspective about ad using a knowledge survey and the “think aloud” technique of cognitive interviewing (ci). background despite the recent government mandate to include cognitive assessment in the annual medicare wellness visit (protection, patient, and affordable care act [ppaca], 2010), many providers are hesitant to screen (borson, et al., 2013). providers are often too busy or unwilling to engage in cognitive screening for fear of causing patient distress and the potential need for follow-through (szymczynska, innes, mason, & stark, 2011). however, the rural older adult online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 183 memory (roam) study (boise et al., 2010), a practice-based intervention to improve dementia screening and diagnosis, demonstrated the success of using trained medical assistants to conduct cognitive screening, followed by favorable outcomes from training clinicians to diagnose and manage dementia in persons referred after screening. a workgroup convened by the alzheimer’s association established an algorithm of cognitive screening and referral. this algorithm aligns with the center for medicaid/medicare services guidelines that nurses can follow when conducting cognitive assessments (cordell et al., 2013). rural health nurses can be a powerful presence in educating other providers and patients regarding the benefits of earlier detection, and in meeting the national alzheimer’s project act objective three of improving early diagnosis and coordination of care of ad (department of health and human resources, 2012). appalachian view of health appalachian residents’ cultural perceptions about health often vary from traditional health views (goins, spencer, & williams, 2011; griffith, pyle, lovett, & miller, 2011). the ability to work has been equated with being healthy among rural and appalachian residents (gessert, et al., 2015). despite ranking in the bottom five nationally in positive health indicators (american health rankings, 2017), griffith et al. (2011) found the majority of over 1,500 appalachian residents surveyed at a regional health fair considered their health as good to excellent (2011). mudd-martin and colleagues (2014) conducted seven focus groups among 88 healthcare employees and residents in central kentucky, garnering participant statements such as “if you don’t eat, you’re not healthy”, and “we just stressed with our children the need to take care of themselves, have regular tests, and all of our children are in pretty good shape…” (p. 88). goins et al. (2011) explored rural appalachian older adults’ definition of health in 13 focus groups across six counties and found that perceptions of well-being included (1) having a clear online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 184 sense of purpose for living and (2) being free from worry. gratitude for god’s presence and grace were integral components of their perceptions of health. goin et al. (2011) emphasized the need for providers to recognize cultural context in the measurement of health outcomes in rural older adults (p. 13). theoretical framework discovering “what matters most” is a principal outcome of engaging the “nursing as caring” in the boykin & schoenhofer (2001) philosophical framework, which offers a practical application for transforming practice (bulfin, 2005). the constructs of the theory include coming to know the care recipient (in this case, the community) through an authentic presence, honest intention to care, and answering the call to nurse using a holistic approach. this theory is a good fit for this work with the appalachian culture that thrives on caring for others, and where health is defined as being productive and caring for family. review of literature studies investigating ad perceptions, knowledge, and incidence in appalachia or in rural populations are scarce. one sentinel study that was found to specifically target appalachia was conducted over ten years in the monongahela river valley. this investigation compared the incidence of ad by age, sex and education between a community in ballabgarh, india with a rural community at the foothills of the appalachians in southwestern pennsylvania (dodge, wang, chang, & ganguli, 2011; dodge, zhu, lee, chang, & ganguli, 2013; ganguli, 2000). the presence of the apoe4 allele, a known ad risk factor, was significantly higher (11%) in the monongahela group than in the indian group (.073%). a random sample of 1,422 agestratified (65 to 74 years, 75-79 years, and 80+) subjects were drawn from the voter registration lists for the 23 communities served by a local health center in the rural southwestern online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 185 pennsylvania region. enrollment criteria included being at least 65 years old, community dwelling at the time of recruitment, fluent in english, and with a minimum of sixth grade education. education categories were defined as less than high school graduate or high school graduate and beyond. in the ten-year longitudinal study, researchers found that persons with less than a high school education had a higher rate of cognitive impairment and had higher rates of possible/incipient dementia (cdr = .5). they also found that men, not women, had higher ad incidence. the researchers posed that perhaps this was due to the emigration of the more educated and more ambitious men from the area to take advantage of government support of education post world war ii. another theory posited was that most of men in the area worked in the coal mines and coke ovens created a chronically hypoxic state from anthracnosis or black lung. they hypothesized that lower education and higher occupational exposure were risk factors that varied by gender and needed to be further investigated. the researchers admitted that the results may have been influenced by lack of literacy and/or the lack of a culturally appropriate research tools. however, knowledge of the disease itself was not addressed in this research and researchers noted a need for research to fill this gap. an early qualitative study (morgan, semchuk, stewart, & d’arcy, 2002) targeted knowledge and perceptions of dementia among rural residents after recognizing the lack of foundational research targeting rural dementia care. a key finding was the magnified inaccuracy in perceptions among residents in closely knit rural communities where dementing behaviors were more likely to be observed and discussed. residents were often described as “covering up” for inappropriate behavior to outsiders, thinking they were protecting their relatives, which led to loss of support from formal and informal resources. participants identified that a major barrier to willingness of rural residents to accept outside support was the lack of knowledge online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 186 about symptoms, prognosis, and benefits of earlier detection. researchers recently examined the effect of social isolation on cognitive function among 267 appalachian older adults ranging in ages 70 94 (m = 78.5) (dinapoli, wu, & scogin, 2014). they found a significant inverse relationship between cognitive function and social isolation, particularly with perceived isolation as compared to social disconnectedness. perceptions about ad knowledge or cognitive screening were not included. friedman et al. (2015) conducted a meta-analysis of 1,115 studies related to the public’s perceptions of cognitive impairment risk or protective factors. only 30 studies met the inclusion criteria of empirical research of community-dwelling adults from 2007 to 2013. only 16 studies addressed alzheimer’s disease, only one specifically targeted rural residents, and none were conducted in appalachia. in another meta-analysis, martin et al. (2015) reviewed 29 international articles investigating perceptions and attitudes toward dementia screening. these researchers concluded that routine cognitive screening may not be accepted by the general population. however, only one article (boise et al., 2010) located by martin et al. (2015) specifically included rural residents, where ad incidence is known to be higher (mattos, et al., 2017). a new investigation of over 2,000 adults recruited from the health and retirement study (ostergren, heeringa, de leon, connell, & roberts, 2017) found that respondents with a history of ad in their family perceived a significantly greatly ad threat (p. < .001) than those with no personal experience. although neither appalachian nor rural residents were measured or specified, the participants were derived from a nationally representative sample. mattos et al. (2017) concluded that more studies are needed of representative rural samples that include appalachian residents. there is a gap in research regarding appalachian residents’ online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 187 ad knowledge, perceptions, and ad incidence (mattos, et al., 2017; wiese, williams, tappen, newman, & rosselli, 2017). method the purpose of this descriptive study was to gain greater understanding of rural residents’ perspectives about ad. this was achieved using a type of cognitive interview technique, the think-aloud, (haeger, lambert, kinzie, & gieser, 2012; lundgrén-laine & salanterä, 2010) when administering the knowledge of alzheimer’s disease scale (jang, kim, hansen, & chiriboga, 2010). the first twenty participants (10%) of a larger sample of 200 were asked to describe why they chose their answers. the think-aloud technique the “think-aloud” technique type of “cognitive interview” (ci) has become recognized as a useful research method for eliciting more information and understanding about the reasoning behind participant survey responses (haeger, lambert, kinzie, & gieser, 2012). ci has also been used successfully with older participants (memon, meissner, & frasier, 2010). other types of ci include verbal concurrent and retrospective probing (haeger, lambert, kinzie, & gieser, 2012) and laddering techniques (price, 2002). investigators have highlighted advantages of using the think-aloud technique as compared to other cognitive interviewing methods. for example, the use of open-ended questions can help to prevent interviewer bias, as compared to concurrent or retrospective probing or laddering, where the interviewer poses further questions based on interviewee responses. asking the participant to describe why they chose a particular answer can help to create a connection between the participant’s response and their thinking process. this in turn allows for the discovery of perceptions that are at the forefront of the working memory (lundgrén-laine & salanterä (2010). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 188 the minimum training required to engage the think-aloud technique is another benefit, but the interviewer must practice effective listening. in this study, the pi was the only interviewer, and made every attempt to bracket any pre-conceived ideas, such as rural residents being hesitant to share their perceptions due to privacy concerns, or potentially having lower knowledge levels due to decreased health care access and information. two questions from the ten-item knowledge of alzheimer’s disease (kad) scale were selected for the interview questions as being the most likely to be more representative of the kad , while not tiring the participants: “alzheimer’s disease is a type of insanity” and “alzheimer’s disease is generally fatal.” the research assistant also took notes during the interviews. the two interview transcripts were compared. only minor discrepancies were noted, which were resolved upon clarification. this study was approved by the investigators’ institutional review board (#303768-1). setting the location of this study was west virginia (wv), the only state to lie completely in appalachia, with 38% of its residents living in rural areas (rural health information hub, 2017). wv has the second highest percentage of older adults in the country after florida (u.s. census bureau, 2010), and when combined with the geographic isolation common in rural appalachia, adds to the ad threat (halverson & bischak, 2008). nicholas county, wv, in the southern portion of appalachia (just north of fayette county and the famed new river gorge) was the primary research site. this county is designated as rural by the u.s. department of health & human services office of rural health policy (orhp/hhs, 2017). in 2016, persons over age 65 comprised 21% of the population, which increased by 4% since 2010 (united states census bureau, 2012). the majority (97.9%) of the online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 189 25,311 residents were non-hispanic white, 83% were high school graduates in the past five years, and 18.5% of the population was living below the poverty level from 2011-2015, with an average monetary income of $39,171. sample the inclusion criteria for this convenience sample included southern wv residents, age 65 or older, and the ability to answer study questions. informal caregivers were included, but formal providers or caregivers were not. a table with signage advertising the study was arranged outside the local health clinic or nearby low-cost merchandize store. when potential participants approached the investigators’ table, they were invited to enroll in the study. the first 20 of 200 persons who met the inclusion criteria and completed the survey (ten percent of the whole sample) were asked to participate in a cognitive interview. seven persons were eliminated from the overall study during analysis due to incomplete surveys; n = 193 for the large sample, and n = 20 for the think-aloud exercise. instruments sociodemographic survey. the participants’ birthplace, gender, caregiver status, previous occupation, religion, ethnicity, marital status, age, distance in miles to a health care provider, and formal years of education (grades 1-12), were the sociodemographic information obtained. knowledge of ad measure (kad). the most widely used dementia knowledge scale has been the alzheimer’s disease knowledge scale (adks) developed by carpenter et al. (2009; 2011). however, the adks was tested in populations with higher levels of educational and socioeconomic backgrounds, health care professionals, or ad caregivers than found in rural populations. the researchers acknowledged the need to eliminate items of high difficulty, maintain an 8th grade reading level, and offer a culturally relevant, language-appropriate tool. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 190 after determining that the adks measure was more appropriate for professional or student populations, jang, kim, hansen, & chiriboga (2010) designed a ten-item, true/false knowledge test to better fit the characteristics of korean seniors. the knowledge of alzheimer’s disease (kad) scale is comprised of a combination previously used ad knowledge scale questions, including the earlier dieckmann, zarit, zarit, & gatz (1988), connell, roberts, & mclaughlin (2005), and ayalon & areán (2004) scales. the kad was translated and back-translated for confirmation of accuracy in the korean language, and tested with 675 korean americans. the kad, first written in the korean language and designed for use among korean americans, was the only recently developed measure designed to investigate ad knowledge among non-health care professional older adults. of note is that the kad is written at a post-graduate high school level according to the flesch-kincaid readability statistic of 40.2, which is college-level (1948). the kad is also limited in terms of scope, as it addresses only a few ad facts and common misunderstandings. however, the straightforward item content, brevity, and relevance of several items supported choosing this tool for use in an appalachian community. permission to use the kad was obtained from the authors. results sociodemographic data and results of the kad for both the overall sample (n = 193) and smaller cognitive interview sub-sample (n = 20) are displayed in tables 1 and 2. most subjects were european american (94%), female (56%), married (47%), and claimed a protestant affiliation (85%), with little difference between the larger and smaller sub-sample. approximate years of education (11), miles from a provider (6), and age (70) were also similar in both groups, with ages ranging from 65 to 92. the kad was administered to all participants in the overall study sample (n = 193). the online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 191 mean score on the 10-item concurrent test, the kad, was 7.9 (sd = .72) out of 10 possible points. item answers to the kad are available in table 3. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 192 table 1 sociodemographics of categorical variables for the kad and think-aloud participants variable overall sample n = 193 n (%) think aloud sub-sample n = 20 n (%) gender male 85 (44) 3 (30) female 108 (56) 17 (70) caregiver yes 39 (20) 20 (100) no 154 (80) 0 (0) ethnicity european american 181 (94) 19 (95) african american 8 (4) 1(5) afro caribbean 0 (0) 0 (0) asian american 0 (0) 0 (0) other 4 (2) 0 (0) religion protestant 164 (85) 17 (85) catholic 6 (3) 1 (5) muslim 0 (0) other 23 (12) 2 (10) marital status single 29 (15) 2 (10) married 90 (47) 4 (20) widowed 55 (29) 4 (20) separated 1(0) 3 (30) divorced 18 (9) 7 (35) table 2 sociodemographic of continuous variables for rural sample and sub-sample overall sample a n = 193 think-aloud sub-sample b n = 20 variable m sd m sd age 69.4 10.5 76.86 7.89 education 11.4 3 10.9 3.13 miles from provider 9 11 4.85 4.73 online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 193 table 3 kad item totals of correct responses for rural sample knowledge of alzheimer’s disease (kad) items + rural sample n (%) alzheimer’s disease could be contagious 16 (74.5) all humans if they live long enough, will probably develop alzheimer’s disease 106 (54.1) alzheimer’s disease is a form of insanity 159 (81.1) alzheimer’s disease is a normal process of aging 142 (72.4) alzheimer’s disease can be cured with medication 153 (78.1) alzheimer’s disease only occurs in the elderly population 115 (58.7) the major symptom of alzheimer’s disease is memory loss* 130 (66.3) symptoms of depression are similar to those of alzheimer’s disease* 39 (19.9) alzheimer’s disease is generally fatal* 111 (56.6) alzheimer’s disease can be diagnosed with a blood test 126 (64.3) notes: n and % = total number correct, * = true. reprinted with permission jang, kim, hansen, and chiriboga (2010), journal of the american geriatrics society, 55, p. 11. responses to the cognitive interview the participant responses collected during the think-aloud exercise were analyzed (table 4) using strauss and corbin’s (1998) method of open coding to organize ideas from disordered and jumbled data (morse, 2011). two nurse researchers read and reread the responses independently, organized statements, identified key words, defined and assigned categories, wrote down possible themes, and met together to compare and reconcile differences in findings (tappen, 2016). think-aloud technique of interview. the following are examples of subject responses to think-aloud questions. question: “can you tell me why you answered this question the way you did: alzheimer’s disease is a form of insanity or mental illness.” “i don’t know if it is or not. it kinda makes sense that it would be, cause these people to lose themselves.” “no…people with alzheimer’s aren’t crazy; they just lose their memory.” “yea, i online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 194 am sure it is; some people just get violent with it.” “no. you may think that they are going crazy when they try to hit you and stuff, but it is a disease, a sickness.” “i really don’t know if they think it is or not…might be…that might be too hard a word to put on someone; being mentally ill.” question: “can you tell me why you answered this question the way you did: “alzheimer’s disease is generally fatal; nothing can be done to prevent it”. “i think if you got it in your genes, there is nothin’ you can do”. “there is no cure because it is a brain disease.” themes two themes were induced from the think-aloud participant statements after both independently and collaboratively discerning meanings and categorizing statements. these themes were “preventing alzheimer’s” (table 5a) and “personal knowing of alzheimer’s” (table 5 b) (alzheimer’s was occasionally referred to as “altimers”, “old-timers”, and “senile dementia”). the theme of preventing alzheimer’s was induced from statements such as “yep; the doctor tells me if i quit smokin’ i won’t have it; i’d rather smoke and take a pill instead” and “maybe it [eating right] helped me; i’m still goin’ strong.” it may be a local practice only, but there were multiple references to taking wild or yellow root to stave off illness: “wildroot was supposed to be a cure for everything and it’s common here”; “my mother always made us drink wildroot tea, and i don’t have a touch of it”, “my mom is funny about doctors”, “i drink it [wildroot] in tea, it doesn’t taste too good. but it’s like my daily medicine”; i’m too old to go out and get it [wildroot], but maybe it helped me; i’m still goin’ strong-ha!” “no, there ain’t no treatment; nothing you can do…my mother in law took the ginsa thing. she got it anyhow. but lots of people roun here took yellowroot growin up…it’s supposed to be good for a lot of stuff”; “i dunno; we always had to chew on wildroot as kids, and i still do a online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 195 good bit. i think i’m okay…” frequent statements based on knowing the person with dementia led to the theme of personal knowing of alzheimer’s, such as “yes, because it attacks the brain my mom had no idea who we were”, and “i don’t think there is any treatment for it; my daddy had it, and it was an awful way to go. he didn’t recognize me, and hit me, and shouted, and tried to get out. i took care of ‘im for four years. he just dies (tear, sob) …i don’t even know what to do with myself, now that he’s gone.” table 4 coding and categorizing think-aloud data to discover themes key words number of references categories and definitions theme mother/mamma/wife’s mother (9) gramma (2) sister/sister-in-law (3) mother in-law (2) husband (1) aunt (1) cousin (1) granddaughter (1) dad (2) ----------- in the brain (5) attack the brain (1) brain disease (1) brain gets those things in it (1) in the head/pointing to head (2) sick in the head (1) a sickness (1) memory (loss) (3) crazy (3) violent (1) 41 knowing someone with alzheimer’s disease defined as having interactions with a person diagnosed with alzheimer’s disease knowing the disease of alzheimer’s defined being familiar with various etiologies and symptoms of the disease personal knowing of alzhiemers online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 196 treat/treatment (5) nuthin’ you can do for it (2) stops it (3) helps (2) drugs (4) medicines (3) yellowroot (4) wildroot (5) peachtree root (1) ginkgo/ginka (2) gardening (2) farming (2) 35 delaying illness defined as the ability to delay onset or disease progression preventing alzheimer’s provider (5) they (referring to healthcare institution or provider (5) 10 seeking help defined as visiting a nurse or physician for screening table 5a selected participant statements reflecting the theme of personal knowing statements of personal knowing i took care of my momma who had it; we both did (pointed to another sister) my cousin was telling me, because her husband has it my mom couldn’t talk to us you get it from your folks my dad made up words i took care of my aunt; she spent six years dyin from it four years my wife and i took care of her yea sure; your brain gets those things in it; everything gets clogged up everyone knows you can’t remember words”, “it’s a physical thing in the brain”, and “yep; that [brain] is where all the problem is i saw my wife’s sister suffer from it; and you become someone else. i would hate that to happen. table 5b selected participant statements reflecting the theme of preventing alzheimer’s disease statements of preventing the earlier you start treatment, the better the medicine for alzheimer’s works, they think yea, there is some new treatment they got up there (the state university) they are coming out with new ways to treat alzheimer’s disease i heard tell of a new drug that will stop it from getting’ worse hope they figure it out soon, it’s awful” “hope they hurry up with it [new drugs] i think it’s all that crap we are eatin’ these days; all the junk; that is what is doin’ us in. if we stopped and went back to farmin’, that would decrease your chances well, if there is a way to prevent it, sign me up! they just need to put it [ways to prevent it]on the radio and on tv; people here listen to one or the other if you take care of yourself you are going to be okay, and if you don’t, you won’t you gotta exercise, not smoke, eat right-you know, avoid the sugar, all that stuff i dunno, exercise might help, and if you call workin in the coal mines all your life exercise, i did. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 197 discussion this study’s purpose was to investigate ad knowledge in a cohort of rural older appalachians and examine the cultural fit and relevance of the knowledge of alzheimer’s disease scale (jang, chiriboga, & kim, 2010). results showed that appalachian residents scored about 80% average on the kad. the think-aloud revealed rich information regarding residents’ personal knowing about the illness, and expectations that there might be ways to delay or prevent ad. both findings were in contrast to the a priori expectations of the pi. this is an important lesson in realizing that prior to conducting educational sessions in varied community settings to increase awareness of risk, assessment of knowledge gaps is essential. throughout most of the interviews, there was a tone of positivity, even hope, for finding treatment for alzheimer’s disease, willingness to be informed, and have access to treatment. there were a few indications that the residents might be more informed than the providers. regardless, multiple statements made by the residents regarding the benefits of healthy eating, exercise, and even taking wildroot demonstrated that most did not view themselves as powerless over alzheimer’s disease. one participant’s statement to “just put it [information about ways to prevent it] on the radio or tv and people here will listen to one or the other” bears further consideration. limitations findings were limited by the singular geographic location and sample size. results may differ in other appalachian communities or other rural populations. coincidentally, all the participants in the think-aloud inquiry had previous history as an informal caregiver. wv, the site for this research, has a high percentage of older adults, therefore finding participants who were not exposed to the age-related illness of ad in family and friends was difficult. there were limitations online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 198 in using the think aloud technique. participants may stray from the topic at hand or state what they imagine the investigator will want to hear (haeger et al., 2012). adhering to the think-aloud technique minimizes the researcher’s tendency to steer the subject’s responses, but it is possible to miss valuable information. it might be of greater advantage to add a laddering method of inquiry that allows for deeper exploration while being mindful to avoid investigator bias (price, 2002). implications for education researchers (schoenberg, howell, & fields, 2012, hatcher, et al., 2011) conducting community based participatory research in appalachian kentucky have successfully demonstrated that education about prostrate and breast cancer risk does increase screening rates. work has begun regarding increasing knowledge about ad in the aging appalachian population. the state of wv adopted a “make a plan” to combat ad in 2011. the wv council on aging now requires employed caregivers going out in the community to complete four hours of ad training. perception of risk, rather than knowledge alone, is a proven motivator of health-seeking behavior (boustani, perkins, monahan, et al., 2008). more work needs to be done in exploring perceptions of rural residents. there also needs to be a greater emphasis on the importance of conducting cognitive screening in persons over 65 in schools of nursing and medicine. this may help to eliminate incorrect assumptions by providers that persons do not want to know (wiese, williams, & tappen, 2014). persons interviewed in the think-aloud inquiry appeared hopeful about treatment, even after having personal knowledge of the illness. education is needed to inform providers and families of the benefits of earlier detection, such as initiating medications that are more effective if started early during the disease, connection with support services, and long-term care planning (dubois, bruno, padovani et al., 2016). many patients who are aware they are losing their memory are fearful of receiving a formal diagnosis, but if they are informed of these benefits, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 199 they may be more motivated to seek outside help. the results of both the kad and think-aloud inquiry revealed that the participants were more familiar with the disease manifestations than with risks or treatment, due to personal knowledge of caring for persons with ad. these findings highlight the need for nurses in rural primary care to (a) become familiar with the new cognitive screening algorithms (wiese & williams, 2015), and (b) to increase their own efforts in educating the communities they serve about the benefits of earlier cognitive screening. implications for practice despite the recent government mandate to include cognitive assessment in the annual medicare wellness visit (ppaca, 2010), there is little to no routine cognitive screening at the wv free clinics (personal communication, june 27, 2017). providers are often too busy or unwilling for fear of causing patient distress to engage in cognitive screening and potential need for followthrough (szymczynska, innes, mason, & stark, c., 2011). however, the rural older adult memory (roam) study (boise et al., 2010), a practice-based intervention to improve dementia screening and diagnosis, demonstrated the success of using trained medical assistants to conduct cognitive screening, followed by favorable outcomes from training clinicians to diagnose and manage dementia in persons referred after screening. rural health nurses are well-positioned to make a difference by conducting brief five-minute cognitive screenings in persons at risk for ad. an update for nurses to implement screening following the alzheimer’s association and centers for medicaid/medicare services guidelines (cordell, borson, boustani, chodosh, reuben, et al., 2013) is available (wiese & williams, 2015). it is imperative to refer persons who may be at risk for ad, depression, or another dementia to a provider that is further trained in geriatric and dementia-specific assessments. gerontological online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 200 and family nurse practitioners can be trained by expert geriatricians and gerontological nurse practitioners to conduct these assessments and provide one answer to the lack of trained providers in the region. implications for research many items on the kad are outdated or do not address current findings. a more current ad survey with an appropriate reading level that addresses the alzheimer’s association ten warning signs, as well as ad risk, detection, and delaying onset, would be beneficial. there is also a gap in research addressing rural residents’ perceptions regarding ad. given the high rates of ad among rural populations, an appropriate instrument to measure ad both knowledge and risk perception in this population is needed before designing future educational and screening interventions. conclusion understanding illness through a cultural lens is important for effective community management of chronic disease (smith & tessaro, 2005). discovering “what matters most” to communities within their own unique culture will help local nurses and providers to identify effective ways to partner in improving health for their residents. this is especially important with the majority of the oldest-old now residing in rural communities where the threat of ad is the greatest (aa, 2017). contrary to previously held beliefs that rural residents often view alzheimer’s as an inevitable illness, rural appalachian older residents in this study expressed belief in the ability to delay or prevent disease through healthy diet, exercise, and herbal use. participants also expressed hope for discovery of effective treatment. these findings suggest that rural residents may be willing to participate in routine cognitive screening that is mandated as part of the medicare/medicaid annual wellness visit by the patient protection and affordable care online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 201 act of 2011. rural health nurses can be a powerful presence in educating other providers and patients regarding the benefits of earlier detection, and in meeting the national alzheimer’s project act objective three of improving early diagnosis and coordination of care of alzheimer’s disease (department of health and human resources, 2012). predictions of the devastating impact of alzheimer’s disease (ad) are heightened in disadvantaged rural populations, yet studies investigating ad in this population are limited. other researchers have shown that when rural appalachian people are aware of their risk for a chronic illness, they are more willing to adopt healthy behaviors (della, 2011; schoenberg et al. 2011), suggesting that educational programs to increase knowledge and perception of risk are needed. the purpose of this article is to report findings from exploring knowledge of alzheimer’s disease in a southern rural west virginia community of residents (n = 193) and a sub-sample of caregivers (n = 20) using cognitive interview techniques of “think-aloud” and “laddering”. the cultural fit and relevance of the “knowledge of alzheimer’s disease scale or kad (jang, kim, hansen, & chiriboga, 2010) was also examined. findings from the kad included that an updated ad measure appropriate for use in rural settings is needed. findings from the cognitive interview included that instead of fatalistic attitudes toward alzheimer’s disease, residents often viewed ad as something potentially preventable through healthier living, use of herbs as children, and eventual discovery of more effective treatment regimens. the themes that emerged were “preventing ad” and “personal knowing of ad”. considering cultural perceptions and determining knowledge gaps in the communities by rural providers is an important component of changing stigma regarding routine cognitive screening for rural older adults at increased risk for alzheimer’s disease. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.469 202 supporting agency sigma theta tau international, iota xi chapter references alzheimer’s association (2017). alzheimer’s association facts and figures report. retrieved from: 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(2017). assessment of basic knowledge about alzheimer's disease among older rural residents: a pilot test of a new measure. journal of nursing measurement, 25(3), 519-548. https://doi.org/10.1891/10613749.25.3.519 please be consistent with the revised title (see page 2 title) 22 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 exploration of health care concerns of hispanic women in a rural southeastern north carolina community carol butler, msn, rn, fnp-c 1 yeounsoo kim-godwin, ph d, rn 2 jane a. fox, edd, aprn, bc, pnp 3 1 bladen healthcare, llc/bladen medical associates, elizabethtown, nc, usa 2 associate professor, school of nursing, university of north carolina at wilmington, nc, usa 3 associate professor, school of nursing, university of north carolina at wilmington, nc, usa key words: rural, access to health care, health care utilization, hispanic women abstract background and research objective: hispanics experience substantial barriers to health care and a disproportionate negative health status in rural southeastern north carolina. the purpose of this study was to explore concerns regarding health care utilization among eight hispanic women residing in this locality. sample and methods: the study utilized a qualitative research design drawing from semi-structured interviews. information obtained from the interviews was categorized using the constructs of andersen‟s behavioral model of health services use: predisposing, enabling, and need characteristics. results and conclusions: limited access to health care service and lack of continuity of care were apparent in this hispanic community and these were due to inability to afford services, difficulties with transportation and appointment schedules, dissatisfaction with services, language barriers, and inability to understand treatment plans. culturally sensitive outreach nursing would be effective to promote preventive health maintenance and continuity of care for those with chronic illness. introduction hispanics are the fastest growing minority group in the united states totaling 14.8% of the total u.s. population (us census bureau, 2008). health indicators of hispanics suggest that health outcomes continue to lag behind other population groups and remain below goals established by healthy people 2010. the 2003-2005 north carolina brfss telephone survey data indicated that a higher percentage of hispanics reported fair or poor health than both whites and african americans (nc dhhs, 2006). while hispanics showed relatively poor health status, the population is faced with barriers to health access. in north carolina, hispanics had substantially higher percentages than whites and african americans for all three measures of health access—no current health insurance, couldn‟t see a doctor due to cost, and no personal doctor (nc dhhs, 2006). while many studies were focused on the barriers of health access for the hispanic population, few studies have exclusively explored the experiences of the female population and their concerns regarding access to health care in the united states. the hispanic population of north carolina has more than quadrupled since 1990 (nc dhhs, 2006). as the hispanic population increases in north carolina, it is important to better understand the experiences of hispanic women as they seek health care, in order to improve health related outcomes for this population. the purpose of this qualitative study was to explore concerns among hispanic women experienced while they are seeking health care in rural southeastern north carolina. http://www.uncw.edu/son/ http://www.uncw.edu/son/ 23 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 literature review multiple internal and external factors, including language barriers, cultural differences, and low socioeconomic status, appear to be significantly related to health care access for hispanics in a rural area. fewer hispanics than whites had a usual source (location and place) of health care and fewer had a usual primary care provider (adams & horn, 2007). according to the 2004 national health disparities report, fewer hispanics than whites had established a relationship to a physician or had made an outpatient visit in the past year (agency for healthcare research and quality, 2004). while members of the hispanic community often seek emergency health care when needed, many do not seek routine health care for primary prevention or management of chronic illness. the literature repeatedly supports the negative impact of limited english proficiency and low literacy levels on health care access and outcomes among the hispanic population (jacobs, karavolos, rathouz, ferris, & powell, 2005; pippins, alegria, & hass, 2007). timmins (2002) reported that non-english speaking status was a marker of population at risk for decreased access to health care. through analysis of data obtained from 1997-2002 in oakland, los angeles, and newark for the study of women‟s health across the nation (swan), jacobs and colleagues found that percentages of women who received breast and cervical cancer screenings were 3040% higher for those who were proficient in the english language than those who were not, concluding that optimal health care is greatly impacted by the inability to speak or read english (jacobs et al., 2005). likewise, cohen and colleagues (2005) who analyzed data primarily from the admission and billing database of a large, regional, academic children‟s hospital, reported that hospitalized spanish-speaking pediatric patients whose families had language barriers were two times more likely to experience a serious medical event than those whose families spoke english (cohen, rivara, marcuse, mcphillips, & davis, 2005). low income, low educational attainment, and unemployment are all associated with a higher rate of health problems and poor health access (miller, guarnaccia, & fasina, 2002; rojas-guyler, king, & montieth, 2008). for example, surveys of hispanic women in georgia and florida revealed that the respondents did not seek preventive health care services because of their inability to pay due to low income and/or no healthcare insurance which suggests that underutilization of preventive services, such as cervical cancer screenings, mammography, and family planning may adversely affect the health status of this group (asamoa et al 2004). in addition, access to care is dependent on the availability of health care providers and services. in a study by casey and colleagues, information regarding barriers to health care access was provided by 54 hispanic key informants interviewed in three rural midwestern communities. the testimony of these informants showed that partial health care needs were being met in rural areas by federally funded community health centers for the urgent and primary care of the uninsured. however, the unmet needs identified by this group included primary care for men and older non-working adults, preventive services, continuity of care for adults with chronic illnesses, and coverage for prescription drugs (casey, blewett, & call, 2004). additional barriers identified in these rural areas were the shortage of physicians and other health care providers. of those providing care in these rural areas, many were hesitant to accept new patients that would require extensive appointment times (office visits are longer with the use of interpreter services), and who are indigent or uninsured (casey et al., 2004). 24 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 conceptual framework andersen‟s behavioral model of health services utilization has served as the conceptual framework for this study. this model describes factors that inhibit or facilitate access to health care, and how these factors are operationalized in the process of healthy utilization (andersen, 1995; wallace, scott, klinnert, & anderson, 2004). population characteristics and health behaviors were the areas of primary focus within the model. three constructs based on population characteristics that are thought to contribute to issues related to health care access have been identified in andersen‟s model: predisposing, enabling, and need characteristics. these factors demonstrate the likelihood that people will need health care services. andersen (1995) suggested that people are predisposed to factors that impact ability or need to obtain health care. demographics, position within the social structure, health beliefs, and psychosocial characteristics define and determine a person‟s access to care (andersen, 1995). such predisposing characteristics are present prior to illness and have great bearing on an individual‟s inclination to seek health care. enabling characteristics are conceptualized as family and community resources such as finances and transportation. but the need characteristic is also based on the individual‟s perception, which impacts the resulting health behavior. perceived need is demonstrated as degree of concern regarding illness, health risks, and health habits. perceptions of health and need for care may be influenced by predisposing and/or enabling characteristics, suggesting that attributes and characteristics may overlap to impact health care access. design and methods a qualitative research design was utilized using semi-structured interviews among eight hispanic women in bladen county, a rural southeastern north carolina county in which the estimated population was nearly 33,000 in 2006, with 5% of that population being hispanic (u. s. census bureau, 2007). industry employing the greatest number of bladen county residents includes agriculture, construction, and manufacturing. of those who are employed, the mean travel time to work is nearly 27 minutes, and there is no form of public transportation in this community. participants and procedures following approval from the university institutional review board, participants were identified and approached by a female spanish speaking key informant of the same community, who provided verbal information of the study to the potential participants in spanish. participants were invited to meet as a group in the home of the key informant for the three interview sessions, and eight to ten women were recruited by the key informant for each interview session; only eight participants participated in two interview sessions (four for each). the key informant served as the translator of the verbal communication between the researcher and the participants during the interviews. during each interview session, both the researcher and the translator were in attendance. an interview guide was utilized to prompt participants to share information regarding their health care experiences and concerns since they have been in the united states. at the conclusion of each interview, information was summarized and presented to the participants during a “debriefing” session without electronic 25 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 recording, allowing participants the opportunity to affirm or refute any information obtained, or to share information “off the record”. for the purposes of data collection, each participant was assigned a number to serve as identification during the study. this method eliminated the use of names or any other identifying information, assuring anonymity during the interview process. all written information had been translated into spanish by an on-line translator service, and back-translated by the key informant for accuracy and appropriateness for the participants of this community. all interviews were taped verbatim to capture the interview questions in english, the response in spanish, and the translation of the responses from spanish to english. to ensure validity of translation, a second translator was utilized to review audio tapes for accuracy of initial translation. english portions of the audio tapes were transcribed into a written verbatim transcript, with integrity of the interaction between researcher and participants being verified by reading them with simultaneous playing of the tape. internal validity was established through the use of quotations from the participants. findings eight hispanic women over the age of 18 years participated in this study. one participant was in the 18-29 years age group. all others were in the 30-49 years age group. ethnicity of the participants was mexican (5), central american (2), and guatemalan (1). of these participants, three had been in the united states one to five years, three had been here six to ten years, and two had been in the u. s. more than 11 years. all were first generation immigrants except for one participant who was a second-generation immigrant. six were married with one never having been married and the other divorced. three participants reported that they did not have a support system outside of the family. all others reported having an extended support system, but did not elaborate on the dynamics. of those reporting, the highest annual income was $20,800. participants had an average 6.5 years of education. spanish was the primary language for all participants. three spoke some english, and the other five spoke no english. six participants perceived their health status to be average, while the other two reported their perceived health status as good. one participant reported that she never utilizes the health care system. five reported utilizing the health care system one to five times annually for themselves or their family members. two reported utilization of the health care system six to ten times per year. health care utlization information obtained from the interviews was categorized using the constructs of andersen‟s behavioral model of health services utilization: predisposing, enabling, and need characteristics (see figure 1). though backgrounds were varied among these participants, many common themes regarding access to health care emerged from the interviews. illnesses among these women and their families included sinus problems, stomach pain, asthma, diabetes, pregnancy complications, and accidental injuries. considering the seriousness of their health status, none of the study participants or their families had a primary care health care provider. a common report among all participants was the utilization of emergency departments or urgent care centers for most of their health care needs. they also reported using home remedies and over the counter medications instead of seeking professional medical attention for most illnesses. 26 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 cultural influences and family structure in many cases the statements of participants reflected the influence of their culture in the manner in which they sought health care. participants reported they had learned practices for use with specific symptoms or illnesses through traditions that have been passed down through the generations. one participant shared that she frequently uses practices learned from her parents and grandparents. she reported using a honey and lime poultice for cough and cold symptoms. she also reported the use of over-the-counter medications to cure her daughter‟s asthma. however, she states, “…if the cough persists, and …nothing is going away with that kind of medicine,…[i] find a way to go to urgent care….” her daughter was not born in the u.s., is uninsured, and the family cannot afford primary health care or maintenance and emergency medications for this child. status within the family structure also seems to have some bearing on access to health care. one participant reported that her husband discourages use of the professional health care system, stating “… [he] doesn‟t like to pay the bills. he says, „you go to the doctor and you waste your money because he only gives you a little pill…don‟t help you for nothing and they get all your money‟.” she told of an incident when she was very sick. “my potassium was very low. my blood pressure was low, and i almost passed out. my husband wanted to wait until the next day [to seek medical attention] to see what was going to happen.” however, she stated that the final decision to seek health care is hers. “if i feel sick, i go to the doctor.” figure 1 andersen’s behavioral model of health care utilization by hispanic women in bladen county, n.c. (modified from wallace, scott, klinnert, & anderson, 2004) predisposing attributes: predispose the need for care social attributes: external environment, ethnicity, socioeconomic status health beliefs: values and attitudes regarding health care system, care, and treatment enabling attributes: enable medical care to occur family attributes: income, health insurance, ability to communicate, ability to understand health care instruction community attributes: availability of health care providers, accessibility of health care services, transportation health care utilization: use of emergency department, urgent care centers, diagnostic testing, prescription & otc medications, home remedies need attributes: inspire the need for care individual attributes: perceived need, symptoms of illness, chronic illness diagnosed needs: evaluated need, signs, diagnosis, management recommendations 27 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 another participant echoed the same decision-making authority when her children are sick. she stated, “i try other kinds of things [home remedies] first. if it don‟t work…i take the kids [to the doctor]. she also stated, “as a mother… [i am] the one to make that decision.” language barriers/literacy levels one participant, whose husband has diabetes, reported that language barriers existed, complicating communication with health care providers. they had difficulties explaining her husband‟s symptoms to health care providers, and were not able to understand the treatment plans since interpreters were not utilized. she stated, “we do what we can understand to take care of his diabetes.” similar instances were reported as another participant reported an instance in which she accompanied a friend to serve as his interpreter when he went in for a colonoscopy. an interpreter had not been utilized during her friend‟s pre-procedure interview, and he had not understood the prep procedure. the colonoscopy was rescheduled because he was not adequately prepped. in addition, he was charged for an office visit for the original day of the procedure. he did not return to have the colonoscopy. additional issues were identified that impeded access to health care as reported by this group. when questioned about their feelings regarding the use of interpreters, one participant stated, … [i] have to tell the other person everything—what [i am] feeling, what is happening…even though [i] want it …or don‟t want it. if it‟s a stranger or if it‟s not a stranger… [i have] to get through with what is needed, or nothing is going nowhere. many participants also reported the need for diagnostic studies or procedures for diagnosis of symptoms. one participant, who was insured, reported having a ct of her abdomen and an endoscopy for her complaints of abdominal pain. she stated, “i don‟t understand what [the tests] were for… they didn‟t help me any.” thus, she discontinued the use of her prescription medication and drank milk to minimize her pain. she reported, “there is nothing else i can do. i‟m just trying to live with it.” low income/uninsured status a common thread of concern among all participants was lack of health access for themselves and their family members because of their uninsured status and low-income status. all of the women complained of the expense of office visits, medications, and tests as reasons for their inability to achieve optimal health. one participant, whose children are uninsured, reported, “i take the children to urgent care…it‟s not too expensive and i can pay a little bit at a time. that is the only way.” this group also expressed concern that because they are not able to afford a primary care provider, there is no follow-up of chronic illnesses, such as asthma and diabetes. one participant tearfully accounted her experiences with her husband‟s diabetes care: my husband is very sick with diabetes…he is not able to work at this moment. no one in the family is working. he is seen in the emergency room [for his diabetes]. he does not have a doctor. they are giving him 28 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 some pills for his diabetes, but he has a lot of headaches. i think he‟s not controlling his sugar right. this participant reported that she encourages her husband to go to the doctor even though there is no availability of financial resources. the implied perception is that her husband‟s health care outcome would be improved if adequate resources were available to him. transportation all participants reported that they have difficulties with arranging and keeping appointments due to transportation issues. one participant reported that it is difficult to get to a specific place at a specific time when one is dependant on another for transportation. another gave an “off the record” report that her driver‟s license had expired, without eligibility for reinstatement. she also shared that her husband‟s driver‟s license will expire in two years, at which time he also will not be eligible for reinstatement of his license. the current and future dilemma is the lack of independent transportation to meet their needs. she is concerned that their vulnerability will increase when neither of them has driving privileges. when participants have been able to access the health care system in this community in the past, perceptions varied regarding their care and subsequent health behaviors. perceptions of health care many participants reported situations such as “too many tests and i didn‟t get well,” “nothing works [so i] stopped doing it,” and “they didn‟t do nothing… i had to pay and didn‟t get nothing.” some of these women were being treated for chronic illnesses for which there is no short term treatment plan—no “cure” for diabetes or asthma. these statements indicate that their perception of care included the expectation that diagnostic tests and short-term treatment would result in wellness. this perception has resulted in apparent dissatisfaction with the health care system. the youngest participant reported that she had been diagnosed with diabetes at an urgent care center. she understood from the health care provider that she is to eat a restricted diet, exercise, and take medication to maintain glucose control. however, she is no longer following health care recommendations. she stated, “the pills are expensive…nothing works, and i just stopped doing it. the more medicine i take, the more headaches i have, and i feel more tired... but, now that i‟ve stopped taking everything and started working…i‟ve started feeling better.” another participant compared her current situation to what she had experienced previously in another state: in california the doctor gives you a prescription for a year… here you have to go back every three months and they give prescriptions for only three months, and you have to go back. i stopped taking it [medicine] because i had this payment of fifty dollars all the time… so i spend money for nothing. in conclusion, access to health care services has been reported to be limited among hispanic women in one rural southeastern n.c. community. while all the participants in the study desired improved overall health status for themselves and their families, it seems that they 29 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 have experienced many health care disparities influenced by their population characteristics. recurrent themes in the study suggest that socioeconomic status, transportation, lack of insurance, and timing of office hours are barriers to health care access. additionally, language barriers and literacy levels impede comprehension and knowledge of necessary health care practices among this group. perception of health and of the need for services was influenced by predisposing and enabling characteristics, as well as other external factors. while some still maintained hope that changes in the health care system would help to resolve some of these issues and concerns, others seemed to have given up on the prospect of having adequate health care services, feeling that they were destined to continue to maintain health and wellness “the best way that i can do it”. discussion this study was a qualitative exploration of concerns among hispanic women seeking health care and confirmed the conceptualization of health care utilization suggested by andersen (1995). findings support that predisposing characteristics such as acculturation significantly impact health care among the hispanic population. all except one participant was a first generation immigrant to the u.s. reportedly, none of the participants or their family members had a primary care provider, although there were many reports of chronic illnesses such as diabetes and asthma among them. the first generation immigrants are more likely to preserve and use traditional health practices while seeking health care than second-generation immigrants and/or those of poor english speaking ability. this conclusion is confirmed by the findings of a previous study which suggested that less-acculturated individuals may possess greater language barriers, limiting social interaction and ability to acquire information (lopez-quintero, shtarkshall, & neumark, 2005). likewise, a review of data in 2003 from the third national health and nutrition examination survey (nhanes iii) revealed that mexican american children, specifically of first generation immigrants, were at a substantially greater risk for health care disparities due to higher poverty levels and lack of health care insurance among other issues (burgos, schetzina, dixon, & mendoza, 2005). according to timmins (2002), the failure to develop adequate spoken english also stood as a marker of a population at risk for decreased access to health care. it is also noticeable that enabling characteristics greatly influenced access to health services in the study. all participants of this study strongly voiced low income, lack of insurance, and difficulties with transportation as major factors that limit their access to health care services. the women in the study asserted unanimously that their poor economic status was the number one barrier. though language barriers and low literacy levels were issues that impacted their care, these factors were of overall less importance to the participants. the findings of the current study offer a framework to better understand health-seeking behaviors among hispanic women. their perceptions of health care needs were based on cultural influences and past experiences with health care in the united states. many of them reported the use of family or cultural practices and over-the-counter medications before they felt the need to pursue professional health care services. some reported dissatisfaction with the health care system, which negatively impacted their perception of need. the focus of this group seemed to be on current illness, as there was no discussion of preventive health care practices. this fact implies that the perception of preventive health care among this group is of minimal importance. findings in this study were consistent with a previous study by zunker and colleagues (2005) 30 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 who surveyed 112 elderly mexicans living on the u.s.-mexico border, found that the participants did not access the health care system at the first sign of illness, but relied on family and cultural practices as an initial response. they cited dissatisfaction with care and services provided, as well as negative experiences to explain the lack of traditional health care. these participants also perceived that preventive health care is available only to those who can afford it. implications there are growing numbers of hispanic population in rural areas. this research provides useful insight into the factors that impact health care access among hispanics in a rural community. nurses and practitioners working in rural clinics need to possess cultural knowledge which includes cognitive understanding of the client‟s culture, involving socio-environmental factors in addition to specific beliefs and practices (kim-godwin, alexander, felton, mackey, & kasakoff, 2007). while the participants and their families suffered from significant chronic illnesses in spite of their hope of improved health status, the lack of continuity in services remained apparent. understanding of their present time orientation as well as the shortage of enabling factors would help to develop culturally effective educational programs that would improve the continuity of care. also, translators should be utilized to improve communication and understanding of necessary health care in rural clinics. to meet these needs an additional program of “outreach nursing” such as a low cost mobile community program for low income hispanics should be considered. in this rural area, there is a large population of hispanic migrant farmworkers who would benefit from low cost health care services delivered directly to them. with limited income and transportation, and inability to meet appointment schedules, outreach nursing utilizing a mobile care unit would be an effective strategy to meet preventive and acute health care needs, as well as provide education on health related issues to this underserved population (diaz-perez et al., 2004). strategies should be developed to promote preventive health maintenance, as well as low cost continuity of care for those with chronic illness. advanced practice nurses, who have historically gone out into the less desirable locations to provide care to the disadvantaged, are perfectly positioned to provide these outreach services at an affordable cost. limitations several limitations of the current study should be noted. first, the small numbers of participants and selection of the group of women who participated in the study restrict the generalization of the findings. although attempts were made to recruit a larger sample size, many of these women were reluctant to participate, fearing deportation following the disclosure of names or other relevant information, with the result that only eight women participated in the interviews. hispanic women have historically been difficult to recruit for participation in research studies due to the lack of culturally appropriate strategies for recruitment and retention (naranjo & dirkson, 1998). in addition, the women who participated in the interviews may be different from other rural hispanic women. among this small group there was very little variation in themes throughout the interviews. except one, all of the participants were first generation immigrants to the u.s. the biases of the key informant in the identification of appropriate participants for the study also had the potential to affect validity as well (kapborg & 31 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 bertero, 2002). external validity could have been strengthened with a larger group of participants to provide greater transferability (kapborg & bertero, 2002). due to the very limited spanish vocabulary of the researchers, the language barriers that existed between the researchers and the participants placed great limitations upon this study. since the researchers were not of the same ethnicity, participants may have also been reluctant to speak freely about particular cultural practices in the presence of one from outside their own culture. although the key informant who identified participants and also served as the translator is very well known and highly respected throughout the community for her involvement in “bridging the gap” between the hispanic and non-hispanic populations, she was not trained in translation for research procedures. due to a limited spanish vocabulary, the researchers were unable to control for the risk of elaboration or limitation of questions or the responses of the participants during translation. thus, content and meaning in some responses to questions could have been lost in translation, which would pose a threat to the validity of the study. references adams, c. e., & horn, k. (2007). hispanics‟ experiences in the health system prior to hospice prior to hospice admission. journal of cultural diversity, 14(4), 155-163. agency for healthcare research and quality (2004). 2004 national healthcare disparities report (pub. no. 05-0014). rockville, md: united states department of health and human services. andersen, r. m. (1995). revisiting the behavioral model and access to medical care: does it matter? journal of health and social behavior, 36 (1), 1-10. [medline] asamoa, k., rodriguez, m., gines, v., varela, r., dominguez, k., & mills, c. g. et al. (2004). use of preventive health services by hispanic/latino women in two urban communities: atlanta, georgia and miami, florida, 2000 and 2001. journal of women's health, 13(6), 654-661. [medline] burgos, a. e., schetzina, k. e., dixon, l. b., & mendoza, f. s. 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[medline] north carolina department of health and human services (nc dhhs) (2006). north carolina minority health facts: hispanics/latinos. dec., 2006. retrieved january, 7, 2007 from http://www.ncminorityhealth.org pippins, j. r., alegria, m., & hass, j. m. (2007). association between language proficiency and the quality of primary care among a national sample of insured latinos. medical care, 45(11), 1020-1025. [medline] rojas-guyler, l., king, k. a., & montieth, b. a. (2008). health-seeking behaviors among latinas: practice and reported difficulties in obtaining health services. american journal of health education, 39(1), 25-33. u.s. census bureau (2006). state and county quickfacts. retrieved october 29, 2007 from http://quickfacts.census.org/qfd/states/37000.html u.s. census bureau. (2008). 2006 american community survey, washington, dc: author. retrieved may 5, 2008 from http://factfinder.census.gov/servlet/dttable?_bm=y&geo_id=01000us&-ds_name=acs_2006_est_g00_&mt_name=acs_2006_est_g2000_b03001 wallace, a., scott, j., klinnert, m., & anderson, m. e. (2004). impoverished children with asthma: a pilot study of urban healthcare access. journal for specialists in pediatric nursing, 9(2), 50-58. [medline] zunker, c., rutt, c., & meza, g. (2005). perceived health needs of elderly mexicans living on the u.s.-mexico border. journal of transcultural nursing, 16(1), 50-56. 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http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15267032%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15608099%5buid%5d editorial 6 editorial continuing education and the rno journal marietta stanton editorial board member over the past several years we have tried periodically to provide contact hours to all of our readers and constituents through the online rno journal. this has primarily been accomplished through questions that can be completed after reading a selected article in the journal and then submitting those completed questions to rno. all of the materials are available within the journal and can be completed electronically or faxed/mailed to rno. after the questions are received, corrected and processed, a certificate of completion delineating contact hours is sent to the individual. this activity has had a very poor response from readers and after three attempts, it is time to reevaluate this practice and consider other options. this was supposed to generate revenue for rno but without any respondents it has been a complete failure. therefore, in the interest of attempting to not only increase revenue as well as provide educational opportunities, it is time to reassess needs. it may be content that is a problem. it also may be cost. as you may know i was mobilized in support of the global war on terrorism on march 21, 2004. i served as the senior case manager for the southeast regional medical command and in that capacity i had quality oversight of case management activities of 50 case managers at 8 different hospital in the region as well as 10-20 case managers at community health centers and mobilization stations. my specific role was to facilitate the transition of ill or wounded reserve and national guard soldiers through the military health care system. this system had traditionally handled and was staffed for active duty soldiers and was ill prepared for the additional patient workload. in addition to the hospitals and facilities being widely dispersed, the level of expertise in and among case managers varied a great deal. this prompted a great deal of oversight and education on my part. because that situation is similar to that of rno, i would like to explore some activities we incorporated and then examine these and others to increase our participation in ce by rno members. • programs offered through video teleconferences. one of the vehicles we used to provide ceus in the military was a bimonthly or quarterly videoteleconference (vtc). • online courses could be made available at the website. these can be developed by members and made available to other members for a fee. • continue providing some sort of ceu activity through the journal. i can be reached at mstanton@bama.ua.edu, and i would appreciate you taking a few minutes to provide some ideas and feedback. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 mailto:mstanton@bama.ua.edu editorial 3 editorial “bloom where you are planted” (author unknown) kathy crooks editorial board member the title of this editorial is taken from a plaque that hangs in the office of one of the site manager’s within the health region in which i live. when i saw this quotation i immediately thought how well it suits the group of nurses i have had the opportunity to spend time with over the past several months. while gathering data for a rural research project, i have been given access to one of the most knowledgeable and hard working group of nurses in my health region. those i have spoken with cover all facets of the rural health care industry i.e. acute care, longterm care, homecare, and public health. i have been made welcome in their work places, at their staff meetings, over lunches, and in their homes. the overwhelming response from these nurses is that they love what they do and they wouldn’t want to be anywhere else. i find this interesting, in light of the fact that recruitment and retention of rural nurses, continues to be a major issue not only in canada but also worldwide. most of the nurses that i spoke with had 20 or more years of rural nursing experience and several are approaching retirement status. therein lies the problem. how do we make rural nursing an attractive career choice for past and future nursing graduates? past studies have demonstrated that monetary incentives alone only work as a short-term device to attract staff (aiken et al., 2001). moreover, other studies have shown most nurses who live and work in rural health care are returning to their place of origin or marrying into the community (bushy, 2000). in other words, rarely does a nurse go to a rural area for anything but personal reasons. this of course is a double-edged sword. many rural nurses have come to an area and stayed there for much of their career resulting in a minimal turn over of staff and no need to recruit. on the other hand, many young nurses from these areas had to leave so that they could pursue a nursing career. consequently their lives took a different path and they were lost to rural health care. with the present “greying” of the nursing population however, there is a desperate need to rectify this recruitment problem. following the lead from other countries, some rural health regions in canada have created scholarship programs that pay for the nursing student’s education, providing the student promises to return to the area to practice for a period following graduation. in addition, because various studies have shown that students who are exposed to rural practica during their education will be more likely to make rural a career choice following graduation (kenny & duckett, 2003), some rural areas are offering to pay students expenses if they are willing to spend a practicum experience in the area. still other sites are offering full-time summer employment as to students as a recruitment approach. hopefully with these types of recruitment initiatives, more and more recent nursing graduates will be drawn back to their communities and continue to “bloom where they are planted”. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 4 references aiken, l.h., clarke, s.p., sloane, d.m., sochalski, j.a., russe, r., clarke, h., et al. (2001). nurses’ report on hospital care in five countries. health affairs, 20(3), 4353. [medline] bushy, a. (2000). orientation to nursing in the rural community. thousand oaks, ca: sage. kenny, a., & duckett, s. (2003). educating for rural nursing practice. journal of advanced nursing, 44, 613-622. [medline] online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11585181%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14651684%5buid%5d editorial 4 editorial cost impact of medicare oasis outcome measurement for rural home health agencies melondie carter editorial board member many home health agencies (hha) are in small towns located in rural areas. due to volume restraints, a rural home health agency desiring to excel financially must endeavor to understand oasis (the outcome and assessment information set). rural hhas must ensure that their oasis assessments are completed thoroughly, consistently, and accurately. oasis was developed over more than a decade by researchers at the university of colorado health sciences center (see http://www.uchsc.edu/), with funding for medicare and medicaid services (cms) and the robert wood johnson foundation. the cms requires that oasis data be reported and this data is used for two purposes: “ to monitor outcomes of home health agency services and (as of october 2000) as an indicator of patient severity and needs in determining payment amounts under medicare’s home health prospective payment system” (keepnews, capitman, and rosati, pg. 79). there are 80 oasis data points that represent core items of a comprehensive assessment of an adult home care patient and are essential for measuring outcomes. these data points are detailed and precisely defined to permit comparative results. eleven of these data points are also currently used for public report card ratings of home health agencies for consumers. the initial assessment is performed at the start of care visit in the patient’s home. findings from the assessment and answers to the oasis questions determine points assigned to the clinical status, functional status, and service utilization domains. points in the clinical domain are based on the primary and first secondary diagnosis that are approved in the orthopedic, neurological, or diabetes category, iv infusions, enteral tubes, wounds, dyspnea, urinary and bowel incontinence, bowel ostomy, and behavioral problems. points in the functional status domain are based on dressing upper and lower body, bathing, transferring, and locomotion. the service utilization domain includes points the patient receives for ten or more therapy visits within a 60-day episode of care. from the start of a patient’s care, the agency must lock the oasis data to the state within seven days. after the oasis is complete, the patient admitted, and the physician’s orders are sent for signature, the hha can submit the request for the anticipated payment document for payment of 60 percent of the home health resource group (hhrg) rate. in determining hhrg payment, care must be taken to ensure accurate reporting. for example, inaccurate assessments can lead to minor mistakes in diagnosis coding that can lead to payment loss dollars. just one level in severity code from c0 to c1 leads to a payment difference of approximately $183; s1 to s2 is greater than $1,600. considering the numbers of patients seen, these types of differences in reimbursement potential demonstrate the necessity of accurate diagnosis coding. references keepnews, d., capitman, j., & rosati, r. (2004). measuring patient-level clinical outcomes of home health care. journal of nursing scholarship, 36(1), 79-85. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.uchsc.edu/ report from australia 4 editorial report from australia desley hegney editorial board member i have just returned from the 5th international rural and remote area nurses conference, which was organised through the icn rural and remote nurses network. held in albury, australia, from the 4th to the 6th march, approximately 90 nurses attended from japan, thailand, canada, usa, new zealand, and australia. there were four keynote speakers—three from australia and dr. judith kulig from canada. the concurrent sessions saw 51 papers presented. in addition, two symposia were presented, both by delegates from the usa and both focusing on disaster management. without the work of the australian rural nurses and midwives (arnm) association, the conference would not have been the success it was. we were also grateful for the work of the conference organising committee in australia and the abstract committee located in the usa. the major theme arising from the conference was one of celebration of the work of rural nurses. from the student to the nurse practitioner, it was apparent that much was being done to ensure that rural nurses are prepared adequately for practice and, once in practice, will have the access they need to remain competent. following this conference, i attended (also in albury) the 9th national rural health conference. there were approximately 1200 delegates, and of these about 250 were students (nurses, medicine, allied health). the conference theme was ‘standing up for rural health: learning from the past, action for the future.’ at this conference, delegates were asked to generate recommendations. these recommendations will be taken to the council of the national rural health alliance, where decisions will then be made by the member bodies. if accepted, the recommendations will form the basis of the alliance’s work for the next biennium. there was a large focus on climate change and the drought. images of rural people using their resilience to overcome adversity were abundant. many health professionals’ papers focused on innovative programs that aimed to increase both the range and reach of available health services to all sectors of the rural community. despite this year being an election year (we are to elect an australian federal government in 2007), representatives of both parties (liberal and labour) outlined how they saw the health of rural australians. of interest was the policy of the australian labour party to increase funds spent on health promotion and prevention. if this occurred, there would be a major policy and expenditure shift. from a personal perspective, it was wonderful to catch up with old colleagues (and like me, most were older) and make new networks. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 editorial 1 editorial letter from the editor: quality health care for rural residents jeri dunkin, phd, rn editor what is quality in health care? in 1990 the institute of medicine (iom) defined quality of care as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (institute of medicine, 2005, p.4) the institute of medicine (iom) was established in the united states, in 1970 by the national academy of sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. the institute acts under the responsibility given to the national academy of sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. the institute has had a long-standing focus on quality of care. in the first phase of the iom quality initiative, the national roundtable on health care quality highlighted serious problems with the overall quality of care delivered in the united states. in the second phase, two reports, to err is human: building a safer health system and crossing the quality chasm: a new health system for the 21st century, were released. both reports called for a fundamental redesign of the health care delivery system (institute of medicine, 2005). in the third and current phase, the iom has sought to elaborate and to realize the vision of a future health systems s set forth in the quality chasm report. the quality chasm report identified six aims for the delivery of health care: care should be safe, effective, patient-centered, timely, efficient, and equitable. among the profound changes needed to achieve these aims are that information technology must play a central role in support of the delivery of acre; that provider payment systems must reward the provision of quality care; and that the education and training of health professionals must encompass evidence-based skills and working in interdisciplinary teams (institute of medicine, 2005). the issue of quality in health care is not unique to the united states. indeed, this issue has been discussed for the past several decades in almost every country in the world. most of these discussions have focused on large systems of care in the large cities with the focus on procedures, encounters and financial implications. that has certainly been true in the united states. indeed, rural providers had largely been left out of the quality discussion. much of what had been developed and published was irrelevant to rural providers and in reality resources had been shifted from the rural areas to support this new initiative. recently the national academy press published another report in its quality series. this one is on rural health care. it is titled quality through collaboration: the future of rural health. with the release of this report rural health care providers had a online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 2 unique opportunity to lead the quality movement to new levels of effectiveness. we must engage!! the report provides us with a rural quality conceptual framework that includes: collaboration, continuity, communication, community, and the iom six aims of health care: safe, timely, patient-centered effective, efficient, and equitable. using this framework the report summarizes almost all the rural health care issues of the past two decades and introduces new insights and recommendations on workforce issues, quality improvement infrastructure, finance, and health information and communication technology. the report advocates development of rural systems of care designed for high quality and realizing the goals of health care. it demonstrates how the rural sector can exert quality leadership and advance the national quality improvement movement. it opens the door to rural engagement of the national “quality establishment” that has not been in the past. and maybe most important, it creates new opportunities for resources for quality health care in rural america. it is a report that every rural health professional should be familiar with and use to support quality health care initiatives. the report can be accessed at http://www.iom.edu/report.asp?id=23359. reference institute of medicine. (2005). quality through collaboration: the future of rural health. washington, dc: national academy press. retrieved january 25, 2005, from http://www.iom.edu/report.asp?id=23359 online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.iom.edu/report.asp?id=23359 http://www.iom.edu/report.asp?id=23359 online journal of rural nursing and health care, 2(2) 7 access to biofeedback therapy for women suffering from headache in rural wyoming dawn peters, fnp, c, rn1 mary beth stepans, phd, rn2 1 sheridan, wy 2 associate professor, fay w. whitney school of nursing, university of wyoming, mstepans@uwyo.edu * * corresponding author abstract biofeedback is an effective treatment for chronic headaches but is poorly utilized by those living in rural areas. an exploratory qualitative study was conducted to determine the barriers and benefits to seeking biofeedback therapy for women experiencing chronic headache pain while living in rural areas. in-depth individual interviews were employed. barriers identified were numerous. seven barriers identified were travel, time, lack of knowledge, skepticism, lack of referral by health care provider, difficulty relaxing, and pharmacologic therapy was already working. the two benefits identified were that biofeedback perceived as a natural therapy and is good for relaxation. health care providers need to work toward eliminating barriers to biofeedback for rural women since it is a treatment of choice for migraine and tension type headaches. keywords: rural, women, biofeedback online journal of rural nursing and health care, 2(2) 8 access to biofeedback therapy for women suffering from headache in rural wyoming headache is an exceedingly common complaint that was accurately described as early as 3,000 b.c. today, an estimated 45 million americans suffer from chronic, recurring headaches and an estimated 50 billion dollars each year are lost by industry because of absenteeism and medical expenses related to headache (national headache foundation, 2000). of those suffering from headache, 70% are women. treatment is often complex and is met with varying degrees of success. for example, a meta-analysis of 78 articles with a total of 2,866 participants revealed that pharmacological therapy was comparable to placebo therapy for recurrent tension headache (bogaards & ter kuile, 1994). ideally, the avoidance of significant pharmacological therapies (because of various possible side effects and questionable efficacy) and the implementation of stress reduction programs, such as biofeedback or dynamic psychotherapy, are preferred for the migraine or tension headache sufferer (gallagher, 1991). however, the dearth of health care professionals available to provide biofeedback therapy in rural areas poses a barrier. little or no research exploring the use of complementary therapies in rural areas is evident in the literature. because biofeedback therapy is considered a primary modality for treatment of tension and migraine headaches (barrett, e., 1996; bussone, grazzi, d'amico, leone, & andrasik, 1998; green, 1993; holden, deichmann , & levy ,1999), identifying issues that would either promote or prevent the rural citizen from obtaining this therapy is important. purpose the purpose of this study was to identify the benefits and barriers to seeking biofeedback therapy for women experiencing chronic headaches while living in rural areas. online journal of rural nursing and health care, 2(2) 9 review of literature biofeedback is a non-pharmacological, non-invasive treatment in which individuals learn neuro-musculoskeletal self-regulation. biofeedback therapies emerged in the 1970s when advances in psychological and medical research converged with developments in biomedical technology (goleman & gurin, 1993). biofeedback has been successfully used in the treatment of migraine and tension type headaches, fecal and urinary incontinence, epilepsy, irritable bowel syndrome, asthma, stroke, hypertension, chronic pain, muscle spasms, pain associated with raynaud’s disease, and other vascular or muscular disorders (green, 1993; schwartz, 1995; shellenberger, amar, schneider, & turner, 1989). efficacy criteria for clinical biofeedback and the use of biofeedback for headache will be described in this article. characteristics of obtaining rural health care will also be discussed. biofeedback therapy biofeedback therapy is a non-pharmacological approach in which clients learn selfregulation. through the use of monitoring instruments that detect and amplify physiological information, clients are trained to perceive and alter parasympathetic responses that are often related to pain and disease (stern & ray, 1977). after becoming aware of heart rate, blood pressure, skin temperature, muscle tension, and other involuntary body functions, conscious mental effort is used to control these functions. multiple component behavioral medicine treatment packages that include biofeedback therapy can lead to reductions in medication use (kabela, blanchard, & applebaum, 1989; o’grady, 1987; young, bradley, & turner, 1995), as well as reduced physician visits, medical costs (to patients and to insurers), and (d) hospital stays (shellenberger et al. 1989; wauquier, mcgrady, louise, klassner, & collins, 1995). when biofeedback information is used to make changes that can help reduce or stop symptoms, online journal of rural nursing and health care, 2(2) 10 feelings of helplessness are replaced with knowledge and the feeling that self-regulation is possible (goleman & gurin, 1993). efficiency criteria for clinical biofeedback biofeedback therapy is considered an appropriate for treatment of a disorder if it is clinically efficacious and low in risk (shellenberger et al. 1989). the following diagnoses have met efficacy criteria for treatment with biofeedback therapy: anxiety disorders, asthma, attention deficit and hyperactivity disorder, cerebral palsy, disorders of the intestine motility (irritable bowel syndrome, rectal pain, rectal ulcer), enuresis, epilepsy, essential hypertension, migraine and tension headaches, fecal and urinary incontinence, insomnia, motion sickness, myofascial pain, temporomandibular joint (tmj) pain, and mandibular dysfunction, neuromuscular disorders, chronic and rheumatoid arthritis pain, raynaud’s disease, and stroke (shellenberger et al. 1989). biofeedback therapy is the treatment of choice for raynaud’s disease/syndrome, certain types of fecal incontinence and urinary incontinence, while it is a treatment of choice for tension-type headaches, migraine headaches, irritable bowel or spastic colon syndrome, essential hypertension, asthma, and a variety of neuromuscular disorders (shellenberger et al. 1989). headache and biofeedback headache frequency, intensity, duration and analgesic intake decrease when biofeedback is used as a form of treatment (wauquier, mcgrady, louise, klassner, & collins, 1995; goleman & gurin, 1993). these factors should lead to a reduction in medical utilization and medication usage. among patients with chronic headaches who received biofeedback therapy, they had 75% fewer physician office visits for headache, used 56% less medication and had 19% fewer emergency room visits than their counterparts (o’grady, 1987). it is noteworthy that for these clients, office visits for headache remained consistently low five years after treatment. online journal of rural nursing and health care, 2(2) 11 pharmacological treatment has been the norm for benign geriatric headache with potential for multiple problems such as side effects, metabolic, absorption and excretion rate abnormalities, and the use of multiple medications (kabela et al. 1989). thus, the use of nondrug alternatives, such as biofeedback, in the treatment of the geriatric headache is a desirable goal. arena, hightower, and chong (1988) treated ten geriatric tension headache patients (aged 62-80) with eight weeks of progressive muscle relaxation using biofeedback. post-treatment assessment at three months revealed significant decreases in overall headache activity (50% or greater). kabela et al. (1989) studied 18 headache patients aged 60 years and older who received either thermal biofeedback (tbf) or electromyographic (emg) biofeedback. there was a significant overall group improvement in medication intake over a 28-day interval. the reduction in medication intake from 63% to 50% is especially encouraging given the greater likelihood of multiple medication use, and ensuing complications, in this population. moreover, of those patients who initially consumed headache medication, five patients essentially eliminated all medication. the efficacy of non-drug treatment for geriatric headache clearly warrants further study (kabela et al. 1989). published research strongly supports the effectiveness of biofeedback therapy as a nonpharmacological treatment of headaches. people living in rural areas could benefit from this type of therapy. rural characteristics according to the 1990 census approximately 61.7 million people live in rural areas (wyoming state government, 1998). rural areas are defined as places having less than 2,500 residents and open territory. in 1993, the office of management and budget (1993) developed online journal of rural nursing and health care, 2(2) 12 the rural-urban continuum code as a classification scheme to describe counties by degree of urbanization and nearness to a metropolitan area. metro counties have 4 classifications that range from 250,000 to over a million population. nonmetro counties have 6 classifications that include urban populations of 20,000 or more that are adjacent to a metro area to completely rural areas with fewer than 2,500 population that are not adjacent to a metro area. being adjacent to a metro area is an advantage when rural residents seek health care because the distances to the services of a health care provider are less. wyoming is predominately a rural state with only 2 counties classified as metro areas with populations between 20,000 and 250,000. the remaining counties are classified as nonmetro counties not adjacent to a metro area. in addition, twenty-one of twenty-three counties in wyoming were designated as health professional shortage areas in 1998 (wyoming department of health, 1999). this shortage means that basic health care needs are not adequately met and specialty care is almost non-existent. traveling from home to obtain health care can present serious difficulties (accommodation, food and transport costs) that might prevent or delay the trip (veitch, sheehan, holmes, doolan, & wallace, 1995). in the rural united states, the spirit of individual responsibility remains strong. primary to the rural resident’s perspective on health care is a fundamental belief in the individual responsibility for self-care (horner, ambrogne, coleman, hanson, hodnicki, lopez, 1994). biofeedback can be a form of self-care. persons are trained to control bodily responses to various physical or psychological problems. for biofeedback therapy to be successful, a trained therapist (shellenberger et al. 1989) must supervise the therapy. nurses, nurse practitioners, clinical psychologists, and other allied medical professionals can be trained to provide biofeedback therapy by obtaining special training and education in addition to their current online journal of rural nursing and health care, 2(2) 13 degree. according to the biofeedback society of america, only 2 certified biofeedback therapists practice in the state of wyoming (association for applied psychophysiology and biofeedback, 2000). method and design an exploratory qualitative study was conducted to examine perceptions about biofeedback therapy from women suffering with chronic headaches in a rural area. individual in-depth interviews of nine women were conducted. exploration and examination of the descriptive responses allowed the data to be interpreted contextually and reported narratively. human subjects the research proposal and consent form were approved by the university of wyoming institutional review board. after potential participants were given an overview of the study, informed consent was obtained. setting and sample purposive sampling was used to select participants from two rural counties in wyoming: platte county and carbon county. platte county covers an area of 2,108 square miles and has a population of 8,425. the county is comprised of mainly farming and ranching communities. carbon county covers 7,956 square miles and has a population of 15,855. this county consists of mainly farming and ranching communities. to be eligible for the study, participants must have been living in a rural setting, and experiencing 1) chronic tension-type headache, 2) chronic migraine headache, or 3) chronic headache of mixed type for at least six months. both women who had received biofeedback and those who had not were included in the study. this strategy permitted a broad exploration of the experience that women have in rural areas related to biofeedback in relationship to a diagnosis of online journal of rural nursing and health care, 2(2) 14 headache. seven participants were obtained by referral through the laramie peak medical clinic located in platte county. two carbon county participants were referred to the researcher by a biofeedback therapist practicing in laramie, wyoming. all potential participants were given information about the study and expressed consent to be contacted by the researcher. procedure each participant was contacted at least twice. initial contact was made by telephone to introduce the researcher, further describe the study, and reaffirm the participant’s willingness to participate. upon agreement to participate, a date and time was agreed upon for the interview. prior to the interview, a consent form, a demographic data sheet and a copy of the interview questions were presented to each participant. once the consent form was signed and reviewed, the interview began and lasted 1 to 2 hours. semi-structured interviewing was the data collection method utilized for this study. the interview was conducted in the participant’s home or other convenient location if the participant desired and was audiotaped. a series of approximately seven open-ended questions were presented to each participant in order to obtain thorough and complete responses. the questions directed each participant to describe her headaches, her perceptions of biofeedback, and how she benefited or did not benefit from biofeedback. each participant was encouraged to discuss freely any opinions, thoughts, and/or ideas related to the topic. the audiotapes were then transcribed onto a computer disk verbatim. field notes were kept for each interview to avoid loss of valuable information and to increase the understanding of the interview. limitations interviewing may have been a limitation in this study. participants may have felt uncomfortable with the taped interview and therefore may have been apprehensive in stating or online journal of rural nursing and health care, 2(2) 15 explaining everything that they experienced. however, the participants, appeared quite comfortable and at ease. successful biofeedback therapy is due, in part, to having a trained biofeedback therapist (schwartz, 1995; shellenberger et al. 1989). the qualifications of the therapists who provided biofeedback to two of the four participants were unknown. two participants received biofeedback from an advanced practice nurse who had training in biofeedback therapy but was not certified. data analysis once gathered and transcribed, data were analyzed to elucidate underlying patterns and relationships. “in analyzing the data, verbatim statements, thoughts, actions, and observations are critically examined to identify patterns, themes, categories or exemplars” (talbot, 1995). common themes were identified and categorized as either a benefit or a barrier to receiving biofeedback therapy. the information was coded, evaluated and grouped into categories. constant comparative analysis continued until similarities and differences in the data emerged. these similarities and differences were then grouped together and analyzed until common themes were identified. the themes identified are not mutually exclusive and tended to overlap each other to some degree. to increase the credibility of the study, member checking was utilized. this process involved checking with or getting feedback from some of the participants to ensure that the researcher had captured their words and meanings by “playing back” to them the interpretations of the data (talbot, 1995). agreement by two of the participants in the study validated the researcher’s interpretation of the transcribed data. in addition, two faculty members familiar with nursing research reviewed the transcriptions and examined the categories and themes. online journal of rural nursing and health care, 2(2) 16 results of the nine women interviewed, four had previously tried biofeedback therapy for their headache management and five participants had not. whether or not they actually participated in biofeedback therapy, all would have traveled 60 to 100 miles for this type of therapy because it is not offered in the communities where they lived. the mean age of the participants was 43 years, with a range from 29 to 56 years. all the women experienced severe headaches. when they were asked to rank their headache pain on a scale of 0-10 (zero being no pain and 10 being the worst pain they had ever felt), most ranked their headache pain as at least a “7.” overall, the participants stated they would do anything to get rid of the pain. medications were used to decrease the headache pain before it reached excruciating levels. central themes the two general categories for grouping the responses related to biofeedback therapy were identified as either barriers or benefits. each category contained common themes that emerged from participant interviews. barriers according to these nine women, more barriers to receiving biofeedback were identified than were benefits. seven common themes emerged which were labeled as barriers to receiving biofeedback: 1) travel, 2) lack of knowledge, 3) skepticism, 4) lack of referral by health care provider, 5) time, 6) couldn’t relax, and 7) pharmacologic therapy was already working. travel was a common complaint of eight participants. jill (all names used in reporting the data are pseudonyms.) described it in this way: online journal of rural nursing and health care, 2(2) 17 the hundred miles is one big barrier to go that far for an hour session…but going a hundred a fifty miles and your meals and gas … plus the expense of the treatment and then wondering whether it was gonna do anything… lucy had a similar opinion: i had to drive thirty-two miles one way, so it’s sixty-four miles just to do this. to me if i can take medication and go to bed, i’d rather do that than get in the car and drive sixty miles to do this. sally continues to drive one hundred miles to obtain biofeedback therapy because she feels she has greatly benefited from it. though she, too, feels that travel is a barrier: it’s not like going twenty miles, it’s like going a hundred miles…so i think travel is a barrier, especially in the winter, travel in the winter is bad here. all nine participants had a lack of knowledge about biofeedback. of the four participants who had tried biofeedback previously, all went into it without really knowing what to expect. of the five participants who had not tried biofeedback, four had heard of the word biofeedback, but could not explain or define exactly what it was. one participant had never heard of biofeedback and had no idea of what it was about. diane expressed what kept her from trying biofeedback: i guess just not knowing anything about it…… (not) having it presented as a viable option. basically ignorance, i guess. it’s just not knowing, anything about it, (not knowing) enough about it to pursue it. online journal of rural nursing and health care, 2(2) 18 sally, who continued to use biofeedback, had another viewpoint: i feel like when i tell someone about biofeedback, they don’t even know what i’m talking about. i don’t think it’s advertised enough, like well, maybe in the papers or something. i never heard of it until the doctor told me. mary, when asked why she had never tried biofeedback, had a simple answer that validated her lack of knowledge about biofeedback: because i don’t know what it is, nobody’s ever mentioned it to me before. without knowing and without reading, i would have to guess that maybe biofeedback is figuring out when you get your headaches and maybe avoiding that. eight out of nine participants were skeptical of biofeedback, including the four participants who had tried it. christy expressed it in this way: i don’t know of anybody who’s cured their headaches by biofeedback. if i had somebody who could tell me, you know, with a testimonial or whatever, and they got rid of it… i would like to visit with somebody who had had it. amy commented that she would like to try biofeedback at this point in her life, but had reservations: there’s a safety net because if it doesn’t work, i know there’s something else that would work that i could fall back on. i needed more assurance that i wasn’t gonna go put all that investment into it (biofeedback) and not have it work. online journal of rural nursing and health care, 2(2) 19 jill had tried biofeedback in the past; however, she had an interesting comment that implied she, too, was skeptical of biofeedback: it was a good experience. mainly it taught me how to relax, and that was a benefit for me. however, i wasn’t convinced that if i did the relaxing that it was going to take the headache away. the four participants who tried biofeedback therapy had learned of biofeedback from their regular health care provider. the five participants who had not tried biofeedback had not been given biofeedback as an option for headache management by their regular health care provider. for example, marsha’s, recommendation to try biofeedback therapy came from a member at the headache clinic in denver, colorado, but not by her regular health care provider. she declined to pursue biofeedback due to the travel and time involved. diane mentioned that she had never been given the option for biofeedback therapy. she would have tried it if it had been an option offered to her by her health care provider. she felt that rural health care providers are not knowledgeable about biofeedback therapy and therefore do not think to refer their patients for it. participants also felt that biofeedback therapy would take too much time. mary puts it succinctly: i think that it would take a lot of time, and time is something that is really precious to me. so at this point in time i think if it’s easier to take medications for my headache, i think i’m probably more willing to do that than i am to take the time. you know, if it means, you know, travel to cheyenne or laramie, or casper… you know, which is exactly why i haven’t gone to a neurologist. online journal of rural nursing and health care, 2(2) 20 not being able to relax meant different things to each participant who had tried biofeedback. two of the four participants who had tried biofeedback stated they could not relax enough. donna stated she could not relax because she and the therapist were too focused on the machines. when she tried relaxing without the machines, she could relax. lucy couldn’t relax because she stated she wasn’t comfortable with the therapist. lucy also described another reason that kept her from relaxing: sitting in that office, i would reach a certain level where i could relax, and then i’d start thinking about how i’m supposed to be relaxing, and then it’d tense me up. and i just could never (relax)…and there’s a noise that you try to get lower and slower, and it would reach a certain level; and i’d start worrying about whether it’s low enough. six participants expressed that their current drugs/therapies were working even though they did not like taking medication. because the medications they were taking to get rid of the headache were currently working, they were reluctant to try anything else. lucy had a simple answer that seemed to sum it all up: i guess it’s easy when you hurt like that, you know you’ve got something that works, it’s hard to try much else…. benefits biofeedback as a natural therapy that teaches relaxation are the two themes that emerged from the participant interviews identifying this therapy as beneficial. the idea that biofeedback is a more natural treatment emerged from both the participants who had tried biofeedback previously and from those who had not. six out of nine participants stated they did not like online journal of rural nursing and health care, 2(2) 21 taking medication and four participants expressed concerns about long-term effects from medication intake. diane explained: i think there’s always a disadvantage when you’re putting a chemical into your body to control it. that really does bother me. i always wonder about what the long-term effects of taking this once a month are. i’m just a firm believer that anything you put in your body is gonna have an effect, and imitrex hasn’t been out that long. p robably five years from now they’ll say, oh, those poor people who were taking imitrex, now they’ve got tumors in their brain or something. and i’ll be going, it worked so well, too bad. i see that as the older i get, where a quick fix was always just the thing that i thought was most important… now i see that taking better care of my body is the most important thing. i would be able to get away from all the chemicals i’m putting in my body if biofeedback worked for me. marsha also agreed that biofeedback would be a more natural therapy and would prefer it over medication. her feelings about taking medications were similar to diane’s: i don’t like to take medications. i wonder what it’s gonna do to me in the long run. i don’t know what it’s doing to my liver and how’s my body handling all this. of the four participants who tried biofeedback, three felt that it helped them relax. lucy was the only one who felt she could not relax: i wasn’t comfortable with the therapist…talking to a stranger, i guess, makes me tense. online journal of rural nursing and health care, 2(2) 22 both donna and sally experienced improvements in their headaches after having biofeedback therapy. donna felt her pain level decreased with biofeedback and that the abdominal breathing and visualization were excellent. sally continued to use biofeedback and commented about her feelings: i think it really helps. it’s my time for my body to be quiet. if i could do biofeedback everyday, i’d probably be wonderful.” jill stated that “it was a good experience. mainly it taught me how to relax, and that was a benefit for me.” discussion the major finding of this study was the discovery that there were more barriers perceived to obtaining biofeedback for this rural sample of women than there were benefits. while the identified benefits of biofeedback therapy were important, the barriers were numerous. there was a general consensus that biofeedback would be a beneficial therapy because it was considered natural. six of the nine participants were concerned about long-term effects of the medications they were taking or just did not like taking medications in general. these women would agree with gallagher (1991) that avoidance of significant pharmacological therapies is desirable, but for different reasons. while researchers are aware of issues related to efficacy (bogaards & ter kuile, 1994; gallagher, 1991), participants were concerned about the long-term side effects, but were satisfied with the efficacy of their medications. they were concerned with getting rid of the headache when it occurred rather than preventing the headache all together. time and travel presented the most significant barriers. travel is an obstacle in most rural communities because it takes time, effort, and money (veitch et at. 1995). the journey to see a biofeedback therapist for women in these two wyoming counties would have taken 1 to 2 online journal of rural nursing and health care, 2(2) 23 hours (traveling at 60 miles per hour) because all lived in areas that are not adjacent to a metro area. because participants led busy lives, taking the required time to travel was not a viable option. however, all would have liked to either try biofeedback or would consider trying it again if it were offered locally. unless rural health care providers are trained to provide biofeedback therapy, these obstacles are not easily overcome. participants viewed biofeedback as beneficial for learning how to relax, but did not have confidence that relaxing would eliminate their headaches. eight of the nine participants were skeptical about the effectiveness of biofeedback. when identifying assumptions that form the background for discussion of biofeedback and applied psychophysiology, schwartz & schwartz (1995) indicate that “patients are skeptical about therapies with psychological features” (p.33). the participants in this study validated this assumption. participants wanted proof that biofeedback worked before they were willing to try it themselves. these participants indicated that the most convincing evidence would stem from a success story of a friend or relative. this is consistent with the view that health-seeking behaviors of rural dwellers are powerfully affected by informal networks of family and friends (weinert & long, 1987). lack of knowledge about biofeedback was another identified barrier. some studies have shown that lack of knowledge regarding services and their locations, lack of awareness of insurance benefits, and inadequate understanding of the disease process act as barriers (melnyk, 1988). headache patients need to gather information themselves on biofeedback therapy if their primary health care provider does not inform them. use of the internet is one way in which this barrier could be overcome. another problem related to lack of knowledge, is that individuals may perceive relaxation/biofeedback as a psychological treatment. patient’s perceptions, expectations, and online journal of rural nursing and health care, 2(2) 24 mood are among the important aspects of therapy and compliance (schwartz, 1995). because mental health professionals more often provide biofeedback-assisted relaxation therapy than other health care professionals, patients may perceive biofeedback as a psychological approach and many patients resist psychological therapies. the health care provider has a powerful influence over patients. if biofeedback is not recommended by heath care providers, the patient may not pursue it, even if they had heard about it from another source. this could be a significant barrier for headache sufferers who trust the opinions and suggestions from their health care providers. all five of the participants who had not tried biofeedback had not been given biofeedback as a viable option by their primary health care provider. this may be a direct result of medical students having little education about complementary therapies and often viewing these therapies as less useful (baugniet, boon, & ostbye, 2000; kligler, gordon, stuart, & sierpina, 2000). many medical schools have incorporated formal training in complementary and alternative medicine in their curriculum (bhattacharya, 2000). this is an important step. mainstream and complementary medicine are both involved in health promotion, have a growing interest in the mind/body connection, and are attentive to the effects of patient/provider communication (burg, 1996). “not being able to relax” was a frequently named barrier for those participants who had experienced biofeedback. “not being able to relax” seemingly contradicts statements that biofeedback was beneficial because it teaches one how to relax. it may be that although biofeedback helps one learn how to relax in a general sense, the women had difficulty in achieving relaxation in the clinical setting. only two of the participants verbalized an understanding that relaxation training and biofeedback therapy are geared toward prevention rather than the treatment of a headache. online journal of rural nursing and health care, 2(2) 25 although cost is often a barrier, reimbursement did not seem to be an obstacle for these women to obtain biofeedback. sally, who has been receiving biofeedback therapy for about two years, has not had to pay for any of her therapy because her insurance has covered all of the expense. currently, many insurance companies and other third party payors reimburse for biofeedback therapy. if clients are informed that insurance will cover their biofeedback therapy, they may be more apt to pursue it. implications for health care providers educating health care providers is important if referral rates for biofeedback are to increase. continuing education, brochures, and in-services should be offered to rural health care providers to increase their awareness of biofeedback therapy as a treatment of choice for headache. the biofeedback society of america can offer current research and literature on biofeedback therapy for health care providers. current biofeedback therapists need to reach out to people in rural communities where biofeedback is not available. this may mean setting up weekly clinics in small towns. offering “specials,” such as one free biofeedback therapy session, is a way to introduce patients to the concept of biofeedback. this would provide an opportunity to educate patients about the benefits of biofeedback therapy. brochures and pamphlets about biofeedback therapy should be available in primary care offices. this could increase the general public’s awareness of biofeedback and could also remind health care professionals to discuss biofeedback therapy with their patients. implications for future research there are several implications for future research. first, this study could be repeated with a larger sample population. eventually a questionnaire could be utilized to survey a larger sample population assessing the barriers and benefits of biofeedback. determining the online journal of rural nursing and health care, 2(2) 26 effectiveness of education in increasing awareness and acceptance of biofeedback therapy as a form of treatment is vital to the successful implementation of a referral system for rural clients. summary although biofeedback therapy is a primary modality for treatment of tension and migraine headaches, several barriers were identified for women in this sample related to obtaining this non-pharmacological form of treatment. these barriers may not be unique to the rural resident although time to travel long distances and the reliance on informal networks of family and friends for information seem to support weinert and burman’s (1994) key rural concepts. rural consumers and health care providers need to be educated that biofeedback therapy is a treatment of choice for tension and migraine headaches. the influence health care providers have on their patients, lack of education about biofeedback, increased travel to see a biofeedback therapist, and skepticism are all barriers to overcome if biofeedback therapy is going to become an accepted and more available form of therapy in rural areas. references arena, j.g., hightower, n.e., & chong, g.c. (1988). relaxation therapy for tension headache in the elderly: a prospective study. psychology and aging, 3, 96-98. http://dx.doi.org/10.1037/0882-7974.3.1.96 barrett, e. (1996). primary care for women. assessment and management of headache. journal of nurse midwifery, 41(2), 117-124. https://doi.org/10.1016/0091-2182(96)00002-x baugniet, j., boon, h., & ostbye, t. (2000). complementary/alternative medicine: comparing the view of medical students with students in other health care professions. family medicine, 32, 178-184. http://psycnet.apa.org/doi/10.1037/0882-7974.3.1.96 https://doi.org/10.1016/0091-2182(96)00002-x online journal of rural nursing and health care, 2(2) 27 benson, h., & mckee, m. g. (1993). relaxation and other alternative therapies. patient care, 27(20), 75-90. bhattacharya, b. (2000). m.d. programs in the united states with complementary and alternative medicine education opportunities: an ongoing listing. journal of alternative and complementary medicine, 6(1), 77-90. https://doi.org/10.1089/acm.2000.6.77 bogaards, m.c., & ter kuile, m.m. (1994). treatment of recurrent tension headache: a meta-analytic review. clinical journal of pain, 10(3), 174-190. https://doi.org/10.1097/00002508-199409000-00003 burg, m. (1996). women’s use of complementary medicine. journal of the florida medical association, 83, 482-488. bussone, g., grazzi, l., d'amico, d., leone, m., & andrasik, f. (1998). biofeedback-assisted relaxation training for young adolescents with tension-type headache: a controlled study. cephalalgia, 18, 463-467. https://doi.org/10.1046/j.1468-2982.1998.1807463.x gallagher, m.r. (1991). headache diagnosis and treatment. journal of the american academy of nurse practitioners, 3(1), 3-10. https://doi.org/10.1111/j.1745-7599.1991.tb01052.x goleman, d., & gurin, j. (1993). mind-body medicine: how to use your mind for better health. yonkers, ny: consumers union of united states, inc. green, j. (ed.). (1993). what is biofeedback? how does it work? how is it used? [brochure]. published by the association of applied psychophysiology and biofeedback. holden, e.w., deichmann, m.m., & levy, j.d. (1999). empirically supported treatments in pediatric psychology: recurrent pediatric headache. journal of pediatric psychology, 24, 91-109. https://doi.org/10.1093/jpepsy/24.2.91 https://doi.org/10.1089/acm.2000.6.77 https://doi.org/10.1097/00002508-199409000-00003 https://doi.org/10.1046/j.1468-2982.1998.1807463.x https://doi.org/10.1111/j.1745-7599.1991.tb01052.x https://doi.org/10.1093/jpepsy/24.2.91 online journal of rural nursing and health care, 2(2) 28 horner, s.d., ambrogne, j., coleman, m.a., hanson, c., hodnicki, d., & lopez, s.a. (1994). traveling for care: factors influencing health care access for rural dwellers. public health nursing, 11(3). 145-159. https://doi.org/10.1111/j.1525-1446.1994.tb00393.x kabela, e., blanchard, e.b., & applebaum, k.a. (1989). self-regulatory treatment of headache in the elderly. biofeedback and self-regulation, 14, 219-228. https://doi.org/10.1007/bf01000095 kligler, b., gordon, a., stuart, m., & sierpina, v. (2000). suggested curriculum guidelines on complementary and alternative medicine: recommendations of the society of teachers of family medicine group on alternative medicine. family medicine, 32, 30-33. melnyk, k.a.m. (1988). barriers: a critical review of recent literature. nursing research, 37, 196-201. national headache foundation (2000). nhf fact sheet. retrieved from http://www.headaches.org/facts.html office of management and budget (1993). rural-urban continuum code. united states department of agriculture. retrieved from http://www.econ.ag.gov/ briefing/rural/data/code93.txt o'grady, m. (1987). headache: selected issues and considerations in evaluation and treatment. part b: treatment. in m.s. schwartz (ed.), biofeedback: a practitioners guide (2nd ed.). new york: guilford press. schwartz, m.s. (ed.). (1995). biofeedback—a practitioners guide (2nd ed.). new york: the guilford press. https://doi.org/10.1111/j.1525-1446.1994.tb00393.x https://doi.org/10.1007/bf01000095 online journal of rural nursing and health care, 2(2) 29 schwartz, n.m., & schwartz, m.s. (1995). definitions of biofeedback and applied psychophysiology. in m.s schwartz (ed.), biofeedback—a practitioners guide (2nd ed.). new york: the guilford press. shellenberger, r., amar, p., schneider, c., & turner, j. (1989). clinical efficacy and cost effectiveness of biofeedback therapy (2nd ed.). wheatridge, co: association of applied psychophysiology and biofeedback. stern, r.m., & ray, w.j. (1977). biofeedback: potential and limits. lincoln, nb: university of nebraska press. talbot, l.a. (1995). principles and practice of nursing research. st. louis, mo: mosby-yearbook. veitch, p.c., sheehan, m.c., holmes, j.h., doolan, t., & wallace, a. (1995). barriers to the use of urban medical services by rural and remote area households. australian journal of rural health, 4, 104-110. https://doi.org/10.1111/j.1440-1584.1996.tb00196.x wauquier, a., mcgrady, a., louise, a., klausner, t., & collins, b. (1995). changes in cerebral blood flow velocity associated with biofeedback-assisted relaxation treatment of migraine headaches are specific for the middle cerebral artery. headache, 85, 358-362. https://doi.org/10.1111/j.1526-4610.1995.hed3506358.x weinert, c., & burman, m.e. (1994). rural health and health-seeking behaviors. in j. fitzpatrick & j. stevenson (eds.), annual review of nursing research (vol. 12, pp. 65-92). new york: springer. weinert, c., & long, k. (1987). understanding the heath care needs of rural families. family relations, 36, 450-455. https://doi.org/10.2307/584499 https://doi.org/10.1111/j.1440-1584.1996.tb00196.x https://doi.org/10.1111/j.1526-4610.1995.hed3506358.x https://doi.org/10.2307/584499 online journal of rural nursing and health care, 2(2) 30 wyoming department of health. (1999). primary care underserved areas report: wyoming 1999. cheyenne, wyoming: office of rural health and primary care. wyoming state government. (1998). wyoming population estimates and forecast from 1991 2006. cheyenne, wy: division of economic analysis. young, l.d., bradley, l.a., & turner, r.a. (1995). decreases in health care resource utilization in patients with rheumatoid arthritis following a cognitive behavioral intervention. biofeedback and self-regulation, 20, 259-268. https://doi.org/10.1007/bf01474517 https://doi.org/10.1007/bf01474517 editorial 2 editorial the health care quality challenge and the clinical nurse leader role (cnl) marietta stanton editorial board member in 2001, the institute of medicine (iom) released the report crossing the quality chasm: a new health system for the 21st century (institute of medicine 2001). based on a large body of evidenced documenting severe problems in the american health care system, the report identifies six aims for quality improvement. these are that health care should be: 1. safe-prevents harm to patients (institute of medicine, 2004). 2. effective-refers to care that is evidence-based (institute of medicine, 2001). 3. patient-centered-addresses care that reflects the qualities of compassion, empathy and responsiveness to the needs values, and expressed preferences of the individual patient (institute of medicine, 2001). 4. timely-considers access to care as a critical factor influencing the quality of rural health care (institute of medicine, 2001). 5. efficient-refers to optimizing resources and minimizing waste to obtain the best value for investments in health care services and administration (institute of medicine, 2001). 6. equitableensures that the availability of care and quality services are based on an individual’s health care needs and not on personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (institute of medicine, 2001). in response to the iom report, the american association of colleges of nursing (aacn) developed a new nursing role in collaboration with leaders from education and the practice arena. aacn is advancing the clinical nurse leader (cnl) role to improve the quality of patient care and to better prepare nurses to thrive in the health care system. the cnl role emerged following research and discussion with stakeholder groups as a way to place highly skilled clinicians in outcomes based practice and quality improvement (aacn, 2005). in practice, the cnl role oversees the care coordination of a distinct group of patients and actively participates in the care. this cnl is masters prepared. cnl’s put evidencebased practice into action to ensure patient benefit from the latest innovations in care, evaluate patient outcomes, assess cohort risk, and have decision making authority to change plans when necessary. the cnl is viewed as a leader in the health care system and the role will vary according to the practice setting. to support the implementation of this new role aacn has launched a national pilot project involving almost 90 education-practice partnerships in 35 states. these education-practice partnerships involve a school/college of nursing collaborating with a clinical agency in the same geographic area to prepare the cnl both with both content and clinical experiences. the cnl program is very much a joint effort. not only does the cnl role conform to the key issues of the iom 2001 report, it also complies with the 2003 iom report health professions education: a bridge to quality which identified five core online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 3 competencies for all health professionals. these competencies include that health professionals provide patient centered care; work in interdisciplinary teams; employ evidencebased practice; apply quality improvement; and, utilize informatics. what does the cnl role have to do with rural setting? the iom report helped launch the quality chasm (institute of medicine, 2005) with a series of meetings where reports about health care were produced. in 2005, the report quality through collaboration; the future of rural health was published. in this report there were a series of key factors and recommendations. as outcomes, the iom committee developed a five-pronged strategy pertaining to health to address the related quality challenges in rural communities (institute of medicine, 2005). the components of this strategy are that rural health care: 1. adopt an integrated, prioritized approach to addressing both personal and population needs at the community level. 2. establish a strong quality improvement support structure to improve quality. 3. enhance the human resource capacity of rural communities including the education training and deployment of health professionals. 4. monitor rural health systems to ensure they are financially stable. 5. invest in building an information infrastructure. not only does the cnl role have implications for urban health care centers, it also has implications for the rural health care agencies especially in light of the above strategy components. the cnl will be able to provide case, disease, and outcomes management for a cohort of patients. this will be especially valuable in rural health care settings and communities. cnl’s will coordinate quality management programs and provide real leadership within rural health care settings. balancing cost and quality is an important component of the cnl role. cnl’s will also have a strong emphasis in therir educational programs on case management, evidence-based practice, informatics and pharmacology. the implications for nursing, nursing education and rural health care are clear. this new role is emerging as a key component of nursing in the near future. the cnl movement has tremendous momentum and it is “hitting on all cylinders” of what the iom report desired in terms of quality care. aacn also is supporting the transition of the preparation of the traditional advanced practice roles i.e. nurse practitioner etc., begin at the doctoral level by 2015. are we prepared in rural nursing for the challenges that lie ahead in nursing and healthcare? references institute of medicine. (2001). crossing the quality chasm: a new health care system for the 21st century. washington, dc: national academy press. retrieved october 7, 2005, from http://www.nap.edu/books/0309072808/html/index.html institute of medicine. (2003). health professions education: a bridge to quality. washington, dc: national academy press. retrieved november 13, 2005, from http://www.nap.edu/books/0309087236/html/index.html institute of medicine. (2005). quality through collaboration: the future of rural health. washington, dc: national academy press. retrieved september 7, 2005 from http://www.nap.edu/books/0309094399/html/index.html online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.nap.edu/books/0309072808/html/index.html http://www.nap.edu/books/0309087236/html/index.html http://www.nap.edu/books/0309094399/html/index.html p80 haydon-clarke article 6_6_11-with maccall edits 80
 
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 health needs assessment and nurse-led health care services of a small island community: methodology and results of a pilot study of the health status of residents of stewart island, new zealand jessica haydon-clarke, bschons-1st class1 eileen mckinlay, ma app-with distinction2 helen moriarty, mgp with distinction3 1 department of primary health care and general practice, university of otago, hayje664@student.otago.ac.nz 2 university of otago, eileen.mckinlay@otago.ac.nz 3 university of otago, helen.moriarty@otago.ac.nz key words: remote communities, health needs assessment, rural nurse specialists, nurse-led services, rural health research, vulnerable communities abstract context: provision of health care needs to small remote communities is a challenge requiring careful consideration. stewart island is a small island located at the far south of new zealand. first-line primary health care services are provided by two rural nurse specialists supported on the mainland by a general practitioner and regional hospital 72 kms away. geographical and professional isolation factors and maintaining personal privacy were key aspects in the design of the study. purpose: to undertake a health needs assessment of a small isolated community considering both resident and health professional perspectives. methods: a mixed methodology was employed to undertake the health needs assessment: selfadministered resident survey and semi-structured interviews with four health professional stakeholders (two on the island and two on the mainland). findings: the survey attracted 106 returns (approx. 30% of adult residents). stewart islanders reported similar rates of established chronic conditions compared to new zealanders as a whole, indicating the need for access to a full range of primary health care services: acute and chronic care; health promotion and illness prevention. residents and health professional stakeholders supported the current model of nurse-led health service provision with remote interdisciplinary support. reported gaps included visiting allied health services, and issues of professional isolation and professional development for the rural nurses conclusion: researching health needs of a confined community raises particular issues in confidential data collection and reporting. remote health service provision brings unique challenges but stewart islanders believe the current model of nurse-led service provision largely meets their needs. introduction provision of health care to small remote communities is a challenge requiring careful consideration (bidwell, 2001; martin-misener, downe-wamboldt, & girouard, 2009). stewart island, the southern-most of new zealand’s (nz) three largest islands, meets the definition of remote, being one to four hours transport time away from a major regional hospital in good weather (with no access in poor weather for several days at a time) (wakerman, 2004). previous publications have described the stewart island health care system and a community profile 81
 
 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 (d.dillon, 2006), noting an older age and male demographic susceptible to economic distress with high alcohol intake and recreational drug use (armstrong & pepers, 1999). international and national research has identified challenges to life in rural or remote areas being geographical (and social) isolation (goins, williams, carter, spencer, & solovieva, 2005; martin-misener et al., 2009), paucity of services (barnett, roderick, martin, & diamond, 2001; mitton, o'neil, simpson, hoppins, & harcus, 2007), transportation cost (m. fitzgerald, pearson, & mccutcheon, 2001; goins et al., 2005) , differences in cultural needs (cormack, robson, purdie, ratima, & brown, 2005; ellison-loschmann & pearce, 2006), low income,(campbell et al., 2002; elliot-schmidt & strong, 1997; hall, holman, & sheiner, 2004) low or seasonal employment (d. dillon, 2006; goins et al., 2005; jerant, von friederichsfitzwater, & moore, 2005), reduced availability of health specialists (gill & martin, 2002; iezzoni, killeen, & o'day, 2006; schoen & doty, 2004), and perceived poor quality health professional care (elliot-schmidt & strong, 1997; jerant et al., 2005). mental and physical health problems may occur at higher rates in rural or remote areas (elliot-schmidt & strong, 1997; rural expert advisory group, 2002). stewart island is 40kms from the nz mainland across foveaux straight (see figure one). weather conditions are changeable; at times the strait is treacherous and impassable to boat or light plane, and crossings are expensive.i most of the island is unpopulated and covered in dense vegetation; walking tracks cover most of the island and there are few roads. fishing and aquaculture are the main occupations but tourism is growing. the latitude results in very cold, often wet, short winter days with long days in summer and a persisting night glow from the sun. as in a number of nz rural areas, first-line primary health care is provided by rural nurse specialists (rns) working within the registered nurse scope of practice,ii (nursing council of new zealand) and using standing orders to distribute medication prescribed remotely and sent from the closest pharmacy (ministry of health, 2002 (revised 2006)). on stewart island the rns are employed by the southland district health board (sdhb).iii the stewart island rns work ten days on and four days off. they are available 24 hours a day via phone or the 111 system, live on-island and are sometimes called to assist in emergencies when off duty. the closest medical support is in invercargill (approximately 72 km away); a general practitioner (gp), base hospital specialists, and a community pharmacy. patients requiring emergency hospital care are evacuated by plane or helicopter, weather permitting. rns services are provided at no-charge to the residents. undertaking a health needs assessment of stewart island residents provided opportunities to consider the challenges of researching small communities and utilise a mixed methodology including a resident health survey and examination of the health care provision. the project fieldwork was undertaken by a current university of otago medical student, also a former resident of stewart island. 82
 
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 figure 1: map of stewart island in relation to new zealand (http://www.stewartisland.co.nz/island_map.htm accessed 6/10/09 permission granted for use by alan kynaston) methods a mixed methods (quantitative and qualitative) approach was taken to conduct the health needs assessment as this method supports triangulation of data thus validating and strengthening research findings (jack & holt, 2008; rowley, dixon, & sheldon, 2002). this approach is increasingly utilized in primary care health services research and was considered suitable for this project taking account of the potential vulnerability of the population.(martin-misener et al., 2009) it obtains “different but complementary data on the same topic” to best understand the research problem and draw on the strengths of different research approaches (morse, 1991). the field researcher (jh-c) was based on stewart island for the duration of the study to administer the health survey; better understand the context of healthcare services through interviewing the stakeholders; re-familiarize with the lifestyle yet maintain a professional distance and assure 83
 
 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 confidentiality. ethical approval was obtained from the nz lower south ethics committee. stakeholder interviews semi-structured, face-to-face or phone recorded interviews were conducted with four stakeholders; the two on-island rns, and from the mainland, the invercargill-based gp and the sdhb manager responsible for the service. interviews covered the roles of those involved in the service as well as the advantages and challenges of the service. recorded interviews were transcribed and these were checked and validated by each participant. resident health survey in line with the new zealand chatham islands focus survey (ministry of health, 2005), the sampling structure was designed to sample as many members of the stewart island usuallyresident population as possible. the first challenge was finding a denominator population of the island as this fluctuates with seasonal work and is confounded by a sense of belonging retained by past residents and cottage owners. published (statistics new zealand, 2001) and unpublished data (statistics new zealand. unpublished data 2007) indicate an estimated 390 permanent residents over the age of 15 years and an indeterminate number of transient workers. even with local post office staff knowledge, it was difficult to know how many people resided at each address since shortage of post boxes necessitates sharing. a pragmatic decisioniv was taken to supply two copies of the resident survey to every post-office boxv with a note requesting each householder over 15 years complete a survey. thirty survey additional tools were supplied to the local department of conservation to distribute to their workers and twenty placed on the postoffice counter where counter mail is collected. in total 420 surveys were distributed. the time of the year (tourist season) meant that some permanent residents had departed and many prior residents and holiday cottage owners had returned. despite all this the survey attracted 106 returns (approximately 27% of adult residents). in terms of statistical power, this meant that proportions calculated for this sample should be accurate to within plus or minus 10% of the true population value (in other words, confidence intervals calculated for sample proportions will spread plus/minus 10 percentage points of the point estimate). confidence intervals are given for all sample statistics. the resident health survey was adapted (and shortened for participant acceptability) from the 2005 chatham island focus survey (ministry of health, 2005). the chatham island focus surveyvi included questions from the new zealand health survey, undertaken every three years, and given that the chatham islands are remote and health services different from the rest of nz, questions were added to determine local health service acceptability and use. questions in the stewart island survey covered self-reported general health, health behaviors, health service utilization and assessment of current services. qualitative comments were sought about perceptions of health service provision and possible improvements to services. a reminder was placed in each post box and on the community notice board approximately three weeks after the survey distribution. following this, a further notice was posted on the community board, along with further survey forms, thanking those who had returned surveys and inviting those who had not to do so. to ensure anonymous return the completed surveys were posted to the health clinic postal address via the nz postal system then redirected to the researcher. returned surveys were numbered and the data entered into the microsoft access database for analysis. an inductive approach was undertaken by the research team (medical student, academic/research 84
 
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 nurse and doctor) to analyze the qualitative interview data (cresswell & plano clark, 2007.; morse, 1991). data were independently reviewed, looking for similarities, differences, emerging themes and commonalities with existing literature (crabtree & miller, 1992; dew, 2007). a biostatistician advised on the design of the study and indicated that the small population of stewart island would not allow the use of comparative statistics for contrasting patterns on stewart island with the remaining new zealand population but would provide an indication of health status at one point in time. a microsoft access database was developed for the survey results and descriptive statistics are reported for proportions of respondent’s selfreported illness responses, with confidence intervals for these proportions. results stakeholder interviews two main themes emerged from the interviews: professional aspects and health care provision. professional aspects. this discussion focused on the scope of the rns role, basis of employment, training and interface with other health professionals off the island. [their] employment structure same as other district nurses, [with a sdhb] manager. [the] funding comes from district health nurses budget [and] includes funding for them to travel to conferences, do study. the clinic building etc is owned by the sdhb [and] they supply the equipment in the clinic. (sdhb manager) a broad nursing role was described: …its provision of health care both on demand but also in response to our own strategic planning… and it’s a broad role because it encompasses acute and chronic care and management, common illnesses, emergency care for people, antenatal, postnatal, well child, well persons, district nursing, occupational health, palliative and home care and also organizing things like assessments for [secondary] services as well. (rns 1) primary health care clinics were provided routinely: you have your morning clinic, quite often we’ll have an afternoon clinic as well if we’re too busy, or we’ll actually advertise and say that we’re having a well child afternoon, or a women’s health , or a men’s health afternoon. (rns 2) the availability and promptness of the local health service was seen as a bonus. people are lucky as they can see them in the clinic straight away for free, whereas in town ed might be waiting for 6-8 hours for similar problem.( sdhb manager) 85
 
 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 rns were always on-call for emergencies: well we have sort of all the equipment a gp would have but we’ve got more than that. we’ve got our life-pac 12 which is vital for diagnosing and treating people with cardiac problems. we don’t have a ventilator nowe don’t we have a [equipment] bag set up that we can mobilize into a boat or helicopter or whatever and we have an ambulance set up that we can drive where we need it and we can use it in the clinic too… lots of drugs intravenous and oral everything you need in a situation, like adrenaline, amiadarone, atropine lots of cardiac things, antiemetics, pain relief, buscopan etc. we do give antibiotics… we have enough stuff to last us for three days … because of the weather. (rns 1) the off-island manager had a different perspective on their equipment and preparedness: …everything that opens and shuts is available to them. (sdhb manager) both rns were highly trained in technical nursing and emergency skills. …we’re primevii trained and several years experience -that’s all you need for the role according to the dhb at this point in time -but we’ve elected to do a lot more training. it’s a clinical masters focusing on pharmacology mainly and assessment. rns 1) …a lot of it was taught just from experience: iv insertion, prescribing, suturing and everything was just something that had to be done and i got on with it and did it but whenever i could pick someone’s brain [i did]… (rns 2) the rns compared their first-line health care to the gp scope of practice: you must remember that rural gp retention in nz is a massive problem. keeping gps in rural practices is very, very difficult and there’s a lot of rural areas now where there’s no gp so we’ve had to step into that role. therefore, that’s why we’ve advanced our training. (rns 2) regular professional supervision (off the island) for rns was funded by sdhb. both nurses were undertaking academic study and working towards nurse practitioner (np) scope of practiceviii but finding time to undertake the study was challenging, ongoing funding was piecemeal and the local program of advanced nursing study was closing down. we’re actually quite sad that they’ve closed that masters program, they’re still putting the last people through, but it’s all to do with funding, real sad actually ‘cause we felt it was good having a southern center. (rns 1) the rns have to organize their work in order to have adequate time-off and have privacy in their lives. 86
 
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 …well we structure our working life ten days on four days off so we can take a decent break and get off the island if we want to. to give is enough time to do that. it is and it’s pretty hard on your health it is generally because you can’t just go for a walk and take your mind off things if you want to. (rns 1) you don’t have a lot of your own personal privacy. (rns 2) health service provision. the rns described how they typically worked in isolation and balanced routine primary health care with emergency services, training of ambulance and volunteer staff. … the most challenging thing …of our workplace is the isolation. it is isolated and we don’t often hear from our [local] dhb … [a] typical week is clinic in the morning 10 till 12.30 or till we’ve got through everybody. home visits before and after clinic to patients for ‘cares’ or whatever in their own homes. we might get called out we’d have to close the clinic, put a sign up if there’s time and re-run it later in the day. apart from that we do home visits. …we’ve got certain things we do monthly and fortnightly basis, like we have our ambulance training our st johns [ambulance] volunteers. … during the week i try to round up women for their cervical screening in the afternoons to do them in a bunch and well child checks at any stage just to give a focus to organizing. (rns 1) time-intensive care competed with routine health services. …well palliative cares about meeting patient’s needs rather than trying to make them well, … you’re making them comfortable and meeting their needs and their major one need is that they want to die at home on the island. …it’s hard work, it’s very challenging for us, especially towards the end when they’re in terminal restless stage. quite often you might not get any sleep at all for a week yourself, you have to watch yourself because you’re still responsible to the community as a whole. you still have to make sure you’re able to diagnose a sick baby or someone else and not be totally strung out. so it is difficult at times. (rns 2) stewart island has always had a nurse-led service and there has never been a resident gp. collaboration and team work has always been a focus and the advancing rns role has evolved from a sharing of healthcare knowledge and formalized support. the rns have phone support from the invercargill-based gp or hospital specialists. mutual respect was evident in the combined working relationships. …we have our doctor dr x and we’ve always worked with him clinically, we’ve got assistance we’ve always got back-up. two heads are better than one anyway so they might think of something we’ve missed. we’ve got all the referral guidelines and stuff just pretty much like throughout nz, they’re all pretty much the same. (rns 1) 87
 
 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 y [rns 1] and z [rns 2] are very good; i provide treatment advice for them… basically i’d write about 50 to 60 scripts each week. they would ring me about twice a day…. and i had two si patients come here today. the one thing is that it is much easier to order investigations here [invercargill] and they are more immediate. that is limited there. (gp) and we use whoever, the thing is if it’s an o&g emergency we use the o&g registrar, if it’s an orthopaedic emergency we’ll ring the orthopaedic registrar or consultant. the thing is usually with eyes and children, paediatrics, we’ll talk directly with the consultants and they’re quite happy with that and we work very closely with them in a very collegial way. (rns 2) i might suggest some investigations they need to do or they might have some they still want to do. (gp) there is no dedicated primary health electronic patient management system but a secondary care database collates information. this lack of appropriate practice support software as well as no videoconferencing facilities adds to professional isolation and vulnerability recalls and reminders were manual and often personal. …people … they like to be personally approached, that works best with everybody. so reminders, notices and things don’t always work. that’s the nature of the people… (rns 1) rns identified privacy as a barrier unique to the small island community. my colleague will quite often run a clinic in the afternoon to do smears with the female patients because it’s more appropriate for them than to sit in the waiting room. …. here everyone knows everyone and so we tend to split the clinic up and use a little more diplomacy and make things as private as possible. (rns 2) health professionals in small communities must retain professional reserve to assure confidentiality. i guess one of the main barriers is that they know us quite well and maybe they might have reservations about what they might want to talk about, that’s concerning at times, wondering if there was something else. (rns 1) boundaries are difficult…i don’t go to parties very often at all now, i don’t hardly socialize with island people at all now because i find all you end up talking about their sore knees and work…you have to be a little bit aloof and professionally aloof from the community at times (rns 2) 88
 
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 young people have to learn to independently access health care, trusting it will be confidential, although the rns also care for their parents. i think the young ones, definitely there [are more] problems [for] the young. … you know, as the kids get older at the school…they have their own relationship developing with us, so they can have that without the parents. (rns 1) those residents with chronic conditions had to face additional barriers. people that are stuck at home in wheelchairs and you know they want to live here still but there are problems in accessing the services they deserve. …we have to get ots (occupational therapists) over in order to do assessments to get ramps into peoples homes…its got to be brought across the strait…so just the remoteness of the place and the fact that everything comes by boat and by plane is a barrier in itself. (rns 2) small population numbers deterred specialist services from visiting the island. …we actively campaign every now and again, we’d like to have a visiting psychologist sometime, we have had at times when we’ve managed to get enough patients together. but the numbers, it’s always the numbers. anything less than eight doesn’t seem to qualify for anything…like right down to weight watchers they won’t form a group unless there’s more than eight clients…you know a scale of economy. (rns 1) there was an insider-outsider culture, which refers to the culture of slow community acceptance of newcomers and consequent sharing of information, which influenced health care approaches. ….there’s a lot of new people and they might not understand [the health care services] very well. and it’s all very well the old hands, they know us, so they know what we do, but the new people might not know what’s availablelike the perceptions can be quite different. overall, the community were viewed as extremely resilient. …yes one thing its wonderful because they are so hardy and they’re very confidant, people just carry on with their illnesses (gp) population health survey the research and researcher were well accepted by the community. the survey time frame constrained return rate, compounding anonymity and confidentiality considerations. the time of the year (tourist season) meant that seasonal workers were very busy, some permanent residents had departed and summer residents and long-term holiday cottage owners had returned. despite this one hundred and six of the distributed surveys were returned (27%), which must be 89
 
 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 interpreted with caveats on the denominator as mentioned earlier and vagaries, such as some surveys, being returned on behalf of several household members, contrary to instructions. selected physical and mental health findings are presented below (table 1). the range of conditions resembled the 2006 nz national health survey (ministry of health, 2008), with expected departures such as more arthritis due to physical labor and stroke absent as island life is a barrier to living there with such conditions. table 2 shows resident age and some self-report lifestyle factors by sex. the average age of male respondents was 52.2 and females 48.7 years (table 2). the alcohol use reported here is number of drinks, not necessarily standard drinks, calculated from self-reported intake. it would appear that the hours of exercise involved in daily chores went unrecognized by some women respondents. drinking behaviour was extremely variable but many respondents reported drinking patterns in excess of (then) current intake guidelines and at worse this was hazardous consumption (alcohol advisory council of new zealand, 2009), as figure 2 demonstrates. the solid line in the centre of the box shows the median; the box edges show the upper and lower quartiles. the reference lines show the new zealand alcohol liquor advisory council recommended guidelines for safe drinking for females (14 standard drinks, short dotted line) and males (21 standard drinks, long dashed line) (alcohol advisory council of new zealand, 2009): standard drinks equal 10 g of alcohol with self-reported drinks likely to be larger. use of health services overwhelmingly, residents highly rated their local health service. approximately 95% of residents thought the healthcare available was ‘very good’ or ‘excellent’ compared to that available on the mainland. positives of the service commonly cited included immediacy, availability, price (the service was free), friendly caring service, the competence of the rns and their willingness to go above and beyond call of duty. the few negatives were: no resident gp, no visiting specialists, delays in getting some prescriptions, and cost of travel to mainland for non-emergency specialised treatment. discussion this model of health care, although very different to other parts of nz and despite some drawbacks in service provision, is well accepted by the stewart island community and is an example of a successful health care innovation in a remote setting. it does meet the first-line primary care and emergency health care needs of stewart island population, which overall are not dissimilar to the nz population as a whole. researchers studying in a remote community should consider potential vulnerability and unique community issues (taylor, hughes, petkov, & williams, 2005). remote communities may have unique and special health concerns which are not well recognised. although underresearched in comparison with the wider community, the vulnerability of a small or a remote population raises methodological challenges which require trust and close engagement with the community itself to solve. this project has demonstrated a methodology that achieved such engagement. 90
 
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 table one: self-report morbidity (residents aged >15yrs) for respondents on the 2007 stewart island survey and from the 2006 nz health survey. self-report health condition 2007 stewart island survey prevalence (95% ci) 2006 nz health survey prevalence a (95% ci) heart b 16% (9.2, 25) 5.2% (4.7, 5.6) stroke 0% (0, 3.1) 1.8% (1.6, 2.1) diabetes 6.4% (2.4, 13.4) 5% (4.6, 5.5) asthma 6.4% (2.4, 13.4) 11.2% (10.4, 11.9) lung c 5.3% (1.7, 12) 6.6% (5.9, 7.3) arthritis 25.5% (17.1, 35.6) 1.5% (1.4, 1.5) osteoporosis 2.1% (0.3, 7.5) 2.9% (2.6, 3.2) back 19.1% (11.8, 28.6) 24.2% (23.2, 25.2) cancer 7.4% (3, 14.7) not collected depression 5.3% (1.7, 12) 10.5% (9.9, 11.1) gynecological d 12% (4.5, 24.3) not collected kidney or bladder 7.4% (3, 14.7) not collected a. cited prevalence figures and confidence intervals are for all adult respondents (unless otherwise noted) from the 2006 nz health survey.(ministry of health, 2008) b. heart disease for 2006 nz health survey is limited to ischaemic heart disease. c. lung disease for 2006 nz health survey is for chronic obstructive pulmonary disease. d. prevalence estimate is based on female respondents only 91
 
 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 table 2: descriptive statistics for lifestyle factors by gender (male n = 42; female n = 40). questionnaire item gender mean median lower quartile upper quartile age male 52.5 54 38.5 65 female 48.6 51 36.25 59.75 alcohol use (number of drinks* per week) male 14.4 10 0.34 23 female 5.5 3.75 1 8 average number hrs exercise per week male 20.8 16.25 3.13 40 female 8 5 2 8.88 proportion 95% confidence interval % reporting using any marijuana at least once per week male 11.9% 3.9, 25.6 female 6.0% 1.3, 16.6 % reporting using tobacco at least once per day male 19.0% 8.6, 34.1 female 6.0% 1.3, 16.6 % told overweight male 16.7% 7, 31.4 female 18% 8.6, 31.4 % told hypertension male 26% 13.9, 42 female 26.2% 14.6, 40.3 92
 
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 figure 2: distribution of number of self-reported alcohol drinks consumed by males and females per week. this methodology for a small community there are recognized challenges in conducting health needs assessments in small remote communities. these include issues of study logistics, confidentiality and liaising with and reporting back to the community (macleod, 2006). although nominally a pilot study, this survey achieved what was most practicable, short of an official census of the adult residents. seemingly simple issues create challenges in small communities, such as determining the current denominator population which was a close-aspossible estimate. the small and close-knit community made it difficult to confidentially distribute and collect surveys from participants. in this instance local knowledge was used to maximize survey return rate. an important philosophical consideration is an ethical research agenda. small communities should not be viewed as convenient data sources but as potentially vulnerable populations (taylor et al., 2005). research undertaken must be useful to the community and service providers, wanted and endorsed by the community – in this case to identify and facilitate recommended number of standard drinks per week males (21 drinks per week ----) females (14 drinks per week ▪▪▪▪) 
 
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 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 improvements to the local health service. it is also important that the confidence of the community is gained; in this study the field researcher was from a respected local family, but sufficiently distanced as not now a resident. timely feedback in a suitable format is important. after this needs assessment news clips and longer research summaries were publicized in the local newspaper and a full report was made available to stakeholders providing the health service. great care was taken in reporting back to this community as all residents are potentially identifiable, a caveat which has prohibited reporting on and publishing potentially useful data on less common conditions and identifiable qualitative comments. the results in general although the response rate was lower than hoped, this was in part due to the timing of the survey at the beginning of peak tourist season, and one of the most demanding times of year for fishing and aquaculture. as more surveys were distributed than there were residents, the reported return rate is probably an underestimate. in addition the younger seasonal workers (who would be counted in the national census) may have felt unqualified to complete the survey, especially if they had not used the health service. despite the intention to pilot an adult health population survey this proved more akin to a household survey. 75% of the returned envelopes only contained one survey form but many respondents also mentioned children or partner’s health, therefore a greater number of individuals were represented than the number of completed returns. this stewart island nurse-led health service is highly appreciated and well-utilized by the residents. this service depends heavily on the good will and dedication of the two health professionals on-island. much of its success is due to their personal characteristics and clinical competence and their understanding of island identity (d. dillon, 2008). stakeholders and residents alike agreed on gaps in health service provision issues: lack of allied health services (especially dentists, counselors, drug/alcohol professionals and physiotherapists), cost and time to access medical care on the mainland. a gap also exists in role support of these health professionals. like other nz rural nurses these two work long hours (frequently on-call), have high workloads and lack privacy as they and their families live on the island (barber, 2007; ross, 1999). they can spend days-off away from the island, but whilst on-island can never be completely free from their roles. by necessity the nurses have taken on expanded roles including traditional medical activities (ross, 1999), but their nursing professionalism has been challenged by some medical and nursing professionals in other parts of nz as losing sight of their nursing role to become ‘mini-doctors’ (r. fitzgerald, 2008). the current service is praised and actively supported by off-island stakeholders but considerations of cost and convenience may have over-ridden due consideration for health professional wellbeing. the health service is particularly vulnerable to the continuing availability of a small and highly skilled on-island professional workforce and there is potential conflict with the requirements of the new zealand health practitioner competence assurance act to have peer review, continuing education and professional support in roles (new zealand government, 2003). unmet health issues on stewart island 94
 
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 there is a reassuring resemblance of this self-reported resident health survey to new zealand’s health status as a whole (ministry of health, 2008), even allowing for differing taxonomy, a predominance of men of workforce age (15 and 65 years), few resident children and young people (statistics new zealand, 2001), despite considerations of return rate and respondent bias. self-reported morbidity and lifestyle risk factors support the current rns dual focus on chronic and acute care management (wagner, 2001). an expanded chronic condition management approach (barr et al., 2003), endorsing health promotion and disease prevention, includes community services and allied health disciplines, however stakeholders report both the latter are missing at present. while the health service meets day-to-day primary care and emergency needs the noticeable deficiencies lie in access to services for mental health and addiction problems, physiotherapy to address the physical demands of island life, as well as dental health care. similar to the 2005 chatham island focus survey (ministry of health, 2005), the amount of alcohol consumed, mostly by male residents, seemed greater than documented in overall nz drug use surveys (wilkins & sweetsur, 2008), which may carry implications for health service provision to meet mental health, social and general health consequences, but particularly workplace safety in an environment where manual labor predominates. these factors, combined with stated resident concerns about the visibility of mental health, drug and alcohol issues, and the difficulty of accessing services, suggest that this is a particular area for service development. it is possible that remote life, harsh living conditions, short winter days and unpredictable weather pre-dispose to higher alcohol intake but alternately, as one off-shore stakeholder explained, people who are predisposed to significant drug, alcohol and/or mental health problems may choose the isolated setting. this is an area deserving further study. conclusion researching the health needs of a remote island community raises methodological and pragmatic issues including confidential data collection and reporting as well as determining the denominator population and efficiently disseminating surveys. the methodology of this study took into account that the first author was known and respected, and who committed to work closely with the community to achieve the overall aims of the project. providing and tailoring health services to a small isolated community are challenging especially using available resources wisely. the survey showed the health needs of stewart island residents seem very similar to the rest of new zealand except for alcohol intake being higher. this means a full range of primary health care services are required and can be delivered by rural nurse specialists, closely supported by mainland specialist services. rural nurse specialists offer expert service to remote communities and have particular education and support needs which must be accounted for by health funders and planners. there are some gaps in service provision but as a whole stewart islanders believe the current delivery model largely meets their needs. references alcohol advisory council of new zealand. (2009). alcohol guidelines. retrieved may 5, 2009, from http://www.alac.org.nz/ armstrong, s., & pepers, m. (1999). a community profile. dunedin: university of otago. 95
 
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 i access to the island is either by ferry ($120nz return from bluff on the mainland to halfmoon bay on the island per person peak time – an hour’s trip) or air carrier ($175nz return from si air strip to invercargill30 minutes flight time). these reflect isolation and single carrier operations. ii there are four scopes of nursing practice in nz: registered nurse, nurse practitioner, enrolled nurse and nurse assistant iii nz has twenty one district health boards. sdhb services the far south of the south island and includes the regional secondary care services at invercargill. iv the 2001 statistics new zealand community profile found 1.9 people living at each stewart island address. v in stewart island mailboxes are centrally located. some households share boxes as there is a waiting list. vi the chatham island focus survey was administered by face-to-face professional interviewers who were non resident. 73% of the population over 15 years took part. vii primary response in medical emergencies. the prime scheme utilises the skills of rural gps and/or rural nurses (rns) in areas where an ambulance crew (two ambulance officers, where one is a paramedic) is more than 20 minutes away (40 minutes in the south island). prime provides a coordinated response to rural emergencies and consistent, and appropriate, management of trauma and medical emergencies. the prime service provider is required to have undertaken a prime training course (approved by acc), within a maximum of two years after signing up with the scheme, followed by a two-day refresher training course for trauma and medical emergencies (approved by acc) at least once every two years. viii in nz a np is a licensed registration with a particular scope of practice. preparation includes completing a master of clinical nurse and an examined portfolio of practice. some nps prescribe within their scope of practice. http://www.ncbi.nlm.nih.gov/pubmed/15921481 http://www.ncbi.nlm.nih.gov/pubmed/11679369 http://www.ncbi.nlm.nih.gov/pubmed/15588265 64 spotlight on rural nurses: implications for a new nursing discipline in jordan karen francis, phd, rn1 hani nawafleh2 ysanne chapman, phd3 1 professor, school of nursing and midwifery, monash university, karen.francis@med.monash.edu.au 2 phd candidate, school of nursing and midwifery, monash university, hani.nawafleh@med.monash.edu.au 3 senior research fellow, school of nursing and midwifery, monash university, ysanne.chapman@med.monash.edu.au keywords: rural area, primary health care, nurses, jordan abstract this ethnographic study sought to provide a snapshot of rural nurses’ practice in comprehensive primary health care centres (cphccs) in jordan. these nurses provide a vital service to local populations although it is recognised that the nursing workforce is predominantly secondary level (e.g. practical nurses and aide nurses). the findings indicate that educational preparation, skill-mix, access to professional development, the lack of collegiate support, nursing practice standards, ineffective management, poor distribution of health resources and geographic isolation are important factors impacting on the cphcc nurses’ practice. the study highlights the need for improved resourcing of the cphccs and advocates immediate action by the ministry of health (moh) and senior nursing administration to support the development of rural nursing. in addition, it is recommended that effective recruitment and retention strategies to address the nursing shortage and improve the nursing skill-mix be developed. introduction the term rural nursing and rural practice are not commonly used in jordan although there is an acceptance that much of the nation is rural. this paper describes the practice of nurses employed in cphccs in rural areas. rural services are defined in this study as services provided outside major urban centres. the jordanian ministry of health (moh) accepts that the level of health service provision offered to less densely populated regions is different to that available in larger regions. they embraced the world health organizations (who) approach to health service provision espoused in the alma ata and subsequent documentation and developed a system of health care centres that are located throughout the nation that provide primarily non-acute medical care (who 1986; kharabsheh 2000). the moh recognised the need to improve the health status of jordanians and argued that greater access to health care was an important first step. the health centres were commissioned to provide primary health care which the who in 1988 identified as a strategy for achieving ‘health for all’ (twinn 2001). health professionals recruited to the cphccs to provide health services include registered, practical and aide nurses [1]. the nurses’ roles traditionally are curative in nature and involve direct patient care (nahas, nour &al-nobani 1999; haddad 2002). most nurses have been trained/educated for practice within an acute care environment and have had little, if any, orientation to practice that is primary level and largely community based. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.med.monash.edu.au/nursing/ mailto:karen.francis@med.monash.edu.au http://www.med.monash.edu.au/nursing/ mailto:hani.nawafleh@med.monash.edu.au http://www.med.monash.edu.au/nursing/ mailto:ysanne.chapman@med.monash.edu.au 65 jordan, like many global nations is experiencing a shortage of experienced registered nurses. it is proffered that many jordanian nurses choose to work abroad as financial reward is greater than that available in jordan (haddad 2002; mrayan 2004). in addition, there are no incentives to encourage nurses to work in jordan, especially areas that traditionally have found recruitment and retention of nurses difficult, namely the southern and isolated (rural) areas. the turnover of staff in these areas is high, reported the moh. he stated that up to 50% of new health professionals do not accept employment outside the major cities (alrai 2003). nursing critics of the moh maintain that the moh could address the nursing shortage if they adopted a practice of paying incentives to staff accepting positions in non-desirable areas (alrai 2003). methodology this study sought to understand the nature of practice of primary care nurses employed in cphccs in rural jordan. an interpretive ethnographic methodology was chosen as this approach allows for in-depth understanding of phenomena that is shared by a cultural group (morse & field 1996; denzin & lincoln 2000). ethnography describes the daily life experiences of a cultural group within a specified context and interprets the meaning of generated data (roper & shapira 2000). denzin and lincoln (2000) advocate that data collection methods include watching, listening and asking questions while spradley (1979) considers that ethnographers should focus on the way people act and use artefacts. observing and listening to jordanian primary care nurses as they provide care to rural communities realises understanding of this cultural group as they engage in caring for people. using such methodology in preference to other qualitative genres allows the researcher to appraise the clinical work of the nurses and challenge work practices and the systems in which they operate. selection of data collection sites following ethics approval from the host university and the jordanian moh three targeted rural cphccs, representative of three broad geographic regions, namely the north, the central, and the southern regions were invited to participate in the study. the emergency departments were selected as the most appropriate context for this study as the nurses provided direct patient care to a range of clients including ambulatory care patients. the researcher was cognizant that his gender excluded him accessing other departments such as maternal and child care services. data collection the researcher spent from 2-4 weeks in each of the three sites. staff were informed of the study and invited to participate. written consent was obtained from staff in the emergency department/s prior to data collection commencing. the researcher engaged initially in general observation of the setting until familiar with the rhythms and patterns of the department prior to commencing fieldwork and field notes were documented every day (morse & field 1995). the familiarisation time differed from site to site and ranged from 3-10 days depending on the department activity level, numbers of staff to observe and acceptance of the researcher’s day to day presence. once the researcher felt accustomed to the setting an intensive period of participant observations were completed. frankfort-nachmias & nachmias (1996, p.282) argue that online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 66 researchers engaged in participant observation must acknowledge their biases prior to entering the field. a justification was offered and recorded and subsequently discussed with other colleagues not associated with the culture and/or the data collection before accepted as legitimate data. the researcher engaged with participants as they practiced seeking confirmation of the rationale for observed activity. the participants included registered nurses, practical nurses and aide nurses. williamson (2002, p. 242) believes that exploratory interviews in the early stages of most research projects allow researchers to explore tentative illuminations. the researcher observed and recorded in a field diary the ordinariness of daily life within the department/s and developed exemplars of usual practice and those that were unusual to guide further observations and the development of vivid descriptive ethnographies. non-verbal communications were observed and recorded in the field notes allowing for elucidation of the culture of nursing practice within these settings (gordon & fleisher 2002). to confirm and further explore conceptual understandings internal key informants (nurse participants within the cphccs) were selected for their perceived capacity to provide further enlightenment of the culture (leininger 1985). external key informants were invited to participate in an in-depth interview (lincoln & guba 1985; williamson 2002). they were recruited from the nursing council, the moh, jordanian universities and elsewhere based on their perception that they either directly or indirectly influenced the practice of the phc nurses as ethnographers seeking to gain insider understanding (emic) and holistic meaning about the interactions and behaviours of certain groups of people (fiveash 1998; leininger 2001). there was no intent to generate consensus of key informants on culture and nursing practice rather, differences as well as similarities were embraced. the approach used for conducting interviews may range from informal dialogue to a formal structured interview process (baillie 1995; morse & field 1995). in this study a focussed or semi-structured interview process was used as it provides the opportunity for the researcher/s to develop a list of questions and is flexible “…. allowing the interviewer to follow up on leads provided by participants for each of the questions involved” (williamson 2002, p. 243). demographic data including age, gender, qualifications and employment history were obtained from each key informant. interviews lasted from 45 minutes to one hour and were audio-taped for subsequent transcription (morse & field 1996). as the practice of nurses is influenced and directed by policy, research and tradition, it was considered important that relevant localised and national documentation be identified and reviewed. according to lincoln & guba (1985), existing records may provide insight into what is occurring in a setting, and/or within a group of people. fetterman (1989) argues that personal documents can assist in understanding how people view their world while public records provide evidence of events that have occurred. spradley (1979, p. 8) suggests that ethnographers’ data collection and analysis is guided by continually asking the data “in what ways do members of the community (under investigation) … actively construct their world, what is it like for a person in this situation, how do people actively shape their lives within this context and what environmental factors influence coping and adaptation.” online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 67 results enthnographic descriptions the cphccs provide a range of services to local populations. they were staffed by general medical practitioners, nurses, midwives, dentists, administrative support personnel and a limited number of diagnostic technicians. however, for the purposes of this study observations of staff were confined to the nurses in the eds. the cphccs were either two storey buildings or single level construction. the emergency department, ambulatory clinics and x-ray units were located on the ground floor of the two level buildings and maternity services, general administration and medical officer accommodation were located on the second level. the eds in the single level cphccs were located at the front of the building allowing easy access with other departments adjoining. the emergency departments within the cphccs were in poor repair and the equipment was of poor quality and often obsolete and/or not functioning. services provided the three rural cphccs provided a similar range of services including primary medical care, midwifery, dentistry, pathology and x-ray services. patients presented to the emergency units of the cphccs for medical treatments that were non-life threatening. the nurses in the eds assisted the medical doctors who directed their practice. nursing practice the work of the nurses was task orientated and directed by the physicians. data revealed that nursing staff were predominantly practical and aide nurses who were recruited locally. interestingly, the nurses engaged in activities that are considered advanced practice such as suturing and venipuncture yet were largely unaware and non-compliant of universal precaution recommendations. the nurses did not engage with the community to promote health issues. dialogue with patients was limited to directions related to the therapy being initiated. nurses had little understanding of contemporary health issues and demonstrated a lack of awareness of ‘safe practice’. nursing practice was ritualized with staff engaging in activities that exposed themselves and others to potential risk of infection. for example nurses recapped used needles before disposal. the needles were deposited in unmarked receptacles that were then collected by hospitality staff and subsequently dumped at the local garbage repository. there was no evidence of nursing leadership in the eds and/or the cphccs. it is offered that the some cphccs did not have registered nurses on staff who would be expected to drive nursing development. nurses responded to the directions of the attending medical doctors and did not initiate interventions unless ordered. they were not consulted by the doctors or the cphcc management on any matters related to the functioning of the centres and/or case management issues. the cphccs offered that they found it difficult to recruit and retain registered nurses. haddad (2002) and mrayan (2004) maintained that many nurses do not value, and therefore do not consider nursing practice in these settings, as a career option. key informants suggested that registered nurses are rare in the cphccs. a nursing supervisor from the southern area indicated online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 68 that they have a major problem; the shortage of nurses at all levels. he offered the following reasons for these shortages: the nursing profession is not a preferred profession for the local people and few of them study nursing. the majority of our nurses are practical and aide nurses while most of the registered nurses are from other cities…they get their first employment then after getting some experience, they transfer to amman or other cities… the moh did not give good incentives for the nurse to stay more in this area… [ahmad, nvivo, section 3.3, paragraphs 59-66]. the cphccs and geographic location the physical environment of the centres and the location of the cphccs influenced the cphccs ability to recruit staff. nader a nursing supervisor from indicated that the cphccs located in the southern region are not well resourced compared with those in more populus centres. it was noted that with increasing rurality (decreasing population base) the number of registered nurses employed in the cphccs decreased. nader commented that he had: … met the general director of aqaba health directors who informed me that seven to ten health centres do not have any qualified nurses and all the nurses there are aide nurses. he claimed that the reason is that many skilled people do not like to work in this area … [nader, nvivo, section 1.1.6, paragraph 19]. it was apparent that the cphccs were poorly resourced. there were insufficient numbers of appropriately prepared staff (medical and nursing) to meet service needs and the physical resources were not conducive to safe, effective and cost efficient service delivery. a head nurse from the southern area stated: … the equipment is not enough for a comprehensive health centre providing a 24 hours emergency service …and the validity of our equipment is not good [nvivo, section 4.1.1, paragraphs 20-22]. it was revealed that the currency and the level of maintenance of the equipment decreased with remoteness. a study conducted in jordan indicated that clinics located in the rural areas are not provided with regular maintenance services for equipment and buildings. hijazi & alma’aitah (1999) asserts this factor compromised the quality of health services provided and influences health professional’s decisions not to accept positions in rural services. when questioned on the techniques they adopted for sterilising, many nurses stated that the shortage of equipment was a major reason for the adoption of poor sterilization techniques: …the sterilization process in the centre is very poor. i am not sure if it is up to 30% 40%. many times, i cleaned the instruments and placed them in the dry heat oven but after few minutes, we use them again for a new case [abdallah, nvivo, section 4.1.1, paragraphs 20-22]. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 69 it was noted however, that compliance with recommendations to avoid cross infection or accidents with needles was not routinely observed. nurses engaged in risky practices that included recapping used needles, disposing of needles and sharps in general disposal units, poor cleaning and sterilising technique and non-compliance with recommended hand washing protocols. many of the practices adopted by the nurses were potentially lethal to themselves and the community. there was no evidence of nurses having access to training and education and no local inservice education programs were provided. external key informants highlighted that there were opportunities for nurses to access training programs citing opportunities provided through the primary health care initiative project that is jointly funded program offered by unaid and the moh. the nurses in this study when asked to comment on the program and availability of training programs reported that were unaware of these programs. discussion the resource limitations identified in the cphccs were offered as the reason for adoption by nurses of poor cleaning and sterilization practices. it is acknowledged by the researchers that it is difficult to work effectively in rural areas where resources are inadequate. indeed, jones and cheek (2003) contend that nurses in rural australia have expressed frustration at the quality of equipment and resources provided. they note the nurses believed their practice and the health of the community was compromised as a result of poor resourcing. poor quality equipment and inadequate supplies including dressing packs, bandages, medications, cleaning solutions and contaminated waste disposal units place staff and the broader community at unnecessary and preventable risk. this study highlights that the practice of nurses in the cphccs is self-limiting. there was an expectation by the moh that the nurses employed in the cphccs provided nursing care that met community needs and was at a standard acceptable to the jordanian nursing profession. the reality however, was the nurses’ practice was directed by physicians. the nurses were not proactive and had little understanding of the role of professional nurses and were not cognisant of contemporary practice standards or the development of an autonomous standing. the data revealed that there is a need for more effective policy to guide and standardise nursing practice. the practice of the cphcc nurses included skills that the profession has identified as advanced practice. to ensure that nurses’ work is consistent with policy directives and the profession of nursing expectations, appropriate training and education must be made available (mrayan, 2004). in addition, cphcc nursing staff require assistance to develop skills that will allow them to engage with patients and the broader community to promote wellbeing. it is also necessary for the nursing skill-mix of the cphccs to be addressed. this can be achieved through a well considered recruitment initiative that targets registered nurse. this initiative must be include an incentive package if it is to be successful. this study has identified that rural nursing practice in jordan is reflective of the global concerns raised by nurses in similar practice contexts (bushy & leipert, 2005; kenny & duckett 2003; francis et al. 2001; macleod et al. 1998). a new nursing discipline, ‘rural nursing’ has emerged for jordan to consider. to ensure that the inequities and the challenges faced by rural nurses are exposed and addressed it is recommended that further research be undertaken to explore nursing practice in rurally based hospitals and in the more remote health centres not covered in this study. moreover, the study has drawn attention to the need for nursing curricula online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 70 at all levels to include content on ‘rurality’. the nurses in this study are victims of a system that has attempted to move forward in response to population health needs and global rhetoric without understanding the impediments to the new initiatives. conclusion this paper reports on an ethnographic study which sought to describe the practice of primary care nurses employed in cphccs in rural jordan. the findings indicate that poor resources, inadequate educational preparation, limited skill-mix and access to professional development, lack of nursing leadership and role models, collegiate support, and geographic isolation are factors impacting on nursing practice in the rural cphccs. it is recommended that resources be directed toward improving the capacity of the cphccs and access to education, training and professional development improved to ensure that incumbent staff are prepared for their roles and that their practice is contemporary. this study has highlighted the potential for an emergent new nursing discipline ‘rural nursing’ in jordan. the jordanian nursing profession needs to embrace the findings of this study by initiating steps to realise the professionalism of nursing in all contexts, regulate to sustain best practice and limit risks thus providing a safe and secure nursing workforce that is effective and responsive to the changing needs of jordanian society. while nursing is western societies is well down the track towards realising professional autonomy, the evolution of nursing in jordan is embryonic. as the profession matures and raises its own strong leaders in nursing, the propensity for nurses to be seen as just hand maidens to physicians will yield towards a more acceptable partnership reflective of similar developments in the western world. this study has identified rural nursing as an explicit practice within nursing. it is anticipated that as the discipline of ‘rural nursing’ gains momentum the needs of this group and those of the communities in which the nurses work and live will be raised. nations such as australia, new zealand, the usa and canada have well organised nursing associations that represent ‘rural nursing’ (francis & lindsey, 2002). it is strongly recommended that jordan investigate the potential for a similar association. notes [1] ‘practice nurse’ is an 18month community college and hospital trained course. ‘aide nurse’ is a nil-6 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(1985). naturalistic inquiry. beverly hills: sage. macleod, m. browne, a. & leipert, b. (1998), issues for nurses in rural and remote canada. australian journal of rural health, 6, 72-78. [medline] morse, j. m., & field, p. a. (1996). nursing research: the application of qualitative approaches. london: chapman & hall. morse, j. m., & field, p. a. (1995). qualitative research methods for health professionals. london: sage publications. mrayyan, m. (2004). perceptions of jordanian head nurses of variables that influence the quality of nursing care. journal of nursing care quality, 19(3), 276-279. [medline] nahas, v. l., nour, v., & al-nobani, m. (1999). jordanian undergraduate nursing students' perceptions of effective clinical teachers. nurse education today, 19(8), 639-48. [medline] 150 physician and nurse refused to work in the moh. (2003 june). al rai newspaper. roberts, k., & taylor, b. (2002). nursing research processes an australian perspective. australia: nelson thomson learning. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9844091&query_hl=5 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12472613&query_hl=7 http://www.dest.gov.au/highered/nursing/pubs/rural_nurses/1 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12581400&query_hl=9 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=14651684&query_hl=11 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9708085&query_hl=13 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=15326998&query_hl=15 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10855143&query_hl=17 72 roper, j., & shapira, j. (2000). ethnography in nursing research. london: sage publications. spradley, j. p. (1979). the ethnographic interview. new york: rinehart & winston. twinn, s. (2001). developments in nursing practice in primary health care in hong kong: opportunities and challenges. journal of clinical nursing, 10(3), 345-351. [medline] williamson, k. (2002). research methods for students, academics and professionals: information management and systems (2nd ed). wagga wagga, new south wales: centre for information studies, csu. world health organisation (who) 1986. health and welfare canada, & canadian public health association. international conference on health promotion: the move towards a new public health. ottawa charter for health promotion, ottawa, who. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11820544&query_hl=19 editorial 5 editorial happy case management week marietta stanton editorial board member i would like to remind you about case management week. it is a special time and it honors case management in all types of facilities and all areas of practice. all over the world, case managers are working to provide patients and their families with the best care possible. case management is especially valuable in rural and underserved areas in this and other countries of the world. case managers maximize resources and access every day. case managers in today’s health care setting come from diverse educational and clinical settings. historically, many case managers came from the worker’s compensation and disability area. other early case managers came from the field of social work and had a significant role in many behavioral health programs. today increasing numbers of case managers address health and wellness within disease management and wellness programs. due to the increasing complexity and coordination responsibilities in emerging case management roles, the kind of experience and education that nurses possess becomes important (mullahy, 2004). case management involves a greater depth and intensity of involvement than traditional nursing especially in the rural community. therefore, the case manager of the future will need to be very experienced and graduate prepared. the potential for case managers to tailor health care in rural resource poor environment is unparalleled. perhaps a day will come when managing the care of the chronically ill in rural areas will be most cost-effective if coordinated by graduate prepared nurse case manager who can be reimbursed for his or her services. it is a growing area of practice within nursing. this week we honor case managers and the potential new arena they can provide for advanced practice in professional nursing. references mullahy, c. (2004). the case manager’s handbook. sudbury, ms: jones and bartlett publishers. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 32 rural elderly caregivers: exploring folk home remedy use and health promotion activities leisa r. easom, rn, phd1 mary ellen quinn, rn, phd2 1 associate professor, division of nursing and health sciences, macon state college, leasom@mail.maconstate.edu 2 associate professor, school of nursing at athens, medical college of georgia, mquinn@mcg.edu keywords: health promotion, rural elderly caregiver, folk home remedies, emotional health abstract this exploratory study examined folk home remedy behavior and engagement in health promotion activities in rural elderly caregivers. data was obtained with a self-report questionnaire, from a probability sample of 80 caregivers (age range = 65-84 years). results indicated that caregivers were very involved in health promotion activities, except for exercise. participants had high rates of folk home remedy use. emotional health was a significant positive predictor of engagement in health promotion activities and an important factor for a healthy lifestyle in the rural, elderly caregiver. the high frequency of folk home remedy use indicates that nursing assessments should include questions about the use of folk home remedies as a measure of health promotion. introduction participation in health promotion activities is essential for maintaining health (pender & pender, 1996; pender, murdaugh, & parsons, 2002) and is particularly important in at risk groups, such as rural elderly caregivers. while caregiving has been found to be physically and mentally exhausting in any population, unique challenges face the rural individual (amirkhanyan & wolf, 2003; buettner & langrish, 1999; farran, dimitra, lindeman, mccann, & bienias, 2004; jackson & cleary, 1995; national alliance for caregiving and american association of retired persons survey, 1997; wallhagen, 1992; wykle, 1994). elders living in rural areas may engage less in health promotion activities, such as physical exercise or screening tests as preventive health measures, as compared to their urban counterparts (national center for health statistics, 2002). rural individuals tend to be older and have more chronic illness and disabilities (center for disease control and prevention [cdc], 2002; johnson, 1991; sanford & townsendrocchiccioli, 2004). lack of access to health care also puts rural elders at risk (virning, moscovice, durham, & casey, 2004). use of folk home remedies may be a response to unmet health care needs in rural elders that may also place them at risk (averill, 2003; conley & burman, 1997; davis et. al. 1991). on the other hand, folk home remedy behavior may be considered a health promotion activity by rural elders. to date, little research exists regarding health promotion in this vulnerable population. the purpose of this study was to explore (a) folk home remedy behavior and (b) engagement in health promotion activities in rural elderly caregivers. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.maconstate.edu/nursing/ mailto:leasom@mail.maconstate.edu http://www.mcg.edu/son/athens.htm mailto:mquinn@mcg.edu 33 theoretical background/conceptual definitions this study utilized pender’s health promotion model (pender, murdaugh, & parsons, 2002) as the theoretical basis, thus the variables under study include perceived self-efficacy, perceived barriers, functional health, emotional health, and health promotion activities. the model was extended to include the variables of folk home remedies (armer & conn, 2001; weinert & long, 1987) and spirituality (boland, 2000) in order to make the model more applicable to rural elderly population. health promotion activities are actions taken to enhance the quality of life in an interactive process between humans and their environment (pender & pender, 1996). studies have shown that older rural adults do not use positive health practices on a regular basis and seek health care only when illness was perceived as severe (johnson, 1991; wright, 1997). research is needed to investigate factors that may influence the practice of positive health practices in this population. perceived self-efficacy or “people’s judgments of their capabilities to organize and execute courses of action required to attain designated types of performances” (bandura, 1986, p. 391) is a critical factor in the development of favorable health practices in elders (carroll, 1995; conn, 1997). although self-efficacy research began as situation or domain specific (bandura, 1977), it can also be conceived of as a global construct (shelton, 1990). perceived barriers (measured as perceived resources in our study) are impediments or deterrents to taking action on the behalf of the individual (bandura, 1977). perceived barriers, such as pain and indifference (resnick, 1998) and lack of information and knowledge (peters, 1995) have been found to be related to health promotion activities in elders. an interaction between perceived self-efficacy and perceived barriers may impact health promotion activities. clark (1999) found that as the number of perceived barriers to practicing health activities increased and self-efficacy was low, the health behavior of the individual decreased. functional health or the older adult’s ability to perform certain activities (duffy & macdonald, 1990) has been found to be enhanced by health promotion activities (ostchega, harris, hirsch, parson & kington, 2000). emotional health represents the elder caregiver’s level of psychological functioning (george & gwyther, 1986) and has been found to be negatively effected by caregiving (wallhagen, 1992; wright, hickey, buckwalter, hendrix, & kelechi, 1999; wykle, 1994). on the other hand, others have found that caregiving can have a positive impact on the caregiver’s emotional health in terms of self-esteem and self-satisfaction from fulfilling obligations to the elder and contributing to the elder’s quality of life (nijboer, triemstra, tempelaar, sanderman & van den bos, 1999). folk home remedies have been defined as any health practices used at home before seeking professional health care assistance (yoder, 1972), exclusive of over-the-counter drugs (secrest, 1964). folk home remedies originate among the people and are contrived from herbs, plants, animal, and mineral substances as well as religious practices and holy words to cure disease and maintain health (helman, 1994; jackson, 1976; secrest, 1964). weinhart and long (1987) suggested that folk home remedies may be a primary selfefficacy related response to symptoms of illness and/or practices of health promotion for rural elderly. spirituality is “the need for meaning, purpose, and fulfillment in life; hope/will to live; belief and faith” (ross, 1995, p. 460). spirituality is thought to be an important and fundamental aspect of human functioning that positively affects healing and online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 34 health (long, 1997; parks, 1998), particularly for elders (reed, 1991; ross, 1995) and for rural elders (armer & conn, 2001). little research exists regarding health promotion in rural elderly caregivers. a greater understanding of health promotion activities is needed in order to design health promotion interventions that will contribute to the healthy people 2010 objective of increasing quality of life in this vulnerable population. in relation to the rural elderly caregiver, the research questions of this study are: 1. what are the types and frequency of folk home remedies used for promotion of health? 2. what is the frequency of participation in health promotion activities? 3. what are the predictors of health promotion activities? methods a descriptive, cross-sectional design was used to examine health promotion activities, perceived self-efficacy, perceived barriers, folk home remedy behaviors, emotional health, and functional health in rural elderly caregivers. the purpose of this design is to examine relationships that exist in a given situation (burns & grove, 2002). sample approval for this study was obtained from appropriate institutional review boards. a power analysis (alpha level of 0.05) was conducted to determine a sample size of 80. the random sample of elderly caregivers (table 1) was obtained from the mailing list of the rosalynn carter institute for human development (rci). the rci focuses on understanding the process of caregiving and discovering new ways to benefit caregivers. the mailing list consisted of 938 caregivers, from a demographic region of 16 rural counties. each caregiver received a letter explaining the study’s purpose, eligibility requirements, risks and benefits of participation, and guarantee of confidentiality. subjects received a telephone call based on their random order assignment in the rci list. subjects were told that participation was voluntary and if they participated, they may withdraw or stop the interview at any time. choosing to answer the questions on the questionnaire indicated implied consent to participate in the study. sample selection continued in this random fashion until the sample size was 80. the inclusion criteria for the sample were: >65 year of age; being a member of the rci; providing unpaid care to an adult with a physical and/or cognitive impairment, which involved at least two personal care activities daily, for a minimum of 3.1 hours per day, during the past 6 months; telephone access; and the ability to understand english. data collection following the random order of the sample selection, each potential participant was contacted by telephone. the interview occurred at the time of the initial call or was scheduled at a time convenient to the rural elderly caregiver. in the event of a “no answer” call for two consecutive days, the next random number was called. to ensure constancy of online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 35 table 1 demographic characteristics of study sample (n=80) variable frequency percent age male 69-79 (range) female 65-84 (range) gender male 9 11.25 female 71 88.75 ethnicity caucasian 54 67.50 african-american 26 32.50 education level < high school 9 11.25 high school graduate 21 26.25 some college 25 31.25 college graduate 25 31.25 marital status single 32 40.00 married 43 53.75 divorced 5 6.25 income level < $10,000 9 12.50 $10,000-$20,000 14 19.44 $21,000-$30,000 19 26.39 $31,000-$40,000 15 20.83 $41,000-$50,000 6 8.33 > $50,000 9 12.50 length of caregiving < 1 year 3 3.75 1-3 years 6 7.50 3-5 years 12 15.00 5-7 years 8 10.00 > 7 years 51 63.75 caregiving class in last year no 70 87.50 yes 10 12.50 chronic illness no 4 5.00 yes 76 95.00 online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 36 communications, the researcher utilized a formal script in each telephone interview to collect the data. instruments health promotion activities were measured using the 44-item health promotion activities of older adults measure (padula, 1997). this tool was designed for use with older adults and addresses health promotion items relevant to older adults. content validity was established through the review and evaluation of six nursing geriatric experts and nursing faculty. construct validity was established through factor analysis that demonstrated support for the five subscales. this instrument uses a 4-point likert response equal-interval scale with responses ranging from always (score of 4) to never (score of 1). the instrument is composed of five subscales: collaborative health management/injury prevention, stress reduction/rest and relaxation, exercise, substance abuse prevention, and nutrition. a health promotion activities total score or subscale scores are achieved by summing responses. the higher the score, the more participation in health promotion activities (padula, 1997). a high cronbach alpha of .96 was reported with previous studies (padula, 1997). cronbach’s alpha was 0.80 for this instrument with this sample. general self-efficacy was measured using the self-efficacy scale. this scale consists of 30 items to which participants respond on a 5 point likert scale ranging from “strongly disagree” (score of 1) to “strongly agree” (score of 5). scores were summed. a higher score reflects higher self-efficacy expectations. construct validity was established through factor analysis and supported through correlations with several personality measures. previous studies reported a cronbach alpha score of .86 (sherer et.al. 1982). a cronbach’s alpha of 0.85 was found in the present study. perceived barriers were measured using the perceived adequacy of resources scale (rowland, dodder, & nickols, 1985), as constructs in this tool were most appropriate to measure the global barriers sought by the investigators. barriers may be identified as a perception of inadequate resources. this 21-item scale assessed the adequacy of resources categorized as physical environment, health/physical energy, time, financial, interpersonal, knowledge/skills, and community resources. participants may respond using a likert scale that ranges from 1 (strongly disagree) to 7 (strongly agree). scores were summed and a higher score indicated a higher perception of perceived resources or low barriers. construct validity of this scale was established through factor analysis. cronbach’s alpha in previous studies was .89 (rowland, dodder, & nickols, 1985). a cronbach’s alpha of 0.87 was found in the present study. functional health was measured using a 10-item subscale from the rand health survey 1.0. items were related to the activities that one might do during a typical day, such as climbing several flights of stairs, walking one, two, or three blocks, bending, kneeling or stooping, lifting and carrying groceries and bathing and dressing oneself. participants may respond on a likert scale that ranges from 1 (yes, limited a lot) to 3 (no, not limited at all). scores were summed. this scale has been widely used in populations of younger and older adults. content validity was established through comparisons to other widely used health surveys while construct analysis was established through factor analysis that demonstrated support for the subscales. previous studies report a cronbach’s alpha of .93 (mchorney, ware, & sherbourne, 1994). a cronbach’s alpha of 0.89 was found in the present study. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 37 emotional health was measured using a 5-item subscale from the rand health survey 1.0. items assessed included feeling downhearted, down in the dumps, calm and peaceful, happiness, and nervousness. participants may respond on a likert scale that ranges from 1 (all of the time) to 6 (none of the time). scores were summed. a high score defines a more favorable health state. validity has been established through factor analysis and comparison with other health scales. previous use of this instrument revealed a cronbach’s alpha of .90 (mchorney, ware, & sherbourne, 1994). cronbach’s alpha of 0.82 was found with this instrument with this sample. the concept of folk home remedy behavior was measured by responses to closedended and open-ended questions regarding the use of home remedies for any health problem(s). the seven home remedies listed in the closed ended questions were solicited through interviews with two family nurse practitioners who work with rural elders in georgia. expert panel review substantiated face validity for this instrument. subjects were also asked to report the frequency of the use of home remedies in terms of per day, week, month, or year. scoring is achieved by multiplying the frequency times the total number of home remedies for a summative score. the higher the total score, the higher the selfreported frequency of use of home remedies. spirituality was measured using the 10-item spiritual perspective scale (sps) (reed, 1987) which measures an individual’s perspective on the extent to which spirituality permeates their lives and, also, the engagement in spiritual activities. each item is rated on a 6-point likert scale ranging from “not at all” (score of 1) to “about once a day” (score of 6). scores were summed. an example of an item from this scale is i seek spiritual guidance is making decisions in my everyday life. validity has been established through factor analysis and comparison with other spirituality measures. previous use of this instrument revealed a cronbach alpha of .90 (reed, 1987; reed, 1991). a cronbach’s alpha of 0.89 was found in the present study. data analyses relationships among the study variables were examined to identify problems related to multicollinearity with no evidence between independent variables noted. descriptive statistical techniques were used to describe the sample, assess the data for violations of statistical assumptions, and to address research questions 1 and 2. multiple regression analysis was used to address research question 3. results frequency distributions were analyzed (table 2) to address research question 1 regarding folk home remedy behaviors and to examine all variables in this study. prayer, as a folk home remedy, was used by 99% of the caregivers. twenty-one caregivers (26%) reported taking apple vinegar as a folk home remedy to lose weight. nine caregivers (11%) indicated that using a honey, lemon and whiskey mixture was helpful for colds, coughing, and sore throat. five (6.25%) caregivers reported using wild garlic as a folk home remedy. to address research question 2 regarding participation in health promotion activities, a frequency distribution revealed overall high levels of engagement (see table 3). specifically, high levels of emotional health, spiritual health, and engagement in health online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 38 table 2 frequencies of folk home remedies (n=80) folk home remedy frequency of use health problem apple vinegar 21 (26.00%) aid digestion constipation decrease swelling high blood pressure general health general maintenance joint stiffness gout coughing leg cramps insect bites sore throat lose weight honey, lemon, & whiskey 9 (11.25%) chest colds coughing sore throat prayer 79 (99.00%) aches/pains all health problems alzheimer’s disease arthritis back pain cancer colon cancer copd depression emotional health fibromyalgia diarrhea osteoporosis general health good health heart disease knee pain mental health painful feet piece of mind energy loss diabetes dieting eyesight sinusitis horse liniment 1 (1.25%) arthritis wild garlic 5 (6.25%) high blood pressure immune system lower cholesterol prevent cancer yellow root 3 (3.75%) diabetes high blood pressure overall health promotion activities (except for exercise) were found (see table 4). addressing research question 3, a multiple regression analysis revealed that emotional health was the sole statistically significant predictor in the model (b = 0.17, p ≤ .05) and accounted for 19% of the explained variance of health promotion activities (see table 5). online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 39 table 3 frequency of engagement in health promotion activities 1.0% 6.0% 11.0% 16.0% 21.0% 26.0% 31.0% 36.0% 110 130 150 170 he alth prom otion activity score s table 4 frequencies of emotional and spiritual health 1.0% 6.0% 11.0% 16.0% 21.0% 26.0% 31.0% 30-38 50 54 58 62 66 72-80 spiritual health scores (range 30-60) em otional health scores (range 36-80) 0% 5% 10% 15% 20% 25% 30% 35% 40% neve r occ. freq. alw ays participation in exe rcis e online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 40 table 5 health promotion activities regression analyses – regression analysis of health promotion activity model (r² = 0.186) independent variable slope (b) se p value pse 0.81 0.74 0.28 par 0.60 0.45 0.18 fh 0.01 0.06 0.86 eh 0.17 0.08 0.05* fhr 0.00 0.01 0.52 spir 2.10 2.41 0.38 pse*par 0.01 0.01 0.16 note. pse = perceived self-efficacy; par = perceived adequacy of resources (measures perceived barriers); fh = functional health; eh = emotional health; fhr = folk home remedy behavior; spir = spirituality; * indicates statistical significance p ≤ .05. discussion and nursing implications the results of this study may provide new knowledge of how nurses might intervene with rural elderly caregivers to enhance health care outcomes by engaging in health promotion behaviors. the following sections address appropriate nursing interventions as well as the need for future research. folk home remedy behaviors ninety-nine percent of participants report using folk home remedies for the promotion of their health within the last year. rural populations learn self-sufficiency in a response to their poor economic status and relative isolation in communities that lack organizations and health care providers (horner et al. 1994). perhaps limited access to formal healthcare settings and subsequent self-sufficiency lead these rural caregivers to utilize folk home remedies. on the other hand, cultural influences, rather then economic or health access factors may relate to this finding. the high levels of folk home remedy behavior in conjunction with high levels of health promotion activities suggest that the use of folk home remedies may not be an obstacle to engagement in health promotion activities in these rural, elderly caregivers. however, folk home remedy use should still be a concern for rural health care providers. the high frequency of folk home remedy use indicates that nursing assessments should include questions about the use of folk home remedies as a measure of health promotion. as noted in this study, participants utilized many folk home remedies in addition to regular health care practitioner visits and medications. folk home remedies may contain natural medications. to avoid complications between folk home remedy behavior and prescribed medications, a query as to the use of folk home remedies should be included in health assessments. further, asking about the use of folk home online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 41 remedies may alert the elderly caregiver that the remedies used may impact their prescribed health care regimen. in addition to providing important health information, questions related to home remedy use demonstrate holistic caring by health care providers (snyder & lindquist, 2002). frequency of health promotion activities overall, participants report a high level of engagement in health promotion activities, which is in contrast to other studies of elders (dancy & ralston, 2002; frank, stephens, & lee, 1998; johnson, 1991). the participants in our study report a high level of engagement in health promotion activities despite having high levels of chronic illness. seventy-six caregivers (95%) report chronic illnesses, as compared to 85% of elders nationwide having chronic illnesses (weinstein & atwood, 1997). chronic illness did not appear to be a barrier to health promotion activities in the participants, although further research is needed to examine this finding. lack of exercise is considered a major health risk factor in elders (lachman & jette, 1997). despite an overall high level of health promotion activity, our findings indicate low levels of exercise. others have also found low levels of exercise in elders (dishman, 1994) and in rural elders (johnson, 1991). rural elderly caregivers appear similar to other elders, in terms of low levels of exercise. however, these findings suggest that rural elders should also be considered an at risk population, due to low levels of exercise. the low levels of exercise in this study may be related to length of time in the caregiver role. gallant and connell (1997) suggest that caregiver health behaviors might decline over the course of caregiving, specifically with a decrease in physical activity. approximately 64% of the caregivers in our study report providing care for more than seven years. because of the extensive length of time in the caregiving role, it is not surprising that the majority of the caregivers in this study report a lack of engagement in exercise practices. the low rate of exercise in this sample suggests that health care providers should address the need for increased physical activity for rural elderly caregivers and for researchers to explore the reasons for low physical activity in this population. rural health care providers should target physical activity in terms of assessment and interventions. assessing exercise behavior may be essential for two main reasons: 1) to stress the importance of exercise to an individual’s health and 2) to determine the appropriate levels of exercise for that individual. furthermore, demonstration of concern by nurses for their overall health may assist the caregiver to assign a higher value to their own health needs and possibly decrease the caregiver guilt related to attention to oneself. counseling regarding the benefits of physical activity in maintaining physical functioning should be directed toward these caregivers. emotional health findings of this study indicate that emotional health is a salient predictor of health promotion activities in rural elderly caregivers. while the amount of variance explained by this model is lower than what has been found in the literature (pender, walker, & sechrist, 1990; weitzel, 1989), this is an exploratory study, which may account for the low amount of explained variance. it may be possible that emotional health enhances participation in online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 42 health promotion activities in this population. the high level of emotional health in our study is in contrast to other studies reporting low levels of emotional health (george & gwyther, 1986). however george and gwyther’s study did include rural elders. the caregivers in our study anecdotally reported feeling strengthened emotionally by the caregiving experience. these findings highlight the importance of emotional health in successful caregiving, particularly in rural elders. nurses must utilize interventions that support the caregiver, reaffirm the caregiver in the performance of their role, and encourage health promotion activities. personal satisfaction in the caregiving role may further encourage the caregiver to engage in more health promotion activities so that they might enjoy good health and continue to sustain the caregiving relationship. if caregivers present with decreased emotional health, then nursing interventions might include attempts to increase engagement in health promotion activities, in addition to any needed mental health interventions. it is interesting that these rural, elderly caregivers report high emotional health in conjunction with high spirituality. future research is needed to explore the effects of emotional health and spirituality on caregiving and health promotion activities in this population. rural health care providers should consider interventions that include collaboration with members of the faith community or the provision of respite to allow for spiritual activities. respite care might be utilized to allow caregivers some personal time or time to attend worship services or other spiritual activities. perhaps health promotion education classes could take place within the community church or laypersons in the church may be trained to teach health promotion during the home visits to the caregivers. limitations of this study should be considered in the interpretation of these findings. this small sample was drawn from only a southern region of the united states. additionally, the data was obtained by self-report. although prayer is often considered a type of folk home remedy behavior (helman, 1994), there may be some overlap between these concepts. future research is needed to provide a deeper understanding of the folk home remedy behavior phenomenon. this exploratory study provides important insight into folk home remedy behavior and the importance of emotional health in the health promotion activities of rural elderly caregivers. future studies are needed to investigate barriers to exercise and interventions to promote exercise in these rural elders. engagement in health promotion activities is essential to the health and quality of life of the rural, elderly caregiver population, in order to sustain the caregiving relationship and maintain the vital service that these informal caregivers provide. references amirkhanyan, a., & wolf, d. 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(1994). the physical and mental health of women caregivers of older adults. journal of psychosocial nursing and mental health services, 32(3), 41-42. [medline] yoder, d. (1972). folk medicine. in r.m. dorson (ed.), folklore and folklife (pp. 191215). chicago: university of chicago press. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8196020%5buid%5d editorial 5 editorial report from australia desley hegney editorial board member in queensland australia we have been the focus of two major inquiries into our public health system – queensland health. the basis for one of the inquiries (a royal commission) was the alleged activities of an overseas trained doctor in a rural town. allegedly he was responsible for several adverse patient outcomes, some of which resulted in the death of patients. as a result of a nurse who decided to ‘blow the whistle’, an initial inquiry into the work of that doctor was established. that royal commission has yet to report its findings. however, a systems review was also established – called the forster inquiry – and i was a member of the rural and remote advisory panel to this inquiry. the forster inquiry report is available from the following web address: http://www.thepremier.qld.gov.au/news/media_matters/2005/30_09_05.shtm. the major recommendations from a rural and remote nursing perspective are: • that rural and remote communities have a right to expect safe and timely access to health services; • that approaches that look at preventing avoidable illnesses, promoting good health, managing chronic disease and coordinating care across the lifespan are critical to the longer term well being and health of rural communities; • geographic isolation means that different models are needed than the models used for larger populations in metropolitan areas; • rural workforces need to be made up predominately of ‘generalists;’ • peer support is very important to prevent ‘burn out’ and the loss of valuable skills for communities. some of the recommendations made included: • safe, sustainable service models should be developed in partnership with rural and remote communities, the commonwealth government and other service providers; • education and training providers will be engaged to assist with increasing workforce supply in rural and remote areas and better develop ‘generalist’ roles including rural generalists doctors, advanced rural and remote nurses, nurse practitioners and paramedic primary care providers; • the queensland government to engage with the australian college of rural and remote medicine to advocate for recognition of rural general medicine as a new speciality; online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.thepremier.qld.gov.au/news/media_matters/2005/30_09_05.shtm 6 • remuneration and incentive packages, including better access to professional development should be improved, to attract clinicians to rural and remote areas; • peer support networks should be established at area health service level, for isolated workers, based around professional groups or streams of care; • all rural and remote services will need to be networked with larger centres, including a tertiary metropolitan hospital. the purpose will be to provide outreach services and some staffing relief; • area health services will establish a register of clinicians willing to perform short or long term country service. the report and its recommendations are currently being rolled out in queensland. we have experienced a spill of all senior positions within queensland health, and new appointments are soon to be made. it will be a major challenge to change a culture which has developed as has been described as one based on bullying and intimidation. people in the past were strongly discouraged from any criticism of the system, and this culture needs to be changed. hopefully we will see all the rural and remote recommendations implemented over time – we can only wait and see. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 61 conceptualizations of "rural": challenges and implications for nursing research frances e. racher, phd, rn1 ardene robinson vollman, phd, rn 2 robert c. annis, phd3 1 associate professor, school of health studies, brandon university, racher@brandonu.ca 2 adjunct associate professor, department of community health, university of calgary, arvollma@ucalgary.ca 3 director, rural development institute, brandon university, annis@brandonu.ca keywords: rurality, defining rural, rural health abstract to identify the nature of the health of rural people and work towards sustaining, supporting, and improving that health, nurses must understand not only differences between rural and urban, but also differences within and among rural people. nurses must understand the implications of defining "rural" in different ways and choose appropriate definitions based upon the foci of their research. in this paper, we discuss variations in the conceptualization of "rural," by examining descriptions, dichotomies, typologies and indices. comprehensive understanding of these conceptualizations will inform nurses in conducting and using rural health research. this knowledge will extend their capacity to identify rural health research questions, to conduct research as insiders living in rural communities, and to use rural health research in providing care and planning programs. introduction interest in rural health is based upon the assumption that rural people reside in rural environments that produce sets of circumstances which are socially, psychologically, geographically, and economically unique, important and identifiable (martin matthews, 1988). and that human attitudes, values and behaviors are indicative of that context and predictive in its evolution. to identify the nature of the health of rural people and work towards sustaining, supporting, and improving that health, nurses must understand not only differences between rural and urban, but also differences within and among rural (humphreys, 1998a). we have hesitated to say rural and urban "what" (areas or regions) for, as nurses, we believe it is more about rural and urban "who" (individuals, families, communities). size, density and location may define the geographical aspect (beshiri, bollman, clemenson, mogan, & mcdermott, 2000), but nursing is predominantly concerned with the human aspect, which must always be foremost (rogers, 1970). as such, nursing research must be driven by the human aspect, although an understanding of the geographical characteristics of rural areas is fundamental in any deliberation on rural people. in this paper, we discuss variations in the conceptualization of "rural," by examining descriptions, dichotomies, typologies and indices. nurses must understand the implications of defining "rural" in different ways and choose appropriate definitions online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.brandonu.ca/academic/healthstudies/ mailto:racher@brandonu.ca http://chs.myweb.med.ucalgary.ca/ mailto:arvollma@ucalgary.ca http://www.brandonu.ca/organizations/rdi/ mailto:annis@brandonu.ca 62 based upon the foci of their research. while some researchers differentiate between the terms "rural," a particular kind of geographic milieu, and "rurality," a particular behavior style associated with such areas (hoggart, 1990), many do not (humphreys, 1998a; martin matthews, 1988; rourke, 1997). for the purposes of this paper no differentiation in meaning will be made between the two terms. variations in the conceptualization of rural halfacree (1993) declared that search for a single, all-purpose definition of "rural" is neither feasible nor desirable and that the definition should be tailored to the task at hand. pitblado et al. (1999) agreed, suggesting that a definition that is suitable for human health resource planning may not be appropriate for the assessment of health status. wootton (1996), editor of the canadian journal of rural medicine, identified the journal’s difficulties in defining rural and challenged readers, “if you have a clear idea of what rural means to you, share it with us.” it has become apparent that definitions of "rural" constructed for particular purposes, by specific disciplines, and for specific circumstances are being applied to current situations for which the fit is debatable. with this in mind, knowledge of the variations remains useful in identifying criteria for consideration in the construction or adaptation of definitions of "rural" to meet existing and evolving research needs. abstractions of "rural" may be organized into four types: (a) descriptions of "rural," (b) dichotomies of "rural" and "urban," (c) typologies across the geographical gamut or specific to "rural," and (d) indices or indexes of factors weighted to determine degree of "rurality." distinction between them, however, on occasion becomes blurred. for example, the "rural and small town canada" definition of "rural" (mendelson & bollman, 1998), begins as a description, creates a dichotomy and upon closer scrutiny is intricately linked to a typology. descriptions according to bealer, willits & kuvlesky (1965), the term "rural," historically referred to areas of low population density, small absolute size and relative isolation, involved with primary production, and offering a homogeneous way of life. although these sociologists identified ecological, occupational, and socio-cultural aspects of the concept "rural," they concluded that description changes over time and more accurate meaning should be explored at an analytic rather than descriptive level. they opined that there is always “some phenomenon toward which the given definition has some presumed explanatory significance”, further “the construct can also be used as an independent variable and as a source of explanatory factors” (p. 342). hoggart (1990) argued that notions of "rurality" should not guide the selection of sites for empirical investigation as the broad category of "rural" is obfuscatory, whether the aim is description or theoretical evaluation, since intra-rural differences can be enormous and rural-urban similarities can be striking. martin matthews (1988) suggested that "real" distinctions that emerge between "rural" and "urban" are a by-product of whether "rurality" is conceptualized in ecological or socio-cultural terms. miller and luloff (1981) extensively reviewed the literature that debated the continued existence of online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 63 a rural culture and a rural ideology, and firmly declared, “rurality is a viable analytic construct with an empirical reference in reality” (p. 609). troughton (1999) concluded, “rural is what people recognize as rural.” descriptions of rural from traditional geographical perspectives tend to include three specific criteria: size, density and location (beshiri et al. 2000; rupri, 2001). size of population refers to the number of people who live within a given area. density is a measure of population concentration, and location, is a function of distance, often from large urban centers. halfacree (1993) outlined three broad approaches to defining rural: descriptive definitions, descriptions based on socio-cultural characteristics, and those founded on locality. he stated that only the last of these is adequate, as it more accurately conceptualizes space, but he concluded that defining the social representation of the space is the more appropriate goal. further, halfacree argued, researchers go away and look for statistics and variables that might fit with their intuitive descriptive ideas of what rural is and define rural accordingly. therefore, he cautioned that descriptive methods only describe rural and do not define it. dichotomies statistics canada definitions. “it is necessary to define "urban" first because the standard definition of "rural" is essentially everything that is not "urban"” (beshiri et al. 2000, p. 1). statistics canada has created a dichotomy in its definition of "census urban," “to be defined as urban the area must have a population of 1,000 or more and a density of 400 per square kilometre or more and where the continuous built-up area does not exceed 1 kilomentre” (p. 3). therefore, "census rural" includes “areas with a population of less than 1,000, a population density of less than 400 people per square kilometre, and in areas where continuous built-up areas exceeds 1 kilometre” (p. 3). this definition has been used to generate a rural/urban variable in large national surveys such as the national population health survey (statistics canada, 1998). the canada census definitions do not differentiate between rural and urban communities and all small rural communities with populations of at least 1000 people are considered to be urban. therefore, using 1996 statistics canada data (2001), small rural towns such as viking, alberta (population 1,081); langenburg, saskatchewan (population 1,191); and deloraine, manitoba (population 1,041) are grouped with large urban cities such as calgary, alberta (population 768,082); toronto, ontario (population, 653,734); and vancouver, british columbia (population 514,008). using this definition, the within-group variation will certainly exceed the between-group variation (coward, mclaughlin, duncan & bull, 1994) and findings will say little about "rural" (hoggart, 1990). american definitions. in the united states, two dichotomies are commonly employed: (a) "urban" and "rural" areas; and (b) "metropolitan" and "non-metropolitan" areas. for the 1990 census, the u.s. bureau of the census defined "urban" areas as “comprising all territory, population, and housing units in places of 2,500 or more persons incorporated as cities, villages, boroughs (except in online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 64 alaska and new york), and towns (except in the six new england states, new york, and wisconsin), but excluding the rural portions of "extended cities," in census designated places of 2,500 or more, or in other territory, incorporated or unincorporated, including in urbanized areas” (rupri, 2001, p. 3). "rural" was residual, based upon the population left over after urban areas were defined. for the u.s. census 2000, "urban" was classified as all territory, population, and housing units located within an urbanized (ua) or and urban cluster (uc), where ua and uc boundaries encompass densely settled territory which consists of core census block groups or blocks that have a population density of at least 1,000 people per square mile and surrounding census blocks that have an overall density of at least 500 people per square mile (u.s. census bureau, 2004). (under certain condition, less densely settled territory may be part of each ua or uc.) "rural" again consisted of all territory, population and housing units located outside of the uas and ucs. initially, the u. s. office of management and budget (omb) defined a metropolitan area as “one large population nucleus, together with adjacent communities that have a high degree of economic and social integration with that nucleus” (rupri, p. 2). a metropolitan area included (a) at least one central county with either, a place with a population of at least 50,000, or a census bureau-defined urbanized area, and a total metropolitan area population of at least 100,000 (75,000 in new england); and (b) one or more outlying counties that have close economic and social relationships with the central county. outlying counties must have a specified proportion of residents commuting to the central counties and must meet standards regarding metropolitan character such as population density, urban population, and population growth. again the definition of "non-metropolitan" is residual, based upon the population left over after "metropolitan" is determined. in june 2003, the omb released a new version of the definitions for "metropolitan" and "non-metropolitan" in keeping with the census 2000 changes to definitions for "urban" and "rural." under the new "core-based statistical area" system, metro areas were defined for all urbanized areas regardless of total area population. in addition, inclusion as an outlying county is based on a single commuting threshold of 25 percent with no metropolitan character requirement. streamlining the criteria in this manner decreases the population covered by metro areas by approximately two million residents, but actual expansion of metro territory during the last decade added 8 million persons. the net effect reduces the 2000 non-metro population from 55 to 49 million persons (usda, 2004a, p. 1) the term "non-metropolitan" is the term for "rural" most commonly used in research, analysis and policy making in the united states (rupri, 2001). whether using the earlier or the revised definition, it is recognized that "metropolitan" areas can include counties with a large amount of "rural" population (using the previous "rural" definition) and "non-metropolitan" counties can include a large amount of "urban" population. another limitation, common to all dichotomies, is that they disregard the diversity (rupri, 2001), and gloss over the richness of rural (weinert & burman, 1999a) and urban life. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 65 table 1 standard geographical classifications geographical unit description enumeration area ea (n=49,361) the geographic area canvassed by one census representative. it is the smallest standard geographic for which census data are reported. all the territory of canada is covered by eas. census subdivision csd (n=5,984) the general term applying to municipalities (as determined by provincial legislation) or their equivalent (such as indian reserves and unorganized territories). in newfoundland, nova scotia and british columbia, the term also describes geographic areas that have been created by statistics canada in cooperation with the provinces as equivalents for municipalities for the dissemination of statistical data. census consolidated subdivision ccs (n=2,607) a grouping of census subdivisions. generally, the smaller, more urban census subdivisions (towns, villages, etc.) are combined with the surrounding, larger, more rural census subdivisions, in order to create a geographic level between the census subdivision and the census division. census division cd (n=288) the general term applied to areas established by provincial law which are intermediate geographic areas between the municipality (csd) and the provincial level. census divisions represent counties, regional districts, regional municipalities and other types of provincial legislated areas. in newfoundland, manitoba, saskatchewan and alberta, provincial law does not provide for these administrative geographical areas. therefore, census divisions have been created by statistics canada in cooperation with these provinces for the dissemination of statistical data. in the yukon territory, the census division is equivalent to the entire territory. province/territory pr (n=13) the major political divisions of canada. from the statistical point of view, they are the basic unit for which data are tabulated and crossclassified. the ten provinces and 3 territories cover the complete country. census metropolitan area cma (n=25) a very large urban area (the urban core) together with adjacent urban and rural areas (urban and rural fringes) that have a high degree of social and economic integration with the urban core. a cma has an urban core population of at least 100,000 based on the previous census. census agglomeration ca (n=112) a large urban area (urban core) together with adjacent urban and rural areas (urban and rural fringes) that have a high degree of social and economic integration with the urban core. a ca has an urban core population of at least 10,000, based on the previous. once a ca attains an urban core population of at least 100,000, based on the previous census, it is eligible to become a cma. source: statistics canada. (1997). georef users guide: 1996 census – reference products. catalogue no. 92f0085xcb. ottawa: author. statistics canada rural/urban codes online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 66 typologies countries have developed typologies or continuums to better define the variations (often in size, density and locality) among primary geographical units. before entering into a discussion of these typologies, some understanding of the classifications of standard geographical units is in order. for the purposes of this paper, canadian geographical units are used, but many nations apply similar constructs in their classification systems. the standard geographical classification operationalized by statistics canada (see table 1) is built upon a primary unit called an enumeration area. enumeration areas (ea) make up census subdivisions (csd), which are aggregated into census divisions (cd) and finally provinces (pr). the census consolidated subdivision (ccs) was developed later, to bridge the gap between the csd and the cd. newer aggregates include the census metropolitan area (cma) and the census agglomerate (ca). large urban municipalities exert social and economic influence beyond their city limits (beshiri et al. 2001). the concepts of cma and ca were created to delimit the extent of the influence of cities and large towns on surrounding municipalities. the primary focus of the rural/urban codes was identification of urban influence on nearby municipalities in response to the “overwhelming urbanization of the society” (r. bollman, personal communication, september 25, 2001). in applying the rural/urban codes, statistics canada uses the primary geographical unit, the ea. each ea is classified according to the definitions numbered 1 to 5 which include; urban core, urban fringe, rural fringe, urban outside cmas/cas, and rural (table 2). table 2 statistics canada rural/urban codes geographical category description 1. urban core urban areas that form the core of the cmas/cas 2. urban fringe urban areas contained within the boundaries of cmas/cas, but not contiguous with the urban core 3. rural fringe non-urban areas contained within the boundaries of cmas/cas 4. urban outside cmas/cas small towns that are urban (based on the census urban definition) and located outside the boundaries of cmas/cas 5. rural non-urban areas located outside the boundaries of cmas/cas source: pitblado et al. (1999). assessing rural health: toward developing health indicators for rural canada. ottawa: health canada. this typology, the foundation of the rural and small town (rst) canada definition, identifies rural and small town canada as including “the population living outside the online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 67 commuting zones of larger urban centres – specifically outside cmas and cas” (mendelson & bollman, 1998). rural/urban codes 1, 2, and 3 are defined as "urban," while 4, and 5 are considered to be "rural." would a possible alternative be to consider the rural fringe as rural? therefore groupings would be 1 and 2 as "urban" and 3, 4, and 5 as "rural." since the launch of the rural and small towns canada analysis bulletin by statistics canada in 1998, the definition of rural and small town (rst) canada has become widely recognized. the initial bulletin further clarified the definition. a cma has an urban core of 100,000 or over and includes neighboring municipalities where 50% or more of the workforce commutes into the urban core. a ca has an urban core of 10,000 to 99,999 and includes all neighboring municipalities where 50% or more of the workforce commutes into the urban core (p. 2). "rural" people, living in municipalities (csds) where 50% of the workforce commutes to an urban core, are counted as and considered to be "urban." the factor determining "rurality" is travel for employment, one’s own employment, or perhaps that of someone else. this approach underestimates the total canadian rural population and forges a definition of "rural" that may be useful for some research purposes and not others. this definition has been used by researchers such as pitblado et al. (1999), who are developing rural health indicators, and keefe (1999), in her study of informal caregiving in rural and urban canada. preliminary typology of rural canada. the traditional process of defining rural areas with reference to an urban benchmark has tended to give the impression that rural canada is one residual area largely homogenous in its demography, employment base, income, culture, and social infrastructure (bollman, 1994). researchers at statistics canada undertook a study to identify, describe and map the diverse features of rural canada. census data from 1981 and 1991 were analyzed. census divisions with similar socio-economic characteristics were clustered and included demographic variables (such as population change and age structure), labor market, income, human capital and infrastructure variables. the result was a preliminary typology of rural canada comprised of seven categories: (a) primary settlements, (b) urban frontier, (c) rural nirvana, (d) agrorural, (e) rural enclave, (f) resourced areas, and (g) native north. description of the categories is provided in table 3. bollman (1994) concluded, “such typologies are useful for describing the diversity of rural canada as it actually is, and as a starting point to developing methodologies for understanding that diversity and its transformation over time” (p. 144). metropolitan influence zone (miz) categories. the metropolitan area and census agglomeration influence zone (miz) is a refinement of the rst definition (beshiri et al., 2000). this classification demonstrates the influence of cmas and cas on surrounding csds beyond the cma/ca areas, or within the rst. commuting flows are measured, based upon 1991 census place of work data of the employed labor force. the four zones are described in table 4. u.s. rural – urban continuum codes and urban influence codes. researchers at the united states department of agriculture, developed codes to distinguish among counties located along different points of the continuum defined by population distance from metropolitan centers and the regional urban-rural mix (ehrensaft & beeman, 1992). since that time, researchers have synthesized u.s. data to show the systematic variation online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 68 table 3 a preliminary typology of rural canada geographical category description 1. primary settlements canada’s seven largest cities with similar characteristics 2. urban frontier cds contain a larger city or are adjacent to larger cities and have characteristics similar to but less extreme than those of the primary settlements e.g., education levels and number of professional and managerial workers tended to be well above average but lower than the primary settlements 3. rural nirvana cds with significant population increase and migration rates suggest the areas are most attractive to young migrants, second highest rates of employment and the lowest unemployment rates (this category is concentrated in southern ontario.) 4. agro-rural small populations in dispersed settlements with the population tending to be older; populations stable or declining 5. rural enclave almost exclusively in the atlantic provinces with low rates of economic activity for men and women and high rates of unemployment; fishing employment was significant in 1991 in 83% of these cd; the lowest household income and high rates of dependency on social transfer payments. 6. resourced areas some cds with a high share of population in towns and other cds with a low share of population in towns (perhaps because the location and extraction of minerals tends to be timebound and haphazard.); high share of young people and very low proportion of elderly; name chosen as relatively high in natural resources (minerals, petroleum, forests) and relatively high in young human capital resources 7. native north cd clustered on basis of youthful populations, low economic activity rates and low skill levels source: bollman, r. (1994). a preliminary typology of rural canada. in j. bryden (ed.), towards sustainable rural communities (pp.141-144). guelph: university of guelph. of social and economic characteristics of local populations across code classes. these codes have been modified and over time two continuums have evolved. table 5 illustrates adaptations of the codes, resulting in the rural – urban continuum codes which classify all u.s. counties by degree of urbanization and nearness to a metropolitan area and the urban influence codes which classify counties based upon the size of the metropolitan statistical area (similar to the cma) or adjacency to msa and size of largest city. in 2003, the continuum codes were adjusted and codes "0" and "1" were combined (usda, 2004b). online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 69 table 4 miz categories geographical category description 1. strong miz includes csds with a commuting flow of 30% to 50% 2. moderate miz csds with a commuting flow of 5% to 30% 3. weak miz csds with a commuting flow of 0% to 5% 4. no miz csds with no commuting to an urban core or there are less than 40 persons in the resident labour force and the data are suppressed source: beshiri, r., bollman, r., clemenson, h., mogan, a., & mcdermott, a. (2000). defining rural. ottawa: draft paper prepared for statistics canada. one advantage of these classification systems over the rural/urban and nonmetropolitan/metropolitan definitions is that for non-metropolitan counties these systems indicate proximity to metropolitan areas. the rural – urban continuum codes also indicate the size of urban population within a county, while the urban influence codes indicate the presence of a city and the city size (rupri, 2001). disadvantages accrue as the rural – urban continuum codes use the previous definitions of rural/urban and non-metropolitan/metropolitan and the urban continuum codes use non-metropolitan/metropolitan, hence, the difficulties with these definitions as stated earlier remain. further, these classification schemes do not help identify rural portions of metropolitan areas. county typology codes. the county typology codes were designed to identify groups of u.s. non-metropolitan counties sharing important economic and policy traits (rupri, 2001). based upon primary economic activity, the six non-overlapping types are: farming-dependent, mining-dependent, manufacturing-dependent, government-dependent, services-dependent, and non-specialized. the five overlapping policy types include: retirement-destination, federal lands, commuting, persistent poverty, and transferdependent. this classification system sorts the wide range of economic and social diversity existing in u.s. non-metropolitan counties into a few important themes. based upon the assumption that knowledge and understanding of different rural economies and their distinctive economic and socio-demographic profiles is useful for rural policymaking, this system makes the identification of rural counties with particular economic and sociological characteristics easier. the limitations of the typology are similar to those of the previous two classification systems. isolated rural areas and frontier areas. the concepts "isolated rural areas" and "frontier areas" were designed to address the limitations of the dichotomies and typologies employed in the united states. the definition of "isolated rural areas" was online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 70 table 5 rural – urban continuum codes compared to urban influence codes rural – urban continuum codes urban influence codes metropolitan 0 central counties of metropolitan areas of 1,000,000 population or more metropolitan 1 fringe counties of metropolitan areas of 1,000,000 population or more 1 central and fringe counties of metro areas of 1 million population or more 2 counties in metropolitan areas of 250,000 to 1,000,000 population 2 small-counties in metro areas of fewer than 1 million 3 counties in metropolitan areas of fewer than 250,000 population non-metropolitan non-metropolitan 3 adjacent to a large metro area with a city of 10,000 or more 4 urban population of 20,000 or more, adjacent to a metropolitan area 4 adjacent to a large metro area without a city of at least 10,000 5 urban population of 20,000 or more, not adjacent to a metropolitan area 5 adjacent to a small metro area with a city of 10,000 or more 6 urban population of 2,500 to 19,999, adjacent to a metropolitan area 6 adjacent to a small metro area and without a city of at least 10,000 7 urban population of 2,500 to 19,999, not adjacent to a metropolitan area 7 not adjacent to a metro area and with a city of 10,000 or more 8 completely rural or fewer than 2,500 urban population adjacent to a metropolitan area 8 not adjacent to a metro area and with a city of 2,500 to 9,999 population 9 completely rural or fewer than 2,500 urban population not adjacent to a metropolitan area 9 not adjacent to a metro area and with no city or a city with a population less than 2,500 source: adapted from rural policy research institute (2001). developed in response to a need to expand rural health outreach grant eligibility to include parts of large metropolitan counties (counties with at least 1,225 mi2) that do not have easy geographical access to central areas. isolated rural areas are defined as rural areas (census tracts) in which less than 15% of the population commuted to work in the central area (operationally, a city of 50,000 or more persons plus the surrounding densely settled suburbs) or rural areas (census tracts) in which more than 15% of the population commuted to work in the central area, if 45 percent of the labour force commuted 30 minutes or more to work (p. 7, rupri, 2001). the term "frontier area" was developed to describe a county or census tract with extremely low population density, usually fewer than 6 people per square mile and characterized by isolation due to distance from central places, poor access to market areas, and people’s isolation from each other in large geographic areas (rupri, 2001). geographic, cultural and human resource problems make the provision of human services, in general and health services in particular, extremely formidable in these areas. some organizations, such as the frontier online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 71 mental health services network, define a "frontier area" as having a population density of 7 people or less per square mile. this type of definition helps identify nonmetropolitan or rural counties and census tracts with special policy and service needs. oecd definitions. in 1994, the organization of economic co-operation and development created internationally comparative definitions of "rural regions" and "rural communities" (beshiri et al. 2000). a "predominantly rural region" was defined as having more than 50% of the population living in rural communities, with a "rural community" being defined as having a population density less than 150 persons per square kilometre. to implement this definition in canada, cds were used to represent "regions" and ccss were used to represent "communities." researchers working with statistics canada have suggested that these rural regions can be divided into three types: (a) those adjacent to metropolitan centres, (b) those not adjacent to metropolitan centres, and (c) rural northern regions (beshiri et al., 2000). two urban regions can also be derived in relation to this definition: (a) an "intermediate region" defined as “where between 15% and 50% of its population lives in rural communities”, and (b) "predominantly urban" regions “where less than 15% of the population resides in rural communities” (p. 7). pitblado et al. (1999) in their work to develop health indicators for rural canada, have compared the population of rural canadians using the oecd typology of "predominantly rural," "intermediate" and "predominantly urban" and the statistics canada rural – urban codes. using the noncma/nonca population of canada (codes 4 and 5, ie. the rst definition), 22.2% of the canadian population is defined as "rural." using the oecd definition of "predominantly rural" 31.5% of the canadian population is considered to be "rural." in canada, the oecd typology is applied at a ccs level, and has been found useful for labour market analysis to the extent that these regions are proxies for functional labour markets. other issues, however, may require smaller geographical units for policy analysis or program development (beshiri et al. 2000) indices researchers and policy analysts have long recognized that focus on defining the nebulous concept of "rural" should extend to measuring differences in the degree of "rurality." with this goal in mind, cloke (1977) developed and applied one of the first "rurality" indices or indexes. index of rurality for england and wales. this index incorporated a total of sixteen variables. the index began with three traditional variables to measure -1. low density, 2. high involvement in rural primary industries, and 3. a consequent low level of commuting to employment outside the area. several demographic variables were added including three related to age structure. the design of the three variables assumed that a non-urban or rural trend is indicated by depopulation and a disproportionate number of elderly people. therefore, an age structure biased towards the 15-45 age group indicated an urban trend. the three variables measured -4. the proportion of the population over the age of 65, 5. the proportion of men present in the 15-45 age group, and 6. the proportion of women in the 15-45 age group. a measure of 7. population change, three migration variables (8. in online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 72 migration, 9. out migration, 10. in/out migration balance), 11. an indicator of the level of household amenities, two occupancy rates (12. % population at 1 1/2 room, and 13. households per dwelling), and three distance variables (14. distance from nearest urban centre of 50,000 population, 15. distance from nearest centre of 100,000, and 16. distance from nearest centre of 200,000) completed the index. in later years, cloke and edwards (1986) re-applied the index. they concluded that rural researchers should seek to avoid the treatment of "rurality" as a static phenomenon. and suggested that although they had demonstrated the measurement of "rurality" between two censal data points, it is equally important to recognize the nature of "rurality" itself changes over time. general practice rurality index for canada. according to leduc (1997), an instrument for measuring the "rurality" of the general practice of medicine in canada is needed to provide a standard of comparison that can be used by researchers, educators, administrators, and rural physicians. he developed such an index, incorporating six variables: remoteness from a basic referral centre, remoteness from an advanced referral centre, drawing population, number of general practitioners, number of specialists, and presence of an acute care hospital. variables were weighted and summed on a 100-point scale. this index was the precursor of a national framework on "rurality" based upon the feedback from rural canadian physicians to the canadian medical association survey on rural medical practices in canada (buske, yager, adams, marcus, & lefebvre, 1999). physicians were asked, “what defines a community as "rural"? the top ten ranked factors at the national level were used to generate four primary factors and six secondary factors. the primary factors included: high level of on-call responsibilities, long distance to a secondary referral centre, lack of specialist services, and insufficient general practitioners/family practitioners. the secondary factors were: long distance to a tertiary referral centre, absence of equipment such as x-rays and laboratory services, difficulty in obtaining locums, no ambulance service, inability to provide services such as obstetrics or general surgery, and a sparsely populated catchment population. the question was asked and physicians provided a list of "what" defines a rural community, only the tenth indicator mentions the "who." perhaps a different list would have been generated if they were asked about the "who" or if they identified the community as the people before focusing on the place. montana state university rurality index. researchers have proposed examining "rural" health along a continuum incorporating population, economic, occupational, and access factors (weinert & burman, 1999). the montana state rurality index is such an example, employing a continuum of "rurality" based on access and population variables. this index uses only two variables: county population and distance to emergency care. the validity of the index does not appear to be compromised by its parsimony (weinert & boik, 1995). this index suggests a starting point in exploring rural issues related to access to health care. depending upon the focus of the research, however, other sociocultural or economic characteristics may need to be incorporated (weinert & burman, 1999). online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 73 challenges and implications for nursing research in light of the myriad definitions of "rural," halfacree’s declaration becomes even more salient. the definition of "rural" and, we suggest, the method for determining it, should be “tailored to the task at hand” (halfacree, 1993, p. 34). weinert and burman (1994) reviewed the nursing literature and identified four major types of rural health research: (a) studies exploring health and health-related phenomena in a rural area, (b) studies specifically examining rural and urban differences, (c) research focused on a concept such as chronic illness, where rurality was one of several demographic variables, and (d) studies of typical rural populations such as farmers, fishers, migrants or first nations. this rural research was of widely differing sophistication and ranged from highly structured studies of large databases to individual case studies and anecdotal reports. nurses are conducting and participating in rural health research. their knowledge of the implications of using different definitions of "rural" is key to ensuring quality and effectiveness in their research activities. nurses are using rural health research in program development. their ability to analyze and interpret that research is pivotal in planning service delivery to improve and promote the health and well-being of rural people. rural health research in canada canada’s study of rural health lags behind other nations, who have considerable rural populations and substantial rural geography. the united states has recently developed a detailed analysis of urban/rural patterns of health in america for use in targeting efforts of prevention and health care access (health and human services news, september 10, 2001). this chartbook provides detailed analysis of population characteristics, health risk factors, health status indicators, and health care measures for residents of counties grouped by five urbanization levels. it also examines patterns by region of the country. the chartbook is available on line and tables at the web site are being updated as new data becomes available (centres for disease control and prevention, 2001). australian research on rural health has a long tradition, resulting in the landmark publication of health in rural and remote australia (australian institute of health and welfare, 1998). this research became possible, after the development of a national rural health strategy, called for the development of national and local indicators for rural and remote health (humphreys, 1998b; 1999). the wisdom of the people of australia is apparent in their development of "national" and "local" indicators. as yet, canada has not developed such agreed sets of indicators. we are just coming to recognize that we need a national rural health research strategy (pong et al. 1999; watanabee & casebeer, 1999). in 2001 a rural health research forum sponsored by the canadian institutes of health research (cihr) was held in st. john’s, newfoundland. forty researchers, practitioners, and policymakers interested in rural health were invited, to develop a set of strategies as a foundation to advance rural health research and knowledge translation in canada (lyons, 2001a). four key research priorities permeated conversations: (a) health status of rural people and communities, (b) determinants and consequences of rural health, (c) rural online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 74 health service in the broadest context, and (d) human and other resources to undertake rural health research (lyons, 2001b). this exciting initiative will generate new directions in rural health research. those in attendance recognized the importance of an agreed upon national "rurality" index for health care planning and resource allocation. regional and local indexes are also required. participants further acknowledged that qualitative studies (including participatory action research) of the health and health-related issues of rural people, are essential to complement quantitative research, for policy development and program planning purposes. taking up the challenge from this initiative and other forums on rural health, mitura and bollman (2003) have provided the first analyses of the health of rural canadians in a recent statistics canada bulletin. nurse in canada are challenged to engage in rural health research and contribute to future understanding of the health status and health behaviors of rural canadians. conclusions defining rural is a complex and multifaceted process that changes, according to the purpose for which the definition is being designed. the definition changes further dependent upon the people and the process involved in its creation. nurses recognize that in rural health research, any definition of rural must focus first on "rural" people, then on the context of their "rurality." nurses provide the bulk of primary care in rural settings and have an understanding of the issues of health status and health behaviors of rural people. from their rural practice, nurses come to understand the rural people and the rural communities whom they serve. this knowledge extends their capacity to identify rural health research questions, to conduct research as insiders living in rural communities, and to use rural health research in providing care and planning programs. nurses recognize the commonality and diversity of rural people and rural places. this knowledge must be incorporated into their research and their practice. weinert and burman (1999) used the sampler quilt to depict their understanding of rural communities –each square is made up of many pieces. across squares, there are pieces that are alike and some that are unique. each square is a work of art unto itself, but only when the squares are stitched together can the overall pattern of the quilt be fully appreciated and understood (p.76). this same metaphor could be used to describe rural health research, for only when a considerable number and variety of studies are completed and placed together as a whole, will an understanding of the health of rural people be apparent. nurses have a pivotal role to play in conducting and using rural health research. to ensure that the needs of rural dwellers are understood, rural health science is advanced, rural health programs are effective, and rural 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(1999). redefining ‘rural’ for the 21st century. in w. ramp, j. kulig, i. townsend, & v. mcgowan (eds.) health in rural settings: contexts for action (pp. 21-38.) lethbridge, ab: univesity of lethbridge press. u.s. census bureau. (2004). census 2000 urban and rural classification. retrieved january 17, 2004, from http://www.census.gov/geo/www/ua/ua_2k.html u.s.d.a. (2004a). measuring rurality: new definitions in 2003. retrieved january 23, 2004, from http://www.ers.usda.gov/briefing/rurality/newdefinitions/ u.s.d.a. (2004b). measuring rurality: rural-urban continuum codes. retrieved january 24, 2004, from http://www.ers.usda.gov/briefing/rurality/ruralurbcon/ watanabee, m., & casebeer, a. (1999). rural health research: the quest for equitable health status for all canadians. a report of the rural health research summit, prince george, british columbia, october 23-25. unpublished. weinert, c., & boik, r. 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(1996). what’s in a definition? canadian journal of rural medicine, 1(2), 55-56. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.census.gov/geo/www/ua/ua_2k.html http://www.ers.usda.gov/briefing/rurality/newdefinitions/ http://www.ers.usda.gov/briefing/rurality/ruralurbcon/ http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=7676078 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=7986579 abstract 57 perspectives of registered nurse cultural competence in a rural state part ii teresa seright, msn, rn1 1 instructor, department of nursing, minot state university, teresa.seright@minotstateu.edu abstract the article is the second in a two-article series. the first article in the series provided the reader a conceptual definition of cultural competence, a literature review and a description of the relevance of culturally competent care in a rural state. in this article, the author described the outcomes of a selfassessment survey completed by registered nurses in a homogenous rural state. the purpose of this study was to determine the relationship between cultural competence and educational preparation. it was hypothesized that the north dakota nurses who reported participation in cultural competency educational programs would rank themselves higher on the iapcc-r than those who had not reported participation in such programs. a voluntary sample of registered nurses from urban and rural hospitals in the state of north dakota were surveyed using the inventory for assessing the process of cultural competence – revised version (iapcc-r) and a demographic survey tool. the data analysis was accomplished through correlational statistics. results of this research indicate that a majority (>80%) of the participants did not consider themselves culturally competent. while higher self rating scores did correlate to participation in educational activities, the quality and frequency of those activities varies. the author offered suggestions for improved rate and quality of cultural competence education as well as suggestions for further research. the impact of a lack of cultural competence health care providers who lack cultural competence may be putting patients at risk for delays in treatment, inappropriate diagnoses, noncompliance with health care regimens, and even death (institute of medicine, march 2002). although health care providers may not see themselves as overtly racist or neglectful, they could be missing pertinent healthcare findings due to cultural blindness. in this style of interacting with clients, described by bell and evans, as quoted in campinha-bacote (2003), the health care professional has made a decision that he/she is committed to equality for all people and therefore treats all people alike, regardless of cultural background (p. 23). this type of interacting style lends to misinterpretation of verbal and physical cues made by the patient and ignores the fact that there are variations within cultural groups. in states where a largely homogenous population resides, cultural blindness could logically exist. this, coupled with the desire to appear politically correct, may lend to behaviors wherein the healthcare provider indicates that she or he has no problem with the patient’s cultural beliefs and as well does not need to know more about them. conceptual definition of culture competence cultural competence can be conceptually defined as a referent to an individual who demonstrates cultural awareness, knowledge and skill and applies these components as he/she interacts with patients, co-workers, and customers. further, the culturally competent individual operates from a platform of respect for others. he/she continuously self-assesses and adjusts to the dynamic and challenging opportunities in remaining culturally aware and effective. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.minotstateu.edu/nursing/ mailto:teresa.seright@minotstateu.edu 58 cultural demographics of north dakota how did cultural competence look in a state such as north dakota where us census bureau data indicated that the population was the 9th most white, or caucasian, state in the union (north dakota fact sheet, 2005)? at the same time, there was a large population of american indians, many of whom were living off of their reservations and in the surrounding communities (north dakota indian affairs commission, 2005). there were also many refugees living mainly in the north eastern area of the state who had emigrated from countries such as kurdistan, haiti, russia, bosnia, zaire, vietnam, somalia, sudan, cuba, armenia, and iraq. these persons, and those who lived in college dormitories, military bases or other group settings, were likely not accurately accounted for in census data. this same us census data showed a trend of rising diversity in the state since 2001; however nd remains more than 90% white. study purpose and objectives the purpose of this study was to evaluate north dakota registered nurses’ self-rating of cultural competency, with the intention of creating dialogue at the board of nursing, health care administrations, and university settings in our state about cultural competency education implementation and evaluation. this study tested the hypothesis that nurses who participate in ongoing and formalized cultural diversity training would rate themselves higher on the inventory for assessing the process of cultural competence-revised (iapcc-r) scale than those nurses who have not participated in such programs. research questions 1. what percentage of registered nurses in north dakota rated themselves as culturally competent? 2. how did those registered nurses who rated themselves high (more competent) on the iapcc-r differ demographically from those that rated themselves low (less competent)? 3. did the type and frequency of cultural competency training impact the registered nurses’ self-rating? theoretical framework madeleine leininger was truly a pioneer in developing the field of transcultural nursing in the 1950’s (boyle and wenger, 2002). since then, several nursing scholars have added to the field-andrews and boyle, spector, giger, purnell and paulanka, campinha-bacote (boyle and wenger, 2002).this study was based on the work of dr. josepha campinha-bacote. brathwaite (2003) described campinha-bacote’s model of cultural competence as one which provided direction for education, practice, and research and which met the criteria used to critically appraise conceptual models. the process of cultural competence in the delivery of health care services is a model that requires health care providers to see themselves as becoming culturally competent rather than being culturally competent (campinha-bacote, 2002). the following are the basic assumptions of the model of care: online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 59 1. cultural competence is a process, not an event. 2. cultural competence consists of five constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. 3. there is more variation within ethnic groups than across ethnic groups (intraethnic variation). 4. there is a direct relationship between level of competence of health care providers and their ability to provide culturally responsive health care services. 5. cultural competence is an essential component in rendering effective and culturally responsive services to culturally and ethnically diverse clients. methods this randomized descriptive study used an established self assessment tool, the iapccr, which was cross tabulated with a demographic tool created by the author. the dependent variable, cultural competency, was correlated to several independent variables on the demographic tool. of special interest to this investigator were the independent variables related to education in the workplace. nurses in select acute care hospital facilities in north dakota volunteered to participate in the proctored survey. returned surveys implied consent of the respondents to participate in the study. of the 205 surveys returned, 26 were eliminated due to missing data for a sample size of 179 (figure 1 and table 1). figure 1. distribution of surveys in the state of north dakota (nd) . n=179 online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 60 table 1 survey participants by region of north dakota and usable surveys region of nd requested returned rate response surveys usable northwest 95 66 69.47% 53 southwest 70 44 62.86% 39 northeast 56 39 69.64% 36 southeast 60 56 93.33% 51 total 281 205 72.95% 179 instrumentation, data collection, and analysis the iapcc-r was a 25 item self-administered tool that was designed for use by health professionals to measure cultural competence. reliability of the iapcc-r had been established in prior research studies which produced cronbach’s alpha coefficients ranging from .77-.90 content validity was established by reviews of national experts in the field of transcultural health care (campinha-bacote, 2003). the iapcc-r measured the five constructs of cultural competence: cultural knowledge; cultural skill; cultural encounters; cultural awareness; and cultural desire. each construct had 5 corresponding questions. the survey items had 4-point likert scales using positive to negative measurements for each of the constructs. designated research assistants at each of the participating facilities proctored the survey process. the demographic questionnaire and the iapcc-r took approximately 20 minutes total for respondents to complete. data analysis campinha-bacote (2003) provided descriptions of how competency scores on the iapcc-r may be grouped: culturally proficient (scores 91-100), culturally competent (75-90); culturally aware (51-74); and culturally incompetent (25-50). higher scores indicated a higher level of competency. this investigator chose to analyze scores instead by grouping them into low, medium and high categories, rather than using the campinha-bacote method for later use in bivariate cross tabulations against the demographic survey tool. frequency distributions were evaluated to determine participants’ gender and age; basic and current level of education; the frequency and types of cultural diversity training; ethnicity; and frequency of contact with individuals from cultures other than their own. bivariate cross tabulations were calculated using spss to compare the dependent variable (cultural competence scores) to the various independent variables and the demographic tool. statistical significance was evaluated using pearson’s chi-square and a .05 level of significance was used. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 61 findings single item analyses and aggregate responses on the iapcc-r and demographic survey the range for the high, medium and low scores on the iapcc-r was 53-86 out of a possible 100 points with a mean of 68.1 and sd of 5.7. the low grouping was defined as scores less than 66; medium to a range of 66-70; and high scores to those over 70. aggregate scores for this analysis revealed high scores to represent 32.4% of participants; medium scorers, 30.7%; and low scorers to represent 36.9% of the registered nurses participating in the surveys (table 2). sharing results of single item analysis of the questions provided in campinha-bacote’s iappc-r tool are not provided for under her copyright. table 2 low, medium, and high scorers on the iapcc-r by region of north dakota with aggregate scores region nw sw ne se total high (71+) 21 (39.6%) 13 (33.3%) 12 (33.3%) 12 (23.5%) 58 (32.4%) medium (66-70) 13 (24.5%) 13 (33.3%) 12 (33.3%) 17 (33.3%) 55 (30.7%) low (<66) 19 (35.8%) 13 (33.3%) 12 (33.3%) 22 (43.1%) 66 (36.9%) total 53 (100%) 39 (100%) 36 (100%) 51 (100%) 179 (100%) descriptive statistics were used to present findings from the demographic survey (table 3). it is not surprising that the majority of respondents were white and female as this correlates not only to the lack of diversity in the state, but to the lack of diversity in nursing as a profession. the majority of participants held a bachelor of science in nursing (bsn) which is also an expected finding as the state of north dakota had the bsn as the entry of level into practice from 1987 until 2003. these nurses were on average 40 years old. respondents were asked to describe all of the types of cultural diversity training in place at their current places of employment. a large percentage (38.6%) reported receiving no cultural diversity training at all in the last three years. even more respondents (61.9%) had not attended any sort of continuing education (ce) program for cultural diversity (table 3). computer modules were selected as the primary source of education at facilities by 43% of participants across the state. guest lecturer or speaker was selected by 28.5%, articles by 34.5%, and role playing by 3% (table 4). cross tabulations aggregate frequency distributions show that 62.5% of the nurses had never attended or participated in a cultural diversity (ce) program. nearly half (45.5%) of those had low iapcc-r scores (i.e., scores <66). for those participants that attended cultural diversity ce programs, selfassessment scores revealed higher levels of competence: 41.8% of high scorers on the iapcc-r (score of 71+) and 35.8% of medium scorers (score of 66-70).these results were statistically significant at the .01 level (figure 2). higher frequency of cultural diversity training attendance correlated to higher scores on the iapcc-r (figure 3). of those that reported no diversity online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 62 table 3 demographic questionnaire aggregate responses from nd nurse participants 1. what is your age? mean 40 yrs; range 22-64 2. what sex are you? a. male (3.5%) b. female (96.5%) 3. your culture/ethnicity can best be described as: a. african-american c. hispanic/latino e. american indian b. asian/pacific islander d. white/non hispanic (98%) f. other (2%) 4. level of basic nursing education: a. ad (16.4%) b. bsn (69.7%) c. diploma (13.9%) 5. level of current education a. ad (15.6%) b. bsn (70.4%) c. diploma(9.5%) d. masters(4.4%) e. doctorate (none) 6. years practicing as an rn: mean= 15 years; range=0-42 years 7. your primary area of expertise/service is best described as: a. critical care (27.5%) b. medical surgical (6.1%) c. rehab (1.2%) d. peri-operative (3.5%) e. women’s health (4.5%) f. mental health g. long term care (4.5%) h. other (17%) 2.4% of respondents did not provide an answer to this question. 8. have you attended a cultural diversity ce program? a. yes (38.1%) b. no (61.9%) 9. if you answered ‘no’ to number 8, would you be interested in attending one? a. yes (90.4%) b. no (9.6%) 10. how many times in the last 3 years have you received cultural diversity training? a. none (38.6%) b. 1-2 (45.5%) c. 2-3 (8.9%) d. 3-4 (6.9%) 11. did your basic nursing program have a cultural diversity course? a. yes (51.3%) b. no (47.3%) 12. place an ‘x’ on the line indicating the amount of contacts you have had with persons from cultures other than your own. the farthest left side of this line indicates no contact at all. note: the numbers have been placed on the line for purposes of reporting results. the respondents received the questionnaire without numerical indicators. ←1⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯2⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯3→ mean=1.71 further right than left: 43.3% further left than right: 42.8% in the middle: 13.9% 13. the types of cultural diversity training currently in place at your principal place of employment include (circle all that apply): a. computer module (43%) b. lecture/speaker (28.5%) c. role-playing (3%) d. articles (34.5%) e. none (none) f. other (none) 14. what number of hours do you work in your primary setting per week? mean = 35.44 hours; range=0-60 hours online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 63 table 4 frequency distributions for types of cultural diversity training methods in place at principle place of employment reported by nurses in north dakota. type frequency percent valid percent computer module 86 42.0 43.0 speaker 57 27.8 28.5 role play 6 2.9 3.0 articles 69 33.7 34.5 45.5 22.4 27.7 35.8 26.8 41.8 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% no yes high score medium score low score figure 2. correlation of cultural competence score by cultural diversity ce program attendance: have you attended a cultural diversity ce program? (significant at the .01 level) 55.6 23.5 26.7 27.3 26.4 33.3 40 27.3 18.1 43.2 33.3 45.5 0 10 20 30 40 50 60 70 80 90 100 none 1-2 2-3 3-4 number of times trained (past 3 years) % high score m e dium score low score figure 3. correlation of cultural competence score by cultural diversity training frequency: how many times in the last 3 years have you received cultural diversity training?(statistically significant at the .01 level) online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 64 training, 55.6% of them had low scores on the iapcc-r. where as, of those who reported frequent training, from 2-4 times per year, nearly 80% had high iapcc-r scores. over half of respondents reported that they had a cultural diversity course as a part of their basic nursing education. the level of cultural competence was not impacted by the presence of a cultural diversity course in the participants’ basic nursing education according to their self-rating scores (figure 4). frequency score results indicated that registered nurses who rated themselves highest on the iapcc-r received the most frequent cultural diversity training through the use of article review. bivariate cross tabulations revealed statistically significant results between the use of articles for use of cultural diversity training but not for other methods of training (figure 5). high score medium score low score 0% 50% 100% no yes 42.2 31.2 27.7 33.3 30.1 35.5 figure 4. correlation of cultural competence level by presence of cultural diversity course in basic nursing education: did your basic nursing program have a cultural diversity course? (differences not statistically significant) 44.3 22.6 29.6 32.3 26.1 45.2 0 % 10 % 2 0 % 3 0 % 4 0 % 50 % 6 0 % 70 % 8 0 % 9 0 % 10 0 % no yes articles as most used method high scores medium scores low scores figure 5. correlation of cultural competency scores by articles as a method of training. (significant at the .01 level) online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 65 discussion percentage of registered nurses in north dakota self-rated as culturally competent as described, only 14.5% of all study participants indicated that they were culturally competent when scores were evaluated using the campinha-bacote method. in examining the data from the perspective of rating these scores on a curve, or in terms of high, medium, and low scores, the distributions are fairly equal (table 2). the mean score of 68.1, however, correlates to the campinha-bacote category of merely “culturally aware” (range score of 51-74), not culturally competent. cultural awareness was described as self-examination and in-depth exploration of one’s own cultural background (campinha-bacote, 2003). without this awareness, health care providers may tend to engage in cultural imposition, which is described as imposing ones own cultural beliefs upon those from another culture (campinha-bacote) or cultural blindness. wells (2000) warned that cultural awareness does not go far enough toward achieving the level of cultural competence development that is required of health care providers and institutions to safely care for diverse populations. some health care providers may believe that by treating others equally, regardless of cultural background that they are doing the right thing. bell and evans, as quoted in campinha-bacote, (2003) described this as racism, however. racism is not easily talked about in health care. the american nurses association (2002) and the institute of medicine (2002) both described the existence of racism in healthcare and the detrimental effects on the health of patients. demographic differences between iapcc-r high and low self-rating scores cultural diversity education, either ce program attendance, or cultural diversity training at the workplace, were factors that correlated to higher iapcc-r scores (p. < .01). research to date demonstrates that training is an effective means of improving provider knowledge of cultural and behavioral aspects of health care (iom, 2002). results revealed that computer modules and article review were the most widely used method of cultural diversity training at the participating hospitals. adams (2000) suggested that training for cultural competency needed to reflect real life in order to be effective. the methods presently in place at participating facilities may contribute to cultural knowledge, but their value in enhancing cultural skill, and sensitivity was not supported in the literature as the sole means of education. salimbene (1999), smith (2001), wells (2000), campinha-bacote (2003) and others emphasize that this training must be ongoing and supported by regular follow-up to evaluate effectiveness. although 62% of the respondents reported never attending a cultural diversity ce program, a majority indicated that they had an interest in participating in one. this was encouraging and may have indicated a desire for varied learning experiences beyond those supplied by their places of employment. it could not be determined if the number of cultural contacts influenced respondents’ iapcc-r ratings. unfortunately this question may not have been designed in a way that would extract the most meaningful information from survey participants. the calculated mean response indicates that on average, participants did not report having substantial contacts with persons of other cultures. cross tabulations to cultural competence scores were not statistically significant in that the results were very similar. low scores correlated to a mean answer of 1.78; medium scores to a mean of 1.75 and high scores correlated to a mean of 1.59 (table 3). online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 66 impact of type and frequency of cultural competency training ongoing education, or cultural diversity training, at the workplace, positively impacted iapcc-r scores more than any other variable. it was hypothesized that study participants who participated in cultural diversity training at their work places would score higher on the iapccr than those who had little or no training at their work places. higher scores did correlate to more frequent training (p. <.01). article review was cited most often by those rns who rated themselves highest on the iapcc-r (p <.01). the participants who reported having a cultural diversity course in their program of nursing did not rate themselves higher on the iapcc-r than those nurses who did not have such a course in their program. although there were no significant correlations made between higher iapcc-r scores and participation in a cultural diversity course within the respondents nursing program, the survey participants did express a need and desire to learn more about those from other cultures. it could be that the amount of content taught in a course on cultural diversity and the time-constraints involved provided little opportunity to focus on important aspects. in koempel’s (2003) study, respondents indicated that it was continuing education and training that contributed to their cultural competence. coffman, shellman, and bernal (2004) suggested that the repeated opportunity to work with people of other cultures raised student nurse scores on the cultural self-efficacy scale (cses).this has implications for curriculum development in cultural diversity courses within nursing programs. even in states that are homogenous, such as north dakota, there is opportunity to provide students with contact with persons of other cultures through community and international service learning projects and guest speakers. recommendations given that the iom has linked health disparities to health care providers’ lack of cultural competence, it was encouraging to see that the majority of respondents (61.3%) were participating in training, though with varying rates of frequency. dr. campinha-bacote (2003) recommends that nurses need to develop their cultural competence through self-examination of their awareness, skill, knowledge, encounters (with cultures other than their own), and desire. computer modules and article review as the main method of learning about other cultures may not provide nurses with the most enriching learning experiences. such linear modes of delivery without the benefit of interaction with an expert or the ability to ask questions could easily lead nurses to make generalizations about other cultures. campinha-bacote’s model indicates that all constructs of cultural competence are important. certainly in north dakota, there may be a perception that there are few opportunities for frequent contact with persons of other cultures; however, healthcare facilities and programs of nursing could incorporate more creative means of providing for learning experiences. facilities participating in this survey received a report with aggregate results of this study. assessment of cultural competence is a step in the right direction toward tailoring educational strategies that would increase cultural competence. evaluation of the effectiveness of education activities will assist facilities in further planning of educational activities. it may be beneficial for individual facilities to collect data on patient demographics for their area of service, as well so that educational sessions can be tailored. a limitation of this study is in that it was a paper and pencil survey. survey participants may be aware of the heightened focus on cultural competency and political correctness in our online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 67 society and may have felt pressure to answer questions based on social desirability. future research may be more meaningful if a trained observer could study participants’ interactions with patients. patients themselves should be surveyed on their perceptions of the cultural competency of healthcare providers in the state. their responses could assist in tailoring healthcare provider training. jcaho and other accrediting bodies mandate that hospitals provide proof that they are providing culturally competent care for their clients. there are no previous surveys to provide benchmarking for cultural competence in north dakota. there are other u.s. states that might be considered equally homogenous based on u.s. census findings. comparison of iapcc-r scores for healthcare providers in those states may reveal differences in educational preparation and training. another limitation of this particular study is that this sample was purposive in that participants were limited to registered nurses employed in acute care settings. study participants were also mainly white females. future work should include additional recruitment of other health care provider types and of culturally diverse providers. cultural diversity training has been identified as a factor that impacts nurses’ rating of their cultural competence. cultural competence may be enhanced by designing and testing educational experiences that will help providers provide culturally safe and appropriate care. dr. campinha-bacote (2003) provides a very fitting quote regarding the journey to cultural competence: the more you think you know; the more you really don’t know. the more you think you don’t know; the more you really know. (p. 66) the results of this study revealed that the majority of nurses in this sample did indeed rate themselves to be less than culturally competent. it was encouraging that they indicated recognition of their own limitations in dealing with clients from cultures other than their own. at the same time, respondents indicated that they desired to learn more. healthcare organization administrators, educators, and faculty in schools of nursing in our state need to foster this cultural awareness through education. summary of recommendations based on the findings in this study the following recommendations are made: 1. replication of this study should be conducted across other disciplines and healthcare settings in north dakota to include doctors, nursing assistants, paramedics, respiratory therapists, dieticians, advanced practice nurses, physical therapists, and counselors. 2. replication of this study should be conducted in other ethnically homogenous states and comparisons run between the states. 3. the iapcc-r can be used as a benchmarking and evaluation tool within facilities when they are evaluating their training programs. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 68 4. health care providers’ iapcc-r scores should be compared with patient satisfaction scores on constructs related to cultural competence. 5. facilities should explore a variety of teaching learning methods to enhance cultural diversity training for healthcare providers. the use of articles as a major method of staff education does not provide for cultural contacts. 6. the iapcc-r can be used in nursing programs and specifically in cultural courses to assess learning needs and effectiveness of teaching/learning strategies. references adams, d. (2000). making cultural competency work. closing the gap [newsletter]. retrieved april 23, 2005, from http://www.omhrc.gov/omh?sidebar?archiveddctg.htm#11 american nurses association. (2002). position statement on discrimination and racism in healthcare. retrieved may 26, 2006, from http://www.mtnurses.org/current%20web/mnastatement.htm boyle, j., and wenger, a. (2002). a summary of the panel discussion: comments from the moderators. journal of transcultural nursing, 13, 200-201. brathwaite, a. (2003). selection of a conceptual model/framework for guiding research interventions. internet journal of advanced nursing practice, 2003, 6(1), 38. campinha-bacote, j. (2002). the process of cultural competence in the delivery of healthcare services: a model of care. journal of transcultural nursing, 3, 181-184. [medline] campinha-bacote, j. (2003). many faces: addressing diversity in health care. online journal of issues in nursing, 8(1), 3. [medline] campinha-bacote, j. (2003). the process of cultural competence in the delivery of health care services: a culturally competent model of care. transcultural c.a.r.e associates. campinha-bacote, j. (2005). inventory for assessing the process of cultural competence among healthcare professionals-revised. fact sheet. retrieved june 6, 2005, from http://www.transculturalcare.net/services.htm coffman, m., shellman, j., & bernal, h. (2004). an integrative review of american nurses’ perceived cultural self-efficacy. journal of nursing scholarship, 36, 180-185. [medline] institute of medicine. (2002). unequal treatment: what health care providers need to know about racial and ethnic disparities in health care. retrieved april 4, 2005, from http://www.iom.edu koempel, v. (2003). cultural competence of certified nurse practitioners. unpublished thesis, minnesota state university, mankato. north dakota fact sheet. 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(2004). cultural diversity in health and illness. upper saddle river, nj: pearson prentice hall. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.omhrc.gov/omh?sidebar?archiveddctg.htm#11 http://www.mtnurses.org/current%20web/mnastatement.htm http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12113146%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12729453%5buid%5d http://www.transculturalcare.net/services.htm http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15227767%5buid%5d http://www.iom.edu/ http://factfinder.census.gov/servlet/safffact http://www/health.state.nd.us/ndiac/statistics.htm http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9926676%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11855050%5buid%5d 69 trompenaars,f., & wooliams, p. (2004). business across cultures. chichester, uk: capstone. wells, m. (2000). beyond cultural competence: a model for individual and institutional cultural development. journal of community health nursing, 17, 189-199. [medline] online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11126891%5buid%5d the impact of a lack of cultural competence running head: the effectiveness of stroke response 54 establishing a stroke response team in a rural setting julie sain justice, rn, bsn msn1 linda a. howe, phd, aprn, bc2 cathy dyches, phd, rn3 barbara a. heifferon, phd4 1student, school of nursing, clemson university, juliejustice@redfoxtv.tv 2associate professor, school of nursing, clemson university, lhowe@clemson.edu 3assistant professor, school of nursing, clemson university, cathyd@clemson.edu 4associate professor, college of architecture, arts and humanities, clemson university, bheiffe@clemson.edu key words: stroke, stroke response team, tpa, rural hospital, remote evaluation for acute ischemic stroke (reach), national institute of health stroke scale (nihss) abstract stroke, a substantial public health problem because of high incidence, prevalence, mortality and economic burden, is the leading cause of long-term disability and the third leading cause of death in the united states (national institute of health, 2005). improvements have been made in the management of ischemic stroke, including the use of a fibrinolytic agent known as tissue plasminogen activator (tpa), and the utilization of stroke response teams. while larger hospitals have the capabilities of instituting improvements, rural hospitals still lack the resources and ability to offer this vital service. the organization of a stroke response team can vary depending on location. however, all such teams can facilitate rapid evaluation and treatment of patients with stroke, thus allowing hospital systems to respond in organized, efficient, and emergent ways. such rapid responses prevent extensive disability: “time is brain.” this manuscript discusses the effectiveness of a stroke response team on tpa utilization and offers an algorithm for rural hospitals to follow. introduction stroke, a substantial public health problem because of high incidence, prevalence, mortality and economic burden is the leading cause of long-term disability and the third leading cause of death in the united states (national institute of health, 2005). according to harvey (2004), “every year approximately 700,000 americans experience a new or recurrent stroke, and every three minutes someone dies from the event” (p. 1). one in every five people will be directly affected by stroke either as a victim, family member, or caregiver (stark, 2002). ischemic stroke accounts for approximately 80 percent of all strokes and it is important to understand stroke and the most effective treatments (national institute of neurological disorders and stroke (ninds), 2004). an ischemic stroke occurs when an artery supplying the brain with blood becomes blocked. cerebral ischemia describes the loss of oxygen and nutrients for brain cells and can eventually lead to infarction meaning the death of brain cells. loss of blood flow to the brain results in a “brain attack”. the term “brain attack” is used to communicate the urgency and importance of promptly recognizing stroke warning signs in an effort to improve the chance for a full recovery. using the term brain attack, like the term heart attack, can perhaps change the way people think about this common but debilitating online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 http://www.hehd.clemson.edu/nursing/ mailto:juliejustice@redfoxtv.tv http://www.hehd.clemson.edu/nursing/ mailto:lhowe@clemson.edu http://www.hehd.clemson.edu/nursing/ mailto:cathyd@clemson.edu http://www.clemson.edu/caah/ mailto:bheiffe@clemson.edu 55 disease (broderich & landis, 2005). goals for therapeutic management of the stroke patient are the preservation of life, prevention of additional brain damage, and reduction of disability (harvey, 2004). education of health care workers and the use of modern technology can help to achieve the goals of more effective therapeutic management. literature review rural hospitals rural hospitals are generally nonprofit, smaller hospitals, many having 50 beds or less (national rural health association [nrha], 2005). rural residents tend to have higher poverty rates, be elderly, have poorer health, fewer doctors, hospitals, and other health resources, thus making it more difficult to obtain effective health services (agency for healthcare research and quality [ahrq], 1996). rural hospitals face numerous challenges including declining public and private reimbursements, lack of staff, out-ofdate technology, and increased dependence on public sources of funding (serb, 2006). for many patients the rural hospital is the only source of health care, and improvement in stroke management in rural settings across the nation would be a significant achievement. one way to improve stroke management is through the appropriate use of tpa, thrombolytic therapy for acute, ischemic stroke. tissue plasminogen activator the only approved thrombolytic therapy for acute ischemic stroke is tpa, and only 3% of patients with stroke receive tpa nationally (albers, 2005). this fibrinolytic agent is made with recombinant dna technology from human melanoma cells that was initially approved in 1996 to treat acute ischemic stroke. given intravenously, it binds to fibrin in a clot and converts plasminogen to plasmin breaking down fibrin and resulting in systemic fibrinolysis, and has a half-life of less than five minutes with a plasma clearance of 380-570 ml/min. clearance is mediated primarily by the liver. (murphy, 2003). to receive tpa, a patient must be definitively diagnosed with ischemic stroke while meeting specific criteria within a three-hour time frame. the inclusion criteria for receiving tpa are: (a) age 18 or older, (b) clinical diagnosis of acute ischemic stroke with a measurable neurologic deficit, and (c) well established time of the onset of symptoms that is less than 3-hours. exclusion criteria are: (a) evidence or suspicion of intracranial hemorrhage, (b) acute bleeding risk such as low platelet count, heparin administration in previous 48 hours, or a prothrombin time greater than 15 seconds, (c) head injury, head or spinal surgery, or previous stroke within the last 3-months, (d) history of aneurysm, (e) seizure witnessed at time of onset of symptoms, and (f) repeated blood pressure measurements greater than 185 systolic and 110 diastolic. other contraindications and precautions include acute myocardial infarction within the previous 3-months, minor or rapidly improving signs of stroke, and a blood glucose of less than 50 mg/dl or greater than 400mg/dl (elmore & miller, 2005). table 1. according to elmore & miller (2005), administration of tpa within the first 3hours of symptom onset may reopen the occluded cerebral artery, reduce the amount of online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 56 table 1 criteria for tpa administration inclusion criteria exclusion criteria age 18 or older dx of acute ischemic stroke symptom onset of < 3-hours evidence/suspicion of ich bleeding risk: ↓ platelets, heparin in previous 48-hours, prothrombin time >15seconds head injury, head or spinal surgery, stroke within previous 3-months history of aneurysm seizure at time of onset repeated bp readings >185/110 note: use precaution: myocardial infarction in previous 3-months, improving signs of stroke, blood glucose < 50 mg/dl or > 400 mg/dl brain tissue threatened by ischemia, and improve long-term outcomes. however, if tpa is administered after the initial 3-hours of symptom onset, the occluded vessel may open causing revascularization of the necrotic tissue resulting in possible cerebral edema and hemorrhage (elmore & miller, 2005). the dosage of tpa is weight based with the recommended dosage being 0.9mg/kg and the maximum dose of 90mg. the infusion should be completed within one hour. clot lysis may be seen in 60 to 90 minutes and symptom improvement may be seen for up to 3 months (elmore & miller, 2005). although this paper does not examine stroke outcomes, numerous studies have shown that using tpa in the recommended 3-hour time frame reduces stroke related disability (hemmen, 2002). determining stroke status making the diagnosis of acute ischemic stroke can be difficult because the history or symptoms may be vague (fulgham, ingall, stead, cloft, wijdicks, & flemming, 2004). to evaluate stroke severity, the healthcare team may utilize several tools: two such tools include a checklist called the seven d’s of stroke care and the national institute of health stroke scale (nihss). the “seven d’s” describes a process that should be carried out to facilitate quick and definitive treatment: detection, dispatch, delivery, door, data, decision, and drug (elmore & miller, 2005). detection is promptly recognizing the signs and symptoms of stroke and determining the onset time. dispatch online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 57 requires notifying emergency medical care and transporting the patient to the nearest stroke center or hospital for rapid triage in the emergency department. data is collected about the patient’s history, lab work, physical assessment, imaging studies, and the time of onset and symptoms. a non-contrast ct should be done within 25 minutes and interpreted within 45 minutes of arrival of the stroke patient. next, a decision concerning the use of tpa must be made using the exclusion and inclusion criteria for tpa therapy, and, if all criteria are met, the drug is started (elmore & miller, 2005). table 2. table 2 d’s of stroke care detection dispatch delivery door data decision drug as part of the seven ds, a detailed assessment includes the use of the nihss. the nihss was developed to provide a conscious cranial nerve assessment in 3 to 8 minutes, while providing insight into the location of vascular lesions related to symptoms (stark, 2002). the patient’s level of consciousness is evaluated by asking specific questions and by giving simple commands. visual fields and gaze are tested by assessing horizontal eye movements and visual clarity. facial movements such as smiling, teeth clenching, and eye closure are evaluated along with arm and leg motor function. limb ataxia is also evaluated to note the smoothness and accuracy of movements. evaluating sensory response can assess for hemisensory loss; a stuporous or aphasic patient will grimace or pull away from the stimulus. practitioners can evaluate language and articulation for aphasia and slurring by asking patients to read or repeat a sentence and identify particular objects or people. extinction and inattention can be assessed by observing if patients ignore an area of their body (elmore & miller, 2005). each area of the nihss is scored with a score greater than 22 indicating a large area of brain damage. high scores mean patients have a high risk for hemorrhage if tpa is used thus making them ineligible for the fibrinolytic agent (meadows, 2005). nihss assessment scores strongly correlate with patient outcomes (schlegel, tanne, demchuck, levine, & kasner, 2004). however, the nihss and the seven d’s are ineffective without a professionally trained health care team to expedite the process for rapid evaluation and treatment of stroke patients. this necessitated the creation of stroke response teams. a proposed algorithm for use in rural hospitals has been developed. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 58 the stroke response team the stroke response team is a 24-hour/ 7-day a week multidisciplinary team developed for rapid evaluation and treatment of patients with stroke. while most current stroke teams are part of stroke centers, they are also appropriate for rural settings. joint commission recognizes primary stroke centers as focusing the services on “critical elements to achieve long term success in improving outcomes” (joint commission, 2006). the brain attack coalition, a group of professional, voluntary, and government entities dedicated to reducing the occurrence, disability, and death associated with stroke, has issued guidelines for the certification of primary stroke centers (warren & emr, 2000). the members on the team may vary depending on the needs of the individual hospital, although one or more neurologists and a nurse are always included (lutsep & clark, 2005). in a rural setting a team that is being used as a rapid response team could be utilized for the code stroke team. the team members should be the most appropriate, such as: emergency department (ed), intensive care unit (icu), neuro icu, or coronary care unit (ccu) nurses and be readily available. the role of the nurse is critical including triaging, monitoring vital signs, expediting studies, and coordinating communication between physicians and families. a neurologist must be available around the clock to evaluate the patient within 15 minutes, and the hospital has to be capable of providing neurosurgical services. the neurologist who is on call is responsible for clinical decisions with the stroke team functioning in a consultative role (saiki & wojner, 2004). after activating the stroke response team via phone or pager, the stroke team responds and begins using the seven d’s (discussed earlier), using the stroke pathway that is best customized with the hospital’s resources. the role of a stroke team is to facilitate care by identifying patients who are candidates for tpa (bratina, greenberg, pasteur, & grotta, 1995). lutsep and clark (p. 2, 2005) state that “to achieve maximal efficiency, the team must integrate itself with all services involved in the care of patients with acute stroke, which include the local community, emergency medical services, the emergency department, ct scanning, and pharmacy.” unfortunately, many hospitals have not yet set up stroke teams. one study shows that 66% of the hospitals surveyed did not have stroke protocols and 82% did not have rapid response for patients experiencing acute stroke (alberts et al., 2000). the study does not indicate hospital size. likewise, the american heart association published a study measuring changes in stroke services over a five-year period. in that 2003 study, a one-page questionnaire completed by 128 state facilities in north carolina was compared with results from a 1998 study. although there was an increase in the availability of technologies, hospital investments in stroke related programs such as organized stroke teams, acute care stroke units, and community awareness programs had not significantly increased (camilo & goldstein, 2003). historically stroke teams have been shown to be effective and that is validated by a retrospective study of eight hospitals conducted in houston, texas that examined delays and deficiencies in recognition and management of stroke patients, while implementing a stroke team and examining the before and after results. the variables included were time from stroke onset to triage, examination by a physician, neurological evaluation, computed tomography (ct), and other tests, vital signs, and treatments. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 59 before the stroke team was introduced, the average time from emergency department arrival to examination by a physician and ct scan was 28 and 100 minutes respectively. the stroke team shortened the time to examination by a physician and to ct by 13 and 63 minutes respectively (bratina, greenberg, pasteur, & grotta, 1995). researchers concluded that establishment of primary stroke centers would increase the number of ischemic stroke patients treated with thrombolytic therapy through a comprehensive retrospective review of medical records (lattimore et al. 2003). the study consisted of an on-call stroke emergency response team and all eligible patients were treated with tpa. during the 12 months prior to establishment of the stroke center 1.5% of ischemic stroke patients were treated with tpa, and 10.5 % received tpa during the two-year period after instituting the center, demonstrating the beneficial impact of a stroke response team on tpa utilization. obviously, multidisciplinary stroke teams facilitate expedited evaluation. the team approach has shown a reduction in the length of time between the patient’s arrival to the emergency department and completion of the evaluation, brain ct, and possible initiation of thrombolytic therapy (fulgham et al., 2004). in a retrospective cohort study by katzan, hammer, hixson, furlan, abou-chebl, and nadzam (2004), potentially eligible patients who received tpa were compared with those who did not. a chart review was performed on all patients admitted with a diagnosis of ischemic stroke over a one-year period, and identified patients who arrived within three hours of symptom onset. common exclusions for receiving tpa among this population included mild neurological impairment and rapidly improving symptoms. however, only 15% of ischemic stroke patients arrived within the 3-hour window of opportunity for tpa, which was the primary reason patients were ineligible to received tpa. according to dr. brett meyer at the university of california san diego medical center, thrombolytics have the potential to be used more often with a stroke team in place (cited in hemmen, hayes, mclean, & lyden, 2002). meyer conducted a study comparing tpa use during a two-year period at the san diego medical center; during the first year of the study a stroke team was not in place. neurologists and physicians were specially trained in stroke treatment and evaluation and tpa was given 12 times in the year. with the stroke team in place, tpa therapy increased to 25 times in the second year. the volume of patients during either year is not given in this study. according to dr. edgar kenton, chairman of the american stroke association advisory committee, this study concludes “dedicated stroke teams are viewed as a crucial link in the chain of survival for acute stroke victims, because of their ability to respond rapidly with assessment and treatment to potentially minimize disability” (cited in hemmen et al., p.1, 2002). continuous review of the stroke team system by investigating delays and outcomes help to improve the overall functioning of the team (lutsep & clark, 2005). implications for nursing practice in a rural setting at present, the recommendation for rural hospitals without acute stroke guidelines consists of transferring the patient to regional hospitals by helicopter and ground transport. however, critical time can be lost during transfer due to factors such as long online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 60 distances, mountainous terrain, etc., thus, making it even more important for the establishment of acute stroke guidelines in all facilities. public health outcomes are significantly impacted by the successful management of ischemic stroke. the primary goal is to limit or reverse the brain injury so that the patient can recover as much as possible. attempting to meet this goal means that all healthcare personnel and the public must learn to recognize stroke as a medical emergency, i.e. “brain attack.” in addition, stroke teams should also be developed in these rural facilities. management in the rural hospital setting would include the development of a stroke team to perform rapid evaluations and to initiate the most advanced treatment and technologies. as the stroke team continues to evolve, stroke team nurses would be encouraged to examine their practice and generate new knowledge to support the care of patients during each phase of stroke management and recovery. subsequently, the opportunity for nurses to expand their roles would require commitment to “ensure timely, expert care delivery, and ongoing performance improvement” (saiki & wojner, 2004). the nurses’ role within the stroke team is multifaceted beyond physical assessment, including facilitation of testing, completion of ct scan, data collection, and coordination of care. the stroke team provides an employment opportunity for advanced practice nurses (apn) in a rural setting. the university of texas-houston stroke team has an apn who functions in a role similar to a stroke attending physician or fellow. the apn is responsible for higher level decision-making, has supervisory authority, and provides formal education to support improved stroke care (saiki & wojner, 2004). once again the role of each member of the team is defined by the individual hospital’s needs and requirements. thus, rural hospitals need to evaluate resources and staffing availability to form the stoke response team best suited for their unique situation. suggestions include selecting a group of nurses from the ed and (icu) to obtain certification to perform the nihss. also, all ed physicians and ed staff need to be educated to recognize the signs and symptoms of a stroke, and when and how to activate the stroke response team. although tpa is readily available, rural hospitals do not typically have neurologists on standby to perform an examination for determining treatment. to address this need, the remote evaluation for acute ischemic stroke (reach) program was developed by the medical college of georgia to facilitate rapid evaluation of the stroke patient (wang, gross, sung, pardue, waller, nichols, adams, & hess, 2004). reach enables a neurologist to review a patient video, perform an nihss, review the ct scans in real time, and to make a recommendation on tpa use (hess, wang, hamilton, lee, pardue, waller, gross, nichols, hall, & adams, 2005). the on-call neurologist is paged and then logs onto the reach website to complete the consult using two-way audio and one-way video. the costs include $6000 for the technology to provide connection (hess et al., 2005), a small expense considering possible outcomes improvement for patients. prior to the medical college of georgia’s institution of reach within eight hospitals, only one had formal acute stroke care guidelines and two had tpa available in the pharmacy. reach has permitted the use of tpa in rural hospitals where it was not previously used and provides the rural hospital with a 24-hour stroke team. the availability of a dedicated stroke team helps to achieve maximal efficiency with the ischemic stroke patient. integration with all services is an important part of the online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 61 function of the stroke team, emphasizing that all members must have a strong common interest in treatment of acute stroke. thus, awareness of the stroke team throughout the hospital is a pertinent part of utilizing this team correctly and efficiently. recommendations to achieve maximal awareness include continuing educational programs for all disciplines directly and indirectly involved. conclusion the major concept to remember is that “time is brain” (stark, 2002), meaning that there needs to be a quick response from the general public in recognizing stroke symptoms along with an equally quick response from the health care system from initial point of patient contact to achieve the most effective treatment of brain attack. to improve stroke treatment in the rural setting, health care workers must be trained to understand the urgency of early evaluation and treatment. ideally, stroke teams and the appropriate use of tpa could be put into place in these rural facilities. education is key to improving outcomes and “starting treatment as soon as possible is and will continue to be a driving force in emergent stroke care” (adams, 1998). references agency for healthcare research and quality. 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[medline] http://www.strokeassociation.org/presenter.jhtml?identifier=3000726 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16051892%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15023810%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12750543%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1728786%5buid%5d http://www.emedicine.com/neuro/topic603.htm http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14604126%5buid%5d http://www.nrharural.org/about/sub/different.html http://community.nursingspectrum.com/magazinearticles/article.cfm?aid=1033 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15262736%5buid%5d http://www.findarticles.com/p/articles/mi_qa3940/is_200210/ai_n9099421 http://www.stroke-site.org/coalition/center_factsheet.html http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15166386%5buid%5d rural hospitals tissue plasminogen activator inclusion criteria exclusion criteria determining stroke status the stroke response team the relationship between weight perception, gender, and depressive symptoms among rural adolescents 23 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the relationship between weight perception, gender, and depressive symptoms among rural adolescents kathryn puskar, drph, rn, faan 1 lisa marie bernardo, phd, rn, mph 2 carl fertman, phd, mba, ches 3 dianxu ren, phd 4 kirsti hetager stark, msn, aprn, bc 5 * 1 professor, school of nursing, university of pittsburgh, krp12@pitt.edu 2 associate professor, school of nursing, university of pittsburgh, lbe100@pitt.edu 3 associate professor, school of education, university of pittsburgh, carl@pitt.edu 4 assistant professor, school of nursing, university of pittsburgh, dir8@pitt.edu 5 project director, school of nursing, university of pittsburgh, kms87@pitt.edu * contact author key words: weight perception, rural, adolescent, depressive symptoms abstract research findings indicate a relationship between weight perception and depression in adolescents. this study explored the relationship between weight perception, gender, and depressive symptoms in rural adolescents. among 623 rural adolescents who completed a health inventory and a depression scale, 75 participants (n = 62 females; n = 13 males) had depressive symptoms and were used in data analysis. a two-way anova model was used to evaluate the effects of weight perception and gender on depressive symptoms in rural adolescents. although the 2-way anova was not significant, there was a statistical significant finding for females who reported perceived weight problems and depression. the interaction between gender and weight perception was of marginal statistical significance (p = 0.07). females who perceived a problem with their weight had higher depressive scores compared to females who did not perceive a problem with their weight (p = 0.0002), however no difference was observed for males. implications are for rural nurses to screen adolescents for depressive symptoms and their weight perception during health care visits, with emphasis on females. introduction current evidence demonstrates a strong relationship between a negative weight perception and depressive symptoms in adolescents, even when physical weight is within a normal range (daniels, 2005; eaton, lowry, brener, galuska, & crosby, 2005; xie et al., 2003). this trend is particularly disturbing considering our nation‟s obsession with body weight and appearance, especially in the adolescent population. weight perception numerous studies conclude that there are discrepancies between adolescents‟ perception of body weight and actual body weight. cheung, ip, lam, and bibby (2007) surveyed nationally 1,132 adolescents and found that there was poor agreement between body mass index (bmi) and perceived weight in females, and a fair agreement in males. females were more likely to employ http://www.nursing.pitt.edu/ mailto:krp12@pitt.edu http://www.nursing.pitt.edu/ mailto:lbe100@pitt.edu http://www.education.pitt.edu/ mailto:carl@pitt.edu http://www.nursing.pitt.edu/ mailto:dir8@pitt.edu http://www.nursing.pitt.edu/ mailto:kms87@pitt.edu 24 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 weight control behaviors, based on their perceived weight, while males used weight control behaviors based on their perceived and actual weights. al-sendi, shetty, and musaiger (2004) surveyed bahraini adolescents (n = 504) to determine relationships between bmi, their perception of self-weight and their perceived opinion of parents and peers about weight. overweight was more prevalent among the females. among females, 6.6% perceived themselves as obese, but 20.4% were classified as obese based on their bmi; 3.2% of males perceived themselves as obese, with 16.3% classified as obese by their bmi. for both males and females, there was a statistically significant difference among their perceived and actual weight based on bmi. depressive symptoms research on mental health in rural adolescents reflected that on average 10-12% of youth have depressive symptoms (puskar, tusaie-mumford, sereika, & lamb, 1999b; puskar et al., 2006). the youth risk behavior surveillance-united states, 2005 (centers for disease control and prevention, 2006) report 28.5% students nationwide felt sad or hopeless and that the prevalence was greater in females (36.7%) versus males (20.4%). numerous data sources point to the prevalence of depressive symptoms in adolescents and rural areas (centers for disease control and prevention, 2006; probst et al., 2006; paxton, valois, watkins, huebner, & drane, 2007; burns et al., 2004). a longitudinal study was done by burns et al. (2004) to ascertain depression and risk factors in rural adolescents (n=64). baseline depression data were related, over time, to the risk factors of tobacco use, substance abuse, and history of physical and sexual abuse. weight perception and depression an emerging body of evidence supports the relationship between weight perception and depression in adolescents. rierdan and koff (1997) surveyed 176 young female adolescents to evaluate their self-reported weight, weight categorization, weight satisfaction and weight concerns. height and weight (bmi) were measured by a school nurse. subjects with a high objective weight tended to underreport their weight. the higher the bmi, the more dissatisfied they were with their weight and their weight concerns were greater as well. there was no relationship between bmi and depressive symptoms; however, weight satisfaction and weight concerns were significantly correlated with depressive symptoms. a weight concern was a significant independent predictor of depression levels. daniels (2005) conducted a secondary analysis of data from the united states youth risk behavioral surveillance system, 1999 and 2001 data, to identify a relationship between weight, perception of weight, weight management behaviors, and the relationship between these variables and depressive symptoms in over 13,000 students. depressive symptoms were related to perceived weight and dieting behaviors, while no relationship was found between self reported depressive symptoms and body mass index (bmi). there was a 35% likelihood of depressive symptoms reported by those who perceived themselves as either underweight or overweight. females were 20% more likely to view their weight as either under or overweight compared to males (daniels, 2005). eaton et al. (2005) explored whether bmi and perceived weight were associated significantly with suicide ideation and suicide attempts. white students who perceived 25 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 themselves as very underweight and very overweight were at greater odds of suicide attempt. regardless of bmi, adolescents with extreme perceptions of body size were at increased risk for suicide ideation and attempts. these authors concluded that perception about weight may be more important than actual weight. xie et al. (2003) investigated weight perception and its relationship with psychological distress among 2,179 chinese adolescents. perceived overweight was more likely to occur in females. also, males and females who perceived themselves as overweight were more likely to experience anxiety and depression. kim and kim (2001) determined if bmi and perception of body weight (having a weight problem) predicted self esteem and depression in korean female adolescents. while only 2.6% of the subjects were overweight, 78.5% desired to be underweight. perception of having a weight problem (overweight) was predictive of self-esteem and depression. ivarsson, svalander, litlere, and nevonen (2006) surveyed 405 swedish adolescents to assess weight problems and their correlation with bmi, body image, depression, and anxiety. females were found to have higher scores for depression and anxiety. females who were overweight had negative self-esteem, compared to males. ozmen et al. (2007) conducted a cross-sectional survey of 2,101 turkish adolescents to examine the effects of weight, perceived weight and body satisfaction on self-esteem and depression. only 9% of the subjects were overweight. among females, a higher socioeconomic status was associated with a perception of overweight. females were also more likely to report dissatisfaction with their bodies. this literature correlating weight perception, depression and combination of weight perception and depressive symptoms found a troubling pattern with adolescent females. females reported more dissatisfaction with their perceived weight than males (cheung et al., 2007; alsendi et al., 2004). other studies identified females with negative perceptions or weight concerns with depressive symptoms (rierdan & koff, 1997; daniels, 2005; eaton et al., 2005; xie et al., 2003; kim & kim, 2001; ivarsson et al., 2006; ozmen et al., 2007). theoretical framework the theoretical framework of stress and coping posited by lazarus (1991) and lazarus and folkman (1984) guided this study. adolescence is a time of turbulence which tests young people‟s coping with (a) life events, (b) changing body images, and (c) issues of belonging and acceptance within peer groups. such events and their meaning are determined by the adolescents‟ perceptions and coping resources. emotions are an integral part of this process and have an impact upon the adolescents‟ biological, social, and cognitive functions. emotions can be positive or negative, healthy or unhealthy. the inability to cope with negative perceptions, such as perceived problems with weight, can possibly lead to depression, anxiety, and other mental health issues. exploring relationships between how adolescents appraise a situation (perception of body weight) and how these appraisals affect their mental health (depression) underpins this research study. purpose of study there is a paucity of research on rural adolescents‟ perception of their weight and depressive symptoms. rural researchers emphasize the importance of assessing adolescents‟ 26 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 somatic complaints and depressive symptoms as part of rural adolescent health promotion (puskar, lamb, & tusaie-mumford, 1997; puskar, sereika, & haller, 2003; puskar et al., 1999a; puskar et al., 1999b; puskar et al., 2006). the research question was “is there a relationship between weight perception, gender, and depressive symptoms in rural adolescents?” method the design was a cross sectional descriptive study. the study was completed in four rural high schools in southwestern pennsylvania. a total of 623 adolescents completed the study measures that are described below. written informed consent was obtained from both the adolescent subjects and parents prior to study participation. the protocol was approved by the university of pittsburgh institutional review board on human subjects and the four participating school districts. measures adolescent health inventory. weight perception was measured with the adolescent health inventory (ahi) (nelson, barnard, king, hassanain, & repoff, 1991), using item number 12 “i have a problem with my weight”. the forced choices were never, occasionally, often, and always. the choices of “never” and “occasionally” were combined to create the group „perception of no weight problem‟. the choices of “often” and “always” were combined to create the group „perception of having a weight problem‟. the ahi measures physical health perceptions, needs, and concerns of adolescents in a 36-item inventory. internal consistency was measured by cronbach‟s alpha with values ranging from .51 to .80 in each of the four areas of need. test-retest reliability was evaluated using pearson‟s correlation and the coefficient ranged from .30 to .86 with greater than 50% being above .70. the percent agreement ranged from 64.39 to 100% with a mean of 81.92% (ware & sherbourne, 1992). content validity of the ahi was determined by expert evaluation of doctors, nurses, and teachers and with an extensive background literature review. reynolds adolescent depression scale. depressive symptoms were measured by the reynolds adolescent depression scale (rads) (reynolds, 1987). the reynolds adolescent depression scale (rads) is an adolescent self-report of depressive symptomatology which measures cognitive, motor, somatic, and interpersonal symptoms commonly associated with depression (reynolds, 1987). the rads consists of 30 items with a four-point likert format. internal consistency and split-half reliabilities are high (.91-.96); test-retest reliability is 0.79 over three months and 0.63 over 12 months. based upon examination of rads scores and on other self-report depression measures, a cutoff score of 77 on the rads identified subjects having depressive symptoms (reynolds, 1987). therefore, in this study, participants were classified as having depressive symptoms if their rads score was greater than or equal to 77. also, participants were classified as not having depressive symptoms (or normal) if their rads score was less than 77. survey procedures the research team met with the superintendent and principal of each of the four high schools to explain the project and obtain their school board approval. next, the team held an 27 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 assembly with students to explain the research project and distribute consent forms. students with signed consents and signed parental consents completed the study two questionnaires (ahi and rads) and a demographic survey during a one-and-a-half hour time period during school. they were given ten dollars to compensate for their time. the reynolds adolescent depression scale (rads) was scanned within 2 days to identify scores >77 points, which indicates depressive symptoms therefore requiring further assessment, intervention and possible referral. data from the students who had depressive symptoms were used for analysis. analysis descriptive statistics were used to report frequencies of weight perception on the ahi (item number 12 “i have a problem with my weight”), gender, and scores > 77 on the rads. to answer the research question “is there a relationship between weight perception, gender, and depressive symptoms in rural adolescents” a two way anova model was employed. sas 9.1 was used for all analyses, and the level of significance was set at 0.05. results this study identified that a negative perception of weight was associated with increased depressive symptoms in rural female adolescents, however not in rural male adolescents. characteristics of subjects the original sample of 623 adolescents from four rural high schools in southwestern pennsylvania have been reported elsewhere (puskar et al., 1997; puskar et al., 2003; puskar et al., 1999a; puskar et al., 1999b). briefly, the majority of the subjects were caucasian (97.27 %, n = 606), female (60.3%, n = 376), with mean age of 15.85 (sd = 0.99). a sub-total of 548 (88%) adolescents scored in the non-depressive range (less than 77 on the rads) while 75 (12%) participants scored in the depressive symptom range (77 or greater) out of the sample of 623. the overall mean score was 57.39 (sd 15.706), the median was 55, and the range of scores was 30-106. for females, the mean rads score was 61.06 (sd 16.182), and the median was 61. for males, the mean rads score was 51.82 (sd 13.15), with a median of 49. of importance, 75 (12%) of the sample scored 77 or greater on the rads which is suggestive of depressive symptomatology. by gender, 16.5% (n=62) of the females and 5.2% (n=13) of the males scored 77 or greater. there were 494 (79%) adolescents who answered “i have a problem with my weight” as never or occasionally (perception of no weight problem). the remaining 129 (21%) adolescents answered “i have a problem with my weight” as often or always (perception of having a weight problem). the effects of weight perception and gender on depressive symptoms of the 75 rural adolescents scoring >77 points on the rads (indicating depressive symptoms), 31 (41%) perceived themselves as having a problem with their weight. according to gender, 25 (33%) females and six (8%) males with depressive symptoms reported a problem with their weight („often‟ or „always‟). 28 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 a two-way anova model with interaction was used to evaluate the association of depressive symptoms with gender and weight perception. the interaction between gender and weight perception was of marginal statistical significance (p=0.07). the appropriate statistical contrast was used to compare the difference between the two perception groups “no weight problem” and “weight problem” for male and female respectively. all the subjects with depressive symptoms, rural adolescent females who perceived themselves as having a problem with their weight had significantly higher depressive scores compared to females did not perceive a weight problem (adjusted mean: 90.3±1.39 vs. 82.9±1.14; p=0.0002). however, no difference was observed in males between perception of having a weight problem and not having a weight problem (adjusted mean: 83.7±2.62 vs. 83.3±2.83; p=0.88) (table 1; figure 1). table 1 two-way anova model associations between gender, weight perception, and depressive symptoms (rads ≥77) gender/weight perception number of subjects with depressive symptoms n = 75 depressive symptoms adjusted mean score (se) gender female male n = 62 (82.7%) n = 13 (17.3%) p = 0.15 86.6 (0.90) 83.5 (1.93) weight perception “i have a problem with my weight” no (never, occasionally) yes (often, always) n = 44 (58.7%) n = 31 (41.3%) p = 0.10 83.3 (1.43) 86.8 (1.58) gender with weight perception female with perception* of : no yes male with perception* of: no yes n = 37 (49.3%) n = 25 (33.3%) n = 7 (9.3%) n = 6 (8.0%) p = 0.07 82.9 (1.14) 90.3 (1.39)** 83.7 (2.62) 83.3 (2.83) * “i have a problem with my weight” ** p = 0.0002 29 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 figure 1: adjusted mean of depressive symptoms by weight perception and gender discussion this rural study found a troubling relationship between weight perception and depressive symptoms in female adolescents, similar to reported findings (rierdan & koff, 1997; kim & kim, 2001; eaton et al., 2005). eaton et al. (2005) supports this study‟s implications that perception about weight may be more important than actual weight. daniels (2005) found depressive symptoms were related to those who perceived themselves as either underweight or overweight. there was a 35% increase in possibility of those youth reporting depressive symptoms than those who perceived their weight as “okay”. xie et al. (2003) found that both males and females with perceived weight problems were more likely to have anxiety and depression. these studies relate to the finding in this paper. the main finding of this study is that rural females with depressive symptoms who perceive themselves as having a problem with their weight tend to have higher depressive scores. rierdan and koff (1997) speculated that adolescent females may have body dissatisfaction and depression in the absence of objective overor under-weight. such dissatisfaction and depression may be related to accepting „implausible ideals about thinness‟ and body-related experiences in early adolescence, such as responses to their developing bodies and bodily changes by families and friends. adjusted mean of depressive symptoms by weight perception and gender 78 80 82 84 86 88 90 92 94 female male d e p r e s s iv e s y m p t o m s perception-no weight problem perception-weight problem n= 37 n= 25 n= 7 n= 6 30 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 limitations there is a need for continued inquiry into the relationship between male and female adolescents‟ weight perception and depressive symptoms particularly in rural youth. limitations to this study include a small sample size, especially for males. actual weight, height and bmi were not measured as an objective comparison. perception of overweight or underweight was not based on bmi, but reported by the adolescents as having a problem with their weight often or always. this sample of four high schools in rural pennsylvania may not be generalizable to other rural high schools. as a cross-sectional study, adolescents were not followed over time for changes in depressive scores and weight perception. implications for rural adolescent health achieving healthy lifestyles can be difficult in a rural area, where there is limited access to organized activities and where poverty may affect diet. other rural challenges of culture and structure include: tv and video game preference over active activities, less sidewalks, and less exercise services (jackson, doescher, jerant, & hart, 2005). nurses practicing in rural hospitals and community settings must be vigilant to adolescents‟ perceptions of their body weight and its relationship to their mental health. sadly, federally designated mental health professional shortage areas have been found to be more than 85% are in rural areas. rural america has been underserved by mental health professions for the past 40 years. factors that prevent rural individuals from receiving the mental health care they need are accessibility, availability, and acceptability (the annapolis coalition on the behavioral health workforce, 2006). rural nurses are in an ideal position to facilitate health promotion among rural adolescents through teaching awareness, screening, and referral for problems with weight perception and depressive symptoms. female adolescents can be further assessed by rural nurses using the findings of this study. rural nurses have the opportunity to teach adolescents about healthy lifestyle choices, including nutrition and physical activity to address healthy body weights and accurate perceptions about weight. studies have explored the effectiveness of interventions to address adolescent nutritional education, one included a world wide web educational intervention (long & stevens, 2004; stewart et al., 1995). other studies included an intervention of physical activity with nutrition education (neumark-sztainer, story, hannan, stat, & rex, 2003; prochaska & sallis, 2004; sallis et al., 2003). nursing interventions need to include education, motivation and skill building to create behavioral change (b. vreland, personal communication, august 12, 2005), especially around weight and mood. screening about weight and depressive symptoms are important primary prevention skills. when nurses perform height, weight and body mass index measurements, they can explore with the adolescent their perception of their weight. rural nurses can engage adolescents in discussions about nutrition and how they view their weight and their weight intentions (daniels, 2005). healthy choices and desired weight ranges need to be explained to promote health. nurses caring for rural female adolescents are in a privileged and trusted position. it is important to ask adolescents if they believe they have a problem with their weight, even if these adolescents do not appear overweight. adolescents who perceive themselves as having a 31 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 problem with their weight can be educated about the health risks associated with too much or too little weight plus be assessed for depressive symptoms. involving parents and caregivers about weight perceptions and depressive symptoms can be an important intervention and implementation will vary from adolescent to adolescent. collaboration and referrals to a dietician, nutritionist, psychiatric nurse practitioner, or other mental health specialists are valuable resources. it may be necessary to refer to an endocrinologist when nutrition and exercise habits have improved but there is no improvement in normalizing the adolescent‟s weight, perception, or mood. those females showing signs of depressive symptoms should be assessed about how they view their weight due to the correlation of increased depressive scores with belief they have a problem with their weight. a screening tool for depressive symptoms could be used, such as the reynolds adolescent depression scale (reynolds, 1987). interventions to treat depressive symptoms and weight concerns are important to the future of these vulnerable adolescents. in conclusion, rural nurses can make a difference in the lives of rural adolescents. acknowledgement supported by national institute of health (nih), national institute of nursing research (ninr) grant no. 5ro1 nr03516-03 references al-sendi, a., shetty, p., & musaiger, a. 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[medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12657338%5buid%5d http://www.annapoliscoalition.org/rural_workforce_issues.php http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1593914%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12944011%5buid%5d microsoft word zust_article.doc 29 labor induction practices in a rural midwestern hospital barbara l. zust, phd, rn1 nicole b. briggs, ba, rn2 1 associate professor of nursing, gustavus adolphus college, bzust@gac.edu 2 graduate student, duke university, nbriggs@gac.edu keywords: rural, labor inductions, nursing shortage, pilot study abstract national databases indicate that induction of labor has risen dramatically in the united states over the last ten years. however, little is known about induction practices in rural areas. the purpose of this pilot study was to explore the induction practices of physicians in a 21-bed, rural hospital. data were collected from the 2003 hospital birth records and from interviews with physicians. findings showed an induction rate of 37.8%. inductions resulted in 58% of the hospital’s unplanned cesarean sections. several physicians said that they scheduled inductions to guarantee the availability of a qualified labor and delivery nurse. however, none of the physicians were aware of the high rate of inductions at this rural hospital. this pilot study lends support for a large, randomized study of labor inductions in the rural area. this study also indicates a need to examine the impact of the nursing shortage on rural induction practices. introduction according to the national vital statistics report from the center for disease control (cdc), induction of labor in the united states (u.s.) has more than doubled in the last ten years, rising from 9.5% in 1990 to 20.6% in 2003 (martin, hamilton, sutton, ventura, menacker, & munson, 2005). the explanation for the overall rise in labor inductions remains undetermined (glanz, 2003). however, there is speculation that this rise is due to patient and physician preference for convenience. although there are medical reasons for inducing labor, there are also risks associated with the procedure and additional costs (rayburn and zhang, 2002). the leading cause of obstetrical liability claims is induction of labor that results in uterine hyperstimulation (simpson, 2004). induction of labor contributes to the rising health care cost in the united states because of the intensive monitoring that is required, as well as the lengthened hospital stay, increased intrapartum interventions, and increased number of cesarean sections that are associated with it (glantz, 2005; crowley, 2000; symon, 2000). the rise in the u.s. induction rate is based on national data collections that do not differentiate between rural and urban hospital sources (glantz, 2003). twenty percent of the total u.s. population lives in rural areas that cover 80% of the country’s landmass (bushy and leipert, 2005). this massive rural area is marked by limited resources, few and far between health centers, and a growing nursing shortage (bushy and leipert, 2005). online journal of rural nursing and health care, vol. 6, no.2, fall 2006 mailto:bzust@gac.edu mailto:nbriggs@gac.edu 30 although some studies note a disparity of birthing outcomes between rural and urban areas, few have explored the labor induction practices in rural areas. the purpose of this study was to explore the induction of labor practices in a rural, midwestern hospital. information from this pilot study contributes a rural focus to the body of knowledge concerning the current rise in induction rates. background induction of labor is defined as the stimulation of uterine contractions to cause the delivery of an infant before spontaneous labor occurs (kirby, 2004). labor is typically induced by using one or more of the following methods: cervical ripening agents, artificial rupture of membranes, and uterine stimulation with oxytocin (duff and sinclair, 2000). each method presents an element of risk to the pregnant woman and fetus. complications associated with artificial rupture of membranes include an increased risk of prolapsed cord and/or cord compression; a commitment to delivery within a narrow window of time; rupture of vasa previa; and increased risk of intrauterine infection (american college of obstetricians and gynecologists, 1999). complications of cervical ripening agents vary according to pharmaceutical agent used, the dose and the fetal/ maternal context (sanchez-ramos and hsieh, 2003). two common cervical ripening agents are misoprostal (cytotec), a synthetic prostaglandin, and dinoprostone (cervidil), a prostaglandin. high doses of misoprostal (50 micrograms every 6 hours) can cause uterine hyperstimulation resulting in compromised fetal oxygenation (acog, 1999). in a meta-analysis of 44 randomized clinical trials, sanchez-ramos and hsieh (2003) found that the use of misoprostol (cytotec) as a cervical ripening agent reduced cesarean section deliveries but raised neonatal intensive care admission from 14% to 18% and doubled the number of abnormal 5 minute apgar scores. these researchers found that women receiving this drug in high doses were more likely to experience tachysystole and uterine hyperstimulation than women who were not given this agent. in a meta-analysis of 52 studies involving dinoprostone, sanchez-ramos and hsieh (2003) found that a 10 mg sustained –release dose of dinoprostone resulted in uterine hyperstimulation with fetal heart rate changes. however, nonsustained-release subgroups of this drug were not associated with any negative effect. uterine stimulation with oxytocin is often used in conjunction with cervical ripening agents and is the most common method of labor induction (duff and sinclair, 2000). complications of oxytocin administration are primarily related to the dosage administered (crane and young, 1998; acog, 1999). the most common complication is uterine hyperstimulation, accompanied by compromised fetal oxygenation (acog, 1999). rare complications include uterine rupture and abruptio placentae (acog, 1999). crane and young (1998) noted that labor induction with oxytocin was associated with postpartum bleeding, increased instrumental deliveries and higher cesarean section deliveries. currently, there is physician controversy over what constitutes an effective, safe dose practice of oxytocin administration for the induction of labor (simpson, 2004). medical indications for inducing labor include gestational diabetes, maternal renal disease, online journal of rural nursing and health care, vol. 6, no.2, fall 2006 31 chronic pulmonary disease, chronic hypertension, chorioamnionitis, fetal demise, pregnancy induced hypertension, preeclampsia, eclampsia, fetal compromise, premature rupture of membranes, prolonged pregnancy, hospital distance, psychosocial variances, and risk of rapid labor (acog, 1999). the number of women with medical indications for induction has remained stable and acog has not increased induction indicators (glanz, 2003). prolonged pregnancies have been associated with a 2-10 times increase in infant mortality (crowley, 2000). in a detailed analysis of induction data from 19891998, macdorman, mathews, martin, and malloy (2002) found that induction of labor for prolonged pregnancies resulted in a 23% decrease in infant mortality. however, the researchers also found that preterm or term induction of labor resulted in a 20% increased risk of infant mortality. duff and sinclair (2000) examined data from 8044 deliveries over a three-year span of time from 1994-1996. out of the 8044 deliveries, 3262 were post-term deliveries and out of that figure, 1008 were induced. duff and sinclair concluded that there was no evidence of improved outcomes for the deliveries that were induced. on the other hand, they noted that the induced group had a slightly greater blood loss, slightly lower apgar scores, a 17% increase in epidural use and a 5% higher cesarean section rate than the spontaneous delivery group. one problem with inductions for prolonged pregnancies is the possible inaccuracy of the due date. in duff and sinclair’s study (duff and sinclair, 2000), 82.9% of the women were certain about their last menstrual period, and even so, 11.2% of this certain group had their due dates revised. macrosomia, as a medical indicator for induction of labor, is defined as a birth weight of over 4000 grams. induction of labor for macrosomia is intended to reduce the risk of shoulder dystocia and need for delivery by cesarean section (rayburn and zhang, 2002). sacks and chen (2000) conducted a review of the literature from 1980 to 1999 to examine the utility of macrosomia prediction in decreasing negative birth outcomes. their findings indicated that shoulder dystocia occurred in up to 58% of babies who did not meet the criteria for macrosomia. they also noted that shoulder dystocia was not reduced by labor induction for infants who were estimated to weigh 4000 grams. induction of labor for specific medical concerns account for only half of the inductions in some hospital settings (yeast, jones and poskin, 1999; dublin, lydonrochelle, kaplan, watts and critchlow, 2000). other indicators such as distance to the hospital, psychosocial variances, and history of rapid labor allow providers and patients to elect induction of labor for marginal reasons such as maternal discomfort and convenience for both provider and patient (dublin et al. 2000; rayburn and zhang, 2002). baxley (2003) cited two benefits of electing an induction: 1) labor and delivery nurses can be staffed appropriately, and 2) inductions are typically scheduled for daytime hours when emergencies have a better response time. however, the risks involved with inductions must be weighed against medical and other indicators. in addition to the risks already noted regarding cervical ripening agents, oxytocin, and artificial rupture of membranes, other risks include increased use of epidurals, increased blood loss, increased cesarean sections, fetal hypoglycemia, and fetal distress online journal of rural nursing and health care, vol. 6, no.2, fall 2006 32 resulting in an increased admission rate to a newborn intensive care unit (baxley, 2003; crane and young, 1998; crowley, 2000; dublin et al. 2000; duff and sinclair, 2000; macdorman et al. 2002; and sanchez-ramos and hsieh, 2003). in spite of the noted risks, induction of labor has risen in the united states dramatically. the reason for this rise is speculated to be due to an increase in elective inductions (martin et al. 2005). rayburn and zhang (2002) conducted a detailed analysis of the data used to determine the rising induction rate. they found that women who have high formal education, early prenatal care, are caucasian and/or have private insurance are more likely to be induced than other women. the cdc’s final report on births in 2003 (martin et al., 2005) supports this finding, reporting that the induction rate for caucasian women was 24.7% compared with 17.5% for non-white hispanic women. kirby (2004) noted that nulliparas are 10% more likely to be induced with a 40-week pregnancy and are 37% more likely to be induced with a prolonged pregnancy than multiparas of the same gestational status. this practice results in a doubling of the cesarean rate for the induced nulliparas. all of these findings raise the issue of election of inductions for reasons of convenience or preference rather than medical necessity. the above induction findings are based on national databases that combine rural and urban hospital induction practices. only a few studies have delineated rural induction practices from urban induction practices. glantz (2003) examined a sample of 31,352 deliveries obtained from a variety of rural and urban hospitals in new york and noted a significant variability in induction practice between hospitals, physicians, and geographical areas. the researcher found no correlation between induction rate and risk status of the hospital. other studies that compare rural versus urban delivery data, find disparity of outcomes between the two areas but do not specifically address induction practice in each area (hulme & blegen, 1999). in order to gain a better understanding of the rise in induction practices, glantz (2003) proposed that more research is needed to examine these practices in the context within which they occur. study, design and methods the purpose of this pilot study was to explore the induction practice in a rural, midwestern hospital using an exploratory study design. internal review board approval for the protection of human subjects was obtained from both the hospital and the supporting school of higher education. the hospital under study was a 21-bed hospital located in a rural midwestern community of approximately 2,500 people. the closest tertiary medical center was 45 miles from this hospital. the labor and delivery unit had three beds to accommodate an average of 95 deliveries per year. there were eleven qualified labor and delivery nurses employed by the hospital. when there were no patients in the obstetrical unit, a labor and delivery nurse was either “on-call” at home within 30 minutes of the hospital or was working in the hospital as the charge nurse in the medical surgical unit while also covering the emergency room. online journal of rural nursing and health care, vol. 6, no.2, fall 2006 33 the medical staff for the hospital consisted of eight delivering family practice physicians. there were no nurse midwives or obstetricians on staff. an emergency cesarean section could be accomplished in 30-40 minutes of notice. due to the limited availability of highly acute services and specialists, all women delivering at the hospital were considered low risk for complications of labor and delivery. prenatal patients who with moderate risk factors were referred to the tertiary birthing center. electronic fetal monitoring was used for all inductions of labor. due to the fact that the hospital did not have a nursery, mothers and babies roomed together. infants born with critical complications were flown out to the tertiary birthing center. data were collected from the birth record of deliveries at this hospital for the year 2003. the delivery record utilized by the hospital was similar to the state birth record, containing routine data gathered for state statistics. for induced deliveries, a blind review of the patient medical record was used to collect data regarding the indications for induction. data obtained included infant birth weight, apgar scores, gestational age, post-delivery infant complications or abnormalities, indications for labor induction, method of induction, pain management, and length of labor. these data were analyzed using simple frequencies and descriptive statistics obtained through spss 11 statistical software. in addition, all delivering physicians were invited to participate in a semi-structured, open-ended interview. the following questions were asked of each participating physician: 1) how do you decide when to induce labor? 2) what do you see as the benefits and the risks associated with induction? 3) what is your opinion about elective inductions? 4) do you think there is a difference in induction rates between urban and rural hospitals? 5) does the fact that this is a rural hospital influence your decision on whether or not to induce labor? each interview was conducted with participating physicians on a one to one basis. physician responses were recorded by the researcher and transcribed following each interview. results there were 90 deliveries at this hospital during the year under study. of these deliveries, 37.8% (34) of the deliveries were induced; an additional 17.8% (16) of the deliveries were augmented after spontaneous labor started; 7.8% (4) were planned cesarean section deliveries; and 33 (36.7%) had spontaneous deliveries requiring no intervention. as noted in table 1, reasons given for the 34 inductions included: continuing the pregnancy would compromise the fetus (1); patient convenience (1); gestational diabetes (3); suspected macrosomia (5); prolonged pregnancy (6); maternal discomfort (7); and undocumented reasons (11). the six inductions for prolonged pregnancy included women who were at or beyond their estimated due date. one of the six inductions for prolonged pregnancy resulted in the cesarean delivery of a premature infant. the baby was transferred to a tertiary birthing center in order to receive neonatal intensive care. the five inductions for suspected macrosomia resulted in deliveries of babies weighing less than 4000 grams. the largest baby weighed 3884 grams and the smallest baby weighed 3289 grams. online journal of rural nursing and health care, vol. 6, no.2, fall 2006 34 table 1 indications for labor induction according to delivering physicians physician a b c d e f g h total # deliveries 27 10 2 9 10 17 7 8 # of inductions 12 5 0 5 0 6 2 4 % inductions 44.4% 50% 0% 55% 0% 35% 28.5% 50% fetal compromise if pregnancy con’t 1 prolonged pregnancy 3 2 1 gestational diabetes 1 2 macrosomia 1 1 2 1 maternal discomfort 3 1 1 1 1 patient convenience 1 undocumented 4 1 3 3 * medical indications for labor induction are in bold italics. medical indicators for induction (macrosomia, prolonged pregnancy, gestational diabetes, fetal distress) accounted for less than half of the inductions at this rural hospital in the year under study. over half of the inductions in this hospital were for elective (patient convenience, maternal discomfort) or undocumented reasons. induction practice varied among the eight delivering physicians from 0% to 55%. the physician with the most deliveries had an induction rate of 44.4%, citing elective or undocumented reasons for 2/3 of the inductions. six of the eight physicians cited elective or undocumented reasons for induction. table 2 summarizes labor and delivery events and outcomes among spontaneous deliveries/ no interventions, augmented spontaneous labor by artificial rupture of membranes (arom), augmented spontaneous labor utilizing oxytocin, induced labor using cervical ripening agents and/or oxytocin, and scheduled cesarean deliveries. complications noted for the induced patients and their babies included one maternal postpartum hemorrhage, one fractured infant clavicle, and the one infant previously noted that was born prematurely and transferred to a neonatal intensive care unit. induced and augmented labor led to the births of infants with slightly higher apgar scores than infants spontaneously delivered. intrapartum interventions involving intrathecals to manage pain were used almost twice as much among induced patients when compared with spontaneous laboring patients. induced patients had a 79.4% (27 of 34) intrathecal usage rate compared to 46.5% (8 of 18) intrathecal use by the spontaneous laboring patients. online journal of rural nursing and health care, vol. 6, no.2, fall 2006 35 table 2 labor and delivery summary of events and outcomes. spontaneous delivery augmentation by arom only augmentation by oxytocin induction by cerv.ripening +/or oxytocin scheduled cesarean sections. total incidence 18 17 14 34 7 90 intrathecal use 8 5 11 23 --47 cesarean section 2 0 3 7 (7) 19 laceration 5 1st deg. 4 2nd deg. 1 3rd deg. 6 1st deg. 3 2nd deg. 3 1st deg. 1 2nd deg. 9 1st deg. 8 2nd deg. n/a apgars 8.1 .65 9.1 .34 8.4 .78 9.1 .76 8.4 .92 9.5 .65 8.4 .85 9.5 .65 8.3 2.16 9.3 1.21 1 min. sd 5 min. sd online journal of rural nursing and health care, vol. 6, no.2, fall 2006 abnormal outcomes 1 shoulder dystocia 2 to nicu 2 shoulder dys. 1 fx clavicle 1 pp bleed 1 to nicu 1 to nicu * artificial rupture of membranes. two inductions resulted in instrumental deliveries involving vacuum extraction. seven inductions resulted in cesarean delivery, accounting for 58% of the hospital’s unplanned cesarean sections for the year. the hospital had a total of 19 cesarean deliveries, twelve of which were not planned. the hospital’s 21.1% cesarean section rate is lower than the national cesarean section rate of 27.5% (martin et al. 2005). all eight of the physicians were interviewed for this study. the following is a summary of their responses to the five questions. 1. how do you decide when to induce labor? all of the physicians listed medical indicators as the deciding factors in inducing labor. prolonged pregnancies, gestational diabetes, intrauterine growth retardation, fetal anomalies, macrosomia and pregnancy induced hypertension were particularly emphasized. 2. what do you see as the benefits and the risks associated with induction? the most important benefit to the mom and baby was noted to be a “resolution of the indication for the induction”. the physicians identified the risks of induction as increased cesarean sections, increased postpartum bleeding, increased fetal 36 distress, and more pain in labor. several physicians also noted that inductions added an increased cost factor to delivery with “more doctor and nurse time and more interventions used, such as scalp electrodes, etc.” one physician commented that “…the cost may be higher, but the provider liability for not doing the induction when medically indicated is much more costly”. 3. what is your opinion about elective inductions? all of the physicians indicated a concern for inductions of convenience. their concerns ranged from strict resolve that there was never a place for elective inductions to acceptance of marginal (elective) indicators for induction such as maternal discomfort. one physician who delivered 10 of the 90 patients and had no inductions of labor for the year under study stated, “i do not participate in many inductions with my patients. but, if i do, there must be a significant reason for the interruption in nature’s process.” another physician who had the most deliveries for the year under study and 44.4% of the inductions said, “i wouldn’t recommend that anyone who wants an induction get one. however, there are situations where induction deliveries may not be necessary, but become an option due to some significant reason such as if a woman is incredibly uncomfortable or can no longer be effective in her normal roles.” five physicians stated that their patients frequently ask for inductions because of labor and delivery reality programs on television. several of the physicians commented that the media often misinformed their patients about obstetrical practices. one physician said, “every pregnant woman begs for an induction some time during pregnancy”. another physician said that the media pushes inductions as a matter of convenience and that “convenience should never be the indicator for induction”. 4. do you think there is a difference in induction rates between urban and rural hospitals? one physician thought that the rural induction rate was equal to the urban induction rate. this physician said, “having practiced in an urban setting while in residency, i use the same philosophy here as i did there.” the remaining seven physicians felt that the rural induction rate was lower than the urban induction rate. all of these physicians made similar comments about “sticking to acog guidelines more than urban docs” because of the need to be “more careful in the rural area”. one physician said, “there’s more conscientious adherence to induction protocols in rural hospitals”. one physician commented, “family docs probably have a lower rate of inductions. i suspect ob gyn docs have more inductions to allow them some control in their practice.” another postulated, “it would be easier to talk a physician into an induction in the urban area than here.” all eight of the physicians made a comment to the effect that they did not see any evidence that would suggest that the induction rate in the rural area would be higher than urban areas. 5. does the fact that this is a rural hospital influence your decision on whether or not to induce labor? several of the physicians said that they sometimes schedule inductions in order to assure the availability of a labor and delivery nurse. all of the physicians made a comment about the problem of not always having a labor online journal of rural nursing and health care, vol. 6, no.2, fall 2006 37 and delivery nurse available for spontaneous deliveries. one physician commented that when nursing staff was not available for spontaneous deliveries, patients in labor were diverted to alternative facilities where they, as the patient’s physician, may or may not have privileges. this physician said, “i know that there are times when we are threatened with the potential transfer of a patient to a surrounding area hospital for delivery due to the lack of ob nurses. this reflects poorly on the hospital and doesn’t preserve our clientele. we avoid this at all costs.” discussion/clinical implications the induction rate at this rural mid-western hospital was found to be 37.7% which is almost twice the national rate of 20.6% (martin, et al., 2005). this is particularly noteworthy because all of the pregnant women reflected in this figure were considered to have low risk pregnancies. although 44.1% of the inductions cited medical indicators, the data indicated that some of the medical indicators (such as macrosomia) were inaccurately assigned. according to rayburn and zhang (2002), the question of physician convenience should be raised concerning the labor inductions that were scheduled without medical indicators. it is possible that physician convenience or patient convenience may have been underlying factors for some of the inductions in this study. however, given the physicians’ concern about safe staffing of nurses, the most likely reason for the undocumented induction of labor in this rural hospital was to ascertain availability of qualified labor and delivery nurses. all of the physicians noted the fact that labor and delivery nurses were not always available for spontaneous deliveries. some physicians described scheduling an induction as a way of guaranteeing safe staffing of a qualified nurse. the fact that almost all of the physicians perceived the induction rate at the hospital to be less than the urban average instead of double the national average, may indicate that the physicians were not aware of the degree to which induction of labor practice might be influenced by nurse staffing issues in this small rural hospital. a future study is needed to explore the degree to which rural physicians schedule inductions to meet nurse staffing needs. the national nursing shortage is compounded in rural hospitals by the fact that small hospitals cannot compete with the salaries offered by larger medical centers. in addition to the wage and benefit inequity, small, rural hospitals do not have the capacity to care for high acuity patients. anecdotal data indicates that because of the low acuity of patients, rural hospitals are perceived by some nurses to be less challenging and therefore less desirable to work in than metropolitan medical centers. in recent years, there has been a rural exodus by nurses who are enticed by the greater opportunities and wages offered by metropolitan medical centers. staffing of qualified labor and delivery nurses in small rural hospitals is a wellknown but undocumented problem. orientation in labor and delivery for inexperienced new registered nurses is extremely difficult in small, rural hospitals where there is a limited number of deliveries per year. it takes a long time to provide enough obstetrical experiences online journal of rural nursing and health care, vol. 6, no.2, fall 2006 38 to prepare a new nurse to become comfortable enough to work alone –as is often the case--in a rural labor and delivery unit. many small, rural hospitals participate in a health system partnership with urban hospitals that have busy birthing centers. there is an opportunity within health system partnerships for nurses employed in action-packed birthing centers to invite new rural nurses to spend part of their orientation period at the urban birthing center and to mentor them in acquiring labor and delivery skills. in the hospital under study a labor and delivery nurse would be expected to take a patient load in the medical/surgical unit and cover the emergency room when the obstetrical unit was empty. this fits with bushy and leipert’s observation (bushy and leipert, 2005) that rural nurses need to be ‘expert generalists’ (p. 1). bushy and leipert urge nursing educators to be intentional about introducing students to the unique challenges of rural nursing. there are a number of limitations of this study. the use of a convenience sample of one small, rural hospital limits the interpretation of the results. data gathered from only one calendar year limited the researcher’s ability to examine long-term factors such as maternal and infant outcomes. another limitation of this study was that not all delivery documentation was complete. none of the delivering physicians were obstetricians and there were no nurse-midwives on staff. a larger, randomized study is needed to explore the induction practices in rural areas. additionally, more research is needed to explore the possible correlation of the rural nursing shortage with rural induction of labor rates. in conclusion, this study was significant to nursing because the findings added to the limited body of knowledge that addresses rural labor induction practices. the findings support the need for nurses to be well informed as patient educators concerning the indications for labor induction. nurses need to help patients understand the need for a medically indicated induction as well as present the potential risks 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[medline] online journal of rural nursing and health care, vol. 6, no.2, fall 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11035351%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10672100%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12911799%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15916205%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10388334%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15153136%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15547518%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12123440%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16176060%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12100818%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10758619%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12521553%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15028930%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11139857%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10076139%5buid%5d prolonged pregnancy the relationship between weight perception, gender, and depressive symptoms among rural adolescents 13 the relationship between weight perception, gender, and depressive symptoms among rural adolescents kathryn puskar, drph, rn, faan1 lisa marie bernardo, phd, rn, mph2 carl fertman, phd, mba, ches3 dianxu ren, phd4 kirsti hetager stark, msn, aprn, bc5 * 1professor, school of nursing, university of pittsburgh, krp12@pitt.edu 2associate professor, school of nursing, university of pittsburgh, lbe100@pitt.edu 3associate professor, school of education, university of pittsburgh, carl@pitt.edu 4assistant professor, school of nursing, university of pittsburgh, dir8@pitt.edu 5project director, school of nursing, university of pittsburgh, kms87@pitt.edu * contact author key words: weight perception, rural, adolescent, depressive symptoms abstract research findings indicate a relationship between weight perception and depression in adolescents. this study explored the relationship between weight perception, gender, and depressive symptoms in rural adolescents. among 623 rural adolescents who completed a health inventory and a depression scale, 75 participants (n = 62 females; n = 13 males) had depressive symptoms and were used in data analysis. a two-way anova model was used to evaluate the effects of weight perception and gender on depressive symptoms in rural adolescents. although the 2-way anova was not significant, there was a statistical significant finding for females who reported perceived weight problems and depression. the interaction between gender and weight perception was of marginal statistical significance (p = 0.07). females who perceived a problem with their weight had higher depressive scores compared to females who did not perceive a problem with their weight (p = 0.0002), however no difference was observed for males. implications are for rural nurses to screen adolescents for depressive symptoms and their weight perception during health care visits, with emphasis on females. introduction current evidence demonstrates a strong relationship between a negative weight perception and depressive symptoms in adolescents, even when physical weight is within a normal range (daniels, 2005; eaton, lowry, brener, galuska, & crosby, 2005; xie et al., 2003). this trend is particularly disturbing considering our nation’s obsession with body weight and appearance, especially in the adolescent population. weight perception numerous studies conclude that there are discrepancies between adolescents’ perception of body weight and actual body weight. cheung, ip, lam, and bibby (2007) surveyed nationally 1,132 adolescents and found that there was poor agreement between body mass index (bmi) and online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 http://www.nursing.pitt.edu/ mailto:krp12@pitt.edu http://www.nursing.pitt.edu/ mailto:lbe100@pitt.edu http://www.education.pitt.edu/ mailto:carl@pitt.edu http://www.nursing.pitt.edu/ mailto:dir8@pitt.edu http://www.nursing.pitt.edu/ mailto:kms87@pitt.edu 14 perceived weight in females, and a fair agreement in males. females were more likely to employ weight control behaviors, based on their perceived weight, while males used weight control behaviors based on their perceived and actual weights. al-sendi, shetty, and musaiger (2004) surveyed bahraini adolescents (n = 504) to determine relationships between bmi, their perception of self-weight and their perceived opinion of parents and peers about weight. overweight was more prevalent among the females. among females, 6.6% perceived themselves as obese, but 20.4% were classified as obese based on their bmi; 3.2% of males perceived themselves as obese, with 16.3% classified as obese by their bmi. for both males and females, there was a statistically significant difference among their perceived and actual weight based on bmi. depressive symptoms research on mental health in rural adolescents reflected that on average 10-12% of youth have depressive symptoms (puskar, tusaie-mumford, sereika, & lamb, 1999b; puskar et al., 2006). the youth risk behavior surveillance-united states, 2005 (centers for disease control and prevention, 2006) report 28.5% students nationwide felt sad or hopeless and that the prevalence was greater in females (36.7%) versus males (20.4%). numerous data sources point to the prevalence of depressive symptoms in adolescents and rural areas (centers for disease control and prevention, 2006; probst et al., 2006; paxton, valois, watkins, huebner, & drane, 2007; burns et al., 2004). a longitudinal study was done by burns et al. (2004) to ascertain depression and risk factors in rural adolescents (n=64). baseline depression data were related, over time, to the risk factors of tobacco use, substance abuse, and history of physical and sexual abuse. weight perception and depression an emerging body of evidence supports the relationship between weight perception and depression in adolescents. rierdan and koff (1997) surveyed 176 young female adolescents to evaluate their self-reported weight, weight categorization, weight satisfaction and weight concerns. height and weight (bmi) were measured by a school nurse. subjects with a high objective weight tended to underreport their weight. the higher the bmi, the more dissatisfied they were with their weight and their weight concerns were greater as well. there was no relationship between bmi and depressive symptoms; however, weight satisfaction and weight concerns were significantly correlated with depressive symptoms. a weight concern was a significant independent predictor of depression levels. daniels (2005) conducted a secondary analysis of data from the united states youth risk behavioral surveillance system, 1999 and 2001 data, to identify a relationship between weight, perception of weight, weight management behaviors, and the relationship between these variables and depressive symptoms in over 13,000 students. depressive symptoms were related to perceived weight and dieting behaviors, while no relationship was found between self reported depressive symptoms and body mass index (bmi). there was a 35% likelihood of depressive symptoms reported by those who perceived themselves as either underweight or overweight. females were 20% more likely to view their weight as either under or overweight compared to males (daniels, 2005). online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 15 eaton et al. (2005) explored whether bmi and perceived weight were associated significantly with suicide ideation and suicide attempts. white students who perceived themselves as very underweight and very overweight were at greater odds of suicide attempt. regardless of bmi, adolescents with extreme perceptions of body size were at increased risk for suicide ideation and attempts. these authors concluded that perception about weight may be more important than actual weight. xie et al. (2003) investigated weight perception and its relationship with psychological distress among 2,179 chinese adolescents. perceived overweight was more likely to occur in females. also, males and females who perceived themselves as overweight were more likely to experience anxiety and depression. kim and kim (2001) determined if bmi and perception of body weight (having a weight problem) predicted self esteem and depression in korean female adolescents. while only 2.6% of the subjects were overweight, 78.5% desired to be underweight. perception of having a weight problem (overweight) was predictive of self-esteem and depression. ivarsson, svalander, litlere, and nevonen (2006) surveyed 405 swedish adolescents to assess weight problems and their correlation with bmi, body image, depression, and anxiety. females were found to have higher scores for depression and anxiety. females who were overweight had negative self-esteem, compared to males. ozmen et al. (2007) conducted a cross-sectional survey of 2,101 turkish adolescents to examine the effects of weight, perceived weight and body satisfaction on self-esteem and depression. only 9% of the subjects were overweight. among females, a higher socioeconomic status was associated with a perception of overweight. females were also more likely to report dissatisfaction with their bodies. this literature correlating weight perception, depression and combination of weight perception and depressive symptoms found a troubling pattern with adolescent females. females reported more dissatisfaction with their perceived weight than males (cheung et al., 2007; alsendi et al., 2004). other studies identified females with negative perceptions or weight concerns with depressive symptoms (rierdan & koff, 1997; daniels, 2005; eaton et al., 2005; xie et al., 2003; kim & kim, 2001; ivarsson et al., 2006; ozmen et al., 2007). theoretical framework the theoretical framework of stress and coping posited by lazarus (1991) and lazarus and folkman (1984) guided this study. adolescence is a time of turbulence which tests young people’s coping with (a) life events, (b) changing body images, and (c) issues of belonging and acceptance within peer groups. such events and their meaning are determined by the adolescents’ perceptions and coping resources. emotions are an integral part of this process and have an impact upon the adolescents’ biological, social, and cognitive functions. emotions can be positive or negative, healthy or unhealthy. the inability to cope with negative perceptions, such as perceived problems with weight, can possibly lead to depression, anxiety, and other mental health issues. exploring relationships between how adolescents appraise a situation (perception of body weight) and how these appraisals affect their mental health (depression) underpins this research study. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 16 purpose of study there is a paucity of research on rural adolescents’ perception of their weight and depressive symptoms. rural researchers emphasize the importance of assessing adolescents’ somatic complaints and depressive symptoms as part of rural adolescent health promotion (puskar, lamb, & tusaie-mumford, 1997; puskar, sereika, & haller, 2003; puskar et al., 1999a; puskar et al., 1999b; puskar et al., 2006). the research question was “is there a relationship between weight perception, gender, and depressive symptoms in rural adolescents?” method the design was a cross sectional descriptive study. the study was completed in four rural high schools in southwestern pennsylvania. a total of 623 adolescents completed the study measures that are described below. written informed consent was obtained from both the adolescent subjects and parents prior to study participation. the protocol was approved by the university of pittsburgh institutional review board on human subjects and the four participating school districts. measures adolescent health inventory. weight perception was measured with the adolescent health inventory (ahi) (nelson, barnard, king, hassanain, & repoff, 1991), using item number 12 “i have a problem with my weight”. the forced choices were never, occasionally, often, and always. the choices of “never” and “occasionally” were combined to create the group ‘perception of no weight problem’. the choices of “often” and “always” were combined to create the group ‘perception of having a weight problem’. the ahi measures physical health perceptions, needs, and concerns of adolescents in a 36-item inventory. internal consistency was measured by cronbach’s alpha with values ranging from .51 to .80 in each of the four areas of need. test-retest reliability was evaluated using pearson’s correlation and the coefficient ranged from .30 to .86 with greater than 50% being above .70. the percent agreement ranged from 64.39 to 100% with a mean of 81.92% (ware & sherbourne, 1992). content validity of the ahi was determined by expert evaluation of doctors, nurses, and teachers and with an extensive background literature review. reynolds adolescent depression scale. depressive symptoms were measured by the reynolds adolescent depression scale (rads) (reynolds, 1987). the reynolds adolescent depression scale (rads) is an adolescent self-report of depressive symptomatology which measures cognitive, motor, somatic, and interpersonal symptoms commonly associated with depression (reynolds, 1987). the rads consists of 30 items with a four-point likert format. internal consistency and split-half reliabilities are high (.91-.96); test-retest reliability is 0.79 over three months and 0.63 over 12 months. based upon examination of rads scores and on other self-report depression measures, a cutoff score of 77 on the rads identified subjects having depressive symptoms (reynolds, 1987). therefore, in this study, participants were classified as having depressive symptoms if their rads score was greater than or equal to 77. also, participants were classified as not having depressive symptoms (or normal) if their rads score was less than 77. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 17 survey procedures the research team met with the superintendent and principal of each of the four high schools to explain the project and obtain their school board approval. next, the team held an assembly with students to explain the research project and distribute consent forms. students with signed consents and signed parental consents completed the study two questionnaires (ahi and rads) and a demographic survey during a one-and-a-half hour time period during school. they were given ten dollars to compensate for their time. the reynolds adolescent depression scale (rads) was scanned within 2 days to identify scores >77 points, which indicates depressive symptoms therefore requiring further assessment, intervention and possible referral. data from the students who had depressive symptoms were used for analysis. analysis descriptive statistics were used to report frequencies of weight perception on the ahi (item number 12 “i have a problem with my weight”), gender, and scores > 77 on the rads. to answer the research question “is there a relationship between weight perception, gender, and depressive symptoms in rural adolescents” a two way anova model was employed. sas 9.1 was used for all analyses, and the level of significance was set at 0.05. results this study identified that a negative perception of weight was associated with increased depressive symptoms in rural female adolescents, however not in rural male adolescents. characteristics of subjects the original sample of 623 adolescents from four rural high schools in southwestern pennsylvania have been reported elsewhere (puskar et al., 1997; puskar et al., 2003; puskar et al., 1999a; puskar et al., 1999b). briefly, the majority of the subjects were caucasian (97.27 %, n = 606), female (60.3%, n = 376), with mean age of 15.85 (sd = 0.99). a sub-total of 548 (88%) adolescents scored in the non-depressive range (less than 77 on the rads) while 75 (12%) participants scored in the depressive symptom range (77 or greater) out of the sample of 623. the overall mean score was 57.39 (sd 15.706), the median was 55, and the range of scores was 30-106. for females, the mean rads score was 61.06 (sd 16.182), and the median was 61. for males, the mean rads score was 51.82 (sd 13.15), with a median of 49. of importance, 75 (12%) of the sample scored 77 or greater on the rads which is suggestive of depressive symptomatology. by gender, 16.5% (n=62) of the females and 5.2% (n=13) of the males scored 77 or greater. there were 494 (79%) adolescents who answered “i have a problem with my weight” as never or occasionally (perception of no weight problem). the remaining 129 (21%) adolescents answered “i have a problem with my weight” as often or always (perception of having a weight problem). online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 18 the effects of weight perception and gender on depressive symptoms of the 75 rural adolescents scoring >77 points on the rads (indicating depressive symptoms), 31 (41%) perceived themselves as having a problem with their weight. according to gender, 25 (33%) females and six (8%) males with depressive symptoms reported a problem with their weight (‘often’ or ‘always’). a two-way anova model with interaction was used to evaluate the association of depressive symptoms with gender and weight perception. the interaction between gender and weight perception was of marginal statistical significance (p=0.07). the appropriate statistical contrast was used to compare the difference between the two perception groups “no weight problem” and “weight problem” for male and female respectively. all the subjects with depressive symptoms, rural adolescent females who perceived themselves as having a problem with their weight had significantly higher depressive scores compared to females did not perceive a weight problem (adjusted mean: 90.3±1.39 vs. 82.9±1.14; p=0.0002). however, no difference was observed in males between perception of having a weight problem and not having a weight problem (adjusted mean: 83.7±2.62 vs. 83.3±2.83; p=0.88) (table 1; figure 1). table 1 two-way anova model associations between gender, weight perception, and depressive symptoms (rads ≥77) gender/weight perception number of subjects with depressive symptoms n = 75 depressive symptoms adjusted mean score (se) gender female male n = 62 (82.7%) n = 13 (17.3%) p = 0.15 86.6 (0.90) 83.5 (1.93) weight perception “i have a problem with my weight” no (never, occasionally) yes (often, always) n = 44 (58.7%) n = 31 (41.3%) p = 0.10 83.3 (1.43) 86.8 (1.58) gender with weight perception female with perception* of : no yes male with perception* of: no yes n = 37 (49.3%) n = 25 (33.3%) n = 7 (9.3%) n = 6 (8.0%) p = 0.07 82.9 (1.14) 90.3 (1.39)** 83.7 (2.62) 83.3 (2.83) * “i have a problem with my weight” ** p = 0.0002 online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 19 adjusted mean of depressive symptoms by weight perception and gender 78 80 82 84 86 88 90 92 94 female male d ep re ss iv e s ym p to m s perception-no weight problem perception-weight problem n= 6 n= 7 n= 25 n= 37 figure 1. adjusted mean of depressive symptoms by weight perception and gender discussion this rural study found a troubling relationship between weight perception and depressive symptoms in female adolescents, similar to reported findings (rierdan & koff, 1997; kim & kim, 2001; eaton et al., 2005). eaton et al. (2005) supports this study’s implications that perception about weight may be more important than actual weight. daniels (2005) found depressive symptoms were related to those who perceived themselves as either underweight or overweight. there was a 35% increase in possibility of those youth reporting depressive symptoms than those who perceived their weight as “okay”. xie et al. (2003) found that both males and females with perceived weight problems were more likely to have anxiety and depression. these studies relate to the finding in this paper. the main finding of this study is that rural females with depressive symptoms who perceive themselves as having a problem with their weight tend to have higher depressive scores. rierdan and koff (1997) speculated that adolescent females may have body dissatisfaction and depression in the absence of objective overor under-weight. such dissatisfaction and depression may be related to accepting ‘implausible ideals about thinness’ and body-related experiences in early adolescence, such as responses to their developing bodies and bodily changes by families and friends. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 20 limitations there is a need for continued inquiry into the relationship between male and female adolescents’ weight perception and depressive symptoms particularly in rural youth. limitations to this study include a small sample size, especially for males. actual weight, height and bmi were not measured as an objective comparison. perception of overweight or underweight was not based on bmi, but reported by the adolescents as having a problem with their weight often or always. this sample of four high schools in rural pennsylvania may not be generalizable to other rural high schools. as a cross-sectional study, adolescents were not followed over time for changes in depressive scores and weight perception. implications for rural adolescent health achieving healthy lifestyles can be difficult in a rural area, where there is limited access to organized activities and where poverty may affect diet. other rural challenges of culture and structure include: tv and video game preference over active activities, less sidewalks, and less exercise services (jackson, doescher, jerant, & hart, 2005). nurses practicing in rural hospitals and community settings must be vigilant to adolescents’ perceptions of their body weight and its relationship to their mental health. sadly, federally designated mental health professional shortage areas have been found to be more than 85% are in rural areas. rural america has been underserved by mental health professions for the past 40 years. factors that prevent rural individuals from receiving the mental health care they need are accessibility, availability, and acceptability (the annapolis coalition on the behavioral health workforce, 2006). rural nurses are in an ideal position to facilitate health promotion among rural adolescents through teaching awareness, screening, and referral for problems with weight perception and depressive symptoms. female adolescents can be further assessed by rural nurses using the findings of this study. rural nurses have the opportunity to teach adolescents about healthy lifestyle choices, including nutrition and physical activity to address healthy body weights and accurate perceptions about weight. studies have explored the effectiveness of interventions to address adolescent nutritional education, one included a world wide web educational intervention (long & stevens, 2004; stewart et al., 1995). other studies included an intervention of physical activity with nutrition education (neumark-sztainer, story, hannan, stat, & rex, 2003; prochaska & sallis, 2004; sallis et al., 2003). nursing interventions need to include education, motivation and skill building to create behavioral change (b. vreland, personal communication, august 12, 2005), especially around weight and mood. screening about weight and depressive symptoms are important primary prevention skills. when nurses perform height, weight and body mass index measurements, they can explore with the adolescent their perception of their weight. rural nurses can engage adolescents in discussions about nutrition and how they view their weight and their weight intentions (daniels, 2005). healthy choices and desired weight ranges need to be explained to promote health. nurses caring for rural female adolescents are in a privileged and trusted position. it is important to ask adolescents if they believe they have a problem with their weight, even if these adolescents do not appear overweight. adolescents who perceive themselves as having a online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 21 problem with their weight can be educated about the health risks associated with too much or too little weight plus be assessed for depressive symptoms. involving parents and caregivers about weight perceptions and depressive symptoms can be an important intervention and implementation will vary from adolescent to adolescent. collaboration and referrals to a dietician, nutritionist, psychiatric nurse practitioner, or other mental health specialists are valuable resources. it may be necessary to refer to an endocrinologist when nutrition and exercise habits have improved but there is no improvement in normalizing the adolescent’s weight, perception, or mood. those females showing signs of depressive symptoms should be assessed about how they view their weight due to the correlation of increased depressive scores with belief they have a problem with their weight. a screening tool for depressive symptoms could be used, such as the reynolds adolescent depression scale (reynolds, 1987). interventions to treat depressive symptoms and weight concerns are important to the future of these vulnerable adolescents. in conclusion, rural nurses can make a difference in the lives of rural adolescents. acknowledgement supported by national institute of health (nih), national institute of nursing research (ninr) grant no. 5ro1 nr03516-03 references al-sendi, a., shetty, p., & musaiger, a. 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[medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12657338%5buid%5d http://www.annapoliscoalition.org/rural_workforce_issues.php http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1593914%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12944011%5buid%5d microsoft word manuscript 1480110_revision_cox_poor_women_final-09-08-11-16-43.docx online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 63 poor women with sexually transmitted infections: providers’ perspectives on diagnoses genevieve r. cox, phd candidate 1 1 department of sociology; university of new hampshire, durham, new hampshire, grg2@wildcats.unh.edu keywords: community and public health, health care, provider perspective and behavior, health care, rural, marginalized populations, poverty, sexually transmitted diseases, women’s health abstract this article presents results from a study of health care providers, mainly nurses and nurse practitioners, who routinely diagnose sexually transmitted diseases (stds) in rural low-income populations in west virginia (wv). a qualitative analysis of eighteen semi-structured interviews reveals that providers who consistently work with low-income populations believe patients undergo a negative change in self-image in response to a chronic std diagnosis. providers express concerns about a number of issues related to lowincome, rural women’s access to sexual health care and see the need for more sexuality education, more funding for free and reduced cost clinics, and more available health insurance. additionally, despite problems working in publicly funded clinic environments, providers attempt to eliminate stigma attached to diagnoses of sexually transmitted disease. introduction sexually transmitted infection (sti) also known as sexually transmitted disease (std) (hendricks, 2001) represents a public health problem with massive economic and social consequences for the united states (us) (cdc, 2009a). viral stds, such as herpes and human papillomavirus (hpv), the group of viruses that cause genital warts and are associated with cervical, vulvar, vaginal, penile, anal, and head and neck cancers (cdc, 2009c, 2010), are particularly problematic because outbreaks often recur over an individual’s life and entail a high level of emotional and physical discomfort. currently, about 45 million people or about one out of five americans live with herpes and at least half of all sexually active people will acquire human papillomavirus some time in their life (cdc 2007, 2009c). providers who routinely diagnose hpv and herpes deal with difficult patient reactions to first time diagnoses of what are often termed “chronic” stds and the negative stigma attached to having an std. some of the characteristics associated with having an std are “indiscriminate promiscuity, pollution, and uncleanness” (lawless, kippax, & crawford, 1996, p., 1371). historically, low-income women with stds have been particularly stigmatized partly because they have been defined as “impure,” “undeserving,” and “sinful” (lawless et al., 1996, p. 1376). providers who diagnose and treat stds in public clinics that cater to populations that are both rural and poor deal with a special set of challenges. issues such as lack of health insurance, transportation problems, inability to pay for services, child care problems, stigma, and lower levels of education make the diagnosis and treatment of stds a particularly difficult situation for the patients and a demanding undertaking for the providers. research from the providers’ perspective about std diagnoses in public online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 64 clinics is needed to better inform policy that can ultimately benefit both the patients and providers. although studies on provider attitudes exist (beatty, o’connell, ashikaga, & cooper, 2003; danielson, barbey, cassidy, rosenzweig, & chowdhury, 1999; lane et al., 1999; merzel et al.2004; o’connell, 1997), many do not focus on rural environments and are narrow in focus. qualitative research in rural environments that focus on the providers’ own perceptions and observations in the field is sorely needed. my research, based on interviews with health care practitioners in west virginia (wv), begins to address this gap. an analysis of 18 interviews with providers who routinely diagnose low-income patients with stds addresses how providers describe the diagnostic process within low-income rural populations and the issues they see these women confront. stds diagnoses and low-income women stds are often physically more problematic for women than for men. for example, hpv can cause more lasting and difficult complications in women (weinstock, berman, & cates jr., 2004) because of hpv’s link with cervical cancer; it has been identified as the main causal agent in over 95% of cervical cancers (beatty et al., 2003). herpes disproportionally affects women, affecting one out of five women versus one out of six men (cdc, 2007). moreover, adolescent girls ages 15-19 and young women ages 20-24 are most likely to contract common stds than men or any other age group (cdc, 2009b). studies like these show the need for more research related to women and sexual healthcare because they underscore the especially high rates of std transmission in women. a vaccine for hpv for women was approved by the federal drug administration [fda] in 2006 that prevents against 4 out of the 100 strands of hpv that cause most types of warts and cancer (fda, 2006). the vaccine is not recommended for women over the age of 26 and can be cost prohibitive for younger women without health insurance (national cervical cancer coalition, 2010). socioeconomic status and access to health insurance is often linked to patient health. persons without health insurance are more likely to report an unmet need for care and are less likely to receive preventive health services (national center for health statistics, 1998). even with government sponsored medicaid for the poor, 48% of poor, fulltime workers were uninsured in the united states in 2000 (waldrop, 2000). women living below the poverty line are more likely to contract hpv (women’s economic agenda project, 2008) and poor women and women without health insurance have a far more difficult time accessing sexual and reproductive health care than higher income women (wyn, ojeda, ranji, & salfanicoff, 2004). frequently, low-income patients or people without health insurance delay seeing a doctor because they cannot afford care. targeting research in locations where public health care providers treat mostly low-income women without health insurance will allow a greater understanding of providers who serve populations encountering the most difficultly accessing treatment for stds. stigma and health care providers’ perspectives some studies claim that receiving a diagnosis of an std and the treatment one receives during the diagnosis by the health care provider can significantly affect a patient’s sense of self (nack, 2002), particularly because of the stigma attached to an std diagnosis. following goffman’s (1963) definition of stigma as “an attribute that is deeply discrediting” (goffman, 1963, p. 3), i refer to stigma in this study as a perceived label that situates a person apart from those who do not have the “deeply discrediting” attribute, that negatively affects the stigmatized person’s sense of self. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 65 stigma associated with stds is not likely to decrease without education efforts and is a major barrier to appropriate sexual health care (fortenberry et al., 2002; lichtenstein, laska, & clair, 2002). provider attitudes are important to patients receiving sexual and reproductive health care (lane et. al., 1999) and as such are important to studying the std diagnostic process and stigma. linnehan and groce (1999) found that stigma related to how health care providers felt about “promiscuous” patients often prevented patients from seeking out prevention and treatment services. they agree that the overwhelming majority of health care providers see hpv infection as a major health problem for young women, “but only 54% spend at least 10 minutes providing education and counseling to all of their hpv patients” (linnehan & groce, 1999, p., 137). nack (2002) found that women receiving diagnoses of herpes or hpv agreed that providers’ deliveries of diagnoses were key to the symbolic meaning the patient initially related to the std. thus, the attitude of providers and amount of time spent in appointments for health education are critically important aspects of care for patients. often, studies that are dedicated to stigma and patient reactions associated with diagnoses of hpv, herpes, and bacterial infections (cdc, 2000; chesson, blandford, gift, tao, & irwin, 2004; khan et al., 2007; nack, 2002) do not focus on poor rural women in the united states and typically omit qualitative research about providers’ perspectives informed from the diagnostic setting. the purpose of this research is to better understand the stigma associated with stds through health care providers’ eyes and the perspectives of sexual health care providers who consistently serve rural low-income populations in publicly-funded environments. publicly funded clinics in wv are good sites to explore this phenomenon. wv is a historically rural state with the third highest poverty rate (17.9%) in the country (us census, 2010a). the median household income in wv in 2008 was $37,528, well below the national median household income of $52,029 (us census, 2010b). moreover, 21% of all women in wv lack health insurance (versus approximately 17% nationally) and close to 36% of low income women in wv are uninsured (henry j. kaiser family foundation, 2007, 2004). these findings imply that women in wv are particularly at risk for encountering difficulties accessing care. research questions associated with my study include: how do health care providers characterize the problems rural low-income populations face with stds in wv? do providers demonstrate an awareness of the stigma attached to std diagnoses? these questions are intended to produce a fuller picture of challenges associated with the std diagnostic process from the health care provider’s perspective than what has been presented in prior research. methods in order to address these questions and more fully understand the process involved in working with low-income populations with stds through the health care providers’ eyes, i engaged health care providers directly in the research process via interviews. qualitative methodology incorporating interviews is especially pertinent for this study because the emotionality involved in recounting complex situations like std diagnoses required in depth discussions. i interviewed 18 health care providers from two clinics who give “free” or reduced-cost reproductive and sexual health care to young poor women in wv about their experience diagnosing low income populations with stds in a face-to-face semi-structured interview format. one clinic mainly serves a student population of ages 18-24, while the other publically funded clinic serves patients of all ages. i targeted providers who work in family planning clinics specifically designed for online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 66 poor women without health insurance. interviews were conducted and recorded in the participants’ offices and clinic locations and later transcribed verbatim for analysis. the health care providers in this study consisted of 4 registered nurses, 7 physicians, a physician’s assistant, 3 nurse practitioners, 2 nurse midwives, and one sexually transmitted infections educator. these providers had been working in sexual and reproductive health care for an average of 19 years. the sample included a much higher ratio of female providers (72% female versus 28% male) due to a greater number of female providers in these clinic locations. providers were recruited based on their practice location, special interests, and also through referrals. i attempted to reach a saturation point of providers by specialty area in these two locations relating to lowincome women’s sexual health care. i received formal irb approval to conduct this research, protocol # 16407. current research suggests a need for provider sensitivity in clinic care (nack, 2002; o’connell, 1997), so interviews focused on issues that may shed light on how providers dealt with delicate patient situations. literature suggests that low-income women have a more difficult time accessing reproductive health care (wyn et al., 2004), leading to questions centered around issues involved in treating low-income women. research (nack, 2002; perrin et al., 2006) also suggests that patients react negatively to diagnoses of viral stds, so providers were asked to explain if they had witnessed any negative reactions to std diagnoses. other examples of interview questions included: what are the most recurring issues you see involved in low-income women’s sexual health care? what are some goals you have in working with this population? what policies would help you do your job better? the responses to the interview were analyzed in transcript form using line-by-line coding, labeling of recurring concepts, incident to incident comparison, and cross referencing of codes and memos. examples of codes include “provider sensitivity to stigma” and “issues with at-risk populations.” after initial coding, i used operational definitions to further the analysis process. the analysis yielded the categories of 1. the process of std diagnosis, which included examples of codes such as “provider sensitivity to stigma” and 2. providers’ views of barriers to care, which included codes such as “issues with at-risk populations.” the scheme provided the basis for discussing patients’ reactions to std diagnoses through the providers’ eyes including patient emotional responses like anger. after determining how providers perceived patients and their reactions to the std diagnoses i was able to better understand the degree of awareness providers exhibited surrounding stigma and specific problems they associate with low-income populations. findings providers’ descriptions of patient reactions to diagnoses anger and sadness are the two most common patient reactions to std diagnoses that providers spoke about, although denial was also a significant reaction. thirteen of the eighteen providers interviewed mentioned sadness, anger, or both as the most prominent factors after initial diagnosis. providers revealed that sadness or crying after the initial clinical diagnosis is a common occurrence in patients diagnosed with stds, but specifically with chronic stds. patient responses to providers included phrases like, “nobody will want to go out with me.” one registered nurse (rn) describes that she has seen a lot of tears…[from patients] thinking… ‘how am i going to tell my partner now? what am i going to tell my partner?” she explained that a patient is typically upset during the diagnosis because they online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 67 are wondering about the changes they will have to make in their interpersonal and sexual lives. sometimes, the fear and uncertainty elicited after receiving a diagnosis contributes to a patient denying the existence of the std or reacting angrily, often directly at the provider giving the diagnosis. according to providers, patients sometimes deny they have the infection or might not believe a provider is correct about their diagnosis. one physician remembers a patient who refused the diagnosis because the patient did not realize her symptoms, like headaches or neck aches, could be linked to herpes. according to him, many patients “are very angry, defensive, and unwilling to accept that they have [an std],” especially when they come to the clinic with a lack of information on stds. another way patients deny the existence of the std might be to get a second opinion days later after symptoms have subsided. one physician described his experience of diagnosing a patient with herpes who was very angry with him and refused to accept the diagnosis. when her symptoms had cleared after the outbreak she went to a different clinic where she was told she did not have herpes and actually came back specifically to tell the physician that he was “out in left field;” or wrong about the diagnosis. it is possible that the provider could have misdiagnosed the patient, but instead of requesting a blood test to be sure, the patient waited until symptoms had disappeared to be told at a different clinic that she did not have herpes. patients might also react angrily toward their partners. providers described many instances when anger at a partner was the first response a patient elicited because the patients immediately assumed a partner had been unfaithful and/or was the source of the infection. “finger pointing” or phrases like, “just wait until i get home” were frequently said by patients. the assumption that a partner has been unfaithful could be correct, but one provider emphasizes to her patients that “this doesn’t [always] mean that your partner has been unfaithful. it means that you probably need to sit down and talk about it and find out.” when assumptions like these are made by patients, the provider must compensate by being emotionally supportive and educate the patient about std transmission. additionally, if providers are actually simultaneously diagnosing infidelity in a partnership, they are the first point of contact. the emotional reactions from patients can prove tricky for providers to counter, while maintaining a balance between professionalism and empathy. in addition to questions of infidelity, the type of std diagnosed also affects a patient’s reaction. in the interviews, providers noted that patient reactions to std diagnoses vary and are often more pronounced with chronic stds such as herpes than with curable stds like chlamydia. stds other than hiv were put into two consistent categories by health care providers; bacterial, curable and viral, incurable. when providers spoke about giving std diagnoses to patients, they referred mostly to the level of difficulty they saw a patient present after receiving a diagnosis and always rated viral stds as being more emotionally difficult to diagnose from the provider’s perspective. a female rn discusses the difficulty of diagnosing a viral versus a bacterial std: patients tend to get much more upset about [viral stds] than about something that they know they can take a pill or drink something and then it’s gone. so, that’s a lot more education talking to them about the long term…and some patients take it very well and other[s] are very upset and sobbing…from an emotional standpoint, [diagnosing viral stds is] harder on both the clinician as well as the individual that’s receiving the diagnosis. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 68 since viral stds are incurable, the provider acknowledges that the diagnostic session might be harder on both the patient and the provider. viral stds require more educational counseling from the provider to the patient about the long-term effects of having a disease that will be with the patient for their whole life and the provider must respond to patients’ questions and explains treatment options. the necessary additional counseling from the provider increases appointment times and might cause already tight schedules in underfunded clinics to run behind which has negative consequences for others in the waiting room, in addition to providers’ schedules. viral stds also carry a larger social stigma. providers are aware that a chronic life-long illness, such as recurrent herpes, often changes a patient’s view of their sexuality. they also generally agree that “the majority of patients are totally devastated by the news that they have hpv or that they have herpes. it’s chilling and horrifying for most of them. they feel dirty. they feel totally unclean.” providers in clinics who consistently work with low-income populations recognize that a patient could feel stigmatized and understand that patients might feel vulnerable disclosing personal histories or that patients are likely to judge themselves and say phrases like, “no one will ever want to have sex with me again.” providers are often aware that the social stigma associated with stds can be damaging to a patient’s sense of self, although patients might not be aware of the provider’s recognition of this. one rn describes patients feeling they might be “scarlet letter[ed]” for life, after a chronic std diagnosis. providers spoke of consistent labels patients put on themselves such as “shame, dirty, slut…and almost always you hear, ‘i feel so ashamed, i feel so gross.’” some providers make stigma-removal a primary goal. the main thing that i’d like to do is get the stigma of stds removed…i tell my patients, “no virus, no bacteria, is a judgment of character, right? can they [the viruses] tell who’s a good person and who’s a bad person?” so i think the sooner we all get to that point, the better. because it’s all that moral stigma that makes people not come in; makes them afraid to talk to their partners. it’s really the moral stigma that causes all of the emotional sequelae. it’s really not medical. like herpes. i always tell my patients, “herpes is the most overrated disease on the planet, i think. whoever cries over a cold sore? nobody! this is the same thing.” and yet, genital herpes…it’s like the end of the world. at some point i wish we could just all get over that. it is evident from this nurse practitioner that she believes the social stigma attached to stds is damaging to a patient’s view of themselves and their sexuality. she views this stigma as extremely problematic and works to remove stigma by likening herpes to having a cold sore. this nurse practitioner helped to navigate some of the patient’s emotional response to herpes by using terminology like “overrated disease.” in the emotionally charged diagnostic appointments, patients might not realize that the provider is attempting to support them as some professional distance must be maintained. providers’ perceptions of barriers to care for low-income populations providers highlight that emotionally-charged reactions from patients, including denial of their infections, anger at the provider or “finger pointing” at their partners, crying, and a change in sexual self-identity, often ensue during the diagnostic session. the difficult process of diagnosing an std is intensified when added to issues of economic insecurity. five providers pointed out that low-income patients will have a difficult time paying for medication. moreover, those in rural areas might have a tough online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 69 time finding transportation to pharmacies to obtain these medications or to the clinic for the appointments themselves. other problematic issues for low income populations providers identified included lack of child care and the inability to get time off work in low paying jobs. because of problems accessing care, low-income patients will frequently miss appointments. one provider explained she thought missing appointments could negatively affect how providers view low-income patients because they are labeled as “no show” and “some providers are put off by people who are repeatedly ‘no show’ without finding out why.” this is just one of the ways low-income patients might be stigmatized, even by their health care providers. the presence or lack of health insurance often dictates what kind of care someone will receive. if a patient cannot pay for care, they will most likely choose not to have a test done or the provider must give less desirable options. for example, one nurse mentioned that a colposcopy, a test that looks for cervical cancer and/or hpv after an abnormal pap smear, typically costs between $400 and $500 dollars in the state of wv without health insurance. many times, a patient has to choose between some essential item such as food or the colposcopy, according to this nurse. thus, the patient cannot get the care he or she needs or deserves. the patients might flat out refuse necessary blood tests or ultrasounds because they cannot pay for it. even when a patient has access to free tests, such as pap smears, the tests are often not as good as pap smears for higher income women. one rn indicated that pap tests given at “free” clinics do not always test for hpv because those tests that do test for hpv are much more expensive. she said that state clinics that offer free and reduced-cost health care often do not have the funding to provide the most up-to-date tests. the kind of health insurance a patient possesses can also influence how a patient is treated. although i asked outright if providers thought that lack of health insurance was a barrier to care, a third of the providers volunteered that government sponsored medicare and medicaid in wv had serious defects inhibiting providers from adequate job performance. one physician mentioned that reimbursements for certain procedures were often unequal, such as the prostate specific antigen (psa) for men, because it is reimbursed at much higher rates than a more labor intensive pap smear. this gender-bias from medicaid towards men’s health care is also shown via contraceptive inequality. another provider mentioned that many private forms of health insurance cover viagra for men, but not birth control pills for women. medicaid also reimburses much less for health care than private health insurance and providers pointed out that they were forced to see a greater number of patients to offset the cost. providers who see more patients with private health insurance might not need to rush through seeing as many patients as possible to make enough money to cover the cost of operating a clinic. one nurse midwife mentioned that she could not give free care without getting charged for it or fired. this same nurse midwife noted that lack of insurance can also mean that low-income women will have more frequent std outbreaks because they cannot afford to pay for medicines, such as suppressive therapies. she said that some medications used in the suppression of herpes might cost around $9 a pill without insurance. so an uninsured patient who cannot afford to pay $9 a pill for suppressive therapy has to, in her words, “just tough it out.” she commented that she tries to give out the free samples that pharmaceutical representatives bring, but pharmaceutical representatives typically do not give out samples to places where uninsured patients are treated, like the clinics in this study. in addition to being underinsured or not insured, times that clinics are open also pose as obstacles for rural low-income populations, according to another nurse practitioner. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 70 clinics can take all day…. low-income women have to go into clinics and they have to take a whole day out of their life because they have to come in, they have to skip class, they have to do this, they have to do that, and then, they all get seen by medical students. i don’t think it’s fair. it just isn’t very sensitive to people’s needs. it shouldn’t be 8-4, rigid hours. wv, we have such a high cervical cancer rate, but a low rate of women who get pap smears. because places where you can get free pap smears are not open at times when women who work for mcdonald’s can get to…clinics should be open seven days a week. it should be in kroger’s [a typical grocery store in wv]. this provider is clearly aware of the difficulties poor women face when trying to get access to health care. the viral stds such as herpes and hpv often require many treatments, which increases transportation difficulties. repeatedly having to go to a clinic can cause stress and financial hardship in addition to the emotional impact of the diagnosis of an std. providers who work in clinics catering to low-income populations also see instances of abuse that complicate the emotionality involved in diagnosis. one female nurse midwife, who mainly works with young low-income women, felt many of her patients were emotionally abused at home. she discusses one young female diagnosed with genital warts. well i had a patient, young girl, 16. just a terrible life history. a lot of abuse. and took care of all her siblings…she was pretty hysterical…i went in to talk to her and she said, “i have something down there. and all i’ve done is sit in the bathtub. and cry for three days.” it just told me how difficult it was for her to come in and how ashamed and she knew it was something; she just didn’t know what. it was truly the worst case of hpv i’ve ever seen…she was just absolutely devastated and hysterical that she had given it to her little sister that she had taken a bath with. and it was very traumatic for her. and i ended up having to treat her with multiple office visits with acid to take them off. using phrases like “it just told me how difficult it was for her” and “devastated” shows the empathy with which the midwife discusses her patient and provides some evidence that during the diagnosis this particular provider might be aware of the complexity of the diagnosis for the patient. most providers revealed that they are paid less money working for public clinics and admitted they could get higher paying jobs elsewhere. yet all the providers interviewed chose to stay in their current job situation. this suggests that providers receive some level of satisfaction from working in clinic environments, helping those without resources. one rn spoke about finding satisfaction in her job, even with the difficulties in treating lowincome patients. 90% of the time when i leave work and i go home i feel like i’ve done something worthwhile and that in itself is enough. even though sometimes when you work for a [public clinic] your pay is not going to be as good as a lot of the other places where i could go and probably make $10 more an hour…i don’t know that i would have that sense of satisfaction. and sometimes we don’t have that sense of satisfaction. we fail sometimes…but at the same time, you still feel like you’ve at least been online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 71 able to impact some one’s life in a positive way. this provider notes that she feels good about her job performance, even in the midst of difficult conditions. not all providers reflected on their occupation as positively as this nurse, but none of the providers indicated that they wanted to change positions to work with higher income populations. discussion studies have shown that stigma related to how health care providers feel about “promiscuous” patients and fear of being “scarlet lettered” often prevents patients from taking advantage of prevention and treatment services (lichtenstein et al. 2002). one study found that almost half of women ages 18-49 had never discussed stds with their provider (henry j. kaiser family foundation, 2003). one of the most commonly reasons cited for women not to speak to their providers was “embarrassment or fear of judgment on the part of the provider” (henry j. kaiser family foundation, 2003, p. 7). although there were some health care practitioners i interviewed who appeared less empathetic, most of the providers were in touch with the degree to which their patients stigmatize themselves and attach a greater symbolic meaning to the disease. the providers in this study highlighted that an std diagnosis was “chilling and horrifying” for their patients and acknowledged that the stigma attached to a chronic std diagnosis might cause a patient to feel “dirty” or “unclean.” although my study is not necessarily generalizable, the acknowledgement of stigma and the willingness to discuss stigma by providers working in the two clinics in my sample suggests that providers in low-income clinics do actually work to avoid perpetuating the stigma attached to stds. fortenberry et al., (2002) found that individuals who had received a gonorrhea test in the past year felt less shame than those who had not been previously tested. in other words, testing for stds helps to alleviate stigma surrounding stds in general. this suggests that “embarrassment or concern” about being judged (henry j. kaiser family foundation, 2003, p. 7) rests more in the overarching negative symbolic meaning of sexually transmitted diseases and less on that of the actual behavior of health care providers. some providers in this study even mentioned that stigma removal was a primary goal of theirs. having health insurance has been shown to be a large predicator of whether or not a person will have access to care and persons without health insurance are more likely to report an unmet need for care (national center for health statistics, 1998). medicaid covers only 1 in 5 low-income women and those women who are on medicaid are dissatisfied with their quality of care (wyn et al., 2004). this trend reflects a need for not only greater health insurance coverage, but an increase in the quality of care for those who have medicaid, especially in wv since 33% of west virginians receive their insurance through medicaid or medicare (henry j. kaiser family foundation, 2010). the providers in this study noted they are often forced into a bind to make health care decisions based on a patient’s ability to pay, rather than the most medically appropriate decision. there are considerable time and funding constraints in most clinics that cater to underinsured populations. for instance, the waiting list to get an appointment at one of the clinics in my sample can be anywhere from three-eight weeks. because of limited availability and scheduling, providers must try and see many patients in one day. moreover, providers in this study pointed out that a significant amount of time is spent counseling patients who are misinformed about std transmission and complications. consequently, patients might have to endure a much longer waiting period in public online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 72 clinic environments in order to account for this time lag. the inconvenience of spending hours in the waiting room for an appointment followed by an hour or more appointment is problematic for rural low-income patients with children or for those who might have transportation issues. the inconvenience is exacerbated when repeated follow up diagnostic or treatment sessions are necessary. this suggests that longer appointment times, in addition to more sufficient and labor-appropriate reimbursements from medicare, might help both providers and patients negotiate a first time std diagnosis and provide more little breathing room for practitioners to offer adequate counseling. the providers i interviewed had been in medicine for an average of 19 years. the views of these seasoned providers may not be equivalent to those of the broader provider population and thus could be a limitation to this study. also, providers who voluntarily work in less desirable conditions are more likely to be empathetic to the needs and difficulties faced by disadvantaged populations. further research should include private practice locations to get a wider range of providers with differing orientations. additionally, there are logistical limitations in this study. the interview sample size is small at 18 participants and the research locations are not representative of all providers in wv, nor of those in the united states and the study is thus not generalizable. however, this qualitative study provides insight into the experiences of these providers and offers a unique perspective on those who work in publicly funded clinics with rural populations. conclusions and implications my research has shown that providers who treat rural low-income populations deal with issues of lack of proper health insurance which necessitates more creativity in terms of treatment options, medicare/medicaid reimbursement problems, screening and contraceptive inequality, partner treatment and cost, medication cost, transportation and child care, inconvenient clinic hours, and lack of comprehensive sexual education in the populations they serve. policies that providers supposed might better address issues involved in treating low-income populations include more sexual education in our school systems, std screenings at every annual appointment, more clinics designed specifically for low-income populations, universal health insurance, and separate counseling appointments for patients who have recently been diagnosed with an std. further research on low-income populations with stds would help inform better policy and give a fuller picture to the effectiveness of sexual education and treatment of stds in publicly funded clinics. providers who treat low-income women on a daily basis must deal with patients missing appointments and understand that it is not always the patient’s fault. they make less money and have fewer supplies and resources. providers routinely work with patients who might be more emotional during diagnostic sessions and who may have fewer emotional support systems at home. low-income patients rarely have had provider consistency or medical counseling. less medical counseling means that patients will have more medical problems in the long term. in addition, the provider might have to take more time finding out what is wrong with the patient because the patient may not have the educational background to fully understand the implications of their disease, making appointment wait times much longer for others. low-income populations are also historically more stigmatized (lawless et al., 1996). the number of years that each of the study participants worked in health care (average of 19 years) suggests that these providers are willing to continue their work despite the problematic aspects of care with low-income populations. it also indicates that online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 73 they receive satisfaction from their occupations and working with low-income populations. despite studies that have documented the need for greater provider sensitivity and asserted that providers often exacerbate the stigma attached to stds (nack, 2002; o’connell 1997), this study suggests that some providers who consistently work with rural low-income patients are very much aware of the problematic nature of stigma attached to stds and try to effectively limit the amount of perceived stigma accompanying an std diagnosis. acknowledgements the author wishes to thank the providers who donated their time in order to be included in this study and melissa latimer, phd, heather turner, phd, michele dillon, phd, and the reviewers who provided excellent and helpful feedback. references beatty, b.g., o’connell, m.t., ashikaga, t., & cooper. k. 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[medline] linnehan, m. j. e., & groce, n. e. (1999). psychosocial and educational services for female college students with genital human papillomavirus infection. family planning perspectives, 31, 137-141. [medline] merzel, c., vandevanter, s., middlestadt, s., bleakly, a., ledsky, r., & messeri, p. (2004). attitudinal and contextual factors associated with discussion of sexual issues during adolescent health visits. journal of adolescent health, 35, 108-115. [medline] mogilevkina, i., tyden, t., & odlind, v. (2001). ukrainian medical students’ experiences, attitudes, and knowledge about reproductive health. journal of american college health, 49, 269-273. [medline] nack, a. (2002). bad girls and fallen women: chronic std diagnoses as gateways to tribal stigma. symbolic interaction, 25, 463-485. national center for health statistics. (1998). health, united states: socioeconomic status and health chartbook. hyattsville, md.: u.s. department of health and human services. national cervical cancer coalition. (2010). frequently asked questions about human papillomavirus vaccines. retrieved from http://www.nccconline.org/patient_info/vaccine/hpv_faq.html http://www.ncbi.nlm.nih.gov/pubmed/11867313 http://www.ncbi.nlm.nih.gov/pubmed/17385971 http://www.ncbi.nlm.nih.gov/pubmed/10437755 http://www.ncbi.nlm.nih.gov/pubmed/8913006 http://www.ncbi.nlm.nih.gov/pubmed/11839216 http://www.ncbi.nlm.nih.gov/pubmed/10379431 http://www.ncbi.nlm.nih.gov/pubmed/15261639 http://www.ncbi.nlm.nih.gov/pubmed/11413944 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 75 neff, j. a., gaskill, s. p., smith, j. a., weiner, m., prihoda, t. j., weiner, r. v., brown, h. p., & newton, e. (1998). preliminary evaluation of continuing medical education-based versus clinic-based sexually transmitted disease education interventions for primary care practitioners. teaching and learning in medicine, 10, 74-82. [medline] o’connell, m.l. (1997). communication: the key to decreasing unintended pregnancy and sexually transmitted disease/hiv risk. journal of perinatal education, 6, 3542. perrin, k. m., daley, e. m., naoom, s. f., packing-ebuen, j. l., rayko, h. l., … & mcdermott, r. j. (2006). women’s reactions to hpv diagnosis: insights from indepth interviews. women & health, 43, 93-110. [medline] united states census bureau. (2010a). small area income and poverty estimates: estimates for the united states, 2008. retrieved from http://www.census.gov/cgibin/saipe/national.cgi?year=2008&ascii=. united states census bureau. (2010b). state quickfacts, west virginia. retrieved from http://quickfacts.census.gov/qfd/states/54000.html waldrop, j. (2000). population profile of the united states. retrieved from http://www.census.gov/population/www/pop-profile/profile2000.html weinstock, h., berman, s., & cates, jr., w. (2004). sexually transmitted diseases among american youth: incidence and prevalence estimates, 2000. perspectives on sexual and reproductive health, 36, 6-10. [medline] women’s economic agenda project. (2008).women, poverty, and sexually transmitted infections. retrieved from http://weap.org/resources/fact-sheets.htm wyn, r., ojeda, v., ranji, u., & salganicoff, a. (2004). health coverage and access challenges for low-income women: findings from the 2001 kaiser women’s health survey. retrieved from http://www.org/w omenshealth/loader.cfm?url=/commonspot/security/getfile.cfm&pageid=33095 http://www.ncbi.nlm.nih.gov/pubmed/9799938 http://www.ncbi.nlm.nih.gov/pubmed/17000613 http://www.ncbi.nlm.nih.gov/pubmed/14982671 microsoft word krebbicks_104-1279-3-ed.docx online journal of rural nursing and health care, 13(1) a dnp nurse-managed hepatitis c clinic, improving quality of life for those in a rural area virginia p. krebbeks, dnp, aprn, anp-bc 1 vivian m cunningham, phd, cnm, fnp 2 1 nurse practitioner, raymond thomas, md,pc, mamausmc@yahoo.com 2 assistant professor of nursing, st. john fisher college, vcunningham@sjfc.edu abstract hepatitis c virus is quickly becoming a national threat, involving 2% of the nation’s population, ranking this as the 11th most prevalent disease in the world. traditionally, treatment for hepatitis c has been conducted in tertiary care settings, limiting access to care for those residing in rural areas. improving access to care through the development of a doctor of nursing practice (dnp) nurse-managed clinic in a rural setting will improve health outcomes and quality of life for those treated outside the traditional setting. caring for those living in less densely populated areas requires an understanding of rural culture. this paper will discuss the development and implementation of a dnp model of care for rural patients being treated for hepatitis c. the model of care starts with identifying the hepatitis c, treating the patient following established medical guidelines, using the nursing model to monitor clinical progress and managing sideeffects caused by the treatment medications. using the dnp model of care, a patient-focused clinic can successfully treat rural patients utilizing the principles of the effect theory for management and the process theory for ongoing evaluation. collaboration with other key resources, utilizing a multidisciplinary approach allows the dnp nurse to care for those requiring treatment for chronic hepatitis c, where they live and work with the assistance of family and social support. online journal of rural nursing and health care, 13(1) keywords: hepatitis c, rural nursing, nurse-managed clinics a dnp nurse-managed hepatitis c clinic, improving quality of life for those in a rural area the institute of medicine (iom), committee on prevention and control of viral hepatitis infections (cpcvhi) considers hepatitis c (hcv) a major health problem and a major cause of liver disease (colvin & mitchell, 2010). approximately 4.1-4.9 million people are affected with hcv in the united states (us), accounting for 1.8-2.0% of the general population (calvert, goldenberg, & schock, 2005; moore, hawley, & bradley, 2009; rustgi, 2007) resulting in 8,000-10,000 deaths annually (wolfe & stowe, 2007; albeldawi, ruiz-rodriguez, & carey, 2010). ranked as the 11 th most prevalent disease in the world, (pozza, 2008), there are 170 million cases of hcv responsible for 1.4 million deaths per year worldwide (moore et al., 2009; pozza, 2008; rustgi, 2007; wolfe & stowe, 2007), but these numbers are difficult to obtain without a national hepatitis c surveillance program (colvin & mitchell, 2010). these statistics are expected to triple in the next 10-20 years (albeldawi et al., 2010), positioning hcv as a “global epidemic” in the new millennium (gane, 2008), even as it has been termed the next “hidden epidemic” (“hepatitis outbreaks outscore ongoing risk”, 2009). a recent analysis showed a rapidly increasing number of deaths among hcv-infected persons, which now surpasses the deaths among hiv-infected persons in the us (ly et al., 2012, p. 276). according to this new study from the u.s. centers for disease control and prevention (cdc) and chronic liver disease foundation recommends routine screening among those born between 1945 and 1965, not just for those at risk to for viral infection (ly et al., 2012). hcv is the most common blood-borne infection in the us and is the leading cause of liver transplants (albeldawi et al., 2010; dienstag & mchutchison, 2006; gane, 2008). the organ procurement online journal of rural nursing and health care, 13(1) and transplantation network, located in the us, states that 6,320 patients underwent liver transplantation in 2009 for treatment of end-stage liver failure, with nearly 17,000 patients currently waiting for a donor liver (sornmayura, 2010). approximately 75%-85% of acutely infected individuals progress to chronic infection with up to 20% developing cirrhosis over 2030 years, putting them at risk for end-stage liver disease and hepatocellular carcinoma (hcc) (rustgi, 2007; talley & martin, 2006) and possible severe quality of life impairment. the risk of hcc is 1%-4% per year when cirrhosis of the liver has been established (el-serag, 2012). hcc is expected to increase in this group over the next decade due to the slow progression of the disease. hcc is the third leading cause of cancer deaths worldwide, the fifth most common cancer among men and the eighth most common cancer among women (sornmayura, 2010). antiviral therapy is considered standard of care even when eradication of the virus may not occur, as it reduces the risk of developing malignancy (talley & martin, 2006). because of routine screening of blood products since 1992, the number of new hcv cases is declining, but the rates of hcv associated morbidity and mortality will continue to rise (rustgi, 2007) for the next 20-30 years. though the incidence of acute and chronic hepatitis a and b is diminishing in this country, and theoretically the eradication of these diseases could occur over the next 20 years through standard vaccination, hcv has multiple types and subspecies with a high rate of mutation, making vaccine development very difficult. until a vaccine is developed, reducing the spread of the hcv needs to be continued though the identification and testing of individuals with risk factors and public education on acquisition of hcv. rural nursing and quality of life rural nursing poses challenges and opportunities for unique care and is different from urban nursing due to the essential attributes and culture of this population. rural nursing has online journal of rural nursing and health care, 13(1) been identified as provision of health care by professional nurses to persons living in sparsely populated areas (mccoy, 2009) though these areas are not well defined. rural can mean country, agriculture, or refer to attributes of rural culture. sparsely populated can be defined anywhere between 3 and 1,000 persons per square mile. the term underserved has been used in association with rural nursing. availability, accessibility, acceptability and affordability are all concerns for the rural nurse (spencer, van dyke, & swain, 2001). the general educational level of the rural population can be a challenge for the rural nurse. these factors compounded by a serious, chronic and potentially deadly virus must be included for the rural nurse’s critical thinking. “after years of debate about universal health insurance legislation, it has not been enacted, leaving the most vulnerable members of society which includes the poor, those living in rural settings and children without comprehensive care” (russell & neff-smith, 2001, p. 81). dnp nurses working in any setting require a model of care with a theory base by which to practice and rural nursing is no exception. once diagnosed with hcv, rural patients may not start treatment due to inconvenient access to specialist care (poll, 2009) which is traditionally available in tertiary care settings located in urban areas. rural health care providers are expected to do more with less and accept responsibilities not usually expected of providers in the urban setting. health and work beliefs, isolation, distance, outsider/insider concept, self-reliance, and lack of anonymity or familiarity are concepts identified with the rural community (long & weinert, 1998). lack of health care accessibility is a major factor with the rural patient. transportation, distance, isolation, weather, finances, time of year (including planting and harvesting of crops, and hunting season), attitudes toward health and patient education may be barriers to care all must be considered before hepatitis treatment is considered (bryant, elliott, hanson, lobner, & thomas, 2001). seasonal agricultural farm workers who are transient and are of a different online journal of rural nursing and health care, 13(1) culture may be included as a subset population. understanding these concepts of rural nursing will require the dnp to create an evidence-based plan of care for the hcv patient undergoing treatment. rural areas may have few mental health clinics, thus primary care providers may be the only source of care. side effects experienced by patients undergoing treatment may be minimal or quite severe. the most common reason to discontinue treatment is psychiatric side-effects such as depression (hopwood & treloar, 2005; treloar & hopwood, 2008) suicidal and homicidal thoughts. “road rage” has been seen in some patients. identifying the key family members for support for those experiencing depression during treatment can augment the rural nurse’s plan of care. the patient’s own coping skills that have been used successfully need to be utilized. keeping the primary care provider aware of treatment and psychiatric concerns early in treatment may avoid disaster from treatment side effects. the dnp nurse should discuss with the collaborating hepatologist any emerging adverse side effects and discontinue treatment if necessary. it is important to remember, that every patient identified with hcv, treated for the virus and who has successfully achieved a sustained viral response (svr), reduces the chance of cirrhosis, hcc and have eliminated the potential spread of that virus to another person. this is imperative no matter where treatment occurs, thus the availability of a rural clinic with a dnp managing the hcv treatment can continue to reduce the morbidity and mortality of this virus. theoretical framework nursing case management, provided by public health nurses and social workers, has been in practice since the 1800’s to improve health care to immigrants and those who could not afford health care. nursing clinics that include advanced practice nurses frequently offer services to online journal of rural nursing and health care, 13(1) those uninsured and underserved that have chronic illnesses. the dnp with advanced preparation will add diagnostic skills and clinical management to those with chronic illness and in need of patient-focused care. the doctor of nursing practice model of care focuses on the patient, allowing the dnp to oversee the hepatitis c treatment while managing response to treatment and monitoring any side effects to care. the office visits, laboratory monitoring and documentation by both the patient and managing nurse allow improved compliance and success rates in treatment. critical thinking and decision making by the dnp is made with evidencebased information and a theoretical base. the effect theory brings together scientific facts and behaviors to deliver interventions and predict outcomes (issel, 2009). this theory demonstrates a relationship between behavioral factors, disease causality, with moderating and mediating mechanisms, and disease outcomes. the identification of risk factors as described by the model will allow an accurate testing of possible disease and prediction outcomes (estes, 2007). the theoretical framework used to implement this model of care for the treatment of hcv is the effect theory, see figure 1. this combination theory provides the reader with an understanding of the complexity of hcv in the rural setting and its impact for treatment outcomes. the dnp nurse practicing in a rural setting can best understand the needs of the hcv patient as this is where the patient is living and where primary intervention occurs. the dnp may also appreciate the cultural complexities of the rural setting using this model. online journal of rural nursing and health care, 13(1) figure 1 a flow chart showing using the effect theory with hcv using a linear chart. adapted from health program: planning and evaluation: a practical systematic approach for community health, by l. m. issel, 2009, p. 181. copyright 2010 by the american psychological association. reprinted with permission. guidelines for intervention (ghany, nelson, strader, thomas, & seeff, 2011; yee et al., 2012). dnp model of care for a rural clinic although traditional treatment for hepatitis c is carried out in tertiary/hospital settings, a rural clinic managed by a dnp nurse, working in collaboration with a hepatologist, can successfully evaluate and manage the multiple complications and side effects commonly seen with hepatitis c treatment. patient-centered availability, access to treatment with cost savings benefits seen by nurse-managed clinics (ehsani, vu, & karvelas, 2006), allows a rural clinic for hepatitis c as an acceptable option for viral treatment. the concerns and challenges of the rural nurse as discussed above were used to develop the dnp model of care. below (figure 2.) is the online journal of rural nursing and health care, 13(1) dnp model of care developed by the author for those with chronic illness in a rural setting and used for the patient being treated with hcv. the patient is the focus of care with the dnp surrounding the outer circle of the model as the manager of the care. surrounding the patient are factors that influence treatment outcomes, such as quality of life or completion of treatment, and failure to eradicate the virus. the accessibility, availability, affordability and acceptability concerns were used to identify the factors affecting the treatment. in a rural setting these complicating concerns for the patient will be different than care within an urban setting, thus it is necessary to incorporate these factors into the surrounding boxes. these individual factors may complicate treatment and thus need to be monitored and managed by the dnp. © 2011 krebbeks figure 2 doctor of nursing practice model of care. online journal of rural nursing and health care, 13(1) a mission statement needs to be made for any clinic development. this should state the purpose of the clinic, how it will be developed and how it will be evaluated (issel, 2009). clinical objectives will need to be established for a dnp managed hcv clinic. these include to: • increase awareness for the prevention of hcv to prevent new infections • target lifestyle changes needed with hcv treatment • improve access to hcv treatment • provide services to those uninsured and underinsured • provide a shorter time from diagnosis to treatment • reduce the impact on health costs for treatment • prevent the complications for cirrhosis associated with hcv • obtain a sustained virological response early in treatment and 6 months following completion of treatment once the mission statement and objectives for the clinic have been established, implementing the plan of care for the patient with hcv will be followed using the guidelines of the model of care and the theoretical framework which is consistent with the program purpose and objectives. the patient is referred to the clinic from their primary care provider, ob/gyn, a red cross or similar blood donating organization or from recent incarceration. on the first visit, the patient enters the clinic with a definite diagnosis for hcv or may be referred to the clinic with abnormal liver function tests. the dnp will either establish the diagnosis of hcv or confirm the presence of chronic active hcv through the identification of active virus with a rna quantitative viral load and genotyping of the virus. supplemental baseline laboratory testing is done at this first visit. these tests include a cbc, hav and hbv antibody levels, online journal of rural nursing and health care, 13(1) chemistries, autoimmune indices, and a ferritin level, tsh, hiv and hcg for female patients and for female partners of male patients if they are of child-bearing age. an abdominal ultrasound is obtained on all patients to observe the contour of the liver. this may give the dnp an indication if cirrhosis is already present. if any question exists, then an ultrasound guided liver biopsy may be obtained, but mandatory liver biopsy is no longer necessary prior to treatment (nazareth, piercy, tibbet, & cheng, 2008). a baseline ekg is recommended (yee et al., 2010). an informational packet that may be provided by the manufacturer of the treatment medication(s), is given to the patient at this first visit. these packets contain information on the treatment drugs including how they are to be taken with possible side effects and cautions regarding their use. these drugs have a “black box warning”, meaning they may have dangerous side effects under certain circumstances. it is important not to overwhelm the patient at this point as they have received an extreme amount of information on this first visit. allowing an hour of time for this visit is not unusual. the second visit is about 2-3 weeks later, allowing the results of all testing done to this point to return to the provider. the dnp will review all the previous testing including the result of the viral quantitative count. if confirmation of hcv is determined with a positive presence of virus, then a more detailed discussion regarding the treatment is made. the patient is given a journal for recording laboratory results, documenting exercise/physical activity done during treatment (mckenna & blake, 2007), and any questions or concerns they may have throughout their time of care. a patient/provider contract for treatment is reviewed and signed by both parties. this contract contains patient and provider responsibilities, including appointment visits, laboratory times, and the importance abstinence of alcohol and non-prescribed drugs. of significant importance is the understanding of not becoming pregnant or impregnating anyone online journal of rural nursing and health care, 13(1) else during treatment or for 6 months following treatment, as treatment drugs for hcv have been determined to be teratogenic. an educational review of the medication side effects should be documented in the contract. a dilated fundoscopic eye exam is important at the beginning of treatment to determine any baseline abnormalities, as some visual difficulties can but rarely occur as a result of the treatment drugs. these visual difficulties usually subside after treatment completion. subsequent exams during treatment are at the discretion of the ophthalmologist performing the initial exam, and it is important to follow-up any finding of fundoscopic cotton-wool exudates. retinopathy is common with pegylated interferon, one of the treatment medications, but most events that may occur clear after treatment is completed (mehta, 2010). an influenza immunization is recommended during the season and vaccination for hav and hbv are important if the patient has not had established immunity. avoiding exposure to influenza and other viruses during treatment may be difficult. it is contraindicated to immunize patients with live virus while undergoing treatment for hcv. regular office visits occur at 1,2,4,6,8,12 and every 4 weeks thereafter until treatment is completed. laboratory testing is obtained at these times to assure no serious consequences are occurring. calculating and documenting serial absolute neutrophil counts (anc) is important when monitoring for serious side effects. following medical protocol regarding these values is essential. it is important to obtain a quantitative viral load at weeks 2, 4,12,24,36, and 48, then 1, 3, and 6 months post-treatment. testing yearly thereafter has not been established. the patient is weighed at each visit to monitor any loss. some weight loss is expected but should not be excessive (suwantarat, tice, khawcharoenporn, & chow, 2010). online journal of rural nursing and health care, 13(1) treatment and screening for hepatitis c the standard treatment of care for hcv is well-documented by the american gastroenterological association (aga), american association for the study of liver diseases (aasld) and the american college of gastroenterology (acg), (dienstag & mchutchison, 2006; gane, 2008; ghany, nelson, strader, thomas, & seeff, 2011, & yee et al., 2012) which needs to be followed by the dnp. any deviation from those protocols needs to be discussed and documented with the collaborating physician. it is important for the patient to know how to self-administer these medications, especially those requiring subcutaneous injection. the start of treatment begins in the clinic office. the dnp or clinic nurse demonstrates to the patient how to administer the medications with an emphasis on technique and hygiene. safe disposal of the used needles and syringes is essential for safety of the patient and any household members. the cost of treatment with pegylated interferon and ribavirin is very high, about $30,000 per patient for the medication alone (calvert et al., 2005). the national surveillance program calculated the cost of screening for hcv to be $1,246 per case detected, though other studies have shown the cost between $374 and $1,047 per case detected (albeldawi et al., 2010). hcv screening and early treatment has the potential to improve average life-expectancy but in the past focused only on those at high risk for the virus (sroczynski et al., 2009). with new concerns regarding the testing of all “baby boomers”, the diagnosis of those with chronic hcv will rise. approximately 30% of patients identified with chronic hcv have normal liver tests but upon liver biopsy, have some degree of liver damage, thus it remains very important to screen for those with current or past risk behavior for the virus (sornmayura, 2010). online journal of rural nursing and health care, 13(1) the treatment for hcv changed may 2011 with the addition of protease inhibitors for the treatment for genotype 1. these additional medications have made a significant increase in the eradication rate of the hcv but treatment complications have increased (stauber & kessler, 2008). the identification of genetic variations with response to treatment may also influence viral eradication (ge et al., 2009), but the use of genetic testing to determine treatment eligibility is controversial. the large tertiary clinics should be able to incorporate these treatment changes with little difficulty, but rural areas may find resources and funding difficult to manage. despite this, the management of hcv treatment in a rural setting should be reasonable with a workable model of care and collaborating health team. evaluation plan evaluating this model of nursing care needs to include both quantitative and qualitative outcomes. mentioned previously are quality of life concerns regarding hcv. observation by the dnp during office visits, conversation with patients and families with review of journal entries are all forms of qualitative measurements. quantitative measurements may include compliance with office appointments, medication adherence and successful eradication of the virus at completion of the treatment contract. some of these measurements can be seen through the monitoring of laboratory values and their expected changes, the measurable depletion of given medication, and lack of unacceptable behavior and legal involvement. clinical office conferences with the possible presence of collaborators involved in those patients undergoing hcv treatment will be essential for the success of the clinic. effective leadership by the dnp manager will require a strong support staff with those wanting to make a difference in care delivery, the creation of ideas and actions, creativity with energetic and committed followers (bethel, 1990). this author advocates a “circle network” that allows and online journal of rural nursing and health care, 13(1) encourages information to move from one member to another equally. communication is simplified and members have easy access to other member’s thoughts (bolman & deal, 2008) with team members sharing responsibility for achieving the common goals of the clinic (freund, & drach-zahavy, 2007). familiarity among clinic staff members is also important for the patients. with a small group in a rural setting, this management structure should be effective. a program evaluation plan must include operating costs of the clinic, with one method being a break-even analysis tool. this mathematical calculation divides the fixed cost of operation of the clinic into the cost per patient equaling the number of patients needed to be seen (issel, 2009). this analysis should be done before the opening of the clinic, early in its operation and throughout its management. unfortunately, lack of health insurance can be a critical factor in treating this potentially vulnerable population. medicare and medicaid can underestimate actual costs for providing services which can greatly affect operational costs. it is essential for patients without health insurance to apply for financial assistance for both their advantage and for the security of the clinic. a bill, h.r. 2754, to amend the public health service act to establish “the nurse-managed health clinic investment program”, was at one time a possible option for those wanting to start and independent rural clinic (capps, 2011) but unfortunately the bill did not become a law, although it may be offered at some future point. another solution is to incorporate the nurse-managed clinic into an existing gastroenterology or primary care practice to help defray the costs. sharing of office equipment and staff with the dnp providing care to those with hcv along with patients with other health problems may need to be done until the clinic is financially secure. a third method to provide cost-effective care is the use of telemedicine. its use in rural and prison settings allows providers to effectively manage patients with chronic illness (arora, thornton, jenkusky, paris, & scalletti, 2007). the process theory showing the online journal of rural nursing and health care, 13(1) components of the organizational and service plans may be used for a nurse-managed clinic as shown below (figure 3). conclusion as health care becomes more complex, evidence-based practice with collaboration among multiple health disciplines needs to be implemented. cost effective care with positive outcomes and individualized care with innovation will be necessary. the iom suggests knowledge about this disease is poor (colvin & mitchell, 2010) and significant stigma surrounds this diagnosis (butt, paterson, & mcguinness, 2008). with an accepted and useful model of care and theoretical framework with an ongoing evaluation tool, a hepatitis c clinic within a rural setting can be successfully managed by a dnp prepared nurse. using the effect and process theory, with the dnp model of care, patients with hcv can be provided quality, culturally sensitive and cost-effective care. with the institute of medicine’s concern regarding the spread of hcv, rising death rates for those with hcv, the recent statement by the cdc regarding testing for the vulnerable age group, and healthy people 2020 (u.s. department of health and human services, office of disease prevention and health promotion, n.d.) including communicable disease a national concern, a dnp nurse-managed clinic can fill the gap and meet the need for addressing this “global epidemic”. online journal of rural nursing and health care, 13(1) organizational plan input human resources dnp medicial technician receptionist collaborating md i n f o r m a t i o n a l resources software for emr (existing) educational handouts/ patient journals monetary resources grant application (if necessary) physical resources pre-existing office, n e e d i n g t w o e x a m rooms and reception area t r a n s p o r t a t i o n resources private car, county area transport bus, va m c t r a n s p o r t , county medicaid cab managerial resources dnp clinical manager time resources 1 and 2 year cycles outputs informational system m o n t h l y / we e k l y reports of intake and outputs budget break-even analysis time line establish estimated start date of clinic organizational chart circle network dnp/md mt/receptionist (bolman & deal, 2008 p. 106) operational manual office protocol office visit frequency, vital signs, flow chart, patient journal, etc. online journal of rural nursing and health care, 13(1) figure 3: the process theory. flow chart showing how a logic model as a tool for program evaluation may be used for hcv. adapted from health program planning and evaluation: a practical systematic approach for community health, by issel 2009, p. 276. copyright 2010 by the american psychological association. reprinted with permission. services utilization plan inputs participants those patients with positive hcv antibody or active hcv virus requiring treatment or monitoring of virus queuing increasing testing for hcv virus info for pcp's decrease wait list time to 2 weeks and start of treatment intervention delivery treatment of hcv virus with the guidelines established by ghany et al., 2011; yee et al., 2012 collaborate with md for updates and treatment response changes social marketing product-treatment price-insurance coverage place-office promotion-posters, public speaking outputs coverage health ins private pay, sliding fees indigent coverage from drug company units of service frequency of lab testing number of visits length of treatment materials produced number of patients in clinic those continued and completed treatment number of patients with sustained viral response (svr) work flow # of patients seen need for regular staff meetings staff education online journal of rural nursing and health care, 13(1) acknowledgement raymond m. thomas, md references albeldawi, m., ruiz-rodriguez, e., & carey, w. 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(2010). early detection of chronic liver disease: when to look for viral hepatitis b and c. clinician reviews, 20(8), 24-29. spencer, g., van dyke, n., & swain, d. (2001). rural underserved populations. in m. s. collins (ed.), teaching/learning activities for rural community-based nursing practice (pp. 3443). binghamton, new york: decker school of nursing, binghamton university. sroczynski g., estaban, e., conrads-frank, a., schwarzer, r., muhlberger, n., wright, d., . . . siebert, u. (2009). long-term effectiveness and cost-effectiveness of screening for hepatitis c virus infection. european journal of public health. 19, 245-253 [medline] http://www.ncbi.nlm.nih.gov/pubmed/19357473 http://www.ncbi.nlm.nih.gov/pubmed/19597380 http://www.ncbi.nlm.nih.gov/pubmed/19128345 http://www.ncbi.nlm.nih.gov/pubmed/17653645 http://www.ncbi.nlm.nih.gov/pubmed/19196737 online journal of rural nursing and health care, 13(1) stauber r. & kessler, h. (2008). drugs in development for hepatitis c. drugs 2008. 68 13471359. suwantarat, n., tice, a., khawcharoenporn, t. & chow, d. (2010). weight loss, leukopenia and thrombocytopenia associated with sustained virological response to hepatitis c treatment. international journal of medical sciences. 7(1), 36-42. [medline] talley, n. j., & martin, c. j. (2006). clinical gastroenterology: a practical problem-based approach (2nd ed.). marrickville, nsw: churchill livingstone. treloar, c., & hopwood, m. (2008). “look, i’m fit, i’m positive and i’ll be all right, thank you very much”: coping with hepatitis c treatment and unrealistic optimism. psychology, health & medicine, 13, 360-366 [medline] u.s. department of health and human services, office of disease prevention and health promotion (n.d.). healthy people 2020 improving the health of americans. retrieved from: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topic id=23 wolfe, m., & stowe, r. c. (eds.). educational review manual in gastroenterology (4th ed.). new york: aga institute. yee, h., chang, m., pocha, c., lim, j., ross, d., morgan, t. & monto, a. (2012). update on the management of hepatitis c virus infection: recommendations from the department of veterans affairs hepatitis resource center program and the national hepatitis c program office. the american journal of gastroenterology, 107, 669-690 [medline] http://www.ncbi.nlm.nih.gov/pubmed/20107528 http://www.ncbi.nlm.nih.gov/pubmed/18569903 http://www.ncbi.nlm.nih.gov/pubmed/22525303 editorial 4 editorial primary care in the workplace: cost savings and improved health outcomes melondie carter editorial board member the major portion of health care dollars is spent on illness care and yet the health outcomes of the united states are poorer than many countries that spend much less. a shift must occur in spending to place more emphasis on prevention. increasing health promotion and wellness programs in industries is one prevention strategy for decreasing health care costs and improving health outcomes. although the workplace is a logical site for health promotion, few small employers offer programs and few understand how to balance program costs against benefits. yet, while at work, the employees are a captive audience and are more likely to engage in wellness activities. there are numerous reasons for incorporating wellness programs in small industries. considering the high percentage of illnesses that can be prevented, that most small industries are self insured and the rising health care costs, health promotion and prevention programs are gaining popularity. two chronic diseases which are readily impacted are cardiovascular disease and diabetes mellitus. in 2001, the healthcare utilization project was conducted by ahrq to determine average hospital discharge costs and length of stays for diagnosis. on average one hospital discharge for diabetes with complications costs $15,721; on average one hospital discharge for hypertension with complications costs $18,955 and a coronary artery bypass graft costs $60,853. when employers are made aware of these potential costs, wellness programs cost effectiveness becomes more apparent. besides decreasing the incidence of possible costly hospitalizations, employee productivity and morale can increase with wellness care. one model for a wellness program in small industries includes nurse practitioners and nurse case managers working as a team. nurse practitioners provide physicals and lab work screenings and a nurse case manager provides follow-up on lab values and individualized health teaching. this prevention model has proven to improve the population’s health outcomes and has provided cost savings for the involved industries. reference healthcare cost and utilization project. (2001). national inpatient sample database. retrieved november 5, 2005, from http://www.ahcpr.gov/data/hcup/hcupnis.htm online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ahcpr.gov/data/hcup/hcupnis.htm 25 the challenges of data collection in rural dwelling samples carolyn pierce, dsn, rn1 elizabeth scherra, rn, ms, anp2 1 clinical assistant professor, decker school of nursing, binghamton university, cpierce@binghamton.edi 2 doctoral student, decker school of nursing, binghamton university keywords: rural, data collection tools, participant selection, rural health abstract data collection in rural areas presents unique problems that impact the research process and thus the outcomes of the research. some of the issues that must be accounted for include utilization of appropriate tools when studying rural dwelling persons, location of appropriate participants, rural health issues, environmental barriers, and ethical considerations. researchers must be aware of these unique problems and issues and consider the impact of these issues on the integrity of the data. introduction it has been recognized that research in rural areas presents unique and varied challenges for the researcher (shreffler, 1999; wilkes, 1999). these challenges are further confounded by variances in cultures across the wide spectrum of rural settings. this discussion will relate some of the issues that challenged the rural research process, including utility of tools developed with urban and suburban persons in rural areas, location of appropriate participants, rural health issues, environmental barriers, and ethical considerations related conducting research with a rural dwelling sample. to gain insight into the experience of heart failure of older rural women, the authors conducted research with a convenience sample of 45 older women in rural upstate new york. the research question focused on health promotion behaviors and involved older rural women with heart failure who were referred by primary care physicians or nurse practitioners. data was collected during visits of one of the authors to the women’s homes. the women were not reimbursed for participation. this article discusses the experiences of the authors during this data collection process. findings of this research process indicated that more research with rural residents is necessary if we are to understand the unique differences seen in rural populations while accounting for the unique issues inherent in data collection in rural areas. appropriate research tools for rural populations one goal of research into rural nursing issues is to confirm that nursing interventions have similar usefulness in rural populations that is found with urban and suburban counterparts (turner & gunn, 1991). because the majority of research in health care issues has been performed with urban or suburban populations, some of the basic premises of data collection and data analysis may not be reliable when transferred online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://dson.binghamton.edu/ mailto:cpierce@binghamton.edi http://dson.binghamton.edu/ 26 without adaptation to research with persons living in rural settings (turner & gunn, 1991). similarly, most data collection instruments and procedures have been developed with urban or suburban populations, and thus may have questionable reliability and validity when used in vastly differing rural geographic regions. an enormous challenge remains for nursing researchers to create new methods to uncover issues that must to be brought to light to improve rural health care. environmental barriers this study was based in the finger lake region in upstate new york. while good roadways crisscross the area, the homes of the women in the study tended to be 25 to 50 miles from major roads, in small villages or farming communities. a few of the women lived on roads maintained as seasonal use only roads. when data collectors made arrangements to meet with women in their homes, travel to meet with the subjects often involved driving distances of 60 miles or further with the major portion of the distance occurring in remote areas. in spite of the best efforts of the data collectors to obtain clear and accurate directions to the homes, frequently it was found that the directions received were sketchy and difficult to follow. several of the women appeared unable to give accurate directions, and some gave the authors grossly incorrect estimates of mileage. this problem may be related to the infrequent travel of many of the women for any distance away from their homes, or that they may have been inexperienced with giving directions because they did not drive themselves. less than 50% of the women drove themselves to their local doctor’s offices, and less than 20% drove themselves further away from their homes than to the office of their cardiologist. several times the women asked family members to assist in giving directions. on more than one occasion we were given instructions that were impossible to follow, such as directions including where people “used to live”, or landmarks that turned out to be missing. the authors learned to allow plenty of extra time to obtain directions locally, and to ask for extra information such as the color of buildings or special landmarks, or unique topography. we found cellular telephones and detailed local maps to be invaluable resources. we also learned to locate stores and gas stations along the way where we might be able to return for directions. the fact that rural residents tend to know most people in the area was useful in finding our participants. the homes we visited mirrored the socioeconomic circumstances of the rural upstate new york area. the majority of the women stated that they were living on social security benefits only. single-family homes were the most common living arrangement, as were family farmsteads where multigenerational families lived together. only a few of the women lived in apartments or trailers. about half of the women lived alone, with most of the remainder living with only one other person. the mean length of residence of this sample was 26 years. these findings mirrored lee’s (1993) description of rural residences with most persons living in single-family homes and residing in same community for the majority of their lives. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 27 locating appropriate participants the design of this study called for accessing rural women who were presently being treated for heart failure through local health care providers, who were asked to recommend women who might be willing to discuss their experience of heart failure with the authors. in every instance the providers stated that they knew their clients well and had treated most of them for many years. the providers related that they liked having this type of relationship with their clients. interestingly, this phenomenon compliments research findings that have shown that rural residents prefer to know their health care providers (pierce, 2001; casarett 1991) found that rural health care workers were friends and neighbors with their clients, and that rural clients found it important to have “neighborly” relationships with their health care provider (p. 252). most of the approximately twenty rural providers we contacted were very willing to cooperate and were pleased to be able to be involved in some way with research. several of them spoke of the dearth of research opportunities in their rural practices and were supportive of any research endeavors with their clients. most of the physicians and nurse practitioners felt that research of this nature that focused on the experience of living with heart failure was critically important to improving rural health care. because the rural health care providers tended to know their clients well, they appeared to make judgments about who would and would not participate in this research. these judgments possibly were their methods of protecting their clients as well as an attempt not to waste the time of the researchers. the providers could easily list the patients they cared for with heart failure and seemed to know a great deal about the living situations of each person. of course, the possible impact of this culling process on the reliability and validity of sample cannot be overlooked. some of the providers stated that they were aware that the treatment regimes they were prescribing for their clients with heart failure differed from those currently espoused in the heart failure literature. they related the fact that knowing their clients included insight into what medications these clients would be willing to take. one physician said that she ordered the old standard medications that her clients had been taking for many years rather than to attempt to switch them to newer, more expensive drugs that she felt quite sure they could not afford to take. impact of rural dwelling on health the women that we studied were captives of the “triple jeopardy” related to living in rural areas, including advanced age, poor economic status, and relative isolation from health care services (henderson, 1992, p.62). many described struggling with role changes as well as decreased physical and mental capacity. in spite of these disadvantages, the women in this study for the most part rejected the sick role described by lee (1993). as is the case with many rural persons, the women in this study talked about being able to do the routine chores around their homes, with their families, and often cited involvement in their churches and charities such as clothing and food banks. this mirrors the definition of health ascribed to rural persons by long and weinart (1989) as being able to work. they expected to go about their daily routines and saw illness as part of the aging process. in spite of relatively advanced new york heart association online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 28 classification levels indicating declining cardiac function, they tended to rate their health as good. one woman who was nearly blind, oxygen dependent, and lived alone rated her health at the highest level. the older rural women in this study indeed represented the notion of the survivor elite (mccullough, 1991), who exude a high level of hardiness and tend to evaluate health in positive ways. while it has been commonly written that rural residents often tend to resist outsiders, the authors found the women in this study were willing to open their doors to researchers. all of the women were at home during the first visit making repeat visits unnecessary. none of the women asked for identification from the researchers but we gave them our business cards as a method of identification. while this lack of distrust may have related in part to the fact that an appointment had been set in advance, we also sensed it as an act of welcoming us, as an acquaintance of their health care provider, into their homes. we also felt that they were comfortable with nurses entering their homes, perhaps reflecting the widely held notion that nurses constitute the most trusted profession. while we were clearly “outsiders” (long & weinart, 1989), we were in each instance treated with respect and with a very welcoming manner. once we were inside the subjects’ homes, many of the women created a social atmosphere where we were treated as welcomed company. often we were served beverages and home baked goods. in addition, we were shown antiques, quilts, handwork, pictures of family members, and other favorite memorabilia. one subject was a nurse who had trained in the early part of the century who related several stories of her nurse’s training days seventy years ago. as the study progressed, we learned to allow extra time for each visit. we planned on time to accept refreshments, as well as for the subjects to show us their favorite items and to reminisce about their life experiences (newburn, 1991). in most cases we were invited to return for another visit or to share the results of the study. the hospitality went both ways when one author occasionally delivered fresh lake trout to one subject who spoke of missing trout since her husband had passed away. a number of the women expressed surprise that nurses would be willing to travel so far away from the university, and they also seemed surprised to find that their experiences were important to study. most said that they did not think they had anything important to say. however, while they stated this, most of the women were very willing to talk about their lives and were eager to be helpful to the researchers and to other persons with heart failure. it was notable that this group was willing to share information about their health experiences, but they did not ask for any advice or additional assistance from the researchers. they may have perceived the authors as researchers only, rather than as active health care providers. ethical issues in rural research throughout the study, it was common that the women wanted to put a positive light on their health experiences. there was also a sense on the part of the authors that the subjects often seemed to want to please the researchers by choosing the ‘right’ answers, almost as if they were going to be graded. one woman was willing to refer to her tax returns, so she would be able to answer the income level question as accurately as possible. we were concerned that this need to have the right answer might be related to a concern that the authors would report findings back to their health care providers. while online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 29 we assured the women we would not share any information with their health care providers and that there were no “right” answers, it seemed clear that they remained concerned about this issue. even though the researchers repeatedly reminded the women that the information was confidential, it is possible that the lack of anonymity (long & weinart, 1989) that is characteristic of rural areas may have biased their answers. also, some were clearly using the only provider in their area, and may have been concerned about causing any problems with that relationship if they answered in a way that might displease the provider. similarly, we developed a concern that the women might feel obliged to participate if they were referred by a health care provider they trusted or knew very well. while we tried to be clear that they were under no obligation to participate unless they were doing so for their own reasons, the authors remained concerned that the women felt obligated to be of assistance to their health care providers and thus the researchers they were associated with. additionally, the women seemed very trusting of the research process. we found that the women rarely read the consent form carefully, in spite of our best efforts to make sure that they were aware of the conditions of the consent they were signing. we did not access reading or comprehension levels, but this would probably add valuable insights into the research findings. one surprising finding was that all of the women stated they took their medications as ordered, and this included those with complex medication regimes as well as those who might have had faulty reasoning and/or comprehension skills. this response pattern may have been related to not wanting to alienate providers, or to not wanting to admit if they were unsure about how to take their medications. the latter may reflect the hardiness factor as described by mccullough (1991). the issue of a lack of anonymity was evidenced at several points in the data collection process. because we were visiting residents in small towns where “everyone knew everyone else”, we experienced situations were subjects would say that they had heard that we visited a neighbor. we also found that the women were eager to tell us the names of other neighbors that they knew who would be willing to talk with us. we did ask those persons to participate in this study. conclusion as we review these issues, the concern for the integrity of the research process may have unique implication in rural areas. the power of the contacts in rural areas where unique relationships exist must be carefully scrutinized to ensure that integrity of the research process is maintained. signifiers of power of a researcher also must be carefully considered when studying vulnerable populations (geldens, 2002). while the outsider status of a researcher can be a barrier, the use of insider connections should be used with caution. it must be a paramount responsibility of the researcher to protect the participants yet foster research outcomes that are in the best interests of all participants (geldens, 2002). as more is learned about the intricacies of rural communication patterns, it is critical that this information be shared and used to perform credible rural research in the future. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 30 references casarett, d. (1991). elders and neighborliness: implications for rural health care. in a. bushy, (ed.), rural nursing (vol. 1). newbury park, ca: sage. geldens, p. (2002). i am not as cool as i thought i was: the challenges of conducting research with young people in rural areas. rural social work, 7, 4550. henderson, m. (1992). families in transition: caring for the elderly. family and community health, 14, 61-70. lee, h. (1993). health perceptions of middle, “new-middle”, and older rural adults. family and community health, 16, 19-27. long, k. & weinart, c. (1989). rural nursing: developing the theory base. scholarly inquiry in nursing practice, 3, 113-127. [medline] mccullough, b. (1991). health and health maintenance profiles of older rural women, 1976-1986. in a. bushy, (ed.), rural nursing (vol. 1). newbury park, ca: sage. newbern, v. (1991). health care in the south: 1990-1945. in a. bushy (ed.), rural nursing (vol. 1). newbury park, ca: sage. pierce, c. (2001). the impact of culture on rural women’s descriptions of health. journal of multicultural nursing and health, 7(1), 5053, 56. shreffler, m.j. (1999). culturally sensitive research methods of surveying rural/ frontier residents. western journal of nursing research, 21, 426-35. [medline] turner, t., & gunn, i. (1991). issues in rural health nursing. in a. bushy (ed.), rural nursing (vol. 2). newbury park, ca: sage. wilkes, l. (1999). metropolitan researchers undertaking rural research: benefits and pitfalls. australian journal of rural health, 7, 181-185. [medline] online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2772454 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11512207 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10745733 editorial 9 editorial violence and violence prevention in rural america molly nolan, msn-c, rn, sane guest columnist violence is an increasingly recognized public health problem in the united states (johnson, 2000). in general, violent crime tends to be higher in urban than in rural areas (duhart, 2000). although usually attributed to a higher population, some of the conditions often associated with increased crime, such as poverty and unemployment, are often as high or higher in rural communities (ruback & menard, 2001). problems faced by service providers and victims in rural areas have started to emerge. they include victim isolation from services, traveling long distances, lack of medical facilities, and dealing with rural law enforcement that is sometimes quite conservative, unsympathetic, and untrained with respect to domestic violence and sexual assaults (lewis, 2004). few quantitative studies of rural domestic violence victims exist, but the significant problems of victims are likely enhanced by rural factors. these factors include: poverty, lack of public transportation systems, shortages of health care providers, underinsurance or lack of health insurance, and decreased access to many resources. these deficiencies make it difficult for victims of domestic abuse to escape the abusive relationship (bushy, 1998). isolation and cultural values can also contribute to the difficult task of ending an abusive relationship in rural areas. rural women may feel as if there is no support for them, and they may have strong ties to the land, family, and community that would prevent them from reporting violent crimes (fishwick, 1993). according to the networking office of the council on abused women services, in 2001 13% of all domestic violence victims in north dakota lived in communities with a population of 1500 or less (dvcc, 2005), and sexual assaults in north dakota rose 7% from 2003 to 2004. this is a significant statistic for health care implications in this state. there are many myths regarding sexual assault. many believe assailants are strangers. however, according to the north dakota council on abused women services, only 12 % of sexual assaults reported in 2004 were committed by a strangers; the remainder were reported to be either a friend, acquaintance or date. in general, the closer the relationship between victim and assailant, the less likely the woman is to report the crime. this familiarity is extremely prevalent in rural communities, and many sexual assaults may go unreported (ruback & menard 2001). this is complicated by the fact that rural law enforcement is likely to be part of the social network; sexual assault victims may be especially concerned with a lack of confidentiality (lewis, 2004). prevention prevention needs to begin at home and in the schools. it’s never too soon to talk to a child about violence. male children need to have strong role models that can offer guidance on how to achieve healthy, respectful relationships. elementary education programs can highlight non violent behavior and encourage human respect. children online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 10 need to be taught at an early age that violence has no place in a relationship (family violence prevention fund, 2005). young people need to be able to recognize early warning signs for physical violence such as a partner's extreme jealousy, controlling behavior, verbal threats, and history of violent tendencies or abusing others, and verbal or emotional abuse (national sexual violence resource center, 2005). sexual assaults quite frequently are alcohol related. too often the victim’s story is that their friends left them at a party because they passed out. the victim wakes up the next day with her undergarments missing and presence of evidence from sexual assault. there are tips to teach our youth about the use of alcohol and violence prevention: do not leave beverages unattended, do not take alcohol from anyone other than the server/bartender, at social functions do not accept opened drinks, and be alert to the behavior of friends. if someone appears to be inebriated, they are in danger of being a victim (abby, zawacki, buck, clinton, & mcausian, 2001). underlying rural social mores often include an aversion to outside involvement. rural individuals may tend to keep things away from public organizations and agencies and instead deal with any problem in a quiet, more private way. health care providers in rural areas understand rural people’s hesitancy to deal with organizations and have found that one solution is to build strong trusting relationships in the community over time. this allows health care providers to gain access to schools and community forums (lewis, 2003). rural health care providers can do many things to address violence in their communities, including: • educate themselves regarding violence in their communities; • know what services are available for victims and perpetrators of violence and their children; • coordinate community initiatives to strengthen safety networks for victims who experience violence; • increase public awareness programs by speaking at schools, community clubs and public forums regarding domestic violence and sexual assault; • support increased access to services for victims and perpetrators of intimate partner violence as well as for their children; • develop educational prevention programs that address how not to be a victim or an assailant. references abbey, a., zawacki, t. buck, p.o., clinton, a.m., & mcauslan, p. (2001). alcohol and sexual assault. alcohol research & health, 25(1), 43-51. [medline] bushy, a. (1998). health issues of women in rural environments: an overview. journal of the american medical women's association, 53, (2): 53-56. [medline] domestic violence crisis center (2005). 2001 sexual assault/domestic violence statistics in north dakota. retrieved june 26, 2005, from: http://www.minot.com/~dvcc/2001statpg.html duhart, d. t. (2000). urban, suburban, and rural victimization, 1993-98 (ncj 182031). washington, dc: bureau of justice statistics. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11496965%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9595896%5buid%5d http://www.minot.com/%7edvcc/2001statpg.html 11 family violence prevention fund. (2005). coaching boys into men. retrieved september 24, 2005, from http://endabuse.org/programs/display.php3?docid=9916 fishwick, n. (1993). nursing care of rural battered women. awhonns clinical issues in perinatal and women's health nursing, 4(3): 441-448. johnson, r.m. (2000). rural response to domestic violence: policy and practice issues. federal office of rural health policy. retrieved september 24, 2005, from http://ruralhealth.hrsa.gov/pub/domviol.htm lewis, s.h. (2003). unspoken crimes: sexual assault in rural america. national sexual violence resource center. retrieved september 24, 2005, from: http://www.nsvrc.org/publications/booklets/rural_txt.htm lewis, s.h. (2004). sexual assault in rural communities. national resource center on domestic violence. retrieved september 24, 2005, from: http://www.vawnet.org/sexualviolence/research/vawnetdocuments/ar_rural sa.php national sexual violence resource center. (2005). intimate partner violence: prevention tips and resources. retrieved september 24, 2005, from http://www.nsvrc.org/ north dakota council on abused womens services. (2005). facts about sexual assault in north dakota: jan—dec 2004. retrieved june 26, 2005, from http://ndcaws.org/assault/statistics.asp royse, b. (1999, september). non-stranger sexual assault, rural realities. national non-stranger sexual assault symposium, proceedings report, denver sexual assault interagency council. ruback, b.r., & menard, k.s. (2001). rural-urban differences in sexual victimization and reporting: analyses using ucr and crisis center data. criminal justice and behavior, 28(2), 131-155. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://endabuse.org/programs/display.php3?docid=9916 http://ruralhealth.hrsa.gov/pub/domviol.htm http://www.nsvrc.org/publications/booklets/rural_txt.htm http://www.vawnet.org/sexualviolence/research/vawnetdocuments/ar_ruralsa.php http://www.vawnet.org/sexualviolence/research/vawnetdocuments/ar_ruralsa.php http://www.nsvrc.org/ http://ndcaws.org/assault/statistics.asp national nurses week (may 5-12)   5 editorial national nurses week (may 5-12) marietta stanton, dsn, rn editorial board member an article appeared in the tuscaloosa news (may 26, 2008) this morning discussing how hospitals in california are now safer places because california has legislated that a nurse patient ratio of 1 to 5 must be maintained on busy medical/surgical wards. not only did the report imply that patients were safer, it also indicated that staff satisfaction was higher leading to less burnout. apparently nurses in 13 other states-arizona, florida, illinois, maine, massachusetts, michigan, minnesota, missouri, new jersey, new york, ohio, pennsylvania and texas are lobbying for california-style safe staffing bills. unfortunately, the hospital industry according to this article is strongly opposed to much needed health care reform. certainly, the improved nurse patient ratios enhance the safety and well being of the patients especially in acute care settings. a series of reports published by the institute of medicine (iom) on quality and health care has certainly highlighted the need for enhancing patient safety. california’s ratios are a spectacular success story. under the ratio law, lives are being saved, nurses perceived ability to be effective advocates for patients is stronger, and more rns are entering the work force and staying at the bedside longer mitigating the nursing shortage. since the law was signed, 80,000 more licensed rns have come into the state’s workforce. in contrast to the years before the law was signed in 1999, more rns are entering the state than leaving, and more are staying at the bedside. because of their achievements, the ratios have sparked a brush fire around the country by nurses demanding similar laws in other states. what was apparent from this article was that in california institutions that had fully complied with the 1:5 patient patients were safer. as a consequence, nursing job satisfaction has increased and job turnover has been reduced. we need to investigate what the staffing ratios are in rural facilities. on the other hand, some groups such as the illinois hospital association oppose the staff to patient ratios. they say california’s experience has yielded: • delays in emergency departments, surgery, and other critical services; • reduced access to care because 11 hospitals have closed; • compliance costs estimated at over $1million per hospital, with 23% attributable to increase in nurse wages. establishing "minimum, specific and numerical" ratios implies that there is a scientific basis for determining the number of nurses to patients above which good outcomes for patients are guaranteed. the reality is no study has provided conclusive evidence of what the "right" threshold should be. as i read both sides of this issue, i couldn’t help but wonder how this kind of legislation would affect rural hospitals. their case mix would probably be different than a large urban online journal of rural nursing and health care, vol. 8, no. 1, spring 2008   online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 6 hospital and their access to an adequate supply of registered nurses to meet the standards might be difficult. what about the expense too? how does it affect care in other countries? it certainly provides food for thought and it might be interesting to note how our rural providers react to this potential change in nursing staffing. if you have questions do not hesitate to contact me at mstanton@bama.ua.edu. mailto:mstanton@bama.ua.edu 37 discussing hope with rural public health nurses and community members judith c. kulig, rn, dnsc1 1 professor, school of health sciences, university of lethbridge, kulig@uleth.ca keywords: hope, rural, public health, nurse, community abstract the aim of this exploratory, descriptive study was to understand the meaning of hope for rural communities, in particular how community members and public health nurses understand this concept, and how they work together to create hope within rural communities. qualitative interviews were conducted with nine community members and five public health nurses using an open-ended interview guide. the participants saw hope as a positive element of life that could be recognizable at the community level. the community members spoke about how they, as individuals, could help create and instill hope within their communities. public health nurses were seen as resources for such communities and could add to the sense of hope being experienced there. however, the two groups did not work together to create hope. recommendations include providing more opportunities for community members and public health nurses to work together on community issues. introduction as a concept, hope has been explored among individuals and families, but only recently has it been addressed within a community setting (kulig, 1999, 2002). most of the nursing studies on hope have been descriptive in nature and have focused on individual participants who were unwell (kylmä & vehuiläinen-julkunen, 1997). examples include research studies that have been conducted with cancer patients (dufault & martocchio, 1988; herth, 1989; owen, 1989; thompson, 1994; bunston, mings, mackie & jones, 1995; herth, 2000; rustoen & wiklund, 2000; chen, 2003) and people living with hiv/aids (akinsola, 2001; kylmä, vehuiläinen-julkunen, & lahdevirta, 2001). there is similar research that focuses on groups such as the elderly (farran & mccann, 1989; gaskins, 1995; zorn, 1997; cutcliffe & grant, 2001), youth (hinds, 1984), homeless families (herth, 1996), children (herth, 1998), and specific religious groups (benzein & saveman, 1998). hope has been defined as a positive and necessary aspect of human life that is a future-oriented, motivating factor (brumbach, 1994). links have been made between spirituality and hope, with suggestions of a need for a belief in a higher power or being (brumbach, 1994; gewe, 1994; thompson, 1994; lepeau, 1996). hope has also been discussed as being a process (snyder et al. 1991) in which activity on the individual’s part is essential (stephenson, 1991). individuals have been described as either having low hope or high hope (snyder et al. 1991). however, the usefulness of placing hope on a continuum that ranges from hope to hopelessness is questionable (dufault & martocchio, 1988). online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.uleth.ca/hlsc/ mailto:kulig@uleth.ca 38 the image of the nurse as being hopeful and providing hope for clients is a common one. however, an understanding of the process through which this is achieved has not been developed. some suggestions for stimulating hope include encouraging individual patients to focus on their past achievements, creating an atmosphere that allows individuals to think about their goals and readjust their plans accordingly (dufault & martocchio, 1988), or simply creating an atmosphere of hope (lange, 1978). hope can also be stimulated through the nurse being encouraging and using good communication (thompson, 1994), seeking relevant information about the situation (lange, 1978), establishing a support system (hickey, 1986; o’connor, 1996), helping the individual patient develop realistic goals (lange, 1978; hickey, 1986), and assisting the individual to renew their spiritual life (lange, 1978; nowotney, 1991; miller 1985 in o’connor, 1996). the concept of hope is particularly relevant to rural communities in canada, which comprise 22% of the total population (duplessis, beshiri & bollman, 2001). rural residence negatively impacts on life expectancy and health status (pampalon, 1991). in addition, rural communities have been facing depopulation, youth out-migration, and erosion of health care services and other resources. the result has been increased levels of stress and mental health problems. for these reasons, more research is needed on hope for rural communities stimulating the author to pursue the research reported here. one recent exploratory, descriptive study focused on the meaning of hope for public health nurses (phns) in their rural-based practice (kulig, 1999, 2002). the 10 phns in the study identified hope as a forward-looking perspective that was significant in their work with individuals, families and communities. the participants believed that communities, as collectives, could also be considered hopeful and that there were conditions (for example, access to resources, hopeful people), as well as characteristics (such as financial stability) and indicators (for instance, being optimistic) for hope at that level. the phns identified that working with individuals or within community-level programs gave hope to the entire community. the findings of this research were used as the basis for the study reported here, in particular to address the research question: what is the meaning of hope for rural phns and community members, and how do these two groups create hope in rural communities? due to the paucity of literature on hope within communities, the research discussed here is intended to address such a gap and offer insights unique to rural communities that may be useful when considering sustainability issues. in particular, the findings are useful for rural phns who can positively impact communities on multiple levels. background for the purposes of this research, hope was defined as the inner belief that helps one deal with difficult circumstances (lynch, 1965; mcgee, 1984). community was defined as "a group of people who are socially interdependent, who participate together in discussion and decision making, and who share practices that both define the community and are nurtured by it" (bellah, madsen, sullivan, swidler & tipton, 1996). the study focused on rural communities, defined as communities outside the commuting zones of larger urban centers with 10,000 or more population (duplessis, beshiri & bollman, 2001). online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 39 the aim of this exploratory, descriptive research was to: 1) explore the meaning of hope for public health nurses (phns) in their rural-based practice and for community members who reside in rural communities; 2) generate information about how phns and community members determine if hope is present in rural communities; and 3) identify how phns and community members instil hope in rural communities. this study allows us to begin to understand the relationship between community members’ sense of hope and the viability and sustainability of their community. these issues are particularly significant to rural communities because of the changes that are occurring within them, for example, depopulation, and loss of employment opportunities for youth (beshiri & bollman, 2001). in order to understand concepts such as hope at the community level, it is necessary to conduct interviews with individuals to ascertain their perceptions and then, through the analysis process, hypothesise the meaning at the community level (brown & kulig, 1996/7; kulig 2000). methods design an exploratory, descriptive design was used to pursue the research question, what is the meaning of hope for rural phns and community members, and how do these two groups create hope in rural communities? exploratory, descriptive studies are intended to generate information about poorly understood concepts (burns & grove, 2001). variables can then be examined in detail to determine differences or similarities but not causation (lo-biondo-wood & haber, 1998). due to the nature of the study, purposeful and snowball sampling are commonly used. purposeful sampling allows for participants to be included who have knowledge about the matter under study (morse, 1989; streubert, 1995) while snowball sampling includes the participants making referrals to other potential participants (haber, 1998). like other qualitative designs, exploratory, descriptive studies focus on generating perspectives and ideas from participants through the use of open-ended questions. additional probes are used to clarify and expand upon the participant’s answers. interviews are conducted until data saturation, or when no additional data is generated, occurs. setting interviews with both phns and community members were conducted within a predominantly agricultural-based regional health authority in southern alberta, canada from 2000-2001. phns are those nurses who deliver care to individuals, families or groups within the community by focusing on health promotion, prevention, and communicable disease control. phns provided this type of care in rural communities and settings scattered throughout the health authority, which serves approximately 88,584 residents in a geographic area of 44,000 square kilometres. in this health region, there is one small city of 51,000 and a number of rural communities that range in size from 150 to 10,000 residents. the second group interviewed were residents within these rural communities and were 18 years of age and older. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 40 data collection data collection commenced after human subject, or ethical, approval was granted from the author’s university. open-ended interviews were conducted until data saturation, occurred. the researcher individually interviewed a total of five phns and nine community members. purposeful sampling was used initially and hence a summary sheet explaining the study was prepared and given to the public health supervisor to circulate to the phns. interested individuals then called the author. the interviews occurred in a mutually convenient time and location, often in the phns’ offices. after informed consent was obtained, demographic information was collected and the interview was audiotaped for later transcription. most interviews took an average of 50 minutes, with the range from 45 to 90 minutes. snowball sampling was also used to locate the community members and hence suggestions for recruiting further participants were made by the phns and the community members themselves. the author contacted these individuals directly to explain the study and set up an interview. informed consent was obtained at the beginning of the interview. after this, demographic information was collected and the interview was also audiotaped for later transcription. these interviews usually lasted from 45 to 75 minutes, with the average being 55 minutes. data analysis included using reflection, creativity and comparison (mariano, 1995). the transcripts were read to identify similarities and differences within the data while using creative thinking to interpret the data. more specifically, after reading the transcripts several times, tentative categories in relation to hope were identified. the data was also analyzed in order to identify themes (schatzman & strauss, 1973), or the ideas shared in common by the participants in each of the groups and between the two groups. constant comparison was also used in the data analysis process (glaser & strauss, 1967). consequently, the transcripts were read to identify the themes regarding the characteristics of hope within rural communities, such as the antecedents and the attributes of hope, as well as how phns and community members instill hope in their communities. any differences noted by the individual participants regarding the categories and themes were identified for further discussion with all of the participants during the follow-up interview. the responses to the specific questions allow for understanding of hope at a community level, a feature of analyzing qualitative data. after the initial analysis of the data was completed, a summary of the tentative categories and themes was distributed by mail to the participants in preparation for the second, follow-up interview. questions that arose in the interviews and during the initial data analysis stage were clarified. a second interview was conducted with four participants who wished to provide further information. the remaining participants indicated that they did not feel they needed to be interviewed again because the summaries reflected their perceptions of the topic and they had no additional comments. the second interview was conducted over the telephone and took approximately 45 to 60 minutes. the interview was also audiotaped for later transcription, and the transcripts were then analyzed with the initial interviews to further understanding of the themes and categories. in this qualitative research, trustworthiness (guba & lincoln, 1981; lincoln & guba, 1985; lincoln & guba, 1986) was established by asking the participants to review online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 41 and validate the initial data analysis, including sufficient detail so that others can follow the decision trail, and ensuring that the findings were generated from the data itself. there are limitations of the research, including that the information generated may only be applicable to phns who practice in rural areas in southern alberta, canada. however, given the paucity of theoretical development in this field of nursing (kulig, 2002), the findings, although limited, contribute to expanding the baseline of knowledge related to community health and public health nursing. results the demographic information indicated that there were seven female and two male community members interviewed, five of which had lived in the same rural area their entire lives. seven of the community members ranged in age from 31 to 45 years. for the five phns who were interviewed, the average length of time working in a rural area was ten years with the range from 2.5 to 20 years. three had bachelor’s degrees, and three worked full-time. the five phns were all experienced in their roles and spoke at length about the type of activities they routinely performed within that role. hence, all were involved with families, schools and seniors in various rural communities and in farm and ranch settings. some of their activities included giving immunizations, conducting postpartum visits, providing health education at school sites and attending inter-agency community committee meetings. they all noted that over time, and with the erosion of the funding to public health, there were many activities, such as community development, to which they could not devote as much time as they would like. they were clearly dedicated to their work, keenly interested in rural communities and concerned about the health and wellbeing of the communities within which they worked. the nine community members represented a range of individuals who were active in their communities at different, but significant levels. although only a few identified themselves as community leaders, all could have been described in this way because each performed leadership roles in one way or another. consciously, or unconsciously, they initiated community activities that distinguished their locales in a positive way. some examples included developing a museum, mobilizing a community in relation to an intensive livestock operation, and developing a community-based food industry. other activities included membership in school-based economic committees, coaching high school sports, and organizing community fairs and suppers. all spoke of the importance of working within one’s own community and passing this value on to their children. initially, the data were analyzed according to the two groups who were included in the sample. however, careful review of the transcripts illustrated that despite the demographic and role variations between the two groups, there were few, if any differences between them regarding their perceptions and understanding of hope within communities. for example, both the community members and the phns described community as a place where people come together to accomplish something; and hope for both groups was seen as a positive aspect of life. thus, the following sections discuss the themes regarding the topic under study from both groups simultaneously. the lack of differences may be due to the small sample size and perhaps another contributing factor online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 42 is that both groups had spent significant time in rural communities leading to more similarities in their perspectives about the topic under study. perceptions of community when asked to define community, the basic element noted by the 14 participants was that community consisted of a group of people who have a common purpose. in addition, the participants made it clear that communities needed to have cohesion among their members, who in turn would feel as though they "belonged." one participant indicated that communities are about relationships that can be developed at different levels and between different kinds of people. the majority of participants emphasized the social aspect of communities, commenting that in communities, people pull together, get along and interact with one another in a positive way. one community member stated, "community is kind of like extension of the family." communities, however, were not seen only as ideal. one participant stated that a community is a bunch of people who get together and make something, either positive or negative happen. geography also influenced the meaning of community because natural boundaries, such as rivers, could determine the community’s boundaries. finally, one participant commented that there are communities within communities, or smaller groups of individuals within the larger community. these smaller groups have their own common goals and ideas but also interact with the larger community. the participants acknowledged that both economics and politics influenced communities. other influencing factors included the sense of cohesiveness in the community, the networking with others in the community, and the involvement of people within the community. the physical size and geographic location of communities can also be considered an influence; those communities that are not doing well (for example, they lack leadership, cohesiveness, or a history of working together) and are within a reasonable commuting distance of 30 to 45 minutes by vehicle to a larger centre can potentially decline even further. in their experience, communities that have a history of successfully working together, have sufficient resources for their residents, and are situated a sufficient distance outside a larger centre, will be more successful at maintaining themselves as a community. the exact distance outside a larger centre is difficult to determine, particularly because rural residents commute so frequently, but an estimate would be 45 minutes by vehicle. what is hope? lengthy discussions were held with each participant about the meaning, indicators and characteristics of hope. the participants saw hope as something positive that was related to a future outcome. for example, hope was described as "knowing tomorrow is going to be a better day," a basic requirement for survival, and a reason to live. however, it was not passive because the individual needed to be actively involved in being hopeful and creating outcomes. hope gave people the courage to move ahead and work toward something that they desired. hope was also a spiritual issue; one participant considered hope as promises from god. although hope was active, it included a passive aspect that things will work out the online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 43 way they should. in further discussion with the participants, it was determined that there were relationships between faith, hope and spirit. the participants expressed that faith is a precursor to hope. in this instance, faith was not necessarily being described from the perspective of a church-based religion. the participants acknowledged that individuals can have faith and hope without a formal religion, but they were unsure about the mechanisms for this to occur. several participants further stated that individuals might be agnostic or atheist and still have hope. hope was described as more tangible, whereas faith was described as more abstract. one community member said that “faith brings you back to the hopeful stage.” both faith and hope deal with the future. furthermore, hope is an element of spirit. the latter is the emotional aspect of one’s faith. for some of the participants, spirit is the active component that brings people together. it can mobilize hope because hope itself is fluid. at the core of all of these concepts is the soul from which spirit and hope emerge. soul is the essence of one’s being, but communities could also have a soul. hopeful communities the participants indicated that communities could also be hopeful, in part, because of the presence of hopeful people, which meant that there would be more community involvement and participation. although it was perceived that some individuals were needed to ensure the community was hopeful, there were differing opinions about the exact number. some participants believed that only one hopeful individual was needed in order to stimulate the community but for sustainability, more than one hopeful individual was required. other participants believed that hope was not related to the number of individuals, but to the kind of people present. people who displayed leadership qualities, had ideas and were willing to work were more important than a specific number of people. leaders brought people together to develop a shared goal and demonstrated tolerance for a wide variety of ideas. overall, it was easier for the community when there were enthusiastic people willing to share the workload. some participants acknowledged that getting involved in the community was a choice and some people did not want to contribute to the community. another concern was the decreased numbers of individuals in rural areas because farms and ranches are becoming larger in order to economically survive, which leads to fewer neighbors and decreased availability of individuals to become involved in the community. the participants perceived hope as important for rural communities to prevent apathy. a final concern was the notion that, as a society, we are becoming more individual-focused; hence, in general, there is a decrease in interest and enthusiasm regarding involvement in community activities. characteristics of hope. a hopeful community is thriving, and contains hopeful people who feel safe living there; not just one age group, but also all ranges of ages, including children, are visible in the community. there were a number of characteristics evident in hopeful communities that can be separated into two categories: physical characteristics and social characteristics. physical characteristics include having: homes with neat yards and well maintained buildings throughout the community; schools and community halls; services; a range of interests among the community members; and an economic base. social characteristics include having: leadership; volunteers; resource online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 44 people, such as health professionals; plans for regular activities; participation in various activities and functions; goals; groups and organizations; and cohesiveness during a crisis. hopeful communities have a history of facing stressors and challenges, but enact an effective problem solving style that brings the community together as one cohesive unit. indicators of hope. besides characteristics of hope, there are indicators of hope, which refer to the way in which hope can be measured within the community. in this study, the participants stated that an indicator of hope was the number of annual events and the number of people participating in them. other indicators would be new people moving in, and the development of industry and economic opportunities for the residents. not all communities were always seen as entirely hopeful. the participants remarked that a sense of hopelessness was probably related to timing, as all communities will have some hopelessness depending upon what is happening. communities with a number of boarded up buildings were displaying hopelessness; some communities die because they are not economically successful. it was perceived that communities with high suicide rates, alcoholism and unemployment were likely showing signs of hopelessness. it was easy to begin to feel hopeless when communities started to lose services such as schools and stores. the participants indicated it takes a great deal of energy to work to maintain such services, and if they are lost after such a struggle, the community can lose more energy and become more hopeless. threats to hope. there were several threats to hope, including the loss of services such as grain elevators and schools, which exemplified economic instability. another threat to hope was the loss of a meeting place, such as a community hall or school. some participants noted that the loss of the school signified the beginning of the end for the community because it was a central part of the community. a number of the participants emphasized that communities existed because of interactions between their members. without a specific meeting area, there would be decreased opportunities for interaction and the potential for the decline of community. another threat to hope was natural disasters and weather patterns, which for farmers most often meant droughts that threaten their existence. fear threatens hope because it immobilizes individuals such that they are not able to move forward with new ideas or make changes. a final threat to hope was the loss of community spirit. the participants were also asked about hopelessness. several participants felt that it was difficult to think that total hopelessness existed. these individuals described themselves as "eternal optimists," and although they could understand that one’s circumstances could make life difficult, they believed that each individual held a grain of hope within them. however, the participants believed that hopelessness was present when the individual could not be involved in changes. depression and alcoholism were seen as symptoms of hopelessness. finally, what represents hope to one individual may be hopelessness to another. for example, others may see a new baby as a source of hope, but the baby’s mother may see the child as hopelessness if she does not have sufficient resources and support. personal sources of hope when the participants were asked about their own personal source of hope, they noted personal participation in organized religions or a personal sense of spirituality. for online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 45 the latter, the individual may believe in a higher power, but not attend a formal church service on a regular basis. there were also comments that the individual participant’s hope stemmed from a sense of belonging in the community, working with other hopeful people, or personal/familial experiences with volunteerism in their community. some also commented that being involved in successfully addressing a particular issue gave them more hope. comments included an inherent belief that things would get better or that there is a plan for everyone’s life and that it will work out the way it should, and that this knowledge gave hope. community members, health care professionals and the creation of hope all the participants acknowledged the importance of hope for rural communities. one comment was that "hope is who public health nurses are." phns create hope through the various health programs, which are bridges that illustrate hope. there was a belief that when phns worked with one family there was a positive impact on the entire community. however, hope can only be encouraged; the participants noted that the individuals with whom phns work must want to be hopeful. in order for the phns to instill hope, they must have established trust with the individual or family and lead by example. furthermore, the phn must be willing to help and participate in the rural community in order for hope to be enhanced. finally, empowering people in the community would lead to hope and was seen as a significant part of the phn’s role. community members also had their own role to play in creating hope in rural communities. they did so by being active volunteers, by instigating initiatives that addressed community needs and supporting those who were trying to do their best. community members created hope by working at winning issues that were important for the community. finally, it was noted that community members chose to be hopeful people and were encouraged to do so in order to create hope in communities. in fact, comments were made that the more hopeful people that were present, the more that can be accomplished in the community. despite the acknowledgement that phns and community members created hope in communities, there was little evidence that these two groups worked together to create hope. outside groups, such as phns, were noted as bringing hope to the communities in which they worked. however, for the specific issues that community members worked on, there was little or no interaction with phns regarding those specific issues. the work of phns was seen as providing individual care to those who needed it, not to larger community issues. discussions understanding communities is a challenging task given the complexity and interrelationships of variables such as history, geographic size, personality differences among community members, and negative and positive influences on communities, such as politics, economics, and policy. exploring the concept of hope at the collective level is a new way to understand the dynamics and internal processes of communities. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 46 for the participants, hope was seen as a positive force in their lives and in the workings of the rural community. it was described as something that gave them courage to go on and therefore, as brumbach (1994) points out, can be a motivating factor. repeatedly, they emphasized that hope was not passive and that individuals had to be actively involved in being hopeful. although it is difficult to ascertain how many hopeful individuals it takes to make a hopeful community, the sense was that even one person could stimulate hope. however, for sustainability of hope, more than one hopeful individual was required. similar to what has been described in the literature (brumbach, 1994; gewe, 1994; thompson, 1994; lepeau, 1996), the participants described hope as having a spiritual aspect that was not necessarily connected to a formal religion. hopeful communities were noted as places where there were leaders who brought people together with common goals, physical resources such as meeting places, inclusion of all age groups, cohesion among the residents, and a history of successfully overcoming challenges. indicators of hope included participation in regular and special events within the community, development of new industry, and the location of new people in the community, at least in part, because the community is known as a hopeful place. rural communities can have their hope threatened by natural disasters, loss of services, presence of fear in the community, loss of meeting places and loss of community spirit. due to the challenges that rural communities are already facing, such as depopulation, these additional threats place the sense of hope in rural communities at a more precarious level. there is a limited discussion in the literature regarding the impact of phns on the collective (kulig, 2000). in this study, phns were seen as having the ability and position to create and enhance hope at the community level. this was accomplished by establishing trust with the community members and working within specific health programs (such as home care services for the elderly). the phn’s role in empowering the rural community also enhanced hope and thus this concept needs to be the basis for the work done when interacting with the community. community members also had a large role to play in creating hope in their communities by supporting community activities, choosing to be hopeful people and instigating community initiatives. interestingly, these two groups (phns and community members) do not often work together in creating hope. more often this is due to the workload of the phn, who now works almost exclusively with individuals in the health region, rather than with communities as a collective. a concerted effort needs to be made by health regions to ensure that health care professionals such as phns are able to work with rural communities as collective units, and not just with the individual families within them. in addition, phns need to be supported by their health region to be involved in community-based initiatives, such as collaborating with community members to plan agricultural shows that could include health information booths. there are many examples in the literature that discuss collaborative initiatives between phns and community members illustrating the opportunity for such endeavours in the case of creating hope at the community level. all of the participants talked about hope as something they could "see" at the community level. credence needs to be given to these observations so that they may be discussed and incorporated within the community assessment tools used by the health online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 47 region. for example, questions that focus on the physical and social characteristics from a hope perspective could be included in existing community assessment tools. community members may want to enhance hope in their own rural communities by focusing attention on the physical appearance of their community as well as implementing activities that support social networks and build leadership. once again, phns could be involved in these initiatives. finally, community members need to work on maintaining their own hope by ensuring they have their own support network intact, which can be used to bolster one another when circumstances become difficult. conclusion the current study suggests that hope is applicable at the collective level but points to the need for additional exploration in a variety of rural communities. further study in communities that have been less successful in addressing problems and difficulties would also be informative regarding perceptions of hope. such studies when combined with the findings from the present study could be used by community members and public health nurses to instil and enhance hope. consequently, the development of social support networks in rural communities is an important activity in order to achieve hope. finally, opportunities for collaborative work between public health nurses 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(1995). what is nursing knowledge? in h. streubert & d. carpenter (eds.), qualitative research in nursing: advancing the humanistic imperative (pp. 15-28). toronto: lippincott. thompson, m. (1994). nurturing hope: a vital ingredient in nursing. journal of christian nursing 11(4), 10-17. [medline] zorn, c. (1997). factors contributing to hope among non-institutionalized elderly. applied nursing research 10(2), 94-100. [medline] online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=7965618&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=9197049&dopt=abstract design running head: rural nurse retention 42 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 who stays in rural practice?: an international review of the literature on factors influencing rural nurse retention candice manahan, msc 1 josée g. lavoie, phd 2 1 instructor, health sciences program, university of northern british columbia, manac000@unbc.ca 2 assistant professor, health sciences program, university of northern british columbia, lavoie0@unbc.ca keywords: rural, nurse, retention, job satisfaction, international abstract this paper explores factors that influence rural nurse retention. a comprehensive literature review was used to highlight, examine and evaluate studies that identify factors, including personal characteristics and experiences, in relation to rural nurse retention and job satisfaction. the findings from the literature review suggest rural nurse retention is influenced by level of job satisfaction. the findings also suggest factors, including personal characteristics and experiences, influence job satisfaction. the literature review findings further indicate factors, including personal characteristics and experiences, affect the duration of rural nurse practice. the current rural nursing retention strategies in british columbia are explored. based on the findings from the literature review, detailed recommendations for future research and recommendations for rural nursing retention strategies are made. the concepts identified inform health human resources retention strategies, specifically nursing retention in rural areas. introduction understanding health human resources is essential to sustaining health care services. the world health organization (who) states the need for health care professionals has grown world-wide, and the quality of health care services heavily depends on the ability to meet that need (poz, kinfu, dräger & kunjumen, 2006). the health council of canada publicly announced the most pressing challenge now facing canada’s health care system is the health human resources requirement (decter, 2005). the canadian institutes of health research’s institute of health services and policy research stated in one of their latest national consultation reports, that one of canada’s top nationwide research priorities is to learn more about the country’s health human resources, and to develop effective recruitment and retention strategies (gagnon & ménard, 2001). the need to understand health human resources has become increasingly evident at the international, national and provincial levels. nurses are the largest health human resource group working in canada, with over 232, 000 registered nurses working throughout the nation (pong & russel, 2003). nurses are often considered the foundation of the canadian health care system, and understanding nurse retention is necessary to the analysis of health care service quality, efficiency and sustainability. the unequal distribution of the nursing workforce between rural and urban areas is well documented (macleod et al., 2004). the who states over 60% of the world’s nurses work in urban areas, suggesting a significantly unequal distribution of nursing service in rural areas (poz et al., 2006). assessments of canada’s nursing workforce show only 18% of registered nurses are serving the http://www.unbc.ca/healthsciences/ manac000@unbc.ca http://www.unbc.ca/healthsciences/ lavoie0@unbc.ca 43 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 22% of canadians who live in rural areas (macleod et al., 2004). it is also more difficult to recruit nurses in rural regions. a study at the university of colorado suggests it takes nearly 60% longer to recruit nurses to rural facilities than to urban facilities (macphee & scott, 2002). despite the importance of rural nurses to the health care system and the evident disparities, there has still been little research that explores the retention of rural nurses (macleod et al., 2004). research question & objectives this paper explores factors that influence rural nurse retention. the current study poses the following research question: what personal factors, such as personal characteristics and experiences, are related to rural nursing retention and job satisfaction? this paper hypothesizes rural nurse retention is influenced by level of job satisfaction. this paper also hypothesizes factors, including personal characteristics and experiences, influence job satisfaction. furthermore, it is hypothesized that factors, including personal characteristics and experiences, affect the duration of rural nurse practice. the current rural nursing retention strategies in british columbia could be improved by addressing the factors that influence job satisfaction and retention. this paper will highlight, examine and evaluate the literature that identifies factors, including personal characteristics and experiences, in relation to rural nurse retention and job satisfaction. based on the findings, detailed recommendations for future research and recommendations for rural nursing retention strategies will be made. the concepts identified will inform health human resources retention strategies, specifically nursing retention in rural british columbia. methods to explore the hypotheses, a literature search using google scholar, pub med and ovid was conducted using the search terms: rural, nurse*, retention, health, job satisfaction. a search using the canadian nursing association and center for rural and northern health research websites search engines were also completed using similar keywords. additional relevant studies were identified using the bibliographies of those articles found in the literature searches. the studies included in this review were conducted between 1996 and 2006; the majority of studies are rural with a focus on canadian research. current literature: rural nursing practice rural nursing practice is characterized by a variety of challenges influencing nurse retention. researchers, pong and russel (2003) at the centre for rural and northern health research, found rural health professionals generally have difficulty obtaining full-time, permanent positions because rural areas often do not have the population base to fund full-time employees. pong and russel (2003) note nurses experience an increased scope of practice in rural areas because they are sometimes one of the only health care professionals in the area. the researchers note the shortage of other health professionals in rural areas make it hard for nurses to get the tools they need, like diagnostic tests (pong & russel, 2003). according to the researchers, nurses can not always deal with the increased variety and responsibility of rural practice, affecting their decision to stay in rural sites (pong & russel, 2003). according to pong and russel (2003), further pressures on the rural nursing workforce arise with the looming loss of “baby boomer” nurses to retirement, the dwindling number of canadian nursing graduates, and the increasing educational requirements for registered nurses. the information from this 44 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 study suggests nursing practice in rural canada has added complexities to consider in assessing job satisfaction and duration of practice. bushy (2002) assessed rural nursing workforces in canada, australia and the united states. bushy (2002) found similar challenges for rural nursing workforces despite regional differences. rural nurses in all three countries are concerned about the recruitment, education and retention of rural nurses. they express concerns about the growing population of elderly in rural areas, while the younger generation move away to find work in urban areas (bushy, 2002). nurses from all countries are concerned with the growing number of rural nurses retiring. other global trends, such as the shift to community care and increasing equitable health care access for rural people, also amplify the need for rural nurses (bushy, 2002). bushy notes “rural lifestyle” affects nurses in all three countries. bushy (2002) explains rural nursing blurs the boundaries between personal and professional life. rural nurses in each country express concern about decreased anonymity and confidentiality in small towns. bushy (2002) suggests nurses who work in rural areas are in high public visibility, and this often extends to their family members. for example, many of the study participants feel they are professionally evaluated by the community, based on how their children behave or what their yards look like. because the boundaries between personal and professional life are broken down in rural nursing, both professional and personal factors need to be addressed when assessing rural nurse retention (macleod et al., 2004). job satisfaction and rural nurse retention the relationship between job satisfaction and the decision to stay in rural nursing is well documented in the literature (stratton, dunkin, juhl, & geller, 1995). when rural nurses are not satisfied with their job, they are more likely to leave their position. using the data from a nationwide survey of canadian rural nurses, macleod and her colleagues (2004) found higher perceived stress and lower job satisfaction are central in the decision to leave rural practice. understanding the relationship between job satisfaction and duration of practice is essential to the successful creation of effective rural nurse retention strategies. pan, dunkin, muus, harris and geller (1995) used a logit analysis of international survey data of 2, 509 rural registered nurses. results suggest job satisfaction is the most influential predictor of staying in rural practice (pan et al., 1995). meanwhile, other studies show rural nurses have lower levels of job satisfaction than their urban counterparts. ndiwane (2003) surveyed 150 rural and urban american nurses. according to the results, rural nurses are less satisfied with their jobs, their pay and their opportunities for promotion. similarly, ndiwane (1999) surveyed nurses in cameroon, africa and found nurses who are less satisfied with their job are working in rural settings. overall, the current body of literature suggests features of rural practice influence job satisfaction, while job satisfaction influences duration of rural practice. factors that influence job satisfaction researchers compared rural and urban nurses in new york regions, and also found rural nurses have lower job satisfaction (ingersoll, olsan, drew-cates, devinney & davies, 2002). ingersoll and his colleagues (2002) used a random-sample survey to ask both rural and urban nurses (n=1,853) about job satisfaction, organizational commitment, demographics, and future career plans. when compared to urban nurses, rural nurses were more likely to be planning to leave their practice within the next year, and less satisfied with their job (ingersoll et al., 2002). however, urban nurses were more likely than rural nurses to be planning to leave their job in five 45 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 years, and more likely to have lower organizational commitment (ingersoll et al., 2002). these findings suggest once nurses have spent a significant amount of time in a rural community, other factors can overcome the influences of job satisfaction on retention. ingersoll and colleagues (2002) explored the factors interrelated with job satisfaction and retention by conducting a correlational analysis on the demographic and job satisfaction data. the researchers found nurses’ with higher levels of education are more satisfied with their job (ingersoll et al., 2002). nurses who are in educator roles or management roles are more satisfied with their job, while part-time and per diem nurses are less satisfied (ingersoll et al., 2002). there is a strong positive correlation between job satisfaction and professional autonomy, organizational commitment, pay scale and task requirements (ingersoll et al., 2002). furthermore, the researchers found nurses who are over 50 years of age reported higher levels of job satisfaction, and intent to stay in comparison to younger nurses (ingersoll et al., 2002). ingersoll and colleagues (2002) suggest the reasons for older nurses reporting higher levels of job satisfaction are still unknown. based on other findings from this study, one may suggest continued education, management roles, educator roles, professional autonomy, higher pay scale and variation in task requirements could be more accessible to experienced nurses, who in turn are more likely to be older. ingersoll and colleagues (2002) acknowledged the limitations of a 46% response rate and that the sample only included registered nurses, limiting the generalizability of the study. future research needs to aim for higher response rates, and use a variety of nursing professions to increase generalizability. nonetheless, this study lends valuable insight to rural nurse job satisfaction and retention. based on the findings from this study, retention strategies need to support nurses in professional development, specialty training, and provide opportunities for nurses to take on educator roles. an example of increasing access to professional development or specialty training could be increasing distance education courses in nursing programs. the findings from this study could also suggest retention strategies need to consider supplementing part-time employment, especially in rural areas. for example, if a rural community does not have the population base to support a full-time nurse, salaries need to increase and/or other part-time employment needs to be arranged. an interpretation of the findings could suggest increasing professional autonomy, and giving nurses a variety of tasks would increase job satisfaction and duration of rural practice. furthermore, although the reasons for older nurses reporting higher rates of job satisfaction are unknown (ingersoll et al., 2002), the results suggest decision makers need to recognize what retention strategies may be suitable for one age group, may not be as suitable for another (pan et al., 1995). chaboyer and colleagues (1999) surveyed 135 rural nurses in central australia to ask about influences on job satisfaction. chaboyer, williams, corkill, and creamer (1999) found higher job satisfaction if nurses have a variety of tasks in their job, peer feedback, and collaborative teamwork. the authors suggest the effects of making nurses part of a health care team are often underestimated (chaboyer et al., 1999). an interpretation of these findings could suggest retention strategies for rural nurses need to include team building initiatives, and plans for rural peer support networks. including rural nurses in an interdisciplinary health care team, or creating an on-line support group for rural nurses, could be considered to improve job satisfaction and lengthen duration of rural practice. an earlier study at the university of kentucky used a multi-state survey of registered nurses serving three different rural populations (stratton et al., 1995). like ingersoll et al. (2002), the researchers surveyed registered nurses only (n=1,647), and had less than half of the target sample respond (40.3%). the analysis shows a positive relationship between tuition reimbursement and job satisfaction (stratton et al., 1995). researchers found rural nurses are 46 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 more satisfied with their job if daycare facilities are provided by the employer (stratton et al., 1995). the findings highlight the need for retention strategies to continue tuition reimbursement, and other education incentives for rural nurses. the findings also suggest decision makers need to consider family life when creating retention strategies, and include supports for rural nurses with children. factors influencing duration of rural practice hegney, mccarthy, rogers-clark and gorman (2002) conducted a cross-sectional survey of 146 registered and enrolled nurses in rural australia. the survey asked nurses to rank 91 separate items on level of importance in relation to the decision to remain in rural practice. the results suggest job satisfaction and being part of a professional team are the most important predictors of remaining in rural practice (hegney et al., 2002). the nurses who remain in rural practice generally appreciate “rural lifestyle”, feel a sense of belonging in the community, and work in a family friendly environment (hegney et al., 2002). like other past studies, the findings suggest professional support networks, managerial support, professional autonomy, maintenance of clinical skills and peer recognition are very important in the decision to stay (hegney et al., 2002). this study provides further evidence of specific influences on both job satisfaction and retention already discussed in this paper. the results of this study raise questions about what constitutes “rural lifestyle”, and identifies a significant gap in the literature. in addition, the study introduces the importance of community satisfaction in the decision to stay in rural practice. researchers, henderson-betkus and macleod (2004) recently surveyed 124 public health nurses in rural, northern british columbia. the survey analysis indicates job satisfaction is most influenced by professional status, professional interactions and autonomy (henderson-betkus & macleod, 2004). however, the researchers note job satisfaction for rural nurses occurs within the context of community satisfaction (see figure 1). henderson-betkus and macleod (2004) suggest rural nurses can only be satisfied with their job if they are satisfied with their community. rural nurses in the study suggest the level of friendliness in the community, number of friends in the community, and level of trust they feel toward the community, all influence community satisfaction (henderson-betkus & macleod, 2004). similar to hegney, mccarthy, rogers-clark, and gorman (2002a), this study indicates having friends living in rural communities, a sense of belonging in the community, and having access to social networks are important predictors of retention. henderson-betkus and macleod (2004) note rural nurses report social/recreational opportunities, safety, and quality of schools increases community satisfaction as well (henderson-betkus & macleod, 2004). the findings suggest loss of anonymity, and work-related questions outside of work, decrease community satisfaction (henderson-betkus & macleod, 2004). small sample size and only using public health nurses in the sample limited the generalizability of this study. a similar study using a larger sample and a variety of nursing professions is recommended. however, these findings could have major implications for rural nurse retention strategies, specifically in british columbia. if job satisfaction occurs within community satisfaction, retention strategies need to pay more attention to community integration. to help nurses become more satisfied with rural communities, retention strategies could promote community events and recreational activities. getting rural nurses more involved in community activities could help nurses find friends, build trust in the community, and increase their community satisfaction. furthermore, retention initiatives need to involve community members, especially other health care professionals, to help create both social and professional 47 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 support networks. community development, including quality education opportunities and community safety initiatives, could also have a positive effect on rural nurse retention. personal characteristics and experiences henderson-betkus and macleod (2004) found the relationship between job satisfaction, community satisfaction, and the decision to leave or stay is interrupted by a number of “filter factors”. the researchers found that even if rural nurses are satisfied with their job and their community, a collection of personal characteristics and experiences, or “filter factors”, still dictate the decision to remain in rural practice (see figure 1). personal circumstances act as “filter factors”, and include retirement, financial needs, family needs, family commitments, and professional growth (henderson-betkus & macleod, 2004). nearing retirement influences nurses to stay in their current position for security; however, if their spouse is retiring, the nurse is more likely to leave (henderson-betkus & macleod, 2004). financial needs influence nurses to stay, but also influences nurses to leave if their spouse cannot find employment (hendersonbetkus & macleod, 2004). family needs and commitments can influence nurses to stay, but sometimes influence them to leave if their family lives somewhere else (henderson-betkus & macleod, 2004). henderson-betkus and macleod (2004) noted nurses who have children or spouses, who wanted post-secondary education not available in the community, are more likely to leave. this has important implications for rural nursing retention strategies. retention strategies need to increase professional development and educational opportunities for the rural nurses and their families. an example of this could be to improve access to post-secondary education by introducing more distance learning options, or offer scholarships for rural nurses’ family members. furthermore, if rural nurses have family living somewhere else, retention strategies may include videoconferencing for family visits. opportunities, like shifts in the economy, real-estate, job availability for self and spouse, as well as loss of benefits, act as “filter factors” (henderson-betkus & macleod, 2004). researchers note rural nurses are more likely to leave the community if there are drops in realestate prices, or other economic misfortunes. henderson-betkus and macleod (2004) show rural nurses are more likely to leave a community if the primary industry is suffering. the researchers found spouses’ employment is a major predictor of retention, and suggest retention may be more dependent on spousal employment than on personal job or community satisfaction (hendersonbetkus & macleod, 2004). based on these findings, future retention strategies should include job match initiatives or professional development programs for spouses. loss of benefits, another opportunistic factor, describes the loss of seniority and other employment benefits if a nurse transfers to another community. henderson-betkus and macleod (2004) found nurses stay in rural communities, even if they are not satisfied with the job or the community, because they do not want to lose employment benefits (henderson-betkus & macleod, 2004). in british columbia, the nurses’ union provincial collective agreement (2006) does not allow nurses to carry their seniority or benefits from one community to another, unless they have been displaced or transferred. although nurses’ pension contributions can usually remain in the same pension plan, each change of employment that incurs triggers a break in service or a change in salary, which can affect the nurses pension in some way (m. hendersonbetkus, personal communication, march 28, 2007). changes in pension and loss of benefits deter nurses from moving (m. henderson-betkus, personal communication, march 28, 2007). threatening nurses with loss of benefits for moving from one community to another, may it be an urban facility to a rural facility or vice versa, could create negative feelings and limit experiences. furthermore, loss of benefits could deter new, young nurses from staying more than 48 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 a couple of years in a rural community because of the commitment. nurses could be more inclined to try rural practice if they knew they could carry their benefits to another community. based on this interpretation, retention strategies need to address the portability of benefits outlined in the provincial collective agreement (2006). retention strategies could create an employment network between provincial hospitals, giving nurses the opportunity to transfer their employment status and benefits among communities. demographic factors, including place of nursing education, spouses’ occupation, and age act as “filter factors” (henderson-betkus & macleod, 2004). the majority of nurses who participated in this study were married, and were working in a small town because of their spouses’ job (henderson-betkus & macleod, 2004). the findings from the study suggest rural nurses, who are satisfied with their job and community, would leave a rural community if their spouse could not find employment in the area (henderson-betkus & macleod, 2004). similar to the ingersoll et al. (2002) study, henderson-betkus and macleod (2004) note older nurses are more likely to remain in rural practice, regardless of their level of job satisfaction. like the study by ingersoll and colleagues (2002), the relationship between age and retention was not determined by henderson-betkus and macleod (2004). however, one may suggest age has indirect influences on other “filter factors” identified in this study. age could have an effect on the number of family commitments made in a rural community, as older nurses could have more time to find a spouse, settle down, and have children. age could also have an effect on financial need, as older nurses may have more time to accumulate financial commitments. furthermore, age could have an influence on loss of benefits, as older nurses may have had more time invested with one employer; therefore, having more seniority and benefits at stake. going back to the australian survey of rural nurses in queensland, hegney et al. (2002a) found very specific personal characteristics and experiences that influence the decision to stay in rural practice. according to their survey, the most powerful predictor of retention is previous positive exposure to rural living and/or positive work experiences in rural areas (hegney et al., 2002a). the majority of participants agreed growing up in a rural community is a predictor of rural practice (hegney et al., 2002a). this finding is supported in rural physician literature, which suggests physicians are over two times more likely to practice in a rural area if they were raised in a rural community (easterbrook et al., 1999). however, henderson-betkus and macleod (2004) found education or training placements in rural areas are unlikely to predict similar long-term practice. the second most powerful predictor of rural practice, according to henderson-betkus and macleod (2004), is having family living in a rural area. also, personal feelings about wanting to raise a family in a rural area are considered predictors of rural practice (henderson-betkus & macleod, 2004). revisiting the comparison of canada, u.s.a. and australia, bushy (2002) found rural background and family connection to community are predictors of rural retention in all three countries. earlier work by hegney, pearson & mccarthy (1997) echoed this discovery in an effort to identify the role and function of rural nurses in australia. based on this research, hegney and colleagues (1997) suggest rural nurses are generally from a rural background and trained in urban education facilities. they become rural nurses because go back to work in rural areas for family or lifestyle reasons (hegney et al., 1997). these findings, along with findings from henderson-betkus and macleod (2004), go beyond retention strategies into the recruitment phase. these studies suggest, in order to retain nurses in rural areas, recruitment and training initiatives need to focus on people from small communities, and/or who want to raise families in rural areas. 49 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 retention strategies in british columbia in rural communities, where recruitment is increasingly complex, the first step in surviving the nursing shortage is to prevent existing rural nurses from leaving practice (muus, stratton, dunkin & juhl, 1993). the ministry of health (2006) in b.c. created a variety of rural nursing retention strategies, which address some influences outlined in this paper. professional development and making nursing education more accessible is one of the major focuses for the ministry’s rural nursing retention strategies (ministry of health, 2006). professional development, up-grading, specialty workshops, tele-health education and tuition reimbursement for nurses who want to work in rural areas, are all part of the ministry of health strategies (2006). the ministry has also dedicated funding to rural nursing research, and has provided research conference opportunities for nurses in rural communities (ministry of health, 2006). the ministry of health (2006) has also funded health authorities to increase management opportunities for nurses, include mentorship programs for new rural nurses, and improve shift scheduling. additionally, the ministry (2006) has funded initiatives aimed to increase the number of nurses in the workplace. special initiatives, including marketing and monetary incentives, have been established to recruit aboriginal students to nursing programs (ministry of health, 2007). more recently, the interprofessional rural program of b.c. was introduced, giving health care students the chance to do their practicum as part of an interdisciplinary team in a rural community (ministry of health, 2007). many of these retention strategies address influential factors identified in the literature, such as the need for professional development, maintenance of clinical skills, resources and professional support. the strategies deal with some of the factors that influence job satisfaction and retention, such as opportunities for management roles, tuition reimbursement, and mentorship. however, there are several factors identified in the literature, especially personal characteristics and experiences, that have not been addressed by these strategies, or that need to be further developed. recommendations based on the research findings, retention strategies need to include creating a more positive work environment for rural nurses. to improve the work environment, the ministry of health, as well as international policy makers, need to promote opportunities for professional interactions, team-based programmes, and professional support (chaboyer et al., 1999). work environments should encourage professional autonomy, job variety, counselling to deal with stress, and peer-feedback. furthermore, international decision-makers and policy-makers need to recognize different groups of rural nurses need different strategies (pan et al., 1995). for example, retention strategies need to address both younger and older nurses in different ways. retention strategies for married nurses need to address spousal employment, possibly creating professional development or training opportunities for spouses. international policies and retention strategies need to consider rural nurses’ family lives. if nurses have children, retention strategies should include recreation and education opportunities for children. retention strategies need to make post-secondary education more accessible to rural families. strategies should support family-friendly work environments, make work schedules more flexible, and provide daycare facilities (stratton et al., 1995; hegney et al., 2002). furthermore, retention strategies need to incorporate less on-call shifts for rural nurses (shader, broome, broome, west, & nash, 2001). international policies and retention strategies need to address both job satisfaction and community satisfaction (pan et al., 1995; henderson-betkus & macleod, 2004). the national 50 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 and provincial governments need to fund initiatives to help create social support networks for new rural nurses, such as sponsoring community integration activities and getting community members involved in retention strategies. furthermore, international policies and retention strategies should incorporate community development, making the rural community attractive to health care professionals (pan et. al., 1995). making rural communities more attractive could include improving schools, encouraging community events, and increasing community safety programs. international policies and retention strategies are the first step in dealing with the nursing shortage; however, recruiting nurses who will stay in rural areas is critical. local recruitment strategies need to target people who already have family and friends in the targeted rural areas, or people who have grown up in similar rural areas (hegney et al., 2002a). the ministry of health (2007) has recognized the need to recruit aboriginal nursing students, but increasing the number of rural residents who become health care professionals needs to be a focal point, as well. this could include further marketing campaigns, like nurses visiting rural high schools to promote the profession, and increasing the number of rural specific seats in nursing programs. retention and recruitment strategies should target nurses who have had positive past experiences in rural areas, and expand the interprofessional rural program of b.c. to allow for longer work terms. the ministry of health and other provincial governments need to identify nurses who are more likely to stay in rural practice, to inform recruitment. for example, research is needed to identify common characteristics and experiences shared by long term, rural nurses. the findings could inform recruitment initiatives. gaps in the literature although the research specific to rural nursing is growing, it is still very limited (macleod et al., 2004). research specific to rural nurses, job satisfaction and retention needs to be replicated and elaborated. further comparative studies between rural and urban nurses need to assess how retention strategies for rural and urban nurses may differ. meanwhile, more attention should be made to how different types of nurses (for example registered nurses versus public health nurses) differ in terms of job satisfaction, community satisfaction and retention in rural areas. many of the studies using surveys had poor response rates; therefore recommendations for future research would include larger sample sizes to improve validity. furthermore, qualitative research is needed to inform concepts identified in the literature, like “rural lifestyle” and how this may differ across regions (johnson, fyfe & snadden, 2006). conclusion in summary, this paper explores challenges facing the canadian rural nursing workforce. this paper describes the relationship between job satisfaction and retention, and briefly assesses the differences in job satisfaction and retention for rural and urban nurses. in addition, this paper discusses how both professional and personal factors influence job satisfaction and retention of rural nurses. the ministry of health (2006) retention strategies are examined and specific recommendations to improve british columbia’s retention strategies and international policies are made. this term paper highlights the need for nursing research to further investigate the inter-relationship between professional and personal factors in both retention and recruitment. 51 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 acknowledgements thank you to dr. cindy hardy at the university of northern british columbia for all of her guidance and support. thank you also to mary henderson-betkus for taking the 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[medline] ndiwane, a. (2003). the effects of practice location and work setting on job satisfaction of nurses. clinical excellence for nurse practitioners, 7(1-2), 27-33. pan, s., dunkin, j. muus, k.j., harris, r. & gellar, j. m. (1995). a logit analysis of the likelihood of leaving rural settings for registered nurses. journal of rural health, 11(2), 106-113. [medline] pong, r. & russel, n. (2003). a review and synthesis of strategies and policy recommendations on the rural health workforce. sudbury, ontario: centre for rural and northern health research, laurentian university. retreived feb. 13, 2007, from www.crnhr.ca poz, m. r. d., kinfu, y., dräger, s. & kunjumen, t. (2006). counting health workers: definitions, data, methods and global results. geneva, switzerland: world health organization, department of human resources for health evidence and information for policy. provincial collective agreement (april 4, 2004 to march 31, 2006). provincial collective agreement between health employers association of british columbia and nurses’ bargaining association. retrieved march 30, 2007, from http://www.bcnu.org/contracts_services/provincial_contract/pdf/bcnu_ca_060331.pdf shader, k., broome, m.e., broome, c.d., west, m.e. & nash, m. (2001). factors influencing satisfaction and anticipated turnover for nurses in an academic medical center. journal of nursing administration, 31(4), 210-216. [medline] stratton, t., dunkin, j., juhl, n. & geller, j. (1995). retainment incentives in three rural practice settings: variations in job satisfaction among staff registered nurses. applied nursing research, 8(2), 73-80. [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12021567%5buid%5d https://www.healthservices.gov.bc.ca/ndirect/nstrategies/ns_summary_0506.html http://www.healthservices.gov.bc.ca/rural/initiative.html http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8473927%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10646412%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10143271%5buid%5d http://www.crnhr.ca/ http://www.bcnu.org/contracts_services/provincial_contract/pdf/bcnu_ca_060331.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11324334%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7598520%5buid%5d 53 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 appendix 1 figure 1. the decision to stay of leave from “retaining public health nurses in rural british columbia: the influence of job and community satisfaction” by m. henderson-betkus and m. l. p. macleod, 2004, canadian journal of public health, 95(1), p. 54. community satisfaction filter factor: demographics filter factor: personal circumstances filter factor: opportunities job satisfaction decision to stay or leave nursing is said to be caring in the human health experience (newman, 1991) 94 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the value of story theory in providing culturally sensitive advanced practice nursing in rural appalachia cynthia denice gobble, msn, aprn, bc 1 1 phd student, school of nursing, west virginia university abstract this paper is based on the premise that nurses come to terms with the realities of patients by forming an understanding of their cultural viewpoints through embracing the person’s story. the author presents her journey in coming to understand the importance of attending to the patient’s story in the delivery of advanced practice nursing. highlights of the journey include: a reconstructed story of a women deeply immersed in the cultural and religious traditions of appalachia; literature on appalachian culture, religious practices, and beliefs; and story theory as a theoretical approach to guide culturally sensitive nursing practice. key words: appalachian culture, story theory, advanced practice nursing introduction the focus of nursing is caring in the human health experience (newman, sime, & corcoran-perry, 1991). each caring relationship is unique, as nurse and patient are both individuals, shaped by past experiences, environment, and the cultural orientation of their people. culture is the lens through which the world is viewed. when people of different cultures interact, each may find the other’s cultural perspective foreign and illogical. the human health experience is shared within the nursepatient relationship and the focus of the experience is the health concern of the patient. the nurse is called to visualize the experience from the patient’s point of view. story theory (liehr & smith, 2008) proposes a structure to guide the nurse-patient health promoting process. as the patient’s story unfolds, beliefs and values underpinning health choices are illuminated. the neomodernist perspective holds that all are born into the ongoing story of history (reed, 1995). every individual has a story, unique in its own right, which contributes to that history. nurses come to terms with the realities of the patient by forming an understanding of cultural viewpoints and appreciating the underlying values and meanings to which that particular culture gives voice. appalachian culture is unique to the rugged, mountainous region of the eastern united states. stereotypes of this culture range from the ridiculous to the romantic. the traditional, fundamentalist mountain religions practiced by many appalachians tend to be misunderstood. jones (1999) writes that “no aspect of appalachian life is as misconstrued and misrepresented as that of religion” (p. 401). appalachia is home to a number of mainstream religious denominations as well as independent self sustaining churches that are loosely affiliated with the church of god, pentecostal or holiness religions. despite the fact that the pentecostal movement originated in california and is now one of the largest and fastest growing denominations in the world, this religion is assumed by many to be an appalachian institution. church of god, holiness, and pentecostal churches may embrace religious practices such as snake handling, fire mailto:school%20of%20nursing 95 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 handling, and drinking of poisons (mccauley, 1995). some religious practices and beliefs that are accepted by many appalachians may seem peculiar to others. this paper is based on the premise that when these practices and beliefs are understood through story theory from the perspective of the patient, nurses will be better able to provide culturally appropriate care to appalachian patients. the paper will portray the author’s journey in coming to understand the importance of attending to the patient’s story in the delivery of advanced practice nursing. the following highlights of the journey will be presented: 1) the reconstructed story of a woman deeply immersed in the cultural and religious traditions of appalachia, 2) literature on appalachian culture, religious practices, and beliefs, and 3) story theory as a theoretical approach to guide culturally sensitive advanced practice nursing. molly’s story the story was gathered by the advanced practice nurse. first, molly wrote about her life in a rural appalachian coal mining community. then the story was developed further through dialogue in clinic visits. the story that follows is the reconstructed story created by the nurse while staying true to the patient’s voice. molly’s fifty years have been spent within twenty miles of the family home place, a rambling old house that was originally a shotgun style cabin, situated deep in the coal fields of appalachia. molly’s was the traditional appalachian family. her father was a coal miner, working for years in both union and non-union mines, usually underground where the coal seams were narrow. many of his working hours were spent on his knees. years of working “low coal” left him with arthritic knees and a perpetual stoop. molly’s mother was a homemaker and lay preacher in the local holiness church. molly recalls family stories of her mother’s activities in the church during molly’s younger years. her mother admitted a call to the ministry only in her later years, but attended prayer meetings in the homes of church members when molly was a little girl. prayer meetings held in homes were more informal than those held in the actual church building, and molly’s mother was actively involved in these more spontaneous, less structured gatherings. these meetings were often held in the homes of those who were too ill or incapacitated to travel to the church for formal services. in those days, many homes were heated by pot bellied cast iron stoves that burned coal. molly said that one home where prayer meetings were frequently held had a particular sort of coal burning stove. it was not a typical stove in that the sides were open and the coals were easily accessible. molly remembers people being touched by the spirit during the prayer meetings and dancing around this open stove and never getting hurt. the family told the story of the time molly’s mother was touched by the holy spirit and reached into this stove and pulled burning coals from the fire with her bare hand. she was unharmed. molly recalls her mother as a woman of great faith. molly remembers the praying at these meetings. the elders, preachers, and those who felt they had the gift of healing would pray and anoint the sick with holy oil. the holy oil had in turn been prepared for anointing by being prayed over by a group of church members. small squares of cotton cloth were anointed with holy oil or water and prayed over. then they were given to the physically or emotionally afflicted to wear as prayer clothes or talismans for protection against the evils and dangers of the world. molly’s mother was believed to have had the gift of healing and discernment. as a healer, the holy spirit would move upon her and she would lay hands upon the afflicted person, praying for god’s intervention. the afflicted would in 96 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 turn be touched by the holy spirit, and “fall out in the spirit”, dropping to the floor or the waiting arms of those praying for them. no harm came to them from the fall. it was seen as a miraculous experience. the gift of discernment allowed molly’s mother to look into the heart of an individual and determine if that person’s heart was truly focused on god or still leaning toward the world. when the holy spirit moved upon her it was not unusual for her to speak in tongues. molly’s mother was greatly respected by her fellow church members. in her younger years, molly’s mother did not believe in seeking the services of health care providers. she believed along with others in her church that turning to others indicated a lack of faith in god and his power to heal. this was a prime example of “leaning on the arm of man” instead of trusting god to do as he had promised. people who did go to health care providers were looked down on as lacking in faith, and faced a certain degree of shunning by those who held steadfast to the word. after her children were born molly’s mother became more tolerant of modern health care practices. while she and her husband continued to avoid contact with physicians, she did insist that the children have their immunizations, and took them to the local clinic when injured or ill. when molly was eight years old, she recalls assisting her mother in preparing the main meal of the day. the meal was taken at noon since her father worked the evening shift at the mine. molly spilled an iron skillet of hot lard over her left arm. she sustained serious burns and was ultimately taken to a neighboring state for skin grafts. although she retained full use of the limb, it remained puckered and scarred. her mother prayed for her recovery, while at the same time, did not hesitate in getting health care for molly. being very young, molly found these actions to be inexplicable. it seemed her mother acted on a double standard. she never questioned her mother as to why she would practice and preach faith healing but still insist that molly obtain modern health care. molly remained strong in her faith, and still believed her mother to be blessed by god to heal. yet in her mind and heart, there were questions, if not doubts. molly was baptized into the holiness church at a revival as a teenager. church was a social as well as spiritual gathering. daily life was centered on church events. molly attended sunday school, homecomings, foot washings and partook of the sacrament. as she matured, she too, was touched by the holy spirit and would speak in tongues. she did not acquire the gift of healing, but saw her music and writing abilities as her contribution to the church. her religious upbringing as a child would provide her with a much needed haven and support in the years to come. molly’s parents did not start seeking health care until late in their lives when they became afflicted with chronic and ultimately life threatening diseases. her parents continued to go to church and requested anointment and prayer regularly. they also began going to the local clinic for testing and treatment. her mother was diagnosed with breast cancer and had a double mastectomy. at one point, she was hospitalized and her prognosis was poor. she said that god came to her in the spirit and told her she would not yet die. molly’s father was diagnosed with prostate cancer. he was taken to a nearby hospital for testing. while there, a stranger offered to pray for him. the family did not know the man, and they never again saw him after that day. molly said that as the stranger prayed the cancer left her father’s body, and subsequent testing failed to find any indication of prostate cancer. molly’s father preceded his wife in death, and died of pneumoconiosis and lung cancer. molly’s mother lived for years after her breast cancer treatment, and told her children that god had promised her that she would die on the anniversary of her husband’s death. she died at home with pneumonia, and as she foretold, she died the same date of the same month in which her husband had died years earlier. 97 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 molly’s sisters married young and left the state. her brothers followed her father into the mines. she had an extended network of kinfolk living nearby. molly graduated from the local high school, and married her first and only serious boy friend. he too became a coal miner. molly held a job in her home community. during her young married life the mines were prospering and the coal miners’ union was at its peak. money was good and the town flourished. there were many stores, a hotel, car dealership, and even a movie theater. the local community health clinic was one of the best equipped and staffed in the state. the miners had excellent insurance coverage. her life seemed to be storybook complete. she and her husband bought a house and had a son and a daughter. they both continued to work. molly remained active in the holiness church, and her husband attended sporadically. she organized the church youth group, played electric bass in the church band, and directed seasonal dramas. her children were also active in the church. they grew up without mishap and graduated from the same high school their parents had attended. their son followed his father into the mines. the daughter married young and started a family. the cycle of mountain life was repeating. however, within the region things were changing. the coal industry was in a decline, and local mines began to shut down. the local economy was dependent on the coal industry. the distance between this region and industrial areas where jobs still were available made commuting difficult. there were no alternative jobs available for the men and women who had planned on working in the mines until retirement. people began to leave the area, following the promise of employment at distant mines or industrial centers. the local community health clinic scaled back its services and closed several adjunct clinics. molly and her husband were fortunate as both kept their jobs. over time, her husband became discontent and began an affair with a local woman. after the children left home, he asked for a divorce. devastated, molly gave in, allowing him to keep the house while she assumed legal responsibility for all of their debt. she filed bankruptcy and set about rebuilding her life. her faith in god bore fruit. her church became her primary source of support and her prayers were often answered. a church friend allowed her to buy the house she was renting, even though she was in the process of bankruptcy. because she had no household appliances, her church purchased new ones for her. her old car broke down and an out of state church acquaintance brought her a chevy sedan. molly saw the hand of god working though all of these things, and her religious beliefs were reinforced. although they were divorced, molly remained faithful to her husband, believing that he was her husband in the eyes of the lord, and that god would bring them together again. as the years passed, molly developed health problems. she had miners’ health insurance and access to health care. she held a lay persons knowledge of common health problems. sporadically she sought advice for her health care concerns. she was diagnosed with diabetes, hypothyroidism, hyperlipidemia, and hypertension. in addition, she became overweight. molly was prescribed appropriate medications and received advice on life style modifications that would slow progression of the diseases. molly would follow health care advice for a time; then for no apparent reason she would simply stop taking her medication and slip back into her old eating and living habits. she would continue on this course for a period of time, and then suddenly decide to resume her medications and life-style modifications, usually under the care of a different provider. over the course of years molly sought the advice of every provider working for the clinic. many providers found molly’s behavior exasperating. molly was intelligent and quite knowledgeable about her health care concerns. her behavior seemed inexplicable. 98 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 while in her late forties molly found a mass in one breast. given her mother’s history of breast cancer, molly had reason to be concerned. a nurse practitioner had recently come to work at the clinic, and as the sole woman on staff, had assumed the role of “female provider”, and was doing most of the women’s health exams. molly approached her in regard to obtaining a clinical breast exam and any further diagnostic testing and follow-up. a review of her chart revealed molly’s sporadic approach to personal health. periods of strict adherence to lifestyle modification and medication regimes alternated with long periods of non-adherence, which reverted back to adherence with a different provider. molly herself was quite frank with the nurse, admitting that she never continued with her plan of care as she was advised, even when she knew that the advice given her was sound. at one visit, molly’s chief concern was a palpable breast mass. she stated that she had a hysterectomy years ago due to fibroid uterine tumors and had not had a clinical breast exam or mammogram since that time. she did perform breast self-exams. the breast mass had been there for over a month. she knew that she should have a breast exam and mammogram and preferred the female nurse practitioner to perform the exam and order the necessary imaging. she again told the nurse that her mother had had a double mastectomy due to breast cancer. the nurse completed the exam and there was indeed a suspicious mass in one of molly’s breasts. arrangements were made for a mammogram. molly agreed to proceed as advised. she then told the nurse that she would be going to a prayer meeting at her church that night. she explained that she believed that god could heal her if she had faith. the nurse knew very little of faith healing, but saw no reason to alienate molly by voicing her doubts. they agreed that molly would go to her prayer meeting, but would also have the mammogram as planned. they would wait for the mammogram results before proceeding with a surgical consult. both were comfortable with this plan. the nurse saw molly at the clinic the next day, and molly asked to speak to her alone. she said that she had gone to a prayer meeting, and that a man had anointed her for healing and laid hands on her as he prayed. she felt the power of the holy spirit move upon her and fell out in the spirit. molly told the nurse that the mass was gone. god had healed her. based on the findings of the exam, the nurse was somewhat skeptical. personally she did believe in a higher power, but did not believe as molly did. the nurse also saw that this was very real to molly, and that the episode had meaning to molly that went beyond the specific matter of the breast mass. the nurse did not express her doubts as to the healing, but did ask if molly would mind telling her a little more about it. molly responded that she knew the nurse did not believe she had been healed. she did however tell the nurse the whole story of what had occurred the previous night. molly commented that the nurse was the first provider that had ever listened to her about her beliefs. molly agreed to follow though with the mammogram; although she now felt it was not needed. the mammogram report came back negative, and another clinical breast exam revealed that the mass had disappeared. molly thought her beliefs had been validated. the nurse thought that there was most likely a more scientifically logical reason for the disappearance of the mass. she kept her thoughts to herself, making no commitment one way or the other. the episode opened a line of communication between nurse and patient. molly became comfortable talking to this nurse about her life and beliefs and began to see the nurse for her health concerns. office visits became opportunities for molly to talk to the nurse. given that her belief in faith healing had a phenomenal effect on her attitude toward her personal health care, the nurse began to invite molly to tell her stories about her religious beliefs, especially those concerning healing. over 99 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 time the stories gave the nurse an idea of who molly was, and the importance of holding on to belief systems grounded in her early childhood. appalachian culture the need to understand molly and the other patients that she served led the nurse to seek out literature on appalachian culture. what she learned gave her a new perspective into the lives of both molly and the rural community in which she practiced nursing. culture is an integral part of the environment. culture is the learned, shared, and transmitted knowledge of values, beliefs, norms and life ways of a particular group that guides their thinking, decision making, and actions in patterned ways (leininger, 1995). it is the technologies, traditions, speech patterns and customs, habits and mythology that are shared by a specific group (shapiro, 1978). culture imparts a group identity bringing a sense of belonging to a people. culture is the context in which story is lived. appalachian culture was sculpted by both geography and the temperament of the original european inhabitants. early appalachian settlers often sought to avoid the religious, social, economic and political hierarchies of their previous environment. they were drawn to the isolation of the rugged mountainous appalachian terrain (jones, 1999; weller, 1965). this self imposed, geographically protected solitude created an independent people who were marked by individualism and bound emotionally to their mountain homesteads (jones, 1999). their cherished solitude instilled in them an inherent distrust of outside influence and contacts, and reinforced their adherence to traditional life ways (jones, 1999). the trials and hardship of life in the mountains was ultimately reflected in a fundamentalist spirituality that permeated the appalachian perspective (jones, 1999; mccauley, 1995). limited contact with and distrust of the outside world necessitated the formation of strong, complex networks of kinship, cemented by an elevated sense of mutual loyalty and family duty (jones, 1999) appalachia remains a patriarchal society, where men generally assume the role of provider and women tend to stay at home, raising the children and running the household. in times of illness the caregiver responsibilities are delegated to the women (stephens, 1994). the stereotyping of appalachians can be traced to the writings of travel journalists who came to appalachia looking for stories of interest at the turn of the 20 th century. they termed appalachia as wild and uncivilized, uneducated and godless, and highlighted the differences of the region from more urban mainstream america (shapiro, 1978). these writers focused on the poverty, illiteracy, and isolation of appalachian. mainstream churches began to send missionaries, social workers and educators to appalachia, hoping to bring salvation, civilization and education to this supposedly dysfunctional people (williams, 2002). in his 1965 book, yesterday’s people: life in contemporary appalachia, sociologist jack weller formalized this pessimistic view of appalachians. he found appalachian culture to be traditionalistic, tied to the old ways of doing things, and uninterested in progress or change. he saw a paternalistic society, focused on family and fundamentalist religious beliefs. weller wrote that appalachians had little use for authority, tended to be fatalistic in their outlook, unwilling to move forward on their own initiative, and tended to blame fate for the hardships and afflictions in their lives. weller’s work helped stereotype appalachian culture well into the 20 th century (shapiro, 1978). the more cynical writers continued to promote their version of appalachia, writing of ignorant hillbillies who went about life feuding and running moonshine. other writers took a 100 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 more romantic view. they wrote of stalwart mountaineers who carved a living from the harsh but majestic mountains (shaprio, 1978). through the 20 th century the media helped keep both stereotypes of appalachians in the public mind. television shows such as the beverly hillbillies and daniel boone reinforced both stereotypes. later, movies such as deliverance painted a dark, frightening picture of appalachia (williams, 2002). the discovery of coal and timber in the late 1899’s led to the wholesale purchase of appalachian land by outside economic interest. these corporations then offered the lands’ previous owners dangerous employment for scant financial return. in the coalfields, dangerous working conditions and low wages eventually sparked the development of the coal miners union and literal war with the outside owned coal companies (williams, 2002).the miners succeeded in obtaining better wages and safer working conditions. better roads, cheaper transportation, the media and internet have decreased the isolation of the region. in many areas the mines are now barren and persons needing gainful employment have left for the hopes of jobs in the bigger cities. despite the efforts of state politicians to bring new industry to appalachia, most of the area remains rural and many are unemployed or employed at minimum wage jobs without benefits (williams, 2002). lack of health care remains an issue in rural appalachia with limited access to existing health care facilities and few health care professionals willing to locate in the area. appalachian mountain religious beliefs evolved from the teachings of the original british borderland settlers who first came to appalachia seeking freedom from church authorities. the religious teachings and rites were primarily handed down from generation to generation in oral format (mccauley, 1995). the bible is taken literally, and much of the preaching is done by laymen who compose their own sermons and site scripture from memory. the ballads and hymns used in church services are often folk songs or the original compositions of congregation members. the independent mountain churches also tend to believe that if there is a god, then logically there is a devil. good and evil are not abstracts. god and the devil are distinct entities, and can interact and cause repercussions in the physical world here on earth. many believe that the devil is out to gain souls just as god is out to save souls. they believe in trying to live a pure life. some see illness and affliction as part of the devil’s actions on this world. in appalachian mountain religion: a history, mccauley (1995) notes that when nonappalachians are asked what comes to mind about religion in appalachia the most common answer is serpent handling. in reality appalachia is home to a variety of primarily protestant christian churches, as well as catholic, jehovah witness, jewish and wiccan organizations. central to appalachian religious beliefs is the nondenominational, independent mountain churches (mccauly, 1995). independent mountain churches may be affiliated loosely with holiness, pentecostal, church of god or baptist denominations; but church leadership, financing, and doctrine are decided by the congregation. while these churches vary in doctrine, most hold to similar rites. baptism by immersion, intermittent celebration of the sacrament, foot washings, and instrument enhanced music are common among many independent churches. the independent holiness, church of god, and pentecostal churches tend to believe in an active holy spirit that allows for faith healing, speaking in tongues, and physical transformation. when touched by the holy spirit, believers may dance, fall to the floor, or run the parameter of a building (mccauley, 1995). some believe that faith healing may be accomplished by individual prayer, prayer from the congregation or the anointment of the individual with holy oil or water. some churches are more traditionalistic than others, stating that women should never cut their hair or wear anything 101 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 but dresses. some are more extreme in their rites, which can include the handling of serpents, drinking of known poisons, or handling fire. while many mainstream americans believe these more extreme rituals to be common in appalachian churches, they are more the exception than the rule. most believe that this life is followed by judgment day and then eternity, which may be spent in heaven or hell, depending on choices made here on earth. the author’s journey in seeking a theoretical approach to guide culturally sensitive nursing practice led her to story theory. story theory story theory is connecting with self in relation through intentional dialogue to create ease (liehr & smith, 2008). the theory is based on the neomodernist view that humans are born into an ongoing story, or history (reed, 1995). life unfolds as personal stories, as humans interact with the environment and are shaped by experience. people are born into existing cultures, which provide belief systems on which an understanding of reality can be based. values are developed based on the beliefs of the culture, and influence thinking, decision making, and action (leininger, 1995). culture bonds humans together as groups, imparting a sense of belonging (shapiro, 1978). culture provides a basis for customs, traditions and lifeways (leininger, 1995). culture is the context in which each human story is lived. despite cultural similarities, no two persons share identical experiences or interactions with the environment. thus each person has a unique reality, and the telling of this reality is expressed as a unique story. if one holds the belief that the focus of nursing is caring in the human health experience (newman, sime, & corcoran-perry, 1991), then nurses need to understand that experience from the view of the patient. one can impart a view of this experience by telling a story. the nurse patient relationship is central to nursing practice. story theory provides structure for use of story within the nurse patient relationship, allowing the nurse to examine the experience of the patient from the patient’s perspective. viewing the experience from the patient’s perspective gives the nurse insight into what the experience means to that patient. it allows the nurse and patient to understand where the patient has been, where the patient is in the present, and the multiple possibilities open to the patient in the future. story theory makes three assumptions about persons: 1. change as they interrelate with their world in a vast array of flowing connected dimensions 2. live an expanded present where past and future events are transformed in the here and now, and 3. experience meaning as a resonating awareness in the creative unfolding of human potential (liehr & smith, 2008, p. 209). these assumptions ground the nurse’s understanding of the process of change as persons interact with the multidimensional environment. an integral part of the environment is the culture in which they are immersed. people live in the present, but past and future connect in the present to create meaning and act as a catalyst to direct change. the past and future color cultural beliefs. one’s culture is the lens through which beliefs and values influence decision making and guide health choices that determine the future. story theory is composed of three interrelated concepts: (1) intentional dialogue (2) 102 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 connecting with self-in-relation, and (3) creating ease (liehr & smith, 2008). intentional dialogue is the deliberate seeking of another’s story concerning a complicating health challenge. this goes beyond collecting facts and clarifying events. the objective is to focus on what matters most to the story-teller, from the perspective of the teller. the nurse listens in true presence, is nonjudgmental and open to differences. the nurse listens closely to the details while attending to the overall story. the nurse listens not only to what is said, but to what is not said. body language, silence, even the inclusion of something that does not at first glance seem pertinent may be part of the underlying meaning. intentional dialogue also includes understanding that the story is ongoing and will be told as the teller determines. a health care challenge may seem to have a clear beginning and end, but in reality it is connected to what has been and what will come. the patient may attempt to impart the whole story, but part will always remain untold. connecting with self-in-relation includes personal history and reflective awareness (liehr & smith, 2008). personal history is the story, the tale of how the patient came to be here and where the patient might be going. in reflective awareness, patient and nurse consider all aspects of the story, all roads that led to this place, and all roads that lead from this place. it is an expanded awareness not only of the roads chosen, but of roads that what might have been or still could be. it is a consideration of all possibilities. it includes a telling beyond actions and events. it is a telling of living a health challenge from the patient’s unique perspective. the concept, creating ease moves toward resolving a complicating health challenge. in re-membering, pieces of the story are brought together in making sense where meaning was once hidden or confused. flow in the midst of anchoring leads to a sense of security in newly understood meaning, with the awareness that life is dynamic and change moves us on (liehr & smith, 2008). it is taking the newly understood meaning and moving forward into the future, with a sense of serenity born of accepting the past as part of being, and moving forward with a newfound sense of purpose and understanding. discussion molly’s complicating health challenge was choosing in the context of deeply rooted religious convictions and established health practices. given molly’s circumstances, it was not lack of opportunity, resources, motivation, or knowledge that kept her from following though with the medication regimen and lifestyle modifications that were central to maintaining her health. it was the stronghold of her religious convictions and cultural practices. as culture imparts the values and beliefs that guide thinking, decision making and action; it was imperative to understand her dilemma in choosing. the literature provided a basic understanding of appalachian life-ways and story expanded an understanding of molly’s world. molly’s story makes it clear that she is a product of her culture. born and raised in the mountains, she has never seriously considered living anywhere else. the concept of home has deep meaning for her, including not just the geographical landscape, but the network of kin and friends that she has known all of her life. molly has and is living her role as daughter, wife, mother and now grandmother. she follows the traditional ways of her people, polite but distrusting of outsiders, and fiercely proud and protective of her kin. her religious experience includes: being touched by the holy spirit, speaking in tongues, prayer meetings, and anointment with holy water. despite the divorce she still considers her marriage valid, and is faithful to her husband despite the efforts of others to get her to socialize and meet prospective mates. she also 103 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 remains an independent woman, working a full time job to meet her financial obligations while shouldering family responsibilities and remaining active in her church and community. it was important to develop a nurse patient relationship that allowed for open communication. a nonjudgmental approach, which did not ridicule or disregard molly’s beliefs, was imperative. rather than taking a stance for or against her religious beliefs, it was made known that the nurse had an open mind, and would not condemn or patronize molly for holding to her beliefs. the nurse patient relationship was built on mutual respect. once molly was comfortable in the nurse patient relationship, she was free to discuss things that she formally would not have discussed with other health care providers. through intentional dialogue, conversations were deliberately guided toward the issue at hand. molly was encouraged to talk about what mattered to her most, and it soon became clear that relationships with her mother and god had a strong hold on her approach to health care. connecting with self-in-relation includes personal history and reflective awareness (liehr & smith, 2008). in telling her personal history, molly revealed that her relationship with her mother had been an important one. molly returned again and again to the subject of her mother’s religious convictions. it was clear that her mother was a dominant figure in her life. molly revered her mother, holding her to be the epitome of strength, faith, goodness and womanly virtue. most of the stories molly told of her mother involved the church or faith. many of those stories are related to health or healing. in her youth, molly’s mother was her caregiver, tending to illnesses, taking her to both doctors and church in search of healing. she had witnessed her mother’s healing touch again and again. her mother taught her that god could heal all things, yet her mother utilized the health care system for molly and her siblings. toward the end of her life, her mother turned to the health care system for her ailments. this was a contradiction. molly was aware of it. in creating ease, the nurse and patient tie things up and move toward acceptance and change (liehr & smith, 2008). the telling of her story to the nurse gave molly a safe arena in which to express her beliefs. in re-membering over time, molly brought the pieces of her past together. she recognized the conflict between her religious beliefs and what she found to be true in the world. she came to understand that she had the tendency to see the situation in black and white. if one had faith, god would heal. therefore there was no need for health care, as long as one had faith. molly could not doubt her mother’s faith. she did however, doubt her own. at times, molly believed she lacked the faith necessary for healing. other times she saw her illnesses as a burden god had placed on her, and thought it was a test of her faith to bear them. she often felt guilt and remorse no matter which path she chose. on the one hand she believed she was failing god; on the other hand she believed she was failing herself by not following health care advice. application of story theory guides the movement toward resolution, but also acknowledges that one’s story continues even as it is being told. molly shared her story over the course of many office visits. while she saw the nurse more frequently than she had the other providers, she still on occasion would stop her health care treatment and rely solely on faith. when she did return for treatment she no longer experienced the need to change providers, and would return to the nurse who understood the evolving story plot, thereby keeping continuity of care and reaffirming the nurse–patient relationship. as nurse and patient came to know each other molly was comfortable bringing additional pieces of her story to the nurse patient dialogue. she found it helpful to pray prior to making any major health related decision, and eventually said short prayers in the office. she continued to pursue her faith healing practices, keeping the 104 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 nurse aware of both victory and disappointment. molly’s story lives on and in the evolution of the story, the nurse has become a significant person in helping her to resolve dilemmas in health care choices. conclusion this scholarly journey of a nurse practitioner into the realm of religious and cultural perspectives and middle range theory offers a model for advanced practice nursing. story theory (liehr & smith, 2008) in nursing practice gives structure to using story to view the world from the patient’s perspective. an understanding of culture and religious beliefs provides understanding of the context in which the story unfolds. listening attentively to what matters most in dialogue enables the caring/healing process that is essential to promoting health. references jones, l. (1999). faith and meaning in the southern uplands. chicago: university of illinois press. leininger, m. (1995). transcultural nursing: concepts, theories, research, and practice. blacklick, oh: mcgraw hill. liehr, p.r., & smith m.j. (2008). story theory. in m.j. smith & p.r. liehr (eds.), middle range theory for nursing (pp. 205-224). new york: springer publishing. mccauley, d. v. (1995). appalachian mountain religion: a history. chicago: university of illinois press. newman, m.a., sime, a.m., & corcoran-perry, s.a. (1991). focus of the discipline of nursing. advances in nursing science, 14, 1-6. [medline] reed, p. (1995). a treatise on nursing knowledge development for the 21st century: beyond postmodernism. advances in nursing science, 17, 70-84. [medline] shapiro, h.d. (1978) appalachia on our mind. chapel hill: university of north carolina press. stephens, c.c. (1994). health beliefs and practices of rural, southern appalachian women from an ethnographic perspective. unpublished doctoral dissertation, university of alabama, birmingham, al. weller, j. e. (1965). yesterday’s people: life in contemporary appalachia. lexington: university of kentucky press. cynthia denice gobble – 1958-2009 on a cold winter morning, in a rural coal mining community, family and friends gathered in a chapel to celebrate the life of cynthia denice gobble who died on january 5, 2009. the pastor spoke lovingly of a quiet yet determined woman who dedicated her life to serving others in rural appalachia. her life story was characterized by a deep faith that served as the foundation of her love for rural people and rural places. she cherished the appalachia way of life and was passionate about upholding beliefs and traditions. she held closely those she served as nurse and spoke of them as “my people”. tributes in the chapel reflected denice’s love of knowledge, strong connectedness to west virginia university, and long history in nursing. a master’s degree diploma, a statue of florence nightingale, a blue and gold wvu throw, a handmade http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1819254%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7778892%5buid%5d 105 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 quilt, and flowers adorned the chapel. at the time of her death she had completed all of the course work to earn the doctor of philosophy degree in nursing. this paper gives voice to her tireless journey to integrate theory, practice and research. it is published here to honor her commitment to contribute to the development of nursing science in promoting the health of rural people. this paper serves as a part of her legacy: a gift she leaves to her family, patients, colleagues, classmates, and faculty. for information about this article, please contact: mary jane smith, phd, rn professor and associate dean school of nursing west virginia university mjsmith@hsc.wvu.edu mailto:school%20of%20nursing mailto:mjsmith@hsc.wvu.edu editorial 6 editorial an australian perspective desley hegney, phd editorial board member well, winter is nearly past and we are now moving into spring. here in queensland we are still desperate for rain, but are told that it is coming soon. nursing in australia now seems to be attracting attention in a way it has not done so before. from a federal perspective, whilst we still have no action on the two reviews of nursing published in 2002, we have achieved some wins in the last federal budget. for example, there have been set aside more places in universities for nursing in 2004 (these places are only for regional universities) and an increase in the funding for clinical placements. these initiatives are a start, however, a lot more is needed to be effective. for example, in the 1999 nursing labour force data released by the australian institute of health and welfare (2003) indicate: • an overall increase in workload in the hospital setting (measured by number of hospital separations) – from 5.3 million in 1995-96 to 6.0 million in 19992000; • there was a slight increase (0.5%) in the number of nurses registered and enrolled in australia since 1997, however the numbers were still lower than in 1993; • the overall increase in the number of employed nurses was accompanied by an increase in the proportion of nurses working part-time, from 46.8% in 1993 to 53.8% in 1999 and a decrease in average hours worked per week from 32.2 hours to 30.3 hours. • the nursing workforce is ageing. for example, between 1993 and 1999 the average age of nurses rose from 39.5 years to 41.6 years; • the number of australian students completing basic nursing studies deceased from 6397 in 1993 to 4465 in 2000; • the number of australian students commencing basic nursing studies decreased from 8010 in 1993 to 7195 in 2000. in australia, however, it is usually the state/territory governments or private employers who are the main employers of nursing. hence, nursing has not had a nationally focused plan. instead, each state/territory has introduced varying schemes to attract and retain nurses. as many nurse leaders in australia have said, there is no point in increasing the number of nurse graduates if the workforce conditions are so poor that they do not remain in nursing. on a positive note, the introduction of nurse practitioners in australia is now progressing well. here in queensland, where things move more slowly – maybe it is the tropical weather, we have just completed the trials for nurse practitioners. the final report is at present with the director general of health, so i am unable to provide details of online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.aihw.gov.au/publications/index.cfm?type=detail&id=7029 http://www.aihw.gov.au/ http://www.aihw.gov.au/ 7 recommendations. it is unlikely, however, that queensland will not follow the other states and introduce models of nurse practitioners. with regard to nursing research, again there is beginning to be a greater interested shown in clinical research by nurse clinicians. one needs to remember that the majority of our nurse clinicians have trained under a hospital program, where we we taught to be obedient and not question the wisdom of other nurses, medical practitioners or allied health professionals. fortunately this has changed and exciting research which is driven by the needs of the clinicians is increasingly being carried out. for example, at the university of southern queensland, we have just completed a partnership with the toowoomba health service where we have become a collaborating centre of the joanna briggs institute for evidence based practice. we have held a workshop for those clinicians interested, and now come up with five topics which the clinicians believe should be the focus of a systematic review. whilst those in the united states might have been undertaking this sort of activity for years, it is really exciting to see research interest in our rural nurses. as i sit in my office and look at the gum trees swaying in the breeze and note the magpies and parrots holding on, i realize that soon the westerly winds which we experience at this time of the year will pass, as will the colder weather we have had during winter. i always feel so hopeful at this time of year as trees begin to bud swell and burst into flower; the winter-sown wheat crops begin to mature; and there is an abundance of lambs and calves in the paddocks. i think about my colleagues on the other side of the world who are probably looking at leaves colouring and falling and beginning to experience the loss of the sun to the southern hemisphere. never mind, we will share it with you again in six months time!! online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 rural boundariesstudent perspective 5 preceptorship rural boundaries: student perspective olive yonge rn phd1 1professor & vice-provost academics, faculty of nursing, university of alberta, olive.yonge@ualberta.ca key words: nursing education, nursing students, boundaries and education, preceptorship abstract this is one part of a grounded theory study that explored the perceptions of both students and preceptors regarding the student-preceptor relationship in a rural setting and the boundaries that must be developed to ensure it is successful. the success of preceptorship lies largely with the preceptor-student relationship and thus, the importance of developing and maintaining professional boundaries is paramount. this is particularly key in rural settings where boundary issues are explicit and challenging and the physical presence of a faculty instructor is often an impossibility. this article will focus on the perceptions of seven nursing students and is the first grounded theory study exploring nursing students' perceptions of learning and boundaries in a rural setting. the resulting core variable was learning and the psychosocial processes were the relationship they formed with their preceptors and members of the health care team. students were highly professional and respected boundaries in their relationship with team members. introduction if there’s anything blocking that relationship, or the relationship has crossed a boundary where you’re friends and you’re not within a professional boundary, then some things can get missed, and maybe i might not be evaluated as strictly as maybe i should be or something. the establishment of a professional relationship between student and preceptor is integral to the preceptorship experience as well as the transition from student nurse to practitioner. implicit in the development of a professional relationship is the formation and maintenance of professional boundaries. the importance of these boundaries is heightened in a rural setting where practitioners work within a small community where visibility is high and confidentiality difficult to maintain. the lack of professional resources makes this challenge that much greater. additionally, faculty support is limited by distance constraints and thus students and preceptors in rural areas who have greater awareness of boundary issues are left without this important source of support. thus, this research aims to understand how professional boundaries are understood in the rural setting and how they are developed and maintained within the student-preceptor relationship. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.uofaweb.ualberta.ca/nursing/ mailto:olive.yonge@ualberta.ca 6 significance of the research nursing shortages have had devastating effects on rural areas and thus it is imperative that education institutions take responsibility for developing recruitment strategies to these areas. for recruitment to be successful, positive work experience in a rural area is cited as a strong factor in influencing graduates to choose rural employment (neill & taylor, 2002). thus, the concern for the educational institution and rural facility is to ensure an effective preceptorship experience. the determinant for a positive experience is largely the student-preceptor relationship and implicit in this relationship are the development and maintenance of professional boundaries. the need for the development of these boundaries is paramount in a setting which relies heavily on teamwork and exists in a small, isolated community where visibility is high and confidentiality low. as there has been little exploration of these issues, this research seeks to identify the processes by which professional boundaries are set, challenges that arise in relation to boundary issues and other factors that determine a positive rural placement experience. review of the literature the literature has discussed rural preceptorship placements as an educational strategy designed to address rural nursing shortages (bushy & leipert, 2005, edwards, smith, courtney, finlayson, & chapman, 2004, van hofwegen, kirkham & harwood, 2005, neill & taylor, 2002). nursing shortages have a devastating impact on rural areas (neill & taylor, 2002) particularly for women and children (bushy & leipert, 2005). bushy and leipert (2005) assert that “the intrinsic value of having an adequate number of adequately prepared nurses in rural communities cannot be overstated”. it has also been found that graduates are more likely to seek employment in areas where they have had previous positive experience (talbot & ward, 2000). students choosing a rural employment most likely have rural backgrounds which have influenced their desire to pursue a rural lifestyle, however, strategies may be developed to provide students with urban backgrounds ‘rural experience’ prior to graduation (edwards et al., 2004). additionally, as the majority of clinical placements are centered in urban areas and as nursing graduates are generally unprepared for rural practice, it may be necessary to give students rural exposure or training in rural nursing theory before the opportunity to select placements arises (edwards et al., 2004). however, neill and taylor (2002) found that 59% of their sample chose rural or remote employment after graduation following a rural clinical placement. though rural areas typically face challenges unique to the rural setting such as isolation, fewer health services, lack of updated resources, and a unique community structure, these paradoxically become assets to student learning and provide a rich variety of learning experiences (van hofwegen et al., 2005). although presenting students with the issues of confidentiality in a small community and isolation from health service colleagues and resources, students are given the opportunity to become ‘expertgeneralists’ and generally are offered a greater variety of learning experiences in the rural placement setting (bushy & leipert, 2005). consequently, students reported greater confidence, competence and organizational skills both prior to and following a rural online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 7 placement experience (edwards et al., 2004). in terms of education for community health, authors suggest that a rural placement offers students the ‘big picture’, giving them the view that they are nursing not merely an individual, but a community (neill & taylor, 2002). the rural setting is a nontraditional and innovative setting for learning concepts such as population health, health promotion and community development (van hofwegen et al., 2005). furthermore, the rural setting allowed students to live and participate in the community in which they worked, giving them a sense of the community structure and the pattern of rural life (van hofwegen et al., 2005). edwards et al. (2004) discovered that students improved their skills for rural work, appreciated the variety implicit in such an experience and increased their awareness of opportunities in rural placements and employment. students that tend to choose a rural placement do so based on personal lifestyle choices, professional goals and personal financial, family and employment situations (bushy & leipert, 2005; edwards et al., 2004). one major obstacle for students pursuing a rural placement is the financial burden involved in relocating to a rural area, transportation and the inability to continue part-time employment (edwards, courtney & finlayson, 2001). thus, it is necessary that adequate financial support be made available for students during these clinical placements (neill & taylor, 2002). lastly, students reporting high levels of confidence and competence in their abilities prior to their placement experience were more likely to choose a rural placement, reflecting the perception of rural nursing as a specialty requiring high levels of initiative, competence and self-confidence (edwards et al., 2004). thus, incorporating rural theory and practice perspectives into nursing curriculum, inviting rural practitioners as guest lecturers to speak with students, and exposing students to the rural context through short-term placements are suggested strategies that may increase familiarity and confidence, encouraging more students to choose a rural placement (bushy & leipert, 2005). there is very little research either on the preceptor-student relationship while in the rural placement setting nor on boundary issues that may arise. thus the research question for the students was, "how do you create and maintain professional boundaries while learning nursing in a rural setting?" methods seven nursing students in their final clinical placement were recruited through inclass presentation and asked to participate in the study. written consent was granted before interviews commenced and before transcripts were released to researchers. permission was granted from the dean of the faculty of nursing and the ethics review committee. data was collected through semi-structured interviews following an interview guide consisting of open-ended questions. this helped to facilitate participants’ freedom of response and allowed for the researcher to clarify responses. to reveal “what is actually going on rather than what ought to be going on”, the researcher chose a grounded theory method (glaser, 1978, p. 14). two reasons that support the use of grounded theory is the general lack of research in the area of preceptorship particularly in the area of boundary formation and the need for more online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 8 middle-range theories in nursing education that can be empirically tested (streubert & carpenter, 1999). to maintain rigour, four specific criteria were used: credibility, fittingness, auditability, and confirmability (guba & lincoln, 1989). preceptors reviewed transcripts, two independent external researchers reviewed the transcripts for themes, participant observation was used and field notes captured when saturation was achieved. the limitations for grounded theory are the inability to generalize to other settings. the data captures the experience of these nursing students at a particular moment in their program. sample seven female students in their final year of a four-year bachelor of science in nursing degree were interviewed. their work experience in the field of nursing was primarily in acute care in the context of university placements, though they had limited experience in the emergency, maternity, surgery, community and mental health. they were completing their final clinical placement of 340 hours at various rural hospitals and community health centres. results the core variable for the student was learning. they viewed the rural location as an excellent opportunity to learn everything from everyone. given this was their last course prior to graduation, they realized this was their last opportunity to say "i am only a student nurse". they soon would become registered nurses and hoped they would be ready to assume the responsibilities concomitant with this title. the psychosocial process was the relationship they formed with their preceptor and the rest of the healthcare team. through these relationships they gained entry into learning about nursing and health care systems. they had a high level of professionalism recognizing they would be evaluated by their preceptors and so needed to be friendly with them but not their friend. she would start by easing back a bit, and then just kind of watching over me, standing in the room and watching what i’m doing, pointing out anything i’m missing, and now it’s got to the point where she just stays out and only comes if i need her. i think that is making me feel more selfconfident, being alone, but i always know that she’s there. a major theme that emerged regarding the role of the preceptee was students felt their goal for the experience was to achieve independence, they were responsible for learning as much as possible and they often had to pursue learning opportunities proactively. one student expressed her goal as “learn as much as i can”, and stated that as “a student, i kind of have to get in there and learn what i want to learn”. the preceptor was viewed as a guide after whom they were to model practical methods and professional behaviour. two students spoke of the preceptee role as a dynamic one, stating “the first day it was to get in the way as much as possible. . . [now] we’re a very strong team.” online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 9 when it comes to learning, sure, i’m still her student, i’m still learning, i’m still green, i’m still wet behind the ears, but she treats me as a colleague and a professional. as a student nurse, she swaddles me a little bit and helps me do growing and all those sorts of things. that’s part of our professional relationship. regarding the learning/teaching process, the students described any planning, discussion, implementation or evaluation of tasks as very informal. in many situations learning experiences were merely spur of the moment with little opportunity for planning or evaluation. however, all students stressed good communication as essential for building a working relationship and fostering a team-work environment as compensation for the lack of formal discussion time and space. one student particularly noted the lack of time to evaluate and reflect and dealt with a difficult day by “going home and thinking about things and having a good cry. . . there’s no sounding room for that [at the hospital]”. if something comes in interesting, they’ll let me watch, and then the next time that same thing comes in, i can be expected to beor feelconfident enough to take part in the situation and not just stand back and watch. students were taught in a three-step process. firstly by watching the preceptor perform the task and occasionally complimenting this knowledge with background reading or a reference. secondly, the student would perform the task under the preceptor’s supervision. lastly, the student was able to complete the task independently using the preceptor as a resource person. many students appreciated constant constructive feedback so as to know “how they were doing”. nearly all students noted that they were “comfortable” in their role as a student nurse and felt that they could ask questions when unsure and set limitations on what they felt capable performing. one student described a situation where a doctor asked her to perform a task in his place. with coaching from her preceptor, she was able to set boundaries on what she felt uncomfortable performing. i thought you’d have to be very professional. but it just developed to the point . . . she almost treats me like her child . . . very caring. if i’m sick, she’s phoning and making sure everything’s okay. she’s just like such a mother to me or a mother-nurse. . . always looking out for my best interests. another major theme that arose was that although professionalism must be maintained, students stressed that a personal relationship must also coexist in this type of working environment. one student noted however, if “the relationship has crossed a boundary where you’re friends . . . then some things can get missed, and maybe i might not be evaluated as strictly”. factors that promoted a positive professional relationship were primarily related to communication and honesty. some of the students also stressed the need for personalities and learning styles to match. most students expressed the wish to keep in touch with their preceptors, frequently acknowledged their preceptor as both a online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 10 teacher and colleague in the form of small gifts, lunches and encouragement, but most restricted personal disclosure to a level appropriate for a professional setting. they’ve been really thoughtful and respectful to my learning in offering me a lot of different experiences. four of the students had requested rural placements or recognized their rural experience was unique in that it allowed them to “get a taste of everything”. one student characterized urban hospitals as being “segmented” into specialized teams and appreciated the breadth of experience her rural placement afforded her. a couple of students recognized the possibility for recruitment to rural areas, but insisted that successful recruitment depended more on lifestyle choice and location of family. some of the challenges the students identified in the rural setting included gossip, culture bashing (i.e. natives), and occasional lack of updated resources. one student noted, “i ran into so many people at superstore and stuff that i worked with hereclientsand it’s just different”. discussion surprisingly, unlike the focus of all the current literature that has studied rural placements, none of these students had employment opportunities in mind nor were they aware of their placement as a recruitment strategy. they were instead focused on their role as a preceptee and recognized the ultimate goal of any preceptorship experience as the achievement of independence as a graduate nurse. thus, they actively sought learning opportunities. the desire for students to experience the widest range of learning experiences could be capitalized upon for recruitment to rural placements as they can offer the ‘generalist’ perspective of nursing (bushy & leipert, 2005, van hofwegen et al., 2005). students appeared to be highly aware of professional boundaries within the preceptor-student relationship. their anecdotes also highlighted the importance of setting these boundariesfor instance, in the scenario between the doctor and the student, the student nurse was encouraged by her preceptor to set limits upon the tasks she could safely and comfortably perform. another area where students recognized the importance of professional boundaries was the area of evaluation. although a friendly working relationship creates a good working environment, the shift from friendly to ‘friends’ may entail a biased evaluation and an inaccurate assessment of a student’s nursing abilities. in areas where boundary crossings are commonsuch as gift-giving and self-disclosure students maintained a level of professionalism appropriate to their workplace. however, these minor boundary crossings should not be seen as negative, but as paving the way for a mentoring relationship to form, further influencing a student to consider rural employment. students generally identified the rural placement as unique both in the opportunities and challenges it presented them (van hofwegen, 2005). however, they felt that factors such as family, the employment of a spouse or lifestyle choice were much more important factors when considering rural employment than their professional experience. this is supported in the literature with students from rural backgrounds and online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 11 students who value rural lifestyle opting for rural employment (bushy & leipert, 2005, edwards et al., 2004). conclusion the opportunities for recruitment to rural areas cannot be explored without giving students an appreciation for the uniqueness and benefits of working in a rural setting. promoting rural nursing theory and exposure within undergraduate programs may encourage a greater number of students to choose rural placements and for those that do, give them a greater awareness of the opportunities their placement has to offer. however, once in the placement setting, both students and preceptors must be made aware of boundary issues, especially in the rural context, to create a positive studentpreceptor relationship. it is this relationship that has the greatest power to influence students while they gain their rural work experience and to sow the seeds for a continuing mentoring relationship that could make the possibility of rural employment much more enticing. however, the key is in the relationship as reflected in this student’s words: i’ll miss her a lot. she’s just been so good to me. she’s so caring and patient. i think that i would never lose contact with her completely, and i’d always like to just stay in touch with her. acknowledgments the author would like to acknowledge the following for their assistance: the university teaching and research fund, and quinn grundy, research assistant. references bushy, a., & leipert, b. (2005). factors that influence students in choosing rural nursing practice: a pilot study. rural and remote health, 5, 387. [medline] edwards, h., smith, s., courtney, m., finlayson, k., & chapman, h. (2004). the impact of clinical placement location on nursing students’ competence and preparedness for practice. nurse education today, 24, 248-255. [medline] glaser, b.g. (1978). theoretical sensitivity: advances in the methodology of grounded theory. mill valley, ca: sociology press. kaviani, n., & stillwell, y. (2000). an evaluating study of clinical preceptorship. nurse education today, 20(3), 218-226. [medline] neill, j., & taylor, k. (2002). undergraduate nursing students’ clinical experiences in rural and remote areas: recruitment implications. australian journal of rural health, 10, 239-243. [medline] öhlring, k.h., & hallberg, i.r. (2000). nurses’ lived experience of being a preceptor. journal of professional nursing, 16, 228-239. [medline] smith, s., edwards, h., courtney, m., & finlayson, k. (2001). factors influencing student nurses in their choice of a rural clinical placement site. rural and remote health, 1(1), 89. [medline] online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15885026%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15110433%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10820576%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12230431%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10932997%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15869369%5buid%5d 12 streubert, h.j., & carpenter, d.r. (1999). qualitative research in nursing: advancing the humanistic imperative (2nd ed.). new york: lippincott. talbot, j., & ward, a. (2000). alternative curricular options in rural networks (acorns): impact of early rural clinical exposure in the university of west australia medical course. australian journal of rural health, 8(1), 17-21. [medline] van hofwegen, l., kirkham, s., & harwood, c. (2005). the strength of rural nursing: implications for undergraduate nursing education. international journal of nursing education scholarship, 2, article 27. [medline] online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11040575%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16646922%5buid%5d 12 characteristics of rural women who attended a free breast health program adrianne j. lane, edd, rn, c1 madeleine martin, edd, rn2 1 professor of nursing, college of nursing, university of cincinnati, adrianne.lane@uc.edu 2 professor of nursing, college of nursing, university of cincinnati, madeleine.martin@uc.edu keywords: rural women, breast health, mammography, self breast exam, rural health, underinsured abstract rural women are particularly at risk of dying from breast cancer, because they do not take advantage of screening procedures that are readily available to their urban counterparts. the purpose of this non-experimental study was to explore characteristics of rural women who attended a free breast health program that included self breast examination education and free mammography. the organizing conceptual framework was the precede/proceed model. five hundred and seventy-five women who lived in four rural midwestern counties participated by completing a questionnaire. results revealed predisposing factors included knowledge of and desire for breast health behaviors, enabling factors included lack of resources to pay such as insurance and adequate income, and reinforcing factors included physician recommendation and self reassurance. data support the need for a continued focus on breast health programs in rural communities. recommendations for future studies include hypothesis development and intervention strategies that strengthen breast health in rural women. introduction the factors that affect breast health behaviors of rural women are largely unknown. two advanced practice nurses, whose practice focus is rural women and health promotion behaviors, examined data to identify characteristics of rural women who attended a free breast health program. consideration of these characteristics according to the precede/proceed model may lead to targeted intervention to improve breast health behaviors. breast cancer is the second leading cause of cancer death in the u.s. and the most commonly diagnosed malignancy in women. over 80% of breast cancer cases can be cured if cancer is diagnosed and treated in its early stages (acs, 2004; white, e., urban, n., & taylor, v., 1993). maximizing the percentage of women who overcome this disease is currently dependent on routine, regular breast screening. the american cancer society predicts in 2004 greater than 40,000 women will die from breast cancer and nearly 216,000 new cases of breast cancer will be diagnosed. mammography has been found as the best way to detect breast cancer in its earliest stage – on an average 1-3 years before a woman feels a lump in the breast self-exam. it also isolates tumors too small to be felt during clinical breast exam. dr. hugh hawkins (2001) reported that mammography has decreased breast cancer mortality by 30-45%. rural women are particularly at risk of dying from breast cancer, because they often do not take advantage of screening procedures that are readily available to their urban counterparts. a wellonline journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.nursing.uc.edu/ mailto:adrianne.lane@uc.edu http://www.nursing.uc.edu/ mailto:madeleine.martin@uc.edu 13 developed body of knowledge regarding barriers to breast cancer screening for urban women is present in the literature (miller, a. & champion, v., 1993; miller, a. & champion, v., 1996; zapka, j., stoddard, a., costanza, m., & green, h., 1989; zapka, j., chasan, l., barth, r., mas, e., & costanza, 1992; danigelis et al. 1995; and kim, y. & sarna, l., 2004). although a number of studies have focused on rural women (love et al. 1993; earp et al. 2002; valdini, a. & cargill, l., 1997; and andersen, m., hager, m., celina, s., & urban, n., 2002), the factors that affect breast cancer screening are unknown for rural women who lack access to publicly funded clinics, lack access to diagnostic facilities and/or who lack the ability to pay. literature review healthy people 2010 identified access to quality health services (objective 1), cancer (objective 3), and educational and community-based programs (objective 7) as focus areas. healthy people 2010 also outlined several strong predictors of access to quality health care: having health insurance, a higher income level, and a regular primary care provider. a key indicator related to access to quality health care has been found to be the use of preventive services. the report further identified barriers to access as financial (no insurance, inadequate insurance), structural (lack of providers and/or facilities), and personal (language, not knowing when or what to do, cultural or spiritual differences, or concerns about discrimination or confidentiality). reasons that prevent rural women from seeking breast cancer screening behaviors may extend beyond access alone. zhang, tao, and irwin (1993) found that differences did exist between rural and urban women in their use of preventive services, particularly mammography. calle, flanders, thun, and martin (1993) analyzed responses from 12,252 women who participated in the 1987 national health interview survey cancer control supplement and reported that the most underserved profile was rural women at 200% of poverty and aged 40 to 49. for this group of women greater than 85% had never had a mammogram. although national rates for women receiving mammograms within the previous 2 years are 84.6%, the rates for all rural poor are now estimated at 50% (cdc, 2000). these rates are reinforced by the health and human services report that more than 20 million rural residents in america have inadequate access to healthcare (2001 fact sheet). the employee benefit research institute reported that the number of uninsured americans continues to grow with current estimates in excess of 42 million non-elderly (2000). the percent of uninsured and underinsured rural americans is at 24% compared to urban americans at 18% (brand, 2004). hafner-eaton (1993) reported that uninsured adults underwent fewer screening services for cancer and himmelstein and woolhandler (1995) found that uninsured adults present with later-stage diagnoses of cancer due to lack of early screening. in 2003, the lowest mammogram prevalence percentage was women with no health insurance at 34%, followed by women with less than a high school education at 49% (cdc, 2003). reports from the cdc in 2003 continue to support the findings of the early 1990’s: screening of the uninsured remains a healthcare issue. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 14 theoretical framework the precede/proceed model, designed by green and kreuter, served as the conceptual framework (green & kreuter, 1991). the framework is useful for grouping the factors likely to be used to bring about the desired program outcomes. the three broad groupings are predisposing factors, enabling factors, and reinforcing factors. predisposing factors include personal attributes such as a person’s knowledge, attitudes, beliefs, values, and perceptions that can promote or hinder motivation for change. enabling factors are those skills, resources, and/or barriers that promote or hinder the desired change. enabling factors are mainly societal forces or systems. oftentimes enabling factors include availability of personal and community resources, accessibility, referrals, laws or statutes, personal skills, services, and facilities. reinforcing factors are the behaviors and attitudes or those around the person such as the rewards and incentives received or the feedback that is received from peers, parents, family, employers, social group, etc. for adopting the desired outcome. the goals of the precede/proceed model are to explain health-related behaviors and provide a foundation for developing and testing interventions to influence both behaviors and environmental conditions affecting the behaviors. the precede component of the model is the diagnostic phase that is useful for identifying the predisposing, enabling, and reinforcing constructs associated with the phenomenon and the proceed component is the development phase outlining the policy, regulatory, and organizational constructs. the precede framework directs attention to what must precede the desired outcome, in this case, a woman getting a mammogram. in order to determine what causes the desired outcome, the factors important to that outcome must be diagnosed before intervention strategies can be designed. without an adequate diagnosis of the important factors, the investigator runs the risk of designing ineffective intervention strategies. two fundamental propositions are emphasized in the precede/proceed model. those are that health and health risks are caused by multiple factors and that, because of this proposition, efforts to effect behavioral, environmental and social change must be multidimensional or multisectoral. the precede component of this model is useful as a framework for this preliminary study because it will provide direction and focus for future investigation of the factors that affect the ability of rural women to adopt breast health behaviors. studies using the precede/proceed model or component parts reported in the literature have primarily focused on urban samples (zapka et al. 1989; zapka et al. 1992; earp et al. 1995; danigelis et al. 1995; love et al. 1993; and miller, a. & champion, v., 1993). in each of these studies, the researchers identified key factors in each precede/proceed category, e.g. predisposing, enabling, and reinforcing. significant predisposing factors included having knowledge about breast cancer screening and family history of breast disease. the key enabling factors were summarized as having the resources to pay for the screening and having a physician provider. lastly, having a physician recommend breast cancer screening was identified as the most commonly occurring reinforcing factor. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 15 studies of non-metropolitan or rural women seeking breast cancer screening even though the review of the literature revealed that the majority of researchers choose to investigate urban samples, several studies focused on non-metropolitan samples. studies by love et al. (1993), earp et al. 2002, valdini and cargill (1997) and andersen et al. (2002) included respondents from non-metropolitan as well as rural sites. love et al. did not distinguish rural as a component of non-metropolitan in identifying predictors of obtaining mammography. although earp et al. 2002 chose a rural sample, the study focus was identification of interventions that increased mammography use among rural african american women rather than identification of factors that affected rural african american women seeking mammography. valdini and cargill (1997) investigated factors affecting access and barriers to mammography in new england community health centers. common reasons identified for not having mammograms were that the patient thought that the ‘test was not important’ (35%) and, secondly, the expense and lack of insurance (23%). overall summary of review of literature the review of the literature revealed that many of the classic studies are more than ten years old. the reported characteristics of this population may have shifted significantly over the past ten years. however, a review of the literature reveals that screening behaviors of the uninsured remain relatively unchanged between 1993 and 2003. further, based on the literature reviewed, a gap in information about underserved rural women and their behaviors related to breast cancer screening, mammography or breast health in general is apparent. many studies have focused on the urban woman and several have used the precede/proceed model as the theoretical framework. data pertinent to factors that affect access of specifically undeserved, rural women to breast cancer screening were not available. knowledge of the characteristics of this population is critical as a foundation for determining the factors related to their breast health behaviors. once these characteristics are known, factors can be investigated and then interventions can be developed to increase the likelihood of early detection and, hopefully, cure. study purpose and research question the purpose of this non-experimental study was to explore characteristics of rural women who attended a free breast health program that focused on education and screening. through descriptive design the researchers were able to describe characteristics of this group of rural women. the research question was ‘what are the characteristics of rural women who self-selected to attend a free breast health program which included self breast examination education and mammography?’ online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 16 methods operational definitions 1. breast health (bh): the act of caring for the health of one’s breast by observing the american cancer society’s guidelines for breast cancer screening which include baseline mammography after age 35, yearly mammograms starting at age 40, clinical breast exams every three years for women between 20 and 40 and then every year after age 40, reporting any changes in the breasts to health care providers found through self breast exam which is an option for any women over age 20 (acs, 2002). 2. rural county: a county with a population less than 50,000 (fritz, 2003). 3. medically underserved county: medically underserved area (mua) as designated by u.s. department of health and human services and reflect assessment of available healthcare resources. 4. screening mammogram: a x-ray examination of the breasts in a woman who has no breast complaints or symptoms (asymptomatic). 5. predisposing factors: personal attributes such as a person’s knowledge, attitudes, beliefs, values, and perceptions that can promote or hinder motivation for bh behavior. 6. enabling factors: skills, resources, and/or barriers that promote or hinder bh behavior, including availability of personal and community resources, accessibility, referrals, laws or statutes, personal skills, services, and facilities. 7. reinforcing factors: behaviors and attitudes such as the rewards and incentives received or feedback that is received from peers, parents, family, employers, social group, etc. for adopting bh behavior. sample the target population for this study consisted of women age 35 years and older, who spoke and understood english, lived in one of four rural, medically underserved counties in the midwest and were appropriate for screening mammography. age recommendations for screening mammography were based on american cancer society guidelines (2002). additional guidelines for screening mammography were based on the criteria of the contracted mobile van and included: no breast discharge or pain, no new lumps or dimpling, no biopsy since last mammogram, no current pregnancy or breast feeding, and no breast augmentation. only screening mammography was provided on the mobile unit. the sampling frame included a convenience sample of 575 women who selfselected to attend one of the free breast health programs offered in this region between march 2001 and october 2003. according to the 2000 census, the total population for this target region was 20,428. the minority population was less than 4% of the total counties’ population. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 17 survey instrument the researchers reviewed the literature and were unable to locate an instrument that met the specific survey needs of being completed in less than 15 minutes and including characteristics reflective of a rural population. based upon the literature and the experience of the researchers, the research team developed a survey to elicit information related to characteristics of rural women seeking mammography. the survey consisted of a 46-item self-administered questionnaire comprised of fixed choice and open-ended questions regarding respondents’ demographic and breast health behaviors. the focus of sixteen items was on predisposing factors, ten items on enabling factors, and six items were reflective of reinforcing factors. examples of survey items are displayed in table 1. face and content validity of the survey was assessed by a panel of experts consisting of a mobile mammography unit director, registered nurse practicing in a breast center, local public health nurse, and researcher with expertise in breast health. the survey was reviewed to ensure that it was accurate and reflective of the rural population. based upon feedback, revisions were made to the final survey. table 1 sample client survey items 1. what is/are the biggest reason(s) you decided to come for a mammogram today? (check one or more) doctor recommended nurse recommended other people (family friends) encouraged it the van was close by my children told me to found a lump or other symptom have a history of breast problems no cost at risk of breast cancer because of age at risk of breast cancer because of family history reassure myself i don’t have breast cancer afraid of getting breast cancer 2. do you believe you are at risk for breast cancer? yes no 3. what kind of health insurance do you have? none private insurance medicare medicaid don’t know 4. does your insurance pay for mammograms? yes no online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 18 procedure in 2001 the research team received initial funding for a breast health project. the project focused on 1) teaching self-breast examination and providing free mammograms to women in four medically underserved rural counties and 2) identifying characteristics of this population using a descriptive research design. the researchers recognized that the american cancer society recommends a three-prong approach for optimal breast cancer screening: annual mammography, clinical breast exam, and self-breast exam. due to funding, delivery of services, and facility limitations, clinical breast examination was not included as a component of this project. for each subsequent cycle, the program was submitted to the institutional review board at the university employing the researchers for human subject review. funding to support these programs was obtained by a combination of state, regional, and private grants from the indiana women’s commission, the greater cincinnati affiliate of the susan g. komen foundation, the health foundation of greater cincinnati, and the ripley county community foundation. the convenience sample was obtained by advertising in the local county newspapers and church bulletins and by posting flyers on bulletin boards throughout the communities. survey data were collected using pencil and paper. the procedure for participation was initiated when a woman responded to local publicity and called the local health department to schedule an appointment. the health department screened the women for participation according to the project inclusion criteria. when a woman arrived at the site for the program, she was offered a 46-item survey to voluntarily complete. assistance was provided if the women needed help with reading or writing. the women were informed that all data collected would be reported in aggregate and that no identifying information would be revealed. the completed survey constituted the woman’s consent to participate in the study. after completing the survey, each woman watched an 8-minute film on self-breast examination, demonstrated ability to perform self-breast examination on a model, received educational materials related to breast health, and received a breast cancer awareness pin. a team of registered nurses specifically trained in the breast health content presented the educational program using materials developed by the american cancer society. qualifying participants then received a free mammogram on the mobile mammography unit parked at the program site. the timeframe for program participation was less than 45-minutes which included survey completion, educational programming, and mammography. data analysis following data collection, data were entered on a spss (spss inc., chicago, il) data file for analysis. descriptive statistics were used to analyze the data obtained. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 19 results demographics the participant response to program publicity was very positive. forty-six percent of the participants reported that they learned of the program through an ad placed in the local newspaper. all appointments in all locations were filled with a ‘no show’ rate of less than five percent. since appointment waiting lists were compiled, women on the waiting lists were called in the event of a ‘no-show’ or cancellation. five hundred and seventy five rural women attended one of seventeen educational programs and received free mammograms on a mobile mammography unit between march 2001 and october 2003. five hundred and sixty four completed the survey. the primary reason for not completing the survey was ‘unwilling to take the time”. the majority of women was caucasian and between 40 and 59 years of age (see table 2). most of the women had a high school diploma as the highest level of education (46%), followed by some post secondary education (26%), and, finally, 16% reported some high school. sixty-seven percent of the women were living with a partner, with 62% being married. slightly over half of the women were employed for pay: full-time (38%) or part-time (13%) for pay. breast screening characteristics of program participants the precede/proceed model served as the conceptual framework for sorting the breast screening characteristics of program participants into factor categories. the three categories of factors outlined in the precede/proceed model were 1) predisposing, 2) enabling, and 3) reinforcing. breast screening characteristics included those descriptors relating specifically to breast health behaviors. identification of breast screening characteristics into such categories will serve as a foundation for designing future intervention studies to enhance breast health behaviors. frequencies for the breast screening characteristics by year of the project are displayed in table 3. predisposing factors. data were examined for predisposing factors such as personal knowledge, attitude, values, and beliefs. overall 29% of the women in the project had never had a mammogram, ranging from 68% in 2001 to 11% in 2003. fortyfive percent of the total sample had not had a mammogram within the previous two years. in 2001 63% reported not having a mammogram within the previous two years. further, 73% of the women reported that they had been previously taught how to perform breast self-exam (bse), ranging from 66% in 2001 to 81% in 2003. even so, of those reported having been taught bse, overall only 35% performed bse monthly. the women reported that key reasons for participating in the program were that they knew the time was due to get a mammogram and they knew they needed it. conversely, a top reason reported for not getting a mammogram within the past two years was that there was no need to get one. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 20 table 2 demographics of respondents n % age (years) 35-39 38 6.7 40-49 174 30.8 50-59 129 22.8 60-69 144 25.5 over 70 30 5.3 no response 49* 8.6* race caucasion 517 91.6 african american 18 3.2 hispanic 2 0.4 other 1 0.2 no response 26 4.6 marital status married 348 61.7 widowed 76 13.5 divorced 93 16.4 separated 6 1.1 never married 13 2.3 no response 28 5.0 living with partner yes 281 66.7 no 116 27.6 no response 24 5.7 highest education level some grade school 23 4.1 some high school 89 15.8 high school graduate 261 46.3 some college 75 13.3 college graduate 35 6.2 graduate/professional education 18 3.2 technical school 20 3.5 no response 43 7.6 work status working full time for pay 214 38.0 working part time for pay 74 13.1 not working for pay 58 10.3 retired 104 18.4 homemaker 67 11.9 no response 47 8.3 • 2001 data not collected in identical ranges online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 21 table 3 breast screening characteristics of program participants 2001 2002 2003 overall counties served dearborn, ohio, franklin, ripley dearborn, ohio, franklin, ripley dearborn, ohio, franklin, ripley dearborn, ohio, franklin, ripley n % n % n % n % total number of free mammograms 141 100% 219 100% 215 100% 575 100% never had mammogram 96 68% 46 21% 24 11% 166 29% never taught bse 44 32% 43 20% 24 12% 111 20%* previously taught bse 90 66% 148 70% 165 81% 403 73%* performs bse monthly 45 33% 79 37% 70 34% 194 35%* income <$25,000 68 48% 120 55% 118 55% 306 53% no insurance (national rate for women: 11%) n/a 83 38% 86 40% 169 39% insurance pays for mammograms n/a 96 44% 101 47% 197 45% no mammogram in past 2 years (national rate: 15%) 89 63% 103 47% 65 30% 257 45% follow up necessary (national norm: 5-10%) 29 21% (range:12-27% among counties) 46 21% (range: 0-27% among counties) 23 11% (range: 5-18% among counties) 98 17% (range: 0-27% among counties) top reasons for no mammography n/a 1. cost a lot n=25 2. no need n=5 1. cost a lot n=10 2. no need n=4 1. cost a lot n=35 2. no need n=9 top reasons for participation 1. time due to get a mammogram n=35 2. need it n=11 1. free n=35 2. doctor recommends n=18 1. mammo van nearby n=32 2. reassure self n=31 1. van nearby n=40 2. reassure self n=31 * n=552, number respondents completing items related to bse online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 22 a special acknowledgment is extended to the indiana women’s commission, the greater cincinnati affiliate of the susan g. komen foundation, the health foundation of greater cincinnati, and the ripley county community foundation for funding provided for this project. enabling factors. when considering the skills, resources, and/or barriers that can promote or hinder breast health behavior, key enabling factors were identified. over half (53%) of the sample reported a family income of less than $25,000. over one-third (39%) reported that they did not have insurance. of those with insurance, 45% reported that their insurance did not pay for mammograms. the number one reason reported for women not getting a screening mammogram was that it ‘cost a lot’. while there were variations by year, key reasons for women participating in the program were that the mammography van was nearby and the program was free. reinforcing factors. six survey questions were related to reinforcing factors, defined as incentives or feedback from others regarding healthy behaviors. in our sample the primary reinforcing factor reported was self-reassurance. another key factor for participation was physician recommendation. discussion the purpose of this preliminary study was to explore characteristics of rural women who attended a free breast health program that focused on education and screening. forty-six percent of the sample reported having completed high school. the us census (2000) reported that nationally among women of the same age, 84% reached this level of education. the average family income reported by over half (53%) of these women was less than the national average annual income of greater than $45,000. in a report issued by ahrq, women covered by private health insurance were more likely to obtain mammograms than those covered by public assistance programs or those uninsured (ahrq, 2001). thirty-nine percent of the sample reported having no insurance as compared to the national rate of 34%. the percent of underinsured women in this sample was 55%, which far exceeds the average rate of underinsured rural americans of 24%. underinsured women are defined by these authors as women who have insurance but their insurance does not pay for screening mammography. the data from this study further revealed that the financial and insurance situations for this target group had worsened between 2001 and 2003. the ahrq report further states that approximately 86% of women aged 50-64 with private insurance received mammogram screening in the past two years compared with 75% of women with public only insurance and 54% for the uninsured. overall, only 55% of the sample had had a mammogram screening in the past two years, which was consistent with the 54% for the uninsured. study mammography rates in 2001 and 2002 were poorer than the national and indiana state averages (85% and 53.5%, respectively). coughlin noted in 2002 that women who lived in metropolitan areas were more likely to have received a mammogram within the past two years (75%) than their rural counterparts (66%). in 2001 and 2002, 21% of the women needed follow-up diagnostic mammography. in 2003, 11% required such follow-up. the overall need for follow-up diagnostic mammography was 17%, which exceeded the national norm of less than 10%. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 23 follow up rates improved from 2001 to 2003. this drop in need for diagnostic follow-up paralleled the decline in rate of first time mammograms, which is consistent with findings of other researchers. the findings support that women in this rural region sought mammography when mobile mammography units were brought into their communities and services were provided at no charge. in a press report issued 2-13-04, martin and pontarelli reported their findings regarding disparities in screening mammography rates (peek & han, 2004, p. 186). they found that “ the most effective patient-targeted strategies to increase mammography use are access enhancing efforts such as mobile vans, transportation services and reduced cost mammograms”. in this four county rural region no other programs were available that offered free or low cost mammography services. even though two community hospitals offered mammography services, the ability to serve those women without private insurance, medicaid, or medicare was severely limited. the waiting period for appointments at the local facilities averaged three months. one hospital had a strong community outreach program and did offer reduced billing for mammography during may as a recognition of mother’s day. the other hospital had limited community outreach programs. there were no mobile mammography programs. the breast and cervical cancer treatment program was not available within this four county region. distance has been reported as a barrier to mammography screening in past studies. distance within the rural community translates to two primary considerations: time and money. for these women, it can be as much as 120 miles or as little as 20 miles round trip to a mammography unit at either of the community hospitals within the region, at one of three free-standing diagnostic units or to a medical center outside of the region. thus, fuel prices for these miles may often be an issue. although distance to the closest facility has been noted as a barrier for some women, it was not identified as a barrier for this group of women. even so, fuel prices may be an issue regarding access to a facility and may increase use of the mobile mammography. the breast health program was designed to provide services to women who did not have access to publicly funded clinics and/or nearby diagnostic facilities as well as lacked the ability to pay. we do not know why some community women choose not to come to the program or why women choose to go to a distant provider. the reasons why can be theorized, but need to be confirmed through further study. the characteristics identified in this study are congruent with breast health behaviors that have been reported in the literature over the past fifteen years. the characteristics and the identified barriers continue to exist. through an updated understanding of factors that affect why rural women seek a breast health program including mammography, interventions can be developed and tested to strengthen breast health behaviors in this population. these findings can serve as the foundation for interventions studies to enhance breast health behaviors in rural populations. limitations the first limitation of this study was the lack of a comparison group of rural women not seeking participation in the program. further, the sample included women between ages 35 and 39 seeking mammography. this 6.7% of the sample could have online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 24 adversely affected the results of those receiving first time mammograms as well as number of mammograms within the last two years. the third limitation was that the survey was only completed by women who chose to participate in the project based upon community advertisement. it is not known if these characteristics are reflective of rural women who received mammography at other sites. additionally, the survey responses were limited to the self-report of women who were provided a free mammogram. while this is a limitation, this method of data collection is consistent with us government data gathering techniques for information regarding health-screening behavior. subsequently, the free mammogram may have introduced a response bias that resulted in women providing responses supportive of continuing the project. lastly, the survey was authordeveloped and lacked tested reliability and validity. it is possible that not all variables that could affect breast health behaviors were included in the survey and that those variables included reflected the three categories of factors reliably. implications for nursing as a result of this study, the researchers have identified that the women participating in the free breast health programs are interested in breast screening behaviors. based upon the findings, several implications for nursing practice were identified: 1. rural women are interested in breast health behaviors. 2. rural women are knowledgeable of bh behaviors but adherence is poor. 3. financial barriers to accessing breast health programs in rural communities need to be addressed. 4. strategies need to be developed to facilitate rural women’s access and use of local mammography facilities. 5. professional nurses have as a role teaching and reinforcing breast health behaviors and advocating for facility access for rural women. summary the results of the study support the continued need for breast health programs in rural communities where the number of underinsured and uninsured is increasing. a number of predisposing, enabling, and reinforcing factors have been identified. in the future a well designed qualitative study could serve to validate these identified factors and provide additional answers to the posed research question. further studies based on findings from this investigation are warranted that identify research hypotheses for the development and testing of intervention strategies that increase breast health behaviors among underserved, rural women. such interventions will ultimately lead to better health outcomes and will provide a natural link to interventions necessary to support follow-up and treatment to underserved rural women. references agency for healthcare research and quality (ahrq). 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[medline] online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10564629&query_hl=51 mailto:pop@census.gov http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9300004&query_hl=1 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8323604&query_hl=3 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9465365&query_hl=5 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2817160&query_hl=7 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10115228&query_hl=9 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=1415857&query_hl=18 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8475011&query_hl=20 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11218321&query_hl=23 table 1 sample client survey items table 3 breast screening characteristics of program participants    rural boundariesstudent perspective 5 fitting a round peg into a square hole: exploring issues, challenges, and strategies for solutions in rural home care settings beverly d. leipert, phd, rn1 marita kloseck, phd2 carol mcwilliam, phd, rn3 dorothy forbes, phd, rn4 anita kothari, phd5 abe oudshoorn, phd, rn (c)6 1associate professor, school of nursing, university of western ontario, bleipert@uwo.ca 2assistant professor, bachelor of health sciences program, university of western ontario 3professor, school of nursing, university of western ontario 4associate professor, school of nursing, university of western ontario 5assistant professor, bachelor of health sciences program, university of western ontario 6lecturer, school of nursing, university of western ontario key words: rural, multidisciplinary, home care, canada abstract while home care has received much attention lately, little research to date has drawn on the experiences of rural multidisciplinary teams providing in-home care. home care is typically studied in urban areas, with the tendency to expand urban practices to rural settings, often with problematic results. this paper presents findings regarding unique rural multidisciplinary home care issues, challenges, and strategies for solutions. five focus group interviews were held with each of three rural multidisciplinary home care provider groups (n=19) in southwest ontario, canada. findings revealed practice issues related to time, distance, communication, recruitment and retention, as well as system issues regarding poor understanding and scheduling of rural practice by administrators and urban employers. study findings indicate that rural home care requires enhanced understanding and changes to policies and practices to provide efficient and effective care to rural residents. best practice guidelines for home care in rural areas are urgently needed. introduction health care providers such as nurses and personal support workers contribute vital human and professional resources for rural home care (forbes & janzen, 2004). few studies to date have drawn on the experiences of rural multidisciplinary teams that provide home care. furthermore, home care is typically studied in urban areas, with the tendency to expand urban practices to rural settings, often with problematic results. this paper presents findings regarding unique rural multidisciplinary home care issues, challenges, and strategies for solutions that emerged from a study in southwest ontario, canada. five focus group interviews, held with each of three rural multidisciplinary home care provider groups that included nurses, personal support workers, and others, highlighted issues, challenges, and strategies for solutions in providing rural home care. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 http://www.uwo.ca/fhs/nursing/ mailto:bleipert@uwo.ca http://www.uwo.ca/fhs/bhsc/ http://www.uwo.ca/fhs/nursing/ http://www.uwo.ca/fhs/nursing/ http://www.uwo.ca/fhs/bhsc/ http://www.uwo.ca/fhs/nursing/ 6 rural is defined as living “outside of commuting zones of urban centres with 10,000 or more population” (duplessis, beshiri, bollman, & clemenson, 2002, p. 1). background rural home care providers offer vital support and care to rural residents. these providers are essential in assisting clients who return home from urban care facilities. while there have been many changes in health care delivery in canada in recent years, three emerging trends (population aging, home care as the fastest growing sector of health service delivery, and empowering partnership models of care) support the need to critically investigate the provision of home care in rural settings. the unprecedented aging of populations world-wide (robinson, novelli, pearson, norris, 2007; world health organization [who], 2004) creates significant opportunities and challenges for health service delivery in both urban and rural settings. it is predicted that by 2025 (in less than 20 years) canada will be in the top 10 countries world-wide having the highest proportion of seniors (who). the majority of these seniors will live in the community. by 2011, in 3 short years, the leading edge of the "baby boomers" (individuals born 1946-1965) will reach the age of 65, with the full impact of the "baby boom" (when all "boomers" fall between the ages of 65 and 85) hitting canada in 2031 (wister, 2005). it is well recognized that there are many shortcomings in research related to aging, particularly regarding contextual factors (community, social environmental) that influence health and health service utilization home care needs of older individuals living in rural settings (arbuthnot, dawson, & hansen-ketchum, 2007; clark & leipert, 2007). it is projected that by 2021 one in four seniors will live in a rural setting (health canada, 2002). in addition, rural home care providers provide care to other groups, such as individuals of all ages recovering from surgeries, with chronic conditions, and/or undergoing treatments for cancer and other conditions. in many small rural communities, the visit from the home care provider is the only access to care that rural clients have (leipert & reutter, 1998). distance, weather, lack of access to or ability to drive or finance transportation, and being ill or in recovery can severely compromise rural residents’ access to care outside their immediate community. thus rural home care providers are essential to the health of many rural residents. in canada, home care has been the fastest growing sector of health care for more than two decades (anderson, 2006; canadian home care association [chca], 2004). public expenditures have grown at almost 20% per annum, double other health spending (coyte, 2003). restructuring of hospital, social, and mental health services, technological advancements, escalating acuity of medical care, and an aging population have increased the volume and complexity of services required. the demand for home care has continued to exceed resources (forbes et al., 2003), despite the care management approach. consequently, case managers (who ration and coordinate in-home services, matching scarce resources to professionally-assessed client needs rather than providing client-driven holistic care) have been forced to deal with caseloads of as many as 120 clients, far in excess of what is recommended (shapiro, 1995). similarly, service provider agencies have been confronted with increasing service demands at a time when recruitment and retention of adequate staffing to meet these demands has become a key problem. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 7 in addition, empowering partnerships of care have become a focus as a way to promote quality in-home service delivery. accordingly, several ontario home care programs have adopted the flexible-client-driven care approach (mcwilliam et al., 2003), which includes optimizing potential to effectively contribute to care by building on the strengths of each provider, drawing out the knowledge, skills and abilities each has to contribute through care partnerships that are often challenged by the geographic spread and isolated nature of work in this health care sector. this approach is supported by canadian health services and case management leaders (salfi & joshi, 2003), theorists (hackstaff, davis & katz, 2004; hagerty & patusky, 2003; rose, 1992), leaders in the field of chronic care management (bodenheimer, wagner & grumbach, 2002; wagner et al., 2001), and by recent evidence (aronson, 2003; chang, li & liu, 2004; hibbard, 2003; nunez, armbuster, phillips & gale, 2003). the evidence to date suggests that improved client satisfaction (gagnon, schein, mcvey & bergeron, 1999) and health outcomes (chang, li & liu, 2004; hibbard, 2003) may be obtained when health care consumers are engaged as partners in care (forbes et al., under review). nonetheless, in spite of the need and importance of home care providers, rural home care providers experience significant challenges. rural in-home providers, for example, must travel over extensive distances to reach clients. as well, in-home providers must be well prepared generalists so that they can address a variety of client needs (lee & winters, 2006; leipert & reutter, 1998). in addition, rural care providers are often under-resourced in terms of personnel, time, and equipment, recruitment and retention of health care personnel in rural settings is often problematic (romanow, 2002), and resources are allocated based on the population served, which in rural areas is quite low, and on urbanstandardized resources and client needs which differ substantially from rural locations (romanow, 2002; sutherns et al., 2004). these issues challenge the provision of effective and efficient home care in rural settings. method study context the study was undertaken in southwestern ontario, canada, a 22,000 square kilometer area with a population of just under one million people (mcwilliam et al., under review). approximately half of this population resides in cities of 30,000 to 360,000 largely focused on light to heavy manufacturing and white collar industry. the remainder of the population resides either in small bedroom communities or in relative isolation across expansive rural areas. the province of ontario has the highest number of rural residents in canada (turner & gutmanis, 2005). southwest ontario consists of varied rural contexts and diverse health and socioeconomic needs and resources and includes agricultural, recreational, and retirement communities (turner & gutmanis, 2005), and aboriginal, mennonite, and other cultural groups. at the time of this study, southwestern ontario was served by six home care programs, each comprised of a government-mandated in-home service brokerage agency providing service access and case management, and multiple service provider agencies supplying the in-home nursing, therapy, social work, and personal support services contracted for clients by the brokerage agency. on average, the six home care programs online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 8 together served approximately 16,000 clients at any one point in time. as approximately half of in-home clients served had longer term chronic care needs, these home care programs serve about 50,000 people annually. to meet client needs, the programs deployed the appropriate mix of services through a total of 1470 full time equivalent providers (200 managers, 390 nurses, 840 personal support workers, 35 therapists, 5 social workers) (mcwilliam et al., under review). sample and recruitment after ethical approval was received from the university of western ontario research ethics board, formal home care providers were recruited in southwest ontario. thirty-three formal care providers responded to recruitment efforts and were included in the study. this paper addresses findings from 19 participants from three rural sites who provided information relevant to rural home care. the 19 members in these three groups included seven nurses, six personal support workers, three case managers, two occupational therapists, and a team assistant (see table 1). the average time in home care varied from one to 20 years; nine participants worked full time and ten worked part time; participants had baccalaureate, diploma, and certificate education. all participants were female, and the mean ages in the three groups were 46, 47, and 49 years. table 1 participant demographics group one group two group three totals occupations nurses 4 2 1 7 personal support workers 2 2 2 6 case managers 0 2 1 3 occupational therapists 1 1 0 2 team assistants 1 0 0 1 totals 8 7 4 19 employment status full time 3 5 1 9 part time 5 2 3 10 education baccalaureate 2 3 1 6 diploma 5 3 1 9 certificate 1 2 1 4 mean ages in years 46 47 49 online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 9 data collection data were collected using focus group methods for building and stimulating ideas and discussion (morgan & krueger, 1998). participants in the three groups completed five 2-hour researcher-facilitated sessions to identify self-developed, self-directed strategies to promote empowering partnering. these strategies were based on the principles of flexible client driven care (mcwilliam et al., 2003), which, in summary, suggests that care should be client-centered and built on the client’s strengths; flexibly respond to client’s choices and abilities for partnering in their everyday care management; include partnering amongst all care providers, clients, and agencies; and foster empowerment by sharing and building on the knowledge, abilities, and potential of all involved. the researchers thus worked with the study participants as partners as they facilitated participants’ exploration of service delivery in the rural context. to facilitate discussion and building of ideas, each group was facilitated by the same researcher for all five sessions. group sessions were audio-taped to facilitate data capture and analysis. data analysis individual and team interpretive analyses using an editing analysis approach (miller & crabtree, 1992) were completed, with the analysis team initially coding key phrases and themes that emerged from the data, and subsequently comparing and contrasting coded data to clarify the interrelationships of concepts and themes. ultimately an edited set of key themes and sub-themes of issues, challenges, and strategies for solutions was developed. rigor was attended to by conducting primary analysis by a minimum of two researchers to identify preliminary conceptualizations, and conceptualizations were brought back to the research team as a whole for consideration (kuzel & like, 1991). these strategies assisted with the development and refining of conceptualizations that accurately reflect data presented by study participants. findings analysis revealed practice and system issues for rural home care providers, and strategies and recommendations to address rural practice and system issues. (see table 2) practice issues practice issues related primarily to time, distance, communication, and recruitment and retention of staff. regarding time, several participants noted that demanding workloads required them to be vigilant about being on time to meet client needs and the challenges this presents in rural settings. as one participant noted, “i have to keep in mind on tuesdays i have certain people i have to do first thing in the morning because they go to day care…and then i have to…[care for] her [another client], and then i still have to be [at] the other [client’s home] by 9 o’clock because she’s diabetic”. because of extensive distances that often existed between clients, staying on time for visits was a challenge. in addition, providers needed to schedule care to accommodate rural seasonal demands, as this participant explained, “i’ve run into problems with the online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 10 table 2 study themes practice issues system issues recommendations time required to reach clients; seasonal requirements for timing of visits lack of understanding of rural practice by urban supervisors and dispatchers reorganization of care provision to accommodate geography distances between clients and between clients and providers; driving demands in rural areas inappropriate scheduling of care providers in relation to client locations enhanced communication strategies to improve understanding about rural care issues communication effectiveness issues recruitment and retention issues related to travel, driving, and remuneration rural community with it being planting season…. [a farmer] wanted me to come at 6 am because it’s not going to rain today and he’s planting…i’m willing to do that but [because of my workload and distances to clients i can’t do this every day]…trying to find a happy medium has certainly been a challenge”. distance was a concern for several reasons. driving long distances was daunting, especially in winter when roads and visibility could be compromised. a participant noted, “a lot of the girls [care providers] live out in the country, and there’s winter driving, you know. some of the girls don’t have a four-wheel drive…if i call the office and say i can’t get there, i literally mean it”. participants also noted the added expenses of driving to provide care in the rural context and the need to have a driver’s license, “[providers in the city] don’t need a car…they can hop a bus [to see clients]”. in addition, participants repeatedly noted that reimbursement for distances driven to see clients was inadequate and inconsistent among homecare agencies, “the only thing you get now is kilometers and not that well paid…with the price of gas…at over a dollar a litre”; and, “they [employers] are saying 15 minutes is allotted for driving from one client to the other…i’m going, ‘well that’s stupid because it takes you 25 minutes’. so i [won’t] get paid [what i should]”. another participant stated, “working in the country now, i have a huge issue with the driving. we’re not paid to drive from a to b. the other day, i was asked to drive to [a location] to see a client and i said, ‘i’m not driving [there]’. they don’t pay me enough to drive my car, they don’t pay me my time to drive there”. a fourth participant noted, “they had me going out to the very end of [region]…i put over 300 kilometres on my van.... i say if it’s [the visit] not here, here, or here, i’m not going there because i can’t subsidize my car to do this job….sometimes we have to do that [subsidize their own costs of providing rural in-home care]”. the challenge of effective communication among rural care providers and between rural care providers and their managers and dispatch personnel was also noted. face-to-face communication was highly prized, even if it was not always readily online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 11 available, as this participant indicated, “voicemail doesn’t cut it. i can’t get the message [details] i need from voicemail all the time”. another participant noted that she could “not even get to talk to [colleagues] with voicemail”. communication was viewed as important to help rural providers schedule their workdays, work better as a team, and establish with clients flexible partnering care. recruitment and retention of staff was a major issue in the rural context that hindered the provision of consistent care and the development of effective flexible clientdriven care strategies. participants noted that the “biggest problem that we are facing is [a shortage of] nursing and personal support worker [staff]”. some participants believed that part of the reason that staff did not apply for or stay with community agencies that provide care in rural areas was due to excessive travel. such travel was hard on personal vehicles (“we’re…wearing and tearing our vehicles [out]”) and interfered with the amount of time the care provider could dedicate to clients. the demands of having to complete clients’ care, no matter where clients lived or how long it took to reach them, were additional reasons for poor recruitment and retention for rural community home care. participants remarked, “most people once they’ve got their personal support worker [education]…go work in a nursing home because they’re getting three, four, five dollars an hour more than we are [in community care], and it’s an eight-hour shift, they’re not driving all over…they’re going one place and they’re done and go home”. other participants remarked, “it’s hard when you’ve only got 10 minutes [with the client] because you drove for 50 [minutes] and the visit time is clicking on and you know at the end of the day, you’re going to be measured for whether you got the task done, not whether the [client] felt good”; and “you don’t want to be still working when the sun goes down [due to driving demands]”. another participant summarized the effects of providing care in rural community settings when she stated, “[home care providers] work five months and they’re outta [home care]. well you can see why, if they’re driving all over the country for one client and then across the country to the next one, [and] not getting paid much”. these comments reveal both the commitment of providers and the challenges to providing care in rural settings. in summary, time, distance, communication, and recruitment and retention of staff emerged as significant issues that affected providers’ ability to engage in home care services in rural contexts. without sufficient staff who were familiar with initiatives, and who felt valued, able, and supported to contribute, the development and implementation of familiar as well as new practice initiatives were challenging. system issues system issues included a lack of understanding of rural practice by urban supervisors and dispatchers, and inappropriate scheduling of care providers in relation to client locations. lack of understanding by urban supervisors and dispatchers of rural practice issues, especially rural distance, was a common theme, as comments by several participants reveal, “they can’t fathom [rural travel time] because they can get anywhere in the city in ten [minutes]”; “city folk don’t really understand rural….we had a boss in our office who was going to meet one of our [rural] case managers and she thought she’d be there in eight minutes. she hadn’t a clue…it’s at least 40 [minutes away]”. other participants noted, “they can’t…visualize…once they’re outside the city, they say online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 12 ‘where is that?’…they call me for a map because they wouldn’t have a clue how to find [a rural location] themselves”; and “if you look at a road map, [the distance from rural location 1 to rural location 2 looks] like only two city blocks on the map, but it’s [rural’s] big”; and “rural is very different from the city”. lack of understanding of rural practice issues such as distance contributed to inappropriate scheduling of care providers in relation to client locations. participants noted that they were sometimes assigned clients who didn’t live in their practice locations. a participant noted, “we have case managers in the [urban] hospital who do the assessing and send clients home [for] service, and they send us clients who don’t even live in our county, that’s how much [little] they understand”. in addition, inappropriate expectations for when care could be provided resulted when rural was not understood, “the dispatchers say, ‘well, it’s only this far on the map. can you be there in 10 minutes?’…i’m like…it’s an hour’s drive…they don’t understand”. as a result, care providers may be overwhelmed with too many widely geographically dispersed clients to visit in a day, and they are challenged to provide adequate care in the limited time they have available when they do arrive at the client’s home. as has been noted, this leads to frustration on the part of the care provider and the client and contributes to recruitment and retention issues. inappropriate scheduling of care providers in relation to client locations also occurred as a result of home health agencies’ policies and methods of procuring clients. in ontario, home care is paid for by the provincial government which, in turn, allocates funding to community care access centres that contract services from private for-profit and non-profit agencies that submit the lowest estimate for the costs of care provision in specific counties (armstrong, 2007). participants noted that this process often resulted in care providers being employed by agencies with geographically overlapping care responsibilities. this procedure was problematic, as the assignment of clients to care providers based on the agency’s county responsibility, rather than the location of their provider in relation to the location of the clients, resulted in care providers being “all over the place, wasting time”, “inefficiency”, and “a dog’s breakfast” approach to care. care providers found themselves driving to clients in rural communities where a care provider from another agency already lived. thus, providers were driving long distances to far off clients, when they could be providing care to clients in or near their own communities which would result in more time available to spend with clients, more clients seen in a day, and less wear and tear on care providers and their vehicles. a participant noted, “i had clients say to me in [a location], ‘well, my neighbor’s got the [provider who lives] across the street. why are you here?’ and i’m like, ‘i don’t know, she could come here and that would be good for her, and i could go and do something else [closer to where i live] and save on gas mileage and everything else’”. another participant agreed, “if [a care provider] is just down the road, she could do twice as many [visits if she could visit there] rather than driving forty minutes in between every visit”. almost every participant remarked on the frustration of having to provide care using an urban-based model that didn’t fit rural needs and resources. the following quotes illustrate participant perspectives regarding rural care situations: “there are structural barriers to having empowering relationships with [rural] clients because we’re driving all over the place, wasting time, not getting paid [sufficiently], and we’re frustrated…we [need to] study the impediments to effective home care [in rural areas]”; online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 13 “currently we’re trying to retrofit an urban [care] phenomenon onto a rural environment and so we run into all of the issues that come with that”. “they don’t understand how to make it work [in the rural context]” was a common statement and sentiment. participants sometimes felt that, as one participant explained, “they’re [employers] not unaware of [our situation]. they might not realize or understand exactly what happens out here but i’m sure they know because i keep sending those ‘unable to serve’ reports”. lack of employer attention to rural practice issues led to a sense of frustration and despair on the part of some participants, as revealed by these comments: “the farther you are from the grassroots, the [more the] weeds get in the way”; “but is it [change] going to happen?”; and “i think we’ve gone as far as we can if they’re not going to listen to us”. these comments indicate significant implications for quality of care and recruitment and retention of providers in rural settings. strategies and recommendations strategies for solutions and recommendations to address practice and system issues focused primarily on reorganization of care provision to accommodate geography and enhanced communication strategies to improve understanding about rural care issues. a participant summarized the solutions, “it has to be geographic if you want it to work in the county”. reorganization of scheduling of care provision to accommodate geography was addressed in several ways. participants recommended that rather than “one, two, three [agencies] in a town…there should be one agency for each town or [area]”; to “divide the county into quadrants and have agencies within a particular quadrant”; and to “bid on rural visits differently than urban visits because of the [higher] costs involved [in providing rural care]”. these recommendations would help formal care providers avoid time and distance issues involved in traveling to clients in a community where another agency already provides care, as a participant noted, “why have somebody from [agency a] go there [when] somebody from [agency b already] goes there?” in addition, scheduling that takes into account geography would, participants felt, facilitate recruitment and retention, as care providers would not have to be “driving around” and would thus feel more fulfilled as they would have more time to provide care. participants explained, “they’re not going to be on the road traveling as much”…. “[providers] could do even more [due to] time with each client…. it could be so much nicer”, “and the person providing the care, when they get to the door, the patient will realize they’re really happy to be there”. in order to highlight to themselves and to others, such as managers, policymakers, urban employers, and dispatchers, distances traveled and locations of formal health care providers and the agencies they represented, participants recommended a mapping exercise as one strategy for enhancing flexible client-driven care in the rural context. on a map that illustrated the counties served, participants recommended that each care provider place a colored pin on the town or rural location where they had clients. pin colors would represent the agency for which the care provider worked, for example agency a would be red, agency b would be blue, etc. thus, the map would convey in color where agencies overlapped, where gaps in care existed, and where changes could be made so that agencies could provide more efficient service delivery that online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 14 required less travel and time, thereby allowing more time for flexible client-driven care. as a participant explained, “you can see the overlap and you know, you’re driving down my street and i’m driving down your street”. participants felt that this mapping exercise could result in agency recognition of the need to reorganize care so that it was ‘closer to home’, which would result in more time with clients and more clients visited in a timely manner. participants commented, “it does show…with the dots [pins on the map] how stupid the system is set up”, and “our next step would be to see how much closer we can bring each worker [to her/his clients] instead of…driving all over the country”. participants believed that trying to “retrofit” urban care provision policies in rural areas was not appropriate and did not work. participants also sensed an undervaluing of rural care, “no agency still yet wants to take the [rural] county when the dollars are in the city [where the majority of clients are]”. a suggestion was made to create “a rural home visiting agency [that] would get the entire contract [for patients in rural areas] and get more money for visits because the costs are higher in terms of transportation and time”. a recommendation was also made to attract nurses and other care providers who “are more interested in rural nursing and [accepting of] the vagaries of rural nursing”, such as distance and location, “so that you have a better match between the client [and the care provider]”. better pay and benefits for rural care providers was also recommended, “they’d probably get people [health care providers] out there if they paid them what they’re worth…better benefits, full-time”.… “they could look at isolation pay”. in addition, parity in salary among the various agencies would facilitate staff retention, as this comment reveals, “make it [salary] uniform…so that you don’t have nurses quitting [agency a] to work for [agency b] because they’re going to pay more…if it was uniform and standardized, it would be way better”. in essence, participants believed that rural care requires not only parity with urban providers but additional incentives and supports to adequately provide care in rural settings and to support the additional costs and commitments that rural care requires. adequate reimbursement for travel expenses and wear and tear on vehicles when providing care and salaries that compensated providers for not only the number of clients seen but also for the miles traveled and the overtime providers sometimes needed to commit to rural care were two examples of supports that would help attract and retain providers in rural settings. recommendations for enhanced communication strategies to improve care included more face-to-face meetings to supplement telephone and email communication across distances (“the case managers and nurse[s] [used to] have a get together round table discussion, maybe a lunch, [to discuss patient care] but they don’t do it anymore…they miss it”) and in-person case conferences (“we used to present case reviews to give a real picture of the situation…they were great eye-openers because it’s real, [not] airy fairy”). working in multidisciplinary teams was recommended as a way to sustain care provision with a small staff and large patient commitments in rural settings, as these participants noted, “the very fortunate part of our job is we’ve got a small team in our office and we work as a team…if we didn’t, we’d all have drowned as individuals. but somehow we keep each other afloat. there’s been times when [the care provider] is far behind and says ‘book [this many clients] that day’, and i’ll say ‘no,…it’s not good for you’”; and “out here…we have a team and we get together and talk about how we’re handling things…if a client load’s too much”. the focus group online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 15 format facilitated the sharing of strategies such as these so that they could be considered, and perhaps adopted, by various disciplines and agencies. other suggestions included the need to learn from and develop best practices for the provision of community care. a participant stated, “ it’s too bad there aren’t best practices that we’re aware of for this kind of [care]…there’s probably in every country where there’s home nursing, nurses in cars visiting people [who] are probably doing it more or less efficiently. but i don’t know what the best practice stuff says about it”. although participants hoped that these and other recommendations could be implemented, a sense of distrust persisted based on the fact that most policies and decisions were made in urban settings, “i just hope that however [solutions] are presented, that they [those who make decisions about policies and practices] get it. i’m not sure they’re going to because they don’t live or work in the county, they don’t understand, and those are the people making the decisions”. in addition, some participants noted urban reluctance to understand or accommodate rural locations, “when we suggested to them [urban employees] to come to [our rural] office for a meeting for a change, all of a sudden it’s like, ‘oh, god, i’ve got to drive all the way there’”. to develop understanding about the rural context and rural practice, and in addition to the mapping exercise described above, participants suggested, “it would be good if they could just follow us around for a whole day and see what we do…how far spread we are… and how thinly spread we are…with two people working in it [the rural community]”. in addition, participants believed it was important to be collectively assertive, “we need to stand up as a group…if we would stand up as a group, i think we could make change. if we just say, ‘we’re not working today. until you fix the gas price, we will not be driving our vehicles’, something would happen”; and “it’s easier to marginalize individuals and [one or two] agencies…if everybody’s saying that we’re all over the place and wasting time, it’s harder for government to disregard the inefficiency, right?” discussion findings of the study reveal several important aspects of rural home care practice and system issues and valuable recommendations for improvement. rural home care providers and clients experience significant challenges that make present practice problematic and that affect the adoption of new approaches such as flexible client-driven care. valuing and supporting rural practitioners and rural home care needs the importance of valuing, including, and listening to rural practitioners was clearly evidenced in this study. practitioners in rural contexts live close to the care experience and, as such, have important and relevant ‘on the ground’ experiences and strategies for practice and system refinements. participant comments indicate their interest and ability to be involved in practice and policy discussions. for effective rural home care practice and planning, practitioners must be included in local, regional, provincial, and agency planning meetings. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 16 participant distrust and frustration regarding the need for, yet the lack of change merit particular attention. change that effectively moves rural home care practice forward must be done, and seen to be done, if practitioner confidence and trust are to be restored. change may not be easy, however. recent restructuring of the home care system in ontario has resulted in a process whereby private for profit and non-profit agencies bid for care contracts, with the lowest bid usually awarded the contract for care (armstrong, 2007). determination of care provision in this way can result in even more underresourcing of care in rural settings, which typically are more costly due to sparse populations and extensive distances. advancing rural home care flexible client-driven care, while a very valuable approach for home care in rural settings, will require additional system supports if rural home care providers are able to learn about and implement them. given rural practice demands and recruitment and retention issues, provider attendance at educational and implementation meetings will be challenged. for example, in this study participants who were not funded to attend sessions and participants for whom no alternative care providers were available found it difficult or impossible to attend sessions. thus, financial support and recruitment and retention issues must be attended to so that providers can have the time to attend and be involved in initiatives that advance rural home care. other initiatives that can help advance rural home care could include the strategies of telemonitoring and home care co-ops. telemonitoring devices may assist rural providers and clients to monitor vital signs, assess drug administration, and instruct regarding other health care regimens and needs from a distance (anderson, 2006). anderson (2006) notes that this use of technology can help care providers to assist rural clients between visits and to see, assess, and educate more patients in one day than was possible in a week of home visits in a rural area. home care cooperatives, which are used largely in home care settings in quebec to provide care to mostly elderly clients in their homes, provide a variety of services and resources to rural clients and have been found to generally perform well in rural settings (anderson, 2006; girard, 2005). communitybased health care models, such as home care co-ops, have also been demonstrated to provide care at substantially less cost per capita (armstrong, 2007) mainly because of lower hospital utilization rates (anderson, 2006). these two strategies, telemonitoring and home care cooperatives, may thus be ways forward in the future in assisting rural home care providers and rural clients to provide and access care. further development, implementation, and evaluation of these methods in rural settings are required to demonstrate and refine their effectiveness. participants in this study identified mapping as a way to identify and illustrate practice locations, needs, and resources. geographic information system (gis) mapping, the pairing of databases of information with advanced mapping capabilities, is being used by senior and community groups in the united states and australia to assist with planning and allocation of health-related resources (anderson, 2006). for example, gis mapping can assist in showing where clients live and thus where resources are needed, to identify isolated clients, and to visually see the distances and spatial relationships between services and between services and clients. thus, mapping may be another way to online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 17 highlight the needs and resource issues of rural providers and clients, and assist in effectively and efficiently planning the delivery home care resources to meet rural needs. participants recommended best practice guidelines for rural home care. this highlights an important opportunity for research to identify these practices and for education among rural health care providers to share practices that work. appropriate knowledge translation and exchange activities are required to share interventions/approaches that have been shown to be effective in meeting the needs of rural home care clients and rural care providers. as well, research is needed to further examine best practices using a rural lens. the study of rural health care and the identification of best practices for rural care by nurses and others in canada have only recently begun (andrews et al., 2005; bushy and leipert, 2005; hartley, 2005; leipert and smith, in press; macleod et al., 2004). these studies and participant issues and recommendations expressed in this study indicate that the important work of identifying and supporting best practices is a vital way forward in strengthening rural home care. finally, advocacy is clearly needed for change at the agency and provincial level so that policies can be adjusted to more effectively provide home care to rural residents. rural home care practitioners who have relevant practice experience and who know how things work – or not should be active participants in advocacy and policy discussions so that effective systemic change occur. for example, rural home care providers must be included on agency boards and governmental health decision-making committees. however, because advocacy may not be an activity with which practitioners are familiar or comfortable, education and support for their involvement should be provided. this may present challenges due to the large number of agencies that employ home care practitioners, the small numbers of practitioners in some agencies, and agency interest in economics of care versus staff development. an agency external to employing agencies, for example professional associations such as the canadian home care association, the ontario home care association, and the registered nurses association of ontario, may be best able to support rural home care provider advocacy needs and initiatives. the findings of this investigation were limited by inconsistent attendance at the focus group meetings used to elicit understanding of the issues, challenges, and strategies for providing home care in rural settings. limited reimbursement for provider participants and limited availability of replacement staff to enable provider participation meant that providers attended whenever they could. sporadic attendance perhaps impeded optimal discussion to elicit the in-depth data sought. nonetheless, rich data were revealed, and issues and strategies important for effective rural home care were identified and can serve as the basis for additional investigation. conclusions best practice guidelines for home care in rural areas are urgently needed. rural home care provider interest and participation in this study, in spite of overwhelming workloads and often on their days off from work, indicate that rural providers are committed to quality care. findings from this research regarding system and rural practice issues and strategies indicate that rural home care practice would benefit from additional participatory action research with rural home care providers. understanding of rural home care could be enriched by interviews with care recipients and the families and online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 18 neighbors who care for them, and by individual interviews of home care providers. exploration of sensitive practice and system issues could then be more fully explored in a confidential manner. research that explores rural care provision by discipline/position (eg. nurses, personal support workers, case managers, etc.) would also provide a deeper understanding of discipline and position-specific needs and solutions. committed financial and personnel support by agencies is vital to research participation by overworked rural care providers. additional research would help to acquire vital information, such as best practices for rural home care, that support the provision of effective and efficient home care in the under-resourced, 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(2004). active ageing: a policy framework. geneva, switzerland: author. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14763340%5buid%5d&webenv=0po1omiqws9ni36t-mb6yvh2y9yyhlibpwghqbmxu5m2lg4owve1vxrafzbn0sisejttnvybveba88%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12492822%5buid%5d&webenv=0y1upnwlusmuha5y-r-0fjeptifmqpthptrt2xmbabqmejqqwhlcuyyemplocaojmhqfuf1rnuplbt%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14655323%5buid%5d&webenv=00z1tx-gsjrhfy-z8ea35q-huu6qlk93whe8atkqjrj4loxgmdmy98ivndfgpye3p1covvz2rov-rr%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7627097%5buid%5d&webenv=0elqz3gxemmk2fdx_v7uek-jjfhcsqwwp_3qky49_2xcxgwx4zxkz0z_zdhgsxbri3en0ak_0slrer%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11816692%5buid%5d&webenv=0qt7jxobz5dsxs3_quy6sf82ya6jkmho-14klaigndhnzpfoqfhyeelgqsabaygw3mbaydrk91vv2v%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11221012%5buid%5d&webenv=0etqfhl1lkm2xtcowvxzflppjqrkjl4wz0bxlg4izk7k5g2ytk6yz3efa9cg-dbopde97vqygsdwx2%4026424f0f76980320_0050sid&webenvrq=1 microsoft word nepal.doc online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 76 antenatal care among women in rural nepal: a communitybased study sulochana dhakal, rn, ma, msc 1 edwin r van teijlingen, ma(hon), med, phd 2 jane stephens, mbbs, msc 3 keshar bahadur dhakal, mbbs, md (obs/gynae) 4 padam simkhada, msc, phd 5 edwin amalraj raja, msc, phd 6 n. glyn chapman, mph 7 1 msc graduate, section of population health, university of aberdeen, dhakal_sulochana@yahoo.com 2 professor, school of health & social care and visiting professor, bournemouth university, uk and manmohan memorial institute of health sciences, nepal, vanteijlingen@bournemouth.ac.uk 3 director, green tara trust, london, doctorjane99@hotmail.com 4 consultant in obstetrics & gynecology, mid-western regional hospital, birendranagar, surkhet, drkeshar_dhakal@yahoo.com 5 senior lecturer, school of health & related research (scharr), university of sheffield, uk and visiting professor manmohan memorial institute of health sciences, nepal, p.simkhada@sheffield.ac.uk 6 research fellow, section of populationhealth, university of aberdeen,amalraj.raja@abdn.ac.uk 7 clinical tutor, university of aberdeen, g.chapman@abdn.ac.uk keywords: utilization, antenatal care, prepartum care, rural women, south asia abstract background and objective: the uptake of antenatal care (anc) is generally poor and inadequate in many developing countries such as nepal. the purpose of our study was to assess the utilization and associated factors of antenatal care uptake among rural women in nepal. the study was carried out in two villages and surrounding areas of kathmandu district in 2006. sample and method: a descriptive, cross-sectional study, which was conducted among 150 women of reproductive age who had delivered a live baby within the 24 months preceding the survey. all women were interviewed using a semi-structured questionnaire. findings: women were influenced by their mother-in-laws on whether or not to use anc. utilization of anc was associated with many factors: women having their second or subsequent pregnancy, illiteracy; tamang ethnicity, women whose husbands were farmers, and women who were farmers themselves (p<0.001). younger women and those with secondary education were statistically more likely to have used anc. twenty-two percent of women did not receive anc. services offered during anc included for most women supply of supplementary iron and folic acid tablets (95%) and checking of maternal weight (94%). few women reported having received information on danger signs of pregnancy (27%), and 16% women had experienced health problems during their last pregnancy. conclusion: the utilization of anc (at least one visit in pregnancy) in our rural study was encouraging as it was higher than the national average, and even fewer women manage to get four anc visits as recommended by the world health organization. the accessibility of anc programs that incorporate an awareness-raising element to encourage pregnant women to attend may help improve anc uptake. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 77 acknowledgements the authors wish to thank, first and foremost, all research participants, and the fchvs, and mr. laba man mahajan, who gave us their valuable time, support and information. our thanks also go to the international nepal fellowship, tuberculosis leprosy project, german institute for medical mission, stichting supplementiefonds sonnevanck (the netherlands), swiss friends for mission to nepal, green tara trust, uk and the university of aberdeen for their direct or indirect support. we also thank the editor and the anonymous reviewers of the online journal of rural nursing and health care for helpful comments on the original submission introduction complications of pregnancy and childbirth such as haemorrhage, hypertensive disorders of pregnancy are leading causes of death among women of reproductive age in developing countries (li, fortney, kotelchuck & glover, 1996). antenatal care (anc) can play a role in the reduction of maternal mortality. anc can help prevents maternal and neonatal deaths by identifying pregnancy-related complications early. secondly, anc offers an opportunity to educate women on obstetric danger signs and motivate them and their families to seek appropriate and timely referral to a maternity care provider (bullough et al., 2005). similarly, other interventions which are part of anc such as routine iron and folic acid supplementation, serologic screening for human immunodeficiency virus (hiv) and syphilis and treatment of syphilis, routine measurement of fundal height, and tetanus immunization are beneficial to mother and child health (lumbiganon, 1998). the world health organization, department of reproductive health and research, family and community (who, drhrfc) has recommended a four-visit anc schedule for low-risk pregnancies (who, drhrfc, 2003). however, a recent systematic review found many barriers to the uptake of anc in developing countries (simkhada, van teijlingen, porter & simkhada, 2008). although, anc has been improving steadily in south asia, only 54% of pregnant women are receiving anc at least once from a skilled health worker as compared to 98% of pregnant women in industrialized countries (abouzahr & wardlaw, 2003). the government of nepal is committed to achieving the millennium development goal of reducing the maternal mortality ratio by three quarters between 1990 and 2015 (united nations development program [undp], 2005). therefore, the safe motherhood program is strongly advocated in the current national plan to improve maternal health. the national maternity care guidelines were developed in 1996 (family health division, ministry of health [fhd, moh], 1996) for the maintenance of standards of maternity practice. it was estimated that the maternal mortality rate was 740 per 100,000 live births in 2000 in nepal (who, 2006). whilst evidence suggests that access to anc is insufficient to meet the population’s need, as 26% of pregnant women in nepal do not receive any anc at all and, of the remainder only 29% of pregnant women receive the recommended four check-ups (demographic and health survey, 2006). reason for this low anc usage include shyness (some women do not want to expose their body) and poor access in rural nepal to health care, and a lack of affordable women-oriented health services (simkhada et al., 2008). gender inequality is deeply rooted in nepalese culture which restricts women’s access to skilled health care (furuta & salway, 2006). generally when a woman marries she becomes part of her husband’s online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 78 family, where the men or older females such as her mother-in-law are in charge (simkhada, van teijlingen, porter, & simkhada, 2006). moreover, the low socioeconomic status of women is also associated with under-utilization of anc (eijk et al., 2006). we conducted a community-based quantitative study on utilization of care around pregnancy and childbirth among rural women in two villages, which are known as village development committees (vdcs) in nepal (dhakal et al., 2007). very few studies on this subject are carried out in rural settings and none have been undertaken in this area of the country. a huge part of nepal, especially rural areas, remain fairly inaccessible due to poor infrastructure including limited electricity services, transport and communication. therefore, our study attempted to assess the range of anc services used, barriers to utilization, perceived health problems and care-seeking behaviour. women were asked for their views and recommendations on how to improve anc services (dhakal et al. 2007). in nepal, there are nearly 4,000 vdcs or villages, each consisting of nine wards. each vdc has a sub-health post which provides primary health care including anc to pregnant women at the community level. female community health volunteers (fchvs) are located in each ward and support the health services (nepal, ministry of health, 1998), by delivering basic health care in areas where there is often no other health care provider available (united states agency for international development [usaid], n.d.). methodology and participants study design our study is descriptive and used a cross-sectional design. this design provided a useful, time and cost efficient method for collecting information regarding the utilization of anc among rural women. the study was conducted in march and april 2006. study population the study population comprised all women in the reproductive age group (15-49 years old) residing in two rural areas of kathmandu valley who had delivered a live baby in preceding 24 months. rural areas there consist of small towns and villages with people living up to two hours walking away from the main road. the study population was estimated on the basis of the last national census data (central bureau of statistics [cbs], 2001) due to the lack of accurate contemporary information. according to the last census data the total population of the two vdcs (called ‘c’ and ‘d’) chosen as sites for data collection was 8,569 people and it is estimated that the under-two-year old population comprises 4.23% of the total population (cbs, 2001). hence, the study population was estimated to be a total of 362 women in the two vdcs combined and a convenience sample was drawn of 150 women. the size of the sample was calculated on the basis of the last census data and information gained at local level by fchvs. the sample size was 41% of the target population. the first author visited house to house with the help of local fchvs to reach all targeted women. ethical approval was granted by the nepal research council and local authorities of the relevant vdcs. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 79 data collection a validated questionnaire was adapted from the nepal demographic and health survey (2006) and the nepal multiple indicator surveillance (cietinternational 1998). a pilot study (van teijlingen & hundley, 2005) was conducted among eight married women in the two study areas prior to the full study. some improvements to the questions were made after the pilot study. data were collected using face-to-face interviews with individual women by the first author (female) using a semi-structured questionnaire at their home or in their village. prior to data collection women were informed of the aim of the study and assured that their identity and the information they provided would be treated as confidential and they would remain anonymous. inclusion criteria were married women of reproductive age who had delivered their last child within 24 months preceding the study. if a woman had more than one child under 24 months, only the most recent pregnancy and delivery was consider in this study. unmarried and women outside of the reproductive age group, and currently pregnant women were excluded. statistical analysis data were entered and analysed using the spss version 13.0 for windows. descriptive statistics such as median and inter-quartile range was provided for skewed continuous data. spearman rank correlation coefficient was obtained between two ordinal data. appropriate chi-square tests were used to find association between socio economic and demographic characteristics of women and antenatal care. the odds ratio (or) and its 95% confidence interval (ci) were calculated to measure the strength of the association between demographic and socio-economic factors and antenatal care. those factors that were significant at 20% level in the univariate analysis were considered for the multivariate analysis. multivariate logistic regression with backward elimination method was used to find best combination of factors predicting anc. a p-value of less than 0.05 was considered to be statistically significant. findings utilization of antenatal care the prevalence of at least one anc visit during the last pregnancy was 78% (95% ci = 71% 84%). the median time of the first antenatal visit was at three-month into the pregnancy with inter-quartile range (iqr) 3 months and 5 months. more than half of the women (51%) had received their first anc check-up during the first trimester and the remaining women (48%) received in second trimester including a small proportion (3%) in third trimester. more than three quarters of the women (78%) who had attended any anc had attended the recommended four or more antenatal visits during their last pregnancy. the median frequency of antenatal visits was found to be 4 (iqr 4-6) times. the majority of women (63%) had attended their last antenatal visit during the ninth month of pregnancy. moreover, the number of anc visit is correlated with not having the first consultation for anc until the last trimester (r=0.51; p<0.001). forty-two percent of women received anc from a local health worker such as mother and child health workers (mchws) or auxiliary health workers (ahws), 39 percent from a doctor and 20 percent from a nurse. the majority of women (53%) had received anc at a hospital, a shp (48%) or other places (7%) such as mobile clinics or clinics run by a online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 80 non-governmental organization (ngo). few women attended both the hospital and the shp antenatal clinics. table 1: association of demographic, socio economic factors & antenatal check up anc (number) n=150 % yes (n=117) no (n=33) odds ratio/ confidence interval p-value age group <20 20 – 24 25 + 16 76 58 11 51 39 14 65 38 2 11 20 1.00 0.84 (0.08 – 4.57) 0.27 (0.03 – 1.39) 0.013 ethnicity brahmin/chhetri+others tamang 61 89 41 59 60 57 1 32 1.00 0.03 (0.0-0.21) 0.001 education of women illiterate primary+ secondary 73 77 49 51 42 75 31 2 1.00 27.68 (6.37-121.4) 0.001 occupation of women house wife + others farmer 43 107 29 71 42 75 1 32 1.00 0.06 (0.0-0.40) 0.001 education of husband illiterate primary + secondary 21 129 14 86 9 108 12 21 1.00 6.73 (2.56-18.32) 0.001 occupation of husband other jobs* farmer 77 73 51 49 71 46 6 27 1.00 0.14 (0.05-0.40) 0.001 # of family members 3-4 5-8 9+ 34 88 28 23 59 19 29 65 23 5 23 5 1.00 0.49 (0.13-1.49) 0.79 (0.16-3.92) 0.331 # of children 1 or 2 3 or more 113 37 75 25 99 18 14 19 1.00 0.13 (0.05-0.34) 0.001 # of pregnancies 1 2 3 or more 68 36 46 45 24 31 61 30 26 7 6 20 1.00 0.57 (0.15-2.14) 0.15 (0.05-0.43) 0.001 age at first pregnancy <18 19 + 53 97 35 65 41 76 12 21 1.00 1.06 (0.43-2.52) 1.00 miscarriages yes no 13 137 9 91 12 105 1 32 1.00 0.27 (0.03-2.18) 0.17 # = number, * other jobs include formal, foreign and other jobs. anc uptake was different among different age groups (p=0.013), with older women significantly less likely to seek anc than younger women. the ‘tamang’ ethnic online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 81 group was less likely to have utilized anc than brahmin/chhetri and other ethnic groups (p=0.001). the occupation of the woman and her husband’s occupation influences her having anc. woman or her husband having farming as their occupation were less likely to seek anc than those working in the formal sector or those being housewives or having other jobs. it was observed that if women or their husbands were educated to at least primary school level women were more likely to seek anc than women who were illiterate or whose husbands were illiterate. the number of family members a woman had was not associated with the level of anc uptake. women with three or more pregnancies or children were less likely to seek anc than women with one or two children (p=0.001). age at pregnancy and miscarriages were not associated with anc uptake. education levels of women, occupation of husband in the formal sector, having fewer children and ethnic group women other than those from the tamang community were significantly associated with seeking anc (see table 2). table 2: association of demographic, socio economic factors and anc check using multivariate logistic regression analysis factors adjusted or 95% ci* ethnicity – tamang educated woman occupation of husband – farmer number of children 3 or more 0.11 9.13 0.26 0.23 0.01-0.97 1.83-44.18 0.08-0.82 0.08-0.64 services offered during anc table 3 (see table 3 here) highlights what kind of services women who received during their anc. table 3: tests and examinations during antenatal visit (n=117) anc examination number % weight 110 94 height 51 44 blood pressure 103 88 urine test 70 60 blood test 73 62 conjunctiva for anaemia 94 80 ankle for swelling 97 83 nearly all (95% of those who had received any anc) had been given iron/folic acid. the minimum duration of taking iron/folic acid was one week and the maximum 36 weeks. the majority of women (70%) had received a t.t. (tetanus toxoid) injection during pregnancy. among t.t. recipients, 65% had received two or more doses and 5% had had only one dose. many had their weight checked (94%), blood pressure measured (88%), conjunctiva for anaemia (80%) and ankle checked for swelling (83%) at least once during their antenatal visits. table 3 further shows that only 44% of women reported had their height checked, or urine tested (60%) or blood tested (62%). the majority of women (79%) reported having received health advice during their anc. most women received suggestions for a nutritious diet (84%), while only 27% got advice on danger signs in pregnancy (see table 4). online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 82 table 4: advice given by health workers to women during antenatal visit (n=117) topic for advice number % nutritious diet 77 84 danger signs 25 27 place of delivery 34 37 breast feeding(colostrums) 29 31 rest/reduction of heavy workload 35 38 only 24% women had received anc free of charge. the median cost per visit was found to be the equivalent of 10 cents (iqr= 3 to 70). interestingly, only 8% of women received anc free of cost from hospitals compared to 34% who had received free anc from sub-health posts in the community. women who received anc were asked their satisfaction with the services which they had received. almost all (97%) women were satisfied on anc. household decision on the utilization of antenatal care women, who had received anc, were asked about the decision-making process, and more women reported that the mother-in-law (37%) made the decision to go for anc, than they did themselves (30%), or their husbands (27%) or others (6%). moreover, mother-in-laws (40%) and husbands (40%) had more power in decisionmaking on the utilization of anc within brahmin/chhetri households. similarly, in the tamang ethnic group, mother-in laws (33%) and husbands (26%) had more influence on the anc decision than the women themselves. perceived barriers to anc all women were asked what they perceived to be the three key barriers to accessing anc in their community. the main problems were: no perceived need to attend anc (38%); distance to a health facility (36%); no money (19%); no transportation (15%); lack of skilled health workers locally (11%); and having, no time available to attend an anc clinic (8%). suggestions for improvement of antenatal care in the community suggestions for the improvement of anc were sought from all women. again up to three suggestions were asked from all participants. availability of health services (46%) in their own villages, increased awareness of anc among women and their family members (35%) and availability of better trained health worker in villages were the main suggestions. in addition, 18% of women suggested more support from family members and 16% more medicine being made available. health problems during pregnancy and seeking care only 16% of women reported having health problems, these included: swollen legs (46%), vomiting in early pregnancy (29%), backache (25%), burning urination (17%), dizziness (12%), vaginal bleeding, jaundice (8%) and high blood pressure (4%). the majority women (79%) had sought care for those problems from a health professional. for the women who did not seek help, the main reason was not being aware of available health services; not perceiving a need; and no time due to workload. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 83 discussion our study showed that the utilization of anc among rural women is found to be encouraging as the overall rate of utilization of anc (78%) in the study area is better than the national percentage (72%). similarly, the percentage of women attending the recommended number of anc visits (4 or more) is found to be much better than national average (ndhs, 2006). it could be due to the rapid urbanization taking place in nearby vdcs of kathmandu valley. our study result agreed with another study conducted in a vdc of kathmandu district (pradhan, 2005). the national maternity care guidelines (fhd, moh, 1996) in nepal suggests that women should seek anc from trained local health workers as soon as a pregnancy is suspected. however, only about half of women (51%) attended their first anc visit in the first trimester. low anc attendance during the first trimester has been found in many developing countries (mwaniki, kabiru, & mbugua, 2002; ndyomugyenyi, neem, & magnussen, 1998). evidence shows that having first anc visit in the second trimester is common in many developing countries, and even in rural australia (trinh & rublin, 2006). accessing anc late in pregnancy may be associated with a lack of awareness, a perception that anc is not necessary, or that anc services available are of low quality. our study revealed that a mother-in-law’s advice is vital in utilization of anc in nepal. the majority of women listed their mother-in-laws’ views as key influencing on their decision-making whether or not to attend anc. recent studies in nepal found that mothers-in-law play a significant influence in the uptake of reproductive health care (masvie, 2006; simkhada, porter & van teijlingen, 2010). this contrasts with rural western kenya where most of women (87%) decided for themselves to visit the anc (eijk van et al., 2006). due to the social system in nepal, most people are living in extended families and most of the younger women do not have decision making power within the household. they are controlled by either their mother-in-law or husband. this is even more common in brahmin/chhetri families. similarly, women in nepal have a lower social status than men, which restricts women’s access to the utilization of anc (matsumura & gubhaju, 2001). moreover, decisions about mobility of women and expenditure on health care are controlled by men or older women of the household, which may limit women’s search for health care in general (vlassoff, 1994). this study has explored several associated factors with the utilization of anc as similar to postnatal care such as ethnicity, education of women, occupation of husband and number of children (dhakal et al., 2007). tamang women, women with many children, illiterate and farmer women have less access to anc. the main barriers are a lack of awareness, time and distance to the health facility. similarly, older age and high parity women are less likely to receive anc, as there was significant reduction in the proportion of women receiving anc as the number of number of living children increases, as reported in other studies (dhakal et al., 2007; shakya & mcmurray, 2001; chandhiok, dhillon, kambo & saxena, 2006). education was found to be a positive factor for anc uptake in our study. other studies have shown that women with secondary education are more likely to receive at least four antenatal visits than women with less or without education (abauzahr & kwardlaw, 2003; pradhan, 2005; matsumura & gubhaju, 2001, shakya & mcmurray, 2001; simkhada et al., 2008). online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 84 generally poverty had an impact of seeking anc, as women living off farming and those from lower caste background (i.e. tamang) are less likely to use anc. similarly, the higher the husband’s education and occupation levels, the higher the uptake of anc (fatmi & avan, 2002; dhakal et al., 2007). poverty levels are, of course, also related to cultural beliefs and media exposure which are both influential factors in the uptake of anc (simkhada et al. 2008). evidence has shown that anc is an important intervention that improves the safety of birthing for both the mother and child and significantly increases the likelihood of having skilled assistance during childbirth (shakya & mcmurray, 2001). however, about one-quarter of women in our study did not receive anc for a variety of reasons. the major obstacles to the utilization of anc are lack: of awareness, unavailability and inaccessibility or distance to health facilities, poverty, charges and associated costs, and poor services offered at the local health facilities (ikamari 2004; larsen, lupiwa, kave, gillieatt & alpers, 2004). although, anc is free of charge in nepal, only less than onefourth of women who had received anc reported that their anc had been free. cost of anc may include: travel cost, and other pregnancy-related diagnosis cost. table 3 shows that only 44% women had their height measured, though maternal height is part of a complex set of determinants of pregnancy outcomes (spencer & logan, 2002). lack of measurement facilities in the health institutions might be the main reason for low levels of measurement. similarly in table 3, the proportion of women who had a urine or blood test was fairly low. in nepal, there is a provision of free supply of iron and folic acid tablets and t.t. injection to each pregnant woman (fhd, moh, 1996), which explains the high uptake of iron and folic tablets in our study, although t.t. coverage was lower. more than three-quarters of pregnant women had received health advice on different topics during their antenatal visits. however, advice on place of delivery (37%) is quite low. similarly, only 27% was informed on danger signs in pregnancy. the anc service in the study area is seen to be worse with respect to advice on danger signs than the national nepalese average (demographic and health survey, 2006) and parts of rural kenya (pradhan, 2005). our study demonstrated that 32% of the women had received anc from local health workers such as mchw/ahw which is higher than the 28% nationally (demographic and health survey, 2006). it is proffered that the availability of anc in sub-health posts in the vdc level improves women’s access. however, more women (55%) who received anc from hospitals were ‘very satisfied’ than women (39%) who received anc from sub-health posts in the community. this might be related to confidentiality and the facilities for anc check-ups separate room, instruments and laboratory test facilities. the perception of quality of anc is an important factor to increase in uptake of anc (acharya & cleland, 2000). women in this study experienced low levels of health problems during pregnancy. perhaps some did not perceive that they had health problems or assumed that only relatively serious conditions should be mentioned as health problems during anc visits (cietinternational, 1998: 8). moreover, limited capacity to recognize danger signs is a major obstacle to seeking care (mesko et al., 2003). limitation of the study online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 85 during the time of the study security situation was very unstable in nepal. the maoists were engaged in a violent conflict with the government and it was not safe to visit to certain remote areas. therefore, the study was limited by the areas which might not comprehensively reflect the normal situation of rural nepal. similarly, our study could not cover large geographical areas due to limited time and resources. data were collected from women who were at their home, so that there might be selection bias since the visits were during the day. similarly, due to lack of information about target population we changed our target group to included women having a live child under 24 months rather than 12 months. this change might be arisen recall bias. conclusions the uptake of anc was encouraging in the study areas which showed higher anc utilization rates than national data. most notably 78% of women who had received anc had attended four or more antenatal visits. moreover, the anc services offered appeared to be satisfactory although some components of the anc examination such as measuring height and advice given to pregnant mothers about danger signs are found to be poor. more interestingly, the study showed that mother-in-laws in nepal play a vital role in decision-making on the utilization of anc. not perceiving the need for anc and no time due to work were the main reasons behind the non-utilization of anc. similarly, a lack of awareness of anc and distance to a health facility were the main perceived barriers to access to anc. the main factors influencing on utilization of anc were ethnicity, education of women, occupation of husband and number of children. availability and accessibility of high quality anc services and awareness of anc among pregnant women, mother-in-laws and husbands are helpful step to improve anc. references abouzahr, c. & wardlaw, t. (2003). antenatal care in developing countries; promises, achievement and missed opportunities: an analysis of trends, levels and differentials. geneva, switzerland: who. acharya, l.b., & cleland, j. (2000). maternal health services in rural nepal: does access or quality matter more? health policy & planning, 15(2), 223-229. [medline] bullough, c., meda, n., makowiecka, k., ronsmans, c., achadi, e.l., & hussein j. (2005). current strategies for the reduction of maternal mortality. bjog, 112, 1180-1188. [medline] central bureau of statistics, (2001). statistical year book of nepal 2001. kathmandu: central bureau of statistics. chandhiok, n., dhillon, b.s., kambo, i., & saxena, c.n. 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(2002). utilization of antenatal and maternity services by mothers seeking child welfare services in mbeere district, eastern province, kenya. east african medical journal, 79, 184-187. [medline] nepal, ministry of health (1998). overview of the second long term health plan – 19972017. kathmandu: ministry of health ndyomugyenyi, r., & neema s., & magnussen, p. (1998). the use of formal and informal services for antenatal care and malaria treatment in rural uganda. health policy & planning, 13, 94-102. [medline] pradhan, a. (2005). situation of antenatal care and delivery practices. kathmandu university medical journal, 3 (3), 266-270. [medline] shakya, k, & mcmurray, c. (2001). neonatal mortality and maternal health care in nepal: searching for patterns of association. journal of biosocial science, 33, 87105. [medline] http://www.ncbi.nlm.nih.gov/pubmed/17767710 http://www.ncbi.nlm.nih.gov/pubmed/12174476 http://www.ncbi.nlm.nih.gov/pubmed/16723298 http://www.ncbi.nlm.nih.gov/pubmed/17298114 http://www.ncbi.nlm.nih.gov/pubmed/16862944 http://www.ncbi.nlm.nih.gov/pubmed/8842811 http://www.ncbi.nlm.nih.gov/pubmed/10075217 http://www.ncbi.nlm.nih.gov/pubmed/15967547 http://www.ncbi.nlm.nih.gov/pubmed/17359562 http://www.ncbi.nlm.nih.gov/pubmed/12932300 http://www.ncbi.nlm.nih.gov/pubmed/12625672 http://www.ncbi.nlm.nih.gov/pubmed/10178189 http://www.ncbi.nlm.nih.gov/pubmed/18650590 http://www.ncbi.nlm.nih.gov/pubmed/11316397 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 87 simkhada, b., porter, m., & teijlingen, e. van. (2010). the role of mothers-in-law in antenatal care decision-making in nepal: a qualitative study. bmc pregnancy & childbirth 10(34), 1471-2393. [medline] simkhada, b., teijlingen, e. van, porter, m., & simkhada, p (2006). major problems and key issues in maternal health in nepal. kathmandu university medical journal, 4 (2), 261-266. [medline] simkhada, b., teijlingen, e. van, porter, m., & simkhada, p (2008). factors affecting the utilisation of antenatal care in developing countries: a systematic review of the literature. journal of advanced nursing, 61 (3), 244-260. [medline] spencer, n.j. & logan, s. (2002). the treatment of parental height as a biological factor in studies of birth weight and childhood growth. archives of disease in childhood, 87, 184–187. [medline] teijlingen, e. van, & hundley, v. (2005) pilot studies in family planning and reproductive health care. journal of family planning & reproductive health care, 31 (3), 219-221. [medline] trinh l.t.t, & rublin, g. (2006). late entry to anteatal care in new south wales, australia. reproductive health 3(8). [medline] united nations development programme (2005). nepal millennium development goals: 5 improve maternal health, retrieved from http://www.undp.org.np/publication/html/mdg2005/08_mdg_npl_goal5.pdf united states agency for international development (n.d.) empowering female community health volunteers: usaid supports 46,000 volunteers in nepal on basic health care to save children, retrieved from http://www.usaid.gov/stories/nepal/fp_nepal_female.pdf van eijk, a., & bles, h., & odhiambo, f., & ayisi, j., & blokland, i., & rosen, d., … & lindblade k. (2006). use of antenatal and delivery care among women in rural western kenya: a community based survey. reproductive health 3 (2). [medline] vlassoff, c. (1994). gender inequalities in health in the third world: uncharterted ground. social science & medicine, 39(9), 1249-1259. [medline] world health organization, department of reproductive health and research, family and community health (2003). integrated management of pregnancy and childbirth. pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. geneva, switzerland: who. world health organization (2006). mortality country fact sheet 2006 retrieved from www.who.int/whosis/mort/profiles/mort_searo_npl_nepal.pdf http://www.ncbi.nlm.nih.gov/pubmed/20594340 http://www.ncbi.nlm.nih.gov/pubmed/18603913 http://www.ncbi.nlm.nih.gov/pubmed/18197860 http://www.ncbi.nlm.nih.gov/pubmed/12193422 http://www.ncbi.nlm.nih.gov/pubmed/16105287 http://www.ncbi.nlm.nih.gov/pubmed/16916473 http://www.ncbi.nlm.nih.gov/pubmed/7801162 editorial 1 editorial letter from the editor: reviewers needed jeri dunkin, phd, rn editor the online journal of rural nursing and health care is the official journal of the rural nurse organization. it is an electronic journal and can be accessed at http://www.rno.org/journal/index.htm. it is a refereed journal and is indexed in cinahl and has an international readership. to complete the review processes necessary for a refereed journal there must be a volunteer panel of reviewers to judge the quality and appropriateness of submissions for publication. the review panel has international members and the published articles are from around the world. however, as peoples’ lives change their ability to provide this valuable service to the online journal of rural nursing and health care changes. that leaves the editorial in constant need of committed reviewers. if you would be interested in serving on the review panel of the online journal of rural nursing and health care please email a note of interest and your resume to the editor, dr. jeri dunkin, at jdunkin@bama.ua.edu. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://www.rno.org/journal/index.htm mailto:jdunkin@bama.ua.edu editorial 7 editorial winds of change in nursing education marietta stanton editorial board member i wanted to highlight changes that are occurring in nursing especially with regard to nursing education. one initiative which is gathering much support and adoption is a role proposed by the american association of colleges of nursing (aacn). it is called the clinical nurse leader (cnl). according to aacn, the role has been created in response to the institute of medicine’s landmark report, to err is human: building a safer health system, which called on health care systems to reorient their efforts to reduce medical errors and improve patient safety. in addition aacn perceived that in nursing we have not succeeded in differentiating practice of rns with different educational preparation. numerous reports have shown that care provided to patient is not high quality. in addition aacn believes that the knowledge base for nurses has increased dramatically. based on these three complex issues this new role was created. aacn appointed a task force to examine new educational models that would develop a “new nurse” graduate, educated beyond a four year baccalaureate program with a new license and a new license and scope of practice. in concept the cnl oversees the care coordination of a distinct group of patients and actively provides direct patient care in complex situations. this master’s degree prepared generalist clinician will put evidenced based practice into action to ensure that patients benefit from innovation in care delivery. the cnl will evaluate patient outcomes, assess cohort risk and has the decision making authority to change plans of care when necessary. the role will vary across settings and facilities. to support the creation of this new nursing role, aacn has launched a national project involving almost 90 education-practice partnerships in 35 states and puerto rico. educational and service partners are working together to develop master’s programs to prepare cnl’s, integrate this nurse into the health care system and evaluate outcomes. nurses from within the partner agency attend the program full-time and return there for an intense clinical experience during the program. this program has been implemented in many nursing schools across the country. in addition to the cnl role, the aacn educational task force has also called for a transformational change in the education required for professional nurses who practice at the most advanced levels of nursing practice. this new degree program will be the doctorate of nursing practice (dnp). in essence these dnp programs will be the preparation for nurse practitioners, clinical specialists, nurse anesthetists, and midwives as well as nurse executives in the future. this transformation is supposed to occur in and around 2015. however, there are some schools that have already implemented a program preparing for this role. although there has been much discussion about both roles and the changes in educational preparation, it does not appear to be a “what if” situation but more a “when “question. this truly has implications for all nurses but especially those nurses who work in rural areas. access to quality educational preparation will truly be an issue. after attending the regional meeting on the dnp hosted by aacn, it became very apparent that many in our ranks are not aware of this paradigm shift in nursing education. for additional information on the cnl and dnp roles visit http://www.aacn.nche.edu. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.aacn.nche.edu/ microsoft word predictors of overweight and obesity in a sample of rural saskatchewan children final.doc online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 51 predictors of overweight and obesity in a sample of rural saskatchewan children jeniffer r. dupuis, rn, mn 1 karen m. semchuk, phd 2 adam d.g. baxter-jones, phd 3 donna c. rennie, rn, phd 4 1 faculty, nursing division, saskatchewan institute of applied science and technology, jeniffer.dupuis@siast.sk.ca 2 professor, college of nursing, university of saskatchewan and school of public health, km.semchuk@usask.ca 3 professor and associate dean, graduate education and research, college of kinesiology, university of saskatchewan, baxter.jones@usask.ca 4 professor, college of nursing, university of saskatchewan and canadian centre for health and safety in agriculture, donna.rennie@usask.ca keywords: child, overweight, obesity, body mass index, physical activity, rural, neighbourhood, neighborhood, saskatchewan abstract the aims of this cross-sectional study were to: (1) estimate the prevalence of overweight and obesity in a sample of 262 rural saskatchewan children and (2) to identify predictors of overweight and obesity. the data were collected using a self-report questionnaire and measurement of height and weight. when bmi values were compared to international standards the estimated prevalence was 25.5% for overweight and 7.1% for obesity. the significant predictors of overweight and obesity were gender, aboriginal descent, parent’s/guardian’s perception of neighbourhood safety, and parent’s bmi. nurses can use these results to develop health promotion programs aimed at reducing the prevalence of overweight and obesity among rural children and their families. there is no conflict of interest or financial disclosure statement required. predictors of overweight and obesity in a sample of rural saskatchewan children in the united states (ogden, flegal, carroll, & johnson, 2002; wang, 2001; wang, monteiro, & popkin, 2002), canada (he & beynon, 2006; janssen, katzmarzyk, boyce, king, & pickett, 2004; veugelers & fitzgerald, 2005; willms, tremblay, & katzmarzyk, 2003), australia (booth et al., 2001), and other countries (wang et al., 2002) the high prevalence of overweight and obesity among school-aged children is a major public health concern because of the longterm physical (hypertension, hyperlipidemia, and type ii diabetes) and psychological (depression and poor self-esteem) effects (carriere, 2003; he & beynon, 2006; veugelers & fitzgerald, 2005). for canadian children aged 2 to 17 years, published estimates vary from 7.7% to 35.2% for the prevalence of overweight (galloway, 2006; haque, de la rocha, horbul, desroches, & orrell, 2006; he & beynon, 2006; janssen et al., 2004; shields, 2005; veugelers & fitzgerald, 2005; willms et al., 2003) and from 2.3% to 19.1% for the prevalence of obesity (galloway, online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 52 2006; haque et al., 2006; he & beynon, 2006; janssen et al., 2004; shields, 2005; veugelers & fitzgerald, 2005; willms et al., 2003), with a higher prevalence of overweight (27.7% to 38%) observed for aboriginal children (bernard, lavallee, gray-donald, & delisle, 1995; hanley, harris, gittelsohn, wolever, saksvig, & zinman, 2000; katzmarzyk, 2008; katzmarzyk & malina, 1998). in addition to dietary factors, the high prevalence of childhood overweight and obesity has been attributed to an increasingly sedentary lifestyle (janssen et al., 2004; tremblay & willms, 2003) characterized by low levels of regular physical activity and high levels of sedentary leisure activities, such as computer and video game usage (davy, harrell, stewart, & king, 2004; janssen et al., 2004; lutfiyya, lipsky, wisdom-behounek, & inpanbutr-martinkus, 2007; tremblay & willms, 2003). one factor related to decreased physical activity levels is unsafe neighbourhoods; children of working parents are often instructed to remain indoors due to safety concerns (molnar, gortmaker, bull, & buka, 2004). compared to urban children, rural children may have a higher risk of becoming overweight or obese because of limited access to recreational programs and facilities (bilinski, semchuk, & chad, 2005; plotnikoff, bercovitz, & loucaides, 2004), associated travel costs (plotnikoff et al., 2004), and socioeconomic factors (lutfiyya et al., 2007). overweight and obesity of rural children was found to be related to a lower income and lower education level of the parents (plotnikoff et al., 2004). the lower socioeconomic status of rural families may affect their ability to purchase recreational equipment and to access recreational programs. in a previous study, using a self-report questionnaire and accelerometers, tremblay, barnes, copeland, and esliger (2005) found no significant differences in self-reported physical activity or bmi between a sample of rural and urban saskatchewan children and a sample of old order mennonite children in ontario, canada. little is known, however, about the prevalence or factors associated with overweight and obesity in rural canadian children. the aims of the present study were to: (1) estimate the prevalence of overweight and obesity in a sample of rural saskatchewan school-aged children and (2) to identify predictors of overweight and obesity. methods this cross-sectional study was conducted in a rural school division in south-eastern saskatchewan where the main industry is agriculture (cattle ranching, wheat, and other grain farming) and there are four first nation reservations. the target population included all students in grades 4 (n = 145), 5 (n = 186), and 6 (n = 194) attending 13 of the 14 schools in the target school division. the study participants lived in the 13 towns (population size: 172 to 1,067 persons) (statistics canada, 2002) or surrounding areas. ethical approval of the study was obtained from the university of saskatchewan behavioural research ethics board (beh 05-201). assent was provided by the child and consent by a parent or guardian. prior to starting the study, a 10 to 15 minute information session was held for the students in grades 4 to 6 at each participating school. each potential participant received a research package (information letter, two copies of the consent form, questionnaire). data collection occurred in october 2005 and included completion of the self-report questionnaire by the child and a parent or guardian at home and anthropometric measurement of the child at the school. the questionnaire consisted of three sections. section one gathered demographic data about the child [date of birth, gender, grade, residency (farm versus town), aboriginal versus non-aboriginal] and the child’s parents or guardian (perceived neighbourhood safety, educational level, height, and weight). section two gathered data on the average number online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 53 of hours per day the child was involved in sedentary leisure activities (e.g., television watching, video games, talking on the phone). in section three, the physical activity questionnaire for older children (paq-c) (crocker, bailey, faulkner, kowalski, & mcgrath, 1997) was used to quantify the child’s physical activity level during the previous 7 days. the paq-c consists of nine items scored 1-5 with a final score calculated as the mean of the nine items. based on previous studies, the paq-c has an acceptable level of test-retest reliability (boys: r = .75, girls: r = .82) for children aged 8 to 13 years and a moderate level of construct validity (r = .46 – .53) (kowalski, crocker, & faulkner, 1997). each participant’s weight (measured + 0.5 pound with a digital scale) and height and sitting height (each measured + 0.1 cm with a stadiometer) were measured twice by the researcher with the child wearing light weight clothing and no shoes. a third measurement was taken when the two height or sitting height measurements differed by > 0.4 cm or the two weight measurements differed by > 1.0 pound. when two measurements were recorded, the average value was used. when three measurements were recorded, the median value was used. each participant’s bmi was calculated using the measured height and weight [weight (kg)/height (m 2 )] and compared to international standards using the participant’s age + 6 months (cole, bellizzi, flegal, & dietz, 2000). age at peak height velocity (phv), calculated using the variables gender, date of birth, date of measurement, height, sitting height, and weight, was used to identify the participant’s maturational age (mirwald, baxter-jones, bailey, & beunen, 2002; http://taurus.usask.ca/growthutility/phv_ui.cfm?type=1). maturity age is calculated by subtracting age at phv from chronological age at the time of measurement. at phv maturity age equals 0. prior to phv maturity age is negative. following phv maturity age is positive (thompson, baxter-jones, mirwald, & bailey, 2002). the data were coded, entered into computer compatible format, and analyzed using spss 14.0. differences between boys and girls were examined using the t-test for independent samples. chi square (with continuity correction) and fisher’s exact tests were used to explore associations between gender and the other categorical variables. one-way anova and scheffé’s post hoc analysis were used to examine group differences in the mean paq-c score. logistic regression analysis was used to identify significant predictors (and first order interactions) of overweight and obesity. statistical significance was indicated by an alpha of .05. results of the 525 questionnaires distributed, 262 were returned completed along with a signed consent form (49.9%) and 251 (47.8%) participants had anthropometric measures. the 262 students included 111 boys and 151 girls. ages ranged from 8 to 12 years (boys: m = 10.7 years, sd = 0.91 year; girls: m = 10.6 years, sd = 0.87 year). the mean age at phv was 13.3 years (sd = 0.52) for boys and 11.8 years (sd = 0.55) for girls. participants were in grades four (27.1%), five (37.4%), and six (35.5%). forty-three (16.8%) were self-identified as aboriginal and 16 (6.1%) lived on a first nation reserve. the proportions of farm (47.5%) and town (46.4%) residents were similar. no significant differences were observed between boys and girls for height (boys: m = 144.0 cm, sd = 8.19 cm; girls: m = 144.0 cm, sd = 8.89 cm), weight (boys: m = 41.4 kg, sd = 11.39 kg; girls: m = 40.4 kg, sd = 11.81 kg), or mean bmi (boys: m = 19.7, sd = 3.98; girls: m = 19.2, sd = 3.98). using age and gender standards for bmi (cole et al., 2000) the estimated prevalence of overweight was 25.5%; the estimated prevalence of obesity was 7.1%; and similar proportions of boys (68.0%) and girls (67.0%) were of normal weight. while the proportion online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 54 overweight was larger for girls (27.3%) than boys (23.0%) and the proportion obese was larger for boys (9.0%) than girls (5.8%), none of these differences were statistically significant. for aboriginal participants, the estimated prevalence of overweight was 41.2% (boys: 56.3%; girls: 27.8%) and the estimated prevalence of obesity was 8.8% (boys: 6.3%; girls: 11.1%). overall, 69.9% of the participants’ mothers and 44.7% of the fathers had some post secondary education. the majority of the parents or guardians surveyed considered their neighbourhoods to be “quite safe” (41.5%) or “safe” (46.5%). based on self-reported height and weight, 87.6% of the participants’ fathers and 53.5% of the mothers were overweight or obese. each participant’s bmi category was compared to the participant’s mother’s and father’s bmi category. for boys, a positive association was found between the boy’s bmi category and the mother’s bmi category [ 2(c) (1, n = 89) = 4.38, p = .036]. for girls, there was a positive association between the girl’s bmi category and the father’s bmi category [ 2(c) (1, n = 121) = 5.48, p = .019]. the proportion of overweight or obese participants (30.7%) with at least one overweight or obese parent was significantly larger than the proportion of overweight or obese participants (0.9%) whose parents were both of normal weight [ 2(c) (1, n = 218) = 4.19, p = .041]. while this relationship was not statistically significant for boys (both parents of normal weight: 1.1%, one parent overweight or obese: 29.0%), the proportion of overweight or obese girls with an overweight or obese parent (32.0%) was significantly larger than the proportion of overweight or obese girls whose parents were both of normal weight (0.8%) [ 2(c) (1, n = 125) = 4.02, p = .045]. participants reported spending approximately 1-4 hours in sedentary leisure activity on school days and on the weekend, with no significant difference between boys and girls. a larger proportion of aboriginal (42.9%) compared to non-aboriginal (21.8%) participants reported spending, on average, > 4 hours in leisure activity on the previous weekend [ 2 (2, n = 253) = 9.28, p = .010]. the mean paq-c score did not differ significantly between boys (m = 3.3, sd = 0.64) and girls (m = 3.2, sd = 0.57). students who spent < 1 hour/day in leisure activity on school days (m = 3.4, sd = 0.63), however, had a higher mean paq-c score compared to students who spent 1-4 hours/day (m = 3.2, sd = 0.60) in leisure activity [anova, f(2, 256) = 3.53, p = .031]. the mean paq-c score did not differ significantly by bmi category (normal weight: m = 3.3, sd = 0.59; overweight or obese: m = 3.1, sd = 0.61). in the multiple variable logistic regression analysis, when boys and girls were considered together (table 1, model 1), with adjustment for the other variables in the model, significant positive associations were observed between the prevalence of overweight or obesity among participants and the variables gender, aboriginal descent, and bmi category of the participant’s mother and father, while an inverse association was observed for the variable parent’s/guardian’s perception of neighbourhood safety. for boys (table 1, model 2), the prevalence of overweight or obesity was higher for aboriginal compared to non-aboriginal boys and for boys whose mothers were overweight or obese compared to boys whose mothers were of normal weight. for girls (table 1, model 3), the prevalence of overweight or obesity was higher for girls whose fathers were overweight or obese compared to girls whose fathers were of normal weight. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 55 table 1 adjusted odds ratio a and 95% confidence interval for overweight or obesity b in participants by logistic regression model and study variables of interest variable model 1 all (n = 194) or 95% ci model 2 boys (n = 83) or 95% ci model 3 girls (n = 111) or 95% ci gender girls boys 4.11 1.31-12.88 1.00 reference aboriginal descent yes no 4.38 1.58-12.15 1.00 reference 13.50 2.59-70.430 1.00 reference 2.41 0.52-11.03 1.00 reference residence farm or reserve town 0.81 0.41-1.60 1.00 reference 2.27 0.62-8.27 1.00 reference 0.44 0.17-1.13 1.00 reference parent’s /guardian’s perception of neighbourhood unsafe-moderately safe quite safe safe 0.26 0.07-0.94 1.08 0.52-2.23 1.00 reference 0.07 0.00-1.71 1.14 0.29-4.45 1.00 reference 0.28 0.06-1.42 1.29 0.47-3.57 1.00 reference education level of mother high school or less some post secondary technical training university degree 0.93 0.28-3.12 0.52 0.15-1.79 0.98 0.32-3.03 1.00 reference 0.18 0.02-1.82 0.11 0.01-1.02 0.11 0.01-1.09 1.00 reference 2.27 0.39-13.10 1.47 0.23-9.45 2.56 0.52-12.70 1.00 reference education level of father high school or less some post secondary technical training university degree 1.30 0.35-4.89 0.35 0.05-2.42 1.44 0.36-5.81 1.00 reference 2.75 0.23-33.13 0.95 0.04-21.01 1.94 0.13-29.09 1.00 reference 1.91 0.27-13.40 0.74 0.04-14.16 3.47 0.45-26.77 1.00 reference bmi category of mother overweight/obese normal weight 5.10 1.56-16.73 1.00 reference 7.21 1.60-32.51 1.00 reference 0.75 0.28-1.97 1.00 reference bmi category of father overweight/obese normal weight 4.53 1.17-17.54 1.00 reference 2.08 0.13-34.31 1.00 reference 5.41 1.04-28.07 1.00 reference weekend day leisure activity > 4 hours/day < 4 hours/day 1.55 0.69-3.48 1.00 reference 1.34 0.29-6.08 1.00 reference 1.93 0.65-5.71 1.00 reference paq-c score 0.75 0.40-1.38 1.80 0.52-6.26 0.45 0.18-1.1 gender*bmi mother c a results of multiple logistic regression analysis. adjusted crude odds ratios were not estimated for the variables age and grade because the bmi estimates on which the classification of normal weight versus overweight or obesity already take into consideration the child’s age. b bmi categories are based on the international standards for body mass index (cole et al., 2000). c statistically significant interaction between the variables gender and bmi category of the participant’s mother (p = .015). with adjustment for the other variables in the model, the odds ratio estimates were: (1) odds ratio = 4.11 (95% ci = 1.31 – 12.90) for boys whose mothers were overweight or obese compared to boys whose mothers were not overweight or obese. (2) odds ratio = 0.68 (95% ci = 0.27 – 1.71) for girls whose mothers were overweight or obese compared to girls whose mothers were not overweight or obese. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 56 (3) odds ratio = 5.10 (95% ci = 1.56 – 16.74) for girls whose mothers were not overweight or obese compared to boys whose mothers were not overweight or obese. (4) odds ratio = 0.84 (95% ci = 0.34 – 2.05) for girls whose mothers were overweight or obese compared to boys whose mothers were overweight or obese. the multiple variable analysis revealed significant interaction between the variables gender and bmi category of the participant’s mother (see table 1, footnote c). a significantly larger proportion of boys whose mothers were overweight or obese were also overweight or obese compared to boys whose mothers were of normal weight (or = 4.11, 95% ci = 1.31-12.90). in addition, for participants whose mothers were not overweight or obese, a larger proportion of girls were overweight or obese compared to boys (or = 5.10, 95% ci = 1.56-16.74). physical activity or inactivity were not found to be significant predictors of bmi category. discussion prevalence of overweight and obesity in this rural sample, the prevalence of overweight was 25.5% and the prevalence of obesity was 7.1%. these results are similar to previous estimates for overweight (7.7% to 35.2%) and obesity (2.3% to 19.1%) in school-aged children in canada (galloway, 2006; haque et al., 2006; he & beynon, 2006; janssen et al., 2004; shields, 2005; veugelers & fitzgerald, 2005; willms et al., 2003). like the previous canadian studies, studies conducted in the united states (davy et al., 2004; lutfiyya et al., 2007; ogden, et al., 2002), australia (booth et al., 2001), england (rudolf et al., 2004), and sweden (berg, simonsson, brantefors, & ringqvist, 2001) revealed wide variation in the estimated prevalence of overweight (6.8% to 22.0%) and obesity (5.0% to 17.0%) among school-aged children. the lack of a significant gender difference in the estimated prevalence of overweight and obesity in the present study is consistent with results of previous studies in canada (haque et al., 2006; veugelers & fitzgerald, 2005) and the united states (davy et al., 2004; ogden, et al., 2002). there were methodological differences between the present study and the previous studies. in two previous studies, bmi data were compared to the nhanes standards (davy et al., 2004; ogden, et al., 2002) instead of the international standards (haque et al., 2006; veugelers & fitzgerald, 2005) used in the present study. in addition, ages of the participants varied; hence, results could not be accurately compared because participants in the present study were not the same age as participants in the previous studies. davy et al. and veugelers and fitzgerald studied grade 5 students, while haque et al. studied children aged 6 to 17 years, and ogden et al. studied children aged < 19 years. factors associated with being classified as overweight or obese factors found consistently to have a significant association with the prevalence of overweight and obesity were self-reported aboriginal descent and the participant’s mother’s and father’s bmi category. in the present study, the estimated prevalence of overweight or obesity was higher for aboriginal compared to non-aboriginal participants. this finding is consistent with results of previous studies in canada (bernard et al., 1995; hanley et al., 2000; katzmarzyk, 2008; katzmarzyk & malina, 1998; shields, 2005) and the united states (eichner et al., 2008; jackson, 1993) where a high prevalence of overweight (25.4% to 38.0%) was found for aboriginal children. according to census canada data, in 2001, 32.9% of the total aboriginal population in canada was < 15 years of age. in saskatchewan, 26% of children aged < 15 years were aboriginal and this proportion is projected to increase to 37% by 2017 (statistics canada, 2005). the large proportion of overweight or obese aboriginal children in saskatchewan and online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 57 canada indicates a need for health promotion and education programs aimed at reducing the prevalence of overweight and obesity in this population. in the present study, the proportion of overweight or obese participants (30.7%) with an overweight or obese parent was significantly larger than the proportion of overweight or obese participants (0.9%) whose parents were both in the normal weight category. in previous studies in canada (carriere, 2003; o’loughlin, paradis, renaud, meshefedjian, & gray-donald, 1998), the united states (cutting, fisher, grimm-thomas, & birch, 1999), australia (burke, beilin, & dunbar, 2001), germany (danielzik, langnase, mast, spethmann, & muller, 2002), korea (park, yim, & cho, 2004), and the netherlands (vogels et al., 2006) positive relationships were observed between parental overweight and obesity and childhood overweight and obesity. the observation, in the present study, that the proportion of overweight or obese participants whose fathers were also overweight or obese (30.8%) was significantly larger than the proportion of overweight or obese participants whose fathers were of normal weight (1.4%) is consistent with findings of previous studies (danielzik et al., 2002; park et al., 2004; vogels et al., 2006) and provides support for the importance of considering familial relationships when assessing obesity patterns in children. the large proportion of overweight or obese girls with an overweight or obese parent (32%) in the present study is consistent with results of a previous study of 9 to 12 year old inner city children in montreal, canada (o’loughlin et al., 1998). the findings that, compared to boys of normal weight, boys who were overweight or obese were more likely to have an overweight or obese mother and, compared to girls of normal weight, girls who were overweight or obese were more likely to have an overweight or obese father are consistent with results of a longitudinal study of australian youth aged 9 to 18 years (burke et al., 2001) in which significant associations were found between the presence of overweight or obesity in fathers and daughters, fathers and sons, mothers and sons, and mothers and daughters. in a study of preschool children in pennsylvania, cutting et al. (1999) found a positive correlation (r = .43, p < .05) between the bmi of mothers and daughters. female weight gain often begins after puberty. it is, therefore, possible that any real positive association regarding pattern of weight gain in girls and their mothers was not detected in the present study because the sample included mainly prepubescent girls. relationship between physical activity level and bmi in this study, physical activity level did not vary by bmi category. similarly, in a study of grade 3, 7, and 11 students in nova scotia, canada, thompson et al. (2005) found no significant association between the average amount of time involved in physical activity and the bmi category of the children. in other studies, however, normal weight children were found to be more physically active than overweight or obese children (ball, marshall, & mccargar, 2005; ekelund et al., 2004; patrick et al., 2004). the inconsistency in findings between the present study and previous studies may be due to differences in the ages of the children studied, geographic location, or instrumentation. for example, the study by ball et al. included only urban dwelling children, while only rural dwelling children were included in the present study. rural children, compared to urban children, may have a higher risk of becoming overweight or obese because of limited access to recreational programs and facilities (bilinski et al., 2005; plotnikoff et al., 2004). differences in instrumentation between studies is another possible explanation for the inconsistent findings regarding the relationship between physical activity level and bmi. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 58 ekelund et al. and patrick et al. used accelerometers to measure physical activity, while the paqc was used in the present study. the paq-c, a self report questionnaire, may not be as sensitive as other methods, such as accelerometers, for identifying differences in physical activity levels. in the present study, students who spent < 1 hour/day in sedentary leisure activity on school days had a higher mean paq-c score compared to students who spent 1-4 hours/day. in contrast, in a study of 9 to 18 year old youth in quebec city, canada, katzmarzyk, malina, song, and bouchard (1998) found no significant association between the self-reported duration of television viewing and physical activity level assessed using a 3 day activity record. these differences may be due to differences in the ages of the children studied, geographic location, or sample size. katzmarzyk et al. studied a sample of 784 urban dwelling youth aged 9 to 18 years. the finding, in the present study, that the mean paq-c score did not differ significantly between boys and girls is consistent with results of other studies of canadian children living in rural (bilinski et al., 2005; thompson et al., 2005; tremblay et al., 2005) and urban (ball et al., 2005; thompson et al., 2005; tremblay et al., 2005) settings. in europe (ekelund et al., 2004) and the united states (patrick et al., 2004), however, boys were found to have significantly higher mean physical activity levels than girls. ekelund et al., patrick et al., and thompson et al. used accelerometers to measure physical activity levels while ball et al., bilinski et al., and tremblay et al. (2005) used a self-report questionnaire similar to the one used in the present study. thus, inconsistencies in findings between this and other studies may be due to the differences in instrumentation. strengths and limitations the convenience sample of children in the present study might not be representative of the target rural population, which may limit the generalizability of the findings. students and parents (or guardians) interested in physical activity and bmi may have been more likely to participate in the study compared to those not interested in the topic. use of a self-report questionnaire to collect information on sedentary leisure activity and physical activity is another limitation of the study. self-report relies on memory and children might not accurately recall their daily activities. results of previous studies, however, indicate that the paq-c yielded an acceptable level of testretest reliability for children aged 8 to 13 years and a moderate level of construct validity (kowalski et al., 1997). in addition, findings of this study are similar to results of a previous study of saskatchewan children who were of the same age and whose height and weight were measured (tremblay et al., 2005). a strength of the present study was the use of measured rather than self-reported data on weight and height to estimate bmi. use of measured height and weight is more accurate due to the tendency to underreport weight and over report height (strauss, 1999). a limitation of using bmi as an indicator of overweight/obesity is that muscle, bone, and level of sexual maturation influence bmi levels (skybo & ryan-wenger, 2003). advantages of using bmi are that it is easily calculated and safe and inexpensive to obtain. key strengths are that this study contributes to the body of knowledge on the prevalence of overweight and obesity among rural children and adds to the empirical literature on differences in the prevalence of overweight and obesity between aboriginal and non-aboriginal rural children in canada. this information is important due to the rapidly increasing size of the population of aboriginal children in canada. conclusion this exploratory descriptive study provided a cross-sectional view of the prevalence of overweight and obesity in a sample of rural saskatchewan children aged 8 to 12 years. significant findings of this study suggest that children whose parents are overweight or obese online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 59 may be more likely to be overweight or obese compared to children whose parents are of normal weight and that efforts aimed at prevention of childhood overweight and obesity must target families. further research is needed to identify specific risk factors for parental and child overweight and obesity in rural populations. although physical activity was not a significant predictor, lifestyle habits, including diet, physical activity, and sedentary leisure activity of both parents and children should be explored. findings of this study conflict with results of a previous study by plotnikoff et al. (2004) in which an inverse association was found between the prevalence of overweight and obesity of rural children and the parents’ income and education levels. in the present study, parents’ education level and perceived neighbourhood safety were not consistent significant predictors of overweight and obesity. in the analysis where boys and girls were considered together an inverse association was observed for the variable perceived neighbourhood safety, which is consistent with the findings of molnar et al. (2004) who attributed decreased physical activity levels to unsafe neighbourhoods. when boys and girls were considered separately, however, perceived neighbourhood safety was not significant predictor of overweight and obesity in the present study. findings of this and other studies support the need to develop health promotion programs aimed at reducing the prevalence of overweight and obesity among aboriginal and non-aboriginal children in canada. these health promotion and education programs should involve collaboration of health professionals, educators, individuals, families, and communities in order to provide holistic and culturally appropriate programs tailored to the needs of individual children and their families. references ball, g.d., marshall, j.d., roberts, m., & mccargar, l.j. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/16286859 http://www.ncbi.nlm.nih.gov/pubmed/16015137 http://www.ncbi.nlm.nih.gov/pubmed/12917717 http://www.ncbi.nlm.nih.gov/pubmed/16157724 http://www.ncbi.nlm.nih.gov/pubmed/17023696 http://www.ncbi.nlm.nih.gov/pubmed/11689534 http://www.ncbi.nlm.nih.gov/pubmed/12036801 http://www.ncbi.nlm.nih.gov/pubmed/12740457 9 health literacy in a rural clinic felecia g. wood, dsn, rn1 1 assistant professor, capstone college of nursing, university of alabama, fwood@bama.ua.edu keywords: health literacy, rural health, realm test abstract purpose: health literacy is a critical prerequisite to effective self-management of any health problem. nearly half of all adult u.s. citizens have difficulty with reading skills. for those living in rural areas who also experience health literacy deficits, self-management of health needs is doubly problematic. rural dwellers are more likely to delay treatment for health problems and more likely to experience chronic health problems than their urban counterparts. the purpose of this research was to assess the health literacy of those seeking care in a rural health clinic. design: the design of this descriptive study was a one-time survey using a convenience sample of 57 patients (89% caucasian, 65% female) from a rural clinic in the southeastern united states. data were collected in fall 2003. methods: the realm (rapid estimate of adult literacy in medicine) test and a demographic questionnaire were administered by trained nursing students to consenting patients as they arrived for clinic appointments. data were analyzed descriptively and with non-parametric one-way anova. findings: the mean realm score was 55.9 on a scale of 0 to 66. half of the participants (n =29; 50.8%) read at the high school level, and 6 (11%) read at grade six or lower. females scored significantly higher than males. the more difficult words included “impetigo,” “colitis,” “osteoporosis,” and “diagnosis.” conclusions: health literacy is a significant barrier to effective health care for many rural dwellers, particularly males. health care providers can minimize the negative consequences of limited health literacy by assessing the literacy of their population and adjusting written and verbal communications accordingly. introduction health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (united states department of health and human services [usdhhs], 2000) or even more simply, as “the ability to read, understand, and act on health information” (andrus & roth, 2002, p. 283). health literacy is crucial if patients are to benefit from health care. people who cannot read or understand the words used to describe health problems, diagnostic tests, medications, and directions for care experience yet another source of confusion in negotiating the health care system and are significantly handicapped in the tasks of self-care or caring for family members. the problems of low health literacy may be especially acute for those who live in rural areas. rural areas are characterized by residents with lower levels of education, higher rates of unemployment, lower salaries, and lack of health insurance (ricketts, online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://nursing.ua.edu/home.htm mailto:fwood@bama.ua.edu 10 1999; gamm, hutchison, dabney, & dorsey, 2003). rural dwellers are culturally likely to delay seeking health care until a condition has become advanced or urgent or until multiple chronic conditions exist. they then experience a relative shortage of health care sites and choices, a need to travel greater distances to reach health care, problems of transportation, and, very probably, an explanation of a complicated treatment regimen to act upon (eberhardt, ingram, makuc et al. 2001; doak, doak, & root, 1996). recognition of the importance of health literacy is a relatively recent phenomenon. ten years ago the concept was rarely studied or remarked upon. today, more than 400 articles and books have been published on the topic. as effective self-care can occur only in those who understand what they must do and why, the purpose of this research was to assess the health literacy of those seeking care in a rural health clinic. background health literacy the state of general functional literacy in the united states is not high. according to the national adult literacy survey (kirsch, jungeblut, jenkins, & kolstad, 1993), nearly half of all adult u.s. citizens have difficulty with reading skills. the state of health literacy can be even lower than general functional literacy because the medical vocabulary people encounter in health care settings or in the news is more complex than that of other areas of life, and because changes in the nature of illness from episodic to chronic conditions and in health care delivery now require patients to be active participants in their care. for example, the patient is the primary caregiver in diabetes. the health care provider assists the patient, since nearly all diabetes care occurs outside the formal health care environment. in addition to self-care for illness, patients must now make critical life choices on entrance into the health care system. consent to treatment, health insurance portability and accountability act (hipaa) acknowledgements, advanced directives, health history forms, and assignment of responsibility all must be completed before entering the patient treatment area. the actual instructions for care, directions to other facilities for diagnostic procedures known by either mystifying initials or “hard” names like “computerized tomography,” and prescriptions and product inserts that appear to be written in a foreign language are difficult enough for educated people but can be overwhelming to those with limitations in health literacy. people of low health literacy are neither unintelligent nor unmotivated (cheatham, 1993; doak, doak, & root, 1996). although reticent to ask for assistance because of shame and embarrassment (cheatham, 1993; nurss et al. 1997; parikh et al. 1996), those who struggle with literacy do have the ability to learn, if appropriate explanations are given or if patient education materials are presented at their level. until quite recently the difficulty of educational materials for patients was not considered and the reading level of many materials was high. health care instructions are frequently written at a ninth grade level (davidhizar & brownson, 1999). a minimum 7th grade reading level was calculated for all but one over-the-counter drug label in a study of 21 common medications (holt, hollon, hughes et al. 1990). for those invited to participate in research, the informed consent is a formidable challenge when written at the 13th-31st online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 11 grade level (andrus & roth, 2002), leading one to question whether the consent can truly be informed. although the production of print and web-based patient education materials is growing and is likely to increase, there is still a need for practitioners to be aware of the importance of health literacy and to assess their populations. nath, sylvester, yasek, and gunel (2001) reported that helping with low health literacy is challenging, but the actual difficulty is identification of those in need. the elderly seem to be at high risk. more than a third of medicare managed care enrollees had poor health literacy in research reported by gazmararian et al. (1999). the only health literacy research focused on a rural population (montalto & spiegler, 2001) was conducted to assess the literacy level of a clinic population and the resultant adjustments in care made by the health care providers. that research used the test of functional health literacy in adults (tofhla) and reported that 15% of the 70 participants had a literacy/numeracy deficit. health care providers who are aware of the very real ill effects of low health literacy may be more willing to consider it in their care. williams, baker, parker, and nurss (1998) compared the health literacy of people with hypertension and diabetes to knowledge about the disease and found that only around half of those with inadequate health literacy knew important clinical signs required for disease self-management. glycemic control was worse for people with diabetes and health literacy problems according to schillinger et al. (2002). the combination of inadequate health literacy and chronic illness, such as diabetes, reduces the likelihood that people will participate in their care to the extent needed for effective disease management (chwedyk, 2003). the complexity of adherence to hiv therapies is made more difficult for those with low health literacy. interventions directed at those with low health literacy were recommended after health literacy was identified as an independent predictor of missed drug doses for hiv-seropositive men and women (kalichman, ramachandran, & catz, 1999). problems with health literacy also increase the costs of care. compared with persons with adequate health literacy, persons of low health literacy experienced greater difficulty in navigating the health care system (weiss, 1999), 50% more hospital admissions (baker, williams, parker, & clark, 1998), and more errors in personal health management (williams, baker, honig, lee, & nowlan, 1998). estimates of 2001 expenditures for health care as a result of low literacy ranged from $32-58 billion (center for health care strategies, 2003). methods population the accessible population for this research consisted of patients in a rural health clinic managed by a college of nursing and university located in the southeastern united states. the nearest acute care facility is 30 miles away. care is provided by nurse practitioners. the clinic serves as a site for baccalaureate nursing student experiences for the college of nursing, and all students enrolled in the medical-surgical course provide care in the clinic each semester. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 12 the clinic serves approximately 2,500 people of all ages who live in the area. more than half of all visits (57.7%) are made by patients with medicare (35.7%) and medicaid (22%) while the uninsured population accounts for 29.7% of all visits to the clinic. a significant proportion of the patients have chronic health problems such as hypertension, diabetes, cardiovascular disease, and lung disease (j. dunkin, personal communication, december 23, 2003). low literacy is likely, considering the nature of the population. all patients age 18 or older were invited to participate in the research during their clinic visit. instruments rapid estimate of adult literacy in medicine (realm) test is a word recognition test appropriate for adults that has been used with patients in clinical settings. the 66-item test consists of three columns of 22 words frequently used in health care that progressively increase in difficulty. the test takes less than 5 minutes to administer and score. grade-range equivalents and probable patient abilities to manage health information are provided as well. for example, scores of 61-66 indicate that the person reads at the high school level and will be able to read most patient education materials. scores of 45-60 reflect a 7th-8th grade reading level and patients will experience difficulty with most patient education materials. those scoring between 19 and 44 will need low literacy materials, and those scoring below 19 will need information presented using a format other than written. reported correlations with other standardized health literacy assessments ranged from 0.88-0.97 and test-retest reliability was reported at 0.99 (davis et al. 1993). the realm was selected for its brevity, ease of administration and scoring, and relevance to the clinic population in that health-related words are used. although word recognition tests do not measure comprehension recognition is a precursor to the more complex skill of comprehension. an individual experiencing difficulty with word recognition will likely have problems with comprehension, as well. comprehension tests also take much longer to administer (nath et al. 2001). the realm provides graderange data; not specific grade-level assessment of literacy, but for use in most health care situations, the lack of grade-specific data is irrelevant (doak, doak, & root, 1996). procedure the research was approved by the university of alabama institutional review board and the rural health clinic in which data were collected. data were collected between september and november 2003. all fall semester students were trained as data collectors by the investigator. the importance of confidentiality in data collection and management was stressed. student ability to read each word correctly was verified. students were instructed in the scoring procedure and their scoring was validated by the investigator. patients were approached in the waiting room of the clinic and informed about the research. oral consent to participate in the research was read to prospective participants by the student data collectors. the oral consent was organized in a question and answer format to facilitate understanding by potential participants. those agreeing to participate online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 13 completed the data collection instruments in a private area to avoid possible embarrassment. the only notation of patient participation was “hl” (health literacy) in the chart to indicate that the patient had been asked to participate in the research. this strategy was designed to prevent repeated requests to patients who may have sought care at the clinic several times during the data collection period. realm scores of participants were not recorded in the patient record to prevent any adverse consequences for the patients, as recommended by giorgianni (1998) and davis et al. (1998). findings students provided care to 133 eligible clinic patients during the data collection period. sixty patients agreed to participate, of whom three withdrew before finishing. the final sample of 57 represented a participation rate of 43%. sample characteristics are displayed in table 1. racially, the sample mirrored the county population with 89% (n=51) caucasian and 11% (n=6) african american. most participants (n=52; 91%) resided in the county in which the clinic is located; the remainder lived in adjacent counties. approximately two-thirds were female (n=37; 65%), and one-third male (n=20; 35%). the mean age of these clinic patients was 46.7 (s.d.=5.3) with a range of 23 to 70. only 18 (32%) of the participants had education beyond the high school diploma; 30% (n=17) had earned the high school diploma and 35% (n=20) had not completed high school. table 1 demographic data of participants in health literacy assessment male female variable n % n % age 20-29 0 0% 3 8% 30-39 8 40% 6 16% 40-49 3 15% 14 38% 50-59 5 25% 8 22% 60-69 4 20% 5 14% 70 0 0% 1 3% ethnicity caucasian 0 0% 34 92% african american 8 40% 3 8% county of residence same as clinic 20 100% 32 68% adjacent county 0 0% 5 14% years education completed 1 less than 6 2 10% 1 3% 6-9 1 5% 2 5% 10-13 4 20% 10 27% high school diploma 6 30% 11 30% some college 6 30% 8 22% college degree 0 0% 4 11% 1 missing data n=2; 4% online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 14 realm scores, displayed in table 2, ranged from 0 to 66. the mean realm score was 55.9 (s.d. = 16.3). nine participants (16%) correctly pronounced all 66 words and 2 (4%) were unable to pronounce any of the words on the assessment. table 2 realm scores (possible range 0-66; actual range 0-66) male female realm score n % n % 0-18 3 15% 1 3% 19-44 0 0% 2 5% 45-60 10 50% 12 32% 61-66 7 35% 22 59% non-parametric one-way analysis of variance was used to test for a difference in realm scores. this test was selected because the distribution of realm scores was not normally distributed. statistical analysis of the relationships between age and realm score, gender and realm score, and ethnicity and realm score yielded only one significant finding. females scored significantly higher than males on the realm in this sample (p=0.036) using the kruskal-wallis test. more than half (n=35; 61%) were unable to pronounce the word “impetigo”; “colitis” was problematic for 30 (53%) of the participants (table 3). other words that were difficult for these clinic patients included “osteoporosis” (n=23; 40%), “anemia” (n=18; 32%), “inflammatory” (n=14; 25%), “allergic” (n=13; 23%), and “diagnosis” (n=12; 21%). table 3 frequently missed words male female word n % n % impetigo 19 95% 17 46% colitis 16 80% 14 38% osteoporosis 13 65% 10 27% anemia 12 60% 6 16% diagnosis 6 30% 6 16% rectal 5 25% 6 16% appendix 7 35% 5 14% allergic 7 35% 6 16% inflammatory 6 30% 8 22% gonorrhea 7 35% 6 16% online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 15 discussion this research demonstrated that health literacy is a very basic problem in the rural clinic population. nearly half (n=28; 49%) of the clinic patients who consented to participate in this research would be unable to read most patient education materials, based on their realm score, and would benefit from low literacy and audiovisual education strategies. the grade equivalent range provided with the realm test indicated that four of the participants (7%) functioned at lower than a fourth grade level in which even low literacy materials would be problematic; another 2 (4%) scored between the fourth and sixth grade levels indicating that these patients would most likely struggle with reading prescription labels and would benefit from low literacy materials. twentytwo (38.6%) were able to read at the seventh or eighth grade level and probably would struggle with reading most patient education materials. twenty-nine participants (50.8%) read at the high school level on this health literacy assessment, a level which should signify ability to read most patient education materials. compared with the research by montalto and spiegler (2001) in which only 15% of the rural population studied experienced health literacy deficits, this research identified nearly half of the sample (49%) with health literacy difficulties. in the county where this research was conducted, only 67.2% of the population had attained high school diplomas in contrast to 75.3% statewide; only 9.1% had earned baccalaureate degrees in the county compared to 19% in the state where data were collected (u.s. census bureau, 2003). even though 62% of the participants had completed high school, nearly half were unable to read health care terminology at a high school level, supporting davidhizar and brownson’s assertion that “reading is a skill that atrophies with disuse” (p. 42, 1999). the number of clinic patients who declined to participate in the research is probably an indicator of literacy difficulties as well (nurss et al. 1997). the research also demonstrated that a quick, easy-to-use assessment of health literacy can be administered and scored as part of the admission assessment in a health care facility. for this sample, females scored significantly higher on the realm than male participants. based on these data, nurses should be particularly attentive to data provided by male patients during the subjective assessment and should use strategies in addition to the printed word to meet the health teaching needs of male patients. nearly one of every five (19-21%) of the participants was unable to read words commonly used in health care. words such as allergic, diagnosis, and inflammatory are extremely common and are critical to effective self-management of many health problems. inability to understand these common words can lead to detrimental health outcomes. patients are frequently given forms to complete asking if they have any allergies. misreading this word could be life-threatening to the person who has a drug or treatment allergy but fails to share that information as a result of inability to recognize the printed word. likewise, the word inflammatory is a common term used with many health care problems. anti-inflammatory medications are prescribed for treatment of many conditions, and a lack of understanding of the word may lead to drug misuse. adherence to treatment prescriptions is likely affected by low health literacy in the 49% of this sample who had difficulty recognizing the words on the realm test. further research should explore the relationships among medication adherence, selfonline journal of rural nursing and health care, vol. 5, no. 1, spring 2005 16 management of health problems, and health literacy to assess the extent to which health literacy contributes to health outcomes such as disease management and cost of care. limitations several limitations may have affected the outcomes of this research. first, selection bias may have excluded those who were unable to read who did not want to reveal their literacy problems. if this did occur, the results would have yielded an even greater literacy problem within the rural clinic clientele. shame and embarrassment are common among those with literacy difficulties, and making the choice not to participate in a study in which the patient would perform poorly is a self-protective mechanism. those who attempt to conceal their literacy difficulties are at increased risk for treatment failure if they are unable to follow written prescriptions. second, the proportion of ethnic minorities in the sample was not large enough to represent rural african americans. further research should strive to achieve diversity in the sample to assess if a difference exists in the health literacy of rural dwellers based on ethnicity. finally, vision of the participants was not assessed and may have affected the performance of some of the participants, although none indicated difficulty during data collection. one of the most common reasons given for inability to complete forms is vision difficulty. “i forgot my glasses” may actually mean “i cannot read these words.” assessment of visual acuity by the researchers will ensure that the word recognition is not limited by inability to see the printed words. conclusions identification of those with limited health literacy is useful if the data are integrated into practice. reducing the literacy level of all patient education materials will improve understanding for the majority of patients. yet some will need even more assistance. nurses have an obligation to ensure that teaching is not only provided, but understood. validation of learning can only be assured if the patient is able to apply the knowledge shared between provider and patient. many useful web-based and print resources are available including the references provided in this paper and the following: • http://www.pfizerhealthliteracy.org • http://www.askme3.org • http://execsec.od.nih.gov/plainlang/guidelines/index.html • http://cancer.gov/cancerinformation/clearandsimple • http://www.hsph.harvard.edu/healthliteracy/index.html these references provide assistance with assessing literacy and creating user-friendly education materials. although most patients in a rural clinic are well known to the health care providers, staff turnover will occur. patient-centered policies need to be developed that allow staff to know which patients need assistance while promoting patient dignity. nath et al. (2001) recommended research to evaluate the effect on patient outcomes and patient online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.pfizerhealthliteracy.org/ http://www.askme3.org/ http://execsec.od.nih.gov/plainlang/guidelines/index.html http://cancer.gov/cancerinformation/clearandsimple http://www.hsph.harvard.edu/healthliteracy/index.html 17 relationships with health care providers for those who are identified to have literacy deficits and with whom interventions are conducted. nurses and other health professionals can recognize the scope of functional health literacy problems and work to identify and assist those who struggle to meet the challenges of health care. acknowlegments the author acknowledges dr. sharol jacobson for her editorial assistance and dr. mitch shelton for assistance in performing the statistical analyses.. references andrus, m.r., & roth, m.t. (2002). health literacy: a review. pharmacotherapy, 22, 282-302. 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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9448555 amber, 9 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 a rural nursing center without walls clarann weinert, sc, phd, rn, faan 1 amber spring, bs 2 shirley cudney, ma, rn, gnp 3 1 professor, college of nursing, montana state university, cweinert@montana.edu 2 project manager, college of nursing, montana state university, aspring@montana.edu 3 associate professor (retired), college of nursing, montana state university, scudney@montana.edu key words: research center, rural nursing research, chronic illness abstract background. conducting nursing research with rural populations is complicated by multidimensional characteristics of rural dwellers; rural environment; paucity of nurse scientists prepared and supported to conduct rural research; and institutional constraints of academic entities serving rural communities. unique research strategies are required to meet these challenges. purposes. to review the history of the center for research on chronic health conditions in rural dwellers (crchc), report the degree to which its objectives were met, summarize its accomplishments over five years, and explicate the strategies used to overcome the challenges of conducting rural nursing research in the western united states. findings. the crchc was successful in building human research capacity, supporting the development of rural nursing science, and increasing research productivity. conclusions. a center model is one mechanism that has been demonstrated to effectively meet the challenges of conducting rural nursing research in the rural mountain west. introduction a sense of charm and nostalgia is associated with rural living—at least as it is characterized in literature and lore--which tends to perpetrate the myth that ―rural‖ is onedimensional and associated with open spaces, fresh air, bucolic life style, and healthy people. while it is true that the rural lifestyle has many positive characteristics, it is no longer, if it ever was, unidimensional or homogeneous. it is a vast and varied tapestry, populated with communities rich in historic, cultural, economic, geographic, occupational, and demographic diversity. it is often presumed that rural dwellers are healthy and robust. in reality, they are burdened with a vast array of health needs associated with chronic health conditions, limited access to health care services, poverty, social issues such as drug abuse, suicide, domestic violence, alcoholism, smoking, and the likelihood of employment in hazardous occupations that expose workers to chemicals and dangerous machinery. the increasingly fluid socio-cultural and demographic profile, geographic contrasts, and health status challenges of many rural dwellers present barriers to an adequate rural definition and to conducting rural health-related research (weinert & burman, 1994). nursing research with rural populations is influenced by the multidimensional characteristics of the population, the rural environment, and rural sub-cultural values. likewise, rural nursing research differs widely in its levels of sophistication (weinert & burman, 1996; weinert, 2006), and there exist only a few nurses prepared to conduct research in the rural context—factors which impact the state of rural nursing research. ideally, rural nursing research is best done by nurse scientists working in academic settings located in rural areas who understand the rural subculture, rural health needs, and rural health care delivery systems. in reality, these rural academic environments are often http://www.montana.edu/wwwnu/ mailto:cweinert@montana.edu http://www.montana.edu/wwwnu/ mailto:aspring@montana.edu http://www.montana.edu/wwwnu/ mailto:scudney@montana.edu 10 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 isolated geographically from other higher education units, have an underdeveloped research infrastructure, and, because there are few faculty members prepared at the doctoral level, have limited resources and expertise for developing programs of nursing research or seeking support from extramural grant funding. with baccalaureate nursing education as the most common primary program focus, faculty members shoulder heavy dyadic and clinical teaching responsibilities, as well as obligations related to governance of the academic unit. their small numbers result in added assignments that include multiple committee memberships, curriculum development and implementation, and advisement of large numbers of students. in the face of these constraints, it is difficult to develop and support the critical mass of nurse investigators required to conduct research that addresses the health issues of rural dwellers. thus, in the face of these challenges, developing a strategy to nurture investigators and foster collaboration among nurse researchers across rural academic settings was imperative to the success of rural nursing science. an organizational entity that was created to overcome some of the barriers to conducting rural nursing research was the center for research on chronic health conditions in rural dwellers (crchc), located in the college of nursing at montana state university (msu). collaborating center investigators and their research teams were located in iowa, montana, nebraska, nevada, north dakota, and wyoming--all rural areas characterized by an agricultural economic base, wide open spaces, sparse populations, limited access to health care, few academic settings, and notable geographic distance between nurse investigators. in an earlier publication, weinert, lotts, & winters (2004) discussed structure, objectives, and some of the proposed strategies for attaining them. the purposes of this current article are to: a) review the history of the crchc; b) report on the degree to which its objectives were attained; c) summarize the accomplishments of the center over its five years of operation; and d) further explicate the strategies used to overcome the challenges of conducting rural nursing research in the greater intermountain region of the western united states. while some of the techniques used to build research skills, link researchers, maximize resources, and develop a true community of scholars over geographic distance can be adapted, there is no intent to generalize this discussion to other rural settings. history of the crchc the crchc was funded as a p20 center by the national institutes of health/national institute for nursing research (1p20nr07790-01) and later supplemented by the sc ministry foundation. the center was in operation from august of 2001 until august of 2006 and was designed to enhance the quality, quantity, and potential impact of rural nursing research. the crchc was under the leadership of director clarann weinert, sc, phd, rn, faan, and associate director, charlene winters, dnsc, aprn, bc, with the assistance of a center manager. objectives of the crchc the crchc was established on five foundational objectives which were to: 1. increase the human capacity for conducting sound rural nursing research; 2. develop the infrastructure to facilitate the development of programs of research to generate new knowledge; 3. provide small grant funding and technical support for pilot projects; 11 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 4. provide a focal point for synergistic linkages of scholars across montana and the region; and 5. develop a knowledge base for addressing the multiple complex issues associated with chronic illness management for persons living in sparsely populated areas. the overarching goal of the crchc was to reduce health disparities and improve the health of rural residents. achieving the objectives: strategies and outcomes research capacity building the first, and foundational objective, was to enhance the prerequisite research skills needed to increase the human capacity for conducting sound rural research. to do so, a basic toolbox of resources was made available to aspiring rural researchers that included on-call writing assistance and consultation about all aspects of the research process from the director, who served as the lead mentor, and two external consultants who were knowledgeable about grant writing and statistical methods. in addition, a variety of strategies were used to enhance the research skills of investigators in montana and the region that included linking with resources at other universities, research brown bag sessions, visiting scholars, a writing support group, and principal investigator meetings. university linkages. the crchc linkages were with the universities of washington, iowa, and wyoming. the university of washington (uw) school of nursing multi-talented faculty shared their bi-monthly research seminars on a wide variety of research topics with the crchc investigators and other interested professionals via telephone connection. for those unable to attend, a video of each session was provided, supplemented with an accompanying handout--all of which have been catalogued and are available on request. collaboration with the gerontological nursing interventions research center at the university of iowa, college of nursing provided a variety of resources. as a seasoned researcher and center director, dr. toni tripp-reimer provided invaluable research insights, the staff at the iowa center were generous in providing us with technical information on the running of a center, and one project was jointly funded through the iowa center and the crchc. the other key linkage was with the nightingale center for nursing scholarship (ncns) located at the university of wyoming. the crchc and ncns collaboratively supported a writers’ group, promoted one another’s research activities on a joint website, and explored the development of joint databases and a mechanism to conduct mock reviews of grant proposals. research brown bag sessions. monthly, the crchc hosted an hour-long research brown bag session, featuring eminent nurse scholars from around the country who addressed multiple and varied research topics. these sessions, using the college of nursing teleconference system, were a low-cost method of providing exposure to some of the foremost scholars from north america. handouts were disseminated to the participating sites prior to the sessions. in all, 23 speakers representing 20 institutions reached over 500 participants (faculty, staff, students, clinical colleagues) at 15 sites across montana and 14 sites in 11 other states. see table 1 for the list of speakers and topics. the research brown bag sessions were enthusiastically embraced and were a highly successful research capacity-building strategy. 12 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 table 1 research brownbag session speakers and topics date speaker topic 9/16/2002 mary ann curry oregon health & sciences university research with high risk populations: persons with disabilities 10/21/2002 lauren aaronson university of kansas unfolding human subjects regulations 11/18/2002 toni tripp-reimer university of iowa certificate of confidentiality and memorandum of understanding 3/17/2003 leslie schmidt montana state university how grants and contracts can help you!! 4/21/2003 carole hudgings nih/ninr techniques and tips for developing a competitive research application 10/20/2003 angela mcbride university of indiana mentors, mentoring, and career development 9/15/2003 joan shaver university of illinois thoughts on creating and sustaining programs of research 12/15/2003 lillian nail oregon health & sciences university sustaining a career, help along the way 11/17/2003 linda cronenwett university of north carolina becoming a successful nurse scientist 3/22/2004 margaret heitkemper university of washington building teams: it takes a village, part one 4/19/2004 nancy woods university of washington building teams: it takes a village, part two 9/20/2004 martha lenz university of washington writing a winning abstract 10/18/2004 adeline nyamathi university of california san francisco recruiting participants from vulnerable populations 11/15/2004 terry badger university of arizona scholarly dilemmas: recruitment and dissemination 1/21/2005 peggy chinn yale scholarship: the paradoxes of the 14 c’s 3/21/2005 rosemary donley,sc catholic university the relationship between research and policy 4/18/2005 marie lobo university of new mexico when the blinded data collector knows about the intervention 9/19/2005 alyce schultz arizona state university clinical nurse scholars: building a community of evidence-based practice mentors 10/17/2005 linda everett university of iowa setting the stage for evidence-based practice in an acute care setting 11/21/2005 suzanne prevost middle tennessee state university finding the resources to support evidence-based practice 1/30/2006 carole estabrooks university of alberta knowledge translation: state of the science 3/20/06 russ mcguire appalachian regional healthcare, inc. evidence-based nursing practice implementation and utilization in central appalachia 4/17/2006 maureen dobbins mcmaster university around the world in sixty minutes: lessons learned in evidence-based nursing 13 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 visiting scholars. the more conventional workshop model was also used as a strategy to enhance research skills. the one-to-two day workshops were usually held on the msu bozeman campus, and faculty and students drove from across the state and region to participate. distinguished presenters and their topics were: carole hudgings,phd, rn, faan, from nih/ninr--grant writing; toni tripp-reimer,phd, rn, faan, university of iowa--qualitative research; shirley moore,phd, rn, faan, case western reserve--electronic interventions in nursing; and ruth kleinpell,phd, rn, acnp, rush university--scientific writing (telephone workshop). the opportunity to be in the physical presence of these distinguished scholars and be able to personally exchange ideas with them added a new dimension to the experience of building the novice researcher’s personal research capacity. western writers’ coercion group. ongoing support for the improvement of writing skills and for increasing scholarly productivity was encouraged through the western writers’ coercion group (wwcg). the overall goal of the group was to facilitate scholarship productivity through multi-disciplinary and inter-institutional ongoing support, critique, mentoring, and scholarly exchange. the wwcg first began the summer of 2001 in the university of wyoming nightingale center for nursing scholarship (ncns) as a local innovation. by the summer of 2002, the group expanded to include faculty from other disciplines such as social work and mathematics. the composition of the group was eclectic (faculty members – nursing, social work, mathematics, doctoral student, clinical nurse researcher) who were located in a variety of settings in montana, nebraska, north dakota, new mexico, and wyoming. meetings (weekly during the summer and bi-weekly during the academic year) were conducted from wyoming’s ncns with support from montana’s crchc for the teleconference connection and website. at each meeting, individual goal attainment was assessed, manuscripts were discussed, and support/encouragement was given. all participants paid a $5.00 filing fee to join the group, and those who, by self-report at the meetings, had not met their goals were ―fined‖ $5.00. over time, the accumulated fees/fines were used to buy a sigma theta tau international brick paver and to make an additional contribution to the honor society's research fund. a total of 22 faculty participated, with an average of 10 participating at each meeting. the wwcg was disbanded in december, 2006, with a notable record of productivity. there were 74 manuscripts prepared (53 published, 9 in press, and 5 in review). wwcg members presented symposia about the writing support group at the western institute of nursing conference (2004) and at the state of the science congress (2006). the impact of such a group as a research capacity-building strategy was reflected in observations from the group members that included: an appreciation for the collegial support and encouragement received; a sense of group loyalty; a feeling of gratitude for the ―gentle coercion‖ to stay on track with individual goals; and the value of the regular accountability to the group. a more detailed description of the western writers’ coercion group is provided in a publication by cumbie, weinert, luparell, conley, and smith, (2005). principal investigator meetings. principal investigators of current and prior pilot projects met periodically by teleconference with the associate director for the purposes of mutual support, problem solving, and generation of ideas. the group ranged from very senior and seasoned researchers to more novice investigators. this rich mixture provided additional opportunities to learn the research process and to develop skills in problem-solving issues related to conducting rural research. 14 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 infrastructure development the second objective--the development of the infrastructure to facilitate the development of programs of research to generate new knowledge—added the physical, technical, and resource support needed to complement the gains in human research capacity building. as well as providing a physical environment to house center activities (office space and equipment, access to the teleconferencing system, etc.), the crchc provided investigators with a wide range of resources to aid them in their research efforts. the center staff assembled a clearinghouse of information useful to researchers in an easily-accessible format on the crchc’s well-developed website where they could connect to a ―research toolbox‖ with useful research links, seminar information, writing tools, the crchc library, audio and video tapes, and consultation services. the crchc staff provided assistance with budget preparation, grant writing, editing, proofreading, and dissemination efforts. these resources were open to all interested investigators from across the region and beyond, as well as to msu students and faculty. this strong infrastructure made it possible to build upon prior research efforts, strengthen ongoing research, stimulate initiatives, increase funding, attract investigators, and enrich student research opportunities (weinert, lotts, & winters , 2004). support for pilot projects to enhance human capacity building, forge regional linkages, and promote rural nursing science, the crchc provided grant funding and technical support for pilot projects related to chronic illness in adults and children living in rural areas—its third objective. through the pilot project program, three studies were funded each year. awards were a maximum of $10,000 and one year in length. collaborative endeavors were encouraged among faculty investigators and master’s prepared faculty, clinical nurses, and inter-disciplinary and inter-institutional projects. the research questions evolved from a wide range of issues related to management of chronic health conditions within the context of the rural environment. study topics addressed the promotion of healthy behaviors, prevention of complications, encouragement of selfmanagement, and support of the family in managing chronic health conditions. the pilot project program funding process was a mentored endeavor from the initial conceptualization of the idea, through the development of the research team, preparation of a phs398 format proposal, conduct of the research, dissemination of findings, and finally, assistance with follow-up funding acquisition. the day-to-day grant management and interface with the msu entities, e.g., office of sponsored projects, personnel, institutional review board, was handled by the center manager. grant management was complicated by the fact that none of the principal investigators and few of the research team members were located on the bozeman campus. to enable the investigators to focus on the science, all necessary paperwork (payroll, personnel, contracts, travel forms, reimbursement, budget tracking, etc.) was handled by the center staff. although it was more efficient for the crchc to assume these duties, the investigators were consistently informed about these processes and engaged in discussions of evolving issues as strategies for enhancing their understanding of grant management. pilot project program proposals were prepared in an iterative process with the center director. a system of formal review for each proposal included review by the pilot core which consisted of one msu non-nurse faculty, one external nurse reviewer, and three college of nursing reviewers. in addition, each proposal was reviewed by two content experts who were external to montana state university and the universities with which the principal investigator and research team were affiliated. 15 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 investigators were encouraged to submit a poster abstract during their year of funding and a podium abstract the year following funding to be presented at the western institute of nursing’s annual conference. the principal investigators provided a written progress report and a final grant report and were required to submit a manuscript for publication, present at a regional, national, or international scientific conference, and submit a research proposal for extramural funding within one year after completing the study. all of these activities were supported and facilitated by the crchc staff. in addition, the pilot project investigators were expected to participate in and support crchc events such as the research workshops, research brown bag sessions, and principal investigator meetings. toward what was, ultimately, to be the end of operations of the crchc because of lack of monetary support, two pilot program project proposals were prepared, submitted, reviewed, and recommended for funding. however, despite their high quality, they could not be funded because of the demise of the crchc. one of the proposals, ―a descriptive analysis of the health status of a national asbestos-related disease cohort,” was prepared by five msu nursing faculty members under the leadership of the crchc associate director. the purpose of the study was to establish a comprehensive understanding of the health status and impact of chronic illness on persons exposed to asbestos in libby, montana. the research team, with the assistance of the crchc, revised the proposal, and, though rejected by one foundation, it was ultimately funded by the hrsa office of rural health policy (r04rh07544-01-01). the second unfunded crchc-approved proposal was ―sustained breastfeeding: preventing chronic illness in rural, hispanic infants,‖ headed by a nurse investigator from the university of nebraska. her research team included three nurse scientists from the universities of nebraska, wyoming, and montana. this study was a direct outcome of a crchc-funded project by the same research team whose overall interest is promoting infant respiratory health in rural settings through sustained breastfeeding and interventions targeted at decreasing environment triggers. the research team re-conceptualized its approach and is currently funded for two projects. the first, ―motivational interviewing to promote sustained breastfeeding,‖ funded by the minority health research seed projects at the university of nebraska, is in progress on a native american reservation in south dakota. the second, ―screening native american children for asthma,‖ is also funded and is being implemented on a second south dakota reservation. overall, the crchc pilot project program funded 13 projects, under the umbrella of chronic illness management, which involved a total of 29 investigators from nine employment affiliations. these researchers were montana state university nursing faculty (n=12); nursing faculty from other universities/organizations (n=12), and non-nursing investigators (n=5). on table 2 are displayed the name, discipline, affiliation, and project(s) for each investigator. the pilot project program was a major strategy of the crchc that was used to successfully advance the state of the science in areas of chronic illness and rural health. 16 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 table 2 pilot program investigators: discipline, affiliation, research project investigator discipline affiliation team 1. brandt nursing st. vincent hospital billings pain management/telehealth crow indians 2. zulkowski (pi) nursing msu pain management/telehealth for crow indians 3. cumbie (pi) nursing u of wyoming nursing care model 4. burman nursing u of wyoming nursing care model 5. conley nursing u of wyoming nursing care model 6. weinert nursing msu nursing care model; spirituality & chronic illness; rural data collection; isolated rural women; native american elders; health care choices 7. sullivan nursing msu cancer management; health care choices; isolated rural women 8. craig (pi) nursing ohsu spirituality & chronic illness 9. walton nursing carroll college spirituality & chronic illness 10. derwinski-robinson nursing msu spirituality & chronic illness 11. holkup (pi) nursing msu native american elders 12. tripp-reimer (pi) nursing u iowa native american elders 13. salois social work independent native american elders 14. ide nursing u north dakota health care choices 15. nichols nursing msu health care choices 16. shreffler-grant (pi) nursing msu health care choices; medical assistance facilities; hospice use of cam 17. mayer nursing msu men's heart network 18. winters (pi) nursing msu men's heart network; isolated rural women 19. parker (pi) nursing msu cancer management 20. rodehorst nursing u of nebraska rural data collection 21. wilhelm nursing u of nebraska rural data collection 22. stepans (pi) nursing u of wyoming rural data collection 23. smith physiology u of wyoming rural data collection 24. kuntz (pi) nursing msu methylmercury risk 25. hill nursing msu methylmercury risk; men’s heart network 26. king engineering msu methylmercury risk 27. lande health & human dev msu methylmercury risk 28. linkenbach health & human dev msu methylmercury risk 29. running (pi) nursing u of nevada hospice use of cam creating scholarly linkages to achieve the fourth objective—provide a focal point for synergistic linkages of scholars across montana and the region—several mechanisms that were available locally, throughout the state, and across the region were utilized to link investigators with the resources of the crchc. these mechanisms included: center affiliates, center collaborators, center investigators, and pilot program investigators. 17 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 center affiliates. center affiliates were an integral part of the overall crchc and contributed to its mission through their support of center goals and participation in center activities. these were non-university related investigators/organizations that promoted the crchc efforts by: a) participating in research that addressed issues related to chronic illness in rural dwellers; b) being involved with the training efforts of the center; and c) engaging in the dissemination of information through workshops, conferences, and media. center affiliates had full access to all crchc resources. likewise, center affiliate investigators could identify with a larger entity when submitting grant proposals and receive assistance from the crchc for preparation of grant applications, help with dissemination efforts, and consultation about conducting research. center affiliation for institutions/organizations provided a research connection for individuals within their institution/organization and the opportunity to identify with research efforts across the state and region. they received advance notice of guest speakers, other educational opportunities, and the center newsletter. the six center affiliates were seen as valued friends and collaborators, a win-win situation for center affiliates and for the crchc. center collaborators. center collaborators included partner universities, industry, and private community researchers who shared common interests with the crchc. they joined with the crchc to write grants, contracted with the staff for consultation or assistance, or teamed with crchc investigators to conduct ongoing research. one center collaborator project, titled ―spirituality and suicide,‖ was headed by a chaplain from a local hospital. his research team consisted of a retired minister, a nursing colleague from oregon health & sciences university, and the crchc director. the goal of this study, funded by a private family foundation, was to better understand the role of spirituality in dealing with suicide and the attendant dynamics of spiritual support and personal faith beliefs of family members coping with this type of loss (craig, weinert, & vandecreek, 2007). to pursue this understanding, the theological difficulties or conflicts experienced by suicide loss survivors in integrating their faith with the tragedy of suicide, the personal trauma of suicide loss, and the appropriate intervention to provide spiritual support for survivors that help lead to healthy resolution of grief were explored. the "cross pollination" of the center collaborators with the other center investigators added to the synergistic health and/or rural nursing research efforts. through this strategy, lasting research relationships evolved, and contributions were made to the overall state of nursing science and health in the usa. pilot project program investigators. the pilot project program strategy, as previously described, was a key player in the forging of inter-institutional and interstate (iowa and wyoming) linkages between nine institutions as well as the non-nursing disciplines of social work and applied physiology. a secondary gain from the interstate linkages was the sharing of the expertise of the more experienced researchers from iowa with the less experienced crchc staff. the strategy of creating scholarly linkages among nurse researchers of the west has been highly productive. weinert and colleagues (2004) emphasized that ―through these linkages, the crchc works to develop both nursing science and nurse scientists which, over time, helps to generate the critical mass necessary to conduct quality rural nursing research that will enhance nursing practice and improve the health of rural dwellers‖ (p. 70). 18 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 table 3 pilot project titles, teams and descriptions project title team project description pain management and telehealth for crow indians zulkowski (pi) brandt determine the feasibility of nursing management of chronic pain using telehealth native american crow exploring chronic illness in isolated rural women winters (pi)\ sullivan, weinert secondary analysis of women to women data to identify themes related to illness uncertainty and illness management. care for chronic conditions in medical assistance facilities shreffler-grant (pi) develop method to assess quality of care for acute exacerbations of chronic health problems in lowacuity low volume facilities spirituality: rural dwellers and chronic illness craig (pi) derwinski-robinson, walton, weinert examine spirituality and health behaviors, quality of life, and illness management and nature of spirituality among rural dwellers with chronic illness. caring for native american elders tripp-reimer (pi) holkup ,salois, weinert develop, pilot, and assess the feasibility of an intervention the family care conference (fcc). cancer management: rural dwellers and their spouses parker (pi), sullivan determine how older rural individuals living with cancer and their spouses manage the symptoms following cancer-related treatments. nursing care model for the chronically ill cumbie (pi), conley, burman, weinert test a client-centered nursing intervention with selected chronically ill rural persons in a clinic setting, men's heart network winters (pi) mayer, hill adapt the women to women2 protocols and materials for use with isolated rural men with cvd health care choices shreffler-grant (pi), ide, nichols, sullivan, weinert explore the extent of use, perceived efficacy, and availability of complementary therapies for chronic conditions. testing protocols for rural sample data collection stepans (pi), smith, rodehorst, wilhelm, weinert develop protocols for monitoring biomarkers and aeroallergens reflective of inflammatory response of the respiratory system of babies (12 18 months). caring for native american elders: prairie addition holkup (pi), trippreimer, salois, weinert gather background and contextual data from one additional tribal community in montana to expand the testing of the family care conference. easing chronic suffering: a survey of hospices use of complementary therapy running (pi) shreffler-grant explore use of complementary therapies by hospice in managing chronic conditions for rural elders at the end of life. methylmercury risk and awareness in american indian women of childbearing age kuntz (pi) hill, king, lande, linkenbach construct and adapt culturally appropriate instrumentation and methods to assess risk for methylmercury exposure in american indian women of childbearing age living on rural reservations. 19 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 developing a knowledge base for chronic illness management the final objective of the crchc was to develop a knowledge base for addressing the multiple complex issues associated with chronic illness management for persons living in sparsely populated areas. the pilot project titles listed in table 3 represent the contribution the crchc has made to the knowledge base related to chronic illness management of rural dwellers across the life span. information obtained about chronic pain management through telehealth, eldercare, and methylmercury risk in native american populations should benefit a traditionally underserved rural population. the knowledge gained about the impact of chronic illness on the emotional and spiritual health of rural dwellers will guide the design of interventions intended to enhance adaptation to chronic illness. delivery of care by rural health care facilities that is appropriate to the needs of those with chronic illness will be informed by the results of the medical facilities study and complemented by the testing of a nursing intervention that can be translated into a client-centered nursing care model for the rural chronically ill. the role of cancer symptom management, health care choices, and complementary therapy in the chronic illness/end of life experiences of elders and others will be illuminated. two protocols have addressed chronic illness issues at opposite ends of the life continuum: 1. the women to women protocols for assisting rural dwellers to adapt to chronic illness have been applied to men with heart disease; 2. protocols for monitoring biomarkers and aeroallergens in babies are being tested. crchc contributions such as these have added to the knowledge base related to the multiple complex issues associated with chronic illness management of rural dwellers and have strengthened rural nursing science. accomplishments of the crchc the productivity of the center investigators and center collaborators is noteworthy especially when measured from the point where most of these investigators began in terms of research engagement, skills, and scholarly productivity. to date, 50 manuscripts have been prepared with 40 published, 2 in press, and 8 in review. there have been 73 published abstracts, 74 papers presented, and 37 poster sessions. seventeen of the 38 follow-up grant proposals have been funded. conclusions the crchc came about through the serendipitous combination of the factors of location, leadership, and a focus on rural nursing research at montana state university college of nursing. the college in which the crchc was located was geographically situated in a prime western location. with the encouragement and support of a nationally acknowledged nurse scientist, dr. clarann weinert, the faculty had begun to focus on forging and fostering bonds among rural nurse researchers scattered across the west in geographically isolated, less researchintensive institutions. at the same time, the college of nursing was becoming nationally recognized in the area of rural nursing research. the crchc was ideally positioned to facilitate the creation of linkages between western nurse scientists, provide research consultation, and promote collaboration among nurse investigators through inter-institutional research projects, seminars, and the western writers’ coercion group. 20 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 from its inception, the crchc facilitated the creation of linkages among investigators across montana and the region. often investigators from the less research intense settings had no senior researchers to serve as mentors, and the crchc was an optimal venue for providing that research mentorship. the multi-site, multi-institutional linkages have: a) further strengthened the rural nursing research efforts in montana; b) enriched both nursing science and nurse scientists; and c) helped to generate the critical mass necessary to conduct quality rural nursing research to enhance nursing practice and improve the health of rural dwellers. with its regional, interinstitutional impact, the crchc evolved into a "scholarly community without walls." it is noteworthy that six of the research teams (which include investigators from across montana and from nebraska, wyoming, iowa, oregon, north dakota), that were forged through the center, continue to actively conduct research to date. these teams have been able to continue to expand and develop their programs of research, have been successful in obtaining intra or extra-mural funding and have been productive in the dissemination of their findings. the challenges to conducting rural nursing research such as distance, research resource poor environment, and lack of nurse investigators were addressed through the crchc using a variety of techniques. distance was often bridged by low tech methods such as the telephone conference system. this system provided a low cost means for: 1. research teams to meet; 2. consultation sessions with the crchc director; 3. the principal investigators meetings; 4. western writers coercion group meetings; and 5. the brown bag sessions. a crchc website provided a mechanism for user-friendly access to critical research information. a toll-free telephone number allowed investigators to call the crchc without charge to themselves. at times the center director traveled to distance sites across montana and the region to meet face-to-face with research teams and some teams traveled to bozeman for consultation. common meeting sites such as the win communicating nursing research conference and the state of the science conference were used as times for sharing among crchc investigators. the pilot program funding provided monetary support to launch projects, as well as, the full array of grant management support from the crchc program director. the ongoing mentoring, along with the linkages forged among investigators across montana and the region helped to offset the limitations of research resource-poor environments. to provide research expertise to each project, in addition to ongoing mentoring, the center director served as a co-investigator to every project that was headed by a non-msu nursing faculty. likewise, she served as a co-investigator to a significant number of the projects for whom a faculty colleague was the principal investigator. this along with the contributions of dr. toni trippreimer provided research teams with assistance from seasoned and well funded nurse scientists. the center mechanism, as means of addressing issues associated with the management of chronic illness within the rural context, has been very successful. indicators that the objectives of the crchc to increase research skills, improve the research infrastructure, support pilot projects, and increase the knowledge base related to the management of chronic illness in the rural setting are most apparent. it is clear from indicators such as the number of individuals and institutions involved, the breadth of the pilot projects, the successful funding of follow-up studies, the impressive dissemination statistics, and the feedback from those involved, that the crchc was a success. unfortunately, despite the successes of the crchc, the university and college of nursing were not financial positioned to support the center. a very serious pursuit 21 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 for funds to sustain the crchc was undertaken and numerous proposals to various agencies, organizations, and foundations were submitted. interest in funding a center was found to be very low, as most funding bodies were interested in specific discrete projects. however, one foundation grant allowed the crchc to continue functioning after the end date of the p20 funding. the bonds of colleagueship and friendship among investigators are treasures gained well beyond the nursing science impacted by the crchc. these bonds are the foundation for continued collaboration across geographic distance and other rural barriers which are establishing a lasting culture of rural nursing scientists that will make a difference in the health and well-being of rural dwellers. what started as a long-standing dream of one nurse scientist grew into the realization of a rural nursing research center that has developed, motivated, and energized rural nurse investigators and their colleagues. during its relatively short tenure, the crchc succeeded in positioning rural investigators to conduct the research necessary to reduce some of the health disparities faced by rural residents and contribute to the improvement of the health status of chronically ill native americans and rural dwellers across the lifespan. although it no longer exists, the influence of the crchc endures, and will continue to do so into the foreseeable future. references cited craig, c., weinert, c., & vandecreek, l. (2007). women's experience of the suicide of a close family member. manuscript submitted for publication. cumbie, s., weinert, c., luparell, s., conley, v., & smith, j. (2005). developing a scholarship community. journal of nursing scholarship, 37(3), 289-293. [medline] weinert, c. (2006). rural health revisited. in j. fitzpatrick & m. wallace (eds.), encyclopedia of nursing research (2 nd ed.) (p. 535-537). new york: springer. weinert, c., & burman, m. (1996). nursing of rural elders: myths and reality. advances in gerontological nursing, 1, 57-80. weinert, c., & burman, m. (1994). rural health and health seeking behaviors. annual review of nursing research, 12, 65-92. [medline] weinert, c., lotts, k., & winters, c. (2004). the crchc: a strategy for enhancing rural nursing research. nursing leadership forum, 9(2), 67-73. [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16235872%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7986579%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16033046%5buid%5d an assessment of infertility in a rural area 75 an assessment of infertility in a rural area roy ann sherrod, dsn, rn1 1 professor, capstone college of nursing, university of alabama, rsherrod@bama.ua.edu keywords: infertility, rural, urban, survey abstract objective: the incidence of infertility is increasing steadily and is not restricted to any geographic area. an assessment of infertility in rural areas was made to determine if there was a difference in infertility rates and related factors between urban and rural groups. design: survey research methodologies were used. setting: phone interviews were conducted to collect data in the homes of subjects who were 18 years or older. results: descriptive statistics were used to analyze data. there was a statistically significant difference in the number of urban and rural subjects who were infertile (p=.05) in this sample. rural infertile subjects were less satisfied with their health care provider if they sought treatment for infertility. additionally, the sample of total rural citizens had to travel longer to their health care provider. conclusion: there are differences related to infertility for rural and urban groups. implications for health care providers and policy makers include providing enhanced reproductive services to rural citizens. call outs 1. more than 10-15% of childbearing age couples experience infertility and there is a need to know if the problems associated with it are similar across geographic areas. 2. there is a critical need to understand the impact of rurality on infertility so that strategies to provide appropriate care can be implemented. 3. nurses and other healthcare providers need to address the differences in the infertility experience for rural citizens through political and professional activism. introduction the word infertility brings to mind many negative connotations: barren, sterile, and unfulfilled. primary infertility has been defined as the inability to conceive after one year of consecutive unprotected intercourse or the inability to carry a pregnancy to live birth (menning, 1980; schoener & krysa, 1996; sherrod, 1995). secondary infertility occurs when couples have achieved a live birth and are unable to do so again (wiczyk, 2000). couples facing infertility who wish to have children may feel unfulfilled, empty, and deprived of what seems to be a natural progression of life events. couples and individuals facing infertility may have to cope with a possible unanticipated life crisis that results in several losses. these losses can include the experience of pregnancy and parenting a biologic child, a positive sense of self, control of one’s life and goals and privacy of one’s body and sexual activity (clapp, 1982; edelmann & connolly, 1986; imeson & mcmurray, 1996). online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://nursing.ua.edu/home.htm mailto:rsherrod@bama.ua.edu 76 approximately 10-15%, or one in six couples of childbearing age must deal with infertility and the number is increasing (hwang, 1999; perry, 1999; tucker, 1997). couples dealing with the emotional and biologic dimensions of infertility may experience a series of reactions in adjusting to the discrepancy between the reality of their present and the ideal. their lives may feel out of control (barber, 2000; tucker, 1997). feelings of decreased self worth, disequilibrium, and anxiety may occur (keye, 1984; laborde, 2000; menning, 1980; sandelowski, 1993). the couple may experience a typical grief response, surprise, denial, isolation, anger, guilt, and sadness and may come to a point of resolution (menning, 1980; sherrod, 1995; tucker, 1997). biologic factors in infertility are varied and complex. problems for the female can be structural such as no ovaries or blocked fallopian tubes or functional such as not ovulating. for the male, there could be problems of too few sperm or impaired motility of sperm or structural problems such as varicose veins in the scrotum. he also may be affected by excessive use of alcohol, marijuana, or tobacco. for both males and females, the biological consequence of stress can negatively impact reproductive efforts (kelly, 2001; robinson & stewart, 1995; trantham, 1996). the diagnostic work up can be invasive and the treatment options painful, expensive and frightening. the access to reproductive health care specifically for infertility can be very limited in rural areas (bushy, 2000; national rural health association [nrha], 1999). the mostly primary care physicians in rural areas are more likely to be without the knowledge and skills to assist the couple (morgan, 2001; ricketts, 1999). this problem is compounded by the fact that even primary care providers are scarcer in rural areas (the center for health professions, 2001). additionally, the time required to cover the distance to access any health care services in rural areas may be great and getting there may be stressful (bushy, 2000). the stress of trying to access services is particularly significant for the infertile couple because they are already dealing with a host of other emotional issues and stresses (imeson & mcmurray, 1996; schoener, 1996). the expense of travel and infertility services can be quite daunting for those who live in rural areas, in light of the fact that there already exists a great deal of poverty and greater incidences of individuals without insurance to assist with some of the cost (nrha, 1999; ricketts, 1999). there are also limited services available to support the couple once they enter into the “world” of infertility. there are support groups such as the one sponsored by the national infertility association, resolve (2002). however, most support groups such as resolve are only available in urban areas. although one might argue that there are other priorities in terms of the health care needs of rural citizens, should not the desires of those individuals be considered? are people less likely to be concerned about procreation because they live in a rural area? it is the assumption of the researcher that this is not the case and health care providers should be challenged to provide services for infertility in rural areas. the change in the united states population from a major rural to predominantly urban one is quite significant, particularly when one considers that the population growth in rural areas is very dependent on “natural” measures or births minus deaths for increase. this natural growth is negatively impacted when people of childbearing age move to urban areas for job and other opportunities (bushy, 2000). most recently, there has been a relatively small in-migration in rural areas of childbearing age individuals who may positively impact the population growth by starting and continuing family building online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 77 (bushy, 2000; ricketts, 1999). given the critical economic impact of rural areas where people are needed to produce agricultural and other related products for the rest of the united states and world, it is essential that there is a sufficient population available to meet this need. if childbearing age rural residents have difficulty contributing to the production of this population, then there may be no children to raise and be encouraged to stay. thus, the question remains is there a problem with infertility and infertility services for those in rural areas and is it different than those in urban areas? purpose the purpose of this study was to explore the difference with regard to selected criteria in the infertility experience for rural and urban individuals in a southern state. for the purposes of this study, rural was defined as all counties in the state other than those 16 in this study in a metropolitan statistical area (msa) that were considered urban. msa is defined as one or more counties having one city with 50,000 or more population or an urbanized area (as defined by the u.s. bureau of census) with at least 50,000 in population and a total of at least 100,000 in the counties comprising the msa. counties included in msa are considered urban. counties not in the msa are considered rural. each msa must include the county in which the central city is located and additional contiguous or fringe counties if they are economically and socially integrated with the central county. using this definition, alabama has 45 (67%) rural and 22 (33%) urban counties (alabama rural health association, 2002). methodology a survey design was used to assess infertility using the capstone poll. the capstone poll is based on a random survey of adult respondents, 18 years or older in alabama. a computer using all of the three digit telephone exchanges in the state drew the random sample of households. households were contacted using these numbers. a respondent in the household was randomly selected by asking for the adult who had the most recent birthday. trained, experienced personnel employed by the capstone poll conducted interviews. data were analyzed using descriptive statistics. percentages were calculated to provide summative data regarding rural and urban subjects. chi squares were used to look at comparisons of rural and urban subjects regarding selected demographics and factors related to the infertility experience. findings a total of 450 subjects comprised the sample. of these, 65.6% were classified as urban and 34.4% were classified as rural based on the definitions used for this study. this composition is somewhat comparable to the approximate 75% urban and 25% rural distribution of the general population of the united states as noted by bushy (2000). there were no statistically significant differences in the selected demographics of marital status, age, education, and income for the total sample based on rurality or urbanicity. with the exception of educational level, the same was true for those in the subsample online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 78 who reported problems with infertility. urban infertile persons were better educated than rural persons. the majority of subjects from the total sample of 450 were married (67.5%). this rate compares to 68.4% of total urban and 65.8% of total rural subjects who were married. with the sample of subjects who experienced problems with infertility, 65.7% of infertile urban and 55.5% of infertile rural respondents were married. given that the prime age range for fertility is between 18-44 years (laborde, 2000), there was slightly greater than half (54.2%) the subjects in the total sample who were in this age range, 53.2% of total urban and 56.1% of total rural were also in this age range. the sample of infertile individuals included 62.8% of infertile urban and 44.4% of infertile rural in this age range. more than two thirds (89.7%) of the subjects in the total sample had a high school education or beyond. of these, 89.1% of the total urban and 90.9% of the total rural had a high school education or more. a similar distribution was noted for the infertile sample with 94.2% of infertile urban and 88.8% of infertile rural. however, urban/rural was not statistically significantly different for the total group. although there was no statistically significant difference in reported income for the total sample with 43.5% reporting an income below $40,000, only 40.6% of total urban subjects who responded had an income below $40,000 compared to 49.0 % of total rural respondents. a similar comparison existed for the infertile urban (48.5%) and infertile rural (55.5%) sample (see table 1). table 1 selected demographics demographics total urban n=295 <65.6%> total rural n=155 <34.4%> infertile urban n=35 infertile rural n=9 total sample n=450 infertile sample n=44 p value total sample p value infertile sample marital status (married) (68.4%) n=202 (65.8%) n=102 [65.7%] n=23 [55.5%] n=5 <67.5%> n=304 63.6% n=28 .88 .36 age (18-44) (53.2%) n=157 (56.1%) n=87 [62.8%] n=22 [44.4%] n=4 <54.2%> n=244 59.0% n=26 .31 .32 education ( > high school ) (89.1%) n=263 (90.9%) n=141 [94.2%] n=33 [88.8%] n=8 <89.7%> n=404 91.1% n= 41 .33 *.03 income (< 40,000) (40.6%) n=120 (49.0%) n=76 [48.5%] n=17 [55.5%] n=5 <43.5%> n=196 50.0% n=22 .24 .87 significantly different (p < .05) using chi square # approaching significance (p < .1) using chi square () indicates proportion of total urban or total rural sample [] indicates proportion infertile urban or infertile rural sample <> indicates proportion from total sample indicates proportion from infertile sample p value is difference in total sample or infertile sample online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 79 approximately 10% of subjects reported a problem with infertility. this percentage is comparable to the prevalence reported in the literature (hwang, 1999; tucker, 1997). results indicated that there were some statistically significant differences in the infertility experience for urban and rural citizens in this sample. urban citizens were more likely to experience infertility (p= .05). of those who reported a problem with infertility, 79.5% were from urban areas and 20.5% were from rural areas. there was no statistically significant difference in who was likely to seek assistance for infertility. however, a greater percentage of urbanites did report that their coverage met their needs better in the infertile sample as indicated by a greater satisfaction with their health care (see table 2). table 2 problems with infertility infertility <n=44 or 9.8% of total sample> urban rural p value experienced problems with infertility 79.5% n=35 20.5% n=9 *.05 sought treatment for infertility [71.4%] n=25 [88.9%] n=8 .54 satisfaction (rated 8 or above on 1-10 scale) {76.0%} n=19 {50%} n=4 .16 health coverage [82.9%] n=29 [100%] n=9 .18 * significantly different (p < .05) using chi square p value is difference in total sample or infertile sample with regard to social factors associated with infertility, there were no statistically significant differences in alcohol consumption, cigarette smoking or stress experience in the total sample or the infertile sample based on urban and rural classifications. in the total sample, those in urban areas tended to smoke more, but not significantly more (p= .20). those in urban areas considered themselves to be more stressed, but not at a level of significance (see table 3). results indicated a statistically significant difference for some health related social factors for the total urban and total rural sample. although not indicated in the table, those living in urban areas rated their health significantly different from those in rural areas (p= .02) when looking at the total range of options from one to ten with one being poor and ten being excellent. however, when looking at specific indicators for a good health rating (eight or above) there was no statistically significant difference (p= .26). the same was true for health perception in the infertile sample (p= .18). there were no significant urban or rural differences in which group was likely to have a regular health care provider. in both the total sample and the infertile sample, there were marginally less rural citizens who had private health insurance but not significantly so. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 80 although not indicated in table 3, there were statistically significant differences (p= .01) in the time to travel to the doctor for urban and rural subjects in the total sample. rural table 3 social factors social total urban n=295 total rural n=155 infertile urban n=35 infertile rural n=9 p value total sample n=450 p value infertile sample n=44 alcohol (two or more/day) (42.0%1) n= 124 (34.2%) n=53 [45.7%] n=16 [17.1%] n=6 .27 .50 cigarette smoking (26.8%) n=79 (21.3%) n=33 [42.9%] n=15 [55.6%] n=5 .20 .50 stress experience ( <4 with 1 being high on 1-10 scale) (33.6%) n=99 (36.1%) n=56 [40.0%] n=14 [33.3%] n=3 .76 .71 perception of health (> 8 with 1 being poor on a 1-10 scale) (68.5%) n=202 (63.2%) n=98 [68.1%] n=24 (44.4%) n=4 .26 .18 regular health care provider (92.5%) n=273 (90.3%) n=140 [94.3%] n=33 [88.7%] n=8 .42 .57 health care coverage (81.7%) n=241 (76.1%) n=118 [82.9%] n=29 [100%] n=9 .16 .18 length of time to reach doctor (>30min) (21.4%) n=63 (30.3%) n=47 [22.9%] n=8 [33.3%] n=3 # .08 .52 significantly different (p < .05) using chi square # approaching significance (p < .1) using chi square () indicates proportion of total urban or total rural sample [] indicates proportion infertile urban or infertile rural sample <> indicates proportion from total sample p value is difference in total sample or infertile sample citizens had to travel for longer periods to seek health care. table three does indicate that when looking further at a comparison of 30 minutes or more, there was no statistically significant difference in either the total urban or rural, nor the infertile rural or urban sample. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 81 discussion the findings of this study have significance for those who are instrumental in providing health care for rural individuals during their reproductive years. some of the generally accepted ideas about rural citizens and their health care are inconsistent with the findings in this sample and warrant reconsideration. in this sample, they were not statistically significantly poorer or less likely to have a health care provider. those rural subjects in the infertile sample, however, were less educated. on the other hand, issues related to quality of care were consistent with dominant perceptions for rural health care. urbanites in the infertile sample reporting that their coverage met their needs better, as indicated by satisfaction when seeking assistance for infertility, is significant in that the “quality” of health services has long been noted to be less in rural areas and may be particularly so for reproductive/infertility health services. this finding supports the position by the nrha (morgan, 2001) that noted that the quality of health services, in general, are of a lesser quality in rural areas. urban subjects experiencing statistically significantly more infertility is not consistent with the fact that they did not smoke more nor have more stress. these two factors, along with alcohol consumption and others, have been associated with increased infertility as noted by robinson and stewart (1995) and trantham (1996). there were no differences in the alcohol consumption in rural and urban subjects in the total sample or infertile sample. this finding is congruent with data reported by ricketts (1999) in which no notable difference was seen in reported alcohol use in urban and rural adults. the author did, however, caution against the validity of this interpretation given that data were obtained by self-report. he further noted that the presence or absence of rural-urban differences with regard to alcohol use could be attributable to other factors such as socioeconomic status, ethnicity and population density and proximity to urban areas. having health insurance is an important factor for general health. however, because insurance companies cover very few infertility costs, this factor may be less of an issue when considering differences in resources for infertile rural and urban citizens. the income of those who are infertile is significant, although not statistically so, since the additional cost for treatment not covered by insurance must come from out of pocket. if one has very little money to begin with, seeking assistance for infertility becomes more challenging when decisions must be made about how to spend the limited funds one may have. findings in this study indicated that this dilemma was not as relevant a factor for this sample. based on data analysis, it is clear that there is a difference in the access to services available to infertile persons in rural areas. rural citizens having to travel farther for health care was supported by results in this sample and is significant in that it adds to the stresses already inherent in the infertility experience as noted by barber (2000). having to travel longer because of greater distances can also significantly increase the expense of infertility treatment for rural citizens. recommendations as a result of this study, several recommendations come to mind for health care, education, and research. there has long been ample evidence that the availability and online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 82 access to health care in the rural areas needs to improve (bushy, 2000; morgan, 2001; ricketts, 1999). although the findings in this sample supported a difference in the prevalence of infertility in rural areas and urban areas, there is still a need for these services in rural areas. because the need is there, it would be astute of policy makers, nurses and other providers of health care to consider how to increase the quality and access of reproductive services when it can be accomplished in a cost effective manner in conjunction with other services. for example, when looking at continuing education offerings and resources for nurse and primary care providers in rural areas, reproductive health issues related to initial infertility work ups such as basal body temperature measures and sperm counts could be included. also, when securing specialists who serve in rural areas for women and men’s health, some additional effort could be made to secure those who have reproductive experience. although it might eventually be necessary for rural residents to travel for infertility services, being able to take care of those initial service needs locally would save on gas, time, frustration and perhaps money. the costs savings would be even greater if they did not need to take off work to travel to the appointment. those who educate nurses and other healthcare providers who work with rural populations must make them aware of the special needs of these citizens. they must also make students aware of how to provide the most cost efficient and effective reproductive services available to those who live in rural areas. for example, teaching patients about some basic infertility care such as diet, alcohol consumption, clothing, stress and similar measures could provide them with some relatively inexpensive measures to address their infertility. additional research is needed to get a better understanding of the impact of infertility for those who live in rural areas. an additional study with a larger sample could provide greater statistical power to data analysis and detect significant differences better. although policy makers and those who allocate resources may be more impressed by quantitative data, qualitative studies will lend the fullest understanding of this phenomenon of infertility and rurality. studies, which look at the needs and perspective of infertile rural residents from their lived experiences, can assist health care providers to better meet their needs. references alabama rural health association (2002, june 17). what is rural? retrieved june 17, 2002, from http://www.arhaonline.org/what-is-rural.htm barber, d. (2000). a fertile field. nursing standard, 14(26), 77-78. [medline] bushy, a. (2000). orientation to nursing in the rural community. thousand oaks, ca: sage. clapp, d. (1985). emotional responses to infertility: nursing interventions. journal of obstetric, and neonatal nursing, 14(6suppl.), 325-355. [medline] edelmann, r.j., & connolly, k.j. (1986). psychological aspects of infertility. british journal of medical psychology, 59, 209-219. [medline] hwang, m.y. (1999). infertility options. journal of the american medical association, 282(19), 1888-1889. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.arhaonline.org/what-is-rural.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11276709 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=3908629 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=3768268 83 imeson, m., & mcmurray, a. (1996). couple's experiences of infertility: a phenomenological study. journal of advanced nursing, 24, 1014-1022. [medline] kelly, a.l. (2001). does stress hurt fertility? joe weider's shape, 20(5), 40-44. keye, w.r. (1984). psychosexual responses to infertility. clinical obstetrics and gynecology, 27, 760-766. [medline] laborde, k.l. (2000). infertility myths and medicine: getting to the bottom of the baby chase. new orleans magazine, 34, 30-31. menning, b. (1980). the emotional needs of infertile couples. fertility and sterility, 34, 313-319. [medline] morgan, a. (2001, september 10). hhs report finds rural community health lacking: nrha cites report as a national call to action. message posted to national rural health association mailing list. national rural health association. (1999, may). access to health care for the uninsured in rural and frontier america. retrieved may 17, 2002, from http://www.nrharural.org/dc/issue.papers/ipaper15 resolve: national infertility association [website]. retrieved may 17, 2002, from http://www.resolve.org/ perry, k. (1999). infertility: fertile ground for managed care. managed health care, 9(5), 2-25. ricketts, t.c. iii. (ed.) (1999). rural health in the united states. new york: oxford university press. robinson, g.e., & stewart, d.e. (1995). infertility and new reproductive technologies. american psychiatric press review of psychiatry, 14, 283-306. sandelowski, m. (1993). with child in mind: studies of personal encounters with infertility. philadelphia: university of pennsylvania press. schoener, c.j., & krysa, w. (1996). the comfort and discomfort of infertility. journal of obstetric, gynecologic and neonatal nursing, 25(2), 167 172. [medline] sherrod, r.a. (1995). a male perspective on infertility. mcn, 20(5), 269-275. the center for health professions. (2001, may 21), university of california, san francisco. trantham, p. (1996). the infertile couple. american family physician, 54, 1001-1010. [medline] tucker, j. (1997). problems of infertility. practice nurse, 13(8), 450, 452, 454-5. wiczyk, h. (2000). infertility: a modern work-up. female patient, 25(8), 72-77. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8933262 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=6488617 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=7418883 http://www.nrharural.org/dc/issue.papers/ipaper15 http://www.resolve.org/ http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8656308 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8784170 microsoft word 153-611-1-pb_fahs.docx online journal of rural nursing and health care, 12(1), spring 2012 1 editorial rn labor supply bubble: what does it mean for rural health care? pamela stewart fahs, dsn, rn a recent article in the new england journal of medicine (staiger, auerbach, & buerhaus, 2012) noted that the registered nurse (rn) labor supply is likely in a bubble with an oversupply of full time rns. these authors note that health care employment is often countercyclical in nature. this means in times of a poor economy the number of health care positions grow, since a larger labor force is available. those nurses who are employed may delay retiring or leaving the job market to continue their education since they have a steady source of income. the nurse may be the sole bread winner if other family members are unemployed, and those who were part-time are more likely to want to work full time to increase income stream in a poor economy. what does this mean to rural nursing? it may mean that rural health care facilities have a larger supply of rns to choose from and they can be more competitive with their urban counterparts. however, extreme caution is advised. as the economy improves, and it always does, the pressures to stay in the work force will ease for current rns. we know there will be a large number of rns retiring in the next few years. in addition, those of us who are baby boomers are aging and will have increased health care needs in the future. if plans for the changes in healthcare with the affordable care act hold through the supreme court challenges, many more americans will have health care coverage and it follows that they will use that coverage to seek care. this is expected to lead to more health care positions including those for rns in all levels but particularly in advanced practice positions. nursing is one of the most flexible types of health care disciplines in terms of types of positions. nurses work in clinics, home health, public health, nursing education, school and industry as well as acute care. in rural nursing there is a need for what i term the “consummate generalist”. the role of the rural nurse is broad and you need a broad and deep knowledge base to practice in this environment. the future of nursing: leading change, advancing health report from the institute of medicine (iom) and robert wood johnson foundation (iom, 2011) discuss several ways to ensure a strong role for nursing in advancing health care in this country. they specifically address rural nursing in a number of ways, chief among these the use of residency programs to assure a smooth transition from education to practice settings in rural environments, easing educational transitions to baccalaureate and higher education, and assuring that nurses can practice to the full of extent of their education and experience particularly in advanced practice roles. this time of a more abundant supply of rns is a time for rural areas to strengthen the ranks of rural nurses. i would implore rural facilities and those of you in leadership positions in rural areas to use the time when rns are available to look ahead and make plans that ensure an adequate supply of rns in the future for your facilities and communities. use this time to reduce professional isolation, provide training that assists both individual nurses and the organization in growth to provide the best possible health care. staiger and colleagues (2012) predict that over the next several years this bubble of abundance of rns will deflate if not burst. as nurses we have seen it before, the cycle of a nurse shortage replaced with predictions that the shortage is over, only to find the next cycle of shortages even worse. hopefully those that employ rns will be able to look at history and use online journal of rural nursing and health care, 12(1), spring 2012 2 this time of adequate nursing labor supply to prepare for the future, to prepare for a role for nurses that allows them to use their skills to the full extent of their scope of practice. references iom (institute of medicine). (2011). the future of nursing: leading change, advancing health. washington, dc: the national academies press. retrieved from http://www.nap.edu/catalog/12956.html staiger, d.o., auerbach, d.i., & buerhaus, p.i. (2012). registered nurse labor supply and the recession — are we in a bubble? new england journal of medicine, 366 (16), 1463-5 [medline] http://www.ncbi.nlm.nih.gov/pubmed/22436050 back ground and significance 13 strengthening and sustaining social supports for rural elders kristie j. clark, mscn(c), rn1 beverly d. leipert, phd, rn2 1 regional geriatric program, st. joseph’s health care, london, on, kclark44@uwo.ca 2 associate professor, school of nursing, university of western ontario, bleipert@uwo.ca keywords: social support, rural elders, rural nursing, rural health, canada abstract rural elders face unique challenges in maintaining and strengthening their social supports. the purpose of this paper is to examine factors that influence social supports for rural elders as well as to identify implications for nursing practice and research. an extensive review of the literature revealed that rural elder social support is affected by factors related to outmigration of youth, geographical distance, transportation, decreased income, as well as rural culture, values, and norms. the literature also reviewed strategies that can facilitate social support in rural areas, including multiple use of one site, use of technology, mobile and outreach services, community development initiatives, and transportation projects. rural nurses have a professional responsibility to share their knowledge of ways to sustain social supports for rural seniors, and to advocate for better funding and programs for this population. however, in order to prepare nurses to effectively advocate on behalf of rural seniors, education for nurses that encompasses the context of rural health is needed. introduction the fastest growing population group in canada consists of individuals over the age of 65 (health canada, 2002). in 2001, one in eight canadians was part of this group (health canada) and as the “baby boomers” (individuals born between 1946 – 1965) age, the number of elderly is quickly increasing. the senior population is expected to reach 6.7 million in 2021 and one in four of these seniors will live in a rural setting (health canada). furthermore, seniors in canada greatly contribute to society by volunteering and in 1992 contributed 5.5 billion dollars worth of unpaid labor to our social programs (health canada). therefore, promoting the health of this population will allow seniors to continue contributing to society in a meaningful and much needed way. as a result of the increase in our population’s age and the recognition of the economic impact this will have on our health care and social systems, a greater social interest in promoting health for older adults is evolving (chapman, 2005; nolan, 2001). health promotion is the process of enabling people to improve and increase control over their health (world health organization (who), 1986). since individuals living in rural and remote canadian communities have diverse social, physical, and economic characteristics that have an impact on their health, it is important to look at the context of the rural setting when promoting health for older populations (health canada, 2003). in fact, rural people have higher rates of chronic illness, shorter life expectancies, higher unemployment rates, lower incomes, and fewer years of education (health canada). thus, in order to promote the health of rural populations, it is important to examine social factors as well as environmental and economic factors and conventional health services (troughton, 1999). online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 mailto:kclark44@uwo.ca http://www.uwo.ca/fhs/nursing/index.htm mailto:bleipert@uwo.ca 14 strengthening social supports (ss) for elderly individuals is one method that can lead to improved health status and decreased use of health care services (forbes, 1998). hence, strengthening ss is an excellent strategy to promote health for rural seniors. the purpose of this paper is to look at factors influencing ss for rural elders. first, social support will be defined and factors influencing ss for this population will be examined. then the authors will discuss strategies used to increase ss for rural seniors and identify implications for nursing practice and for nursing research. defining social support social support is a broad term and many definitions for it appear in the literature (chappell, gee, mcdonald, & stones, 2003). however, all the definitions for ss have a common underlying theme of relationships that contribute to individuals’ self worth and ability to function in society. for the purpose of this paper, social support will be defined as: formal and informal activities and relationships that provide for the needs of people in their effort to live in society. these needs include education, income security, health care; and especially a network of other individuals and groups who offer encouragement, access, empathy, role models, and social identity (barker, 1995, p. 357). social support may include informal sources such as family, friends, neighbors, and community members, as well as more formal ss that encompass outside agencies such as support groups, housekeeping services, health care professionals, and volunteer organizations. lack of ss is a mitigating factor in the deterioration of health for individuals so strengthening ss for elderly people can contribute to their well-being (choi & wodarski, 1996). in fact, increases in ss can lead to increases in: a) quality of life (chappell et al., 2003; graydon & ross, 1995); b) morale (edmunds, 2003; wilson, calsyn, & orlofsky, 1994); c) activity (chogahara, cousin, & wankel, 1998); d) medication and health care regime compliance (kitchie, 2003); and e) self care abilities (wang & laffrey, 2001). as well, ss can lower levels of depression (bothell, fischer, & hayashida, 1999) and feelings of isolation for those living in rural and remote areas (mullins, elston, & gutkowski, 1996; saito, sagawa, & kanagawa, 2005). for these reasons, it is important that nurses explore the impact that ss has on rural elders and factors that influence ss for this population. factors influencing social support rural elders face unique challenges in maintaining and strengthening their ss due to their geographical location. developing an understanding of the unique factors influencing ss for rural elders will help nurses plan care and create programs that meet the specific needs of this population. while there are no studies that look directly at factors influencing ss for rural elders, the literature identifies specific factors that contribute to promoting and maintaining ss. issues such as outmigration of youth, geographical distance, transportation, decreased income, and rural culture, values, and norms are recognized as factors influencing ss for the rural elderly. outmigration of youth. individuals growing up in rural environments often face limited opportunities and therefore leave their rural homes for urban centres where educational and online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 15 employment prospects are more abundant (bushy, 2000; gerrard, kulig, & nowatzki, 2004; mclaughlin & jensen, 1998; stoller, 1998; troughton, 1999). additionally, adult children who are gay or lesbian often move away because they prefer the invisibility and increased ss that urban areas can offer (stoller, 1998). since rural elders have a strong preference for informal ss, especially from family members and friends (magilvy & congdon, 2000; weinert & long, 1993), this outmigration of youth from rural areas has a significant impact on their informal ss. as well, formal supports may be affected by this outmigration of youth because fewer youth will be available to deliver more formal services either as paid professionals or as volunteers. furthermore, outmigration of youth may result in smaller communities having higher proportions of elders. these rural communities of elders have greater health needs compared to other younger and less isolated communities, but may be, by virtue of their needs and demographic characteristics, too small to sustain geriatric social and health services (mclaughlin & jensen, 1998). geographical distance. geographical distance has a negative impact on ss and can lead to social isolation (anderson, 2003). in fact, the further the distance between individuals and their ss, the less contact and access they have with these support systems (anderson, 2003). in addition, weather can further limit ss for rural elders living in geographically distant locations because it can lead to unsafe driving conditions such as poor visibility, mudslides, icy roads, and even road closures (johnson, 1998, kihl, 1993). these unsafe driving conditions limit the ability of rural elders to maintain or access their ss networks. moreover, in geographically isolated areas there are fewer educated or trained individuals to deliver social services thereby limiting the number of formal ss available to those elders living in geographically distant areas (nagarajan, 2005; romanow, 2002). transportation. for elders living in isolated, rural areas, the ability to drive has a positive impact on their quality of life and mobility because the ability to drive results in being able to access social services and support networks independently (kihl, 1993). for some rural seniors, functional declines related to aging, such as reduced vision, reflexes, and reaction time, may lead to losing their driver’s licenses, thereby limiting their access to ss (johnson, 1998; rashba & pavelock, 2006). disturbingly, older rural adults may continue to drive even after they have lost their licenses because no alternative transportation is available (johnson, 1998; rashba & pavelock, 2006). in fact, most rural areas do not have reliable public transportation systems such as buses or taxis, and seniors from these areas are dependent on themselves, neighbours, and family members to provide transportation (kihl, 1993). consequently, a lack of reliable transportation is a major barrier when setting up satellite clinics or formal support programs in rural areas (choi & gonzalez, 2005; kihl, 1993). likewise, rural elders who still have their licenses face unsafe driving conditions prevalent in rural areas, such as inclement weather, gravel roads, unlit roads at night, and mountainous or monotonous terrain (johnson, 1998, kihl, 1993; leipert, 2006). decreased income. lower levels of socio-economic status are linked to lower levels of ss and increased incidences of social isolation (health canada, 2005). since both seniors (ahn & kim, 2004; health canada, 2002) and individuals living in rural areas (health canada, 2003; troughton, 1999) are more likely to experience decreased incomes, rural seniors are at an increased risk for living in poverty. while income and ss are not the major focus of the literature analyzed for this paper, the link between poverty for rural elders and decreased ss is repeatedly mentioned in the literature (ahn & kim, 2004; comerford, henson-stroud, sionainn, & wheeler, 2004; magilvy & congdon, 2000; wang & laffrey, 2001). rural seniors with limited online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 16 incomes may not have enough money to pay for transportation and other expenses associated with social programs or to pay for more formal supports such as house cleaning and homecare services (ahn & kim, 2004; gerrard et al., 2004; keating, keefe, & dobbs, 2001). furthermore, individuals living in lower income rural areas may need two incomes to support their families and therefore more adult children may need to work outside of the home, thus decreasing the amount of informal support available for rural elders (magilvy & congdon, 2000). the limited amount of research addressing the link between ss and poverty is from a quantitative focus. while statistical data is important, it does not tell us about the impact poverty has on ss and the lives of rural elders. therefore, more qualitative research addressing poverty and ss is needed in order to gain an understanding of these issues from the perspective of rural dwelling elders. since women, immigrant, and aboriginal populations in rural areas experience limited job opportunities, lower paying employment, and increased incidences of poverty (black, cook, murry, & cutrona, 2005; gerrard et al., 2004; health canada, 2005; leipert, 2006; mccracken et al, 2005; mcculloch & kivett, 1998; ship, 2004; wang & laffrey, 2001), specific attention should be given to these groups. rural values, culture, and gender differences. prevalent in the literature on rural health are the strong values of independence and self-reliance (bushy, 1990; gerrard et al. 2004; lee & mcdonagh, 2006; long & weinert, 2006; shenk, 1998; thomlinson, mcdonagh, crooks, & lees, 2004; weinert & long, 1993). as already mentioned, if help is needed, rural elders prefer informal supports such as family, friends, and neighbours (bushy, 1990; lee & mcdonagh, 2006; shenk, 1998; weinert & long, 1993). in fact, one study finds that rural individuals are less likely to use formal services even if they were available (weinert & long, 1993). thus, for rural elders, assistance from family and friends buffers against poor health and loss of independence (keating et al. 2001). moreover, volunteerism is a strong part of rural culture (keating et al. 2001; keefe & side, 2003; little, 2002; rowles, 1998; sutherns, mcphedran, & haworth-brockman, 2004) and this can enhance ss for rural elders. however, it is important to recognize that women are primarily responsible for providing voluntary care to rural elders, even if they work or have young children for whom they care for at home (little, 2002). as rural populations age, continuing to expect women to provide these supports to rural elders when they may already be juggling multiple roles may have detrimental effects on the health of both the rural woman caregiver, as well as the rural recipient of care. regrettably, there is no research that explores these issues or that identifies supports rural women caregivers may need in order to maintain their well being. since rural women are a strong source of support for the rural elderly, research that focuses on rural women and caregiving is desperately needed. rural cultures also tend to prefer and enact gender differences in how ss are maintained and accessed. for instance, women are predominantly responsible for maintaining social relationships and ss (krout, mcculloch, & kivett, 1997; little, 2002; shenk, 1998). as well, rural women are more likely to receive ss from family and friends, whereas rural men rely more heavily on their wives for support because they have fewer resources to turn to and find it harder to ask for help (krout et al. 1997; weinert & long, 1993). thus, there is a risk for rural men, especially those who are single or widowed, to have poorer ss than women. furthermore, it is important to recognize that rural communities are heterogeneous and that subpopulations within communities will have their own values and traditions. in the literature on ss, there is a paucity of information regarding ss and minority populations. one study found that rural older lesbians receive help and support from their neighbours but these women still need to leave town on a regular basis to seek emotional support that respects their online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 17 lesbian social identity (comerford et al. 2004). additionally, in rural areas informal support networks are commonly church-based and not well utilized by lesbians because of the historic disapproval of homosexuality that is prevalent in many religions (comerford et al. 2004). studies that examine rural, minority and ethnic populations demonstrate a common theme: increased ss from family and friends coupled with decreased uses of formal ss due to racism and cultural insensitivity (adelson, 2005; black et al. 2005; ship, 2004; radina, longo, & armer, 2005; weiner, burhansstipanov, krebs, & restivo, 2005). in order for rural nurses to deliver care that is culturally sensitive, more research that explores ss and rural minorities is needed. significantly, in canada, a large portion of aboriginals live in rural and remote areas (health canada, 2003) and yet there is very limited information on ss for this group; consequently, this is one area that researchers need to concentrate on in order to promote better health for this population. as identified, there are many factors influencing the ss of rural elder. in addition to having a better understanding of what these factors are and how they affect ss, nurses need to use innovative and creative strategies to strengthen and sustain ss for older individuals living in rural settings. strategies to strengthen ss for rural elders since rural elders have unique determinants of health, it is important to establish creative ways to address the challenges these individuals face in maintaining their health. unfortunately, there is only a small amount of literature looking at innovative ways already implemented to strengthen ss of individuals living in rural areas. through the literature review, common themes were revealed regarding ways to increase the ss of rural people include multiple uses of one site, use of technology, mobile and outreach services, community development initiatives, and transportation projects. while some of these strategies are not specific to strengthening ss for older rural residents, these strategies could be utilized to increase ss for this population. multiple uses of one site. creating multi-use centres that house more than one social support service or agency can increase access to ss for rural seniors. in quincy, illinois a rural senior centre that houses 14 different service agencies and provides meeting and activity space to 182 groups was built in 1992 (rowley, 2004). within this centre there is assisted living housing for up to 14 individuals; social support programs such as art classes, support groups, and adult day care; support for informal care givers; and care provided by a nurse practitioner. although centralizing ss in one centre is an ideal way to increase ss for elderly rural people, not all communities can afford the cost of building and operating major centres. therefore, it is important to look at services already existing in the community that can be utilized to house multiple ss. in the video fear on the farm (birdsong communications, 1993), a rural community was portrayed that utilized the local church to centralize information about the ss and health programs available to its community. since most rural individuals have strong ties to the local church (little, 2002), this is an excellent solution that is relatively inexpensive. on the other hand, it is important to keep in mind that not all rural community members will access church-based services as identified earlier when addressing the ss needs of older lesbian women (comerford et al. 2004). an alternative to help address the special needs of populations not comfortable with accessing church-based services is to use other common meeting areas within the community, such as local libraries or post offices, to distribute information about ss for the area. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 18 additionally, in order to meet the need for more long-term care beds in rural areas and the accompanying ss needs of rural elders who require this type of care, magilvy & congdon (2000) advocate for using acute care beds that can be converted to long-term care beds when needed in rural hospitals. such an adaptation prevents the need to send elderly individuals to centres that may be hours away from their informal ss. this is an excellent idea because it makes good use of hospital resources, while at the same time sustaining smaller rural hospitals. to this end, the multi-use of rural beds could be broadened to include multi-use of rural hospital space that provides low cost or free areas for local social support programs such as meals on wheels, social clubs, volunteer transportation services, and other geriatric services. even with such an innovative plan, providing reliable, affordable transportation for rural elders to the multiuse centres remains a priority. use of technology. recently the uses of the internet, web-based programs, and teletechnology have been used as ways to increase ss for rural residents. using the internet to form support groups is one way to address the issues of anonymity and access for people who are geographically isolated and who have limited mobility (cudney, butler, weinert, & sullivan, 2002; hill & weinert, 2004; weinert & hill, 2005). one example of a successful internet support program is the women to women program in montana (rowley, 2004). this program used the internet to link women with chronic illnesses living in remote areas to virtual support networks. to date, this project demonstrates that this type of intervention is successful for increasing ss to rural women with chronic illnesses (rowley, 2004). accordingly, the use of technology is one strategy practitioners should consider when looking at ways to increase ss for rural elders, as well as for their informal caregivers and other informal ss personnel such as family and friends. in addition to using the internet, rural seniors are using the world wide web to access information related to health issues and resources (thomlinson et al. 2004). currently, in missouri, a project using online communities that house health-related resources and information for specific rural areas is underway (centner, 2006). nurses could develop websites like the one mentioned as an inexpensive way to provide information about local ss resources to rural elders. tele-technology and the use of videoconferencing have also increased access to health care and ss for rural elders. for example, the interactive home health care program in kansas links homebound, elderly, rural individuals to registered nurses through the telephone and specialized television sets with cameras (lindberg, 1997). nurses in this program provide physical assessment, care recommendations, and coordination of care services to these clients. while the focus of this program is heavily based on the physical aspects of care, this technique could be enhanced to focus on providing ss to rural elders and their informal caregivers. also, other projects have successfully used telecommunications and videophones for nurses to provide support and resources to rural patients and their caregivers (maxwell, 2006; rowley, 2004). although these other projects are not specifically targeted at older rural residents, they do provide evidence that these types of initiatives are successful at increasing ss and should be considered for use with rural seniors and their informal ss. while there is growing evidence to indicate that the use of technology can improve the health and access to services for rural dwelling individuals, it is important to recognize that not all individuals are computer literate. furthermore, not all remote areas will have the technical infrastructure available to support internet and telecommunication services, so this option may not be available to all rural populations. moreover, even though the use of technology can online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 19 increase some ss for rural elders, this type of technology does not address needed physical supports such as housekeeping, help with activities of daily living, or reliable transportation. mobile and outreach services. creating interdisciplinary, mobile health units is a resourceful solution with the potential to increase the quality of health care for rural elders (alexy & elnitsky, 1996; hayward, 2005). for instance, there is the isu senior healthmobile, a health service designed to deliver mobile health and wellness interventions to rural residents over the age of 60 in idaho (hayward, 2005). this program encompasses an interdisciplinary, community development approach that addresses the specific needs, both physical and social, identified by communities. regrettably, hayward provided little information about the issue of insider/outsider status that is prevalent in rural communities (boland & lee, 2006; long & weinert, 2006) and whether or not the outsider status of service providers presented any barriers to the program, given rural residents’ preference for care by known others (bushy, 1990; lee & mcdonagh, 2006; shenk, 1998; weinert & long, 1993). one way to increase the success of mobile outreach teams would be to include insiders, such as local health care professionals or community members, as part of the unit’s team. alternatively, lay individuals or local professionals could be educated to deliver these services and the mobile team could act as a support resource. community development initiatives. using community members to identify, create, and run needed programs can lead to the sustainability and success of services because doing so increases community capacity, ownership, and utilization of programs (averill, 2003; gustafsson-larsson & hammarstrom, 2000). in jamtland, sweden, women’s networks were created to develop social networks for women living in rural areas (gustafsson-larsson & hammarstrom, 2000). these networks address a community-identified need and women are involved in unpaid activities such as competence development, preservation of the local culture, community development, or caregiving for young children and the elderly. these networks lead to improved health and stronger ss for participants (gustafsson-larsson & hammarstrom, 2000). a project like this one could be considered for rural elders in canada to enhance their ss. another community development initiative, the promatoras project, utilizes lay community educators to help strengthen the social and economic infrastructures of their own communities (ramos, may, & ramos, 2001). using lay community educators could be a strategy used to strengthen ss for older rural individuals. furthermore, since this approach is culturally based, it may be the optimal approach to use with rural immigrant and aboriginal populations as a way of ensuring culturally sensitive care. on the other hand, it is important to note that, in order for these programs to be successful they need to be supported with sufficient funding and supportive policies and should not be viewed as a way to fill gaps within the health care system (gustafsson-larsson & hammarstrom, 2000). transportation projects. most of the literature looking at transportation issues for rural populations focuses on the barriers presented by having no reliable transportation. little information is available about initiatives or programs addressing inadequate transportation systems for rural residents. in iowa, a review of rural transit services for the elderly was conducted and this report found that due to inflexible scheduling and poor accessibility of rural transit systems, many rural elders preferred to pay others to drive them rather than use transit (foster, damiano, momany, & mclearns, 1997). since rural communities face unique needs for transportation, rural individuals may benefit more from informal, local, community-created transit options. for instance, the amount of money needed to sustain rural transit systems could be provided to rural communities to purchase a wheelchair accessible van that could be available online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 20 through centralized booking to transport community members. alternatively, the funding for rural transit systems could be used to reimburse informal supports already transporting rural elders and to help ensure that these individuals have proper insurance for doing so. this manuscript provides the reader with some creative ways to strengthen and build ss for rural elders. the authors’ own experiences of living and working in rural areas, have revealed that there are very likely several other programs and initiatives occurring in rural areas, but that these have not been written about or otherwise publicly shared through publications and conferences. for example, during flu season, many public health nurses travel out to farms to immunize rural seniors who cannot travel to town to visit the health unit. these public health nurse visits provide excellent opportunities to also assess and provide ss to rural seniors. another example is the informal network of rural seniors who shared their skills and expertise to help one another remain in their rural homes. for example, a farmer with a tractor would cut the grass and clear snow for those unable to do so, and a senior lady would make meals that could be frozen and deliver them to seniors who needed them. ideally, a network of rural communities could be created that shares information about challenges and solutions rural residents have faced in implementing supports. this network could readily disseminate information important to the success of supporting health and resources for rural elders to health care professionals, policy makers, and rural residents themselves, thereby promoting the health of rural elders and rural communities. implications for nursing practice first, when planning care or developing programs for rural elders, it is essential to assess existing supports and to include informal ss in the process. as a result, care and programs in situ that are sensitive to the unique needs of elderly rural individuals can be better supported and developed. issues surrounding transportation and costs to participants should be key considerations when program planning occurs, and reliable and affordable transportation should be factored into program costs and needs. if formal rural transportation is not available, then appropriate monetary compensation should be made available to suitable rural individuals who are willing to transport rural elders. as well, due to the higher rates of lower incomes faced by many rural seniors, cost of programs should be kept to a minimum. if rural elders require funds for travel, these monies should be provided upfront, before travel commences, to avoid lack of participation due to not having enough funds a priori. second, program planners should incorporate a community development approach when developing programs to promote health and strengthen ss with older rural community members. since rural populations are heterogeneous, using this approach allows community members to identify needs specific to their areas. additionally, taking a community development approach allows individuals in the community to take ownership of the initiatives and builds on the preexisting strengths within the community, thereby contributing to the success of programs while building capacity within the community (averill, 2003; gustafsson-larsson & hammarstrom, 2000). third, rural nurses need to advocate for programs based on needs, not on numbers or on how programs relate to costs of services. while nurses have a responsibility to provide care that is cost effective, there are some communities that will never have high enough numbers of elderly individuals to make programs cost effective. therefore, nurses need to find resourceful ways to deliver much needed services that contribute to strengthening the ss of rural elders. one online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 21 way this can be done is by utilizing lay service providers who could be supported by health professionals in other geographical areas. this approach would not only provide services needed by the elderly, but could also lead to potential employment opportunities in rural areas, potentially keeping rural youth in the community. rural nurses also need to advocate for more resources for the elderly, specifically focusing on more funding and on the creation and support of knowledgeable resources, both formal and informal, to provide services to this population. fourth, sensitivity to gender issues and cultural needs and differences is needed in order to provide ss that are holistic and valued by rural community clients. for instance, men have a harder time asking for help (shenk, 1998); therefore, when working with rural men it may be more appropriate to offer help instead of waiting for them to request it. likewise, women are mainly responsible for providing informal ss to rural seniors (little, 2002) so it would be important to make sure that these women are well supported themselves and that resources are put in place so that these women are not overextended and exploited. furthermore, rural seniors prefer informal ss to formal ones, and they receive more ss from informal networks than urban seniors (forbes & janzen, 2004). consequently, nurses need to explore how caregiving affects the health of these informal ss care providers, and determine and advocate for supports that are needed to sustain these critical rural caregivers. finally, in canada there is a lack of rural health courses in nursing curricula, and those nurses already working in rural areas have limited opportunities to enhance their practice knowledge (kenny & duckett, 2003). thus, in order for nurses to fully comprehend the complex factors influencing health and ss for rural communities, rural health courses need to be available to these nurses. through increased knowledge about the health of rural canadians, nurses will be better prepared to deliver care that is holistic and that meets the needs of rural communities. future research as already emphasized, more research is needed to better understand and address factors that influence ss for rural elders. most of the literature that discusses ss for individuals living in rural areas focuses on how ss are related to the health of individuals from a quantitative perspective. grounded theory, a methodology used to create meaning out of social interactions (beck, 1999), would be an excellent approach for researchers to use in order to gain an understanding of factors that influence ss and of ss processes used to maintain and promote health from the perspectives of elderly individuals living in rural areas. in addition, the use of ground theory research can contribute to the development of much needed theories for rural health nursing (beck, 1999). furthermore, there is limited information about the health of rural canadians, and although some of the research from australia and the united states can be applied to rural communities in canada, it is important, for relevance and utility that canadian context-specific knowledge be identified and used to advance the health of rural elderly people within the canadian rural setting and health care system. specifically, in canada additional research is needed to: a) gather more data regarding ss in aboriginal populations; b) increase our understanding of gender differences and ss; c) explore the link between poverty and ss; and d) develop nursing theory about strengthening ss for rural communities. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 22 conclusion social support can increase the health of rural elders. by examining the personal experiences of rural seniors and their ss, an appreciation for the day-to-day challenges these people face can be created. in this way, nurses can better plan care and develop programs that address specific factors that influence ss for elderly rural populations. in addition to creating innovative ways to sustain ss for rural individuals, nurses have a professional responsibility to share with policy makers and other health care professionals their knowledge about factors influencing ss for these individuals. as well, nurses need to advocate for services and funds to strengthen the ss for older rural people. in addition, information should be widely disseminated regarding what is being done and what needs to be done in order to foster ss for the rural elderly. in these and other yet-to-be determined ways, rural policies, programs, and funding for health initiatives can be strengthened and rural elders’ health promoted. however, in order to prepare nurses to effectively advocate with and for rural seniors, enhanced education for nurses that encompasses the context of rural health is needed. references adelson, n. 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(2000). the crisis nature of health care transitions for rural mullins, l.c., elston, c.h., & gutkowski, s.m. (1996). social determinants of loneliness among nagarajan, k. (2005). rural and remote community health care in canada: beyond the kirby rowles, g.d. (1998). community and the local environment. in r.t. coward & j.a. krout (eds.), aging in rural settings: life circumstances and distinctive features (pp. 105-126). new york: springer. saito, e., sagawa, y., & kanagawa, k. (2005). social support as a predictor of health status thomlinson, e., mcdonagh, m.k., crooks, k.b., & lees, m. (2004). health beliefs of rural wang, h.h., & laffrey, s.c. (2001). a predictive model of well-being and self-care for rural weiner, d., burhansstipanov, l., krebs, l.u., & restivo, t. (2005). from survivorship to weinert, c., & long, k.a. (1993). support systems for the spouses of chronically ill persons in weinert, c., & hill, w.g. (2005). rural women with chronic illness: computer use and skill wilson, j.g., calsyn, r.j., & orlofsky, j.l. (1994). impact of sibling relationships of social world health organization, canadian public health association & health and welfare canada. editorial 1 editorial letter from the editor jeri w. dunkin, phd, rn editor the online journal of rural nursing and health care is the official journal of the rural nurse organization. we are proud that we are now listed in the cumulative index of nursing and allied health literature (cinahl). we are in the process with medline as well. the editorial and support staff of the online journal of rural nursing and health care has worked diligently to expand the features of each issue to respond to reader needs. this issue has both a student paper and continuing education program. the online journal of rural nursing and health care has been developed and operated through support of the university of alabama, capstone college of nursing, where the website and webmaster reside. all have given generously of their time and talents to make the journal an ongoing reality. in addition, the managing editor, dr. steve maccall, has brought to bear his tremendous knowledge and talents in information management to create and maintain our digital library and the electronic referencing feature of each article in the journal. we would not have been able to do it without all the support for both the online journal and the rural nurse organization. we are always open to input on the presentation style and content of the journal. please contact me with suggestions or interest in either rno or the journal. it seems that every state in the u.s. and areas of canada are currently facing budgetary deficits and economic hard times. that is true in alabama as well and as a result the amount of time and effort that the webmaster and information management staff can contribute is in serious jeopardy. it is clear that we will have to begin compensating them for their work. this is very difficult, as the journal has no revenuegenerating capacity of its own, and rno needs additional funds to provide this level of financial support to the journal. currently, the online journal of rural nursing and health care is open to all readers, and we do not require that authors be members to publish in the journal. the board of rno made this decision as a way to provide support for rural nurses and health care practitioners because resources are always less available in rural areas as compared to urban. however, we are revisiting that decision. this is one of the few organizationbased journals that are open to non-members. other journals are supported by member dues, where members freely access to the journal, and non-members must pay for access or they are subscription based. additionally, many of the medical related journals have an advertising department where they solicit paid advertisements to assist with support of the journal. the rural nurse organization governing board and the editorial board of the journal are wrestling with the need for revenue, and our mission to support rural practitioners. it appears that we are either going to have to limit the opportunity to publish in the journal to members only or limit the reading of the journal articles to members only. we do not want to limit readership and will probably start with limiting online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 2 the opportunity to publish to those who hold membership. we may possibly have to limit access to the journal to members only at some time in the future. it is in that spirit that i ask our readers to consider supporting the online journal by joining the rural nurse organization. the membership application can be accessed and printed at www.rno.org. mail it and your check for $55.00 to rno at rural nurse organization administrative offices, c/o letterman lanning, p.o. box 248 spokane, washington 99210-0248, usa. my email address is jdunkin@bama.ua.edu. you may also email the administrative offices at rno@bama.ua.edu. please let us hear from you. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.rno.org/ mailto:jdunkin@bama.ua.edu mailto:rno@bama.ua.edu microsoft word 1491209 her world gets smaller and smaller final 2_27_11.docx online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 27 “her world gets smaller and smaller with nothing to look forward to”: dimensions of social inclusion and exclusion among rural dementia care networks dorothy forbes, r.n., ph.d. 1 catherine ward-griffin, r.n., ph.d. 2 marita kloseck, ph.d. .3 marissa mendelsohn, ph.d. 4 oona st-amant, rn, mscn 5 ryan deforge, msc 6 kristine clark, mscn, rn 7 1 associate professor, faculty of nursing, university of alberta, dorothy.forbes@ualberta.ca 2 professor, arthur labatt family school of nursing, faculty of health sciences, university of western ontario, cwg@uwo.ca .3 associate professor, school of health studies, health & rehabilitation sciences, faculty of health sciences, university of western ontario, mkloseck@uwo.ca 4 previous cihr postdoctoral fellow, arthur labatt family school of nursing, faculty of health sciences, university of western ontario, mmendelsohn@rogers.com 5 doctoral student, arthur labatt family school of nursing, faculty of health sciences, university of western ontario ostamant@uwo.ca 6 doctoral candidate, health & rehabilitation sciences, faculty of health sciences, university of western ontario, rdeforge@uwo.ca 7 director of nursing care, the village of glendale crossing, london, ontario, kristie.clark@schegelvillages.com keywords: social inclusion and exclusion, living with dementia, rural setting. abstract the purpose of this research was to critique the nature of rural dementia care from the perspectives of persons with dementia, their family caregivers and home care providers through a social inclusion/exclusion lens. a critical gerontology approach within a human rights framework (townsend, 2006) was used. three rural dementia care networks were included consisting of persons with dementia (n=3), spouse caregivers (n=3), adult children (n=9), grandchildren (n=2) and home care providers (n=3). thematic analysis (lubrosky, 1994) revealed three overarching inclusion/exclusion themes. members of the dementia care network were being denied and afforded opportunities with respect to: (i) experiencing quality relationships among network members; (ii) having a voice in dementia care decisions; and (iii) participating in care, social, and work activities. this study contributes evidence that challenges the myth of the idyllic nature of rural places. findings revealed the diversity of lived experiences within dementia care network members who described both positive (e.g., close community ties, life-long work opportunities) and negative (e.g., stigma of dementia, dangers of rural setting) aspects of the link between living in a rural setting and living with dementia. introduction this paper will challenge the assumptions about the idyllic nature of growing old with dementia in rural communities. a critical gerontological perspective is used to examine ways in which place (rural), political, economic, and social issues contribute to social inclusion and exclusion at the micro level through the experiences of rural dementia care networks. dementia care networks include persons with dementia, their family and friend caregivers, and home care providers. living with dementia in a online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 28 rural setting is a double jeopardy; both the rural setting and the symptoms of dementia present additional challenges that contribute to social exclusion of dementia care network members. much has been published on the wide variation in how ‘rural’ is defined (du plessis, beshiri, bollman, & clemenson, 2002; pitblado, 2005; williams & cutchin, 2002). for the purpose of this paper, the canadian home care association’s (chca, 2008) definition of rural was used in this study: “settings with small populations, low population densities and/or relatively large distances from major urban centres” (p.10). although many canadian rural communities are experiencing declining populations, they are also experiencing a faster growing proportion of older adults than in urban areas due to a combination of the out-migration of youth, aging in place, lack of in-migration, and the attractiveness of some rural communities for retirees (mccracken et al., 2005; ramsey & beesley, 2006). indeed, 33% of older adults reside in predominantly rural regions, with proportions of older adults increasing as the distance from urban centres increases (dandy & bollman, 2008). in addition, the 9.9 million canadian baby boomers (foot & stoffman, 2004) are entering the age of greater risk of being afflicted with dementia. the most widely used definition of ‘dementia’ (robillard, 2007) is acquired impairment in shortand long-term memory, associated with impairment in abstract thinking, judgment, and other disturbances of higher cortical function, or personality changes (american psychiatric association, 1995). in 2008, there were 480,000 people with dementia (one new case every 5 minutes) and this number is estimated to be 1,125,200 by 2038 (one new case every 2 minutes) (alzheimer society of canada, 2010). informal care will also increase as care shifts away from care facilities to communities. the annual total economic burden is expected to increase substantially from $15 billion in 2008 to $153 billion by the year 2038 (alzheimer society of canada). a major challenge facing the canadian health care system is the need to deliver cost-effective and efficient health care services in rural areas (chca, 2008). rural persons with dementia and their caregivers experience: (i) difficulty accessing available services, (ii) lack of health care services and providers, and (iii) inconsistency of care providers who often lack the skills necessary to provide quality dementia care (forbes & hawranik, in press). home care, although often lacking in rural areas (forbes & edge, 2009), is the largest component of community-based services and the fastest growing sector of the health care system (von canada, 2008). canadian home care is defined as “a range of health and support services received at home with costs being entirely or partially covered by a national/provincial/territorial health plan. these services enable clients incapacitated, in whole or in part, to live in their home environment” (canadian institute for health information [cihi], 2004, p.2). core home care services include: maintenance, rehabilitation, long-term supportive care, acute care substitution, and end-of-life care (cihi, 2004). in ontario in 2008, 67% of home care was provided by personal support workers (psw) and homemaking unregulated personnel and 27% by nurses (ontario home care association, 2008). with the aging of the population worldwide, the looming dementia care crisis (forbes & neufeld, 2008), and the additional challenges in caring for rural family members with dementia, further qualitative research is needed to critically examine the experiences of dementia care networks using a social inclusion and exclusion lens. social inclusion and exclusion social exclusion is defined as “the dynamic process of being shut out, fully or partially, from any of the social, economic, political and cultural systems which determine the social integration of a person in society” (walker, 1997, p. 8). within a human rights framework (townsend, 2006), measures of exclusion typically incorporate dimensions such as individuals’ lack of accepted levels of material well-being and of social benefits (burden & hamm, 2000), lack of opportunity to have a voice in their community (cook, 2008), lack of engagement in meaningful social relationships, lack of participation in civic activities, lack of access to formal services (cook, 2008; pantazis, gordon, & levitas, 2006; scharf & bartlam, 2008), and lack of fair representation in decision-making that affects their health, online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 29 and in subsequent program and service delivery and evaluation (commission on social determinants of health, 2008). although relevant to rural settings (commins, 2004; innes & sherlock, 2004; philip & shucksmith, 2003), the concept of social exclusion has primarily been studied in urban settings (scharf & bartlam, 2008). the lack of empirical evidence relating to social exclusion of rural older people and specifically those with dementia (innes & sherlock, 2004) contribute to the perpetuation of idyllic myths that highlight: (i) the integration of rural older people with close and supportive family and friend networks; and (ii) the supportive nature of rural communities (wenger, 2001). on the contrary, keating, dosman, fast, and swindle (2008) and statistics canada (2005) have revealed that rural older adults are not as embedded in strong networks of family and friends as previously thought and the differences between rural and urban residents are smaller than expected in terms of social engagement and isolation from family, friends, and helping others. our own research (hawranik et al., 2008) has revealed that rural communities are often seen by health care providers as settings in which family and friend support networks are available and willing to assist with dementia care needs, a view not shared by rural family caregivers. rather, rural caregivers report having no remaining energy to socialize, as well as feeling isolated from others. another common myth is that rural older people have fewer service needs because they are healthier and more satisfied with life than their urban counterparts. however, evidence from several sources (e.g., canadian institute for health information, 2006; mitura & bollman, 2003) report that rural older adults experience poorer socio-economic conditions, lower educational attainment, exhibit less-healthy behaviours, and have higher overall mortality rates compared to their urban counterparts. this misconception may be related to the disparity between objective measures of health status and rural older adults’ subjective accounts that emphasize the more positive aspects of rural life (scharf & bartlam, 2008), perhaps due to their sense of stoicism, self-sufficiency, independence and pride (eales, keefe, & keating, 2008; forbes et al., 2008). clearly, further critical, in-depth exploration of the experiences of rural dementia care network members using a social inclusion and exclusion lens is needed. purpose the purpose of this research was to critique the nature of rural dementia care from the perspectives of the dementia care networks, that is, persons with dementia, their family caregivers and home care providers, through a social inclusion/exclusion lens within a human rights framework (townsend, 2006). the aim was to determine how best to support dementia care networks that strive to enhance the well-being of persons with dementia in rural settings and to illuminate the care work of unpaid caregivers and paid care providers. methodology design this study utilized a critical gerontology approach which sheds light on the nature in which the lives of older people with dementia, their family caregivers and home care providers are either advantaged or disadvantaged by prevailing socio-political and economic structures. by focusing on social exclusion, the varied and often hidden nature of disadvantage experienced by persons with dementia and their caregivers is illuminated through hearing their voices (scarf & bartlam, 2008). a critical gerontology approach also assists in challenging taken for granted assumptions, and distorted views and myths in relation to rural ageing (phillipson & scharf, 2005). this paper describes the secondary analysis of data that were collected for a larger critical ethnographic study titled “client-caregiver-provider relationships in home-based dementia care: a critical analysis” (ward-griffin, mcwilliam, forbes, kloseck, & bol, 2006). the original study online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 30 examined values, beliefs, relationships and the experiences of providing/receiving care in the home using multiple in-depth interviews over time, participant observation and focus groups. prior to initiating the study, ethical approval was obtained from the research ethics board at the university of western ontario. signed and assent consents were obtained from all participants according to recent ethical guidelines (fisk, beattie, & donnelly, 2007). sample participants were recruited from the south west-community care access centre (ccac), in ontario, canada that currently serves a jurisdiction of 22,000 square kilometres with a population of just under one million people; 30% of whom live in rural areas (south west-local health integration network, 2006). organization administrative leaders and case managers (n= 200) oversee the work of 1470 full-time equivalent home care providers delivering in-home care to approximately 16,000 clients at any one point in time (mcwilliam et al., 2008). the ccac case managers and four in-home provider agencies assisted with recruitment of persons with dementia and their family caregivers. once they agreed to participate, their home care providers were approached to also participate. our secondary analysis included 18 interview transcripts and field notes from three rural dementia care networks at several time points over 19 months. the three networks included persons with dementia (n=3), spousal caregivers (n=3), adult children (sons=2, daughters=7), grandchildren (grandson=1, granddaughter=1), and personal support workers (n=3). an ecomap of each of the networks can be found in figures a , b, and c. all names are pseudonyms to protect the identity of the participants. network one was the smallest network. harold and linda lived on the family farm which was located approximately two kilometers from their daughter, sharon, who lived in the nearest village. brendan, their son, who owned a farm nearby, and their nearest neighbour was approximately two online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 31 kilometers away. harold, at 75 years of age, still farmed with son brendan. susan, their psw, visited linda two hours twice a week in order to give harold some respite from his caregiving duties (figure a). network two included frank and beatrice who lived in a two-storey farmhouse, surrounded by fields of corn. their wood stove provided not only heat for their home but was also used for cooking. their daughter, abigail and granddaughter, mary lived on the same property in the original family home. frank worked in his rural community until the age of 85 at which time abigail took over but continued to involve her father whenever he was available. the other three daughters and son lived about 1-2 hours drive away. the closest urban centre was approximately 40 kilometers away. two psws were involved with this family, each visiting once a week to help frank with his bath (figure b). similarly, network three was large. peter and fay immigrated from holland as newly weds and built their family home, a bungalow, on an acreage about a 15 minute drive from the city limits. jessica, a daughter with 8 children, and their son johnny lived about a 15 minute drive from their parents, while the remaining three daughters lived between 1-2 hours drive away (figure c). online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 32 data analyses transcripts from the participants’ personal interviews were coded using lubrosky’s (1994) thematic analysis. main ideas and topics that had the most meaning to participants were identified by the analysis team and coded using key phrases that emerged from the data. the codes were grouped into themes (a higher conceptual level) and sub-themes. by comparing and contrasting the coded data, sub-themes, themes, interrelationships and patterns were revealed. to ensure rigor and trustworthiness, members of the analysis team independently conducted the primary coding analysis. these preliminary conceptualizations were shared with the research team as a whole for development and refinement of the themes and patterns, to ensure that the conceptualizations reflected the data presented by the study participants and to encourage the emergence of multiple perspectives around the interpretation of data. the data from these three networks provide opportunity for a rich, deeper of understanding how relationships are negotiated and supported in the context of rural, home-based dementia care; such understandings may well resonate with other care recipients and providers in similar contexts. data were stored and managed using nvivo 8 software. findings three overarching inclusion/exclusion themes were identified. members of the dementia care network being denied/afforded opportunities: (i) to experience quality relationships among network members; (ii) to have a voice in dementia care decisions; and (iii) to participate in care, social online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 33 activities, and work. each of the themes is described and exemplar excerpts are presented to illuminate dimensions of these themes. theme one: to experience quality relationships among network members persons with dementia, even with severe cognitive impairment, continued to recognize the familiar faces of family members and enjoy their company. if he [husband] has to go, he brings me to my daughter's and i’m always welcome there (laughs). she has eight young children, and the first words are always when i come in there, ‘oma did you bring rumica?’(laughs). they want to play rumica (laughs). we love doing that stuff too like my husband and i know rumica and dominos and all that. and so that works out good, really good (n3, fay, client). however, family relationships were different now that their spouse/parent was presenting with symptoms of dementia. the person with dementia was no longer the same grandparent, parent or spouse with whom the family members were familiar. adjusting to the perception of her/his impatience, anger and poor judgment were not easy for the adults and particularly the children. so i would say sometimes she [mother with dementia] got a little angry with me and she gets angry with the kids quicker. like they do something, like you know kids they grab something, well she just grabs it right back (n3 daughter, jessica). attempting to understand the difficult behavioral and mood changes of the person with dementia tended to enhance the relationships between the sisters and between the primary caregiver and daughters. family members found it necessary to frequently get together to share their perceptions of the symptoms presented by their parent and to collectively develop strategies about how best to support the primary caregiver in his/her belief that the family home was the best place for the person with dementia. their strong family values and beliefs became apparent through their substantive efforts to support the primary caregiver. similar efforts were not as apparent in terms of attempting to understand the inclusion needs of the person with dementia. in our family everybody does what they can and i tried not to think ‘oh that person should be doing more or that person should be doing more’ like i just thought everybody should do what they can. if we all try to do what we can, there’s a bunch of us, it’s going to help my dad out a lot you know so i think it’s been good. but i think that’s sort of how we were raised too. that my dad was very family-oriented and family was important and you know he probably knocked that into us (n3, daughter, jessica). family members described several reasons why it was important to maintain quality relationships among the dementia care network members. love and compassion for their life-long partner and a strong commitment to marriage vows were revealed, even when their loved one was demonstrating behaviours that were challenging to manage. family members reported a sense of abandoning their spouse or feeling like a failure when formal services were needed. you know i really admire him [father] because he really took his marriage vows seriously. the first time he took my mom to the day program he felt really awful. like he felt like he was doing something wrong. he didn’t say that but i just know. one time he said to me ‘i used to feel bad dropping her off, i don’t feel that anymore.’ but that’s been over a year so it took him a long time to realize it’s okay (n3, daughter, jessica). family members also reported that they were pleased to be able to reciprocate the love and support their parents had provided them as children and young adults. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 34 he [father] gave me $125 a month. so when i finished university and graduated as an engineer i didn’t have any debt! so you gotta look after the old bugger! (n2, son, david). however, many family members found the symptoms of dementia too stressful and were not able to maintain a quality relationship with the person with dementia. see quite frankly right now, i kind of avoid being one-on-one with my mother. dad used to leave once in a while to go here and there, he’s not allowed to do that anymore. i’d show up and mom would be there. like twenty minutes and i’m thinking ‘god i gotta get out of here’ (n3, son, david). not understanding the reasons for the symptoms and challenging behavious and how to manage them were particularly distressful for family members as these episodes often occurred in the evening when other family members and supports were unavailable. trial and error strategies were implemented with varying success. the worst part of this is she sees things. like, there’s always people. the house is full of people. the memory part, you can live with, that’s easy but it’s just like looking out after a four to five year old…now after supper that’s the hardest time. she wants to go home but yet she doesn’t know where home is. you just get in the car when it gets real bad, and go for a drive and then come home. and everything is okay then (n1, husband, harold). incontinence was another symptom that caregivers had difficulty talking about and managing. family members were often unaware of incontinence products and approaches that would be of assistance in preventing and managing incontinence of urine and stool. incontinence is a precipitating factor in admission to a long-term care facility, which may be located at a distance from their rural community. symptoms of incontinence and institutionalization may result in excluding the person with dementia from their family members and friends. you can’t talk to her [mother with dementia] about it because she says ‘oh i’ve always had that or i dribble a bit’. she won’t use appropriate products, she uses toilet paper instead of using a pad. these are just sensitive things that are not an easy thing to talk to your father about. she did have a bowel accident at my sister’s and my dad’s reaction was not like ‘oh my god’, it almost gave you a sense that this was not the first time. i can usually ask them questions about most things, but i feel like if i talk to them about this, especially my dad, a wall goes up a bit. it’s not really something he wants to talk about (n3, daughter, susan). abusive behaviours were particularly difficult for family members to accept and manage and often resulted in excluding the person with dementia from future similar situations, thus further isolating and decreasing their contact with family, friends and members of their community. i know she [mother] hit one of her grand daughters who is 20. it was like wow she never would have done that before… hit her grandchildren ever, never would have done that but now it was like ‘okay you’re bothering me’, smack! (n3, daughter, raine). a successful approach to managing the symptoms of dementia was to focus on the person instead of her/his symptoms. a positive verbal and non-verbal, caring, and consistent approach also contributed to an inclusive relationship. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 35 i’ve had people that have never known my name. i’ve went there for five years have never known my name but they recognized my face. i have a lady that actually is one that was aggressive, and she actually kicked me in the stomach. not too long after, she went to the hospital. i stopped up to see her a few times. she never knows my name but she always recognizes me. you know, just my face and the smile i think. and a handshake, i always shake their hand always or give them a hug. i feel that’s important and they like it (n1, psw, susan). however, not all of the psws were as effective in developing quality relationships with their clients. others saw their role as primarily providing physical care while neglecting the emotional care. i happened to be there a few fridays when she [psw] gives mom her bath and washes her hair and that takes 15 minutes. i guess she is supposed to give an hour and she basically sat there. i’d say to her, like we were playing rumica, ‘do you want to play?’ ‘nope, i’ll watch you play’ (n3, daughter, raine). other home care providers focused primarily on risk factors rather than considering the civil rights and self-determination of the person with dementia: i make sure he’s safe, because my concern mainly with him is… he is prone to falling (n2, psw, joanne). in summary, experiencing quality relationships among family members, friends, and home care providers was valued by most of the dementia care network members and in particular by persons with dementia. their psws sometimes became a friend while others focused on the task or risk factors rather than the person. the dimensions of the theme experiencing quality relationships reflected their reasons for wanting to sustain relationships among the network and the effort that was required to build meaningful relationships as the symptoms of dementia became increasingly challenging. theme two: to have a voice in dementia care decisions often the person with dementia was excluded from discussions and decisions surrounding his/her care based on perceptions that he/she was incapable of making these decisions due to cognitive impairment. a rare example of a respectful holistic approach that valued the ‘personhood’ of the family member with dementia follows: i have a lot of admiration for my dad, like he didn’t make her [mother] go to the day program. he said that if she doesn’t want to go, i’m not going to make her. so he had to really re-assure her and she said to him ‘you won’t make me stay if i don’t want to stay?’ he said ‘no he wouldn’t’. now she goes two days and i think it’s fine but she never seems to remember what she has done there (n3, daughter, raine). enactment of positional power was also used to exclude family members in care decisions. gender, birth order, status, income, prior relationship with the person with dementia and their caregiver all influenced decision making authority within the network. in the excerpt that follows the only son and a daughter, who had some experience as a health care provider, had power of attorney, even though another daughter, abigail provided the majority of care. the caseworker made the recommendation [need for placement to long-term care facilty]. lynda [sister] and i had lunch together and we said, ‘what are we gonna do?’ ‘we could call a family meeting’. but we said, ‘if you called a family meeting and everybody was against it, are we gonna still go along with it because we think that’s right?’ so we said, “well, you know we’ll make the decision to do it [admit to ltc]”, and then met with the family after and explained to them what we did and why we did it. i think my sister, next door, she felt she should have been consulted a little more. even online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 36 though we had the power of attorney, like every time something came along we should check with her because she had been doing the care (n2, son, david). other reasons for not participating in care decisions included being grateful for what was provided and not wanting to request additional services, and feeling powerless because they perceived that they did not possess the skills or qualifications to contribute to the care plan. these perspectives are commonly held by older adults. the case manager was doing a follow up and dad said “i think they want to offer more help”, but you know there’s nothing for debra [psw] to do. she is done in less than an hour with mom and she’s just sitting there watching the clock. i said maybe we can ask if she can take mom for a walk. my dad said “i’m not going to tell them what they should be doing in their job”. my dad figures ‘i’m getting this for free i can’t complain about it’. my dad and lots of clients i know feel that way that they should be just grateful for what they’re getting. i find that seniors are quite a grateful population compared to what i’m going to be like when i get up there (h3, daughter, susan) the second theme, to have a voice in dementia care decisions, revealed that persons with dementia are often not included in discussions related to care decisions that affect them due to the stigma of the diagnosis of dementia. in addition, older adults, disempowered family members and psws were reluctant to contribute to relevant discussions because of their perception that they lacked the necessary skills to participate and/or were not provided opportunities to have a voice in dementia care decisions. theme three: to participate in care, social and work activities in a rural community where most people know each other, the lack of anonymity may limit participation in care group activities such as support groups for caregivers, may discourage the receipt of home care services provided by individuals known to the recipient of care, or prevent attending a memory clinic located in a small community. the stigma attached to dementia that results in treating the person with dementia differently was a concern to the participants. they had all those people come there [support group] and it was basically caregivers and kids from the caretaker. so i didn’t say nothing there about [fay] because i didn’t want to do that. i didn’t find it appropriate to talk about it with all those people (n3: husband, peter). many of the persons with dementia had lived in the same rural community all of their lives. they farmed the land, raised their children, participated in building and maintaining their churches, and contributed to the social and economic fabric of the community. most continued to value their involvement with their friends, neighbours, church, and social networks. the community has been pretty helpful too. they’ve been good to them. they line dance and they bowl and there’s been ladies who pick her up for choir practice and bring her back home. so they have a good community there. cause my mom wants to go. it doesn’t matter where (n3, daughter, jessica). however, maintaining their life-long social networks was not without difficulty, as their symptoms increased, their worlds became smaller. i don’t know if they were in a museum and somebody was standing in her way and mom just shoved them out of the way… just threw them out of the way and just pushed her out of her way…like this is just such foreign behavior for her. she was always so polite online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 37 and careful what people will think or say about you. like the scope of what you can do with her gets smaller and smaller (n3, daughter, raine). a couple of the participants continued to work beyond normal retirement age. working the land and delivering the rural mail were part of who they were. as long as they were physically able, the participants carried on with these roles which appeared to enrich their lives. receiving home care services facilitated these continued work activities. the only time it bothers me [caregiver of 75 yrs] is in the spring when we’re starting the seed, or in the fall when we’re taking it off. the son and i farm together. as long as i’m home here, it isn’t bad but if i go to his place, i won’t leave her [wife with dementia] alone…susan [psw] comes on thursdays and tuesdays and she [wife] goes to day care on wednesdays. so you get stuff done then (n1, husband, harold). the third theme, to continue to participate in care, social and work activities was important for all of the dementia care network members. while the rural setting presented some challenges such as the lack of anonymity and knowing most of the community members, there were also positive aspects such as the opportunity to continue working the land. their rural routes were strong and their connections to their community remained although to a lesser extent as the symptoms of dementia increased. discussion social inclusion is important in preserving the well-being of persons with dementia (cook, 2008). when examined within a human rights framework (townsend, 2006) and using a critical gerontology approach, dimensions of social inclusion and exclusion became apparent. the dimensions revealed in this study related to quality relationships among rural network members, having a voice in dementia care decisions, and participating in care, social activities, and work. other researchers (cook, 2008; innes & sherlock, 2004; innes, 2009; scharf & bartlam, 2008) have reported similar but less developed dimensions of social inclusion and exclusion. each of these dimensions is discussed below. being denied and afforded opportunities to have quality relationships among rural network members there are multiple benefits of close social relationships for all members of the network and particularly for persons with dementia who derive companionship, love, and a sense of safety and support from quality relationships (cook, 2008). all three dementia care networks in this study included family members who were committed to supporting the person with dementia to remain in the family home for as long as possible, at great sacrifice to their own daily lives. relationships between the daughters and between the spouse caregiver and the adult children were often strengthened due to these common goals. however, maintaining their relationship with the person with dementia was often difficult due to the challenging symptoms of dementia such as hallucinations, incontinence, abusive behaviors, repetitive questioning, and wandering. the manifestation of these ‘anti-social’ symptoms (blackstock, innes, cox, smith & mason, 2006), especially in public places and the fear of stigmatization often resulted in further social exclusion of the person with dementia. friends and neighbours tended to become increasingly less involved as these symptoms progressed. home care front-line staff and case managers, although well-positioned to be working with family members to manage these symptoms, did not appear to have the skills, resources, funding or time to share with the family members information and resources about the disease trajectory. rather, getting the task completed in the brief allocated time was a priority for the psws with little emphasis on emotional and information support. professional and non-regulated workers have low expectations of the potential of persons with dementia to engage with others which limits their opportunities for online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 38 inclusion and social interaction (cook, 2008). educational programs that incorporate dementia care should be a mandatory component of home care providers’ training (mason, blackstock, cox, innes, & smith, 2005) because of the complexity and challenging aspects of the disease. the responsive behaviours of persons with dementia that reflect resistance or abusive symptoms are too often interpreted as challenging behaviours. instead, focusing on the meaning of the behaviours that challenge (innes, 2009) follows more closely the person-centred philosophy of kitwood (1997). kitwood defines personhood as “the standing or status that is bestowed upon one human being, by others, in the context of relationship and social being” (p. 8). this definition can also be applied to persons with severely compromised cognitive function. a personhood approach requires a holistic perspective that rejects a narrow focus on cognitive abilities and recognizes the emotional, social, spiritual, and artistic dimensions of the person (cantley & bowes, 2004). o’connor et al. (2007) have broadened the vision of this definition to encompass three unique but interrelated dimensions of the person-centred approach: the subjective experience of the person with dementia, the immediate interactional environment and the broader socio-cultural context. all of these levels, from the micro to the macro, need to ensure that the person with dementia’s way of responding is understood, as well as the need to examine the impact social structures and processes have on the lives of those with dementia. only including networks which incorporated supportive family members was a limitation of this study. networks without family members were not included. this may be a reflection that home care programs are reluctant to provide services to persons with dementia who do not have adequate family/friend support. home care resources are allocated primarily based on service provision capabilities and not on the needs of dementia care networks. mason and colleagues (2005) found similar findings in scotland. thus, persons with dementia with inadequate or no family support are usually admitted to a more costly long-term care facility, often located at a distance, resulting in being physically excluded from their social networks and communities (cook, 2008; forbes & hawranik, in press). further research is needed to examine the experiences of those who are most vulnerable persons with dementia without family supports. being denied and afforded opportunities to have a voice being denied and afforded opportunities to have a voice in dementia care decisions was the second overarching theme. many of the members of the dementia care network either experienced or contributed to the silencing of other members. persons with dementia felt disempowered because of their exclusion from participating in decisions that affected their lives and their limited choice and control. contributing to this are assumptions that care network members make such as people with dementia are not capable of participating in care decisions. ultimately, their fundamental rights as citizens and human beings may be infringed (cantley & bowes, 2004). as well, family members had limited choice in the type and amounts of home care services received and in who provided the care. family members’ birth order, employment status, income, and relationship with each other all influenced decisional making authority within the network. similar findings from another secondary analysis of the same data, examined siblings/siblings-in-law relationships in home-based dementia care and reveled that gender, birth order and proximity determined how dementia care decisions were made and who provided care (st-amant, ward-griffin, & forbes, under review). in the current study, home care case managers’ assessments of persons with dementia often placed greater emphasis on risks rather than considering their civil rights and self-determination. as well, their focus was on the family caregiver’s ability and willingness to provide support for their loved one, rather than on the caregiver’s needs. family caregivers' needs must be addressed as well to ensure that they are able to sustain their care work. the care planning and service provision tended to over online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 39 ride people’s own rights and desires. front-line home support workers also reported feeling undervalued and inadequately supported and trained to provide quality dementia care. the employer should provide adequate dementia care training for new staff and ongoing mandatory in-services/workshops should be offered to ensure that the front-line providers are kept up-to-date on the best available evidence on dementia care. for all dementia care network members, the silencing of members comes about through a range of interconnected factors and processes. these occur at all levels, from the collective ideology and culture through to interpersonal and individual levels (cantey & bowes, 2004). clearly there are challenges in raising the voice of dementia care networks. cooks (2008) recommends a strong self-advocacy movement for persons with dementia, similar to the disabled group’s movement. this would have the added benefit of challenging stereotypes around dementia and overcoming the stigma related to dementia. persons with dementia should be active participants in all relevant activities (e.g., policy, practice, and research), ‘nothing about us without us’. being denied and afforded opportunities to participate in care, social and work activities the third overarching theme was to have opportunities to participate in care, social and work activities. attempting to maintain their life-long social networks in their rural communities was important to a number of the dementia care networks, while others were concerned with the stigmatism and safety of the person with dementia. while the rural landscape can offer comfort to those with dementia, it can also become a source of danger when disorientation and wandering occur in later stages of dementia. home care personnel have an important role to play in ensuring that people with dementia who are unable to get out and about by themselves have the support needed to engage in social relationships and meaningful activities, both in their homes and in their communities (cook, 2008). home care personnel themselves may be the main source of socialization for individuals living at home with dementia, thus they need the training and support to engage in meaningful activities with these individuals. policy makers also have a role to play in promoting social inclusion through initiatives that encourage local commissioning of innovative services such as respite services (sargeant, 2008), the first link program (mcainey, harvey, & schulz, 2008) which connects persons with dementia and their caregivers to a community of learning, services, and supports early in their alzheimer journey (http://alzheimerott.org/first_link/index.htm), and dementia cafés which provide an informal place for persons with dementia and their caregivers to meet, share experiences, and find out more about dementia (cook, 2008). however, it must be recognized that there are often greater barriers to providing these services in rural areas which results in fewer available service options and fewer qualified home care providers. as well, rural dementia care network members have greater distances to travel to access some of these amenities that are not available online. conclusion this study contributes evidence that challenges the myth of the idyllic nature of rural places through a critique of rural dementia care networks using a social inclusion/exclusion lens within a human rights framework. the diversity of lived experiences within rural dementia care networks was revealed as both positive aspects (e.g., close community ties, life-long work opportunities) and negative aspects (e.g., stigma of dementia, dangers of rural setting) were identified. this suggests that the participants were realists who did not portray rural life as either ‘romanticism or despair’ (blackstock et al., 2006). home care programs and policies need to address this diversity both within rural communities and within dementia care networks. policies and services should place person-centred approaches within the dementia care network’s spatial and social context (morgan, semchuk, stewart, & d’arcy, 2003). as partners in care, the voices of those who comprise dementia care networks, including the persons with dementia, must be heard, and encouraged to participate in dementia care decisions. home care case managers are well positioned to take a greater role in assisting members of online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 40 dementia care networks to enhance the quality of their relationships, to have a voice, and to participate in care, social, and work activities. diminishing social exclusion and promoting social inclusion are the first steps in preserving and promoting the health, well-being, and ethic care that kitwood (1997), we, and most rural families espouse. acknowledgements funding for the original study titled “client-caregiver-provider relationships in home-based dementia care: a critical analysis” was received from the alzheimer society of canada, in partnership with the canadian nurses foundation, canadian institutes of health research institute of aging, and canadian health services research foundation. the principle investigator on this grant was dr. catherine ward-griffin. references alzheimer society of canada. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/15887771 http://www.ncbi.nlm.nih.gov/pubmed/15887771 rural nursing in africa: acts of mercy 1 online journal of rural nursing and health care, vol. 8, no. 2, fall 2008 editorial uncertain times equals opportunities jeri dunkin, phd, rn editor as nurses we must be alert to opportunities to assist our communities as we move through these difficult times around the world. there will certainly be an impact on the health of all people as the economic dynamics of the current world wide recession evolves before us. nurses are problem solvers who are not afraid to use innovative solutions. rural nurses, particularly, have done this for a long time as the rural areas are always resource poor and thus the use “non-traditional” approaches are not new. thus, we must be ready for the opportunities that will come to us individually and as rural nurse and members of the nursing professions as the economies of regions and even nations struggle to come to balance. the american academy of nursing has released a video that talks about the role of nurse and nursing leadership in health care reform. it addresses the need to have nursing actively participate in any health policy discussions. nursing has repeatedly demonstrated models that are efficient and effective in improving patient outcomes while reducing the cost of health care. the video can be viewed at http://www.youtube.com/user/aanraisethevoice. let us be ready… http://www.youtube.com/user/aanraisethevoice editorial 5 editorial rural and remote area nursing: an australian perspective desley hegney editorial board member g’day from the land of oz. i would like to thank professor jeri dunkin and her team for my appointment to the board. i live in a provincial city of about 90,000 people with a further catchment of about 250,000 people. toowoomba is the largest inland city in australia. situated on the darling downs it sits on the edge of the great dividing range (which is nothing like your rocky mountains) and is a major service centre for the darling downs and further west. queensland, the state in which toowoomba is situated, has the third largest population in australia – about 4 million people. i always feel i should remind people that australia’s population is only about 19 million people. toowoomba is a beautiful city known for its gardens. at present we are in the middle of a protracted drought that has seen crop failure and stock being slaughtered due to the lack of water and feed. however sad this always is, australia is a dry country and in many cases the european farming practices we have used have decimated a fragile environment. i hold a joint appointment with the public sector – toowoomba health service as well as the university. we have two private hospitals of about 200 beds each as well as a similarly sized public hospital. there are mental health and aged care facilities in toowoomba and these are all in demand, as many people from western queensland prefer to come to toowoomba rather than the capital city, brisbane. the centre for rural and remote area health (crrah) was established in july 2001 and you can access our activities through our website: http://www.usq.edu.au/crrah. at present usq offers a nurse practitioner accredited program at the master’s level. we also offer research only degrees at the masters and phd levels. we do not offer any professional doctorate programs. i trained in brisbane in a private hospital in the late 1960’s. i then, like many of my generation, traveled around australia until i met and married my husband. as my husband was a farmer, i ended up living on a farm for the early part of my married life, until an extended 8-year drought made us leave the land to move to toowoomba. as a city woman, it was only after i met my husband that i experienced rural life. as he had moved to the east coast (we met in sydney in new south wales), both of us were ‘newcomers’ in the farming district when we established our orchard and production nursery. in 1991 i established the association for australian rural nurses inc and the australian journal of rural health. at that time, the ‘rural health’ movement in australia was just beginning to have some momentum mostly due to the pressure from rural doctors. last friday i was in canberra (our national capital) where a workshop was convened by the national rural health alliance (nrha) to discuss 16 recommendations relating to rural and remote area nursing. the major players were the association for australian rural nurses inc (aarn), the council of remote area nurses (crana) and online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.usq.edu.au/crrah 6 the australian nursing federation (anf). approximately 100 people attended the workshop and members included consumers as well as nurses. the workshop, through group selection, prioritised 7 recommendations for immediate action. the remaining recommendations are still considered to be important, but will be progressed at a slower pace. the workshop could not have been held at a better time with the nurse education review and senate inquiry into nursing having been released in the preceding 6 months. while the workshop participants recognised the importance of these two reviews, it was believed that work begun should continue for rural and remote area nursing. an overview of the seven recommendations is provided below. 1. that all nursing schools that offer education and training (universities, tafe, hospitals and so on) ensure that they cover rural and remote area nursing, cultural safety and indigenous health and that the federal government provide sufficient funding to allow nursing students to access clinical placements in rural and remote areas. 2. that health service providers in rural and remote areas where it is difficult to attract and retain nurses offer incentives including re-imbursement of relocation costs; an accommodation allowance; appropriate housing; financial recognition for years of experience in rural and remote areas; annual airfares to the nearest capital city for nurses and their families; a salary loading to reflect the degree of isolation; education on local cultural issues guaranteed locum relief and regular isolation leave. 3. that health services providers in rural and remote areas provide workplace environments which have adequate levels of human, financial and material resources including adequate facilities and equipment, flexible employment models, reliable relief systems and professional support mechanisms. 4. that postgraduate advance practice training programs for rural and remote area nurses be funded and include context specific advanced clinical nursing skills and public health, clinical supervision and coordination of trainee support and placements. 5. that the aarn, crana, anf, state and territory governments and rural and remote communities co-operate to market to the public and all other relevant stakeholders an image of nursing in rural and remote areas that is positive, enthusiastic and contemporary, highlighting that nurses are valued and necessary for the continued health care of these communities. 6. that health service providers meet their duty of care obligations to nurses in rural and remote areas by adopting risk management strategies covering comprehensive orientation for practice relevant to the specific health setting of practice including context relevant clinical skills, occupational health and safety, violence, personal safety and coping skills and cultural safety. 7. that health service providers provide it access and the education necessary to use it to all rural and remote area nurses. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 7 the workshop was funded by the federal government’s department of health and ageing and it was wonderful to have this support. there was time for reflection of the role of the nurse and a message that was given to us from a previous member of the federal senate was that nurses do not market themselves and the work they do. as she noted, this was particularly evident in the media presentations of the bali bombings where the work of medical practitioners have been highlighted and there is barely a mention of nurses and their contribution to this terrible australian tragedy. the work facing rural and remote area nurses in australia is to make rural and remote area nursing a place where nurses not only wish to gain employment but also wish to continue to work within. like all other countries we have a shortage of nurses who wish to work in nursing. certainly the workshop and the work of aarn, crana and the anf is a step forward. we all look forward to the continued work of these associations on our behalf. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 meti advanced class report 7 editorial menace: methamphetamine in rural communities angela collins, rn, dsn, aprn-bc, ccns editorial board member over 35 million persons worldwide regularly use or abuse methamphetamines (who, 2008). this statistic then puts methamphetamine as the second most common abused drug after cannabis. methamphetamine addiction differs from other illicit drugs such as cocaine or heroin. drug addicts describe this drug as “one hit, one hook.” this defining characteristic of crystal methamphetamine is that addiction appears to occur upon first use. methamphetamine use causes multiple anatomical defects in the brain and damages the frontal decision-making center. the action of the drug on the dopamine and serotonin-containing neurons creates false circuits. even upon discontinuation of the drug, antipsychotic treatments are often required (national institute of drug abuse, 2006). the consequences of these illicit drugs can be the destruction of families, depression, anxiety, paranoia, aggression, cardiovascular events, sexual abuse, and child endangerment (grant, kelley, agrawal, meza, meyer, & romberger, 2007). dea (2008) statistics report that 20 percent of the meth labs seized last year had children present on site. children are even more vulnerable to the life time consequences of the toxins of methamphetamines on both pulmonary and neurological systems. methamphetamines are at the epicenter of circles of addiction that cause health consequences throughout our global community. this information is familiar data for nurses who practice in rural areas. methamphetamine is pervasive in all geographic regions but has found a niche in rural settings. methamphetamine labs thrive in regions that are sparsely populated and lean in law enforcement. ingredients to manufacture methamphetamine, such as fertilizer, are easily accessed in rural farming communities (sexton, carlson, leukefeld, & booth, 2006). when confronted with the community health menace that methamphetamine use triggers, one individual can be easily overwhelmed. however, there are interventions that can impact the reclaiming of rural areas from the drug dealers. rural health care providers can be instrumental in interventions to stem the influx of methamphetamines into rural communities by: • in the united states partnering with local law enforcement agencies with the drug enforcement agency. the dea not only provides local training but also assists with the cost of the toxic clean up of these labs (dea, 2008). • in communities outside the us partnering with agencies that target either community health or environmental concerns can also be helpful. resources are also available through the world health organization. • educate the community in all venues such as churches, schools, nursing schools, first responders, emergency personnel, and other community forums. • having former addicts or their families speak gives the message more passion and power. an excellent website for methamphetamine education is http://www.drugfree.org/portal/drugissue/meth/index.html. this website has online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 http://www.drugfree.org/portal/drugissue/meth/index.html online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 8 stories of individuals and families who experienced the sequalae of methamphetamine use (dea, 2008). • developing greater access to mental health services for both the recovering addict and their families. emergency rooms and general acute care facilities are inadequate in both resources and staffing to handle the complex physiological and psychological consequences of methamphetamine use (huff, 2006). research on how to best provide these needed services in the rural area is paramount to solving the problem. as an advanced practice nurse in alabama, this writer has cared for hundreds of individuals and their families in the critical care environment who pay the physiological and psychological price for their use of methamphetamines. the majority of these cases are originated from a rural community and, if they survive, they will return home to their region. instead of believing that the problem is too big to change, this writer has become an educational speaker locally on the critical need to increase access to mental health services for substance abuse. this effort is indeed small but my passion for this clinical problem is grounded in the words of martin luther king, jr. “our lives begin to end the day we become silent about things that matter” (quotations page). silence about the impact of methamphetamine use in both acute care and community care health services is not an option for health care providers. will you chose to speak up? references grant, k.m., kelley, s., agrawal, s., meza, j., meyer, j., & romberger, d. (2007). methamphetamine use in rural midwesterners. american journal on addictions, 16, 7984. [medline] huff, c. (2006). crystal crush. (2006). hospital and health networks, 59-64. retrieved march 31, 2008, from www.hhnmag.com. national institute on drug abuse research report. (2006). methamphetamine abuse and addiction. u.s. department of health and human services. retrieved march 31, 2008, from www.drugabuse.gov. quotation. retrieved march 31, 2008, from www.quotationspage.com/quotes/martin_luther_king_jr. sexton, r., carlson, r., leukefeld, c., & booth, b. (2006). patterns of illicit methamphetamine production (“cooking”) and associated risks in the rural south: an ethnographic exploration. journal of drug issues, 0022-0426/06/04, 853-876. u.s. drug enforcement agency. (2008). retrieved march 31, 2008, from www.dea.gov/concern/meth. world health organization. (2008). retrieved march 31, 2008, from www.who.int/substance abuse. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=17453608%5buid%5d http://www.hhnmag.com/ http://www.drugabuse.gov/ http://www.quotationspage.com/quotes/martin_luther_king_jr http://www.dea.gov/concern/meth http://www.who.int/substance%20abuse http://www.who.int/substance%20abuse online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 27 assessing the influences on rural women's reproductive life plans: a cross sectional descriptive study lori may jagoda, ms, rn, phn 1 jeri l bigbee, phd, rn, faan 2 1 clinical nurse director, wellspace health, ljagoda@wellspacehealth.org 2 adjunct professor betty irene moore school of nursing at uc davis, jlbigbee@ucdavis.edu abstract purpose: this study explored the influences on rural women’s reproductive life planning (rlp). methods: thirty rural, non-pregnant, english-speaking women, age 18-35 years, living in two northern california counties participated in a cross-sectional descriptive study based on the health promotion model (hpm). data were collected in a local beauty salon using an ipad and an anonymous on-line survey, which included basic demographic information, reproductive plans, contraceptive use, pregnancy readiness, and usefulness of the survey. findings: participants were predominantly single, white, educated, religious, long-term rural residents with health insurance, regular healthcare providers, and a desire to have children in the future. although most felt they would feel “very happy” or “fairly happy” if they were pregnant now, 64% reported they were not ready or unsure if ready for a pregnancy. forty-seven percent were currently using contraception and 81% reported a history of using birth control. reasons for discontinuing contraception included side effects (80%), dislike of the method (58%), and/or forgot to use it (32%). reasons for never having used contraception included a personal health issue and confidentiality concerns. eighty percent reported religion played some role in of their online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 28 daily lives. the majority provided positive feedback regarding the understandability and usefulness of the survey. conclusions: results support rlp usefulness and acceptability among rural women, consistent with the hpm. further research is indicated examining the observed discontinuity of sexually active women reporting they do not want to get pregnant, yet are not using contraception; the influence of religious/spiritual beliefs on reproductive planning; and the effectiveness of reproductive life planning in reducing unplanned pregnancies. nurses, with a focus on person/family-centered health promotion, should serve as leaders in promoting reproductive life planning. policy implications include instituting culturally-tailored rlp as a reimbursed component of care that is routinely provided by nurses and other health care providers. keywords: reproductive life planning, rural, women, health promotion model assessing the influences on rural women's reproductive life plans: a cross sectional descriptive study during the twentieth century, a hallmark of family planning included a woman’s increased ability to achieve desired birth spacing and family size (centers for disease control and prevention [cdc], 1999). one of the top ten greatest public health achievements during the twentieth century was the significant improvement in reproductive health (cdc, 1999). the advent of more effective birth control empowered women with the means to make informed decisions regarding family planning and to prevent unintended pregnancies (cdc, 1999). an unintended pregnancy is defined as a pregnancy that is mistimed, unplanned, or unwanted at the time of conception (cdc, n.d.). about 5% of reproductive aged women in the online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 29 united states have an unintended pregnancy each year, with 27% of all pregnancies reported as mistimed and 18% unwanted (guttmacher institute, 2016). to ensure planned pregnancies, it is crucial that effective tools are available that promote reproductive health and life planning. one identified tool is a reproductive life plan (rlp) which starts the conversation between women, their partners, and their health care providers regarding pregnancy intentions in the context of their personal values and life aims. many factors can influence women’s reproductive health decision-making processes including social norms, cultural, physical, and social environments, and national health policies (hawks, madanat, merrill, goudy, & miyagawas, 2002; orleans, 2000). because of their unique environment, rural women may experience unique influences in comparison with women in urban settings. nurses play an essential role in promoting reproductive health. as such, nurses need to understand the unique influences women experience when making reproductive decisions. the purpose of this study was to explore what these influences may be for rural women through a cross-sectional descriptive study, using a specifically designed survey based on the health promotion model (hpm) (pender, murdaugh, & parsons 2011). background and conceptual framework the literature related to the origin and concept of reproductive life planning along with women’s reproductive health decision-making has identified a variety of potential influences for consideration. previous research, particularly related to rural women and families, is limited. the theoretical basis of this area of study has also received little attention. the following provides a critical review of the historical, empirical, and conceptual literature to date related to reproductive life planning among rural women. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 30 influences on women’s reproductive health decision-making rural women’s reproductive health decision-making processes may be influenced by a variety of factors, including the sociopolitical history of reproductive health, the perception of empowerment for women, the stages of women’s development, and rural culture. history of contraception and reproductive health. women’s reproductive health and health care in the u.s. have been impacted by powerful historical events and trends. one of the most significant trends was the development of effective birth control methods. effective birth control is defined as a contraceptive method resulting in a pregnancy rate of fewer than 10 pregnancies per 100 woman-years and was not widely available to women until 1960. prior to modern contraception, withdrawal, abstinence, abortion, and sterilization were the only existing family planning methods (our bodies ourselves, 2014; zurawin, 2012). since the 1970’s, birth control has become more widely available, with more effective methods introduced as well as emergency contraception for contraceptive accidents or non-use (our bodies ourselves, 2014). in spite of the advances in contraception, during the 20th century many american women continued to have more children than they wanted, with research identifying that women with lower socioeconomic status experienced inequitable access to contraceptives. research also identified an association between unintended pregnancy, increased poverty, and dependence on public assistance programs, resulting in the reduction of women’s opportunities to participate in the workforce or complete an education (gold, 2001). in response to the research, in 1965 the federal government developed grants to support the provision of family planning services as part of the johnson administration’s war on poverty online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 31 that culminated with the enactment of title x of the public health service act in 1979. the title x program remains central to the national effort, and is the only federal program dedicated solely to family planning (gold, 2001), with other federal programs, including medicaid, and state/local funds available to subsidize family planning. empowering women. while affordable, effective, and available contraception is essential to unintended pregnancy prevention, empowerment is also key to women achieving their reproductive life goals. the working definition of women’s empowerment includes having decision-making power, access to information and resources, a variety of options to choose from, the ability to make changes in one’s life, the ability to learn skills a woman defines as important, and the means to increase positive self-image and overcome stigma (chamberlin, 2013). empowerment is a process rather than an event (chamberlin, 2013) and is a multi-leveled concept with environmental, cultural, and historical factors playing important roles that influence one’s perception of empowerment (sadan, 2004). women’s development. a woman’s current stage of development is another key element to consider in reproductive life planning (schuiling & low, 2006). young adult women may face a variety of social, cultural, and economic challenges that may influence achieving their reproductive goals. an important factor to consider regarding reproductive health decisionmaking is moral/spiritual development which may be related to the physical and social environment (milestones of human development, 2012). a 2011 guttmacher report examined the impact of spiritual and religious beliefs on reproductive age women’s contraceptive use and found that the majority of reproductive aged women (age 15-44) had a religious affiliation, attended religious services at least once a month, and indicated religion is very important in their daily lives (jones & dreweke, 2011). evangelical women of reproductive age who reported online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 32 never having had sex were more likely to give religious or moral reasons as their primary reason for abstinence (jones & dreweke, 2011). among sexually experienced women, 99% had used a contraceptive method other than natural family planning, with a woman’s religious service attendance or importance of religion to her daily life unrelated to her use of highly effective contraceptive methods (jones & dreweke, 2011). in addition, srikanthan and reid (2008) reported both religious and cultural factors have the potential to influence the acceptance and use of contraception by couples. rural influences. the literature has established that place matters, however little research dedicated to rural women and their reproductive health needs has been reported. rural culture, economics, and health care—specifically reproductive health care—are important factors to consider. rural communities have a unique but diverse culture with distinct features, each possessing a variety of distinctive strengths and challenges (kouame, 2010). hallmarks of rural america include: low population density, limited available services, challenging geographic distance or terrain, limited transportation services, larger proportions of elderly, higher unemployment and underemployment rates, higher percentages of low-income, uninsured and underinsured individuals, and a higher percentage of minorities (hart, larson, & lishner, 2005; kouame, 2010; national rural health association [nrha], 2013). social isolation and higher prevalence rates of substance abuse, domestic violence, chronic illness, unintended injuries, and premature deaths are common in rural areas (kouame, 2010; nrha, 2013). on average, rural women are less likely to engage in preventive and health promotion behaviors, including mammography, cervical cancer screening, and prenatal care and are more likely to engage in high-risk behaviors such as smoking, lack of seat belt use, and lack of regular exercise (leipert, leach, & thurston 2012; nrha, 2013). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 33 in contrast to urban communities, rural cultures often have distinctive religious, political, and cultural influences (kouame, 2010). rural residents are generally more religious (dillon & savage, 2006), morally conservative, and family-oriented, adhering to traditional values (gimpel & karnes, 2006). however, many—although a minority—avoid church and religious involvement and hold more liberal values (dillon & savage, 2006). in regards to political affiliation, political conservatives are more concentrated in rural areas (pew research center, 2014). local religious, cultural, and political systems may influence the contraceptive choices available to rural women (srikanthan & reid, 2008), shaping the family planning and reproductive health care services available to them. another important element of rural culture is the social dynamics. living in a rural community promotes familiarity among residents and can be viewed as both a strength and a challenge. the perceived and genuine lack of anonymity in some communities (especially where health care and social services are scarce) is a significant barrier to consider when accessing health care, particularly reproductive health care. frequently, professional-patient relationships overlap, with health care providers being related to or participating in many of the same social activities as their patients. these multiple relationships can enhance as well as complicate the provision of care with rural providers often possessing a level of knowledge of their patients that is unlikely to occur in most other settings (klugman & dalinis, 2008). rural reproductive health research. few studies exist that focus on rural u.s. reproductive health care. martin, damm, hellerstedt, and gilliam (2014) support this observation, stating urban/rural differences have been an under-recognized factor shaping the dynamics of u.s. family planning care. kitsantas, gaffney, and cheema (2012) compared prenatal care between rural and urban women with high-risk pregnancies and found no online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 34 difference in rates of unintended pregnancy between the two groups. both rural and urban women experienced a significantly increased risk of not starting early prenatal care if they did not have a medicaid card, did not have available childcare, had too many things going on, or did not want anyone to know they were pregnant. having two or more of these barriers increased the risk of starting prenatal care late by 2.85 times for rural women and 2.01 times for urban women. mccall-hosenfeld and weisman (2011) found rural women were less likely to report receiving preventive counseling services; predictive factors to receiving counseling included younger age, higher educational level, having continuous health insurance coverage, seeing an obstetrician/gynecologist, and having the need for counseling, such as smoking status or obesity (mccall-hosenfeld & weisman, 2011). campo, askelson, spies, and losch (2010) found significant barriers to preventing unintended pregnancy and contraceptive use for rural young adults included the cost of contraception, fear of parents knowing about contraceptive use, alcohol use, lack of planning, inconsistent use and forgetting or difficulty using particular methods, such as oral contraceptives. reproductive life planning in 2006 the cdc published official recommendations to improve preconception health and health care including the recommendation for every woman, man, and couple to develop a reproductive life plan (rlp). a reproductive life plan is a patient-centered blueprint that takes into consideration the stages of the woman’s development, her future intentions for children (cdc, 2006) and her intentions for the number and timing of pregnancies in relation to personal values and life goals (cdc, 2007). it outlines a plan to achieve those goals (files et al., 2011), with a focus on the specific health, economic, social, and cultural issues pertinent to the individual. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 35 research on reproductive life planning. the current state of the science regarding reproductive life planning is limited. five studies found in the literature (bello, adkins, stulberg, & rao, 2013; bommaraju, malat, & mooney, 2015; dunlop, logue, miranda, & narayan, 2010; moos, bangdiwala, meibohm, & cefalo, 1996; stern, larsson, kristiansson, & tyden, 2013) came to a number of important conclusions. first, exposure to preconceptional health information during routine family planning visits might affect the intendedness of subsequent pregnancies. second, both patients and providers reported that reviewing the patient’s reproductive plans was important in their health care visits. both patients and providers reported the reproductive life plan presented new and thought-provoking material that promoted patient participation and facilitated counseling during the appointment. finally, study results suggest that using a reproductive health self-assessment tool may activate women to participate more fully in their health care, including contraceptive choice and continuity (bello et al., 2013). reproductive life planning may empower women by helping them understand what aspects of reproduction they can control—such as lifestyle habits--and those they cannot—such as declining fertility with advancing age (stern et al., 2013). in a large 2105 study, bommaraju and colleagues (2015) looked at rlp counseling and effective contraceptive use among urban women served by one title x clinic. results indicated rlp counseling did not encourage effective method use. however, a major limitation noted by the authors was the lack of fidelity related to the rlp intervention, with no standardized curriculum used and reliance on the providers reporting they discussed rlp with their clients. additional limitations were that no input from the consumers was included and that the sample only included women receiving services at an urban title x clinic. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 36 reproductive life planning tools. while the research suggests the importance of reproductive life planning, very few evaluated assessment tools are available, as suggested by the bommaraju et al. study (2015). the “life plan booklet” is one available tool (thompson & archer, 2012) which covers a range of topics related to preconception health and well-being, including future dreams, financial security, alcohol and tobacco use, and family planning. the evaluation of the booklet indicated that women felt positively about the tool, reporting a sense of empowerment after reading it and that articulating goals and writing them down made the goals tangible and made the women feel accountable to work towards achieving them. the positive reports regarding the usefulness of a reproductive life plan support the need for further development of effective reproductive life planning tools and improved ways to administer and evaluate them. conceptual framework pender’s hpm was used as the conceptual framework for this study. this well-established model states that biological, psychological, and socio-cultural factors can influence behavior and decision-making (pender et al., 2011). the hpm’s theoretical propositions are applicable to reproductive life planning and rural women. the specific hpm elements relevant to this study include the following: • prior related behavior (past contraceptive use) • personal factors (age, race, ethnicity, educational level, religious beliefs) • perceived barriers (insurance status, cost of contraceptives) • perceived self-efficacy (current contraceptive use) • activity-related affect (readiness and feelings if learned pregnant today) • interpersonal influences (family, health care providers) online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 37 one previous application of the hpm to reproductive health (baheiraei, et al., 2011) identified health-promoting behaviors of reproductive aged women and their determinants. proposed determinants, or influences, included perceived social support, sociodemographic characteristics (including age, marital status, education, occupation, sufficiency of income for expenses), and primary support source (a. baheiraei, personal communication, december 21, 2014). identifying the health-promoting behaviors of reproductive aged women and their determinants need consideration if preventive strategies and interventions are to be effective in promoting women’s health (baheiraei, et al., 2011). figure 1. health promotion model diagram. reprinted with permission from http://deepblue.lib.umich.edu/handle/2027.42/85351. perceived benefits of action perceived barriers to action perceived self-efficacy prior related behavior personal factors biological psychological socio-cultural activity –related affect interpersonal influences (family, peers, providers); norms, support, models situational influences options demand characteristics aesthetics immediate competing demands (low control) and preferences (high control) health promoting behavior commitment to a plan of action behavioral outcome behaviorspecific cognitions and affect individual characteristics and experiences online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 38 purpose statement given the uniqueness of rural cultures, the purpose of this study was to explore the influences on reproductive life planning among rural, young adult women. methodology the study used a cross-sectional, quantitative, descriptive design and a survey instrument developed based on samples found in the literature and the conceptual framework. the population sampled included residents of two rural northern california counties, both classified as nonmetropolitan counties consistent with current rural/urban definitions (united states department of agriculture economic research service [usda ers], 2013). the two counties had similar age and race/ethnic distributions, education/income levels, and political makeup with the majority of the population over the age of 65 years, white, with a high school education, and registered voters with the republican party. however, county b had a much higher percentage of religious affiliation in 2010 with 69% of residents affiliated with a religious organization compared to county a (24%) and california as a whole (45%). of the 69% in county b, the majority (80%) were catholic, followed by evangelical protestant (association of religious data archives [arda], 2010). the predominant religious group in county a was also catholic, followed by evangelical protestant, the church of jesus christ of latter-day saints, and mainline protestant (arda, 2010). data were collected at a beauty salon located in county a, which provided access to community-based participants who may or may not be motivated to seek health care or have access to health care services. the salon catered to a younger population with seven of the eight stylists between the ages of 18 and 35 years. one stylist was fluent in spanish. inclusion criteria were females, non-pregnant, age 18-35 years, english speaking and reading, and living in online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 39 county a or b. exclusion criteria were non-english speakers, pregnant women, women who could no longer bear children, and non-county a or b residents. given time and resource constraints, the sample size was limited to 30 women and included both stylists and customers. thirty-three surveys were completed with three surveys excluded from the analysis; two participants reported their age as older than 35 years and one reported residency outside of county a or b. two women identified as eligible to participate declined, for a refusal rate of 6%. one hundred percent of those eligible who agreed to participate completed the survey. no suitable established tool was available to measure rural women's reproductive life planning, thus constructing a new tool for this study was necessary (the tool is available upon request). based on the hpm, the intent was to identify background or modifying factors having the potential to influence rural women’s reproductive life planning. the proposed modifying factors included demographic characteristics (age, education, relationship status, and race/ethnicity); prior related behavior (past contraceptive use); situational factors (current health insurance status, county of residence, and current number of children); current behavioral factors (current contraceptive use, importance of pregnancy planning, current readiness for children, reaction if learned she was pregnant today, and ideal number/spacing of future pregnancies); and interpersonal influences (how important religion was to their daily life, and having a regular source of health care). finally, questions were incorporated addressing the woman’s perception of the tool’s overall usefulness when thinking about her future family plans. the instrument was administered electronically using qualtric and allowed the use of the program’s branching function, or skip logic so participants only viewed the questions relevant to them. the survey questions were primarily multiple-choice with some fill-in-the-blank and had a flesch-kincaid reading grade level of 4.2. the instrument was reviewed and critiqued by research colleagues online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 40 specializing in rural nursing, primary care, and psychology. the instrument was then pre-tested with a small sample of rural women. final revisions were made based on the feedback received. to protect the confidentiality of participants, all potential participants received a flyer upon entering the salon describing the purpose of the study, the eligibility criteria, and a request for participation. if a woman agreed to participate and was eligible, she completed the on-line survey using an ipad provided by the investigator. when finished, she received a preconception health pamphlet titled “show your love! steps to a healthier me!” (http://www.cdc.gov/preconception/showyourlove/documents/trifoldhealthierbaby-me508.pdf) modified to reflect “health care provider” rather than “physician” as the source of health care (with permission from the cdc) and a small thank you gift. approval was obtained from the university of california, davis institutional review board prior to data collection (id#625011-2). participation was voluntary and anonymous. to ensure anonymity, signed consents were not obtained; however, a consent information sheet was provided. identifiable data traceable to individual participants were not collected. participants were informed they could skip any of the questions they did not want to answer and could stop the survey at any time. although there was minimal risk to participants in this study, there was a potential risk of psychological stress secondary to answering personal questions. the pi was an experience registered nurse who monitored participants during the data collection for stress symptoms and could stop the survey and provide referrals to local resources as needed. the data were entered into an excel spreadsheet and analyzed using descriptive statistics. for continuous variables, means, standard deviations, and ranges were computed. for categorical variables, frequencies and percentages of responses were compiled. qualitative comments were compiled as stated by the participants. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 41 results the sample included predominantly single, white, educated, religious young adult women who were long-term rural residents, with health insurance and a regular healthcare provider (see table 1). sixty-three percent of the participants lived in county a with the majority (95%) having lived there for more than one year. most were high school graduates and had completed some post-secondary education (80%). regarding the importance of religion, only 20% reported it was not at all important in their daily life. eighty percent of the women reported they had health insurance and two-thirds (67%) reported having a regular healthcare provider. of the 30 participants, 53% (n = 16) reported currently having children with the majority their biological children. the range of the current number of children was one to four. of those who currently had children, 63% (n=10) indicated that they wanted to have more. of this 63%, most reported wanting one or two more children and indicated they wanted to wait one to eight years between births of future children with a mean of 4.10 years (sd = 2.3). of the 47% (n=14) who reported that they currently did not have children, only one participant reported she did not want to have children in the future. the most frequent answer to the question “how many children do you want to have?” was two. one participant reported she was not sure and none of the women reported wanting more than three. when asked about birth spacing, those who currently did not have children but desired them in the future reported wanting to space children by one to three years with a mean of 2.09 years (sd = .54). the majority of those who currently did not have children reported they wanted to have their first online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 42 child one to five years from now. of all the participants who desired children in the future (n=23), 43% reported wanting to finish childbearing by age 30 and 43% by age 35 years. table 1 characteristics of study participants future family plans survey n=30 variables n % m (sd) age 26.7 (5.6) 18-20 5 16 21-23 3 10 24-26 8 27 27-29 5 16 30-32 1 3 33-35 8 27 county of residence county a 19 63 county b 11 37 education less high school 0 0 high school 1 3 some college 24 80 bachelor’s or higher 5 17 marital status married/domestic partner 11 37 single (never married) 17 57 divorced 2 7 widowed 0 0 separated 0 0 race/ethnicity white 20 67 hispanic or latino 7 23 african-american/aa 0 0 native american or american indian 1 3 asian/pacific islander 0 0 something else 2 7 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 43 thirteen percent reported they wanted to finish childbearing by age 40 years and none responded by age 25 years or age 45 years. when asked how ready they would be if they learned they were pregnant today (n=30), more reported feeling “not ready” than “ready” with 17% unsure (see figure 2). more women reported they would feel “very happy” or “fairly happy” versus “very unhappy” or “fairly unhappy” if they learned they were pregnant today (see figure 3). finally, when asked how important it was for them to not get pregnant, only 17% reported it was not important and none responded “not sure” (see figure 4). figure 2. pregnancy readiness (n=30) figure 3. feelings if learned pregnant today (n=30) 17% 47% 37% 0% 20% 40% 60% not sure not ready ready percent r ea di ne ss 27% 30% 20% 17% 7% 0% 20% 40% very happy fairly happy neither happy/unhappy fairly unhappy very unhappy percent f ee lin gs online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 44 figure 4. importance of not getting pregnant (n=30) of the 30 participants, 47% (n=14) reported that they were currently using a method of birth control and 53% (n=16) were not. a variety of birth control methods were listed with multiple responses allowed by the participant (e.g. participant could choose both birth control pills and condoms as current methods of birth control). of the methods being currently used, birth control pills (29.6%), and condoms (29.6%) were the most frequently reported, followed by abstinence (18.5%). one participant reported an “other” method (3.7%) which she declined to describe. of the 16 participants who were not currently using birth control, 13 (81%) reported having used it in the past. those who reported currently or ever having used birth control (n=27) were asked if they had ever stopped using a method, with 96% (n=26) responding affirmatively. the top three reasons reported for stopping a method were side effects (80%), didn’t like using it (58%), and forgot to use (32%). four participants responded “another reason” for stopping their method of birth control, reporting in narrative format “no need to be on it” (n=1), “lowered sex drive significantly” (n=1), “not sexually active at the moment” (n=1), and “ i was taking it for regulating purposes and no longer needed it” (n=1) as the other reasons. of the three women who reported never using a method of birth control, reasons reported were “i didn’t think it was 50% 33% 17% 0% 20% 40% 60% very somewhat not at all percent im po rt an ce online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 45 healthy to use” (n=1), “didn’t think i could use for medical reasons” (n=1), and “afraid someone would find out” (n=1). finally, participants were asked a series of questions evaluating the survey overall. when asked how difficult it was to complete, 97% responded it was “very easy” and 3% “somewhat easy”. all thirty participants reported the questions were “very understandable” and 100% indicated that the survey was “somewhat” or “very interesting”. when asked how helpful the survey was in assisting them in thinking about their future family plans, 98% (n=29) felt it was “very” or “somewhat helpful”. additional findings of the 16 women reporting that they were not currently using birth control, five (31%) reported it was “very important” and seven (44%) reported it was “somewhat important” not to get pregnant right now. of the 10 women reporting they wanted to wait one to five years or more before having a child, half were currently not using a method of birth control. ten (83%) of the twelve women who indicated that religion was a “very” or “fairly important” part of their daily life reported they were not currently using a method of birth control. discussion the purpose of this cross-sectional descriptive study was to explore the potential influences on reproductive life planning among rural young adult women, using a specifically designed survey based on the hpm. strengths of this study included the fact that 100% of the women who started the survey completed it and only two women who were eligible to take the survey declined. the ipad proved to be an effective method to administer the survey, maintaining privacy and ease of use for the participants. in addition, using the qualtric software program’s skip logic was very online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 46 effective in targeting appropriate questions for each individual and helped ensure effective use of the participant’s time with only questions relevant to that woman asked. the women completing the survey were generally open to the questions asked with only seven “decline to answer” responses documented regarding methods of birth control currently in use or used in the past. the data collection location was creative in that it was not a health care facility, with participants recruited who may not be motivated and/or able to access reproductive health care services. the ethnic diversity in the sample, the fact that participants were rural women—a frequently overlooked population in research—and that religious influence was included as a variable were additional strengths. finally, the survey included questions about the importance of not getting pregnant and what their feelings would be if they learned they were pregnant today, two variables not found in prior studies. limitations of this study included the small sample drawn from only one geographic area, limiting the generalizability of the findings given the diversity of rural populations. although small, the sample did reflect the rural population from which it was drawn. the survey also did not ask county b participants how long they had lived in their community. the scope of the survey did not include men, nor prior unintended pregnancy. discussion of findings in relation to previous research and conceptual framework the results of this study reflect the findings of previous research (bello et. al, 2013; campo et al, 2010; dunlop et. al, 2010; stern et. al, 2013) suggesting that rural women in this study were similar to other study participants in regards to their future family plans. for example, 57% percent of the women in this study who did not have children reported they wanted to wait one to five years before having a child, similar to dunlop et al.’s (2010) results where 30.6% of urban participants indicated they wanted to wait a year or more before having a child. of those women online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 47 who expressed a desire to wait a year or more before having a child in the dunlop study, 45% were at risk for unintended pregnancy. fifty percent of similar participants in the current study were also not currently using a method of birth control. in stern et al.'s (2013) study, the mean preferred age of urban women for last child was 34-35 years, consistent with the results of this study where 86% of the participants reported wanting to finish childbearing by age 30 or 35 years. barriers to contraceptive use reported in this study were also consistent with campo et al.’s (2010) findings, where common barriers to effective contraceptive use for young rural women were expense, inconsistent use (i.e. “forgetting to use”), and side effects. additionally, reasons reported for never having used birth control in this sample were consistent with campo et al.’s (2010) findings. the majority of participants in the current study responded favorably to the reproductive life planning survey, demonstrating acceptability levels consistent with bello et al. (2013), dunlop et al. (2010), and stern et al.’s (2013) previous findings. the prior reproductive life planning studies did not address the influence of religion. however, the rural sociological literature suggests religion is an important influence for many rural women (dillon & savage, 2006). this study’s findings offer support to that premise; the majority of participants revealed religion played an important role in their daily lives, suggesting personal religious/spiritual beliefs may be an important influence on behavior and reproductive decision-making among rural women. the 2011 guttmacher study reported a large majority of sexually active women of all religious denominations, urban and rural, practiced contraception and used highly effective methods (jones & dreweke, 2011). although this study did not ask about specific religious affiliation, of the 17 women who reported that religion was “very important” or “fairly important” in their daily lives, the majority (59%) reported they were not online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 48 currently using birth control. further research examining whether religious influence is greater for rural women is suggested. in summary, the rural women in this study gave similar responses to rural and urban women described in other studies (bello et. al, 2013; campo et al, 2010; dunlop et. al, 2010; stern et. al, 2013). an important finding in all of the research is that many women who indicate that it is important they not become pregnant now are at risk of unintended pregnancy. this is in spite of having health care coverage, a regular health care provider, and access to contraceptives. it is vital that health care providers address this inconsistency, by asking the important questions at each encounter about the individual’s pregnancy intentions, what she/he is doing to accomplish that goal, as well as identifying the barriers and benefits for each individual woman/man/couple to achieve their personal reproductive goals. furthermore, the findings lend support to using the health promotion model framework as a relevant model for future research to identify potential influences on health behavior. for example, the hpm framework states one primary source of interpersonal influence is health care providers (pender et al., 2011). with 67% of study participants reporting having a regular health care provider, providers may play a key role in influencing women to consider their reproductive life goals and in helping to achieve them. second, both perceived barriers and perceived selfefficacy influence successful reproductive life planning. examples include participants reporting they could not afford a method of birth control (perceived barrier) and those reporting they forgot to use it or became pregnant while using a method (perceived self-efficacy). finally, personal factors such as religious beliefs play a role influencing behavior. more than half of the women who reported that religion played a role in their daily lives also reported they were not currently using a method of birth control. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 49 implications for practice, theory development, policy, and research the results of this small study have broad implications for nursing practice, theory development, policy, and research and highlight several important issues. the affordable care act (aca) supports the principle that every american has the right to affordable and effective health insurance coverage regardless of income or health status (sonfield & pollack, 2013). the aca guarantees preventive services, including birth control, are covered and increases access to family planning services for low income women (national partnership for women and families, 2012). although a basic covered service, the question remains who will provide these reproductive services most efficiently and in what manner? recognition of the powerful role that health care providers—including nurses—play in influencing patients’ behavior and reproductive decision-making, particularly with rural populations, is critical. nurses, with their foundational focus on health promotion and person/family-centered care serve at the forefront in promoting reproductive life planning and are key to providing quality, cost effective reproductive life planning counseling. reproductive life planning should be included in all health promotion visits for all women, men, and teens of reproductive age. school nurses can play an integral role in providing family life planning education with the students and families they serve. in relation to theory development, the hpm proved to be a valuable conceptual framework in this study, with its emphasis on biological, psychological, and socio-cultural factors as influences of behavior and decision-making. further research using the hpm to ascertain its effectiveness in identifying religious/cultural influences (including rural culture) on behavior and reproductive health decision-making is suggested. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 50 finally, policy initiatives to support reproductive life planning, particularly in the area of reimbursement to pay for provision of rlp counseling, should be evaluated. california’s family planning, access, care, and treatment (fpact) program is a model that recognizes the need to reimburse for counseling and education services by nurses, nurse practitioners, nurse midwives, physician assistants, and physicians (california department of health care services, 2014). reimbursement for services provided by nurses is particularly important in rural settings where registered nurses often are the sole provider of health care (winters, 2013). the feasibility of the application of the fpact model in other states should be explored along with, mandated reimbursement by all health insurance programs for rlp counseling. the intent of reproductive life planning is not only to decrease the rate of unintended pregnancy, but also to encourage women and men to achieve healthy lifestyles resulting in healthy birth outcomes, if that is their goal, and to prevent or treat other health conditions. a 2008 report released by the trust for america’s health and the robert wood johnson foundation demonstrated that an annual investment of $10 per person in proven, communitybased public health programs could save the united states more than $16 billion within five years—a $5.60 return for every $1 invested (robert wood johnson foundation, 2013). in addition to practice, theory, and policy recommendations, an essential area of future research is determining if reproductive life planning is effective in decreasing the incidence of unplanned pregnancy. the inclusion of men, particularly rural men, in reproductive life planning research is also indicated. with the findings in this small study and other larger studies highlighting the “disconnect” of sexually active women who report they do not want to get pregnant yet are not using contraception, research addressing this phenomenon is crucial. determining the best methods to promote reproductive life planning is also vital. is print media online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.398 51 as effective as social media? alternatively, is addressing rlp at each provider visit more effective? should rlp be included in high school health education curricula, or even sooner? finally, comparing the results from this study with a larger sample, other rural populations, other regions in the us, and internationally is recommended. summary rural women experience unique influences from their urban counterparts, particularly in relation to their reproductive health. reproductive life planning is a valuable process for each individual of reproductive age, subject to personal, biological, social, and cultural influences as well as their own perceptions. this study addressed rlp in a sample of rural women age 18 to 35 years living in two northern california counties. further research examining the influence of religion on rural women’s reproductive decision-making as well as the disconnect of some women reporting that they are not ready to be pregnant but are not using contraception is suggested. nurses and other health care providers must continue to facilitate positive behavior change and reproductive decision-making through effective reproductive life planning in order to reduce unintended pregnancies and the associated consequences for women, families, children, and society. empowering women, men, and couples to plan and achieve their reproductive life goals will enhance the health of future generations. references association of religious data archives. 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(2012). tubal sterilization. medscape. retrieved from http://emedicine. medscape.com/article/266799-overview#a0101 55 rural licensed tobacco merchants’ smoking status and the sale of tobacco to youth jeanine e. gangeness, ms, rn1 loretta j. heuer, phd, rn, faan2 tracy evanson, phd, aprn, bc3 1 assistant professor, department of nursing, bemidji state university, jgangeness@bemidjistate.edu 2 associate professor, college of nursing, university of north dakota, loretta.heuer@att.net 3 assistant professor, college of nursing, university of north dakota, tracyevanson@mail.und.edu keywords: tobacco, licensed merchants, tobacco control, youth, rural abstract the purpose of this study was to compare the sale of tobacco to youth between smoking and nonsmoking merchants in a rural county. licensed tobacco merchants were mailed surveys regarding their personal smoking status, and the returned surveys (75.9 %, n=44) were matched with tobacco compliance results which indicated if the business sold tobacco to youth during a county compliance check. merchants who smoked tended to sell tobacco products to youth more often than those who did not smoke chi-square (2, n=41) 6.66, p=0.036. this finding suggests the need to focus on smoking status of merchants as a prevention strategy for youth tobacco use. introduction the second most preventable cause of death in the world is tobacco use (world health organization, 2006b) whereas it is the most preventable cause of disease and death in the united states (centers for disease control and prevention, 1999). the result of long-term tobacco use leaves the nation with an economic liability that is between 50 and 73 billion dollars per year in medical expenses alone (centers for disease control and prevention, 2000). to decrease the chronic effects associated with tobacco use, public health professionals need to implement prevention efforts that are age appropriate and occur throughout the lifespan. due to the long-term effects and economic costs of tobacco use, a special focus needs to be placed on tobacco control for youth. it is imperative that public health officials learn how youth obtain tobacco and characteristics of those who supply them with these products. this paper describes the results of a study which compared rural merchants’ smoking status to their sales of tobacco to youth. worldwide most smokers initiate tobacco use prior to their 18th birthday, further data indicates tobacco use by 13–15 years of age is more than 10% (world health organization, 2006a). it is estimated that more than 3,000 youth become regular smokers every day in the u.s. (centers for disease control and prevention, 1997). to address the issue of youth tobacco use, the united states congress enacted the alcohol, drug abuse and mental health administration reorganization act (public law 102-321) in 1992 (united states, 1992). this public law defines youth as individuals under 18 years old and reinforces that all tobacco products are not to be sold to any individual ages 0-18 years. the intention of the synar amendment of this act (section 1926) was to control youth access to tobacco (united states department of health and human services, 1998). online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.bemidjistate.edu/nursing/ mailto:jgangeness@bemidjistate.edu http://www.nursing.und.edu/index.cfm mailto:loretta.heuer@att.net http://www.nursing.und.edu/index.cfm mailto:tracyevanson@mail.und.edu 56 the federal government, through the u.s. department of health and human services, substance abuse and mental health services administration [samhsa] (substance abuse and mental health services administration, 2001) collects national statistics on youth commercial access to tobacco. as a result, this federal agency connects the amount of state samhsa funding to the rate of tobacco sales to youth made at local businesses. this action sent a strong message to the states that they were to stop local tobacco merchants from selling to youth or lose federal funding. in minnesota, officials have strived to decrease the noncompliance rates of youth tobacco sales to ensure the samhsa funding would not be jeopardized. in 2000, the state rate of noncompliance by tobacco merchants was 27.7% (substance abuse and mental health services administration, 2001). in addition to monitoring the state rate, the minnesota government has required each county to adopt a tobacco ordinance, which mandates annual tobacco compliance checks to be completed on all licensed tobacco merchant establishments. in 2001 in one rural, north-central minnesota county, for the population of interest it was found that 45.5% (n=20) of the merchants sold tobacco to youth when their businesses were tested by the public health division compliance program (deboer, 2000). the levels of compliance with state and local laws have been studied as part of community education programs. biglan, ary, koehn, levings, smith, wright et al. (1996) as a part of project sixteen in oregon, evaluated how community intervention impacted sales of tobacco to youth. this community intervention included community support, merchant education, consequences to clerks for either selling or not selling tobacco to youth, publicity and feedback regarding not selling to youth. increased community awareness and regulation of tobacco sales to youth lead to a decrease in sales of tobacco to youth. the memphis health project, a four-year prospective evaluation where 6,967 seventh grade students were surveyed, found that the “best predictor of experimentation with cigarettes was the perception that they were easily available” (robinson, klesges, zbikowski, & glaser, 1997, p. 653). regulation of tobacco sales, community support and perception of availability influence commercial availability of tobacco to youth (biglan et al. 1996; robinson, klesges, zbikowski, & glaser, 1997). youth access to tobacco is influenced by a variety of factors such as the day of the week the tobacco compliance checks were conducted, type of store, and rural location (clark, natanblut, schmitt, wolters, & iachan, 2000). clark et al. (2000) connected rural locations with an increase in illegal tobacco sales to minors. in addition, communities with a higher percentage of people living in a lower socioeconomic situation tend to have a higher tobacco industry presence than communities with higher socioeconomic standards (barbeau, wolin, naumova, & balbach, 2005). while it is evident that youth can access tobacco through commercial sources (klonoff, landrine, & alcaraz, 1997) in rural communities (clark et al. 2000) it is unclear if there are characteristics of the tobacco merchant that influence compliance rates. specifically, the smoking status of the merchant and their propensity to sell tobacco to youth has not been studied. the purpose of this study was to compare the rates of compliance in youth tobacco sales between smoking and non-smoking merchants. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 57 methods sample the rural minnesota county where this study occurred has a total population of 27,150 in which 87% of the population are white and 11% american indian (minnesota department of administration, n.d.). none of the most populated areas of this rural county have a population of 2,500 or less. the socioeconomic conditions of the county indicate that 13.6% of the county residents lived in poverty compared to the state poverty level of 7.9% (minnesota department of administration, n.d.). the sample for this comparative study consisted of merchants who were licensed to sell tobacco in the year 2001. fifty-eight retailers were licensed and all were mailed surveys; 44 of these merchants returned completed surveys for a response rate of 75.9%. all of the surveys were completed by either owners or managers of the businesses. instrument the researcher and staff at the university of minnesota school of public health, department of epidemiology collaborated in the development of the tobacco merchant survey. this survey consisted of twenty-seven likert scale, multiple option, and openended questions. the content areas of the survey included: 1) the knowledge level of tobacco merchants in regard to state and local tobacco laws, policies and practices, 2) demographic information that included their smoking status, and 3) business practices and polices. results of the merchant business polices and knowledge levels are reported elsewhere (gangeness, evanson, & webb, in review). first, the tobacco merchant survey was tested for content validity with two panels of experts. the first expert panel to review the survey was the county health advisory committee which consisting of 10 members. the second panel consisted of 5 local coordinators for the minnesota tobacco prevention grant. after the survey review was complete by the two expert panels, no changes were recommended and it was piloted with five licensed tobacco merchants. it was determined that no changes were needed after the pilot testing was completed. data collection tobacco merchant survey. data collection of the tobacco merchant survey took place between the months of november 2001and march 2002. institution review board approval was obtained prior to the study from the university board, and the county advisory board. the tobacco merchants were mailed a cover letter describing the study, the survey, and a self-addressed stamped envelope. consent was assumed with return of the survey. all merchants received a postcard seven days after the initial mailing, reminding them to fill out and return the tobacco merchant survey. each returned survey was matched with tobacco compliance data, which indicated if that particular business sold tobacco to youth during a county compliance check during 2001. compliance check data. to control youth access to tobacco, compliance checks are conducted on an annual basis. the compliance check data for the 2001 fiscal year was online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 58 obtained from the county health advisory board. the compliance check data included the names and addresses of licensed tobacco merchants, and whether the businesses sold tobacco to youth at their 2001 annual tobacco compliance check. this agency performed a minimum of one tobacco compliance check per year on each area business. for those businesses that sold tobacco to youth during their previous tobacco compliance check, additional checks were completed. the county public health agency recruited, trained and supervised the youth during every compliance check. those hired to complete these compliance checks were between the ages of 15-17. they entered businesses that were licensed to sell tobacco and attempted to purchase these products. the youth who participated in this program had the consent of their parents and extensive training on the policy and procedure for tobacco compliance checks (cass county public health and human services, 2000). data analysis data from the tobacco merchant survey and compliance checks were analyzed using the statistical package for social sciences (spss). the returned surveys (75.9 %, n=44) were matched with tobacco compliance results which indicated if the business sold tobacco to youth during a county compliance check. the chi-square test was utilized to indicate if significant (p= .05) differences in compliance with the sale of tobacco products to youth occurred between smoking and non-smoking merchants. chi-square analysis was used to determine significance between compliance and merchant gender and type of establishment. two-sample t-test was used to compare compliance and age of merchant. results table 1 presents the tobacco use and compliance check percentages for the surveyed population. of the merchants who responded to the survey, 56.8% (n=25) did not personally use tobacco products while 29.5% (n=13) used them on a daily basis. compliance check data indicated that of those merchants who responded, 52.3% (n=23) were compliant with the tobacco laws and had not sold tobacco to youth in their most recent tobacco compliance check while 45.5% (n=20) had sold tobacco to youth during their 2001 compliance check. one merchant was newly licensed, completing the survey but did not have a compliance check 2.2% (n=1). comparing smoking to nonsmoking merchants, of those who used tobacco everyday, 66.7% (n=8) sold to youth, whereas 33.3% (n=4) had not sold it to youth. the merchants who did not use tobacco at all, did not sell to youth 72.0% (n=18) of the time, and of these non-smokers only 28.0% (n=7) sold tobacco to youth. the chi-square was utilized to compare the merchants’ personal tobacco use in relation to the sales of these products to area youth. the chi-square test was statistically significant chi-square (2, n=41) 6.66, p=0.036 which indicates that merchants who smoked were statistically more likely to be non-compliant with youth tobacco checks than merchants who did not smoke. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 59 table 1 number and percentage of 44 merchants’ tobacco use and compliance characteristics n % tobacco use every day 13 29.5 some days 4 9.1 not at all 25 56.8 missing 2 4.5 recent compliance to tobacco laws yes (youth could buy tobacco) 20 45.5 no (youth could not buy tobacco) 23 52.3 missing 1 2.3 the age of the individual who completed the survey ranged between 25 and 79 years (n=41, m=47.76, sd=10.23). a two-sample t-test indicated that there were no significant differences in mean ages of the tobacco merchants who were selling tobacco to youth and those who did not sell tobacco to youth, t(42) = -1.14, p = 0.265 (two-tailed), df = 27. there were an equal number of male (n=21, 47.7%) and female (n=21, 47.7%) tobacco merchants; two merchants did not respond to this question. the difference in compliance rates between male and female merchants was not significant chi-square (1, n=42) 0.241, p=0.623. the number of years in which the merchants either owned or managed their business ranged between 1 and 47 years (n=40, m=11.43, sd=11.55). from the total number of licensed tobacco merchants who returned the surveys, the types of businesses represented included: 15 (34.1%) from convenience stores, 12 (27.3%) from bars/pubs where food was served and minors allowed entrance, 5 (11.4%) from grocery stores, 3 (6.8%) from resorts, and 7 (15.9%) grouped themselves into the “other” category. these businesses ranged in number of employees between 0 (the owner/manager was the only employee) and 103 with a mean of 13.36 employees (sd=20.09). the larger business with 103 employees was by far the rare case in this study; most of the businesses in this rural county were small, “mom and pop” style businesses with few employees. type of establishment was not significant when compared to compliance chi-square (4, n=42) 5.752, p=0.218. discussion this is the first study of its kind that compared the noncompliance rates between smoking and non-smoking merchants. one strength of this study is the high response rate by tobacco merchants (75.9%). the most significant result of this research study was the difference noted between the merchants’ self-reported tobacco use and their business’ youth tobacco sales compliance rate. merchants who smoked were more likely to sell tobacco to youth. robinson et al. (1997) found that the best indicator of cigarette online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 60 experimentation among youth was a perception that it was easy to obtain them in their community. youth may perceive a merchant who smokes as someone who supports their use of tobacco, which would support the robinson et al. (1997) study. age and gender of the tobacco merchant did not impact the sales of tobacco to youth. the types of businesses merchants either owned or rented included convenience stores, grocery stores, bars/pubs, and resorts. neither the type of business nor the number of employees impacted the sales of tobacco to youth. rural community interventions public health nurses practicing in rural communities are champions of prevention education in the community. this study indicates that tobacco merchants’, who use tobacco themselves, should be a target group for smoking cessation. decreasing smoking rates of tobacco merchants may decrease the sale of tobacco products to youth, thus decreasing the long-term health effects of smoking. in the rural communities, public health nurses are often consulted on issues related to tobacco merchant compliance, tobacco control, and sales of tobacco to youth. the findings of this study can guide community assessments in relation to the problem of youth access to tobacco, as merchant tobacco use should be considered as a possible indicator to tobacco sales to youth. once the community assessment has been completed, a specific plan can be developed that targets community education needs, especially for those merchants who smoke, thereby fostering the greatest impact on youth access to tobacco. smoking status of merchants and youth access to commercial sources of tobacco could be used in community education programs by encouraging community stopsmoking campaigns, and increased awareness for businesses about smokers possibly being more tolerant of teen tobacco use. the information about merchant smoking status and compliance could supplement current commercial tobacco information for parents and businesses, providing strength to the comprehensive community education projects that have demonstrated some success (biglan et al. 1996). study limitations this study is limited due to the small sample size. the strength of a direct association between smoking and youth tobacco sales is unknown; this direct association was not a part of this study. the survey instrument was developed for the study and reliability was not established beyond content validity. in addition, the merchants who responded to the survey may not have been involved with direct sales, making it difficult to know if the difference between merchants was because those who smoked were more likely to sell to youth or they were more likely to not enforce the law with their employees, or both; or if the difference was attributable to another reason entirely. recommendations for research currently, there is limited knowledge about licensed tobacco merchants’ smoking status and the impact it has on the sale of tobacco products to youth tobacco control. this study should be replicated with larger sample sizes, expanding to urban and international online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 61 populations. further studies should be designed to establish association and possible contributing factors between smoking status and sales of tobacco to youth. since the majority of research studies focus on youth behaviors or just the compliance levels themselves, there is a need to expand the body of research to include the characteristics and behaviors of tobacco merchants. research needs to be completed on tobacco merchants and those employed at businesses with regards to their smoking attitudes, beliefs, and sales practices. further research needs to be conducted on merchant smoking status and youths’ perceptions on tobacco availability. additionally, studying smoking cessation campaigns directly targeted at merchants who smoke, to determine if this improves overall compliance to youth tobacco laws (and not selling tobacco to youth) would be relevant to this line of research. conclusions this study indicated a significant difference between the smoking status of tobacco merchants and their sales of tobacco products to youth. tobacco merchants who smoked were more likely to sell tobacco to youth than those merchants who did not smoke. further studies need to be conducted, in an effort to explore the relationship between tobacco merchant smoking status and the merchant’s tendency to sell tobacco to youth. acknowledgements derek webb, phd, at bemidji state university did statistical analysis for this article. this research was supported by the minnesota youth tobacco prevention grant from the minnesota department of health. references barbeau, e.m., wolin, k.y., naumova, e.n., & balbach, e. (2005). tobacco advertising in communities: associations with race and class. preventive medicine, 40(1), 1620. [medline] biglan, a., ary, d., koehn, v., levings, d., smith, s., wright, z., et al. (1996). mobilizing positive reinforcement in communities to reduce youth access to tobacco. american journal of community psychology, 24, 625-639. [medline] cass county public health and human services. (2000). policy and procedure: tobacco compliance checks (policy). walker, mn: cass county public health and human services. centers for disease control and prevention. (1997). cdc's tips: overview. retrieved march 10, 2001, from http://www.cdc.gov/nccdphp/osh/issue.htm centers for disease control and prevention. (1999). best practices for comprehensive tobacco control programs. atlanta, ga: u.s. department of health and human services. centers for disease control and prevention. (2000). youth tobacco surveillance—united states, 1998-1999. morbidity and mortality weekly report, 49(10), 1-94. [medline] online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15530576%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9145494%5buid%5d http://www.cdc.gov/nccdphp/osh/issue.htm http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11057729%5buid%5d 62 clark, p.i., natanblut, s.l., schmitt, c.l., wolters, c., & iachan, r. (2000). factors associated with tobacco sales to minors: lessons learned from the fda compliance checks. journal of the american medical association, 284(6), 729734. [medline] deboer, g. (2000, november 30). minors still able to buy tobacco. pilot independent, pp. 1a, 7a. gangeness, j. e., evanson, t., & webb, d. (in review). business practices that predict sales of tobacco. preventing chronic disease. klonoff, e.a., landrine, h., & alcaraz, r. (1997). an experimental analysis of sociocultural variables in sales of cigarettes to minors. american journal of public health, 87, 823-826. [medline] minnesota department of administration. (n.d.). minnesota county profiles. retrieved may 27, 2005, from http://www.demography.state.mn.us/countyprof.html robinson, l.a., klesges, r.c., zbikowski, s.m., & glaser, r. (1997). predictors of risk for different stages of adolescent smoking in a biracial sample. journal of consulting and clinical psychology, 65, 653-662. [medline] substance abuse and mental health services administration. (2001). state synar noncompliance rate table, ffy 1997ffy 2000. retrieved june 18, 2001, from http://www.samhsa.gov/centers/csap/synar/01synartable.html and http://www.samhsa.gov/centers/csap/synar/require.htm united states. (1992). alcohol, drug abuse and mental health administration reorganization act united states congress. united states department of health and human services. (1998). implementing the synar regulation: strategies for reducing sales of tobacco products to minors. world health organization. (2006a). about youth and tobacco. retrived march 4, 2006, from http://www.who.int/tobacco/research/youth/about/en/index.html world health organization. (2006b). why is tobacco a public health priority? retrieved march 4, 2006, from http://www.who.int/tobacco/health_priority/en/index.html online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10927782%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9184513%5buid%5d http://www.demography.state.mn.us/countyprof.html http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9256567%5buid%5d http://www.samhsa.gov/centers/csap/synar/01synartable.html http://www.samhsa.gov/centers/csap/synar/require.htm http://www.who.int/tobacco/research/youth/about/en/index.html http://www.who.int/tobacco/health_priority/en/index.html editorial 2 editorial wanted! nursing educators marietta stanton editorial board member for a number of years, we have been speaking about the nursing shortage and the dramatic impact this shortage will have on health care outcomes for the united states healthcare system. the nursing shortage is especially problematic in the rural areas of our country where this shortage affects not only access to health care but quality outcomes for vulnerable rural populations. the thoroughly acknowledged nursing shortage is compounded by the shortage of faculty to teach nursing. even in areas where nursing applications to schools of nursing have increased, students are unable to gain admission because there is simply not enough faculty to teach those nursing students. currently, there are approximately 3,500 nursing programs (practical nurse, associate degree, diploma, baccalaureate, master's, and doctoral), "housed" in nearly 2,500 schools of nursing. these schools enroll a total of approximately 300,000 students. with the projected "shortfall" of nurses to meet the health care needs of our increasingly diverse and aging population, schools may need to increase their enrollments by as much as one-third to "fill the gap," bringing the ideal number of enrolled students close to 400,000. using a ratio of 10:1 (students: full-time faculty member), the number of fulltime faculty required to teach those 400,000 students enrolled in today's 3,500 programs may be as high as 40,000. current data suggest we now have less than 50% of that number, and the supply of individuals available to meet this demand is shrinking rapidly as the result of three phenomena: the retirement of large numbers of faculty (many of whom were prepared as educators), the limited number of graduate programs that offer options to specialize in nursing education, and the declining enrollments in graduate programs that are designed to prepare nurse educators (nln, 2006). to ensure an adequate supply of competent nurse educators, the national league for nursing (nln, 2006) strongly urges the nursing education community to engage in an immediate and focused effort to provide increased opportunities in graduate programs to prepare faculty and to provide greater support for faculty development activities. nln also strongly advocates that careers in nursing education be promoted vigorously to talented neophytes and experienced nurses who have already demonstrated nurse educator skills, and that funding to support the preparation of nurse educators and the development of the science of nursing education be increased significantly. in light of the looming crisis in the supply of faculty to teach in schools of nursing, the time has come for the nursing profession to outline a preferred future for the preparation of nurse educators. this crisis must be used as an opportunity to recruit qualified individuals to the educator role, to ensure that these individuals are appropriately prepared for the responsibilities they will assume as faculty and staff development educators, and to implement strategies that will serve to retain a qualified nurse educator workforce (nln, 2006). nln (2006) further asserts that the nurse educator role requires specialized preparation and every individual engaged in the academic enterprise must be prepared to online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 3 implement that role successfully. in addition, each academic unit in nursing must have a cadre of experts in nursing education who provide the leadership needed to advance nursing education, conduct pedagogical research, and contribute to the ongoing development of the science of nursing education. the nursing shortage is already having a profound effect on rural areas in terms of health care. the nursing faculty shortage will also have an effect on our rural based lpn and rn educational programs which act as feeders for rural health care agencies. therefore, this crisis caused by decreasing numbers of faculty is special cause for concern for our rural and frontier supply of nurses. what can we do? the time has come to encourage our best and brightest to consider a career as a nursing educator. we need to provide financial support and good access to programs that prepare nurses as faculty. we as a profession need to realize that nursing surely needs folks at the bedside but we also need them in administration, in research and most certainly in nursing education. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 73 understanding physical activity patterns of rural canadian children hope bilinski, rn, mn1 karen m. semchuk, phd2 karen chad, phd3 1 instructor, phd student, college of nursing, university of saskatchewan, h.bilinski@usask.ca 2 professor, college of nursing, university of saskatchewan, km.semchuk@usask.ca 3 professor, college of kinesiology, associate vp, research, university of saskatchewan, karen.chad@usask.ca keywords: rural children, physical activity, cardiovascular risk factors abstract the purpose of this cross sectional study was to explore the physical activity patterns of a group of rural children living in saskatchewan, canada. of the 103 participants (aged 8-13 years), 53.7% met the national guideline for the amount of physical activity required to achieve optimal health benefits. children’s involvement in out of school organized physical activities, (e.g. baseball, soccer, dance) was associated with whether or not they met the guideline. there was no statistically significant association between the children’s physical activity and their participation in physical activities in school, television watching behavior, or their parents’ educational levels. results suggest that many rural children in saskatchewan are not physically active enough for health benefits and several factors can potentially influence the physical activity of this group of children. further exploration of such factors may assist families, communities, schools, and health professionals in promoting physical activity in this population. introduction physical activity has significant implications for the physical and mental health of children. in canada, it has been estimated that 49% of children aged 5 – 12 years (53% of boys and 44% of girls) are physically active enough to achieve health benefits (cflri, 2000). the low prevalence of physical activity among canadian children is a concern since physical inactivity in children has a direct influence on obesity (fu & hao, 2002; kelishadi et al. 2003) and other cardiovascular risk factors, such as low high-density lipoprotein cholesterol levels (eisenmann et al. 2003), high triglyceride levels (al-hazzaa, 2002), high low-density lipoprotein cholesterol levels (vasankari et al. 2000), and high total cholesterol levels (schmidt, walkuski & stensel, 1998). the prevalence of overweight and obesity in the canadian population has increased remarkably over the last 15 years, with this increase in prevalence being greater in children than in adults (tremblay, katzmarzyk, & willms, 2002). a recent study comparing the estimates of the prevalence of overweight and obesity in school-aged youth ranked canada as fifth highest out of 34 countries in the world (janssen et al 2005). studies in the united states (janz, dawson, & mahoney, 2000) and canada (trudeau, laurencelle, tremblay, & shepard, 1999) suggest that physical activity patterns may track from childhood to adulthood. hence, physical activity habits formed in childhood may predict physical activity levels later in life and influence an individual’s online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.usask.ca/nursing/ mailto:h.bilinski@usask.ca http://www.usask.ca/nursing/ mailto:km.semchuk@usask.ca http://www.usask.ca/kinesiology/ mailto:karen.chad@usask.ca 74 risk of obesity and other chronic diseases (coronary heart disease, diabetes, peripheral vascular disease) and conditions (hypertension, osteoporosis, back pain, depression, decreased flexibility). previous canadian studies (pampalon, 1991; cflri, 1999), which included both children and adults, suggest that rural residents are not as physically active as their urban counterparts. recent studies (statistics canada, 2002) have identified that geographic variations also exist in the obesity of canadians, with rural populations aged 20 to 64 years having higher proportions of overweight residents compared to urban populations. lower physical activity levels among rural children and adults may be a contributing factor in the observed prevalence of obesity in rural areas. as lifelong habits, such as physical activity patterns, originate in childhood, further exploration of the physical activity of rural children may provide valuable information on the present and future health of this population, their risks for future diseases and conditions, and direction for health promotion initiatives. in canada, there are few data on the physical activity of rural children. the purpose of this study was to explore and describe the physical activity patterns of a group of elementary school children in grades 4 to 6 living in rural saskatchewan. the research questions that guided the study were: 1. what are the estimated usual physical activity patterns of rural elementary school children in grades four, five, and six living in the study area? 2. how do the estimated physical activity patterns of the study population compare with national guidelines? 3. what factors are associated with the physical activity patterns of the study population? methods the target school division for the study, which was one of 53 rural school divisions in saskatchewan, included four public schools (kindergarten to grade 12), each located in a separate town with population sizes ranging from 535 to 1,046 persons (saskatchewan health, 2000). each town was located over 100 kilometers from the nearest major city (population of over 200,000 persons), 35 80 kilometers from the next largest city (population of 39,000 persons), and 50 160 kilometers from two smaller cities (populations of 5,000 and 6,000 persons). the total enrollment of the target school division in 2001 was 951 students with 218 students in grades 4, 5, and 6 (aged 8 to 13 years). the students in this school division lived in one of the four towns or the surrounding rural areas. the study was approved by the university of saskatchewan advisory committee on ethics in behavioral science research. the director of education for the target rural school division and the principals of the four schools agreed to support the study. the questionnaires were distributed through the schools by the first author (h.n.b.). the data were collected over a three-week period in the month of june. the data were collected using a self-report questionnaire, which the student and a parent (or guardian) completed together at home. the questionnaire was divided into sections. the first section asked for demographic data about the student (age, grade, gender, and whether the child lived on a farm or in town for more than 6 months of the online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 75 previous year) and parents (education), and information on whether the student had any health-related problems that interfered with physical activity. section two collected information on all of the student’s physical activities (i.e., type, duration, intensity, and frequency) during the previous seven days, using a standardized physical activity recall history (paffenbarger, wing, & hyde, 1978; sallis et al. 1985). children’s physical activity was categorized into light, moderate, or vigorous levels and the total duration was averaged for the week reported. this section also included a question on the daily number of hours the children spent watching television or playing computer or video games before or after school. section three asked about the student’s involvement in organized physical activities at school and outside of school, the average distance traveled to activities outside of school, and the activities the student would like to participate in closer to home. the data from the questionnaires were coded, entered into a data file using the statistical package for social sciences (spss) data entry program for ibm pc microcomputers, and verified using double entry. the data were cleaned and analyzed using spss base 10. categorical variables were analyzed using descriptive statistics. chi square tests (i.e., with continuity correction, test for overall trend, or fisher’s exact test) were used to make comparisons (across schools and grades, between boys and girls, and between town and farm residents) and to assess relationships between each categorical variable and physical activity levels. analysis of variance (anova) was used to compare the mean distance students traveled (one way) to activities for school and town/ farm residence. responses to the qualitative questions were analyzed using content analysis to identify the physical activities children participated in school and outside of school, and activities the children would like to see offered closer to home. for all statistical tests, significance was indicated by an alpha level of less than .05. results of the 218 eligible students, 103 (60 girls, 42 boys, gender not reported for 1 student) returned the completed questionnaire, for an overall response rate of 47.2%. the majority of students (88.2%) were between 10 and 12 years of age, while 8.8% were between 8 and 9 years of age, and 2.9% were 13 years of age. the respondents were in grade 4 (28.4%), grade 5 (32.4%), and grade 6 (39.2%). the distribution of boys and girls did not differ significantly by grade [χ2 (2, n = 102) = 2.1, p =.343]. a significantly larger proportion of the respondents reported living on a farm (61.4%) for most of the year [single proportion binomial z test, z = 2.19, p = .029 (fleiss, 1981, p.13)]. the proportions of farm and town residents did not differ significantly between boys and girls [χ2c (1, n = 101) , p = .487]. the majority of respondents (90.0%) reported having no health problems that interfered with their ability to be physically active. similar proportions of boys (10.0%) and girls (10.2%) reported health problems; these students reported participating in physical activities throughout the target week and were included in the analysis. the majority of the respondents reported participating in light (94.0%), moderate (93.8%), and vigorous (82.6%) physical activity during the previous 7 days. seventy six percent of the respondents (78.6% of the boys and 74.1% of the girls) reported participating in organized physical activities at school during the target week. seventy online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 76 one percent of the respondents, with significantly more boys (83.3%) than girls (62.1%), reported participating in organized physical activities outside of school [χ2c (1, n = 100) = 4.4, p = .037]. the proportion of respondents who reported participating in organized physical activities outside of school (71.0%) did not differ significantly between town (35.7%) and farm (64.3%) residents [χ2c (1, n = 99) = 0.39, p = .534]. farm and town residents reported participating in similar types of physical activities. the most frequently reported out-of-school activities were baseball and swimming. hockey, soccer, and dancing were reported less frequently. seventy of the 99 respondents (31 boys and 39 girls) reported that they would participate in more organized physical activities if the activities were offered closer to home. the types of activities that students said they would like to have in close proximity to their homes were soccer, baseball, swimming, karate, dance, and football. at the time of the study, the canadian fitness and lifestyle research institute (cflri) adopted the guideline for physical activity suggested by corbin, pangrazi, and welk (1994) which recommended that children participate in daily physical activity at a moderate to vigorous intensity level with a duration of activity necessary to expend at least 6 to 8 kcal/kg/day, which is equivalent to 60 minutes of moderate to vigorous physical activity that may be distributed in three or more activity sessions each day. the cflri, (1999) suggested that this guideline may also be achieved with 30 minutes of moderate to vigorous physical activity (such as martial arts) plus 60 minutes of lighter physical activity (such as walking) each day. using these guidelines in the present study, 53.7% of the respondents met the guideline for physical activity. a significantly larger proportion [χ2c (1, n = 94) = 4.0, p = .045] of students who reported participating in physical activities outside of school (60.3%) during the target week met the guideline for physical activity compared to only 34.6% of students who did not participate in physical activity outside of school. as table 1 shows, the proportions of respondents who met and who did not meet the cflri guideline for physical activity did not differ significantly by gender, residence, grade, involvement in physical activities in school, hours of television watching, school (data not shown), mother’s education level, or father’s education level. the mean distance traveled (one way) by respondents to participate in organized physical activities was 42.2 kilometers (sd = 35.3 kilometers). respondents living in town (mean = 56.4 kilometers, sd = 38.9 kilometers) reported traveling significantly farther to participate in organized physical activities compared to respondents who lived on the farm (mean = 35.7 kilometers, sd = 31.7 kilometers). no statistically significant interactions were found between the distance traveled and the participant’s gender, grade, parents’ education level, hours of television viewing, or participation in physical activities in or out of school. discussion this exploratory study provided a ‘snapshot’ of the physical activity patterns of a group of rural elementary school children living in the province of saskatchewan, canada. during the target week, only 53.7% of the rural children were physically active enough to meet the recommended guideline for the physical activity. although direct comparison is difficult due to differences in methodology, national studies (statistics online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 77 table 1 distribution of respondents whose physical activity during the target week met the cflri guideline for physical activity: saskatchewan, canada, 2001 met cflri guideline yes no variable number % number % gender boys 25 62.5 15 37.5 girls 25 46.3 29 53.7 residence town 15 44.1 19 55.9 farm 34 57.6 25 42.4 grade 4 12 50.0 12 50.0 5 19 61.3 12 38.7 6 20 50.0 20 50.0 involvement in physical activities in school yes 43 58.9 30 41.1 no 7 33.3 14 66.7 involvement in physical activities outside school yes 41 60.3* 27 39.7 no 9 34.6 17 65.4 hours of television watching < 1 hour/week 20 55.6 16 44.4 2-3 hours/week 24 57.1 18 42.9 > 4 hours/week 7 41.2 10 58.8 mother’s education level high school or less 16 43.2 21 56.8 some post secondary 33 60.0 22 40.0 father’s education level high school or less 29 54.7 24 45.3 some post secondary 19 54.3 16 45.7 all respondents 51 53.7 44 46.3 note. the cflri guideline for physical activity: 60 minutes daily x 7 days a week at a moderate to vigorous intensity level.* met the cflri guideline for physical activity, involvement in physical activity outside of school (yes versus no) [χ2c (1, n = 94) = 4.0, p = .05). canada, 1998, health canada, 1999, cflri, 1999) of both rural and urban children found similar results and suggest that canadian children regardless of where they live, are not active enough to obtain optimal health benefits. there are limited canadian data that focused specifically on the physical activity of rural children. outside of canada there have been other studies of the physical activity of rural children. studies in the united states (harrell et al. 1997; felton et al. 1998) and ireland online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 78 (kelly et al. 2005) found that rural children were relatively inactive. conflicting results have been reported in studies that have compared the physical activity patterns of rural and urban children. while proctor et al. (1996) observed rural children living in west africa and ozidirenc et al. (2005) observed rural children living in turkey were more physically active than urban children, researchers in sweden (sunnegardh et al. 1985), canada (pampalon, 1991), belgium (guillaume et al. 1997), greece (manios et al. 1998) and iceland (kristjansdottir & vilhjalmsson, 2001) found that rural children were less physically active than urban children. other studies in the united states (mcmurray et al. 1999) and canada (plotnikoff, bercovitz, & loucaides, 2004) found no differences in the activity levels of rural and urban children. while some studies report conflicting results between the physical activity of rural and urban children, much of the literature reports the high prevalence of physical inactivity of children, irrespective of geographical location. further research, especially in canada, is needed to examine the differences in the physical activity patterns of rural and urban children. determining and addressing such differences would assist health professionals in tailoring health promotion efforts that would be most effective in promoting the physical activity of children in their geographic location. three factors that may have the potential to influence the physical activity levels of rural children were identified in the present study. these factors included participation in physical activities at school, participation in physical activities out of school, and parental support. the frequent, regular contact that children have with schools provides a unique opportunity to positively influence the physical activity of children. in this study, similar proportions of boys (78.6%) and girls (74.1%) reported participating in organized physical activities in school. this finding suggests the important role schools have in reducing gender differences in the physical activity levels of school aged children. this role becomes even more important as children become adolescents and gender differences in physical activity (with girls becoming less physically active than boys) become more evident. interestingly, studies of urban children (riddoch, savage, murphy, cran, & boreham, 1991, o'loughlin, paradis, kishchuk, barnett, & renaud, 1999) reported a smaller proportion of urban children participating in physical activities in school. again, while direct comparison is difficult, due to differences in methodology among studies, these findings suggest that there may be differences in the participation rates in school physical activities between rural and urban children. the smaller gender differences in participation rates and the high prevalence of participation in physical activities in school suggest that high proportions of rural children participate in physical activities in school. schools in rural areas play a unique role in positively influencing the physical activity levels of both girls and boys. this ‘venue’ of physical activity opportunities appears to have addressed the common trend towards lower rates of physical activities among girls and assists in developing lifelong healthy habits among all children although physical activity rates seem to be higher in those that participated in programs offered at school, the results indicate that their interest or participation in such activities are not at a level to obtain optimal health benefits as outlined in the national guidelines. one possible explanation for this non-significant finding is the small sample size and low statistical power of the test. alternatively, the frequency, duration, and intensity of the physical activities in school may have been confounding factors in the online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 79 relationship between children’s participation in physical activities in school and whether they met the guideline for physical activity. as schools have the potential to positively influence the physical activity patterns of rural school aged children, rural educators and health professionals may develop strategies that improve the children’s physical activity to levels that meet the national guidelines. this study found that children who met the recommended guideline (compared to children who did not) were more likely to be involved in physical activities outside of school. the results further showed that a significantly larger proportion of boys (compared to girls) participated in organized physical activities out of the school environment. these findings suggests that for this sample of saskatchewan rural children, accessibility to organized physical activities outside of school may be an important determinant of children’s physical activity. factors that may influence accessibility are costs of activities (registration, supplies), required time commitment of parents and children, purpose of activity (competition versus participation for recreational activity), and geographical location. although the trend of gender differences in the participation in leisure time physical activities has been previously observed, this raises questions about potential differences in the types of physical activities available in rural areas outside the school setting and whether these activities are directed more towards interests of boys than girls. hence, health promotion efforts need to target not only enhancing accessibility to physical activity opportunities, but include those that meet the needs and interests of both genders outside of the school environment. the third factor that was explored in the present study was the potential influence that parental support had on the physical activity of rural children. the substantial distances driven by parents every week to enable their children to participate in physical activities observed in the present study provided evidence of the high degree of parental support. sallis et al. (1992) suggested that parents who provide transportation for their children to participate in physical activities demonstrate strong support and encouragement of physical activity in children. approximately two-thirds of the respondents in the present study traveled an average of 42.2 kilometers (sd=35.3 kilometers) one way to participate in organized physical activities. since rural children’s participation in physical activities outside of school depends on parental support, community strategies that acknowledge, support, or assist the families in transporting their children to activities are important to positively influence the physical activity of these children. this exploratory study provided a description of the physical activity patterns of a group of rural children (grade 4 – 6) in canada and suggests directions for future research. replication of the study with a larger, representative sample (i.e., a random sample or population based sample that includes children in all age groups) would increase generalizability of this information. in addition, examining seasonal variation in rural children’s physical activity, perhaps several times in one year, may provide a more accurate view of the physical activity patterns of children living outside of urban communities. this is particularly relevant given that the types of physical activities available to children vary by season (i.e., baseball in summer and ice hockey in winter) and by the school year (i.e., organized in-school physical activities during the fall and winter and organized out-of-school physical activities during summer holidays). online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 80 approximately 54% of the rural children in the present study were found to be physically active enough for health benefits. as the associations between physical activity and obesity and other cardiovascular risk factors have been well documented, increasing the physical activity of rural children can have a significant impact on the present and future health of this population. factors such as participation in physical activities in school and out of school, and the influence of parental support appeared to be factors that may influence the physical activity of rural children. health professionals, families, communities, and schools can all play a role in examining and developing strategies that utilize these factors in assisting rural children to increase their levels of physical activity. references al-hazzaa. 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[medline] online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9475651&query_hl=74 http://www.statcan.ca/daily/english/020508/d020508a.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=4090966&query_hl=76 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12075581&query_hl=78 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9927018&query_hl=80 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10924716&query_hl=82 online journal of rural nursing and health care, 2(2) 31 hope at the community level according to rural-based public health nurses judith c. kulig, rn, dnsc1 1 associate professor, school of health sciences, university of lethbridge, kulig@uleth.ca abstract the purpose of this exploratory, descriptive study was to generate the meaning of hope for 10 public health nurses in their rural-based practice. ultimately, the study sought to answer if hope is a significant concept for communities rather than just individuals or aggregates. analysis included coding of the transcripts and use of an auditor. hope is identifiable at the community level and serves in part to confirm the residents’ collective status. in order to have hope, certain conditions such as the presence of hopeful people and resources (i.e., education) need to be present. communities that are hopeful have specific characteristics such as a diverse economy and agreed upon community goals as well as the presence of community leaders. there are also indicators of community hope such as a sense of optimism and flexibility. hope is an important element of the practice of the public health nurses included in this study. keywords: hope, community/public health, rural communities, concepts, descriptive analysis online journal of rural nursing and health care, 2(2) 32 hope at the community level according to rural-based public health nurses i think a community definitely does have hope...and if they’re planning for the future...i mean that’s why they have a parent council up at the school to plan a future for their children. hope has been recognized as important for nursing practice, particularly in the care of individual clients. a number of research studies on this topic have been conducted with cancer patients (bunston, mings, mackie, & jones, 1995; dufault & martocchio, 1988; herth, 1989; owen, 1989; thompson, 1994) as well as the elderly (farran & mccann, 1989; gaskins, 1995; zorn, 1997), youth (hinds, 1984), and homeless families (herth, 1996) and children (herth, 1998a; herth, 1998b). despite the usefulness of the information generated from these studies, there are limitations in applying the results by public health nurses who work with communities as collective units. this article discusses a recently completed study that addressed hope beyond the confines of the individual. available definitions of hope see it as a positive aspect that is necessary for human life. it is more often considered future-oriented and can be a motivating factor (brumbach, 1994) therefore implying action in order to achieve that for which one hopes. some definitions specifically emphasize the relationship between hope and goal attainment (see stotland, 1969). there are also links between spirituality and hope. for example, hope is thought to be at least interconnected, or part of the process (farran, herth, & popovich, 1995), in the search for the meaning of life (ersk, 1992, as cited in kylmä & vehuiläinen-julkunen, 1997) and therefore suggestive of a belief in a higher power or being (brumbach, 1994; gewe, 1994; lepeau, 1996; thompson, 1994). comments made by community-based workers indicated their perception that even at the community level, hope is linked with spirituality (kulig, 1998). a recent concept online journal of rural nursing and health care, 2(2) 33 analysis of hope acknowledged it as having a future-orientation. it was postulated that research is needed to determine if positive events can stimulate hope (benzein & saveman, 1998). theory construction in relation to hope has commenced but thus far is limited to individuals (haas, britt, coward, leidy, & penn, 1992; morse & dobemick, 1995; morse & penrod, 1999). different frameworks have been used to understand the meaning of hope but all of these emphasize the individual level (dufault & martocchio, 1988; thompson, 1994). other authors have postulated that there are four attributes to hope: 1) it has meaning for the person, 2) it is a process that involves thought and relationships, 3) it has a sense of anticipation, and 4) it holds a positive future outlook (stephenson, 1991). there is also some suggestion that there are specific antecedents of hope such as a crisis, which can act as a catalyst to hope (stephenson, 1991). stephenson also believes that there are varying degrees of hope and describe individuals as either having low hope or high hope (stephenson, 1991). however, the usefulness of placing hope on a continuum that ranges from hope to hopelessness is considered questionable (dufault & martocchio, 1988). several instruments have been developed to measure hope but all have focused on individuals such as the chronically ill (raleigh & boehm, 1994), cancer patients (herth, 1989), young psychiatric patients (erickson, post, & paige, 1975 as cited in raleigh & boehm, 1994), the non-institutionalized elderly (miller & powers, 1988; zorn, 1997), inner city adolescents (canty, 1993) or well adults (herth, 1996; snyder et al. 1991). although each of these scales has merits, all were developed for use among individuals with none of them being useful in understanding hope at the community level. the study discussed here attempts to generate information about hope at the collective rather than the aggregate level. online journal of rural nursing and health care, 2(2) 34 there has been some work assessing the impact of hope on an individual client’s response to nursing interventions (miller & powers, 1988) and only a few articles that discuss how nursing practice has an impact on hope (see for example cutcliffe, 1995). o’connor (1996) discusses the importance of hope for home care nurses while they conduct their practice but the ideas are not based upon research findings. in a survey of home health nurses, brumbach (1994) asked them to describe a time when they felt hopeful about their nursing practice. in this study, the participants felt hopeful when they had made a difference in the lives of patients through the use of their nursing skills, had experienced positive relationships, including one with god, and had received affirmation from their coworkers and the patients’ family members about the work they had done. palliative care clients were asked about the relationship between their perceptions of hope and the health care professionals who provided their care (koopmeiners et al. 1997). the authors concluded that health care professionals both positively and negatively influenced hope among the clientele studied. the specific ways in which this was accomplished include the health care professional being present and giving information. another way in which nurses can assist individual patients to become hopeful includes links to spirituality (lange, 1978; miller, 1985 as cited in o’connor, 1996; nowotney, 1991). stimulating hope through being encouraging and using good communication (thompson, 1994), seeking relevant information about the situation (lange, 1978), analyzing the past for successes (gewe, 1994), establishing a support system (hickey, 1986; o’connor, 1996), ensuring that the client has control (gewe, 1994) and helping the individual patient develop realistic goals (farran et al. 1995; farran, wilken, & popovich, 1992; gewe, 1994; hickey, 1986; lange, 1978) have also been suggested. online journal of rural nursing and health care, 2(2) 35 in summary, although research has been completed that addresses the concept of hope, there is still a lack of clarity about its meaning for nursing practice, more specifically for public health practice in a rural setting. as well, the studies that have been conducted include individuals; there is no information about how a community as a collective unit exhibits hope. thus, the purpose of this exploratory, descriptive study was to explore the meaning of hope for public health nurses (phn) in their rural-based practice, generate information about how phn determine if hope is present in rural communities, and identify how phn instill hope in the rural communities within which they practice. methods an exploratory, descriptive study was the most appropriate method because there is no information available on the meaning of hope at the community level. for this study rural-based public health nurses were those nurses who delivered care to individuals, families or groups within rural communities by focusing on health promotion, prevention, and communicable disease control. all of the participants worked in a provincially funded health region and thus clients had universal access to care. an initial guiding definition of community was “a group of people who are socially interdependent, who participate together in discussion and decision making, and who share practices that both define the community and are nurtured by it” (bellah, madsen, sullivan, swidler, & tipton, 1996, p. 333). interviews were conducted with 10 practicing phn who were working either full or parttime in rural communities. open-ended interviews were conducted until data saturation occurred. purposeful sampling was used to select the participants, consequently individuals who had knowledge related to the concept (i.e., hope in rural-based public health practice) were recruited (morse, 1989; streubert, 1995). online journal of rural nursing and health care, 2(2) 36 each participant was interviewed twice by the author. the initial individual interviews took 45-80 minutes and began with the collection of demographic information and then proceeded with questions from a research guide. questions included asking the participant to describe well functioning communities, a typical day in their life as a phn, what has helped them deal with the difficult days they encounter and specific questions such as their definitions of hope, was it significant in their practice and what are the characteristics of communities that have hope. additional questions were also asked based upon the answers provided by the participant. for example, clarification questions were used to determine size of communities, specific information about issues communities had dealt with or their role as a phn with communities that were not functioning well. because data analysis and collection occurred simultaneously, questions derived from the earlier interviews were developed for use with subsequent participants. the interviews were tape-recorded and confidentially transcribed verbatim for simultaneous analysis with the data collection. data analysis included frequent reading of the transcripts, focusing on identifying similarities and differences within the data and using creative thinking in interpreting the data. more specifically, after reading the transcripts several times, tentative categories such as the classification of hope were identified. the data were also analyzed in order to identify themes such as the identification of characteristics of hope within rural communities. any differences (i.e., in definitions or beliefs) in these categories or themes noted by the participants were also identified for further discussion with all of the participants during a follow-up interview. analytic memos, or notes describing the emerging theoretical ideas in relation to the concept (schatzman & strauss, 1973), were also written on the actual transcripts. online journal of rural nursing and health care, 2(2) 37 after an initial analysis of the data as outlined above was completed, a summary of the tentative categories and themes was distributed by mail to each of the participants in preparation for the follow-up interview. this provided opportunities to “check” the investigator’s understanding and analysis of the data that was generated. in addition, questions that arose while reading the interviews and during the initial data analysis stage were clarified with the participants. for example, clarification was sought about the definition of a tragedy at the community level, how a community illustrates it is optimistic, and individual characteristics of hope that can be exemplified at the community level. the second interview, which lasted from 45-65 minutes, was conducted over the telephone and also tape-recorded for later transcription. the participants agreed with the preliminary data analysis and offered additional insights. this manner of providing opportunities for the participants to give feedback had been used in two previous studies and resulted in a greater understanding of the research topic and an increase in the trustworthiness of the data (kulig, 1996; kulig, 1998). the transcripts from both interviews were analyzed and are reported here. two additional steps were undertaken to ensure the accuracy of the data analysis and to increase rigor. first, an auditor was used to check the data analysis and findings for accuracy. the auditor was a master’s prepared phn who had experience in research and rural communities. copies of two transcripts, one from the first interview and one from the second, and the generated categories and themes were sent to this individual for review. the auditor responded in writing to specific questions identified by the author. second, after the data analysis was completed, a summary of the preliminary findings was distributed to three ruralbased phn at another health region for their review. these individuals responded in writing and indicated their agreement as well as rationale for any disagreement. changes in the data analysis online journal of rural nursing and health care, 2(2) 38 were made as necessary and appropriate based upon the feedback of the auditor and the other phn. an example is the clarification of terms such as indicators and characteristics when describing hope. findings all of the phn who were interviewed were female. eight had baccalaureate degrees with one holding a public health diploma and one other with either a baccalaureate degree or diploma. in regards to the participant’s age, there were one each in the 21-25, 26-30, 31-35, 5155 and 56-60 year categories, 3 in the 36-40 year category and 2 in the 41-45 year category. the six full-time phn had been in their positions from 1.5 to 26 years with an average of 14 years. the four part-time phn had been in their positions from 6 months to 6 years with an average of 2.2 years. as a group, they had worked in rural areas from 3 months to 27 years with an average of 11.2 years. six of the participants both lived and worked in the same rural community. all of them worked in agricultural-based communities that ranged in size from 150-3500 people. the meaning of community at the beginning of the interviews, detailed discussions were held with the phn about their definition of community. two types of communities emerged from their comments: 1. a social community, which is not dependent upon physical closeness but instead, relies upon the shared values, beliefs and relationships between people. words such as “togetherness,” “sense of community,” and “attachments” were used to express this notion. 2. a physical community, which is defined by boundaries, that is sometimes imposed by the regional health authority but can also be reinforced by the presence of buildings online journal of rural nursing and health care, 2(2) 39 such as churches and schools. one other characteristic of this type of community is a connection to the land that is often noted in natural resource-based communities. most of the participants commented about the “sense of community” they perceived in the rural communities within which they worked. this was defined as a sense of belonging or being part of the whole and having shared goals, interests and responsibilities in relation to one another. the presence of a sense of community was a necessary base upon which other aspects of the community are built. other characteristics identified by the participants emphasized the quality of relationships and interactions between community members. examples include a sense of inclusivity, cohesiveness, personal connections between residents, and the presence of community spirit and pride. these characteristics are particularly evident in rural communities during tragedies as well as community celebrations. even if communities are doing well, the participants indicated that they needed to invest a substantial amount of energy into working with the community as a collective. in order to accomplish this, the phn said that they needed to work with individuals in the community. consequently, the phn built and maintained trust and assisted in the building of community. the latter is accomplished by the phn encouraging community gatherings, building their trust with community members and establishing credibility in the community. when asked, most of the participants agreed that the subtle way of working with individual community members could be described as “gentle persuasion.” this refers to the manner in which the phn interacts with the client in order to introduce new ideas or behaviors. the phn will provide information and continually address the issue over time in hopes that the client will incorporate the knowledge or change into their or their family’s lives. only one participant responded that she worked from an empowerment model (i.e., working with clients in a manner that ensures their online journal of rural nursing and health care, 2(2) 40 full input while providing the opportunity for them to take increased control of their lives) and thus used this phrase to more accurately describe her work. the others also recognized and worked from an empowerment model within their work, but believed that a variety of methods, including “gentle persuasion” were necessary. the meaning of hope the phn saw hope as a forward-looking perspective and as a positive feeling about the future or as a wish or dream. one of the participants defined it as “an expectation that something will be different” (i.e., better) whereas another said it was “a positive behavior-based action.” because hope is set in the future it can act as a form of motivation. it was also seen as fluctuating over time due to changing circumstances and experiences. most of the participants believed it was active in nature. in comparing faith and hope, all but one participant saw them as separate entities. moreover, faith was described as intangible and associated with the present whereas hope was associated with the future. however, faith was seen as a precursor to hope. the participants also discussed the differences between spirit, attitude, mentality/outlook, and hope. not all agreed on the finite details between these concepts but there was considerable overlap in their answers. spirit was predominately seen as active. it was exemplified through levels of enthusiasm within the community. one participant defined it as the inward drive that results in outlook. spirit was something that was inherent to the individual rather than something that can be instilled. for some of the participants spirit was equivalent to mentality or outlook. attitude was seen as active by most of the participants. some saw this concept as the core of hope but also as the internal aspect of self that could change. attitude was seen as linked to the individual’s spirit. some of the participants commented that a hopeful attitude can be seen as a positive spirit. for online journal of rural nursing and health care, 2(2) 41 others, mentality or outlook was seen as an internal process that is passive in nature. outlook can vary daily but hope can remain as an overall goal due to changing circumstances. hope in communities the community level of hope was seen as incrementally related to the individual level of hope. the participants believed that with a greater number of hopeful individuals present, the community as a collective is more hopeful. one participant stated, “the obvious relationship would be the more individuals that were hopeful in a community, the greater the hope in a community would be.” there were also a number of external influences on hope including economic issues (loss of industry, loss of employment, having outside owners who make decisions that negatively affect the local residents), politics (polices and decisions such as highway location changes, school closures), media (reporting of tragedy), loss of infrastructure (health care restructuring), migration patterns (loss of population or increase of population), poor health status (substance abuse, addictions), social conditions (discrimination, poverty, crime, religious atmosphere), and weather and acts of nature (droughts). in order for hope to occur at the community level, specific conditions needed to be present. these included having access to resources, the presence of hopeful people, the presence of leaders, team work, having future plans, having trust/faith in others, a belief that positives can come from negatives, flexibility, past experiences with hope, any signs or indicators of improvement, livable conditions, healthy people within the community, and a need or issue that can stimulate hope. one participant stated that a hopeful community is one that “is more sensitive and caring and is involved a little bit more in the service end of things.” a few of the participants stated that conditions were necessities whereas resources were things that would be nice to have, but were not necessary. this conclusion was drawn from their experiences of online journal of rural nursing and health care, 2(2) 42 working with individuals in communities in developing and implementing programs—the individuals themselves were able to identify what was lacking or present in their community and hence worked at accessing resources from outside the community if necessary. for the participants, people were both resources and a condition. for those who believed that resources were necessary, they listed the following: money or at least access to it or to an “in-kind” contribution that would be considered an equivalent of money; social support; education; health care; and, infrastructure (i.e., community centre). there was a relationship between hope and resources, i.e., both having and not having resources stimulated hope. finally, there was no attempt to identify the most important resource for hope but more often the participants automatically stated “people” first when resources were discussed. a community can have indicators of hope including being optimistic, flexible and having a positive outlook. for example, the condition of tidy yards with gardens and the presence of businesses in the community exude an optimistic, positive feeling. one other positive sign was community celebrations. flexibility is inter-related with community leadership. however, temporarily strained circumstances within a community do not necessarily mean that people feel hopeless. therefore boarded-up buildings and physical deterioration are not always signs of losing hope. the participants were not always sure that “hopeless” communities necessarily die. some traits of hopeless communities include an increase in apathy and a decrease in cohesion among the community members and a loss of regular community activities such as sports events. the latter would mean that the opportunity for networks, social support and positive interactions would be decreased. the phn identified that communities with hope had specific characteristics for which they assessed including infrastructure characteristics and social characteristics. infrastructure online journal of rural nursing and health care, 2(2) 43 characteristics included: economic diversity; financial stability; access to education; increase in population; well tended yards, houses, streets and businesses; and, an increase in the population. social characteristics included: having community champions or leaders present, people who both live and work in the community, community residents as volunteers, community celebrations, community involvement, active community clubs and service agencies, political activities, evidence of a vision or direction as a community, goals for the future of the community’s children, community pride and spirit, presence of community support, having a positive outlook and attitude, and, interactions between community members. in general, a thriving community was seen as a hopeful one. hope and empowerment hope and empowerment were seen as intricately linked in part because they are both internal processes. in this instance, empowerment is “the possibilities for people to control their lives” (rappaport, 1981, p. 15). the participants stated that when people felt hopeful, they felt empowered which in turn could empower others. one participant stated, “people that have hope, they are very powerful people. and they can empower others.” furthermore, having hope provides the impetus to act in ways through which empowerment is increased. being empowered helps people to feel more hopeful. finally, empowerment helps people to realize their vision and build toward becoming more hopeful. although these comments focus on individual empowerment, there was a belief that individual empowerment was inter-related with community empowerment. instilling hope was also seen as having a symbiotic relationship with empowerment. hopeful people were seen as empowered to move towards a vision or goal. the higher the level of individual empowerment, the more hope would be experienced by the individual. phn have online journal of rural nursing and health care, 2(2) 44 opportunities to empower people through positive reinforcement, connecting community members to resources, boosting morale, and providing educational opportunities for the community. the creation of hope most of the participants believed that a critical mass, per se, was not needed to build hope and that in fact often only one person was required. one of the participants made the insightful comment that the numbers were not so important as the characteristics of the individuals. hence, if you had the “right” kind of individuals, hope could easily be built in a community. one of the participants stated that you need to have someone who is “a good communicator, friendly, good listener, well connected and positive.” others noted that you could start with one, but in order to sustain the feeling of hope, more individuals would need to become involved. daily interactions within the community helps residents feel as though they are valuable members of the community, which also instills hope among them. in communities where respect and dignity are present among the members, it was generally considered to be an environment within which hope could be instilled. the phn noted specific activities they did in their work and through the roles they played (i.e., advocate, resource person, facilitator) that instilled hope for the individuals and communities with which they worked. one participant noted that when working with community members, it was important to be supportive of people and encourage them to get together with the professionals to make things happen. they also firmly believed, in relation to the notions of empowerment that individuals needed to be involved in creating health within their own communities. the participants also identified that they needed to be hopeful themselves as they saw their own attitude as instrumental to their work with community online journal of rural nursing and health care, 2(2) 45 members. this was further supported when they stated the need to continually look for the good in every situation and have a positive attitude. they also believed that with time and patience small investments in terms of activities or interactions would culminate in larger benefits for the whole community. encouraging clients by being supportive of their ideas and health behaviors were also part of the phn’s routine. hope was also instilled when the phn became part of committees within their assigned communities. specific programs were seen as important in instilling hope in families including community kitchens and programs for high-risk families. the phn believed that helping families and other community members through such programs would positively influence the entire community thereby giving hope to all. ultimately, the phn needed to have trust and credibility within the community in order to enhance or instill hope. finally, it was important to encourage community members to care about one another because this was believed to be the basis for all other relationships within this setting. the phn had goals for hope for the communities within which they worked. one participant noted that her communities were hopeful and hence she worked on maintaining it. she described her communities as “positive, stable, supportive, enthusiastic and wanting to do things for the community.” among other participants, comments were made about goals at both the individual and community level in regards to hope. for those who emphasized goals in relation to hope for individuals, they believed that hope would carry over to the community level. one example was having a goal of healthy children within the school system. those with goals for hope that related to the community as a collective talked about having smoking bylaws for their entire community or working on decreasing the level of poverty. the participants therefore believed that hope was important for their work in public health. online journal of rural nursing and health care, 2(2) 46 the phn were also asked questions about the basis of their hope. although religious beliefs played a part, it was not crucial for every participant. for those however who identified the importance of religion, they indicated that faith, belief in god, and support from prayers and other individuals of the same religious affiliation made a significant difference in their lives. others indicated a reliance upon a belief in spirituality rather than organized religion. sometimes this included a belief in god or a higher being that oversaw daily life events. however, one participant did not necessarily believe in god but acknowledged that “something” was looking after her life and its path. the other participants talked about their upbringing and its relationship to their feelings of hopefulness indicating the links between past experiences and their current level of hope. they elaborated by stating that their parents and other family members were hopeful, positive people. these feelings were reinforced by other significant individuals such as teachers, classmates or fellow workers. regardless of how their own hope was created, the participants believed in looking to the future and that they could make a difference in the lives of others. in essence, the work they did reinforced their hope and further enhanced it. discussion the findings generated from this study need to be considered in light of the small sample size and limitation to one health region. despite this, the comments and ideas generated about hope from a community perspective add to the growing knowledge base about this concept. for example, stephenson’s (1991) attributes of hope for individuals (it has meaning for the person; it is a process involving relationships; it has a sense of anticipation; and, it holds a positive future outlook) are also noted in the information generated in this study. hope had significant meaning for the phn in their practice, they saw it as a positive, forward moving process that involved online journal of rural nursing and health care, 2(2) 47 relationships with individuals as well as the community in its entirety. the participants talked about hope as having meaning for the community as a whole because activities are held which further confirm their status as a collective unit through the building of cohesiveness and unity. hope in rural communities is illustrated at celebrations and as reactions to tragedy and are based upon relationships within the community. there is a sense of anticipation as community members look forward to coming together as a group at celebrations. finally, community members hold a future outlook when they plan events and set goals for themselves. the findings also showed that like individuals, communities have indicators and characteristics of hope including both physical and social characteristics. furthermore, interrelationships between concepts such as spirit, mentality/outlook, attitude, and hope were noted with hope being an active state that can stimulate spirit and attitude even at the community level. additional information about these links, as well as that between hope and empowerment would assist in further understanding the significance of hope for phn and the rural communities within which they work. like other concepts, it is difficult to determine the exact relationship between individual and community hope. most of the participants believed that one person who was hopeful in a community could make a difference and there are case examples to support this notion (see hinsdale, lewis & waller, 1995; nozick, 1992). however, it is unclear whether a critical mass is needed or if it is the characteristics of the individual that are key to the further creation of hope at the community level. in all likelihood, the relationship is probably linked to the level of empowerment and the community’s history and ability to deal with adversity as well as the presence of community champions and reaffirmation of their success through community stories. online journal of rural nursing and health care, 2(2) 48 the phn who were interviewed believed that hope was important to their practice and that what they did for individuals helped in the creation of hope at the community level. unlike the literature, not all of the phn who were interviewed indicated that their personal level of hope was related to organized religion or spirituality. instead, they emphasized relationships, including those with parents, teachers and the like, as significant in this regard. this finding alone calls attention to the need to examine the personal basis of hope from different perspectives. more information needs to be generated about the models through which phn provide care within communities and the transformation through which hope is generated at the community level. acknowledgment a heartfelt thank you is extended to the public health nurses and all other individuals who participated and contributed to this study. this research was, in part, financially supported by a grant provided by the hope foundation, edmonton, alberta. online journal of rural nursing and health care, 2(2) 49 references bellah, r.n., madsen, r., sullivan, w.m., swidler, a., & tipton, s.m. 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(1995). what is nursing knowledge? in h. streubert & d. carpenter (eds.), qualitative research in nursing: advancing the humanistic imperative (pp. 15-28). toronto: j.p. lippincott. thompson, m. (1994). nurturing hope: a vital ingredient in nursing. journal of christian nursing, 11(4), 10-17. https://doi.org/10.1097/00005217-199411040-00006 zorn, c. (1997). factors contributing to hope among non-institutionalized elderly. applied nursing research, 10(2), 94-100. https://doi.org/10.1016/s0897-1897(97)80161-9 https://doi.org/10.1037/0022-3514.60.4.570 https://doi.org/10.1037/0022-3514.60.4.570 https://doi.org/10.1111/j.1365-2648.1991.tb01593.x https://doi.org/10.1097/00005217-199411040-00006 https://doi.org/10.1016/s0897-1897(97)80161-9 editorial 5 editorial quality rural health care: the future is today dale quinney, mph executive director alabama rural health association dr. jeri dunkin's excellent letter from the editor on the important subject of "quality health care for rural residents" in your fall 2005 issue was informative and insightful concerning the actions that must be taken by our rural health care industry. it is only natural that our rural health care industry leads the way in improving quality of care. our rural health care industry has a much greater interest in providing high quality health care since its survival depends on such care being provided. urban facilities stand to gain a greater share of the health care market by enhancing their quality of care, but many rural facilities will survive only if their local consumers recognize that quality care is being provided. the national rural health association (nrha) recently announced that all rural community-based health care delivery systems should cover the continuum of care, achieve optimal quality/performance standards, be financially viable, continuously improve performance and quality, and address population health measures. these requirements are inter-related. nrha further identified the greatest barriers to providing quality care in rural communities as including resource limitations, the serving in a lowvolume environment, challenges with recruiting and retaining health care professionals, and difficulty in paying for and implementing needed technology. i recently talked with a rural georgia hospital administrator who described how his facility had remodeled an unutilized room and installed rather inexpensive equipment that would allow a local primary care physician to sit with his/her patient in this room while the patient was being diagnosed by a subspecialist situated many miles away. the local physician and subspecialist only charge for office visits. the hospital collects a small usage fee. the patient (especially elderly patients) avoids having to make a lengthy journey to receive specialty care. the use of emerging technologies is expanding rapidly in rural alabama. rural clinics are providing high-risk patients with limited transportation with rather inexpensive equipment to allow for the monitoring of vital signs by telephone. most rural hospitals without staff radiologists are using high-speed internet to have patient's scans quickly read by highly-trained radiologists. expanding the use of emerging technologies can provide an answer to several of the requirements for improving quality while removing barriers. through such technology, rural health care facilities can offer its consumers an expanded continuum of care and possibly offer this at a lower cost. local consumers receiving such convenient and specialized care at their local health care facility will be more likely to enhance the local facility's financial viability by returning to that facility for other health care needs. the use of emerging health care technologies can also aid in decreasing the tremendous online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 6 pressure that rural facilities face in trying to provide subspecialty care for its local consumers. the recruiting of health care professionals into rural areas has been an issue of growing concern. there are now several innovative and promising approaches to recruiting health care professionals into rural and underserved areas. there is general agreement that the solution to this need is to admit more students from rural areas into medical and other health care professional institutions. students from rural areas are more likely to return to practice in rural areas. the medical pipeline established at the capstone college of medicine at the university of alabama has successfully adopted this approach. the success of this program has prompted the establishment of a second such pipeline in east alabama. another innovative and rapidly expanding program with a mission of getting primary care physicians to practice in rural and underserved areas of alabama is the emerging alabama medical education consortium (amec). this consortium consists of 19 alabama colleges and universities and three osteopathic medical schools. amec recommends students for admission to the medical schools based upon need. approximately 70 medical school slots are allowed for alabama students each year. alabama students attend medical school on-campus for the first two years and return to alabama for their final two years of medical school and their residency. perhaps no single component of health care has a greater impact upon the consumer's perception of quality than the service provided by nurses. in most health care visits, nurses have the greatest amount of personal contact with the patient. if this contact is professional, comforting, and satisfying, the patient will have a more positive feeling about the quality of the care, even if the physician or other health care professionals falter. i have inquired about staffing needs at numerous alabama health care facilities. the shortage of nurses has always been the most critical need identified. this could create a situation where the quality of nurses being trained could be sacrificed for the sake of producing more nurses at a faster rate. because of the vital importance of nurses to the quality of care, our nursing schools must carefully balance the need for more nurses with the quality and completeness of the training. the prospect of having alabama's rural health care facilities lead the way to a higher quality of care is encouraging. there is considerable debate over how quality health care should be defined and measured. numerous definitions will emerge and standardized measurements will be used in an attempt to measure quality. in the end, local consumers will identify quality through their use or lack of use of local health care facilities, regardless of how quality is defined or measured. nurses will be of great importance in making this determination. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 168 influences of turnover, retention, and job embeddedness in nursing workforce literature susan louisa adams, phd(c), fnp-bc 1 1 phd student, east tennessee state university, associate professor of nursing, king university, adamss@etsu.edu abstract examining literature related to nursing turnover, retention and job embeddedness has implications applicable to employer and patients. turnover is expensive and can lead to adverse patient outcomes and few studies focus on rural nurses. keywords of nurse, rural, turnover, retention, and job embeddedness entered into three search engines produced 39 references from 1995-2015. predominance of convenience samples, lack of discussion of reliability and validity information, and lack of theoretical or conceptual frameworks accompanied by lack of studies focused on rural nursing highlight the gaps in knowledge regarding what keeps nurses in their jobs. keywords: nurse, rural, turnover, retention, job embeddedness influences of turnover, retention, and job embeddedness in nursing workforce literature understanding the characteristics of nurses who stay in the workplace aids employers as well as patients. examining the concepts of turnover, retention, and job embeddedness provides a comprehensive view into factors influencing this phenomenon. for practical purposes, the online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 169 term “turnover” implies voluntary turnover. the cost of turnover of one nurse can be up to twice the cost of a year’s wages (stroth, 2010). turnover is associated with adverse patient outcomes linked to increased nurse workload. one study found that surgical death rates rose seven percent per added patient to a nurse’s workload (stroth, 2010). the most recent nursing statistics note a 17.2% turnover rate per year compared to a 13.5% rate per year four years earlier according to a study performed by nursing solutions, incorporated (nsi) (2015). retention refers to those nurses who do not quit their jobs. the nsi (2015) report also noted that many of the participating institutions in their study population did not have comprehensive retention strategies despite noting that such a strategy is important to prevent turnover (nsi, 2015). projected nursing shortages also highlight the need to retain practicing nurses in place (dotson, dave, cazier & mcleod, 2013). job embeddedness (je) refers to those who stay in place as well. this concept consists of six components covering “on-the – job: and “off the – job” factors associated with maintaining current employment (holtom & o’neill, 2004). je arose from a need to “build a better mousetrap” when attempting to explain determinants of turnover and retention beyond previously used tools and theories (reitz & anderson, 2011). keeping nurses working in rural areas is especially difficult for several reasons (stroth, 2010). the rural nurse is unique in that generalist skills are paramount and the nurses may feel overwhelmed at the breadth of responsibilities expected in practice (molinari & monserud, 2008). these nurses also have the added stressor of “professional isolation” as well as having a higher profile status as they care for friends and neighbors (dotson, dave, cazier, mcleod, 2013). this feeling may lead to turnover. understanding how to retain the rural nurse has implications for health care organizations, communities, and patients (holtom & o’neill, 2004). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 170 nurses are the most abundant rural health care professional and the least well studied concerning the choice of rural practice (daniels, vanleit, skipper, sanders, & rhyne, 2007). studies examining the rural nurse are few and sample sizes are usually small and therefore lack generalizability (molinari & monserud, 2008). the aim of this review is to examine the theoretical and empirical evidence in the existing literature regarding influences associated with nursing retention, turnover, and job embeddedness (je), especially in rural nurses. method gathering references for this review was challenging due to lack of studies involving rural nurses. pubmed central, cumulative index to nursing and allied health literature (cinahl), and google scholar provided a variety of findings. pubmed central represents multiple health care professions, cinahl primary focuses on nursing literature, and google scholar is an allpurpose search engine that may include literature missed by the other two options. the following search terms were included: nurse, rural, turnover, retention, and job embeddedness in the title or abstract. empirical articles, theoretical articles, intervention reports, and theses/dissertations from 1995 to the present were included. exclusion criteria consisted of articles focused on nursing leadership style on retention and turnover rather than individual nurse characteristics associated with search terms, not about nurses in the united states, and not related to search terms after further review. items not specifically about rural nurses were included if the other search terms were present in the title or abstract in order to provide contextual depth to the review. two hundred seventy seven selections comprise the initial search engine findings. after reading these findings a manual search of journal tables of contents, review articles, and reference lists that included search terms yielded another twelve items. after again scanning the online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 171 search results, one hundred eight items warranted further evaluation. by eliminating duplicates, items deemed not primarily related to the identified search terms, and unavailable articles, 39 items met final review inclusion criteria. results when examining literature for a review, multiple criteria should be included. cronin, ryan, and coughlan (2008) outline topics to include when summarizing selections and this list guided the critique portion of this review. references fall into three sections for comparison – turnover, retention, and job embeddedness. conceptual definitions, instruments, and method, sample characteristics, use of theoretical frameworks, and outcomes are discussed for each section. turnover ten selections related to turnover are included in this review. six research studies and four reviews of literature revealed themes related to nursing turnover. no nursing turnover theoretical references appeared in the search results. definitions of turnover and rural. turnover describes those who left jobs during the study period (ranging from 6 months up to three years) (barenholdt & mark, 2009; hodgin, chandra, & weaver, 2010). turnover can also mean past job change (hunt, 2009; levasseur, wang, mathews, & boland, 2009) and intent to leave (hauck, quinn-griffin, & fitzpatrick, 2011). rural refers to communities with less than 50,000 people (barenholdt & mark, 2009) and non-metropolitan areas (brewer, kovner, greene, tukov-shuser, & djukic, 2012). only two studies included the same definitions of turnover and online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 172 neither had the same definition of rural (cooper, 1998; hayes, et al., 2012). this lack of consistency limits comparability of findings. method and instruments. of the ten turnover empirical references, four employed a cross-sectional quantitative design (barenholdt & mark, 2009; hauck, et al., 2011; hodgin et al., 2010; shader, broome, broome, west, & nash, 2001). another reference featured a prospective longitudinal panel design (brewer, et al., 2012). one employed mixed methods (levasseur, et al., 2009) and four were literature reviews (gilmartin, 2013; hayes, et al., 2012; hunt, 2009; wagner, 2007). it is not surprising most studies were cross-sectional in nature as this design saves time and money. however, longitudinal studies provide information regarding changes over time and can better inform employers regarding factors associated with turnover (grove, burns, & gray, 2012). careful selection or creation of research instruments is critical for accurate data collection and reporting study instrument validity information lends confidence to findings (polit & beck, 2012). four of the six research studies reported reliability and validity data regarding the selected research instruments (barenholdt & mark, 2009; brewer, et al., 2012; hauck, et al., 2011; shader, et al., 2001). two studies included a previously developed tool associated with turnover “the anticipated turnover scale” (hauck, et al., 2011; shader, et al., 2001) among other measurement tools. the other studies used original tools. the lack of consistency in tools used in the nursing turnover literature inhibits comparisons of findings. turnover literature sample characteristics. most studies in the turnover literature focused solely on nurses. however, hodgin et al. (2010) included licensed practical nurses in their study. barenholdt & mark (2009) compared online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 173 rural and urban hospitals as the focus of study. convenience samples dominate the review references regarding nursing turnover. this type of plan has inherent sampling bias risks and results must be viewed in this light (polit & beck, 2012). only two studies reported randomization of participants (barenholdt & mark, 2009; brewer, et al. 2012. sample sizes were quite large (over 1000 nurses) in two studies (brewer et al., 2012: levasseur et al, 2009). four other studies had smaller numbers (97 253) (barenholdt & mark, 2009; hauck, et al. 2011; hodgin et al, 2010; shader et al., 2001). random sampling improves the representativeness of the study population (polit & beck, 2012). effect size. performing a power analysis and calculating effect size aids in determining appropriate study sample size (polit & beck, 2012). one large study reported a small effect size (brewer, et al., 2012). a medium effect size was reported in one smaller study (hauck, et al., 2011). the other three studies did not report effect sizes (barenholdt & mark, 2009; hodgin et al., 2010; shader, et al., 2001). performing a power analysis and reporting effect size helps reduce type ii errors (polit & beck, 2012). effect size reporting also assists in comparing studies (sullivan & feinn, 2012). the lack of effect size reporting limits the ability to compare findings in the turnover literature. turnover use of theoretical frameworks. including a theoretical or conceptual framework in nursing research has double benefits. the theory frames the study and the findings test the theory (polit & beck, 2012). three of the six studies mention a theoretical or conceptual framework but none was the same. the literature review by gilmartin (2013) focused solely on various theories associated with turnover. hayes, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 174 et al., (2012) and wagner (2007) include sections on theory but hunt (2009) did not. a more detailed description of the various theories presented will follow in the “theory” section. turnover literature outcomes. research outcomes in the turnover literature reflected a theme in organizational commitment and other work related factors such as workload and work stress (brewer, et al., 2012; hauck, et al., 2011; shader, et al., 2001). barenholdt and mark (2009) compared rural and urban hospitals but did not find a significant difference in job satisfaction and turnover rates related to location. rather, work environment and nursing unit characteristics such as number of beds, support services, and safety climate were factors associated with turnover. brewer, et al. (2012), included rural and urban nurses in their study and found intent to stay was influenced by job satisfaction and organizational commitment. comparing rural versus urban nurse turnover was not a study aim. levasseur, et al. (2009) and hodgin, et al., (2010) noted organizational and personal factors associated with turnover. two literature reviews also reported organizational issues were major influences on turnover (wagner, 2007; hunt, 2009). hayes et al., (2012) reported nursing turnover had multiple ties to on the job and off the job factors. the overall common theme of organizational issues influencing turnover provides clues for employers although personal issues appeared in two references. organizational issues can be addressed by changes in leadership, workloads, and support services, for example, and potentially lower turnover rates. retention of the three concepts comprising this review, retention provided the most references totaling 19 titles along with the most discussion of rural nurse retention. two literature reviews, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 175 two reports of interventions, one theoretical article, and 14 research studies are included in this section. definitions of retention and rural. definitions of retention in the literature selections include variations of “not quitting” your job and “intent to stay” (atencio, cohen, & gorenberg, 2003; blake, leach, robbins, pike, & needleman, 2013; buffington, zwink, fink, devine, & sanders, 2012; cordeniz, 2002; codier, kamikawa, kooker, & shoultz, 2009; ellenbecker, porell, samia, byleckie, & milburn, 2008; hayhurst, saylor, & stuenkel, 2005; hinson & spatz, 2011; karlin, schneider, & pepper, 2002; katz, o'neal, strickland, & doutrich, 2010; kippenbrock, stacy, & gilbert-palmer, 2004; mcellistrem-evenson, 2010; salt, cummings, & profetto-mcgrath, 2008). the opposite phrase of “intent to leave” your job was also used to determine those plan to stay in their jobs (cheng, kelly, carlson, & witt, 2014; daniels, et al., 2007; dotson, et al., 2013; dotson, cazier, dave, spaulding, 2014; murray, havener, davis, jastremski, & twichell, 2011; wieck, dols, & landrum, 2010). although phrased differently, these definitions essentially elicit the same information – did the nurse stay in place or leave? kippenbrock, et al. (2004) and daniels, et al. (2007) defined “rural” as towns with populations less than 50,000. retention method and instruments. quantitative studies also predominate the nursing retention literature. few longitudinal studies are present in the retention references. atencio, et al. (2003) collected data over two years from an urban west coast hospital. ellenbecker, et al., (2008) collected initial data and repeated the survey one year later. hayhurst, et al., (2005) collected retention data from a northern california hospital three times over an eighteen-month period. the remaining eleven online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 176 studies collected data in a cross sectional fashion. the downfall of cross sectional design is that this “snapshot” in time does not reflect trends over time (polit & beck, 2012). instrumentation used to determine retention is as varied as the reasons nurses stay in place. unless otherwise specified, validity information regarding the tools was provided. atencio, et al., (2003) and hayhurst, et al., (2005) used “the moos work environment scale” to evaluate occupational influences of retention such as work pressure, autonomy, and task orientation. the “practice environment scale of the nursing work index revised” assesses aspects of a nurses’ involvement in the organization, staffing, leadership, and nurse-physician collegiality. this scale was used along with another established instrument called the “icu nurse-physician communication questionnaire to determine retention of pediatric intensive care nurses (blake, et al., 2013). buffington, et al., (2012) chose to use along with the “revised casey-fink nurse retention survey” along with qualitative methods in their nursing retention study. this instrument investigates “work environment, support, and encouragement”. cheng, et al., (2014) selected price and muller’s “causal model” to study advanced practice nurse retention. a study to determine if a link exists between emotional intelligence and nurse retention conducted by codier, et al., (2009) used the established “mayer salvey-caruso emotional intelligent test” instrument. using previously validated instruments adds to the body of knowledge regarding the subject matter as one can compare study results when the same tool is used. however, only two studies used the same tool in this instance. four references included original tools. daniels, et al. (2007) study had a rural focus and did not include validity data regarding their questionnaire. dotson, et al. (2013) developed a tool to study rural nurse retention. dotson, et al., (2014) reported a cronbach alpha greater than .7 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 177 for their tool created to form a “retention model”. ellenbecker, et al. (2008) created the “home healthcare nurse job satisfaction scale” which assesses on the job and off the job influences on retention and reported an adequate reliability score. providing reliability information adds rigor to nursing research (polit & beck, 2012). retention sample characteristics. urban locations predominate the retention literature. seven references discussed urban hospital nurse retention (atencio, et al., 2003; blake, et al., 2013; buffington, et al., 2012; hayhurst, et al., 2005; hinson & spatz, 2011; salt, et al., 2008; wieck, et al., 2010). five references addressed rural nurse retention in various settings. daniels, et al. (2007) included nurses along with several types of rural health care providers in new mexico. kippenbrock, et al. (2004), featured nurse practitioners in rural arkansas in the study. katz, et.al. (2010) discussed native american nurses working in their home communities. dotson, et al. (2013) and dotson, et al., (2014) compared rural and urban nurse retention in the southeastern united states using the same data set. ellenbecker, et al. (2008) and karlin, et al. (2002) recruited nurses from four states but did not specify rural or urban locale. daniels, et al. (2007) noted the lack of literature regarding rural nurse retention and unfortunately this situation has not improved in the past eight years. sampling pattern. convenience sampling methods commonly appear in the retention references (atencio, et al., 2003; blake, et al., 2013; buffington, et al., 2012; cheng, et al., 2014; codier, et al., 2009; dotson, et al., 2013; dotson, et al., 2014; hayhurst, et al., 2005; karlin, et al., 2002; kippenbrock et al., 2004; wieck, et al., 2010). katz, et al., (2010) chose purposive sampling to online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 178 conduct a qualitative retention study of native american nurses working with the indian health service (n = 9). one study employed a stratified random sampling method (daniels, et al., 2007). ellenbecker, et al. (2008) used random sampling to select nursing homes to invite participants in their study of 1912 home health nurses in new england. all but one study recruited sample sizes over 100. karlin, et al., (2002) recruited 36 geriatric nurse practitioners participants in ambulatory settings in colorado and massachusetts for their nursing retention study. the studies regarding turnover by far had the largest sample sizes. large sample sizes sound impressive, but as most of these studies used convenience samples, the findings may still not be representative of the desired population (polit & beck, 2012). effect size. only one reference listed effect size. blake, et al., (2013) achieved a small effect size in their study of pediatric critical care nurses. as stated earlier, failure to report or calculate an effect size limits comparability among studies (polit & beck, 2012). retention literature use of theoretical frameworks. as was the case with instrumentation, a variety of theoretical and conceptual frameworks appear in the retention literature (atencio, et al., 2003; blake, et al., 2013; cheng, et al., 2014; codier, et al., 2009; dotson, et al., 2014; ellenbecker, et al., 2008; katz, et al., 2010). none were the same. eight out of fourteen research studies in this review lacked reference to any theory. the use of theoretical or conceptual frameworks aid in linking findings to previous research, thereby improving quality of the literature (polit & beck, 2012). however, as no two studies used the same theory, the ability to link findings is limited. discussion of retention related theories follows in the “theory” section. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 179 retention literature outcomes. workplace issues such as autonomy, pressure, task orientation, leadership, feeling valued, salary, intent to leave, job satisfaction, and interventions to improve retention influenced staying on the job regardless of setting (atencio, et al., 2003; blake, et al., 2013; buffington, et al., 2012; daniels, et al. ,2007; dotson, et al., 2013; hinson & spatz, 2011; murray, et al., 2011). nonwork related factors such as family size, emotional intelligence, generational differences, “values match”, and altruism also influenced retention (cheng, et al., 2014; codier, et al., 2009; cordeniz, 2002; dotson, et al., 2013; wieck, et al., 2010). previous work or educational experience in rural areas influenced retention of nurses in this setting along with loan forgiveness and other financial incentives improved rural retention rates (daniels, et al., 2007; kippenbrock, et al., 2004; mcellistrem-evenson, 2010). reviews of literature addressing nurse retention revealed several suggestions to keep nurses (both rural and urban) in place. mcellistrem-evenson (2010) echoed daniels, et al. (2007) by suggesting targeting students with rural backgrounds to work in rural areas and improve financial compensation for working in these areas. salt, et al. (2008) reported that preceptor programs were effective in retaining new graduate nurses. these findings inform those concerned with nursing workforce retention issues and note the multifactorial influences upon nurse retention in any area. job embeddedness the search for job embeddedness literature matching inclusion criteria produced a few more references than turnover, but less than retention. six research studies, two literature reviews, and three theoretical articles provide insight on this concept. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 180 job embeddedness definitions. job embeddedness rose from the business literature around 2001 (reitz & anderson, 2011). organizational and community “fit”, “links”, and “sacrifice” wind together to embed a person in place (mitchell, holtom, lee, sablynski, & erez, 2001). fit refers to how well the person is at ease in their surroundings, links refer to connections with coworkers and neighbors, and sacrifice refers to how hard it would be to change jobs or move (reitz & anderson, 2011). gibbs (2015) and jiang, liu, mckay, lee and mitchell (2012) and mitchell, holtom, lee, sablynski, & erez (2001) compared job embeddedness to “stuckness”. halfer (2011) and holtom and o’neill (2004) use the term to describe those who did not leave their jobs during a specific amount of time. “intent to stay” also is used to define job embeddedness (reitz, 2014a). suggestions to amend the original job embeddedness tool to represent specific populations or occupations appear in the literature. for example, reitz and kim (2013) suggested changes to better study rural versus urban nursing je. by changing the tool, the contextual components of job embeddedness changes although the overall conceptual definition remains the same. this limits generalizability of the findings despite the use of the term “job embeddedness”. “rural” was defined using the rural urban commuting area (ruca) method by the two studies specifically contrasting rural and urban populations (reitz, 2014a; reitz and anderson, 2011). job embeddedness literature method and instruments. the job embeddedness tool is a quantitative instrument; therefore, all the research studies were of this design. three studies were cross sectional (gibbs, 2015: reitz, 2014a; reitz & anderson, 2011). two were longitudinal (halfer, 2011; holtom & o’neill, 2004). as stated earlier, longitudinal studies provide clues to change over time (polit & beck, 2012). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 181 the original job embeddedness tool was used in each of the six studies reviewed (gibbs, 2015; halfer, 2011; holtom and o’neill, 2004; reitz, 2014a; reitz & anderson, 2011; reitz & kim, 2013). this tool has 40 items divided into six categories three each for organizational and community factors (i.e. fit, links, sacrifice) that potentially influence retention. holtom and o’neill 2004 report an overall tool alpha reliability of .87. additional tools such as “the nurse job satisfaction” and the “intent to stay” instruments rounded out the dissertation research by gibbs (2015). these were included as job satisfaction and intent to stay were study aims in addition to determining the total job embeddedness score. halfer (2011) included a career development questionnaire to examine retention influences in new graduate nurses. tools to evaluate organizational commitment, job alternatives, job search behavior, and intent to leave provided context for holtom and o’neill’s 2004 study of hospital employees. the additional context led to the finding that the job embeddedness tool better predicted retention than the other instruments (holtom & o’neill, 2004). all references included validity information for selected instruments. job embeddedness literature sample characteristics. four studies focused on je had sample populations comprised only of registered nurses. halfer (2011) studied 191 new graduate nurses in an urban, inpatient setting. eighty two nurses from across the nation working in long term care comprised the sample for reitz (2014a). reitz & anderson (2011) and reitz & kim (2013) used the same data set of 400 urban and 400 rural nurses from illinois. gibbs (2015) studied 101 registered nurses and 24 health care assistants working in a north texas hospital. holtom and o’neill (2004) surveyed 232 midwestern hospital employees and specifically mentioned nurses in the findings. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 182 sampling pattern. in contrast to the turnover and retention references in this review, random sampling predominates in the je literature. four studies randomized the sample population (holtom & o’neill, 2004; reitz, 2014a; reitz and anderson, 2011; reitz and kim, 2013). only two studies employed convenience samples gibbs (2015) and halfer (2011). the use of random sampling reduces risk of bias related to sample selection (polit & beck, 2012). effect size. effect size appears in three references. gibbs (2015) calculated 170 participants would achieve a moderate effect size but the actual study only had 125 participants. reitz (2014a) needed 138 participants for a small effect size but had only 82 participants in the final study. reitz and anderson (2011) required 200 participants for a medium effect size and achieved this goal. the same population was used for secondary data analysis in a later study (reitz and kim, 2013). reporting effect size gives the reader clues to the strength of the relationship of variables (polit & beck, 2012). job embeddedness literature use of theoretical frameworks. the je literature understandably draws heavily on the job embeddedness theory first proposed by mitchell, et al., in 2001. other theoretical references used in the je studies include self-efficacy theory, locus of control (gibbs, 2015), voluntary turnover (holtom & o’neill, 2004) and the unfolding model of turnover (stroth, 2010). these theories will be discussed further in the theory section of the review. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 183 job embeddedness literature outcomes. job embeddedness (je) studies often report the total je score as well as the scores of the individual factors of link, fit, and sacrifice as these vary among age groups, locations, and job title, for example. a high total je score implies a low intent to leave current employment (holtom & o’neill, 2004). total je score was associated with intent to stay in all but one study however determining the total je score was not a study aim (halfer, 2011). organizational fit was reported twice as significant for nurses (gibbs, 2015; halfer, 2011). this is consistent with the turnover and retention literature regarding nurses. stroth (2010) noted turnover rates in organizations dedicated to je had half the turnover rate of those who were not. organizational links, community fit, and community sacrifice were also important to nurses more than healthcare assistants (gibbs, 2015). age appears to influence which of the six job embeddedness dimensions is significant in the study samples. community embeddedness was found to be associated with retention in one study including an older population of nurses (holtom &o’neill, 2004). younger nurse turnover was associated with lack of organizational fit (halfer, 2011). the job embeddedness literature points to the overall total je score to be associated with lower levels of intent to leave even if different versions of the tool are used (reitz & anderson, 2011; reitz, anderson, & hill, 2010; reitz & kim, 2013). individual characteristics appear stronger is some populations and less in others but the total score remains predictive. this provides employers with a broad picture of embeddedness and specific information to use while attempting to individualize retention interventions. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 184 theoretical influences of turnover, retention, and job embeddedness. theoretical underpinnings of studies examining nursing retention, turnover, and job embeddedness build on one another. the use of theory in research adds depth and insight to findings (gilmartin, 2013). nurses stay in jobs they are dissatisfied with and leave jobs they enjoy. in order to explain this anomaly, lewin’s field theory suggests that individuals are surrounded by a “perceptual life space” and are connected to the world by web strands (as cited in mitchell, et al, 2001). surviving “shocks” in one’s personal and professional life influence turnover and are discussed in the “unfolding model” of turnover (as cited in mitchell, et al, 2001). additional turnover theoretical influences in nursing literature include price and mueller’s “causal turnover model”, hinshaw and atwood’s “anticipated turnover model”, parasuraman’s “integrated turnover model”, and borda and norma’s “absence and turnover model” (gilmartin, 2013). gilmartin (2013) provides an overview of these models along with others previously mentioned. she highlights the “unfolding turnover model” and the “job embeddedness model” as guides to shape further research for nursing as these address the needs of the profession more adequately than other models. multiple theoretical frameworks appear in the retention literature and often incorporate “job satisfaction”. the “organizational and personal factors and outcomes” conceptual framework by shaefer and moos incorporates multiple organizational and personal influences on workers in order to understand the influence on these factors on quality of care and patient outcomes was used to study nurse retention (as cited in atencio, et al., 2003). dotson, et al. (2014) developed an original “retention model” that includes job satisfaction, job stress, value congruence, and financial factors. the “theoretical model of home healthcare nurse job online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 185 retention” suggests nurse characteristics, job satisfaction, and market characteristics influence intent to stay and improve retention (ellenbecker, et. al., 2008). job embeddedness theory was designed to fill gaps left by previous turnover and retention theories. six “dimensions” influence retention and are divided in to community and organizational themes regarding “fit, links, and sacrifice”. fit describes how well the person perceives belonging to the organization or community. links describes relationships the person has at work and in the community. sacrifice reflects the stress involved with leaving the organization or community (mitchell, et al, 2001). gibbs (2015) combined self-efficacy theory with job embeddedness theory and locus of control in a dissertation. having an internal locus of control and believing one is capable of doing their job well leads to confidence that they belong in the job they have and this is proposed to raise the level of job embeddedness in nurses (gibbs, 2015). understanding rural health theory strengthens studies regarding rural nurses (lee & mcdonagh, 2013). work relationships and work independence were cited as factors influencing job satisfaction in rural nurses according to a literature review on international rural nurse job satisfaction (manahan & lavoie, 2008). hiring “outside” leadership to lead rural health care entities can conflict with the patient preference of working with “insiders” noted in rural nurse theory. growing nurse leaders from the inside could appeal to the independent nature of rural residents and nurses (lee & mcdonagh, 2013). rural theory was not cited in the rural nurse references selected for this review. discussion online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 186 theoretical and empirical evidence regarding influences associated with nursing retention, turnover, and job embeddedness (je), especially in rural nurses are not exhaustively present in nursing literature. although several titles exist for each topic, lack of consistency in study aims, design, instrumentation, and use of theory cloud the ability to compare results among the findings. few references address the rural nurse. however, similar themes emerge from the present state of the science and inform employers of issues influencing intent to stay or go. a table summarizing these findings can be found in table 1. the outcomes of all three concepts (turnover, retention, je) are reported in terms of job embeddedness dimensions to note themes across the literature. table 1 characteristics of turnover, retention, and job embeddedness literature turnover retention job embeddedness characteristic n = 10 n = 19 n = 10 rural samples 0 3 0 rural / urban mix sample 3 2 2 urban only sample 3 7 1 unspecified sample location 0 2 3 effect size calculated 2 1 4 reliability discussed* 4 10 6 cross sectional design 4 11 3 longitudinal design 1 3 2 empirical (primary)** 6 14 6 empirical (secondary)*** 3 2 2 theoretical*** 1 3 3 fit 9 19 4 links 7 10 3 sacrifice 6 9 1 note. *reliability (i.e. cronbach alpha score) discussed in primary empirical studies; **primary = research study; ***secondary = review of literature (cronin, et al., 2008). theoretical sources include reports of interventions. multiple influences ranging from unit level, organizational level, community level, and personal level affect whether a nurse remains in place or moves on to another organization or online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 187 profession. employers are urged to understand these factors in order to attract and keep adequate staffing. of the six job embeddedness “dimensions”, organizational fit was consistently most noted across the three concepts as associated with staying in place. organizational fit can be expressed as job satisfaction, commitment, or workload. links followed second, and sacrifice was third. links can come in the form of support services or relationships with leaders. sacrifice in the form of financial compensation, altruism, and family ties can affect one’s desire to stay with an organization. conclusion several gaps appear in the literature regarding the concepts of turnover, retention, and job embeddedness, especially within the rural nursing workforce. nursing turnover literature exhibits a lack of a consistent definition of “turnover”, use of multiple measurement tools, and small sample sizes. a lack of longitudinal studies was noted as problematic (hayes, et al., 2012). longitudinal studies are preferred as events influencing turnover occur over time (gilmartin, 2013). only six studies were longitudinal. the literature associated with nursing retention also suffers from lack of a consistent definition of “retention”, use of multiple tools used to assess this phenomenon, lack of effect size reporting, and inconsistent use of theory. the job embeddedness literature had common themes associated with the theory of job embeddedness, but several versions of the tool were employed thereby reducing comparability among the studies. this lack of a consistent method of studying nursing workforce issues, especially in rural areas, points to a need for further research. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.405 188 future research determining the best method to study what keeps nurses (especially rural nurses) on the job, and how to interpret and apply the findings guides future research for those interested in nursing workforce issues. of the three concepts examined in this review, the job embeddedness tool addresses multiple factors associated with keeping nurses in place and has an adequate cronbach alpha score. the job embeddedness theory also encompasses other theoretical frameworks regarding retention and turnover thereby functioning as a comprehensive model to interpret studies regarding job embeddedness. gilmartin (2013) concluded that nursing research would benefit by using models from the business world. she states that nursing is “behind the times” when it comes to this type of management research and she specifically mentions “the unfolding turnover model” by and the “job embeddedness model” as preferred frameworks. combining rural theory to future research is also suggested as well as taking under advisement the use of re-configured versions of the original job embeddedness tool tailored to rural nurses as designed by reitz & kim (2013). the use of this information in rural nurses has been limited in the past. with little research to build upon, maximizing efficiency, and increasing rigor would be advised in order to gain maximum information from research efforts. references atencio, b., cohen, j., & gorenberg, b. 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(2010, january). retention priorities for the intergenerational nurse workforce. nursing forum 45(1), 7 17. https://doi.org/10.1111/ j.1744-6198.2009.00159.x editorial 10 editorial continuing education in the journal marietta p. stanton, editorial board member dear rno member: beginning with this issue, we will provide you with an opportunity to earn continuing education credits on line. each issue will contain a designated article for you to read. following the article will be a set of questions and an evaluation form for the learning experience that you will also need to complete and send in with your fee. you will need to print the forms and mail them with your check or money order. once these are received, i will send you a certificate documenting your course completion and continuing education credits. there are complete instructions in every issue to guide you on completing materials. in upcoming issues, we will focus on educational, practice, or administrative content that specifically applies to or is of interest to rural nurses. we believe this will provide a method for you to update your knowledge on a variety of topics right from the convenience of your own home or practice setting. in addition, i would like to work with individuals that would like to develop on line learning modules on topics that would benefit rural nurses. if you are interested in developing course materials, please contact me. these would be a welcome addition to our website and would be an excellent way to share important content. i look forward to working with you and believe this is an exciting beginning. sincerely yours, marietta p. stanton, phd, rn,c, cnaa, bc, cmac continuing education coordinator rno professor and graduate program coordinator capstone college of nursing university of alabama mstanton@bama.ua.edu online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 mailto:mstanton@bama.ua.edu editorial 3 editorial a long, hot summer: a canadian perspective kathy crooks editorial board member the spring and summer of 2003 have been difficult for many canadians. this is particularly true for those living in predominantly rural areas in the western part of the country. problems began in may of this year when a single cow was diagnosed as having bovine spongiform encephalitis (bse). this neurological disorder commonly known as “mad cow disease” has effectively shut down the canadian cattle industry for the past four months. hundreds of cattle have been slaughtered and yet none, since that first case, have shown evidence of disease. shipment of canadian beef was halted immediately and has only reopened recently to allow limited consignment to other countries. unfortunately, as one rancher noted in the local newspaper, "the border is more closed than open." interestingly, cattle producers from the united states have indicated an overriding concern for their cattle industry should the border remain closed. the governor of montana and various u.s. senators and human resources that rely on the cattle industry for their livelihood. needless to say, the health care resources of many rural areas have seen the result of the stress brought about by this situation. the dry, hot summer brought huge wildfires that have decimated large portions of the forests of british columbia. thousands of people that live in small communities throughout the interior of that province had to be evacuated. they stood by helplessly as their homes burned to the ground. firefighters from across the country fought the fires to the point of exhaustion with the assistance of the canadian military. the canadian red cross has asked for nurses to help with the casework that surrounds such misfortune. the recruiter i spoke with suggested that nurses are ideal for disaster relief because of their problem solving ability, desire and ability to advocate for clients, and skill at accessing necessary resources in the midst of such devastation. in the past few day’s much needed rain has begun to fall in that part of the country. the expectation is that by sometime in october all the fires will be out. west nile virus, a mosquito-borne disease brought into the united states from africa in the 1960s, has finally found its way to canada’s prairie provinces. saskatchewan has had 68 cases and alberta has recorded 42. the canadian blood service has stopped accepting donations from the area of the country in which i live because of the possibility of spreading the disease through blood transfusions. i am sure by this time you are likely wondering what is the point of my relaying information about this devastation to you. not only are the determinants of health evident in each of the issues faced by canadians this past summer, but all these disasters piled on top of one another demonstrate the resilience of the rural population. this is likely something that has been passed down from previous generations. early settlers followed the course of the rivers west and homesteaded large parts of this country. they confronted an frequently hostile environment and made rural canada one of the mainstays of this country. earlier generations lived through the drought of the depression online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 4 era and survived the economic setbacks of hoof and mouth disease in their cattle. the result of these trials and tribulations was a sense of community that continues to this day. community cohesiveness and resilience is apparent when considering the ways in which individuals, populations, and government have banded together to overcome the variety of problems rural canadians have been confronted with recently. when other countries refused to accept our beef, communities held barbecue's, sold beef for next to nothing from the back of refrigerator trucks, and gave meat to the food banks. as a way to promote beef, the premiers of the prairie provinces, as well as other government officials, served beef on a bun to attendees at a "rolling stones" concert. the resoluteness of individuals and communities became apparent during the mass evacuation of people from the path of the fires. the devastation left in the aftermath of the forest fires has resulted in truckloads of goods being shipped to victims to offset the loss of personal items. others have given up their homes to shelter victims. still others have forfeited vacation time to help out with disaster relief. the government is stepping in to assist those who do not have property insurance and communities are beginning to recuperate. despite the problems encountered over the past several months, i think that those of us who live in western canada have discovered a renewed sense of what it means to be canadian, what it means to be from the west, and most importantly what it means to be rural. we have stuck together through disease, devastation, and pestilence, and we have learned that like our ancestors we too can come back and be even stronger than before. for questions or comments, e-mail me at kcrooks@acd.mhc.ab.ca. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 mailto:kcrooks@acd.mhc.ab.ca 78 barriers to recruiting an adequate sample in rural nursing research shirley cudney, ma, rn, gnp1 carol craig, ph.d., rn, fnp-c2 elizabeth nichols, dns, rn, faan3 clarann weinert, sc, phd, rn, faan4 1 researcher, college of nursing, montana state university, scudney@montana.edu 2 associate professor, school of nursing, oregon health sciences university, craigc@oit.edu 3 associate professor, college of nursing, university of north dakota, elizabeth.nichols@mail.und.nodak.edu 4 professor, college of nursing, montana state university, cweinert@montana.edu keywords: rural, nursing research, sampling, recruitment abstract recruiting an adequate sample in rural nursing research has its unique challenges. in this article, nurse researchers share their adventures in recruiting study participants from four studies in the rural west. distilled from these adventures, the authors present several issues to consider when developing recruitment strategies as part of the overall planning of a rural study. these include: (a) uniqueness of the rural culture and context, higher costs of recruitment, (b) necessity for ruralsensitive recruitment materials, (c) over-sampling, and (d) lack of local research infrastructure. introduction in the quest for well-designed and executed research studies, decisions regarding the most effective designs, measurement tools, and methods of data collection and analysis have been debated and re-debated by nurse researchers over the years. despite the profound influence the issue of recruitment of research participants can have on the success or failure of a project, it has been neglected in these discussions (diekmann & smith, 1989; holden, rosenberg, barker, tuhrim, & brenner, 1993; wray & gates, 1996). the recruitment of participants is a crucial factor in the success of a research project but can be problematic if the target population is not easily approachable. in rural nursing research, the unique characteristics of the rural setting can pose significant challenges to the recruitment process (nichols, 2003). for example, in rural areas, the numbers of those who meet study criteria may be limited and may be difficult to contact in remote locations on ranches and in small towns. difficulty complying with institutional review boards regulations, formidable distances to health care centers, relatively few health care resources, and inadequate transportation systems complicate the process of seeking potential study participants. under these circumstances, creative recruitment methods are required. this article is based on the real life adventures of conducting studies with rural dwellers in montana, idaho, north dakota, oregon, south dakota, and wyoming. the nurse researchers share their challenges in recruiting rural study participants. from these experiences have been distilled several recruitment issues to be considered by researchers planning rural studies. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.montana.edu/wwwnu/ mailto:scudney@montana.edu http://www.ohsu.edu/son/ mailto:craigc@oit.edu http://www.nursing.und.edu/ mailto:elizabeth.nichols@mail.und.nodak.edu http://www.montana.edu/wwwnu/ mailto:cweinert@montana.edu 79 participant recruitment adventures in rural areas recruitment challenges for four research studies form the basis for discussion. some were more successful than others in overcoming recruitment barriers. the lessons learned will be shared, thus meeting the obligation cited by wray and gates (1996) to share professional struggles as well as success stories. the four studies were multi-site team endeavors, funded extramurally, and conducted with adult rural dwellers who lived in communities of less than 20,000, more than 25 miles from major commerce centers, and/or in remote areas on farms or ranches. the titles of the studies were: (a) health care choices (to determine the complementary therapy use of elders); (b) living with cancer: a four state study (to evaluate the psychometric properties of two fatigue scales in persons undergoing cancer therapy); (c) spirituality: rural dwellers and chronic illness (to assess spiritual influences in chronic illness management); and (d) the women to women project (an ongoing research-based computer outreach support and education intervention targeting chronically ill rural women). adventure 1: health care choices (hcc) complementary and alternative therapies have been used by individuals for many years. recent increases in the use of these approaches to manage or prevent health problems have focused on the actual extent of use of such therapies (astin, 1998; eisenberg et al. 1993; eisenberg et al. 1998; harris, 1987; paramore, 1997). national studies of complementary therapy use have been extrapolated to sub-groups, such as rural dwellers, or the elderly, but little research has focused on the rural-dwelling elderly. the research team of four investigators from two rural, northern-tier states was interested in the elderly’s use of complementary and alternative therapies; what factors correlated with such use; what therapies were used; and for what purposes they were used. to answer these questions, the team decided to telephone interview rural elderly in north dakota and montana. the recruitment challenge was to obtain a sample large enough to support inferential statistical analysis as well as to ensure a representative sample. using national survey data to determine expected values, statistical consultation and power analysis determined the necessary sample size to be 320. the specific recruitment goals were: (a) ensuring distribution of the sample across the two states and four different rural economic bases, (b) obtaining the names and addresses of the target population from which to draw the random sample, and (c) enticing randomly selected rural residents to participate in the telephone interview. four strata were developed based on economic and geographic characteristics. from these strata, ten communities were randomly drawn. the number of participants to be recruited from each community was based on the proportion of residents older than 60 years of age in those communities compared to the population older than 60 in the state. names, addresses and other biographical information about heads of households older than age 60 with mailing addresses in the selected communities were obtained from a commercial listing company, senior source. senior source listings were developed from a variety of public sources of information, so were deemed to be fairly comprehensive, although not exhaustive, listings of the target population. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 80 the research team employed a unique approach to gain access to the targeted communities and engage potential participants in the study. initially, a logo and a simple, distinct project name were developed to place on all communications. the individuals who had been selected were given advance information about the study through letters of introduction and explanation, and an article about the impending study was placed in local newspapers. local senior centers were asked to post flyers in prominent places. these promotional activities were timed to take place approximately two weeks before telephone interviewing began in a community. data collection was arranged for an “off” time in the rural cycle of life, avoiding spring planting time, branding, harvest, and round-up times. once the interviews were completed, all those whose names had been drawn were sent a “thank you” letter. one version was sent to those who were interviewed and another to those who were not interviewed, based on the interview quota for that community having been met. a short newsletter reporting study findings was mailed to the participants at the end of the study. to ensure efficient administration of the telephone questionnaires by experienced interviewers, trained students from the social science research institute at the university of north dakota were employed. interviewee participation may have been enhanced because the calls were identified as coming from the research institute at the university of north dakota on caller id systems, thus avoiding confusion with telemarketers. this process of identifying, recruiting, and interviewing participants took almost 18 months. the actual interviews were completed in two one-month time blocks. to obtain 325 completed interviews, 960 letters of invitation were mailed to heighten the visibility of the study within the community. the large number of letters reflects oversampling to ensure adequate and appropriate participation in each target community. the participation rate for those who were actually contacted by telephone was 69.3%, a very satisfactory rate. adventure 2: living with cancer: a four state study fatigue, a subjective experience of tiredness (winningham et al. 1994), is a most troublesome problem for people undergoing cancer therapy. for this reason, the research team tested mail survey measures that had the potential to discriminate levels of fatigue in a population of urban and rural persons with cancer. the aim of the study was to assess the reliability and validity of two scales: (a) the fatigue severity scale (krupp, lauraceae, muir-nash, & steinberg, 1989) and (b) the visual analogue scale for fatigue (lee, hicks, & nino-murcia, 1991). four data collection sites were identified in order to obtain an adequate and diverse rural and urban sample. investigators at the university of vermont, operating base for the study, and maine medical center, portland, maine, were responsible for the urban samples. the rural samples, one predominantly black and the other white participants in a sparely populated area, were recruited by co-investigators from georgia southern university and montana state university–bozeman. at each site, 130 individuals undergoing cancer therapy and 20 individuals without a diagnosis of cancer were to be recruited for a total of 520 and 80 respectively. the present discussion focuses on the challenge of recruiting the sample from a sparsely populated area. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 81 eligibility included rural women and men, between the ages of 30-70, who were able to read and write in english. the montana co-investigator centered her initial recruitment efforts in the largest city in the state since the health care facilities there provided cancer treatment for a very large rural area of eastern montana and northern wyoming. a key clinical nurse contact, known to the montana co-investigator, was the president of the local oncology nurses society, and was also a well-established master’s prepared oncology nurse based at one of the two city hospitals. she routinely traveled with the hospital oncology team to small clinics throughout the area, was enthusiastic about the project, and encouraged other nurses to fully participate in recruiting participants. the oncology nurse and co-investigator worked together on a written data collection protocol to guide the selection of participants and assist clinic nurse collaborators. to determine rural residence, a list of all zip codes in montana and wyoming that did not qualify was also included. after being oriented to the study protocol by the oncology nurse, the clinic nurse approached potential participants at the time of their visit for treatment and, after describing the study, had them sign consent forms and data identification sheets. the nurse then gave a participant the attractive questionnaire packet that was designed following the total design method (dillman, 1978). the packet could be completed while waiting for treatment or filled out later at home, to be returned to the researchers in a self-addressed, stamped envelope. upon receipt of the questionnaire in the research office, a “thank you” letter was sent to the study participant. entering into the recruitment phase of the study, there were a number of reasons to believe that recruiting 130 participants would present few problems. first, the cancer treatment centers in the city had a flow of patients that appeared to have more than an adequate pool of eligible participants. second, the oncology nurse was very energetic and committed to the project, and her presence in the health care community provided legitimacy to the research. third, the recruitment burden on the clinic nurses was reduced by careful preparation of materials and a limited time commitment. fourth, the questionnaire could be completed in about 30 minutes while the participant was waiting at the treatment center. the study was publicized by placing articles in all the daily and weekly newspapers throughout the state and by sharing a one-page description of the study with nursing students and the health care community. with this background, recruitment began in the three metropolitan cancer treatment centers on february 15, 2000, but only 24 useable questionnaires had been received by the end of june, necessitating additional strategies to enhance recruitment. five additional clinical sites in montana and wyoming were added. the montana coinvestigator periodically called or sent notes to the nurse recruiter at each site, thanking her for participating and giving an update on the progress of data collection. in july the co-investigator traveled 1,030 miles to visit each of the data collection sites and spoke personally with the nurse recruiters, expressed gratitude for their help, answered questions, and encouraged them to continue recruiting. when they were called or visited, the cooperating nurses seemed enthusiastic about the project, but often said that they did not have clients who met the criteria or who wanted to participate. an additional strategy engaged two senior nursing students who assisted the nurse recruiters in the city. they communicated with the clinical sites, provided them with online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 82 adequate survey materials, and helped screen the patient lists for potential research participants. at first, the efforts seemed to be paying off, but recruitment again waned. no new efforts were initiated because the window of time for recruitment was closed, the holidays were approaching, and study resources were exhausted. while it was disappointing to collect only 50.7% of the target sample, the response rate was a respectable 84.6%. data analysis was not completely compromised, since data were being collected in three other states. recruitment for the cancer-free group (n=20) was somewhat more successful. the two senior nursing students contacted high school teachers, churches, conducted blood pressure checks at a small rural grocery store where they distributed the survey, worked with other students who had contacts in rural communities, traveled to two small communities in a 50 mile radius of the city, and used word of mouth. they were successful in getting 32 completed questionnaires from the 38 which were distributed, for a response rate of 84.2%. adventure 3: spirituality: rural dwellers and chronic illness spirituality is an overarching human characteristic, an integrating force that allows us to be most fully human. spirituality appears to have an effect on helping people to heal, to manage illness, and to find comfort during illness (colantonio, kask, & ostfeld, 1992; idler & kasl, 1997; morris, 2000 ). the extent of the connection for rural people, who have greater risk for poor outcomes, with chronic illness and spirituality is unclear. the chronic illness and spirituality project was a pilot study with a three-fold purpose to: (a) examine the association between spirituality and health behaviors, quality of life, and illness management; (b) explore the nature of spirituality among ruraldwelling people with chronic illness; and (c) investigate the psychometric properties of a new instrument to measure spirituality. the research team had a history of working with rural dwellers and was interested in exploring spirituality. their definition of “spirituality” was: “a sense of meaning and purpose in life; connection to others, a higher power, or to nature; and a commitment to something greater than the self” (craig, 2001). participants were rural dwellers in oregon and montana, 18 years or older, with a chronic health condition, defined as any prolonged illness that does not resolve spontaneously and is rarely cured completely. a sample size of 240 was determined by power analysis. the recruitment challenge was to identify and enroll a rather large number of people with chronic illnesses who were living in very rural places. parish nurses and church leaders seemed logical groups to approach because they had an interest in spirituality themselves. senior centers were likely places where people with chronic illnesses could be found in large numbers. a flyer was developed with a description of the study and 204 of them were sent with a cover letter and business cards to rural parish nurses, churches, and senior centers in montana and oregon. press releases were sent to religious newsletters in both states. individuals could volunteer by calling a toll-free number. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 83 the response was dismal. recruiting began in september, and by early november, only 12 people had agreed to participate. because funding was limited, e-mail was used to send a message to 740 parish nurses. a press release was also submitted to all rural newspapers in both states, which generated a modest response. by february, 64 participants responded, but still far from the anticipated goal of 240. next, telephone contacts were made with parish nurses, spiritual leaders, senior centers, and leaders of self-help groups, and the press release was sent to newspapers in larger towns, with the reasoning that rural residents often read papers from larger cities in their states. personal contacts were not productive, but the newspaper response was encouraging. after re-evaluation, the research team decided that the prominent use of “spirituality” as the first word on news articles and letterhead might be discouraging people from participating. the news articles were rewritten with “chronic illness” as the headline and “chronic illness” was used in the letterhead instead of “spirituality.” this strategy increased response to some extent, but recruitment had to be terminated because of financial and time limitations. the recruitment period ended with a total of 111 participants. adventure 4: the women to women project for eight years, the focus of the women to women project (wtw) has been the testing of a computer-based intervention for the delivery of social support and health education to rural, isolated, middle-aged, chronically ill women and evaluating its impact on the women’s potential to successfully adapt to their long-term illnesses (cudney & weinert, 2000; weinert, 2000). wtw is being implemented in two phases. in the first four years (phase one), 150 women were recruited to participate in the testing of a computer support group and off-line health education experience (five cohorts of 30 women each). in phase two, the study was revised to include an interdisciplinary research team, expand its scope from state to regional, and use an internet-based health education experience. based on a 20% attrition rate in phase one of the project, the sample size was increased to 60 women per cohort (three groups of 20 per cohort) in phase two. the recruitment challenge for wtw was finding a sufficient number of women living in remote areas of five western states that met study criteria and were willing to commit to participate for 24 months. inclusion criteria were: 35-65 years of age; chronic illness; and residence in a rural area of montana, idaho, north dakota, south dakota, or wyoming. as recommended by steger (1997), developing a protocol that described the recruitment procedure, time-line, and a checklist for recording the dates recruitment activities were initiated and completed was an essential first step needed to keep track of the many contacts involved. since the procedure has been repeated seven times in both phases of wtw, and one more recruitment effort is in progress to complete the study, this protocol has proved to be invaluable. recruiting the participant sample was initiated by one designated research team member, six to nine months in advance of the commencement of the computer phase of the project. it took considerable time to make all the necessary contacts through telephone calls, e-mail, fax, and/or regular mail. recruitment efforts were facilitated through newspapers, voluntary agencies (arthritis foundation, national multiple sclerosis society, american diabetes association, online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 84 american cancer society, and american heart association), state agricultural extension services, schools of nursing, public and professional libraries, and word of mouth, for example, former participants in wtw and nursing students. an article in the montana nurses’ association “pulse” reached every nurse in montana, and a recruitment notice in the wtw project biannual newsletter was mailed to all current and past participants, professional colleagues, and “friends” of the project. the newspaper announcement was disseminated to all daily and weekly newspapers in the state. in some states, the extension service offices distributed project information by contacting each of their local agents through e-mail list serves or mailing each an informational flyer. they also put an announcement in the pbs grapevine of their state. some agents, who had local radio programs, broadcasted the information. voluntary agencies participated in a variety of ways. most included an item about wtw recruitment in their periodical newsletters. some agencies were willing to participate in a personalized letter campaign, a strategy recommended by diekmann & smith (1989), although it is costly. in the most recent recruitment effort, one agency sent 183 letters netting four responses and another sent 361 letters with 18 responses, at a cost of $11.18 per response. other agencies posted wtw information on their web sites or placed wtw information in their agency resource book. consistent with studies reported by topp & bawell (1992) and wray & gates (1996), the best response came from newspaper publicity, representing 42% of the women recruited for the most recent two cohorts. voluntary agencies’ newsletters and personal letters were next with 25%, and the rest were evenly distributed between health professionals (14%), word of mouth (14%), and 5% unknown. discussion the importance of the sample to the credibility of the study findings demands that attention be paid, not just to how many participants the researcher must engage, but strategies the researcher can use to successfully recruit them. from the four recruiting “adventures” that have been presented, it is apparent that there are several issues to consider in developing recruitment strategies as part of the overall planning of a rural study: uniqueness of the rural culture and context, higher costs of recruitment, necessity for rural-sensitive recruitment materials, over-sampling, and lack of local research infrastructure. uniqueness of the rural culture and context at the outset, the researcher must internalize an appreciation for the uniqueness of the rural culture and context. these include the concept of “insider vs. outsider” and recognition of rural life cycles. “insider” vs. “outsider.” long and weinert (1989) described rural dwellers as resistant to help or services from “outsiders” and more readily responsive to those “who know us.” in rural areas, the researcher may be seen as an “outsider” and techniques are needed to reduce this perception. familiarity with the setting as demonstrated in the researcher’s timing, language, and contacts can help reduce suspicion. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 85 the “living with cancer” study applied shreffler’s (1999) suggestion that involving local community leaders throughout the recruitment process, for example, incorporating their input into recruitment strategies. she encouraged meeting with them on a regular basis, and maintaining contact by phone and mail throughout the study, to help them develop ownership in the outcome, as well as minimize the “outsider” perception of the researcher. nurses practicing in rural areas need to be enlisted as key members of the research team. their presence provides a bridge between “insider” and “outsider,” and their enthusiasm can add momentum to the recruitment process and successful implementation of the study. useful as these approaches are, it must be recognized that they also present inherent hindrances to the researcher’s attempts to provide ongoing supervision and encouragement in distant data collection sites. in this project, the clinic nurses and students were not involved in the study protocol until after the study was funded. commitment by these “insiders” could have been enhanced by including them in the actual development of the proposal or by inviting them to serve as experts in the establishment of the study protocol. cycles of rural life. recognition of the importance of the participants’ physical and social environment is essential. this insight was illustrated by the hhc study when it ensured that the research demands on the participants’ time were not competing with rural life or work cycles. higher costs of recruitment the “running out of resources” difficulties of adventures #2 and #3 can be often be offset by careful planning in advance for the time and budget required for participant recruitment. the challenge of recruiting an adequate sample from small, geographically dispersed populations necessitates that proposals be crafted to convince reviewers who may not be familiar with rural research that more time and resources must be allotted for the recruitment phase. recruitment almost always takes longer and costs more than expected because participants are difficult to locate when they are scattered over thousands of miles. the hcc study successfully overcame this hurdle by using a commercial listing that met study criteria. the other “adventures” were less fortunate. enlisting the aid of rural clinics, parish nurses, churches, and senior centers was largely unproductive and finding sufficient numbers of chronically-ill women living in five sparsely populated western states took months of intensive recruitment effort. blending with the rural culture and finding adequate samples in rural areas remain a challenge and reinforce the fact that research in the rural context is unique. developing rural-sensitive recruitment information developing recruitment information that is sensitive to rural dwellers helps to engage potential participants. the examples presented here support dillman’s (2000) claim “that people must understand clearly what is wanted of them if they are to respond” (p.13). most people do not understand health care or research language, so word choices should reflect concepts and words that are commonplace and not suggestive of taboo subjects. the experience with the term “spirituality” is a case in point. highlighting the online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 86 chronic illness aspect and maintaining spirituality as a secondary focus was a more fruitful approach. another strategy is to develop a logo that reflects the rural culture and to use a simple title to help establish the identity of the project. follow-up communications such as “thank you” notes, as was done in all the studies, provide personal attention or social exchange (dillman, 2000) that can be important in maintaining the individual for the duration of the study, as in wtw, or as a potential participant for future studies. over-sampling koop (2001) emphasized that recruiting research participants in sufficient numbers is crucial to the success of a research project, so over-sampling is a useful approach when working from listings of names. the strategy used in the hcc study was to sample three times the desired number of participants. this was critical in communities with small target samples because it facilitated data collection when individuals refused to participate, when telephone numbers were incorrect, or if people had moved or died. the very nature of “sparsely populated” in conjunction with the focus on obtaining rural samples for research means that each potential subject becomes increasingly precious and potentially over-studied. lack of local research infrastructure rural researchers face problems when rural study areas lack local research infrastructures that provide for institutional review and comply with federal regulations. recent changes in federal regulations dealing with human subjects are making the recruitment process in rural settings even more complex. by federal mandate, all health professionals who are participating in any aspect of a research study, including recruitment, must complete an online in-service study unit entitled “human participant protections education for research teams.” most health professionals in rural settings have not completed this study unit and, therefore, are not eligible to assist researchers in the recruitment process. to add to the problem, small health care facilities do not have an institutional review board to approve research projects. this, in effect, negates some of the strategies discussed earlier related to the involvement of key local health professionals and health care units. the federal mandate is a relatively new challenge that is being faced by rural researchers, such as the wtw team, in ongoing recruitment efforts. recruiting participants for research studies is always challenging. the very nature of rural areas--sparsely populated, long distances, remote locations, the rural ethos– present unique challenges to the research team. appreciation of the rural culture, careful planning, an adequate budget, sufficient time, creative recruitment strategies, and awareness of the potential stumbling blocks are the ingredients necessary for success. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 87 notes health care choices (hcc) was funded by nih/office of complementary and alterative medicine (1r15at00095-03). the “living with cancer” fatigue measurement study was funded by nih//national institute of nursing research (1r15nr04872-01). funding for the spirituality study was provided by the center for research on chronic health conditions in rural dwellers, nih/national institute of nursing research (1p20nr07790-02). funding for women to women, phase one, was provided by the u.s. department of agriculture, nih/national institute of nursing research, sc ministry foundation, american cancer society, u.s. west, montanans on a new trac for science, montana state university college of nursing, arthritis foundation, and montana chapter, national multiple sclerosis society. phase two was funded by nih/national institute of nursing research (1r01nr07908-01). references astin, j. 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(1996). problems of recruiting participants for nursing research: a case study. ntresearch, 1, 366-373. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9403524 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2062970 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2772454 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11565405 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9095565 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8139999 health care choices: a student's perspective 44 health care choices: a student's perspective kelly coloff, rn1 1 kalispell, mt, kellycoloff@yahoo.com key words: nursing research, health care, complementary therapies, student abstract the purpose of this paper is to describe student experiences as a research assistant on the health care choices project, a study of the use of complementary therapy by older adults living in rural areas. the goal of this project, headed by a doctorally prepared nurse faculty member, was to “explore the use, cost, and satisfaction with complementary therapy by older adults in rural communities” (shreffler, 1999). the research group recruited both undergraduate and graduate students from three university campuses to participate in the project. undergraduate students were primarily recruited to assist with telephone interviewing, piloting, media campaigning, and to further their own academic experience. graduate students participated in data collection, data processing, and data analysis and were able to apply their work to degree completion. introduction the purpose of this paper is to describe student experiences as a research assistant on the health care choices project, a study of the use of complementary therapy by older adults living in rural areas. the goal of this project, headed by a doctorally prepared nurse faculty member, was to “explore the use, cost, and satisfaction with complementary therapy by older adults in rural communities” (shreffler, 1999). the research group recruited both undergraduate and graduate students from three university campuses to participate in the project. undergraduate students were primarily recruited to assist with telephone interviewing, piloting, media campaigning, and to further their own academic experience. graduate students participated in data collection, data processing, and data analysis and were able to apply their work to degree completions. health care choices study purpose as stated previously, the purpose of the hcc project was to better understand the use, cost, and satisfaction with complementary therapies in rural adults. the literature review and grant proposal were completed before student assistants became involved in the project. although students involved in the project were not able to see this process first hand, review of the pertinent project literature and the proposal provided orientation to the applied research tools. the researchers worked constantly to maintain the project within the original aims presented in the approved grant. standard reporting intervals were in place to ensure the funding agency that the project money was being spent appropriately and that the research was progressing in a timely manner. rules based on ethical standards applied to all aspects of the research process from recruiting student 44online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 mailto:kellycoloff@yahoo.com 45 volunteers to ensuring confidentiality in human subjects testing. for example, student interviewers went through online training to ensure proper qualifications for involvement with human subjects. interview questions were focused on types of complementary therapies, as well as estimated costs of each therapy. the study explored both providerbased complementary therapies such as chiropractors, physical therapy, acupuncture, accupressure, as well as self-directed practices not based on provider direction such as use of vitamins, herbs, and copper band. researchers researchers from two universities were involved in this research project giving the interpretation of the data a broader perspective for rural adults. four nursing professors, two representing each university, collaborated on this project. all four researchers worked on the grant proposal, human subjects verification, research tool, data collection, data analysis, and conclusions. study population although one university is an urban center in the state with a population of approximately 78,000, it is surrounded by very rural communities. this intermixing of urban and rural communities provided me with insight into a large and diverse nursing client base. the study population for the hcc project consisted of adults age 60 or older living in rural areas. ten research sites in each state were randomly selected with the assistance of a statistician. potential participant names were purchased from a national name supplier and then were randomly selected from each town for the study. this method of acquiring names proved to be only somewhat reliable. the pilot interviews revealed that many individuals called were under the age of 60 and did not meet the criteria for participation in the project. several individuals contacted for the project were curious about how their names were chosen. whereas, consumers often expect telemarketers to have lists of names, it is less common to have research groups contact a person via a home phone number for a lengthy interview. the study group included both males and females, married, single, or widowed. the primary criteria were that participants be age 60 or older and live in a rural area. as secondary criterion, all participants were required to have telephone service because telephone interviewing was the mode of data collection. the sample group consisted of 320 rural dwelling older adults, 160 living in each state. no assessment was made regarding the amount of time participants had lived in their communities. initially, rural communities less than 20,000 residents were randomly selected equally from eastern and western portions of both states. from these communities, names of individuals older than 60 years of age were randomly selected to serve as possible participants in the project. an excess number of individuals were initially selected to allow for disqualification, refusal, and unavailability of participants. 45online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 46 media campaign before piloting began, a media campaign using flyers was organized and it was used throughout the data collection process. the purpose of the media campaign was to increase community awareness of the hcc project. these flyers were meant to inform people of the study goals and process and to encourage participation to benefit their community. flyers were sent to churches and senior citizen centers with letters encouraging these facilities to post the flyers. during the beginning stages of the project, creating the media campaign was the focus of this student’s involvement. the student assisted in writing letters to local newspapers which included a description of the study as well as a statement of implications of the study for the community. these letters inquired if the newspaper would consider publishing a short excerpt about the study in the local newspaper. locating and contacting these newspapers was often a challenge because many of these rural communities did not have their own daily paper but rather a countywide newspaper. as a result of these letters, many of the newspapers published the entire description that was provided. the newspaper articles contained similar information to that in the flyers. letters were also sent to the personal address of each randomly selected individual. these letters were sent out two to three weeks before the interview calling began. these letters were intended to provide advance notice to possible participants that they might be contacted for an interview. these letters also reviewed the process and purpose of the study and assured confidentiality. after interviewing was completed in each community, thank you letters were sent to all people contacted by telephone regardless of their decision to participate or decline. project piloting/interview tool revision initially, students piloted the interview tool with their own family members who were over the age of 60. the purpose of these pilot interviews was primarily to detect major problems with the wording and sequencing of questions. this process eliminated several questions and required laborious rewording of others. the second phase of piloting focused on an actual, randomly selected community. the appropriate number of interviews were completed with participants in this community. this piloting process was completed primarily by students. the most important aspect of this piloting was documenting each call and the difficulties encountered. during this phase of piloting, the age discrepancies (people in the sampling frame younger than 60 years old) were noted and the name supplier was notified to make the appropriate corrections before actual interviewing began. methods telephone interviewing was the method of data collection used in the hcc study. the interview tool included a large section of questions on the use, cost, and satisfaction with complementary therapies. many of these questions were developed by the research team, but some pre-written and tested scales were incorporated for questions specifically relating to spirituality and health-related quality of life. demographic 46online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 47 questions were included at the beginning and end of the interview. as well as collecting necessary information, these questions provided a comfortable introduction and conclusion to the interview process. after initial piloting with family members and friends of the research group, the questions were revised, reworded, and rearranged to provide the optimal sequence of questions to reduce confusion and expedite the interviewing process. since so many questions were deemed necessary in the interview, each interview took approximately 2030 minutes. the interview length proved to be a deterrent for a portion of the selected interviewees. the researchers expected that rural adults would be difficult to contact during mid-day hours, so evening hours were chosen for most interview calls. the researchers considered harvesting, planting, and other farming and ranching seasons when planning the timing for interviews. results difficulties encountered: the “real world” of research student recruitment was extremely difficult for all four of the primary researchers. interest seemed low to begin with and many students were not willing to stick with the project for any length of time. the busy schedules of nursing students may have made it difficult for these students to consider volunteer work on projects. with the diversity in the nursing field and the many opportunities for clinical learning, lack of interest in specific research topics may have been related to the student’s focus on another area of nursing. lack of undergraduate student interest posed a significant problem in completing the required number of interviews. eventually, a survey research service at one university was used to complete the interviews in both states for a set fee per interview. due to the need for conference calling between three campuses, time restraints and scheduling also posed obstacles for this research team. despite scheduling meetings with four very busy professors, the conference calling in itself was a major challenge. the principal investigator provided an agenda via e-mail prior to each meeting to focus the group and expedite the meetings. due to the distance separating the investigators, they chose conference calling as their primary method for communication. conference calling allowed more direct communication with all researchers at one time and was more cost effective than traveling between research sites. problem solving was difficult in conference calls with four or more individuals voicing their opinions. each person had to adapt to different cueing for these calls in order to prevent interruption and frustration of all members involved. by sticking to the agenda and supplementing the conference call meeting with e-mails and one-on-one phone calls, the study proceeded relatively smoothly. this use of technology showed the trend in nursing as well as other health-related research. many difficulties were encountered using telephone interviewing as the data collection method. first, a machine answered many of the telephone numbers called and despite leaving several messages, no person was ever contacted. with new technology such as caller identification, people in general are more prone to screen their calls and ignore all unknown callers dismissing them as telemarketers. even when individuals 47online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 48 were contacted by telephone, many were unwilling to participate especially when they were informed of the length of the interview. some people were offended by receiving a call from a stranger requesting information from them. another problem with telephone interviewing was the time required for each interview, which limited the number of interviews that could be completed within a time frame. one interesting fact is that the majority of people stated they had never received the informational letter or received it but did not remember the contents of the letter. positive aspects of the hcc study the study in general focused on a group of individuals, rural adults, not previously singled out for study on this subject. the two-state involvement provided a broader rural perspective for information and improved generalization of results. although telephone interviewing required patience and was both stressful and anxiety producing, talking with willing participants was quite rewarding. many were very interested in the study, providing information that was accurate and more than the minimum that was requested. they asked questions and offered information of interest both useful to the study and helpful in inspiring the students’ future telephone calling efforts. nursing students had a chance to understand the rewards of personal interaction with people in a different context than providing direct nursing care. discussion the benefits of working on this research project applied to the student experience as well as clinical practice after graduation. although bsn programs typically include a research course, the main focus is on research as an adjunct to evidence-based practice. the emphasis in such courses is on the research process, critiquing research articles, and applying them to clinical practice. although this is valuable, direct involvement in a university-based research project allows for an in depth look at the research process. participation in the research experience promoted an increased awareness of research and how it can be applied to clinical practice. also, being aware of complementary therapy use is very important in understanding all of the processes involved in sickness and healing for patients. for example, employment in a semi-rural setting has revealed that the vast number of people use complementary therapies, most often vitamins and herbal supplements. often the use of these remedies is not disclosed unless addressed directly by the nurse. understanding that there is high volume use of complementary therapies in all age groups highlighted the need for review of alternative therapy use when taking patient histories. increased awareness of this topic will encourage nurses and nursing students to include questions about complementary health care use in patient history taking. in conclusion, undergraduate student participation in research projects is a valuable experience for both the student and the research team. the experience of being part of the health care choices project improved this student’s understanding of research and its application to practice. it also enriched the research project by adding the fresh and creative perspective that undergraduate students can offer. 48online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 49 acknowledgments i wish to extend my gratitude and thanks to jean shreffler-grant, phd, rn for her help in writing and editing this manuscript and for her encouragement in pursuing my nursing career. references shreffler, j., weinert, c., nichols, e., & ide, b. (1999). complementary therapies in rural areas. grant 1r15-at095-01, national center for complementary and alternative medicine, national institutes of health. 49online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 p02 pams editorial 6_6_11final 2
 
 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 editorial thank you pamela stewart fahs, rn, dsn, editor thank you is a simple expression of gratitude that at times like these seems inadequate; yet is heartfelt and so deserved. i want to thank dr. jeri dunkin for her extraordinary efforts as editor –in – chief over the last decade. the online journal of rural nursing and health care is an outstanding journal and it reflects the leadership in rural nursing by jeri dunkin as well as her commitment to excellence for the journal. jeri and i have been working together over the last few months to make this transition as smooth as possible. i hope that the transition will be seamless for you, the reader. however, the reality is that there is a rather large learning curve to taking on this endeavor, so i beg your patience and understanding as i move into a new role and the journal moves into a new home at the decker school of nursing (dson), binghamton university. as one of the reviewers noted when she learned i would be taking on the editorship of the journal “you have some big shoes to fill in following jeri”. i completely agree. i have discovered that it takes many people to make this journal a reality. i want to thank those who review for the online journal of rural nursing and health care, their services are invaluable not only to the journal but to the discipline of nursing and those that we serve. even in my short time moving into this role i have found that the reviewers give of themselves every time they review a manuscript, their comments and support of the authors is amazing. i want to thank dr. steven maccall from the university of alabama for his assistance in helping us learn the “nuts and bolts” of publishing online. i also want to recognize the work of erin ruston, associate librarian, binghamton university who will be the new managing editor for this journal. i would also like to thank the administration and staff of the dson for their support in moving the journal to binghamton. dr. joyce ferrario, dean was instrumental in bringing the journal to binghamton university. dr. mary ann swain, professor and director of the phd in nursing, currently the only phd in nursing focused on rural nursing, was able to garner funds to purchase a new server and upgrade the software needed to publish this journal. my thanks go also to cynthia altmansberger, assistant dean, scott pionteck, sr. program analyst, information technology services, and brenda holcomb. secretary for their assistance in actually making this all happen. finally i want to thank the board of directors of the rural nurses organization for their support and guidance during this period of transition. i want to assure our readers that the rural nurse organization (rno) and the editorial board of the journal remain committed to keeping an open source journal, which is freely accessible by all and focused on the nursing and health care of rural populations. my goal is to uphold the quality of the journal that has been obtained during the tenure of dr. jeri dunkin and hopefully contribute to this great journal as we move forward. i look forward to meeting many of you october 5, 6, and 7, 2011 at the rural health conference co-sponsored by the rno and the decker school of nursing entitled the canopy of health care for rural and underserved populations: strengthening the root system. it is an honor to be the new editor for the online journal of rural nursing and health care. empowerment in adolescent obesity: 63 empowerment in adolescent obesity: state of the science jill cochran, msn, rn-c, fnp1 1quinwood, wv, jicochran@suddenlink.net keywords: empowerment, self-esteem, motivation, goal directed activities, enabled potential, adolescents, obesity, rural, culture abstract obesity rates have dramatically increased across the nation. rural areas, however, have a higher rate of obesity and physical inactivity than urban areas. interventions for obese adolescents require change behavior and motivation. one factor involved in this process is empowerment. empowerment may be defined differently by disciplines, yet the overall meaning is similar. self-awareness, enabled potential, and outcome related activities are defining attributes of the concept. this paper provides a conceptual analysis of empowerment through the literature, examines methodological tools and issues, and describes empirical aspects of the concept. a literature review of the aspects of empowerment and its relationship to obesity shows that low self-esteem and obesity are related. more research is needed to adequately understand how self-esteem, motivation, and goal-directed behavior impact the process of reducing obesity in the adolescent population. the cultural definition of empowerment must be considered to adequately understand the influence of the concept in adolescent weight reduction. introduction obesity is a significant health concern for children and adolescents in the united states. since 1999, obesity has increased in children and adolescents from 13.9% in 1999 (ogden, flegal, carroll, & johnson, 2002; de ferranti et al., 2004) to 15% in 2001-2003 (ogden et al., 2006b). this latest reporting period of 2003-2004 finds that 17.1% of children and adolescents 2-19 years of age were overweight defined as body mass index (bmi) ≥95th percentile of the age specific bmi-for-age growth chart (kuczmarski et al., 2000; cdc national center for health statistics, 2004; ogden et al., 2006a). rural areas have a significantly higher population of obese children than urban areas. in rural areas, the obesity rate is 16.5% compared to an urban rate of 14.8%. the highest rate of obesity in the nation are found in the clustered southern states of west virginia, kentucky, tennessee, north caroline, texas, south carolina, mississippi, and louisiana (liu et al., 2007). the majority of these state are in the appalachian region (appalachian regional commission, 2007). physical inactivity and obesity are strongly related. about 2 out of 3 children in the united states meet the physical activity requirements of at least 20 minutes of vigorous activity 3 or more days a week (sallis & partick, 1994; liu et al., 2007). rural areas have a substantial lower rate of physical activity the urban areas (p< 0.05). in urban areas, 29.3% of children meet physical activity requirement. in rural areas, only 25.4% of children meet the same requirement (liu et al., 2007). another correlating factor for obesity is poverty. in both rural and urban families, obesity decreased as income increased. children from families with a poverty rating of 100% below the online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 mailto:jicochran@suddenlink.net 64 federal poverty level (fpl) had an obesity rate of 21.3% compared to 10.2% of children in families at or above 400% fpl (liu et al., 2007). rural areas, especially appalachia have a higher rate of poverty. in appalachia states the poverty rate is 14.3% compared to 12.6% nationally (u.s.census bureau, 2007). consequences of obesity in children, risk factors for heart disease, such as high cholesterol and high blood pressure occur with increased frequency in overweight children and adolescents compared to children with a healthy weight. overweight adolescents have a 70% chance of becoming overweight or obese adults. this increases to 80% if one or more parents are overweight. the most immediate consequence of overweight as perceived by the children themselves is social discrimination associated with poor self-esteem and depression (carmona, 2004). obesity is not just a cosmetic problem. obesity is accompanied by a host of co morbid conditions that are plaguing our youth. problems of adult obesity, elevated cholesterol and triglycerides have now invaded the ranks of younger patient (demerath et al., 2003) adult onset diabetes has dramatically increased in this population (rosenbloom, joe, young, & winter, 1999). the developmental state of adolescents creates difficult challenges for healthy teens. adding the insult of obesity and comorbid conditions to this stage of life creates new challenges. in appalachian culture, health promotion and disease prevention are not relevant until the process interferes with life processes (cochran, 2005). many parents do not perceive their child as obese or see it as a problem (strauss, 2000). facilitating healthy behaviors is a continued challenge to nurses. health problems are complex and the interventions must be appropriate to the client and the culture. empowerment is frequently associated with changing health behaviors. the concept of empowerment has continually surfaced in the literature. this paper will analyze the concept of empowerment as related to adolescent obesity and synthesize conceptual, methodological, and empirical literature related to the concept. empowerment: conceptual analysis aim of the analysis: empowerment the power of a concept resounds in the common use and understanding of the term within a culture (rodgers, 1989). the aim of this analysis is to examine empowerment, its defining attributes, and how the concept is used in the prevention and treatment of adolescent obesity. it is the analytical and clear analysis of the concept that builds and powers the basis of nursing knowledge. analysis of the concept through the nursing literature provides credibility of the nursing profession and allows the concept to be operationalized for research and practice. a literature search was conducted using academic search elite; agricola; alt healthwatch; applied science & technology abstracts; biomedical reference collection: comprehensive; cochrane controlled trials register; cochrane database of systematic reviews (cdsr); pre-cinahl; cinahl; medline; clinical pharmacology; database of abstracts of reviews of effectiveness; eric; women's studies international; health source: nursing/academic edition; health source consumer edition; mla international, bibliography; online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 65 psycarticles; and humanities abstract. search terms included empowerment, self-esteem, adolescents, obesity, obese, weight loss, weight reduction, motivation, and outcomes. sixty-four articles were selected based on relevance of the topics. empowering is described as giving authority or power to someone. this represents a passive acceptance. it is also defined as a method of inspiring someone or giving self-esteem (soukhanov, 2002). the thesaurus suggests synonyms such as authorize, allow, sanction, make powerful, and to give power (mccutcheon, 2003). related concepts are: self-directed, motivational, autonomy, responsible, advocacy, accountable and powerful. a broader definition describes empowerment as a process by which people, organizations and communities gain mastery over their lives (rappaport, 1984). empowerment is cultivated by the effects of individual demand and a collaborative effort. it is based on the individual needs of the person (kieffer, 1983). in nursing, empowerment represents a social process of recognizing, promoting and enhancing the client’s abilities to meet his/her own needs. it involves mobilizing the necessary resources to feel in control of their own lives (gibson, 1991). in a study of public health nurses, empowerment was conceptualized as an active, yet internal process of growth (falk-rafael, 2001). empowerment is a goal of nursing care. it may involve exposing power imbalances that prevent the patient from meeting his or her full potential (butterfield, 1990). the nurse enables the client to realize the ability he or she possesses to exercise inner power. caring and empowerment are closely linked in the process of nursing (clifford, 1992). thee levels of empowerment are: individual or psychological, organizational, and community. at each level, empowerment is defined and applied to various settings. the definitions of empowerment are specific to the context of the level in which they are utilized. individual or psychological empowerment draws on the work of carl rodgers and views power as a personal attribute (rogers, 1977). this personal power grows with self-understanding. change must occur in psychological empowerment on an individual level. other models see the change involving beliefs and attitudes as well as knowledge of resources and the ability to be an effective change agent (zimmerman, 1995). individual empowerment has a separate connotation from that of organizational and community empowerment. it involves individual competence, self-esteem, skill development and participatory behaviors (wallerstein, 1992). at the organizational level, empowerment means creating and maintaining a work environment that involves the values that facilitate the employees’ choice to invest and own personal actions which result in positive contributions to the mission of the organization (tebbitt, 1993). kanter (kanter, 1993) theorized that power in organizations was derived from the structural conditions in the work environment, not the individual or socializations effects. empowerment is a means of increasing overall organizational performance by allowing every person to contribute. in total quality management, employees are given the opportunity to solve problems and assist with decision making processes through quality circles in order to increase empowerment (randeniya, baggaley, & rahim, 1995). community empowerment describes the synergy that results from people and communities working together for a common goal. the combined efforts result in a greater production than an individual production (katz, 1983b; gilbert, 1995). this model describes evenly distributed resources which, in turn, creates collective action (katz, 1983a). in nursing, community empowerment is a middle range theory developed to give direction to improving health in the communities (persily & hildebrandt, 2003). this theory involves a process model based on shared information, interaction, and partnership (persily et al., 2003). online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 66 empowerment: definition, attributes, and uses based on the definitions in the literature, empowerment can be defined as an inner awareness of enabled potential resulting in outcome directed activities in the person-health environment. the defining attributes of empowerment are: inner awareness, enabled potential and outcome directed activities. each of these attributes represents a cascade of thoughts, theories, and actions that are reciprocal and interrelated. inner awareness. inner awareness symbolizes multiple behavioral traits identified as selfesteem, (rosenberg, schooler, schoenbach, & rosenberg, 1995), self-actualization (hogan & mcwilliams, 1978), and self-concept (noppe, 1983; planinsec & fosnaric, 2005). early theories of self-esteem emerged in the 1800’s and have held fast in the literature. philosopher, william james (1890) defined self-esteem as somewhat of a balance between reality based attainment relative to one’s goals and aspirations (coopersmith, 1967). rosenberg’s work with self-esteem described the principals of self-esteem formation as reflected appraisal, social comparison, and self-attribution (rosenberg, 1979). self-esteem may be global or specific. global refers to the attitude toward self as a whole. specific self-esteem deals with the facets of self-concept. a person may feel good about themselves in certain aspects, but not others (rosenberg et al., 1995). more recent studies describe self-esteem as a function of development. studies reflect that evaluative judgments become less positive as children move into preadolescent years (pomerantz, ruble, frey, & greulich, 1995b). self-esteem, it is a term that inspires a thought process related to how we value ourselves. enabled potential. the human potential is an ever fluent energy source that rises from a cellular level to a social and psychological level. the literature sees potential as unfolding action often triggered by multiple stimuli. whether it be an immune response (cochran, 1995), action potential (graham & blair, 1947), developmental (raju, ariagno, higgins, & van marter, 2005), religion, (poloma & pendleton, 1989) , the result is change. what provides the motivation to change? self-determination theory sees behavior as motivated by needs for autonomy, competence, and relatedness with others (deci & ryan, 1980b) intrinsic motivation is key to this theory. self-determination theory focuses on how individual motivation promotes development and persistence in an activity by personal choice without reward. when activities are not freely chosen, they are extrinsically motivated (frederickrecascino & schuster-smith, 2003). human potential and human behaviors are influenced by motivation that is internal and external. motivational theories are well studied in literature. in health care, motivation is applied to health promoting and disease preventing behaviors. in nursing, it involves the interaction of the nurse with the client to facilitate change or restoring of health (ball & cox, 2003). clients hold the ability and energy potential to change behaviors. the nurse provides the stimulus by education, self-esteem training, or the use of behavior modification. outcome directed activities. outcome directed activities are the result of an empowered individual. the components that lead to the desired outcome may be the result of a positive selfesteem and an enabled or activated potential. goal striving (bagozzi & warshaw, 1992), selfefficacy (bandura, 1986), self-determination (deci et al., 1980b) are all examples of theories that encompass the essence of activities performed by the individual related to a goal. the goal related outcomes described in the given definition of empowerment are health related and often steered by the nurse. the theory of planned behavior (ajzen & fishbein, 1969) includes attitude, intention, control, subjective norms related to an action. in weight loss, this theory considers attitude and personality as predictors of success (schifter & ajzen, 1985). online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 67 the interactions of these concepts are continuous and interdependent on the other. each attribute could be the antecedent or the result of the other. self-esteem is influenced by the person’s ability to understand and complete the activities related to the desired outcome. enabled potential depends of self-esteem to assert the energy needed to perform the task. outcome related activities intertwine the other concepts and are not only the end result, but also the stimulus for self-esteem and enabled potential. the flowing, yet sometime turbulent path of empowerment carves behavioral changes and integrates new activities as a way of life. empowerment and its defining attributes have matured and evolved through the literature. the use of the terms in nursing literature is vast, especially in health promotion and chronic disease. empowerment is used both in the hospital and primary care settings. it can be applicable to the patient, the nurse, the employer, and the community. methodological analysis empowerment and its defining attributes have been easily translated in practice. multiple tools measure empowerment. empowerment scale measures individual (spreitzer, 1996), organizational (matthews, diaz, & cole, 2003), and community empowerment (israel, checkoway, schulz, & zimmerman, 1994). however, this methodological analysis will focus on tools that reflect self-esteem, enabled potential, and outcome related activities. each of these elements represents part of a process and must be measured accordingly. implications for practice are identified in each aspect of the definition. self-esteem five tools to measure self-esteem appeared frequently in the literature. they are: culturefree self-esteem inventories for children and adults (sei) (battle, 1997), coopersmith selfesteem inventories (csei) (coopersmith, 1967), tennessee self-concept scale (tscs) (fitts, 1965), the piers-harris children’s self-concept scale (cscs) (piers, 1984), and rosenberg selfesteem scale (rse) (rosenberg, 1965). these instruments are self-report instruments and each tool may be used in children. these instruments measure global self esteem. while each instrument may be used in children, coopersmith self-esteem inventories and culture-free self-esteem inventories are designed for the youngest children. the pier-harris children’s self-concept scale and the tennessee self-concept scale are suitable for teenagers; rosenberg self-esteem scale is designed for use with teenagers. in nursing literature, self-esteem and obesity have been studied extensively. in 1995, a literature review of studies involving self-esteem and obesity was conducted. of the 35 studies, thirteen clearly showed lower self-esteem in obese adolescents. five out of six studies demonstrated lower body self-esteem in obese children and adolescents. results in six out of eight treatment studies showed improved self esteem (french, story, & perry, 1995). other studies show that by adolescence, obese hispanic and white females demonstrate significant levels of lower self-esteem compared to their nonobese counterparts (strauss, 2000a). in other studies, obesity was more common in mothers with less education (30% vs 17%) as well as their children (baughcum, chamberlin, deeks, powers, & whitaker, 2000). strauss and knight (1999) concluded that children with obese mothers, low family incomes, and lower cognitive stimulation have significantly elevated risks of becoming obese. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 68 enabled potential and outcome related activities the literature is rich in studies of motivation, both intrinsic and extrinsic. the theory of reasoned action (ajzen & fishbein, 1969) and self-determination theory (deci & ryan, 1980) are the basis of the conceptual framework that that are operationalized in instruments to measure action or motivation (o'connor & vallerand, 1994). although the basis of these instruments is motivation or action, a good deal of the research involves motivation to a particular activity or behavior. since the outcome or activity is seen as part of the action or motivation, a tools that encompasses both have been developed (ryan, frederick, lepes, rubio, & sheldon, 1997). education (pomerantz, ruble, frey, & greulich, 1995a), physical activity (standage & treasure, 2002), behavior change (herrera, johnston, & steele, 2004) are only a few of the studies using measures of the concepts. in each of theses studies, motivation and a specified action have been evaluated. the motivation is measured by the accomplishment of the outcome. nursing has embraced aspects of motivational measurement and related them to health promotion and health prevention. interventions to increase the patient’s participation, readiness to change, and ultimately improve the health state of the individual are fundamental to nursing. studies involving specific problems such as cardiovascular risk reduction (fleury, 1992; krummel et al., 2001), smoking (matson, lee, & hopp, 1993) and children’s obesity (rhee, de lago, arscott-mills, mehta, & davis, 2005) are only a few of the conditions that have been studied. health beliefs and health promotion instruments are tools commonly employed in nursing research. pender has developed and refined instruments that measure the individuals health promotion beliefs and abilities (pender, barkauskas, hayman, rice, & anderson, 1992). the perceived health competence scale, (smith, wallston, & smith, 1995) and modification of the champion health belief model (champion, 1984) have been used in the female population. the studies involved evaluating women without breast cancer, in breast self-exam (champion, 1985), and mammography (vadaparampil, champion, miller, menon, & skinner, 2003). the health selfdetermination index (cox, 1985), and the health self-determinism index for children (cox, cowell, marion, & miller, 1990) measures health behaviors and satisfaction with care. in most of these studies, motivation was positively correlated with performing health behaviors. children and adolescents, however, were not well studied in motivational literature related to health behaviors. bandura’s theory of self-efficacy (bandura, 1986) has been incorporated into nursing theory and research. studies have demonstrated positive outcomes with self-efficacy (resnick & zimmerman, 2002). self-efficacy or competence scales demonstrate that self efficacy should be measured at a very specific level, and should correspond to the behavior being studied (resnick, 1996). the many facets of empowerment are well documented in the disciplines of sociology, psychology, and education. throughout the nursing literature, empowerment and its defining attributes have developed a substantial body of knowledge that continues to build. research proliferates as the concept matures, divides, and generates additional nursing research questions. the multiple definitions of empowerment and the contextual environment of the concepts allow a multitude of instruments to measure the concept and its attributes. selection of the proper tools must include as assessment of the population, their age and literacy level. the goal or outcome should correlate to the conceptual definition used to define empowerment in the setting chosen. one solitary tool is not established as the standard in researching of empowerment. this prevents a strong empirical definition of the concept. the defining attributes of empowerment have online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 69 more valid and reliable tools for measurements. however, studies involving self-esteem, motivation, and outcomes, or behavior change have not been studied collectively in relationship to weight reduction. the tools need further testing and refinement in the adolescent population. empirical knowledge empowerment and its attributes have a valid place in nursing literature. many facets of empowerment have emerged as the concept matured and developed. from the individual to the work place and community, our understanding of empowerment has changed. empowerment materialized as a solitary concept. however, the meaning of empowerment has changed with the personal and social environment. the attributes have emerged and taken on their own meaning, thus further diversifying the basic meaning of empowerment. the vastness of the meaning and methods of measurement have somewhat dampened the force of research. the diversity and development of the concept has accelerated more rapidly than the operationalized definition. despite the fact that many studies have incorporated the attributes of empowerment into a body of knowledge, many gaps still remain. the prevalence of adolescent obesity demand interventions that meet the individual needs of the patient. concepts such as self-esteem, motivation, and empowerment have shown to be related to treatment of obesity. what really empowers or motivate adolescents is not clear. it may be as individual as the person. methods to measure the desire to change need to be developed in the adolescent population. in addition to addressing the adolescent population, cultural aspects of empowerment must be considered. the literary definition of empowerment is not complete until it is defined culturally. rural areas, like appalachia, have strong cultural underpinnings that shape values and personal characteristics. religion is a central theme in appalachian culture (cochran, 2005). the impact of spirituality reassigns the source of personal power and could change the perception of empowerment. empowerment must be operationalized based on the cultural definition of the studied population. it is at that point that the influence of empowerment can be fully evaluated. future studies should be conducted to understanding the cultural concept of empowerment in specific populations. tools to measure empowerment must be developed based on the cultural definition and the age group studied. the importance of empowerment in weight loss can only be determined when the characteristic of the population are considered. references ajzen, i., & fishbein, m. 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[medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10333956%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=4045706%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10150421%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11916466%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10617752%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8433167%5buid%5d http://www.censusmapper.com/appalachia http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10146784%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8851341%5buid%5d self-esteem microsoft word handley_article.doc 7 emotional responses to pregnancy based on geographical classification of residence marilyn c. handley, rn, phd1 1 assistant professor, capstone college of nursing, university of alabama, mhandley@bama.ua.edu keywords: pregnancy, rural, anxiety, depression, uncertainty abstract pregnancy is a time of life-changing events. how the woman adapts to pregnancy varies greatly. these variations may be seen in the measurements of anxiety, depression and uncertainty. these emotional responses may be influenced by factors in her psychosocial environment. of interest in this study was whether the woman’s emotional responses to pregnancy was influenced by whether she lived in a rural or urban setting. a descriptive design was used to compare pregnant women’s responses to a survey instrument measuring the aspects of anxiety, depression and uncertainty based on geographical classification of residence. a sample of 128 first-trimester primaparas was recruited from obstetrical providers’ offices in three southern cities. the providers cared for women living in the urban area and surrounding rural counties. rural residence was significantly related to anxiety, depression and uncertainty scores in pregnant women. these findings should alert nurses and other healthcare providers to screen for these differences and plan interventions to reduce high levels of negative emotional responses and hopefully improve outcomes. introduction the process of adapting to pregnancy and the resulting life changes is often difficult even when pregnancy is planned. this is because pregnancy is a time of complex physical and emotional change. the woman must recognize and incorporate these changes into her self-image, her social network and her life-style. when the pregnancy is unplanned, the psychosocial changes may be even more profound and result in greater problems adapting to pregnancy. usually this adaptation is eventually accomplished without major problems; however a substantial portion of pregnant women face difficulty with the emotional adjustments. pregnant women living in rural areas may be faced with additional stressors that could increase the anxiety, depressive symptoms, and uncertainty even more than urban pregnant woman. rural women are generally less educated, have lower socioeconomic status, have longer distances to access healthcare, and fewer sources of social support than women living in urban areas (bushy, 2005). the purpose of this study was to explore the emotional concerns in women during the first trimester of their first pregnancy based on county of residence and other demographic variables. findings may increase our understanding of the emotional impact of pregnancy in this population and lead to increased understanding and more supportive interventions by health professionals, especially nurses. the research questions included the following: online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://nursing.ua.edu/home.htm mailto:mhandley@bama.ua.edu 8 1. what are the demographic, socioeconomic, and social support characteristics of rural pregnant women compared to urban pregnant women? 2. is there a difference in the levels of anxiety in pregnant women based on geographical classification of residence? 3. is there a difference in levels of depression in pregnant women based on geographical classification of residence? 4. is there a difference in uncertainty in pregnant women based on geographical classification of residence? literature review physical changes of pregnancy the physical changes of pregnancy occurring in virtually every body system are well-known and quickly apparent. early changes include amenorrhea, breast enlargement and tenderness, nausea and vomiting, urinary frequency and fatigue. changes in complexion and body size and shape, occur as pregnancy progresses, accompanied by changes in gait, and concerns of loss of attractiveness. these changes are generally addressed during prenatal care and are described as minor and are limited in duration. the symptoms generally resolve without major consequences. unless the woman alerts the healthcare provider of her associated concerns, the symptoms may receive little attention or explanation. emotional changes of pregnancy women’s mental health should be a primary concern by all women’s health nurses because of the higher prevalence of depressive and anxiety disorders in women. goodman (2005) reported as many as 21% experience depression and 34% deal with an anxiety disorder at some time during their lives. the varying hormone levels and stressors during pregnancy may precipitate the occurrence of depressive symptoms. pregnancy-specific anxiety may occur as the woman worries about the fetus, the delivery, physical changes in her body and her maternal attitudes toward the pregnancy and future baby. typical concerns involve thoughts such as, “am i really pregnant?” “are my symptoms normal?” “will labor and delivery be safe?” “will i be able to deal with the pain of labor?” “will my baby be alright?” “how will pregnancy and a baby change my relationships and life-style?” a delay in reporting troublesome symptoms may occur when anxiety levels are high. ristvedt and trinkaus, (2004) reported a correlation between delayed reporting of symptoms and higher anxiety levels. such delays could result in worsening physical or emotional conditions. the emotional changes during pregnancy are compounded as the woman adapts to her changing image and new responsibilities. the emotional changes are just as complex as the physical changes, but may not be openly discussed. the woman may fear that others do not understand her feelings or consider them insignificant. when this happens the woman may be left to deal with her concerns and fears alone. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 9 anxiety anxiety is a diffuse apprehension, vague in nature and associated with feelings of uncertainty and helplessness. most women and healthcare providers view an undefined level of anxiety as common and acceptable in pregnancy. cote-arsenault (2003) define pregnancy-specific anxiety as a “typical set of worries about the fetus, the delivery, physical changes in the body and the woman’s maternal attitudes.” anxiety may be generalized to the pregnancy or specific to identified concerns. depression a meta-analysis on perinatal depression identified depression as a major complication of pregnancy, affecting as many of 14.5% of women during pregnancy or the following year (gaynes, et al., 2006). perinatal depression may involve minor or major depression or combination of classifications. depression during this period can have far-reaching consequences on the woman and her family. the researchers recommended screening for depression, interventions to reduce depressive episodes, and further research to study various questions about perinatal depression. uncertainty mishel’s uncertainty theory (mishel, 1981; mishel, 1990; mishel, 1997) is wellrecognized in health care. mishel describes uncertainty as a complex cognitive stressor that impacts an individual’s ability to make sense of events. uncertainty occurs when the person is unable to accurately predict outcomes because sufficient cues are lacking. uncertainty is especially present when events are ambiguous, complex, or if the outcome of the event cannot be predicted. these event characteristics make it difficulty to develop certainty about the situation. uncertainty may be foundational to both anxiety and depression as the woman may be unable to accurately determine the meaning of the symptoms or changes in her life because the situation may not be adequately structured or categorized because sufficient cues are lacking. mccormick’s (mccormick, 2002) concept analysis of uncertainty supports many of the basics of uncertainty, but also discussed alternate definitions that encompassed a broader environment than an illness event. mccormick (2002) acknowledged the relationship between uncertainty and high emotional distress, anxiety and depression. geographical classification of residence women in both rural and urban settings share many of the same concerns about pregnancy and face many of the same difficulties in life. while it is difficult to provide distinct differences, it is possible to discuss general differences between rural and urban women. in the last decade, the professional literature has addressed rural and urban populations on a continuum (bushy, 2005). the urban woman generally has a higher level of formal education, a higher level of income, and more social support. the urban woman also typically lives in a resource-rich environment and has greater access to prenatal care and public transportation. the reduced geographical distance between online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 10 family and friends in the urban area results in less social isolation as compared to the rural woman. the first impression of rural residential areas is often one of a peaceful landscape with a low population density. while this is generally true, the classification of rural is multifaceted and lacks universal agreement on criteria (bushy, 2005). variations of the criteria for rural classification include population size and density, proximity to urban areas, economic and trade activities. a county-based classification is often used (hart, larson, & lishner, 2005). rural residents comprise approximately 20% of the us population (bushy, 2005). residents of rural areas often have lower educational levels, lower socioeconomic levels, are more underinsured, and have greater travel distances to access healthcare than their urban counterparts (hart et al.., 2005). these characteristics may have a negative impact on the pregnant women who may be less able to read and understand patient education materials, afford or access routine health care and attend regular appointments. these factors may negatively influence the woman’s attempt to deal with unfamiliar symptoms and life changes. on the positive side there have been many indications that maternal and perinatal care for rural and other underserved population has improved over the past decade. however, lishner, larson, rosenblatt and clark (1999) state that certain trends have emerged or persisted that are cause for concern. among rural women, especially those from certain minority groups; high rates of childbearing among rural teenagers and limited access to family planning services; marked disparities in post-neonatal death among rural as compared to urban residents; signs that regionalized perinatal care systems my be unraveling; and evidence that economically disadvantaged rural women continue to experience significant barriers to obstetric care. methodology the study was a descriptive correlational study. relationships among the variables of anxiety, depression, and uncertainty were examined to determine differences in pregnant woman based on their place of residency. a descriptive design was appropriate as the method to gain additional information about a particular group or situation. there was no attempt to establish causality. sample and setting based on a desired power of 80%, a significance level of 0.05, a small effect size (0.20 to 0.22) and the number of variables in the study; a sample size of 125 was required. criteria for inclusion in the study were women: (a) with a positive diagnosis of pregnancy receiving care from an obstetrical health care provider, (b) who had not previously delivered an infant, (c) 18 to 40 years of age and (d) who consented to take part in the study. exclusion criteria were: (a) an uncertain estimated due date, (b) inability to read and speak english and (c) any diagnosed cognitive dysfunction that would interfere with understanding the tools or the basic directions given by the researcher. the women within this sample included variations in the classifications of age, rural/urban dwellers, racial groups, socioeconomic levels, educational levels, health status and pregnancy status online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 11 (normal/high-risk). these characteristics were included because the variables are among those most frequently included in studies of uncertainty, anxiety, and depression. the actual sample of 128 first-trimester primiparas was recruited from obstetrical providers’ offices in three southern cities. the providers’ practices were located in urban areas, but also provided care for a sizable number of women living in surrounding rural areas. extraneous variables were controlled in a variety of ways. obtaining the sample from several practice groups helped assure that results were not due to the specific conditions in a single practice group. recruiting participants during the first trimester decreased the influence a specific practice group might have over the course of the pregnancy. including only women who had not previously delivered a child avoided the comparison between the current pregnancy and any previous pregnancy. instrumentation three instruments, (a) a demographic data form, (b) a modification of mishel’s muis to include pregnant women called the muis-ob, and (c) the anxiety and depression subscales of the abbreviated scale for the assessment of psychosocial status in pregnancy (asapsp) were combined into one questionnaire for data collection. the anxiety and depression subscales and the muis-ob were likert-type scales with 5-point responses ranging from strongly agree to strongly disagree. the asapsp was compiled and tested by goldenberg et al. (1997) as a screening tool for psychosocial problems in pregnancy. five existing scales measuring anxiety, self-esteem, mastery, and depression were combined into abbreviated subscales for each category. the abbreviated scales were evaluated with 1223 pregnant women at risk for poor pregnancy outcomes. the findings were highly correlated (r=0.97) with the full scales and supported the use of the abbreviated instrument instead of using the longer, separate instruments. the muis-ob was a slightly modified version of the mishel’s uncertainty in illness scale (muis). the muis has demonstrated reliability and validity with a standardized alpha of .91 was reported by mishel (1983). mishel recommends modification to fit different populations. the current modification, the muis-ob, was developed with the assistance of an expert panel, and pilot tested with pregnant women. the modifications adjusted the statements to fit the symptoms of pregnancy rather than the symptoms of illness. the alpha coefficient on the muis-ob was 0.74. data collection procedures permission for the study was obtained from the institutional review board at the university of mississippi medical center. exempt status was granted therefore no consent form was required. permission to enlist participants from obstetrical patients was also obtained from the health care providers in the selected practice groups. the researcher worked with the staff to identify women who met the eligibility criteria to participate in the study. those women who agreed to participate and met study inclusion criteria completed a survey packet which included a demographic data form, anxiety and depression subscales from the abbreviated scale for the assessment of psychosocial status in pregnancy (asapsp) and a revision of mishel’s uncertainty in illness scale for online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 12 use with pregnant women (muis-ob). the demographic data form requested information concerning age, race, income, residential classification, marital status and pregnancy-related data. the women were recruited from the waiting area of the obstetrical providers’ office as they signed in for their appointments. the purpose of the study and the requirements for participation were explained. the researcher or office staff explained to the women that (a) all information would be kept confidential, (b) they were not required to participate, (c) their decision concerning participation would not affect their care, and (d) they could withdraw from the study if they so decided at any time prior to returning the completed instruments and forms. the instruments were distributed and collected during the women’s routine prenatal visits at the obstetrical providers’ offices. the women completed the instrument as they waited for their obstetrical appointments then placed the materials in the provided envelope, sealed the envelope, and returned the completed packet to the office staff. the sealed envelopes were placed in a file box and stored in a secure area until they were collected weekly. the brevity of the instrument and the waiting time required for office visits allowed the women to complete the forms during the same visit. estimated completion time for the instrument and data form was 30 minutes based on the time required by two volunteers selected by the researcher to complete the instrument. data collection occurred over a three month period. analysis the statistical package for social science (spss) 13.0 was used for statistical analyses. descriptive statistics were used to characterize the population based on geographical county of residence. independent t tests were computed to explore the differences in the levels of uncertainty, anxiety and depression in pregnant women based on geographical classification of residence. the muis consisted of four subscales whose individual scores were combined for a total uncertainty score. each item was scored in a range from one to five. in the total scale, a possible uncertainty score ranged from 29 to 145. the higher the total score, the higher the level of uncertainty. the item responses of the subscales were totaled and analyzed to study the factors of uncertainty. the asapsp also consisted of subscales that measured the five emotional states previously described. cronbach’s alpha coefficient is the most commonly used method to assess internalconsistency reliability. this analysis tests the degree to which all items in the instrument measure the same construct. a cronbach’s alpha was obtained to determine the reliability of this current study’s data collection instrument (muis-ob) and the asapsp’s anxiety and depression subscales in this research sample. results a description of the sample and the findings are presented in this section. the geographical classification of residence was classified as rural or urban based on the classifications developed by the alabama rural health association (alabama rural health association, 2003). online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 13 in the total sample 31.4 % (n = 40) of the women resided in a rural county compared to 68.4% (n = 88) that resided in an urban county. the percent of rural residents for this sample is somewhat greater than the reported national percent (20 %) (dhhs, 2001). the women in the sample ranged from 18 to 31 years of age with a mean age of 22.8. the rural women were younger with a mean age of 21.4 years, compared to the mean age of the urban residents of 23.6 years. slightly over half of the women in the total sample were married (59%, n = 75). fewer rural women (n = 14), 35 % were married compared to 69% of urban women (n = 61). eighty four percent of the total sample had completed high school (n = 108) however the educational level was lower in rural women. twenty five percent of the rural women in this sample (n = 10) had not completed high school as compared to only 11 % of the urban women (n = 10). a large majority of rural women (85%, n = 34) reported an income of less than $40,000 as compared to urban women (41%, n = 36). the percentages according to ethnic group in the rural women was 82.5% african-american (n = 33), 17.5% caucasian (n = 7), and no asians or hispanics as compared to urban women who reported being 25% african table 1 descriptive statistics for demographic variables based on geographical classification of residence (n = 128) sample age marital status race education income rural (n=40) 21.4 yrs m = 14 (35%) c = 7 (17.5%) < hs = 10 (25%) < $40,000 = 34 (85%) s = 26 (65%) aa = 33 (82.5%) hs = 24 (60%) $40,000 – 79,990 = 4 (10%) hispanic = 0 (0.0%) college = 6 (15%) $80,000 or > = 2 (5%) asian = 0 (0.0%) urban (n= 88) 23.6 yrs m = 61 (69%) c = 61 (69.3%) < hs = 10 (11%) < $40,000 = 36 (41%) s = 27 (31%) aa = 22 (25%) hs = 37 (42%) $40,000 – 79,990 = 38 (43%) hispanic = 3 (3.4%) college = 41 (47%) $80,000 or > = 14 (16%) asian = 2 (2.3%) total (n = 128) 22.8 yrs m = 75 (59%) c = 68 (53%) <hs = 20 (16%) < $40,000 = 70 (55%) s = 53 (41%) aa = 55 (43%) hs = 61 (47%) $40,000 – 79,990 = 42 (33%) hispanic = 3 (2%) college = 47 (37%) $80,000 or > = 16 (12%) asian = 2 (1.5%) online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 14 american (n = 22), 69% caucasian (n = 61), and 2% asian (n = 2). therefore, the rural women were somewhat younger, less likely to be married, more likely to be africanamerican, less likely to have graduated from high school and more likely to be poorer than their urban counterparts (see table 1). the demographic variable of geographic residence was measured as a categorical variable. independent t-tests were done to determine the difference in the uncertainty, depression, and anxiety scores. data analysis indicated that pregnant women living in rural counties rated higher on all three emotional scales. the rural women had significantly higher scores on the anxiety scale (p= 0.001), the depression scale (p= 0.000) and on the uncertainty scale (p= 0.000) (see table 2). table 2 differences between levels of uncertainty, anxiety, and depression in pregnant women based on geographical classification of residence. rural (n = 40) urban (n = 88) emotional responses of pregnant women x sd x sd t p uncertainty score 79.73 11.48 69.17 15.06 3.939 <0.001 depression score 20.85 6.29 17.61 4.71 3.651 <0.001 anxiety score 21.25 6.30 17.61 4.70 3.141 <0.001 anxiety on the anxiety subscale, the total sample mean was 18.63 (sd = 4.86). the women in rural counties scored a mean of 21.25 (sd = 6.30) compared to their urban counterparts score of 17.61 (sd = 4.70). the alpha coefficient on the anxiety scale in this study was 0.77. depression the scores on the depression subscale were similar. the total sample mean was 18.76 (sd = 5.69). the rural pregnant women scored a mean of 20.85 (sd = 6.29) while the women living in urban areas yielded a lower mean of 17.61 (sd = 4.71). the alpha coefficient on the depression scale was 0.78. uncertainty the mean uncertainty score analysis demonstrated the same pattern. the mean score for the total sample was 72.47 (sd = 14.83). the rural group’s score of 79.73 (sd = 11.48) was significantly higher than the urban groups mean score of 69.17 (sd = 15.06). online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 15 discussion the purpose of the research reported here was to describe the population based on geographical residence and to examine the difference in mean uncertainty, anxiety and depression scores in pregnancy when geographical classification of residence was considered. limitations of the study, conclusions, implications, and recommendations are presented in this section. limitations the use of a purposive, convenience sample was necessary because of the sample requirement of participants being women in the first trimester of their first pregnancy. this sampling method limits the generalizability of the study findings to those pregnant women in that population. another limitation was the timing of the data collection. the women sampled may have had one, two, or three visits to the obstetrical care provider office. while all participants were in the first trimester, the occurrence of previous visits could have decreased the uncertainty level by the establishment of a credible authority relationship with a health care provider or the provision of information. a third limitation was the use of the revised muis instrument. while analytical results supported the reliability of the instrument, this was the first time the revised instrument had been used. continued use of the instrument in future research will allow for further analysis and greater confidence in the instrument’s reliability and validity. conclusions the data were normally distributed and the response ranges were similar to the ranges reported by mishel and other researchers (mishel, 1997). in this study, rural residence were slightly younger (2.2 years), 34 % less likely to be married, 57.5% more likely to be african american, 24 % less likely to complete high school and 44 % more likely to have an income of less then $40,000 than their urban counterparts. significant differences in the level of uncertainty, anxiety, and depression concerning their pregnancy were demonstrated when residential location was included in the analysis. the rural residential classification was significant when considering the impact of area of residence with the emotional scores on anxiety, depression and uncertainty scales in pregnant women. although it is not known why these scores were higher in pregnant women living in rural areas it may be related to difficulties in travel to access health care from the rural areas. age, race, marital status, income and education may have also influenced the higher uncertainty, anxiety, and depression scores in rural woman. theses findings are consistent with other research studies that have explored the variables that may impact pregnancy (goldenberg et al.. 1997; goodman, 2005; lishner et al.., 1999; mishel, 1997). the new information in this study included the differences found between urban and rural pregnant women in emotional responses. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 16 implications the findings from this study have a number of implications. pregnancy is an almost universal experience for women, yet the responses to pregnancy are generally not included in research studies. adequate screening, recognition of emotional responses, and appropriate interventions are essential to the promotion of a healthy adjustment to pregnancy. nurses and other healthcare providers should consider the difficulties encountered by pregnant women in rural areas and develop appropriate interventions to improve outcomes. recommendations these recommendations are based on the findings of this study and are of importance to the care of pregnant women and are applicable to practice, education and research. the majority of these recommendations may easily be incorporated without substantial costs. healthcare providers should consider the possible impact of emotional responses in pregnancy. attempts to decrease high levels of uncertainty, anxiety, and depression should be incorporated into care. screening tools such as the goldenberg’s asapsp abbreviated scale for psychosocial assessment in pregnancy may be a useful and practical measure to administer during the first trimester of pregnancy. younger, africanamerican women, living in rural areas with less social support, income and education should be targeted for interventions that decrease high levels of uncertainty, anxiety, and depression. the provision of accurate, consistent information in a timely manner will give the woman a basis on which to understand the events of her pregnancy. providing information at the appropriate educational level may promote understanding and decrease uncertainty, anxiety, and depression. the development of trust relationships requires the expression of concern for needs of the pregnant woman and support for her self-esteem. inclusion of a significant member of the woman’s social support system may strengthen the woman’s understanding of the pregnancy and development of trust in healthcare providers. and for rural woman, inquiring about transportation and making provisions for transportation may significantly reduce their levels of anxiety and uncertainty. some recommendations for future research have been identified. initially, research should be expanded to explore how emotional responses might change during the course of pregnancy. this would provide a basis for determining the most stressful periods of pregnancy for women and the effective timing of interventions. secondly, studies that seek to identify the causes of emotional stress in rural pregnant women would allow health care providers to develop and implement appropriate interventions. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 17 references alabama rural health association. (2003). selected indicators of rural health status in alabama. alabama rural health report, 3(1), montgomery, alabama. retrieved may 6, 2005, from http://www.arhaonline.org/pdf%20files/rhrv3no1.pdf bushy, a. (2005). rural nursing practice and issues. nevada rnformation, 14(2), 22-27. cote-aresnault, d. (2003). the influence of perinatal loss on anxiety in multigravidas. journal of obstetric, gynecologic & neonatal nursing, 32(5), 623-629. [medline] department of health and human services. (2001). health, united states, 2001. (dhhs publication no. phs 01-1232-1). gaynes, b.n., gavin, n., meltzer-brody, s. lohr, k.n., swinson, t., gartlehner, g., et al. (2005, february). perinatal depression: prevalence, screening accuracy and screening outcomes (agency for healthcare research and quality [ahrq] evidence reports, numbers 119). rockville, md: ahrq. retrieved june 7, 2005, from http://www.ahrq.gov/downloads/pub/evidence/pdf/peridepr/peridep.pdf goldenberg, r.l., hickey, c.a., cliver, s.p., gotlieb, s., woolley, t.w., & hoffman, h.j. (1997). abbreviated scale for the assessment of psychosocial status in pregnancy: development and evaluation. acta obstetricia et gynecologica scandinavica, 76, 19-29. [medline] goodman, j. h. (2005). women’s mental health. journal of obstetrical, gynecological, and neonatal nursing, 34, 245. [medline] hart, l.g., larson, e.h., & lishner, d.m. (2005). rural definitions for health policy and research. american journal of public health, 95, 1149-1155. [medline] lishner, d.m., larson, e.h., rosenblatt, r.a., & clark, s.j. (1999). rural maternal and perinatal health. in t. c. richketts, iii (ed.), rural health in the united states (pp. 134-149). new york: oxford press. mccormick, k.m. (2002). a concept analysis of uncertainty in illness. journal of nursing scholarship, 34(2), 127-131. [medline] mishel, m.h. (1981). the measurement of uncertainty in illness. nursing research, 30, 258-263. [medline] mishel, m.h. (1983). adjusting the fit: development of uncertainty scales for specific clinical populations. western journal of nursing research, 5, 355-369. [medline] mishel, m.h. (1990). reconceptualization of the uncertainty in illness theory. image: journal of nursing scholarship, 22, 256-262. [medline] mishel, m.h. (1997). uncertainty in acute illness. annual review of nursing research, 15, 57-80. [medline] ristvedt, s.l., & trinkaus, k.m. (2004). psychological factors related to delay in consultation for cancer symptoms. psychooncology, 14, 339-350. [medline] online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://www.arhaonline.org/pdf%20files/rhrv3no1.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14565741%5buid%5d http://www.ahrq.gov/downloads/pub/evidence/pdf/peridepr/peridep.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9219452%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15781602%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15983270%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12078536%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=6912987%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=6559492%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=2292449%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9262787%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15386764%5buid%5d chapter i 46 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 a model for assessment of potential geographical accessibility: a case for gis ann graves, phd, rn 1 1 assistant professor, capstone college of nursing, university of alabama, agraves@bama.ua.edu key words: rural, geographical information systems (gis), access, healthcare disparities abstract health is geographically differentiated thereby creating an inextricable link between “place” and “health”. differences in access to healthcare services and resulting adverse health outcomes when there is inadequate healthcare are major public health priorities. while the literature is replete with research about disparities in healthcare access and health outcomes, a greater understanding of geographical enabling factors and predisposing characteristics is needed. the purpose of this concept article is to present a discussion of development of a theoretical framework for study of potential geographical access to healthcare from a perspective of andersen’s behavioral model of health services use (andersen, 1995). an adaptation of andersen’s model, the model for the assessment of potential geographical accessibility, is presented as a conceptual framework to aide in future studies of potential geographical accessibility. the application of geographical information systems (gis) technology and methodology as an analytical tool will also be presented. introduction differences in access to healthcare services and the resulting adverse health outcomes are major public health priorities. the institute of medicine (iom, 2002) and the department of health and human services (usdhhs, 2000), identified the need for strategies to improve access to healthcare services and to support improvement of health outcomes (ahrq, 2002; iom, 2002). furthermore, healthy people 2010 designates two central goals for the nation’s health: (a) to increase quality and years of healthy life, and (b) to eliminate health disparities (usdhhs, 2000). many studies have been conducted to identify the characteristics of disparities in healthcare access and health outcomes. findings of these studies indicate that while most americans have high quality healthcare available, gaps or disparities in healthcare access and health outcomes continue to exist. these disparities are associated with age, education, race and ethnicity, gender, income and socioeconomic status (ses), and place of residence and location of healthcare services. healthcare policy changes over the past decade have drastically decreased access to healthcare services. the rural health environment has been impacted by these changes in many ways (bushy, 2000; folland, et al., 2001). significant decreases in healthcare services to an already vulnerable, at-risk rural population have compounded existing problems of resource disparities. loss of community health services, healthcare professional shortages, rapidly rising cost, hospital closures, homecare cut backs, and tighter government payment schedules are just a few of the changes that have led to greater resource disparities for rural populations (usdhhs, 2000; eberhardt, et al., 2001). because of structural, financial and sociocultural barriers in rural populations, they have fewer healthcare resources than urban populations. these rural resource disparities often lead to comlex adverse health outcomes and rural health status disparities (fryer, et al., 1999; lovett, haynes, sunnenberg, & gale, 2002; lin, allen, & penning, 2002). http://nursing.ua.edu/ mailto:agraves@bama.ua.edu 47 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 while the amount of research about disparities in healthcare access and health outcomes is overwhelming, there is a paucity of literature that provides a greater understanding of geographical enabling factors and predisposing characteristics. more information about the relationship between and the effect of social and geographical factors that enable people to obtain healthcare is needed. specifically, are healthcare services located in a manner that allows equal access? research linking specific types of mortality of specific regions of the country to access to specific types of healthcare services could provide information to assist in the reduction of the excess mortality found in at-risk populations. andersen’s behavioral model of health services use has often been used as a framework for the assessment of healthcare access, outcomes, and quality. within this framework is embedded the premise that the lack of timely access to healthcare services may potentially cause adverse health outcome as evidence by higher mortality rates. framework for the study of access r.m. andersen began to examine the concepts of “access” in 1968. his seminal work explored “systems” and “behavior” of medical care and identified and defined concepts of “access” (andersen, 1970). andersen, along with l. a. aday, further examined concepts of access in a comprehensive literature review (aday & andersen, 1974). this work both conceptualized and operationalized “access” to medical care and provided an integrated theoretical framework for use in the study of access to medical care. in these works, the authors showed how empirical indicators could be derived from the concepts of access. later andersen updated this framework of access to a behavioral model of health services use (figure 1) (andersen, 1995). today, concepts of andersen’s model remain relevant and are used as a framework for assessment of healthcare access, outcomes, and quality (love, et al., 1995; fryer, et al., 1999; phillips, et al., 2000; henton, et al., 2002; leong-wu & fernandez, 2006; lo & fulda, 2008). figure 1. an emerging model – phase 4 note. from revisiting the behavioral model and access to medical care: does it matter? by r. m. andersen, 1995, journal of health and social behavior, 36, (march) 1–10. reprinted with permission. health care system external environment predisposing enabling need characteristics resources personal health practices use of health services perceived health status evaluated health status consumer satisfaction 48 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the concepts identified by andersen within a framework for study of access are defined (andersen, 1995). in table 1 these concept definitions provide a clear basis for understanding the application of the model. table 1 concepts within a framework for the study of access concept definition health policy andersen (1995) suggests that it is the evaluation of the effect of health policy that health planners and policy makers are most concerned about. characteristics of the healthcare delivery system a. resources i. organization ii. entry iii. structure specifically, “delivery system” “those arrangements for the potential rendering of care to consumers” (andersen, 1995). a. resources – the labor and capital devoted to healthcare. these resources include health personnel, physical structures, equipment, and materials for the provision of healthcare and are assessed by both volume and distribution of services. i. organization – “what the system does with its resources. it refers to the manner in which medical personnel and facilities are coordinated and controlled in the process of providing medical services” (andersen, 1995) ii. entry – process of gaining entrance into the healthcare system and can be measured in terms of travel time, waiting time, etc. another term for entry is “access”. iii. structure – includes whom the patient sees and how he is treated as measures of what happen to the patient after entering the system. characteristics of the population at risk a. predisposing component b. enabling component c. need component individual’s determinants of health service use. a. predisposing component – variables that exist before the onset of the illness that describe the individual propensity to use services. measures of this component include age, sex, race, religion, and values about health and illness. b. enabling component – means or resources individual have available for the use of services. individual or family resources include income and insurance coverage, while attributes of the community of residence include rural-urban character and region. c. need component – level of illness that brings about health service use. may be perceived by the individual or evaluated by delivery system. utilization of healthcare services a. type b. site c. purpose d. time interval external validation of the effect of the characteristics of the population at risk and of the delivery system on entry (or non-entry) into the system. andersen (1995) state that health policy makers are concerned with both those who do and do not get into the healthcare system. a. type – kind of services received (hospital, physician, pharmacy, etc.) b. site – place where the service is received. c. purpose – whether care is preventive in nature, illness-related, or custodial. these reason or purposes for care have different patterns of care seeking in the concept of access. the purpose of health services is important to the understanding of the specific healthcare demands of those who seek healthcare services. d. time interval – is measured in terms of contacts, volume, or continuity measures. 49 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 andersen’s original behavioral model of health services use was initially developed in the late 1960’s to help understand the use of health services; to define and measure equitable access to healthcare; and to assist in health policy development to promote equal access to healthcare (andersen, 1995). in the revised “behavioral model of health services use” andersen posits that health service use is a function of people’s predisposition to use services, factors that enable or impede use, and their need for care (andersen, 1995). these factors make individual contributions in prediction of healthcare use. predisposing characteristics include demographic factors, social structure factors, and health beliefs. biological imperatives such as age and sex would be included in demographic factors that might explain the need for healthcare. measures of social structure are education, occupation, ethnicity, as well as social networks, social interactions, and culture. it is andersen’s position that while health beliefs add to the model’s ability to explain health services use in general, measures of enabling resources and need explain more of the variation. in assessment and measurement of “enabling resources” andersen further challenges researchers to go beyond obvious measures of “regular source of care”, “physician populations” and “hospital bed counts”. andersen believes that for healthcare service utilization to happen, it is imperative that both “personal enabling resources” and “community resources” be socially and geographically available. the kinds and types of health services available where people live as well as their organizational structure and process are important factors. both community and personal enabling resources must be present for use to take place. first, health personnel and facilities must be available where people live and work. then, people must have the means and know-how to get to those services and make use of them. income, health insurance, a regular source of care, and travel and waiting times are some measures that can be important here (andersen, 1995). one of the strongest determinants of this model of health service use is the “need” factor. andersen presents “need” as perceived health status, evaluated health status, or consumer satisfaction. he sees perceived health status as a social phenomenon that is explained by social structure and health beliefs. evaluated health status is a biological imperative represented by “professional judgment” about health status (i.e. functional status, mortality, and morbidity, etc.). these biological and social components are dynamic and interrelated and vary with changes in medicine and medical care that is driven by technology, policy, and geography. evaluated need (such as mortality) is most related to “kind and amount of medical care provided” (andersen, 1995). a more specific model for assessment of access can help with understanding the health status of specific populations in relationship to the provision of specific health services. evaluation of specific small-area “need” and the relationship to that area’s predisposing factors and enabling resources can change health outcomes. assessment of mortality rates and the relationship to location or distance to health services can improve mortality rates. a model for assessment of potential geographical accessibility (see figure 2) is presented for the study of diseases by specific geographical areas. this model was originally adapted from andersen’s “behavioral model of health services use” to guide a study of access to cardiac intervention services in alabama and mississippi (author, 2007). the model provides a framework that can be replicated or modified based on specific healthcare systems, predisposing characteristics, enabling resources, need, or health status variables to guide studies of access and health outcomes. 50 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 figure 2. model for assessment of potential geographical accessibility adapted with permission r. m. andersen (see appendix d) healthcare access access as defined by andersen is the “ability to use health services when and where they are needed” (andersen, 1995). cromely & mclafferty further describe access as the “power to command health service resources” (2002). potential access or the population’s potential for access is more simply defined as the “presence of enabling resources” (andersen, 1995). the lack of enabling resources can lead to decreased access to healthcare services. barriers of access such as race, age, education, income, sex, culture, ethnicity, sexual orientation, lack of insurance, and geographical location can affect the use of healthcare services (cromley & mclafferty, 2002; ahrq, 2002). the concept of access is multidimensional. dimensions of access include availability, accessibility, accommodation, affordability, and acceptability. aday and andersen further divide accessibility into socio-organizational and geographical aspects (1974). the geographical dimension of access includes empirical measures such as distance, travel time, transportation, and the associated cost. measures of access often focus on geographical location of service “provision” and the relationship to the population in “need”. both “time” and “space” create constraints to access (cromley & mclafferty, 2002). therefore, the location of healthcare services and the associated distance and travel time are important health policy issues. over thirty years ago julian tudor hart described the imbalance between “need” and “provision” of healthcare services in great britain (hart, 1971). hart’s seminal research described class gradients in mortality and morbidity in britain and proposed that a more “just” distribution of healthcare resources would subsequently equalize the social and geographical differences in health outcomes such as mortality. the “inverse care law” proposed by hart stated that “the availability of good medical care tends to vary inversely with the need for it in the predisposing characteristics enabling resources need demographic and social structure • age • education • race • rurality • ses • sex community • distance to cardiac interventional services evaluated • county myocardial infarction mortality health care system location use of health services (cardiac intervention services) outcome evaluated need county myocardial infarction mortality 51 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 population served” and that this law “operates more completely where medical care is exposed to market forces, and less so where such exposure is reduced” (usdhhs, 2000). the inverse relationship between “need” for healthcare and “provision” of healthcare continues to exist despite advances in healthcare. current literatures suggest that this phenomenon is evident in healthcare in both developed and undeveloped countries. need is most often assessed using population characteristics and risk factors such as population distribution, age, sex, income, etc. but need is more than a function of population distribution and other population characteristics. need is better defined by burden of disease indicators such as morbidity and mortality data. mortality data have been widely used as an indicator or surrogate for health status or healthcare needs evaluation (gatrell, 2002). where high rates of mortality exist, there is a high burden of disease. mortality data can indicate the geographical areas where resources are most needed. research relating mortality data to the geographical location of healthcare services by specific diseases and procedures can help healthcare planners and policy makers achieve equitable distribution of resources. geographical resource distribution studies are needed to describe and analyze inequity in the spatial distribution of healthcare resources and the relationship to burden of disease. access and health outcomes health status is an outcome of multiple determinants. individual biology and behaviors, physical and social environments, policies and interventions, and access to quality healthcare are predisposing factors that can contribute to the health of people and communities (usdhhs, 2000; eberhardt, et al., 2001; ricketts, 1999). these predisposing factors for health status are often interdependent and interrelated creating a complex web of causation for health outcomes (bushy, 2000; friedman, 1994). there are many structural, financial, and socio-cultural barriers to access to quality healthcare. these barriers are an integral part of the complex web of causation of many disease processes because they affect health-seeking behaviors, health service utilization, and ultimately may lead to adverse health outcomes (bushy, 2000; friedman, 1994). according to andersen (1995), health outcomes are measured and defined by health status, satisfaction, and quality of life. dunkin states that outcomes are “complementary in measuring access, especially for complex chronic health problems” and “can provide insight about barriers that may impede access to services” (dunkin, 2000). over the years many studies have documented differences in health outcomes as well as challenges that groups experience in accessing quality healthcare (blustein & weitzman, 1995; black, et al., 1995; weitzman, et al., 1997; bullen, et al., 1996; goodman, et al., 1997). differences in health outcomes and health status are referred to as “healthcare disparities”. when there are differences or variations in health outcomes among populations, inequality in healthcare access is a valid assumption (ahrq, 2002). inequalities also exist when all patients do not have access to care that meets the standards for “best practice”. these inequalities create underserved, at-risk populations and have been identified by congress as priority populations. these groups include women, children, the elderly, minority groups, low-income groups, residents of rural areas, and individuals with special healthcare needs varying across regional and geographical areas of the country. priority populations are the targets of many health initiatives directed toward identifying strategies to improve access and health outcomes (ahrq, 2002; usdhhs, 2000). one such strategy could be the use of gis for assessment of healthcare access and health outcomes. 52 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 a case for gis geographic information systems (gis) are a growing technology and methodology. gis are computer-based information systems that combine mapping capabilities with data referenced by spatial or geographic coordinates. they can capture, organize, store, manipulate and analyze spatial data. gis can link and join geographical features on a map with attribute data as well as query databases to produce patterns of health outcomes (gatrell, 2002). they can produce maps beneficial for medical geography. gis are important tools for showing inequalities in health between regions. because where healthcare is located matters, gis analysis of health data and healthcare service locations is valuable for describing and understanding relationships between healthcare access and health outcomes. mapping of health data can establish patterns of health disparities. gis can integrate statistical and geographic data and allow for the visualization of spatial relationships. gis is efficient for analyzing health data, revealing trends and determining relationships that might be missed in a strictly tabular format. mapping and visualization of health disparities and their relationship to the geographical location of healthcare services can allow for better resource allocations to disparate and underserved populations (scott, et al., 1998; blake & bentov, 2001; luther, studnicki, kromery, & lomando-frakes, 2003; love & lindquist, 1995; lovett, et al., 2002; gatrell, et al., 2002; leong-wu & fernandez, 2006). the world health organization (who, 2003) identifies the value of public health mapping and gis. according to the who geographical information systems (gis) provide ideal platforms for the convergence of disease-specific information and their analyses in relation to population settlements, surrounding social and health services and the natural environment. they are highly suitable for analyzing epidemiological data, revealing trends and interrelationships that would be difficult to discover in tabular format. moreover gis allows policy makers to easily visualize problems in relation to existing health and social services and the natural environment and so more effectively target resources. the literature is replete with reports of regional, locational, and small-area analysis of health disparities (bullen, et al., 1996; andrews & phillips, 2002; bamford, et al., 1999; haynes, et al., 1999). gis is effective in the management and analysis of health data at these levels. analysis at the census tract or county level is important in the identification of patterns of healthcare outcomes and the association or linkage to political processes and policy makers (cromley & mclafferty, 2002; gatrell, 2002; elliot, et al., 2000; meade & earickson, 2000). summary the united states department of health and human services identifies in its national health initiative the priority that all people, including the most vulnerable, should have health that allows them to have a productive life by the year 2010 (usdhhs, 2000). healthcare access is becoming increasingly complex as a growing and diverse population and rapid healthcare reform continue to modify the provision of healthcare services. improving healthcare access, reducing geographical variability in health outcomes, and eliminating disparities are major social and political issues. 53 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 many disparities exist within the current united states healthcare system. these inequalities have been shown to restrict healthcare access and lead to regional health outcome disparities. decreasing access contributes to patterns of excessively high disease incidences, morbidity, and mortality. because the match between “need” and “provision” is an important determinant of equitable access more studies are needed to describe specific geographical patterns of health. the literature supports the use of small-area analysis for the study of access. andersen’s behavioral model of health service use provides one approach to the assessment of access to healthcare services. application of the adapted model for the assessment of potential geographical accessibility (see figure 2) provides an opportunity to evaluate the specific relationship between location and “provision” of healthcare and mortality rates or “need”. it can provide a guide for future studies of healthcare access. the model can be modified by using other healthcare services, predisposing characteristics, enabling resources, healthcare need, or by other health outcomes or health status variables. further research is also needed in the use of gis to both visually identify and empirically measure spatial relationships of geographical, environmental, and social influences of disease. more research of predisposing characteristics and enabling factors for other specific populations is needed. gis is becoming instrumental in the synthesis of information to foster awareness of specific health concerns, facilitate development of intervention strategies, and enhance utilization of resources. gis technology can be of great value in health planning, the development of health policies and the allocation of healthcare resources. regional disparities in mortality rates observed can provide valuable starting points for the analysis of healthcare service accessibility. with further analysis, those responsible for the development of healthcare policy can modify healthcare services and define quality healthcare sensitivity and responses to these issues of decreased access and excess mortality. social justice requires the reversal of healthcare inequalities by better distribution of resources. healthcare policy must not neglect the vulnerable populations created by geographical inequality. references aday, l.a., & andersen, r.m. 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(2003). public health mapping. retrieved on april, 2004, from http://www.who.int/csr/mapping/en/ http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7860317%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12137192%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16791533%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12747322%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11115195%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9804638%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9070548%5buid%5d http://www.who.int/csr/mapping/en/ advanced nursing practice in rural areas: online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 24 advanced nursing practice in rural areas: connectedness versus disconnectedness margaret m. conger, rn, msn, edd1 * karen a. plager, dnsc, rnc, fnp2 1 professor emeritus, school of nursing, northern arizona university, margaret.conger@nau.edu 2 associate professor, school of nursing, northern arizona university, karen.plager@nau.edu * contact author keywords: connectedness, disconnectedness, education for rural advanced practice nursing, rural advanced practice nursing abstract scarcity of health care providers leads to reduced access to health care for rural residents. better understanding of constraints confronting nurses in rural practice is needed. our program prepares advanced practice nurses (apns) to work in rural areas. using interpretive phenomenology we studied program terminal outcomes as practiced by our apn graduates. individual interviews and focus groups were conducted with graduates who had been in practice for at least one year. this paper describes one theme – rural connectedness versus disconnectedness– that was uncovered in the larger study. elements leading to rural connectedness included development of support networks, relationships with urban health care centers, connections with local communities, and support through electronic means. rural disconnectedness resulted from lack of relationships with other health care providers, lack of mentors and support staff, and the absence of electronic support. implications for education for rural advanced practice are discussed. introduction the development of rural nursing theory has been explicated through the work of the montana state university nursing group (lee & winters, 2004; lee & winters, 2006). unique characteristics of the rural dweller and how the rural person describes health are expanded upon from earlier reported work (lee & winters, 1998). they suggest that further study is needed to develop an understanding of constraints that confront nurses in rural practice. it is important to address those constraints to attract sufficient numbers of qualified nurses to work in rural areas. in arizona the scarcity of health care providers has reduced access to health care for rural residents (moore-monroy, 2005). factors such as isolation from other health care professionals, lack of anonymity, and perhaps most important of all, the outsider status of the professional who enters the new community with little understanding of rural issues all lead to difficulties in both attracting health care professionals to rural areas and even more importantly retaining them in these practices. http://www.nau.edu/nursing/ mailto:margaret.conger@nau.edu http://www.nau.edu/nursing/ mailto:karen.plager@nau.edu online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 25 to address this issue of lack of health care providers, northern arizona university school of nursing provides education for advance practice nurses (apns) that prepares them to work in rural areas. the students are first prepared academically with knowledge about working in a rural area by studying concepts related to rural communities. rural theory provides them with an understanding of critical issues related to rural practice. in addition, all students are required to have a clinical experience in a rural community. even those who are urban based are placed in rural areas for clinical experience during the program. in this paper we report on a secondary analysis of data from an outcomes study of advanced practice nurse (apn) graduates from a university in the southwest united states. we refer to apns as both nps and cnss; however, at points where we need to differentiate these roles we will use np or cns. the original study aimed to answer the research question of how graduates actualized our program terminal competencies and how the two apn roles were differentiation. our terminal competencies are based on domains of practice as established by the national organization of nurse practitioner faculties (2000), the national association of clinical nurse specialists (1998), and american association of colleges of nursing (1996). one of the themes that emerged from our data analysis was rural connected versus disconnected, a theme related to the concerns of lee and winters (1998) about the constraints of rural practice. [note: an earlier version of this paper was presented at western institute of nursing conference, san francisco, ca, april, 2005] literature review in a review of literature of nursing practice in rural communities, a sense of isolation was identified (shreffler, 1998) as common to rural nursing practice. strategies to overcome this isolation are important to understand and utilize if the rural community is to retain its health professionals. several reports from australia have addressed the problems faced by health professionals working in rural and remote areas (hegney, 2002; hegney, mccarthy, rogers-clark & gorman, 2002; kenny & duckett, 2003). they focused on development of clinical skills required for successful nursing practice in these areas. very few studies focused on the environmental constraints important to rural practice. one study by hegney et al. (2002) looked at reasons why nurses resigned from positions in rural areas and found that, in addition to the lack of confidence in skills needed to practice in these areas, issues such as professional isolation and culture shock were also critical. this group also identified that the first 12 months of practice in a rural area were essential to success of the nurse. during this time it was vital that the nurse have adequate resources both in peer mentoring and continuing education. another study from australia examined the issue of advanced practice nursing roles in rural areas. kenny and duckett (2003) identified the need for nurses trained at advanced levels in rural areas, but did not believe that it was possible to attract nurses with advanced education to such areas. they conclude that apns would choose to remain in metropolitan areas where support for their practices and possibilities for advancement were greater. in a program outcomes study done in tennessee, the investigators found 46 % of health professional students whose clinical practicums were completed in a rural area returned to online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 26 practice in rural areas after graduation. more of the nursing graduates indicated an interest in returning to a rural practice, but were unable to find a rural position (florence, goodrow, wachs, grover & olive, 2007). this suggests that providing clinical practicums in a rural area is a positive strategy to attract health professionals to a rural area. the investigators noted a limited opportunities for rural practice, but did not elaborate on why this occurred. penz et al. (2007) studied barriers to participation in continuing education courses of nurses working in rural and remote areas in canada. barriers found included distance from educational institutions, inadequate staffing to allow nurses attend conferences, and lack of employer support. nurses reported that it was unrealistic to expect the nurse working in an isolated area to be responsible for covering the travel and lodging costs to attend a continuing education event. to overcome some of these isolation factors experienced by nurses working in rural and remote areas, australia has developed a remote area nurses’ incentive package. nurses in remote areas can qualify for two weeks of professional development activities per year. both travel and conference fees are fully paid. the program also provides two airfare tickets per year to a metropolitan area for the nurse and family members to reduce the sense of isolation. funding is also provided to cover the cost of replacing the nurse during the professional development and recreational time (“currently working”, 2007). methodology methodology and study design this study utilized both focus group and individual interview techniques. focus group data collection is a qualitative data collection technique that is not tied to any theoretical perspective and thus can be used with interpretive phenomenology as used in this study (smith, 2005). individual interviews were also used in this study. seal, bogart, and ehrhardt (1998) suggest that using both data collection techniques enhances the quality of the data. it is suggested that group anonymity enhances free disclosure that can be problematical in individual interviews (seal, bogart, & ehrhardt, 1998; vaughn, schumm, & sinagub, 1996). interpretive phenomenology was the methodology used. this qualitative research methodology aims to uncover meaning in narrative-text analogues for analysis and interpretation and leads to increased understanding of phenomena. in this study, the aim was to uncover the meaning in apn practice based on their lived experience. the study was partially supported by an intramural grant from northern arizona university. approval by the university institutional review board occurred before data collection commenced. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 27 recruitment and sample all nursing master’s graduates who had been in practice for at least one year since graduation were invited to participate in the study. informed consent and demographic data from each participant was obtained before the interview process began. semi-structured, open-ended questions based on the program terminal competencies that elicited the lived experience of the graduate apns’ practice were used. the terminal competencies were based on the work of benner, tanner, & chesla (1996), brykcyznski (1998), fenton (1985), and fenton & brykcyznski (1993). participants were interviewed either in a focus group or an individual interview depending whether they lived more locally or more distant from the university. the same set of questions was used with both. see appendix for the interview schedule used for the study. data collection five focus groups (16 participants) and 14 individual interviews (mostly by conference call) were conducted. of 40 eligible graduates, 30 participated (75% response rate), including 7 of 9 rural health specialists (rhs) (clinical specialist with a rural focus) and 23 of 31 fnp’s. focus groups or phone interviews lasted about 1 to 2 hours each. all interviews and focus groups were audiotaped and transcribed verbatim. each transcript of the narrative-text analogue was reviewed for accuracy by one of the researchers. analysis and interpretation two researchers independently read the narrative-text analogues to uncover themes. themes were then discussed between the researchers for consensual validation. three strategies were used for analysis and interpretation, including thematic analysis and identification of exemplars and paradigm cases (benner, 1994). analysis for themes occurred independently by each researcher and then consensual validation was achieved through interpretive dialogue. study findings and discussion rural practice demographic data derived from this study indicate that the majority of graduates were employed in rural practices. data from 30 graduates indicate 87% of the apn graduates are serving in rural areas. eight (27%) are serving in communities with populations between 50,000 to 99,999 residents, 18 (60%) are working in rural/frontier areas, and only 4 (13%) returned to large metropolitan areas to work. these data suggest that an educational program in which students are assigned to rural communities for clinical practice has a positive impact in providing rural areas with health care providers. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 28 theme: rural connectedness vs disconnectedness. one theme that was revealed in the participants’ stories was rural connectedness versus disconnectedness. aspects of the environment were identified that led to a sense of feeling connected. the absence of these led to a sense of being disconnected. rural connected apns a sense of connectedness was revealed in four ways by the participants: development of support networks, relationships with large urban medical centers, availability of electronic communications, and connections with the rural community. each influence that led to a sense of connectedness for apn graduates working in rural and remote areas is discussed. figure 1 demonstrates each of these. apn connected internet presence of other health professionals support persons and services telecommunication with urban hospital telemedicine fax phone journal club with other health professionals figure 1. rural connected apn online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 29 develop support networks. many of the graduates discussed the importance of developing support networks. some of this support came from former classmates and was based on relationships formed during graduate study. the graduates found that communicating with former classmates was important to their practice. one rhs graduate talked about the ease of getting patient discharge information from the regional hospital back to her rural community health setting because of the program that another rhs graduate had established at that hospital: you know what i’ve got to say that i went to school with [another student] and that was something she was really interested [in] was communication with outside facilities. so when she started working on that, sometimes we would get two fax’s of discharge information. two fnp graduates discussed this connectedness when they first began their practices: p1: there were times i called p2. p2: oh yes p1: we collaborated. its like, dear god! p2: she’s in kingman and i’m in phoenix and she [called and] said, “how high can an inr be before you worry?” for a new graduate working in an isolated practice with a not very accessible physician colleague, this connection with a former fellow graduate student provided a sense of reassurance that other resources were available to support her clinical decision making. many times graduates working in remote indian health service (ihs) facilities described that the presence of other health professionals in the same health center led to a sense of being connected. they often had the availability of well developed public health nursing centers and could collaborate with the public health nurses to seek out patients who needed to come into the clinic for checkups. others working in community health centers found the importance of a collaborative practice and a mentor to be invaluable to their success in their early years in practice. the presence of a resource such as a pharmacist to assist with calculating complicated drug dosages for pediatric patients or patients with renal disease provided tremendous support to the new apn. other support persons cited by participants included nutritionists, community health nurses, and mental health workers. the presence of a mentor to discuss complex patient problems also provided a sense of connectedness. an fnp graduate working at an ihs health center explained that: when you’re in a multiple provider practice ...you get this incredibly complicated patient and you say, do i really have to go back to ground zero and start all over again? you get together and just talk. bring me up to date on what’s going on here online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 30 and then. pass on what everybody’s learned to help the next person move forward with that patient. relationships with urban health care centers. another way to develop a sense of connectedness was to establish a strong relationship with an urban health center. this was done in several ways. one graduate talked of planning a lunch time in-service when a specialist from the urban setting would come to the rural clinic for patient consultations. this gave the staff at the rural clinic time to become updated on new management strategies as well as develop a sense of collegiality with the urban specialist opportunities for face-to-face times with urban specialists were found to be especially helpful. this person could then be called to get advice when needed for a complex patient care situation. one fnp graduate explained: try to get that name relationship with the physicians and surgeons... that takes work because they are this voice at the other end of the phone and it helps when you see them and they come down and pay you a visit. another noted that: we have certain physicians with specialties, who are contracted with ihs, and so, for example, a kid comes in with a fracture and there’s quite a bit of angulation to it, we will refer him to ortho and that is a contracted service and we’ll set them up for a conference. another strategy that helped the apn feel connected was through telephone contact with urban providers. one graduate who worked in a rural clinic fairly close to a large urban area was able to have daily communication with the urban hospital. several other graduates mentioned the programs provided by large university medical centers who had a “one call’ system to connect the rural provider with a specialist. this service could be accessed even when they were geographically very far distant. as one fnp graduate describes: hospital “one call system”... system is wonderful. gets needed advice... they have all these residents and they all, you know, chip in to be available and take calls and so you have somebody you can fax an ekg to. another fnp graduate who worked in her own nurse-run family primary care clinic noted: and i had already discussed with [the patient] we had to get her off that armour (thyroid), but i really wanted to talk to a specialist to see how to do it...we can call any specialist...and they come to our aid immediately...most of the time we try not to ask stupid questions, but we have a reason to call them... and they will see our patients in consult with an appointment... if necessary. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 31 this graduate felt connected by her ability to contact specialists at a university hospital at a moment’s notice, resulting in needed reassurance to provide point of care service to her patients. support through electronic means. the importance of communication through electronic means cannot be overemphasized. when telecommunication equipment was functioning, it was invaluable. one graduate said “makes us feel less alone out here” when the telemedicine equipment was functioning. however, it was not always functional. one graduate reported: we have telemedicine, you know and we’re able to do that kind of thing... but you know when you’re in the clinic and its four o’clock in the afternoon and you have this problem come up and you need to solve it right then because it’s a possible serious nature, it just became a nightmare... an fnp graduate working in a school whose student body was from around the world depended on the availability of email connections to keep in contact with students’ parents: “i did a lot of communication by e-mail. that was the way that a lot of this could happen because the time differences were so incredible.” the internet was also used to obtain information to manage clients and to follow up with distant health care providers. as well the internet provided a means to obtain continuing education classes when travel to a distant site was prohibitive. connections with local communities. a final factor found to be important to success in rural practice is community connections. this was achieved in several ways. one graduate emphasized the importance of participating in community activities to get to know the people and their culture. this helped in gaining community acceptance. one graduate provided health related talks to various groups as a means to become as a trusted community member. an fnp graduate reported that a home visit to an elderly resident living out on a country road helped to establish him in the community. soon he noted hearing from a community member: “you came out and saw so and so....he’s a relative.” this began a trusting relationship in the community. another way in which apn graduates were able to connect to community agencies was in providing inservices on wound care or other procedures needed to care for a client who would be transferred to a skilled nursing facility. by teaching the staff how to do complex care, the patient could be safely transferred from the acute care hospital thus providing quality care at a lower level of intensity and cost. this contact with other health care agencies helps to make transitions of patients from one agency to another go more smoothly: we interact a lot with the home health agencies,... the agencies in outlying areas... we bring them in to see how we can work better with them.... helps make the transitions go smoothly. rural disconnected apns graduates who reported a sense of disconnectedness when working in a rural community were less likely to remain in that community. it is important to understand what environmental online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 32 factors lead to a sense of disconnectedness and then prepare students with strategies to prevent them once they are out in practice. the situations leading to a sense of disconnectedness are depicted in figure 2 and discussed below. lack of relationships with other health care centers. if the rural clinic does not have a well established relationship with the urban medical center, apns may have a very difficult time in securing the needed services for their patients. it may also be difficult to get the urban hospital to send information back to the rural clinic. one graduate told of an experience trying to get a needed radiological test for a client. she called the radiology department at the urban hospital and made arrangements for the test. however, the clinic did not have an established relationship with the admitting department. when the client arrived at the urban hospital, she was turned away because she did not have cash to pay for the test. the admitting personnel claimed they had no knowledge of arrangements with the clinic and would not accept the payment authorization letter the clinic had sent with the patient. the radiology staff was upset because they thought the patient was a “no show”. the apn was upset because she did not get the test report needed to determine a plan of care for the patient. it took several weeks to get this whole situation resolved. what the apn learned was that it is not sufficient to make test arrangements with the radiology department alone. the admitting department also had to be consulted. to keep such unfortunate experiences from happening again, the clinic arranged for a face to face meeting with hospital staff to work through how best to communicate with each other. apn disconnected garbled communication with urban hospital poor or non-existent internet connection lack of other health providers ‘no other eyes” lack of electricity/personnel to run equipment breakdown of communication client has no telephone isolation “m iddle of nowhere” unable to attend professional meetings no backup coverage distance too far figure 2. apn disconnected online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 33 the importance of developing working relationships with the urban hospital was emphasized by several of the graduates. one said: when we need help, we need help. we don’t need to be told that there’s no room in the inn because the patients we’re sending actually do need to be cared for in the facility. another graduate told of an experience sending a patient to the urban hospital for testing for a possible brain tumor. several weeks went by without receiving the test results. she found that the urban hospital had sent the test results to another facility where they were “lost” because this facility had no record of the patient. the urban hospital was not aware that the patient had been sent from a satellite clinic rather than the larger facility. the need for better communication among nurses from the urban hospital and the rural clinic were also described. one rhs graduate said “i’m alone... there is no one out here but me and the agency wants all this paper work.” when working in an isolated setting with no support staff, it is hard to meet the same standards for paper work as found in larger facilities. discharge planners often lack of understanding of the rural setting. one graduate told of an encounter with a discharge planner at an urban hospital when trying to obtain equipment for a paraplegic patient about to return to an american indian reservation. she had to argue to have a hospital bed with a trapeze attached sent with the patient because there were no possibilities to get such equipment in the rural area. another interesting problem reported by an fnp graduate working in a community health center near the mexican border was the difficulty in establishing viable communications with health care facilities “across the border”. she asked: how do we coordinate care across the border so tests aren’t needlessly repeated? how do we share information on positive things? how do we get people back and forth across the border to get care appropriately and learn to work with the healthcare system down there? these were issues that this graduate at a border clinic struggled with frequently in working with “across the border” patient care situations. lack of mentors/support staff. as noted by hegney et al. (2002), the need for mentors and other support staff are vital to successful early experience as an apn. graduates who accepted positions in isolated areas reported a great deal of frustration in learning this new role. one graduate described it as: one of the most frustrating things for me was that i was the only person there and there was nobody to turn to and learn from….to say ‘this is what i hear, this is what i see. do you agree with me? this is what i want to do. am i on the right track?’... online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 34 i had phone calls, which isn’t nearly the same as another pair of eyes looking at the same person you are. while phone connections to the urban hospital were helpful, they were not the same as having “another pair of eyes” to see the situation and help in making a judgment. this lack of an on site mentor to collaborate with led to a sense of loneliness and isolation. it often challenged the apn to be creative in ways to access clinical support and mentoring from afar. other graduates talked about the need for back up staff such as a case manager to help with the tremendous amount of follow up needed to make sure connections between the urban hospital and the clinic were working smoothly. those working at an ihs facility found that having the support of public health nurses to track down patients often satisfied this need. but those working without this support soon realized that they were carrying two roles the apn during the regular clinic hours and the case manager role after the clinic was closed. one graduate stated case managers were needed but “will it ever happen?” in the case of the fnp graduates, they were learning to be case managers on the job because their formal education did not include course work to prepare them for this role yet they often found that case management was essential in providing quality care. electronic supports lacking. while the availability of telemedicine equipment was noted by many of the graduates working in rural clinics, problems with this equipment were often experienced. in one clinic a problem identified was lack of sufficient power to run the equipment. i think one of the hardest things is the delay in radiology reports, but they do have the equipment for tele-radiology. but its just that there is a problem with the mechanical problems so they didn’t have the proper transformer that could carry the power load and things like that, so once those things are in place then it would be really helpful. it took several years for adequate electrical power to be provided in the community before the equipment could be used. some clinics were so isolated that such equipment was unavailable causing problems during emergency situations when precise information was urgently needed. you know you really need some experience with those urgent care issues when there really is no one there. now hopefully maybe tele-medicine will help. implications for education and practice several implications for education and practice can be derived from these findings. this study provides further insight into both the ability of an educational program to prepare apns to work successfully in a rural or remote setting and to identify what constitutes success in their practice. students who are prepared in rural theory and have clinical practicums in rural and remote areas can be successful in moving in rural practices following graduation. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 35 rural theory and practice long and weinert (2006) state that the provision of health care to clients living in rural communities differs from those living in urban areas. one cannot apply the same theories to both populations. thus educational programs preparing students to work in rural communities must put an emphasis on teaching rural health theory. the faculty at the school of nursing at montana state university has been actively working on and publishing about rural theory development and has defined a number of concepts to consider (lee, 1998; lee & winters, 2006). of these, several are pertinent to this discussion of connectedness versus disconnectedness. these include isolation and distance, lack of anonymity of the health care provider, the issues of insider-outsider status, and the health beliefs of rural residents. students need to be introduced to these concepts first in the classroom setting prior to moving out into clinical practice in a rural area. in our program at nau-son, all students are required to take a course in rural nursing theory during their first year of graduate work. as part of this course, the students conduct a small assessment of a rural community to begin to understand the health issues facing that community as part of the student’s education, clinical practice in rural settings has been demonstrated to be vital to future success in this area. kenny and duckett (2003) advocate for such practice. they state “if they (nursing students) understand what rural practice is like and get a taste of it when they are studying, they come here with their eyes wide open” ( p. 12). florence et al. (2007) found that graduates of their program who utilized rural settings for clinical education were providing care to rural undeserved populations at a significantly higher percentage than were graduates who had not participated in the rural clinical experiences. in another study, neill and taylor (2002) found that placing students in rural clinical practicums increased graduates choosing rural or remote employment. thus an important part of preparation for rural practice is to be placed in rural settings for their clinical practicums. preparation for negotiation another aspect of education for future rural nurses is to help develop the negotiation skills needed for the first job interview. knowing the issues that lead to a sense of disconnectedness is important in defining the conditions for employment. the presence of a mentor during the first year in practice is vital to the graduate’s success and needs to be investigated during the preemployment interview. graduates need to know how to negotiate for continuing education opportunities including support for travel and expenses as well as for a replacement coverage while away from the job. they need to investigate what connections the rural health center has with other health centers either by tele-medicine or other contractual arrangements. knowing what support systems are in place prior to accepting a new position will reduce frustration with the job and hopefully lead to long term commitment to rural practice. in the nau son graduate program, all students take a capstone course in their last semester of the program. this course focuses on transitions into advanced practice. included in the course is preparation for marketing oneself to find an advanced practice position. in addition, online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 36 they explore skills needed for management and negotiation related to patient care once out in practice. the students also were required to interview an advanced practice nurse to learn the realities of advanced practice. since this research a unit on ways to establish and maintain connectedness in rural practice was added to the course curriculum. conclusion while practice in a rural area presents many challenges to apns, education to prepare for this role helps to make a smoother transition. the environmental factors that lead to a sense of connectedness must be stressed during the educational program. the development of strong support systems are necessary for survival in rural working environments. the students must understand the importance of these support systems and learn how to negotiate for such support when making decisions about their first job. if their initial experience leads to a sense of disconnected ness, it will discourage them from remaining in rural practice. the goal of our program is to prepare graduates to remain in rural areas to provide desperately needed health care providers for rural residents. hegney (2002) has summed this need up well: “the work facing rural and remote area nurses...is to make rural and remote area nursing a place where nurses not only wish to gain employment but also wish to continue to work within” . references benner, p., tanner, c.a., & chesla, c.a. (1996). expertise in nursing practice. caring, clinical judgment, and ethics. new york: springer. brykcyznski, k.a. (1998). an interpretive study describing the clinical judgment of nurse practitioners. scholarly inquiry for nurse practice, 3(2), 75-104. [medline] currently working or thinking about working in a remote area? (2007). the queensland nurse, 26 (1), 19. fenton, m.v. (1985). identifying competencies of clinical nurse specialists.. journal of nursing administration, 15(12), 31-37. [medline] fenton, m.v. & brykcyznski, k.a. (1993). qualitative distinctions and similarities in the practice of clinical nurse specialists and nurse practitioners. journal of professional nursing florence, j.a., goodrow, b., wachs, j., grover, s., & olive, k.e. (2007). rural health professions education at east tennessee state university: survey of graduates from the first decade of the community partnership program. the journal of rural health, 23 (1), 77-83. [medline] hegney, d. (2002). rural and remote area nursing: an australian perspective. online journal of rural nursing and health care, 3 (1). retrieved may 25, 2007 from http://www.rno.org/journal/index.php/online-journal/article/view/103/99. hegney, d., mccarthy, a., rogers-clark, c., & gorman, d. (2002). why nurses are resigning from rural and remote queensland health facilities. collegian, 9(2), 33-39. [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=2772457%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=3852865%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=17300482%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12054393%5buid%5d online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 37 kenny, a., & duckett, s. (2003). educating for rural nursing practice. journal of advanced nursing, 44, 613-622. [medline] lee, h.j. (ed.). (1998). conceptual basis for rural nursing. new york: springer. lee, h j., & winters, c.a. (2004). testing rural nursing theory: perceptions and needs of service providers. online journal of rural nursing and health care, 4 (1). retrieved may 25, 2007 from http://www.rno.org/journal/index.php/online-journal/article/view/128/126 lee, h.j., & winters, c.a. (eds.). (2006). rural nursing: concepts, theory, and practice (2nd ed.). new york: springer publishing company. long, k.a., & weinert, c. (2006). rural nursing: developing the theory base. in h.j. lee & c.a. winters (eds.), rural nursing: concepts, theory, and practice (2nd ed.) (pp. 3-16). new york: springer. moore-monroy, m. (2005). community partnerships: a study of the impact of arizona rural health programs (1991-2004). tucson, az: university of arizona, rural health office. national association of clinical nurse specialists research and practice committee. (1998). statement on clinical nurse specialist practice and education. harrisburg, pa: national association of clinical nurse specialists. national organization of nurse practitioner faculties. (2000). domains and competencies of nurse practitioner practice. washington, dc: nonpf. national organization of nurse practitioner faculties (nonpf). (2002). nurse practitioner primary care competencies in specialty areas; adult, family, gerontological, pediatric, and women’s health. rockville, md: us school of health and human services health resources and services administration bureau of health professions, division of nursing (hrsa). neill, j., & taylor, k. (2002). undergraduate nursing students’ clinical experiences in rural and remote areas: recruitment implications. australian journal of rural health, 10, 239-243. [medline] penz, k., d’arcy, c., stewart, n., kosteniuk, j., morgan, d., & smith, b. (2007). barriers to participation in continuing education among rural and remote nurses. journal of continuing education in nursing, 38(2), 58-66. [medline] seal, d., bogart, l., & ehrhardt, l. (1998). small group dynamics: discussions as a research method. group dynamics, 24, 253-266. shreffler, m.j. (1998). professional isolation: a concept analysis. in h. j. lee (ed.), conceptual basis for rural nursing (pp. 420-4270. new york: springer publishing company. smith, a.j. (2005). qualitative psychology: a practical guide to research methods. london, uk: sage publications. vaughn, s., schumm, j., & sinagub, j. (1996). focus group interviews in education and psychology. thousand oaks, ca: sage publications. http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14651684%5buid%5d http://www.rno.org/journal/index.php/online-journal/article/view/128/126 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12230431%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=17402377%5buid%5d online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 38 appendix focus group/individual interview questions when answering the following questions, please address your nursing practice since graduating with your master’s degree in nursing from nau. please note whether you graduated from the fnp or rhs track. 1. what is your role in managing the health-illness continuum of clients that you work with in your nursing practice? • please tell us some specific examples from your practice. 2. what activities that monitor and ensure quality health care are you involved with in your nursing practice? • please tell us some specific examples from your practice. 3. what types of activities are you responsible for in managing and negotiating health care delivery systems in your nursing practice? • please tell us some specific examples from your practice. 4. tell us about the professional activities that you are involved in. • please tell us some specific examples from your practice. 5. tells us about the teaching and coaching activities you are involved with in your nursing practice. • please tell us some specific examples from your practice. 6. please describe how you collaborate with other health care professionals in your nursing practice. • please tell us some specific examples from your practice. 7. tell us how you are involved in consulting with or for other health care professionals in your nursing practice. • please tell us some specific examples from your practice. 8. tell us how you promote the nurse-client relationship in your nursing practice. • please tell us some specific examples from your practice. 9. tell us how well you feel that your educational program prepared you for the role that you assumed as a new graduate after receiving your master’s degree from nau. • what learning strategies were most/least helpful for you? • what additional learning would have helped you better assume your role as a master’s degree prepared nurse? 9 rural nurse administrators: essentials for practice carol r. eldridge, msn, rn1 sharon judkins, phd, rn, cnaa2 1 instructor, department of nursing, tarleton state university, eldridge@tarleton.edu 2 assistant professor, school of nursing, university of texas at arlington, judkins@uta.edu key words: nurse, rural, health, administration abstract the rural practice setting has unique nursing and health care needs that significantly impact the role of rural nurse executives. this article describes aspects of the rural environment pertinent to rural nursing and helps identify the special competencies needed by nurses who work as managers and executives in rural settings. introduction there is growing recognition that the roles and functions of nurse managers and executives vary according to the setting. studies of health care administration practices indicate that management responsibilities differ by state, size of facility, and practice location (purnell, 1999). the rural environment in particular has several unique characteristics that affect how nurses and nurse administrators function. by exploring the qualities that distinguish rural health care from its urban counterpart we can define some of the implications for nurse executives. characteristics of the rural health care environment health factors certain aspects of rural life have significant implications for health care providers, such as the higher risk factors and proportionally older and poorer compositions of rural populations as compared to urban. tables 1 and 2, representing data from the national center for health statistics (eberhardt et al. 2001), indicate a greater percentage of people age 65 and older living in rural areas than urban, with higher numbers of uninsured rural residents and more who exist on incomes below the poverty line. a larger proportion of rural inhabitants engage in high-risk health behaviors such as cigarette smoking, more are obese, and more consume five or more alcoholic drinks per day. hospitalization percentages and death rates are higher in all age brackets. although the homicide death rate is lower in rural areas, deaths due to both suicide and unintentional injuries occur more frequently. other studies have found that women in rural areas compose 25% of reported aids cases, compared to a national rate of 15%. approximately 1 in every 16 women with aids lives in a rural area, 1 in 10 in the rural south (voelker, 1998). online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.tarleton.edu/%7enursing/ mailto:eldridge@tarleton.edu mailto:school%20of%20nursing mailto:judkins@uta.edu 10 table 1 selected data on urban and rural health: united states, 1996-1999 nonmetropolitan counties (rural) metropolitan counties selected data no city >10,000 city >10,000 small large fringe large central % total population ≥ age 65 15.3% 13.7% 13.0% 11.8% 11.8% cigarette smoking: teenagers 18.9% 15.2% 16.1% 15.9% 11.0% adult men 30.6% 28.4% 27.1% 23.6% 25.4% adult women 26.5% 24.0% 23.7% 19.5% 20.0% obesity: men 22.0% 20.1% 19.6% 19.0% 17.9% women 23.3% 21.0% 19.9% 16.3% 20.2% alcohol ≥ 5 drinks/day 24.8% 29.6% 27.2% 29.5% 24.8% infant deaths per 1,000 births 7.7 7.7 7.5 6.1 7.5 deaths per 100,000: ages 1-24 58.5 46.2 41.7 35.4 44.5 ages 25-64 421.5 399.8 384.9 319.1 419.6 age 65 and over 5,407.4 5,428.4 5,227.1 5,111.4 5,063.8 due to ischemic heart disease 269.2 256.0 239.6 245.9 259.1 due to copd 61.5 64.0 61.1 54.7 52.9 due to unintentional injuries 54.1 44.6 36.5 29.1 31.2 due to homicide 5.4 5.2 6.4 3.9 11.5 due to suicide 18.0 16.5 15.2 12.6 13.2 births per 1,000 female adolescents aged 15-19 57.9 54.6 53.6 36.1 59.6 limitation in activity due to chronic health conditions 18.2% 17.6% 15.8% 13.0% 14.0% total tooth loss among persons aged 65 and over 37.6% 33.5% 29.9% 25.7% 26.8% provider shortage many rural areas fall far short of having sufficient numbers of health care providers. only 10% of physicians practice in rural communities, even though 20% of the nation's people live in rural areas. over 20 million nonmetropolitan residents live in online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 11 table 2 frequency counts and percentages of demographic variables (n=30) with depression nonmetropolitan counties (rural) metropolitan counties demographic variable no city >10,000 city >10,000 small large fringe large central population in poverty 16.1% 14.6% 13.2% 8.0% 15.6% uninsured 21.0% 18.1% 16.1% 12.2% 19.6% physicians per 100,000 population 80.0 147.2 227.7 223.5 308.5 hospital discharges per 1,000 population 92.6 70.8 65.0 67.5 72.9 areas with shortages of primary care physicians (north carolina rural health research program, 1997). forty-five percent of rural health care administrators report a very limited supply of nurses in their region, versus 10% of urban administrators. sixteen percent of rural administrators note significant difficulty in recruiting nurses, as opposed to 7% of urban (lasala, 2000). health care facilities the majority of rural hospitals are small, averaging 74 beds, with nearly half having 50 or fewer beds. in contrast, urban hospitals average 231 beds. hospitals with fewer than 25 beds constitute 10% of rural hospitals and only 2% of urban hospitals. while two-thirds of urban hospitals belong to a multihospital chain, only one-third of rural hospitals are similarly affiliated, their smaller size making them acutely vulnerable to changes in payment systems (mohr, 1999). characteristics of rural nursing rural nurses are generalists and must be comfortable functioning with significant autonomy, increased responsibility for action and decision-making, and self-sufficiency in practice. exceptional assessment and technical skills and a broad base of knowledge are essential, along with creativity and resourcefulness. rural nurses rank flexibility and multiple skills as their most important attributes (crosby et al. 2000), as they must handle a multitude of widely varied duties with limited support from peers and other personnel. they may be required to be on call at all times. it is not uncommon for rural nurses to work in three or more departments on a daily basis, going from the emergency room to labor and delivery to the operating room in a single shift (cook, hoas, & joyner, 2001). online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 12 equipment and supplies are sometimes limited or outdated. nurses often spend more time with rural clients, since low-income clients with poor health status require additional teaching and help with accessing resources. in one study, rural home health patients required a total of 150 minutes more rn direct care time than urban patients (adams, michel, defrates, & corbett, 2001). one of the most prominent characteristics of rural nursing is the lack of privacy and confidentiality afforded both the nurse and the health care client. nurses who work and reside in a small community do not have the anonymity of nurses who live and work in urban settings (bushy, 1999). this compounds some of the ethical dilemmas faced by rural nurses, yet 41% say they are uncomfortable with the subject of ethics and do not know who is supposed to make decisions when ethical issues arise (cook et al. 2001). nurses in rural areas are, on average, older and less educated than those in urban areas. rural hospitals have lower ratios of registered nurses to licensed practical/vocational nurses, and fewer of the registered nurses possess a bachelor’s degree. for example, only 21.8% of the registered nurses in rural brown county in texas hold baccalaureate or higher degrees, while in nearby metropolitan dallas county 55.2% of the registered nurses hold baccalaureate or higher degrees (board of nurse examiners state of texas, 2001). essential competencies for rural nursing administrative practice #1 financial management the ability to plan and implement creative strategies for financial survival in the rural environment. rural hospitals with well developed strategic planning have higher profits, higher operating margins, greater planning effectiveness, lower costs, and higher patient revenues per patient day (smith, piland, & funk, 1992). knowledge of critical access hospital designation requirements, strategies for keeping rural hospitals open, the ability to seek and obtain government grants, and familiarity with various federal and state programs are essential tools in the rural nurse administrator's portfolio. #2 leadership the ability to communicate a comprehensive, integrated vision and lead a rural organization to achieve its goals as a unified team. the difficulties that plague health care in general tend to be intensified in rural areas, making progressive, visionary leadership an important component of the administrative role (carpenter, 2001). executive nurses from both urban and rural hospitals list leadership as their most important role (murray et al. 1998). building a team that works toward a common goal is a challenge in any environment, easier to say than it is to do. fitzpatrick (2001) emphasized that successful leadership begins with trust, including leading by example, maintaining integrity, establishing clear, open, honest communication (overcommunicating if necessary), being available, visible and direct, and thriving on relationships. elements of leadership such as these transcend community settings. another aspect of rural leadership is the role that healthcare facilities and their executives play in the community. hospitals and their administrators are often highly visible to the online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 13 community. rural nurse executives should expect to take an active role in community and civic organizations and in healthcare leadership throughout the area. #3 workforce management the ability to develop and manage a rural workforce. nurse executives in rural areas must be able to organize the nursing delivery system to capitalize on the strengths and abilities of the available workforce while responding to volume and reimbursement issues. successful strategies for recruiting and retaining nurses in rural areas include paying relocation expenses, waiving benefit eligibility periods, giving educational reimbursement, offering finder's fees for recruiting full-time nurses, providing refresher courses for nurses desiring to reenter the job market, and increasing paid time off benefits. with a shortage of physicians as well as nurses, the use of nurse practitioners to provide primary care in rural areas is growing, and has been shown to increase revenues, increase and improve service offerings, and reduce the costs of recruiting physicians (bergeron, neuman, & kinsey, 1999). rural nurses have significant educational needs, partly because most of them have only the minimum nursing education required for licensure and partly because their work requires broad generalist knowledge. access to continuing education programs, however, is usually limited in a rural community. rural nurse executives and managers need to provide opportunities for continuing education in their facilities, encourage interaction between rural nurses and urban peers, form educational partnerships to tap into the resources of urban agencies, and allow for precepted experiences. continuing education offerings should focus on the generalist perspective. citing isolation, lack of information, and inadequate support as their greatest concerns, rural nurses often request activities that allow them to discuss health care issues with other nurses (cook, hoas, & guttmannova, 2000). nurse executives can help by creating electronic mail groups, listservs or chat sites, issuing newsletters, arranging for satellite or online access to university courses, encouraging staff to join professional nursing organizations, and finding other creative ways to support rural practice. educational development may need to include programs that assist nurses in obtaining baccalaureate or advanced degrees. cooperative agreements with local colleges or universities may assist in degree advancement as well as continuing education. growing numbers of schools are offering nursing degrees on the internet, and many organizations provide continuing education hours online. arranging for access to computers with internet connections can facilitate both continuing education and degree acquisition. nurse managers should be encouraged to take advantage of online master's degree programs, perhaps by arranging for a flexible schedule or time off. rural health care agencies can help their nurses by providing information about the many grants, tuition reimbursement opportunities, and loan forgiveness options available for nurses that work in underserved areas. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 14 #4 cross-disciplinary management the ability to manage the delivery of all types of client care, nursing and nonnursing, inpatient and outpatient, in a rural setting of broad-based generalist care. a survey of department heads in a variety of practice settings found that respondents from facilities with less than 300 beds were more likely to be responsible for additional departments, along with nursing, making cross-disciplinary management skills essential for rural nurse executives. nurse administrators in smaller facilities spend more time on marketing activities, community events, and direct patient care than urban managers (purnell, 1999). rural nurse executives are involved in every aspect of operations across a comprehensive continuum of care, from primary to acute to long-term. such integrated organizations are more financially viable and more successful in meeting community needs. case management programs can be efficient care delivery systems in rural areas. case management in the rural community is unique, with a broad, diverse scope of practice that blends individual case management with disease management activities and community interventions (stanton & packa, 2001). nurse executives must be prepared to work closely with interdisciplinary services to ensure prompt discharge processes in both inpatient and outpatient settings. ongoing education of nurses is required to maintain consistent application of case management principles at every stage of service. #5 integration of need-based community services the ability to understand rural environmental conditions and effectively organize health care operations to meet the needs of a rural community. nurse executives should know how to assess and profile health and risk issues of targeted populations within communities. they must understand the political workings of a rural community and be able to facilitate interagency collaboration and organizational relationships to improve health care programs and decrease costs. since rural residents have less political power than urban dwellers, government attention to rural problems is often slow and solutions imperfect. healthcare administrators who understand rural health issues can develop local strategies to meet the community's needs. recognition of high-risk health behaviors inherent in many rural populations should lead nurse executives to shift the health care emphasis to prevention and health education within their communities. collaborative relationships with community agencies such as local or state health departments and senior citizen's centers may offer outreach opportunities to high-risk populations that can ultimately improve health and potentially reduce the need for inpatient hospitalizations. #6 maximizing resources the ability to use advanced communication and information technology to enhance client care and maximize resources in rural settings. synchronous communication technology is available that allows two-way, audiovisual interaction between clients, rural health care providers, and urban specialists located in different geographical areas without requiring physical proximity (fishman, 1997; miller & carlton, 1998). by 1997, nearly 30% of rural hospitals were using some kind of telemedicine technology, and that percentage continues to increase. telecommunication online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 15 and videoconferencing can be used to give information and support to rural residents with chronic illnesses who cannot easily come to health care facilities for follow-up, providing a method for identifying developing problems and intervening early. linking central systems to portable notebook or laptop computers can assist nurses in providing efficient and knowledgeable care to rural clients. nurse executives should lead the development of telehealth resources, capitalizing on the potential savings and advantages to improve rural health care and provide at least a partial solution to the problems of poor access in underserved areas. while knowledge of technology is important to nurses in any setting, the nurse administrator who is competent in acquiring and implementing this technology can help overcome rural provider undersupply. areas for future study it is our desire that this review of the rural practice setting may assist readers to understand the uniqueness of rural health care and its administration. moreover, we hope that the process of identifying essential competencies for nursing administrators will help direct ongoing studies into the special abilities required for leading rural systems. studies of rural nurse administration could take many forms. issues of nurse recruitment and retention in rural areas could be contrasted with urban settings, as could effects of gender and ethnic bias on healthcare. examination of decision-making responsibility and control among nurse managers in rural agencies may guide nurse executives as they lead rural facilities. outcome studies such as community partnering and its impact on population health would assist rural nurse executives in making financial decisions about where to invest limited resources. suggestions such as these are only the tip of the iceberg, but we are confident that these processes will significantly contribute to the practice of nursing administration in all healthcare settings, whether urban or rural. references adams, c.e., michel, y., defrates, d., & corbett, c.f. (2001). effect of locale on health status and direct care time of rural versus urban home health patients. journal of nursing administration, 31, 244-51. [medline] bergeron, j., neuman, k., & kinsey, j. (1999). do advanced practice nurses and physician assistants benefit small rural hospitals? journal of rural health, 15, 219-32. [medline] board of nurse examiners for the state of texas. (2001). currently licensed texas rns residing in texas by county and highest degree. austin, tx. bushy, a. (1999). nursing in the rural community: concepts & practice issues (instructor manual ed.). orlando, fl: university of central florida. carpenter, d. (2001, june). so, you want to be a rural ceo. why? hospitals and health networks, 75(6):64-6, 68. retrieved july 1, 2001, from http://hhnmag.com [medline] cook, a.f., hoas, h., & guttmannova, k. (2000). bioethics activities in rural hospitals. cambridge quarterly of healthcare ethics, 9, 230-38. 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characteristics of the rural health care environment cigarette smoking: teenagers obesity: men deaths per 100,000:  ages 1-24 due to ischemic heart disease births per 1,000 female limitation in activity due to total tooth loss among persons aged 65 and over #1 financial management the ability to communicate a comprehensive, integrated vision and lead a rural organization to achieve its goals as a unified team. the difficulties that plague health care in general tend to be intensified in rural areas, making progressive, visionary leadership an important component of the administrative role (carpenter, 2001). executive nurses from both urban and rural hospitals list leadership as their most important role (murray et al. 1998). building a team that works toward a common goal is a challenge in any environment, easier to say than it is to do. fitzpatrick (2001) emphasized that successful leadership begins with trust, including leading by example, maintaining integrity, establishing clear, open, honest communication (overcommunicating if necessary), being available, visible and direct, and thriving on relationships. elements of leadership such as these transcend community settings. another aspect of rural leadership is the role that healthcare facilities and their executives play in the community. hospitals and their administrators are often highly visible to the community. rural nurse executives should expect to take an active role in community and civic organizations and in healthcare leadership throughout the area. 22 research and collaboration in rural community health kathleen huttlinger, phd1 jennifer m. schaller-ayers, phd2 sr. bernadette kenny, cfnp3 james w. ayers, dsw, acsw4 1 professor and director, center for nursing research, college of nursing, kent state university, khuttlin@kent.edu 2 associate professor, college of nursing, east tennessee state university, schaller@etsu.edu 3 director of st. mary's health wagon, st. mary's hospital, wise, va 4 professor, department of social work, east tennessee state university keywords: rural, community health, community collaboration abstract developing collaborative projects that involve community health nurses, researchers, health providers, community groups and individuals is one way to increase an awareness of critical health needs. this paper describes a community, collaborative effort to bring a remote area medical (ram) event to southwestern virginia and northeastern tennessee. it also presents a description of the information gathered from the attendees of the ram event that was used by local community health care agencies and politicians to leverage state and national officials for increased health care services for this area of appalachia. introduction community participation with the implementation of health programs is an important way to raise the public’s awareness and involvement with acute health problems (maher, 2003; mckinnon, 2002). this paper describes the collaborative efforts of local community health nurses, nurse researchers, community groups and individuals, and local and regional health care providers with a remote area medical (2002) (ram) event in rural appalachia. this collaborative ram event arose out of a need to address access to health care services in southwestern virginia and northeastern tennessee (virginia health care foundation, 2001). officially, ram is "a non-profit, volunteer, airborne relief corps dedicated to serving mankind by providing free health care, dental care, eye care, veterinary services, and technical and educational assistance to people in remote areas of the united states and the world. founded in 1985, ram is a publicly supported all volunteer 501 (c) (3) charitable health relief corps with no paid employees. volunteer doctors, nurses, pilots, veterinarians, and support workers participate in expeditions…at their own expense. medical supplies, medicines, facilities, and vehicles are donated (http://www.ramusa.org). a community group consisting of community health nurses, nurse researchers, nurse practitioners, health providers, local service groups, churches, individuals and other community groups worked together with the ram to offer health care events in two rural communities. the nurse researchers, who are also community health nurses, agreed to assist the project by collecting information from the attendees that could be used to disseminate information about the health care needs of this area to local, state, and national legislators. while ram had provided valuable health services to people in this online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.kent.edu/nursing/ mailto:khuttlin@kent.edu http://www.etsu.edu/etsucon/ mailto:schaller@etsu.edu http://www.etsu.edu/socialwork/ http://www.ramusa.org/ 23 region in the past, no information had been collected from the attendees on the actual availability of health care in their home area, the distances that they traveled to get to the ram site or their specific, and ongoing, health care needs. this paper describes the information that was collected during two ram events that were held in wise, virginia, and mountain city, tennessee, in july and october, 2002, respectively. the driving force behind this collaborative project arose from the recognition of need for a ram event by a local nurse practitioner and community health nurse, sister bernie kenny. sr. kenny operates a mobile health van that delivers primary care services in very inaccessible, mountainous, and remote areas in southwest virginia. in her several years of operating the mobile health van, she was impressed by the large number of people who were in desperate need of not only primary care, but dental and visual health services as well. she contacted the ram organization and asked them to consider southwest virginia as a site for a ram, health care event. in addition to ram personnel, she enlisted the aide of the local lions club, local universities, other service organizations in the area, church groups, hospitals, state dental and optometry associations, medical and nursing organizations, clinics and individuals for support with the event. the amount of support that was rendered varied greatly. there were individual community members with no health care experience who assisted with such things as parking, food service, directing ram attendees to needed services, registering volunteers, registering patients, and transportation of patients from the parking area to the ram site, and other needed services. those volunteers with health care experience included primary care physicians, nurse practitioners, optometrists, dentists, dental hygienists, social workers, psychiatrists and psychologists to name a few. other volunteers dispersed health information about such things as cancer prevention, smoking cessation, depression and family violence. planning for the ram took one year. sr. kenny organized monthly planning meetings for the local volunteers, with meetings increasing in number as the event drew closer. an open invitation was extended and advertised in local newspapers to anyone or any group to participate. the ram organization provided guidelines for setting up the event and assisted with identifying health care providers and others who could assist the endeavor. the scheduling of ram events was determined by the ram organizers and was based upon each community’s resources including the availability of an appropriate site for the event and volunteer assistance. planning for ram used a model similar to patch, planned approach to community health, which was developed by the centers for disease control. this networking model has been successfully used in numerous settings and provides for planning, implementation, and evaluation. horizontal (local) and vertical (regional, state or national) networks emerge while maintaining local ownership (wurzhach, 2003). background and geographical location wise, virginia, is located in the far southwest corner of virginia and is nestled in the hills and hollows of appalachia. the area is noted for its beauty and for the large number of people who exist at or below the poverty level. previous studies have illustrated that this area has higher morbidity and mortality rates than the rest of virginia online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 24 (schaller-ayers, huttlinger, lawson, & ayers, 2001; huttlinger, schaller-ayers, lawson & ayers, 2003). it is an area isolated by rugged mountains narrow valleys and few major transportation linkages to other areas. families have lived in this area for hundreds of years, caring for their own, and working in coal fields, harvesting timber and growing tobacco. the schaller-ayers et al. 2001 study documented many of the problems that working poor people without adequate health insurance encounter when attempting to utilize existing health care services. the findings from this study illustrated that individuals who live in southwest virginia experienced far more health problems than people in other parts of virginia. hypertension, loss of many teeth, mental health problems, diabetes, asthma, arthritis, obesity, and back problems were identified as the primary health problems. health insurance was another consideration, with 96% of the respondents indicating that their quality of life was negatively affected by their lack of adequate health insurance. lastly, people from the 2001 study indicated that despite their ongoing and chronic health problems, their greatest need was for visual and dental health care services. given this information, the ram organizers, along with the community volunteers, determined that the 2002 ram event would primarily focus on dental and visual services although limited primary care would also be available. community members from mountain city, tennessee, requested that a ram event be held in their community as well. mountain city lies approximately 80 miles from wise and is, like wise, virginia, an isolated regional appalachian community with similar health problems and high levels of poverty. this community is located in the very far northeastern corner of the state, with higher morbidity and mortality rates for chronic and debilitating disease than other parts of tennessee (meyer & blumenthal, 1996). in 2002, therefore, two ram events were held, one in wise in july, and the other in mountain city in october. a total of 3,310 people participated in the services that ram offered in wise and mountain city in 2002. a survey of those who attended both events was conducted to determine how satisfied they were with the ram event, to identify their perceived health care needs, and to determine the geographical service area that the ram event covered. the results of the survey were to be used to improve future ram events in the area and to demonstrate to local, state and national political leaders the need for health care services. survey instrument the survey instrument was adapted from an earlier study conducted by the researchers (schaller-ayers et al 2001). it had been previously pilot tested for reliability and validity. there were 25 forced answer items and three open-ended items. the variable categories included: descriptions of who came to the event, how satisfied they were with the services they received, an identification of services most needed and suggestions to improve the event. in addition, the organizers of the mountain city event wanted to include questions about tobacco use and overall health status, two items which were not included in the wise survey as data were collected on this criteria at a previous study (huttlinger, schaller-ayers, ayers & lawson, 2003). completed surveys were obtained from 517 attendees in wise and 235 attendees in mountain city. the following online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 25 table lists the demographics of the ram attendees in 2002 and notes the major services performed. table 1 demographics of ram event, wise, virginia, and mountain city, tennessee, 2002 site number of people attending number of teeth pulled number people having teeth cleaned number of teeth filled number of eye exams number of glasses distributed mountain city, tn 661 533 38 91 304 285 wise, va 2,649 2,908 260 871 1,042 642 method and human subjects approval attendees were approached as they stood in line waiting to register for ram or as they waited to be seen at one of the health care service areas and asked if they would complete a survey form. a disclaimer stated they were under no obligation to complete the survey and that services would not be withheld if they did not participate. the investigators explained the disclaimer to the attendees and assured them that if they participated in filing out a survey that all of their responses would remain anonymous as their names would not be taken or recorded. there were no attendees who agreed to participate with the survey that could not read or write. official human subjects approval was obtained from the organizing committee of both ram events and from the internal review board at east tennessee state university. results the most overwhelming finding was the high satisfaction that people had with the ram event. the mean response for satisfaction with services on a 5-point likert scale was 5. comments from attendees were also extremely positive regarding the delivery of “needed” care. for example, the following is a comment from wise site: “thanks so much. lots of people would be without care if not for this.” another comment from the mountain city site noted, “i was very satisfied. come to johnson county more often. i certainly appreciate everything everybody did for me. thanks so much. be safe and will see you next time. thanks.” the following tables describe survey findings from both sites. table 2 illustrates the percentage of first-time attendees relative to total number of attendees. at both sites, almost 75% of the attendees were first-time users of ram services. in addition to ram services and how often services were used, attendees were asked how many people lived in their household, if they had attended another ram event in appalachia during 2002, and the age range of household members. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 26 figure 1. ram attendees wait to register table 2 ram, first-time attendees online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 27 table 3 number of visits to a ram event this year table 4 ages of household members site mean age of household members mountain city, tn 48.6 years (21-90) wise, va 47.9 years (20-103) the number of visits made by attendees to 2002 ram events during 2002 varied from one to three, with most people (76-81%) visiting a ram event one time. some people could and did attend more than one event in the region (4.7 %). the ram event in wise, virginia, was held over three days, while the mountain city was held for two days. the extra day in wise might have allowed people from out of the immediate region the opportunity to attend. repeat visits in one year were less than 20% for both groups. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 28 table 5 number of visits to a ram event in 2002 the number of people living in each household was also of interest to the ram organizers and community members. the general belief was that there were large, extended families living under one roof throughout the region. however, the average in terms of median was two family members for each household in both communities, which surprised the ram organizers as they expected the number of people living in a household to be much higher. another interest of the ram organizers was the amount of time that it took to get to a ram event. since there is no public transportation in the region, it was believed that people must drive themselves or depend on a relative or friend to bring them to the event. travel time to the ram sites and when people started their trip are illustrated below. for both miles traveled and time traveled, a significant difference existed between wise and mountain city. wise attendees traveled further and were in their vehicles longer than were the mountain city attendees. the range for travel for wise attendees was 1.50250 miles whereas the range for mountain city event was 0.5 to 240 miles. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 29 table 6 number of people per household table 7 miles traveled to a ram event information from previous ram events indicated that people left their home several hours prior to the ram event to get an early place in line for services. table 8 illustrates the hours people left home to get to the ram site and the time that they arrived to receive services. in general, the wise attendees left earlier and arrived earlier than the mountain city attendees to get in line for health services. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 30 table 8 time leaving for ram event site mean hour of day left home range of time mean arrival time range of arrival time mountain city, tn 5:53 am 12 am-10:45 am 6:29 am 3:15am-12:45 pm wise, va 5:06 am 12 am-12:30 pm 6:00 am 1:00 am-12:40 pm since the major focus of ram was to deliver services to the uninsured and underinsured, the organizers wanted to know the extent and kind of health insurance that was held by the ram attendees. in many instances, ram attendees had insurance, such as medicare and medicaid, that provided coverage for primary health care services but did not cover eye and dental care. sometimes, the general public assumes that if one has health insurance then one has access to all health care services, which is not the case. one of the concerns of the ram organizers was that there were unmet health care needs even with those who had insurance. one other point is that sometimes, the deductibles for use of health care insurance were so high that many people elected not to use their insurance coverage and did without health care. tables 9 and 10 illustrate ram attendees’ health insurance coverage. there were no statistical differences between the wise and mountain city sites. more than one half of the attendees had insurance, with medicare and medicaid being the most common carriers. table 9 insurance coverage online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 31 table 10 type of insurance how the attendees learned of an upcoming ram event was important to the organizers. those who attended ram at both sites learned of it through via several sources including friends and neighbors, television, newspapers, and flyers posted at community gathering places. the following pie tables illustrate how individuals learned of the health fairs. since ram services were targeted to the uninsured and underinsured, it was not surprising to learn that health providers were not frequent sources of information. although flyers were considered more useful in wise than mountain city, flyers seemed to be important for both groups. chart 1 sources of information for ram event – mountain city online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 32 chart 2 sources of information for ram event – wise because of a concern regarding points of service, attendees were asked what they would do if ram was not available for their dental and visual care. the following tables illustrate what most people indicated they do if ram dental and eye care were not available to them at these events. table 11 if no ram, what would you do for dental care? online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 33 table 12 if no ram, what would you do for eye care? six items on the survey instrument addressed satisfaction with services received at ram. the following tables illustrate high levels of satisfaction for all services. there were no statistical significant differences for satisfaction levels between the wise and mountain city sites, except for other services. more “other” services were identified at the wise site. the cronbach alpha for these items was 0.92. although information on tobacco use was not collected on the ram attendees in wise in 2002, the information from the 2001 survey was compared to that obtained from the ram 2002 mountain city attendees. there were statistically significant differences between wise and mountain city attendees in data reflecting health status and tobacco use. there were no statistically significant difference for income and exercise. overall, the wise attendees indicated lower health status and greater tobacco use than did the mountain city attendees. there were only slight differences, 2%, in numbers of people using alcohol. attendees’ comments in addition to closed ended questions on the survey form, a space was provided for attendees to write in additional comments about desired health care services not offered at ram, improvements, and suggestions. forty-four percent of the wise and 78% of the mountain city attendees made comments. a few of the attendees’ comments are listed below. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 34 table 13 satisfaction with services table 14 tobacco use and health status site mean income range health status (good to excellent) tobacco use exercise regularly use alcohol mountain city, tn 10,000-14,900 49% 55% 58% 19% wise 10,000-14,999 31% 72% 48% 17% services requested. attendees requested more doctors, dentists, eye doctors, medication, hearing services, dentures, dermatology, diabetic services, physicals, orthopedics, cancer services, cardiovascular check ups, cholesterol screening, and x-rays. examples of comments included: • i really needed a partial plate, real bad. i came so early i still did not get any so i got my teeth cleaned instead. i was very disappointed not getting any partial. • flu shots and other types of shots. people with bad health problems that need these services have a way for them not to have to wait as long as everyone else but they need proof of their illness. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 35 need for further ram events. overall, attendees desired ram services to be available more frequently, have longer hours, and more days. examples of these comments included: • have this service more than three days. all people in this area are poor, and have no insurance or jobs. it would be great if this service could last a bit longer because lots of people get turned away. • have more days and be here longer. organization. attendees desired greater organization of services offered. for example, they commented: • hand out numbers when you get off the bus to prevent people from skipping line. • i suggest entertainment and more shelter and chairs. • reduce smoking in line! • i got 11 teeth pulled and feel great. would do it all over again. • eye care and dental care is the most important and to do partial. the wait could not be as long and they could offer food or drinks and chairs. they could also give pain medicine when you get a tooth pulled. summary and conclusions this paper described how community health nurses and nurse researchers collaborated with other health care providers in a rural area to enlist the support of the community to host a ram event. information collected from ram attendees was used to better plan future events and to increase public awareness of the need for health care in rural appalachia. importantly, this awareness was transferred to hard data that could be used by legislators at local, state and national levels to leverage money and programs for health care. this collaborative effort yielded not only a health care service event for an underserved area but revealed important information about access to health care services as well. the actual findings from this study indicated that the attendees at both sites were very satisfied with services provided, but wished that the services could be offered more frequently. in addition, although the majority of the attendees had some form of insurance, having health insurance did not guarantee access to needed health care. the attendees had low income levels, high tobacco use, and poor health status ratings. these findings alone indicate a need for comprehensive and affordable health care for all and how the collaborative efforts of a community can raise public awareness of a critical health issue. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 36 references huttlinger, k., schaller-ayers, j., & lawson, t. (in press). population-based care: an appalachian case study. journal of public health nursing. maher, d. (2003). the role of the community in the control of tuberculosis. tuberculosis, 83, (1-3), 177-182. [medline] mckinnon, m. (2002). the participation of volunteers in contemporary palliative care. australian journal of advances nursing, 19(4), 38-44. [medline] meyer, g.s., & blumenthal, d. (1996). tenncare and academic medical centers: the lessons from tennessee. journal of the american medical association, 276, 672676. [medline] remote area medical volunteer corps. (2003). what is remote area medical? retrieved january 26, 2003, from http://www.ramusa.org schaller-ayers, j., huttlinger, k., lawson, t., & ayers, j. (2001). health care access in rural appalachia. symposium presentation at “head for the hills: a retreat for primary care providers,” breaks interstate park, october 26, 2001. virginia health care foundation. (2001). results of virginia’s 2001 health access survey. joint commission on health care. richmond, va: virginia health care foundation. wurzhach, m. (2002). community health education and promotion: a guide to program design and evaluation. gaithersburg, md: aspen publications. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12758209 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11111426 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8769543 http://www.ramusa.org/ microsoft word nichols_article.doc 40 complementary and alternative medicine providers in rural locations elizabeth nichols, dns, rn, faan1 clarann weinert, sc, phd, rn, faan2 jean shreffler grant, phd, rn3 bette ide, phd, rn4 1 professor, college of nursing, montana state university, bozeman, egnichols@montana.edu 2 professor, college of nursing, montana state university, bozeman, cweinert@montana.edu 3 associate professor, college of nursing, montana state university, jeansh@montana.edu 4 professor, college of nursing, university of north dakota, betteide@mail.und.edu keywords: cam, rural health care, naturopathic practice abstract the purpose of this study was to determine the availability of complementary and alternative medicine (cam) resources to individuals in twenty rural communities in two western states and to ascertain the contribution of one type of cam provider, naturopathic physicians, to rural health care. resource data were collected through internet phone directories searches and an on-line survey of montana naturopaths. seventy-three cam providers were identified in the target communities. the naturopathic physician’s practices were located in urbanized areas of montana, some with outreach clinics. most naturopaths made regular referrals to conventional medical practitioners; however few received referrals. comparison of use patterns of cam by older residents of these communities to the presence of providers in the communities suggests that local availability is not the critical factor in use of a cam therapist or self-directed therapy. introduction the availability of health care in rural areas is a national policy issue (institute of medicine, 2005), particularly as the older populations in rural communities is increasing. isolated rural communities often have difficulty recruiting and retaining primary or specialist health care providers. long distances over poor rural roads and through often unpredictable winter weather add to the challenges that older rural residents face in obtaining health care. improving access to care requires understanding the care older rural dwellers seek, their use of health care, and the distribution of resources: mainstream, complementary, and self-directed. rural residents tend to be more independent, engage in more self-care, and have less access to allopathic care than do urban residents. the access of rural residents to alternative health care (cam) is less well documented. studies of cam use show conflicting results for a variety of reasons: varying definitions of cam, limitations in sampling, and more focus on urban and suburban areas than rural ones (barnes, powell-griner, mcfann, & nahin, 2004; harron & glasser, 2003; johnson, 1999; vallerand, foulabakhsh, & templin, 2003). shreffler-grant and colleagues (shrefflergrant, weinert, nichols, & ide, 2005) found use of cam among rural residents online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://www.montana.edu/nursing/ mailto:egnichols@montana.edu http://www.montana.edu/nursing/ mailto:cweinert@montana.edu http://www.montana.edu/nursing/ mailto:jeansh@montana.edu http://nursing.und.edu/ mailto:betteide@mail.und.edu 41 approximated rates of use reported for urban and suburban populations when the use of self-directed practices was included in the definition of cam. self-directed practices included such things as nutritional and herbal supplements, meditation, use of magnets, and other non-provider delivered treatments. use of cam therapists, however, was found to be significantly lower in this rural population than in national studies. in this paper we are reporting the subsequent research by the shreffler-grant research team on the availability of cam resources (providers and purchasing outlets). this study was a further investigation of cam use in the 20 communities involved in the original study (shreffler-grant, weinert, nichols, & ide, 2005) and included an exploration of the contribution of one type of complementary provider (naturopathic physicians) to the delivery of health care in rural areas. examining the location of cam providers in relation to users may provide some insight into use patterns and how cam providers articulate into the overall health care system in rural areas. distance from one's health care provider has been posed as a barrier to health care utilization, and rural dwellers generally live some distance from their providers. in a recent study of 233 rural women living in montana and the contiguous states the average distance to emergency care was 16.7 miles (one way) and to routine care it was 57.3 miles (one way) (weinert, 2002). nemet and bailey (2000) and arcury, gesler, preisser, sherman, spencer, and perin (2005) suggested that it is the location of providers in relation to the individual’s normal activity space that is more important than the actual distance involved. that is, health care services are more likely to be used if they are convenient to the normal activities of life. arcury et al. found that distance was not significant to obtaining chronic or acute health care, but did impact upon discretionary care, care for health promotion or disease prevention purposes, rather than care in response to illness or disease. cam use by older rural residents in north dakota and montana the initial exploration of the use of cam by the research team was conducted with older adults living in 20 rural communities in montana and north dakota. all towns with populations of 500 or greater, but less than 20,000 and not within 25 miles of a population center of 20,000 people or greater were identified. twenty towns (ten in each state) were selected randomly from the total. a random sample of 325 individuals was interviewed by telephone (shreffler-grant, weinert, nichols, & ide, 2005). as noted earlier, use of cam therapists was less than that found in other prevalence studies, although use of dietary supplements, herbs, etc. was consistent with prior research. as the research team considered reasons for this discrepancy, two major questions emerged. first, are there therapists available in these rural communities? second, do the beliefs and attitudes of the respondents prevent them from considering and using cam? to determine whether there were cam therapists or places to purchase supplements in these communities, the researchers tried to identify all complementary and alternative health care providers available in the 20 communities of the original survey through internet and paper-based phone directory searches. internet phone directories searched were: yahoo! yellow pages, and yellowpages.com. the searches online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 42 were done by zip code and by general categories, such as alternative medicine, pharmacies, chiropractors, massage, etc. only providers with mailing addresses in the predetermined town zip codes were selected. pharmacies were included in the list of therapies/therapists because in rural communities the pharmacies often stock dietary supplements and other complementary and alternative mixtures. in addition, dexonline.com, the online directory for qwest, was searched by using names of town and state. this search resulted in no additional information. to determine if there were differences between the paper copies of dex, the qwest official directory of montana and the internet version, montana phone books were examined and the results compared. as no differences were found, only the internet directories were used to identify north dakota providers. the internet search for complementary therapists, e.g., acupuncture, aroma therapy, massage, chiropractic, etc. was conducted using the msn search engine at http://www.msn.com/. the object was to locate online provider listings and caches of registered members contained within professional organizations, such as the american chiropractic association. such sites were searched by zip code and the registered members from each organization retrieved. information found included individual practitioners and offices in which they practiced. specific therapies or sites searched included chiropractic, health club, massage therapy, natural and organic food, naturopath, nutrition and supplements, pharmacy, podiatrist, reflexology, and other, e.g., yoga, reiki, therapeutic touch, biogenesis. the categories of providers which were identified in the rural communities are shown in table 1. table 1 complementary and alternative care providers in target communities by type and state provider type north dakota montana total chiropractor and massage therapy 1 1 2 health club 0 3 3 chiropractors 10 12 22 massage therapy 5 9 14 natural and organic food 1 4 5 naturopath 0 1 1 nutrition and supplements 1 3 4 pharmacies 9 8 17 podiatrist 0 3 3 reflexology 0 1 1 yoga, reiki, therapeutic touch, bach flower remedies, biogenesis and hanna kroeger's 0 1 1 totals 27 46 73 online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://www.msn.com/ 43 examining the availability of cam providers in rural communities was just one piece of the puzzle of rural health care accessibility. we wondered whether cam providers traveled to other more remote rural communities to deliver services as some mainstream providers do, to what extent cam providers were seen as primary care providers, how people learned about local cam providers, and what the referral relationships were between mainstream and complementary providers. to begin to find information about those components of the puzzle, we conducted an internet-based survey of the naturopathic physicians in montana. this group was selected as they are licensed in several states, they present themselves as primary care providers, there were comparative data from other states, and we were able to access these providers through their state professional organization. the survey of the practice characteristics of naturopathic physicians was sent to all twenty-five licensed naturopaths in montana after approval by the montana state university institutional review board for the protection of human subjects. following a sequence of prompts and resending of the questionnaire, 11 naturopathic physicians completed the survey for a 44% response rate. findings cam provider availability a total of 73 complementary providers were identified across the 20 rural towns. forty-six of these were in montana towns and 27 in north dakota towns. in both states, chiropractors were the most common providers identified:10 in north dakota towns and 12 in montana towns. this is consistent with the pattern of provider use found in the original study – chiropractors were the most used cam provider. two towns in each state listed no alternative therapists. after chiropractic, pharmacies (16 listings) and massage therapy (14 listings) were the most common. with the exception of pharmacies, there were higher numbers of alternative providers in montana towns than in north dakota towns. also, the variety of providers was greater in montana than in north dakota (see table 1). characteristics of naturopathic practices all of the naturopathic physicians had their primary practices in the more urbanized areas of the state, although three of them indicated they did have outreach practices in smaller communities. they reported traveling an average of 147 miles to the more rural sites, and said that patients traveled an average of 25 miles to their primary practice site. when asked what percent of their patients they saw as a primary care provider, 64% of them indicated that over half of their patients saw them for primary care. their clients, they reported, selected a naturopath primarily because they did not feel that the mainstream provider had been effective in treating them (n = 11, 100%), they had a desire for a more natural approach to health care (n = 10, 91%), and/or that the mainstream provider did not spend enough time with them (n = 8, 73%). naturopathic physicians stated that patients learned of their services mostly by word of mouth (n = 11, 100%) and/or through listings in local telephone books (n = 7, 64%). almost two-thirds online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 44 (63.6%) of the respondents indicated they made monthly referrals to mainstream providers. however, only 36% indicated that they received any referrals from mainstream providers, and these were estimated to be at the rate of one a year. another 36% indicated they had never received such a referral. discussion care seeking behavior is very complex and there are interrelationships between many of the variables hypothesized to predict health care use (arcury et al. 2005). these interrelationships are made even more complex when the role that cam is increasingly playing in health promotion and illness management is considered. differences in cam use found in the original study are not well explained by the availability of providers in the selected communities. north dakotans were more likely to use complementary therapists than were montanans; however, it was evident that there were more, and a greater variety of, cam providers in the montana communities. montanans were more likely to use cam practices that were self-directed or not administered by a cam practitioner than were north dakota participants – 45.6% compared to 26.1% (shrefflergrant, weinert, nichols, & ide, 2005). this discrepancy between use patterns and the availability of providers in the two states suggests that local availability is not the critical factor in the decision to use or not use cam. boon and colleagues (boon et al., 2004) in a two-state study of cam providers, reported that visits to naturopathic physicians were primarily for chronic complaints and that these visits lasted a mean of 40 minutes – similar to the data reported by our sample of naturopaths. cherkin and associates (cherkin et al., 2002) in another publication from the same study noted that visit rates to these providers was low, a finding consistent with our work. while naturopaths may be increasing in number, they continue to be a small component of health care delivery in rural areas. with the mainstreaming of cam it is increasingly difficult to get an accurate picture of the availability of products and providers. thus we recognize that these results likely represent an under-estimate of the availability of dietary supplements and other self care cam products in rural areas. these products are now readily available in grocery stores, general merchandise stores, as well as by mail and over the internet. the use of providers is also less limited by local availability as has been noted earlier; use of services is more related to trade patterns than to absolute differences in availability of providers. rural individuals group activities around trips to trade centers, thus a trip to a larger community may well include a stop at a discount store that sells dietary supplements, a visit to the cam provider, a stop at the farm and feed store for supplies, and a stop at the grocery store. in fact, all of these may be accomplished at one stop! andrews (2003), a researcher in great britain, suggested that when complementary providers are grouped into a practice, there is greater use and use of a greater range of therapists, and, further, people will travel greater distances for treatment than is the case when cam providers are in individual practices. the group practices, they noted, were generally in well-populated areas; practices in rural areas tended to be individual in nature. we found that rural residents traveled significant distances to visit the naturopathic provider who met their needs and offered a relatively broad set of cam online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 45 options. economic and socio-cultural realities also impact on the selection of practice sites of providers (andrews & phillips, 2005). this appears to be the case in this study where the practice sites for the naturopaths were in the state’s population centers that offered a market potential, opportunities for cultural and social activities, and the potential to be close to colleagues, factors found to be important to cam providers in choosing practice locations (williams, 2000). these factors have also been found to be important in the choice of practice locations for mainstream health care professionals (robinson & guidry, 2001). limitations data on provider availability were only collected from twenty communities in two states and in one section of the united states, therefore it is not known whether these provider and consumer patterns are reflective of the broader set of rural communities and residents. it has become increasingly difficult to define cam and cam providers and to differentiate between cam and mainstream providers since some mainstream providers have begun to integrate cam into their allopathic practices. further, as only a few of the various cam therapies require licensed providers, identification in this study was reliant upon self-disclosure (advertising) and participant report (who they used). this probably does not result in an exhaustive list of the providers in these various communities, however, it does provide a picture of those providers who were used and why they were used. conclusions these two studies, while modest in nature, begin to clarify how and why rural residents use cam and the relationship between cam use and mainstream medicine. clearly additional research is needed to more fully understand the true rates of cam use and whether that use is related to availability of cam providers in rural areas, distance to cam and mainstream providers, beliefs and attitudes regarding cam use, or some combination of these and additional factors. understanding the role that cam plays in overall health promotion and illness management among rural residents is important in rural health care practice, and warrants additional research. health care professionals working with rural residents need to be well informed regarding cam therapy and therapists in order to better assist their clients in making informed health care decisions regarding the use of cam. acknowledgements the research team wishes to acknowledge the work of student research assistant becky dusenberry in the collection of the provider location data. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 46 refernces andrews, g. 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(2000). distance and health care utilization among the rural elderly. social science medicine, 50, 1197-1208. [medline] robinson, j., & guidry, j. (2001). recruiting, training, and retaining rural health professionals. in s. loue & b. quill (eds.), handbook of rural health (p. 337353). new york: kluwer academic/plenum publishers. shreffler-grant, j., weinert, c., nichols, e., & ide, b. (2005). complementary therapy use among older rural adults. public health nursing, 22, 323-331. [medline] vallerand, a., foulabakhsh, j., & templin, t. (2003). the use of complementary/alternative medicine therapies for the self-treatment of pain among residents of urban, suburban, and rural communities. american journal of public health, 93, 923-925. [medline] weinert. c. (2002). rural chronically ill women: online support network. unpublished raw data. williams, a. (2000). the diffusion of alternative health care: a canadian case study of chiropractic and naturopathic practices. canadian geographer, 44, 152-166. online journal of rural nursing and health care, vol. 6, no. 2, fall 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14499218%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15955291%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15663706%5buid%5d http://nccam.nih.gov/news/camsurvey.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=puresearch&db=pubmed&details_term=15496231%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12350060%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12839136%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10628113%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10728841%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16150013%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12773356%5buid%5d 28 health and health practice in rural australia: where are we, where to from here? karen francis, phd, rn1 1 associate professor, school of nursing and midwifery, monash university, karen.francis@med.monash.edu.au keywords: rural health, rural practice, australia, recruitment and retention, service delivery, disadvantage abstract this paper provides an overview of rural health discourse in australia highlighting contemporary rural health practice, models of care and the challenges experienced in recruiting and retaining an effective workforce. socioeconomic difficulties, inequitable access to services including education and health, lower employment levels, harsher environments, occupational hazards, and geographic and social isolation are factors identified as contributing to rural disadvantage. these concerns are described by health professionals when asked if they would consider rural practice as a career option. new initiatives designed to improve the recruitment and retention of health practitioners including nurses to “the australian bush” are explored. introduction australia is often described as the "lucky country" yet evidence suggests that many australians are disadvantaged and have poor health (best 2000; australian institute of health and welfare aihw 2003). cheers (1990; 1998) argues that people who live in rural and remote australia have poorer life chances than their urban counterparts, while phillips (2002) concludes that health status decreases with increasing remoteness. the human rights and equal opportunities commission found that. the health of populations living in rural and remote areas of australia is worse than that of those living in capital cities and other metropolitan areas. mortality and illness levels increase as the distance from metropolitan centers increases. relatively poor access to health services, lower socioeconomic status and employment levels, exposure to comparatively harsher environments and occupational hazards contribute to and may explain most of these inequalities. also, a large proportion of the population in the more remote parts of australia are aboriginal and torres strait islander people, who generally have poorer health status (aihw, australia’s health 2000, p. 223). the provision of an equitable health service is seen as a human right, yet health service delivery in rural and remote areas in australia are more limited in range than in urban areas (francis et al. in national review of nursing education 2002). the rural, remote and metropolitan area (rrma) classification system defines "rural" communities as those with a population of 5,000 99,999 and "remote" communities as those with populations less than 5,000 (australian government 2005). rural and remote communities desire and need the services of a range of health professionals yet recruitment of health professionals to these areas is problematic. it is proffered that there is reluctance by many health professionals to work in small rural areas and an inability by health services to employ the range of health professionals online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.med.monash.edu.au/nursing/ mailto:fwood@bama.ua.edu 29 required to meet community needs (australian medical workforce advisory committee, ‘amwac’ 1996; francis et al. in national review of nursing education 2002; hegney, 1997; larson, 2002). this paper explores the socio-political, economic and professional concerns underpinning health professional’s decision making when considering career opportunities that include practice in the "bush" and highlights the nature of rural health practice as it is currently experienced in australia. finally, recruitment strategies developed by government and rural communities to attract health professionals are described. rurality handley (1998) suggests defining "rural" is difficult because rural environments are diverse and must include a range of seemingly unrelated usage of land geographically distant from urban centers such as dairy farming areas, forestry, wheat and sheep country, seaside tourist resorts, horticulture and fruit growing regions, mining districts and industrial areas. humphreys and rolley (1991 in handley 1998, p.2) consider rural australia “… characteristically encompasses large distances, sparsely distributed populations, often harsh environments, extensive land uses and social and economic diversity.” while the term "rurality" has been used to describe behavior or lifestyle in a context which is not urban, gray and lawrence (2001), believe rurality refers to “… the distinguishing features of rural life and the condition of possessing them, which make differences apparent between urban and rural situations.” they further contend that a "rural ideology" pervades the discourses focused on rurality. this ideology embraces dogma which views farming as a noble endeavor because those engaged in such business are hardworking, are characteristically persevering and they epitomize the australian image of family. this ideology is embraced by rural communities, politicians and other australians and has traditionally been linked to the myth that living in the country equates with a healthy lifestyle. humphreys and rolley (1991, p. 19), in handley (1998) explain that a number of methods have been used to arrive at an unambiguous definition of rural. they argue that there is no agreed consensus as definitions are developed in response to the research being undertaken. these definitions describe rural as being “… synonymous with anything which is non-urban in character to positive attempts to specify important elements of rural identity” (humphreys and rolley 1991, p. 19), in handley (1998). hegney and mccarthy (2000) and humphreys and rolley (1991, p. 1) suggest that people who live in rural and remote australia experience many health disadvantages. these include higher mortality and morbidity rates for some diseases, higher exposure to injury in the workplace, socioeconomic disadvantage, and inequitable access to health services in comparison with urban counterparts (simmons & hsu-hage in wilkinson & blue, 2002; mcmurray, 2003). this description echoes the situation in new zealand, canada and the united states of america (bushy 2000; mcmurray, 2003). contemporary australian rural communities contemporary australian rural communities are characterized by diverse populations that include indigenous and non-indigenous australians and immigrant online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 30 peoples (smith 2004). rural people see themselves as different from city people; they are proud of their heritage and the type of lives they live. however, life in the bush has changed. rural communities are declining and there is a net movement of people from the bush. jensen (1997 in smith 2004) describes these changes as the "rural crisis" indicating that this phenomenon is attributed to "new managerialist" practices, years of drought and a government policy that has embraced centralization as an efficiency strategy (francis et al. in national review of nursing education, 2002). as a result rural communities are faced with many social, economic and cultural challenges, all of which impact on the viability of the community. globalization has indirectly resulted in the decline of the rural sector, a net loss in circulating money and changed community demographics. young people move from rural communities out of necessity to more populous centers that offer greater opportunities for education, employment and career development (aihw 2003). this experience, coupled with community inability to match opportunity available in urban and larger centers, acts as a recruitment and retention disincentive for rural professionals. the rural health workforce the rural health workforce includes nurses (who represent 65% of the total health workforce), medical doctors, indigenous health workers, allied health staff, pharmacists and others, with the diversity and the number of health professionals inversely related to remoteness (francis et al. in national review of nursing education, 2002). vacancies are reported for all health professional groups, with the level rising the more remote the setting (aihw 2003). best (2000) acknowledges that the shortage of rural doctors has been a government priority for many years. he claims that a range of strategies have attempted to address the rural doctor crisis including financial incentives, recruitment of overseas trained doctors and the establishment of rural workforce agencies (rwa). research demonstrates that some doctors consider rural communities to be socially and culturally under-resourced and question the financial viability of rural practice. doctors also name poor collegiate support, limited access to locum relief and reduced career opportunities as factors that negatively influence their choice to practice in the bush (best 2000). alexander (1998) believes that national and state initiatives have failed to address the personal issues identified by doctors such as family education, housing and resourcing needs. the issues and support structures required by doctors are similar to those reported by nursing and allied health professionals. unfortunately there has been little consideration of the needs of these members of the rural health workforce (amwac, 2000; bishop, 1998; malko, 2001; hegney, 1997) the australian institute of health and welfare (aihw, 2003) report that the rural nursing workforce is in crisis. in 1999 alarm was raised in all australian states and territories that nursing graduate numbers were insufficient to maintain the workforce (smith, 2004) and that the shortages were most critical in rural areas. the profession of nursing has endeavoured to draw attention to the issues underpinning this crisis; however, government has been slow to recognize and accept responsibility for addressing nursing matters (handley 1998). recently a national nursing workforce taskforce (national nursing and nursing education taskforce) was established, with a remit to investigate online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 31 and develop strategies for addressing nursing concerns identified in the national review of nursing education (2002) and the senate inquiry into nursing (www.aph.gov.au). it appears that a situation of crisis must be reached before nursing issues are acknowledged by the australian government. rural health practice blue (in wilkinson and blue, 2002) argues that rural health professionals have common practice characteristics that are different to urban counterparts. he believes that rural health professionals have a broad scope of practice and diverse practice skills, are professionally isolated, and find it difficult to access professional development programs but have more autonomy in their practice. he concedes that the rural health workforce is aging, practitioners have high workloads and often live a "fish bowl" existence (blue in wilkinson and blue, 2002, p. 200). rural practice, maintains best (2002), requires practitioners to be highly skilled, have a broad well-developed knowledge-base and be capable of working in resource-poor environments with little collegiate support. while many studies argue that rural health professionals should have specialist training before they begin to practice in these environments (blue in wilkinson and blue, 2002; cramar 2000), hegney maintains that rural nursing practice must remain generalist in nature. there is however ongoing debate about the level of skills and knowledge required by nurses for rural practice. australian governments at all levels (commonwealth, state/territory) are being forced to focus on addressing the rural health workforce shortfalls, and it appears that the preparation for rural practice programs at the undergraduate and postgraduate levels is one area being targeted as part of a recruitment and retention strategy. many australian universities have included in undergraduate health programs rural health issues and related clinical exposure, and have taken advantage of incentives provided by the australian government to support such programs (dunbabin & levitt 2003; francis et al. 2004; strasser in wilkinson & blue 2002). there is a growing body of evidence that indicates that students who are recruited from rural communities and educated in rural universities are more likely to practice in the bush after graduation (smith 2004; dunbabin & levitt 2003; strasser in wilkinson & blue 2002). rural health professionals report that maintaining currency of their skills and knowledge-base is difficult. they cite an inability to secure locum relief and backfill positions as inhibiting factors (francis et al. in national review of nurse education 2002). the need for many rural health practitioners to travel to access professional development, training and education is identified as limiting their ability to access educational opportunities (smith 2004). the issue of professional isolation is reported in the literature as a key factor impacting on health professionals' decisions to work and/or stay in rural practice (wilkinson and blue 2002; smith 2004; francis, bowman, & redgrave 2002). best (2000) argues that the expectation that rural practice is a life commitment has been a disincentive for many graduates to take up the challenge of rural practice. recently, issues including personnel safety and security have been raised as issues of concern that are reportedly impacting on recruitment and retention of rural health professionals (aarn 2004). online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 32 recruitment and retention the recruitment of health professionals is a key concern for all levels of government in australia. in an attempt to increase the number of undergraduate health students to consider rural practice, a number of incentive schemes have been implemented. the australian government has funded scholarship programs including the john flynn medical scholarship scheme, the rural australian medical undergraduate scheme (ramus), the undergraduate and postgraduate rural and remote nurses scholarship scheme (currns) and the undergraduate allied health scholarship scheme (crrahs). in addition, a bonded rural medical scholarship program has been introduced to increase the number of graduate medical students practicing in rural australia (http://www.sarrah.org.au/nrrahas/summary_of_scholarship.pdf). the australian government has supported the establishment of university departments of rural health who are charged with supporting and facilitating multidisciplinary education, training, and professional development including the clinical placement of students and the establishment of rural medical clinical schools to increase the exposure of medical students to rural practice (strasser, 2002). funding has been made available to a number of professional organizations to support rural and remote practice such as association for australian rural nurses (aarn), council remote area nurses australia (crana), council of aboriginal and torres strait islander nurses (catsin), rural doctors association of australia (rdaa), australian college of rural and remote medicine (acrrm), services for australian rural and remote allied health (sarrah). more recently the australian government has announced changes to the medicare rebate scheme and increased funding to aged care services (australian government 2003). under the medicare changes divisions of general practice receive additional funding including rebates for practice and nurse initiated interventions. additionally, incentive programs have been made available to support general medical practice development in rural areas. the majority of these initiatives, however, have focused on supporting medicine with little consideration of nursing and allied health. the potential attractiveness of rural practice is complicated by high levels of vacant positions that remain vacant due to non-appointment and poor recruitment strategies. this leads to gaps in service, frustration and increasing workload by incumbent practitioners. the frustration experienced by disenfranchised staff becomes known and may result in some practitioners seeking alternative employment, choosing urban-based practice or simply leaving the health workforce in general (aihw 1996; francis et al, in national review of nurse education 2002). many local governments in rural australia have responded to the critical shortage of health professionals and developed policies and practices designed to attract staff. it seems obvious that a multi-sectorial approach to recruitment and retention is needed if the workforce issues are to be tackled. while governments have implemented recruitment initiatives there has been limited consideration of long-term retention strategies, although it is acknowledged that the australian government is supporting "rural mentorship" projects for undergraduate student nurses and more recently the incumbent rural nursing workforce to limit professional and social isolation (mills et al. 2005). however, addressing the workload issues, safety, and access to education and providing incentive and appropriate level online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.sarrah.org.au/nrrahas/summary_of_scholarship.pdf 33 remuneration packages for all health professionals, particularly nurses and allied health professionals, remain the dream with little evidence that long-term planning is occurring. models of service provision health professionals practice in environments and in a manner reflective of contemporary thinking. mclean (1998, p. 1) points out that in rural australia there has been an increasing emphasis on “… primary care and health promotion and illness prevention has been commonly supported even if not put in place in every rural community.” meeting the needs of rural communities by providing quality health services is a priority. the challenge facing all governments is how to fund equitable, quality services that provide the range and diversity of health expertise in rural areas that urban people take for granted. models that are currently used to supplement and/or replace existing services include: • integrated services, e.g., multi-purpose centers, regional health services • discrete service providers, e.g., general practice, nurse practice models, case management • outreach arrangements, e.g., mobile services (royal flying doctor service, ‘rfds’), visiting medical specialists, oral health services • information technology, e.g., telehealth, oral health education and training (humphreys in wilkinson and blue 2002, p.286) many rural health services have experienced successive reformation of service delivery models generally in response to changing governments. health indicators for rural and remote populations, however, remain unchanged (aihw 1996; 2000; 2003). sustainable, effective models of service provision that are integrated and multidisciplinary in nature will only be achieved if there is collaboration between rural communities, rural health practitioners and the health bureaucracy. conclusion all australians have a right to an equitable range of health services. it is recognized that with increasing remoteness the diversity of services that can be provided is limited when economies of scale underpin funding mechanisms. this approach to management is endemic in all industries including education, health, policing and banking and has resulted in the rationalization and centralization of many services that once were diversified throughout australia. the impact on rural communities has been a down turn in many rural economies and an associated leakage of human capital to centers of higher population in search of educational and career opportunities. the popular portrayal of rural communities as crippled by adversity such as that described reduce the potential for these communities to attract and retain health professionals. rural practice is challenging and rewarding but must be sold if these communities are to be serviced equitably. government initiatives including incentive and remuneration initiatives must be coupled with local government and industry strategies to promote rural living and rural practice if health professionals are to be recruited and online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 34 retained. in addition, the number of students undertaking health education programs must be increased and rural practice preparation included in all health curriculum if workforce needs are to be met. references alexander, c. 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(2002). the new rural health. south melbourne: oxford university press. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.nnnet.gov.au/ http://www.aph.gov.au/ microsoft word leks_manuscriptphysical activity.doc 56 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 physical activity within rural families of overweight preschool children: a pilot nuananong seal, ph.d., rn 1 eleanor yurkovich, ed.d., rn 2 1 assistant professor, college of nursing, university of north dakota, lekseal@mail.und.edu 2 professor, college of nursing, university of north dakota keywords: physical activity, overweight, preschool, parents, motivation, qualitative descriptive design abstract the purpose of this descriptive qualitative research was to explore physical activity patterns of families of overweight preschool children aged 3 to 5 years living in a predominantly rural agricultural state. this paper presents the second part of a dually focused study related to healthy eating and physical activity (pa) in this selected population. methodology used was a focus group discussion with 10 parents of overweight preschool children aged 3 to 5 years. transcripts were coded and analyzed for emergent themes using n vivo qualitative analysis software. the findings revealed that all parents were not engaging in any healthy structured pa beyond their daily functioning actions and were not involved in organized sports; however, they had some knowledge of the significance of pa and its benefits for themselves and their children. also, the parental participants‟ perceptions that the children were active (busy with their own play) and their weights were acceptable (as compared to other children) probably influenced their lack of recognition for the necessity of healthy structured pa. they did identify personal and environmental barriers to engaging in pa. the results provide significant implications for health professionals in planning/developing educational materials for pa interventions, enhancing motivation for pa of rural populations and working towards the reduction of barriers through policy and relevant resource acquisition. continued research with this population could inform health care providers about more culturally appropriate ways to increase motivation to do and effective environments for physical activity within a rural population. introduction childhood obesity is one of the most multifaceted health problems currently challenging the nation, with serious medical and financial implications for the future (finkelstein et al., 2004). being overweight in childhood has been linked to an increased risk for cardiovascular disease, hypertension, cancer, sleep problems, orthopedic disease, and obesity in their adult years (world health organization, 1997). in addition, the connection between overweight children and type 2 diabetes is apparent (young-hyman & schlundt, 2001). since early obesity has adult adverse health consequences, intervention aimed at early childhood prevention is a high priority. recognition of the increasing overweight status of children has prompted the need to identify factors associated with this trend. it seems certain that besides unhealthy eating patterns an increase of childhood obesity has coincided with a lack of physical activity (united states department of health and human services, 2000); physical activity levels among children are progressively decreasing, and the prevalence of obesity in children is escalating. a midwest study comparing rural youth to a national sample revealed that rural youth were less active than urban youth (paxton, estabrooks, & dzewaltowski, 2004). prevalence of overweight was also higher among rural children than ones from urban areas (joens-matre, welk, calabro, russell, nicklay, & hensley, 2008). a review of research on rural–urban differences pointed that the higher http://www.nursing.und.edu/ mailto:lekseal@mail.und.edu http://www.nursing.und.edu/ 57 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 prevalence of obesity in rural areas may be attributed to the lower socioeconomic status (ses) of rural populations (wang, 2001). the association between this demographic variable and obesity prevalence; however, needs to be further researched. promoting physical activity in young children may be a promising intervention for preventing obesity thus, improving the prognosis of their health status as adults. there is strong evidence that physical activity contributes to a healthy lifestyle, prevents obesity (chakravarthy & booth, 2004), plays a key role on body fat morphology, and contributes to the social and mental wellness of young children (logstrup, 2001). furthermore, a recent study suggests that high levels of physical activity beginning in the preschool years may delay the onset of the period of rapidly increasing body fat that generally occurs between the ages of 4 and 6 years (moore et al., 2003). the decline in everyday activity, outdoor sports, and the ubiquitous accessibility of computers, (including computer games, internet and chat rooms) coupled with increased television viewing have all been linked to an increase in obesity among children (steinbeck, 2001). in addition, children who become overweight during the preschool period are at particular risk for obesity throughout childhood (nader at al., 2006). therefore it appears to be critical to establish an active lifestyle early in childhood since these patterns of physical activity are retained from childhood through adolescence and beyond (moore, et al., 2003). parents and primary caregivers are a key influence on children‟s physical activity behaviors. children may not be inclined to participate in physical activity if their parents are not modeling physically active lifestyles (davison et al., 2003). given this, it is essential to gain an understanding of what are the patterns of physical activity in the families of overweight preschool children. historically, little information has been available regarding physical activity patterns in these families. the purpose of this study is to explore the physical activity patterns of families with overweight preschool children aged 3 to 5 years living in a predominantly rural agricultural state. understanding the patterns of and motivation for pa in these families helps to establish better health care education and interventions that could lead to healthier lifestyles for the whole family and alter unhealthy patterns of limited physical activities in obese preschool children. methods research design and participants the research design is qualitative descriptive since the intent was to explore the perceptions held by parents related to their physical activity patterns. the qualitative descriptive design keeps a researcher close to the data collected and does not require a highly interpretive process such as the creation of models or other abstract presentations of data (sandelowski, 2000). thus in the reporting of findings one stays close to the words used by participants yet is able to move towards a beginning level of abstraction. some data is also presented in a simple descriptive numerical presentation (e.g. demographics and bmis). data collection methods included a focus group discussion and a family demographic survey. a focus group discussion guided by krueger and casey (2000) methodology was conducted by requesting parents to describe the physical activity patterns of their family which included overweight preschool child/children between 3 to 5 years of age. eligible participants included parents, either mother or father who lives with an overweight preschool child aged between 3 to 5 years (body mass index (bmi) > 85th percentile). the parents spoke english and provided written consent for participation in the study. 58 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the focus group consisted of 10 biological parents, eight mothers and two fathers. the mean age of the parents was 30 (range 25-35). table 1 summarizes the participants‟ demographic characteristics. all lived within a 50-mile radius of a small northern plains city/town with a population of approximately 97,000 (u.s. census bureau, 2006). the mean age of the ten children table 1 the characteristics of parents and children parents (n = 10) number (%) children (n = 10) number (%) gender: mother father n = 8 (80) n = 2 (20) gender: girl boy n = 3 (30) n = 7 (70) age (years): 25-29 30-35 n = 4 (40) n = 6 (60) age (years): 3 – <4 4 – 5 n = 2 (20) n = 8 (80) bmi: normal overweight n = 2 (20) n = 8 (80) bmi: overweight obesity n = 8 (80) n = 2 (20) education: high school college professional degree n = 1 (10) n = 7 (70) n = 2 (20) education: day care home n = 9 (90) n = 1 (10) employment status: full time part time unemployed n = 7 (70) n = 2 (20) n = 1 (10) was four (range 3-5). seven children were boys. one child was cared for in the home while all the other children attended day care (four were enrolled in the local head start, and five were enrolled in different private day care agencies). the children who enrolled in the local head start participated in arranged activities approximately 50 minutes (min.) each day. these included 1) music and movement for 10 to 15 min., 2) indoor gym four of the five days for 20 min., 3) “hall way” activity (ride tricycle or free walk/run) 20 min. or outdoor playground (only in the summer for 30 min). no information about the activity of the children enrolled in other day care agencies was accessible. 59 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 procedure following approval by the university institutional review board, 10 parents of overweight preschool children were recruited through newspaper and public postings. interested parents telephoned for the time and place of the focus group meeting; eligibility screening was conducted during these phone conversations. informed consent and permission to tape record the session were obtained from the parents prior to beginning the focus group discussion in a public but private setting to maintain confidentiality. height and weight of the children and their parents were measured using standardized procedures by two trained research assistants. height of children and their parents were measured, to the nearest 0.1 centimeters (cm), using a measuring tape fixed on the wall, with each participant standing with shoes off, feet together and flat on the floor with his/her back straight. weight was measured, to the nearest 100 grams (0.25 pounds [lb]), using a manual medical scale. weight was measured with each participant standing with shoes off, no outer layers of clothing, and no other items that could add weight such as hat, belt, key, purse, or scarf. height and weight were recorded twice. if the two height and weight measurements differed by greater than 0.1 cm or 0.25 lb, respectively, a third measurement was taken by the same researcher. bmi of the parents and children were calculated by converting height from cm to meters and weight from lbs to kilograms and then dividing weight by height squared (keys et al., 1972). this study uses the following definitions for child at risk of overweight and child overweight (obesity). a child „at risk of overweight‟ has a bmi > 85th percentile. „child overweight‟ (obesity) is when the child‟s bmi > 95th percentile, based on the age and sex specific percentile, bmi growth charts (centers for disease control and prevention, 2000). after body weight and height were taken, children were escorted to an activity area while parents completed a one page demographic survey and the focus group discussion. the focus group was designed to explore parental perceptions of the physical activity patterns of their family thru a semi-structured group process which supports the creation and sharing of interesting insights. social cognitive theory guided this study. initial questions were developed based on a review of the literature. the central questions used during the focus group were:  what kind of physical activities do you do?  what kind of physical activities do you do with your child?  what kind of physical activities does your child enjoy?  what kinds of barriers prevent you and your child from being physically activity?  what do you think or believe are the benefits of the physical activity?” the focus group discussion session with all parents engaged in the discussion lasted approximately 120 minutes, and was audio taped. a research assistant facilitated the discussions while the principal investigator made comprehensive field notes related to group dynamics and nonverbal behaviors. opportunity was provided for parents to validate and clarify perceptions, subsequent to the researcher asking questions and making summative statements during the focus group process. this added credibility to the data collected and analysis of data. to encourage participation in the focus group, all parents were offered refreshments and given a gift certificate following the session. 60 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 data analysis verbatim transcripts of audiotapes were the primary data used in the content analysis. using techniques described by miles and huberman (1984), the researcher conducted a thematic content analysis using the group‟s communication as the unit of analysis. themes of the focus group‟s discussion were systematically identified, categorized, and coded using n vivo qualitative analysis software (2006). notes taken during the focus group were analyzed along with the transcribed data. the researcher read all the transcripts while simultaneously listening to the tapes, to fill in missing words and to ensure the quality of the transcripts. all analysis was verified by the research assistant and an external reviewer to minimize analyst bias. findings while parents were recruited by having a preschool child with bmi > 85th percentile, the majority of parents were overweight (80%). the mean bmi of parents and children were 26.1 (range 24.6-27.4) and 17.3 (range 17.1-17.8) respectively. only two parents were normal weight (see table 1). these two parents had children that were at the lowest bmis, 17.10 and 7.13 respectively. the remaining eight parents had children that had bmis at 17.20 to 17.80. the findings support that parental bmi is associated with their children‟s bmi (klesges, klesges, eck, & shelton, 1995). the majority of parents completed college (demographics reported in table 1), reported that they were working full time (70%), and had very limited time to spend with their children. the following findings focus on the analysis of the qualitative data. since this is a pilot with only one focus group of 10 parents representing 10 families, the findings should be interpreted with caution and need further studies with other rural focus groups to expand maximum variation within the purposive sample. physical activity of the family all parents reported that they were not engaging in any structured healthy physical activity or organized sports beyond their daily work and functional activities. the usual, weekly physical activity that most parents reported doing included cleaning their living space, and hand washing/waxing a car. the other common physical activities identified included walking, biking, playing ball (during appropriate seasons), and play wrestling with their children. when asked about the average amount of time on a weekly basis, that the parent spent by oneself doing physical activity, their reported time averaged to approximately 50 minutes. the amount of time that parents spent with their children in doing an activity was approximately 15-20 minutes a day during the week, and 30-50 minutes a day during the weekend. most of the parents agreed that they usually let their children engage in their own play behaviors. for example: as we are working outside the house, we have little time to do physical activity or play with our kids. we just let them play in their own activities and they always have their own activity [by] themselves. 61 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 in the winter, i just let them play with each other in the house. we have lots of books and games. dad and i sometimes wrestle with them and that is what we do as a physical activity. during the summer, we walk around the neighborhood. another parent spoke of a creative way to help the children play in the winter, i snow blowed a circle track in our back yard so the kids would run around there and…my daughter would pull our son on the sled. most parents felt that their children were active and did physical activity every day by “climbing on the sofa, running around and chasing each other in the house.” when asked about the average television viewing as part of the daily activities, the parents reported that it was 4-5 hours a day. activity enjoyed “needs to fit” besides the identified activities above, the parents spoke of activities that their older children were involved in for example gymnastics. what was apparent among the parents was the importance of fitting the activity to the child and determining if it should be a team sport or a singular activity like tea kwon do. the child‟s personality needed to be considered in determining what he/she would be involved in and how to assist/support this process of being pa. a parent stated: parents have to know their own kids because activity means a lot of different things and not every activity [is a fit.] my nephew was not a team sport kid from the get go…he laid around a lot…they couldn‟t get him active…then they realized taekwondo which was totally up his alley and now i‟m kinda tuned into that…[also] you can‟t just say yep, go ahead and go. some kids need that bond of either a friend or a parent that actually goes with them. another parent spoke of the following to describe their variation in activity due to seasonal changes including the decision making process that recognizes fit: summer or winter we keep them involved in their own activities. our daughters are both in gymnastics up until a week or two ago. they pulled my son‟s gymnastics so we‟re looking for whatever else he can do until we can redo something in may and went to tae kwon do. he‟s been very interested in that. [i have] already got them signed up for swimming lessons. so they each have some type of activity that they get going. and they have to like it. i made my son play soccer. he will go to the ymca and play soccer for the six-week sessions, but i made him do two sessions…he doesn‟t like it and doesn‟t want to go back. so i let him chose. do you want this…or do you want to do this? yes! so they always each have their own activity themselves, a weekly thing. then as a family in the winter, it gets hard to get out but we did, until we got the really cold spell, we were getting out and going skating. we bought skates for everyone including our 3-year old and once or twice we would get out and go skate…after church and lunch, we will go sledding to get our exercise, on that hill (dike). so we specifically look for those kinds of things to do to get out. my kids are happy. they have been begging to go to the mall and 62 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 play in the play area. that gets them out of the house and they run around for an hour and just play and climb on that stuff. and then in the summer, we go walk around the neighborhood. we ride our bikes, but as a family we will all get on our bikes, our 3 years old can‟t ride and keep up with us, and we pull her. this information was provided by one of the parents and the degree and variety of pa is an outlier from the rest of the group. however, this quote explicates requirements needed to accomplish this level and varying of activity which includes resources, transportation, and purchasing power. not all group members had these available as the findings under barriers will show. barriers to physical activity the barriers to doing physical activity and engaging in active play with their children discussed in the focus group by the parents emerged as personal and environmental barriers. the most common personal barrier expressed in the group was lack of time and low energy levels related to performing multiple roles. parents indicated that they had work and family responsibilities; they felt too tired to do anything else. a parent encapsulated the personal barriers in the following quote, “i work full time, then i come home, i have to take care of my kids and do some housework. when i finish, it is bed time. i just want to go to bed.” in addition to the personal barriers of lack of time and decreased energy, several environmental barriers emerged. parents voiced most concerns regarding a lack of programs for the whole family including childcare issues, lack of flexibility in program offering, high cost of memberships and activities, and the weather. these participants showed concern about the family engaging in exercise and activities together. just as in their discussion of eating habits/preferences during part one of the study, the parents believed that the children learn by watching the role modeling of their parents. the environments for pa are not conducive or not designed to support this concept. the following quotes address these concerns: by our children seeing us do it, that makes them want to do it. [my child will say,] “mommy, i want to do it mommy, watch me jump like you can jump. watch me do jumping jacks.” so everything that we are involved in, is taking away from the opportunity for us to teach our children [if they can‟t be involved also]. we need a program that the whole family can partake. the whole family needs to do it or we are not going to do it. other parents stated: most programs do not provide child day care or child facilities and so i cannot go. we need a place that parents and kids can go and do activity together. when my kids see us do exercises or activity, they want to do it too. however, what we have now is taking away from the opportunity for them [children] to do activities with the parents. in regards to the timing of the programs offered several comments were made. the following one is an example of this information: time is a factor. most programs, even church, are offered for the evening like 6.30 – 8.30 pm or 7.00 – 9.00 pm. my kids go to bed between 7.30 and 8.00 pm. i 63 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 don‟t want him to be out this close to his bed time. we don‟t have a program that is offered at varying times or is flexible. because the parents worked they often had set schedules that dealt with all the tasks and time related stresses that need to be dealt with on a daily bases. this allowed for very little flexibility in their use of time and inclusion of pa. cost and the weather are also environmental barriers for the parents to get involve in physical activity. some parents stated and others agreed that: most programs required a membership and the cost is unreasonable. we have a long winter here and we can‟t play outside. it is too cold to go out. during the summer, we walk or sometimes we play ball but the summer is short. furthermore, the weather or four seasons required variation in the types of activities they can do. parents agreed, we‟ll admit, like he said, the wintertime they (children) get more video games and things like this. there‟s not as much [to do] but in the summer they know my rules. my son will tell you no video games unless it‟s a rainy day. i‟m likeyou have 4 months to be outside. if you don‟t go out that is your choice but you‟re not playing with the computer or the video games unless it‟s raining. what is again apparent in the quotes is the perception that playing/being busy outside or inside is equivalent to structured healthy physical activity or at least meets the expectation that their children are physically active in a healthy way. the benefits when the parents were asked about their beliefs regarding the benefits of the physical activity, most of them expressed that physical activity helps to reduce stress and tension. the following is a quote that a parent stated related to the benefits of pa for the child and herself: it reduces stress and tension. i think, like you (another participant) said, school recess is a break [for pa]. they [kids and teachers] need it. i don‟t get a break before lunch…and i notice the difference myself if i don‟t take time for myself. those kids need that recess at school. they need to go run off that energy; you feel refreshed and ready to go. i know how i feel. i get up at five and exercise until six in the morning because i can‟t do that at night, but those few nights where i have to, i‟m dragging, but think how you feel when i‟m done. i do feel better. it helps keep the weight down and it helps me. some parents reported that physical activity helps their children sleep better. for example, “i noticed that my child sleeps deeply when he plays hard like running all day.” all parents agreed that part of the benefit of physical activity to their children is that they do have fun doing it. even with this knowledge, they also stated that they have to give it priority over other chores, (e.g. “over dusting”) for it to occur. 64 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 discussion this study is the first to qualitatively examine physical activity patterns of families with overweight preschool children living in rural areas. although parents in this study agreed that physical activity reduces stress and tension, promotes enjoyment of life, and establishes deep sleep, the majority of them never encouraged their children to engage in any structured healthy physical activity. even though, their children were obese, the parents perceived their children to be active and their standards for activity to not be a problem; and in essence saw the daily play behaviors of their children to be adequate. the national association for sport & physical education (2000) has set guidelines for preschoolers regarding kinds and amounts of physical activity. the following is a list of three of the five guidelines relevant to this discussion:  preschoolers should accumulate at least 60 minutes daily of structured pa.  preschoolers should engage in at least 60 minutes and up to several hours of daily, unstructured pa and should not be sedentary for more than 60 minutes at a time except when sleeping.  preschoolers should develop competence in movement skills that are building blocks for more complex movement tasks. the description of pa presented by the parents indicates that these guidelines are not being met at home or even at head start where the child gets 20 minutes of structured pa and approximately 35 minutes of unstructured active play/exercise. furthermore their sedentary time in front of the tv and at the computer should not exceed the 60 minute limit (guideline 2). in support of limiting sedentary behavior, the american academy of pediatrics has recommended that children over 2 years of age should limit their television viewing to no more than 2 hours per day (committee on public education, 2001). these families, however, spent 4 to 5 hours in front of the television; longer than both recommendations. in addition to being physically active, children need to learn fundamental motor skills and develop health related physical fitness (cardiovascular endurance, muscular strength and endurance, flexibility, and body composition). the description of play behaviors at home and at preschool would not meet this criteria or the above third guideline. some of the family‟s and organized sport activities mentioned as desirable and a fit with their child‟s personality would achieve this criteria/guideline. however, the parents identified barriers interfered with the ability for the majority of the families to engage in this level of structured pa. additionally, research suggests that parents play a significant role in motivating children to participate in physical activity (kalakanis et al., 2001). children of active parents are more likely to participate in physical activity or sports than do the children of passive parents. children, particularly those who are young, learn and model the behaviors from what they see and observe from their parents and significant others (golan & crow, 2004). children's and parents' activity levels might develop and be maintained accordingly because children and parents live in a shared family environment that provides both cues and social support for similar activity levels. children, therefore, are more likely to be active and stay active throughout their lives if they see their parents being physically active and having fun. research suggests that parents‟ physical activity and support, and opportunities to do physical activity or exercise were 65 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 associated with young children‟s physical activity (golan & crow, 2004). young children are dependent on their parents for guidance and role modeling of physical activity patterns. some of the parents recognized the need to have their children see them do and then have their children engage with them in pa. it appears that daily expectations and schedules, and adult role behaviors over shadow the larger picture of needing health promotion and illness prevention strategies to be enacted on a daily bases through pa. the analyzed data supports that lack of role modeling and involvement in physical activities by adults is affecting the preschoolers‟ weight and levels of healthy structured physical activity. the personal barriers discussed in this study were consistent with previous research conducted with different populations (bellows-riecken & rhodes, 2007). programs that include the whole family and provide to the child a visible presence of parents doing pa could help to increase physical activity levels of children and adults. however, there is an unspoken personal barrier that also exists that needs identification by the parents, which is lack of knowledge about the guidelines for healthy pa for their preschooler, and what a healthy weight level is for their child. children attending head start programs are weighed and measured at a maximum of 3 times a year (personal communication with a local head start officer, may 2008) and parents have access to this information, yet these parents seemed unaware of their preschoolers‟ health status of overweight or obese based on national scales. this lack of knowledge/concern by parents is a barrier to engaging in their change of eating and pa habits. therefore, it is important to raise awareness among the parents through the provision of information about national guidelines, positive outcomes of spending quality time with their children by doing physical activity, role modeling of physical activity, and reducing video games and family‟s television viewing. parents also need information about current research related to the effects of obesity in preschoolers on their long term health status including predispositions to health problems as adults. patterns of physical activity/behaviors established in childhood may help to reduce the risk of morbidity and disability associated with a lack of physical fitness in adulthood. importantly, adequate physical activity for all young people represents a cost-effective way to reduce the risk of obesity and other adult chronic diseases. therefore, keeping children active is important to helping children stay healthy. the provision of information on the benefits of physical activity and potential negatives without it, through local newspapers, printed materials placed in pediatric clinics and family physician‟s offices, and by radio broadcasts, could begin to reduce this barrier of knowledge/awareness and begin to implant the seeds for change. environmental barriers voiced by the parents were weather, cost, and infrastructure. these could be altered through promotion of policies supporting development of infrastructures such as building indoor/outdoor walking trails, low cost user fees by subsidizing (at county, state, and federal levels) the maintenance of the infrastructures, flexible availability, culturally appropriate physical activity and family exercise programs in easily accessible schools, churches, and various community centers or gathering places. currently in a few rural areas, city councils are collaborating with public school systems to reduce many of these barriers to engaging in structured healthy physical activity (gangeness, 2007). study strengths and limitations this qualitative descriptive pilot utilized focused group methodology to gain preliminary information about physical activity patterns of the families of overweight preschool children. this method provides valuable thoughts, perceptions, and attitudes from a group of parents with 66 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 children experiencing weight problems. these findings begin to inform health care providers about the issues surrounding the promotion of physical activity of a rural population. in regards to limitations, one should note that the findings reflect the perceptions of a small group of parents with overweight preschool children who had a college education thus the results may differ for families from different educational backgrounds and economics. more studies are required to determine whether these findings are indicative of the target population as a whole with maximum variation represented. conclusion currently, more than one-third of u.s. children are overweight and at risk of becoming overweight (ogden et al., 2006). given the importance of this epidemic and the health consequences associated with this, serious attention should be given to all levels. knowing the physical activity patterns of families with overweight preschool children may inform directions in planning and developing physical activity interventions within this population. through the focus group discussion, participants presented personal barriers as lack of time and low level of energy due to many tasks, while identifying environmental barriers as program cost, program format, and the weather as significant interference in establishing healthy patterns of physical activity. however, the parents‟ unrecognized lack of adequate information (appropriate levels of structured activity and weight for a preschooler) which may be significant to motivating change is probably the greatest personal barrier. these results provide initial insights into potential interventions that affect both parents‟ and children‟s physical activity. health care providers can help parents to understand the type of physical activity that their children need, what being overweight or obese means, how an overweight preschool status can impact the child as an adult, and the need to influence the obesity epidemic by alteration of health policies and practices in their communities. a socioecological framework involving children, families, schools, and their communities would help to implement programming to address the unique needs of rural populations. this qualitative pilot reinforces current research understandings from the personal perspectives of rural families and provides new awareness about lack of knowledge which influences motivation. conflict of interest the authors have no conflict of interest to declare. the funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. acknowledgement this study was supported by grant from the senate scholarly activity committee, university of north dakota, which is appreciated. the author would like to thank the participants who shared their experiences in the study. references bellows-riecken, k.h., & rhodes, r.e. 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[medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14660491%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11158483%5buid%5d http://www.ed.gov/offices/osdfs/physedrpt.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12972881%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14742838%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=14981230%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=18257870%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11561385%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7770289%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=4650929%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12043359%5buid%5d http://www.ehnheart.org/files/phyactivity-084635a.pdf http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12799124%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16950951%5buid%5d http://www.aahperd.org/naspe/template.cfm?template=ns_active.html http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16595758%5buid%5d 68 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 paxton, r.j., estabrooks, p.a., & dzewaltowski, d. (2004). attraction to physical activity mediates the relationship between perceived competence and physical activity in youth. research quarterly for exercise & sport, 75, 107-111. [medline] steinbeck, k.s. (2001). the importance of physical activity in the prevention of overweight and obesity in childhood: a review and an opinion. obesity reviews, 2, 117-130. [medline] united states department of health and human services (2000). healthy people 2010 (2nd ed.). washington, dc: government printing office. u.s. census bureau: state and county quick facts. (2006). data derived from population estimates, census of population and housing, small area income and poverty estimates, state and county housing unit estimates, county business patterns, nonemployee statistics, economic census, survey of business owners, building permits, consolidated federal funds report. retrieved on august 16, 2007, from http://quickfacts.census.gov/qfd/states/38/38035.html vandewater, e.a., rideout, v.j., wartella, e.a., huang, x., lee, j.h., & shim, m. (2007). digital childhood: electronic media and technology use among infants, toddlers, and preschoolers. pediatrics, 119, e1006-e1015. [medline] wang, y. (2001). cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. international journal of epidemiology, 30, 1129. [medline] world health organization (1997, june). obesity, preventing and managing the global epidemic. report of a who consultation (pp. 894). world health organization: geneva. young-hyman, d., & schlundt, d.g. (2001). evaluation of the insulin resistance syndrome in 510 year old overweight/obese african-american children. diabetes care, 24, 1359-1364. [medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15532367%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12119663%5buid%5d http://quickfacts.census.gov/qfd/states/38/38035.html http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=17473074%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11689534%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11473070%5buid%5d the rural barrier of transportation 27 distance and access to health care for rural women with heart failure carolyn pierce, dsn, rn1 1 assistant professor, decker school of nursing and department of bioengineering, binghamton university, cpierce@binghamton.edu key words: rural, access to health care, heart failure, women abstract background and research objective: heart failure (hf) is a disease state requiring ongoing and specialized health care. for persons living in rural areas, access to care may be delayed or difficult as best due to the distance involved. distance to obtain health care can be further confounded by such issues as weather and lack of transportation. to further understand these issues, a sample of women diagnosed with hf and living in rural upstate new york was studied to explicate the impact of distance and weather on access to health care. sample and method: a convenience sample of 45 women living in upstate new york diagnosed with hf was studied to assess the impact of distance and the associated issues on accessing health care. mileage to primary care and specialty care was quantified. frequencies for associated issues such as the need for emergency care, weather, and the ability to drive were measured. results and conclusions: the mean distance to obtain primary care was 6.4 miles, while the mean distance to obtain cardiology care was 32.6 miles. however, only 50% of the sample actually sought ongoing care from a cardiologist. when assessing the impact of weather or distance on access to health care, no significant influences were found. however, with increasing age, weather was shown to approach significance (p=. 059). these findings further illustrate the ongoing issues experienced by rural dwellers when accessing health care for hf. introduction accessing health care in rural areas is confounded by such varied problems as an insufficient health infrastructure, the press of chronic diseases and disabilities, socioeconomic barriers, and physical barriers (ricketts, 2001). many rural dwellers must travel formidable distances to obtain even the most basic of health care services. distance issues may be further affected by accessibility of transportation, the inability to drive, lack of a driver’s license, physical and mental impairments that may impact the use of public transportation, and severe or inclement weather (bushy, 1993). understanding how rural dwellers perceive distance when accessing health care is an important in factor in policy formation as well as service delivery. to better understand this phenomenon, a sample of older rural women in upstate new york diagnosed with heart failure (hf) was studied to better understand the impact of distance on accessing health care services. this paper describes the findings of this research. distance henson, sadler, and walton (1998) defined distance as “a degree of separation between two or more entities” and added that “the nature of that entity may be in space, online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.binghamton.edu/dson/ http://bioeng.binghamton.edu/ mailto:cpierce@binghamton.edu 28 time, or behavior” (p. 51). distance can be measured in various ways including linear distance on a map, road distance, travel time, perceived distance, perceived travel time, and distance to the nearest provider (arcury, gesler, preisser, sherman, spencer, & perin, 2005). distance is comprised of three attributes including mileage, time, and perception (henson, sadler, & walton, 1998). nemet and bailey (2000) found that elders in vermont who had to travel longer than 10 miles tended to go to physicians less often. in addition, distance in miles can be compounded by weather or physical barriers. persons living in rural appalachia have been found to receive less preventative and routine health care because of the mountainous and relatively inaccessible terrain (gatz, rowles, & tyas, 2004). this effect however is not universal. in rural north carolina, distance was not found to be associated with either acute or chronic health care utilization (arcury, gesler, preisser, sherman, spencer, & perin, 2005). while distance may impact access to health care from rural areas, this factor is also confounded by the availability of affordable care. health insurance coverage differs for the rural population, with fewer persons having private insurance because of the industries in which they are employed or because of part-time employment status (schur & franco, 1999). farmers and persons who are self-employed or work in small establishments often lack health insurance. twenty percent of rural persons are uninsured as compared to 16% of urban residents (schur & franco, 1999). of concern is the fact that rural dwellers tend to use fewer health care services than their urban counterparts. use of health services by elders was studied over an 8-year period at a south carolina area agency on aging; findings indicated that urban dwellers were twice as likely to use services as rural dwellers (wallace, lockhart, & boyle, 1995). similarly, (1998) examined readmissions of 9,112 persons with hf to new york hospitals over the period of a year and discovered that patients treated in rural hospitals were less likely to be readmitted. in contrast, those with higher readmission rates were black, had medicare and medicaid insurance, had more co-morbid conditions such as chronic lung disease or diabetes, and had experienced the need for telemetry monitoring during their hospitalizations. the north carolina health resource program (slifkin, goldsmith, & ricketts, 2000) also found that rural minorities were more disadvantaged than urban dwellers in several areas, including cardiovascular disease. this disadvantage was related to the higher levels of poverty in rural areas and the historical access problems in rural areas. even if transportation is available, health care providers may be in short supply. about 20% of the u.s. population lives in rural areas, but only about 9% of the nation’s physicians serve that population (rosenblatt & hart, 1999). large metropolitan areas have 304 active physicians per 100,000 population, and small metropolitan areas have 235. rural areas average much lower numbers of physicians, with rural areas not adjacent to metropolitan areas having only 53 physicians per 100,000 persons (rosenblatt & hart, 1999). although federal programs have been successful in redistributing family practitioners to rural areas, specialists are underrepresented in rural areas. metropolitan counties have 190 specialists per 100,000 persons, whereas non-metropolitan counties have only 54.6 specialists per 100,000 persons (schur & franco, 1999). distance compounds the issue of time which is especially critical in situations such as time to receive trauma care. rural persons are 50% more likely to die from trauma than urban dwellers (young, torner, sihler, hansen, peek-asa, & zwerling, online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 29 2003). uneven distribution of services may also confound the issue of distance in rural areas. rural residents are less likely to obtain the services of a specialist. rural persons who reported poor health were found not to have visited a physician in the past year (schur & franco, 1999). as managed care systems evolve, there is concern that these systems will restrict their services to areas with ample insurance and large aggregates of population, leaving rural areas without access to quality health care (rosenblatt & hart, 1999). rural dwellers also must be concerned about reaching specialists care, filling prescription medications, and obtaining emergency care (lee & winters, 2004). bushy (1993) wrote that rural perceptions of time and space vary. indeed, even long distances may not be seen as isolating by rural dwellers who utilize trips from rural areas to perform multiple tasks along the way. rural persons have been found not to expect to have services available locally and expect to have to travel to receive those services (pierce, 2001). bushy (2000) wrote that perception of distance in rural areas can be altered by the person’s sense of social connectedness and that persons who live miles apart may consider each other as neighbors. perceptions about distance in rural areas are currently shifting due to the advance of communication technologies and the net effects of globalization (rosenblatt, 2001). conceptual model this research is rooted in the work of moos (1979) who developed a socioecological model illustrating the transaction between an individual, the environment and health. the primary interaction occurs between the individual and the environment, which is comprised of such factors as distance, temperature, weather, and topography. this interaction influences the level of the individual’s cognitive appraisal, the degree of activation, which activates the individual and allows for coping to occur. coping with the environmental press ultimately impacts health status and health related behaviors. these actions ultimately provide feedback to both the individual and the environmental systems (moos, 1979). this research focuses on the physical portion of the environment as well as the cognitive appraisal of the environment in reference to health seeking behaviors. design and methods the purpose of this study was to gain a further understanding of the impact of distance on access to health care for rural women in upstate new york diagnosed with heart failure. a descriptive correlational design was used to explicate such factors as distance and time involved in assessing routine and cardiology health care. it was hypothesized that distance, weather and other environmental factors would negatively influence access to health care. sample approval for this study was obtained from the human subjects research review board at binghamton university. a convenience sample of 45 women aged 65 years or older constituted the subjects of this study. these women were diagnosed by a primary care provider with hf related to any cardiovascular condition. the women were recruited online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 30 from primary health care practices located in rural areas in rural upstate new york state classified according to the beale code levels 6 through 9 of the rural-urban continuum code for new york (u.s. department of agriculture, 2001). findings the mean age of this sample of rural women was 77.7 years (range= 65-98 years). the mean age at time of diagnosis with hf for this group was 71.6 years (range = 54-93). all of the women described themselves as white. table 1 lists the findings related to the demographic variables including marital status, length of residence, yearly household income, educational level, and insurance coverage. the largest percentage of this sample were widowed (48%), while 29 (42.2%) were married. more than half of the women (55.5 %) listed their yearly household incomes at less than $20,000. the majority obtained a high school education or less, while the remainder had attended college. nearly half of the women (46.7%) lived alone, while 19 (42.2%) lived with one other person. five persons stated that they lived in households of three or more persons. table 1 demographic findings demographic n % marital status single 2 4.4 married 19 42.2 divorced 2 4.4 widowed 22 48.9 years at current residence 1-5 8 17.8 6-20 14 31.1 21-72 23 51.1 yearly household income $0-10,000 10 22.2 $10,001-20,000 15 33.3 $20,001-30,000 6 13.3 $30,001-50,000 4 8.9 no response 10 22.2 years of education 1-6 1 2.2 7-12 26 57.8 12-16 14 31.1 > 16 14 8.9 years of education medicare 40 89.0 medicaid 6 13.3 private 23 51.0 online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 31 the following self-reported co-morbidities were found: hypertension (71.1%), diabetes (37.8%), myocardial infarction (35.6%), copd (15.6%), cva (15.6%), history of cancer (15.6%), and kidney disease (6.7%). fourteen (31.1%) reported 2 comorbidities, 11 (24.4%) reported 3 co-morbidities, and 4 (8.9%) reported 4 or more comorbidities. the researchers assessed a new york heart association classification level based on the women’s report of symptoms. fourteen (31.1%) of the women exhibited symptoms at class 1, 18 (40%) at class 2, 13 (28.8%) at class 3, and none at class 4. twenty-five (57%) of the women stated that they smoked in the past, and 3 (7%) currently smoked. pack/years for the past and current smokers averaged 30.3 (range 3-70 pack/years). the women listed the medications they were currently taking with the average number per subject being 8.14 (range 3-19). forty-three (96%) stated that they “always” took their medications as ordered and only two (4%) women stated that they occasionally forgot to take their medications. none of the women in this study lived in areas with access to public transportation. therefore, the women were obligated to arrange for private transportation to health care providers. the average distance to the local provider for this sample was 6.5 miles. this number appears to be lowered significantly by the presence of several small clinics placed in small towns throughout the area by two competing hospital systems from a nearby city. the rural offices were usually staffed by a part-time physician, a nurse practitioner, and an office assistant. one woman was cared for by a physician who visited her in her home, and another woman with severe symptoms used a scooter for transportation to the doctor’s office that was close to her home. some women were able to walk to a doctor’s office or drove only a very short distance. the longest commute to a primary provider for this study was 30 miles. the relatively short commute times may reflect changing methods of providing health care services driven by managed care. this trend is reflective of the findings of rosenblatt and hart (1999) who found that 90% of rural areas are in services areas covered by managed care providers that increase access to providers and provide institutional support to physicians in communities that would be unable to support such services independently. table 2 presents the information regarding access to primary and cardiology care. it was found that 53% women were driven to the primary provider, while 91% were driven to the cardiology providers presumably because these offices were further away from their homes. the women stated that they were grateful to have services close to their homes and were very pleased with the quality of the care received there. surprisingly, not all of the women eligible for medicare were enrolled. table 2 access to rural health care access primary cardiology method (md/ np) (md/np) routine care 45.0 (100%) 22.0 (49%) miles to office 6.4 (0-30 miles) 32.6 (1-90 miles) minutes to office 13.2 (0-35 min) 39.1 (10-90 min) drive self 21.0 (47%) 4.0 (9%) online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 32 only fifty per cent of the women in this sample were treated regularly by a cardiologist and the average distance traveled to see that provider was 32 miles, while some of the women traveled as far as 90 miles to see a cardiologist. schur and franco (1999) found a great disparity in the availability of specialists between urban and nonmetro areas and a 15% deficit in the volume of services provided to medicare beneficiaries in non-metro areas. while many of the women in this study drove many miles to see specialists in urban areas, it was noted that there were visiting cardiologists in the small town clinics maintained by the hospital systems in this area. this reflects a trend initiated by the medicare administration to increase the amount of care provided by specialists close to the homes of persons requiring that care (health care financing administration, 2001). although some of the women had significant distance or time involved in traveling to health care, only 12 (29%) of the women indicated that weather kept them from keeping health care appointments. the women who did not drive themselves to appointments responded that they were transported by family members. these included husbands, children, or grandchildren, or neighbors. only one woman who was driven to health care appointments by a neighbor paid for this transportation. in addition, access to emergency care in rural areas was determined with questions about the availability of 911 service and the time until arrival of emergency responders. thirty-seven (82%) of the women stated that 911 was available in their locality. twelve (27%) of the group had received emergency care at home. of this group, the average time from the call for help until the arrival of the emergency responders was approximately 9 minutes and this service was provided by a network of volunteer ambulances in rural areas. all of the women who required emergency health care in their homes rated the quality of service as good. when asked about use of emergency services without using an ambulance, the women described calling children or a neighbor to take them to a hospital or other facility for care. the average time to access this care after leaving home was over 18 minutes. sixteen (36%) of the subjects had visited an emergency department in the past year for symptoms of hf, and 11 (24%) of the women had been admitted to the hospital during the previous year for treatment of hf. see table 3 for the findings related to ed and hospital admissions. table 3 ed visits and hospital admissions in previous year for hf year ed visits hospital adm. 1 10 (22%) 8 (18%) 2 3 (7%) 2 (4%) 3 2 (4%) 1 (2%) 4 1 (2%) 0 when applying correlational statistics to environmental factors including distance and weather on access to health care for rural women with heart failure, no significant findings emerged. there was however, a trend that weather might impact access to care which approached significance (p=. 059). this finding supports previous research which online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 33 indicates that rural dwellers manage to access health care in spite of obstacles presented by distance (arcury, gesler, preisser, sherman, spencer, & perin, 2005; pierce, 2001). conclusions rural women with hf need ongoing and specialized health care. the distance to obtain that care, while considered by most rural dwellers as a normal part of rural life, must be factored into each person’s decisions about access to health care and emergency care. the lack of full-time primary or specialty care in rural clinics, lack of emergency providers during traditional work hours, limited access to 911, limited or non-existent public transportation, lack of insurance or underinsurance, and weather restrictions are some of the factors that put direct access to appropriate health care for rural dwellers in jeopardy. nurses who provide health and emergency care for rural women with hf must be aware that women with hf take living in rural areas in their strides, but they often must rely on others to provide transportation to that health care, especially if it is at a distance from their homes. older women with heart failure may have an increased need for help accessing health care in bad weather and this need coordination of transportation and or health care available at home. nurse practitioners who specialize in cardiac diseases such as heart failure have the specialized skill set necessary to provide sophisticated care in rural areas thus offsetting access issues. the need for increased funding to provide both education and placement of nurse practitioners in rural areas must be communicated to the appropriate legislators. discussions about access to emergency care must take place with the knowledge that rural areas often rely on volunteer services which may delay the time involved. while this sample of women obtained the health care they needed in spite of distance, transportation issues, and / or weather, it must be noted that some rural dwellers may forgo ongoing care for these reasons. weather is not found to be a concern for rural women who must deal with this on a routine basis in certain areas in the country, but contingency plans for maintaining a continuity of care for hf should be discussed. this is especially important as women get older and travel in poor weather may present issues of safety. nurses must be aware that access for rural dwellers to specialty care for such diseases as hf presents some unique difficulties in accessing health care and planning in advance for that care is key to successful management strategies. references arcury, t., gesler, w., preisser, j., sherman, j., spencer, j., & perin, j. (2005). the effects of geography and spatial behavior in health care utilization among residents of a rural region. health services research, 40, 135-155. [medline] bushy, a. (1991). rural determinants in family health: considerations for community nurses. in a. bushy (ed.), rural nursing (vol. 1, pp. 133-145). newbury park, ca: sage. bushy, a. (1993). rural women. lifestyle and health status. nursing clinics of north america, 28, 187-197. [medline] online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15663706%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=8451207%5buid%5d 34 bushy, a. (2000). orientation to nursing in the rural community. thousand oaks, ca: sage. gatz, j., rowles, g., & tyas, s. (2004). health disparities in rural appalachia. in n. glasgow, l. morton, & n. johnson (eds.), critical issues in rural health. (pp. 183-194). ames, ia: blackwell. health care financing administration. (2001). summery report on the rural medicare population. retrieved on december 14, 2001, from http://www.hcfa.gov/research/reports/rural%5fexecsum.htm henson, d., sadler, t., & walton, s. (1998). distance. in h. lee (ed.), conceptual basis for rural nursing (pp. 51-60). new york: springer. lee, h., & winters, c. (2004). testing rural nursing theory: perceptions and needs of service providers. online journal of rural nursing and health care, 4(1), 51-63. retrieved april 5, 2005, from http://www.rno.org/journal/index.php/onlinejournal/article/viewfile/128/126 moos, r. (1979). social-ecological perspectives on health. in g. stone, f. cohen & n. adler (eds.), health psychology: a handbook. san francisco: jossey-bass. nemet, g., & bailey, a. (2000). distance and health care utilization among the rural elderly. social science & medicine, 50, 1197-1208. [medline] philbin, e., & disalvo t. (1998). influence of race and gender on care process, resource use, and hospital-based outcomes in congestive heart failure. american journal of cardiology, 82, 76-81. [medline] pierce, c. (2001). the impact of culture in rural women’s descriptions of health. the journal of multicultural nursing & health, 7(1), 50-53, 56. ricketts, t. (2001). the rural patient. in j. geyman, t. norris & l. hart (eds.), textbook of rural medicine (pp.15-26). new york: mcgraw-hill. rosenblatt, r. (2001). the health of rural people and the communities and environments in which they live. in j. geyman, t. norris, & l. hart (eds.), textbook of rural medicine (pp. 3-14). new york: mcgraw-hill. rosenblatt, r., & hart, g. (1999). physicians in rural america. in t. ricketts, (ed.), rural health in the united states (pp. 3851). new york: oxford. schur, c., & franco, s. (1999). access to health care. in t. ricketts (ed.), rural health care in the united states (pp. 25-37). new york: oxford university press. slifkin r, goldsmith l, & ricketts, t. (2000). race and place: urban– rural differences on health for racial and ethnic minorities (working paper no. 66). chapel hill: north carolina rural health research program. u.s. department of agriculture. (2001). measuring rurality: ruralurban commuting areas. retrieved september 18, 2001 from http://www.esr.usda.gov/briefing/rural/data/desc.htm wallace, d., lockhart, j., & boyle, d. (1995). service use by elders with heart disease. research in nursing & health, 18, 293-301. [medline] young, t., torner, j., sihler, k., hansen, a., peek-asa, c., & zwerling, c. (2003). factors associated with mode of transport to acute care hospitals in rural communities. journal of emergency medicine, 34, 189-198. [medline] online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.hcfa.gov/research/reports/rural_execsum.htm http://www.rno.org/journal/index.php/online-journal/article/viewfile/128/126 http://www.rno.org/journal/index.php/online-journal/article/viewfile/128/126 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10728841%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9671013%5buid%5d http://www.esr.usda.gov/briefing/rural/data/desc.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=puresearch&db=pubmed&details_term=7624523%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12609651%5buid%5d although some of the women had significant distance or time involved in traveling to health care, only 12 (29%) of the women indicated that weather kept them from keeping health care appointments. the women who did not drive themselves to appointments responded that they were transported by family members. these included husbands, children, or grandchildren, or neighbors. only one woman who was driven to health care appointments by a neighbor paid for this transportation. editorial 11 editorial cost and performance issues factors rural nurse managers consider when make staffing decisions similar to nurse managers in other hospital settings melondie carter, dsn, rn editorial board member the healthcare industry is under tremendous pressure to lower cost while improving quality (levit, lazenby, & braden 1998). since nursing cost is the single largest item in providing care for hospitalized clients, nurse managers must make nursing staffing decisions that control labor expenditures and yet allow for the provision of quality care. managing nursing labor costs by making timely staffing decisions is essential for hospitals to survive. two studies were conducted to determine the usefulness of a labor computer decision support system, developed by the investigator, to control nursing labor cost and provide quality nursing care. the first study was conducted in a large medical and a large psychiatric hospital in the south. two nurse managers participated from both hospitals (carter & cox, 2000). the second study included the nurse manager from two small rural hospitals, one from the south and the other from the north central united states (carter, 2002). as part of these two studies, nurse managers were interviewed weekly for a three-month period to determine factors they considered in making personnel changes and the changes in personnel that they made to improve cost or quality of care. changes that were made will be reported in the next issue. factors the nurse managers considered when making staffing changes the nurse managers (nms) primarily considered three factors when making personnel changes. table 1 depicts the nurse managers' most frequent responses in the three different hospitals. the three most frequent responses reported by the nms regardless of setting were a-acuity, b-balance (the level of staff needed to handle nonvolume related activities such as admissions and discharges) and c-census. these three factors accounted for a mean of 79% of the factors (80, 82, and 75) the six nms considered when making staffing changes. census as a factor had the highest response rate with a mean of 34%. census was the major factor considered by the two nms in the medical hospital and the two nms in the small rural hospitals. in the rural hospitals, census was the factor used to determine staffing changes 41% of the time, and the medical nurse managers considered census 34% of the time. the census factor was considered by the psychiatric nurse managers 27% of the time. the psychiatric nms reported that acuity was the factor considered 44% of the time in making staffing changes. the medical nms reported 23% and the rural nms reported 27% of their staffing changes were based on the acuity factor. balance was the third largest factor considered with a mean of 14%. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 12 table 1 factors the nurse managers considered in making staffing changes factors considered medical psychiatric rural mean patient census 34% 27% 41% 34% patient acuity 23% 44% 19% 27% balance 13% 15% 15% 14% total abcs 80% 82% 75% 79% other factors the six nurse managers considered were staff available (e.g. decreased lpns available), one to one nurse patient ratio (psychiatric nms), nurse resignations, a difficult patient family, rn to lpn ratios, and the need to maintain a qualified pool of staff (rural nms). conclusion regardless of hospital setting, census, acuity and balance were considered the three primary factors considered when nurse managers made decisions about nursing staffing changes. therefore, the abcs of nursing staffing decisions were acuity, balance and census with census being number-one. with the changing healthcare environment facing today's nurse managers, knowledge about factors considered when making nursing decisions and staffing changes made by nurse managers to control cost or quality of care is useful. references carter, m. (2002). rural nurse managers' use of a labor computer decision support system. nursing economics, 20, 237-243. [medline] carter, m., & cox, r. (2000). nurse manager's use of a computer decision support system: differences in nursing labor costs per patient day. nursing leadership forum, 5(2), 57-64. [medline] levit, k., lazenby, h., & braden, b. (1998). national health spending trends in 1996. health affairs, 17(1), 35-51. [medline] online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12382544%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12004422%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9455013%5buid%5d 51 testing rural nursing theory: perceptions and needs of service providers helen j. lee, phd, rn1 charlene a. winters, dnsc, aprn, bc2 1 associate professor, college of nursing, montana state university, hlee@montana.edu 2 assistant professor, college of nursing, montana state university, winters@montana.edu keywords: rural nursing theory, concept validation, service-related occupations, qualitative research, health perception, symptom-action-time-line process abstract the purpose of this study was to validate concepts from rural nursing theory (long & weinert, 1989) by exploring the health perceptions and needs of rural adults employed in service industries and living in communities of less than 1,500 persons. thirty-eight adults in eleven rural communities participated in interviews asking questions about their health and how they responded to their own illnesses and injuries. naturalistic inquiry using field research techniques was the method used for the study. four major themes emerged from the qualitative analysis: definition of health, distance and access to resources, the symptom-action-time line process, and choice. for these participants, being healthy meant being able to function whether at work or play. distance was a major part of their lives, particularly in accessing prescription medications, health care specialists and emergency care. the symptom-action-time-line process was evident in seeking care for illness and injury. a previously unidentified theme in the rural nursing theory was the concept of choice, choice of residence and choice of health care providers (hcp). participants chose to live in rural communities because of family ties; others had moved in from other states or, having moved to a more densely populated area, chose to return. choice of hcp was dependent on availability of resources, time of day, weather conditions, and knowledge of the available quality of care. implications for practice and recommendations for research and rural nursing theory development are discussed. introduction the theory development activity and the subsequent publication of the article, “rural nursing: developing the theory base” (long & weinert, 1989), was founded on qualitative and quantitative studies of health perceptions and needs conducted in the late 1970s and throughout the 1980s. the qualitative studies consisted of interviews conducted principally with individuals working in the extractive industries—farmers, ranchers, and loggers. to extend the earlier qualitative work, the purpose of this study was to explore the health perceptions and needs with adults employed in the rural service sector. to accomplish this purpose, the aims of this qualitative research study were to (1) determine the health perceptions, needs, and practices of service workers living in a sparsely populated rural setting, and then (2) compare the concepts emerging from this study with those in the rural nursing theory base. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.montana.edu/wwwnu/ mailto:hlee@montana.edu http://www.montana.edu/wwwnu/ mailto:winters@montana.edu 52 review of literature rural nursing theory the theory for rural nursing evolved because of a recognized need for a framework for practice that considers perceptions and needs of persons from whom care is being provided (shannon, 1998). prior to its inception it was assumed that care of rural persons was similar to the care of persons living in urban environments. the resulting theory contains three statements and their related concepts. the first says that “rural dwellers define health primarily as the ability to work, to be productive, to do usual tasks” (long & weinert, 1989, p. 120). key concepts associated with this statement are work beliefs and health beliefs. the second statement is “rural dwellers are self-reliant and resist accepting help or services from those seen as 'outsiders' or from agencies seen as national or regional ‘welfare’ programs” (long & weinert, 1989, p. 120). rural persons preferred to seek health care from “insiders,” persons with whom they were familiar. additional key concepts pertaining to the statement are old-timer and newcomer. the third statement focuses on health care providers (hcps); it indicates they experience lack of anonymity and much greater role diffusion than providers in urban or suburban settings. lack of anonymity also applies to the recipients of health care in rural areas as all persons in that environment have a “limited ability . . . to have [a] private area in their lives (long & weinert, 1989, p. 120). other concepts important in understanding the health care-seeking behavior of rural residents are isolation and distance from health care. the qualitative data upon which the theoretical work was based indicated that rural residents did not feel isolated despite the fact the fact that descriptive quantitative data revealed they were, on average, 23 miles from their nearest emergency room (long & weinert, 1989, p. 119). related nursing literature the rural nursing theory article published by long & weinert (1989) was and is widely quoted in nursing literature, in community nursing texts and chapters about rural nursing, and in presentations given about rural nursing. however, in a review of the rural nursing literature, only one citation was found that focused specifically on perceptions and needs of rural persons (bales, 2002a). her qualitative study findings included four themes previously documented in rural nursing literature--self-reliance, hardiness, community support, and inadequate health insurance--and two new themes, conscious consumer and informed risk taker. in other recent research studies pertaining to the health of rural persons, the concepts of distance (pierce, 2001), lack of access (pierce), use of an informal network (pierce), familiarity (magilvy & congdon, 2000), and self-reliance (roberto & reynolds, 2001) were supported. in research articles about rural hcps, the concept of familiarity led to significantly greater patient satisfaction with nurse practitioner service (knudtson, 2000) and to more positive practices in pain management and restraint use by rural nurses with older patients (courtney, tong, & walsh, 2000). online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 53 methods setting setting montana is the fourth largest state in the united states and has an overall population density of 6.2 persons per square mile (census, 2002). according to the 2000 census, 90.6% of the state’s residents are caucasian; the principle minority population is native american (6.2%). farming, fishing, and forestry occupations occupy 2.2% of the population while 42.4% of the population is employed in service, sales, and office occupations (census, 2002). methods the method used for the study was naturalistic inquiry using field research techniques (lincoln & guba, 1983; miles & huberman, 1994; rossman & rallis, 1998). the researchers used an inductive approach to encapsulate the perceptions of the rural service providers, to learn what they understood about their health and how they managed their day-to-day health care situations (wolcott, 1982). using this open-ended approach allowed themes to emerge from the interview narratives (miles & huberman, 1994), thereby enabling the researchers to make comparisons with the concepts and statements contained in the rural nursing theory. interviews were conducted with individuals living in eleven rural towns of less than 1,500 persons who were employed in service occupations in their respective communities. demographic data and health characteristics of the communities were collected; individual demographic information was collected from each participant. the interview schedule contained open-ended questions asking the participants about their perceptions of health and how they responded to their own illness and injuries. procedures graduate nursing students enrolled in a first semester rural nursing course are assigned to interview a rural population subgroup to learn their health perceptions and needs. for fall 2000 and 2001, students were invited to participate in a faculty-designed study to gather information from adults employed in service occupations. all students enrolled chose to participate. the study was approved and followed procedures outlined by the msu-bozeman’s human subjects committee. following the selection of a rural community meeting the criteria of less than 1,500 persons, students entered the community to conduct the interviews. the initial interview was usually done with someone known or referred to the student. additional participants were obtained using snowball or chain sampling, a technique in which the initial interviewee was asked to put interviewers in touch with other persons they knew who were employed in the service sector (miles & huberman, 1994). following an explanation of the study and the signing of a consent form, the interviews were conducted. they lasted 30 to 60 minutes and were audio taped. once transcribed, the interview narratives were analyzed for themes; the students then wrote and submitted individual papers addressing the themes emerging from their six interviews. in addition, the online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 54 transcripts were emailed via attachment on webct (distance education web browser) to the faculty. using the webct browser provided more security for the interview contents than the regular internet email. the interview data were subsequently entered into the qualitative software program, qsr nud*ist (qualitative solutions, 1997). demographic information was entered into the statistical package for social scientists (spss, 2002) to compile descriptive information about the sample. analysis the analysis was conducted using two sources of data, transcriptions and students’ papers. of the 96 interviews conducted by the students, a subset of 38 transcriptions was selected. these 38 interviews were of persons who represented a purposive, homogenous sample of rural persons employed in the service sector. excluded were interviews conducted with unemployed, retired, or professional persons (those requiring college degrees for their occupation), those not meeting the study criteria of having lived in the rural area for five years, and interviews assessed as “thin.” in this qualitative research, trustworthiness (guba & lincoln, 1981; lincoln & guba, 1985; lincoln & guba, 1986) was established by asking the participants to review and validate the initial data analysis, including sufficient detail so that others can follow the decision trail, and ensuring that the findings were generated from the data itself. there are limitations of the research, including that the information generated may only be applicable to phns who practice in rural areas in southern alberta, canada. however, given the paucity of theoretical development in this field of nursing (kulig, 2002), the findings, although limited, contribute to expanding the baseline of knowledge related to community health and public health nursing. sample of the 38 participants, 14 were male and 24 were female. thirty-five were caucasian and three were native american. participants’ ages ranged from 22 to 85 with a mean average of 49 years. their years of education ranged from 7 to 18 with a mean of 13 years. most were living in households with a spouse and one child and were likely to be a member of the lutheran or catholic religious faith. occupations of participants varied widely and included grocery store clerks (n=4) secretaries (n=3), hospital workers (n=3), restaurant workers (n=3), beauty stylists (n=2), kennel attendants (n=2), museum operators (n=2), county employees (n=2), window treatment designers (n=2), and others (n=12). on the single health perception item with ratings of excellent, very good, good, fair, and poor, the majority rated their health as “good.” in response to a question about health insurance coverage, 29 said “yes” and 8 indicated “no;” one individual did not respond. participants had lived in rural communities from 5 to 84 years (mean = 34). the population size of the communities ranged from 70 to 1728 persons (one community’s population rose from less than 1500 in1990 census to 1728 persons when the 2000 census was published in october 2001.). the density of the counties in which these rural communities were located ranged from 0.8 to 29.8 persons per square mile. the distance online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 55 to the nearest large town ranged from 12 to 250 miles (mean = 60 miles). the distance to emergency care ranged from 0.1 (a local health care clinic) to 110 miles; the average distance was 30 miles. results four major themes emerged from the analysis of the interviews--definition of health, distance and access to resources, the symptom-action-time-line (satl) process, and choice. these themes are presented first and are followed by findings related to other rural nursing theory concepts. included are examples of participant statements supporting each of the themes. definition of health the health beliefs and values that individuals hold affects how they seek health care, participate in treatment and preventive interventions and develop health promoting behaviors (long, 1993). participants were asked to explain their health perception rating and to define “healthy.” overall, the participants stated that being healthy meant being able to function and to “do the things you want to do and feel good at it, both working and playing.” for some, qualifiers for being able to do what they wanted included “at my age,” “no chronic illness,” “no ailments,” “you aren’t at the doctor all the time,” “limited amounts of cold and flu,” and “not being overweight.” however, many stated they were healthy but also shared that they had chronic illnesses; conditions mentioned included arthritis, obesity, headaches, and heart disease. for these participants, being able to function included being physically, mentally, and emotionally fit. staying physically fit included eating right and exercising. being mentally and emotionally fit included reading and taking “a walk for my mind every day.” pacing their activities was important for those with chronic illnesses. ultimately, being healthy meant having “quality of life.” distance and access to resources distance means the separation (space, time, and behavior) between the rural participants and their health care resources (ballantyne, 1998; henson, sadler, & walton, 1998). dealing with distance when accessing health care resources was definitely a part of these participants’ lives. specific areas of concern mentioned were obtaining specialist care, prescription medications, and emergency care. specialist care. while family practice hcps were usually available within a “fairly short distance,” obtaining the care of a specialist meant travel. “you just know that [with] certain diseases [and] you want to stay in this area, you are going to have to travel for treatment.” “that’s part of living here.” participants reported that many communities benefited from having visiting specialists such as orthopedic surgeons, neurosurgeons, and oncologists. however, if surgery or specialized treatment were needed, travel to the city of the specialist’s home base was required. prescription medications. obtaining prescription medications through a local pharmacy was not an option for many participants. some mentioned that local online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 56 pharmacies had been available in the past; “you know, it used to be you could just go downtown and get what you needed, but there’s nothing here anymore, so it’s hard.” obtaining a new prescription from the local hcp meant a “hop in the car and drive to [nearest large town/city].” working full time made it difficult for some participants to obtain their refills; they described getting their refills through the mail or having them hand-delivered by neighbors who were pharmacists or other drug store employees commuting to work at nearby towns. emergency care. four differing perceptions of thought emerged about accessing emergency care. the first was absolute confidence in the volunteer emergency medical technician (emt) staff available in the communities to provide care; “. . . they are very dedicated and they really keep the equipment up. i would feel real confident if i had to call them.” another stated, “i’m totally comfortable if i had to call the ambulance for any reason; i know me or my family will be taken care of.” the second perception of emergency care contained similar expressions of confidence in the volunteer emt staffs. however, when queried further about the system, they qualified their enthusiasm about available emergency care by saying it was pretty good “for a rural community.” the third perception included persons who were not comfortable with the local emergency care available. one participant stated, “we have a lot of activities that can lead to injury. . . . i don’t think we’re adequately staffed. i really think we need a paramedic and better support staff to help him [local physician’s assistant] to do his job.” the fourth perception came from persons who had a vague idea of the kinds of emergency services available. responses to questions about the potential occurrence of injury at work or the handling of a large accident included statements starting with “i think.” or “i don’t know.” the symptom-action-time-line (satl) process participants were asked what they would do if they experienced an illness or injury. the interviewers provided examples of illness (flu or cold) and injury (a cut or broken bone). the acronym satl (symptom, action, time line) describes the process participants used when confronted with illness or injury. the satl process involves recognition and assessment of symptoms, the decision to act on that assessment, and the time it takes to do so (buehler, malone & majerus, 1998). the time to act, or time line, for the chosen intervention was dependent on the intensity, duration, and degree of disruption in function the participants experienced. actions included wait and see what happens, “gut it out,” self-care (use of home remedies, over-the-counter [otc] medications, rest, etc.), consultation with family members, or a visit to a hcp. the decision and time taken before seeking care from the hcp were influenced by the failure of self-care to achieve desired outcomes, the assessment that the condition was beyond their ability to provide self-care, urging of family members, the distance to the hcp, and what their health insurance provided for care. satl illness. in response to illness such as a cold or flu, actions taken were based on prior experience with the illness, knowledge of what had worked in the past, access to health care, and ability to miss work. self-care could last for up to seven days before seeing the hcp for “something that was nagging” or “that drug on.” self-care was online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 57 quickly initiated and hcps were readily seen for symptoms known to require prescription medications or cause the participant to miss work. choosing to see a hcp also depended on the day of the week participants felt ill, and whether access to medications and health care professionals was available. “it all depends on if it was on a monday or on a thursday. nothing like waiting and putting it off then comes the weekend.” if participants became ill and needed otc medications such as aspirin or tylenol, they often “. . . have to go without unless it is daytime hours.” because of distance and access issues, participants were prepared. “you should see that medicine cabinet of mine . . . i’m prepared.” satl injury. for injuries, participants assessed the seriousness of the injury, the immediacy of needed hcp care, and the ability to take the necessary self-care actions. for cuts, the length, depth, and the presence of profuse bleeding were assessed. self-care included using antiseptics to disinfect, pulling the edges together if only a “couple of inches long,” and bandaging. injuries “i didn’t think i could put a band-aid on” meant a trip to the hcp. the further away from an immediately available hcp, the less likely participants would access care. fractures were assessed for seriousness based on whether the bone was “sticking out” or for “anything that might cause the loss of the use of the extremity.” participants stated they usually drove themselves or had a family member drive to the nearest emergency site because waiting for the arrival of an ambulance doubled travel time. choice a previously unidentified theme in the rural literature emerging from the data was that of choice. choice, defined as conscious decision making, was evident in two different spheres. the first was choice of residence--choosing to live in a rural area. the second sphere of choice referred to needed services of hcp. it included the knowledge of where and when the resources were available, the skill level of personnel, and weather and road conditions affecting access. choice of residence. two avenues of thought appeared regarding the choice to live in a rural area. for those who had grown up in the rural area in which they resided, a bond appeared because of family. “i was raised here. my parents were raised here. my grandparents were raised here . . . you know, i belong here, that kind of attitude.” others who chose to reside in a specific area, either because of having moved into the state or having moved from more densely populated areas within the state stated, “i like it here. it is absolutely beautiful” or “i feel our quality of life here is as good as any place in the state.” these choices are made despite having to drive long distances to work and “prices are high.” some commented on people who “come back . . . to retire. when they can afford to, then they come back to the peace and quiet.” choice of health care provider. after assessing the seriousness of a potential injury or illness, participants determined which resources to use. if a local clinic was available, it was usually the first choice. however, if the local resource was not available due to the time of the day (evenings) or day of the week (closed on weekends), the next decision was which town or city and, sometimes, which direction. often, direction was dependent on weather and the road conditions. traveling to a distant city on the plains often won over driving “over a mountain.” an exception to this choice would occur if the online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 58 highways were icy, and the mountain pass in the other direction was well maintained. impassible roads in all directions means contacting the nearest consolidated population area hospitals for helicopter transport. knowledge of the quality of care available and familiarity with the available resource(s) in the distant town or city also affected the choice. in addition, the assessment of the illness or injury determined whether the open nearby clinic was bypassed because participants knew that distant hospital personnel saw more of that particular illness or injury and could take better care of it. finally, having family or friends living in a consolidated population area influenced decision making as participants and their families could stay while receiving treatment, thereby decreasing health care costs. concepts from rural nursing theory concepts emerging from the data that validated those from previous rural nursing theory development included insider, lack of anonymity, and familiarity. self-reliance, frequently identified in student papers, was observed within the context of participants’ discussion of self-care strategies in managing injury and illness. in the four differing perceptions related to emergency care, the first two groups expressed confidence in their local volunteer emt staff showing preference for insiders. their perceptions of the known insiders would guide them in dealing with an emergency; they trusted these individuals to act in their best interests. lack of anonymity means “one cannot remain nameless or unknown” (lee, 1998, p. 77). several participants commented that living in a small community means “everybody knows who everybody is” and “everyone knows what everyone is doing.” “you see people walk into the hospital and you wonder where they are going.” familiarity “includes the positive ideas of thorough knowledge of or acquaintance with and closeness and intimacy . . . and the contrasting perspective of offensive, unwarranted, intimate conduct” (mcneely & shreffler, 1998, p. 91). participants commented that they did not appreciate the familiarity when they were younger because “everybody’s in your business.” however, they appreciated having the quality as they raised their own children, particularly because of the smaller schools and the availability of one-on-one education. the lack of anonymity and familiarity influenced some participants as they sought health care. “if i had a problem i didn’t want the whole town to know about, i wouldn’t go to the [local facility]. . . . there are so many people in the facility and maybe some of them are curious, and maybe somebody is breaking confidentiality.” this was particularly true in seeking care for gynecological and mental health problems. in contrasting physical and mental health problems, one participant stated that “people accept a diagnosis of diabetes whereas a diagnosis of clinical depression [means] you are a weak person. . . . it is not really an illness.” online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 59 discussion definition of health the rural persons’ definition of health in previous theoretical work was “the ability to work and be productive” (long & weinert, 1989, p. 12). this study’s findings suggest that work and health beliefs of this group of rural persons differ from those that formed the early theory work. therefore, the researchers suggest the definition needs to be broadened as participants in this study defined health as being able to do what they wanted to do, whether that included work or play. this finding may relate to the difference between the population samples (extractive occupations vs. service providers) or may be due to changes in perceptions occurring in the 20 years between the 1980s and the beginning of the 21st century. the informants in the earlier studies were more likely to be independent managers of their chosen trade (farmer, rancher, logger); therefore, they focused on the need to work because there no one else was available to do it. if they could not complete the work, they financially could not make it. the persons in this study were more likely to be employed with a small group of people. potentially, another factor changing the definition of health is the increased exposure to and emphasis on health, preventive strategies, and the promotion of wellness through the media--television, newspapers, magazines, books, computers, and the internet. children bring home information about these topics from school; adults are exposed to this knowledge through their work and other community activities. distance and access to resources. while distance and access to resources were linked in this paper, distance is only one of many dimensions of access to health care resources (gulzar, 1999). the concept of access needs further study and conceptualization with regard to the rural environment. scales to measure some dimensions of access are available; gulzar recommends that newer and better measures are needed. the concept of access combined with the satl process (see below) may be the most lucrative in terms of movement of rural nursing theory development. satl process. the satl process (buehler et al. 1998) was strongly evident in the findings of this study’s data. the identification of this process emerged through a grounded theory study conducted with rural and frontier caucasian (n=8) and native american women (n=8). while bearing differing labels, similar processes have emerged in two other grounded theory studies (bales, 2002b; koehler, 1998). bales discovered that remote rural women (n=11) of childbearing/childrearing age followed a similar course of action for themselves and their families; she identified the process as “episodic evaluation” (p. 49). koehler found a major strategy her rural and frontier elders (n=30) used to protect their independence was “managing [their] illness episodes” (p. 247). the steps included “gauging the seriousness of an episode, deciding on the course of action for the episode, and . . . dealing with distance” (p. 247.). because the satl process was not conceptualized at the time of the earlier rural nursing theory publication, it was not part of that work. the process is very relevant and needs further investigation, both from qualitative and quantitative perspectives. the process lends itself to becoming a focal area in future rural nursing theory development because of the potential for real and actual differences between rural and urban individuals, particularly for differences in time line. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 60 choice. deciding to live in a sparsely populated area has ramifications for the availability of health care. accessing health care resources for rural persons is much more complex than for urban persons because of all the interrelated concepts of distance and accessibility (see discussion above). with the possible exception of the fourth and last group of perceptions about accessing emergency care, these participants were aware how their residential choice effected their health care choices. rural concepts. while the concepts of distance, insider, self-reliance, familiarity, and lack of anonymity readily emerged throughout these interviews, the concepts of outsider, old-timer, and newcomer, were not apparent. boland (2000) explored the concept of old-timer with elderly persons in small rural communities. her findings suggest that the old-timers’ influence may no longer exist. she attributed her findings to “changes within the community, loss of respect for the elderly, and advances in technology” (pp. ix). since boland’s study was conducted in one rural locale and with elderly persons, additional exploration of this concept is needed. also, study of other rural nursing concepts to determine whether they influenced health care as much as seemed evident in the late 1970s and 1980s is needed. implications for practice. the themes identified from the transcripts--definition of health, distance and access to resources, satl, and choice--have several types of implications for nursing practice. in view of the change in rural individuals’ definition of health suggested by the findings of this study, nursing interventions need to be directed toward helping individuals not only achieve physical fitness but also mental and emotional fitness. during each visit to the hcp, time should be allotted for assessment and discussion of health practices, environmental health concerns, and self-care activities to maintain health. because of the unavailability of amenities like health care fitness clubs and parks containing walking paths, assisting rural persons to see how they might adapt recommendations to achieve health to their rural lifestyle is needed. information about activities related to achieving and maintaining a health lifestyle should be available and discussed with each individual. the themes of choice, distance, and access to resources, are interrelated; persons making the choice to live in a rural area are placing themselves in a position of having to make multiple layers of decisions with regard to health care. those persons who chose to live “out” as opposed to “close in” to consolidated population areas need to be skilled in self-care practices, prepared to travel to specialists, and bear the increased financial burden associated with increased travel for care. health care providers need to provide instruction about illness self-care; particular emphasis should be paid to discussions of signs and symptoms that require the attention of the hcp and strategies related to access and distance to care. because of the necessity to travel for specialized care, collaboration between local hcps and distant specialists is essential for the coordination of follow-up care for rural persons and their family caregivers. rural persons and hcps share responsibility for open and clear communication about the care received from specialists at distant health care facilities. given the concerns raised by these participants related to lack of online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 61 anonymity, confidentiality of information exchanged during visits with hcps should be assured and maintained. conclusion the choice of a qualitative approach provides an in-depth look at a specific group of individuals. the limitations of the approach are a small sample size and the use of a convenience sample. therefore, the findings cannot be generalized to the state of montana or to other sparsely populated areas. the rural nursing theory base was developed through studies that were generalizable to rural persons living in sparsely populated areas. however, the theory has been generalized to all rural populations, especially from the clinical perspective. since rural areas are known for their diversity, additional studies of health perceptions, needs and practices of persons living in differing rural areas are needed. replication of this study is needed in rural states throughout the united states as well as in other nations. while it is known that similar studies have taken place in north dakota and in alberta, canada, access to these studies’ findings in the literature is limited by the lack of publications. comparison studies with persons living in consolidated population centers located in states with a predominantly rural population are needed. studies are needed to ascertain whether differences exist between perceived health needs in rural versus urban persons. studies contrasting health perceptions and needs between differing environments will contribute to the needed base for developing interventions, strategies, and criteria needed for evidence-based nursing practice in both urban and rural settings and for rural persons obtaining care in urban health care facilities. several participants in this study were older and dealing with chronic illnesses. additional information is needed about rural persons and how they use the satl process in handling the symptoms that accompany their chronic illnesses and how they manage acute exacerbations. this knowledge will assist the health care personnel in rural hospitals to make decisions about keeping patients or transporting them to urban centers. this knowledge will also help nurses and other health care personnel in urban facilities provide the needed education for rural persons in managing their illnesses while living in and returning to the rural environment. the knowledge can be used to influence decision making about needed changes in the present day balance of bringing rural persons to the experts versus bringing the experts to where the rural persons live (mueller, 2002). acknowledgments the authors wish to acknowledge (1) the study participants, (2) the graduate nursing students: d. albrecht, r. bales, d. benton, j. bischoff, e. cadenhead, d. culp, s. harris, c. johnson, m. maher, e. mullenberg, j. neal, c. reichelt, m. k. thurston, k. timmer, c. walton, c. white, (3) manuscript reviewers patricia butterfield and jean shreffler-grant, and (4) research grant funding received from the zeta upsilon chapter of sigma theta tau international. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 62 references bales, r.l. 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(1998). familiarity. in h. j. lee (ed.) conceptual basis for rural nursing (pp. 89-101). new york: springer. miles, m.b., & huberman, a.m. (1994). qualitative data analysis: an expanded sourcebook (2nd ed.). thousand oaks, ca: sage. mueller, k.j. (2002). rural health policy: past as a prelude to the future. in s. loue & b. e. quill (eds.), handbook of rural health (pp.1-24). new york: kluwer academic/plemum. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://factfinddr.census.gov/ http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11111426 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10081206 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11930439 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8451203 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2772454 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11012996 63 pierce, c. (2001). the impact of culture of rural women’s descriptions of health. journal of multicultural nursing and health, 7(1), 50-53, 56. qualitative solutions & research pty ltd. (1997). non-numerical unstructured data indexing searching and theory-building (qsr nud*ist) (version 4.0) [computer software]. thousand oaks, ca: scolari, sage. roberto, k.a, & reynolds, s.g. (2001). the meaning of osteoporosis in the lives of rural women. health care for women international, 22, 599-611. [medline] rossman, g., & rallis, s. (1998). learning in the field: an introduction to qualitative research. thousand oaks, ca: sage. shannon, a.m. (1998). developing an educational structure for rural nursing research and theory. in h.j. lee (ed.), conceptual basis for rural nursing (pp. 399-407). new york: springer. statistical package for the social sciences (2002) (version 10) [computer software]. chicago: spss. wolcott, h.f. (1982). differing styles of on-site research, or, “if it isn’t ethnography, what is it?” review journal of philosophy and social science, 7(1 & 2), 154-169. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12141850 rural nursing theory setting editorial 5 editorial helping an older person remain independent bette ide, phd, rn editorial board member barbara dahlen, m.s., fnp, abd has been assisting her sister, who her 91-yearold mother, mrs. marie charbonneau, lives with, come up with strategies that will help their mother remain as independent as possible. they have made modifications to her living environment that help her deal with failing eyesight while remaining productive. she has difficulty seeing the edges of steps. they use the yellow and black tape that you can buy in hardware stores, placing strips along the edges of the steps. she can see the edges and does not trip. she loves to sew, making quilts, pot holders, etc. for family members and for sale. modifications in her sewing environment have been made to accommodate her diminishing vision and difficulties in getting up from a sitting position. they have focused on increasing the amount of light, particularly natural light, available by placing her sewing machine under a window, using mini-blinds, and installing halogen lamps in the corners of the room. she has an l-shaped work space which she can maneuver around in using an office chair on wheels. everything is easily accessible, and she does not have to stand up frequently. she has bright-colored totes in primary colors that are on wheels, available from k-mart, in which to keep her sewing materials separated. she also has special needles so she doesn’t have to thread a needle. her sewing machine has been modified by adding a rectangular magnifying glass so she can see the settings. to avoid her having to use needles in putting a quilt together, she uses a plastic gun such as the ones used for stapling price tags on clothes and red staples that she can see easily. the plastic guns and staples are available at quilting centers. the dining room has a flat carpet and a round table with chairs with wheels. the flat carpet prevents the chairs from sliding out from under her. she is able to go around the table, tying quilts, and doesn’t have to stand up. she is also in less danger of falling. they have encouraged the making of “crazy quilts” because she doesn’t have to cut straight .pieces. these modifications have kept her productive– she sews every day–and independent. for questions or comments, e-mail me at bette_ide@mail.und.nodak.edu. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 mailto:bette_ide@mail.und.nodak.edu 89 small, rural hospitals: a fight for survival julie w. robinson1 grant t. savage, phd2 richard scrushy3 1 graduate assistant, health care management, university of alabama 2 professor and healthsouth chair, health care management, university of alabama, gsavage@cba.ua.edu* 3 healthsouth, birmingham, al * corresponding author keywords: medicare reforms, rural health policy, hospital strategy abstract declining reimbursements, resulting from the 1997 balanced budget act (bba), have placed an enormous strain on small, rural hospitals that are typically dependent on medicare patients for the majority of their revenue. under the bba, new managed care and private options are available, payments to hospitals are reduced, part b premiums are increased, and a prospective payment system (pps) is authorized for outpatient, home health, and skilled nursing services. the balanced budget refinement act of 1999 (bbra) attempts to rectify some of the reductions in reimbursement. nonetheless, to take advantage of the bbra and to address declining reimbursements from other sources, rural hospitals should expand outpatient services, embrace telemedicine and telehealth initiatives, and actively seek alternative funding. introduction rapid changes in technology, reimbursements, and regulations between 1980 and 1989 resulted in the closure of more than 200 small, rural hospitals (hart, amundson & rosenblatt, 1990). as we enter the 21st century, rural hospitals—servicing populations in non-metropolitan counties throughout the u.s.—are once again facing immense pressures, especially from aging populations and from public and private payers. these pressures are most intense for small hospitals, with fewer than 100 beds. most rural hospitals are dependent on medicare for the majority of their revenue, and the 1997 balanced budget act (bba) has drastically reduced their medicare reimbursements (coburn, fluharty, hart, mackinney, mcbride, mueller, & wakefield, 1999). rural hospitals cannot continue business as usual, even with the recent relief provided through the 1999 balanced budget revision act (bbra). to reduce the negative impact the bba has had and to take advantage of the provisions in the bbra, small rural hospitals should expand outpatient services, embrace telemedicine and telehealth initiatives, and actively seek alternative funding from foundations and other sources. background medicare was enacted in 1965 as title xviii of the social security act and began in 1966 under president lyndon b. johnson. the program currently is managed by the online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.cba.ua.edu/hcm/ http://www.cba.ua.edu/hcm/ mailto:gsavage@cba.ua.edu 90 health care financing administration (hcfa) which was formed in 1977 as an agency of the federal department of health and human services. the data that determines medicare eligibility is maintained by the social security administration. medicare provides coverage for people aged sixty-five and older, for people who are disabled and eligible for social security, and for people with permanent kidney failure. medicare has two parts, a and b. medicare part a provides hospital insurance and is financed through a 2.9 percent payroll tax. employers and employees each pay half the tax. a premium payment is not required, but beneficiaries do pay a deductible of $764 on hospital stays each year. federal actuaries initially estimated future expenditures for medicare part a so that a payroll tax could be established based on potential costs. however, the government's 1965 estimates were based on a worker to beneficiary ratio of 5:1; in 1995 that ratio was 3:1, and it is projected to be 2.2:1by 2020 as the baby boomer generation matures (barton, 1999). medicare part b is known as supplementary medical insurance (smi). it helps pay the cost of medical equipment and supplies, outpatient hospital services, and physician services. general tax revenues provide 75 percent of the funding, while beneficiaries pay a monthly premium that funds the remaining 25 percent of part b. the smi program covers 80 percent of the allowed charge for health services (barton, 1999; the century foundation, 1999). changes and controversies in medicine in 1997 congress passed legislation signed by president clinton to balance the federal budget, thereby authorizing major reductions in medicare funding. unresolved issues with the bba were the conflicting interests of the small, rural hospitals, the health care financing administration, and congress. rural health care facilities believed the federal government was balancing the budget at their expense. congressional proponents of bba insisted that measures had been taken to reduce the inequalities rural health care facilities historically have experienced. from the small, rural hospitals' perspective, however, the health care financing administration’s implementation of the bba created an expectation gap, and made bba reforms an important issue for hospitals and rural communities. as issue management experts have argued (wartick & mahon, 1994), expectation gaps between "what is" versus "what ought to be" tend to become the focus for conflicts and are the impetus for social and organizational change. indeed, these conflicts were perceived as so severe that lobbying efforts from the health care provider community and other stakeholders in 1999 resulted in revisions to the 1997 legislation (jones, 2000). the major aspects of both the bba of 1997 and bbra of 1999 are discussed below. the balanced budget act of 1997 under the auspices of the balanced budget act of 1997, medicare had drastic budget reductions. measures were enacted to reduce the projected growth of medicare spending by $116.4 billion by 2002. the impact of this funding decline for medicare has been compared to the impact in the 1980s of the prospective payment system (pps) on hospital insurance (arent fox alerts, 1998). many of the provisions were to be phased in through 2002. new managed care and private options, reduced payments to hospitals, online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 91 increases in part b premiums, and a pps for outpatient, home health, and skilled nursing services were a few of the major changes. managed care and private options managed care is becoming increasingly the norm for employer-based health insurance, according to research conducted by the century foundation. one study notes that in 1993, 78 percent of workers in firms with 1-24 employees, and 65 percent of those with 25-49 employees had access to traditional fee-for-service health insurance. only two years later, both those figures had fallen to 30 percent. (the century foundation, 1999: 2)as of october 1999, approximately 16 percent of all medicare beneficiaries were enrolled in managed care plans (shay, mcbride, & mueller, 2000). medicare+choice allows private insurance companies to offer managed care coverage to beneficiaries. everyone who has medicare parts a and b is eligible, except those who have end-stage renal disease. managed care plans often encourage preventive health, especially if they are based on a fixed payment per patient. for example, the majority of managed care plans cover annual physicals, eye exams, certain immunizations, ear exams and outpatient prescription drugs. proponents of medicare managed care believe medicare+choice has the potential of cutting costs and perhaps improving the quality of care. however, the savings have yet to be seen. the health care financing administration is taking steps to educate medicare recipients of the benefits of managed care plans. in the medicare & you 2000 (1999) handbook, the hcfa uses easy to read graphs to show the results of a survey it conducted. the survey measured the communication skills of managed care doctors as viewed by a sample of medicare managed care plan members. this booklet is just one of the ways hcfa is attempting to educate beneficiaries about the reform. according to a 1997 u.s. congressional budget office report, medicare paid about 5 percent more for the beneficiaries who enrolled in hmos than it would have spent if the participant had remained with traditional coverage (the century foundation, 1999). one of the reasons for these higher costs was the process of risk selection. this is the practice of managed care plans marketing to healthier beneficiaries who want lower out-of-pocket costs and more benefits. less healthy beneficiaries are more likely to stick with what they know. the possible effects of this selection bias are increased premiums and payroll tax rates for those receiving traditional fee-for-service medicare. in accord with the bba, a new risk adjustment procedure is being instituted during 2000. this adjustment takes into account the prior hospitalization experience of beneficiaries as a factor for determining the per capita payments for medicare+choice plans. another change congress has made under the 1997 bba is to fix the growth rate of managed care plans at a lower rate per capita than in medicare’s traditional fee-for-service section. in the past, the rate had been a percentage of the program's expected fee-for-service costs. this measure is anticipated to save $23.2 billion. these medicare reform proposals that rely on competition among managed care organizations, however, ignore many seniors living in rural areas. for example, according to a study by families usa, a consumer advocacy group, alabama has nearly 240,000 rural medicare beneficiaries, and only participants in walker county have access to a medicare hmo (“rural medicare hmos,” 1999). moreover, national data shows slow online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 92 growth in medicare+choice for rural (2.5%) versus urban (20.3%) communities, with extreme regional variation in the growth and decline in managed care enrollments during 1999 (shay, mcbride, & mueller, 2000). reduced payments to hospitals the second major bba reform reduced payments to hospitals, constituting almost 30 percent of the expected medicare program savings over the next five years (the century foundation, 1999). this reduction is where rural hospitals have suffered the most since they derive the majority of their revenue from these reimbursements (rural policy research institute, 1999). according to robert a. berenson, director of the center for health plans and providers, a division of the health care financing administration, one in four medicare beneficiaries live in rural areas (berenson, 1999). the bba froze payment increases under the prospective payment system for the 1998 fiscal year, while setting rates for 1999 through year 2002 slightly below the expected increases in medical costs (the century foundation, 1999). increase in part b premiums a third bba reform was to increase part b premiums. in 1997, monthly premiums were $45.50. under the bba they increase to $64.00 in 2002. since the elderly spend an average of 21 percent of their disposable income on health care (the century foundation, 1999), this increase undoubtedly will place a strain on low-income beneficiaries. according to the century foundation, about 78 percent of medicare beneficiaries have incomes below $25,000. prospective payment system (pps) a pps sets pre-determined rates for different categories of medical services. since 1984, medicare has had pps for inpatient services based on diagnostic-related groups (drgs); the bba authorizes a pps for outpatient services, which is slated for implementation during 2000. the bba of 1997 reduced cost-based outpatient services as conversion was completed to a pps. at the same time, the bba immediately imposed a pps for skilled nursing services and introduced an interim payment system with conversion to a pps after 2000 for home health service payments. taken together, these measures had unforeseen negative impacts on reimbursements for rural hospitals, all which provide outpatient services and 72% of which offer either or both home health and skilled nursing services (coburn et al. 1999). from 1990 to 1996, the rate of medicare spending on home health and skilled nursing services grew at a fast pace. understandably, the pps for skilled nursing services and reductions in home health reimbursements was one of the earliest bba reforms implemented, but with unanticipated adverse results. for example, between mid-1997 and mid-1999 over 2,500 medicare-certified home health agencies were closed, and home health payments decreased 38% from 1997 to 1998 (national association of home care, 1999). indeed, congressional testimony on revisions to the bba in 1999 focused on the hardships such closures have created for the elderly (berenson, 1999). online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 93 the balanced budget revision act of 1999 the medicare, medicaid, and schip balanced budget refinement act of 1999 was signed into law on november 29, 1999, providing approximately $17 billion in additional funding over the next five years. many of the provisions of the bbra have a direct impact on rural health care delivery and access to services for rural medicare beneficiaries. the following discussion highlights these provisions drawing on analyses from the rural policy research center (mueller, 1999) and reports from the health care financing administration (2000). section 202 in the bbra benefits rural hospitals with 100 or fewer beds by allowing them to receive the same payments for outpatient services as they would have received without the implementation of a pps. this relief extends until january 1, 2004. section 404 extends the medicare dependent hospital program to october 1, 2006, benefiting rural hospitals with fewer than 100 beds which have 60% or more of their inpatient services attributable to medicare. these designated hospitals receive enhanced payments. in addition, the bbra increases the attractiveness of the critical access hospital (cah) designation. the cah designation is appropriate for very small hospitals (15 beds or less) with low daily patient census that provide limited inpatient services for an average of no more than 96-hours per patient. the bbra provides cahs with allinclusive rates for inpatient and outpatient services and eases their use of swing beds. recommendations clearly, small rural hospitals that depend on medicare patients for the majority of their revenue must take an active role to benefit from the bbra of 1999 and to counter the negative impacts from the bba of 1997. while some rural facilities that are strategically positioned with ample community support may be able to muddle through the changes wrought by the bba and the bbra without major reorganization, other hospitals will have to take radical steps. we suggest that at least three different approaches should help rural hospitals survive: (1) expanding outpatient services, (2) embracing telemedicine and telehealth initiatives, and (3) seeking alternative funding sources. expand outpatient services to address reduced reimbursements from medicare, small rural hospitals may expand outpatient services while cutting back on similar inpatient services. of course, all rural hospitals are already offering some outpatient services. according to a recent study by the project hope walsh center for rural analysis, rural hospitals obtained more than two-fifths of their total revenue from outpatient services in 1995 (center for health affairs, 1998). in the past, medicare paid for hospital outpatient services based on hospital-specific costs. under the 1997 bba, congress has enacted several reforms that authorize the implementation of a hospital outpatient pps. as of august 2000, hospitals will be paid for outpatient services based on their national median costs, and services will be classified into ambulatory payment classification (apc) groups, similar to drgs for inpatient services. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 94 fortunately, under the bbra of 1999, all rural hospitals of 100 beds or less are exempt from the outpatient pps until january 1, 2004. moreover, critical access hospitals (cahs) benefit from a pps exemption, and receive all-inclusive rates for inpatient and outpatient services. hence, expanding outpatient services and reducing inpatient beds is definitely advantageous, both for medium-sized rural hospitals with slightly over 100 beds and for small hospitals with daily inpatient census counts close to the cah 15-bed constraint (mueller, 1999). cahs also have advantages since they are not required have the same level of physician staffing as do secondary and tertiary care hospitals, and may rely more heavily on nurse practitioners and physician assistants (hcfa, 2000). for medium-sized rural hospitals, attracting non-medicare as well as medicare patients can help to offset the future possible adverse affects of the pps for outpatient services. outpatient services appear to be ideal niche for small rural hospitals due to their low number of beds and the fact that, when possible, people prefer to drive to larger hospitals for tertiary or quaternary inpatient services (rural policy research center 2000). embrace telemedicine and telehealth initiatives the 1997 bba includes several new provisions authorizing payment for telemedicine and encouraging telehealth initiatives. the purpose is to bring urban expertise to rural providers, while increasing access to specialist and preventive care for rural populations (berenson, 1999). telemedicine allows for medical consultations and telehealth advice to take place through the internet, via wide-area networks, or over the telephone. as a noted physician and expert on medical monitoring devices notes: during the next decade diseases requiring medical intervention will be much the same as those being treated today. the site of care may, however, be moved away from the community general hospital to a non-hospital site or to a higher order or specialty hospital at a distance (wilson, 1999: 1). the telecommunications act of 1996 includes subsidies to help rural health care providers gain access to a variety of telecommunications services at lower rates. according to the federal communication commission (1997), in addition to discounted services, rural providers located in an area without toll-free access to the internet can receive subsidized toll-free access for up to 30 hours of connection time or $180 a month, which ever is less. as of january 1998, a pool of $400 million a year has been available for funding (american hospital association, 1999). a national survey of telemedicine programs reveals a dramatic growth in telemedicine from 1993 – 1997. the study found a total of 80 active telemedicine programs in 38 states and washington, d.c, as compared to 12 active programs in 1993 (grigsby & allen, 1997). the majority of these programs uses broadband technology and is located in academic medical centers or community hospitals; however, after decades of refining, telemedicine is now less expensive and easier to use. new internet-based alternatives have been created for smaller projects, as opposed to the high-end systems used by nasa and in pentagon programs; moreover, ordinary telephone service (pots) is the preferred mode of transmitting voice, video and data. systems that use narrow-band lines have the advantage of being accessible to roughly 99% of the population and are inexpensive to operate. although speed and online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 95 picture resolution are lower quality than in broadband applications, early reports from the field indicate that pots is a satisfactory method of employing telehealth to deliver healthcare services. the advances in narrow-band technology along with the availability of a national infrastructure to deliver services with this technology create unprecedented opportunities (zajtchuk & gilbert, 1999). radiology for example, is a common application in rural telemedicine (hassol et al. 1997) and its use in emergency departments is expanding (baker & festa, 1999). moreover, it would be advantageous for rural hospitals to adopt telemedicine and telehealth initiatives not only to expand access to health services but also to improve the quality of patient information (shepperd, charnock, & gann, 1999). seek alternative sources of funding small, rural hospitals cannot absorb the medicare cuts in the bba of 1997 for an extended period of time and expect to remain unscathed. these vulnerable facilities must seek federal, community, and private funding in order to remain open. for example, a clinic in bessemer, alabama staved off closing its doors after an anonymous donor and jefferson county each donated $125,000. the clinic serves more than 2,000 patients. most of these patients are senior citizens with little or no medigap insurance. there are several grant programs specifically targeted at rural areas. in fact, the united states department of agriculture (1999) offers financial support through a program called discover rural development. funding is also available from the health resources and services administration’s (1999) federal office of rural health policy through its rural health outreach grant program, which makes funds available to rural facilities to expand existing services and enhance health services delivery. other sources of funding are listed at pennsylvania state university’s (1999) office of rural health web site. these types of grants could be used to expand outpatient services and/or adopt a telemedicine or telehealth system. clearly, a grant writer may be a small, rural hospital's best asset. if rural hospitals do not have the staffing and expertise to write grant proposals, they should look toward community volunteers and seek alliances with state and local university programs in health care management. on the one hand, retired and other individuals in the local community may be both experienced and willing to help draft grant proposals. on the other hand, students in health care management undergraduate and graduate programs typically must fulfill internship or other practicum requirements and can be a valuable resource for writing grants, especially when supervised by experienced faculty members and administrators. conclusion clearly, if rural hospitals can implement each of the recommendations they should be able to survive the changes wrought by the bba and the bbra, all other matters being equal. however, reality suggests that none of the proceeding recommendations is equally applicable to every rural hospital; each hospital faces it own unique situation. hospital ceos and their boards should assess their strengths, weaknesses, and resources, and then craft a strategy that best fits their opportunities and online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 96 goals. it may not be feasible for a small, rural hospital to expand outpatient services or to adopt telemedicine and telehealth systems. grant writers may not already be on staff, easily trained, or available for hire. the money or support may not be there. such barriers, nonetheless, are not insurmountable, and one or more of these recommendations should still be practicable. in any case, these recommendations should help rural hospitals take advantage of the opportunities under the bba of 1997 and the bbra of 1999. even if rural hospitals can only implement one of these recommendations, they should be better able to sustain their mission of providing 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[medline] online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.medicare.gov/publications/mandy.pdf http://www.hcfa.gov/pubforms/tr/hi2000/seciia.htm http://pathsrvr.rockford.uic.edu/hrsa/ruralhp.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11066960 http://www.nahc.org/nahc/newsinfo/99nr/hhout.html http://www.cas.psu.edu/docs/casdept/aers/porh/federal.html http://www.rupri.org/rnumbers/health/index.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10488009 http://www.rurdev.usda.gov/rd/index.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10484993 health promotion behaviors of rural women with heart failure 28 health promotion behaviors of rural women with heart failure carolyn pierce, dsn, rn1 1 clinical assistant professor, decker school of nursing, binghamton university, cpierce@binghamton.edu keywords: heart failure, health promotion, perceived health, social support abstract the purpose of this study was to predict the influence of socioecological factors, including social support, barriers to hpb, perceived health status, and demographic variables on the health promotion behaviors (hpb) of rural women with heart failure (hf). a descriptive correlational design was used with a convenience sample of 45 older rural women with hf. instruments to assess social support, barriers to health promotion, perceived health, and demographic data were utilized. multiple regression was used to identify sociological influences on hpb, indicating that a significant variance in hpb was predicted by two variables: (1) new york heart association classification level (negative association), and (2) a history of diabetes mellitus (dm). measures of social support, barriers to hpb, and perceived health status were not found to be predictive of hpb. introduction approximately 5 million persons are living with heart failure (hf) in the us today, with approximately 550,000 new cases of hf per year (american heart association, 2004). hf is the chief cause of 300,000 deaths in the united states per year and contributes to another 225,000 deaths yearly (hunt, baker, chin, cinquegrani, feldman, & francis, 2001). hf is the first listed diagnosis in about 900,000 hospitalizations yearly in the united states and is the most common diagnosis for persons 65 years of age and older (hunt et al. 2001). while the incidence of death related to cardiovascular disease has been declining since the 1960’s, the incidence of deaths related to hf have steadily increased (national heart, lung, & blood institute, 2004). an estimated $25.8 billion is spent for direct and indirect costs associated with hf in the us per year (aha, 2004). in 1999, medicare paid $3.6 billion or $5,456 per discharge for the care of persons with hf. health promotion behaviors in rural women with heart failure heart failure (hf) is a chronic disease with potentially debilitating symptoms that can impact activities of daily living and thus the ability to engage in health promotion behaviors (hpb). the ability to perform hpb may be also compromised by the loss of social support that may occur with aging. women living in rural areas may experience multiple barriers when trying to obtain comprehensive health care for the management of acute and chronic hf. the experience of hf may be different for women than men in several ways. the framingham heart study showed that women were more likely than online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://dson.binghamton.edu/ mailto:cpierce@binghamton.edu 29 men to have hypertension (lloyd-jones, martin, leip, beiser, d’agostino, kannel et al. 2002). women have also been shown to experience more symptoms of hf than men do (mendes, davidoff, cupples, ryan, & jacobs, 1997), and also reported a higher level of impact of symptoms on daily life from fatigue and dyspnea (bennett, baker, & hunter, 1998). those with more symptoms also described a poorer quality of life. feelings of depression and poor quality of life have been attributed to inadequate social supports available to women (friedman, 1997). hpb are actions taken to promote health and prevent further decompensation of the existing disease state (stuifbergen & rogers, 1997). these behavioral, cognitive, and emotional actions may include exercise or physical activity, nutritional strategies, lifestyle adjustment, maintaining a positive attitude, health responsibility behaviors, and seeking and receiving interpersonal support. health promotion emphasizes self-care with an active and involved attitude rather than submitting to professional care with a disengaged attitude (stuifbergen & rogers, 1997). sociological models postulate that hpb are influenced by intrapersonal, social, cultural, and environmental factors and thus provide a vehicle for supporting hpb in rural women with hf. one such model developed by moos (1979) posits that factors such as the environmental system, the personal system, cognitive appraisal, the degree of activation, and efforts at adaptation mediate the relationship between the environment and health. this model also identifies multiple feedback mechanisms that mutually influence each other factor. the environmental system, as construed by moos (1979), includes such aspects as the physical setting, organizational factors, the human aggregate, and the social climate, all of which are critical concerns of health care delivery in rural areas. access to appropriate health care can be problematic among rural women, who experience higher rates of chronic diseases and also higher acuity of illness than their urban counterparts (bushy, 1998). rural women also tend to have fewer visits with physicians and higher rates of hospitalization when they do seek medical care. rural women with hf may also require specialized cardiac care not routinely found in rural communities. rural women may have different expectations about access to health care, as well as differing conceptions of health and personal responsibility toward health behaviors, when compared to urban or suburban women. because rural residents have been found to define health as the ability to work and carry out usual tasks (long & weinert, 1989; pierce, 2001), they are found to be less concerned with comfort, cosmetic, and lifeprolonging aspects of care than their urban counterparts. confounding the complexities of rural health care are issues related to self-reliance, resisting help from “outsiders”, and seeking advice and treatment from neighbors and friends prior to accessing conventional medical care (long & weinert, 1989). moos (1979) described the personal system to be concerned with age, socioeconomic status, gender, intelligence, cognitive and emotional development, ego strength, self-esteem and previous coping experiences. an especially important factor in the personal system is that of interpersonal relationships. intrinsic in those relationships is social support. social support has been described as an exchange of resources between two individuals that is perceived by the sender and/or the recipient as enhancing the wellbeing of the recipient (callaghan & morrissey, 1993). social support provides the individual with feelings of being loved, cared for, and valued and of belonging to a online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 30 mutually obliging communication network. johnson (1996) found that older adults living in rural areas experienced decreased social support. of concern are the findings that an absence of emotional support was a strong predictor of fatal and nonfatal cardiovascular events in elderly women in the first year after hospital discharge for treatment of hf (krumholz et al. 1998). the personal system is constantly receiving feedback from the other systems about health and hpb (moos 1979). perceived health status, or the subjective sense of well-being and physical health (barsky, cleary, & klerman, 1992), has been shown to be related to the performance of physical activity, involvement in interpersonal relationships, good nutrition, and spiritual growth behaviors in older community-dwelling women (lucas, orshan, & cook, 2000). similarly, speake, cowert, and pellet (1989) found that positive perceptions of present health were associated with higher scores of nutrition, interpersonal relationships, and self-actualization. single questions about the severity of perceived health have been found to correlate with the evaluation of illness by physicians (johnson, 1996). an important concern when evaluating the environmental system, as conceived by moos (1979), is the portion of that system that represents barriers to the performance of hpb. rosenstock (1966) defined barriers as the perceived negative costs of health behaviors taken in response to a health problem. barriers may be related to avoidance if the health behaviors are perceived to be inconvenient, expensive, unpleasant, painful, or upsetting. personal barriers to health promotion may include fatigue, boredom, lack of skills needed to gain access to health care, lack of knowledge about what health care is needed, negative past experiences with the health system, or lack of confidence in ability to change (rosenstock, 1974). environmental barriers to health promotion may include lack of services, physical obstacles, cultural beliefs, lack of ability to pay for services, negative attitudes of care providers, health care program or governmental agency rules and regulations, and social policy issues. the composite of the personal system and the environmental system, together with the degree of cognitive appraisal, the degree of activation, and efforts at adaptation in turn impact health status and hrb (moos 1979). coping efforts, health status, and hrb’s in turn provide feedback to the personal and environmental systems. thus, the socioecological perspective provides a global lens to view the multiple factors influencing hrbs in rural women with hf. purpose of the study the purpose of this study was to predict the influence of socioecological factors, including social support, perceived health status, barriers to hpb, and selected demographic variables on the hpb of rural women with hf. the research hypothesis was as follows: significant variance in hpb of rural women with hf will be explained by social support, barriers to health care behaviors, the individual’s perception of health status, and selected demographic variables. operational definitions hpb are actions that are appropriate to promote health and prevent further decompensation of the existing disease state. these behavioral, cognitive, and emotional online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 31 actions may include exercise or physical activity, nutritional strategies, lifestyle adjustment, maintaining a positive attitude, health responsibility behaviors, and seeking and receiving interpersonal support (stuifbergen & rogers, 1997). these behaviors were operationalized by the health promoting lifestyle profile ii (walker, sechrist, & pender, 1995). perceived health status, or the subjective assessment of overall health (barsky, cleary, & klerman, 1992), was operationalized using self rated likert-style question as adapted from johnson (1996). rural is defined as the territories, population and housing units not classified as urban (u.s. bureau of the census, 2005). in this research, rural was defined using counties designated as 6 through 9 in the beale code of the rural urban continuum for the state of new york (u.s. department of agriculture, 2001). this code rates counties according to both population and the level of metropolitan influence. levels 6 through 9 include those of “less urbanized” (6 and 7) and “thinly populated” (8 and 9). socioecological barriers to hpb, or the intrapersonal, interpersonal, and/or environmental factors that inhibit or negatively affect hpb and/or quality of life (stuifbergen, seraphine, a., & roberts, g., 2000), were operationalized using the barriers to health promoting behaviors for disabled persons scale (becker, stuifbergen, & sands, 1991). social support is the supportive social network of people in which one maintains social contact and a social bond involving a feeling of belonging and of being accepted, loved, esteemed, valued, and needed for oneself (pender, 1996). in this research, social; support was operationailzed using the personal resource questionnaire 85 (brandt & weinert, 1987). design this research utilized a correlational design with a convenience sample of 45 rural women with a medical diagnosis hf. potential subjects for this research were women diagnosed by a primary care provider with hf related to any cardiovascular condition. because most women are diagnosed with hf at age 71 + 10.6 years (ho, anderson, et al. 1993), women who are age 65 or older were included. the women were recruited from primary health care practices from rural areas according to the beale code levels 6 through 9 of the rural urban continuum code for new york (u.s. department of agriculture, 2001). other inclusion criteria included being able to read and write english and being willing to participate in the study. multiple regression analysis was used to predict the variance in hpbs of rural women with hf influenced by the effects of social support, perceived health status, barriers to health care, and selected demographic variables. descriptive statistics of several demographic factors and factors related to the health of women with hf living in rural areas were collected for comparison purposes. sample approval for this study was obtained from the appropriate institutional review boards. forty-five women who lived in rural counties in upstate new york were the subjects of this study. the ages of the group ranged from 65 to 98 (m=77.7, sd=8.4 years). all of the women described themselves as white. the majority of women were widowed (48%), while 29 (42.2%) were married, 2 (4,4%) single, and 2 (4.4%) were divorced. twenty five (55.5 %) listed their yearly incomes at less than $20,000. ten online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 32 (22.2%) listed their yearly income above $20,000 and ten (22.2%) did not respond to this question. one (2.2%) listed less than 6 years of education, 26 (57.8%) listed 7 to 12 years, 14 (31.1%) listed 12-16 years, and 4 (8.9%) listed greater than 16 years. twenty one (46.7%) of the women lived alone, while 19 (42.2%) lived with one other person. five persons stated that they lived in households of three or more persons. the following selfreported comorbidities were found: hypertension (71.1%), diabetes (37.8%), myocardial infarction (35.6%), copd (15.6%), cva (15.^%), history of cancer (15.6%), and kidney disease (6.7%). fourteen (31.1%) reported 2 cormorbidities, 11 (24.4%) comorbidities, and 4 (8.9%) with 4 or more comrobidities. the researchers assessed a new york heart association classification level based on the women’s report of symptoms, with class 1 that indicated persons with cardiac disease without any resulting physical limitation through class 4 that indicated persons with cardiac disease having an inability to perform any physical activity without symptoms. fourteen (31.1%) of the women exhibited symptoms at class 1, 18 (40%) at class 2, 13 (28.8%) at class 3, and none at class 4. twenty-five (57%) of the women stated that they smoked in the past, and 3 (7%) currently smoked. pack/years for the past and current smokers averaged 30.3 (range 3-70 pack/years). the women listed the medications they were currently taking with the average number per subject being 8.14 (range 3-19). forty-three (96%) stated that they “always” took their medications as ordered and only two (4%) women stated that they occasionally forgot to take their medications. all of the women stated that they routinely visited a physician and drove an average of 6.4 (0-30) miles to their doctor‘s. twenty two (49%) also visited a cardiologist whose office was an average of 32.6 (1-90) miles distance from their homes. twenty one (47%) were able to drive themselves to their local physician, while only 4 (%) drove themselves to the cardiology office. method the principal investigator visited the offices of primary health care providers in rural counties in upstate new york to explain the purpose of the study and to ask providers to identity potential subjects according to the inclusion criteria. as potential subjects were identified, the primary providers asked subjects about interest in participating in the research. once potential subjects were identified, each individual as called to explain the study in detail and to ask the person to participate, if the individual was willing, the researcher scheduled an appointment of about 1 hour at the convenience of the participant. during a visit to the participant’s home, the study was explained in detail. signed consent was obtained, and the tools were administered. four instruments were used to obtain data for this study. hpb were measured by using the health promoting lifestyles profile ii (hplpii) developed by walker, sechrist, and pender (1995), based on pender’s health promotion model. this instrument has been used extensively to assess behaviors aimed at decreasing the impact of illness and promoting wellness. reliability of the hplp ii was established with cronbach’s alphas as follows: health responsibility (.861), physical activity (.850), nutrition (.800), spiritual growth (.864), interpersonal relationships (.872), stress management (.793), and total (943) (s. walker, personal communication, february 15, 2001). factor analysis continued to support the presence of the six factors used as subscales (s. walker, personal communication, february 15, 2001). online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 33 barriers to health promotion activities were measured by using the barriers to health promotion behaviors for disabled persons scale (bhadps) (becker et al. 1991). this is a 16-item, 4-point scale asking respondents to indicate how often the barriers listed in the tool prevent them from taking care of health matters. the barriers were developed from a review of the literature and expert analysis of the content of interviews of disabled university students and experts working with disabled persons by using definitions from pender’s (1996) model of health promotion. internal consistency was computed by using cronbach’s alpha at .82, with item/ total correlations ranging from .25 to .59 (becker, stuifbergen, & sands, 1991). factor analysis with a varimax rotation found the three factor solution accounting for 48% of the variation. to test validity, a ttest analysis of a disabled group was compared with a nondisabled group and showed the disabled group scored significantly lower than the nondisabled group (t=8.45, df=259, p<.001) overall, as well as on the motivation subscale (t=5.71, df=272, p<.001, and the external barriers subscale (t=9.01, df=271, p<.001). situational and perceived social support were assessed with the personal resource questionnaire 85 (prq85) developed by weinert (1987). part 2 of this instrument includes a 7 point likert-type questionnaire composed of 25 items addressing self-help issues of the individual and the effect of self-help on social support. it is expected that an increased score of self-help would inversely correlate with the level of social support received from relationships. cronbach’s alpha’s were calculated at .87 to .90. factor analysis showed that three factors, including intimacy/ assistance, integration/ affirmation, and reciprocity accounted from 43.3% of the variance (weinert & tilden, 1990). for this research a single question was used to determine the subject’s selfassessment of perceived health status by choosing from a range of 1 (i think my present health is very good) to 5 (i think my health is very poor) as used by johnson (1996). this approach has been used widely and has been shown to have a high level of correlation with physician’s assessment of health (johnson 1996) and as a predictor of the use of health services (johnson & wolinsky, 1993). spss 10 was used to analyze descriptive and inferential statistics. a power analysis level of.80 was utilized with an alpha level of .05 and a medium effect size (.35) to project the sample size of 45 subjects (cohen, 1988). findings the research hypothesis was tested by using multiple regression analysis with hpb as the dependent variable. independent variables included social support (prq2), barriers to health promotion activities for disabled persons, the rating of perceived health status by the individual, and selected demographic variables. analysis of the pearson correlations indicated that a history of diabetes (r = .431, p < 0.05) and the new york heart classification level (r = –.275, p < 0.01) were the two variables that predicted hpb. the findings of the regression are presented in table 1. the regression model indicated that the nyha classification level (negatively associated) and a history of diabetes predicted a significant variance in hpb (r2 = .334). social support, rating of health, and barriers to hpb were not found to be significant predictors of the variance in this population. the negative association with the nyha online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 34 classification appears to indicate that persons with less impact of cardiac symptoms were more likely to perform hpb. a history of diabetes was positively associated with hpb. because the pearson correlations for subjects taking insulin in this sample were significantly correlated with hospital admissions (.539) (p=.01) and emergency department visits (.321) (p=.05), it appears that the diabetics in the group were receiving more frequent health care and presumably more health care teaching and monitoring about hpb. the adjusted r2 was calculated to be .248, indicating the shrinkage error associated with the sample size and the number of variables. in this research, multicollinearity was not judged to be a problem because the tolerance of the variables (.789 to.999) and the variance inflation factor (1.073 to 1.283) were well above the acceptable levels. the power of the research was recalculated after completion of the study. with five variables and an r2 of .334 with an alpha of .05, the power was computed to be .95 (cohen, 1988). the power was adequate to confirm the research hypothesis. internal consistency reliabilities for all instruments and subscales used in this study were computed by using cronbach’s alpha. table 2 displays the alpha coefficients for each instrument or subscale and the number of items per scale. all instruments had a reliability index greater than .75 and were judged to be satisfactory for use in this study. the lower reliabilities for the subscales in the hplp may be related to the limited number of items; thus, the subscales were considered in total in further analysis. discussion forty-five women participated in this research. all of the subjects described themselves as white, which reflects the homogeneous nature of the older women in this rural upstate new york area but limits the generalizability of the findings to a larger, more diverse population. although it might be assumed that the decision to include only women 65 years of age and older might positively skew the average age of this population, the mean age of 77.7 + 9.95 years is similar to the age of samples of other studies of women with hf (philbin & disalvo, 1998). social support was not significant in predicting variance in hpb. this finding differs from numerous research findings that have indicated a positive link between social support and health promotion (adams, bowden, humphries, & mcadams, 2000; bennett, pressler, hays, firestine, & huster, 1997; johnson, 1996). the lack of effect of social support in this population may be related to the impact of rural life on the social support network. although some of the subjects had very strong, supportive family and friends, others lived alone and had limited support mechanisms. it is also possible that rural women have differing attitudes about the presence or quality of social support they receive. barriers to health care did not contribute to the predictability of this model, which may be related to the finding that rural persons tend not to see distance or other obstacles normal to rural life as barriers (pierce, 2001). nor do such persons expect to have services close to their homes. the subjects in this study also may have been unwilling to identify issues of barriers because of past experiences of futility when dealing with obstacles or because of a perceived need to remain positive about health care providers. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 35 perceived health also was not useful in predicting hpb in the study (see table 3), which is consistent with studies in other populations (lucas, orshan, & cook, 2000; speake, cowert, & pellet, 1989). the comparison of nyha classification and perceived health showed that some subjects rated their health at a much higher level than might be anticipated when considering the level of symptoms. for instance, two women who were nyha class 3 rated their health as very good. it is possible that the rural women in this study considered their health to be good because of perceived social support from family and friends. also, it has been found that rural women define health in the context of being able to work (long & weinert, 1989; pierce, 2001). therefore, if the women are able to maintain the activities around the home and community that are important to them, they may consider themselves to be healthy despite of physical symptoms or limitations. however, the lack of usefulness of perceived health in this sample may be related to a feeling of older women that complaining does little good or that it important to make the best of their situations. in this research, a history of diabetes and the nyha level were important predictors of the variance in hpb. the impact of the diagnosis of diabetes is surprising, but may be related to an increase in teaching and contact with health care professionals associated with management of their diabetes. rockwell and reigel (2001) found that symptom severity and education were predictive of self-care. it is possible that those persons with diabetes had more symptoms thus requiring more frequent health care visits, and that an increased amount of teaching about hpb occurred during those visits. nurses must become knowledgeable about the factors influencing actions taken by older women to promote health while living with the chronic illness of hf. because this segment of the population is growing, it is critical to utilize this knowledge in efforts both to increase well-being and to decrease the cost of health care interventions. this research has identified factors that influence health promotion behaviors of women with cardiac diseases that heretofore have been underrepresented in research projects. rural women have unique environmental factors of accessing health care related to distance or weather, however they do not consider these to be barriers. the perception of health status in this sample, which was quite different from that of previous findings, may have varied because of the impact of rurality on the perception of health. factors such as attitudes toward health, attitudes about outsiders or unfamiliar health care providers, and attitudes about the necessity to work rather than to take time to seek health care that have been previously identified in research with rural individuals must be further investigated. conclusions the participants in this research were surprisingly active in performing hpb (mean hplp = 142.07), and the selected features of the socioecological model for this research was useful in predicting those behaviors in rural women in upstate new york with hf. the nyha classification and a history of diabetes were responsible for predicting the variance; however social support, rating of health, and barriers to health care were not found to be predict variance. the subjects of this research tended to minimize the impact of hf on their lives. the impact of rurality on the attitudes toward social support was not studied in this research and requires further investigation. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 36 references adams, m., bowden, a., humphries, d., & mcadams, l. 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[medline] online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2772454&query_hl=52 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10885344&query_hl=54 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9313599&query_hl=56 http://www.nhlbi.nih.gov/about/03factbk.pdf http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9671013&query_hl=58 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11174364&query_hl=66 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=5967464&query_hl=68 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2704843&query_hl=77 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9161672&query_hl=79 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10882316&query_hl=81 http://www.census.gov/geo/www/ua.ua_2k.html http://www.ers.usda.gov/briefing/rural/data/desc.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=3306610&query_hl=84 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=2367200&query_hl=86 editorial 1 editorial letter from the editor jeri w. dunkin, phd, rn editor as you know the online journal of rural nursing and health care is a peerreviewed journal. that means that a professional panel must review all manuscripts. this is a completely volunteer professional service. without this effort the journal would not be the quality journal that it is. because this work is voluntary, i am hesitant to send more than four manuscripts to any one reviewer in a year’s time. therefore, we need a large number of reviewers to complete the work. if you would be interested in this professional service activity for the online journal of rural nursing and health care, please send me a note by email telling me of your area of interest and attaching your curriculum vitae. my email address is jdunkin@bama.ua.edu. please put “manuscript reviewer” in the subject box so that i might efficiently respond. thank you for assisting us in continuing to make the online journal of rural nursing and health care the fine e-journal that it is. it seems that every state in the united states and areas of canada are currently facing budgetary deficits and economic hard times. that is true in alabama as well and as a result the amount of time and effort that the webmaster and information management staff can contribute is in serious jeopardy. it is clear that we will have to begin compensating them for their work. this is very difficult, as the journal has no revenue-generating capacity of its own, and rno needs additional funds to provide this level of financial support to the journal. currently, the online journal of rural nursing and health care is open to all readers, and we do not require that authors be members to publish in the journal. the board of rno made this decision as a way to provide support for rural nurses and health care practitioners because resources are always less available in rural areas as compared to urban. however, we are revisiting that decision. this is one of the few organizationbased journals that are open to non-members. other journals are supported by member dues, where members freely access to the journal, and non-members must pay for access or they are subscription based. additionally, many of the medical related journals have an advertising department where they solicit paid advertisements to assist with support of the journal. the rno governing board and the editorial board of the journal are wrestling with the need for revenue, and our mission to support rural practitioners. it appears that we are either going to have to limit the opportunity to publish in the journal to members only or limit the reading of the journal articles to members only. we do not want to limit readership and will probably start with limiting the opportunity to publish to those who hold membership. we may possibly have to limit access to the journal to members only at some time in the future. it is in that spirit that i ask our readers to consider supporting the online journal by joining the rno. the membership application can be accessed and printed at www.rno.org. mail it and your check for $55.00 to rno at rural nurse organization online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 mailto:jdunkin@bama.ua.edu 2 administrative offices, c/o letterman lanning, p.o. box 248, spokane, washington 99210-0248, usa. my email address is jdunkin@bama.ua.edu. you may also email the administrative offices at ruralnurseorganization@msn.com. please let us hear from you. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 mailto:jdunkin@bama.ua.edu mailto:ruralnurseorganization@msn.com the australian perspective 1 editorial letter from the editor jeri dunkin, phd, rn editor we have worked very hard this year to transition the online journal of rural nursing and health care to the new format. it has been challenging to say the least, but i believe we now have the new look, the author guidelines operational, and the new e-mail account set up (rural.nurse.organization@gmail.com). we are looking forward to this new set-up and hope that it will facilitate communication and expedite the review process. please let us know how you like the new look, and “feel” of the journal. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 mailto:rural.nurse.organization@gmail.com depression in rural hospice family caregivers 14 depression in rural hospice family caregivers christie ladner, rn, msn1 norma g. cuellar, phd2 1 nurse practitioner, petal, ms 2 assistant professor, school of nursing, university of southern mississippi, norma.cuellar@usm.edu key words: rural, hospice, caregiver, depression, conventional treatment, non-conventional treatment abstract informal, family caregivers assume an overwhelming responsibility to care for the dying in the home. although not a long term situation, the outcomes for family hospice caregivers often have negative consequences with minimal mental health resources available in rural settings. diagnosis and treatment of depression in caregiving has been underdiagnosed. few studies have identified depression and treatment specifically in hospice family caregivers. the purpose of this study was to determine if informal, hospice, family caregivers in rural settings were depressed and if so, were the caregivers receiving treatment for depression, either by conventional or nonconventional interventions. the descriptive study included 30 hospice family caregivers who reported on symptoms of depression. forty percent of the hospice caregivers were depressed with only 17% receiving treatment for depression. future studies should include exploring interventions and outcomes of depression to improve rural health care in caregivers. introduction: depression in rural hospice family caregivers depression is a common, yet serious condition facing much of our population. according to the national institute of mental health (2001), depression is the leading cause of disability worldwide and is associated with symptoms of sad mood, loss of interest, change in appetite, difficulty sleeping or oversleeping, agitation, loss of energy, feeling of worthlessness, difficulty thinking, and suicide ideations. due to limited health care resources in rural areas, family caregivers are often ignored, misdiagnosed and mistreated when presenting with signs of depression. with the elderly living longer and an increase in chronic illnesses that coincide with aging, the family is assuming more responsibility for caring for their loved ones. family members become informal hospice caregivers who are unpaid and not formally trained, often leading to negative outcomes like depression. the lack of diagnosis and treatment of depression can have extreme consequences for rural, family hospice caregivers and the health care industry. depression depression is defined as a period of at least two weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. the symptoms must persist for most of the day, nearly everyday. the episode must be accompanied by clinically significant distress or impairment in social, occupational, or online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.usm.edu/nursing/ mailto:norma.cuellar@usm.edu 15 other areas of functioning. the individual must also experience at least four additional symptoms including: changes in appetite or weight, sleep, or psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; and recurrent thoughts of death, suicidal ideations, plans, or attempts (dsm-iv-tr, 2000). depression is a costly illness with expenditures of $30 – 44 billion dollars yearly (nimh, 2001). almost ten percent of the population suffer from major depressive disorders each year with women having twice the occurrence as men. stress due to chronic illness or the death of a close family member can trigger depression in at risk and vulnerable groups. people with major depression have an increased risk for early death and suicide attempts (koenig & george, 1998). treatment for depression can be either through conventional or unconventional. conventional methods are identified as treatment with anti-depressant medications, cognitive behavior therapy, and interpersonal therapy. non-conventional therapies may include exercise, herbs, or any alternative therapy (nimh, 2001). antidepressant medications include serotonin reuptake inhibitors (ssris), tricyclic antidepressants (tcas), and monoamine oxidase inhibitors (maois). although both generations of medications are effective in relieving depression, some people will respond to one type of drug, but not another. st john's wort (hypericum), an herbal product used to treat minor depression, must be used with caution due to interactions with drugs like indinavir, cyclosporine, digoxin, and warfarin (nimh, 2001). when treated properly, 80 % of people with depressive disorders will improve. rural population twenty five percent of the united states is rural. comparisons of rural and urban population from the u.s. department of agriculture (2001) can be seen in table 1. in rural areas, access to and availability of mental health specialists, such as psychiatrists, psychologists, psychiatric nurses and social workers, are seriously lacking presenting barriers to mental health care. poverty, geographic isolation and cultural differences further hinder the amount and quality of mental health care available to these people. the residents who do suffer from mental illnesses often do not seek care because of the stigma associated with mental illness and the lack of understanding related to treatment options, where to go for treatment, and the inability to pay for care. the primary care physicians who do treat rural patients for depression and mental illness may lack the training, time and resources to diagnose and treat mental illnesses effectively (nimh, 2000). caregivers informal family caregivers make up one-quarter of the united states population (national alliance for caregiving, 2002). the prevalence of informal caregivers who are at risk for depression is almost three times higher than in general populations of similar age (schulz, tompkins, & rau, 1998). sixty percent of caregivers report depressive online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 16 table 1 comparisons of rural and urban population from u.s. department of agriculture (2001) population rural urban elderly 18% 15% poverty 14.3% 11.2% african americans living in poverty 35.2% 26.9% private health insurance coverage 64.5% 68.9% medicare expenditures per capita $4,375 $5,288 symptomology (national family caregivers association, 2001). depression in caregivers can lead to early institutionalization, neglect, and elder abuse of the care-recipient. the cost of caregivers to be replaced by formal health care providers would cost approximately $45-94 billion per year (u.s. administration on aging, 2001). caregivers in rural areas are least likely to receive medical social services or therapeutic visits from aides, physical/occupational therapy, or speech therapy (kenney, 1993). rural caregivers reported higher depression levels at 3 and 12-month intervals than urban caregivers (kotila, numminen, waltimo, & kaste, 1998). how a caregiver may cope can determine outcomes like depression (haley, roth, coleton, ford, west, collins, & isobe, 1996; lawton, rajagopal, brody, & kleban, 1992). spousal caregivers have reported to be more depressed than non-spousal caregivers (harper & lund, 1990). hospice family caregivers in rural areas experience a variety of unmet needs partly due to access to primary care, fewer resources to choose from, lower income, less comprehensive health coverage, ill-equipped or poorly staffed health care agencies, and geographic isolation (cuellar & butts, 1999; given, given, & harlan, 1994; pierce, 2001; tebb & jivanjee, 2000). caregivers who provide long term care and live in rural areas have a high risk of depression (meyers & gray, 2001). a lack of grief counseling for family members going through the bereavement process has been documented, including consequences that extend beyond institutionalization and death of the care-recipient (grant, adler, patterson, dimsdale, ziegler, & irwin, 2002; grbich, parker, & maddocks, 2001). these challenges may contribute to the lack of diagnosis and interventions for depression. few articles in the literature discuss rural hospice caregivers, depression, and outcomes of treatment of depression. purpose the purpose of this study was to determine if informal, hospice caregivers in rural settings were depressed and if so, were treatments with conventional or non-conventional interventions being implemented for depression. there is a gap in the literature related to hospice caregivers, treatment for depression, and outcomes of treatment of this needless, mental health problem. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 17 research questions the study was designed to answer 3 research questions: 1. are rural hospice informal caregivers depressed as determined by a score of 16 or higher on the ces-d scale? 2. are rural hospice informal caregivers who are depressed receiving conventional interventions (anti-depressant medications, cognitive behavior therapy, and interpersonal therapy) for depression? 3. are rural hospice informal caregivers who are depressed receiving nonconventional interventions (exercise, herbs, or any alternative therapy) for depression? definition of terms for the purpose of this study, the following terms were defined. 1. depression: depression is operationalized as a self-report using the ces-d with a score of 16 or higher. 2. informal caregiver: any adult 18 years or older who cares for a hospice patient at least 8 hours a day in the home, not paid for services. 3. hospice care: providing care to people in the home who have been judged terminally ill with six months or less to live. benefits include nursing care, respite for caregiver and family, spiritual and bereavement counseling, medical equipment and supplies, social work services, on-call nursing care, and prescription co-payments (mcleod, 2002). 4. conventional interventions: defined as anti-depressants, cognitive behavior therapy (cbt), and interpersonal therapy (nimh, 2000). 5. non-conventional interventions: defined as exercise, herbs, and alternative therapies (nimh, 2000). 6. rural: all territory, population, and housing units located outside of urban areas or clusters (population density of at least 1,000 people per square mile and surrounding census blocks that have an overall density of at least 500 people per square mile) (census bureau, 2002). instrumentation the center for epidemiologic studies depression scale (ces-d) (radloff, 1977) is a self-report measure of depressive symptomology developed for the non-psychiatric population aged 18 and older and has a reported reliability of .90. the ces-d provides an index of cognitive, affective, and behavior depressive feature and the frequency the symptoms have occurred. major components include depressed mood, feeling of guilt and worthlessness, psychomotor retardation, loss of appetite, and sleep disturbances indicating present levels of functioning (devins & orm, 1985; radloff, 1977). the cesd is a 20 item questionnaire assessing frequency and duration of depressive symptoms in online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 18 the last week. a score of 0-15 indicates no depression; 16-20 indicates mild depression; 21-30 indicates moderate depression; and 31 or higher indicates severe depression. methdology this study used a descriptive design with a convenience sample of 30 rural hospice caregivers recruited from hospice home health agencies. subjects were described using demographic data, self-report of depressive symptomology (ces-d), and the use of conventional and non-conventional interventions for depression. demographic data included age, gender, ethnicity, marital status, socioeconomic status, employment status, current medications, medical diagnosis, and length of time since diagnosis. exclusion criteria included any caregiver with a history of psychiatric illness. inclusion criteria included being a primary caregiver, caring for a hospice patient for 8 hours a day. irb approval for human subject’s protection was obtained. upon receiving permission from the hospice agency, the hospice nurses identified primary caregivers who qualified for the study. the hospice nurses contacted the subjects and informed them of the study, requesting them to be a part of study. it was made clear that the decision to be in the study or not, would not interfere with the care received from the hospice agency. once the hospice nurse obtained verbal consent, the names of the potential subjects were turned over to the researcher who then contacted the family caregivers and made an appointment convenient to the caregivers in the home for an interview. at the time of the interview, the goal of the study was discussed. written consent was obtained. confidentiality was assured. the hospice agency would not be aware of individual responses of the study. the researcher read and recorded the responses from the demographic data sheet and the ces-d. the caregiver was observed for any emotional changes in behavior. in the event needed, counselors and mental health providers were available for consult as well as a list of community referral sources for caregivers. results demographic data were collected on the caregiver's age, gender, ethnicity, marital status, socioeconomic status, and employment status. see table 2 for frequency and percentages of demographic variables. medical diagnosis of the patients who required hospice care included cancer (n=19), lung diseases (n=2), heart diseases (n=2), neurological diseases (n=4), unknown (n=3). instrument the instruments used in the study were found to be reliable. according to frankstromsburg (1988), the reliability of attitudinal measures should be .70 or higher. the reliability of the ces-d for the family, hospice caregivers using cronbach alpha was calculated at .88. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 19 table 2 frequency counts and percentages of demographic variables (n=30) with depression descriptive variable n = 30 (%) depressed (n=12) age 29-38 39-48 49-58 59-68 69+ 2 (6%) 5 (17%) 12 (40%) 5 (17%) 6 (20%) 0 3 4 2 3 gender male female 8 (27%) 22 (73%) 4 8 ethnicity caucasian african american asian 24 (80%) 5 (17%) 1 (3%) 11 0 1 marital status single married divorced widowed 5 (17%) 18 (60%) 5 (17%) 2 (6%) 0 10 1 1 socioeconomic status < $20,000 $21-40,000 $41-60,000 $61-80,000 >$80,000 no answer 15 (50%) 8 (27%) 3 (10%) 1 (3%) 1 (3%) 2 (6%) 6 3 1 1 0 1 employment status employed unemployed retired 12 (40%) 7 (23%) 11 (37%) 2 4 6 statistical analysis the first research questions asked if rural hospice informal caregivers were depressed (a score of 16 or higher on the ces-d scale)? using the ces-d to measure depressive symptomology, the subject’s scores ranged from 3 to 43, with a mean score of 16 (sd = 11.68). twelve subjects had scores >16, indicating that approximately 40% of the participants were depressed with 5 of the 12 severely depressed. see table 3 for breakdown of scores. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 20 table 3 depression scores of family hospice caregivers (n=30) score frequency % <16 (not depressed) 18 60 16-20 (mild depression) 2 7 21-30 (moderate depression) 5 17 >31 (severe depression) 5 17 total 30 100 chi square analysis was performed to determine if there was a relationship between depression and the demographic variables. a significant difference in depression scores was found by ethnicity (p = .004) (table 4). the majority of caucasian caregivers were depressed. table 4 depression by ethnicity ethnicity n mean (sd) range significance african americans 5 6 (2.7) 3-10 .004* caucasians 24 17 (12.06) 3-43 *significant at .05 the second research questions asked if rural hospice informal caregivers who were depressed were being treated with conventional interventions (anti-depressant medications, cognitive behavior therapy, and interpersonal therapy) for depression (scores greater than 16 on ces-d). of the 12 caregivers who were depressed, only 2 were being treated by conventional methods for depression. these 2 were never reevaluated for depression or prescribed different medications for depression. of the 18 caregivers who were not depressed, 3 were on anti-depressants, meaning therapeutic effects of the anti-depressant were being seen. see table 5 for breakdown of use of antidepressant medications for subjects. the third research question asked if rural hospice informal caregivers who were depressed were being treated with non-conventional interventions (exercise, herbs, or any alternative therapy) for depression. three of the 12 who were depressed reported exercising on a regular basis. of the 18 subjects who were not depressed, 7 of these reported exercising on a regular basis. of the 18 caregivers who were not depressed, 3 reported using herbal therapies for depression. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 21 table 5 medication for depression medication for depression depressed not depressed total yes 2 3 5 (17%) no 10 15 25 (83%) total 12 18 30 (100%) in summary, 40% of the rural hospice caregivers reported depression to some degree. of the 40% (n = 12), 2 were being treated with anti-depressants, and 3 were using non-conventional therapies for depression with exercise being the most common. none of the depressed caregivers took herbs and male hospice caregivers were more depressed than female hospice caregivers. discussion demographics the setting for this study was in a rural state where all of the caregivers lived. significant differences in depression scores were found by ethnicity. a large percentage of the hospice caregivers were depressed (40%) with only 17% being treated for depression. this is an alarming number of patients being untreated for depression while routinely being visited by health care providers frequently through hospice care. it is significant to note that there were no statistically significant findings related to treatment of depression in the depressed and non-depressed group because so few are being treated. it should also be noted that many people treat themselves with herbs when suspected to be depressed without consulting a physician. this may be in part to the stigma associated with depression. a clinical diagnosis by a physician is not needed to self-treat with nonconventional therapies. the clinical findings from this study are relevant. significant findings by ethnicity have been noted. caucasian caregivers were more depressed than african american caregivers. these findings are consistent with previous findings in the literature that say african american caregivers tend to have less depression than the caucasian cohorts. coping as predictors of depression may be influenced by culture (aranda & knight, 1997; haley et al. 1996; miller & guo, 2000). african american caregivers have a larger support network and may have more satisfaction with the help received due to a commitment to family. african americans also may be able to adapt to crisis situations due to the higher incidence of mortality and expectations of life. spirituality and religiosity has been considered as a non-conventional intervention for depression but was not identified by either group. married caregivers, either to the care-recipient or a mate, were more depressed than single caregivers. these findings are supported in a variety of articles in the literature (cuellar, 2002; jansson, nordberg, & grafstrom, 2001). married caregivers, to someone else beside the care-recipient, may have a feeling of overload, being split between caring for a parent or sibling and being unable to meet the commitment of their online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 22 own household. married caregivers, to the care recipient, may have more feelings of loss related to a lifetime partner and end of life decisions for the relationship. single caregivers, often children who work full time, may not see the caregiving situation as an end to a life situation but as a situational crisis that is expected in life. male caregivers were more depressed than female caregivers. these findings do not support the majority of findings in the literature that say that female caregivers are usually more depressed then male caregivers (given, given, stommel, & faouzi, 1999; haley et al. 1996; schott, 1993). of the 8 male caregivers, 6 were married to the spouse who was receiving hospice care. this may bring issues of spousal end of life decisions. males may be less able to deal with emotional feelings of death and deal with emotional issues different than females. male caregivers may have more trouble adapting to the fact of widowhood. the transition for males through widowhood may be just as difficult as for women (given et al.). if the caregiver is married to the hospice patient, it may be assumed that the stress of caregiving may be related to the fact that the spouse has been diagnosed by physician to have less than 6 months to live. conventional treatment of depression it is disturbing to see that only 2 of the 18 caregivers who were depressed were receiving anti-depressant therapy. none were receiving cognitive behavior therapy or interpersonal therapy. these findings may be due to the availability of resources in rural areas, knowledge of these resources, as well as the lack of knowledge related to symptoms of depression. the opportunity for mental health treatment in rural areas is a major issue. the best treatment for depression has been identified as a combination of anti-depressants, cognitive behavior, and non-conventional therapies. these options for treatment may not be available to rural hospice caregivers who suffer from depression. also, rural populations may have further constraints to health care access, poverty, stigma related to diagnosis, insurance coverage, geographic isolation and cultural differences. non-conventional treatment of depression few caregivers were using non-conventional therapies like herbs, exercise, or alternative therapies. research has identified many of these treatments beneficial to outcomes of depression. exercise like walking could easily reduce depression levels (king, baumann, sullivan, wilcox, & castro, 2002). alternative therapies have been used for depression with successful results (ernst, rand, & stevinson, 1998). the overwhelming responsibility of caring for a loved one who is dying may have too many physical restraints on caregivers, limiting the time to exercise. a responsibility to the hospice patient may also cause the caregiver to neglect personal health due to burden, guilt, or anxiety. limitations of this study are noted. a larger sample size may give more information related to demographics and depression. the diagnosis or history of caregivers and the care-recipients may play a role in depression scores as well as time of care giving role. sampling issues related to convenience and bias is recognized. generalizability should be considered due to these limitations. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 23 implications to practice health care providers should be aware of interventions specific to rural hospice caregivers who do not have the same resources that urban counterparts have. as the family structure changes in our society (fewer marriages, more single head of households, fewer couples having children or having fewer children), as the elderly population is the fastest growing population, and as more elderly are moving in to rural areas, nurses must address the caregivers who may not have the familial support and resources available to them. despite the fact that hospice caregiving may be a situational or developmental crisis, strategies to assist family hospice caregivers should be included in the plan of care in hospice settings. the american medical association (2002b) has recently published information to assist health care providers in assessing coping and health of family caregivers available to health care providers, including a caregiver self-assessment survey, as well as a list of resources for caregivers (2002a). health care providers should be aware of depressive symptomology in hospice caregivers. hospice nurses must be aware of depression and be prepared to conduct depression screening for the family caregivers as well as collaborate with the hospice mental health nurse, social worker, or nurse practitioner. conventional therapies should be implemented for the caregivers. assuring patients of confidentiality of treatment, related to stigma of depression, may alleviate fears of being “labeled”. cognitive behavior therapy (cbt) and interpersonal therapy may be encouraged through community resources, or religious affiliations. the goals of cbt relate to ways of acting, feeling, thinking, dealing, and coping with specific current issues (association for advancement of behavior therapy, 1999). see table 6 for recommendations of cbt that can be used for rural, hospice, family caregivers. health care providers may encourage the use of communication by phone to other hospice caregivers providing a network of support between each other. if available, internet support for caregivers should be given as a reference, notifying caregivers that this is available at all public libraries. see appendix for a list of caregiver web pages. non-conventional therapies should be advised cautiously. exercise is a common form that is safe and efficacious. if possible, caregivers should be encouraged to walk or do something in the home for exercise. encouraging short 10-minute intervals 3 to 4 times a day is effective and beneficial. journaling, music therapy, prayer, aromatherapy, nutritional support, relaxation techniques and meditation are a few complementary therapies that could be encouraged that are safe and therapeutic. use of alternative therapies that are not documented as safe, like many herbs and vitamins, should be advised with caution. cultural and spiritual issues related to the use of complimentary and alternative medicines should be considered. health care providers must respect the choices the caregivers make in relation to complementary and alternative therapies. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 24 table 6 cognitive behavior therapies that can be used with caregivers cognitive behavior therapy use ways of acting • identify positive assets and positive qualities of the situation. • ask for help – consult hospice services or mental health centers for available help in rural areas. • reach out: use the phone or computer to contact other people in your own situation. • use support groups and community agencies for hospice caregivers if available. ways of feeling • identify views and perceptions of the situation as it is now. • avoid comparisons with other situations. ways of thinking identify negative self-talk and replace with positive statements and/or affirmations. • list all or nothing terms, avoid using words like “all the time” or “never” or “always”. ways of dealing • read inspirations poems or books. • arrange for respite. ways of coping • do something enjoyable every day (at least one thing) • laugh…find something entertaining to read. • contact spiritual or religious network – ask for home visit from church members, priest, rabbi, or minister. • do some form of exercise daily. future research caregiving research, as well as research in rural areas, is difficult because of access to the home and trust that must develop between the researcher and caregiver. researchers must continue to make an effort to study caregiving, specifically family, hospice caregivers due to the trend in migration of elderly to rural areas, as well as the increasing number of elders with chronic health conditions. health policy should be considered for hospice caregiving, which may be short-term but abrupt, disrupting lives of families. cultural diversity issues should also be considered in the use of conventional and non-conventional treatments for depression, especially considering alternative therapies. future studies should include: online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 25 • comparison of rural and urban family, hospice caregivers with a larger sample size, • use of complementary and alternative therapies and outcomes of depression, • examine issues of cultural diversity issues of hospice caregivers, • explore interventions that reduce isolation of hospice caregivers, • determine outcomes of depression of caregivers with evidence based practice guiding caregiving interventions, and • compare the outcomes of use of religiosity 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(2000). mental health in rural america: how research is helping. retrieved april 24, 2002, from http://www.nimh.nih.gov/research/senatemhwg.cfm pierce, l. (2001). caring and expression of stability by urban family caregivers of persons with stroke within african american family systems. rehabilitation nursing, 26(3), 100-121. [medline] radloff, l. (1977). the ces-d scale: a new self-report depression scale for research in the general population. applied psychological measurement, 1, 385-401. schott, b. (1993). dependent care, caregiver burden, an self-care agency of spouse caregivers. cancer nursing, 16(3), 230-236. [medline] schulz, r., tompkins, c., & rau, m. (1998). a longitudinal study of the psychosocial impact of stroke on primary support persons. psychology and aging, 3, 131-141. [medline] tebb, s., & jivanjee, p. (2000). caregiver isolation: an ecological model. journal of gerontological social work, 34(2), 51-72. u.s. administration on aging. (2001). family caregiving. retrieved april 10, 2002, from http://www.aoa.gov/may2001/factsheets/family-caregiving.html u.s. department of agriculture. (2001). rural information center health service. retrieved may 21, 2002, from http://www.nal.usda.gov/ric/richs/stats.htm appendix web pages for caregiver support national family caregiver alliance http://www.nfcacares.org/ educates, supports, empowers and speaks up for caregivers of chronically ill, aged or disabled loved ones hospice caregivers http://www.hospicenet.org/ provides information and support to patients and families facing life-threatening illnesses caregiver.com http://www.caregiving.com/ helps persons who care for an aging relative; online support groups national alliance for caregiving http://www.caregiving.org/ provides support to family caregivers and professionals; increases public awareness of family caregiving issues empowering caregivers http://www.care-givers.com/ provides a safe, nurturing place for family caregivers and professionals on an emotional and spiritual level family caregiver alliance http://www.caregiver.org/ addresses the needs of families and friends providing long-term care at home today’s caregiver magazine http://www.caregiver.com/ provides information, support and guidance for caregivers; developed for caregivers, about caregivers and by caregivers online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.nimh.nih.gov/research/senatemhwg.cfm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12035690&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=8348531&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=3268251&dopt=abstract http://www.aoa.gov/may2001/factsheets/family-caregiving.html http://www.nal.usda.gov/ric/richs/stats.htm http://www.nfcacares.org/ http://www.hospicenet.org/ http://www.caregiving.com/ http://www.caregiving.org/ http://www.care-givers.com/ http://www.caregiver.org/ http://www.caregiver.com/ 28 allzwell caregiver page http://www.alzwell.com/ helps dementia caregivers to find understanding, wisdom, and support throughout the caregiving journey christian caregivers http://www.christiancaregivers.com/ caregiving from a christian perspective online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.alzwell.com/ http://www.christiancaregivers.com/ methdology   married caregivers, either to the care-recipient or a mate, were more depressed than single caregivers. these findings are supported in a variety of articles in the literature (cuellar, 2002; jansson, nordberg, & grafstrom, 2001). married caregivers, to someone else beside the care-recipient, may have a feeling of overload, being split between caring for a parent or sibling and being unable to meet the commitment of their own household. married caregivers, to the care recipient, may have more feelings of loss related to a lifetime partner and end of life decisions for the relationship. single caregivers, often children who work full time, may not see the caregiving situation as an end to a life situation but as a situational crisis that is expected in life. microsoft word fahs_402-2249-1-ed.docx online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.402 1 editorial sticky buns and scholarship pamela stewart fahs, phd, rn, editor imagine the scene, it is a cold december day yet the inside is cozy, with a roaring fire and large covered bowels of dough beside the hearth. the smell of yeast dough permeates the house. “sticky buns”, an old family recipe from the appalachian mountains in southeastern ky, for homemade cinnamon buns with a decadent caramel and nut topping, are being prepared for the holidays. not the scene usually associated with scholarship yet a professor and doctoral students are working on an abstract for submission to a rural nursing research conference. sister arminger (1974, p. 160) said “life experiences, all of them, make the scholar”. the socialization of a scholar has traditionally taken place in a male dominated academy. the manner of socialization to scholarship may vary by discipline and place and yes even primary gender within the area of science. the purpose of academia and thus the faculty within the system is to create and disseminate knowledge. research is a strong component in the creation of knowledge and critical to dissemination are the components of teaching and scholarship. the method of dissemination can vary significantly by discipline and is of course in transition as our technology changes. whether it is in a typical classroom, authoring a book, journal article, presentation, webinar. poster, or dissemination of knowledge in clinical practice we can and should take opportunities to socialize our nurse scientists to participate in both research and scholarship. the abstract (pribulick, quaranta, srnka-debnar, & daws, 2009) prepared in this seemingly incongruent setting emerged from a piece of research that was conceived in the classroom, carried out in rural communities and was disseminated at a national conference online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.402 2 focused on rural nursing and health. busy schedules and creative planning allowed this project to come to fruition. this may not have been what sister arminger had in mind but it was certainly a unique life experience that did help build scholars in rural nursing science and one that could be viewed as fitting given the students were completing their doctoral work in a program focused on rural nursing. the 2016 international rural nursing conference is going to be held in rapid city south dakota, july 19 -21, 2016. whether you are a clinician, educator, or student; conducting research, providing care, or working on health policy this conference is one you should explore. abstracts are being accepted until february 1, 2016 at www.mhch.org/international-ruralnursing-conference-abstract-submission . bring your scholarship to this upcoming conference as part of your life experience. references arminger, b. (1974). scholarship in nursing. nursing outlook, 22, 160-164. pribulick, m., quaranta, j., srnka-debnar, f., daws, m. (2009, june). perceptions rural fair attendees: the relationship of nurse body size, gender and level of confidence in receiving health teaching. poster session presented at the rural nurse organization conference. quality: the rural nurse perspective. boise, id editorial 1 editorial letter from the editor jeri w. dunkin, phd, rn editor as many of you know, over the last year the online journal of rural nursing and health care has been unavailable at times. we had a number of problems occur during that time but hopefully we have those solved, and are getting back on track. the journal has been reorganized and the web site redesigned. we hope these changes will enhance your use of the journal. we have an international editorial board and columns from our board members from canada and australia can be found in this issue. additionally, we are introducing the first ce offering in this issue. dr. marietta stanton has joined the editorial board to manage our ce section. the instructions for ce credit should be clear, however if you have question please feel free to email me at jdunkin@bama.ua.edu or mstanton@bama.ua.edu. the development of the international federation of rural and remote nurses is moving slowly, primarily because we do not yet have the necessary funds to for the legal fees associated with obtaining international non-profit status as an organization. however, we continue to move forward and are hoping the have the 4th international congress of rural and remote nurses in 2004. we are currently planning to combine that meeting with the international conference of nurse practitioners in the netherlands. if you would like to help in this exciting endeavor please email me (jdunkin@bama.ua.edu) or sreel@nursing.arizona.edu. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 mailto:jdunkin@bama.ua.edu mailto:mstanton@bama.ua.edu mailto:jdunkin@bama.ua.edu mailto:sreel@nursing.arizona.edu microsoft word bopp_25-1159-2-ed.docx online journal of rural nursing and health care, 12 (2) urban-rural differences for health promotion in faith-based organizations melissa bopp, ph.d 1 benjamin l webb, ms 2 elizabeth a fallon, ph.d 3 1 assistant professor, kinesiology, pennsylvania state university mjb73@psu.edu 2 graduate research assistant, kinesiology, pennsylvania state university blw5236@psu.edu 3 director, health studies program, university of rhode island, efallon@mail.uri.edu abstract background: rural faith-based organizations (fbo) serve an important social, cultural and political role in their communities, but compared to their urban counterparts, less is known about their ability to deliver health and wellness activities (hwa). this study’s purpose was to examine differences in factors related to hwa between urban and rural fbos. methods: a convenience sample of faith-leaders (n = 824) completed an online survey assessing faith leader demographics (age, sex, education, body mass index, race), fbo demographics (denomination, location), types of hwa, and barriers to hwa. results: respondents were primarily white (93%), male (72%), middle aged (53.2+ 12.1 yrs.), with methodist (42.5%) or lutheran (20.2%) affiliations. compared to urban faith leaders (n=599), rural faith leaders (n=225) reported lower physical activity levels and higher rates of overweight (p’s<0.05). compared to urban fbos, rural fbos were more likely to report offering no hwa (χ2=3.00, df=1, p=0.04), and rural fbos offered fewer hwa (3.73±2.89) than urban fbos (4.98±3.25; t=4.92, df=781, p<0.001). urban fbos offered more educational health classes, health fairs, health screenings, and physical activity/sports groups compared with rural fbos (ps<0.05). rural fbos were more likely to report a lack of congregational interest and lack of lay leadership as barriers to hwa, whereas urban fbos indicated that other fbo activities conflicted with hwa (ps<0.05). conclusions: this study revealed important differences in factors related to hwa in urban and rural areas. this study provides public health professionals with insight regarding implementation of hwa in rural and urban fbos. keywords: faith-based, urban, rural, social environment urban-rural differences for health promotion in faith-based organizations approximately 50 million people in the united states live in nonmetropolitan areas, representing 17% of the total population (cromartie, parker, breneman, & nulph, 2011). rural areas face significant challenges for healthcare and health promotion, including: lack of access to quality health services, higher chronic disease rates, less participation in healthy behaviors, greater poverty compared with urban areas and an aging rural population (gamm, hutchison, dabney, & dorsey, 2003). these health and health care inequities are not only relevant for acute medical care, but also for preventive health promotion programs needed to reduce the lifestyle risk factors for chronic disease such as physical activity, diet, smoking cessation and screening participation (the national advisory committee on rural health and human services, 2008). chronic diseases such as cardiovascular disease, cancer and diabetes cost the united states (us) online journal of rural nursing and health care, 12 (2) economy billions of dollars annually (devol & bedroussian, 2007); however the risk of developing these conditions can be significantly reduced with lifestyle modifications. healthy people 2020 (u.s. department of health and human services [usdhhs], 2010) and the national rural assembly (national rural assembly, 2011) emphasize the importance of creating social and physical environments supportive of health and behaviors by engaging multiple community sectors for improved policies, practices and programs. previous evidence has shown numerous benefits of partnering with community institutions e.g., schools, worksites faith-based organizations [fbos] for health programming. using a community-based approach enhances the likelihood of the program being accepted by the target population and increases the chance of sustainability (bopp & fallon, 2008; minkler & wallerstein, 2002). it is important to note the benefits of partnering with fbos to deliver health promotion interventions. in the us, 40% of individuals attend religious ceremonies one or more times a week, and an additional 20% attend services/activities 2-4 times/month(pew research center, 2008b), affording a great amount of reach into the general population, across all racial and ethnic groups, age groups, and income levels. health promotion interventions delivered within fbos have great appeal for approaching underserved populations (dehaven, hunter, wilder, walton, & berry, 2004) because they allow for more cultural tailoring, greater buy-in from community members, and a stronger potential for sustainability. finally, faith-based efficacy and effectiveness trials show positive results across a wide variety of health conditions and behaviors (bopp, peterson, & webb, 2012; campbell et al., 1999; lasater, becker, hill, & gans, 1997; lasater, carleton, & wells, 1991; markens, fox, taub, & gilbert, 2002; sbrocco et al., 2005; wilcox et al., 2007; yanek, becker, moy, gittelsohn, & koffman, 2001). despite the evidence for the effectiveness of health promotion programs in fbos, there is limited evidence for the role of rural fbos. approximately 18% of church attendees in the us report that their congregation is located in a rural area (chaves & anderson, 2008). the church is recognized as the foremost social institution for americans residing in rural areas and has historically served as the setting for much of the faith-related and non-faith-related social interaction between members of the rural community (bennett, 1957). for many rural dwelling persons, the church serves as an extended family, often providing social support services to the poor and elderly in the community (boydfranklin, 1989). the prominence of the church in rural communities signifies the need to examine more thoroughly the role of rural fbos in health promotion initiatives. a recent study examining the beliefs of rural church leaders and members about health promotion provided insight into the expectations for churches to offer health promotion messages (williams, glanz, kegler, & davis, 2009). consistent with other studies (catanzaro, meador, koenig, kuchibhatla, & clipp, 2007; demark-wahnefried et al., 2000; peterson, atwood, & yates, 2002), williams and colleagues (2009) noted that the faith leader and their perception of health is extremely influential on the church health promotion environment, though there are a number of other social and physical environmental influences on church related health promotion programs. kegler and colleagues (2010) examined the perceptions of social and environmental support for physical activity and healthy eating in rural southern churches and found a lack of existing programs and minimal advice from their faith leader on these habits; however social support from fellow church members for these behaviors was common. these studies suggest a more informal approach to health promotion in rural fbos compared with more structured and formal approaches. despite these few studies, there is a significant gap in the literature indicating the current status of health and wellness programming and possible online journal of rural nursing and health care, 12 (2) influences on offerings in rural fbos throughout the country. according to organizational change theories (butterfos, kegler, & francisco, 2008), the process of initiating health promotion programs within institutions begins with defining and recognizing the lack of preventive health programs before adoption or implementation of initiatives can take place. therein, the primary purpose of this study was to examine the differences between urban and rural fbos for health promotion programs and activities, including types of programs, barriers to programs, and parent organization support. the secondary purpose of the study was to examine differences between urban and rural faith leader health and behaviors. methods an online survey system, axio learning systems, manhattan, ks, was used to conduct this cross-sectional study examining differences in health and wellness programming between urban and rural fbos. this survey was approved by the institutional review board. setting & subjects a convenience sample of faith leaders from across the us was recruited to complete the survey. based on pew forum data (pew research center, 2008b), we identified the top three most common religious denominations for each state. subsequently, we searched for websites representing that denomination’s state level organization/conference/diocese, allowing us to gather email addresses for primary faith leaders e.g. pastor, priest, secondary leaders e.g. associate pastors, and or general fbo contacts, resulting in 13,644 individual email addresses. the data collection period was march-december 2009. individuals were sent an initial email invitation requesting participation in “a survey on faith and health”, explaining the purpose of the anonymous survey, assuring confidentiality, and providing a link to the survey and informed consent statement. two email reminders were sent two to three weeks after the initial invitation email. as an incentive to improve response rates, respondents were given a chance to enter a drawing for prizes at the end of the survey. a number of initial emails were returned as undeliverable (n = 1468; 10.7%), resulting in 12,176 eligible respondents. in total, 1,012 people accessed the survey, and 844 individuals completed the survey (6.9% response rate from those who received the email invitation, 83.4% completion rate). it should be noted that this response rate is overly conservative, as the emails may have been diverted to spam or sent to defunct, but functioning email accounts. measures faith leader demographic and health information. faith leaders reported their age, sex, racial/ethnic group, education level, their primary responsibility at the fbo e.g. primary leader, secondary leader, etc., if they were employed full or part time and the length of time they had been a faith leader. the behavioral risk factor surveillance system physical activity module (centers for disease control prevention, 2010) was used to determine if individuals were meeting current physical activity guidelines (haskell et al., 2007). participants also reported: a) the number of daily fruits and vegetables consumed, b) their chronic health conditions, and c) height and weight, for calculating body mass index. perceived health status was assessed with a single item using a 5-point likert scale, 1=excellent to 5=poor. faith organization information. respondents reported their fbo’s zip code, church/congregation size, racial/ethnic diversity of the congregation, and religious affiliation. zip codes were matched with region, states and counties and the county’s rural-urban online journal of rural nursing and health care, 12 (2) continuum code (rucc) was assigned and categorized as urban/metropolitan (rucc codes 15), rural/non-metro (rucc codes 6-9) (nance, denysenko, durbin, branas, stafford, & schwab 2002; u.s. department of agriculture, 2008). health and wellness activities (hwa). participants reported their fbo’s health-related activities in the past year. these were classified as either action-oriented programs: clubs/teams related to physical activity, individual counseling about health, educational classes about health, screenings for health conditions, hands-on instruction about health, group counseling about health, or health fairs or providing educational materials such as health pamphlets, bulletin boards, inclusion of health and wellness information in church materials, health library, instruction about health and wellness as a part of other church classes. a sum of these materials and activities was calculated as the number of health and wellness activities (hwa). the faith leader was also asked to report their role in initiating or organizing the action-oriented programs by selecting one of the following options: a) initiated and overseen by myself, b) initiated by myself and overseen by others, c) initiated by others and overseen by myself, or d) initiated and overseen by others. leaders that indicated one of the first three options were considered to be involved in the activity. barriers and facilitators to faith-based health programming. participants used a 5-point likert scale, 1=not a barrier at all to 5=a very large barrier, to indicate whether barriers influenced hwa. the six barriers we inquired about were based on other literature in the field about common barriers to health in fbo and included: a) lack of financial resources, b) lack of interest, c) lack of lay leadership, d) leadership does not believe that health and wellness should be addressed at the fbo, e) competition for time and space with other institutional activities. from their responses, a summary score was created ranging from 6 30. we also asked participants to indicate (yes/no) whether various factors would be useful for motivating the fbo to increase hwa: a) additional trainings, b) financial resources, and c) interest/awareness from congregation. the development of the list of barriers was based on findings from previous faithbased studies that have indicated common barriers to delivering programming (campbell et al., 2007; peterson, et al., 2002). perceived health concerns of faith institution. faith leaders were asked to select what they perceived as the top five health concerns for members of their fbo from a list that included several chronic diseases and conditions, e.g. heart disease, cancer, diabetes, stress and special populations, e.g. child or maternal health. analysis basic descriptive statistics and frequencies were used to describe the sample. differences between urban and rural fbos were examined using t-tests and χ2 analyses. all statistical analyses were run using the statistical package for the social sciences, version 17.0 (spss, chicago, il) and significance levels were set at p=0.05. results sample characteristics table 1 provides the characteristics of the sample. participants (n = 824) were primarily white, male, middle-aged, and serving as the primary (72.9%) or secondary (17.8%) leader at their fbo. respondents most often reported that their fbo was affiliated with methodist (41.1%) or lutheran (20.4%) denominations. for the purposes of comparison, denominations online journal of rural nursing and health care, 12 (2) were collapsed into the top five categories: a)methodist, b) lutheran, c) catholic, d) baptist, and e) united church of christ/congregational while the remaining denominations were placed in an “other” category episcopal (n=16), church of christ (n=6), free evangelical (n=15), assembly of god (n=2), non-denominational (n=7), jewish (n=5), african methodist episcopal (n=1), presbyterian (n=14), christian (n=1), church of the nazarene (n=3). an examination of fbo characteristics revealed that faith leaders were primarily affiliated with medium sized institutions (100 500 members), with little diversity (> 90% white) and located within the midwestern us. based on zip codes, participants were categorized as either rural fbos (n = 225) or urban fbos (n = 599). faith leader differences characteristics of faith leaders are displayed in table 1. urban faith leaders were more likely to meet current physical activity recommendations (χ2 = 3.13, df = 1, p = 0.04) compared with rural faith leaders. rural faith leaders were more likely to be overweight or obese (χ2 = 16.89, df = 2, p < 0.001) compared with their urban counterparts. urban faith leaders were more likely to perceive that they were in excellent/very good health (χ2 = 4.24, df = 1, p = 0.02). there were no urban-rural differences for age, gender, fruit and vegetable intake, number of chronic health conditions, amount of health and wellness instruction in school, or years of service. online journal of rural nursing and health care, 12 (2) online journal of rural nursing and health care, 12 (2) faith-based organization differences fbo organization characteristics are displayed in table 1. rural fbos were more likely to be smaller, (χ2 = 41.1, df = 3, p < .001), and less diverse (χ2=35.01, df = 2, p < .001), compared with urban fbos. compared to urban fbos, rural fbos were more likely to report offering no hwa (χ2 = 3.00, df = 1, p = .04). rural fbos offered fewer hwa (3.73 ± 2.89) than urban fbos (4.98 ± 3.25), (t = 4.92, df = 781, p < .001). there were no differences in parent organization support between urban and rural fbos. details of health and wellness activities are displayed in table 2. an examination of action oriented activities revealed that urban fbos were more likely to offer educational health classes (χ2 = 16.81, df = 1, p< .001), hands-on health classes (χ2 = 6.57, df = 1, p = .006), health fairs (χ2 = 14.95, df = 1, p < .001), health screenings (χ2 = 23.25, df = 1, p < .001), group counseling for health (χ2 = 5.85, df = 1, p = .009), and physical activity groups/sports (χ2 = 26.58, df = 1, p< .001), compared with rural fbos. urban fbos were also more likely to offer a number of educational materials compared with their rural counterparts: a) bulletin board related to health and wellness (χ2 = 13.56, df = 1, p < .001), b) health related pamphlets/leaflets (χ2 = 5.94, df = 1, p = .009), and c) health/wellness instruction as a part of other fbo classes (χ2 = 6.37, df = 1, p = .005) were more common in urban compared with rural fbos. urban faith leaders reported that the top five health concerns for the congregation were: a) heart disease, b) cancer, c) diabetes, d) stress and e) depression; while rural faith leaders reported that: a) heart disease, b) cancer, c) diabetes, d) arthritis and e) obesity were the main health concerns at their fbo. analyses by congregation size, denomination and diversity are found elsewhere (bopp & fallon, in press). online journal of rural nursing and health care, 12 (2) barriers and facilitators to hwa are displayed in table 3. rural fbos reported a greater number of barriers to hwa (t = 2.26, df = 801, p = .02). a lack of lay leadership or volunteers was more likely to be reported as a barrier for rural fbos compared with urban institutions (χ2 = 6.32, df = 1, p = .007). in urban institutions, a lack of financial resources for staff time was frequently reported as a barrier compared with rural fbos (χ2 = 3.98, df = 1, p = .03). rural fbos were more likely to indicate that a lack of interest from the congregation in health and wellness was a barrier (χ2 = 10.05, df = 1, p = .001), and urban fbos more frequently reported that competition for time and space with other fbo activities was a barrier (χ2 = 7.87, df = 1, p = .003). both rural (68.4%) and urban (66.4%) leaders frequently reported that increased health and wellness interest/awareness from congregation members would motivate their fbo to offer more hwa. discussion this is among the first studies to examine urban-rural differences in faith-based health promotion programming. fbos have the potential to reach a large portion of the population with health promotion programming, serving as a strong public health partner to target disease prevention. this study revealed a number of important trends and influences on health promotion in urban and rural fbos that provide insight into future interventions and population-level strategies for improving health. fbos have been valuable partners in delivering health promotion programs (dehaven, et al., 2004) and continue to be a strong community partner for reaching diverse and underserved groups. the potential for health promotion and chronic disease prevention among specific groups that are more likely to be affiliated with fbos are: a) older adults, b) ethnic minority groups, and c) low income populations (pew research center, 2008a). targeting these groups could result in significant public health impact and is congruent with healthy people 2020 initiatives for online journal of rural nursing and health care, 12 (2) achieving health equity (usdhhs, 2010). throughout the us, rural areas generally have a higher proportion of older adults in their population compared with urban areas, suggesting that rural fbos could serve as an important point for health promotion among this population (rogers, 2002). studies examining parish nursing practices in urban and rural areas have also noted some specific differences in type of nursing care, intensity and place of care which could be reflective of these demographic differences (chase-ziolek & striepe, 1999). in the southern us, a greater portion of the rural population report being of low socioeconomic status (mclaughlin, 2002), which has significant implications for healthcare access and preventive health behaviors, an issue that rural fbos could help address. there were a number of interesting findings concerning faith leader health. urban faith leaders were more likely to meet current physical activity recommendations and were less likely to be overweight or obese compared with rural faith leader. some of these findings were consistent with similar studies examining a general population of faith leaders’ health (proeschold-bell & legrand, 2010). although not significant, there were trends indicating that urban faith leaders were more likely to consume five or more fruits and vegetables daily and had fewer chronic diseases compared with their rural counterparts. other studies have documented poor health and behaviors among pastors, especially concerning mental health issues (e.g. burnout, stress, depression, anxiety) (weaver, flannelly, larson, stapleton, & koenig, 2002), though none have looked at differences in urban and rural populations. rural faith leaders are more likely to have high levels of debt, have other jobs in addition to their pastoral duties and possibly have multiple congregations to oversee (jung et al., 1998; van biema, 2009), resulting in the possibility of a lack of time for self-care or participation in healthy behaviors. separate analyses of this data have indicated that faith leader health and behaviors are related to the amount of hwa within an fbo (bopp & fallon, 2011), indicating the importance of targeting faith leader health with future initiatives. these strategies may fit logically into programs developed through the parent organization e.g. conference or diocese, through health insurance incentive programs or initiatives to ensure a wide reach across both urban and rural regions. fbos in rural areas were less likely to offer hwa and the programs and activities they did offer were more educational and less of a time burden. this is congruent with the finding that rural fbos were more likely to be smaller, suggesting they have a smaller volunteer base to draw from for organizing activities, a smaller fbo administrative staff, and less physical space for programs. this indicates that educational activities that require minimal resources, time and space may be a viable option compared with more action-oriented, hands-on approaches. though often not culturally tailored for spiritual settings, fbos could make use of materials widely available from trusted sources e.g. american heart association, national cancer institute to provide members with basic information pertaining to health. fbos could also employ technology to reach their congregation members with minimal resource commitments. for example; parent organizations could design website or other online materials for fbos to disseminate to their members, or faith leaders could communicate health messages via email or listserv to minimize costs. using other evidence based programs e.g. body and soul (resnicow et al., 2004) that have been designed for widespread dissemination offers possible effective strategies for improving the health of fbo members in institutions with limited space, staff or resources. parish nurses could play a role in disseminating information or programs, and may be a possibility even for rural churches that may share the time and effort of one parish nurse that receives training and support from parent organizations. online journal of rural nursing and health care, 12 (2) across both urban and rural fbos there was the consistent finding that the barriers to hwa included a lack of lay leadership/volunteers, lack of resources for staff time and a lack of interest from the congregation. parent organizations could attempt to address these barriers through a variety of different educational or training programs for faith leaders or fbo lay leaders. faith leaders would benefit from instruction in some of the basics of health promotion program planning, stressing the importance of how to recruit reliable, interested members to participate and conducting needs assessment to better understand the needs and preferences of their congregations to encourage more interest and engagement in health related programs. another possible vehicle for delivering this information to faith leaders would be as a part of seminary school instruction where the majority of faith leaders learn about not only theology but the administrative aspects of running fbos. in either of these approaches, special mention should be made of some of the unique challenges rural fbos may face. although there were some significant contributions of this study, several limitations must be noted. it should be noted that some denominations were better than others at offering current contact information for faith leaders, which limited the pool of recruits to individuals whose fbo website offered contact information, and also filtered our email invitation into their inbox, rather than junk mail or spam mailboxes, resulting in a low, however very conservative response rate. there was also a volunteer bias, with individuals motivated or interested enough to access and complete the survey more likely to respond. our final limitations were a result of our measures and designs. for this study we employed the use of self-report measures which are subject to bias and the perceptions of a single individual within a fbo. our cross-sectional study design limits our ability to determine predictors of fbo hwa and/or fluctuations in hwa over time. additional research in this area should consider alternate methodology, including random sampling procedures and providing increased incentives for participation for a better response rate. future investigations may include mixed methodologies to allow for a qualitative, in-depth examination of some of the influences on health promotion programs in rural fbos. despite these limitations the findings from this study provide valuable insight in regard to the current status of health and wellness programming and activities currently being offered at fbo throughout the us. previous evidence-based approaches have shown that fbos can serve as a place for health promotion strategies effective for changing health and behaviors, indicating the importance of this community institution as a place for delivering public health messages. understanding the unique needs, preferences and barriers to hwa within rural fbos can lead to tailored strategies for addressing some of these challenges and result in effective programming to target health promotion and disease prevention. references bennett, g. w. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/12564398 http://www.ncbi.nlm.nih.gov/pubmed/17234487 http://www.ncbi.nlm.nih.gov/pubmed/19960262 http://www.ncbi.nlm.nih.gov/pubmed/11889276 microsoft word fahs_318-1582-1-rv.docx online journal of rural nursing and health care, 13(2) 1 editorial see you in montana at the international rural health and nursing research conference pamela stewart fahs, rn, dsn, editor july 29 – 31, 2014, do you know where you will be? i will be in bozeman, montana at the international rural health and rural nursing research conference and hope to see you there! montana state university college of nursing is our host. this conference will give you the latest information in rural health care and nursing. the keynote speakers are dynamic and well known: mary wakefield, phd, rn, administrator, health resources and services administration; susan wilburn, mph, rn, technical officer, world health organization; larry gamm, phd, regents professor, school of rural public health, texas a & m university health science center; judith kulig, phd, rn professor and university scholar, faculty of health sciences, university of lethbridge and clarann weinert, sc, phd, rn, faan, professor emeritus, montana state university. there will be podium presentations and posters that will add to our knowledge and stimulate ideas and possible collaborations. the rno will be sponsoring awards for the best posters and there will be a mentoring program available. rural nursing and health care is broad, yet like a rural community it is small with a good deal of familiarity. judging from past rural conferences there will be friends old and new attending. this is a conference for practitioners, educators, and researchers. so if you work to ensure the health of rural populations, this is a conference you will not want to miss. top this off with an optional tour to yellowstone national park and i am sure this is a conference that will not only be informative but also fun, and one that the rno is proud to support. to see what is being offered and register to be part of the international rural health and rural nursing research conference, go to http://eu.montana.edu/rural/health/ 70 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 obesity risk factors for women living in the appalachian region: an integrative review tara o‟brien msn, rn 1 laura a. talbot edd, phd, rn, gcns-bc 2 1 school of nursing, university of north carolina at charlotte, obrien8@uncc.edu 2 director, hsr phd program, dean colvard distinguished professor in nursing, university of north carolina at charlotte, ltalbot@uncc.edu key words: obesity, physical activity, women, appalachian region, mortality, rural abstract research objective: this paper examines the current literature on obesity among women living in the appalachian region and looks at factors contributing to obesity in this area. methods: a systematic review was conducted of research published between 1989 and 2009 regarding the research on obesity among women living in the appalachian region. this review included both urban and rural appalachian settings. the search used four electronic databases: cinahl, eric, medline, and academic search premier. the key search terms included: appalachian region, women, obesity, and mortality. eight studies met the criteria for our review. results: the research suggests that both rural and urban appalachian women report a lack of regular physical activity, and many are at high risk for obesity, which contributes to the high mortality rates in this group. in addition, obesity, poverty, low educational attainment, and cultural norms are associated in this group. conclusions: in appalachia, cultural influences handed down for generations are more significant than the urban or rural environment in influencing obesity. to decrease the prevalence of obesity among appalachian women, nurses need to develop, community-based interventions that take into account the income and health literacy needs of these women. introduction obesity is a contributing factor in many chronic illnesses that lead not only to poorer health outcomes, but also to higher health care costs. in 2000, the estimated medical cost of obesity was $117 billion. obesity has both direct medical costs (prevention, diagnosis, treatment services) and indirect costs (mortality and morbidity) (center for disease control and prevention, 2009). obesity is a complex epidemic rooted in biological, social, and economic factors. the social determinants of health framework (wilkinson &marmot, 2008) suggest that individuals who live in poverty experience shorter life expectancy and poorer health than the more affluent. the appalachian region is largely rural and characterized as having high poverty rates, low educational attainment, aging population and high rate of chronic illness (tessaro & smith, 2005). life expectancy for women living in the appalachian region has seen a decline in recent years, and obesity and obesity-related illnesses have been cited as major contributors. the prevalence of obesity among white women in the appalachian region is estimated at 6.9% to 25%; among black women it is estimated at 11.3% to 47.1% (halverson et al, 2004). five mailto:obrien8@uncc.edu mailto:ltalbot@uncc.edu 71 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 appalachian states (al, ms, sc, tn, and wv) have overall obesity prevalence rates equal to or greater than 30% (centers for disease control and prevention, 2009; halverson et al., 2004; ezzatil et al., 2008). race seems to be a risk factor in obesity, with prevalence for white women in the appalachian region estimated at 6.9% to 25%, while among black women prevalence is estimated at 11.3% to 47.1%. many biological, socio-cultural and economic factors play a role in the development of obesity among women, including weight gain associated with pregnancy, menopause, estrogen metabolism, a sedentary lifestyle, and socio-economic status. the health consequences of obesity include coronary heart disease, type 2 diabetes, cancers (including breast and colon), respiratory problems, hypertension, and stroke, all contribute to the disparities in life expectancy for appalachian women (halverson et al., 2004; centers for disease control and prevention, 2009). the appalachian region is mostly white, with some representation of blacks and native americans (denham, meyer, toborg, & mande, 2004). the region includes 420 counties that follow the spine of the appalachian mountains, which spread across parts of 12 states and all of west virginia. eightytwo of these 420 appalachian counties are considered distressed counties (appalachian regional commission, 2010). forty-two percent of the people living in the appalachian region are in rural areas, as compared with 20% of people in the us as a whole (appalachian regional commission, 2010a). poverty rates in the region range between 13 and 27%. the number of residents with at least 12 years or more of education ranges from 68 to 77%, (appalachian regional commission, 2009) and most people are employed in blue-collar jobs. unemployment is high, with many families dependent on public assistance and supplemental security income (ssi) for disability. residents have limited access to health care. this is the nation's most economically depressed and medically underserved area, with proportionately more counties considered distressed than in the rest of the nation (bagi, reeder, & calhoun, 2002). from this perspective, the lives of appalachian women are shaped by the distribution of money, power and resources, and these forces are responsible for health inequities in this population, including obesity. this review presents what is currently known about factors that contribute to the high obesity levels among appalachian women, identifies best practice interventions, and recommends areas for future research. methods a comprehensive literature search was conducted for the years 1989 to 2009 using four electronic databases: cinahl, eric, medline, and academic search premier. we used the keywords (mesh terms): “appalachian region” and “women” or “female” and “obesity”, or “female” and “mortality”, with and without and “obesity”. the following criteria were used for inclusion in the review: (a) adult population (19+ years old); (b) randomized controlled trial, observational study, epidemiological study, qualitative study, or secondary analysis of data from the appalachian region; (c) original report, not a review or meta-analysis; and, (d) findings reported separately for women. the search returned a total of 926 hits; however, only 8 studies met the inclusion requirements. they are summarized in table 1. 72 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 results the eight studies were conducted in the appalachian region between the years of 2002 and 2009. five studies used a combination sample from both rural and urban settings in the region(armstrong, et al., 2004; denham, et al., 2004; ezzatil, friedman, kulkarni, & murray, 2008; halverson, barnett, & casper, 2002; ramsey & glenn, 2002). three studies were conducted only in rural settings (schoenberg, hatcher, & dignan, 2008; tessaro, et al., 2007; tessaro & smith, 2005). one study was conducted in west virginia and did not state whether the sample was from a rural or urban setting; however, the majority of the counties in west virginia are rural(rye, rye, tessaro, & coffindaffer, 2009). five studies were quantitative, using secondary analysis descriptive designs (armstrong, et al., 2004; ezzatil, et al., 2008; halverson, et al., 2002; ramsey & glenn, 2002; rye, et al., 2009). two studies were qualitative and used ethnographic designs (denham, et al., 2004; schoenberg, et al., 2008). only one study was an intervention study (tessaro, et al., 2007). four studies reported on biological factors that were associated with obesity in appalachian women, (ezzatil, et al., 2008; ramsey & glenn, 2002; rye, et al., 2009; schoenberg, et al., 2008) and four studies reported on socio-cultural factors associated with obesity in these women (armstrong, et al., 2004; denham, et al., 2004; halverson, et al., 2002; tessaro, et al., 2007). two studies obtained samples from the national center for health statistics (armstrong, et al., 2004; ezzatil, et al., 2008). adult appalachian women were included in all eight studies, and the range of participants‟ reported ages in the studies was 40-64 years. the highest level of education reported in three studies was high school (ezzatil, et al., 2008; rye, et al., 2009; schoenberg, et al., 2008). four studies did not report the level of education of participants (armstrong, et al., 2004; denham, et al., 2004; halverson, et al., 2002; tessaro, et al., 2007). only two studies compared black and white women, and in both of these studies the majority of participants were white women (ramsey & glenn, 2002; schoenberg, et al., 2008). two studies did not report the race of participants (ezzatil, et al., 2008; tessaro, et al., 2007). in three studies the majority of women earned an annual income less than $20,000 (ramsey & glenn, 2002; schoenberg, et al., 2008; tessaro et al, 2007). four studies found a decrease in life expectancy for appalachian women and an increase in chronic illnesses related to obesity (armstrong, et al., 2004; ezzatil, et al., 2008; halverson, et al., 2002; schoenberg, et al., 2008). one study found that women living in rural regions had the highest rate of obesity (ramsey & glenn, 2002). socio-cultural factors related to obesity in appalachian women physical activity. many appalachian residents do report engaging in some type of physical activity. according to the behavioral risk factor surveillance system, when residents of appalachian states were asked if they participated in any form of exercise in the past month, an average of 27.33% reported “no”(cdc, 2008). when examining women, the appalachian regional commission (2004) reported 19.6% to 58% of white appalachian women are physical 73 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 table 1. appalachian women & obesity first author purpose sample design setting rural/urban contributing factors outcome suggested future strategy armstrong to determine the extent to which death rates from colorectal cancer by age, race, & gender subgroups of appalachians differ from rates of the same sub groups elsewhere in the us residents of all appalachian counties in 13 states quantitative secondary data analysis 13appalachia counties in both rural and urban settings of the appalachian region socio-cultural factors related to the lack of education & geographic isolation ( access to care) death rates among obese white men & women were significantly higher for colorectal cancer in the appalachian region than in the rest of the country appalachian region may benefit from targeted obesity prevention to eliminate health disparities. sample group was provided from the multiple cause of death public file; death certificate, which was provided by the national center for health statistics (nchs).sample size was not provided age 50-80 men & women were analyzed separately for the study denham to determine if behavioral health interventions could be more successful if culturally sensitive sample group was provided from the multiple cause of death public file; death certificate, which was provided by the nchs qualitative study 24 appalachian counties in ten states in both rural and urban settings of the appalachian region socio-cultural factors related to sensitivity of the delivery of education methods appalachian mothers play a major role in the health of their family members and play a major role for promoting positive health behaviors for the family. in appalachian families women most often have the power to influence the family health needs (including chronic conditions such as obesity), but often need support to make effective use of this role. important cultural considerations are the need for personal contact, politely framed messages, & reliance on facts which may allow women in the appalachian region to disseminate health information. age 50-80 (mean age 3645 for the adult women‟s group) focus groups, common themes were analyzed gender analyzed separately for the study sample size 52 focus groups included 469 persons adolescents n =16, adult men n= 30 adult women = 273 74 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 first author purpose sample design setting rural/urban contributing factors outcome suggested future strategy ezzati to compare average life expectancies in various regions of the us sample group was provided by the us census population from 1961 to 1999 which was provided by the nchs quantitative secondary data analysis all us states both rural and urban settings of the us biological factors related to chronic diseases life expectancy decline for women living in the deep south of the u.s. extending into the appalachian region. programs need to be established that increase insurance coverage for interventions for chronic disease. patterns of female mortality rise are consistent with smoking, high blood pressure & obesity men & women were analyzed separately for the study sample size was not provided halverson to examine geographical, racial/ ethnic differences in heart disease & stroke mortality. residents of all appalachian counties in 13 appalachian states quantitative secondary data analysis 403 appalachian counties in 13 appalachian states both rural and urban settings of the appalachian region socio-cultural factors included low education attainment, low per capita income, limited access to medical care were associated with higher rates of morbidity & mortality nearly 35% of the us counties with the highest rates of heart disease mortality for white men & women are in appalachia 25% of counties with the highest rates for black men & women are the appalachian region distressed counties need to use direct money & resources to make policy decisions at the local level to improve health outcomes for people living in the region. these policy changes would include various approaches to promote a healthy lifestyle for people living in the appalachian region. sample group was provided national vital statistics system by the nchs white men 35-64 white men 65& older white women 35-64 white women 65& older black men 35-64 black men 65& older black women 35-64 black women 65 & older sample size was not provided ramsey to investigate the differences between rural, urban, & suburban southern women based on socioeconomi c factors 4,391 women living in the southern region of the us quantitative descriptive study women living in urban, suburban, and rural regions analyzed separately for the study biological factors for white women associated with morbidity & mortality rates participants with higher incomes & educational levels had better health outcomes community health care providers should use community based health strategies to manage weight through new or existing programs. programs need to be sensitive to income & educational factors that characterize rural regions urban n= 1,042 suburban n=1,977 rural n= 1,372 ages 40-64 data from national health survey women living in rural regions had the highest rate of obesity & reported the poorest health. obesity & poor health related 75 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 first author purpose sample design setting rural/urban contributing factors outcome suggested future strategy rye to investigate the prevalence of lack of time & motivation as barriers to physical activity among low income women 733 women living in west virginia quantitative descriptive rural and urban areas of west virginia biological factors associated with lack of motivation & time contributed to higher rates of obesity for women a lack of time & support was the greatest barrier reported by participants motivational counseling is a critical intervention to increase motivation & social support for physical activity, which will assist in decreasing the prevalence of obesity. 244 aged 40-64 489 aged 50-64 health risk/ behavioral survey tessaro to evaluate a computer based interactive nutrition intervention 262 women living in rural west virginia quantitative intervention two rural counties of west virginia socio-cultural factors included to low income and rural region with a history of chronic disease the computer based interactive nutrition intervention showed potential change in the diets for the women in the intervention group personal delivery of information may not always be available in rural regions. technology may be one way to bridge the gap between education and behavior change. 131 intervention 131 control mean age 50.25 schoenberg to determine what appalachian women consider the most pressing threat to their communities snowball sample from four rural appalachian kentucky counties qualitative focus groups using open ended questions four rural appalachian counties in kentucky biological factors of poor diet & exercise contribute to obesity participants identified the greatest threats to their communities as substance abuse, cancer, heart disease & diabetes, poor diet, lack of exercise, & obesity lifestyle-related choices comprise the core risk factors for developing chronic disease. the best approach for addressing these threats is to develop coalitions to target troublesome community health problems. community health promotion can best be implemented by respecting existing community knowledge, priorities, & capacities through community research partnerships that point to proven interventions. n = 52 65% women mean age 52 several appalachian areas have the highest rates of obesity & physical inactivity in the country 76 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 inactivity, as compared to 12.9% to 54% of white women in the nation. also, 35.8% to 67.2% of appalachian black women reported physical inactivity, as compared to 25.4% to 58.1% black women in the nation. some studies have found relationships between the lack of physical activity and long work hours, low motivation or will power, and lack of resources to participate in regular exercise, such as fitness centers, walking paths or bike paths (rye, et al., 2009; schoenberg, et al., 2008). using a cross sectional survey design, rye and colleagues examined barriers to physical activity among low-income appalachian women aged 40 to 60 years (n=733). lack of support and lack of willpower were the greatest barriers to physical activity. interestingly, among these women, lack of time was not perceived as a major barrier to physical activity. schoenberg and colleagues interviewed 52 middle-aged rural appalachian women in focus groups. women perceived that lack of character or intelligence contributed to low physical activity. further, they said cable tv and the internet had replaced walks to visit neighbors. long work schedules and insufficient resources such as fitness centers also contributed to sedentary lifestyle. diet/nutrition. residents of the appalachian region are often older, with higher poverty rates, and more limited access to healthcare than their non-appalachian counterparts (armstrong, et al., 2004; ezzatil, et al., 2008; halverson, et al., 2002; ramsey & glenn, 2002). the association between poverty and obesity may be related to the low cost of energy dense foods. many appalachian women report eating fewer fruits and vegetables, more red meat, and more foods high in saturated fats than their non-appalachian counterparts (schoenberg, et al., 2008; wewers, katz, paskett, & fickle, 2006). people with lower incomes are more likely to be able to afford these non-nutrient energy dense foods, including refined grains and foods containing high fat and sugar. they are less likely to be able to afford lean meats, fish, fresh vegetables, and fruits. in the studies, appalachian residents said that overeating, defined as frequently consuming high calorie foods, was often a problem (schoenberg, et al., 2008; wewers, et al., 2006). moreover, many women reported being taught to prepare traditional appalachian foods, with recipes handed down through generations for cornbread, fried potatoes, biscuits and gravy, stack cakes, chicken „n‟ dumplings, and grilled cheese sandwiches, all dense with calories to sustain those performing heavy manual labor (ramsey & glenn, 2002; schoenberg, et al., 2008; tessaro, et al., 2007). education and socioeconomic status. the women living in the appalachian region received less primary education as compared to other parts of the nation (ramsey & glenn, 2002; rye, rye, tessaro, & coffindaffer, 2009). ramsey & glenn, 2002, found that obese women often had less primary education. often women living in urban and suburban areas with higher income level have more education and report better health than women living in rural areas. as noted earlier, the appalachian region has high poverty and low education levels (ramsey & glenn, 2002). cultural norms. the appalachian community also holds values that are related to obesity; cultural heritage influences food choices. two studies reviewed here concluded that the appalachian family is the central unit for making decisions about food selection and preparation. the mother plays the dominant role in the family, and other members of family learn from the mother‟s choices (denham, et al., 2004; schoenberg, et al., 2008), which tend to be high calorie. effects on mortality and economic burden. the health consequences of obesity include elevated mortality rates and economic burden. living in the appalachian region is linked to health disparities, more chronic illnesses and higher mortality rates for women. over the past 77 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 few decades, average life expectancy has increased for most americans; however, for women in this region life expectancy has decreased (armstrong, et al., 2004; ezzatil, et al., 2008). mortality rates are higher for white, older appalachian women than for women in the rest of the nation, and mortality is most often due to heart disease and stroke (armstrong, et al., 2004; ezzatil, et al., 2008; halverson, et al., 2002). biological factors related to obesity in appalachian women genetic risk factors influence energy metabolism and makes some individuals susceptible to weight gain and obesity. even with genetic susceptibility, however, a nutritious diet and regular physical activity enable maintenance of a healthy weight. none of these studies described caloric intake or energy expenditure or genetic variations in the metabolism of women living in the appalachian region. future research should examine associations between caloric intake and energy expenditure of women living in this region. discussion appalachian women are an understudied population in the us. life expectancy in these women declined in recent years, with obesity and obesity-related illnesses cited as contributing factors (halverson, et al, 2004). biological factors in obesity include gender, age, and genetic variations in metabolism. socio-cultural factors include socioeconomic levels, educational levels, and cultural norms. this review summarizes what is known about biological, socio-cultural and economic factors that contribute to the high levels of obesity among appalachian women. these women clearly experience high rates of obesity, which is a multifaceted problem and is associated with both biological and environmental factors. the per capita income of people living in the appalachian region is approximately $4,000 less than the national average, and 15.3% of households are at the poverty level (armstrong, et al., 2004). only 68% to 77% of people living in the appalachian region have at least 12 years of education (wewers, et al., 2006). they also have low health literacy skills, which compounds the problem of obesity. finally, the appalachian region has many barriers to healthy lifestyles, including limited access to health care and limited facilities for recreational activity (tessaro, et al., 2007). these studies did not include body mass indices (bmi‟s) or caloric intake of participants. further, the majority of the studies were cross sectional or qualitative; few obesity intervention studies have been conducted with appalachian women, making it impossible to draw causal associations. future investigations should test interventions for women in appalachia and other regions with high obesity rates. implications for nursing despite their limitations, the studies reviewed provide evidence that awareness of barriers to physical activity can assist nurses in developing approaches to increase activity in appalachian women. in addition, exploring cultural influences on food selection and preparation can suggest strategies for decreasing high calorie diets and overeating. decreasing obesity in rural appalachian women can in turn assist in decreasing chronic illness related mortality. best practice strategies for addressing the increasing obesity rates in appalachian women include emphasis on education about health promotion and better access to preventive health care in low-income, medically underserved communities. given the documented increase in 78 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 mortality among appalachian women and its relationship to obesity, interventions should be tailored to women. best practice interventions take into account appalachian cultural and socioeconomic features, such as income and health literacy needs. nurses can re-educate appalachian women about healthy food choices using educational material that are culturally diverse and written at a low literacy level. also, interventions directed at providing women with motivational and support training helps them make better healthcare decisions. exploring obesity interventions using information technology systems or telehealth will allow education to be delivered in remote rural regions. health care policies need to focus on ways to improve living environments and make healthier communities, especially communities with high obesity rates and few resources. health care services to low-income households, including nutrition education, and health screenings to manage weight, need to be a priority. community coalitions and neighborhood associations promoting active lifestyles for appalachian women can provide health interventions which focus on reducing obesity, and improving health outcomes for people living in rural regions. references appalachian 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(2009). u.s obesity rates and trends. retrieved july 31, 2009, from http://www.cdc.gov/obesity/data/trends.html denham, s., meyer, m., toborg, m., & mande, m. (2004). providing health education to appalachia populations. holistic nursing practice, 18(6), 293-301. [medline] ezzatil, m., friedman, a., kulkarni, s., & murray, c. (2008). the reversal of fortunes: trends in county mortality and cross county mortality disparities in the united states. plos medicine, 5(4), 557-568. [medline] halverson, j.a., byrd, r.c., ma, l., & harner e.j. (2004) an analysis of disparities in health status and access to health care in the appalachian region. office of social environment and health research (oseahr)/prevention research center, west virginia university. halverson, j., barnett, e., & casper, m. (2002). geographic disparities in heart disease and stroke mortality among black and white populations in the appalachian region. ethnicity & disease, 12 (4), 82-91. [medlne] ramsey, p., & glenn, l. 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(2009). perceived barriers to physical activity according to stage and body mass index in west virginia wisewoman population. women health issues, 19 (2), 126-134. [medline] schoenberg, n., hatcher, j., & dignan, m. (2008). appalachian women's perceptions of their community's health threats. journal of rural health, 24(1), 75-83. [medline] tessaro, i., rye, s., parker, l., mangone, c., & mccrone, s. (2007). effectiveness of a nutrition intervention with rural low income women. american journal of health behavior, 31(1), 35-43. [medline] tessaro, i., smith, s.l & rye, s. (2005). knowledge and perceptions of diabetes in an appalachian population. preventing chronic disease: public health research, practice, and policy, 2(2), 1-9. [medline] wewers, m., katz, m., paskett, e., & fickle, d. (2006). risky behavior among ohio appalachian adults. preventing chronic disease, 3(4), 1-8. [medline] wilkinson, r., & marmot, m. (2008) the social determinants of health: the solid facts. geneva, sw: world health organization. http://www.ncbi.nlm.nih.gov/pubmed/19272563 http://www.ncbi.nlm.nih.gov/pubmed/18257874 http://www.ncbi.nlm.nih.gov/pubmed/17181460 http://www.ncbi.nlm.nih.gov/pubmed/15888224 http://www.ncbi.nlm.nih.gov/pubmed/16978502 online journal of rural nursing and health care, 2(2) 1 editorial educational issues—cyber-learning: a primer to get you started angeline bushy, phd, rn, faan, editorial board member is going back to school in your plans? perhaps, you have considered pursuing a bachelors or masters degree in nursing or completing a mandatory continuing education offering? maybe you already are enrolled in school and are required to take an on-line course? or, have been asked to develop an educational program for patients having a particular diagnosis who seek care in the health care facility in which you work? internet classes are here to stay, and increasingly these will target consumers and health professionals alike. this column will present a brief overview of some of the concepts and ‘lingo’ associated with web-based educational offerings. traditionally, learning occurred among a group of learners with a teacher, meeting a face-to-face within a classroom. computers and network technologies, however, are modifying where learning occurs as well as how students learn. in fact, most educational programs are using the internet to offer entire courses on-line, and/or enhance existing courses. metaphorically, an internet-course can be described as a place (context) without physical boundaries (i.e., cyberspace), having a wealth of information (content) waiting to be actively sought by the teacher and the learner(s) as partners. in turn, from an environment filled with experts waiting to be accessed—the learners create in-depth and meaningful knowledge. along with the potential for greater student diversity, a potential benefit of on-line courses is that it can reduce or even eliminate commuting time and to teach and/or attend classes. conversely, enrolling in an on-line course may require a greater degree of self-direction and online journal of rural nursing and health care, 2(2) 2 motivation on the part of the learner while the teacher may feel less in control of the learning environment. along with technology are some unfamiliar terms. for example, distributive learning is a rather recently coined term used in lieu of the more traditional descriptor >outreach or distance education. of the two, distributive education has a broader connotation in respect to the time when a class is offered (schedule) and the site(s) to which it is delivered. compared to the traditional classroom confined within a >bricks-and mortar structure, community of learners assumes a broader dimension in reference to a virtual classroom that is located in cyberspace. a course can be fully web-based (offered entirely on-line) or web-enhanced (supplementary materials offered on-line to augment classroom content); both of which may decrease actual student seat-time in the traditional classroom. logging on refers to the action of accessing the course on the internet via a computer. in the virtual classroom discussions can be synchronous (real time) and asynchronous (one can log onto the internet-based classroom at any time within a 24 hour time frame). posting is the action of responding (in writing) to an online assignment or to a peers comment; subsequently, the posted comments become apparent in the browser window (screen/page). types of technology and software that is used with web-based courses varies from one institution to another; and from one student to another. at this point in time, the lack of standardization seems to present the greatest challenge to both the instructor and students. for example, it is not usual for a student, or as the case might be, a patient to use a computer with windows 95, or in some cases even dos operating systems while the university or hospital uses a state of the art operating system that does not support older versions. in other words, the two computer systems “do not communicate” or even ‘miscommunicate” with each other; online journal of rural nursing and health care, 2(2) 3 usually, resulting in the student becoming extremely frustrated and many times dropping or even failing the course. before enrolling find out what hardware and software the university’s computer department recommends for students who take web courses. a few words about the software that is used to deliver a web courses such as webct or blackboard. these are tools used to transition an educational offering from a ‘traditional classroom’ to an ‘on-line format’. usually, the program includes lesson plans (learning modules) with specific assignments, links to sites for student discussions and email communication; sometimes there is on-line testing and chat room capabilities, too. in other words, the software is comparable to the architectural structure of a school building and provides the environment for students to meet with the teacher. teaching-learning strategies must, however, be modified to make the best use of ever changing technology. internet security is of utmost concern and everyone should have current and reliable antivirus protection on their computer! become knowledgeable about the virus protection provided by the university for its information system. know how to install and update antivirus software and scanning files in your own computer. privacy and confidentiality are two other important considerations in an online course. if such an environment is not present, participants will not establish rapport with each other. in a web course, class discussions usually are restricted to enrolled students and the instructor, and, on occasion, a guest speaker. when the audience is not comfortable about respect for privacy, the quality and quantity of individuals participation will also suffer. in brief, technology is here to stay! technology can make education more available and accessible to health professionals and consumers especially in more remote rural settings. most who enroll in these courses rate them quite favorably and usually take another such offering. to online journal of rural nursing and health care, 2(2) 4 be successful, though, the individual must become “computer literate” and able to complete the course without feeling frustrated and completely overwhelmed. as with most new things, such as playing a musical instrument or using a new piece of equipment in the hospital, there is a learning curve, that is, one must first learn the language, then organize the necessary equipment, and finally, practice to become proficient in its use. comments and questions should be directed to: angeline bushy phd, rn, faan professor & bert fish chair university of central florida school of nursing @ daytona beach campus 1200 international speedway blvd. daytona beach, florida 32114 abushy@pegasus.cc.ucf.edu rural boundariesstudent perspective 21 on breast cancer detection, directors of nursing and female residents: a study in rural long-term care rebecca j. rudel, phd, rn, cne1 1assistant professor, college of nursing, university of north dakota, rebeccarudel@mail.und.nodak.edu key words: breast cancer, directors of nursing, rural, women, long-term care abstract breast cancer is a leading cause of mortality in women throughout the world. rural women have a higher risk of dying from breast cancer than do their urban counterparts. breast cancer incidence rises sharply with age, and research on breast cancer screening for the old-old women in long-term care facilities is scarce. the purpose of this study was to investigate the screening services available for breast cancer detection for the elderly women in rural, skilled long-term care facilities in a midwestern state. participants in the study were directors of nursing for rural long-term care facilities, of which the response rate was 68.4%. results revealed that elderly women in the rural long-term care facilities do not receive breast cancer screening services within the guidelines of the american cancer society and the national cancer institute. also, the self-reports by female directors of nursing indicate that even these professionals do not practice or utilize breast cancer screening services within consensus guidelines. data support the need for a continued focus on breast health programs for rural elderly women in long-term care, and for health-seeking behaviors of nursing professionals. introduction “millie” was a beloved wife, mother, grandmother, and friend in her small rural community. late in life, millie manifested dementia and eventually entered long-term care. it was her second year in long-term care when her chest wall became notably disfigured. breast cancer was diagnosed by the obvious—a lump clearly visible and thought to be well encapsulated. staging and treatment were not recommended by her health care provider; “she’ll die from something” was the prevailing and accepted advice. two years after a gruesome and painful saga of breast cancer with bony invasion, millie’s precious life finally ended. two years! two horrific years ended a life well lived. as has been long understood, the united states is undergoing a dramatic demographic shift with the aging of the population, the “graying of america.” consequently, a greater emphasis is being placed on the health care needs of the elderly than ever before in history. although many health care issues affect older americans, one that has received relatively less attention in comparison with its prevalence has been breast cancer in older women. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 http://www.nursing.und.edu/ mailto:rebeccarudel@mail.und.nodak.edu 22 in the united states, breast cancer is among the most common cancers in women, second only to lung cancer as a cause of cancer death (american cancer society, 2006). although the breast cancer death rate has declined since the early 1990s, the national cancer institute (2006) reports a steady increase in breast cancer diagnosis rates. every two minutes, a woman in the united states is diagnosed with breast cancer. it is estimated that in 2006, approximately 212,920 new cases of invasive breast cancer will be diagnosed among women in the united states, along with 58,000 new cases of noninvasive breast cancer, and 40,000 women are expected to die from this disease (american cancer society, 2006). breast cancer incidence increases with age, with 80% of all cases occurring in women over age 50 years (national cancer institute, 2003). because the incidence of most cancers is highest at older ages, the proportion of persons affected by cancer who are elderly at the time of diagnosis is growing, and the incidence of breast cancer now peaks at the ages of 75 to 79 years (edwards et al., 2002; sweeney, blair, anderson, lazovich, & folsom, 2004). data describing screening practices for breast cancer in the oldest age groups are relatively limited, and the debate of the efficaciousness of breast cancer screening continues. research questions improvement of health care in the united states is a national priority, and nursing intervention research can contribute substantially to addressing this priority. detecting and diagnosing breast cancer early, when it is most curable, holds the greatest promise for saving the lives of women with the disease (institute of medicine, 2006). breast cancer screening for all women, including the very old, could result in substantial improvement in the quality of life until one’s life ends. given the high incidence of mortality of breast cancer among older women, the lack of published data reflecting the promotion of breast cancer detection for elderly women in long-term care (ltc), and the limited data on cancer-related issues within rural populations, this research serves as a basis for future interventions, and focused on the following questions: 1. what is the reported frequency of clinical breast examination provided for elderly women in one state’s rural, skilled ltc facilities? 2. what is the reported frequency of mammography provided for women in a one state’s rural, skilled ltc facilities? 3. what factors influence the screening services available for elderly women in rural, skilled ltc facilities? study design the health belief model (hbm) is a useful framework to predict a woman’s intention to obtain breast cancer screening mammograms and clinical breast examinations. it suggests that a woman is more likely to be screened for breast cancer if she feels susceptible to breast cancer and if she perceives that the behaviors (mammograms or examinations) are beneficial and that the existing barriers (to screening) are manageable (stein, fox, murata, & morisky, 1992). previous studies have online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 23 shown that perceived barriers and benefits have the highest correlation to behavior change (champion, 1999). in this study, the three constructs of the hbm model were considered: perceived barriers, benefits, and susceptibility (champion, 1999). the model was incorporated as a guide with indirect application to the study. frail elderly women in ltc are largely unable to self-report and to self-advocate; they are not able to act on individual intention. however, directors of nursing (dons) in ltc were assumed to be the individuals who have major influence on the medical services and activities related to resident care. the postulate was that the dons’ perceptions of the three hbm constructs (barriers, benefits, susceptibility) could transpose to advocacy action, if she/he believed that benefits and susceptibility outweighed any barriers for screening activities. review of the literature a pathophysiology brief breast cancer is a major public health concern throughout the world. breast cancer is not one disease, but many, depending on the tissue of the breast involved, it’s estrogen dependency, and the age at onset. malignant breast tumors are usually solitary, irregularly shaped, firm, nontender, nonmobile masses with a tendency to adhere to the pectoral muscles and to the skin. this causes a retraction or dimpling of the skin. elderly women with early breast cancer have survival rates superior to the general population, because tumor growth in these patients is slower than in younger patients. diab, elledge, and clark (2000) reported an extensive study in which advancing age was associated with a more favorable tumor biology. in that study, the eight-year survival of elderly lymph node negative breast cancer patients was similar to the rate of breast cancer survival in all women, irrespective of any concommitant disease status which commonly presents in the frail elder population. breast cancer most frequently metastasizes to bone (in more than 50% of patients), specifically the spine, ribs, and proximal long bones. patients with bony metastasis will endure or manifest localized, deep-seated, unrelenting pain. pathological fractures are common, and compression fractures with associated neurological impairment frequently present (phipps, monahan, sands, marek, & neighbors, 2003; yarbro, groenwald, frogge, & goodman, 2000). highly educational web-based education modules on breast cancer are available online. one such product, the breast and cervical cancer detection program, was developed with support from the wisconsin department of health and family services, well woman program, and the centers for disease control, national breast and cervical cancer early detection program (settersten, dopp, & tjoe, 2006). at this site, readers may easily review knowledge about breast cancer in preparation for the study of breast cancer screening modalities, as well as for the accepted protocol for the follow-up of abnormal screening results. see http://www.son.wisc.edu/ce/programs/asynch/bccd/index.html. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 http://www.son.wisc.edu/ce/programs/asynch/bccd/index.html 24 breast cancer and aging age alone puts women at greatest risk for the development of breast cancer. the incidence of breast cancer peaks at the ages of 75 to 79 years (siegelmann et al., 2006). for a woman who lives to be 85 years old, chances of developing breast cancer are 1 in 7 in her lifetime. over 50% of the breast cancer deaths are found in elderly women, those past the age of 65 (american cancer society, 2004). for decades, studies have challenged that treatment for breast cancer differs considerably by patient age and that older women are more likely to receive substandard therapy. literature reviews consistently report elderly women as less likely to receive detection screening, standard-of-care surgery, radiation therapy, and chemotherapy (diab et al., 2000; greenfield, blanco, elashoff, & ganz, 1987; samet, hunt, key, humble, & goodwin, 1987; silliman, troyan, guadagnoli, kaplan, & greenfield, 1997). researchers at the university of texas m. d. anderson cancer center recently completed an investigation of care patterns for older breast cancer patients. this report indicates that issues for decreased guideline concordance for breast cancer are probably multifactorial and may include a higher rate of patient comorbidities, poorer performance status, less social support, difficulty with transportation, patient or family preference, concerns about quality of life, lower life expectancy, and age bias (giordano, duan, kuo, hortobagyi, & goodwin, 2006). breast cancer and long-term care residents there is a paucity of literature related to prevention services for the elderly in ltc. some time ago, kenney and keenan (1991) posed challenges when they described women residents in ltc facilities as being at high risk for the development of breast cancer. this study suggested an age-related bias among health-care providers concerning the breast cancer detection practices for ltc residents. another study, entitled keeping a watchful eye, described the extent to which women in ltc facilities received preventive screening services (mccabe, bergmanevans, & grasser, 1998). the authors reported that while general physical examinations of the women residents met the 40% recommendation of healthy people 2000 (u.s. department of health and human services, 1990), the one exception was that clinical breast examination and pap smears were not a part of the annual physicals. the authors reported that nurses in ltc have an opportunity to enhance residents' quality of life by ensuring consistent use of preventive screening services (mccabe, bergman-evans, & grasser, 1998). breast cancer and rural women only limited data are available to assess cancer incidence, cancer prevention behaviors, and cancer-related mortality within rural populations. there is no nationwide cancer registry in the us; however, data are available through the national program of cancer registries (2002) and the national cancer institute’s (nci) surveillance, epidemiology, and end results (seer) registry program (hance, anderson, devesa, young, & levine, 2005; nci, 2003). further, cancer registry data are not presented by online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 25 metropolitan areas versus nonmetropolitan areas, and when presented by urban/rural residence, data are not presented by individual cancer sites (amey, miller, & albrecht, 1997). while reports are relatively sparse, we have known that rural areas report a higher prevalence of chronic diseases, including heart disease and cancer (monroe, rickets, & savitz, 1992; ricketts, 1999; skinner, fraser-maginn, & mueller, 2006). this finding has been attributed, in part, to a population that is older, poorer, and less educated. steven et al. (2002) examined both breast and cervical carcinoma screening practices of women living in rural and nonrural areas of the united states from 1998 through 1999, using data from the behavioral risk factor surveillance system. this study underscores the need for continued efforts to provide breast screening to women living in rural areas of the united states. moreover, rural residents have been shown to be diagnosed at a later stage of a cancer disease compared to urban residents, higher proportions of rural cancer cases were unstaged at diagnosis, and reports indicate that rural breast cancer patients had significantly less access to state-of-the-art technology. (higginbotham, moulder, & currier, 2001; howe, lehnherr, & katterhagen, 1997; wright, champagne, dever, & clark, 1985). public policy one of the fundamental features of america’s population of elderly women is it’s larger majority, basically because their death rates are lower than those of men. life expectancy has increased rapidly this past century and some predictions are that by 2050, the average life expectancy for women will be 90 years. today, the life expectancy of the average 70-year old woman is 15.5 years, and six additional years are contemplated for the woman who reaches 85 years of age (olshansky et al., 2005). the availability of many medical screening tools, tests, therapies, and procedures presents ethical, legal, and political questions. breast cancer screening issues for elderly women have presented challenges for years. ethically, are health care providers able to decide who should or should not be screened? if a woman who reaches 85 years today has a life expectancy of up to six more years, could the lack of screening or treatment be a grossly unethical disservice? or, what of women with dementia in ltc— would screening for this population be carrying an issue carried too far? initially, it may seem so; yet terminal disease secondary to breast cancer is very painful, very slow and the lack of simple treatment efforts could be construed as outrageous. summary at present, the benefits of early diagnosis and treatment for greater numbers of elderly women are many. early diagnosis and treatment prevent a later-staged disease. the consequences of metastasis are physically and emotionally devastating, and often persist for long periods of time. the medical, nursing, socioeconomic, and psychosocial costs of end-stage cancer are staggering by comparison to the costs of early disease treatment (drugay, 1993). as the number of elderly women in this country rises, so does the incidence of breast cancer. there has been limited research on the old, old segment of the breast online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 26 cancer population. well over a decade ago, constanza et al. (1992) asserted that qualityof-life issues greatly affect the appropriateness of breast cancer screening for women of all ages. zapka and berowitz (1992) offered a challenge to dispel negative attitudes toward making prevention services available to elderly women. important questions remain regarding how the rural elder women in ltc fare regarding breast cancer screening, diagnosis, and treatment. methods sample the purpose of this descriptive study was to examine the breast cancer screening services available for the elderly women in skilled long-term care facilities (ltc) in a rural us state. the study was approved by the researcher’s institutional review board. the target population for this study was the directors of nursing (dons) for skilled ltc facilities in a rural state. ltc facilities were considered “rural” if they were situated in communities with a population of under 2500. for this statewide study, 57 facilities met the inclusion criteria for this purposeful sampling. instrument the survey instrument was developed against the literature, the researcher’s experience, and upon counsel of expert practitioners. champion (1993, 1994) and others have published extensive research to establish strong evidence for construct validity of the health belief model, with a lengthy list of statements that evidence validity and reliability of each hbm scale (perceived susceptibility, seriousness, benefits, and barriers for screening). those items deemed relevant to the research questions were selected for this study. items considering the dons’ roles, responsibilities, and perceptions of their professional influence were largely adapted from the american nurses association statement on the roles, responsibilities, and qualifications of nurse administrators in ltc and a review of the literature (aroian, patsdaughter, & wyszynski, 2000; buchanan et al., 2006; ebersole, hess, touhy, & jett, 2005). validity for the final survey instrument was assessed by a breast health research expert, two oncology nurses, and a registered nurse whose expertise is in breast health. the survey began with an introduction and purpose, and proceeded with fixedchoices, likert-scales, and qualitative open-ended questions considering (a) an estimate of how many elderly women in each ltc facility receive a regular clinical breast exam— by either the physician or nurse, and of how many women residents receive a mammogram per american cancer society guidelines; (b) items reflecting components of the health belief model, which identifies variables that may affect a woman’s perception of breast cancer susceptibility and breast cancer seriousness, as well as the perception of the benefits of breast cancer screening and barriers to screening; (c) the responding don’s perception of ability to influence care for the residents in his/her facility; (d) the personal value placed on practices for breast cancer screening by the female dons themselves; and (e) demographic information. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 27 procedure each participant in this purposeful, inclusive sample received a questionnaire packet which included the survey and a self-addressed, postage paid return envelope. the letter of introduction explained the study purpose, provided contact information, indicated that participation was purely voluntary, and assured anonymity in any subsequent study reporting. data analysis study data were analyzed using the statistical software package spss (spss inc., chicago, il). descriptive and inferential statistics were used to analyze the quantitative data; qualitative data were analyzed as appropriate. results study sample description there are 57 skilled ltc facilities in rural communities of this state. each director of nursing in these facilities were used as the target population for this study. a total of 39 dons completed and returned the survey, for an overall return rate of 68.4%. demographics the dons ranged in age from 32 to 63 years, most held a baccalaureate degree, and the majority were female. employment experience overall was of 21 years, with the experience range being 4 to 43 years, and the geriatric-specific practice an average of 13.8 years. the dons averaged 10.7 years of employment at their present facility; two had been there for 30 years. the dons had an average of 6.7 years as directors of nursing, with a range of 1 to 30 (see table 1). table 1 demographics of respondents variable n valid % m sd age 39 45.9 8.0 education baccalaureate degree 24 diploma 10 associate degree 5 12.8 gender female 27 94.0 male 2 6.0 years of nursing experience 39 21.1 9.1 years of geriatric nursing 39 13.8 7.0 years of employment at facility 39 10.7 8.6 years of director of nursing experience 39 6.7 6.8 online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 28 research question #1 – clinical breast exam frequency the dons were asked to indicate an estimate of the number of elderly women in their facility who receive regular (annual) clinical breast examinations (cbe). responses were analyzed using frequencies and percentages. fourteen (25.9%) dons reported that many (over 75%) of the elderly women in their ltc facility do receive regular cbes by a provider. seventeen (43.6%) respondents reported that less than 25% of the elderly women in their ltc facility receive a cbe. thirty two (82%) of the dons reported that few, if any (0-25%) of the elderly female residents receive breast examination by a nurse (see table 2). table 2 breast cancer screening services utilized for elderly women as reported by long-term care facility directors of nursing variable n valid % estimate of female residents receiving annual breast examination by physician 0–25% 17 43.6 26–50% 5 12.8 51–75% 3 7.7 over 75% 14 35.9 estimate of female residents receiving annual breast examination by nurse 0–25% 32 82.1 26–50% 3 7.7 51–75% 0 31.1 over 75% 4 10.2 estimate of female residents receiving regular (annual) mammogram 0–25% 34 87.0 26–50% 3 8.0 51–75% 2 5.0 over 75% 0 0.0 n = 39 research question #2 – mammography frequency the dons were also asked to report an approximate percent of the elderly women in their ltc facility who receive a regular (annual or bi-annual) mammogram. thirty-four (87.2%) dons reported that 0-25% of the elderly women in their facility receive a regular mammogram, and indicated that most never have a mammogram. three dons responded that 26-50% of their ltc women receive mammograms, and two indicated 51-75% of the female residents in their facility receive a regular mammogram (see table 2). three dons provided comment that access to mammography is a barrier for mammography utilization. for those facilities where women did receive mammography, the elderly resident needed to be transported to a nearby hospital for the service. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 29 research question #3 – factors influencing screening services the third study segment was an inquiry of how the health belief model (hbm) may relate to individuals (dons) who are charged with the care delivery for those who may not be in a position to act or speak for themselves, such as is the case for a majority of old-old women in ltc. this data analysis involved a recoding of some of the items, so that all survey statements were presented in the same direction, negative to positive. every (n = 39) don reported a strong responsibility to serve as advocates for the residents in ltc, and that they have considerable influence with provider decisions for the care delivery of ltc residents. internal consistency reliability coefficients (cronbach's alpha) ranged from .70 to .85 for the don’s roles and responsibilities subscale, and .89 for the total scale, which were quite favorable and comparable to heine's (1998) published psychometric estimates. the last segment involving a don’s perception of influence was considered in relation to actual screening utilizing chisquare; significance was established at 0.05. the dons were asked to rate the hbm concepts of perceived susceptibility (to breast cancer), benefits (of screening), and barriers (to screening) on 12 hbm items, the reports are presented categorically: perceived susceptibility. in broad summary, most of the dons reported that they “agree” and “strongly agreed” that “elderly women’s’ changes of getting breast cancer are great.” dons documented some level of disagreement that breast cancer for elderly women is considered a hopeless disease. perceived benefits of screening. all of the responding dons in these rural ltcs considered the early detection of breast cancer as pivotal in prolonging life, and that early detection and treatment could prevent cancer suffering for elderly women in ltc. to some degree, all of the dons felt that elderly women do benefit from screening. perceived barriers to screening. the majority of dons documented mammography as appropriate for elderly women in ltc, though one completely disagreed. they reported that facility physician(s) do not encourage mammograms; although seventeen respondents do have providers who they felt would be open to increasing breast cancer screening prevalence in their facility. the large majority of respondents report that embarrassment for elderly women residents would not be an issue for screening, and six believe that mammograms are too expensive to be efficacious in ltc. most dons felt that the time for breast exams and mammography was not an issue, or barrier, to screening services. directors of nursing: personal screening behaviors four survey statements were designed to gain additional insight regarding breast cancer experience and screening strategies by the don respondents. one of the dons was a breast cancer survivor. twelve (30.8%) of the dons reported that they perform breast self-examination monthly; many (56%) perform bse only occasionally, every three to four months. three dons reported performing bse once a year or less. eighteen (30%) of the dons responding (n=39) do not receive regular mammograms, and 70.3% (n=26) of the dons receive a regular (annual or bi-annual) clinical breast examination (see table 3). online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 30 table 3 reports by female directors of nursing on personal breast cancer issues variable n valid % directors who practice breast self-examination 0–25% 3 7.7 26–50% 22 56.4 51–75% 12 30.8 over 75% 2 5.1 directors who receive regular mammograms yes 19 51.4 no 18 48.6 directors who receive regular clinical breast examinations yes 26 70.3 no 11 29.7 n = 37 discussion the purpose of this descriptive study was to examine the breast cancer screening services available for the elderly women in rural, skilled long-term care facilities. the respondents in this study were directors of nursing for rural ltc facilities in one rural state. the dons were seasoned nurses and experienced managers. the majority of the dons held baccalaureate degrees in nursing. they all report holding high value on breast screening practices, and perceive themselves as being strong advocates and having strong influence for the care delivery of their ltc residents. interestingly, a chi-square revealed no statistically significant association as to the don’s own perception of strong influence on directing care and the number of those elderly women who receive breast cancer screening. the majority of dons reported that less than half of the elderly women in their facilities receive a cbe regularly. as expected, 87.2% of the dons report that mammograms are seldom, if ever, given to the elderly in their ltc. there was significant association between the few ltc facilities whose dons reported regular mammography screening for their elderly women and the availability of on-site service (chi-square = 25.50, df – 4, p = .001). a t-test showed significance when relating dons who report having few clinical breast examinations in their ltc to the dons whose personal breast screening practices were also low. no statistically significant relationships were found between breast cancer screening practices and demographics, nor to the dons’ perception of the elderly woman’s susceptibility (to breast cancer), of the benefits (of screening), and of the barriers (to screening). breast exams were noted by a few of the dons to be a “part of the annual physician’s examination.” several commented on their appreciation of inspiring them to trigger this level of secondary prevention for breast cancer in their facilities. one don wrote this concluding comment, “in rural areas such as ours, physicians are pushed to the online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 31 limits for client care, both in and outside of the nursing home. breast exams and mammograms are simply not a priority.” another don wrote, “i had a cancerous condition for which i had a double mastectomy about 12 years ago; i feel these exams are important for every woman alive!” the american cancer society guidelines for breast cancer detection call for annual mammograms starting at the age of 40, and for clinical breast examinations every three years for women 20-39 and annually for women 40 and older. the recommendation is for self-breast examination monthly starting at the age of 20 (american cancer society, 2003). not only are the elderly women in this study far behind the american cancer society guidelines for breast cancer detection, the dons in these rural ltc facilities fall far behind as well. the results of this research strongly suggest that the elderly women are not being assessed for potential breast cancer findings; and that majority of the female dons are not practicing breast self-examination every month as recommended by consensus guidelines. in addition, few elderly ltc women receive a regular mammogram, and only one-half of the dons studied receive a routine mammogram themselves. all dons agreed to some extent that “early detection of breast cancer can prolong life,” and the majority that “early detection and treatment could prevent suffering for elderly women.” in addition, dons agreed that advancing age makes it more likely that women could get breast cancer. however, the breast cancer prevalence and screening beliefs of the dons did not correlate with the directors’ health promoting activities. the majority report that breast cancer detection is seldom utilized and few believed that nurses in their facilities would perform cbes. limitations the first limitation of this study was that while the response rate was impressive at 68.4%, the sample is not necessarily representative of all rural, skilled, ltc facilities. the question of validity and accuracy of self-reporting by the facility dons could be an issue in that respondents may have been inclined to present the perceived correct (but false) response. in addition, the constructs of the health belief model must be modifiable to replace “individuals” with “health care providers” (responsible for a ltc resident’s care). finally, the survey was largely author-developed and survey segments lacked tested reliability and validity. conclusion and recommendations as with the findings by kenny and keenan (1991), the elderly women in the rural ltc facilities of this state are not receiving breast cancer screening services according to established guidelines. the majority of elderly women in these rural facilities do not receive breast examinations and routine mammograms. moreover, the professional nurse leaders in these rural facilities do not adhere to consensus guidelines for breast cancer screening. it appears that some health care providers consciously set an upper age limit at which they stop ordering mammography or performing breast exams. in the past, zapka and berkowitz (1992) documented concerns related to screening elderly women, (a) online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 32 whether the screening and testing procedures are worth the time, and (b) whether preexisting medical conditions are more of a threat to a woman’s health and welfare than breast cancer, and thus negate the efficacy of breast cancer screening options. one physician was quoted, “she would have died of something else before she would have died of cancer” (zapka and berkowitz, 1992, p. 94). this negative approach to healthcare delivery for older woman is “a good example of the paternalism that has dominated the medical care system in our country and has probably has been a force in the care of older women, who were totally dependent on the provider, and whom she never doubted or questioned” (salk, sanford, swenson, & luce, 2001, p. 678. a review of the literature supports the importance of breast cancer detection for women over age 65. the american cancer society recommends that mammograms be received annually once age 50 and beyond. asymptomatic elderly women should have a cbe every year, and monthly breast examination should be done by, or for, women of all ages (american cancer society, 2003). routine breast self-examination is a simple technique, certainly to be understood by the healthcare professional as one important aspect of personal health surveillance. mammography is known to be an effective weapon in the early detection of breast cancer; nurses must commit to regular mammograms and advocate for women to receive mammography. nurses in gerontology can incorporate a regular breast exam for their elderly female residents; and, perhaps providers for those who might see screening as “unnecessary” would respond to advocacy efforts by nurses. clinical breast examination and mammography are preventive health activities. these activities cannot assure any diminished chance of contracting breast cancer, but these techniques can detect cancer at the earliest possible stage. this detection can not only prevent suffering and incredibly gruesome sequelae, but also afford a woman the better chance for survival. nurse leaders must believe and demonstrate the value of breast cancer screening. reports of the personal underutilization of screening services by rural directors of nursing in long-term care are of concern and indicate that a large segment of these dons evidently place little value on their own breast health. consequently, the director may devalue the benefits of screening the elderly woman for whom she directs and controls care. the gerontological nurse who operates from a framework that devalues the elderly in relation to health promotion may not deliver, or encourage, the important opportunity for health screening activities. when placing a high personal value on prevention and screening, health care clinicians can then best advocate for those whom they direct care for. nurses are in position to assume a proactive stance for efforts at early detection and diagnosis of breast cancer in older women. nurses in all realms must practice and advocate the recommended modalities for cancer detection. the elderly women in ltc appear to be a nearly forgotten segment of the research arena. there are little data to support screening activities for elders in ltc. long-range studies of the old, old women in ltc may observe how their health care patterns change, and may observe just how the health care providers respond to aging. online journal of rural nursing and health care, vol. 7, no. 2, fall 2007 33 references american cancer society (2003). cancer facts & figures 2003. atlanta, ga: author. american cancer society (2004). breast cancer facts & figures. atlanta, ga: author. american cancer society (2006). cancer facts and figures. atlanta, ga: author. amey, c., miller, m. & albrecht, s. 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[medline] http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16764745%5buid%5d&webenv=0vqoh4fhwzhk9-5o-ubmaprw_pcjrv8c2epcdp11wa9wu_usxib6rv0u3sntd5wiawcybd9hjyrx-%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9317187%5buid%5d&webenv=0mjninnao1mfqmadhquknbbczeo6yssdchhyp70hw6_nue3mjfnajyycksd7yerikfkxshoepc1lw%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16715593%5buid%5d&webenv=0yvugdrqbzbdysubcv0jkd3fplgumiqjphea2x5o0k5zvsmbpmoj7so1binaneuua34g436xichtd%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1452446%5buid%5d&webenv=0amip81nz1iry1nqfibr2eby1igocqm8qbpbbczqlvii12kymfhtjvqa9dffvjwnodfcgumorcdoo%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12115366%5buid%5d&webenv=0bko5yd5duscfrsyhonoxkqfu8w6slvdxkvril1zrggute3djtjkjpmfjxyt5ac9h7c-mqpalsj3u%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15496539%5buid%5d&webenv=0wbogdgunae7xq8ofiuvr-ymd3xulkatvg1we7ifkwhgnitzqwitkxjtzvfbrezyplrhxt9n8sywq%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=3870890%5buid%5d&webenv=0vwwhfcbjcea7ih4kfe_2xurnoltrxgyljx3uydgfgwh1c2xbn99nrnuwstr9dtbu9tgyybzpcfbk%4026424f0f76980320_0050sid&webenvrq=1 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1430891%5buid%5d&webenv=0f4wnjczdml77hvmdg_ov1fcz6b_ro2xys-v3s1-ve3pev5sme2tdpthcoqlbitahxctx96d4srf-%4026424f0f76980320_0050sid&webenvrq=1 48 seniors’ learning preferences, healthy self-care practices and computerized education implications deana l. molinari, phd, rn, cns1 paul blad, ms, aprn2 margaret martinez phd3 1 assistant professor, intercollegiate college of nursing, washington state university, dmolinari@wsu.edu 2 assistant teaching professor, college of nursing, brigham young university, paul_blad@byu.edu 3 president and ceo, the training place, inc., oro valley, arizona, ttpinform@trainingplace.com keywords: learning orientation, health promotion, computers, rural, self-care abstract health promotion uses an increasing amount of internet-based education. understanding seniors' learning orientation and self-care practices can inform instructional designers how to use the internet with this population. a correlational, descriptive study of community-based seniors’ (n=87) learning orientation and healthy self-care practices was conducted in a western state. implications for internet-based health promotion include associations between rural and urban location, age, health condition, self-care practices, informational preferences, and learning orientation factors. difference between urban and rural populations and illness severity were identified. respondents used the internet as much as they did television and friends for health promotion materials. transforming learners used the internet while conformers did not and yet conformer learners performed the most self-care practices. implications for designing differentiated health promotion materials based upon learning orientations are discussed. introduction anticipating a budget cut, a regional department of aging in a western u.s. state considered developing a centralized health promotion program. using the precedeproceed model (green & kreuter, 1999), a health promotion assessment was initiated to explore how community-based elders learn about and then practice self-care strategies. program leaders questioned how seniors examined and experienced health education according to age, residence, and health status. the need policy makers consider health promotion an important strategy for reducing the expected costs of chronic disease in an elderly baby boomer generation (department of health and human services, 2003). educators and health care providers search for methods of teaching people disease prevention while attempting to control costs. one strategy is to adopt “cheaper” computerized health education programs, but understanding who benefits from online curriculum is not well understood (gore, 2002). a major reason for developing computerized education programs is to reach more people using fewer dollars (gore, 2002). providers feel pressured by economics to shorten the time spent with clients, which limits educational opportunities and leaves patients wanting more information (frank, 2003). at the same time, the need for health online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.icne.wsu.edu/ mailto:dmolinari@wsu.edu http://nursing.byu.edu/ mailto:paul_blad@byu.edu http://www.trainingplace.com/ mailto:ttpinform@trainingplace.com 49 care is expected to grow. the anticipated cost of chronic disease management for the baby boomer generation constitutes the highest single health care cost in the united states. the cost is expected to exceed 906 billion dollars by 2050. prevention of chronic disease through self-care is a major public health strategy (national center for chronic disease prevention and health promotion, 2003). informal self-care accounts for 75% of all health care in the united states (levin, 1976). self-care is based upon health care information. the public longs for inexpensive, reliable information that is not always available. the lack of insurance prevents some people from accessing providers, while others postpone provider visits until a crisis occurs (staff, 2004). the internet can meet several health promotion information needs if more is understood about its role in health care (voelker, 2005). the prevention of chronic illness entails aggressive self-care, providing information that people will incorporate into their lives, demands attention to complex, interrelated issues. according to the “precede” portion of the precede-proceed model (green & kreuter, 1999, p 11), program planning depends on understanding the predisposing, reinforcing, and enabling conditions impacting lifestyle, health decisions, and quality of life. chronic disease results from intertwined and synergistic play of many risk factors (public health works, 2003). for instance, the single concept of health literacy includes knowledge, motivation, attitudes, behavioral intentions, personal skills, and self-efficacy (nutbeam, 1999; bruhn, 1997). understanding the computer’s role in health literacy requires cross discipline study of health, education, and informatics. promoters rank internet technology with antibiotics, genetics, and computers as among the most important changes in health care delivery history. researchers find the internet an effective communication and educational tool (hern, weitkamp, hillard, trigg, guard, 1998; colombet & chatellier, 2001). access to the tool increases each year. forty percent of elders in 1996 reported using computers (marks, 1996), and researchers expected the use of electronic health strategies “to expand exponentially” (coile, 2000). twenty-two percent of people over age 65 were found to use the internet in 2001 (fox, 2004). twenty-one percent of seniors were found to use online health information in 2004 by voelker. of these, 53% of elders between 50 and 64 used the internet for health information, indicating a difference between generations (voelker, 2005). organizations and agencies targeting elders with online education include professional health care associations, the federal government, state governments, universities, insurance companies, drug companies, health care providers, and vendors (science daily, 2003). the timely question of the efficacy of computerized health education remains. who uses the computer? what are their learning characteristics and needs (dutta-bergman, 2003)? understanding learner motivation, attitudes, and intentions are central to both the precede-proceed health promotion model and online instructional design. individual cognitive learning needs are different (kesler & alverson, 2003), and recent research indicates that the role emotions play in learning may be more important than cognitive aspects because information first travels through emotional brain centers before entering cognitive centers (sapolsky, 1998). chiesa (2003) states, “if you are motivated enough, you will make it” when discussing the important role of emotions in goal achievement. motivation increases the individual’s ability to respond and act upon stimuli (sapolsky, online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 50 1998). recent research shows that emotions form before reasoning begins and then remain after memory fades, further impacting educational outcomes. assessing learner characteristics and preferences is important to health promotion instructional development. learning preferences “learning orientation” describes the emotional characteristics a person knowingly utilizes to manage learning situations. preferences include emotions, values, and intentions. margaret martinez developed the learning orientation model and questionnaire (martinez & bunderson, 1999) in a whole-person effort to understand learning differences and to improve educational outcomes. the framework provides a foundation for personalizing and customizing instructional events to meet learners’ needs and is used to guide concept organization, outcomes prediction, process monitoring, and progress assessment. learning orientation can even advise teachers when and how to promote social relationships. the learning orientation model (martinez & bunderson, 1999) describes dominant psychological factors influencing knowledge acquisition. the perspective considers the student's 1) emotional investment, 2) committed strategic planning and effort, and 3) independence or learning autonomy. the approach incorporates cognitive, emotional, and intentional characteristics to describe how individuals feel about learning and how they may want or intend to learn differently. the learning orientation questionnaire (loq) describes people as possessing one of four orientations. the cronbach alpha was listed at .89 by the author but performed at a .78 for this study. the “transformer” is highly motivated, passionate, and persistent. learning is of great value to transformer learners and acquiring new expertise is enjoyable. these individuals use their personal strengths to achieve goals despite failures. transformer learners may become frustrated in environments that constrain their aggressive learning styles and will not take information on “trust” (martinez, 2001). “performers” are persistent in learning situations of interest to them; otherwise, they seek extrinsic rewards. performers are systematic, sophisticated learners that think hierarchically. these people need an important reason or seek perceived benefits to reach for short-term goals. performers want to explore the details and follow the best steps towards task completion. these individuals try to avoid making mistakes or setting challenging goals. they are said to desire reaching the instructor-defined goals quickly and efficiently. performers enjoy coaching, social interaction, and collaboration (martinez, 2001). the “conformer” learner is described as preferring routine, explicit, supportive environments in which all expectations are made clear. conformers tend to be passive learners who will accept, store, and reproduce information to please others. they like others to make the decisions, avoid discovery, and complex thinking. conformers like to begin at the beginning and want to proceed in an orderly fashion. this population wants to be shown how to accomplish each step. these learners will work in teams if with strong leaders (martinez, 2001). the “resistant” learner lacks the belief that academic knowledge is useful but may enjoy studying outside academic settings. these people like to gain knowledge using online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 51 their hands and experience. martinez describes the orientations as generalized characteristics that alter with some situations. it is not known if health status alters learning orientation. people succeeding in online courses are generally more motivated and exert more self-control than their less successful peers. the loq demonstrated the ability to predict who will succeed in web-based courses (jones, 2001; molinari, 2005; molinari, dupler & lungstrom, 2005). stress was found to be related to learning orientation and achievement online, which prompts more self care questions (molinari, anderberg, dupler, lungstrom, 2005). these findings make the model useful in answering questions about seniors’ use of the internet for health promotion programs. if centralized patient education programs require highly motivated learners, then learner motivation needs to be assessed. methodology the study was conducted after approval from an institutional review board and in collaboration with senior centers in three communities. the study considered what healthy self-care practices seniors used and what demographic conditions related to their learning preferences. seniors completed two surveys: the learning orientation questionnaire (loq) and a personal information survey. the loq asks twenty-five questions with a likert-like scale anchored in “very characteristic and uncharacteristic of me”. the questions focus on the conative/emotional aspects of learning. this study represents the first time the measure was used in a health care setting (martinez, personal interview, 2000). the primary investigators designed the demographic survey. the questions explored environmental conditions, self-care practices, education materials, and feelings. the survey included barriers to education and healthy practices as well as perceptions of health education and locations. as many questions as possible matched the loq for consistency. the tool was piloted with five senior volunteers. changes including wording and font size were based upon the feedback. descriptive statistics, correlations and anovas were performed to see if relationships existed among demographic variables and learning orientations. results and discussion participants came from a variety of ages and locations. ninety-two people completed some portion of the survey tools. ninety-five percent (n=87) completed all questions. surveys were gathered from rural (n=50) and urban (n=37) seniors lunching at senior centers. fifty-seven percent lived in rural communities. males constituted 37.9% of the sample and females 62.1%. ages ranged from 49 to 105 with 40.2% under age 60. twenty percent of the sample was between the ages of 61 and 70, 21% between the ages of 71 and 80, and another 20% were over the age of 80 . health promotion access the most frequent locations for learning about self-care were the doctor’s office (61%), home (46%), and the hospital (40%). participants used a variety of information online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 52 sources (figure 1.) health care providers and books were the most popular choices. the internet was chosen about the same number of times as television and friends. fortyseven percent of participants denied having an illness, 15% reported being ill for 1 to 5 years, while 21% reported having an illness for over 5 years. in f o r m a t io n s o u r c e s 0 1 0 2 0 3 0 4 0 5 0 6 0 p r o v id e r s b o o k s b r o c h u r e s t v in t e r n e t f r i e n d s v i d e o s c d figure 1. information sources self-care characteristics the top three reasons preventing completion of healthy self-care practices included: finances (29%), lack of motivation (21%), and lack of time (20%), with mobility, transportation, vision, low priority, pain, lack of information, memory, and attention problems also mentioned. sixty-six percent of respondents indicated they believed in and were satisfied with the information received from their health care providers. personal feelings about caring for oneself included: 47% felt guilty, 61% felt confident, while a third felt angry and helpless. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 53 learning orientation results from the learning orientation questionnaire (loq) indicate the majority of seniors were performer and transforming learners. only 24.1% indicated conforming or resistant preferences. this is similar to younger samples that typically have 20% conforming and resistant learners according to an interview with martinez (2000). age was not related to learning orientation. differences in location were identified. location resistant conforming performing transforming rural 9% 18% 52% 20% urban 0% 25% 56% 6% a t-test showed significant relationship between the number of healthy self-care practices and the loq score (t = 0.85, p < .05) indicating the more control one likes to exert over learning the fewer the number of self care practices reported. transformer learners like to exert control over their learning goals, methods, and process. the more control a person wanted to exert over their learning in this sample the less likely they were to do what they were told were healthy practices. qualitative responses provided further information on this finding when transformer learners reported doubting the advice published by researchers and health care providers, “they change their minds about what you should do” and “i don’t really think they know what is true.” people with a conforming orientation reported the highest number of self-care practices. perhaps conformers prefer to perform activities meant to keep them safe. a ttest of the number of self-care practices by age showed a significant relationship (p < .01). anova s of the prediction of self-care by age (f = 7.748, p < .01) showed people over 70 years less likely to practice self-care. bivariate pearson correlations were identified for a number of variables. associations between gender and time ill (p < .05) and between rural residence and the number of healthy self-care practices (p < .04) were found. learning preferences related to gender and time ill with the longer someone was ill being associated with less autonomy and motivation for learning. the more severe the illness the less autonomy and learning motivation reported. as the severity of illness increased the number of self-care practices decreased (p < .03). the time ill was associated with the severity of the illness (p < .00), which is indicative of chronic disease. conformer and resistant learners reported the most self-care practices and also indicated experiencing the most wellness. three quarters of those using the internet were rural residents indicating an “availability” factor. twenty of the 21 reporting using the internet for health care information reported high performer and transformer strategies, which agrees with learning orientation literature (jones, 2001). seniors reported consulting the internet as often as they did their friends about health promotion indicating trust in the information. implications seniors’ internet use has several implications. why do rurally based people use the internet more than their urban peers? do time and distance contribute to this difference? the literature does not differentiate location in studies with findings of little online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 54 elder internet use (meischke, eisenberg, rowe, & cagle, 2005). brunk (2003) found that younger elders used the internet more than older elders. the increasing amount of internet use indicates a need to teach elders how to best utilize the internet. several types of information need to be taught such as how to construct search strategies and how to evaluate information found (ullrich & vaccaro, 2002). providers could share aids to help the public evaluate health care like the health on the net logo or the peer-reviewed journal articles found on pubmed (http://www.pubmed.gov). although increasing numbers of physicians are using the internet in their own practice (federation of state medical boards, 2002), how many providers recommend internet education sites? patients may feel informed, which will alter their communications with providers. provider education programs need to instruct future caregivers how to relate to internet users. further, seniors need to know how to approach their health providers with information. the internet may alter physician and patient roles in health promotion. no longer are providers the only authoritative resource, but they can serve as counselors in understanding the expanding patient self-care role. evaluation skills could empower people to make better search and selection decisions. not everyone responds the same to health care information from authorities. although the majority of the sample did not use the internet, the majority of internet users indicated a performing or transforming learning preference. elders reporting a transformer preference indicated skepticism about the quality of the information they receive from physicians. they did not perform as many healthy self-care practices as conformers. the different approaches to self-care and internet-based information require attention. instructional designers must meet conformers’ and transformers’ different needs. the issue of information evaluation will also impact conforming and resistant learners. conformer learners desire to please authorities and are stressed by their health and security events (martinez, 1999). conformers want clear, step-by-step instructions they can accomplish. they are not interested in underlying causes, extra resources, alternative choices, or theoretical materials. conformers are less likely to think about costs and benefits, information reliability, or to express skepticism of what an “authority” says. the conformer may believe and follow incorrect information delivered by an authoritative figure. each learner orientation poses a different set of self-care challenges. martinez (2003) and the findings of this study indicate conformer and resistant learners seem most likely to do what they are told is good for them. transformer learners may question the wisdom of a health care practice and performers may not work during adversity if the “costs” were too high. motivating transformers to change behaviors may require instructional approaches that encourage the weighing of longand short-term behavior consequences, experimenting with alternative self care practices, or creating their own plan of action based upon sound principles. conformers do not tend to seek out information on their own and do not tolerate alternative choices and will benefit from a less complicated teaching approach. internet sites with many links would be avoided for this population. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.pubmed.gov/ 55 findings suggest educators may want to provide different information presentations for different learning orientations. health promotion programs can use learning orientation tools to assess student-learning preferences before the teaching moment and then guide clients to the program that best meets their needs. this is called differentiated programs. a health promotion site constructed with learner preference theory discriminates in the amount of information provided, provides concept sequencing, efforts required, and supports provided for each orientation type. transformer and performer learners are the most likely to use the internet. transforming learners want several resources from which they can choose. links to a variety of research materials offering different viewpoints could be provided. transformers prefer non-linear learning environments where they can innovate. the ill transformer may tire before finishing an educational task and require direction to meet outcome expectations. performer learners may be interested in the topic if it pertains to their health but not tolerate theoretical discourse. performers are interested in the most efficient method of reaching a learning goal. these learners want hands on learning with tools and demonstrations. they like personal attention with coaching and support groups. links to extraneous materials would not be appreciated. conforming learners enjoy linear, step-by-step, explanatory materials. time spent on the computer should be short. cds in a provider’s office with directed materials would be their computer preference. conformers prefer instructors to control the teaching. their tolerance for technology glitches is low. these learners might enjoy linear programs using touch screens under the direction of a health educator. they would appreciate printouts to take home. there is not much information about the resistant learners’ preferences except in a negative sense. they are not fond of books or academic settings. not much is understood about the types of learning “resistance.” martinez states resistant learners prefer trial and error to books and authorities (2001). the resistant learner wishes for hands-on learning and immediate results for labor inputs. findings in this study indicate conformer and resistant learners did not use the internet and yet performed the most healthy self-care practices. these learners prefer to learn about health care from hospital and clinic personnel, according to these findings. an example of how to apply this knowledge is that conformer and resistant learners would like to try out exercises and taste foods in the clinic setting. a centralized computerized educational system might utilize pictures of doctors and nurses with audio to help this type of learner through a linear instructional program. a text based program with clicking on links would not be as successful with these learners. the majority of respondents in this study expressed satisfaction with the information received from health care professionals but felt negative about their self-care abilities. self-care doubts may pertain to different stages of health. findings suggest chronic illness impacts how people prefer to learn. providing individualized instructional materials could meet the changing needs of chronic illness. opportunities to control and question authoritative resources may work best for people feeling confident, energetic, and in control of their learning, while those feeling tired and sick may desire clear, simple directions. findings indicate a need to review further the link between severe and long term illness and the conforming learning orientation. the most ill patients did not practice self-care. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 56 limitations of this study include the lack of ethnic and educational diversity. there is a lack of information about the relationship between learning orientation and socioeconomic influences. larger samples for both rural and urban populations are needed before generalizations can be applied. seniors tired during the long survey process. completers expressed difficulty relating some of the learning orientation questions to their stage of life. another version of the learning orientation questionnaire is needed for non-academic populations. a short chronic ailment assessment would also be useful. conclusions technology advances have moved faster than the understanding of individual learning needs. technology is now available to tie educational programs and patient communications to the electronic health record. a continued multidisciplinary search for best practices is needed so that when all systems are tied together, optimal outcomes will occur. the development of individualized educational programs for different learning preferences needs further study. seniors reported similar learning preferences to younger people, but differences in health were associated with different learning orientations. the level of wellness may alter individuals’ learning orientation by altering independence, effort, and motivation commitment levels. those using the internet were highly motivated and self-controlling learners, indicating less-motivated people may not use internet-based health promotion materials. instructional designers may consider designing health promotion materials to meet the needs of various levels of goal setting, information management, change process management, and need for pleasurable outcomes. more information is needed about how learning orientation relates to age level, residency, and 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(2000). healthy people 2010. with understanding and improving health and objectives for improving health. 2 vols. washington, dc: u.s. government printing office. voelker, r. (2005). seniors seeking health information need help crossing the digital divide. journal of the american medical association, 293, 1310-1312. [medline] online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=15647729 http://www.cdc.gov/nccdphp/overview.htm http://www.health-in-action.org/ahln/cdp_comosh%20framework_sept03%20-%20nov12.pdf http://www.health-in-action.org/ahln/cdp_comosh%20framework_sept03%20-%20nov12.pdf http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11923675 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=15769951 63 the perceptions of diabetes lay educators working with migrant farmworkers loretta heuer, phd, rn, faan1 cheryl lausch, ms, ma, rn2 jane bergland, phd, rn3 1 associate professor, college of nursing, university of north dakota, loretta.heuer@att.net 2 research consultant, migrant health service, inc, fargo, nd, cblausch@cableone.net 3 assistant professor, nursing department, minnesota state university moorhead, berglanda@mnstate.edu keywords: hispanic, migrant, seasonal, farmworkers, diabetes, access to health care abstract diabetic medical care for hispanic migrant farmworkers has been hard to obtain due to the lack of continuity in health care and limited access to services. these factors have led to either gaps or duplications of services for these clients. migrant health service, inc. (mhsi) diabetes program staff addressed these issues through the development of a diabetes lay educator program. this qualitative study explored the lived experience of diabetes lay educators (dles) as they worked with migrant farmworkers traveling between multiple states. the sample consisted of seven female participants who migrated from southern texas. four main themes emerged: understanding the lifestyle; self-managing diabetes when traveling; roles of the diabetes lay educators; and access to health care services. the utilization of dles is an effective way to provide health care and education to this migrant population. introduction migrant workers continue to suffer greater mortality and morbidity rates than the vast majority of the american population, due in part to the combination of poverty, limited access to health care, and hazardous working conditions (migrant clincians network, 2006). the health status of this population is among the worst when compared to any other subpopulation because they lack access to preventive health care services; there are numerous occupational hazards; and the majority does not receive health insurance and have little money for out-of-pocket services. when compared to the general population, migrant farmworkers have higher rates of infectious diseases, diabetes, hypertension, tuberculosis, anemia, parasitic infection, and mental health disease (farmworker health service, inc., 2005). to address these health issues, some communities are utilizing the concept of lay health advisors (lhas) within the migrant population. these individuals are part of the community and provide informal care, advice, and emotional support to their neighbor, friend, or coworker. if the lhas travel with the farmworker population, they are able to encourage farmworkers to seek preventive care and assist them in accessing health care services in different locations. they can also bridge the cultural diversity gap in language and health beliefs that occur between farmworkers and health care providers (watkins et. al. 1994). in a study conducted by watkins et. al. (1994), lhas were utilized with online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.nursing.und.edu/index.cfm mailto:loretta.heuer@att.net http://www.ndsu.nodak.edu/hcwb/partners/migranthealth_files/migranthealth.html mailto:cblausch@cableone.net http://www.mnstate.edu/nursing/ mailto:berglanda@mnstate.edu 64 migrant farmworker women and children who received services at two health care delivery sites. when the researchers assessed the impact lhas had on the health status of patients over a year, mothers who interacted with these lhas were more likely to bring their sick child in for care and had increased knowledge of health practices. additional studies within non-migrant hispanic populations have shown that peer educators, promotoras, lay health-outreach workers, and bicultural community health workers have been used (balcázar, alvarado, hollen, gonzalez-cruz, & pedregón, 2005; ingram, gallegos, & elenes, 2005; phillis-tsimikas et al. 2004; teufel-shone, drummond, & rawiel, 2005). the peer educators are individuals with diabetes who explenify the traits of a “natural leader.” these peer educators are trained in the areas of diabetes and associated complications. they must meet established competencies before teaching classes on their own (phillis-tsimikas et al. 2004). in an effort to build broad community support for diabetes care, the border health strategic initiative used promotoras to work individually with the diabetic population (ingram, gallegos, & elenes, 2005; teufel-shone, drummond, & rawiel, 2005). corkery et al. (1997) utilized bicultural community health workers to determine their effect on the completion of diabetes education in inner-city hispanic patients. their findings revealed that an intervention with a bicultural community health worker improved completion rates of a diabetes education program for inner-city hispanic patients irrespective of literacy or educational levels attained. due to their mobile lifestyle, diabetic medical care for the migrant population has been fragmented because they lack continuity of care and have limited access to health services. this has led to either gaps or duplications of services for these clients. migrant health service, inc. (mhsi) diabetes program staff addressed these issues through the development of a diabetes lay educator program in which hispanic leaders from the migrant farmworker population were trained as diabetes lay educators (dles) in the areas of health promotion, prevention, and basic medical knowledge. these dles provide support group meetings and diabetes education in minnesota and north dakota from april to september. they then return to their homes in southern texas where they continue to provide support group meetings and home visits to their migrant clients from october through march (heuer, hess, & klug, 2004 p. 266). the purpose of this phenomenological study was to explore the lived experiences of diabetes lay educators as they worked with migrant farm workers traveling between multiple states. in this article, the word hispanic was used to designate individuals who have mexican american or mexican heritage. the term “migrant farm workers” encompasses both migrant and seasonal farm workers (lausch, heuer, guasasco, & bengiamin, 2003). methods through the use of the phenomenological approach, the researchers studied the lived experience of hispanic dles as they worked with migrant farm workers between minnesota, north dakota, and texas. phenomenological reflective inquiry was utilized to interpret the meaning or meaningfulness associated with the phenomenon of lived experience (van manen, 2002). in this study, the research question was, “what were the online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 65 perceptions and experiences of diabetes lay educators as they worked with hispanic migrant farm workers in minnesota, north dakota and texas?” the sample consisted of seven female participants who migrated from southern texas. participants ranged in age from 21-47. of these participants, six were married and one was single. the average level of education completed was the eleventh grade. three participants were diagnosed with diabetes and all had immediate family members diagnosed with this chronic disease. the interview guide for this research study was based on a tool developed by individuals from migrant clinicians network. this tool had previously been used with migrant farm workers diagnosed with diabetes. the authors’ adapted the tool to specifically address content related to the perceptions of dles, their training, and interaction with clients. content included demographics, personal history of diabetes, dle training, clients’ self-management of diabetes, and experiences in the diabetes lay educator program. the second author conducted the tape-recorded interviews, with interviews lasting 60 90 minutes. participants were interviewed two times, approximately six months apart depending on their work or migratory schedule. they were interviewed at the beginning of the dle program and again upon their return from texas. twelve of the interviews were conducted at their place of employment. the interviews for one participant were conducted in her home. for each interview, the dles were compensated for their time with a $20.00 gift certificate for a local merchant. all the interviews were transcribed verbatim by a skilled transcriptionist. these transcripts were reviewed for correctness and then checked for accuracy against the audiotapes. working as a team, the researchers developed a codebook to analyze the data. validity and reliability were confirmed when the researchers identified similar recurrent themes independent of one another. these dominant themes are described in the results section. results based on the experiences of the dles, the researchers identified four main themes that were common to all or most of the participants. these themes included: understanding the lifestyle; self-managing diabetes when traveling; roles of the dles, and access to health care services. theme 1: understanding the lifestyle migrant farmworkers who travel to the upper midwest include large extended families. the dles interviewed were part of this network of migrant farmworkers. they provided the researchers with insights into the family life, dietary preferences, and seasonal employment of migrant farmworkers diagnosed with diabetes. i understand the problems they have because i am a migrant, i know because i have been [through this] experience also, so i try to understand them. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 66 the dles described that in the hispanic culture “family” is priority. with the diagnosis of diabetes, it was difficult for family members to take care of themselves because they tended to put the needs of other family members before their own. its hard because some of them, they do have a large family and say ‘well i have to attend to my kids first, before i attend to my own health’. along with family, food is a central aspect of the hispanic culture. according to the dles, the hispanic migrant diet is high in carbohydrates and fat. it’s the way that we eat. it is the way the hispanic people are used to eating. that is what i have been telling them...to eat less than whatever they are used to. the amount and the food that we eat...is really greasy. another aspect of this culture is that farm workers travel thousands of miles each year for agricultural employment. yet, agricultural work is unstable and often unpredictable as it varies by region, season, and crops; it is also vulnerable to any unseasonable conditions and natural disasters (farmworker health services, inc., 2005). the dles described seasonal employment as it related to their financial status: and then they come here and sometimes they work and sometimes they don’t and it is a long trip for them. and then sometimes there is not work for them and they need to go back without money which is hard for the people. seasonal employment further complicated the ability to adapt to the nutritional changes required for diabetes management. the dles stated that many of the families did not have the financial means to purchase different foods. you don’t have the money to buy whatever you can eat...so if everyone eats different from those ones, then you can’t buy the different food because of money. you have to eat whatever everyone is eating. the dles perceptions of the difficulties that migrant farm workers encountered when trying to self-manage their diabetes was supported in a study by hunt, pugh, & valenzuela in 1998. these researchers interviewed 51 patients from southern texas regarding their experiences and personal histories with type 2 diabetes. they reported that some patients stated that if they followed the recommended diet including fresh fruits and vegetables, they would need to prepare one meal for themselves and another for their family members. many of these clients conveyed that they could not afford to prepare the recommended meals for themselves. others stated that the ability to stay on the recommended diet varied over time, depending on their financial status on any given day (hunt, pugh, & valenzuela, 1998). according to the dles, managing diabetes as a migrant farm worker was complicated by multiple factors such as food preparation for large families, seasonal employment, and financial limitations. one dle eloquently summarized these factors: online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 67 well i can tell you that it is difficult because if you want to go to work you can’t prepare food for you and prepare food for your family because you want to go to work and just work and then eat whatever you can. theme 2: self-managing diabetes when traveling each year, 20,000 to 30,000 migrant farm workers and their families travel to minnesota to work in agriculture and food processing plants. the majority of these families come from southern texas. the travel time from their home to the upper midwest is a 30-40 hour drive or an estimated 1,800 miles one-way (contreras, duran, & gilje, 2001). according to the dles, it was difficult for migrant farm workers with diabetes to care for themselves while traveling between states. many of the migrant families preferred not to make extended stops when traveling due to the cost of overnight lodging, meals at restaurants, and work related time constraints (contreras, duran, & gilje, 2001). as a result, farm workers with diabetes had difficulty eating healthy meals. they don’t bother to stop and get the proper food to eat, they will just stop at a grocery store and pick up a coke or whatever. in other words, they are just trying to eat what they can because they are trying to get here as soon as they can. they hate being on the road that long. just get whatever we can eat and go. because you know, when they are on the road, they go and eat fast foods. they have a lot of grease and it is not healthy foods they eat on the road. the dles also reported that migrant farm workers with diabetes have a difficult time maintaining their medication regimen. if it is oral, they will take their medications but not the ones who have to take the insulin. during their time on the road, many of the migrant farm workers have limited time for daily exercise. it’s hard to get exercise. some of my patients, they stop in rest areas...walk a little bit. theme 3: roles of the diabetes lay educator initially, the dles were hired to hold support groups for migrant farm workers diagnosed with diabetes when they resided in minnesota and north dakota during the summer months and in texas when they returned to their home in the winter months. as part of their job, the dles recruited clients for these meetings, obtained blood pressures and blood sugars, and interpreted when needed for the health care providers’ educational component of meeting. after listening to the professional speaker at the meeting, it was online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 68 the dles’ role to provide clarification and/or demonstration of the educational session to clients along with the provision of english or spanish educational materials. the dles described their recruitment efforts for diabetes support group meetings: i took some flyers and gave it to the priest. and he announced it at mass...i was putting flyers everywhere they would let me. some we called them by phone because they lived far [away]. or we just contacted them by the farmer. give them a call or send them a letter. the dles held support group meetings every three weeks when not migrating between the northern states and texas. according to the dles, these well-attended meetings were beneficial because it increased their knowledge about their clients’ perceptions of their diabetes. in addition, the clients had a place to learn about this disease and then be able to talk with others on how to self-manage their diabetes. [they are] talking to each other and asking ‘how do you take care of your diabetes…’ i listen to them, and then i learn about what they are sharing. these 17 people, that’s who i talk with. everybody tries to come to the meetings because i heard they feel better and they learn stuff that they have never heard about from diabetes...they are so excited because their blood sugar goes down...they feel so [much] pride and [are] so excited. initially, the dles were provided with a stipend to purchase food for these support group meetings. this was in an effort to make the support group meetings more of a welcoming and social experience for the educators and participants. as the dles evolved in their role, they suggested providing incentives for clients attending these meetings: maybe i could encourage people to go to the sessions if you promise them something that you are going to give them. as a group, the dles decided to offer incentives that reinforced the educational component of the meeting. i usually try to provide my clients at least a bottle of water at my support group meeting...some kind of a fruit, i give them for answering questions [about information they have learned on diabetes]. they like little presents as well. it is a little box that comes [for] medication [pill caddy]. i also pass them out, like that little ball for a massage. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 69 when the dles returned to their home in texas, they identified the need to expand their role to include home visits. during these often lengthy and frequent visits, clients were provided with medical, emotional, and social support from the dle. i don’t go to a home visit that lasts 30 minutes or an 1 hour. sometimes i am there three hours. i visit my patients...i go to their house every two weeks or almost every three weeks. additionally, the dles provided assistance for obtaining health care services or medications. i go to his home and i find out that he doesn’t have meds or he does have meds, and he is having problems. i don’t stop there, i always try to get them into their clinic. i would go to their houses and they would gladly [invite] me in and they would gladly let me check their sugars. if needed, many of the dles were willing to expand their assistance to clients. one dle provided the following example: if i can help you with anything let me know. i may not be able to help you with money but if i can go down there and interpret for them, fine, i will do it. as part of their role in home visits, they provided and reinforced diabetes education for clients as depicted in the following quote: [i] show them how to clean inside their toes and whatever, show them how to clean and look with a mirror under their feet. the dles perceived that individuals in the community respected them. they reported with pride: i like to work with people and i like they way they treat me you know. they respect me very well. i said, ‘i am a dle, an educator’. theme 4: access to health care services when farm workers were employed in minnesota and north dakota, mhsi provided access to health care and education through the operation of 1) four seasonal, satellite, nurse-managed health centers, 2) two seasonal mobile units (open two-five online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 70 months a year), and 3) three primary centers that operated on a year-round basis (heuer, hess, & klug, 2004). nursemanaged health centers provided health care for acute and chronic conditions. farm workers presented to these centers on a walk-in basis. they were either treated for their condition at one of these nurse-managed centers or they were provided a voucher to cover the cost of a referral visit with an affiliated health care provider. after this office visit, if medications were needed, the client received a pharmacy voucher that covered a portion of their medication cost. over the years, a relationship has been built between mhsi and the farm worker population. according to the dles, migrant farm workers relied on the services provided by these nurse-managed centers in the upper midwest to address some of their health care needs. here in minnesota they are so used to having migrant health services. anything they need, they go to migrant health services. now that they are up here, they can get the medicine until migrant health [seasonal site] closes. as long as migrant health is here, they know they can get medicine...then down in texas that is where the problem comes [getting services and medicine]. in collaboration with the mhsi seasonal staff, the migrant health diabetes program staff provided referrals to community providers, prevention screenings, educational sessions, and diabetes cluster clinics (guasasco, heuer, & lausch, 2002). cluster clinics provided care, education, and counseling to farmworkers from a multidisciplinary diabetes team that consisted of an ophthalmologist, nutritionist, dental hygienist, diabetes educator, phlebotomists, nurses, including some specializing in podiatry, mid-level practitioners and/or physicians, bilingual outreach staff, and diabetes lay educators (heuer, hess, & klug, 2004). the dles believed migrant farmworkers received comprehensive diabetic care in the upper midwest. they have more diabetic care [in minnesota] than in texas. although these specialized health care services were available in minnesota and north dakota, some of the dles expressed concern regarding the utilization of these services by farmworkers. they described the number of barriers affecting their clients’ ability to attend these clinics that included distance to be traveled, lack of transportation, and extended work hours. the [diabetes cluster clinics] screening clinics are too far away when they go to fargo, [north dakota]. …we don’t get out of work until 7:00 p.m. the [diabetes cluster clinics] screening is too far…and we do not have anyone to drive us. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 71 the dles conveyed how they encouraged their clients to attend these clinics because of the comprehensive care they would receive as depicted in the following quote: [i tell them] you don’t understand, you are getting checked for everything where care down in texas, you don’t have any of that. the dles discussed that when the migrant farm workers returned to their homebase in texas; their clients would seek services from either local community health centers or travel across the border to mexico. they are asking me if they can have the same migrant health down there...the only thing i can refer you to is the low income clinic they have down in texas. like when we are in texas, they don’t have any migrant program to help them with medicines or to go see doctors. what they do is cross the border. they go into mexico and try to find a doctor...they are cheaper in mexico. in texas, people go to mexico to buy medication. discussion this project demonstrated that the implementation of dles with a hispanic migrant farmworker is effective because they have a shared perspective of the cultural, social, and economic worldview. according to zuvekas, nolan, tumaylle, & griffin (1999) community health workers (or dles) usually racially and ethnically reflect the communities they serve. these dles understood the inherent difficulties farmworkers encountered while managing their diabetes and traveling between states. due to long hours on the road and their financial constraints, it was difficult for the farmworkers to follow their nutritional plans, medication regimes, and exercise programs. according to eng and young (1992), lhas can pursue a variety of goals and roles by using a mixture of activities and tactics. as part of their roles at the community level, dles disseminated health education and information through one-on-one client interactions, support group meetings, and home visits. eng and young (1992) separated the role of an outreach worker and a lha. the outreach workers’ role was described as reaching out to a specific population and motivating them to comply with the existing health care regimens, whereas the role of the lay health advisor was described as the health educator for their community and as the one to assist in mobilizing and advocating for health resources. the dle, employed by mhsi, functioned in both capacities, as outreach workers recruiting migrant farm workers with diabetes and then educating them on utilizing the health care system. migrant health service, inc. staff and the diabetes program staff offered comprehensive health care and educational services through their nurse-managed health centers, diabetes cluster clinics, and community activities such as prevention screenings. the dles expressed their concern that even though such programs existed, only a limited number of clients sought these services during the summer months. upon their return to online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 72 texas, the dles believed that it was even more difficult for migrant farmworkers to receive health care services for diabetes. their belief has been supported in a policy implication paper written by hale, burke, & arias-cantu (2004). these authors cited fragmented health services delivery systems and personal lifestyle choices as perpetuating health disparities among texas populations. according to the dles, fragmented health care become even more problematic for the migrant farmworker population because they received health care from a variety of health care providers in different states. conclusion this study is significant because it has captured a little known phenomenona, the perceptions of dles as they worked with migrant farmworkers who traveled between multiple states. the successes of the dles’ work and interactions with the hispanic migrant farmworkers were based on their similarity of culture, language, and health care experiences. information gained from this study could be useful in developing policy that would fund lay educator programs to address issues such as access to health care and the prevention and treatment of chronic disease in this mobile population. additional research should be conducted on the impact of the dles regarding access, use of services, and the farmworkers’ knowledge and behavior changes in relation to self-managing their diabetes. with this additional knowledge, the dle would be a more effective liaison and advocate for the migrant farmworker population. acknowledgements this research project was supported by an otto bremer grant from the otto bremer foundation, st. paul, minnesota. the program was funded by the rural health outreach grant # do 4rh 00251-03 from the office of rural health policy, health and human services, rockville, md. award: migrant health services, inc. diabetes lay educator program was the 2003 recipient of the national rural health association’s outstanding rural health program award. gratitude is expressed for the research and technical assistance of andrea smith, chronic disease coordinator and kristi jacabson, research and enrollment facilitator. references contreras, v., duran, j., & gilje, k. (2001). migrant farmworkers in south-central minnesota: farmworker-led research and action for change. cura reporter, xxxi (1), 1-8. corkery, e., palmer, c., foley, m.e., schechter, c.b., frisher, l., & roman, s.h. (1997). effect of a bicultural community health worker on completion of diabetes education in a hispanic population, diabetes care, 20(3), 254-257. [medline] online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9051367%5buid%5d 73 balcázar, h., alvarado, m., hollen, l.u., gonzalez-cruz, y., & pedregón, v. (2005). evaluation of salud para su corazón (health for your heart)—national council of la raza promotora outreach program. preventing chronic disease public health research, practice, and policy, 2(3), 1-9. retrieved february 13, 2006, from http://www.cdc.gov/pcd/issues/2005/jul/04_0130.htm eng, e., & young, r. 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nursing and health care, 12(2) 102 rural nursing: searching for the state of the science martha a. williams, phd student1 jill a. andrews, phd student2 karen l zanni, phd student3 pamela s stewart fahs, dsn4 1 binghamton university, mwilliams@aomc.org 2 binghamton university, andrewsj@binghamton.edu 3 binghamton university, kzanni1@binghamton.edu 4 professor and decker endowed chair of rural nursing, binghamton university, psfahs@binghamton.edu abstract background: during the development of the strategic plan for the rural nurse organization in 2009 a request was made for a comprehensive literature review regarding the state of the science of rural nursing. this request led to the collaboration on this project by doctoral students in the rural nursing program at binghamton university. purpose: the purpose of this review was to identify the current state of the science of rural nursing, and the use of theoretical principles that guide this subcomponent of the discipline. methodology: an integrative review of the literature was conducted utilizing the methodology by cooper (1998). two hundred ninety five articles were identified with publication dates ranging from 1989 through 2010. from these, 107 were included in the review and analysis. articles were evaluated for level of evidence and scientific merit. data were categorized with sub-headings of rural definitions, theoretical frameworks, research focus, countries of origin and publication source. results: forty-two percent of the articles reviewed provided no definition for the term rural. the remaining articles revealed no general agreement on the definition of rural. although the majority of studies used some theoretical framework, the one prominent theory was rural nursing theory (long & weinert, 1989). minimal testing of theory was evident in the literature. disease management was the most common focus of research. there was a dearth of studies emanating from asian and south american countries. the online journal of rural nursing and health care published the greatest number of articles included in this review. conclusions: there has been a proliferation of rural nursing research over the last two decades. the level of evidence revealed was low, predominantly level vi. the use of numerous and widely varied theories in the literature indicates that rural research is fragmented and lacks a solid theoretical foundation to guide research and practice. more robust research is needed to strengthen the body of knowledge and develop the specialty of rural nursing. keywords: rural, nurs*, theory, integrative review, research online journal of rural nursing and health care, 12(2) 103 rural nursing: searching for the state of the science in april 2009, the rural nurse organization (rno) strategic plan called for a review of the literature on rural nursing to examine a variety of possible issues such as conditions in rural areas, recruitment and retention needs, educational desires, state of the science in rural nursing research and professional organization services. in september of that year pamela stewart fahs, rn, dsn and rno secretary proposed that this review be the basis of a project for doctoral students working on a phd in rural nursing at binghamton university. it was agreed that this review would be conducted and be peer reviewed for suitability for publication in the online journal of rural nursing and health care. thus the idea was born for an integrative review into the rural nursing literature. the major purpose was to identify the current state of the science of rural nursing, and the use of theoretical principles that guide this subcomponent of the discipline. the project was conceptualized as a class project, where the search and identification of the literature to review would be done as part of class work. evaluation of the individual articles was completed by each student utilizing a scoring grid to identify level of evidence and scientific merit. once this information was gathered, it was entered onto a literature comparison chart for further analysis. a systematic approach to analysis was performed as described by cooper (1998). cooper delineated the process of conducting a research review as encompassing a problem in stages, similar to the stages of conducting primary research, the key components are (a) problem formulation for the literature review, (b) literature search, (c) data evaluation; (d) data analysis; and (e) presentation. the initial stage of any review method is a clear identification of the problem that the review is addressing and the review purpose. subsequently, the variables of interest and the appropriate sampling frame are determined. having a well-specified review purpose and variables of interest facilitates all other stages of the review, particularly the ability to differentiate between pertinent and extraneous information in the data extraction stage. data extraction from primary research reports can be complex because a wide range of variables will have been studied across multiple reports. any integrative review can encompass an infinite number of variables; therefore, clarity of the review purpose is important. a well-specified research purpose and literature search strategy will facilitate the ability to accurately operationalize variables and thus extract appropriate data from primary sources regarding the state of the science of rural nursing. in any case, a clear problem identification and review purpose are essential to provide focus and boundaries for the integrative review process. methodology materials were gathered from a systematic review of electronic databases utilizing ebscohost. these included the cumulative index of nursing and allied health literature (cinahl) and medline to identify the state of the science of rural nursing. key words used in the search included: nurs*, theory, and rural. search delimiters were english language, available abstract and publication dates of 1989 to 2010. the beginning search date of 1989 was purposefully chosen in an effort to include a seminal article on rural nursing. the initial search yielded 294 items. a companion article to one of the original search articles was added using heritage method for a total of 295 items for review. the initial review of titles and abstracts was performed collectively by the group, generating a list of articles for inclusion, exclusion and those for further evaluation. any definition of rural was accepted. articles were included for review if they: (a) discussed any online journal of rural nursing and health care, 12(2) 104 traditional rural concept, (b) provided a framework for rural nursing, (c) explored or generated theories of rural nursing, (d) discussed the meta-paradigm: health, nursing, environment, and person as it related to rural nursing, (e) examined relationships between rural nursing and practice environments or (f) discussed rural nursing as a specialty or sub-specialty of nursing. all dissertations were excluded due to difficulty accessing electronic copies and prohibitive cost associated with obtaining copies for review. one article was excluded because of duplication in search results. nine articles were judged to have low scientific merit based on the established scoring criteria. major exclusion rationale included articles which were rural in setting only, 76; results that were not specific to rural nursing practice, 21; and one article which was excluded for both these reasons. thus a total of 107 items met the inclusion criteria for review (abrahams, wood, & jewkes, 1997; allen, 2004; anderko & uscian, 2000; anderko, uscian, & robertson, 1999; andrews, morgan, & stewart, 2010; annan, 2008; appel, giger, & davidhizar, 2005; barredo & dudley, 2008; bathum, 2007; boucher, 2005; boyd & mackey, 2000a, 2000b; breda et al., 1997; brennan & stevens, 1998; brewer, zayas, kahn, & sienkiewicz, 2006; brodie et al., 2005; buehler & lee, 1992; burman, 2001; bushy & kost, 1990; cesario, nelson, broxson, & cesario, 2010; crigger et al., 2004; cuellar, 2002; davis & droes, 1993; day & boynton, 2008; drury, francis, & chapman, 2008; eaves, 2006; eisenhauer, hunter, & pullen, 2010; france, fields, & garth, 2004; gibb, 2003; gibb, forsyth, & anderson, 2005; gobble, 2009; green & davis, 2005; grubbs & frank, 2004; grzybowski, kornelsen, & cooper, 2007; haegert, 2000; hall et al., 2005; hanna, 2001; harrison, 1998; heath, 1998; hegney, 1997; holt & reeves, 2001; howell, nelson-marten, krebs, kaszyk, & wold, 1998; hylton, 2005; jervis, shore, hutt, & manson, 2007; juhl, dunkin, stratton, geller, & ludtke, 1993; keller, 2008; kelley, 2004; keogh, 1997; kim, kim, park, & kim, 2010; kulig, 2000; lauder, reel, farmer, & griggs, 2006; lee & winters, 2004; lee, arthur, & avis, 2007; leight, 2003; lesergent & haney, 2005; lethbridge, 1989; lo & brown, 1999; long & weinert, 1989; martin, garcia, & leipert, 2010; mastaglia & kristjanson, 2001; mayne & glascoff, 2002; mcclune, 2009; mcconigley, kristjanson, & morgan, 2000; mccoy, 2009; meraviglia, 2004; mills, chapman, bonner, & francis, 2007; mills, francis, & bonner, 2007a, 2007b, 2008a, 2008b; modungwa, poggenpoel, & gmeiner, 2000; molinari & monserud, 2009; morgan, semchuk, stewart, & d'arcy, 2002; mostafanejad, 2006; nichols, 1999; ostlund, 2010; penz & stewart, 2008; price, burkhart, burkhart, & islam, 1999; prior, 2009; pullen & walker, 2002; racher & vollman, 2002; racher, vollman, & annis, 2004; reay, patterson, halma, & steed, 2006; schumacher, 2010; scott-findlay & chalmers, 2001; sellers, poduska, propp, & white, 1999; shambley-ebron & boyle, 2006; sizemore, robbins, hoke, & billings, 2007; sliep, poggenpoel, & gmeiner, 2001a, 2001b; soltis-jarrett, 1995; sossong, 2007; sullivan, weinert, & cudney, 2003; takase, maude, & manias, 2005; textor & porock, 2006; van der merwe, 1999; weinert, cudney, & spring, 2008; werle, 2004; white & mortensen, 2003; williams, 2001; witte, dm, & steyn, 2008; wittig, 2001; woodhouse, 2009; xiao, 2010; yonge, 2007, 2009; yurkovich, buehler, & smyer, 1997). of these, 62 were qualitative, 25 quantitative, one was mixed methods and 19 were not data based. figure 1 summarizes the search process. online journal of rural nursing and health care, 12(2) 105 figure 1. results of literature search procedure after the studies were identified, they were divided among the writing group members for systematic review and categorization according to a rating system for the critical appraisal of the ebsco host search engine 295 articles (1 from heritage search) inclusion criteria: rural concepts & frameworks, rural nursing, rural nursing speciality or subspeciality, rural practice environments, & rural health care. articles meeting criteria: 107 excusion criteria: dissertations (80), duplications (1), low scientific merit (9), results not rural [rnr] (21), rural in setting only [rso] (76), both rnr & rso (1) articles excluded: 188 online journal of rural nursing and health care, 12(2) 106 evidence, as defined by fineout-overholt and colleagues (fineout-overholt, melnyk, stillwell, & williamson, 2010). the procedure used in this review also included identification of scientific merit for each research article (association of women's health obstetric and neonatal nurses [awhonn], 2003). level of evidence levels of evidence range from i to vii, see table 1. the majority of the studies were nonexperimental, descriptive correlational design, level vi. while randomized controlled studies control best for bias, none were found during this review. table 1 scientific merit scoring criteria qualitative studies were evaluated for merit using a literature scoring grid adapted from cesario et al., (2002) with a possible score of 30 points. articles scoring 15 or less were deemed to have low scientific merit and were excluded. quantitative studies were evaluated for merit using a literature scoring grid with a possible score of 24 points adapted from awhonn (2003). articles receiving a score less than 12 out of 24 based on this evaluation were not considered for review literature comparison grid a literature comparison grid was developed to organize the data under the original subheadings of: reference, reviewer initials, rural definition, study-theoretical framework, research focus, sample methodology, instruments, dependent variables and findings. group discussions led to the identification of which of these sub-headings provided the clearest picture of the state of the science of rural nursing. from this discussion a final table was generated that included: rural definitions, study theoretical frameworks, research focus, country of origin, publication source, level of evidence, and scientific merit. the focus of the research was summarized under major nursing topics such as professional and higher nursing education, disease management, cultural competence, workforce issues and mentoring. the grid assisted in the identification and organization of theories, models and frameworks reported in the literature. this comparison was especially beneficial in analyzing and categorizing the multiple ways rural was defined in studies. finally, the results were synthesized into a summary of the state of the science of rural nursing. online journal of rural nursing and health care, 12(2) 107 findings models, theories, and frameworks of the 107 inclusion articles reviewed, theories, models or frameworks were mentioned a total of 77 times. the most frequently cited, six times, was rural nursing theory (lee & winters, 2004; long & weinert, 1989, 1999; mccoy, 2009; sullivan et al., 2003; weinert et al., 2008 ). this was closely followed by leininger’s theory of cultural care diversity and universality (holt & reeves, 2001; molinari & monserud, 2009; schumacher, 2010; sellers et al., 1999; wittig, 2001); bandura’s social cognitive theory (anderko & uscian, 2000; cuellar, 2002; hall et al., 2005; kelley, 2004; molinari & monserud, 2009): and self-efficacy which is a component of other social theories (cuellar, 2002; hall et al., 2005; l. l. lee et al., 2007; molinari & monserud (2009) and price et al., (1999) were each cited five times. nursing for the whole person theory (modungwa et al., 2000; sliep et al., 2001a, 2001b); watson’s theory of human caring (france et al., 2004; green & davis, 2005; witte et al., 2008) and ajzen-fishbein theory of reasoned action (anderko & uscian, 2000; howell et al., 1998; lo & brown, 1999), were each mentioned three times. knowles adult learning theory (bushy & kost, 1990; textor & porock, 2006), and lazarus theory of stress and coping (cuellar, 2002; lesergent & haney, 2005) were each cited two times. the remaining 45 models and theories were each cited only once. the majority of the authors identified a theoretical basis for their work. several articles provided solid examples of general theory testing. molinari and monserud (2009) successfully tested several aspects of bandura’s self-efficacy construct and parts of leininger’s theory of cultural care diversity and universality. in this study, self-efficacy increased the time, effort and persistence that individuals expend when challenged, and the authors concluded that nurses selfefficacy was related to job satisfaction scores. the actual testing of rural theories or propositions was minimal. studies often denoted the rural concepts (winters & lee, 2010) such as distance, isolation, familiarity, and professional concepts including autonomy, generalist, and role diffusion. however, these concepts are seldom used as study variables. a notable exception was a study of differences in autonomy and nursephysician interactions (penz & stewart, 2008). one qualitative study (h. j. lee & winters, 2004) validated and expanded long and weinert’s (long & weinert) original rural nursing theory adding the concepts of choice of residence and the process of symptom action timeline symptomaction-time-line (satl) and further clarified the definition of health; however concepts of outsider, old-timer, and newcomer were conspicuously absent. some of the qualitative literature reinforced rural concepts, such as isolation (mostafanejad, 2006), role diffusion and the related concept of professional boundary challenges as described by yonge (2007, 2009). rural definitions the definition of rural is methodologically important, and holds considerable implications for ongoing development of rural nursing theory. yet, 42% of the articles reviewed provided no definition for the term rural. the remaining 58% of the articles revealed a multitude of definitions, about which there was no general agreement. of those articles that did define rural, two useful categories for classifying their definitions emerged. authors generally described rural using either subjective terminology or demo-geographic terminology. subjective definitions outnumbered demo-geographic definitions by nearly three to one; 46 articles (43%) defined rural in subjective terms, while the remaining 17 articles (15%) used demo-geographic terms. online journal of rural nursing and health care, 12(2) 108 the subjective definitions of rural generally described aspects of location pertinent to the phenomenon being studied. in many cases, the term rural was not described, but the reader could usually conclude the study was conducted in a rural setting based on some contextual information, for example, describing appalachia as a “rugged mountainous region of the eastern united states” (gobble, 2009, p. 94) or describing regions of new york state as “extremely rural areas in the northern and southwestern parts of the state” (brewer et al., 2006, p. 54). thirty-four articles used distinguishing subjective terms such as, “small rural hospitals” (gibb et al., 2005), “miles from an urban center” (keogh, 1997), not urban or “outside of major metropolitan centres” (mills, francis et al., 2007b, p. 583), “who live in a certain rural village” (modungwa et al., 2000, p. 64), or simply a “rural community” (woodhouse, 2009, p. 22). demo-geographic definitions or taxonomies were primarily used by researchers to officially define a specific characteristic of a particular rural place. those definitions included the us rural taxonomies such as office of management and budget (omb) (anderko & uscian, 2000; juhl et al., 1993; leight, 2003), centers for disease control and prevention (cdc) (mash et al., 2008), and us census bureau (mccoy, 2009). australian taxonomies such as accessibility/remoteness index of australia (aria) rural, remote and metropolitan areas (rrma) (drury et al., 2008, p. 784); and additional governmental designations set forth by statistics canada and organization of economic cooperation and development (oecd) (kulig, 2000; morgan et al., 2002; penz & stewart, 2008; pullen & walker, 2002; scott-findlay & chalmers, 2001). other demo-geographic definitions were unofficial population based, for example, four articles specifically cited long and weinert’s (1989) sparsely populated areas as the way they described rural (cuellar, 2002, p. 38; davis & droes, 1993, p. 159; h. j. lee & winters, 2004, p. 51; long & weinert, 1999, p.259). others used terminology that quantified size such as “greater than six, but < 100 persons per square mile” (buehler & lee, 1992, p. 300 ); “less than 1,500 population” (h. j. lee & winters, 2004, p. 51); “a rural area of taiwan that has a population density of 75 persons per square kilometer compared to a density of more than 3000 persons for the country as a whole” (l. l. lee et al., 2007, p. 161); “greater than 100 kilometers from perth [australia]” (mcconigley et al., 2000, p. 82), “the state is sparsely populated with an average of 6.2 people per square mile” (sullivan et al., 2003, p. 567), and “small rural town of about 28,000 people”(wittig, 2001, p. 204). one article, (racher et al., 2004) laid out the multiple ways “rural” can be defined. topics fifty-four different topics emerged. the most common category was disease management, addressed in 22 articles. this was further subdivided into more specific categories such as cancer, cardiovascular/stroke, mental illness, antibiotic use and pain. nursing or professional education, along with mentoring was the focus of 13 articles. cultural issues were cited 10 times while women’s health was the topic of nine articles. topics that were conspicuously absent included telehealth, technology, and communication infrastructure, or lack thereof. an exception to this finding was the discussion of a chronic illness model derived from a computer-based intervention for managing the health of chronically ill women in rural areas (weinert et al., 2008). also limited was research based on the core rural concepts of distance and isolation, with the exception of one article which described families' perceptions of their experiences and challenges that were due to living a great distance from a cancer treatment center (scott-findlay & chalmers, 2001). online journal of rural nursing and health care, 12(2) 109 source country of origin. the majority of the articles, 56, emanated from the united states. other countries where studies originated were: australia,18; canada, 14; south africa, 6; dominican republic, 2; malawi, 2; new zealand, 2; united kingdom, 2; and honduras, korea, peru, sweden, and taiwan, 1 each. publication. articles were published in 66 journals. the online journal of rural nursing and health care published 10 of the articles reviewed. the journal of advanced nursing published six; journal of transcultural nursing, five; curationis, oncology nursing forum and public health nursing four each; and australian journal of advanced nursing and nurse education today three each. seven journals published two articles and fifty one published one article each. discussion limitations some significant contributions to the rural nursing body of literature were potentially missed due to the methodology used in this review. the exclusion of dissertations from this review, while practical, limits the scope of the findings. the use of the selected search engines limited textbooks as a source of information, for example the bushy series on rural nursing (bushy, 1991a, 1991b) or the book on nursing in the rural community (bushy, 2000). evidence-based practice guidelines, white papers, and position statements were not located through the search parameters. the deliberate choice of ebscohost as a search engine may have led to the exclusion of some publications by authors from disciplines other than nursing. some journals publishing articles pertinent to rural healthcare, such as the journal of rural health, were not found through this search. the use of english language as a search delimiter potentially minimized international contributions. the subjective identification of “rural in setting only” as an exclusion criterion may have further contributed to what is perceived as a gap in the body of literature. topics labeled as rural in the title or abstract without further elucidation of how they apply to healthcare in the rural setting were excluded. additional review was conducted where doubt regarding classification existed; however, inter-rater reliability was not calculated. conclusion rural nursing has experienced rapid growth over the last 23 years. since the first seminal article by long and weinert (1989), there has been a proliferation of literature specific to rural nursing. however, the majority of the research found in this review was descriptive-correlational in nature. the discipline needs to produce higher levels of evidence to advance the state of the science and to formulate a basis from which to develop clinical practice guidelines and competencies specific to the specialty of rural nursing. the theoretical principles that guide rural nursing have been identified, and while evolving, they have not been sufficiently tested. the use of numerous and widely varied theories in the literature indicates that rural research is fragmented and lacks a solid theoretical foundation. defining the concept of rural has been imprecise over time and continues to be problematic in this review. it is useful to categorize definitions of rural for the purpose of discussion. rather than standardizing definitions into a few all-purpose designations, nurse researchers should specify which aspects of rural are relevant to the phenomenon being studied, and then apply the online journal of rural nursing and health care, 12(2) 110 most appropriate definition. authors have a responsibility to operationally define rural in future work. the use of the term rural in the title or abstract can be misleading. if the study is rural in setting only, it may add little to the body of literature. those studies in which the concept is reflected throughout the study are more likely to contribute to the state of the science of rural nursing. studies pertinent to rural healthcare issues like disease management or professional practice need to include rural concepts as independent variables in order to accurately identify how these concepts affect outcomes. while increased communication infrastructure holds the promise of improved access for rural dwellers, a dearth of literature on the topic was found in this review. therefore, the relationship between communication infrastructure and access to care should be further developed and tested. few articles spoke to the specialized skills and knowledge required to care for rural populations. more work is needed in the area of rural nursing as a specialty. almost half of the seven billion people on earth live in rural areas (brownlee, 2011). the sources of literature were not evenly distributed from a global perspective. sixty-five percent of the articles reviewed were from north america. this may be due in part to the discussed limitations; however greater geographical diversity would provide a more comprehensive representation of rural nursing. when accessing rural literature, no one search engine will adequately produce all-inclusive results. well-defined literature search strategies are critical for enhancing the rigor of any type of review because incomplete and biased searches result in an inadequate database and the potential for inaccurate results (cooper, 1998). ideally, all of the relevant literature on the state of the science of rural nursing would be included in the review; yet obtaining dissertations was challenging and costly. computerized databases proved efficient and effective; however, limitations associated with inconsistent search terminology and indexing problems yielded some studies that took place in rural settings only. thus, other recommended approaches to searching the literature should include journal specific review and use of multiple search engines. inherent in conducting rural research is the need to operationally define rural. the variety of definitions, the absence of any definition, or the inappropriate application of a rural definition are methodological challenges for rural studies. while the state of the science of rural nursing research continues to have many weaknesses, we are making strides in expanding the body of knowledge, conducting more sophisticated and methodologically sound studies, and developing ongoing programs of nursing research. many challenges face the nursing research community in its efforts to expand the empirical knowledge base to inform rural nursing practice. few journals specialize in rural health as a primary focus. more journals need to include manuscripts that adequately address issues of rural healthcare. nurse researchers also have a responsibility to increase the scientific merit and level of evidence or their work. funding agencies have a responsibility to acknowledge the challenges inherent in conducting rural research and support studies that will improve rural healthcare. an increased focus on rural nursing research and greater interdisciplinary collaboration can improve the state of the science of rural nursing and healthcare. online journal of rural nursing and health care, 12(2) 111 acknowledgements the authors would like to acknowledge the contributions of ralph klotzbaugh and rosemary collier, phd students dson; binghamton university and erin rushton, associate librarian, binghamton university. references abrahams, n., wood, k., & jewkes, r. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/16502966 http://www.ncbi.nlm.nih.gov/pubmed/17149048 http://www.ncbi.nlm.nih.gov/pubmed/10583636 http://www.ncbi.nlm.nih.gov/pubmed/19094152 http://www.ncbi.nlm.nih.gov/pubmed/15040767 http://www.ncbi.nlm.nih.gov/pubmed/18539874 http://www.ncbi.nlm.nih.gov/pubmed/11989035 http://www.ncbi.nlm.nih.gov/pubmed/20712659 http://www.ncbi.nlm.nih.gov/pubmed/9355607 faith communities and breast/cervical cancer prevention: results of a rural alabama survey 83 faith communities and breast/cervical cancer prevention: results of a rural alabama survey linda l. dunn, dsn, rn, cce1 joann oliver, msn, rn2 margaret a. lyons, phd, rncs3 1 associate professor, capstone college of nursing, university of alabama, ldunn@bama.ua.edu 2 instructor, capstone college of nursing, university of alabama, joliver@bama.ua.edu 3 associate professor, capstone college of nursing, university of alabama, mlyons@bama.ua.edu keywords: breast/cervical cancer, rural, faith communities, health promotion abstract limited research has been conducted in the area of faith-based health promotion programs. data reported here are from a survey of faith communities in walker county, alabama for the following purposes: 1. to ascertain if breast and/or cervical cancer education was being offered by faith communities in walker county, alabama; 2. if so, what opportunities do faith communities provide; 3. to identify barriers that might inhibit the offering of breast/cervical cancer education to women in walker county, alabama; and 4. to determine the willingness of faith communities to meet with researchers to explore the option of providing breast/cervical cancer education to their faith communities. a survey was sent to 218 faith communities that were listed in the daily mountain eagle (walker county newspaper). a total of 46 surveys were returned, for a response rate of 25%. data were analyzed using spss 11.0 for windows. researchers with qualitative expertise conducted the content analysis. less than 1% of the faith communities reported any involvement in breast/cervical cancer education. barriers to offering breast/cervical cancer education included a lack of financial resources and a lack of clergy/spiritual leaders with experience in providing breast/cervical cancer education. in addition, breast/cervical cancer education was not seen as part of the faith community’s mission. ministers cited a lack of community resources and a personal lack of knowledge about breast/cervical cancer as reasons for not providing health promotion activities in this area. ninety-nine percent (99%) stated that they would be willing to meet with the researchers to plan breast/cervical cancer education. one percent (1%) stated that such informational offerings would not be necessary. introduction cancer is the second leading cause of death in the united states and is projected to become the number one cause of death for all age groups within the next 10 years (american cancer society, 2004). breast cancer is one of the most common cancers in women and has a five year survival rate of 95% if caught at an early stage. mammography continues to be the most efficient and reliable method for detection of breast cancer, however, close to 13 million women, over the age of 40, in the united states, have never had a mammogram (national breast cancer foundation, 2005). cervical cancer is also highly curable if caught early. however, significant numbers of women have never had a pap smear, the only reliable way to diagnose cervical cancer. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://nursing.ua.edu/home.htm mailto:ldunn@bama.ua.edu http://nursing.ua.edu/home.htm mailto:joliver@bama.ua.edu http://nursing.ua.edu/home.htm mailto:mlyons@bama.ua.edu 84 since cervical cancer symptoms are usually absent or negligible, it is often too late by the time a woman is diagnosed (american cancer society, 2003). a variety of reasons have been postulated for the fact that women are not being screened. urban vs. rural residence, lack of knowledge, low educational levels, issues of access, race, income, cultural beliefs, mistrust of the health care system, and lack of physician referral are a few examples (bushy, 2000; esser-stuart & lyons, 2002). nationally, overall cancer mortality rates decreased during 1990-2000 and the concomitant reduction in breast and cervical cancer mortality was presumed to be the result of both earlier detection and improved treatment (berry et al., 2005). however, not all states were fortunate enough to experience a reduction in breast or cervical cancer rates. female breast cancer incidence increased by 4.2% in alabama during 1996-2002. cervical cancer rates also increased during that time frame (american cancer society, 2004). alabama is ranked 49th in women’s overall health status (national women’s law center, 2001). in keeping with healthy people 2010 objectives (usdhhs, 2000), healthy alabama 2010 objectives were developed to assist in the reduction of health disparities and to improve the overall health status of all alabamians. a primary objective is to increase the percentage of adults aged 18 and older who will receive breast and cervical cancer screenings (adph, 1999). patient education, as part of primary and secondary prevention strategies, is a key factor in increasing the numbers of women who receive screening, thereby decreasing morbidity and mortality from breast/cervical cancer (cdc, 2004). one segment of alabama that is of particular interest to the researchers is women in rural alabama. while there are numerous definitions for rural, most of the literature is in agreement that an area is rural if it has a low population density and is diverse (lee, 1991). rural populations are demographically different from urban populations since rural populations tend to be older, poorer, and less educated (ormond, zuckerman, & lhila, 2000; casey, call, & klingner, 2001). studies have shown that women who are less educated and live in rural areas, such as those in alabama, are less likely to be screened for cancer and are more likely to be diagnosed at a later stage in the disease (boughton, 2000; alabama statewide cancer registry, 2004). the delivery of preventive care, such as cancer screening, is often more difficult in rural areas. rural communities have fewer hospitals and fewer physicians. accessing resources is more cumbersome for rural women. rural women travel greater distances for appointments and feel more isolated. they are less likely to know what services are available to them and are less confident about taking the necessary steps to access those services that they do know about (ormond, zuckerman, & lhila, 2000; lyons, 2004). cultural factors such as race, ethnicity, and socioeconomic status may also be associated with poor breast/cervical cancer screening rates for women living in rural alabama (schootman & fuortes, 1999). thus, effective community-based interventions are needed to help alleviate disparity in prevention and screening services. reaching the rural community through education regarding health promotion and disease prevention in the area of breast/cervical cancer is imperative for enhancing the health status of rural women. community education or support groups sponsored by local faith-based communities could be useful in meeting the need for education and support regarding available services in rural areas. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 85 faith communities and health professionals can be dynamic partners in achieving health promotion outcomes. faith-based health promotion can improve the health of community residents through education, screening, referral, treatment, and group support. establishing collaborative partnerships between faith-based communities and health professionals has been successful in implementing health promotion programs in vulnerable, underserved populations (peterson, atwood, & yates, 2002). however, establishing educational programs for rural communities can be problematic, particularly for “outsiders” or those health professionals who are unknown or new to the community (dunkin, 2000). an initial distrust of the health care professional may be encountered (bailey, 1998). the purpose of this article is to report the results of a survey of faith communities in walker county, alabama. faith communities were selected as the population for this survey because they can facilitate access to the lay community. these organizations exist in practically every community and have the ability to influence the hardest-to-reach populations (tesoriero, parisi, sampson, foster, klein, & ellenberg, 2000). walker county was selected as the site for this study because breast/cervical cancer related morbidity and mortality in this rural north alabama county exceed both state and national rates. walker county, alabama was ranked #1 in cancer incidence and mortality rates by county, for males and females and all races combined (alabama statewide cancer registry, 2004). walker county, alabama, is located in the foothills of the appalachian mountains and compares poorly with state and national levels of poverty and education. using the federal definition of poverty, 16.5% of walker county residents are below the poverty level compared to 16.1% of alabama’s population and 12.4% of the united states (u.s.) population. in addition, 32.8% of persons ages 25 and older in walker county did not graduate from high school compared to alabama’s rate of 24.7% and the national rate of 19.6% (u.s. census bureau, 2000). method the purpose of this research was to ascertain what breast and/or cervical cancer education was being offered by faith communities in walker county, alabama; to identify barriers that inhibit the offering of breast/cervical cancer education; and to determine the willingness of faith communities to meet with researchers to explore the option of providing breast/cervical cancer education to their congregations. each purpose was then formulated into a research question. prior to data collection permission was obtained to use the data collection instrument from the author of a previous study of faith communities (tesoriero et al., 2000). the study design, survey instrument, and consent form were reviewed and approved by the university of alabama institutional review board for the protection of human subjects before the study began. faith communities (n=218) in walker county, alabama comprised the sample for this study. all of the faith communities listed in the walker county church directory, as published in the local newspaper, the daily mountain eagle, were mailed a packet that included a letter of informed consent, the survey, and a stamped self-addressed return envelop. of the 218 surveys that were mailed out, 52 were returned due to an incorrect online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 86 address or lack of a mail receptacle. of the 52 surveys returned unopened, 21 of the faith communities were located and were sent another packet (total n=187). a follow-up phone call was made to the pastor of the faith community if the survey was not returned by a specific date. overall, 46 of the 187 faith communities returned the survey for a response rate of 25%. the 25% return rate was within an acceptable range for mailed surveys (fain, 2004). findings data were analyzed using descriptive statistics and content analyses. we used spss 11.0 for windows to analyze the data. table 1 depicts the characteristics of the faith communities that participated in the survey. two researchers with expertise in analyzing qualitative data conducted the content analysis using the following steps: 1. participant’s comments were read several times, 2. transcripts were broken down into key segments, and 3. key segments were grouped into central meanings. table 1 characteristics of congregations responding to survey (n = 46) variable percent religious affiliation protestant 70% catholic 0% jewish 0% other 30% racial/ethnic composition of congregation white 97% african american 2% hispanic 1% other 0% another expert in qualitative research then followed the decision trail of the other two researchers to synthesize a central meaning that best described participant responses (lobiondo-wood & haber, 2006). the three research questions were answered as follows: question 1: what health activities, if any, are being offered by your faith community, particularly in the area of breast/cervical cancer? forty-three of the 46 faith communities reported that they do not provide any breast/cervical cancer education to the community. only one church reported that they distribute breast/cervical cancer literature once or twice per year. thus, less than 1% of the faith communities in walker county are involved in breast/cervical cancer education. (figure 1) online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 87 0 5 10 15 20 25 30 35 40 45 figure 1 health activities not offered health activities offered figure 1. what health activities, if any, are being offered by your church, particularly in the area of breast/cervical cancer ? question 2: what barriers inhibit the offering of breast/cervical cancer education? fifty-four percent of those surveyed identified financial constraints as barriers to breast/cervical cancer education in their faith communities. fifty percent identified clergy/spiritual leaders’ lack of experience or ability to provide education as a barrier. forty-seven percent of the faith communities reported that breast/cervical cancer education was not part of their mission. forty-three percent of the faith communities identified the lack of qualified staff to provide the education as a barrier. thirty-seven percent identified that their own lack of knowledge about breast/cervical cancer was a barrier to providing education. (figure 2) online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 88 0 5 1 0 1 5 2 0 2 5 f i g u r e 2 f i n a c i a l r e s o u r c e s e x p e r i e n c e n o t a p a r t o f m i s s i o n q u a l i fi e d s t a ff k n o w l e d g e figure 2. what barriers inhibit the offering of breast/cervical cancer education? question 3: would your faith community be willing to meet with researchers to explore the option of providing breast/cervical cancer education to your community? forty three percent of the faith communities reported they were not sure if they would be willing to meet with the researchers, 30% replied that they would be willing to meet and discuss options for providing breast/cervical cancer education, 1% stated they would not be willing, and <1% stated that it would not be necessary to provide breast/cervical cancer education (figure 3). 0 2 4 6 8 1 0 1 2 1 4 1 6 1 8 2 0 f ig u r e 3 n o t su r e if th e y w o u ld o r w o u ld n o t b e w illin g w o u ld b e w illin g w o u ld n o t b e w illin g r e p o r te d it w o u ld n o t b e n e c e ssa r y figure 3. would church representatives be willing to meet to discuss options for providing breast/cervical cancer education and prevention to your congregation? online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 89 comments shared during the telephone follow-up calls added insight for the researchers. for example, some of the pastors reported that they were bi-vocational pastors and had a heavy workload. one pastor stated, “i have two other jobs in addition to pastoring this church. i didn’t have time to fill out the survey.” the researchers also sensed distrust and an unwillingness to pursue the issue. for example, one pastor stated, “i’ll take it (survey) to the elders and discuss it,” but the survey was not returned. some of the returned surveys had written comments indicating why they did not offer health related activities: “we are a small church, only 20 members” or “we are mostly an elderly congregation,” or “we can’t accurately answer all these questions due to our size.” many seemed uncomfortable with the topic of breast/cervical cancer. comments included statements such as “the health issues you mentioned…” or “the conditions you stated in the survey…” which conveyed to the researchers that they were uncomfortable or embarrassed to say the words “breast and cervical.” discussion we found that only one of the faith communities was providing breast or cervical cancer education and preventive services to the community. this finding suggests that faith communities in walker county, alabama are not providing information about state and federally funded breast/cervical prevention programs such as the alabama breast and cervical cancer early detection program (abccedp) (cdc, 2005). the abccedp was established in 1991 and provides a vehicle whereby women over the age of 40 or who currently have breast problems, who are at 200% below the poverty level, and who have no insurance or are underinsured, may receive mammograms at no cost. this finding is important because it is possible that the residents of these faith communities do not have information available to them that could result in participation in screening services. education about the importance of health screenings enhances compliance in rural communities (cyrus-david, michielutte, paskett, d’agostino, & goff, 2002). dunkin (2000) stated that rural residents do not use preventive screening services as often as people who live in urban areas. faith communities could be the key to reaching a large number of rural women concerning breast/cervical cancer education and available services. similar to the findings of ormand, zuckerman, and lhila (2000) our findings indicated that faith communities lacked financial resources and the professional staff that could provide breast/cervical cancer education. however, it is our supposition that individuals in the community are able to learn about primary prevention strategies and available services and could be taught by the researchers to pass this information on to others in the community. as indicated in the findings some of the clergy appeared to be embarrassed at the mention of the words “breast” or “cervical”. such responses are not surprising in view of the sensitive nature of the topic. however, sensitivity may tend to diminish as individuals become acquainted with the importance of breast/cervical cancer education in saving the lives of women in their faith communities. age of congregation members as well as size of the congregation was a factor for one minister in deciding that his congregation did not need breast/cervical cancer education. the implication seemed to be that “older” individuals didn’t need to worry online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 90 about breast or cervical cancer and that the small size of the congregation negated the importance of the task. when in fact, it is known that one woman in seven who lives to age 85 will develop breast cancer during her lifetime (national breast cancer foundation, 2005). the issue of distrust is an important one. without trust it is impossible to breach the barriers that keep health professionals outside of the community “loop”. because people in rural communities tend to refuse help or services offered or provided by people that are unknown to their communities (dunkin, 2000) efforts need to be directed at getting to know who the community leaders are and establishing rapport with them. these individuals are likely to be members of the faith community and can provide an important function in convincing pastors of the importance of health care education. conclusions and plans for follow up individuals in walker county need health education about breast and cervical cancer. we are hopeful that a follow-up meeting with the faith communities who reported a willingness to meet with the researchers can be planned to explore the provision of breast/cervical cancer education and screenings. we plan to include nurse practitioners from our college that are wellknown practitioners in walker county. this should help address the issue of distrust and “outsiders”. in addition, the researchers have worked with two of the churches over the past few years in conducting community health fairs. therefore, we believe it will be not be difficult to establish rapport and gain trust as we offer interventions through faith communities. also, since none of the faith communities are providing testicular and prostate cancer education or screening, we plan to include these additional topics so that the men in this rural county can also receive health intervention. health education/promotion is imperative, especially in rural communities. participants of these faith communities have the potential to not only receive potentially life saving messages, but to disseminate health information to others in the community that may not attend a particular faith community. disseminating health information is vital in decreasing the morbidity and mortality of this rural community. study limitations the selected sample was a convenience sample. the survey was only mailed to faith communities who were listed in the walker county church directory as published in the daily mountain eagle. findings were based on self-reported, subjective data from the participants. the findings can only be generalized to the rural south and may not be representative of faith communities in other geographical areas. acknowledgements the authors thank the capstone college of nursing for the faculty research award that financially supported this survey, karla jordan for her technical assistance, and graduate students (cathy mitchell, brenda warbington, and carolyn nelson) for their data management assistance. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 91 references alabama 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(2000). healthy people 2010: understanding and improving health (2nd ed.). washington, dc: u.s. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.nwlc.org/pdf/2001reportcardexecutivesummary.pdf http://www.urban.org/urlprint.cfm?id=6487 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12406175&query_hl=11 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10491538&query_hl=13 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11354338&query_hl=15 http://quickfacts.census.gov/qfd/states/01/01127.html online journal of rural nursing and health care, 2(2) 67 partnership for healthier rural communities margaret a. lyons, phd, rncs1 carolyn crow, phd, rn2 linda dunn, dsn, rn3 becky edwards, msn, rn4 ann graves, msn, rn5 mitch shelton, phd, rn6 jeri dunkin, phd, rn7 1 assistant professor, capstone college of nursing, university of alabama, mlyons@bama.ua.edu 2 faculty emeritus, capstone college of nursing, university of alabama, ccrow@bama.ua.edu 3 associate professor, capstone college of nursing, university of alabama, ldunn@bama.ua.edu 4 director of facilities, technology and distance education, capstone college of nursing, university of alabama, bedwards@bama.ua.edu 5 assistant professor, capstone college of nursing, university of alabama, agraves@bama.ua.edu 6 university of alabama, mshelton@cchs.ua.edu 7 professor, capstone college of nursing, university of alabama, jdunkin@bama.ua.edu online journal of rural nursing and health care, 2(2) 68 abstract the purpose of this project was to assess the health status of residents of a small rural community with limited health resources while providing a teaching-learning environment that increases students’ knowledge and skills relative to nursing in a rural community. twenty-two men, 45 women, and six children participated in a one-day health fair sponsored by a school of nursing. results indicated that participants need assistance with health promotion in several areas: weight loss/obesity, blood sugar control, lowering cholesterol levels, vision and hearing follow-up, and further screening and possible treatment for depression. students who conducted the health fair were asked to complete a short questionnaire examining their beliefs related to the usefulness of the health fair. responses were generally positive; however, some students rated the health fair negatively. recommendations are given for concentrated follow-up with the study participants as well as suggestions for increasing student assessment of the usefulness of this activity. keywords: rural nursing, health fair, health promotion, nursing clinics, health risk appraisal online journal of rural nursing and health care, 2(2) 69 partnership for healthier rural communities the influence of health care reform and the emphasis on access to primary health care in rural communities can provide a unique opportunity for partnership development between universities and communities. rural communities often need assistance in identifying their health care needs in a formal and systematic method. traditionally, concepts of community as client and community assessment have been core components of undergraduate nursing curricula. it stands to reason that involvement in planning and conducting a community assessment can provide an excellent learning opportunity for students while addressing the needs of a community (bayne et al. 1994). this article describes a collaborative community health assessment project implemented by a university school of nursing and a rural alabama community. the partnership arrangement, the project, and project outcomes are described, along with recommendations for improvement of the process as well as student learning. background the purpose of this project was to assess the health status of residents of a small rural community with limited health resources while providing a teaching-learning environment that increases students’ knowledge and skills relative to nursing in a rural community. the health status of the community, based on objective data and the perceptions of those living in the community, was an important first step in determining desirable health resources. walker county, alabama, is located in the foothills of the appalachian mountains and compares poorly with state and national levels of poverty, education, infant mortality, and teen pregnancy. using the federal definition of poverty, 20.1% of alabama’s population was below poverty level compared to 13.8% at the national level in 1995. in walker county 17.8% of residents were below the poverty level (remington, 1998). the percentage of adults who did not online journal of rural nursing and health care, 2(2) 70 graduate from high school in alabama was 33%, while in walker county, where 72.8% of the population is rural, that percent reached 44%. in 1995, the u.s. infant mortality rate was 7.3 per 1,000 live births while alabama’s rate was 9.8, and walker county’s was 10.2. the teenage pregnancy rate for walker county at 65.9/1,000 was higher than the u.s. (54.4) and alabama (57.6) (center for business & economic research (cber), 1997). mortality rates for cancer, motor vehicle accidents, pneumonia/influenza, and suicide are higher in walker county than in alabama and the u.s. (alabama department of health & community affairs, 1997). the recent establishment of the capstone rural nursing center (crnc) in walker county was the impetus for the recent project and is currently the first nursing practice arrangement developed by the faculty at the university of alabama, capstone college of nursing (ccn). the center focuses on a) improving the health of rural alabamians in walker county, many of whom are medically underserved and b) enhancing the educational mix and utilization of the basic nursing workforce. a positive impact is anticipated for the recipients of service, students, faculty, cooperating disciplines, systems, agencies, and the health care of the state (dunkin, 2000). literature review rural health the past decade has seen numerous changes that have negatively impacted the provision of health care services in rural areas. the balanced budget act (bba) of 1997 created drastic cuts in health care services. coupled with hospital closures, home care cut-backs, deficits in community health service funding, decreases in numbers of physicians, inadequate emergency services, lack of insurance and transportation problems, disparities in healthcare are readily online journal of rural nursing and health care, 2(2) 71 evident in rural areas (bushy, 2000; caffry & williams, 1999; henderson, 1992; weinert & long, 1993). health promotion the rural environment poses singular challenges for health promotion and maintenance. because agriculture, forestry, mining, and fishing are major economic supports, increased workrelated injuries and exposure to pesticides/herbicides tend to be more prevalent in rural areas (bushy, 2000; stanhope & lancaster, 1999). a lack of specialist and mental health services in rural communities coupled with attitudes of resistance towards substance abuse and mental illness often hinders effective treatment (bushy, 2000; weinert & burmen, 1994). among rural residents, illness tends to be labeled as illness only when individuals are unable to carry out their regular work duties (bullough & bullough, 1990; bushy, 2000). rural residents tend to be selfreliant, although they will rely on family, friends and neighbors during illness (henderson, 1992; weinert & long, 1993). health care providers and educators are often viewed as outsiders and may not be trusted initially unless they are from the local area (bushy, 2000; lee, 1993). historically, health activities have emphasized primarily treatment of disease with little or no attention to prevention or wellness promotion. however, health is not merely the absence of disease. it is also the prevention of illness and a focus on wellness. the american nurses’ association social policy statement (1980) has moved the promotion of a wellness model forward by defining health as “a dynamic state of being in which the developmental and behavioral potential of an individual is realized to the fullest extent possible” (p.5). today disease prevention and health promotion are at the forefront of health care policy. the u.s. government publication, healthy people 2010: understanding and improving health (2000), focuses on goals of health promotion, health protection and disease prevention. online journal of rural nursing and health care, 2(2) 72 specifically these goals were to help individuals of all ages: 1) to increase life expectancy and improve their quality of life, and 2) eliminate health disparities that result from gender, race or ethnicity, education or income, disability, geographic location or sexual preference. the pew commission report (shugar et al. 1991) indicated that health care will be increasingly directed toward health promotion and focused on populations at the community level. if these goals are to be realized, health care must focus on wellness. a healthy lifestyle is brought about by both health-protecting behavior and healthpromoting behavior. according to pender (1996) health promotion is any activity that maintains or enhances well-being or self-actualization. rather than looking at a particular response to a specific health problem, health promotion focuses on healthy human development. health prevention addresses risk factor identification and reduction to prevent chronic illness. health promotion uses approach behavior (eating a healthy diet, regular exercise, managing stress, adequate rest, etc.), while health prevention uses avoidance behavior or the avoidance of negative events (immunizations, reducing risk factors, control of pollution, screening or education to detect early disease, and minimizing residual disabilities). rural partnerships other schools of nursing have collaborated with communities in an effort to provide service while providing learning experiences for students (bayne et al. 1994; caffrey & williams, 1999; doerr, sheil, baisch, & vogtsberger, 1998; feenstra, 2000; hall-long, 2000; kulig & wilde, 1996; lutz, herrick, & lehaman, 2001; perkins, vale, & graham, 2001; schaffer, mather, & gustafson, 2000; tanner & lethbridge, 1998). faculty, students, community residents, and agencies benefit from collaborative efforts designed to meet the needs of communities. traditionally, universities often have been viewed as separate from the online journal of rural nursing and health care, 2(2) 73 practicalities and realities of the everyday world (cavanaugh, 1993) producing graduates who are protected from the actuality of low-income rural experience. more collaborative efforts between universities and communities are needed to prepare graduates who are reality based. an added benefit of the current partnership is that the arrangement meets the university of alabama’s mission of teaching, research, and service. oakman was chosen as the site for this project because it is a rural area and ccn students have ready access to area residents through the crnc. method preliminary work/procedures plans for the health fair began during a “brain storming” session in which the second semester faculty generated ideas for student participation in the capstone rural nursing center. the idea for a community health fair surfaced where all the second semester students would have a clinical day that would involve activities in health screenings and health promotion. the planning phase for the health fair began the first week in january 2001, with a target date of april 2001 for the health fair. the crnc project director met with the project advisory committee and oakman community leaders to present the idea for the health fair. the response was remarkable as a local pastor offered the church family life center as the site for the health fair and a sunday, after church, was selected as the date for the health fair. the rationale for choosing a sunday was the possibility that many people would be in attendance at one of the local church services, making the fair easily accessible. the health fair was conducted from 12:30 – 5:00 p.m. and a free lunch was provided for workers and participants. the university public relations chair handled publicity for the project. online journal of rural nursing and health care, 2(2) 74 in an effort to create an interdisciplinary approach to this fair, several groups were invited to participate. in addition to second semester nursing students, two other semester groups from the nursing college were involved. first semester nursing students created health promotion handouts on a variety of topics (i.e. hypertension, exercise, smoking, nutrition, etc.). a fourth semester student designed the participant evaluation tool and contacted various community agencies to provide information booths at the fair (i.e. poison control, water safety, fire safety, bicycle safety, ident-a–kid, immunizations, etc.) and organized children’s activities (face painting, cartoons, coloring, fire truck, etc.). several other university groups assisted in the project as well. the rural medical scholars (rms), a group on campus who plan to enter medical school once they complete their undergraduate degree, nutrition, pharmacy, and audiology students requested to be involved in the health fair. since rms students routinely conduct health fairs they were able to provide numerous posters, models, and videos for health education purposes. frequent meetings were held between semester ii faculty, the project director, and the nurse practitioner assigned to work with the rural medical scholars. a graduate nursing student was assigned to contact businesses to obtain food donations for the free lunch. two second semester faculty assumed major responsibility for planning and coordinating the fair. student pre/post evaluation forms, data collection instruments, and a request for institutional review board approval to conduct a descriptive study of the health status of a rural community were prepared and submitted. university vans were scheduled to transport materials/equipment, students, and faculty. a training session was scheduled for demonstration of cholesteck machines for faculty and students. all of the second semester students were required to participate in the health fair because it was counted as a clinical day. online journal of rural nursing and health care, 2(2) 75 purpose the purpose of the ccn health fair was to do a basic community assessment of health care needs involving a multidisciplinary team of faculty and students. the findings from the assessment would then be used to design health promotion activities, which ccn students would implement with community residents. sample the sample was composed of 22 men, 45 women, and six children. participants ranged in age from 10-79. a majority were low-income individuals with an average educational level of 12th grade. sixty-seven were caucasian and six were african american. individuals were christian, represented by church of god, church of christ, pentecostal, and baptist denominations. prior to conducting the health fair institutional review board approval was obtained from the university of alabama. community members were invited to participate in the health fair by community leaders and through a variety of media e.g. newspaper, radio, church announcements, and posters in the pharmacy and local clinic. prior to participation and screening each participant was informed of the purpose of the health fair and signed a health screening consent and liability waiver form. each was informed that all data collected would be kept confidential and used only in aggregate form. individuals were informed of their right to participate in all or only portions of the health fair. a total of 62 nursing students participated in the health fair; 30 first semester students in the design of postures and brochures, and 32 second semester students in the actual conduct of the fair. second semester students also participated in a pre and post-health fair evaluation. online journal of rural nursing and health care, 2(2) 76 data collection the ccn health fair was conducted by students and faculty in the fellowship hall of one of the larger churches in oakman. measures of blood pressure, height/weight, hemoglobin and hematocrit, vision and hearing were obtained from participants and fed into a computerized health risk appraisal program. participants received a health assessment “report card” detailing screening results, indicating abnormal findings, and recommendations for further evaluation as deemed appropriate by the screening party. depression screening, using the center for epidemiological studies depression scale (ces-d), was also available as an adjunct service of the health fair. instruments the ces-d (roberts & vernon, 1983) is a well-established 20-item scale that measures the major symptoms of clinical depression. alpha coefficients were .84 for the general population and .90 for a patient sample. test-retest correlations of .48 (n=378) were moderate but appropriate as the ces-d was designed to measure the current level of depression. the health risk appraisal is a software package, available from a variety of medical software providers that allows health risks to be assessed by an interviewer and directly inputted into a computer file via laptop computer. this software rates the health risks for each subject and provides direction for deceasing health risks. in addition, to providing direct information for each subject the software develops a database that can be used to provide epidemiology data for future studies for selected populations. nursing students who participated in the health fair completed pre-health fair and posthealth fair surveys. the surveys consisted of three items: 1) health screenings are useful, 2) participation in community health fairs is a valuable experience, and 3) as a nursing student, i online journal of rural nursing and health care, 2(2) 77 have the responsibility to help educate society in health promotion and disease prevention. the items were rated by students using a five-point scale (1 strongly disagree to 5 strongly agree). findings student data analysis of variance (anova) was used to test for significant difference (p<0.05) between the pre-health fair surveys and the post-health fair surveys. on item one of the survey; students had a mean of 4.40 on the pre-health fair survey and a mean of 4.17 on the post-health fair survey. these scores were not significant (f=0.091, df=3). this indicates that students agree that health screenings are useful. students had a mean of 3.93 on the pre-health fair and 3.67 on the post-health fair for item two. again, not a significant difference (f=1.025, df=3). although, this is a positive response that community health fairs are a valuable experience, it should be noted that 30% of the students rated this item as disagree or no opinion. the prehealth fair mean for item three was 4.28, while the post-health fair mean was 4.17. item three also showed no significant difference (f=0.645, df=3) between the pre-health fair surveys and the post-health fair surveys. participant data data analysis revealed that 19% of the sample (n=73) exhibited an elevated serum glucose, 41% of the sample evidenced a cholesterol of greater than 200, 6% had an abnormally high heart rate, and 7% had an elevated blood pressure. of those who engaged in vision and hearing testing (n=35), 74% were experiencing hearing difficulties and 7% were evaluated as having need for vision follow-up. of those screened with the ces-d 75% (n=33) scored as acutely depressed. online journal of rural nursing and health care, 2(2) 78 other findings indicated that obesity was a significant problem for 27% of the sample (n=73) and positively correlated with an elevated cholesterol (p=0.014). additionally, an elevated glucose was positively correlated with obesity (p=0.014). discussion the oakman health fair was a positive experience for residents, students, and faculty. as noted by kulig & wilde (1996) the concept of health promotion is inextricably linked with community development and primary health care. the process of engaging community members in assessing their health was a health promoting activity which enabled residents to verbalize health concerns and needs as well as to identify potential health problems. results from health fair data indicated that participants need assistance with health promotion in several areas: weight loss/obesity, blood sugar control, lowering cholesterol levels, vision and hearing followup, and further screening and possible treatment for depression. the fair was used as a means of identifying the health status of the residents, providing much needed health promotion materials on mental health, safety issues, and identification of health barriers, beliefs, and behavior from the perspective of the rural resident. congruent with the conclusions of glick, hale, kulbok, & shetting (1996) this fair was an example of community development where residents actively participated in an attempt to control and manage their own resources. residents requested future health fairs that would include chest x-rays, weight loss information, cancer screening, and dental screening. although students verbalized that conducting a health fair was a positive experience some students rated its usefulness negatively or simply did not respond to the survey question. several reasons could account for such negative responses. the health fair was held on a sunday, which meant students were expected to spend a weekend day in a school related activity online journal of rural nursing and health care, 2(2) 79 when normally they would have done a variety of other things. some students were assigned “mundane” tasks such as taking vital signs, rather than the more complex and interesting tasks of interviewing, blood collection, or data entry. for future health fairs it might help students to “buy into” the idea of a health fair by exposing them to the economic, political, and social climate of the area to be assessed. it might also be helpful if students were more integrally involved in the planning process and thus more vested in the success of the fair. second semester students in this fair had only to show up to receive credit for a clinical day and were not given choices about attending or their specific role in the health fair. conclusions improving the health of rural communities with their unique needs and limited resources is a significant present day concern. the challenge now is to increase access to effective health promotion, health prevention, and health-related interventions for the oakman community. yearly health fairs, with concentrated follow-up, in collaboration with the capstone college of nursing will help to achieve those aims. other communities could well benefit from health fairs such as ours. the challenge is to other schools of nursing, rural health care providers, and community leaders to replicate ccn efforts. health promotion has and will continue to play a major role in the reduction and prevention of disease and mortality. our best results can be brought about by those health promotional activities that are community-based. online journal of rural nursing and health care, 2(2) 80 references alabama department of health & community affairs. 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(1994). rural health and health-seeking behaviors. annual review of nursing research, 12, 65-92. https://doi.org/10.1176/ajp.140.1.41 https://doi.org/10.1353/hpu.2010.0746 https://doi.org/10.1097/00003727-199304000-00009 editorial 13 guest editorial guest column: what was it like down there? laura terriquez-kasey, rn, ms, cen decker school of nursing binghamton university what was it like down there? oh it must have been horrible. i wish i could have helped or been there. these are some of the comments i have heard from fellow colleagues and student nurses since returning from ground zero, on the 20th of sept 2001. well frankly it’s been difficult to respond to some questions. no one could quite imagine the magnitude of trauma and grieving process that had been such an intricate part of our emergent response to the site. nurses from all over the country responded and assisted on different dmat teams. our response was one of caring for the rescuers and assisting the mourners. many family members where trying to dig. the firefighters, police, and other rescuers where overwhelmed with sorrow at not finding people alive. how do i feel? i feel a sense of pride, many nurses did respond and many of us assisted in different ways. nurses are a committed group perhaps it’s the need for us to allways help our fellow man perhaps it’s the need to fill a void in the community. nurses who are in nursing long enough some where along the line come upon a disaster or such a tremendous community need that we jump in with both feet some times never quite prepared for what we will have to do and how we will need to respond. recently when i joined the new york dmat team and participated in training sessions. this team is a medical and nursing team that trains monthly and has a small warehouse of tents and hospital equipment in storage and responds to disasters within the united states. the team is one of many that the department of human services assists and directs through its office of emergency preparedness (oem). these teams are called up to back up and assist the us public health service in responding to natural disasters and occasionally terrorist or man-made disasters. these teams are in need of new members and the need for nurses and other members is critical. nurses also should consider assisting in their own communities, as nurse medics, and red cross volunteers. perhaps we should all reconsider the need for nurses in these roles, and provide additional education to nurses in all roles of nursing. . all nurses in the community should participate in community disaster drills and be prepared to take on a different role in their community. when we participate and obtain training and education we can transform the nursing response to a disaster and perhaps be better prepared for the event. it is my hope that the rural nursing community will continue to prepare for any type of disaster, by providing additional educational opportunities for nurses, nursing students and the public to obtain disaster preparedness education throughout our rural communities. the rural nurse is frequently becoming a nurse that must fill the difficult public health needs of our communities. note: laura is a member of the new york disaster medical assistance team. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://dson.binghamton.edu/ 31 predictors of asthma treatment adherence in rural appalachian adults with asthma heidi putman, rn, dnsc1 1 associate professor, school of nursing, west virginia university, hputman@hsc.wvu.edu keywords: asthma, adults, adherence behaviors, rural appalachia, health beliefs, attitudes, behavioral intention abstract this descriptive, non-experimental study in a sample of 102 rural appalachian adults with asthma evaluated relationships between treatment regimen adherence and health beliefs, attitude, behavioral intention, and age. major predictors of adherence were health beliefs and attitude toward asthma. findings provide partial support for the theorized relationships. recommendations include future intervention studies designed to improve asthma care outcomes among rural appalachian adults diagnosed with asthma. introduction helping individuals achieve adherence with prescribed asthma treatment regimens, including asthma medications, avoidance of allergens, and keeping follow-up asthma monitoring visits with the health care provider, is a major goal of nursing care to society. adherence is defined in this study as the extent to which a person’s behavior coincides with medical or health advice. specifically, adherence with recommended asthma treatment regimens is defined as the extent to which a person’s behavior coincides with recommendations for self-administering inhalers on time and at the prescribed daily doses; avoiding known environmental “triggers;” performing peak-flow readings daily, if prescribed; and keeping follow-up visits with the health care provider (national institutes of health, 1997). little is known about factors that contribute to adherence with asthma treatment. this lack of knowledge about adherence behaviors in asthma is a concern for the nursing profession, considering that adherence is essential to minimizing asthma complications and that asthma complications are a major health care problem in the united states (national institutes of health, 1997, 2002). in the united states, acute exacerbations of asthma are responsible for 466,000 hospitalizations, 1.9 million emergency department visits, and 5,500 asthma-related deaths, costing $11 million annually. while the prevalence of asthma increased 42 % between 1982 and 1992 in the u.s., it increased a dramatic 82% in the last 15 years in west virginia, a rural appalachian state. according to the national institutes of health asthma in america report, nearly 17 million persons, 5.5 % of the united states’ population, suffer from asthma (national institutes of health, 1997, 2002). the number of asthma cases has more than doubled since 1980 and, nearly 3 million workdays are lost annually due to asthma exacerbations (redd, 2002). within rural appalachia, in the state of west virginia, alone, an estimated 69,000 adults suffer from asthma (west virginia department of health and human resources, 2001). online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.hsc.wvu.edu/son/ mailto:hputman@hsc.wvu.edu 32 empirical evidence indicates that acute exacerbations of asthma intensify when patients do not adhere to asthma treatment regimens. yet, little is known about the influence of health beliefs, attitude, behavior intention, knowledge of asthma, and demographic characteristics on adherence with asthma treatment (lynch, mahr, & rooklin, 2001). periodic exacerbations may occur secondary to a triggering illness, such as a viral or bacterial infection or exposure to an allergen, even when asthma is being effectively treated. a landmark study conducted in a large, california-based health maintenance organization found that fewer than 50% of a sample of 5,580 adult asthmatics reported using their inhalers daily as prescribed (legoretta, christian-herman, o’connor, hasan, evans, & leung, 1998). documented clinical observation has revealed a consistent lack of adherence with asthma care regimens (berg, dunbar-jacob, & sereika, 1997; legoretta et al. 1998; tettersell, 1993). the potentially serious complications and consequences of non-adherence to recommended asthma care regimens are often not fully realized by the adult asthma patient, resulting in costly complications, and even death in some instances (klaus & grodesky, 1997). adherence with asthma care is especially challenging for people living in medically underserved areas and in poverty because they have fewer resources to cover health care costs (united mine workers of america, 2000). rural is defined in this study according to the official united states federal guidelines as places, incorporated or unincorporated, with fewer than 2,500 residents. a rural area is outside the boundaries of metropolitan areas, and has no cities with as many as 50,000 residents (united states department of agriculture, 2000; united states census bureau, 2001). the overall poverty rate in rural appalachia is 15.3%, compared to the united states national poverty rate of 13.1%. to minimize the problem of asthma in rural appalachian adults, the west virginia department of health and human resources (2002) has recommended managing asthma according to established guidelines, which involves controlling exposure to environmental asthma triggers, adequate pharmacological management, and patient education. however, access to and availability of adequate health care is lacking in many areas of appalachia (appalachian regional commission, 2002). despite the increasing prevalence of asthma and the magnitude of the problem of asthma complications, research related to asthma adherence behaviors in adults is sparse, and in rural adults is practically nonexistent. however, after a thorough electronic search of the pubmed and cinahl databases during the time this study was designed in 2000, only three studies (berg et al. 1997; tettersell, 1993; legoretta et al. 1998) were found specifically investigating adult asthma patient adherence issues, with only two of these studies focusing on rural adults with asthma. review of literature research specific to adherence with asthma treatment regimen in adults first, berg et al. (1997) studied 55 rural adults with asthma in a quasiexperimental study, evaluating adherence with prescribed inhalers using an electronic chronolog device and self-report after an educational intervention. patients who received education regarding their medications were more adherent than those who had no online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 33 intervention. medication adherence to inhaled corticosteroids was the focus of this study, not the entire asthma treatment regimen. second, tettersell (1993) conducted a study in rural england using an instrument she developed to measure asthma patients’ adherence with asthma drug therapy in a sample size of 108 adults. adherence to asthma medications was measured by self-report of the patients. patients over 50 years old were more adherent with use of their inhalers than the younger participants. the majority of the sample (73%), lacked knowledge related to the illness of asthma and medication knowledge. the study only examined asthma drug adherence and not other aspects of the asthma treatment regimen. third, legoretta et al. (1998) surveyed over 5,000 adult asthma patients in the kaiser permanente hmo in california and found that more than 50% of the sample did not take their daily asthma inhalers as prescribed by the health care provider. this study was a landmark study in adult asthma treatment adherence because it had the largest sample and it was one of the few studies located to address adherence among adults with asthma. in summary, the three studies reviewed focused mainly on asthma medication adherence only. patient adherence to all aspects the recommended asthma treatment regimen, including inhaled medications (corticosteroids, bronchodilators), routine medical follow-up with exam, lung function monitoring, medication adjustment, and avoidance of triggers could potentially decrease morbidity and mortality among asthma patients (lynch et al. 2001). furthermore, health beliefs and attitudes are, theoretically, related to adherence with asthma treatment regimen (scherer & bruce, 2001). however, at the time this study was designed in 2000, no studies were located that evaluated the influence of health beliefs and attitudes on adherence with the asthma treatment regimen in adults with asthma. therefore, a more holistic approach examining multiple aspects of asthma treatment regimen adherence is justified. previous studies focusing on the adult asthma patient have shown that those diagnosed with asthma for a longer period of time, and older adults are more adherent with the treatment regimen compared to younger adults, and that attitude toward having the disease of asthma influences adherence to the asthma treatment regimen. knowledge of asthma has been shown to increase adherence rates with the asthma treatment regimen in some instances, but not consistently in asthma research focusing on asthma patient's knowledge of the disease of asthma (berg et al. 1997; boulet, 1998; scherer & bruce, 2001). research of adherence to treatment regimen for other chronic diseases many recent studies in people with chronic diseases other than asthma have provided evidence of associations between the desired outcome of treatment regimen adherence and health beliefs, attitude toward their illness, and behavioral intention to adhere (chesney, 2003; coombs, deane, lambert, & griffiths, 2003; dunbar-jacob, & mortimer-stephens, 2001; dunbar-jacob, bohachick, & sereika, 2003; duncan, & pozehl, 2003; holland, wiesel, cavallo, edwards, halper, kalb, morgante, narney, o'leary, & smith-williamson, 2001; johnson, 2002; konkle-parker, 2001; lo, 1998; lo, 2001; lutfey, & wishner, 1999; mikhail & petro-nustas, 2001; poss, 2000; rose, kim, dennison, & hill, 2000; rosina, crisp, & steinbeck, 2003; scherer, & bruce, 2001; stubblefield, & mutha, 2002; toljamo, & hentisen, 2001; vermeire, hernshaw, van royen, & denekens, 2001). research in chronic illnesses other than asthma has online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 34 operationalized the concepts in the health belief model and the theory of planned behavior, including health beliefs, attitude, and behavioral intention, and demonstrated the influence of those concepts' over adherence behaviors with recommended treatment regimens. specifically, knowledge, health beliefs, attitude, and behavioral intention have been correlated significantly with target behaviors and outcomes in hypertension, cancer, heart disease, and diabetes (grady & jaloweic, 1995; landenpera & kynagas, 2001). the positive correlations of these variables with treatment regimen adherence in patients with other chronic illnesses suggest that similar relationships may exist in asthma treatment regimen adherence, relationships that have not been investigated. these findings in patients with chronic diseases other than asthma, strengthens the evidence documenting the size and impact of the problem of adherence with asthma care. the limited research on adherence with asthma treatment regimens by rural adults justified this investigation. the purpose of this study was to investigate the influence of knowledge of asthma, health beliefs, attitude toward the illness of asthma, and behavioral intention to adhere on adherence behaviors with recommended asthma treatment regimens in rural appalachian adults. this study was guided by the following two research questions: 1. is there a significant relationship between the demographic variables of age, gender, education level, yearly income, age at diagnosis of asthma, number of family members with asthma, and adherence with prescribed asthma treatment regimens in rural appalachian adults with asthma? 2. does the combination of knowledge of asthma, health beliefs, attitude toward the illness of asthma, and behavioral intention to adhere predict adherence behaviors with prescribed asthma treatment regimens in rural appalachian adults better than any single variable alone? conceptual framework the model for investigation (see figure 1) was developed from selected concepts and their hypothesized relationships. the concepts are components from the health belief model (rosenstock, 1966; becker, drachman, & kirsch, 1974) and the theory of planned behavior (ajzen, 1988; ajzen, 1991), combined in an attempt to capture the complex phenomenon of adherence behaviors with recommended asthma treatment regimens. the health belief model (becker et al. 1974) postulates that in order for people to participate in behaviors that prevent illness, they must believe that they are personally susceptible to illness, that contracting the illness would have a negative impact on their life, that taking a particular action would be beneficial, and that taking action would not involve overcoming perceived barriers. the theory of planned behavior (ajzen, 1988) interprets social behavior on the level of decision-making. the conceptual elements of the theory of planned behavior are attitude, subjective norm, perceived behavioral control, behavioral intention, and the behavior itself. elements of the theory used for this study include attitude, behavioral intention, and the behavior itself (adherence). online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 35 figure 1. schematic model of investigation depicting hypothesized relationships between variables and corresponding instruments for empirical measurement. note. the study instruments are represented by the following abbreviations in the figure; kai = knowledge of asthma instrument, hbia = health belief instrument for adults diagnosed with asthma, atai = attitude toward asthma instrument, abii = asthma behavioral intention instrument, aai= asthma adherence instrument the model for investigation proposed sequential, linear relationships and postulated that knowledge influences health beliefs, which influence attitude toward the illness of asthma, which influences behavioral intention to adhere, which directly influences actual adherence behavior. literature supports the use of a combination of concepts from the health belief model and theory of planned behavior through studies examining adherence behaviors with recommended treatment regimens in chronic illnesses, such as tuberculosis, diabetes, and heart disease, to more completely explain the phenomenon of the performance or nonperformance of a particular target behavior. similar behaviors have been found in patients who deal with chronic illness. patients with asthma and other chronic illnesses have a need to believe in the effectiveness of the online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 36 treatment regimen in terms of medication and other possible uncomfortable or undesirable treatments. in addition, patient attitude combined with health beliefs and the intent to be adherent to what is perceived by the patient as an effective and beneficial treatment regimen over an extended period of time, has been found to be essential to the success in treating many chronic illnesses, including asthma. the possible lack of perceived immediate threat to the asthma patient in comparison to other, possibly more immediate life threatening chronic illnesses, may be a difference which needs to be considered in the adult asthma patient compared to other patients with chronic illness. in addition, lack of immediate medical resources in rural appalachia may additionally affect adherence to the recommended asthma treatment regimen (fishbein, bandura, triandis, kanfer, becker, & middlestadt, 1991; berg et al. 1997; poss, 2000; vandlandingham, suprasent, grandjean, & verasit, 1995). an assumption of this study was that, while treatment regimens for asthma are specific and prescribed by health care providers, the health care provider and patient work in a collaborative relationship to achieve mutual goals and positive outcomes with asthma care. the patient is an active, participating member in their care. the concept of adherence in this study was examined as the performance of recommended asthma treatment regimens and quantified to measure an outcome, and not as a judgment or reflection of persons as good or bad or a reflection of personal characteristics. method setting the setting for this descriptive, non-experimental study was a private allergy and asthma practice, located in western maryland, with approximately 6,000 patients. this site was selected because the researcher had enter, being employed at the practice during the time of this study. the practice serves western maryland, a large portion of northern west virginia, a small area of northwestern virginia, and western pennsylvania, all areas classified as rural appalachia by the united states government’s appalachia regional commission. there is not another specialty practice in allergy and asthma for an approximate 75-mile radius. sample a total of 250 patients met the specific criteria for the study, and were invited to participate. the patients were selected by manual chart review conducted by the researcher, and all patients who met the inclusion criteria were invited to participate. inclusion criteria were being an adult (18 years or older), living within the geographical study setting, and responsible for self-care. potential participants were diagnosed with asthma for varying lengths of time, ranging from 6 weeks to years; currently prescribed a daily inhaler (corticosteroid), an “as needed” bronchodilator (beta-agonist), also known as a “rescue” inhaler; and have been allergy tested and instructed to avoid specific environmental “triggers,” such as cats, dogs, dust mites, cut grass, weeds, and molds, all important aspects of asthma control, and stressed in the asthma treatment regimen. a potential participant was required to have been seen at the office at least one time prior to online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 37 participation in the study. criteria for inclusion in the study was determined by the researcher based on the diagnosis of asthma, medication regimen, and being a consenting adult. due to the limited number of eligible participants (many of the asthma patients seen at the practice are children), all adult patients being seen at the practice, meeting the inclusion criteria, were invited to participate in the study to maximize the sample size. power analysis was performed using the sample power computer program (borenstein, rothstein, & cohen, 1997). the minimal sample size was determined to be 98 based on the number of variables in the study. instruments the asthma questionnaire, consisting of a compilation of five different instruments, was developed for this study because no instruments existed that measure all of the specific study variables in an asthma population (putman, 2002; scherer, & bruce, 2001). the table in the appendix presents selected sample items from each instrument used in this study. the questionnaire had a section with 11 questions asking pertinent demographic data and the following five instruments: knowledge of asthma instrument (kai) (7 items), attitude toward asthma instrument (atai) (11 items), health belief instrument for adults diagnosed with asthma (hbia)(14 items), asthma behavioral intention instrument (abii) (6 items), and the asthma adherence instrument (aci) (4 items). all instruments were written at the 5th grade level, according to the fleschkincaid readability scale, and current medicaid and medicare reading level requirements for written materials as guidelines (flesch, 1974). content validity for all instruments used in this study was established by a panel of five health care practitioners with expertise working with adults with asthma. two members of the panel were medical doctors specializing in asthma care and treatment; one was a nurse practitioner; one a clinical nurse specialist; and one, an asthma nurse educator employed by a large pharmaceutical company. the content validity index was obtained for all instruments after the expert panel rated the relevance of each item in the instruments using a 4 point rating scale on a content validity form. the likert scale on the content validity form ranged from 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = very relevant (burns & grove, 1997). each instrument had the following calculated content validity index; the knowledge of asthma instrument (kai) .96, attitude toward asthma instrument (atai) .95, health belief instrument for adults diagnosed with asthma (hbia) .89, asthma behavioral intention instrument (abii) .96, asthma compliance instrument (aci) .93. the asthma questionnaire was pilot tested with a total of 32 rural appalachian adults with asthma. to avoid a potential confounding variable, patients included in the pilot study were excluded from participation in the main part of the study. patients in the pilot study consisted of those having an office visit during a specific 6-week time period and met the study inclusion criteria. a total of 35 patients were invited to participate in the study when they came in for an office visit, and 32 agreed to participate. a registered nurse explained the study to the patient, obtained informed consent, and administered the asthma questionnaire. most patients were able to complete the entire questionnaire within 15 minutes. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 38 reliability was evaluated using cronbach alpha for internal consistency reliability. the cronbach alphas ranged .62 to .76 in the pilot (n = 32) and .69 to .84 in the study (n = 102). the minimal acceptable internal-consistency reliability coefficient was based upon .7 for a newly designed instrument (burns & grove, 1997). construct validity for all instruments except the knowledge of asthma instrument (criterion-referenced instrument in multiple choice format), was established using exploratory factor analysis (tabachnick & fidell, 2001). items below the accepted eigenvalue of .3 were dropped after the pilot study and items above the .3 value were retained, unchanged and utilized in the sample of 102 patients. instruments were not retested in this study. the following describes each instrument in detail. attitude toward asthma instrument (atai). the atai, measuring attitude toward the illness of asthma, was designed based on suggestions by wigal, stout, brandon, winder, mcconnaughy, creer, and kotses (1993), researchers working on instrument development and testing with the concepts of attitudes and self-efficacy focusing on adults diagnosed with asthma. specifically, suggestions from those researchers that were addressed in the design of the atai included constructing the instrument on a 5-point likert scale format, and focusing on aspects of patient attitude toward managing asthma from day to day. items included in the atai are topics regarding the patient, healthcare provider relationship, attitudes toward taking asthma medications and following the asthma care regimen. the atai contains 11 items in a 5point likert scale format (1 = strongly disagree; 5 = strongly agree) measuring attitude toward asthma meaning the participant’s disposition to respond favorably or unfavorably to adhering to the performance and following of a regimen (inhalers, environmental precautions, etc.), institution, or event (disease of asthma) (ajzen, 1988). patient scores on the atai were obtained by summing the responses. the minimum possible score on the atai is 11, and the maximum possible score is 55. the internal consistency reliability of the atai was α = .70 in this study. health belief instrument for adults diagnosed with asthma (hbia). the hbia, measuring health beliefs, is based on a review of the literature (bennett, milgrom, champion, & huster, 1997) and the clinical asthma care experience of the investigator. the hbia contains 14 items in a likert scale (1 = strongly disagree; 5 = strongly agree) format measuring perceptions about the severity, susceptibility, threat, and seriousness of asthma, as well as the benefits of and barriers to performing prescribed asthma treatment regimens (becker et al. 1974). scores on the hbia were obtained by summing the patient responses. the minimum possible score on the hbia is 14, and αthe maximum possible score is 70. the internal consistency reliability was = .77 in this study. asthma behavioral intention instrument (abii). the abii, measuring how likely or unlikely an individual is to perform behaviors related to prescribed asthma and allergy treatment regimens, was designed from recommendations by fishbein and ajzen (1975) and ajzen (1988). specifically, suggestions from those researchers that were addressed in the design of the instrument were constructing the scale using a 7-point semantic differential format using the anchor terms of 1 = "unlikely" to 7 = "likely." the abii contains six items using a 7 point semantic differential scale format with anchor terms “likely” and “unlikely.” scores on the abii were obtained by summing the patient responses. the minimum possible score on the abii is 6, and the maximum possible score is 42. the internal consistency reliability was found to be α = .84. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 39 asthma adherence instrument (aai). the aai, measuring adherence, is based on literature related to adherence with asthma treatment regimens (ajzen, 1991; tettersell, 1993). the aai contains four items constructed on a 4-point likert scale format (1 = hardly ever; 4 = all of the time) and measures how often a person performs a specific component of the prescribed asthma regimen. scores on the aai were obtained by summing the patient responses. the minimum possible score on the aai is 4, and the maximum possible score is 16. the internal consistency reliability result for the aai was α =.69. knowledge of asthma instrument (kai). the kai, a criterion referenced, multiple choice format test, was constructed to measure mastery of knowledge about asthma. the kai is a 7item, 7-point multiple-choice exam that tests numerous facets of asthma knowledge, including knowledge of the disease of asthma and concepts related to routine self-management of asthma. the kai, developed by the investigator, is based on data included in the national institutes of health guidelines for the diagnosis and management of asthma (1997, 2002), current literature (theodorakis, 2000), and the clinical asthma care experience of the investigator. scores on the kai were obtained by summing the patient responses. the minimum possible score on the aai is 0, and the maximum possible score is 7. analysis of test-retest reliability of kai in future investigations is needed to establish evidence of reliability demographic sheet a demographic data sheet consisting of 11 items was included on the front the asthma questionnaire. demographic data collected included gender, age, highest level of completed education, marital status, residential location, yearly income level, occupation, health insurance status, length of time diagnosed with asthma, age at diagnosis with asthma, and number of family members also diagnosed with asthma. procedure following university institutional review board and study site approval, and a manual chart review by the researcher, all patients in the practice, who met the study inclusion criteria, received a mailed letter explaining the study, including contact information for questions regarding the study process, a cover letter, a questionnaire, and a stamped, addressed return envelope. participants were instructed not to include any self-identifying information when returning the questionnaire. study data were completely anonymous because questionnaires were not coded in any manner to link with patient identifiers. return of the questionnaire implied consent. dillman’s (1978) total design method was used to collect the data by mail. consistent with the dillman method and with the anonymous nature of this study, a postcard was sent out to each potential participant as a reminder one week after the initial mailing. three weeks after the initial questionnaires were mailed out, a follow-up letter and replacement questionnaire were sent to each participant as a reminder. data collection was stopped one week after this mailing, as specified by dillman's total design method. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 40 analysis bivariate correlation was used to analyze the relationships among all the variables to be examined as predictors of adherence to the recommended asthma treatment regimen. simple and stepwise regression analysis was also calculated. results descriptive statistics of sample a total of 102 of the 250 patients sent the questionnaire participated in the study, a 41% response rate. the age range of the sample was 19 to 80 years, with an average age of 44 years. twenty-five percent of the sample was male and 75% female, 100% were caucasian and 93% of the sample reported having either public or private health insurance. participants reported being diagnosed with asthma an average of 16.2 years, with the mean age of 16.8 years at diagnosis. the average number of other family members diagnosed with asthma was one person. for additional demographic data, see table 1. table 1 demographic data by category, number and valid percent (n = 102) category number valid percent gender male 22 25.0% female 80 75.0% marital status single 14 14.7% married 70 68.6% separated/divorced 14 13.7% widowed 3 2.9% income up to $5,000 1 1.1% $5,001-$10,000 11 10.5% $10,001-$20,000 12 13.0% $20,001-$30,000 20 21.7% $30,001-$40,000 24 26.1% $40,001 and above 24 26.1% education junior high school 2 2.0% high school 46 45.1% technical school 10 9.5% college 32 30.5% graduate school 12 11.4% online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 41 descriptive statistics of theoretical variables measures of central tendency, variability, and skewness were obtained for the total scores on each instrument measuring the theoretical variables examined and are summarized in table 2. findings revealed a range of scores on the instruments. scores on the knowledge of asthma instrument (kai), attitude toward asthma instrument (atai), asthma behavioral intention instrument (abii), and the asthma adherence instrument (aai) were statistically skewed to the left, meaning that overall, participants had acquired knowledge about the disease of asthma, attitudes toward asthma were positive, and patients intended to follow-through with the recommended asthma treatment regimen. the mean range of scores answered by participants on the kai were from 4 to 7 points, which suggests that participants had a high number of correct test items related to asthma knowledge. mean scores on the atai ranged from 33 to 55, and on the abii, the mean range of scores was 6 to 42. the scores on the atai and the abii indicated an overall positive attitude toward asthma and intention to adhere to the recommended asthma treatment regimen. participants reported a high adherence rate with the recommended asthma treatment regimen on the aai, meaning that participants were adhering to the recommended asthma treatment regimen. the scores on the health beliefs instrument for adults diagnosed with asthma (hbia) were approximately normally distributed. participants' mean scores on the hbia ranged from 44 to 70, indicating neutral results in regard to health beliefs, and no extremely skewed scores . table 2 range, mean, standard deviation (sd), median, mode, and skewness for study instruments (n = 102) instrument/ score range actual score m/sd mdn mode skewness kai (0 – 7) 4-7 6.42/.75 7 7 -1.16 atai (11-55) 33-50 44.35/3.97 45 46 -.613 hbia (44 – 70) 44-70 57.10/5.42 57 61 .029 abii (6 – 42) 6-12 35.58/6.53 37 42 -2.19 note. instruments in this table are represented by the following abbreviations: kai = knowledge of asthma instrument, atai = attitude toward asthma instrument, hbia = health beliefs instrument for adults diagnosed with asthma, abii = asthma behavioral intention instrument, aai = asthma adherence instrument research question 1: is there a significant relationship between the demographic variables of age, gender, education level, yearly income, age at diagnosis of asthma, number of family members with asthma, and adherence with prescribed asthma treatment regimens in rural appalachian adults with asthma? two demographic variables, age and length of time diagnosed with asthma, were found to have a significant relationship with adherence behaviors representing adherence with prescribed asthma treatment regimens in this sample of rural adult with asthma. age online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 42 was found to be moderately related to adherence behaviors (r = .344, p = .01). the older the patient, the more likely the patient was to be adherent to an asthma treatment regimen. a weak relationship was found between the length of time diagnosed with asthma and adherence behaviors (r = .209, p = .05). the longer the patient had been diagnosed with asthma, the more likely the patient was to be adherent with recommended asthma treatment regimens. none of the other demographic variables were significantly related to adherence behaviors with prescribed asthma treatment regimens. research question 2: does the combination of knowledge of asthma, health beliefs, attitude toward the illness of asthma, and behavioral intention to comply predict adherence behaviors with prescribed asthma treatment regimens in rural appalachian adults better than any single variable alone? relationships found between the study variables are presented in table 3. weak to moderate correlations were found among several of the variables, with the strongest relationship identified between health beliefs and attitude toward the illness of asthma (r = .586, p = .01). simple linear multivariate regression analysis revealed that three of the variables significantly contributed to the predictive value of adherence behaviors with prescribed asthma treatment regimens. health beliefs accounted for 16.7 % (p = .01) of the variance in adherence behaviors, with attitude toward the illness of asthma explaining 15.6 % (p = .01), and behavioral intention to comply explaining 12.6 % (p = .01) of the variance. knowledge of asthma was not a significant contributing variable to the variance in asthma adherence behaviors. table 3 intercorrelations between study variables variable 1 2 3 4 5 1. knowledge --.134 .202* .041 .073 2. health beliefs -- .586** .305** .409** 3. attitude -- .467** .394** 4. behavioral intention -- .354** 5. adherence -- *p = .05. **p = .01 when evaluating the relative contribution of the candidate predictors to adherence with recommended asthma treatment regimens using stepwise linear multivariate regression analysis, the best model explained 32.3% (r2 = .323, p < .0001, f = 20.033) of the variance in adherence and consisted of two variables: health beliefs (r2 = .167, p < .0001, f = 19.238) and attitude toward asthma (r2 = .156, p < .0001, f = 18.431) (table 4). thus, regression analysis showed that the combination of health beliefs and attitude toward asthma better predicted adherence behaviors with prescribed asthma treatment regimens among this sample of rural appalachian adults diagnosed with asthma better than any one variable alone. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 43 table 4 summary of simple and stepwise regression analysis for variables predicting adherence behaviors in rural appalachian adults with asthma (n = 102) variables r2 f test β simple regression knowledge .000 .036 -.019 attitude . 156 18.431** .394 health beliefs .167 19.238** .409 behav. int. .126 14.356** .354 stepwise regression health beliefs .167 19.238** .409 attitude .156 18.431** .409 health beliefs and attitude .323 20.033** .584 p < .0001** description and implications for practice the findings that both health beliefs and attitude toward asthma were predictors of adherence with asthma treatment regimen provide the first empirical evidence from research of these theorized relationships in adults with asthma. these findings also suggest that the model for investigation be modified to reflect non-sequential, non-linear relationships prior to future investigations as suggested in by the relationships in table 3. also, the demonstrated relationships between adherence, age, and length of time since diagnosis suggest that patient characteristics be added to the model of investigation for future investigations because, in a larger sample, these variables may be predictors of adherence. the correlation between age and adherence was consistent with several studies looking at adults with asthma and adherence with and knowledge of asthma medications. older patients tended to be more adherent to prescribed asthma medications and younger patients tended to be less adherent (abdulwadud, abramson, forbes, james, light, thien, & walters, 1997; tettersell, 1993). this suggests that future programs designed to assist rural adult asthma patients with adherence behaviors related to prescribed asthma treatment regimens may need to have certain aspects of the program geared toward the specific needs of younger adults. certainly, additional research is needed to examine age issues related to adherence behaviors in rural adults with asthma. health beliefs as a predictor of adherence with asthma treatment regimen is consistent with other findings in the literature examining adherence behaviors in other chronic illnesses (bennett et al., 1997; chesney, 2003; holland et al. 2001; lo, 1998). nursing practice with the rural adult asthma patient must take into account the deeply grounded health beliefs held by individuals. this supports the team approach, collaborating with the patient in order to bring about the best outcomes in asthma care. by having an awareness of the patient’s health beliefs, the nurse may be able to work with the patient to improve the overall success of long-term asthma treatment outcomes instead of imposing a situation, which, the patient feels has no value or benefit. these online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 44 results stress the need for congruence and consistency between the nurse and the adult with asthma. the nurse also needs to help the patient gain access to health care in a way that the patient feels is realistic and obtainable, in addition to being consistent with their perceived abilities. patient attitude toward the illness of asthma as a significant predictor of adherence behavior with the asthma treatment regimen also is consistent with research findings in other chronic illnesses and health conditions (jennings, 1997; jennings-dozier, 1999; poss, 2002). a careful baseline nursing evaluation of the rural adult asthma patient's attitude toward having asthma is needed prior to establishing a mutual care planning session with the patient. this will assist the nurse to have a unique perspective about the patient's perception of asthma, and facilitate an individualized approach with each patient, thus increasing the likelihood of a successful patient care asthma outcome. behavioral intention as a predictor of adherence with the asthma treatment regimen suggests that patients need to internalize the value of treatment regimens as beneficial. nurses may stress the importance of adhering to specific treatment regimens; however, if the value of that regimen is not supported and internalized by the patient, it is likely that adherence will not occur. again, the nurse needs to engage in a collaborative, team approach with the patient in an effort to stress the value and benefit of the treatment to the patient, thus potentially improving outcomes. this study contributes to the literature of adherence behaviors related to prescribed and recommended asthma treatment regimens in rural adults with asthma, specifically focusing on rural appalachia. research related to asthma and adherence behaviors in rural adults with asthma is sparse, thus, this descriptive study was conducted to contribute to an understanding of rural populations of adults diagnosed with asthma. the study pinpoints variables that were significantly related to adherence behaviors including knowledge, health beliefs, attitude, and behavioral intention to comply with the recommended asthma treatment regimen. three of the four theoretical variables (attitude, health beliefs, and behavioral intention) and two patient characteristics (age and length of time diagnosed with asthma) were related to adherence behaviors. however, of those five variables, health beliefs and attitude toward asthma together were the strongest significant predictors of adherence behaviors with the recommended asthma treatment regimen. although no comparable studies focusing on adults with asthma exist with which to compare these findings, they do provide support for some of the theorized relationships in the model investigated. knowledge of asthma was not a significant correlate or predictor of adherence behaviors with this group of rural appalachian adults with asthma, even though other studies in the literature suggest that knowledge is a significant predictor of adherence behaviors with varying groups of people diagnosed with other chronic illnesses (boulet, 1998). the findings suggest that the variables examined (knowledge, health beliefs, attitude, behavioral intention, and adherence behaviors) are not related in a linear, “domino effect” fashion as hypothesized. adherence behaviors and factors that predict whether or not a person will be adherent are multifaceted. human behavior does not follow a straight line, and must be viewed in a holistic manner, keeping in mind that the whole is greater than the sum of the parts. adherence behavior is complex and is influenced by many factors in a person’s life. use of path analysis in future studies would reveal the direct and indirect effects of these variables on adherence. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 45 overall results of this study indicated that health beliefs and attitude toward asthma demonstrated significant predictive influence over adherence behaviors with prescribed asthma treatment regimens. therefore, an in-depth understanding of factors influencing adherence behaviors is essential for nurses to employ the best strategies to improve asthma outcomes. this understanding will help practicing nurses have a better idea of the rural adult’s personal experiences of living with and coping day to day with the chronic disease of asthma. these results have clinical implications for practicing nurses and researchers and provide a launching platform from which to proceed with further study. when nurses work with asthma patients, they need to work with the patient using a collaborative approach to “connect” and listen to the message the patient is sending and assist the patient to deal with possibly overwhelming feelings related to the self-management of asthma, in addition to respecting individual health beliefs and integrating those beliefs into the plan of care. the nurse needs to assess patients’ health beliefs, attitude, and behavioral intentions to adhere in relation to chronic illness, in this case asthma. care and treatment of rural adults with asthma must focus on the person, not simply the “nuts and bolts” of asthma care. the nurse must function as an active listener, supporter, and mutual planner with the patient through a partnership that facilitates the achievement of the greatest degree of positive asthma care outcomes. adult asthma patients need to be assisted to internalize the degree of their susceptibility to the detrimental effects of the disease of asthma and the benefits of adhering to the asthma treatment regimen into their belief system. it is premature to suggest specific nursing interventions on precisely how this can be achieved. however, based on the results of this study, future investigation with a larger sample that is more characteristic of the population in rural appalachia is needed to better inform future nursing interventions to assist rural adults with asthma. strengths and limitations the strength of this study is that it is the first to address adherence issues among rural adults with asthma using a combination of the health belief model and the theory of planned behavior. the findings of this study support the utilization of the model and theory together to explain some of the variance in adherence behaviors. the study had good internal validity. the instruments used to measure concepts had content and construct validity and internal consistency reliability. the study also presents several new instruments measuring health beliefs, attitude, behavioral intention, and adherence behaviors among rural adults with asthma, for consideration and further development and testing. preliminary and limited psychometric testing has been performed on the newly developed instruments in this study. testing with a larger sample size of adults with asthma needs to be considered in order to strengthen the validity of these instruments. the limitation of the study pertains to external validity or generalizability, because the sample was not representative of the rural appalachian population with asthma due to the nature of the convenience sample recruited from the asthma clinic. first, 70% of those who were eligible for participation in the study were women, while us census bureau (2001) statistics indicate that about 51.4 % of the rural appalachian population are female. second, the demographic data indicated that subjects were welleducated and earned relatively high incomes (52.2 % earned $30,000 and above annually). online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 46 these demographic data indicate the study sample is not typical of the population residing in the rural, geographical area in which this study was conducted. finally, an uncontrollable confounding event may have influenced participant response and profile, contributing to the lower response rate than usually achieved with the dillman method (dillman, 1978) and to the sample not being representative of the rural appalachian population with asthma. the dillman total design method is a recommended method to increase mailed survey returns. questionnaires and cover letters were mailed to qualified patients. in one week, a postcard was sent out to each patient as a reminder including the topic of the study, and signed by the primary investigator. three weeks after the initial mailing of the questionnaires, a follow-up letter and replacement questionnaire was sent to each patient as a reminder. questionnaires were initially mailed on monday, september 10, 2001, one day prior to a national crisis in the united states, the terrorist attacks at the world trade center in new york city, and the pentagon in washington, d. c. the fourth hijacked plane crashed within the rural area in which the study was being conducted. the problem with anthrax contamination in the us postal system occurred during the time for follow-up mailings for this study. the effect of these events on the return rate of questionnaires by mail and on study results is unknown. future research the results of the study are a beginning foundation of support for the future design of exploratory studies and resulting interventional programs that nurses may use in their practice to serve rural adult asthma patients by helping to decrease morbidity and mortality rates related to asthma. future study should focus on a replication of this study with a larger sample of rural appalachian adults, which is more representative of the known rural adult appalachian population mix. additional research recommendations, based on the results of this study, include the design and implementation of interventional studies using a larger sample size to establish the best methods for delivering asthma education and treatment programs for rural adults with asthma. in addition, further confirmatory psychometric testing, expansion, and evaluation should be performed on the instruments designed for this research study. little research has focused on the rural adult diagnosed with asthma and adherence behaviors with prescribed asthma treatment regimens indicating that this topic is in need of further examination and development. conclusions the findings of this study are applicable to the clinical research setting. preliminary results suggest that nurses who work with rural adults with asthma should be aware of specific variables, especially health beliefs, attitude, and behavioral intention to adhere to recommended asthma treatment regimens in order to deliver better and more effective nursing care to this population. since this is the first study investigating these relationships specific to adults with asthma living in a rural setting, additional research is needed to confirm these findings. additional psychometric testing must be performed on the instruments. nurses must take into consideration the experiences and attitudes of rural adults with asthma to improve outcomes for these patients. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 47 author note the author wishes to acknowledge dr. shirlee drayton-hargrove, widener university, for her guidance of this study, and dr. june larrabee, west virginia university, for guidance in development of the manuscript, and dr. patricia simoni, west virginia university, for her editorial peer review of the manuscript. references abdulwadud, o., abramson, m., forbes, a., james, a., light, l., thien, f., & walters, e. 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[medline] appendix example of selected items from instruments comprising the asthma questionnaire ________________________________________________________________________ knowledge of asthma instrument (kai) (multiple choice format) what happens to a person's lungs during an asthma episode? a. swelling and inflammation b. muscles tighten c. mucus increases d. all of the above what are the classic symptoms of asthma? a. coughing and/or shortness of breath b. loss of hair and/or acne c. wheezing and/or tightness in the chest d. a and c which of the following factors may trigger an asthma attack? a. history of a rib fracture b. tobacco smoke c. leg cramps d. an ingrown toenail attitude toward asthma instrument (atai) (5-point likert scale format) taking my asthma medication is important to me. i want to work in partnership with my healthcare provider in taking care of my asthma. learning as much as i can about my asthma is important to me. my asthma is not problem to me as long as i feel alright. health belief instrument for adults diagnosed with asthma (hbia) (5-point likert scale format) i believe i will always need my asthma medications. i would have to change too many habits to follow taking my medications as prescribed by the doctor. my asthma would be worse if i did nothing about it. i believe my asthma medications will control my asthma. i believe i can control my asthma. asthma behavioral intention instrument (abii) (7-point semantic differential format) online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11679023 http://www.wvdhhr.com/hp2010/objective http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8404182 51 i will take my asthma medications daily as prescribed. i will make an effort to avoid items in the environment that i know i am allergic to. i will keep my next follow-up appointment with the allergist. asthma adherence instrument (aai) (4-point likert scale format) how often over the past 3 months did you take the asthma medications prescribed by the doctor? how much of the time during the last 3 months did you follow the environmental precautions for items you are allergic to as recommended by the doctor? how much of the time during the past 12 months have you kept your follow-up appointment with the allergist? ________________________________________________________________________ note. table includes a sample of items chosen from each instrument developed and utilized for this study. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 microsoft word 333-1721-1-ed_fahs.docx online journal of rural nursing and health care, 14 (1) 1 http://dx.doi.org/10.14574/ojrnhc.v14i1.333 editorial the importance of reviewers pamela stewart fahs, rn, dsn, editor i recently attending a session at the eastern nurses research society in philadelphia, pa and was able to attend a workshop on “publishing in high-impact nursing journals”. four of the top nursing journals were represented by their editors. one point in their presentations was the importance of those in the professional community who give so unselfishly of their time and effort in the role of journal reviewers. i know how important this role is for the journal of rural nursing and health care. we are an open source journal, and can be accessed free of charge electronically. we do not charge our authors for publication of the manuscript. unlike the bigger journals, we do not have a paid staff. everything done for this journal is done because of the commitment to rural health and populations along with the importance of scholarship. this journal is the official organ of the rural nurse organization (rno) and we often call upon our colleagues to review manuscripts. those answering the call are so appreciated, but they are few in number in an organization the size of the rno. there is a need for more of us to step up and take the challenge to review. reviewing can be helpful to the referee by: (a) keeping you abreast of the field, (b) exposing you to more examples of writing which ultimately can help your own scholarship, and (c) this role can be helpful in promotion for both academic ranks and clinical ladders. much of the benefit gained from those who are reviewers for journals goes to the individuals who submit their manuscripts for consideration. you as a reviewer can help the author(s) see where a passage needs to be strengthened or where flow of the writing can be enhanced. you help them see problems that they may not be able to recognize because they are so close to the piece. you can online journal of rural nursing and health care, 14 (1) 2 http://dx.doi.org/10.14574/ojrnhc.v14i1.333 bolster their confidence by pointing out what works well and encouraging them to pull one more piece into the findings that connect the work to rural nursing. having a broader base of reviewers strengthens the journal and the discipline by increasing the breadth and depth of expertise. we seem to attack a lot of manuscripts on issues of advanced practice nursing, so having nurse practitioners and clinical nurse specialist on the list of reviewers is very helpful. we also attract a wide range of topical areas, and population focused work. if you are interested in reviewing please email me at psfahs@binghamton.edu with your contact information and a curriculum vita or resume. if you are working with a colleague who should be reviewing, please give them my contact information. most of the time those chosen to review have been published themselves. however, i am also looking for people who are expert clinicians in many health care topics. for those of you who do review for the online journal of rural nursing and health care, thank you for your contribution to the discipline, scholarship and this journal. microsoft word mallow_276-1653-1-ed.docx online journal of rural nursing and health care, 14(1) 43 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 using mhealth tools to improve rural diabetes care guided by the chronic care model jennifer a mallow, phd, fnp-bc 1 laurie a theeke, phd, fnp-bc, gcns-bc 2 emily r barnes, dnp, fnp-c 3 tara whetsel, pharmd, bcacp, bc-adm 4 brian k mallow, pmp, mcdba, mcse, mcsd 5 1 wvctsi scholar, assistant professor at west virginia university school of nursing, jamallow@hsc.wvu.edu 2 associate professor at west virginia university school of nursing, ltheeke@hsc.wvu.edu 3 clinical assistant professor at west virginia university school of pharmacy, ebarnes@hsc.wvu.edu 4 clinical associate professor at west virginia university school of nursing, twhetsel@hsc.wvu.edu 5 consultant at sovern run llc, bkmallow@gmail.com abstract background and objective: used as an integrated tool, mhealth may improve the ability of healthcare providers in rural areas to provide care, improve access to care for underserved populations, and improve biophysical outcomes of care for persons with diabetes in rural, underserved populations. our objective in this paper is to present an integrated review of the impact of mhealth interventions for community dwelling individuals with type two diabetes. materials and methods: a literature search was performed using keywords in pubmed to identify research studies which mhealth technology was used as the intervention online journal of rural nursing and health care, 14(1) 44 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 results and discussion: interventions using mhealth have been found to improve outcomes, be cost effective, and culturally relevant. mhealth technology that has been used to improve outcomes include: seeking out health information via the web, access to appointment scheduling and medication refills, secure messaging, computerized interventions to manage a chronic condition, use of a personal health record, use of remote monitoring devices, and seeking support from others with similar health concerns through social networks. conclusion: using the validated chronic care model to translate what is known about mhealth technology to clinical practice has the potential to improve the ability of healthcare providers in rural areas to provide care, improve access to care for underserved populations, and improve biophysical outcomes of care for persons with diabetes in rural underserved populations. while these approaches were effective in improving some outcomes, they have not resulted in the establishment of the necessary electronic infrastructure for a sustainable mobile healthcare delivery model. keywords: mhealth, rural, diabetes, chronic care model using mhealth tools to improve rural diabetes care guided by the chronic care model mobile health (mhealth) is an emerging field that has been defined as “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices” (istepanian, laxminarayan, & pattichis, & 2006). in the united states, there is widespread use of mobile devices and access to broadband internet service is improving (smith, 2010). applications using mhealth devices are being developed to improve and augment the care of type 2 diabetes patients in the community (katz r, 2012). however, careful attention to existing healthcare delivery structures must be online journal of rural nursing and health care, 14(1) 45 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 considered during development of mhealth applications. use of the validated chronic care model will assist in successful and sustainable implementation of mhealth as a treatment option. background & significance rural populations with low socioeconomic status are at higher risk of poor diabetes control, decreased self-management, and development of complications (utz, 2008). there are 62 million americans currently residing in rural areas (denavas-walt, proctor, & smith, 2011) and it is estimated that 20 percent of this rural population is uninsured. even with healthcare reform, this number is projected to increase to 25 percent by 2019 (garrett, loan, headen, & holahan, 2010). in the united states, diabetes is most prevalent in the rural southeastern region (barker, kirtland, gregg, geiss, & thompson, 2011). nearly 12 percent of people in this region have diabetes compared to 8.5 percent in the remainder of the country. due to a lack of primary care providers in rural, underserved areas, there is a critical need for development and effectiveness testing of novel interventions that could improve health outcomes such as: effective patient–provider communication, adherence to treatment, selfmanagement ability, and biophysical outcomes. achieving these improved outcomes must be done while allowing primary care providers to deliver culturally acceptable interventions that optimize time-efficiency and affordability (barker et al., 2011). the ability of such interventions to improve care and reduce strain on rural healthcare practices will depend on the effective use of technology (effken & abbott, 2009). our objective in this paper is to present an integrated review of the impact of mhealth interventions for community dwelling individuals with type 2 diabetes. the review structure is based on the chronic care model and a model of evidence-based healthcare delivery is proposed. structuring what we know about mhealth technology using the concepts of the model online journal of rural nursing and health care, 14(1) 46 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 adds clarity to the literature review and assists with translation to clinical practice. the chronic care model has been used in clinical practice for over 12 years and is designed to assist healthcare practices to improve patient health outcomes by changing the routine delivery of care. figure 1:the chronic care model figure 1: edward h. wagner, md, mph, chronic disease management: what will it take to improve care for chronic illness? effective clinical practice, aug/sept 1998, vol 1 (wagner, 1998). disclaimer: the american college of physicians is not responsible for the accuracy of the translation. this is done through six interrelated system changes meant to make patient-centered, evidencebased care easier to accomplish (roger et al., 2012). the major concepts in the model are the health system, community support, self-management support, decision support, clinical information systems, and delivery system design (pullicino et al., 2011). a prepared healthcare online journal of rural nursing and health care, 14(1) 47 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 team delivering planned interactions, self-management support with effective use of community resources, integrated decision support, and supportive information technology (it) are designed to work together to strengthen the provider-patient relationship and improve health outcomes (pullicino et al., 2011). therefore, the literature in this article will be presented based on the major concepts of the chronic care model (see figure 1). methods the pubmed data base was searched from late june to mid-august 2012. the following search terms were used: ‘diabetes and mhealth’ ‘diabetes and telemedicine’ ’mhealth and health disparities’, ‘mhealth and chronic care model’ ‘mhealth and clinical information systems’. limits were set for articles that were published in the last five years, and published in the english language. the inclusion criteria were: (1) studies which included participants with type 2 diabetes; (2) mhealth technology was used in the intervention (3) there was randomization of participants to intervention and control groups. literature reviews and state of the science papers were reviewed for individual references, but not included in this review. a total of 157 articles were found. after examining the title, abstract and keywords of retrieved records, we identified 23 articles meeting the inclusion criteria. the articles were then reviewed via a matrix method and placed into categories based on the concepts of the chronic care model. health system five articles were found that incorporated health system changes using mhealth interventions. health system characteristics are traditional structure and process elements of organizations, such as size, ownership, skill mix, and technology. the health system online journal of rural nursing and health care, 14(1) 48 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 characteristics are considered to directly affect and be affected by patient outcomes. the system characteristics mediate the relationship between patient characteristics and interventions in producing patient outcomes (mitchell, ferketich, & jennings, 1998). the system of interest to us is the rural healthcare delivery system. compared with their urban counterparts, rural residents are more likely to be poor, be in fair or poor health, and have chronic conditions. rural residents are less likely than their urban counterparts to receive recommended preventive services and on average report fewer visits to health care providers. uninsured, rural adults are more likely to report the following difficulties: access to care, referrals to specialists, and timeliness of care for an illness or injury (agency for healthcare research and quality, 2008). in recent years, the united states through the center for medicare and medicaid services (cms) and a number of private health plans has relied on the use of technology with disease specific registries to facilitate tracking and the provision of quality care (muntner et al., 2011). diabetes is well suited to the use of clinical information technology and use of emrs because its management is routinely characterized by easily quantifiable outcomes and process measures (kleindorfer et al., 2011). it is feasible to incorporate mhealth technologies into an existing healthcare system (see table 1). however, it is evident from this review that problems in mhealth technology use still exist and need consideration. face-to-face communication, live technical support, and cost are found to affect use of mhealth tools by patients. technical problems and difficulty of use increased the likelihood of patients stopping use of the mhealth technology and one study reported that telephone interventions were as likely to improve outcomes as mhealth interventions. hence, developing a model of healthcare delivery using mhealth technologies online journal of rural nursing and health care, 14(1) 49 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 must incorporate live technical support, be easy for users, include face-to-face communications, have a lower cost to patients than traditional interventions, and incorporate back-up interventions for technical issues that cannot be resolved in real time. table 1 mhealth and health systems reference sample size purpose results rabin and bock, 2011 14 to evaluate smart phone physical activity assistants smart phone physical activity assistants are feasible for tracking physical activity from a distance. basoglu, daim, and topacan, 2012 22 to evaluate the attributes and preferences of mhealth service by users users preferred low input effort, availability of face-to face communication, live technical support, quick response time, and low cost istepanian et al., 2009 137 bluetooth transmitted glucose readings that were viewed with a webbased application. attrition was higher in the intervention group due to technical problems. those who completed the intervention group had lower a1c than those in the control group. zolfaghari, mousavifar, and pedram, 2009 77 compare the effectiveness of sms texting to nurse telephone calls for follow up care both groups had a significant reduction in a1c and were feasible for patients. online journal of rural nursing and health care, 14(1) 50 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 reference sample size purpose results lyles et al., 2011 8 use of the web and cell phones with a case manager to provide feedback on finger sticks qualitative analysis shows that participants expressed frustrations with using the cell phones but liked the wireless system for collaborating with healthcare professionals and receiving automatic feedback on their blood sugar trends. community resources & policies the chronic care model recognizes the influence of community on patient outcomes (kabagambe et al., 2011). patients traditionally seek health information in three ways: on their own, from professionals, and from friends and family (ahern, woods, lightowler, finley, & houston, 2011). the use of technology does not change this pattern. due to the ubiquitous nature of mobile devices and the internet, our idea of community has expanded from the traditional definition, people living in a particular area or place, to a much boarder network of social connections. patients seek support from others with similar health concerns or conditions through lists-serves and social networks (fox, 2011). social networks bring peer support directly to patients without leaving one’s home (ahern et al., 2011). therefore, current conceptualizations of community should include the on-line community, which can be defined as a network of individuals who interact through media, crossing geographical boundaries but united by a particular topic, interest, or goal. patients can now access health information, healthcare clinics, and providers through internet searches, secure e-mail, messaging, online medication refills, appointment requests, and secure patient access to electronic medical records (emr) (halanych et al., 2011; judd et al.; online journal of rural nursing and health care, 14(1) 51 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 muntner et al., 2012; wadley et al., 2011). the internet allows patients to quickly access vast amounts of disease specific information. enhanced understanding of how patients seek health information may improve the way healthcare systems incorporate technology into the delivery of care. while an enormous amount of information is available with the click of a button, the quality of that material varies. in the united states, there is widespread use of mobile devices and access to broadband internet service is improving (smith, 2010). the accessibility of 3g service is available and reliable in the most densely populated areas of the united states. however, when considering implementing mhealth interventions in a rural population, 3g service is not always reliable. still, many of these areas have access to 1g and wired connections that could allow participation in mhealth interventions. it has been reported that even in the most rural areas of the united states, 77% of adults have a cell phone, which is only 10% less than more urban areas (zickuhr, 2013). six in ten adults (63%) go online wirelessly with one of these devices (smith, 2010). self-management diabetes self-management includes mindfulness related to: eating habits, physical activity, monitoring blood glucose, medication taking, and communicating with healthcare professionals (unverzagt et al., 2011). evidence shows that patients who participate actively in their care achieve valuable and sustained improvement in physical and psychological well-being (howard et al., 2011). the use of technology is making it possible to empower patients to learn new skills, enhance their self-management abilities, and structure personal care routines related to their illness (kleindorfer et al., 2011). handheld devices can be used by patients and health care providers to support selfmanagement of diabetes. through a phone and an internet site, patients can upload information online journal of rural nursing and health care, 14(1) 52 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 about their illness so that it can be interpreted by health care providers and patients can receive more immediate feedback. technology allow patients to receive appointment reminders, education, and health behavior support, as well as measure glucose levels, blood pressure and weight and transmit this health information directly to data stores for clinical evaluation (ãrsand, tufano, ralston, & hjortdahl, 2008; cho, lee, lim, kwon, & yoon, 2009; cox et al., 2011; earle, istepanian, zitouni, sungoor, & tang, 2010; faridi et al., 2008; jae-hyoung, hye-chung, dong-jun, hyuk-sang, & kun-ho, 2009; logan et al., 2007; quinn et al., 2009; soliman et al., 2011; turner, larsen, tarassenko, neil, & farmer, 2009; yoo et al., 2009; zweifler et al., 2011). not only have patients found that the use of mhealth tools are feasible and culturally acceptable, but as shown in table 2 there have been improved outcomes for diabetes patients include improved a1c, decreased blood pressure, improved cholesterol levels, improved adiponectin levels, stable c-reactive protein and stable interleukin-6 levels (ãrsand et al., 2008; cho et al., 2009; cox et al., 2011; earle et al., 2010; faridi et al., 2008; jae-hyoung et al., 2009; logan et al., 2007; quinn et al., 2009; soliman et al., 2011; turner et al., 2009; yoo et al., 2009; zweifler et al., 2011). table2 self-management of diabetes via mhealth technologies. reference sample size (n) length of study intervention description outcome yoo et al., 2009 123 3 months text messages with bluetooth glucose monitoring & exercise monitoring. feedback improved a1c & bp, cholesterol. decreased adiponectin levels in intervention group. c-reactive protein and interleukin-6 levels online journal of rural nursing and health care, 14(1) 53 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 reference sample size (n) length of study intervention description outcome provided immediately based on algorithms. remained the same in both groups. faridi et al., 2008 30 3 months impact on clinical outcomes using tailored daily messages via cell phone improved a1c and self-efficacy scores for intervention. technology was not user friendly. jae-hyoung et al., 2009 69 3 months intervention glucose-monitoring data were automatically transferred to their emr and they received medical recommendations by short text message. significant decrease in a1c levels. quinn et al., 2009 30 3 months mobile phone application wirelessly obtained from the glucometer and transmitted glucose readings to automated database with real-time feedback and lifestyle recommendations significant decrease in a1c levels. turner et al., 2009 23 3 months mobile phone wirelessly obtained and transmitted glucose readings; real-time feedback of input and semiautomated messages for selfsignificant decrease in a1c levels. online journal of rural nursing and health care, 14(1) 54 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 reference sample size (n) length of study intervention description outcome management logan et al., 2007 33 4 months bluetooth enabled bp cuffs and mobile phones were provided to patients in order to transmit data to a central server for data processing then fax was used to send reports to physicians. bp decreased significantly. patients perceived the system as acceptable and effective. earle et al., 2010 137 6 months patients used adapted sensors via bp cuffs and mobile phone to transmit weekly bp readings and received real time feedback using a webbased application bp decreased significantly. those with the most decreased bp also had decreased glucose levels. zweifler et al., 2011 51 6 months text messages sent by providers based on review of data provided by patient via internet. significant decrease in a1c levels. soliman et al., 2011 43 6 months pda recording of blood glucose, medications, meals, exercise, etc., with summary output significant decrease in a1c levels. cox et al., 40 3 months customized schedule for significant decrease in a1c levels. online journal of rural nursing and health care, 14(1) 55 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 reference sample size (n) length of study intervention description outcome 2011 sms reminders to obtain blood glucose readings. reading submitted via sms resulted in positive feedback if in range, and instructions if out of range cho et al., 2009 69 3 months combination mobile phone and glucometer transmitting glucose reading to provider who sent treatment adjustments via sms significant decrease in a1c levels. decision support decision support is defined as embedding evidence-based guidelines into daily clinical practice and integrating the expertise of specialists into primary care practices (kabagambe et al., 2011). a typical way of interacting with specialists is for primary care practices to send patients to specialist visits and hope to get a letter back in return. through the use of technology, we can get beyond traditional referral letters to real-time consultation and exchanges with patients and providers in different locations. primary care providers, specialists, care teams, and individual patients can benefit from problem or case-based learning, collaborating across geographical boundaries through the use of chat, voice, and video communications (basoglu et al., 2012; istepanian et al., 2009; lyles et al., 2011; rabin & bock, 2011; zolfaghari et al., 2009). these technologies will allow providers to jointly inform patients about guidelines and information online journal of rural nursing and health care, 14(1) 56 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 pertinent to their care without lengthy waits between primary care visits and specialist appointments. this shift in the delivery of care allows for shared decision making and education between patients and the care team (pullicino et al., 2011). this type of decision support will take a drastic change in the healthcare system. while mhealth tools have the potential to change practice, the authors could not find articles related to community dwelling type 2 diabetes patients and use of imbedded decision support. clinical information systems clinical information systems are used to collect, integrate and distribute information within the context of a healthcare setting (pullicino et al., 2011). the extent to which these resources and services are available varies widely. while rural healthcare clinics are often the last to adopt such practice changes due to cost, there are several free electronic medical record programs that can be incorporated into non-profit and free clinic settings. integration of secure messaging, evisits, home monitoring with feedback, health-risk appraisal with feedback, medication refills, tailored interventions, social network services, and links to community programs is now possible (ahern et al., 2011). a delivery system redesign is needed to develop patient-centered clinical information systems. these information systems can be incorporated, with little cost, into free clinic settings. delivery redesign living in rural areas presents multiple barriers, one of which is limited access to care due to distance (arcury, preisser, gesler, & powers, 2005). rural populations with low socioeconomic status have poor outcomes and the lack of primary care providers in rural, underserved areas demands a shift in healthcare practices. through the widely validated chronic care model, it is possible to deliver care to patients in their homes in remote underserved areas. bluetooth online journal of rural nursing and health care, 14(1) 57 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 enabled devices and the use of chat, voice, and video communications allows the healthcare team to provide many of the elements of a traditional office visit. a delivery system redesign is needed to develop patient-centered clinical information systems within the rural health care clinic setting. the use of innovative technology affords a low-cost, flexible means to supplement formal healthcare and is central in reshaping the care of rural populations. developing a model of healthcare delivery using mhealth technologies should incorporate live technical support, be easy for users, include face-to-face communications, have a lower cost to patients and practices than traditional interventions and incorporate back-up interventions for technical issues that cannot be resolved. provider approved educational content, social networking and access to emr is still needed within the context of the healthcare system redesign (see figure 2). discussion individuals with low socioeconomic status living in rural parts of the u.s. suffer disproportionately from poor health status, health disparities, and problems in accessing healthcare. the current rural healthcare system places the burden of caring for diabetes on patients and families who have very few resources. the cost of travel due to long distances between rural healthcare clinics and patients’ homes frequently prevents patients from seeking needed healthcare. mobile technologies are a promising approach to solving health disparities. used as an integrated tool and based on sound practice models such as the chronic care model, mhealth may improve: the ability of healthcare providers in rural areas to provide care, access to care for underserved populations, and biophysical outcomes of care. although individual interventions to impact outcomes for diabetes patients using technology have been studied, no approach to date has used an integrated system of mhealth tools to deliver healthcare at a distance within existing rural health clinics. individual mhealth interventions have been online journal of rural nursing and health care, 14(1) 58 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 found to improve outcomes, be cost effective, and culturally relevant. examples of how technology has been used to improve outcomes include: patients seeking out health information via the web, access to services such as appointment scheduling and medication refills, communication with providers via secure messaging, engaging with computerized interventions to manage a chronic condition, use of a health record to store personal health information, use of remote monitoring devices such as blood pressure monitors, glucometers, and scales, and seeking support from others with similar health concerns or conditions through social networks. conclusion using the validated chronic care model to translate what is known about mhealth technology to clinical practice will assist in developing a model of healthcare delivery using mhealth technologies that is usable and meaningful to both patients and rural healthcare providers. a delivery system redesign using mhealth technology must incorporate live technical support, be easy for users, include face-to-face communications, have a lower cost to patients and rural providers than traditional interventions, and incorporate back-up interventions for technical issues that cannot be resolved in real time. this article supports ongoing research and implementation of a substantive departure from the status quo. namely, the approach of integrating multiple mhealth tools into an existing rural health clinic to go beyond traditional office visits and shifting to real-time exchanges between patients and providers across geographical boundaries. funding agencies this project is supported by the wvctsi through the national institute of general medical nih/nigms award number u54gm104942 online journal of rural nursing and health care, 14(1) 59 http://dx.doi.org/10.14574/ojrnhc.v14i1.276 references agency for healthcare research and quality (2008). healthcare cost and utilization project (hcup). http://www.hcup-us.ahrq.gov/toolssoftware/icd_10/ccs_icd_10.jsp . ahern, d. k., woods, s. s., lightowler, m. c., finley, s. w., & houston, t. k. 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(nnurse), tywils56@frontiernet.net keywords: rural/frontier nursing, mentorship, preceptorship, culture, american indian abstract rural areas often face severe nurse shortages that result in many challenges to health care agencies located there. of particular concern is the need for preparing nurses from urban areas to the realities of rural practice. the navajoland nurses united for research, service, and education, inc. (n-nurse) developed a culturally based mentorship program entitled the navajo nursing pathway of mentorship to meet this need. the program is used to support nurses in their transition to rural practice. the newly hired nurses attend a workshop and can be assigned a mentor who serves as a cultural bridge builder to assist them with their transition to rural practice in a culturally diverse area. introduction rural areas often face severe nurse shortages that results in many challenges to health care agencies. the lack of a stable workforce provides not only poor coordination of services but also leads to decreased optimum care. the reasons for nurse shortages in rural areas are many. not the least of these reasons is the lack of comfort with rural culture on the part of nurses coming from urban areas. nurses coming into rural areas from urban settings are often culturally unfamiliar with the population they will be serving. in addition, nurse researchers are coming to realize that practice in a rural area requires a broad knowledge and skill base not normally required in an urban setting. they also need to be able to practice very independently and have a strong sense of selfreliance (britten, hahn, & ragusa, 2003). however, many nurses in rural areas, educated at the associate degree level, need to develop the leadership skills taught at the baccalaureate level (pierce, 2007). to prepare nurses for practice in a rural area, strategies must be developed to overcome these barriers. some nursing programs have developed specific course work to teach rural nursing (pierce, 2007). however these are not common enough to meet the 44 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 challenge. another approach is to provide a strong mentorship program for newly recruited nurses to a rural setting. literature review needs of rural nurses in a study by conger and plager (2008), challenges faced by new ms nurses working in rural settings in northern az were examined. many of these graduates experienced frustration in learning their new role in the rural community. both the location and the new cultural environment provided unique challenges to those coming from urban areas. those that experienced a sense of disconnectedness tended to return to an urban area. they identified the need for better preparation for working in the rural area. cultural dissonance was a huge factor in their adjustment to their new environment. those who lacked understanding of the cultural norms found it difficult to be accepted by the community. one of the nurses described learning that you can’t use the ‘anglo” interrogation method to obtain information from the client. instead, the patient’s story had to emerge. learning patience to wait for the reason why the patient was seeking health care was important. many of the nurses talked about the sense of isolation experienced. one described it as “its lonely out here”. another troubling factor was the loss of anonymity they had known when living in a urban area. they had nowhere to “hide” from the population they served. because of their outsider status, they felt cut off from the inner working of the community. hegney (2003) reports that the experience of the first 12 months of the new nurse in a rural setting will be significant to the nurses’ success in the community. during this time special effort is needed to support them. a mentor who is culturally connected to the community can be the guide needed to help socialize the new nurse to the cultural norms of the community providing support during the adjustment period. mentoring nurses new to the rural environment need role models. many hospitals provide a preceptor to newly employed nurses. the preceptor can be helpful in learning about the work setting. but when the nurse is new to the culture, more than a preceptor is needed. this need can be met through a mentorship program. even though the terms preceptor and mentor are used interchangeably, there are differences. a preceptor is one who assists the new nurse in the role transition to the new assignment. it tends to be task oriented, time limited, and is focused on the work. in the nursing literature there are a number of examples of the use of the term mentor in which the actions described would be better termed preceptor. this often happens when the relationship is between a staff nurse and a nursing student. heale, mossey, lafoley and gorham (2009) describe the use of mentors to work with individual students in a clinical setting. in this situation, the nurse is actually better described as a preceptor guiding the student’s clinical experience. in britain, a similar model is found. beskine (2009) describes the role of the mentor for the nursing student to be accountable for the students learning. his/her role is to orient the student to the clinical environment, 45 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 assess the student’s progress, and evaluate the student’s performance including failing the student if warranted. similar use of the term mentor is found in clinical settings with nursing staff members when the term preceptor would be more appropriate. mentoring is often used to describe a relationship in which a more experienced nurse works with a new nurse to develop clinical skills. mariano, et al. (2009) describes a mentoring program in which the mentor is utilized to assist staff nurses to develop skill in the use of evidence-based practice. aid with goal development is also stressed, but the goal development is related to the new nurse’s interest and use of evidence-based practices. a program to promote oncology nursing skills through use of mentors described by marble (2009) and hurst and koplin-baucum (2005) denotes the role of mentor as a coach, guide and teacher. mentorship is designed to promote both psychosocial and instrumental development of the nurse new to the assigned clinical area. in the vocational literature, a mentor is described as having a larger role. in addition to assisting the new employee in the tasks of the new role, the mentor is more focused on supporting him/her in the new environment. the role is designed to help the mentee learn about the new organization with the aim of developing culture competency. the mentor can also assist the mentee to develop a career path in this new setting. sawalsky and enns (2009) describes the psychosocial role of the mentor as one who role models, counsels, and supports the mentee to promote professional advancement. such mentoring was found to be a positive force for recruiting and retaining nursing faculty in academic settings(singh, ragins, & tharenou,2009). singh et al. (2009) found that mentoring was a positive predictor for the promotion, achievement expectations, and turnover intentions of the mentees. gibson (2004) states even though there is no consistent definition or common description of mentoring, it is commonly used to enhance the career success of a new employee. several elements included in its purpose are to improve the socialization, orientation and aid the mentee in gaining access to informational networks in the work environment. gibson (2004) identified several themes common to the mentoring experience. the mentee viewed the mentor as one who cared about the mentees best interests and provided a feeling of connection. providing insight into how things were done in the work environment was cited as being very important. anderson and ramey (1990) list five roles of a mentor (a) educator, (b) sponsor, (c) coach, (d) counselor, and (e) confronter. kram (1983) states career and psychosocial development are the primary responsibilities of a mentor, not skill acquisition. using the broader definition of mentoring, the focus of a mentoring program should be to prepare the mentor to support the mentee in developing psychosocial skills and cultural knowledge necessary to be successful in the new environment. programs focused on skill acquisition are better described as preceptorships. in light of the voluminous literature on the need for mentors for newly hired employees, programs for developing mentor/mentee relationships should be considered an important goal for all organizations. rural area mentorship program need for program a rural area that has a great need for a mentorship program is in northern az with the american indian population. the navajo tribe, one of the largest american indian 46 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 groups in the united states residing in a geographical area approximately the size of wv, is located in the four corners region. the majority of the people are in az, but tribal lands extend into ut and nm. much of this area is considered frontier.. the health care systems consist of indian health service (ihs) hospitals and clinics as well as tribally owned facilities. the ihs hospitals lie in remote areas on several american indian reservations serving a culturally unique population. these health care facilities are chronically understaffed. the ihs system in the area reports a 20-45% vacancy rate and the average age of these nurses is 46. furthermore, the number of nurse vacancies doubled between 2007 and 2008 (“nursing shortages”, 2008). a large number of nurses working in these facilities come from urban areas with little or no cultural knowledge about the people they will serve. many of them are there to “pay back” time in underserved area required for having accepted scholarships from the federal government during their school years. however, the need for a culturally appropriate approach is essential to rendering effective and responsible services to clients (campinha-bacote, 2007). nurses new to the navajo culture have a “steep learning curve” in developing cultural competence. navajoland nurses united for research, service, and education, inc. the navajoland nurses united for research, service, and education, inc (nnurse is an example of a non-profit organization that was an outgrowth of a grant provided by the william randolph hearst foundation “mentorship for nursing careers in the navajo nation” 2003-2006. n-nurse prepares both potential mentors and mentees working on or near the navajo reservation, with the ihs and health care centers in northern az. nurses from this group have developed a workshop that combines a mentorship/mentee program and a cultural orientation program for nurses new to the area. its purpose is to prepare new nurses for the realities of practice in this rural environment that serves a large american indian population. the workshop participant has the option to continue with a mentor after the conclusion of the workshop. the mission of n-nurse (n.d.) is “to embrace cultural harmony by giving voice to nurses”. the group “shares wisdom, nurtures mentorships, partnerships, and research for quality navajo health” (n-nurse inc., n.d.). the program entitled “navajo nursing pathway of mentorship © 2004” has a strong component on guiding cultural aspects of health care for developing an authentic mentoring relationship. it is particularly suited to helping more junior navajo nurses balance their traditional worldviews with the western nursing worldviews. it is also helpful for nurses new to the navajo culture to adapt their nursing practices to meet the cultural traditions of the navajo clientele. the navajo nursing pathway of mentorship” utilizes a culturally congruent basis for working with the navajo population. a cultural norm for the navajo population is reflected in this statement: “before one begins any activity, one must enter into one’s silence” (knoki-wilson, 2006). this is an idea that is culturally foreign to most in western society. the navajo nursing pathway of mentorship workshops include using navajo health beliefs to promote a mentorship/mentee paired relationship between an experienced, culturally knowledgeable nurse with a more junior nurse moving into the navajo area or an american indian nurse who is returning to the reservation following nursing education in an urban area. the purpose of the mentorship is to develop understanding and provide a more culturally congruent interface with the navajo while helping the mentee formulate and follow their career development, which may be in 47 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 education, job changes, etc. the mentor knowledgeable about the navajo culture serves as a cultural bridge builder, a person who guides the mentee through interchanges with navajo clients. the mentor establishes rapport with the mentee so that the pair can identify a plan to provide opportunity for the mentee’s development. the mentee’s learning habits and opportunities for professional development are discussed. both the mentor and mentee are enriched by the association. to develop a culturally congruent mentor/menteeship program both language and symbol of the people being addressed are essential. the navajo nursing pathway to mentorship model utilizes language and symbols of navajo philosophy (fig 1). figure 1: navajo nurse mentorship pathway used with permission from n-nurse (knokie-wilson et al., 2004). the six mountains, sacred to the navajo people that surround the navajo nation form the theoretical framework. they are mount blanc on the east, mount taylor on the south, mount hesparus on the north, the san francisco peaks on the west and the door way mountains huerfano and gobernador knob. the mentor/mentee enter the pathway from the east and cognitively follow the six sacred mountains for their developmental journey along the cardinal directions (east, south, west, north, east) and completing a cycle in the east again. in navajo east is located at the top of the page. progression of growth as a mentor and mentee follows benner’s (1984) novice to expert clinical concept. beginning in the east, the mentor/mentee is at the novice stage. moving to the south the mentor/mentee is at the advanced beginner stage. in the west the nurse who has developed social competence can be considered at the proficient stage. the north represents the nurse at the expert level. using the traditional navajo view of the stages of life moving from east to north, the mentor and mentee emerge through the east doorways practicing nursing competence and completing a pathway cycle. 48 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 results of the mentorship education program nursing students enrolled in the american indian program of the school of nursing of northern arizona university participated in the navajo nursing pathway of mentorship workshops in 2009.. even though the majority of these students are american indian, they found that the program provided them with information that enhanced their ability to provide culturally relevant nursing care. they stated that this is what they had hoped they would receive in nursing school. other individuals who have participated either as a mentor or mentee have expressed that this program re-enforced their own beliefs,if they have been away from the area awhile, or provided cultural understanding of how to work more “in harmony” with the populations found in northern az. both the rural and indigenous populations are addressed in a more culturally congruent manner after participation in this program. for example, from the persepective of a layperson, anatomy and physiology may be understood from that of the sheep since these are the main type of live stock raised in the area and explanations can be provided using this background. assumptions are not made that the patient “doesn’t care” if an individual does not come into a clinic “on time” or at the first sign of disease or injury due to the fact that distances and transportation have to be considered; cost of transportation, who will care for animals while gone; are there “elderlies” and small children that have to be cared for if one leaves, etc. time, distance, beliefs and understanding of using both indigenous and western ways are seen as congruent cultural interventions for the population being served. moreover, this mentor/menteeship program has provided a mechanism for helping those not from the area to feel more comfortable working in this setting and remaining in the area. in addition to the workshop, there is opportunity for nurses new to the area to be paired with a mentor to continue the cultural learning. this support provides the needed reinforcement for a successful transition to rural/frontier nursing with a culturally unique population. conclusion the n-nurse organization provides an example of a culturally congruent model for a mentor-mentee relationship for nurses working with the navajo and rural population to follow. while it is more specific to this cultural group, the concept of utilizing appropriate philosophy, beliefs, practices, language and symbols can be applied to other cultural populations. such culturally appropriate models can be used to assist and socialize nurses new to an environment. congruent with the literature and the n-nurse example, a focus for all organizations would be to develop a mentor/mentee program that encompasses the psychosocial skills and cultural knowledge necessary for adaptation to a new work setting and environment. in implementing such a program, a more stable workforce and increased optimum of care for the population would result. references anderson, r.t., & ramey, r. (1990). women in higher education: development through administrative mentoring. in l.b. welsch, (ed), women in higher education: changes and challenges (pp.183-190). new york, ny: praeger. benner, p. (1984). from novice to expert: excellence and power in clinical nursing practice (pp12-34). menlo park: addison-wesley. 49 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 beskine, d. (2009). mentoring students: establishing effective working relationships. nursing standard, 23(30), 35-40. [medline] britten, m., hahn, l., & ragusa, t. (2003). teaching rural nursing to urban students. in m. collins (ed.). teaching/learning activities for rural community-based nursing practice (pp. 54-71). binghamton, ny: binghamton university. campinha-bacote, j. (2007). the process of cultural competence in the delivery health services: the journey continues (5th ed.). cincinnati oh: transcultural c.a.r.e. associates. conger, m. & plager, p. (2008). advanced nursing practice in rural area: connectedness versus disconnectedness. online journal of rural nursing and health care, 8(1), 24-38. gibson, s. (2004). being mentored: the experience of women faculty. journal of career development, 30, 173-188. heale, r., mossey, s., lafoley, b, & gorham. r. (2009). identification of facilitators and barriers to the role of a mentor in the clinical setting. interprofessional care, 23(4), 369-379. [medline] hegney, d. (2003). rural and remote nursing: an australian perspective. online journal of rural nursing and health care, 3(1), 5-7. hurst,s & koplin-baucum, s. (2005). innovative solution: mentor program: evaluation, change, and challenges. dimensions of critical care nursing, 24. 273-274. [medline] knokie-wilson, u. (2006, summer). navajo mentoring project. summer intensive program: developing cultural competence. northern arizona university, school of nursing. knokie-wilson, u., phoenix, l., eraccio-yazzie, m., thompson, s., crow, k., overman, b., & petri, l. (2004 june 18) n-nurse navaho nurse mentorship model. adapted from the intervention wheel developed by the public health nursing department at northern medical center in shiprock, new mexico and the chinle service unit performance improvement cycle. kram, k.e. (1983). phases of a mentoring relationship. academy of management journal, 26. 608-625. marble, s. (2009). five-step model of professional excellence. clinical journal of clinical oncology nursing. 13, 310-315. [medline] mariano, k., caley, l., eschberger, l.,woloszyn, a., volker, p., leonard, m., & tung, y. (2009). building evidence-based practice with staff nurses through mentoring. journal of neonatal nursing, 15(3). 81-87. n-nurse, inc. (n.d.) retrieved from http://www.n-nurse.org nursing shortages. navajo times, thursday, february 7, 2008. pierce, c. (2007). using the concept of the nursing paradigm to sustain rural populations. in l.l. morgan and p.s. fahs (eds.) conversations in the disciplines: sustaining rural populations. (pp 85-96). binghamton, ny.: global academic publishing: binghamton university,. sawalsky, j.a., & enns, c.l. (2009). a mentoring needs assessment: validating mentorship in nursing education. journal of professional nursing, 25,145-150. [medline] http://www.ncbi.nlm.nih.gov/pubmed/19408493 http://www.ncbi.nlm.nih.gov/pubmed/19517286 http://www.ncbi.nlm.nih.gov/pubmed/16327512 http://www.ncbi.nlm.nih.gov/pubmed/19502189 http://www.ncbi.nlm.nih.gov/pubmed/19450785 50 online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 singh, r., ragins, b., & tharenou, p. (2009). what matters most? the relative role of mentoring and career capital in career success. journal of vocational behavior, 75(1), 56-67. 7 intimate partner violence and rural public health nursing practice: challenges and opportunities tracy a. evanson, phd, aprn, bc1 1 assistant professor, college of nursing, university of north dakota, tracyevanson@mail.und.nodak.edu keywords: rural, public health nursing, home-visiting, intimate partner violence, domestic violence, phenomenology abstract health care providers of all disciplines encounter victims of intimate partner violence (ipv) in all practice settings. however, few studies have examined the role of public health nurses (phns) who visit the homes of families where ipv is occurring, and none have focused on the unique aspects of rural phn practice with these families. this research, derived from a larger descriptive phenomenology study, describes the unique challenges and opportunities experienced by rural home-visiting phns when working with families where ipv was occurring. the rural phns described unique opportunities in their abilities to establish and maintain relationships with families, to assess for ipv, to advocate for victims with other community providers, and to keep perspective about their work. however, living and practicing in rural areas also created unique challenges related to barriers to disclosure of ipv, maintaining confidentiality, helping victims access resources, getting support for themselves, and establishing and maintaining professionalpersonal boundaries. introduction intimate partner violence (ipv) is a serious public health issue, resulting in approximately $4.1 billion in direct health care costs each year in the u.s. (national center for injury prevention and control, 2003). at least 1.3 million women are physically assaulted by an intimate partner annually in the u.s and at least 22% of women in the general population have been physically assaulted by a former or current intimate partner sometime during their lifetimes (tjaden & thoennes, 2000). populationbased studies, which provide evidence of ipv prevalence among rural women, do not exist (johnson, 2000), but results of several convenience sample studies (johnson & elliott, 1997; kershner, long & anderson, 1999; persily & abdulla, 2000; van hightower & gorton, 1998; wagner, mongan, hamrick & hendrick, 1995) suggest that the prevalence of ipv experienced by rural women is at least as high if not higher than rates in the general population. in the largest study to date, kershner et al. (1999) found that among 1,693 rural women seeking care in rural medical clinics and women, infants, children (wic) clinics, 21.4% reported current abuse, and 37% had experienced abuse as an adult at some point in their lifetimes. health care providers of all disciplines encounter victims of ipv in all practice settings. however, few studies have examined the role of public health nurses (phns) who visit the homes of families where ipv is occurring, and none have focused on the unique aspects of rural phn practice with these families. public health nurses, who work online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.usask.ca/nursing/ mailto:tracyevanson@mail.und.nodak.edu 8 with families through home visiting, may serve a pivotal role in ipv prevention and intervention. they have a unique advantage of being in a position to recognize a potential for violence in the home before it begins or worsens (bekemeier, 1995) and they are able to gain unique insights into family health that do not present when these same people are seen in hospitals or clinic examining rooms (shephard, elliot, falk & regal, 1999; zerwekh, 1991). the role of phns in ipv prevention and intervention is likely to be especially significant in rural areas, where phns may be one of the few hcps available in communities, and where an ipv victim may be hesitant to disclose abuse to her primary care provider because that same person is likely to also be the abuser’s primary care provider (leipert, 1999). while minimal research exists regarding the realities of rural battered women’s lives, various rural factors have been anecdotally described (adler, 1996; fishwick, 1993; goeckermann, hamberger & barber, 1994) as uniquely contributing to ipv and complicating victims’ lives. isolation, a major means of control among abusers, is easier to achieve in rural areas. a rural woman may be less likely to contact law enforcement because she may know the officers, and even if she does contact them, response times are often lengthy because of driving distance. the seasonal nature of agricultural work creates long periods in which men may be at home, creating more opportunities for abuse to occur. other rural factors that have been described are a lack of ipv prevention programs and other social services, less availability of transportation and telephones, increased risk of lethality because of the availability of guns in the home, and lack of privacy and anonymity. kershner et al. (1999) found the greatest barriers for a rural abused woman to disclose the abuse to a nurse or physician were: shame; fear of being seen by someone; fear that clinic staff would talk about them or wouldn’t understand; and a high reliance on self, friends/family, and/or god to solve their problems. public health nurses, living and working in rural areas, may play a key role in ipv prevention and intervention efforts in their home communities. however, research to date has not described or evaluated the role of rural home-visiting phns in ipv prevention. the purpose of this research article is to describe the unique challenges and opportunities experienced by rural home-visiting phns when working with families where ipv was occurring. identification of the challenges and opportunities of rural nursing practice has been named a top research need in the area of rural nursing (bushy, 2000), and this study contributes to that research priority. policies and practices that are developed in urban settings are not always readily transferable to the rural setting (ulrich, fulton & macleod, 2004), and therefore a thorough understanding of the issues that rural phns face is essential in order to effectively address the issue of ipv in rural areas. research methods design the findings presented here are part of a larger study (evanson, 2003), which sought to describe the practice of home-visiting phns (both rural and non-rural) when working with childbearing/childrearing families experiencing ipv. the research approach utilized in the study was descriptive phenomenology (dahlberg, drew & nystrom, 2001). in the design of the larger study, it was purposefully planned to recruit online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 9 approximately half the sample of phns from health departments serving rural areas and half from non-rural areas. this was done in an attempt to describe the phenomenon as fully and richly as possible, and also to ascertain if there were any major differences in practice related to rural vs. non-rural phns. this article describes the practice challenges and opportunities unique to the rural phns in their work with families where ipv was occurring. in this study, rural was defined as places of 2,500 or less persons either inside or outside of incorporated areas (u. s. census bureau, 1995). participants participants were recruited from county health departments from throughout a midwestern state in the u.s. purposive sampling was utilized, and participants were chosen based upon specific inclusion criteria that insured they were experienced and knowledgeable in relation to the phenomenon of interest (morse, 1989; streubert & carpenter, 1999). inclusion criteria were phns who a) were currently certified as a phn in the state in which they were practicing, b) were currently providing home visits to childbearing/child-rearing families at least half-time c) had a minimum of five years of experience as a phn, d) felt they had experiences of working with families where ipv had occurred and were able to describe those experiences. in the larger study, participants included thirteen phns, six practicing in nonrural areas and seven practicing in rural areas. the findings presented here pertain to the seven rural phns, who were recruited from four different rural health departments. the seven rural phns had an average age of 41.9 years (range 28 – 51 years). all were caucasian and all were female. they had an average of 15.2 years of experience as a registered nurse (range 6 – 26 years) and an average of 13.4 years as a public health nurse (range 5 – 22 years). all of the rural phns had a baccalaureate degree in nursing. only two of the seven participants reported they had received any education about ipv in their baccalaureate programs, but all had received continuing education (ce) on the subject since entering practice and most (five) had attended more than one ce session. all of the phns lived in the rural areas in which they practiced. protection of human subjects the study received institutional review board approval from the human subjects committee at the university of minnesota before research commenced. each phn received verbal and written descriptions of the study purpose and methods. written consent was obtained from each participant, and they were provided with a copy of the signed consent. to assure anonymity and confidentiality, participants were assigned codes used to mark the audiotapes and the transcripts of the interviews. all names and identifying information were removed from the transcripts. participant codes, audiotapes and transcripts of the interviews were all kept in separate files accessible only to the researcher. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 10 data collection and analysis each participant completed a demographic questionnaire, which was developed for the study, in order to describe the sample characteristics. two semi-structured interviews were conducted with each participant. the interviews were audio recorded and transcribed verbatim for analysis. the purpose of the first interview was to elicit specific descriptions of phns’ experiences working with families where ipv was occurring. lines of inquiry focused on how the phn identified that ipv was occurring, and how assistance was or was not able to be provided to the family. the purpose of the second interview was to identify the factors in the phns’ practice that were perceived to influence their ability to identify and provide assistance in cases of ipv. the second interview was also a time for the researcher to follow-up on questions that had arisen from analysis of the first interviews, and to gain more depth on data gathered on the first interview. the interval between the first and second interview was three to four weeks. the interviews ranged from 60 to 95 minutes in length, averaging 74 minutes. the interviews were at a location of the participants’ choosing. all but one of the interviews were conducted at the participants’ places of employment and during their regular work hours (with permission from each of the participating agencies). one interview, at the request of the participant, was conducted in the participant’s home, during non-work hours. the researcher personally conducted all of the interviews. initial analysis began with the first interview and continued with all subsequent interviews. dahlberg’s approach to descriptive phenomenology analysis was used as the framework (dahlberg et al, 2001). this analysis structure involves a fluid movement between whole – parts – whole. in the first phase, the researcher read all of the data repeatedly to get a sense of the whole. the focus then shifted to examining parts of the text, which were identified by shifts in meaning, and the text was organized into meaning units. as the meaning units were identified, the researcher named the meaning, using the words of the participants whenever possible. once meaning units were named, a process of organizing the units into clusters of meaning was utilized. the next phase of analysis was to return to the whole and give it expanded meaning. the clusters of meaning were synthesized into a structure that bound them together, and a model of the phenomenon was formed, with constituents, themes, and subthemes. in order to determine if there were differences between the rural and the non-rural nurses’ practices, a process of constant comparison between the rural and non-rural phns’ transcripts was employed (k. dahlberg, personal communication, june 11, 2002). as differing aspects of practice were identified, analysis focused on whether the meaning of the particular aspect was a separate constituent, theme, or subtheme of the phenomenon, or if it was simply a variation within those components. findings in the larger study, it was discovered that there were no major differences between rural and non-rural phns in the constitutents, themes or subthemes of their practices when working with families where ipv was occurring. however, the rural phns described variant aspects within those practice themes that were due to the rural nature of the communities in which they worked and lived. the rural phns described online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 11 unique opportunities in their abilities to establish and maintain relationships with families, to assess for ipv, to advocate for victims with other community providers, and to keep perspective about their work. however, living and practicing in rural areas also created unique challenges related to barriers to disclosure of ipv, maintaining confidentiality, helping victims access resources, getting support for themselves, and establishing and maintaining professional-personal boundaries. establishing and maintaining a relationship with families the rural phns had an advantage over the non-rural phns in relation to establishing and maintaining a relationship with families, because they had more opportunities to have contact with their clients both in work and non-work settings. the non-rural phns typically reported that home visiting with families was the primary or sole responsibility of their job. however, because of the smaller size of their health departments, rural phns were not only doing home visiting, but were also working in other settings in the health department, such as wic clinics, immunization clinics, communicable disease work, etc. in addition, it was not unusual for rural phns to see their clients in various settings in the community, such as at church, the grocery store, school or community functions, etc. in the words of one rural phn: the women who i visit in the home, i will see them in a different setting as well. . . i see them in the grocery store. i see them out in the parking lot with their boyfriend and their kids . . .where in a metro area, you wouldn’t have that opportunity. i suppose we are just a closer-knit community and you see people outside of the home setting. their generalist roles and their encounters with families through rural living provided the phns with increased opportunities for repeated contact with families in multiple settings, resulting in more opportunities for building relationships. identification of ipv the multiple settings in which the rural phns encountered their clients also afforded them increased opportunities to observe and listen for risk factors and indicators of ipv. as one rural phn described: there have been times where i have been able to see women in different settings other than their home, and noticed relationship issues between them and their significant others. in a metro area you would probably never run into them like that. i think back to a few years ago, when in a grocery store, when i heard some verbal abuse going on between a boyfriend and one of my clients. i just found it interesting that i was able to pick up on that in a grocery store. it was not unusual for rural phns to have separate cases of families related to each other. in these cases, knowledge of extended family history or current issues in one online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 12 family helped inform the assessment of the other family and provide clues to potential ipv. it was also not uncommon for rural nurses to have personal knowledge of a family’s history and issues because the phn may have known them through some aspect of the phn’s personal life. as one rural phn noted, some of these women, i went to high school with. some of them, their parents were my teachers. . . the public health nurses, they pretty much know—well they grew up here, so they know everybody in the families, or somebody in the office knows the family, unless it is somebody that just moved in. it is much easier to do that in a smaller community, to know the support systems and to know what their relationships were like, when you were growing up with them too in the same town. at the same time, rural phns faced a unique disadvantage in relation to identification of ipv. the rural phns reported they frequently knew their clients personally, or they had mutual friends or acquaintances. in these circumstances, the rural phns perceived that victims of ipv might be reluctant to disclose the abuse to the phns, because of their personal ties. as one rural phn stated: like one gal i had, i had taught her in sunday school. and she found out i was her nurse, and she thought, ‘oh, no.’. . i’m sure she thought she couldn’t possibly share her sexual history with her sunday school teacher, now could she? confidentiality all of the phns, rural and non-rural alike, described that maintaining confidentiality was integral to their abilities to build trusting relationships with families. if it was learned they breeched confidentiality with a family, they not only risked losing the trust of the family, but also their reputation as a professional in the community. situations sometimes occurred where a phn was contacted by extended family members (such as the client’s mother, siblings, etc.), particularly when working with teenage parents. in those cases, the phn still respected the confidentiality of the client and informed the family member they could not disclose any information without a written release of information from the client. as mentioned, it was not unusual for rural phns to be visiting more than one extended family member, or to be visiting two or more clients who could be friends. this, coupled with their high visibility in communities, created special challenges for rural phns to maintain confidentiality, as one nurse noted: in [a very small town], it turns that out of the three [pregnant mothers] that i was visiting in [that town], they all delivered in a span of three or four months—and they all knew each other. . . they would say, ‘weren’t you just over at so-and-so’s?’. . . but whatever they tell me is private and i hope they know that i won’t disclose anything. ‘didn’t you just see soand-so?’ and i’ll say, ‘well, you know i can’t say.’ so it puts you in a spot with a small community that they know where you are going, who you’re seeing. online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 13 rural phns faced other unique challenges when maintaining confidentiality. for example, the phn and family may have had mutual personal contacts, or may have even known each other personally outside of the professional relationship. rural phns described attending the same church with their clients, having children who were friends, having children on the same sports teams, frequently seeing clients when out in the community on non-work hours, etc. additionally, the car that the phn drove was easily identifiable and recognized in small communities, thereby indicating which house she was visiting. the lack of privacy and anonymity required the rural phns to be constantly vigilant at maintaining confidentiality, and at times, required that they withhold the truth from others, as one phn described: if i see them in the grocery store, i just say ‘hi,’ and they say ‘hi.’ if they want to talk more, they will. they’ll come up and say something, and then i’ll keep going with the conversation. but if they don’t want to talk to me, then i just keep on going. my kids are bigger now, and they’ve gotten to the point of, ‘how do you know them? how do you know them?’ and i, ‘oh, i just know them. they work over by me.’ i’ll make up something like that. community resources the rural phns in this study generally felt there were adequate resources within their communities to assist victims of ipv. the one exception to this was the availability of accessible and acceptable shelters. in the rural areas, many communities did not have shelters available, but instead had safe houses. however, these were not always easily accessible because options for transportation were lacking. even if women accessed the safe houses, the phns perceived there were still other unique challenges to staying safe in a rural community. this was explained by one rural phn, when she said, one of the things in a rural community that is difficult . . . is having a place for the women to go to that is safe. it doesn’t take long for the men to figure out in a rural area where the safe houses are at, and they can harass the women and stalk the women going there. it is really hard to keep women safe in a rural area. . . because a lot of areas are really accessible. it’s not that far to drive. many women have specific cars that might stick out, and if they go anywhere in the county, men can find them. the big shelters, if they wanted to go to [a shelter in another county], they are usually very full. so what they get in [our] county is just a private home that has been opened up to a family for a short time to use as a shelter. things can be seen. if you’re in town and somebody sees your car outside of the house, it’s not very difficult to figure out that the woman is in that house, and that is the temporary shelter where she is staying. so that is real scary for women. the other thing is that they know that they can’t go to those places for very long. they are real temporary things. . . and if they want to leave, they don’t want to go somewhere for just a few online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 14 days. they want to go somewhere for a while. so they don’t very often use [the shelters]. the lack of accessible and acceptable emergency shelter care put an extra burden of care on the rural phns. they had fewer options for safety to provide to victims, requiring that they utilize more creative strategies when assisting victims with planning for their safety. for example, one rural nurse described how, when safety planning with a woman, “we found a safe place in the barn where she could hide if she needed to.” the rural phns also perceived they had a unique advantage in relation to community resources. unlike most of their non-rural counterparts, the rural phns typically knew other providers in the community on a personal level, or had multiple professional contacts with them, given the small community size. one rural phn explained how this could work to their advantage when advocating for victims. the positive of the rural area is that you know everybody and know who to contact. like in the police department, you know who has perhaps handled a case and done a good job, or you know who you are not going to call on because you know from past experience that he does not handle the situation very well. you know somebody at social services that can help handle the needs of the children—some time away, or whatever. . . so it’s more personal contacts. you know the people that you are working with, and sometimes that saves a lot of time. you can say, ‘you need to call so-and-so,’ and you can direct them to the right person. that sometimes saves a lot of time and stress, not only for you, but for the client. personal-professional boundaries in order to work effectively with families where ipv was occurring, the phns needed to use strategies that helped them keep perspective about their role, the purpose of their work, and their abilities to create change in the families. one of the strategies used by all of the phns to keep perspective, was by setting boundaries between their personal and professional lives. the phns, rural and non-rural alike, described how, in working with families where ipv was occurring, they needed to be able to develop a close relationship and empathize with the victims; but at the same time, they needed to be able to maintain a professional distance so they were not becoming enmeshed in the family and it’s issues. while all of the phns described that setting boundaries was an important strategy for preserving themselves in the difficult work of ipv, the rural phns needed to have somewhat looser boundaries than the non-rural phns. the rural phns related that because they had more personal ties with clients in their communities, the boundaries between their personal lives and their professional lives were not black and white. instead, their boundaries were grayed at times, and more permeable than those of the non-rural nurses. however, the rural phns described that they simply accepted this as part of being a rural nurse, and with experience, had found ways to be comfortable with less distinct boundaries. they had also learned to be flexible with their boundaries, depending on the online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 15 individual situation. the permeability and flexibility of the personal-professional boundary is illustrated in the following quote by a rural phn. it’s just a given in a small town that you are going to see some of these people [in your personal life]. . .that’s an important part of being a public health nurse in a small town. you’ve started with them, and maybe that means that you can never totally forget them or give them up because you might be seeing them in the community. . . i don’t have people calling me at home. it’s when i go out in the community and i see them that i visit with them. i just think that’s fair game. if they see me out in the community, so be it. . . i don’t allow people to call me at home and talk to me. that would be extremely rare that anybody did that—well, unless they had a really pressing problem and they maybe needed to find a resource out in the community that i could help them with. that has actually happened several times through the years, where people will call me at home and say, ‘i know you’re not seeing me anymore, but i just need you to tell me where i can locate another resource.’ and i do that. it’s just a given that you are going to see your clients out in the community, and i don’t mind that. sometimes it’s really fun. having a balanced workload to keep perspective another strategy for keeping perspective in their work with families where ipv was occurring, was to try to maintain a balanced workload. one way in which all of the phns tried maintain a balanced workload was to not have all high-risk or multi-problem families, such as those experiencing ipv, in their home-visiting caseloads. they tried to balance these more difficult and demanding cases with some cases that were considered lower risk. the rural phns had the opportunity to achieve a balanced workload in a way that most of the non-rural phns did not. as mentioned, for most of the rural phns, their role in the health department required them to be generalists. these nurses expressed that having a variety of roles was an additional way they were able to have a balanced workload and keep perspective about their work. many described that the other roles offered them more obvious rewards than home-visiting with multi-problem families. one rural phn described this when she talked about her role with the wic clinics within the health department. wic, i think can be more rewarding sometimes than doing the home visits, because you are able to give them a product. you do a lot of nutritional education too, but you give them a voucher, and they say, ‘oh, this is really going to help.’ so i get a lot more positives that way. i think the combination of both helps balance things out. . . you need to have some rewards sometimes where a person says, ‘gosh, this really helped my baby,’ or ‘you really helped us get through the month.’ online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 16 getting support an important component of all of the phns’ practice with families experiencing ipv was to get support for themselves. this strategy involved using external sources to help find validation for the significance of one’s work as well as easing the emotional labor involved when working with families where ipv was occurring. the phns perceived that it was important for them to be able to receive support from others so they were able to have the emotional reserves to, in turn, support the victims and work effectively with them. getting support from coworkers was unanimously described as the most significant strategy that all of the phns used for preserving themselves and coping with the stress of working with families where ipv was occurring, as well as other high-risk families. home-visiting required that they work very independently, spending much of their day alone, without interactions from peers. therefore, the phns perceived it was very important to have others that they could turn to in order to verbalize what was going on in their caseloads, to receive personal validation and encouragement for their work, and to obtain feedback about their role. every participant in the larger study identified support from coworkers as a strategy that they routinely used. most of the phns reported they did not routinely share their stresses about their caseloads with their family or friends. family and friends were not able to understand, relate, and give feedback in the same effective way that their phn coworkers could. for the rural phns, sharing anything about their clients with family or friends was not even viewed as an option because of unique issues of confidentiality. while non-rural nurses could share their stresses by leaving out names and still maintain the confidentiality of their clients, rural phns were not able to do this. even if they did not use names, rural phns felt their family or friends might still be able to identify the family they were talking about because they knew the family and their situation. in the words of one rural phn, “our husbands can very easily figure out who we are talking about.” so, for the rural phns, being allowed and taking the time in the workplace to be able to talk with and receive support from their coworkers was even more important for effective practice. discussion the findings from this study suggest that, when working with families where ipv is occurring, rural phns encounter unique challenges and opportunities not encountered by their non-rural peers. the issues related to a generalist orientation, increased contacts with client through close interactions with the community, challenges to confidentiality, and a high degree of visibility and lack of anonymity, described by the rural phns in this study, are supported by others who have described unique aspects of rural nursing (bigbee, 1993; bushy, 2000; crooks, 2004; davis & droes, 1993; ide, 2000; mahaffy, 2004; shellian, 2002; weinert & long, 1991). the phns typically spoke positively about their generalist role and perceived that it resulted in multiple benefits in their home-visiting work with families experiencing ipv. first, the variety of roles and settings offered increased opportunities for contact with families. second, by having the opportunity to observe families in settings additional to online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 17 the home, the rural phns had more frequent opportunities to pick-up cues that ipv might be occurring. the contact rural phns frequently had with families in the community when on non-work hours also provided these same opportunities in their practice. it is possible that these additional contacts could potentially be further opportunities to provide victims of ipv with assistance. this would be particularly true if the abuser is usually in the home when the phn visits, but is not present when the victim, for example, comes to wic or an immunization clinic. a final benefit related to the multiplicity of roles was that it helped phns keep perspective about their work. some of their other, more immediately rewarding work helped to provide a balance to the emotionally demanding work of home-visiting with high-risk families. this may be an important strategy for prevention of staff burn-out. another opportunity in their work with ipv was that the phns often had valuable interpersonal knowledge about families, which contributed to their ability to identify that ipv was occurring. the rural phns were also likely to have more personal relationships with providers in other agencies, and this made it easier to advocate for victims when helping them connect with community resources. while the rural phns described many opportunities in their practice, they also faced challenges that the non-rural nurses did not. first, the rural phns faced greater challenges in relation to confidentiality. this required that the rural phns be hypervigilant in maintaining the confidentiality of the families with which they worked. second, their level of personal contact and interpersonal knowledge was also perceived to be a potential barrier to disclosure of ipv. women they had some personal contact with might feel embarrassed, or might fear that the phn would share what was disclosed with their mutual contacts. davis & droes (1993) reported that rural phns in their study described an additional disadvantage of interpersonal knowledge, in that knowing clients well may cause one to make assumptions that could lead to inadequately assessing the client. while not described as an issue by the phns in this study, this could be a particular problem in ipv assessment if the phn made assumptions about who is/isn’t an abuser or victim, based upon interpersonal knowledge about the family. a third challenge was that the rural phns were less likely to be able to share the stresses of their work with friends and family and still maintain confidentiality; and so were highly dependent upon their peer to provide them with the support they needed to cope with the emotional labor of their work. this may help explain the greater cohesiveness and camaraderie that is a unique characteristic of rural nursing practice (bigbee, 1993). a lack of available, accessible, and acceptable emergency shelter for victims created an extra burden of care on the phns to creatively strategize how to keep victims safe. emergency shelters were often located long distances away and transportation was not readily available. this perception is supported by the work of goeckerman et al. (1994), who found that among rural wisconsin women who had accessed dv programs, 56% had no transportation of their own, and had traveled an average of 59 miles to access service. finally, because of their high visibility and lack of anonymity in communities, rural phns had less obvious boundaries between their personal and professional lives. among the few studies that have examined rural phn practice, there have been varied findings in how this challenge has been perceived. the rural phns in this study never online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 18 described feeling uncomfortable or resentful of their visibility and lack of anonymity, whereas davis & droes (1993) reported that lack of anonymity and intrusions into offwork hours were perceived to be a distinct disadvantage of rural public health nurses. oberle & tenove (2000) reported that the rural phns in their study “had to make a deliberate attempt to keep their personal and professional lives separate in the interests of confidentiality for the client and self-preservation for themselves” (p. 433). leipert (1999), in her qualitative study of rural phns’ practice in women’s health in canada, also found that rural phns faced the challenge of frequently encountering clients in their offduty hours. she reported that some of the phns found this contact to be intrusive into their personal life. however, other phns, like the rural phns in this study, “welcomed the contact with the public these experiences afforded, and saw them as ways to further build relationships and promote health” (p. 287). the difference in phn perceptions between these studies may be related to the fact that the phns in this study were expert practitioners who may have learned to cope with looser boundaries and, through years of experience, found positive benefits in a high level of visibility and lack of anonymity. the phns in this study generally spoke quite passionately and positively about their work with families where ipv was occurring and expressed concern about the social and health implications of ipv. when participants were recruited for the study, all phns who met the inclusion criteria were invited to participate. however, in some of the agencies, some phns who were eligible did not participate. the characteristics of nonparticipants are unknown and therefore cannot be compared to those of the participants. it is possible that phns who were less concerned about the issue of ipv, or who felt less confident and competent in addressing it did not come forward to participate and would describe very different perceptions of challenges and opportunities in their practices. this is a limitation of this study and a direction for future research. further studies with phns from other parts of the u.s. are also recommended. this study contributes to the small, but emerging bodies of research on rural public health nursing, and on the role of phns in ipv work. the findings are significant in that they provide unique insight into rural phn practice when working with families experiencing ipv. nurses who are new to rural public health nursing, or rural phns who are not comfortable with ipv work, may gain a better understanding of how to maximize the opportunities and cope with the challenges that come with working with ipv in their practice. the findings can contribute positively to nursing education courses that address concepts of rural nursing, community health, or intimate partner violence. the findings may also be useful in helping rural public health supervisors, administrators, and policy makers understand some of the unique issues that rural phns must deal with, so that appropriate policies can be put in place to support the nurses in their work. an important implication of the findings is that all rural agencies should create opportunities for nurses to support each other in their work with ipv and other multiproblem families. peer support should be encouraged to occur informally among nurses, and ideally, formal mechanisms for support should also be instituted through routine staff meetings or case conferences. public health nurses are a key link in the chain of prevention for ipv in rural communities. while the work of phns in ipv prevention and intervention is not new, the potentially important role that phns play and the practice issues that they face are just beginning to be examined and elucidated. this is the first study in the u.s. to examine online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 19 rural phn practice related to ipv, and further knowledge needs to be developed in this area. if we are to end the violence that occurs in people’s homes, then the health care providers who go into those homes should be one of our primary modes of prevention and intervention, and we should strive to learn from them and support them in their work. acknowledgements this study was funded in part by a pre-doctoral fellowship from the national institute of nursing research, national institutes of health, #f31 nr07936, and by a sophia fund award from the university of minnesota, school of nursing. references adler, c. 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(1995). urban and rural definitions. retrieved january 26, 2002, from http://www.census.gov/population/censusdata/urdef.txt ulrich, c., fulton, t., & macleod, m. (2004). creating supports for rural nursing practice. nursing bc, 36(5), 27. [medline] van hightower, n.r., & gorton, j. (1998). domestic violence among patients at two rural health care clinics: prevalence and social correlates. public health nursing, 15, 355-362. [medline] wagner, p.j., mongan, p., hamrick, d., & hendrick, l.k. (1995). experience of abuse in primary care patients. racial and rural differences. archives of family medicine, 4, 956-962. [medline] weinert, c., & long, k.a. (1991). the theory and research for rural nursing practice. in a. bushy (ed.), rural nursing (pp. 21-38). newbury park, ca: sage. zerwekh, j.v. (1991). tales from public health nursing. true detectives. american journal of nursing, 91, 30-36. [medline] online journal of rural nursing and health care, vol. 6, no. 1, spring 2006 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10499017%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15310097%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11221402%5buid%5d http://www.rno.org/journal/index.php/online-journal/article/viewfile/84/80 http://www.rno.org/journal/index.php/online-journal/article/viewfile/84/80 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11928217%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10528507%5buid%5d http://www.census.gov/population/censusdata/urdef.txt http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15633526%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9798423%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=7582062%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1897588%5buid%5d editorial 2 editorial hello from western canada! kathy crooks editorial board member my name is kathy crooks and i am a new addition to the editorial board of the on-line journal. i have been asked to briefly introduce myself and to provide my insights into the state of rural nursing in canada. first, i would like to say how very pleased i was to be asked to be on the board. this provides me with the opportunity to network with the "cream of the crop" in this rapidly expanding area of nursing. my initial exposure to information in rural nursing occurred when i was introduced to literature that came from the united states. exposure occurred when i was asked to develop an undergraduate course in rural nursing. this introduction led me to the realization that there were a growing number of other people who recognized the unique and specialized nature of nursing in a rural setting. from this beginning i was fortunate to be put in touch with dr. angeline bushy who in turn introduced me to some of the other leaders in american rural nursing. my exposure to these dynamic individuals resulted in my desire to seek further education in the area of rural nursing. as a result i am presently enrolled in a doctoral program at the university of calgary. for the past 12 years i have worked as a nursing instructor in the division of health studies at medicine hat college, which is located in the province of alberta in western canada. prior to coming to medicine hat, i worked as a staff nurse in several small acute care facilities in the southern part of the province. medicine hat is a city of 50,000 people and is approximately three hours south east of the city of calgary and about two hours north of havre, montana. this area of alberta shares a lot of similarities with the state of montana although we are not as sparsely populated. alberta is primarily agrarian although there is also a huge oil and gas industry, as well as many recreational opportunities. all of these, are of course, high-risk industries. until the very recent past, the idea that rural residents had different health care concerns than their urban counterparts was not a consideration in canada. unlike the united states and australia, canada has been slow to realize the distinct nature of the rural culture and particularly, rural nursing. in 1998, the government of canada finally established the office of rural health under the auspices of health canada. the mandate of the office of rural health is to provide a rural perspective in the development of healthy public policy and programs. while this is decidedly worthwhile, it is important to note that a physician is charged with heading this office. the appointment of a physician to this position represents the traditional organization of health care and publicly reinforces the notion of physicians as powerful resources, thus ignoring the contribution of the registered nurse (sorrells-jones & weaver, 1999). further, canadian rural physicians have positioned themselves to influence rural health care through the establishment of the society of rural physicians of canada. while there seems to be a heightened awareness of rural health issues, as well as of issues pertaining to the role and function of the rural physician, there is a lack of canadian information available online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 3 regarding the rural nurse. this may be the result of the failure of canadian rural nurses to become organized in the way their australian and american counterparts have. or, it may be the result of a scarcity of nurses with the appropriate experience, interest, and funding to develop an extensive canadian rural nursing knowledge base. although much of the present information outlining the peculiarities of canadian rural nursing practice is anecdotal, there is presently a study in progress by mcleod and kulig et al. regarding the nature and practice of rural nursing. research aimed at clarifying the role and responsibilities of the rural nurse will increase awareness and result in sensitizing politicians, physicians, and the public to the unique nature of rural practice. the need for canadian rural nursing to become organized and place itself in a position to influence health sector policy makers is essential. while the idea of a rural physician shortage is a concern that has been expressed by the media and governments, there is virtually no discussion regarding the acute shortage of rural nurses. shreffler (1998) suggests that recruitment and retention of health care professionals is one of the foremost concerns in maintaining access to rural health care. while the average age of rural nurses is slightly younger than that of the urban nurse, rural nurses are leaving the profession at an earlier age (canadian institute of health information, 2002). presently the reasons behind the early departures remain unclear. however, if those entering the profession are older and rural nurses are known to leave the profession at an earlier age it is reasonable to assume that the rural nursing shortage will reach a crisis point sooner than expected. while it is imperative that the entire profession of nursing increase the public understanding of the role of nurses in health care (buresh, 2001), it is vital in the canadian rural context. the predicted rural nursing shortage could prove calamitous to a population whose health care is already marginalized because of distance and the gravity of health concerns. the majority of the canadian population is clustered along canada's southern border (statistics canada, 1999) and until recently, rural institutions in the south have not been faced with the prospect of recruiting or retaining staff. presently the incentives being offered to attract nurses to rural health care are generally monetary and the attraction of the "great out doors". according to aiken at al. (2001), recruitment and retention strategies that fail to consider more than monetary incentives to improve productivity are sure to fail. consideration must be given to "including opportunities for career advancement, lifelong learning, flexible work schedules, and policies that promote…loyalty and retention" (aiken et al. p. 5). health canada (2001) has identified the interface of home life and work life as an area of concern related to the sustainability of the nursing workforce. this is especially true for nurses living and working in the rural and remote areas of canada because there is little, if any, separation between their work and home environments. i would suggest that when canadian policy makers and program developers seek to transform rural health care, they expand their knowledge and incentives to include the social-life, and home-life concerns of the nurses expected to function within that structure as well as providing monetary incentives. failure to do so will affect efforts to recruit and retain a new generation of rural nurses. consequently, there will be a negative impact on quality of nursing care and patient outcomes (nunn, 2001). troughton (1999) suggests that health care adds social and economic well being as well as traditional health care to a rural community; therefore it is essential to the life online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 4 of the community. therefore key to the survival of a distinct canadian rural culture is the presence of available health care for its residents (canadian policy research networks, 2001). consequently, the ability to recruit and retain nurses to provide health care is vital for more than the survival of the profession itself. it is imperative that rural nurses position themselves to get this message across to governments and policy makers. references aiken, l.h., clarke, s.p., sloane, d.m., sochalski, j.a., russe, r., clarke, h., et al. (2001). nurses' report on hospital care in five countries. health affairs, 20(3), 4353. [medline] buresh, b. (2001). the missing voices in the coverage of health. in e.c. hein (ed.), nursing issues in the 21st century (pp 74-78). philadelphia: lippincott. canadian institute of health information. (2002). supply and distribution of registered nurses in rural and small town canada. ottawa, on: author. canadian policy research networks. (2001). asking citizens what matters for quality of life in canada: a rural lens. ottawa, on: author. health canada. (2001). the 2001 national work-life conflict study: report one. ottawa, on.: healthy communities division shreffler, m.j. (1998). professional isolation: a concept analysis. in h.j. lee (ed.), conceptual basis for rural nursing. new york: springer. sorrells-jones, j., & weaver, d. (1999). knowledge workers and knowledge-intense organizations, part 1: a promising framework for nursing and healthcare. journal of nursing administration, 29(7/8), 12-18. [medline] statistics canada (1999). the 1999 canada yearbook. ottawa, on: author. troughton, m.j. (1999). redefining "rural" for the twenty-first century. in w. ramp, j. kulig, i townshend, & v. mcgowan (eds.), health in rural settings: context for action (pp 21-38). lethbridge, ab: university of lethbridge printing service. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11585181&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10451654&dopt=abstract microsoft word addison_300-1660-1-ed_9.docx online journal of rural nursing and health care, 14 (1) 66 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 rural nurses' perception of disruptive behaviors and clinical outcomes: a pilot study kara addison, rn, aprn, mn, fnp-c1 susan luparell, phd, aprn, acns-bc, cne 2 1 graduate student, montana state university, karaaddison@gmail.com 2 associate professor, college of nursing, montana state university, luparell@montana.edu abstract purpose: the purpose of this pilot study was to explore rural nurses’ perceptions regarding disruptive behavior and its impacts on interdisciplinary relationships, patient safety, and patient outcomes. methods: montana nurses working at either of two rural facilities, one a small hospital and the other a critical access facility, participated in the study. the study replicated a larger study conducted by rosenstein and o’daniel (2005) in the vha west coast hospital network. a questionnaire was sent to nurses electronically via their agency’s email system to assess perceptions of disruptive behavior and its effects on patient outcomes. findings: fifty-seven nurses participated in the study, yielding a 47.5% response rate. disruptive behavior was reported to be displayed more often by nurses than physicians in this study. nurses perceived that disruptive behavior is linked to adverse events, and may also have a negative impact on patient safety and satisfaction. in addition, participants perceived a link between disruptive behavior and the psychological and behavioral variables impacting individual nurses. finally, the majority of respondents indicated that their facility lacked appropriate reporting and counseling policies for addressing disruptive behavior. online journal of rural nursing and health care, 14 (1) 67 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 conclusions: like their vha west coast counterparts, nurses working in rural settings experience disruptive behavior and believe there is a link between disruptive behavior and negative patient outcomes. however, results from this pilot study suggest that disruptive behavior by nurses in rural settings is more prevalent than that of physicians, findings that contradict previous work. keywords: disruptive behavior, workplace incivility, patient outcomes, patient safety, rural nursing rural nurses' perception of disruptive behaviors and clinical outcomes: a pilot study disruptive behavior has been defined as any behavior that undermines communication, team performance, patient care, and patient safety, and includes “…overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities” (joint commission [jc], 2008, p. 1). historically bad behavior in health care has been excused and normalized, even being accepted as a status of the profession (evans, 2007). mounting evidence suggests that disruptive behavior is a threat to patient safety, as it may result in errors, injury, or death (evans, 2007; jc, 2008; rosenstein & o’daniel 2005, 2008; saxton, hines, & enriquez, 2009). indeed, communication breakdown is consistently listed as one of the top three most frequently identified root causes of sentinel events (jc, 2013). in a landmark study, more than 8 in 10 nurses and physicians witnessed disruptive behavior within the healthcare setting and over 60% felt that potentially adverse events occurred directly from disruptive behavior (rosenstein & o’daniel, 2005). online journal of rural nursing and health care, 14 (1) 68 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 the consequences of disruptive behavior and general workplace incivilities are also significant to health care team members, whose health has been shown to suffer (vessey, demarco, & difazio, 2010). frustration, fear, stress, anxiety, depression, and loss of concentration have been reported in response to disruptive behavior (mckenna, smith, poole, & coverdale, 2003; rosenstein & o’daniel, 2005; vessey et al., 2010). additionally, workplace incivility has been associated with decreased nurse productivity (hutton & gates, 2008), reduced job satisfaction (saxton, hines, & enriquez, 2009), and intent to leave an organization (sofield & salmon, 2003). recent studies assessing incidence, perceptions, and ramifications of disruptive behavior appear to have taken place in mostly metropolitan areas. however, rural nursing culture is distinctively different than urban nursing culture. according to scharff (2010), rural nurses often are personally acquainted with everyone who works at the hospital, including all of the physicians and most of the patients. these highly connected interpersonal relationships have been shown to produce greater depth of interpersonal exchange and greater accountability for interpersonal exchange (scharff, 2010). presumably, then, disruptive behavior should be less of an issue in rural health care settings, but this has not been validated in the literature. there is sparse research examining the rural perspective on disruptive behavior and how nurses in smaller, more rural health care facilities experience disruptive behavior or its effects on patient care. therefore, the purpose of this pilot study was to explore perceptions of nurses working in smaller, more rural hospitals regarding disruptive behavior and its impacts on interdisciplinary relationships, patient safety, and patient outcomes. the research questions addressed were: 1. what is the occurrence of disruptive behaviors among nurses in rural hospitals in montana? online journal of rural nursing and health care, 14 (1) 69 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 2. is there a perceived link between disruptive behavior and adverse events, patient safety, and medical errors? 3. do nurses perceive a negative link between disruptive behavior and psychological or behavioral variables such as stress, frustration, communication, and team collaboration? methods a cross-sectional, descriptive design was employed. following approval by the investigational review board at montana state university (#ka120611-ex), chief nursing administrators were contacted in each of five rural hospitals in montana, a primarily rural state, and permission was sought to use the individual hospital intranet to contact nurses and distribute the survey. for the purpose of this pilot study, rural was defined as a territory with a population less than 50,000 (u.s. census bureau, 2010), and rural facilities were defined as those within a rural territory comprised of less than 125 beds. of the five administrators contacted, two replied to the request. one of the two participating agencies was designated as a critical access facility (caf) reporting 11-20 beds. the other agency was a small hospital reporting 51-100 beds. sample ultimately, 120 nurses in two central montana hospitals received an invitation to participate in the study. fifty-seven surveys were returned resulting in a 47.5% response rate. most (94.5%) nurses completing this survey were women (table 1). sixteen (29%) of the respondents worked in an 11-20 bed caf, 70.9% worked in a hospital with 51-100 beds, and 1% of nurses did not identify their work setting. online journal of rural nursing and health care, 14 (1) 70 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 table 1 sample demographics (n=57) characteristic n (%) * female 52 (94.5) employing agency small hospital (51-100 beds) 39 (70.9) critical access facility (11-20 beds) 6 (29) age 20-29 years 15 (26.8) 30-39 years 19 (33.9) 40-49 years 8 (14.3) 50-59 years 10 (17.9) 60 years or older 4 (7.1) experience in nursing less than 1 year 1 (1.9) 1-5 years 16 (29.6) 6-10 years 13 (24.1) 11-15 years 10 (18.5) 16-20 years 9 (16.7) greater than 20 years 5 (9.3) * some data points not provided by all participants instrument and data collection dr. alan rosenstein’s questionnaire, used in his seminal work exploring disruptive behavior in the vha west coast hospital network (rosenstein & o’daniel, 2005), was used with permission for this study (rosenstein, march 7, 2011, personal communication). the questionnaire has been used in three previous large-scale studies (rosenstein, 2011; rosenstein & o’daniel, 2005, 2008). the questionnaire consists of 21 questions including multiple choice, yes-no answers, 5 and 10 point scales, and open ended questions (rosenstein & o’daniel, 2008). examples of these questions include: 1. have you ever witnessed disruptive behavior from a physician at your hospital? 2. have you ever witnessed disruptive behavior from a nurse at your hospital? 3. what percentage of physicians would you say exhibit disruptive behavior at your hospital? online journal of rural nursing and health care, 14 (1) 71 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 4. what percentage of nurses would you say exhibit disruptive behavior at your hospital? 5. how often does physician disruptive behavior occur at your hospital? 6. how often does nurse disruptive behavior occur at your hospital? 7. how often do you think there is a link between disruptive behavior and adverse events, patient safety, and medical errors? 8. are you aware of any specific adverse events that did occur as a result of disruptive behavior? face validity of the instrument had been previously established by the developers and the questionnaire had been field tested at two urban hospitals (rosenstein & o’daniel, 2008) and adapted as indicated. the items on the questionnaire are applicable to all nurses of any background and did not require alteration for use with the montana nurse sample. the questionnaire was put into electronic format using survey monkey for this study. nurses of any educational preparation who were employed in either of the two agencies were eligible and received an invitation to participate in the study, which included a letter of explanation about the study and a link to the electronic questionnaire. one reminder email was sent at day 15, and the questionnaire was available online for 30 days. completion of the survey implied consent, and data were automatically de-identified by survey monkey upon submission in order to protect anonymity of respondents. results the occurrence of disruptive behavior almost all nurses (98.2%) had witnessed disruptive behavior by physicians, and most (87.8%) had witnessed disruptive behavior by nurses. the percentage of physicians estimated to online journal of rural nursing and health care, 14 (1) 72 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 exhibit disruptive behavior was identified as between 2-5% by the majority (64.9%) of respondents. a higher percentage of nurses were perceived to display disruptive behavior than physicians, with almost half of respondents (42.8%) suggesting that 6-10% or more of nurses at their facility exhibited disruptive behavior (figure 1). nurses were perceived to display disruptive behavior with greater frequency than physicians. although no one described the frequency of disruptive behavior by physicians as daily, 18.2% of the 55 respondents to this item reported disruptive behavior occurring weekly; 52.8% reported occurrence once to twice monthly (figure 2). alternatively, disruptive behavior by nurses was reported as occurring daily (18.2% of 55 respondents), weekly (28.3%), and once or twice monthly (30.9%). online journal of rural nursing and health care, 14 (1) 73 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 of the 44 respondents who identified particular settings (multiple responses possible) where disruptive behavior was most prevalent, 73.3% identified the emergency department, 37.8% indicated the icu, and over 35% indicated the medical and surgical units. additionally, the majority of nurses (79.1%) perceived cardiology to be the specialty where disruptive events occurred most often, while 25.5% of nurses felt that anesthesia was a specialty with frequently occurring disruptive events. perceived link between disruptive behavior and adverse events almost two-thirds (61.8%) of respondents were aware of potential adverse events that could have occurred as a result of disruptive behavior, while almost half (45.5%) were aware of a specific adverse event that did occur as a result of disruptive behavior. of these (n=29), 82.8% thought that the adverse event could have been prevented (figure 3). online journal of rural nursing and health care, 14 (1) 74 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 almost half (47.3%) noted that there was no code of conduct or policy for handling of disruptive behavior/abusive behavior at their facility, and, of those who said they did have one, 72.1% said it was ineffective. the most frequently identified barriers or resistance to the reporting of disruptive behavior were the feeling that nothing ever changes, fear of retaliation, and lack of confidentiality. of those nurses who knew of a physician who had been counseled about his or her behavior, the large majority (81.8%) indicated minimal satisfaction with the results of counseling. of those who knew of a nurse who had been counseled about his or her behavior, 58.2% indicated that they did not believe the counseling process was successful. psychological and behavioral consequences of disruptive behavior all respondents believed that disruptive behavior could potentially have a negative effect on patient outcomes. additionally, nurses were asked how often disruptive behavior resulted in stress, frustration, loss of concentration, reduced team collaboration, reduced information transfer, reduced communication, and impaired physician-nurse relationships. the large majority of nurses reported that each was frequently or constantly a result of disruptive behavior (see table 2). online journal of rural nursing and health care, 14 (1) 75 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 table 2 percentage of respondents answering, “how often does disruptive behavior result in the following (psychological or behavioral effects)?” never rarely sometimes frequently constantly stress 0% 0% 9.3% 40.7% 50.0% frustration 0% 0% 10.9% 40.0% 49.1% loss of concentration 0% 3.7% 16.7% 27.8% 51.9% reduced team collaboration 0% 1.9% 18.5% 27.8% 51.9% reduced information transfer 0% 1.9% 16.7% 38.9% 44.4% reduced communication 0% 1.8% 14.5% 32.7% 50.9% impaired rn/md relations 0% 1.9% 20.4% 27.8% 51.9% to assess the nurses’ perceptions of the link between clinical outcomes and disruptive behavior, participants were asked how often they thought there was a link between disruptive behavior and the following clinical outcomes: adverse events, errors, patient safety, quality of care, patient mortality, and patient satisfaction. in all cases, the majority of nurses indicated that specific clinical outcomes were sometimes, frequently, or constantly linked to disruptive behavior (table 3). table 3 percentage of respondents answering, “how often do you think there is a link between disruptive behavior and the following clinical outcomes?”. never rarely sometimes frequently constantly adverse events 0% 11.1% 51.9 14.8 22.2 errors 0% 9.3 40.7 18.5 31.5 patient safety 0% 13.0% 33.3% 14.8% 38.9% quality of care 0% 9.1% 29.1% 25.5% 36.4% patient mortality 7.4% 27.8% 48.1% 3.7% 14.8% nurse satisfaction 0% 0% 14.5% 38.2% 47.3% physician satisfaction 0% 1.9% 32.2% 37.7% 28.3% patient satisfaction 0% 5.5% 27.3% 21.8% 45.5% discussion the findings from this pilot study suggest that disruptive behavior may be common in rural healthcare settings, and rural nurses’ experiences with disruptive behaviors are both similar and online journal of rural nursing and health care, 14 (1) 76 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 dissimilar to that of vha nurses studied by rosenstein and o’daniel (2005). participants in this study perceived that disruptive behavior may be linked to adverse events and may also have a negative impact on patient safety and satisfaction. in addition, these participants perceived a link between disruptive behavior and the psychological and behavioral variables impacting individual nurses. finally, the majority of respondents indicated that their facility lacked appropriate reporting and counseling policies for addressing disruptive behavior. some respondents offered comments that illustrate the consequences of disruptive behavior on both patient outcomes and the psychological well-being of nurses. for example, in describing negative ramifications of disruptive behavior, one respondent noted: on our unit, we have had three nurses quit due to negative staff milieu. there are a couple of nurses who are rude, passive aggressive, demeaning, and manipulative. their behavior is never addressed and nothing has changed even with reporting such behavior. therefore, incredible nurses left because of ill feelings, increased stress, hurt feelings, and inability to function in such a negative environment. other comments also demonstrate the perceived impact on patient well-being: there are some physicians that nurses’ cringe when they have to call; no matter the reason for the call. this is detrimental to patient safety and makes it even more difficult to communicate effectively. i believe that this is a very important issue that needs to be addressed in the healthcare setting. i see it too often, especially nurse-nurse. i believe patients suffer when nurses are abusive to each other, because the nurse may then be distracted, have a negative attitude, or be afraid to ask for help. online journal of rural nursing and health care, 14 (1) 77 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 several specific findings of this pilot study contradicted previous work by rosenstein and o’daniel (2005). in particular, the percentage of nurses who witnessed disruptive behavior by both physicians and nurses was higher by at least 10% in the current study. additionally, although physician disruptive behavior was more prevalent in the vha study, in this study disruptive behavior by nurses was perceived to be more prevalent and more frequent than disruptive behavior by physicians. greater percentages of nurses in this study perceived links between disruptive behavior and adverse events, patient safety, quality of care, patient mortality, and patient satisfaction. for example, about 54% of the vha sample identified a link between disruptive behavior and patient safety, while 87% of the montana sample identified a link, a 33% increase. it is difficult to know what these differences in perceptions reflect. however, one possible explanation is that disruptive behavior inordinately magnifies the many challenges already encountered in many rural agencies. it seems counterintuitive that disruptive behavior may be more prevalent in rural settings, given the degree of interpersonal connectedness among rural dwellers. according to scharff (2010), the highly connected interpersonal relationships among rural health care workers have been shown to produce greater depth of interpersonal exchange and greater accountability for interpersonal exchange. presumably, people who know each other well and see each other frequently in the community would be inclined to interact in a more courteous manner, but this pilot study did not bear that out. however, perhaps the high level of familiarity itself degrades any perceived need for professional courtesy in the workplace. additionally, the very nature of the relationships in rural settings may add to the unique impact of disruptive behavior. as one nurse shared: working in such a small setting, disruptive behavior does not occur too online journal of rural nursing and health care, 14 (1) 78 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 frequently, however; when it does occur, it is severe. when a physician or midlevel gets angry at me for forgetting to enter an order, or not report a lab value to them, it is very embarrassing. usually it is in front of patients or other nurses. i always feel ashamed whether i was in the right or not. of additional concern is the finding that disruptive behavior was perceived to be more prevalent amongst nurses in this study. nursing is considered a nurturing profession, however; “it is paradoxical that within a discipline that has caring for others as its main focus, employee relationships are so poor” (farrell, 1997, p. 507). there are some potential procedural lessons to be learned from the implementation of this pilot study. because of budget constraints, the survey was administered in an online format and delivered via each agency’s intranet. the participation was largely dependent on nurses checking their hospital email. many nurses do not check their hospital emails on a regular basis or at all, causing a potential for decrease in response rate. some nurses in this study indicated that they often receive multiple emails a day, so they frequently delete them without reading the content. lastly, nurses stated that they rarely had time to check email or respond to a survey at work. one nurse stated that if the survey had been mailed or emailed to her home, she would have taken the time to participate in the survey (personal communication, 2012). according to shih and fan (2008), postal mail surveys continue to have a better response rate with professionals than email surveys. although email surveys tend to be quicker and less expensive, their overall response rates are decreased in comparison to the postal route (shih & fan, 2008). in some of the rural facilities originally explored for possible inclusion in the study, nurses did not have access to computers and therefore would not be able to complete the survey. access to computers by nurses working in rural hospitals has been documented in other studies (e.g., online journal of rural nursing and health care, 14 (1) 79 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 o’lynn, luparell, winters, shreffler-grant, lee, & hendrickx, 2009). although it appears that most urban hospitals within the u.s. have some access to computers, many rural hospitals may still largely depend on paper charting and have limited or no access to computers for personal use at work. use of traditional paper-and-pencil questionnaires may be a more fruitful method for data collection in rural nurses. finally, disruptive behavior can be sensitive and intimidating for some participants. for those nurses who have experienced disruptive behavior, reflecting back on such incidences may have caused emotional trauma or fear of retaliation. these feelings alone may cause the nurse to decline participating in the survey. also, some nurses may fear participating in the survey because it was sent out to their hospital email. they may have feared that their survey was seen or tracked by the hospital, which may result in their punishment for sharing hospital related events. these fears may be particularly exaggerated in rural agencies where employees are fewer and there is a lack of anonymity in general. limitations caution should be used when interpreting these findings. the sample size is small and represents the perceptions of nurses from only two facilities in montana. additionally, although the response rate was 47.5%, we cannot know the extent of non-response bias and whether the perceptions of those who did not complete the survey are similar or dissimilar to those who did. conclusion this particular study is consistent with previous studies performed in presumably more urban settings, which examined the occurrence and consequences of disruptive behavior in the healthcare setting. both studies illustrate that the occurrence of disruptive behavior is high in both physicians and nurses in the hospital setting. however, in this particular study, rural nurses online journal of rural nursing and health care, 14 (1) 80 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 perceived a higher occurrence of disruptive behavior in nurses than physicians. as in previous research, rural nurses indicated that disruptive behavior is linked to adverse events, decreased patient safety, and impaired staff relationships. references evans, s. (2007). silence kills: challenging unsafe practice. kai tiaki nursing new zealand, 13(3), 16-19. [medline] farrell, g.a. (1997). aggression in clinical setting: nurses’ views. journal of advanced nursing, 25(3), 501-508. http://dx.doi.org/10.1046/j.1365-2648.1997.1997025501.x hutton, s., & gates, d. (2008). workplace incivility and productivity losses among direct care staff. aaohn journal, 56(4), 168-175. [medline] joint commission. (2008). behaviors that undermine a culture of safety. sentinel event alert, 40. retrieved from: http://www.jointcommission.org/assets/1/18/sea_40.pdf joint commission. (2013, september). sentinel event data: root causes by event type 2004-june 2013. retrieved from: http://www.jointcommission.org/assets/1/18/root_causes_by_event _type_2004-2q2013.pdf mckenna, b., smith, n., poole, s., & coverdale, j. (2003). horizontal violence: experiences of registered nurses in their first year of practice. journal of advanced nursing 42(1), 90-6. http://dx.doi.org/10.1046/j.1365-2648.2003.02583.x o’lynn, c., luparell, s., winters, c.a., shreffler-grant, j., lee, h.j., & hendrickx, l. (2009). rural nurses’ research use. online journal of rural nursing and health care, 9(1), 34-45. rosenstein, a., & o’daniel, m. (2005). disruptive and clinical perceptions of behavior outcomes: nurses and physicians. nursing management 36(1), 18-29. [medline] http://www.ncbi.nlm.nih.gov/pubmed/17511206 http://www.ncbi.nlm.nih.gov/pubmed/18444405 http://www.ncbi.nlm.nih.gov/pubmed/15659998 online journal of rural nursing and health care, 14 (1) 81 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 rosenstein, a., & o’daniel. (2008). a survey of the impact of disruptive behaviors and communication defects on patient safety. the joint commission journal on quality and patient safety, 34, 464 471. retrieved from: http://www.physiciandisruptive behavior.com/articles.php?direction=1&start=8 rosenstein, a. (2011). managing disruptive behaviors in the health care setting: focus on obstetrics services. american journal of obstetrics & gynecology, 187-192. http://dx.doi.org/10.1016/j.ajog.2010.10.899. saxton, r., hines, t., & enriquez, m. (2009). the negative impacts of nurse-physician disruptive behavior on patient safety: a review of literature. journal of patient safety, 5(3), 180-83. http://dx.doi.org/10.1097/pts.0b013e3181b4c5d7 scharff, j. (2010). the distinctive nature and scope of rural nursing practice. in winters, c.a. & lee, h. j. (eds.), rural nursing: concepts, theory, and practice (3rd ed.) (pp. 249-68). new york, ny: springer. shih, t., & fan, x. (2008). comparing response rates from web and mail surveys: a metaanalysis. field methods, 20(3), 249-271. http://dx.doi.org/10.1177/1525822x08317085. sofield, l., & salmond, s. w. (2003). workplace violence: a focus on verbal abuse and intent to leave the organization. orthopaedic nursing, 22(4), 274-283. http://dx.doi.org/10.1097/00006416-200307000-00008 u.s. census bureau. (2010). 2010 census urban and rural classification and urban area criteria. retrieved from: http://www.census.gov/geo/www/ua/2010urbanruralclass.html vessey, j. a., demarco, r., & difazio, r. (2010). bullying, harassment, and horizontal violence in the nursing workforce: the state of the science. annual review of nursing research, 28, 133-57. http://dx.doi.org/10.1891/0739-6686.28.133 online journal of rural nursing and health care, 14 (1) 82 http://dx.doi.org/10.14574/ojrnhc.v14i1.300 winters, c. a., & lee, h. j. (2010). rural nursing: concepts, theory, and practice (3rd ed.). new york, ny: springer. microsoft word 28-68-2-rv_graves.doc online journal of rural nursing and health care, 12(1), spring 2012 67 focused community-based research for eliminating cvd risk disparities in a rural underserved population barbara ann graves, rn, phd 1 1 assistant professor of nursing, capstone college of nursing, the university of alabama, agraves@bama.ua.edu abstract background: cardiovascular disease (cvd) is the leading cause of death and chronic illness in the u.s. in parts of the rural south disparities in both health care access and cvd health outcomes are pervasive. descriptive analyses of community-based cvd risk factors are valuable to begin to unfold the complex nature of cvd mortality in specific rural, underserved populations. objective: to evaluate the prevalence of cardiovascular disease (cvd) risk factors among patients age 25 and over at a primary rural healthcare setting in a specific rural, medically underserved population to guide the development of community-based cvd treatment and prevention strategies. methods: this study used a descriptive retrospective explorative design. data were collected through chart audits from a random sample of 197 patients at a rural health center in northwest alabama, u.s. cardiovascular risk factors were identified using health data, anthropometric measures and icd-9 codes. prevalence was evaluated and descriptive statistics were used to describe cardiovascular risk factors as well as socio-demographics variables. findings: in this rural medically underserved cohort (n= 197), the prevalence of selected cardiovascular risk factors was: smoking: 39.1%; hypertension: 58.4%; dyslipidemia: 15.1%; diabetes mellitus: 27.9%; and obesity: 44.5%. smoking, hypertension and diabetes were noted to be higher in men, while women had higher rates of dyslipidemia and obesity. rates of hypertension and diabetes increased with age as seen in similar studies. more than 48% of the study population ages 41-55 years were noted to have dyslipidemia. conclusions: this community-based cvd risk factor assessment can be used to guide future community-based research and interventions. the high prevalence and inadequate control of cvd risk factors seen in this population coupled with an existing shortage of physicians is an opportunity for nursing interventions. the use of advanced practice nurses for cvd assessment and interventions may be one practical strategy for this rural, medically underserved population. keywords: prevalence, cardiovascular disease, risk factors, disparities, community-based research, rural, underserved, appalachian focused community-based research for eliminating cvd risk disparities in a rural underserved population cardiovascular disease (cvd) is the leading cause of death and chronic illness in the united states. more than 79 million americans,1 in 3, have some form of cvd. in 2004, cvd accounted for 36.3% of all deaths (aha, 2007). the cost of cvd and stroke for 2007 was estimated at more than $431.8 billion from both healthcare expenditures and lost productivity (aha, 2007). even as cardiovascular mortality rates have shown patterns of decline, patterns of cvd health disparities are pervasive (mensah & dunbar, 2006). it is predicted that by 2020 heart online journal of rural nursing and health care, 12(1), spring 2012 68 disease will remain the number one cause of death worldwide (aha, 2007). furthermore the pattern of decline in cvd is not equal across race, gender, socioeconomic levels, and geographic areas (aha, 2007; mensah & dunbar, 2006; usdhhs, 2008). the problem is particularly acute in parts of the rural south. rural areas have challenges associated with resource disparities and the associated health outcome disparities. one disparity that is evident in rural populations is a pattern of higher prevalence of cvd risk factors and cvd mortality (appel, giger & davidhizar, 2005; hamner & wilder, 2008; kettle, roebotban & west, 2005; mcdonald, hertx, unger & lustik, 2009; taylor, hughes & harrison, 2002). in alabama, heart disease is the leading cause of death and a major health disparity with a mortality rate of 292.2 as compared to the national rate of 241.7 per 100,000 (alabama health statistics, 2007). background and significance from an epidemiological view, cvd is a complex, multifactorial disease process. predisposing risk factors of cvd are interrelated within a complex web of causation. known modifiable risk factors include obesity, smoking, hypertension, dyslipidemia, and diabetes. consideration of cvd and its associated risk factors must include consideration of the complex relationships that exist among risk factors, geography and social determinants of health. differences or “disparities” in access to healthcare services and the resulting adverse health outcomes are major public health priorities. the institute of medicine (iom) and the u.s. department of health and human services (usdhhs) have identified the need for strategies to improve access to healthcare services and to support the improvement of health outcomes and health disparities (ahrq, 2008; iom, 2004). healthy people 2010: national health promotion and disease prevention objectives designated the elimination of health disparities as a major goal for our nation’s health (usdhhs, 2000). findings from studies conducted for the purpose of identification of characteristics of health differences indicate that gaps or disparities continue to exist. the literature documents disparities associated with age, education, race and ethnicity, gender, income and socioeconomic status (ses), and place of residence or location of healthcare services (aha, 2007; christian, rosamond, white & mosca, 2007; finketstein, khavjou, mobley, haney & will, 2004; kanjilal, et al., 2006; lillie-blanton, maddox, rushing & mensah, 2004; mcdonald, et al., 2009; mensah, mokdad, ford, greenlund & croft, 2005; pilote, et al., 2007; usdhhs, 2008; yarvi, et al., 2006). furthermore, from the national healthcare disparities report, it is evident those disparities in health still exist and that many opportunities for improvement remain across racial, ethnic, socioeconomic, and geographical groups (mensah & dunbar, 2006). in consideration of healthcare disparities, geography may be destiny (lin, allan & penning, 2002). access to quality healthcare is an ongoing problem for rural populations. financial, socio-cultural, and structural features of the rural environment create barriers to healthcare. these factors affect healthcare access, health-seeking behaviors, and ultimately health outcomes for rural populations (bushy, 2000; nchs, 2003; ricketts, 1999). the loss of community health services, healthcare professional shortages, rapidly rising cost, hospital closures, homecare cut backs, and tighter government payment schedules are just a few of the changes that have led to resource disparities for rural populations (nchs, 2003; usdhhs, 2000). rural areas are often identified as medically underserved areas (muas) and medically underserved populations (mups) and have a disproportionate burden of health disparities. because the burden of poor health is great in terms of cost and disability, research into specific healthcare disparities for specific rural communities is needed. online journal of rural nursing and health care, 12(1), spring 2012 69 communities have identities developed from their unique strengths and resources. health is relevant to this identity. israel, schulz, parker, and becker (2001) conducted a review of literature regarding community-based research. from this seminal review comes a collaborative approach to research that can serve to “enhance understanding of a given phenomenon and the social and cultural dynamics of the community, and integrate the knowledge gained with action to improve the health and well-being of community members” (israel, schulz, parker & becker, 2001, p. 177). empowerment of a community can generate knowledge and interventions to solve a community’s health problems. furthermore, the literature supports the use of small-area analysis to allow an opportunity to evaluate community patterns of disparities (gatrell, 2002). it is important to learn as much as possible about the ecology of health and disease within the context of specific rural communities. according to feigin and howard (2008) population-based epidemiology research is important as a starting point in the “spectrum of evidence” to guide healthcare decisions. even though descriptive studies provide the lowest level of evidence, they can serve as the basis for specific population-based research (feigin & howard, 2008). from this basis, hypotheses can be generated and research can advance to higher levels of evidence (descriptive – cohort – experimental – clinical trials) designed to address specific health disparities for specific communities. the prevalence of cardiovascular risk factors has been reported in many large u.s. and international studies. but what is now needed is community-specific risk factor identification for this rural, underserved appalachian population with known excess cvd mortality. research at the community-specific level can promote a better understanding and guide interventions aimed at the reduction of risk, disparities and mortality. the purpose of this retrospective, descriptive, explorative study was to examine and describe the prevalence of cvd risk factors in a specific rural, underserved appalachian population. gender-related and age-related differences in risk factors are described and compared to state and national data and to healthy people 2010 targets. results specific to this population can provide evidence to support proposal of randomized trials. this progression of evidence can be instrumental in development grassroots community-based prevention and treatment strategies. methods data collection procedure the study population consisted of approximately 1,500 medical records of approximately 500 patients seen at a rural health center in an underserved area of north alabama between january 2008 and march 2008. because we know men and women have different cvd risk factors a quota sampling method was used. using population characteristics of the rural health center the sample was stratified on the basis of gender. this method prevents the overrepresentation of either gender. a random numbers list was used to select patient visits for inclusion in the study. because the patient base of the rural health center was almost equal when stratified by gender the goal was to select approximately 100 male and 100 female patients. inclusion criteria for this study are as follows: • age 25 or older (patients born before 1983) • established patient (more than one visit to the center) • health center visit within a 3 month time period (january 2008 and march 2008) online journal of rural nursing and health care, 12(1), spring 2012 70 data was collected using medical record numbers to allow for organization and inclusion of all pertinent records. a dummy identifier was created and the medical record number was removed from the data. data was collected from a sample of 197 patients’ electronic medical records. data was entered and stored in an electronic database protected by passwords. data included weight and height (for the calculation of body mass index (bmi), systolic and diastolic blood pressure and diagnosis of hypertension, lipid profiles when available and diagnosis of dyslipidemia, smoking status, and diagnosis of diabetes. demographic data were collected on date of birth (for calculation of age), race/ethnicity and gender. there was no at risk population in this study. no subject identifiers were maintained, therefore, the identification of human subjects was not possible and no manipulation of variables occurred. the research presented no more than minimal risk of harm to subjects and involved no procedures for which written consent is normally required. the institutional review board (irb) of the university of alabama granted approval of the research protocol as well as consent wavier (irb# 08-or-092-me). data analysis procedure demographic characteristics and cardiovascular risk factors were identified by personal data, anthropomorphic measures, biochemical parameters, and diagnostic codes from the international classification of diseases, ninth revision [icd-9]. these included age, gender, race/ethnicity, smoking, hypertension, dyslipidemia, diabetes mellitus, and obesity. risk factors were entered dichotomously as “yes” or “no”. differences by gender and age were compared after dividing into age tertiles (25-40 years, 41-55 years, and 56-72 years). chi-square tests were used to compare categorical variables. spss® was used for all calculations. results from this study were compared with state and national level data on cardiovascular risk factors. both state and national level heart disease risk factor prevalence data for 2007 was obtained from the national center for chronic disease prevention and health promotion, behavioral risk factor surveillance system (brfss). the brfss is a state-based telephone survey of u.s. civilian population aged > 18 years. results a total of 197 patients were included for analysis. patient characteristics, biochemical variables and other cvd risk factors are shown in table 1. the study sample was predominately caucasian (87.6%) which is consistent with the demographics of this area. the range of ages was 25 to 72 years of age. there were no differences in age between men (49.4 years) and women (49.7 years) in this cohort. differences in prevalence of risk factors by gender are presented in table 2. the men had a higher frequency of smoking (47.1%) and hypertension (61.8%) than the women (30.5% and 54.7%, respectively). women were more likely to have dyslipidemia (45.2%) than men (27.3%). to compare age differences in the prevalence of cvd risk factors the following age tertiles were used: 25-40 years, 41-55 years, and 56-72 years. table 3 summarizes these analyses. patients age 41 to 55 years old were more often smokers and had dyslipidemia (48.4%) than patients in the 56 to 72 years range. both diabetes and hypertension showed a gradient effect with prevalence increasing across age ranges and this was found to be statistically significant for hypertension (p<.001). online journal of rural nursing and health care, 12(1), spring 2012 71 table 1 characteristics of the sample (n= 197) table 2 gender-related differences in cvd risk factors the following sections present discussion of the results from this study as well as a comparison with state and national data and healthy people 2010 target goals. for comparison online journal of rural nursing and health care, 12(1), spring 2012 72 of state and national level heart disease risk factor prevalence the national center for chronic disease prevention and health promotion, behavioral risk factor surveillance system (brfss2007) was used. comparisons are presented in table 4. table 3 age-related differences in cvd risk factors table 4 comparison with state, national, and international data discussion smoking in this study cohort, 39.1% of patients gave information that they currently smoked or used tobacco. one large national study of trends in cvd risk factors from 1999 – 2002 reported a prevalence of smoking among adults ages 25 to 74 years ranging from 13.9% to 37 (kanjilal, et al., 2006; kettle, et al., 2005). kettle et al., (2005) reported a high 43.0% prevalence of smoking in a rural population. women in the current study were less frequently identified as smokers than men (30.5% versus 47.1%). other investigators found rates for men: 40.6% versus women: 34.6% in a similar white, low education, predominately caucasian sample (mensah & dunbar, 2006). no studies reviewed reported that more women smoke than men. however, it cannot be ruled out that smoking among women could be underreported. smoking was consistent across age groups with no significance differences noted between age tertiles. the frequency of smoking was more than two times the national average (19.7%) and greater than three times the national target goal (12%), which speaks strongly for its importance as a risk factor for cvd in this population as well as in the general population. online journal of rural nursing and health care, 12(1), spring 2012 73 hypertension in this rural underserved population 58.4% of the patients had a diagnosis of hypertension. in contrast, kanjilal et al., (2006) found the prevalence of hypertension to range from 16.4% to 22.6%. also, in this cohort the prevalence of hypertension was greater than the rest of the state of alabama (33.1%) and the united states as a whole (27.5%). age gradients were observed with increasing prevalence of hypertension with increasing age as seen in other similar studies (mcdonald, et al., 2009). more men (61.8%) were hypertensive than women (54.7%), but the difference was not statistically significant supporting nearly equal prevalence between men and women as demonstrated in the nhanes data (cdc, 2007). this study supports the possibility that the potency of hypertension as a risk for the development of cvd varies by geography, community and culture. the overwhelmingly high prevalence of hypertension further supports the need for more research to identify community-specific strategies to reduce the prevalence of hypertension. diabetes diabetes mellitus was observed in 27.9% of patients in this study. other studies show the prevalence of diabetes ranges from 3.5% to 9.7% (aha, 2007). no evidence of significant gender/gender differences was found in the current study (men: 28.4%; women: 27.4%) which supports similar studies reporting men: 11.9%; women: 13.3% (menah & dunbar, 2006) and men: 33.0%; women: 29.4% (pilote, et al., 2007). age-related differences follow a gradient pattern of increasing prevalence of diabetes with increasing age as seen in other studies (mcdonald, et al., 2009). dyslipidemia evidence shows that elevated cholesterol levels increase cvd risk (expert panel on detection, 2001). in this cohort, 34.9% of patients had a diagnosis or cholesterol level evident of dyslipidemia as compared to 37.5% in the us general population. data show that 39.4% of the general population of alabama 18 years or older have indicators of dyslipidemia. a significant difference was noted in this cohort in dyslipidemia prevalence of 49.5% in women compared to 27.3% in men. overall, national data shows that mean serum total cholesterol vary significantly between men and women with the highest prevalence rates seen in women 65 years or older (cdc, 2007). mcdonald et al. (2009) noted similar results. using national-level data from the national health and nutritional examination survey (nhanes) for 1999 – 2004 their analysis revealed dyslipidemia prevalence 58.7% in women and 62.3% in men 65 years of age and older. petrella, et al. (2007) found a high prevalence of dyslipidemia in canadian primary care that was largely untreated in family practice settings. lipid determinations are not a standard of care for all patients seen in a rural health center. it is possible that dyslipidemia is underreported in the general populations as well as in this rural, underserved population due to cost constraints and the lack of insurance coverage. therefore, it is difficult to ascertain true prevalence of dyslipidemia and the association with cardiovascular risk in this population. future research regarding dyslipidemia in women is warranted. obesity over the past decade there has been a significant increase in obesity prevalence in the u.s. obesity is one of the modifiable risk factors of cvd with important implications. in 2007, state online journal of rural nursing and health care, 12(1), spring 2012 74 level obesity (bmi>30kg/m 2 ) prevalence ranged from19.3% to 32.6% (cdc, 2007). alabama is near the top of the range with almost one third of all alabamans being obese (30.9%) compared to a national prevalence (26.3%). the results of this study showed an overwhelming 44.5% of this rural, underserved sample classified as obese by having a bmi > 30 kg/m 2 . other national studies have reported the prevalence of obesity prevalence at 28.6% (sundaram, ayala, greenlund & keenan, 2005) and 32.2% (ogden, et al., 2006). women in the cohort had a higher occurrence of obesity than men (57.1% versus 53.9%) which was consistent with other studies. ogden et al. (2006) demonstrated no significant difference in obesity between women (33.2%) and men (31.1%). the prevalence of obesity in this rural underserved population is overwhelmingly high. addressing the growing epidemic of obesity could positively impact obesity as well as other cvd risk factors such as hypertension, dyslipidemia, and diabetes mellitus, leading to decreased cvd risk and mortality. nurses can provide interventions to change patterns of excess obesity. limitations in this study, a descriptive, community-based research approach was used to identify and describe the prevalence of cvd risk factors in a cohort of patients seen at a rural health center in northwest alabama. one limitation of this study was the nature of the sample. patients seen at a rural health center are less likely to seek routine and preventative care and are more likely to delay visits even when they are ill (bushy, 2000). people who live in rural areas also have a lack of financial resources and insurance and are less likely to accept cvd screening (ricketts, 1999). another limitation of concern is possible errors in recording data from medical records, leading to inaccurate prevalence rates of risk factors. the lack of quantification of some risk factors (ie, severity and control of hypertension, dyslipidemia, obesity, or diabetes mellitus, number of cigarettes smoked or pack years) is a possible threat to the validity of the study. these are areas for future study. data was obtained exclusively from a cohort of patients seen at a rural health center in north alabama. while these results may not be generalized to all other communities, they can be beneficial in the development of community-based interventions. specific descriptions and characterization of this rural underserved community can guide strategies to reduce cvd disparities in this and similar communities. summary in the united states today cvd is the leading cause of death. reducing disparities in cvd and its risk factors is a major challenge. cardiac care disparities are evident in excessively high rates of cvd mortality seen in the rural south. movement toward the elimination of health disparities (iom, 2004) will require description of specific patterns of cvd risk within a community, allowing targeted preventive and treatment interventions. central to the issues of cvd and its associated excess mortality is the progressive decline in access to healthcare services. despite the fact that healthy people 2010: national health promotion and disease prevention objectives (usdhhs, 2000) identified as a national priority that all people should have health that allows them a productive life by 2010, healthcare policy changes continue to decrease access to healthcare services. rural populations have fewer healthcare resources than urban populations, which lead to adverse health outcomes and rural health disparities. decreasing access may contribute to the excessively high cvd mortality observed in rural populations. community-based research is needed to identify specific patterns of cvd in online journal of rural nursing and health care, 12(1), spring 2012 75 specific underserved, rural appalachian populations and to place this pattern into cultural context for designing community-based cvd prevention and intervention strategies. nurses, living and working in the community, can bridge the gap in access to quality healthcare. regional disparities in cvd mortality observed in rural alabama provided for an opportunity to understand the complex nature of cvd mortality in a rural underserved appalachian population. this descriptive analysis has documented excess cvd risk factor prevalence for this rural, medically underserved population. studies such as this can provide valuable insight into the specific nature of cvd mortality in rural, underserved populations. conclusions high prevalence of cvd and cardiovascular risk factors, apparent in this rural underserved population, suggest the need for nurses to incorporate cardiovascular assessment as a part of routine care and the development of community-specific cvd interventions. nurses who practice in rural communities are in a position to impact cvd disparities. as providers of cardiovascular care, it is important for nurses and especially advanced practice nurses to step up and contribute to cvd health promotion, disease prevention, and disease management. furthermore, community-specific research results can provide information for those responsible for the development of healthcare policy and healthcare allocations toward the elimination of cvd disparities. acknowledgements sigma theta tau international, epsilon omega chapter references agency for healthcare research and quality (ahrq). 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/15257843 http://www.ncbi.nlm.nih.gov/pubmed/16682616 http://www.ncbi.nlm.nih.gov/pubmed/18588661 http://www.ncbi.nlm.nih.gov/pubmed/14742017 http://www.ncbi.nlm.nih.gov/pubmed/17130388 http://www.ncbi.nlm.nih.gov/pubmed/15842789/ http://www.ncbi.nlm.nih.gov/pubmed/15358011 http://www.ncbi.nlm.nih.gov/pubmed/19181717 http://www.ncbi.nlm.nih.gov/pubmed/17293734 http://www.ncbi.nlm.nih.gov/pubmed/15769763 http://www.ncbi.nlm.nih.gov/pubmed/16595758 http://www.ncbi.nlm.nih.gov/pubmed/17617298 online journal of rural nursing and health care, 12(1), spring 2012 77 pilote, l., dasgupta, k., guru, v., humphries, k.h., mcgrath, j., norris, c.,…tagalaki, v. (2007). a comprehensive view of gender-specific issues related to cardiovascular disease. canadian medical association, 176(6), s1-44. ricketts, t.c. (1999). rural health in the united states. new york: oxford university press. sundaram, a.a., ayala, c., greenlund, k.j., & keenan, n.j. (2005). differences in the prevalence of self-reported risk factors for coronary heart disease among american women by race/ethnicity and age: behavioral risk factor surveillance system, 2001. american journal preventative medicine, 29 (5s1), 25-30. [medline] taylor, h.a., hughes, g.d., & garrison, r, j. (2002). cardiovascular disease among women residing in rural america: epidemiology, explanations, and challenges. american journal of public health, 92(4), 548-551. [medline] u.s. department of health and human services (usdhhs). (2007). national healthcare disparities report: 2007. retrieved from http://www.ahrq.gov/qual/nhqr07/chap2a.htm. u.s. department of health and human services. (usdhhs) (2000). healthy people 2010: healthy people 2010: national health promotion and disease prevention objectives. washington, dc: usdhhs. http://www.ncbi.nlm.nih.gov/pubmed/16389122 http://www.ncbi.nlm.nih.gov/pubmed/11919049 29 smoking cessation practices of rural and urban health care providers linda d. scott, dns, bc-fnp1 kathleen b. lasala, phd, rn, cs, pnp2 carolyn z. lyndaker, phd, rn, cce3 sherry neil-urban, phd, rn4 1 family nurse practioner, spectrum healthcare resources, fort bragg, nc, sweetpea7095@aol.com 2 associate professor, beth el college of nursing, university of colorado at colorado springs, klasala@uccs.edu 3 associate professor (retired), james madison university 4 instructor, nursing and allied health division, western nevada college, neilurba@wncc.edu keywords: smoking cessation, enhancement factors, barriers, interventions, rural health care providers, urban health care providers abstract the purpose of this descriptive research was to identify the similarities and differences of demographic characteristics, specific intervention practices, perceived barriers, and enhancement factors associated with smoking cessation interventions of rural and urban primary health care providers. a convenience sample consisted of 342 physicians, registered nurses, and advanced practice nurses with the majority of urban health care providers being younger aged physicians and advanced practice nurses compared to older, registered nurses in rural areas. findings revealed minimal basic educational preparation of health care providers for smoking cessation interventions. rural health care providers reported diverse, multiple practice settings with a generalist view, estimated that more of their clients smoked, and were less likely to assess clients’ smoking practices and initiate smoking interventions. consistent, strong curricula education at all health provider levels and continuing education for new and more effective strategies is essential to empower health care providers to address smoking cessation interventions consistently and effectively. introduction an estimated 47 million or 25% of adult americans currently smoke. tobacco dependence is a chronic condition that causes disease and death in america with a societal cost of $100 billion annually even though tobacco dependence is a preventable disease. it is estimated that more than 70% of all smokers want to quit smoking completely and need the assistance of their health care providers. approximately 46% of smokers attempt to quit smoking each year and more than 70% of smokers visit a health care setting each year. provider-delivered interventions are effective in promoting smoking cessation, especially with treatment intensity or minutes of contact (centers of disease control and prevention, 2002; fiore et al. 2000; satcher, 2001; u.s. department of health and human services [usdhhs], 2000b). the national health objective of healthy people 2010 requests that 75% of health care providers offer tobacco cessation online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.shrusa.com/ mailto:lscott@fau.edu http://web.uccs.edu/bethel/ mailto:klasala@uccs.edu http://www.wnc.edu/academics/division/nalh/ mailto:neilurba@wncc.edu 30 assistance to adult smokers (u.s. department of health and human services [usdhhs], 2000a). all health care providers need to be more cognizant and consistent in the identification, documentation, and treatment of every tobacco user encountered in a health care setting as smoking cessation promotes the client’s health and quality of life. background numerous studies have documented the similarities and differences of smoking cessation practices, attitudes, and interventions among various health care providers. secker-walker et al. (1994) compared the tobacco cessation practices of primary care physicians, dentists, dental hygienists, family planning counselors, community mental health counselors, and women, infants, and children (wic) counselors in four new england counties. physicians and counselors were most likely to identify patients who used tobacco and counsel them about tobacco use. kviz et al. (1995) compared physicians, nurse practitioners, and nurses to find that smoking cessation attitudes did not vary between groups; however, physicians and nurse practitioners were more likely to implement smoking cessation activities than nurses. zapka et al. (2000) reported that nurse practitioners and midwives were significantly more likely to counsel pregnant women about smoking cessation than physicians, nurses, and nutritionists. consistency in monitoring tobacco usage and providing tobacco counseling at follow-up visits were low for all providers. moody, smith, and glenn (1999) described the practice patterns of nurse practitioners (np) in primary care in tennessee and compared the findings with a national survey of officebased physicians. findings revealed similar health care practices by both groups with the np providing more health care to women, caring for a younger population, and implementing health education and counseling more frequently than physicians. the np and physicians reported similar types of health education and counseling, such as nutrition counseling (19% compared to 15%), exercise counseling (12% compared to 7%), smoking cessation (7% compared to 2.5%), weight reduction (5% compared to 4%), and family planning (5% compared to 0.1%). the np provided smoking cessation education three times more frequently than physicians. only one study addressed the smoking cessation practices, attitudes, and interventions of rural health care providers. block, hutton, and johnson (2000) surveyed 614 rural dentists, chiropractors, primary care physicians, physician specialists, nurse practitioners, physician assistants, and public health nurses in 16 upper midwestern counties about tobacco assessment practices of clients, intervention practices, attitudes, skills, barriers, and desire for tobacco education. findings showed that 58.5% of all providers consistently assessed tobacco use; however, fewer providers (10%) offered consistent pharmacological interventions or referrals to community resources. providers reported supportive attitudes toward interventions, awareness of community resources, and sufficient tobacco counseling skills. low patient priority and lack of time for counseling were the common barriers to tobacco counseling. approximately two-thirds of the providers desired further tobacco education. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 31 there were no documented studies in the literature that addressed the similarities and differences in the smoking cessation practices, attitudes, and interventions of rural and urban health care providers. it was estimated that 20% of the american population lived in rural or non-metropolitan areas. rural areas reported more elderly, mostly caucasian, native-born residents with few minority residents. rural residents were more likely to attain a high school education, experience lower incomes with higher levels of poverty, encounter lower levels of insurance coverage, perceive lower levels of health (fair to poor), sustain higher trauma mortality rates, specifically in motor vehicle accidents and gun-related incidences, experience higher rates of chronic diseases, report higher infant mortality rates, demonstrate less utilization of hospitals and health care providers, and use less preventive health screening than urban residents (coburn & bolda, 1999; national center for health statistics [nchs], 2001; rural information center health services [richs], 2001a; ricketts, johnson-webb, & randolph, 1999). adults living in rural areas were more likely to smoke (27% in women and 31% in men) than adults living in urban areas (20% in women and 25% in men). similarly, rural adolescents were more likely to smoke than urban adolescents (19% and 11% respectively). two factors associated with higher rates of smoking in rural residents were lower educational attainment and limited access to medical and media resources for lifestyle changes. rural areas reported less available health care providers (10% physicians, 25% of physician assistants, and 24% of nurse practitioners) than urban areas (coburn & bolda, 1999; nchs, 2001; richs, 2001a; ricketts, johnson-webb, & randolph, 1999). research is needed to determine if similarities and differences among rural and urban health care providers exist. the research questions were as follows: 1. what are the demographic characteristics (type health care provider, age, gender, personal tobacco use, family or significant other tobacco use, and educational preparation of smoking cessation interventions) of rural and urban health care providers? 2. what are the characteristics of the work environment (type of practice setting, practice location, and perceived percentage of clients who smoke) in rural and urban health care providers? 3. what are the smoking assessment patterns, smoking cessation interventions, and prescribed pharmaceutical methods of rural and urban health care providers? 4. what are the perceived enhancement factors to implementing smoking cessation interventions of rural and urban health care providers? 5. what are the perceived barriers to implementing smoking cessation interventions of rural and urban health care providers? methods the purpose of this descriptive research was to identify the similarities and differences of demographic characteristics, specific intervention practices, perceived online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 32 barriers, and enhancement factors associated with smoking cessation interventions of rural and urban primary health care providers. the study was approved by four universities’ institutional review boards. primary health care providers were surveyed in three regional tobacco use prevention and control networks: southeastern (alabama and virginia), rocky mountain (colorado), and western (nevada). diverse definitions and characteristics of rural and urban areas have been documented in the literature. for this study, rural was defined as territories, populations, and housing units not classified as urban generally located 15 to 30 miles from a community with a population no larger than 10,000 residents. urban was defined as a community with a combined population of at least 50,000 from a central city and contiguous closely settled territory (rural information center health service, 2001b; u.s. census bureau, 2001; u. s. office of management and budget, 1994). a convenience sample of 342 subjects was obtained from a population of primary health care providers listed in their professional society directories (medical and nursing). the selection of subjects was equitable. each subject was contacted by telephone to explain the purpose of the study, confirm name and address, and obtain willingness to participate in the study. each subject was mailed a cover letter that explained the purpose of the study, confidentiality of information, informed consent, names of principal and coinvestigators, and institutional associations along with a questionnaire, and a selfaddressed, stamped envelope. the return of a completed questionnaire served as consent of voluntary participation. a follow up letter and second copy of the questionnaire were mailed to subjects who did not respond in three weeks. data were collected over eight weeks with a return rate of 46% (342 subjects). sample the convenience sample consisted of physicians (md), registered nurses (rn), and advanced practice nurses (apn), such as nurse practitioners and certified nurse midwives. the 230 rural health care providers were from a four-county continuum or contiguously close areas with a population range of 1,500 to 20,000 located in the eastern and southern regions of the united states. the rural areas were less populated with greater distances between towns or incorporated areas and consisted of fewer shopping opportunities and minimal health care services and providers than the urban areas. the 112 urban health care providers were from a two-county continuum or contiguously close areas with a population range of 40,000 to 80,0000 located in the mid-western and western regions. measures the primary care health provider survey: influences on implementation of smoking cessation practices is a 38-item, 5-point likert scale that measured the demographic characteristics, specific smoking cessation intervention practices, perceived enhancement factors, and barriers associated with smoking cessation interventions. lasala, the primary investigator, developed content items from the smoking cessation online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 33 concepts identified in the literature. content validity was determined in a pilot study of 10 expert primary health care providers that were not subjects in the study. a content validity index was used to quantify the extent of agreement, assure clarity of items, and confirm the readability of items. minor revisions of five items were based on the findings of the pilot study. a cronbach alpha of .7740 confirmed reliability. data analysis data were analyzed using the spss 11.0 for windows for descriptive statistics and pearson’s product-moment correlation. descriptive statistics were performed on all study variables. means and standard deviations were calculated; means were in expected ranges and sufficient variation was present. pearson’s product-moment correlation of all items was obtained with the significant level of p < .05. results the first research question asked: what are the demographic characteristics (type health care provider, age, gender, personal tobacco use, family or significant other tobacco use, and educational preparation of smoking cessation interventions) of rural and urban health care providers? the major rural health care providers were registered nurses and the major urban health care providers were physicians. the majority of health care of providers was aged 30.1 to 50 years, female, never smoked, no family members or significant others who smoked, and educational preparation about smoking cessation from combined resources for both rural and urban areas (table 1). there was a significant difference in types of professional rural and urban health care providers (chisquare = 13.506, p = .009). there was a significant difference in the ages of the rural and urban health care providers (chi-square = 9.251, p = .055). the second research question asked: what are the characteristics of the work environment (type of practice setting, practice location, and perceived percentage of clients who smoke) in rural and urban health care providers? the most commonly reported practice setting was family practice located in private clinics (table 2). there was a significant difference in the primary focus of the practice setting of rural and urban health care providers (chi-square = 44.935, p = .000), type of practice setting of rural and urban health care providers (chi-square = 30.924, p = .000), and estimation of the percentage of clients that currently smoke by rural and urban health care providers (chisquare = 10.705, p = .058). the third research question asked: what is the smoking assessment patterns, smoking cessation interventions, and prescribed pharmaceutical methods of rural and urban health care providers? urban health care providers assessed clients’ smoking practices more frequently than rural health care providers (70.7% and 68.7%, respectively) (table 3). rural health care providers were less likely to assess clients’ smoking practices once or never (8.6% and 1.8% respectively) than urban health care providers. there was a significant difference in the frequency of initiating smoking interventions (chi-square = 9.728, p = .045), types of smoking cessation interventions most frequently recommended online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 34 table 1 demographic characteristics of rural and urban health care providers rural (n = 230) urban (n = 112) variable n % n % health care provider physicians 75 32.6 51 45.9 registered nurses 84 36.5 20 18.0 advanced practice nurses 71 30.9 40 36.0 age 20-30 years 21 9.1 2 1.8 30.1-40 years 74 32.2 36 32.1 40.1-50 years 78 33.9 44 39.3 50.1-60 years 48 20.9 21 18.8 60.1 or more years 9 3.9 9 8.0 gender male 69 30.0 35 31.2 female 161 70.0 77 68.8 personal tobacco use never smoked 145 63.0 74 66.0 life-time (1-2 times) 29 12.6 12 10.7 past smoker (>2 for some time) 48 20.9 20 17.9 current “light” smoker (occasional) 5 2.2 6 5.4 current “heavy” smoker (>2 daily) 3 1.3 0 0 smoker in family or significant other yes 92 40 37 33 no 138 60 75 67 educational preparation formal academia curriculum 20 9.1 4 3.6 formal continuing education programs 10 4.3 5 4.5 professional literature 22 9.6 10 8.9 pharmaceutical literature or salesperson 4 1.7 3 2.7 informal professional networking 30 13.0 10 8.9 other (combinations of above) 143 62.2 80 71.4 n = 342 (chi-square = 15.744, p = .072), and pharmaceutical methods prescribed (chi-square = 22.905, p = .011). the fourth research question asked: what are the perceived enhancement factors to implementing smoking cessation interventions of rural and urban health care providers? both rural and urban heath care providers strongly reported that a client’s request for online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 35 table 2 characteristics of work environments rural (n = 230) urban (n = 112) variable n % n % primary focus of practice setting pediatric 27 11.7 22 19.6 family 77 33.5 45 40.2 women 30 13.0 32 28.6 adult 42 18.3 11 9.8 other 54 23.5 2 1.8 type practice setting private clinic 101 43.9 72 64.2 public clinic 30 13.0 15 13.4 hospital 47 20.4 3 2.7 school 26 11.3 19 17.0 other 26 11.3 3 2.7 estimation of clients who currently smoke 0 5 2.2 4 3.6 1-25% 97 42.2 63 56.3 25.1-50% 88 38.3 37 33.0 50.1-75% 28 12.2 7 6.3 75.1-100% 12 5.2 1 0.9 n = 342 smoking cessation intervention to be a strong enhancement factor and all other factors as having moderate enhancement to smoking cessation interventions (table 4). there were no significant differences between rural and urban health care providers in relation to the 10 perceived enhancements for smoking cessation practices. the fifth research question asked: what are the perceived barriers to implementing smoking cessation interventions of rural and urban health care providers? both rural and urban health care providers strongly reported that lack of client commitment or compliance and the addictive mechanism of nicotine were perceived barriers to cessation interventions and moderately rated the other perceived barriers, i.e., time constraints, cost factors, community resources (table 5). however, several health care providers expressed lack of clinical intervention skills (33.6% of rural and 21.4% of urban, respectively). the only significant barrier to implementation of smoking interventions between the rural and urban health care providers was the lack of perceived effectiveness of smoking cessation (chi-square = 8.188, p = .085). online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 36 table 3 assessment and intervention practices of health care providers rural (n = 230) urban (n = 112) variable n % n % assessment of client smoking practices never 10 4.3 2 1.8 once 10 4.3 0 0 several times (2-49%) 52 22.6 31 27.7 frequently (50-99%) 113 49.1 58 51.8 always (100%, every visit) 45 19.6 21 18.9 initiation of smoking interventions never 23 10.0 4 3.6 once 13 5.7 2 1.8 several times (2-49%) 100 43.5 44 39.3 frequently (50-99%) 82 35.6 53 47.3 always (100%, every visit) 12 5.2 9 8 follow-up on smoking interventions never 36 15.7 11 9.8 once 13 5.7 4 3.6 several times (2-49%) 107 46.5 51 45.5 frequently (50-99%) 62 26.9 41 36.6 always (100%, every visit) 12 5.2 5 4.5 smoking cessation interventions none 26 11.3 4 3.6 self-help materials 34 14.8 13 11.6 individual counseling 33 14.3 12 10.7 group counseling 4 1.7 3 2.7 combination of above methods 133 57.8 80 71.4 pharmaceutical methods prescribed none 39 16.9 24 21.4 nicotine gum 3 1.3 2 1.8 nicotine replacement patches 26 11.3 4 3.6 nicotine inhalers or sprays 13 5.7 13 11.6 zyban 36 15.6 17 15.2 other (combinations of above) 113 49.1 52 46.4 n = 342 online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 37 table 4 perceived enhancements to implement smoking cessation interventions rural (n = 223) urban (n = 112) variable n % n % health risks of smoking behaviors none 5 2.2 5 4.5 mild 25 11.2 11 9.8 neutral 25 11.2 12 10.7 moderate 92 41.3 45 40.2 strong 76 34.1 39 34.8 long-term costs for client none 18 8.1 6 5.4 mild 51 22.7 25 22.3 neutral 53 23.8 26 23.2 moderate 66 29.6 40 35.7 strong 35 15.7 15 13.4 client request for cessation intervention none 8 3.6 2 1.8 mild 17 7.6 6 5.4 neutral 30 13.5 15 13.4 moderate 55 24.6 26 23.2 strong 113 50.7 63 56.3 reimbursement for intervention none 30 13.5 20 17.9 mild 31 13.9 15 13.4 neutral 58 26.0 30 26.8 moderate 65 29.1 30 26.8 strong 39 17.5 17 15.2 personal skill and knowledge of interventions none 7 3.1 2 1.8 mild 17 7.6 10 8.9 neutral 45 20.2 26 23.2 moderate 112 50.2 49 43.8 strong 42 18.8 25 22.3 availability of community resources for referral none 18 8.1 5 4.5 mild 33 14.8 16 14.3 neutral 67 30.0 27 24.1 moderate 75 33.6 52 46.4 strong 30 13.5 12 10.7 online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 38 personal peer support and encouragement none 13 5.8 5 4.5 mild 24 10.8 14 12.5 neutral 65 29.1 38 33.9 moderate 96 43.0 46 41.1 strong 25 11.2 9 8.0 media-tobacco campaigns none 25 11.2 6 5.4 mild 54 24.2 34 30.3 neutral 74 33.2 27 24.1 moderate 56 25.1 38 33.9 strong 14 6.3 7 6.3 law & public policy restrict smoking in public places none 22 9.9 13 11.6 mild 44 19.7 22 19.6 neutral 58 26.0 24 21.4 moderate 70 31.4 34 31.3 strong 29 13.0 18 16.1 personal commitment to implement interventions none 3 1.3 1 0.9 mild 13 5.8 7 6.3 neutral 35 15.7 16 14.3 moderate 101 45.3 42 37.5 strong 71 31.8 46 41.0 n = 335 discussion and recommendations this research provides the first comparative view of demographic characteristics, work environment characteristics, smoking assessment patterns, smoking cessation interventions, prescribed pharmaceutical methods, and perceived enhancement factors and barriers to implementing interventions of rural and urban health care providers across four geographical areas. the results of this study must be interpreted with caution because of the nonrandomized, convenience sample and the inequity of numbers of the two groups’ participants. there are a greater number of rural health care providers (67.3%) than urban health care providers (32.7%) that participated in this study. the majority of the urban health care providers consisted of younger aged physicians and advanced practice nurses compared to rural health care providers (81.9% and 63.5% respectively) who used prescriptive authority and possibly viewed the questions from a different perspective than rns. the rural health care providers consisted of more registered nurses (36.5% and 18% respectively) than the urban health care providers. findings revealed that the majority of the sample consisted of older women who had online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 39 never smoked and reported combined resources for educational preparation for smoking cessation interventions. block, hutton, and johnson (2000), kviz et al. (1995) and zapka et al. (2000) reported similar findings of providers related to age, gender, and educational preparation. table 5 health care providers perceived barriers to implementation of smoking interventions rural (n = 223) urban (n = 112) variable n % n % time constraints of practice setting none 12 5.4 4 3.6 mild 42 18.8 19 17.0 neutral 38 17.0 18 16.1 moderate 78 35.0 51 45.5 strong 52 23.8 20 17.8 cost factors for client none 19 18.5 5 4.5 mild 30 13.5 8 7.1 neutral 36 16.1 21 18.8 moderate 84 37.7 52 46.4 strong 54 24.2 26 23.2 lack of clinical intervention skills or knowledge of interventions none 37 16.6 28 25.0 mild 50 22.4 32 28.6 neutral 61 27.4 28 25.0 moderate 54 24.2 15 13.4 strong 21 9.4 9 8.0 lack of perceived effectiveness of interventions none 19 8.5 16 14.3 mild 37 16.6 26 23.2 neutral 57 25.6 32 28.6 moderate 89 39.9 28 25.0 strong 21 9.4 10 8.9 lack of reimbursement none 31 13.9 15 13.4 mild 29 13.0 15 13.4 neutral 47 21.1 33 29.5 moderate 74 33.2 29 25.9 strong 42 18.8 20 17.9 online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 40 lack of community resources for referral none 21 9.4 11 9.8 mild 43 19.1 28 25.0 neutral 58 26.0 27 24.1 moderate 70 31.4 35 31.3 strong 31 13.9 11 9.8 lack of client interest none 4 1.8 2 1.8 mild 8 3.6 4 3.6 neutral 17 7.6 8 7.1 moderate 76 34.1 30 26.8 strong 118 52.9 68 60.7 lack of client commitment or compliance none 4 1.8 2 1.8 mild 8 3.6 4 3.6 neutral 15 6.7 8 7.3 moderate 66 29.6 31 28.2 strong 130 58.3 67 59.8 addictive mechanisms of nicotine none 6 2.7 3 2.7 mild 10 4.5 5 4.5 neutral 26 11.7 9 8.0 moderate 76 34.0 33 29.5 strong 105 47.0 62 55.4 media or advertisement influence none 22 9.9 6 5.4 mild 34 15.2 21 18.8 neutral 58 26.0 27 24.1 moderate 77 34.5 34 32.1 strong 32 14.3 22 19.6 personal beliefs associated with smoking none 125 56.1 72 64.0 mild 27 12.1 8 7.1 neutral 39 17.5 22 19.6 moderate 19 8.5 3 2.7 strong 13 5.8 7 6.3 n = 335 the rural health care providers reported diverse, multiple practice settings with a generalist view compared to urban heath care providers who reported private practice settings in family or specialty areas. rural health care providers estimated that more of their clients smoked than the clients of urban health care providers. these findings are congruent with the known characteristics of rural residents (cobrun & bolda, 1999; nchs, 2001; richs, 2001a; ricketts, johnson-webb, & randolph, 1999). online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 41 the health care providers of this study indicated the need for more knowledge, skills, and confidence to assess, initiate, and follow up on smoking interventions. this finding was supported by block, hutton, and johnson (2000). consistent and strong curricula education at all health provider levels about tobacco use, nicotine dependence, and cessation interventions is critical to empower health care providers to address smoking cessation interventions effectively. rural health care providers were less likely to assess clients’ smoking practices and to initiate smoking interventions. urban health care providers were more likely to initiate smoking interventions that consisted of combined methods, i.e. counseling, selfhelp materials, group counseling, and pharmaceutical methods of nicotine patches, sprays, or zyaban. these findings were comparable to the study by kviz et al. (1995). continuing education of all health care providers is essential for learning new and more effective strategies for smoking cessation. possibly more continuing education programs need to be available to rural health care providers or they should focus on other accessible resources, such as journals or internet resources (table 6). table 6 tobacco resources for clinicians website url agency for healthcare research and quality http://www.ahrq.gov american heart association http://www.americanheart.org american lung association http://www.lungusa.org center for disease control http://www.cdc.gov/tobacco national cancer institute http://www.mci.nih.gov nicotine anonymous http://www.nicotine-anonymous.org nursing spectrum (continuing education) http://www.nursingspectrum.com quick reference guide for clinicians http://www.surgeongeneral.gov/tobacco/tobaqrg quit net http://www.quitnet.com it is critical that health care providers implement smoking cessation interventions. the u.s. public health service provided specific evidenced-based recommendations for brief, intensive, or system-level changes for tobacco cessation interventions. the five step plan consisted of the 5 a’s: 1. ask-systematically identify all tobacco users at every visit, 2. advise-strongly urge all tobacco users to quit, 3. assess determine willingness to make a quit attempt, 4. assist aid the client in quitting, and 5. arrange common elements of practical counseling (problem solving, skills training, intratreatment supportive and extratreatment supportive interventions (centers of disease control and prevention, 2000; fiore et al. 2000; spoljoric, 2000; usdhhs, 2000b). online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.ahrq.gov/ http://www.americanheart.org/ http://www.lungusa.org/ http://www.cdc.gov/tobacco http://www.mci.nih.gov/ http://www.nicotine-anonymous.org/ http://www.nursingspectrum.com/ http://www.surgeongeneral.gov/tobacco/tobaqrg http://www.quitnet.com/ 42 health care providers have multiple client opportunities to address smoking cessation. health care providers armed with enhanced knowledge, confidence, and an intervention plan will achieve the healthy people 2010 goal to consistently assess and initiate smoking cessation interventions of clients (usdhhs, 2000a). further research is required about rural and urban health care providers’ practice patterns of clients’ smoking cessation to determine if this study’s results are comparable to other regions of the united states. a larger, more equitable randomized sample of similar health care providers is essential to determine significant similarities and differences between and among groups. the characteristics and needs of rural and urban residents are different; therefore, further research is needed to determine if smoking cessation interventions for each area’s residents should be the same or different. acknowledgments we would like to thank jenenne nelson, rn, phd, cns, at the university of colorado at colorado springs for her assistance with statistical analysis. references block, d.e., hutton, k.h., & johnson, k.m. 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[medline]. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.nal.usda.gov/ric/richs/stats/htm http://www.nal.usda.gov/ric/faqs/ruralfaq.htm http://www.cdc.gov/tobacco/overviewg/oshang.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=7855113&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12462818&dopt=abstract http://www.census.gov/geo/www/ua/ua_2k.html http://www.health.gov/healthypeople/document http://www.surgeongeneral.gov/tobbacco/tobaqrg.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10630141&dopt=abstract smoking cessation practices of rural and urban health care providers microsoft word austin_268-1512-1-ed.doc online journal of rural nursing and health care, 13(2) 23 older rural women moving up and moving on in cardiac rehabilitation elizabeth n austin, phd, ma, rn, cne, cen 1 1assistant professor at department of nursing, towson university; graduate program director, integrated homeland security management, eaustin@towson.edu abstract purpose: cardiac disease often strikes without warning. its sudden nature interrupts the lives of individuals and families. recovery from cardiac events may take months or even years. cardiac rehabilitation (cr) is an essential step in the recovery process. cr improves physical fitness and provides education for the reduction of risk factors for future cardiac events. women are known to be under-referred to cardiac rehabilitation. women are also under-represented in cr research, are less likely to attend cr than men, and may have worse outcomes than men. little is known about the experiences of older rural women in cr. the purpose of this study was to describe and interpret the experiences of older women who lived in rural communities and attended cr. sample: a purposive sample of 10 women (ages 60-83) was recruited from three cr centers in pennsylvania and new york. all women were residents of rural communities and had been discharged from cr. method: participants were enrolled in a phenomenological study to identify the meaning of cr for older rural women. interviews were audio-recorded, transcribed, and analyzed using van manen’s methodology. findings: three themes emerged from the study: (a) companionship, (b) hospitality, and (c) accomplishment. online journal of rural nursing and health care, 13(2) 24 conclusions: the women described cr as a program offering companionship in an atmosphere of hospitality to assist women in accomplishing their personal goals. the study has implications for nursing practice, education, policy, and theory development in rural nursing. keywords: older rural women, cardiac rehabilitation, phenomenology, companionship, hospitality, accomplishment older rural women moving up and moving on in cardiac rehabilitation cardiac rehabilitation (cr) is a program of exercise and education designed to (a) enhance physical and psychosocial health, (b) reduce risk factors for cardiovascular disease and its complications, and (c) promote healthier lifestyles (united states department of health and human services, 1995). the centers for disease control and prevention called for improved access to cr programs for those who live in rural and isolated counties (barnett, braham, & halverson, 1998); improved physician guidelines and tracking of cr attendance; reminders for cr compliance, education, counseling; and research to identify those factors that may enhance the lifestyle modifications recommended in cr programs (ayala et al., 2003). women are less likely to be referred to, or attend, cardiac rehabilitation than men and are more likely to have their first myocardial infarction (mi) 10 years later in life than men (barber, stommel, kroll, holmes-rovner, & mcintosh (2001). women and older adults are under-referred to cr despite the fact that they are known to have a higher risk of subsequent complications and further disease (spencer et al., 2001). women are also underrepresented in cr research (moore, dolansky, ruland, pashkow, & blackburn, 2003). the american association of cardiovascular and pulmonary rehabilitation (american association of cardiovascular and pulmonary online journal of rural nursing and health care, 13(2) 25 rehabilitation [aacvpr], 1999) recognized the need to learn more about the “risk-reduction regimens most likely to benefit women, and in particular, elderly women” (p. 6). factors that affect women differently than men include the presentation of cardiac symptomatology; cardiac risk factors such as age at onset, obesity and diabetes; mood, social isolation, physical fitness, level of disability, and physician referral, which tends to be lower in women (aacvpr, 2004). quality of life (gulanick, gavic, kramer, & rey, 2002) and depressive symptomatology (josephson, casey, waechter, rosneck, & hughes, 2006; todaro, shen, niaura, & tikemeier, 2005) may be worse for women than for men. arthur, wright, and smith (2001) found that women were reluctant to share their stories and pain with others. women may also perceive that their roles in the home are a higher priority than completing cr (schou, jensen, zwisler, & wagner, 2008). rural women in appalachia have had higher coronary heart disease (chd) death rates than women elsewhere in the us (barnett, braham, & halverson, 1998). rural dwellers encounter multiple issues that affect their attitudes about illness and health care as well as their ability to access health care (lee, 1998; lee & winters, 2006). women who live in rural places face time and distance issues when they must travel to cr programs (de angelis, bunker, & schoo, 2008; king, thomlinson, sanguins, & leblanc, 2006; harrison, & wardle, 2005) while balancing responsibilities at home. the purpose of this research was to study the lived experience of cr in older women who live in rural areas. developing an understanding of the lived experiences of older rural women who have completed cardiac rehabilitation will enhance the ability of nurses to assess, plan, implement, and evaluate individualized care for future patients. online journal of rural nursing and health care, 13(2) 26 methodology phenomenological study uncovers and defines the essence of an experience (merleauponty, 1956). we perceive the world because we live through the world (merleau-ponty, 1945/2006). through phenomenological research, we identify lived experiences, describe them, and are not concerned with causal explanations or analysis. phenomenological researchers understand that personal experience is absolute for each individual and may not be the same experience of another person. we give meaning to human experiences through activities such as remembering them, writing of them, discussing them and relating them to others (van manen, 1990). phenomenology is compatible with the nursing focus on the holistic care of the individual including “mind, body, and spirit….just as caring for only part of the client is inconsistent with nursing practice, so, too, is the study of humans by breaking them down into parts” (speziale & carpenter, 2003, p. 65). design hermeneutic phenomenology was the process used to explore the lived experiences of the women in the study. hermeneutic phenomenology “links understanding with interpretation” (plager, 1994, p. 72) that is critical to the practice of nursing. van manen’s (1990) method of research was employed to guide the process. van manen (1990) described phenomenology as reflective. we cannot have an understanding of a lived experience if we are living in the midst of the experience. through our reflection and description of the experience, we attempt to search for the essence of the experience and to have a more complete and in-depth understanding of the experience and its meaning in our lives. we “become more fully who we are” (van manen, 1990, p. 12). in order to online journal of rural nursing and health care, 13(2) 27 capture the reflective experience, participants were interviewed a minimum of two weeks after they were discharged from cr. interview transcripts became the data that were used for analysis. van manen described his research methodology with six essential steps that are dynamically intertwined. briefly, the six steps are: (1) turning to a phenomenon which seriously interests us and commits us to the world; (2) investigating experience as we live it rather than as we conceptualize it; (3) reflecting on the essential themes which characterize the phenomenon; (4) describing the phenomenon through the art of writing and rewriting; (5) maintaining a strong pedagogical relation to the phenomenon; (6) balancing the research context by considering parts and whole. (van manen,1990, pp. 30-31) setting and recruitment recruitment began in june, 2008 and continued through january 2009. women were invited to participate if they had completed at least six weeks of phase two cr and had been discharged from their programs. phase two is an outpatient program that involves structured exercise electrocardiogram monitoring. all patients undergo a pre-exercise assessment that includes risk stratification based upon factors such as complications during and after the cardiac event, ejection fraction, congestive heart failure, and depression. outpatient cr may last only a few weeks or sessions for clients who have a low cardiac risk, or it may last for as long as three months for clients who have high risk (aacvpr, 2004). all cr programs in this study were conducted by registered nurses. participation in the study required an individual interview with the principal investigator (pi). online journal of rural nursing and health care, 13(2) 28 the study was conducted through three cr programs that served rural populations in pennsylvania and new york. all programs participated in a local network of cr programs. each of the program sites was supportive of the research process and provided space for interviews with study participants. the pi contacted the women in the last week of the program to discuss the study and interview requirements. interviews were scheduled with women who were interested in the study. participants were given their choice of interview locations in order to overcome some of the barriers to participation in rural research, such as travel expense (morgan, fahs, & klesh, 2007). five interviews were held in the cr facilities where the women had been patients. four interviews were conducted in the homes of participants. one was conducted at a coffee shop that was convenient for that participant. sample the purposive sample included 10 female participants, age range 60-83. all women lived independently. three women lived alone. two women were employed full-time and a third was employed but did not specify if she worked full-time or part-time. seven women were married and living with their spouses. the women resided in rural towns in bradford and sullivan counties in pennsylvania, and tompkins county, ny. the definition of rural was a population density of <500 people per square mile (united states census bureau, 2002). diagnoses for the women included coronary stent placement, myocardial infarction, angina, coronary artery bypass graft surgery, and aortic valve replacement. one woman was unaware of her diagnosis. two women had mis and stents during their cr and were re-enrolled in the program. both of those women had cabg surgery prior to having the mi. one woman had also received cr many years ago. medical records were not reviewed and all data were self-reported. online journal of rural nursing and health care, 13(2) 29 protection of human subjects approval for the study was obtained from the binghamton university human subjects research review board (protocol number 777-08) and the guthrie health institutional review board (irb number 0802-03). all women selected a fictitious name for the study. the names of all participants, nurses, hospitals, and towns were changed in the collection, analysis, and reporting of data. data collection whitehead (2004) suggested having one question to start each interview. the primary question for this study was, “would you please tell me about your experience in cardiac rehabilitation?” other questions followed, as needed, for clarification or to stimulate discussion. reflective questions were asked in order to clarify meaning. all interviews were tape-recorded and conducted by the pi. having one investigator for a study with multiple sites reduced the complexity of the study (marshall & rossman, 2006) and facilitated the opportunity for the investigator to establish rapport and trust with the participants (truglio-londrigan, gallagher, sosanya, & hendrickson-slack, 2006). data analysis recordings were transcribed and entered into the atlas.ti (atlas.ti 5.2 scientific software, 1993-2009) data base. initial coding was completed, reviewed, and analyzed for meaning. transcripts and recordings were reviewed on multiple occasions in order to facilitate understanding the experiences of the women. the process of listening, writing, reading, listening to the language, and theorizing about experiences is essential to van manen’s (1990) methodology. the researcher attempts to describe a phenomenon with “a certain transparency, so online journal of rural nursing and health care, 13(2) 30 to speak: it permits us to ‘see’ the deeper significance, or meaning structures, of the lived experience it describes” (p. 122). three themes emerged from the common experiences of the women: (a) companionship-we did it together, (b) hospitality-warm, friendly, fun, and safe, and (c) accomplishment-i did it! companionship we did it together companionship was described as a nurturing relationship between each woman and one or more persons during the cr class. all women described situations where other people were present and helped them with some aspect of cr. women met others who supported and challenged their perceptions of health and encouraged recovery. for some women, the stories of families and friends added to the sense that the women were supported, or surrounded, by their companions in life. in some cases, the companions required home care for which the women were responsible. the nurses also provided companionship in the midst of other nursing activities. interestingly, none of the women reported continuing relationships with other cr clients after graduation. jean completed cr twice. companionship was a central theme in jean’s story. she enjoyed all the people she met and able to exercise while she socialized with her classmates. jean’s husband was a companion who played a crucial role in jean’s cr experience by driving her to class. i did enjoy it. i missed it when i wasn’t coming. and, uh, everybody was great. and it was fun on the machines when you had somebody next to you. you visited and you still worked away and i, i really liked it….‘cause you got to know them all. i knew people from, met people from smallville that i never even knew…. everybody just seemed to have a good time. online journal of rural nursing and health care, 13(2) 31 isabelle came to cr in very poor physical condition after a long and arduous recovery from surgery. she did not want to come to cr and wept at the thought. she was further dismayed to learn that she had to go three times a week. it took isabelle a full five weeks to feel in control of her experience. isabelle describes her experience on the first day with the nurse who stood by her as she began her exhausting cr sessions. the first day was indescribable. i could hardly do anything, let alone just walk around the room. and then, when she [the nurse] wanted me to pedal a bicycle, i said, “i can’t even crawl up on it.” and she said, “i’ll stand here with you.” and she stood there…. it was very, very exhausting for me; the whole one hour. and, so, uh, then i thought, “oh my gosh, i’ve gotta come back in a day and do this again. and i just really didn’t think i could do it. i really didn’t. being in cr with other people also gave sammy an opportunity to look at cr and appreciate the experiences of other people. well, a lot of other people did it. and, if they can do it, i can do it…a lot of them are in a lot worse shape. you know, and they just do it, they just do it at their pace. hospitality-warm, friendly, fun, and safe the women spoke very positively of the cr nurses and the environments they created. each woman came to cr with a different need. some were in better physical condition than others. some had never used exercise equipment and one was a skilled athlete. the nurses had the knowledge that provided a safety net for exercise and the positive attitudes to foster an environment that was conducive to an enjoyable experience. hospitality was an enjoyable atmosphere that fostered mutual learning, respect, recovery, safety, and healing for the women. online journal of rural nursing and health care, 13(2) 32 women felt that the nurses were able to answer any questions they may have. the women were also impressed when they watched the nurses care for other clients who had different problems. the nurses were credited with having positive attitudes that helped the women do their best while maintaining a home-like atmosphere. the nurses were encouraging and motivating. each woman came to cr after an unexpected cardiac event. they had fears related to exercising, falling, having another cardiac event or even dying. cr was a safe environment to learn and exercise in an effort to maintain optimal physical and mental condition. sammy described the atmosphere that was set by her nurses. “the nurses, of course, they’re very, very good. they answer all your questions” and they create a program were people “were friendly and warm and so fun. so you enjoy, i enjoyed the people very much.” annette spoke of the benefits of exercise, exercise education, and the positive qualities of cr. i liked going to the exercise classes….i really enjoyed the way they started one machine. and, then they actually teach you how to use the machines, because not everybody’s been to exercise classes….i’ve never even used a treadmill. helen provided an example for hospitality that reflects the atmosphere of hospitality that the women observed. helen’s example is especially noteworthy as she was in better physical condition than most cr clients. cr for helen was certainly very nice and encouraging. people [would say], “oh hi, how you doing,” or they would know a bit of each other’s health or family issues….you had a sense that people walking in with a smile and were greeted with a smile. so, it was nice…. and then, just once i got to know sarah [the nurse], i really felt very confident there. and she, there was, you know, a sub if she was away who was also, very mindful of everybody and keeping online journal of rural nursing and health care, 13(2) 33 track of us….i can do what she says and know that i’m safe…. one of the people we know... was having a lot of health issues other than just cardiac rehab. it was just kind of neat watching how she questioned him and worked with him and made suggestions, “well, let’s just back this off today” or something and, you know, just seemed to be totally tuned in to people, and uh. you know, even though i didn’t think i had any of those kinds of things, it just made me feel like she was tuned in to me, too, to see what she was watching. accomplishment-i did it! accomplishment refers to the achievement each woman realized after completing cr. the theme of accomplishment was echoed by the women regardless of how much physical progress had attained. some women did not realize how far they had slipped into poor health. all women had a sense of accomplishment. the nurses were instrumental in helping each woman to identify her path to recovery. nurses were providing direction, flexibility, and support. the women reported overcoming fear and persevering despite their hardships. the women felt a sense of personal responsibility for taking care of themselves. they knew they needed to exercise in order to remain independent. the women overcame significant obstacles in order to attend cr. mary needed to arrange for her daughter to care for her husband. isabelle needed someone to drive her for a few weeks. jean needed her husband to help her with the driving. some realized that they had not been exercising as much as they should. helen came to cr with a desire to know more about how to exercise safely. liz provided an excellent description for accomplishment. she had been told that she needed coronary artery bypass surgery but that she could not safely have surgery. she had to learn to manage her disease and symptoms with medication, lifestyle modification, and cr. liz did not think she could complete cr. online journal of rural nursing and health care, 13(2) 34 cardiac rehab i thought i was going to die when i first went…yes, because when i saw all those machines, and there was no way. i think it’s called a treadmill, there is no way that i thought i could ever live to get on that because with that thing going and my feet trying to move that fast, and the one lady told me, she says, you have got to walk faster. so, you know, i’m __ years old and i’ve always walked at this speed and i don’t think i can pick it up much faster that what i’m doing right now. so, i told her [the nurse] so. but, you know something, at the end of my 12 weeks, i went on that machine all by myself, plugged it in, tilted it, and sped it up so that i could go a littler faster, and by golly i did it. and i think cardiac rehab is a wonderful thing for anybody….don’t complain if you’re older, you can do it. it make take a couple weeks to get used to riding a bicycle again, but believe me, it all comes back to you, you don’t forget those things. phenomenological description of cardiac rehabilitation phenomenological description allows an experience to be recognized, understood and tangible. merleau-ponty (1945/2006). when writing the stories of the women in this study, it was most crucial to capture and name the essence of the experiences in order to understand the experience (gadamer, 1975/2004). the essence of cardiac rehabilitation was described as companionship in an atmosphere of hospitality that allowed the women to accomplish their goals. trustworthiness final member checking of the themes of companionship, hospitality, and accomplishment was accomplished with all ten women. all of the women agreed that the themes and essence of cr correctly described their experiences. isabelle, who had a very complicated recovery from a horrific experience, was silent at first as each theme was read. after moments of reflection, her online journal of rural nursing and health care, 13(2) 35 response was, “yes, yes, that’s it, very much so! oh yes!” rather than being sad at a reminder of her experience and the many obstacles she needed to overcome in order to simply survive, isabelle thought that the themes put “a face on what i was going through.” the title of this paper was selected by one of the women. all other women agreed that the title “moving up and moving on” accurately described how they felt about their experience in cr. rural concepts the participants discussed a variety of issues that are related to concepts of rural nursing practice (lee & winters, 2006). all women had the characteristic of being old-timers in their communities. there did not appear to be insider-outsider, participant anonymity, or professional anonymity issues. work and health beliefs sammy, annette, and helen remained employed during their time in cr. each wanted to keep working and needed to arrange cr around work requirements. liz, cinderella, and mary saw their work as related to caring for spouses and family members or home and property. cinderella perceived a difference between rural women and urban people, specifically women, and the amount of work that needed to be done as a normal part of living. “i think rural women have more to do than city people.” distance distance from the cr center presented the most problems for annette. annette was working full time and lived the farthest from her cr facility. she needed to rise at 5:30 in the morning for the long ride to cr and then return to her job. she had to stay late at her job to make online journal of rural nursing and health care, 13(2) 36 up the hours. annette felt a tremendous pressure to keep working as she was the only one in the family who was employed. for liz, the drive was just part of everyday reality and was a reason to stay active and independent. as a long-time resident of her community, she drove to her job for 13 years at hospital t and never encountered any difficulty. liz was adamant about refusing the public transportation that was available. but, then, if i come on [the bus] what does that look like? it looks like they sent the bus out for me….and, you know, i have to be honest with you. when i was younger, i used to call that the elder bus. cinderella indicated that she would not have travelled any farther than she did to cr. her home was just under 10 miles from the cr program. mary discussed distance issues as they related to cr and other neighbors. the distance from other people contributed to a feeling of isolation. the distance from the cr program made attendance complicated as it required her daughter to take more time from work to be at home when mary needed to drive to cr and exercise. jean lived about 10 miles from cr. she was not fond of driving and refused to drive in any amount of snow. her husband helped and drove her to some of her sessions. she would have loved to stay in cr, but felt the driving in the winter was problematic. distance issues were complicated by the rise in gasoline prices. gasoline during the initial recruitment of the study was around $4.00 per gallon. the cost of commuting to cr could easily be seen as a burden for rural populations. during the early months of the study only two women were found between four cr centers in pennsylvania and new york. it is conceivable that the cost of travel and winter weather were barriers to attendance and, therefore, recruitment. online journal of rural nursing and health care, 13(2) 37 isolation mary discussed isolation as an unfortunate aspect of her current life. she acknowledged that she and her husband moved to their home “30 years ago we were young and spry, like you, you know, we thought, oh boy, nothing would stop us.” but now, she found that she felt alone and isolated with the added burden of caring for her husband. when she had her mi, she was forced to leave him alone in the house for several hours until a daughter could get there. cr provided an outlet for mary. “i enjoyed it. it got me out and got me moving; which i think is good. especially when you’re like me and you’re tied down at home.” self-reliance all women in the study lived independently and maintained all their responsibilities. cr helped them to recover from their events. mary and cinderella knew they needed to be selfreliant in order to care for their husbands. mary lived some distance from neighbors and two daughters. she described how important her physical condition was to self-reliance and the ability to care for her husband. mary discussed the night that she had to call 911 for herself. the experience was a motivation for mary to improve her physical condition in the hope that she would never have to experience such a frightening event again. but it’s very hard, like when i had my heart attack, i couldn’t call her [her daughter] at work because she couldn’t come home. and, i didn’t know who to call, i called 911 and told him he had to stay there by himself until somebody could get to him....they took me away at two in the morning and my daughter didn’t, another daughter didn’t get up there until nine in the morning. it’s kind of a helpless feeling when they’re driving you away in the ambulance and he’s standing there alone, nobody to take care of him. i think he was little panicked. i wouldn’t want that to happen again….it’s kind of hard. i just figure it’s online journal of rural nursing and health care, 13(2) 38 something you have to do when you’re, get down you have to pick yourself up…. i just don’t like leaving him alone. cinderella also provided care for her husband. she lived in an apartment in the same house as a son and his family. that did help. however, she did report that there were many burdens that often fell to her, especially when the other family members were at work and school. one of her responsibilities was to tend to the woodstove so that she and her husband had heat in the winter. cr helped her to be in better physical condition to address the many issues around the home. i think once you’ve had a heart attack or something like that, you need something like this [cr]to strengthen yourself back up. 'cause, if you don’t, you take it and you go home and you sit in a chair and, you just lose everything. i didn’t realize i was in such bad shape, until it happened, you know?.... i figured i was in pretty good shape. i was working all time, and moving around. i know i was getting so i was hurting more and more, but, i figured that was old age. the only thing i can tell you is you’ve got to look after yourself. that’s the most important thing….you have lots of people to after yourself, but you have to consider yourself a#1….” liz discussed her life in the country and the fact that her children wanted her to move closer to them, perhaps to a senior living facility. living rurally has made her “tougher,” especially in the two years since her husband died. living on her own in the country was her choice and carried many benefits and responsibilities. the urban areas have buses that come and pick you up and do everything for you. i wouldn’t have my lawn to worry about. i wouldn’t have to worry about my furnace. but, you know, it keeps you more on your toes to have a little something to worry about. so, i would recommend, you know, if you can, just keep going, watch yourself at all times. online journal of rural nursing and health care, 13(2) 39 informal networks the women in the study were fortunate to have informal networks of care outside of cr. these people were family and friends. the relationships with these people were crucial to their ability to get to cr and their motivation for completing the program. for example, isabelle’s perception of her recovery before cr was different than that of her family. isabelle felt that climbing the steps and having access to her whole house was fine. isabelle’s son was instrumental in taking the next step. i felt that i went upstairs on my own; that my daughter and granddaughter could leave me. and that was the beginning of my rehab. but, little did i realize, my son and, uh, daughterin-law wanted me to go to rehab….but i said, “oh, i don’t need this.” and, uh, they said, “well, ok, we’ll take it from here one step at a time.” and one day tim, my son, came in and said “mom we’re going to rehab.” i cried. he did. he took me down. and he more or less told my story. and i said, “oh, i can’t come three times a week.” i said, “i’m not even driving yet.” i said, “i can’t expect my family to bring me down here three times a week.” and, he said, “you let us worry about that.” so, very reluctantly, i started my three days a week and one of my grandchildren brought me down. during cr, isabelle resumed driving. she was able to do all home tasks with the exception of unloading groceries and carrying them up stairs. in order to accomplish that task, she left the trunk of her car open to signal to her family that she needed their help with the food. the family lived within sight of isabelle’s home and was able to come and assist. online journal of rural nursing and health care, 13(2) 40 meaning and relevance companionship: we did it together! the theme of companionship was relevant and important to all the women in the present study. the women described the various companions in their cr experience in a way that is similar to the concept of socialization that has been discussed in the literature (dolansky, moore, & visovsky, 2006; mcsweeney & coon, 2004; visram crosland, unsworth, & long, 2007; white, hunter, & holttum, 2007). women tend to want individualized attention for their emotional concerns and the socialization aspect of cr. dolansky et al. (2006) made an interesting suggestion that cr nurses try to pair women at the end of their cr programs with women who were new to the program. isabelle described this process when she met a woman who had also received an aortic valve replacement. she felt a special bond with the woman and started an informal mentoring for that woman advising her to not be as “stubborn” as isabelle perceived she had been. when i mentioned to isabelle that she had become the teacher, she seemed surprised and reflected on her accomplishment, well, i think was hoping that maybe somehow, i encouraged her. because, i too, did not feel like it was going to happen. that i would never, ever get out of this situation. and here i am, i drove down here to see you! day and batten (2006) reported the perception of a woman who felt isolation amidst other cr clients because she did not feel that she had a similar experience as other clients. dolansky et al. (2006) reported that a client did not like exercising next to someone who was outperforming him. visram et al. (2007) suggest that women may want to have their own exercise groups. these comments serve as reminders that nurses need to know and understand each individual. there may be opportunities to connect people in cr better by utilizing schedules of classes or online journal of rural nursing and health care, 13(2) 41 equipment. interestingly, none of the women reported a desire to maintain personal contact with the other women in the cr classes. hospitality: warm, friendly, fun and safe hospitality is the “creation of free and friendly space where we can reach out to strangers and invite them to be our friends…on many levels and in many relationships” (nouwen, 1975, p. 79-80). cr presents a unique opportunity for nurses to engage clients in open and friendly settings over a period of months. positive attitudes and creating a home-like atmosphere was very important for the women in the present study. the theme of hospitality very aptly describes the experience of the women. white et al. (2007) described the need for “shared experience and understanding” (p. 282) for women who had been to cr. their work described a profound need for interpersonal communication that can be fostered by nurses and other cr participants in an atmosphere of hospitality. day and batten (2006) made an observation that women thought they received more individualized attention in cr than they received in the hospital. both mary and cinderella remarked that coming to cr was a time for them to enter a different environment that did not have the pressures of their stressed home lives. nurses in this study excelled at providing the atmosphere of hospitality described by nouwen (1975). the women talked about the safety they felt to progress at their own rates while feeling safe. liz also told us how her emotions changed from being angry with her cr nurse to finally understanding why the nurse was emphasizing increased exercise levels. the hospitality of the environment allowed her the time and freedom to make that connection. online journal of rural nursing and health care, 13(2) 42 accomplishment: i did it! fleury and sedikides (2007) made an important observation about the growth of self as cr participants moved forward in the program and away from the immediacy of their cardiac event. participants grew in confidence that they were progressing and their level of understanding of themselves increased. the theme of accomplishment echoes this observation. liz captured this change in attitude and self-efficacy when she described her transition from her start in cr where she was motivated by guilt to stay in the program. the nurses were wonderful to me, and um, they were all trying so hard to help me and i was the one that was resisting. i mean, the machines were there, i was there, and i talked to other people. i met a lady that was, um, had just been 80, she had just turned 80, and she was there. and i thought to myself, what would people think if i don’t keep this up. i mean, i can do it, it’s gonna take me awhile, but i can [emphasis added] do this. and so i drove back and forth, 20 miles each way, and got to the point where, i just couldn’t miss a class because it was very important. it was like when i was a kid going to school, i didn’t want to miss anything so i was always out there in time for the bus. pâquet, bolduc, xhignesse, & vanasse (2005) reinforced the importance of time in the recovery from an mi. when analyzing the stories of the women in this study, it was especially important to note the various accomplishments that they were able to make over a period of time and how meaningful those accomplishments became. van manen’s existential concepts the stories of the women in this study bring to life van manen’s (1990) discussion of the four existential concepts that ground human existence: (a) lived space, (b) lived body, (c) lived time, and (d) lived relationships (p. 101). nurses, clients, and family members become part of online journal of rural nursing and health care, 13(2) 43 these concepts as they interact with each other through cr and the recovery of the women from the insults of cardiac disease. the goal of nurses must be to understand the complexities of the “human issues and concerns” (benner & wrubel, 1989) lived space. space is a concept that can described mathematically, measured, experienced, and felt (van manen, 1990). we enter spaces, live in spaces, and are affected by the space that surrounds us. consider how we might feel in a large outdoor space or the confines of a hospital room. the large outdoor space may invoke a feeling of wonder and freedom if it is associated with natural beauty. we each have perceptions of the space that are influenced by our past experiences. the confines of a hospital room may invoke fear of illness and suffering. jean and isabelle both described these feelings when they described experiences in the cardiac catheterization laboratory, for jean, and the intensive care unit and helicopter, for isabelle. for liz, on the other hand, the hospital was a place where she was surrounded and supported by friends. she had worked in the hospital for many years. she knew, and handpicked her physician. she spoke fondly of her experience. dr. x. came in and visited with me and she said, you always said that um, if anything happened you wanted me to do the surgery, well, here i am. that was what she said when she came into the room. and everybody was just wonderful. the whole team came in to visit me. as i said i had worked at the hospital, so, they just figured they had me now, you know. cr is conducted in rooms filled with different types of exercise equipment. the space may be overwhelming from the moment women enter the space. sammy described her experience of the space. “it’s you know, like overwhelming when you first walk in.” liz was equally emphatic with her description when she thought she was going to die” on cr machines. online journal of rural nursing and health care, 13(2) 44 the theme of hospitality that emerges from the stories describes van manen’s (1990) concept of lived space. van manen (1990) described the home as “a very special space experience which has something to do with the fundamental sense of our being….home is where we can be what we are” (p. 102). the women in this study provided different descriptions of home in relation to cr. joydan’s said that the nurses “make you feel like you are at home, you know, there’s to just, just to ah, be here, you know.” for helen, cr was a reunion of sorts that compared with “old home week.” for liz, cr changed from being a space where she was overwhelmed to a place where she felt compelled to go because it was important. the nurses were wonderful to me, and um, they were all trying so hard to help me and i was the one that was resisting…. i just couldn’t miss a class because it was very important. it was like when i was a kid going to school, i didn’t want to miss anything so i was always out there in time for the bus. lived body. all humans have an experience of the body. merleau-ponty (1945/2006) stated that we are “in undivided possession” (p. 112) of our bodies and that we know our bodies through our perception of “body image” (p. 113). we meet others in life through the presentation of our bodies. “in our physical or bodily presence we both reveal something about ourselves and we always conceal something at the same time-not necessarily consciously or deliberately, but rather in spite of ourselves” (van manen, 1990, p. 103). we may feel differently when we are with others. that feeling may be positive or unpleasant. the theme of accomplishment describes the change in lived body for the women. for example, the women in the study had to recover from their acute illnesses and adapt to life with bodies that were forever changed in some respect. some women had intracoronary stents, some experienced myocardial damage, some had surgery, and all described some changes in their online journal of rural nursing and health care, 13(2) 45 bodies. subtle change was described by cinderella when she said, “i figured i was in pretty good shape. i was working all the time, and moving around. i know i was getting so i was hurting more and more, but, i figured that was old age.” isabelle made very interesting observations about her body as she learned to adapt to her new artificial valve. her valve was a porcine, or pig valve. isabelle referred to the pig and her frustrations with the pig that wasn’t working. i think that i was disillusioned that i didn’t jump out of bed the day after surgery, of having that pig put in me. it didn’t work…. i felt that the pig was working, you know, wasn’t he doing his job?...i thought, you know, i’ve got this pig, and he’d better start working. ‘cause i went through a lot to get him in there. isabelle’s perception of the pig changed after her completion of cr. she was able to return home to independent living, drive a car, and live in her home with her cat and the pig. and she described the post-cr pig, “i guess the pig is working.” lived time. van manen (1990) made a distinction between time that is lived and subjective, and time that is measured, or objective. our perceptions of lived time are affected by our activities. time includes “dimensions of past, present, and future constitute the horizons of a person’s temporal landscape” (van manen, p. 104). the women in the study experienced an interruption in their lives when they required care for cardiac problems. participating in cr poses a significant addition to the time required to recover from the cardiac event. the women made references to the time of day they needed to (a) report to cr, (b) the amount of make-up time required at work for annette; (c) the benefit of time away from care giving responsibilities for mary and cinderella; (d) time spent exercising with family or friends, for sammy, jean, helen, and cinderella, and (e) the time required to be able to see improvements in health and the time online journal of rural nursing and health care, 13(2) 46 required to re-gain control of one’s life as in isabelle’s example. the theme of companionship describes the relational component of transitions from the past to the present and future. the theme of accomplishment provides a sense of finality for the lived time element of cr. lived relations. an essential theme of the women’s experience was companionship: we did it together. the women reinforced this theme repeatedly through the study. all women felt a relationship with someone other than themselves. this is not to say that they made new or lifelong friends. they did, however, share an “interpersonal space” (van manen, 1990, p. 104) with others that allowed them to be present to others and to experience others. jean was an exemplar of the importance of relationships with others. she frequently described how being with others positively influenced her exercise habits during and after cr. the women had significant relationships with their families that took on new meaning during their cr time. while most of these relations were positive, some were more stressed. jean relied on her husband to drive her to cr. annette’s husband helped her to begin walking by driving her part of the way to or from work. mary relied on her daughter to care for her husband. many women exercised with family members during and after cr. isabelle had two family members who moved in to help her during her recovery. all women had positive and informative relationships with their nurses during cr. the nurse-client relationships represented key parts to each essential theme in this study. the nurses were instrumental in being with the women as they adjusted to cr and life after the cardiac event. when we meet others, “we are able to develop a conversational relation which allows us to transcend our selves” (van manen, 1990, p. 105). liz spoke of her relations with the nurse who was pushing her to accomplish more. online journal of rural nursing and health care, 13(2) 47 the one that i used to dislike so much because she was always telling me, you gotta walk faster, you gotta take bigger steps, you gotta push, push, push. she was right! even though i was against her, you know, in the beginning. but, she was right. i used to come home and i’d be mad at her. isabelle often spoke in relational terms about “the pig” as if it was a being that had let her down. she was finally able to see that the pig “was working.” isabelle also spoke of her defining moment when she knew she could speak to another woman about her experience in order to encourage the woman. and even though she had the mechanical one, she didn’t have the setbacks that i did. and, uh, we would compare pains here and pains there. and uh, then we’d laugh at um. i said, “oh, they’ll disappear, you wait and see.” and so, uh, we connected with each other. well, i think was hoping that maybe somehow, i encouraged her. because, i too, did not feel like it was going to happen. limitations the study has a number of limitations. the sample included only caucasian women who were > 59 years of age who lived independently. it would be realistic to expect that younger or urban dwelling women in cr would have different concerns. the study does not include issues or concerns of men, ethnicity, education, socioeconomic status, or women who may live in supported environments such as assisted living communities or nursing homes. the women in this study may also have cultural views and experiences that are not shared by women in other parts of the country. these limitations affect the transferability of the data. the fact that the women voluntarily consented to be in the study presented the possibility of selection bias and the fact that the experiences of the women does not reflect the experience of women who did not online journal of rural nursing and health care, 13(2) 48 complete cr. all women in the study reported positive outcomes, which may not be a reflection of the experiences of other women. the researcher in this study has had experience in cr and professional associations with all professional staff and sites that were discussed in this study. every attempt was made to limit the potential influence of these associations. implications future nursing research further nursing research is needed to improve the cr experience for older rural women. qualitative data adds a richness of knowledge and understanding that is needed in the area of cardiac rehabilitation. this is the only nursing study known to the author to utilize the method of phenomenology to examine the meaning of cr in older rural women. the study should be replicated in older men, older women who live in urban areas. and women of ethnic diversity. another area of nursing research would be to extend the benefits of cr to rural women who have significant risk factors for cardiovascular disease before they require intervention for events such as mis. some women in this study described how their physical health had deteriorated even prior to their cardiac events. early intervention with cr or other nurse-led interventions to reduce cardiac risk may give women the proper environment and support necessary for effective risk reduction. nursing practice future research in the area of nursing practice must address the long term implications of cr and mental health outcomes on older rural women. the member-checking process in this study enabled the researcher to reconnect with the women after their cr discharge. none of the women reported any difficulties but a few did relate that they felt they were losing some of their physical strength because they were no longer exercising at the intensity levels used in their cr online journal of rural nursing and health care, 13(2) 49 programs. arthur et al. (2001) found that women felt they needed time exceeding six months to fully “cope with the sequelae” (p. 27) following their cardiac events. doerfler, paraskos, and piniarski (2005) suggested that patients with a perceived lack of control over their cardiac symptoms had an increased risk for developing symptoms of post traumatic stress disorder (ptsd) months after experiencing an mi. while their study included more men than women, it raises concerns about the possibilities of ptsd in women, particularly those such as isabelle and annette who experienced horrific events and mary, zoie and jean who experienced multiple mis. helen felt that anyone who had experienced and mi must be “scared witless.” many of the women in the present study reported being more in control of their lives after cr. nurse education cr would provide an excellent learning opportunity for nurse education. nursing students would certainly gain from the insight of the women and their experiences of a cardiac crisis. nursing students would also gain knowledge of the differences between hospital care in a crisis and the advantages of cr that is exemplified by companionship, hospitality, and the accomplishment of the clients. graduate nursing students would be ideally positioned to conduct further research into the benefits of cr for older women in all communities. policy zoie raised an important policy issue that has implications for all older adults who reside in senior living facilities. i likes the nu-step. i’ve been thinking about those i could get one into [the residence] here because it is much easier to use than the bike and less stressful than the treadmill….our problem here is insurance. if you brought a nu-step into [the residence], [the residence] is online journal of rural nursing and health care, 13(2) 50 responsible for it. and, if somebody got hurt on it, or whatever. and, there’s no easy way to have supervision. so, i don’t know, i suppose it will never work. austin, johnston, and morgan (2006) reported similar obstacles when working with a community garden project at a senior center. the garden project was to provide an opportunity for exercise, community building, and improved nutrition for the participants. multiple obstacles related to ground use and liability needed to be overcome before the successful program was initiated. nurses must be advocates for safe exercise opportunities for older adults living in all circumstances. nursing theory cr presents an opportunity for older rural women to improve their lives by promoting lifestyle changes to reduce the risk of future cardiac events. nurses must generate or identify theoretical frameworks that enhance the delivery of cr for all women in culturally competent, accessible, and affordable options. replicating this study in other populations will help nurse researchers to define characteristics that are unique to rural populations. conclusion cardiac rehabilitation provides an important bridge for patients who have suffered a cardiac event. the literature supports the need for cr to address physical, emotional, and social needs for both men and women. the literature supports the need for nurses to provide individualized care in atmospheres where clients can recover and gain perspective on their health and self-efficacy and knowledge for health promotion and the reduction of cardiac risk factors. cr can provide essential links, particularly for women, where clients become mentors for other people. the stories of the women in this study and the literature on cr support the themes of companionship, hospitality, and accomplishment that have become the essence of cardiac online journal of rural nursing and health care, 13(2) 51 rehabilitation for the women. research cr is needed to explore opportunities to facilitate enrollment and completion of cr for older women who live in rural communities. the women in this study clearly demonstrated that cr was critical to their physical endurance and independent living. references american association of cardiovascular and pulmonary rehabilitation. 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(2006). building trust between the older adults and researchers in qualitative inquiry. nurse researcher,13, 50-59. [medline] united states census bureau. (2002). census 2000 urban and rural classification. retrieved from http://www.census.gov/geo/www/ua/ua_2k.html united states department of health and human services. (1995). clinical practice guidelines: cardiac rehabilitation (ahcpr publication no. 92-0047). rockville, md: author. van manen, m. (1990). researching lived experience: human science for an action sensitive pedagogy, albany, ny: state university of new york. visram, s., crosland, a., unsworth, j., & long, s. (2007). engaging women from south asian communities in cardiac rehabilitation. british journal of community nursing, 12(1), 13-18. [medline] white, j., hunter, m., & holttum, s. (2007). how do women experience myocardial infarction? a qualitative exploration of illness perceptions, adjustment and coping. psychology, health & medicine, 12, 278-288. [medline] whitehead, l. (2004). enhancing the quality of hermeneutic research: decision trail. journal of advanced nursing, 45, 512-518. [medline] http://www.ncbi.nlm.nih.gov/pubmed/15818192 http://www.ncbi.nlm.nih.gov/pubmed/16594369 http://www.ncbi.nlm.nih.gov/pubmed/17353806 http://www.ncbi.nlm.nih.gov/pubmed/17510897 http://www.ncbi.nlm.nih.gov/pubmed/15009354 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 141 rural long term care nurses’ knowledge of palliative care carol a evans, dnp, rn, ned, cne 1 1 associate professor, rn-bsn program, school of nursing, western kentucky university, carol.evans@wku.edu abstract purpose: regardless of the location, rural nurses care for patients and their families across the trajectory of an illness and into death in long term care facilities. the purpose of this study was to examine rural nurses' knowledge of palliative care for end of life patients in long term care facilities. method: a quantitative descriptive correlational design was utilized with a convenience sample of nurses (registered nurses and licensed practical nurses) in three rural long term care facilities in south-central kentucky. demographical data was utilized to describe the study subjects, and the palliative care knowledge test was utilized to measure the rural nurses' knowledge of palliative care. descriptive statistics and cross-tabs with a chi-square test for independence were used for analysis. findings: the rural nurses lacked knowledge of palliative care on the palliative care knowledge test. although the study sample scored below 50%, registered nurses were more knowledgeable than licensed practical nurses on many of the items on the palliative care knowledge test. this study supports that the total years practiced in long term care does not affect the knowledge on the palliative care knowledge test. registered nurses were more knowledgeable than licensed practical nurses on some items of the palliative care knowledge test. conclusion: nurses cannot practice what they do not know. nurses who lack knowledge about the philosophy and principles of palliative care may lower the quality of end of life care for 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 142 patients in long term care facilities. an evaluation of the knowledge level of nurses for palliative care is an important first step in instituting an educational intervention. keywords: rural nurses, palliative care knowledge, palliative care knowledge test rural long term care nurses’ knowledge of palliative care regardless of the geographic location, nurses care for patients and their families in long term care (ltc) facilities across the trajectory of an illness and into death. a rural ltc facility is a facility that is located within an area with a population of less than 50,000 people (united states census bureau [uscb], 2013). according to the american nurses association’s (ana) (2016), nurses are expected to provide the highest quality of life and care for end of life (eol) patients and their families. the nurse’s fidelity entails providing comfort measures and relief from physical, emotional, spiritual, or existential suffering. another responsibility of the nurse is to provide information on eol choices before death occurs (ana, 2016). the american association of colleges of nursing (aacn) has recognized that eol issues in nursing curriculum have been inconsistent or missing. as a result, the aacn has created eol competency statements that every undergraduate nursing student should achieve. nursing faculty in colleges and universities can voluntarily integrate this content into curriculum at their institutions (aacn, n.d.a.). the aacn in washington, d. c. and the city of hope in los angles, california direct the end of life nursing education consortium (elnec). this researcher is an elnec-geriatric trainer who wishes to disseminate the elnec-geriatric educational content to nurses in rural ltc facilities. the elnec-geriatric curriculum addresses the palliative care educational essentials for nurses who may practice in rural ltc facilities. the elnec-geriatric program 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 143 contains nine modules and geriatric patterns are incorporated across each module. a distinctive feature of the program is geriatric palliative care (aacn, 2016). palliative care is a specialty within its own right. curative or disease modifying treatments can be continued with palliative care, but this is not the case with hospice care where the prognosis of living is six months or less (meier, 2011). according to ferrell et al. (2007), individuals in palliative care can live weeks, months, or years with their chronic illness. a multidisciplinary approach is utilized in palliative care to promote the best quality of life for the patients and their families. palliative care will assess and manage symptoms, support the patients’ decisions and keep patients and their families informed to reach attainable goals (ferrell et al., 2007). according to artnak, mcgraw, and stanley (2011), geographical location does create a disparity between the health care needed and the health care received. the institute of medicine (iom) and the institute for healthcare improvement (ihi) triple aim initiative has created a framework to summon all that are involved in healthcare to recreate healthcare in concurrence with specific objectives (artnak et al., 2011). according to dibello and coyne (2014), the specific objectives of the triple aim initiative include improving patient experience, population health, and reducing healthcare costs. artnak et al. (2011) estimates that by the year 2050, the population of 65 years and over will double. some of this elderly population will be in ltc facilities which demand entrance and continuous healthcare services that are not being met because of a lack of accessibility to palliative care (artnak et al., 2011). madigan, wiencek, and vander schrier (2009) examined availability patterns of community-based eol providers in eight states of the united states. the community-based eol providers were medicare-eligible since medicare protects individuals 65 years of age and 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 144 older. skilled nursing facilities, home health agencies, and hospices which were either homebased or residential were the most common community-based providers. hospice was the least available community-based eol provider in the study population. madigan et al., (2009) found that 62% to 92% of the study population of rural counties did not have hospice providers. patients who reside in rural ltc facilities have chronic diseases, and carter and chichin, 2003 (as cited in brazil, brink, kaasalainen, kelly& mcainery, 2012) predicts that 40% of the 65 years of age and older population in the united states will die in ltc facilities which demonstrate the need for nurses working in ltc facilities having knowledge of providing eol care. palliative care is an option for eol care. nurses are the healthcare professional in rural ltc facilities who are responsible to ensure that patients’ healthcare choices will be implemented. the purpose of this quantitative descriptive correlational study was to examine nurses’ (registered nurses (rns) and licensed practical nurses (lpns)/licensed vocational nurses (lvns) knowledge of palliative care for eol patients in rural ltc facilities. the knowledge of palliative care encompasses the philosophy and principles of palliative care, management of pain and other symptoms, spiritual, and psychosocial aspects of care (ross, mcdonald, & mcguinness, 1996). background nurses in rural ltc facilities are on the frontline in providing palliative care to the geriatric population. this population can have life-limiting conditions or diseases and may choose palliative care at any stage in the trajectory of their illness. palliative care will provide patient-centered care that enhances quality of life, facilitates patient independence, access to information, and choice of treatments during times of distress for the patient and their families (mahon & mcauley, 2010). 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 145 the knowledge of palliative has been measured most frequently with the palliative care quiz for nurses (pcqn). the validity and reliability of the pcqn was established in 1996, but the definition of palliative care does not follow the world health organization (who, n.d.) definition of palliative care (nakazawa et al., 2009). according to the who (n.d.), palliative care is a specialty of healthcare that will increase the quality of life for patients and their families that is confronted with a life-threatening illness. palliative care is implemented with early and thorough assessments and the treatment of pain and other symptoms, physical and spiritual factors to prevent and relieve suffering (who, 2014). the palliative care knowledge test (pckt) was selected because it reflects the most recent definition of palliative care by the who (nakazawa et al., 2009; who, n.d.). ross et al., (1996) investigated the level of knowledge of palliative care with the palliative care quiz for nurses (pcqn) in a generic 4-year baccalaureate nursing program and a post-rn nursing program that were progressing toward a baccalaureate nursing degree and nurses who were practicing that had obtained a rn license or registered practical nurse license. the mean scores for rns were 75%, post-rn students were 65%, registered practical nurses were 60%, and generic nursing students were 46%. the mean percentage of correct responses on the pcqn for the total sample was 61% out of 100% which demonstrated that nursing students and nurses lack knowledge of palliative care (ross et al., 1996). according to prem et al. (2012), nurses had a low understanding of the philosophy of palliative care and a low understanding of the general knowledge of palliative care. brazil et al. (2012) found nurses in ltc facilities had a mean score of 59.5% out of 100% on the pcqn, according to brazil et al. (2012), nurses in the study understood 12 out of 20 questions pertaining to palliative care on the pcqn . 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 146 hodgson, landsberg, lehning, and kleban (2006) conducted a mailed survey of 91 administrators of ltc facilities in pennsylvania. investigators found that urban ltc facilities were more likely to offer palliative care services than a rural ltc facility. the rural ltc facilities identified a need for training in pain management, and the urban facilities identified a need for bereavement training. larger ltc facilities were found to have established pain management practices within their facilities which were independent of geographical location. the interdisciplinary team which is fundamental to palliative care is usually not found in a rural setting. the majority of the facilities in this study were nonprofit. according to hodgson et al., (2006), geographical location can affect accessibility and delivery of the physical and social aspects of palliative care (hodgson et al., 2006). significance of project for nursing and health care the united states department of health and human services, centers for medicare and medicaid (cms), and the national quality forum (nqf) describe palliative care as patient and family-centered care. according to the national consensus project for quality palliative care (ncpqpc, 2013), palliative care augments quality of life by anticipating, inhibiting, and managing suffering. palliative care provided throughout the trajectory of illness addresses the physical, intellectual, emotional, social, and spiritual needs and enables patient autonomy, right of information, and choice for patients and their families (ncpqpc, 2013). the iom’s (2015) report entitled, dying in america: improving quality and honoring individual preferences near the end of life recommends several key factors related to palliative care. health care should provide patient and family centered care that is available to eol patients everywhere and delivered by health care organizations which are covered by federal and private insurers. advance care planning should take place but not replace continuous open 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 147 communication with the patient and family about eol issues. educational institutions and health care professionals should expand the palliative care knowledge base. the iom also recommends a reorientation of reimbursement systems to reflect the needs and preferences of patients at the eol. lastly, the iom recommends that there is a need for public education and dialogue on eol issues (iom, 2015). nurses in rural ltc facilities are on the frontline in providing palliative care to the geriatric population. this population can have life-limiting conditions or diseases and may choose palliative care at any stage in the trajectory of their illness. palliative care will provide patient-centered care that enhances quality of life, facilitates patient independence, access to information, and choice of treatments during times of distress for the patient and their families (mahon & mcauley, 2010). theoretical foundation the study can be conceptualized by applying the donabedian model. according to moran (2014), the donabedian model demonstrates that quality healthcare flows from three categories: structure, process, and outcome. a quality structure leads to quality processes which lead to quality patient outcomes (moran, 2014). according to mcquestion (2006), the structure is the characteristics of the setting where palliative care will be provided. the process category of donabedian model determines if best practices have been carried out or have not been carried out. the outcome of donabedian model determines the impact that the healthcare services have on the health status of the patient and their families (mcquestion, 2006). in the donabedian quality of care framework, quality improvement occurs when deficits in the structure and process categories are corrected or improved which requires the structure and the processes to be monitored. this feedback assists with quality improvement (mcquestion, 2006). as the field of palliative care evolves, nurses’ knowledge and perceived 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 148 confidence/competency to provide palliative care to eol patients in rural ltc facilities are examined in the context of a quality improvement framework utilizing the donabedian model. structure. the structure describes the characteristics of the three rural ltc facilities in south-central ky. the structure of the rural facilities can be described by the nursing home profile. the nursing home profile provides information on the number of certified beds, participation within medicare and medicaid, ownership, placement of automatic sprinkler systems within the facility, location within a continuing care retirement community or hospital, and accessibility of a resident and/or family council (cms, n.d.a). there are more characteristics that are important to the structure of the ltc facility. the number of patients who reside at the ltc facility is a characteristic. an important characteristic is the personnel who provide direct care such as the rn, lpn/lvn, certified nurse aide (cna), and the physical therapist (pt). a ltc facility must have at least one rn on duty for eight straight hours, seven days a week, and either a rn or a lpn/lvn on duty twenty-four hours per day. the federal government does not mandate a specific staffing level for ltc facilities (cms, n.d.b). according to ferrell et al. (2007), the national quality forum (nqf) in 2007 published a set of preferred clinical practices for quality palliative care which can be implemented across the continuums of care. the nqf’s preferred clinical practices were created from the ncpqpc. the ncpqpc outlined a framework that defined eight domains of quality palliative care. the ncpqpc’s domain one addresses that healthcare professionals should receive advanced training and certification in palliative care (ferrell et al., 2007). since nurses are providing care and 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 149 educating the patient and their families about choices, nurses in rural ltc facilities must have the knowledge of palliative care. process. the process category of the donabedian model determines if best practices have been followed or have not been followed (mcquestion, 2006). according to ferrell et al., (2007), the ncp’s domains two through eight addresses the physical, psychological, social, and spiritual needs that are required of palliative care patients. the ncp’s domains also recognize the importance that culture has on illness and death, and the essentials of palliative care become more imperative as the patient nears death. the nqf’s preferred clinical practices are voluntary and are not a requirement for certification for ltc facilities at this time (ferrell et al., 2007). the time that the personnel (rns, lpns/lvns, cnas, pts) work at the ltc facilities has a direct impact on if best practices have been followed or have not been followed. the total number of hours that is provided by licensed staff nurses (rns and lpns/lvns) per patient per day is reflective of the characteristics of the ltc facility. the cna provides care to patients every hour of every day. the care that the pt provides is dependent on the needs of the patient. the staffing hours from the ltc facilities are reported to the state survey agency two weeks before an inspection. the staff hours are the amount of hours provided to each patient per day. the staffing hour per patient per day ratio is calculated by dividing the time worked by the number of patients at the ltc facility (cms, n.d.b). the mds version 3.0 is an assessment done by the nurses at the ltc facilities at fixed intervals on every patient who resides in a medicare or a medicaid certified facility. the mds version 3.0 collects information on the patient’s health, physical activity, psychological status, and overall well-being. the information from the mds version 3.0 is utilized to evaluate the patient’s needs and create a plan of care. the quantity of time that rns and lpns/lvns work 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 150 with patients can greatly impact if the plan of care or if best practices have been followed (cms, n.d.a). outcome. the outcome category of the donabedian model is the result of the structure and process category (mcquestion, 2006). according to the cms (n.d.a), ltc facilities are rated on a scale of one to five stars. a facility with five stars is considered to have above average quality when compared to another facility in the same state. when the ltc facility has one star, the quality is below the average in that state, but the ltc facility still meets medicare’s minimum requirements. therefore, the more stars the ltc facility has the higher quality of care that the facility provides. the overall five star rating is established on the star ratings from three different categories such as health inspections, quality measures, and staffing levels. the health inspection rating includes information on annual visits, complaint investigation findings, and onsite inspections from the last three years. the quality measure rating is based on the factors of percentage of patients with pressure ulcers, patients with mild to severe pain, and number of patients who have had changes in their mobility. the quality measure rating explains how well the ltc facilities provide care for these measures. the staffing level rating provides information on the amount of time of care that is given by the nursing staff to each patient in a day. the staffing level rating takes into consideration the level of care that is needed in the different ltc facilities too (cms, n.d.a). according to cms (n.d.a), the overall star rating system for ltc facilities comes from different sources. the cms’s health inspection database includes information on the ltc facility’s attributes and health deficits that occurred within the last three state inspections and compliant investigations. information for the staffing category comes from the star rating system 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 151 and penalties that have been imposed on ltc facilities which are derived from the cms health inspection database too. the quality measure category from the five star rating system is derived from minimum data set (mds) repository (cms, n.d.a). information from on-site inspections from state surveyors is entered into the online survey, certification and reporting (oscar) data network which is maintained by cms and the state surveying agencies. the oscar data contains information for the purpose of certification of ltc facilities for participation in the medicare and medicaid programs. the oscar entails the utmost comprehensive source of a ltc facility’s level of information regarding the facility’s operations, patient census and regulatory compliance. on-site evaluations occur once during a 15 month interval or in response to a complaint being investigated. during on-site inspections, state surveyors will collect information on the ltc facility’s standard health and life safety deficits. the information collected on the standard health survey are assessed to determine if the ltc facility is providing care and services that meet the federal government’s standard of quality healthcare and the patient’s assessed needs. information that is gathered on the life safety survey are assessed to determine if the ltc facility is meeting the requirements for the life safety code fire and building safety standard which is integrated into the federal requirements (american health care association [ahca], n.d.). when state surveyors discover a substandard of healthcare, a follow-up visit will be conducted. a substandard quality of care is described as a ltc facility having one or more deficiency with scope/severity levels on the mds version 3.0 sections’ f, h, i, j, k, and l in any of the regulatory grouping of patient behavior and facility practices, quality of life, and 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 152 quality of care. on the follow-up visit, the state surveyors will reevaluate if the ltc care facility is in compliance with the standard of quality care and service (cms, n.d.c). the conceptual framework of donabedian model provides a foundation for quality improvement within this study. the structure of where nurses are practicing can impact if nurses have the knowledge of palliative care. the process of donabedian model can assess if nurses in rural ltc facilities have implemented the ncp’s preferred clinical practices for quality palliative care. the outcome of donabedian model will evaluate the quality of palliative care that patients in rural ltc facilities received and if improvements need to be made. the research questions for this study were: • what is rural nurses’ knowledge of palliative care as measured by the pckt for eol patients in ltc facilities? • what is rural nurses’ knowledge of the different subsets of palliative care as measured by the pckt for eol patients in ltc facilities? • is there a difference on the palliative care knowledge test (pckt) items and the demographic variables such as age, highest education level completed in nursing, duration as a nurse, duration of employment, and total years practiced in ltc facilities for rural nurses? methodology a quantitative descriptive correlational design was implemented. after ethical consideration for human subjects was approved by the university’s institutional review board (irb) and approval by directors of nursing (dons) and administrators from participating facilities, a convenience sample of rns and lpns/lvns were recruited from three rural ltc facilities. a recruiter statement was read to potential subjects by the researcher. a convenience sample from three rural ltc facilities was utilized. all nurses employed at the facilities had the 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 153 opportunity to participate regardless of their gender, age, racial, ethnic group, marital status, socioeconomic status, or level of education. the inclusion criteria were that the nurses had to have an active license to practice nursing in the state of ky and be english speaking. the rural ltc facilities were for-profit, accept medicare, medicaid, and private reimbursement from their patients, and were located in south-central ky. measures the researcher received permission to utilize the pckt (nakazawa et al., 2009). two instruments were utilized within the study: the demographical data survey and the pckt. demographical data survey. the demographical data survey which was developed by this researcher provided descriptive data for the rural nurses. the demographical data survey included: age; race; ethnicity; highest educational level completed; years employed at present facility; total years employed in ltc facilities; number of palliative care in-services/continuing education courses attended within the last two years; level of care (personal care, intermediate care, or skill care) worked at the ltc facilities; and a relative or significant other cared being for in a palliative care unit. palliative care knowledge test (pckt). the pckt measured knowledge of palliative care (nakazawa et al., 2009). the selfadministered test contained 20 “true”, “false”, or “unsure” items. the philosophy of palliative care subset (items 1-2) and the symptoms of pain (items 38), dyspnea (items 9 –12), psychiatric (items 1316), and gastrointestinal problems (items 17-20) were measured with the pckt. the highest achieved possible score is 20 which can be converted to a percentage score. the achieved score was multiplied by five to calculate the achieved percentage of correct responses (nakazawa et al., 2009). 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 154 nakazawa et al. (2009) established reliability of the pckt with internal consistency and a test-retest examination. the internal consistency was established at 0.81. the intraclass correlation for test-retest examination for the tool was 0.88. the five subsets of the pckt had an intraclass correlation that ranged from 0.61 to 0.82. the known-group validity for the pckt was established by comparing nurses working on a palliative care unit with other nurses in the sample. the known-group validity for the pckt was p < 0.001 which was established between the two groups. validity for the five categories varied between p < 0.01 to p < 0.001. the researchers set the significance level at p < 0.05 (2-tailed) (nakazawa et al., 2009). according to devon et al. (2007), the pckt demonstrated acceptable reliability because the internal consistency for a research tool needed to be ≥ .70, and the pckt was .81. the pckt demonstrated a high correlation of .88 on the test-re-test, and the acceptable correlation was ≥.70. the validity for the pckt was labeled criterion validity because of the low significance levels. the r should have been ≥ .45 to be acceptable (devon et al., 2007). analytical strategies data was analyzed using spss software, version 23 (ibm, 2015). the statistical analyses utilized were descriptive to designate the quantitative data of demographic variables and pckt total and subsets. the statistical analysis of frequency was used to determine the responses on the individual pckt items. lastly, cross-tabs with a chi-square test for independence was utilized to determine differences on the pckt items and the demographic variables of age, highest education level completed in nursing, years as a nurse, years of employment, and total years practiced in rural ltc facilities. the assumption of chi-square was examined with the yates’ correction for continuity to determine if the assumption was violated with a 2 by 2 table, the effect size was determined with the phi coefficient value. fisher’s exact probability test 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 155 was utilized when the assumption of chi-square was violated with a 2 by 2 table. the likelihood ratio was utilized to check for the violation of the assumption for chi-square for 2 by 3 or larger table, and the effect size was determined with the cramer’s v coefficient. the alpha level was 0.05. findings demographics a convenience sample of 33 nurses was recruited from an accessible population of 34 inservice/meeting attendees. the sample accounted for 97 percent of the accessible population. all 33 nurses met the inclusion criteria. the subjects were white and consisted of females (n = 30) and males (n = 3). the age of study subjects ranged from 25 to 61 years of age. the mean age of the sample was 44.5 years of age with a standard deviation of 9.5. the sample consisted of lpns (n = 18) and rns (n = 15). the duration as a nurse for the study subjects ranged from 1 month to 28 years. the majority of the study subjects worked on the skilled care level (n = 30) compared to the intermediate care level (n = 3) of the facility. twenty-five subjects reported not having had a relative or significant other in a palliative care unit, compared to eight subjects who reported having had a relative or significant other in a palliative care unit. study subjects responses on the pckt the study subjects responded below 50% on seven (3, 5, 10, 12, 15, 17, and 18) of the 20 questions on the pckt. the subset of philosophy on the pckt had two of the highest scored items on the pckt by lpn/lvns and rns. eighty-five percent of the sample responded correctly on the question, “palliative care should only be provided for patients who have no curative treatment available”; and 91% of the sample responded correctly on the question, “palliative care should not be provided along with anti-cancer treatments”. one hundred percent 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 156 of the subjects responded correctly on item 6, “the effect of opioids should decrease when pentazocine (talwin) or buprenorphine hydrochloride (buprenex) is used together after opioids are used”. table 1 demonstrates the responses for the pckt items for the total study sample. the rural nurses achieved a total score of 48.5% out of 100% with a mean of 9.7 (sd = 2.60) on the pckt. the rural nurses scored the lowest on the subscales of dyspnea (mean = 1.24; sd = 0.90) and psychosocial issues (mean = 1.70; sd = 0.77) on the pckt. the rural nurses scored the highest on the subscales of gastrointestinal problems (mean = 2.42; sd = 1.03) and pain (mean = 2.58; sd = 1.20). table 2 represents the descriptive statistics for the subsets of the pckt. table 2 rural nurses pckt subsets scores rural (n = 33) pckt subsets *questions/subset m (sd) philosophy (2) pain (6) dyspnea (4) psychosocial (4) gastrointestinal(4) 1.76 (0.56) 2.58 (1.20) 1.24 (0.90) 1.70 (0.77) 2.42 (1.03) note. (n) =number of population. m = mean. (sd) = standard deviation. *questions/subset denotes the number of questions in each subset. table 1 responses for the pckt items for the total study sample subsets questions responses f (%) item true false unsure missing philosophy item1 palliative care should only be provided for patients who have no curative treatment available. 5 (15.2) *28 (84.8) item 2 palliative care should not be provided along with anti-cancer treatments. 2 (6.1) *30 (90.9) 1 (3.0) pain item 3 one of the goals of pain management is to get a good night’s sleep. *6 (18.2) 8 (24.2) 19 (57.6) item 4 when cancer pain is mild, pentazocine (talwin) should be used more often than an opioid. 8 (24.2) *17 (51.5) 8 (24.2) item 5 when opioids are taken on a regular basis, non-steroidal antiinflammatory drugs should not be used. 8 (24.2.) *7 (21.2) 17 (51.5) 1 (3.0) item 6 the effect of opioids should decrease when pentazocine (talwin) or buprenorphine hydrochloride (buprenex) is used together after opioids are used. *33 (100) item 7 long-term use of opioids can often induce addiction. 24 (72.7) *7 (21.2) 2 (6.1) -+ item 8 use of opioids does not influence survival time. *24 (61.5) 7 (17.9) 2 (5.1) dyspnea item 9 morphine should be used to relieve dyspnea in cancer patients. *28 (84.8) 4 (12.1) 1 (3.0) item 10 when opioids are taken on a regular basis, respiratory depression will be common. 21 (63.6) *2 (6.1) 10 (30.3) item 11 oxygen saturation levels are correlated with dyspnea. 9 (27.3) *18 (54.5) 6 (18.2) item 12 anticholinergic drugs or scopolamine hydrobroomide (transderm-v) are effective for alleviating bronchial secretions of dying patients. *12 (36.4) 11 (33.3) 10 (30.3) 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 158 subsets questions responses f (%) item psychosocial item 13 during the last days of life, drowsiness associated with electrolyte imbalance should decrease patient discomfort. *2781.8) 5 (15.2) 1 (3.0) item 14 benzodiazepines should be effective for controlling delirium. *25 (75.8) 5 (15.2) 3 (9.1) item 15 some dying patients will require continuous sedation to alleviate suffering. *13 39.4) 17 (51.5) 3 (9.1) = item 16 morphine is often a cause of delirium in terminally ill cancer patients. 4 (12.1) *26 (78.8) 3 (9.1) gastro-intestinal problems item 17 at terminal stages of cancer, higher calorie intake is needed compared to early stages. 18 (54.5) *9 (27.3) 6 (18.2) item 18 there is no route except central venous for patients unable to maintain a peripheral intravenous route. 19 (57.6) *11 (33.3) 3 (9.1) item 19 steroids should improve appetite among patients with advanced cancer. *17 (51.5) 9 (27.3) 7 (21.2) item 20 intravenous infusion will not be effective for alleviating dry mouth in dying patients. *18 (54.5) 12 (36.4) 3 (9.1) note. correct responses with asterisks and bold typed. from “the palliative care knowledge test: reliability and validity of an instrument to measure palliative care knowledge among health professionals,” by y. nakazawa, m. miyashita, t. morita, m. umeda, y. oyagi, & t. ogasawara, (2009), palliative medicine, 23(8), 754-766. f = frequency of the total population per response of the item. % = percentage of the total population per response of the item. 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 159 the demographic variable of age was divided into two groups because this variable had such a wide range. group 1 consisted of those age 25 to 44 years of age, and group 2 included subjects of 45 to 61 years of age. a chi-square test for independence was conducted to compare age with the items on the pckt. there was no significant association between the pckt items and age except on item 17 of the pckt. on item 17 of the pckt, a chi-square test for independence (with likelihood ratio) indicated there was a significant association between age and item 17 on the pckt, (2, n =33) = 7.3, p = .03, cramer’s v = .03. group 1 correctly responded more on item 17 of the pckt than group 2. a chi-square test for independence was conducted to compare the highest education level completed in nursing (lpn/lvns and asns) with the items on the pckt. there was no significant association for lpn/lvns and asn on the pckt items except on pckt items 1 and 8. on pckt item 1, fisher exact probability test indicated that there was a significant association between the highest education level completed in nursing and pckt item 1, (1, n = 33) = 2.99, p = .05, phi = .03. the asns correctly responded more on item 1 of the pckt than the lpn/lvns. item 8 of the pckt with the likelihood ratio had a significant association between highest education level completed in nursing and pckt item 8, (2, n = 33) = 7.1, p = .03, cramer’s v = .05. the asns correctly responded more on item 8 of the pckt than the lpn/lvns. the demographic variable of duration as a nurse was divided into two groups because this variable had such a wide range. group 1 was the shortest duration (1 to 13 years) as a nurse and group 2 (14 to 40 years) was the longest duration as a nurse. there was no significant association between duration as a nurse and the items on the pckt except item 18 on the pckt. on pckt item 18, a chi-square for independence (with likelihood ratio) indicated that there 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 160 was an association between duration as a nurse and item 18 of the pckt, (2, n = 33) = 7.3, p = .03, cramer’s v = .06. those in nursing longer, group 2 correctly responded more than group 1. the demographic variable of duration of employment at present facility was divided into two groups because this variable had such a wide range. group 1 was the shortest duration (0.1 month to 4 years) of employment at present facility and group 2 (5 to 28 years) was the longest duration of employment at present facility. a chi-square for independence was conducted to compare the duration of employment at present facility with the items on the pckt. there was no association between duration of employment at present facility and the pckt items except on the pckt items 1 and 6. on pckt item 1, fisher exact probability test indicated that there was a significant association between duration of employment at present facility and pckt item 1, (1, n = 33) = 4.1, p = .02, phi = .01. group 1 responded correctly more than group 2. for pckt item 6, a chi-square for independence (with likelihood ratio) indicated that there was an association between duration of employment at present facility and pckt item 6, (2, n = 32) = 6, p = .05, cramer’s v = .06. group 2 answered correctly more on item 6 of the pckt than did group 1. the demographic variable of total years practiced in ltc facilities was divided into two groups because this variable had such a wide range. group 1 was the shortest (1 to 13) total years practiced in ltc facilities and group 2 was the longest (14 to 36) total years practiced in ltc facilities. a chi-square for independence was performed which demonstrated no association between the total years practiced in ltc facilities and the pckt items. discussion the results from this study support the findings of previous studies (brazil et al., 2012; ross et al., 1996; thompson, bott, boyle, gajewski, & tiden, 2011) that nurses lack knowledge 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 161 of palliative care. the study participants scored less than 50% out of 100% on the pckt. ross et al. (1996) found that nurses who have more nursing educational preparation have more knowledge of the philosophy of palliative care than nurses who have less nursing educational preparation. the rns in this study were more knowledgeable than the lpn/lvns on one of the questions from the philosophy of palliative care subset. the aacn (n.d.b) recognizes that eol issues in nursing curriculum are inconsistent or missing, and the elnec-geriatric program has a distinctive geriatric palliative care program (aacn, 2016). rural nurses in this study who have been employed a shorter duration at the ltc facility had more knowledge about one of the questions from the philosophy of palliative care subset. hodgson et al., (2006) found that nurses in rural settings have a greater need for pain management training than urban nurses. the findings of this study indicated the subset of pain on the pckt was one of the subsets that the rural nurses scored the highest; although the subset was still scored low. the rural registered nurses were more knowledgeable than the rural lpn/lvns on one of the questions from the pain subset of the pckt. nurses who have been employed a shorter duration at the present rural ltc facility were more knowledgeable on one of the questions from the pain subset of the pckt than the nurses who had been employed for a longer duration at the present rural ltc facility. this study supports the shorter the duration as a nurse and nurses aged 25 to 44 (group 1) had more knowledge on some of the questions in the gastrointestinal subset of the pckt. clinical implications nurses cannot practice what they do not know. nurses who lack knowledge about the philosophy and principles of palliative care may lower the quality of eol care for patients in rural ltc facilities. an evaluation of the knowledge level of nurses for palliative care is an important first step in instituting an educational intervention. nurses respond to the needs of society and their patients. the study participants were very receptive to participate in the study 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 162 which was evident by the 97 percent participation rate of the potential sample of nurses. findings from this study support the need for future educational interventions for nurses in the rural settings to improve the quality of palliative care services to eol patients in ltc facilities. limitations a potential limitation was the fact that this researcher did not have an established rapport with some of the facilities within south-central ky. therefore, some of the facilities were hesitant at the beginning of the research study to allow the researcher within their facility. the researcher needed to speak with the administrator and don of each facility in-person instead of speaking with the don on the telephone. the don would relay the potential study to the administrator within their facility who then would grant permission for the study. another limitation was that there was only one investigator at each of the three rural ltc facilities. the sample was a convenience sample of nurses who were present on the day of data collection. for the purposes of this time-limited project, the number of facilities and nurses that participated in the study was adequate, but a larger sample size would have increased generalization of the findings. recommendations the aacn (n.d.b) recommends that every undergraduate nursing student should achieve end-of-life competencies which should be integrated into their practice. the researcher who is a geriatric elnec trainer has offered to provide all or any of the nine modules in the elnec geriatric curriculum to the facilities in this study. the nine modules include: principles of palliative care; pain assessment and management; non-pain symptoms at the eol; goals of care and ethical issues at the eol; cultural and spiritual considerations in eol care; communication; loss, grief, and bereavement; ensuring quality eol care; and preparation for and care at the time 1online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.409 163 of death. educational intervention will serve as a basis for quality improvement for the rural ltc facilities. the geriatric elnec curriculum was developed from a project hosted by the aacn which recommends competencies and curricular guidelines for eol nursing education and practice. the elnec curriculum explains the information and skills that nurses require to deliver quality eol care to the geriatric population (aacn, 2016). recommendations include encouraging facilities to arrange for presentation of the geriatric elnec curriculum as a quality improvement effort in order to reach rural ltc facilities. other research that maybe performed is to compare rural and urban nurses’ knowledge of palliative care in ltc facilities which would provide a larger more heterogeneous sample. schreibeis-baum et al. (2016) identified that there was no consensus policy agenda at the state and federal level for palliative care, but authorities recognized that acknowledging present consensus statements was a starting point. therefore, evaluating nurses’ knowledge of palliative care in rural ltc facilities and instituting educational policies are a starting point. references american health care association (ahca). (n.d.). what is oscar data? retrieved from http://www.ahcancal.org/research_data/oscar_data/pages/whatisoscardata.aspx american association of colleges of nursing. (n.d.a). use of elnec materials. retrieved from http://www.aacn.nche.edu/faculty/faculty-development/elnec/useofmat.pdf american association of colleges of nursing. (n.d.b). peaceful death. recommended competencies and curricular guidelines for end-of-life nursing care. retrieved from http:// www.aacn.nche.edu/elnec/publications/peaceful-death american association of colleges of nursing. 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(1996). the palliative care quiz for nursing (pcqn): the development of an instrument to measure nurses’ knowledge of palliative care. journal of advanced nursing, 23(1), 126-137. https://doi.org/10.1111/j.1365-2648.1996. tbo3106.x schreibus-baum, h. c., xenakis, l. e., chen, e. k., hanson, m., ahluwalia, s., ryan, g., & lorenz, k. a. (2016). a qualitative inquiry on palliative and end-of-life care policy reform. journal of palliative medicine, 19(4), 400-407. https://doi.org/10.1089/jpm.2015.0296 thompson, s., bott, m., boyle, d., gajewski, b., & tiden, v. (2011). a measure of palliative care in nursing homes. journal of pain and symptom management, 41(1), 57-67. https://doi.org/10.1016/j.painsymman.2010.03.016 united states census bureau. (2013). 2010 census urban and rural classification and urban area criteria. retrieved february 22, 2014, from http://www.census.gov/geo/reference/ua/urban -rural-2010.html world health organization. (n.d.). who definition of palliative care. retrieved from http://www.who.int/cancer/palliative/definition/en/ microsoft word aguirre_327-1884-4-ed.docx online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 49 medication administration: interruptions in a rural hospital and evaluation of a red light intervention trina aguirre, phd, rn 1 susan wilhelm, phd, rnc 2 susan backer, msn, aprn-cns, acns-bc 3 susan schoeneman, msn, aprn-np, aocnp 4 ann koehler, ms 5 1 college of nursing, assistant professor, taguirre@unmc.edu 2 college of nursing, assistant professor & assistant dean, west nebraska division slwilhel@unmc.edu 3 regional west medical center, cns patient care division, susan.backer@rwhs.org 4 regional west medical center, susan.schoeneman@rwmc.net 5 university of nebraska medical center, ann.koehler@unmc.edu abstract purpose: this study was conducted to determine the prevalence and types of interruptions nurses experience during the peak medication administration period (weekdays 7:00 am-9:00 am) at a rural regional hospital and to evaluate the effectiveness of a red light intervention to reduce interruptions. online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 50 sample: participants were a convenience sample of registered nurses who agreed to be observed administering medications. the same nurses were observed during both phases of the study. methods: this study employed a prospective exploratory design. the same observation procedures were used during both phases of the study. during each 2-hour observation period, each participating nurse was accompanied by two observers who recorded all interruptions. during the intervention, a small flashing red light was attached to the medication administration computer. when turned on it served as a signal to avoid interruptions. educational flyers were distributed to staff, physicians, patients, and visitors to inform them about the meaning of the light. findings: average interruptions per 2-hour medication administration period dropped from an average of 7.2 during baseline to 3.0 during the red light intervention. the top two source of interruptions during both phases were other personnel and not having needed medical supplies/equipment, though the rankings were reversed. the relative prevalence of interruptions caused by other personnel declined from 27.6% (baseline) to 21.8% (intervention). conclusions: the major categories of interruptions at this rural regional acute care hospital were similar to those identified in studies in urban settings. the red light intervention effectively reduced the average number of interruptions per 2-hour period and reduced the incidence of interruptions caused by other personnel. the prevalence of interruptions due to missing supplies/equipment remained high and should be addressed by implementing procedures to ensure that carts are appropriately stocked. keywords: medication administration, interruptions, rural online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 51 medication administration: interruptions in a rural hospital and evaluation of a red light intervention nurses play an essential role in patient safety and the safe administration of medications. acute care nursing is demanding, unpredictable, fast-paced, and requires the ability to make clinical decisions while managing care for a group of patients. this includes adapting to technological changes and frequent distractions and interruptions while attending to the needs of patients, families, physicians and other staff, admissions/discharges, and patient education, all while administering medications (jennings, sandelowski, & mark, 2011; kalisch & aebersold, 2010; redding & robinson, 2009; westbrook, woods, rob, dunsmuir, & day, 2010). this work environment creates conditions conducive for errors to occur. there is growing interest in understanding the role of interruptions in medical errors, particularly medication errors which are the third most frequent cause of unintentional harm (institute of medicine [iom], 2006). interruptions and distractions may be a contributing factor (kreckler, catchpole, bottomley, handa, & mcculloch, 2008; thomson et al., 2009) with increased frequency of interruption associated with greater incidence (scott-cawiezell et al., 2007; westbrook et al., 2010) and severity (westbrook et al., 2010) of errors. though these relationships are complex and not yet well understood (see reviews in biron, loiselle, & lavoie-tremblay, 2009; grundgeiger & sanderson, 2009; hopkinson & mowinski jennings, 2013; raban & westbrook, 2013), reducing interruptions is often suggested as a means of reducing the potential for errors (biron, loiselle & lavoie-tremblay, 2009; kliger, blegen, gootee, & o'neil, 2009; mcgillis hall, ferguson-pare et al., 2010; mclean, 2006). efforts to reduce the incidence or effects of interruptions include establishing “no interruption” times or areas during medication administration (anthony, wiencek, bauer, daly, & anthony, 2010; nguyen, connolly, & wong, online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 52 2010) and use of checklists and/or visual cues (vests, signage, aprons, lights) (kliger, singer, hoffman, & o'neil, 2012; pape, 2003; pape et al., 2005; relihan, o'brien, o'hara, & silke, 2010). purpose the purpose of this study was to determine the prevalence and types of interruptions nurses experience during the peak medication administration period (weekdays 7:00 am-9:00 am) at a rural hospital and to evaluate the effectiveness of a red light intervention to reduce interruptions. methods setting this study was conducted in a medical oncology unit of a fully accredited regional acute care hospital that serves the rural nebraska panhandle and portions of south dakota, wyoming, and colorado. the nebraska panhandle is 14,180 sq. miles in area with a population of 87,000, having an average of 6 people per sq. mile. scotts bluff county, where the hospital is located encompasses 739 miles with a population of 36,000 for an average of 50 persons per square mile (united states census bureau, 2014). compared to states averages, people living in scotts bluff county tend to be older (17.1% vs 14.1% ≥ age 65), more are hispanic (22.6% vs 9.9%), and more live below the poverty level (15.1% vs. 12.4%) (united states census bureau, 2014). experimental design this study employed a prospective exploratory design. baseline observations were conducted (fall 2011) to determine the frequency and types of interruptions registered nurses experience during the peak medication administration period (weekdays 7:00 am-9:00 am). subsequently (spring 2012) the same observation procedures were used to evaluate the online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 53 effectiveness of using a red light intervention to decrease interruptions during medication administration. ibm® spss® statistics version 22 was used to determine descriptive statistics. participant sample participants were a convenience sample of registered nurses who agreed to be observed administering medications. the same nurses were observed during both the baseline and intervention phases of the study. informed consent was obtained through letters of invitation for the baseline portion of the study and through written consent for the intervention portion of the study. no individually identifying information was collected. patients receiving medication were not consented because medication administration was part of their normal care and observers did not enter patient rooms. this study was conducted under irb approval (#459-11ex) from the university of nebraska medical center and regional west medical center. medication administration this hospital uses electronic medical records (emr) and barcoded patient wristbands and medication labels to help ensure that the appropriate medications are administered. patient records were accessed using a laptop on a cart that was rolled to the patient rooms as needed. the cart also provided storage for non-medicine medical supplies. the pharmacy stocked patient medicines (pill form) in locked medicine boxes attached to the wall outside each patient room. highly regulated medicines (e.g. opiates) were dispensed using a pyxis® medstation system that was kept in a room in the core of the nursing unit behind the nursing desk. iv equipment was also stored in this room. for the purpose of this study, medication administration was defined as beginning when the nurse checked the patient’s record on the computer, continuing through the verification and preparation steps, and ending when the nurse finished administering the medicines to the patient. online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 54 interruptions interruptions were defined as anything that disrupted the nurse’s focus on or caused a break in the task she/he was performing. the principle (pi) and co-principle (co-pi) investigators categorized the interruptions following the observations. observation period observations were conducted weekdays from 7:00 am to 9:00 am. within this period, interruptions were recorded during medication administration for each patient individually as described above. activities occurring after administering medication to one patient, but before beginning medication administration to the next patient were not included. observation procedures the pi and co-pi’s provided orientation for the nurses and trained the observers before observations began. nurses were instructed to conduct business as usual as though the observers were not present. observers stayed 5-10 feet away from the nurses during observations and did not interact with the nurses or go into patient rooms. during each 2-hour observation period, each participating nurse was accompanied by two observers. each observer recorded all interruptions, one using an audio recorder and the other recording her/his observations in writing. both recorded and written observations were transcribed to determine the frequency and type of interruptions. to address inter-rater reliability, only interruptions recorded by both observers were included in the statistical analysis. a possible limitation of this approach is that persons who know they are being observed may behave differently than those who are unaware of observation (the hawthorne effect) (mccarney et al., 2007). intervention procedures online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 55 the intervention consisted of a small inexpensive battery-operated flashing red light that was clipped to the medication administration computer. the nurse turned the light on during medication administration as a signal to avoid interruptions. educational flyers were distributed to staff, physicians, patients, and visitors to inform them about the meaning of the light. this effort was reinforced through informational meetings and emails for staff and physicians and supportive scripting for nurses and admissions personnel. results average interruptions per 2-hour medication administration period dropped from an average of 7.2 during baseline to 3.0 during the red light intervention. table 1 lists the relative prevalence (%) of different types of interruptions in descending order for each phase (baseline and intervention) of the study. the top source of interruptions during the baseline period was other personnel, including technical assistants (ta’s), certified nursing assistants (cna’s), and housekeeping and dietary personnel. though still a substantial source of interruptions, this category dropped to second place during the invention phase (table 1). the other major source of interruption (second place baseline, first place intervention) was not having needed medical supplies/equipment in the cart (table 1). during baseline, medication administration was also interrupted fairly often when nurses stopped to stock patient supplies unrelated to the patient’s medications, or to respond to questions from student nurses (miscellaneous category) (table 1). in contrast, the third place source of interruptions during the intervention phase was the administering nurse initiating conversations unrelated to the medications (table 1). online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 56 table 1 sources of interruption at baseline and during intervention baseline (fall 2011) intervention (spring 2012) source of interruption % source of interruption % other personnel1 27.6 medical equipment not available 24.8 medical equipment not available 19.5 other personnel1 21.8 miscellaneous2 12.2 nurse non-medication conversation 11.2 patient 8.9 physician 7.3 staff nurse 8.1 staff nurse 7.3 other patient 5.7 phone calls 6.3 physician 4.9 medication not in box 5.8 visitor 3.3 visitor 4.9 nurse knowledge 3.3 patient 3.4 nurse non-medication conversation 1.6 other patient 2.9 equipment failure3 1.6 equipment failure3 1.9 medication not in box 1.6 miscellaneous2 1.0 phone calls 0.8 nurse knowledge 1.0 emergency (code) 0.8 emergency (code) 0.5 1 ta’s, cna’s, housekeeping, dietary 2 stocking non-medication patient supplies, questions from student nurses 3 laptop, pump, pyxis®, etc. online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 57 discussion this study demonstrated that a simple visual cue can be used to reduce the number of interruptions during medication administration. similarly, (anthony et al., 2010) reported a 40.9% reduction in interruptions using a “no interruption zone” outlined in red. we did not evaluate whether this intervention led to changes in medication error rates. also unknown is whether this intervention would be sustainable over time or whether people would habituate to the presence of the light. similar to the findings of others, personnel (mcgillis hall, pedersen, & fairley, 2010; mcgillis hall, ferguson-pare et al., 2010; redding & robinson, 2009) and missing supplies/equipment (biron, lavoie-tremblay, & loiselle, 2009; mcgillis hall, pedersen, et al., 2010; palese, sartor, costaperaria, & bresadola, 2009; redding & robinson, 2009) were the most common sources of interruptions, and at times nurses interrupted medication administration themselves (biron, loiselle, et al., 2009; mcgillis hall, pedersen, et al., 2010; relihan et al., 2010). as expected, the impact of this visual intervention was primarily observed in sources of interruptions involving face-to-face interactions. for example, the percentage of interruptions attributed to other personnel declined during the intervention, whereas the percentage attributed to missing supplies/equipment increased. the latter can be reduced by implementing procedures to ensure that the carts are properly stocked. the rural setting may have contributed to the prevalence of interruptions due to personnel, colleagues, and the nurses themselves observed in this study. rural culture encourages being friendly and personable. in addition, in rural communities it is not uncommon for people to know each other outside of the workplace and/or to be related to each other (bradley, werth & hastings, 2012). these attributes make it easy to initiate or become involved in conversations. online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 58 educational efforts may be needed to increase awareness of the importance of avoiding unnecessary conversations during medication administration. interruptions will never be eliminated from healthcare, and some are necessary. though infrequent during this study, there were instances where a nurse needed to stop to get additional information to properly administer a medication (nurse knowledge) or to respond to an emergency code. understanding the relationship between interruptions and medical errors continues to evolve. there is still much to learn about the contexts where interruptions are likely to have adverse consequences, the mechanisms involved, the effectiveness of coping strategies, etc. (biron, loiselle, et al., 2009; grundgeiger & sanderson, 2009; hopkinson & jennings, 2013; raban & westbrook, 2013). conclusions we explored the frequency and types of interruptions during medication administration at a regional acute care hospital in rural western nebraska and evaluated the efficacy of a red light intervention. the major categories of interruptions were similar to those identified in studies in urban settings. the red light intervention effectively reduced the average number of interruptions per 2-hour period from 7.2 to 3.0. in addition, the relative prevalence of interruptions caused by other personnel declined from 27.6% to 21.8%. the prevalence of interruptions due to missing supplies/equipment remained high and should be addressed by implementing procedures to ensure that carts are appropriately stocked. supporting agencies regional west medical center online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 59 references anthony, k., wiencek, c., bauer, c., daly, b., & anthony, m. k. (2010). no interruptions please: impact of a no interruption zone on medication safety in intensive care units. critical care nurse, 30(3), 21-29. http://dx.doi.org/10.4037/ccn2010473 biron, a. d., lavoie-tremblay, m., & loiselle, c. g. (2009). characteristics of work interruptions during medication administration. journal of nursing scholarship, 41(4), 330-336. http://dx.doi.org/10.1111/j.1547-5069.2009.01300.x biron, a. d., loiselle, c. g., & lavoie-tremblay, m. (2009). work interruptions and their contribution to medication administration errors: an evidence review. worldviews on evidence-based nursing, 6(2), 70-86. http://dx.doi.org/10.1111/j.1741-6787.2009.001 51.x bradley, j., werth, jr. j., & hastings, s. (2012). social justice advocacy in rural communities: practical implications and issues. the counseling psychologist, 40 (3), 363-384. http://dx.doi.org/10.1177/0011000011415697 grundgeiger, t., & sanderson, p. (2009). interruptions in healthcare: theoretical views. international journal of medical informatics, 78(5), 293-307. http://dx.doi.org/10.1016/ j.ijmedinf.2008.10.001 hopkinson, s. g., & jennings, b. m. (2013). interruptions during nurses' work: a state-of-thescience review. research in nursing & health, 36(1), 38-53. http://dx.doi/org/10.1002/ nur.21515 hopkinson, s. g., & mowinski jennings, b. (2013). authors' response to the letter to rinah editor: interruptions are significantly associated with the frequency and severity of medication errors. research in nursing & health, 36(2), 117-119. online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 60 institute of medicine. (2006). iom report: the future of emergency care in the united states health system. academic emergency medicine, 13(10), 1081-1085. http://dx.doi.org/10. 1197/j.aem.2006.07.011 jennings, b. m., sandelowski, m., & mark, b. (2011). the nurse's medication day. qualitative health research, 21(10), 1441-1451. http://dx.doi.org/10.1177/1049732311411927 kalisch, b. j., & aebersold, m. (2010). interruptions and multitasking in nursing care. joint commission journal on quality and patient safety / joint commission resources, 36(3), 126-132. kliger, j., blegen, m. a., gootee, d., & o'neil, e. (2009). empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. joint commission journal on quality and patient safety / joint commission resources, 35(12), 604-612. kliger, j., singer, s., hoffman, f., & o'neil, e. (2012). spreading a medication administration intervention organization wide in six hospitals. joint commission journal on quality and patient safety / joint commission resources, 38(2), 51-60. kreckler, s., catchpole, k., bottomley, m., handa, a., & mcculloch, p. (2008). interruptions during drug rounds: an observational study. british journal of nursing, 17(21), 13261330. http://dx.doi.org/10.12968/bjon.2008.17.21.31732 mccarney r, warner j, iliffe s, van haselen r, griffin m, fisher p; warner; iliffe; van haselen; griffin; fisher (2007). "the hawthorne effect: a randomised, controlled trial". biomedcentral medical research methodologies 7(30). http://dx.doi.org/10.1186/14712288-7-30 online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 61 mcgillis hall, l., ferguson-pare, m., peter, e., white, d., besner, j., chisholm, a., . . . hemingway, a. (2010). going blank: factors contributing to interruptions to nurses' work and related outcomes. journal of nursing management, 18(8), 1040-1047. http://dx.doi.org/10.1111/j.1365-2834.2010.01166.x mcgillis hall, l., pedersen, c., & fairley, l. (2010). losing the moment: understanding interruptions to nurses' work. the journal of nursing administration, 40(4), 169-176. http://dx.doi.org/10.1097/nna.0b013e3181d41162 mclean, d. (2006). medicines administration rounds can be led by pharmacy technicians. pharmacy in practice, 16(1), 19-23. nguyen, e. e., connolly, p. m., & wong, v. (2010). medication safety initiative in reducing medication errors. journal of nursing care quality, 25(3), 224-230. http://dx.doi.org/10.1097/ncq.0b013e3181ce3ae4 palese, a., sartor, a., costaperaria, g., & bresadola, v. (2009). interruptions during nurses' drug rounds in surgical wards: observation goal study. journal of nursing management, 17(2), 185-192. http://dx.doi.org10.1111/j.1365-2834.2007.00835.x pape, t. m. (2003). applying airline safety practices to medication administration. medsurg nursing, 12(2), 77-93; quiz 94. pape, t. m., guerra, d. m., muzquiz, m., bryant, j. b., ingram, m., schranner, b., . . . welker, j. (2005). innovative approaches to reducing nurses' distractions during medication administration. journal of continuing education in nursing, 36(3), 108-16; quiz 141-2. raban, m. z., & westbrook, j. i. (2013). are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. bmj quality & safety, http://dx.doi.org/10.1136/bmjqs-2013-002118 online journal of rural nursing and health care, 2015(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.327 62 redding, d. a., & robinson, s. (2009). interruptions and geographic challenges to nurses' cognitive workload. journal of nursing care quality, 24(3), 194-200; quiz 201-202. http://dx.doi.org/10.1097/01.ncq.0000356907.95076.31 relihan, e., o'brien, v., o'hara, s., & silke, b. (2010). the impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration. quality & safety in health care, 19(5), e52. http://dx.doi/org/10.1136/qshc.2009.036871 scott-cawiezell, j., pepper, g. a., madsen, r. w., petroski, g., vogelsmeier, a., & zellmer, d. (2007). nursing home error and level of staff credentials. clinical nursing research, 16(1), 72-78. http://dx.doi.org/10.1177/1054773806295241 thomson, m. s., gruneir, a., lee, m., baril, j., field, t. s., gurwitz, j. h., & rochon, p. a. (2009). nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications. journal of the american geriatrics society, 57(2), 266 272. http://dx.doi/org/10.1111/j.1532-5415.2008.02101.x united states census bureau (2014). quick facts. retrieved from http://quickfacts.census.gov/qfd/states/31/31157.html . westbrook, j. i., woods, a., rob, m. i., dunsmuir, w. t., & day, r. o. (2010). association of interruptions with an increased risk and severity of medication administration errors. archives of internal medicine, 170(8), 683-690. http:dx.doi.org/10.1001/archinternmed.2010.65 microsoft word efendi_260-1777-2-ed.docx online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 32 what do indonesian nurses want? retaining nurses in rural and remote areas of indonesia ferry efendi, s.kep.ns, msc 1 mrs. purwaningsih, s.kp, m.kes 2 anna kurniati, skm, ma 3 angeline bushy, rn, phd, faa, phcns-bc 4 1 lecturer, community health nursing department, airlangga university, surabaya indonesia, fefendi@indonesiannursing.com 2 lecturer, fundamental nursing department, airlangga university surabaya indonesia, ppurwaningsih13@yahoo.co.id 3 deputy director of hrh planning, center of planning and management of human resources for health, moh of indonesia, annakurniati@gmail.com 4 professor, community health nursing department, university of central florida, angeline.bushy@ucf.edu abstract introduction: lack of nurses in rural and remote communities of indonesia has been a major concern of national and provincial governments. given that imperative the ministry of health implemented (moh) the special assignment initiative which assigned nurses in underserved communities this study examine factors that influenced participants in the program to remain (retention) in their assigned rural setting. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 33 methods: survey techniques were used to collect data from a convenience sample of 140 nurses enrolled in the initiative. variables included age, gender, marital status, financial incentives and non-financial incentives. descriptive and correlation statistics were used to analyze the data. results: findings indicated that both financial incentives and nonfinancial incentives along with age correlated positively with nurses’ intention to stay in the current rural setting. non-financial incentives were as important for these nurses especially achieving employment security as a civil servant (government employee). younger nurses seem to be more willing to work in rural and remote areas, which may be attributable to an individual seeking practice experience along with increased financial remuneration for doing so. conclusion: the findings of this study provide baseline descriptive information on the retention of nurses in indonesia’s remote and rural underserved regions. providing an attractive incentive scheme by considering certain demographic characteristic can increase their intention to serve in rural and remote area. keywords: nurse retention, rural, remote areas what do indonesian nurses want? retaining nurses in rural and remote areas of indonesia globally, one of the most complex challenges for national governments is having an adequate supply of health care providers who can deliver services to those living in rural and remote locations (world health organization [who], 2010). indonesia, in particular, has critical shortages of physicians, nurses and midwives (world bank, 2009). regarding access to basic health care services, of indonesia’s 497 district/cities, 83 districts located within 27 provinces lag behind. ninety-two districts in the outermost small islands and 34 small outlying islands do not have even basic services (ministry of health [moh] of indonesian, 2012a, 2012b). sustaining an online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 34 adequate and effective health professional workforce in rural and remote parts of indonesia is crucial to address the health care needs of people who live in those regions, and a stated priority in the government of indonesia’s national workforce development plan (ginwdp) for 20102014 (moh, 2010a). the ginwdp sponsored a special assignment initiative that involved strategic placement of doctors, nurses and midwives in underserved rural and remote areas of this widely dispersed nation. the ministry of health (moh’s) regulations included the following criteria for nurse participation (kurniati & efendi, 2012; moh, 2010b): • provision of travel expenses along with additional incentives (financial and nonfinancial) • placement for a minimum of three months at a particular site, but this time frame could be extended. • a minimum level of diploma iii nursing education preparation. the initiative has been in place for approximately two years however there has been no evaluation of the program. given the information deficit related to the initiative, the researchers of this study were interested in examining factors that contributed to the retention of nurses in underserved rural and remote areas of indonesia. purpose the purpose of this study was to examine factors affecting nurses’ retention in rural and remote areas of indonesia. variables to be examined included nurses’ age, gender, marital status, financial incentives, non-financial incentives and retention. financial incentives included an additional monthly monetary award that was over and above the nurse’s base salary. non financial incentives consisted of employee benefits including housing, health insurance, transportation, and an opportunity to become a government employee. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 35 methods setting rural and remote areas have been defined by the ministry of development of remote areas of indonesia and ministry of health of indonesia. based on this official definition, districts in which nurses were assigned and included in this study were sumatera utara, kepulauan riau, bengkulu, kalimantan barat, kalimantan timur, sulawesi tengah, sulawesi utara, nusa tenggara timur, maluku and papua. instrument survey methods were used to obtain data from nurses who were enrolled in the special assignment initiative. the survey tool was developed by the two authors (fe; ak), and consisted of a cover page with demographic information; and, a second page that included three subsections, each having six items, to be rated by respondents on a 5-point likert-type scale (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree). the first subsection focused on financial incentives; the second subsection focused on nonfinancial incentives; and the third subsection included items focusing on nurse retention. protection of human subjects anonymity of respondents was addressed by the researchers with the use of numerical assignment to each survey instrument. sample & procedure potential subjects were identified from the moh nursing database for the special assignment initiative. out of a possible 210 nurses in the initiative, a convenience sample of 140 nurses was recruited to participate in the study. the survey instrument was hand delivered to each subject by moh personnel while making a site visit to the nurse in the rural setting. at that online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 36 time, the moh representative officially invited each nurse to complete. who, in turn, returned the questionnaire in a sealed envelop which had no personal identification to the representative while on the site visit. subsequently, the university-based researchers received the questionnaire directly from moh representative upon her return from the rural site visit. analysis & findings table 1 demographic characteristics (n = 140) data number percentage (%) gender male female 32 108 22.9 77.1 age ≤25 ≥26 108 32 77.3 22.7 salary 500,000-1 million idr >1 millions idr 75 65 53.6 46.4 financial incentive 1-2 millions idr >2 millions idr 8 132 5.7 94.3 non-financial incentives yes no 27 113 19.3 80.7 the analysis of pearson’s correlation (table 2) indicated three independent variables were positively related to nursing retention namely age and nurses retention (r = 0.208; p = 0.013), retention and financial incentives (r = 0.821, p = 0.000) and between retention and non-financial incentives (r = 0.826, p = 0.00) incentives (r = 0.826, p = 0.000). table 2 pearson correlation result variable retention r p age 0.208* 0.013 gender -0.062 0.464 financial incentives 0.821 (**) 0.000 non-financial incentives 0.826 (**) 0.000 online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 37 ** correlation is significant at the 0.01 level (2-tailed) * correlation is significant at the 0.05 level (2-tailed) multiple regression analyses determined how much of nurses’ retention was predicted by financial incentives, nonfinancial incentives, age, gender, and marital status. as shown in table 3, the model variables accounted for 75.6% of the nurses’ retention variance. financial incentives (β = 0.460, p < 0.001), non-financial incentives (β = 0.428, p < 0.001), and younger age (β = 0.112, p < 0.05) were significantly related to nurses intention to stay or remain in the workplace. gender and marital status were not significantly related to willingness of retention (table 3). table 3 multiple regression model of nurses’ retention predictors ß t financial incentives .460*** 5.465 nonfinancial incentives .428*** 5.092 age -.112* -2.105 gender -.008 .167 marital status .014 .264 r2 = 0.756 f (df = 7, 132) = 58.479*** * p< 0.05, **p < 0.01, *** p < 0.001 (2 tailed) discussion this study provided insights into factors that contribute to nursing retention in rural and remote indonesia. indonesia has a high rate of unemployment. latest data from jawa timur province shows that unemployment rate for nurse in this region has reached 10,800 per year (mulyono, 2012). in this study, younger nurses (77.3%) as in table 1 seem to be more willing to work in rural and remote areas. some experts attribute this finding to traditional indonesian cultural advocating individual responsibility to work with the underserved. one could speculate that this finding may be attributable to an individual seeking nursing practice experience coupled with increased financial remuneration for doing 3so. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 38 nursing is a predominately female profession but there are no precise data related to the gender of nurses in indonesia. consistent with other studies, variance between males and females along with their marital status did not seem to impact retention for nurses in this study (dieleman & harnmeijer, 2006; dussault & franceschini, 2006; lehmann, dieleman, lexomboon & matwa, 2005; shields & price, 2002; tai, bame, & robinson, 1998). given the preponderance of females in the nursing workforce it is important to understand the specific needs to retain both women as well as men in the rural and remote areas. for example, family considerations often are important factors in career choices, but these may vary between males and females. there is a paucity of research that focuses on gender and marital status and the retention of nurses in rural and underserved regions, particularly in underdeveloped nations (dussault & franceschini, 2006). the majority of nurses (85%) in this study indicated ‘single status’, on the one hand they may have had had fewer immediate family responsibilities; thus allowing them to participate in this initiative which offered additional financial incentives. conversely, one could speculate, a nurse may have had family responsibilities that could benefit from a higher salary coupled with the employer fringe benefits. in the analysis of the data, financial incentive was significantly associated with retention of nurses in the program. as the financial incentive increased, so did the respondent’s interest in remaining at his or her assigned location. internationally, financial as well as nonfinancial incentives are widely used to recruit, retain and motivate an employee, and nurses are no exception. however, financial incentives may not be what motivate some nurses to relocate to a rural remote or underserved area. for some, nonfinancial benefits may be preferred and considered motivating forces (van de pas, 2010; world bank, 2009; who, 2010; ). more specifically, non-financial incentives were at least as important for nurses in this study especially online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 39 achieving the security of employment as a civil servant (government employee). the benefits of being a civil servant include health insurance coverage, retirement pays and remuneration for travel and housing costs. civil servants may also receive a monthly supply of rice in lieu of a financial incentive. date were absent as to the number of nurses in this study who achieved civil servant status as part of participation in the special assignment initiative. for indonesia, the potential for civil servant status with the associated benefits may be the most significant strategies to entice nurses to serve in rural and remote areas. conclusion this study was an initial effort to obtain baseline data about nurses who were assigned to work in rural and remote regions of indonesia. the preliminary findings can offer provide insights about the demographic characteristics and incentives that may impact recruitment and retention in this indonesian government-sponsored initiative targeting underserved rural and remote regions of this developing nation. developing incentives package along with recruitment of younger nurse can increase their intention to serve in rural and remote area of indonesia. supporting agency faculty of nursing airlangga university surabaya indonesia acknowledgement we would like to express our gratitude to centre of planning and management human resources for health, moh, indonesia for permission granted. references dieleman, m. & harnmeijer, j.w. (2006). improving health worker performance: in search of promising practices. geneva, switzerland: world health organization. retrieved from: online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 40 http://www.hrhresourcecenter.org/node/1701 and http://www.who.int/hrh/resources/ improving_hw_performance.pdf dussault, g. & franceschini, m.c. (2006). not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. human resources for health. 4(12). http://dx.doi.org/10.1186/1478-4491-4-12 kurniati, a., & efendi, f. (2012). kajian sumber daya manusia kesehatan di indonesia. jakarta: salemba medika. lehmann, u., dieleman, m., lexombooon, d., & matwa, p. (2005). the staffing of remote rural health services in low-income countries: a literature review of issues and options affecting attraction and retention. paper presented at the 3rd public health conference 2006, making health systems work, midrand-south africa. retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2259330/ ministry of health. (moh). (2010a). rencana strategis kementerian kesehatan tahun 20102014. jakarta: moh. retrieved from: http://www.nationalplanningcycles.org/sites/default/ files/country_docs/indonesia/indonesian_minstry_of_health_strategic_plan_2010-2014.pdf ministry of health of indonesia. (moh). (2010b). keputusan menteri kesehatan republik indonesia nomor 156/menkes/sk/i/2010 tentang pemberian insentif bagi tenaga kesehatan dalam rangka penugasan khusus di puskesmas daerah terpencil, perbatasan dan kepulauan. jakarta: moh. retrieved from: http://www.hukor.depkes. go.id/up_prod_kepmenkes/kmk%20no.%20156%20ttg%20pemberian%20insentif%20ba gi%20tenaga%20kesehatan.pdf ministry of health of indonesia. (moh). (2012a). pelayanan kesehatan dasar di daerah tertinggal, perbatasan dan kepulauan (dtpk). retreived from: http://buk.depkes.go.id/ online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 41 index.php?option=com_content&view=article&id=225:pelayanan-kesehatan-dasar-didaerah-tertinggal-perbatasan-dan-kepulauan&catid=111:dasar&itemid=136 ministry of health of indonesia. (moh). (2012b). kemenkes prioritaskan pelayanan kesehatan di dtpk. retrieved from: http://buk.depkes.go.id/index.php?option=com_content&view =article&id=106:kemenkes-prioritaskan-pelayanan-kesehatan-di-dtpk mulyono, b. (2012). jumlah sekolah perawat banyak, tapi hanya luluskan pengangguran, surabaya pagi. retrieved from: http://www.surabayapagi.com/index.php?3b1ca0a43b79 bdfd9f9305b812982962dc178d92de1ea22bc5bb32b3db20b9ef shields m. a. & price, s.w. (2002). racial harassment, job satisfaction and intentions to quit: evidence from the british nursing profession. economica, 69, 295 326. http://dx.doi.org/10.1111/1468-0335.00284 tai t, w.c., bame, s.i. & robinson, cd. (1998). review of nursing turnover research, 19771996. social science and medicine, 47(12), 1905-1924. http://dx.doi.org/10.1016/s02779536(98)00333-5 van de pas, r. (2010). human resources for health, opportunities & challenges in the indonesian province of papua. master degree, royal tropical institute, amsterdam. retrieved from: http://www.papuaweb.org/dlib/s123/vandepas/_mih.pdf world bank. (2009). indonesia’s doctors, midwives and nurses; current stock, increasing needs, future challenges and options jakarta. retrieved from: https://openknowledge. worldbank.org/handle/10986/3053 world health organization. (who) (2010). increasing access to health workers in remote and rural areas through improved retention. geneva: who. retrieved from: http://www.who. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.260 42 int/hrh/retention/guidelines/en/ and http://whqlibdoc.who.int/publications/2010/978924156 4014_eng.pdf microsoft word rhodes_340-1952-1-ed.docx online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 60 depression and smoking in the pregnant rural population: a literature review joyce marie rhodes-keefe, ms, rnc clinical assistant professor, decker school of nursing, binghamton university, jrhodes@binghamton.edu abstract background: there is a lack of literature specific to depression in the rural smoking population. the effect of smoking on the fetus and mother combined with the challenges posed by underlying depression make this issue complex and necessary to investigate. in addition, strengths and challenges specific to the rural population need to be considered, but have not been addressed in previous studies. purpose: the purpose of this review was to identify the current status of research on the topic of the relationship between smoking status, rurality, and depression in the pregnant population. methodology: an integrative review of the literature was conducted using the terms pregnancy, depression, smoking, and rural. nursing and psychology domains were accessed as well as the cochrane library. within the nursing domain, twelve articles were identified for review. one hundred fifty articles were found within the psychology domain. a search of the cochrane library yielded one thousand thirty one articles. inclusion of all four key terms was a criterion for review. titles and abstracts were reviewed for relevance. dissertations and opinion papers were excluded. results: twelve articles within the nursing domain were reviewed and did not include all four key terms. of the one hundred and fifty articles noted in the psychology domain, none contained all four of the key terms. lastly, no articles stemming from the cochrane library search addressed all key terms. aspects such as depression management and depressive disorders were online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 61 predominant. a total of four articles were deemed appropriate for inclusion. all of these articles stemmed from the nursing domain search. none of the analyzed articles used a theory, model, or conceptual framework to guide their research. of the four articles, only one was experimental. while rural was defined specifically according to butler and beale’s criteria of metropolitan vs. nonmetropolitan in one article, it was not clearly defined in one article that was published in a rural nursing journal. the studies reviewed spanned a large segment of rural populations with samples drawn from various countries around the world. conclusions: there is a dearth of research in the area of depression in the rural pregnant smoker. of the research located, there is limited definition of rural, no use of a theory, and no incorporation of concepts inherent to the rural population. in order to conduct a comprehensive study of this population, efforts must be made to address these concepts via information gathering, study design, and/or implementation processes. research focusing on these areas will lend a truly holistic view of the topic. keywords: pregnancy, smoking, depression, rural. depression and smoking in the pregnant rural population: a literature review pregnancy, for some, is known as a time of joyous anticipation. the family eagerly awaits the birth of a new member. depression during and after pregnancy can lead to a multitude of negative consequences ranging from interrupted relationships to death. risk factors associated with depression during pregnancy include few support systems, low socioeconomic status, lower educational level, and being of certain minorities (logsdon, birkimer, & usui, 2000). in addition, harvey and punn (2007) found an unplanned pregnancy, financial stressors, and few supports as themes correlating to depression in the pregnant population. sears, danda, and online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 62 evans (1999) discuss the relationship between depression, rurality, and smoking status in a low income female population. in their research validating the mood module of the primary care evaluation of mental disorders tool’s use in a rural setting, nurses in two rural clinical settings located in northern florida administered the questionnaire. participants were shown to have higher depression scores compared to participants’ scores in urban settings. little has been done, however, to investigate the interrelated nature of all of the above concepts. the purpose of this paper is to analyze the literature to identify studies that address smoking status, depression, and rurality in the pregnant population. analysis of the relationships of the concepts may define if smoking is a coping mechanism for the rural pregnant population as well as what role rurality and pregnancy play in the experience of depression. several questions may be posed about the above relations. just one of many possible questions is: “is smoking a means of self-medicating for depression?” answers to this question will have a profound impact on the healthcare provided this population, especially in regard to nursing care as nurses are on the forefront of patient contact. nurses in rural settings play a pivotal role in care of patients, being instrumental in identification, follow through, and evaluation of treatment plans. rural nurses balance familiarity with anonymity to establish a therapeutic relationship. increased knowledge regarding depression and smoking in the pregnant patient living in a rural setting will provide nurses with the ability to provide optimal care. an initial literature search was conducted to identify the current status of research on the topic of the relationship between smoking status, rurality, and depression in the pregnant population. initially, the subject nursing was chosen to identify a suitable data base. cumulative index to nursing and allied health literature (cinahl), medline, psychology and behavioral sciences collection databases were initially chosen. the search was then expanded to all online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 63 databases available through nursing within the binghamton university library electronic system. the initial search mode used was “find all search terms”. peer review was the chosen limiter and the subject terms used were pregnancy, depression, smoking, and rural in that order. poster abstracts, opinion papers, and dissertations were excluded. this search yielded nine articles. four articles remained after a detailed review of the abstracts, all addressed the terms pregnancy, depression, smoking, and rural. changing the search mode to “find any of my search terms” and keeping the terms pregnancy, depression, smoking, and rural, along with the prior limiters and exclusions, did not yield a change in the number and titles of articles found. in the psychology databases utilizing the same search terms, delimiter, and exclusion criteria, no new articles were identified. one formerly identified article was produced as well as three articles that addressed stress or anxiety, but did not address depression in the rural smoking pregnant population. as a final approach to on-line investigation for the literature search, the cochrane library was accessed. the topic mental health was chosen with 353 available articles. further limiting the search to depression brought the count to 51 articles. narrowing the topic further to depressive disorders/major depression yielded a count of 49. antidepressant prevention of postnatal depression brought the article count to three articles, none were appropriate based upon review of the abstracts. a different approach within the cochrane review was to use tobacco addiction as the topic and 69 articles were found. accessing a subtopic of cessation narrowed the number to 56; however, none were appropriate based upon review of the titles. the final topic accessed in the cochrane library was pregnancy, yielding 609 articles. the subtopic of antenatal had nine articles, yet none were appropriate per title review. basic care during pregnancy, another subtopic under pregnancy and childbirth, had 13 associated articles, but a online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 64 review of the titles demonstrated that none were appropriate. the final subtopic under pregnancy and childbirth, psychological well-being during pregnancy, had seven articles with none appropriate per title review (see figure 1). considering that the above on-line search resulted in four potentially appropriate articles, it was decided to use an additional means of investigation. six sources were accessed via a heritage search. of the six sources noted, none contained all four of the required search terms, yielding no suitable results. for the purpose of this review, four articles were chosen based upon the above inclusion criteria of all the terms pregnancy, depression, smoking, and rural as well as peer review. exclusion criteria were poster abstracts, opinion papers, and dissertations. chosen articles were required to address all four of the already mentioned terms (bullock, et al., 2009; guest, & stamp, 2009; ho-yen, bondevik, eberhard-gran, & bjorvatn, 2007; simmons, huddlestoncasas, & berry, 2007). due to the fact that only four articles with potential merit were identified in this exhaustive search, it would suggest that there is a scarcity of literature regarding depression and smoking in the pregnant rural population. thus this is an area worthy of further study. further evaluation of the above four articles led to identification of strengths and gaps in the body of literature. each article was evaluated individually for validity and reliability. sample size, design, method of sampling, identification of a purpose and research question, use of a conceptual framework or theory as a guide, statistical tests, and clinical significance of findings were evaluated via a scoring tool (association of women’s health, obstetric and neonatal nurses [awhonn] (2003). the search flowchart demonstrates the multiple sources accessed with only four potential articles yielded, with several limitations (see figure 1). online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 65 figure 1 flowchart of literature review strengths and gaps in the literature strengths a majority of the articles reviewed had a larger sample size (bullock et al., 2009; ho-yen et al., 2007; simmons, et al. 2007) with one using a power analysis to determine an adequate sample to mitigate the chance of a type ii error (bullock et al., 2009). the larger sample size was a strength as inferences made from analysis of results are deemed more valid for generalization. in addition, all studies used screening instruments that have already been online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 66 established as valid and reliable; two used the edinburgh postnatal depression scale (epds) (guest & stamp, 2009; ho-yen et al., 2007), one used the center for epidemiologic studies depression scale (ces-d) (simmons et al., 2007) and one used a perceived stress scale along with a prenatal psychosocial profile (bullock et al., 2009). three of the studies were purely descriptive in nature (guest & stamp, 2009; ho-yen et al., 2007; simmons et al., 2007). although the low level design is a weakness, the studies do provide information pertinent in a topic area where there is little known regarding depression in the rural, pregnant smoker. descriptive designs are most often used when there is limited literature specific to the target population. one study was an experimental design using randomization and investigated interventions aimed at smoking cessation among rural pregnant smokers along with measuring depression levels. although the sample included those with and without depression, a good portion of the sample scored high (18.7%) on the mental health index-5 (mhi-5) measure, indicating depression (bullock et al., 2009). gaps in regard to gaps in the body of literature, none of the analyzed articles used a theory, model, or conceptual framework to guide their research. use of a theory would help drive the research process, giving it direction. in addition, while stating a rural focus, rurality was not defined in regard to population size, geography, or other factors in two of the articles (bullock et al., 2009; ho-yen et al., 2007). while rural was defined specifically according to butler and beale’s criteria of metropolitan vs. nonmetropolitan in one article (simmons et al., 2007), it was not clearly defined in one article that was published in a rural nursing journal (guest & stamp, 2009). working with the rural population poses unique challenges and approaches and rural research needs to take this uniqueness into consideration. two of the studies were conducted online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 67 outside of the united states (ho-yen et al., 2007, guest & stamp, 2009), potentially introducing geographic location as a factor that should be addressed. a final gap noted in the overall body of literature is the lack of studies aimed at the presence of depression in the pregnant smoker living in a rural setting. the studies reviewed spanned a large segment of rural populations with samples drawn from various countries around the world. this diversity in samples gives a broad picture of factors of depression among smoking rural women, however it does call into question the transferability of the studies to rural populations with variances in cultural norms. review in their study, ho-yen et al. (2007) found that risk factors such as polygamy, husband’s alcoholism, earlier onset of depression, depression present during the current pregnancy, and smoking were significantly related to development of depression, however, there was no significant difference between the rural and urban populations. although polygamy is illegal in the us and thus not often a relevant risk factor, other risk factors noted in the ho-yen et al. study are relevant. in contrast, guest and stamp (2009) found that rural women had higher epds scores postpartum, indicating depression, than urban women and rural women had a decreased incidence of smoking. this study did have the smallest sample size n = 85, adding questions of the generalizability of results to other pregnant rural women with depression who smoke. replication of the study would be beneficial. guest and stamp’s premise that rural women have an increased incidence of reported depression was refuted by simmons et al., (2007) who found that pregnant women living in areas defined as rural according to established criteria were less apt to identify themselves as depressed. in addition, they noted that women, who had been pregnant within the past three years, therefore having contact with a provider, online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 68 were less likely to identify themselves as depressed. also, women identified as depressed had more illnesses and injuries resulting in contact with the health care system. they recommend increased provider awareness to the signs and symptoms of depression. increased contact with providers may be a means by which women could be educated about the signs and symptoms of depression, potentially promoting appropriate self-identification. the simmons et al. findings may explain the difficulty in comparing depression rates between rural and urban populations. that is, is a lower incidence of identified depression related to a lack of depression or to a failure to identify existing depression? in the study by bullock et al (2009), high levels of stress and depression as well as few social supports were noted in pregnant women who smoked. effective treatment focused upon social support combined with specific interventions. women successfully abstaining from smoking utilized one of the offered interventions as well as had more social support (bullock et al., 2009). to summarize, the body of knowledge assessed in this review indicates: (a) risk factors are present in regard to depression in pregnancy, (b) smoking has been associated with depression in the rural pregnant population, (c) depression and limited supports promote continuance of smoking, and (d) rural women do not necessarily identify themselves as depressed, especially if recently pregnant. there remains an unanswered question as to the role of rurality in depression in the pregnant smoker. recommendations of the reviewed articles, three were descriptive and one was a randomized controlled trial. with a beginning level description of depression in rural women who are pregnant and smoke, the need to move toward investigating interventions is important. increased numbers of randomized controlled studies and ultimately systematic reviews would add to the level of online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 69 evidence. more studies need to be done employing interventions specific to smoking cessation and depression diagnosis and treatment in the rural pregnant woman. in addition, a clearer definition of how rural is defined will promote analysis and comparisons of smoking and depression rates within this population. interventions and variables should be tailored to this specific population. use of an appropriate theory would also benefit future research. theory driven research would give direction to the study as well as assist in interpretation/application of results. there is a definite need to focus on rurality when studying pregnant women in regard to depression and smoking. none of the articles addressed concepts specific to the rural population. according to brown and schafft (2011) poverty rates are higher in inner cities and nonmetropolitan areas. in addition, women, especially women as the sole head of the household, have an even higher rate of poverty. considering the population studied in the literature review, poverty is an important concept that should be included in any analysis. all of the prior studies collected sociodemographic information. the concept of poverty in the rural population could be studied in more detail to increase the body of knowledge about the co-existence of smoking and depression in a vulnerable patient. rural concepts concepts such as resilience, hardiness, anonymity vs familiarity, isolation, and outsider/insider need to be addressed in any analysis of a rural population. resilience, according to leipert (2010) entails the ability to withstand difficulties and have perseverance. hardiness entails “taking a positive attitude, following spiritual beliefs, developing fortitude, and establishing self-reliance.” (leipert, 2010, p. 110-111). anonymity vs. familiarity impacts on health seeking behaviors as well as health care provision. isolation impacts on the rural online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 70 population’s access to healthcare and outsider/insider defines perceptions of healthcare providers (findholt, 2010). future studies of depression in the rural pregnant smoking population would benefit from measurement and analysis of the above concepts. the presence, or absence, of resilience and hardiness has potential impact on any interventions aimed at smoking cessation or depression recognition and treatment. associated self-efficacy can be studied as a cause of, or factor promoting, hardiness and resilience. evaluating one’s self-efficacy may lead to appropriate interventions. smoking may also be seen as acceptable via multigenerational transmission (nichols, 2011) and culturally acceptable in some rural areas. in addition, smoking may be seen as a means of self-medication for depression that allows women to feel more resilient. incorporating an analysis of resilience, hardiness, and self-efficacy can evaluate associations with smoking status and depression. familiarity vs. anonymity and outsider/ insider concepts should be investigated to maximize research effectiveness. lack of anonymity may hinder disclosure of depression due to the associated stigma (simmons et al., 2007). the ability of these women to trust professionals not within their informal network is affected by their perception of outsider/insider. future studies could investigate the role that these concepts have on acceptance of an assessment/treatment plan. an outsider may not be trusted, even if treatment would be beneficial. investigators may be seen as outsiders, limiting future information gathering abilities. analysis of rural women’s attitudes toward insider/outsider status and anonymity vs. familiarity can play a role in research attempts, potentially impacting them, as well as intervention success. collaboration between “local” care providers and researchers may be valuable to avoid inside/outside bias. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 71 women who are isolated due to geography may have limited access to condition-specific healthcare, such as depression and smoking cessation. attention to the component of isolation via a clear definition of rural as well as assessing for feelings of isolation is important in order to develop access to care and promote continued provider competence specific to these needs. incorporation of a theory during the research process that reflects rural components is imperative as further research is developed in this area. in addition, use of assessment tools that reflect status of the aforementioned concepts, such as self-efficacy and poverty, will assist in analysis of depression in the rural pregnant smoker. experimental studies incorporating use of tools that reflect rural concepts would be optimal and raise the level of evidence for future use in practice. as an example, use of a screening tool for self-efficacy along with the epds and sociodemographic factors, with a clear definition of rural, would address concepts of depression, smoking status, rurality, isolation, resilience, and hardiness. attention to the concepts of insider/outsider and anonymity vs. familiarity could be addressed by inclusion of members of the informal network who are insiders in the research process as well as treatment regimen. conclusion in conclusion, a literature search was conducted investigating depression in the rural smoking pregnant population. multiple databases were searched yet only four articles were suitable according to established inclusion/exclusion criteria. upon analysis of the four articles, strengths and gaps in the body of knowledge were identified as well as areas in which research could be improved. suggestions as to ways to incorporate concepts into future research have been offered. there is a scarcity of research in the area of depression in the rural pregnant smoker. of the research located, there is limited definition of rural, no use of a theory, and no incorporation of concepts inherent to the rural population. in order to conduct a comprehensive online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 72 study of this population, efforts must be made to address these concepts via information gathering, study design, and/or implementation processes. research focusing on these areas will lend a truly holistic view of the topic. acknowledgements i would like to acknowledge pamela stewart fahs, rn, phd, associate dean professor & dr. g. clifford and florence b. decker chair in rural nursing decker school of nursing; binghamton university editor in chief online journal of rural nursing and health care for all of her assistance in development of this article. supporting agencies binghamton university, decker school of nursing references association of women’s health, obstetrics and neonatal nursing [awhonn]. (2003). evidence-based clinical practice guideline: cardiovascular health for women: primary prevention. (2nd ed.). washington, dc: awhonn. brown, d. l., & schafft, k. a. (2011). rural people & communities in the 21st century: resilience transformation. malden, ma: polity. bullock, l., everett, k. d., mullen, p. d., geden, e., longo, d. r., & madsen, r. (2009). baby beep: a randomized controlled trial of nurses’ individualized social support for poor rural pregnant smokers. maternal & child health journal, 13, 395-406. http://dx.doi.org/ 10.1007/s10995-008-0363-z findholt, n. (2010). the culture of rural communities: an examination of rural nursing concepts at the community level. in c.a. winters & h.j. lee (eds.). rural nursing: concepts, theory, and practice (pp. 373-383). new york, n y: springer. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.340 73 guest, m. l., & stamp, g. e. (2009). south australian rural women’s views of their pregnancy, birthing and postnatal care. rural and remote health, 9, 1-9. [medline] harvey, s. t., & pun, p. (2007). analysis of positive edinburgh depression scale referrals to a consultation liaison psychiatry service in a two-year period. international journal of mental health nursing, 16, 161-167. http://dx.doi.org/10.1111/j.1447-0349.2007.00463.x ho-yen, s., bondevik, g. t., eberhard-gran, m., & bjorvatn, b. (2007). factors associated with depressive symptoms among postnatal women in nepal. acta obstetricia et gynecologica scandinavica, 86, 291-297. http://dx.doi.org/10.1080/00016340601110812 leipert, b. (2010) rural and remote women and resilience: grounded theory and photovoice variations on a theme. in c.a. winters & h.j. lee (eds.). rural nursing: concepts, theory, and practice (pp. 105-129). new york, new york: springer. logsdon, c. m., birkimer, j. c., & usui, w. m. (2000). the link of social support and postpartum depressive symptoms in african-american women with low incomes. the american journal of maternal/child nursing, 25, 262-266. http://dx.doi.org/10.1097/ 00005721-200009000-00009 nichols, m. p. (2011). the essentials of family therapy (5th ed.). boston: allyn & bacon sears, s., danda, c., & evans, g. (1999). prime-md and rural primary care: detecting depression in a low income rural population. professional psychology, research and practice, 30, 357-360. http://dx.doi.org/10.1037/0735-7028.30.4.357 simmons, l., huddleston-casas, c., & berry, a., a. (2007). low-income rural women and depression: factors associated with self-reporting. american journal of health behavior, 31, 657-666. http://dx.doi.org/10.5993/ajhb.31.6.10 developing cultural competence in rural nursing 28 developing cultural competence in rural nursing lindsay lake morgan, phd, rn, gnp1 sally j. reel, phd, aprn, c-fnp, bc, faan, faanp2 1 assistant professor, decker school of nursing, binghamton university, lmorgan@binghamton.edu 2 clinical professor and associate dean, college of nursing, university of arizona, sreel@nursing.arizona.edu key words: rural, culture, curriculum, community, collaboration abstract preconceptions of rural lifestyle and culture can color the perspective of future health care providers. to encourage advanced practice nurse (anp) students to think beyond the mythology about a rural place different than where they practice, two nurse educators and universities teamed up to develop a unique curriculum in which students immersed themselves in a new rural experience. in this innovative curriculum design, students visited a rural appalachian coal-mining community in an immersion experience to conduct a community assessment and worked with local health care providers in community health education projects in collaboration with a nurse educator and anp who provides health care to the community through a primary care clinic. the students discovered for themselves the distinctions of rural life in rural west virginia. this project led to experiential learning and heightened attainment of cultural competence on the part of the students and demonstrated how a collegial effort between nurse educators in two universities and long distance collaboration can benefit students who may someday deliver care in rural communities. introduction: developing cultural competence in rural nursing health care providers may have preconceived and even erroneous perceptions of people living in rural areas regarding their lifestyles, health habits, and culture. although there are some concepts considered to be central to rural people as a whole, the culture of rural areas may vary widely from region to region. since rural culture can be manifested in many ways and often differs by setting, nursing educators need to consider broadening the perspective of students to a variety of cultural settings in an effort to increase rural cultural competency. the purpose of this article is to describe the collaborative relationship and the unique curricular design of a practicum in which students visited a rural community quite different from their own. they conducted a community assessment, assisted on a community health teaching project, and immersed themselves in a rural community in a coal mining area of west virginia in order to build cultural competence. this project allowed students to discover for themselves the distinctions of rural life in a unique locale. cultural immersion providing high quality health care and assisting people to change behaviors and understand the benefits of health living is fundamental to nursing practice. cultural online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.binghamton.edu/dson/ mailto:lmorgan@binghamton.edu mailto:college%20of%20nursing mailto:sreel@nursing.arizona.edu 29 misunderstandings and miscommunications may form obstacles that thwart the level of nursing services provided (national alliance for hispanic health, 2001). rural america is diverse with varying populations, geographies, economies, and ethnicities. appalachia is a predominantly rural and diverse region within the united states. as a population of health interest, many appalachian people exceed other americans in years per life lost on many national health indicators (health risks, 1995). culturally, appalachian people have been portrayed throughout the twentieth century as a static, homogenous, white mountain culture (reel, 2002; newell-withrow, 1997). however, appalachia traverses a broad stretch of land from new york to northern mississippi with diverse geographies, economies, and people (appalachian regional commission, 2002). this paper presents a cultural immersion strategy for exploring diversity of rural appalachia between new york and west virginia. cultural immersion, as a strategy to educate culturally competent nurses and has been successfully utilized elsewhere to develop cultural competence and cultural self-efficacy among nursing students (ryan, twibell, brigham & bennett, 2000; st. clair & mckenry, 1999; jones, bond, & mancini, 1998). cultural immersion in this project relied on a short-term program that permitted graduate nursing students from binghamton university to have lived experiences in rural west virginia, and promoted opportunities for transforming static perspectives about rural appalachian people and places. this approach is consistent with that of the american academy of nurse experts on culturally competent care, which supports that cultural sensitivity is prerequisite to cultural competence (leininger, meleis, davis, ferketich, flaherty, isenberg, koerner, lacey, stern & valente, 1992). while rurality is diverse, one of the challenges to understanding any culture, including rural ones, is recognition that human societies tend to develop ethnocentrism— the viewing of one’s own cultural standards as the true universal and the judging of other cultures by one’s own standards (national alliance for hispanic health, 2001). culturally immersed clinical experiences promoted opportunities for transforming static perspectives about rural appalachia in west virginia and rural new york. for example, the target county for cultural immersion experiences is located in the southern west virginia coalfields. rural life in this county is dominated by the coal industry and changes affiliated with this industry, and differs considerably from the predominantly farming rural areas with which nursing students at binghamton university are familiar. the educational exchange between binghamton university and marshall university relied on immersion as a strategy to expand student’s realities of rural diversity as well as to dispel negative connotations historically associated with appalachian people. how it all began: brainstorming leads to collaboration the connection began in 1998 at the first international congress of rural nursing in saskatoon, saskatchewan, canada. the authors met and discussed methods to teach diversity in rural nursing courses. the brainstorming and sharing of ideas lead to collaboration between two nurse educators at the two universities. the common bond for these educators was searching for ways to increase cultural competency in nurses who would be advanced nursing practitioners working with rural people. the decker school of nursing (dson), of binghamton university is part of the state university of new york system. binghamton university began as triple cities online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 30 college in 1946 and has grown into one of the four premier university centers in the state university of new york educational system. the dson was established in 1969 and today offers baccalaureate, master of science, and doctor of philosophy programs in the field of nursing. fifty-one percent of decker school master of science (ms) degree nurse practitioner graduates practice in rural under-served areas after graduation. the dson is the first in the country to offer a ph.d. in nursing focusing on rural health care. in 1998 the o’connor office of rural health was created at the decker school of nursing. the purpose of this office is to serve as a resource regarding the health care needs of rural residents. myths about rural lifestyles are common among americans. the picture of a pastoral life, healthy eating, and fresh air is promoted from early childhood books to the current media of film, television, and advertising. further, specific regions of rural america have a second layer of mythology, especially seen in common views regarding appalachia and coal mining areas. the decker school of nursing has integrated rural concepts and experiences into every part of the curriculum and offers an eight-credit concentration in rural nursing to ms students. however, the focus had been on the rural experience in upstate new york. many of these students have lived and worked in rural upstate new york, where dairy and fruit farming are prevalent. the goal was to encourage students to think beyond the mythology about another rural place. the marshall university college of nursing and health professions is one of nine schools and colleges in marshall university, a public university founded in 1837. consistent with the mission of marshall university, the college of nursing is committed to offering quality undergraduate and graduate nursing education. the focus of the school of nursing is upon being interactive with the community in assessing the health care needs of the people, including rural and under-served areas, and in responding to contemporary and future needs of society and the nursing profession. all health science students in west virginia public institutions of higher education must receive training in rural areas. marshall university nursing students all experience a clinical rotation with rural or under-served population prior to graduation. in 1998, the u.s. department of health and human resources, health resources and services administration, division of nursing, funded a nursing special project grant to the marshall university college of nursing and health professions. this grant created the marshall university appalachian rural outreach primary care nursing center (aronpcnc), which is located in an elementary school in the target county. advanced nursing practice is the cornerstone of the nursing center. the immersion practicum for decker school of nursing students was designed to incorporate the objectives of the rural nursing concentration within the context of a rural nursing center practice located in an appalachian coal-mining community. this project not only gave students an opportunity to meet individual and course objectives but also built connections for future collaboration in education and research between the two universities. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 31 curriculum design of the rural nursing immersion experience assumptions and definitions this course was based on the assumption that rural life is a culture. for the purposes of this course, rural communities may be considered rural by nature of their low population, sparseness of population, isolation, dependence on the land, or lack of urban influence. students were expected to define and provide rationale for a community to be considered rural. purnell and paulanka define culture as “the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making” (1998, p. 2). cultural competence (purnell and paulanka, 1998) is achieved through four actions: (1) developing an awareness of one’s own existence, sensations, thoughts, and environment without letting it have an undue influence on those from other backgrounds, (2) demonstrating knowledge and understanding of the client’s culture, (3) accepting and respecting cultural differences, (4) adapting care to be congruent with the client’s culture. cultural competence is a conscious process and not necessarily linear (p. 2). setting: appalachia appalachia is an ancient region that has periodically claimed national attention. considerable debate lingers regarding whether a distinct appalachian culture exists as the lines of appalachian culture are heterogeneous and often overlap both rural and urban norms. both literary writers and scholars have portrayed appalachian people as ignorant, uneducated, backward, and primitive. after john f. kennedy was elected president, appalachia was the common arena for new public assistance policies and programs designed to alleviate the suffering of those residing there. yet, despite a concentration of national attention, the health status of appalachian people remains one of risk. about 23 million people live in the 410 counties of the appalachian region, which is predominantly rural (appalachian regional commission, 2002). much of central appalachia (which encompasses the southern coal belt) has a poverty rate of 27 percent, rural per capita income only two-thirds of the national average, and unemployment much higher than the national average. demographically, west virginia is the second most rural state in the united states with 63.9% of the total state population living in counties designated as rural (u. s. census bureau, 1995). historically, the state is poverty-plagued with impoverished children the most significant concern. one quarter of the population under age 18 is impoverished and in four counties, 100 percent of female-headed households with children under age 5 are impoverished (wv primary care access plan, 1996). this immersion experience was conducted in a rural county located in the heart of the southern west virginia coalfields. the majority of towns in the target county are quite small. no local bus systems operate within or between them, and the mountainous terrain and winding secondary roads lead to transportation barriers being repeatedly identified as an issue that affects health care access. the county has a total population online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 32 base of 25,870 residents. coal, although no longer “king” throughout appalachia, is the central economic resource of the county. job layoffs are common among the mines, and there are no other major employers to accommodate displaced miners. new york state itself is quite diverse, encompassing pockets of both great wealth and deep poverty; as well as remote mountains, rolling farmlands, and vast metropolitan new york city. statistics fail to capture the rural aspects of the state because the data are usually merged with those of metro areas. binghamton university is situated in a county that is part of the appalachian region. it has a metro area surrounded by farmlands. terrain is rarely a barrier to services, but poverty and distance can be. the public transportation in the rural areas is inadequate to assist with obtaining services. when farmers leave farming, there are sometimes alternative occupations available, often in manufacturing, the service industry, or tourism. table 1 displays census data comparing the two counties, two states, and the united states. table 1 comparison of the two counties, two states, and united states; as of the 2000 u. s. census broome co., new york new york state boone co., west virginia state of west virginia united states population 200,536 18,976,457 25,535 1,808,344 281,421,906 population density 283.7 persons per sq. mile 401.9 persons per sq. mile 50.8 persons per sq. mile 75.1 persons per sq. mile 79.6 persons per sq. mile percent rural -15.7% -63.9% 24.8% persons below poverty 13.8% 15.6% 19.7% 16.8% 13.3% (u. s. census bureau, 2000) objectives and learning strategies the learner will: 1. develop personal cultural competence by: a. developing an awareness of one’s own existence, thoughts, and environment without letting it have an undue influence on those from other backgrounds; b. demonstrating knowledge and understanding of the client’s culture; online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 33 c. accepting and respecting cultural differences; d. adapting care to be congruent with the client’s culture. 2. analyze the health status of a rural community using a framework. 3. develop skills to enhance practice in rural communities. 4. synthesize rural cultural competence and advanced nursing practice. teaching/learning strategies included a personal journaling, readings, discussion, immersion in the new community, e-mail consultation with colleagues, community assessment, community education project, and a poster presentation. implementation implementation begins with planning. collaborating faculty and institutions worked together to assure an effective learning experience for the students. many details had to be discussed and worked out prior to the students embarking on the practicum. these details included logistics such as professional licensure, legal contracts, getting the students to the site, living arrangements, exposure to the culture and the people of the area as well as designing the actual learning experience. ramifications of small details can have a potentially large effect on the outcomes of the project. for instance, there was discussion of what messages students might inadvertently bring to the community by driving a car with new york state license plates in rural west virginia. another big consideration was living arrangements. there were benefits and problems with each potential living situation and these had to be weighed and balanced. for instance, if the students lived in a setting together it would allow ample discussion time among them as well as promote work on the assessment project while the students were on site. the alternative considered was placing the students with families. the benefit would be access to key informants to clarify and amplify information collected during the day. living with the people would provide a true immersion. however, this option would place undue burden on both students and the host families and would be more difficult to arrange for the entire group. costs of the course were not considered prohibitive by the students. the students paid for their professional licensure in west virginia. while they were not providing “hands-on” care, this precaution was made to legitimize the community assessment process and because they were developing a community education project. since this was a clinical course, malpractice insurance is provided through the school of nursing and is part of tuition expenses. travel expenses (gasoline and hotel en-route for two nights) were borne by the students and were variable according to choices. some meals were provided by community residents and some were purchased by the students. the educational experience—an immersion practicum each student was expected to meet the course objectives of developing personal cultural competence, analyzing the health status of a rural community using a theoretical model, develop skills to enhance practice in rural communities and to synthesize rural cultural competence in advanced nursing practice. these objectives were to be met through a mix of group and individual learning activities. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 34 students had already successfully completed a three-credit didactic and theoretical course in rural health and rural health care systems. this summer semester five-credit course was the clinical portion of a concentration in rural health. the experiential part of this concentration was designed to bring the theory to life and allow the students, with the guidance of the local nurse educator, to focus on developing cultural competence. the actions of developing cultural competence (purnell & paulanka, 1998) were used to design the learning strategies for students to participate in this rural nursing practicum where they immersed themselves in a rural coal-mining community in west virginia. students prepared themselves for this immersion experience by reviewing the literature about coal mining communities in addition to the reading popular literature, viewing pertinent videos, and participating in class discussion. there were 2 pairs of students that visited the site for 1 or 2 weeks over a period of one summer. a third pair was scheduled to go, but experienced unforeseen personal barriers (health and family responsibilities). the students went by car to west virginia. one overnight was necessary so that they would arrive in daylight to the clinical site. the aronpcnc project director / preceptor in west virginia arranged for a windshield survey of the area with a driver who had grown up in the community. this took the better part of a day, and this person served as a key informant and access point for them to speak with other residents. after this introduction, each team created their own paths to obtain the information desired for their portions of the community assessment. they were expected to involve themselves in as many community activities as possible in addition to their assessment activities. choices made included church services, dances, family dinners, and hiking. each evening they participated in e-mail consultation with their classmates in new york state. the preceptor arranged an excellent housing opportunity for the students on the second floor of a collaborating health care facility (in renovated former hospital rooms). this supplied them with privacy, bedrooms, showers, computer access, telephones, tv/vcr, and library. each team on site reported daily via e-mail to classmates who recorded information in a community-oriented health record (stanhope & lancaster, 2000) and responded with questions for the on-site team to follow up. the students used anderson and mcfarlane’s (2000) community-as-partner model to guide the community assessment. each student selected one “piece of the pie” to focus on. areas of assessment data were recreation, physical environment, education, safety and transportation, politics and government, health and social services, communication, and economics. since students might gather information for any section, the “owner” of each section was responsible for organizing and following up on missing data. the students maintained personal journals to confront personal biases and preconceived notions about the community visited. this journal was shared with the instructor who offered suggestions and feedback about progress. the students were expected to assist local health providers in health education projects as well as share the community assessment document with the aronpcnc project director / preceptor. the project completed was a brochure to advertise a cancer prevention program. finally, the students prepared a poster on their experience and the community assessment for presentation at a rural nursing conference. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 35 outcomes objective 1 the students demonstrated development of personal cultural competence in their journals and the extent to which they successfully immersed themselves in the new culture. objective 2 the students found that the “community as partner” model (anderson & mcfarlane, 2000) was very useful for information gathering. they went on to describe this success in their poster presentations. objective 3 skills for practice in rural communities were developed, although the extent of this development is becoming more evident as they pursue their practices post graduation. objective 4 the synthesis of rural cultural competence and advanced nursing practice is evidenced to some degree; however, this remains a lifelong goal. the students met the objectives of the course, and in some cases exceeded expectations. students viewed themselves as having increased their cultural competence to work with individuals in a rural community that was new and different than those they had previously experienced. one student shared candidly in her journal her preconceived notions about appalachia and coal mining, as well as her evolution considering where she will begin her nurse practitioner work upon graduation. it appeared to the instructor that the course was extremely helpful and well timed for her personal and professional development. the student has since obtained employment in a third world country and continues electronic journaling and seeking input via e-mail from faculty and colleagues. two have sought employment as rural nurse practitioners – one in a southern state and one in new york. others are pursuing more education and continue to demonstrate their interest in rural health. the students chose to share their experiences and findings with the professional community by developing and presenting a peer-reviewed poster at a rural nursing conference. as a team they were very excited to see the work come together on the poster. the poster is entitled “appreciating the importance of using a community assessment wheel model to identify the needs of a rural community.” the student team presented similar posters at the local sigma theta tau chapter research conference and at the american public health association convention in november 2000. the community assessment was a team effort and the model assisted in dividing the tasks among the students. it was an ambitious project that took longer than expected. one lesson learned is that it is difficult to maintain momentum for completion in a long online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 36 distance project with students completing the immersion portion of the course at various times. life events and scheduling difficulties of adult students planning an immersion experience can cause scheduling problems for the faculty, preceptors, and community contacts and lead to the need for creative strategies. even families left at home had the opportunity to consider some of the realities of rural life while adjusting to their family member’s preparations and absence. these issues of distance, time, and limited resources for education are areas for further exploration with future groups. conclusion the practicum course with its immersion experience provided opportunities for students to develop cultural competence as well as for the two universities and the schools of nursing to develop a beginning working relationship with rural communities quite different from the surrounding areas of each school. with some modifications, the course design will be used again, and it is hoped that relationships among schools and communities will evolve to provide more opportunities for students. rural clinical sites with adequate supervision are sparse and must be used efficiently so that as many students as possible can develop cultural competence. this unique curriculum with the immersion model supplied excellent access for students to begin their progress toward such competence. acknowledgements this project was supported in part with funds from the u.s. department of health services, health resources services administration, division of nursing, grant 1 d10 hp 30401-03. references anderson, e.t., & mcfarlane, j.m. (2000). community as partner: theory and practice in nursing (3rd ed.). philadelphia: lippincott. appalachian regional commission. (2002). appalachian region. retrieved november 10, 2002, from http://www.arc.gov/index.do?nodeid=2 jones, m., bond, m., & mancini, m. (1998). developing a culturally competent work force: an opportunity for collaboration. journal of professional nursing, 14(5), 280-287. [medline] leininger, m., meleis, a.i., davis, l.h., ferketich, s., flaherty, m.j., isenberg, m., et al. (1993). aan expert panel report on "culturally competent health care" [letters to the editor]. nursing outlook, 41, 281-283. [medline] national alliance for hispanic health. (2001). a primer for cultural proficiency: towards quality health services for hispanics. washington, dc: estrella press. purnell, l.d., & paulanka, b.j. (1998). transcultural health care: a culturally competent approach. philadelphia: f. a. davis. reel, s., morgan-judge, t., peros, d., & abraham, i. (2002). school-based rural case management: a model to prevent and reduce risk. journal of the american academy of nurse practitioners, 14, 291-296. [medline] online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.arc.gov/index.do?nodeid=2 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=9775635&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=8309804&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12138523&dopt=abstract 37 ryan, m., twibell, r., brigham, c., & bennett, p. (2000). learning to care for clients in their world, not mine. journal of nursing education, 39, 401-408. [medline] st. clair, a., & mckenry, l. (1999). preparing culturally competent practitioners. journal of nursing education, 38, 228-234. [medline] stanhope, m., & lancaster, j. (2000). community health nursing (5th ed.). st. louis: mosby. u. s. census bureau. (1995). urban and rural population: 1900 to 1990. retrieved november 19, 2002, from http://www.census.gov/population/censusdata/urpop0090.txt u. s census bureau. (2000). american factfinder. retrieved november 19, 2002, from http://factfinder.census.gov west virginia primary care access plan. (june 1996). prepared by the west virginia university office of health services research for the wv department of health and human resources, bureau for public health, office of community and rural health services, division of primary care, charleston, wv. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11138745&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10438097&dopt=abstract http://www.census.gov/population/censusdata/urpop0090.txt http://factfinder.census.gov/ cultural immersion     microsoft word mcnamar_280-1651-1-ed.docx the online journal of rural nursing and health care, 14(1) 18 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 a pediatric office-based quality improvement project in a rural health clinic: retrospective evaluation patricia mcnamar, dnp, aprn, np-c 1 deborah g loman. phd, aprn, cpnp 2 1 nurse practitioner, kiowa district hospital and clinic. presently at medicine lodge memorial hospital and physicians clinic, rivervue@sctelcom.net 2 associate professor, st louis university, loman@slu.edu abstract purpose: an office-based pediatric quality improvement project was implemented to increase the number of well-child health visits and increase the documentation of pediatric quality measures in a midwest rural clinic. project description: the bright futures framework provided the structure for the project and a retrospective evaluation was performed six months after the initiation of practice changes, reminder letters, and public service announcements. chart review was performed with a convenience sample of children ages 0 to 47 months from the database of the organization that supports the family practice clinic and emergency department. the descriptive analysis included change in proportions and percentages and chi-square analyses. outcomes: there was an increase the number of well-child visits by 65% in the six month period with a wider range of ages being seen. there was a 40% response rate of visits within two months of the reminder letters. documentation increased in four out of nine quality measures with two measures remaining at 100%. validated developmental and behavioral assessment tools the online journal of rural nursing and health care, 14(1) 19 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 were used consistently. a dialogue with the local health department was established to coordinate immunization and well-child visits. conclusions: the practice changes were found to be sustainable and consistent with quality pediatric care. keywords: rural pediatric, office-based, quality improvement a pediatric office-based quality improvement project in a rural health clinic: retrospective evaluation background well-child preventive health (wcph) visits, with a consistent source of care, are the cornerstone of child primary practice and lead to fewer unmet health needs, improved continuity of care, and opportunity for earlier intervention for problems (devoe, saultz, krois, & tillotson, 2009). caregivers of children want information regarding the health and development of their children, education regarding appropriate child rearing practices, and reassurance with time to discuss those areas of importance to the parent (radecki, olson, frintner, tanner, & stein, 2009). a family centered approach is essential to successful pediatric care. it enables the child and family to develop capacities to interact successfully with the biological, physical, and social environment, and achieve one’s health and developmental potential (bethell, reuland, schor, abrahms, & halfon, 2011). early childhood development includes physical, emotional, and social aspects, with each child developing at their own pace. regular assessment using quality measures assists with finding delays or problems and allows for early intervention. pediatric quality indicators for well-child preventive care have been defined by the national committee for quality assurance (2011) and the bright futures guidelines for health supervision of the online journal of rural nursing and health care, 14(1) 20 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 infants, children, and adolescents (hagan, shaw, & duncan, 2008). the bright futures initiative was started in 1990 with funding from the u.s. department of health and human resources and services administration, maternal and child health bureau. it contained evidence-based strategies and tools to improve child health. the american academy of pediatrics has led the initiative since 2001 with input from other organizations focused on child health (hagan et al., 2008). the first three years of life are a time of phenomenal growth in all areas of a child’s development; therefore, the ages of 0 through 47 months were chosen as the focus of this project. twelve wcph visits are recommended during the first 36 months of life with nine of the wcph visits occurring between the ages 0 to 15 months (hagan et al., 2008). local problem as rural practitioners have discontinued their obstetric practices, pregnant females must travel a longer distance for prenatal care and delivery (cohen & coco, 2009). wcph visits are often performed in the same community as obstetric care, which presents an access problem for the rural dweller. time, distance, and the financial burden of travel often prevent the recommended number of wcph visits from taking place (u.s. department of health and human services ,health resources and services administration, maternal and child health bureau [usdhhs], 2011). the centers for disease control and prevention (n.d., a) estimated that 17% of the children in the united states have a behavioral or developmental problem with less than 50% being identified before starting school. these low rates of detection have created missed opportunities for health promotion/disease prevention, early identification of problems with early intervention, and anticipatory guidance in children (bethell et al., 2011). the online journal of rural nursing and health care, 14(1) 21 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 in like manner, the local midwest rural hospital and the associated rural health clinic (rhc), where the quality improvement project took place, discontinued obstetric care in the early 1990’s. within five years the rhc eliminated childhood immunization services due to vaccine costs and storage issues. the local county health department (lhd) became the sole provider of childhood immunizations in the county since centralization at one site is cost effective in the rural setting (freed, cowan, & clark, 2009; glazner, beaty, pearson, & berman, 2004; glazner, beaty, & berman, 2009). with closure of obstetric and immunization services the wcph visits at the rhc decreased and have remained at low levels (mcnamar, 2008). in 2009, local primary care providers (nurse practitioners and physicians) in the rural county were interviewed by the primary author. the local providers presumed that wcph visits were being completed at the time of immunizations at the lhd (p. wilhelm, p. meador, & r. garcia, personal communication, august 15, 2009). a follow-up interview conducted by the primary author with the lhd administrator found that wcph visits were not routinely being performed with the immunizations due to budget constraints and lack of personnel unless an obvious need was identified or upon parental request (h. hinke, personal communication, august 16, 2009). during an internal assessment at the rhc in 2009, the clinic family nurse practitioner (fnp) (primary author) determined that the rhc was underprepared to conduct wcph visits. some of the equipment for well-child care was not functional, forms were inappropriate, the developmental tool did not meet current standards, and preventive/child health promotion materials were unavailable. staff needed education regarding current wcph visit guidelines (mcnamar, 2008). the online journal of rural nursing and health care, 14(1) 22 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 setting the rhc is part of a hospital district located in a frontier county in a midwest state, with 4.3 persons per square mile (u.s. census bureau, 2012). a simple definition of frontier is a county with six or fewer people per square mile (rural assistance center, n.d.). according to the u. s. department of agriculture economic research service (usda, n.d.), the county of the rhc is classified with a frontier and remote area code (far) of 1. a county far area code of 1 designates that the majority of the population lives 60 minutes or more from an urban area of 50,000 people or more (u.s. department of agriculture, economic research service [usda], 2013). a rural urban continuum code (rucc) of nine is given to the county of the rhc (usda, 2013). a county with a rucc of nine designates a county that is completely rural, not adjacent to a metro area (usda, 2013). complex issues of isolation, distance, time, and cost to travel for care are common. the hospital district includes the rhc, a critical access hospital (cah), and a nursing home. at the time of the project, there were approximately 1629 people in the hospital district, with 104 children below the age of 5 (u.s. census bureau, 2012). the rhc had two providers that included an fnp (primary author) and a physician (md). in addition to the providers, the rhc staff included an office manager, an office assistant/nursing assistant and two registered nurses. the database of the hospital district contained 90 children who were 47 months of age or less and seen either in the rhc mainly for ill-child visits or in the emergency room (er) of the cah for ill-visits during 2011. during the first six months of 2011, 2245 patient visits occurred at the rhc, with 23 wcph visits (1%) made with 15 children. the online journal of rural nursing and health care, 14(1) 23 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 planning the office-based quality improvement project the design of the project evaluation was retrospective with a chart review six months after implementation of practice changes in the rhc. the office-based quality improvement (obqi) project was focused on children, ages 0 through 47 months, who received well-child preventive health (wcph) visits at the rhc. the aims were to evaluate change in the following key measures from the six month baseline pre-implementation period (phase 1) to the six month post-implementation period (phase 2) of the obi: the number of well-child preventive health (wcph) visits the use and documentation of pediatric quality measures for wcph visits the number of children, ages 0-15 months with 2 or more wcph visits initially, a business plan was developed and presented to the chief executive officer (ceo) that cited a potential for increased revenue from an increase in wcph visits while costs would be minimal (mcnamar, 2010). after administrative approval, the clinic infrastructure was updated. equipment necessary for well-child care services was purchased in 2010 at a cost of approximately $1156. an in-service for clinic staff on the recommended well-child preventive health visit content was presented by a pediatrician from the local state chapter of the american academy of pediatrics at no charge. use of the ages and stages questionnaire (asq) and the modified checklist for autism for toddlers (m-chat) was reviewed with the primary author (fnp), md, and nursing staff. the asq is a developmental screen for young children ages 1-66 months and has established validity and reliability (squires, twombly, bricker, & potter, 2009). the m-chat is a screening tool for autism that contains 23 items and may be used in children from 16-30 months (robins, fein, & barton, 1999). the online journal of rural nursing and health care, 14(1) 24 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 formal and informal staff meetings were conducted prior to and during implementation to update and refresh staff on wcph visit guidelines, discuss problems and answer questions. public service announcements describing the purpose and importance of well-child visits were placed in the local weekly newspaper the month prior to implementation, during the first month of the project, and then every two months during the next six months. a database of children less than 48 months of age seen in the clinic for sick or well-visits or in the emergency room for sick visits during the year prior to the obqi was developed from the hospital district records. the database was used to send reminder letters at the beginning of the project and monthly. the reminder letters focused on the purpose and importance of well-child visits and invited parents to bring their child to the rhc for an initial or subsequent wcph visit. a record of letters mailed was kept for evaluation of response rate. a brochure, specific to the rhc, was developed that described the purpose of well-child visits and was distributed at the county health fair, hospital, clinic, emergency room, and various places in the community. the quality measures selected were length/weight, age appropriate anticipatory guidance in all children, head circumference in children up to age 24 months, body mass index (bmi) beginning at two years, developmental screening using the asq at all visits beginning at age 2 months, autism screening using the m-chat in ages 17.5 to 30 months, and lead screening and referral if risk factors were present in all children age 6 months and older. the quality measures also included documentation of maternal depression screening in mothers who presented with infants ages six months or younger. the validated edinburg postnatal depression scale (epds) with 10 items was used as recommended in bright futures (hagan et al., 2008; cox, holden, & sagovsky, 1987). schaar (2011) discussed the ease of implementation of the epds into practice with its third grade reading level that made it the online journal of rural nursing and health care, 14(1) 25 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 appropriate for the general population. olson, dietrich, prazar, & hurley (2006) cited numerous studies demonstrating the adverse impact maternal depression can have on a mother’s ability to parent effectively. mothers with depressive symptoms are more likely to seek urgent care for their child and utilize more health services and are less likely to limit tv, to read to their child, and to implement safety measures (olson, dietrich, prazar, & hurley, 2006; walker, im, & tyler, 2013). time and distance to follow up care for postpartum women combined with lower economic status in rural areas are barriers to missed discussions of depression (walker et al., 2013). a preventive services prompting tool (pspt) was developed outlining the quality measures to be included at a particular age visit. the pspt was a table modeled after the recommendations for preventive pediatric health care (rpphc) (hagan et al., 2008) with ages along the horizontal axis and quality measure listed on the vertical axis. shading was provided at the intersection of the axes to indicate that a particular quality measure should be assessed at a particular age visit. the tool was given to the fnp (primary author) and md to assist with documentation. in the clinic intake room, the pspt was placed on the wall to act as a visual reminder for staff while obtaining vital signs, length/weight, or body mass index (bmi) measurement. the bright futures tool and resource kit (american academy of pediatrics [aap], 2010) was purchased and topics from the toolkit were used to prepare packets of age appropriate anticipatory guidance material to be distributed to parents at the time of the wellchild visits. the fnp and md at the rhc chose to use the asq at each wcph visit starting at age 2 months and the m-chat was used at any wcph visits between ages 17.5 months through 30 months visit in an attempt to ensure screening was done at the recommended intervals (hagan et the online journal of rural nursing and health care, 14(1) 26 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 al., 2008). after feedback from parents that it was difficult to complete all the items on the developmental or behavioral assessment in the waiting room the forms were mailed with the reminder letters starting in month three of the project. evaluation of the obqi aims ethical issues approval was obtained from the ceo of the rhc on april 6, 2012 and the university institutional review board (irb) on august 3, 2012 to conduct a retrospective analysis of the obqi project (irb protocol # 22079). the data were retrieved from the medical records by the rhc fnp (primary author) who normally had access to the information. charts were reviewed of children, ages 0 through 47 months, seen for well-child visits in phase 1 (january-june 2011) and phase 2 (january-june 2012) at the rhc upon completion of the six month project. each medical record was accessed only one time and data were recorded anonymously in an excel data file. the project and objectives are consistent with the scope of practice of an advanced practice registered nurse who is certified as a fnp (kansas state board of nursing, 2012). sample and data analysis ninety children less than 48 months of age who had visited the clinic or emergency room in 2011 were considered available for wcph visits during 2012 for the obqi. the phase 1 comparison group was defined by the children ages 0 through 47 months who had been eligible for wcph visits in 2011 (n=86), with a focus on those children who had wcph visits in the baseline period, january through june 2011. a retrospective chart review was performed six months after the implementation of the obqi project. charts were reviewed of children seen for well-child visits at the rhc in phase 1 (prior to project period) and phase 2 (after implementation). data retrieved include age, gender, the online journal of rural nursing and health care, 14(1) 27 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 ethnicity, and type of payer. additional data included: the phase the child was seen, the number of visits made in each phase, the age in months of the first visit in the phase, the number of visits made between 0 to 15 months, and the number of times each quality measure was recorded if appropriate for age. for phase 2, the date for reminder letters and if a visit occurred within two months of each reminder letter were noted. data were recorded in an excel spreadsheet and uploaded into spss (version 20). descriptive statistics were used to describe the population, including age, gender, race/ethnicity, and type of payer. the total number of well-child visits was calculated for each phase. chi square analyses and descriptive analyses, including change in proportions and percentages, were performed to calculate if there was a significant increase in the number of wcph visits and in the number of documented quality indicators between preand post-implementation. results demographics table 1 demographics characteristics total number of visits phase 1 (n = 15) phase 2 (n = 26) gender male female 6 (40%) 9 (60%) 14 (54%) 12 (46%) ethnic/racial white/non-hispanic black german/mennonite 12 (80%) 2 (13%) 1 (7%) 20 (77%) 3 (11.5%) 3 (11.5%) payer cash medicaid private insurance 1 (7%) 8 (53%) 6 (40%) 0 17 (65%) 9 (35%) the online journal of rural nursing and health care, 14(1) 28 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 the demographic characteristics are shown in table 1. the majority of children were insured by medicaid in both phases. the percentage of minority children that utilized the rhc for well child visits was greater than the percent noted in the 2010 census data for the county (whites -96%, hispanic2.4%, blacks (0.5%), and other (1%) (u.s. census bureau, 2012). outcomes there was an increase in the total number of wcph visits by 65%. in phase 1 there were 23 visits by 15 children: nine children had one visit; four children had two visits; two children had three visits. thirty-eight wcph visits made by 26 children in phase 2: 19 children had one visit; three children had two visits; three children had three visits; one child had four visits. there were 13 visits in children ages of 0 to 24 months in phase 1 as compared to 18 visits in the same age group in phase 2. during the project period the percent of wcph visits increased to 1.7% of the total number of rhc visits. there was no significant difference in the number of children aged 0 to 15 months with two more wcph visits during phase 2 as compared to phase 1. in phase 1 there were 6 of 13 (46%) eligible children with two or more visits, while in phase 2 there were 6 of 12 (50%) eligible children. the age of the child and the time of the visit needed to be considered for eligibility. in phase 2, although there were a total of 12 children aged 0 to 15 months, two children had their first visit in the last month of the project and one child had the first visit at age 15 months. there were only nine children aged 0 to 15 months in phase 2 eligible to have the suggested 9 visits. six of the nine children had two or more visits. all of the 13 eligible children in phase 1 were young enough and seen early enough in the study to have had more than one visit. table 2 shows the age range in each phase, with phase 2 demonstrating a wider range of ages. the online journal of rural nursing and health care, 14(1) 29 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 table 2 age of children in months phase (n) mean (sd) range 1 (15) 7 (7.2) 0.124 2 (26) 18.5 (11.8) 0.238 an 11.5% percent increase was seen in children who attended the rhc and had one or more wcph visits in phase 2 compared with phase 1. in phase 1 there were 15 children who had wcph visits out of 86 eligible children (17.4%). in phase 2 there were 26 children who had wcph visits out of 90 eligible children (28.9%). nine children had wcph visits in both phases. although the plan was to use mcnemar’s test on the paired data and chi-square analysis on the non-paired data, the sample size was not large enough to perform mcnemar’s test. data were not collected on those children who had wcph visits prior to phase 1. there was a 40% response to the reminder letters within two months in phase 2. ninety general reminder letters were sent during month one of the project. over the next five months, 85 age-specific reminder letters were sent and 34 wcph visits were made within two months. in addition, several visits were made after the two month period. these visits may be attributed to the general or specific reminder letters, the newspaper articles, brochures or handouts in the community, and/or public service flyers available at the immunization clinics at the lhd. the documentation of quality measures is shown in table 3. between phase 1 and phase 2 there was an increase in documentation of four quality measures, though none showed a significant increase: anticipatory guidance, bmi, use of m-chat, and lead screening. there was no change in length/weight documentation and documentation of referral in any child with a positive lead screen was 100% in both phases. though not statistically significant, bmi documentation percent increased the most. the online journal of rural nursing and health care, 14(1) 30 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 there was no increase in documentation of use of the asq or the epds. the asq was used sporadically in phase 1 and in all ages starting at age 2 months as planned for phase 2 with the goal of having at least one screen performed per child, in case the child did not return for the next scheduled wcph visit. initially, parents completed the asq or m-chat in the clinic. after feedback from parents, the forms were mailed with the reminder letters starting in month 3 of phase 2. mailings increased the number of forms returned, but some forms were forgotten at home. if the form was returned at a later time, the documentation of its return and evaluation was not recorded in the chart. table 3 documentation of quality measures quality measure phase 1 (n) = 23 phase 2 (n) = 38 % change chi-square lth/wt 23/23 (100%) 38/38 (100%) ↔ not computed ag 22/23 (95.7) 38/38 (100%) ↑ x 2(1) = 1.680, p = 0.195 hc 21/23(91.3) 27/31 (87.1%) ↓ x 2(1) = 0.237, p= 0.627 bmi 0/1 (0%) 10/11 (90.9%) ↑ fisher’s exact p = 0.167 asq 7/8 (87.5%) 16/22 (72.7%) ↓ x 2(1) = 0.716, p = 0.398 m-chat 0/2 (0%) 3/11 (27.3%) ↑ fisher’s exact p = 0.577 ls 2/23 (8.7%) 9/38 (23.7%) ↑ fisher’s exact p = 0.128 lr 2/2 (100%) 4/4 (100%) ↔ not computed epds 3/12 (25%) 3/12 (25%) ↔ not computed note. lth/wt = length/weight; ag = anticipatory guidance; hc = head circumference; bmi = body mass index; m-chat = modified checklist for autism in children; ls = lead screening; lr = lead referral; epds = edinburgh postnatal depression scale; ↑ = increased; ↓ = decreased; ↔ = no change. discussion summary the obqi project had several outcomes that were clinically significant with several potential child and organizational benefits noted in phase 2. there was an overall increase in the number of wcph visits with a wider range of ages and more children ages 0 to 24 months having at least one visit. eleven new children had wcph visits including three newborns. the age-specific reminder letters proved beneficial with a 40% response within two months of the the online journal of rural nursing and health care, 14(1) 31 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 mailings. parents, both new and returning, often commented about an increased awareness of the benefits of wcph visits. several parents who brought their children to the rhc for their first wcph visit stated they became aware of the rhc ability to provide the service through the public awareness campaign and/or the reminder letters they received. documentation of four quality measures showed an increase with a 90% increase in bmi documentation—one of the measures required for meaningful use with electronic health records (centers for medicare and medicaid services, n.d.). documentation of two measures remained at 100% and one remained at 25%. through mailing of the developmental and behavioral tools, the clinic is now consistently using standardized tools across a large range of ages beginning at age 2 months. through informal discussion with the primary author and other staff members during phase 2 and after the obqi was ended, several parents stated they preferred “one stop shopping” where they could complete well-child visits and immunizations all at the same time. if that was not possible, often a choice was made. immunizations are required for daycare and school admission; well child visits are not. frequently, due to work schedules, time, distance and travel costs, immunizations at the lhd located 25 miles from the rhc were chosen and well-child visits were not seen as a priority. after completion of the obqi project, the primary author began discussion with the administrator of the lhd in an effort to find a way to provide the wcph visits by the rhc and the immunizations by the lhd at the same setting. costs and revenue have been tracked. in the pre-implementation phase, approximately $1156 was spent upgrading the physical infrastructure with the purchases of electronic infant scales, a yearly subscription to a professional pediatric online care resource, updated asq, and pediatric visit documentation forms. ongoing costs are estimated at $250 annually for the online resource. the utilization of the pediatric portion of the ehr will eliminate any further purchases the online journal of rural nursing and health care, 14(1) 32 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 of documentation forms. there were no staff additions and staff were able to incorporate the time to send the reminder letters within the work week. the paper and postage of the monthly reminder letters continue at the cost of approximately $10/month. the revenue from the 2011 phase 1 wcph visits was $1710, and the revenue from the 2012 phase 2 wcph visits was $2881. rhc access to the state immunization registry has been beneficial for the children and the lhd. during wcph visits, fnp, md, and nursing staff are able to counsel parents regarding missed or upcoming immunizations and provide information when local immunization clinics are scheduled. in addition, the hospital’s infection control nurse has begun entering adult immunizations into the state immunization registry and has improved the reporting of adult immunizations. the rhc staff began recording the adult and pediatric immunizations from the paper charts into the electronic health record. during phase 2, implementation of an electronic health record (ehr) began system wide at the rhc and hospital. with the emphasis on improving wcph visits, the project increased the familiarity and use of the pediatric portion of the ehr and improved documentation by the rhc’s providers and registered nurses. relation to evidence rural children are more likely to be poor and live below the poverty level (national rural health association, n.d.). children in poverty are more likely to have physical health problems such as low birth weight or lead poisoning, and behavioral and emotional problems (usdhhs, 2011). children in poverty also tend to exhibit cognitive difficulties, as shown in achievement test scores, and are less likely to complete basic education (usdhhs, 2011). table 4 shows data for the county the rhc serves. the online journal of rural nursing and health care, 14(1) 33 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 table 4 rural risk factors indicator rhc county other frontier counties % in poverty* 19.4% 19.61% % <6yrs in poverty** 11.7% (no data available) low birth wt infants* 8.11% 7.43% elevated blood lead levels (2008)*** 2.3% of the 43 tested (available n= 290) 53.10% risk d/t housing** youth tobacco use* 15.96% 13.78% hospitalized for mental health* 0.91% 0.78% high school graduation* 91.8% 89.54% * (kansas action for children, 2012) **(healthy communities institute, n.d.) ***(centers for disease control and prevention, n.d., b) receipt of a yearly wcph visit is estimated to be 85.9% of all eligible children in small rural areas (rucc greater than 6.1) (usdhhs,2011). that statistic is higher at 93.6 % when looking at the ages 0-5years in small rural areas (usdhhs,2011). prior to the obqi project the rhc was well below that statistic with only 17.4% of the eligible children receiving a yearly wcph at the rhc. the obqi project increased that percent by 11.5%. it is suggested that many of the adult illnesses and chronic diseases have their start or basis in childhood (coker, thomas, & chung, 2013). coker et al. (2013) contend that well-child preventive health visits could change patterns that normally would lead to adult morbidity and mortality. in the rhc’s county the rate of adults diagnosed with diabetes is 20.4%, which is above the national average of 8.3%. the prevalence of hypertension, the number one cause of stroke and other co-morbid conditions is 44.3% in the rhc’s county. the county of the rhc ranks third in the state for prevalence of chronic lung disease and accounting for 53.3 deaths per 100,000 with cancer deaths being the number one cause of death with 225.7 deaths per 100,000 population (healthy communities institute, 2013). childhood interventions, including wcph visits, have the potential to promote healthy lifestyles and influence later adult health in rural areas. the online journal of rural nursing and health care, 14(1) 34 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 anecdotal feedback to the rhc staff from parents who brought their children to the rhc for wcph revealed parental satisfaction with the amount of time spent by the provider, with parental questions solicited and addressed, health and developmental assessments reviewed and discussed, and anticipatory guidance provided on child rearing practices. understanding why parents bring their children for well-child care is important for initial and continued care (radecki et al., 2009) and confirms that time spent during visits increases parental satisfaction (halfon, stevens, larson, & olson, 2011). the consistent use of standardized developmental and behavioral tools led to early identification of problems or delays and allowed early referral and intervention. three children were referred for evaluation of developmental delays and one child for growth delay. lannon et.al, (2008) assessed the ease of implementing practice changes in 15 pediatric primary care practices. six office components to improve preventive and developmental care were compared before and after an educational intervention. the six components included the “preventive services prompting system, structured developmental assessment, parental strength and needs assessment, recall/reminder system, community linkages checklist, and identification of children with special healthcare needs” (lannon et al., 2008, p 166). the last three components were most frequently adopted. the intervention project of lannon et al. (2008) found that rural practices had the greatest degree of success of implementing practice changes based on the screening activities listed in the rpphc from bright futures (hagan et al., 2008). evaluation of the practice changes at the rhc illustrated that implementation of key components of the framework was possible with a small number of clinic staff and providers. reminder letters increased the number of visits made and increased the number of young children having preventive visits. use of the pspt was instrumental in identifying the quality areas for the online journal of rural nursing and health care, 14(1) 35 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 assessment and documentation by the staff. the strengthening of community linkages with the lhd provided opportunities to find solutions to improve the delivery of wcph visits and immunization rates. the consistent use of developmental and behavioral tools and quality measures documentation increased the identification of children with special needs with three children referred for further evaluation during the project period. the eliciting of parental concerns and discussion of age appropriate anticipatory guidance furnished a time to assess parental and child strengths and needs (lannon et al., 2008). barriers and limitations evaluation of the project occurred after six months and many office-based changes were made at the same time. it will be important to track the number of well child visits, parental feedback/satisfaction using a formal systematic method, as well as associated costs over a longer time frame. the low volume of children seen did not allow for staff to stay familiar with wcph visit guidelines. the preventive services prompting tool was available to assist with age-specific visit content but was not utilized to its full extent. this was evidenced by the slight decrease in the percent of young children with documentation of head circumference. finding time to include all the necessary components in a visit and a preference for brief screening tools (rare use of the epds) by the providers were identified as barriers to the project. in discussion by the primary author (fnp) with md at the rhc it was confirmed maternal depression screening was being performed but more often with a non-validated screening tool. lack of belief that the epds would change the screening outcomes led to low use of the validated tool during the wcph visit. this finding is consistent with patterns in other rhcs (tudiver, edwards, & pfortmiller, 2010). it was then decided by the fnp and md at the rhc to use the epds only at the postpartum follow-up visit with the mother to assess for depression. the online journal of rural nursing and health care, 14(1) 36 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 the patient health questionnaires (phq-9 & phq-2) are alternative brief validated depression screening questionnaires (aap, 2010) with the phq-9 available in english and 30 other languages (american psychological association, n.d.) and are being evaluated for use during the wcph visits. sustaining the reminder system by the clinic fnp (primary author) was time consuming. the rhc staff is working with the electronic health record (ehr) software provider to implement a recall and reminder system through the ehr. at the time of the project implementation, training for use of the ehr also took place. the initiation of ehr by the providers competed for time and attention and may have decreased attention to the new practice changes. since charts were only reviewed once at the end of the project period, in agreement with the irb protocol, there was no baseline data of quality measures documentation collected prior to the beginning of the project and charts were not reviewed on a regular basis during the project. there was no clear distinction between new and returning patients or families and many of the patient numbers were too small to conduct statistical analyses. as the infrastructure was improved and staff education was provided regarding pediatric guidelines during the two years prior to phase 2, there was a gradual use of aspects of the updated wcph visit format. the presence of the proper equipment, tools and knowledge may have improved the quality measures in the phase 1 outcome measures. implications for the future positive provider and staff feedback has encouraged rhc staff to sustain the strategies from the obqi project. alternatives to mailing reminders are being explored. when a wcph is finished, parents are encouraged to make the next age appropriate appointment and asked for the online journal of rural nursing and health care, 14(1) 37 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 their preferred method of reminder. patient contact information is updated at the time of the visits. options within the ehr are being explored so staff can send visit reminders in the patient preferred method. the rhc does not have the ability to have parents fill out the developmental screening tools electronically prior to wcph visit but this approach is being explored. the rhc staff are also looking at other strategies to improve the pediatric care. one such area is culturally competent care. as the mix of cultures changes in the united states including the rural areas, all health care professionals must be sensitive to the cultural views of health, illness, and treatment approaches (gobble, 2009). the rhc sees several non-english speaking hispanic and german-mennonite families. due to language barriers both during the visit as well as with written materials, satisfaction may be less in the minority groups of parents (grinberg, 2011). the clinic staff plans to review various options, including translated printed materials and interpretive services, to address the diversity in the community and provide responsive care. through a congressional oversight, the rhc is not currently eligible for meaningful use incentives from use of ehr because of the rural health clinic status (porter, 2011). the clinic will be poised to receive the incentives when the oversight is corrected due to the improvement in office-based practice and documentation and the use of the ehr for wcph visits. this midwest state in which the rhc is located will be moving forward towards a managed care model for the medicaid population in 2014. this will potentially increase the number of parents seeking care for their children. there is a further emphasis on the medical home model that includes access to quality care that is continuous and comprehensive and promotes preventive health and care coordination (hagan et al., 2008). the obqi project demonstrates the importance of a medical home model for children and has implications for expansion to the adult population. the online journal of rural nursing and health care, 14(1) 38 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 the evaluation of the obqi project at the rhc has shown that practice changes and public education can improve the use of pediatric preventive care. collaborative approaches are being explored with the lhd and rhc staff on options to provide county supported immunizations and wcph visits by the rhc on the same day, in the rhc community. ongoing discussion includes issues such as billing for the wcph visit and the vaccines as well as vaccine transport and storage. it is hoped that the joint effort between primary care and public health will result in the full service of care, accessed closer to home. acknowledgements the authors wish to thank alden vandeveer, paul wilhelm, melissa stroh, kristi coggins, heather rankin, tami hill, lynne johnson, janell goodno, and staff of the kiowa district hospital and clinic. references american academy of pediatrics.(aap). 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(n.d.). frontier frequently asked questions. what is the definition of frontier? retrieved from http://www.raconline.org/topics/frontier/frontierfaq.php the online journal of rural nursing and health care, 14(1) 42 http://dx.doi.org/10.14574/ojrnhc.v14i1.280 schaar, g. l. (2011). is your new mom depressed (did you ask?). the journal for nurse practitioners, 7(10), 879-880. squires, j., twombly, e., bricker, d., & potter, l. (2009). ages and stages questionnaires: users guide. (3rd ed.). retrieved from brookes publishing http://agesandstages.com/pdfs/asq3_technical_report.pdf tudiver, f., edwards, j. b., & pfortmiller, d. t. (2010). depression screening patterns for women in rural health clinics. the journal of rural health, 26(1), 44-50. http://dx.doi.org/10.1111/j.1748-0361.2009.00264.x u.s. census bureau. (2012). state and county quick facts. retrieved from http://quickfacts.census.gov/qfd/states/20/20007.html u.s. department of agriculture, economic research service (usda). (n.d.). rural classifications. retrieved from http://www.ers.usda.gov/topics/rural-economypopulation/rural-classifications.aspx#.uoerfxbkyso u.s. department of health and human services (usdhhs), health resources and services administration, maternal and child health bureau. (2011). the health and well-being of children in rural areas: a portrait of the nation 2007. rockville, maryland: u.s. department of health and human services retrieved from http://mchb.hrsa.gov/nsch/07rural/moreinfo/pdf/nsch07rural.pdf walker, l. o., im, e., & tyler, d. o. (2013). maternal health needs and interest in screening for depression and health behaviors during pedeiatric visits. journal of pediatric health care, 27(4), 267-277. http://dx.doi.org/10.1016/j.pedhc.2011.11.008 microsoft word dunn_column 3   online journal of rural nursing and health care, vol. 10, no. 2, fall 2010  editorial creating healing environments: a challenge for nursing linda dunn, dsn, rn, cnl editorial board member in my very first editorial, i issued a personal challenge to all readers to find time each day to nourish one’s spirit. in another editorial, i asked nurses to use the fica tool for both personal assessment of one’s spiritual history as well as that of patients. in this editorial, i again want to challenge nurses to be diligent in providing spiritual care to all patients as well as to oneself. after all, nurses are perhaps the ones who spend more time with patients than any other member of the healthcare team. if indeed nurses are instruments of healing, then we must be spiritually well ourselves before we can be positively present with the patient. the human spirit is what sustains a person and what enables one to cope when stressed or challenged by daily life (puchaski & mcshimming, 2006). as you well know, america’s healthcare system is in crisis. many agencies are working short staffed; many healthcare providers are impelled to increase the number of patients seen daily; patients feel the impact with shorter physician visits or less attention by nurses, social workers, and other healthcare providers. while healthcare providers may experience burn out, patients are feeling alienated (puchalski & mcskimming, 2006). so how will nurses protect themselves from burn out and at the same time provide patients with the spiritual care they deserve? i believe what we need is healing environments. this concept has weighed heavily on my mind in recent weeks. in conducting a database search, i could only find one article that actually addressed this term. puchalski & mcskimming (2006) reported on a study they conducted with two organizations for the purpose of identifying a solution to the depersonalization of healthcare. as a result of this study, they created the healing environment intervention to reintergrate spiritual awareness into the role of each health care provider. on a smaller scale, i began to think about how nurses could create healing environments for themselves and their colleagues. stop for a moment and think about where you work. if it is a hospital-type setting, there is probably a chapel as well as chaplain support. these services are for staff as well as patients. think about the unit on which you work: staff restrooms, break rooms, and yes, even the space around the time clock, are great places to post poems or positive thoughts for the day that could encourage each other. look around for bulletin boards or sites to place a bulletin board. post “gotcha’s” of staff who were “caught” doing good deeds for others without being asked, for those who went out of their way to assist a patient or family member, or positive comments that patients may send in a thank you note or a hospital evaluation of care. look around the perimeter of your work place…do you have an area to create a meditation garden? this could be a great project that could be on a continuum from 4   online journal of rural nursing and health care, vol. 10, no. 2, fall 2010  simple to elaborate. items might include a water fountain or birdbath, a garden bench, flowers/shrubs, or a birdfeeder. if we can provide outside smoking areas, seems to me that we could provide a place to meditate and reflect about the stresses of the day and “regroup” before going home. then at home, find your own area to have quiet time, such as a corner of your favorite room. other opportunities include forming support groups, card ministries, book clubs, prayer groups, yoga classes, exercise groups … even a jail ministry can be meaningful!! the list of possibilities is endless. be creative, be an encourager, help stomp out burn out by creating healing environments. refreshed spirits are better prepared to provide spiritual care regardless of the setting. then share the referenced article with your agency administration for strategies to create healing environments…patient satisfaction will definitely be enhanced and staff turn-over might be reduced! references puchalski, c.m., & mcskimming, s. (2006). creating healing environments. health progress, 87(3), 30-35. [medline] microsoft word grundy_216-1350-1-ed.docx online journal of rural nursing and health care, 13(1) “you have to rely on everyone and they on you”: interdependence and the team-based rural nursing preceptorship olive j. yonge, rn, phd 1 florence myrick, rn, phd 2 linda ferguson, rn, bsn, pgd (cont ed.), mn, phd 3 quinn grundy, phd(c), rn 4 1 professor & vargo distinguished teaching chair. university of alberta, oyonge@ualberta.ca 2 professor & associate dean, university of alberta, flo.myrick@ualberta.ca 3 professor and director of centre for the advancement of the study of nursing education & interprofessional education (casnie), college of nursing, university of saskatchewan, linda.ferguson@usask.ca 4 university of california, san francisco, quinn.grundy@ucsf.edu abstract purpose: a photovoice study was conducted to construct a narrative of teaching and learning to nurse in rural settings as seen through the eyes of nursing students and their preceptors. this article explores the rural context of team-based preceptorship; that is, how interdependence characterizes the quality of the transition from student to professional support networks, and in particular how professional, team-based networks function in rural settings. methods: photovoice is a participatory research method wherein participants document their lived reality through photography, and supply narrative context to the photographs through group discussion. four students and their four preceptors, based at health care sites in rural western canada, were supplied with digital cameras with which they took over 800 photographs over a online journal of rural nursing and health care, 13(1) ten-week preceptorship course. preceptors and students were active participants in generating the thematic data analysis. findings: the central thesis of this project was that rural nurses bring a strong sense of community ethos to clinical practice. one aspect of this community ethos was the importance of the rural health care team in precepting a nursing student. students experienced a transition from their urban, school-based networks to rural-based, professional networks; preceptors and the interdisciplinary team supported students through this transition. as students gained independence from the university and emerged from their student status, they were integrated into the rural interdisciplinary team and community, greatly facilitating their transition to graduate nursing practice. conclusions: more than any other single aspect of rural nursing, we feel teamwork (and community ethos, by extension) is the key to promoting rural preceptorships and rural careers. this model for preceptorship has implications for selecting rural placements and may be transferable to other settings. ultimately, this knowledge can be used to strengthen student placements in rural areas with implications for the recruitment and retention of nurses in rural areas. keywords: photovoice, rural preceptorship, participatory research method “you have to rely on everyone and they on you”: interdependence and the team-based rural nursing preceptorship since the earliest days of its establishment by nursing coordinators, preceptorship has encompassed a variety of models (myrick & yonge, 2005). widely used in a number of countries to aid the transition of senior undergraduate students to professional practice, it is online journal of rural nursing and health care, 13(1) traditionally defined as a one-to-one relationship between a staff nurse and a student during an intense, time-limited clinical experience, with a member of the nursing faculty supporting the process of student learning and evaluation (udlis, 2008). while it is traditional for one or two nurses to precept a student in any clinical area, some students have been precepted by nonnurses, and others by specialized teams. typically one team member serves as the primary contact person as required by the educational institution. in rural settings, where all disciplines work together, it is not unusual for the entire health care team to oversee a nursing student, even if only one or two team members are designated preceptors (sedgwick, 2011). because the oneto-one relationship is recognized as the gold standard for the preceptorship model (luhanga, billay, grundy, myrick & yonge, 2010), the implications of team-based preceptorship may be highly context-dependent. this article explores the rural context of team-based preceptorship; that is, how interdependence characterizes the transition from student-based support networks to professional ones, and in particular how professional, team-based networks function in rural settings. we emphasize the importance of team cohesion, and of student integration with the greater rural community, to a successful preceptorship experience. background the rural setting is advantageous for nursing students on a number of accounts. the ‘expert generalist’ nature of rural nursing (bushy & bushy, 2001) fosters a wide range of competencies and clinical experiences, and the kinship-like, community bonds around and within rural health care teams constitute an informal, psychosocial support network (hegney, mccarthy, rogersclark, & gorman, 2002; kulig et al., 2009). these networks are welcoming places for students, not least because rural health care teams are eager to recruit new nurses in an era of critical staff shortages (world health organization [who], 2010), and/or create advocates for rural online journal of rural nursing and health care, 13(1) specialization. students who do undertake rural preceptorships are typically longstanding rural insiders, often from the communities where they choose placement, although this does not invalidate the importance of prior, contextual training in rural nursing (edwards, smith, courtney, finlayson, & chapman, 2004). research has also shown that the choice of clinical practicum placement prior to graduation influences a nurse’s choice of practice setting (charleston & goodwin, 2004; edwards et al., 2004), and moreover, that positive preceptorship experiences in rural settings are associated with intention to practice in smaller settings (coyle & narsavage, 2012). due to the fact that many students face relocation from urban centers to rural communities to pursue these opportunities, financial assistance or assistance in-kind can be crucial to the success of a preceptorship (neill & taylor, 2002; yonge, hagler, cox & drefs, 2011; yonge, ferguson & myrick, 2006). these measures are among the recommendations adopted by the who (2010). while researchers of preceptorship have typically focused on individual nursing students and preceptors, or on the student-preceptor-faculty triad, this focus has lately shifted to the teaching and learning context, and the interdisciplinary environment in which the preceptorship experience takes place. for example, in a survey of eight students, webster et al. (2010) found it was important for their respondents to feel part of a team. nursing students enrolled in a senior, undergraduate rural nursing course in west virginia cited the opportunities to practice as part of an interdisciplinary team, and to interact with students of other health professions, as one of their most valuable learning experiences (coyle & narsavage, 2012). sedgwick (2011), using focus groups and interviews, found that rural, interdisciplinary team members were always open to informing students about their roles and responsibilities, upon request; furthermore, if the preceptor was a team player, the student was more likely to be welcomed and supported by the online journal of rural nursing and health care, 13(1) other disciplines. in an ethnographic study, sedgwick, yonge and myrick (2009) found that nursing students undertaking rural preceptorships were eager to become team members and readily disclosed information about themselves to gain acceptance. furthermore, in both their orientation to the rural setting and the evaluation of their performance, these students gained a new appreciation of team effort. in the current study, we employed photovoice to construct an account of rural preceptorship through the eyes of senior undergraduate nursing students and their rural preceptors. in this article, we explore the contributions of the rural health care team to preceptorship, and the effect of rural context on the one-to-one preceptor-student relationship. method photovoice is a participatory research method wherein participants document their lived reality through photography and supply narrative context to the photographs through group discussion. our participants took photographs of their experience, removed the ones they did not want to share with the researchers, then explained to the researchers which ones they had chosen and why. this process occurred at the midpoint and endpoint of each student’s ten-week practicum. the justifications for photovoice are: 1) it fosters participant reflexivity; 2) it enables the communication of tacit knowledge through images and narrative; and 3) its end products— such as exhibits, photo-essays and online slideshows—are more accessible to stakeholders and policymakers (wang & burris, 1997). our primary aim was to construct the story of teaching and learning for students and preceptors in rural settings. context the context for this project comprised rural health care sites and the unique characteristics of rural practice, which we have defined as autonomous practice indicative of smaller centers; online journal of rural nursing and health care, 13(1) complexity of work; distance from the educational institution and supervising faculty involved; limited access to educational experiences and resources; and difficulty in recruiting nurses to the setting (bushy & bushy, 2001; macleod, kulig, stewart, pitblado, & knock, 2004; yonge et al., 2006). we selected this setting with the challenges of rural nursing and the uniqueness of the rural environment in mind, while recognizing the need to enhance rural preceptors’ development as clinical educators. six rural sites—four acute careand two community-based—were selected across two western canadian provinces, based on students’ chosen placements; it was understood however, that each of the six sites differed in their rural contexts. these contextual differences were considered in the analysis of data, and added to the breadth and complexity of the narratives derived from each site. ethics we obtained ethical approval from our respective university research ethics boards, rural acute and community care sites where the research was conducted, and the regional health authorities overseeing these sites. as the nature of photographic data renders participant anonymity problematic (harrison, 2002), we obtained signed permission from all persons taking or appearing in photographs for their use. pseudonyms have been used in the presentation of the study findings. recruitment and orientation at our invitation, clinical instructors in two western canadian undergraduate nursing programs recruited four senior nursing students undertaking rural preceptorships, along with their four rural preceptors. mindful of bias, we took care to select only participants with whom we had no prior academic or professional relationship, and assured these individuals they would be free to withdraw from the study at any time. students were approached by the clinical online journal of rural nursing and health care, 13(1) instructor, not a member of the research team, who in turn invited their preceptors to participate. our sample comprised four senior undergraduate nursing students: one female and one male in alberta, one female and one male in saskatchewan. their four preceptors (all female) comprised two acute care rns in alberta, an acute care rn and a home care rn in saskatchewan. all the participants were caucasian. we equipped these primary participants with inexpensive digital cameras, theirs to keep upon the conclusion of the study and encouraged them to share the cameras with friends, family, and other health care team members to maximize photographic coverage of each rural site. wang and burris (1997) emphasize the importance of a ‘facilitator,’ namely a community expert who 1) liaises between the researchers and the participants; and 2) directs group discussions in which participants supply context for their photographs. members of the research team took on this role, being familiar with the rural health care context as clinical instructors and preceptorship coordinators. the facilitators were responsible for conducting site orientations as well as moderating the midpoint and endpoint discussions. following consultation a professional medical photographer regarding key ethical, legal and cultural considerations, our facilitators led open-house orientations at each research site. these orientations were tailored to promote the participation of as many members of the health care team and rural community as possible, while maintaining ethical standards for visual research methods. the orientations covered topics such as camera operation, basic photography skills, consent procedures and power dynamics within photography (wang & burris, 1997). we asked our participants to consider themselves photojournalists in their workplaces and communities, with the prerogative to document whatever they felt was relevant and be as online journal of rural nursing and health care, 13(1) creative as they desired. digital technology would enable participants to review and delete photographs they did not wish to share with us. data collection, analysis and rigor two stages of data collection took place: a four-week acclimation period, followed by a further four weeks of more intensive exploration of themes emerging from a midpoint discussion (wang & burris, 1997). as the research design was participatory, participants were responsible for selecting which of the photographs taken would be included as data, according to their discretion. during the discussion sessions, participants made comments suggesting that they had been selective of which photographs to include; use of digital technology greatly facilitated participants’ discretionary judgment as it allowed them to take numerous photographs and to delete them easily prior to sharing the images. by the end of the ten-week preceptorship, the participants had provided the research team with over 800 digital photographs. a discussion session followed each phase of data collection. to facilitate group discussion and participatory analysis, the photographs taken by participants were compiled into powerpoint slide shows. facilitators guided midpoint and endpoint discussions with open-ended questions such as, “what do we see here?” and “what does this photo mean to you?” afterwards, recordings of these discussions were transcribed for analysis. preceptors and students took part in data analysis as they collaborated with the facilitator to select meaningful photographs; contextualized the photographs through narrating the selected photographs; and codified the images through identification of relevant themes, issues or theories that emerged from their photographs (wang & burris, 1997). this dialogue is central to the photovoice methodology and occurs best in a group setting, where both individual and collective meanings can be elicited. with the aid of qualitative research software, nvivo8, we developed thematic categories through online journal of rural nursing and health care, 13(1) the coding of transcripts and images. a third and final session was conducted at each site, wherein we presented the overarching thematic findings, including images taken at the other sites, to participants as a powerpoint slideshow. this provided validation of the themes and gave participants the opportunity to expand on their previous commentary and to substantiate the data from other sites. these discussions were also recorded and transcribed and the transcripts were used to further refine and conceptualize the thematic categories. the long-term, in-depth engagement with these participants and their rural sites, including the multiple, collective conversations, produced a rich and rigorous dataset. findings the central thesis of this project was that rural nurses bring a strong sense of community ethos to clinical practice. one aspect of this community ethos, here explored in detail, was the importance of the entire rural health care team in precepting a nursing student. throughout the preceptorship, students experienced a transition from urban-based networks, formed during their nursing program, to rural-based, professional networks; preceptors and the interdisciplinary team supported students through this transition. as students gained independence from the university and emerged from their student status, they were integrated into the rural interdisciplinary team and community, greatly facilitating their transition to graduate nursing practice. transitioning to rural support networks one of the more compelling patterns to emerge was the students’ common experience, upon commencing their rural practica, of being cut off from their accustomed urban, schoolbased support networks. “i had one phone call with my [clinical instructor] on my final evaluation after emergency,” said becky (student), “but that was the only contact i got.” becky’s online journal of rural nursing and health care, 13(1) rural preceptor was particularly irked by this situation: “i think the student would have liked to hear [from the faculty person]. that would have been nice. just because [students are] so used to hearing feedback.” remoteness from peers was another aspect of the students’ perceived rural isolation. “you [get] used to doing clinical groups [with] other students, and you can complain about the instructor, or complain about the person that you had to be with that day, or what really went excitingly well,” becky remarked. “here it was like, ‘well, i can’t talk to my boyfriend because it’s confidential, and he won’t care or understand what’s going on.’ so yeah, i found it comforting to talk to the other nurses, but it would have been nice to brag to other students.” for nursing students unaccustomed to the periodic stresses of acute care, peer support was hardly a trivial matter, as becky hastened to add. “i know one student saw [an] infant code; it was her first day and she was traumatized by it. she really took it hard, and she had no one really to talk to except for the co-workers.” the rural nurse preceptors who took part in the study were sympathetic to this predicament, and spoke of their constant mindfulness with regard to their preceptees’ psychosocial wellness. “i always made sure what she looked like,” said margot (rn), becky’s preceptor; “is she having a good day, or is she dragging her butt out the door?” more important, the preceptors endeavoured to pull their students into the social fabric of the rural workplace, which they characterized as open and collegial. angelina (rn) said, “we have social night … open to everybody in the hospital. on friday nights at [the pizza place], everybody gets together. it’s a drop-in; if you want to come, you come.” a crucial element of this camaraderie was the common, community bond shared by all staff members, which tended to undercut any traditional hierarchies. “some of the doctors we call by their first names, because that’s what they’ve online journal of rural nursing and health care, 13(1) requested,” added angelina. “they know us; they are [part of the community]. . . [two of the doctors] have farms here; they have cattle and stuff.” for their part, the students—even those from rural backgrounds—were struck by the democratizing, community ethos of the rural health care team. “in [the city], we never really got to talk to the physio [therapists], or occupational therapists, or social workers, and here… everyone works together. it’s really refreshing. figure 1: "[the doctors] know us...[they] have farms here." the doctors aren’t intimidating…. it’s not a hierarchy,” remarked becky (student). tellingly, one of our onsite photovoice discussions was attended by the hospital administrator, who had taken an interest in the student’s progress and even assembled the staff for his group photo. “you helped me get that all organized,” peter (the student) marveled. this young man was clearly gratified to have the personal attention of a busy administrator. working together and for each other the most pertinent aspects of community ethos, vis-à-vis teaching, were mutual trust and regard amongst members of the health care team. preceptors implicitly trusted their colleagues to help guide and evaluate the students, resulting in a broader preceptorship experience. in one instance, unforeseen circumstances necessitated a switch in personnel: “i was sick. i was a online journal of rural nursing and health care, 13(1) patient… so that’s why… [peter] got some good experience with a really experienced preceptor” (angelina, rn). more often, preceptors delegated their colleagues in the effort to optimize the students’ time: if i have six nights in a row—nights can be quiet here, or they can be action-packed—i won’t make my student work for six nights. i will ship them everywhere else… we had [her] in just about every area of the hospital. just to give them some variety, so that on those slow days, you’re not just sitting doing nothing. you’re still gaining lots of skills in other areas. (donna, rn) putting the students’ needs first was a recurrent theme in preceptors’ remarks. becky’s preceptors, who had earlier expressed frustration with the lack of faculty involvement in her preceptorship, repeatedly went out of their way to track their students’ progress amongst the entire team: i hear what’s going on and [i] know where she’s going, but know i need some examples [for the assessment], so then [my colleague] says, ‘well don’t worry about it, i’ll write in what i want and then you write in what you want,’ and i said, ‘oh sure, that’ll work you know.’ so, [the] poor [student] has got all these people that have evaluated her. she had two instructors, two preceptors in her first mental health [practicum] and now she’s got two more of us, so we’re all going to be adding to this very thick assessment. (sarah, home care rn) one of sarah’s photographs stood out as a symbolic projection of this attitude: the entire home care team gathered in their office for a photo with her student becky, whom they sat in the center of the group. online journal of rural nursing and health care, 13(1) extensive feedback, and experience with multiple situations across an entire hospital, are invaluable assets for senior nursing students facing imminent licensure examinations— something the preceptors, themselves practicing nurses, did not forget. the students acknowledged that this onslaught of information was initially overwhelming, but they quickly grew to appreciate their preceptors’ willingness to hand them off to colleagues. becky spoke gratefully of the “crash course on wound care products” she received from the hospital specialist one afternoon. rodney, another student, recalled being “blown away” by the level-headed ability of one rn (not his preceptor) to turn an incoming motor vehicle accident (mva) into a teachable moment: [she said,] ‘we’ve got an mva coming in… the eta’s ten minutes. let’s go into the outpatient room. [we’ll] go step-by-step through the process of what we can expect to do in an mva,’ and that’s exactly what we did. we did that twice— actually two or three times—and on top of that, after the situation, the nurse asked if there’s anything we could have done differently, and she got the whole team to debrief the situation. online journal of rural nursing and health care, 13(1) figure 2: "we're all going to be adding to this very thick assessment." (sarah, rn) occasions such as this exemplified donna’s (rn) characterization of the rural preceptor role as that of ‘quarterback’ amidst an entire staff committed to precepting. for the students, the most significant learning outcome was the experience of becoming a team insider. “if you’re willing to work, you’re fair, and you treat people well, you’ll do well here,” said donna (rn). “it’s a lot easier than you think, because people are willing to give you a chance, and [they] expect the best.” both preceptors and students characterized the process of student integration into the team as welcoming, particularly if the student demonstrated a favourable attitude toward work and team-oriented behaviors. viewing a photograph of herself with two staff members, shannon (student) remarked, “there’s the girls working together. [it says] we’re a team… because maggie’s an lpn [licensed practical nurse] but you don’t consider her an lpn; she’s part of your team. sharon’s a supernumerary so she’s just a new nurse there.” shannon’s words reflect a vital insight into frontline rural health care: designations are secondary. the staff treated her as an equal, and she responded in kind. peter (student), whose online journal of rural nursing and health care, 13(1) initial shyness prevented him from taking a picture of another person for several weeks, found himself acting as a de facto nurse on an evening when the hospital was short-staffed (another example of a rural frontline reality). this experience, borne of a crisis, proved transformative. “i tagged along quite a bit too closely at first,” peter admitted, “but by the end you’re given a lot more freedom, so you have to learn how to rely on everybody, and they have to learn to rely on you.” for these students, the opportunity to develop their own sense of teamwork in practice proved to be the greatest incentive to return to rural health care as fully-fledged nurses. “you get a lot more support from the staff, and the physicians as well,” explained peter. “i guess there’s that sort of bonding experience you have, you know, that maybe you wouldn’t have in other areas.” discussion for most students, a practicum is a decisive turning point in a program of study. if we take into account the isolation initially experienced by our participating students, a rural nursing practicum begins to resemble a crisis in its truest sense: a time of peak uncertainty and a liminal rite of passage. in the absence of classroom and peer support, these students had to make the intuitive leap, as peter (student) expressed above, that teamwork is driven by mutual reliance. online journal of rural nursing and health care, 13(1) figure 3: "there's the girls working together. [it says] we're a team. (shannon, student) mills, francis, and bonner (2008) state that rural nurses “are motivated by a need to look after each other” (p. 602); the same could be said of rural populations in general, whose survival is predicated on such reliance. we submit that attuning a student into this community ethos is the signature outcome of a successful rural preceptorship, and the findings of other studies (sedgwick, yonge & myrick, 2009; webster et al., 2010) tend to support this viewpoint. perhaps we should not be too quick to indict the faculty members who left their rurally placed students to discover this for themselves. the experience of being cut off from accustomed supports may have actually facilitated the growth of the preceptor-student relationship and fostered student independence from their instructors. this observation has been echoed in other studies of rural preceptorships (sedgwick & yonge, 2009; yonge et al., 2006). while such rotations pose additional challenges to faculty involvement due to geographic distance from the university, this may also be a part of the natural progression of preceptorship; students and preceptors can be coached through this transition. online journal of rural nursing and health care, 13(1) while prior contextual training of the sort advocated by edwards et al. (2004) might have been welcomed by our participants, their remarks all pointed toward the implication that rural teamwork can only truly be understood through firsthand experience, and running a gauntlet of unpredictable situations. this is where the support of the preceptor, and indeed the entire health care team, became crucial in assisting students to navigate the uncertainties inherent in rural nursing. by its very nature, rural nursing practice enables a wide variety of learning experiences for students (bushy & bushy, 2001). van hofwegen, kirkham and harwood (2005) see this as a layering of clients in every stage of life, needing every type of care; interdisciplinary teamwork; and engagement with the community. our findings show that these learning opportunities depend on the respect team members have for each other’s abilities, regardless of discipline or designation. an overly possessive or mistrustful preceptor would have resulted in stretches of “just sitting doing nothing,” as donna (rn) put it. in this light, sedgewick’s (2011) observation that rural preceptors need to have rapport with other team members, for the good of their students, seems particularly relevant; in fact, the relationship the student has with the preceptor may act as the vehicle for integration into the team. nursing students can also do their part in optimizing the rural preceptorship experience. being flexible, adapting quickly to different teaching styles and using this knowledge to seek out multiple learning opportunities all benefited our participants. that being said, these attributes can only proceed from a measure of confidence and trust in one’s precepting nurse and the team surrounding that nurse. if our findings and those of others (hegney et al., 2002; kulig et al., 2009) are any indication, rural health care teams are the ideal crucible for the formation of such confidence and trust. more troubling is the instance of a student filling in during a staffing shortage. the preceptor-student—or team-student—relationship contains an inherent power online journal of rural nursing and health care, 13(1) differential, and nurse educators perennially struggle to ensure that nursing students in clinical settings are not exploited as unpaid labor. for all the interdependence that may evolve over the course of a practicum, students remain vulnerable as novices, learners and outsiders. nursing faculty and preceptors must therefore ensure that students are not placed in compromising positions. as gratifying as being treated as an equal may seem to a student at the time, it can erase gains in clinical nursing education, to say nothing of the potential ethical and legal consequences. in a previous review of literature, the one-to-one preceptorship was submitted as an ideal model on account of its consistency; trust and safety within the learning space; preceptor availability; and individualized feedback (luhanga et al., 2010). had the learning experience in our study been restricted to the one-to-one relationship, however, the students would have been denied the depth and variety of health care teamwork. this is not to undermine the crucial role of the preceptor in closely monitoring the student’s transition to their new support network; coordinating experiences with other team members; and acting as a clearing house for feedback and evaluation of student work. limitations the complexity of this teaching-learning experience suggests that this type of preceptorship model needs greater exploration, including its application in non-rural settings. comparative research would be valuable in understanding the unique effects of the rural context on the preceptorship experience, and the extent to which these positive aspects could be transferred to other settings. the participant sample size was small which is appropriate for a qualitative study and for the entire study the participants generated over 800 photographs. a recent photovoice study completed by leipert and anderson (2012) had participants generating online journal of rural nursing and health care, 13(1) 144 photographs. the huge variation in the number of photographs between both studies creates questions about the photovoice method that need to be explored. as a method, photovoice requires more critique. conclusion teamwork is the key to promoting successful rural preceptorships, for students and preceptors alike, whereby the latter rely on their colleagues to provide a meaningful experience for the former. the findings of this article show that rural health care teams provide a uniquely comprehensive clinical experience, socialize nursing students into the insider discourse of rural health care, and act as gatekeepers to the rural community at large. an implication for this study is that when rural preceptors are recruited, their working environment should also be assessed. more than any other single aspect of rural nursing, we feel teamwork and community ethos, by extension, is the key to promoting rural preceptorships and rural careers. delivered with sufficient breadth and force, this message may help offset the staff shortages currently affecting rural health care sites across the globe. supporting agencies social science and humanities research council of canada (sshrc) references bushy, a., & bushy, a. 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(1997) photovoice: concept, methodology, and use for participatory needs assessment. health education and behaviour, 24(3), 369-387. [medline] webster, s., lopez, v., allnut, j., clague, l., jones, d., & bennett, p. (2010). undergraduate nursing students' experiences in a rural clinical placement. australian journal of rural health, 18(5), 194-198. [medline] world health organization (who). (2010). increasing access to health workers in remote and rural areas through improved retention. geneva: world health organization. retrieved from http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf http://www.ncbi.nlm.nih.gov/pubmed/21263278 http://www.ncbi.nlm.nih.gov/pubmed/9158980 http://www.ncbi.nlm.nih.gov/pubmed/21040080 64 oregon's economic crisis and the national nursing shortage: a transformational opportunity for rural areas wendy a. mason, pmhnp1 1 psychiatric nurse practitioner, tillamook family counseling center, tillamook, or, wendym@tfcc.org keywords: rural health, rural culture, recruitment and retention, rural uninsured abstract oregon’s drastic budget cuts and the national nursing shortage pose severe barriers for consumers and providers of human services and health care in rural areas. because of the unique culture, demographics and a deficit of human service and health care providers, metropolitan based decision and policy making aimed at improving human service and health care delivery, may actually cause harm in rural areas. this time of crisis must be viewed as a transformational opportunity for nurses. creative alternatives must be explored to decrease the higher rates of human service and health-related disparities for individuals, families, and communities in rural areas compared to those in metropolitan areas. in addition, nurses must invest in furthering the development of the field of nursing to reverse the nursing shortage and prevent shortages in the future. this paper will explore the effect of oregon’s economic crisis and the national nursing shortage on human service and healthcare delivery and economic development in rural areas. in addition, the effects of the unique culture of rural areas and metropolitan-based decision and policy making on recruitment and retention of nurses in rural areas will be explored. finally, solutions will be explored to reverse the nursing shortage, prevent future nursing shortages and further the field of nursing. economic crisis oregon is in a severe economic crisis. unemployment rates are at an all-time high, college tuition and fees are increasing while faculty and programs are being cut, and healthcare costs are forcing revisions in the quality and quantity of services available. the oregon center for public policy revealed, in an analysis of census data for 1998 to 2000, that 7.2 percent of rural oregonians live in homes with hunger compared to oregon’s overall hunger rate of 6.2 percent. oregon’s rural counties had an unemployment rate that exceeds national rural areas and the rate of employment fluctuates more. on the oregon coast, after adjusting for inflation, in 2000 the earnings were 19 percent lower than they were in 1979 (leachman, 2002). cuts to the oregon university system are reducing, and in some cases, eliminating technical and human service education programs, exacerbating the economic crisis in the long run. restructuring the delivery and implementation of state funding (e.g., oregon health plan, oregon medical assistance program, department of human services) for human services and health care, while increasing the number of individuals eligible to receive services, actually reduces the amount of coverage for each individual. more individuals and families will have coverage; however, the necessary human services and health care may not be covered. further, consolidating services and online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.oregoncoast.com/tfcc/index.htm mailto:wendym@tfcc.org 65 establishing premiums and co-pays for medicaid may force individuals and families to relinquish coverage altogether. in rural areas, other compounding factors exist. reimbursement rates and the methods of how reimbursements are managed for human service and health care providers are affected by geographical location. first, medicare reimbursement rates are lower for human service and health care providers in rural areas than they are for providers in metropolitan areas. second, the distribution of funding at the state level (e.g., medicaid) varies in a number of ways. in some counties, funding is paid out as a fee-forservice to health care providers. other counties may select existing insurance organizations to manage medicaid monies (e.g., blue cross/blue shield). finally, funding may be distributed to health care networks which further disperse the money to clinics in a capitation payment system. this structure operates much like that of a managed care organization. the idea behind the managed care approach is to prevent the duplication of services so unnecessary costs are avoided. in metropolitan areas, where an abundance of human service and health care providers exist, the managed care philosophy is certainly with merit. however, for many rural areas, where there is already a deficit of human service and health care providers, the managed care approach is inappropriate (rosman, m. & van hook, m, 1998). state budget cuts negatively impact human services and health care in rural areas drastically. the negative impact of budget cuts to human services and health care in rural areas often extends beyond the deficit of services available for consumers. in rural areas with human services and health care available, these industries provide a consistent structure of economic stability and employment for the community. state level budget cuts result in higher rates of unemployment for individuals with higher levels of education and higher levels of income. with fewer job opportunities, highly educated individuals relocate to metropolitan areas, taking expertise and economic contributions with them. rural culture, human services, and health care despite the heterogeneity of culture in rural areas, research conducted by the rural health task force of the federal office of rural health (hhs rural task force, 2002) revealed that human service and health care program structure and delivery closely resembled that of metropolitan areas. whether this similarity is the result of the effect of metropolitan decision and policy making or an evolution of efficacious service delivery and implementation in rural areas remains unclear. the relationship between the culture of rural areas (in all of their heterogeneity), human service and health care delivery and implementation, and metropolitan based policy and decision making remains to be examined. a closer look at the construct of rural culture will clarify the ambiguity of the issue. rural areas vary vastly in regards to culture because of the primary economic industries. for example, a southern agricultural community is similar to that of a rural coastal community in the seasonal nature of fluctuations of the economy (related to production, weather, tourism); however, strong differences also exist. demographic composition, impact of weather (e.g., droughts in agricultural areas versus torrential rain online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 66 in coastal regions), proximity to metropolitan areas, impact of primary industry on statewide economy, etc., influence the beliefs, values and attitudes of communities. history plays a strong role in rural culture, as well. many individuals and families in rural areas have roots in specific geographic locales dating back for generations. historically, rural individuals and families migrated into unexplored territories in pursuit of financial, religious, and intellectual freedom. long and weinert (1989) described independence and self reliance as key concepts in relation to understanding rural health needs and rural nursing practice. the ability to be independent and self reliant is often entrenched in being able to provide and care for oneself and family. financial resources and the ability to work are a pivotal point in relation to human service and health care delivery and implementation in rural areas. “health is assessed by rural people in relation to work role and work activities, and health needs are usually secondary to work needs,” (long & weinert, 1989). thus, human service and health care delivery is strongly affected by the high value placed on independence and self reliance by rural individuals and families. because independence, self reliance, and the ability to work govern decision making, human service and health care needs are typically acute and often critical when rural individuals and families present for assistance. the challenge of obtaining necessary assistance is compounded by multiple factors. first, the availability of human services and health care in rural areas, as mentioned before, is limited. proximity to human service and health care providers where assistance may be obtained may also present obstacles. for example, poverty may prevent rural individuals and families from traveling to sites where assistance may be accessed, whether they lack a vehicle or funds to pay for fuel. public transportation systems are often non-existent. geographical isolation may also inhibit rural individuals’ and families’ awareness of preventative and supportive services. thus, there is a national movement to utilize information technology to increase accessibility to human services and health care. advances in technology have expanded the ability to access human services and health care for many rural individuals and families. information can be found on the internet in abundance. videoconferencing has increased opportunities for rural individuals and families to access human service and health care providers in metropolitan areas. human service and health care providers are able to access educational resources and metropolitan based providers for consultation, mentoring, and support. although technology has the demonstrated the potential to expand resources and decrease isolation for consumers and providers, few rural areas are equipped to implement and utilize such resources. availability of the internet and information technology resources and staff are often limited, too expensive or non-existent. reimbursement protocols for services received utilizing videoconferencing require further development and clarity (ormond, wallin, & goldenson, 2000). resistance to access metropolitan resources may be a factor, as well. long and weinert (1989) described the tendency for rural individuals and families to access informal versus formal systems (local versus regional or national) and “insider” as opposed to “outsider” support. a familiar human service and health care general provider is far more likely to be sought for assistance than an unfamiliar specialist. providers often find themselves in unfamiliar territory acting as mediators, advisors, spiritual counselors, negotiators, online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 67 educators, mentors, evaluators, brokers, liaisons, advocates, coordinators, collaborators, facilitators, and researchers (stanton & packa, 2001). the role of rural human service and health care providers is challenging due to the diversity of hats worn and the responsibility attributed to the role. interdependence of human services, health care, and economic development in 2001, the u.s. department of health and human services created the rural task force under the leadership of the health resources and service’s administration’s office of rural health policy and the department office of intergovernmental affairs. the rural task force was established to examine program investment, regulatory policy, and barriers to providing human services and health care in rural america. the report generated by the rural task force revealed that rural residents experience poorer health and social welfare outcomes than urban residents. the greatest health related disparities for rural residents were in the areas of mental health, substance abuse, oral health, and public health outcomes. the greatest human service disparities included higher levels of poverty and unemployment. the rural task force pointed out in the report that there is a distinct interdependence of health care, human services and economic development. “to be healthy, a community needs not only health care, but a thriving economy, low levels of poverty and reliable social service networks” (hhs rural task force, 2002). inadequate insurance coverage, limited provider availability and accessibility, regulatory barriers, inappropriate dispersal and utilization of federal and state level funding, and naivete` of metropolitan based decision and policy makers of the unique heterogeneity of rural culture were some of the reasons for the existing disparities in human service and health care outcomes between rural and urban residents. “possibly the most important factor in fragmentation and lack of coordination in rural areas is the continuing conceptual and practical separation among primary health care, behavioral health care and social services. although health and social welfare are strongly associated with one another, in many cases federal, state, and local planning efforts continue to address them separately,” (hhs rural task force, 2002, p. 10). the rural health task force established five goals to direct health and human services in driving the movement to integrate human services, health care and economic development and reduce disparities for rural individuals, families and communities. the five goals are: 1. improve rural communities’ access to quality health and human services; 2. strengthen rural families; 3. strengthen rural communities and support economic development; 4. partner with state, local, and tribal governments to support rural communities; and 5. support rural policy and decision-making and ensure a rural voice in the consultative process. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 68 a detailed description of the themes of each goal can be found in the hhs rural task force report to the secretary at the website www.ruralhealth.hrsa.gov/publicreport.htm. the five goals are broad and complex. in order to achieve the aims of the goals, individuals with a vast knowledge base in health care, human services, and economic development must be utilized. therefore, nursing is an ideal profession to enlist in the venture. the knowledge base of nurses is holistic, integrating multiple facets of individuals, families and communities. training for nurses enrolled in accredited bsn programs entails health care, social services and economic development for individuals, families, and communities. educational and clinical experiences for nurses incorporate assessing primary care, mental health and substance abuse across age, gender and ethnic barriers and teaching illness prevention and health promotion strategies. quality assurance, health policy, leadership, role development, and management are incorporated into the curriculum and experiential learning of accredited msn training programs. many bachelor’s, master’s and doctoral level degree nurses are involved in decision and policy making at local, state and national levels. the nursing profession is well equipped to address the complex task of integrating human services, health care, and economic development in an attempt to reduce the health disparities encountered by rural individuals, families and communities. because nurses are a valuable commodity in rural areas, particular attention should be turned towards the recruitment and retention of nurses. the economic crisis in oregon poses a threat to the number of human service and health care providers, including nurses. compounding the current state of affairs, a national shortage of nurses exists and the statistics are projected to worsen. effects of the nursing shortage on rural areas the nursing shortage nation wide has created obstacles in recruiting and retaining nurses in all venues of health care and human services. because rural areas experience a deficit in health care and human service providers, the obstacles posed in recruitment and retention of nurses are even more detrimental to rural individuals, families, and communities than those in metropolitan areas. recent statistics have shown that nurses in rural areas have the largest percentage of older nurses (macphee, 2002) and the rate of individuals under the age of 30 entering the field of nursing declined by 25.1% between 1980 and 2000 (engen, 2002). filling nurse vacancies in rural health care facilities has taken up to 60% longer than filling those in a metropolitan area (tone, 1999). tone (1999) reported a recruitment period of 150 days for advanced practice nurses in rural areas as opposed to 90 days for metropolitan areas. while the nursing shortage continues towards the projected peak in 2010, fewer young individuals enroll in nursing (engen, 2002) and increasing quantities of older nurses retire, negatively affecting rural individuals, families and communities. challenges specific to nursing in rural areas macphee (2002) stated three distinct barriers exist to recruiting new nurses to rural areas, including nursing-related barriers, community-related barriers, and online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ruralhealth.hrsa.gov/publicreport.htm 69 professional interaction barriers. clark (2002) described multiple nursing-related barriers that contribute to the national nursing shortage, including economic changes affecting health care, lower wages and reimbursement rates than those in metropolitan areas for services rendered, an increasing shift to outpatient health care services, ineffective recruitment, and inadequate application of nursing knowledge, educational preparation and educational systems for nurses. factors unique to rural areas complicate matters further. long and weinert (1989) and tone (1999) reported that community-related barriers such as lack of anonymity, limited social opportunities for single nurses, lack of employment options for spouses of nurses, and inadequate access to academia or continuing education opportunities exacerbate the nursing shortage in rural areas. the multifaceted role of the rural nurse and the complex needs of rural human service and health care consumers (who often present in acute or critical need) were also intimidating and taxing (tone, 1999). community involvement, personal acceptance and extended periods of time are required for rural areas to accept the presence of nurses entering rural areas (long & weinert, 1989; baldwin, sisk, watts, mccubbin, brockschmidt, & marion, 1998). social support affected the satisfaction and retention of nurses (macphee, 2002) and while there was the expectation of personal and professional investment, there was a delay in acceptance for nurses new to rural areas. baldwin et al. (1998) suggested that because many rural communities lack prior exposure to advanced practice nurses, public education on the qualifications and roles is necessary to increase the likelihood of their acceptance. tone (1999) and macphee (2002) revealed that even though many rural physicians accept and accommodate advanced practice nurses, the poor quality of relationships with physicians continued to pose significant professional interaction barriers. nurses must be critical thinkers, steadfast, patient, skillful, and knowledgeable to endure the nursing role and provide quality health care services in a rural area. needs specific to nursing in rural areas degney (2002) identified two primary categories important to nurses staying in rural practice: 1) issues related to the rural context of practice and 2) professional issues. issues related to the rural context of practice centered on rural lifestyle and the sense of belonging to a community, including personal security and social support. the category of professional issues addressed teamwork, skill acquisition and maintenance, and organizational structures. clearly, rural nursing needs are complex. the needs of nurses in practice in rural areas can be stratified into three levels: 1) the personal level, 2) the community level, and 3) the professional level. on the personal level, the lifestyle and pace of the rural dweller, a sense of reciprocity between the nurse and the community, and a social support network for the nurse and the nurses’ family are critical elements for the rural nurse in practice. employment opportunities must exist for spouses, adequate childcare and education for children, and opportunities to develop social contacts with similar interests for all family members. second, on the community level, the rural nurse must have an understanding of the culture of the community and the culture of the health care and human service environment within the community. awareness of the economic trends of the primary industries of the community and the effects of decision and policy making affect the online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 70 nurse’s ability to influence resource utilization to the maximum benefit of the community. further, increased community involvement and awareness enables the rural nurse to establish, communicate, clarify, and improve the roles and responsibilities of nurses at all levels of practice. third, on the professional level, access to affordable and up to date continuing education is imperative for ensuring quality practice. opportunities must be created to network with community human service and health care providers to establish communication and improve continuity of care. opportunities must also be created to network with human service and health care providers from metropolitan areas to enable rural nurses to exchange innovative ideas for improving the quality of practice they provide. strategies to increase recruitment and retention of nurses in rural areas meeting the complex human service and health care needs of rural areas with a deficit of providers and a multitude of challenges facing those that are present, is no small task. numerous strategies have been implemented to increase the recruitment and retention of nurses in rural areas. tone (1999) reported that rural recruiters have attempted to hire traveling nurses, foreign nurses, temporary nurses and new grads. affiliations with nursing schools and state loan repayment and scholarship programs have been established to recruit nurses to rural areas and to attract rural natives back to their communities (macphee, 2002; tone, 1999). preceptorship programs and rural nursing courses have been implemented to introduce students and new graduates into nursing practice in rural areas (baird-crooks, graham, and bushy, 1998; tone, 1999). baird-crooks et al. (1998) stated that to be successful as a nurse in a rural area, there is a need to expose nurses as students to the rural environment. after implementing a rural nursing course aimed at immersing students fully into the rural environment, bairdcrooks (1998) concurred that a rural practicum is a logical transition from more institutionally based experiences. the investigators reported that the course increased students’ rural cultural competence while inspiring them to consider rural employment following graduation. recognizing the unmet human service and health care needs in rural areas, faculty at oregon health sciences university established the innovative "rural frontier delivery program." the program consists of rural health clinics aimed at training baccalaureate level nursing students in rural areas while providing health care for an underserved rural population. the training utilizes distance learning modalities while forming partnerships with local health care hospitals and agencies. students are able to increase their cultural competence for nursing and achieve professional nursing degrees while residing in rural areas. thus, the likelihood that students will remain in the community after graduation increases. more information about the programs can be found at the website http://www.ohsu.edu/son-clinical/clinical.html. creative options to expand the nurse workforce are at the forefront of human service and health care education, delivery and decision and policy making. rural and metropolitan human service and health care providers continue to seek alternatives to increase recruitment and retention of nurses, while attempting to make accessible, online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ohsu.edu/son-clinical/clinical.html 71 affordable, appropriate, adequate, acceptable health care available. thus, alternative approaches to providing human services and health care are being considered. “instead of perceiving the current situational crisis with fear and trepidation, the nursing shortage should be viewed as a transformational opportunity to reformulate and recreate postmodern nursing as the most caring respected and unified of the health care professions,” (clark, 2002). the oregon nursing leadership council composed the “onlc strategic plan, solutions to oregon’s nursing shortage,” detailing five specific goals aimed at transforming nursing education, delivery and decision and policy making. the five goals are: 1. double the enrollment of oregon nursing programs by 2004; 2. develop, implement, and evaluate staffing models that make the best use of the available nursing workforce; 3. redesign nursing education to meet more directly the changing health care needs of oregonians; 4. recruit and retain nurses into the profession; and 5. create the oregon center for nursing that will coordinate implementation and ongoing evaluation of this plan. the full version of this report, detailing the strategies to implement each goal, can be located on the oregon state board of nursing’s website at http://www.osbn.state.or.us/shortage.htm. legislation at the federal level has supported solutions enabling nurses to provide human services and health care to underserved and rural areas, reversing the nursing shortage and ensuring adequate nursing educational preparation and systems exist. the nurse reinvestment act, pl 107205, signed into law by the president on august 1, 2002, amended title viii of the public health service act. the nurse reinvestment act has required the division of nursing (at the health resources and services administration which is part of the u.s. department of health and human services) to develop a funding allocation methodology accounting for its education and practice programs. the funding methodology is required to account for the health care needs of the us population (including those of minorities, and of those residing in medically underserved areas and in rural areas) and workforce needs (including its current composition, geographic distribution, and capacity to meet the changing needs of the us health care delivery system over time) (center for health policy research and ethics, http://www.gmu.edu/departments/chpre/donfunding/home_donfunding.html). mckeon (2002) explained that the new law has expanded authority for existing federal programs, while creating a number of new provisions. the new law has granted the authority for the following: 1. expanding loan repayments and establishing scholarships for nursing students who commit to working in a health care facility deemed to have a critical shortage of nurses; online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.osbn.state.or.us/shortage.htm http://www.gmu.edu/departments/chpre/donfunding/home_donfunding.html 72 2. establishing a nursing loan cancellation program for master’s and doctoral students who commit to working as full-time faculty after completing their degree; 3. establishing a career ladder program to create partnerships between health care facilities and schools of nursing to support nurses and nurses aides who wish to advance within the profession, and to reestablish preentry programs for nursing students; 4. establishing geriatric training grants to support educators and nursing students who provide care to the elderly; 5. establishing grants for public service announcements to educate the public regarding nursing to promote student aide programs. state nurses associations are eligible to receive some of these grants; 6. establishing “nurse retention and patient safety enhancement grants” based upon criteria of the magnet recognition program, administered by the ana’s subsidiary, the american nurses credentialing center. these competitive grants encourage health care facilities to increase collaboration between nurses and other health care professionals and to promote nurse involvement in the governance of the facility with the ultimate goal of increasing nurse retention and improving patient care. updates on the nurse reinvestment act are available on the department of human and health services website at http:/bhpr.hrsa.gov/nursing, (mckeon, 2002). the new legislation is aimed at improving nursing practice, increasing the quantity of nurses, advanced practice nurses and nursing educators and encouraging the participation of nurses in decision and policy making. tone (1999) reported that the average age of current nursing school faculty is about 53 years old. nurses must be encouraged to aspire to higher levels of education to reverse the current nursing shortage while preventing shortages in the future. participation in decision and policy making at state and federal levels is imperative for nurses to expose issues affecting nursing practice and educational preparation and systems, which influence the recruitment and retention of nurses. the new legislation is particularly important for nurses in rural areas. as demonstrated by baird-crooks (1998) and ohsu faculty, educational preparation and educational systems specifically designed to integrate rural culture into the curriculum increase the probability of recruitment and retention of nurses in rural areas. incentives (such as loan repayments) aimed at encouraging master’s and doctoral level prepared nurses to commit to full time faculty positions, particularly if they are invested in human service and health care delivery in rural areas, increase the probability of reversing the nursing shortage while preventing a similar crisis in the future. encouraging participation in decision and policy making ensures that the voices of rural human service and health care providers and consumers (individuals, families, and communities) are heard. revealing the detrimental effects of metropolitan-based decision and policy making on rural areas serves to enlighten metropolitan-based decision and policy makers. therefore, the likelihood that the effects of metropolitan based decision and policy making on rural human service and health care providers and consumers are considered in the legislative process increases. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 73 conclusions with recent and impending drastic budget cuts, oregon’s human service and health care industries and economic development is hindered with rural areas encountering the most severe impact. rural areas experience higher rates of human service and health related disparities than metropolitan areas, and a deficit of human service and health care providers poses challenges for rural areas. oregon’s economic crisis, the unique culture of rural areas, metropolitan based decision and policy making and the national nursing shortage exacerbate the barriers for human service and health care providers and consumers. to implement the five goals of the rural health task force, culturally sensitive and economically conscious strategies must be devised for rural areas specifically. because nurses’ training is holistic, they are well suited for human service and health care delivery and economic development in rural areas. utilizing nurses maximizes their intrinsic knowledge base while integrating human services, health care, and economic development in an attempt to reduce the health disparities encountered by rural individuals, families and communities. although a national shortage of nurses poses further challenges in providing human services and health care to individuals, families, and communities in rural areas, creative solutions to reverse the nursing shortage enable culturally sensitive and economically conscious alternatives. oregon’s economic crisis and the national nursing shortage should be viewed as a transformational opportunity to develop efficacious strategies for recruiting and retaining nurses in rural areas. the nurse reinvestment act provides a vehicle for reversing the nursing shortage and preventing future nursing shortages. authorities included in the act support incentives for entering nursing, further education aimed at teaching and conducting research, and involvement in decision and policy making. the nurse reinvestment act enables advancement of field of nursing. in addition, human service and health care providers and individuals, families and communities in rural areas will also benefit from the act. nurses must recognize the value of their contributions to rural areas while encouraging the development of the field of nursing. developing culturally sensitive and economically conscious models of human service and health care delivery for rural areas benefits consumers and providers. achieving higher levels of education with the intent of teaching and conducting research and supporting other nurses in doing so contributes the reversing the nursing shortage and preventing a shortage in the future. involvement in decision and policy making ensures that the voice of human service and health care providers and consumers in rural areas is heard. nurses, as advocates, are responsible for individuals, families and communities in rural areas and further development of the field of nursing. online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 74 references baird-crooks, k., graham, b., & bushy, a. (1998). implementing a rural nursing course. nursing educator, 23(6), 33-37. baldwin, k., sisk, r., watts, p., mccubbin, j., brockschmidt, b., & marion, l. (1998). acceptance of nurse practitioners and physician assistants in meeting the perceived needs of rural communities. public health nursing, 15(6), 389-397. [medline] clark, c. (2002). the nursing shortage as a community transformational opportunity. advances in nursing science, 25(1), 18-31. [medline] department of health and human services. (2002). one department serving rural america: hhs rural task force report to the secretary. retrieved october 13, 2002, from http:/www.ruralhealth.hrsa.gov/publicreport.htm hegney, d., mccarthy, a., rogers-clark, c., & gorman, d. (2002). retaining rural and remote nurses: the queensland, australia experience. journal of nursing administration, 32(3), 128-135. [medline] leachman, m. (2002). oregon rural residents, workers, and renters more likely to go hungry compared to their counterparts nationally. retrieved november 11, 2002, from http://www.ocpp.org/ long, k., & weinert, c. (1989). rural nursing: developing the theory base. scholarly inquiry for nursing practice, 3(2), 113-127. [medline] macphee, m., & scott, j. (2002). the role of social support networks for rural hospital nurses: supporting and sustaining the rural nursing work force. journal of nursing administration, 32(5), 264-272. [medline] mckeon, e. (2002). the nurse reinvestment act: putting law into action one step at a time. american journal of nursing, 102(11), 24-25. [medline] oregon health sciences university. (n.d.). rural health: rural frontier delivery program at ohsu school of nursing in eastern oregon. retrieved november 30, 2002, from http://www.ohsu.edu/son-clinical/clinical.html oregon nursing leadership council. (2001). onlc strategic plan: solutions to oregon's nursing shortage. retrieved november 15, 2002, from http://www.osbn.state.or.us/shortage.htm ormond, b., wallin, s., & goldenson, s. (2000). supporting the rural health care safety net. washington, dc: urban institute. retrieved november 15, 2002, from http://www.newfederalism.urban.org/html/op36/occa36.html rosman, m., & van hook, m. (1998). changes in rural communities in the past twentyfive years: policy implications for rural mental health. retrieved november 14, 2002, from http://www.narmh.org/pages/refone.html stanton, m., & packa, d. (2001). nursing case management. lippincott's case manager, 6(3), 96-103. tone, b. (1999). looking for a job? think about moving to the country. retrieved november 28, 2002, from http://www.nurseweek.com/features/99-3/rural.html online journal of rural nursing and health care, vol. 4, no. 1, spring 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9874920 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12889575 http://www.ruralhealth.hrsa.gov/publicreport.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=11984243 http://www.ocpp.org/ http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10744512 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12021567 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=12436070 http://www.ohsu.edu/son-clinical/clinical.html http://www.osbn.state.or.us/shortage.htm http://www.newfederalism.urban.org/html/op36/occa36.html http://www.narmh.org/pages/refone.html http://www.nurseweek.com/features/99-3/rural.html running head: a description of rural grain workers online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 69 rural agricultural workers and factors affecting research recruitment key words: rural agricultural worker, research recruitment, barriers rural research, rural health disparities. linda prinz, bsn, rn 1* margaret kaiser, phd, aprn-cns 2 katherine l. kaiser, phd, aprn-cns 3 susanna g. von essen, md, mph 4 1 nursing instructor, northeast community college, lindap@northeastcollege.com 2 assistant professor, college of nursing, university of nebraska medical center, mkaiser@unmc.edu 3 associate professor, college of nursing, university of nebraska medical center, kkaiser@unmc.edu 4 professor, college of medicine, university of nebraska medical center, svonesse@unmc.edu * contact author abstract health disparities exist in rural populations calling for more research in this area, yet rural research recruitment presents obstacles. the aim of this descriptive research was to describe a population of rural workers exposed to grain dust and to determine factors that influence recruitment of rural workers for research studies. this qualitative study involved 82 rural agricultural workers (raw) in eastern nebraska. after completing a demographic questionnaire these raws answered opened questions regarding factors that contributed to their decision to participate in the research study along with qualities that distinguish them from other occupations. rural agricultural workers participated primarily because of the desire to know/learn, and altruism. barriers to research participation included a dislike of the time consumed during research. descriptors of self-identified characteristics included having unique environmental conditions, values and beliefs, skill set and capacity. utilizing healthcare professionals with community connections was the key recruitment strategy for this study. introduction rural communities often have unique environmental and cultural factors that potentially increase the risk of health disparities (hartley, 2004). health disparities between rural, urban, and suburban areas call for a better understanding of health and residence (eberhardt & pamuk, 2004). many research studies of rural agricultural workers suffer from inadequate sample size (mccauley et al, 2006) which can lead to misleading or inconclusive results (polit & beck, 2004). the rural agricultural population is not homogeneous and consists of multiple subgroups including farmers, livestock farmers, grain farmers, migrant farmworkers, seasonal farmworkers, and rural agricultural workers who may work in an agriculturally related industry. for this study the terms farmworker and rural agricultural worker (raw) are synonymous. there are documented difficulties in analyzing the overall size of the u.s. raw population due to the movement of seasonal and migrant workers (mccauley et al., 2006; villarejo, 2003), but the population is estimated to be from 2.5 to 5 million (hansen & donohoe, 2003; mccauley et al., 2006). actual raw numbers in nebraska are difficult to ascertain but the overall rural population in nebraska is 756, 613 (united states department of agriculture mailto:lindap@northeastcollege.com http://app1.unmc.edu/nursing/conweb/pub_home.cfm mailto:mkaiser@unmc.edu http://app1.unmc.edu/nursing/conweb/pub_home.cfm mailto:kkaiser@unmc.edu http://www.unmc.edu/dept/com/ mailto:svonesse@unmc.edu online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 70 [usda], 2007). information about the occupational health and safety issues of raws is inadequate (hons, 1998) and statistics indicate that health outcomes are worse for rural residents (eberhardt & pamuk, 2004). research is an important step in the process of reducing health disparities. recruitment of rural agricultural participants into research is essential in order to reduce rural health disparities. research results are essential to evidence based practice that seeks to improve population health outcomes. the u.s. department of health and human services (usdhss) encourages research in order to achieve the healthy people 2010 goals of facilitating improved quality of life and life expectancy, and eliminating health disparities between populations (usdhss, 2000). adequate recruitment of rural populations into research would help to develop the evidence needed to reduce rural health disparities. little has been written about research recruitment and research recruitment strategies for raws. there is also a void in the literature about the population characteristics of raws. in order to increase rural research participation, there needs to be an awareness of rural population attitudes, knowledge and beliefs, (coyne, 2004). as an attempt to fill these gaps, the aim of this qualitative research was to describe a population of raws exposed to grain dust and to assess for factors that influence recruitment of rural workers for research studies. background rural agricultural worker rural populations have been described as having a solid work ethic, strong spiritual belief, solid values, strong sense of place, and strong family ties, (coyne, demian-popescu & friend, 2006; phillips & mcleroy, 2004). additional descriptors include kind, outgoing, openhearted, helpful, hospitable, loyal, dependable, trust worthy and dedicated (coyne, et al., 2006). demographics. national raw demographic statistics may differ from state statistics. in the u.s., the average raw age is 33 years of age with 79% being men, 75% being born in mexico, 81% being spanish speaking with the median level of education being 6 th grade (us department of labor, [usdl], 2005). in 2002, there were 57,971 hired nebraska farm laborers (usda, 2002) where spanish, hispanic, or latino ethnic origins represent only 1% and women represent 3% of nebraska farm operators (centers for public affairs, research, 2002). nationally, the mean annual average wage of the raw is $20, 630 which is comparable with the nebraska mean annual average wage of $20,260 (usdl, 2006). health statistics. rural areas have higher death rates from unintentional injuries, suicide, chronic obstructive lung disease, cardiovascular disease, and cancer (eberhardt, ingram & makuc, 2001; eberhardt & pamuk, 2004). risky health behaviors of rural populations include smoking more, exercising less, and having less nutritional diets than suburban populations. these risky health behaviors of rural populations may be cultural health determinants rooted in strong social networks (hartley, 2004). in a study with rural new mexico families, participants described themselves as suffering from drug and alcohol abuse, domestic violence, and teenage pregnancy (harris, 2006). hazards and risks. rural agricultural workers encounter hazardous work environments. as the second most dangerous occupation in the us (morgan, cole, struttmann & percy, 2002), raws are not only at risk for injuries, they are also exposed to chemical and environmental online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 71 hazards. prolonged agricultural work exposures to pesticides, dust, pollens, and molds can lead to respiratory illness (larson, 2002; von essen, & mccurdy, 1998). rural agricultural grain workers are exposed to air borne hazards such as grain dust and other endotoxins that negatively affect respiratory health (von essen & auvermann, 2005). this can be compounded by risky health behaviors such as tobacco use and the failure to wear a mask while working with grain. rural agricultural worker research recruitment a major task of research is recruitment of a sample representative of the population (polit & beck, 2004). validity and interpretation of the results are dependent on an adequate sample size. gaps in rural and minority research participants recruited for research have been noted (baquet, 2006; polit & beck, 2004). a search of the literature reveals little in regards to recruitment of rural agricultural workers, but rather addresses more broadly successful strategies and barriers for research recruitment of various rural populations. known successful strategies. healthcare professionals who have gained the trust of the community are considered key stakeholders in rural research recruitment (coyne, 2004; loftin, barnett, bunn, & sullivan;, 2005; parra-medina et al., 2004; weinert & long, 1991). the existence of trusting relationships such as family, friends, and community members were found to be successful rural recruitment strategies in a study of recruitment and retention of rural african americans with type 2 diabetes (loftin et al., 2005). in a study conducted in montana (johnston & herzig, 2006), hispanic raws were recruited by utilizing investigators with prior associations such as sitting on the montana migrant council. the use of small rural networks or community coalitions was the most successful research recruitment strategies for a study of firstgeneration latinos in a rural community (rodriguez, rodriguez, & davis, 2006). coyne et al., (2006) successfully recruited rural appalachians by utilizing community organizations and obtaining input on recruitment strategies by a local community advisory committee. enlisting community members to help with participant accrual and enlisting community representatives to create a list of potential raw research participants (arcury, quandt, & russell, 2002) have been found to be successful research recruitment strategies (arcury, austin, quandt, & saavedra, 1999; mccauley et al 2006). utilizing community-based participative research (cbpr) (arcury, et al., 1999; arcury et al., 2007; cartwright et al., 2006), a participatory research model (yawn, 2004), and/or developing partnerships with community health centers (parra-medina, et al., 2004) have been reported to be successful rural research recruitment strategies. community-based participatory research used by the national institute of environmental health sciences (niehs) encourages community involvement in the multiple steps of the research process, thereby promoting trust between the researchers and the community (o’fallon, & dearry, 2001). a similar model was used for successful recruitment of hispanic raws in idaho by using promoters from the community who had already established trusting relationships through prior health related projects. in this approval, the community was given flexibility as to how the research was conducted (cartwright et al, 2006). cultural competence is important in the recruitment process for rural research (loftin et al, 2005; parra-medina et al, 2004). if rural communities are considered to have ethnic diversity then the research and recruitment strategies of ethnic minorities should be considered. the national institutes of health (nih) recommend that research investigators: 1) understand the research population, 2) establish a clear outreach plan, 3) ascertain a consensus on research plans online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 72 and design, 4) obtain evaluations, and 5) establish and preserve communications (nih, 2002). phillips and mcleroy (2004) contend that a clear recognition of rural populations should be considered a contextual matter that requires special attention due to the differences in public resources, social capital, and social networks that differ from other populations. barriers. rural communities may have atypical research recruitment factors as rural populations have strong social ties (coyne, et al., 2006) and frequently are not accepting of outsiders (bigbe, 1993; loftin, et al., 2005). mistrust issues (paskett et al., 2002) and a rural prejudice against outsiders (debartolo & mccrone, 2003; loftin et al., 2005) has been found to be recruitment barriers for select rural populations. rural research may present unique challenges including a lack of resources (especially of personnel), geographical dispersion of recruits spread over several counties, and ethnic diversity (rodriguez et al., 2006). each rural community may have unique historical and cultural customs (harris, 2006). in a nebraska study of breast cancer survivors, rural areas were unique as to which research recruitment strategy worked over others, indicating various research recruitment needs from diverse rural areas (ott, twiss, waltman, gross, & lindsey, 2006) the use of newspaper ads and family/friends were the two most successful research recruitment strategies in this nebraska study of both rural and urban populations, but the third successful recruitment strategy varied among select rural areas. one rural area required flyers/posters while another rural area responded to radio ads. paskett et al. (2002) also discussed time issues as a rural research recruitment barrier. in a rural/urban study of medically underserved elderly diabetics using telemedicine, reasons given by the 28% who did not participate were that they were too busy (23%) and that they were uncomfortable with the technology (22%) (palmas, 2006). ninety percent of the people who did not participate in this rural/urban study were from rural areas suggesting the difficulty of recruiting rural participants. research recruitment is essential in order to obtain adequate sample size that ensures data analysis interpretation with integrity. the literature portrays some successful research recruitment strategies for rural populations and outlines barriers to rural research participation. however, the literature lacks clarity in regards to specific research recruitment strategies and barriers for the raw. methods this qualitative study was part of a larger biomedical quantitative study of agricultural workers exposed to grain dust. the study was approved by the institutional review board of the university of nebraska medical center (unmc) and colorado state university (csu). both the colorado and the nebraska state grain and feed associations were consulted and were supportive of the research. sample inclusion criteria for the study included participants that were grain workers from cattle feedlots or grain elevators/feed mills. the grain workers handled corn and soy beans on a daily basis in a grain elevator/feed mill or in a cattle feedlot. the majority of the participants were recruited from rural communities familiar to the research investigators who were physicians and nurses. two investigators lived in or formerly lived nearby a county that held one of the highest concentrations of cattle feedlots in the state of nebraska and subsequently many grain online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 73 elevators/feed mills. two investigators lived or had lived in a community with one of the largest cooperative grain elevator/feed mills in nebraska. these investigators were the main contact people for recruitment in their own communities. procedures the grain elevator/feed mill or cattle feedlot was contacted initially for permission to conduct the research at the site; after which a date, time, and place were scheduled for data collection. investigators with local ties were able to contact key supervisors or owners at each site who would in turn provide access to agricultural workers or potential research participants. investigators contacted sites that agreed to participate anywhere from one to four weeks before potential research data collection. investigators also called each site one to two days before as a reminder of the scheduled data collection. research investigators planned data collection times before the participants began their workday and after their workday was completed. the research study was explained to potential participants, questions answered, and consent forms signed prior to data collection. participants were given $20 as compensation for their time at the completion of data collection. data collection pre and post-shift self-administered, paper questionnaires were given to all participants that worked the day shift. the pre-shift questionnaire was completed by participants just prior to the beginning of the work shift and included questions pertaining to work history and respiratory health. a post-shift questionnaire was completed at the end of the work shift and included questions pertaining to post-shift respiratory symptoms and three open ended questions. two of the open ended questions asked participants to explain positive and negative factors that contributed to their decision to participate in the research study. the third question asked participants to explain what qualities distinguish the rural, agricultural worker from other populations. data management and analysis the pre and post-shift questionnaires which were free from identifiable information were filed by respondents’ identification number into notebooks. a database dictionary code was made of the participants’ responses. data was entered into excel format and reviewed by at least two or more investigators for accuracy before demographic data were analyzed using descriptive statistics. the three open ended questions were thematically analyzed, synthesized, and reviewed by the investigators. results population characteristics a total sample of 82 raws from eastern nebraska agreed to participate in the research. analysis of the demographic statistics utilized 81 of the 82 tested because of deletion of an identified outlier. out of the 81 participants, 79 were white (98%) and 78 (96%) were men. online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 74 women and minorities were included in the research despite being few in number. the rural worker age range was from 18-72 years of age with the mean age of 41 years of age (sd=13) (table 1). forty two percent of this raw study had more than a high school education. only 3.7% of this raw sample had not gone farther than 8 th grade in school. thirty one percent of this raw population reported income less than $30,000 while 64% reported income between $30,000 and $100,000 a year. table 1 demographic and health behavior variables and responses demographic and health behavior variables mean (sd) range n (%) age 41 (13) 18-72 gender male female 78(96%) 3 (4%) race (q1.4) white other 79 (98%) 2 (2%) currently lives on a farm (q1.7) yes no 34 (42%) 47 (58%) type of employee feed lot grain elevator/feed mill 33 (41%) 48 (59%) years worked in the job listed (q2.3) 10.3 (11.6) 0.25 48 smoking status never ex-smoker current smoker 59 (73%) 9 (11%) 13 (16%) pack-years for exand current smokers 12.3 (11.4) 0.60 – 43 pack-years for exand current smokers <10 >= 10 11 (50%0 11 (50%) uses tobacco in any form yes no 17 (21%) 64 (79%) did you wear a dust mask at work today (p6.5) no mask was worn mask was worn other 60 (74%) 18 (22%) 3 (3%) have you been trained to use and fit a respirator (p7) yes no 88 38 (47%) 42 (52%) 1 (1%) note. from “endotoxin exposure and genetic factors in organic dust,” by l. m. smith, 2006, unmc memorandum. nebraska’s health sciences center, received september 1, 2006. used with permission from l.m. smith. online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 75 the work history of the participants included 41% who worked in feedlots while 59% worked in a grain elevators/feed mills. the mean years that the participants worked with grain was 10.3 years (sd=11.6) (table1). health behaviors important to decreasing the health effects of grain dust were use of tobacco and wearing of a respirator/mask during work hours. tobacco use of the raws included 73% who never smoked, 11% who were ex-smokers, and 16 % who currently smoked tobacco. seventy four percent of the raws did not wear a mask the day the study was conducted; 52% had never been trained to use and fit a respirator; and 52% were not concerned that breathing grain dust at work or at home may cause health problems (table1). qualitative themes the major themes that emerged from the qualitative data gathered in response to three open ended questions asked of each of the participants were perceived benefits to participation in research, perceived barriers to participation in research, and unique self-identified qualities of raws. the two major perceived benefits to participation in research included: (1) gaining knowledge/learning, and (2) altruism. the first perceived benefit of wanting to gain knowledge or learn included wanting knowledge about three aspects of grain dust exposures. the first aspect included gaining knowledge about the biological or health effects of grain dust: i would like to see how much dust i breathe in every day would like to know the effects of grain dust on a person i’ve wondered about the dust, i can definitely tell the days when i’ve been exposed a lot the second aspect involved gaining knowledge about the status of the workplace in relation to grain dust exposure: to help find any problems that cause lung problems curious to see my exposure to dust in the workplace interested in how much dust i am exposed to the third aspect described wanting to learn about personal risk to their health because of exposure to the grain dust: wanted to see what effect the grain dust has on my lungs after 40+ years wanted to know condition of lungs, and i wanted to know if there are side effects to dust exposure the second major perceived benefit of altruism was described by the raw as a feeling of helping to support the research, the researchers, and the agricultural industry: help agricultural industry good for health and medical problems now and in the future online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 76 to help with research for a good cause help in a study to improve working conditions perceived barriers to participation in research were identified retrospectively to participation in the current study. participants identified equipment used for data collection of the quantitative part of the study and length of time of data collection (the entire workday) as reasons that may affect their future participation in similar research studies. these raws wanted to work and felt that the equipment and the time it took to participate in the research prevented them from doing the quality or quantity of work they desired: having the pump all day machine too noisy time consuming just a little more time than i thought it would take the unique self-identified qualities that participants thought distinguished them as raws and from other worker populations included: 1) unique environmental work conditions, 2) strong moral values and beliefs, and 3) their skill set and capacities. participants referred to their unique environmental work conditions as setting them apart from other worker populations: as a farmer in more dust outside all day long work under all weather conditions we work more in dust, around diesel fumes and livestock participants felt that they possessed strong moral values and beliefs that differentiated them from other worker populations: work ethics honesty, integrity more common sense self-confidence we’re tougher long hours active skill set and capacities identified by the participants that distinguished them from other worker populations included: knowledge of animals and agricultural crops i feel we are diversified in our abilities knowing equipment the ability to perform many tasks online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 77 discussion the sample from this study indicated that 96% of the raws were men which is similar to the 97% of the nebraska farm operators who are men (centers for public affairs research [cpar], 2002), but differs from the rate of 79% of raws that are men on the national level (usdl, 2005). the 4% of the raws that were women in this study is comparable with the rate of 3% of women farm operators in nebraska (u.s. census bureau, 2006) but is much lower than the national rate of 21% for raws who are women (usdl, 2005). the mean age of participants of this study was 41 years of age as compared to the national average raw age of 33 years (usdl, 2005). thirty one percent of this raw population made less than $30,000 annually and 64% made from $30,000 to $100,000 annually as compared to the nebraska mean annual wage of the raw at $20,260 and the national mean annual wage of the raw of $20,630 (usdl, 2006). also 96% of the raws in this study completed more than the 8 th grade in school with 42% receiving some sort of post high school education which is greater than 31% of nebraska rural residents completing some college (usda, 2007) and the 6 th grade median level of education for the national raw (usdl, 2005). the data suggests that this raw population consisted of older, more educated, and better paid workers, consisted of more men and fewer migrant rural workers than the national raw. hartley’s (2004) suggestion that risky health behaviors of rural populations are a cultural health determinant that may be reflected in the 74% of grain workers in the current study who did not wear a mask and 52% who were not concerned that breathing grain dust at work or at home may cause health problems. however, 73% of the raws in this study never smoked as compared with hartley (2004) who contends that rural populations smoke more. almost one third of the participants in this study were altruistic and participated because they wanted to help with the research. this is consistent with paskett et al. (2002) who found altruism as one of the motivators that increased accrual of rural research participants into research studies. a perceived barrier to participation in the current research study was that some participants felt the equipment they had to wear as a part of the quantitative study was cumbersome. also, the raws of this study did not like the amount of time it took to participate in the study which impedes the normally autonomous and demanding work environment of many raws. palmes (2006) also found that reasons given for not participating in research included those who were uncomfortable with the equipment (22%) and those who were too busy (23%) (palmes, 2006). the findings in this study regarding identification of the unique self-identified qualities of strong values and beliefs and skill set and capacities were similar to findings from harris’s (2006) study of rural workers. in harris’s study, rural families of new mexico described themselves as having a solid work ethic, hardiness, determination, and an acceptance of life’s challenges. enrollment of the participants into this study seemed to encounter few recruitment barriers. eighty two participants were recruited and tested in 3 months. this recruitment process went quite well especially when the investigators could only test for 10 days with a maximum of 10 participants a day. the use of nurses and physicians with community connections was the key to the successful rural research recruitment of this study which is consistent with other studies that have found healthcare workers as key research recruitment stakeholders (loftin, et al., 2005; coyne, 2004; parra-medina et a., 2004; weinert & long, 1991). nurses and physicians with online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 78 community connections would most likely have strong social ties (coyne et al, 2006), would not be considered outsiders (bigbe, 1993), would not be mistrusted (paskett et al, 2002) would have an understanding of the research population (nih, 2002), and have trusting relationships with recruiters and respondents (cartwright et al, 2006; loftin et al, 2005; nih, 2002; o’fallon & dearry, 2001; paskett et al., 2002; rodriquez et al, 2006), also, the primary investigator had conducted research in one of the communities in the past. this correlates with a study that successfully used community members who had established trusting relationships through prior health related projects for rural research recruitment (cartwright et al., 2006). in addition, there were several grain elevators/feed mills and feedlots that allowed investigators to set up research where only one or two of their employee’s participated while other employees from other feedlots or grain elevators drove to the testing site before and after work. this is consistent with other rural population descriptors of openheartedness, helpfulness, hospitality (coyne et al., 2006). a limitation of this study is that findings can be generalized only to the study sample of raws. a second limitation of this study was self selection of participants which may have caused bias of study results. for example, respondents who wanted to learn or were altruistic would be more likely to participate in the research. self selection of participants also may display an under representation of rural workers with other values who did not participate. implications for nursing research recruitment of rural populations carries unique and sometimes diverse recruitment requirements (ott et al., 2006). research is suggested that would reveal why various rural populations respond to certain research recruitment strategies over others. investigators need to take into consideration the skill set and value system of the rural population when conducting research recruitment. rural agricultural workers may be reluctant to participate in research studies, yet may be interested in the research outcome. therefore nurses need to educate the raw that rural research would help to reduce rural health disparities. in order to eliminate health disparities of raws and improve raws quality of life and life expectancy, more research needs to be done in rural agricultural populations. one implication would be that the raw needs definitive terminology in order to compare groups. there should be an assessment of the rural population and a consideration of cbpr for future raw research. suggested future studies should address specific factors facilitating raw education and compliance with health behaviors such as wearing a mask or a respirator while handling grain. the identified perceived benefits of participation in this research may be helpful in recruiting rural workers in future research. minimization of burden to participants such as use of equipment and time needed to complete the study procedures should be taken into consideration when planning future research studies. utilizing physicians and nurses with community connections was the driving force behind the successful recruitment of participants for this study. references arcury, t.a., austin, c.a., quandt, s.a., & saavedra, r. 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(2005). the national agricultural workers survey. retrieved on july 12, 2007, from http://www.doleta.gov/agworker/naws.cmf u.s. department of labor (usdl). (2006). occupational employment and wages, may 2006. retrieved on august 26, 2007, from http://www.bls.gov/oes/current/oes452093.htm villarejo, d. (2003). the health of u.s. hired farm workers. annual review of public health, 24, 175-193. [medline] von essen, s.g., & auvermann, b.w. (2005). health effects from breathing air near cafos for feeder cattle or hogs. journal of agromedicine, 10(4), 55-64. [medline] von essen s., & mccurdy, s.a. (1998). health and safety risks associated with work in production agriculture. western journal of medicine, 169, 214-220. [medline] weinert, c., & long, k.a. (1991). the theory and research base for rural nursing practice. rural nursing, 1, 21-38. yawn, b.p. (2004). participatory research in rural primary care. minnesota medicine, 87(9), 5254. [medline] http://www.doleta.gov/agworker/naws.cmf http://www.bls.gov/oes/current/oes452093.htm http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12359914%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=16702123%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9795581%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=15495878%5buid%5d bio for dr 1 editorial editorial board changes jeri dunkin phd, rn editor there have been some changes in the editorial board since the last issue. dr. melondie carter, from the university of alabama, has completed her term on the board as has ms. kathy crooks from medicine hat college in alberta, canada. we have added three new board members. dr. linda l. dunn, is currently a tenured, full professor at the university of alabama and has been a faculty member within the capstone college of nursing for 27 years. dr. dunn received her bsn from the university of alabama school of nursing in 1967, her msn from the mississippi university for women (family nurse practitioner) in 1983, and her dsn from the university of alabama in birmingham in 1989. her research trajectory has focused mostly on spiritual health. in 1992, dr. dunn was a collaborator (20%) on a 5 year nih grant ($350,000) entitled a prospective study of psychosocial job strain and birth outcomes which resulted in two publications, both of which included findings related to spirituality. she has also received funding for other studies that included the investigation of spirituality, such as the study of faith communities and breast/cervical cancer prevention in a rural alabama county and the investigation of nurses on a maternal-infant unit in a hospital in the southeastern united states. two other spirituality studies included ante-partal women on bed rest and the statewide omnibus poll of adults (alabama). her dissertation was a qualitative study of the lived experience of battered women. dr. collins is a clinical associate professor of nursing with a clinical focus in critical care, pharmacology, intra-operative nursing and adult health. she received her as and bsn from samford university in 1976 and 1977, and earned her msn from medical college of georgia in 1978. she completed her dsn from the university of alabama in birmingham in 1991. dr. collins has a 31-year history of clinical nursing experience. she has published in the areas of cardiovascular pharmacology and patho-physiology. she also speaks locally, regionally, and nationally on topics of clinical relevance to postanesthesia care, and gastrointestinal physiology. she has eleven years experience as a surgical clinical nurse specialist. in this role she assisted patients and staff to improve patient outcomes through education and advanced practice nursing interventions. dr. graves received her b.s in nursing from the capstone college of nursing at the university of alabama in 1979. she earned her m.s. degree in nursing from the university of alabama in birmingham in 1983 and her phd in clinical health science at the university of mississippi medical center in jackson, mississippi in 2007. she has worked and taught extensively in critical care and cardiovascular nursing since 1981. dr. graves’ areas of expertise and clinical research interests include: primary and secondary prevention of cvd; health disparities and geographical access; geographical information systems and mapping of health issues; human patient simulation use in teaching cardiovascular nursing; health promotion and disease prevention; and evidencebased practice. online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 http://www.rno.org/journal/index.php/online-journal/about/editorialteam online journal of rural nursing and health care, vol. 8, no. 1, spring 2008 2 i am excited about the added diversity these new members bring to the board. i hope you will find their columns interesting and useful. if you are interested in being considered for a position on the editorial board please contact me at jdunkin@bama.ua.edu. mailto:jdunkin@bama.ua.edu microsoft word garner_377-2039-1-ed.docx online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.376 4 reducing barriers to healthcare for rural homeless individuals and families: experiences of community health nursing students presented at the 2014 international rural health & rural nursing research conference cosponsored by the montana state university college of nursing and the rural nurse organization (rn0). linda garner, phd, rn, aphn-bc, ches 1 1 assistant professor, department of nursing southeast missouri state university lgarner@semo.edu reducing barriers to healthcare for rural homeless individuals and families: experiences of community health nursing students purpose the purpose of the project was to organize a wide variety of services in a central location for homeless individuals and families in a rural setting. the project was designed to reduce barriers and offer services in one day that would ordinarily take months. numerous partners from the rural community were involved in the planning and implementation of the project, including the department of nursing from a local university. twenty-eight community health nursing students were integrated into the project as a pilot study to explore the effectiveness of this type of hands-on service learning experience. background experiential learning opportunities enhance student understanding of complex health issues in a variety of populations. service learning affords the opportunity to match student and community needs. through an organized service activity with a defined target population, students come to online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.376 5 understand the unique needs of the population within the context of a specific community’s resources. description student preparation involved focused reading assignments and group discussions regarding the unique health issues found in homeless populations. emphasis was placed on how the face of homelessness often looks different in a rural versus urban setting. based on the findings from a recent community assessment, students developed a variety of prevention and health promotion activities designed to address the specific needs of the homeless population. a modified version of the attitude towards homeless people scale developed by zrinyi and balogh (2004) was administered to the students as a preand post-event measure. students also completed a postevent written reflection activity. throughout the event, students conducted an initial health history for each incoming client, assisted clients in identifying their priority needs, and guided individuals and families from one station to the next. in collaboration with other healthcare providers, students assisted with activities such as hiv and hepatitis b/c screening, administration of flu, tetanus, and pertussis immunizations, diabetes education, and blood pressure screenings. students also provided oral hygiene education, application of dental varnish, and assisted with teeth extractions through use of the university’s mobile health clinic on wheels. students rotated through the various stations throughout the day to gain different perspectives about the health services being provided and the population they were serving. outcomes students were less afraid of homeless people after their participation in the event (p< .01). even though data analysis did not demonstrate a statistically significant difference in the student online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.376 6 attitudes regarding homelessness as a social versus health issue, the post-event means were higher on both measures. the majority of students (79%) felt their understanding of vulnerable populations increased as a direct result of participation in the event. additionally, 86% of the students felt the experience met the stated learning objectives. with the exception of dental services, students also felt the event met the needs of the 200+ homeless individuals who participated in the event. qualitative themes from the reflection activity indicated that students were mostly unaware of the homeless population within their community. students also reported that, prior to the event, they had not interacted face-to-face with an individual who was homeless. factors that contribute to and sustain health disparities in the rural region were also described, including lack of accessible resources, low paying and limited jobs, lack of public transportation, low health literacy, language barriers, lack of healthcare insurance, and geographic challenges in the more remote parts of the region. students also described their perceptions of the relationships between health outcomes, prevention education, health screenings, and referrals. conclusion this pilot study demonstrated that an organized service learning experience for community health nursing students increased their understanding of vulnerable populations in a rural setting and decreased their fear of working with homeless individuals and families. future studies with a larger sample size are needed. no external funding was received for completion of this study. microsoft word khalil_298-1552-1-ed.docx online journal of rural nursing and health care, 13(2) 2 guest editorial “systematic reviews and beyond…………….” hanan khalil, phd 1 1 senior lecturer and pharmacist academic, school of rural health, monash university in australia; director of the centre of chronic disease management, an affiliated centre of the joanna briggs institute the cochrane collaboration endeavours to provide, disseminate and integrate evidence into clinical practice. since its foundation in 1993 by ian chalmers and his colleagues, it has provided a strong platform utilizing evidence based healthcare through its publication of the cochrane library. a key component of the cochrane library is the collection of protocols and systematic reviews addressing a variety of interventions in healthcare. the cochrane library has contributed to the significant number of published systematic reviews which is reported be in excess of 5,000 reviews in 2012. systematic reviews aim to analyse contemporary research using the best available evidence. those reviews often become the foundation for clinical practice guidelines for practitioners and consumers. this year the cochrane collaboration is celebrating its 20th anniversary. the collaboration has strived to improve the science of systematic reviews by developing and testing new methodologies. it has also been the leader in developing a gold standard for systematic reviews through the rigour of its methodological structure, the transparencies of its methods and the dissemination of its reviews online which are available to all clinicians and consumers of the healthcare system. online journal of rural nursing and health care, 13(2) 3 more recently, the cochrane library has moved to publish overviews of reviews. cochrane overviews use different methods from cochrane intervention reviews; they summarize existing intervention reviews rather than original studies. the aim of publishing overviews is to summarize evidence from systematic reviews of the effects of interventions. overviews of systematic reviews may inform policy makers about the latest evidence regarding a particular intervention. the launch of the cochrane nursing care network (later renamed cochrane nursing care field [cncf]) in april 2009 marked a significant milestone in the collaboration and nursing practice. the international cncf is coordinated from adelaide, australia and consists of six different groups with members from over thirty five countries across the world. its main objective is to improve health by increasing the use of the cochrane library by nurses and others involved in delivering, leading or researching nursing care as well as engaging nurses and others with the cochrane collaboration. several studies (khalil, 2009; khalil & leversha, 2010; mollinari, jaiswal, & hollingerforrest 2011, roberge, 2009) have recently identified many challenges faced by rural and remote health practitioners including nursing staff. these include the recruitment and retention of adequate numbers of staff, professional isolation, long and inflexible working hours, staff shortages, insufficient locum relief, and inadequate support for continuing education (gruen, weeramanthri, knight, & bailie 2003; grobler et al., 2009). the cncf has contributed significantly to rural nursing practice by providing an outlet for a number of summaries of nursing care relevant cochrane reviews to be published. this has resulted in increased awareness of cochrane by nurses and others associated with nursing care; improved access and usage of cochrane reviews; and promoting the ongoing contribution of nurses to the cochrane online journal of rural nursing and health care, 13(2) 4 collaboration. the online journal of rural nursing and health care highlights the importance of the work to rural health, nursing and or policy through the publication of high quality research articles including systematic reviews (o’lynn et al., 2009; williams, 2012). references grobler l.a., marais b.j., mabunda s.a., marindi p.n., reuter h., & volmink j. (2009). interventions for increasing the proportion of health professionals practising in rural and other underserved areas. cochrane database of systemic reviews, issue 1. art no.: cd005314. [medline] gruen r..l, weeramanthri t.s., knight s.e., & bailie r.s. (2003). specialist outreach clinics in primary care and rural hospital settings. cochrane database of systematic reviews, issue 4. art. no.: cd003798. [medline] khalil h (2009). rural pharmacy workforce where to go from here? australian pharmacist, 28(10), 812. khalil h, & leversha a (2010). rural pharmacy workforce challenges: a qualitative study, australian pharmacist, 29, 256-260. molinari dl, jaiswal a, & hollinger-forrest t (2011). rural nurses: lifestyle preferences and education perceptions. online journal of rural nursing and health care, 11(2) 16-25. o’lynn c., luparell s., winters c.a., shreffler-grant j., lee h.j., & hendricks l. (2009). rural nurses’ research use. online journal of rural nursing and health care, 9(1) 3445. http://www.ncbi.nlm.nih.gov/pubmed/19160251 http://www.ncbi.nlm.nih.gov/pubmed/14974038 online journal of rural nursing and health care, 13(2) 5 roberge c m (2009). who stays in rural nursing practice? an international review of the literature on factors influencing rural nurse retention. online journal of rural nursing and health care, 9(1) 82-93. williams ma (2012). rural professional isolation: an integrative review. online journal of rural nursing and health care, 12(2) 3-10. 15 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 guest column rural health clinics: contributors to efficiency and effectiveness gerald-mark breen judith ortiz (co-pi) thomas t. h. wan (pi) natthani meemon seung chun paek chiung-ya tang abiy agiro college of health and public affairs university of central florida introduction to our team and research our team began its current research on rural health clinics (rhcs) in august of 2008. to summarize, we are exploring organizational and contextual determinants regarding rhc efficiency and effectiveness. dr. thomas t. h. wan, the study’s principal investigator, referred to this grant-supported research as an “evidence-based approach to improving the effectiveness and efficiency of rhcs.” our team consists of a combination of university of central florida (ucf) research faculty and doctoral students from the public affairs doctoral program (paf), an integral division of the college of health and public affairs at ucf. we would like to first take this opportunity introduce our readers to the individuals responsible for our research design and execution, and literature: thomas t. h. wan (pi), judith ortiz (co-pi), chiung-ya tang, abiy agiro, gerald-mark breen, natthani meemon, and seung chun paek. we acknowledge the health resources and services administration, office of rural health policy, as the funding source of our current research project entitled “rural health clinics: measuring efficiency and effectiveness.” we must also establish that the opinions and statements made in our literature reflect our views only and do not represent those of the funding agency. the general goals of this study are twofold: 1) to determine the factors that influence the variation in rhc performance and 2) to ascertain the relationship of the performance indicators. performance is represented by two aspects: efficiency and effectiveness. in terms of our progress thus far, we have successfully examined thousands of rhcs within the scope of a nationalized study; consequently, we are increasingly developing the capacity to make generalizations on the factors that lead to efficient and effective administration of rhcs. our goal is to disseminate research findings that will assist rhc leaders to scientifically plan for the future and to attain higher degrees of efficiency and effectiveness in their rural practices. as such, our findings will contribute to an overall improvement in rhc operations. http://www.cohpa.ucf.edu/ 16 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 purpose of this column our purpose in writing this column is simple and straightforward – to share our recently compiled, preliminary survey results from data gathered during 2008 and 2009. we believe that this outlet – the online journal of rural nursing and health care (ojrnhc) – is an ideal venue for public sharing and reporting of the preliminary results of our study. the purpose of our nationwide survey was to identify the possible contributors to rhc efficiency and effectiveness. we received survey responses from 402 rhcs. the regional distribution of the responding rhcs was comparable to that of all rhcs nationwide. the survey results reveal a current, representative perspective of rhc conditions, focusing on aspects such as structure, location, and operations. our goal in this journalistic product is to furnish interested scholars and health practitioners with an evidence-based article on rhcs in the united states. following our presentation of key rhc elements, we will present our plans for forthcoming projects, all of which we intend to develop out of our extensive research into our current data and the robust analyses we will subsequently make. preliminary results of rhc survey seven facets of rhc operations were explored in the survey. (titles of aspects are listed alongside charts and figures.) in the following section, we present a series of both pie and bar charts to illustrate our preliminary survey findings and improve insight into our evidenced-based research on rhcs. rhc classification: provider-based or independent-based the first facet of rhcs we explored is classification, that is, whether the rhcs are either provider-based or independent-based. figure 1 displays these results. figure 1: rhc classification rhc regional distribution the second facet is rhc regional distribution, that is, the percentage of rhcs located in each of the four u.s. census bureau regions: midwest, south, west, and northeast. figure 2 displays these results. 17 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 figure 2: rhc regional distribution rhc ownership the third facet is rhc ownership; that is, the percentages of for-profit (individual, corporation, partnership), not-for-profit (individual, corporation, partnership), and government (local, state, and federal) owners. figure 3 displays these results. figure 3: rhc ownership 18 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 rhc participation in an integrated health system the fourth facet is rhc participation in an integrated health system, ranging from no participation at all to over 10 years of participation. figure 4 displays these results. figure 4: rhc participation in integrated health system rhc financial characteristics the fifth facet is rhc financial characteristics, that is, rhc revenue sources ranging from medicare, fundraising, to patient visits. figure 5 displays these results. rhc technology use the sixth facet is rhc technology use, that is, the types of technologies rhcs use and the number of years rhcs have used electronic medical records (emrs). figure 6 displays these results. rhc clinical management programs and practices the seventh facet is rhc clinical management programs and practices. figure 7 displays the details of these results. 19 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 figure 5: rhc financial characteristics 20 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 figure 6: rhc technology use figure 7: rhc clinical management programs and practices 21 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 figure 7: rhc clinical management programs and practices (continued) nurse practitioner (np), physician assistant (pa), and physician staffing we specifically analyzed our survey data to determine how clinics are staffed according to three employee categories: (1) nps, (2) pas, and (3) physicians. the mean number of ftes for each category is: nps = 1.01, pas = 1.09, and physicians = 1.80. the mean percentage for each category – per the total of the three categories – is as follows; nps = 34%; pas = 24%; and physicians = 42%. the median percentage for each category consists of the following: nps = 27%; pas = 4%; physicians = 46%. future directions and next team agenda our subsequent research advances will, in part, draw upon our survey research findings and will move forward into the development of executive decision support systems for optimizing the efficiency and effectiveness of clinical practice in rural areas, as well as other important, currently unexplored areas of research regarding rhcs. for instance, we intend to investigate important topics such as: 1) the role and contribution of nps in rhcs, 2) the identification of key or specific characteristics of efficient and inefficient rhcs, 3) the influence of community socioeconomic status on the efficiency and effectiveness of rhcs, 4) the trends in efficiency and effectiveness in rhcs, and 5) the impact of information technology (it) adoption on rhc efficiency and effectiveness. these five research prospects are a few among a myriad of ideas we plan to vigorously pursue given the extensive data we have been able to collect. we will continue to use our survey responses toward answering many very important questions concerning rhcs. our research efforts will be actualized via various health-oriented/medical-based publications, professional presentations at conferences (e.g., national association of rural health), and scholarly, academic journal articles. upon completion of the statistical analyses, we will conduct a focus group of rhc administrators, medical directors, pas, and nps to discuss the interpretation of the analytical results. the opinions of rhc administrators and medical directors/personnel will be incorporated into the study results to help illuminate many more 22 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 insightful conclusions, conditions, and study foci that would otherwise be difficult to decipher or reveal via direct interpretation of our study analyses. acknowledgements this research is, in part, supported by the health resources and services administration (hrsa), office of rural health policy (orhp), grant number: r04-rh10661-01-00. address correspondence to dr. judith ortiz, college of health & public affairs, 3280 progress drive, suite 108, orlando, fl 32826, usa e-mail: jortiz2@cfl.rr.com; phone: (407) 679-5813. mailto:jortiz2@cfl.rr.com title: examining life circumstances and sources of support for senior women in rural nova scotia 35 senior women and rural living elsa arbuthnot, rn, bn, mn1 jane dawson, phd2 patti hansen-ketchum, rn, bn, mn3 1 assistant professor, school of nursing, st. francis xavier university, earbuthn@stfx.ca 2 associate professor, department of adult education, st. francis xavier university, jdawson@stfx.ca 3 assistant professor, school of nursing, st. francis xavier university, phketchu@stfx.ca keywords: senior women, well being, rural life, formal and informal support, health and social policy abstract this study examined perceptions of what is important to maintaining health and well-being for senior women, 65 years or older, living independently in a rural community. one-on-one interviews were conducted with 22 senior women and 10 informal and formal support providers identified by the women participants. participants discussed physical and psychosocial health care needs, available resources, and accessibility to health-related services. the senior women also expressed their desire to remain in their own home and community despite the challenges of household maintenance, distant family members, loneliness, chronic transportation difficulties, and limited access to social resources. burdens placed on the voluntary efforts of informal care providers were also identified. study findings suggest that women’s needs exceeded the resources available, and that accessible health and social support services must be organized, funded and factored into future health services and community development planning to meet the needs of senior women in an aging society. introduction this article reports on findings from a study of the health, well-being and sources of support for senior women living in rural nova scotia, canada. the study provided insight into the broad determinants of health, and the social as well as health care supports available for senior women living independently in the region. issues related to community-based development and community sustainability, in terms of the circumstances and challenges faced by rural senior women, were also explored. the aim of the study was to learn more about what senior women living independently in a rural community identify as necessary to maintain their health and well being. for the purposes of this discussion, “senior” is defined as age 65 or older. “independently” is defined as living in one’s own home, either alone or with others. “formal support” refers to publicly funded health care and community services, including the church. “informal support” is associated with family, neighbors, and other community groups and networks. our definition of “rural” follows the canadian census definition of a rural area, pertaining to “individuals living outside places of 1000 people or more, or outside places with densities of 400 or more people per square kilometer” (health canada, 2002). online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.stfx.ca/academic/nursing/ mailto:earbuthn@stfx.ca http://www.stfx.ca/academic/adulted-diploma/ mailto:jdawson@stfx.ca http://www.stfx.ca/academic/nursing/ mailto:phketchu@stfx.ca 36 background by the middle of the 21st century the proportion of seniors in north america is expected to more than double (statistics canada, 2001; cox, 2004). seniors today are generally healthier, and economically better off than seniors in previous generations. due to their increased life expectancy, women over 65 years of age outnumber their male counterparts. however, the more rural their location, the more likely they are to live alone, experience a number of health-related concerns and have less access to social resources and health care than their urban counterparts. additionally, recent canadian federal and provincial restructuring policies, particularly in the areas of health care and social services, have been particularly problematic for senior rural women living in their own homes (romanow, 2002) as levels of support have been severely cut. hospital closures and reduced funding for home care and community services have disproportionally affected the rural elderly because of their greater health needs and distance from necessary hospital and health care services (armstrong et al., 2001; division of aging and seniors, 1998).therefore, it is important to know more about the rural conditions in which senior women live and the supports available to contribute to their health and well-being. for many older rural dwellers, with strong ties to community and the land, the ability to live independently in their homes is an important marker of quality of life. in a study of rural culture in upstate new york, pierce (2001) found that seniors associate their level of health and well-being with their level of independence and ability to remain in their homes and would not consider living anywhere else despite the challenges of rural living. however, living at home is not always an easy or entirely positive experience, especially when independence is accompanied by isolation, poverty, ill health, and inadequate social and health services. it is a mistake to assume that elderly people in either rural or urban communities have strong support networks of family and friends (coward & krout, 1998). in rural atlantic canada, as elsewhere, there is growing fragmentation of families both socially and geographically. great distances often separate aging parents and their adult children who must relocate to find employment in urban centers (statistics canada, 2001). despite widespread knowledge that population aging is anticipated to be one of the most significant challenges of the next few decades, there are few participatory initiatives to engage seniors in discussions about their own concerns, perceptions and needs. more particularly, there are few locally-based empirical studies examining the living conditions and formal and informal support needs of senior women living independently in rural communities. a health-related scan carried out in rural nova scotia (guysborough antigonish strait regional health authority [gasha], 2002) demonstrates that there were no health-related studies that examined the overall health of elderly women within this predominantly rural district. socio-cultural setting while the health concerns of senior women are international in scope, the sample population for the study lived in a rural area in northeastern nova scotia, canada. the region’s approximately 45,000 inhabitants are distributed among several small towns, villages and rural routes, with an average population density of 8.0 per square kilometer. the largest town and service centre in the region has a population of approximately 5000 and is the site of the regional hospital. at 14.5%, the senior population is greater than the provincial and national average. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 37 approximately 56% of the seniors in the region are women, and approximately 29% live alone (gasha, 2001; statistics canada, 2001). the geographic area has a long history of economic challenges. the settlement population relied primarily on subsistence farming, fishing, and forestry. recent decades have been characterized by limited availability of services, out-migration of youth, and a relatively high incidence of senior women living alone on low retirement incomes (nova scotia provincial health council, 2000; veugelers & hornibrook, 2002). more recent social changes and service cutbacks have placed the burden of care on families and volunteer services to care for seniors, or for seniors to independently cope with limited resources and support. methods a participatory evaluation guide prepared by the national advisory council on aging (1998) was used as a framework for the study. a core principle of participatory evaluation is that it uses a “bottom up” rather than “top down” approach to exploring the phenomenon in question. likewise, the themes addressed in the study were not locked-in in advance, but emerged during the qualitative research process. data collection entailed observation and open-ended interviews carried out by a research assistant. all standard ethics review protocols were employed in designing and conducting the research. participants the sample population included 22 senior women, five informal, and five formal support providers identified by the senior women. informal support providers were identified by the women participants, and were usually either neighbors or family members. formal support providers included health and home care providers or members of the clergy. senior women participants were living independently in the community, as defined earlier. a few of the women lived in apartments designated as seniors’ residences but none required extended care or lived in long term care facilities. senior women participants ranged from 65 to 80-plus years of age. participants were recruited by word of mouth and a variety of community publications. interviews most of the interviews were carried out in the women’s homes, the research assistant’s home, or in places of mutual convenience. in most cases, the senior women participated in the interview on their own, although sometimes family members were also present. the interviews lasted from 20 minutes to 1. 5 hours. data were coded and analyzed for common themes. findings the interviews provided valuable detail about the health and well-being of many senior women living in this rural area, and a broad profile of the possibilities and limits of the various forms of support available to them. some of the women came from backgrounds where they had started factory work in their early teens, had given birth to numerous children (in one instance, online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 38 19) or had been homemakers all their lives. a smaller number had retired from professional careers. several themes emerged from the interviews about the conditions in which the women lived, and the individuals and organizations active in the region providing various forms of formal and informal care. the context: home life and rural circumstances one of the most prevalent themes that emerged from the interviews concerned the concept of home and the importance of remaining there. some lived with their husbands or with other family members, such as an adult child (sometimes quite senior themselves) or sibling, but many lived on their own. many of the women were living in the same homes they had lived in all their married life, and in some cases in the same house that had been in their family for generations. others had grown up in the area, gone away for work or marriage, and returned later in life. a minority were relative newcomers to the area, having retired to the region from the city or other parts of the country. although the interview participants reflected a wide range of lifestyle and socioeconomic backgrounds, a common perception was a strong tie to home and place, and a strong wish to remain where they lived. for virtually all of the senior women, home life provided a vital sense of purpose, independence, meaning and pride, as well as an opportunity for physical activity. the advantages of living at home identified by the women included enjoying the scenery, taking pride in home decoration indoors and out, gardening, and being able to keep active through carrying out routine housekeeping activities. as one participant stated: i do a lot of various things. i do all the work outside...like mowing the grass in the summer and shoveling the snow in the winter, and whatever i can do myself, i do…..if it’s not a big snowstorm or too cold...i like to keep active, i guess, rather than sit around. many of the women felt that to move away from home and go to a nursing home meant death, and would do almost anything to maintain their independence in their home. in the words of one of the formal support providers: i get the sense from talking with the women that...they would like to stay in their own environments, their own homes. they don’t want to go to nursing care facilities unless they really have to.....they have lived there all their life, many of the women are widowed and they’ve been living on their own and by themselves and it is a big change to move in to a facility where they many have to share a room with someone else....it is pretty traumatic for them to have to face that. despite the women’s strong commitment to remaining at home, the choice to do so was not without difficulty and presented a variety of challenges, not only to the women but to the people who provided their support and care. many of the women lived in areas which were in “not just [a] rural but an isolated setting.” the communities in which the women lived were often scattered, with neighbors “not always immediately handy” according to one formal service online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 39 provider, although “typically at least in sight.” access to amenities was also sometimes problematic. as one participant stated, “to get to a store is big, basically half a day.” an additional source of difficulty was the severity of winter weather. as one service provider commented: the weather conditions [are a factor]...it puts added stress on the caregivers to know if [the women] are going to [be okay]. there are instances where there is no power. you worry about people falling. you wonder if they are burning candles or using lamps that are unsafe. are they able to get something to eat, are they warm? are they scared? those are many of the concerns i have. however, a common attitude among the women was that they simply did what they had to do, and sometimes even enjoyed the seasonal challenges. another difficulty posed by weather conditions was that many of the women lived in older homes that were poorly insulated, and were heated either by a wood or oil furnace. the maintenance of wood heating systems can be labor intensive and potentially hazardous. with regard to oil, there was a concern about fuel-trucks being able to make deliveries during difficult winter driving conditions. participants also commented on the risk of power outages causing problems with water supply from wells that were dependent on electricity for operating the pump. despite these difficulties, what emerged from these interviews was a portrait of women who were proud of their independence and accustomed to the challenges of rural life. they largely accepted that facing these hardships in their own home led to a better sense of well-being than moving away to someplace less beloved and familiar. physical health and health care a second theme concerned the day-to-day needs involved for the senior women in looking after their physical health and well-being. for some, these concerns involved minor aches and pains. “i think i’m in perfect health,” said one woman, “except for the old creaky joints, the stiffness and soreness that happen to us all as we go along.” others had more serious concerns. some recounted long histories of acute physical ailments, having had to contend with shattered bones, hip replacements, cancer and attendant treatments, loss of eyesight, and other major diseases. others were facing challenging problems with significant health concerns requiring ongoing medical treatment, such as kidney dialysis, oxygen supply, chemotherapy and radiation, and colostomy care. with these physical realities, access to appropriate and effective medical care was naturally an important consideration. one dimension of this involved being able to get to the pharmacy, the hospital, and the doctors’ offices (general physicians and specialists) in a timely and effective manner. those who lived in more isolated areas sometimes had to travel long distances to get to the drug store or doctor’s office. the women had access to a regional hospital in a nearby town which provided a sufficient level of care to attend to their more routine health needs, but for specialist services, a number of women had to travel back and forth to the two major urban areas in the province, both entailing a trip of between 2 and 4 hours each way. one woman, taking treatment for cancer, needed to travel to the urban area on a regular basis, online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 40 which involved a 3 and a half hour drive, followed by a 4 or 5 hour treatment: “it’s a tiring trip, it’s a long trip [and] you’re never sure when you’re going to be going. and there’s the weather factor, so you watch the weather a bit. last year there was a lot of storms.” although it was often necessary to travel to receive needed medical care, some medical services were also available in the home. “i have a nurse coming twice a week,” said one woman. another mentioned “a nurse that comes in and checks my [oxygen] machine. she checks my pressure and, every so often, if she has time, she calls for an appointment.” one informal support provider said: the “nurse comes in once a week, usually tuesday or wednesday, and she checks her blood pressure, checks the toenails, makes sure that i have supplies, catheter supplies, blue liners and that type of thing.” other participants spoke of the availability of other in-home services such as palliative care, traveling foot and diabetic clinics. the portrait of physical health concerns for rural senior women revealed by the interviews was not, however, simply a catalogue of conditions and ailments, and the forms of health care treatments available. in response to questions of what kept them healthy, matters of self-care and overall well-being also came up frequently. many of the women commented on the importance of healthy practices such as diet, exercise, sleep, and maintaining a positive attitude. as one woman commented: regular check-ups and the care doctors give me [is important, but also there is] good food...and trying not to worry too much....if you sit and worry about things you’re not going to get anywhere, you know. i try to be positive about everything. it makes it easier. many of the women also identified the beneficial effects of keeping up with various recreation and crafts activities, including crosswords and jigsaw puzzles, baking, sewing, rug-hooking, bird watching, reading, watching the news, and learning how to use a computer. the women consistently placed a positive emphasis on the importance of keeping active, upbeat, and connected with the world around them. “at home” connections a third theme concerned the importance of other dimensions of connectedness. in living at home, often alone and at a distance from others, it was vital for the women to overcome feelings of isolation and to have a sense of connection “to the outside.” this was not always easy. often, the work of looking after themselves and keeping up the home was beyond their capability. in many cases, the women were assisted by various kinds of home care, in addition to the in-home medical care mentioned previously. many women had access to different levels of housekeeping support. sometimes this was provided by a home support service, with financial assistance available for these services. sometimes the women independently paid for assistance with some of the heavier activities, such as chopping wood and other outdoor chores. however, the availability and level of interest in home care was not without attendant challenges regarding, first of all, what various homecare service agencies could do. according to one formal support provider: online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 41 what they are allowed to do is fairly limited...these elderly women… need extra things done such as house cleaning…the refrigerators cleaned out, their ovens cleaned, they need the heavier type of work… and also groceries, things that need to be picked up at the drug store…it is a very strict criteria that allows the home support workers to do that for them. another problem, according to a different formal support worker, involved the women’s’ reluctance to use services available: most elderly women are unwilling to take in home care. they feel that if they have to have help come in the home for any length of time, that they have failed their duty as a wife or in their career as a homemaker, so they tend to resist having any in home support…. these women have been the queen of the castle for, many of them, fifty, sixty, seventy years and they don’t want to be told what to do. then there is the problem of they don’t want to admit that they do have problems…that they need help with at home. another dimension of “at-home” connections important to the women concerned keeping in touch with family, and receiving support from family members. for all of the women, family connections were paramount, and all spoke of the vital meaning they attached to being able to see or speak with family members as often as they could. for some of them family was quite far flung, reflecting a characteristic of the region. as one formal support provider stated: of course, in many of the areas now their young people, the families, the nieces, the nephews, the grandchildren have all moved away because there is no employment in the area so that connection with them is gone, and they may get home, if they are lucky, maybe once every couple of months. for others, family and close relatives were either living with the women or close by, and seeing to the women’s’ needs on a regular basis. in some cases, family members were the primary caregivers. as one woman stated, “i have to have my daughter-in-law come and ah flush the line every day. i have to have somebody come every day.” as another said, “it’s only my family that’s any help.” sometimes family members stepped in of necessity, due to the limitations in the availability of funded in-home formal support, filling the gap to maintain the senior women’s health and independence in the home. many of the women, as well as support providers, noted the pressure on families that can result from caring for their senior relatives on top of maintaining jobs and caring for their own families. in the words of one family support provider: “i can think of numerous occasions… where family members are carrying the load…there is a lot of pressure on the family members or immediate family. where is the respite for these people? how do they get a break?” in a similar vein, another formal support provider noted gaps in the provision of palliative care, where all of the attention is focused on the dying person, not the people providing care who are left alone once the dying person has gone: online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 42 once this spouse passes on, there you are, you’re left, after he’s gone, after the whole process of the death and the funeral and all of that takes place and everybody goes back to their lives, here you are left sitting with a whole ton of issues and the services are pulled. bang! another area of concern, according to this same formal support provider, was that sometimes family members were not the best people to be involved in dealing with difficult situations. at times, family members are not always the ones that can deal most efficiently with these women. it takes, sometimes, somebody from the outside to come in because of the different perspectives and it’s just the whole family issue and family get frustrated with their loved ones because they don’t do what they are suggesting, etcetera because [the women] want to remain independent. socialization a fourth theme that emerged from our analysis revealed the importance of wider patterns of support and socialization beyond the home, family, and health care system. senior women discussed the importance of getting out and socializing with other people, and being involved in activities outside the home and family circle. some of the social connections beyond the family identified as important included opportunities to travel, and to take part in community activities. events mentioned ranged from bingo to carpet bowling to volunteer work to church attendance. for some of the women, opportunities to get together with people of the same age were deemed important for their sense of identity as well as a source of comfort. as one participant stated, “i value [the] companionship…with people of our own age. you know, just being with a group you can have fun with. because younger people don’t…have the same idea. they’re a little different than we are.” for some, friends and neighbors in the local community were also an important part of their social life. they not only contributed to a sense of well-being but sometimes helped out with various tasks, and kept an eye on them. “my neighbors do things,” said one. “i find that neighbors are like that, little things like that are appreciated.” as one formal support provider stated, sometimes neighbors are a life line, taking on a sense of responsibility for the seniors, especially those living alone and/or with mobility challenges, in their community. “they automatically assume the responsibility. not necessarily legally, but still morally they say, i’ve got to care for this person.” another formal support provider said: people help each other without batting an eyelash…. i know two little old elderly ladies who lived on a country road and they could see across to the front window of each house. one of them was frailer than the other and the most frail lady used to pull her blinds up in the morning to tell her neighbor that she was up and alive and awake. and the agreement was that if the blind wasn’t up by ten o’clock the neighbor was supposed to walk down the road, across the street and go in and see what was wrong with her. so they looked after themselves and each other very well. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 43 another important lifeline was the telephone. it allowed communication with friends and loved ones at any time of day. one formal support provider stated, “there’s usually someone around who calls up and says how are you today?” however, the need to be in touch by telephone could also create a burden for friends and families to make time and be available when the call arrived. despite all of these points of contact and sources of socialization however, a sense emerged from the data that one of the most persistent concerns faced by the women had to do with a chronic sense of loneliness, and sometimes even isolation. the women expressed a sense of loneliness due to their physical separation from others, and they related that they and others like them were sicker when the necessary supports were not in place. one individual commented further that “a lot of the support i think the women need, it’s more of an emotional support. not more, but there’s a lot of emotional support. a friendly visitor, or whatever you want to call it.” of course, the women who had no family members nearby faced many challenges regarding loneliness and isolation. for these women, emotional support from informal and formal support providers was not adequately addressed by anyone. there was a commonly expressed sense of loneliness and yearning for companionship and affirmation that they were valued and important to society. said one formal support provider: they need that reassurance that they are still valuable, that they can still contribute to the world and what is going on around them. these women that i talk to, they’re sharp and they know, they’ve got a lot of experience and they can teach a lot….a lot of them are much more open to change than we anticipate….there is still a lot of resources and knowledge and information that we can glean from these people if we give them a chance. transportation a final theme centered on the challenges associated with the lack of transportation. many formal support providers as well as senior women and family members consistently indicated that transportation was one of the most critical factors affecting the senior women’s health and well-being. “the greatest need i think is transportation,” said one of the formal support providers. due to the rural setting of the study, public transportation services were limited. there was no local transit, an ever-shrinking inter-provincial bus system and taxi services largely restricted to the towns. therefore, transportation primarily meant access to and use of a car. however, as one support provider commented, “in that generation of women we are speaking of now, very few of them drive. very, very few.” another commented: transportation is a contributing factor….for many, they no longer drive, [and] their partners, if they have them, are no longer driving, and it is an inconvenience for others to drive them and they don’t like that. or in some cases people are charging them to drive them to the doctor’s appointments….even those who have automobiles can’t drive necessarily after dark and in winter they don’t get to as many social functions as they would like. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 44 another dimension of this was not simply accessibility but the negative feelings associated with being dependent on others for their mobility. as one woman said, “you hate to be phoning people all the time…well, are you going here? can i go with you? you know…and i just get tired of it and they don’t ask me…well, sometimes i don’t ask to go either….” discussion and recommendations the findings from this study outline the perspectives of a group of rural senior women, along with people involved with providing their care, about the everyday circumstances of their lives and the sources of support they identified as important to their health and well-being. the findings are not necessarily representative of all senior women in the region since, as a qualitative study, the aims of the project were not to determine generalizable patterns but to gain insight into the particularities of individual experience. however, the results provide a glimpse into the kinds of realities faced by a sector of canadian society who are not often consulted about the nature of their life circumstances or their views on what matters to them as contributors to their health and well-being. similar to other studies, many women who participated in the research project described themselves as healthy and active, yet virtually all of them identified some manner of physical condition which they had to factor into their daily living. although seniors generally report good health in their later years, they are more likely than younger people to suffer from chronic conditions, to have activity limitations, and to be dependent on others for assistance with activities of daily living (division of aging and seniors, 1998; statistics canada, 1999). yet, one important result of the study was the consistent view that the various forms and levels of physical infirmity these rural women experience are only one aspect of their health and well-being. while physical health concerns were always a factor, there was a larger sense of urgency and poignancy associated with the broader picture of life in a rural community. our data revealed that the ordinary life circumstances of the women were inextricable from their overall sense of happiness and well-being. it was difficult to separate their medical concerns from other physical concerns of daily life such as getting the groceries in, the house cleaned, the lawn mowed, the wood stacked, and the driveway plowed in winter. it is essential that such factors be included in the development and implementation of social programs and policy that meet the needs of rural senior women. another significant finding of the study was that the women and their care providers placed as much importance on social and emotional needs as they did on physical concerns. our findings conform closely to the view that “social relations and support from family, friends and communities have been shown to contribute to health” (genuine progress index atlantic, 2002, p. 64). in accordance with other studies that show a strong correlation between negative wellbeing and feelings of loneliness and isolation (hall & havens, 1999; patrick, cotrell & barnes, 2001), our study emphasized the importance of maintaining an active and socially engaged life style alongside adequate provision of health care and disease treatment. an overarching recommendation is to have a nurse leading a multidisciplinary team to plan and evaluate holistic support, tailored to the on-going needs of the client. in accordance with pullen, walker and fiandt (2001), health services for rural senior women need to be holistic and involve a focus on health promotion and prevention of disease and disability. this includes a composite array of services, attending to both physical and psychosocial aspects of health and online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 45 well-being, and attuned to the particular needs of women living in rural settings where services of any kind are difficult to access and fairly limited. regarding specific nursing care, recommendations that emerged from the study include the need for such programs as traveling clinics for foot care, diabetic services, health promotion counseling, and increased availability of nurse practitioners as a means of improving access to medical and nursing care. concerning psychosocial needs, resources such as a telephone lifeline, and a network of neighbors keeping an ‘eye out’ for each other, are other central factors vital to the health continuum. in addition to these dimensions, another result of the study touches on the all-important challenge of transportation in rural settings. for women participants in rural nova scotia, transportation was a key element in maintaining independence and quality of life at home. however, because these senior women were often unable to drive, they were dependent on others to meet their transportation needs and, in juxtaposition, the women were hesitant to ask for help related to transportation issues. as corroborated by michalski (2002), lack of transportation, particularly in rural areas, is a major barrier to health and well being for those who require health and social supports outside the home. another important implication concerned societal views of senior women as a resource with something to offer, rather than simply as a burden needing care. as other studies have shown, for healthy rural communities to be sustained, seniors must be seen as central to community strength and identity (jensen & royeen, 2002). thus, holistic care is not simply a matter of seeing health services more holistically, but also seeing the place of seniors in the community in a more holistic and integrated way. final words health and social policy not informed by individual and community interests are seldom successful or lasting (meegan, 1993). this study serves as a foundation for additional community-based research projects aimed at increasing awareness of the support needs of senior women in the region, and developing policy and practice recommendations for improving the availability of support for these women. data from this study indicates that, within one rural community, senior women are struggling to sustain their health and well-being and live independently in their own homes. these women and others like them will be unable to continue living independently with an adequate quality of life without an improved array of holistic, accessible and funded support. acknowledgments the authors would like to thank the st. francis xavier university research council and the centre for regional studies for funding this study. sincere gratitude is also extended to our research assistant; nancy emerson. last but not least, a special ‘thank you’ to participants who shared their life stories. online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 46 references armstrong, p., amaratunga, c., bernier, j., grant, k., pederson, a., & wilson, k. (2001). exposing privatization: women and health care reform in canada. aurora, ontario: garamond press. coward, r., & krout, j. (eds.). (1998). aging in rural settings: life circumstances and distinctive features. new york: springer. cox, c. (2004). community care for an ageing society: issues, policies and services. new york: springer. division of aging and seniors. (1998). canada’s aging population. federal report on aging. ottawa: health canada. genuine progress index atlantic. (2002). measuring sustainable development: application of the genuine progress index to nova scotia. health canada, population and public health branch, atlantic region. guysborough-antigonish-strait health authority [gasha]. (2002). health status and district profile. guysborough antigonish strait health authority. hall, m., & havens b. (1999). experiences of older manitobans with the 1997 red river flood. report submitted to manitoba health, may 1999. health canada/ sante canada. (2002). definitions of “rural” summary. ottawa: author. jensen, g., & royeen, c. (2002). improved rural access to care: dimensions of best practice. journal of interprofessional care, 16(2), 117-128. [medline] meegan, m. (1993). a framework for survival. lancet, 342, 1100-1101. michalski, j. (2002). what matters to canadian ngo’s on aging: an analysis of five public dialogue discussions. ottawa, on: canadian policy research networks. national advisory council on aging. (1998). how are health reforms affecting seniors? a participatory evaluation guide. ottawa, on: minister of public works and government services canada. nova scotia provincial health council. (2000). health for nova scotians: the results of a public consultation process. halifax, nova scotia: provincial health council. patrick, j., cottrell, l., & barnes, k. (2001). gender, emotional support, and. well. being among the rural elderly. sex roles, 45, 15-29. pierce, c. (2001). the impact of culture on rural women’s descriptions of health. journal of multicultural nursing & health, 7(1), 50. pullen, c., walker, s., & fiandt, k. (2001). determinants of health-promoting lifestyle behaviors in rural older women. family and community health, 224(2), 49-72. [medline] romanow, r. (2002). shape the future of health care: interim report. ottawa: government of canada: commission on the future of health care in canada. statistics canada. (1999). health among older adults. health report special issue, 11(13), 4761. statistics canada. (2001). shifts in population size in various age groups. 2001 population census. veugelers, p., & hornibrook, s. (2002). small area comparisons of health: applications for policy makers and challenges for researchers. chronic diseases in canada, 23(3) 100110. [medline] online journal of rural nursing and health care, vol. 7, no. 1, spring 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12028893%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11373166%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=12443566%5buid%5d 38 chronically ill rural women’s views of health care clarann weinert, sc, phd, rn, faan1 allene littell whitney, ms, md2 wade hill, phd, rn3 shirley cudney, ma, rn, gnp4 1 professor, college of nursing, montana state university, cweinert@montana.edu 2 swedish family medicine obstetrics fellowship, university of washington, allene@fastmail.fm 3 assistant professor, college of nursing, montana state university, whill@montana.edu 4 research associate, college of nursing, montana state university, scudney@montana.edu* * corresponding author keywords: rural health, chronic illness, communication with health care providers, technology application abstract successful adaptation to chronic illness requires a collaborative relationship between ill individuals and health care providers. this article reports a secondary analysis of data from a computer-outreach intervention that examined the experiences of 110 chronically ill rural women in communicating with their health care providers and determined factors that influenced their satisfaction with care received. five themes identified from qualitative data were: self-reliance; treatment/therapies; interactions with health care providers; financial constraints; and accessibility of health care. quantitatively, three independent variables contributed significantly (p<.05) to the prediction of health care satisfaction: quality of life, life change, and health status change. overall, 25% of the variance in satisfaction with health care was explained by the model. health care providers can enhance chronically ill rural women’s satisfaction with care by: improved interpersonal relationships; collaboration in care management; appointment scheduling that accommodates rural life-styles; and open discussion of financial concerns. introduction access to quality health care in rural areas has historically been limited by scarcity of health care providers, limited dissemination and application of up-to-date health care information, vast distances, primitive road conditions, and in winter, inclement weather. recent efforts to overcome these barriers to the delivery of quality care in rural areas have included the development of area health education centers (moscovice & rosenblatt, 2000), strategies to increase the number of health care providers in underserved areas (bowman, 2005; phillips & dunlap, 1998), and the proliferation of health-related applications of telecommunications (bauer, 2003; boulanger, kearney, ochoa, tsuei, & sands, 2001; lin, chen, chen, & hou, 2001; nesbitt, hilty, kuenneth, & siefkin, 2000; nesbitt, marcin, daschbach, & cole, 2005; weinert, cudney, & winters, 2005). whether these innovations are producing a level of health care that is considered by the rural consumer to be satisfactory is a question to be addressed. some general assessments of rural dweller’s satisfaction with the health care they receive have been made, focusing on evaluation of hospitals (davis et al. 2000), online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.montana.edu/wwwnu/ mailto:cweinert@montana.edu mailto:allene@fastmail.fm http://www.montana.edu/wwwnu/ mailto:whill@montana.edu http://www.montana.edu/wwwnu/ mailto:scudney@montana.edu 39 provider performance (knudtson, 2000), or service profitability (davis et al. 2000; knudtson, 2000; yasin & green, 1995). yet, such surveys do not elucidate the rural consumers’ opinions of quality of the health care they receive and may mask the true perceptions of individuals with particular health care needs, such as those with chronic illness. the unrelenting nature of a chronic illness compounds a rural dweller’s difficulties in accessing quality health care. a greater proportion of rural residents (1819%) find their activities limited by chronic health conditions as compared with urban dwellers (12-14%) (eberhardt, ingram, & makuc, 2001). regular health care appointments, over years of illness, incur many hours of travel, added expense, and fatigue. for example, in one large western state, it is not unusual for a person to travel 240 or more miles round trip to a health care specialist (winters, 1999). more than their urban counterparts, rural people equate health with their ability to work, function, and perform daily tasks (lee, 1989; ross, 1982). thus, chronic illness with its long-term impacts may disrupt activities that rural people consider particularly important in their views of self and health. the ability to manage their illnesses in concert with their health care providers may impact their level of success in adapting to their chronic illnesses (thorne, con, mcguinness, mcpherson, & harris, 2004). it is unclear how rural people with chronic illness perceive the quality and efficacy of health care services. while poor health status itself may predispose individuals to a lower satisfaction with care, this influence is relatively small (wensing et al. 1997). in one study, individuals with chronic illness (without regard for urban versus rural setting) ranked effectiveness of treatment as the most important aspect of care, followed by providers’ knowledge level, continuity of care, adequacy of information given by the provider, length of visits, and provider empathy (van der waal, casparie, & lako, 1996). it is unknown whether these indices of quality care are equally pertinent to rural dwellers with chronic illness; therefore, it is of interest to determine rural dwellers’ perceptions of and satisfaction with care received. information regarding rural consumers’ perceptions of the quality of their health care was available from the women to women project (wtw) at montana state university college of nursing. wtw was a telecommunications intervention that provided peer support and health information to rural dwelling women with chronic illness via personal computers in order to evaluate its impact on their psychosocial health. this intervention has been described in detail in earlier articles (cudney & weinert, 2000; sullivan, weinert, & cudney, 2003; weinert, 2000). the purposes of this article are to report the results of a secondary analysis of a portion of the wtw data related to the experiences of chronically ill rural women in communicating with their health care providers and to examine the factors related to the women’s level of satisfaction with their health care. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 40 methods women were recruited for the wtw project via announcements in health care providers’ offices, nursing schools, public media, and local offices of the arthritis foundation, national multiple sclerosis society, american cancer society, and american diabetes association. criteria for participation included: a diagnosis of a chronic illness, e.g., diabetes, cancer, multiple sclerosis, or rheumatoid condition; age 35 through 65; ability to read, write, and speak english; the sight and dexterity to use a computer (regardless of computer literacy); and residence in a small town (less than 12,500) or surrounding area that was at least 25 miles away from an urban area of 12,500 or more. design in this phase of the women to women project, a total of 120 women were randomized into two groups. half participated in a computer intervention group, a 5month online peer support and health education experience. in a chat room "conversation," women in the intervention group shared information, personal experiences, and insights. in a second chat room, "healthchat," they discussed health information and health care issues. the other half of the women participated in the comparison group with no access to the computer-based intervention. all women were involved in the study for 10 months including participating in telephone interviews and completing repeated measures mail questionnaires at baseline, 2 1/2, 5, and 10 months. the virtual support group, “conversation,” was available 24/7 for asynchronous discussion on any topic. many of the messages concerned experiences with chronic illness and the health care system. this support group was of, for, and by the women, and while the research staff monitored the conversations, they rarely actively participated. the “healthchat” discussions focused on nine health and health care topics, each for two weeks. each week, the nurse monitor, who was a member of the research staff, posted questions to “healthchat” to stimulate discussion (cudney, sullivan, winters, paul, & oriet, 2005). as part of the topic concerning communicating with health care providers, the women first responded to the question, “what are some of your greatest frustrations in getting the health care you need?” in the week that followed, the second question was, “what have you done/can you do to reduce the frustrations associated with getting health care?” the messages from both “conversation” and “healthchat” were downloaded, deidentified, and loaded into nud*ist for coding and thematic analysis. these computer exchanges provided a rich qualitative database from which to examine the women’s perceptions of their health care. data analysis for the study being reported in this article, the secondary analysis of data associated with the women’s perceptions of the quality of their health care was conducted by a senior medical student at the university of new mexico as a thesis project. the focus of the investigation was to determine the women’s perceptions of and satisfaction online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 41 with their health care gleaned from wtw’s computer exchanges and from selected measures in the mail questionnaires. a two-pronged approach was used. first, chat room messages from the 53 women who completed the computer activities (7 did not complete) were thematically analyzed to determine which aspects of health care were of greatest importance to the participants. second, for the analysis of the questionnaire responses, baseline data were used from all study participants for whom there was complete information (n=110; 10 were incomplete). demographic and psychosocial variables were examined for association with the level of satisfaction with health care. analysis of messages. the women’s messages were categorized in a coding tree associated with the nud*ist qualitative analysis software system (qualitative solutions and research pty ltd, 1997). the approach to analyzing the messages in “conversation” consisted of two phases: deductive and inductive (sullivan et al., 2003). the deductive phase occurred during the design of the original wtw project. data were coded and sorted into categories according to the aims of the study, for example, “social support-given, received, and sought.” for the purposes of the secondary analysis, messages relating to health care were grouped into an additional deductive category, “health care system.” in the inductive phase, the “health care system” body of messages was scrutinized by the senior medical student who identified and categorized additional subthemes embedded in the messages. these included the major categories of positive, negative and neutral experiences associated with health care and sub-categories such as interaction with providers; efficacy of treatment; financial concerns; and accessibility of care. (see table 1 for complete list.) an eclectic approach to qualitative analysis (norwood, 2000) was used to analyze the data generated through the online health education program, “healthchat.” this blended deductive and inductive analytic processes. in the deductive phase, the data were coded according to the health information topics of the interactive educational discussions dealing with health promotion and health maintenance, e.g., communicating with your health care provider. the inductive phase entailed categorizing problems identified by the women and the strategies they suggested for dealing with the health topics discussed. toward a “satisfaction index.” since an in-depth exploration of the clientprovider relationship was not a central focus of the larger study, there was no measure that specifically addressed this area. thus, for this secondary analysis, a measure of client satisfaction, "satisfaction index," was constructed using data from one of the instruments that contained relevant items. the psychological adjustment to illness scale (pais) (derogatis & fleming, 1996) contained five items targeting the women’s satisfaction with/assessment of their treatment, each with a choice of four responses scored on a fourpoint likert scale. areas addressed in these items were: a. expectations about treatment; b. amount of information received about treatment; c. adequacy of content and detail of information given by health care staff; d. judgments regarding health care providers and the treatment provided; and e. assessment of health care today and the health care professionals who provide it. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 42 scores from the satisfaction items were summed to form a new five-item “satisfaction index” (si) to address our inquiry into the women’s level of satisfaction with their health care. test-retest reliability of the si, estimated by pearson correlation between the t1 and t2 survey administrations, was high (r=0.78, p<.001). internal consistency, at t1, estimated with cronbach's alpha, was adequate (.80). table 1 themes that emerged from inductive analysis of “health care system” positive provider conveys caring provides patient education collaborates available therapy (effective, tolerable) finances/insurance (positive perception of expense or ability to obtain aid) accessibility of care humor diagnostic process negative provider uncaring inadequate patient education non-collaboration unavailable therapy (ineffective) finances/insurance (negative perception of expense, inability to obtain aid) inaccessibility of care humor diagnostic process neutral provider expected collaboration therapy finances/insurance accessibility humor diagnosis self-reliance self-education alternative therapies (sought by participants) online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 43 psychosocial measures to explore factors associated with health care satisfaction, the scores from several available measures were used. the sickness impact profile (sip) (bergner, bobbitt, carter, & gilson, 1981), a 26 item behaviorally-based measure of health status, was used as a measure of the impact of disease on physical and emotional functioning. reported internal consistency for the sip was .94, and for this study it was .90. social support was measured by the 25-item personal resource questionnaire (prq85) (weinert & brandt, 1987). reliability for the prq was reported as .90; for this study, it was again .90. the quality of life index (qol) (ferrans & farrell, 1990; ferrans & powers, 1985), with an established reliability of .95, used 68 items to determine a person’s satisfaction with four aspects of life: health and functioning, socioeconomic, family, and psychological/spiritual. the qol reliability for this study was .92. scores from the social readjustment rating scale (holmes & rahe, 1967) were used as an indicator of major life events. this 43item scale attempts to measure the impact of life events and determine their relationship to subsequent illness. test-retest reliability ranged from .67 to .77 and criterion and construct validity were above .90. other data changes in self-reported health status were examined with single question, "how does your health compare to your health 2 ½ to 3 months ago? responses could range from 1 (“much worse”) to 5 (“much better”). standard demographic data were collected in a telephone screening interview. ethical considerations the wtw research-based project, including associated secondary analyses of study data, was approved by the montana state university human subjects committee. written consent was obtained from the women to participate in wtw and permit project data to be shared with health professionals, and, if appropriate, with the general public. appropriate assurances were given the women that no one could be identified in any published reports related to the study. findings sample among participants with complete data (n=110), their diagnoses included cancer (n=13), diabetes (n=27), multiple sclerosis (n=30), rheumatoid conditions (n=38), and other (2). the mean age was 50 years with an average of 14 years of education, 8 years since diagnosis, and a median annual income in the range of $35,000 to $39,999. content of messages the 53 women who completed the computer portion of the study generated 2,156 messages between the “conversation” and “healthchat” chat rooms, and 341 messages online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 44 made references to some aspect of health or health care. five health care themes predominated: treatment/therapies (34%), interactions with health care providers (22%), financial considerations in relation to health care (17%), and accessibility of care (10%). the most prominent theme, however, was the strong sense of self-reliance shown by the women in managing their illnesses (37%). often more than one theme emerged in a single message thus the percentages sum to more than 100%. self-reliance. throughout their computer exchanges, self-reliance was a strong theme in the women’s approaches to illness. ….i think it's really important to take an active role in preserving your own health and not just let the doctors tell you what to think and do. that way you feel you have some control over your own body and its health. self-reliance was expressed in a variety of ways. often the women demonstrated interest and resourcefulness in controlling their own therapy. they shared information on prescription drugs, diets, vitamins, and herbs, and recommended physical therapists, massage therapists, and physicians to one another. they also supported one another’s individual efforts in carrying out exercise regimens or quitting smoking. the women were strongly interested in self-education, sharing resources such as book titles, information from articles they had read, and announcements of seminars: i feel bad that when i was diagnosed with ms, that i was so sick and vulnerable that i didn't have it in me to research. i think if i had, i may have chosen a different course of action than steroid treatment, at least to start with…. i think it is very important to use all the available information and try to balance it all out. another stated, staying informed about my disease is the most important thing i can do to stop the frustration [with health care]. also it's taken me 2 yrs to realize and accept the fact that my doctors don't always have answers and they are not going to take the time to research all of the ins and outs of this disease. i'm going to have to do it myself!!! the theme of self-reliance was also woven throughout other health care themes, discussed below. treatment/therapies. frustration or delight with various modalities of treatment or therapy was a common theme among the women. the women frequently discussed the effectiveness and side effects of their medications, and many of their messages indicated frustration with dependence on multiple medications. "i really dislike being a walking pharmacy, and i think that is what i am anymore." the women expressed relief when the number of medications could be reduced. finally, the women gave recommendations to one another of other modalities, including massage therapy and counseling. interactions with health care providers. rapport with providers was extremely important to the participants. "i absolutely love [dr. x]! he's been so supportive and has online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 45 taken time to answer many of my questions and to just offer reassurance when i needed it." this positive statement contrasts with another woman’s experience: [my doctor] did manage to say 2 things that (as usual [sic]) did not help. 'a lot of people would be happy to be in as good of condition as you are' and, 'you need to start to exercise more. push it even if it makes you feel sick.' i have been working all day not to be depressed about it. throughout their messages, the women expressed the wish to be listened to, to be understood, to be given clear explanations of their conditions and therapies by their health care providers, and to take part in health care decision-making. subcategories within the provider theme included conveyance of caring and education, accessibility of the provider, and collaboration between providers or between provider and individual. one woman wrote: ...neurologists don't seem to like alternative medicine and vice versa. nutritionists (generally) don't have much time for medical doctors. chiropractors and medical doctors--the same! i know that there is always an exception to the rule, but it does seem that there could be a little more cooperation among all these caregivers. the desire for collaboration with their health care providers related strongly to the sense of self-reliance discussed above. the women were appreciative of those providers who included them in the process of managing illness; one woman commented on collaboration between providers in several disciplines: “it was wonderful to finally find people who worked with the ‘whole’ me to help me find a direction in my health care.” others, however, felt that their physicians failed to include them in treatment decisions. “i hated being treated like a recalcitrant child who needed to be patted on the head and sent home with a sugar pill.” participants worked to find new providers when collaboration was poor. participants also commented that they wanted their providers to be knowledgeable and willing to provide education concerning their illnesses. financial constraints. although the group’s median income was slightly above the state average (3 year [2000-2002] median montana income, $33,900) (u. s. census, 2005), financial concerns were a prominent theme. "our doctors are very good generalists…. i don't feel under-served in that at all. but going to [the city] is expensive. it is a six hour drive or a hundred dollars by plane." in another computer exchange one woman wrote: just incurred $2000 in medical bills, so i'm a little stressed!! then they tell you they will take $15 a month, but [they] don't understand that there are many people wanting at least that, and my $475 a month only goes so far. the women not only held concerns about the high cost of health care and travel to obtain care, but they also wished for their providers to understand the many obstacles they faced. accessibility of health care. a common theme was the disruption the women faced in their daily lives in order to obtain care: online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 46 "spring and summer is a very busy time. many have children underfoot, gardens to tender [sic], fields to assist with, vacations, visitors…etc. personally, i travel every wednesday to great falls, a 90 mile trip one way, to receive my chemo which lasts approx. 4 hrs in addition to the trip. i also try to shop in great falls to get fruits and vegetables…. i work full time and this is my busiest time of year." to compound the problem, this was one woman's experience after she arrived: the doctor was running behind his schedule and had overbooked, too. my appointment was at 10 a.m. and i saw him at 11:30. i didn't mind this as it happens to everyone all the time. but then the doctor (who was seeing me for the first time) was in a hurry to get through my visit. so 10 minutes later i was going out the door. thus, the difficulties of adjusting the responsibilities associated with rural living to accommodate health care provider appointment schedules became increasingly frustrating when providers themselves were not attentive or personally accessible. level of satisfaction overall, the women’s satisfaction with their health care was moderate. mean satisfaction index (si) score was 10.0 (sd +/2.8) on a scale that could range from 5 (least satisfied) to 20 (most satisfied). the actual scores ranged from 5-18. to begin to explore the factors associated with satisfaction with health care, the si was regressed on social support (prq85) (weinert & brandt, 1987), major life events (social readjustment scale) (holmes & rahe, 1967), health change (single item), degree of disability (sickness impact profile) (bergner et al., 1981), and quality of life (ferrans & powers, 1985). analysis was performed using spss regression and spss frequencies for evaluation of assumptions. no transformations were considered because the variables appeared normally distributed and no outliers were found after an examination of mahalanobis distance. on table 2 are displayed the correlations between the variables, the unstandardized regression coefficients (b) and intercept, the standardized regression coefficients (β), r2 change and total r2, and adjusted r2. r for the regression was significantly different from zero, f(4, 105) = 8.57, p < .001. for the three regression coefficients that differed significantly from zero, 95% confidence limits were calculated. the confidence limits for qol were -.254 to -.011, for life change .000 to .008, and health status change -.809 to -.038. only three of the independent variables contributed significantly (p < .05) to the prediction of health care satisfaction including qol, life change, and health status change. social support was retained in the model as significance level for the regression coefficient very nearly reached statistical significance (p = .058) and the aims of the analysis were not directed at hypothesis testing but toward hypothesis generation. altogether, about 25% (22% adjusted) of the online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 47 variability in health care satisfaction was predicted by knowing the scores on these four independent variables. table 2 stepwise regression of health variables on health care satisfaction variables md satisfaction (dv) qol life change health status change social support b β r2 change qol -.36** -.132* -2.12 .133** life change .32** -.32** .004* .194 .046** health change -.22** .03 -.06 -.424* -.186 .041* social support -.35** .46** -.26** .11 -.023 -.185 .026 means 10.0 17.0 137.1 2.7 intercept = 130.1 15.87 standard deviation 2.8 4.5 130.7 1.2 34.4 r2=.246 adjusted r2=.217 r=.496** *p < .05 **p< .01 discussion the interactive computer-based messages personalized the women’s experiences of isolation and focused on the women’s self-reliance, responses to treatment/therapies, relationship with their health care providers, financial constraints, and accessibility of care. as advocated by others (casebeer & verhoef, 1997; corner, 1991), the quantitative examination of the interactions of the women’s level of satisfaction with other measurable factors as related to the women’s more qualitative interactive messages was an attempt to gain a fuller and more insightful understanding of the women’s views of their health care. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 48 quantitative perspectives comparisons of the satisfaction index with quality of life, life and health status changes, and social support produced a somewhat limited perspective of the women’s level of satisfaction with their health care. interpretation of the correlations and regression coefficients requires an understanding that the lower the score on the satisfaction index, the “better” or more satisfied the participant was with their health care. for example, the higher the reported quality of life among the participants, the lower their score on the satisfaction index (indicating more satisfaction). likewise, more health changes and greater social support also predicted reports of greater satisfaction with health care. however, a greater degree of life changes resulted in less satisfaction. while these findings are of interest in terms of understanding what factors predict health care satisfaction among this sample, understanding the mechanism by which each independent variable relates to satisfaction with care is difficult. in all, the quantitatively measured explanatory variables accounted for only 25% of the variability in the women's satisfaction with their health care. thus, the qualitative data was critically important in elucidating other factors that influenced satisfaction. the women indicated that the quality of their communication and level of collaboration with their providers impacted their adaptation either negatively or positively. qualitative perspectives an expanded understanding of the women’s satisfaction with health care providers in these areas was found in their interactive messages. women living in less populous counties, farther from care, were likely to be more negatively impacted by the exigencies of travel, which they discussed extensively. those who indicated they had strong social support described being able to mitigate these difficulties by relying on friends or family to help with travel or with duties at work and home. the comments from the women in different diagnostic groups, who had significantly different levels of satisfaction with their health care, suggested that these differences may have been related to the nature of each illness, the level of its uncertainties, and the impact it had on their day-to-day activities or from the varying abilities of the health care system to address their unique needs. according to lemaistre (1999), one of the worst psychological abuses of the chronically ill by health care providers is the “stop complaining--you simply must adjust!” attitude. the depression experienced by the woman whose doctor said, “a lot of people would be happy to be in as good condition as you are” and the disappointment felt by the woman who was “treated like a recalcitrant child” illustrated the negative impact of these types of responses. the buoyancy felt by the woman who found “people who worked with the ‘whole’ me to help me find a direction in my health care” highlighted the power of a positive collaboration with a provider. the women’s comments often paralleled the strategies offered by buchholz (1993) for improving the health care provider-recipient relationship. the woman who advocated not letting the doctors “tell you what to think and do” and having “some control over your own body and its health” echoed buchholz’ philosophy of viewing the relationship between the “owner” of the body and the health care provider as going both ways and online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 49 requiring a give-and-take dialogue. the participant’s observation, “i think it’s really important to take an active role in preserving our own health,” reflected buchholz’s notion that chronically ill persons bring to the table their problems to be solved and a mind-set for working with the health care provider. in turn, the health care providers contribute the expertise and professional judgment that forms the basis for their counsel about effective adaptation patterns. if a productive relationship can be forged, chronically ill individuals can better manage their diseases on a daily basis, and, ultimately, adapt to their chronic illnesses more successfully (thorne et al. 2004). the women’s concerns about financial constraints were akin to reports of studies from other rural areas where higher percentages of women than men did not receive health care because of the high cost or lack of health insurance was a significant barrier to treatment (beck, jijon, & edwards, 1996). accessibility of care, particularly health care that required referral to a specialist in a distant city, was a unique problem because trying to meet a scheduled appointment involved leaving farm or ranch chores unattended for an extended time, a drain on limited energy pools, and added costs for gas and lodging. limitations the results of the analysis using the newly derived satisfaction index are preliminary and may not be extrapolated to other populations. to be of use in further research, the newly developed satisfaction measure must undergo sound psychometric evaluation. in the case of studies in which the quality of the client-provider relationship is a major focus, a mature, psychometrically sound measure with a good conceptual fit should be employed. a given limitation of a secondary analysis is that the data which are available may not perfectly address the research question or give information that would enrich the interpretation of findings. for example, it would be informative to know the gender mix of the providers and if the level of satisfaction and the computer comments varied based on provider gender. implications for intervention satisfaction with health care services is a contributing factor that can help rural women to adapt more successfully to living with their chronic illnesses. among those in this study, satisfaction with health care was influenced by their quality of life, life changes, and health status changes. important factors that shaped their perspectives of the health care they received included recognition of their self-reliance, effectiveness and side effects of therapy, rapport and collaboration with providers, financial constraints, and the degree of interruption of daily life and travel distances required to access care. urban-based health care providers serving chronically ill rural dwellers may improve satisfaction through an increased awareness and accommodation of these concerns. actions to improve care might include relationship-building that incorporates active collaboration in managing care, and better management of appointment scheduling to accommodate rural life styles, e.g., scheduling primary care and specialist referrals on the same or adjacent days and allowing more time during appointments. online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 50 conclusions and future directions these rural women’s observations about their experiences in dealing with chronic illness, in concert with their care providers, give direction for evidence-based practice and future research. providers need to improve interpersonal relationships; offer opportunity for collaboration in health care decisions; consider the implications of a long journey and time away from home on rural chronically ill women’s ability to meet appointments and follow treatment regimens; and recognize the impact of financial constraints on the women’s health care decisions. areas of future research include: psychometric evaluation of the newly developed satisfaction measure; primary research further exploring the rural-urban patient-provider relationship; investigation of the gender mix of the health care providers and its relationship to satisfaction with care; comparison of satisfaction of care between rural and urban women, women in a variety of rural contexts, and in different diagnostic groups; and examination of self-reliance as a driver of rural women’s satisfaction with the health care system. dissemination of findings related to quality health care for rural women may influence providers and policy makers alike. acknowledgments the women to women project was supported by ten different funding sources including nih, department of agriculture, and a variety of foundations and health associations. the authors thank amber spring and larry phillips for their assistance with manuscript preparation and data management. references bauer, k. 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[medline] online journal of rural nursing and health care, vol. 5, no. 2, fall 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=15667014&query_hl=48 http://www.nrharural.org/dc/issuepapers/ipaper13.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=14651679&query_hl=54 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=14725173&query_hl=56 http://www.census.gov/hhes/income/income02/statemhi.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=8685732&query_hl=57 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=3433744&query_hl=62 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=15681989&query_hl=64 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9248311&query_hl=66 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10549045&query_hl=68 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10154945&query_hl=70 microsoft word fahs_452-2701-1-ed.docx online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.452 1 editorial social determinants of health and rural nursing pamela stewart fahs, phd, rn, editor social determinants of health is a term defined by the healthy people 2020 (office of disease prevention and health promotion, n.d., section understanding) as “…conditions in the environment in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality of life outcomes and risks”. in this definition “place” matters, as does race/ethnicity, age, education, social support etc. – all of the factors that are part of one’s socio-economic status. thus being a rural dweller alone does not put your health at risk but if you are a rural dweller with little social and economic resources you will have a higher risk for ill health. you may need to use more resources to access health care than someone in a more urban place, simply because of limited accessibility. for those living in a rural setting without reliable transportation being able to access health care is more arduous than for those with access to transportation as well as health care. anyone with even a modicum of knowledge on the history of nursing can connect the profession and past efforts and successes in enhancing population health through work on the social determinants of health. this work can be seen in urban areas by nurses such as lillian wald at henry house in new york and rural areas in the work of mary breckenridge and the frontier nursing service. in both cases nursing was caring for individuals and families but also looking at the macro level problems of poverty, lack of formal education, poor housing, lack of access to health care; all of which would be deemed today as improving the social determinants of health. since the 1920’s with the work of wald and breckinridge we have made inroads into the health status of people in the us. in general we have better living situations for individuals online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.452 2 and families, more education and more wealth. however, the upward trajectory in health status over the years is not carrying all and healthy people 2020 (n.d.) promotes a place based organizing framework that addresses five major determinants of health: a) economic stability, b) education, c) social and community context, d) health and health care, and e) neighborhood and built environment. nursing has a clear role in providing health care beyond care of the individual. flynn (2016) writes that “…nursing may have more potential than other health professions in bringing power and authority to the idea of social determinants and incorporating this content into training and professional perspectives” (p.7). how as nurses do we influence social determinants of health? first, in order to address an issue, nurses have to be aware of the problems posed. the problems are not ones with an easy or quick fix. nurses need to use our abilities to collaborate and coordinate with other professions to address these broad problems. interventions must go beyond the micro or individual problems to the macro level of the issues. this type of intervention requires that we use our collective power, experience and knowledge to address issues of families, communities and societies. there is an ever increasing need for nurses to influence health policy. nurses can also be instrumental in helping to assure that the environments in which our population lives is one that supports health and wellness. it is as imperative today has it has ever been for nurses to be leaders in all facets of health care. references flynn, m. (2016). health plus social: in inquiry into the social determinants of health. ca: usc school of social work, green house. office of disease prevention and health promotion (n.d.). healthy people 2020. author. retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/socialdeterminants-of-health microsoft word 35-442-2-ed_atav1.docx online journal of rural nursing and health care, 12(1), spring 2012 29 comparison of coding schemas for rural-urban designations with new york state counties and birth outcomes as exemplars a. serdar atav, ph.d. 1 rosa darling, ph.d., rnc-nic 2 1 associate professor, decker school of nursing, binghamton university, atav@binghamton.edu 2 clinical assistant professor, decker school of nursing, binghamton university, rdarling@binghamton.edu abstract purpose: the purposes of this article are to provide background information on the agencies responsible for the development of rural coding schemas at the county level, to explain the types of codes and the definitions of terms included in the codes, and to provide a concise table that presents the assigned codes for each county in new york state. findings: roles of u.s. census bureau, office of management and budget, and economic research service were described. at the county level, urban influence codes, rural urban continuum codes, and nchs codes were outlined and compared. ruca and frontier community codes were discussed as non-county based rural classification schemas. conclusions: nursing is integral to the attainment of better health outcomes through advocacy and policy recommendation at federal, state, and local levels. accurate measures of rurality should be applied at the decision making level for the allocation of scarce resources that support projects and programs most effective for vulnerable rural populations. maintaining policies that benefit vulnerable populations requires funding; but needs analyses using inappropriate coding schemas can result in lack of funding or the implementation of policies that are ineffective for the targeted population. this study attempted to elucidate nuances among the three rural coding schemas and demonstrated that using the appropriate rural coding schema may highlight rural/urban health disparities more clearly. keywords: classification schemas, county, rural definitions, rural-urban codes, new york state comparison of coding schemas for rural-urban designations with new york state counties and birth outcomes as exemplars nursing is integral to the attainment of better health outcomes through advocacy, participation in policy recommendation at the local, state, and national levels, and through the provision of skilled care for vulnerable populations in community and hospital settings. working in tandem with policy planners, advanced practice nurses play a key role in ensuring that the voice of nursing is heard and that evidence-based practices are implemented (bent, 2011). policies and programs that achieve better health outcomes are vital for both rural and urban settings. however, attainment of appropriate policies and programs can be difficult since the definitions of rural and urban are complex. to date, there are over a dozen definitions for rural and urban that are being used by federal agencies (cromartie & bucholtz, 2008). definitions for urban and rural have been based on three concepts: the administrative concept, the land-use concept, and the economic concept. the administrative concept defines online journal of rural nursing and health care, 12(1), spring 2012 30 urban based on municipal boundaries or jurisdictional boundaries while the land-use concept employs definitions based on population density. the concept most often used for rural research is the economic concept that is based on commuting patterns that allow rural areas to access the labor, trade, and media markets found in urban locations (cromartie & bucholtz, 2008). from a health policy perspective, in order to match the administrative structures responsible for policy implementation and evaluation, policy analyses and recommendations need to be conducted at the county level rather than smaller geographic areas. yet, some classification schemas assign codes for statistical areas that cross county and state lines. maintaining policies that benefit vulnerable populations requires funding; but needs analyses using inappropriate coding schemas can result in lack of funding or the implementation of policies that are ineffective for the targeted population. new york state: an exemplar there are 62 counties in nys. the economic base of each of these counties is dependent, in part, on federal grants that are determined by the rural or urban classification of the county. counties have been designated as rural or urban by one system, as nonmetropolitan or metropolitan by another and as metropolitan statistical or micropolitan statistical areas by a third. there is a need for articulation of the meanings embedded in different codes and their relationships to the counties of new york. among the agencies that have developed classification codes, there is no standard method of classification. definitions of rural have been based on geographical units of counties, zip codes, and census blocks. counties are political jurisdictions that have stable boundaries, but they vary greatly in population and landmass. in addition, larger counties possess both urban and rural areas. while zip codes are more precise than county designations, they are used primarily by the postal service and tend to change more frequently. census blocks are the most precise. “policies based on census tract definitions can be hard to implement, because census geography information is not commonly used by programs and payers, including medicare intermediaries, insurance companies, and medicaid” (coburn et al., 2007). classification schemas chosen by researchers or policy analysts are often based on the applicability of their definitions to policies, populations, and desired outcomes. for example, choosing a classification scheme whose definition is inappropriate can result in the lack of accessibility of a program designed for rural populations that are located within a metropolitan or urban county. the purposes of this article are to provide background information on the agencies responsible for the development of coding schemas at the county level, to explain the types of codes and the definitions of terms included in the codes, and to provide a concise table that presents the assigned codes for each county in new york state. agencies responsible for developing codes there are four agencies that have developed codes: the united states (us) census bureau, the office of management and budget (omb), the economic research service (ers) of the us department of agriculture (usda), and the national center for health statistics (nchs) of the center for disease control and prevention (cdc). the first two have provided definitions based on population and land area. the ers has devised the codes that are used to determine eligibility for federal grant programs in rural areas, by policy makers when they implement programs and laws, and by researchers and government agencies for statistical consistency and accuracy in their studies (rural assistance center, 2009). the nchs codes are based on the codes devised by the other three agencies and are used with the nchs data systems “to study the association online journal of rural nursing and health care, 12(1), spring 2012 31 between urbanization level of residence and health and to monitor the health of urban and rural residents” (center for disease control and prevention, 2006). u.s. census bureau. “the census bureau identifies and tabulates data for the urban and rural populations and their associated areas solely for the presentation and comparison of census statistical data (u.s. census bureau, 2002). the census bureau has divided geographic areas into census block groups. for the 2000 census, the bureau defined urban by territory, population, and housing units. the classification of urban was further divided into urban areas and urban clusters. urban areas have populations of at least 50,000 and urban clusters have populations between 2,500 and 50,000. each of these classifications was determined by total land area and population. urban areas and urban clusters each have core areas as well. core areas are within the urban area or urban cluster and have a population density of 1,000 per square mile (coburn et al., 2007). the census bureau classified rural as all territory, population, and housing units located outside of urban areas and urban clusters (u.s. census bureau, 2002). “the bureau’s definition is the only federal definition that applies the term ‘rural’ in an official, statistical capacity, allowing it to be viewed as the ‘official’ or ‘default’ definition of rural.” (rural assistance center, 2009). although the definitions are used as a basis for the ers classifications, the census bureau’s urban areas and urban clusters are not assigned by county. in new york, there are 16 urban areas, some of which extend into pennsylvania, connecticut, and new jersey and 116 urban clusters, most of which are towns or cities. office of management and budget. the omb classifies population and areas solely for statistical purposes. in 2003, the omb developed the designations of metropolitan, micropolitan, and combined statistical areas so that national definitions would be consistent (bolten, 2004; rural assistance center, 2009). designations are updated annually to reflect changes in population estimates. “the omb classifies counties as metropolitan, when one or more county is the ‘core’ and other counties are included based on commuting patterns into the core” (coburn et al., 2007). according to the omb, counties included in metropolitan and micropolitan statistical areas contain both urban and rural territories and populations (bolten, 2004). a metropolitan area contains at least one central county with urbanized areas. micropolitan counties are located outside metropolitan areas and are divided into micropolitan areas and noncore counties. micropolitan areas have at least one urban cluster with a population between 10,000 and 50,000 plus adjacent territory with high commuting ties (coburn et al., 2007; office of management and budget, 2008). combined statistical areas are groupings of metropolitan and micropolitan statistical areas. since they are combinations of these areas, they cannot be compared with individual metropolitan and micropolitan statistical areas (office of management and budget, 2008). as of 2008 in new york, there were 14 metropolitan statistical areas, 15 micropolitan statistical areas, and 6 combined statistical areas. a complete list of these areas can be found at http://www.whitehouse.gov/omb/assets/omb/bulletins/fy2009/09-01.pdf. although this document is large, it provides lists of these areas for all states in list 6 beginning on page 112 of the document. economic research service. the economic research service (ers) of the united states department of agriculture’s office of rural health policy is an agency in which research is conducted that provides information on economics and policy for decision making in the areas of food, farming, natural resources, and rural development (united states department of agriculture, 2009). ers is the agency responsible for developing the urban influence codes online journal of rural nursing and health care, 12(1), spring 2012 32 (ui), the rural-urban continuum codes (rucc), and the rural urban commuting area (ruca) codes. types and definitions of codes county level codes. urban influence codes. in 2003, the ers revised ui codes based on changes in omb definitions. these codes were designed to capture differences that exist among economies so that smaller economies would be able to benefit from the influences of information, communication modalities, trade, and finance they could access in urban economies (united states department of agriculture economic research service, 2007). for that reason, using census bureau definitions, counties have been designated as metropolitan, micropolitan, and noncore based on population, land area, and commuting patterns. metropolitan counties are coded as 1 or 2 and nonmetropolitan counties are coded as 3-12. table 1 provides a summary of these codes. rural urban continuum codes. in 2003, the ers also revised rucc using omb designations of metropolitan and nonmetropolitan as a basis for the revision. while working with county level data, these codes allow researchers to subdivide nonmetropolitan data into more precise residential groups that permit the analysis of trends applicable to rural locations and proximity to metropolitan locations (united states department of agriculture economic research service, 2004). metropolitan counties are coded 1-3, based on population, and nonmetropolitan counties are coded 4-9 based on urban population in the county and whether they are adjacent to a metropolitan area. table 2 shows a summary of these codes. national center for health statistics. the nchs codes classify all us counties and county equivalents as either urban or rural based on a six-level scheme. definitions are based on omb definitions and rucc and uic classifications (center for disease control and prevention, 2006). within this classification scheme, large metropolitan central counties are coded as most urban and nonmetropolitan noncore counties are coded as most rural. large metropolitan counties are divided into the categories of large metro central, code 1, and large metro fringe, code 2, to differentiate between the health measures reported for the residents living in these two types of counties. there are 36 metropolitan counties and 26 nonmetropolitan counties in new york state. included in the 26 nonmetropolitan counties are 11 nonmetropolitan noncore counties. a weakness of the nchs classification schema is that all noncore counties are coded as 6. by grouping the 11 nonmetropolitan noncore counties together, smaller noncore counties with limited resources may be at a disadvantage as they attempt to implement and maintain programs that address their unique health measures. according to the nchs, their county classification scheme should only be used for data files in which data for all counties have been reported (center for disease control and prevention, 2006). information about this classification scheme and data sets can be accessed at http://www.cdc.gov/nchs/data_access/urban_rural.htm. table 3 shows the descriptions and definitions for each of the nchs codes. additional codes. ruca codes. the ers, working with the wwami rural health research center of the university of washington, developed the ruca codes. these codes are based on census tracts and use the “bureau of census urbanized area standard and place definitions in combination with commuting information to characterize rural and urban status of census tracts” (rural assistance online journal of rural nursing and health care, 12(1), spring 2012 33 center, 2009). ruca codes are tiered based on level of commuting and primary flow to urban areas and urban clusters. codes 1-3 are for metropolitan areas, codes 4-6 are for micropolitan areas, codes 7-9 are for small rural town cores, and code 10 is for an isolated small rural area. the ers has a spreadsheet on its website at http://www.ers.usda.gov/data/ruralurbancommutingareacodes/2000 that provides 2000 ruca codes by either state census tracts or all us census tracts. the wwami research center provides a zip code approximation of ruca codes at its website http://depts.washington.edu/uwruca/ruca-data.php where two choices are available: general methods or census tract ruca codes (rural health research center, n.d.a.). since ruca codes use smaller geographic units, this system is more precise than county-based coding systems (washington state department of health, 2009). in the healthcare arena, use of ruca codes can help to delineate areas of poverty, and to support the need for federally funded programs for those living in impoverished locations. in addition, ruca codes are valuable for the determination of provider ratios for specific areas, especially when those smaller areas are located in larger metropolitan areas. frontier community codes. the federal office of rural health policy in collaboration with ers is working on a new definition of rural. this project, to have been completed in 2011, will provide a standardized definition for rural frontier/remote (rural health research center, n.d.b.). the national center for frontier communities has defined frontier as “fewer than seven people per square mile” (rural assistance center, 2011). the designation of frontier is achieved through a point scale that totals a maximum of 105 points. points are awarded for density, distance, and travel time. an area needs to accrue 55 points to reach the designation of frontier. the detailed point scale can be found at http://www.frontierus.org/documents/matrix.htm (national center for frontier communities, n.d.). comparison of alternative coding schemas based on the definitions for each of the codes and the foci of the agencies responsible for assigning codes, counties whose code numbers are different may actually be defined essentially the same way. the urban influence codes, the rucc, and the nchs classification schemes all assign a code of “1” for metropolitan counties whose population is equal to or greater than 1 million, but nchs further divides its metropolitan counties into central and fringe counties with populations equal to or greater than 1 million to address the diverse health needs that exist in these types of counties (center for disease control and prevention, 2006). an rucc of “2” has essentially the same definition as an nchs code of “3,” indicating counties in metro areas with populations of 250,000 to 1 million. an rucc of “3” has essentially the same definition as an nchs code of “4,” indicating counties in metro areas with populations of fewer than 250,000. the urban influence code “2” corresponds to the ruccs “2” and “3” and the nchs codes “3” and “4.” examination of the coding schemes through contingency tables demonstrated that only 7 counties are coded as “1” and only 5 counties are coded as “6” in all three classification schemes. the remaining county codes may be similar for two of the agencies and differ for a third or may differ for all three agencies. for example, alleghany county has a different code for each classification scheme. the urban influence code for alleghany county is “9,” the rucc is “7,” and the nchs code is “6.” clinton county’s urban influence code is “8” while both the rucc and nchs codes are “5.” seneca county’s urban influence code is “3,” but it is “6” for both online journal of rural nursing and health care, 12(1), spring 2012 34 rucc and nchs codes. these three counties highlight the differences that exist in the assignment of county codes. it is not difficult to see why county code designations require articulation. it is necessary to understand both the purposes of the agencies which assign codes and the definitions of the codes themselves. tioga county, in nys, illustrates this well. based solely on its 2007 population of 50,453, tioga county would be classified as a rural county by any conceptual measure. however, since it is located near a metropolitan area with a population of 50,000-250,000 and a substantial number of its residents commute from a nonmetropolitan to a metropolitan area for employment, tioga county is classified as a “2” for urban influence code, “2” for rucc, and a “4” for nchs. when deciding on the classification scheme, it is important to remember that the terms rural and nonmetropolitan are not equal. the term nonmetropolitan includes the county commuting patterns. since nchs codes differentiate between health measures that exist in the counties, the assigned code of “4” identifies tioga as a county with health measures consistent with counties in metropolitan areas containing populations of 50,000-249,000. table 1 shows the codes for each of the classification schemes presented in this paper and table 2 provides comparisons of the codes and their definitions for the three classification schemas. from a perusal of table 2, one can see that using nchs codes can simplify analyses since the groupings of micropolitan counties and noncore counties have resulted in fewer codes. however, the simplicity of this coding system is only valuable when this classification schema is the best choice for the research being conducted. application of codes in the analysis of birth outcomes in new york state counties the importance of choosing the appropriate rural coding schema can be demonstrated using low birth weight (lbw) as an example. healthy people 2010 and healthy people 2020 include the improvement of the health of women, infants, and children as goals. both emphasize the importance of maternal physical and emotional health and both recognize the effect their absence can have on birth outcomes. both call for the reduction of lbw (peck & alexander, n.d.). many nurse researchers have addressed issues, in general, related to poorer birth outcomes such as race, smoking, and substance abuse. african american women have the highest rate of lbw (center for disease control and prevention, 2002, july 12; gorman, 1999; kramer & hogue, 2008; laditka, laditka, & probst, 2006; nabukera et al., 2009). a goal of both healthy people 2010 and rural healthy people 2010 is the reduction of substance abuse (peck & alexander, n.d.). lbw is defined as a birth weight less than 2500 grams (5.5 pounds) at birth and vlbw is defined as less than 1500 grams (3.3 pounds) at birth. data for vlbw, by definition, are included in lbw data. from 2006-2008 in nys, the percentages of lbw and vlbw infants were 8.2% and 1.5% respectively (new york state department of health, 2010a, 2010b). online journal of rural nursing and health care, 12(1), spring 2012 35 online journal of rural nursing and health care, 12(1), spring 2012 36 for the purposes of this exemplar, birth outcomes was defined as lbw, but not vlbw (>1500 grams to 2500 grams), with an attempt to capture nuances for this population of infants that may help guide policy makers as they evaluate programs to help reduce the incidence and prevalence of lbw. using lbw but not vlbw (between 1500 and 2500 grams) as an outcome variable, neither rucc nor urban influence codes yielded any significant differences among nys counties. hence, one could conclude that rurality is not related to birth outcomes. however, when the same analysis was conducted using the nchs schema, the results indicated significant differences among nys counties, contradicting the previous results. this finding reinforces the necessity for carefully choosing the coding schema that provides the basis for decisions regarding policies, programs, and resource allocations. the classification schema chosen may change the amount of federal funding allocated for the implementation and support of programs that are important for the reduction of this birth outcome so that policy gaps and needs that yield more convincing scientific evidence are illuminated. policies that address teen pregnancy and birth rates, substance abuse, and medicaid providers are of particular value for the reduction of lbw and lbw, but not vlbw. online journal of rural nursing and health care, 12(1), spring 2012 37 conclusion the role of nurses at all levels of care is vital for the reduction of health disparities and the attainment of better health outcomes. nurses advocate and lobby for the vulnerable and underserved populations. advanced practice nurses and nurse researchers must participate in online journal of rural nursing and health care, 12(1), spring 2012 38 policy formulation at state and national levels so that best practices are implemented as a result of evidence-based practice research. in the light of the recent major cuts in federal budgets, securing funding for improving the health of vulnerable populations has become even more challenging for the nursing profession. accurate measures of rurality should be applied at the decision making level for the allocation of scarce resources that support projects and programs most effective for vulnerable rural populations. this study attempted to elucidate nuances among the three rural coding schemas and demonstrated that using the appropriate rural coding schema may highlight rural/urban health disparities more clearly. “the key is to use a rural-urban definition that best fits the needs of a specific activity, recognizing that any simple dichotomy hides a complex rural-urban continuum, with very gentle gradations from one level to the next” (cromartie & bucholtz, 2008, p. 29). in this study new york state counties and birth outcomes have been used as exemplars. other states and health outcomes need to be studied in similar manners to guide researchers and policy makers in their decisions. there are limitations to each of these coding systems. since they are based on commuting patterns and populations, they do not specify whether a county is rural or urban. as county populations and commuting patterns shift, codes can change. it is the responsibility of researchers and grant writers to decide which code best fits the project on which they are working based on the aggregates included in the study as well as the aggregates excluded from the study and to provide clear explanation that justifies the code’s implementation. references bent, k.n. (2011). where policy hits the pavement: contemporary issues in communities. in d. j. mason, j. k. leavitt, & m. w. chaffee (eds.), policy & politics in nursing and health care. (6 th ed.), (pp. 651-658). st. louis, mo: elsevier. bolten, j. b. (2004). omb bulletin no. 04-03. retrieved from http://www.whitehouse.gov/omb/ bulletins_fy04_b04-03 center for disease control and prevention. (2002). infant mortality and low birth weight among black and white infants united states, 1980-2000. morbidity and mortality weekly report, 51(27), 589-592.[medline] center for disease control and prevention. (2006). 2006 nchs urban-rural classification scheme for counties. retrieved from http://www.cdc.gov/nchs/data_access/urban_rural .htm coburn, a. f., mackinney, a. c., mcbride, t. d., mueller, k. j., slifkin, r. t., & wakefield, m. k. (2007). choosing rural definitions: implications for health policy. retrieved from http://www.rupri.org/forms/ruraldefinitionsbrief.pdf cromartie, j., & bucholtz, s. (2008). defining the "rural" in rural america [electronic version]. amber waves, 6, 28-34, retrieved from http://www.ers.usda.gov/amberwaves/june08 /features/ruralamerica.htm gorman, b. k. (1999). racial and ethnic variation in low birthweight in the united states: individual and contextual determinants. health & place, 5, 195-207. [medline] ingram, d. d., & franco, s. (2009). 2006 nchs urban-rural classification scheme for counties. retrieved from http://wonder.cdc.gov/wonder/help/cmf/urbanization-methodology.html kramer, j. r., & hogue, c. r. (2008). place matters: variation in the black/white very preterm birth rate across u.s. metropolitan areas, 2002-2004. public health reports, 123, 576585. [medline] http://www.ncbi.nlm.nih.gov/pubmed/12139201 http://www.ncbi.nlm.nih.gov/pubmed/10984575 online journal of rural nursing and health care, 12(1), spring 2012 39 laditka, s. b., laditka, j. n., & probst, j. c. (2006). racial and ethnic disparities in potentially avoidable delivery complications among pregnant medicaid beneficiaries in south carolina. maternal & child health journal, 10(4), 339-350. [medline] nabukera, s. k., wingate, m. s., owen, j., salihu, h. m., swaminathan, s., alexander, g. r., & kriby, r. s. (2009). racial disparities in perinatal outcomes and pregnancy spacing among women delaying initiation of childbearing. maternal & child health journal, 13(1), 81-89. [medline] national center for frontier communities. (n.d.). definition of frontier. retrieved from http://www.health.ny.gov/statistics/chac/birth/vlowbwt.htm new york state department of health. (2010). low birthweight births (<2500 grams) percent of live births. retrieved from http://www.health.state.ny.us/statistics/chac/ birth/lowbwt.htm new york state department of health. (2010). very low birthweight births (<1500 grams) percent of live births. retrieved from http://www.health.state.ny.us/statistics/ chac/birth/vlowbwt.htm office of management and budget. (2008). omb bulletin no. 09-01: appendix. retrieved from http://www.whitehouse.gov/omb/assets/omb/bulletins/fy2009/09-01.pdf peck, j., & alexander, k. (n.d.). maternal, infant, and child health in rural areas. rural healthy people 2010. rural assistance center. (2009). what is rural? frequently asked questions. retrieved from http://www.raconline.org/info_guides/ruraldef/ruraldeffaq.php rural assistance center. (2011). frontier frequently asked questions. retrieved from http://www.raconline.org/info_guides/frontier/frontierfaq.php howmuch rural health research center. (n.d.a.). ruca data. retrieved from http://depts.washington .edu/uwruca/ruca-data.php rural health research center. (n.d.b.). ruca. retrieved from http://depts. washington.edu/uwruca/ u.s. census bureau. (2002). census 2000 urban and rural classification. retrieved from http://www.census.gov/geo/www/ua/ua_2k.html united states department of agriculture. (2009). economic research service: overview. retrieved from http://www.ers.usda.gov/abouters/overview.htm united states department of agriculture economic research service. (2003). 2003 urban influence codes. retrieved from http://www.ers.usda.gov/data/urbaninfluence codes/2003/ united states department of agriculture economic research service. (2003b). measuring rurality: rural-urban continuum codes. retrieved from http://ers.usda.gov/ data/ruralurbancontinuumcodes/2003 united states department of agriculture economic research service. (2004). measuring rurality: rural-urban continuum codes. retrieved from http://www.ers.usda.gov/ briefing/rurality/ruralurbcon/ united states department of agriculture economic research service. (2007). measuring rurality: urban influence codes. retrieved from http://www.ers.usda.gov/briefing/rurality/urbaninf/ washington state department of health. (2009). health data guidelines. retrieved from http://www.doh.wa.gov/data/guidelines/ruralurban1.htm http://www.ncbi.nlm.nih.gov/pubmed/16496219 http://www.ncbi.nlm.nih.gov/pubmed/18317891 microsoft word jones_366-2012-2-ed.docx online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 88 lessons learned: a mixed methods analysis of barriers to swing bed utilization in critical access hospitals in montana faith jones, msn, rn, nea-bc 1 tawnie sabin, jd, bsie 2 karen l. roper, phd 3 samuel crocker 4 roberto cardarelli, do, mph 5 1 chief clinical officer; mineral regional health center, frontier medicine better health partnership, superior mt, fjones@mymrhc.org 2 director of community and lean coordination; mineral regional health center, frontier medicine better health partnership, superior mt, tsabin@mymrhc.org 3 research associate; university of kentucky, department of family & community medicine / division of community medicine, lexington, ky, karen.roper@uky.edu 4 university of kentucky, department of family & community medicine / division of community medicine, lexington, ky, samuel.crocker@uky.edu 5 professor and chief of community medicine; university of kentucky, department of family & community medicine / division of community medicine, lexington, ky, rca234@uky.edu abstract purpose: critical access hospitals (cahs) provide access to care and economic stability to rural online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 89 regions. at times rural populations need higher-level health care from distant urban-based acute care hospitals (achs), distancing them from their social network. sample/method: this paper evaluates potential barriers to transferring patients back to cah swing beds for restorative care through formative interviews with staff from both achs and cahs. four cahs also completed workflow analytics to identify process factors that impede timely transfer of patients from achs to cah swing beds. findings: thematic messages included a lack of consensus about swing bed eligibility criteria and delay in response from cahs on transfer requests. workflow analytics identified numerous opportunities to improve efficiency in transfer requests. results showed an average of 217.5 hours were required from time of transfer request to when the patient arrived to the cah. conclusions: educational programs are underway to help address these knowledge deficiencies and process barriers. keywords: critical access hospital (cah), rural, swing beds lessons learned: a mixed methods analysis of barriers to swing bed utilization in critical access hospitals in montana rural populations in the us suffer disproportionate rates of disease and access to care (amey, miller, & albrecht, 1997; blair et al., 2006; higginbotham, moulder, & currier, 2001; liff, chow, & greenberg, 1991; monroe, ricketts, & savitz, 1992). elder rural populations, already known for high rates of poverty and low educational levels, experience more medical conditions and greater functional limitations than their urban counterparts (congdon & magilvy, 1998a, 1998b). this known phenomena is compounded by the distant access to tertiary medical care when needed (calonge, 2001), and further complicates discharge planning for these online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 90 patients, especially when they require skilled-care to maximize the probability of re-stabilized health. most transition care processes at (primarily) urban-based acute care hospitals (achs) involve in-patient or transfers to skilled nursing facilities (snfs) within the urban setting. indeed, approximately 20 percent of medicare beneficiaries alone are discharged to snfs, with an average length-of-stay of 27 days (grabowski, 2010; herndon, bones, kurapati, rutherford, & vecchioni, 2011). for a rural and frontier patient, this lengthens the time away from one’s community, family, and social network, potentially impairing the restorative process. repeated research has found a strong sense of independence by rural elders and an influential family support network that may influence the decision-making process to seek care that is distant from one’s home (craig, 1994; johnson, weinert, & richardson, 1998; magilvy, congdon, & martinez, 1994). older rural populations depend on family and their social network during time of acute or advanced chronic care (long & weinert, 1991), and one qualitative study found that many of these individuals consider transition of care away from home as “crises”, and decisions were often made “hastily”(magilvy & congdon, 2000). receiving restorative care at a cah allows individuals to be re-immersed within their social network and families and, in most cases, easily transition back to their primary care home. while cahs serve an important role in providing acute care in rural/frontier areas, they remain underutilized in transitional and skilled-care from achs (schlenker & shaughnessy, 1989). this is a lost opportunity to bring patients closer to their communities, and, simultaneously, assist in the stability of the cahs by using vacant hospital beds (magilvy & congdon, 2000). indeed, many cahs struggle financially in the us as a result of high rates of empty beds (li, schneider, & ward, 2007; schlenker & shaughnessy, 1989). in the late 1980’s online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 91 approximately 9% of covered snf admissions in the us were to small, rural hospitals or cahs known as swing beds that participate in centers for medicare and medicaid services (cms) and have approval to provide post-hospital care (silverman, 1990). in montana, a decidedly rural state with 45 of its 56 counties considered ‘frontier’ based on population density (montana department of public health & human services, 2011), the status of cahs has enormous impact both on local economy and resident health status. while swing-bed utilization rates in the state are variable, the service is still not self-supporting and many cahs in montana no longer offer snfs (since 2003, approximately 15 cah-based snfs have closed). efforts must be made to sustain cahs as research has demonstrated the substantial economic impact they have in rural counties through tax generation and workforce development (ona & davis, 2011). the current gap of utilization includes the lack of knowledge by achs of the accessible swing bed services offered by cahs. this available service also goes unrecognized by eligible patients as this service or option is not offered. little is known about the factors that impede the utilization of swing beds in cahs for restorative care and there has been scarce research on the topic. the intent of this mixed-methods quality improvement program was to elucidate the opinions of key personnel in the discharge and admission processes of achs and cahs in montana and apply lean methods to conduct workflow analyses in an effort to identify process barriers. methods mineral regional health center in superior, mt received a health care innovation award from center for medicare and medicaid innovation (cmmi) in july 2012 to form the center for frontier medicine innovations and research with the mission to improve the health and well-being of montana residents. the center for the advancement of healthcare education online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 92 and delivery institutional review board (irb) determined the research reported here to be exempt (irb00009003). montana, with 99.7% of its land mass designated as rural ("2010 census urban and rural classification and urban area criteria," n.d.), is served by 46 critical access hospitals (cahs) and 9 acute care hospitals (achs), 25 of which were partners on the montana cmmi program. for the current program, formative interviews were conducted with case management directors and case manager staff at the two achs and with the directors of nursing, case managers, and key nursing staff from two cahs to assess their understanding about the swing bed program and its appropriate use, swing bed criteria, and their usage and experiences in transferring patient to cah swing beds. this convenience sample was selected by sending invitations to the cmmi program cah partners, of which two agreed to participate, one from each side of the state. the two ach serving the same general catchment community areas as the two cahs also agreed to participate. group and individual interviews were conducted by the montana cmmi program’s chief clinical officer (cco). interviews were prompted by only 5 open-ended questions including, “what do you know about swing beds?”; “what type of patients are suitable for transfer for swing bed care?”; “what are the criteria for swing bed transfers/admittance?”; “what are your perceived benefits of using swing beds?”; “what are the barriers or reasons for not using swing beds?”. all interviews were captured with manual notes and were transcribed and reviewed to ensure accuracy of the information. any clarifications were made directly with the interviewees after the interviews. the cco and another staff member independently reviewed the data highlighting themes and messages based on the root questions listed above. these were then compiled and categorized by the research team to identify barriers and opportunities related to swing bed use by achs. online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 93 workflow and time-point analyses were then performed in five cahs (two of which participated in the interviews described above) using lean healthcare west methods. again, these 5 cahs represent a convenience sample and agreed to participate. cah case managers or nursing supervisors responsible for patient transfer completed data entry sheets to document various specific elements in each of the 6 process categories, the time to complete each process category, and the time to progress to the next process category (i.e., waiting time). these 6 categories included (1) contact by achs, (2) determine swing bed availability, (3) evaluate admitting criteria for swing bed use, (4) identify an accepting physician, (5) schedule the transfer, and (6) admit to the cah swing bed. an event was defined as being contacted by an ach for a potential transfer to a cah swing bed. elements of each process category were then determined and documented. minimum, maximum, and average times to complete each process category, and the transition between each process category, were analyzed using value stream mapping by evsm software. results formative interviews individual and group interviews were conducted with 22 directors of nursing, care management, and discharge planning staff members in 2 cahs and 2 achs. these interviews resulted in four overarching themes discussed below. benefits of bringing patient closer to home. the general consensus was that there was value to bringing patients closer to home for their remaining post-acute care needs. there was an understanding of the importance of having patients closer to families and their social networks. interviewees sensed this was important and preferred by patients. online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 94 understanding of swing bed criteria. discussions about swing bed admission criteria were assessed and compared against formal criteria set by cms (table 1). table 1 swing bed admission criteria* 1. be ordered by a physician 2. require the skills of technical or professional personnel 3. be furnished directly by, or under the supervision of, such personnel 4. be provided on a daily basis for a condition: a. for which the beneficiary received inpatient hospital or inpatient critical access hospital (cah) services; or b. which arose while the beneficiary was receiving care in a swing bed hospital for which he or she received inpatient hospital or inpatient cah services. *source: code of federal regulation, 42 cfr 409.31 [48 fr 12541, mar. 25, 1983, as amended at 58 fr 30666, may 26, 1993; 68 fr 50854, aug. 22, 2003; 70 fr 45055, aug. 4, 2005] there was a significant lack of consensus in both knowledge of swing bed criteria for admission and their interpretation. for example, many believed that if a patient did not have a condition that required rehabilitation therapy performed by a physical therapist (pt), occupational therapist (ot), or speech therapist, then the patient did not qualify for swing bed care and needed to be discharged either to home or to a nursing home to receive nursing care. another disconnect was related to the acuity of the patient and the appropriateness to be transferred to a swing bed. at the ach, patients were deemed appropriate for post-acute care following their minimum 3-day stay. however, upon receiving the patient at the cah, the cah staff evaluated and determined the patient as still needing acute care and, therefore, admitted to online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 95 acute care instead of swing care. this misunderstanding created a readmission statistic for the ach, exacerbating the communication barriers between the two organizations. services available at swing bed cahs. there was also a general lack of understanding of the significant heterogeneity in services provided by cahs. a large amount of posthospitalization care needed is secondary to orthopedic-based procedures such as knee and hip replacements, requiring formal pt/ot. many cahs lack pt/ot providers. on the other hand, swing beds are often overlooked as a source for restorative care including nutritional support and strengthening. paradoxically, these are services that most cahs can offer as these are delivered by nurses. timeliness of cah acceptance notification. a clear thematic message from the interviews was a prolonged response from cahs in either accepting or denying transfer requests. discharge planning is pressured within achs to transfer patients when acute care needs are resolved. these instances result in transferring patients to skilled nursing facilities close to achs. furthermore, if these negative experiences are recurrent, then discharge planners become desensitized and no longer consider cahs as viable options for post-hospitalization care. workflow and time-point analyses six workflow process categories were identified for swing bed transfer and admission through the interviews. as discussed previously, elements were then identified for each process category as listed in figure 1. these elements are the steps and processes that occur within each online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 96 category. the average time to complete, and transition between, each process category was calculated for the 4 cahs. an average of 16.5 hours was required to identify the appropriate decision maker at the cah by the ach. once this contact was made it took over 7 hours on average to determine bed availability and another 7 hours to determine swing bed admission criteria. on average, 40 hours lapsed between determining criteria and starting the process of identifying an accepting physician for the transfer. once the previous processes were completed, it took approximately 1.5 hours to initiate and start the transfer planning process, and 24 hours for the actual transfer to occur from the ach to the cah. in summary it took an average of 217.5 hours to complete all processes to transfer a patient to a swing bed in a cah. online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 97 discussion the results of the qualitative and quantitative workflow data provides a better understanding of the barriers and limitations for cahs to be considered as a source for posthospital care. a basic understanding of the criteria that qualifies a patient for swing bed care is needed by both cahs and achs. it is difficult to overcome the heterogeneity of services offered by the different cahs and this can only be addressed by building relationships between cahs and achs. it will require cahs and achs covering overlapping catchment areas to better understand the processes and workflow factors that can complement the services that each organization offers. outreach by both organizations will be needed if the best interest of the patient is to be considered. another area of opportunity is for cahs to collectively identify areas of posthospitalization care that are commonly provided by all cahs, in an effort to prevent the “desensitization” toward cahs by discharge planning staff within achs. for example, while many cahs do not have pt/ot, all will have nursing staff that can provide care for many of the necessary post-hospitalization needs. this may include restorative care for malnutrition, strengthening, incontinence, just to name a few. limited research in the early 1990’s highlights this paradox. in one study, most swing bed admissions were for rehabilitation services for poststroke or orthopedics surgery (lammers, 1992). research by shaughnessy, schlenker, and kramer (1990) reported swing beds to be more effective in functional outcomes related to activities of daily living, while nursing home care was best suited for long term care patients with limited rehabilitation potential, such as post-stroke (shaughnessy et al., 1990). there is limited evidence to suggest that a discordance exits between post-hospitalization needs and what swing bed care can offer. it must be noted that these general observations do not apply to all online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 98 cahs. there are robust cahs with high-volumes that are able to sustain ancillary services, such pt/ot. currently, the frontier medicine better health partnership grant project in montana is working with a team of clinical experts across cahs in developing evidence-based restorative care guidelines in the areas of nutrition, incontinence, and strengthening. once these care guidelines are developed and standardized, the team plans to disseminate and implement a swing bed restorative education program for both cahs and achs. the promise of the proposed educational program is to impact the general understanding about commonly available restorative services offered by cahs, and align them with evidence-based guidelines that are best suited for swing bed care. the results identified in the current analyses will be useful in assuring the successful implementation of the proposed educational program. the qualitative interviews did not express concern about the quality of skilled nursing care provided by cahs. the primary concerns of the ach interviewees were focused on the processes of the transfer, such as delayed response from cah, and understanding of swing bed eligibility criteria. there has been mixed results related to swing bed outcomes in the literature. as mentioned above, early studies found swing bed care to be more effective in enhancing functional outcomes and discharge to independent living compared to nursing home care (shaughnessy et al., 1990). however, in these studies swing bed care was less effective in patients with no rehabilitation potential. results from a study involving only one cah in the early 1990’s found 11% of patients transferred to swing beds died and 28% were readmitted for acute care (lammers, 1992). however, this single site study may have skewed results as the average age of swing bed transfer patients was 81. online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 99 while interviewees of the program were supportive of bringing patients close to home for their post-acute care needs, none of the discussions mentioned the importance of supporting cahs in their financial stability. an economic impact analysis by ona and davis (2011) determined that rural counties with a cah had a beneficial impact compared to counties without cahs. kentucky cahs, for example, had a direct employment impact of 3,503 jobs and an income direct impact of $179.5 million. efforts to enhance working relations between achs and cahs must acknowledge the reciprocal financial impact that both organizations have on one another. the results of the study have also identified the importance for cahs to implement process improvement strategies within their organizations. excessive delays in identifying the appropriate decision maker within cahs and determining swing bed eligibility criteria highlight the need for process improvements. an educational program, as previously discussed, will assist in defining the processes; however, process strategies must be implemented to ensure that assessment and transfer of patients to swing beds can be promptly and efficiently made. there is pressure on discharge planning staff to transition patients no longer needing acute care to home or to a skilled nursing facility as deemed appropriate. the cah must be prepared to assess, process, and receive potential transfer requests. efficient process measures will ultimately benefit the patient who will be closer to home and their social network in a timely manner. unnecessary delays to receiving restorative care may also impede the healing process needed during the post-acute period. there are limitations of the program that must be noted. the program was conducted only in montana, potentially limiting the generalizability of the data. only four cahs provided online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 100 workflow time analyses data which may also limit the identification of factors impeding the use of swing beds. the methods to collect and analyze data preclude statements of causal effects. in conclusion, there are knowledge and process factors that must be overcome to increase the use of swing bed care in cahs, while ensuring high quality care. the impetus for reaching this goal has both patient-level benefits and community-level benefits. immersing patients back within their social network and community will help dissipate the stress associated with distant care in achs (magilvy & congdon, 2000). filling empty beds in cah will further stabilize the financial status of cahs, ensuring they continue to be a significant economic factor within the community (ona & davis, 2011). supporting agencies center for medicare and medicaid innovations references 2010 census urban and rural classification and urban area criteria.(n.d). retrieved from http://www.census.gov/geo/reference/ua/urban-rural-2010.html amey, c. h., miller, m. k., & albrecht, s. l. (1997). the role of race and residence in determining stage at diagnosis of breast cancer. journal of rural health, 13(2), 99-108. http://dx.doi.org/10.1111/j.1748-0361.1997.tb00939.x blair, s. l., sadler, g. r., bristol, r., summers, c., tahar, z., & saltzstein, s. l. (2006). early cancer detection among rural and urban californians. bmc public health, 6, 194. http:dx.doi.org/10.1186/1471-2458-6-194 calonge, n. (2001). new uspstf guidelines: integrating into clinical practice. us preventive services task force. american journal of preventive medicine, 20(3 suppl), 7-9. http://dx.doi.org/10.1016/s0749-3797(01)00264-1 online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 101 congdon, j. g., & magilvy, j. k. (1998a). home health care: supporting vitality for rural elders. journal of long term home health care, 17(4), 9-17. congdon, j. g., & magilvy, j. k. (1998b). rural nursing homes: a housing option for older adults. geriatric nursing, 19(3), 157-159. http://dx.doi.org/10.1016/s01974572(98)90062-3 craig, c. (1994). community determinants of health for rural elderly. public health nursing, 11(4), 242-246. http://dx.doi.org/10.1016/s0197-4572(98)90062-3 grabowski, d.c. (2010). post-acute and long-term care: a primer on services, expenditures and payment methods. washington d.c.: office of disability, aging and long-term care policy, office of the assistant secretary for planning and evaluation, u.s. department of health and human services. herndon, l., bones, c., kurapati, s., rutherford, p., & vecchioni, n. (2011). how-to guide: improving transitions from the hospital to skilled nursing facilities to reduce avoidable rehospitalizations. cambridge, ma: institute for healthcare improvement. higginbotham, j. c., moulder, j., & currier, m. (2001). rural v. urban aspects of cancer: first year data from the mississippi central cancer registry. family and community health, 24(2), 1-9. http://dx.doi.org/10.1097/00003727-200107000-00003 johnson, j. e., weinert, c., & richardson, j. k. (1998). rural residents' use of cardiac rehabilitation programs. public health nursing, 15(4), 288-296. http://dx.doi.org/10.1111/j.1525-1446.1998.tb00352.x lammers, j. e. (1992). swing bed program in a small rural hospital: discharge outcome. south med j, 85(12), 1184-1186. http://dx.doi.org/10.1097/00007611-199212000-00008 online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 102 li, p., schneider, j. e., & ward, m. m. (2007). effect of critical access hospital conversion on patient safety. health services research, 42(6 pt 1), 2089-2108; discussion 2294-2323. http://dx.doi.org/10.1111/j.1475-6773.2007.00731.x liff, j. m., chow, w. h., & greenberg, r. s. (1991). rural-urban differences in stage at diagnosis. possible relationship to cancer screening. cancer, 67(5), 1454-1459. http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2007.00731.x/abstract long, k. a., & weinert, c. (1991). rural nursing: developing the theory base. nln publication (21-2408), 389-406. magilvy, j. k., & congdon, j. g. (2000). the crisis nature of health care transitions for rural older adults. public health nursing, 17(5), 336-345. http://dx.doi.org/10.1046/j.15251446.2000.00336.x magilvy, j. k., congdon, j. g., & martinez, r. (1994). circles of care: home care and community support for rural older adults. ans advances in nursing science, 16(3), 2233. http://dx.doi.org/10.1097/00012272-199403000-00005 monroe, a. c., ricketts, t. c., & savitz, l. a. (1992). cancer in rural versus urban populations: a review. journal of rural health, 8(3), 212-220. http://dx.doi.org/10.1111/j.17480361.1992.tb00354.x montana department of public health & human services, quality assurance division. (2011). montana's rural health plan. helena, mt. ona, l., & davis, a. (2011). economic impact of the critical access hospital program on kentucky's communities. journal of rural health, 27(1), 21-28. http://dx.doi.org/10.1111/j.1748-0361.2010.00312.x online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.366 103 schlenker, r. e., & shaughnessy, p. w. (1989). swing-bed hospital cost and reimbursement. inquiry, 26(4), 508-521. shaughnessy, p. w., schlenker, r. e., & kramer, a. m. (1990). quality of long-term care in nursing homes and swing-bed hospitals. health services research, 25(1 pt 1), 65-96. silverman, h. a. (1990). swing-bed services under the medicare program, 1984-87. health care financing review, 11(3), 99-106. microsoft word sherrod_277-1514-2-ed.docx online journal of rural nursing and health care, 13(2) 110 infertility help-seeking: perceptions in a predominantly rural southern state roy ann sherrod, phd 1 rick houser, phd 2 1 professor of nursing, capstone college of nursing, the university of alabama, rsherrod@bama.ua.edu 2 professor and chair, department of educational studies in psychology, research methodology & counseling, the university of alabama, rhouser@bamaed.ua.edu abstract purpose: as the incidence of infertility increases to a public health concern, there are a number of factors, including social and cultural ones, which influence help-seeking. an assessment of infertility perceptions in a rural southern state was conducted to gain a better understanding of how they might impact help seeking for rural dwellers from the social and cultural context. sample: phone interviews were conducted to collect data from adults, 18 years or older in a rural state. method: survey research methodologies were used. findings: descriptive statistics were used to analyze data. respondents reported most often that “doctors” should be the person sought for help with infertility and infertile persons should assume the financial responsibility for any help they seek for their infertility. conclusion: the perceptions of participants in this study may have direct influence on the infertility experience of those in their environment from a social and cultural context. advice they give and support they provide may impact those who experience infertility. implications for online journal of rural nursing and health care, 13(2) 111 social scientist, health care providers and policy makers include focusing on nurses and doctors in primary care settings and providing enhanced reproductive support for rural citizens. infertility help-seeking: perceptions in a predominantly rural southern state infertility has been defined as the inability to deliver a live birth after at least 12 months of regular unprotected intercourse (sherrod, 2004). the emotional aspects of infertility have been well documented but what have been less documented are the aspects of infertility that impact decisions to seek help by those who suffer from infertility. some researchers have noted the disparities in infertility help-seeking (white, mcquillan & greil, 2006). for example, white, et al. (2006), noted that it is well established that african american couples have lower utilization of infertility services than white couples. also, sherrod (2004) found differences in rural and urban groups related to satisfaction with their providers when they sought help for infertility. others, greil, mcquillan, benjamins, johnson, johnson and heinz (2010) have found a number of factors that affect medical help-seeking such as religion. religiosity according to greil, mcquillan, et al. (2010) is associated with increased importance of motherhood which in turn is associated with greater help-seeking. johnson and johnson (2009) found that both partners contribute to the infertility help-seeking process but different factors such as intentions to get pregnant, importance of parenthood and total family income may play a role in different stages of help-seeking. other factors that influence help-seeking are social and cultural factors (griel, slausonblevins & mcquillan, 2010). culture refers to shared meanings by members of social groups (bachrach & abeles, 2004). significant differences in coping with infertility may be learned from one’s social network and reference group (schmidt, christensen & holstien, 2005). much of that social impact is grounded in the day to day interactions and communications with those online journal of rural nursing and health care, 13(2) 112 whom comprise the environment of the infertile. these individuals may be co-workers, family members, friends, church members or even the local grocer. as infertility help seeking is likely influenced by cultural issues, perceived alternative treatments, social solutions (e.g. adoption) and ideas about who should be a parent, knowledge of the nature of these influences is critical to sufficiently provide guidance to medical professionals and policy makers in their efforts to provide relevant care (national institute for child health and human development, 2007). efforts to assist the infertile to deal with the emotional impact of infertility should include preparing them to deal with these interactions and communications from those in their environments. this preparation may be particularly more relevant for rural dwellers experiencing infertility because of the sense of closeness of community members that is so prevalent (bushy, 2012). this closeness may lend an additional sense of being able to freely share opinions and attitudes with others in the community. for those who are infertile, some additional assistance may be needed to deal with this liberty from others. key to providing that assistance is knowledge on the part of the health care provider of perceptions those in the community have regarding infertility. therefore, the purpose of this study was to provide information related to infertility from a sample of citizens 18 years and older in a predominantly rural southern state to assist health care providers and policy makers to better formulate services and support. methodology a survey design was used to assess infertility perceptions using the capstone poll at the institute for social science research. the capstone poll is based on a random survey of adult respondents, 18 years or older in alabama. after university institutional review board (irb # ex-11-cm-083) approval, a computer using all of the three digit telephone exchanges in the state drew the random sample of households. households were contacted using these numbers. a online journal of rural nursing and health care, 13(2) 113 respondent in the household was randomly selected by asking for the adult who had the most recent birthday. trained, experienced personnel employed by the capstone poll conducted interviews. for the purposes of this study, the alabama rural health association’s (arha) classification of areas as "rural" or "urban" was used. prior to june 2003, the arha used the white house's office of management and budget (omb) classification of counties as being urban if in metropolitan statistical areas (msas) or rural if not in msas. a re-determination of counties included in msas announced by omb in june 2003 resulted in several alabama counties which must be regarded as being "rural" being included in msas that necessitated development of a more acceptable method for classifying counties as "rural" or "urban". the method developed and used by the arha includes four variables generally accepted as being characteristic of "rural" areas in a formula with each variable accounting for 25 of a possible 100 points. the higher the overall score, the more "rural" a county is considered as being. the four variables are: the percentage of total employment by public school systems, dollar value of agricultural production per square mile of land, population per square mile of land and an index to assign county scores based on population of the largest city in the county, other cities in the county, and the population of cities which are in more than one county. using this methodology, 55(82.09%) alabama counties are classified as "rural" and 12(17.91%) are classified as "urban" (alabama rural health association, 2012) and is therefore a predominantly rural state. data were analyzed using descriptive statistics. percentages were calculated to provide summative data regarding selected demographic characteristics and respondents perceptions of factors related to the infertility experience. online journal of rural nursing and health care, 13(2) 114 sample the sample of 237 respondents included 42.8% who knew a couple who had problems with having children and 12.29% who themselves had problems having children. married respondents comprised 58.74% of the sample and 19.42% each were widowed or divorced. slightly more than half (50.65%) of the sample had been to church within the last 30 days at least once and 81% identified themselves as protestant. almost two-thirds (70.04%) of respondents were female with 29.96% being male. the majority (73.84%) reported themselves as white, 18.99% reported themselves african american, .84% reported their-self native american, and 1.69% indicated “other”. the u.s. census bureau (2010) reports that these results are somewhat consistent with the expected population in alabama with the exception of african-americans whom comprise 26% of the population (http://factfinder2.census.gov/faces/tableservices/ jsf/pages/productview.xhtml?pid=dec_10_dp_dpdp1) . results participants were asked to respond to a number of questions related to infertility. the first question asked of respondents was “what do you think is the most common medical condition that prevents people from having children?” more than half 148 (62.45%) of the 237 respondents indicated they had no idea. for those who did supply a response (n = 89), their answers reflect conditions that could be attributed to males, females, both or either. results are reported in table 1. some respondents gave more than one condition in their responses and each response was counted in the appropriate category. the “other” category included items indicated by two (2.24%) respondents each that included stds, abortion and “don’t want any”. three (3.34%) online journal of rural nursing and health care, 13(2) 115 people each also mentioned obesity and cancer. one (1.12%) person each noted “it might be blood pressure”, “handled by god”, erectile dysfunction, stamina and high levels of stress. table 1 medical conditions preventing people from having children n=237 male female both either don’t know/na 148 n = 89 low sperm/ mobility 11 (12.35%) infertility 1 (1.12%) 27 (30.33%) 1 (1.12%) sterile 6 (6.74%) endometriosis 9 (10.11%) ovary issues 4 (4.49%) poverty 2 (2.24%) drugs/lifestyle 3 (3.34%) age 3 (3.34%) other 22 (24.71%) when asked if they thought people who cannot have children will seek help, 76.27% said yes, 7.2% said no and 16.53% indicated they did not know. respondents were also asked who they thought people who cannot have children might seek help from. their responses are presented in table 2. table 2 who to seek help from type n=168 % doctors 120 50.63% fertility specialists 20 8.4% ob/gyn 23 9.70% friends/family 4 1.68% clinic 9 3.79% male doctor 1 0.42% spiritual advisor 1 0.42% adoption agency 9 3.79% church/pastor/pray 6 2.53% again, some respondents had multiple responses and 93.3% of respondents provided at least one online journal of rural nursing and health care, 13(2) 116 response with only 6.7% indicating did not know or hand no response. in addition to responses in table 2, other answers indicating who to seek help from by at least one (0.42%) respondent were social worker, professional, orphanage, and surrogate mother. when asked if everyone should have access to health care to help them have children, 64.83% of respondents said yes, 19.92% said no and 15.25% indicated they did not know. in a follow–up question to those who responded “no” regarding what their reasons were for feeling that someone should not have access, a variety of responses were noted and categorized . these responses are reported in table 3. table 3 reasons for not having access to healthcare to have children reason (n = 47) n % can’t afford infertility care then can’t afford children 9 19.15% should bear the responsibility for that care themselves 7 14.89% should have basic care but not specialty care like this 3 6.38% some people don’t need to have children 11 23.40% if it is meant to be, they would have them 2 4.25% too many children in the world 3 6.38% other 8 17.02% do not know/na 4 8.51% responses in the “other” category included “unmarried people to engage in sexual activity out of wedlock”, “everyone is not going to use it effectively”, “they can’t take care of kids, go to social services, “mental disability”, “have access, not a federal program” and “public funds should not be used for anything other than indigent people to sustain life.” discussion and conclusions with regard to the first question, it is noteworthy that more than half of respondents did not know nor had a response for conditions that prevent people from having children. for those who are infertile and living in rural areas already with limited access to care as a normal part of rural online journal of rural nursing and health care, 13(2) 117 dwelling, so their immediate initial support and guidance may come from lay people in their environments. while 30.33% noted infertility as the medical condition for why people do not have children, there was no specific indication of what type of infertility was the reason why. it would be helpful if these individuals in the infertile person’s immediate environment knew more about infertility so that their inadequate and maybe inaccurate perceptions do not add to the already emotional turmoil of those who are infertile. therefore, there is a need for increased lay communications through various media outlets about infertility. additionally, the equal attribution of endometriosis and low sperm count as the reason why people do not have children appears to indicate some understanding that reasons for infertility are not solely because of a problem with the man or woman but rather an experience and condition that is shared by them both equally. this perspective of cause of infertility is documented in the literature (kolettis, 2003) and would be comforting and helpful if participants were having conversations with someone experiencing infertility. as schmidt et al. (2005) noted, how one copes with infertility may be influenced by one’s social group and the interdependence of social groups in rural communities is quite clear. for the question related to what type of assistance those who cannot have children should seek, the indication that they seek assistance from the “doctor” by the majority of respondents is noteworthy. because rural dwellers are reluctant to seek specialized care, they appear more willing to use a general practitioner or primary care provider for healthcare and have greater access to this type of provider (blank, mahmood, fox, & guterbock, 2002). it seems reasonable that “doctor” is the most frequently indicated source of help. the issue then for general practitioners is to be aware that they may be the provider who infertile persons are initially referred to by those in their social environments and cultural groups and that they need some online journal of rural nursing and health care, 13(2) 118 beginning understanding of infertility to provide the appropriate care (jordon & ferguson, 2006). ob\gyn specialists were also noted, but the limited access to specialty care in rural areas is well documented (pierce, 2007). another interesting response from participants was seeking adoption agency assistance. it has been suggested (lakhvich, 2012; sherrod, 1992) that adoption is not always an appropriate option for those who are experiencing infertility and advice to seek this type of assistance should be tempered with an understanding of where the couple is in their infertility journey especially in the early help-seeking phases. another issue related specifically to rural dwellers is the limited availability and significant costs of help from adoption agencies. for the question related to reasons for not having access to healthcare to have children, the most frequent response was “some people don’t need to have children”. this response is complex in terms of its implications but it does lend support to the stereotypical ideas held by some regarding ethnic groups and fertility (greil et al., 2010) with the idea that there is too much procreation in these groups. another item with a comparable response rate was “if they cannot afford the fertility care, then they cannot afford to have children”. this sentiment is reflective of a prevailing position in rural communities by rural dwellers that you must be selfsufficient (bushy, 2012). it also highlights the fact that the economic challenges most rural dwellers face are relevant to those experiencing infertility and that they should be prepared to be independent or self-sufficient in their help-seeking when it comes to financial resources for infertility care. bitler and schmidt (2006) have noted that in some states, insurance companies are mandated to cover some infertility care costs but not all states have this requirement. however, it should be noted that rural dwellers are more likely to not have insurance or be underinsured (bushy, 2012). none-the-less, the response by participants in this sample provides some context for helpseeking from this standpoint. as greil, mcquillan, shreffler, johnson, and salson-blevins online journal of rural nursing and health care, 13(2) 119 (2011) concluded, individual characteristics related to help-seeking are influenced by social structural realities that from these authors’ perspective are tied to responses from participants. one final note is the clear presence of religion/religiosity in responses from participants to questions. greil, mcquillan, et al. (2010) stated that “religion can influence the types of medical treatment perceived as appropriate” (p. 735). the strong religious influences on the sociocultural context of infertility experiences are supported by responses from participants. blank et al. (2002) have noted the role of faith and religious personnel in rural communities. “churches in the south are well recognized as central to the social order and character of their region. they are the strongholds of cultural and community identity and, because of congregational commitment, hold great promise for influencing the attitudes and behaviors of members.” (p. 1672). there are several methodological limitations of this survey study. one limitation is that sinlge state was used in the survey and rural residents in this state may have unique perceptions of infertility and help-seeking. second, there may be a bias in the respondent as a consequence of the time of day that the survey was completed, e.g. during normal work time (8 a.m. to 5 p.m.). for example, 70 percent of the respondents were female and there was a slightly lower rate of african-americans who responded. in conclusion, the perceptions of respondents in this sample provide policy makers and healthcare providers with a context from which to develop policies for those who are experiencing infertility and particularly those in rural areas. careful preparation of those experiencing infertility regarding what responses they might expect from those they interact and communicate with in their environment from a social and cultural perspective can assist them in navigating the experience in the most effective way. online journal of rural nursing and health care, 13(2) 120 references alabama rural health association (2012, february 27). rural/ urban areas. retrieved from http://www.arhaonline.org/rururbcomp.htm bachrach, c. a., & abeles, r. p. (2004). social science and health research: growth at the national institutes of health. american journal of public health, 94(1), 22-28. [medline] bitler, m., & schmidt, l. (2006). health disparities and infertility: impacts of state-level insurance mandates. fertility and sterility, 85(4), 858-865. [medline] blank, m. b., mahmood, m., fox, j., & guterbock, t. (2002). alternative mental health services: the role of the black church in the south. american journal of public health, 92(10), 1668-1672. [medline] bushy, a. (2012). the rural context and nursing practice. in molinari, d., & bushy, a. (eds.) the rural nurse: transition to practice (pp.3-21). new york: springer publishing company. greil, a. l., mcquillan, j., benjamins, m., johnson, d. r., & heinz, c. r. (2010). specifying the effects of religion on medical helpseeking: the case of infertility. social science & medicine, 71(2010), 734 742. [medline] greil, a. l., mcquillan, j., shreffler, k. m., johnson, k. m., & slauson-blevins, k. s. (2011). race-ethnicity and medical services for infertility: stratified reproduction in a populationbased sample of u. s. women. journal of health and social behavior, 52(4), 493-509. [medline] greil, a. l., slauson-blevins, k., & mcquillan, j. (2010). the experience of infertility: a review of recent literature. sociology of health & illness, 32(1), 140-162. [medline] johnson, k. m., & johnson, d. r. (2009). partnered decisions? u. s. couples and medical helpseeking for infertility. family relations, 58(4), 431-445. [medline] http://www.ncbi.nlm.nih.gov/pubmed/14713689 http://www.ncbi.nlm.nih.gov/pubmed/14713689 http://www.ncbi.nlm.nih.gov/pubmed/12356619 http://www.ncbi.nlm.nih.gov/pubmed/20547437 http://www.ncbi.nlm.nih.gov/pubmed/22031500 http://www.ncbi.nlm.nih.gov/pubmed/20003036 http://www.ncbi.nlm.nih.gov/pubmed/20160961 online journal of rural nursing and health care, 13(2) 121 jordon, c. b., & ferguson, r. j. (2006). infertility –related concerns in two family practice sites. families, systems & health, 24(1), 28-32. kolettis, p. n. (2003). evaluation of the subfertile male. american family physician, 67(10), 2165-2173. lakhvich, y. e. (2012). infertility resolution as a factor of adoption adjustment. problems of psychology in the 21st century, 1(1), 26-35, 10p. national institute for child health and human development. (2007). demographic and behavioral sciences branch-report to the nachhd council. author. pierce, c. (2007). distance and access to health care for rural women with heart failure. online journal of rural nursing and health care, 7(1), 27-34. sherrod, r. a. (1992). helping infertile couples explore the option of adoption. jognn, 21(6), 465-470. [medline] sherrod, r. a. (2004). an assessment of infertility in a rural area. online journal of rural nursing and health care, 4(1), 75-83. schmidt, l., christensen, u., & holstien, b. e. (2005). the social epidemiology of coping with infertility. human reproduction, 20(4), 1044-1052. [medline] u.s. census bureau (2010). 2010 demographic profile data. http://factfinder2.census.gov/faces/ tableservices/jsf/pages/productview.xhtml?pid=dec_10_dp_dpdp1 white, l., mcquillan, j., & greil, a. l. (2006). explaining disparities in treatment seeking: the case of infertility. fertility and sterility, 85(4), 853-857. [medline] http://www.ncbi.nlm.nih.gov/pubmed/1494086 http://www.ncbi.nlm.nih.gov/pubmed/15608029 http://www.ncbi.nlm.nih.gov/pubmed/16580364 52 the effects of a stress management program on knowledge and perceived self-efficacy among participants from a faith community: a pilot study angeline bushy, phd, rn, faan1 marietta p. stanton, phd, rn, cmac2 holly k. freeman, ms, rn3 1 professor & bert fish chair, school of nursing, university of central florida, abushy@pegasus.cc.ucf.edu 2 professor, capstone college of nursing, university of alabama, mstanton@bama.ua.edu 3 clinical instructor, capstone college of nursing, university of alabama, hfreeman@bama.ua.edu abstract educational programs can be an effective intervention for anticipatory guidance and health promotion across the lifespan. a particular concern for health care providers in rural areas is how to access high-risk populations and then provide programs that are culturally and linguistically appropriate. in recent years, religious congregations (faith communities) have been identified as an effective way to reach hidden and vulnerable populations in rural as well as urban settings. this article presents a pilot study describing an educational intervention related to stress management with participants who were accessed through a faith community. both quantitative and qualitative tools were used the measure the dependent variables. quantitative data were obtained with pencil and paper assessment tools measuring levels of self-efficacy and knowledge about stress. qualitative data helped determine types of stress participants experienced and if stress management techniques learned in the course were used to manage day-to-day stressful situations. while the setting for this study was urban, the findings are highly relevant to nurses who provide care to rural and other underserved populations with limited access to health care. background educational program can be an effective intervention for anticipatory guidance and health promotion for at risk and vulnerable populations. the term vulnerability is used in reference to individuals and groups who experience risks that can be detrimental to health or can result in a health disparity. the purpose of this pilot study was to evaluate the effects of a stress management program on the knowledge level and perceived selfefficacy among a group of participants (n=17) who were recruited from a faith community located in new york. education can modify individuals’ health beliefs and knowledge about certain health issues. however, knowledge in and of itself does not always result in changed behavior. examples of other factors that contribute to behavior changes include perceived self-efficacy and its predictive value relative to a given behavior. moreover, personal expectations associated with self-efficacy are culturally based and have been shown to mediate and reinforce lifestyle behaviors (janz & becker, 1984; schaubroeck, lamm & xie, 2000). the concept of self-efficacy has been widely discussed in the literature for several decades. early on, bandura (1977; 1982) found activities that promoted mastery of techniques to control behavior produced higher levels of self-efficacy, thereby enhancing online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.cohpa.ucf.edu/nursing/ mailto:abushy@pegasus.cc.ucf.edu http://nursing.ua.edu/home.htm mailto:mstanton@bama.ua.edu http://nursing.ua.edu/home.htm mailto:hfreeman@bama.ua.edu 53 targeted behavior change. a decade later stanton, dittmar, wooldridge & lihjen (1992) found a statistically significant relationship between increased levels of self-efficacy and the number of formal smoking cessation classes attended by participants in their study. in other words, the more classes attended, the higher one’s score on the self-efficacy measure and the greater the probability of long-term smoking cessation. essentially, a body of literature reiterates that an increase in self-efficacy is instrumental in assisting patients, as well helping caregivers, to deal more effectively with a wide range of adverse and chronic health problems such as diabetes, asthma, cardio-vascular and pulmonary conditions, arthritis and multiple sclerosis (barnason, zimmerman, nieveen, schmarder, carranza & reilley, 2003; borsody, courtney, taylor & jairath, 1999; clark & dodge, 1999; hellstrom, lindamrk, wahlberg, fugl-meyer, 2003; mckenzie & peragine, 2003; lorig, ritter, laurent & fries, 2004; raizi, thompson & hobart, 2004; scherer & schmeider & shimmel, 1995; vander der palen, klein, & seydel, 1997). increased selfefficacy also has a role in modifying high risk behaviors in order to achieve healthier outcomes such as engaging in a regular exercise program and smoking cessation to prevent and manage chronic health problems (avey, manthny, robbins & jacobson, 2003; mcdougall, montgomery, eddy, jackson, nelson, stark & thomsen, 2003; oetker-black, teeters, cukr & rininger, 1997; stretcher, devellis, becker & rosenstock, 1986). formal education programs are a cost effective strategy for enhancing self-efficacy and behavior change. methods this study examined the effects of a formal stress management program and its impact on participants' perceived self-efficacy. the goal of the intervention was to help participants become aware of stressful situations and then learn new coping behaviors to more effectively mediate these types of events. setting and subjects participants were recruited from a faith community to attend a stress management course via announcements in the weekly church bulletin, during services and at other congregational functions. participation in the program was voluntary and was provide at no cost to participants. interested individuals were invited to contact the instructor by telephone at which time enrollment details were provided. the study received approval from the institutional review board (irb) committee of the state university of new york at buffalo. each participant signed an informed consent prior to enrolling and procedures were undertaken by the investigator to insure confidentiality and anonymity. the intervention study was conducted in a classroom located at a church in an inner city. twenty-two individuals enrolled in the first class; 17 completed the program. the group met for 90 minutes over a six-week period. the curriculum, course materials and instruments were used with the permission of pace university health care center. at that time of this study, the investigator was a faculty member in the school of nursing and had taught other stress management classes. the course included content on stress, reactions to stress, and instruction on several stress management techniques including online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 54 guided imagery, relaxation and abdominal breathing. table 1 includes an overview of the program schedule and content. table 1 overview of stress management intervention program class session content activities week #1 • definition of stress • types of stress • individual variability • sources of stress complete pre-tests homework briefing • log a • goals week #2 • review instruments • set goals • complete contract • personal/current sources • acute/chronic stress responses homework briefing • log a • goals week #3 • abdominal breathing exercises • relaxation exercises homework briefing • log a • goals week #4 • discuss video on stress and breathing • nutrition and exercise for decreasing stress • centering exercises homework briefing • log a • goals week #5 • you are not the target exercise • assessing your personal health • books, tapes, videos stress management • use of the library • community self-help and support groups homework briefing • log a • goals week #6 • principles of assertiveness/personal empowerment • stress club • contract reviews, goals and logs • complete post-tests • program evaluation online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 55 instruments this study included both quantitative and qualitative approaches. in respect to quantitative methods, a pencil and paper 50-item instrument was used to assess participants’ knowledge about stress. this tool (developed by and used with permission of pace university) measured knowledge of stress and stress management techniques. content validity tool was established via an expert panel. self-efficacy, relative to stress management, was measured likert-type tool having a five-point rating scale for each of the ten items. the instrument was developed by one of the authors (m.s.) for an earlier study (stanton et al. 1992). the tool was modified to accommodate a fifth grade reading level of participants in this study. a second section included demographic questions for participants to complete. the self-efficacy scale had a reliability of r>.80 as determined in a previous study (stanton et al. 1992). the survey tools were administered upon enrollment (pre-test) and repeated (post-test) upon completing the program. qualitative methods determined if and when participants identified stressful events in their lives; and, weather or not "healthier" stress management techniques were used on a more frequent basis as a result of taking the program. to collect qualitative data participants maintained a daily log in which they described day-to-day stressors and how they coped with these. logs were later used as a learning tool and served as a reference point for participants during class discussions, as well as for content analyses purposes. procedure during the first class session participants’ completed the pencil and paper survey to help them identify major source(s) of stress and their preferred response to stressor(s). the questions focused on six major categories of stress; specifically, over stimulation, frustration, under stimulation, anxious personality, type-a behaviors and self-image. these data were not analyzed per se. rather, the information helped participants to become more aware of life stressors and preferred coping styles. subsequently with that information participants developed a written stress management plan (contract). participants included a "self-reward" in their contract if they successfully achieved his or her stated goals and behaviors. individuals monitored personal progress through log narratives. upon completing the program, each participant rated their level of achievement with a letter grade (i.e., a, b, c) to determined if their self "reward" was earned. the stress management intervention program was evaluated after the last class meeting and again six months later to elicit feedback on the perceived usefulness of course materials, effectiveness of the instructor, as well as the learning environment. data analysis analyses of quantitative data consisted of descriptive and comparative techniques. t-tests were performed on pre-test and post-test mean scores relative to knowledge level and self-efficacy. chi-square analysis examined demographic items relative to selfefficacy and knowledge measures. qualitative data obtained from the written logs were all analyzed weekly and again at the end of the course. content analysis procedures were online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 56 undertaken with these self-reports to identify common themes and recurrent situations. in the analyses, all references to stressful events were tabulated for each individual; then averaged for the group as a whole. references to use of stress management techniques learned in the course were similarly tabulated. for the program evaluation frequencies and percentages were used in the analyses of the questionnaires. results even though the sample was quite small (n=17), the group was highly diverse. demographically, the group consisted of 16 females and one male including caucasians (n=2), african americans (n=11), hispanics (n=3), and a native american (n=1). fewer than half (41%) characterized themselves as employed in a skilled/professional occupation, with the remainder (59%) classifying themselves as “somewhat skilled” or “unskilled.” in terms of education, one individual had only completed grammar school, ten graduated from high school and six reported attending “some college.” the average income for the group was $10,000 per year. all but one of the participants characterized themselves as being in “excellent” or “good physical health.” paired t-tests compared the mean scores of the pre-test and post-test for the selfefficacy and knowledge measures. a statistically significant difference was found in the perceived levels of self-efficacy (p<.002) and on knowledge/health beliefs (p<. 05). differences in pre-test and post-test scores are depicted in figure 1. chi-square analyses demonstrated that number of classes attended had a statistically significant relationship with changes in the pre-test and post-test self-efficacy scores (p<.0015). chi-square analysis performed on demographic data demonstrated that level of education and annual income were the only two characteristics that related to the scores obtained on self-efficacy and knowledge measures (p≈ .0015). cronbach's coefficient a was used to calculate reliability for the self-efficacy scale (r>.93) and knowledge test (r>.67). changes in recognition and reaction to stress in the daily lives of the participants were derived from a content analysis of qualitative data found in the logs. the analysis revealed participants’ perceptions of stress during early weeks of the course were quite different compared to the last half of course. for example, before taking the course one woman was unaware of the high level of stress she experienced in her job of 10 years. ultimately, as a result of new insights she actually quit her job and went to work somewhere else and was happier for it. the logs further revealed which of the new stress management techniques were actually used by individuals. on average each participant noted about two stressful events over the first three weeks period. during the last half of the course, the average number of stressful events increased (on average) to four incidents. table 2 highlights findings from participants’ logs, specifically weekly averages of stressful events and use of stress management techniques. post-course evaluations indicated nearly all of the participants (95%) met their self-generated objectives and targeted behavior changes. the majority (90%) were highly satisfied with the instructor, course materials and the curriculum. the post-six month evaluation reflected similar feelings about the course content and materials (<.80%). of those completing the program, nearly all reported abiding by their stress management plan. overall the class averaged 95% for achieving objectives initially and again in six online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 57 months. participants indicated they were eager to participate in other educational programs focusing on breast self-examination, nutrition and smoking cessation. table 2 summary of findings from logs (n=17): average (number) of stressful events and stress management techniques by week week -1 week -2 week–3 week -4 week -5 week -6 average number of stressful events 1 2 2 2 3 4 average number of stress management techniques used 0 0 0 1 2 2 discussion the results of this pilot study reinforced that a formal program on stress management increased knowledge and enhanced perceived self-efficacy among participants. the information in self-reported logs demonstrated that individuals became more adept at identifying stressful events over time and increased their reliance on use of stress management techniques learned in the course. findings from the qualitative selfreports, supported by chi-square analysis revealed increases in self-efficacy were positively related to the number of classes attended. essentially, attendance at the stress management classes increased knowledge level and self-efficacy, anecdotally and statistically. the logs in particular help participants identify stress producing situations as well as monitor progress in achieving their stated goal(s) over the six-week period. the reported awareness of stressful events and use of newly learned stress management techniques could indicate that increased knowledge and perceived self efficacy does indeed result in actual behavior change. of particular interest are characteristics of the participants in this study. primarily socio-economically disadvantaged, participants predominately were of minority backgrounds with limited access to health prevention programs. most stated they never had attended a formal health education program such as this one on stress management. their educational background was extreme; specifically, one had very limited reading skills, while several others had attended some college and were proficient readers. the wide educational variation entailed a great deal of faculty time in explaining and clarifying content and materials on a one-to-one basis, which may have influenced changes in behavior for some individual. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 58 there were serendipitous outcomes as well. for example, participants enjoyed talking with one another about events in their lives, and there were wide variations in self-reported stressors. variations substantively were socioeconomic in nature associated with very low income and educational levels. at different times during the program, it became obvious the type and number of stressors confronting some individuals were far more complex than originally anticipated by the investigator associated with racism, extreme poverty and domestic violence. individuals with overwhelming concerns were referred to various community support systems. future facilitators for programs of this nature are strongly encouraged to consider geographic, cultural and gender-related preferences of their audiences that could hinder or enhance acquisition of knowledge and self-efficacy. for example, a consumer-oriented health education programs must incorporate language, content and examples that are culturally relevant to a group. pastors as well as other informal leaders of a faith community particularly in rural areas often are able to provide useful insights related to the socioeconomic background and cultural preferences of their congregation. limitations certainly this research is very limited in terms of generalizability associated with the small sample size, lack of control for intervening variables, and self-selection of the participants. while the logs seem to substantiate changes in behavior there were no other legitimate data sources to support the self reported short term or long term changes among participants. nor were control measures in place to mange extraneous or intervening variables among program participants. thus, self-reported changes noted during this program might be attributable to a hawthorn effect among participants. in respect to data analyses, these were limited to a comparison of pre-test and post-test scores. due to the very small sample size, analyses were not undertaken to differentiate between or among groups by demographic and dependent variables. future studies are recommended with larger diverse samples to determine the role of selfefficacy in modifying high risk behaviors among various cultural and ethnic populations. implications the major implication of this pilot study is that enhanced self-efficacy and knowledge may increase the likelihood of positive health behavior change. however, to be truly effective it is critical that health education programs be tailored to the cultural, ethnic, educational, economic backgrounds and circumstances of the group. language and examples of stress must be culturally sensitive and stress management techniques should fit the abilities and lifestyle of participants. gender and geographic location also need to be considered. for example, residents in rural settings may encounter different kinds of stressors and have other coping preferences than urban counterparts. differences may be associated with living in a more geographically and socially isolated setting in which access to services and health care providers may be more restricted. additionally, available social support systems (or the lack there-of) can produce and modify stressful situations. social structures may vary among residents in less populated regions compared to a highly populated region which in turn also impacts health behaviors. online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 59 the faith community is an excellent mechanism for reaching vulnerable individuals and providing educational programs at a low cost both rural and urban residents. in recent years a number of requests for proposals (rfps) targeting faith communities have been sponsored by both federal and philanthropic organizations. in particular these rfps target minority groups in rural and underserved settings. programs such as the one described in this article could serve as a model for nurses to reach vulnerable groups in both urban and rural environments for the purpose of health promotion and anticipatory guidance. finally, findings in this small study revealed that self-efficacy and changes in knowledge level were enhanced by participation in a formal course. the enthusiasm of the participants in this program supports the effectiveness of such offerings to groups having limited access to health education and /or prevention programs. references avey, h., manthny, k., robbins, a., & jacobson, t. 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[medline] online journal of rural nursing and health care, vol. 4, no. 2, fall 2004 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=15076811 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?orig_db=pubmed&db=pubmed&cmd=search&defaultfield=title+word&term=854%5bpage%5d+and+oetker-black+s%5bauth%5d http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=7633617 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=7633617 online journal of rural nursing and health care, 2(1) 1 editorial letter from the editor: isolation: real or perceived? jeri w. dunkin, phd, rn, editor in the mid-nineties, researchers at the university of north dakota, rural health research center conducted a large study of job satisfaction and retention of rural nurses. one aspect of that project was to determine the areas of concern related to work for the participants. isolation from other nurses was a major concern noted by the participants. this isolation was evident in issues such as lack of access to resources that could help the nurses with knowledge relative to nursing care decisions, work-related conflict, and the sharing of what works and what doesn’t, including continuing education. there seems to be little evidence that this has changed over time. however, with the advances in technology that has occurred in the last 10 years, isolation from other nurses is no longer a necessary part of rural nursing. while geography not changed, there are many resources available to rural and remote nurses, primarily through the internet, but some are available through mail, telephone, and fax. the key is commitment, commitment by the rural nurse to become involved in professional organizations. organizations such as the rural nurse organization or the american nurses association provide access to many resources. professional organizations exist to provide their members with information through newsletters, journals, on-line chat groups, resource directories, interest groups, etc. however, they cannot exist without commitment, financial commitment to join by the members. that commitment must be sustained in order for the organizations to meet the needs of the members. online journal of rural nursing and health care, 2(1) 2 additionally, commitment is needed from the members to get involved in the activities of the organization. commitment is being informed about new treatments, changes in procedures, etc. that will keep your practice current. this can now be more easily accomplished through continuing education that is on the internet, provided in most paper copy journals, (e.g. ajn) and through video-tapes. complete college courses are now readily available to students at a distance. commitment also means being part of the solution to problems in the work environment. using the existing networks, one can find information and suggestions on approaches to challenges, conflicts, and innovations that will help rural nurses provide high quality care. become committed today. if you have comments please contact me at jdunkin@bama.ua.edu. microsoft word hernandez_302-1638-3-ed.docx online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 3 community outreach along the u.s./mexico border: developing hiv health education strategies to engage rural populations kristen hernandez, mph 1 holly mata, ph.d., ches 2 elias provencio vasquez, ph.d., rn, faan, faanp 3 jacob martinez, rn, bsn 4 1 research associate, school of nursing, university of texas at el paso, kehernandez2 @gmail.com 2 postdoctoral research fellow at the hispanic health disparities research center and school of nursing, university of texas at el paso, mata.holly@gmail.com 3 dean of the school of nursing and principal investigator of the hispanic health disparities research center, university of texas at el paso, eprovenciovasquez@utep.edu 4 research assistant and community health educator at the hispanic health disparities research center, university of texas at el paso, jmartinez41@miners.utep.edu abstract although there have been ongoing efforts in the united states to reduce new infections and improve care in people already living with the human immunodeficiency virus (hiv) and other sexually transmitted diseases/infections, hispanics continue to bear a disproportionate burden of hiv/sti’s. reducing sexual health disparities is a key aspect in achieving health equity, and requires prioritization of groups most at risk for hiv/sti infection and least likely to have regular access to preventive healthcare. a growing body of nursing research highlights the need online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 4 for addressing hiv-related health disparities among hispanics. our research in the u.s. – mexico border region contributes to our ability to respond to hiv-related health disparities in hispanic populations in the border region and beyond. nurses have much to contribute to community-based efforts to promote societal and structural changes to reduce hiv risk, and bring unique expertise, experience, and perspective to community mobilization efforts. the purpose of this article is to explore strategies in disseminating hiv health education information and research findings in rural areas along the u.s./mexico border. we conducted a needs assessment of clinics serving rural areas to enhance our dissemination and outreach efforts and to inform the development of culturally and linguistically appropriate health education materials. increased capacity to integrate screening, referral, and education into routine clinic visits may improve prevention education, screening, and treatment engagement for sti’s and hiv. translating local research findings into improved clinical practice and services can promote health equity among medically underserved people in our region. prioritizing rural practitioners who are often generalists and meet many of the health care needs of their community – is a replicable dissemination approach for nurses and other health professionals committed to building health equity. keywords: hiv; health equity; hispanic health; rural health online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 5 community outreach along the u.s./mexico border: developing hiv health education strategies to engage rural populations background although there have been ongoing efforts in the united states to reduce new infections and improve care in people already living with the human immunodeficiency virus (hiv) and other sexually transmitted diseases/infections, hispanics continue to bear a disproportionate burden of hiv/sti’s (centers for disease control and prevention, 2011; chen, gallant, & page, 2012). in 2009, the white house office of national aids policy (onap) began to engage diverse stakeholders to develop a coordinated and comprehensive response to the hiv epidemic. the onap developed strategies and overarching goals to reduce hiv infection, improve treatment engagement and outcomes, and reduce hiv-related disparities (onap, 2010). reducing sexual health disparities is a key aspect in achieving health equity, and requires prioritization of groups most at risk for hiv/sti infection and least likely to have regular access to preventive healthcare. the focus of hiv/aids prevention has been to move from individual risk behaviors to community mobilization focusing on empowerment (harper, willard, & ellen, 2012; parker, 1996). community mobilization “engages all sectors of the population in a community-wide effort to address a health, social, or environmental issue… [and] empowers individuals and groups to take some kind of action to facilitate change” (centers for disease control and prevention, n.d.). coordinated by the local department of public health, our hiv community mobilization team was convened in 2013, and over a period of several months developed a cohesive mission online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 6 to advocate and promote a unified, inclusive, and community-based approach to improve hiv prevention, awareness, services, and public policy. with small groups of team members representing interests and concerns of our lesbian, gay, bisexual, transgendered (lgbt) community, healthcare providers, school-based personnel, faith-based organizations, and media groups, the team aims to mobilize community support for their mission. our participation in this initiative sparked a desire to increase engagement with practitioners in rural areas, and to contribute to their ability to recommend appropriate sexual health screening and services for their clients, most of whom are hispanic of mexican origin. a growing body of nursing research highlights the need for addressing hiv-related health disparities among hispanics (gonzález-guarda, florom-smith, & thomas, 2011; gonzálezguarda, vasquez, urrutia, villarruel, & peragallo, 2011) although most of the literature focuses on individual risk and risk reduction as opposed to social and contextual changes. recognizing and responding to the diversity of hispanics in the u.s., our research in the u.s. – mexico border region contributes to our ability to respond to hiv-related health disparities in hispanic populations in the border region and beyond. nurses have much to contribute to communitybased efforts to promote societal and structural changes to reduce hiv risk, and bring unique expertise, experience, and perspective to community mobilization efforts. community involvement has been shown to increase effectiveness of outcomes in hiv/aids programs. community involvement facilitates conversations in communities to empower hiv/aids affected communities to take ownership of their health, in turn increasing health enhancing prevention behaviors (campbell & cornish, 2010). communities face many challenges related to increasing hiv awareness and disseminating culturally and linguistically appropriate information. for example, many clinics lack the resources to spend adequate time online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 7 discussing sexual health and risk behavior and hispanic women in particular may be reluctant to initiate conversations about their risk and/or exposure. many rural communities are sometimes left out of these community discussions, and at times outreach resources do not extend to far areas of the county or other outlying counties. with this in mind, an interdisciplinary team participating in the community mobilization campaign is assessing rural community health clinic perspectives on hiv education and testing. the team is comprised of a public health nurse, a community health educator with a masters in public health, and a certified health education specialist with a doctorate, affiliated with a school of nursing. the outreach efforts also extend to the neighboring rural areas in the state of new mexico. the purpose of this article is to explore strategies in disseminating hiv health education information and research findings in rural areas along the u.s./mexico border. the term “rural” is defined differently by government agencies and healthcare organizations, and is often a designation applied at the county level. for the purposes of this project, “rural” is defined as an area outside of the metropolitan city limits in which residents have limited access to primary care and public health department services because of distance, lack of transportation, and/or limited availability of services at satellite clinics. because of our location in the border region, many of the areas served through this project are considered colonias – residential areas characterized by a lack of infrastructure such as water, electricity, sewer, roads, and other basic necessities. colonias tend to have high unemployment and poverty rates, as well as increased health risks due to living conditions. in el paso county alone, there are more than 300 colonias (mora & schultz, 2013; texas secretary of state, 2013). many of the areas served through our project are adjacent to counties designated as rural by state and federal agencies, and our dissemination strategies are designed for geographically defined rural areas as well as online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 8 demographically similar regions adjacent to these boundaries. although geographic designations often define rural areas for funding and/or service eligibility purposes, poverty and limited access to healthcare services rarely fall neatly into geographic areas. healthcare teams serving rural areas should be aware of the complexity of rural health issues and the inconsistencies in definitions of rural across programs and policies. hiv rural community needs assessment process recent research conducted by our team assessed hiv risk behavior knowledge among a community-based sample of hispanic (mostly of mexican origin) men and women; significant gaps in knowledge were identified especially in terms of safe condom use (martinez, provenciovasquez, mata, arredondo, & desantis, 2013). these gaps in hiv risk behavior knowledge likely exist in our regional urban and rural populations, and discussions about risk knowledge can be part of clinical and community-based services. this research and community collaboration strengthened local existing community partnerships, and began broadening the scope of hiv discussion with practitioners. health education is one way for clinicians to address individual risk knowledge and behavior. accordingly, through this project we conducted a needs assessment of clinics serving rural areas to enhance our dissemination and outreach efforts and to inform the development of culturally and linguistically appropriate health education materials. setting el paso, texas has a population of more than 800,000 and shares a border with ciudad juarez, chihuahua, mexico. el paso city’s limit extends to mexico and cities of southern new mexico. the rural communities included within this project were outlying towns that surround the city of el paso, texas within east and west areas of el paso county and dona ana county, new mexico. all of the communities served by participating clinics are predominately hispanic online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 9 (mostly of mexican origin), and many residents lack health insurance as well as access to regular medical care (mora & schultz, 2013). method the hiv rural resource dissemination project was developed to assess services and resources related to hiv/ sexually transmitted infections (sti) available in clinics serving rural communities. the long-term goal of our project is to bridge communication between local clinicians, our school of nursing, and other stakeholders to improve community health services to rural populations on the broader topic of sexual health. the project prioritizes clinics in rural locations to determine services provided, familiarity with regional hiv/sti screening and treatment services, and staff preference for dissemination of community-based research results (e.g., through research briefs, staff trainings/in-services, or individual visits from university researchers and health education specialists). we also solicit input on developing culturally and linguistically appropriate sexual health promotion materials. for example, in a recent meeting with the entire caseworker team of one of our clinic partners, we shared our findings and they provided guidance on developing relevant and useful materials. this is a needs assessment rather than research with human participants; all information collected relates to services provided and preferences for dissemination of health education resources. accordingly, an institutional review board (irb) did not review the project. however, the research studies mentioned here which provided the basis for health education materials were reviewed and approved by the university of texas at el paso irb. development of hiv health information material. when developing health education resources to disseminate research results from previous studies in the community, we first shared results with clinic partners serving people living with online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 10 hiv/aids. the initial feedback from practitioners enabled us to tailor the materials to our priority population and to design educational resources for clinic staff to use with clients in discussions of hiv risk reduction. subsequent meetings with clinicians led to the need for educational materials that incorporated research results from local studies so as to make them more relevant to clients participating in discussions of hiv/sti risk and reviewing health education materials. clinicians also suggested that these materials could be used to integrate hiv risk behavior knowledge into conversations with clients about sexual health and safer sex practices regardless of their hiv status. ongoing discussions with clinic staff and practitioners helped our team realize that it was not only essential for patients being seen in hiv/sti care settings, but also in primary care and other clinic settings throughout the region. we began to prioritize rural communities and clinics where provider availability, transportation, and limited resources are often barriers to regular sexual health screenings and access to care. responding to input from our clinical partners, we are developing tailored health education materials including a waiting room presentation to show on clinic tv screens, colorful flipcharts that caseworkers can use as a visual aid when providing client education on safe condom use, and handouts designed to encourage clients to discuss these issues with their healthcare providers during their appointment. our clinic partners found it helpful to brainstorm strategies to use local research results to communicate health education and risk reduction information with their clients. evaluating and refining our dissemination strategies with input from our clinical partners will help us understand and respond to practitioner and client preferences. hiv community mobilization collaboration. as previously discussed, our team participates in a community mobilization effort organized through our local department of public health, and contributes to the community’s online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 11 discussion about hiv/aids along the u.s. / mexico border. collaborating in such discussion improves the facilitation of community change and increases social capital (miller, bedne, & guenther-grey, 2003). in our initial outreach in rural communities, we realized that many of the clinics lacked the resources to distribute condoms to patients, and through our participation in the community mobilization project we were able to connect with department of public health staff and expand their outreach and condom distribution program to several of the rural clinics we visited. thus, we are often able to extend the reach of health department resources to clinics outside of the city limits, and were also able to distribute condoms and sexual health education materials to clinics who otherwise might not have received these resources. in meeting with rural clinicians and staff we have identified clinics who would like to offer material on sexual health to clients as a way to begin their conversation with the clinician. during our assessment we were also able to identify additional services that are offered in new mexico but not in texas, such as a needle exchange program used in the field as a harm reduction intervention for injection drug users. sharing these practices and services from bordering counties helps engage community stakeholders involved in the hiv community mobilization initiative, and broadens our perspective regarding policy alternatives and policy advocacy strategies. hiv rural community needs assessment. clinics in outlying communities were located through internet searches, local resource guides, and word of mouth from nursing and public health colleagues. the nurse and the community health educator on our team contact clinics by phone to schedule a time to meet with clinic staff. the assessment takes approximately 20 minutes and is done with office managers, online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 12 supervising medical assistants, and directors of community clinics. the 29 questions query respondents on community demographics, migrant worker services, and other questions related to the population served. participants also discuss existing protocol for hiv/sti screening, availability of sexual health education resources, strategies for discussions of sexual health and hiv/sti risk during routine visits. they also provide input on how we can facilitate patient/provider communication on sexual health risk and screening. many of the other questions were adapted from an existing measure (lifson, et al., 2009) that evaluates clinic staff ability to screen for hiv and sti’s, manage clients infected with hiv and sti’s, and access most recent sexual health guidelines, prevention materials and reporting guidelines. following discussions with clinic staff, our team left an informational handout describing the purpose of the needs assessment, our desire to collaborate with rural community clinicians and administrative staff, and our contact information. to date, we have met with 8 of the 17 clinics prioritized for outreach. lessons learned from hiv outreach strategies our interdisciplinary team benefits tremendously from being able to assess services provided in outlying communities. as expected, clinic prioritization of hiv/sti screening ranged from “not much of a priority” to “high priority”. some clinics had informal referral systems to other practitioners that provide low-cost testing services in the communities they serve, while others mentioned that it was cumbersome to perform hiv and sti tests because the lab work took a while to come back with results taking longer than in the city. most practitioners indicated that hiv/sti screening was based on either self-reported behavioral risk or presenting symptoms of hiv/sti’s. routine and universal discussions about sexual health were uncommon based on our assessment, and determination of behavioral risk is primarily at the discretion of the online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 13 practitioner. as expected, most of the clinics we visited also had wait lists for enrolling new clients and wait times to schedule a visit for established clients were lengthy. several of the clinics we visited did say that if a client or someone really did want to get a hiv/sti test quickly they would refer them to the public health department where they could be seen faster. we did encounter some unexpected difficulties in conducting our needs assessment. some agencies that were satellite clinics, or part of a network of clinics, needed approval from administrative personnel at other locations which in some cases took time to obtain. as recent graduates with little experience in clinical settings, we felt like we had an advantage in that we were highly flexible but we sometimes found it daunting to go through several layers of administrative approval before visiting a clinic. we also realized that because it is our area of research focus, sexual health education and prevention may be a higher priority to us than to rural healthcare providers. in addition, clinicians with limited resources are often focused on treating chronic diseases and have limited time to deal with sexual health promotion and education. implications for practitioners we recommend and are advocating for increased training and resources related to hiv/sti screening for practitioners serving rural populations. increased capacity to integrate screening, referral, and education into routine clinic visits may improve prevention education, screening, and treatment engagement for sti’s and hiv (lifson et al., 2009). moreover, it is important that community health practitioners provide culturally and linguistically appropriate hiv risk reduction programs to reduce sexual health disparities (lanier & sutton, 2013; rios-ellis et al., 2008.). online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 14 this is a foundation from which we can continue our work with rural practitioners, and look forward to collaborations that build on the strengths of nurses and health education specialists in primary care settings. community outreach strategies that engage rural health providers along the u.s. mexico border are relevant and replicable in communities throughout the u.s., especially those in which sexual health issues are often addressed as part of a routine clinic visit for other health issues. we anticipate providing resources to other rural counties that surround el paso county, sharing health promotion and education materials developed based on local needs and data while learning more about their resources, challenges, and opportunities to promote sexual health and reduce hiv/sti risk. translating local research findings into improved clinical practice and services can promote health equity among medically underserved people in our region. prioritizing rural practitioners who are often generalists and meet many of the health care needs of their community – is a replicable dissemination approach for nurses and other health professionals committed to building health equity. we look forward to learning from our colleagues in nursing and public health through our outreach and dissemination efforts. supporting agency national institutes of health, national institute on minority health and health disparities (grant # 1p20 md 002287-04); rural health funding provided by the state of texas references campbell, c., & cornish, f. (2010). towards a "fourth generation" of approaches to hiv/aids management: creating contexts for effective community mobilisation. aids care: psychological and socio-medical aspects of aids/hiv, 22(s2), 1567 1579. http://dx.doi.org/10.1080/09540121.2010.525812 online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 15 centers for disease control and prevention (2011). hiv among latinos. division of hiv/aids prevention. atlanta: centers of disease control and prevention. retrieved from http://www.cdc.gov/hiv/pdf/risk_latino.pdf centers for disease control and prevention (n.d.). community mobilization guide. division of hiv/aids prevention. atlanta: centers of disease control and prevention. retrieved from http://www.cdc.gov/stopsyphilis/toolkit/community/communityguide.pdf chen, n. e., gallant, j. e., & page, k. r. (2012). a systematic review of hiv/aids survival and delayed diagnosis among hispanics in the united states. journal of immigrant and minority health, 14(1), 65-81. http://dx.doi.org/10.1007/s10903-011-9497-y. gonzález-guarda, r. m., florom-smith, a. l., & thomas, t. (2011). a syndemic model of substance abuse, intimate partner violence, hiv infection, and mental health among hispanics. public health nursing, 28, 366-378. http://dx.doi.org/10.1111/j.15251446.2010.00928.x. gonzález-guarda, r. m., vasquez, e. p., urrutia, m. t., villarruel, a. m., & peragallo, n. (2011). hispanic women’s experiences with substance abuse, intimate partner violence, and risk for hiv. journal of transcultural nursing, 22(1), 46-54. http://dx.doi.org/10.1177/1043659610387079. harper, g. w., willard, n., ellen, j. m., & the adolescent medicine trials network for hiv/aids interventions. (2012). connect to protect®: utilizing community mobilization and structural change to prevent hiv infection among youth. journal of prevention & intervention in the community, 40(2), 81-86. http://dx.doi.org/ 10.1080/10852352.2012.660119. online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 16 lanier, y., & sutton, m. y. (2013). reframing the context of preventive health care services and prevention of hiv and other sexually transmitted infections for young men: new opportunities to reduce racial/ethnic sexual health disparities. american journal of public health, 103, 262-269. http://dx.doi.org/10.2105/ajph.2012.300921. lifson, a. r., rybicki, s. l., hadsall, c., dickson, s., van zyl, a., & carr, p. (2009). a training program for nurses and other health professional in rural-based settings on screening and clinical management of hiv and other sexually transmitted infections. journal of the association of nurses in aids care, 20, 77-85. http://dx.doi.org/ 10.1016/j.jama.2008.09.008 martinez, j., provencio-vasquez, e., mata, h., arredondo, s., & desantis, j. (2013). hiv risk behavior knowledge among hispanics: implications and opportunities for practitioners in diverse settings. san francisco: 2013 society of behavioral medicine annual meeting. miller, r. l., bedne, b. j., & guenther-grey, c. (2003). assessing organizational capacity to deliver hiv prevention services collaboratively: tales from the field. health education & behavior, 30, 582-600. http://dx.doi.org/10.1177/1090198103255327 mora, a., schultz, l. (2013). community health assessment and improvement plan – city of el paso department of public health. el paso, tx: department of public health. retrieved from http://home.elpasotexas.gov/health/_documents/el_paso-cha_narrative_final %20revised%20july%2031%202013%20combined.pdf office of national aids policy, the white house. (2010). naional hiv/aids strategy: federal implementation plan. the white house. parker, r. g. (1996). empowerment, community mobilization and social change in the face of hiv/aids. aids, 10(3), s27-s31. [medline] http://www.ncbi.nlm.nih.gov/pubmed/8970709 online journal of rural nursing and health care, 14 (1) http://dx.doi.org/10.14574/ojrnhc.v14i1.302 17 rios-ellis, b., frates, j., d’anna, l. h., dwyer, m., lopez-zetina, j., & ugarte, c. (2008). addressing the need for access to culturally and linguistically appropriate hiv/aids prevention for latinos. journal of immigrant and minority health, 10, 445-460. [medline] texas secretary of state. (2013). directory of colonias located in texas. austin, tx: texas secretary of state. retrieved from http://www.sos.state.tx.us/border/colonias/regcolonias/elpaso.shtml http://www.ncbi.nlm.nih.gov/pubmed/18157640 21 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 pap smear rates: predictor of cervical cancer mortality disparity? ruby s. morrison, dsn, rn, cnl, cne 1 pamela moody, dnp, aprn-bc (crnp, msn, phd) 2 mitch shelton, phd, crnp 3 1 professor, capstone college of nursing, university of alabama, rmorriso@bama.ua.edu 2 director of nursing, alabama department of public health, tuscaloosa, al 3 clinical instructor, center for health & biological sciences, jefferson state community college key words: cervical cancer mortality, pap smear rates, disparity abstract considered preventable by the national cancer institute, cervical cancer continues to be a severe health threat for women. although efforts at early detection have resulted in a decline of 50% in incidence and mortality in the in the last 30 years, still more than 14,000 new cases of cervical cancer are diagnosed and more than 4,8000 women die of cervical cancer annually. significantly higher cervical cancer mortality rates in tuscaloosa county, alabama, for african-american women prompted an investigation into the pap smear rates for african-american and white women. the unexpected results of the analysis were that in all three years, african-american women had pap smear rates higher than white women, 384.81 and 254.17 per 1,000 respectively. obviously, the difference in pap smear rates does not explain the disparity in cervical cancer mortality in tuscaloosa county. further exploration of the causes is needed. introduction one purpose of health care is to reduce mortality from disease, accidents, and disasters. disparity in mortality rates based on race and ethnicity is confounding in the present era of perceived equality. however, 2000-2004 data for tuscaloosa county, alabama, indicated a startling sevenfold increase in cervical cancer mortality for africanamerican women when compared to white women (higginbotham, 2006). the tuscaloosa county cervical cancer mortality rates during 2000-2004 revealed 3.27 per 100,000 of all women; 7.07 per 100,000 african-american women; and 1.40 per 100,000 of white women. review of literature worldwide, cervical cancer kills 275,000 women annually (cadman, 2006). in the united states (u.s.), more than 4,100 women die of cervical cancer annually (hoyo, et al, 2005). in alabama, cervical cancer mortality was more than 50% higher for africanamerican women than white women, with rates of 5.4 and 2.4 per 100,000 respectively (higginbotham, 2006). although cervical cancer incidence and mortality rates have declined dramatically over the past several decades, the cervical cancer incidence rate for alabama between 2001 and 2005 is 9.9/100,000 (alabama statewide cancer registry, 2007). from 2002 to 2006, african american women (11.1/100,000) died from cervical cancer at a much higher rate than white women (7.9/100,000) (american cancer society, 2010). however, mailto:capstone%20college%20of%20nursing mailto:rmorriso@bama.ua.edu http://www.adph.org/search.asp http://www.jeffstateonline.com/centerhealthbiologicalsciences/index.aspx 22 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 more african american women (89.0%) reported having had a pap smear within three years than white women (87.8%) (james, et al, 2009). cervical cancers adenocarcinoma, one of the most prevelant cervical cancers, accounts for 25% of cervical tumors, most often in younger women. originating in the mucous producing gland cells of the endocervix, adenocarcinoma is associated with the human papillomavirus (hpv) and use of oral contraceptives. it is more difficult to treat than the next most frequent squamous cell carcinoma (tiffen & mahon 2006). most cervical tumors are squamous cell carcinomas. most cervical cancers begin as an alteration of the transformation zone and originate from precursor lesions called cervical intraepithelial neoplasia (cin) (tiffen and mahon, 2006, p. 528). progression beyond the basement membranes and invasion of the cervical stroma is considered invasive or malignant. due to the slow progression from cin to invasive cancer early detection and treatment of precursor lesions can essentially eliminate mortality due to this cancerous process. because the prognosis regarding which lesions will become invasive is uncertain, all patients should receive timely treatment for precursor lesions. laboratory analysis of cervical epithelial cells (pap smears) is used to determine the progression of cervical cancer. pap smear results are classified according to cell abnormalities. of the three pap smear reporting systems, the bethesda system is routinely used because of its clarity and differentiation. the report includes data on the adequacy of the specimen and a recommendation to repeat smears when the specimen is inadequate or the cells are abnormal (hatcher et al., 2004). since the 1990’s, management protocols have become more conservative treatment ranging from monitoring progression of low-grade squamous intraepithelial lesion to performing radical hysterectomy or radiation for invasive carcinoma. other treatments include coloscopy, ablative therapies, excision or radiation (mcfadden & schumann, 2001; hatcher et al., 2004). invasive cervical cancer is a preventable disease. prevention is the key to effective treatment. localized cervical cancer will advance to invasive disease within two to ten years (mcfadden & schumann, 2001). risk factors for cervical cancer a vast 99% of cervical cancers are caused by the human papillomavirus (hpv), the most frequently sexually transmitted infection in the united states. of the more than 100 types of hpv, most are benign and resolve without intervention. visible lesions or warts, known as condylomata acuminate, may be seen. high-risk hpv types tend to persist and are associated with development of precancerous lesions and cervical cancer. although cervical cancer is associated with about 15 high-risk hpv types, invasive cervical cancer is predominantly caused by hpv 16 and 18 (tiffen & mahon 2006). primary epidemiological risk factors for the development of cervical cancer are (a) smoking, (b) infection of hpv or chlamydia, (c) use of oral contraceptives, (d) immunosupression, (e) diet low in fruits and vegetables, (f) three or more full-term pregnancies, (g) younger than 17 years old at the time of the first full-term pregnancy, (h) 23 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 poverty, (i) use of diethylstilbestrol, and (j) family history of cervical cancer (american cancer society, 2010b; tiffen & mahon, 2006).the correlation between a higher incidence of invasive cervical cancer and low income level may be due to a lower use of preventive care, lack of medical screening, and a higher incidence of hpv (mcfadden & schumann 2001). screening recommendations the importance of pap smear testing to detect and treat cervical cancer early cannot be over estimated. approximately 50% of women diagnosed with cervical cancer had never had a pap smear prior to the present one used to diagnose the cancer. an additional 10% had not had a pap smear in the previous five years (tiffen & mahon, 2006). although opinions regarding when and how often to begin regular pap smear screening vary the alabama department of public health developed guidelines for health care providers in the state based on published guidelines of the american cancer society and the american college of obstetricians and gynecologists (alabama department of public health, 2008). those are presented in figure 1. background the office of performance review of the u.s. department of health and human services (dhhs) human resource service administration (hrsa) initiated a meeting of numerous grant recipients, health care providers, and other interested parties in tuscaloosa, alabama, to discuss health issues of concern to the community. the goal of the meeting was to establish strategic partnerships to address health issues in the community to improve health outcomes. the tuscaloosa strategic partnership identified three issues of concern and the group sub-divided into teams to address specific issues. the work of the team addressing the issue of cervical cancer mortality disparity in tuscaloosa county is described in this manuscript. the team’s initial response to the cervical cancer mortality rate was that lack of access to affordable pap smears was the problem. equipped with the knowledge that cervical cancer can be prevented with risk reduction strategies and cured if identified via papanicolaou (pap) tests and treated promptly, led to the immediate response that africanamerican women must not be screened with pap smears. the team identified several resources available in tuscaloosa county to provide free or low-cost pap smears; therefore cost of the procedure was not the root problem. convinced that affordable pap smears were available, the team needed to collect data on pap smear rates in order to plan strategies to reduce the cervical cancer mortality disparity by promoting pap smear screening. the team anticipated finding racial disparities in cervical cancer detection via pap smears for women of tuscaloosa county. the research hypothesis is: african-american women are being screened for cervical cancer via pap smears less frequently than white women. the null hypothesis is: there is no statistically significant difference in pap smear rates of african-american women and white women in tuscaloosa county, alabama. 24 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 low risk patient: high risk patient: figure 1. pap smear protocol pap smear testing guidelines (alabama department of public health (2008). clinic protocol manual revised february 2008, p. 29)  family planning program: 1. when to start performing pap smears women should have their first pap test approx. 3 years after first sexual intercourse, or by age 21, whichever comes first. 2. women under the age of 21 who have unreliable abnormal pap smear history from outside provider or have delivered a baby: a. if patient indicates an unreliable history of abnormal smear(s) from outside provider, begin annual smears. b. if patient has delivered a baby in the past, begin annual smears. 3. if patient requests an iud/ius and has not had a pap smear in the previous 12 months, obtain pap, then follow routine pap regimen based on age. 4. screening regimens for low-risk patient based on age: a. adolescent patients 20 years of age and younger – once pap smears are initiated, obtain “thinprep only” until the age of 21; hpv not performed in this age group. b. women 21 – 29 years of age – obtain annual smears with hpv reflex test if result indicates ascus until the age of 30. c. women > 30 years of age – obtain pap smear and hpv testing, regardless of cytology results. if both tests are negative, perform routine screening of both tests in 3 years. if abnormal result(s), follow management based on result.  abccedp program: biennial smears (every 2 years) with hpv reflex test if result indicates ascus. if obtain 3 negative paps (including ascus with negative hpv) in a 60-month timeframe, space paps to every 3 years.  family planning program 1. regardless of age the following conditions require more frequent pap smears:  an immunocompromised patient, i.e., hiv positive, organ transplant, chemotherapy (if within 5 years of last treatment), chronic steroid use (defined as continuous use x 6 months or longer)  a woman exposed to diethylstilbestrol (des) in utero 2. screening regimens for high-risk patient based on age: a. adolescent patients 20 years of age and younger – obtain a pap smear annually; hpv test not performed in this age group. b. women 21-29 years of age – obtain annual smears with hpv reflex test if result indicates ascus. c. women > 30 years of age – obtain annual smears with hpv reflex test if result indicates ascus.  abccedp program regardless of age the following conditions require annual pap smears with hpv reflex test if result indicates ascus:  an immunocompromised patient, i.e., hiv positive, organ transplant, chemotherapy (if within 5 years of last treatment), chronic steroid use (defined as continuous use x 6 months or longer)  history of cervical cancer (hsil or worse on pap smear)  smoker  more than 1 sex partner in the last 3 years  a woman exposed to diethylstilbestrol (des) in utero 25 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 methods first, the team identified the laboratories that analyzed pap smear specimens collected by health care providers in the county. a telephone survey of selected tuscaloosa county healthcare providers was completed to determine the laboratories used to analyze pap smears. those providers included the county health department; 17 ob/gyn physician practices; and two primary care centers. because three major labs were identified, the team made the assumption that other healthcare providers (nurse practitioners, family practice physicians) who obtain pap smears for health screening would likely use the same laboratories as the groups surveyed. a secondary analysis of laboratory reports of pap smears analyzed from 2003-2005 was conducted. data on the number of pap smears analyzed and demographic data of race and age for the patients were requested from the labs for 2003-2005. the team faced several obstacles in obtaining and analyzing the data. one of the labs did not have data on race for their patients. this lab analyzed only 15% of the total pap smears. racial comparisons were made on the remaining 85%. to calculate pap smear rates, 2000 census data for tuscaloosa county was used. the number of females between 10 and 84 was used to correspond with the youngest and eldest patient receiving a pap smear. certainly not all females between those ages would be recommended to receive pap smear screening. however, no account of the actual female population who should be screened was available. readers are cautioned not to interpret the data to mean that the portion of 1000 who did not receive pap smears should have had them. some would have not yet become sexually active and some would have had hysterectomies, thus not needing the screening. census data used was categorized as white and non-white as limitation. findings results were that tuscaloosa county pap smear rates for 2003-2005, per 1,000 women show a 297.25 total for all women; 254.32 for white women; and 387.11 for africanamerican women. the conclusion of the results reveals that pap smear rates were not the reason for the disparity in cervical cancer mortality rates. the null hypothesis is rejected, as is the research hypothesis. this is because african-american women actually had a significantly higher pap smear rate than did white women. discussion disparities in screening and mortality rates are not explained by the findings of this study. same-year comparisons of screening prevalence and mortality rates are not expected to correlate precisely due to the time lapse between routine screening, diagnosis, and cancer death. the authors acknowledge this limitation and recommend longitudinal studies to track diagnosis and mortality rates of women who are and are not adhering to cervical cancer screening guidelines. other factors to consider as a reason for the disparity will include the woman’s age at diagnosis; socioeconomic status; follow-up for abnormal results; the woman’s general health; availability of transportation; religious beliefs; a fear of treatment and outcomes; stage of 26 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 cancer at time of diagnosis; and cultural issues. some cultural issues include the reluctance of african-american women to “participate in agencies viewed as serving primarily caucasian women, or that are located in areas perceived to be anti-african-american” (kiger, 2003). there is the issue of women of low socioeconomic status and minority women being at risk for not adhering to cancer screening guidelines (loerzel & bushy, 2005). religious beliefs, may affect health screening behaviors. according to kiger, 2006, “prevention is not emphasized in many low-income communities, where religious beliefs may teach that everything is in god’s hands.” (p. 309) system barriers such as the lack of insurance or being underinsured; no primary care physician; transportation issues; child care issues; and communication within the healthcare system are factors contributing to the disparity, according to loerzel & bushy (2005). human barriers include low educational levels; low socioeconomic status; fear of the test itself (actual or perceived discomfort); fear of results indicating illness; trust; communication skills; previous negative experience with cancer screening; previous diagnosis of cancer; lack of knowledge regarding risk factors for cancer; cultural beliefs associated with cancer; (loerzel & bushy, 2005; kiger, 2003); and “women with previous abnormal findings were less likely to follow-up in a timely manner” (loerzel & bushy, 2005 p. 84). conclusion the tuscaloosa strategic partnership provided multiple educational programs about cervical cancer, risks, prevention, detection, and treatment. a study using focus groups of women with cervical cancer who did not follow-up with healthcare after learning of having an abnormal pap smear to ascertain underlying causes is also currently in the works. future study of the risk factors of women diagnosed with cervical cancer would be helpful to primary care providers in patient teaching and health screening recommendations. acknowledgements reader comments or questions should be addressed to the corresponding author, dr. morrison at rmorriso@bama.ua.edu. authors would like to acknowledge contributions of other team members participating in this project: stephen dorage, hrsa; labridgette ellis, senior site manager, whatley health services; deborah tucker, ceo, whatley health services; dr. albert white, chair, board of health and medical society and health officer with the tuscaloosa county health department; al fox, special projects, ecn director, birmingham health care-alabama; donna marrero, vice president of outpatient and ancillary services, dch health systems; dr. cindy perkins, clinical research coordinator, dch health systems; debra davis, m.d., west alabama internal medicine, llc; dr. chelley alexander, assistant professor and chair; assistant dean for graduate medical education, college of community health science, the university of alabama; and vickie may, dch cancer treatment center. references alabama department of public health (2008). clinic protocol manual. revised february 2008. mailto:rmorriso@bama.ua.edu 27 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 alabama statewide cancer registry (2007). alabama cancer facts and figures 2007. montgomery, al: alabama department of public health. american cancer society. (2010a). cancer facts & figures 2010. american cancer society, 2007). atlanta: american cancer society. american cancer society. (2010b). cervical cancer: causes, risk factors, and prevention. atlanta: american cancer society. retrieved october 19, 2010, from http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer cadman, l. (2006). know the facts. nursing standards, 21(9), 17. [medline] hatcher, r.a., et al. (2004). contraceptive technology (18 th ed) new york: ardent media, inc. hermens, r.p., siebers, b.g., hulscher, m.e., braspenning, j.c., van doremalen, j.h., hanselaar, a., grol, r.p., & van weel, c. (2005). follow-up of abnormal or inadequate cervical smears using two guidance systems: rct on effectiveness. preventive medicine, 41, 809-814. [medline] higginbotham, j.c. (2006, april). health disparities and access to health care in tuscaloosa. paper presented at the county eighth annual rural health conference, tuscaloosa, al. hoyo, c., yarnall, k.s., skinner, c.s., moorman, p.g., sellers, d., & raid, l. (2005). pain predicts non-adherence to pap smear screening among middle-aged africanamerican women. preventive medicine, 41, 439-445. [medline] james, c.v., salganicoff, a., thomas, m., ranji, u., lillie-blanton, m., & wyn, r. (2009). putting women’s health care disparities on the map: examining racial and ethnic disparities at the state level. menlo park: ca: henry kaiser family foundation. kiger, h. (2003). outreach to multiethnic, multicultural, and multilingual women for cancer and cervical cancer education and screening. family and community health, 26, 307-318. [medline] loerzel, v.w., & bushy, a. (2005). interventions that address cancer health disparities in women. family and community health, 28(1), 79-89. mcfadden, s.e., & schumann, l. (2001). the role of human papillomavirus in screening for cervical cancer. journal of the american academy of nurse practitioners, 13(3), 116-128. [medline] tiffen, j., & mahon, s.m. (2006). cervical cancer: what should we tell women about screening? clinical journal of oncology nursing, 10(4), 527-531. [medline] http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer http://www.ncbi.nlm.nih.gov/pubmed?term=cadman%5bauthor%5d+and+facts&transschema=title&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=16169582%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15917039%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=kiger%5bauthor%5d%20and%20%22outreach%22%5ball%20fields%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=11930583%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=tiffen%5bauthor%5d+and+cervical&transschema=title&cmd=detailssearch 19 the lived experience of rural mental health nurses vicki drury, rn, rmhn1 karen francis, phd, rn2 geoff dulhunty, rn3 1 assistant professor, edith cowan university, v.drury@ecu.edu.au 2 professor, school of nursing and midwifery, monash university, karen.francis@med.monash.edu.au 3 sydney, australia keywords: hermeneutic phenomenology, mental health, rural nursing abstract the lived experiences of five registered mental health nurses employed in community settings in the southwest region of western australia were examined in this study. the study was generated in response to concerns of clinicians working in the area about their scope of practice. study participants were interviewed concerning their everyday “lived experience.” interviews were audio taped, transcribed and coded numerically to ensure participant confidentiality. data was analysed using van manen’s hermeneutic phenomenological approach. five essential themes were identified. they were holistic care of clients; isolation, autonomy and advanced practice; professional development and status recognition; educational support; and caseload numbers and caseload composition. the purpose of the study was to determine whether community mental health nurses (cmhn) employed in the southwest region of western australia encountered similar problems and role demands to those of generalist nurses working in rural australia. introduction nurses working in rural and remote areas of western australia (wa) are often sole practitioners and are, therefore, expected to function at higher levels than nurses employed in urban areas (health department of western australia, 2000a). although the health department of western australia acknowledges the advanced scope of practice of rural and remote area nurses and is currently developing competencies to validate an advanced practice role, not all clinicians working in rural or remote areas have the experience or training to work at an advanced level. within the nursing career structure in western australia, community mental health nurses (cmhn) are most commonly appointed at level 2, whereas an advanced practitioner would be appointed at level 3. the region identified in this study has four level 3 cmhn appointments and eleven level 2 appointments. three level 3 nurses and two level 2 nurses were interviewed for this study. previous studies have focused on the generalist nurse in these areas and not on the specialist mental health nurse. the purpose of this paper is to describe nursing roles of registered mental health nurses working in rural and remote areas of wa using a phenomenological approach. information gathered from this study will be helpful in defining roles and may give guidance to nurses who practice in these areas. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 mailto:fwood@bama.ua.edu http://www.med.monash.edu.au/nursing/ mailto:karen.francis@med.monash.edu.au 20 background and significance although there is available literature regarding roles and responsibilities of mental health nurses working in urban areas (australian and new zealand college of mental health nurses, 1995; martin, 1985; nurse's board of western australia, 1999; puskar, 1996; taylor, 1995) and the role of generalist nurses working in rural and remote areas (bradley & mclean, 2000; gray & pratt, 1989, 1991; mccoppin & gardner, 1994), an extensive literature search using cinahl and medline failed to find any literature specifically addressing roles and responsibilities of registered mental health nurses working in rural and remote areas of australia. the mental health division (mhd) of the health department, wa (hdwa), has made a commitment to the rural sector to provide cost effective community based care. the mhd, framework for reform (1998) acknowledges the difficulties faced in wa due to the dispersal of the population, vast geographical distances and diversity within varying rural sectors in relation to isolation, economic level and lifestyles. investigation of educational and research priorities of rural nurses and all that it encompasses suggests that a reason for the failure to address issues of importance in rural nursing is that little is known about the conditions of rural nursing practice (bell, daly, & chang, 1997b; hegney, 1998). this study will partially fill that gap. defining rural and remote nursing there appears to be no universally accepted definition of rural and/or remote nursing; however, the literature reveals a commonality in themes of diminished services, autonomy of practice, limited medical and allied health support and distance from tertiary services (alcorn & hegney, 2000; bell et al. 1997b; bradley & mclean, 2000). taking this and the rural and remote literature into account, the definition accepted for this study was that “rural nursing…is carried out by a nurse who works in a health facility where the support services (medical and allied health) are predominantly visiting, and in a community or district nursing service in a non metropolitan area” (hegney, 1998, p145). nursing in rural australia there is a current shortage of trained and experienced nurses worldwide (bussert, 2001; daly, 2000; nevidjohn & erickson, 2001). less than 25% of registered nurses in australia work in rural areas and this number is expected to decline further in the future due to the current age of the nurses and recruitment issues (borland, 2000b; hegney, 1998; national rural health alliance, 2002a). federal and state governments in australia have been forced to recognize and address the problems of attracting medical practitioners to rural and remote areas by offering incentives for doctors to practice in rural areas. however, they have failed to respond to the lack of nurses in these areas (alcorn & hegney, 2000; bradley & mclean, 2000; mccoppin & gardner, 1994). the hdwa designates all areas outside the perth metropolitan region as either rural or remote and acknowledge that nurses provide the highest proportion of health care in rural and remote regions (health department of western australia, 2000b; national rural health alliance, 2002a, 2002b). online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 21 borland (2000a, p18) described some of the issues that nurses in rural australia face: unique challenges to the delivery of quality services – dispersed population, poor health status, diverse cultures, geographic isolation, problematic transport, poor infrastructure, small economic base, limited political clout, harsh extremes of climate, and a high turnover of health professionals. this portrayal validates the perception that rural and remote mental health nursing offers few incentives and few rewards in spite of increased responsibility and accountability. many nurses working in rural and remote areas provide the only health service to the area and, out of necessity, are forced to function outside both legislative guidelines and their scope of practice. a major concern discussed in the literature has been the prescribing of medication, particularly antibiotics, by nurses working in rural and remote australia (bell et al. 1997b; health department of western australia, 2000a; hegney, 1998). registered nurses are reluctant to work in rural and remote areas because of a lack of peer and collegial support, and the need to be more autonomous in practice and take on greater responsibility (clinton, 1999; shanley, 1999). shanley (1999) argues that formalized support structures for staff in rural areas would help minimize feelings of isolation and assist rural nurses to identify effective strategies for coping with everyday stressors. advanced standard practice there is considerable literature and discussion regarding the nurse practitioner or advanced practitioner role in all areas of nursing practice (allen, 1998; australian and new zealand college of mental health nurses, 1995; brown, 1998; health department of western australia, 2000a; hegney, 1998; puskar, 1996). brown (1998) focused on the educational needs of rural mental health nurses in northern new south wales, while puskar (1996) developed a rationale for advanced practice from a north american perspective. studies by these authors have a common theme indicating advanced practice is not a new role. rather, it is a role that has been performed by nurses for many years that requires clarity of function and identification of responsibilities. both studies indicate a need for training and education and the development of formal support networks for nurses in this role. allen (1998), in a study of mental health nurses working in great britain, identified that advanced practice included psychiatric diagnosis, prescribing single emergency doses of medication, modifying doses of a wide range of psychotropic drugs, additional powers under the mental health act and enhanced autonomy in admission and discharge of patients. the western australian mental health act (1996) ("mental health act 1996," 1996) has already granted additional powers to nurses facilitating best practice within the community; however, these powers do not extend to the skills identified in allen’s (1998) study. the australian new zealand college of mental health nurses (1995, p. 4) has developed advanced standards of practice for mental health nurses. according to these standards, advanced practice nurses go beyond specialized competency; they are individual, independent and innovative in their work; and they demonstrate the highest level of achievement in ethics, practice and standards of professional conduct. gray and pratt (1991) argue that despite considerable effort by the nursing profession to develop role statements or describe nursing by task or job analysis, a definitive description of advanced practice has not evolved. they reason is that defining practice, paradoxically, has a online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 22 limiting effect on the scope of practice. rather, nurses should move forward, stating what the profession sees as the future role of nursing in australia. there is support for nurses in rural australia to be recognized as advanced practitioners (alcorn & hegney, 2000). research method and design an interpretive paradigm, using a hermeneutic phenomenological method, was used for this qualitative study. the researcher, through openness and dialogue with participants, sought to understand, describe, and interpret the relevant meanings of the phenomena as described by the participants. rather than focusing on statistical relationships, this method enabled the researcher to understand meanings as described by the participants as they are lived in everyday existence. van manen’s (1997, p. 37) conceptualization of hermeneutic phenomenology is used in this study as it takes into account the fact that the researcher is concerned with the lived experiences of registered mental health nurses, and the consequent meanings and behavior derived from these experiences. this method generates an understanding of the lives of these registered nurses within their own unique working environment. participants and sampling method selection of participants used purposive sampling whereby participants had to meet three predefined criteria. five participants were selected. all participants gained their initial nursing qualifications through hospital-based nursing programs. of the five participants, three also have tertiary qualifications. three males and two females participated in the study. four participants had in excess of ten years mental health nursing experience. the remaining participant’s experience in mental health was three years; however, she had more than ten years experience in forensic nursing. data collection and instrumentation a focused self-report technique using face-to-face interviews of 1-3 hours duration was used for this study. this allowed participants to tell their own stories in a narrative fashion, and allowed the use of a topic guide to stimulate ongoing dialogue. the use of open-ended questions minimized closed responses. data was recorded on an audiotape, allowing the researcher to feel a sense of involvement and participation. findings data analysis and interpretation themes were identified using thematic analysis, which involved listing patterns of experience identified from the transcribed interviews; identifying data that related to the classified patterns and cataloguing these patterns into sub-themes. coding and thematic analysis revealed five essential themes common to all participants. these were: online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 23 1. holistic care of clients; 2. isolation, autonomy and advanced practice; 3. professional development and status recognition; 4. educational support; 5. caseload numbers and caseload composition. holistic client care. participants related their experiences and identified the responsibilities they had for managing client care. participants viewed the role of the nurse as complex and involving many facets. this included an awareness of, and responsibility to, the community. participant statements included: “as a community mental health nurse i am part-time social worker, friend, counselor, nurse”; “you need to be aware of things like surfing conditions”; “i see my role as a community mental health nurse rather than a mental health nurse. i put the emphasis on the community rather than just on the patient.” therapeutic use of self, client assessment, ongoing monitoring, planning, implementing and evaluating care, crisis intervention, psychoeducation, caregiver support, advocacy, liaison with other agencies and assisting clients with their social needs were responsibilities mentioned by most participants. “we do what is necessary to ensure a patient’s wellbeing, which can include ringing centrelink and liaising on their behalf, advocating on their behalf, organizing their tablets, organizing their scripts or just dropping in and having a cup of tea and bit of a chat. so it’s a range of things you do while monitoring and assessing their mental state.” the model of care used by participants varied. one participant cited sharing responsibility for care with the gps. other participants spoke of working as members of a team. of these, only one participant viewed the team as a “partnership” and discussed working closely with other health care workers. the need to be aware of what was happening in the community and knowing clients’ networks of family and friends was crucial to the delivery of holistic care. the lack of resources and facilities in many of the areas meant the nurse became the resource, a “jack of all trades,” prepared and willing to undertake many different tasks. isolation, autonomy and advanced practice. the interplay between the themes of isolation, autonomy and advanced practice was evident in narrated experiences with participants speaking of the independence and interdependence of their roles. independence and autonomy were closely aligned and were discussed as significant factors supporting the need for experienced nurses. there was a perceived devaluing by metropolitan nurses of the rural role, and a lack of understanding about the isolation and how that relates to clinical issues and clinical decision making. participants cited geographical isolation as a part of everyday experience. in practical terms, this meant that nurses visited remote farmhouses, saw patients alone in areas where mobile phones did not work and had limited access to immediate collegial support. all participants cited maintenance of personal safety as being a concern. one participant described the experience of being a community mental health nurse as “10% terror” due to concerns for personal safety related to changes in patients’ mental states. although ensuring all safety protocols were followed, taking another nurse on a visit, and online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 24 organising clinical supervision helped diminish these feelings, the stress and perceived lack of support in the community have challenged her clinical confidence and self esteem. isolation and the lack of available services appeared to have a direct impact on nursing practice. participants described their experiences of decision making and autonomy as an integral component of their job. limited medical coverage necessitated autonomy for rural community mental health nurses to make decisions regarding client care. the nurses were also used as a resource within their local areas, assisting staff at local hospitals and gps with management of patients. all participants in the study shared this experience. all participants believed that they were working at an advanced level that was not acknowledged through status or remuneration. professional development, status recognition and supervision. three of the five participants mentioned the lack of professional training opportunities. the inability to attend training due to the tyranny of distance coupled with a lack of relief was discussed by all participants as being a major obstacle to training. this is discussed at length in the literature as a major issue for all rural nurses in australia (bell et al. 1997b; borland, 2000a; brown, 1998). experiences related to orientation and training in community mental health were limited. one participant, when employed in the united kingdom, had received formal training, paid by his employer, in the area of community mental health and viewed this as important. however, he felt that this opportunity was lacking within the current western australian system. he explained that in the united kingdom training was linked to career structure and salary, validating and professionalizing practice. one participant noted the need for a more defined philosophy and goals and more structure within the working environment. she felt that there was minimal direction given to new staff and that a defined philosophy and goals would provide a framework for practice. two participants identified a lack of regular clinical supervision as being problematic. clinical supervision lacked a formal structure and was reliant upon the practitioner seeking supervision when he/she felt it was needed. concern was voiced by one participant that supervision was “after the event” rather than at the time of an event. educational support. three participants mentioned the clinical supervision and support provided by them to local hospitals. this supervision and support was varied and included direct patient care, such as performing a mental state examination or risk assessment, development of clinical management plans for patients and education of staff on a wide range of topics relating to mental health. a collegial relationship between the participants and the agencies allowed participants to work in a consultancy-type role. two participants identified student supervision and facilitation of student learning as having an impact on their workloads. both participants supported student education; however, they felt the tertiary institutions should provide more support to the students than was evident. the need to provide students with positive experiences, and encourage them to see mental health nursing as a viable option, was discussed by both participants, who felt they had a professional responsibility to preceptor students. participants said that although they were supportive of student nurses, providing learning experiences for a student involved more work. these clinicians felt unable to provide the students with the experiences and support required due to their increased workloads. this had resulted in them having no nursing students gaining clinical experience, in their area, in recent months. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 25 caseload numbers and caseload composition. all participants cited increased acuity, excessive caseload numbers and complexity of cases as being problematic. nurses performed the same tasks, irrespective of their experience. there was a sense of being over burdened with high caseloads, and having no validated method of determining case complexity. there was consensus that individual case numbers in urban areas were fewer and that in urban areas cases were assigned according to complexity and the nurse’s experience. participants argued that their high caseload numbers, coupled with case complexity and geographical isolation, meant that they should be employed as advanced practitioners. limitations essentially this study met its objectives, although its limitations must be acknowledged. the sample size was small and taken from one rural region, placing limitations on the extent to which results can be generalized. although hermeneutic phenomenology will not aid in the prediction of roles undertaken by rural community mental health nurses, it provides an understanding of the issues and concerns faced by these nurses. due to a shortage of information on the roles and responsibilities of registered mental health nurses working in rural areas, extensive meaningful comparison of findings in related literature was difficult. recommendations and conclusions this study has reinforced the literature findings regarding issues faced by rural nurses in australia (alcorn & hegney, 2000; bell, daly, & chang, 1997a; borland, 2000b). unifying themes that were woven through all narratives were those of isolation, autonomy and advanced practice. findings indicate that the role of these nurses is complex, involving local knowledge, awareness of community resources, therapeutic interventions and support to other clinicians. these findings support prior studies regarding the enhanced role of generalist nurses in rural and remote australia (national rural health alliance, 2002b). the development of skills and knowledge necessary for undertaking a rural community mental health nursing role was described as experiential. this is consistent with findings on generalist nurses in rural areas (alcorn & hegney, 2000; national rural health alliance, 2002b). accessible, formal education programs are needed to validate the role and provide a framework for practice. this study highlights the need for formal recognition of advanced practice and structured clinical supervision for rural community mental health nurses. furthermore, it was identified that community mental health nurses were often the sole providers of care for the client and were responsible for coordinating all aspects of the clients’ care. this multifaceted, advanced role of rural community nurses is supported by current literature (bell et al. 1997b; hegney, 1998; national rural health alliance, 2002a). furthermore, there is a need to address specific issues such as formal recognition of established rural and remote nursing roles, the role of the nurse practitioner, recognition of the nurse practitioner role by gps, prescribing rights, advanced emergency clinical skills, and ongoing competency training if nurses are going to be encouraged to work in rural areas (bradley & mclean, 2000) action on these issues will be required if the mental online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 26 health needs of rural australians are to continue to be met by community mental health nurses. references alcorn, g., & hegney, d. 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(1996). the nurse practitioner role in psychiatric nursing: expanding advanced practice through the np role. online journal of issues in nursing. retrieved august, 12, 2000, from http://www.nursingworld.org/ojin/tpc1/tpc1_2.htm shanley, e. (1999). report of the review of mental health nursing education in western australia. perth: edith cowan university & graylands hospital. taylor, c. (1995). jack of all trades and master of none. archives of psychiatric nursing, 9, 231. [medline] van manen, m. (1997). researching lived experience: human science for an action sensitive pedagogy (2nd ed.). london, ontario: the althouse press. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=3891811 http://www.nursingworld.org/ojin/tpc1/tpc1_2.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&dopt=abstract&list_uids=3891811 microsoft word bigbee_346-1845-1-ed.docx online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 150 rural older adult readiness to adopt mobile health technology: a descriptive study anita depatie, ms, rn, ccm 1 jeri l. bigbee, phd, rn, fnp-bc, faan 2 1 nurse case manager, fallon health, adepatie@ucdavis.edu 2 adjunct professor, the betty irene moore school of nursing at university of california davis, jlbigbee@ucdavis.edu abstract purpose: the purpose of this study was to gain insight into the readiness of rural older adults to accept mobile health technology. results will be useful in the design and delivery of mobile health technology to assist with health management, wellness interventions, and aging in place. sample: convenience sampling was used to recruit 30 participants from two rural northern california multipurpose senior centers. methods: participants attended a demonstration and participated in a blood pressure screening using a mobile health device followed by a survey. mixed methods of data collection were used to capture categorical data as well as contextual, socio-cultural, and experiential factors for understanding the potential for future use of mobile health technology by older adults in rural communities. results: participants indicated they wanted control over their health data by choosing when and where to share the information, with the exception of alerts sent in a crisis situation. results were evenly split on the importance of using technology to connect with patient education and support groups on-line. important facilitators that would promote adoption of mobile health technology include ease of use, convenience, and affordability. barriers to adoption include moderate concern with risk to the privacy and security of their health information, and high cost. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 151 conclusion: mobile health technologies that are easy and convenient to use, affordable, and a good fit for each individual have the potential to facilitate patient engagement, patient empowerment, and individual responsibility for health and wellness. additional nursing research on innovative models of care is needed to validate and promote mobile health technology for the health and aging in place needs of rural older adults. rural nurse leaders can take the lead to innovatively leverage mhealth technology solutions that impact rural health and wellness. keywords: mhealth, rural, older adults, age in place rural older adult readiness to adopt mobile health technology: a descriptive study with knowledge gained through research and advances in health care delivery, people are living longer with multiple chronic illnesses. rural older adults are more likely than their urban counterparts to have chronic illnesses and face more barriers in accessing health care (goins & krout, 2006). limited health care resources and the reduced availability of formal and informal caregivers, services and support for frail older adults living in rural communities, result in a multitude of pressing health care problems that need to be addressed (milligan, 2009). innovative programs incorporating remote and home-based care solutions, developed with a focus on the unique needs of the aging population of rural older adults to promote wellness, and prevent and manage chronic illness, are possible solutions. innovative health care approaches, such as mobile health technologies (mhealth), have the potential to increase access to care, reduce health care costs and assist older adults living in rural communities to “age in place,” as appropriate. the centers for disease control and prevention define aging in place as “the ability to live in one’s own home and community safely, online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 152 independently, and comfortably, regardless of age, income, or ability level” (farber & shinkle, 2011, p. 15). technology to assist aging in place can be cost effective, enhance quality of life, and promote positive outcomes for older adults (center for technology and aging, 2011). mobile smartphones along with other mobile technologies offer a myriad of applications that measure, monitor, store, and share health information. mobile monitoring devices enable individuals to record real-time health measures allowing timely exchange of health information with clinicians. real-time monitoring can detect a problem and alert a health care provider regarding condition alterations before the patient deteriorates to the point of requiring emergency treatment and more costly care scenarios. users can also get personalized feedback and health reminders with access to health information, social networking, and discussion forums to share and benefit from collective experience. mobile health technologies can overcome the limitation of distance and local access to health care faced by older adults living in rural areas. the growing adoption of smartphones and mobile health technology offers a potentially practical solution to health management for rural older adults who strive to age in place. rural nurses can provide the technology link to health care delivery through research, assessment, planning, implementation, teaching, and evaluation of mobile health technology. the institute of medicine’s future of nursing: leading change, advancing health report outlines expanding “opportunities for nurses to lead and diffuse collaborative efforts to improve health outcomes and reduce costs” (institute of medicine [iom], 2011, p. 2). recommendation #2 supports this goal by calling for private and public funders to collaborate on advancing models of care for innovative solutions that will enable nurses to improve health and health care. this recommendation also calls for health care organizations to support nurses in taking online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 153 the lead in developing and adopting innovative patient-centered care models. furthermore, nursing education programs can provide entrepreneurial professional development that will enable nurses to initiate programs and businesses that will contribute to improved health and health care (iom, 2011). nurses and other health care providers are needed to champion mhealth with their colleagues and patients. as nurse leaders, we are challenged to identify, develop, implement, and evaluate innovative solutions to assist with chronic disease management and aging in place. rural health/chronic illness/aging in place rural older adults experience disproportionately high rates of chronic illness and limited access to adequate health care services. in a 2006 study, sharkey and bolin concluded that many factors, such as increased rates of poverty and limited availability of health care resources contribute to this problem. while the personal and financial consequences of chronic disease are greatest for those who become ill and their families, we as a society cannot ignore the impact that chronic disease has on all health care resources and expenditures. the rising rate of chronic disease is a key contributor to the growth in health care expenditures. the centers for disease control and prevention [cdc] (2011) report that among the older adult population, “about 80% have at least one chronic condition, and 50% have at least two” (p. 2); accounting for over 75% of health care costs. the prevalence of chronic disease combined with the fact that 18% of the united states age 65 years or older live in areas designated as rural (national rural health association, 2007), validates the need for studies of solutions that improve clinical outcomes and reduce chronic care costs. added to this is the challenge of increasing access to adaptive technologies that can assist rural older adults to remain independent and living in their communities. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 154 a 2011 report by the national conference of state legislatures and the american association of retired persons (aarp) public policy institute (farber & shinkle, 2011) stated that 90% of people age 65 and over want to age in their own homes as an alternative to longterm care. safely aging in the familiar surroundings of home and community offers many benefits that support health and life satisfaction. however, the report also addressed the issue of isolation faced by many who choose to age in their own homes. lack of available transportation is a significant barrier to needed services, and lack of contact with others may lead to depression and poor health outcomes. this is especially true for rural older adults who may not have the breadth of transportation options and support services that are available in metropolitan areas (farber & shinkle, 2011). the concept of ‘aging in place’ requires a system to support older adults so they may safely and comfortably remain in the environment of their choice with appropriate services (rantz, skubic, miller & krampe, 2008). emerging mobile health technologies that improve on existing home monitoring methods offer promising solutions to increase access to care, lower health care costs, provide opportunities for socialization, and assist aging in place. remote health monitoring technology modern technology presents an opportunity to enhance the quality of life and independence of older people and their caregivers. home health monitoring, remote monitoring, telehealth, telecare, and mhealth technology are terms used to describe any technology that enables the health monitoring, evaluation, and management of an individual over distance through a remote interface (center for technology and aging, 2011). clinical data such as vital signs, medication management, physical and cognitive status, and environmental conditions can be transmitted by telecommunications technology to a health care provider for review, online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 155 management, and patient education. ease of use is a concern of many emerging technologies and a potential barrier to adoption. tablets, smartphones, and e-readers are relatively easy to use and age does not have to be a barrier. many older adults are already accustomed to using everyday technology such as those incorporated into automobiles, various electrical appliances, and automated teller machines (atms). a prime example of the use of technology to support chronic illness management has been developed by the veterans health administration (vha), the largest integrated health system in the united states. as part of the vha’s commitment to increase non-institutionalized care for aging veterans with chronic conditions, a national home telehealth program was introduced in 2003. the vha piloted and subsequently instituted the care coordination/home telehealth (ccht) program to support veterans with chronic care management using electronic monitoring in their homes. the program was implemented as an adjunct to its health information technology infrastructure, as they transitioned the majority of care from hospitalbased to an outpatient focus. a key case report on the vha ccht program showed a significant decline in hospital utilization. between 2003 and 2007 a total of 43,430 patients were enrolled in the program. between 2006 and 2007 satisfaction surveys were administered to 42,460 participants every three months. sixty percent of the ccht population responded with a mean satisfaction score of 86%. outcomes data were reported for 17,025 enrolled patients, including both rural and urban residents, between 2006 & 2007. participants included in the outcomes study ranged in age from 20-98 (mean age 65), with the majority of patients (9,410), in the 50-69 age range. the results indicated that there was a 29.2% reduction in hospitalizations among the 9,880 urban patients, a 17% reduction among the 6,782 rural patients, and a 50.1% reduction among the 294 patients living in highly rural or frontier areas. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 156 the cost of the program is $1,600 per patient per annum (darkins, et al., 2008). the vha attributed the success of this program to its comprehensive and systematic approach to the unique clinical needs of each patient, extensive education of care coordinators, integration into the vha’s existing computer based record system, and routine monitoring of quality and performance data. this innovative program provided a solution to the changing demographics of veterans who are living longer and choosing to live at home with chronic disease versus institutional care, including the 32% of the veteran population who are residing in rural areas (darkins, et al., 2008). although this landmark study included a significant number of rural participants (42%), the majority of participants (58%) lived in urban areas. additionally, this study only addressed the veteran population; with an age range of 20 to 98, and 96% of the participants were male, which limits the generalizability of the study. this study also did not report how often care coordinators had direct contact with patients. yet despite these limitations, there is currently no other study of this size and complexity for comparison. however, the limited research to date suggests that the use of technology can “increase the time that older adults can live independently outside of institutions, relieve caregiver strain, and provide a cost effective means of providing care while reducing clinical visits” (calvert, kaye, leahy, hexem & carlson, 2009, p.1). overall, home care technology has the potential to enhance the diffusion and sharing of health information and health care (gamm & hutchison, 2004). this may be of particular significance to rural older adults provided that we can reduce the digital divide that exists between the urban-rural and young-old populations. digital divide the rural assistance center is a national resource center for rural health and human services information (http://www.raconline.org ) and provides a link to the report by kruger and online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 157 gilroy (2013) which defines “digital divide” as the disparity in effective access to digital and information technology among people of certain demographic groups such as rural dwellers, lower socioeconomic classes, older adults, and those with disabilities. this term also includes the differences in the ability and skills required to participate in using technology resources. important findings from the pew internet and american life project indicate significant progress in closing the gap. among a sample of 2,254 adults age 18 and over, data on digital differences indicate that as of april 2012, 53% of adults age 65 and older use the internet. this is a marked increase from 41% in 2011, and 12% in 2000 using similar samples. according to the pew research findings, a higher level of education and income correlates with higher adoption and use of technology (zickuhr & smith, 2012). cellular phones, varying from basic handsets to smartphones, are the most popular mobile devices in use in the united states today. as of april 2012, results from the pew internet and american life project survey indicated that 69% of americans age 65 and older own a cellular phone, an increase of 8% from may of 2010 (zickuhr & madden 2012). a subsequent pew research survey of 3,014 adults 18 and older, including 29% of whom lived in rural areas, in 2012 indicated that 11% of adults age 65 and older (n=830) owned a smartphone. fox and duggan’s research (2012) indicated that 9% of those age 65 and older (n=599) reported using their cellphone to access health information, and 10% (n=105) report using health applications on their smartphone (fox & duggan, 2012). the number of people who access health information using their cellphones has nearly doubled in the past two years. the only groups that did not report a significant increase in this activity were those ages 65 and older and those who did not graduate high school. other studies suggest that there has been a slow but steady increase in adoption of mobile technology among older adults, however, cellphone ownership is far more common among younger adults. although great online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 158 strides have been made in closing the digital divide for rural residents and older adults, there are still some key challenges. according to the 2010 u.s. census only 61% of rural adults have mobile broadband or other internet services in their homes as compared to 73% of urban adults (u.s. department of commerce, 2010). data from the u.s. census show that, of all rural americans with internet access, only 57% have high-speed (broadband) connections in their homes compared with 70% in urban households (national telecommunications & information administration, 2011). technology has the potential to strengthen support for rural older adults; but might not be a viable option for people in areas that lack technical infrastructure, or for those who are not computer literate, have sensory limitations or have marginal economic resources. acceptance of health technology perceived usefulness with direct benefits and proficiency in learning to use new technologies are fundamental predictors of user acceptance (mahoney, 2011). a study conducted with 61 urban and suburban australian older adults by wade, cartwright and shaw (2012), found that perceived usefulness and ease of use of telehealth by frail older adults and caregivers correlated with their acceptance of these systems as a therapeutic tool. the investigators concluded that there is limited knowledge about other facilitators and barriers to telehealth compliance by this group, who are potentially a significant user group of health technology in the future. this study was conducted exclusively in australia, did not include rural older adults, and was limited by its small sample size. over the past few decades there have been many studies conducted in an effort to gain knowledge of the factors that influence technology acceptance. a key systematic literature review funded by the national library of medicine was performed to identify factors promoting online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 159 consumer health information technology (chit) acceptance (or & karsh, 2009). the report highlighted the importance of considering user characteristics to predict patient acceptance and guide implementation. a total of 52 articles met five inclusion criteria of (1) determining characteristics associated with acceptance of chit, (2) the object of the chit was to promote health, well-being, or self-care, (3) individuals studied were patients, (4) the article was written in english, and (5) the article was published in a peer-reviewed journal or research conference proceedings. nineteen of 39 studies reported that higher age was a significant negative predictor of acceptance. gender had no effect on acceptance in 84% of the studies that tested for this variable. sixty-eight percent of 28 studies that examined education found acceptance to be positively associated with higher education levels. fifteen of 20 studies found a positive correlation between prior experience with computer and/or health technology use. only seven of the 52 studies tested for both perceived usefulness and perceived ease of use, and all reported these factors were reliable predictors of technology acceptance. the two studies that tested for self-efficacy reported this to be a significant positive predictor of acceptance. the review also reported on two studies that indicated physical, visual, and cognitive limitations to be possible negative predictors of acceptance. the authors acknowledged that indicators such as social influence, culture, and group norms were not examined in any study reviewed. these have been predictive factors in prior technology acceptance studies that did not include health care technology. the authors mention that patients may be more receptive to chit if their health care providers, children, or grandchildren urge them to use it (or & karsh, 2009). this systematic review is limited to general consumer computer-based systems for health information access and exchange; it did not specifically mention mobile health technology. the review did not address vulnerable or rural populations, and did not specify if any of the studies online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 160 examined older adults exclusively. despite a thorough literature review, specific studies addressing the accessibility and use of mobile health technologies for rural older adults were not found. studies that address the potential of mobile health technology to assist rural older adults using key theories to provide a framework for explaining and predicting phenomena that support and inform research are needed. conceptual framework two conceptual models were used to inform this study, the adoption of technology model (mahoney, 2011), and rural nursing theory (long & weinert, 1989). each of these models will be described along with their application to the study. the adoption of technology model (figure 1) was developed by nurse researcher, diane mahoney (mahoney, 2011). this model is an adaptation of diffusion-of-innovation theory that suggests which factors determine whether an innovation is adopted or not (rogers, 1995); with integrated aspects from the trans-theoretical behavioral change model (prochaska, 1997), which outlines specific stages of readiness for change and assesses the processes of behavioral change affecting whether or not one adopts and uses an innovation. this model considers the factors that lead to adoption or rejection of technology-based interventions by frail and cognitively impaired older adults and their family caregivers. the model identifies socio-demographic characteristics as pre-disposing factors; and enablers and barriers as mediating factors leading to proximal outcomes of adoption or rejection. if the technology is adopted it leads to distal outcomes variables such a peace of mind, security, and well-being. the keys to adoption of technology, according to the model, are an individual’s willingness to learn about and use the product, and their ability to perceive direct benefits. another key to adoption of intervention technology is a product tailored to the individual needs of older adults and their caregivers. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 161 other considerations of this model include affordability, the issue of safety versus independence, privacy, security, and whether or not the individual views the technology as dehumanizing. enabling factors must be able to overcome perceived barriers including loss of privacy and intrusiveness concerns, and information overload. due to the recent development of this model it has not been tested in empirical research. long and weinert’s (1989) rural nursing theory was also used to direct inquiry in this study. according to this theory, rural health care perspectives vary greatly from those in urban and suburban areas. rural dwellers define health as the ability to work, be productive, and/or do usual tasks. this belief often leads rural dwellers to put work priorities ahead of health care needs. time and distance to receive health care, as well as cost, are of concern to rural individuals. many will self-treat to save time and money or will wait until their health is severely compromised before traveling for care. rural dwellers tend to be self-reliant and resist services from those seen as outsiders. health care recipients and health care providers in rural areas must also deal with a lack of anonymity. due to limited rural health care resources and specialties, health care workers also experience much greater role diffusion than their urban and suburban counterparts (long & weinert, 1989). a recent review of the current state of rural nursing science concluded that descriptivecorrelational studies of disease management were the most common foci of research. the authors suggest that further testing of rural concepts as independent variables is needed to investigate how these concepts affect outcomes to develop evidence based knowledge and further develop the specialty of rural nursing (williams, andrews, zanni & fahs, 2012). additional research related to health perceptions, health care needs, and technology for health in differing areas is needed to develop health programs and shape rural health policy. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 162 figure 1. adoption of technology model figure 1. details of the adoption of technology model copyright 2010 by d. mahoney. reprinted with permission. purpose the purpose of this study was to identify facilitators and barriers to the use of mobile health technology among rural older adults. the following research questions were addressed: 1. what is the level of readiness for rural older adults to adopt mobile health technology? 2. what identified facilitators would promote adoption of mobile health technology? 3. what identified barriers would impede adoption of mobile health technology? online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 163 methods design a descriptive exploratory research design was used in this study. quantitative and qualitative data collection by survey was used to capture categorical data, including the contextual, socio-cultural, and experiential factors for understanding the potential for future use of health technology by this population. the survey was designed to obtain information on demographics, technology and mobile device use, as well as opinions regarding how participants would like to use technology and mobile devices for health care. setting and sample this study took place in the fall of 2012 at two northern california rural multipurpose senior centers serving the 60-plus population. both senior centers are located within california’s rural gold country at the foothills of the sierra nevada mountains. the calaveras senior center is located in san andreas, california. according to the 2010 u.s. census, the total county population is 45,578. with 1,020 square miles of land area, the population density is 44.7 people per square mile. of this population total, 21% (n=9,565) are over the age of 65. among those age 65 and older 10.3% (n=1,942) live alone. the majority of the population is white (92.6%), and 19.6 % of the population age 25 and above has attained a bachelor’s degree or higher (united states department of commerce, 2010). the amador senior center is located in jackson, california. the amador county population is 38,091. with 595 square miles of land area, the population density is 64.1 people per square mile. of this population total, 20.6% (n=7,865) are over the age of 65. among those age 65 and older 10.5% (n=1,545) live alone. the majority of the population is white (87%) and online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 164 19% of the population age 25 and above has attained a bachelor’s degree or higher (united states department of commerce, 2010). convenience sampling was used, recruiting participants before or after lunch at the senior centers. inclusion criteria included adults age 60 years and older. non-english speaking people were excluded from participation in the survey, as it was written in the english language only. thirty participants chose to have the blood pressure screening and fill out the 16-question survey. a description of the sample demographics is included in the results section that follows. procedures this study was approved by the uc davis institutional review board protocol number 362813-1, prior to data collection. participants were provided with an informational consent form describing the purpose of the study and contact information for further questions prior to the presentation, blood pressure screening, and data collection. a presentation on blood pressure measurement and monitoring using an ipad and ihealth blood pressure system and application was given. participants were then given the option to have a free blood pressure screening using the system. the demonstration concluded with participants anonymously answering a 16question survey directed at the three research questions. participants were given the option to have the blood pressure screening without completing the survey, and were also given the option to complete the survey without having the blood pressure screening. all participants chose to have both the blood pressure screening and complete the survey. the 16-question paper and pencil survey was developed after evaluating several similar surveys on older adults and technology use. quantitative and qualitative questions were incorporated into the survey. demographic data were collected including age, gender, level of online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 165 education, number of years living in the area, number of miles from a health care provider, and inquiry on experience with technology, mobile devices, and the internet. questions about technology use for health care were structured using a five point likert scale. demographics, technology, and mobile device use data were collected using quantitative inquiry to develop a profile of the participants. qualitative inquiry was added to capture the rich detail of people’s personal experiences of phenomena related to the local context. questions on how participants would use technology and mobile devices were designed based on the adoption of technology model and rural nursing theory to address the three research questions. institutional review board approval was obtained prior to commencement of the study and data collection. data were entered into an excel spreadsheet and descriptive statistics were generated for each survey question, including frequencies and percentages for categorical data. ordinal data were analyzed for mean, standard deviation, and range. qualitative data from the open ended questions were content analyzed by two nurse researchers to identify recurring themes. results description of the sample table 1 summarizes the demographic data that were provided by the 30 participant convenience sample of the rural older adult population. all participants were 60 or older, and the majority of respondents (57%) were older than 73. most (80%) of the participants were female. educationally, (43%) reported some college, (17%) achieved a bachelor’s degree, and (13%) completed a graduated level of education. eighty percent reported living in the community for over 20 years, including two lifelong residents. sixty-seven percent reported living within 15 miles or 30 minutes proximity to their health care provider. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 166 survey questions six through 10 provided further information regarding the sample by querying participants’ current use of technology and mobile devices (table 2). the majority of participants (67%) reported using a computer at least several times per week. table 1 characteristics of study participants technology for health survey n = 30 variable n % q1. gender female 24 80 male 6 20 q2. age 53 to 62 1 3 63 to 72 12 40 73 to 92 6 20 83 to 92 8 27 93 and over 3 10 q3. level of education less than 12th grade 1 3 high school graduate 7 23 some college 13 43 bachelor’s degree 5 17 graduate degree 4 13 q4. length of time living in community less than 6 months 0 0 less than 1 year 1 3 less than 5 years 2 7 less than 10 years 2 7 less than 20 years 7 23 less than 30 years 5 17 30 years or more 10 33 lifelong resident 2 7 no answer provided 1 3 q5. how many miles/minutes from health care provider less than 15 miles or 30 minutes 20 67 more than 15 miles or 30 minutes 9 30 no answer provided 1 3 online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 167 seventy percent use the internet, including 53% who use the internet at home. seventy percent, however, did not use a smartphone or tablet. twenty-seven percent reported that they were currently using email or the internet to communicate with their health care provider. table 2 participants’ technology experience technology for health survey n = 30 variable n % q6. frequency of computer use never 8 27 less than once per month 0 0 about once per month 0 0 several times per week 5 17 daily 15 50 no answer provided 2 7 q7. internet use yes 21 70 no 7 23 no answer provided 2 7 q8. where the internet is used home 16 53 work 2 7 home and work 2 7 community location 1 3 no answer provided 9 30 q9. participants’ use of smartphone or tablet yes 7 23 no 21 70 no answer provided 2 7 q10. currently using email or the internet to communicate with health care provider yes 8 27 no 20 67 no answer provided 2 7 q11. comfort with communicating with health care provider using email or the internet not at all comfortable 9 30 somewhat comfortable 4 13 comfortable 7 23 online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 168 very comfortable 3 10 extremely comfortable 3 10 no answer provided 4 13 q12. participants’ interest in incorporating using email, ipads, cellphones, text messages or other technology into daily life for health tracking and communication with a health care professional i am not at all interested 10 33 i am somewhat uninterested 4 13 i am somewhat interested 7 23 i am very interested 3 10 i already use it today 4 13 no answer provided 2 7 readiness to adopt mobile health technology the first research question, “what is the level of readiness for rural older adults to adopt mobile health technology?” was assessed through survey questions 11 and 12 (see table 2), specifically measuring comfort and interest in using technology for health care. in table 3, participants’ responses related to how they would use mobile devices for health care are summarized. participants’ comfort level with using email or the internet to communicate with a health care provider was evenly split. forty-three percent reported either being somewhat comfortable or not at all comfortable communicating with a health care provider using email or the internet, and 43% were comfortable to extremely comfortable on a scale of 1 to 5 with 1 being not at all comfortable and 5 being extremely comfortable. responses to interest in incorporating email, ipads, cellphones, text messaging, or other technology into daily life for health tracking and communication with a health care professional indicated that 33% had no interest, 23% were somewhat interested, and 13% indicated that they already used this technology. survey questions 14a through 14g provided additional data related to readiness to adopt mobile health technology by measuring participants’ level of importance ratings on features of online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 169 mobile health technology systems. participants’ responses as to how they would like to use mobile health technology are summarized in table 3. sixty-seven percent indicated that it would be moderately to extremely important to use technology to monitor their own health, but would not share this information with a health care provider. (sd = 1.51). fifty-three percent indicated that it was somewhat or extremely important to monitor their own health and share the information with a health care provider at clinic visits (sd = 1.24). forty-six percent indicated that it was somewhat or extremely important to monitor their own health and share it over the internet with a health care provider (sd = 1.44). fifty-seven percent indicated that it was somewhat or extremely important to monitor their health and send automatic alerts to health care providers and family members when a crisis is detected (sd = 1.35). fifty-four percent indicated that it was somewhat or extremely important to receive health updates, appointment reminders, medication reminders, and motivational statements from health providers (sd = 1.35). forty-four percent indicated that it was moderately, somewhat, or extremely important to use mobile health technology in conjunction with periodic in-home nurse visits, while 43% indicated that it was not very to not at all important (sd = 1.41). forty percent indicated that it was somewhat or extremely important to connect with patient education and support groups online, and 37% indicated that it was not very important or not at all important (sd=1.60). facilitators of mobile health technology adoption the second research question, “what identified facilitators would promote adoption of mobile health technology?” was assessed by survey questions 13a through 13d. participants were asked to rate their level of agreement with four statements regarding the use of email, ipads, cellphones, text messaging, or other technology for monitoring health. table 4 summarizes expressed facilitators of mobile health technology adoption. seventy-four percent online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 170 agreed or strongly agreed that it must be easy to use (sd = 0.56). seventy-six percent agreed or strongly agreed that it must be convenient to use. eighty percent agreed or strongly agreed that it must be affordable. seventy-seven percent agreed or strongly agreed that it must have a clear benefit to health and well-being. table 3 readiness to adopt mobile health technology q14. would use mobile technology for technology for health survey n = 30 variable mean sd q14a. to monitor health, but not share the information with a health care provider 2.88 1.51 q14b. to monitor health and share the information with a health care provider at clinic visits 2.17 1.24 q14c. to monitor health and share the information with a health care provider over the internet 2.48 1.44 q14d. for health monitoring with automatic alerts sent to health care providers and family members when a crisis is detected 2.08 1.35 q14e. to receive health updates, appointment reminders, medication reminders & motivational statements from a health care provider 2.20 1.35 q14f. in conjunction with periodic in-home nurse visits 3.22 1.41 q14g. to connect with patient education and support groups on-line 2.96 1.60 measured on likert scale 1-5, with 1 = extremely important & 5 = not at all important it was interesting that one participant mentioned their insurance company as a facilitator, as insurance reimbursement may be the driving force that leads to widespread mobile health technology adoption. the participant stated: online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 171 “if my insurance company paid or someone gave me this device and paid for maintenance, i would use it.” barriers to mobile health technology adoption the third research question, “what identified barriers would impede adoption of mobile health technology?” was assessed through survey questions 15a through 15g. participants were asked to rate their level of agreement with six statements that may discourage them from adopting mobile health technology. table 4 facilitators of mobile health technology adoption q13. using email, ipads, cellphones, text messaging, or other technology for monitoring health. technology for health survey n = 30 variable mean sd q13a. ease of use 1.30 0.56 q13b. convenient to use 1.30 0.47 q13c. affordable 1.21 0.41 q13d. clear benefit for health and well-being 1.42 0.58 measured on likert scale 1-5, with 1 = strongly agree & 5 = strongly disagree table 5 summarizes barriers to mobile health technology adoption. twenty percent strongly agreed that using mobile devices for health technology is a risk to privacy, and 30% neither agreed nor disagreed with that statement. thirty-four percent agreed or strongly agreed with concerns about security of health information on mobile devices, and 33% neither agreed nor disagreed. forty-seven percent disagreed or strongly disagreed that using health technology will make them look like they need help, while 30% neither agreed nor disagreed. forty-three percent neither agreed nor disagreed that mobile health technology systems are not designed for online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 172 their individual needs. cost stood out as a concern to many participants. forty percent agreed or strongly agreed that mobile health technology costs too much to buy, while 37% neither agreed nor disagreed. one participant reflected on concerns by stating: “i enjoy technology, but i doubt i would spend any money on health technology. benefit would have to be high and cost very reasonable.” the final question asked participants about their level of agreement with the statement “i don’t like using computers and other technology.” forty-three disagreed or strongly disagreed with that statement, and 20% neither agreed nor disagreed. table 5 barriers to mobile health technology adoption q15. factors that would prevent participants from adopting mobile health technology. technology for health survey n = 30 variable mean sd q15a. risk to privacy 2.88 1.33 q15b. concerns about security of health information 2.73 1.19 q15c. using health technology makes participant look like they need help 3.73 1.15 q15d. systems are not designed for individual needs 3.12 1.27 q15e. costs too much to buy and maintain 2.36 1.08 q15f.participant does not like using computers and technology 3.56 1.36 measured on likert scale 1-5, with 1 = strongly agree & 5 = strongly disagree in response to the inquiry regarding current use of email or the internet to communicate with a health care provider, an interesting finding emerged indicating that some are waiting for their health care provider to take the lead in adopting technology and introducing it to them. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 173 participants responded with statements such as: “occasion has not risen,” “never proposed to me,” and “was not invited to do so.” discussion this study addressed the important topic of health care delivery and chronic care management for frail older adults living in rural populations. this is the first known study to address the potential use of mobile health technology to help fill gaps in health care services and support for frail older adults living in rural communities. it is essential to identify this population’s level of readiness along with identified facilitators and barriers to ensure successful design, implementation, and adoption of mobile health technology solutions. the intent of this study was to explore these variables to better understand how this innovative new technology can best serve the needs of this population. summary of major findings in relation to the first research question, “what is the level of readiness for rural older adults to adopt mobile health technology?,” participants were queried on their comfort level and interest in using mobile health technology. given the majority (57%) of participants were older than 73 years of age, and 80% reported living in the rural community 20 years or more, the principal investigator expected to find that very few would be users of computers and technology. however, 67 % reported using a computer at least several times per week, and 70% reported using the internet. these results are surprising considering that data collected by the pew internet and american life project in april 2012 indicated that only 53% of adults age 65 and older use the internet (zickuhr & madden, 2012). it was expected that the advanced age of the majority of the participants in this study combined with their rural location, would result in less use of computers and technology. interestingly though, 30% reported that they use a online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 174 smartphone or tablet. these results may be related to the fact that 73% of the participants reported post-secondary education, and pew reported that higher education is a positive indicator of technology adoption. the term “use” in this case may refer to the fact that they do not necessarily own a smartphone or tablet, but may use one owned by a family member or acquaintance. this finding is in line with data collected in the pew internet and american life project in august and september of 2012 that indicate 11% of adults 65 or older own a smartphone. data collected in april 2012 indicate that 53% of seniors use the internet and email (zickuhr & madden, 2012). internet, email, and on-line social networks can be an important access to social connections and access to care for frail older adults who have difficulty with mobility and leaving their homes. according to choi and wodarski (1996), social support or lack thereof is a significant factor in the health status of older adults. there was an even split in the results regarding the importance of using health technology to connect with patient education and support groups online. this may be an indication that rural older adults are adapting to accepting new technology and social media. mobile health technology that incorporates social networking may be very useful for health and social connectedness of rural older adults. some evidence suggests that men in rural culture may tend to find it difficult to ask for help. while rural women may rely on friends or family, men tend to rely solely on their wives for support. this leaves rural men at higher risk for social isolation and poor health if they are single or widowed (weinert & long, 1993). technology can provide the access link to information that helps to assess the seriousness of an illness or injury, and aid with formulating a plan of action for treatment at home or assist with the decision to seek care depending on the symptom-action-time-line concept outlined by online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 175 buehler et al. (1998). technology like mhealth could also provide a vital link to health tracking and socialization for rural dwellers. results regarding interest in using email, the internet and technology for health tracking and communication with a health care provider were evenly split. this is in sharp contrast to the aarp study which indicated that only 11% of people age 50 and above are interested in using technology to track health measures. the trend in the data may indicate that rural older adults are beginning to adapt to the fact that technology for in-home health care is becoming much easier to use and as commonplace as everyday household appliances. it may also indicate that they recognize the potential of technology to break down the barriers of distance and access to service and view it as a vital link to care and the ability to age in place. the findings indicate that participants want to control their health data by tracking and choosing when and where to share the information. this may be a result of concerns with lack of anonymity and confidentiality that are prevalent in rural culture. there was, however a high level of interest in having automatic alerts sent out for help when a crisis is detected as well as receiving automated health information and reminders. a discussion of facilitators of mobile health technology acceptance in the next section will provide further understanding of acceptance by this population. in relation to the second research question, “what identified facilitators would promote adoption of mobile health technology?” participants were queried on ease, convenience, affordability, and the benefit of using mobile health technology to health and well-being. greater than 75% of participants agreed that mobile health technology must be easy and convenient to use, affordable, and must have a clear benefit to health and well-being. these results support the adoption of technology model which outlines the user’s perception of a online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 176 good fit with their needs and direct benefits as key factors in adoption of health monitoring technology (mahoney, 2011). these results also support findings that correlate acceptance of technology to perceived usefulness and ease of use (wade et al., 2012). the results also challenge the common myth stereotyping older adults as afraid of technology. as discussed in the study by calvert et al. (2008) older adults have adopted many technologies such as microwave ovens and dvd players as they became affordable, easier to use, and provided a direct benefit to meet their needs. these positive results indicate the potential for acceptance of mhealth as a tool to support ageand/or health-related changes and improve quality of life if tailored to individual clinical and cognitive needs. in relation to the third research question, “what identified barriers would impede adoption of mobile health technology?” participants were queried on factors such as privacy, security, design, and cost that may discourage them from adopting mobile health technology. privacy and security concerns of governments, health care providers, insurance companies, and patients have been a major limitation in advancing mobile health technology. the study participants were moderately concerned with risk to privacy and the security of their health information while using mobile devices for health monitoring. this finding is consistent with mahoney (2011) finding that 67% of the 60 participants expressed concerns about loss of privacy, and 50% perceived a sense of “big brother” watching over them. concerns about privacy can also be linked to long and weinert’s rural nursing theory concept of insider/outsider and whether a mobile health technology system and the support services connected to it would be considered an intrusion by outsiders (long & weinert, 1989). it is interesting that a high percentage of survey respondents indicated the importance of periodic in-home nursing visits in conjunction with mobile health technology use. the survey question did not specify whether the nurse online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 177 would be known to the patient or not. most disagreed that using health technology will make them look like they need help. this response may account for the fact that new technology such as ipads and iphones and associated applications have many uses and cannot be distinguished exclusively as assistive devices. to reduce the possible stigma attached to relying on a device to remain safe and independent, commonplace technology devices such as cellphones and tablets can be customized to meet individual health and wellness needs. a surprising finding in this study was that the majority of participants responded with a neutral answer when asked if they thought mobile health technology system design did not consider individual needs. this is contrary to the european study findings that indicated the importance of considering the perspective of older adults in designing technology systems to meet their care needs (milligan, roberts & mort, 2010). systems design must take into account that some individual patients and families are no longer passive recipients of care, but crucial and active members of the care team involved in all aspects of the plan of care. not surprising, were the number of participants who responded that technology costs are too high. this finding related to results of the vha study which showed the value of home monitoring technology in reducing hospitalizations and ultimately reducing health care costs in urban as well as rural populations (darkins, et al., 2008). this finding and the vha study results also demonstrated the value to the insurer to take a vested interest in reducing the cost of health care. until the costs of mobile health devices are covered by insurance, it will be up to rural older adults and their families to weigh the benefits versus risks and cost-effectiveness of adopting. will strong ties to land and home be enough of a motivator? if it gives them the opportunity to age in place instead of long-term care, will they adopt? these questions, along with studies that determine outcomes and cost analysis, need to be addressed with further research. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 178 limitations a number of limitations of this study should be noted, in particular its small sample size. the survey was written in the english language only as most of the population was presumed to be white and english speaking. the high level of education reported by study participants is not likely a true representative of rural older adults in general. for the purpose of obtaining a convenience sample of rural older adults age 60 and above, this study was conducted at two rural senior centers. both senior centers were located within the county seat, which offers health services and other conveniences not typical of many rural communities. further study and replication with varied rural populations is needed to confirm the findings. implications the emergence of smartphones and tablets has transformed communications and changed the way in which we access information and perform everyday transactions such as banking and shopping. the time has come for this technology to transform how health care is delivered to empower the patient, increase access, and lower the cost of health care. mobile health technologies are rapidly evolving as a means to track health measures and deliver interventions that can be tailored to the individual. mhealth has the potential to improve the practitionerpatient relationship by improving communication and providing more accurate data to providers while increasing the patient’s participation in their own health care. health care providers need to take the lead and encourage adoption as older adults tend to trust in and turn to their providers for the best advice on health care and health care devices, thus provider buy-in will play a pivotal role in patient-focused adoption of mobile health technology, especially in the rural setting. additional nursing research on these innovative models of care is needed to validate and promote mobile health technology as a viable strategy for the health care and aging online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 179 in place needs of rural older adults. further development and testing of theory such as the acceptance of technology model is needed to provide a framework that outlines aspects of research inquiry for mobile health technology specifically. nursing education programs can facilitate research and technology transformation by offering educational development and programs that empower nurses with skills that advance mobile health technologies to improve health and health care. policy makers are challenged to coordinate infrastructure, regulatory, and reimbursement models to enhance and sustain emerging mobile health technologies. conclusion this study addressed the important topic of health care delivery and chronic care management for older adults living in rural populations. there is a critical need for appropriate and cost-effective innovations that overcome geographical barriers to promote quality health care. emerging mobile technologies with health care applications will alter the time and place of health care delivery, and potentially improve health care outcomes for those in underserved areas including older adults in rural populations. mobile health technology that is easy and convenient to use, affordable, and a good fit for each individual has the potential to facilitate patient empowerment and individual responsibility in the areas of health and wellness. utilizing technology requires an interprofessional team approach in which rural nurse leaders can take the lead to innovatively leverage mhealth technology solutions that impact rural health and wellness. if we can get programs into the community to help people better care for themselves, we can improve health and reduce the burden on the health care system that we have now. innovative solutions such as mobile health technology have the potential to increase access to care, reduce health care costs and assist older adults living in rural communities to “age in place.” the results of this study present important implications for the future use of mobile online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.346 180 health technology to help fill gaps and improve quality in health care delivery for rural older adults. acknowledgements the gordon and betty moore foundation; estella m. geraghty, md, ms, mph, facp, gisp; peter reed, phd, mph; julie rainwater, phd; patricia gonsalves, ms, rn; laurie webb, rn; brandi poole; family and friends references buehler, j., malone, m., & majerus, j.m. 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(2012). digital differences. retrieved from http://www.pewinternet.org/2012/04/13/digital-differences microsoft word kroger-jarvis_271-1683-2-ed.docx online journal of rural nursing and healthcare, 14(1), 2014 83 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 evaluating prostate cancer knowledge in rural southeastern indiana county melanie kroger-jarvis, rn, dnp, msn, cns 1 1 assistant professor of clinical, college of nursing, university of cincinnati, krogerma@ucmail.uc.edu abstract introduction: prostate cancer is the most prevalent form of non-cutaneous cancer in the male population and a major cause of death in men. the purpose of this study was to evaluate knowledge of prostate cancer screening rural men in ripley county, southeastern indiana. methods: an 11 item survey was developed and distributed in two family practices, multiple retail sites, and eateries located within ripley county, southeastern, indiana findings: a convenience sample of 59 men over the age of 50 was recruited by the primary investigator (pi). through descriptive analysis, the data demonstrates men in ripley county, indiana are aware of current prostate cancer screening guidelines. although they indicated knowing updated information regarding prostate cancer screening, many have not obtained screening. study findings point to the need for educational programs designed to improve prostate cancer screening rates in this population. conclusion: results demonstrate men state they have enough information regarding prostate cancer screening, however many have not obtained screening. the influence of the healthcare provider, spouse, and the men obtaining prostate cancer screening were found to have relationships. keywords: prostate cancer screening, survey, theory, models online journal of rural nursing and healthcare, 14(1), 2014 84 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 evaluating prostate cancer knowledge in rural southeastern indiana county prostate cancer is the most prevalent form of non-cutaneous cancer in the male population and a major cause of death in men (american cancer society [acs], n.d.). interventions have been conducted to detect prostate cancer at an earlier stage so that it may be cured or prevented from spreading. incidence rates increased in the 1990s mainly because of prostate cancer screening (national cancer institute [nci], n.d.). despite efforts to promote prostate cancer screening to detect abnormalities of the prostate, many men do not obtain prostate cancer screening, consistent with current research. there is much controversy surrounding prostate cancer screening guidelines and a national consensus, but many medical organizations have made statements that include informed decision making (idm) (driscoll et al., 2008). idm occurs when the patient understands the disease for which he is being screened, the benefits, the risks, and the options available after being screened (rimer, briss, zeller, cahn, & woolf, 2004). o’dell, volk, cass, & span, (1999) demonstrated that knowledge deficit is a barrier to men seeking prostate cancer screening, making an informed decision, and seeking treatment. populations at risk each year one in every six american males is diagnosed with prostate cancer (american urological association [aua], 2013). the incidence increases with age, with 50% of men being diagnosed before the age of 68 (acs, n.d.). those from rural populations are found to be more at risk and less informed than men from urban populations (driscoll et al., 2008). the literature demonstrates there are differences in cancer screening and staging among rural populations of men. in rural populations, cancers tend to be diagnosed at a more advanced stage (gosschalk & carozza, 2003). rural americans have reported less access to healthcare and less involvement in online journal of rural nursing and healthcare, 14(1), 2014 85 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 cancer screening detection programs (casey, call, & kinger 2001). men in rural areas have both a higher incidence and mortality than men in urban areas or where more barriers exist to healthcare (matterne & sieverding, 2008). existing barriers include geographic isolation and lack of healthcare providers (matterne & sieverding, 2008; weinrich, 2006). rural populations of men have also been found to be more at risk and less informed regarding prostate cancer screening (driscoll et al., 2008). a nursing research study found rural men are more likely to present to their healthcare provider with prostate cancer in advanced stages of the disease than their urban counterparts (weinrich, 2006). prostate cancer screening current guidelines no longer recommend routine screening for men 40 to 54 years of age (aua, n.d.). if a there is a positive family history of the prostate screening would be recommended at an earlier age (acs, n.d.; aua, n.d.). prostate cancer in men under 40 years is rarely diagnosed, but is more aggressive in earlier ages (aua, n.d.). prostate cancer is asymptomatic and usually presents with symptoms when the cancer has grown and affects the urethra or invades the sphincter, resulting in lower urinary symptoms (hamilton & sharp, 2004). as of 2013 the aua and the acs recommend both the prostate specific-antigen (psa) blood test, and the digital rectal exam (acs, n.d.; aua, n.d.). the united states preventative task force (usptf) reports screening can detect some prostate cancer; however, each clinician is advised to use an individualized approach (usptf, 2008). both the benefits and harms of screening should be presented to each patient (usptf, 2008). knowledge of prostate cancer, risks, and benefits are significantly low, with less than 30% of men answering prostate knowledge questions correctly (mccormack et al., 2009). the effect on mortality of prostate cancer screening that utilizes both the psa test and the digital rectal exam is still unknown. online journal of rural nursing and healthcare, 14(1), 2014 86 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 however, the psa test and digital rectal exam are the current evidencebased methods recommended for early–stage prostate cancer detection (liberatore, nydick, daskalakis, kunkel, & myers, 2009). informed decision making research demonstrates why prostate screening is important and why rural populations of men are at greater risk. although there is no consensus on prostate cancer screening practices, most medical organizations declare that idm is important for good practice (acs, n.d.; rimer et al., 2004). the uspstf recommends that all physicians use idm, which includes discussion of the patient’s preferences, in order to individualize care (uspstf, 2008). in a quantitative, quasi-experimental study, the results demonstrated men who attended prostate screening educational events are more likely to be married, have more than a high school education, and a greater desire to obtain more information after the presentation (arrasboyd, boyd, & gaehle, 2009). the role of the healthcare provider is a positive influence in a man’s decision to be screened. a study which examined 63 physicians and the pre-screening discussions for idm found that the majority, 71.4%, reported having pre-screening discussions with their patients and discussed the benefits and harms of screening (linder et al., 2009). however, two styles were found to influence idm; some allowed the patients to decide and others recommended the patient to seek screening (linder et al., 2009). a qualitative study examined barriers and facilitators to physicians having prostate cancer screening discussions with their patients (guerra, jacobs, homes, & shea, 2007). barriers were reported, which include lack of screening discussion secondary to treatment of comorbid conditions, physician forgetfulness, patient refusal of screening, and negative attitude of online journal of rural nursing and healthcare, 14(1), 2014 87 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 physician toward screening (guerra et al., 2007). lack of trust in their healthcare provider was also found to be a barrier in a man’s decision to obtain prostate cancer screening (jones, steeves, & williams, 2009). in contrast, facilitators to screening were identified as patient’s request for screening information, and physician’s favorable attitudes regarding screening, and men with a family history of prostate cancer (guerra et al., 2007). jones et al. (2009) also found family support was a key facilitator in men obtaining prostate cancer screening. through systematic reviews of the literature and analysis of the research studies, gaps have been found in research relating to lack of knowledge in order to make an informed decision regarding prostate cancer screening. one study found men who attend more formal educational events, have more higher education, attend educational seminars, and wanted more information about prostate cancer screening (arras-boyd et al., 2009). the investigators recommended future studies should explore the question where do less educated men get their information regarding screening (arras-boyd et al., 2009). other studies found that married men were more likely to be informed about prostate cancer screening (plowden, 2006). this information leaves a gap regarding men who are not married and men who are less informed. in addition, limited medical research exists exploring the knowledge of rural populations of men (arras-boyd et. al, 2009; avorn, kantoff, wang, & levin, 2004; krist, woolf, johnson, & kerns, 2007; mccormack et al, 2009). in a study utilizing the prostate cancer questionnaire(pcq), it was found that advanced practice nurses must perform needs assessments and use these in planning and implementing educational interventions related to prostate cancer (nivens, herman, weinrich, & weinrich, 2001). this was the only study by nurses addressing needs assessments in regards to prostate cancer screening. online journal of rural nursing and healthcare, 14(1), 2014 88 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 identification of problem there are various implications for a project as the result of the current research. a needs assessment through a community survey is a good starting point for assessing needs with a high risk population (witkin & altschuld, 1995). implications for nursing practice are defined in the study cues to participation (nivens et al., 2001). there is a need for healthcare professionals to know what influences rural men to obtain prostate screening. clinical practice has long held the assumption that men will seek screening based on prior sources of information, but little has been done to prove this assumption. although many previous studies found correlations between different types of information and cancer, there were no studies which specifically addressed prostate cancer, demographics, and sources of information as having direct relationships (nivens et al., 2001). methods study design a needs assessment survey was used for this project. this survey guided the evaluation of the relationships among prostate cancer screening and men’s knowledge in rural ripley county, southeastern indiana. for the purpose of this project, the following objectives were examined: 1) evaluate men’s knowledge about prostate cancer screening. 2) evaluate whether men feel they have enough information regarding prostate cancer screening. 3) evaluate where men obtain information, in order to find the most effective modality to educate rural men. 4) evaluate whether men have obtained prostate cancer screening, or if they plan to. this study was approved by the institutional review board at the university of cincinnati (irb protocol number 12011101). online journal of rural nursing and healthcare, 14(1), 2014 89 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 sampling criteria for inclusion for the study were men who: (a) were at least 50 years of age or older, (b) resided in ripley county, (c) were english speaking and able to read and write in english, and (d) consented to complete the questionnaire after being provided the flyer and information sheet. criteria for exclusion were men who: (a) were non-english speaking (b) were cognitively impaired, (c) were illiterate, and (d) under 50 years of age. ripley county indiana is rural with a population 25,583 and has no metropolitan statistical areas (united states census bureau, n.d.). methods for recruitment included flyers, posters, and the principle investigator (pi) asking for participation in both the family physician offices, and the retail shops and eateries within ripley county, indiana. written permission was obtained by hospital administration prior to recruitment at the doctors’ offices and verbal permission was obtained from the eateries, and retail establishments. once permission was granted posters were placed on the walls of the two physician offices, and secured in front of a table at the eateries and retail establishments. the posters and flyers provided information about the survey and personal contact information through telephone, or email communication of the pi. the participants who desired to complete the survey were given an information sheet explaining the survey’s purpose, and criteria for inclusion, exclusion, risks, and benefits of the survey. the participants were informed that participation was voluntary and they had a right to refuse or withdraw at any time. participants were assured that all results would be kept anonymous, with no identifying individual information included. those desiring to participate in the survey completed the form and placed it in a lock box on-site. a pamphlet from the american cancer society (acs) with the new prostate cancer guidelines was given to the men after completion of the survey. online journal of rural nursing and healthcare, 14(1), 2014 90 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 measures the instrument used in the study was formulated by the pi and the capstone committee members. the survey consisted of 11 items to measure prostate cancer screening guidelines knowledge, whether men have obtained screening or plan to and influences to seek screening. the last question asked if men felt they had enough information to make a decision on whether or not to get personally screened. face validity of the survey questions was measured by asking the committee members to evaluate whether the questions were well constructed and useful. one of the expert committee members made recommendations to change the types of questions and how the questions were worded before the survey was conducted. four of the responses were scored true/false, one yes/ no, and two select all that apply. three were arranged on a 5-point likert scale with “1” indicating strongly disagree and “5” indicating agree. a demographic portion provided information on race, marital status, education, computer access, internet service, employment status and residence. knowledge of prostate cancer screening was evaluated by examining whether men in rural, ripley county, indiana understood the guidelines and if they were aware the guidelines had recently had changed. decision making influences including information from doctors or nurse practitioners, as well as pressure by a spouse were evaluated. participation in screening and where the men go to get their information was evaluated. demographic data was used in comparison to each of the prostate cancer screening knowledge questions. these comparisons included use of descriptive statistics along with nonparametric evaluation using chi-square test of association. online journal of rural nursing and healthcare, 14(1), 2014 91 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 results approximately four thousand men live in the ripley county in southeastern, indiana (http//www. in.gov). margaret mary community hospital reports that in 2011 only 106 attended free prostate cancer screening (t. dwenger, personal communication, october 10, 2011). a total number of 59 men living in ripley county, indiana were recruited and completed the survey. table 1 depicts demographic information on the sample where a majority owned a personal computer with internet access (68%). the age of the survey participants ranged from 50-88 with a mean age of 64 years (s.d. = 10.72). table 1 demographic characteristics of survey respondents (n=59) demographics n (percentage) race caucasian 59 (100 %) marital status single 0 (0%) married 54 (92%) divorced 1(2%) widowed 3 (5%) no response 1 (2%) highest level of education less than high school 0 (0%) high school graduate 32 (54%) associate degree 6 (10%) bachelor degree 12 (20%) master degree 4 (7%) doctoral degree 5 (9%) own a home computer and maintain internet service yes 38 (64%) no 21 (36%) employment status full time 25 (42%) part time 2 (3%) unemployed 1 (2%) retired 31 (53%) county of residence ripley 59 (100 %) online journal of rural nursing and healthcare, 14(1), 2014 92 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 data obtained from the sample were analyzed as group data. approximately one third (37%, n = 59) of the participants indicated that they knew what the prostate cancer guidelines were; however, well over half answered false to knowing that the guidelines had recently changed (66%, n = 59). over half (54%, n = 59) of the participants indicated that they had an appointment to obtain prostate cancer screening. approximately one third (36%, n = 59) have obtained prostate cancer screening. approximately one half (55%, n = 59) of the participants indicated they plan on talking to their healthcare provider this year about getting prostate cancer screening. in addition, the majority (83%, n = 59) believed men over 50 years of age should obtain prostate screening every year and well over half (66%, n = 59) believed some men over the age of 50 do not have to obtain prostate cancer screening. for those indicating why they obtained prostate cancer screening, approximately one third (38%, n = 59) of the men have obtained prostate cancer screening because their doctor told them to or they knew it is the important. another influence was marital status. participants noted that their spouse requested them to obtain screening (19%, n = 59). the majority of men (83%, n = 59) felt that they had enough information regarding prostate cancer screening to make a decision personally on whether or not to have to obtain screening. table 2 knowledge (n=59) knowledge response n(percentage) i know what the guidelines for prostate screening are. strongly disagree 12 (20%) disagree 3 (5%) neither agree or disagree 11 (19%) agree 27 (27%) strongly agree 6 (10%) i have an appointment to get my prostate cancer screening this year. strongly disagree 13 (22%) disagree 7 (12%) online journal of rural nursing and healthcare, 14(1), 2014 93 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 knowledge response n(percentage) neither agree or disagree 7 (12%) agree 16 (27%) strongly agree 16 (27%) i plan on talking to my healthcare provider about getting a prostate cancer screening this year. strongly disagree 12 (20%) disagree 3 (5%) neither agree or disagree 3 (5%) agree 18 (31%) strongly agree 14 (24%) i have gotten my prostate cancer screening this year. yes 21 (36%) no 38 (64%) i have gotten my prostate cancer screening because: a nurse practitioner told me 1 (1%) a doctor told me 22 (37%) my wife told me 9 (19%) i have a family member with prostate cancer 2 (4%) the local hospital told me to 0 (0%) i know this is important to do 14 (29%) i believe all men over the age of 50 should get prostate cancer screening every year. true 48 (83%) false 10 (17%) i believe men over the age of 50 should have a discussion with a doctor or nurse practitioner about prostate cancer screening before getting screened. true 51 (88%) false 7 (12%) i know that the medical guidelines for prostate cancer screening have recently changed. true 20 (34%) false 38 (66%) i believe it is okay for some men over the age of 50 not to have prostate cancer screening. true 20 (34%) false 38 (66%) if i need information about prostate cancer screening, i would: ask my doctor 31 (81%) ask my nurse practitioner 2 (5%) ask my friend 0 (0%) ask my wife 1 (3%) go to the library 0 (0%) i feel like i have enough information about prostate cancer screening to make a decision about whether to personally have or not have my prostate screened. true 49 (83%) false 10 (17%) online journal of rural nursing and healthcare, 14(1), 2014 94 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 discussion the survey used in the needs assessment was developed to evaluate men’s knowledge of prostate cancer screening. non-parametric testing confirmed a statistically significant relationship in men’s education level and participation of prostate cancer screening (p = .036). a significant probability was found with married men and the physician influence to why they obtained screening (p = 0.05). an evaluation of married marital status and the belief that men over the age of 50 should be screened yielded a significant statistical probability (p = 0.028). the majority of men were married and indicated that they have obtained screening because of their healthcare providers influence or spousal influence. a significant relationship also exists between married men and the belief that every man age 50 years and older should have a discussion with their healthcare provider before obtaining screening. education and screening demonstrated a significant relationship as well. plowden (2006) in a qualitative study exploring factors influencing a man’s decision whether to obtain screening, identified knowledge as a motivator. these findings agreed with the importance of healthcare provider recommendations found earlier in the review of literature (linder et al., 2009; arras-boyd et al., 2009). the strength of this study was an adequate sample size was to perform chi-square testing. limitations of this study include no construct validity or reliability on the survey. because associative relationships were reported, a potential for confounding variables may exist because of the association among the variables. additionally, the findings of this study cannot be generalized beyond the sample of men in ripley county, indiana because the study was confined to a single region in southeastern, indiana. another limitation was the survey questions did not measure knowledge level and was not able to define the education level that made obtaining online journal of rural nursing and healthcare, 14(1), 2014 95 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 screening significant. the survey did not ask the men if they had a healthcare provider or health insurance. there is also the risk of the questions being answered honestly with self-reporting. conclusion men should not be unaware if the risks and options for early detection of prostate cancer (acs, n.d.; aua, n.d.). nurses and healthcare providers in collaboration with the community stakeholders must identify the best delivery methods for rural populations of men to obtain prostate cancer screening education. through the use of a needs assessment, information was obtained as a basis to evaluate if men in ripley county, indiana have knowledge of prostate cancer screening or if a need exists for a community education program. an effective needs assessment can be used as a basis for comprehensive planning of programs (issel, 2009). a formal planning team is a critical part in planning programs. stakeholders such as hospital administration, men, spouses, primary and secondary healthcare providers, and community members in ripley county, indiana should be included to establish goals and action plans. men in ripley county, indiana indicated they had knowledge of prostate cancer screening guidelines. a relationship was demonstrated between the healthcare provider and why the men obtained screening. an additional influence was found to be the spouse. men seeking more information regarding prostate cancer screening indicated they would ask their physician or nurse practitioner. healthcare providers should provide education regarding prostate cancer screening risks and benefits so that men can make an informed decision. additional studies are needed to expand on these findings with open ended questions regarding what men actually know and understand concerning prostate cancer screening. interventions that include a spousal or healthcare influence should be developed and tested. future research is needed to survey family members and friends to ascertain if they are a positive online journal of rural nursing and healthcare, 14(1), 2014 96 http://dx.doi.org/10.14574/ojrnhc.v14i1.27 influence or a trigger to the man’s participation in a community education programs. assumptions should not be made that men already possess knowledge regarding their health. men must be adequately exposed to information including the risks and benefits and be able to make a self-directed informed decision regarding prostate cancer screening. advance practice nurses must be advocates to their patients and assess their knowledge thoroughly to provide for idm. continuous quality improvement is integral to identify which educational activities are associated with effective promotion of idm in this rural population of men. references american cancer society 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[medline] united states census bureau (n.d.). quick facts (2010).retrieved from www.census.gov u.s. preventative services task force (2008). screening for prostate cancer: u.s. preventative services task force recommendation statement. annals of internal medicine, 149(3), 185191. weinrich, s.p. (2006). prostate cancer screening in high-risk men. cancer, 106(4), 769-803. [medline] witkin, r.b. & altschuld, j.w. (1995). planning and conducting needs assessments. thousand oaks, california http://www.ncbi.nlm.nih.gov/pubmed/17253082 http://www.ncbi.nlm.nih.gov/pubmed/15316908 http://www.ncbi.nlm.nih.gov/pubmed/16411222 microsoft word mallow_381-2180-2-ed(1).docx online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 3 understanding genomic knowledge in rural appalachia: the west virginia genome community project jennifer a mallow, phd, fnp-bc 1 laurie a theeke, phd, fnp 2 patricia crawford, ms, ches 3 elizabeth prendergast, ms, ches 4 chuck conner 5 tony richards 6 barbara mckown 7 donna bush 8 donald reed 9 meagan e. stabler, phd, ches 10 jianjun zhang 11 geri dino, phd 12 taura l. barr, phd, rn 13 1 assistant professor, wvu school of nursing; robert wood johnson foundation nurse faculty scholar, wv clinical & translational institute scholar alumni, jamallow@hsc.wvu.edu 2 associate professor, wvu school of nursing; clinical associate professor, wvu school of medicine, robert wood johnson nurse faculty scholar alumni, american nurses foundation scholar, ltheeke@hsc.wvu.edu 3 co-chair , wv prevention research center community partnership board; director of rural outreach, west virginia school of osteopathic medicine pcrawford@osteo.wvsom.edu online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 4 4 west virginia university prevention research center eprendergast@hsc.wvu.edu 5 wv prevention research center community partnership board, chuckrayconner@yahoo.com 6 wv prevention research center community partnership board, gparichards@gmail.com 7 wv prevention research center community partnership board, bmckown@mhhcc.com 8 wv prevention research center community partnership board; rural coordinator, institute for community and rural health , djbush@hsc.wvu.edu 9 wv prevention research center community partnership board, tobaccospecialist@strongcommunities.org 10 west virginia university, school of public health, department of epidemiology, mstabler@hsc.wvu.edu 11 west virginia university prevention research center, jzhang@hsc.wvu.edu 12 west virginia university public health, west virginia university prevention research center, gdino@hsc.wvu.edu 13 chief scientific officer ceredx, robert wood johnson foundation nurse faculty scholar alumni, taurabarr@gmail.com abstract purpose: rural communities have limited knowledge about genetics and genomics and are also underrepresented in genomic education initiatives. the purpose of this project was to assess genomic and epigenetic knowledge and beliefs in rural west virginia. sample: a total of 93 participants from three communities participated in focus groups and 68 participants completed a demographic survey. the age of the respondents ranged from 21 to 81 online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 5 years. most respondents had a household income of less than $40,000, were female and most were married, completed at least a hs/ged or some college education working either part-time or full-time. method: a community based participatory research process with focus groups and demographic questionnaires was used. findings: most participants had a basic understanding of genetics and epigenetics, but not genomics. participants reported not knowing much of their family history and that their elders did not discuss such information. if the conversations occurred, it was only during times of crisis or an illness event. mental health and substance abuse are topics that are not discussed with family in this rural population. conclusions: most of the efforts surrounding genetic/genomic understanding have focused on urban populations. this project is the first of its kind in west virginia and has begun to lay the much needed infrastructure for developing educational initiatives and extending genomic research projects into our rural appalachian communities. by empowering the public with education, regarding the influential role genetics, genomics, and epigenetics have on their health, we can begin to tackle the complex task of initiating behavior changes that will promote the health and well-being of individuals, families and communities. keywords: rural, genetics, genomics, focus groups, community based participatory research online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 6 understanding genomic knowledge in rural appalachia: the west virginia genome community project genetics is the study of heredity; genomics is the study of the interaction between the genes in the genome; and epigenetics is the study of the interaction between the genes in our genome and the environment (anderson & monsen, 2014). increasingly, individuals and families have to make decisions that involve both genetics and genomics in the areas of health promotion, disease prevention, screening, diagnosis, selection of treatment, and evaluating treatment effectiveness. hence, our understanding of the link between genetics, genomics, and epigenetics is rapidly changing the way nurses and other healthcare professionals approach the health and disease of individuals, families, and communities. these advances and their application to common chronic illnesses have generated a need to translate knowledge into interventions and provide education to communities (calzone, jenkins, bakos, et al., 2013). the evidence base on epigenetics and genomic literacy (as defined above) is developing (badzek, henaghan, turner, & monsen, 2013; calzone, jenkins, nicol, et al., 2013; conley et al., 2013; roberts, dolinoy, & tarini, 2014). ensuring the public has access to the knowledge and skills needed to keep up with the technical intricacies of “genetic and genomic information” has been a focus of the american public health association, health people 2020, and the institute of medicine. however, members of rural communities are underrepresented in genomic education initiatives. in addition, little is known about rural populations’ knowledge, literacy, and desire to integrate this knowledge into their lives. recently, a blueprint for genomic nursing science was developed, and emphasized that the focus for nursing should include all care settings, be addressed with varied populations, be centered on the person, family, and community, and incorporate cultural contexts (calzone, jenkins, bakos, et al., 2013). nurses and online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 7 other healthcare providers must include key stakeholder groups from rural populations as we progress in developing interventions that affect these communities. using qualitative research to contribute to the development of community-based interventions, and providing ongoing assessments in real world situations allows for the development of true patient and community centered interventions (jansen, foets, & de bont, 2010). the medical research council (mrc) guidance on developing and evaluating complex interventions (craig et al., 2008) and a process for community based participatory research (cbpr) (minkler & wallerstein, 2011) are being used to guide the development of a series of community engagement projects in rural appalachia. the first step of the mrc framework requires identifying evidence and acquiring knowledge of the phenomenon (craig et al., 2008). the process of cbpr involves a great deal of time and a high level of community involvement. developing such a partnership is likely to address the health concerns of highest concern to native communities and thus, increase the probability for success (minkler, blackwell, thompson, & tamir, 2003). the first step of this series of community engagement projects involves the assessment of rural communities’ knowledge, beliefs, and desires about genetics/genomics. assessing knowledge and beliefs can be done through questionnaires. however, eliciting rich responses related to a communities’ desires and concerns may be best accomplished through community lead focus groups discussions (kitzinger, 1995). to begin the process, town hall focus group discussions in three rural wv communities were completed. information was collected via open discussions regarding family health history. information was gathered about: 1) knowledge surrounding genetics, genomics, and epigenetics, 2) how participants talked to their families, friends, and health care providers about genetic and genomic information and 3) perceptions of online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 8 risks and benefits surrounding genetics and genomics. in addition, surveys of demographic information were collected. the primary purpose of this project was to assess genetic and genomic knowledge of persons living in rural wv communities. methods the research team included the wv prevention research center (prc), a community partnership board (cpb), an inter-professional academic research team, and identified lay leaders in three rural wv communities. the communities were selected due to their respective leadership requesting collaborative activities and involvement with the university. together, this team developed the research questions, study methodology, identified target communities, recruited participants, collected the data, interpreted the findings, and disseminated results, which included generating future research recommendations. the use of a cbpr approach safeguarded the voices of our rural appalachian communities and enhanced relevance for rural populations. prior to implementation, we followed a 7 step cbpr process which included: 1) identifying cpb members to lead the initiative in their respective communities and by helping to integrate concepts and priorities for all three communities. 2) utilizing the cpb partners to engage community leaders in their respective communities. 3) facilitating a community-academic dialogue meeting to solidify a shared agenda and discuss the cbpr process. 3) collectively determining the most effective ways to assess knowledge, attitudes, and beliefs about genomics in their communities. 4) developing focus group talking points and survey questions. 5) developing methods and procedures for incorporation of the broader community. 6) seeking approval by the wvu institutional review board. (this study was approved by the wvu institutional review board: protocol id 1301011317.) 7) completing community focus groups. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 9 focus group sampling. a focus group is an interview method that uses members of a specific group who share similar characteristics, and have information to share about a pre-determined topic (kitzinger, 1995). while one-on one interviews may illicit responses, the type and range of information generated through the interaction of the group are often deeper and richer (krueger, 2009). the recruitment for each forum was directed by the cpb and the research team. approximately 100 personal invitations per community were sent to community leaders and lay persons1-3 weeks in advance. in addition, flyers were hung in local areas (places of worship, grocery stores, community centers, etc.). cpb members suggested that the invitations and flyers not include the words “genetic” or “genomic”, but rather “genes” and “a discussion of family health history.” all participants that came to the forum were welcomed, no participant was turned away, and informed consent was not required for participants to listen or speak. questionnaire. informed consent was obtained prior to completion of demographic surveys and all participants who completed a survey received a $20 gift card. the survey contained basic demographic information as well as qualitative and quantitative questions. the first step in questionnaire development was to provide the cpb team with some background information including: the national human genome research institute (nhgri) vision for genomic medicine (collins, morgan, & patrinos, 2003), questions and themes derived from a national genocommunity think tank sponsored by the office for public health genomics, in the centers for disease control and prevention ("genocommunity think tank knowledge modules," 2011), and the topics of interest to the researchers and cpb team. all team members developed a series of questions for the survey. these questions were compiled into one document for discussion. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 10 multiple meetings were held to discuss the inclusion and exclusion of compiled questions. once the survey questions were unanimously agreed upon, a letter of exemption was applied for and received from the west virginia university institutional review board. community forum implementation. an important part of each forum was having a community person begin the evening with a discussion of a personal family health story. this was a way to engage the community through story-telling and gain trust by using a respected community leader. our cpb leaders identified these key informants at all sites. the family health stories took about 15-20 minutes. following the stories, pre-developed questions to stimulate discussion where used. in all instances, the focus group facilitator let the community lead the discussion and only talked when the conversation needed propagation or re-direction. the conversations lasted from 1 ½ to 2 hours. during each community discussion, members of the investigative team took field notes. immediately following the conversation, participants completed the demographic surveys. community leaders and prc members were available to assist participants who could not read or write. data analysis. the field notes were entered into a microsoft access database with the demographic information and responses to specific questions to identify key concepts related to family health history, genetic/ genomic literacy and the interaction between genes and the environment. several procedures were employed to maximize the transcription quality, and to ensure that quality standards were maintained (poland, 2003). verification of the accuracy of the field notes was achieved by randomly cross-checking the field notes by research team members present during the focus group. an analysis team of researchers and the cpb members was formed. “an online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 11 analysis was conducted by each member of the team in order to discover the key concepts of each of the three focus groups. each team member made a list of key results identified from being present at the focus groups and reading the transcribed field notes. each team member then presented their personal analysis to the team. a group vote was held and consensus was considered to be achieved by a simple majority.” the results of each focus group were then summarized and are presented in the results below. results sample demographics. a total of 93 people from three communities participated in 3 different focus group discussions (group 1 n = 28, group 2 n = 31, group 3 n = 34) and 68 (73%) completed a survey. the age of the respondents ranged from under 21 to 81 years with the majority of respondents between the ages of 52 and 69 years (52%). over half of the respondents had an annual household income of less than $40,000. there majority were female (65%) and most were married living with their spouse (58%). approximately 81% of the population was caucasian and 10% african american; the percent of african americans was higher than that in west virginia (3%). over 42% identified themselves as a parent and a grandparent, 48% completed at least a hs/ged or some college education, and 60% were working either part-time or full-time. questionnaire results. most participants (84%) felt that knowing family health history is “very helpful” for understanding their health and the health of their children. about 89% had at least one family member who has died of heart disease, diabetes or cancer. about half of the participants said online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 12 they would participate in genetic studies of family health history (52%), chemicals and the environment (44%), obesity and diet (47%), and inherited risk for diseases (49%). younger participants (<58 years) ranked the importance of knowing family health history higher on average in comparison to older participants (97.73% vs 83.33%, p = .03). most respondents, believed that healthy lifestyle behaviors such as not smoking, healthy eating habits, and physical activity could prevent disease (i.e., heart attack) even when a positive family history of that disease is present. however, older participants [younger than 58 (97.37%) vs. 58 and older (77.27%), p .01] and females of all ages [male (100%) vs females (83.78%), p = .05] were less likely to believe that health promotion could mediate disease risk in the presence of a family history. knowledge and beliefs surrounding genetics/genomics, epigenetics. most participants had heard of genetics and had some basic understanding of its meaning, associating it with something that would pertain to family. the comments related to genetics focused on inheriting illness and disease, not the converse of health or hardiness. a few participants described genetics in reference to research and as “science fiction.” there was very little understanding of the interaction between our genes and genomics. while participants did not use the word epigenetics, most participants discussed that the environment can influence health. participant discussions identified the influence of the physical environment, such as air and water quality, pollutants, and the land (soil). conversations centered on beliefs that the environment can affect “breathing problems” such as “coal dust in mining towns and cancer from high wires with electricity.” in addition, living where there is less pollution, opposed to areas surrounded by factories, was believed to be healthier. mining and coal dust were topics brought up in all conversations and participants saw them as negatively online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 13 impacting their health. lastly, cigarette smoking was viewed as a harmful behavior that can adversely influence health. in addition, some respondents perceived their current state of health as worse than those of our ancestors and attributed this to the environment. few participants viewed psychological stress, or how they reacted behaviorally or emotionally to a situation, as a part of their environment. when asked whether stress can play a part in disease, participants agreed that it is important, but they did not view it as a part of their environment or as a risk factor for poor health. participants did report healthy and/or unhealthy behaviors as part of their environment and agreed that behaviors can be inherited just as genes are inherited. participants discussed the need to “eliminate stressors” but noted that there are some psychological stressors that they could not change. managing stress was discussed as an activity that needed to be done in reaction to a particular stressful situation, not as something to be prevented. how participants talked to their families about genetic/genomic information. most participants reported that they would “just ask” if they wanted to discuss family health history with relatives. however, this discussion would normally follow a crisis or event. participants did not discuss family health history as a prevention tool. in fact, the discussions were presented in the future tense, as “i would” do this or “i would” do that when i had the discussion. the future tense used implies that these discussions have not yet happened. participants reported not knowing much of their family history. many talked about looking up their personal family history prior to the focus group in preparation for the event. in some cases, participants were involved in the care of their parents, thus they were privy to the information without asking. in addition, a few participants responded that the family “would not share” this online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 14 information. these participants thought older generations were less open to sharing their personal diagnoses and issues surrounding their health. even though the majority of participants had no problem discussing family health history, there was agreement that mental health and substance abuse were not generally discussed within families. there were various reasons for not discussing these topics; ranging from “not wanting to upset or scare my children” to concerns about the social “stigma” attached to mental health disorders and substance abuse. some participants did agree that it was easier to discuss these issues when family support was available, but most remarked it “would create family problems”. perceptions of risks and benefits surrounding genetics and genomics. participants were divided between those who felt there were no risks associated with genetics (e.g., “they could help you get a better understanding of your health and family health”) and those who had a fear of the unknown. there were many participants who expressed concerns that the information given to them by health care providers may not be accurate. others had a concern about discrimination or being segregated. one example would be discussions about health insurance agencies gaining access to personal information that could subsequently lead to difficulty obtaining coverage. some participants expressed a sense of futility over gaining information about risk of disease without the ability or knowledge to prevent occurrence. respondents also expressed fear of learning about undisclosed adoptions through genetic testing. overwhelmingly, respondents wanted to participate in the study to gain knowledge. this knowledge seeking was expressed in all discussions. community members wanted to know about diseases, signs and symptoms. in addition they questioned ways to prevent or decrease their risks, and how to teach their children. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 15 discussion genetic and genomic knowledge. these rural communities understand that genetics, lifestyle choices, and the environment can influence health and disease. however, many people believed that our genes are our destiny – they are fixed and ultimately set the limits of the diseases we get and how we will respond to them. scientific advancements have shown that lifestyle choices and environmental factors can change the way genes are expressed and that these changes can be passed on to the next generation, affecting disease risk and outcomes (gapp, von ziegler, tweedie cullen, & mansuy, 2014). helping patients and communities understand the concepts of epigenetics may serve as a powerful strategy to promote healthy lifestyle changes. it has been suggested that a broader understanding of how genomics relates to chronic conditions could help clinicians better assess risk and plan management of patients (taylor et al., 2013). conversely, it is obligatory that providers understand the community knowledge so that care can be comprehensive and culturally sensitive (badzek et al., 2013). the national health and genomics research institute has supported community conversations on genetics and genomics in primarily urban settings (collins et al., 2003). the current study is one of the first to conduct these conversations in a rural setting. the information we have gathered provides direction for future genetic education targeting rural communities, such as those in the appalachian region. the information learned in this project could be used to identify target areas of focus for culturally competent nursing interventions that give knowledge and address the fear that people experience related to potential heritability of illness. the identification of fear as an emotion experienced by these participants is new and may require intervention. fear is a known online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 16 psychosocial stressor that is linked to negative health outcomes such as depression, making this finding significant (krishnan, 2014). based on these themes we would approach genomic education interventions by addressing the concurrent fear that members of these rural communities have expressed. genetic literacy affects family conversation. the general public’s genetic literacy is modest and for rural communities with high health disparities and low socioeconomic status (ses), genetic literacy is estimated to be even lower (lea, kaphingst, bowen, lipkus, & hadley, 2011). therefore, educational efforts to address health literacy, combined with genetic education, should be implemented (kutner, greenburg, jin, & paulsen, 2006). these findings confirm the importance of oral reporting and the use of the narrative to engage individuals with limited health literacy. recent evidence within a latino population supports the importance of alternative methods like using lay health advisors who understand the community to engage health illiterate people (kaphingst, lachance, gepp, d’anna, & rios-ellis, 2011). the challenge for genomic medicine is to provide individual risk estimates in a manner that motivates individuals to reduce risky behaviors and embrace positive health behaviors. developing understandable and usable information about genomics and how it applies to health will be critical for implementing community-based health promotion initiatives. engaging community leaders will be critical in teasing out the best approach to providing individualized risk plans within the context of culture and community history. similar to the literature, these findings suggest open family dialog, including children and grandchildren to begin this process. genetic knowledge is lower in older individuals and these individuals are also more likely to attribute disease to genetics, rather than behavior (ashida et al., 2011). intergenerational online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 17 educational efforts may help to alleviate these age disparities. all of our participants were knowledge seeking, which is consistent with recent studies in other rural populations (kelly, andrews, case, allard, & johnson, 2007). they understood their limitations in understanding how to use family health history and were eager to learn. perceptions of risks and benefits. our conversations did reveal that fatalistic views of health and disease still exist in rural appalachia. lifestyle choices are complex and mediated by cultural beliefs (denial, fatalism, and resistance to change), economic stability, and attitude. the perceived role of genetics and heredity (i.e., family health history) varies and is mediated by a personal history of disease; those who have a positive family history for a disease are much more likely than those with a negative history to attribute the disease to genetics (lea et al., 2011). perceived risk of developing a disease and fatalism will affect how individuals respond to genomic information and motivate behavior change (drew & schoenberg, 2011). in addition, we understand that people who experience identified social determinants of health like poverty and poor access to fresh foods and those not currently having symptoms of a disease may be less likely to adopt health promoting behaviors (koh, piotrowski, kumanyika, & fielding, 2011). evidence suggests that significant access barriers exist for genetics services in rural areas (hawkins & hayden, 2011; kelly et al., 2009). most populations deemed “fatalistic” are also low resource communities who lack health insurance or who have low access to health care and have less education. contrary to popular belief, appalachian fatalism is not a cultural tradition, rather the result of poverty and isolation (theroit, 2001). fatalism can be addressed by using community engaged research approaches to gain the trust and respect necessary to implement educational initiatives. in addition, identifying individuals who changed behavior and thus online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.381 18 avoided diseases even with a positive family history of disease will be important to provide concrete, relevant examples. conclusion this project is the first of its kind in west virginia and is foundational to future infrastructure development for serving these communities. future initiatives that extend genomic projects into our rural appalachian communities are needed. this success of this project is owed to the strong partnership with our community partnership board (cpb) who identified and facilitated interaction with our target communities. advancing the epigenetic knowledge of rural communities requires ongoing dialogue with rural residents, respected community leaders, and community health professionals. by empowering the public with education regarding the influential role genetics, genomics, and epigenetics has on health, communities can begin to tackle the complex task of initiating behavior changes that could lead to enhanced health and well-being of individuals, families and communities. involvement of the community at all stages of development will enhance acceptability and increase the likelihood of community selfsustained positive culture of health. funding sources robert wood johnson foundation nurse faculty scholars & the wv clinical & translational institute references anderson, g., & monsen, r. b. 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[review of book authorized to heal: gender, class, and the transformation of medicine in appalachia, 1880-1930, by s.l. barney]. west virginia history, 59(2001-2003), 152. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 196 u.s. frontier distribution of advanced practice registered nurses and population health lynn jakobs, phd, fnp-c 1 jeri bigbee, phd, rn, faan 2 1 clinical instructor, college of nursing and professional disciplines, nurse practitioner program, university of north dakota, lynnjakobs@hotmail.com 2 adjunct professor, betty irene moore school of nursing, university of california, davis, jlbigbee@ucdavis.edu abstract residents of frontier counties have disparate access to healthcare due to geographic and economic factors that impact the availability of health care providers and services. the purpose of this study was to evaluate the distribution of advanced practice registered nurses (aprns) in u.s. frontier counties and to evaluate the relationship between the presence of aprns and population health outcomes those counties. the sample included data from 308 frontier counties in 14 states and 858 licensed aprns residing in those counties. this cross-sectional ecological comparative study utilized the concept of nurse dose to evaluate the relationship between the presence of aprns and population health outcomes in frontier counties. findings include significantly lower premature death and teen birth rates in frontier counties where aprns or physicians are present. keywords: frontier, advanced practice nurses, rural/remote online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 197 u.s. frontier distribution of advanced practice registered nurses and population health according to 2010 data provided by the state departments of rural health, over five million people live in remote areas of the united states (us) that are classified as frontier (rural health information hub). in these areas access to healthcare, or services of any kind, is often limited by extreme distances and travel time. according to the last known figures, the majority of frontier counties have two or fewer health services of any type and as many as a quarter million people may be living in frontier counties with no available health services (frontier education center, 2000). disparate access to rural healthcare has been a federal concern since the early 1970’s. with passage of the medicare bill in july 1965, the federal government assumed a responsibility for the healthcare coverage of older americans regardless of geographic residence. rural underserved medicare recipients had limited access to healthcare, therefore, the rural health clinic act of 1977 was passed to incentivize rural practice and increase access to care. this act authorized medicare and medicaid payments to qualified rural clinics for services provided by nurse practitioners (one of the four categories of advanced practice registered nurses) and promoted their use by mandating that at least 50% of the services in rural health clinics be provided by nurse practitioners or physician assistants (department of health and human services, 2013). the traditional aprn roles are nurse practitioner, certified registered nurse anesthetist, clinical nurse specialists, and certified nurse-midwife. in 1991, to further incentivize nurse practitioners (nps) to practice in frontier and other underserved areas, the national health service corps (nhsc), the largest public program addressing the geographic maldistribution of the u.s. healthcare workforce, added nps and certified nurse midwives (one of the four categories of advanced practice nurse) to their student loan repayment program (earle-richardson & earle-richardson, 1998). to benefit online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 198 from this program advanced practice registered nurses (aprns) agree to practice in a designated healthcare professional shortage area for a minimum of two years. in 2009, this program was bolstered by the american recovery and reinvestment act which allotted a $300 million supplement to the nhsc. during the recovery act period, march 2009 through february 2011, the increase in numbers of nurse practitioners recruited was proportionately higher than all other healthcare professionals (pathman & konrad, 2012). despite federal incentives to encourage frontier aprn practice studies have shown that only a fraction of aprns are practicing in frontier or other underserved areas (kaplan, skillman, fordyce, mcmenamin, & doescher, 2012). in the year 2000, the last year that a national survey of aprns was conducted, data on nurse practitioners indicated that approximately 15.2% were practicing in rural areas with only 2.5% of all nurse practitioners practicing in frontier areas (kaplan et al., 2012). although efforts to recruit aprns to frontier areas continue, little is known about the population health effects in frontier counties where aprns practice. this study utilized a census-based method of defining a frontier county; one with a population density of less than seven persons per square mile (ricketts, johnson-webb, & taylor, 1998). according to the national center for frontier communities (ncffc), in 2010 there were 486 unique frontier counties in the continental united states. states with the most frontier counties were: colorado, idaho, kansas, minnesota, montana, nebraska, north dakota, new mexico, oklahoma, south dakota, and texas. demographics federal lands comprise approximately 48% of the acreage of the 11 western states and the majority of frontier land is under federal stewardship (lorah, 2000). seventy-seven percent of all non-metropolitan federal land counties are found in the frontier, and 23% of frontier counties online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 199 consist largely of only federal land (frontier education center, 2000). key frontier industries include farming/ranching, mining, forestry and oil, gas and mineral extraction. the majority of tribal land continues to be located in frontier areas; however, frontier communities are becoming more ethnically diverse owing to regional migration patterns. during the 1990s and post-2000 period, the rural hispanic population grew at the fastest rate of any racial or ethnic group while the white population grew at the slowest rate (johnson, 2006). the frontier population is also aging; since 2010, the increase in birth rate (natural change) has not matched the rate of outmigration (u.s. department of agriculture, economic research service [usda], 2015). current evidence suggests that health status declines with increasing rurality (singh & siahpush, 2014). health outcomes are worse in rural/frontier areas for patients with conditions that account for a large percentage of early deaths, i.e. heart disease, (bhuyan, wang, opoku, & lin, 2013; kulshreshtha, goyal, veledar, & vaccarino, 2014) cancer, (nguyen-pham, leung, & mclaughlin, 2014; singh, 2012; weaver, geiger, lu, & case, 2013), diabetes, (hale, bennett, & probst, 2010) and chronic obstructive pulmonary disease (jackson, coultas, suzuki, singh, & bae, 2013). obesity rates are higher in rural areas (befort, nazir, & perri, 2012), and rural/frontier residents may be less likely to receive preventive care; from 1998-2005, frontier residents had the overall lowest screening rates for colo-rectal cancer when compared to other demographic groups (cole, jackson, & doescher, 2012). in the most isolated frontier areas, 78.7% of women travel at least 60 minutes to the nearest hospital offering perinatal services (rayburn, richards, & elwell, 2012), and are significantly less likely to receive counseling related to smoking, alcohol/drug use, and contraception (mccall-hosenfeld & weisman, 2011). the rates for unintentional injuries, which include motor vehicle accidents, and suicide, are much higher in rural/frontier areas than in urbanized areas (singh, azuine, siahpush, & kogan, 2013). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 200 despite the limited resources and health disparities in frontier areas, there are positive attributes that may enhance health. frontier communities are often located in some of the most beautiful settings in the world. residents tend to be close-knit, the air is clean, there are bountiful resources, and low crime rates (brown & schafft, 2011; jones, fly, talley, & cordell, 2003; mcgranahan, 2003; monk, 2007; wells & weisheit, 2004; wood, 2008). although frontier dwellers have an increased risk for multiple morbidities, social support and self-management practices are evident in these communities, reflecting a culture of self-sufficiency (bardach, tarasenko, & schoenberg, 2011) conceptual framework this study builds on the concept of nurse dose which includes three components: dose, nurse, and host response (brooten & youngblut, 2006; brooten, youngblut, deosires, singhala, & guido-sanz, 2012). the underlying assumption of this framework is that specific nurse characteristics (experience, expertise, and education), along with the number of nurses in a setting, are related to the overall health of their community. this concept has been useful in measuring the effects of registered nurses (rns) as well as aprns (brooten et al., 2012; brooten, youngblut, kutcher, & bobo, 2004). this study evaluated the relationship between the advanced education and clinical expertise of aprns (nurse), as well as the presence or absence of aprns (dose), and the population’s health in frontier counties (host response). the purpose of this study was twofold: to evaluate the distribution of aprns in u.s. frontier counties and to evaluate the relationship between the presence of aprns and population health outcomes in u.s. frontier counties. the research questions were: what is the workforce distribution of aprns in u.s. frontier counties? is there a mean difference in population health online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 201 outcomes in u.s. frontier counties where aprns are present compared to u.s. frontier counties where aprns are not present? method a cross-sectional, ecological, comparative study was conducted utilizing a secondary analysis of existing national data. the data were compiled as part of the nurses and the population’s health study funded by the national council of state boards of nursing center for regulatory excellence (bigbee, evans, lind, perez, jacobo & geraghty, 2014). advanced practice registered nurse is defined as: nurse practitioner, certified registered nurse anesthetist, certified nurse-midwife, clinical nurse specialist (stasa, cashin, buckley, & donoghue, 2014). information regarding aprn numbers by county of residence in 2013 was obtained directly from 14 state boards of nursing while physician numbers in each county were obtained from the 2012 county health rankings (chr) database (university of wisconsin, 2012). state boards of nursing do not differentiate between the four types of aprns when reporting numbers of aprns in each county. it is the assumption of the researchers in this study that aprns practicing in the frontier are more likely to be primary care aprns, such as nurse practitioners. health outcome data were also obtained from the 2012 chr database in which a variety of health indices are used to describe the current health status in most u.s. counties. counties within each state are ranked utilizing a weighted summary of several measures: health outcomes (based on an equal weighting of mortality and morbidity measures), health factors (including health behaviors), and the physical environment (environmental quality and the built environment). a complete description of all indices, data sources, and measures included in the chr is available at www.countyhealthrankings.org/our-approach. to allow for comparative analysis between frontier counties in multiple states only raw health outcome and health factor data were utilized. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 202 this study evaluated the relationship of aprn presence and the most consistently reported frontier county health indices: premature death rate (mortality); the percentage of low birth weight births; sexually transmitted infection rates (sti); and adult smoking rates. the dataset included information from 308 frontier counties in 14 states: california, idaho, louisiana, maine, minnesota, montana, north dakota, nebraska, new mexico, nevada, oregon, south dakota, texas, and wyoming (figure 1). it also included information on 858 licensed aprns residing in frontier counties in those states. population health indices in counties with aprns (n=215) were compared to those counties without aprns (n=94) using t-test analyses. it should be noted that population health data were not reported consistently for the frontier counties in this study. the data were analyzed using spss (version 22.0). descriptive statistics were computed for the counties including aprn distribution as well as aprn and physician numbers per county. the descriptive analysis was supplemented with visualization through the use of geographic information systems (gis) analysis (arcmap version 10.2.1.3497, esri, redlands, ca). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 203 figure 1. map of continental u.s. counties a frontier counties included in this study are color-coded. results the diversity of the frontier counties included in this study is reflected in the descriptive findings as illustrated in table 1. there was considerably more variability in the number of physicians per county compared to the number of aprns. the wide range in the numbers of both aprns and physicians per county may indicate the presence of population centers within larger frontier counties. of the 308 frontier counties included in this study all had at least one rn and 215 had at least one aprn. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 204 table 1 frontier county descriptive findings variable n mean sd range aprns 215 2.79 4.03 0 – 29 primary care physicians 232 7.08 8.46 0 – 51 population density (persons/square mile) square miles 308 308 3.08 2,292 1.78 2,336 0.2 6.9 431 18,181 table 2 lists the distribution of aprns in this study by state of residence. states with the highest number of frontier aprns were: wyoming, montana, and new mexico. according to census data, in 2010 the population per square miles in those states was: 5.8, 6.8, and 17. states with the lowest number of frontier aprns were: louisiana, maine, and minnesota. the population per square miles in those states was: 104.9, 43.1, and 66.6. table 2 distribution of aprns in frontier counties by state state # frontier counties # frontier counties with aprns #aprns ca id la me mn mt nd ne nm nv or sd tx wy 6 16 1 1 7 45 38 39 16 10 10 38 64 17 5 14 1 1 6 38 26 19 15 6 8 30 29 17 42 31 6 15 21 189 79 44 102 24 31 72 50 120 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 205 as noted above, not all frontier counties in the study reported population outcomes. among those counties with available data, independent ttesting revealed several significant differences. as illustrated in table 3, a significantly lower premature death rate, a significantly lower teen birth rate, and a significantly higher sti rate were found in counties with aprns compared to counties without aprns. no significant differences were found in relation to the adult smoking rates and the percentage of low birth weight babies. table 3 comparison of health outcomes / behaviors in frontier counties with and without aprns outcome n mean sd t(df) p premature death aprns 121 8867.87 3248.18 3.14(136) .002* no aprns 17 11712.74 4959.57 teen birth rate aprns 153 45.50 22.73 4.07(188) .000* no aprns 37 63.40 28.87 sexually transmitted infection rate aprns 214 227.68 309.55 -2.49(306) .013* no aprns 94 138.89 232.21 % low birth weight aprns 140 7.70 1.67 1.47(167) .144 no aprns 29 8.19 1.53 % adult smoking aprns 169 18.68 6.25 .695(210) .488 no aprns 43 17.90 7.71 b asterisk indicates 2-tailed significance. discussion nearly 20% of the frontier counties (n=308) in this study reported no licensed aprns or primary care physicians residing in those communities. this finding is consistent with a report by the frontier education center (2000), which found there were no health services available in as many as 78 frontier counties spread over 21 states. aprns and primary care physicians were fairly evenly distributed over the remaining 248 counties in the study. of the 33 frontier counties online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 206 that reported no aprns, 16 were in texas. texas and nebraska were the only states with more than 50% of frontier counties without aprns. at the time of data collection both states had restricted aprn practice (kaplan, skillman, fordyce, mcmenamin & doescher, 2012). nebraska has since acquired autonomous aprn practice while texas is one of 13 states which still require physician delegation/supervision of aprn practice (american association of nurse practitioners, 2016). this would indicate that the ability to practice autonomously may be an incentive for aprns to locate to frontier counties in those states that allow it. many of the disparities in the health status of frontier residents may be attributed, at least in part, to disparate access to healthcare. provider-to-population ratios are a primary measure of workforce adequacy and distribution. studies suggest that primary care physician-to-population ratios are associated with positive population health indicators including self-rated health, life expectancy, low birth weight rates, and lower all-cause cancer, heart disease, stroke and infant mortality rates (chen, roy, haddix, & thacker, 2010; macinko, starfield, & shi, 2007; shi et al., 2005; shi et al., 2004; shi et al., 2003). this finding has implications for improving frontier health outcomes through increased access to primary healthcare providers. of the 308 frontier counties in this study, only 214 had aprns; 209 of those counties also had physicians. strategic workforce planning is hampered by the lack of reliable data on the numbers and types of health professionals currently employed in the frontier (institute of medicine, 2011). this study provides county-specific evidence regarding the presence of aprns and physicians in frontier counties. additionally, this study provides information regarding a potential frontier aprn workforce. every frontier county included in this study had at least one rn. rural workforce research indicates that grow-your-own recruitment strategies may yield better results than other recruitment methods (walker, dewitt, pallant, & cunningham, 2012; royston, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 207 mathieson, leafman, & ojan-sheehan, 2012; rural health research center, 2014). the rns residing in the frontier counties included in this study represent potential aprns who may be more likely to stay and practice in their frontier communities if given an opportunity to advance their education without leaving their local areas. although county health indices were not available for many frontier counties, the sti rate was reported by all frontier counties. the significantly higher rate of reported sti cases in counties with aprns is somewhat unsettling, but may reflect greater access to screening and, therefore reporting, or may be related to other factors not accounted for in this study. this finding may also correlate with the lower teen birth rate in counties with aprns, as family planning clinics that screen for stis also provide contraception services. counties with aprns also reported significantly lower premature death rates than counties without aprns. while this finding may reflect the primary care and emergency care competencies that aprns may bring to remote areas, it may also be related to other factors not accounted for in this study. results of this study indicate virtually no difference in the adult smoking rates between counties with and without aprns. there was also no significant difference in the low birth weight percentage of residents in frontier counties with aprns compared to those without aprns. this finding may be related to frontier structural disparities that are unrelated to the presence of aprns. in general, frontier counties have the worst self-reported health of all geographic designations; this finding can be explained in part by rural structural disadvantage, including higher rates of unemployment and lower educational levels (monnat & pickett, 2011). limitations while this study included data from 308 frontier counties representing 63% of the 486 frontier counties in the continental us, it was limited not only by variations in the numbers of online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 208 frontier counties with available health outcome data, but also by variations in the types of indices reported. missing outcome data from as many as 122 counties represented a major limitation in this study. furthermore, aprn data utilized in this study was based on county of residence and may not represent employment location. also, this study did not take into account the presence or absence of other providers such as physicians and physician assistants. it is possible that the 84 counties without aprns or physicians may be served by visiting or rotating primary care providers; however, without conducting individual county surveys it is unlikely that this information is available. in addition, this comparative study did not account for social determinants of health, including income, education and race/ethnicity, which as noted above, have powerful impacts on population health (lutfiyya, mccullough, haller, waring, bianco & lipsky, 2012). thus drawing causal inferences from the results of this study is not possible. implications for further research frontier residents experience a gap in accessing primary healthcare. with over five million people living in frontier counties, investigating reliable patient outcomes stemming from healthcare delivery models, particularly those which include aprns, is a crucial step to bridging this gap. population health outcome data are limited in many frontier areas. as rural accountable care organizations develop in response to the affordable care act, there may be greater opportunities to gather reliable, electronic data on frontier populations (kutscher, 2013). consistent reliable data would enhance research with populations in both frontier and rural areas. research addressing frontier healthcare and delivery is challenging due to methodological and statistical issues which include: small sample sizes, social/cultural issues, and inherent diversity among rural/frontier communities (bigbee & lind, 2007). therefore, qualitative studies online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 209 that illustrate the impact of aprn presence on the delivery of frontier healthcare could be informative. definitional inconsistencies also make research with frontier populations challenging (bigbee & lind, 2007). rurality, specifically frontier areas, is defined in a variety of ways (hart, 2012). much of the information regarding frontier health and healthcare has been ferreted out of rural health research and may not accurately represent frontier communities. as noted earlier, larger frontier counties may contain urban or metropolitan population centers. data from population centers may potentially skew aggregate county population data. utilizing health outcome data based on zip-code rather than county designation may provide more accurate frontier data (inagami, gao, karimi, shendge, probst, & stone, 2016; knapp & hardwick, 2000; wang, ponce, wang, opsomer, & yu, 2015). a recently published study regarding health system challenges in america’s frontier areas found significantly fewer primary care physicians practicing in frontier versus non-frontier counties despite a higher need for primary care services (nayar, yu, & apenteng, 2013). the researchers did not take into account the presence of aprns serving frontier counties although they recommended the use of aprns and pas as a solution to some of the disparities. research into the specific contributions made by aprns in both rural and frontier communities would inform healthcare policy. the aprn role was conceptualized to provide patient care in underserved areas (ford & silver, 1967), however, it would appear that few aprns have ventured into the frontier. research into effective recruitment and retention strategies targeted specifically at frontier areas, is warranted (grobler, marais, & mabunda, 2015). the grow-your-own recruitment and retention concept has implications for nurse educators as education has long been a recognized determinant online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.423 210 of the availability and distribution of the nursing workforce. research into best educational practices to prepare frontier rns to provide advanced practice care in their local communities is a priority. conclusion residents in u.s. frontier communities represent a small but vulnerable population owing to disparate access to healthcare services. despite federal incentives to promote the use of aprns in rural and frontier settings, there is a lack of aprn presence in some u. s. frontier counties. more aprns need to heed the call to improve population health in frontier areas of the u.s.) the rns residing in the frontier counties included in this study represent potential aprns who may be more likely to stay and practice in their frontier communities if given an opportunity to advance their education without leaving their local areas. this study provided insight into the distribution of aprns in u.s. frontier counties. although limited by sporadic reporting of frontier health outcomes, results of this study indicate that frontier residents who have access to health care, regardless of type of provider, are likely to have better health outcomes than frontier counties without access to medical care. this highlights the necessity for improved reporting systems to garner 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(2008). survival of rural america: small victories and bitter harvests. lawrence, ks: university press of kansas. a comparison study of urban and small rural hospitals financial and economic performance 38 a comparison study of urban and small rural hospitals financial and economic performance mustafa z. younis, drph, ma, mba1 1 school of allied health sciences, jackson state university, mustafa.younis@ccaix.jsums.edu abstract this study examines the performance of hospitals based on location (geographical region, rural, urban). in this study, recent data has been used to better understand the hospitals performance after the introduction of prospective payment system (pps). the data set used by the study is much comprehensive in its coverage and information on a number of relevant variables. we have included a number of new economic and financial variables in the analysis and examined the effects of conversion of hospitals from not-for-profit to for-profit on hospital performance. our empirical findings suggest that the size of hospitals, occupancy rate of hospital beds, ownership status, degree of competition faced in the market, teaching status, and measure of financial indebtedness of hospitals are significant determinants of hospital performance holding location constant. the empirical model also suggests that the relationship between hospital efficiency measure and its various determinants is actually non-linear in nature and therefore, it is important to adopt appropriate non-linear econometric models for empirical estimation of the performance function. finally, our findings show that rural and small hospitals face significant factors that hinder its performance in comparison to urban and larger hospitals such as the lack of (dsh) payments and economy of scale due to their smaller size and lower proportion of medicaid patients. introduction the profitability and financial performance of rural hospitals and their determinants -have been important subjects of research and of great interest to federal and state agencies as well as banks, creditors, rating agencies, and regulators. most studies to date have focused on the issues of differential access to urban and rural hospitals, and ignored the issues related to their financial performance. (institute of medicine, 2000) rural hospitals differ from urban hospitals by being smaller with average size of less than 50 beds. another characteristic of rural hospitals is its dependence on medicaid and medicare as a source of payment. medicare pays for almost 50% for all hospital discharge compared with 37% for urban hospitals. medicaid patients count for 17% of rural hospitals inpatient days in comparison to 26% of urban hospitals. urban hospitals showed an average length of stay (los) of 5.9 days versus 7.4 days in rural hospitals. (ricketts, 1999). there are many factors determine the level of access to hospitals healthcare such as health insurance, education, and race (lee and estes, 2000), however, an equally important factor contributing to health care access is the hospital’s financial performance and profitability. in the long run, hospitals with financial insolvency problems would either be expected to reduce their level of care to the poor, uninsured, and other indigent populations, or face closure, bankruptcy or merger. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.jsums.edu/%7ealliedhealth/alliedhealth.htm mailto:mustafa.younis@ccaix.jsums.edu 39 sear (1990) examined the issue of profitability in a sample of 50 investor-owned or for-profit (fp) hospitals and 60 not-for-profit (nfp) hospitals in florida during the period 1982-1988. his results indicated that fp hospitals are more profitable than nfp hospitals and the average length of stay (los) and wages per adjusted patient day were important in explaining hospital profitability. walker (1993), using a logit regression model, found that financial variables, by themselves, failed to discriminate between profitable and non-profitable hospitals and thus did not provide a complete explanation of financial condition. watt et al. (1986) reported that fp hospitals have higher average revenues than their nfp counterparts. herzlinger and krasker (1987) found that nfp hospitals neither perform as well financially as do fp hospitals, nor do they compensate for this by returning higher levels of social benefits. however, other authors (haddock et al. 1989; arrington and haddock, 1990) reexamined herzlinger and krasker’s (1987) methods and found that the nfp hospitals were less profitable than fp, but provided more access to care to the indgent population through the admission to their emergency room.. in short, the performance of hospitals varied by ownership, thus refuting the findings of herzlinger and krasker (1987). on the other hand, based on a sample of hospitals in florida in 1980, sloan and vraciu (1983) found that fp and nfp hospitals were virtually identical in terms of profitability. younis et.al. (2001) found that the most profitable hospitals are located in the southern region of the country and the hospitals located in the northeastern region where the least profitable. in this study, we revisit the issue of rural and urban hospitals financial performance by taking several new directions compared to previous studies. first, we examine the variation in financial performance between urban and rural hospitals.* unlike earlier studies, which used data from the pre-prospective payment system (pps) period, the data set employed in this study is obtained from the post-pps period and is therefore more relevant to the payment system currently faced by the hospitals. unlike the previous cost-based mechanism, reimbursement under pps is set at a predetermined rate. pps operating cost payment was initiated in 1983 and phased-in over the five-year period 1983-1988 to provide the hospitals the appropriate time to adjust to the new payment system. second, we incorporate in our empirical analysis additional economic and financial variables (e.g., degree of competition and financial indebtedness) that are likely to affect hospital profitability. moreover, since early 1990s, hospitals in the u.s. went through significant changes in ownership pattern, and the more recent data allow us to investigate the effect of conversion of not-for-profit (nfp) hospitals to for-profit (fp) status on profitability. third, we used a proxy variable, consistent with the literature, to identify rural hospitals, and we acknowledge the potential limitations of this approach at the end of the paper. fourth, since long-term and specialty hospitals are reimbursed under tax equity and fiscal responsibility act of 1982 “tefra” we included only short-term care hospitals (ettner, 2001). background this study examines the financial performance and conversion of u.s. hospitals in relation to geographic region and urban-rural differences. the area variation and change of ownership have been ignored in the past. this research contributes online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 40 significantly to the issue of variation of financial performance between small rural hospitals and its urban counterpart. in this study, recent data from the medicare cost report (mcr) have been used to understand the economic performance of hospitals following the introduction of the prospective payment system (pps). the data set used includes information on a number of relevant variables such as length of stay, occupancy rate, and full-time employee casemix. we also included to our regression analysis the effect of serving medicaid population on rural and urban hospitals performance. objectives to examine and compare the financial performance between rural and urban hospitals. methods piecewise regression model. econometric methodology followed using the return on assets (roa) as the dependent variable to understand the factors affecting the hospital profitability and efficiency, the following regression model was estimated: roa = f(bedsize, occurate , ownerstatus, lengthstay, debt, ftecmx, teachstatus, sole, year, ratio of medicaid days to total hospital days) in this model, a number of variables were considered to have non-linear which can be approximated by piece-wise linear models. for example, it has been hypothesized that profitability is dependent on hospital size (bedsize), which is the proxy variable for location in this model. but the effect of bedsize on roa should change if size exceeds a certain minimum level. at another higher level, the effect on roa can change again. to allow this constant effect of bedsize on roa for a specific size range and another constant effect for another size range, the variable bedsize was decomposed into three variables (bedsize0-50, bedsize50-400 and bedsizeover400). the first redefined variable shows the actual size of beds for all hospitals with bed sizes less than 50. and if the size is 50 or more, the variable takes the value of 50. similarly, the second redefined variable (bedsize30-400) is 0 if size is less than 50; it is actual bed-size minus 50 if the number of beds in the hospital is between 50-399, and 400 when the size is 400 or more. similarly, bedsizeover400 takes the value of 0 if the size of the hospital is less than 400, and bed-size minus 400 if the size is over 400. such redefinition allows the slope of hospital size to change in the regression model. in this regression model, we have allowed non-linearity (piece-wise linear) for another variable -occupancy rate (occurate). occurate was also redefined into three variables following the procedure mentioned for bedsize. the categories defined online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 41 for the three variables are: occupancy rate less than 10%, 10 to 50%, and more than 50%. other variables entered in the model are: • ftecmx = number of full-time employees per 100 admissions adjusted for case mix. • ownerstatus = dummy variable indicating type of ownership (equals 1 for nfp status, 0 for fp status). • eachstatus = dummy variable, taking the value of 1 if the hospital provides teaching and interns training, 0 otherwise. • ole = dummy variable capturing the degree of competition facing a hospital (equals 1 if a hospital is the sole medicare provider, 0 otherwise). • year = dummy variable, taking the value of 0 if year is 1991 and 1 if year is 1995. • debt = debt per bed in service. debt is defined as bonds issued plus loans. • convert = dummy variable, taking the value of 1 if a hospital is converted from nfp status to fp status between 1991 and 1995 and 0 otherwise. • days medicaid/tota days = the ratio of inpatient days medicaid to total hospital days the estimation methodology used the ordinary least squares (ols) with heteroscedasticity adjustment to standard errors, following white (1980). data and descriptive analysis hospital data for the years 1991 and 1995 were obtained from the medicare cost report (mcr) with support from hcia, inc. we consider the data is recent given the untimely release of the medicare cost report to the public and skills needed to make the file in readable format. the hospitals in this study were divided into three categories: notfor profit hospitals in both 1991 and 1995, for-profit hospitals in these two years, and hospitals that were converted from not-for-profit status to for-profit status between 1991 and 1995. table 1 shows some basic characteristics of the hospitals during these two years. note that for the year 1991, the data set contains 521 for-profit hospitals, 3,478 not-for-profit hospitals, 614 for-profit hospitals, and 3,406 not-for-profit hospitals in the year 1995. table 1 also presents descriptive statistics on the hospitals in the sample for the years 1991 and 1995. full-time employees per 100 adjusted discharges declined by about nine percent (9%) for rural hospitals over 1991 and 1995, but the decline was much steeper for urban hospitals (15.5%). in general, rural hospitals are smaller in size than urban and suburban hospitals, and over the years hospitals in general experienced an approximately 1.6 % decrease in size. the length of stay per adjusted acute case also declined from about 4.3 days to about 3.7 days between 1991 and 1995 for rural hospitals, while urban hospitals experienced more extensive declines in los. however, hospitals converting from np to fp showed steeper declines in occupancy rates than nonconverting hospitals. it appears that the hospitals experiencing a change in profit status found themselves relatively weak in terms of market power (needleman et al. 1997). the online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 42 table 1 descriptive statistics for dependent and independent variables variable 1991 1995 regional distribution (number of hospitals) total northeast midwest west south 3,999 705 1,070 1,531 693 4,020 706 1,067 1,559 688 return on assets (roa) fp and nfp fp nfp 3.44 3.52 3.22 5.32 8.55 4.76 ownership status (ownerstatus) (number of hospitals) fp and nfp fp nfp 3,999 521 3,478 4,020 614 3,406 teaching status (teachstatus) (number of hospitals) fp and nfp fp nfp 904 51 853 988 93 895 conversion of ownership status during 1991-1995 (convert) (number of hospitals) from nfp to fp 138 full-time employees per 100 adjusted discharges, adjusted for case mix (adjfulltime) fp and nfp fp nfp 6.01 5.06 6.24 5.24 4.53 5.35 length of stay per adjusted acute case mix (adjlengthstay) fp and nfp fp nfp 4.34 4.35 4.34 3.6 3.57 3.6 debt per bed (debt) fp and nfp fp nfp 105,432.21 109,144 104,871.62 133,795.79 97,756.95 140,302.96 sole community provider (sole) (number of hospitals) fp and nfp fp nfp 516 16 500 518 19 499 number of beds in service (bedcapacity) fp and nfp fp nfp 207.07 160.67 214.29 203.07 176.28 208.81 occupancy rate (occurate) fp and nfp fp nfp 52.84 50.25 53.24 48.71 47.51 48.93 notes: fp (nfp) denotes for-profit (not-for-profit) hospitals. the source of data is the medicare cost report data and the data were provided by hcia, inc. baltimore, maryland. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 43 number of sole community providers in urban locations was only 4 in 1995, indicating that most urban hospitals face competition from other hospitals in the community. the measure of profitability used in this study is return-on-assets (roa), a continuous financial status variable defined as net income divided by total assets. roa reflects the efficiency score of hospitals as it relates hospital output to non-labor inputs. the profitability of the hospitals in the sample increased over the years 1991 and 1995. this is true both for rural and non-rural hospitals. the enhanced financial performance of hospitals is often considered to be related to improvements in collections and electronic payments. it should be noted that rural hospitals in general were losing money in 1991, whereas urban hospitals were doing much better than even the for-profit hospitals in terms of profitability. results we found that hospitals profitability has improved over time. however, the magnitude of the improvement was far lower for rural hospitals than urban hospitals. lower profitability will hinder the ability of the rural hospitals to provide charity care and other uncompensated care. table 2 presents the results of the regression model. a major controversy in the health care field centers around the effect of ownership on economic performance of hospitals. the variable of ownership status was found to be negative and statistically significant which indicate that fp hospitals are more profitable than np. on the average, for-profit hospitals are likely to have higher roa ratios than not-for-profit hospitals. this result is obtained after controlling for the time trend in profitability. the estimated coefficient of time trend is quite high (2.18) with high t-values, implying that hospitals in general had a higher roa in 1995 compared to 1991. this is consistent with earlier studies, most of which found for-profit hospitals to be more efficient and profitable than not-for-profit entities (younis et al. (2001). the teaching status variable in the model turned out to be negative and significant. teaching hospitals are less profitable than non-teaching hospitals possibly due to the costs associated with training as well as the charitable services these hospitals provide. teaching hospitals provide training for interns and residents, which increase the cost of operation of the hospitals. in many cases, teaching hospitals have affiliations with medical schools and try to maintain a charitable image in the community in order to attract donations and contributions. the significant difference between teaching and nonteaching hospitals may also be due to the scope of services provided by the teaching hospitals. teaching hospitals tend to be larger and located in urban and economically depressed inner-city areas (hcia, 1997). consequently, teaching hospitals provide access to the indigent population from the surrounding areas with little or no compensation. hospitals with less than 50 beds in service appear to be less profitable than larger hospitals. in fact, hospital sizes 50-400 and more than hospitals with less than 50 beds, thereafter profitability declines for hospitals over 400 beds because the economy of scale cease after the 400 beds range. the larger the hospital, beyond a certain point the lower its profitability. the variable sole (measure of lack of competition) was also significant in the model, although the value of the coefficient is positive and small. this may be online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 44 table 2 descriptive statistics for dependent and independent variables variable 1991 1995 rural hospitals -0.1785 2.87 average size hospitals 3.55 5.39 return on assets (roa) large size hospitals 3.84 5.62 rural (f-p) 6 6 ownership status (ownerstatus) (number of hospitals) rural (nfp) 134 146 rural hospitals 4 4 average size hospitals 504 596 teaching status (teachstatus) (number of hospitals) large size hospitals 391 371 rural hospitals 7.19 6.49 average size hospitals 6.05 5.11 full-time employees per 100 adjusted discharges, adjusted for case mix (adjfulltime) large size hospitals 5.97 5.63 rural hospitals 4.29 3.76 average size hospitals 4.31 3.56 length of stay per adjusted acute case mix (adjlengthstay) large size hospitals 4.57 3.64 rural hospitals 46,500.10 57,055.96 average size hospitals 99,487.00 124,571.84 debt per bed (debt) large size hospitals 168,121.14 219,292.30 rural hospitals 46 47 average size hospitals 464 465 sole community provider (sole) (number of hospitals) large size hospitals 3 4 rural hospitals 24.99 24.42 average size hospitals 154.52 155.34 number of beds in service (bedcapacity) large size hospitals 582.25 581.12 rural hospitals 27.16 23.53 average size hospitals 51.02 47.36 occupancy rate (occurate) large size hospitals 60.57 55.32 notes: f-p, (nfp) denotes for-profit (not-for-profit) hospitals. rural hospitals are a proxy for hospitals with less than or equal 50 bed. average size hospitals, has beds between 51 and 400 beds, large size hospitals has over 400 beds. the source of data is the medicare cost report minimum data set. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 45 because the number of hospitals in this category is simply regulated to overcharge patients for hospital care. occupancy rate also shows a significant impact on profitability, and only statistically significant coefficient was for occurate0to10 and occurate10to50. the sample sizes in other groups were too small to obtain significant results. the higher the number of full-time employees adjusted for case mixes, the lower the profitability, holding all other variables constant. case mix index (cmi) is analogous to product mix in a manufacturing context. it is a measure of the mix of patient illness types treated in the hospital, relative to the national average, and proxies for relative resource consumption. thus, a hospital with an above-average cmi is expected to consume more resources than a hospital with a lower cmi. employee full-timeequivalents (ftes) are divided by the cmi to provide an adjusted (standardized) fte measure. a full-time employee is a good proxy for the variable cost of the hospital. however, employees has a low coefficient value with a low significance level. this suggests that hospitals may be operating on an optimal number of employees, and any reduction in the number of employees would not lead to significant improvement in profitability, however, the level of significance does not warrant strong conclusions. finally, the ratio of total medicaid days to total days had a significant contribution to hospitals financial performance because hospitals with higher proportion of medicaid patients will get additional payment through medicaid disproportionate hospital share (dsh) payments system. rural hospitals are in disadvantaged position to receive (dsh) payments because most of medicaid patients are located in the large metropolitan areas and inner cities. conclusions and policy implications our empirical findings suggest that rural hospitals generate less revenue per bed than urban hospitals due to several factors such as lower medicaid volume, which lead to a lower disproportionate share hospital (dsh) reimbursement rate and the lack of economy of scale due to their small size and large overhead cost. other variables such as, occupancy rate, ownership status, degree of competition faced in the market, teaching status, and financial indebtedness are significant predictors of hospitals financial performance. the model also suggests that the relationship between hospitals profitability and its various determinants is non-linear in nature and therefore, it is important to adopt appropriate non-linear econometric models for empirical estimation of the performance function. the findings also indicate that rural and small hospitals are significantly disadvantaged in terms of performance compared to urban and larger hospitals. furthermore we conclude that nfp rural are in disadvantage because they receive no or little donation in comparison to larger urban nfp hospitals (cutler, 2000). traditionally, the measure of performance of hospital industry has relied on the calculation of the financial ratios from hospitals’ financial statements (income statement and balance sheet). the financial ratios measure the hospital’s historic performance. banks, creditors and rating agencies use these ratios to predict the hospital’s future performance and credit extension. however, this research demonstrates that there are equally important measures that should be used in evaluating hospital performance. these factors are occupancy rate, staffing ratio, and total expense per adjusted discharge. online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 46 these measures tend to clarify the underlying factors that produce a favorable or unfavorable financial performance. for example, since the implementation of pps, and in the current era of declining use of inpatient services vis a vis outpatient treatments, occupancy rate has been considered a key predictor of financial performance. a declining trend in occupancy rate would have an adverse effect on efficiency, profitability, and liquidity. at a lower rate of occupancy, operating expense per adjusted discharge will be greater, which will hinder ability to operate efficiently. in conclusion, the financial performance of the hospital industry cannot be expressed by any one measure alone. major differences exist among hospitals in terms of their location, scope of services provided, size, ownership, organizational structure, and amount of graduate medical education provided. moreover, associated with these structural and locational differences are factors such as in-patient and payor mix, government regulations, and several non-financial factors, over which a hospital may have little or no control. such diversity in hospital market structure makes any analysis of hospital efficiency and profitability extremely difficult to interpret. other empirical analyses have shown that affiliation with a school of medicine has an important influence on hospital profitability, services, and access for indigent populations (hcia, inc., 1997), which is comparable with the regression results of this study. limitations and future research due to rapid changes in the health care system, current models may not work two years from now. new research related to the prediction of hospitals’ mergers and takeovers can be suggested. as discussed in morck et al. (1988), insider ownership may reduce the probability of mergers and takeovers in non-health care industries. research related to the prediction to prediction of hospitals’, mergers and takeover is therefore suggested. prediction of hospital bankruptcy is another area for future research. there might be a strong correlation between bankruptcy, payment system, location, access to health care, mergers, and acquisitions. finally, the trend in rural hospital closures and mergers (mostly through conversion from nfp to fp status) is attracting the attention of the regulators and public citizens’ groups. a full analysis of rural hospital performance and access to health care possible endogeneity of location, size and characteristics of the rural populations could not be carried out here due to data limitation. the study was constrained by the variables obtained from the medicare cost report. another limitation of the study is that although each of the hospitals occurred twice in the sample, this research did not correct for the repeated measure issues. also, non-reporting hospitals may have created some selectivity bias and led to having a fewer number of rural hospitals in the data set. the non-reporting problem could be related to the going administrative and organizational changes in such hospitals. this study should be updated with more recent data to examine the effect of the balanced budge act of 1997 (bba) which includes a significant cut in medicaid disproportionate hospital share (dsh) payments. the balance budget act no doubts online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 47 would affect the financial performance and profitability for hospitals with high volume of medicaid patients. acknowledgments the author would like to thanks professor jeri dunkin, university of alabama, capstone college of nursing, professor anthony mawson, director of the institute of epidemiology and health services research, at jackson state university, and professor william & mary cissell, department of health studies, at texas woman’s university and two anonymous reviewers for their valuable comment. all content and any errors are the author responsibility. address for correspondence: dr. mustafa z. younis, school of allied health sciences, the medical mall, 350 w. woodrow wilson avenue, suite 2301-a, jackson state university, jackson, ms 39213 usa, mustafa.younis@ccaix.jsums.edu references arrington, b., & haddock, c. (1990). who really profits from not-for-profits? health services research, 25, 291-304. [medline] cutler, d. (2000). the changing hospital industry: comparing not-for-profit and forprofit institutions. chicago: university of chicago press. ettner, s.l., & hermann, r.c. (2001). the role of profit status under imperfect information: evidence from the treatment patterns of elderly medicare beneficiaries hospitalized for psychiatric diagnoses. journal of health economics, 20, 23-49. [medline] fitzgerald, j., & jacobson, b. (1987). study fails to prove for-profits superiority. health progress, 68, 32-37. [medline] haddock, c., arrington, b., & skelton, a. (1989). who profits from not-for-profit: a reconsideration. health services management research, 2, 82-103. [medline] hcia, inc. (1997). the comparative performance of u.s. hospitals: the sourcebook. deloitte & touche llp. chicago, illinois. herlinger, r., & krasker, w. (1987). who profits from non-profits? harvard business review, 65(1), 93-105. [medline] institute of medicine. (2000). america’s health care safety net. washington, dc: national academy press. lee, p., & estes, c. (2000). the nation’s health. boston: jones and bartlett. needleman, j., chollet, d. & lamphere, j. (1997). hospital conversion trends. health affairs, 16, 187-195. [medline] ricketts, t.c., johnson-webb, k.d., & randolph, r.k. (1999). populations and places in rural america. in t.c. ricketts (ed.), rural health in the united states (pp. 7-24). new york: oxford university press. sear, a.m. (1991).comparison of efficiency and profitability of investor-owned multihospital systems with not-for-profit hospitals. health care management review, 16(2):31-37. [medline] sear, a.m. (1992). operating characteristics and comparative performance of investor owned multithospital systems. hospital and health services administration, 37, 403-415. [medline] online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 mailto:mustafa.younis@ccaix.jsums.edu http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=2354959%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11148870%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10282276%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10304268%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10280177%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=9086668%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=1905279%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10120498%5buid%5d 48 sloan, f.a. & vraciu, r.a. (1983). investor-owned and not-for-profit hospitals: addressing some issues. health affairs, 2, 25-37. walker, c. (1993). a cross-sectional analysis of hospital profitability. journal of hospital marketing, 7(2), 121-138. [medline] watt, j., renn, s., hahn, j., derzon, r., & schramm, c. (1986). the effects of ownership and multi-hospital system membership on hospital functional strategies and economic performance. in for-profit enterprise in health care (pp. 260-290). washington, dc: national academy press. white, h. (1980). a heteroscedasticity-consistent covariance matrix estimator and a direct test for heteroscedasticity. econometrica, 48, 817-838. younis, m., rice, j., & barkoulas, j. (2001). an empirical investigation of hospital profitability in the post-pps era. journal of health care finance, 28(2), 65-72. [medline] online journal of rural nursing and health care, vol. 3, no. 1, spring 2003 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=10129243%5buid%5d http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=detailssearch&term=11794758%5buid%5d methods microsoft word o'brien_324-1800-1-ed.docx online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 80 perceptions of older rural women using computerized programs for weight tara renee o'brien, phd, rn, cne 1 carolyn jenkins, phd, rn, drph, aprn-bc-adm, rd, ld, faan 2 elaine amella, phd, rn, faan 3 martina mueller, phd, rn 4 michael moore, phd 5 meredith troutmanjordan, phd, rn 6 steffanie sullivan, msn, np-c, rn 7 1 assistant professor, college of nursing, university tennessee health science center, tobrien5@uthsc.edu 2 college of nursing, medical university of south carolina, jenkinsc@musc.edu 3 college of nursing, medical university of south carolina, amellaej@musc.edu 4 college of nursing, medical university of south carolina, muellerm@musc.edu 5 college of health and human services, university of north carolina at charlotte, michael.moore@uncc.edu 6 school of nursing, university of north carolina at charlotte, meredithtroutman@uncc.edu 7 school of nursing, university of north carolina at charlotte, steffaniewilliams@msn.com abstract purpose: to explore older rural women’s perceptions of an internet assisted weight loss program. sample: the sample (n = 24) included white women (70%) and black women (30%) age 55 and older recruited from two rural senior centers in the appalachian region of north carolina. method: a qualitative design was used to explore rural older obese women’s perceptions of an internet assisted weight loss program using semi-structured interviews. a total of six focus online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 81 groups were held with a convenience sample (n=24) of appalachian adult women (age 55 and older) from two community sites. findings: the 24 women gave their perspective on the use of the internet for weight loss. six themes emerged from the two groups were: awareness, use of the internet, personal relationships, self-image, peer support, and obstacles. conclusions: weight loss is a sensitive subject matter for rural obese older women. evidence from this study suggests that rural women lack social support for weight loss. nurses may assist women living in rural areaswith weight loss through the use of the internet weight loss social support program in which older obese women can access in the privacy of their own homes. keywords: rural, technology, appalachian region, older adults perceptions of older rural women using computerized programs for weight obesity is one of the most challenging health complications in the united states (us). more than a third (35.7%) of us adults are considered obese (ogden, carroll, kit, & flegal, 2012), defined as having excess body fat with a body mass index (bmi) of 30 or higher (lopezmiranda & perez-martinez, 2013). according to lee, wu, and fried (2013) obesity is related to multiple health complications, including coronary artery disease, type ii diabetes, cancer, hypertension, dyslipidemia, stroke, respiratory problems, osteoarthritis, gynecologic issues, liver, and gallbladder disease. in addition to health related complications, economic difficulties may also arise as a result of obesity, including direct medical charges for preventative, diagnostic, and treatment services as well as indirect costs related to morbidity and mortality (hammond & lavine, 2010). health care associated with obesity now costs medicare, medicaid, and private online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 82 insurance payers $147 billion annually. if obesity trends continue, the cost of healthcare related to obesity is estimated to increase to $344 billion by the year 2018 (grantham, 2013). in the us, 40% of rural residents are considered obese (pease, 2012). people living in rural areas often consume a high fat and high calorie diet; lack education related to nutrition information, do not exercise, have higher costs for fresh fruit and vegetables, and are physically isolated (befort, nazir, & perri, 2012). obesity rates of rural low-income women are higher than for women living in urban areas (patterson, moore, probst, & shinogle, 2004). yet while women living in a rural area are interested in losing weight, they often do not use evidence based weightmanagement strategies. for example, boeckner, pullen, walker, oberdorfer, and hageman (2007) found that 95.6% of their respondents reported having a primary care provider, but they lacked effective diet counseling and information. ely, befort, banitt, gibson, & sullivan (2009) who explored influences on weight control for rural living women found that the top five reported themes were lack of support from primary care providers, lack of community resources, lack of dietary resources, the importance of group support, and the need for more intense intervention for weight control. few studies have investigated how technology may assist older rural women to achieve weight loss. therefore, this study explored older rural women’s perceptions of an internet assisted weight loss program. the study was part of a larger study of the effects of the internet assisted weight-loss program, “lose it,” on appalachian women, which has been reported elsewhere (o’brien et al., 2013). methods the study used focus groups to explore to gain insight into women’s familiarity with internet technology, and their feelings, about being overweight, their expectations for using the online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 83 technology for behavior change. institutional review board approval for the study was obtained at two southern universities. a convenience sample was recruited over 4 weeks from two different rural senior centers in north carolina. the principal investigator (pi) obtained informed consents and screened participants for eligibility requirements. inclusion criteria included age 55 and older, bmi > 25, and current residence in burke county or yadkin county in north carolina. participants were excluded from the study if they were actively participated in a weight loss program, planned to move out of the area within the next 12 weeks, or were taking medications for weight loss. participants received a $10.00 gift card to a regional grocery store. data collection two focus groups were held with control participants in the larger study (baseline and 12 weeks), and four were held with intervention participants (baseline, and weeks 4, 8, and 12) to gain insight into the women’s familiarity with internet technology and their views of using the technology in regard to behavior change. the focus groups used an interview guide, which was reviewed by experts in qualitative research for face validity. the interviews were recorded, and memo writing was done using krueger and casey’s (2000) guidelines. ever note was used to organize the transcripts for analysis. first the text from the audio recordings and field notes was assessed using line-by-line analysis (hesse-biber & leavy, 2011). next the authors engaged in "open" coding, to capture the deeper meaning of the context. focused coding was then applied to identify patterns and relationships among the codes. themes that emerged from the data were analyzed and assessed for areas of importance related to behavioral change and use of technology. the research team determined theoretical saturation after six focus group interviews were conducted and no information was collected (hesse-biber & leavy, 2011). all of the online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 84 research team members had experience in planning and conducting focus group research, and in qualitative analysis. results participants the initial sample was composed of 24 adult women (aged 55 and older) living in the appalachian region of north carolina. after 2 weeks, two participants dropped out of the intervention group due to family illness, leaving 12 women in the group. in the control group one person dropped out in week 8 due to a hospitalization. thus, in total, of the 24 participants, 3 (12.5 %) dropped out and 21 participants completed the study. no significant differences were found in the demographic data of the two groups. their mean age was 69 + 8 years; and their mean body mass index (bmi) (kg/m2) was 34.2. ± 8. the majority of women (66.7 %) had a high school diploma or ged. almost half (45.8 %) had an annual household income of less than $29,000. most of the participants (87.5%) were white women; 12.5% were african american. table 1 provides an overview of their demographic data (table 1). focus groups focus groups were held at two different senior centers (site 1 n = 14) and a church (site 2, n = 10). six themes emerged from the analysis of the two groups. the key theme was awareness; other themes identified were: a) use of the internet, b) personal relationships, c) self-image, d) peer support, and e) obstacles (table 2). online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 85 table 1 participants characteristics by group with mean (sd) or n(%) overall m (sd) or n (%) (range if applicable) n = 24 intervention m (sd) or n (%) (range) n = 14 control m (sd) or n (%) (range) n = 10 p-value age 69 (8) (57–83 years) 69.4 (6.8) (57 – 79 years) 67.4 (6.8) (58–83 years) .792 c bmi( kg/m2) 34.2 (8.4) (25.3–51.4) 34.2 (7.2) (.4 – 50.5) 34.0 (9.3) (25.3–49.5) .598 c ethnicity hispanic non-hispanic 1 (4.2%) 23 (95.8%) 1 (7.1%) 13 (92.9%) 10 (100%) 1.00 a race africanamerican white 3 (12.5%) 21 (87.5%) 14 (100%) 3 (30%) 7 (70%) .059 a marital status married single widow 14 (58.3 %) 3 (12.5%) 7 (29.2 %) 9(64.3 %) 2 (14.3%) 4 (21.4 %) 5 (50 %) 1 (10%) 4 (60 %) .613 b education* < hs diploma > hs diploma no report 16 (66.6%) 7 (29.1%) 1 (4%) 10 (62.5%) 4 (57.1%) 6 (37.5%) 3 (42.9%) .809 b income* < $ 29,000 or less > $ 29,000 no report 11(45.8%) 7 (29.2%) 6 (24.6 %) 5 (35.6%) 5 (35.6%) 6 (42.8%) 2 (14.3%) .280 b note. a fisher’s exact test b pearson chi square test c wilcoxon signed rank tests *p-values were obtained for the dichotomous variables of education and income awareness the women in the intervention group indicated that the weight loss program made them more aware of their portion sizes, food choices, and the need for physical activity each day. one woman said, “the “lose it” program gives you more visualization of what you ate for the whole day;” another said, “the calorie counter bar in the “lose it” program helps me to stay focused each day.” the women noted that the “lose it” program made them aware of their daily calorie intake. one woman said, “i think now before eating that piece of pie,” and another woman noted, online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 86 “it has helped me to be more aware of the portion sizes, before i would put food on my plate without thinking. now i am measuring it.” the women talked about how they had changed some of their eating habits due to using the internet program. one said, “it made me cut down on my coffee drinking,” and another said, “i used to eat a lot of potatoes and now i look at them and say, no they are too bad for me.” a third woman said, “the ‘lose it’ program has made me more conscious and it encourages me to eat better.” table 2 semi-structured interview comments themes exemplar quotes awareness “the “lose it” program gives you more visualization of what you ate for the whole day” “the calorie counter bar in the “lose it” program helps me to stay focused each day” “it has helped me to be more aware of the portion sizes, before i would put food on my plate without thinking. now i am measuring it.” usage of internet “i use facebook to keep up with what is going on in the church and my relatives.” “facebook to look at pictures of my niece and stuff, but i do not post anything” personal relationships “my family…. when i am overweight, they are down on me 24/7. “i had my plate and i was really trying to watch what was on my plate and i thought i had done really good job…. another woman said, you need sidebars for that plate” self-image “i can’t get in any clothes, my clothes are all tight. i feel like a dump.” peer support “i have very little support from anyone, i just have lose it” obstacles “the only negative thing is that we cook a lot at home, so i have to create the food items in the program. also, a lot of the grocery stores and restaurants in the “lose it” program we do not have in this area” online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 87 the women said that the “lose it” program also made them more aware of the need to do physical activity each day. one woman commented, “i eat all my food, but i watch the calorie counter bar in the “lose it” program and realize that i have to do exercise or work in the yard to keep the calorie counter bar down.” another said, “if i do not do my exercises, the program makes me feel guilty.” the women noted that the “lose it” program encouraged them to be physically active by logging their food intake and subtracting their energy expenditure through physical activity. one woman said, “the program encourages me to do physical activity each day.” many women said that the internet program kept them motivated to lose weight. one woman said, “it helps motivate me to lose weight” and one said, “the ‘lose it’ program is something to look at and refer back to. it keeps me motivated.” use of the internet many of the women in the intervention group indicated that they had high-speed internet coverage in their home and they used the internet for checking and sending emails. another use of the internet they reported was looking at facebook. one woman said, “i use facebook to keep up with what is going on in the church and my relatives.” many of the women indicated that they used the internet to look up information for genealogy and gardening information. only one woman indicated that she used the internet to look up health information. this woman said, “i go to a health website to look at information about my diet.” the women in the control group also had high-speed internet coverage in their home. however, they reported that they used the internet not for checking and sending emails, but for looking at facebook. one woman said, “i go on facebook to look at pictures of my niece and stuff, but i do not post anything.” another said, “i look at my family on facebook.” still another woman commented that she used facebook to keep updated about her family: “i read what my family is talking about on online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 88 facebook.” the women said that they believed the internet could be helpful for them to lose weight because they could look up information about diet and exercise. one woman said, “you can look things up in the privacy of your own home.” personal relationships the women spoke about how their weight affected their personal relationships with friends and family. one woman said, “my family…. when i am overweight, they are down on me 24/7. i have lost some weight; i have gone from taking 24 medications to now i am taking 11 medications.” another said, “it doesn’t matter anymore. take me for what i am.” yet another woman said, “it doesn’t impact my relationships with others, i am not dating so it doesn’t bother me.” still another said, “a family member said to me, boy you have gained a lot of weight since i seen you last!” one woman noted that it was a blessing to have diabetes because her family would not pressure her to eat. she said, “being a diabetic in a way has been a blessing, because my family leaves me alone when i say i cannot eat that because i am a diabetic.” the women also spoke about how people judged them based on their weight status. one woman said, “people judge you on your appearance before they even know what you are like on the inside.” another said, “when you get to be big, you cannot be fashionable, i think a lot of people prejudge you, you can tell by their eyes and the way they act.” yet, another woman spoke about how people judged her intelligence based on her weight. she said, “they think you are not smart enough because you are big.” in the control group the women talked in depth about how being overweight influenced their personal relationships with people in the community and their family. one woman said, “i have a story….i had my plate and i was really trying to watch what was on my plate and i thought i had done a really good job…and then a woman said, ‘you need sidebars for that plate.’ i said, ‘hmmm, i believe both of us could use sidebars on our plates.” online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 89 another woman spoke about her husband: “i used to get after my husband for gaining weight, now he gets after me for being bigger. he says “honey you have a behind.” yet another woman spoke about how obesity had affected her son: “if it is my family, it has to be their decisions. my son was 400 pounds and the doctor told him that he had to lose weight if he wanted to see his daughter graduate. he has lost a lot of weight and i am very proud of him, before i could not even get my arms around his neck to give him a hug. he is in his 50’s.” another woman spoke about her daughter. she said, “my daughter is always on me, she will say, mom why did you eat that… you are going to have a heart attack.” self-image many of the women mentioned that being overweight negatively influenced their selfimage. one woman said, “i can’t get in any clothes, my clothes are all tight. i feel like a dump.” another woman said, “if i do not look at myself in the mirror then i do not have to acknowledge the fact that i am overweight,” and another said, “i do not like to look at myself in the mirror. i know that i would feel better if i lost weight.” another woman said, “i cannot fit into my clothes, i do not want to look at myself.” the women said that losing weight would help them feel better and have a more positive outlook. one woman said, “when i lose weight, i feel better,” and another noted, “you feel more positive.” peer support the women defined peer support as people getting together and supporting each other. one woman said, “peer support is when people encourage you,” and another said “peer support is when people come together and support you.” the participants said that they received very little peer support for weight loss, indeed, and the only support the intervention group had for weight loss was through the “lose it” program. one woman said, “i have very little support from online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 90 anyone,” and another said, “i just have ‘lose it’.” the women spoke about how the “lose it” discussion forum motivated them. one woman said, “it encourages me to write in my food and exercise, because i can see that the others have entered their information for the day.” another woman noted, “it tells me when people have logged in or lost weight, i think….oh she is ahead of me.” however, after 12 weeks of using the “lose it” program, all of the women in the intervention group reported that they still preferred peer support face-to-face. one woman said, “it is more informative when we talk as a group; i do not have the time to get on the internet to talk.” obstacles to using the internet program the women mentioned a few obstacles to using the “lose it” internet program, most had to do with not being able to find all of their food selections. one woman said, “the only negative thing is that we cook a lot at home, so i have to create the food items in the program. also, a lot of the grocery stores and restaurants in the ‘lose it’ program we do not have in this area.” another person said, “i think it is geared toward people who eat out a lot and live in a city.” still another woman commented about restaurant selections, “we went to olive garden last night and i had a chicken dinner, but i could not find it in the “lose it” program. i had to call olive garden to find out how many calories were in my dish.” another commented, “if you do not have a nutrition label, then you do not know and you have to guess.” the women felt that if more food and restaurant choices were listed, the “lose it” program could be improved for older adults. discussion women in both groups, those assigned to the “lose it” program (intervention group) and the daily wellness tips group (control group) lost weight over the 12-week period (table 3). however, during the focus group interview the control group did not credit the daily wellness online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 91 tips provided by an internet program to help them to achieve weight loss. two common themes found in both groups were “personal relationships” and “use of the internet.” these women believed they were often judged in a negative manner due to their weight. similarly, baturka, hornsby, and schorling (2000) found that rural african-american women often felt they were not accepted by family members and members of the community due to their weight status, and they reported a lack of social support. another study found that older overweight women were often stereotyped to be lazy (zaretsky, 2013). table 3 outcome variables outcome variable time intervention m (sd) n = 14 control m (sd) n = 10 p-value weight (lbs) baseline 4 weeks 8 weeks 12 weeks 195.9(45.7) *191.1 (46.8) *189.9 (47.4) *188.7 (47.2) 202.9 (65.6) 200.1 (66.5) *198.7 (69.4) *196.1 (69.1) .815a .947a .776a .722a bmi (kg/m2) baseline 4 weeks 8 weeks 12 weeks 34.2.± 8.0 *32.6 ± 7.2 *32.6 ± 7.9 *32.1 ± 7.1 34.2 ± 8.1 33.7 ± 9.4 *32.8 ± 9.7 *32.6 ± 9.7 .598 a .869 a .594 a .546a note. a mann-whitney u test, *intervention group data analyzed for 12 participants, *control group data analyzed for 9 participants, * bl = baseline the internet was used most often for looking at personal information, but not for exploring health information. in a study conducted by choi (2011) found that older adults were the most frequent users of the us health care system, yet they were the least likely to use health information technology for the selfmanagement of chronic disease. although the women in this study believed, the internet provided them privacy in their own home to explore health information about diet and exercise. the internet was used in both groups to access facebook in order to stay connected to their families. this is a similar finding to how young adults use online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 92 internet to maintain social connections among peers through the use of facebook and email. according to brenner and smith, (2013) 67 % of young adults use facebook to stay connected with family and friends. the intervention group reported a greater visual awareness of the need to eat low calorie food items and participate in daily physical activity. they reported that the social support group provided through the “lose-it” program made them aware of others’ success and their own personal goals for weight loss. interestingly, after 12 weeks, all but one of the women in the intervention group said that they planned to continue with the program. in fact, they planned to set monthly meetings and talk about their weight loss. similarly, a recent study using mobile phone application (app) to provide social support to a group of obese women found that after 8 weeks the women who received the support app reported a greater increase in positive emotion for behavior change (brindal et al., 2013). twitter has also shown to be a source of social support of weight loss. turner-mcgrievy et al. (2013) recently found that when 96 participants were randomized to a weight loss program, the group who posted to twitter and received feedback from fellow participants had significantly lower bmi at 6 months (31.5 ± 0.5) than non-users (32.5 ± 0.5) (p = 0.02), and they lost more weight than the group which did not post to twitter. we were only able to collect focus group interviews in two rural settings of north carolina. therefore, our study may have limited generalizablity to other populations of older adults living in other settings in the us. despite this limitation, saturation of themes was achieved indicated the need for future studies to explore internet use promote weight loss among older women living in other rural settings of the us. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 93 implications for nursing this study highlights the need for nurses to have an understanding of how the internet may influence older obese rural women in the weight loss process. first, nurses need to have the understanding that weight loss is a sensitive subject matter for older obese women. often these women have experienced false judgments made about them based on their weight status. the stigma of weight affects women often negatively and increases their stress and anxiety levels. second, obese rural women often lack social support for weight loss. however, the internet may be one resource they can use privately in the own home to connect to other women who may have similar issues with weight loss. currently, older adults are the fastest growing population to use the internet for self-management of care. nurses in the twenty-first century need to promote self-management of care by educating older rural women how to navigate the internet so they can utilize internet support programs to self-manage their health to prevent chronic disease. nurses need to be proactive to advocate for policies protocol development for how health care providers offer client support for the use of internet self-management programs. lastly, programs for communication training will need to be implemented between the, primary care provider, health care provider, and the client for selfmanagement internet program to maintain health and prevent chronic disease in older rural women. acknowledgements the gamma iota chapter research award, sigma theta tau national honor society for nurses online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 94 references baturka, n., hornsby, p., & schorling, j. (2000). clinical implications of body image among rural african-american women. journal of general internal medicine, 15, 235-241. http://dx.doi.org/10.1111/j.1525-1497.2000.06479 befort, c. a., nazir, n., & perri, m. g. (2012). prevalence of obesity among adults from rural and urban areas of the united states: findings from nhanes (2005-2008). journal of rural health, 28, 392-397. http://dx.doi.org/10.1111/j.1748-0361.2012.00411 boeckner, l. s., pullen, c. h., walker, s. n., oberdorfer, m. k., & hageman, p. a. (2007). eating behaviors and health history of rural midlife to older women in the midwestern united states. journal of the american dietetic association, 107, 306-310. http://dx.doi.org/10.1155/2012/618728 brenner, j., & smith, s. (2013). 72% of online adults are social networking site users. retrieved from http://pewinternet.org/~/media//files/reports/2013/pip_social_networking_sites_ update_pdf.pdf brindal, e., hendrie, g., freyne, j., coombe, m., berkovsky, s., & noakes, m. (2013). design and pilot results of a mobile phone weight-loss application for women starting a meal replacement programme. journal of telemedicine and telecare, 19, 166-174. http://dx.doi.org/10.1177/ 1357633x13479702 choi, n. (2011). relationship between health service use and health information technology use among older adults: analysis of the us national health interview survey. journal of medical internet research, 13(2), 3. http://dx.doi.org/10.2196/jmir.1753 online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 95 ely, a. c., befort, c., banitt, a., gibson, c., & sullivan, d. (2009). a qualitative assessment of weight control among rural kansas women. journal of nutrition education and behavior, 41(3), 207-211. http://dx.doi.org/10.1016/j.jneb.2008.04.355 grantham, s. l. (2013). obesity and weight management. in t. m., buttaro, j., trybulski, p. polger-bailey, & j , sandberg-cook (4th ed), primary care: a collaborative practice, (pp. 105 119), st. louis, mo: mosby elsevier. hammond, r. a., & levine, r. (2010). the economic impact of obesity in the united states. diabetes, metabolic syndrome and obesity: targets and therapy, 3, 285 295. http://dx.doi.org/10.2147/dmsott.s7384 hesse-biber, s. n., & leavy, p. (2011). the practice of qualitative research (2nd ed.). thousand oaks, ca: sage. krueger, r., & casey, m. (2000). focus groups: a practical guide for applied research. thousand oaks, ca: sage. lee, m. j., wu, y., & fried, s. k. (2013). adipose tissue heterogeneity: implication of depot differences in adipose tissue for obesity complications. molecular aspects of medicine, 34, 1, 1-11. http://dx.doi.org/10.1016/j.mam.2012.10.001 lopez-miranda, j., & perez-martinez, p. (2013). it is time to define metabolically obese but normal-weight individuals. clinical endocrinology, 79, 3, 314-315. http://dx.doi.org/10.1111/cen.12181 o’brien, t., jenkins, c., amella, e., mueller, m., moore, m., & troutmanjordan, m. (2013), internet assisted weight loss program intervention for older obese rural women. manuscript submitted for publication. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.324 96 ogden, c. l., carroll, m. d., kit, b. k., & flegal, k. m. (2012). prevalence of obesity in the united states. nchs data brief, 82(1). patterson, p. d., moore, c. g., probst, j. c., & shinogle, j. a. (2004). obesity and physical inactivity in rural america. journal of rural health, 20, 151-159. http://dx.doi.org/ 10.1111/j.1748-0361.2004.tb00022 pease, j. (2012). obesity higher in rural america than in urban parts of the country, uf researchers, colleagues find. news university of florida. retrieved from http://news. ufl.edu/2012/09/14/rural-obesity/ turner-mcgrievy, g., beets, m., moore, j., kaczynski, a., barr-anderson, & tate, d. (2013). comparison of traditional versus mobile app self-monitoring of physical activity and dietary intake among overweight adults participating in an mhealth weight loss program. 20(3), 513-518. http://dx.doi.org/10.1136/amiajnl-2012-001510 zaretsky, s. (january). overweight women continue to be judged harshly for everything, everywhere – including courtrooms. above the law. retrieved from http://abovethelaw .com/2013/01/overweight-women-continue-to-be-judged-harshly-for-everythingeverywhere-including-courtrooms/ microsoft word gregg_21-52-2-rv.docx online journal of rural nursing and health care, 12(2) 41 rural adolescent substance abuse: prevention implications from the evidence jason allen gregg, aprn, fnp-c, dnp 1 1 assistant professor of clinical, fnp program coordinator, college of nursing, university of cincinnati, jason.gregg@uc.edu abstract purpose: to identify appropriate adolescent substance abuse prevention programming for rural populations through the application of three concepts: effectiveness (best clinical evidence), efficiency (benefit to rural populations), and equality (access). methods: a review of the literature guided by these concepts was conducted to identify criteria essential to the tailored development of rural adolescent substance abuse prevention programming. an advanced search of the substance abuse and mental health services administration’s (samhsa) national registry of evidence-based programs and practices (nrepp) was then conducted using criteria tailored to rural populations. findings: results from the literature search support the inclusion of two components directed at improving quality of outcomes through a customized approach to rural adolescent substance abuse prevention programming: inclusion of parents in prevention education efforts and use of the internet as an appropriate method of program delivery. these components were satisfied by one program listed on samhsa’s nrepp: parenting wisely. conclusions: while parenting wisely is an ideal program for rural adolescent substance abuse prevention strategy, it may not be suitable for all communities. parallel to recommendations from the samhsa and institute of medicine, other evidence-based prevention programs need to be expanded to include a web-based delivery option. strategies for moving forward would include the use of advanced-practice nurses at the forefront of discussion for rural professionals, researchers, educators, and policymakers. keywords: access to care, technology, substance abuse prevention, rural rural adolescent substance abuse: prevention implications from the evidence adolescent substance abuse is a considerable problem in the united states. although alcohol can best be described as an older problem with increasing incidence, illegal drug usage is a fairly new phenomenon in rural america (schoeneberger, leukefeld, hiller, & godlaski, 2006). with increased access to cell phones, internet usage and migration of peoples to rural areas, what was formerly considered an urban issue is becoming an increasingly apparent problem in rural america (dew, elifson, & dozier, 2007). lambert, gale, and hartley (2008) note rural youth have a greater incidence of alcohol and methamphetamine usage when compared to urban youth. the authors also demonstrated a negative correlation between population and use of these substances in that alcohol and methamphetamine usage increases as population decreases. the substance abuse and mental health services administration (samhsa) demonstrated these rural trends with its 2008 national survey results on drug use (samhsa, online journal of rural nursing and health care, 12(2) 42 2009). in 2008, alcohol binge drinking rate for young persons ages twelve to seventeen was greatest in nonmetropolitan areas at 9.8%. small metropolitan areas had a rate of 9.0%, while large metropolitan areas had a rate of 8.4%. illicit drug use in completely rural counties rose from 4.1% in 2007 to 6.1% in 2008. while it seems rural youth substance abuse rates now parallel their metropolitan counterparts, there still remains a disparity in resources available to combat the problem (rural assistance center, 2010). regardless of geographical context, youth substance abuse results in the following problems: disrupted peer and family relationships (collins, johnson, & becker, 2007), school problems such as misbehavior and academic failure (henry, smith, & caldwell, 2006), and higher risk behavior (lambert et al., 2008). spending on substance abuse treatment is projected to increase to thirty-five billion dollars by 2014 (levit, kassed, coffey, mark, mckusick, king, vandivort, buck, ryan, & stranges, 2008). this spending increase coupled with the added social costs of overextended law enforcement, educational, and counseling-related services can deplete the already limited resources of a rural community. therefore, it is imperative to identify effective strategies for youth substance abuse prevention and that those strategies be tailored specifically to the needs and abilities of rural communities. in order to reduce resource strains while maximizing the quality of outcomes, strategy development for the rural community can be guided by the vision of a pioneer in healthcare quality, archibald “archie” cochrane. methods a review of the literature guided by the concepts of effectiveness (best clinical evidence), efficiency (population benefit), and equality (access) as defined by archie cochrane (1972) was carried out in order to identify criteria essential to the development of rural adolescent substance abuse prevention programming. methodology which incorporates the processes of a systematic review and meta-analysis affords clinicians the ability to summarize information from research literature in order to apply best evidence-based strategies to clinical practice (haase, 2011). this review process incorporated a three-tiered approach. first, the cinahl, medline, pubmed, and cochrane library databases were utilized to conduct a text search of the research literature using several keywords: rural, adolescent, substance abuse, and prevention. subsequently, search results were analyzed through the application of an a to d letter grade scale (titler, 2002). grade criteria are as follows: grade a (evidence from well-designed meta-analysis or other systematic reviews); grade b (evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment); grade c (evidence from observational studies or controlled trials with inconsistent results); and grade d (evidence from expert opinion or multiple case reports). based on the concepts of effectiveness and efficiency (cochrane, 1972), articles were reduced to those graded as either a or b. according to cochrane (1972), equality can only be met by satisfying the concepts of effectiveness and efficiency. as a result of this preliminary literature search, a secondary examination of the literature was conducted via methods similar to the initial search but using the following keywords: parents, prevention, and technology. based on the concept of equality (cochrane, 1972), results were reduced to information relevant to the prevention of mental health issues including parenting skills education utilizing methods designed to increase access with hard to engage groups such as those in rural populations. in the third tier of this review process, an advanced search of the samhsa national registry of evidence-based programs and practices (nrepp) was conducted (samhsa, 2010) using the following search criteria: areas of interest (substance abuse prevention); geographical online journal of rural nursing and health care, 12(2) 43 location (rural and/or frontier); ages (6-12 [childhood], 13-17 [adolescent]); and setting (home, workplace, other community settings). this search method was designed to identify substance abuse prevention programs which would satisfy the concepts of effectiveness and efficiency (cochrane, 1972). program results were then tailored to rural populations by narrowing interventions to those that included delivery methods suggested by the secondary literature review which would satisfy the concept equality (cochrane, 1972) by increasing access. results in the first tier of the literature review process, search terms yielded over two hundred articles. through application of titler’s (2002) letter grade criteria, search results were reduced to less than a dozen research articles. none of these a or b grade articles addressed the use of technology-based methods for substance abuse prevention program delivery. however, the secondary literature review did produce some evidence through data supporting use of the internet as a delivery method for prevention programming in mental health including education designed to improve parenting skills. in a grade b randomized study, calam, sanders, miller, sadhnani, and carmont (2008) demonstrated improvement in parenting skills and child behavior. in addition, internet-based training methods demonstrated principles inherent to the concept of equality (cochrane, 1972): provide mental health services access to families who might not otherwise receive them (feil, baggett, davis, sheeber, landry, carta, & buzhardt, 2008), meet cultural demands today for internet-based delivery methods (feil et al., 2008), and improve costeffectiveness by permitting parents access convenience of services whenever needed (calam et al., 2008). an advanced search of the samhsa nrepp (samhsa, 2010) yielded one program that encompassed the concepts of effectiveness, efficiency, and equality resulting in a prevention approach tailored to the needs of a rural community. in order to put the results into full perspective, it is important to address specific findings individually through each of the three concepts and tailored approach results. effectiveness cochrane describes effectiveness as the best clinical evidence (cochrane, 1972). in other words, clinical applications of evidence should be derived from high quality research designs such as randomized controlled trials, systematic reviews, and/or meta-analyses. most of the substance abuse prevention programming interventions in the research literature for both rural and urban populations are targeted towards one of three key aspects: parenting skills, peer socialization skills, or school-based interventions. a systematic review demonstrated significant findings for these same populations: positive outcomes were most evident in the areas of parenting skills and peer socialization skills; programs directed at parenting skills and improving family processes demonstrated great success in substance abuse reduction outcomes; and the most beneficial approaches were those that focused on parental involvement (petrie, bunn, & byrne, 2007). the cochrane library, named after archie cochrane (cochrane, 1972), currently has two systematic reviews in its database of cochrane reviews demonstrating similar results with parental findings. the first systematic review examined school-based programming focused on illicit drug use prevention in both rural and urban settings (faggiano, vigna-taglianti, versino, zambon, borraccino, & lemma, 2005). findings indicated social skills programs were most popular and effective in reducing substance use. the second systematic review examined non school-based programs designed to prevent drug use in young people (gates, mccambridge, smith, & foxcraft, 2006). this review examined the prevention programming types of online journal of rural nursing and health care, 12(2) 44 motivational interviewing or brief intervention, education or skills training, family interventions, and multi-component community interventions. findings were mostly inconclusive due to lack of homogeneity in research designs, but the authors did conclude there was enough evidence to suggest that family-based interventions including contact with parents to be beneficial in preventing substance use. the aforementioned research findings supporting benefit with parental inclusion in prevention efforts parallel adolescent reports in samhsa’s 2008 national survey on drug use and health (samhsa, 2009). a majority of adolescents ages twelve to seventeen reported a belief that their parents would strongly disapprove of substance usage: 90.8% in regard to marijuana or hashish; 89.7% in regard to alcohol usage; and 92.4% in regard to cigarette usage. adolescents who believed their parents would strongly disapprove of substance usage were less likely to use substances than those who sensed a lesser degree of parental disapproval (samhsa, 2009). research has demonstrated that changing parental opinions is necessary in altering adolescent beliefs (abbey, pilgrim, hendrickson, & buresh, 2000). adolescents view parents as believable in terms of drug knowledge, and substance abuse prevalence decreases as perceived family penalties for such usage increases (kelly, comello, & hunn, 2002). survey results also demonstrated level of parental involvement including support, oversight, and control of adolescent activities affected substance usage. use of substances including illicit drugs, alcohol, and cigarettes was less for adolescents ages 12-17 who reported regular parental monitoring of behaviors than those whose behaviors were rarely monitored by parents (samhsa, 2009). as depicted in table 1, substance usage rates for adolescents whose parents seldom or never monitored behaviors were approximately twice that of adolescents whose parents were always or sometimes involved (samhsa, 2009). table 1 efficiency cochrane describes efficiency as involving benefit to a predefined population (cochrane, 1972). in other words, interventions found to be effective through research should provide a benefit to the community. substance abuse prevention programming that includes parental involvement has demonstrated benefits other than just youth substance abuse prevention. a systematic review found such interventions improved both parenting skills and family processes resulting in greater family cohesiveness and less family fighting (petrie et al., 2007). other benefits include saved dollars from reduced usage of resources provided by both society and the government (samhsa, 2007). an example of a family-based program demonstrating an increase in cost benefit is the strengthening families program. this prevention program for parents and youth ages ten to fourteen cost $851 per child participant to implement but yielded an estimated $9656 social cost benefit (aos, lieg, mayfield, miller, & pennucci, 2004). while this program demonstrated a online journal of rural nursing and health care, 12(2) 45 benefit greater than eleven times the investment, not all programs provide similar results; however, even the smallest measure of mental and behavior problem prevention will result in significant cost-benefit and savings for rural communities (samhsa, 2007). a key to improving rural community benefit is by focusing on equality, specifically access to the prevention intervention. equality according to cochrane, equality can be met by satisfying the preliminary steps of effectiveness and efficiency. he hoped this third concept would provide a humanitarian bridge in the gap of care between the rich and poor (cochrane, 1989). in order to bridge this gap, access to substance abuse efforts need to be increased in rural populations. failure to provide access to evidence-based substance abuse prevention programming in rural populations will result in continued financial strains with agencies at the local, state, and national levels (samhsa, 2007). geographical disparities often provide an obstacle to substance abuse prevention efforts with rural populations. in comparison to their metropolitan counterparts, rural areas typically lack assets needed to implement evidence-based substance abuse prevention programming: adequate funding, trained professionals to implement the programs, sufficient infrastructure, and appropriate facilities for instruction provision. in addition, population numbers in rural areas are less and more widely dispersed in comparison to their urban counterparts. these disparities often reduce cost effectiveness due to lessened access (samhsa, 2007). as a result, the uniqueness of rural populations facilitates the need for tailored implementation strategies designed to increase access. basic principles to increasing family involvement are dependent upon making programs more accessible and acceptable (samhsa, 2007). program effectiveness and population acceptance can be increased when programs are tailored to cultural and community norms of rural populations. program tailoring would include strategies designed to integrate the intervention into the normal daily schedule of participants, utilizing community assets, and adaptation to financial limitations (samhsa, 2007). in order to successfully tailor substance abuse prevention efforts in rural communities, one solution method for program implementation would be a nontraditional, web-based programming approach. interestingly, the same technology that has increased rural access to substances of abuse can be used to target parents with prevention efforts. the significant increases in internet usage and demand has led to alternative delivery method considerations for mental health services (calam et al., 2008). parallel with traditional direct-contact approaches, nontraditional webbased prevention methods have demonstrated ability to improve both child behavior and parenting skills (feil et al., 2008). in addition, these web-based programs also have the ability to increase cost-effectiveness by allowing parents access to needed services at the time and location most convenient to them (feil et al., 2008). according to the united states department of agriculture (usda) economic research service (2009), current estimates describe the rate of internet use for individuals in rural areas to be 71%. in 2007, 63.3% of rural residents accessed the internet at home or elsewhere, whereas 51.9% maintained home internet service. broadband, considered the gold standard in internet connection and speed, has seen rapid growth in rural areas since 2000. due to this rapid growth, rural broadband service access has been considered much more common in recent years (usda economic research service, 2009). online journal of rural nursing and health care, 12(2) 46 not only does web-based access to substance abuse prevention programming increase the ability to reach larger numbers in rural populations, it also provides the ability to tailor efforts to the cultural and community norms. individuals would be able to fit the intervention into their routine schedule whenever and wherever they have internet access (i.e., home, work). this method would utilize preexisting assets within the community, specifically computer and internet access. in addition, costs are reduced by: web-based programming that is not labor intensive in comparison to traditional face-to-face classroom approaches; participant need for transportation and lost work time would be decreased; and a less number of highly skilled professionals would be needed to implement the programs. it is not uncommon to see rural communities provide some degree of evidence-based substance abuse prevention programming targeting youth within the school system. however, these same communities often lack the funding to incorporate parents and/or guardians into the prevention education efforts. programs focused on improving parenting skills and family processes have demonstrated great success in substance abuse reduction outcomes, and the approaches that include parental involvement seem to be the most beneficial (petrie et al., 2007). with this in mind, the focus in rural communities should be directed at technology-based prevention programs involving parents to complement the programs already being provided to their children within the school system. tailored approach an advanced search of the samhsa’s nrepp initially yielded fourteen evidence-based substance abuse prevention programs meeting basic appropriateness for rural communities (samhsa, 2010). of these fourteen interventions, table 2 demonstrates eight prevention programs that include parental involvement through either family-based approaches or a sole parent focus; however, only one of these programs offers a web-based program delivery option: parenting wisely (family works, 2010). table 2 online journal of rural nursing and health care, 12(2) 47 parenting wisely offers an online program for parents of children ages 9-18 years. this program is designed to improve communication and disciplinary skills of parents resulting in reduced substance abuse and behavior problems with their children. for each of eleven modules, parents watch recorded video(s) of family situations. throughout these scenarios, parents are provided with interactive questions and answers along with rationales for both appropriate and inappropriate responses to these situations. at the conclusion of each module, parents answer a brief quiz of approximately five questions to demonstrate knowledge retained. through payment of a subscription fee, parents can access the parenting wisely program for as little as $16.50 per participant. parents can complete the program in approximately 3 hours (family works, 2010). with this in mind, parenting wisely is an ideal intervention for rural populations due to aspects inherent to the program: evidence-based, accessibility, convenience, and relative low cost for implementation. discussion the institute of medicine (iom) identified six core needs for quality healthcare interventions: safe, effective, patient-centered, timely, efficient, and equitable (iom, 2001). as demonstrated through the theoretical application process, parenting wisely has the potential to be effective, efficient, and equitable. since this substance abuse prevention program offers an internet-based delivery method, parenting wisely directly satisfies the remaining three core concepts (iom, 2001): safety (avoiding injury), patient-centered (care individualized to patient preferences, needs, and values), and timely (reducing waits and delays). while this program does satisfy the iom core concepts of quality healthcare interventions, issues related to barriers need to be addressed. under the guide of archie cochrane’s vision, the greatest barrier to effectiveness and efficiency is with research itself. while some higher quality research including randomized controlled trials (newton, andrews, teesson, & vogl, 2009), systematic reviews (petrie et al., 2007; faggiano et al., 2005; gates et al., 2006), and meta-analyses (collins et al., 2007) have been conducted in recent years, gaps in the research literature remain, including studies with a rural population focus, technology-based interventions, and the cost-effectiveness of prevention programs. a systematic review found that study designs were limited in both number and similarity thus lessening the ability for comparative evaluations (gates et al., 2006). the largest gap in the research literature is related to cost evaluations of substance abuse prevention programming efforts. a systematic review of interventions for prevention of youth substance abuse delivered in non-school settings found cost-effectiveness was not addressed in any of the seventeen randomized controlled trials reviewed (gates et al., 2006). samhsa acknowledges a large gap in the number of thorough cost-related evaluations in research literature (samhsa, 2007). when adding cost as an outcomes identifier to the advanced search criteria as described in the prior section, the number of programs on samhsa’s nrepp decreased from fourteen to zero (samhsa, 2010). a barrier to equality in substance abuse prevention programming efforts in rural populations is related to technology. although internet access, including broadband services, has increased in geographically rural areas in recent years, there is still a disparity with urban counterparts. in 2007, the disparity of internet access was at minimum ten percent. current estimates demonstrate the disparity has slightly decreased with 71% of rural residents having internet access in comparison to 77% of urban persons. in addition, there is a positive correlation online journal of rural nursing and health care, 12(2) 48 between income levels and at home internet service for rural households with less income resulting in reduced access (usda economic research service, 2009). as a result, intervention access may be further decreased for rural persons with lower incomes, a known risk factor for substance abuse. the iom acknowledges that in order to overcome these barriers, changes in the healthcare environment are needed in specific areas: applying evidence to healthcare delivery, using information technology, and preparing the workforce (iom, 2001). use of parenting wisely as a model program for rural adolescent substance abuse prevention incorporates the applications of evidence and information technology to healthcare interventions; however, preparing the workforce is well-suited for a focus on empowering stakeholders in leadership positions throughout the rural community. in regard to the iom recommendations, a team-based approach is essential in meeting the changing and challenging aspects of our current health care system. this method helps reduce waste while improving outcomes through a combined effort of various disciplines: education (teachers, school nurses, and school administration); legal (police and court officials); social services (counselors and other service providers); local government (elected officials); and medical (doctors, nurses, and non-physician providers such as nurse practitioners and physician’s assistants). advanced practice nurses, specifically nurse practitioners, are particularly suited as an important adjunct to the rural health care system where there is a worsening shortage of primary care physicians. their inclusion in community-based group efforts, as well as their critical coordination of care skills, provides a viable solution to help improve evidence-based practice, clinical outcomes, and access points for prevention (montoya & kimball, 2007). research demonstrates it is beneficial to incorporate parents into prevention education efforts by providing these services through settings and methods easily accessible to these caregivers (samhsa, 2007). technology, specifically web-based programming, provides a method that can achieve this task. in addition, involving the aforementioned leaders further increases access to prevention education. conclusions parenting wisely provides a logical solution in rural substance abuse prevention programming through its ability to promote the concepts of effectiveness, efficiency, and equality along with the other iom concepts of safety, patient-centered, and timely. however, one program will not satisfy the prevention needs of all communities. samhsa recommends professionals expand current programs by incorporating new knowledge and resources (samhsa, 2007). this includes updating other known evidence-based substance abuse prevention programs to nontraditional approaches. in addition, this includes advocating the expansion of rural internet and broadband services at the local, state, and national levels (usda economic research service, 2009). while increasing environmental access to rural substance abuse prevention programming is critical to efforts, those labors are futile unless acceptance of both prevention programming and method of delivery is created. it is important to advertise the financial and social benefits resulting from investment in prevention programming (samhsa, 2007). rural communities must view substance abuse prevention programming as an investment that reaps profitable rewards to the community by reducing costs related to substance abuse. such a view is dependent upon expanded research with a focus including rural acceptance of programs along with reductions in both substance usage and costs. results of this research will demonstrate to rural populations the return on investment. even minimal gains in reducing the incidence of online journal of rural nursing and health care, 12(2) 49 mental health and behavior problems will produce significant cost savings and quality improvement in the lives of all stakeholders in the rural community. on the other hand, failure to improve access points for evidence-based prevention programming will result in less than optimal outcomes resulting from a depletion of community resources (samhsa, 2007). with the disparities in community assets well-documented in rural areas, this population cannot afford to delay a concerted effort in adolescent substance abuse prevention. education methods involving parents should be included as a focus in substance abuse prevention programming efforts. references abbey, a., pilgrim, c., hendrickson, p., & buresh s. (2000). evaluation of a family-based substance abuse prevention program targeted for the middle school years. journal of drug education, 30(2), 213-228. [medline] aos, s., lieg, r., mayfield, j., miller, m., & pennucci, a. (2004). benefits and costs of prevention and early intervention programs for youth. olympia: washington state institute for public health. calam, r., sanders, m.r., miller, c., sadhnani, v., & carmont, s.a. (2008). can technology and the media help reduce dysfunctional parenting and increase engagement with preventative parenting interventions? child maltreatment, 13(4), 347-361. [medline] cochrane, a.l. (1989). archie cochrane in his own words: selections arranged from his 1972 introduction to “effectiveness and efficiency: random reflections on the health services.” controlled clinical trials, 10, 428-433. [medline] cochrane, a.l. (1972). effectiveness and efficiency: random reflections on health services. london: nuffield provincial hospitals trust. collins, d., johnson, k., & becker b.j. (2007). a meta-analysis of direct and mediating effects of community coalitions that implemented science-based substance abuse prevention interventions. substance use & misuse, 42, 985-1007. [medline] dew, b., elifson, k., & dozier, m. (2007). social and environmental factors and their influence on drug use vulnerability and resiliency in rural populations. the journal of rural health, 23, 16-21. [medline] faggiano, f., vigna-taglianti, f., versino, e., zambon, a., borraccino, a., & lemma p. (2005). school-based preventions for illicit drugs’ use. cochrane database of systematic reviews (2). family works, inc. (2010). welcome to parenting wisely online. retrieved from http://www. familyworksinc.com/parentingwisely/index.php . feil, e.g., baggett, k.m., davis, b., sheeber, l., landry, s., carta, j.j., & buzhardt, j. (2008). expanding the reach of preventive interventions: development of an internet-based training for parents of infants. child maltreatment, 13(4), 334-346. [medline] gates, s., mccambridge, j., smith, l.a., & foxcraft d. (2006). interventions for prevention of drug use by young people delivered in non-school settings. cochrane database of systematic reviews (1). [medline] haase, s.c. (2011). systematic reviews and meta-analysis. plastic and reconstructive surgery, 127(2), 955-966. [medline] henry, k.l., smith, e.a., & caldwell l.l. (2006). deterioration of academic achievement and marijuana use onset among rural adolescents. health education research, 22(3), 372 384. [medline] http://www.ncbi.nlm.nih.gov/pubmed/10920600 http://www.ncbi.nlm.nih.gov/pubmed/18641169 http://www.ncbi.nlm.nih.gov/pubmed/18641169 http://www.ncbi.nlm.nih.gov/pubmed/17613959 http://www.ncbi.nlm.nih.gov/pubmed/18237320 http://www.ncbi.nlm.nih.gov/pubmed/18843143 http://www.ncbi.nlm.nih.gov/pubmed/16437511 http://www.ncbi.nlm.nih.gov/pubmed/21285802 http://www.ncbi.nlm.nih.gov/pubmed/16968870 online journal of rural nursing and health care, 12(2) 50 institute of medicine (2001). crossing the quality chasm: a new health system for the 21 st century. national academy press. retrieved from http://www.nap.edu/html/ quality_chasm/reportbrief.pdf . kelly, k.j., comello, m.l., & hunn l.c. (2002). parent-child communication, perceived sanctions against drug use, and youth drug involvement. adolescence, 37(148), 775-787. [medline] lambert, d., gale, j.a., & hartley d. (2008). substance abuse by youth and young adults in rural america. the journal of rural health, 24(3), 221-228. [medline] levit, k.r., kassed, c.a., coffey, r.m., mark, t.l., mckusick, d.r., king, e., …stranges e. (2008). projections of national expenditures for mental health services and substance abuse treatment, 2004–2014. rockville, md: u.s. dept. of health and human services, substance abuse and mental health services administration. montoya, i.d. & kimball o.m. (2007). marketing clinical doctorate programs. journal of allied health, 36(2), 107-112. [medline] newton, n.c., andrews, g., teesson, m., & vogl l.e. (2009). delivering prevention for alcohol and cannabis using the internet: a cluster randomized controlled trial. preventive medicine, 48, 579-584. [medline] petrie, j., bunn, f., & byrne g. (2007). parenting programmes for preventing tobacco, alcohol or drugs misuse in children < 18: a systematic review. health education research, 22(2), 177-191. [medline] rural assistance center (2010). substance abuse. retrieved from http://www. raconline.org/info_guides/substanceabuse/ . schoeneberger, m.l., leukefeld, c.g., hiller, m.l., & godlaski t. (2006). substance abuse among rural and very rural drug users at treatment entry. the american journal of drug and alcohol abuse, 32, 87-110. [medline] substance abuse and mental health services administration (2009). results from the 2008 national survey on drug use and health: national findings. rockville, md: dept. of health and human services, substance abuse and mental health services administration, office of applied studies. substance abuse and mental health services administration (2010). samhsa’s national registry of evidence-based programs and practices. retrieved from http://nrepp.samhsa. gov/ . substance abuse and mental health services administration, center for mental health services (2007). promotion and prevention in mental health: strengthening parenting and enhancing child resilience. (dhhs publication no. cmhs-svp-0175). rockville, md. titler, m.g. (2002). toolkit for promoting evidence-based practice. department of nursing services and patient care, research, quality and outcomes management. university of iowa hospitals and clinics. united states department of agriculture economic research service (2009). rural broadband at a glance: 2009 edition. economic information bulletin number 47, february 2009. retrieved from http://www.ers.usda.gov/publications/eib47/eib47.pdf . http://www.ncbi.nlm.nih.gov/pubmed/12564828 http://www.ncbi.nlm.nih.gov/pubmed/18643798 http://www.ncbi.nlm.nih.gov/pubmed/17633968 http://www.ncbi.nlm.nih.gov/pubmed/19389420 http://www.ncbi.nlm.nih.gov/pubmed/16857779 http://www.ncbi.nlm.nih.gov/pubmed/16450645 online journal of rural nursing and health care, 2(1) 3 editorial administrative insights: leadership beth roder, ma, rn, editorial board member recently i invited a colleague to attend a leadership workshop with me. her first response was “i don’t lead anyone so why should i attend?” this nurse is the director of a wellness program in a local hospital, diabetic educator for the community, conducts foot clinics for the region, and oversees the fundraisers for diabetes in the community. additionally, she is responsible for various youth activities in her church. she has underestimated her leadership role which transcends any title. do we as nurses fail to realize the impact that we have as leaders in our own spheres of influence? almost daily we find ourselves being questioned about some health care issue by family, friends, and acquaintances. lay persons look to nurses for answers. we are, in their minds, leaders in a different way than we have boxed it in our minds. in an era of nursing shortage throughout the country it is our responsibility to accept that role of leader, no matter how humble. it will not only build confidence and self-esteem, but will be helpful to those who depend on us for care, compassion, and knowledge. be the leader that you are and continue to expand that leadership role. for comments or questions please contact me at b_roder10@yahoo.com. 59 select saskatchewan rural women’s perceptions of health reform: a preliminary consideration pammla petrucka, phd, rn, bscn, mn,1 donna smith, med, rn2 1 assistant professor, college of nursing, university of saskatchewan, pammla.petrucka@sasktel.net 2 associate professor, faculty of nursing, university of alberta, donna.smith@ualberta.ca keywords: reform, rural women, saskatchewan health care, health policy abstract health policy is often developed, implemented, and evaluated with minimal consideration of the impact (real or perceived) and implications for individuals, groups, and communities involved. of note, rural women’s experiences with health restructuring have been largely overlooked, ignored, or subsumed (armstrong & armstrong, 1999; bernier & dallaire, 1999; fuller, 1999; gurevich, 1999; howard & willson, 1999; rosser, 1994). the purpose of this qualitative research study was to gain insights into the perceptions of rural women on the impact of health reform in saskatchewan and manitoba. this paper considers preliminary findings of the perceptions of individual and communities of saskatchewan rural women regarding health reform/renewal policy in an effort to provide a broader perspective on the impacts and implications of that province’s health reform directions. by identifying the perceptions and opinions of rural women, this research potentially contributes to rural women’s understanding of health policy and may encourage them to become more directly engaged in future health policy making and planning. introduction health policy is often developed, implemented, and evaluated with minimal consideration of the impact (real or perceived) and implications for individuals, groups, and communities involved. in recent years, health reform or health renewal has become an increasingly debated and scrutinized health policy agenda. much of the ensuing health policy research focuses on economic, fiscal, and political motivations and consequences of this policy direction. in light of the rapid progression of health reform initiatives nationally and internationally, there is an increased need to consider the meaning and implications of such health policy decisions to various sectors of the population beyond these traditional indicators. according to torrance (1987), changes in the health system tend to mirror changes in canadian society (i.e., a shift to urban, decentralization, and individualization). baumgart and larsen (1992) added to the list of challenges to the health system with issues of emergent diseases, increasing morbidity rates, cultural diversity, and household composition (i.e., single person households, one parent families). collier (1993) stated that “rural areas and people are still subject to decisions made far away in the economic and political centres. rural people are still separated from these centres by important differences in ways of living, being, seeing, and thinking” (p. xvii). it is therefore critical to recognize this context within which rural residents interface with health reform policy. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 http://www.usask.ca/nursing/ mailto:pammla.petrucka@sasktel.net http://www.nursing.ualberta.ca/ mailto:donna.smith@ualberta.ca 60 of specific concern is the lack of a consideration of the issues and needs of rural women beyond traditional biomedical health care. in fact, women’s experiences with health restructuring have been largely overlooked, ignored, or subsumed (armstrong & armstrong, 1999; bernier & dallaire, 1999; fuller, 1999; gurevich, 1999; howard & willson, 1999; rosser, 1994). rural women constitute a unique segment of the population affected by change in health care services available in their local communities. the impact of change may be reflected in the role of substitute care provider, job loss (due to nursing jobs and health care support jobs being primarily female occupied), and increased fear for safety and health status of family and community. walters (1987) stated that “if (health) policy is to reflect women’s priorities, it is critical that women collectively assert their concerns and establish structures for their discovery and articulation” (p. 322). according to the women’s health clinic of manitoba (1998), “it is imperative for women to have a voice in the (health sector) change and any subsequent decision-making structure(s) which would evolve from the reform process” (p. 8). this paper considers preliminary findings of a research study, the purpose of which is to articulate the level and type of impact of health reform/renewal policy on select rural women in saskatchewan from their perspectives. the rationale for the specific consideration of women emanated from the potential for multiple roles and challenges experienced by rural women in the reconfiguring health care system. this paper reflects a subset of a study considering this issue and further comparisons with rural saskatchewan and manitoba women regarding health reform policy implications. saskatchewan context over the past decade, rapid and significant changes in health care delivery, technology, and public expectations have challenged canadian and provincial governments to re-construct a health care system which balances current and future political, legal, economic, and social realities. for many involved, health restructuring has remained an amorphous, resource consuming policy approach. to most canadian consumers of health service, it has meant exposure to a new order and emphasis within health care from treatment towards prevention and promotion; from universality to sustainability. for the residents of saskatchewan, health care reform/renewal has meant significant redistribution of organizational entities through regionalization/district formation, uncertainties in terms of service/facility continuance, and decentralization of power. in 1992, the government of saskatchewan introduced health reform/renewal with the abject objectives of introducing a wellness (non-treatment oriented) philosophy for health services and enhancing the individual communities’ control of health care delivery, including devolution of authority to partially elected district health boards. it created the mechanism for formation of health districts with expansive planning, capital, operational, and administrative roles and responsibilities for most aspects of health care services in the province. in addition to dissolution of more than 400 previous health care service boards, the initial phases of health reform/renewal in saskatchewan entailed closure or conversion of 52 small, primarily rural hospitals and establishment of 32 geographically defined districts. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 61 for some women of rural saskatchewan, health reform/renewal was yet another policy decision impacting on the economic, demographic, and resource sustainability of “small town” saskatchewan, the rural “family,” and the “rural” individual. consideration of the consequences for rural women of restructuring of health service delivery and redistribution of resources under the policy is critical for individuals who are already overburdened, multi-tasking, economically marginalized, and laden with socially constructed roles and responsibilities. so, how have the women in rural saskatchewan communities fared in the implementation of the health renewal/reform policy agenda? further, what does this perspective mean for future public policy changes in rural saskatchewan? design the research study employed a multiple case study approach appropriately “investigating a contemporary phenomenon within its real-life context” (yin, 1989, p. 13). by definition, the case study is an in-depth, multi-faceted investigation using several data sources (feagin, orum & sjoberg, 1996). this approach is preferable for this study, as it is a non-interventive, empathetic, and holistic consideration of a high-profile issue such as health care reform. method a community-based sample of adult women (i.e., age 18 and over) occurred in two rural field settings. women who were or had been health care providers were excluded based on the potential for a more “intimate” knowledge of the health care system. the recruitment of potential participants was undertaken by the saskatchewan women’s institutes, a rural-based group committed to the promotion of leadership and community development locally, nationally, and internationally. a total of 14 women (within the age groups of 25 to 65+) participated in 2 focus groups and 3 individuals were subsequently interviewed. the criteria for selection of the rural health districts settings, derived, in part, from the literature review, included: • community rurality, i.e., communities where focus group occurred were at least 30 minutes from a secondary or higher level of service center; and • population base, i.e., each health district did not exceed 50,000 people. before the focus group sessions, all participants were asked to read and sign a consent form. in accordance with ethics approval through the university of alberta health review ethics board, all participants were assured that their participation was voluntary and that all reporting would protect their identity. a semi-structured question guide was followed by the author. open-ended questions and prompts were utilized to elicit descriptions and derive meaning of the women’s perceptions of health reform policy in their lives, on personal, and, more broadly, community levels. the focus groups, which lasted between 1½ and 2 hours, were captured on audiotape and transcribed. participants were offered the opportunity to online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 62 contact the facilitator directly to arrange an optional subsequent individual interview. of these, three individuals self-selected and participated in a follow-up interview, which were again conducted by the primary author and utilized the same semi-structured question guide. all participants were sent copies of the focus group transcripts and, as applicable, interview transcripts for member checking purposes. data analysis data analysis for the purpose of this study included triangulation of data from multiple sources and through multiple methods. this approach potentially deepens and broadens one’s understanding of the phenomenon of interest and, according to mitchell (1986) strengthens the rigor of the study. after reviewing the transcripts, a preliminary coding framework was developed to assist with pattern/theme identification (krueger, 1998; miles & huberman, 1994). theme identification involved several steps: each transcript was reviewed line by line to elicit key words and concepts; from these initial analyses, broad patterns emerged. this phase guided the gathering of utilization data, select statistics, critical historical documents, and related information to permit triangulation in order to validate key observations. an extensive review of the primary and secondary data sources was undertaken to confirm or disconfirm derived themes and findings of the research. direct quotes and observational data from the interviews and focus groups, and all other documents were then analyzed for congruence with resulting themes and sub-themes. preliminary findings and interpretations the key issues, within the extant research and writings on health reform in saskatchewan and from the current research, that contribute to understanding the complexity of this issue fell into four major themes: 1. disconnect to connect 2. irrational to rational 3. dys-integration to reintegration 4. silence to voiced each theme is described herein and seminal findings from informants and document reviews are provided. disconnect to connect the focus of the “disconnect to connect” theme rests within the explicit objective of saskatchewan’s health reform agenda to “provide high-quality health care services to our rural residents” (government of saskatchewan, 1992). this objective was rooted in the promise of public meetings and public consultation in order to attain and gain confidence in the health renewal/reform agenda. this commitment by the government of online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 63 saskatchewan appeared in the inceptional legislative debates (government of saskatchewan, 1992) and health renewal/reform documents (saskatchewan health, 1992; 1996). from the perspective of the informants, the level of disconnect with health reform was reflected in comments such as: it’s pretty lonely out here in the country and sometimes the hospital is the only place you can go for help; people were calling (into the radio show) from all over the place and they were mad – damn mad about what was going on (regarding closures); and there was lots of confusion and rumors … caused real problems. according to briere (2003), the early days of health reform/renewal led to thousands rallying in regina and in their own communities. most communities actively lobbied saskatchewan health and local politicians by writing letters, attending rallies, and holding town meetings; many making their case by researching local needs; negotiating with local health districts; forming advisory committees; and participating on district committees (kouri, 2000). the media was replete with the concerns of rural saskatchewan-ians that “their needs were not going to be met … (and) that people would die before ambulances arrived, or on the way to the hospital” (briere, 2003, p. c3). the study participants indicated that a number of individuals/stakeholders (i.e., former hospital administrator, doctors) became involved in advocating or “being vocal” on the pending changes. information about the pending changes to their health services were gleaned from newspapers, radio, board members, women’s auxiliaries, hospital personnel, and coffee row/table top discussions. the women spoke of efforts to ensure staying involved to preserve their community’s interests in statements such as: i remember talking about how we had to fight for what we had…that everything could be lost; and we had big crowds – cause we all care about what was going to happen here …it showed that so many people out there really cared when the hall was packed. focus group participants in a health services utilization review commission (hsurc) study expressed a number of concerns about how saskatchewan health handled the cuts to acute care funding in 1993. their primary concern was that before the announcement of the cuts, people living in rural communities had not been made aware of any overall long-range plan for local health services that included alternative service arrangements for primary and emergency care (hsurc, 1999). it was noted by this study’s participants in one community that the lack of certainty and inconsistent information was problematic as “you were never sure whether you were going to be getting health care services if you need them.” comments such as “(misinformation like) all of us were going to lose our hospitals and there were only going to be 6 or 10 in all of the province” represent the pre-reform information gaps from this community’s perspective. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 64 in order to “reconnect” with the rural peoples of saskatchewan, the government invoked a community process (simard, 1997) as “saskatchewan moved to smaller districts because they did not want to lose community involvement and input because community ownership of health is so important in achieving population health. there was concern that if the districts were too large that small communities would be left out” (p. 77). further, “the district boundaries were not defined. we deliberately stayed away from defining boundaries and districts because in our experience defining boundaries caused people to focus on whether the boundaries were accurate” (simard 1997, p. 80). many participants in a saskatchewan study by kouri, dutchak, and lewis (1997) indicated that the community consultation processes did not appear to be legitimate – believing the outcomes were prearranged and the process was disrespectful to saskatchewan’s health care pioneers. these sentiments were reflected by this study’s informants in statements such as: by the time we got to the meeting, the decisions had already been made…really (we) had no say…all the decisions were made in the city and we live with it; and the city people (from the department of health) came out here that haven’t got a clue about what goes on in these small communities and they’re making decisions for us that they don’t even have any idea about what it does to us. according to hsurc (1999), most rural respondents (82%) recalled being satisfied with health services prior to the 1993 acute care funding cuts. in 1999, more than half (54%) were dissatisfied with current health services, mostly relating this dissatisfaction to reduced availability of doctors, emergency, and hospital services. only half (49%) of public respondents felt that, overall, canadians were currently receiving quality health care; down 18% from 1999 (pollara, 2000). contrary to what they anticipated (40% in 1993), 89% of respondents reported that the funding cuts had no effect on their personal health (hsurc, 1999). focus group participants in this study indicated that, in the initial phases of health reform/renewal, most of the citizens of one community were “scared for (lack of health access) for families and friends”. in the second community, the women stated that the health reform/renewal process was replete with losses for their community. for example: the district didn’t affect us that much, not as much as losing our hospital status and taking the beds away from us; our doctor left because he was overworked; we are losing our (community-raised) money … our hospital is closing, and we are losing our health care … there is nothing we can do about this; and if you lose the hospital you lose so much importance. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 65 one woman commented that “this health reform stuff is killing our small towns – maybe it’s a political move against us rurals.” kouri (2000) stated that clearly the strategists and politicians have not succeeded in obtaining enough agreement among the rural residents about their benefits of health reform/renewal. there is a significant component of the rural community that has become increasingly distrustful. rural communities continue to be discontented and community health care services capacity is uneven (kouri, 2000, p. 47). rural women, in this study, indicated that “it is hard to cope with something like this … (we were) afraid and angry…frustrated; and health is always on our minds … the (health reform/renewal process) has put an edge on health care in rural saskatchewan.” it is apparent that health reform policy has, at best, minimally achieved the desired “reconnect” from the perspective of rural women in these two communities. this insight potentially provides direction for policy makers and implementers in their strategic interactions with the community. irrational to rational the focus of the “irrational to rational” theme rests within the often cited, yet seldom acknowledged, objective of the health renewal/reform agenda to reduce costs and alter health service utilization patterns. according to kinross (1992) and kouri (2000), regardless of the form of regionalization (and vicariously the health reform policy), the primary aim is to contain or cut health costs and service utilization. funding. cost containment, and variations on this objective, have become the touchstone of virtually all health care policy decisions and dominates the health care reform agenda of all provinces. during the early days of the health reform/renewal agenda in saskatchewan, the minister of health indicated that there will “no doubt be cost efficiencies created in the system because there will be duplication removed and increased coordination of services” (government of saskatchewan, 1992). the health budget was to be ‘realigned’ “for programs like home care and community therapies…family planning and an aids (acquired immune deficiency syndrome) strategy. the opposition (i.e., saskatchewan progressive conservative party) envisioned that … this fiscally driven wellness model is designed to save money for the treasury” without consideration of the impact on the people of saskatchewan (government of saskatchewan, 1992). the governmental funding process, prior to health reform/renewal, had always required the submission of annual budgets and periodic actual and budgeted statements from all the health care facilities. however, with the inception of health reform and with the immediate interest to curb the ever-increasing health care costs, saskatchewan health shifted its attention from universal budgeting and accounting processes to “needs-based funding allocation” (saskatchewan health, 1993). in doing so, saskatchewan health ignored the importance of the overlapping economic and social relationships of historical health services, historical funding, and historical level of health care employment of the districts. under a needs-based funding allocation, a global budget was provided to district health boards by broad service areas. boards had the responsibility to allocate funds in a manner consistent with local needs, as identified in their needs assessment. saskatchewan health provided direction to boards in terms of expectations, for services to be delivered, online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 66 and guidelines around reallocations among services through the program management and expenditure plan guidelines" (saskatchewan health, 1993, p. 3). the women in one community indicated dissatisfaction with the approach, stating “(we are) sick of having to beg for a dollar to keep our (health) services.” respondents from one community referred to the entire process as “hellness and wealth reform.” according to them, health reform has come to mean “bad things for our town. it means less things for our town.” most women believed that health reform had more to do with cost-cutting than wellness and that its pace had been too fast, and many felt that the health reform agenda was all about money. the focus group participants indicated concern with the locally acquired funds, both from spending and acquisition perspectives. for example, before health reform, it was perceived that “the community generosity was great. now it's not” and that “huge sums of money have disappeared.” further, respondents referred to the loss of community autonomy in the use of health care funding dollars. participants stated that: now to spend our own money we have to fill out forms and get grants to get your own money back; now when we do give a donation to the health centre, we have to stipulate what we want to do for (our community); and (the health district) has us over a barrel because they have the money and what they decide goes. utilization. until recent years, the most common diagnosis for the problems in the canadian and other health care systems was lack of money. amid the funding turbulence of the 1990s was a growing awareness of quality problems and utilization anomalies quite unrelated to absolute levels of funding. the growing capacity to undertake health services research (including the establishment of provincial centers in british columbia, saskatchewan, manitoba, and ontario in the 1990s) began to generate findings that could not be attributed to resources alone. for example, a number of provinces documented the widespread use of hospitals for non-acute care – an expensive utilization pattern that contributes nothing to improved health (hsurc, 1994; decoster, peterson, kasian, & carriere, 1999). participants in this study stated “(we were not) sure whether we were going to be getting health services if we need them.” while 60% of people surveyed had anticipated their health would be harmed by the changes, 89% reported the funding cuts had in fact no effect on their health status. similarly, while 57% had expected the changes would limit their access to health services, 74% said their service use had stayed the same or increased (harrison, 1999). so, with the introduction of health reform policy, what significant utilizationrelated strategies were introduced in saskatchewan? new provincial acute-care bed guidelines established targets of 2.5-3.0 beds per 1,000 population (yielding a reduction of 1,200 acute-care beds between 1991 and 1995) and new long-term care bed targets of 120-140 beds per 1,000 population aged 75 years and over (health planning and policy development branch, 1995). this targeting was partially addressed by a reduction in online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 67 hospitals to 69 hospitals, from 131 in 1993 (hsurc, 2000). in the 52 communities affected by funding cuts, as of may 2003, briere (2003) reported that 49 continue to have health facilities – 36 operate as health centers and/or special care homes; 13 were replaced with another facility in the same community. in saskatchewan, hospital closures, although high profile when instituted, were limited when compared to other provinces and, for the most part, the hospitals were converted to health centres (kouri, 1999). roos (2000a, 2000b) contends that all of the headlines about hospital downsizing and bed closures exaggerate the negative effects of health care reform. focus group participants emphasized that their aging population have special needs and that they “feel strongly about our older population being able to stay here” for services. in this study, the women stated that health reform had affected their access to services in that “we have longer waiting lists; we’re driving farther, and getting less services; and the (health) system gives us less now than before.” generally, when asked the women feel that the irrational has persisted with the decisions not reflecting their personal and community needs and conditions; however, they have articulated that the health services have remained stable through the health reform process. dys-integration to reintegration the focus of the “dys-integration to reintegration” theme rests within the explicit objective of the health reform agenda to “encourage communities to come together…to co-ordinate and integrate their health care services” (government of saskatchewan, 1992). honourable louise simard, minister of health in saskatchewan, stated that reform will take place in a spirit of “... mutual aid, partnership and cooperation ... the saskatchewan way” (government of saskatchewan, 1992). according to simard (1997), “restructuring (health renewal) was only the vehicle to bring us closer to a revitalized, better co-ordinated and integrated health system” (p. 83). some have referred to this inclusive and expansive continuum of health care services as ‘upstream service’ (kouri, 2000). one participant in the current study indicated that “the nice part – the concept we liked out of the whole package (was) the wellness model … (but) nothing happened.” rather, some participants indicated that there has been “a loss of control of our health care” as a result of health reform. the canadian hospital association’s director of policy development stated that “by linking the various services … there will be a better flow of patients and clients through all types of health care services” (kinross, 1992, p. 5). a recurring message focused on getting people both inside and outside the health care system to stop thinking only about beds and hospitals and start thinking about services and resources for health. to the extent that the early focus on attention was almost by necessity on producing financial reductions, the ability to shift rather than just reduce resources was identified as key (casebeer & hannah, 1996). however, leatt and nickoloff (2001) suggested that regional health organizations may have reduced some of the problems of uncoordinated care, but it is not clear whether it has improved integration of many patient-care processes. rural women clearly perceive problems with the way the health care system is organized and managed, under the guise of integration, especially in light of the shift online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 68 from the institutions into the community and the home (fast & keating, 2000; roberts & falk, 2001). according to participants from one community, “you never know who’s in charge…no one seems to know anything (about health care services).” according to some study participants, “(reform) has made us aware of how much the need is for care here.” the shift from institutional to community and home care has created new demands on informal caregivers” (willson & howard, 2000). the implication was that by freeing up health resources from institutional care, these other health needs could be addressed. research on the impact of health reforms, and in particular the shift of health care from institutions to the community and the home, has not, for the most part, examined how lay providers (many of whom are women) are directly affected by policies such as early release from hospital and the shift toward outpatient care (fast & keating, 2000). “unpaid caregivers report feeling that the responsibilities and pressures of care frequently had been transferred to them, with little recognition of, or value for, the work they were engaged in on a daily basis” (payne, grant, & gregory, 2001, p. 4). according to lees (1997), hillman (2000), and donner, busch, and fontaine (2000), it is critical that the health care system recognize unpaid caregivers (mostly women) have multiple roles: spouses, children, careers, friends, and other relatives. with little or no guidance, teaching, or follow-up, the work these women did often exacted a high price. reduced personal physical and emotional well-being, social isolation, and financial hardships were directly attributed to their work as carers (lees 1997; payne, grant, & gregory, 2001, p. 4). according to the women and health reform working group (1997), when government health reforms emphasized “partnerships with the community, women are often the partners … expected to provide more care at home doing so without sufficient support services” (p. 8). women informants in this study indicated that the elderly and the chronically ill (i.e., dialysis clients) and their families/support network were experiencing concerns regarding frequent trips for health care services in statements such as: i know if he (the patient) was my dad, i could not take him that much (to the city). i cannot take that much time off; my mom is getting more and more frail. she is needing to get to a doctor more often and i don’t mind helping, but it takes time and we all know that the cows don’t feed themselves when we get stuck in the city. even our kids suffer, because we are away with mom; we have to drive to (larger city) to see a foot doctor … she used to come here … so 20 of us can drive (to the services) instead of one of them driving here; and sometimes the hospital will not give you drugs. we had to go to (larger community) to buy drugs and come back to get the hospital to administer them. according to lewis and fooks (2002), “the jury is still out as to whether (the reformed health environment) has achieved the goals of better integration and improved online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 69 population health” (p. 7). lewis (1997) indicated that “conceivably boards could reallocate major portions of their budgets towards determinants such as economic development, educational upgrading … (but this is) in practice entirely unrealistic given the expectation that sickness care services will be maintained and improved, and in light of the roles of others in the determinants realm” (p. 2). women in one community stated that they have “learned to move on…because in rural saskatchewan you are always unsure about things … so what else could we do?” at best, the reformed health care system in saskatchewan has allowed for more joint or intersectoral planning; it has fallen short of its ‘wellness’ potential in being able to address issues such as employment, economic policies, and many of the broad determinants of health. silence to voiced the focus of the “silence to voiced” theme rests within the explicit objective of the health reform agenda to increase citizen participation in the reconfigured health system. according to simard (government of saskatchewan, 1992), the renewed health system would emphasize the community input, community values, community involvement, and a community-driven health care system. so, the government’s charge to the communities was to ask them to “organize on a district basis, to coordinate and integrate their health services.” the saskatchewan vision for health (saskatchewan health, 1992) encapsulated the proposed changes associated with health reform/renewal in the statement that “a community-based and community directed health system is being developed to place health decisions in the hands of saskatchewan people” (p. 4). according to study participants, it was imperative in the health reform process to have “a good spokesperson…a local (person) so then everyone buys in.” also, these individuals felt that it was important that the community “speak out …and send out lots of information…because the more you challenge, the more the district and the political people back off.” clearly the current study’s participants indicated that they were not listened to during health reform introduction or implementation phases. for example: government should have listened to our ideas before acting; they would have made better decisions if they would have listened to us; we were treated like children…no choices, no options; and they (government) made you feel as if you don’t know anything any more. they make you feel as if you have no voice in anything. also, the women felt that the community had to be mobilized, inclusive, and focused “on one or two things (really needed) – not everything.” community mobilization was encompassed in comments such as: (town hall meetings) wouldn’t have happened if it weren’t for the people in the area; and online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 70 (people should) attend – nothing happens if you don’t get people out – whether you are for it or against it, go to the meetings. inclusiveness was further addressed in the comment that “we have a wide range of ages (in our community)…we all have a voice.” among the political goals of regionalization is to create greater citizen awareness of and participation in health and health care issues and decisions (lewis, 1997). the question remains whether or not health reform/renewal has led to achieving this goal in saskatchewan. “although some communities continue to struggle with changes to health care delivery, others appear to have adapted as a result of strong community leadership, the development of widely accepted alternative services, and local support and voice in creating innovative solutions” (hsurc, 1999, p. 1). study participants indicated that they lacked “power over government to change things” and often felt that what was needed was “discussion, not them (government) preaching to us.” in addition, the participants felt that they were balanced in their approach to government in statements such as “we didn’t just go there (to public meetings) to criticize but we also told them how they could make it (health care) better.” it was obvious that they felt it was imperative for members of the public to “stay informed … and don’t get hung up on the rumor mill.” the participants in one focus group felt that there were not many women on the new health board, and it was important to “get more women involved in the decisions, since we are out their caring for everyone in our community.” generally, the women indicated that they personally and communally found voice in the health reform process through a variety of informal mechanisms. clearly, they continue to perceive themselves as lacking the formal voice to affect policy direction and implementation. summary this paper considers preliminary findings on impacts and implications of health reform/renewal policy as perceived by rural women in two saskatchewan communities. in undertaking such a study, there is recognition of the unique voice and interaction of this group with health care services and providers. this study’s findings yield four dichotomous thematic couplings (i.e., “disconnect to connect”; “irrational to rational”; “dys-integration to reintegration”; “silence to voiced”), which further highlight the variability in responses to health reform by rural women in saskatchewan. this study provides insights into the need for government, health policy makers, and health providers to consider the unique roles and needs of rural women in future policy directions. it further emphasizes the need for ongoing research with rural women regarding the health care issues and challenges affecting their personal, familial, and community well-being. clearly, the need for inclusiveness of rural women in health policy formulation and evaluation was articulated in this study. finally, the need to study health reform implications for rural women in other provinces is strongly suggested given the unique manner in which each jurisdiction approaches this policy. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 71 references armstrong, p., & armstrong, h. 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(1989). case study research: design & methods. newbury park, nj: sage. online journal of rural nursing and health care, vol. 5, no. 1, spring 2005 online journal of rural nursing and health care, 1(3) 8 editorial education issues: education at a distance elvira szigeti, phd, rn, editorial board member in the past i have spoken about the shortage of both nurses and faculty for schools of nursing. in fact, federal officials as well as nursing leaders agree that an acute nursing shortage will occur in 2010 when the baby boomers begin to retire. fewer young people are taking up the profession and those in nursing are moving to other professions such as business and law. rural areas tend to have community colleges rather than universities. with a decrease in numbers of nurses and qualified faculty nationwide, rural areas are especially hard hit. the purpose of this column today is to discuss ways in which nurses can prepare for a career in nursing education for community colleges in their own area. a number of colleges and universities have tailored their nursing programs for students at a distance. for example, some upper division nursing programs for associate graduates provide general education as well as nursing courses online for students such that the students do the work at a time convenient to them—late at night, early morning, midday. more recently i have seen total graduate nursing programs provided via the web. students graduate from programs where they have never seen the campus. these programs cover all types of courses including but not limited to midwifery, care of the older adult, and care of the child. what a wonderful way for nurses in rural settings to earn bachelors and masters degrees in nursing. i was at the doctoral conference sponsored by the american association of colleges of nursing in late january 2001. faculties in colleges of nursing are aware that it is difficult for many nurses to be on a university campus to earn a doctoral degree. they are developing online journal of rural nursing and health care, 1(3) 9 doctoral programs for these potential students. depending on the type of doctoral program (and finances), nurses can choose a program where they never go to the campus—all courses are via the internet or two way video. other programs are designed for nurses to go to campus for several weeks in the summer to learn in a group format and return home for coursework the rest of the year via internet. these programs, taught at a distance, are for the part time learner and i view these programs as designed especially with the rural nurse in mind. nurses in rural settings can continue their professional nursing education in the same manner as their urban counterparts. through the use of advanced technology, they can be in classes with their urban counterparts as well as colleagues from any state. having the appropriate degree for the nursing positions is paramount and distance today should not be a factor. rural nurses have always gone the extra mile to become educated; the fact that colleges of nursing have addressed the need for access should help, especially in preparing rural nurses for faculty positions. for more information: e-mail szigetie@upstate.edu. microsoft word fahscolumn_278-1380-1-ce.docx online journal of rural nursing and health care, 13(1) 1 editorial becoming a published author in the online journal of rural nursing and health care pamela stewart fahs, rn, dsn, editor fit of material to the journal is essential and to become a published author in the online journal of rural nursing and health care (ojrnhc), a manuscript must be relevant to our readers. who are our readers? primarily those that provide health care or support the health of rural populations. there are two top reasons for an immediate “decline submission”. the first is when author guidelines are not followed such as when the electronically uploaded manuscript has identifiable author information. the more common reason for decline of submission is when the word “rural” is only found in the title or abstract and not integrated throughout the paper. the articles most likely to be accepted for publication in our journal are ones that include the importance of the work to rural health, nursing and or policy. a “fatal flaw” of a manuscript can also lead at worse to an immediate decline or at best, a “resubmit with major revisions”, which means it goes back through the review process and lengthens time to publication. in connection with research studies, inclusive of human subjects, it is imperative that the protection of these subjects be addressed. institutional review board (irb) protocol numbers or exempt status can go a long way to satisfying the reviewers on this front. a major consideration for reviewers at the ojrnhc is the inclusion of the conceptual or operational definition of “rural” in the manuscript. for data based manuscripts, how “rural” was measured or determined is important to the reader so comparisons can be made across studies. for non-data based manuscripts, a conceptual definition of “rural” will help the reader know what constitutes rural in regards to this work. online journal of rural nursing and health care, 13(1) 2 an issue that often comes up in query letters is whether the ojrnhc will accept evidenced-based papers or systematic reviews of the literature. the short answer is yes. however, i caution authors to clearly state how they define the inclusion and exclusion criteria not only for their search but also for deciding whether each article will be included or excluded from the review. seldom is a strong review of the literature limited to only four articles. graduate program faculty may have students complete a limited review on a specific number of articles as a learning experience. in commenting on those papers, faculty may encourage the author to look into publishing the results; however, that does not mean these papers are publishable as written. those who are referees for our journal volunteer their time and efforts to support science which is in part based on blind peer review. many reviewers nurture the next generation of scientist, practitioners and scholars, giving time and effort to provide in-depth comments in critique of a work even if it is not up to standards for publication in the initial submission. indeed their feedback can be crucial in honing a manuscript for publication. reviewers’ time is valuable and i often have more manuscripts than reviewers in a particular topic area. the decision to “decline submission” without review may be made if it is obvious a review of literature has not been developed in a systematic manner or if it is unclear how the author chose to review a limited number of studies. the best systematic reviews of the evidence are conducted in a way that is reproducible and thorough. another critical issue for becoming a published author in the ojrnhc is proper citation. i would agree with an editorial by gennaro (2012) that authors need to use the style manual of the journal. here at ohrnhc we use the american psychological association style and are currently using the 6 th ed. (apa, 2010). a critical component of becoming published is that citations are accurately documented in both the text and on the reference list. hours are wasted online journal of rural nursing and health care, 13(1) 3 by editorial staff and manuscripts delayed for publication when references are checked and found to be inaccurate in date, have incomplete citations, or when there are citations in text not on the reference list or the flip is true. please carefully proof the accuracy of your citations prior to submitting a manuscript. these may not be “fatal flaws” but they also do not endear you as a thorough scholar to the editorial staff or reviewers. and finally the absolute critical component in getting accepted for publication and having your publication seen as scholarly work is to avoid plagiarism. if you cannot improve upon the words of the original author you can properly quote and cite the source and page number, e.g. “tip 5: make sure all the words you use are your own.” gennaro (2012, p. 203). that said, too many quotes often indicate you do not have a good grasp on the material and will lead reviewers to recommend revisions prior to publication. learn the art of paraphrasing, quote when necessary, and cite correctly. this editorial does not touch upon all components necessary to writing a publishable paper; however, the ones mentioned above can play a critical role in whether you become a published author in the ojrnhc. so in answer to your query, yes we would be delighted to review your manuscript, provided you at a minimum follow the author guidelines posted at http://rnojournal.binghamton.edu/index.php/rno/about/submissions#authorguidelines references gennaro, s. (2012). editorial five tips on getting research published. journal of nursing scholarship, 44, 203-204. [medline] http://www.ncbi.nlm.nih.gov/pubmed/22882585 microsoft word twigg_370-2335-1-ed.docx online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 97 nurse staffing and workload drivers in small rural hospitals: an imperative for evidence diane e twigg, phd, mba, b hlth sc (nsg) hons 1 jennifer h cramer, phd, mna, dtph, rn 2 judith d pugh, phd, med, rn 3 1 dean, professor of nursing at the school of nursing and midwifery, edith cowan university ; research consultant at the centre for nursing research sir charles gairdner hospital, d.twigg@ecu.edu.au 2 senior research assistant at the centre for nursing, midwifery and health services research, school of nursing and midwifery, edith cowan university, j.cramer@ecu.edu.au 3 adjunct senior lecturer at the school of nursing and midwifery, edith cowan university and senior research fellow at the school of health professions, murdoch university, j.pugh@murdoch.edu.au abstract purpose: the aim of this study was to explore staffing issues and the workload drivers influencing nursing activities in designated small rural hospitals of western australia. a problem for small rural hospitals is an imbalance between nurse staffing resources and work activity. sample: a purposive sample of 17 nurse leaders employed at designated small rural hospitals in western australia. method: a qualitative research design was used. data were collected by focus group and semi-structured interviews and review of western australian country health service records. thematic analysis was used to interpret data. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 98 findings: a minimum nurse staffing model is in use. staff workload is generated from multiple activities involving 24-hour emergency services, inpatient care, and other duties associated with a lack of clinical and administrative services. these factors together impact on nursing staff resources and the skill mix required to ensure the safety and quality of patient care. conclusion: nurse staffing for small rural hospitals needs site-specific recording techniques for workload measurement, staff utilisation and patient outcomes. it is imperative that evidence guide nurse staffing decisions and that the workload driving nursing activity is reviewed. keywords: rural health nursing; nursing staff; skill mix; workload; workload measurement; hospitals, rural; rural health services. nurse staffing and workload drivers in small rural hospitals: an imperative for evidence small rural hospitals providing emergency and inpatient services are often situated in sparsely populated outlying regions of countries such as australia, the united states (us), and canada, and rely on registered nurses (rns) to maintain continuity of health care. the small rural hospital environment, with limited medical, clinical and administrative support services, impacts on nurse staffing and nurse workloads (baumann, hunsberger, blythe, & crea, 2006; havens, warshawsky, & vasey, 2012; hegney, 2007; sullivan, hegney, & francis, 2012; wa country health service (wachs), 2011). the nurses’ workload is influenced by hospital bed size, distance from urban centres, variability of 24-hour emergency department (ed) activity, fluctuations in patient acuity, and the staffing pool available (cramer, nienaber, helget, & agrawal, 2006; hegney, 2007; klingner, moscovice, tupper, coburn, & wakefield, 2009; mackinnon, 2012). there is, however, limited online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 99 exploration of workload drivers in small rural hospitals and the implications for nurse staffing and patient care. the term rural generally describes geographic areas outside metropolitan cities, and contributes to a lack of awareness regarding the context of small rural hospitals (montour, baumann, blythe, & hunsberger 2009; pitblado, 2005). an imprecise definition has implications for health policy, resource distribution, and research initiatives (cox, mahone, & merwin, 2008; mcgrail & humphreys, 2009; neumayer, chapman, & whiteford, 2003). in australia, canada and the us, the small rural hospital, with minimum nursing staff, constitutes the local health service (cramer et al., 2006; mackinnon, 2012; ross & bell, 2009; thornlow, 2008; wachs, 2011). appropriate allocation of resources for staffing rural hospitals is hindered by a lack of site-specific reporting systems for accurately monitoring patient activity and acuity and, therefore, nurse staffing requirements (cramer, jones, & herzog, 2011; wachs, 2011). the aim of this paper is to describe the nurse staffing issues and workload drivers that affect nursing activity at designated small rural hospitals in western australia (wa). setting a tiered ‘hub and spoke’ model delineates the role of hospitals operated by the western australian country health service (wachs). as in queensland, services in this wa network model of health service delivery with lower level capabilities are formally linked to higher level services (queensland health, 2010). wa has six regional hospitals, 15 integrated district hospitals, and 50 ‘designated small rural hospitals’ (wachs, 2007). the latter provide 24-hour health care in sparsely populated rural, regional and remote wa, an area almost one-third of the australian continent. most of these hospitals are located more than 150 km from a regional hospital and 500-1,500 km from a major metropolitan hospital. overnight capacity ranges from 5-54 beds (including residential care), with most having 10online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 100 12 beds. of these hospitals, 30 are multi-purpose services (mps) jointly funded by the federal and state governments to provide residential aged care. western australia’s coastal and inland rural populations vary in size, age distribution, social conditions, and local industry, such as agriculture, fisheries, cattle farming, and mining (wachs, 2007). population size also fluctuates between permanent and temporary residents. with tourists and mine site fly-in fly-out staff, for example, a population could swell by 1,500 5,000 residents during peak periods (australian bureau of statistics, 2012). rural population health is generally characterised by an ageing population and high rates of chronic diseases, mental health problems, drug and alcohol issues, and accidental trauma (australian institute of health and welfare, 2014). in wa, mortality rates in most age groups tend to be higher in rural populations than the state averages (wachs, 2007).the demand at small rural hospitals is influenced by the geographic isolation and the paucity of local health services. method a descriptive qualitative research design used a focus group and semi-structured interview technique to explore workload and staffing issues at designated small rural hospitals. sample the university's and health service's human research ethics committees approved the study (protocol no. 9389 and 2013:22 respectively). informed consent was obtained from participants. the purposively selected sample comprised nurse leaders from designated small rural hospitals in the great southern, wheatbelt, mid-west, and kimberley regions of wa including six directors of nursing (don), one health service manager (hsm), and 10 clinical nurse managers (cnm) (equivalent to nurse unit manager). regions were online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 101 nominated by an industry liaison, a senior wachs officer familiar with the state’s rural health services, as representing wa's diversity in terms of demographics, economy, industry, and geography. data collection and analysis data was collected from september to december 2013 through two focus groups with dons, the hsm and cnms, and 10 semi-structured interviews with cnms. the 60-90 minute focus groups were conducted in person and by videoconferencing. the 1-hour interviews with cnms were conducted by videoconferencing. all focus groups and interviews were conducted by experienced qualitative researchers, digitally-recorded, and transcribed verbatim. in terms of their nursing backgrounds, one researcher (co-author d.t.) had held metropolitan-based nursing executive positions and was familiar with the nurse staffing methodology in wa, one (co-author j.c.) had nursed in country health services throughout australia and internationally, while the third (co-author j.p.) had nursed in metropolitan acute care hospitals. the researchers engaged in regular dialogue from the outset so as to enrich the conceptual analysis and interpretation and help to reduce bias that might arise from any one perspective (barry, britten, barber, bradley, & stevenson, 1999). focus group discussions were used to elicit the main staffing issues in small rural hospitals encountered by participants, the resources and/or strategies they used to solve staffing problems, and factors impacting rn workloads. we drew on recurrent issues in the literature pertaining to the rural environment of nursing care, the scale and scope of nursing activities in isolated small rural hospitals, gaps in patient services, and workforce shortages for prompts to encourage the flow of ideas and discussions (krueger & casey, 2009). semi-structured interview questions were developed from the information gathered in the focus group discussions. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 102 qualitative data analysis involved the researchers independently coding words/phrases in the interview transcripts, crosschecking within and between coders for consistency, and grouping coded data into content categories with similar meaning (leech & onwuegbuzie, 2007). themes were formed through a process of analytic interpretation (burns & grove, 1999). as a team, the researchers compared records and differences in analysis were resolved. individual interview transcripts were made available to participants for them to check the accuracy of details. to ensure that the interpretation captured essential aspects (interpretive validity), the researchers presented a summary of the interviews and an outline of the themes at a meeting with wachs dons. the dons confirmed their agreement with the key findings. findings nurse staffing models of care together with a diversity of workload factors driving nursing activity present a major challenge for the provision of safe and quality patient care in small rural hospitals and were of fundamental concern to the nurse leaders. the main impacts on nurses and hospital services, which compromised patient care, were the availability of clinical staff resources, the multiple demands for in-patient and emergency care for unplanned presentations, alongside non-clinical activities. each 24-hour period at small rural hospitals is covered by three shifts: morning, evening, and night shift. a minimum 2/2/2 nurse shift roster operates over the 24-hour cycle. each shift is staffed by either two rns, or an rn and an enrolled nurse (en) working under the direction and supervision of the rn for delegated care. the minimum roster is constant irrespective of differences in the work activity level, such as bed usage and patient acuity; the frequency and distribution of unplanned ed patient presentations; and the small hospital's distance from a regional hospital. the clinical skills and skill-mix of available nurses is most important given their responsibilities in ed. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 103 staffing management adapts the nurse hours per patient day (nhppd) staffing method used state-wide in public hospitals, which determines ward category by distinct patient types and the complexity of nursing care required (twigg & duffield, 2009). the demands on nurse staffing resources, however, arise from workload drivers particular to small rural hospitals. the nhppd reporting, which uses patient activity as a denominator, was thought to misrepresent small hospital staffing as either significantly overor under-staffed (wachs, 2011). workload drivers workload drivers in this study are the elements of a service and its context that influence or generate nursing activity. workload drivers for nursing in a small rural hospital relate to multiple areas of activity involving direct and indirect care; access to staffing resources; and regional population and health characteristics (figure 1). multiple areas of activity • emergency department (unplanned, planned/ambulatory) • general practitioner clinic • outpatients (visiting health professionals) • inpatient (acute care, sub-acute care) • residential aged care (high care, low care, respite care) • non-clinical ‘add-on’ activities (audits, portfolios, clerical) • clinical support activities (e.g., pathology, pharmacy, radiology, ambulance) staffing resources • nursing staff (24-hour) • skill mix (clinical nurse manager, registered nurse, enrolled nurse) • general practitioner service • ancillary staff • recruitment • staff development regional characteristics population • resident population • population composition (population ageing, age groups, gender) • population distribution • population change (growth/decline; migration) • industry (mining, agriculture, tourism) • social trends: fly-in fly-out workers; transients health • mortality and morbidity • chronic disease • mental health • alcohol and other drug use • trauma figure 1. workload drivers for nursing in small rural hospitals in western australia. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 104 multiple areas of activity according to nurse managers, the range of nursing activities in a small rural hospital is all-encompassing comprising direct and indirect care within multiple areas of activity. in ed and inpatient wards, rns routinely work across areas of the service when providing nursing care: “sometimes it is one rn triaging and treating all the people in ed, managing sick inpatients and doing the medications on the ward as well” (cnm 10). an important component of the nurses’ workload, and integral to patient care, is their collaboration with medical practitioners, particularly the royal flying doctor service (rfds) based at regional centres, and/or a local general practitioner (gp). emergency department. the 24-hour ed service, attended as needed by an rn, has a major impact on nurses’ workload and on staffing resources. the ed accommodates all unplanned patient presentations and, during weekday mornings, a medical clinic and an outpatient service. ed attendance is exacerbated by the lack of alternative local health services, particularly for mental health, alcohol and other drug use, dentistry and after hours’ medical problems. the unpredictable surges and diversity of emergency presentations at small rural hospitals produce large variations in nurses’ routine workloads. australian triage scale (ats) category 4 patients (less-urgent) and category 5 patients (non-urgent) are assessed and routinely treated by nurses and usually depart ed without medical review. aside from the medical assessment, whether patients presenting to ed are admitted or transferred to another health service largely depends upon the rns clinical skills and support resources. ambulance services. high acuity patients are rarely admitted to wa small rural hospitals. instead, these patients are transferred by the rfds either to a regional or major metropolitan hospital by volunteer ambulance officers of the st john ambulance wa service with an rn escort if online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 105 needed. a road ambulance patient transfer could take 3-8 hours, depending on the distance, weather and road conditions. if accompanied by an rn, road ambulance transfers stress nursing resources further. a shortage of volunteer ambulance officers may delay patient transfers and require continued rn presence in ed thereby reducing the rn’s availability to provide inpatient care and residential aged care. medical practitioner services. general practitioners employed by wachs usually provide a 24-hour medical contact for the hospital nursing staff, either on-site or on-call, during week days only. at the gp week-day morning clinic in ed, rns triage patients prior to a medical consultation, and collect specimens for pathology or perform x-rays if requested. with tacit approval from wachs, an rn in ed supports the gp practice: the gps [conducting a clinic in the hospital] see the service as an extension of their practice, and that generates work – work that shouldn’t be necessarily ours . . . so it’s not uncommon for a nurse to see mostly outpatients with some ed intermingled [who are] there to see the doctor. (don 4) the absence of a town gp, limited operating hours of a medical clinic or a gp’s limited availability may increase hospital attendance. when patients are unable to attend ed during scheduled medical clinic times, they often present to ed after-hours. sometimes, however, patients simply choose to “wait until the doctor is out of town and come up to the hospital because then that is more convenient [for them]” (cnm 6). outpatient services. in addition to supporting the gp services, rns may assist visiting medical specialists during their consultations. a daily outpatient clinic within ed, distinct from the medical clinic, generates additional nursing activity that is difficult to resource: “outpatients is not necessarily an emergency department activity or an extension of a gp clinic. it is about the online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 106 outpatient activity in ed being unplanned and not being able to get planning in place, and get planning in place for the community” (don 4). to reduce congestion in ed, managers may reschedule outpatient clinic opening times to coincide with the overlap period between morning and afternoon shifts. although reducing nursing handover time, this arrangement enables the manager to staff the outpatient clinic with an additional nurse. ward inpatients. active inpatient bed numbers ranged between three and 12. if a gp is unavailable, patients requiring more than 48 hours’ care are usually transferred to another health service such as a regional hospital. a variety of inpatients occupy beds in the one ward, for example: “the maximum beds we have are five. there could be anyone in those five beds. now we have three palliative care patients, and a couple of acute patients” (don 1). ward inpatients might include admissions for longer-term non-residential aged care or respite care, such as a patient with a non-acute mental illness. palliative inpatient stays can vary between a few days and several weeks: “we do have palliative care. the patient will choose to come to hospital rather than be at home. they tend to stay at home for as long as the family can cope, then for the last few days or few weeks they might come to us” (cnm 8). an inpatient’s length of stay could be extended by delays in discharge planning, such as waiting on gp services. other inpatients include those who, previously transferred out, return and are admitted for ongoing care. such decisions depend on the rns’ capabilities and resources: “sometimes patients are transferred out in an emergency and then come back for rehab (sic) or further management. if their acuity is high we can’t accept them, say a stroke patient who lives here. we don’t have the capacity to provide appropriate care” (cnm 8). online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 107 residential aged care. small rural hospital services could include the oversight of aged and community-based care, which has implications for nursing workload and for staff management. at several small rural hospitals and mps sites, inpatient beds are utilised for respite care lodging and for residential aged care, comprising both high and low care and dementia care services. the demand for residential aged care has increased and, at several sites, represents “a high proportion of nurses’ workload” (cnm 8). mps sites in wa provide 3 54 beds for aged care residents. while the basic staff level at these sites remains at a 2/2/2 roster, staffing for residential aged care is occasionally supplemented by the employment of unregulated care assistants. additionally, small rural hospitals may provide community-based services: “the cnm, don or hsm will not just oversee the hospital [but] other sectors as well and how they actually staff this and the workload are important issues” (don 3). associated clinical support activities. nurses routinely undertake clinical support activities associated with general stock supplies, pharmacy, pathology, and x-ray services, in addition to their patient care workload. nurses may, for example, liaise with a pharmacist and access pharmacy services from another hospital that functions as a health hub. often of a night shift, nurses perform the inventory management, including ordering, storage and auditing for pharmacy and other clinical supplies: “it’s the same with stores, and that sort of stuff. nurses have to order the equipment, they have to do all the re-stocking and basically make sure we have got enough resources to keep running” (cnm 9). in several hospitals a state pathology service phlebotomist attends for limited weekday morning hours. outside of these hours or apart from these sites, all specimens are collected and packed by nurses for courier transport to pathology bases in regional centres or metropolitan perth. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 108 rns trained as x-ray operators perform limb and chest imaging as requested by medical personnel. in any one hospital, few rns are qualified as x-ray operators due to training costs. rn substitution for clinical support services is time-consuming and detracts from nursing care: “the nursing time you are using in pharmacy, and the time that is used in radiology, adds up. and that is a half an hour for an x-ray, for example, and with the volume that is quite a lot of nursing time that nurses in other hospitals don’t do” (cnm 2). non-clinical ‘add-ons’. other determinants of nurses’ workloads in small rural hospitals, and peculiar to this context, are non-clinical activities termed ‘add-ons’. these are necessary additional activities performed daily by nurses at small rural hospitals “that you could argue a lot of which is not necessarily nursing work. it is that there is nobody else to do it” (don 3). the major add-ons are regular audits, staff portfolios, and other administrative work. in effect, these activities enlarge nurses’ workloads, and absorb nursing time that could otherwise be used for direct patient care. wachs policies for hospital performance and clinical governance require nurses to submit a range of monthly audit reports: “we audit almost everything. it is a huge amount of work. the mr1s [forms for documenting patient care] in ed are done monthly. we are currently in accreditation for aged care so it is all aged care documentation. it is falls, hygiene, and injuries. it is everything. everything is audited these days” (cnm 6). each nurse, other than agency or casual staff, is assigned a portfolio or ‘extra job’ such as staff development, pharmacy stores, or infection control. a ward clerk is usually employed during weekday office hours. after hours, however, there is no clerical support and nurses perform all administrative tasks including reception and retrieval of medical records. attending to telephone calls and the hospital reception after hours is a major source of frustration for the rn who, at the same time, covers both inpatient and ed areas: “a huge issue that is very time-consuming and falls on the emergency online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 109 department nurse is answering the telephone. you are trying to manage a busy ed and answer the telephone. . . . the nurses complain bitterly about the amount of time, and you just have to keep stopping care to answer the telephone”. (cnm 8) such undocumented nursing time and activities make it difficult for nurse leaders to validate what nurses in small rural hospitals do and their impact on patient safety and quality of care. staffing resources for small rural hospitals nurse leaders in small rural hospitals attempt to balance the diverse workload that generates nurses’ activities with limited nursing staff resources. nurse managers regarded performance-based management as an important mechanism for exposing the shortcomings of service and potential risks to patient safety and quality of care. they reflected, however, that service delivery and patient care was potentially compromised by the lack of human resources, specifically adequately skilled nurses or an appropriate skill mix and a practice of ‘making do’ when resources were depleted. a skeleton staff. participants described staffing in terms of a skeleton structure, “running at a bare minimum” (cnm 4) and “nursing services on the bone; barely functional” (cnm 6). across all small rural hospital sites a minimum 2/2/2 shift roster of nurses over a 24-hour cycle remains the norm. the nhppd staffing method lacks the flexibility to reflect staff movements and the nursing hours worked between areas of care, and various patient types within one ward. capturing ed data within the nhppd system presents another problem: “with our nursing hours per patient day we have two categories, two areas, we enter in for the ward and we enter data for ed as well. so there are two reporting mechanisms within the current system. how we calculate the hours is a bone of contention, and if the data is accurate” (don 1). online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 110 another major issue is rn clinical skills and the skill mix needed for practice in a small rural hospital setting. nurse leaders found it difficult to staff each shift over a 24-hour period, seven days a week with appropriately skilled nurses: “the skill mix is difficult because we need nurses with ed experience . . . you have got one nurse in one area and one in another, and it is difficult to have junior staff who are not ed savvy and, with a small roster, can’t go on night duty” (don 2). a minimum staffing model with few clinically skilled rn reserves left nurses leaders few options. they reported ‘juggling the roster’ or performing a ‘juggling act’ in order to maintain staffing at their hospitals. they used staff on-call and overtime, made adjustments to full time equivalents (fte), and relied on part-time and casual relief staff. on-call and overtime. provision of an rn on-call roster and use of overtime was needed to cover for clinically-skilled staff shortages, and remain ready for unpredictable emergency presentations. an on-call rn might provide back-up assistance in ed or elsewhere in the hospital if urgently needed. at times, the extent of over-time worked was considered onerous and posed additional staffing problems for nurse managers: “nurses are under pressure week in and week out with overtime and overall we are getting busier. the rn staff we have are picking up extra shifts, more than i would really like. and i haven’t got a workable tool that allows for those spikes in workload. there is no capacity for staffing when we spike and i can’t predict that” (cnm 8). managers could modify the roster to manage rn overtime and to maintain staffing levels. backfilling, when a nurse filled in for another nurse, required re-arranging shift times to enable a nurse to have reasonable stand-down time without on-call. this, in turn, imposed on other staff, including nurse managers, to cover a roster: “either you get the nurse that’s worked a morning shift to do some overtime and stay on until the rn can come in. or, online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 111 sometimes a don will pick up a shift. sometimes you will call in someone who is on days off” (don 4). full time equivalent (fte) adjustments. the fte allocation for small rural hospitals hampered nurse managers trying to ensure rn cover for each shift over the 24-hour, seven day week cycle. there is a lack of quantitative data capturing the range of nursing activities in these hospitals that would permit accurate fte estimates. fte cutbacks within wachs added to the difficulty nurse managers experienced when managing a minimum staff roster: “they’ve just cut me down again to 4.1 fte and my concern is that it is going to become unsafe. i still have to accommodate a 2/2/2 roster” (cnm 4). one approach to manage the allotted ftes was to roster nurses part-time instead: “sometimes i’m a bit reluctant to put too many full-time staff because if you put them on say at 0.8 or 0.9, they have got capacity to pick up an extra shift” (cnm 9). despite the roster adjustments, the overtime worked by an rn could amount to an additional fte at small rural hospitals with a high demand for emergency care and ambulance services: “i look at the record of ambulance call-outs and sometimes it would equate to a fte, sometimes a full-time fte for a month, sometimes a bit more than that. and if you add up all the times nurses are getting overtime on night duty, not having meal breaks, it could probably get 1.4 of an fte” (don 5). part-time and relief staff. apart from permanent full-time nursing staff, small rural hospitals often employ nurses from the local community on a part-time, casual, or contract basis. relief rns employed on short-term fixed contracts are sourced from the state government’s relief nursing staff service, a private nurse recruitment agency, or other employment services. before employing an agency rn for short-falls in the roster, however, nurse managers might work additional online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 112 shifts themselves: “rn-wise i could probably cope depending on how many management days i’m rostered. but if i’m already doing five or six clinical shifts a fortnight then it is really hard. i need to get an agency nurse for anything more than four shifts” (cnm 3). casual contract nurses usually specify their availability. in some situations, casual nurses are semi-permanently rostered while permanent part-time staff work extra hours. a high proportion of staff are on casual contracts and refuse to sign permanent contracts. “we have nurses on a casual contract and working full-time hours, or permanent hours. come harvesting or school holidays, or whatever, they walk. so we have a high proportion of agency, or an increase in permanent part-time staff always picking up hours, or we have fulltime staff doing over-time. (don 3). repeatedly using part-time and casual staff and relying on full-time permanent rns for over-time work, however, has implications for the quality of care in small rural hospitals: other significant issues impacting on staffing are rn recruitment, staff development, and career opportunities. nurse recruitment and training rn recruitment at small rural hospitals is a constant challenge. although a large number of applicants apply for advertised rn positions, few have the ed clinical experience needed. the nurse manager on-site is responsible for the time-consuming process of reviewing and short-listing as many as 60-70 applicants, many of whom do not fit recruitment criteria. the appointment of applicants from overseas requires a minimum three-month process for obtaining employer sponsorship, immigration approval for a temporary work (skilled) visa, and nursing registration. according to nurse leaders, employing overseas nurses on these visas represents an important adjunct for staffing small rural hospitals but is not a sustainable solution. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 113 whether rns are appointed from within australia or overseas, if they cannot work independently, nurse leaders found that they require prolonged preparation on-site to acquire the requisite clinical skills for nursing in a small rural hospital. a new recruit, therefore, represents considerable investment in terms of resources and time: “for the first six months, new nurses do take a lot of resources. it has great ramifications for our roster because i don’t put them on without another rn for a considerable time until i think they are safe” (cnm 7). while online learning at induction and refresher training is mandatory for wachs nurses, updating clinical skills for, and practice experience in, nursing high acuity patients is not feasible by e-learning. moreover, few ed presentations provide opportunities to “see high acuity managed patients to maintain nurses’ skills and competencies to ensure best practice” (cnm 10). however, budget constraints for time, travel and accommodation, which are considerable given wa’s size and diverse geography, present a barrier to off-site clinical education. study leave is further curtailed by the lack of replacement nurses to backfill for the regular nurses. nurse leaders reported that limited opportunities for clinical skills development and career advancement influence the retention of rn staff. moreover, the predominant hiring of rns at the lowest level of the wa career structure, and in nonpromotional positions, failed to attract suitable nurses. limitations this research focused on nurse staffing and workload drivers and was limited to the perspective of nurse leaders employed in designated small rural hospitals in wa. the findings are, therefore, primarily based on the interview data with the selected participants. the study, however, resonates with previous published reports on nurse staffing in small rural hospitals. nursing and health care providers at small rural hospitals throughout australia and overseas would be able to evaluate the relevance of the study for their circumstances. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 114 discussion the study findings are consistent with local and international research on small rural hospitals that describe features of minimum staffing, and the workload that generates multiple activities by nurses for direct and indirect patient care within a context of scarce resources, and distance from urban hospital services (baker & dawson, 2013; cramer et al., 2011; ross et al., 2009; thornlow, 2008; wachs, 2011). objective evidence is lacking, however, to verify claims of deficiencies in nursing resources for workload demand. the inadequacies of data present a barrier to constructive improvements for nurse staffing and workload management in small rural hospitals. a common problem for nurse managers in such hospitals is the lack of site-specific quantitative data, or even appropriate techniques to measure workload and nurse staffing (jiang, stocks, & wong, 2006; montour et al., 2009; sullivan et al., 2012). the ed is the main source of workload variability for nurses in small rural hospitals. this is compounded as the ed in these hospitals is not a dedicated unit with assigned staffing and resources as is defined by the australasian college for emergency medicine (2012). baker (2009) and baker and dawson (2013) describe small rural emergency facilities as a distinct type with shared features of an ed but different in that the service is not medically staffed and is attended as needed by an rn rostered to a general ward. in this context, and as revealed in this study, it is usual for patients triaged 4 (less-urgent) or 5 (non-urgent) by a nurse, to be treated and discharged without medical review (baker et al., 2013; chen & tescher, 2010). despite the demand for emergency care at wa small rural hospitals and the additional nursing workload activities associated with the provision of ambulance services, inadequate reporting of ed activities is likely to underestimate the workload of nurses in these hospitals. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 115 staffing frameworks that use annual aggregates of hospital unit activity for nurse staffing calculations, such as the nhppd, are clearly inadequate for this context. the averages do not reflect the wide variability of nursing input (wachs, 2011). moreover, it is difficult to derive meaning from averages with few beds in use and where a ward is occupied by patients of no particular diagnostic group, hence not captured within specific ward categories and criteria (australian industrial relations commission, 2002). in a small rural hospital where, in one shift, nurses work across separate areas of care, as well as undertake clinical support functions and administrative duties, nursing hours may be under-reported and thus obscure the extent of direct and indirect care activities performed by nurses. in a major us study, cramer et al. (2011, p. 341) reported similarly that nurses’ workloads and nurse staffing in small rural hospitals are under-reported and hence under-estimated, because they do not consider the full range of rn activities that benefit the patient. the extraordinary and under-resourced practice environment, unpredictable patient care needs, and discontinuous access to on-site medical practitioners necessitates an appropriate staffing skill mix and flexibility of rn staffing (nsw rural critical care committee, 2004). the limited clinical back-up support at small rural hospitals for managing high acuity patient care at small rural hospitals also requires consideration. that rural nurses ‘get by’ and ‘make do’ with the skills they possess to provide a service perpetuates the mismatch between staff resources and workload variations, while associated patient care outcomes remain unmeasured. the multi-faceted issues of nurse staffing costs, workload measurement, practice environment and patient care are a prominent subject for research in large hospital settings with designated units of service (gerdtz & nelson, 2007; mcgillis hall et al., 2006; spetz, harless, herrera, & mark, 2013). nonetheless, valid tools from which reliable nurse staffing decisions are made in any hospital context remain elusive (ferguson-pare & bandurchin, online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 116 2010). according to mcgillis-hall et al. (2006), nurse staffing and workload variability particular to small rural hospitals, and as is reported in this study, warrant further scrutiny in order to inform an effective staffing system and workload management. conclusion the work environment, resources available, and patient acuity influence the nature of nursing activities and nurse staffing needs in wa designated small rural hospitals. inattention to the well-known difficulties for nurse staffing and resource inadequacies in these hospitals compromises the service and the capacity for providing safe patient care. this study elucidates the need for on-site evaluation of current workforce utilisation and workload issues for nursing in small rural hospitals of wa and other countries with similar entities. sitespecific data recording techniques for workload measurement, nurses’ activities, patient acuity, and outcomes of care are particularly required. the imperative is to acquire high-level evidence from small rural hospitals to guide nurse-staffing decisions and to safeguard patient care. funding agencies this project received funding of aud$71,813 from the nursing and midwifery office, department of health, western australia. references australasian college for emergency medicine. 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(2009). a review of workload measures: a context for a new staffing methodology in western australia. international journal of nursing studies, 46(1), 132-140. http://dx.doi.org/10.1016/j.ijnurstu.2008.08.005 wa country health service. (2007). foundations for country health services: the wa country health service strategic plan 2007-2010. east perth, wa: department of online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.370 121 health. retrieved from http://www.wacountry.health.wa.gov.au/ fileadmin/sections/publications/publications_by_topic_type/corporate_documents/fin al_web_version_foundations_may_2007.pdf wa country health service. (2011). nursing hours per patient day small hospitals review. east perth, wa: wa country health service microsoft word oosterbroek_430-2584-3-ed.docx online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 23 rural nursing preceptorship: an integrative review tracy a oosterbroek 1 olive yonge, rn, phd, rpsych 2 florence myrick, phd mscn bn rn 3 1 nursing instructor, university of lethbridge & doctoral student, university of alberta, tracy.oosterbroek@uleth.ca 2 professor, vargo teaching chair, faculty of nursing, university of alberta, oyonge@ualberta.ca 3 professor emerita, university of alberta, amyrick@ualberta.ca abstract introduction: canadians living in rural and remote areas experience lower health outcomes and life expectancy than their urban counterparts. registered nurses employed in rural and remote areas are often the sole health care provider and are crucial to the delivery of high quality health care. adequate preparation of future nurses who will work in rural and remote communities is thus essential to ensure access to safe, competent nursing care. nursing preceptorship is the vehicle through which nursing students become immersed in a particular setting over an extended period of time. the purpose of this literature review is to determine the state of knowledge regarding rural nursing preceptorship. methods: an integrative review of the literature was conducted using the spider tool for analysis of qualitative evidence. from a limited pool of relevant articles, over 40 were retrieved published between 2004 and 2015. of these, 19 articles met the inclusion criteria and were online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 24 included in the review and analysis. each article was evaluated for adherence to the criteria of ethics and rigor using the research appraisal checklist (rac) tool of appraisal. results: of the 19 articles reviewed, various definitions of rural practice were provided. standard definitions of rurality and rural practice is currently lacking. four main themes emerged from the review of the literature around the nature of the rural experience interprofessional collaboration, recruitment and retention of nurses to rural communities and student performance evaluation and feedback. conclusions: preparation of future nurses who are competent and confident to practice in rural settings is crucial. support and preparation required by faculty advisors and preceptors to ensure successful preceptorship experiences is not clearly understood. recruitment and retention strategies aimed at the shortage of the nursing workforce in rural settings should highlight the unique nature of rural practice. future research should focus on the challenges experienced by nursing students that may prevent them from seeking employment in rural communities. keywords: rural nursing, preceptorship, rural preceptorship, rurality rural nursing preceptorship: an integrative review the health care needs of rural individuals is an international challenge. in canada, a country that is largely rural, adequate health care is viewed as a health priority and a right for all residents (kulig, kilpatrick, moffitt, & zimmer, 2015; kulig & williams, 2012). approximately 30% of the total canadian population resides in rural communities where significant barriers to health care access are being reported and registered nurses are often the only primary health care providers (health canada, n.d.; kulig, et al., 2015; kulig & williams, 2012; macleod, browne, & leipert, 1998; tambly, 2011; white, 2013). the socioeconomic status of rural residents is online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 25 reportedly lower than in urban communities across canada (canadian institute for health information [cihi], 2002; jackman, myrick & yonge, 2010; sorenson & depeuter, 2002). furthermore, rural canadians are reportedly the least healthy of the canadian population, as measured by shorter life expectancy and higher rates of chronic disease, mental health conditions, smoking, and substance abuse (cihi, 2002, 2006; kulig, et al., 2015; kulig & williams, 2012; cihi, 2006; grol, wensing, eccles, & davis, 2013). kulig et al., (2015) lament a shortage of nurses in rural and remote areas and posit that this occurrence is compounded by the lack of educational preparation of nursing students for rural practice. as few as eight percent of nursing students are exposed to rural practice in undergraduate programs (edwards, smith, courtney, finlayson, & chapman 2004). failure to adequately prepare nurses for the complexity of the rural environment has resulted in poor job satisfaction and poor staff retention (sedgwick & yonge, 2008). high levels of staff attrition can be detrimental to the health of rural citizens and more likely to occur when nursing, and other health professionals lack investment in the overall health of the community. hence, educational preparation of nurses for rural nursing practice is urgently required (jackman, myrick, & yonge, 2010). rural-based nursing research is increasing but significant gaps continue to persist (greiner, glick kulbok, mckim-mitchell, 2008). laurent (2002), for example, identifies that recruitment and retention of health care providers to rural communities has focused largely on physicians. he found rural health professionals work longer hours with fewer resources which, in turn, has a negative impact on work-life balance and employment retention, concluding that educational online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 26 preparation of health professionals who are equipped for the specificity of rural settings is insufficient. preparation of nursing students for the rapidly changing health care environment, coupled with the ever increasing complexity of knowledge is an ongoing challenge for nursing educators (yonge, myrick, & ferguson, (2011b). the health care needs of individuals and families who reside in rural settings require care from health professionals who are responsive to their unique needs. geographical distance from primary health care centers and limited resources influence both community needs and the ability of health care service providers to address local health care priorities. preparation of health care professionals for rural practice is thus essential in identifying and effectively addressing the needs of residents and the promotion of the overall health of the community. researchers have found that nursing curricula lack integration of contextual values and beliefs specific to rural communities (dowdle-simmons, 2013). other researchers agree that a sustainable rural nursing workforce is dependent upon the educational preparation of nurses specific to the rural environment (hunsberger, baumann, blythe, & crea, 2009). not only is the preparation of rural nurses challenging, but the shortage of nursing and other health team members is critical to effectively meet the complexity of rural health care needs (forbes & edge (2009). these findings are noteworthy inasmuch as a national nursing shortage looms and strategies for recruitment and retention are urgently required for all settings (health canada, n.d.; cihi, 2002, 2015, 2016; canadian nurses association [cna], n.d.). preceptorship provides the vehicle through which students become immersed in a particular setting over an extended period of time (jackman, myrick & yonge, 2012). the preceptorship online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 27 typically occurs in the last year of baccalaureate nursing programs and affords students the opportunity to consolidate their learning. the preceptorship is completed prior to the student’s entry into professional practice and provides full-time immersion in a specific area of practice while being supervised by an experienced registered nurse who is available to them on a one-toone basis. preceptorship offers a contextually specific nursing practice experience that is uniquely relevant to the particular setting or nursing practice area. definitions of terms to guide the search, the definitions of nursing preceptorship, rural, rurality preceptor and faculty advisor have been provided to clarify the context of the terms. nursing preceptorship is typically a consolidated nursing practicum that occurs at the conclusion of the undergraduate nursing program. students are assigned one-to-one with a registered nurse (rn) and a faculty advisor from the educational institution. nursing students are often permitted to self-select the placement settings in which they would like to complete the preceptorship based upon availability of the requested placement. there is an absence of a universally accepted definition of what constitutes rural (pitblado, 2005; pitblado, koren, macleod, place, kulig, & stewart, 2013). for the purpose of this review, rural was defined as a community with a population of less than 50,000 residents at least 20 km distant from the nearest urban community (kulig, et al., 2015). rurality is viewed as a sense of place and way of life associated with living in a rural community (balfour, mitchell, & molestane, 2008). the preceptors are registered nurses (rn), who are employed in acute in-patient or community-nursing role in a rural community. preceptors are assigned one-to-one with undergraduate nursing students and provide supervision and evaluation of the student’s performance throughout the preceptorship placement. the faculty online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 28 advisors role is to liaise between the nursing students and preceptors. typically, the faculty advisors orient and provide support to preceptors and students during the practicum and meet with the students and preceptors for evaluations, either face-to-face or remotely via skype or other mobile technology. methods the purpose of this literature review was to ascertain the state of knowledge regarding rural nursing preceptorship. the spider (sample, phenomenon of interest, design, evaluation, research type) tool (table 1) for qualitative evidence synthesis was utilized for the purpose of this literature review. table 1 spider tool s (sample) nursing students in the final practicum (preceptorship) course of a four-year baccalaureate program pi (phenomenon of interest) rural undergraduate nursing preceptorship d (design) interview, focus group, ethnography, phenomenology, thematic analysis, grounded theory e (evaluation) student, preceptor and faculty advisor experiences related to the challenges or opportunities experienced during the course of rural preceptorship placements r (research type) qualitative, quantitative and mixed methods studies search strategy the review was integrative in nature and consisted primarily of automated searches of electronic databases including academic search premier (1995-2015), cinahl (1995-2015), eric (1995-2015), cochrane database (2005-2015) and ovid medline in-process and other online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 29 (1995-present), journals@ovid full text (july, 2015), your journals@ovid, health and psychosocial instruments (1985-2015), ovid healthstar (1999-2015). following electronic searching, manual reference checking of selected articles as well as citation searching was conducted. in an attempt to capture seminal publications, current literature and research published in the past ten years was acquired with the search extended beyond this date to 1995. search terms applied included nursing education, preceptorship, nursing preceptorship, rural preceptorship, preceptorship challenges, preceptorship opportunities, rural and rurality. truncation and search syntax were applied as per the applicable database to accommodate variations in spelling and word usage. all references were imported and stored using endnote reference manager. data evaluation and analysis limited scholarly activity in the area of rural preceptorship was discovered during the search process. initially, 41 references related to rural preceptorship were retrieved. the studies were reviewed by reading the abstract and scanning the article for inclusion using pen and paper evaluation with the reporting assessment checklist (carroll, booth & lloyd-jones, 2014). of these, 19 original research articles were selected for applicability and review. evaluation of the selected articles was completed to promote clarity, consistency and accuracy of the data extraction process and included the selected references (table 2). thematic analysis was conducted by the authors to synthesize extracted data (walker, rossi, anastasi, gray-ganter, & tennent, 2016) from which the main themes and subthemes emerged from the individual articles and across articles. online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 30 results a slowly growing number of articles have been published on rural preceptorship. the majority of authors focused on operationalization of rural preceptorship. evaluative research studies remain limited. student, faculty advisor and nurse preceptor perspectives of rural preceptorship, its benefits to interprofessional collaboration and recruitment and retention, and the issues related to students’ evaluations were commonly found in the existing research. table 2 rural nursing preceptorship research articles # author/date sample design ethics/rigor outcomes 1 charleston & goodwin, 2004 n=167 quant survey na/na rural preceptorship (rp) workshop imp/evaluation 2 jackman 2011 n= qual gtb √/√ relational process r/t rp 3 macdowell, glasser, weidenbacherhoper, & peters, 2015 n=52 quant ppc √/na interprofessional rp 4 meyer bratt, baernholdt, & pruszynski, 2014 n=468 quant lca na/na rural/urban preceptorship outcomes 5 pront, kelton, munt, & hutton, 2013 n=7 qual csd √/na rp and student learning 6 schoo, mcnamara, & stagnitti, 2008 n=110 qual pp √/√ recruitment/retention r/t rp 7 sedgwick 2011 n=8 qual ede √/√ rural interdisciplinary preceptorship 8 sedgwick & rougeau 2010 n=32 qual citf √/√ belonging r/t rural preceptorship 9 sedgwick & yonge, 2008 n=12 qual feg √/√ meaning of socialization r/t rural preceptorship 10 sedgwick & yonge, 2009 n=12 qual fe √/√ student perception of faculty involvement in r/p 11 sedgwick, yonge, & myrick, 2009 n=12 qual fe √/√ multidisciplinary approach 12 yonge 2009 n=11 qual gt √/√ boundaries r/t rural preceptorship online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 31 13 yonge, ferguson, myrick, 2006 n=49 qual gt √/√ preceptor/student rp experiences 14 yonge, hagler, cox, & drefs, 2008 n=12 qual srh √/√ limited evidence r/t preceptor development 15 yonge, myrick, & ferguson, 2011(a) n=23 qual gt √/√ evaluation framework for rural preceptorship 16 yonge et al., 2011(b) n=23 qual gt √/√ student perspectives of feedback during rp 17 yonge et al., 2011(c) n=26 qual gt √/√ evaluation processes r/t rp 18 yonge, myrick, ferguson, & grundy, 2013(a) n=8 qual pari pv √/√ rural context r/t team preceptorship 19 yonge et al., 2013(b) n=8 qual par pv √/√ rural landscape perspectives r/t rp note: a longitudinal cohort design; b grounded theory; c pre-posttest; d case study; e exploratory descriptive; f clinical incident technique; g focused ethnography; h systematic review; i participatory action research examination of the challenges experienced by the members of the preceptorship triad engaged in rural preceptorships were not evident in the existing literature. the four main themes which emerged from the analysis of the current literature entailed the nature of the rural experience, the importance of interprofessional collaboration, issues related to recruitment and retention of nurses to rural communities, and factors associated with student performance evaluation and feedback. within each of the main themes, patterns of subthemes were identified and found across articles (see table 3 – themes and subthemes). the rural experience in a study by yonge et al. (2013a) the rural experience was captured vividly through the use of photographs. these researchers supported previous findings regarding the urgent need for increasing opportunities for nursing students in rural practice settings, more curricular emphasis on rural health, and context specific preparation related to content and skills. online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 32 table 3 themes and subthemes rural experience interprofessional collaboration (ipc) recruitment and retention evaluation and feedback coping with challenges belonging to community nature of teaching and learning benefits of ipc belonging to the team understanding of roles relational process and authentic rural experience inconclusive trends data related to undergraduate placements and employment statistics preceptor preparation and support relationship between student-preceptorfaculty advisor challenges they found the rural landscape as being representative of the physical environment of the rural community signifying the essence of the rural identity that served to inform student and preceptor’s perceptions of the rural community (yonge et al., 2013b). space and distance were key findings illustrating the time required for rural residents and health care providers to travel to access local services such as schools, and health services. belonging was found to be a defining factor of rural preceptorship in three of the articles reviewed. students must find their way into the close-knit culture of the community that exists in the rural settings (sedgwick & rougeau, 2010). these researchers found that the spirit of community was a central tenet of rural life and concluded that successful teamwork was the key to successful rural preceptorship. meyer bratt et al., (2014) affirmed the importance of a sense of belonging as being influential to one’s intention to seek employment upon completion of the nursing placement. sedgewick and yonge (2008a) concluded that experiences of belonging significantly impact the preceptorship experience for both students and preceptors alike. hence, students who are supported in learning, feel safe to ask questions and learn from errors. in 2011, online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 33 jackman explored the relational process of teaching and learning during rural preceptorships from the perspective of the students, preceptors and faculty advisors. she found students whose rural preceptorships exemplified an authentic rural experience were more likely to remain and practice in the rural setting following completion of the preceptorship. challenges of living and working (learning) in a rural community was a finding in three of the articles reviewed. yonge et al., (2006) found that most, but not all of the students involved in their study, requested a rural placement for the preceptorship, motivated by their desire to live and work there after graduation. however, even those who did not request rural placements reported the experience as one that was positive, thus rejecting their preconceived ideas about rural nursing. while the purpose of this research study focused on the teaching and learning process, some of the students reported challenges they experienced during rural preceptorship, for example, limited technology, a sense of isolation and unpredictability of patient census. the level of complexity of patient care pleasantly surprised the students and was viewed as a benefit of rural preceptorship by their preceptors. these findings reinforce the importance of developing a sustainable rural preceptorship placement as a recruitment and retention strategy. in their study, pront et al., (2013) reported similar findings related to living and learning in the rural environment. they found that preceptorship in rural communities provided many of the same learning opportunities as corresponding urban experiences. the students were surprised by the level of complexity in rural nursing. however, students described the high levels of complexity at times as “chaotic” and “overwhelming” (pront et al., 2013, p. 284) which, in turn, had at times a negative impact on their learning. professional relationships and boundary issues online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 34 were also reported by students as adding to the complexity of the rural preceptorship experiences (pront et al., 2013; yonge, 2009). interprofessional collaboration eight research teams reported that interprofessional collaboration is intrinsic to effective health care service delivery in the ability of health care providers to interact and collaborate with other team members in the planning, provision and evaluation of service delivery. macdowell et al., (2015) found dysfunctional teamwork as one of the leading causes of health care errors while increased knowledge regarding the roles of other health care professionals resulted in an attitudinal change toward working within interprofessional teams. these findings are supported by other nursing researchers who have explored the benefits and necessity of interprofessional education in nursing education, in particular during preceptorship (sedgwick, 2011; sedgwick & rougeau, 2010; sedgwick & yonge, 2008; sedgwick et al., 2009; yonge et al., 2013a). in 2009, sedgwick and yonge conducted an ethnographic study in rural communities examining precepted students’ perceptions of learning in a rural-based hospital. overwhelmingly, the students reported feeling as authentic members of the interprofessional team in the rural placement unlike their former supervised clinical experiences in urban settings. however, another study conducted by sedgwick (2011) found integration with members of the interprofessional team required deliberate planning by preceptors and faculty advisors to ensure students were allocated time to spend with different members of the health care team. sedgwick (2011) found it was essential that students and healthcare team members be provided information regarding roles and responsibilities of each of member of the team. how best to plan and implement interprofessional experiential learning opportunities aimed at a number of improvements such as recruitment, retention, and improved patient outcomes was online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 35 identified in five of the research articles reviewed. researchers explored the benefits and necessity of interprofessional education in nursing education, in particular during preceptorship (sedgwick, 2011; sedgwick & rougeau, 2010; sedgwick & yonge, 2008; sedgwick et al., 2009; yonge et al., 2013a). the ways in which rural and urban preceptorship differ may have an impact on the student’s experience of belonging and the efficacy of the interprofessional team. recruitment and retention whether or not rural preceptorship influences future employment is, to date, poorly understood but was identified as a focus of three of the articles reviewed. on average, 12-50% increased interest has been noted following rural clinical experiences, although these findings are not limited to nursing preceptorship placements (courtney, edwards, smith & finlayson, 2002; schoo et al., 2008). the placements included supervised clinical placements and non-nursing, allied health student placements (courtney, et al., 2002; schoo et al., 2008). while these placements are recognized as a recruitment strategy for nursing units in rural and urban centers, schoo et al. (2008) noted post-preceptorship employment data is inconclusive. retention of rural nurses, especially in specialty areas such as psychiatry, is an ongoing challenge internationally (charleston & goodwin, 2004). these researchers propose that successful preceptorship in rural and specialty practice areas may be effective as a recruitment and retention strategy. they identified some challenges related to the logistics of rural course delivery, most specifically evaluation and feedback, and found support for students to be one of the key indicators of a successful preceptorship experience. evaluation and feedback of the articles reviewed, issues related to students’ performance evaluation emerged as a finding in four articles. student evaluation during preceptorship is a combined effort which takes online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 36 place among members of the preceptorship triad: the student, preceptor and faculty advisor. students may be required to complete some type of self-evaluation, however, the evaluation of their progress typically is a joint endeavor among the triad. the determination of the final grade whether it be pass/fail or a letter, is usually the sole responsibility of the faculty advisor (sedgwick & yonge, 2009). throughout the process, it is important students and preceptors feel supported by the faculty advisor despite the lack of physical distance and presence. thus, a variety of resources such as texting, telephone, skype, teleconference or videoconference are used. this study by sedgwick and yonge was limited to student perceptions of faculty involvement during preceptorship. other researchers have found preceptors report that ongoing and consistent contact with the faculty advisor enhances their feelings of confidence and preparation for the preceptor role (yonge et al., 2008). in a study examining evaluation between students and preceptors, students reported formative evaluation to be the most frequently used and most effective form of feedback from their preceptors (yonge, et al., 2011b; 2011c). the students were less clear about their role in the evaluation process but identified receptivity to feedback as their responsibility. preceptors, on the other hand, identified challenges related to student evaluation, stating they often felt ill equipped to conduct and document evaluation feedback. the preceptors indicated they often sought assistance from the students with the actual use of the evaluation tool and required orientation to the evaluation process that was context specific. in the second phase of the same study, yonge et al., (2011b) investigated the most effective evaluation tools and models for use by preceptors during the rural preceptorship. they found rural preceptors require more support than their urban counterparts. physical distance makes it online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 37 difficult for faculty members and preceptors to meet frequently in person. as a result, the rural preceptor may, in fact, receive less faculty support than urban preceptors. an outcome of the research was a framework depicting the roles and expectations of each member of the preceptorship triad that need to be explicit prior to commencement of the preceptorship. other key concepts the researchers addressed, included criteria with regard to what is evaluated, by whom, when, where, why and how. the framework was developed to provide preceptors with distinct strategies to address each of the components. discussion the themes that emerged from the analysis of the data provide the foundation for the current state of the knowledge concerning rural preceptorship (see figure 1 – results model). these themes reportedly influenced students, preceptors and faculty advisors’ perceptions of preceptorship success in the rural context and in some studies were suggestive of an enhanced desire of graduates to seek permanent employment in the rural setting. students, preceptors, and faculty advisors’ preparation and support throughout preceptorship, are concepts gleaned from the analysis of the data as being integral to mitigating the challenges associated with rural preceptorship. adequate preparation of each member of the preceptorship triad is essential to the success of the preceptorship. preparation for preceptorship in rural settings is still not clearly understood. orientation of each member of the preceptorship triad is essential for success in any preceptorship setting. inadequate understanding of the roles, responsibilities and expectations of each of the members of the triad can lead to miscommunication and unrealistic expectations. strategies to provide online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 38 orientation for preceptors in rural locations who do not necessarily meet face-to-face with the faculty advisor present unique challenges. figure 1 results model challenges experienced by students during preceptorship have the potential to impede their ability to cope with rural preceptorship. issues related to isolation are vast and range from travel concerns to accessibility of a student’s psychosocial support system during the preceptorship. a review of the literature conducted by killam and carter (2010) addressed the challenges of rural student preceptor faculty advisor rural experience interprofessional collaboration recruitment and retention evaluation and feedback online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 39 nursing clinical placements. they concluded the most common sources of challenges for nursing students fall into seven categories: political, environmental, community, nursing, organizational, relational and personal. while these researchers identified a variety of challenges that nursing students face, they affirm that more research must be conducted to purposely address the specific challenges unique to rural practice placements. doing so, they concluded, has the potential to positively influence long-term recruitment and retention of rural nurses. what is more, researchers have found that students who report positive rural preceptorship experiences are inclined to stay and work in the rural setting (crow, conger, & knoki-wilson, 2011; edwards, et al., 2004; hunsberger, et al., 2009; killam & carter, 2010; webster, lopez, allnut, clague, jones & bennett, 2010). only one study (yonge, et al., 2011b) identified challenges of evaluation experienced by preceptors and students concerning conflicting perceptions of students’ progress. however, strategies to address these challenges have not been specifically explored. moreover, the evaluation process during the rural preceptorship may create unique challenges for students and preceptors who are only able to communicate remotely with their faculty advisors. by lacking face-to-face meetings, students may feel isolated and unsupported when receiving difficult feedback, while preceptors may experience difficulty in delivering feedback to the struggling students. more research is needed to understand the perspective of preceptors and students regarding the evaluative component of preceptorship. recommendations for future research high quality health care delivery is a canadian priority (canadian health services research foundation [chsrf], 2006; lobiondo-wood, haber, cameron, singh, 2012). further online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 40 research is needed to address gaps that exist in the current literature regarding rurality and rural preceptorship. preceptorship is inherently a high stakes clinical placement that takes place at the completion of the undergraduate nursing program. failure or inability to successfully complete the preceptorship can result in a devastating cascade of events for students that includes a potential delay of graduation, inability to write the licensure exam, and failure to secure employment. nursing students who complete practice placements in rural settings may be faced with challenges that are unique to the rural setting and irrelevant in urban settings. an increased understanding of the challenges and opportunities nursing students or future nurse’s experience as part of rural nursing practice can: a) foster an environment conducive to the creation of strategies to address these challenges; and b) maximize the opportunities to enhance not only student learning, but recruitment and retention of nurses to rural communities. this approach has the potential to increase students’ motivation to choose rural placements that not only expose them to rural practice, but also provide incentive for rewarding employment opportunities (edwards, et al., 2004). students who request preceptorship in their home rural community are faced with challenges unique to the rural setting regarding confidentiality and boundaries. more research is needed to address both the challenges and opportunities experienced by these students and preceptors as well as development of strategies to assist these students to navigate the unique nature of close personal relationships that are common in small rural settings. whether or not the challenges experienced by students during rural preceptorships deter them from seeking online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 41 employment in that setting is unclear. research is thus required to develop a more coherent understanding of the relationship between rural placements and rural employment. other factors that have not as yet been examined include the current job and employment market in the rural and corresponding urban centers, as well as student motivation to seek rural placements and preceptorships beyond the students’ desire to return to their home community. the degree to which consistent support received by students and preceptors from the faculty advisors throughout the preceptorship influences overall satisfaction with the preceptorship and intent of graduates to seek employment, is not clearly understood. challenges faced by nursing students during rural preceptorship and the supports required to ensure success have not been examined. for example, how students experience belonging in rural preceptorship and how belonging influences interprofessional team effectiveness. lastly, how nursing students cope with the isolation of rural practice has not been thoroughly examined. recently, researchers examined the learning needs of newly graduated nurses and found that preparation for rural practice in addition to support and mentorship for new graduates in the rural setting is indeed required for successful recruitment and retention of a rural nursing workforce (sedgwick & pijl-zieber, 2015). however, lack of clarity concerning preparation is two-fold: whether nursing students are prepared for preceptorship in rural settings and whether the rural preceptorship prepares them for entry to practice in the rural settings. hence, preparation of nursing students prior to rural preceptorships requires examination. what’s more, support and preparation required by preceptors and faculty advisors related to evaluative processes of preceptorships is not clearly understood. online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 42 further research is need to generate solutions to the aforementioned points as well as the following questions: 1. what are the factors unique to the rural experience and how do these factors directly influence students learning and success? 2. what are the challenges and opportunities experienced by nursing students, faculty advisers and preceptors during rural preceptorships? 3. how do nursing students cope with the isolation of rural practice? 4. what are the motivators of nursing students who seek employment in rural communities? 5. how does the undergraduate nursing curricula prepare nursing students for preceptorships in rural communities? 6. do nursing students and preceptors in rural communities have unique preparatory needs that are significantly different from their urban counterparts? recommendations for nursing education the purpose of this integrative review was to assess the state of the current knowledge regarding undergraduate nursing preceptorship in rural communities. the following recommendations are offered based on the themes and subthemes that emerged as a result of this review and are intended as a basis for collaborative endeavors between the educational institution and practice partners: 1. identify strategies to circumvent the challenges intrinsic to practice in rural communities that have the potential to negatively impact student learning. 2. create and implement specific strategies to ensure consistent support for students and preceptors throughout the duration of the preceptorship. online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 43 3. delineate the roles and responsibilities of each member of the interprofessional team and provide these definitions for students and preceptors during site orientation. 4. ensure site-specific orientation as an essential component for nursing students prior to commencement of the preceptorship. 5. explore the potential to increase opportunities for supervised practice placements in rural communities. 6. develop and deliver annual preceptor-orientation sessions or workshops to address issues related to rural preceptor preparation. 7. address issues related to entry-to-practice transition to enhance students’ interest and desire to “go rural, and stay rural” (sedgwick & yonge, 2008). conclusion the body of knowledge concerning rural nursing preceptorship is growing but gaps persist. to date, it remains unclear as to how best to effectively prepare and support students and preceptors in rural settings. the challenges and opportunities in rural preceptorships need to be examined to improve the preceptorship experience for the student and preceptor, assist in developing recruitment strategies for the new graduate and address challenges such as a sense of isolation. researchers have identified the importance of forming relationships, belonging to a team and being in a community. there are significant teaching and learning opportunities when students are placed in a rural setting for their preceptorship practicum. it is time to focus on a concerted approach to adequately preparing nursing students for a successful rural experience. online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.430 44 references balfour, r. j., mitchell, c., & molestane, r. 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(2013a). nursing preceptorship experiences in rural settings: "i would work here for free". nurse education in practice, 13(2), 125 131. http://dx.doi.org/10.1016/j.nepr.2012.08.001 yonge, o.j., myrick, f., ferguson, l.m., & grundy, q. (2013b). multiple lenses: rural landscape through the eyes of the nurse preceptors and students. journal of rural and community development, 8(1), 143 159. microsoft word leipert_342-1900-3-ed.docx online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 74 working through and around: exploring rural public health nursing practices and policies to promote rural women’s health beverly d leipert, rn, phd 1 sandra regan, rn, phd 2 robyn plunkett, rn, phd 3 1 professor, arthur labatt family school of nursing, university of western ontario, london, on, canada. bleipert@uwo.ca 2 assistant professor, arthur labatt family school of nursing, university of western ontario, london, on, canada. sregan4@uwo.ca 3 professor of nursing, humber college, on, canada. robyn.plunkett@humber.ca abstract purpose: to discuss findings from research in ontario, canada, that addresses the following objectives: 1) identify organizational attributes and local and provincial health policies that enable or impede the work of ontario public health nurses to improve rural women's health, and 2) critically examine roles, job descriptions, and practices of ontario phns that will improve rural women's health. sample: 20 frontline phns and 14 supervisors and managers in three ontario public health units that serve people who live in rural locations. method: six focus group interviews were conducted with phns and phn managers in three rural ontario public health units. study participants were asked to describe policies and practices that guided their practice regarding rural women's health, identify organizational attributes that online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 75 enable or impede public health nursing practice regarding rural women's health, and indicate roles and practices for phns to improve rural women's health. findings: 1) policies address rural women's health and rural public health minimally or not at all, 2) phn practice is primarily focused on child bearing women and children to the exclusion of other populations of rural women such as seniors, 3) phns work through and around policies to address rural women' s health more effectively, and 4) institutional, government, community, professional, and personal factors play significant roles in shaping public health nursing practice and policy regarding rural women's health. conclusions: this research facilitates understanding regarding policies, contexts, and values that shape rural phn practice, and provides evidence for policies and practices that enhance and support public health nursing for more effective promotion of rural women's health. clearly, more investigation is needed; this research forms the basis for ongoing inquiry in this area. keywords: rural public health nursing, rural women's health, policy, practice, canada working through and around: exploring rural public health nursing practices and policies to promote rural women’s health “geography should never be an excuse for discrimination or inequity in health.” allan rock, former federal minister of health (the ontario rural council [torc] (2009, p.11). over the next ten years, jurisdictions throughout canada can expect to experience rising rates of chronic preventable diseases such as obesity, diabetes, heart disease, stroke, tobaccorelated illnesses, and environmental illnesses (joint task group on public health human resources [jtgphhr], 2005; public health agency of canada, 2012). all of these health issues are prevalent and growing in rural canada (canadian institute for health information [cihi], online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 76 2006). although these issues are amenable to public health intervention, rural areas in particular are struggling to maintain essential public health services, including the retention of public health nurses (phns) (canadian nurses association [cna], 2005; jtgphhr, 2005). as a result, the health of rural canadians, especially those who experience vulnerabilities and inequities, such as rural women, is particularly at risk. the ontario government has recently highlighted the priority need for equity of access to health and health care in rural contexts (mohltc, 2010a, b; 2011). understanding what are and should be practices and policies of rural phns regarding rural women’s health could significantly enhance the present and future health of rural women, families, and communities. this information could also help to promote more accessible and better integrated programs (community health nurses of canada [chnc], 2010; mohltc, 2010a, b) and more effective public health nursing services in underserved rural communities. rural people in canada are sicker, die sooner, and experience severe health challenges, such as limited or no health care, compared to other canadians (cihi, 2006). rural women, in particular, experience many health issues related to social isolation, poverty, disempowerment, limited knowledge, and other factors that phns could effectively help them address (sutherns, mccallum, & haworth-brockman, 2008). women in rural communities often have few or no health promotion resources, illness prevention services, or access to female health professionals (leipert, leach, & thurston, 2012; leipert, 2013). thus, phns are essential health resources for rural women because they are mostly female and have pronounced expertise in health promotion and illness and injury prevention practice (stamler & yiu, 2012). phns may assist in addressing sensitive health issues for rural women who might not seek health services from male care providers or from physicians and pharmacists whose staff might be well known in the online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 77 community thereby risking compromised confidentiality (leipert, matsui, wagner, & rieder, 2008). rural women have noted the immense need for and dearth of health promotion and illness prevention services in their communities. yet, little research has been conducted on public health nursing practices and policies related to the health of rural women in canada (leipert et al., 2008; leipert & reutter, 1998). public health nurses provide services of health promotion, disease and injury prevention, health protection, health surveillance, population health assessment, and emergency preparedness (canadian public health association [cpha], 2010; chnc, 2010; stamler & yiu, 2012). they are often the only health care providers to provide these services in small rural communities (leipert & reutter, 1998). increasing access to the social determinants of health and empowering under-resourced and vulnerable populations, such as rural women, are foundational to phn practices (cpha, 2010; joint opha/alpha working group on social determinants of health, 2010; stamler & yiu, 2012). yet in recent years, public health nursing in canada has experienced a hollowing out, a decreasing of support, resources, regard, and recognition, that has serious implications for the health of rural people as well as for rural nursing (falk-raphael, 1999; leipert, landry, & leach, 2012). indeed, nurses at over half a dozen rural public health units in ontario have been in labour disputes throughout the past five years, which in some cases has included strike action (ontario nurses’ association, 2012, 2013). some rural areas have been particularly challenged due to decreased public health services or closure of offices in small towns, thereby requiring rural residents and phns responsible for those areas to drive lengthy distances to access or provide services (ontario nurses’ association, 2011). in the 2011 report of the chief medical health officer of ontario (ministry of health and long-term care [mohltc], 2011), increasing access to the social determinants of health and online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 78 reducing inequities were identified as key areas where increased public health efforts must be made. public health nurses are crucial providers of public health care in canada generally (jtgphhr, 2005) and in rural areas in particular (kulig, macleod, stewart, & pitblado, 2012; leipert, 1999). thus, more knowledge about their practices and policies is needed to support and enhance their work in order to address key areas of public health concern, including rural women’s health. the objectives for this research were to: 1) identify organizational attributes and local and provincial health policies that enable or impede the work of ontario public health nurses to improve rural women’s health, and 2) critically examine roles, job descriptions, and practices for ontario phns that will improve rural women’s health. rural is defined as communities “with a population of less than 30,000 that are greater than 30 minutes away in travel time from a community with a population of more than 30,000” (mohltc, 2010a, p. 4). study design methodology this study was guided by interpretive description methodology (thorne, 2008). interpretive description methodology is “designed to create ways of understanding clinical phenomena that yield application implications” (thorne, reimer kirkham, & o’flynn-magee, 2004, p.1) by capturing themes and patterns within participants’ experiences to inform clinical understanding. rural phns and rural women have historically been included in few research endeavors (sutherns & haworth-brockman, 2012), thus this project provided enhanced opportunities for respectful and meaningful inclusion, as well as the important potential of gaining significant new rural health knowledge. online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 79 sample, recruitment, and data collection ethical approval for the study was obtained from western university health sciences research ethics board (protocol number 18295e). the three health units in this study were selected for their rural characteristics, such as isolation and low economic status, as well as for their interest and ability to participate in the research. the health units included in the study serve some of the most rural populations and settings in the province. all three health units had higher percentages of older adults over 65 years, higher overweight and obesity, and higher avoidable mortality from preventable disease than the provincial average (table 1). table 1 characteristics of public health unit catchment areas* ontario (provincial average) health district #1 health district #2 health district #3 population over 65 (%) 12.7 10% higher than provincial average 30% higher than provincial average 50% higher than provincial average visible minorities (%) 25.9 1.5 3.5**** aboriginal population (%) 2.4 1.0 – 3.5**** overweight/obese % 27.6/17.4 both above provincial average both above provincial average both above provincial average avoidable mortality from preventable causes (per 100,000)** 71.5 above provincial average above provincial average above provincial average rural area population*** (%) 14.1 double the provincial average double the provincial average quadruple the provincial average census population of major city (n) n/a 25,000 to 35,000 65,000 to 75,000 15,000 to 25,000 notes: *numbers have been approximated to protect the identity of the communities (statistics canada, 2012, 2014). **age-standardized rate of premature deaths could potentially have been prevented through primary prevention efforts. *** areas with fewer than 1000 residents and a population density with fewer than people/square foot. **** range is for all three health districts combined. public health nurses and managers were recruited by contacting managers in health units in ontario that serve rural populations. the managers informed staff about the study and invited online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 80 their participation. all phns and managers who volunteered for the study and who could meet for a focus group at the time that best suited the majority of those interested participated in the research. group interviews were then conducted with 20 frontline phns and 14 health unit managers at their health unit locations. the phns and managers at each of the three health units were interviewed separately, for a total of six group interviews, three with phns and three with managers or supervisors. in audiorecorded interviews of one to two hours in length, participants were asked to describe policies and practices regarding rural women’s health, identify organizational attributes that enable or impede public health nursing practice regarding rural women’s health, and indicate roles, job descriptions, and practices for phns that could help to improve rural women’s health. examples of the interview questions included: what health needs do rural women in your areas have? how do health unit policies and practices affect your work with rural women, positively or negatively? how would you change these policies and practices to better support rural women’s health? what organizational attributes (resources or lack of resources, understanding of rural women’s needs, inclusion of public health nursing in practice and policy development, etc.) enable or impede the work of public health nurses to improve rural women’s health? what should public health nurses do to better address rural women’s health? the semi-structured interview guide was emailed to each health unit prior to the interview to allow participants additional time to reflect upon the questions. analysis the interview recordings were transcribed verbatim and the transcripts checked with the audio recordings to ensure accuracy. transcripts were analysed individually, as a whole as well as by distinct health unit (i.e. phn and manager transcripts from the same health unit). online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 81 transcripts were interpreted alongside community assessments for each health unit catchment, which included information such as demographic information, major types of employment, and salient health challenges. in interpretive description, “the researcher constantly explores such questions as: why is this? why not something else? what does this mean?” (thorne et al., 2004, p. 11). using these questions and content analysis (patton, 2002), the transcribed interviews were analyzed line-by-line by a minimum of two researchers to determine consistent codes and themes that addressed policies and practices pertaining to rural public health nursing practice regarding rural women’s health (e.g. types of work phns may or may not engage in), organizational attributes that enabled and impeded phns work regarding rural women’s health (e.g. support of managers), and phn roles, job descriptions, and practices that helped or could help to improve rural women’s health (e.g. need for more support and respect). in addition, the research team met during analysis to discuss emerging codes and their meanings. the qualitative software program nvivo 9 (qsr international, 2010) assisted with the organizing, labeling, and retrieving of codes and themes during analysis (ulin, robinson, & tolley, 2005). findings “you put a nurse in (the community), you’re going to address a million issues… and because you’re a nurse, [they] … tell you all their problems. it’s fabulous.” carla, rural public health nurse. the findings are categorized into three main themes: 1) promoting rural women’s health through phn practice in community, 2) policy and managerial valuing of phn practices to support rural women’s health, and 3) evidence used to inform policy, funding, and practice. pseudonyms are used to represent the names of study participants. online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 82 promoting rural women’s health through phn practice in community phns in the study repeatedly and emphatically emphasized the importance of their presence in rural communities, noting that rural women are often isolated, have limited voice and power, and limited opportunities for health promoting activities. phn amy described a rural community she served as … a very traditional, patriarchal community, so women do not have a voice...i [once asked] what [programs and activities are] available for women. and the supervisor [of community programs] laughed at me and he said, ‘well you’ll have to [drive an hour to the city] for that.’ being present in rural communities provided phns with privileged information regarding available health resources as well as health needs. chantal, a manager, described a benefit of her team working directly in a rural community, rather than from a distant location, “the more we worked in that community, the better we got a sense of what the needs were.” this deepened understanding of health needs allowed chantal and her team to identify relevant health resources that might benefit the community. as a result, the health unit was successful in obtaining external funding to bring nurse practitioner services to that rural location. study participants also believed that being visible and located within rural communities was important to address mental health issues. betty explained that that the personal nature of home visiting has been an effective way for public health nurses to confidentially assess rural mental health needs, provide mental health education, and encourage clients to access resources. she stated, “mental health is still very, very stigmatized … [there have been] people that we’ve visited … with undiagnosed ppd (post-partum depression) and … you… get them to the point where they [agree to see] the doctor ….”. in sensitive situations such as these, study participants online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 83 perceived that if phns were not positioned in the rural community and engaging in direct client contact, such as through home visits, trust could be compromised and women would be less likely to be receptive to, know about, or access mental health and other services. study participants also commented on the significance of long term, consistent staffing in rural communities so that familiarity, trust, and effectiveness could be enhanced. hazel, a manager, referred to parental preferences in her rural area, “(what) they really wanted was one (nurse) that they could go to…they developed a trust … they got confidence in one person and that’s something that they felt they really needed…out there…in the county.” phns and managers repeatedly mentioned that limited ability to address social determinants of health, such as poverty, isolation, and lack of resources, was a primary concern regarding rural women’s health. hazel, a manager, reported, “[our county dwellers don’t] have a lot of resources and the [phn] might be the only person that they’re counting on for their information.” the opportunity to be present in the community and getting to know its residents was extremely valued by the public health nurses in addressing health determinants. alexis noted, it…speaks to what we do, making connections and empowering people…giving them the opportunity to be able to take that next step to advocate for themselves … we’re the ones who make that connection to acknowledge their humanity… their suffering. managers in the study noted the multi-faceted roles of phns in under-served rural areas. nancy, a senior health unit manager, stated, “waiting lists [for health] services … [are] a huge problem. and so the public health nurses end up really filling a role with…supportive counseling and screening and being able to identify people that need to be prioritized.” another manager, helen, recalled, online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 84 when [phns] were pulled out of schools, the school board and physicians…said “we want our nurses back!” we tried pamphlets and they didn’t want pamphlets, they wanted the nurses…. so, now, they cost share…the salaries of the nurses because they want the one-on-one counseling…precisely [because of] the isolation of the schools from services. however, study participants noted that recent provincial public health policy directing a more centralized approach to offering programs and services was problematic for rural phns and rural residents. the closure of satellite public health offices in rural communities meant that phns were no longer readily accessible in rural settings, thereby hindering assessment, relationship building, and intervention inherent to successful public health nursing practice and rural health. phn jill shared one of her concerns of satellite office closures, “we [phns] won’t have any visibility, which is a real issue for public health because people [won’t] know how to access us.” as geographic areas become larger with the closure of rural offices, the ability of nurses to reach clients, and vice versa, will be even more compromised. in addition, centralization meant that rural residents would now be required to travel to distant centres to obtain public health nursing services. this, too, posed challenges, especially for residents with limited finances and transportation (such as for those with no vehicle or who use horses and buggies), many of whom were the most in need of phn services. phn jill commented on rural transportation issues facing her clients, “there are challenges with transportation…because most of [our clients] are [at least an hour’s drive away]”. several phns acknowledged having driven clients to services in their own cars. sharon and anita explained this policy-practice disconnect, “we get reminded we’re not to be taking people in our online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 85 own vehicles…”, “[but] depending on the situation, if we’re out there…there is just no other way”. additional issues related to the fact that most public health programs for women were targeted at those in their childbearing years, leaving young women, women with no children or whose children were older, older women and others, with limited or no public health services and programs. phn bronwyn explained, the provincial [public health] mandate [to provide pap smears] is actually for young people under the age of 24.... a lot of health units do [enforce the age restriction], but our philosophy here…is that if you need public health service…then we’ll give it to you. so we recently did a … drop-in pap clinic. and we did 40 paps [pap smears]… all older women…over 40. policy and managerial valuing of phn practices to support rural women’s health study participants reported that some provincial policies lacked relevance to rural areas. for example, labour and employment policies tended to be developed with an urban focus and, as such, often did not relevantly support rural public health nursing practices. sharon, a rural phn, noted, “some of the legislation that comes out [has] certain … standards [to protect us nurses] ... and one of our rules … is about [avoiding] risky premises … but the definition [of risky premises] is the [same] definition of a rural setting!” betty added, you go to leave from teaching a pre-natal class at 9:30 at night. it’s jet black, there aren’t lights and you have to go out to your car. well you’re supposed to have a personal alarm with you, but who’s going to hear it?” … “(it’s a good thing) we’ve got our baby scales (to protect us)! online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 86 thus, although the rural contexts in which phns work may threaten their or their clients’ safety, phns in the study found that urban-centric provincial policies offered little or no useful understanding or support for their risky rural work. accordingly the needs and contexts of clients sometimes required that phns forego policy to provide appropriate and safe care. sherry recalled a situation, in which she had to disregard health unit policy to ensure that her client received necessary care, a person came in the middle of winter for clinic and (the government official from the city) said “oh you need to go back home and get your health card.” the (client) said to me, “well that will take me 6 hours to drive (home in the snow by horse and buggy).” so needless to say, i drove (the client), probably broke all sorts of policy and procedures. a manager elaborated poignantly on the harsh realities and demands of rural community nursing practice, “i have covered those (community nursing activities)…and … it’s almost like third world medicine.” phns felt that their work was continually being shifted away from one-to-one services towards a population-based practice that often did not fit with rural practice and rural needs. they noted that one-to-one practice was often more effective in rural settings due to the unpredictability and individuality of health needs in sparsely populated areas, and the need for confidentiality and privacy in rural care. as phn sharon commented, “[people] know everybody…in the doctor’s office…[they] don’t …want to access care from [a physician] who’s known [them] all [their] life”. phns noted that home visits are essential in ensuring that services can be provided in confidential ways. however, such practice was deemed by health units as contradictory to a changing provincial population-based policy focus, and thus discouraged. for online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 87 example, phns noted that policy was becoming more restrictive regarding eligibility for home visits. phn sheryl commented, “people that [aren’t] considered at risk aren’t… getting those home visits anymore whereas everybody used to be offered a home visit post-partum. and you would pick up lots of things [during these routine visits].” thus local implementation of provincial public health policies made it difficult or impossible to appropriately address rural health needs. perspectives about current and future directions for public health nursing practice and policy sometimes varied between managers and phns. phns in one health unit attributed this disconnect to several factors: management not understanding or valuing the work of front line public health nurses in rural settings, phns feeling/being disrespected, and overly directive nurse-manager relationships. phn carol commented, “i don’t know whether they truly … understand what we do … on a day-to-day 8:30 to 4:30 basis”, and phn lauren stated, “we have to be believed too. like when we’re saying that this is how things are … we have to have at least internally [at health unit level], if not provincially and federally, some buy-in to our frontline opinion and that doesn’t seem to happen.” in a phn interview, when asked about satisfaction with working with administration, the response by the group was a lengthy silence before a phn finally commented, "[we can] wait for [administration] retirements and fly under the radar." having a supportive management team that valued public health nursing and nursemanager relationships grounded in mutual respect clearly facilitated phns’ ability to interpret health policies and work effectively. however, this wasn’t always the case, as sheryl noted, “…that used to be a regular thing that you would take your presentation of what you’re doing in your program to the board of health and do your presentation [at one of their regular board online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 88 meetings] but that like i haven’t really heard of that being done [recently]”. other phns then commented that “[now] you’re insubordinate [if you contact board members]”, “even though we are residents of the municipalities who they are representing on our board”. as a result of attempts at silencing and marginalization, phns did, from time to time, work around health unit policies in order to serve rural areas in ways that may not be authorized by managers or supported by policy, but that were necessary for effective rural health promotion. betty commented, “well sometimes…we do things. we ask for forgiveness, not permission (laughs)”, and lauren stated, “there’s really… a ceiling, a definite concrete lead-filled ceiling to get major change happening. but in the meantime, we’re all trying to fly under the radar and do what we think is best.” several managers recognized the limited resources available to nurses in rural health units as well as phn role constraints based on public health policy. participants noted that policy change was both a valuable and a sensitive process, and one that could be fraught with consequences. manager jeff stated, “change requires us to…lobby…it can be done but it has to be done carefully and sensibly and it has the potential to place you in conflict and hot water with the folks who you are reporting to.” phn lauren added, “(management is) not protected by [a] union … so their jobs are literally on the line if they speak out of turn and out of line.” evidence used to inform policy, funding, and practice study participants consistently reported that quantitative, epidemiological data were the primary and priority sources of evidence, “there’s a lot of focus on … what can be evaluated, so numbers…deliverables…things that … can be tracked.” “proof”, “impact”, “efficiency”, and “effectiveness”. phn gwenyth commented, “[managers are] always about the numbers…”, and online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 89 manager hazel noted, “now one of the things we’re in the process of doing right now is … realigning our nursing teams to … match the neighborhood stats.” the perceived reliance on quantitative data conflicted somewhat with the type of data phns thought was important regarding their practices to promote rural women’s health. they noted that rural women’s health needs were often best served by public health nurses’ relationship building with rural residents and ability to take advantage of vicarious rural contacts to promote health, activities that do not lend themselves to quantitative representation. phns recommended evidence that included relational and personal knowledge. amy provided an illustrative example of the nature and importance of relational practice, i was giving a screening kit…to…this woman and her six sisters came to the home…. and it was just this big discussion [for] an hour and a half. these women would not access services for months and months unless public health was out there and that’s so important.” another phn recalled, when i first started working here, you had your own neighbourhoods… people would get to know you, “oh she’s our nurse” … so sometimes if there was someone you were concerned about you could … go up to the house and knock on the door and say “i’m the visiting nurse…and someone down the street mentioned (you) to me”. you could … do that because people knew …(you)…. phns doubted that their practices were effectively acknowledged or represented by quantitative data. for example, quantitative data that note one visit do not reveal the time and nature of relationship building and trust so essential to rural practice, thereby providing limited understanding and valuing of the nature and impact of rural phn practice. when numbers only online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 90 were used to define effective practice, phns believed the number of clients seen took precedence over the value of and time for each public health nurse-client interaction. phns perceived that program funding was based on community statistics, ever-changing and inconsistent provincial funding, and new public health policy mandates. phns explained that reliance on these allocations was inappropriate, given the small rural populations that need consistent services and personnel to foster trust and effectiveness, and that funding instability, or “flavour of the month” funding as they termed it, adversely affected phn care. alexis explained, “there’s no stability with our funding … we get something started…we reach out…make connections, then [funding is cancelled] ... so we leave a hole. it’s very frustrating, and it really impacts our care…even more in the rural community.” amy explained, it … affects your relationship with the health care providers because they lose the trust in your service when you cut (the funding and the program). … in (one of our small towns, the sexual health program) was there and then (it was) stopped and it was like pulling teeth to get the health care providers, the physician, to buy into it again. participants perceived that valuing and retrieving evidence that more accurately and clearly represents their rural practices and rural needs, such as qualitative, case study, and storytelling data, would enhance understanding and support of rural practice and rural women’s health. discussion study findings suggest a number of significant issues and implications. first, women’s health was viewed and addressed in public health programs and services largely with a focus on women of reproductive years and children. other women and girls, such as school aged, teens, and young women, women without children or whose children are not of preschool age, older online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 91 women, and women with special needs such as those with disabilities, received limited (ie. focused on reproductive services or falls) or no obligation within public health nursing practice and policy. such limited phn care for women is problematic for rural areas for several reasons. rural areas are comprised of a variety of ages of girls and women, with a growing population of older women (cihi, 2006). indeed rural communities could be described as feminized aging communities, as the large cohort of baby boomers remain or move there for retirement and husbands tend to die before wives (keating, 2008); by 2021 one in four seniors will live in a rural setting (health canada, 2002). the rural areas in the three health units in this study include some of the highest numbers of seniors in the province. these populations require and would significantly benefit from the health promotion expertise that public health nurses can provide. perhaps most significantly, phns can travel to clients, rather than clients having to travel to care, thereby helping to ensure that even the most vulnerable and isolated women can receive effective assessment and intervention support. the health promotion expertise of phns is unique and essential in rural settings, as few and often no other health care professionals exist there with this type of expertise (leipert, 1999; leipert & reutter, 1998; stamler & yiu, 2012). all three health units in this study had high rates of avoidable mortality from preventable causes. in underserved rural communities that have few resources, such as female health care providers, expanded public health policies and practices would result in significant health promotion resources for vulnerable rural populations, such as women and girls. second, participants suggest that policy decisions to centralize public health services in distant urban centers with resultant closure of rural offices are having a significant impact for online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 92 rural communities, particularly women, as well as for phns themselves. centralization compromises access to effective knowledge about the needs, resources, and determinants of health of each unique rural setting and the rural women who live there, decreases access to and by phns, and hinders health promotion services for vulnerable rural women and girls who can’t or won’t reach out for support. the most vulnerable, such as those experiencing poverty or abuse, those living with physical or mental impairments, and those with limited access to transportation including certain cultural groups such as amish women, will be especially exposed to geographic marginalization from health services. this neglectful reduction of access to health care and resources for the most vulnerable is unacceptable. the health of these people requires enhanced access to local rural phn offices, not centralization of services, as the phns and some managers in this study emphasized. third, findings reveal that the culture of respect, valuing, and inclusion accorded to rural public health nursing varies among health units. in two health units in the study, phns and managers worked collaboratively to try to interpret implementation of provincial public health and local health unit policy as effectively as possible for rural settings. however, in the third health unit, the limited power and voice of phns resulted in compromised rural health care for women because phns were not able to nurse to their full scope of practice and were instructed to follow the health unit’s prescriptive directives instead of executing and promoting their work with professional autonomy. this situation also resulted in extreme dissatisfaction and low morale among phns. when managers’ exclusion and negation of phns’ frequent and vehement recommendations advising against the closure of satellite rural offices was discussed during the interview, several phns became emotionally upset as evidenced by tears, voices vibrating with frustration, and statements indicating hopelessness and despair. online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 93 a primary implication of limited rural phn power, voice, and expertise is that rural policy, practice, and public health becomes weakened and compromised. furthermore, nurses are hindered in their ability to fulfill their professional requirement of advocating for health and populations (cna, 2008). their practice and work life become unsatisfactory and untenable, moral distress results, and recruitment and retention of phns becomes even more problematic (stewart, et al., 2010). all of these implications result in negative consequences for women who live and work in rural settings. fourth, this study revealed that when policies were inappropriate for rural women or rural phns, nurses would work through and around these policies to help to ensure that rural women could be supported. indeed, phns felt ethically bound to provide care to their rural populations. obviously, rural phns have commendable commitment and expertise regarding the promotion of rural health, and these merit greater valuing and inclusion in rural policy and practice. however, these findings suggest that effective work by rural phns may often remain, and be made to remain, invisible, thereby preventing the sharing, valuing, and support of such practices by other phns, managers, and in other rural settings. concealment of and lack of support for rural expertise and practice serve to disempower and undervalue the professional knowledge and capacity of rural phns and impedes the development of healthy rural public policy, practice, and health. suggestions for effective rural phn practice and policy regarding rural women’s health include the following: • public health units, local boards of health and public health departments at the provincial level should promote meaningful and respectful involvement of phns on policy committees, in program development, and regarding other decision-making activities. online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 94 • meaningful and valued inclusion of rural women in developing, interpreting, implementing, and evaluating health policy at the local, regional, and provincial level is needed for effective promotion of rural women’s health. • the development and implementation of provincial level public health nursing consultants and other leadership positions would assist in ensuring consistent, effective, and ethical policies and practices essential to rural women’s health and rural public health nursing practice, locally as well as province-wide, and in advocating for needed support, voice, and power to and by rural public health nurses. • value and use multiple sources of evidence, both qualitative and quantitative data, to inform provincial and public health unit policy development and implementation to appropriately develop, interpret, implement, and evaluate rural public health practice and policy. • public health nurses must maintain and continue to develop firm commitment to political action and advocacy. they need to support each other in these actions, at the health unit, regional, and provincial levels, to ensure effective public health programs and services in rural settings and sufficient and appropriate support for rural phn practice. conclusion this study, although limited to three health units, has nonetheless revealed that development, interpretation, and implementation of health policies and practices at provincial, regional, and local levels result in both possibilities and problems. power, position, voice, respect, ethics, inclusion/exclusion, evidence, the needs and resources of rural women and rural phns, as well as many other factors, must be respectfully considered and effectively incorporated into rural health if appropriate public health nursing practice, policy, and relevant rural health promotion for women and all rural people are to be achieved and maintained. opting online journal of rural nursing and health care, 2015(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.342 95 out of these commitments is not an option. rural women, rural public health, and rural public health nursing require and deserve better. supporting agencies the university of western ontario academic development grant. references canadian institute for health information. 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(2004). the analytic challenge in interpretive description. international journal of qualitative methods, 3(1), 1-21. ulin, p., robinson, e., & tolley, e. (2005). qualitative methods in public health: a field guide for applied research. san francisco, ca: jossey-bass. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 58 emergency room nurses transitioning from curative to end-of-life care: the rural influence roberta a. rolland, phd, rn, fnp 1 1 assistant professor, college of nursing, upstate medical university, rollandr@upstate.edu abstract rural nurses typically fill several roles as needed from acute and extended care settings and to the emergency room. the nurse’s role with aggressive curative efforts involves an intense clinical focus; while end-of-life care entails an intense psychosocial focus. emergency room (er) nurses commonly experience these two intense foci of care in succession. purpose: with the limited resources in rural hospitals, it was necessary to explore the rural influence on rural er nurses transitioning from curative to end-of-life care. the goal was to capture areas of need to best support rural nurses caring for dying patients and their families in the rural communities. method: a secondary analysis using deductive content analysis incorporated rural nursing theory to identify rural influences with rural er nurses transitioning from curative to end-of-life care. in a primary study, grounded theory was used to explore er nurses’ personal transitioning when the focus of patient care changes from curative to end-of-life. registered nurses (n=10; rural n=6, urban n=4) from four hospitals (2 rural and 2 urban) in four different counties in upstate new york participated in semi-structured interviews. analysis yielded 29 concepts and producing five categories: preparing caring, immersion, making sense, changing online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 59 gears, and reflecting. three sub-processes, focus, feelings, and conflict were identified as common threads with conflict as a moderating factor influencing nurses transitioning from curative to end of life care. findings: the concepts of distance, resources, and familiarity had the greatest influence on rural er nurses transitioning from curative to end-of-life care. the strongest characteristic of rural nurses was self-reliance. for this reason, adequate support and resources are essential to care for dying patients and their families in rural communities. conclusions: implications for rural er nursing include strategies to improve staff resources, access to education, and mentoring. keywords: rural, end-of-life, transition, emergency, nurse emergency room nurses transitioning from curative to end-of-life care: the rural influence although “fewer than one percent of emergency room (er) visits result in death,” nearly a quarter of a million deaths occur in ers annually (centers of disease control and prevention, 2013, p. 29). key efforts in the er are focused on saving lives and prolonging life (bailey, murphy, & porock, 2011).when curative efforts are exhausted and the focus of care changes to end-of-life; the nurse’s focus must change as well. aggressive curative efforts may involve an intense physiologic focus; while end-of-life care may entail an intense psychosocial focus. emergency room (er) nurses commonly experience these two intense foci of care in succession. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 60 norton, hobson, and klum (2011) proposed guidelines for palliative and end-of-life care in the er including nurse-to-patient ratios 1:1 or 1:2 when a nurse is caring for a patient at end-oflife. the authors recommend a multidisciplinary team be available for family, spiritual, and social needs. considering the limited resources in rural communities, such recommendations may be difficult to maintain. time and the nurse’s comfort with caring for dying patients were among additional barriers to end-of-life care in the er (bailey et al., 2011). exploring the needs of er nurses in rural areas helps in developing strategies to best incorporate the proposed guidelines. the dearth of literature on rural er nursing further support rural populations are poorly represented in research (morgan, fahs, & klesh, 2007). beckstrand and colleagues explored rural er nurses’ perceptions of end-of-life care obstacles (beckstrand, gile, luthy, callister, & heaston, 2012). the authors used a questionnaire to rank specific items by magnitude and frequency. among the highest ranking obstacles were family and friends continually calling the nurse for updates as opposed to the designated family member, knowing the patient or family personally, and the poor design of the emergency room for end-of-life care. nurses not being comfortable with caring for dying patients and/or their families was among the lowest ranking obstacles. this article provides a brief summary of the primary project and a secondary analysis examining the rural influence of er nurses transitioning from curative to end-of-life care. the primary study (rolland, 2014) included rural and urban nurses and explored the social process of er nurses transitioning when aggressive curative efforts are exhausted. although all nurses in the study followed a similar process when transitioning from curative to end-of-life care, specific online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 61 rural concepts and dimensions were more evident among rural er nurses. the aim of this secondary analysis was to further examine the rural components and identify areas of need for the development of education, resources, and supportive measures to assist nurses with end-oflife care in rural communities. this was accomplished by incorporating the theoretical framework of rural nursing theory (lee & mcdonagh, 2013) among the categories and subprocesses of the primary study’s integrated model, caring driven. theoretical framework rural nursing theory originated by long and weinert (1989) and was later revised by lee and mcdonagh (2013). the theory highlights characteristics and dimensions unique to rural populations and nursing in rural areas. lee and mcdonagh organized rural nursing theory within three theoretical statements as follows: theoretical statement 1. “rural residents define health as being able to do what they want to do; it is a way of life and a state of mind; there is a goal of maintaining balance in all aspects of their lives” (lee & mcdonagh, 2013, p.22). the concept of health belief is important to understanding what constitutes health among the rural population. having a disease process may not necessarily be viewed as having poor health as long as one can perform daily activities. a second concept is isolation and depicts the awareness of separation geographically, socially, and professionally. another concept is distance considering mileage and time. perception is a component of distance. access to health is a consequence of distance (lee & mcdonagh, 2013). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 62 theoretical statement 2. “rural residents are self-reliant and make decisions to seek care for illness, sickness, or injury depending on their self-assessment of the severity of their present health condition and of the resources needed and available” (lees &mcdonagh, 2013, p. 22). self-reliance is defined as a capacity to provide for one’s own needs characterized by independence, skills, and decision making. additional aspects of self-reliance are self-confidence and self-competence. the concept of outsider has defining attributes including differentness, unfamiliarity, and disconnectedness involving cultures, practices, and beliefs. the concept of insider considers one’s relationship to a group physically or socially (lee & mcdonagh, 2013). one who is long established in a place or a position is defined as the concept of old-timer. a new-comer is defined as newly arrived and unaware of the history of the area. resources are defined as property or assets. resources can be something accessed or something resorted to. informal networks consist of family members, friends, neighbors, and coworkers that supply emotional, physical, and social support (lee & mcdonagh, 2013). theoretical statement 3. “health care providers in rural areas must deal with a lack of anonymity and much greater role diffusion than providers in urban or suburban settings” (lee & mcdonagh, 2013, p.20). the concept lack of anonymity pertains to being visible and identifiable and characterized by diminished personal and professional boundaries. the concept familiarity is characterized by relationship, intimacy, and informality. the consequence of familiarity may be unwarranted intimate and personal interactions or behaviors. the concept professional isolation is characterized by the lack of resources to fulfill professional responsibilities and needs. resources online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 63 for education, specialized staff, and technology may be difficult to access and may not be readily available (lee & mcdonagh, 2013). method approval was obtained by the institutional review board (irb) of binghamton university and a convenience sample of hospitals. hospitals without an irb completed a letter of approval. informed consent was obtained from participants prior to interviews. participants chose an alias to ensure confidentiality. emergency room nurse managers distributed invitation letters to nurses who met inclusion criteria (registered nurse, at least 18 years of age, english speaking, and a minimum of one year of er experience with direct patient care). nurses willing to participate contacted the researcher and scheduled an interview. participants were recruited from four upstate new york hospitals throughout four different counties. both urban and rural hospitals were included to involve a more diverse sample considering the variation of services and experiences among hospitals. two urban hospitals and two rural hospitals from upstate new york participated in the study for the recruitment of er nurses. the urban hospitals consisted of a mean inpatient capacity of 366 (range 242 489) and mean er capacity of 24 (range 12 35). the rural hospitals consisted of a mean inpatient capacity of 22 (range 20 23) and mean er capacity of 3 (range 2 5). participants the participants (n=10) were equal in gender (five male and five female). rural er nurses (n=6) were equal in gender (three male and three female) and were predominately caucasian, ages 40 49, associate degree prepared, lived in a rural area, and had little experience working online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 64 in an urban setting. urban er nurses were equal in gender and were predominately caucasian, age 30 39, lived in an urban area, and had little experience working in a rural setting. education among urban nurses was equally represented with associate and baccalaureate preparation. religious affiliation among both urban and rural nurses was predominately christian. rural nurses averaged 15.4 years of nursing experience (range 5 to 30 years) with an average of 12.6 years er nursing experience. they averaged 1.3 years of nursing experience in an urban setting (range 0 to 3 years). urban nurses averaged 11.25 years of nursing experience (range 6 to 18 years) with an average of 9.7 years er experience. the urban nurses averaged 1.5 years of nursing experience in a rural setting (range 0 to 6 years) (table 1). rural and urban was defined by rural urban commuting area codes (rucas) (rural health research center, nd). table 1 demographics of participants urban rural total male 2 3 5 female 2 3 5 age (mean years) 35 48 rn (mean years) 11.25 15.4 urban er (mean years) 9.7 1.3 rural er (mean years) 1.5 12.6 total participants 4 6 10 data collection data were digitally recorded and collected by the primary investigator using semistructured interviews. the primary study involved grounded theory methodology as outlined by corbin and strauss (2008). data were collected in accordance with constant comparative analysis and theoretical sampling. data collection was complete once no new data emerged and online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 65 saturation was achieved. all data were transcribed by the researcher and rechecked twice against the recordings. trustworthiness was determined using three criteria, credibility, dependability, and confirmability (polit & beck, 2012). credibility was supported by the degree of involvement with participants. in addition, brief summaries were shared with participants to confirm accuracy of their data. dependability was maintained through a clear audit trail including memos, notes, and journaling documents. confirmability was established by sharing data with experts seasoned in qualitative research and grounded theory. summaries and themes were shared and confirmed by participants. in addition, a participant and er nurse nonparticipants related the results to their personal experiences. primary study the primary analysis revealed twenty-nine concepts producing five categories. the categories, also seen as phases, were labeled preparing caring, immersion, making sense, changing gears, and reflecting. the sub-processes found throughout the categories were based on the common threads of focus, feelings, and conflicts (table 2). table 2 categories and sub-processes categories preparing caring immersion making sense changing gears reflecting su bpr oc es se s focus preparing self giving your all building a bigger picture customizing needs judgment feeling hope detached emotion frustration relief delayed emotion conflict readiness distraction knowing consensus coping online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 66 preparing caring takes place prior to the nurse encounter with the patient. nurses gathered information about the impending encounter to prepare what to do next. immersion was the second phase. once the nurse encounters the patient, his/her focus was primarily on the patient. as the situation deemed more critical, the nurse’s focus intensified. nurses responded almost instinctively. the third phase was making sense. nurses described a trigger factor causing them to step back and reassess the situation. they questioned their skills, equipment, and knowledge. they were making sense of the situation to plan what to do next. the fourth phase was changing gears. nurses inferred aggressive efforts were exhausted although curative efforts may or may not have been formally discontinued. nurses’ prioritized care directed toward a good death and highlighted psychosocial skills. reflecting, the fifth and final phase, routinely did not take place until after the nurse left the workplace. nurses’ experiences evoked reflection, critique, and evaluation. they were able to vividly recall specific details from experiences ten or more years earlier. caring was the driving medium through the transitioning phases as nurses responded to what was needed next. the sub-process conflict was found to be a moderating factor. transitioning was influenced by the degree of conflict experienced during a particular phase. the integrated model, caring driven illustrates the nurse’s transitioning from the curative care role to the end-of-life care role (figure 1). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 67 figure 1. caring driven note. integrated model adapted from “the personal transitioning of emergency room nurses when care changes from curative to end-of-life: the rural influence,” by r. a. rolland, 2014, proquest dissertations and theses. copyright 2014 by proquest. the matrix and model for caring driven remained constant throughout the rural and urban data. nurses moved through the phases in a forward motion; however, the movement through the process was greatly influenced by the degree of conflict. unlike many transitions that portray a linear model, the cyclic model captures that every experience influences the nurse’s baseline online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 68 preparedness and readiness for the next event with caring for a patient where the focus of care changes from curative to end-of-life. secondary analysis content analysis a secondary analysis was conducted using deductive content analysis (polit & beck, 2012) and incorporated rural nursing theory. data were reviewed for content that exemplified the theoretical statements and concepts of rural nursing theory within each category of caring driven: preparing caring, immersion, making sense, changing gears, and reflecting (table 3). a description of the categories and supportive data will follow. preparing caring. rural characteristics were most visible in this category. nurses familiarized themselves with their resources and environment and prepared for probable situations. although both rural and urban nurses triaged and treated patients, the goals were somewhat different. while urban nurses may hold and treat serious patients in larger ers with access to diagnostics and advanced procedures, rural nurses focused on stabilizing and transferring seriously ill or injured patients. rural nurses usually knew early into the patient encounter if transfer would be necessary. although all the nurses prepared to care for patients in an emergent situation, rural and urban nurses prepared somewhat differently given the resources, the purpose, and capabilities of their specific facility. most rural nurses worked or volunteered in the community as well, usually with a fire department or ambulance corps. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 69 table 3 theoretical statements within caring driven theoretical statement 1 theoretical statement 2 theoretical statement 3 preparing caring if i don’t, who’s going to . . . i can do it so i need to do it. you have to know them (resources) out here in the rural setting because, if you don’t, you can get in trouble very quickly. maybe 90% of the time it’s people that we know. immersion when he went into cardiac arrest, it was a son and the brother-inlaw who were doing cpr on him in the back of the pickup truck 20 miles out. i would say after about 20 minutes of giving him meds, having him asystole, on the monitor, we intubated him. . . by that time the doctor was in. the family was helping (in the er) because they were hunting with him and they ended up bringing him in. making sense time is brain, time is heart, time is everything. the biggest resource we have is the staff that stays here, that gains the knowledge, every nurse here because sometimes you’re alone. with that gentleman, it was like i couldn’t do anything right.. what else could you do?” changing gears it’s almost like i flip a switch in myself. cpr, ivs, breathing for the patient, all that other stuff . . . you don’t need that anymore. somebody had to see what the family’s needs were at that time. i had a real emotional tie to that as a friend and people that i work with so i wanted do more and more and a lot more. reflecting he wanted help and we didn’t get their soon enough. i always feel that we’re limited at what we can do because we are a small size but, what we can do, we do very well. it was really hard seeing my neighbor die. the health and well-being of a community depended on the skills and knowledge of its dwellers. eric was committed to help maintain health in his community. after the death of a young boy, he questioned continuing in the field healthcare. then he thought, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 70 if i don’t, who’s going to? i care enough to do this and i’m knowledgeable enough, so why waste that. and even though it’s not a comfortable situation all the time, and sometimes it’s very uncomfortable the situations we’re put in, i can do it, so i need to do it. the perception of isolation and the concept of distance influence health and a way of life in the rural community. edgar was a nurse in the er, as well as a member of the ems, and noted the ambulance covered over a twenty mile radius. although rural nurses recognized the barrier of distance, they did not see themselves as totally isolated. technological resources such as telestroke and tele-medicine gave nurses the tools and information needed to care for patients and stabilize for transport. when melissa was asked if she felt isolated, she answered, “no,” and expanded further about her perception and effect of distance and time. i know that a helicopter is eight minutes away. . . there is some frustration. . . we may need an ambulance and it’s going to be a two hour eta. ok, we are going to find the next thing. it may be the helicopter. it may be calling a local volunteer ambulance. medical staff may not be on site when patients first arrive. nurses were self-reliant and required advanced training to prepare and take charge of situations until medical staff was available. the nature of the er was described as not knowing what was coming in next. many times nurses were alerted by scanner and emergency medical services (ems) correspondence. other times patients walked in unannounced. rural hospitals were minimally staffed in the er with nurses within the hospital who are cross-trained to assist in the er when needed. one remote rural hospital did not staff the er around the clock, but opened the er when needed. rn staff within the facility were trained and prepared to address emergency situations. eric described the operations of his particular er. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 71 we cross-train to work together all the time; so there is nobody in the er. the lights are off all day long…if someone comes in and they want to be seen in the er, there is a little cord and they pull it. we get this buzzer at the nurse’s station and we have to go down and reset the cord. melissa worked in various settings and compared working at a larger hospital that having more staff and resources narrowed your responsibilities, autonomy, and accountability. she explained: you have all your resources ready there. as a nurse, it is nice to say, “i need something,” and respiratory is there… i had the intensivist there (larger hospital)…but i really didn’t have to think a whole lot. i mean, i did but, there was always somebody higher. . . i felt kind of distant from that care. i wasn’t able to be more of a one on one team. i did feel like part of a team but, it was a very large team. here we have the resources as well. people were a phone call away. i am now responsible, which could be a good or bad thing but, i am more responsible of having to do that breathing treatment. is it working? if not, are they on the ventilator? do i adjust the settings? you know what you need to do? i am always a phone call away from somebody. i have my computers. melissa continued to explain the importance of being connected and knowing your resources. “you have to know them (resources) out here in the rural setting because, if you don’t, you can get in trouble very quickly.” the concept of insider and outsider as perceived by the residents (dwellers) and community was demonstrated through the connectedness and relationship of the rural dweller with the healthcare system and providers. many nurses recognized the comfort and value the residents online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 72 ascribed with the local facilities and providers and the reluctance to travel outside the community even for a higher level of care. melissa shared how she saw her patients and community dwellers’ perception about transferring to an outside facility. you have people who are about forty five minutes just from us let alone and now adding another hour on to that for them to go to ____. you have a lot of elderly people here …“i have come to this hospital for years, if you guys can’t fix me then don’t worry about it.” bill spoke of a close relation and her reluctance to travel to a larger hospital with a higher level of care to manage her cancer. “she didn’t want to go anywhere else. . . she said she loved __ hospital. . . but, she liked this little hospital and knowing all the nurses.” melissa reiterated, our hospitalist will come down and talk with them and make them aware of what is available. a good portion of the time, they are able to convince them to go. but some of the elderly, no. they are like, “i have had a good life. i’m ok with this and just let me either go home or could i go upstairs?” … some people are very adamant. they don’t want to go to a bigger place. . . they just don’t feel like they get that same care. judy relayed her feelings about treatment at a larger hospital while caring for a close relation, “you are a number. you are a patient just like everyone else. . . in the cancer center you were just a number. up here in the rural area you are family.” the data captured nurses’ familiarity and lack of anonymity among the rural community among. gabrielle clearly illustrated, “a lot of the time, maybe 90% of the time, it’s people that we know, like community members, friends, and family members of people we work with.” melissa depicted, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 73 being in that small community, they know you. i can’t go to the grocery store without having anybody asking, “how is so and so doing?” or “hey, i feel much better!” sometimes it is a benefit and sometimes it is not so much of a benefit. you want to go under cover but, they know that and they respect that. eric made a point to note that he was not familiar with a particular patient, “this was someone i didn’t know. he was passing through town, just happened to be going through.” rural nurses prepared themselves knowing the majority of the patients they encountered were known or familiar to them personally or through a relation. when asked to recall a situation or patient encounter rural nurses spoke of how they knew the patient before they went into details about the encounter. gabrielle recalled a young man, “a young man we took care of jl. maybe he was 45; i don’t think he was even that old. he was a smoker and drinker and a very nice guy and you see him out all the time he was very nice.” bill captured the relationship and connectedness of the community and staff. it was a situation two houses down. actually we lived in __ for 15 years. we ended up selling our house to the gentleman i am talking about. he ran a business...was a very good friend … his wife went on to nursing school and was very good friends with my wife…so anyway we ended up selling them our house. there was a call one night that he had collapsed on the floor. at the same time his brother was a family nurse practitioner practicing here. immersion. immersion encompassed both urban and rural nurses with minimal components specific to rural communities. nurses engaged in aggressive life-saving measures with little room for emotion or distraction. nurses described their actions as robotic, mechanical, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 74 and instinctive. rural dwellers are self-reliant to do what was necessary when it is necessary. gabrielle shared the experience of a patient and his family, “ when he went into cardiac arrest, it was his son and the brother-in-law who were dong cpr in the back of a pickup truck 20 miles out.” physicians were on call and may not be on site. in some instances, a nurse practitioner may be the first line to medical staff. nurses were self-reliant and responded to a situation until medical staff arrived. gabrielle recalled a situation where she was in charge, “i would say after about 20 minutes of giving him meds, having him asystole, on the monitor, we intubated him. . . by that time the doctor was in.” since resources for the family can be limited in rural hospitals, family’s needs may distract the nurse who is immersed in aggressive or resuscitative efforts. however in emergent or critical situations, rural families either stepped back to not interfere or helped as an extra set of hands as previously noted by gabriel about family members doing cpr, “the family was helping because they were hunting with him and they ended up bring him in.” eric recalled a family choosing to gather in the waiting room as opposed to witnessing resuscitative measures assuming the family did not want to disturb efforts. although he did recognize the presence of the family, consistent with urban nurses, his focus was on the patient. they were there when we first started. we turned and said, “this is what’s going on. you can stay if you want to.” they all went out because they wanted to. i think more they wanted to get out of our way so we could do everything we could do. because of it being such a small er, it’s a small room. they didn’t want to be in our way. they wanted us to be able to do everything we could, so they stepped out. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 75 urban er nurses struggled more with distraction and disruptive family members or visitors. other staff was usually called in to address such issues. rural ers typically did not have additional staff on hand and was perhaps sensed by families and visitors. in other situations, lack of anonymity led to distraction where family members contacted the nurse instead of the designated contact person for the family. emotions and familiarity were discarded and set aside. edgar explained, getting chest tubes, trying to get the blood out of his chest, his heart starts beating again and we are getting a blood pressure…i think you are in the heat of it technically and you don’t allow that emotional aspect of, wow, this is somebody’s son. this is somebody’s boyfriend. this is somebody’s brother. making sense. the third category, making sense, focused on the nurse’s perception and effectiveness of aggressive efforts. the nurse’s prior experience and knowledge influenced nurses transitioning through this pivotal phase. nurses gathered information to support aggressive curative efforts or were such efforts exhausted. trigger factors allowed nurses to step back and reassess the situation. time and distance were a trigger factors and indicated survivability. melissa conveyed, “time is brain, time is heart, time is everything.” bill explained the importance of experienced recourses, “the biggest resource we have is the staff that stays here, that gain the knowledge, every nurse here because sometimes you’re alone.” eric spoke of a seasoned nurse, who had the knowledge and experience to build a bigger picture of the situation at hand, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 76 she said that she could see it coming. but i didn’t see it. . . i really didn’t realize the extent of it. i just had this belief that we were going to get him back. this is just a quick temporary thing. familiarity influenced personal conflict and frustration. bill illustrated with a gentleman he had known coded. although the gentleman had a history of cardiac disease, knowing the patient influence an internal conflict to exhausting efforts, “but then, with that gentleman it was like i couldn’t do anything right. you felt like okay i should be doing something more. what else could you do?” changing gears. the fourth category, changing gears, the nurses focused care on palliative and end-of-life needs. one nurse depicted, “it’s almost like i flip a switch in myself. cpr, ivs, breathing for the patient, all that other stuff . . . you don’t need that anymore. your focus is changing.” nurses may have internally transitioned to consider end-of-life needs while still physically performing curative measures. although bill was formally involved in resuscitation efforts, he saw them as not effective. his personal focus then changed to include the family, “i made the decision this person is not going to live…number one, somebody had to see what the family’s needs were at that time.” nurses staged the environment to help comfort the families and ease them through the death of a loved one. eric explained, so my focus at that point was making it look like what they (the family) are going to remember the rest of their lives. i don’t want them to see him naked covered in vomit. i want them to see him lying in a bed, peaceful, with his eyes closed. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 77 nurses expressed relief when all persons were in consensus. familiarity influenced the consensus to exhaust efforts and implement end-of-life care. expanding on bill’s earlier experience, familiarity conflicted with consensus, i’ve been in so many codes. i think each one is different. i think the one with ___, i had a real emotional tie to that as a friend and people that i work with so it’s like i wanted do more and more and a lot more. both rural and urban nurses struggled when patients were younger in age. curative efforts typically extend for a longer period of time yet, familiarity compounds the situation. eric delayed transitioning when a code was called a young gentleman with acute bacterial meningitis, “he was at the store last tuesday. now he’s dead in front of me.” reflecting. nurses reflected and judged the various stages of the patient encounter that all that could be done was done. melissa explained, “i think not knowing that you didn’t do something that you could have done would have been way worse to know.” time and distance was usually out of the nurse’s control however; it impacted how nurses judged the outcome. edgar recalled a situation where distance was a factor with a man calling 911 in respiratory distress, “he wanted help and we didn’t get their soon enough. . . it took about over ten minutes to get there and his heart stopped.” eric recognized strengths and resources of the rural hospital that all could be done within their capabilities. i always feel that we’re limited at what we can do because we are a small size but what we can do we do very well. and that is attributed to us all getting along so well and being able to go to each other when we need to. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 78 cody had worked in a rural and urban er. although he valued the close relationship of the rural hospital, he reflected about a patient when resources were limited, there were times when i worked at the smaller hospital where i felt we barely got through the night . . . we barely provided care that we are supposed to. and that’s not our fault, because we do everything we can, but it’s just we were poorly staff or we got slammed. you do the best you can. you go home feeling, “ok, this sucks.” i didn’t do the best i could because we didn’t have the resources. we could have helped that patient a 100 times better. here (in a larger urban hospital), i’m sure it happens but, it’s far less because there’s better staffing and there’s more ancillary help, more help just in general. emotions were typically delayed until after their shift or later at home. judy relayed, i guess i put up a strong front in front of people but it’s…it hurts really bad you know when you go home you are like, oh god, how could that have happened? oh god, these poor people. how are they going to get through this?’ but, we all get through it. again, familiarity played a role. gabrielle shared that her personal coping mechanism where she was able to calm herself was getting more difficult as time passed due to the personal connection with patients. once you have your adrenaline and when the adrenaline stops it’s like calm. i was calm. but the more i go in nursing; i find the more years i’ve done it and the more experiences i have, i find that i am losing the calm. that once it wears off that i’m more upset and i find it harder to control my feelings. judy expressed her feelings of familiarity influencing coping. “i’m disconnected because i am not related to them. it was really hard seeing my neighbor die. it was really hard seeing this online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 79 mother, who i know, her child die.” gabrielle expressed the importance of closure when taking care of a patient for an extended length of time, “we follow them from the er to the floor and i know if i’m off and i’ve been taking care of this patient i attend the calling hours.” bill was comforted that he was able to be there to care for friend who died in the er, “and i just remember the wife hugging me and saying i’m glad we were there, it was like …i don’t know.” discussion rural concepts and characteristics were most evident in the first category preparing caring. the concepts of familiarity and connectedness were common components throughout all categories. conflicts within the model influenced nurses transitioning from curative to end-oflife care. familiarity and resources were evident among such conflicts. nurses in this study agreed that resources are imperative to streamline effective care however, the perception of resources varied. self-reliance, knowledge, and experience were essential for the rural er nurse. mentoring newer nurses will help build confidence and independence. three areas of concern resulted from this study. gaps in education, staff resources, and personal and professional support may affect rural nurses transitioning from curative to end-oflife care. addressing these areas will assist rural nurses caring for patients and families at end of life. education. nurses gained information from several sources. nurses need a strong foundation of knowledge and access to information to make critical decisions while planning appropriate care to best serve patients and families in crisis. a pivotal point of transitioning was when nurses recognized aggressive curative efforts were exhausted. patient care then required a different focus considering end-of-life needs. nurses shared they were thinking of the patient’s online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 80 and family’s end-of-life needs before aggressive efforts were formally discontinued. nurses who were less experienced delayed transitioning to the end-of-life care role. critical situations in the er can change abruptly; therefore, the nurse’s focus must also change to effectively plan the care for patients where death is imminent. formal education including the elements of end-of-life care in curriculum is essential to effectively and efficiently transition from the curative care role to the end-of-life care role. end-of-life care essentials are a necessity with orientation to any healthcare facility. encouraging staff to attend conferences and seminars on end-of-life care is vital for current information and imperative with professional development. in addition, annual face-to-face in-services should be mandated to ensure staff is current with end-of-life care issues. rural nurses face barriers and obstacles with education. continuing education will help strengthen assessment and end-of-life skills to better identify patient and family needs during critical situations and prepare for end-of-life care. penz and colleagues (2007) recognized the barriers to continuing education activities among rural nurses include distance, time, and financial constraints. scheduling time to travel to conferences can be difficult with limited staffing (penz et al., 2007). technological advances allow for teleconferences and streamlining workshops. such opportunities are encouraged to bring the current education to remote areas. staff resources. nurses held staff resources in high regard. nurses typically recalled what staff was available during a specific event and its impact on their experience. staff resources affected all phases of transitioning in various capacities with educational, professional, and personal support. norton and colleagues (2011) advocate for er nurse-to-patient ratios 1:1 or 1:2 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 81 when a nurse is caring for a patient at end-of-life. in addition, the authors recommend a multidisciplinary team be available for family, spiritual, and social needs (norton et al., 2011). this study revealed the importance of staff resources for nurses to allocate adequate time and various tasks to best address patient and family needs. in addition, personal support for both seasoned and novice nurses were found important for coping. achieving adequate staffing has been a challenge in most acute care settings (american nurses association, nd). smaller and more remote hospitals face a greater challenge with staffing where support staff were commonly on-call and may not be readily available. strategies to address staff resources remain an area to explore. mentoring. nurses in this study recalled how they, as newer nurses, felt overwhelmed and unprepared when caring for a patient where curative efforts were exhausted. nurses empathized with newer nurses having difficulty with traumatic events. arbour and wiegand (2014) acknowledged the various roles nurses assume when curative efforts are discontinued. the authors stressed the importance of mentoring to educate and prepare newer nurses to employ such complex roles. mentoring newer nurses involves a supportive relationship focused on knowledge, professional practice, and career development (mills, francis, & bonner, 2007).mentoring influences several areas including clinical decision-making skills (seright, 2011), feelings of professional isolation, and psychosocial support (medves, edge, bisonette, & stansfield, 2015). such factors impact performance and retention of staff resources. supporting newer nurses with mentoring will subsequently create new mentors for future nurses. limitations online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 82 human recall is a limitation that can threaten the accuracy of data (hassan, 2005). the researcher must consider the data reported as truth; however, it is realistic to acknowledge human error or gaps in memory. other limitations included the homogenous sample of caucasian participants and only two settings within one state. implications for nursing the nurse is an enduring presence at the bedside and vigilant to patients’ needs. nurses moved through the phases of caring driven in a forward manner impelled by what was needed next. conflicts foster a more difficult or problematic transitioning process. establishing and strengthening support mechanisms will countervail the influence of conflicts on nurses transitioning roles in the er. rural nurses in this study identified knowledge and resources as barriers with end-of-life care in the er setting. meleis (2010) referred to such barriers as insufficiencies. supplementations with education, staff resources, and mentoring may help nurses transitioning their role from curative to end-of-life care. future research future research is needed to further explore the effect of education, staff resources, and mentoring on rural nurses transitioning from the curative care role to end-of-life care. general policies and recommendation may not suit the structure of rural health care systems. research involving rural populations will produce valuable data to assist and support nurses caring for dying patients and their families in rural communities. conclusion emergency room nurses are exposed to a fast pace setting where patients often present in a life threatening crisis. education, resources, and support are essential components for nurses online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 83 caring for patients and families facing death (bailey et al., 2011). education, staff resources, and mentoring may help nurses transition smoothly and effectively to the end-of-life care role. continued research in this area will further clarify the needs and effective measures to support rural nurses caring for patients and families at end-of-life. funding source omicron alpha chapter, sigma theta tau international references arbour, r.b., & wiegand, d.l. (2014). self-describing nursing roles experienced during care of dying patients and their families: a phenomenological study. intensive and critical care nursing, 30, 211-218. http://dx.doi.org/10.1016/j.iccn.2013.12.002 american nurses association. (nd). nurse staffing. retrieved from http://www.nursing world.org/mainmenucategories/thepracticeofprofessionalnursing/nursestaffing bailey, c., murphy, r., & porock, d. (2011). trajectories of end-of-life care in the emergency department. annals of emergency medicine, 57(4), 362-368. http://dx.doi.org/10.1016/j. annemergmed.2010.10.010 beckstrand, r. l., gile, v. c., luthy, k.e., callister, l.c., & heaston, s. (2012). the last frontier: emergency nurses’ perceptions of end-of-life care obstacles. journal of emergency nursing, 38(5), e15-e25. http://dx.doi.org/10.1016/j.jen.2012.01.003 center of disease control and prevention. (2013). health, united states, 2012. retrieved from http://www.cdc.gov/nchs/data/hus/hus12.pdf corbin, j., & strauss, a. (2008), basics of qualitative research (3rd ed.). los angeles: sage. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.396 84 hassan, e. (2005). recall bias can be a threat to retrospective and prospective research designs. the internet journal of epidemiology, 3(2). retrieved from http://ispub.com/ije/3/2/13060 lee, h .j. & mcdonagh, m. k. (2013). updating the rural nursing theory base. in c. a. winters.(4th ed.), rural nursing: concepts theory, and practice (pp. 15-33) .new york: springer. long, k.a. & weinert, c. (1989). rural nursing: developing a theory base. scholarly inquiry for nursing practice: an international journal, 3, 113-127. medves, j., edgae, d.s., bisonette, l., & stansfield, k. 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(doctoral dissertation, state university of new york, binghamton) proquest dissertations and theses. retrieved from http://search.proquest.com/docview/1564222242 rural health research center (nd). ruca. retrieved from http://depts.washington.edu/uwruca/ seright, t. j. (2011). clinical decision-making of rural novice nurses. rural and remote health, 11(3), 1-12. online journal of rural nursing and health care, 2(1) 24 restructuring rural health care: expanding the pace for rural elders jeanette l. vandermeer, dsn, rn1 grant t. savage, phd2 jullet a. davis, phd3 1 assistant professor, capstone college of nursing, university of alabama, jvanderm@bama.ua.edu 2 professor, college of commerce and business administration, university of alabama, gsavage@cba.ua.edu 3 assistant professor, college of commerce and business administration, university of alabama, jdavis@cba.ua.edu abstract the balanced budget act (bba) of 1997 created an opportunity for improving long-term care for the rural frail elderly by granting permanent provider status to the program of all-inclusive care for elders (pace) under medicare. pace is a unique managed care model that provides comprehensive, integrated acute and long-term services for frail elders and program providers assume full financial risk. however, all existing pace sites are currently located in urban settings. this article reviews the pace provisions in the bba legislation and describes the current pace model. two possible adaptations of the model are discussed for expanding pace into rural areas. keywords: balanced budget act of 1997, long-term care, rural, frail elders, family caregivers, program of all-inclusive care (pace), medicare restructuring online journal of rural nursing and health care, 2(1) 25 restructuring rural health care: expanding the pace for rural elders comprehensive long-term care includes the sum of health, social, housing, transportation, and other supportive services needed by people with physical, mental, or cognitive limitations that compromise independent living (binstock, cluff, & vonmering, 1996). currently, long-term care in the u.s. is a costly, fragmented non-system that emphasizes sickness care rather than a comprehensive, integrated package of health, rehabilitation, and social services (evashwick, 1996). many rural elders would be able to remain at home if support services were available, such as meal preparation, housekeeping chores, medication management, and personal care. this article examines the provisions of the balanced budget act (bba) of 1997 and the medicare, medicaid, and schip balanced budget refinement act (bbra) of 1999 related to the program of all-inclusive care for elders (pace). pace is a unique managed care model that currently provides comprehensive, integrated acute and long-term care services for frail elders in urban settings. this article reviews the pace provisions in the recent legislation and describes the current pace model. two possible adaptations of the model are also discussed for expanding pace into rural areas. the growing need for rural elder care in rural areas, persons aged 65 and older make up a larger proportion of the population than is found in urban areas, 18% as compared with 15% (rogers, 1999). the number of rural elders varies from region to region, with the largest percentage concentrated in the south and midwest portions of the united states (ricketts, 1999). smaller, rural communities with less than 2,500 residents consistently have the highest proportion of older persons across all age categories. because older persons are at greater risk for disability and chronic illness, they are substantial users of medical and social services. the projected increase in the proportion of online journal of rural nursing and health care, 2(1) 26 elderly in the population will have a tremendous impact on future long-term care delivery systems, especially in rural communities. in many rural communities, health care services for the elderly are less accessible and more costly to deliver than in urban areas (bull, howard, & bane, 1991; liken & king, 1995; ricketts, 1999). the larger proportion of low-income individuals, especially elders, in rural areas also leads to a smaller tax base to support local social and health services (rogers, 1999). between 1980 and 1990, the poverty rate for older persons living in rural counties increased. the poverty rate ranges from 12.8% for elders living in counties with populations of 20,000 adjacent to a metro area to 20.6% for those in rural, nonadjacent counties. older women are also more apt to be poor than are older men (rogers, 1999). rural elders receive a higher proportion of their income from social security, but they receive lower average monthly benefits than those living in urban areas and are more apt to be classified as "poor" or "low" income (ricketts, 1999). the most economically vulnerable cohort is the rural population over the age of 85 (rogers, 1999). currently, there is no reimbursement under medicare for non-skilled eldercare in any setting, such as personal care services and/or supervision for those with cognitive impairment. medicare home health benefits are limited to skilled services related to an acute illness or exacerbation of a chronic illness and only for homebound elders. moreover, family members who provide home care for their rural elders who have chronic illnesses and dementia must also pay out-of-pocket for any respite services. additionally, medicare part b provides no coverage for prescription medications. the elderly who reside in rural areas—and their caregivers—are forced to deal with additional difficulties that may not impact those living in urban areas. in rural areas, there is limited availability of local health and social service providers, lack of transportation, and online journal of rural nursing and health care, 2(1) 27 frequently vast distances for elders and their families to travel to obtain needed services. in addition, elderly poor have limited access to support services, often have inadequate nutrition and sub-standard housing, and are less apt to be healthy (rogers, 1999). clearly, better models are needed for delivering comprehensive long-term care in rural communities where many vulnerable elders reside and disparities exist between health needs and resources. according to aaronson (1996), health services organizations are products of the way in which the services they deliver are financed. a major impediment to the development of a continuum of long-term care, especially for rural community-based elders is the lack of a system of financing services for individuals with complex and, frequently, chronic care needs. how the bba and bbra increased provisions for pace one of the most promising provisions for restructuring the current system of eldercare in the u.s. was included under subtitle i of the bba of 1997 (u.s. congress, 1997). this legislation granted permanent provider status to the program of all-inclusive care for elders (pace) under medicare. state medicaid agencies were also given the option to include pace as a medicaid benefit. the bba of 1997 granted the 23 existing pace sites, serving approximately 7,000 enrollees, permanent status as medicare providers. the legislation raised the cap on the number of programs to forty in 1998, with a provision for 20 new programs each year thereafter. the opportunity for 10 for-profit organizations to become new demonstration sites was also included in the legislation (hansen, 1999; rupri, 1999). in the bbra of 1999, there was only one provision that specifically addressed pace. subtitle cdemonstration projects and special medicare populations, section 536 extended the medigap “guaranteed issue” protections for medicare+choice plan enrollees to all pace participants (u.s. congress, 1999). online journal of rural nursing and health care, 2(1) 28 pace provides for comprehensive, multi-disciplinary acute and long-term care services to frail elders who are certified eligible for nursing home placement. objectives for the program are fourfold: (1) enhancing the quality of life and autonomy for frail, older adults; (2) maximizing the dignity of, and respect for older adults; (3) enabling frail older adults to live in the community as long as medically and socially feasible; and (4) preserving and supporting the older adult's family unit (national pace association, 2001). the health care financing administration's goal vis-a-vis pace is to reduce the fragmentation of services and effectively integrate acute and long-term care services and financing into a single seamless system (vladeck, 1996). the pace model of care began in 1973 in san francisco as a community-based, adult day health center named on lok ("peaceful happy abode" in cantonese). in 1975, on lok added in-home support services and in 1978, hcfa provided a 4-year demonstration grant to include primary medical services. in 1983, on lok obtained waivers from both medicare and medicaid to test a new financing method for long-term care. capitated monthly payments were received from medicare and medicaid for each participant and on lok delivered the full range of services, including hospital care. in 1986, with additional grant support from several foundations, on lok began replication of the innovative service delivery and financing method in six additional public and nonprofit sites. at that point, the new program was renamed the program for all-inclusive care for elders (pace) (bodenheimer, 1999; eng, pedulla, eleazer, mccann, & fox, 1997; lee, eng, fox, & etienne, 1998). pace is the only program that integrates acute and long-term care service delivery and financing (lee, eng. fox, & etienne, 1999). the underlying philosophy of the program is that provision of intensive medical and supportive outpatient and home care services for frail elders online journal of rural nursing and health care, 2(1) 29 will save money by reducing rates of hospital and nursing home care. the two cornerstones of pace are (1) a multidisciplinary team approach and (2) the pace center. the pace center is an adult day health center attached to a full service medical clinic. the multi-disciplinary team includes primary care physicians, nurse practitioners, clinical nurses, home health nurses, social workers, occupational and physical therapists, dietitians, aides, recreational therapists, and transportation workers. typically, pace sites function as staff model organizations for primary care, with all clinicians employed by the site and salaried (bodenheimer, 1999). the entire team serves as care manager for each participant, without going through third-party payers. services may be provided at the pace center, in homes, or at inpatient facilities (see figure 1). center-based services include visits with the health care provider—physician, nurse practitioner, and/or social worker—meals, exercise, recreational activities, and educational sessions. other medical services can include visits with medical specialists, prescription drugs, x-rays and laboratory tests, and receipt of durable medical equipment and supplies. home care services include visits from the home health nurse, personal care, and chore services. other elder care services under pace include: case management; dental and vision care; nutritional counseling; physical, occupational and speech therapy; companion services; home-delivered meals; transportation; caregiver training; and respite for informal caregivers (eng, pedulla, eleazer, mccann, & fox, 1997). a pace provider must make available all items and services under title xviii (medicare) and title xix (medicaid) without limitations on amount, duration or scope, and without application of deductibles, co-payments, or other cost sharing. older adults who are financially ineligible for medicaid must pay out-of-pocket for the medicaid portion of the pace capitation. however, participants who are eligible for medicare only and who need fewer hours online journal of rural nursing and health care, 2(1) 30 of care services per week may be allowed to purchase a reduced or lower cost eldercare program (bodenheimer, 1999). according to the national pace association, certain organizations may have alternative tiered payments that complement their pace program. in 1998, the medicaid monthly capitation rate among all pace sites ranged from $1,750 to $4,301. once enrolled, a participant must receive services only from pace staff or contract providers authorized by pace staff (eng, pedulla, eleazer, mccann, & fox, 1997). expanding pace for rural elders how can we take the best aspects of pace and adapt the program for implementation in a rural setting? hansen (1999) states, "there is no one answer to caring for frail elderly, pace must fit into a variety of approaches that will be different in each state" (p.6). pace is primarily a program for low income, frail elders with eligibility in both medicare and medicaid. expanding pace into rural areas can create a lower cost package similar to the one currently available at on lok in san francisco. currently only about 5% of elders nationwide are certified eligible for nursing home placement, thus limiting the number of elders eligible for pace participation. in 1995, there were approximately 8.2 million persons over the age of 65 residing in rural places (ricketts, 1999). therefore, if 5% of the rural elders nationally are eligible for nursing home placement, then approximately 410,000 will qualify for enrollment in pace under current policies. this estimate of the potential beneficiaries for a rural pace initiative is conservative. it does not take into account either the growing number or the generally poorer health of rural elders (rogers, 1999), nor does it account for potential easing of eligibility policies for rural pace enrollees. online journal of rural nursing and health care, 2(1) 31 what have we learned from pace? coordination and support are necessary for success. during the early years, several hospitals that sponsored the programs found themselves in the unfortunate position of having to absorb pace program losses. therefore, it is important that the rural hospital or community health center sponsoring the pace is financially stable and has sufficient resources to assist in program development. furthermore, since reimbursement depends on enrollment, rural providers may need to assist with educating the community on the benefits of this program. during the early years of pace, several sites experienced problems with enrollment, which had a negative impact on program profitability (branch, coulam, & zimmerman, 1995). depending on client characteristics, not all clients may be appropriate candidates for pace programs. branch, coulam, and zimmerman (1995) compared seven pace programs with the on lok program and found that clients who exhibit disruptive behaviors, cognitive deficiencies, and substance abuse problems are less likely to be admitted into a program. therefore, for pace to be successful in rural areas, these programs need to provide mental health and other cognitive services for even the most difficult of clients if they are in the catchment area. although costly, these services may be necessary to attract a sizable client base to ensure program success (branch, coulam, & zimmerman, 1995). staffing issues present a major obstacle to the success of rural pace programs. although the use of contract staff may offer a temporary solution, it may be too costly for longterm use. however, in terms of recruiting certain staff, one study found that nursing assistants who worked in five pace programs reported greater job satisfaction than those who worked in traditional nursing homes (friedman, daub, cresci, & keyser, 1999). two other staffing options might also be considered: online journal of rural nursing and health care, 2(1) 32  local community residents who are employed or retired can be hired and trained as pace personal care workers. they will receive the national standardized nursing assistant program and upon graduation, be certified by the pace program. these local workers will be assigned to provide all unskilled home care services to a limited number of frail elders. these workers will build a trusting relationship with the elders—and their caregivers—and spend as much time as required to meet each elder’s needs.  if family members are available, capable, and willing to receive the nursing assistant training, they can be "certified" as personal care workers and receive some payment for provision of eldercare services. family caregivers can also negotiate for relief from eldercare by requesting respite services from one of the local, trained personal care workers. two possible models the two cornerstones of current pace initiatives are (1) the pace center and (2) the multi-disciplinary team. on one hand, replicating this center-based, multidisciplinary model in a rural setting is possible. on the other hand, a home-based, multidisciplinary model might also be needed. under either model, the multidisciplinary team can consist of employees from the local hospital, plus contractual arrangements with others. in rural settings, there are limited numbers of primary care physicians, and elders may be reluctant to leave their physician. the rural pace site can make contractual arrangements with participants' private physicians to continue as their primary care providers. contracts can be negotiated with specialty physicians, dentists, optometrists, and podiatrists from both rural and urban locations. all of these contracted personnel will receive payments from the pace site. master's prepared nurse practitioners and/or nurse case managers will serve as coordinators for the multidisciplinary team. other online journal of rural nursing and health care, 2(1) 33 members of the team will be the hospital-based nutritionist, social worker, nursing aides, x-ray and laboratory personnel, and rehabilitation therapists. well elders who are able to live independently, and want to receive some of the pace center services, can be allowed to purchase a lower cost or partial program. enrollment strategies, similar to those used by the child health insurance program (chip), can be used to locate eligible elders and enroll them in the rural pace initiatives. personnel from the local area agency on aging (aaa) and the states’ department of human resources (dhr) can assist with the enrollment process. a center-based pace model for rural elders. probably the best site for the rural pace center is the local community hospital with an adjoining or nearby health clinic. alternatively, a community health center (chc) might serve as a suitable site. the hospital or chc can also consider the feasibility of constructing an adult day care center because these services are needed and pace capitated funds can be used to pay for day care services. a suitable building can be leased and renovated to forego the larger capital outlay for new construction. the number of frail elders in need of day care due to physical or cognitive impairment will probably support the center. provision of adult daycare will allow family caregivers to work outside the home and receive income and also some respite. many rural elders are dependent on home care provided by family members who may be unable or unwilling to be full-time caregivers, thus increasing the risk of elder abuse and neglect. the pace participants can be transported to the center by family members or receive transportation from vans provided by the hospital-based pace site or the area agency on aging (aaa). if a local hospital also operated a home health agency, those personnel can provide assistance for homebound elders as needed. hospital maintenance personnel can be used to online journal of rural nursing and health care, 2(1) 34 assess the appropriateness of housing for pace participants and make needed repairs and disability accommodations, such as constructing wheel-chair ramps. durable medical equipment for use by pace participants can be obtained through local providers. the hospital cafeteria can furnish meals for participants attending the pace site and meals for homebound participants can be obtained from the local aaa nutrition site. a home-based pace model for rural elders. some frail elders in rural settings will be unable to travel to the pace center due to physical or cognitive impairments. they may also require more supervision, meal preparation, and medication administration than is provided under the medicare visits from the home health agency. the nurse practitioner or nurse case manager overseeing the pace team will provide supervision for personal care workers. interdisciplinary team meetings will be held periodically to discuss each pace participant's plan of care. all members of the team, including the elder and participating family members, will make decisions about changes in the participant's plan of care. when a pace participant requires more care than can feasibly be provided in the home setting, alternative arrangements can be made. these arrangements can include admission to the local hospital-based pace center and/or to a community boarding home, assisted-living facility, or skilled nursing facility. of course, when facilities are used for eldercare that are not owned or operated by the hospital-based pace center, then contractual arrangements must be made for payment for participants' care. implications and conclusion the balanced budget act of 1997 began the process of restructuring medicare and provided a mechanism for extending and improving care for frail rural elders. pace provides a online journal of rural nursing and health care, 2(1) 35 unique managed care model for delivering and financing long-term care services to low-income, frail elderly 55 years old and older. commercial managed care plans have been reluctant to enter rural markets (mueller, 2001). pace sites, unlike commercial hmo's, have actually reduced costs for both the medicare and medicaid programs (bodenheimer, 1999). we discussed two different, but complementary models, for adapting pace to rural settings and providing comprehensive, integrated long-term care services that can be cost-efficient and acceptable for all elders. quality is a necessary and important component of health services delivery. in urban areas, there are many providers from which to choose; however, rural areas have disproportionately fewer providers. therefore, the likelihood that a chosen provider will offer substandard care may be greater in rural areas. the sponsoring hospital, community health center, or other institution will have to maintain strict oversight to ensure that providers meet appropriate standards and employ measures to correct any quality problems as quickly as possible. this may be a costly but necessary process, requiring additional staff. certainly, further research may be necessary to determine which quality measures and approaches are suitable for rural pace initiatives. for rural communities affiliated with academic health centers and related institutions, quality of care issues may be less prominent. indeed, university-sponsored health profession training programs should be encouraged to participate in rural pace initiatives. excellent opportunities for interdisciplinary training in rural elder care for students in medicine, nursing, social work, nutrition, and health care management will be available. faculty and students can also engage in empirical research, increasing the number of published studies on rural health services. online journal of rural nursing and health care, 2(1) 36 future research should focus on ways to solve the obstacles highlighted in this paper. while early reports suggest pace programs are successful in meeting the needs of the frail elderly, all of the programs studied are in urban areas. we suggested two methods for implementing pace in rural settings, but the implementation of these models will not be without some level of difficulty, given the nature of rural health care delivery. existing rural health providers will need to commit both financial and organizational resources to allow for innovations, restructuring, and fine-tuning. in other words, action-oriented research is needed to determine what modifications in the pace model may be necessary to ensure program success in rural settings. online journal of rural nursing and health care, 2(1) 37 references aaronson, w. (1996). financing the continuum of care: a disintegrating past and an integrating future. in c. j. evashwick (ed.), the continuum of long-term care: an integrated systems approach (pp.223-252). albany, ny: delmar publishers. binstock, r.h., cluff, l.e., & vonmering, o. (1996). the future of long-term are: social and policy issues. baltimore, md: johns hopkins press. bodenheimer, t. (1999). long term care for frail elderly people-the onlok model. new england journal of medicine, 341(17), 1324-1328. https://doi.org/10.1056/nejm199910213411722 branch, l.g., coulam, r.f., & zimmerman, y.a. (1995). the pace evaluation: initial findings. gerontologist, 35:349-359. https://doi.org/10.1093/geront/35.3.349 bull, c.n., howard, d.m., & bane, s.d. (1991). challenges and solutions to the provision of programs and services to rural elders. kansas city, mo: national resource center for rural elderly. eng, c., pedulla, j., eleazer, g., mccann, r., & fox, n. (1997). program of all-inclusive care for the elderly (pace): an innovative model of integrated geriatric care and financing. journal of the american geriatrics society, 45, 223-232. https://doi.org/10.1111/j.15325415.1997.tb04513.x evashwick, c.j. (ed.). (1996). the continuum of long-term care: an integrated systems approach. albany, ny: delmar publishers. https://doi.org/10.1056/nejm199910213411722 https://doi.org/10.1093/geront/35.3.349 https://doi.org/10.1111/j.1532-5415.1997.tb04513.x https://doi.org/10.1111/j.1532-5415.1997.tb04513.x online journal of rural nursing and health care, 2(1) 38 friedman, s.m., daub, c., cresci, k., & keyser, r. (1999). a comparison of job satisfaction among nursing assistants in nursing homes and the program of all-inclusive care for the elderly (pace). gerontologist, 39, 434-439. https://doi.org/10.1093/geront/39.4.434 hansen, j. (1999). practical lessons for delivering integrated services in a changing environment: the pace model. generations, 23(2), 22-29. lee, w., eng. c., fox, n., & etienne, m. (1999). pace: a model for integrated care of frail older patients. geriatrics, 53(6), 64-74. liken, m.a., & king, s.k. (1995). home health aide services: barriers perceived by dementia family caregivers. home healthcare nurse, 13(6), 60-68. https://doi.org/10.1097/00004045-199511000-00008 mueller, k. j. (2001, january 16). benefits improvement and protection act provisions: where do we go from here? retrieved from http://www.rupri.org/healthpolicy national pace association. (2001). national pace association home page. retrieved from http://www.natlpaceassn.org ricketts, t.c. (1999). rural health in the united states. new york: oxford university press. rogers, c.c. (1999). changes in the older population and implications for rural areas. (economic research services – rural development research report no. 90). washington, dc: us department of agriculture. rupri. (1999). rural implications of the medicare, medicaid, and schip balanced budget refinement act of 1999. columbia, mo: the rural policy research institute. u.s. congress. (1997). the balanced budget act of 1997, hr 2015. pub.l. no. 105-33. https://doi.org/10.1093/geront/39.4.434 https://doi.org/10.1097/00004045-199511000-00008 online journal of rural nursing and health care, 2(1) 39 u.s. congress. (1999). the medicare, medicaid, and schip balanced budget refinement act of 1999, hr 3426. pub.l. no. 106-113. vladeck, b. (april 18, 1996). long term care options: pace and s/hmo. statement before the u.s. congress, subcommittee on health, house committee on ways and means. washington, dc. microsoft word 281-1819-3-ed_quaranta.docx online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 97 interpersonal influences on the asthma self-management skills of the rural adolescent judith quaranta, phd, rn, cpn, ae-c 1 mallory wool, rn, bs 2 kayla logvis, rn, bs 3 kimberly brown, rn, bs 4 david joshy 5 1 assistant professor, decker school of nursing, binghamton university, jquarant@binghamton.edu 2 decker school of nursing, binghamton university, mwool1@binghamton.edu 3 decker school of nursing, binghamton university, kbrown10@binghamton.edu 4 decker school of nursing, binghamton university, kbrown8@binghamton.edu 5 college of community and public affairs, binghamton university, djoshy1@binghamton.edu abstract purpose: the purpose of this study is to understand how self-management behaviors of the adolescent with asthma are influenced by the perceived expectations (normative beliefs/subjective norms) for self-management behaviors from healthcare providers, school nurses, teachers, family and friends. sample: seven rural adolescents (five males and two females with an age range of 13-17 years) method: focus groups were conducted with analysis for common themes influencing management behaviors. results: the majority of participants perceived provider and parental expectations for asthma management as only consisting of medication compliance. the students did not report any online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 98 perceived expectations from the school nurse except independent inhaler use. there was no expectation to report use to the school nurse. the participants felt that their teachers were not aware of their asthma diagnosis; therefore, no expectations were noted. expectations from peers had no influence on self-management behaviors. conculsion: the results from this study demonstrate the influence of the expectations for asthma self-management by significant people in the adolescents’ life. the adolescents in this study were unable to identify what behaviors they needed to perform in order to control their asthma. except for taking their prescribed medications, no other behaviors were addressed by their health care provider, parents, friends or school nurse. the lack of expectation for other self-management behaviors that are essential for asthma control, such as knowledge of asthma symptoms, trigger avoidance and when to seek help during an asthma attack may be a leading contributor for uncontrolled asthma. asthma action plans, if consistently used by health care providers, parents and schools, can reinforce the expectation for behaviors that will result in good asthma outcomes. keywords: asthma, adolescent, self-management, theory of planned behavior, policy interpersonal influences on the asthma self-management skills of the rural adolescent the purpose of this study was to explore how asthma management behaviors of the adolescent with asthma are influenced by the perceived expectations (normative beliefs/subjective norms) for asthma management behaviors from parents, healthcare providers, peers, teachers and school nurses. normative beliefs are the perceived behavioral expectations of important referent groups or individuals. for this study, self-management behaviors were defined as (a) knowledge and avoidance of triggers; (b) knowledge and proper use of medications; (c) ability to identify asthma warning signs ; (d) the ability to take appropriate actions. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 99 adolescence is a time when asthma exacerbations may prove extremely detrimental, resulting in emergency room visits, hospitalizations, missed school as well as diminished health status. if the adolescent has been symptom free for an extended period, they may be unprepared to recognize or manage their asthma crisis. however, asthma management behavior is dependent upon more than just knowledge. expectations of people in one's life influences behavior (ajzen, 2006). this study proposes that asthma management activities will be more likely to occur if appropriate asthma management expectations are clearly defined. the need for effective asthma management for the adolescent is evident. more than ten million children in the united states (us) under the age of 18 years have been diagnosed with asthma and almost seven million still have asthma (bloom, cohen, & freeman, 2012). in 2011, the highest asthma prevalence rate (105.5 per 1000 population) was for ages 5-17 years. asthma attacks occur more often in those younger than 18 years, with prevalence rates of 54.6 per 1000 compared to 39.4 per 1000 in those older than 18 years. the disproportionate impact on children with asthma is further evidenced by the fact that approximately 29% of all asthma hospital discharges in 2010 were for children less than 15 years of age, even though they comprise only 21% of the us population (american lung association [ala], 2012). almost 38% of children with asthma younger than 18 years old report their current health status as fair or poor (bloom et al., 2012). between 2007 and 2009, children ages 0-17 years had higher emergency room visit rates compared with adults ages 18 and over (10.7 compared with 7.0 per 1000 persons with asthma) (moorman et al., 2012). in 2008, asthma accounted for an estimated 14.4 million lost school days in children with an asthma attack in the previous year (ala, 2012). children with asthma and their families may have difficulty determining when asthma is not under control. if asthma symptoms are not disruptive to family life, there may be little impetus to online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 100 seek care, thus increasing the risk for poor outcomes. price et al. (2002) surveyed parents and children with asthma ages 9-14 years old. sixty-five percent of respondents described asthma as well controlled, despite reporting at least weekly symptoms of difficulty breathing, nocturnal waking, dry cough or difficulty speaking due to asthma. similar findings were noted by dozier, aligne, and schlabach (2006) who found that parents considered their children’s asthma under control despite having missed school, experiencing asthma symptoms, needing unscheduled office visits, or using a rescue inhaler. parents’ perception of asthma control did not match the child’s reported symptoms in 42% of the cases. scores from the childhood asthma control test indicated that children perceived their asthma to be less well controlled than did their parents or adult caregivers (carlton, thompson, wan, conboy-ellis, & coates, 2010). circumstances of rural living compound the issues confronting the adolescent with asthma. distance to healthcare may impede seeking care until the asthma exacerbation becomes critical, at that point requiring emergency care and hospitalization. rural people typically define health in terms of ability to work (long & weinert, 1989). as long as the adolescent can complete the school day, asthma symptoms may be ignored, until an asthmatic crisis necessitates seeking treatment. lack of anonymity (long & weinert, 1989) found in rural culture can be a barrier to carrying out asthma management behaviors in a public setting, such as school. this lack of anonymity, coupled with the adolescent fear of “being different”, may deter the rural adolescent from sharing the asthma diagnosis with others and not performing the necessary asthma management behaviors. in addition, the most rural residents a 30% higher likelihood of being uninsured compared to urban residents, as well as being uninsured for longer periods of time. physician shortages in rural areas, combined with hospital closures in the past 20 years, and lack online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 101 of public transportation, create barriers to health care for rural residents (crosby, wendel, vanderpool, casey & mills, 2012). theoretical framework the theoretical framework guiding this study is the theory of planned behavior [tpb] (ajzen, 2006). according to the theory, if a person is in favor of doing a behavior, the behavior is more likely to occur. the individual must believe that the behavior will have desirable outcomes (attitude). the level of social pressure, or expectation, the person feels to do the behavior (subjective norm) and whether the person feels in control of the behavior (perceived behavioral control) determines if the behavior will actually occur. attitude toward the behavior, subjective norm, and perception of behavioral control lead to the formation of a behavioral intention. generally, the more favorable the attitude and subjective norm, and the greater the perceived control, the stronger the person’s intention to perform the behavior in question. aiming interventions at attitudes, subjective norms, or perceptions of behavioral control can change behavior. changes in these constructs may produce changes in behavioral intentions and with adequate control result in new behaviors. the construct of subjective norm is the focus of this study. review of the literature a review of the literature was conducted using cinahl (cumulative index of nursing and allied health literature) focusing on subjective norms. search terms included asthma, adolescent, asthma management, asthma self-management. articles that incorporated the referent groups of (a) parents; (b) health care providers; (c) peers; (d) teachers; (e) school nurses were contained in the search. these referent groups were used to organize the search. no articles were found that specifically looked at the asthma management behaviors of the adolescent with asthma online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 102 in relationship to the theory of planned behavior. studies that investigated subjective norms with the adolescent regarding other behaviors were included in the review of literature, as well as studies that discussed the above mentioned referent groups in terms of asthma management. parents no studies were found specifically examining the influence of parental influences on the asthma management of the adolescent using the theory of planned behavior as the framework. however, there were studies found that used the theory of planned behavior to investigate parental influence on other behaviors of the adolescent. kassem and lee (2004) examined soda consumption among male adolescents (n=564). the researchers examined the influence of parents, doctors, teachers, friends, restaurant owners, and everyone who drinks regular soda. results indicated that subjective norms were significant indicators of intention to drink regular soda. the referent groups with the most influence on soda-drinking behaviors were parents and doctors. kuther and higgins-d’alessandro (2003) explored the impact of perceived parental norms on alcohol use on eleventh grade students (n=87). parental norms were not found to be significant predictors of alcohol consumption for this age group. alcohol consumption behaviors occurred independent of the individual's perception of parental norms toward drinking. while not specifically addressing the theory of planned behavior and the construct of subjective norm, the literature demonstrated that parents greatly influenced asthma management behaviors for the child with asthma. parental knowledge as well as attitude toward the outcomes of asthma behaviors influenced the child’s actions. if the parent was uncertain about how to manage their child’s asthma, then the child had no referent point and was unaware of the expected norm behavior. children with parents who were more knowledgeable about asthma felt more competent to manage their asthma (barton et al., 2002; miles, sawyer, franz, & kennedy, 1995). online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 103 parents who feared their child having an asthma attack controlled and limited the child’s activities, making the child dependent on the parent for management, as the expectation was not geared toward self-management (rich, taylor, & chalfen, 2000). parents reported a lack of confidence in their ability to manage their child’s asthma and identified the need for more clear, consistent and correct education about asthma management. these parents viewed emergency room visits as a “fact of life” for children with asthma and something that could not be avoided with asthma management. parents were concerned about side effects of medications and were hesitant to use them, especially inhaled corticosteroids (taylor-fishwick, major, kelly, butterfoss, clarke & cardenas, 2004). maternal support was vital to the adolescent management of asthma symptoms. adolescents depended on maternal support for advice and confirmation of asthma management decisions (hughes, 2012); while the effect of paternal support was not considered in the hughes study. health care providers while no studies were found specifically citing the theory of planned behavior in relationship to the impact of health care provider’s expectations on the asthma management behaviors of the adolescent with asthma, the literature review highlighted the impact of health care providers on the adolescent with asthma. perceived expectations from health care providers influenced self-management skills and the likelihood of controlling asthma symptoms. studies revealed that students were reluctant to tell health care providers about asthma symptoms if the student did not want more medication to be prescribed or their activities to be restricted. students refrained from asking questions regarding their asthma, as they feared the provider would be irritated. a predominant theme was that students did not feel they had been given enough information by their provider to self-manage their asthma (van der meer et al., 2007; van es, online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 104 lecoq, brouwer, nagelkerke, & colland, 1998). hughes (2012) found that the adolescent with asthma did not take an active role with the health care provider if a parent were present during the appointment. the assumption was that the parent would obtain the information and assist the adolescent with this information when needed. peers review of the literature did not reveal any studies utilizing the theory of planned behavior with peer influence on the asthma self-management of the adolescent with asthma. however, a study by kuther and higgins-d’alessandro (2003) on alcohol consumption of adolescents demonstrated perceived peer norms positively predicted alcohol consumption and attitudes about the consequences of drinking. perceived favorable peer norms for alcohol consumption resulted in increased alcohol consumption as well as a more supportive attitude of drinking behaviors. this study validates the impact of peer subjective norms of the behaviors of the adolescent. if this relationship is a constant in the life of an adolescent, it is possible that the asthma selfmanagement behaviors of the adolescent with asthma are influenced by the peers in the adolescent’s environment. further studies provided insight into the influence of the peer group on adolescents with asthma. the literature has shown mixed results with respect to the influence of peers in the management of asthma by adolescents with asthma. studies indicated that middle school students did not want to be different from their peers. they reported denying their asthmatic condition, ignoring symptoms and attempting to hide their asthma in order to remain with their friends. other students reported not wanting to take their medications as this identified them as being different from their friends (ayala et al., 2006; rich et al., 2000; velsor-friedrich, vlasses, moberley, & coover, 2004). if instructions for treatment and care did not fit into their lifestyle, online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 105 the students were reluctant to carry their inhaler (kyngas, 1999; velsor-friedrich et al., 2004). students reported that it was difficult to turn down a friend’s offer to play basketball when the pollen count was high, even though the student with asthma knew an asthma exacerbation could result (kyngas, 1999). conversely, van es et al. (1998) identified that a majority of their subjects were inclined to tell others they had asthma, and that these students were not afraid to take their medications in front of their friends. students surveyed identified themselves as normal and viewed asthma as something they have to live with (horner, 1999). students who felt social support did not experience shame or feeling different when using inhalers (knight, 2005). teachers no studies were found in the literature review explicitly using the theory of planned behavior to examine the influence of school teachers on the asthma management behaviors of the adolescent with asthma. several studies were found that underscored the impact that teachers have on the adolescent with asthma resulting in decreased asthma management behaviors. students reported that teachers and coaches did not believe when they were having an asthma attack; students were accused of faking an asthma attack. this inhibited the student from reporting the attack and self-managing their asthma when an exacerbation occurred (ayala et al., 2006; horner, 1999; kyngas, 1999; velsor-friedrich et al., 2004). the normative beliefs of referent group, the teachers, resulted in the subjective norm of denying asthma symptoms and not practicing selfmanagement behaviors. school nurses the role of the school nurse for asthma management is defined by the national association of school nurses (nasn, 2011). provision of health care and health education, medication online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 106 administration, and collaboration with parents and providers are specifically identified as competencies of the school nurse. the literature indicated that school nurses were knowledgeable about asthma. they fulfilled multiple roles and functioned as required by law, but had little time for health promotion and prevention practices. few school nurses provided asthma education for their students with asthma. most of the school nurses had not participated in any asthma education in the past six months (calabrese et al., 1999). students with asthma acquired the greatest knowledge with multiple educators: (a) families; (b) schools; and (c) health professionals (paterson, nayda, & paterson, 2012). summary of literature review the lack of studies specifically investigating asthma management behaviors of the adolescent with asthma using the theory of planned behavior provided evidence for the need for the current study. research question the research question that guided this study was as follows: how do perceived behavioral expectations from parents, health care providers,peers, teachers and school nurses influence the asthma management behaviors of the adolescent with asthma? methods focus groups were the method used for this study. morgan (1997) characterizes focus groups as group interviews, with reliance on interaction within the group, based on topics provided by the researcher who typically takes on the role of moderator. this group interaction is the hallmark of focus groups, allowing for insights that would be less accessible without this interaction. self-contained focus groups serve as a principal data source, requiring a careful matching of the research goals with the data that the focus group can generate (morgan, 1997, online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 107 pp.2-3). binghamton university’s human subjects’ research review committee approved the study (protocol no. 994-08). adolescents with asthma from two rural middle/high schools participated in one hour-long focus group centering on interpersonal influences of parents, teachers, health care providers and peers on their asthma self-management. school nurses identified potential subjects. a mailing to the parent/guardian of these students included a description of the study, a demographic sheet, and the informed consent/assent form with a stamped return envelope. adolescents who participated in the study and then later validated the findings received a stipend. seven adolescents (five males and two females with an age range of 13-17 years) agreed to participate. two separate focus groups were conducted at the convenience of the participants. focus groups took place between june and july 2009, with each session lasting approximately one hour. an interview outline guided each session. (see table 1). all participants were in agreement with the focus groups being recorded. two recorders were used in case of equipment failure of one of the recorders. participants chose pseudo names to protect their identity. the recordings were transcribed by a transcriptionist. analysis was done by reading through the transcripts and finding common repeating themes influencing their management behaviors. the researcher and two undergraduate nursing students analyzed the transcripts independently and then met to discuss the findings and come to consensus. after completion of the analysis, each subject met individually with the researcher to validate the findings. all subjects concurred with the themes identified and had no corrections or additions. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 108 table 1 focus group questions 1. tell me about your asthma. what do you think it means when we say, “my asthma is under control”? do you feel your asthma is under control? what signs or symptoms let you know your asthma is ok and what signs and symptoms let you know you are not ok? 2. tell me about your doctor or health care provider. what does your doctor think you should do to take care of your asthma? do you feel you should do this? do you agree with what they feel you should do for your asthma? 3. tell me about your parents or guardian. what do they feel you should do to take care of your asthma? do you feel you should do this? do you agree with what they feel you should do for your asthma? 4. tell me about your teachers. what do your teachers feel you should do to take care of your asthma? do you feel you should do this? do you agree with what they feel you should do for your asthma? 5. tell me about your friends. what do your friends feel you should do to take care of your asthma? do you feel you should do this? do you agree with what they feel you should do for your asthma? 6. tell me about your school nurse. what does your school nurse feel you should do to take care of your asthma? do you feel you should do this? do you agree with what they feel you should do for your asthma? setting this study took place in chenango county, ny the u. s. department of agriculture’s (usda) rural-urban continuum codes classifies chenango county, ny as a nonmetro county with an urban population of 2,500-19,999, adjacent to a metro area (usda, 2004). according to the 2010-2013 community health assessment, chenango county encompasses 894.36 square miles with 57.5 persons per square mile. lack of major highways in the county impedes access to health care. nys route 12, where most of the health services are located, is a two-lane highway that bisects the county and is the only major north-south route. only one hospital is located in chenango county. chenango county has 27 full time primary care physicians resulting in a physician to population ratio of 1:1885. this has led to the designation of chenango county as a health professional shortage area (hpsa) by the u.s. department of health and human services for single county, low income, primary care (chenango county public health, 2009). online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 109 these factors increase the risk for adverse outcomes for the rural adolescent with asthma as health care becomes inaccessible and unavailable. results results from this study revealed the influence of expectations for asthma self-management from parents, health care providers, peers, teachers and school nurses. eight consents and assents were returned. of those eight, seven of the adolescents attended the focus group and validated the findings. all of the subjects were caucasian, from rural areas in upstate ny, and attended middle school or high school fulltime. (see table 2). table 2 study participant demographics gender age grade in school female female male male male male male 16 14 16 16 15 13 17 10th 8th 10th 10th 10th 7th 11th the most striking finding was the lack of awareness of asthma symptoms indicating uncontrolled asthma. these students did not have an understanding of what “asthma under control” meant. most of the participants in the study utilized their rescue inhaler more than two times a week. some participants needed to use it multiple times during the course of a gym period. none of these students were aware of having an asthma action plan, which would have assisted with their ability to self-manage. management of their asthma was through medication use only. there was a disconnection between the student’s description of asthma symptoms, their ability to identify triggers and their ability to appropriately use prescribed medications. although online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 110 able to correctly name and identify each inhaler, subjects described their use inappropriately, confusing rescue and controller medications. the students accepted their current asthma symptoms and had no expectations for better control. perceived expectations from parents all participants stated that their parents felt it was the adolescent’s responsibility to manage their asthma. management was typically defined as taking the medications prescribed by the health care provider. one subject stated that it was usually her parents and family who would remind her to take her medication. four subjects stated it was up to them to manage their asthma. statements from the subjects included: “they said they’d stop riding me to take the singulair, because it’s not their job to do it, it’s my job…” “they told me to take care of it on my own.” “…… just deal with it…. i think by the time your kids are a certain age, they realize like they don’t want to be in that kind of pain or deal with it, so they kind of realize to keep it under control” “they’ll like say, “go get your inhaler cause you’re not—like you can’t catch your breath or anything.” “… they usually say to do what the doctor said so nothing can ever happen—like if i ever had like an asthma attack or anything. so they tell me to do it when i need to.” perceived expectations from health care providers six of the seven participants perceived the expectations of their health care providers as taking the asthma medications as prescribed. two of the participants stated that their doctor told them to try to take their inhaler as “little as possible”. six of the seven participants stated that their health care provider had no other expectations. one participant was instructed in trigger avoidance, but only for two of the several triggers this participant mentioned. no others mentioned expectations for trigger avoidance or recognition of symptoms that would require online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 111 additional intervention. none of the participants had a written asthma action plan. pertinent comments that validate these findings include: “..he really thinks that i wouldn’t have any problems if i took like the allergy medicine he gives me.” “i just get a new inhaler whenever i need it or like with my allergies, i just got a new medicine for my allergies and stuff.” perceived expectations from peers perceived expectations of peers did not appear to be a significant factor in influencing the self-management behaviors of the participants. six of the subjects did not feel uncomfortable using their inhalers in front of their peers. statements from the subjects validating these conclusions include: “…i’m not going to die because somebody else is like ‘oh, that’s not cool’”. “i wouldn’t care—it’s going to help me breathe better, so--i wouldn’t be embarrassed by using it.” “i could care less what they think about it because, you know, it’s a fact of life. people have asthma, i mean, that’s the way it is. i use it regardless of what they think.” perceived expectations from teachers the participants did not report any asthma management expectations from their teachers. most felt that the teachers would not know what to do in the event of an asthma attack. some subjects were not sure if all of their classroom teachers were aware that they had asthma. subjects identified gym teachers as being more aware of the student having asthma. when questioned if the participants felt the gym teachers would know what do to in case of an asthma attack, three students responded they did not think they would know what to do. statements validating these findings include: “none of my normal teachers [know i have asthma]—i don’t think so. like we were playing a game – i was like “ok, i’ve got to sit out” and she’s like “are you ok?” and i’m like “yeah, i’m fine”. she’s like “you need to go to the nurse?” i’m like “no.” so i just sat there and waited for it to go away.”“i don’t think so [that they have any expectations for how i manage online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 112 my asthma]—as long as i’m not dead on the floor or something”. specific statements concerning physical education teachers included:“---they just don’t really feel like they’re responsible. they just say, “ok, well this is a nurse issue. go to the nurse.” perceived expectations from the school nurse five of the seven participants carried their own rescue inhalers. one participant was inconsistent in carrying the inhaler during the school day. all reported that the school nurse knew they had their inhalers. all stated that they used their inhalers during the school day but did not report this to the school nurse. the two subjects from the school with a school-based clinic stated they do tell the school nurse when they use their inhalers, but they did not do this consistently. statements from the subjects include: “i usually just take my inhaler when i need it. so i usually don’t see her for my asthma or anything, cause like, i just bring in a note and give it to her so i can carry it on me.” “…you carry it on you so that way you like don’t have to make the trip down there to get it and let them know you need it” “... the gym teacher tried telling me to go around to the nurse, and i was like, ‘yeah, but what’s she going to do about it?’ you know, there’s nothing you can really do till this goes away.” discussion the results from this study demonstrate the influence of the expectations for asthma selfmanagement by significant people in the adolescents’ life. the adolescents in this study were unable to identify what behaviors they needed to perform in order to control their asthma. except for taking their prescribed medications, no other behaviors were addressed by their health care provider, parents, friends or school nurse. the lack of expectation for other self-management behaviors that are essential for asthma control, such as knowledge of asthma symptoms, trigger avoidance and when to seek help during an asthma attack may be a leading contributor for online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 113 uncontrolled asthma. asthma action plans, if consistently used by health care providers, parents and schools, can reinforce the expectation for behaviors that will result in positive asthma outcomes. for these adolescents, exercise was the most commonly identified as their asthma trigger. none of the students discussed modifying their participation in gym during the school day. students used albuterol during the gym period but did not premedicate. the students considered this good asthma management. consistent with the literature, these students did not practice trigger avoidance (exercise) as they felt this was not a viable option (ayala et al., 2006; kyngas, 1999; rich et al., 2000; van der meer et al., 2007; van es et al, 1998; velsor-friedrich et al, 2004). the perceived expectation for management of their asthma from health care providers, parents, school nurses and teachers was to take asthma medication as prescribed. only one of the seven students discussed trigger avoidance as an expectation, but only for two of the many triggers identified by this student. except for one adolescent (who was the youngest subject interviewed), the perceived expectation was that they were responsible to take care of their own asthma, despite not having all the tools and knowledge to adequately keep their asthma under control. these findings are similar to those found by rich et al. (2000). if management skills are not assessed or addressed, and no expectations for management behaviors are communicated to the adolescent, then the adolescent’s current management behaviors become the expected norm, despite being ineffective in controlling their asthma. adolescents in this study did not report feeling different from their peers who did not have asthma. they stated their friends knew they had asthma and would remind them to take their medications. they denied feeling embarrassed while using their inhaler in front of their peers. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 114 this was consistent with knight (2005) who found that students with the perception of social support do not experience shame or feeling different when using inhalers. consistent with horner (1999), these students identified themselves as normal and viewed asthma as “something they have to live with”. in contrast with other studies, these students did not deny their asthma (ayala et al., 2006; rich et al., 2000; velsor-friedrich et al., 2004). none of the adolescents reported having an asthma action plan; in addition, none of these adolescents knew what an asthma action plan was. previous studies identified lack of asthma action plans as a barrier to effective asthma management (borgmeyer, jamerson, gyr, westhus & glynn, 2005; calabrese et al., 1999; van der meer et al., 2007). asthma action plans are essential to ensure control of this condition. the written plan delineates the expected self-management behaviors for rural adolescents with asthma. these behaviors need to be shared with all the key adult players influential in the adolescents’ life. the 2007 national heart, blood and lung institute (nhbli) guidelines for asthma management emphasize self-management education to control asthma (united states department of health and human services [usdhhs], 2007). emphasis is on the collaborative partnership between provider and patient to develop an asthma action plan. the action plan should address the medical management of the condition as well as the ability of the patient to (a) identify and avoid asthma triggers; (b) use medication and devices appropriately; (c) identify symptoms that indicate uncontrolled asthma; and (d) perform the steps needed when these symptoms are present. individualization of the plan for each patient is necessary to assure that carrying out the plan is able to fit within one’s lifestyle (usdhhs, 2007). this is especially true for the rural adolescent with asthma. due to limited access to health care providers in a rural environment, the asthma action plan becomes essential for self-management. if the plan is unrealistic and cannot be online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 115 implemented during the school day or afterschool activities, then adherence to the plan is unlikely. asthma self-management must be as unobtrusive as possible so as not to interrupt the daily living activities of the adolescent. the national association of state boards of education (nasbe) has developed a researchbased, best practice model policy for prevention and management of asthma that schools can adopt/adapt (nasbe, 2009). the school asthma plan recommends identifying and monitoring all students with an asthma diagnosis, obtaining individualized asthma action plans for all students with asthma, establishing emergency protocols for students without asthma action plans, and ensuring students are aware of the opportunity to selfcarry rescue inhalers. self-mamangement education and case management for he student with asthma is also recommended. this policy also advocates for asthma education of all school personnel as well as the need for a full time registered nurse in every school. implications distance to healthcare mandates the role of the school nurse in assisting the rural adolescent in their asthma self-management. the rural adolescent needs to keep the school nurse informed about their asthma status and to report when they needed their rescue inhaler. the school nurse can assist the rural adolescent in discerning asthma symptoms that are not acceptable and refer the student to a health care provider when necessary. without a written asthma action plan, this collaborative partnership between the school nurse, the health care provider and the rural adolescent with asthma is difficult to both obtain and sustain. asthma has been determined to be a disabling condition. a disabled person includes an individual who has a physical impairment that substantially limits one or more life activities, including breathing and learning (jones & wheeler, 2004). title ii of the americans with online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 116 disabilities act of 1990 (section 202), states that “…no qualified individuals with a disability shall, by reason of such disability, be excluded from participation or be denied the benefits of the services programs or activities of a public entity, or be subjected to discrimination by any such entity”. section 504 of the rehabilitation act of 1973 states that… “no qualified handicapped person shall, on the basis of handicap, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity which receives federal financial assistance” (united states department of education [usdoe], 2013). under this provision, recipients of federal funds must address the needs of the disabled so that they can participate in services and programs to the extent necessary to prevent discrimination. by working together with the adolescent with asthma and assuring a written asthma action plan, the school nurse has the opportunity to influence the self-management of the adolescent with asthma. creating the expectation for the self-management activities as indicated on the asthma action plan reduces the possibility of asthma becoming a disabling condition. the recommended policies of the nasbe (2009) have the capability to address those issues identified by the students in this study. teachers, with an increased awareness about asthma, would have higher expectations for self-management, enhancing the perceived expectation and subsequent management of their asthma. requiring asthma action plans, as previously stated, highlights the behavioral expectations for asthma management from all involved players and has a greater impact on the adolescent managing his/her asthma. conclusion the focus groups for this study were conducted with students from rural school districts. key findings from this study highlighted the influence of the perceived expectations for asthma management by significant persons in the lives of the adolescent, supporting the construct of online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.281 117 subjective norm in the theory of planned behavior. analysis of the recorded transcripts revealed that the majority of participants perceived provider and parental expectations for asthma management as only consisting of medication compliance. the students did not report any perceived expectations from the school nurse except independent inhaler use. there was no expectation to report use to the school nurse. the participants felt that their teachers were not aware of their asthma diagnosis; therefore, no expectations were noted. expectations from peers had no influence on self-management behaviors. actual performance of asthma self-management behaviors mirrored the behavioral expectations of the significant people. these results demonstrate the usefulness of the theory of planned behavior in improving asthma management behaviors for the adolescent with asthma. expectations for self-management behaviors of the adolescent with asthma must be clear and consistent. providers, parents, school nurses and teachers need to speak the same language and hold the adolescent accountable for performing those behaviors necessary to ensure good health outcomes. the asthma action plan allows this consistent message to be communicated to all those adults influential in the adolescents’ life. these behaviors and asthma outcomes need to be evaluated and reinforced at each possible opportunity, whether during a school nurse visit or an appointment with a health care provider. further research needs to investigate ways to increase and enhance asthma management behaviors necessary to reduce the adverse outcomes associated with uncontrolled asthma. investigating ways to increase and operationalize the expectations of those individuals significant to asthma management behaviors has the potential to lead to improved asthma management. the theory of planned behavior provides a well-suited framework to guide future studies. online journal of 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(2007). internet-based self-management offers an opportunity to achieve better asthma control in adolescents. chest, 132, 112-119: http://dx.doi.org/10.1378/chest.06-2787 van es, s.m., lecoq, e.m., brouwer, a.i., mesters, i., nagelkerke, a.f., & colland, v.t. (1998). adherence-related behavior in adolescents with asthma: results from focus group interviews. journal of asthma, 35(8), 637-646. http://dx.doi.org/10.3109/02770909809048966 velsor-friedrich, b., vlasses, f., moberley, j., & coover, l. (2004). talking with teens about asthma management. the journal of school nursing, 20(3), 140-148. http://dx.doi.org/10.1177/10598405040200030401 untitled online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 34 relationships among distress, appraisal, self-management behaviors, and psychosocial factors in a sample of rural appalachian adults with type 2 diabetes roger d. carpenter, phd, rn1 laurie a. theeke, phd, fnp-bc, gcns-bc2 jennifer a. mallow, phd, fnp-bc3 elliott theeke, ba4 diana gilleland, ms, mba5 1 assistant professor, department of adult health, west virginia university school of nursing, rcarpenter@hsc.wvu.edu 2 associate professor, west virginia university school of nursing, ltheeke@hsc.wvu.edu 3 associate professor, west virginia university school of nursing, jamallow@hsc.wvu.edu 4 research coordinator, west virginia university research corporation, etheeke1@hsc.wvu.edu 5 associate professor, west virginia university school of medicine, dgilleland@hsc.wvu.edu abstract background: diabetes contributes to the development of multiple chronic conditions including cardiovascular disease, stroke, blindness, kidney disease, and lower-limb amputations. currently, it is known that the appalachian region is an area of significant disparity in the occurrence of diabetes. persons with diabetes can develop high levels of cognitive stress related to the experience of living with diabetes. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 35 method: this paper presents the results of a descriptive study guided by the transactional model of stress and coping (tmsc), aiming to enhance understanding of the relationships among diabetes-related distress, appraisal, and self-management in a sample of 102 adults who were living rurally in appalachia. findings: the majority of the study sample were low-income, obese, and had mean a1c levels above the goal for adequate diabetes control. over one-third of the sample had a high likelihood or possibility of limited health literacy. participants reported adhering to medication on over 6 days of the week but adhering to diet and exercise on fewer days per week. overall, the sample had a lower level of distress related to the diagnosis of diabetes. participants perceived diabetes as more of a challenge than a threat, harm, or benign stressor. diabetes related distress was inversely correlated to challenge appraisals and benign appraisals, but positively correlated to threat and harm appraisals. anxiety and depression were significantly positively related to diabetes related distress, threat appraisals, and harm appraisals and significantly negatively correlated with challenge and benign appraisals. conclusions: recommendations for future research include the development and testing of targeted interventions that address the study findings including health literacy level, challenge appraisals, and the interrelationships of psychological and physical health variables. knowing that diabetes is appraised as a challenge enhances the likelihood that it may be amenable to intervention. the interrelatedness of anxiety and depression to self-management further informs future intervention design. keywords: psychosocial factors, rural, diabetes, adults, self -management, cognitive appraisal, distress online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 36 relationships among distress, appraisal, self-management behaviors, and psychosocial factors in a sample of rural appalachian adults with type 2 diabetes diabetes mellitus is one of the major causes of disease morbidity and mortality in the united states (us) and throughout the world. it is estimated that 29.1 million people in the united states have diabetes (9.3% of the u.s. population), with 1.7 million new cases diagnosed in people 20 years or older in 2012 (centers for disease control and prevention [cdc], 2014). diabetes is the leading cause of cardiovascular disease, stroke, blindness, kidney disease, and lower-limb amputations, and has been estimated to cost the unites states $176 billion in direct medical care costs and $69 billion in indirect costs from disability, productivity loss, and premature death (cdc, 2014). the burden of diabetes is especially heavy in rural appalachia. for this study, the rural population was conceptualized as people residing in rural appalachia. appalachia is a 13 state region of the eastern united states and west virginia is entirely within appalachia. west virginia ranks 48th in the nation for lowest number of citizens with the highest underinsured population, low high school graduation rates, highest incidence of infectious disease, highest prevalence of low birth-weight infants, and low availability of primary care providers (united health foundation, 2012). of west virginia’s 55 counties, 49 counties contain areas that are designated as medically underserved (west virginia vital statistics, n.d.). chronic illnesses such as diabetes are more prevalent in appalachia than other more urban regions of the united states (barker, kirtlans, gregg, geiss, & thompson, 2011; howard et al. 2011). national data indicate that prevalence of diabetes is higher in rural areas, the southeast, and appalachia (cdc, 2011; krishna, gillespie, & mcbride, 2010). appalachians are 1.4 times as likely to have diabetes as non-appalachians (serrano, leiferman, & dauber, 2007). for many online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 37 appalachians with diabetes, the distress associated with diabetes is constant and significantly affects daily life. as an area recognized for health disparity, appalachia is characterized by high poverty, an aging population, and low educational attainment (smith & tessaro, 2005), adding to the complexity of managing diabetes. significance/literature review high levels of diabetes-related distress have been described in the literature (karlsen, oftedal, & bru, 2012). the distress can be linked to the complexity of integrating treatment regimens into daily life and can leave people feeling overwhelmed, frustrated, and discouraged (polonsky et al., 2005). thus, diabetes related distress can lead to reduced well-being, anxiety, and depression, (fisher, glasgow, & strycker, 2010; papelbaum et al., 2010). a vast amount of research suggests that diabetes-related distress affects self-management of diabetes (glasgow, toobert, & gillette, 2001; nozaki et al., 2009; ogbera & adeyemi-doro, 2011), and indicates that distressed individuals may have difficulty maintaining self-management regimens (landelgraham, yount, & rudnicki, 2003; morris, moore, & morris, 2011). both the objective and subjective experiences shape the intensity of the distress an individual experiences in living with diabetes. for many adults with type 2 diabetes, the associated distress is constant and significantly affects daily life. patient responses to diabetes-related distress may include decreased self-management activities and may be dependent on how they appraise their diagnosis of diabetes. appraisal refers to the process of how people constantly evaluate what is happening to them from the standpoint of its significance for their well-being. research has demonstrated that appraisal is a modifiable psycho-social determinant of health and can change after a psychological intervention (bargiel-matusciewics, trzcieniecka-green, & kozlowska, 2011). in online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 38 the literature, diabetes can be appraised in multiple ways including threatening, harmful, or challenging. findings suggest that in persons with diabetes, appraising the illness as challenging, instead of threatening or harmful, has been linked to improved self-management behaviors (carpenter, 2012). despite this, the relationship between diabetes appraisal and selfmanagement has not been well-studied. most work on diabetes focuses on emotional outcomes (e.g., well-being, anxiety, distress) following diagnosis, and less on how individuals appraise their illness and self-manage their diabetes (thoolen, de ridder, bensing, gorter, & rutten 2008). diabetes self-management is an ongoing struggle for people with type 2 diabetes (morris et al., 2011). most research on diabetes has found that a significant proportion of patients fail to engage in adequate self-management (peyrot et al., 2005; thoolen, et al., 2006). only a scant amount of research describes the self-management of diabetes in appalachia. most studies are qualitative, describing the impact of cultural, socio-economic, and knowledge deficits about diabetes. once diagnosed, appalachians report receiving little information from health care providers about diabetes and, consequently, develop personalized approaches to selfmanagement. these approaches are usually affordable modifications of medical recommendations and are often based on cultural beliefs, socio-economic environments, and lack of knowledge about diabetes (smith & tessaro, 2005). it is generally accepted that interventions targeting appraisal and self-management will be effective for some persons with diabetes under certain circumstances, however, the results of research on distress-reduction interventions remain inconclusive (morris et al., 2011). to increase our understanding of an individual’s appraisal of diabetes and its impact on selfmanagement, and ultimately to develop more successful distress-reduction intervention online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 39 programs, research needs to focus on an individual’s appraisal of their disease. to address this gap in the literature, researchers need to look beyond emotional outcomes to consider how patients’ appraisal of diabetes influences their self-management activities. the purpose of this study was to describe relationships among diabetes-related distress, appraisal, self-management, and psychosocial factors in rural appalachians with type 2 diabetes. this study had the following two research questions: 1. how is diabetes-related distress, diabetes appraisal, and self-management described by rural appalachians with type 2 diabetes? 2. what are the relationships between diabetes-related distress, diabetes appraisal, and self-management? theoretical framework this study was guided by the transactional model of stress and coping (tmsc), as described by lazarus and folkman (1984). through the process of appraisal, a stressor is evaluated from the standpoint of its significance to the individual’s well-being. this appraisal and the concomitant coping behaviors contribute to outcomes (lazarus & folkman, 1987). when a stressor is encountered, it is appraised in terms of relevance to the individual’s wellbeing. the model posits two forms of appraisal: (a) primary appraisal, and (b) secondary appraisal. in primary appraisal, stressors are appraised as irrelevant (no significance to wellbeing), benign-positive (does not tax or exceed personal resources and signals only positive consequences), or stressful. stressful appraisals include harms, threats, and challenges. primary appraisal is shaped by an array of personal and situational factors, such as personal beliefs and commitments. a challenge appraisal is a judgment that the demands associated with a stressor can be met or overcome, whereas a harm appraisal cites damage that has already occurred, and a online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 40 threat appraisal reports anticipated harm from a stressor. secondary appraisal involves the evaluation of coping resources and options. for persons living in appalachia, cultural beliefs, such as traditionalism, individualism, and religious fundamentalism, have been implicated as influencing the adoption of preventive health behaviors (gobble, 2009; weller, 1965). these values influence health beliefs and practices of the people from this region, and have been interpreted as evidence of fatalism about health (behringer & friedell, 2006; deskins et al., 2006). such beliefs may put appalachians at risk for poor self-management behaviors required for successful diabetes management. however, qualitative evidence describes people from appalachian culture as possessing qualities of selfdetermination and self-reliance (smith & tessaro, 2005). primary and secondary appraisals and coping work together to predict immediate and longterm effects, as defined by lazarus and folkman (1984). however, the literature suggests that the appraisal of diabetes warrants individual attention (thoolen et al, 2008). understanding how an individual appraises their diabetes may provide more knowledge about self-management behaviors. method this descriptive study used a correlational design with a convenience sample of adults with type 2 diabetes. a letter of approval was obtained from the west virginia university institutional review board (protocol #1310118078) prior to beginning the study. four unique research sites located in north central west virginia were used to capture the diversity of the potential participants from this rural geographic area, each site operating with a unique care delivery model: an academic medical center primary care family medicine clinic; a nurse-managed primary care site in the community; a free clinic that provides care to the online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 41 uninsured; and a human performance lab that provides exercise prescription for special populations with chronic medical conditions. to be included in this study, the participant needed to be an adult between the ages of 20 and 75, read and speak english, and have had a diagnosis of type 2 diabetes for at least one year. the diagnosis of at least one year was selected based on literature that supports that most people underestimate the seriousness and overrate their ability to control their diabetes when first diagnosed (adriaanse, et al, 2003; eboral, et al., 2007; skinner et al, 2006; thoolen et al, 2008). measures primary study variables. diabetes-related distress was measured with the problem areas in diabetes (paid) scale (polonsky et al. 1995). this is a 20-item measure of diabetes-specific emotional distress. items are scored on a 5-point scale producing a total score between 0 and 100, with higher scores indicating greater emotional distress. prior internal reliability analyses showed that all 20 items on the paid scale correlated 0.30 or higher with the total score, and that cronbach’s alpha was 0.95 for the total scale. concurrent and discriminant validity have also been demonstrated (polonsky et al., 1995; welch, jacobson, & polonsky, 1997). appraisal was measured with the cognitive appraisal of health scale (cahs) (kessler, 1998). the cahs consists of 28 items that are scored on a 5-point likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). subjects are asked to respond to each item based on his/her appraisal of his/her current health condition. higher scores on each item indicate greater agreement with that appraisal. this measure of appraisal was selected because it can be used to categorize primary appraisal of diabetes into four groups (threat, challenge, harm, and benign/irrelevant). it is important to note the inclusion of the benign/irrelevant category, which allows for an appropriate evaluation if diabetes is not perceived as distressing. for this study, online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 42 only the 23 items of the four primary appraisal subscales were used, and each item was rephrased to be specific to diabetes. internal consistency estimates for subscales have been reported at .70 and greater (kessler, 1998). internal, construct, and concurrent validity have also been demonstrated (ahmad, 2004; kessler, 1998). self-management was measured with the summary of diabetes self-care activities (sdsca) (toobert & glasgow, 1994). the sdsca is a brief self-report instrument measuring levels of self-management of seven parts of a diabetes regimen. the tool measures each component rather than providing a cumulative score due to the multidimensional nature of selfmanagement. its use in adults with type 2 diabetes is well-established. average inter-factor correlations ranged from .16 to .21, and average inter-item correlations within each subscale exceeded .50. initial validity testing with principal component factor analysis to evaluate factor patterns showed that all items loaded highly on their intended underlying factor (toobert, hampson, & glasgow, 2000). for this study, the subscales for diet, exercise, and medicationtaking were used. for each of these subscales, the subject is asked about these specific diabetes self-management activities over the past seven days. the number of days per week is recorded on a scale of 0 to 7. secondary study variables. the following secondary variables were collected to describe the sample: health literacy, anxiety, depression, comorbidities, diabetes-related complications, hemoglobin a1c, height, weight, body mass index (bmi), age, gender, ethnicity, duration of illness, marital status, number of people living in the home, education, income, employment status, and distance from clinic. health literacy was measured with the newest vital sign (nvs) tool. the nvs is a measure of health literacy based on a nutrition label from an ice cream container. participants are online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 43 given the label and asked to refer to it in answering six questions asked orally by a healthcare provider or researcher. the number of correct responses corresponds to the participant’s health literacy level. scoring is as follows: 0-1 suggests high likelihood (50% or more) of limited literacy; 2-3 indicates the possibility of limited literacy; 4-6 almost always indicates adequate literacy. cronbach’s α > 0.76 has been reported in a reliability analysis and validity has also been established (weiss, et al., 2005). anxiety and depression were measured with the patient health questionnaire for depression and anxiety (phq-4). the phq-4 is a brief screening scale for anxiety and depression. cronbach’s alpha has been reported to be 0.85 for the scale. construct and factorial validity have also been established (kroenke, spitzer, williams, & lowe, 2009). the following data was obtained from the medical record: most recent hemoglobin a1c; most recent height, weight, and bmi; the comorbidities of obesity, hypertension, dyslipidemia, obstructive sleep apnea, fatty liver disease, cancer, fractures, cognitive impairment, hearing impairment, and periodontal disease; and the diabetes-related complications of vision loss, kidney failure, peripheral neuropathy, and amputations of legs or feet. demographic data was collected with a self-report demographic data form and included age in years, gender, ethnicity, duration of illness, marital status, number of people living in the home, education level, income, employment status, and distance from clinic. procedure sampling and data collection. staff at all recruitment sites were educated about the study and worked with the research team to recruit participants. the research team maintained a table in the waiting areas of research sites for recruitment, along with posting flyers describing the study in the waiting areas and throughout the research sites. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 44 upon obtaining informed consent, participants were assigned a study id number and administered the surveys by a member of the research team in a private space. approximate time to administer the surveys was 25 minutes. upon completion of the questionnaires, the researcher accessed the participant’s medical record to obtain health data. in addition, participants received a $20 gift card for their participation. all data were de-identified to protect the confidentiality of participants. participation was voluntary, and the participant could withdraw from the study at any time. data analysis. data were analyzed with spss 21.0. descriptive statistics of the demographic variables, variables obtained from the medical record, health literacy, anxiety, and depression were reported to describe the sample. means, medians, and standard deviations were calculated for the continuous variables of age, duration of illness, number of people living in the home, distance to the clinic, hemoglobin a1c, height, weight, bmi, number of comorbidities and complications, health literacy score, anxiety score, and depression score. frequency tables were generated for the categorical variables of gender, marital status, education level, income, and employment. independent samples t-tests were used to compare mean differences by gender on each of these study variables. for research question one, descriptive statistics were used to describe the study variables of distress, appraisal, and self-management. independent samples t-tests were used to compare mean differences by gender on each of these study variables. for research question two, bivariate pearson correlations were run between appraisal, distress, and self-management variables. significance level was set at alpha of .05. diabetes-related distress was measured as a continuous variable on a scale of 0 to 100. measures of central tendency and variation were reported. appraisal of diabetes was measured on 4 subscales: threat, harm, challenge, and online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 45 benign/irrelevant. a weighted score was reported for each subscale based on the number of subscale questions. frequencies for each category of appraisal were reported. to describe selfmanagement, the subscales for diet, exercise, and medication-taking from the sdsca were used. for each of these subscales, the subject was asked about these specific diabetes self-management activities over the past seven days. the diet subscale has two questions corresponding to general diet and two questions corresponding to specific diet. the exercise and medication subscales each have two questions. for each of these subscales, the average number of days per week the participant followed the recommended self-management activity were reported. results a convenience sample of 102 adults was enrolled in this study (men = 32.4%, 82.4% white, mean age = 54.03 years (sd 10.89, range 20-75,). table 1 includes additional sample descriptors including number of people living in the home, marital status, highest education completed, household income, and employment status. table 2 includes chronic illness descriptors of the sample by gender including duration of diabetes, a1c, bmi, anxiety, depression, total number of comorbidities, total number of diabetes complications, and health literacy. these descriptors indicate that the majority of the study sample were of low income, obese, and had mean a1c levels above the goal for adequate diabetes control. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 46 table 1 sociodemographic sample descriptors compared by gender (n = 102) variable female (n = 69) mean (sd) men (n = 33) mean (sd) difference statistic sig (p) age 54.46 (11.08) 53.12 (10.24) t = 0.59 .559 number of people living in home 1.36 (0.75) 1.50 (0.80) t = 1.29 .199 marital status χ2 = 6.36 .276 single 10 10 married 32 14 separated 3 2 divorced 14 4 widowed 8 1 significant other 2 2 highest education completed χ2 = 6.39 .381 less than high school 10 3 high school/ged 23 12 some college 16 9 2 year college degree 8 2 4 year college degree 5 4 graduate degree 7 3 household income ($/year) χ2 = 2.32 .509 less than $20,000 39 19 $20,001 $34,999 15 5 $35,000 – $49,999 8 3 $50,000 and higher 6 6 employment status χ2 =1.99 .574 employed 23 15 not employed 15 5 retired 13 4 unable to work 18 9 note. equal variances assumed. note. * means p value was ≤ .05, ** means p value was ≤ .01. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 47 table 2 chronic illness sample descriptors compared by gender variable female (n = 69) mean (sd) men (n = 33) mean (sd) t sig (p) duration of diabetes (years) 10.62 (7.15) 10.87 (8.45) 0.16 .875 a1c 8.23 (1.99) 8.46 (1.85) 0.53 .596 bmi 38.74 (8.81) 33.39 (6.18) 3.09 .003** anxiety score (phq4) 2.82 (2.28) 2.00 (2.28) 1.70 .091 depression score (phq4) 2.37 (2.20) 1.48 (1.95) 1.98 .050* number of comorbidities 2.89 (1.31) 2.87 (1.45) 0.08 .936 number of diabetes complications 0.38 (0.62) 0.44 (0.62) 0.46 .648 health literacy 3.84 (1.73) 3.88 (2.07) 0.09 .922 note. * = p < .05, ** = p < .01. research question one: how is diabetes-related distress, diabetes appraisal, and selfmanagement described by rural appalachians with type 2 diabetes? the means comparisons by gender for diabetes-related distress, appraisal subscales, selfmanagement, anxiety, and depression are in table 3. overall, the entire sample had a mean of 32.14 (sd 23.59) on diabetes related distress indicating a lower level of distress related to having diabetes, and there were no significant differences by gender. when evaluating the subscales on appraisal of diabetes as an illness, study participants had a higher mean score on the challenge subscale compared to the other three subscales of threat, harm, and benign. overall, participants reported adhering to medication on over 6 days of the week but adhering to diet and exercise on fewer days per week on average. there was no difference by gender in diabetes-related distress, diabetes appraisal and general self-management. significant differences by gender were found on specific diet and depression, such that women reported better adherence to specific diet on more days of the week, and reported more depressive symptoms than men. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 48 table 3 mean gender comparisons for diabetes-related distress, appraisal subscales, and self-management outcome group baseline t p mean sd diabetes-related distress female 33.55 23.91 0.87 0.39 male 29.20 22.98 challenge score female 3.80 0.74 -0.39 0.70 male 3.86 0.68 threat score female 2.82 1.01 -0.90 0.37 male 3.01 1.01 harm score female 2.30 0.90 -1.43 0.16 male 2.59 1.01 benign score female 2.55 0.89 -0.40 0.69 male 2.63 0.84 general diet female 4.46 1.96 1.32 0.19 male 3.89 2.16 specific diet female 3.93 1.45 2.76 0.01** male 3.00 1.82 exercise female 2.58 2.40 -0.76 0.45 male 2.95 2.23 anxiety female 1.41 1.14 1.70 0.09 male 1.00 1.14 depression female 1.19 1.10 1.98 0.05* male 0.74 0.98 note. * = p < .05, ** = p < .01. what are the relationships between diabetes-related distress, diabetes appraisal, and self-management? table 4 describes the correlations among diabetes-related distress, diabetes appraisal, selfmanagement, anxiety, depression, and health literacy. multiple significant correlations are reported. diabetes related distress was inversely correlated to challenge appraisals and benign appraisals, but positively correlated to threat and harm appraisals. diabetes related distress was inversely correlated to all self-management variables but this relationship was not statistically significant for medication adherence and exercise. there is a significant positive correlation between higher appraisals of challenge and days taking medicine. there is a significant negative correlation between threat appraisal and general diet and specific diet. there were significant online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 49 negative correlations between harm appraisal and both general and specific diet. there was a significant positive correlation between benign appraisals and general diet. anxiety and depression were significantly positively related to diabetes related distress, threat appraisals, and harm appraisals and significantly negatively correlated with challenge and benign appraisals. depressive symptoms were significantly inversely related to adherence to general diet. health literacy had a significant inverse relationship with diabetes-related distress and depression, but a significant positive correlation with challenge appraisal scores. though relationships among appraisal type and individual self-management variables differed and some were significant on correlations, none were predictive of these specific self-management behaviors. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 50 table 4 correlation coefficients for distress, appraisal, and self-management (n = 102). variable 1 2 3 4 5 6 7 8 9 10 11 12 1. paid total (distress) 1 2. challenge appraisal -.578** 1 3. threat appraisal .671** -.490** 1 4. harm appraisal .688** -.545** .769** 1 5. benign appraisal -.494** .347** -.657** -.505** 1 6. general diet -.240* .189 -.307** -.315** .261** 1 7. specific diet -.268** .189 -.377** -.322** .190 .514** 1 8. medication -.131 .209* -.035 -.081 -.077 .161 .113 1 9. exercise -.099 .194 .089 -.191 .167 .165 .099 -.301** 1 10. anxiety .477** -.229* .429** .396** -.360** -.151 -.110 .030 -.046 1 11. depression .486** -.346** .362** .385** -.338** -.20* -.167 -.015 -.132 .720** 1 12. health literacy -.373** .256** .259 .048 -.004 .162 .190 -.115 -.039 -.139 -.227* 1 note. * = p < .05, ** = p < .01. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 51 discussion the findings from this study were surprising and in contrast to what has been reported in historical literature about distress and diabetes. it has been documented in the health and social science literature that the experience of diabetes is related to high distress (barnard, et al., 2016; karlsen et al.,2012; pandit et al., 2014; polonsky et al., 2005). since the sample had relatively high mean a1c scores but reported relatively low distress scores related to their diabetes, understanding the complexity of factors that influence appraisal of diabetes in this population of disparity should be a priority. two prior qualitative studies conducted in rural appalachia with underserved persons with diabetes have described distress associated with living with diabetes. the first study described diabetes as a distressing health challenge, calling out related thoughts and experiences which included knowledge of life circumstances, daily struggles, life choices, and feelings of inability to move forward from the present (carpenter, 2014). the second study described living with the stress of diabetes as involving living with pain, fear of future unknowns, worry over family health and needs, and managing health behaviors (carpenter, 2015). both studies reaffirm that diabetes in this population is a distressing illness, and that the experience of diabetes is accompanied by prominent physical and psychological health difficulties. nurses who are caring for persons with diabetes in rural appalachia should consider assessing for the distressing nature of diabetes. recognizing the distress associated with the diagnosis of diabetes could lead to additional care planning. this planning could include a comprehensive approach and incorporate an emphasis on mind-body interactions that occur with chronic conditions. knowing that distressing situations can impact physical health (mccain, online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 52 gray, walter, & robins, 2005) makes it important that nurses in rural areas be knowledgeable about interventions that could diminish distress. it was interesting, given the current literature and qualitative work, that study participants predominantly appraised living with diabetes as a challenging experience rather than a threatening, or harmful experience. in this study, perceiving diabetes as more of a challenge, than a threat or harm, was associated with increased adherence to diet recommendations. this is consistent with a separate study of persons with diabetes in appalachia (carpenter, 2012). from a theoretical perspective, challenge appraisal implies that the demands of diabetes can be met or overcome. this finding is in contrast to commonly held beliefs about appalachian culture as being fatalistic. in fact, appraising diabetes as a challenge means that behaviors may be amenable to change with selected interventions. motivational interviewing is one intervention that has demonstrated success for improving self-management behaviors and a1c levels at 6 months post intervention (song, xu, & sun, 2014). nurses who are caring for persons with diabetes in rural appalachia may influence outcomes of diabetes by incorporating motivational interviewing techniques into their interactions with this population. a systematic review of problem-solving therapy in persons with diabetes also indicates that there is potential benefit for decreased a1c levels when using this technique. (hill-briggs & gemmell, 2007) participants in this study did relatively well with medication adherence, but only moderately well with diet, and less with exercise. these findings are similar to the selfmanagement adherence rates of other patient populations managing type 2 diabetes (delamater, 2006; murata et al., 2004; nelson, mcfarland, & reiber, 2007). diet has been identified as a major stressor in persons with type 2 diabetes (peyrot et al., 2005: vijan et al., 2005). in addition, qualitative data suggests that diet is a major challenge for person with type 2 diabetes online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 53 (carpenter, 2015). it is important for nurses to note that in spite of being part of a group who suffer from worse health than many other sub-populations (halverson, 2004), the adherence rates to behaviors of rural persons from appalachia are similar to other patient populations. this similarity could be attributed to the exposure to known behavioral and social determinants of health (cdc, n.d.) in rural appalachia, rather than to the geographic region. thus, it can be logically concluded that nursing interventions that have demonstrated effectiveness for enhancing adherence in other populations known to experience these determinants of health may have potential to be helpful to persons with diabetes in rural appalachia. it was not surprising that anxiety and depression related significantly to distress, appraisals, and self-management. these psychological problems are well-documented in the literature as influential factors to how people think about illness and engage in health behaviors (duke, 2016; katon et al., 2004). given the high prevalence of anxiety and depressive symptoms in this study sample and the positive relationships between appraisals of threat and harm with anxiety and depression, it is important to know current status of anxiety, depression, distress, and appraisal of illness prior to planning care. these results support adhering to current national guidelines for screening for all adults for anxiety and depression (u.s. preventive services task force [uspstf), n.d.). the relationships among study variables is complicated by the findings regarding health literacy. it is very problematic that 37.2% of the sample had a high likelihood or possibility of limited literacy. low health literacy has been identified as problematic in appalachian regions (o’brien & talbot, 2011). literature does support the association between health literacy and health outcomes. in addition to poorer health and more advanced disease when first seen by a health care provider, patients with low or limited health literacy skills are more likely to report online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 54 less knowledge of their chronic disease and self-management (rudd, renzulli, pererira, & daltroy, 2005), low health knowledge, and less use of preventive services (berkman et al, 2004; berkman, sheridan, donahue, halpem, & crotty 2011). specifically in persons with type 2 diabetes, inadequate health literacy has been shown to be associated with worse glycemic control and higher rates of retinopathy (schillenger et al, 2002). assessing for health literacy level is important so that it can be incorporated into and potentially enhance nursing interventions. one tool that nurses could consider to use for assessment of health literacy in diabetes is the newest vital sign (weiss, et al., 2005) instrument that was used for this study. the relationships among the appraisal variables in this study support the theoretical predictions of the transactional model of stress and coping, specifically the inverse relationship between challenge appraisals and threat and harm appraisals, and the positive relationship between threat and harm appraisals and distress. the transactional model served as a useful framework to guide the study, with concepts from the model serving as a basis for selecting and then operationalizing study variables. implications for future research recommendations for future research should include the development and testing of targeted interventions that address the study findings including health literacy level, challenge appraisals, and the interrelationships of psychological and physical health variables. first, any intervention designed for this study population should be developed with an appropriate health literacy level. health literacy needs to be an integral component of intervention development because it is known to be influenced by multiple factors, including changes in life experience, education, and the presence of comorbid conditions such as functional status, mental illness, stress, or depression (rudd et al., 2005). second, focusing a novel intervention to facilitate an online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 55 increased challenge appraisal could lead to a positive impact on adherence to diet recommendations for person with type 2 diabetes. likewise, interventions to decrease perceptions of threat and harm of diabetes may have impact on diet adherence. finally, future studies must include psychological assessments of anxiety and depression, given the known relationships of these variables to diabetes, appraisal, and diabetes outcomes. limitations this study had several limitations including convenience sampling, homogeneous sample, self-reported data, and limited control of confounding variables. participants volunteered for this study, thus the possibility exists that only the more adherent patients were willing to participate. this, paired with the homogenous nature of the sample leads to the conclusion that the study results could be applied to predominantly white, middle-aged females who have had diabetes for approximately ten years. it is possible that there was bias in the self-reported data. conclusions this study enhances knowledge about appraisal of illness in persons with diabetes in appalachia. this knowledge conveys the important message that diabetes is not perceived as distressing or as a threat by people in this study residing in appalachia. knowing that diabetes is appraised as a challenge enhances the likelihood that it may be amenable to intervention. the interrelatedness of anxiety and depression to self-management further informs future intervention design. the findings will be instrumental to future intervention success. targeting the low literacy level of this population while working to enhance challenge appraisals while acknowledging psychological determinants of health could lead to positive health behaviors, and subsequently, positive diabetes-related health outcomes. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.446 56 acknowledgements sigma theta tau, international references adriaanse, m.c., snoek, f.j., dekker, j.m., spijkerman, a.m., nijpels, g., van der ploeg, h.m., & heine, r.j. 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(n.d.). west virginia department of health and human resources, bureau for public health, health statistics center. retrieved from http://www.wvdhhr.org/bph/hsc/ 1-16 17 18-31 microsoft word hoover_29-769-3-ed.docx online journal of rural nursing and health care, 12(2) 30 relationships among functional health literacy, asthma knowledge and the ability to care for asthmatic children in rural dwelling parents evelyn l. hoover, phd, rn 1 carolyn s. pierce, dsn, rn 2 gale a. spencer, phd, rn 3 mary x britten, edd, rn 4 martha neff-smith, phd, faan 5 gary d james, phd 6 sarah h. gueldner, dsn, rn, faan 7 1 nursing program chair itt, technical institute high point, ehoover2@itt-tech.edu 2 associate professor, decker school of nursing, binghamton university, cpierce@binghamton.edu 3 suny distinguished teaching professor, decker chair in community health, binghamton university, gspencer@binghamton.edu 4 associate professor, decker school of nursing, binghamton university, mbritten@binghamton.edu 5 retired professor, globaldoc1@msn.com 6 professor decker school of nursing and department of anthropology, binghamton university, gdjames@binghamton.edu 7 arline h. and curtis f. garvin professor of nursing, frances payne bolton school of nursing, case western reserve university, sarah.gueldner@case.edu abstract purpose: this orem-based study examined the relationships among functional health literacy, asthma knowledge, the ability to care for asthmatic children and sociodemographic factors among rural parent/guardians. method: a descriptive correlation design was used. the convenience sample of 57 parents and one guardian who cared for asthmatic children was recruited from three rural health districts in the eastern united states (virginia, north carolina, and upstate new york). subjects completed the test of functional health literacy in adults (tofhla) and the asthma questionnaire-parent survey (aq-p) and provided additional demographic and health status information. findings: the results show that tofhla scores were directly related to asthma knowledge (aq-p scores), p=.04. subjects who had not completed high school had significantly lower tofhla scores than those who had completed high school, and their children were hospitalized more often (p=.05). those with higher income also had higher health literacy (tofhla scores) (p=.008) and regression analysis revealed that smoking status was also directly associated with functional health literacy (p=.004 conclusions: the findings confirm that rural health care providers need to be diligent in assuring that health education materials and verbal instructions are presented in the most simple and easy to read format in order to maximize understanding. keywords: health literacy, asthma knowledge, orem’s theory of dependent care agency online journal of rural nursing and health care, 12(2) 31 relationships among functional health literacy, asthma knowledge and the ability to care for asthmatic children in rural dwelling parents despite advances in asthma management, childhood asthma remains one of the highest ranked causes of pediatric hospitalizations and school absences in the us (cox & taylor, 2005). the 2002 national health interview survey (nhis) estimated that there were 9 million us children under the age of 18 years diagnosed with asthma, and that 7.7% were between 0-4 years of age (center for disease control & prevention [cdc], 2002). because asthma management is centered in the home, it is crucial that parents/caregivers have the information that they need to provide effective care for their children. a number of studies have shown that caregivers with low health literacy capacity have difficulty comprehending written materials, that they may not understand the importance of asthma prophylactic therapy, and that they may not be able to demonstrate the proper use of the asthma metered-dose inhaler (apter et al., 2006; dewalt, dilling, rosenthal, & pignone, 2007; williams et al., 1995). addressing these issues, this study examined the relationship between rural parent/guardian’s level of formal education and their functional health literacy score, in relation to their capacity to effectively manage their child’s asthma. the impact of health literacy on health outcomes it is generally assumed within our current health care system that adequate literacy is the norm and that the individuals we see are capable of providing self-care or dependent care. therefore, printed instruction booklets, brochures, and single sheet instructions are often issued without consideration of reading and comprehension ability. while most education materials are written at the eighth to twelfth grade reading levels, approximately half of the population struggles with basic third to fifth grade reading skills (davis et al., 1994). three of the ten objectives of healthy people 2010 regarding asthma focus on (a) reducing the rate of hospitalization for children under age five; (b) reducing emergency department visits related to asthma; and (c) increasing the proportion of individuals with asthma who receive formal asthma education. another objective affirms the commitment to improve the health literacy of persons with inadequate or marginal literacy skills (healthy people 2010, 2008). it is therefore essential that nurses and other health care professionals determine when a knowledge deficit exists, and that information be provided in a format that the patient can understand. however, this determination is difficult at times, because patients and caregivers may be embarrassed to tell their health care provider that they cannot read or understand medical terminology (parikh, parker, nurss, baker & williams, 1996). theoretical perspective: orem’s theory of dependent care agency orem’s theory of dependent care agency (dca), a parallel extension of her original self-care deficit nursing theory (s-cdnt), provides the theoretical underpinnings for this study (orem, 2001). as a dependent-care agent, the mature or maturing person meets the therapeutic self-care demands of another person, in this case a child diagnosed with asthma. the specific actions of the dependent care agent to provide health care are determined by changes in the health of the dependent person, and may include the management of complex technology associated with care (orem, 2001; taylor, renpenning, geden, neuman & hart, 2001). the general action themes that the caretaker engages in are 1) detects, interprets, and monitors meaningful symptoms; 2) regulates and administers medications; 3) identifies and avoids environmental triggers; and 4) seeks appropriate medical advice in a timely manner. online journal of rural nursing and health care, 12(2) 32 thus the care of children with asthma constitutes an exemplar of orem’s dependent care agency. the research problem while parents are expected to be the dependent-care agents for their child diagnosed with asthma, the high number of hospitalizations and emergency room visits for their children (akinbami & schoendorf, 2002; national center for health statistics [nchs], 2001) would indicate that many parents are unable to effectively manage the complex care issues associated with childhood asthma. critical learning activities include recognizing asthma triggers and performing the necessary dependent-care actions for children who have asthma (cox & taylor, 2005; national asthma education & prevention program [naepp], 2007). however, parents who are unable to read and understand the complex written instructions given to them during their brief visits with their healthcare providers may not be able to perform these actions effectively. thus, the purpose of this study was to examine the relationship among rural parents’/guardians’ capacity to read (as measured by their level of education, their scores on the test of functional health literacy in adults (tofhla), their score on the asthma questionnaire-parent survey [aq-p]), other sociodemographic characteristics and their ability to care for their children with asthma, as measured by the number of visits to the emergency department and hospitalizations of their child. methods study design and subjects a descriptive correlation design was used to determine the relationships among the parent/guardian’s level of functional health literacy, their knowledge of asthma their asthma care and other sociodemographic characteristics relevant to their ability to manage their child’s asthma symptoms. permission to conduct the study was obtained from the institutional review board at binghamton university in upstate new york, and a signed informed consent was obtained from each participant before the interviews were conducted. potential subjects were recruited from three health departments and three physician offices in rural health districts in three eastern states (a) virginia, (b) north carolina, and (c) upstate new york). the census bureau’s classification was used to define rural for this study (census 2000 urban and rural classification, 2001). the convenience sample (n = 58) consisted of 57 english-speaking parents and one guardian who were the primary caregivers for a child less than 9 years of age who had been diagnosed with asthma. the average age of the participants was 31.5 years, with a range of 20-55 years. all but one of the caregivers was female and the lone male participant was the father of the child. all of the female participants were the mothers, with the exception of one woman who was the child’s guardian. the ages of the children that they acted as the dependent care agent for ranged from 4 months to 9 years, with a mean age of 5 years. most (82.7%) of the sample was european-american (white, non-hispanic), 10.3% was africanamerican, and 6.9% was hispanic, non-white. thus 17.2% of the parents were from minority segments of the population. more than half (55.2%) of the sample had either completed high school or passed the ged equivalency exam (n = 15). seven (12.1%) of the participants did not graduate from high school; 11 (19.0%) had completed two years of college; 5 (8.6%) had completed four years of college; and 3 (5.2%) reported more than four years of college education. sixteen online journal of rural nursing and health care, 12(2) 33 (27.7%) of the participants reported a combined annual family income of less than $10,000; eight (13.8%) reported an income of $11-20,000 per year; nine (15.5%) reported their annual income to be $21-30,000; four (6.9%) reported an annual income of $31-40,000 per year; and 17 (29.3%) reported an annual income of $41,000 or more. three respondents (5.2%) declined to answer the question related to income, and one (1.7%) said that they did not know the amount of their annual household income. procedures as previously noted, subjects were recruited from health departments and physician offices in rural health districts in three eastern states (a) virginia, (b)north carolina, and (c) upstate new york. subjects were contacted at the facilities and signed consents. they then completed the test of functional health literacy in adults (tofhla) and the asthma questionnaire-parent survey (aq-p), and provided additional demographic and health status information. all data were collected by the first author. assessment tools test of functional health literacy in adults (tofhla). the tofhla, developed by nurss and colleagues, was used to measure literacy capacity in this sample (nurss, parker, & baker, 2001). the tofhla measures reading comprehension and numeracy skills using real and relevant hospital materials and labeled prescription vials. it consists of two sections, including a 50-item reading comprehension assessment and a 17-item numerical assessment, and takes about 20 minutes to administer. the reading comprehension section uses a modified cloze method, where every fifth to seventh word is omitted and a list of choices are provided for a fill-in-the-blank answer. to assess numeracy skills, the participant is given cue cards or labeled bottles and asked to respond to oral questions regarding the information written on the cue cards or bottles. the tofhla has been tested for both its reliability and validity in measuring health literacy. its internal reliability is excellent, with a cronbach’s alpha of .98 (parker, baker, williams, & nurss, 1995). it was also cross validated with the rapid estimate of adult literacy in medicine (realm) (davis et al., 1993) and the wide range achievement testrevised (wrat-r) (jastak, wilinson, & jasteak, 1984), showing strong correlation with each (.84-realm and .74-wrat-r) (parker et al., 1995). individuals scoring 0-59 on the tofla are considered to have inadequate functional health literacy; those scoring 60-74 are considered to have marginal functional health literacy, and those scoring 75-100 are considered to have adequate functional health literacy (nurss, et al, 2001; parker, et al. 1995). interestingly, all 58 participants scored at an adequate level of functional health literacy (75-100); in fact, 27 (almost half) of the participants scored in the highest 94-100 range. asthma questionnaire-parent survey (aq-p). the asthma questionnaire-parent survey (aq-p) by adams et al. (2001) was designed to obtain information about general asthma-related knowledge, basic facts about asthma, and problem solving capacity in the management of pediatric asthma. the survey consists of 23 general asthma knowledge questions, plus an additional three sections that assess competency if the parent uses a nebulizer (4 questions), inhaler (3 questions) and/or peak flow meter (3 questions) to manage their child’s asthma. participants are instructed to skip any of the last three sections online journal of rural nursing and health care, 12(2) 34 (nebulizers, inhaler, or peak flow meter) that are not a part of their child’s asthma management regimen. the aq-p has a fourth grade readability level using the flesch-kincaid grade level quotient (adams, et al., 2001). all of the questions presented are in a multiple-choice format with the exception of the medication section. each of the multiple-choice items has three incorrect response options, one correct option, and one choice of “i do not know the answer.” the range of correct responses on the basic knowledge asthma questions was 7 to 23 out of a possible 23 correct. sections b, c, and d of the test were only answered by those for whom it applied: i.e., the nebulizer questions of section b were answered by 47 participants; the inhaler questions of section c were answered by 42 participants; and the peak flow meter questions of section d were answered by 19 of the participants. demographic and health status information. the demographic information questionnaire was designed by the investigators and contained a 13-item personal response format using items extrapolated from demographic questionnaires found in the literature regarding pediatric asthma (bennett, robbins, al-shamali, & haecker, 2003; dewalt, et al, 2007; scherer & bruce, 2001), and included assessment of variables such as gender, age, ethnicity, level of formal education, and income. health status information for the child included whether or not the parent/guardian smoked, and if during the past year their child had been 1) taken to the emergency department, 2) hospitalized for asthma, or 3) taken for one or more unscheduled office visits for asthma-related symptoms. participants were also asked to tell how many times during the past year that each of the above situations had occurred. the remaining check-off responses requested information related to race/ethnicity, relationship to child, and whether or not the parent or guardian had previously attended an asthma education program. the socioeconomic information consisted of the highest-grade level of school completed by the parent/guardian, and the combined household income. finally, health status outcomes were measured by the answers to five questions: 1) do you smoke? 2) have you ever completed an asthma education program? 3) have you taken your child to the emergency department (ed) during the past year? 4) has your child been hospitalized for asthma during the past year? and 5) how many unscheduled office visits for asthma during the past year? twenty-one (36.2%) of the dependent care agents reported that they smoked. eighteen (31.0%) reported that they had taken their child to the ed during the past year for asthma related symptoms, while 40 (69.0%) had not. most of the parents who said they had taken their child to the ed said they had gone between 1 and 3 times during the last year. however, one parent took their child to the ed 5 times, and another had taken their child to the ed 8 times within the past year. the mean number of visits for the parents who had reported taking their child to the ed was 2.3. seven (12.1%) of the caregivers stated that their child had been hospitalized for asthma related symptoms during the past year. collectively, these seven parents/caregivers reported a total of 12 hospitalizations. the range of child hospitalizations was 1 to 2 during the past year, with a mean of 1.6 visits per child. during the past year, 42 (72.4%) of the parents/guardian reported taking their child for unscheduled office visits. of those who had made unscheduled office visits, the number of visits ranged from 1 to 20 visits during the year, with a mean of 4.2 visits per child. finally, fifty-three of the participants (91.4%) said they had never attended an asthma education program. the length of the educational programs attended by the five individuals ranged from one 45 minute session to several sessions over a five month period. instruction in these sessions was received from a respiratory therapist from a home health company or online journal of rural nursing and health care, 12(2) 35 by participation in open airways, an ongoing national program offered by the american lung association. data analysis it was hypothesized that the parents/guardians who scored lower on the tofhla would also score lower on the aq-p (asthma knowledge), and report more frequent use of the ed, more hospitalizations, and more frequent non-scheduled office visits for asthma than those who scored within the adequate range on the tofhla. it was also postulated that parent/guardians who scored at the inadequate or marginal level of the tofhla would be more likely to smoke, to never have attended an asthma education program, to report a lower level of education completed, and to have a lower family income. statistical analysis was performed using sas/stat ® software (sas institute, 2008). correlational analysis was used to examine associations among the number of correct responses for the general asthma knowledge questions (n = 23) (aq-p (23), the tofhla score, the number of correct nebulizer questions (n = 3), the metered dose inhaler questions (n = 4), education level, income and the child’s age. correlations were considered statistically significant at p < 0.05. t-tests were conducted to determine if tofhla scores were significantly different between: 1) smokers and nonsmokers, 2) adults who had completed an asthma education program and those who had not, 3) ed use and no ed use, 4) adults whose child had been hospitalized for asthma during the last year and adults whose child had not been hospitalized, and finally, 5) adults whose child had been taken for an unscheduled office visit for asthma in the last year and adults who had not taken their child for an unscheduled office visit for asthma. tofhla scores were also compared by education level (less than 9 th grade and some high school and income vs. high school graduate or ged to four year college graduate) and income (below $30,000 vs. $30,000 or above). lastly, stepwise regression was used to develop the most parsimonious model of the predictors of tofhla scores. the f to enter criterion for the model was set at p < 0.05. findings table 1 shows the results of the correlational analysis. as indicated, there was a direct association between health literacy as reflected in the tofhla scores and asthma knowledge (aq-p (23) scores (p = .04), such that the higher the health literacy, the higher the asthma knowledge. there was also a direct association between asthma knowledge (aq-p (23) scores) and education level such that as education level increased asthma knowledge increased (p = .0003). aq-p (23) scores were also directly associated with income level such that as income increased, asthma knowledge also increased (p = .004). the results of the t-test analysis revealed no statistically significant differences in tofhla scores between smokers and non-smokers, adults who had completed an asthma education program and those who had not, those who had taken their child to the ed use and those who had not, those whose child had been hospitalized and those whose children had not been hospitalized, and finally, those whose child had been taken for an unscheduled office visit and those whose child had not. however, the comparison between the low education group (less than 9 th grade and some high school, (n = 7; mean = 86.3) and the higher education group (high school graduate or ged to four year college graduate (n = 51; mean = 92.6)) showed that those with higher education had higher tohfla scores (p = .008). the comparison between the low and high income groups (below $30,000 (n = 33) and $30,000 online journal of rural nursing and health care, 12(2) 36 or above (n = 21)) showed a difference of 3.3 in tohfla score, with the high income group having the higher score (p = 0.04). the results of the stepwise regression analysis are shown in table 2. as indicated, level of education (β=-6.48, p=0.01), number of nebulizer questions answered correctly (β = 3.6, p = 0.002), being a non-smoker (β=3.6, p=0.004) and child hospitalizations (β = -4.42, p = 0.05) were independent predictors of tofhla scores. these results support previous findings and provide additional information regarding the competence level of rural parents whose children have asthma. discussion despite the fact that all participants in this study scored at an adequate level of fhl, the findings show that functional health literacy (as reflected in the tofhla score) was directly related to asthma knowledge (as reflected in the aq-p(23) score) among dependent care agents who provide care for children with asthma. consistent with the findings of previous studies that used tofhla to determine the level of health literacy (gazmaraian, williams, peel, & baker, 2003; montalto & spiegler, 2001; yin, dreyer, fotlin, van schaick, & mendelsohn, 2007), the participants in this study who had completed a higher level of education and reported a higher income also had higher health literacy scores. the fact that no participants scored below an adequate level on the tofhla test precluded a more definitive examination of the relationship between functional health literacy and the other demographic variables of interest. in addition, asthma knowledge as reflected in the aqp(23) was related to education and income, such as those who were better educated and who had higher income had greater asthma knowledge. online journal of rural nursing and health care, 12(2) 37 the stepwise regression results revealed that there were several independent predictors of health literacy (tofhla scores). the regression model suggests that education and smoking status as well as one aspect of asthma knowledge and one measure of asthma care (number of hospitalizations) each have independent contributions to the variation in parental health literacy, even though all the study participants had relatively high health literacy. these findings suggest that even small changes in functional health literacy of rural parents is related to their background and health habits and variation in their child’s asthma care. the findings of this study also raise awareness of the important link between the parent/caregiver’s level of education and their ability to gain the knowledge that they need to be successful in caring for their children with asthma. likewise, the findings confirm that the tofhla score predicts asthma knowledge, and that a higher level of education and income are also associated with higher asthma knowledge. while none of the participants scored within the inadequate level of health literacy, the tofhla scores of those parents who had not completed high school were significantly lower than those who had completed high school, and their children were hospitalized more often than the children of those who had completed high school. a limitation of the study was a failure to recruit any participants who scored in the inadequate range of the tofhla. this limitation is likely to pose a similar challenge to future researchers on this topic, and indicates the need to develop more effective recruitment strategies for future studies that focus on level of literacy. it is possible that parents with low literacy skills may not have been able to read and interpret the information on the recruitment flyers, or that they may have been self-conscious or fearful that their participation in the study might lead to the discovery that they did not know how to read. that the recruitment activities yielded no participants with a low literacy score is a poignant reminder that illiteracy is silent and unrecognizable, and raises awareness of the need to devise ways to reach and enroll individuals with low literacy into health related studies such as this one. this finding also reminds clinicians of the need to take the level of health literacy into account in their day-to-day assessments of the health care recipients that they see. conversely, a notable strength of the recruitment strategy for this study is that 17.2% of the sample represented minority populations, including african american (10.4%) and hispanic non-white (6.9%). while it would have been desirable for the minority representation to have been even higher, this feature does represent a positive characteristic of the sample. implications for nursing practice perhaps the most important observation in terms of the immediate clinical application for nurses is that 91.4% of the literate and relatively well educated participants in this study reported that they had never attended an asthma education program. this finding reveals a serious and generally unrecognized gap in the availability/attendance of asthma education programs, and holds immediate implications for community health nurses who interface with caregivers of children with asthma. it provides evidence that a stronger system of community based education for individuals who care for children with asthma is needed in order to decrease the health care costs associated with asthma management for children and improve the health related quality of life for the children and parents involved. asthma education to properly manage asthma is listed as an objective in healthy people 2010 (2008), and is also a recommendation of the asthma education and prevention program (naepp) expert panel-3 online journal of rural nursing and health care, 12(2) 38 (2007). unfortunately the findings of this study provide overwhelming evidence that these objectives are far from being met. likewise, the surprising frequency of emergency department visits and the high number of hospitalizations and unscheduled office visits identified in this study have additional important implications for clinical practice. almost one third of the parents in this study had taken their child to the ed at least once during the past year, and one parent had taken their child to the ed eight times during the year. in addition, 8 parents (13.8%) reported that their child had been hospitalized for asthma related symptoms, and 42 (72%) had taken their child for unscheduled office visits. this possibly preventable use of health care services increases costs within the larger health care system, and may impose additional stress on the parents and their child. formal and informal processes of education need to be developed within the healthcare environment to address this issue. these findings also confirm that health care providers need to be more diligent in assuring that health education materials as well as verbal instructions can be read and understood by the health care recipients that they serve. conclusion this study builds on and extends the work of cox and taylor (2005), who postulated pediatric asthma to be an exemplar of orem’s theory. the tenets of orem’s theory of dependent care were shown to be consistent with and supported by the findings of this study, in terms of factors that enhance the capacity of parents or guardians to care for their child with asthma. the findings also provide support for the dependent care capacity of parents who care for their children with asthma, and point to the need for additional research to test and extend orem’s conceptualization of dependent care in children. it is also important that research-based models be developed to increase the capacity of parents and guardians to care for their children with asthma. references adams, c. d., brestan, e. v., ruggiero, k., hogan, m. b., wilson, n., shigaki, c., & sherman, j. 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(2001). nursing: concepts of practice (6th ed). philadelphia: mosby. parikh, n. s., parker, r. m., nurss, j. r., baker, d. w., & williams, m. v. (1996). shame and health literacy: the unspoken communication. patient education counseling, 27(1), 33-39. [medline] parker, r., baker, d., williams, m., & nurss, j. r. (1995). the test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. journal of general internal medicine, 10, 537-541. [medline] sas/ stat. (2008). statistical analysis with sas/ stat software. cary, nc: sas institute. scherer, y. k., & bruce, s. (2001) knowledge, attitudes, and self-efficacy and compliance with medical regimen, number of emergency department visits, and hospitalizations in adults with asthma. heart & lung, 30, 250-257. [medline] taylor, s. g., renpenning, k. e., geden, e. a., neuman, b. m., & hart, m. a. (2001). a theory of dependent-care: a corollary theory to orem’s theory of self-care. nursing science quarterly, 14(1), 39-47. [medline] williams, m., parker, r. m., baker, d., parikh, n. s., pitkin, k., coates, w. c., & nurss, j. r. (1995). inadequate functional health literacy among patients at two public hospitals. jama, 274, 1677-1682. [medline] yin, h. s., dreyer, b. p., fotlin, g., van schaick, l., & mendelsohn, a. l. (2007). association of low caregiver health literacy with reported use of nonstandardized http://www.ncbi.nlm.nih.gov/pubmed/8115206 http://www.ncbi.nlm.nih.gov/pubmed/17261479 http://www.ncbi.nlm.nih.gov/pubmed/14630383 http://www.ncbi.nlm.nih.gov/pubmed/11392190 http://www.ncbi.nlm.nih.gov/pubmed/8788747 http://www.ncbi.nlm.nih.gov/pubmed/8576769 http://www.ncbi.nlm.nih.gov/pubmed/11449211 http://www.ncbi.nlm.nih.gov/pubmed/11873353 http://www.ncbi.nlm.nih.gov/pubmed/7474271 online journal of rural nursing and health care, 12(2) 40 dosing instruments and lack of knowledge of weight-dosing. ambulatory pediatrics, 7, 292-298. [medline] http://www.ncbi.nlm.nih.gov/pubmed/7474271 http://www.ncbi.nlm.nih.gov/pubmed/17660100 microsoft word medves_337-1976-2-ed.docx online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 7 supporting rural nurses: skills and knowledge to practice in ontario, canada jennifer medves, rn, phd 1 dana s. edge, rn, phd 2 linda bisonette, rn, bscn, mhs, che 3 katherine stansfield, rn, mn 4 1 director school of nursing and vice-dean (health sciences), queen's university, kingston, ontario, jennifer.medves@queensu.ca 2 associate director (graduate nursing programs) and associate professor, school of nursing, queen's university, kingston, ontario, dana.edge@queensu.ca 3president & ceo perth & smiths falls district hospital (retired), smiths fall, ontario, bisonette@ripnet.com 4 vice president and chief nursing officer, quinte health care, belleville, ontario, kstansfield@qhc.on.ca abstract background: nursing in rural settings requires the skill set of a multi-specialist who is adaptable to change and different ways of working. maintaining skills needed for emergency management of complex health issues is difficult, and retention is affected by the paucity of further education opportunities and mentors. purpose: in collaboration with five small community hospitals in southern ontario that experience challenges in recruiting and retaining sufficient nursing staff, this project used critical ethnography to ascertain appropriate retention strategies. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 8 methods: data collection included environmental scans, interviews with 45 rural nurses, and completion of 156 surveys from nurses on rural nursing careers. during the project, staffidentified, educational strategies were implemented in 3 of the 5 community hospitals. findings: seven themes emerged from the data. overall, rural nurses identified that they were content to stay, as long as there was sufficient work. conclusion: retention interventions that are locally constructed with attention to community factors have the greatest likelihood of succeeding. keywords: rural nursing, nurse retention, critical ethnography, retention strategies supporting rural nurses: skills and knowledge to practice in ontario, canada the complexity of healthcare in acute care hospitals has increased rapidly. the expectations of canadians to receive care close to home means that a hospital is highly valued, and in small rural communities, the local hospital is often a symbol of viability. however, delivery of acute healthcare services, particularly critical care, requires specialized skills and rural providers often struggle to maintain competence. a number of initiatives, including telehealth, specialized education programs including advanced cardiac life support (acls), and transportation to tertiary centres, are now integral parts of canadian healthcare systems; yet, in reality, the vast geographic area and heterogeneous rural populations across the country makes rural acute and critical care competency complex and multi-dimensional. in 2000, nurses composed about 35% of the total health care provider population in canada, with approximately 18% of this total serving in rural areas (pong & russell, 2003); the proportion of nurses practicing in rural areas dropped 5% from the reported levels in the early online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 9 2000’s but stabilized by 2012 at 13% (canadian institute for health information, 2013). today, there is a better understanding of why nurses work and stay in rural canada than in the 1990’s because of significant research in this area (macleod, kulig, stewart, pitblado, & knock, 2004). from their work with public health nurses in rural british columbia, henderson betkus and macleod (2004) proposed filter factors that can influence retention: demographics, personal circumstances, and opportunities. others have proposed models of residency (bratt, baernholdt, & pruszynski, 2014; keahey, 2008), clinical placement in pre-registration education (schoo, mcnamara, & stagnitti, 2008), and desired nurse attributes (sivamalai, 2008) to attract rural nurses and retain them. some factors are amenable to education programs to help prepare nurses for the realities of rural living (baernholdt & mark, 2009; medves et al., 2006), while others are personal such as spousal employment, age and education requirements of children, and lifestyle (molinari, monserud, & hudzinski, 2008). this report describes a two-phase study designed to: a) identify modifiable factors to help maintain nursing competence; and, b) implement interventions to possibly retain rural nurses, based on phase one findings. specifically, we chose to study the supports offered by staff nurses, managers and decision makers in five, small rural hospitals that could assist nurses acquire and maintain knowledge and skills to retain them in their current job. the definition of rural used was that of a community less than 10,000 population residing outside of commuting distance. literature review the increased demand for health care providers has resulted in a shortage, and this is especially true in rural and remote canada. policies and programs to help alleviate the problems of shortages are usually urban centred (bowman & kulig, 2008). nursing in rural and remote canada is unique, and each setting has additional differences that make them unique from each online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 10 other. as described by molinari et al. (2008) “a rural nurse may manage traumas, calm the mentally ill, stabilize the critically ill, deliver emergency births, care for children and comfort the dying within the same shift” (p.3). the skill sets required are of a multi specialist who is adaptable to change and different ways of working than more traditionally experienced in urban settings (bushy, 2002; hegney, 1996). the role was described by kosteniuk, d'arcy, stewart, and smith (2006) as ‘multi-skilled autonomous expert generalists’ (p. 101). often there are limited numbers of health care professionals available and recruitment can be a challenge when there is no work or limited work for family members (macphee & scott, 2002). maintaining skills needed for emergency management of complex health issues is difficult, and retention is affected by loneliness, the paucity of further education opportunities and mentors, and a trend to centralization of services that effectively undermines the confidence of rural providers. the number of nurses living in rural settings is less than the equivalent population ratio in urban canada (pitblado, medves, macleod, stewart, & kulig, 2002). as articulated by the researchers in the rural and remote nursing study, “in small communities, nurses' personal and professional roles are inseparable. the intertwining of nurses' everyday practice and their personal lives needs to be taken into account in developing policies and services” (macleod et al., 2004, p.v). rural dwellers value locally available health care services, recognizing that they may have to travel for highly specialized and complex care; the challenge then becomes the ability to provide primary health care, secondary intervention, and on occasion, emergency stabilization and medical evacuation to urban centres. in the past ten to fifteen years, numerous very small hospitals have discontinued services such as 24-hour emergency care and maternity units (grzybowski, stoll, & kornelsen, 2013). in some communities there has been a concerted political engagement to save their hospital from closure or reduction of services. political action online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 11 can sometimes really undermine the health care professional’s ability to maintain services while under intensive scrutiny, as was demonstrated in the efforts of stevenson memorial hospital in alliston, ontario ("hospital ceo and vp resign," 2007). while closures have been essential for safety reasons, those hospitals in small communities that remain often struggle to cover all shifts with adequately prepared health care professionals. models of rural delivery of care are often more interprofessional in nature as professional scopes of practice are fully utilized (stewart et al., 2005). rural health care providers identify that courses such as acls are geared more to an urban setting where there are teams of people available to respond to emergencies; furthermore, access to educational, research and practice resources, particularly courses, are often limited or non-existent (penz et al., 2007). by necessity there is often a different approach to care delivery in small centres. in addition, rural canadian nurses surveyed overwhelmingly relied on rural nursing colleagues for information (kosteniuk et al., 2006); therefore, supporting rural nurses in their own context may be more efficient and effective in continuing education. while urban hospitals are experiencing a shortage of nurses, rural hospitals underwent this trend earlier; arguably, to lose one nurse out of a group of 20 is much more critical than losing one out of a group of 50. recruitment of nurses often requires an expensive search, as well as costs associated with moving to the community. health care professionals need to understand the rural context and may have unrealistic expectations of rural life. recruiting professionals who understand the complexities of rural life and work is essential to minimize the constant recruitment cycle. one approach is to develop a retention strategy that is locally appropriate and sustainable in the long term, yet we do not fully understand all of the issues related to retention in rural communities. “recruitment and retention of nurses can be more successful when done with an understanding of the perceptions of nurses in rural and remote online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 12 communities and in partnership with the communities themselves” (macleod et al., 2004 p.v). this study aimed to provide evidence to further inform decision makers, managers and nurses in understanding interventions which may be helpful to maintain a highly skilled and professional cadre of rural nurses who practice collaboratively, both intraand inter-professionally, to provide patient-centred care. conceptual frameworks and methodology the investigation was designed to be carried out in two phases: a) an environmental scan of the participating communities and small rural hospitals, using several data collection techniques; and, b) an intervention phase that was informed by phase one and developed in partnership with the rural hospital staff, targeting retention strategies. as the study was occurring in vivo, troughton’s (1999) framework was applied during phase one in the assessment of the rural communities. likewise, to guide the intervention phase, dicenso and colleagues’ work on evidence-based practice informed our actions (dicenso, guyatt, & ciliska, 2005). a brief synopsis of both frameworks follows. the troughton framework (1999) originated in community development and has been adapted for use to incorporate health care into a global understanding of a particular community. the framework provides a template to assist researchers assess each component of the community, including economic structure, social services, distribution of goods and services, community self-determination, and cultural and environment quality of life. communities less than 10,000 in population were defined as rural for the purposes of this study (du plessis, beshiri, bollman, & clemenson, 2001). the model from dicenso and colleagues (2005) helps organize the factors required for excellent clinical expertise and is particularly helpful in rural hospitals where there may be online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 13 limited resources. the model for evidence based clinical decisions has four overlapping concepts, and when factored into practice, lay the foundation for clinical expertise. the factors are: clinical state, setting and circumstances; patient preferences and actions; research evidence; and, health care resources. the premise of the model implies that by working through the adoption of evidence based, best practice changes that may be required, the rural community recognizes that they may have to adapt because of distance to tertiary care, patients may prefer to receive care close to home and be unwilling to travel, and there may not be all of the available health and human resources to have specialist care. conventional ethnography is a methodology suited to describe and interpret culture and cultural phenomenon, whereas the use of critical ethnography uncovers the covert social structures (e.g. patterns of exclusion) and attempts to change them (averill, 2006; bransford, 2006; simon & dippo, 1986; thomas, 1993). as the study purpose exceeded the mere description of rural nurses’ retention experiences, we maintain that critical ethnography was the most appropriate method to guide the study. in partnership with each hospital and local community, data collection methods incorporated a review of pertinent local archives, ethnographic interviews, and participant observation. the researchers were mindful of specific research procedures germane to critical ethnography, which included: a) vigilant scrutiny of interview and observational data for imposition of the researchers’ values; b) searching for anomalies in the interview data that lead to deeper meanings; and, c) the use of ‘defamiliarization’, the process of scrutiny of data from a familiar culture using a critical lens (bransford, 2006). following the implementation of retention strategies, we used survey methodology for evaluative purposes. the authors’ university granted ethical approval (reb #nurs-222-08), as well as the affiliated hospital ethics review boards. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 14 communities and participants the five participating communities selected for inclusion all operate a community hospital that provides acute care inpatient capabilities, ranging from 10 to 53 beds. two of the hospitals provide maternity care; all have an emergency department. the communities are different. one is a summer resort and so has a seasonal increase in the summer; one provides care to a medium size town and to families from a military base; one has a population engaged in forestry and mining, and another recently suffered major job loss with the primary employer closing a factory. the participants were registered nurses (rn) and registered practical nurses (rpn) working in the aforementioned hospitals in a rural area of southern ontario. throughout the remainder of the text, they will be referred to in the collective as ‘nurses’. procedures & interventions phase one of the project was completed between june and november 2008 and consisted of an environmental scan of each community and hospital, using a critical ethnographic approach. in this phase, four forms of data collection were used: a) document analysis that resulted in hospital and community profiles; b) participant observation; c) a short demographic survey; and, d) interviews. of note, a new provincial policy to recruit new graduates into fulltime positions, entitled the nursing graduate guarantee initiative, began in 2007, and continued through the data collection period (healthforceontario, 2014). a research associate (ra) was hired for each corporate institution to understand the culture of each hospital and to establish priorities with the nursing staff of participating hospitals. as one of their first tasks, the ras collected community and hospital data. data for the community profiles were derived from the 2006 census using the community profile feature of the statistics canada website (statistics canada, 2008). all of the communities have fairly online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 15 similar profiles with english as a mother tongue, and having proportionately lower percentages of young adults and few recent immigrants. during the six months of phase one, the ras immersed themselves within the five communities and sites to a level in which they would no longer be as prominent as an outsider to the local residents and hospital staff. this was accomplished by joining many of the staff on breaks and by simply having a presence at the hospital frequently enough so that the staff was familiar with them. during the more than 600 hours of direct observation of nursing units, informal discussions with nursing staff and managers took place and detailed field notes were kept by the ras. it was during this phase that a 17-question survey on nursing career and demographic information was distributed to those nurses willing to participate. the surveys were anonymously distributed and collected onsite to gain baseline data. a total of 156 surveys were completed. the research team had planned to conduct focus groups with the nurses at all sites; however after spending hours observing and speaking with the nursing staff, it became apparent that this strategy was not going to work in any of the rural hospitals. in order to accommodate the nursing staff as much as possible and interfere as little as possible with daily routines, oneon-one informal interviews were deemed the best solution. a protocol of 13 interview questions was developed which helped guide the research team’s ability of extracting the data necessary to gain an understanding of retention issues amongst rural nurses in southern ontario (see figure 1). following written consent, the research assistants and the authors used digital recording methods to conduct the interviews in unoccupied rooms within the hospitals settings. recordings were transcribed shortly after the interviews (n=45) and reviewed for completeness. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 16 based on findings and recommendations from phase one of the project, planned interventions were undertaken in three out of the five hospital sites in phase two over 13 months (december 2008-december 2009). interventions were site-specific and included the following eight activities: a) a two-day mock trauma session: b) critical care education; c) development of an orientation module; d) identification of external funding for staff development; e) investigation of potential library services; f) application support for academic and certificate development; g) staff appreciation events; and, h) a preceptor recognition program. external events outside the control of the research team prevented our planned interventions in two of the hospital sites, as nursing educators were hired by hospitals to address our previously identified educational needs. follow-up interviews and post-surveys (n=108) to evaluate the effect of the interventions by rural nursing staff were completed between january and february 2010. 1. can you tell me about your job at this hospital? 2. how long have you worked here? 3. when you started working here what were the expectations of qualifications in addition to your nursing registration were you required to have? 4. how easy is it for you to access continuing education opportunities? 5. what keeps you working in this hospital and community? 6. can you reflect on why other nurses stay at this hospital? 7. if a new nurse were to come and look around this hospital, what would you tell her the benefits to working here are? 8. are there any policies and contracts that make it difficult for retaining nurses at this hospital? 9. have you been a preceptor/mentor for nursing students at this institution? 10. what other support staff are available for you to do your job effectively? 11. do you find you have an effective working relationship with other professionals? 12. do you feel your issues, concerns, values and assessments are heard and acknowledged by other staff? 13. do you have anything you would like us to know or to add to anything? figure 1. main questions of interview protocol without probes online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 17 data analysis to identify themes, the authors and two research assistants read transcripts of the interviews and participatory observation field notes independently; group meetings were held to discuss and critically reflect upon emerging themes. similarities in nurse responses between sites were noted and implications for rural nursing retention arising from these common themes were identified. survey data was analyzed for frequencies and proportions using spss® 18.0. the age distribution and the aggregate characteristics of those who participated in the survey are found in figure 2 and table 1, respectively. the interview data was interpreted in tandem with the field notes, as well as the results from the document analysis and demographic survey data. the following findings represent the triangulated results from this process. table 1 characteristics of survey participants (n=156), in 5 ontario rural hospitals characteristic n* (%) sex male female 3 153 (1.9) (98.1) nursing position rn rpn 110 46 (70.5) (29.5) employment status full-time, 8 hr full-time, 12 hr part-time casual part-time, casual 56 34 62 2 2 (35.9) (21.8) (39.7) (1.3) (1.3) highest nursing educational level rpn certificate rpn diploma rn diploma rn degree rn extended class (np) master’s 29 18 87 19 2 1 (18.6) (11.5) (55.8) (12.2) (1.3) (0.6) accept employment under new graduate guarantee initiative yes no 10 145 (6.4) (92.9) live in same community as work yes no 94 60 (60.3) (38.5) length of time living in rural area <1 yr 1-5 yr 1 3 (0.6) (1.9) online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 18 characteristic n* (%) 6-10 yr 11-15 yr 16-20 yr 21-25 yr >25 6 4 14 23 10 (3.8) (2.6) (9.0) (14.7) (64.1) location of birth southeastern ontario other ontario other provinces international 97 42 6 3 (65.5) (28.4) (4.1) (2.0) years working as a nurse <2 yr 2-5 yr 6-10 yr 11-15 yr 16-20 yr 21-25 yr >25 yr 10 10 10 13 16 19 78 (6.4) (6.4) (6.4) (8.3) (10.3) (12.2) (50.0) years working in rural setting as a nurse <1 yr 1-5 yr 6-10 yr 11-15 yr 16-20 yr 21-25 yr >25 8 22 18 10 17 22 53 (5.2) (14.1) (11.5) (6.4) (10.9) (14.1) (33.9) years planning to nurse at this location <1 yr 1-2 yr 3-5 yr >5 yr 6 16 26 104 (3.9) (10.5) (17.1) (68.4) not all counts will total 156, due to missing data figure 2. age distribution of participants (n=154) online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 19 findings small rural hospitals’ inability to offer full health care services after providing a general overview of their typical day, the nurses were also asked to present the disadvantages to working in the rural sites. many of the downsides reflected their lack or equipment and resources needed they want to be able to provide their patients. one nurse stated: “i am disappointed…i feel like we’re a band-aid station. to fix and transfer out. to stabilize and transfer out, and it’s not good.” several nurses also commented on how experiences are missed in rural areas because they aren’t equipped to handle them. comments included: “…may be not be as challenging of nursing that they could find elsewhere”; “you don’t expand your knowledge base here as much as you would in a bigger hospital”; and, “well if you are a new grad and you’re looking for experience, you’re going to do a little bit of everything coming here, but you’re not going to see a lot….” one nurse commented on how due to the lack of seeing different experiences and health concerns, skill proficiency may suffer as a result of only doing it every six months or longer. …there’s lots of things you don’t see…[coming from a larger centre] i was quite used to and familiar with working with central lines and i come here and you might not see another central line for 6-9 months and then it comes and it is a big deal to think about all of the things you have to do…it is a simple thing, but they become huge things because you don’t see them very often… from our environmental scan, we documented that not all hospital sites had in-patient surgical services, computerized tomography (ct), or obstetric services. while there were barriers and limitations voiced because of hospital size, a strong theme was that of providing very good care to their patients. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 20 belief they provide very good care the nurses frequently described how they believed they gave very good care that was valued by patients, families and the community. one nurse shared the following story: …one nurse that just started with us [from a large urban centre] came in as a patient and i triaged her and she said ‘oh you’re so kind here and the service is so good here’ and i guess she went home and wrote a letter about what a good experience she had here…and then she decided she would like to work here as she lives between [site] and toronto… this belief encouraged them to stay working at their institution: “…the people here actually care about their hospital and they care about the community, so there’s a sense that we want to look after the patients…there’s more of a commitment because we feel they’re our own…”. rural nurses have the ability to use all of their skills, instead of only a specific set, again mirroring the “generalist-specialist” idea, and one nurse furthered this by saying, “i think you get to have more control over…your profession and your practice then you do in larger sites…here you’re allowed to think a bit more and we tend to have a bit more open relationship with the physicians…and you can really see how your care effects your patients.” one nurse spoke of how it is easier to get more from your patients in terms of information when they feel they can trust you and that they aren’t going to be seeing many different nurses throughout their stay. she added: “…patients feel comfortable on the floor and they know some of the people and know friendly faces and little bits about them… and talk about issues that they might necessarily shy away from and asking questions.” patients are often referred to as a number in larger hospital settings and many nurses spoke of how patients comment on how it is online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 21 more personal and how they are not made to feel this way. one nurse commented: “…we are able to give our patients much more attention, so that they are not just a number.” in a small and rural hospital, when you get to know a patient and their history very well, it is inevitable that along with developing a relationship with the patient you develop a relationship with the patient’s family members and support group as well. this was explained further: “…i know the patient’s family members and they trust me and feel as though they can talk to me…” the theme of the ‘belief they provide very good care’ was further borne out by the hospital participant observations and the documentary data that provided evidence of strong community support for these five rural hospitals. another nurse described a beneficial factor of working rurally and referred to it as a holistic approach: “we’re probably a more holistic approach…because we are so multi-tasked, where often in the city, people specialize in specific things. you can really see that in our emerg [sic] doctors…they need quite a broad education because they are it….” while nurses stated that they gave very good care there was also a concern about sufficient work for all the nurses. content to stay, as long as there is sufficient work and sufficient schedule nurses hope more full-time positions will be created. results from the survey support this statement, as 42% of those surveyed reported working in part-time or casual positions. fiftyeight percent of the sampled staff worked in full-time positions, with 36% in full-time, eighthour shifts, while another 22% worked full-time 12-hour shifts (see table 1). the staff members were further asked if they work in a part time position, what the reason was for it, and 26% stated that it was because of the lack of full-time positions available. interestingly, 66% of participants were born in the study area, predominantly from communities of less than 10,000 people. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 22 during the interviews, nurses were asked if they ever work overtime hours, and if so, why they choose to. the majority of the participants interviewed (63%, n=34) stated they work overtime often, for reasons such as “to help out”, explaining they know how it feels to be short handed, and the part time employees explained they did it for “the extra shifts and money”. a small percentage of the interviewed population (13%) answered that they do not pick up any overtime and explained that it was mainly because they have full-time positions and the part-time employees are offered it first and generally always take the opportunity. the final 25% of the participants (n=11) were not asked the question. the staff mentioned numerous areas where the staff shortage affects different areas of their working environment, such as the inconsistency in the scheduling. as a result of not having enough staff to cover all the needed shifts, the nurses end up working a variety of shifts to make sure every time slot is covered, and in turn, this culminates in having a negative effect not only on the staff, but the patients as well. as was mentioned earlier, the patients enjoy and respond better to knowing their nurse very well and because of all of the scheduling difficulties the nurse patient relationship lacks in consistency. one nurse commented “…there is no consistency on your shift and there is no consistency for the patients you are dealing with.” it was also mentioned that because of the lack of staff, there is an increased pressure on the existing staff to always be available to work and feel as though they can’t leave “…even if something family wise comes up…” let alone if someone is wanting to take some vacation time or days for education; “…there might be only one available person that you could switch with out of the part time staff and it is probably their first time off so they don’t necessarily want to switch…” online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 23 the misunderstood “generalist-specialist” role nurses interviewed in all five sites described how they worked to assess and manage the patients under their care, often with limited resources. commonly, they spoke of the breadth of their responsibility: “…you do see every aspect of care from emerg [sic] to orthopaedics, we don’t get surgery but cardiac, so your pediatric patient, the palliative you just see a whole, you know it is interesting.” consequently, a common concern was the need for continuing education and the challenge of remaining current: …that is the challenge to for nurses in the rural setting because they need to keep up on acls [advanced cardiac life support], they need pals [pediatric advanced life support] and neonatal resus [sic] and trauma care, so there are a lot of components if you go out there and try and keep up to date on all of the changes it’s the same for the physicians trying to keep up to date… of those who participated in the survey, 29% had completed acls and nearly 11% pals. working as a team was deemed crucial to functioning in their role as rural nurses. quotes from two nurses illustrate the role of teamwork: you work together a lot but then again it’s a small setting – you can’t work on your own, you cannot work in isolation in a place like this because you need those people to physically help you or you know, there’s nobody else you can call – you’ve got to be able to work with the people you are working with. …[we are a] very close knit, everyone works together, we have a nursing team approach still. several rural nurses, in particular those who worked in critical care areas and the emergency room, expressed frustration with not being fully appreciated by colleagues in larger centres: “…we are not just a first aid station here, we do know what we are doing. we may not online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 24 have all the resources that we require, but we do a lot of things here…”. when interacting with larger, tertiary facilities, they voiced that they feel they are perceived as “uneducated” and “incompetent”. in actuality, rural nurses are highly educated and skilled and as one participant stated, “i feel that rural nursing is a specialty…you’re kind of on your own a lot of the time and you have to handle the situation….”. others indicated that it can be difficult to “switch gears” as a rural nurse may care for the chronically and acutely ill, deal with a critically ill patient, or work in a maternity situation all in one shift. this ‘generalist-specialist’ role that the nurses described was reported as often being misunderstood by their peers in larger centres. ingrained community differences and traditions the setting for the study occurred in rural communities with varying economic and historical origins. the documentary analysis and participant observation assisted in understanding differences between the five sites. past events occasionally surfaced to the forefront by participants as explanations for the current hospital practices. one of the major events that shaped perceptions, responses and actions was the ‘forced administrative marriage’ of three rural hospitals with a larger institution by the province nearly 15 years ago. although several hospital sites are located within an hour’s drive of each other and institutionally, operate with very similar styles, current perceptions of communities by those working within hospital organizations continue to be shaped by historical events. the unique culture of each site necessitated a tailored approach to interventions for retention in phase two of our study. local initiatives do work in phase two, our interventions focused primarily on educational priorities identified by rural nurses and activities to recognize and acknowledge their work. from the follow-up survey (n=108) at the completion of the interventions, 64% of respondents were aware of the research online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 25 project in their facilities. along with the follow-up survey, interviews were conducted with key informants (n=7) at the conclusion of the study to try and determine the effect of the study and how far the educational interventions reached. all individuals who had knowledge on the preceptor recognition program supported this initiative and hoped that it will be sustained past the completion of the project. one participant said:“…i think that it is great because that just shows the staff that you are working hard and we do recognize that.” response to the orientation manual at one site was positive from those involved; one manager explained that the orientation manual was “…an absolutely fantastic benefit to us because that is something we had let slip.” finally, twenty nurses in the smallest facility attended a two-day mock emergency workshop hosted by the research team; overwhelmingly, the participants agreed that the workshop was useful to their practice (71% ‘strongly agreeing’, 29% ‘agreeing’). the uptake of the initiatives along with the positive feedback contributed to our finding that interventions appropriate to local environments do work. provincial policies require tailored responses to retention comments by participants about retention varied from site to site. this is not surprising, given the differences in hospital bed numbers and visits to the emergency department, geographical location, staff needs and educational levels between the five hospitals. in one region, staff expressed that full-time jobs would allow for increased flexibility in continuing education prospects. from the survey in phase one, nearly 89% of respondents reported they had the opportunity to take additional course(s) or educational offerings in the past 12 months. others commented on the importance of clinical educators in the promotion of best practice and about the availability of educational funds through the registered nurses association of ontario (rnao): online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 26 …i am just afraid with these cutbacks again, you know oh don’t get rid of these educators, these professional practice people, you know they support you, they can tell you what is new, what is working, wound care – what’s the best thing now, because you can’t keep up on everything and that is what they do. the new initiative through rnao is incredible because that is how i took my critical care; they paid for it…that has been a big thing that has helped a lot of nurses. other participants who were closer to retirement age identified that recruitment would become a priority in the near future and should be the focus, rather than retention strategies. they consistently voiced the opinion that the best probability of acquiring new graduates to a rural hospital is to either recruit those who are originally local or who are from a rural community. one site, facing retirement of long-serving staff, had instituted a locum type of approach by recruiting nurses who were interested changing to a different working pace, or who were planning to retire in a few years to their cottage in the region. despite interesting approaches, recruitment remains a challenge for these small, rural hospitals. of those surveyed, only twenty-two nurses (14%) reported planning on staying with their current employer for less than two years. of these 22 respondents, most (n=15) were between ages 53 and 59, whereas only two respondents under the age of 30 indicated their intent of staying less than two years. concerns over not fully using educational qualifications were voiced by one participant: i don’t know how long i will be here, if i find something that’s more on pace with what i’m doing and i can find more equivalence…it’s because i paid lots of money for my education and i don’t want it to stagnate… online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 27 the majority (68%) planned on nursing at their current location for more than five years (see table 1). yet, among those under 60 years of age who plan to work less than two years at their current workplace, significantly more were in full-time positions (n=17) than in part-time or casual (n=3) employment (χ2 =7.10, df=2, p=0.03). this finding is at odds with those nurses who agreed to be interviewed. the nursing graduate guarantee (ngg) initiative did not emerge as a topic during the interviews, and of those who completed the survey, 10 nurses indicated that they had taken employment under the ngg (table 2). interestingly, 6 out of the 10 new graduates indicated that they intended to remain at their current workplace more than five years. table 2 plans to continue work by participants in provincial new graduate initiative (n=10) how long do you plan on nursing at this location? 1-2 years 3-5 years > 5 years total* current employment status ft 8 hour shift 0 1 1 2 ft 12 hour shift 1 0 2 3 pt 0 1 2 3 casual 0 0 1 1 total 1 2 6 9 * missing data=1 discussion in the study, we set out to identify modifiable factors that might affect nursing competence and possible retention in rural hospitals. overall, we found that while rural nurses acknowledge that working ‘rural’ denotes reduced resources available to do the job, they are confident that they provide very good care, and that rural communities appreciate their work. intention to remain in their current position was high, but tempered by a clear signal that full-time work availability and scheduling issues could change that balance. a theme of the rural nursing role online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 28 being misunderstood by colleagues in more urban centres also emerged. finally, the intervention strategies that arose from the research findings reinforced the importance of tailoring solutions to the local rural context. the study was guided by the troughton model (1999) – particularly during the environmental scan phase of the study. it did not prove as useful during the interviews and surveys but the model components raised the awareness of the differences between the rural sites for the research team. understanding the rural context also assisted the researchers in designing education initiatives that fit the context and need of each site. the dicenso framework (2005) has guided the thinking about rural practice settings for the research team on several studies and proved most helpful when articulating the components of care in any setting to the nursing staff who participated. by articulating to staff that there are patient preferences and actions, health care resources, research evidence, patients’ clinical state, circumstances and setting, and clinical expertise to consider, the framework helps structure discussion about what components need to be contemplated, particularly when examining retention strategies. rural hospitals, by their very structure and setting, are not typically designed to provide onsite specialized services (calico, dillard, moscovice, & wakefield, 2003; moscovice, wholey, klingner, & knott, 2004). yet in our study, a few rural nurses identified the ‘fix and transfer out’ realities of rural practice to be troubling. most nurses identified the limitations to their scope of practice and accumulation of nursing skills as the biggest drawback to rural practice. this finding is contrary to a recent qualitative study from southeastern united states exploring rural nurses’ perceptions of quality care; in the u.s. study, rural nurses highlighted their role in successful transfers as an example of quality care, and the issue of restricted practice was not reported (baernholdt, jennings, merwin, & thornlow, 2010). however, similar to our findings, online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 29 baernholdt and colleagues found that rural nurses perceived their care to be more holistic than larger centers and that “patients are what matter most” (p. 1349). comparable findings of nurses’ strong connections to the rural communities where they live have been reported by other investigators (hunsberger, baumann, blythe, & crea, 2009; kulig et al., 2009; penz, stewart, d'arcy, & morgan, 2008). since our study was designed, a paper has been published that identified organizational characteristics and satisfaction levels of rural nurses in the northwestern united states (molinari & monserud, 2008). the opportunity to work straight days, work hours, nursing peers and relationships with physicians emerged as the most important factors to job satisfaction. opportunity to work part time was the least related to satisfaction, but was still high in their study (molinari & monserud, 2008). in our investigation, not having full-time employment was highlighted by those interviewed as one of the issues that would force nurses to seek employment elsewhere. likewise, the ‘limiting nature of rural nursing structure’ was a theme that emerged as a barrier to retention in a qualitative descriptive study of rural healthcare managers in newfoundland and labrador (alyward, gaudine, & bennett, 2011). the limited number of full-time positions in rural areas of the province was cited as an example of this structural barrier. the authors of a study undertaken in rural southwestern ontario between 2002 and 2004 identified a similar finding, with only 46% of rural nurses having full-time jobs, which led to job dissatisfaction (baumann, hunsberger, blythe, & crea, 2006; hunsberger et al., 2009). in a 2007 qualitative study (n=21), rural nurses in the niagara region of ontario also reported concerns with lack of full-time employment (montour, baumann, blythe, & hunsberger, 2009). these findings are in contrast to an earlier comprehensive survey of heath service agencies in online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 30 northeastern ontario (pong & russell, 2003) that reported geographic isolation (66%), rural setting (57%), lack of opportunities for partners to work (42%), and lack of community support (27%) as the most often cited reasons why people (excluding physicians) did not accept employment. the rural southern ontario settings utilized in our study, as well as those of baumann and colleagues, are not as geographically isolated as northeastern ontario, which presumably accounts for the difference in findings. institutional factors such as staffing clearly influence levels of satisfaction and ultimately, may affect retention efforts and must be considered by nursing managers and executives. rural nurses in our study described the roles they undertook; in particular, they highlighted the need for teamwork, the breadth of their responsibilities, and the need to ‘switch gears’ during a shift. while several posited that rural nursing was a nursing specialty, no participants specifically referred to a ‘generalist-specialist’ role, a finding that molanari and colleagues (molanari, jaiswal, & hollinger-forrest, 2011) also noted in their investigation of 106 enrollees of a rural nurse residency program in northwest united states. what did emerge in our study, however, was a sense of being misunderstood by their urban counterparts. interestingly, hunsberger et al. (2009) reported that the rural nurses in their ontario study “…felt demeaned because staff at tertiary care settings did not appreciate the challenges of transporting unstable patients…(p. 21).” jackman and colleagues (jackman, myrick, & yonge, 2010) argue that rural nursing needs to be acknowledged as important, by other nurses, decision-makers and by governments, otherwise, marginalization of rural nurses will ultimately affect the rural populations they serve. a recent systematic review that drew upon five previous systematic reviews (i.e. umbrella review) on rural nurse retention summarized the strength of the evidence for effective retention online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 31 strategies (mbemba, gagnon, pare, & cote, 2013). the authors developed a taxonomy of rural nurse interventions consisting of four categories: i) education and continuous professional development; ii) regulatory; iii) financial incentives; and, iv) personal and professional support (p. 7). strategies that address personal and professional support had either strong or moderate evidence. for instance, strong evidence was found for investing in rural infrastructure, such as water supply, roads, and housing. attempts to reduce nurses’ feelings of professional isolation through telehealth communications and the provision of supportive supervision through such means as mentoring, preceptorship or clinical supervision garnered moderate evidence as interventions. regulatory interventions, such as recognizing overseas qualifications, had low evidence, whereas the strength of the evidence for financial incentives to nurses to work in rural and remote areas ranged from low to moderate. the review found moderate support and evidence for educational interventions in rural retention. educational strategies that have been implemented in rural and remote settings include the targeted recruitment of students from, and education within, rural areas (norbye & skaalvik, 2013; playford, wheatland, & larson, 2010) as well as continuing education assessments and professional strategies (banks, gilamrtin, & fink, 2010; fairchild et al., 2013; healey-ogden, wejr, & farrow, 2012; macleod, lindsey, ulrich, fulton, & john, 2008). our interventions focused on educational gaps that had been identified by the staff nurses in three of the five rural community hospitals, and can be classified as support for continuous professional development, as outlined by mbemba and colleagues (2013). there is growing acknowledgment that numerous educational strategies, including exposure to rural clinical settings in basic nursing programs, should be employed to attract and to keep nurses in rural communities (hunsberger et al., 2009; lenthall et al., 2009; molanari et al., 2011). the importance of tailoring nursing interventions, online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 32 including educational opportunities, based on the size of a rural hospital and its contextual factors was identified in a national sample of 280 rural hospital nurse executives in the united states (newhouse, morlock, pronovost, & sproat, 2011). in particular the authors suggested the use of clinical ladders in promoting staff development in smaller, rural hospitals. although autonomy in practice did not emerge as a finding in the umbrella review, in a significant study of over 3,000 rural and remote nurses in canada (stewart et al., 2011), satisfaction with autonomy was the only significant predictor of intention to remain in practice. we did not gather information about autonomy, but compared to stewart and colleagues’ finding of 17% of rural and remote nurses’ intention to leave within a year, only 4% indicated likewise in our sample. none of the rural workplaces in the present study are considered remote, a factor that contributed to the intention to leave in stewart and colleagues investigation. one of the critical factors emerging in the rural nursing literature is the importance of community satisfaction in the retention of rural nurses (bratt et al., 2014; kulig et al., 2009; manahan & lavoie, 2008; molanari et al., 2011; stewart et al., 2011). this finding has not been observed in studies of urban-based nurses. limitations of our study include the convenience survey sampling, lack of retention data from the hospital corporations, and the inability to fully implement educational initiatives in all study sites. our findings, similarly, are not generalizable, given the small number of institutions involved. participant observation and our partnering with hospital nurse executives, however, provided solid footing for interpreting the interviews within a rural context. implications for nursing education, practice and research educational institutions strive to ensure that their nursing programs matriculate practitioners who are equipped to deal with the realities of practice; yet, the gap between online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 33 education and practice continues. while not tested in this study, it could be hypothesized that those nursing programs that actively consult and engage with practice partners are more likely to instill clinical competence and confidence in their students, providing a solid basis to practice regardless of the setting. once in practice, maintaining and updating clinical knowledge and skills can be a struggle for rural nurses and their managers, as access to relevant courses and programs may be limited. continuing professional development that is ongoing and relevant to the clinical realities of rural practice requires innovative strategies between educational institutions and rural healthcare facilities. rural nurse managers and administrators should view a healthy workplace environment as a part of a successful retention strategy. furthermore, there is emerging literature to support the premise that enhancing local infrastructure in rural communities contributes to retention efforts (buykx, humphreys, wakerman, & pashen, 2010). rural healthcare administrators can be influential by advocating for community quality improvements at the local level. the multiple factors influencing nursing retention in rural communities are beginning to be elucidated, but more research is needed to define and clarify our understanding. conclusion the five-site research study sought to find modifiable factors to maintain rural nursing competence that would potentially enhance nursing retention in small rural hospitals. we identified key areas that support previous findings identified in the literature; however, the overall intention to leave the workplace was low compared to other reports, despite the relatively low full-time employment status of nurses. community social relationships, such as family connections, played a large role in the decision to remain amongst those interviewed. rural and remote nursing practice is shaped by a myriad of community factors, and it important to online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.337 34 distinguish that rural is distinct from remote (martin misener et al., 2008). ultimately, it is the unique qualities of a community that require attention in both rural recruitment and retention efforts. funding agency ontario ministry of health and long-term care (mohltc) references alyward, m., gaudine, a., & bennett, l. 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(1999). redefining "rural" for the twenty-first century. in w. ramp, j. kulig, i. townshend & v. mcgowan (eds.), health in rural settings: context for action (pp. 21-38). lethbridge, ab: university of lethbridge. microsoft word hendrickx_307-1708-1-ed.docx online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 exposing nursing students to rural healthcare practice: creating a rural simulation experience lori hendrickx, edd, rn, ccrn 1 becka foerster, ms, rn 2 julie hansen, ms, ma, rn 3 lois tschetter, edd, rn, cne, ibcle 4 1professor, college of nursing, south dakota state university, lori.hendrickx@sdstate.edu 2 instructor, college of nursing, south dakota state university, becka.foerster@sdstate.edu 3 instructor, college of nursing, south dakota state university, julie.hansen@sdstate.edu 4associate professor, college of nursing, south dakota state university, lois.tschetter@sdstate.edu abstract background: continued nursing shortages in rural areas have prompted the call for nursing education programs to prepare nursing students for rural practice. including curricular content on rural health issues and placing students in rural health care facilities are methods used by some institutions. an additional strategy for preparation of students for rural practice is simulation. method: this project involved the use of simulated health care facilities in rural communities, incorporating rural concepts into rural simulation scenarios and developing a twenty-two member family tree of rural residents for use in the simulation scenarios. nursing students participate in rural simulation scenarios throughout the curriculum in lecture and lab settings. online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 conclusions: using simulation with rural health experiences provides nursing students the opportunity to experience caring for patients from rural areas while increasing their understanding of health care issues, challenges associated with rural health care and opportunities for rural practice. keywords: simulation, rural, scenarios, nursing education exposing nursing students to rural healthcare practice: creating a rural simulation experience in recent publications, promising reports indicate that the registered nursing (rn) workforce is experiencing significant increases in the numbers of new graduates. the bureau of labor statistics employment projections 2010-2020 (2012) indicates that the number of employed nurses will increase 26% from 2.74 million in 2010 to 3.45 million in 2020. despite reports that the numbers of rns are increasing, fahs (2012) urges caution for rural health care facilities that traditionally have experienced greater shortages than their urban counterparts. it is imperative that rural health care facilities continue to maintain recruitment efforts to ensure there are adequate numbers of rns to meet current and future needs of rural communities. despite the increased numbers of rns in the workforce in recent years, much of the literature indicates that rural healthcare facilities continue to face challenges recruiting and retaining qualified rns and other health care professionals (bushy & leipert, 2005; bushy, 2006; roberge, 2009; schmitz, claiborne, & rouhana, 2012). several potential solutions have been proposed to address issues of recruitment and retention in rural areas. researchers exploring the role of nursing education in preparing students for rural practice have identified several conclusions based on survey data from faculty and administrators of baccalaureate nursing programs (straub & frels, 1992). among their recommendations was the need to recognize “rural” as a specialty and that nursing programs should include specific online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 content on rural nursing. additionally, it was recommended that collaborative education and internship programs be developed between rural health care facilities and nursing education programs. later studies have supported these early findings. one predominant theme arising from the literature is the importance of having curricular content on rural health care and providing educational experiences in rural health facilities (devine, 2006; strasser & neusy, 2010). coyle and narsavage (2012) studied the effects of a rural clinical rotation on nursing students and found that the rural experience had a positive influence on interest in rural health and working in a rural area. a survey of rural hospital nurse managers identified several benefits to a rural clinical experience. benefits included the exposure to a variety of patient situations, exposure to different departments and interdisciplinary practice, and increased understanding of the nurse generalist role. respondents also indicated that exposing nursing students to rural practice was an effective recruitment tool as several former students were now employed by those rural facilities (hendrickx, mennenga, & johansen, 2013). in a study by daniels, vanleit, skipper, sanders, and rhyne (2007), several factors important in rural recruitment were identified. in addition to the importance of a rural background and a desire to return to a rural community, rural training programs or practicum experiences were identified as influential factors for rural recruitment efforts. statement of the problem south dakota is primarily a rural state, spanning over 75,000 square miles with only three cities having populations over 25,000. fifty-four of the sixty-six counties are considered frontier with fewer than seven people per square mile. while 86.2% of the state’s residents are nononline journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 hispanic white, 8.9% are american indian and 3.1% are hispanic (united states census bureau, 2012). rural and frontier areas of the state have fewer options for health care services and are medically underserved. see figure 1. figure 1: south dakota medically underserved areas while some nursing students at south dakota state university have rural backgrounds and plan to practice in rural health care environments upon graduation, others have had limited exposure to rural health. rural hospital administrators have indicated that educating prospective nurses about rural health care issues is one of the most critical needs rural facilities have (hendrickx et al., 2013). an understanding of rural health issues and development of the skills necessary to work in rural health care systems that are increasingly technology based are core online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 components of preparing pre-licensure students for practice in rural settings. some nursing education programs do use rural health care facilities for clinical placement, but there may not be adequate numbers of rural sites for all students to get rural health care experience. purpose in order to address the education needs in rural underserved areas of south dakota, the college of nursing at south dakota state university (sdsu) implemented the “simulation informatics technology enhancement” (site) program for pre-licensure baccalaureate students. the objectives for this project included preparation of nursing students to practice in rural health care environments through expanded use of human patient simulation. simulation scenarios and activities that mimic the types of patients, rural environments, issues rural dwellers face, and facilities typical of the midwest were developed and incorporated into the undergraduate curriculum. creation of rural towns and healthcare facilities to represent realistic rural community characteristics and health care facilities serving a rural population, the town of prairie view was created. prairie view is a rural community with a population of 2,000 people. the name prairie view describes the region’s geographic makeup. prairie view clinic is one of the health care facilities used for simulation scenarios and case studies. it is a clinic staffed with four primary care providers: two physicians, one family nurse practitioner, and one physician assistant. prairie view community hospital is attached to prairie view clinic and nursing home. the hospital has 20 patient beds and is equipped with telehealth and telemedicine specifically for consultation, emergency care, and intensive care services. outreach physicians travel to prairie view a few days each month for patient consults, clinic appointments and to perform select surgical procedures at prairie view community online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 hospital. the hospital does not offer obstetric services. the local volunteer fire department provides the prairie view ambulance services. the fictitious dakota health system is a hospital located in dakota city, which is two hours away from prairie view and is a 310 bed level 2 trauma center. dakota health system is incorporated into unfolding simulation scenarios that may include transport of critical patients from prairie view community hospital or patients needing specialty services not offered by prairie view clinic or community hospital. dakota health system provides the telehealth and telemedicine services to prairie view community hospital. rural patient profiles with collaboration from a team of content experts and nursing faculty members at sdsu, a five generation fictional family, the jacksons, was created. the jackson family tree is comprised of 22 unique family members. a profile was developed for each member of the jackson family. each profile includes: name, age, ethnicity, medical problems, occupation, hobbies, lifestyle choices, living arrangements, and religion. each family member is characterized by a photograph, and pictures of the family members’ homes are also used as visual aids for students. locating appropriate photographs for each family member was a challenge. copyright issues, cost, and realistic physical appearance matching individual profiles were all considered when choosing the photographs. a sample of patient profiles is detailed in table 1. family members’ ages range across the lifespan from five days old to 95 years old. based on the ethnic distribution of the rural state, non-hispanic, native american, and hispanic ethnicity are represented within the jackson family. special cultural considerations and beliefs specific to the non-hispanic, native american, and hispanic backgrounds are woven within the simulation scenarios and case studies. online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 table 1 samples of rural simulation family profiles fictional family member health history home environment george jackson • 67 years old, married (wife pauline) • caucasian • enjoys hunting, fishing • active rancher • smoker • lutheran faith hip fracture from fall off horse, copd, coronary artery disease, history of basal cell skin cancer lives on original family homestead 15 miles from town of prairie view with retired parents (aged 86 & 95) next door bonnie jackson • 41 years old, daughter-in-law of george • caucasian • employed as nursing assistant in long term care setting; husband farming • married to john jackson • lutheran faith cerebral vascular accident (cva), history of atrial fibrillation, hysterectomy lives in two-story farmhouse in the country, approximately 10 miles from in-laws jennifer rabbit tail • 22 years old, native american, niece of bonnie jackson • single mother of 5 day old female • college student on government assistance programs: medicaid, wic, snap. gravida 1, para 1; infant son with hyperbilirubinemia lives in one bedroom income-based housing unit in town of dakota city two hours away from parents; baby’s father unknown david conn • 38 years old, • caucasian • catholic faith, non-practicing • unemployed, picks up odd jobs as available • ex-military, served in iraq as ied specialist alcohol dependence and suicidal ideation related ptsd homeless use of patient profiles in the curriculum the jackson family members have been incorporated into existing simulation scenarios, skills lab, and classroom case studies and profiles have been developed to allow for growth and online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 adaptation. as new scenarios or case studies are written, the family profiles continue to be revised with minor changes to meet individual course or clinical needs. one or more of the jackson family members are utilized in every simulation experience at south dakota state university. the starting point for integrating jackson family members into simulation scenarios, skills lab, and classroom case studies is based on the developed health history for each of the family members. for example, jackson family member george jackson is used within many of the medical-surgical nursing courses because of his history of hip fracture, chronic obstructive pulmonary disease, coronary artery disease, and basal cell skin cancer. for a simulation related to surgical care, gladys conn (david conn’s mother) is hospitalized following knee replacement surgery. she has symptoms of a wound infection which students should recognize during their assessment. a compounding problem is that her surgeon is an outreach surgeon who is not housed in the rural hospital but provides surgery on a scheduled basis. post-operative questions and follow-up can be done through phone calls or telemedicine technology. another example is jackson family member david conn who is primarily integrated within the mental health nursing course due to his history of alcohol dependence and suicidal ideation related to posttraumatic stress disorder. the simulation involving mr. conn focuses on therapeutic communication in the mental health setting. the rural environment, patient profiles, and concepts are developed within the case study. when a jackson family member is being used in simulation, these rural concepts are either provided to the students in written or oral form prior to the activity. students work through the simulation exercise and during the debriefing address issues related to rural health. one question used during simulation debriefing has been, “after an experience such as this, what unique online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 aspects of rural health care such as environment, access to care, technology, communication, culture, and nursing practice can you identify?” for skills lab, the jackson family members are used as patients within the electronic medical record and for various skill check offs. in the classroom, faculty members integrate the jackson family members into course case studies and assignments. for example, in the lecture on care of a patient with a cerebral vascular accident (cva), bonnie jackson is presented. students relate her history of atrial fibrillation to the cva and develop a plan of care for this type of patient. for discharge planning, students develop a plan for the patient’s physical therapy needs, while considering the travel distance to therapy sessions, alternative transportation when her husband is busy with harvest, possibilities for follow-up visits using telemedicine technology and adjusting the two-story farm house environment to accommodate her mobility needs. rural concepts in addition to developing the rural town, rural health care facilities, and jackson family profiles, a significant emphasis was placed on rural concepts within every simulation scenario and case study for the jackson family. when students receive the medical and social history of the patient, the rural concepts specific for the simulation scenario or case study are also shared. six rural components were identified to help shape the rural context of each simulation scenario and case study. the six rural components are rural environment, rural health risk or issue, rural health care access, rural healthcare technology, rural nursing practice, and rural culture. key characteristics of each category were also identified. for example, within the rural environment component, distance to care, condition of roads and weather are distinctive physical features of living in a rural area and may affect a patient’s ability to obtain health care services. specific rural health risks or issues may include farm injury, motor vehicle injury, sun exposure, online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 health literacy, substance use, and under insurance or lack of insurance. the rural health care access component is the availability of health care services and providers. considerations for the rural health care technology component are utilization of telehealth and the overall lack of patient care technology in rural areas. unique aspects of the rural nursing practice component are confidentiality challenges in a small town with respect to the health insurance portability and accountability act (hipaa), professional boundaries, lack of resources, and the expert generalist role needed to provide nursing care in a rural area. the rural culture component encompasses many common traits rural dwellers possess. these traits include delays in seeking treatment, social networks and connectedness, service orientation, enjoying work or productivity, lack of privacy and more traditional gender roles. additional characteristics may include being stubborn, frugal, religious, resourceful and dedicated. the concept of insider and outsider differentiation in relation to health care providers is also addressed. discussion participating in rural simulation activities introduces nursing students to a variety of rural health care situations. by using simulation, students can care for rural residents in various situations that incorporate rural concepts such as rural environment, rural health risk or issue, rural healthcare access, rural healthcare technology, rural nursing practice, and rural culture. family profiles present opportunities to deal with patients and families who are isolated and live an extended distance from large medical centers, work in professions typical of rural environments, and exemplify rural culture. in the simulated rural clinic, hospital, or home care settings, students develop an understanding of the potential unavailability of advanced technology and lack of specialist practice; while gaining an appreciation for emerging technologies such as telehealth services and consultant visits via the electronic icu or er. online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 perhaps one of the most significant experiences for nursing students is the opportunity to function as a nurse generalist and gain an appreciation for the diffuse role of the rural nurse. students care for medical-surgical, pediatric, geriatric and obstetric patients in the acute care setting, the rural clinic setting and do simulated home visits. patients with mental health issues are also incorporated into the scenarios. while rural health care simulation experiences have provided a valuable learning opportunity for nursing students, expanding clinical rotations into rural health care settings is also planned. currently sophomore nursing students in their first patient care rotations have been placed in rural hospitals. several of the rural hospitals also have attached long term care facilities or home health departments that allow for additional patient care opportunities. evaluation of these early clinical rotation experiences has shown benefits for not only the students, but also the facilities and patients. students had exposure to a variety of patient care situations with multiple diagnoses, exposure to different departments throughout the organization, and had the opportunity to perform multiple skills (hendrickx et al., 2013). challenges related to the use of rural facilities for clinical experiences include the traditionally lower daily census. a typical clinical group has eight students, which may be difficult when making patient care assignments if other experiences such as outpatient surgery or home care visits are not available. using simulation can provide the types of experiences that may occur in rural settings for a large group of students at one time. one recommendation when facing lower census is to take smaller clinical groups to rural facilities. this may not be feasible financially but a plausible solution has been to place senior students in rural facilities for preceptorship or internship experiences in a rural nurse fellow program. students are placed in rural clinical experiences with a practicing rn for their capstone online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 experience. these students not only gain an understanding of the generalist role but have the opportunity to increase their understanding of specific rural health care issues through journaling and discussion, while applying the content learned through simulation in actual clinical practice. conclusion workforce issues continue to be a challenge for rural health care and ensuring that rural facilities have adequate numbers of qualified nurses is a priority. equally important is the preparation of nurses for rural practice. nursing education programs, particularly those serving rural areas, have the responsibility of developing appropriate content and clinical experiences to provide the educational experiences necessary for rural practice. using simulation is an effective way to provide rural health care experiences for nursing students and increase the understanding of the uniqueness of rural nursing. supporting agency division of nursing, (dn), bureau of health professions (bhpr), health resources and services administration (hrsa), department of health and human services (dhh) #d11hp22198 acknowledgement the authors acknowledge dr. lois tschetter, pi for the s.i.t.e. project. references bushy, a., & leipert, b. (2005). factors that influence students in choosing rural nursing practice: a pilot study. rural and remote health, 5, 1-12. [medline] bushy, a. (2006). nursing in rural and frontier areas: issues, challenges and opportunities. harvard health policy review, 7,(1), 17-27. http://www.ncbi.nlm.nih.gov/pubmed/15885026 online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 bureau of labor statistics. (2012). economic news release: the 30 occupations with the largest projected employment growth, 2010-20. retrieved from http: //www.bls.gov/news.release/ecopro.t06.htm coyle, s. b. & narsavage, g.l. (2012). effects of an interprofessional rural rotation on nursing student interest, perceptions, and intent. online journal of rural nursing and health care, 12(1), 40-48. daniels, z., vanleit, b., skipper, b., sanders, m., & rhyne, r. (2007). factors in recruiting and retaining health professionals for rural practice. the journal of rural health, 23(1), 62-71. http://dx.doi.org/10.1111/j.1748-0361.2006.00069.x devine, s. (2006). perceptions of occupational therapists practicing in rural australia: a graduate perspective. australian occupational health journal, 53(3), 205-210. http://dx.doi.org/10.1111/j.1440-1630.2006.00561.x fahs, p. (2012). rn labor supply bubble: what does it mean for rural health care? online journal of rural nursing and health care, 12(1), 1-2. hendrickx, l., mennenga, h., & johansen, l. (2013). the use of rural hospitals for clinical placements in nursing education. in c.a. winters (ed.). rural nursing: concepts, theory and practice. (pp. 293-301). new york: springer. roberge, c. m. (2009). who stays in rural practice? an international review of the literature on factors influencing rural nurse retention. online journal of rural nursing and health care, 9(1), 82-93. schmitz, d., claiborne, n., & rouhana, n. (2012). defining the issues and principles of recruitment and retention. national rural health association policy brief. retrieved from http: online journal of rural nursing and health care, 14(1) http://dx.doi.org/10.14574/ojrnhc.v14i1.307 //www.ruralhealthweb.org/go/left/government-affairs/policy-documents-and-statements/officialpolicy-positions/official-policy-positions strasser, r. & neusy, a. (2010). context counts: training health workers in and for rural and remote areas. bulletin of the world health organization, 88(10), 777-782. http://dx.doi.org/10.2471/blt.09.072462 straub, l. & frels, l. (1992). the role of nursing education in preparing students for rural practice. journal of rural health, 8(4), 291-297. http://dx.doi.org/10.1111/j.17480361.1992.tb00370.x united states census bureau. (2012). state and county quickfacts. retrieved from http: //quickfacts.census.gov/qfd/states/46000.html 17 suffering it out: meeting the needs of health care delivery in a rural area kathleen huttlinger, phd1 jennifer schaller-ayers, phd2 tony lawson3 james ayers, dsw, acsw4 1 professor and director, center for nursing research, college of nursing, kent state university, khuttlin@kent.edu 2 associate professor, college of nursing, east tennessee state university, schaller@etsu.edu 3 executive director, southwest virginia graduate medical education consortium 4 professor, department of social work, east tennessee state university abstract the health status of the people in the coal-producing counties of southwest virginia is poor despite an apparent high provider to population threshold. this study used a qualitative approach to obtain information about accessibility to health care services and about perceptions of personal health status. interview and focus group data revealed that the delivery of health care services is compromised by poverty and the large number of medically underinsured and uninsured individuals. emergent themes included “suffering it out," a strong sense of community, quality time with provider and needed fixes. another significant finding revealed the need for specialty providers. community health nurses can provide a valuable service by making people aware of free and low cost prevention and prescription assistance programs, assist with understanding government health forms, and locating other low-cost health services for clients in their districts. introduction rural settings present an array of challenges for community health nurses including an ongoing struggle to offer the most optimal care with very limited resources. prior studies have indicated a rural nurse organization digital library relationship between the availability of primary health care providers and the health status of a population (beaulieu & webb, 2002; pol, rouse, zyzanski, rasmussen & crabtree, 2001). it is generally accepted that when more primary care providers are available, a population will be healthier (mcbride & mueller, 2002). however there is a paradox in the coal-producing counties of southwest virginia where the health status of the people is poor despite an apparent adequate supply of primary care providers (gmec, 2000). morbidity and mortality rates for heart disease, malignant neoplasms, chronic obstructive pulmonary disease and diabetes are high and people in this region tend to die at a younger age than the u.s. median life expectancy (east tennessee state university, 1996; hrsa, 2000). despite the data that describes the general health status of people and the provider-patient ratio in southwest virginia, little is known about how people here view their personal health status and what ideas and knowledge they have about the kind and quality of health care services that are available to them. therefore, the purpose of this study was to explore perceptions of health and access to health care services in southwest virginia. the research question that guided the project was, “if there is no acute shortage online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.kent.edu/nursing/ mailto:khuttlin@kent.edu http://www.etsu.edu/etsucon/ mailto:schaller@etsu.edu http://www.etsu.edu/socialwork/ 18 of primary care providers in southwest virginia, what accounts for relatively poor health in the region?" background southwest virginia is in the geographical heart of central appalachia and is a rural region defined by rugged ridges and remote valleys. mountains extend from 4,000 feet in elevation on the loftiest peaks to 2,000 feet in the surrounding valleys. although small towns dot the region, most of the population of almost 400,000 people is scattered among secluded communities in the hills and the natural narrow hollows of the area. generally, people here are characterized as being hard-working and industrious. although the region is transected by major four-lane highway systems, southwest virginia does not lie on any of these direct transportation routes. the coal-producing counties of southwest virginia are considered economically depressed area since technological advances in the coal industry decreased the need for laborers. this area, like many other rural communities throughout america, must contend with the effects of corporate downsizing, business and industry closings and relocations, along with diminishing state funds and increased competition for the little government support that is available. therefore, the challenge for community health nurses and other health providers in this area is to address the health care access and health disparities as described in healthy people 2010 while controlling costs in a geographical area that continues to experience economic decline (u.s. department of health and human services, 2000). health care in rural southwestern virginia primary health care services are often seen as the basic foundation for health care and the entry point for specialized health care services. however, like many rural areas across the united states, residents of southwest virginia do not experience the same level of access to basic primary and specialty healthcare services that is available to urban americans. this condition exists despite a virginia survey that indicated an ample number of primary care physicians and nurse practitioners (virginia health care foundation, 2001). the reality is that access to basic health care services in southwest virginia is complicated by poverty, inadequate transportation, geographical distances, the seclusion of small communities, an aging population and economic decline (ahcpr, 1996). the population includes disproportionately small numbers of younger adults and large numbers of elderly people. low educational attainment and a high percentage of individuals on government assistance also contribute to low economic status and consequent poor health. a recent report by the virginia health care foundation (2001) indicated that southwest virginia led the state in the percentage, 20.4%, of medically uninsured people and consequently, in the percentage of people not being seen by a primary care provider. educational attainment and personal income are key indicators used to predict the health status of a population (gmec, 2000). in southwest virginia, 47% of the population over the age of 25 does not have a high school diploma or a general education diploma. this high rate contrasts sharply with the virginia state rate of 25%. in fact, 27% online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 19 of the people in southwest virginia have less than nine years of formal education as compared with 11% for the rest of the state. likewise, the poverty rate for southwest virginia is twice the rate of virginia as a whole, 20% compared to 10.5%, and per capita income in the southwest is 65% of per capita in virginia. people with income levels at or below 200 percent of poverty are nearly twice as likely to be medically uninsured as people at higher income levels (virginia health care foundation, 2001). more than 25% of the population in southwest virginia receives social security benefits but not all of these beneficiaries are elderly. eight per cent of the region’s population receives social security disability benefits. these beneficiaries represent those with poor health status and, given the small pension paid by social security, more than likely are poor or near poor. in southwest virginia, the ratio of the number of younger (18-45 years), workingage people to the number of older, non-working people is disproportionate, with the older non-working group outnumbering the younger, working group. unemployed workers, part-time workers and homemakers comprise 75% of uninsured people in virginia (virginia healthcare foundation, 2001). indeed, almost 77% of the uninsured are in the 18-64 age group and are those people who are unemployed or who work at part-time, low wage jobs. out-migration of individuals and families in search of employment may account for the relative low numbers of working age people in the region. recruiting and retaining physicians and nurse practitioners in a region beset by economic decline remains a challenge. a lack of competitive salaries, shortages of specialty providers for consultation, the high cost of facilities and equipment, and social isolation are just a few of the obstacles to overcome when recruiting and retaining primary care providers. in addition, a shortage of nurses throughout the nation adds difficulty to the task of maintaining adequate nursing ratios. at present, local hospitals are experiencing a nursing vacancy rate of between 8 and 11%. difficulties in recruiting providers to southwest virginia has created a revolving door phenomenon of health professionals who come to the region for a short stay prior to leaving for more lucrative jobs in urban areas. methods this study used a qualitative approach to gather information from three informants and twenty-four participants in three focus groups. the intent was to elicit information that described their perceptions of the availability of health care services in southwest virginia and how they viewed the relative health status of themselves, their family members and their neighbors. setting the interviews and focus groups took place in a small rural community in lee county, virginia. lee county is the western-most county of virginia and lies adjacent to kentucky on the north and tennessee on the south. the community [1], spring hollow, consists of approximately 80 families with about 325 people. this is a fairly typical southwest virginia community where 40% of the people have less than a high school education and work in blue collar jobs such as with the state transportation department, in online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 20 forestry, the garment industry, in the coal mines or nearby federal prisons. some of the older male residents are retired or on disability from years of working in the coalmines. many people work two or more part-time jobs and some work a full-time job along with a part-time job in order to provide for their families. small towns a few miles away provide employment opportunities for some of the residents of spring hollow. there is a strong sense of community and family in spring hollow. in fact, most people identify themselves as first being members of the spring hollow community and then of lee county, virginia. there are two churches in the community, baptist and united methodist. cattle raising, tobacco growing and timer harvesting is done on a limited basis and often serves as a supplement to a full-time or part-time job. informants and focus group participants three informants were selected for individual interviews. two elderly women, ages 63 and 62, were identified as potential informants by other members of the community because of their in-depth knowledge of the community and their ability to articulate the health care needs of its residents. these two women turned out to be key informants in that information derived from the focus groups and from conversations with other community residents could be verified or substantiated by them. the third informant, who was 34 years old, expressed interest in the study and asked to be able to participate. the informants were paid a nominal sum of money for their participation. participants for the three focus groups were recruited by word of mouth. one of the research team members announced the opportunity to participate in the study to the congregation in a local church. two of the three focus groups were treated to dinner before the meeting and participants in all focus groups were paid a nominal sum of money. the third focus group was composed of individuals who wanted to participate but could not attend the “dinner” meetings. the groups consisted of 9, 10 and 5 participants. two of the groups met in a local church hall where dinner was served and the third group met in one of the participant’s homes. ages for participants in the focus groups ranged from the 20’s to the 70’s and there was a mixed representation of employment statuses that reflected the community’s demographics. consent institutional approval was obtained before the interviews were carried out. all of the informants and the focus group participants signed a human subjects’ disclaimer form and all had the study explained to them before the interviews and discussions began. the investigators made certain that everyone understood that they were under no obligation to participate in the study, that they could withdraw/leave the interview/focus group at any time and that all of the information gathered would be used in such a way that no one person would be identified. it was also explained that at any time during the discussion or interview that they could request that the tape recorder be turned off. prior to the data collection process, the investigators were concerned that the participants in the focus groups were well-known to each other and that some might be reticent to express their beliefs and views about health care in their community. as it turned out, the anticipated problem did not materialize. all of the participants engaged in online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 21 active conversation and information sharing, agreeing or disagreeing with discussion points and with each other throughout the meeting. data collection all individual interviews and focus group sessions were tape recorded. neither the informants nor the participants in the focus groups objected to having the discussions taped. the tapes were destroyed after transcription. there was only one instance where a participant asked for the tape recorder to be paused while a heated conversation about a local provider took place. the investigators developed a series of open-ended, lead-in and discussiongenerating questions to initiate a general conversation about health care and health care services. examples of the questions used included: 1) “would you describe some of the ways that you keep yourself and your family healthy?; 2) what do you do when you or someone in your family gets sick?; 3) what kinds of health-care services do you use most often?; 4) have you had to change your doctor within the last 5 years?; 5) if you could change one thing about health care in your community what would it be?; and 6) what kinds of health services are not available to you?” as the intent of the questions was to stimulate conversation and to elicit those ideas and thoughts that were of primary concern to the participants, the researchers did not insist on asking all of the above mentioned questions. two of the investigators served as “leaders” for the focus groups and guided the discussion to keep the discussions focused on issues of health, health care, and access to services in their community. data analysis the data were analyzed using strategies consistent with a qualitative approach. each interview and focus group discussion was transcribed, organized, coded and interpreted in terms of recurrent verbal patterns and expressions. each interview was transcribed, read and initially coded and interpreted before subsequent interviews with the idea that questions and discussion points could be generated for future interviews and discussions. each of the investigators read and made comments on the transcribed interviews and then met to discuss interpretations. the dialogue that emerged between the investigators revealed congruent interpretations for most of the transcribed interviews. recurrent patterns of expression were grouped or synthesized into categories (decontextualized) that were then fit and linked together. the links were compared and contrasted and they in turn were linked back together into common themes. there was a constant looping backwards and forwards as new ideas and thoughts emerged and were identified from the data by the investigators. four of the major themes that were identified included: 1) making do/making a shift and suffering it out, 2) sense of community, 3) quality time with provider and 4) needed fixes. in addition, for each theme identified, there seemed to be a general descriptor related in terms of “my story” that emerged. each informant and focus group participant expressed the need to tell “their story” and the essence of these stories often served as narrative examples and descriptors of the themes. excerpts from the stories are included with a description of the following themes. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 22 presentations of themes and interpretations making do/making a shift/suffering it out. people seemed to have a sense that the way in which things occur to them and within the community was a way of life and that the best approach for them was to “make do,” “suffer it out” or “make a shift.” to the informants and focus group participants, making do, making a shift or suffering it out might involve a change in personal behavior, routine or method. it was not uncommon to hear the expressions, “this is just the way things are” and “we have to adjust.” the investigators did not interpret this seemingly “fatalistic” approach to life as complacency, but rather a mechanism for adaptation and setting priorities in order to cope with life’s everyday challenges and stresses. it was also a way that people could adjust their expectations to perceived reality and to life events as they occurred around them. there were some things that were seen by them as things that “could not be changed” or “challenged” by them as individuals or as a community. “making a shift” or “making do” was perceived as a positive reaction to life events as compared to “doing without” which was perceived negatively. the health care that they received and basic health care services in their community were two such things that they perceived as things “they” couldn’t change. therefore, the informants and focus group participants stated that they “made shifts” to adapt to the existing system. for example, during one of the focus groups, a participant recounted: i used to go to the doctor on a regular basis but now i just have to shift away from that and go when i just get really sick…i don’t take blood medicine no more because i don’t have insurance to pay for it no more…just do and suffer it out…do without, i guess… or, as others related, you have to switch gears or make a shift from what you’re used to doing, especially when you have kids. they need the care first and we as parents just make do without. when you get old, you just have to make do, do without and suffer it out. when i was working and had health insurance, i could go more often and it didn’t seem to cost as much. for many people in this study, putting food on the table and providing housing and clothing for their families came before their own health care needs. although all expressed the importance of maintaining their health, it was seen as something intangible and difficult to obtain. most made comments that “the system just didn’t support working people.” in fact, several focus group participants expressed frustration at the way that many people “fooled” the system into thinking they were “disabled so that they could get benefits” while “us honest and hard-working people just seem to get punished." part of their frustration was based on the high cost of health insurance premiums and deductibles and the unwillingness of many of their employers to provide low-cost health care for their workers. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 23 i know i need to have more checkups, but i can’t afford the premiums, so i just suffer it out. when asked how they would compare their health and the health of their family members to the rest of virginia, the informants and over half of the focus group participants identified either themselves or someone in their household as having a chronic illness. this finding supports research from other rural areas that indicates people in rural areas are at a greater risk for such diseases as cancer, heart disease and diabetes and have a greater difficulty seeking out preventive care (krummel, humphries & tessaro, 2002; mmwr, 2002; rosswurm, 2001). interestingly, the informants and participants in this study related the “poor economy” of the region with the “poor health of the people.” when asked to explain this relationship, most people explained that “when you live in a poor area,” it was expected that the health of the people here would be also poor. further exploration of this idea resulted in a discussion of “how it has just always been this way.” most people do not see a change in this status unless another large industry comes to the area to provide jobs like coal mining once did. historically, when coal mining became unionized, health care was part of the labor agreement. sense of community. strong ties to the community and to people living in that community emerged as an important theme. just about everyone had family within close geographical proximity to spring hollow and southwest virginia, eastern kentucky or northeastern tennessee. several remarked that even though they may have left the area for “a time” to attend school or for military service, but that they missed the “hills and hollows” enough to return and raise their families. this heritage can be traced through common surnames throughout the area and it is “local knowledge” that you need to be “careful who you talk about as everyone is related” in some way or another. many of the family names and actual family members can be traced one hundred or more years to the region. people express a strong allegiance and pride in belonging to the region and they regard their neighbors as “family” even if a blood relationship does not exist. in addition, membership in the local churches served to cement community relationships and people watch out for and also support their neighbors as members of their church. the sense of community and neighboring extends to concerns for the health and well being of the residents. during the context of the interviews and the focus groups, it was not unusual for a person to relate a tale of woe only to add that someone else in their community, a neighbor or someone just “down the road” was “worse off." for example: i am lucky – i have pretty good health, good insurance and good doctors. there are so many of my neighbors who do not have this. in this country of ours, there is no excuse that all can’t have health care plus their medications. this is a big problem and our congressmen need to act fast. i am able to get to see my doctor when i need to but so’s many’s can’t and it is just sad. my neighbor lady can’t get her medicine when she needs it and just can’t wade through all the paperwork that is needed. i tried to help her read it, but i don’t understand much of it neither. she has no one online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 24 to drive her to the insurance office and my son comes by and takes her when he can. there seem to be so many like her. it is just sad. the strong sense of community, however, can have adverse implications for health care providers who are not from the region. these providers are often viewed as “outsiders” who come for a short period of time to take “from” the community but not participate in community activities or give back to it. for example, many physicians and nurses who come from the “outside” provide home schooling for their children or send them away to boarding schools. the informants were quick to point out, however, that there were many health care providers who came to the region as outsiders but who did make an attempt to become part of the community. these particular providers were held in high esteem. it has been written (batteau, 1990; best, 1996) that the people of appalachia are often slow to warm up to and they hesitate to develop trusting relationships with people who are not from or who were not born in the area. the reluctance is reflected in historical accounts of “outsiders” who exploited appalachia not only for its natural resources but for its rich cultural heritage, yet portray its inhabitants with unflattering terms. as one residents of appalachia explains: outsiders “didn’t trust us hill folk to speak plan or act for ourselves….they became our planners and our actors. and so they’ll go again, leaving us and our poverty behind” (west, 2003). mr. west goes on to proclaim that many outsiders make claims of wanting to save appalachia and the appalachian people but, in actuality, they come to take away from the area and impose a way of life that is not compatible with the lifestyles of the people living there. quality time with provider. another important theme that emerged and was seen as an integral part of the overall health status of the people here was an individual’s relationship with their primary care provider. this was especially important for the older informants and participants and for those with chronic illnesses. quality time with a provider, whom they identified as physicians and nurse practitioners, may reflect back on the strong sense of community and the desire for providers to become part of that community. “quality time” was viewed as the mutual giving of respect and knowledgesharing that occurred between the informant/participant and the provider. the informants were quick to identify and list the names of the providers in their community who seemed to respect them as individuals, who listened carefully to their complaints and symptoms and acknowledged the fact that the informants “knew their bodies best.” for the informants and the focus group participants, the time spent with health care providers was very important, whether it was five or fifty minutes. they acknowledged the fact that they lived in an area far away from basic services and that their physicians and nurse practitioners were making sacrifices to practice here. for this reason, many stated that they didn’t mind waiting for a provider an hour or more after the scheduled time if the provider acknowledged the wait and apologized. however, during the course of the focus groups, it was discovered that it was very common for people to wait upwards of four or more hours to see the provider even if they online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 25 had a scheduled appointment. rarely did they receive an apology from the staff or the provider. almost all of the informants identified that providers in their area “seemed” to be overworked and that many providers “overbook” the daily caseloads with the result that the provider sees them as a number and not as a person. others defended the providers by stating that most of the providers “overbook” because there were so many people who didn’t show up for scheduled appointments and, in addition, that there were so few providers that they felt obligated to see everyone who called. one point of interest that was revealed was that, for most, “waiting” seemed to be an accepted part of the health care experience. several informants stated that they had to take off a day from work to go to the doctor or take a relative because they knew that it would take “all day.” even more interesting was that the “waiting” did not affect their responses and discussion of “quality time with provider.” needed fixes. one important theme that emerged from this study was that people wanted to help each other and in doing so wanted the investigators to understand what could make the “health care system better.” all of the informants and focus group participants indicated a need for a better health care system in the united states. they were distressed that there seemed to be a wide discrepancy between those who were able to afford health care and those who were not. one informant stated that “we need to have a way that all people can be taken care of and get to see a doctor when they need to.” most of the informants in this study were associated with health care plans that required so large a deductible that it was impossible to cover all the family members. in these cases, the individuals enrolled their children in a state-supported system and did without their own health care insurance. others indicated that they used the local emergency room for their “real illness” experiences and still others noted that they generally “did without.” of concern to the investigators was that delays in seeking out health care could exacerbate many chronic illnesses and could also thwart any primary prevention strategies. even if the informants and participants stated that they had health insurance coverage or medicare or medicaid, 80% of them had no vision or dental coverage. another needed fix was “easy forms.” the elderly informants and focus group participants stated that their medicare claims were confusing to process and interpret and that the premiums still cost so much that they couldn’t afford their medications or even routine health care visits on their limited, retirement incomes. just about all indicated a frustration with having coverage for prescriptive medications. they recognized that this problem was more than a local problem and that many people throughout the nation were in similar situations. another “fix” was the need for more qualified health care specialists for their area and especially those that could provide for eye diseases and for the more chronic conditions such as respiratory diseases and cancer. several of the focus group participants asked, “why can’t our government do something to help all people?” [1] fictitious name of the research community online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 26 summary and implications for future research people in southwest virginia recognize that they are not as healthy as the rest of the state and that they live in an economically poor region where it is harder to attract and keep health care providers. in interpreting the results of the study, it would appear that the major factors that contribute to this poor health include: 1) a large number of medically underinsured and uninsured individuals; 2) a shortage of specialty health care providers and 3) knowledge of available prevention services. consultation services are available to providers in southwest virginia with specialists in larger medical complexes though telemed. physicians and nurse practitioners do make use of this service, but they indicated that in many instances the ill person needs to be seen by a specialist. even if the cost of the specialist is covered by insurance, transportation to the specialist may be 200 or more miles away and, therefore, involves an overnight stay. this is problematic for those on very limited budgets and for family members who must take off work to transport their ill relative. several of the providers that the investigators spoke with indicated that many of their referrals are ignored by their patients for this reason. the results of the study also indicated that community health nursing can and does play an important role in the health care of people in this region. a few suggestions for improved care would include: • a focused effort to deliver health promotion and disease prevention information to residents of the area including a listing resources for low cost services such as mammography, diabetes testing, colonoscopy, etc. many of the informants and participants in this study were unaware of the services available to them. • identification of those dentists in the area who will provide low-cost or free dental care. free dental services are offered once a year at a remote area medical expedition (ram) event in wise county. however, a mechanism still needs to be developed whereby ongoing, low-cost or free dental services can be obtained by those in need. • identification of “prescription aid” programs and pharmacies that offer assistance to those who need help paying for their prescriptive medications. many of the people in this study were unaware that prescription services were available. • identification of individuals, including volunteers, in the community who help with medicare and medicaid paperwork. • greater partnership relations between providers and the community organizations and populations. • although many of the community churches in the community are small, there may be a way in which they could band together to support a faith-based initiative such as parrish nursing for the community. one faith-based hospital exists in the area and the nuns are very active in their attempts to help with the delivery of services. in fact, one of the sisters operates a mobile health van in the more remote areas and she was the principle organizer for the ram event. • the community, the local university, the health department, local health practitioners and individual citizens recognize the need for low cost services online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 27 in the area and have worked together to sponsor a ram event each year in wise county. perhaps this same group could work to increase political awareness for the need for low cost-health services to this area. as a result of this study, the investigators would like to explore in greater detail the social and cultural dimensions of health in rural and medically underserved areas. for example, on what basis do people prioritize their health care needs and how do they go about making decisions with respect to health care? it is anticipated that this study can and did lay the groundwork for research that will investigate these questions along with other dimensions involved in perceptions of health and illness. acknowledgments this study was supported by the southwest virginia graduate medical education consortium at the university of virginia’s college at wise, 2000-2001. references agency for health care policy and research. (1996). improving health care for rural populations. research in action fact sheet (publication no. 96-po40). washington, dc: department of health and human services. batteau, a. (1990). the invention of appalachia. tucson: university of arizona press. beaulieu, j. & webb, j. (2002). challenges in evaluating rural health programs. journal of rural health, 18(2), 281-285. [medline] best, b. (1996). being of these hills. appalachian heritage (summer), 16-18. east tennessee state university, school of medicine. (1996). wise county health assessment. johnson city, tn: east tennessee state university. graduate medical education consortium (gmec). (2001). virginia’s mountaineers: a not –so-healthy people in 2000. wise, va: university of virginia’s college at wise. health resources and services administration (hrsa). (2000). community health status report. retrieved may, 3, 2002, from http://www.communityhealth.hrsa.gov krummel, d.a., humphries, d., & tessaro, i. 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(2000). healthy people 2010 (2nd ed.). washington, dc: u.s. government printing office. online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12135148&dopt=abstract http://www.communityhealth.hrsa.gov/ http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11917670&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12061510&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=12088143&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11573461&dopt=abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11606899&dopt=abstract 28 virginia health care foundation. (2001). results of virginia’s 2001 health access survey. richmond, virginia: joint commission on health care, virginia health care foundation. west, d. (2003). poverty pays. retrieved june 6, 2003, from http://www.appalachianfocus.org/papers/poverty_pays.htm online journal of rural nursing and health care, vol. 3, no. 2, fall 2003 http://www.appalachianfocus.org/papers/poverty_pays.htm microsoft word baernhold_328-1857-1-ed.docx online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 3 a comparison of quality of care in critical access hospitals and other rural hospitals marianne baernholdt, phd, mph, rn, faan 1 jessica keim-malpass, phd, rn 2 ivora d. hinton, phd 3 guofen yan, phd 4 marilyn bratt phd, rn 5 1 professor, school of nursing, virginia commonwealth university; director langston center for quality, safety, and innovation, mbaernholdt@vcu.edu 2 assistant professor, school of nursing, university of virginia, jlk2t@virginia.edu 3 coordinator of data analyses and interpretations, school of nursing, university of virginia, idh2r@virginia.edu 4 associate professor, department of public health sciences, university of virginia, gy4g@virginia.edu 5 associate professor, college of nursing, marquette university, marilyn.bratt@marquette.edu abstract purpose: the united states has about 2100 rural hospitals. approximately 1300 are critical access hospitals (cahs) with 25 beds or less. cahs receive cost-based reimbursement through the federal flex program with the goal to improve quality and access to health care. reports on quality of care (qoc) and factors that influence quality in cahs are mixed. this study online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 4 compared qoc and factors that influence qoc in cahs and other rural hospitals. sample: 385 staff nurses in 6 cahs and 9 other rural hospitals in north carolina and virginia. method: descriptive cross-sectional design using nurse surveys aggregated to the hospital level, data from provider of services file, and the united states department of agriculture, economic research files. variables on community, hospital, and nursing unit characteristics, the nurse work environment, nurse rated qoc and community perception of hospital quality were compared using t-test or chi-square. findings: there were no differences in the majority of factors influencing qoc. a culture of safety, the nurse work environment, and qoc were rated high in all hospitals. compared to other rural hospitals cahs tend to be located in communities with better economic status and their nurses had more years of nursing experience. more nurses in cahs felt their community recognized their hospital as a good place for minor health issues and would recommend the hospital to family and friends. conclusions: the high ratings of qoc were accompanied with the presence of safety cultures and work environments rated as highly as in magnet hospitals. the lower poverty levels in communities with cahs suggest possible community financial benefits from cahs. more studies are warranted to explore these relationships. further reporting to public quality indicator databases by all cahs should be encouraged and qoc measures relevant for small rural hospitals should be developed. keywords: small rural hospitals, cahs, quality of care, nurse surveys online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 5 a comparison of quality of care in critical access hospitals and other rural hospitals about 19 percent of the unites states (us) population (59.5 million) reside in 72 percent of the us land area considered rural and receive most of their health care in their local hospitals (u.s. census bureau, 2012; united states department of agriculture. economic research service [usda ers], 2013). in 2012, 40% percent (1,980 of 4,999) of us community hospitals registered with the american hospital association (aha) were rural (american hospital association resource center, 2014). compared to urban hospitals rural hospitals are smaller (2/3 have less than 100 beds), have less technology, fewer nurses per patient, and nurses with less education (bushy, 2013; skillman, plazzo, keepnews, & hart, 2006). studies that compare quality of care (qoc) in rural and urban hospitals have mixed results. for example, patient satisfaction is higher in small rural hospitals but process of care measures for acute myocardial infarction and heart failure are lower compared to larger urban hospitals(baldwin, chan, andrilla, huff, & hart, 2010; casey & davidson, 2010). a comparison of rural and urban patient safety indicator rates (psis) found, that observed rates were higher for small urban hospitals than for rural hospitals for nine psis, including death in low mortality drgs, decubitus ulcer, failure to rescue, and selected infections due to medical care (vartak, ward, & vaughn, 2010). it is not clear why these differences in qoc exist; perhaps it is attributed to differences in the populations rural and urban hospitals serve and the hospital’s role in the community. compared to urban hospitals, rural hospitals have fewer resources, but often serve populations with higher prevalence rates of major chronic diseases (institute of medicine [iom], 2005). rural communities have higher rates of older adults with hypertension, emphysema, chronic bronchitis, cancer, and diabetes (centers for disease control and prevention, 2009). online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 6 further, rural areas have higher mortality rates across the life span, residents who rate their health status as poor or fair, and lower rates of people with health insurance (baernholdt, 2012; ingram & franco, 2012). both the increase in patient care needs related to chronic diseases and worse socioeconomic factors influence rural patients’ risk for adverse events and poorer qoc. rural hospitals’ role in their communities also differs from their urban counterparts. a rural hospital is often the major force that organizes and delivers health care and at times the only one available in the community after regular working hours (aha, 2011; iom, 2005). moreover, because they are often the largest or second largest employer in the community, and often stand alone in their ability to offer highly-skilled jobs, rural hospitals play an essential part in the economic and social identity of the community (doeksen & schott, 2003; moscovice & stensland, 2002). it is estimated that for every job in a hospital in a rural community, 0.29 more jobs are created in the local economy, spurred by the spending of either the hospital or its employees (oklahoma state department of health, office of rural health, 2009). because of the vital role played by small rural hospitals, the us congress created the medicare rural hospital flexibility program (flex program) in 1997, whereby hospitals receive cost-based reimbursement if they are licensed as critical access hospitals (cahs) (casey, moscovice, hung, & barton, 2012). cahs had to be certified as such before january 1, 2006 or located more than 35 miles from another hospital (or 15 miles in areas with mountainous terrain or secondary roads). cahs must have 24 hour emergency care services available, a maximum of 25 acute care and swing beds (a bed used for either acute or skilled nursing facility care), and maintain acute care average length of stay of 96 hours or less. in 2010, there were 1328 cahs (casey et al., 2012). online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 7 research suggests that almost half of cahs will experience financial problems if the costbased program is eliminated (holmes, pink, & friedman, 2013). some will be forced to close with a subsequent decrease in access to care in rural communities. when a rural hospital closes the community residents experience an average increase in travel time of 30 minute to the nearest hospital (fleming, williamson, hicks, & rife, 1995). access is important but so is quality. cahs are currently exempt from the 2010 affordable care act whereby hospitals must meet quality achievement and improvement standards to avoid reductions in medicare reimbursement (code of federal regulations [cfr] parts 422 and 480, 2011). many cahs, however, are voluntarily reporting quality measures (casey et al., 2012). qoc in cahs although 74% of cahs participate in the centers for medicare and medicaid services (cms) hospital compare public reporting database for hospital quality measures, few report on all measures relevant for cahs (casey et al., 2012). while both cahs and all other hospitals in hospital compare have increased their quality scores consistently since they started reporting, cahs continue to report lower quality scores on acute myocardial infarction and heart failure measures, and mixed scores on pneumonia and surgical infection care measures compared to other small rural and urban hospitals (casey et al., 2012; joynt, harris, orav, & jha, 2011). further, risk-adjusted mortality rates for congestive heart failure, stroke, acute myocardial infarction, pneumonia, and gastrointestinal bleeding were higher in cahs compared to other rural and urban hospitals (joynt et al., 2011; joynt, orav, & jha, 2013; medpac, medicare payment advisory commission, 2005). cahs did report higher ratings of patient satisfaction scores than all other hospitals, and compared to larger rural hospitals, patients in cahs online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 8 developed fewer decubitus ulcers and postoperative pulmonary emboli or deep vein thrombosis (casey et al., 2012; medpac, medicare payment advisory commission, 2005). the evidence is sparse on what factors influence qoc in cahs and other rural hospitals. studies regarding rural and urban hospitals report factors such as hospital size, joint commission (jc) accreditation, nurse staffing, level of nurse education, and characteristics of the nurse work environment (aiken et al., 2011; bae, 2011; casey et al., 2012). compared to rural hospitals with more than 25 beds, rural hospitals with 25 beds or less (including cahs) were less likely to be accredited by the jc (newhouse & morlock, 2011). of cahs who reported to hospital compare, jc accreditation was linked to better performance on 20 out of 23 measures for acute myocardial infarction, heart failure measures, pneumonia, and surgical care (casey et al., 2012). however, all cahs scored below the 90% benchmark suggesting there is a need for improvement regardless of the jc accreditation. cahs and other small rural hospitals have less number of registered nurses (rns) employed and less rns with a bsn degree compared to larger rural hospitals (newhouse & morlock, 2011), both are features which have been linked to lower qoc (aiken et al., 2011). cah nurses have previously identified the nurse work environment as important for qoc (baernholdt, jennings, & lewis, 2013). compared to larger rural hospitals, nurses in cahs and other small rural hospitals reported work environments with greater shared visions such as working together for common patient-centered goals, but less engagement in quality and safety activities (newhouse & morlock, 2011). given the inconclusive findings on qoc in small rural hospitals, this study compared qoc and factors that influence qoc in cahs and other rural hospitals. online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 9 method this cross-sectional descriptive study used nurse surveys and large public databases to collect data on community (three variables), hospital and nursing unit characteristics (eight variables each), the nurse work environment (ten variables), quality of care (six variables), and community perception of hospital quality (8 variables). since only one cah participated in hospital compare we used only nurse rated qoc variables. sample after institutional review board approval, rural hospitals in virginia (va) and north carolina (nc) with 110 licensed beds or less (n= 65) were invited to participate. the 28 cahs and 37 other rural hospitals were identified using the 2006 aha’s files and the 2007 area resources file (arf) database’s variable on geographic designation. the arf’s rural-urban continuum codes from usda ers (2012) were used to produce designations for rural location. rural counties were defined as counties with no adjacent metro areas (continuum codes 5, 7, and 9) and those adjacent to metro counties (continuum codes 4, 6, and 8). procedure the chief nursing officer (cno) for all 65 hospitals received an invitation to participate by mail and email. next, attempts were made to reach each cno by phone and all were left a voice mail or message with their administrative assistant. a total of 44 cnos or designated persons communicated with the primary investigator. four hospitals declined, 20 considered but did not return subsequent emails and phone calls. twenty hospitals provided a contact person and number of employed staff nurses within their institution. staff nurses were all part-time or full-time rns and licensed practical nurses (lpns) who provided direct patient care in the hospital. in october 2009 bulk mailings were sent to the contact person in the 20 hospitals with online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 10 study packages to be distributed to all staff nurses. each staff nurse received a packet containing a cover letter explaining the study and a username and password for a web survey option, a consent form for their records, a 12 page paper survey, return envelope with postage, and payment information for a $5 coupon to food lion. two additional bulk mailings were sent three weeks apart with participation reminders to be distributed to all staff nurses. each hospital which had nurses participating received $100 for a staff nurse event of their choice. variables the nurse survey included questions on demographic variables, hospital characteristics, unit characteristics, the nurse work environment, ratings of qoc, and community perception of hospital quality. other variables were extracted from the public databases, the provider of services file and usda ers files. the provider of services file is data collected through the cms. the data, which are updated quarterly, contains provider numbers, names, addresses and characteristics of the medicare-approved providers (cms, 2009). community characteristics there were three community characteristic variables included in the study. state was either nc or va. economic base was measured in two variables; percent of population in a county that had an income below the poverty level and median household income for the county. both were extracted from the 2010 usda ers files hospital characteristics eight hospital characteristic variables were included in the study: cah designation, hospital size (number of licensed beds), joint commission accreditation, and ownership (whether a hospital was for-profit, non-profit, or public), staffing was measured in two variables: number of full time equivalent rns and lpns. all five variables were extracted from the online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 11 provider of services file 2009. three hospital safety culture dimensions variables were from nurse surveys using the agency for healthcare research and quality hospital survey on patient safety culture (hsopsc): team work across hospital units (four items), hospital handoffs and transitions (four items), and hospital management support for patient safety (three items). while the later dimension is originally developed for the unit level, it was used in this study to measure small hospital managements’ support at the hospital level as suggested by the authors sorra and nieva (2005). all three variables were 4-point likert-type scales. higher values denote better patient safety culture. previous studies using hsopsc reported cronbach alpha’s for the three scales from .68-.85 (blegen, gearhart, o’brien, sehgal, & alldredge, 2009; sorra & nieva, 2005). we found alpha coefficients from .79-.81. nursing unit characteristics there were eight variables measuring nursing unit characteristics. type of unit referred to what type of unit nurses worked on most of the time (medical/surgical unit, emergency department, intensive care unit, or other). work complexity was a seven item 6-point likert-type scale. the items asked nurses if they needed more information about their patients, if physicians’ orders were changed frequently and if the unit had a high number of transfers and admissions. higher scores represent higher work complexity. previous studies have reported cronbach alphas of .82 .85 (baernholdt & mark, 2009; salyer, 1996). in our study the alpha coefficient was .88. availability of support services was measured by a checklist of 21 possible support services where staff nurses indicated whether a specific service was consistently available (2), inconsistently available (1) or not available (0). higher score denotes more availability of support services. unit safety culture was measured in five likert-type scales from the hsopsc. supervisor/manager expectations and actions promote safety was four items rated online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 12 1-4 from strongly disagree to strongly agree, organizational learning-continuous improvement was three items rated 1-4 from strongly disagree to strongly agree, communication openness was three items rated 1-5 from never to always, feedback and communication about errors was three items rated 1-5 from never to always, and non-punitive response to error was three items rated 14 from strongly disagree to strongly agree. higher scores represent a more positive unit safety culture. all five scales had cronbach alphas of .57-.82 in previous studies (blegen et al., 2009; sorra & nieva, 2005). in our study alpha coefficients ranged from .68-.82. nurse work environment the nurse work environment had ten variables. education was measured as the highest level of education obtained by the individual nurse from lpn to above a bsn. experience was number of years working as a nurse. expertise was an eight-item 6 point likert-type scale that measured nurses’ ability for early recognition of patient problems, for example, nurses’ ability to recognize subtle changes in patients and initiate appropriate actions (minick & harvey, 2003). previous alpha coefficient was .92 (baernholdt & mark, 2009). in our study the alpha coefficient was .94. commitment to care was an eight item, 6-point likert-type scale that measured the extent to which nurses felt responsible for the care on their unit, for example, if they continue to seek clarification or question the physician when an order did not quite make sense, and if they approached and counseled a staff member who provided sub-standard care. in previous studies a cronbach ’s alpha of .81 has been reported (baernholdt & mark, 2009). in our study the alpha coefficient was .79. professional nursing practice was measured using the practice environment scale of the nursing work index (pes). this 31 items 4-point likert-type scale depicts the work environment through a composite score and five subscale scores: nurse participation in hospital affairs (nine items), nursing foundations for quality of care (ten items), online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 13 nurse manager ability, leadership, and support of nurses (five items), staffing and resource adequacy (four items), and collegial nurse-physician relations (three items). aggregated values above 2.5 indicate general agreement that the characteristics measured are present in the practice environment while values below indicate they are not. previous studies have found cronbach alpha’s from .71 .84 (lake, 2002). in our study alpha coefficients ranged from .75 .86. higher scores indicate more expertise, higher commitment to care, and better professional practice environments. quality of care the six variables measuring quality of care were all from the nurse surveys. overall quality of care was assessed in one item asking nurses to rate the overall quality of care in their hospital (aiken et al., 2001). things left undone was measured using a checklist of 12 tasks indicating good nursing care such as oral hygiene, skin care, and teaching (aiken et al., 2001). the nurses indicated how many of these tasks they did not do on their most recent shift/day of work. safety outcomes were rated using four measures from the hsopsc (sorra & nieva, 2005). number of events reported in the past 12 month was a single item measure with categories from none to 21 or more and a category of prefer not to answer. an event was defined as any type of error, mistake, incident, accident or deviation regardless of whether or not it resulted in patient harm. higher scoring indicates more events have been reported; frequency of events reporting was a three items 5-point likert-type scale about how often events are reported from always to never; overall perceptions of safety was a four items 4-point likert-type scale about whether patient safety beliefs and procedures are in place and rated from strongly agree to disagree; patient safety grade was a single item rating on a 5-point scale from excellent to failing. for all three measures higher scores are better. cronbach alphas in previous studies were online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 14 .53-.84 (blegen et al., 2009; sorra & nieva, 2005). in our study alpha coefficients ranged from .74 -.82. community perception of hospital quality the nurses rated their community’s perception of hospital quality using eight single items rated on a 4 point likert scale from strongly agree to strongly disagree with a higher number being more positive. the items included whether the community felt patients get good care, it is a good hospital for minor health issues, they would rather go here than a larger hospital, it is a desirable hospital, if services are available at a larger hospital they want ours, there is good care coordination across settings, and they would recommend hospital to a friend or family member. these items were developed from previous studies on how qoc is measured in rural hospitals and what factors are important for qoc in rural areas baernholdt, jennings, merwin, & thornlow, 2010; baernholdt, jennings, & lewis, 2013). analysis we aggregated all variables to the hospitals level. for the nurse surveys we had between 302-373 responses and at least five nurse responses/hospital for each variable. comparisons between cahs and other rural hospitals were done in spss version 18 using t-test or chi-square as appropriate. results of the twenty hospitals that agreed to participate, 17 had 385 nurses who submitted surveys (99 nurses online and 286 paper surveys). the hospitals reported employing a range of 40-241 staff nurses (n= 2299) leaving response rates from 1041%. of the 17 hospitals, 15 had at least five nurses respond and were therefore included in this analysis of 6 cahs and 9 other rural online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 15 hospitals. nurse respondents were primarily female (91%), white (90%) or african-american (4%), and on average 44.6 years old. in communities with cahs, there were less people below the poverty level (p< .041) (table 1). other rural hospitals had significantly more beds and rns than cahs. hospital safety culture and all nursing unit characteristics did not differ between cahs and other rural hospitals. both the hospital and unit safety culture dimensions were all rated high. for the nurse work environment only experience differed between cahs and other rural hospitals. cahs had nurses with an average of 19.7 years of nursing experience while other rural hospital had nurses with 15.2 years of nursing experience. all of the professional nursing practice areas were above the 2.5 benchmark level indicating all hospitals had good practice environments. qoc was also rated high and similar by nurses in both types of hospitals. the events report average was 3.93 across all hospitals indicating nurses had filled out events report for an error, mistake, incident, accident or deviation regardless of whether or not it resulted in harm to a patient close to 10 times in the last 12 months. however, about17% of the nurses chose the option “prefer not to answer” and 3% had missing data. for the community perception of hospital quality, two items were significantly higher in cahs. compared to nurses in other rural hospitals, cah nurses rated their community felt their hospitals were a good hospital for minor health issues (3.34 vs. 3.14, p < .027) and that the community would recommend their hospital to family or a friend (3.23 vs. 2.96, p < .027). table 1 comparison of critical access hospitals and other rural hospitals all n = 15 cahs n = 6 other rural n = 9 range community characteristics state, n north carolina 8 3 5 online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 16 all n = 15 cahs n = 6 other rural n = 9 range virginia 7 3 4 economic base, mean percent below poverty level 19% 14% 21% 10-32% median household income ($) 38606 42251 36176 3044957174 hospital characteristics hospital size (licensed beds), mean 73 25 105 25-166 ownership, n for-profit 10 4 6 non-profit 2 1 1 public 3 1 2 joint commission accredited, n 14 5 9 staffing, mean (sd) rn full time equivalents 78 (44.66) 47 (21.69) 99 (44.35) 28-148 lpn full time equivalents 22 (21.40) 14 (6.60) 27 (26.37) 2-81 hospital safety culture, mean (sd) teamwork across hospital units 2.73 (0.17) 2.843(0.05) 2.67 (0.05) 2.36-2.99 handoffs and transitions 2.71 (0.16) 2.78 (0.14) 2.67 (0.16) 2.34-2.98 management support for patient safety 2.93 (0.17) 2.956(0.14) 2.91 (0.20) 2.58-3.17 nursing unit characteristics type of unit (%) medical/surgical 22% 25% 21% 0-56% icu/ccu 13% 12% 13% 0-20% ed 17% 15% 18% 0-64% other 48% 47% 48% 9-75% work complexity, mean (sd) 19.21 (2.95) 18.29 (3.37) 19.82 (2.66) 14-24.75 availability of support services, mean (sd) 28.58 (4.01) 26.88 (4.57) 29.71 (3.40) 19.00 33.31 unit safety culture, mean (sd) supervisor/manager promote safety 2.59 (0.09) 2.81 (0.27) 2.78 (0.29) 2.36-2.99 organizational learning 2.79 (0.16) 3.10 (0.24) 3.09 (0.16) 2.79-3.31 communication openness 3.31 (0.19) 3.36 (0.06) 3.29 (0.24) 2.81-3.58 feedback and communication (errors) 3.65 (0.20) 3.54 (0.26) 3.63 (0.16) 3.24-3.86 non-punitive response to error 2.93 (0.17) 2.60 (0.12) 2.44 (0.27) 2.58-3.17 nurse work environment education (%) lpn 12% 17% 10% 0-38% diploma/ad 60% 58% 60% 40-100% bsn 21% 20% 22% 0-45% above bsn 3% 2% 4% 0-9% experience years in nursing, mean (sd) 17.01(4.38) 19.70 (3.81) 15.22 (3.94) 8.64-23.40 expertise 43.66 (1.22) 43.57 (1.67) 43.72 (.93) 40.9445.50 commitment to care, mean (sd) 41.27 (.99) 41.20 (1.39) 41.32 (.72) 40-43.84 professional nursing practice, mean (sd) nurse participation in hospital affairs 2.56 (0.21) 2.63 (0.22) 2.52 (0.19) 2.25-2.89 nursing foundation for quality care 3.04 (0.15) 3.08 (0.12) 3.01 (0.16) 2.78-3.29 online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 17 all n = 15 cahs n = 6 other rural n = 9 range nurse manager ability, leadership, & support 2.95 (0.12) 2.95 (0.14) 2.96 (0.11) 2.74-3.11 staffing and resource adequacy 2.76 (0.23) 2.83 (0.20) 2.71 (0.24) 2.25-3.07 collegial nurse-physician relationships 2.71 (0.22) 2.77 (0.20) 2.67 (0.24) 2.33-3.00 composite score 2.81 (0.15) 2.86 (0.14) 2.78 (0.15) 2.58-2.99 quality of care, mean (sd) overall quality of care 2.80 (0.22) 2.76 (0.21) 2.82 (0.23) 2.44 3.18 things left undone 2.02 (0.56) 1.84 (0.65) 2.15 (0.49) 1.30 3.13 safety outcomes number of events reported in the last 12 m 3.93 (0.52) 3.86 (0.60) 3.98(0.50) 3.20-4.60 frequency of events reporting 3.68 (0.20) 3.69 (0.17) 3.67 (0.24) 3.22-4.06 overall perceptions of safety 2.80 (0.19) 2.83 (0.16) 2.79 (0.22) 2.43-3.03 patient safety grade 2.69 (0.57) 2.60 (0.74) 2.76 (0.46) 1.40 3.55 community perception of hospital quality mean (sd) patients get good care 3.10 (0.23) 3.20 (0.21) 3.03 (0.23) 3 4 good hospital for minor health issues 3.22 (0.17) 3.34 (0.09) 3.14 (0.18) 3 3 rather go here than larger hospital 3.01 (0.26) 3.17 (0.27) 2.91 (0.20) 3 3 desirable hospital 3.05 (0.25) 3.17 (0.23) 2.98 (0.24) 3 3 service in larger hospital, wants ours 2.97 (0.25) 3.12 (0.20) 2.87 (0.24) 3 3 good care coordination across settings 3.02 (0.16) 3.06 (0.21) 3.00 (0.13) 3 3 do not realize how good care we provide 2.12 (0.21) 2.13 (0.25) 2.12 (0.20) 2 2 would recommend hospital to family or friend 3.07 (0.24) 3.23 (0.15) 2.96 (0.24) 3 3 bolded values denote statistically significant difference, p <. 05; sd = standard deviations discussion one of the main findings from our study is the differences in community characteristics and nurse-rated community perception of hospital quality between cahs and other rural hospitals. cahs had a lower proportion of people below the poverty level compared to other rural hospitals. in general, rural communities tend to have higher proportions of people who are poor compared to urban areas (hartley, 20014). for example, in rural areas, 33% of the population earns less than $7/hour and 24% are uninsured, compared to $19/hour and 15% respectively in urban settings (merchant, coussens, & gilbert, 2006). between rural hospitals there were no socioeconomic differences, including percent below poverty level, between counties with cahs and those counties with other small rural hospitals in the beginning of the flex program (dalton, slifkin, poley, & fruhbeis, 2003). later studies have found that online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 18 compared to counties with no cahs, counties where a hospital converted to a cah have positive economic benefits including higher employee and annual payroll growth rates (ona & davis, 2011). further, having a cah in a community increases total retail sale by 28% compared to communities with no cah. this is a similar influence as having a walmart in a community (brooks & whitacre, 2011). perhaps the cahs in our study are in communities that were more affluent before their hospital became a cah. another possibility is that the cahs in our sample have created financial advantages for their communities. these advantages include both the indirect “walmart effect” and the direct effect on the health sector through possible development of collaborative delivery systems to meet community health and health system’s needs as expected and encouraged by the flex program (gale, coburn, gregg, slifkin, & freeman, 2007). however, overall cahs lag behind both other rural and urban hospitals in community benefit engagement activities including having a long-term plan for improving the health of the community, a specific budget for community benefit activities, and working with other local providers, public agencies, or community representatives to conduct a community health assessment and develop an assessment of appropriate health service capacity in the community (croll, gale, & coburn, 2012). whether the cahs in our sample did engage extensively with their communities is not known but the nurses did feel the community viewed their hospital favorably. the cah nurses in our study described the community recognized their hospitals as a good hospital for minor health issues and the community members would recommend their hospital to family and friends. these findings are in contrast to other studies of patients’ recommendation of their hospital in rural areas and hospital bypass rates of patients who live close to a cah (casey, & davidson, 2010; liu, bellamy,& mccormick, 2007). casey and davidson (2010) found no online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 19 differences in the hcaps score of whether patients would recommend their hospital to others between hospitals in the most rural (including cahs), less rural, and urban areas. further liu and colleagues (2007) found up to 60% of patients who lived within 15-20 miles from a cah bypassed it in favor of another rural or urban hospital. this is higher than other hospitals’ bypass rates of 20-50%. however, when excluding patients who were transferred by their health care provider (12%), those who needed services not provided by their cah (4.5%), and those required by insurance to go elsewhere (2.2 %), about 41% choose to bypass their cah. patients stated lack of specialty services, poor reputation of service providers, and quality of local services as reasons for bypassing. whether patients in the cahs in our study show similar behaviors needs further exploration as do comparisons of congruence of patient and health care provider perceptions and ratings. the nursing unit and the work environment we did not find differences between cahs and other rural hospitals in the nursing unit characteristics and the nurse work environment, except for years in nursing. in fact, all nurses rated their nursing units and the nurse work environment highly. the five unit safety culture dimensions were all rated well above neutral means of 2.0 (for the four item scales) and 2.5 (for the five-item scales). there are no comparisons available of ratings from studies of other rural hospitals, but our high ratings might be explained by previous findings of greater shared visions to improve quality and safety in small rural hospitals (including cahs) (newhouse & morlock, 2011). the greater shared vision is explained by the nature of smaller organizations where there is the ability of more direct interaction between all who are working there. this more direct interaction might also explain the higher ratings on the unit safety culture dimensions of online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 20 supervisors who promote quality, an organization that encourages learning, an environment that has open communication and feedback about errors as well as a non-punitive response to errors. our study’s incidence reporting rates of almost 10/12 months is difficult to compare with other studies which report error rates as percentages of staff that have filled out at least one report in the last 12 months. in our study, 79 % had submitted at least one report in the past 12 months which is higher than previous reports of 52% among all health care workers (sorra, khanna, dyer, mardon, & famolaro, 2012). however previous reports have also found that nurses are involved in more preventable adverse events than they submit reports for (blais et al., 2013). perhaps our high incidence reporting rates are because the nurses feel comfortable reporting. even though we had 17% who preferred to not answer the question and 3% with missing data, the high scores on all hospital and unit safety dimensions suggest these nurses were comfortable reporting errors in order to improve quality and safety in their hospitals. compared to previous studies of rural and urban nurses, the nurses in our study had higher ratings of unit expertise which is the nurse’s ratings of their colleagues’ ability to collectively recognize patient problems early and initiate appropriate actions (baernholdt & mark, 2009). our nurses also had higher ratings on commitment to care which is the extent nurses perceive that the nurses on their unit feel responsible for care (baernholdt & mark, 2009). the high expertise and commitment to care may have offset the nurses’ lower ratings on availability of support services in these small rural hospitals. professional nursing practice ratings were all above 2.5 with nurses in cahs scoring higher or the same (but not significantly different) suggesting all nurses in our sample felt their practice environments were good. the nurses had comparable scores as reported in other studies in rural hospitals or all hospitals except for the subscale collegial nurse-physician relationship. online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 21 our nurses scored lower on collegial nurse-physician relationship (2.77 in cahs and 2.67 in other rural hospitals) than nurses in another study of rural hospitals (2.95) (havens, warshawsky, & vasey, 2012). in six studies that took place in all hospitals (with no rural-urban distinction), our nurses scored lower than nurses in five of the studies (calarco, 2011; eaton-spiva et al., 2010; lake & friese, 2006; manojlovich, & laschinger, 2007; moorer, meterko, alt-white, & sullivan, 2010; patrician, shang, & lake, 2010). the exception was a rating of 2.54 in a study in a hospital in the southeastern us which is the same area as our study. perhaps there are regional differences in the work environment related to local education and culture. however, for the other four subscales and the composite score the nurses in our sample scored as high or higher as reported in other studies. for nursing foundation for quality care and staffing adequacy the cah nurses scored as high or higher as nurses in magnet hospitals (lake & friese, 2006), and for nurse manager ability, leadership, and support our means in both cahs and other rural hospitals were higher than means in magnet hospitals (lake & friese, 2006). staffing and resource adequacy was rated well above the 2.5 level in both types of hospitals (2.83 in cahs and 2.71 in other rural hospitals) which is in contrast to cramer and colleagues findings where cah nurses reported that the fluctuation in staffing patterns because of frequent floating between inpatient and outpatient units, left them feeling overextended (cramer, jones, & hertzog, 2011). quality of care the nurses rated the qoc as high on all measurements. our ratings were higher than previously reported (aiken et al., 2012). we could not compare the nurses’ ratings with other qoc measurements as only one of the cahs in our sample reported measures to hospital compare. in 2010 a total of 977 cahs submitted data on at least one inpatient measure to online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 22 hospital compare (casey et al., 2012). overall cah participation rates in hospital compare have increased from 41% in 2004 to 74% in 2010. future studies therefore can more easily compare qoc measures from a variety of sources. nurse ratings have been correlated with other qoc measures (aiken et al., 2012), so it is plausible that the hospitals in our sample have high qoc despite the lack of reporting on qoc measures. to further strengthen qoc reporting from small rural hospitals, indicators relevant for these hospitals should be included in public databases. one example is transfer time because transfers happen more frequently in small rural hospitals (baernholdt et al., 2010). limitations our study had several limitations. first, our study procedure to reach staff nurses through their cno proved difficult. other studies, with higher response rates, have used national directories to reach the nurses directly (aiken, et al., 2011). the low response rate may also be partly explained by survey fatigue due to both the length of our survey and other surveys the hospital have their nurses participate in. for example, in a hospital that participates in the national database of nursing quality indicators or does patient safety culture surveys. finally, the low response rate may be attributed to how that information about the study was delivered through a third party. having local champions in each hospital might have increased our response rates. further, our sample may not be representative of nurses who chose not to respond to the survey. our high scores in both factors that impact qoc and qoc ratings may be attributed to a positive bias in the nurses who did respond. however, as discussed, our results do compare to other studies with higher response rates and in rural and urban areas. moreover compared to the 2004 national rn rural workforce statistics (skillman et al., 2006), our study sample was similar online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 23 in regards to gender (6% male versus 5.1% in national rural areas), had less white nurses (90% white compared to 95%) and were older with an average age of 44.6 years old compared to the rural national average of 43.1 years old. additionally our sample had a lower percent of bsn or higher degree (27%) compared to national rural areas (32%) and urban areas (47%). it is noteworthy that our sample of nurses with less education did produce high ratings of quality. this is in contrast to national findings where higher proportions of nurses with at least a bsn are associated with better rates of quality of care indicators (blegen, goode, park, vaughn, & spetz, 2013) and nurses’ ratings of quality (aiken et al., 2012). this suggests that our finding of less education yet high nurse quality ratings in small rural hospitals needs further exploration. finally, the questions about community perception of hospital quality have not been examined for reliability and validity. conclusion the cahs in this study provided as good as or higher qoc compared to other rural hospitals. however, we could only compare nurses’ ratings of qoc. there were no differences in the vast majority of factors influencing qoc. our finding that poverty levels were lower in communities with a cah suggests that cahs may have a positive financial impact on the communities they live in. previous evidence that cahs have both direct and indirect positive economic benefits can be used by community members and policy makers to work towards keeping polices that ensure small rural hospitals remain open. to further strengthen their hospitals future, cah hospital administrators can assure that their hospital participate in public reporting on qoc on all measures relevant for cahs, have projects in place to improve quality if their hospital do not meet benchmarks, and assist in developing qoc indicators relevant for small rural hospitals to be included in public databases. while more studies are warranted that online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.328 24 include other qoc measures and their relationship to characteristics of the community, hospital and nursing unit, it is encouraging that the rural hospitals in this study fulfilled their purpose of providing qoc to their rural communities. funding agencies national institute of nursing research (dr. baernholdt k01 nr0105556) and national institute of diabetes and digestive and kidney diseases (dr. yan 5r01dk084200-02) references aiken, l. h., cimiotti, j. p., sloane, d. m., smith, h. l., flynn, l., & neff, d. f. 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(2010). patient safety outcomes in small urban and small rural hospitals. journal of rural health, 26(1), 58-66. http://dx.doi.org/10.1111/2fj.1748-0361.2009.00266.x online journal of rural nursing and health care, 2(1) 4 editorial rural practice forum: working with farm families in crisis bette ide, phd, rn, editorial board member marlene buchner ms., rn has worked with farm families in crisis for several years. she has some concrete suggestions for rural nurses. over the past years, many family farms have been declared disaster areas by the president because of floods, storms, and crop disease. because of this turmoil the farmer has had to make some very hard decisions that affect his life, the lives of his family and even those of the people who live and work in his community. the pressure from those decisions create tremendous stress that becomes evident in physical and psychological manifestations of disease. rural health nurses, public health nurses, and parish nurses should all be aware of the signs of depression, mental anxiety, and profound lack of willingness to survive or cope with life. to do this the nurse must be trained well in communication skills that allow her to take a detailed history of the patient. this history will provide a basis to treat the person holistically and address his/her physical, psychological and spiritual needs. many farm families are not aware that they are in need of help or have any problems. many are in the different stages of grief, one of which may be denial. to begin to address the health needs of the rural farm population, there needs to be an understanding of what services may be available in the farming community. the parish nurse is working in some of these areas. parish nurses are trained to assist in health screenings and can link farm families with health services. they can provide referral resources, give out information and conduct small group meetings. parish nurses need to educate the clergy and others about their training. online journal of rural nursing and health care, 2(1) 5 rural response networks can work with church groups such as lutheran social services. they can train facilitators to help farm families who are experiencing transition in a lifestyle change, they can provide counseling on the telephone for those that are not comfortable in group sessions, they can also conduct group sessions. they can connect the farm families to resources and services and they can initiate programs that provide food boxes to churches and food pantries. rural health care systems may also have programs to help farm families cope with the farm crises. kids programs can provide an outlet that helps farm children express their concerns and the impact of the farm crisis on their lives. a program for preteens and teenagers can focus on self-esteem and peer pressures. mental health counseling services may be available for farm families (us department of health and human services, 2000). for questions or comments, e-mail me at bette_ide@mail.und.nodak.edu. online journal of rural nursing and health care, 1(2) 10 editorial rural practice forum: hospitalizing older adults bette ide, phd, rn, editorial board member jeanie niemoller, ms, rnc, director of extended care at ivinson memorial hospital in laramie, wy, is a rural nurse who speaks from many years in community health and hospital nursing. she sends the following practice "tip." it encompasses useful advice for anyone, particularly an older adult from a rural area, who is planning on hospitalization or currently hospitalized: when a person spends time in the hospital, and has surgery or serious illness, it is not unlikely that they will need help at home after the hospitalization. whenever possible, they or the nurse should find out about home care providers, the services offered by the local senior citizen center or area association for aging prior to the hospital admission. they can also talk to friends and neighbors about services they have used and what is available. a good question to ask home health agencies is "how often can you visit since i live 10, 30, or 50 miles from town?" if services are not available, the individual may need to plan to stay temporarily at a nursing home or assisted living center to get the aftercare they need. asking questions beforehand will save lots of stress and possible longer stays in the hospital. stephanie christian rn, ms, ccrn, concurs with the above. she works and teaches nursing students in the acute care setting in altru hospital, grand forks, nd, a small city within a large rural area. she states that preplanning is great but not always possible, and it is essential to begin discharge planning on admission to the hospital. prior living situations, support systems and availability of possible resources are important factors to assess. family involvement is particularly important because, due to the acuity of care required on admission, discharge planning is not usually a priority for online journal of rural nursing and health care, 1(2) 11 the patient. as the patient recovers their involvement significantly increases, and family involvement is reinforcement for the patient. education and plans upon discharge seem to be more successful when support systems are involved. post discharge follow-up with a nurse, hopefully through a home visit, helps to ensure that the patient is doing well and the support following discharge is adequate. ms. christian collaborated with ellen j. o’conner, ms, rn, cs, a community health nurse in rural north dakota and northwestern minnesota for many years, in conducting a pilot hospital-to-home program at altru hospital during the summer of 2000. most of the patients involved had multiple diagnoses such as copd and a variety of cardiovascular problems, or had had a cardiac procedure such as cabg. the students functioned in leadership and primary care roles while their patient was hospitalized. they were able to observe what the patient and family were going through during and after a short but intense hospital stay. patients loved the support and wanted it to continue. thus, these rural nurses describe some ways to smooth the transition from hospital to home for rural residents. comments and questions should be directed to bette_ide@mail.und.nodak.edu. microsoft word 459-3026-2-ce.docx online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 148 the nursing community apgar questionnaire in rural australia: an evidence based approach to recruiting and retaining nurses molly prengaman, phd, fnp-bc1 daniel r. terry, phd2 david schmitz, md3 ed baker, phd4 1 associate professor, school of nursing, boise state university, mollyprengaman@boisestate.edu 2 research fellow, department of rural health, university of melbourne ; lecturer, school of nursing, midwifery and healthcare, federation university, duidelike@live.com 3 professor, department of family and community medicine, university of north dakota, david.f.schmitz@med.und.edu 4 professor, center for health policy, boise state university, ebaker@boisestate.edu abstract purpose: to date, the nursing community apgar questionnaire (ncaq) has been effectively utilized to quantify resources and capabilities of a rural idaho communities to recruit and retain nurses. as such, the ncaq was used in a rural australian context to examine its efficacy as an evidence-based tool to better inform nursing recruitment and retention. sample: the sample included nursing administrators, senior nurses and other nurses from six health facilities who were familiar with the community and knowledgeable with health facility recruitment and retention history. participants were registered nurses and/or directly involved in nursing recruitment. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 149 method: the 50 factor ncaq was administered online. data were cleaned, checked, and analyzed by assigning quantitative values to the four-point scale of community advantages or challenges for each factor and then weighted according to the participant’s perceived importance to create a community asset and capability measure. higher scores represented more developed community assets and capabilities relating to nursing recruitment and retention. findings: the findings demonstrate that lifestyle, emphasis on patient safety and high quality care, availability of necessary materials and equipment, perception of quality were among the highest scoring factors and considered to have the most impact on recruiting and retaining nurses. the lowest factors impacting recruitment and retention included spousal satisfaction, access to larger communities, and opportunities for social networking within communities. conclusions: the implementation of the ncaq has the capacity to offer health facilities and managers to examine what is appealing about the health service and community, while highlighting key challenges impacting recruitment and retention. the ncaq assists health services to develop strategic plans tailored specifically to enhance recruitment and retention of nursing staff. its use has the capacity to provide health services with greater evidence as they seek to address site specific or regional recruitment and retention issues. keywords: rural, nursing, workforce, recruitment, retention, community apgar the nursing community apgar questionnaire in rural australia: an evidence based approach to recruiting and retaining nurses internationally, rural communities continue to experience significant challenges recruiting and retaining nurses due to many and varying factors (aylward, gaudine, & bennett, 2011; becker, hyland, & soosay, 2013; manahan & lavoie, 2008; prengaman, bigbee, baker, & schmitz, 2014). rural and remote regions across the us, canada, and australia have a rapidly online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 150 aging workforce with populations experiencing the lowest levels of health access and the greatest health disadvantage (adams, 2016; aylward et al., 2011; hanna, 2001; prengaman et al., 2014). to meet these challenges policy responses have sought to sustain rural access to health services and have made gains (blaauw et al., 2010; buchan & sochalski, 2004; mbemba, gagnon, pare, & cote, 2013); however, retention of rural health care workers remains problematic and continues to impact rural health outcomes (adams, 2016; aylward et al., 2011; blaauw et al., 2010). in addition to policy, previous programs and research have focused on health workforce employment satisfaction, personal experience and individual personality traits that impact taking up of and the longevity of rural employment (campbell, eley, & mcallister, 2016; molinari & monserud, 2008). while, other studies have focused on ‘interventions’ that promote and enable retention of nurses in rural or remote areas, such as financial incentives, professional development, personal and professional support, and regulatory interventions (bourke, waite, & wright, 2014; mbemba et al., 2013). an alternative approach that examined the attributes of a community and health facility was conceived to address physician recruitment and retention issues in rural idaho (schmitz, baker, nukui, & epperly, 2011). through this approach the community apgar questionnaire (caq) was developed to play a key role in recruitment and retention across the us (baker, schmitz, wasden, mackenzie, & epperly, 2012; schmitz & baker, 2012), and was later expanded to address similar nursing recruitment and retention challenges. this led to the development of the nursing community apgar questionnaire (ncaq)(prengaman et al., 2014). traditionally, the apgar is used to quantify resources and capabilities of newborns (apgar, 1966), so too the ncaq is used to quantify resources and capabilities of a rural community to recruit and retain nurses (prengaman et al., 2014). the aim of the ncaq is to provide an evidence base of key strengths, online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 151 challenges, and the community’s overall capacity to recruit and retain nurses, while supporting health facilities to develop achievable long-term goals to meet the needs of a rural community (prengaman et al., 2014; schmitz et al., 2011). the ncaq contains 50 key recruitment factors relevant to recruitment and retention of nurses, which are first scored as being advantages or challenges to the community and then scored as to how important the factors are to rural nursing recruitment and retention. these factors are classified into five classes that include: (a) geographic factors, (b) economic and resource factors, (c) management and decision-making factors, (d) practice environment and scope of practice factors, and (e) community and practice support factors. in addition, three qualitative open-ended questions provide an opportunity to validate the 50 factors and identify less know factors that may be specific to individual communities (prengaman et al., 2014; schmitz et al., 2011). since its inception, the caq has been successful across alaska, idaho, indiana, iowa, maine, montana, north dakota, utah, wisconsin, and wyoming (baker, schmitz, epperly, nukui, & miller, 2010; baker et al., 2012; schmitz, baker, mackenzie, kinney, & epperly, 2015; schmitz et al., 2011), while the use and efficacy of the ncaq has been demonstrated in idaho to date. after consultation with a number of rural health facilities in australia, it was noted that although family physican recruitment and retention was difficult, nursing recruitment and retention was likewise challenginge and also essential to maintaining the viablity of a health service. as such, the value and efficacy of ncaq as an evidence-based tool that seeks to better inform nursing recruitment and retention activities in rural areas was examined in an international context. the aim of the study was to pilot the ncaq across communities in the hume region of rural victoria and develop a greater understanding of the broad and unique community factors that impact rural recruitment and retention of nurses. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 152 methods the hume region of victoria is just smaller than switzerland in size with more than 300,000 people living across the 40,000 square kilometer area. it encompasses 12 local government areas and there are 27 health facilities consisting of three public and three private hospitals in major centres (25,000-60,000 people), and 19 district health facilities and 2 bush nursing services that service their respective communities (1,000-10,000 people) (regional development victoria, n.d.). ethical approval for the study was obtained by albury wodonga, northeast health wangaratta, and the goulburn valley health human research ethics committees. in the study, district health facilities were specifically targeted, of which eight showed interest and six (32%) participating in this study. the target population were nursing administrators and senior nurses who were familiar with the community and knowledgeable about the health facility’s recruitment and retention history and practices. due to the diversity and complexity of each health facility, participants included two chief executive officers (ceos), two directors of clinical services (dcs), two directors of nursing (don), seven senior nurses, and three ‘other’ nurses. in most cases, participants were registered nurses or were directly involved in nursing recruitment. the ncaq was administered online after each participant provided informed consent. the administration of the ncaq in the hume region differed to the original idaho ncaq in that it was a self-administered online rather than face-to-face assessment experience. this approach was undertaken to aide in the sustainability of the tool while examining its value online. once collected, data were cleaned, checked, analyzed using spss version 22.0 (ibm, http://www.ibm.com) and scored by assigning quantitative values to the four-point scale of online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 153 community advantages or challenges for each factor (major advantage = 2, minor advantage = 1, minor challenge = –1, major challenge = –2) (prengaman et al., 2014). each factor was then weighted according to the participant’s perceived importance on a four-point scale (very important = 4, important = 3, unimportant = 2, very unimportant = 1), as outlined in the following algorithm: advantage/challenge score x importance score = community apgar score. adv x imp = apgar for example, an individual participant may state the factor ‘access to larger community’ is a minor challenge (-1) and very important (+4) for their community. thus the calculation of the apgar score for this individual is: -1 x 4 = 4 as such, the algorithm was applied to every participant’s individual response for each factor to provide a community asset and capability measure (apgar) for each factor across the hume region that ranged from -8 to 8. higher scores are representative of a more developed community asset and capability related to nursing recruitment and retention. a similar process was then applied to provide further insight into the overall scores for each factor in terms of the relative advantages/challenges, the importance of each factor and overall apgar scores experienced within the hume region, as outlined in the following algorithm: cumulative advantage ÷ participant number x cumulative importance ÷ participant number: 𝐴𝑑𝑣$ 𝑛 × 𝐼𝑚𝑝$ 𝑛 = 𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝐴𝑝𝑔𝑎𝑟 thus, the calculation of the apgar score for ‘access to larger community’ across the hume region was calculated: (-1-2-1-2+2-2-2-1-2+1-2-1-1-2-1-1 ÷ 16) x (+3+4+4+4+4+4+3+4+4+3+4+4+4+3+3 ÷ 16) = -1.13 x 3.69 = -4.17 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 154 once all data were collected and calculated, site specific data and comparison data for the region were confidentially fed back to ceos which provided an opportunity to further discuss the strengths of their health facility or how the identified challenges may be overcome. findings among the 21 identified district health and bush nursing services, six (32%) sites chose to participate with a final sample of 16 participants. each provided responses to the 50 factors within the ncaq and the three open-ended questions. the reliability of the caq was assessed using cronbach’s alpha coefficients, a standard measurement of reliability. the overall cronbach’s alpha = 0.914, which was above 0.7 and considered acceptable. mean nursing apgar scores were then calculated from the 50 factors. the average scores for factors within and across each class were ranked with the top and bottom 10 nursing apgar scores across all 50 factors being identified for the hume region. advantages and challenges community and practice support was identified as the highest community advantage class across the hume region, followed by management and decision-making. the top 10 individual advantages were 1) lifestyle, 2) hospital leadership/management, 3) emphasis on patient safety/high quality care, 4) sense of reciprocity between nurses and community, 5) availability of necessary materials/ equipment, 6) perception of quality, 7) nurses involved in selecting/implementing new technology/ equipment, 8) recognition/positive feedback, 9) autonomy/respect, and 10) ethical climate. the top 10 challenges were 1) spousal satisfaction, 2) access to larger community, 3) social networking, 4) moving allowance, 5) recreational opportunities, 6) electronic medical records, 7) flexible scheduling and optimal shift availability including 12-hour shifts, 8) demographics/patient mix, 9) benefits, and 10) day care being equal online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 155 tenth position with shift differential, professional development opportunities/career ladders, and nursing workforce adequacy and stability. importance. again, community and practice support was identified as the highest importance class across the communities, and this was followed by practice environment and scope, and management and decision-making class. the highest important factors across all 50 factors were 1) access to larger community, 2) nursing workforce adequacy and stability, 3) manageable workload/increased time with patients, 4) emergency medical services, 5) emphasis on patient safety/high quality care, 6) job satisfaction/morale level, 7) effective partnership between medical and nursing staff, 8) positive workplace culture/supportive working environment that fosters mentoring, 9) acceptance of nurses new to area, and 10) nurse empowerment being equal tenth position with recognition/positive feedback and ethical climate. overall community apgar. the nursing community apgar algorithm, derived from the community advantage/challenge score, weighted by its relative importance, was calculated. the management and decision-making class was identified as the highest community asset and capability and far outweighed the other four classes, which included community and practice support, practice environment and scope, economic and resources, and geographic classes. in addition to the management and decision-making class, the top 10 community apgar factors were 1) lifestyle, 2) emphasis on patient safety and high quality care, 3) hospital leadership and management, 4) sense of reciprocity between nurses and community, 5) availability of necessary materials and equipment, 6) perception of quality, 7) recognition and online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 156 positive feedback and ethical climate, 8) nurses being involved in selecting or implementing new technology and equipment, 9) autonomy and respect, and 10) nurse empowerment. the bottom 10 community apgar factors were 1) spousal satisfaction, 2) access to larger community, 3) social networking, 4) recreational opportunities, 5) nursing workforce adequacy and stability, 6) moving allowance, 7) flexible scheduling and optimal shift availability including 12-hour shifts, 8) electronic medical records, 9) professional development opportunities/career ladders, and 10) day care, as outlined in table 1. table 1 overall advantages/challenges, importance and overall community apgar scores (n=16) overall score mean scores advantage or challenge importance nursing apgar geographic class access to larger community -1.13 3.69 -4.17 demographics/patient mix -0.75 2.94 -2.21 social networking -1.06 3.25 -3.45 recreational opportunities -0.88 3.38 -2.97 spousal satisfaction (education, work, general) -1.19 3.31 -3.94 schools -0.38 3.31 -1.26 climate -0.06 3.06 -0.18 lifestyle 1.13 3.00 3.39 size of community -0.63 3.19 -2.01 nurses having trained /lived in rural areas 0.50 3.13 1.57 economic and resource class cost of living 0.25 3.00 0.75 benefits -0.75 2.63 -1.97 moving allowance -1.06 2.38 -2.52 education support (ce, tuition) 0.25 3.25 0.81 day care -0.69 3.31 -2.28 salary -0.13 3.31 -0.43 shift differential -0.69 2.75 -1.90 housing availability /affordability -0.13 3.31 -0.43 availability of necessary materials/ equipment 0.69 3.44 2.37 internet/technology access -0.25 3.13 -0.78 management and decision making class hospital leadership/management 0.94 3.38 3.18 nurse empowerment/ nurses involved in design of best practice environment/ unit-based decision making/ professional collaboration between management and staff nurses 0.44 3.50 1.54 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 157 (n=16) overall score mean scores advantage or challenge importance nursing apgar nurses involved in selecting/implementing new technology/ equipment 0.56 3.44 1.93 professional development opportunities/career ladders -0.69 3.38 -2.33 thorough orientation/preceptorship for new nurses 0.19 3.25 0.62 flexible scheduling/ optimal shift availability/12-hour shifts -0.81 3.06 -2.48 recognition/positive feedback 0.56 3.50 1.96 effective partnership between medical and nursing staff 0.00 3.56 0.00 teaching/mentoring opportunities/administrative role involvement/ challenge of multiple roles (direct care, leadership, teaching, etc.) -0.19 3.44 -0.65 autonomy/respect 0.56 3.25 1.82 practice environment and scope class clinical variety and challenge/emergency care -0.38 3.38 -1.28 electronic medical records -0.88 2.75 -2.42 positive workplace culture/supportive working environment that fosters mentoring -0.25 3.50 -0.88 positive relationships/communication among different generations of nurses 0.31 3.44 1.07 manageable workload/increased time with patients -0.25 3.63 -0.91 ethical climate 0.56 3.50 1.96 emphasis on patient safety/high quality care 0.88 3.63 3.19 evidence-based practice/opportunities for research 0.13 3.06 0.40 job satisfaction/morale level -0.06 3.56 -0.21 stress levels -0.44 3.31 -1.46 community and practice support class perception of quality 0.69 3.31 2.28 emergency medical services 0.13 3.63 0.47 welcome and recruitment program 0.25 3.44 0.86 acceptance of nurses new to area 0.38 3.50 1.33 sense of reciprocity between nurses and community 0.81 3.44 2.79 image of rural health care and nursing/ positive image of job environment 0.31 3.25 1.01 distance education access -0.63 3.44 -2.17 community health/ nursing services -0.19 3.00 -0.57 family-friendly environment 0.06 3.38 0.20 nursing workforce adequacy and stability -0.69 3.69 -2.55 the cumulative nursing apgar scores for each of the participating health facilities were derived by adding all nursing apgar scores of each 50 factors among participants. the cumulative online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 158 nursing apgar scores ranged from a high of 57 to a low of -80. higher scores indicated greater community assets and capabilities for a particular health facility as they relate to nursing recruitment and retention, outlined in table 2. table 2 community apgar scores by cumulative score location id geographic economic and resource management and decision making practice environment and scope community and practice support apgar score 1 -22 -3 63 -8 27 57 2 -5 28 70 3 -41 55 3 -11 -19 42 4 6 22 4 -61 -26 34 -4 22 -35 5 -61 -66 53 29 -25 -70 6 -54 -52 85 -73 14 -80 it must be noted that geographical isolation of a health facility or community did not always determine an overall nursing apgar score, as some more remote health facilities scored higher apgars than less geographical isolated health facilities. in addition, the overall apgar score distribution indicated that the tool was sensitive enough to differentiate between communities that were high and low performers in terms of nursing recruitment, as previously indicated in rural idaho (prengaman et al., 2014) and shown in figure 1. additional barriers highlighted. additional open-ended responses from participants considered health services provided in rural communities as sub-acute, residential aged care and community health focused. it was felt being less acute may impact the competency of nurses when encountering emergency situations, even after adequate training has been provided. it was stated there was a fear of de-skilling in rural areas due to lack of complex inpatient services or specialty areas. often nurses are looking online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 159 for higher acuity engagement or health specialties which challenge nurses professionally, which may have both workforce and educational implications for health care planners. figure 1: apgar score distribution across sites additional barriers to recruitment and particularly retention were highlighted to be competition with other health services and the perceived isolation of some communities. it was indicated that distance and travel time is prohibitive, which suggests that nearly all health facilities had some nurses that would live in larger population centres and travel to their place of employment for work. it was indicated that employment closer to home, child minding and after school care was why some nurses left positions at the various health facilities. in contrast to the key barriers outlined by participants, another participant stated the nature of rural nursing is actually appealing once you understand it. it offers a very broad area of practice, a great opportunity for autonomous practice, greater interaction between community and nurses, and a more personal and co-operative relationship with all health professionals. (nurse, site 1) online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 160 this suggests that although there may be barriers to living and working as a nurse in rural communities there are key positives that may not be experienced within larger health facilities and communities. however, nurses need to first understand and be cognizant of the opportunities that may not be available elsewhere. discussion the findings demonstrated that among the five classes of factors, management and decisionmaking class outweighed the other four classes, and suggests that nursing candidates may be acutely interested in and consider the management and decision-making practices within certain health facilities. having trust and confidence in an effective executive and nurse managers may not be at the forefront of a candidate’s mind; however, this may vary by work experience level of the candidate such as new graduate versus an experience nurse. the level of trust and confidence in management can demonstrate to a candidate very quickly the environment where they are considering employment (bovbjerg, ormond, & pindus, 2009; chenoweth, merlyn, jeon, tait, & duffield, 2014; jeon, chenoweth, & merlyn, 2010). other aspects of employment that candidates may consider include their capacity to be involved in and empowered to participate in the decisionmaking and development of their environment (amstrong & laschinger, 2006; belden, leafman, nehrenz, & miller, 2012; hegney, eley, plank, buikstra, & parker, 2006; laschinger, 2008; laschinger, einegan, sbamian, & casier, 2000; manojlovich & decicco, 2007; purdy, laschinger, finegan, kerr, & olivera, 2010; shields & ward, 2001). further, candidates may also examine if there is the encouragement of and the capacity for specific rural training, further career development and professional advancement (amstrong & laschinger, 2006; belden et al., 2012; breau & rheaume, 2014; chenoweth et al., 2014; hegney et al., 2006; laschinger, 2008; laschinger et al., 2000; manojlovich & decicco, 2007; purdy et al., 2010; shields & ward, 2001). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 161 beyond management and decision-making, it was indicated that lifestyle, emphasis on patient safety and high quality care, hospital leadership and management, and sense of reciprocity between nurses and community were among the highest scoring community apgar factors and were considered to have the most impact on recruiting and retaining nurses. in the hume region, the various communities have what many may consider a ‘typical’ rural lifestyle and nurses with an interest in serenity, communities with strong social networks, where a close proximity to families and friends are valued, may view rural lifestyles as an advantage (dotson, dave, & cazier, 2012; hegney, mccarthy, rogers-clark, & gorman, 2002). in addition, training nurses in rural environment has been shown to be an important step in workforce generation through integrating and reciprocity with the community and gaining an appreciation for rural health practice, which correlates with training physicians in rural areas (dunbabin & levitt, 2003; playford, larson, & wheatland, 2006). further, health facilities in the region emphasize and promote patient safety and quality care as a top priority, and among nursing staff there is confidence in hospital leadership and management that facilitates staff feeling valued and empowered. at times, nurses who may not be from the area or who have trained in urban areas may have the perception that rural facilities lack vital materials and equipment. working in a health facility that has current and adequate materials, while having access to up-to-date equipment and technology assists nurses in their practice and decision-making (dawson, stasa, roche, homer, & duffield, 2014; goh, gao, & agarwal, 2016). having a well-kept health facility and access to current medical technology equipment ensures that current and potential nurses see the health facility as relevant, and thus may be advantageous and further assist with the perception of quality of health services and a community (dawson et al., 2014). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 162 the lowest individual factors nursing apgar identified included spousal satisfaction and access to larger community. although the region may be considered a typical rural lifestyle, social networking was also one of the lowest factors identified. solutions for the lowest scoring factors that have the greatest impact on recruitment and retention may include treating the recruitment of the spouse or partner as importantly as recruitment of the candidate. provide information for the spouse or partner as a part of recruitment packages, and encourage them to accompany the candidate as a part of the selection process (becker, hyland, & soosay, 2013). this may encompass finding ways to get the spouse or partner engaged in the community through volunteering or socialising (becker et al., 2013). consider applying a community network approach to finding work for dual-career couples to facilitate their relocation to the region (becker et al., 2013). alternatively, the process may be about organizing employment matching initiatives, professional development programs or to examine tele-commute options for a spouse or partner (manahan & lavoie, 2008). in addition to considering the spouse, accessing a larger community often means access to specialized dining, entertainment, shopping, cultural and religious opportunities (aylward et al., 2011; hanna, 2001). potential solutions may include offering candidates long weekends off so they can take an extended trip to a larger community. alternatively, sponsor or promote online access to specialized services (becker et al., 2013; terry, baker, & schmitz, 2016), or have cultural night events where specialty cuisine and culture is sampled and new staff and their families are invited along (becker et al., 2013; durey, malcolm, critchley, & crowden, 2008). this further extends into social networking and connecting nursing candidates with social contacts during their onsite visit. if recruiting a candidate who may have trouble integrating into a community, try to recruit two or more candidates who have similar interests or come from similar areas, or include online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 163 community leaders in the hiring process to address local opportunities for social relationships (baernholdt & mark, 2009; d. molinari, jaiswal, & hollinger-forrest, 2011). when comparing the rural victorian data with rural idaho, there were some contrasting findings. the top ten factors in rural idaho included family friendly environment, recreation, and emergency medical services being scored as the highest community factors. this may be due to the contrasting aspects of the community and health care contexts between each country. for example, emergency medical services scored much lower in the hume region than in idaho and may be due to the diversity of practices and services within the various hume health care facilities. health services had either no emergency medical service, urgent care clinics (treating walk-in patients with non-life threatening injuries or illnesses) or more complex urgent care centres with limited x-ray and laboratory services. these various services similarly have diverse approaches to staffing which includes full time salaried family physicians, private family physicians providing on-call and/or rural and isolated practice endorsed registered nurses (ripern) who were being used to cover urgent care centres. while some services used telehealth to interact with regional trauma services in larger regional centres to alleviate physician on-call responsibilities (victoria state government n.d.). despite these difference between idaho and victoria, it is noted that professional factors such as autonomy, respect or the ability for nurses to direct their own practice was scored very similarly between the two countries, and globally remains a key factor contributing to job satisfaction and retention (lu, barriball, zhang, & while, 2012; prengaman & bigbee, 2012). in addition, there were five factors that were common among the lowest scoring factors and included spousal satisfaction, social networking, moving allowance, electronic medical records, and day care. many of these same factors have been highlighted as similar issues among other health professions in online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 164 rural areas and may be why they remain similar between countries (fleming, mcrae, & tegen, 2001; hancock, steinbach, nesbitt, adler, & auerswald, 2009; mcgrail, humphreys, scott, joyce, & kalb, 2010; russell, humphreys, mcgrail, cameron, & williams, 2013; stanley & bennett, 2005). limitations. a limitation of this study is that participating communities and respondents may not represent all communities and health facilities in the specified region or across the state. this may limit the ability to generalize the findings. in addition, differences between australian and us based community apgar research were observed, such as how data were collected, the structure and distance of communities from major centres, and how health facilities are structured and function. conclusion the hume region of rural victoria was the first area outside the us to implement the ncaq, and its reliability as a tool was indicated to be relatively high with a cronbach’s alpha = 0.914. the ncaq has provided an analysis of the comparative strengths and challenges that each health service encountered, and has established the distinctiveness of each community it services. key factors that each community had to offer nurses were identified, while indicating the types of nurses that may be best matched with each community. as a process, the ncaq is useful as it helps health services understand how they are performing, while highlighting or reaffirming key areas to improve the recruitment and retention of nurses. the implementation of the ncaq has the capacity to offer health managers and facilities an opportunity to examine what it is about their community and health service that is appealing, while providing the opportunities to address a number of the key challenges identified. the ncaq online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.459 165 assists health services develop strategic plans that can be tailored specifically to enhance recruitment and retention of nursing staff. as a tool, the ncaq has identified trends and overarching factors that directly impact rural communities. its use in australia will provide a greater evidence base for health services to work collaboratively as they network in and across rural regions as they seek to address issues of recruitment and retention, and impact health care policy. acknowledgements australian government department of health through the rural health multidisciplinary training programme references adams, s. 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(2016). community assets and capabilities to recruit and retain gps: the community apgar questionnaire in rural victoria. rural and remote health, 16(3990), 1-10. retrieved from http://www.rrh.org.au/publishedarticles/article_print_3990.pdf victoria state government (n.d.). urgent care in regional and rural areas. retrieved from https://www2.health.vic.gov.au/hospitals-and-health-services/rural-health/urgent-carerural microsoft word tabi_362-2306-1-ed.docx online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 59 helping minority students from rural and disadvantaged backgrounds succeed in nursing: a nursing workforce diversity project marian tab, phd, mph, cfcn, rn associate professor & director, program outcomes, georgia southern university school of nursing, mtabi@georgiasouthern.edu abstract introduction: retention and graduation rates among minority nursing students continue to be a challenge in nursing education. while multiple strategies have been implemented to increase diversity in the nursing workforce, disadvantaged minorities from rural backgrounds often face challenges that create barriers to their academic success. the run 2 nursing program, a nursing workforce diversity program funded by the u.s department of health and human services, recognized the need to use faculty mentoring and peer tutoring to make a difference in the academic success of minority nursing students from rural and disadvantaged backgrounds. methods: data were collected from a convenience sample of 62 minority students and 22 faculty mentors. descriptive statistics including mean and standard deviation were used to report the aggregate data from the mentoring survey. findings: retention rate of 93% and nclex-rn pass rate of 93% were achieved for the minority students enrolled in the nursing workforce diversity project. these findings suggest the peer and faculty mentoring were effective support strategies. conclusions: preparing a well-skilled, competent and diverse workforce of health professionals is a priority in eliminating health disparities, particularly in rural and medically underserved online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 60 communities. nwd programs, such as the run 2 nursing program, with well-structured mentoring and peer tutoring services can make a difference in nursing workforce diversity. keywords: faculty mentoring, minorities, nursing workforce diversity, peer tutoring, rural, disadvantaged helping minority students succeed in a rural nursing program: a nursing workforce diversity project the are (r) you (u) in (n) to (2) nursing (run 2 nursing) program, located at a regional university school of nursing in rural southeast georgia, was a nursing workforce diversity program funded by the u.s. department of health and human services. this three-year comprehensive program was implemented from 2010-2013 with a one-year no cost extension that ended in june, 2014. the goal of the program was to provide minority nursing students with the necessary skills to successfully complete their bsn education to practice as registered nurses in rural georgia. the major aims of the run 2 nursing program were: 1) to increase the graduation and nclex-rn exam pass rates of minorities enrolled in the nursing program, and 2) to reduce the attrition rate by creating a welcoming culture that nurtured bsn minority students academically and socially to achieve success. faculty and students at the school of nursing are 86% and 24% caucasian and african american respectively. with very little diversity, the school of nursing is committed to increasing diversity in its baccalaureate program. increasing minority representation in the nursing workforce is a priority in eliminating health disparities that exist among populations. southeast georgia, the geographic focus of the run 2 nursing program, is characterized by a diverse population with a high incidence of poverty, food insecurity, limited access to educational opportunities and lack of health insurance, conditions that impact health equity in the online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 61 region. great disparities in poverty rates exist by race and ethnicity: 23.8% of blacks and 33.2% of hispanics compared to 10% of whites live in poverty statewide (u.s. department of agriculture, economic research service [usda, ers], n.d.). in georgia, 144 of 159 counties (91%) represent medically underserved areas (muas); 137 (86%) counties represent designated health professional shortage areas (hpsas); and, 19 counties are designated significant primary care shortage areas with scores of 17 or greater (on a range of 0 to 25). according to america’s health rankings (united health foundation, 2015), of the 50 states, georgia ranks 40th in overall health measures, 41th in incidence of diabetes, 36th in cardiovascular disease, and 46th in insurance coverage. based on these statistics, it is clear that the health of georgians could benefit from a competent and diverse nursing workforce. according to the american association of colleges of nursing (aacn), increasing the racial and ethnic diversity of students in nursing programs is a high priority in achieving a diverse workforce in the nursing profession (american association of colleges of nursing, 2015). past studies have shown that educationally and economically disadvantaged minority students face unique challenges to success including lack of financial support, inadequate emotional and informational support, insufficient academic advising and program mentoring, and structured support mechanisms (amaro, abriam-yago, & yoder, 2006; dowell, 1996; loftin, newman, dumas, gilden, & bond, 2012). these challenges can obstruct nursing students’ success by causing early dropout, poor academic performance and by having a negative impact on their educational experiences. the aacn, the american nurses association and the national league for nursing (nln) support programs focused on educationally and economically disadvantaged minority students (american nurses association, 2011; national league for nursing, 2010; smedley, butler, & bristow, 2004) despite this support from nursing online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 62 organizations, diversity in the nursing workforce has not fully come to fruition (health resources and services administration, 2013). a considerable amount of research shows that mentoring and tutoring services can improve retention and graduation rates for educationally and economically disadvantaged minority nursing students. abriam-yago (2002) identified three types of mentors to meet the needs of minority nursing students: professional nurse mentors, peer mentors, and faculty mentors. each type of mentor has a specific role in helping educationally and economically disadvantaged students with academic, informational and emotional support (abriam-yago, 2002). several authors have discussed the importance of faculty mentors and student tutors in supporting students’ academic success (alvarez & abriam-yago, 1993; robinson & niemer, 2010; sutherland, hamilton, & goodman, 2007). sutherland et al. (2007) described the affirming atrisk minorities for success (arms) program that utilized faculty-student advisement, mentoring, and seminars in success to increase retention, graduation, and national council of licensed examination for registered nurses (nclex-rn) pass rates for disadvantaged students in nursing. the results suggested that these interventions were effective and eliminated the effects of ethnicity on nclex-rn pass rates among minorities and non-minorities (sutherland, et al., 2007). a similar peer-based mentor tutor program (pmtp) described by robinson and niemer (2010) focused on implementation and outcomes for at-risk students in a traditional baccalaureate nursing program. they found that mentees earned significantly higher test scores throughout the year and a higher average gpa than a control group. however, the program failed to change attrition rates when compared to previous years (robinson & niemer, 2010). online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 63 numerous studies have documented success for both faculty mentoring and peer tutoring services as individual strategies. however, there are few studies in which both faculty mentoring and peer tutoring services were combined to support academic improvement and to determine the effectiveness of this synergistic approach in achieving desired outcomes. the run 2 nursing program not only combined faculty mentoring and peer tutoring, but also offered other support services such as scholarships, leadership training, and cultural sensitivity workshops. the purpose of this paper is to add to the current body of knowledge on best practices to increase diversity in the nursing workforce. description of the run 2 nursing program the run 2 nursing program was a three-year funded program aimed at supporting the health resources and services administration’s (hrsa) initiative to increase diversity in the nursing workforce to meet the goals of healthy people 2020. specifically, the program addressed retention and graduation rates of minorities from rural and underserved communities in baccalaureate education. retention and graduation activities designed to support academic success of minority nursing students included peer tutoring, faculty mentoring, nclex preparation for licensure, leadership and professional training, diversity training, and workshops on study and time management skills. scholarships were provided to assist students with financial needs including cost of tuition, books, transportation to clinical sites, and other expenses. recruitment of program participants minority nursing students were recruited to the program via classroom presentations by program staff, fliers, information posted on the program’s website, and by word of mouth from students and faculty. minority included members of racial and ethnic groups who were online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 64 economically and educationally disadvantaged. eighty-five percent of the program participants were african americans, 10% were hispanics, and 5% were other. student recruitment to the program was done in the fall and spring semesters. interested students had to apply to be admitted into the program. program eligibility criteria were as follows: (a) cumulative gpa of 3.0 or higher; (b) identifying as a minority; (c) educationally and/or economically disadvantaged; (d) resident of a rural or underserved county in the state of georgia; (e) intent to practice in a rural or medically underserved community after graduation; and, (f) a written essay on choosing nursing as a career. the length of participation in the program varied from a minimum of one year to two years depending on the class level of the student at the time of enrollment. students admitted into the program received an acceptance letter and attended a mandatory information session. the information session discussed the program, services, expectations, and addressed students’ questions. all students admitted into the program, regardless of their class standing, were assigned to faculty mentoring and peer tutoring. the program was managed by a project director who was responsible for day-to-day operations and two graduate assistants. the program was supported by the school of nursing administrators and faculty. ethical considerations permission and approval was obtained from the author’s institutional review board (irb) to use collected program data for research and publication. informed consent was also obtained from program participants to use their collected program data for research purposes. while collection of program data was for reporting of program outcomes to the funding agency, participants had the option to refuse consent for inclusion of their data in any program research or publications. data were kept confidential; all identifiers were removed and anonymity was maintained for research purposes. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 65 faculty mentoring and recruitment the success of the run 2 nursing program relied heavily on the school of nursing faculty’s willingness to mentor students in the program. of the 22 faculty at the school of nursing, only one was a minority. this made it even more important that the faculty who were recruited to be mentors understood their role and commitment to work with students from diverse backgrounds. recruitment of faculty as mentors was done in the fall semester during the school of nursing’s annual faculty institute where information was presented to faculty about the program. mentor eligibility criteria were: (a) a voluntary commitment to mentor assigned minority students in the run 2 nursing program; (b) ability to work with students from diverse backgrounds; (c) ability to meet at least three times or more with assigned mentees; and, (d) ability to complete a faculty-mentee survey form to measure outcomes of the mentoring relationship. a one year commitment was required from faculty mentors. the commitment was renewable each year for the three year funding period. faculty received a small stipend for compensation of their time and commitment. each faculty mentor was assigned an average of six mentees. peer tutoring and recruitment upperclassmen nursing students that demonstrated outstanding academic performance were recruited to provide peer tutoring to at-risk nursing students. peer tutors were recruited based on self-nomination and/or faculty referral. since this was a paid position, hired applicants were both screened and interviewed. the peer tutor position was advertised on the university’s human resources website. interested applicants had to complete an application, submit an online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 66 academic transcript with a cumulative gpa of 3.5 or higher, have achieved a b or better in nursing courses, and submit a reference letter of recommendation. the position required each peer tutor to provide 15 hours of tutoring per week, provide course specific academic support, provide individual and/or group tutoring, and work with culturally diverse students. in addition, peer tutors were required to keep attendance logs and monitor the academic progress of their respective assigned students. each peer tutor was paid $12/hour and their ability to continue on in the tutor position was dependent on their successful academic performance each semester. those who were unsuccessful were released from the position. the run 2 nursing program staff supervised the peer tutors. six peer tutors were used per semester, with two tutors per each junior level class. there were a total of 14 tutors for the threeyear period, of which, six were minorities. peer tutors provided tutoring to junior classmen and to struggling classmates that approached them for assistance. at the beginning of each semester, peer tutors, with permission from faculty, made class presentations to students in their assigned junior classes. the presentations included an introduction, information about the tutoring service and its benefits, hours, location, and contact information. peer tutor profiles and tutoring information were posted on the program’s website and on a bulletin board located in a common area for baccalaureate nursing students. although peer tutors were specifically assigned to minority students enrolled in run 2 nursing, they also assisted non-minority students referred by faculty. each minority student was required to maintain weekly contact with his/her assigned peer tutor regardless of academic performance in the nursing program. this was necessary for continuous monitoring of each student’s academic progress and to minimize oversight of online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 67 academic issues that could be problem solved early on. each peer tutor maintained an average of 8-10 students. mentoring and peer tutoring evaluation faculty mentors completed an evaluation form on each mentee at the end of each semester. the faculty-mentor and mentee surveys (see table 1 for the measured items and results) were created by program staff based on run 2 nursing program objectives, outcomes, and literature on mentoring. the surveys were 18-item questionnaires that used a likert scale that ranged from (1) strongly disagree to (5) strongly agree. the faculty-mentor survey measured each mentee on attendance, motivation, and academic progress. the mentee survey measured their perceived experiences, level of satisfaction, and academic success. each student mentee and faculty mentor completed the survey at the end of each academic semester. the surveys were distributed to faculty and mentees via email. surveys completed by faculty and mentees were returned via email or a drop-box at a designated location. results of the collected de-identified surveys were shared with faculty mentors and mentees to improve mentoring outcomes. the presentation of results to mentors and mentees (each done separately) helped in two ways: it allowed us to objectively validate the results with the stakeholders, and allowed us to identify other issues and concerns that were not addressed or captured by the surveys. compiled results from faculty mentors and students from 2010-2013 are presented in table 1. students who received services from the run 2 nursing peer tutors completed peer-tutor evaluation forms at the end of each semester for us to gauge the effectiveness of the tutoring. results from the tutoring evaluation were shared with tutors for continuous improvement. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 68 results of faculty mentoring descriptive statistics including mean and standard deviation were used to report the aggregate data from the mentoring survey (see table 1). sixty-two students evaluated faculty mentors on availability, encouragement, faculty support and feedback. the mean score for “availability” was 4.86 out of 5 (sd=0.30). this item addressed the frequency of faculty contact with students, availability outside of scheduled meetings, and friendliness of mentors. the mean score for “encouragement” was 4.96 out of 5 (sd=0.08). this item assessed the role of the mentor in establishing an environment that encouraged growth of students in the nursing program. additionally, this item also assessed the enthusiasm of the mentor about the student’s academic career and aspirations beyond the bsn degree. the mean score for “faculty support and feedback” was 4.84 out of 5 (sd=0.38). this item assessed faculty mentors’ guidance and assistance provided to mentees struggling in academic coursework and constructive strategies to achieve academic success. the mentors’ evaluation of participants also produced similar findings to that of mentees. the mean score for the subscale item measuring “eager to learn” was 4.74 out of 5 (sd=0.14). this item assessed readiness of students for rigorous academic work in the nursing program and also to acquire new skills. the mean scores for the subscale items measuring “seeking support” and “quality of mentor-mentee relationship” were 4.84 (sd=0.19), and 4.79 (sd=0.28) respectively. the mean score for overall mentor experience was 5 out of 5 (sd=0.00). mentors were very satisfied with the students’ enthusiasm for the work and their academic progress in the nursing program. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 69 table 1 summary of findings from mentoring and tutoring evaluations evaluations subscale items mean sd student evaluation of peer tutors (n= 55) academic enhancement 4.72 0.36 support and feedback 4.74 0.42 student relationship 4.71 0.35 student satisfaction 4.86 0.33 faculty mentors evaluation of students (n=68) eager to learn 4.74 0.14 seek for support 4.84 0.19 enthusiastic 4.81 0.24 relationship 4.79 0.28 overall experience 5.00 0.00 student evaluation of faculty mentors (n=62) availability 4.86 0.30 encouragement 4.96 0.08 support and feedback 4.84 0.38 student satisfaction 4.87 0.33 ranges from 1 “strongly disagree” to 5 “strongly agree” results of peer tutors’ evaluation descriptive statistics, including mean and standard deviation were used to report the aggregate data from the tutoring survey (see table 1) that measured peer tutors on academic enhancement, support and feedback, student relationship, and student satisfaction. the mean score for “academic enhancement” was 4.72 out of 5 (sd=0.36). academic enhancement assessed the tutor’s ability to create a learning environment that encouraged the learner’s growth and knowledge to achieve academic success. the mean score for “support and feedback” was 4.74 out of 5 (sd=0.42). this item assessed the tutor’s ability to provide appropriate guidance to support the student learners to develop a study plan and time table to improve academic performance in course work. the mean score for “student relationship” was 4.71 out of 5 (sd=0.35). this item measured availability, accessibility, and personal interactions of peer tutors online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 70 with student learners. the mean score for “student satisfaction” was 4.86 out of 5 (sd=0.86). this item assessed the overall experience and satisfaction of students with their tutors. minority retention and nclex-rn pass rates the effectiveness of a bachelor of science in nursing (bsn) program depends on these three important outcome measures: retention, graduation, and nclex-rn pass rates. the ability of a bsn program to measure its program outcomes is essential to achieving overall student success. among the 68 minority bsn students who enrolled during the four-year implementation of the program, the retention rate was 93% and the attrition rate was 5.8% (see table 2). students’ nonsuccess was due to academic dismissal from the nursing program as a result of failing two or more courses. of the 53 graduates, 51 passed the nclex-rn on their first attempt, a 96% pass rate. these graduates are now practicing registered nurses in rural and medically underserved communities. twenty-eight percent of these graduates are currently enrolled in graduate nursing education, and the majority plan to seek graduate education in the future. table 2 enrollment, graduation, & nclex pass rate 2010 – 2014 minority bsn students enrolled (n = 68) frequency (n) percent (%) number lost to attrition 5 7.4 number retained 63 93 number of graduating 53 78 nclex-rn pass on first attempt 51 96 number of failing nclex-rn on first attempt 2 4 online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 71 discussion of findings the run 2 nursing program met its goal of academically supporting minority bsn students to add to the nursing diversity workforce. while other factors may have contributed to the academic success of the minority students in the program, the role of faculty mentoring and peer tutoring made a significant difference. reflecting on program activities over the past four years, there were three main lessons learned that can be applied to other nursing workforce diversity programs. key lessons learned build a community of support for the program. the success of the program depended heavily on faculty, staff, and supportive leadership at the school, college, and university. with a focus on retention and academic success of disadvantaged racial and ethnic minorities, student buy-in and support of the program were essential. classroom presentations on the program and its purpose were conducted each semester which helped to garner support from both minority and non-minority students. emphasis was placed on the benefit of diversity in the nursing workforce to improve health outcomes for all populations. create a nurturing environment to support academic success. a nurturing and welcoming environment can make a difference in the academic success of all students. many minorities complete their k-12 education in predominately black institutions and receive limited exposure to main stream culture prior to college. this leaves many of these students burdened with a lack of skills to navigate through college. a caring and nurturing environment where minority students perceive faculty and peers to be open, nonjudgmental, online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 72 trustworthy, culturally sensitive, approachable, non-intimidating, and able to listen is crucially important. a non-threatening environment such as this can promote effective positive interaction and student learning. to successfully attract and retain these students, it is essential to provide psychological safety, a sense of belonging, and support of self-esteem and self-actualization. to decrease attrition, retention strategies should include tutoring, academic support, career planning, and improvement of cultural competency skills among academic advisors and faculty members. train faculty and students to be diversity minded. all students are culturally unique. for this reason, it is important that committed faculty mentors and peer tutors assess each student for behaviors, beliefs, and values which may present unique needs and may impact academic success for the student. in addition, communication barriers including language and regional accents can create challenges for disadvantaged students. cultural training and sensitivity are crucial to support inclusion and acceptance of students from disadvantaged backgrounds that may feel marginalized. while there is a lack of diverse faculty and students in most nursing programs, nonminority faculty mentors and peer tutors can be equally effective. it takes a committed faculty and dedicated students to recognize the need to “go the extra mile” to support students from disadvantaged backgrounds that are capable of succeeding. program sustainability though funding for the run 2 nursing program ended in june 2014, faculty mentors and students have expressed the desire to continue mentoring and tutoring. peer tutors will document their tutoring as service hours on their resume. faculty will continue with the process of referring at-risk students for tutoring. the minority students involved in the program formed the first ever online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.362 73 black students nursing association to provide informal mentoring to pre-nursing and nursing students. the project director serves as the advisor for this group. in addition, the project director will continue to hold monthly meetings with students to provide coaching, guidance, and encouragement. the commitment from students and faculty to use volunteer hours to sustain the program demonstrates its perceived value. conclusions although the percentage of minorities in the us is estimated to increase to nearly 50% in 2050 (u.s census bureau, 2011), these individuals represent a smaller proportion of the health professions workforce. preparing a well-skilled, competent and diverse workforce of health professionals is a priority in eliminating health disparities, particularly in rural and medically underserved communities. nwd programs, such as the run 2 nursing program, with wellstructured mentoring and peer tutoring services can make a difference in nursing workforce diversity. it takes a team of faculty and students that embrace diversity and are a part of a nurturing environment that exhibits caring and a sense of belonging to support the academic success of minority nursing students. there is a need to increase the number of practicing minority rns in rural communities to reduce health disparities and improve health outcomes for all populations. there is no doubt that minority nurses are needed to bridge the cultural gaps between racial/ethnic minority patients in the u.s. health care system. supporting agencies department of health and human services, health resources and services administration references abriam-yago, k. 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(2011). overview of race and hispanic origin: 2010 retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf microsoft word armstrong_438-2663-3-ce.docx online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 100 a quality improvement project measuring the effect of an evidence-based civility training program on nursing workplace incivility in a rural hospital using quantitative methods nancy elizabeth armstrong, rn, dnp 1 1 assistant professor, murray state university school of nursing, narmstrong1@murraystate.edu abstract workplace incivility is a well-documented issue in nursing. it has the potential to cause emotional and physical distress in victims, and potentially affect the quality of care provided. research in acute care settings found that facilitated educational training sessions related to workplace incivility, in combination with experiential learning activities, assisted nurses in improving their understanding of workplace incivility and their communication skills. it has also been found to reduce workplace incivility. the purpose of this quality improvement project was to see if implementation of a civility training program would: a) increase the staff nurses’ ability to recognize workplace incivility, b) reduce workplace incivility on a nursing unit, and c) increase confidence in the staff nurses’ ability to respond to workplace incivility when it occurs. the project design involved implementing a civility training program that included education about incivility through facilitated discussions, as well as teambuilding exercises and experiential learning activities involving practice in responding to incivility in a safe environment. the project was implemented in a medically-focused medical-surgical unit at a rural kentucky hospital with a sample of nine registered nurses. the findings of the project included no significant changes in online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 101 the frequency of the nurses’ experiences with incivility in their unit. it did result in statistically significant increases in the nurses’ self-assessed ability to recognize workplace incivility and confidence in the nurses’ ability to respond to workplace incivility when it occurs. it was concluded that implementing this type of intervention in other rural nursing settings might help nurses have greater confidence in their ability to recognize and respond to workplace incivility. keywords: incivility, nursing, experiential learning a quality improvement project measuring the effect of an evidence-based civility training program on nursing workplace incivility in a rural hospital using quantitative methods workplace incivility, or bullying, is a behavioral issue that can occur in the healthcare setting. anderson and pearson (1999) defined workplace incivility as low-intensity, deviant behaviors that are intended to harm the victim and demonstrate a lack of mutual respect. incivility seems to occur as the result of poor communication and discourteous attitudes that fall outside of expected work norms. rural areas are not immune to nursing incivility. fairchild et al. (2013) interviewed 40 nurse administrators from rural communities. the administrators reported workplace civility education as a specific area of need. some of the interviewed administrators described periodically having to mediate with employees for both overt and covert acts of workplace incivility, such as name-calling, intimidation, and sabotaging behaviors. this quality improvement project was implemented at a rural hospital in kentucky. the community containing the hospital is defined as rural, because the county has a population of less than 50,000 people (omb, 2010). online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 102 background and significance multiple studies have linked incivility to patient safety and the quality of patient care. wright and khatri (2014) queried 1,078 nurses working for a midwest hospital system about workplace bullying and medical errors, and found a significant, positive relationship between being a victim of workplace bullying and the perception of the bullied nurses’ risk of committing medical errors (β weight = .370, p < .001). laschinger (2014) questioned 336 canadian acute care nurses about their exposures to workplace incivility, and the perceived effects of workplace incivility on patient safety and the quality of care they provided. a significant correlation (r2 = 0.03-0.06, p = .000) was discovered between workplace incivility experiences and the nurses’ perceptions about decreased quality of care provided, increased adverse events, and higher patient safety risks. hutchison and jackson (2013) completed a mixed-methods systematic review of literature related to the effect of hostile nursing work environments on patient care. they discovered ten studies related to nurses bullying fellow nurses. five of the studies found that nurses reporting exposures to workplace bullying frequently felt overwhelmed and at increased risk for errors in patient care. in four of the studies, nurses reported that workplace incivility prevented requests for assistance from coworkers when dealing with complex clinical situations or where patient safety was at risk. the evidence supports the need to improve nursing workplace communication and civility behaviors to maintain a safe, effective care environment for patients. nursing incivility can affect hospital finances as well. laschinger, leiter, day, and gilin (2009) surveyed 612 staff nurses from five canadian hospital systems about incivility. they found that empowerment, incivility, and burnout were correlated with job satisfaction, organizational online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 103 commitment, and turnover intentions of nurses. high nursing turnover rates increase the frequency, and therefore cost, of training and orienting new nurses. ortega, christensen, hogh, rugulies, and borg (2010) surveyed 9949 danish nurses working in the elder-care setting about bullying in the workplace and monitored long-term, sickness-related absences over a one-year period. a longterm sickness absence was defined as over six consecutive weeks of absence related to ill health. of the nurses reporting occasional exposure to workplace bullying, long-term sickness absences were more common than those not exposed to bullying. nurses who were frequently exposed to bullying were at a 92% higher risk of experiencing a long-term sickness absence. the replacement of nurses who require long absences increases the overall cost of providing effective patient care. incivility has been identified in multiple studies as a problem experienced by nurses in the workplace. edward, ousey, warelow, and lui (2014) completed a systematic review of the literature involving violence against nurses. of the 137 articles reviewed, 31 focused on workplace aggression between nurses, and between nurses and other healthcare professionals, with five surveying nurses about exposures to workplace incivility. high levels of reported collegial aggression were found in the reviewed studies, with 21% to 90% of the nurses surveyed from the studies reporting exposures to workplace bullying within the last year. smith, andrusyszyn, and laschinger (2010) surveyed 117 novice canadian nurses about workplace incivility. of those responding, 90.4% reported that they had experienced at least some form of co-worker incivility. many nurses experience workplace incivility. as the available evidence has demonstrated, the consequences of dealing with incivility can be costly for nurses, employers, and patients. the purpose of this quality improvement project was to implement a civility training program that included education about incivility, teambuilding exercises, and experiential learning online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 104 activities. implementation of the civility training program was expected to: a) increase the staff nurses’ ability to recognize workplace incivility, b) reduce workplace incivility on a nursing unit, and c) increase confidence in the staff nurses’ ability to respond to workplace incivility when it occurs. the plan was based on the best available evidence, with a focus on its suitability for the participating agency. the plan included education about workplace incivility, teambuilding exercises, and an experiential learning exercise that allowed for practice in responding to workplace incivility scenarios in a safe environment. a quality improvement framework was used to guide the project. theoretical framework benner (2001) theorized that nurses transform information into knowledge through experiential learning. in her seminal work, benner (2001) detailed her philosophy of how basic knowledge is transferred from superficial to deep understanding through the practice of nursing, as a nurse goes through the five major stages of nursing experience. nurses at the novice level, are beginning learners. they have a basic knowledge of nursing practice through rote memorization of facts and some classroom application, but they have not experienced learning through actual interactions with nurses and patients, or have very limited experience. once a nurse has had a fair amount of clinical experience, he or she moves to the advanced beginner stage (benner, 2001). through experience, the advanced beginner can demonstrate some understanding beyond the basic level. the advanced beginner can begin to prioritize care, but still needs supervision and guidance in decision-making and in the management of care. the next stage of nursing is the competent stage, which occurs after the nurse has two to three years of experience (benner, 2001). the knowledge that the competent nurse applies to practice is objective, as well online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 105 as abstract and analytical. the competent nurse has enough experience to effectively cope with the management of patients. however, he or she may lack the speed or flexibility of the expert nurse. according to benner (2001), the final two stages of nursing knowledge development are proficient and expert. the proficient nurse’s knowledge allows for an understanding of the whole situation, rather than isolated parts. subtle patient needs or issues are detected more readily by the proficient nurse, as compared to the competent one. the proficient nurse can perceive a situation and the flexibility to respond, if the situation changes. the expert nurse is no longer thinking or perceiving based primarily on previous training or education, but knowledge from experience (benner, 2001). benner’s (2001) philosophy of nursing knowledge development can be useful in assisting nurses in dealing with workplace incivility, because it provides a framework for nursing staff education. using benner’s philosophy, the project leader was able to guide nurses in recalling their previous experiences as they progressed through the different stages of personal and professional development as a nurse. the project leader also assisted the nurses in discovering their current expertise levels, and help them to better understand and assist other nurses with less experience. benner’s philosophy also encourages the use of experiential learning in moving learned information, such as interpersonal communication techniques, into deeper understanding for actual utilization in practice. according to benner (2001), for nurses to truly learn, they must be exposed to situations, through actual or simulated practice, in order to transfer superficially understood information into true knowledge and understanding. once true understanding takes place, learned skills can be fully used in practice. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 106 review of literature there are four major categories of available evidence related to interventions aimed at helping nurses manage workplace incivility. there are studies that involved non-interactive, or non-facilitated, educational sessions about workplace incivility with experiential learning exercises. facilitated training refers to learning sessions that are interactive and involve group discussion, rather than traditional one-way teaching methods. some of the studies have facilitated educational sessions, but no experiential learning exercises. studies were found that included educational sessions only, with no facilitation or experiential learning exercises. finally, there were studies that focused on a combination of facilitated educational sessions about workplace incivility with experiential learning exercises involving practice in responding to bullying behaviors effectively. non-facilitated education and experiential learning exercises mallette, duff, mcphee, pollex, and wood (2011) used a randomized controlled trial to study effective formats for training nurses in managing nursing incivility. the purpose of the study was to evaluate the effectiveness of traditional educational methods versus a virtual world-based experiential learning program in helping nurses successfully deal with horizontal violence, or incivility, in the workplace. the study was conducted in one canadian hospital using a convenience sample of 164 nurses who were past their probationary periods, and who worked in tertiary care. the participants were randomly divided into five groups. one group completed a workbook about incivility and how to respond to it. another group did a self-directed e-learning module. a third group participated in a virtual world training program, using the second life format, to role-play, practice, and receive feedback on responding to incivility in the virtual online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 107 workplace. a fourth group completed both the e-learning module and the virtual world training program. the final group was a control group with no training provided. mallette et al. (2011) found that all forms of educational training resulted in high satisfaction rates, with the highest being given to the combined e-learning module (m = 6.43, sd = 0.60) and virtual world training sessions (m = 6.12, sd = 0.51) on a 7-point likert-type scale. there was overwhelmingly positive feedback given by those using the second life virtual world program. all types of educational training formats resulted in increased knowledge about horizontal violence, comparing the pretest to the posttest, except the group using the virtual world training alone. the participants’ ability to respond to horizontal violence with a trained actor was not significantly different for any of the groups, including the control group. however, all the intervention groups showed improvement in self-efficacy and confidence, especially in their confidence in their ability to respond to incivility. dahlby and harrick (2014) studied the use of an educational program about lateral violence, or incivility, in the workplace and cognitive rehearsal of appropriate responses to lateral violence in improving nurses understanding of lateral violence and frequency of experiences with lateral violence in the workplace. the study involved 46 rns from two medical-surgical units in one healthcare organization in the united states. while there were positive increases in the nurses demonstrated understanding of lateral violence and its potential negative consequences in the workplace when comparing the pretest and posttest, the results were not statistically significant. there was qualitative data from a manager from one of the assessed units stating that she had seen nurses discussing how to respond to a situation involving lateral violence, based on the training they received. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 108 ceravolo et al. (2012) evaluated a program to improve communication in response to incivility, or lateral violence, and to improve the workplace culture in one healthcare system. over a three-year period, 4,032 practicing rns at a five-hospital, integrated healthcare organization in the northeastern united states participated in a 60-to-90-minute training workshop. findings indicated a decrease in verbal abuse at work from 90% (n = 633) to 76% (n = 369) following the interventions. the nurses reported an increased ability to problem-solve in the post-intervention survey. there was also a reduction in the vacancy and turnover rate for nurses. facilitated educational sessions with no experiential learning exercises clark, ahten, and macy (2013) studied the effects of educating senior nursing students about nursing incivility and using observed role play in the academic setting involving incivility in the nursing workplace. in this study, the researchers used problem-based learning, in which the participants were given preparatory readings about nursing incivility, and how to respond to it, prior to the training. the researchers lead the 65 student participants in a one-hour, interactive class discussion. the students then observed role play by actors, who were not students, acting out a scenario involving nursing incivility. after the training session, the senior nursing students had small-group debriefing sessions and provided written feedback about the perceived effectiveness of the training. the feedback from the students about the effectiveness of the training was generally positive, although some students were disturbed by the realistic nature of the scenario. clark et al. (2014) then completed a 10-month follow-up qualitative study with the students, who were now working in the practice setting as licensed rns. the 18 participating novice rns reported that the training they received in the classroom setting had prepared them to better recognize and respond to nursing incivility when it occurs. they also named several barriers to online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 109 truly responding to incivility effectively, such as being a new nurse and intimidation. in this study, the researchers did not have the participants actively practice responses to incivility. rather, they observed role play and discussed appropriate responses to the instigator. grenyer et al. (2004) also used an incivility educational training program containing facilitated training, but without experiential exercises. the researchers developed modules pertaining to aggression and violence minimization that were used to train workers in managing incivility in nursing. the healthcare workers received education about workplace incivility and used training exercises with the objective of communicating effectively in response to aggression. the training was divided into two eight-hour modules, one four-hour module, and one two-hour module. mean scores were significantly higher on the post-test (m = 4.03, sd =.59, t = 3.23, p = .00) when compared to the pre-test scores (m = 3.63, sd =.79) for the nurses perceived ability to management incivility. there were some complaints about the length of the training sessions. barrett et al. (2009) evaluated the role that a teambuilding and lateral violence training program had on improving group cohesion and job satisfaction in nurses. surveys were sent to rns in an inpatient surgical unit, a critical care unit, an emergency department, and an inpatient operating room at a rhode island magnet hospital two months prior to and three months after the training. the teambuilding and lateral violence prevention training involved two 2-hour team training sessions with facilitated learning in small groups. the median pre-score (540) was significantly lower than the postscore (612, p = .037). the median score (md = 540) for group cohesion had a statistically significant improvement after the intervention (md = 612, p= .037). there was also an improvement in the nurses reported job satisfaction. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 110 educational sessions only dimarino (2011) researched the use of an evidence-based intervention with the purpose of combating lateral violence in the workplace. a convenience sample of all employees at a maryland surgery center was used. the intervention involved three major steps, including the development of a workplace code of conduct that focused on caring, communication, and respect in the workplace. employees were required to sign a pledge that they would adhere to the code of conduct. another component of the intervention was that the managers in this facility were instructed to maintain an open-door policy in response to employee complaints of incivility in the workplace. they were required to counsel perpetrators of incivility and respond to interpersonal conflicts promptly. persistent incivility would result in the loss of employment. the policy involved all employees, including healthcare providers and managers. the final intervention involved the use of a training program that was developed to educate the staff about lateral violence in the workplace and its effects. the program transitioned into a mandatory yearly in-service for all employees. the researchers performed a follow-up assessment one year after training completion. they found that there had been zero staff turnover and no reported incidences of lateral violence in the period following training completion. the staff offered qualitative feedback about the positive impact the program had on the work environment. chipps and mcrury (2012) developed a pilot study to address workplace bullying in nursing. the purpose of the study was to examine the effect of an educational program on workplace bullying in nursing in a hospital setting. the intervention involved a three-month training program aimed at providing education about workplace bullying, establishing a learning community, allowing for personal reflection about their role in workplace civility, and assisting healthcare online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 111 workers in developing effective conflict management skills. a questionnaire was administered prior to the intervention and four months after completion of the educational sessions. participants also kept a logbook of any observed or personally experienced bullying behaviors in the workplace. the intervention resulted in a decrease in from 37.5% (n = 6) to 6.3% (n = 1) participants reporting personal experiences with bullying. unit managers also reported observing the nurses using conflict management skills more frequently after the training program was completed. however, the job satisfaction scores of the group were unchanged from preintervention to post-intervention. there was a non-significant increase in overall experiences with workplace bullying, including observed acts, following the training. the researchers attributed this increase in bullying behaviors to the small size of the sample for the pilot study. greater success at reducing bullying behaviors was discovered in studies that used facilitated educational sessions, along with experiential learning exercises. facilitated educational sessions with experiential learning exercises there are several studies that support the use of facilitated training sessions with experiential learning activities in improving nursing workplace incivility and related outcomes. griffin (2004) developed a program in which cognitive rehearsal, a form of mental practice, was used to train nurses to respond effectively to bullying through education and practice in using preset responses to bullying in a non-threatening setting. this is a seminal work in developing effective interventions to reduce incivility in the nursing workplace. twenty-six newly licensed nurses hired at a new england hospital were selected to participate in the study. they were taught about incivility in nursing and given cue cards with assertive responses to common forms of bullying behaviors in the nursing workplace. the novice nurses were then guided in cognitive online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 112 rehearsal to practice mentally responding to those behaviors using the hints on the cue card. one year after the training, post-intervention interviews revealed a 100% (n = 26) stoppage of bullying behaviors on the units in which the nurses worked. the novice nurses reported that either they experienced no bullying after training or that their use of assertive responses to bullying behaviors resulted in no repeated bullying experiences. oostrom and mierlo (2008) researched the use of an assertiveness training program with healthcare workers in the netherlands. the training program included three four-hour training sessions with each session offered two to three weeks apart. in part one of the training program, participants engaged in exercises related to assertiveness and communication training. part two involved exercises dealing with conflict management in the workplace, including the use of role play. the third part of the program allowed the participants to practice their newly-learned behaviors in a safe environment. this intervention resulted in the participants reporting that they gained insight in understanding aggressive and assertive behaviors and were better able to cope with an adverse work environment stagg, sheridan, jones, and speroni (2011) researched the use of a two-hour training session for 15 medical-surgical nurses at two rural community hospitals to improve nursing civility and communication. the training involved education about appropriate communication techniques in response to bullying behaviors and included time to actively rehearse those techniques in a safe, non-threatening environment. the nurses were given small cue cards that could attach to their work badges, as a reminder of the techniques they learned for application in future situations. the intervention resulted in increased understanding of workplace bullying and the ability to recognize effective responses to bullying behaviors. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 113 stagg, sheridan, jones, and speroni (2013) sent an electronic follow-up survey to the 15 participants in the pilot study of the previously discussed research by stagg et al. (2011). ten nurses responded to the survey. the follow-up survey was given six months after the two-hour cognitive rehearsal training session to test for exposure to bullying and ability to respond to bullying behaviors. seventy percent (n = 7) of the respondents stated that they felt able to respond to incivility after the training. however, of the six participants who had observed bullying behaviors since the training session, 83% (n = 5) stated that they did not respond to the observed bullying, primarily due to fear. nicotera, mahon, and wright (2014) developed a study with the purpose of measuring the effect of the transformation for nurses program on workplace communication and bullying behaviors in nurses. the training involved education about conflict, structural divergence, and conflict management techniques with an aim toward creating common ground during conflict. the term structural divergence refers to when cultural, social, and structural norms are viewed differently by different individuals, creating conflict. communication and conflict management techniques were practiced using experiential exercises in each of the small groups. the intervention resulted in reduced feelings of persecution and better relational effects in the intervention group. qualitative feedback from the participants was overwhelmingly positive from the experimental groups. substantial improvements in appropriate communication and reductions in destructive communication were reported in the experimental group. nikstaitis and simko (2014) piloted the use of a 60-minute training program using education about incivility in the workplace, case studies, and discussion of past experiences with incivility to reduce incivility in the workplace. twenty-one nurses participated in the study. there online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 114 was a slight increase in measured perceived incivility after the educational sessions. the researchers hypothesized that this likely occurred due to increased awareness of what actions by others are defined as incivility. leiter et al. (2011) completed a study to discoverg whether the crew (civility, respect, and empowerment in the workplace) program could improve civility and social relationships, and thereby improve worker burnout, turnover intentions, job commitment, absenteeism, trust in management, and job satisfaction. the sample included healthcare workers, including nurses, employed in acute care hospitals in nova scotia, canada. there were eight intervention units and 33 control units with 181 workers in the intervention group and 726 in the control group. the intervention was the crew training program, which was developed by the united states department of veterans affairs. the crew program involves facilitated, small-group training sessions with active learning exercises (united states department of veterans affairs, 2017). the foci of the program are to teach about workplace incivility and its effects, to train nurses how to respond to incivility when it occurs, and to improve group cohesion thorough teambuilding exercises aimed at improvements in respect and communication. the experiential learning exercises help the workers to practice new communication techniques and responses to bullying behaviors in a safe environment, so that they are better prepared to use those skills in a real situation in the workplace. following crew training, there was a significant decrease in feelings of burnout and job turnover intentions. job satisfaction and trust in management had a greater improvement in the intervention group were improved in the intervention group. absenteeism for the intervention group dropped by more than one-third, while the control group’s absence rate remained static. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 115 study findings indicated improvements in the intervention groups in all major areas studied, including workplace civility. laschinger, leiter, day, gilin-oore, and mackinnon (2012) implemented the previously mentioned crew program with rns working at five hospitals in nova scotia, canada, with eight intervention units and 33 control units. the intervention resulted in significant increases in trust in management and significant decreases in supervisor incivility. oore et al., (2010) evaluated 361 health care team members, in a subset of the laschinger et al. (2012) study. the surveys were used to evaluate the role incivility plays in the stressor-strain relationship. the crew training program was found to have improved the nurses’ physical and mental responsiveness to stressors in the workplace, especially related to workload strains. overall, the evidence demonstrates that the use of facilitated training about incivility and how to respond to it, with experiential learning activities, such as cognitive rehearsal, can help reduce workplace incivility and help nurses be better prepared to respond to workplace incivility when it occurs. there was a lack of consistency with the type of education provided. although most of the provided training focused on education about incivility and how to respond in an assertive manner, a variety of programs were used. also, there was a lack of consistency in the type of instrument and the outcomes measured in the studies. however, the literature consistently demonstrated that the combination of education about incivility, facilitated training sessions on how to respond to incivility effectively using assertive responses, and active practice in responding to bullying behaviors in the workplace produced positive outcomes in reducing workplace bullying, improving understanding of incivility, and increasing nurses’ confidence in responding to incivility effectively. the crew program contains the components of training that were found online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 116 to be effective in helping nurses better understand and respond to workplace incivility, as well as reducing unit incivility. agency description the hospital is a non-profit, public hospital. the hospital holds two medical-surgical floors. one of the medical-surgical units (ms-1) primarily focuses on surgical recovery, while the other unit is medically-focused (ms-2). the implementation involves an intervention with the evening shift nurses on ms-2 medical-surgical unit. the unit holds 28 patient beds and primarily admits elderly patients and young pediatric patients. routinely this unit has multiple admissions and discharges during the two primary 12-hour shifts. the target population for this project was evening shift nurses on ms-2. the evening shift on the unit had eight registered nurses (rns). at the time of the project, the unit also had several rns from a recently closed wound care floor routinely working on the evening shift. all the nurses on this shift and on this unit, were females and the majority were caucasian. usually four rns worked on the unit on a given night. they generally did not use unit clerks, but they occasionally had nursing assistants on this shift. travel nurses were not generally utilized on this shift, but asneeded workers were sometimes used. the unit was recommended to the project leader by the unit manager and was selected because they did not have major reported issues with incivility. the intervention was developed for work environments that are not experiencing extreme problems with incivility. even though there were no major incivility problems on ms-2, the nursing staff reported experiences with routine workplace tensions and conflict, such as occasional irritation at the behavior of coworkers. issues that put the nurses at risk for workplace incivility included nursing staff attrition and administrative changes. in recent months, some nurses left online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 117 their positions on this shift, and new nurses were employed to take their place. also, the primary charge nurse had recently accepted a new position. the recently appointed primary charge nurse was new to the fulltime leadership role. with the recent turnover, several novice or advanced beginner nurses were hired to work on the unit on the evening shift within the last year, often without the opportunity to work with more experienced nurses. there were also variety of age groups represented in the nurses working on the evening shift, from college-aged to middle-aged. this was a potential source of workplace conflict. the intervention was completed during the shift at a time when the nurses typically experienced downtime, to avoid overtime and to increase participation. project design model for improvement the model for improvement (mfi) by langley et al. (1996) was used to guide the proposed intervention. the model includes the fundamental questions: what are we trying to accomplish? how will we know that a change is an improvement? what change can we make that will result in an improvement (langley et al., 1996)? these questions are posed to allow for the setting of aims, establishing measures, selecting changes, and testing changes. the model emphasizes the importance of including the right team members in the plan. it also includes the plan-do-studyact (pdsa) cycle to guide each step in the process of developing and implementing a quality improvement project. the beginning step of using the mfi (langley et al., 1996) involves deciding on the goal, or aim, of the project. the primary goals of the quality improvement project were to increase the nurses’ ability to recognize workplace incivility, reduce unit incivility, and assist nurses in better online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 118 responding to workplace incivility in a medically-focused unit at a rural hospital in kentucky. the next step would be to establish measurement plans for the project. the measurement of the nurses’ ability to recognize workplace incivility, exposures to nursing incivility on the unit, and the nurses’ ability to respond to incivility were established using evidence-based instruments. the next step in the mfi is to select an evidence-based intervention for the project. in the case of nursing incivility, the literature reviewed supported the use of facilitated training sessions with education about incivility, teambuilding exercises, and experiential learning activities, as the most evidence-supported interventions in assisting nursing in managing incivility in the workplace. the mfi also encourages including the right people in the process improvement team to improve the chances of implementing a successful intervention. along with members of the capstone advisory committee, key personnel of the agency were identified to ensure that all stakeholders are involved in the process. in the action phase of the mfi (langley et al., 1996), the pdsa framework is used to guide each step of the implementation process. the beginning step in preparing for actual implementation of the quality improvement project proposal is planning. an agency review was completed to establish contact with the appropriate people involved in the implementation of the proposed incivility intervention. this included the hospital’s chief executive officer, the vice president of patient care services, the unit manager, and the quality improvement project faculty advisor. upon the advice of the unit manager, the timeframe for implementation was set at eight weeks in the fall of 2015 on the evening shift at the hospital. the second element of the framework cycle is the doing phase and involves completion of the planned interventions. this involved training sessions every week for four weeks with the online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 119 nurses on the evening shift on the medical-focused unit. the facilitated training sessions lasted 20-30 minutes and included teambuilding activities, education about incivility, and experiential activities to practice responding to incivility in a safe environment. the third step in the cycle is the study phase and involves studying the results of the quantitative data measurement. measurement instruments were used to measure the nurses’ ability to recognize workplace incivility, their self-assessed ability to respond to incivility, and an assessment of current incivility on their unit using the pretest-posttest method of measurement. the final step in the process is to act. the project leader takes the results of the project to determine what changes need to be made based on the results of the intervention in the pilot group. based on the results of the project, a recommendation can be made to stakeholders about whether to establish a program to perform this intervention throughout the facility. project methods description of evidence-based intervention the crew program was the intervention in this project. crew focuses on developing a culture of civility, respect, and engagement in the workplace (usdva, 2017). in crew, a trained facilitator meets with a small group of employees from one unit with a plan to direct teambuilding exercises, discuss improvement to the work environment, and encourage problem-solving. experiential learning exercises are included in the plan to develop communication skills and improve group cohesiveness. the crew plan is geared toward bi-weekly meetings for a sixmonth time period. however, the crew program allows for flexibility in its implementation, with the facilitator choosing which activities to include in the training program. the plan is individualized for each group, based on their needs and group dynamics. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 120 the timeframe for implementation on ms-2 was developed at the recommendation of the unit manager and primary charge nurse. while the number of training sessions was lessened to four, the crew format and crew concepts of civility education, facilitated learning, teambuilding, and experiential learning were used. the project leader received training to become a crew facilitator during summer 2014 prior to implementing the intervention. the training occurred at the minneapolis veterans affairs medical center, over two eight-hour days. the training included, education about the crew program, instruction and practice performing meeting facilitation, and training in using program interventions. the project leader conducted the meetings and exercises with the evening shift registered nurses on the ms-2 unit. this intervention was for four weeks, with one meeting per week. day one and day two of the intervention involved icebreaker-type activities. the day one session included the anything anytime tool. anything anytime involves providing a generic subject and discussing how it is viewed differently by different members of the group. the group then participates in a facilitated discussion about what surprised them, commonalities, and differences, followed by a debriefing session about how the activity relates to workplace civility. the day two session involved the tool geometry of work styles. geometry of work styles involves participants selecting from four geometric shapes that relate to a personality type. participants choose the shape that best fits their work style. the facilitator discusses the work styles that the shapes represent. the facilitator leads a discussion about how the work styles are different and similar, and how this relates to a civil workplace. the focus for each of these activities is recognizing that each person is unique and has different ways of viewing life, but they also have common interests, such as providing excellent online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 121 patient care. the goal is teambuilding. each facilitated discussion concludes with a discussion on how a civil workplace can be achieved, despite individual differences. day three included a facilitated discussion about the definition, characteristics of incivility and how to respond to incivility effectively. the group facilitator providing insights from nursing research, which included talking to the bully in private and respond in an assertive, objective manner to the situation. on day four, the group facilitator reminded the participants about effective responses to incivility, as discussed in the previous week's session. the participants practiced actively responding to incivility scenarios provided by the project leader in a safe, but interactive environment. each participant provided responses to the scenarios in the small group setting. procedures irb submission. because the rural hospital does not have an institutional review board, they granted permission for the proposed project based on the approval of the eastern kentucky university irb. eastern kentucky university irb approval was received prior to the project. exemption status was granted (institutional review board irb00002836, dhhs fwa00003332). measures and instruments. the level of exposure to workplace incivility on the nursing unit was measured using the workplace incivility scale (cortina et al., 2001). this instrument was used in three of the reviewed studies (leiter et al, 2011; laschinger, et al, 2012; oore, et al, 2010). this scale contains seven items related to the frequency of incidents of personally experienced incivility in the workplace, such as rude and exclusionary behaviors. the items are 6-point likert-style questions, with answers that range from 1 (never) to 6 (daily). higher scores indicate a greater frequency of experiences with workplace incivility. leiter et al. (2011) found online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 122 the internal reliability to be between .84 and .86. cortina et al. (2001) found strong reliability of the scale with a cronbach’s alpha coefficient of .89. they also found that the scale had positive convergent validity with another standardized scale for incivility. the original scale asked about incivility in the past five years. however, it has been modified previously to measure incivility in the previous month. the revised version was used in the quality improvement project. the participants’ ability to recognize incivility and confidence in their ability to respond to incivility was measured using the confidence scale developed by mallette et al. (2011). the confidence scale is domain specific to incivility. in the instrument, a 100-point scale is used to measure confidence in ability to respond to incivility, to recognize incivility when it occurs, and to modify the response to a situation related to incivility. the strength of efficacy is measured on a scale that uses 10-point increments, ranging from no confidence (0 points) to high certainty in the ability to respond (100). there is no psychometric analysis of this instrument available at this time. however, no other instrument was found for measuring self-efficacy related to nursing incivility with psychometric testing. implementation one month before the implementation of the intervention, the project leader met with the charge nurse of ms-2 to discuss the project, project objectives and implementation plan. the primary charge nurse assisted by acting as a change agent during the implementation process. the project leader remained in contact with the primary charge nurse during the preparation phase of the project, as well as during the implementation. the unit manager was the primary contact person during the preparation and implementation phases of the quality improvement project. the online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 123 unit manager assisted the project leader in contacting potential participant emails and accessing rn staff schedules. recruitment activities included a unit presentation, emails, and a flyer. the project leader met with the participants in three separate small groups prior to the beginning of the intervention for an informational session to briefly explain the project, the reasoning behind the training, and answer any questions potential participants had about the quality improvement project. an emphasis was placed on improving workplace communications, rather than reducing incivility, to reduce a perception of the unit being problematic. the members of the group were assured of confidentiality of any content discussed at the training sessions. they were also assured that all data collected during the implementation would be maintained without participant identifiers, and reported in the aggregate. an informational email, with a copy of the cover letter attached, was sent to the participants via email two weeks and one week prior to the intervention. during the informational sessions, a copy of the cover letter was provided to the participants and reviewed by the project leader. an informational flyer was posted in two areas of the unit, designated by the unit manager, one week prior to the intervention, as a reminder of the upcoming project. the pilot project was open to all registered nurses, with an active license, hired to work on the evening shift on ms-2. this included nurses from the closed wound care unit. the training sessions were completed on the evening shift during an unscheduled break period, due to the anticipated difficulty of getting the nurses to return to the facility on days that they are not scheduled to work. this break period did not replace the nurses’ normally scheduled work breaks. the project leader duplicated each training session multiple times each week, until all participants attended each training session. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 124 the participants completed a paper and pen questionnaire containing the ten questions from the workplace incivility scale and the confidence scale during the informational session. the questionnaire generally took three to five minutes to complete. the questionnaire was given a second time two weeks following the completion of the training program. there were a variety of timeframes for evaluating program effectiveness in the literature, from immediately following the training to six months after training was completed. the data collection timeframe did not appear to effect the study outcomes. two weeks was selected because it allowed for some distance from the training sessions. individual participant questionnaires were coded by the participant, using two close family member’s dates of birth, so that they could be paired for data entry. demographic data, including sex, age, race, and work experience were collected on a separate form during the informational sessions. the demographic information was collected in a separate envelope to avoid participant identifiers from being attached to the questionnaires. the participants were asked to sit at a distance far enough from each other to avoid being able to see other participants’ responses when completing the questionnaires and the demographic data. the data from the questionnaires and demographic form were entered into a spss (version 21) file developed and coded for the project. descriptive analysis, including mean and standard deviation, of the pretest and posttest questionnaires was performed. a paired two-tailed t-test was used to analyze the difference in mean scores for the items on the pretest and posttest. the level of significance was .05. the effect size was also calculated. data entry was performed by the project leader. the items from the two questionnaires used in the quality improvement project were analyzed separately. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 125 results demographic data were collected from each participant. nine participants completed the quality improvement project in its entirety. all the participants were female, ranging from 24 to 56 years of age, with a mean age of 38. eight of the nurses were caucasian. one participant was asian. the mean years of experience as a registered nurse was 3.65 years (sd = 6.18), with the majority of the nurses having three or less years of experience as an rn. the median years of experience working on this nursing unit was two years. workplace incivility scale a paired t-test was performed to compare the pretest and posttest means for each of the seven items from the workplace incivility scale. table 1 paired t-test comparison of workplace incivility scale means item means ± sd t df p how often does someone put you down or condescend to you? (n = 9) -.333 ± 1.12 -.894 8 .397 how often does someone pay little attention to your statement or opinion? (n = 9) -.333 ± 1.23 -.816 8 .438 how often does someone make mean or derogatory remarks to you? (n = 9) -.222 ± .44 -1.512 8 .169 how often does someone address you in unprofessional terms? (n = 9) .111 ± 1.05 .316 8 .760 how often does someone ignore or exclude you from professional camaraderie? (n = 9) -.111 ± 1.05 -.316 8 .760 how often does someone doubt your judgement? (n = 9) -.222 ± .83 -.800 8 .447 how often does someone make unwanted attempts to discuss personal matters? (n = 9) .000 ± 1.00 .000 8 1.000 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 126 there were no statistically significant differences in the mean scores for any of the seven items on the scale (table 1). none of the posttest items of the workplace incivility scale had statistically significant differences when compared with the pretest (table 2). table 2 workplace incivility scale pretest and posttest means item pretest means ± sd posttest means ± sd how often does someone put you down or condescend to you? (n = 9) 2.11 ± 1.27 2.44 ± 1.51 how often does someone pay little attention to your statement or opinion? (n = 9) 2.22 ± .97 2.56 ± .88 how often does someone make mean or derogatory remarks to you? (n = 9) 1.78 ± 1.30 2.00 ± 1.66 how often does someone address you in unprofessional terms? (n = 9) 1.78 ± 1.56 1.67 ± 1.00 how often does someone ignore or exclude you from professional camaraderie? (n = 9) 2.00 ± 1.23 2.11 ± 1.05 how often does someone doubt your judgement? (n = 9) 2.22 ± 1.20 2.44 ± 1.74 how often does someone make unwanted attempts to discuss personal matters? (n = 9) 1.89 ± 1.17 1.89 ± 1.36 confidence scale a paired t-test was performed to compare the pretest and posttest mean scores for each of the three items from the confidence scale (table 3). the analysis revealed a statistically significant increase in the posttest mean scores for each item on the instrument, when compared to the mean scores on the pretest. on the item related to the participants’ ability to recognize online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 127 incivility when it occurs, there was a statistically significant increase in the mean score on the posttest (m = 93.33, sd =8.66, t (8) = -2.871, p =.021), when compared to the pretest mean score (m = 78.89, sd = 17.64). effect size was calculated for this item, with the eta squared statistic (.51) indicating a large effect size. on the item related to the participants’ confidence in their ability to respond to situations involving incivility, there was a statistically significant improvement in the posttest mean score (m = 85.56, sd =20.07, t (8) = -4.667, p =.002), when compared to the pretest mean score (m = 62.22, sd = 18.56). the eta squared statistic (.95) for this item indicated a large effect size. on the item related to the participants’ confidence in their ability to modify their response to situations involving incivility, there was a statistically significant improvement in the posttest mean score (m = 86.67, sd = 19.37, t (8) = -4.40, p =.002), when compared to the pretest mean score (m = 62.22, sd = 22.79). the eta squared statistic (.95) for this item indicated a large effect size. table 3 paired t-test comparison of mean confidence scale scores item means ± sd t df p how certain are you that you can recognize horizontal violence? (n = 9) -14.444 ± 15.09 -2.871 8 .021 how certain are you that you can respond to a situation involving horizontal violence? (n = 9) -.23.333± 15.000 -4.667 8 .002 how certain are you that you can effectively modify your response to horizontal violence as the situation changes? (n = 9) -.24.444± .16.667 -4.400 8 .002 discussion in this project, a modified version of the crew program was used as an intervention to analyze the program’s effect on nursing workplace incivility on one medically-focused medical online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 128 surgical unit in a rural kentucky hospital. the program included facilitated educational discussions about workplace, teambuilding exercises, and experiential learning activities. the project resulted in no significant changes in the nurses’ experiences with incivility on their unit. in fact, in five out of seven of the items on the workplace incivility scale, there were slight increases the frequency of the nurses’ encounters with workplace incivility. however, this occurred in one of the studies that used a program like crew (nikstaitis & simko, 2014). the researchers in that study suggested that the participants’ increased understanding and recognition of workplace incivility may have been the cause of the small increase in the frequency of experienced incivility following the civility training program. this may have occurred in this project, as well. based on the confidence scale results, there was a statistically significant increase in the nurses’ self-reported ability to recognize incivility in the workplace. similarly, the weekly discussions of workplace incivility may have increased the nurses’ sensitivity in detecting workplace bullying behaviors. it was also revealed in the facilitated discussions on the unit that most of the nurses’ experiences with incivility did not occur with their fellow participants. their incivility experiences in their current workplace tended to occur with persons from other units or shifts. the most common complaint involved uncivil behaviors by registered nurses on the day shift, including gossiping or backbiting behaviors. since the project only involved a small group of the individuals in which they interact in the workplace, there was a decreased likelihood that the project would greatly change their workplace exposures to incivility. as well, the mean pretest scores on the workplace incivility scale items reflected low frequencies of exposures to incivility, with most of online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 129 the mean scores equated to “never” and “once or twice a year.” thus, there was not a great deal of room for improvement. following the intervention, there were statistically significant increases in the nurses’ selfassessed ability to effectively recognize, respond to, and modify their reactions to workplace incivility. this outcome was replicated in other studies that used similar programs (stagg et al., 2011; oostrom and mierlo, 2008). being able to actively practice responses to incivility in a safe setting, appeared to help increase the nurses’ confidence in their ability to respond to bullying behaviors effectively. although, qualitative data were not collected in this project, the project leader observed a general desire to discuss workplace incivility by the nurses involved in the training sessions. once the training sessions were completed, the nurses frequently continued to casually discuss their experiences with workplace incivility and the effect that those experiences had on their nursing careers. the participants appeared to be fully engaged in the training process and eager to discuss workplace incivility in the small group setting. there were several limitations to this project. there was a small number of participants, with nine participants completing the project. this limits the project leader’s ability to extrapolate the results in evaluating the potential use of the program facility-wide. the conditions of the implementation were less than ideal. the project leader met with the participants during down times of their work shift. so, the full group of participants were never present at the same time. as well, there were occasional distractions and disruptions during the training sessions, as patient and worker needs were always prioritized over the training sessions. these limitations may have reduced the effectiveness of training sessions that aimed at improving group communication and teambuilding within the entire group. another limitation of the training program is that it was online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 130 shortened from the original crew program. while there is flexibility in the implementation and content of the crew program, it preferred that the training sessions occur every other week over a six-month period. this project only evaluated the effectiveness of the shortened program format. another limitation of this study was the project leader’s decision to only include registered nurses in the project. it would have been preferable to include all unit workers, not just registered nurses. however, time and logistical constraints made it difficult to include part-time and as-needed staff. implications the use of civility training sessions that include teambuilding exercises, facilitated discussions that focus on better understanding workplace incivility, and experiential learning exercises may have helped nurses on the ms-2 unit increase their confidence in their ability to recognize and respond to workplace incivility effectively. these outcomes were consistent throughout the literature reviewed, specific to the use of the crew program. this type of program may be helpful to nurses throughout the facility and on all shifts. to truly improve workplace incivility, it would be helpful to include workers throughout the facility in the training. it might also be helpful to include the program in the orientation plan for nurses newly hired to work at the facility, as new or inexperienced nurses might be more vulnerable to workplace incivility, due to their inexperience. implementing the modified version of the program on a yearly basis for all nurses could be useful, to maintain program results. if the program were implemented throughout the facility, it would be recommended that the training sessions be completed away from the nursing unit or department, so that there are fewer distractions and more department members could participate at the same time. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 131 long-term evaluation of this project could be completed to include administration of the workplace incivility scale and confidence scale after additional time has elapsed following the initial training of the participants. evaluating patient outcomes, such as medication errors and patient satisfaction, could also be helpful in the future. further study is needed to support the use of crew in combating workplace incivility in rural nursing settings. addision and luparell (2014) surveyed 55 rural nurses in montana about workplace disruptions caused by other healthcare workers. eighteen percent of those surveyed reported that they had observed nursing colleagues demonstrating disruptive behaviors daily. the researchers concluded that the familiarity between coworkers that occurs at rural hospitals might increase incivility, due to a reduced perception of the need to maintain personal courtesy in workplace relationships. the available research, along with this quality improvement project, indicates the need to provide routine educational programs that train employees in how to recognize and manage incivility in all healthcare settings, particular so in rural healthcare settings. summary/conclusion nursing workplace incivility has the potential to cause detrimental effects to the quality of care provided by nurses. workplace incivility may also cause emotional and physical distress to those exposed to it on a routine basis. some research suggests that rural healthcare environments may be more prone to workplace incivility than urban ones (addision & luparell, 2014). the effects of workplace incivility, such as nursing turnover, may be more difficult for rural facilities to overcome, due to potentially reduced opportunities to recruit quality nurses (bragg & bonner, 2014). therefore, it is essential that rural healthcare facilities address workplace incivility. a modified version of the crew program was used in this quality improvement project to help online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.438 132 nurses on one medical-surgical unit in a rural kentucky hospital learn about workplace incivility. the modified crew program included teambuilding exercises, facilitated discussions about workplace incivility, and experiential learning activities. this included practicing responding to workplace bullying scenarios in a safe environment. there were no significant differences in the frequency of the nurses’ exposure to workplace incivility following their participation in the program. however, there were statistically significant improvements in the nurses’ self-assessed ability to recognize, respond to, and modify their responses to workplace incivility, following the crew program intervention. the results suggest that this type of program may be suitable for use in other rural settings to address nursing workplace incivility. supporting agency murray state university references addision, k. & luparell, s. 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(2014). bullying among nursing staff: relationship with psychological/behavioral responses of nurses and medical. health care management review, 0, 1-9. https://doi.org/10.1097/hmr.0000-0000.2014.00015.x microsoft word pribulick_261-1274-1-ed.docx online journal of rural nursing and health care, 13(1) c-reactive protein (hscrp), diet, and physical activity (pa) in rural women margaret pribulick, rn, phd 1 pamela stewart fahs, rn, dsn 2 gale spencer, rn, phd 3 theresa n. grabro, rn, fnp-bc, crnp, phd 4 steve wiitala, phd 5 1 assistant professor, school of nursing, norwich university, mpribuli@norwich.edu 2 professor and decker endowed chair in rural nursing, decker school of nursing (dson), binghamton university, psfahs@binghamton.edu 3 distinguished teaching professor and decker endowed chair in community health nursing, decker school of nursing (dson), binghamton university, gspencer@binghamton.edu 4 associate professor, emeritus, decker school of nursing (dson), binghamton university, tgrabo@binghamton.edu 5 professor emeritus, university of phoenix and norwich university, profwiitala@gmail.com abstract purpose: the purpose of this study was to evaluate the effect of dietary fruit and vegetable intake and physical activity (pa) levels on inflammatory marker high sensitivity c-reactive protein (hscrp) among rural women 35-65 years of age. sample: rural, non-smoking women (n = 99) in two states. online journal of rural nursing and health care, 13(1) method: cohort analysis from a primary study with randomized-controlled trial (rct). results: the dependent variable was calculated as: (a) the log-transformed (log) hscrp difference, post minus pre values and (b) post log hscrp. there was no difference between the intervention groups on log difference hscrp (t (97) = -.88, p = .38); however, those women in the experimental group had half the level of log hscrp. there was a significant difference in log hscrp differenceby activity level (f (2, 90) = 3.67, p = .03) indicating higher activity reduced hscrp. those women with a moderate activity level in the experimental group had the lowest hscrp levels. the log hscrp difference was not significantly different when evaluated for those who increased or did not increase their fruit and vegetable intake (p = .35). when analyzed by body mass level there was a significant difference in log hscrp difference (f = 2.96, 7, 47, p = .001). a multiple regression with three variables accounted for 12% of the variance in log hscrp. conclusion: cardiovascular health of rural women is an area of great concern but limited research. the results of this study indicate increased levels of pa and fruit and vegetable intake by rural women are associated with decreased levels of hscrp and thus with improved cardiovascular health. this study can contribute to the body of knowledge concerning the role of diet and physical activity on cardiovascular health in rural female populations. keywords: rural, c-reactive protein, diet, physical activity, female cardiovascular disease, cvd online journal of rural nursing and health care, 13(1) c-reactive protein (hscrp), diet, and physical activity (pa) in rural women health in rural areas is supported by a collaborative effort from public and private entities, community members, and healthcare providers. nursing has multiple roles in the community, particularly in rural areas. nurse researchers use information from community health assessments, the literature, and practice to develop questions and studies that will eventually guide nursing interventions to strengthen the health of the community. data is becoming increasingly important in the development of evidence-based practice and nurses are in a unique position to use data to help guide health care interventions. in rural communities nurses can influence health care delivery, policy, and environmental issues in multiple arenas such as clinics, hospitals, schools, and public health. the rural environment is challenging in the provision of both prevention and intervention in cardiovascular disease. one author (graves, 2009) suggests that there is a need to meld community, innovation, evidence-based practice and technology in framing cardiovascular health in rural populations. the aim of this study was to further the evidence of the effects of dietary fruit and vegetable intake and pa levels on hscrp particular to a target population of rural midlife women. in addition an analysis of the factors that predicted a portion of the variance of hscrp was conducted. transtheoretical (velicer, rossie, prochaska, & diclemente, 1996) and moos socio-ecologic models (moos, 1979) were used to develop interventions for the parent study described in the methods section. this report contributes to the body of knowledge concerning the role of diet and physical activity on measures of hscrp in a rural female population. online journal of rural nursing and health care, 13(1) c-reactive protein (hscrp) research is being conducted on the benefits and importance of a healthy diet and physical activity (pa). health care researchers have shown that a healthy lifestyle reduces risk of chronic diseases. c-reactive protein (crp) is a biomarker of inflammation (ridker & rifai, 2006); and an independent predictor of vascular and chronic diseases (bilhorn, luo, lee, & wong, 2012); this measure contributes to an individual’s burden of heart disease. awareness can be a strong motivator for women to make change. much like knowing your numbers around cholesterol and blood pressure, crp may add another link to cardiovascular disease (cvd) burden reduction. c-reactive protein and specifically hscrp measure the same molecule in the blood as mg/l to different degrees of sensitivity (ridker & rifai, 2006). levels of less than one equate to a low vascular risk, one to three is moderate, and greater than three is high. previously there was a belief that a persistent crp value greater than 10 mg/l, related to systemic inflammation from other origins, was not pertinent to cvd. evidence now suggests otherwise, according to ridker and rifai (2006) those with values greater than 10 mg/l are at a very high vascular risk even if the point of origin is not cardiac. risk factors of heart disease such as age, smoking, diabetes, high blood pressure and dyslipidemia are widely known. these factors are part of the framingham coronary heart disease risk assessment (framingham) (wilson et al., 1998). the framingham calculates risk of chd within a 10-year period for those without known heart disease; but does not predict other cvd risks (wilson et al., 1998). other factors that may influence cvd risk that are not included in risk calculations are obesity, inactivity, and dietary intake. another tool currently used in the medical field is the reynolds risk score (cook et al., 2012). this measurement includes hscrp as a factor along with family history of premature myocardial infarction. hemoglobin a1c online journal of rural nursing and health care, 13(1) (ha1c) is included as a factor in the reynolds measure for diabetics only. cook et al. (2012), compared reynolds risk score to the framingham based model. the reynolds score, which included hscrp measures, was shown to be a better discriminator for predicting cvd risk in a sample of 1,722 cases (cook et al., 2012). american heart association (aha) guidelines (mosca et al., 2011) currently recommend hscrp assessment only in women at a moderate or high level of risk of cvd. high risk chd is now defined as ≥10 points on the framingham instrument. during the time of data collection for this study, moderate risk was defined as < 20 points and high as ≥20 on the framingham. the 2011 guidelines (mosca et al., 2011. p. 1247) assert that a framingham score of ≥ 10 points in women indicates high risk for all cvd, not just chd. studies have not yet provided evidence of linkage between reduced hscrp and clinical outcomes (mosca et al., 2011). through an exhaustive literature search, several studies were noted to have looked at the relationship of hscrp to diet and pa among various populations but this is the first to investigate the relationship in rural women. along with current guidelines of cholesterol and lipid panels, hscrp provides a more specific measure of cvd risks. cardiovascular disease was estimated to cause about 1 death per minute in us women in 2007 (mosca et al., 2011. p. 1244). the rate of coronary heart disease (chd) mortality among women 35 – 54 years of age is increasing, possibly due to an increase in obesity (mosca et al., 2011). there is a lack of literature specific to cvd and chd in rural women. many of the studies of cvd risk that are available are from single rural locations or regions and are not female specific (fahs et al., 2012). in this study, cvd was assessed to be a major risk of women living in two rural counties, one in ny and the other in va. the largest town in the ny county was coded as ten, an isolated small rural area, on the rural-urban commuting area (ruca) online journal of rural nursing and health care, 13(1) scale which ranges from one to ten (atav & darling, 2012). the largest town in the va county had a ruca of seven. both counties had a rural urban continuum code (rucc) of six where the range is one to nine and the higher the code the more rural the county (u.s. department of agriculture & economic research service, n.d.-a, n.d.-b) . both ruca and rucc are measurement systems used to identify rural areas (u.s. department of agriculture & economic research service, n.d.-a, n.d.-b) background physical activity (pa) and c-reactive protein (hscrp) physical inactivity is a major risk factor leading to heart disease (snell & mitchell, 1999). a literature review found studies relating pa and hscrp (akbartabartoori, lean, & hankey, 2008; albert, glynn, & ridker, 2004; aronson et al., 2004; boekholdt et al., 2006; borodulin, laatikainen, salomaa, & jousilahti, 2006; church et al., 2002; colbert et al., 2004; davis et al., 2008; dvorakova-lorenzova et al., 2006; ford, 2002; geffken et al., 2001; huffman et al., 2006; jae et al., 2007; lamonte, ainsworth, & durstine, 2005; mcfarlin et al., 2006; milani, lavie, & mehra, 2004; mora, cook, buring, ridker, & lee, 2007; murphy, murtagh, boreham, hare, & nevill, 2006; okita et al., 2004; olson, dengel, leon, & schmitz, 2007; panton et al., 2007; pitsavos, panagiotakos, chrysohoou, kavouras, & stefanadis, 2005; stamatakis, hillsdon, & primatesta, 2007; stewart et al., 2007; vigorito et al., 2007; woolf et al., 2008). four studies (davis et al., 2008; huffman et al., 2006; murphy et al., 2006; panton et al., 2007) report that pa did not reduce hscrp. a short term, low level intervention (davis et al., 2008) was less likely to reduce hscrp than studies with exercise interventions of longer than 6 weeks (okita et al., 2004; stewart et al., 2007; vigorito et al., 2007). more research is necessary to be able to predict hscrp response to variations in pa. online journal of rural nursing and health care, 13(1) diet and c-reactive protein (hscrp) fruits and vegetables are excellent sources of antioxidants, vitamins, and fiber. dietary recommendations for adults are between 2 4 servings of fruit and 3 5 servings of vegetables per day. specific fruit intake and hscrp were reviewed. strawberries consumption has been found to decrease hscrp (sesso, gaziano, jenkins, & buring, 2007), but not at a statistically significant level (p = 0.35). in a study of cherry consumption, after 28 days, hscrp had decreased by 25%, (p < 0.05) (kelley, rasooly, jacob, kader, & mackey, 2006). the relationship between fruit and vegetable consumption and hscrp was examined (gao, bermudez, & tucker, 2004) and the results showed that hscrp had a significant inverse relationship with fruits and vegetables independent of other effects, (p trend 0.010) a more complete review of the literature regarding specific dietary elements and crp is available (pribulick, 2009). the purpose of the current study was to evaluate the effect of dietary fruit and vegetable intake and pa levels on hscrp among rural women ages 35-65 years of age. in addition, factors such as stage of change (soc), framingham coronary heart risk score (framingham), bmi, and county were analyzed to account for the amount of variance of hscrp methodology design this study was conducted as an analysis of a cohort of non-smokers from the primary study (fahs et al., 2012) promoting heart health in rural women (phh), funded by a grant through the national institute of health (nih) as a r15 study 1r15nr009218-01a. the primary study was an experimental, design with convenience sampling and random assignment to group that has been described in detail elsewhere and summarized below (fahs et al., 2012; pribulick, online journal of rural nursing and health care, 13(1) willams, & fahs, 2010). two rural communities, one in upstate ny and another in va, were chosen as sites based on previous studies completed in those states. human subject protocol approval was granted for the parent study from two universities and the protocol for this cohort analysis was also approved. the phh study lasted 14 months for each subject. it included demographic, stage of change (soc), dietary intake, physical activity, chd risk assessment and anthropometric data. a convenience sample was randomized to group: a) staged matched nurse and community intervention (smn+ci) or b) community intervention (ci) only. the theoretical framework included the transtheoretical and moos socio-ecological models and interventions are described in detail elsewhere (fahs et al., 2012). of the 117 rural women completing the phh study, a cohort of non-smoking women was created for the purposes of this study (pribulick, 2009). the initial cohort in this study included 99 non-smoking rural women between the ages of 35 and 65 years of age. the upstate ny sample was larger consisting of 72 women (99% caucasian); whereas the virginia participants numbered 27 including 7 african american and 2 hispanic women. participants in the phh study who self-reported smoking or had cotinine levels indicating active smoking were excluded since research has shown that smoking in and of itself may lead to secondary increases in crp levels (ridker & rifai, 2006, p. 4). six participants had fasting labs and anthropometric measures at completion but did not submit the final questionnaire. therefore, up to 93 subjects could be used in the analysis specific to dietary intake and pa. some measures such as the yale physical activity survey (ypas) required coding of “do not know” as missing data, thus reducing the potential sample for those measures of activity. online journal of rural nursing and health care, 13(1) the mean age in this sample was 51.57 with a standard deviation (sd) of 7.89; smn+ci mean age = 52.69 (7.65) and ci = 50.46 (8.04) years. the stage matched nurse intervention group (smn+ci) for this study had a sample of 49 women with n = 50 for the ci. there were no statistically significant difference between groups, smn+ci and ci on age. the mean body mass index (bmi) for the smn+ci group was 30.90 kg/m 2 , sd = 5.60 kg/m2, and for the ci group, 30.52 kg/m 2 , sd = 7.25 kg/m2. there was no statistically significant difference on bmi pre intervention by group instruments for the purposes of this study, the following instruments were used: (a) university of rhode island stages of change instruments for 5-a-day and physical activity, (b) nih/nci fruit and vegetable by meal screener, (c) yale physical activity survey (ypas), (d) hscrp, (e) anthropometric measure of bmi and (f) framingham coronary heart risk score (framingham). instruments to measure stage of change (soc) have been developed for use in studies that utilize the transtheoretical model. these tools ask about the current engagement in the behavior and how long the individual has been engaged in the behavior as well as intent and anticipated timeframe for future behavior (velicer et al., 1996). instruments for soc for dietary intake of fruits and vegetables, exercise, smoking, and weight loss are available online at http://www.uri.edu/research/cprc/measures.htm (cancer prevention research center [cprc], n.d.). the nih/nci fruit and vegetable by meal screener was first developed in the early 1990’s to track fruit and vegetable changes among specific populations (national cancer institute, 2008). the tool assesses portion size and frequency of fruit and vegetable intake over a 24-hour period. thompson and colleagues assessed fruit and vegetable tools to find a moderate validity among three instruments: (a) food frequency questionnaire, (b) by-meal online journal of rural nursing and health care, 13(1) screener, and (c) all-day screener (thompson et al., 2002). the nih/nci by-meal screener measures fruit and vegetable intake in this study. a self-report tool that was originally developed to measure physical activity among older populations, the ypas, has been used and compared in many studies. the ypas and the international physical activity questionnaire were compared for reliability and validity (kolbe alexander, lambert, harkins, & ekelund, 2006). reliability for ypas ranged from r = .44 to .80 for men and r = .59 to .99 for women. the results were comparable for reliability and criterion validity. there are several tools available to measure activity. however, the ypas was chosen because the design focus was on a group of women that included older adults and the ypas included questions on activities that many rural women participate in such as gardening. this instrument has also been used in samples that include african american women (young, jee, & appel, 2001). the instrument has not been previously tested specifically in a rural sample. the three subscales of the ypas are: (a) total time summary index (ttsi) which measures self reported activity in hours per week, (b) energy expenditure summary index (eesi) is reported as kilocalories for the week, and (c) activity dimensions summary score (adss) which includes weekly amounts of time spent in vigorous and leisurely walking, moving about, standing, and sitting. the framingham is an algorithm for calculating coronary heart disease risk in the next 10 years. a score of over 20 points indicates high risk of having a heart attack in the next 10 years (wilson et al., 1998). the measure used in this study was specifically designed for women and incorporates measures such as blood pressure, cholesterol, and smoking status. the framingham score sheet for women and other versions for this tool can be viewed at the framingham online journal of rural nursing and health care, 13(1) webpage (the national heart lung and blood institute [nhlbi] & boston university, n.d.). women in this study had framingham scores of 20 points or less. the anthropometric measure for this study was bmi. weights were taken on the same commercial scale placed on a hard surface for each participant; height was measured against a rigid scale, calibrated in inches fixed to the wall. cut points for bmi were classified into (a) normal, bmi of less than 25 kg/m 2 , (b) overweight 25 ≤ 30 kg/m2, and (c) obese > 30 kg/m2 (association of women's health obstetric and neonatal nurses., 2003). plasma indicator c-reactive protein (hscrp) was measured once for each woman at the beginning and end of their 14-month participation. all fasting blood samples obtained were processed through a local hospital with hscrp sent to quest diagnostic laboratory for analysis. one milliliter of serum was required (personal communication united health services and quest diagnostics, 2008). c-reactive protein was measured in milligrams per liter. in any given sample population hscrp levels can have a large variance. one way to correct for positively skewed data is to log transform the values (field, 2005). log transformation reduces positively skewed data by condensing the right tail of the distribution (field, 2005, p. 80). for this reason the study utilizes a log transformation to report hscrp. for the purposes of study hscrp was reported in two ways: (a) the hscrp value was log-transformed and (b) a log hscrp difference was calculated by subtracting the post-intervention log transformed hscrp from the pre-intervention value. the difference in log is measuring the ratio of the reported values and not the difference. dependent variables for hscrp in this study are either log transformed or log hscrp difference. the hscrp pre-intervention in this sample ranged from a minimum of .20 mg/l to a maximum of 36.70 mg/l, sd = 5.43 mg/l. after log transformation, the range was -1.61 to 3.60 with a mean of .58, online journal of rural nursing and health care, 13(1) sd = 1.21. original hscrp units reported as mg/l become log (mg) – log (l) after transformation; for ease of reading in this report transformed hscrp continue to be noted as mg/l. results stage of change for both pa and diet was categorized into two groups: (a) preparation or lower and (b) action or higher since cells using the original five categories had too few subjects (see figure 1). precontemplation contemplation preparation or lower preparation action maintenance action or high figure 1: stage of change (soc) categorized into two groups the mann-whitney u test (green & salkind, 2004), to evaluate differences in the medians of populations, for pa was not statistically significant, z = -1.55, p = .12. those subjects making no change or who had lower soc scores in the area of pa had an average rank of log hscrp of 52.12 among the 93 subjects, while those making a positive change had an average rank of 43.31. in this sample, a positive change in pa stage correlates with lower crp. a mann-whitney u test was also conducted on log hscrp and dietary soc. the test results were not significant, z = -1.21, p = .23. those subjects making no change or who had lower soc dietary scores had an average rank of hscrp of 50.37, while those making a positive change had an average rank of 43.59. as with pa, positive change in dietary soc correlates with a lower hscrp and thus overall lower cardiovascular risk factors. online journal of rural nursing and health care, 13(1) intervention in diet and physical activity (pa) and hscrp an independent-samples t-test was conducted to evaluate whether behavioral lifestyle intervention related to diet and pa would reduce hscrp measurements in rural women. the t test compared group of smn+ci and ci on the log hscrp difference, at an interval level of measurement. a t-test on the difference was conducted, and was not significant, t (97) = -.88, p = .38. the mean log hscrp difference of the smn+ci group was -.05 mg/l, sd = .84 and .11 mg/l, sd = .94 for the ci group. the smn+ci group has a healthier hscrp level, half that of the ci group demonstrating that though there was not a statistical difference, hscrp change was in the direction predicted. physical activity (pa) levels yale physical activity scale and hscrp. for the relationship between levels of pa and hscrp for the entire sample, correlation coefficients were computed among the three ypas subscales: ttsi, eesi, and adss. there was a weak negative significant relationship between the adss and the log hscrp difference, r (80) = -.24, p = .04. to further understand this relationship, a frequency was run on adss to find the cut points for three groups which were labeled: (a) low, (b) moderate; and (c) high levels of activity. a one-way analysis of variance (anova) was conducted to evaluate the effect of levels of pa, as described above, on the log hscrp difference. the anova was significant, f (2, 90) = 3.67, p = .03. follow-up dunnett’s t3 tests were conducted to evaluate pairwise differences among the means, since the population variances among the three groups were unequal; sd ranged from .61 (± .37) to .93 (± .87). there was a significant difference in the means between the moderate level of activity and the high level of activity, mean difference (md) .52, p = .04. this indicates that an increase in pa reduced hscrp measures in rural women. correlations were also run on the adss ratio, calculated as post-intervention score online journal of rural nursing and health care, 13(1) minus pre-intervention score, providing the log hscrp difference. there was a weak, inverse, statistically significant correlation between the variables, r (80) = -.24, p =.04. physical activity levels increased hscrp decreased, as desired. to further ascertain the effects of increasing pa on hscrp, each of the subscales from the ypas were recoded into new variables showing the change between pre and post-intervention activity. each ypas subscale was recoded into two groups: (a) those with an increase for the subscale versus (b) no change or a decrease. an independent-sample t-test was conducted with log transformed hscrp post-intervention. in each of the three ypas subscales, the group with increased pa had lower, more positive hscrp means, implying a trend of reduced risk of heart disease; however, none of the tests reached significance (see table 1). table 1: t-test in comparing increased physical activity (pa) by yale subscales log post hscrp t-test no change or lower pa mean (sd) n increase pa mean (sd) n ttsi t = .915, df = 91, p = .36 .71 (1.01) 43 .49 (1.28) 50 eesi t = .483, df = 91, p = .63 .66 (1.18) 40 .54 (1.16) 53 adss t=.311, df=91, p = .76 .64 (1.28) 36 .57 (1.09) 57 eesi = energy expenditure summary index in kcal per week, ttsi = total time, adss = total daily activity duration score online journal of rural nursing and health care, 13(1) table 2 shows descriptive statistics for low, moderate and high activity levels on the activity dimension measure of adss, ypas subscale for both the intervention (smn+ci) and control (ci) group. group differences in moderate activity level on mean log hscrp in the smn+ci and ci groups were large and can also be seen in figure 2. table 2: activity dimensions summary score levels for group and mean log hscrp activity level group mean sd n low smn+ci 1.38 .98 16 ci .72 1.25 16 total 1.05 1.15 32 moderate smn+ci -.25 .91 11 ci 1.23 1.02 6 total .29 1.19 17 high smn+ci .20 .81 21 ci .55 1.27 23 total .38 1.08 44 total smn+ci .49 1.10 48 ci .71 1.23 45 total .60 1.18 93 smn+ci = stage matched nursing and community intervention; ci = community intervention online journal of rural nursing and health care, 13(1) in addition, a factorial anova was computed with the categories of low, moderate or high activity and intervention group; smn+ci or ci. activity dimension summary score was chosen for one independent variable because this subscale best represents pa overall. log transformed hscrp post data were used as the dependent variable. the anova was significant, f (2, 87) = 3.8, p = .03. the lowest estimated marginal means post log hscrp were seen in the smn+ci group with the moderate activity level (see figure 2). figure 2: group activity dimension summary scores with post hscrp online journal of rural nursing and health care, 13(1) figure 2 shows a large dip in post hscrp means for the smn+ci group who were categorized as having a moderate level of activity as measured on the sum of indices on the activity dimension summary score (adss) of the yale physical activity scale (ypas). intake of fruits and vegetables and hscrp. mean intake of fruit and vegetable servings increased in the smn+ci and ci group; with the largest mean intake in the smn+ci group post-intervention (see table 3). table 3: fruit and vegetable servings, pre and post-intervention by group group fruit & vegetable intake pre-intervention (n) mean sd fruit & vegetable intake post-intervention (n) mean sd smn+ci 49 7.90 3.01 48 10.04 3.44 ci 50 8.60 3.43 45 8.95 3.30 smn+ci = stage matched nursing and community intervention, ci = community intervention correlation coefficients were computed with dietary intake of fruits and vegetables pre and post-intervention. there was a weak, negative significant relationship between dietary intake of fruits and vegetables post-intervention and log hscrp difference (r (93) = -.21, p = .05). there was a significant difference in the soc for diet reported in the parent study (fahs et al., 2012) therefore it was not surprising to find this inverse relationship. as dietary intake of fruits and vegetables increase, the log hscrp difference decreases by a proportionate amount. to answer the question “what is the effect of an increase in fruits and/or vegetable intake on hscrp?” a new variable was computed representing the difference of fruits and vegetables pre-intervention from fruits and vegetables post-intervention. this new variable was then online journal of rural nursing and health care, 13(1) recoded into two groups: (a) those that increased their diet in fruits and vegetables and (b) those that had not changed or decreased their diet in fruits and vegetable. those that increased fruit and vegetable servings (n = 71) had a mean increase of 2.39 portion servings (sd = 2.23), while those in the second group (n = 22), had a mean decrease of 1.77 servings (sd = 1.28). the mean log post hscrp for those that increased their fruit and vegetable consumption was .44 mg/dl compared to those that had no increase in fruit and vegetables at 1.09. the t-test reported was for equal variances assumed and was significant, (t = 2.33, df = 91, p = .02). next an independent sample t-test was conducted using the log hscrp difference, and the new variable of increase or no change in servings of fruits and vegetables (t = .95, df= 91, p = .35). in this configuration, there was no significant difference between those that increased or decreased their intake of fruits and vegetables. bmi and hscrp. three correlation coefficients were examined to assess the relationship between bmi and hscrp (see table 4). each relationship between bmi and hscrp was statistically significant. consistent with the literature as bmi goes up, hscrp correspondingly rises. table 4: correlation of bmi and c-reactive protein (hscrp) and log transformed hscrp n = 99 pearson correlation r sig. (2 tailed) p pre hscrp and bmi .31 .002 post hscrp and bmi .21 .03 log hscrp post and bmi post intervention .43 .00 online journal of rural nursing and health care, 13(1) body mass index post-intervention was then classified into three groups: (a) normal, (b) overweight, and (c) obese. an anova was conducted to evaluate the relationship between bmi and log hscrp post-intervention. the anova was significant, f (2, 96) = 7.47, p = .001. the strength of relationship between bmi and hscrp, as assessed by the partial eta squared, was moderate, with bmi accounting for 14% of the variance of hscrp. follow-up tests to evaluate pairwise differences among the means of the three groups were then conducted. given that the variances among the groups ranged from .96 to 1.68 homogeneity was not assumed and the dunnett’s t3 test was chosen. there was a significant difference in the means between the overweight group and the obese group. the obese group had a significantly higher hscrp level. a higher bmi is associated with a higher hscrp level. all factors and hscrp. a multiple backward regression analysis was conducted to evaluate how well the following variables measured post-intervention predicted log hscrp difference: (a) age, (b) sum of fruit and vegetables (c) adss (d) ttsi (e) soc for physical activity (f) soc diet (g) bmi (h) framingham, (i) county and (j) group. both the adss and ttsi are subscales of activity as measured on the ypas. a backward regression placed all variables in the model. each variable was measured against a removal criterion which determined whether the variable added significance; if no significance was added, the predictor was removed. this test was repeated until only the variables that give significance to predicting the dependent variable were in the model (field, 2005). three variables remained in the model; sum of fruits and vegetables, adss, and the framingham. the anova revealed the overall model was significant (r = .35) (f (3, 88) = 4.03, p = .01). this finding represents a linear relationship; the three independent variables significantly predicted the dependent variable, log hscrp difference. the model summary online journal of rural nursing and health care, 13(1) showed r2 = .12, adjusted r2 = .09. the r value looks at the correlation between the predicted and observed values of the dependent variable hscrp. the r 2 explains that 12% of the variance in hscrp is predicted by the three independent variables. table 5 reports the regression model coefficients. table 5: regression model coefficients for three predictor variables on hscrp difference variables mean (sd) beta unstandardized (standardized) t p zero order partial tolerance sum f & v 9.52 (3.42) -.54 (-.21) -2.07 .04 -.21 -.22 .99 adss 46.86 (21.84) -.01 (-.23) -2.21 .03 -.20 -.23 .95 framingham 4.16 (3.58) -.05 (-.22) -2.08 .04 -.15 -.22 .95 sum f & v = number of portion servings for fruits and vegetables per day, adss = total daily activity duration score the role of the inflammatory marker hscrp is likely to become more prominent in the diagnosis and treatment of cardiovascular disease as research findings begin to guide practice. several studies have examined the influence of multiple variables on hscrp levels; however, none have specifically looked at hscrp in rural us women up to this point. recommendations for primary prevention measures with regards to heart disease in low to moderate risk patients include lifestyle changes such as improving diet and physical activity. the findings of this study online journal of rural nursing and health care, 13(1) add to the body of knowledge concerning the influence of behavioral modifications, higher levels of intake of fruits and vegetables, and increased pa and how these factors can influence hscrp. power calculations for parent and cohort study with a completion of 117 subjects the power for ascertaining differences in fruit and vegetable intake in the parent study, phh was .79, alpha = .05. prior to completion of the parent study, the effect size for differences in hscrp between groups with a nurse run intervention was unknown (fahs et al., 2012). a calculation of the mean differences for log hscrp between intervention groups indicated a small effect size (pribulick, 2009). this information suggests that it would take a large sample of 158 subjects per group (n = 316) to detect a 1% change in hscrp, at a power of .80. this study has a low calculated power of 13.3% to detect difference in hscrp by group. the low power of the test may mask significant differences that were not detected by the analysis. only replication with a larger sample will answer the question of whether a type ii error exists. the study found significant associations between log hscrp and the factors of dietary intake and pa. stage of change, interventions, and log hscrp rural women in the higher soc categories, action or maintenance, on both diet and physical activity had lower levels of hscrp in this study. the mann-whitney u that ranked median log hscrp did not indicate a significant difference by level of soc for either diet or pa. yet the mean log hscrp post was lower for those in the action or higher level of soc for both diet (m = .44, sd = 1.17) and pa (m =.43, sd = 1.16) than those in preparation or lower (m = .70, sd = 1.15 and m = .84, sd = 1.13) respectively. there is a clear need for future study with a larger sample to more fully test whether nurse interventions in pa and diet can significantly reduce hscrp. online journal of rural nursing and health care, 13(1) there are other factors that can affect hscrp levels during the course of a 14 month study. for instance, four subjects in this cohort began cholesterol lowering therapy at some point after the study was underway. at the beginning of the study seven (14%) smn+ci and five (10%) ci subjects reported being on cholesterol lowering drugs, all on a medication to reduce cholesterol had been on that drug for a minimum of one year. cholesterol lowering medications have been shown to decrease hscrp and to prevent vascular events with normal ldl cholesterol and elevated hscrp (ridker et al., 2008). at the end of the study, six (13%) smn+ci and ten (22%) ci subjects reported being on cholesterol lowering drugs. a chi-square did not show a difference between the smn+ci and ci groups on pre or post use of cholesterol lowering medications, (x2 = 1.905, df = 3, p = .59). the exact time the cholesterol lowering therapy began is not known. in addition, subjects were not asked to report what type of cholesterol medication they were on. therefore it is not possible to know if or to what degree this situation could affect outcomes. there is also the possibility that the screening data influenced subjects to seek medical assistance given the knowledge of their lab results and framingham 10-year coronary heart disease risk score. the findings in this study are supported by several previous studies (aronson et al., 2004; lamonte et al., 2005; mcfarlin et al., 2006) that also found that increased levels of physical activity were associated with lower hscrp levels. two studies found differences in hscrp relationships with pa depending on gender (albert et al., 2004; borodulin et al., 2006). the albert (2004) study reported no statistically significant relationship between levels of physical activity and hscrp in women, p trend = .38 while most subgroups of physical activity in men remained significant. borodulin et al. (2006) found a statistical significance in women but only a borderline significance in men. in this study, all subjects were women. online journal of rural nursing and health care, 13(1) a 9-week lifestyle intervention program in the literature (dvorakova-lorenzova et al., 2006) focused on diet and physical activity was successful in 30% reduction of hscrp levels, 4.31 ± 3.71 to 3.01 ±3.12 mg/l. the physical activity was supervised 1-hour training sessions plus three added sessions per week of cycling, jogging or brisk walking. another program (stewart et al., 2007) used a supervised, aerobic and resistance exercise program, three days per week for 12 weeks. their groups included young and old, physically inactive participants who received the supervised exercise and a similar group who maintained their usual activity level as the control group. the experimental group, both young and old, had a significant decreased in hscrp post training, p < 0.01. although this study intervention did not reduce hscrp at a significant level, the trend toward a reduction in the smn+ci group, were the moderately active group had the lowest hscrp (see figure 2) is supported by the literature (dvorakova-lorenzova et al., 2006; stewart et al., 2007). this also indicates that a large sample size may have been needed to see the small effect size in change in hscrp. the above studies (dvorakova lorenzova et al., 2006; stewart et al., 2007) had supervised pa activity unlike this study. it may be that a more structured, supervised pa component would be more successful in reducing hscrp. a previous study (gao et al., 2004) found an inverse dose-response between fruit and vegetable intake and crp (p trend = .017) and is reflective of the current study which found significant inverse associations between these two variables. gao et al. questioned whether the antioxidant components of fruits and vegetables were the contributing factor to the anti inflammatory effect found. the role of fruits and vegetables in reducing hscrp has been established. future research should focus on having women eat adequate fruits and vegetables on a consistent basis as well explore the role of antioxidants in relation to hscrp levels. a study of online journal of rural nursing and health care, 13(1) total antioxidant capacity (tac) of diet (brighenti et al., 2005) included a stepwise multiple regression analysis of contributing food groups to the tac. fruit, vegetables, and nuts accounted for 5.6% of the tac. brighenti et al. hypothesized that the metabolism of hscrp may be regulated by the tac of the diet as opposed to any single antioxidant compound. this may also apply to the concept of increasing fruits and vegetables in the diet. there may be a greater dose response if the dose consists of a variety of fruits and vegetables as opposed to a select few. inoue, komoda, uchida, and node (2008), considered the effects of a single tropical fruit, camu-camu. camu-camu is found in the amazon, contains high vitamin c, and is juiced for dietary consumption. the camu-camu group had a significant reduction in hscrp from baseline whereas the vitamin c group had no change. though the sample size was small, the impressive findings were based on one fruit with high antioxidant properties. yet this is a fruit seldom reported in the american diet and it is unlikely women in this study had access to camu-camu juice. not surprisingly, bmi and hscrp were highly correlated. past studies have also shown strong correlations between bmi and hscrp (colbert et al., 2004; dvorakova-lorenzova et al., 2006). however, more work is needed on the effect lowering bmi may have on hscrp and whether or how much of a genetic component influences hscrp levels. limitations standard guidelines used for hscrp as a risk marker specify that measurements of hscrp be performed twice; the average number being used to evaluate risk (ridker & rifai, 2006). the primary study only obtained lab samples once at the beginning and completion of the study. this is a limitation; however the log transformation changed the shape of the distribution and mitigated the effects of the outliers. a second limitation is that information regarding chronic online journal of rural nursing and health care, 13(1) conditions was not collected. certain chronic conditions such as rheumatoid arthritis would predispose participants to an elevated hscrp level. randomization into smn+ci and ci groups was designed to correct for this type of limitation. stage of change for both diet and physical activity was collapsed into two levels, preparation and below or action and above, since there were not enough subjects to run analysis by the five levels of soc. a larger sample size would permit analysis by each of the five levels of soc. the primary study included a calculated 21% attrition (fahs et al., 2012). for the purposes of this study, the smn+ci group numbered 49 participants and 50 for the ci. six participants did not return their final questionnaires, thus analysis of self-report data such as pa and dietary intake had maximum of 93 subjects. another limitation is the self-report data used in the evaluation with soc, ypas, and the nih/nci fruit and vegetable screener. a participant’s answers may reflect what they feel is expected of them or a genuine miscalculation instead of factual data. however, all instruments had previously been calculated for validity and reliability. hormone replacement therapy (hrt) has been shown to increase hscrp levels according to ledue and rifai (as cited in ridker & rifai, 2006, p. 354). seven women at the beginning of the study answered affirmatively to taking hrt compared to five women at the completion of the study. c-reactive protein values at the beginning of the study for those women on hrt (m = 3.1, sd = 3.62) were not significantly different from those not on hormone replacement therapy, (m = 3.70, sd = 5.58) t = .46, df = 97, p = .67. however the influence of hrt on hscrp was not analyzed as part of this study. application of the research to practice this research can be useful in generating programs related to diet and physical activity specific to producing a change in hscrp levels. however, nurses need to be aware that rural online journal of rural nursing and health care, 13(1) communities often do not have accessible and acceptable facilities for recreational activities especially during seasons with inclement weather. sidewalks are often in disrepair, if they exist at all and rural roads may not be safe for walking. although there are no recommended guidelines to reduce hscrp through exercise, this study, along with others support the notion that moderate levels of activity are associated with lower hscrp levels. since a relationship between intake of fruits and vegetables and decreased hscrp was shown in this study, guidelines to increase intake of fruits and vegetables should be implemented in attempts to reduce hscrp. although rural areas may have agricultural capabilities not all rural citizens have the space, inclination, resources, or skill to produce their own fruit and vegetables. often access to food stores is problematic and with rising costs and lack of public transportation, “food deserts” can exist in rural as well as urban areas. unstable environmental and economic forces are negatively influencing food cost and accessibility. the findings of this study indicate it is important to improve pa and dietary intake of fruits and vegetables to reduce hscrp levels and thus have a positive influence on heart health for rural women. some of the challenges mentioned above need to be taken into consideration when developing programs designed to improve healthy living behaviors in rural communities. this study indicates that women who have higher levels of pa and diets richer in fruits and vegetables have better hscrp. however, the nurse intervention program, smn+ci tested against the ci did not significantly reduce hscrp and a possible type ii error may exist since the power calculated for this cohort study was low. the possibility exists that if women are informed of their crp, and told how to reduce this biomarker, they can be motivated to make changes to their diet and pa online journal of rural nursing and health care, 13(1) this study contributes to the research on hscrp among rural women. collectively with other research, future designs can be more focused and tightly defined. the more evidence produced on diet and pa to reduce hscrp over multiple studies, the more likely the research will influence not only practice but also policy development. research contributes to policy by bringing forth evidence based on scientific theory, yet policy is not always based on research findings. policy development takes place not only at the federal level but also within professional organizational structures such as the american nurses association and rural nurse organization, health focused organization such as the american heart association; or hospital or community health agencies, particularly with the advent of medical homes and the push for data driven practice with the affordable care act. this study adds information on hscrp, lifestyle modifications, pa levels, and dietary intake of fruits and vegetables that may contribute to future research, practice and policy considerations; particularly for rural women. supporting agencies nih funding 1r15nr009218-01a1. thank you to faculty and students from uva, son and binghamton dson with phh; susan wiitala, rn, ms and ellen f. hall, mals, ahip, library director emerita, norwich university for their assistance in manuscript revision. references akbartabartoori, m., lean, m. e., & hankey, c. r. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/17264174 http://www.ncbi.nlm.nih.gov/pubmed/9603539 http://www.ncbi.nlm.nih.gov/pubmed/18502225 http://www.ncbi.nlm.nih.gov/pubmed/11404661 microsoft word 454-2991-4-ce.docx online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 103 a story of emergent leadership: lived experiences of nurses in a critical access hospital judith m. paré, phd, rn1 dayle boynton sharp, phd, dnp, mcph, aprn, fnp-bc2 polly petersen, phd, rn3 1 director/nurse education, workforce quality & safety massachusetts nurses association, judithmpare@gmail.com 2 clinical associate professor/director of family nurse practitioner program, nursing department, university of new hampshire, dayle.sharp@unh.edu 3 assistant professor, college of nursing, montana state university, billings campus, polly.petersen@montana.edu abstract purpose: the purpose of this study was to understand the lived experiences of nurses working in a predominantly rural care setting. in order to meet the needs of an aging population with multiple comorbidities, it is essential for leaders to understand the strategies to recruit and retain highly qualified nurses in cahs settings. sample: nine registered nurses working both full and part time with one to 40 years of experience participated in the interview process that queried their attitudes regarding working in a rural setting. findings: five major themes included self-reliance, social responsibility, empathy, isolation, and emergent leadership. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 104 conclusions: the findings from this study support the notion that there is not a universal response to the lived experience of nurses working in cahs. the unique needs of each nurse should be considered to enhance the practice environment and diminish experiences that result in feelings of isolation. isolation impacted the five themes; if nurses are not able to maintain current knowledge and skills in a supportive environment, their self-reliance is compromised. keywords: rural, nursing, self-reliance, emerging leader a story of emergent leadership: lived experiences of nurses in a critical access hospital nursing in a rural setting is very different than nursing in an urban area. nurses work and live within close proximity of their patients and their extended families. they usually know how a patient will handle a hospital admission, who will be their support after discharge, and who to call if there is no support for the patient. rural nursing practice is generalist in its nature, requiring broad knowledge and flexibility (montour, baumann, blythe & hunsberger, 2009). an understanding of the lived experience of rural nurses is imperative as rural hospitals and healthcare settings face financial struggles, shortages of providers and an aging nurse and patient population. the examination of the daily practice of nurses working in critical access hospitals (cahs) is the phenomenon that is the focus of this research. examining this phenomenon provides foundational evidence to better understand the challenges and opportunities of rural nursing practice and the development of recruitment and retention strategies for nurses who are willing to continue to provide leadership in nursing care for a diverse rural population. rural nursing kind of has a rap, like when you say “rural”, a new graduate may be thinking nursing home and it’s not like that at all. rural nursing is the heart online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 105 of nursing and there are wonderful opportunities for young nurses to learn and grow. literature review many times, nurses who work in a rural setting have made a decision to return to live in the small community where they grew up (bushy & leipert, 2005). rural, defined by the u.s. census bureau, encompasses all population, housing, and territory not included within an urban area (u.s. census, 2016). urban areas represent densely developed territory, encompassing residential, commercial, and other non-residential urban land uses. two types of urban areas are the urbanized areas (uas) of 50,000 or more people and urban clusters (ucs) of at least 2,500 and less than 50,000 people. rural nurses are required to handle every clinical issue that presents in their practice setting. they come with a general knowledge and willingness to make a contribution to their family and home community. the lack of access to primary care and specialty services, such as mental health supports, can create situations where the nurse generalist may need to assume multiple roles in order to meet the needs of the patient population (bushy, 2014). nurses who are working in cah settings must continually redirect their care and skills to adapt to changing situations of census, culture, patient needs, and acuity of care (cramer, jones & hertzog, 2011). they might be working with minimal support of other healthcare professionals, simply as a result of limited personnel resources available. rural nurses, especially nurses working in cahs face both positive and negative challenges related to whether the support and resources are available to manage these situations (hunsberger, bauman, blythe & crea, 2009). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 106 nurses in cahs predominantly are educated at the associate degree level and typically care for patients of various ages and diagnoses (newhouse, morlock, pronovost & sproat, 2011). due to limited staff, nurses frequently float between units (havens, warshawsky, & vasey, 2012; newhouse et al., 2011), adding to the need to be cross-trained to work in multiple clinical areas. even with cross-training, nurses working in a cah setting feel overextended related to fluctuations in staffing patterns (cramer et al., 2011). this situation highlights the need for increased knowledge in a more robust patient population. economies of scale that encompass practice knowledge often represent barriers for nurses and providers from being able to participate in mentoring and professional practice experiences that simply don’t exist outside of urban settings (lovelace, n.d.). hunsberger et al. (2009) found the balance between practice demands and resources influenced workforce sustainability in rural healthcare settings. “with patient acuity increasing and experienced nurses approaching retirement, the imbalance between demands and resources may become critical” (hunsberger et al., 2009, p 22). chief nursing officers (cnos) from rural health settings reported they need to create practice environments that “provide resources and support nurses to design and deliver excellent patient care” (havens et al. 2012, p. 519). without qualified nurses working in rural areas, the access to quality healthcare is at risk. many cahs face challenges related to recruitment as they are in competition with urban hospitals offering higher salaries, specialized clinical practice area, and educational opportunities (havens et al., 2012). the consequence of not providing these types of environments often results in nurses becoming dissatisfied and choosing to commute long distances to work in urban settings. urban settings offer broader opportunities for professional advancement tied to continuing education and tuition reimbursement along with higher salaries. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 107 the ability to be flexible and resolve issues in their clinical practice that may not even be identified appear to be common attributes of rural nurses. there is a better need to understand the attributes influencing nursing practice in cahs and their impact on the recruitment and retention of nurses, in order to design interventions to attract nurses to rural settings, retain existing nurses, and encourage the return of those who have left rural settings to practice in urban locations. these attributes may be described as self-reliance or resilience. resilient people have an awareness of both their capabilities and limitations (wagnild, 2014). in order to understand the attributes of rural nurses working in a cah were interviewed to determine how resources and environmental support impact career satisfaction, recruitment and retention. methodology study the study took place in a cah located in a predominantly rural northwestern state in the u.s. criteria for cah designation includes transfer or discharge of a patient within 96 hours and a capacity of 25 inpatient beds. a cah must be more than 35 miles from another hospital. this particular facility serves a community with a total population of 8,796 (u.s. census, n.d.) and is approximately 140 miles from a larger tertiary center. this cah employs 75 registered nurses, has an average daily census of 15 and became a cah in 2010. the facility has had a recent high nurse turnover, requiring augmentation of staffing with temporary nurses as well as current representation with a collective bargaining unit. these circumstances presented an opportunity to explore the phenomena of nurses who practiced in one unique rural setting. research design in order to understand the role of the bedside nurse in a cah setting located in rural northwestern us, a collaborative effort was initiated. the collaborative team included a hospital online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 108 board member who is also a nurse researcher, a newly appointed chief nursing officer, and a nurse researcher from new england who had previously studied nurses working in a cah in new hampshire. this group of long-distance nursing professionals organized, implemented, and analyzed findings from a qualitative study utilizing colaizzi’s method of descriptive phenomenology (colaizzi, 1973) with the additional step cited by edward and welch (2011) to better understand the lived experiences of nurses caring for individuals and families in a rural hospital located in a small community in eastern montana. utilizing a purposeful convenience sample, nine participants with 1 40 years of nursing experience were interviewed. each participant was scheduled for an initial 30-minute audio-taped interview that included openended questions about their personalities, attributes, and coping strategies utilized to enhance their clinical practice in a rural setting. each participant received a written transcript of their interview via a secured server so that they could validate the transcript from the initial interview. key themes were extracted from the data. to avoid potential identification of nurses who were interviewed, resulting themes were not provided to the participants. however, an experienced qualitative researcher familiar with colaizzi’s techniques was asked to review the themes identified through the process of bracketing participants’ comments and responses. this outside reviewer validated identified themes after reading all transcripts. recruitment nurses were notified of the research opportunity via the hospital intranet approximately four weeks prior to the onsite visit. schedule of the interview times was extensive, to accommodate maximum participation. a two-day interview schedule allowed for weekday and weekend nurses who worked days or nights to participate in the study. posters were placed online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 109 throughout the cah, reminding participants of the times the researcher would be present for the opportunity to participate and the purpose of the study. sampling the sample of participants was from a pool of all current nurses employed at the selected cah. participation was voluntary. participants came to the researcher at their own convenience. each participant consented prior to the start of the interview. this study was reviewed and approved by the montana state university institutional review board, protocol number pp072415-ex. signature of the consent form indicated willingness to participate in the study. limitations nine (9) individuals were participants. this sample size represented 12% of the total nursing staff of the facility. an additional limitation was characteristics of the study location. the participant pool was homogenous; all nurses were female, all but one nurse was caucasian with a history of family living and working in this northwestern rural community. data collected included the responses of nurses employed at only one cah in a rural northwestern state. rural communities are different from one another and thus the workplaces and roles of the nurses who work in these communities will also vary (macleod et al., 2004). data analysis interview data were transcribed using dragon naturally speaking tm. utilizing colaizzi’s method of phenomenological inquiry, the following steps with the inclusion of the additional step noted by edward and welch (2011) resulted in five major themes. ● step 1 involves transcribing the interviews to gain a feeling and understanding the meaning behind the words. interviews were sent to each participant to ensure accuracy online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 110 and to allow for the expansion of ideas or comments. the participants returned the transcripts with their approvals and/or additional comments one week after receiving the initial documents. three of the nine participants expanded their statements. all nine validated their statements for accuracy. ● step 2, the researchers reviewed each transcript and extracted significant statements. when duplication or repetition of statements occurred, repetitions were eliminated. ● step 3 of colaizzi’s method required the researchers to extract a meaning for each significant statement. this required a thorough review on the part of the researchers to determine the meaning behind the words of each research participant ensuring to stay within the boundaries of the subjects’ lived experiences (colaizzi, 1973). ● step 4, all of the formulated meanings from the significant statements were grouped into categories that reflect a cluster or theme. similar meanings are placed into groups of similar type (edwards & welch, 2011). once completed, groups of clusters or themes were integrated to form a unique construct of the 5 themes. ● step 5 included defining all evolving themes into a thorough description of the phenomenon being studied. once this thorough description emerged, the entire structure of the phenomenon of study became apparent. ● step 6 the researcher interprets the analysis of symbolic representation from participant interviews (edward & welch, 2011). this additional step was added to colaizzi’s previous phenomenological inquiry methods. ● step 7 encompassed the development of a complete description or fundamental structure of the phenomenon of study. during this process, changes were applied to elucidate clear relationships between clusters of theme and their extrapolated meanings. data were online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 111 collected through 9 interviews with data saturation. after data collection and coding, members of the research team provided feedback on categorization of data. throughout the data analysis process, discussions of the data occurred among the research team to ensure each researcher analyzed data in the same way. ● step 8, findings were validated. the process of validating requires the researchers to return the transcripts to the study participants. although transcripts were returned; due to the small sample size, and potential to disclose participant identity, the resulting themes and phenomenal essence were not provided for review. results participant characteristics nurses working in this cah who participated in the study were all female, primarily educated as associate degree registered nurses. age ranged from 24 to 61 years, with years of practice from 1 year to 40 years (figure 1). they were all members of a collective bargaining union. figure 1. age of participants and years of practice participant responses online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 112 five major themes were identified, including self-reliance, social responsibility, empathy, isolation, and emergent leadership. these themes were consistently echoed in the analysis of interviews that were conducted with the bedside nurses at the research site. the participants who had twenty or more years of experience in rural settings emphasized their added responsibility to “teach” or “instill” a sense of self-reliance in nurses with less experience. the experienced participants readily acknowledged that sharing their experiences provided a common ground for new graduates who may feel alone and isolated in their nursing practice. self-reliance participants discussed constraints related to continuing their education stating “there is no motivation to pursue an advanced degree at this facility. your pay doesn’t go up with additional degrees and they don’t offer any educational assistance.” in addition to limited motivation, participants also found financial constraints impacted their ability to attend college courses and/or conferences. they had to pay for college and conferences on their own. “we don’t get too many opportunities to go elsewhere for educational offerings.” to help facilitate educational opportunities for the rural nurse, continuing education has expanded to online learning and teleconferences. however, the respondents were not comfortable with online learning, one nurse stated, “i don’t really like online anything so i know it is going to be a hard transition for me.” despite limited funding and career advancement, the nurses continued to feel an obligation to remain current in yearly competencies. they felt they were accountable for their own learning. “each nurse must have self-motivation to want to stay current, improve, and learn. each nurse should believe that they need to better herself in order to better serve her patients.” nurses employed various techniques to continue their learning, to remain current in their skills, and to have information at their fingertips allowing them the ability to be self-reliant. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 113 everything that i learn … i write down in two little books. because we are a small facility and i don’t see everything, every day i write down everything... if you don’t do these things every day it is easy for them to slip out of your mind. social responsibility the nurses felt they had a commitment to the community. one participant stated, “we need to let our patients know that we want to know about them, what they do for a living, tell us what is bothering them, we need to show patients that we care enough to communicate and that their lives and health are important to us.” caring for the community expanded to offering shelter to community members in need. “we … use the swing bed for … a homeless patient that has no place to go, we will … for a month or two.” empathy the nurses spoke of having empathy for their patients. one nurse spoke about caring for a patient in need, “today, i am caring for a new patient, a young patient, with hep-c and she is devastated by it so i am trying to educate her about the disease and what we can do to help her to succeed outside of here once she’s over the initial shock of the diagnosis.” “you get to know your patients. i know that other nurses who are actually from here, know their patients in and out of the hospital and that is one of the things that makes a rural setting special.” the nurses discussed that they lived in “a small, intimate community” where “you ... get to know the people and you have to be caring”, that unfortunately the caring continues when the patient is transferred to another hospital. one nurse mentioned empathy for the families of patients that had been transferred to a hospital that was located 150 miles away. “due to the online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 114 distance, family members were not able to be with their loved one during their illness or transition into death. nurses also talked of empathy for each other by supporting each other when necessary. when an emergency occurs or a unit is short staffed “we go and offer consult, support, and whatever we can to help. we are always a resource for the other departments, especially if they have questions or if they need some extra help or some extra expertise.” isolation respondents stated they enjoyed face-to-face networking with other conference attendees, “it would be interesting to hear from other nurses, i like the idea of networking” and that without the opportunity to travel outside their local area, they felt isolated, “it is so easy to become closed off here.” one of the participants recalled a missed opportunity to achieve emergency certification when a severe storm closed a highway: “i had waited two years for the training to come to our area, and now it will be another two years before i have another chance.” the nurses felt isolated by not having the option to go to conferences. “there are some, not a lot of opportunities to go to conferences. i want to get my cen but there are no certification classes in montana this year to do that. last year we had two and i scheduled myself to attend and we got snowed in and they shut the freeway down so i never made it.” another form of isolation mentioned was the staffing levels that do not allow for a nurse to actually leave the unit to participate in educational offerings at the cah. they did not have the opportunity to view this offering within the unit or perhaps even accessing it at a convenient time. “it would be nice for the hospital, for example, to bring in a group of nurses to cover a floor so that a group of nurses could attend a conference and know that the floor and patient care needs were covered.” one nurse mentioned that she felt isolated from others in the hospital, “if online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 115 the internet was compromised, there was no one to contact in the middle of the night; there was no it support.” one nurse thought this isolation forced you to work harder to be competent in all areas. “i worry about being good at assessing patients that we just don’t get here, it is isolating here, for example the biggest hospital is in billings and it is 2 hours away so, of course it can be isolating.” emergent leadership the setting for this study had recently employed a new chief nursing officer (cno). this was the first leadership role for this cno. one staff nurse spoke about “the nurses trusting their new nursing administrator.” nursing administration had changed three times in a short period of time. the staff nurse discussed nursing morale, stating “morale is better than it was since the change in nursing leadership. . . there had been morale improvement throughout the facility since that leadership change.” however, there were times when staff were apprehensive about a new leader. “i can understand that the staff is reluctant to trust administration. this is not personal, they simply have been exposed to multiple changes in leadership and that would make any team reluctant to trust leaders.” as a result of the changing nursing leadership, many of the experienced nurses had assumed an informal leader role. “i am a mentor here because i have been here 15 years. i’ve helped with orientees and i’ve been on our main nurse council here.” tied to the theme of selfreliance, many of the senior nurses felt a responsibility to mentor the younger or newer nurses on each of their units, evolving into an emergent leader. discussion utilizing the steps outlined by colaizzi (1973), once consistent themes were identified, the groups of clusters or themes were integrated to form a unique construct of theme. these online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 116 evolving themes then provided the researcher with a thorough description of the phenomenon being studied, leading to the entire structure of the phenomenon of study. five themes that were identified include self-reliance, social responsibility, empathy, isolation, and emergent leadership. self-reliance self-reliance, defined as having the capacity to provide for one’s own needs (agich, 1993), includes self-confidence and allows for a certain degree of freedom, providing the opportunity to make one's own decisions (the pulp, 2012). self-confidence allows an individual to make decisions necessary to complete daily tasks that are affected by changing circumstances (chafey, sullivan, & shannon, 1998). changing circumstances might include a change in job requirements, including floating to a different unit or a change in patient status. this is essential for the registered nurse as they move from novice to expert (benner, 2001). as the nurse grows professionally and moves towards expert level, they demonstrate autonomy in their practice stimulating personal and professional growth (hanson, jenkins & ryan, 1990). many of the nurses talked of floating to a unit, which they also correlated to enhancing their knowledge but at times, felt overextended as there were limited opportunities for formal learning of these different patient foci. the study participants experienced barriers in this professional development, which influenced their self-reliance. these barriers included a lack of a career ladder to encourage professional growth, promotion opportunities that were not correlated to advanced level of education, and there was no tuition reimbursement benefit. with this better understanding of the nurses’ resilience as an attribute, influencing nursing practice interventions can be designed to attract nurses to rural settings, retain existing nurses, and encourage the return of those who have left rural settings to practice in urban locations. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 117 social responsibility social responsibility is demonstrated by meeting the social and health needs of the community (international council of nurses, 2012), having a sense of duty to help others. all nurses have a sense of this responsibility due to the association between social responsibility and professional values. but are rural nurses different than urban nurses? do they have a stronger sense of social responsibility? due to the close ties of rural communities, lack of services, and social injustice, can it be assumed rural nurses engage more with their patients and community than their urban counterparts? “socially responsible nurses should all have professional selfconfidence” (faseleh-jahromi, moattari, & peyrovi, 2014, p. 292), but are rural nurses more selfconfident? what are the influences that may enhance a sense of social responsibility for rural nurses? the answer to these questions lies in the deep connectedness that rural nurses feel towards the patients they encounter. often these individuals are friends, relatives, or others who are known to the nurses that are providing care. to remain a nurse in the rural setting, a strong sense of social responsibility is vital, as demonstrated by these participants. empathy dinkins (2011) defines empathy as understanding another’s feelings, instincts, worries, or desires. empathy was apparent in three areas; nurses had empathy for the community, their patients, and among their fellow nurses. living in a small intimate community impacts a nurse’s relationship with their patients. they know their patients and they know the patient’s families; they are part of the community. thus, caring for patients is not limited to one individual or to one community. they felt empathy for the families trying to care for an ill family member, and this extended to times patients were transferred to a hospital that was located many miles away. due to distance, sometimes family members were not able to be with their loved one during their online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 118 illness or transition to death, leaving the rural nurse to assume the role of a surrogate member of the family. isolation rural nurses can experience isolation in a variety of ways. isolation can be geographic, such as living in an area that is a great distance from family, friends, and services. isolation can be professional when the nurse is unable to contact other members of the healthcare community for consultation or support. isolation can affect professional growth; nurses can experience limited access to continuing education opportunities. when the number of nurses is limited, the idea of exclusion from social and professional development situations only further contributes to a sense of isolation. our findings concur with past research. professional, geographic, social, and feeling like an outcast were identified through a meta-analysis conducted by williams (2012). the majority of the literature focused on the geographic and social isolation. emergent leadership the setting for this study had recently employed a new chief nursing officer (cno). this was the third cno for the facility in the past year. while the nurses were accepting of changes that impacted the quality of patient care, the multiple changes in leadership may have influenced the emergence of this theme. it is difficult to assess how the appointment of a new cno may have impacted the participants’ responses but the frequency of their remarks indicated concern for nursing leadership support. with the instability of nurse leadership, informal leadership positions emerged and senior nurses, many times, found themselves in a leadership position. implications for practice the themes that were identified from this study emphasize the sense of self-reliance that nurses feel to maintain current knowledge and skills in the care of patients at all points in the life online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 119 cycle. one benefit mentioned was the opportunity to care for all types of patients with a wide scope of care issues. one nurse had taken the opportunity to float to labor and delivery, an area that she had not been in since her nursing education. the nurse expressed frustration as she was not sure of the consistency of that experience again. this is not the case for nurses who practice in an urban setting, who might have daily chances to float to a new area. critical access nurses often feel disenfranchised from the larger nursing community due to geographic distances or limited access to technology and educational opportunities. because of these challenges, critical access nurses need unique support to maintain linkages to the larger community of nurses. identifying how nurses in this setting perceive their role and experience has provided insight into the systems and supports that will be necessary to recruit new nurses and retain emergent leaders among this unique population. providing cognitive and affective support for nurses working in rural settings is inexplicably connected to maintaining and growing the nursing workforce in these practice settings. this type of support might take the form of travel to a larger facility to expose nurses to new practice standards, current professional issues or trends in nursing and patient care. the ability to collaborate with a peer group could prove valuable for retention. likewise, the circumstances of the generalist cah nurse might enlighten urban nurses who lack knowledge of rural healthcare and its challenges. understanding the experiences of critical access nurses will broaden our understanding of why these nurses chose to stay and work within this practice setting, impacting nurse populations in rural settings. implications for education while some argue about what features cause rural practice to be unique, other suggest rural practice should be considered a specialty (bushy & leipert, 2005). interviews with rural nurses working in cahs have shown the differences in rural practice. due to these differences, it is online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 120 imperative nursing students be educated about the uniqueness and benefits of working in a rural setting. rural nursing requires additional skills and modifications to care for patients due to limited access to healthcare, fewer resources, and limited specialties. students can learn about the uniqueness of rural practice through changes in didactic and clinical components of nursing education programs. one solution could include inviting rural nurses as guest lecturers and exposing student nurses to rural areas through clinical placements allowing the student familiarity with rural nuances (sharp, 2010). previous research indicates having a rural background positively affects future employment in a rural community. along with a rural background, the number of years an individual lived and worked in a rural setting impacted their decision to accept a rural clinical placement. financial and family considerations also influence clinical placement. students needing to work while completing their education often choose a clinical placement near their place of employment. rural clinical placement improves student clinical skills needed for rural practice. through rural placement, students with no previous rural experience can appreciation the rural practice environment (edwards, smith, courtney, finlayson, & chapman, 2004). an understanding of rural communities can also be provided by mentors who can exposure students to both the social and professional community (sharp, 2010). mentoring should include knowledge outside the clinical setting. this is important in rural areas, as knowledge related to the distinctive factors of rural living gives the student an understanding that rural practice extends past the hospital walls. links between rural roots established during childhood and a desire to practice in a rural location reinforce the need to recruit nursing students from rural areas. increased access to educational programs can minimize the students commute from rural online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 121 areas (kippenbrook, stacy, & gilbert-palmer, 2004). through the use of current technology, students can remain in rural settings and care for rural residents while advancing their education. conclusion interconnected themes emerged from the analysis of data throughout this research process. isolation is a result of geography, compromised technology, lack of access to continuing education, and challenging internet connectivity. isolation impacts all other themes; if nurses are not able to maintain current practice knowledge in an environment that they find supportive, selfreliance is compromised. feelings of social responsibility and empathy are diminished as the nurse no longer feels he or she have the expertise for their rural community. this results in inadequacies, limiting each nurse of their growth potential as an emergent leader. certainly, more research is needed to identify the contributing factors that pose both challenges and opportunities for rural nurses working in critical access hospitals. however, with the strides in technology and its role in patient care, it is important to know what role this technology has in supporting rural nursing practice. cnos in rural health settings need to create practice settings that provide resources and support nurses in their efforts to design and deliver excellent patient care. without qualified nurses working in rural areas, the access to quality healthcare is at risk. ultimately, the findings from this study support the notion that there is no universal meaning to the lived experience of nurses working in cahs. individual needs should be considered to enhance the practice environment and diminish experiences that result in feelings of isolation. the lived experiences of rural nurses are influenced by multifactorial challenges that require further focused research. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 122 references agich, g.j. 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(2011). nursing staffing in critical access hospitals: structural factors linked to quality care. journal of nursing care quality, 26, 335 343. https://doi.org/10.1097/ncq.0bo13e318210d30a dinkins, c. (2011). ethics: beyond patient care: practicing empathy in the workplace online journal of issues in nursing, 16(2), 1. https://doi.org/10.3912/ojin.vol16no02ethcol01 edward, k.l. & welch, t. (2011). the extension of colaizzi’s method of phenomenological enquiry. contemporary nurse, 39(2), 163 171. edwards, h., smith, s., courtney, m., finlayson, k., & chapman, h. (2004). the compact of online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 123 clinical placement location on nursing students’ competence and preparedness for practice. nurse education today, 24, 248 255. https://doi.org/10.1016/j.nedt.2004.01.003 faseleh-jahromi, m., moattari, m., & peyrovi, h. 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(2011). rural hospital nursing: results of a national survey of nurse executives. journal of nursing administration, 41(3), 129 137 https://doi.org/10.1097/nna.0b013e31820c7212 sharp, d. b. (2010). factors related to the recruitment and retention of nurse practitioners in rural areas (doctoral dissertation). retrieved from http://digitalcommons.utep.edu/dissertations/aai3409167/ the pulp. (2012, december). self-reliance: the four exercises of ralph waldo emerson. retrieved from http://pueblopulp.com/self-reliance-the-four-exercises-of-ralph-waldo emerson united states census bureau (n.d.) american fact finder. retrieved from https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml united states census bureau (2016). defining rural at the u.s. census bureau. retrieved from https://www2.census.gov/geo/pdfs/reference/ua/defining_rural.pdf wagnild, g. (2014). true resilience: building a life of strength, courage, and meaning. new jersey: cape house books. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.454 125 williams, m. a. (2012). rural professional isolation: an integrative review. online journal of rural nursing and health care, 12(2), 3-10. retrieved from http://rnojournal.binghamton.edu/index.php/rno/issue/view/28 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 112 comprehensive assessment of the needs of chronic obstructive pulmonary disease patients residing in east-central indiana and west-central ohio ladonna h. dulemba, rn, dnp, anp 1 greer glazer, rn, cnp, phd, faan 2 jason allen gregg, rn, aprn, fnp-c, dnp 3 1 assistant professor, school of nursing and health sciences, indiana university east, ldulemba@iue.edu 2 dean of the college of nursing, associate vice president for health affairs at the university of cincinnati, greer.glazer@uc.edu 3 assistant professor of clinical, fnp program coordinator, college of nursing, university of cincinnati, jason.gregg@uc.edu abstract purpose: to conduct a needs assessment and develop an action plan to implement early interventions to improve health outcomes of chronic obstructive pulmonary disease (copd) patients residing in east-central indiana (in) and west-central ohio (oh). sample: a convenience sample of 70 adult copd patients in east-central in and west central oh. method: the vulnerable populations conceptual model (vcpm) was used to construct a survey that assessed available resources, relative risk, and health status of copd patients. the online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 113 thirty-item survey was distributed in two pulmonary practice sites and a rural hospital’s outpatient services. findings: the project used descriptive analysis and t-tests. results demonstrate resource availability mean (m) 7.06 ± 1.88 (sd) out of 0 to 11, relative risks (m) 4.16 ± 1.25 (sd) out of 0 to 9, and health status (m) 5.36 ± 1.60 (sd) out of 0 to 9. participants who had 2 or more comorbidities and took 5 or more daily prescriptions were more likely to have increased emergency room (er) visits and hospital admissions. conclusion: the results demonstrate the greatest frequencies for resource availability were education level and caregiver support. low resource scores were found for available health programs and enrollment in them. smoking and increased sadness were the greatest relative risks. implications of the project support developing copd interventions and programs that address smoking cessation, depression screening, and self-management that work to improve the health status of the population and improve their health outcomes. keywords: copd, rural, vulnerable populations, hospitalizations, emergency room visit. comprehensive assessment of the needs of chronic obstructive pulmonary disease patients residing in east-central indiana and west-central ohio chronic obstructive pulmonary disease (copd) has a major impact on the lives and health of americans. it exerts a huge cost on the health care system, taxing financial and medical resources. early intervention can ease some of the burden and relieve strained resources in addition to reducing health care costs (national committee for quality assurance, 2009). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 114 prior to developing an early intervention program, a comprehensive needs assessment is beneficial to establish potential needs and to guide informed decision-making (issel, 2014; witkin & altschuld, 1995). the project objectives were to conduct a comprehensive needs assessment for copd patients residing in a rural area and to disseminate the assessment findings to appropriate stakeholders. future plans include utilizing the assessment findings to develop an action plan that will work to improve health outcomes. prevalence in the united states (us) copd affects more than 6.3%, an estimated 15 million, of the adult population with an increase in rural areas (bellamy, bolin, nelson, & gamm, 2011; center for disease control and prevention [cdc], 2014). it was the 12th leading cause of morbidity and the 3rd leading cause of mortality in the us with 133,956 deaths from copd occurring in 2009 (american lung association, n.d.). in 2010, the total economic burden of copd in the us was estimated at $49.9 billion (qaseem et al., 2011). prevalence is estimated at 15.8% for those age 45-64 years old diagnosed with copd and greater than 23.7 % among those aged 65 years old and older. the states with the highest copd prevalence rates are kentucky, 9.3% and alabama, 9.1%. indiana copd rate is 7.9% and ohio is 7.1%. states with the lowest copd rates are minnesota and washington, both at 3.9% (cdc, 2012). risk factors copd has several risk factors, some of which are modifiable. smoking is the primary risk factor. thirty-three percent of copd patients have a history of smoking (cdc, 2012). other modifiable risk factors include prolonged exposure to air pollution, second-hand smoke, occupational dusts and chemicals, and history of childhood infections. sixty-nine percent of online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 115 patients with copd are 45 years old or older. in 2011, copd was almost twice as prevalent in females (10%) as male patients (6%) and four times as common in caucasians as all other races combined. heredity and low socioeconomic status are additional risk factors. adults with a diagnosis of copd asthma during their lifetime (47.2%) and those with an alpha-1 antitrypsin deficiency (1-3%) are at increased risk for developing copd (cdc, 2012; sandhaus, 2004). poor and rural areas have been linked to increased copd mortality rates (american lung association, n.d.). the association between these risk factors and copd is not clear, but factors related to low socioeconomic status for example indoor and outdoor air pollutants, poor nutrition, crowding, infections have been indicated as exposures (global initiative for chronic obstructive lung disease, inc., 2014). copd management clinical management of copd is complex. because the clinical progression is one of gradual impairment with episodes of acute exacerbation, copd patients have increased emergency room (er) visits, hospital admissions, and demands on acute hospital services (bustacchini, chiatti, furneri, lattanzio, & mantovani, 2012). the copd population is susceptible to receiving fragmented care due to movement from one health care setting to another. this process is laden with possibilities for adverse effects and poor outcomes (long, 2012). despite the need to reduce fragmented care for this population, few interventions have been developed to assist copd patients and their caregivers transition out of the hospital into their home. this results in an increase in hospital readmissions (coleman et al., 2004; fromer, 2011) past research by shelton, sager and schrader (2000) validates that individuals living alone, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 116 with decreased ability to complete activities of daily living (adls), one or more co-morbidities, five or more daily prescriptions, an er visit in past six months, frequent physician visits and one or more hospital admissions in a year are at higher risk for increased healthcare use (shelton et al., 2000). additional research (cihi, 2013) identifies elderly age, people of color, and unemployment as predictors for increased healthcare use. resources such as having a high school diploma, being married, maintaining employment, and having someone who helps with care are predictors for improved health outcomes in chronically ill patients (cihi, 2013). rural east-central in and west-central oh the rural region of east-central in and west-central oh includes wayne county (co), in; union co, in; fayette co, in; randolph co, in; preble co, oh; and darke co, oh. the center for rural development (purdue university, 2013) classifies union co, in; randolph co, in; preble co, oh; and darke co, oh as rural or an area without a city of 10,000 or more persons. wayne and fayette counties are classified as rural/mixed areas or a rural county with larger towns having a population of the largest city between 10,000-30,000 persons (purdue university, 2013). wayne county, in, where a majority of the health care services resides, is located on us interstate 70. the nearest trauma i hospital is st. vincent indianapolis hospital, indianapolis, in, an hour and 18 minutes away and with the next largest hospital in dayton, oh or munice in 45 minutes away. reid hospital and healthcare services (rhhcs) in richmond, in, is the local hospital that services patients in five rural in counties and two rural oh counties (reid hospital & health care services, n.d.). of their service population, 13.2% has a prevalence of copd compared to 8.4% nationally. concerning er visits, 7.8% of rhhcs patients have had greater than two online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 117 visits to the er in 2013 as compared to the national average of 6.5% (professional research consultants, 2013) project importance there is a growing body of evidence that recommends early intervention programs targeted for those with increased risk helps to improve health outcomes and reduce care costs (cihi, 2013). a crucial point to effective early intervention is identifying the patients who will most likely benefit before they become frequent users of the health care system with increased hospital admissions (cihi, 2013). an additional study by coleman et al. (2004) reports results found advanced practice nurses (apns) that implemented patient-centered interventions to assist elderly patients’ transition out of the hospital and back into the home found those patients were half as likely to be re-hospitalized as patients who did not receive the interventions. the apns had weekly contact with the patients by phone or home visit to monitor progress and communicate concerns between patients, their care givers, and primary care providers for approximately 24 days after discharge (coleman et al., 2004). model & application vulnerable populations conceptual model vulnerable populations are defined as social groups who have an increased susceptibility to adverse health outcomes, among these are rural, poor, and elderly patients (leight, 2003). the vulnerable populations conceptual model (vpcm) proposes there are inter-relationships between a vulnerable population’s resource availability, relative risk, and health status (see figure 1). adapted from (flaskerud & winslow, 1998). the framework assumes that communities are accountable for the well-being of its members to offer resources and online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 118 opportunities to attain and preserve health. the vpcm concepts address: patient resource availability: a) socioeconomic resources (patient education level, marital status, employment, living arrangements) and b) environmental resources (health program options, access to quality health care, transportation); relative risk (the exposure to disease and poor health, lifestyle choices, certain demographics); and health status (mental, physical, and social well-being). a community with limitations in resource availability has an increase in relative risk potential. increased risk affects the possibility of morbidity and mortality or the health status of the community. an increase in morbidity and mortality rates further deplete the amount of resources which results in poor health outcomes (rawlett, 2011). resource availability socioeconomic • education, marital status, work environmental • health programs, program options, quality care relative risk risk exposures • race, gender, lifestyle choices, health habits health status • life expectancy, co-morbidities, disease, mental status, age related differences online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 119 figure 1. vulnerable populations conceptual model. adapted with permission from wolters kluwer: flaskerud, j. & winslow, b. (1998). conceptualizing vulnerable populations health related research. nursing research, 47, 69-78. promotional and commercial use of the material in print, digital or mobile device format is prohibited without the permission from the publisher wolters kluwer. please contact healthpermissions@wolterskluwer.com for further information. application of the vpcm to the project. a vulnerability assessment can be used to identify limitations in resources resulting in higher risks for morbidity and mortality of the target population (smith, 2011). the project purpose was to develop an action plan to provide early interventions and improve health outcomes by identifying the resource availability, relative risk and health status of rural copd patients. method design a descriptive statistics design was used to determine the population’s resource availability, relative risk, and health status. the internal review board (irb) at the university of cincinnati approved the project as a not human subject research (id: 2014-1181). irb approval was also granted by rhhcs. sampling methods of recruitment included advertising by posters and word-of-mouth strategies. posters were placed at two pulmonary care practices and other rhhcs departments that serviced copd patients (pulmonary rehabilitation, transitions services, disease navigators, and case management). word-of-mouth strategies included verbal advertisement via social networking at the hospital and outpatient services. eligible subjects were adult males or females: (a) diagnosed with copd, (b) utilizing online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 120 rhhcs for copd management, (c) english speaking, (d) residing in east-central in westcentral oh. non-eligible subjects included: (a) non-english speaking adults, (b) persons not clinically diagnosed with copd, (c) a known cognitive impairment, (d) persons not residing in east-central in/ west-central oh areas. after advertisement began, subjects who desired to complete the survey were given an informed consent letter describing the project and an envelope with the survey enclosed. the informed consent assured participation was voluntary and they had the right to refuse or withdraw at any time. subjects who agreed to participate filled-out the survey and placed it in a sealed envelope or a lock-box on site. sealed envelopes were collected on-site by the primary investigator (pi). lock-box surveys were collected by the pi every other business day. project recruitment lasting for three months yielded 70 participants who completed surveys. sample demographics collected were comparable to the pre-assessment data provided by rhhcs for age, gender, and county of residence. while the total number of surveys collected was 70, some participants chose to leave certain questions blank. when dichotomizing and calculating the total of each category, the blank responses were not included in the total. measures measures of assessment were completed in a two-step process: pre-assessment and assessment. pre-assessment the pre-assessment was to learn demographics of the current rural copd population so they could be compared to the demographics of the surveyed population for comparability. demographic data was retrieved for all patients receiving services at rhhcs for copd (icd-9 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 121 codes 490-491, 494, 496) in the fourth quarter of 2013 (october, november, december), including age, gender, and place of residence. the pre-assessment data disclosed there were 1235 (n = 1,235) patients seen for copd at rhhcs during that time. of those patients, 55% (n = 676) were females and 45% (n = 559) were males. the largest age percentage of age groups were between 60-69 years old 26% (n = 317) and 70-79 years old 25% (n = 313). seventy-four percent (n = 910) of the patients resided in wayne county, in, 5% (n = 74) resided in fayette co. in; 10% (n = 124) resided in union co. and randolph co., in; and 10.5% (n = 127) resided in preble co. and darke co., oh. assessment the assessment included surveying the copd participants from october 1st thru december 31st of 2014. tool. a 30-item assessment survey was used. the survey was constructed using three evidenced-based assessment tools: the community assessment risk screen (cars), the hospital admission risk prediction (harp) tool, and the patient-centered copd questionnaire. the cars instrument is a screening tool used to identify elderly persons at risk for hospitalization or emergency room visits; receiver operating characteristic (roc) curve risk classification 0.74, the alpha p = .05 (shelton et al., 2000). the harp tool assists health care providers to identify patients who are at risk of future hospitalizations and increased users of health system resources (cihi, 2013); 95% confidence interval: 0.57 – 0.77 (beaton & grimmer, 2013). the patient-centered copd questionnaire is a copd specific instrument used to measure patient’s perceived impact of copd on daily life; chronbach’s alpha 0.93 0.74. (pommer et al., 2013). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 122 readability for the survey was set at the sixth-grade level (my byline media, 2014). no identifying information was included on the survey. survey questions one to fifteen were demographic style questions. questions 16 30 were arranged on a five-point likert scale with 1 indicating never and 5 indicating always. survey questions assessed for resource availability, relative risk, and health status. resource availability was comprised of socioeconomic and environmental resources. socioeconomic resources included questions that assessed education level, marital status, living arrangement, and employment status. a score range of zero out of four was possible for socioeconomic resources. environmental resources included questions that assessed health program availability, health program enrollment, quality of copd management, satisfaction of copd management, access to health care for shortness of breath (sob), friends available to assist with sob, and transportation availability to medical appointments. a score range of zero out of seven was possible for environmental resources. the total resource availability score included the sum of socioeconomic and environmental resources. a score range of zero out of 11 was possible for total resource availability. relative risk questions included age, gender, race, county of residence, smoking habits, copd knowledge, copd support needed, increased sadness, and access to medical attention for sob. a total score range of zero out of nine was possible for relative risk. health status questions included co-morbidities, number of hospital admissions and doctor visits in the past year, possible er visits in past six months, number of daily prescriptions used, and number of daily over-the-counter medications used. a score range of zero out of nine was possible for health status. analysis. data analysis was done using spss version 21 for descriptive statistics. percentage online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 123 frequencies were recorded as well as totaled and calculated for the mean (m) and standard deviation (sd) (lipsey, 1990). likert questions results were dichotomized into two main groups 1) never/a little (1, 2) and 2) often/a lot/always (3, 4, 5) for reporting of frequencies (statistics café, 2011). to prevent skewing the mean for these results, questions with an answer of no response were omitted from the total (n). socioeconomic resources n = 65 indicates 5 of the 70 subjects had no response. comparisons were completed using the t-test for statistical significance. p ≤ .05 was considered significant. results of the survey sample, 64% (n = 45) of the sample was greater than 65 years old, 51% (n = 35) were female, 61% (n = 43) lived in wayne co, in; 3% (n = 2) lived in fayette co, in; and 36% (n = 25) lived in the surrounding rural counties. the sample surveyed for the project during october, november, and december of 2014 was comparable to the population of copd patients seen at rhhcs during october, november, and december of 2013. resource availability the possible range of total resource ability score was zero to 11. the sample range of total resource availability was three to 11. the resource availability mean was 7.06, sd 1.88 (n = 54). the mean score was in the higher end of the zero to 11 ranges indicating there is a moderate level of resource availability. socioeconomic resource availability. the possible range of socioeconomic resource availability scores was zero to four. the sample range of scores was zero to four. socioeconomic resource mean was 1.92, sd 1.04, (n = 65). the mean was in the slightly below the midpoint of the zero to four range indicating there is a moderate level of socioeconomic online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 124 resource availability. the highest frequency for socioeconomic resources was an educational level of a high school diploma or higher level of education. next highest frequencies were having someone that helped with their care and being married or living with someone. employment was only 9% or six out of the 70 participants. environmental resource availability. results for environmental resource availability are depicted in table 1. the possible range of environmental resource availability scores was zero to seven. the sample range of scores was one to seven. the mean score was 5.12, sd 1.30 (n = 58). the mean score was in the higher end of zero to seven ranges indicating a high level of environmental resources. the highest frequency for environmental resource availability was having transportation to medical appointments (car, shuttle, bus, friend, etc.) at 90%. second highest was having friends who help with sob episodes. further results demonstrated 79% of participants felt they get good copd care management. the lowest environmental resources were having health program options (37%) and being enrolled in a program (30%). table 1 environmental resources environmental resources (n = 58) n % transportation to medical appointments often/a lot/ always never/ a little 63 3 90 4 have friends to help with shortness of breath yes no 60 6 86 9 good copd care management often/a lot/ always never/ a little 55 10 79 14 satisfied with copd care management often/a lot/ always 54 77 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 125 never/ a little 11 16 access to healthcare when short of breath often/a lot/ always never/ a little 54 10 77 14 have options to join health programs often/a lot/ always never/ a little 26 54 37 77 have enrolled to health programs often/a lot/ always never/ a little 21 47 30 68 risks results for relative risk are depicted in table 2. the possible range of relative risk scores was zero to nine. the sample range of scores was two to seven. the mean score was 4.16, sd 1.25 (n = 50). the mean score was in the middle of the zero to nine range indicating there is a moderate level of risk. the highest frequency for relative risk was age 65 years or older. other high scores were being a smoker and increased sadness with having copd. for example, thrtynine percent of copd patients continue to smoke. at the low end of relative risk were need table 2 relative risks relative risks (n=50) n % age less than 45 years old 45-54 years old 55-64 years old 65-74 years old 75-84 years old greater than 85 years old 2 9 13 30 10 5 3 13 19 43 14 7 gender male female 34 35 49 50 smoke yes 27 39 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 126 relative risks (n=50) n % no 43 61 increased sadness often/a lot/ always never/ a little 23 40 33 57 county of residence wayne county, indiana fayette county, indiana randolph county, indiana union county, indiana darke county, ohio preble county, ohio 42 2 6 4 1 12 60 3 9 6 1 17 need more copd support often/a lot/ always never/ a little 18 50 26 72 know what having copd means often/a lot/ always never/ a little 54 14 77 20 do not seek medical attention for shortness of breath episodes because no doctor cannot afford it no transportation use home remedy two or more of the above 0 1 1 5 25 21 0 1 1 7 36 30 race caucasian african american hispanic american indian 65 2 1 1 93 3 1 1 more support from copd care provider, do not know what having copd means, and do not seek medical attention for sob. table 3 health status health status (n = 64) n % able to complete activities of daily living often/a lot/ always never/ a little 45 7 89 10 visits to doctor in the past year online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 127 health status (n = 64) n % 3 or more 0 2 55 11 79 16 know how to handle shortness of breath episode often/a lot/ always never/ a little 55 10 78 14 seek health care when short of breath often/a lot/ always never/ a little 54 10 77 14 daily prescriptions 5 or greater 0 4 52 10 74 14 co-morbidities 1 or more none 46 24 66 34 experience shortness of breath often/a lot/ always never/ a little 45 21 64 34 hospital admissions in past year 1 or more 0 37 32 53 46 visited the emergency room in past 6 months yes no 36 34 51 49 health status results for health status are depicted in table 3. the possible range of health status scores was zero to nine. the sample range of scores was three to nine. the health status mean was 5.35, sd 1.60, (n = 64). the mean score was in the slightly above the middle of the zero to nine range indicating that the health status of the participants were in the moderate level. the highest frequency reported for health status was completing adls. further results show high scores for visits to the doctor, five or more daily prescriptions, and know how to control breathing when short of breath. additionally high scores were calculated for experience shortness of breath, seek health care when short of breath, and admitted to the hospital. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 128 t-tests demonstrated statistical significance for copd patients with one or more comorbidities as more likely to have one or more hospital admissions per year (n=17, m2.5 +/0.9, p = 0.03) and use five or more prescriptions daily (n=36, m=5.61, sd+/0.99, p = 0.005). statistical significance was also seen for participants who reported having one or more hospital admission and completing adls a little/ never (n=33, m4.67, sd +/0.1.21, p = 0.007). results demonstrated participants who reported increased sadness (p=0.22). participants with no hospital admissions reported more often they did not have a friend help them with sob episodes (n=33, m 1.83, sd 0.28, p = 0.05). participants living in rural counties surrounding wayne co were more likely to use a home remedy and not seek medical attention for a sob episode (n=41, m 5.0, sd +/1.25, p =0.02). discussion while the sample size was only 7% of the target copd population, the sample demographic statistics were comparable to the actual copd population for age, gender, and place of residence. this supports the sample as representative of the copd population. copd patients had a high level of resource availability, with greater levels of environmental resources than socioeconomic resources. the majority of participants had graduated from high school and over half the participants had someone to assist with their care. half of participants were married, meaning their caregiver lived within the home. a large majority of the sample was retired or unemployed. the vast majority of copd patients had transportation to medical appointments and had friends to assistance them when short of breath. the majority of participants utilizing rhhcs services reported they received good copd care and were satisfied with their care. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 129 notably, less than half the sample reported having health program options and only onethird reported being enrolled in a program. with a perceived lack of health program options and only one-third of the population being enrolled in current health promotion programs, additional assessments should be conducted to determine what health programs are available, if the programs are accessible to patients in terms of location, time, and insurance reimbursement, and what the current recruitment process is. there was a moderate amount of relative risk for the sample. the majority of participants were greater than 65 years old and one-third reported increased sadness with having copd. interventions need to be developed for patients 65 years or older that are geriatric friendly. in terms of participants with increased sadness, a depression screening tool such as the beck’s depression inventory conducted in the medical provider’s office or by case managers would be useful to determine if a patient is suffering from depression. collaboration with the patient’s primary care providers would be beneficial for additional insight. copd support groups for dealing with the disease would provide mental health support. social networking possibilities may be a viable option. in 2014, social networking usage among internet users 65 years and older rose to 59% (smith, 2014). collaboration with mental health clinicians may be necessary depending on the depression screen results. an important consideration in relative risk category is 39% of participants reported they smoke. smoking cessation is the single most important intervention for slowing the progression of copd (national committee for quality assurance, 2009). each patient should be assessed for smoking at every visit (agency for healthcare research and quality, 2012). providers should communicate a strong, clear anti-smoking message for smokers to quit. fewer than half online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 130 of providers regularly screen their patients for smoking (kulig, 2005). smokers should be flagged in their medical record for the providers. smokers should be educated concerning smoking cessation barriers. common barriers include: patient misinformation, levels of motivation, health beliefs, and poor communication with medical professionals. selecting an appropriate smoking cessation program is important. the program should be one that will appeal to the age and the needs of the patient. patients can be evaluated for one’s readiness using the stages of change theory (prochaska & diclemente, 1983). the model identifies five stages of change: precontemplation, contemplation, preparation, action, and maintenance. individualized smoking cessation strategies can be developed based on the stage the patient is in. for example, most smokers who fall in the preparation stage are ready to quit and fully intend to do so. the health care provider should explore and formulate realistic options with them, encouraging the smoker to select a specific quit date in the near future (huber & mahajan, 2008). research by coronini-cronberg, heffernan, and robinson(2011) demonstrated obtaining an annual spirometry measurement with a brief smoking cessation intervention, followed by a personal letter from the medical provider had a higher year abstinence rate among copd patients (coronini-cronberg, et al., 2011). smokers who have a long history of smoking should be considered for nicotine therapy replacement (nrt), behavioral therapy, and depression screening as smokers report higher levels of depression (thomas, supiano, chasco, mcgowan & beer, 2009). ask-assess-assist-advise-arrange is a smoking cessation approach supported by the national cancer institute. the process involves: asking and documenting if the patient uses tobacco at every visit; strongly advising against smoking and urging every tobacco user to quit; assessing if the patient is willing to make an attempt to quit; assisting the willing online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 131 patient in the quit attempt by initiating nrt and behavior counseling; and arranging for a follow-up contact in person or by phone within the first week after the quit date (agency for healthcare research and quality, 2012). thirty-three percent (33%) of the sample reported they live in a solely rural area. twentysix percent reported they need more support for their copd and 10% reported they do not get medical attention during an sob episode due to lack of provider, transportation, or finances. continuity and coordination of care can be a difficult challenge for increased rural areas (bellamy et al., 2011). further assessments are necessary to determine what type of copd care support patients need and how to solve the lack of access to medical attention for sob. selfmanagement interventions could be practical in this setting. the most effective self-management plans combine pharmacological management, remote monitoring by telephone or telemonitor, and an individualized plan that includes educational strategies of self-regulation, self-care, and managing the barriers to self-care (bourbeau & nault, 2007; bourbeau & saad, 2013). this sample was moderately healthy. for example, the majority of the sample reported they could regularly complete their adls (89%) and knew how to handle their sob episodes (78%). congruent with current research (shelton et al., 2000) the sample’s indicators of decreased health status are: the majority visited their doctor greater than twice per year (78.5%), take five or more prescriptions daily (74%), have two or more comorbidities (66%) and often feel short of breath (64%). at least half of the sample reported visiting the er in the past six months (51%) and had at least one hospitalization in the past year (52.9%). consequently only a small portion (17%) does not seek health care when sob. research supports the strongest predictors of increased use of hospital services are history of er visits and hospitalization, co online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 132 morbidities, and five or more daily prescriptions (cihi, 2013). health status results appear to be the strongest indicator for developing an action plan and early intervention program. given the statistical significance that participants living in rural counties surrounding wayne co were more likely to use a home remedy and not seek medical attention for a sob episode, a selfmanagement program is recommended to allow for regular assessment of patients’ mental and physical status. this would include collaboration of the patient, caregiver, and health care providers to implement strategies to relieve the sob and keep the patient in the home longer. self-management programs have been shown to support chronically ill patients and their caregivers, improve patient outcome and prevent hospitalization (muenchberger & kendall, (2010). there are different self-management program models. for example, living well with copd program is a self-management program that consists of patient and caregiver education, health promotion interventions, and regular follow-ups to support the patient in managing their at home (bourbeau & van der palen, 2009). further assessments are needed to determine which self-management program would be effective for this population. the program should include a combination of direct communication using home visits, telephone, and telehealth (bourbeau & van der palen, 2009). post assessment activities given that there are a significant number of patients diagnosed who copd who are smokers, smoking cessation screening and programs should be implemented into the care program in order to address this health issue. there are also a significant number of patients with increased sadness. depression screening is recommended to identify the number of copd patients who need mental health support. health care providers and support staff should evaluate online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 133 their treatment methods in order to address this issue. perhaps patients would not want to continue treatment because of the negative influence on their lives. stakeholders need to know that patients reported they need more support for their copd. further assessment should be conducted to determine what type of copd care support is needed. copd providers should address the need for self-management with an education platform to educate the patient on their disease. a working collaboration between primary care providers, specialty providers, case managers, and other medical support is needed to address the priority needs of copd patients. this will work to provide better service and address relative risk challenges for patients. moreover, additional assessments to determine specific patient gaps related to access to care are needed. limitations project limitations include a small and homogenous sample size, therefore, the project results are not generalizable to other populations with copd. regarding representation, participants willing to fill out the survey may have been in better health and more likely to participate in their health care. for example, 23% of the participants were recruited from pulmonary rehabilitation services. furthermore, some participants may not have be willing to share personal information for fear of lack of anonymity. implications when comparing the scores, the results demonstrate a high to moderate amount of resource availability and a moderate amount of relative risk and health status. these considerations are important when planning future care for this population (lemmens, nieboer, & huijsman, 2008). for example, the participants’ education level and social support are factors to consider when online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.378 134 implementing smoking cessation which may include a caregiver’s support. caregiver assistance and transportation would be useful when enrolling a copd patient in a health promotion program such as pulmonary rehabilitation. risks are also important when considering interventions, increased sadness and more copd support needed warrants further study to determine the level of sadness and support needed. research (henry, man, & fung, 2013) has been conducted concerning the effectiveness of nurse-led copd management programs to improve health outcomes and prevent rehospitalizations. successful programs were ones who utilized a primary apn assigned to the copd patient. the apn maintained weekly communication, made bi-weekly home visits and maintained regular collaboration with the primary care provider or specialist to adjust the treatment plan as needed (long, 2012). utilizing the project findings, these early interventions can be instituted to promote health outcomes. conclusion copd is complex and incurable, yet it is manageable (rasekaba, williams, & hsu-hage, 2009). a needs assessment is an effective tool to use as a basis for developing effective early interventions targeted at improving health outcomes of copd patients (issel, 2014). stakeholders such as physicians, nurses, copd support services, and significant others should be included when establishing goals and action plans. qualitative research is warranted to understand what support is needed and why copd patients are still smoking. further assessment is needed to examine what additional health promotion interventions would be successful with this population. for example, investigating if telemedicine be useful with this population. online journal of rural nursing and 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 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 editorial farewell jeri w. dunkin, phd, rn, chce, faan as i begin my retirement, unpacking boxes from my office at the university of alabama, i am finding many items that have led to reflections of years past. many of the most poignant memories are those related to the online journal of rural nursing and healthcare. the concept of an open access journal for rural nurses began to emerge as the dean of capstone college of nursing at the university of alabama , sara barger, dpa, rn, faan and i discussed strategies for positioning capstone college of nursing at the university of alabama in a way that would enhance the mission of the university of alabama’s focus on rural residents of alabama as we looked forward to a new millennium. as a result of those discussions and our passion for rural nursing and health care, i began searching for any existing journal that was freely assessable by rural nurses that served as a resource for their practice. there were numerous journals on the topic of rural healthcare but none that were fully electronic in format that targeted rural nurses and other health professionals, and freely accessible to anyone who needed information. i begin talking with anyone and everyone i knew that were involved in rural nursing about this idea and their willingness to serve on the editorial board for the journal. through those discussions it became clear that the journal would be most useful if it could serve as a forum for related research, issues, concerns and practices of rural nurses around the world. the editorial board began its work as an international group and it continues to reflect the international foundation still. the review panel was developed to reflect the international nature of the journal as well. it too, remains internationally representative, thus providing the broad knowledge base of rural nursing and healthcare needed to critique manuscripts from around the world. with the assistance of the local area network manager, at the university of alabama capstone college of nursing, and dr. steven maccall from the university of alabama school of library and information studies, who served as managing editor, i began accepting manuscripts for consideration by the review panel in preparation of publication of the first issue of the journal. the firs tissue of the journal was published in the spring of 2000. over the years since that first issue, the journal’s popularity has grown around the world with a readership that now spans over 90 countries. it is referenced in the cinahl data base and available through ebsco and other literature search organizations. as the journal grew i came to realize that it in order to continue to grow and offer all the features available for online journals that a larger more integrated base of operations was going to be needed soon. i began talking about this need with the board of directors of the rural nurse organization, the official parent organization of the journal, about this need. after much discussion, the decision was made to move the journal operations to binghamton university, the decker school of nursing in binghamton, new york, under the editorship of dr. pamela stewart fahs, rn, dsn. this is her first issue and i am really excited about what she has done. i think you will agree that she has provided a high quality issue for us and that she will continue to do so as time goes on. i know she will facilitate the growth and enhancement of the journal in a way that will reflect the diversities and similarities of rural nursing around the world. i leave you in good hands and thank you for all your support over the years. microsoft word dunkin_column 1   online journal of rural nursing and health care, vol. 10, no. 2, fall 2010  editorial nursing and health care by jeri w. dunkin, phd, rn, faan editor i want to focus my editorial for this issue on the role i believe nurses should take in the development, implementation and refinement of health care systems at the local, state, national and international level. this was reaffirmed for me with the release of the institute of medicine (iom) and the robert wood johnson foundation landmark report, “the future of nursing: leading change, advancing health” on october 5, 2010. in that report nurses are cited as a catalyst for the transformation of health care system, ensuring that care is patient-centered, effective, safe and affordable. while this report provides a blueprint for improving health care in the united states, which calls for the remodeling of a health care system to ensure high-quality, patient-centered care through the leadership of nurses, the messages it carries are applicable to nursing and health care around the world. the culmination of a rigorous and consequential two-year initiative, the report outlines four overarching messages directed toward policymakers, national, state and local government leaders, payers, and health care researchers, executives, and health care professionals. these messages, i believe transcend geographic boundaries and encompass all nursesfrom those in the most populous to the most sparsely populated areas of every country, and furthermore, rural nurses everywhere share the historical experience of collaboration and cooperative practices needed to achieve high quality health care for their patients and communities. the four key messages include: • nurses should practice to the full extent of their education and training; • nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression; • nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the united states; and • effective workforce planning and policy making require better data collection and an improved information infrastructure. the report acknowledges that to achieve significant improvements to local, state and national health policy, the largest segment of the health care workforce – nurses – need to be fully engaged with other health professions, and i believe that this nursing leadership and collaboration should, no must, be centric to health care programming around the world. i believe that now more than ever rural nurses must step forward and share their experiential knowledge of collaboration and cooperation with other health professionals that will provide other nurses with the “models that work” to move the health care systems of the world to be effective, efficient, affordable in providing high quality health care. 2   online journal of rural nursing and health care, vol. 10, no. 2, fall 2010  i have included the links to the full report and the overview of the report for more details. to view the report visit: http://www.nap.edu/catalog.php?record_id=12956 and to view institute of medicine overview visit: http://tinyurl.com/2bpzer2.   online journal of rural nursing and health care, 1(3) 10 domestic violence and pregnancy in rural west virginia cynthia armstrong persily, phd, rn1 shamira abdulla, ba2 1 associate professor and chairperson, school of nursing, west virginia university, cpersily@hsc.wvu.edu 2 school of nursing, west virginia university abstract recently, domestic violence has been recognized as a health problem of crisis proportion. pregnant women are at twice the risk of battery. abuse during pregnancy affects one woman in six. the purpose of this pilot study was to determine the incidence of domestic violence in pregnant patients residing in a rural area of west virginia, and to describe the demographic characteristics of those abused women. the medical records of 63 pregnant women at a rural health clinic were reviewed. twelve of 63 pregnant women (19%) reported recent or past abuse; 12.7% reported physical abuse and 9.5% reported mental abuse. four out of 63 subjects (6.3%) were treated for physical abuse during pregnancy. significant relationships existed between std history and abuse (x2 = 8.672, df = 1, p = .0032), tobacco use and abuse (x2 = 9.079, df = 1, p = .0026), and marital status and abuse (x2 = 10.03, df = 3, p = .0183) in pregnant women. individual, provider and community strategies for assessment and intervention with abused women in pregnancy are presented. keywords: domestic violence, abuse, pregnancy, rural, community online journal of rural nursing and health care, 1(3) 11 domestic violence and pregnancy in rural west virginia every 12 seconds in this country, a woman is a victim of domestic battery. battered women are defined as women who have suffered one or more episodes of battery from their male partner or ex-partner. battery includes slapping, kicking, punching, shoving, torture, and sexual assault. women who are physically abused also suffer psychological and emotional battery (bohn, 1990). s ince there are no racial, ethnic or socioeconomic predictors of abuse, all women are at risk of being abused. an overwhelming 50% of all women will experience physical violence in an intimate relationship (bohn, 1990). women in rural areas may be at increased risk due to a lack of resources, social isolation and cultural traditions which inhibit reporting of domestic violence. physical assault during pregnancy also occurs at an alarming rate in the us. pregnant women are at twice the risk of battery; abuse during pregnancy affects one woman in six (16.6%) and is an indicator for increased risk of tobacco, alcohol and illicit drug use. abuse during pregnancy has also been correlated with poor pregnancy outcomes (mcfarlane, parker & soeken, 1996a). usually, violence escalates during pregnancy, and blows to the genitals, breast and abdomen are especially common (mcfarlane, parker & soeken, 1996b). again, rural women may be at increased risk. health care providers working with rural women must carefully assess for domestic violence, and intervene in a culturally relevant manner. recently, staff at a rural health clinic became aware of a seemingly increased rate of reports of domestic violence in their pregnant population. this rural health care facility mainly provides care to low income, under insured and uninsured families. in considering action, the providers decided that the first step was to identify the incidence of domestic violence among the pregnant women cared for in the prenatal care program. next, providers thought that valuable online journal of rural nursing and health care, 1(3) 12 information regarding the incidence of other associated risk factors associated with domestic violence should be collected. finally, a plan of action which included careful patient assessment, referrals, provider education and community awareness was initiated. this article will outline the results of each of these steps. methods the purpose of the initial step of the plan was to determine the incidence of domestic violence in pregnant patients residing in a rural area, and to describe the demographic characteristics of those abused women. the following research questions were used to guide collection of data: 1. what is the incidence of reported domestic violence in pregnant women in a rural health clinic? 2. is there a difference in the sociodemographic characteristics of pregnant women who have been abused versus those women who were not abused? after receiving approval from the charleston area medical center/west virginia university institutional review board, a retrospective chart review was completed. a standard pregnancy risk assessment system was used with all subjects and was available on each chart. questions regarding abuse included whether the subject had experienced abuse, and whether the abuse was physical, mental, sexual or child abuse. during the initial prenatal interview and subsequent prenatal visits, the two question screening method as described by mcfarlane and colleagues (1995) was used to assess for physical and sexual abuse. accordingly, women were asked if within the last year they had been hit, slapped, kicked or otherwise physically hurt by the partner or a family member, or forced to have sexual activities. also, risk factors, such as smoking and substance use (alcohol and illicit drugs) were measured. other sociodemographic online journal of rural nursing and health care, 1(3) 13 characteristics measured included: ethnic background, age, marital status, work status, insurance type, and education of the patient and partner. information regarding past pregnancy history, contraceptive methods used, sexually transmitted diseases contracted and presence of other children in the household was also collected. the data collection was limited to that available in the chart for this retrospective study, therefore, some data, such as income, was not available. results the medical records of all pregnant women who had sought prenatal care at the rural health clinic since the inception of the prenatal program (2 years) were reviewed. the number of charts was 63. the demographic characteristics of the pregnant women and their partners appear in table 1. all of the women were caucasian. most pregnant women were between the ages of 20-29, 41.3% were adolescents. the mean age for pregnant women was 21.49 (52.4% in range of 20-29). the mean age for partners of pregnant women was 24.58 (51.6% in range of 20-29). data analysis indicated that abused women were all older than age 19 (range 19-32). almost half of the partners of abused women were under the age of 30 (range 22-34). more than half of the pregnant women (52.4%) and their partners (54.2%) had less than 12 years of education. among abused women, data showed that 41.6% had less than 12 years of education, and 72.7% of partners of abused women had less than 12 years of education. most of the pregnant women (55.6%) were single; 38.1% were married. of abused women, 41.6% were married, 33% were single. in non-abused women 37.2% were married and 60.7% were single. the majority of pregnant women (63.5%) were unemployed; 41.4% of partners of pregnant women had mostly low paying, full-time jobs. abused women and their partners were more likely to be unemployed than non-abused women and their partners. most of the women were experiencing online journal of rural nursing and health care, 1(3) 14 their first (46%) or second (31.7%) pregnancy. twelve out of 63 patients (19%) reported recent or past abuse (within a year prior to pregnancy); 12.7% reported physical abuse. mental abuse, including emotional abuse was reported by 9.5% of the subjects. four out of 63 subjects (6.3%) were treated for physical abuse during pregnancy. all who reported abuse reported that the abuse was perpetrated by a spouse or male partner. characteristics of abuse, std history, contraception use and substance use characteristics are shown in table 2. data indicated that most of the pregnancies were not planned and only 31.7% of women used contraceptives prior to pregnancy. the proportion of women who reported a past std was 6.3%. tobacco use prior to conception was 55.6%; 11.17% used alcohol, and 9.5% used illicit drugs before pregnancy. during pregnancy, tobacco use was most prevalent in the population, (44.49%) followed by alcohol use, (3.2%). no illicit drug use was reported during pregnancy. there were no significant differences between abused women and non-abused women and their partners in age, highest level of education completed or employment. also, no significant differences between abused and non-abused pregnant women were found in contraception history, alcohol use, illicit drug use or presence of other children at home. however, significant relationships did exist between std history and abuse, tobacco use and abuse, and marital status and abuse in pregnant women. table 3 presents characteristics of abused pregnant women versus non-abused pregnant women. a consistent increase in percentage was found among tobacco use, alcohol use, std history and contraception use in abused, pregnant women. while some statistically significant results were noted, given the small numbers of abused women in the sample (n=12), a discussion of the trends in the data are included as important to consider in future research. a significant relationship existed between tobacco use and abuse in pregnant women. a high proportion of online journal of rural nursing and health care, 1(3) 15 women, 83.3%, who were abused used tobacco (x2 = 9.079, df = 1, p = .0026) versus only 35.3% of pregnant women who were not abused. no significant relationships were found between alcohol use or illicit drug use during pregnancy in abused women. however, alcohol use was more prevalent among abused women (8.3%) than among non-abused women, (2.0%). another significant relationship was found between std history and abuse in pregnant women. twenty-five percent of the women who were abused had experienced a past std (x2 = 8.672, df = 1, p = .0032) versus 2.0% of women who were not abused. contraception use prior to pregnancy was similar in abused and non-abused women. a third significant relationship was found between marital status and abuse (x2 = 10.03, df = 3, p = .0183). women who were abused were more likely to be married than women who were not abused. also, although there was no significant relationship between abuse of pregnant women and the presence of other children at home, 75% of abused women had other children at home compared to 39.2% of nonabused women who had other children at home. online journal of rural nursing and health care, 1(3) 16 online journal of rural nursing and health care, 1(3) 17 online journal of rural nursing and health care, 1(3) 18 online journal of rural nursing and health care, 1(3) 19 discussions after reviewing the data collected during the initial phase of this evaluation of domestic violence in pregnancy in a rural health center, several key factors were felt to deserve provider attention. first, the incidence of abuse during pregnancy among women in this rural area of west virginia was found to be 19%. this percentage is considerably higher than found in the literature where abuse during pregnancy has been reported to affect one in six women (16.6%)(mcfarlane, parker, and soeken, 1996a). we found that 12.7% of women experienced physical abuse and 9.5% experienced mental abuse. some women experienced both types of abuse. most abused women and their partners were in their twenties and married, which was inconsistent with the findings of other studies in the literature (dye, tolliver, lee & kenney, 1995). consistent with the stressful life situations experienced by abused women, there was clearly a higher incidence of substance use during pregnancy in abused women. a significant relationship existed between tobacco use and abuse of pregnant women. a low incidence of alcohol and illicit drug use was noted in pregnant women. however, compared with smoking, the use of alcohol and illicit drugs is more socially unacceptable and, as a result, is difficult to measure via self-report. another significant relationship which was found was between std history and abuse in pregnant women. this finding may be attributed to a predisposition of abusive male partners to have more than one sexual partner, and to not practice safe sex, since a common characteristic of abusers is exercising "controlling" behavior towards their partners (parker, 1995). accordingly, most pregnancies in this study were not planned. all of these factors place these pregnancies at risk of poor outcomes. online journal of rural nursing and health care, 1(3) 20 next, even though no significant relationship was found between other children living at home and abuse of pregnant women, an overwhelming 75% of women who reported abuse had other children at home. the degree of abuse against the woman and abuse during pregnancy may be risk factors for potential child abuse. children who witness or directly experience abuse may later exhibit a wide range of problems. school achievement anxiety, phobias, depression, difficulty forming relationships, sexuality and communication are all negatively affected. the majority of abusive men come from homes where they witnessed the abuse of mothers or were abused themselves as children (bohn, 1990). in one-third to over one-half of homes of battered women, children are physically abused or seriously neglected (bekemeier, 1995). finally, a significant relationship was found between marital status and abuse of pregnant women. abused women were more likely to be married than single. battered women in rural areas may be more likely to stay in an abusive marriage for financial reasons. access to help may be limited by a lack of public transportation, by distance, and by unavailability of supportive social agencies. it is likely that many women fail to seek help because they do not know what resources are available. some women aren't even aware that domestic violence is a crime. furthermore, some women have been socialized to carry the burden of keeping the marriage together; failed marriages are often damaging to a woman's self-esteem. women may also fear losing family relationships and, especially in this group, fear losing their children (noel & yam, 1992). limitations of the study several limitations of this study are recognized. first, the retrospective nature of the study is a limitation. certain data which would have provided a clearer picture (such as income) of the population were not available. therefore, proxy measures of employment and insurance online journal of rural nursing and health care, 1(3) 21 status were used, but may be deceiving. next, only small numbers of charts were available for review. this is a realistic limitation in research conducted in single, rural communities, as only small numbers of the population may be affected by the variable of interest, in this case pregnancy, and further, domestic violence in pregnancy. currently, efforts to overcome these limitations in analyzing domestic violence in pregnancy in this rural community are ongoing. data related to domestic violence are being collected prospectively on all pregnant women who initiate and continue prenatal care at the rural health center. this has allowed the tailoring of assessments and data collection to best meet the needs of clinicians for care provision, and researchers for program evaluation. additionally, multi-year data are being collected to allow for larger numbers of subjects for future evaluation. implications for practice in response to these problems identified in this pilot study, strategies at three levels were initiated. these included strategies at the individual, provider, and community level. individual strategies since the incidence of domestic violence in pregnancy is thought to be underreported, and there have been no sociodemographic predictors of domestic violence in pregnancy identified, we concur with the recommendations of others in the literature to screen all pregnant women for abuse. in addition, we have found that using at every prenatal visit the brief method of clinical screening recommended by macfarlane and colleagues(1996b), which includes only two questions, has been successful in identifying abuse in a large segment of our population. once abuse has been identified, appropriate individual strategies are implemented. these include safety assessment, support, counseling, referral to abuse services, and ongoing prenatal care. implementation of these services required provider education and awareness. online journal of rural nursing and health care, 1(3) 22 provider strategies the rural health center where this program was implemented serves as a year round education site for health sciences students from the disciplines nursing (graduate and undergraduate), medicine, pharmacy, physical therapy, and dentistry. university faculty and field faculty serve as providers of care as well as educators for students. through the west virginia rural health education partnerships program, multidisciplinary seminars are provided weekly for all students. the faculty and providers felt that this was an excellent opportunity to provide education and information for students from all disciplines regarding assessment of abuse and danger, support services that are available in the rural community, referrals, and protocols for practice. monthly inclusion of a topic related to domestic violence and abuse has been instituted. community strategies many opportunities exist for community education relative to domestic violence. the results of this study document the need for community awareness of an urgent health care problem. representatives of domestic violence programs are now included in health fairs and information sessions held in the community. domestic violence education has been integrated into the curriculum for training lay home visitors of pregnant women in the community. information for patients is available in the health center waiting rooms, restrooms and examination rooms and throughout the community. domestic violence information has also been included in the center’s quarterly newsletter, mailed to every household in the community. implications for future research the pilot study reported here documents the need for further evaluation of domestic violence in pregnancy and related factors in rural health centers. an ongoing study seeks to online journal of rural nursing and health care, 1(3) 23 extend the pilot study by evaluating prenatal and delivery outcomes in this rural health center. the specific aims of this study included development of a data base to link prenatal outcomes achieved at the rural health center with delivery outcomes accomplished at the urban delivering hospital. this data base allows providers and researchers to, among other things, evaluate the incidence of domestic violence in the prenatal period, and to also evaluate links between that violence and pregnancy outcomes. rural health centers frequently do not have the infrastructure to link these outcomes, but information regarding outcomes is essential for evaluation of care and program planning. the system developed in this study can serve as a model for other rural health centers providing prenatal care. data analysis for this study is underway. another proposed study seeks to intervene in rural communities to improve pregnancy outcomes. that study will use a community empowerment model to facilitate home visiting and ongoing support during pregnancy by lay women, and to empower community members, organized into local "community empowerment boards", to capitalize on the strengths found within the community while analyzing and overcoming barriers to improved pregnancy outcomes. this model, which shifts control from health care providers to people indigenous to rural communities, offers promise in tackling complex health and social problems such as domestic violence and pregnancy. a funding decision is pending. conclusion with the inclusion of domestic violence assessment as a part of the initial and ongoing routine assessment for all pregnant women in a rural health clinic, episodes of domestic violence at a rate somewhat higher than that noted in the literature were discovered. it is imperative that providers take the initiative and include abuse assessment as part of every routine clinical assessment. the prenatal period, when health promotion is a priority, is an opportune time for online journal of rural nursing and health care, 1(3) 24 assessment, intervention and prevention of abuse. providers should partner with women, their families and the community to improve pregnancy outcomes through providing secondary prevention services for abused pregnant women and primary prevention services for non-abused women. online journal of rural nursing and health care, 1(3) 25 references bekemeier, b. (1995). public health nurses and the prevention of and intervention in family violence. public health nursing, 12, 222-227. https://doi.org/10.1111/j.1525-1446.1995.tb00140.x bohn, d.k. (1990). domestic violence and pregnancy: implications for practice. journal of nurse midwifery, 35(2), 86-97. https://doi.org/10.1016/0091-2182(90)90064-c dye, t.d., tolliver, n., lee, r., & kenney, c. (1995). violence, pregnancy and birth outcome in appalachia. pediatric and perinatal epidemiology, 9, 35-47. https://doi.org/10.1111/j.1365-3016.1995.tb00117.x mcfarlane, j., greenberg, l., weltge, a., & watson, m. (1995) identification of abuse in emergency departments: effectiveness of a two question screening tool. journal of emergency nursing, 21, 391-394. https://doi.org/10.1016/s0099-1767(05)80103-5 mcfarlane, j., parker, b., & soeken, k. (1996) abuse during pregnancy: associations with maternal health and infant birth weight. nursing research, 45, 1, 37-42. https://doi.org/10.1097/00006199-199601000-00007 mcfarlane, j., parker, b., & soeken, k. (1996). physical abuse, smoking and substance use during pregnancy: prevalence, interrelationships, and effects on birth weight. journal of obstetric, gynecologic, and neonatal nursing, 25, 313-320. https://doi.org/10.1111/j.1552-6909.1996.tb02577.x noel, n., & yam, m. (1992). domestic violence: the pregnant battered woman. nursing clinics of north america, 27, 871-85. parker, v.f. (1995). battered. rn, 58(1), 26-29. https://doi.org/10.1111/j.1525-1446.1995.tb00140.x https://doi.org/10.1016/0091-2182(90)90064-c https://doi.org/10.1111/j.1365-3016.1995.tb00117.x https://doi.org/10.1016/s0099-1767(05)80103-5 https://doi.org/10.1097/00006199-199601000-00007 https://doi.org/10.1111/j.1552-6909.1996.tb02577.x online journal of rural nursing and health care, 1(1) 6 editorial rural practice forum: understanding rural health care bette ide, phd, rn, editorial board member this column will deal with how the rural health professional actually practices. as a health care provider living in a rural community, how do you deal with the characteristics of rural people, cultures and communities on an everyday basis? the literature has emphasized certain characteristics of rural people and communities that influence the role of rural health professionals. they include factors such as a present time/crisis orientation, emphases upon individualism and independence, reliance upon self-care for health problems, and a tendency to tough-it-out. health is often defined by rural people as the ability to work. also impacting the role of the health professional is the strong role of opinion leaders, those few influential people or families in the community who control the degree to which people and ideas are accepted. the rural community often acts as gatekeeper, conferring status and acceptance of ideas, thus preferential treatment is common and insider/outsider distinctions are often made. rural people tend to be conservative and tradition-oriented, family and friends are very important, and the rural health professional is part of the social support network (often being seen as a friend first and a professional second). in addition, the rural health professional often deals with populations with greater proportions of the dependent and vulnerable, high rates of risk taking behaviors, and differences in how mental health problems are viewed and interpreted. as a health care provider, the rural health professional often crosses over other disciplines in role, is overwhelmingly a generalist, practices independently to a degree unknown by urban health professionals, and encounters frequent gaps in health care, especially the in the online journal of rural nursing and health care, 1(1) 7 areas of primary care, health promotion, emergency care, and mental health services. physical and professional isolation are counter-balanced by a lack of anonymity and a mixing of professional and everyday roles. the health professional is expected to be available on a 24-hour basis, sometimes giving professional advice while standing in line at the local grocery, and may have to leave town to get a day off. in providing health care, the rural health professional must also deal with situations where the health professional’s values conflict with those of the community. this offers a lot of opportunity for ingenuity and innovation in designing and carrying out programs that are acceptable to the rural community. this column asks how you, as a rural health professional, have dealt with, taken advantage of, and risen above problems or issues such as the foregoing. what ways have you developed to deal with them in your everyday practice? in planning and carrying out programs? we can learn from each other. we are interested in your "ingenuity and innovation." what "tips" can you offer to other rural health professionals? please send a description of the problem or problems you have encountered in practice and how you dealt with those problems by e-mail to: bette_ide@mail.und.nodak.edu. online journal of rural nursing and health care, 1(1) 1 editorial letter from the editor: welcome jeri w. dunkin, phd, rn, editor welcome to the online journal of rural nursing and health care, the official journal of the rural nurse organization. in this time of rapidly expanding knowledge and shrinking resources, the time is appropriate to have a mechanism for rural health professionals to access current research and practice information in an expedient and economical manner. i hope you find the journal informative and easy to use. we have tried to make the format "user friendly." please feel free to contact me with comments and suggestions as we continue to refine the style and format of the journal. you will notice several features that make the journal unique. for example, each article has a discussion forum attached that facilitates discussion and networking among readers and author(s). additionally, each of the columns has the e-mail address of the editorial board member responsible for that column so that you, the reader, can provide feedback and suggestions for future topics. you can be as interactive as you wish, and we hope that you will become very involved in the discussion groups. finally, the citations in the text are "linked" to an alert box so that you can see the full reference immediately without losing your place in the article. also, each citation in the reference list is linked to its respective medline record, should one exist, which takes advantage of the national library of medicine's pubmed service. the online journal of rural nursing and health care is a peer-reviewed interdisciplinary journal that focuses primarily on rural nursing but not exclusively. this decision was made by the board of the rural nurse organization as the journal concept was developed because rural practice is necessarily interdisciplinary. future plans call for the journal to be indexed in online journal of rural nursing and health care, 1(1) 2 cinahl and medline within the upcoming year. there are requirements for listing that includes numbers of issues published that must be met first, but rest assured that our managing editor, dr. steven maccall, will have the journal listed as soon as possible. on behalf of the editorial board of the online journal of rural nursing and health care and the rural nurse organization, i thank you for being a part of this new venture. if i can be of assistance please do not hesitate to e-mail me at jdunkin@nursing.ua.edu. microsoft word robinson_367-2151-2-ed.docx online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 3 beliefs about cholesterol lowering drugs and medication adherence among rural adults with hypercholesterolemia lisa bridwell robinson, dnp, ccrn, cne, np-c assistant professor, university of west georgia, tanner health system school of nursing, lisarobinsonnp@gmail.com abstract coronary artery disease (cad) accounts for 600,000 deaths annually in the united states and is the leading cause of death for both men and women around the world. treatment of hypercholesterolemia has been proven to decrease both morbidity and mortality of cad. primary and secondary prevention of cad is based on controlled ldl cholesterol levels. patient's beliefs related to lipid lowering medications impacts adherence to these medications. influences on health are also impacted by place of residence. negative influences on total health care are based on barriers present in rural communities. the use and acceptance of these medications by rural populations are essential. this pilot project begins to fill knowledge gaps related to rural patients beliefs about medication adherence. purpose: the purposes of this pilot project were to describe rural patient's (a) belief's about high cholesterol and cholesterol lowering medications, (b) their adherence to taking these medications, and (c) relationships between adherence and beliefs. sample: this was a convenience sample obtained at a rural georgia clinic. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 4 method: a descriptive survey approach was used to explore rural dwelling patients' at a primary care clinic in rural georgia. findings: the morisky scale addressed the patient's adherence to their prescribed cholesterol medications. the habit tool examined patients' beliefs. calculations were completed on the responses of the participants. spearman's rho correlation revealed patient's who believe the mediations work, and patient's who believe elevated cholesterol increases the risk of heart attack were more likely to be adherent with their cholesterol lowering medications. conclusion: increasing the patient's knowledge and addressing beliefs can result in increased adherence with cholesterol lowering medications. keywords: coronary artery disease, rural populations, patient's beliefs, medication adherence beliefs about cholesterol lowering drugs and medication adherence among rural adults with hypercholesterolemia coronary artery disease (cad) accounts for 600,000 deaths annually in the united states (us), (centers for disease control and prevention [cdc], n.d.). the leading cause of death for both men and women in the us and worldwide has remained cad (calderon, cubeddu, goldberg, & schiff, 2010; schedlbauer, davies, & fahey, 2010). one in two men and one in three women are expected to develop cad in their lifetime (murphy, roth, & andrea, 2005). treatment of hypercholesterolemia has been proven to decrease both morbidity and mortality of cad (cross & franks, 2005). primary and secondary prevention of cad is based on controlled low-density lipoprotein (ldl) cholesterol levels (calderon et al., 2010; marquez, casado, motero, & online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 5 martin, 2007; vrijens, belmans, matthys, deklerke, & lesaffre, 2006). primary prevention of cad suggests lipid lowering medications be prescribed to asymptomatic adults who have a risk of developing cad in the next ten years (national institute for health and clinical excellence [nice], 2006; scottish intercollegiate guidelines network [sign], 2007; schedlbauer et al, 2010). secondary prevention in cad treatment with lipid lowering medication could decrease death and disability rates by more than 50%. control of hypercholesterolemia can reduce the five year incidence of cardiovascular events irrespective of the initial lipid profile (nice, 2006; sign, 2007; schedlbauer et al, 2010). substantial impact on public health can be achieved with lipid lowering medications. the use and acceptance of these medications by the public are essential. according to crawford et al. (2010), caucasians are the highest proportion of the population diagnosed with hypercholesterolemia at 25.7%. african american populations have a 17.2% occurrence rate. males have an occurrence rate of 25.1% and females follow at 19.2%. as age and body mass index (bmi) increase, the prevalence of hypercholesterolemia also increases. calderon et al. (2010) also found persons older than 60 years have occurrence rates above 50%, and as bmi exceeded 35 the occurrence of hypercholesterolemia climbs to 33.9%. a reported 105 million americans have elevated ldl levels. forty two million of those have values considered at high risk and qualify for medication therapy (calderon et al., 2010). further, rural populations in the southern us have higher rates of smoking, physical inactivity, poor diet, death from ischemic cad, which increases risks and makes medication adherence even more important and births to adolescents (hartley, 2004). online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 6 unique barriers to health care have been identified in rural populations (devoe et al., 2007; hoerster et al., 2011; hartley, 2004). the impact of place of residence on health has been established. multiple disparities such as access to care, transportation, and diminished affordability arise more frequently in rural areas (devoe et al., 2007; hoerster et al., 2011; hartley, 2004). background and significance research into medication adherence has been extensive in the last decade. increased emergency room visits, hospital admissions, and morbidity and mortality have resulted from poor medication adherence (benner et al., 2009). distinctions have been made between poor adherence that is a result of deliberate actions by the patient versus poor adherence that may accompany complex regimens, lack of self-management skills, or inaccurate perceptions or beliefs. toh, jackson, gascard, manning, and tuck (2010) define unintentional non-adherence as a patient’s inability to follow directions due to poorly defined regimen or a physical disability and defined intentional non-adherence as a patient’s decision not to take prescribed medications. schwartz et al. (2009) attempted to identify barriers, predictors, and facilitators of medication use in african americans with hypercholesterolemia. the authors studied medication adherence in african american patients, who were treated in a primary care clinic outside of a large urban city, and found medication adherence to fall below 30% (schwartz et al, 2009). barriers to adherence included timely diagnosis and treatment. other factors preventing medication adherence were attributed to cost, forgetfulness, polypharmacy, and the absence of symptoms. the research indicated diagnosis and treatment should be based on nationally online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 7 accepted guidelines, and combined with primary patient education to increase medication adherence (schwartz et al, 2009). scientific evidence related to the effectiveness of lipid lowering medications for the treatment of hypercholesterolemia abounds. statin drugs, the most effective for lowering cholesterol levels, work by inhibiting hmg coa (calderon et al., 2010; cross & franks, 2005; foley, vasey, berra, alexander, & markson, 2005; hachem & mooradian, 2006; schedlbauer et al, 2010). this synthesis reduction decreases cholesterol content in the liver which lowers serum ldl cholesterol. the drugs from the statin category currently available reduce ldl levels approximately 30-50% in clinical trials (besseling, van capelleveen, kastelein, & hovingh, 2013). achieved control of ldl levels with statin medications reduces the relative risk of cad as much as 35% (alla et al., 2013). treatment to achieve goals often requires additional tests, and office visits with changes in medication therapy, frequently leading to decreased medication adherence (foley et al., 2005). as statin drugs are titrated to achieve therapeutic goals, maximum statin doses come with increased side effects, including rhabdomyolosis (hachem & mooradian, 2006). at the same time, reports in the literature suggest poor medication adherence to hmg coa reductase inhibitors continues (harrison et al., 2013). for years research has shown patients fall short of the national cholesterol education program (ncep) standards for effective treatment of hypercholesterolemia (besseling et al., 2013). one study in a primary care clinic outside of a large urban city found medication adherence to fall below 30%. fewer than half of patients achieve cholesterol goals with the initial statin dose (chi, 2014). medication adherence in the treatment of hypercholesterolemia online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 8 has been shown to significantly lower morbidity and mortality related to cad (besseling et al., 2013). rural populations experience many disparities in the utilization of health care (hartley, 2004). these disparities in rural areas are associated with social status, income, occupation, education, and place of residence. negative influences on total health care are based on the barriers present in these rural communities. water quality, agricultural methods, forestry, or mining can also impact health care for rural residents. access to health care is impacted by decreased numbers of providers and transportation issues related to distance to receive care (hartley, 2004). vehicle ownership has been associated with increased utilization of health care services (hartley, 2004). rural populations had diminished resources available to allocate to vehicle ownership inhibiting access. public transportation also remains absent in rural areas. additional barriers present in rural areas are a lack of insurance and costs related to health care. uninsured and underinsured populations may struggle with co-pays, high deductibles, and prescription drug cost. decreased numbers of health care providers is prevalent in rural areas (pieh-holder, callahan, & young, 2012). access to care and the limitations caused by rural life style can complicate diagnosis, treatment, and follow up in this population. conditions seen in the rural demographic constitute a unique set of challenges. access to care and the limitations caused by rural life style can complicate diagnosis, treatment, and follow up in this population. this pilot project begins to fill knowledge gaps related rural patients beliefs about medication adherence. purpose online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 9 the purposes of this pilot project were to describe rural patient’s (a) belief’s about high cholesterol and cholesterol lowering medications, (b) their adherence to taking these medications, and (c) relationships between adherence and beliefs. methods conceptual framework donabedian provides an excellent framework to explore beliefs affecting medication adherence in the treatment of hypercholesterolemia. this model can be applied to the rural population to assist the primary investigator in understanding the unique challenges in this specialized population. examination of beliefs related to medication adherence with statin medications in the treatment of hypercholesterolemia can be achieved through review of the structure, process, and outcomes as delineated by donabedian (driel, sutter, christiaens, & maeseneer, 2005). design and setting a descriptive survey approach was used to explore rural dwelling patients’ at a primary care clinic in rural georgia. the population of the county is 11,346, with the following ethnic composition: 89% caucasian, 10% african american, and 1% hispanic. growth in the population over the last 25 years was seen only in the caucasian population. age range statistics are 27% under age 18, 63% ages 18 to 64, and 10% over age 65. average household income is $41,066 (heard county community partnership, 2008). mobile homes comprise 38% of the dwellings in the county. over 51% of the school children receive free or reduced cost lunches (heard county community partnership, 2008). completion of high school or equivalent level of education had not been achieved by 34% of the adult population. attainment of a four year degree was online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 10 achieved by only 1.6% of the population (heard county community partnership). social and cultural issues of the area include the prevalence of an agrarian lifestyle. commercial timber, poultry houses, and cattle production prevail as 80% of the county remains in an agricultural or forestry land status (heard county community partnership, 2008). economically, the county benefits from having six power plants located within the area. (heard county community partnership, 2008). health and access to health care within the county are available through only one clinic staffed by one physician and one nurse practitioner. the active patient population of the clinic is approximately 1,300 patients. the clinic provides care to families and children beginning at age eight. the clinic also has a staff of two certified medical assistants, an office manager, a receptionist, and one person responsible for medical records management. the clinic hours are monday through friday from 8am to 5pm. the nearest emergency room and hospital are more than 30 miles away. over 20% of the population is uninsured, and 42% receive some form of medicaid. births of premature infants average 20%, well above state and national averages (heard county community partnership, 2008). infant mortality rates, also above state and national averages, are 11.3%. tobacco use during pregnancy is reported at an alarming 24%. the teen pregnancy rate of 22.6% is double the rate reported for the state of georgia. notably, 26.6% of babies born in the county are to mothers with less than 12 years of education (heard county community partnership, 2008). measures three separate forms were used to collect information in this project, a demographic questionnaire, the morisky scale, and the habit survey. the online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 11 demographic questionnaire included the participant’s specific age, and length of time the participant had knowledge of an elevated cholesterol level. marital status was also acquired, the participants were able to select between single, widowed, married, separated, divorced, or long term relationship options. categories listed for race included white, black, native american, pacific islander, asian, or multi-racial. ethnicity was also an option as hispanic or non-hispanic. educational status was obtained with the length of education divided up by obtainment of elementary, middle, high school, college, graduate, and post graduate education. employment data collected provided options of full time, part time, unemployed, retired, cardiac disabled, or other disabled. lastly, participants were asked to indicate if they had ever been diagnosed with heart disease, had a heart attack, coronary angioplasty, coronary stent, coronary artery bypass surgery, or chest pain. the morisky scale was used to assess the patient’s beliefs about medications. the purpose of the morisky scale is to identify the patient’s beliefs and pinpoint persons with low adherence (bharmal et al., 2009; bondesson, hellstrom, eriksson, & hoglund, 2009; morisky, ang, krousel-wood, & ward, 2008; shalansky, levy, & ignaszewski, 2004). initially, reliability and validity of the morisky survey were established in a study of patients diagnosed with hypertension (bharmal et al., 2009; morisky et al., 2008). following the successful use of the tool with patients diagnosed with hypertension, the scale has been utilized in studies which did not contain a homogenous group. modifications to the morisky survey allows for assessment about patient beliefs and medication adherence. bondesson et al. (2009) suggest the scale should be tailored to specific medicines or groups of medicines. consequently, the format of the tool used in online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 12 this study was modified to address beliefs about medication adherence to statin drugs in the treatment of hypercholesterolemia. the morisky scale items were scored with either a yes or no response. the eight items included questions inquiring if the participant ever forgets to take their statin medication, were any doses missed in the prior two weeks, and had the participant ever decreased or stopped their statin mediation with first discussing the issue with their provider. further questions related to medication adherence and travel. one item inquired if the participant felt taking the mediation was an inconvenience. lastly the morisky questionnaire asked how often the participant has difficulty remembering to take all of their medications. the final component of the packet was the habit survey for patients developed by foley et al. (2005) for assessing attitudes and beliefs about hypercholesterolemia and its pharmacological treatment. statistical reliability and validity of the instrument were established by the authors. a five point likert scale allowed patients to select the degree to which they agree or disagree with each of the attitude statements. the statements used in the survey are rated at a sixth grade reading level. three subscales of the habit survey were used in this study, effectiveness of statin medications, perceptions of adverse side effects at higher doses of statin medications, and severity of health problems if statin medications not taken. eleven items comprised the habit survey and targeted the participants beliefs related to their statin medication. questions included inquiry into efficacy of statin medications, side effects, and if long term exposure could lead to liver damage or muscle aches. then questions were directed to inquiry into statin medications and their online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 13 relationship to cad. questions included beliefs about the correlation between high cholesterol and a heart attack, and if taking statin medications lower the risk of a first or second heart attack. one question asked if the participant believed worries about cholesterol levels were relevant only if someone had already had a heart attack. lastly the tool inquired if the diagnosis of high cholesterol was less serious than a diagnosis of diabetes and hypertension. data collection data collection occurred over a two month period. initial identification of eligibility was established by the primary investigator by reviewing a list of patients scheduled at the clinic on the days the study was conducted. a certified medical assistant offered each patient the option of participation, with explanation participation would not impact the care provided at the clinic. further explanation emphasized to the patients there would be no penalty based on the decision not to participate. dropping out at any time was acceptable and carried no penalty or consequence to the patient, and there was no impact to care received at the clinic. patients who agreed to participate were then given the project packet with the study instruments. all patients who were approached agreed to participate in the study. participants were instructed to complete the forms in the packet onsite at the clinic and to return the packet to the medical assistant. the participant was also given the option of taking the forms home to return them by the postal service. an addressed stamped envelope accompanied the packet if patients elected this option. inclusion in the study was not affected based on completion onsite or offsite. participants were given a $3 gift card to a local grocery store redeemable for purchases of any items at the patient’s online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 14 discretion after completion of the survey. upon reaching the goal of completion of 30 surveys, data collection was concluded. description of the sample the convenience sample was obtained at a rural georgia clinic. permission for the study was granted through the mercer university institutional review board (irb). the study protocol number is h1112300. the inclusion criteria consisted of a diagnosis of hypercholesterolemia, documentation of a prescribed statin medication, age of at least 18 years, mental capacity to self-administer medication, and ability to understand and sign the study consent form. the study forms packet was available in english only. exclusion criteria included the inability to read or speak english. the study also excluded any persons who were incarcerated or residents of nursing homes, as staff at these facilities administer the prescribed medications. data for the 30 participants were analyzed. descriptive statistics were used to describe the sample. the age range of the participants was from 35-81 years with a mean of 54.8 years of age. the majority, 73.3%, n=22 were female and 26.7%, n=8, were male. time since diagnosis of high cholesterol ranged from 1-10 years with a mean of 4.1 years. . thirty six percent (n=11) of the group reported they had been diagnosed with cad. the group was predominantly white, at 86.7% (n=26) and 13.3% (n=4) were black. these proportions are congruent with the demographics of the area. the level of participant’s formal education ranged from middle school to college attendance, with 60% reporting high school graduation. the study participants report significantly higher high school graduation rates than the published demographics of the area where only 34% had completed high school. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 15 findings patient adherence to cholesterol lowering medications the morisky scale addressed the patient’s adherence to their prescribed cholesterol medications. table 1 reports participants responses to each of the 7 yes/no questions in the morisky scale. the two questions indicating the highest levels of non-adherence were “do you sometimes forget to take your medication” and “then traveling, do you sometimes forget to bring your medications along”. the final question on the morisky scale asked participants about remembering to take all of their medications. the format of this question was a likert scale. participants were asked “how often do you have difficulty remembering to take all your medications?” the responses were as follows: never/rarely 30% (n = 9), once in a while 23% (n = 7), sometimes 26% (n = 8), usually 17% (n = 5), and all the time 3% (n = 1). indicating almost 80% of participants has difficulty remembering to take their medications at least some of the time. scoring of the morisky scale is determined by the number of “yes” answers. totals of 0 1 “yes” responses indicates high adherence. medium adherence is scored as 2 3 yes responses, and 4 or more yes responses indicates low adherence. analysis of the morisky scale revealed a mean score of less than six for 70% (n=21) of the participants placing them into a category of low adherence. patients beliefs about cholesterol lowering medications the habit tool examining patients’ beliefs, the range of scores from one-strongly disagree, to five-strongly agree was utilized. calculations were completed on the responses of the participants. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 16 table 1 patient responses related to adherence on the morisky scale question no yes 1. do you sometimes forget to take your cholesterol medication? 33% (n=10) 66% (n=20) 2. people sometimes miss taking their medications for reasons other than forgetting. thinking over the past two weeks, were there any days when you did not take your cholesterol medication? 56% (n=17) 44% (n=13) 3. have you ever cut back or stopped taking your cholesterol medication without telling your doctor, because you felt worse when you took it? 44% (n=13) 56% (n=17) 4. when you travel or leave home, do you sometimes forget to bring along your cholesterol medication? 30% (n=9) 70% (n=21) 5. did you take your cholesterol medication yesterday? 13% (n=4) 77% (n=26) 6. when you feel like your cardiovascular disease is under control do you sometimes stop taking your cholesterol medication? 40% (n=12) 60% (n=18) 7. taking medication every day is a real inconvenience for some people. do you ever feel hassled about having to keep taking cholesterol medication? 40% (n=12) 60% (n=18) when participants were asked about a cad history, 63% (n = 19) believed they had no cad, and 36% (n = 11) confirmed a prior diagnosis of cad. regarding the patients’ belief about statin drug efficacy, 93% (n = 28) stated they agreed or strongly agreed cholesterol drugs work. when asked if the patient wonders whether or their cholesterol medication is working 70% (n = 23) selected agree or strongly agree. analysis of the habit beliefs questionnaire revealed patients had a slightly stronger belief that higher doses would lead to more severe side effects. inquiry related to beliefs about side effects revealed 73% (n = 22) of participants believed increasing dose of cholesterol medications may lead to muscle aches. beliefs relating cholesterol and impact on health demonstrated that 96% (n = 29) believe high cholesterol increases the risk of a heart attack. additionally 93% believe lowering cholesterol would reduce the chances of a heart attack online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 17 in the future. fifty six percent (n = 19) saw cholesterol as serious of a problem as hypertension and diabetes while 43% (n = 13) saw cholesterol as a less serious problem. table 2 below summarizes the findings. table 2 patient response related to beliefs on the habit scale habit scale question strongly disagree disagree neither agree or disagree agree strongly agree 1. in general, do you think cholesterol lowering drugs work? 0% (n=0) 3% (n=1) 3% (n=1) 73% (n=22) 20% (n=6) 2. do you wonder whether or not your cholesterol lowering drug is working? 10% (n=3) 20% (n=6) 0% (n=0) 60% (n=18) 10% (n=3) 3. side effects are not related to the dose of cholesterol drugs. 10% (n=3) 46% (n=14) 0% (n=0) 40% (n=12) 3% (n=1) 4. increasing the dose of cholesterol drugs may lead to muscle aches. 10% (n=3) 13% (n=4) 3% (n=1) 60% (n=18) 13% (n=4) 5. high doses of cholesterol drugs may cause liver problems. 3% (n=1) 10% (n=3) 6% (n=2) 63% (n=19) 16% (n=5) 6. the side effects from cholesterol drugs are relatively minor. 10% (n=3) 26% (n=8) 6% (n=2) 52% (n=16) 3% (n=1) 7. people with high cholesterol are more likely to have a heart attack than people with low cholesterol. 0% (n=0) 0% (n=0) 3% (n=1) 79% (n=24) 16% (n=5) 8. lowering cholesterol will help lower the chances of having a heart attack or other heart problems in the future. 0% (n=0) 3% (n=1) 3% (n=1) 73% (n=22) 20% (n=6) 9. high cholesterol is not a serious problem, i feel fine. 10% (n=3) 17% (n=5) 3% (n=1) 73% (n=22) 0% (n=0) 10. people don’t need to worry about their cholesterol if they have never had a heart attack. 13% (n=4) 57% (n=17) 0% (n=0) 26% (n=8) 3% (n=1) 11. the health problems caused by diabetes and high blood pressure are much more serious than the problems caused by high cholesterol. 3% (n=1) 40% (n=12) 0% (n=0) 43% (n=13) 13% (n=4) relationships between beliefs and adherence tests were completed comparing the various items with two significant findings. item analysis with spearman’s rho correlation revealed two specific statements online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 18 significantly associated with better adherence. first “in general, do you think cholesterol lowering drugs work?” p=.015. also the statement “people with high cholesterol are more likely to have a heart attack than people with low cholesterol” p=.035 was related to better adherence with cholesterol lowering medications. discussion the purpose of this research was to examine patient’s beliefs about high cholesterol and cholesterol lowering medications, their adherence to taking these medications, and relationships between adherence and beliefs. the findings demonstrate the relationship between beliefs about statin medications for the treatment of hypercholesterolemia and increased medication adherence with these medications. rates of adherence to cholesterol medications demonstrated in this study are consistent with findings in other studies (benner et al., 2009; besseling et al., 2013; bondesson et al., 2009; chi, 2014; harrison et al., 2013; schedlbauer et al, 2010) reponses by participants also found adherence to their other medications was at a slightly higher rate. contributing factors to low adherence include not taking medications when traveling and forgetfulness. forgetfulness was also a common finding by schwartz et al 2009. significant numbers of participants reported stopping their cholesterol medications when they felt their cardiovascular disease was controlled. when asked about beliefs related to cholesterol medications, participants were more likely to agree the medications work, yet they also wonder if their own medication is working. stronger responses were related to participant’s beliefs about complications of taking cholesterol medications. most of the responses indicated a belief these medications would cause liver damage. further, the belief prevailed of increased dosing was linked to online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 19 muscle aches. this data parallels findings already published related to increased dosing not being tolerated by many patients (besseling et al., 2013; harrison et al., 2013). beliefs related to high cholesterol and cardiac conditions found significant numbers of the group believed high cholesterol increased the risk of a heart attack. similarly, the belief prevailed; lowering cholesterol lowered the risk of a heart attack. the respondents were nearly equally divided on the belief on whether high cholesterol is as significant a health risk as diabetes and high blood pressure. this is difficult to explain based on patient’s reporting better adherence to medications treating those conditions than to the medications treating cholesterol. implications the small size of this pilot study and the convenience sample hamper these findings from being extended to other populations. additionally, the morisky scale was modified from the original version for this study. the findings can inform care for providers in rural areas similar to the sample used for this study. the issue of adherence should be addressed at the time of diagnosis and reinforced throughout treatment. as suggested by harrison et al. (2013), these conversations should begin as early as possible and be individualized to each patient’s situation. discussions with patients should incorporate strategies promoting adherence. strategies for remaining adherent while traveling, in the absence of symptoms, and preventing forgotten doses are great examples. this education should focus on the crucial role of treating hypercholesterolemia in the management and prevention of cad. consideration and discussion should be given to the problem of symptomless diagnoses such as hypercholesterolemia, and the lack of motivation to adhere to daily treatment. the essential role of statins in treatment should begin as early online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 20 as testing for the condition. as suggested by besseling and colleagues (2013), established evidence based guidelines are available and should be used upon diagnosis with each patient (nice, 2006; sign, 2007). presentation of the facts related to optimal benefit from statin therapies, reducing morbidity and mortality from cad, and preventing heart attack are all vital. issues faced by rural communities including access to care, low income, and uninsured or underinsured all may impact adherence. suggested areas of patient education may include feasibility of follow up visits, the cost of medications, and insurance coverage. additionally, teaching patients the rational of monitoring cad and cholesterol, along with improvement strategies is vital (besseling et al, 2013; harrison et al., 2013). efforts are needed to provide the vital information related to cad and cholesterol in rural communities. strategies could include taking advantage of access to the population through religious and civic groups or workplace. increasing the public’s knowledge can result in increased adherence with cholesterol lowering medications, as evidenced in this study. references alla, v., agrawal, v., denazareth, a., mohiuddin, s., ravilla, s., & rendell, m. (2013). a reappraisal of the risks and benefits of treating to target with cholesterol lowering drugs. drugs, 73, 1025-1054. http://dx.doi.org/10.1007/s40265-013-0072-9 benner, j. s., chapman, r. h., petrilla, a. a., tang, s. s., rosenberg, n., & schwartz, j. s. (2009). association between prescription burden and medication adherence in online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 21 patients initiating antihypertensive and lipid lowering therapy. american journal of health system pharmacists, 66, 1471-1477. http://dx.doi.org/10.2146/ajhp080238 besseling, j., van capelleveen, j., kastelein, j., & hovingh, g. (2013). ldl cholesterol goals in high-risk patients: how low do we go and how do we get there? drugs, 73,293-301. http://dx.doi.org/10.1007/s40265-013-0028-0 bharmal, m., payne, k., atkinson, m., desrosiers, p., morisky, d., & gemmen, e. (2009). validation of an abbreviated treatment satisfaction questionnaire for medication among patients on antihypertensive medications. health and quality of life outcomes, 7(36). http://dx.doi.org/10.1186/1477-7525-7-36 bondesson, a., hellstrom, l., ericksson, t., & hoglund, p. (2009). a structured questionnaire to assess patient compliance and beliefs about medication taking into account the ordered categorical structure of data. journal of evaluation in clinical practice, 15, 713-723. http://dx.doi.org/10.1111/j.1365-2753.2008.01088 calderon, r. m., cubeddu, l. x., goldberg, r. b., & schiff, e. r. (2010). statins in the treatment of dyslipidemia in the presence of elevated liver aminotransferase level: a therapeutic dilemma. mayo clinic proceedings, 85, 349-356. http://dx.doi.org/ 10.4065/mcp.2009.0365 centers for disease control and prevention. 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(2005). clinical outcomes associated with pharmacist involvement in patients with dyslipidemia. disease management outcomes, 13(1), 31-42. http://dx.doi.org/10.2165/00115677-200513010-00004 devoe, j. e., baez, a., angier, h., krois, l., edlund, c., & carney, p. a. (2007). insurance typology of barriers to health care access for low-income families. annals of family medicine, 5, 511-518. http://dx.doi.org/10.1370/afm.748 driel, m. l., sutter, i. d., christiaens, t. c., & maeseneer, j. m. (2005). quality of care: the need for medical, contextual, and policy evidence in primary care. journal of evaluation in clinical practice, 11, 417-429. http://dx.doi.org/10.1111/j.13652753.2005.00594 foley, k. a., vasey, j., berra, d., alexander, c. m., & markson, l. (2005). the hyperlipidemia: attitudes and beliefs in treatment (habit) survey for patients. journal of cardiovascular nursing, 20(1), 35-42. http://dx.doi.org/10.1097/0000 5082-200501000-00008 hachem, s. b., & mooradian, a. d. (2006). familial dyslipidemia. drugs 2006, 66, 1949-1969. http://dx.doi.org/10.2165/00003495-200666150-00005 online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 23 harrison, t., derose, s., cheetham, c., chiu, v., vansomphone, s., green, k., … reynolds, k. (2013). primary nonadherence to statin therapy: patients’ perceptions. the american journal of managed care, 19(4), e133-e139. hartley, d. (2004). rural health disparities, population health, and rural culture. american journal of public health, 94, 1675-1678. http://dx.doi.org/10.2105/ ajph.94.10.1675 heard county community partnership. (2008). family connection community threeyear strategic plan [unpublished manuscript]. franklin, ga: author. hoerster, k. d., mayer, j. a., gabbard, s., kronick, r. g., roesch, s. c., malcarne, v. l., & zuniga, m. l. (2011). impact of individual-, enviromental-, and policy level factors on health care utilization among us farmworkers. american journal of public health, 101, 685-692. http://dx.doi.org/10.2105/ajph.2009.190892 morisky, d., ang, a., krousel-wood, m., & ward, h. (2008). predictive validity of a medication adherence measure in an outpatient setting. the journal of clinical hypertension, 10, 348-354. http://dx.doi.org/10.1111/j.1751-7176.2008.07572.x national institute for health and clinical excellence, (2006). statins for the prevention of cardiovascular events. national institute for health and clinical excellence (nice). retrieved from http://www.nice.org.uk/nicemedial/pdf/ta094guidance.pdf marquez, c., casado, m., motero, c., & martin, p. (2007). therapy compliance in cases of hyperlipidemia, as measured through electronic monitors: is a reminder calendar to avoid forgetfulness effective? atencion primaria, 39, 661-668. murphy, p., roth, c. s., & andrea, c. z. (2005). latest advances in aggressive lipid management. formulary, 2-12. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 24 pieh-holder, k.l., callahan, c., & young, p. (2012). qualitative needs assessment: healthcare experiences of underserved populations in montgomery county, virginia, usa. the international electronic journal of rural and remote health research, 12:2045. schedlbauer, a, davies, p., & fahey, t. (2010). interventions to improve adherence to lipid lowering medications. cochrane database of systematic reviews, issue 3. http://dx.doi.org/10.1002/14651858.cd004371.pub3 schwartz, k. l., dailey, r., bartoces, m., binienda, j., archer, c., & neale, a. v. (2009). predictors, barriers, and facilitators of lipid lowering medication use among african americans in a primary care clinic. journal of the national medical association, 101, 944-952. scottish intercollegiate guidelines network (sign), (2007). risk estimation and the prevention of cardiovascular disease. a national clinical guideline. retrieved from http://www.sign.ac.uk/pdfsign97.pdf . shalansky, s., levy, a., & ignaszewski, a. (2004). self-reported morisky score for identifying nonadherence with cardiovascular medications. the annals of pharmacotherapy, 38, 1363-1368. http://dx.doi.org/10.1345/aph.1e071 toh, c. t., jackson, b., gascard, d. j., manning, a. r., & tuck, e. j. (2010). barriers to medication adherence in chronic heart failure patients during home visits. journal of pharmacy practice and research, 40(1), 27-30. http://dx.doi.org/10.1002/j.2055-2335.2010.tb00721.x vrijens, b., belmans, a., matthys, k., deklerke, e., & lasaffre, e. (2006). effects of interventions through a pharmaceutical care program on patient adherence with online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.367 25 prescribed once-daily atorvastin. pharmacoepidemiology and drug safety, 15, 115121. http://dx.doi.org/10.1002/pds.1198 404 not found microsoft word cudney_258-1278-2-ed.doc online journal of rural nursing and health care, 13 (2) 84 perceived health status of farm/ranch women shirley cudney, ma, rn 1 clarann weinert, sc, phd, rn, faan 2 nicole todorovich, fnp-bc 3 1 associate professor (retired), college of nursing, montana state university, scudney@montana.edu 2 professor emerita, college of nursing, montana state university, cweinert@montana.edu 3 st. peters medical group, interventional pain management. helena, mt, thetodors@hotmail.com abstract purposes: to (a) describe the self-reported perceptions of health among a group of farm/ranch women with chronic illness, and (b) examine the women’s impressions of the impact of farm/ranch living on their health. sample and methods: a secondary analysis was done with data generated from a paper/pencil survey of 21 farm/ranch women with chronic illnesses who participated in the women to women (wtw) computer-based support and health education project at montana state university during the past decade. questions were related to perceived general health status, health as it relates to chronic illness, and health problems associated with farm/ranch living and work. findings: farm/ranch women perceived their health positively. in addition to their chronic illnesses, some had illnesses or injuries related to living and or working on a farm/ranch, though few attributed their health problems to the farm/ranch life style. online journal of rural nursing and health care, 13 (2) 85 conclusions: rural healthcare providers need to be aware of the challenges faced by farm/ranch women with chronic illness such as: isolation, healthcare access, healthcare costs, fatigue, pain, and feelings of anger and guilt. in response, they must provide preventive counsel for the health risks, e.g., injuries, skin conditions, hearing impairment, respiratory disease, which may be associated with living and working on a farm/ranch. keywords: chronic illness, farm/ranch health, rural women perceived health status of farm/ranch women background farming and ranching, a 24/7 lifestyle, is characterized by work that seems to have no end. even with its advantages and benefits, this way of life carries health risks to those who till the soil and nurture the beasts that provide the world’s population with food (bolwerk, 2002). farmers’, ranchers’, and their families’ lives are inextricably bound with the land where they work, live, and play (high plains/midwest ag journal, 2004). thus, the nature of the life style carries increased risks for health hazards and injury, especially for women. there has been a notable rise in the number of women farmers. thirty percent of the united states farm operators in the 2007 census were women, which was a 19 percent increase from 2002 (u. s. department of agriculture, 2007). women comprise the fastest growing segment of the agricultural population, concurrently seeking off-farm jobs to provide health insurance for the family (reed, browning, westneat, & skarke, 1999). women juggle multiple roles on farms and ranches--as housewives, business managers, and reserve labor, as well as off-farm employment and family responsibilities (gallagher & delworth, 1993). attempting to fill all online journal of rural nursing and health care, 13 (2) 86 these roles positions women for high health risks related to the intermittent nature of the work, the number of hours worked, and the presence of a chronic illness. farm/ranch health risk factors for women mccoy, carruth, and reed (2002) reported that the risk for unintentional injury and illnesses increase for women who participate only intermittently in farm chores because of their unfamiliarity with and ignorance of the exposure and associated safety hazards. conversely, those women who contributed more than periodic hours to farm work stated that, although they were aware of the health hazards and dangers associated with agriculture occupations, they may not have given adequate safety precautions a priority because of limited time and stress (bowlerk, 2002). added to the unpredictability of and stressors associated with farming/ranching, women’s risk of injury is impacted by the amount of time spent doing farm/ranch work (carruth, skarke, moffett, & prestholdt, 2001). the physiological differences of women, such as being shorter in height, having less strength in the upper body, and being at increased risk for osteoporosis (engberg, 1993), may make them more likely to: be harmed by large animals; be run over and killed by machinery or hospitalized as a result of injury from machinery; or have fractures after they reach age 60 (dimich-ward et al., 2004). if, in addition to these physical disadvantages, farm/ranch women have chronic health conditions that affect mobility, impair their sight or hearing, or decrease their alertness, their risk for injury increases (carruth et al., 2001). impact of chronic illness on farm/ranch women farm/ranch women with chronic illnesses are distinctively challenged in managing not just their day-to-day lives, but their health as well. their health care decisions are affected by great distances to health services, inclement travel conditions, and burdensome related costs (winters, online journal of rural nursing and health care, 13 (2) 87 cudney, sullivan, & thuesen, 2006). such costs have caused some farm families to delay getting medical or dental care, even for those with private medical insurance or medicare (reed, rayens, winter, & zhang, 2008). other hurdles farm/ranch women face in trying to successfully manage their chronic conditions are excessive turnover rates of rural healthcare providers, limited access to healthcare specialists, and dealing with complex health insurance issues (cudney, sullivan, winters, paul, & oriet, 2005; winters, et al., 2006). existing with chronic illness is fraught with fatigue, pain, and feelings of depression, fear, and anger. added to the challenge of managing the multitude of physical and emotional symptoms of chronic illness, is the guilt that many farm/ranch women experience because they may have difficulty meeting the many responsibilities of home, family, and work (sullivan, weinert, & cudney, 2003; winters, et al., 2006). purpose although there has been a variety of research investigations related to the health risks associated with farm or ranch work, little research exists on the actual and perceived health status of farmers and ranchers, and even less about that of farm/ranch women. thus, the purpose of this study was to learn more about the health status and experience of farm/ranch women living with chronic illness. armed with a better understanding of the factors that influence the health of farm/ranch women, healthcare providers will be more prepared to meet this group’s special needs. the specific aims were to: (a) describe the self-reported perceptions of health among a group of farm/ranch women living with chronic illness, and (b) examine the women’s perceptions of the impact of farm/ranch living on their health. methods online journal of rural nursing and health care, 13 (2) 88 for this study, data from the longitudinal women to women (wtw) project were secondarily analyzed (weinert, 2000; weinert, cudney, & winters, 2005). the wtw intervention was designed to deliver virtual self-help support and web-based health information to rural women as a means of assisting them in their efforts to manage and adapt to chronic illness. participants in the wtw project were required to have a diagnosis of a chronic health condition and live in a rural area, a small town, or on a farm/ranch at least 25 miles distant from a town of 12,500 or more residents. as part of the wtw project, a sub-study was initiated with one of its goals being to gather specific health information about farm/ranch women. to participate in this sub-study, the women were asked to complete a questionnaire that addressed their perceptions of their current health and health related to the farm/ranch life-style. the wtw research-based project and sub-studies were each approved by the university institutional review board for the protection of human subjects. participants the women who had participated in the intervention groups of the wtw project from 1995 to 2005 were contacted by letter to determine whether they were willing to participate in the subproject. a total of 21 women who lived on a farm or ranch agreed to participate, and their demographic information, the data collection methods, and data analysis are described below. all participants were caucasian and averaged 57.5 years of age (see table 1). nineteen of the women were married and seven had dependent children under the age of 18 living at home. the mean number of years in school for the group was 14.9. individual income varied, with seven women reporting an annual income between $25,000 and $34,999; three between $35,000 and $44,999; and four with an annual income greater than $75,000. the mean number of years online journal of rural nursing and health care, 13 (2) 89 since the onset of their primary chronic illness symptoms was 23.1 years with a mean of 19.8 years since diagnosis. additional demographic characteristics are shown in table 1. data collection the questions for the mail questionnaire were based on the past experience of the women to women research team and the literature. the questions used in this secondary analysis were selected on the basis of the concepts seen in the literature and to meet the first aim of this study, “describe the self-reported perceptions of health among a group of farm/ranch women living with chronic illness.” the questions chosen addressed quality of life and general health, physical health issues related to chronic illness, impact of chronic illness on activities of daily life, and health status specific to farm/ranch participants. some of the items were combined to form the physical health issues scale and the chronic illness impact scale in an effort to further describe the health status reported by these farm/ranch women living with chronic illness. quality of life and general health status. feedback from two questions was examined to gain insight into the women’s perceptions of their quality of life and general health status,.the first, “how would you rate your quality of life at the current time?” was scored on a 10 point scale, ranging from 1 (poorer than most) to 10 (better than most). the second question was, “how would you rate your health today as compared to one year ago?” this question was also scored on a 10 point scale, ranging from 1 (much worse) to 10 (much better). physical health issues. to better understand the difficulties participants faced in dealing with common physical health problems, questions were analyzed that addressed each of the following nine common physical health issues: vision, hearing, mobility, chronic pain, fatigue, coordination, climbing stairs, holding items, and breathing. the degree of difficulty was indicated on a five-point scale: 1 (no difficulty) through 5 (great difficulty). the impact of each online journal of rural nursing and health care, 13 (2) 90 potential health issue was examined individually and the nine questions were summed to develop the physical health issues scale with a range of scores from 9 to 45. the higher the score, the greater the perceived difficulty in handling physical health issues secondary to chronic conditions. the physical health issues scale had a cronbach’s alpha of 0.83. table 1 participant characteristics (n=21) characteristic age (years) 57.5 (sd) = 7.07 education (years) 14.9 (sd) = 2.38 years since onset of symptoms 23.1 (sd) = 10.37 years since diagnosis 19.8 (sd) = 10.06 race caucasian 21 marital status married 19 never married 1 living together 1 income less than $14,999 1 $15,000 to $25,000 2 $25,000 to $34,999 7 $35,000 to $44,999 3 $45,000 to $54,999 1 $55,000 to $64,999 1 $65,000 to $74,000 1 over $75,000 4 primary chronic illness arthritic condition 5 diabetes 5 multiple sclerosis 6 fibromyalgia 3 lupus 1 urinary problems 1 online journal of rural nursing and health care, 13 (2) 91 chronic illness impact on daily life. to determine the impact of the women’s primary chronic health problem on daily living, nine common activities were assessed including: household cleaning, recreational activities, participating in activities with friends and family, attending church service or bible study, being present at community events, being active in organizations, having sexual intercourse, going shopping, and performing farm/ranch responsibilities. a 6-point scale was used which ranged from 0 (not applicable), to 1 (small impact), through 5 (great impact). as was done in examining the impact of physical health issues, the individual questions were combined to create the chronic illness impact scale. the higher the score, the greater the personal perception of the impact of chronic illness on the individual’s daily life. scores on the chronic illness impact scale could range from 0 to 40, and had a cronbach’s alpha of 0.91. health concerns related to farm/ranch life. consistent with the second aim of the study, a series of health status questions was analyzed to examine the women’s perceptions of the impact of farm/ranch living on their health. one question was, “in the past twelve months, have you had any illness or trauma that you suspect might have been related to the farm/ranch environment?” if the answer was positive, a description of the illness or trauma was requested. a second question was, “how would you compare your health to women your age who are not farm/ranch women?” with the possible responses of: a lot better, better, about the same, worse, and a lot worse. further investigation of their experiences with health conditions directly related to living and working on farms and ranches was conducted by asking yes/no questions about the incidence of skin conditions, hearing loss, breathing problems, and injuries. if they answered yes to any of online journal of rural nursing and health care, 13 (2) 92 the questions, they were asked to describe their specific health concerns and whether they considered their health condition to be related to living or working on a farm or ranch. results the results are reported consistent with the aims. first, the farm/ranch women’s perceptions of their quality of life and health are discussed, and second, the impact of farm/ranch living on the women’s health. quality of life and current health a report of a positive quality of life and a slight improvement in their health today compared with one year ago (see table 2) was seen in the women’s responses. the mean of the scores for the question, “how would you rate your quality of life at the current time?” was 6.86 (sd = 2.14) of a possible 10. this result indicated that the 21 farm/ranch respondents considered their quality of life to be at least the same to better than most. for the question, “how would you rate your health today as compared to one year ago?” the mean was 6.29 (sd = 1.79) of a possible 10 thus, the respondents considered their health to be somewhat improved. table 2 health status results farm/ranch mean (sd) measurement quality of life 6.86 (2.14) 0-10 higher better current health status 6.29 (1.79) impact of farm/ranch living on the women’s health the impact of farm/ranch living on the women’s health was reported in three areas. they were: physical health issues, the impact of their chronic illness on daily living, and health status as it related to farm/ranch living. online journal of rural nursing and health care, 13 (2) 93 physical health issues. nine common physical health issues (see table 3) were rated by the participants on a scale of 1 (no difficulty) through 5 (great difficulty), to determine the degree to which they felt disabled by their chronic condition. of these physical health issues, difficulty with fatigue was rated the highest with a mean score of 2.86 (sd = 1.19), and difficulty with breathing the lowest with a mean score of 1.52 (sd = 0.98). individual item responses were summed to determine a total physical health issue scale score which had a mean of 20.28 (sd = 7.07). on each individual item, the farm/ranch women’s mean score was less than 3, and that of the physical health issue scale was near the lower end of the possible range. given these outcomes, the women did not report having any significant difficulty with the selected physical health issues. chronic illness impact. of the nine daily living activities (see table 4), fulfilling farm/ranch responsibilities (mean score = 2.81, sd = 1.53) and doing recreational activities (mean score = 2.76, sd = 1.67) were most impacted by their illness. they considered attending church and being present at community events to be similar with a mean score of 2.38 (sd = 1.52 and 1.62) for each. least impacted by their illness with a mean score of 1.71 (sd = 1.76) was being active in an organization such as 4h or other women’s leagues. table 3 farm/ranch physical health characteristics results assessed characteristic mean (sd) measurement (higher = worse) fatigue 2.86 (1.19) 1-5 chronic pain 2.71 (1.45) climbing stairs 2.57 (1.24) mobility 2.38 (1.11) holding items 2.33 (1.3) coordination 2.29 (1.00) vision 2.05 (1.02) hearing 1.57 (0.81) online journal of rural nursing and health care, 13 (2) 94 breathing 1.52 (0.98) physical health scale 20.28 (7.07) 9-45 in addition to looking at each item individually, the cumulative chronic illness impact scale was used (see table 4). the scale had a mean score of 18.80 (sd = 11.03). given these results, it can be concluded that the farm/ranch women considered their chronic illness to have a moderate impact on their activities of daily living. table 4 chronic illness impact measured daily living activity farm/ranch mean (sd) measurement (higher = worse) performing farm/ranch responsibilities 2.81 (1.53) 1-5 recreational activities 2.76 (1.67) household cleaning 2.62 (1.53) participating in activities with friends 2.57 (1.50) having sexual intercourse 2.57 (1.77) going shopping 2.48 (1.47) being present at community events 2.38 (1.62) attending church service or bible study 2.38 (1.52) being active in organizations 1.71 (1.76) chronic illness impact scale 18.80 (11.03) 0-45 health status related to farm/ranch living. five of the 21 farm/ranch women replied yes in response to the question that asked whether they had any illness or trauma that might have been related to living in the farm/ranch environment. these conditions included stress, depression, contusions, joint stiffness, joint swelling, and back pain. nine women rated their health as about the same and eight rated their health as worse or a lot worse than non-farm/ranch online journal of rural nursing and health care, 13 (2) 95 women their age when asked to compare their health to women who did not live on farms or ranches. a variety of responses were gleaned from the assessment of the women’s experiences with the hazards of farm/ranch living and working (see table 5). of the 11 women with one or more skin problems, six considered their skin condition to be the result of exposure to sun, chemicals, or other skin irritants, but not necessarily stemming from living and working on a farm/ranch. none of the five of the women who experienced hearing loss associated it with farm or ranch work. the four farm/ranch women participants who reported breathing problems did not attribute their breathing difficulties to farm or ranch exposure. table 5 health conditions related to farming/ranching question frequency results farm/ranch related trauma yes = 5 skin problem? types for those answering yes. no = 8 rash = 4 sores = 1 excessive dryness = 11 skin cancer = 1 skin conditions related to sun, chemicals, or other substances? yes = 6 hearing loss? yes = 6 is your hearing loss related to working on the farm/ranch? no = 6 breathing problems? yes = 4 is your breathing problem related to working on the farm/ranch? no = 4 todorovich, 2011, p. 28 discussion the aims of this study were to learn about the health status and impact of ranch/farm living on the health of a group of farm/ranch women living with chronic illness. an examination of the online journal of rural nursing and health care, 13 (2) 96 participants’ responses provided insights into their views of their health and perceptions of how their health and quality of life were impacted by rural living. observations follow about how their perceptions compared with those of others, as reported in the literature. quality of life gill and feinstein (1994) noted that health related quality of life can only be completely assessed as seen through the eyes of the individuals themselves. judging what factors influence their views of this multi-dimensional concept of overall enjoyment of life and wellbeing can be an elusive endeavor (segen, 2002). however, it is reasonable to expect that symptoms, discomfort, and physical limitations associated with having a chronic illness can put a person at risk for an impaired quality of life (mccabe & mckern (2002). add to this the possible social isolation of rural living, and another factor that can influence quality of life negatively becomes part of the equation. it has been shown that individuals with chronic conditions who have opportunities to interact socially have a better quality of life over time compared to those with limited social support (mccabe, stokes, & mcdonald, 2009; so et al., 2009). rural women, especially those with significant illnesses, are often unable to access support services and the companionship of distant friends and family, therefore may feel isolated (bettencourt, schlegel, talley, & molix, 2007) and thus be at risk for a decreased quality of life. given these factors, it was surprising to find that the chronically ill, farm/ranch study participants considered their quality of life to be as good to better than most. one feasible explanation for the group’s reported perception of a high quality of life was proposed by bowlerk (2002). the participants in the bowlerk study reported that rural living encouraged them to get outdoors in the fresh air, and increased their physical activity and enjoyment of the pleasant surroundings. it is also possible that the women’s positive perceptions of their quality of online journal of rural nursing and health care, 13 (2) 97 life was related to the support they received through the wtw project—a health education and social support intervention that has been shown to enhance the lives of isolated rural women living with chronic illness (weinert, cudney, & hill, 2008). the women’s reports of a good quality of life were encouraging because an increased quality of life has been linked with enhanced health promotion behaviors such as eating well and being active, and decreased illness symptoms such as fatigue (strine, chapman, balluz, moriarty, & mokdad, 2008). health status it is expected that, as individuals with chronic conditions age, their lives become characterized by increasing dependence and impotence (ryan & farralley, 2009). yet, the women in this study rated their health to be as good as or better today than it was one year ago. since all were living with a chronic health condition, why they reported such a perception is puzzling, but it may be attributed to healthcare needs that were being met, adequate management of their chronic illnesses, and/or that they were positively responding to a computer-based support and health knowledge intervention that had a part in improving their perception of their health during the past year. stress and fatigue can be lessened and emotional and physical functioning improved in individuals with chronic illnesses by their participation in self-care and lifestyle modification programs (malec, 2002). for example, in the women to women program (weinert et al. 2008), it was shown that this computer-delivered intervention bolstered social support, reduced loneliness, enhanced the ability of rural women to self-manage, and ultimately helped them to adapt more successfully to living with a chronic condition. improved chronic illness management was also reported by massey, appel, buchanan, and cherrington (2010) in online journal of rural nursing and health care, 13 (2) 98 individuals who participated in programs that incorporated the use of telemedicine, telephone help lines, web-based interventions, and community health advisors. time also allows individuals to improve their management of chronic health conditions. thus, past participation in the wtw study and the passage of time could have aided the women in this study to consider their health to be the same to better than it was one year ago. fatigue a major health issue fatigue is a common companion to those suffering with chronic conditions. in fact, all the participants reported fatigue as the most significant physical health issue related to rural living and their chronic illness. given the endless responsibilities that women living and working on a farm/ranch face, it is to be expected that those who also carry the burden of a chronic illness are at an even higher risk from suffering the consequences of fatigue. if a woman is also employed off the ranch, her responsibilities are multiplied. adding together off-ranch employment, home and parenting responsibilities, and farm/ranch tasks, the women may experience what gallagher and delworth (1993) described as the third shift phenomenon. bolton (2000) proposed yet a different type of third shift that she titled the endless shift. this shift is characterized by the stress of getting things done, balancing responsibilities, and defining role identity. fulfilling the demands imposed by these multiple “shifts” can raise concerns in the women about their ability to complete chores and meet financial obligations while concurrently dealing with their own illnesses and limitations in silence for fear of being a burden to the family (reed et al., 1999). impact of chronic illness on farm/ranch living chronic illness impacts one’s ability to do farm/ranch work when the considerable physical demands outstrip the diminished capacities imposed by the chronic condition. even the concentration and time involved with paper work could be stressful. thus, it was not surprising online journal of rural nursing and health care, 13 (2) 99 that the study participants cited farm/ranch responsibilities as the category of tasks most negatively affected by their chronic illnesses. conversely, the women in the study considered their chronic illness to have the least negative influence on their participation in community and service organizations—possibly because this type of activity was less physically and mentally demanding than farm/ranch duties. in fact, bolwerk (2002) found that church activities and volunteering were considered by many farm/ranch women to be part of their leisure time farm/ranch related injuries and health risks injuries and illnesses for women in agricultural occupations have been poorly documented. this may be due to the historical fact that the women’s role in farm/ranch work was not widely acknowledged, and because of the diversified positions women have on the farm or ranch (mccoy, carruth, & reed, 2001). in this study, five of the farm/ranch women reported back pain and stiff joints, but the cause of these symptoms was unclear. possible causes could have been overuse, past injury, and/or arthritis, a chronic illness commonly reported among the women. stress and depression were linked to farm/ranch work in studies by amshoff & reed (2005) and reisnch & woodgate (2008). it can be seen that the pressures of overwhelming responsibilities, as described previously in the context of the third shift phenomenon (bolton, 2000), could be a source of unrelenting stress for farm/ranch women, especially those with chronic conditions, and ultimately lead to situational depressive symptoms. a farm-related injury could also cause or exacerbate such symptoms (carruth & logan, 2002). other contributing factors that could contribute to the onset of depressive feelings have also been identified. amshoff & reed (2005) observed that farm and ranch dwellers frequently associate their worth with the amount of work they can accomplish. thus, when farm/ranch online journal of rural nursing and health care, 13 (2) 100 women’s abilities are diminished so might their sense of well-being. bowlerk (2002) added that feelings of depression could be engendered by the social isolation imposed by rural living, long hours, and few days off. according to gaetano et al. (2009), farm/ranch workers’ exposure to outdoor elements puts them at increased risk for skin problems such as sores, rashes, excessive dryness, and cancer. in this study, there were few reports of untoward skin conditions, with the exception of excessive dryness, and only six women attributed the conditions to farm/ranch exposure to sun, chemicals, or other substances. according to reed (2007), preventable chemical or sun burns among agricultural workers are commonly seen because of stress and time constraints that lead to faulty safety techniques and failure to take precautions. although there is documentation related to noise-induced hearing loss in agricultural workers in general (penn state extension, 2013; mccullagh & robertson, 2009), there is none addressing the incidence and prevalence of hearing loss specifically in farm/ranch women. a general approach to hearing loss prevention related to noise in all populations has been included in the objectives of healthy people 2020 (us. department of health and human services, n.d.). other non-farm/ranch related causes for hearing loss across groups, including farm/ranch women, are advanced age, genetics, infection, taking ototoxic medications, and trauma (national institute on deafness and other communication disorders, 2009). never-the-less, because of the noise factor, those living and working on farms and ranches are at increased risk for hearing loss (bean. 2008). although five of the 21 study participants reported hearing loss, none associated the loss with farm/ranch activities. possibly the women were unaware that exposure to agricultural noise could damage their hearing, and given the over 57 year average age of the group, they may have considered their hearing loss to be age related. online journal of rural nursing and health care, 13 (2) 101 numerous sources of air contamination, dusts kicked up while tilling the land, pesticides, etc., exist that pose breathing risks to agricultural workers that range from minor allergies to fatal respiratory responses (grisso, hetzel, & stone, 2005). for example, among nonsmoking farm women, pesticides have been associated with chronic bronchitis and atopic asthma (valcin et al., 2007; hoppin et al., 2008). valcin et al. also indicted grain and dust exposures as causes of chronic bronchitis. however, no one in the study group identified themselves as having a primary chronic health problem related to respiratory difficulties, and just one cited emphysema as her secondary chronic health condition. milder breathing problems were reported by four women, but none associated her problems with living on a farm/ranch. from these findings, the possibility was considered that the breathing problems reported may have been acute in nature, fairly mild, and may have only occurred intermittently during certain times of the year. inherent in the women’s denial of the potential residential and occupational risks to the respiratory system associated with ranch/farm work and living is the danger that common agricultural occupational related respiratory illnesses such as farmer’s lung and organic dust toxicity syndrome may go unrecognized or misdiagnosed until the condition becomes advanced and difficult to treat successfully. suggestions for future research and clinical application to build on the knowledge gained from this small study of the perceived health status of a group of farm/ranch women, further research might focus on: (a) expanding the study to a larger sample and incorporating a control group with similar demographics; (b) exploring new territory by ascertaining the incidence and prevalence of specific illnesses, chronic conditions, and injuries unique to farm/ranch women; and (c) implementing and monitoring an expanded online journal of rural nursing and health care, 13 (2) 102 telecommunication support network for farm/ranch women throughout the northwest with the goal of enhancing the women’s perceived health status and quality of life. because of this study’s small sample size of 21, a similar, larger scale study incorporating a control group could have a greater potential for producing more informative and sound conclusions. in addition, a design which uses a primary, mixed method approach, rather than being limited to secondary data, could be promising. adding more open-ended options to the mail questionnaire would elicit a wider range of responses than is possible with just questions with yes and no answers and multiple choice responses. since the questions used in the study were research team generated, adding a qualitative component of follow-up interviews with those who took the survey might serve to supplement the questions or clarify responses. another option would be to design a stand-alone qualitative project, combining interviews and observation as the vehicle for data-gathering. implications for nursing healthcare providers in largely rural states, such as montana, must recognize the nature of rural demographics and their influence on the unique health needs of not just rural women but specifically farm/ranch women. health screening tools that are specific to farm/ranch issues need to be developed and used with both men and women farmers/ranchers. rural healthcare providers need to be fully aware of the health risks and challenges associated with living and working on a farm or ranch, especially those faced by farm/ranch women with chronic conditions. they need to fully appreciate the impact on these women of social isolation, limited healthcare access, inflated healthcare costs, persistent fatigue, chronic pain, and feelings of anger and guilt. equipped with a true understanding of these factors, providers will be better prepared to provide farm/ranch women with optimum health care. they will be positioned to help these online journal of rural nursing and health care, 13 (2) 103 women to better manage their chronic illnesses and address their unique health issues, such as farm/ranch related injuries, skin conditions, hearing impairment, and respiratory disease. it is important for health care providers to consider all aspects of farm/ranch women’s lives so that adequate treatment and preventive education may be provided to ensure better chronic illness management and avoidance of other illnesses and injuries to which an agricultural lifestyle places them at risk. further, given the limited health care available, it is essential that farmers and ranchers themselves—men, women, and children—be encouraged to become partners in their health care. in such a partnership, farm/ranch dwellers become more responsible for their own care and take an active role in making health care related decisions in concert with their health care providers (fox & chesla, 2008). to do so successfully requires information and health education. therefore, the health care providers’ role is to open the door to the partnership and provide information and guide their farmer/rancher clients toward resources for improving their health literacy--the ability to read, understand, and act on health care information (hill, 2008). optimal combinations of these elements can enhance health literacy and foster productive interactions between informed farmers/ranchers and their health care providers (weinert, cudney, & kinion, 2010) in the quest to obtain and maintain better health and safety in a farm/ranch environment. references amshoff, s., & reed, d. (2005). health, work, and safety of farmers ages 50 and older. geriatric nursing, 25, 304-308. [medline] bean, t. l. (2008). noise on the farm can cause hearing loss. retrieved from http://ohioline.osu.edu/aex-fact/pdf/aex_590_08.pdf http://www.ncbi.nlm.nih.gov/pubmed/16213982 online journal of rural nursing and health care, 13 (2) 104 bettencourt, b.a., schlegel, r.j., talley, a., & molix, l. (2007). the breast cancer experience of rural women: a literature review. psycho-oncology, 16, 875-887. [medline] bolton, m.k. (2000). the third shift: managing hard choices in our careers, homes, and lives as women. new york: jossey-bass. bowlerk, c. (2002). the culture of farm work and its implications on health, social relationships and leisure in farm women and men in the united states. journal of cultural diversity, 9, 102-107. [medline] carruth, a., & logan, c. 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(2011). perceived health status of farm/ranch women. master thesis montana state university, bozeman, montana. retrieved from http://etd.lib.montana.edu/etd/2011/ todorovich/todorovichn0511.pdf u. s. department of agriculture. (2007). census of agriculture: women farmers. retrieved from http://www.agcensus.usda.gov/publications/2007/online_highlights/fact_sheets/demogra phics/women.pdf u.s. department of health & human services. (n.d.). healthy people 2020: hearing and other sensory or communication disorders. increase the use of hearing protection devices. retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist. aspx?topicid=20 valcin, m., henneberger, p. k., kullman, g j., umbach, d. m. london, s. j., alavania, j. c...hoppin, j. a. (2007). chronic bronchitis among nonsmoking farm women in the agricultural health study. journal of occupational and environmental medicine, 49, 574583. [medline] weinert, c. (2000). social support in cyberspace for women with chronic illness. rehabilitation nursing, 25(4), 129-135. http://www.ncbi.nlm.nih.gov/pubmed/18080207 http://www.ncbi.nlm.nih.gov/pubmed/14651679 http://www.ncbi.nlm.nih.gov/pubmed/17495700 online journal of rural nursing and health care, 13 (2) 109 weinert, c., cudney, s., & hill, w. (2008). rural women, technology, and self management of chronic illness. canadian journal of nursing research, 40(3), 114-134. [medline] weinert, c., cudney, s., & kinion, e. (2010). development of my health companion to enhance self-care management of chronic health conditions in rural dwellers. public health nursing, 27, 263-269. [medline] weinert, c., cudney, s., & winters, c. (2005). social support in cyberspace: the next generation. computers, informatics, nursing, 23(1), 7-15. [medline] winters, c., cudney, s., sullivan, t., & theusen, a. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/18947095 http://www.ncbi.nlm.nih.gov/pubmed/20525099 http://www.ncbi.nlm.nih.gov/pubmed/15681989 http://www.ncbi.nlm.nih.gov/pubmed/17212876 microsoft word rohatinsky_273-1557-1-ed.docx online journal of rural nursing and health care, 13(2) 149 mentorship in rural healthcare organizations: challenges and opportunities noelle rohatinsky, rn, phd 1 linda ferguson, rn, phd 2 1 assistant professor, college of nursing, university of saskatchewan noelle.rohatinsky@usask.ca 2 professor, college of nursing, university of saskatchewan, linda.ferguson@usask.ca abstract introduction: recruitment to and retention of healthcare professionals in rural workplaces are often difficult due to inadequate resources, limited positions, and facility remoteness. mentorship of employees can serve as a recruitment and retention strategy in rural organizations. purpose: the purpose of this study was to explore managers’ perceptions of their roles in creating mentoring cultures, discover the processes in creating a culture of mentoring, and explore the organizational features supporting and inhibiting mentoring cultures. the objectives included: (a) exploring managers’ perceptions of their role in creating a mentoring culture, (b) discovering the processes of creating a culture of mentoring, and (c) exploring the organizational features supporting and inhibiting this process of developing a mentoring culture. the ruralspecific findings from the larger study will be discussed. sample: twenty-seven front-line nurse managers working in acute care hospitals, long term care, and integrated facilities from both urban and rural locations were interviewed. twelve participants managed rural facilities and their opinions surrounding rural mentorship strategies and challenges emerged. online journal of rural nursing and health care, 13(2) 150 method: data was analyzed using glaserian grounded theory. findings: nurse managers discussed the impact of being in a rural area and highlighted the rural-specific considerations for mentoring. they outlined the strategies, challenges, and opportunities for supporting staff mentoring relationships in rural organizations. participants stated all employees were responsible for mentoring new individuals, regardless of occupation. managers believed cross-professional mentoring enabled staff to understand team member roles and established collaborative work environments. conclusions: in order to successfully recruit and retain healthcare employees in rural areas, innovative mentorship initiatives to ensure quality work environments are encouraged. interprofessional mentorship can assist with the challenges of socializing new employees to rural workplaces by offering a means to encourage collaborative relationships and ultimately foster positive patient outcomes. keywords: mentorship, rural organizations, interprofessional, healthcare mentorship in rural healthcare organizations: challenges and opportunities it is a continuous struggle to recruit and retain qualified nurses and other healthcare professionals to work in rural and remote areas. globally, half of the world’s population live in rural areas whereas only 38% of the nursing workforce is employed rurally (world health organization [who], 2010). more specifically, only 10.8% of the registered nurse (rn) workforce and 17.5% of licensed practical nurses (lpns) work in rural and remote areas in canada (canadian institute for health information [cihi], 2012). there are numerous barriers to recruitment and retention of nurses in rural facilities including limited resources, decreased online journal of rural nursing and health care, 13(2) 151 professional development opportunities, and a lack of interpersonal ties to the area (aylward, gaudine, & bennett, 2011). strategies need to be put in place to ensure individuals in rural communities have access to skilled healthcare professionals. mentorship can serve as a means for recruitment and retention of healthcare professionals by addressing these barriers. ultimately, ready access to the qualified individuals can create healthier rural and remote communities. the authors discuss interprofessional mentorship as one of the strategies to utilize when healthcare providers in rural communities are scarce. background mentoring is defined as “…a guided, nonevaluated experience, formal or informal, assigned over a mutually agreed-on period of time that empowers the mentor and mentee to develop personally and professionally within the auspices of a caring, collaborative, and respectful environment” (grossman, 2007, p. 2). mentoring relationships are dynamic, mutually beneficial, learning relationships between a more experienced person (a mentor), and a less experienced person (a protégé or mentee) (johnson & ridley, 2008; zachary, 2005). the concept of mentoring has been investigated and published at length in the business and organizational behavior literature. conversely, mentoring from a nursing perspective continues to be relatively novel and there is a limited empirical literature base on mentoring in nursing (beecroft, santner, lacy, kunzuman, & dorey, 2006; halfer, graf, & sullivan, 2008; jakubik, 2008; jakubik, eliades, gavriloff, & weese, 2011; latham, hogan, & ringl, 2008; newhouse, hoffman, suflita, & hairston, 2007; wolak, mccann, queen, madigan, & letvak, 2009). by contrast, anecdotal and thematic literature on mentoring in nursing abounds (block, claffey, korow, & mccaffrey, 2005; burr, stichler, & poeltler, 2011; cottingham, dibartolo, battistoni, & brown, 2011; mckinley, 2004; tourigny & pulich, 2005; woodard-leners, wilson, connor, online journal of rural nursing and health care, 13(2) 152 & fenton, 2006). areas in mentoring that have been investigated in both the business and nursing environments included outcomes and benefits of mentoring, negative mentoring experiences, characteristics of effective mentors and protégés, the roles and responsibilities of each individual in the mentorship, phases of mentorship, program evaluation, and types of mentoring. authors have called for enhanced nursing mentorship in rural areas (henwood, eley, parker, tuckett, & hegney, 2009; kwansah et al., 2012). research into rural nursing mentorship remains limited. some researchers have explored mentoring managers into their own rural positions (waters, clarke, ingall, & dean-jones, 2003), whereas others have investigated the experience of mentoring nurses in rural areas and the training required (mills, 2009; mills, lennon, & francis, 2007; mills, francis, & bonner, 2007; mills, francis, & bonner, 2008a,b; scott & smith, 2008; stewart & wootton, 2005). crow, conger, and knoki-wilson (2011) developed a program to mentor rural nurses working with culturally diverse populations. who (2010) called for rural and remote mentorship opportunities in order to recruit and retain healthcare professionals to these areas. rural healthcare professionals were more likely to remain in rural areas if they were connected through peer support networks, had relationships with both urban centers and rural communities, and had means to communicate electronically with others (conger & plager, 2008). rural mentorship can provide these opportunities to create those connections and has the potential to result in employee retention (curran, hollett, hann, & bradbury, 2008). online journal of rural nursing and health care, 13(2) 153 purpose the purpose of this dissertation study was to explore managers’ perceptions of their roles in creating mentoring cultures. through this process managers’ strategies in creating a culture of mentoring were discovered. specific organizational features supporting and inhibiting this mentoring culture became apparent. in this article, we will discuss the rural-specific findings from the larger study. methodology glaserian grounded theory (glaser & strauss, 1967; glaser, 1978) was used to collect, code, and analyze the data from the main study using constant comparative analysis to develop codes, memos, and theory. the researcher continuously hypothesized about the relationships between concepts and categories and constantly examined these propositions against the data until a core category and theory emerged. a specific category, rural mentorship considerations, emerged from the data and will serve as the basis for this article’s content. sample and setting six health regions within one canadian province were utilized for the study. each health region consisted of both urban and rural locations. managers were front-line nurse managers working in acute care hospitals, long term care, and integrated facilities from both urban and rural areas. a rural area was defined as having a population of less than 10,000 individuals (bollman & alasia, 2012). first line managers were described as managers who have responsibility for nursing units, where staff nurses report directly to them, and where there is no level of management below them (laschinger & wong, 2007). nursing units and facilities utilized depended upon the managers who volunteered to take part in the study. online journal of rural nursing and health care, 13(2) 154 ethical approvals were obtained from the university of saskatchewan research ethics board (beh study # 10-262) and the participating health regions prior to study commencement. recruitment and data collection occurred between january and august 2011. numerous avenues were pursued to target all managers, including attending facility or health region-wide manager meetings, and sending written letters of invitations and brochures via email or mail. if interested in participating, managers were responsible for contacting the researcher. written informed consent was obtained and semi-structured interviews were conducted. purposive and theoretical sampling was used to recruit participants. saturation was reached at 27 managers. twenty-five managers were registered nurses and two were nonnurses. twenty-five managers were female. twelve managers worked in rural areas and 15 worked in urban centers. eleven managers supervised acute care units, seven were in long term care units or facilities, and nine worked in integrated facilities offering a mix of acute care and long term care services. the term “nursing unit” could represent either a single nursing unit or an entire facility, depending on its size. managers are identified by the term “mon” (manager of nursing). data analysis once interviews were transcribed, they were reviewed for errors and notations on emotions, behaviours, and environmental factors by comparing the original audio-recordings and the interviewer’s field notes. the researcher simultaneously collected, coded, and analyzed data using constant comparative analysis (cca) to develop coding and theoretical memos, and to develop the theory. using cca, the researcher constantly compared data against itself, other data, and the emerging concepts and theory at all times during the grounded theory process (boychuk-duchscher & cowin, 2004; glaser & strauss, 1967; schreiber, 2001). cca directed theoretical sampling and ensured that the emerging theory would not be merely descriptive and online journal of rural nursing and health care, 13(2) 155 lack conceptual depth (mccann & clark, 2003). thus, cca enhanced the theoretical sensitivity and assisted the researcher in creating a theory that was grounded in the data. data continued to be collected, coded, and analyzed until no new categories emerged and existing categories were saturated, thus reaching theoretical saturation (glaser & strauss, 1967). saturation was confirmed at 27 participants and 33 interviews. after nineteen interviews, saturation of most categories was noted and the researcher began to revise the interview questions to further substantiate, expand, and refine properties of categories, concepts, and relationships between concepts, as wuest (2007) suggested. the interview questions became more specific to the phenomenon under study as the theory developed. after 27 interviews, second interviews were completed with managers to further clarify and validate the emerging theory, as well as to discuss proposed relationships between concepts. nvivo 9 software was used to manage and organize the data collected. trustworthiness lincoln and guba’s (1985) trustworthiness criterion for establishing rigor within a qualitative framework included the categories of credibility, transferability, dependability, and confirmability. lincoln and guba (1985) described credibility as whether the reality of the participants was correctly represented by the researcher. strategies used to maximize credibility in this study included peer debriefing and member checks (lincoln & guba, 1985). in order to allow for exploration of areas that may remain implicit or unexplored and to test emerging hypotheses, peer debriefing with the researcher’s supervisor was performed. member checks were used to clarify and validate the emerging theory with participants. during secondary interviews, the researcher described the emerging theory to participants and asked them to share online journal of rural nursing and health care, 13(2) 156 their thoughts on the theory. in addition, participants’ own language was utilized to code, categorize, and develop the theory in order to strengthen credibility. transferability referred to the generalizability of findings by providing a substantial description of the context and experience in order to allow others to visualize applying the theory in their contexts (lincoln & guba, 1985). dependability was described as leaving an audit trail so that others could follow the researcher’s thought and decision making progression throughout the research process, and was evident in researcher memos. in this study, memoing was included during data collection, coding, and analysis by using written and audio digital theoretical memos. memoing aided the researcher to hypothesize and identify the relationships among concepts and the emerging theory, and assisted the researcher to conduct subsequent data collection with the emerging theory in mind. finally, confirmability referred to the ongoing documentation of the research process including memoing, verbatim transcription of interviews, and field note documentation (lincoln & guba, 1985), and these components were included in the study. the researcher considered and included credibility, transferability, dependability, and confirmability to ensure trustworthiness in this study. findings twelve managers oversaw rural facilities and their opinions surrounding rural mentorship strategies and challenges arose. the category, rural mentorship considerations, emerged from the data provided by the 12 rural managers and will be described. rural managers discussed the importance of properly mentoring new nursing staff because these individuals would typically be in charge of the whole facility, especially on night shifts. “you’re in charge of the patients, the residents, the staff and the building. it’s a huge, huge commitment to come out to work in rural” (mon j). within rural emergency facilities, there was an unpredictability of the nursing online journal of rural nursing and health care, 13(2) 157 workload and a wide range of patients coming to the emergency department. new nursing staff needed to feel comfortable dealing with the unknown and unexpected. managers mentioned several challenges of supporting employee mentorship in rural areas and they discussed many strategies they used to encourage and support mentoring despite the perceived obstacles. challenges in supporting employee mentoring rural nurse managers discussed the influence of being in a rural workplace on recruitment and mentorship of new staff. being in a rural environment was particularly challenging for managers, because they believed they had inadequate resources, limited staff, and difficulties recruiting and retaining new nurses. some rural managers saw mentoring as a tool for recruitment and retention in the rural area. “there’s so many opportunities and in rural particularly, we’re not really given a pool of applicants and so if we don’t put processes in place to support these people, they’ll leave” (mon n). managers recognized budgetary constraints and limited access to mentorship resources. they expected the organization to allocate funding for the development of mentorship programs and various mentoring education activities for staff. “…you absolutely need senior leadership because if there's no money for it, you don't do it at the end of the day” (mon y). lack of finances and resources for mentorship inhibited managers’ abilities to establish mentorship programs for employees. in many rural facilities, staff members frequently worked their shifts in isolation or with minimal staff of different disciplines. as a result, these factors made it challenging for managers to pair up two employees of the same discipline for mentorship. most rural managers indicated their frustrations with hiring nurses under time-limited contracts, because these nurses typically left after the contract expired. managers identified that more work needed to be done in order for the issues of recruitment and retention of staff in rural online journal of rural nursing and health care, 13(2) 158 areas to be addressed. they discussed the need for providing full-time permanent positions, finding permanent housing, developing relationships with other staff members, and establishing community networks to encourage new staff to be retained. managers mentioned that offering mentoring programs only in larger centers as opposed to smaller centers was a concern. managers identified experienced staffs’ hesitancy to drive into the larger centers to attend the mentoring workshops. reasons were: being uncomfortable driving on the highway; driving in the larger center; attending the workshop alone; lacking funds to pay for mileage, hotel accommodations, or meals; or finding replacement staff to work the shifts while the potential mentor attended the workshop. strategies to support employee mentoring rural managers identified several strategies used to support new nursing staff in their roles and to support mentorship amongst employees. one of the advantages of being in a rural environment mentioned by the managers was that a smaller staff allowed new employees to get to know their colleagues and develop relationships more quickly. managers saw mentoring as a way to support the new staff, especially if they were new graduate nurses or new to the rural environment. “i think that’s really important that they feel supported and they know where to go if there is a problem” (mon n). mentors were seen as a source of knowledge to let new staff know who to call when a problem of any nature arose. managers believed the lack of physicians in rural environments had the potential for new nurse feelings of isolation and increased responsibility. in order to combat those feelings, managers ensured there were experienced staff members on shift with the novices. in the rural areas, these experienced staff members could be from the same or different discipline. managers paired new nurses with experienced staff members of the same discipline until they indicated online journal of rural nursing and health care, 13(2) 159 they were comfortable. if new nurses were working alone, the manager arranged to have experienced nurses on call to act as resources. managers offered their contact information after hours in case new nurses had questions. several rural managers talked about mentoring new staff to become acquainted with the greater community as well, especially if new nurses were unfamiliar with rural environments. managers believed it was important for mentors and other staff members to socialize new staff members into the community, because if new nurses did not have roots in the area, they tended to move to a bigger center after a period of time. socialization included introducing new staff to community activities, providing information on school options for those with children, and inviting them to community events. managers indicated that trust needed to be established between the new individual, the employees, and the community members. many rural facilities hired internationally educated nurses (iens) and their socialization into the community was seen as important. because of cultural differences, the newcomers had to be welcomed to both the facility and community. this welcoming even included finding them housing and linking them with other iens in nearby towns so they could develop their own support group. managers suggested offering mentoring workshops in rural areas either by videoconference or in person with the facilitator coming to the rural facility. they suggested that some nurses from the other rural facilities would be more likely to drive to another rural facility given their hesitancy with driving to larger centers. managers also mentioned that by having employees stay in rural areas for mentorship workshops allowed for it to be financially feasible for more individuals to attend because time off and coverage for driving, staying overnight, and for workshop attendance was not needed. online journal of rural nursing and health care, 13(2) 160 discussion the emergent category, rural mentorship considerations, was described by the participants. rural nurse managers discussed the challenges of providing mentoring and professional development opportunities in their areas due to limited resources, opportunities, and staff. lynds and ven der walt (2011) highlighted the common challenges to successful mentorship in rural areas including lack of rewards or incentives for volunteering, health care professionals’ broad scope of practice in a rural area, and the lack of formal mentoring programs. with limited staff in a rural area, mentor volunteering and selection often became challenging, because of a lack of voluntary mentors to engage in mentorships (lynds & ven der walt, 2011). mccoy (2009) also identified these concerns stating that nursing in a rural setting was unique and special considerations needed to be made when new nurses were entering into the rural environment. for example, mccoy (2009) and aylward et al. (2011) mentioned the limited resources for professional development and orientation in smaller hospitals. other considerations included lack of nursing staff to cover shifts, extra travel time and distance to locations where programs were offered, and additional expenses incurred for mentoring or other continuing education initiatives, which were all seen as challenges to ongoing staff education (mccoy, 2009). mccoy suggested partnering rural nurses with urban hospitals and mentors to allow for collaboration to occur between the areas. managers in this study discussed the limited opportunities for providing new employees with full-time permanent positions. they identified that this had the potential to inhibit recruitment and retention. aylward et al. (2011) also found that lack of full-time positions were considered barriers to recruitment and retention of staff. staff were less likely to move to rural areas if they did not have the security of a permanent full-time position. online journal of rural nursing and health care, 13(2) 161 mills, lennon, and francis (2007) saw mentoring as a retention strategy for rural nurse managers to use in their workplaces. education for potential mentors was viewed as an essential component to the success of the relationship in rural areas, because knowledge of mentoring, mentoring skills, and confidence in the role increased if training was taken (mills et al., 2007). ensuring that mentoring education was provided for nurses in rural areas would contribute to the success of mentorship initiatives. additional educational support and professional networking using such strategies as telehealth and video-conferencing are important and inexpensive methods to provide training and education by linking the urban and rural communities. mills, francis, and bonner (2007) discussed rural nurses’ experiences with mentoring, and they found that mentoring did not occur solely in the clinical environment. considerations were also made for living and working in the same small community. the results found in this research were similar to these findings. for example, socialization was needed in both the rural facility and the rural community (crow et al., 2011; mills et al., 2007). in a rural community, nurses may often be seen as part of the community, and the mentors’ role was to explain the culture of the rural community to the new staff members by explaining the local practice or methods of communication used between colleagues or community members and the new nurses. special considerations need to be made to socialize new nurses to their communities as well, in order to increase the likelihood that new employees will develop relationships and be more willing to stay. managers in this study felt that a lack of connection with community contributed to nurses’ migration. the study findings were similar to those results found by aylward et al. (2011) where managers believed a lack of familial ties, social activities and services, and feelings of isolation were barriers to recruitment and retention and that having a social network and a sense of community belonging were facilitating factors. therefore, online journal of rural nursing and health care, 13(2) 162 relationship development within the community is an important factor to consider in order to improve retention rates in rural areas. from the discussions with rural managers, the authors contend that greater assistance needs to be put in place to support mentoring of new nurses in rural areas. the who (2010) called for innovative and accessible education and professional development programs for staff in rural areas. strategies could include e-learning opportunities where mentoring workshops are videoconferenced into rural areas and mentors and protégés connect via electronic means like email, discussion boards, and texting (hamilton & scandura, 2003). these electronic means would allow mentoring information to be disseminated broadly, allow a greater number of people to be involved in mentorships, and individuals would be able to be mentored in their own communities irrespective of their geographical location. with electronic mentoring, a more diverse pool of mentors could be attained because there would be no limitations regarding regional boundaries (hamilton & scandura, 2003). mentors assisting multiple protégés could be another solution to limited staffing. a further suggestion could be having mentors from rural facilities pairing with protégés from a different facility. most rural managers, in this study, ensured that new employees were supported when working alone, by having supports available if needed, such as having other staff on-call to answer questions. this strategy was important to ensure that new staff had resources available to them as needed. lynds and ven der walt (2011) called for rural facilities and healthcare organizations to collaborate to establish locally adapted mentoring programs that reflected the unique rural environment. this suggestion was a novel idea to better support and reflect the unique nature, challenges, and opportunities of a rural setting. online journal of rural nursing and health care, 13(2) 163 opportunities for inter-professional mentorship nurse managers described informal inter-professional mentorship as one of the strategies to integrate new employees into work environments. managers’ believed each employee was responsible for mentoring new individuals, regardless of the position they held. “i think everybody has a part to play, everything we need to learn isn’t always all clinical and so it definitely needs everybody’s support as far as teaching and what value we’re adding to that individual’s experience at work” (mon aa). mon r further added to this perspective by stating, “i think everyone has a responsibility to mentor like i mentioned – housekeeping, laundry, kitchen, people that work together on a certain part of the team, have a responsibility – a moral responsibility – to help out their teammates, right?”. managers believed each individual had a role in mentoring new staff. they listed several individuals who were responsible for mentoring new nurses including managers, clinical educators, clinical coordinators, rn staff, lpn staff, special care aides, housekeeping, dietary, laundry, maintenance, therapists, and physicians. managers believed it was the whole unit or facility that mentored the new employee. each employee provided new nurses with a different perspective to enable them to see the whole picture and to provide the best possible care for their clients. furthermore, managers indicated the importance for each professional to know how their colleagues’ jobs fit together in order to provide the best care for their client population. crossdiscipline mentoring enabled new staff to know the roles of each of their healthcare team members. morrow (2009) believed that every nurse should be responsible for welcoming the new nurse to the unit, answering any questions, and providing guidance as needed. furthermore, managers mentioned that all employees were responsible for mentoring new nurses regardless of online journal of rural nursing and health care, 13(2) 164 their positions. inter-professional teamwork in rural facilities plays a significant factor in recruitment and retention and positive patient outcomes (aylward et al., 2011). inter-professional mentorship of employees has been relatively unexplored in the literature, but several managers in the study discussed its presence and importance. marshall and gordon (2010) described the goal of inter-professional mentorship as learning about and from other professions in order to provide quality care to clients. ralph and shaw (2011) observed that no matter what the discipline, common goals and beliefs must be established for the mentorship to work. healthcare professionals commonly train in isolation of one another and this lack of interaction has the potential for a lack of understanding of professionals’ values, cultures, and knowledge bases. they further maintained that this lack of understanding could in turn lead to ineffective inter-professional mentoring experiences. ralph and shaw (2011) proposed that inter-professional education should precede inter-professional practice, and that this strategy must be incorporated into educational programs in order to strengthen inter-professional mentorship in clinical areas. likewise, lait, suter, arthur, and deutschlander (2011) found that students involved in inter-professional mentoring learned about different professions and how to work as a team to care for patients. lynds and van der walt (2011) recommended inter-professional mentorship as a means to assist with the limited number of staff and the unique nature of rural health care environments. they maintained that by involving several different healthcare professionals in the mentorship process, mentoring cultures could be established, and quality environments where staff work harmoniously together would be attained. online journal of rural nursing and health care, 13(2) 165 limitations the researcher requested volunteer participants and those who volunteered may have had strong opinions regarding the topic or may have been more interested in the study. the researcher did not examine perceptions of the managers who did not volunteer. when managers chose not to participate in the study, their reason for not participating was not examined as only those managers interested contacted the researcher. evaluation of the effectiveness of any formal or informal mentoring programs currently or previously implemented was not addressed as that investigation was beyond the scope of this study. the researcher acknowledges that mentoring may have occurred for all staff on the nursing unit, but only how the nurse manager created a mentoring environment for registered nurses was investigated. the researcher did not study registered nurses’ and greater organizations’ perspectives on how the nurse manager attempted to or did not attempt to create a mentoring environment. therefore, the authentication of statements made by the managers did not occur. not all health regions in the province were selected to be part of the study, so the researcher did not study differences in manager perceptions from other health regions. this study was limited to one province in canada and may not be representative of mentoring occurrences in other provinces or countries. because the researcher could not approach managers directly due to ethical protocols, reliance was often needed on administrative assistants or chief nursing officers to forward the study letter of invitation, brochures, and follow-up reminders to potential participants. this arrangement posed some risk that the study information would not be received by the potential nurse managers, due to the busyness of the individuals sending out the information on the online journal of rural nursing and health care, 13(2) 166 researcher’s behalf. thus, all potential participants may not have been included in this study opportunity. future research researchers need to further investigate mentorship in rural areas, particularly from the employees’ perspectives, in an effort to better recruit and retain healthcare professionals to rural facilities. research in the area of inter-professional mentorship is also required. topics for examination could include contributing and facilitating factors, barriers, and outcomes of interprofessional mentorship conclusion rural healthcare facilities have unique needs that need to be considered when arranging mentorship opportunities for staff. managers in this study identified several challenges in rural environments that make mentoring more difficult such as limited staffing, working in isolation, and inadequate financial resources. however, they also mentioned strategies they used to foster mentoring relationships like establishing colleague and community relationships, formally pairing up staff, and offering mentorship workshops locally. in order to successfully recruit and retain healthcare employees in rural areas, innovative mentorship initiatives to ensure quality work environments are encouraged. inter-professional mentorship can assist with the challenges of socializing new employees to rural workplaces by offering a means to encourage collaborative relationships and ultimately foster positive patient outcomes. online journal of rural nursing and health care, 13(2) 167 references aylward, m., gaudine, a., & bennett, l. 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(2010). increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. geneva, switzerland: author. wuest, j. (2007). grounded theory: the method. in p. l. munhall (ed.), nursing research: a qualitative perspective (4th ed., pp. 239-272). toronto, on: jones and bartlett zachary, l. j. (2005). creating a mentoring culture: the organization’s guide. san francisco, ca: jossey-bass. online journal of rural nursing and health care, 2(1) 40 imogene king’s interacting systems theory: application in emergency and rural nursing leigh ann williams1 1 graduate student, capstone college of nursing, university of alabama, sugarbaker22@hotmail.com abstract imogene king is a nursing theorist who has made significant contributions to the development of nursing knowledge. this paper gives an overview of king’s conceptual framework and theory of goal attainment and applies the theory to emergency and rural nursing. while all of king’s concepts may not be applicable to emergency and rural nursing, applicable concepts are discussed. specific clinical examples are presented to support king’s work in practice. the concepts of self, body image, growth and development, time, communication, and interaction are the concepts from king’s theory that the author identifies as being most useful when working with clients in the emergency room and in the rural environment. keywords: rural health, inclusion, children, special health care needs online journal of rural nursing and health care, 2(1) 41 imogene king’s interacting systems theory: application in emergency and rural nursing imogene king developed a conceptual model for nursing in the mid 1960’s with the idea that human beings are open systems interacting with the environment (king, 1981). king’s work is considered a conceptual model because it comprises both a conceptual framework and a theory (fawcett, 2000). king’s conceptual framework and theory of goal attainment and use of the model in an emergency room setting are discussed. finally, king’s work is compared to rural nursing theory in an effort to identify common themes. king’s theory the central focus of king’s framework is man as a dynamic human being whose perceptions of objects, persons, and events influence his behavior, social interaction, and health (king, 1971). king’s conceptual framework includes three interacting systems with each system having its own distinct group of concepts and characteristics. these systems include personal systems, interpersonal systems, and social systems. king’s basic assumption maintained that nursing is a process that involves caring for human beings with health being the ultimate goal (torres, 1986). the three systems that constitute king’s conceptual framework provided the basis for the development of her theory of goal attainment. the personal system that king speaks of refers to the individual. the concepts within the personal system and fundamental in understanding human beings are perception, self, body image, growth and development, time, and space (king, 1981). king (1981) viewed perception as the most important variable because perception influences behavior. king summarized the connections among the concepts in the following statement: “an individual’s perceptions of self, of body image, of time and space influence the way he or she responds to persons, objects, and events in his or her life. as individuals grow and develop through the life span, experiences online journal of rural nursing and health care, 2(1) 42 with changes in structure and function of their bodies over time influence their perceptions of self” (king, 1981, p. 19). interpersonal systems involve individuals interacting with one another. king refers to two individuals interacting as dyads, three individuals as triads, and four or more individuals as small or large groups (king, 1981). the concepts associated with interpersonal systems are interaction, transaction, communication, role and stress. the interactions and transactions that occur between the nurse and the client, or the dyad, represent an example of an interpersonal system. communication between the nurse and the client can be classified as verbal or nonverbal. verbal exchanges include both spoken and written communication, while nonverbal communication includes such things as appearance, distance, facial expressions, posture and touch (seiloff, 1991). the third and final interacting system in king’s model is the social system. social systems are groups of people within a community or society that share common goals, interests, and values. social systems provide a framework for social interaction and relationships, and establish rules of behavior and courses of action (king, 1971). examples of social systems include the family, the school, and the church. it is within these organizations that individual's beliefs, attitudes, values and customs are formed. the concepts that king identified as relating to social systems are organization, authority, power, status, and decision-making. the relationships between these three systems led to king’s theory of goal attainment. the conceptual framework of the interpersonal system had the greatest influence on the development of this theory. king (1981) stated, “although personal systems and social systems influence quality of care, the major elements in a theory of goal attainment are discovered in the interpersonal systems in which two people, who are usually strangers, come together in a health online journal of rural nursing and health care, 2(1) 43 care organization to help and to be helped to maintain a state of health that permits functioning in roles” (p. 142). king believed that interactions between the nurse and the client lead to transactions that result in goal attainment. furthermore, king proposed that through mutual goal setting and goal attainment, transactions result in enhanced growth and development for the client (woods, 1994). king used ten major concepts from the personal and interpersonal systems to support the theory of goal attainment. those concepts include human interactions, perception, communication, role, stress, time, space, growth and development, and transactions. to capture the essence of these interrelated concepts, king stated that “nurse and client interactions are characterized by verbal and nonverbal communication, in which information is exchanged and interpreted; by transactions, in which values, needs, and wants of each member of the dyad are shared; by perceptions of nurse and client and the situation; by self in role of client and self in role of nurse; and by stressors influencing each person and the situation in time and space” (king, 1981, p. 144). after careful analysis of king’s conceptual framework and theory of goal attainment, it is evident that this model can be implemented in an emergency room setting. the concepts associated with the personal system can be integrated into the assessment phase of the nursing process. initial assessment of a patient is of utmost importance in the emergency room, especially with regard to trauma patients. however, after completion of the primary survey (airway, breathing, and circulation), nurses should take into account the patient’s feelings in regard to perception, self, body image, growth and development, time, and space. disturbances in perceptions of self and body image often occur in trauma patients who have sustained significant bodily injury. a classic example of this in an emergency room setting involved a young college student who had a traumatic amputation of an arm due to a motor vehicle online journal of rural nursing and health care, 2(1) 44 accident. once this patient was stable from a hemodynamic standpoint, the nurse’s attention was refocused on assisting the patient in coping with the feelings of loss, separation, and anger that he was experiencing. attempting to restore this patient’s self-esteem, in light of his traumatic loss, was a mutually established goal between the nurse and the client. in this particular example, it was also important for the nurse to realize that the patient’s perceptual field was narrowed because of the pain and emotion that he was experiencing. a busy emergency department often creates an intimidating environment for patients and they may feel threatened, or feel that they have no control over decisions that affect their care. a clinical example of this occurred recently when a middle-aged woman who was experiencing acute pulmonary edema was brought to the emergency department by her husband. because of the severity of her condition, the emergency room nurses caring for this patient immediately began taking actions to stabilize her condition, such as securing an iv line, drawing blood for labs, applying oxygen, and inserting a foley catheter. at the same time, the patient was asking, “what are you doing to me?” when the patient’s condition did not significantly improve, the physician explained to the patient and the husband that she needed to be placed on a ventilator to assist her breathing. the client was adamant that she did not want to take drastic measures, but the husband indicated that he wanted whatever was necessary to improve his wife’s condition. this is an excellent example of a client losing the sense of self-hood. in regard to the concept of self, king (1981) stated “if nurses and other professionals interact with patients or clients as human beings, and let the individuals be themselves, even if they do not match the stereotype of the ‘good patient’, nurses and patients would help each other grow in self-awareness and in understanding of human behavior, especially in stressful life experiences” (p. 28). online journal of rural nursing and health care, 2(1) 45 the primary complaint of emergency room patients is the length of waiting time. waiting two hours for test results may seem like an eternity for the patient, but for the nurse, time passes swiftly because s/he is usually busy caring for other patients, or performing other duties. king (1981) emphasized that waiting makes time seem even longer. one intervention that has proven successful in this situation has been the installation of televisions and telephones in patient rooms in the emergency department. these devices seem to help the patients pass the time and reduce some of the frustrations associated with long waiting times. of all the concepts mentioned in regard to interpersonal systems, communication requires the most attention in the emergency department. good communication skills are imperative in the emergency room setting. in an environment that requires one to be reactive and responsive, clients often perceive nurses as being too busy or too hurried. king (1981) encouraged nurses to be aware of how they present themselves to their clients because the manner in which nurses enter a client’s room sets the tone for the entire encounter. poor communication skills lead to poor transactions and interactions between the nurse and the client. poor communication skills also affect goal setting and goal attainment. this is especially true in the emergency department as evidenced by patients returning for follow-up visits who have not followed their discharge instructions, and hence, their health has suffered. a clinical example of this is a young adult male with diabetes who was treated recently in an emergency department for a wound to the lower leg. the patient returned for a follow-up visit with the wound open to air and infected. an in-depth assessment revealed that the patient did not understand the dressing needed changing daily and that he need to keep the extremity elevated. this lack of communication between the nurse and the client resulted in goals not being attained. online journal of rural nursing and health care, 2(1) 46 rural nursing theory rural residents are a unique group of individuals. they acknowledge one another on the streets, share their garden vegetables in the summer, and congregate on sunday to worship according to their faith. for the most part, rural residents are independent, hardworking, and self-sufficient individuals who consider themselves healthy if they are able to go to work each day and perform their usual activities of daily living (weinart & long, 1987). because of the strong work ethic in rural communities, health care needs often come second to work needs. rural residents are more likely to comply with health care regimens that do not interfere with their daily routines, or create inconveniences for them. for these reasons, nurses dealing with rural populations must be aware of the differences that exist between rural and urban populations. “while rural nursing theory is clearly still a work in progress, much of what has been learned to date can be applied, albeit with caution, in nursing practice” (long, 1998, p. 481). this statement supports this author's belief that king’s conceptualizations about nursing can be implemented in the rural setting. while all of king’s concepts may not be applicable in the rural setting, some discussion of the concepts that are useful may be helpful to nurses practicing in rural settings. after careful consideration of the concepts associated with king’s three interacting systems, the concepts of perception, growth and development, time, communication and interaction are helpful to the nurse when attempting to explain and predict the health practices of rural clients. rural dwellers have a different perception of health than that of urban dwellers. data indicate that rural clients often delay seeking health care until their health has been severely compromised (weinart & long, 1998). the nurse working with rural clients must consider the online journal of rural nursing and health care, 2(1) 47 client’s perceptions of health when conducting an assessment. rural clients may not have the same access to health care as urban dwellers, and health is often not a priority for them. it is important for the nurse to be non-judgmental in these situations because this is simply a way of life for rural residents, a way of life that they have come to accept as the norm. growth and development is another concept that is applicable to rural nursing. it is common to see boys operating farm equipment and performing the same tasks as their older counterparts on the farms in rural communities. the boys learn to drive much earlier than may be the norm in cities, and occasionally the accelerator and brake pedals have large blocks added to them to enable the boys to reach the pedals in order to operate the farm equipment. for these reasons, the nurse must be attuned to the fact that the growth and development patterns of these youngsters may differ from those expected at their chronological age. these youngsters have been mainstreamed into society to function in adult roles and this must be taken into account when dealing with adolescents in the rural environment. king’s concept of time can also be attributed to rural communities. rural residents are more likely to participate in health care if it can easily be accommodated into their work schedules (weinart & long, 1987). if rural residents must travel 60 to 70 miles for healthcare, they may feel that this takes too much time out of their day, and so they may fail to keep appointments. long (1998) described a man whose finger was caught in a grain thresher. because he was able to control the bleeding with a handkerchief, he delayed seeking treatment until after the work in the field was completed. the man later stated “it goes to show you that if you go to those doctors too soon, you end up with lots of unnecessary treatment and bills.” this demonstrates the typical mindset of rural residents in relation to the concept of time. time is online journal of rural nursing and health care, 2(1) 48 valuable to rural residents; another concept that must be taken into consideration when addressing the health care needs of rural communities. the last two concepts from king’s framework that are useful when working with rural clients are communication and interaction. we have already established that good communication leads to positive interactions. if the nurse is to have any influence on the health behaviors of rural residents, then s/he must be able to communicate with them effectively. this might mean speaking in layman’s terms instead of using medical terminology that is confusing or ambiguous to the client. the nurse must acknowledge that rural clients may not have the same educational level as urban clients. once the nurse has established an effective means of communicating with rural clients, s/he may be able to implement health-promoting behaviors. good communication will result in a trusting relationship between nurse and client; an essential element for favorable interactions. while all of king’s framework may not be applicable to rural nursing theory, some of the applicable themes have been identified. using king’s theory of goal attainment in the rural community presents some challenges for the nurse. mutual goal setting would only be successful if the clients trusted that the goals would benefit them. rural clients are not immediately receptive to newcomers in their community, which presents an obstacle for the nurse when setting goals with clients. because rural residents are time-oriented individuals, the goals must be attainable without interfering with their daily lives, or the goals will most likely go unmet. there are elements of king's theory that are applicable to both the emergency and to nursing practice in rural settings. concepts from king’s work are useful regardless of the context in which they are used. human beings are dynamic individuals and they are online journal of rural nursing and health care, 2(1) 49 continuously interacting with their respective environments. king conceptualizations in the early 1960’s continue to guide the practice of nursing. online journal of rural nursing and health care, 2(1) 50 references fawcett, j. (2000). analysis and evaluation of contemporary nursing knowledge: nursing models and theories. philadelphia: f.a. davis. king, i.m. (1971). toward a theory for nursing: general concepts of human behavior. new york: wiley. king, i.m. (1981). a theory for nursing: systems, concepts, process. new york: wiley. long, k.a. (1998). the concept of health: rural perspectives. in h.l. lee (ed.), conceptual basis for rural nursing (pp. 211 – 221). new york: springer. long, k.a. (1998). future directions for rural nursing theory. in h.l. lee (ed.), conceptual basis for rural nursing (pp. 475 – 484). new york: springer. seiloff, c.l. (1991). imogene king: a conceptual framework for nursing. newbury park, ca: sage. torres, g. (1986). theoretical foundations of nursing. norwalk, ct: appleton-century-crofts. weinart, c., & long, k. (1987). understanding the health care needs of rural families. journal of family relations, 36, 450-455. https://doi.org/10.2307/584499 weinart, c., & long, k. (1998). rural nursing: developing the theory base. in h.l. lee (ed.), conceptual basis for rural nursing (pp. 3 – 18). new york: springer. woods, e.c. (1994). king’s theory in practice with elders. nursing science quarterly, 7, 65-69. https://doi.org/10.1177/089431849400700206 https://doi.org/10.2307/584499 https://doi.org/10.1177/089431849400700206 microsoft word amponsah_351-2020-3-ed.docx online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 185 health disparities in cardiovascular disease and high blood pressure among adults in rural underserved communities william a amponsah, phd 1 marian m tabi, rn, phd 2 godfrey a gibbison, phd 3 1 associate professor, department of finance and economics, georgia southern university, waamponsah@georgiasouthern.edu 2 associate professor, school of nursing, georgia southern university, mtabi@georgiasouthern.edu 3 dean and associate professor, school of professional studies, college of charleston, gibbisonga@cofc.edu abstract purpose: this study examined the factors contributing to health disparities in cardiovascular disease (cvd) and high blood pressure (hbp) among adults in three rural underserved communities in southeast georgia. socioeconomic status as well as geographic location plays a significant role in one’s quality of health outcomes. methods: individuals in three counties in southern georgia participated in the study. the study was motivated by review of retrospective data from the 2008 georgia cardiovascular health initiative (cvhi) database to explain the factors contributing to the incidence of health disparities. a survey questionnaire was administered by telephone to adult members of online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 186 households to determine the incidence of health disparities in cvd and hbp among rural african american and white adult populations. six hundred respondents participated in the survey but four hundred completed surveys were used in the study, yielding a 67% response rate. data were analyzed using applied multivariate logistic analysis. findings: findings indicated that older men and male residents in counties a and b regardless of racial background were significantly more likely to be diagnosed with both hbp and cvd. college educated women were significantly less likely to have hbp. findings also revealed that married men were significantly less likely to have cvd. uncontrolled elevated cholesterol levels contributed to the incidence of chronic hbp and cvd. conclusions: the findings add to the current knowledge of research and to the understanding of the critical elements in reducing health disparities among populations in rural underserved communities. keywords: health disparities, cardiovascular disease, high blood pressure, rural underserved communities, african americans, caucasians health disparities in cardiovascular disease and high blood pressure among adults in rural underserved communities in a series of reports, the u.s. department of health and human services (u.s. dhhs) noted the importance of health disparities in the nation, especially in rural areas (u.s. dhhs, 2011). previous studies indicated that rural adults were more likely to report poor health status, obesity and limitations in activity than urban residents (downey, 2013; office of minority health (omh), 2012; national advisory committee on rural health and human services, 2011; online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 187 national rural health association, 2007; patterson, moore, probost, & shinogle, 2004). health disparities refer to racial or ethnic differences in morbidity and mortality, and access to health care (braverman, 2006). in a report launched in january 2000, the dhhs admitted the gravity of the problem of health disparities and also committed the nation to eliminate it (u.s. dhhs, 2000). a subsequent 2004 report by the u.s. dhhs (u.s. dhhs, 2004) documented significant disparities in health care access and costs between rural and urban areas. the report found that rural residents often faced barriers to quality care in chronic disease morbidity and mortality, especially in cardiovascular disease (cvd) and diabetes. the health, united states 2011 report also documented some of the health disparities experienced by rural residents (national center for health statistics, 2012). for example, african americans had the highest incidence of high blood pressure (hbp), which was associated with the largest death rates related to cvd and stroke (centers for disease control and prevention [cdc], 2014; omh, 2012; omh, 2014). in november 2010, secretary kathleen sebelius charged u.s. dhhs with developing a department-wide action plan to reduce racial and ethnic health disparities that would influence other key national initiatives such as healthy people 2020, the first lady’s let’s move! initiative, and the president’s national hiv/aids strategy (u.s. dhhs, 2011). the action plan acknowledged the existence of persistent and well-documented health disparities between racial and ethnic populations making health equity elusive. the action plan also committed the department to continuously assess the impact of policies and programs on racial and ethnic health disparities, and to promote integrated approaches that are evidence-based and apply best practices to reduce these disparities. online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 188 differences in health status across racial and ethnic groups in the united states, particularly between african americans (or blacks) and caucasians (or whites), have been the subject of numerous public health and social science research (fowler-brown, ashkin, corbie-smith, thaker, & pathman, 2006; opara et al., 2013; james, thomas, lillie-blanton, & garfield, 2007; karlamangla, merkin, crimmins, & seeman, 2010; kressin, orner, manze, glickman, & berlowitz, 2010; mujahid, roux, & morenoff, 2008; rooks et al., 2008). some studies apply a variety of health measures to delineate the relatively worse health status in african-american men and women compared with that of caucasians for a number of chronic diseases such as high blood pressure, cvd, and diabetes (adler & rehkopf, 2008; dressler, oths, & gravelee, 2005; farmer & ferraro, 2005; keita et al., 2014; kressin et al., 2010). evidence of contributing factors related to health disparities such as socioeconomic status and geographical location are well documented (adler & rehkopf, 2008; farmer & ferraro, 2005; fowler-brown et al, 2006; kressin et al., 2010; thorpe, brandon, & laveist, 2008 ). there is evidence that suggests that health inequities affect individual and community economic development (karlamangla et al., 2010; keita et al., 2014; morenoff et al., 2007; mujahid et al, 2008). geographically, minorities, particularly, african americans in the rural south have been found to frequently perceive persistent racial barriers to medical care, fueling mistrust and dissatisfaction with care (fowler-brown et al., 2007). however, obtaining usable estimates for health services and access measures among rural residents is a challenge. many studies use nationally representative datasets that are limited by the number of rural respondents. in the united states, about 77.9 million (1 out of 3) adults have hbp. for caucasians, 33.4 percent of men and 30.7 percent of women have hbp as compared to 42.6 percent of men and 47 percent of women among african americans. the 2009 overall death rate from hbp was 18.5 online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 189 per 100,000. death rates were 17 percent for white males, 14.4 percent for white females, 51.6 percent for black males and 38.6 percent for black females. the estimated direct and indirect costs of hbp in 2009 were $51 billion (american heart association, 2013). heart disease is the first leading cause of death for men and women in the united states. cvd accounts for more than one-third (33.6 percent) of all u.s. deaths. in 2010, the total costs of cvd in the u.s. were estimated to be $444 billion (cdc, 2014). in the state of georgia, cvd is the leading cause of death; accounting for one-third of all deaths at 21,042 (georgia: burden of chronic diseases, 2008). georgia’s cvd death rate was 9% higher than the national rate in 2007; and was 1.4 times higher for men than women and 1.3 times higher for african americans than caucasians in the same reported year. the cost of cvd in georgia in 2007 was also estimated at $11.2 billion, which included direct health care costs and lost productivity from morbidity and mortality (georgia department of community health, 2009). the georgia department of public health (http://health.state.ga.us/pdfs/epi/cdiee/ cvd_program_and_data_summary) reported that in 2010 approximately 137,000 hospitalizations occurred among georgia residents due to cvd, and total hospital charges for cvd in georgia increased by over $2.1 billion between 2003 and 2010, from $3.4 billion to $5.5 billion. additionally, the percentage of adults in georgia with hbp increased from 26% in 1999 to 31% in 2009. the report also stated that hbp compounds cvd risk but can be controlled through lifestyle changes such as physical activity and healthy diet and, if necessary, medications. unfortunately, similar information on the rural sector is lacking. moreover, alkadry and tower (2010) reveal that geographical location (for example rural underserved georgia) also restricts the type of treatment available to residents, particularly access to quality healthcare, availability of qualified health care providers, facilities and online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 190 insurance coverage. uneven access to healthcare services and lower quality of care combined with cultural barriers tend to decrease minority trust in the healthcare system (downey, 2013; moulton, 2009; rooks et al., 2008). study aims and research questions the objective of this study was to explore the incidence of health disparities in rural underserved counties in southern georgia with respect to cvd and hbp. additionally, the study investigated the factors contributing to disparities in these diseases among adult men and women residents in the rural undeserved communities. research on the existing health disparities in these underserved rural communities is important since understanding rural patterns of health status in the communities has important implications for improving the rural health outcomes so as to reduce any disparities. the u.s. dhhs, health resources and services administration (hrsa) defines medically underserved areas/populations as areas or populations designated by hrsa as having too few primary care providers, high infant mortality, high poverty and/or high elderly populations.. the research questions addressed were: 1. are there significant health differences in cvd and hbp among adult african american and caucasian men and women in the selected rural underserved communities in georgia? 2. do demographic and socioeconomic characteristics such as race, age, gender, level of education, income and marital status play a significant role in explaining health outcomes of men and women in rural underserved communities in georgia? methods sample initial baseline data on cvd was undertaken through the georgia cardiovascular health initiative (cvhi) which was launched in 2004. demographic telephone survey was undertaken online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 191 by the bureau of business research and economic development (bbred) at georgia southern university, following approval of the study by the institutional review board (irb) at the university (h08152), with the underlying motivation to analyze factors influencing choice of health behaviors and perceptions about health disparities and access to health services in rural georgia. the u.s. census bureau (2010) classifies a county with the population of 50,000 or less as a rural county. rural counties a and b had populations of 11,452 and 11,455 residents, respectively, in 2008 whereas the peri-urban county c had the population of 58,491. african americans made up 23%, 34%, and 44%, respectively of the population in the three counties. the composition of other ethnicities (hispanic, native american and asian) was less than 1%. therefore, the study focused on the two principal demographic groups of caucasians and african americans. additionally, all three counties are designated by the hrsa as medically underserved areas. such designation is determined at http://muafind.hrsa.gov/index.aspx by clicking on the relevant state and county. state of georgia data explains that death from cvd may be related to a number of risk factors such as lack of regular exercise, poor diet, hbp, high cholesterol, and diabetes (georgia department of community health, 2009). therefore, initially the study focused on three diseases that are associated with the leading cause of deaths in the state of georgia; cvd, hypertension or hbp, and hypercholesterolemia or high cholesterol. instrument description and statistical methods the household survey used for data collection was designed as a stratified multistage sample. questions were based on a modification of the 2006 georgia stroke and heart attack awareness survey (clarkson, 2008). the survey reported in this research was conducted by an online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 192 interviewer on a telephone using a systematic random sampling approach. participants were at least 18 years of age. a total of 600 respondents participated in the three county survey. however, only 400 fully completed responses were used in this study. the survey respondents were asked if they were ever told by a doctor that they had a particular disease, which required an answer of yes or no. variables were created for the disease diagnosis (yes = 1 and no = 0), separately for all three diseases; cvd, hbp, and high cholesterol diagnoses. the survey questionnaire also contained standard questions about the respondent’s income, availability of health insurance, marital status, age, race, gender, education level, and county of residence. these questions comprise the independent variables. binary variables were created for those variables that required “yes” and “no” answers. to validate those variables included in the study, separate cross tabulations for each dependent variable with each of the selected independent variables were implemented by using the chi-square test. the likelihood ratio was used to determine significance of the relationships between the dependent and independent variables. those independent variables that had the strongest relationships with the dependent variable, according to the chi-square test, were chosen and used in a logistic multivariate-regression model. for example, access to health insurance was not significant with any of the dependent variables and was excluded in the statistical model. however, wang, shi, nie, and zhu (2013) showed that low socioeconomic status was associated with lesser access to care and lesser utilization of healthcare, even among those with health insurance. also, opara et al. (2013) studied 30,852 adults and found that respondents with hbp were more likely to have less than 12 years education, be unemployed, or have low income. respondents that reported that they had been diagnosed by a physician with hbp and cvd also reported that they had been diagnosed with high cholesterol. current knowledge of the online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 193 genetic links associated with diseases such as cvd and stroke indicates that these links may be strongest through an associated risk factor such as hypercholesterolemia (macdonald, waters, & wekwete, 2005). based on this known information, a multivariate analysis model was used to explain the incidence of hbp and cvd among the identified racial groups using high cholesterol as an explanatory variable. the education variable was stratified into two binary responses; one for those whose highest education attainment was high school completion and another for those who have completed college education, respectively. for marital status, a single variable was used; married (coded as 1) versus single (coded as 0). age was a continuous variable measured in years. household income of more than $45,000 was coded equal to 1, and income of $45,000 or less was 0. for the gender variable, male was coded as 1 and female as 0, and for the race variable, consistent with the 2006 georgia survey, african american was coded 1 and 0 for caucasian. residence in rural counties a and b were respectively coded as binary variables where residence in either one was 1 and 0 in county c (with slightly more than 50,000 residents). of the 400 (n=400) reported in the study, 240 were from counties a and b, and 160 from county c. logistic model description the logistic model was utilized to parameterize and estimate separate equations for cvd diagnosis and high blood pressure diagnosis. consistent with previous studies (wang et. al, 2013; opara et al., 2013), the standard logistic regression model was used to estimate coefficients to explain the two chronic diseases. results were computed using the statistical package for the social sciences (spss). the model formulation was as follows: online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 194 prob (d = 1) = f (βixi), prob (d = 0) = 1 f (βixi) where the probability of disease (d) being diagnosed was a function of βixi. d = 1 if an individual had been diagnosed with a certain medical condition, and d = 0 otherwise. the two key diseases (dependent variables) upon which the regression model was based were hbp and cvd. the parameter β was a vector of coefficients to be estimated and xi was a vector of independent variables based on individual i’s responses to the survey questionnaire. the probability model was expressed as a regression of the form: e[y] = 0 [1f (βixi)] + 1[f (βixi)] = f (βixi) assuming logistic disturbances, the density function was of the form: prob (d =1) = eβixi 1 + eβixi the inverse function of the logistic model was easy to obtain (if we let prob = p) as: ln [p/ (1-p)] = βixi . consistent with literature reviewed on previous studies, as already discussed, included in the explanatory variables were social and economic data of respondents such as age, race, gender, level of education, household income, marriage status, and high cholesterol. additionally, residence in counties a and b were included separately to delineate the two rural and underserved communities as compared to the peri-urban county c. therefore, the probability of diagnosing hbp and cvd by the model was explained as follows: ln [p/1-p] = β0 + β1 age + β2 race + β3 gender + β4 education + β5 household income + β6 high cholesterol + β7 married + β8 county a + β9 county b (1) online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 195 results descriptive data table 1 shows sample characteristics of the respondents. four hundred respondents were included in the study; 124 males and 276 females with a mean age of 50 years. about 39% of the respondents had hbp, 35% had high cholesterol, and 9% had cvd. about 67% of the respondents were married, 26% were african american, 37% of the households were earning $45,000 or more, about 90% had completed high school, 22% had graduated from college, and 31% were males and 69% were females. table 1 summary descriptive statistics of study sample variable n = 400 percent (%) counties a b c 120 120 160 30.0 30.0 40.0 gender male female 124 276 31.0 69.0 education high school completion college education 358 88 89.5 22.0 income equal or less than $45,000 greater than $45,000 252 148 63.0 37.0 diseases high cholesterol high blood pressure (hbp) cardiovascular disease (cvd) 140 156 104 35.0 39.2 25.8 race african american caucasian 104 296 26.0 74.0 age: mean 50.1 years (range 19 to 94 years; sd± 50.1) online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 196 table 2 presents the logistic regression results of hbp for the combination of men and women, and separately for men (table 3) and women (table 4). in the combined results, individuals diagnosed with high cholesterol were positively associated with being diagnosed with hbp. the result was statistically significant with a relatively large odds–ratio (or = 4.924). this positive and significant association of high cholesterol with hbp was also observed in the separate results for men and women. higher education was negatively but not significantly related to hbp for the combined results for men and women. however, there were important differences in the results obtained separately for educated women as compared to educated men. women with higher education had a negative and significant association with being diagnosed with hbp. however, for men, there was a positive relationship between higher education and hbp, although the result was not significant. the results also showed that there were differential effects of having hbp among african american males and females relative to caucasians. being an african american male was positively and significantly associated with being diagnosed with hbp, with large odds ratio (or = 4.496). odds ratios were reported with 95% ci. this finding was neither significant for african american females nor for the combined results for men and women. findings also revealed older males were significantly more likely to be diagnosed with hbp (or = 1.079) but not older women. invariably, men and women living in the rural underserved community b were significantly more likely to have hbp (or = 2.52), although the results also showed that being a male resident in counties a and b significantly increased the likelihood of being diagnosed with hbp. higher income was negatively related to hbp in all the results, although it was not significant in all cases. online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 197 table 2 logistic regression results for high blood pressure: combined men and women variable β standard error t-test p-value odds-ratio constant age education high cholesterol married african american income gender rural county a rural county b chi-squared log-likelihood mcfadden r2 n -1.213 0.001 -0.565 1.594 -0.182 0.351 -0.039 -0.008 0.464 0.945 78.535 228.674 0.146 400 0.263 0.001 0.301 0.236 0.254 0.268 0.261 0.027 0.302 0.299 4.613 1.381 1.875 6.765 0.718 1.307 0.148 0.291 1.537 3.162 0.000 0.167 0.061 0.000 0.4725 0.191 0.882 0.771 0.124 0.002 1.001 0.568 4.924 0.833 1.420 0.962 0.992 1.590 2.52 table 3 logistic regression results for high blood pressure: men variable β standard error t-test p-value odds-ratio constant age education high cholesterol married african american income rural county a rural county b chi-squared log-likelihood mcfadden r2 n -6.720 0.076 0.435 1.757 0.676 1.503 -0.285 2.102 1.853 64.098 52.822 0.378 124 1.405 0.0195 0.605 0.550 0.623 0.670 0.548 0.820 0.682 4.783 3.907 0.720 3.195 1.084 2.245 0.520 2.563 2.719 0.000 0.0001 0.472 0.001 0.278 0.025 0.603 0.010 0.006 1.079 1.545 5.798 1.965 4.496 0.752 8.185 6.380 online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 198 table 4 logistic regression results for high blood pressure: women variable β standard error t-test p-value odds-ratio constant age education high cholesterol married african american income rural county a rural county b chi-squared log-likelihood mcfadden r2 n -0.673 0.001 -1.304 1.396 -0.416 0.308 -0.066 0.082 0.469 52.535 158.507 0.142 276 0.296 0.001 0.409 0.284 0.294 0.324 0.325 0.355 0.376 2.270 0.981 3.188 4.919 1.413 0.950 0.204 0.231 1.247 0.023 0.326 0.001 0.000 0.158 0.342 0.839 0.818 0.212 1.001 0.271 4.039 0.659 1.361 0.935 1.085 1.599 regression results for cvd were also reported for the combination of men and women (table 5), and separately for men (table 6) and women (table 7). the combined results show that diagnosis of high cholesterol was positively and significantly related to the diagnosis of cvd. high cholesterol was also positively and significantly related to diagnosis of cvd among men (or = 17.527) but not significantly among women. additionally, older age positively and significantly explained cvd in the combined results for men and women and also separately for the results for men and women. online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 199 table 5 logistics results for heart disease: combined men and women variable β standard error t-test p-value odds-ratio constant age education high cholesterol married african american income gender rural county a rural county b chi-squared log-likelihood mcfadden r2 n -6.407 0.056 -0.342 0.911 -0.023 -1.528 -0.389 0.575 0.775 1.130 51.159 97.734 0.207 400 1.089 0.014 0.536 0.390 0.423 0.494 0.469 0.410 0.496 0.437 5.883 3.952 0.637 2.333 0.054 0.522 0.830 1.400 1.563 2.584 0.000 0.0001 0.524 0.0196 0.957 0.602 0.407 0.162 0.118 0.010 1.058 0.711 2.486 0.977 0.773 0.678 0.776 2.170 3.095 the results also showed that married males were significantly less likely to have cvd; although that result was not significant for the combination of men and women. additionally, men and women living in rural county b were significantly more likely to have cvd (or = 3.095). in general, there was a positive and significant likelihood for males in rural counties a and b of being diagnosed with cvd with high odd-ratios of 12.568 and 13.397, respectively. however, being african american per se did not significantly lead to being diagnosed with cvd. online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 200 table 6 logistic regressions results for heart disease: men variables β standard error t-test p-value odds-ratio constant age education high cholesterol married income african american rural county a rural county b chi-squared log-likelihood mcfadden r2 n -9.924 0.107 -1.515 2.864 -2.785 0.735 0.523 2.531 2.595 43.870 21.899 0.50 124 3.278 0.046 1.083 1.019 1.135 1.060 1.060 1.193 1.023 3.027 2.326 1.398 2.811 2.455 0.694 0.495 2.122 2.537 0.002 0.020 0.162 0.005 0.014 0.488 0.621 0.034 0.011 1.112 0.219 17.527 0.062 2.086 1.688 12.568 13.397 table 7 logistics results for heart disease: women variable β standard error t-test p-value odds-ratio constant age education high cholesterol married income african american rural county a rural county b chi-squared log-likelihood mcfadden r2 n -6.310 0.056 -0.254 0.166 0.856 -0.542 -0.242 0.542 0.797 25.924 66.292 0.164 276 1.276 0.016 0.702 0.472 0.547 0.596 0.624 0.590 0.549 4.944 3.446 0.362 0.352 1.564 0.909 0.388 0.918 1.453 0.000 0.001 0.717 0.725 0.118 0.363 0.698 0.358 0.146 1.058 0.766 1.181 2.353 0.582 0.785 1.710 2.219 online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 201 discussion in response to the two research questions motivating the research study, first, it was discovered that there was significant health disparity in hbp between adult african american males and their caucasian counterparts in the rural underserved counties, but not among adult women regardless of race. nevertheless, the results did not reveal any significant health disparity in cvd among african americans and caucasians. this finding is consistent with previous studies that showed that african americans have a higher prevalence of diabetes, high cholesterol and hbp (moulton, 2009, moreno, 2013, opara et al., 2013, holland, carthron, duren-winfield, & lawrence, 2014; lefevre, 2014). moreover, the american heart association (2013) reported that one in three african american adults – compared to the national average of one in four american adults – has hbp. the racial disparity in hbp is also captured by the behavioral risk factor surveillance system (brfss), conducted by the center for disease control and prevention (cdc). using the prevalence data and data analysis tools at http://www.cdc.gov/brfss/data_tools.htm nationally there is a higher percentage of blacks (42%) who reported that they have been told they have hbp than whites (32.5%). it is important, therefore, that healthcare providers in the rural underserved communities bring awareness and encourage behavior modification and treatment of hbp among adult african american males. improving access to health care is an important factor in enhancing overall health. second, the study revealed that older males were significantly more likely to have hbp while both older males and women were significantly likely to have cvd. also, generally having higher levels of education significantly reduced the likely incidence of hbp among women but not among men in the rural underserved communities. this was similar to the results by opara et al. (2013); except in the latter african americans of both sexes with lower education online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 202 also had hbp. however, higher educational attainment did not significantly explain the incidence of cvd. third, consistent with national data, adult men in the two rural counties were significantly more likely to have both hbp and cvd, although married men were significantly less likely to have cvd. higher income in the rural counties did not significantly influence health outcomes. study limitations first, the ethnic and other racial compositions (native americans, asian pacific and hispanic) of the three counties were very few that they were excluded from the study. second, there were many incomplete or missing survey responses about access to health insurance that contributed to its exclusion following the likelihood ratio test. the survey was administered by telephone and that means the data were self-reported and subject to recall biases. third, the survey did not collect data on access to a personal doctor or health care provider and whether or not cost was a consideration in gaining access to health care. conclusions and clinical implications the results from this study provide important information that adds to the current knowledge in understanding disparities in the incidence of hbp and cvd among adult residents in the rural underserved communities in southern georgia that are similar to studies undertaken in more urban settings. the results provide health care practitioners (including nurses) and policy makers with critical information to design culturally appropriate health promotion and education policies for rural and medically underserved counties similar to those on which this research was based. the findings add to the existing body of knowledge in encouraging healthy behaviors to improve health outcomes for all populations, particularly, those in rural underserved communities. online journal of rural nursing and health care, 15(1) http://dx.doi.org/10.14574/ojrnhc.v15i1.351 203 while great progress has been made in understanding the factors contributing to health disparities among people in rural and medically underserved communities, access to health care providers, including nurses and physicians, become so compelling. health disparities can be reduced if appropriate resources such as funding and health care personnel are committed to improve the quality of health access for all people irrespective of socioeconomic status and geographic location. the findings reinforce the important role of nurses and other health care providers to educate individuals, particularly, african americans at risk for high blood pressure and heart disease about dietary and lifestyle modification for healthier outcomes. for at risk populations, uncontrolled high blood pressure cannot be taken lightly. it can lead to stroke, renal failure, heart disease, and other comorbidities. references adler, n. e., & rehkopf, d. h. 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(2013). race/ethnicity, insurance, income and access to care: the influence of health status. international journal for equity in health, 12:29. http://dx.doi.org/10.1186/1475-9276-12-29 microsoft word whisenant_427-2658-1-ed-pe.docx online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 52 the use of community based participatory research to assess perceived health status and health education needs of persons in rural and urban haiti debra pettit whisenant, phd, msn, msph 1 cyndi cortes, dr.p.h., m.s.n., m.r.e., cpnp-pc, crrn, coi 2 patrick ewell, phd 3 norma cuellar, phd, rn, faan 4 1 assistant professor of graduate nursing, capstone college of nursing, university of alabama, dpwhisenant@ua.edu 2 professor of graduate nursing, samford university, ccortes@samford.edu 3 assistant professor of psychology, kenyon college, ewellp@kenyon.edu 4 professor of graduate nursing, capstone college of nursing, university of alabama, ncuellar@ua.edu abstract purpose: haitian communities have limited access to health care. the purpose of this study was to determine the perceived self-health status and health education needs of rural versus urban haitians using a community based participatory research design. sample: residents of two rural and one urban haitian communities (n = 340) were surveyed to obtain demographic information, perceived health status, and priority of health education topics. methods: surveys were used to collect demographic data and the personal importance of various health education topics were obtained. native haitians were trained to use the survey instrument and conducted the short interview with willing participants in rural and urban settings. online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 53 findings: health related status significantly varied by rural versus urban community type in that those in urban communities (m = 2.64, sd = 1.10) viewed their health as significantly better than those in rural communities (m = 2.26, sd = 1.14), t(324) = 2.93, p = .004. the highest rate topics for requests in health education included spiritual health (m = 4.44, sd = 0.84). interest was shown in learning about injury prevention, improving maternal mortality, helping children live longer, environmental issues such as water, food, and sanitation. less interest was shown in learning about weight management and exercise. conclusions: a health education curriculum was developed to train laity in faith based organizations to be community health promoters. this project offers sustainable interventions to empower communities to take responsibility of their own health. keywords: health promotion, rural health, international health, faith based health promotion, self perception of health the use of community based participatory research to assess perceived health status and health education needs of persons in rural and urban haiti haiti is the poorest country in the western hemisphere and ranks the lowest in health status indicator measures (world health organization [who], 2016). ten million people inhabit haiti and more than half the population are 24 years of age or younger. haiti has a high incidence and prevalence of both communicable disease (cd) and non-communicable diseases (ncd). communicable disease, maternal, perinatal, and nutritional conditions are responsible for 42% of deaths while cardiovascular disease, cancer, chronic respiratory disease, diabetes, and other ncds make up 49% of deaths. injuries are a significant (9%) cause of death as well. in haiti 47% of the online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 54 population live in rural areas (who, 2016). the challenges and struggles of the rural haitian people are significant and unique to this population who has dealt with a high incidence and prevalence of both natural and man-made disasters affecting the health of the entire country. tragic events over the last several years, including the earthquake of 2010 and subsequent disease outbreaks related to this event have taxed an already inadequate health care system. many rural haitian communities have little to no access to health care providers. even when a heath care provider is available, many individuals and families cannot afford to pay for care. poverty and lack of economic resources plague haitians whose average annual income is approximately $1800 usd/year while on the same island of hispaniola the residents of the dominican republic average $12,800 usd/year (central intelligence office [cia], 2015). in 2010 the cia estimated that more than 40% of haitians were unemployed while in 2012 it was estimated that more than 58% lived below the poverty line (cia, 2016). as evidenced in many areas around the world, poverty leads to lack of health care and health literacy as well as higher rates of disease, injury, and poorer health outcomes (sepehri & guliani, 2015; von philipsborn, steinbeis, bender, regmi, & tinnemann, 2015). educating individuals on health promotion will prepare them to make informed choices and promote a healthier lifestyle. in global areas where access to health care is difficult due to costs, transportation, or geographic region, basic health education can provide information that may translate to health protection. health education can allow individuals the ability to understand how to protect their own health and the health of family members (whisenant, cortes, hill & holston, 2015). numerous individuals, faith based groups, philanthropists, non-governmental organizations, and government agencies from many countries around the world have provided aid, including online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 55 medical assistance, health education, and health care, to the people of haiti for many years. this aid is important in relieving some of the suffering of the population, but is not a sustainable and completely effective method of providing health education and health care to the haitian population. providing relevant and timely health education to any group is crucial for best health practices and best health outcomes. therefore, the purpose of this study was to determine the perceived self-health status and health education needs of haitian adults within the communities (rural versus urban) using a community based participatory research (cbpr) design. the research questions were 1. what is the self-perceived health status of haitian adults? 2. what is the self-perceived health education needs of haitian adults? 3. are there differences in self-perceived health status in rural versus urban haitian adults? 4. are there differences in self-perceived health education needs in rural versus urban haitian adults? 5. is the cbpr approach effective in gaining health information in both the urban and rural haitian population? community based participatory research the national institutes of health [nih] (n.d.) describes cbpr as an applied collaborative approach that provides an opportunity for the community residents to participate in the entire research process. advantages of cbpr include: • joining partners with diverse expertise to address complex public health problems. • improving intervention design and implementation by facilitating participant recruitment and retention. • increasing the quality and validity of research, online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 56 • enhancing the relevance and use of data. • increasing trust and bridging cultural gaps between partners. • providing resources for the communities involved. • benefiting the community and researchers alike through the knowledge gained and actions taken. • the potential to translate research findings to guide the development of further interventions and policy change. the focus of cbpr is to determine the specific needs of the community of interest by involving community residents. an important premise of cbpr is that research is conducted by, for, or with community members (markey, halseth, & manson, 2010). a partnership between the researchers and the community of interest is established with the goal of improving the health of the residents in the community. community residents are empowered though the use of cbpr (bomar, 2010; markey et al, 2010) by combining education and social action to effect a positive change in health status through health promotion and disease prevention activities. community based participatory research has been shown to effectively introduce evidence-based research into community settings. topics typically researched include quality of life, health care, and social determinants of health (bomar, 2010). collecting data, maintaining participant privacy, acknowledging cultural variances within communities, and demonstrating how the research will positively affect the community are issues that must be addressed before beginning the study (agency for healthcare research and quality [ahrq], 2009). when conducting research in an impoverished or developing country, attention should be given to any issue that may lead to mistrust or biased results. community members should also be involved in the dissemination of the research results (ahrq, 2009). additionally, online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 57 it is important for professional researchers to relinquish the role of “expert” to the community leaders (velasquez, knatterud-hubinger, narr, mendehall, & solheim, 2011). involvement of community members helps ensure the research question is relevant and important to the community. in an effort to improve the health outcomes of the population in western haiti, education/health literacy, health promotion and disease prevention, a cbpr model is appropriate. this model aids in the assessment of what individuals and the community believe are important to learn in order to improve health and demonstrate differences in rural and urban areas. cbpr is an appropriate form of research in developing countries that are experiencing economic, social, and political restructuring because of its flexibility and understanding of the community (markey et al., 2010). literature review the cbpr model has been implemented successfully in multiple partnerships between academic institutions, faith based organizations, and communities that address health care disparities (ahrq, 2009). cbpr has been used in numerous studies to assist researchers to understand community member’s experiences, facilitate community outreach, and augment cultural awareness as well as to implement projects effecting improvements in asthma, diabetes, smoking cessation, among others (velasquez et al., 2011). several examples of the use of cbpr in rural communities, in developed, and developing countries were found in the literature search. sukhera, cerulli, gawinski, and morse (2012) utilized cbpr methodology to study how a rural honduran community defined and responded to intimate partner violence. the researchers met informally with community leaders to obtain preliminary information about cultural norms, community hierarchies, and gender roles (sukhera et al., 2012). non-medical community residents online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 58 (both male and female) as well as community health workers and local midwives participants were recruited for a qualitative study in order to obtain the most accurate and comprehensive perspectives of the scope and nature of their research interest. differences were found in the perspectives of the female health care volunteers and the male community leaders which emphasized the importance of education and involvement of community residents in the design and implementation of intimate violence prevention programs (sukhera et al., 2012). several cbpr project partnerships in the lower mississippi delta between academic researchers, organizational entities, and local communities were implemented and yielded positive outcomes (kennedy, et al., 2011). one of the projects appraised the effectiveness of a faith based peer led weight loss program and found the faith based organization setting to be an effective setting for health and nutrition education programs (kennedy et al., 2011). baffour and chonody (2009) used cbpr methodology in a rural community with a majority african-american population to understand community perceptions of infant mortality among african-american women that are pregnant or have young children. the research question was selected because of the health disparity that exists between the infant mortality rate in african-americans and other racial groups. the authors noted that understanding the community members’ conceptualizations were valuable in developing “community-based instead of community-placed practice and policy strategies” (p. 380). additionally, baffour and chonody (2009) utilized paraprofessionals to provide social support, promote healthy lifestyles and coping strategies, and increase their trust of traditional health and social service providers. methodology online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 59 design community based participatory research model employing direct surveys within the community was utilized. researchers and interpreters gathered data in places of business, faith based organizations, and personal homes of individuals in urban and rural communities. institutional review board (irb) approval was granted from the primary investigators university irb committee. setting the study took place in three cities in western haiti: carrefour, leogane, and gressier. carrefour is a small city 10 miles from port au prince and is in an urban area with a hospital, business area, schools, and residential areas. leogane and gressier are rural communities consisting mainly of small huts and schools and where people earn money from small farms or from home based businesses. sample participants were residents of either carrefour, leogane, or gressier, haiti. inclusion criteria were adult men or women who were willing to answer questions from the interviewers. there were no exclusionary criteria. each participant was approached and voluntarily completed the survey either independently or with the assistance of a trained haitian creole/english interpreter. measures each participant was asked a series of questions regarding demographics including age, gender, occupation, number of children, education, and residence (rural/urban). questions asked were 1) perceived personal health status and 2) perceived need for health education. personal health related status included questions such as “how do you perceive your current health?”(1 being poor and 5 being excellent). perceived health education needs included questions such as online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 60 “do you believe education on health related issues would improve your and your family’s health?” each participant was also given a list of 12 general health topics and asked to rate each one on “how interested are you in education on this topic?” with 1 being “no interest” and 5 being “very interested.” participants were also asked to determine the 12 general health topics that most interested them and rate them 1 – 5 as described above. procedure participants were recruited by word of mouth and were randomly approached by the researchers and interpreters in the three cities. they were not compensated. researchers and interpreters approached individuals at participant’s place of employment with permission of the business owners. street vendors and their patrons were also offered the opportunity to complete the survey. parishioners were invited to stay after worship services to complete the survey. others were approached while walking through the cities or at their homes. all individuals approached were invited to participate by asking if they would be interested in completing a survey. the interpreters explained the purpose of the study and how the information would be used. consent was determined by the individuals’ agreement to complete the survey. if individuals could not read, the survey was read to them and their responses were noted by the interpreter. researchers were available to help answer any questions related to the survey. statistical methods simple descriptive statistics were conducted on demographics, health related status and health education. independent t-test and one-way anovas were conducted between variables to understand if differences existed within the sample. finally, correlations were conducted for exploratory purposes in hopes of discovering additional clues to improve health and health education. online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 61 results residents of the west region of haiti (n = 340) responded to the request for information. some participants did not complete all the demographic data. see table 1 for descriptive data. table 1 demographic data of haitian sample. total rural urban gender male 36.8 (124) 31.1 (68) 49.6 (56) female 61.7 (208) 68.9 (124) 50.4 (57) marital status married 17.8 (60) 26.9 (46) 13.3 (14) single 36.5 (123) 36.8 (63) 57.1 (60) separated / widowed 11.3 (28) 16.4 (28) 9.5 (10) common law 16.3 (55) 19.9 (34) 20.0 (21) of those employed (85%), 26 jobs were identified as held in communities or in the home. additional demographics for the participants can be found in table 2. table 2 demographic characteristics total (n = 336) rural (leogane & gressier) (n = 221) urban (carrefour) (n = 115) variable m (sd) m (sd) m (sd) age 37.07 (16.63) 37.78 (16.96) 35.75 (15.99) children 2.06 (2.17) 2.23 (2.07) 1.89 (2.26) years of education 8.4 (4.82) 7.61 (4.99) 9.38 (4.42) health related status 2.40 (1.14) 2.26 (1.14) 2.64 (1.10) online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 62 health descriptive statistics health related status. participants reported a mean perceived health related status of 2.40 (sd = 1.14) suggesting that the majority of the participants believed their health was somewhere between fair and good. however, only 4.2% of the participants perceived their health to be excellent and 27.3% believed their health to be in poor condition (table 2). males (m = 2.71, sd = 1.06) perceived themselves as significantly more healthy, t(320) = 3.98, p < .001) than females (m = 2.20, sd = 1.14). an independent samples t-test demonstrated that health related status significantly varied by rural versus urban community type, t(324) = 2.93, p = .004. those in urban communities (m = 2.64, sd = 1.10) viewed their health as significantly better than those in rural communities (m = 2.26, sd = 1.14). the urban communities (m = 9.38, sd = 4.42) also reported significantly more years of education than the rural communities (m = 7.61, sd = 4.99), t(250) = 2.93, p = .004. health education. the overwhelming majority of the participants agreed that becoming more educated on health issues would result in improved health for themselves (94.7%) and families (92.6%). in addition, 92.5% of the participants wanted to receive more education on how to be healthy. of the 12 general health topics, all received a high level of interest (above 3.4 on a scale of 5). the highest rated topics included spiritual health (m = 4.63, sd =.75), overall health (m = 4.49, sd =.99) and mental health (m = 4.44, sd =.84). the lowest rated areas included exercise (m = 3.50, sd = 1.39) and weight management (m = 3.81, sd = 1.23). for a complete list of topics and means, see table 3. when participants were asked to choose the topic they most wanted to receive information, 30.9% chose infectious diseases, 15.9% chose raising healthy babies and 11.9% chose online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 63 environmental health. findings from the survey data revealed the participants’ ranking of potential health education topics as follows: spiritual health, overall health (or improving overall health), mental health, preventing infectious diseases, preventing injuries, improving infant mortality, improving child mortality, improving maternal mortality, environmental issues such as water and sanitation, food (diet and nutrition), weight management, and exercise. table 3 means and standard deviations of health education needs compared by area type. rural (n=221) urban (n=115) test statistics health topics m (sd) m (sd) t (p) diet 4.18 (1.10) 4.12 (1.17) -.458 (.647) exercise 3.54 (1.38) 3.41 (1.41) -.805 (.422) environment 4.31 (1.03) 4.12 (1.11) -1.51 (.133) infectious diseases 4.36 (1.08) 4.42 (.808) .573 (.567) healthy babies 4.26 (1.07) 3.85 (1.32) -2.82 (.005) mother’s during birth 4.37 (.977) 3.86 (1.26) -3.78 (.001) healthy children 4.45 (.915) 4.06 (1.09) -3.39 (.001) physical injuries 4.14 (1.10) 4.31 (.867) 1.45 (.147) overall health 4.53 (.814) 4.40 (.928) -1.39 (.165) weight management 3.88 (1.21) 3.68 (1.26) -1.46 (.145) mental health 4.44 (.878) 4.45 (.765) .057 (.955) spiritual health 4.68 (.739) 4.54 (.754) -1.60 (.110) independent t-tests were conducted comparing the rural and urban populations to investigate differences in health education needs. there were significant differences between the rural and urban communities in three categories; maintaining healthy babies, t(193.22) = -2.82, p = .005, protecting mothers during childbirth, t(186.37) = -3.78, p < .001, and maintaining healthy children, t(327) = -3.39, p = .001. in all three cases the rural population was more interested in health education about these subjects. exploratory correlations. age was negatively correlated with perceived health r(319) = .292, p < 0.001 and interest in education about exercise, r(319) = -.137, p =.015, and infection diseases r(320) = -.115, p =.015. in other words, the older participants were the lower they ranked online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 64 their health and the less interested they were in health information on exercise or infection diseases. age was positively correlated with interest in education about spiritual health r(319) =.117, p =.037, suggesting the older the participant, the more they were interested in spiritual health. see table 4. table 4. correlations with age age health topics r exercise -.137* infectious diseases -.115* spiritual health .117* * correlation is significant at p ≤ .05 level education was positively correlated with interest in several health topics including; exercise, r(250) = .194, p = .002, infectious diseases, r(250) = .239, p <.001, preventing injuries, r(250) = .194, p = .002, overall health, r(249) = .187, p =.003, weight, r(250) = .249, p < .001, and mental health, r(251) = .132, p =.038. years of education were also positively correlated with perceived health r(250) = .293, p < .001. these correlations suggest the younger and more educated the participant, the more likely they were to be interested in these health topics and perceive themselves in better health. see table 5. table 5. correlations with education education health topics r exercise .194** infectious diseases .239** physical injuries .194** overall health .187** mental health .132* online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 65 perceived health .293** * correlation is significant at the .05 level; ** correlation is significant at the .01 level discussion the western haitian population provided interesting diverse findings related to the participants. while the mean age was 37.07 years of age, the who (2016) reported the mean age of haitian citizens to be 22 years of age. the who (2016) also reports the life expectancy for males at 62 years and females at 66 years. our sample provided information from some of the older citizens despite the fact that 37 years of age is very young for most countries. as well, participants reported only two children per family which seems to be a low number for persons in developing and poor countries. with the infant mortality rate of 55 per 1,000 births (world bank, 2014), it is possible individuals would have reported greater number of children if the question had included both live and deceased groups. completion of intermediate school in haiti is the 8th grade, when many leave school to begin working, compares with our finding of mean education at 8.4 (sd = 4.82) years of education. dropping out of school at this early age can negatively affect education achievement and also health status and opportunities for prioritizing health. the level of education should be taken into consideration when assessing results and planning health education and related interventions for health literacy. most participants perceived health related status as good to fair. this may be congruent with other countries in the caribbean. for instance, jamaican women were surveyed using the same tool with 75% of participants reporting at least good health (whisenant, et, al. 2015). landefeld et al. (2014) found in the dominican republic that higher wages were correlated with higher selfperception of health indicating greater economic opportunities may equal improved self-perceived online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 66 health status. improving economic environment in haiti could improve health status and health outcomes. males perceived themselves as significantly healthier than females. worldwide, women require and utilize more health care than men due to pregnancy, childbirth, and subsequent issues. women in haiti have inadequate access to health care. it would be expected that men in haiti perceive better health than women perceive their health as women in haiti lack many basic hygiene tools and basic medical care that could improve their real and perceived health. many haitian women perceive themselves as weaker and subservient. women may serve themselves after the men and the children have eaten so they may do without so that other family members have enough. reported health status significantly varied by community – whether it was rural or urban. this is not an uncommon finding as many studies have identified that persons in rural areas report lower levels of perceived health than urban counterparts. this is a common finding internationally as well (dickstein, neuberger, golus, & schwartz, 2014; sangster et al, 2013; zimmer, wen, & kaneda, 2010). rural areas may have less access to education, economic opportunities, and health care. for individuals living in haiti, especially rural areas of haiti, managing life can be extremely difficult. these difficulties can translate into lower perception of health and increased desire for health education. most of the participants believed that becoming more educated on health issues would result in improved health for themselves and families. in addition, the majority of the participants wanted to receive more education on how to be healthy. these findings correlate to findings in jamaica where participants believed increasing health education would also improve health status (whisenant, et al, 2015). the participant’s desire for health education supported our plan for online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 67 implementing health education programs in each community. health education topics being taught correlate with the most requested topics from the survey. the highest rated topics that participants were interested in were spiritual health, overall health, and mental health. the rating of these topics is different than in developed countries. haitians spirituality is of great importance to them and they wish for spirituality to be incorporated with other aspects of life, including health. this information was used when developing our health promotion programs. the health education programs were grounded in faith based organizations utilizing the ministers and others who were well known and received in the religious community. participant’s age was negatively correlated with perceived health and interest in education about exercise and infection diseases. as would be expected, the older the individual the poorer health was perceived. age was positively correlated with request for guidance related to spiritual health suggesting the older the participant, the more they were interested in spiritual health. the “older” participants had less interest in learning about exercise and prevention of infectious diseases than spirituality with the assumption there was no personal benefit in learning more about these other topics. this would run parallel with the culture of haiti and the importance of spirituality especially among the older population. education was positively correlated with perceived health, interest in exercise, infectious diseases, preventing injuries, overall health, weight, and mental health. these findings support that higher levels of education can improve individual efforts to learn more about personal health, therefore improving family and community health as well. younger participants also reported higher levels of education. community residents reported that some primary schools addressed health topics such as prevention of hiv, other sexually transmitted infections, and hygiene related online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 68 diseases. introducing these topics early in school may empower individuals to seek additional information as they age or become parents. our study assessed how effective the use of cbpr was to gain health information from adult haitians living in the western region of the country. the haitian people were interested and pleased to participate in research to assist in improving not only their own health status and education, but also the health status of families and communities. there was a 100% participation rate among individuals approached by researchers. many individuals shared with neighbors and co-workers the survey opportunity resulting in a snow-ball effect of sampling. several community residents who spoke english offered their services to assist in introducing us to community leaders and in encouraging residents to trust us and to participate in the study. these english speaking residents volunteered to stay with us each day without pay. this was indicative of how important and how much the community valued the cbpr approach to gaining information. limitations participants were surveyed from the western region of haiti. selection bias may have been a limitation as there was no specific guidelines for recruitment and the “snow-ball” effect could result in people who are homogenous. the persons who did participate, may have been highly motivated to do so – which limits findings to persons who may have not felt comfortable talking to strangers. as haiti is unique in its culture and circumstances results may not be generalizable to other geographical locations. the statistical analysis identified more variance in the rural group than the urban group of participants. also, the mean age of participants who completed the survey was younger than the mean age of the haitian population. community engagement online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 69 this study focused on the self-perceived health care needs and educational needs of the western haitian population. the majority of the participants wanted to receive more education on spirituality, overall health, and mental health. therefore, further development of programs in these areas is being developed. as well, it is important to improve the planning and delivery of care that is of interest to the community at large. chronic health care conditions plague many of the haitian citizens. identifying the needs of the community can impact individual and personal development. the high level of involvement shows the need for ownership and empowerment in community members. participation in health care programs may increase if there is a true sense of ownership and involvement in what is being taught in the community. if community members are not involved, implementation of health care interventions may fail. the process of engaging the community is essential for community members to participate and be involved. our study identified that the people of haiti, both rural and urban, are interested in health education based on their own perceived health care needs. implications for interventions in rural versus urban haiti identifying the needs of rural versus urban community members is essential in identifying a plan to care for the individual as well as developing sustainable programs that can be replicated to improve health education and health care. as seen in this study both rural and urban groups wish to learn more about health promotion and disease/injury prevention, but there were distinct differences in interest in some topics. understanding the different health interest and education within these two populations is essential in developing health promotion programs that will be well received and effective for both groups within their specific geographic area. this study supports the need to develop specific health education and health promotion programs based on specific geographic areas and information gained from the individuals who online journal of rural nursing and health care, 17 (1) http://dx.doi.org/10.14574/ojrnhc.v17i1.427 70 reside in these areas. as seen in haiti and internationally rural populations may have different needs than urban population. haiti has many health issues which are relevant to both rural and urban groups. the need for health education, health promotion, and basic health care are great throughout the country. unfortunately, health disparities as well as lack of resources limit access to health education and health care negatively affecting the wellbeing of this country. simple, cost effective health promotion programs can be implemented in haiti. these programs can improve health literacy and empower the haitian people to manage their personal health and the health of their families and communities while addressing the significant limitations which affect health outcomes in their country. references agency for healthcare research and quality. 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(2010). a multi-level analysis of urban/rural and socioeconomic differences in functional health status transition among older chinese. social science & medicine, 71, 559 567. https://dx.doi.org/10.1016/j.socscimed. 2010.03.048 microsoft word montgomery_431-2653-2-ed.docx online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 87 rural nursing and synergy sheila ray montgomery, msn, edd, rn 1 andrea l. sutton, msn, crnp 2 judith paré, ph.d., rn 3 1 adjunct professor, becker college, sheilamontgomery41@gmail.com 2 crnp, neurology east, birmingham, alabama, asutton@neurologyeast.com 3 dean, school of nursing & behavioral sciences, becker college, judithmpare@gmail.com abstract purpose: the purpose of this writing is to evaluate the utility of the synergy model for patient care as a theoretical foundation for rural nursing practice. process: an analysis of the four major concepts of the metaparadigm was completed to evidence the applicability of the synergy model to rural nursing practice. the use of case study examples demonstrates the congruence between the synergy model, rural theory, and rural nursing practice. findings: the synergy model can be expanded beyond critical care and applied to rural nursing practice. evidence-based practice supports the utility of the synergy model for application within rural environments and populations. keywords: rural nursing, rural nursing theory, synergy model, synergy online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 88 rural nursing and synergy the synergy model for patient care (sm) provides the ideal theoretical foundation for nursing care delivery in rural healthcare settings (american association of critical care nurses [aacn], n.d.). the basic tenants of the sm complement the rural nursing theory and constructs of rural nursing as outlined in rural nursing: concepts, theory, and practice (lee, winters, boland, raph, & buehler, 2013) and allow clinical nurses the ability to meet the needs of patients from the time of conception to end-of-life. the sm is applicable to current nursing practice, and it is currently being utilized as a framework for professional nursing. working in congruence with rural nursing constructs, sm illustrates the true value of patient-centered care and the achievement of optimal health status. this paper will further investigate the sm, and introduce the model’s utility in rural nursing practice. analysis of the theory the aacn’s model (n.d.) provides a rich foundation that can be utilized in rural nursing and can be adapted to work in congruence with the outlined rural nursing constructs (lee et al., 2013). the sm recognizes the uniqueness every patient and family unit while still acknowledging the common needs that patients and families experience along the continuum of health and illness. matching nurse competencies to patient needs on a model that allows for the integration of specific patient needs demonstrates versatility. according to kaplow (2002); “since the implementation of the sm, numerous exemplars have been published illustrating its incorporation into clinical practice.” (p.77). there are eight characteristics embedded into the sm, and they allow for numerous nursing competencies to be incorporated into daily nursing online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 89 practice. this assemblage of nurse attributes includes: clinical judgment, clinical inquiry (innovator/evaluator), facilitation of learning, collaboration, systems thinking, advocacy and moral agency, caring practices, and response to diversity. there are eight patient attributes identified within the theory which are resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision-making, and predictability (hardin & kaplow, 2005). synergy occurs when the institutional needs, nurses’ competencies and the patient needs are in harmony. optimal patient care outcomes are the cumulative result of the nurse and patient’s coordinated efforts within the framework of the institution. the sm can be expanded beyond the acute care setting. collins and strother (2008) stated that unswerving preparation and substantiation of nurses “in key behaviors improve the assessment and recognition of complications and prompt interventions regardless of the location of the patient” (p. e7). the improvement of assessment and clinical inquiry skills for rural nurses will likely maximize the patient care outcomes for patients with emergent care needs in rural areas. nurse competencies vary greatly over the present continuum of care within the united states resulting in many variables to be considered. the sm offers a simplistic method to measure and assign nursing competencies and optimize patient care while addressing the unique needs of each patient care experience. the model offers a novice to an expert level for each nurse characteristic (hardin & kaplow, 2005). aligning nurse characteristics to patient care needs creates a mode for unlimited usage of this model, as well as optimal patient-centered care regardless of the patient’s location or level of vulnerability. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 90 the four major concepts of the nursing metaparadigm described within the sm allow for its application to nursing care delivery in all patient care settings. the concepts of human beings, environment, health, and nursing are identified as the major concepts for providing humanistic care (fawcett & desanto-madeya, 2013). human beings are defined as the recipients of care or the patients, and they are continually changing, holistic systems. mind, body, and spirit are all included in the human experience (hardin & kaplow, 2005). the sm allows for a holistic view of the patient with its eight intertwined patient needs. for example, resource availability can be related to the isolation of a rural patient in regards to the accessibility of nurses with advanced clinical inquiry skills, the predictability of their physical, mental, and emotional needs, and the patient’s ability to actively engage in decision making. it is also incorporated into nurse competencies. the systems thinking competency identifies environmental factors. the environment as defined by the sm embraces the patient, family, and community (aacn, n.d.). the meaning of health within the sm is what the patient decides it is. this model preserves the patient in the center of care, allowing patient needs to drive health care delivery. three levels of outcomes are described: patient-level, unit-level, and system-level. this allows the patient to remain as the center of the continuum and actively participate in their own care. the needs or characteristics of the patients and their families continually influence and drive the characteristics of nursing interventions. the sm allows the patient to be a holistic ‘being’, with their own ideas and concerns, instead of a human ‘doing’, that is required to conform to someone else’s preconceived notion of their health status. as defined by the sm, “a goal of nursing is to restore a patient to an optimal level of wellness as defined by the patient. death can be an online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 91 acceptable outcome, in which the goal of nursing care is to move a patient toward a peaceful death” (aacn, n.d.). the fourth major concept of the metaparadigm is nursing. nursing is defined as “the nursing actions or processes that are beneficial to human beings” (fawcett & desanto-madeya, 2013, p. 6). the nurse competencies listed in the sm define the nurse’s role and actions within the framework of the nurse’s environment, scope of practice, and expertise. listing the nurse’s competence from advanced beginner to expert in each category creates a medium to streamline optimal care by evaluating the nurse’s eight competencies and identifying areas that may be deficient (kaplow, 2002). the sm, while supporting the patient, allows for the identification of nurse competency development in differing professional environments. application to current practice there is a growing body of knowledge related to the application of the sm as a foundation for nursing practice (kaplow, 2002). in critical care, acute care, and progressive care settings, the sm is providing a foundation for relationships and patient-centered care. the model is applicable in current nursing practice as evidenced by its adoption as nursing model by magnet hospitals like baylor (2005), and university of alabama at birmingham (uab) hospital. the model has also been used to identify needed reform in the educational components of hospital competencies. collins and strother (2008), stated that within the sm, “a clinical nurse specialist (cns) and nurse educator intervene on the individual patient-family level, the nurse to nurse level, and systems level to improve outcomes in the critical care setting”(p. e1). the model centers on the patient and their needs as the focal point of care. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 92 academic institutions are utilizing synergy to improve student outcomes. applying the sm to identify the student as the patient within the model, colleges like duquesne university, pittsburg, pa have adopted it as their basic framework for the education of nursing students. this unique application of the sm emphasizes its flexibility and utility as a foundation for both nursing practice and education. by creating synergy between the university, educators and student, rather than the hospital, patient and the nurse, this model was easily adjusted (duquesne university, 2008). collins and strother (2008), educators at uab hospital identified a need and developed a competency assessment tool that highlights an example of the versatility of the model. the sm creates an environment that allows for assessment of the patient and the nurse; it defines the relationship in such a dynamic manner that it can be utilized universally in all types of patient care settings. congruence with rural nursing constructs the sm acknowledges that all patients have similar needs and experience these needs across varied continuums from health to illness (aacn, n.d.). working in congruence with a developing rural nursing theory presently defined by constructs of rural nursing practice (long & weinert, 1989), the sm illustrates the impact that nursing care can have on the continuum of health to illness. these statements highlight the rural nursing theory and correlate within the framework of the sm. the definition of health that is often used to express the lived experience of rural residents is directly related to individuals and their ability to be productive members of their communities (lee et al., 2013). rural residents achieve health when they have found a balance in every area of their individual lives. older rural residents are more likely to define health in ways that relate online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 93 directly to their capacity to work, be useful and complete typical responsibilities (shrefflergrant, nichols, weinert & ide, 2013). rural patients typically view health in the context of functioning, particularly within rural areas with extractive industries. the sm acknowledges that human beings possess differing views of health. figure 1 rural nursing constructs, patient characteristics, and nurse competencies. patient characteristics • resiliency • vulnerability • stability • complexity • resource availability • participation in care • participation in decision-making • predictability rural nursing constructs •availability •accessability •accomodation •affordability •acceptability nurse compentencies • clinical judgment • advocacy and moral agency • caring practices • collaboration • systems thinking • response to diversity • facilitation of learning • clinical inquiry (innovator/evaluator) online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 94 incorporation of the prominent view of health in rural populations and the goal of nursing within the sm to “restore a patient to an optimal level of wellness as defined by the patient” (aacn, n.d., p. 1) would foster rural cultural beliefs about health with focus on the goal of remaining functional. in a case study conducted by bales, winters, and lee (2013) included in the book entitled rural nursing (winters, 2013), six major themes emerged from the data: (a) selfreliance, (b) hardiness, conscientious consumer, informed risk, community support, and inadequate insurance. this qualitative, descriptive study was informed by a primarily female sample (n = 5) and one male. ages ranged from 37-76 years of age. the participants included newcomers and old-timers having lived in the montana community between 3-30 years. globally the residents tried to engage in self-care behaviors (prior to seeking medical care), but there was a varied degree of selfreliance notably based on length of time within the community. a married couple participating in the study had only lived in the rural community for a brief period after retiring. they admittedly accessed formal health care more quickly than longtime residents and factors influencing their self-reliance included quality health care, easy access health care prior to moving to montana city and the diagnosis of a chronic health condition. another example within this case study involved that of a woman planning a non-emergent surgery to allow safer, easier travel in the area despite still having to use a snowmobile in a heavily laden snow region. with respect to hardiness, an older participant demonstrated endurance while caring for her terminally ill husband after undergoing a shoulder surgery herself. prior to her discharge from the hospital, the woman was informed that she was not ready for discharge and her extended stay left her without care for her husband. the woman was told that she would be charged $118.00 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 95 per-day for her husband’s care. due to this extreme financial and emotional burden, she was forced to abandon recommendations for her own health and solicit help within her family to assist in providing end-of-life care for her beloved spouse. informed risk was a theme of great discussion among the study participants. despite warnings from their physicians (with respect to individuals who retired to the rural community), these people understood their risk with limited access to health care, especially in an emergency. they agreed that one day they may be forced to move again because of their health, but wished to stay put until that time came. one participant commented, “those of us who have been here for years, we just try to take care of ourselves without having to get any medical attention. sometimes that is okay. we realize the risk we are taking” (bales et al., 2013, p. 73). the above case provides a clear example of the harmony that exists between the rural nursing theory and the sm. the characteristics of patients that can be easily identified in the sm include resiliency, predictability, resource availability, and participation in decision-making. similarly, the sm emphasizes the congruence between longevity of residence being positively related to the themes of resiliency, predictability, resource availability, and participation in decision-making. access to health care is both literal and figurative. congress attempted to address it from a literal standpoint with the passing of the health professions educational assistance act of 1976 (hpsa) and affordable care act of 2010 (aca) out of concern for the maldistribution of primary care physicians. at this writing, there is uncertainty regarding how the aca will be changed in the future. the hope would be that one of these pieces of legislation would increase access to primary care physicians in underserved areas. this legislation was thought to help online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 96 provide affordable healthcare options. over 40 percent of people living in rural counties travel outside their home county for physician services for reasons such as high local physicians’ fees, inadequacy of local physicians’ skills or medical equipment, and inability of local physicians to meet community health needs (gamm, castillo, & pittman, 2010). rural inhabitants are very independent. they make decisions to seek care for infirmity, disease, or injury depending on their ideas of harshness of the present health problem and their perception of the available resources. the exception is rural residents with infants and children (rasmussen, o’lynn, & winters (2013). rural dwellers will seek care more quickly for their children than for themselves. as discussed earlier within the sm eight patient characteristics are identified. the model intrinsically recognizes the patient’s resource availability, and participation in care. these patient characteristics support the rural patient and their decisions of when to seek care. it enables the identification of specific areas of need within the rural community. the sm realizes that different patients operate with differing contexts. the person, their direct support system and their kinship reinforce the foundation of the nurse-patient relationship (aacn, n.d.). this also supports the rural patient and their decision of when to seek a relationship with the nurse. “health care providers, in rural areas, must deal with a lack of anonymity and much greater role diffusion than provides in urban or suburban areas” (long & weinert, 1989, p. 120). the nursing characteristic as outlined by the sm recognizes that different nurses have differing competencies. the greater role diffusion required to fulfill the requirements of rural nursing can be found within the caring practices, response to diversity and collaboration. unified nursing online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 97 characteristics draw a picture of the nurse who is capable and competent to deliver care within the more rural areas. summary in summary, evidence-based practice supports the utility of the sm for application within rural environments and populations. the sm was designed specifically for use on critical care units within medical institutions; however, its implications are far reaching. rural nursing’s theoretical foundation can be easily interjected into the sm. the eight characteristics of the patient and the nurse allow for synergy within acute, chronic, and community-based health care organizations. the adaptation within rural nursing that would create synergy between the nurse, patient and rural health delivery system would create a streamline effect. this effect could maximize resources, and create optimal patient-centered outcomes. references american association of critical care nurses (n.d.). synergy model: basic information about the aacn synergy model for patient care retrieved from https://www.aacn.org/nursingexcellence/aacn-standards/synergy-model#nurse bales, r.l., winters, c.a., & lee, h.j. (2013). health needs and perceptions of rural persons. in c.a. winters (ed.). rural nursing concepts, theory and practice (4th ed., pp. 65-78). new york: springer. baylor health care system. (2005). baylor health care system professional nursing practice model [brochure]. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 98 collins, a.s., & strothers, d. (2008). synergy and competence: tools of the trade. journal for nurses staff development, 24(4), e1-e8. http://dx.doi.org/10.1097/01.nnd.0000320672. 58200.8d duquesne university, school of nursing. (2008). nln designates duquesne a center for nursing excellence in education. retrieved from: http://www.duq.edu/news/nln-designatesduquesne-a-center-of-excellence-in-nursing-education fawcett, j., & desanto-madeya, s. (2013). contemporary nursing knowledge: analysis and evaluation of nursing models and theories. (3rd ed.). philadelphia, pa: f.a. davis. gamm, l., castillo, g., pittman, s. (2003). access to quality health services in rural areasprimary care: a literature review. in l. gamm, l. hutchison, b. dabney & a. dorsey (eds.). rural healthy people 2010: a companion document to healthy people 2010 (17 – 29). retrieved from https://srph.tamhsc.edu/srhrc/docs/rhp-2010-volume2.pdf hardin, s.r., & kaplow, r. (2005). synergy for clinical excellence: the aacn synergy model for patient care. sudbury, ma: jones and bartlett. kaplow, r. (2002). the synergy model in practice: applying the synergy model to nursing education. critical care nurse, 22(22), 77-81. lee, h.j., winters, c.a., boland, r.l., raph, s.j., & buehler, j.a. (2013) an analysis of key concepts for rural nursing. in c.a. winters (ed.), rural nursing: concepts, theory, and practice (4th ed., pp 469-480). new york: springer. long, k.a., & weinert, c. (1989). rural nursing: developing the theory base. scholarly inquiry for nursing practice: an international journal, 3, 113 – 127. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.431 99 rasmussen, a.d., o’lynn, c., & winters, c.a. (2013). beyond the symptom-action-timeline process: explicating the health-needs-action process. in c.a. winters (ed). rural nursing: concepts, theory, and practice (4th ed., pp 141-157). new york: springer. shreffler-grant, j.m., nichols, e., weinert, c., ide, b. (2013) complementary therapy and health literacy in rural dwellers. in c.a. winters (ed.), rural nursing: concepts, theory, and practice (4th ed., pp 469-480). new york: springer. winters, c. (2013). rural nursing concepts, theory, and practice. (4th ed.). new york: springer. microsoft word hatcher_486-2911-3-ce.docx online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 40 rural grandparent headed households: a qualitative description jennifer hatcher, phd, mph, rn1 kaitlin voigts, bsn, rn, phd student. 2 amanda culp-roche, phd student3 adebola adegboyega, phd, rn4 traci scott, ba5 1 professor, mel & enid zuckerman college of public health, associate director for community outreach & engagement, the university of arizona cancer center, jennifer.hatcher@uky.edu 2 phd student, university of kentucky college of nursing, kaitlin.voigts@uky.edu 3 phd student, university of kentucky college of nursing, adculp2@uky.edu 4 postdoctoral scholar, university of kentucky college of nursing, adebola.adegboyega@uky.edu 5 university of kentucky college of nursing, traci.scott@uky.edu abstract purpose: to explore, from an emic perspective, the unique socio ecological context in which rural grandparent headed households (ghh) exist, and therefore provide a foundation for the development of culturally-appropriate interventions that might impact their health. methods: this qualitative descriptive study was based on the conduct of in-depth, semi-structured interviews with fifteen grandparents, residing in rural appalachian kentucky, who were the primary caretakers for their grandchildren. the interviews were conducted using an interview online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 41 guide that was based on the premises of the social ecological model (sem). a basic assumption of this model is that intrapersonal, social-cultural, organizational, and policy factors influence individual health and health behaviors, and that these influences are interrelated and reciprocal. data was analyzed by the research team using line by line coding of the audio recorded transcriptions of the interviews. findings: ghh experience both barriers and facilitators to maintaining the health of ghh. many grandparents viewed the experience of belonging to a ghh as a positive one, believing that having their grandchildren in their home improved their health. they relied on formal and informal networks such as extended family and churches to help with caretaking responsibilities. grandparents experienced notable barriers to health related to having the primary responsibility of their grandchildren, including lack of resources and family tension related to incarceration and/or opioid drug use by biological parents. conclusions: ghh, one of the fastest growing family constellations in rural appalachia and the us, may be particularly vulnerable to health threats elevating their risk for many chronic diseases. effective health related interventions to address this risk should be based on the socio-ecological context in which these families exist. keywords: rural, grandparent headed households, qualitative, socio-ecological model rural grandparent headed households: a qualitative description grandparent headed households (ghh) are one of the fastest growing family constellations in the country. the most recent data show that in 2012, an estimated 7 million grandparents live with at least one grandchild, and 2.7 million of these grandparents have the responsibility of raising online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 42 their grandchild (united states census bureau, 2014). these numbers reflect an increase in ghh over the course of the past 25 years (united states census bureau, 2014). further, there is likely an underestimation of the number of ghh, given the informal kinship arrangements that exist for many of these households (b. hayslip, jr., fruhauf, & dolbin-macnab, 2017). these families, often referred to as skipped-generation families, develop as a result of various circumstances, including: parental incarceration, death, mental illness, and/or substance abuse (bachman & chase-lansdale, 2005; winokur, holtan, & batchelder, 2014). regardless of the reason for the family composition, there are both challenges and benefits inherent in this family constellation. these challenges and benefits include mental, physical, and emotional factors for both grandparents and grandchildren (b. hayslip, jr. et al., 2017). for example, children residing in ghh, who might have otherwise been placed in state care, are often able to maintain connections with birth parents and cultural and ethnic traditions (koh & testa, 2008). additionally, grandparents who are raising their grandchildren report greater life satisfaction and happiness by keeping their family united (bullock, 2005; goodman, 2001). challenges for those in ghh include a greater likelihood of poverty, limited resources, stress due to fear of removal of children from the home, a lack of food security, and social isolation. these challenges are in part due to the fact that two thirds of ghh have a household income less than 200% of the federal poverty line, with nearly half of those households below the 100% federal poverty (dunifon, ziol-guest, & kopko, 2014). despite this level of poverty, only 12% of these household receive public assistance of any kind and one third of the ghh receive food stamps (dunifon et al., 2014). there is also a growing body of evidence that suggests that grandparents raising their grandchildren suffer disproportionately from poor health compared to their peers who are not raising grandchildren. for example, in one study conducted across boston, chicago, and online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 43 san antonio, custodial grandmothers reported worse perceived physical health compared to custodial mothers (bachman & chase-lansdale, 2005). this may be due to the fact that grandparents, who are raising grandchild, are less likely to engage in preventative health behaviors compared to grandparents who are not raising grandchildren, even when considering financial and emotional hardships within the household (baker & silverstein, 2008). much of what we know to date about ghh is based on findings from studies with urban african american families (haglund, 2000; kelley, whitley, & campos, 2013; minkler & fullerthomson, 2005). however, the largest number of ghh in the country live in rural areas. for example, the state of ky, a largely rural state, has one of the highest rate of children being raised by non-parent family members in the united states (generations united, 2016).in ky, over 58,000 grandparents are the householders responsible for their grandchildren who live with them, and of these households, nearly a third do not have either parent present (united states census bureau, 2016). rates of ghh are even higher in the appalachian counties of ky, where an estimated 23,000 grandparents are responsible for their grandchildren, and over half of these households have no parent present (united states census bureau, 2016). despite the large number of ghh represented in rural appalachia, there is a dearth of research elucidating any unique health issues faced by these families. while they are likely to face issues similar to other rural residents, including access to quality medical care, sparse community and medical services, and persistent poverty and unemployment, these may be further compounded by their family constellation. the purpose of this paper is to explore, from an emic perspective, the unique socio-ecological context in which rural ghh exist, and therefore provide a foundation for the development of culturally-appropriate interventions that might impact their health. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 44 theoretical framework because the health of ghh members is influenced by multiple factors in the physical and social environment, in addition to personal attributes and behaviors, we draw on the social ecological model (sem) for conceptual guidance (stokols, 1992). the premise of sem is that human behavior is best understood as interplay between the person and their environment. a basic assumption of this model is that intrapersonal, social-cultural, organizational, and policy factors influence individual health and health behaviors, and that these influences are interrelated and reciprocal. prior to the inception of the sem, health promotion efforts focused solely on the individual and individual health behaviors. thus, the sem was created by a social ecologist to bridge the gap between health promotion efforts and existing knowledge of how an individual’s environment impacts their health (stokols, 1992). we selected to use the sem as a guiding framework, as this study aims to holistically examine health behaviors and health risks present in grandparents who are raising their grandchildren. using the sem as a framework for this study requires exploration of the interaction between the environmental and community resources available in the region and the culture, health habits, and life-styles of those residing in the area. employing this broad and dynamic model allows us to identify, in a grounded and authentic manner, leverage points for intervention without the traditional focus on individual level factors alone. methods for this qualitative, descriptive study, we conducted face to face, in-depth, semi-structured interviews with fifteen grandparents, residing in rural appalachian ky, who were the primary caretakers for their grandchildren. the participants resided primarily in whitesburg, kentucky. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 45 whitesburg is located in letcher county ky, a county that rates a 9 on the rural-urban continuum code, indicating that the county is completely rural. the range on the rucc is 1 to 10 with 10 being the most rural (united states department of agriculture, 2013). the interviews were conducted using an interview guide that was based on the premises of the sem. the interviews began with open-ended prompts (e.g., describe how you came to be the primary care taker for your grandchild. what community resources do you use to help your grand family? who makes the decisions about what your family eats?) the interviews lasted approximately one hour, they were voice recorded and professionally transcribed, and then each transcript was checked against the recording for accuracy. a codebook was developed inductively from the interviews using line by line coding with the sem framework as a guide. trained research assistants separately coded all the transcripts, and then the full research team met to discuss discrepancies until consensus was reached. prior to conducting the study, institutional review board (irb) approval was obtained from the university of kentucky irb. the protocol approval number is 14-0311-pih. results the sample consisted of 15 grandparents all residing in rural appalachian ky. all participants identified as white, non-hispanic females. in this sample, the mean age was 58.9 years (sd = 6.09). the majority of participants were married (n = 9, 60%). the average years of education for this sample was 11.1 years (sd = 3.1). employment status varied among participants, 26.7%(n = 4) were homemakers, 20% (n = 3) were employed full time or part time outside the house, 20% (n = 3) were on sick leave or disability, 13.3% (n = 2) were retired due to illness, 6.7% (n = 1) were retired not due to illness, 6.7 % (n = 1) were unemployed or laid off, and 6.7% (n = 1) were unemployed by choice. all of the participants were insured. while the online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 46 majority were insured through government insurance (n=13, 86.7%), 13.3% (n=2) had private insurance. the findings from the study are presented in the context of the sem and describe the socioecological factors that influence the health of rural appalachian ghh family members under the five domains: intrapersonal, interpersonal, community, organizational/institutional and policy. intrapersonal intrapersonal factors are individual characteristics including knowledge, attitudes and beliefs that influence health and health behavior. intrapersonal challenges to grandparent health included role changes and knowledge. adapting the role of primary care giver versus grandparent challenged many of the grandparents to concentrate on their own health and placed them in the role of disciplinarian and care taker. while they appreciated this new role, it seemed to challenge their ability to interact with the grandchildren in the expected or traditional ways, adding mental, emotional and physical stress to the relationship and perhaps contributing to altered decisions regarding their own personal health. “you miss out on the joy of being a grandparent because you have to discipline them to. you can’t just spoil them for a while and they’ll go home. you don’t get to do that”. “there is a real difference in just being plain old grandma.” participants were conflicted between the traditional roles of a grandparent versus the parental role they assumed. this took an emotional toll on some grandparents, “…sometimes i got to be the bossthe bad guy.” societal dangers also added to this role change, “…you want to be easier on your grandchildren because they are your grandchildren. but in this day and age, you really have to stick to your guns in all matters.” some grandparents found themselves in a more demanding role, “i have to be on my feet all day, everyday…my feet swell real bad and everything. but you have to keep on going until the good lord chooses otherwise.” online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 47 an additional personal challenge to the health of the grandparents was their own knowledge level regarding healthy lifestyles and available community resources for families structured like their own. others admitted to limited knowledge about healthy lifestyle, “i’m just an old fogey...about eating and food and cooking, and frying and baking or whatever.” while grandparents faced multiple personal challenges to their health, they also acknowledged the personal health benefits of being in a ghh. many grandparents expressed that their grandchildren make them feel healthier, happier, and stronger because they are active in keeping up with their grandchildren. one grandparent stated “...it just makes me happy, healthy...it helps my sugar stay calmer, all that. i am doing stuff...if i didn’t have them i don’t think i could make it.” another added, “i have more strength now than before i got them, they saved my life.” avoiding illness and staying healthy was a motivator for many grandparents. grandparents related, “well, you have to be in good health for them” and “i want to be healthy for my grandkids so i can help raise them.” as stated by another grandparent, “what would two old people do? we’re waiting for our golden years but all it is going to the doctor’s. but with them, we’ve got something always to do”. one grandmother summed, “i don’t want to get sick cause i take care of him.” many grandparents sought and acquired new knowledge in their caregiving role to understand and help the children. one grandmother stated “i’m learning. i try to figure out what they are doing on the phone.” another stated, “…keep my mind always going. so it’s benefitted me in the long run.” worry over the health of their grandchildren motivated grandparents to stay healthy and make better choices. one grandmother cited, “now we both watch what we eat, like i told …the dietician at mountain comp, she was telling me how to… (watch) the portion size…his papaw, he’s a real bad diabetic. so you just have to watch…try to do the best i can…” another online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 48 grandmother stated. “i am very picky. i try to watch, i don’t give them a lot of sugar or junk food. i make sure they eat healthy.” many grandparents felt that traditions were helpful in maintaining a healthy lifestyle. outdoor play, gardening, and preserving food were traditions cited as facilitators to healthy behavior. one grandmother stated, “right now we have a lot of fresh vegetables from the garden and i also can a lot.” daily chores helped many grandparents stay active and were a way to help them teach grandchildren healthy behaviors, such as gardening and cooking. grandparents also found that their traditional foods often conflicted with their grandchildren’s preferences. some grandparents adapted meals to include foods such as pizza or macaroni and cheese to appease picky eaters. others cooked separate meals for themselves and the grandchildren, one grandparent makes “three or four different meals for supper cause they don’t all like the same stuff. i have to cook them stuff that they like.” convenience and fast food has encroached on healthier traditional foods such as garden-raised vegetables, with some of this related to fatigue or not having time to cook. one grandparent commented, “we eat whatever’s handy to fix and easier to fix rather than take the time…eating fast food when we have ball practice.” many expressed frustrations about not being able to provide healthier foods for their families. one grandmother stated, “you can’t get something that’s going to be healthy and then skip the month. you have to look at it from the first [of the month], and see what’s going to go that whole month. and they’re not going to go to bed hungry.” interpersonal interpersonal factors are social relationships that impact health and health behavior such as extended family support, neighbors, and friends. support from family members was cited as a online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 49 healthy facilitator, with spousal support being the most commonly cited. one working grandmother stated, “my husband is really good, he does a lot. he’s not much of a cook. he does everything else.” support from extended family members was important for grandparents without spouses or whose spouses were ill. “…my family, my children, my mother. my mother is my root.” and “…my daughter…she’s the one who takes her dad to his radiation,” represented this support. even the grandchildren living with the grandparent provided support, “… (grandson), he helps his papaw do a lot of things cause he can’t no more. so he helps a lot.” this support was critical to maintaining a healthy lifestyle while raising grandchildren. faith and church were a critical part of social support. one grandmother stated, “i am going to say god. the grace of god,” when asked who provided her the most support. given the older age of grandparents, many of them are subject to serious and chronic illnesses while raising grandchildren. this is further impacted by the family constellation and also contributes to added stress in the household. one grandparent commented, “the kids and i thought everything was going to be ok…then cancer walks in the door. my husband is eaten up with cancer.” it can also impact the finances of the household, “his papaw’s got prostate cancer now, has to go five days a week to have radiation. he’s a diabetic, he’s got a bad hearthe has a pacemaker and a defibrillator…it’s going to be hard.” an often cited interpersonal challenge was parental interference. as one grandmother related, “…the mother instinct in me comes out maybe because she’s always trying to interfere with my family.” parents would, at times, undermine the grandparents’ authority, “[my daddy said i don’t have to mind you, you’re not our boss…] it’s not good, it’s not healthy.” strained family relationships also caused stress. causes for this strain included: perceived mistreatment of the grandchildren by the biological parents, parental substance abuse, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 50 incarceration of the grandchildren’s parents, remarriage of the parents, and custody conflicts. this grandparent felt anger and resentment, “he gets on my nerves. he doesn’t do what he’s supposed to do so i just try to leave it. i just try not to go around him much—because he doesn’t do right by them (grandkids). and when i think about it, it makes me mad.” as put by another grandparent, “i have watched these kids cry. and that hurts”. parental substance abuse was a significant challenge to nearly half of the grandparents interviewed. many grandparents made multiple attempts to help their children, “she wouldn’t listen. i told her, you’re going to die if you don’t get off of this junk…me and my husband saved up some money. we took $1200 and took her to … (rehab). she walks out—right back to the same thing.” emotionally, many of these grandparents suffered. as one grandparent relayed, “he’s put us through everything but we still love him because he’s our son but i wish he would straighten out. those old drugs took over.” most grandparents in the study cited adequate support from family. however, some lacked support either because their spouse was ill or had passed away, their family lived out of state, or their families were not helpful. these grandparents seemed to struggle and were less likely to seek outside help, “i can raise her. the way i am, we do good…lord will, we’ll make it.” community community factors are geographical and political structures and also include social networks. grandparents relied on churches to provide them with options they would not have otherwise. churches provided a sense of community where “everyone pitches in.” participants stated that churches provided assistance with child care, supplemental food, christmas presents, and community outings for the children. participants were more likely to seek opportunities for exercise and cultivate healthy habits when they perceived their communities to be safe for them and their grandchildren. local parks online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 51 that were in close proximity to their homes facilitated physical activity. motor traffic and perceived illicit drug use made outdoor activities unsafe. one grandparent explained, “between the motorcycles and the four-wheelers and the people who are doing drugs in the neighborhood, and we know where they are, i have to be the bad mamaw and not let them go wherever they want to go.” the cost of recreational facilities was also a hindrance. “when you’re on a fixed income, sometimes that three or four dollars is hard to come up with.” another agreed, “they want to charge you just to get through the door. they have everything you want to do there, but it’s expensive.” it was suggested that the community needs “a safe place in the community that’s not a money racket for big shots…a place in the community that’s not expensive.” although some grandparents relied on food pantries to supplement their diets, many viewed these offerings as inadequate and unhealthy. “it’s not a lot. you get some canned stuff. sometimes you get one or two things of bread. maybe one freezer meat.” another added, “last time i went, we got two bags of potatoes, a frozen pizza, and i think they gave us a box of those white castles. i got a little roll of hamburger meat.” grandparents often felt overlooked by community services, and even when offered, many grandparents did not know about them. as stated by one grandmother, “i didn’t know stuff like this existed, like people would help grandparents.” organizational/institutional institutional factors that influence health include those that impact the health and the health challenges of families such as schools, workplaces, and healthcare providers. the grandchildren’s schools were a facilitator to a healthy lifestyle. schools provided programs and classes to encourage health-centered behaviors. one grandparent stated that “even school, even their daycarethey are going to start a physical program for the kids.” family resource centers within online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 52 schools also provided food, clothing, and school supplies, decreasing financial strain for some grandparents. social services helped grandparents obtain legal custody of their grandchildren and gain access to financial assistance from governmental agencies. this assistance lessened some worry and stress that many grandparents felt. programs provided by local extension offices provided services to support health in participants and their families. “they’ve got a lady up thereshe’ll measure it all and show you what’s in this—you wouldn’t believe the kind of stuff in our food!” grandparents frequently sought opportunities through the extension office because of the low financial obligation, “that county extension teaches everyone! if you want to go, it’s free. you can walk in there any time.” other community services were also helpful, as one grandmother said, “to me, that’s phenomenal. when you can go and get a free test and tell you how bad it is, even down to my sugar. that is great!” grandparent groups provided social support. one grandparent stated, “when you see other grandparents and you’re doing the same thing, you can communicate.” policy grandparents repeatedly expressed frustration related to lack of public assistance for skipped-generation households, specifically, child support enforcement, assistance programs to defray costs of transportation or community centers, elimination of kinship care, and food assistance programs. grandparents stated that policies that provide help, such as increased food and financial assistance would eliminate many of their challenges. thirteen of the fifteen interviewed grandparents received assistance from governmental programs such as, supplemental nutrition assistance program (snap), social security, disability, or kinship care. fixed incomes were a reality for most grandparents and additional financial online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 53 assistance was helpful, as one grandmother stated, “they receive kinship care…that helps us buy food.” vouchers for the local farmer’s market helped provide healthier foods. in this sample, 86.7% of grandparents had access to free or low-cost healthcare through government insurance, facilitating their health. one grandparent stated, “…we have insurance and that helps a whole lot. when you can go to the doctors for free, when you want to.” most grandchildren had medicaid; therefore, grandparents did not have to sacrifice their health to pay for the grandchild’s healthcare. emotional and behavioral health was often facilitated by services such as mountain comprehensive care. the creation of the affordable care act (aca) allowed some participants to obtain health insurance. one grandparents stated, “we now all have that wellcare… we didn’t have insurance until then.” she continued, “you just don’t go if you don’t have insuranceyou put it off.” challenges to healthy behavior for grandparents came from lack of assistance from government, court systems, and employers. financial support from the government was viewed as insufficient. many had to rely on community support such as food banks, churches, and family resource centers within the public schools. cuts in state programs, such as kinship care and the snap program, have made making ends meet more difficult. as one grandparents stated, “i wish they would give the [food] stamps back the way they did. they took a big cut out of it. we’re raising our grandkids–and that helped raise our grandkids. … they don’t look at kentucky–they talk about poverty everywhere else…. they took the kinship and stopped that. … that’s going to stop grandparents–how are they going to take care of them? we have nothing here.” younger grandparents who did not qualify for social security and could not work had to rely on welfare to make ends meet. this assistance often covered basic necessities and grandparents online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 54 were not able to afford needed healthcare items not covered by their health insurance. as one grandparent stated, “i can’t afford glassesi need them but i can’t afford them.” work often conflicted with grandparents’ ability to raise their grandchildren. “it just became a real hectic struggle. i wasn’t bringing enough money home to drive back and forth.” employers were not sympathetic to the needs of grandparents. “i had to take different shifts and something always came up with them (grandchildren)... and i couldn’t get their mommy or daddy to do anything. so i would have to call in, and of course my employer didn’t like that.” jobs that offered hours conducive to raising younger grandchildren was another challenge cited. grandparents expressed frustration over lack of child support enforcement. while willingly taking on the role of primary caretaker of her grandchildren, one grandparent wished she had “a bit more support in forcing their dad to pay his child support.” another supported this, “i wish the parents would take care of the children. but it ain’t gonna work out that way.” grandparents reported poor financial assistance as a barrier to healthy behaviors. existing programs often assist families based on income; however, grandparents explained that regardless of income-based payment, transportation and recreation center membership remains unaffordable for their families. one grandparent stated, “that [transportation] is going to cost you an arm and a leg!” several felt the lack of assistance is due to a lack of recognition that grandparents are frequently raising grandchildren. one grandparent stated, “i think that grandparents are kind of overlooked in a way because people don’t realize that grandparents are the ones raising a lot of children. they assume.” discussion this paper provides a socio-ecological examination of the unique facilitators and barriers to the health of family members of rural appalachian ghhs. understanding this context is critical online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 55 to the design of interventions to improve the health and decrease health risks of this fast growing family constellation. research to date has focused primarily on urban african american families, who arguably have access to a different set of resources and view health and wellness from a different cultural lens. this paper provides insight into the experiences of being a member of a rural appalachian ghh and the impact of that experience of the health of the family members. the sem provides a framework that elucidates the unique social contextual factors that contribute to the health of these families, which are important considerations in all health promotion efforts. in each area of the sem (intra and interpersonal, community, institutional, and policy) there are factors influencing the health of these families that should be considered in the design of culturally appropriate interventions. importantly, many grandparents in this study view the experience of belonging to a ghh as a positive one, they believe that having their grandchildren in their home improved their health. “running after” grandchildren and increased household chores pushed grandparents to be more active which may be helpful in reducing chronic illnesses. many grandparents expressed being “happier” and “having more energy” since assuming care for their grandchildren. the majority of the grandparents who expressed those views also had a strong social support system made up of family, friends, faith, and community organizations. the intra and interpersonal factors influencing the health of these families may be mediating factors that can be drawn on to design innovative programing that relies on the strengths of the family relationships and the social support that is a pillar of the rural community. family interventions that involve extended family members and/or lay health workers who are aware of both formal and informal social networks could be designed to take advantage of the strong social and family ties in the rural community in which these grandparents live. an example of this would online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 56 be kinship navigator systems (triwest group, 2005). these programs demonstrate the need to address relevant issues to informal caregivers who may deal with situations that are outside of the system and utilize knowledgeable local lay workers and program providers to do so (fruhauf, pevney, & bundy-fazioli, 2015). in addition to the positive inter and intra personal and community factors rural grandparents experienced there were a number of notable barriers to healthy living that supported the development of interventions to reduce health risks for these vulnerable families. grandparents expressed frustration as many community services overlooked grandparents as primary caretakers for their grandchildren (fruhauf et al., 2015). grandparents were often too young for older adult services, such as social security or retirement benefits, or were not considered primary caretakers of grandchildren; thus, denied community services. it has been reported that grandparents raising grandchildren typically have the least amount of access to assistance, but often have the greatest need (strom & strom, 2011). families in the rural appalachian area expressed particular concern related to the increasing number of families impacted by incarceration and other sequela resulting from the opioid epidemic that is impacting their lives. while all states have demonstrated an increase in nonmedical prescription opioid morbidity and mortality during the last decade, death and injury resulting from non-medical prescription opioid misuse is concentrated in rural states such as ky and wv (keyes, cerda, brady, havens, & galea, 2014; schoenberg, hatcher, & dignan, 2008; schoenberg, howell, swanson, grosh, & bardach, 2013). this pressing public health problem is not only a contributor to the growing number of rural ghh but also provides a complex threat to their well-being. grandparents who head these households are often not only raising children who may be suffering from drug related disabilities but they are simultaneously dealing with the stress of a drug addicted child who may demonstrate hostility and place the wellonline journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 57 being of the family in danger (hughes, waite, lapierre, & luo, 2007; kicklighter et al., 2007; letiecq, bailey, & porterfield, 2008). there is a critical need to provide support to these families in a variety of ways. interventions that include connections to local social services and help families identify legal, financial, and social resources are necessary (fruhauf et al., 2015). the rich description of the socio-contextual factors impacting the health of ghh provides a framework for the development of culturally relevant interventions to reduce the risk of these families for chronic diseases. for example, residents of rural appalachia are at increased risk for diabetes mellitus (dm) by virtue of experiencing higher rates of obesity, limited food choices, limited access to exercise and other factors. these risk factors for diabetes are shared among family members due to common patterns of race/ethnicity, physical activity, nutrition, and obesity (rodbard et al., 2012). addressing chronic disease risk is important in ghh, as the health of the grandparent can directly impact a number of factors in ghh, including: personal resilience, wellbeing, grandchild difficulties, stress, and life disruption (b. hayslip, blumenthal, & garner, 2014) further, understanding and intervening to modify the risk of the family may contribute to decrease chronic disease disparities for all generations. conclusion residents of rural appalachia suffer rates of chronic diseases that are among the highest and most rapidly increasing in the country. ghh, one of the fastest growing family constellations in rural appalachia and the us, may be particularly vulnerable to health threats elevating their risk for many of these disease. this paper provides a holistic look at the socio-ecological context of these families and forms the foundation for interventions that are culturally and contextually appropriate and may significantly reduce the risk 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(2013). rural-urban continuum codes. retrieved from https://www.ers.usda.gov/data-products/rural-urbancontinuum-codes/ online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.486 62 winokur, m., holtan, a., & batchelder, k. e. (2014). kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment. cochrane database of systematic reviews (1), cd006546. https://doi.org/10.1002/14651858.cd006546.pub3 microsoft word ruffin_372-2009-2-ed.docx online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 132 prenatal education, significant other support and demographic determinants of breastfeeding within a rural community senora dianna ruffin, dnp, rn-c 1 michele renaud, rn, phd 2 1 interim director of inpatient services, riverside shore memorial hospital, senoraruffin@yahoo.com 2 adjunct associate professor, old dominion university, doctorate of nursing practice program, mrenaud@odu.edu abstract introduction: breastfeeding is the most natural and nutritious way to encourage a baby’s optimal development and research over the past two decades clearly indicates multiple benefits to infants. still, underprivileged, underserved, and minority women are not breastfeeding at rates that are comparable with national averages. national estimates indicate breastfeeding is initiated at much lower rates for minorities, adolescent mothers, socio-economically disadvantaged women and women who reside in rural areas. purpose: this study evaluated the impact of prenatal education, significant other support and demographics on breastfeeding initiation of women residing in a small rural community. methods: the study used a cross-sectional design that prospectively examined the breastfeeding intentions of the targeted population. a convenience sample of 41 post-partum women were recruited from a rural hospital within 48 hours of giving birth. participants were administered a selfreporting 27-item questionnaire. descriptive, pearson’s rho and chi-square analysis were conducted to determine associations. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 133 results: approximately 65.9% of the women reported initiating breastfeeding. prenatal education was not statistically significant associated using chi-square analysis at p < 0.05. based on a likert scale ranging from 1least supportive to 3very supportive, breastfeeding moms report a high level of support from healthcare providers and family members with mean scores ranging from 2.44 to 2.96. older, more educated and women who had breastfed a previous baby were more likely to breastfeed at p< 0.05. breastfeeding was initiated at higher rates in women whose extended family were breastfed. conclusion: continued research aimed at increasing breastfeeding in rural communities will be useful in identifying best practices that will improve the health of mothers and infants. keywords: breastfeeding, healthcare, rural community, prenatal education, significant other support and demographic determinants of breastfeeding within a rural community extensive research conducted over the past two decades has shown multiple benefits of breastfeeding. initiatives by the american academy of pediatrics (aap), the u. s. department of health and human services (usdhhs), centers for disease control and prevention (cdc), healthy people 2010, and the world health organization (who) have resulted in a gradual increase in breast-feeding rates in the united states. in 2005 the overall initiation rate was 71% (centers for disease control and prevention (cdc), national center for chronic disease prevention and health promotion, 2013). according to the cdc division of nutrition, physical activity, and obesity national immunization survey (2014), breastfeeding rates continue to rise, and in 2009 they increased from 74.6% to 76.9% representing the largest annual increase over the previous decade. breastfeeding at 6 months increased from 44.3% to 47.2% and from 23.8% online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 134 to 25.5% at 12 months. in 2011, 79% of newborns were breastfed immediately after birth. yet breastfeeding did not continue for as long as recommended. of infants born in 2011, 49% were breastfeeding at 6 months and 27% at 12 months. “healthy people 2020: maternal, infant, and child health” published by the u. s. department of health & human services (usdhhs) 2011 objectives for breastfeeding are: • ever breastfeed 81.9 % • at 6 months 60.6 % • at 1 year 34.1 % • exclusive through 3 months 46.2 % • exclusive through 6 months 25.5 % it is encouraging that the overall breastfeeding rate has increased in the united states. there are however significant disparities within these data as rates vary widely by ethnicity, age, marital status, education, and income. national estimates indicate while breastfeeding continues to increase across all racial/ethnic groups, breast feeding is initiated at much lower rates for nonhispanic black children compared to non-hispanic white, or hispanic children (belanoff, mcmanus, clark, mccormick, subramanian, 2012). a retrospective population-based cohort study of all live births in 2006 and 2007 in the state of ohio concluded adolescent mothers who have the least social support and are socio-economically disadvantaged are the least likely to breastfeed their newborns (apostolakis-kyrus, valentine & defranco, 2013). of the adolescent mothers, 44% initiated breastfeeding compared to 65% of older women. another study showed women who participate in women, infants, and children (wic) program are almost 12% less likely to initiate breastfeeding than the general population and are less likely to continue for a year (hedberg, 2013). a combined longitudinal cohort study of 1292 women paralleled with an online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 135 ethnographic study of 30 families in north carolina concluded rural breastfeeding rates lag behind national averages (cadigan, flower, perrin, randolph & willoughby, 2008). on the eastern shore of virginia, a low income, rural and medically underserved area, rates are much lower than national norms. data collected from hospital records in 2007 indicated that 34% of mothers initiated breastfeeding. the current statistics are disappointing at 30% , significantly less than the healthy people 2020 target objectives for breastfeeding. research cites many barriers to successful breastfeeding including lack of knowledge, feelings of embarrassment, and a lack in their professional and social support (beattie-fairchild, 2013). the lack of staff to provide conventional in-home support has led some communities to explore telemedicine as an adjunct to assist women once they have been discharged (macnab, rojjanasrirat & sanders, 2012). rapid return to work following childbirth has also been cited as a significant barrier to breastfeeding (rojjanasrirat & sousa, 2010). other barriers include maternal attitudes and inconsistent breastfeeding friendly hospital policies and procedures. opportunities exist for implementing baby friendly hospital initiatives (bfhi) to improve breastfeeding rates in these disadvantaged women. this study evaluated the impact of breastfeeding education and significant other support on breastfeeding initiation in the population studied. demographic factors were also assessed to determine breastfeeding initiation associations. review of the literature breastfeeding is the most natural and nutritious way to encourage a baby’s optimal development. the american academy of pediatrics (aap) in its 2012 policy statement outlines many benefits of breastfeeding (american academy of pediatrics, 2012). the risk of hospitalization for lower respiratory tract infections during the first year of life has been reduced online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 136 by 72% in infants breastfed for 4 months exclusively. otitis media has been shown to be reduced by 33% and four randomized clinical trials performed between 1983 and 2005 support the conclusion that premature infants that have been breastfed have a 58% reduction in the incidence of necrotizing enterocolitis. breastfeeding for any length of time has been associated with a 64% reduction in nonspecific gastrointestinal tract infections. other benefits include reduction in severity of a wide range of infectious diseases such as bacterial meningitis, urinary tract infections and sepsis in preterm infants (pound & unger, 2012). breastfeeding helps the baby’s immune system mature, protecting against viral, bacteria and parasitic infections. it also increases the effectiveness of immunizations thereby increasing protection against polio, tetanus, and diphtheria. the skin to skin contact encouraged in the first hour of birth increases breastfeeding rates and duration as well as enhances emotional security and maternal bonding (phillips, 2013). the benefits for the mother are not as well studied as the advantages to the child; however there is sufficient evidence of maternal benefits. women who have breastfed for two years or more show a 37% lower risk of developing coronary heart disease. longer duration of breastfeeding is also associated with reduced incidences of type ii diabetes and lowered risks of ovarian, uterine, and breast cancer (godfrey & lawrence, 2010). women who breastfeed for 24 months have a 25 percent lower risk of premenopausal breast cancer (steinkraus, 2007). breast milk is always fresh, perfectly clean, just the right temperature and is the healthy choice at the least expensive cost. oxytocin produced after childbirth stimulates contractions, minimizing blood loss and encouraging rapid uterine toning. because breastfed babies are generally healthier, their mothers miss less work and spend less time and money on pediatric care. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 137 breastfeeding women report psychological benefits such as increased self-confidence and a stronger sense of connection with their babies. there are social and community implications of breastfeeding as well. one estimate suggests if 90 percent of us women breast-fed exclusively for 6 months, there could be a cost savings of $13 billion due to the direct and indirect costs of otitis media, gastroenteritis, necrotizing enterocolitis, lower respiratory tract infections, atopic dermatitis, obesity, sudden infant death syndrome, childhood asthma, childhood leukemia, type 1 diabetes, and the cost of premature death (bartick & reinhold, 2010). the american academy of pediatrics (2005) outlined specific strategies to improve breastfeeding initiation rates that include the following: • pediatricians and other health care providers should recommend breast feeding and provide complete, current information to all parents so that their decision is informed. • education and practices to optimize breastfeeding initiation and maintenance should include education both before and after delivery. • avoid procedures or medications that interfere with breastfeeding. • assess attitudes about infant feeding from healthcare providers, significant others and pregnant women. • healthy infants should be placed in skin to skin contact with the mother immediately after delivery and until the first breastfeeding is initiated. • newborns should remain with mothers 24 hours a day and breast feed at least 8 times a day. • supplements should not be given to breast fed infants unless ordered by a physician for medical reasons. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 138 • formal evaluation and documentation of breastfeeding should be undertaken by trained caregivers at least twice daily and include observation of position, latch, and milk transfer. • the role of health care providers to support optimal breastfeeding includes making it the cultural norm, providing enthusiastic support, promoting hospital feedings that support breastfeeding such as no formula gift packs and adequate encouragement by all staff. • training for hospital staff should be in depth and provided for all staff. • breast pumps should be available to all patients (gartner et al., 2005). the baby-friendly hospital initiative (bfhi), a global program launched by the world health organization and the united nations children’s fund similarly has outlined ten steps to successful breastfeeding (pound & unger, 2012). the guidelines (table 1) were developed by a team of global experts and consist of evidence based practices that have been shown to increase breastfeeding initiation and duration. evidence based research has supported the role the ten step initiative has played in increasing breastfeeding initiation rates as well as sustainable breastfeeding up to 12 months, both exclusive breastfeeding and breastfeeding with supplemental fluids. a practice development initiative by barnes, cox, doyle and reed (2010) demonstrated significant changes in breastfeeding results after implementing ten step recommendations. an analysis of 317 retrospective chart reviews before the program and 273 prospective reviews post program revealed a 9% increase in exclusive breastfeeding at discharge and a 20% increase during the following 18 months. in the same study, a pre and post program survey was conducted to determine client knowledge and satisfaction. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 139 table 1 ten steps to successful breastfeeding step content 1 a written breastfeeding policy that is routinely communicated to all health care staff. 2 train health care staff in skills necessary to implement the breastfeeding policy. 3 inform all pregnant women about the benefits and management of breastfeeding. 4 help mothers initiate breastfeeding within a half hour of birth. 5 show mothers how to breastfeed and maintain lactation, even when they are separated from their infants. 6 give newborns no food or drink other than breast milk, unless medically indicated. 7 practice rooming-in, allow mothers and infants to remain together 24 hours a day. 8 encourage breastfeeding on demand. 9 give no artificial treats or pacifiers to breastfeeding infants 10 foster the establishment of breastfeeding support groups and refer mothers to them at discharge from the hospital or clinic. the convenience sample of 223 preprogram surveys and 161 post program surveys revealed significant differences (t (378) = -4.976, p = .000) in their responses related to breastfeeding preparation. with a maximum total score of 45 on a likert scale, the preprogram participants had a mean score of 29.27, standard deviation of 10.74 while the post program participants had a mean of 34.05, standard deviation of 7.9. the postnatal satisfaction was similarly higher in the post program participants with a mean score of 36.19, standard deviation versus a mean score of online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 140 33.90, standard deviation of 5.182 in the preprogram group with a significant difference between the two groups (t (378) = -4.375, p = .000). similar results were found in a study by kornides and kitsantas (2013). descriptive statistics and chi-square analyses were conducted to determine the association between prenatal variables and breastfeeding initiation and postpartum continuation at two months. an analysis of 3033 mother baby couplets at birth and another 2546 at two months postpartum revealed a significant relationship between maternal knowledge and breastfeeding initiation and continuation. an additional study by pound and unger (2012) showed 68% of mothers who experienced a minimum of five of the ten steps were still exclusively breastfeeding at 16 weeks as compared to those who had no exposure breastfeeding with rates of 53%. methods rural setting the study was conducted at the only local hospital on the eastern shore of virginia. riverside shore memorial is a 125 bed rural, community hospital with no other hospitals within a 45-60 mile radius. there is a level i nursery with an annual delivery rate of approximately 450. according to the us census bureau rural areas encompass all housing and territories not included within an urban area. the population is greater than 2500 without substantial commuting (hart, larson, & lishner, 2005). the eastern shore is located on the east coast as part of the delmarva peninsula, a 70 mile stretch of rural land bordered on the east by the atlantic ocean, on the west by the chesapeake bay and on the north by the eastern shore of maryland. the rural community is unique in that it is not connected by land to the rest of virginia. each of the two counties has been designated as medically underserved areas, online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 141 medically underserved populations, and health professional shortage areas by the health resources and services administration (2014). the economy is heavily dependent on agriculture and seafood industries both of which are in decline, and there is limited manufacturing and industry. according to the latest community assessment (kiger, 2011), an estimated 20% of the population lives in poverty, compared to a 10% rate for all of virginia. household income is about 57% the state average and can be traced to lower levels of educational attainment, fewer job options, and a chronic history of poverty and unemployment. approximately 22% of the population lacks a high school diploma as compared to a state rate of 12.5%. the percentage of college graduates in the community is half the state average. the small peninsula is cultural diverse with 31.5% african american, white 59.7%, hispanic 8.4%. the number of births to teenage mothers is double the state average. only 47.3% of women who deliver live infants receive the recommended number of prenatal visits. 11.15% of the 556 babies born in 2009 were born with low weight ranking the shore in the bottom quartile. the total infant death rate is 9 per 1000 while the state reference rate is 7. design the study used was a cross-sectional, correlation design examining the relationship among breastfeeding initiation and prenatal education, significant other support and demographic factors-age, education, race, parity, and socio-economic status. government funding included medicaid, food stamps, wic and temporary assistance for needy families (tanf). breastfeeding initiation was defined as any breastfeeding during the hospital stay regardless to duration, continuation or supplementation with other fluids. the health belief model was used as the framework for conducting the study. the model contains the following components: perceived threat, perceived benefits, perceived barriers, cues to action, other modifying variables, online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 142 and self-efficacy. the components work together to influence an individual’s choice to take action or not (boslaugh, 2014). it suggests certain cues to action such as prenatal education will encourage pregnant women to breastfeed. families, peers and health care professionals exert influences that may either support or dissuade the decision. the model further purports certain demographic variables will have an impact on this decision; for instance the higher the educational level, the greater the likelihood that the woman will breastfeed or that minorities are less likely to initiate breastfeeding. instrument the survey method was used to obtain data. participants completed a 27 item selfreporting questionnaire. the instrument was developed by the primary investigator, a maternal child health nurse of 30 years. validity was obtained by face value via expert evaluation, including phd faculty, breastfeeding moms, and maternal child healthcare providers. the survey obtained pertinent demographic information, breastfeeding history and perceptions about significant other support. this was a pilot study. additional instrument reliability and validity could be established in future research using multiple sites and participants. protection of human subjects irb approval as an exempt study was obtained as it met all of the criteria according to the code of federal regulations (cfr), title 45, part 46.101(b) as “exempt.” anonmity was addressed by the use of numerical codes with no identifiable data included. sample and procedure a convenience sample of 41 women was recruited during their initial 48 hours post-partum period. exclusions were any pregnancy or neonatal complications that would delay initiation or continuation of infant feeding. prospective participants were provided a cover letter to include online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 143 the nature of the study and that their anonymity would be protected. a $10 walmart gift card or gift of equal value was used to incentivize their participation. completed questionnaires were identified by a numerical code and contained no identifiable patient related information. they were secured by lock and retrievable by the primary investigator only. once the data was retrieved, it was entered into a password protected database accessible by the primary researcher exclusively. analysis and findings descriptive statistics, pearson’s rho and chi-square analysis were conducted to identify any associations between the independent variables and breastfeeding initiation. using a likert scale format, participants used a 3 point scale indicating their perceptions regarding significant other’s degree of support defined as 1) not supportive of the decision to breastfeed, 2) somewhat supportive and 3) very supportive. the mean scores for each of the variables determined the perception of significant other support in those women who initiated breastfeeding. table 2 represents descriptive statistics. the majority of the women (65.9%) reported initiating breastfeeding. 63.4% of the respondents reported receiving prenatal education while 36.6% did not. of those that received prenatal education, 69.2% reported breastfeeding initiation compared to 60.0% who breastfed without the education. table 2 demographics demographics study group (n = 41) percentage (%) breastfeeding yes 27 65.9 % no 14 34.1 % breastfed previous child yes 22 64.7 % no 12 35.3 % online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 144 extended family breastfed yes 17 41.5 % no 14 34.1 % unknown 10 24.4 % age 20 & under 2 4.8 % 21-30 28 68.3 % 31-40 8 19.7 % 41-50 2 4.8 % unknown 1 2.4 % parity 1 8 19.5 % 2 13 31.7 % 3 13 31.7 % 4 2 4.9 % 5 2 4.9 % 6 1 2. 4 % 7 1 2.4 % ethnicity white 16 39.0 % african american 19 46.3 % hispanics 5 12.2 % other 1 2.4 % marital status married 18 43.9 % divorced 1 2.4 % single 19 46.9 % separated 3 2.4 % educational level elementary school 1 2.4 % high school 15 36.6 % some college 13 31.7 % associates degree 4 9.8 % bachelor’s degree 6 14.6 % graduate degree 2 4.9 % household income less than $20k 21 51.2 % $20k-$50k 16 39.0 % $50k & over 4 9.8 % government funding received yes 28 68.3 % no 12 29.3 % unknown 1 2.4 % prenatal education received yes 26 63.4 % no 15 36.6 % online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 145 breastfeeding mothers report a high level of support from healthcare providers and family members. mean scores ranged from 2.44 to 2.96 with the in-laws providing the least support and the nurses providing the highest level of support, followed by pediatrician with a mean score of 2.93. using chi-square analysis, table 3 shows demographic associations with breastfeeding initiation. prenatal education is positively associated with a woman’s decision to breastfeed. it is not statistically significant using pearson’s chi-square analysis at p < .05. race, marital status, annual salary, the number of children and government funding were also positively associated though not statistically significant. the age and educational level of women were significantly associated with the decision to initiate breastfeeding at p < .05. women who had previously breastfed were statistical significantly more likely to breastfeed subsequent children at p < .05. of approximately 64.7% of the women who reported breastfeeding other children, the majority (77.3%) breastfed this child also. only 25% of those who had not breastfed a previous child reported breastfeeding the current child. women who reported breastfeeding practices among extended family members were more likely to breastfeed their own children at a statistically significant level of p < .05. overall there were 41.5% of the respondents that reported breastfeeding in extended family members. the majority (82.4%) of these women also breastfed while 35.7% breastfed when their extended family did not. table 3 demographic associations with breastfeeding initiation chi-square asymp. sig. (2sided prenatal education .360 .548 race 3.759 .289 marital status 1.379 .710 age 27.692 .049* education level 14.728 .012* annual salary .354 .838 online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 146 government funding 754.000 .385 number of children 9.400 .152 previous child breastfed 8.759 .003* extended family breastfed 8.604 .014* * statistically significant at p < .05 other significant findings: in table 4 pearson’s analysis showed a statistically significant association at p < .05 between the education level of women and family support of their decision to breastfeed. table 4 correlations pearson’s correlation education level family support education level 1 .400* sig. (2-tailed) .031 family support .400* 1 sig. (2-tailed) .031 discussion there are several factors that influence a woman’s decision to breastfeed in rural communities. this study indicates specific demographic variables such as age and educational level as well as support from family and healthcare professionals impact breastfeeding outcomes. a woman’s decision to breastfeed is linked to breastfeeding a previous child and having extended family that have also been breastfed. a limitation of the study is its small sample size and therefore it is not generalizable. studies have demonstrated statistical significant associations between prenatal education and breastfeeding. a detailed exploration of the course curricula referenced in this study may lend more credibility to the results. due to the uniqueness of the targeted population, a community assessment and consideration of a qualitative study with a broader focus evaluating attitudes of online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 147 the workplace environment, local policy makers, healthcare providers and the overall community may be warranted in efforts to increase breastfeeding to healthy people objectives. implications while extensive research has validated the benefits of breastfeeding, disparities still exists in vulnerable populations. underprivileged, underserved and minority women are not breastfeeding at rates that are comparable with national averages. this research study was designed to evaluate factors that were associated with breastfeeding initiation within rural communities. there were several associations identified that are reflective of previous research. other associations though positively associated were not statistically significant. future research is needed to analyze barriers to breastfeeding through conduction of an overall community assessment. funding through rural health grants may provide an avenue for subsidizing research geared toward promoting breastfeeding. conducting an in-depth study regarding attitudes toward breastfeeding, workplace support of breastfeeding and the existence or nonexistence of policies that are reflective of successful breastfeeding will produce valuable information. the research findings will be useful in identifying best practices with subsequent revision of policies, procedures and guidelines to meet health people objectives. lack of access to care and services creates a major challenge to breastfeeding women living in rural isolated communities. resources such as lactation consultants and peer support are necessary for making exclusive breastfeeding the cultural norm. telehealth through the use of social media to enhance breastfeeding support should be investigated as a cost-effective approach to address such barriers. specific to targeted rural populations and other underserved areas, standardized prenatal education curricula and lactation services could be provided through the use of social media or other telehealth modalities. online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 148 references american academy of pediatrics (aap). 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(2011). healthy people 2020: maternal, infant, and child. retrieved from online journal of rural nursing and health care, 15(2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.372 151 http://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-childhealth/objectives microsoft word molanri_rural nurses-10-12-11-21-07.docx online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 rural nurses: lifestyle preferences and education perceptions deanna l molanari, phd, rn, cne 1 ashvin jaiswal, ba 2 tamara hollinger-forrest 3 1 professor, school of nursing, idaho state university, molidean@isu.edu 2 graduate student, college of pharmacy, idaho state university, jaisashv@pharmacy.isu.edu 3. assistant coordinator northwest rural nurse residency, idaho state university, holltama@isu.edu keywords: rural nurse, recruitment, retention, administration, education abstract background: the recruitment and retention of rural nurses is often complex, costly and difficult. administrators report new graduates are often unprepared for the role and little is known about their perceptions of lifestyle and education preparedness. there is also insufficient information about why nurses choose rural generalist roles. purpose: the study investigated relationships among lifestyle preferences, perceptions of educational preparedness for the rural generalist role, and the intent to move. methods: participants in a rural nurse residency answered online survey questions requiring both qualitative and quantitative responses. the study employed a descriptive, correlation design. results: the sample (n = 106) consisted of both novice and expert rural nurses from 22 states. “proximity” was given as the main reason for choosing the rural generalist role. most participants rated their education as ineffective. a significant 11% intended to move. one hundred percent of those with intent to move worked fewer than 12 months. preference for the rural lifestyle and a particular community influenced the choice for the first employment position rather than a desire for the rural generalist role. perceptions of preparedness influenced the intent to move. conclusion: findings suggest community-based strategies highlighting recreation, climate, cultural opportunities, and relationships can improve nurse recruitment and retention. academic and professional development education are proposed for rural nurse preparedness. introduction despite the fact that a global economic recession eased the nurse shortage, the need for nurses continues to grow (hendren, 2009; holloway, baker, & lumby, 2009; kenny, 2009). rural administrators find hiring new employees challenging and costly. recruiting rural nurses takes longer and the turnover rate is higher than for urban centers (cramer, nienaber, helget, & agrawal, 2006; rosseter & american association of colleges of nursing, 2010). the literature states work environments are linked to job satisfaction which is then linked to nurse turnover, but little is said about the retention role of communities (baernholdt & mark, 2009). understanding nurse perceptions is the first step to developing successful recruitment and retention strategies (baker, 2009; molinari & monserud, 2009; wieck, dols, & landrum, 2010); therefore, understanding why nurses choose rural practice is vital to managing the rural shortage (hu, chen, chiu, shen, & chang, 2010; nooney, unruh, & yore, 2010). the purpose of this study is to examine rural nurse lifestyle and career preferences, educational preparation perceptions and the intent to move. the study is based on the rural nursing theory framework (lee & winters, 2004). the theory posits rural practice is different from urban practice due to a number of issues including: environmental, patient health definitions, and health provider use patterns. theoretical principles discuss differences in the roles and skills between rural and urban nurses (baernholdt & mark, online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 2009). in order to discover more about how rural nurses practice, the following research questions were asked: why do nurses choose to work in rural settings and how prepared are graduates for the rural generalist role? a correlational, cross sectional design was used. background the economic recession eliminated many positions in all major industries but the demand for health care personnel continued to rise (u.s bureau of labor statistics, 2009). rural regions experienced a more complex and long term nurse shortage (bushy & leipert, 2005; cramer, et al., 2006). therefore, administrators seek to understand the personal, community, and education factors that influence recruitment and retention. the literature discusses both individual and community reasons for the shortage but little is said about lifestyle preferences of preceptors of educational preparation for rural practice. economic factors suggest lower salaries, fewer leadership opportunities, and family employment issues contribute to the issue (molinari & monserud, 2008). personal nurse factors such as ageing, generation, and family life reasons were found to be important in several urban samples (wieck, et al. 2010; palumbo, mcintosh, rambur, & naurd, 2009; lea & cruickshank, 2007; skillman, palazzo, keepnews, & hart, 2006; macphee & scott, 2002). rural community factors such as school quality, fewer spouse employment opportunities, and the lack of educational access influence nurse recruitment (cleary, mcbride, mcclure, & reinhard, 2009; kenny, 2009; mason, 2004). little is mentioned about why nurses choose a rural generalist specialty role over urban medical/surgical roles. education is often used as an intervention to increase nurse confidence and competence (park & jones, 2010; molinari & monserud, 2008). the reasoning suggests nurses who know how to perform are less likely to feel stressed or to make errors. several studies explore new graduate skills needed for practice but little was found about the perceptions of academic educational effectiveness. rural nursing practice rural research samples are needed because nursing differs from urban settings in definition, duties, facility size, population health, economic conditions, and available technologies ( kulig et al., 2009; bushy & leipert, 2005). rural nursing is described as a generalist practice with specialty knowledge in crisis assessment and management (crooks, 2004; drury, francis, & dulhunty, 2005; rosenthal, 2005). small rural hospitals support fewer than 25 acute care beds and provide rehabilitation services, long term care, and clinics (rural assistance center, 2009). the rural nurse generalist role requires a specific skill set due to the need to provide care for all disciplines, acuity levels, and age groups during one shift (molinari & monserud, 2009). rural nursing theory also suggests residents prefer independent decision making which impacts self-care practices; experience high rates of no health insurance, and delay use of health care providers. the result is that rural nurses manage more crises than urban peers (bushy & leipert, 2005). the lack of insurance results in less preventative care followed by higher rates of chronic disease with co morbidities. rural communities also support larger proportions of elderly and youth using medicaid funding (molinari & monserud, 2008). studies indicate new rural nurses experience high anxiety levels and burnout within the first 18 months of professional practice (duchscher, 2008). online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 summary researchers propose several retention strategies but there is no definitive marketing approach for hiring successful rural nurses. the lack of information about why nurses choose rural practice hampers recruitment strategy development. more understanding of the effectiveness of basic education for the rural generalist role is needed as well. methods one hundred and six new enrollees in the northwest rural nurse residency (nwrnr) completed an author created personal information online survey. the data contains both open and close-ended question responses. questions pertained to demographics, the importance of community characteristics, perceptions of lifestyle and educational preparation. the questionnaire was based on literature findings, reviewed by experts, piloted and placed online after approval for human subjects by the institutional review board. the cross-sectional, mixed method design gathered both qualitative and quantitative responses. participants were applicants to an online nurse residency program. the responses of new nurses employed for less than one year and expert nurse employed in rural facilities were compared for similarities and differences. data analysis data were investigated according to question type. open-ended questions were explored for concepts, categories and themes then tallied for frequency. answers to quantitative items were placed in statistical package for social sciences version 17 (spss®) for descriptive analysis of ordinal data. tests conducted considered the ordinal nature of the data. analyses included: factor analysis, mean rank comparisons, spearman rank order correlation coefficient, kruskal-wallis one-way of analysis of variance-by-ranks and wilcoxon rank sum test (mcdonald, 2009). a null hypothesis of no differences among groups was assumed. significance levels were set at 0.05. significant spearman correlation relationships are categorized as weak (r=.100-.399), moderate (r=.400-.599) or strong (r=.600 and above). qualitative data were descriptively described using thematic analysis. responses were placed in a word document, coded, sorted and sifted according to emerging constructs. concepts and categories were formed from commonalities. themes were constructed from generalizing of categories (maura, 2002). results an analysis of the sample was performed before perceptions and preferences were inspected. a chronbach alpha analysis of internal reliability of the educational preparation (a=.93) and lifestyle (a=.86) subscales was performed. results are reported in five sections: sample, intent to move, rural life perceptions, factor analysis, and educational preparation. both qualitative and quantitative analyses are reported. sample females comprised 95% of the 106 respondents. participants reported employment experience of one-half month to over 36 years. the mean experience was 27 months with 69% employed less than one year. since the majority of subjects worked fewer than 12 months, comparisons with those employed longer than a year were conducted. perceptions of educational preparation and reasons for choosing the rural generalist role were similar for all levels of experience. online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 forty-five percent of participants reported salaries ranging from $31,000-$45,000. thirtyfive percent of nurses were over age 40 with 41% under the age 30. those reporting a racial or ethnic category were 91% caucasian, 5% were hispanic, 2% were native american and 3% reported other. most participants obtained an associate degree (53%) before practice. sixty-seven percent of the sample described a rural birthplace. sixty-eight percent of participants were married, 26% were single, and 7% were divorced. fifty-one percent reported children at home. intent to move one prediction of turnover is the intention to move within two years. eleven percent of the sample reported an intent to move (z= -10.247, p <0.000). an analysis of the perceptions of those with the intent to move was conducted to seek factors contributing to turnover. a mannwhitney u test indicates those with more experience were less likely to intend to move (z= 2.06, p 0.04). one hundred percent of those with the intent to move worked fewer than 12 months. younger participants (age 20-25) were more likely to move than older nurses, mannwhitney u (z = -1.964, p .05). participants without children were also more likely to move, mann-whitney u (z = -2.153, p .031). participants who considered the rural lifestyle as unimportant or somewhat important were more likely to move than those who rated the lifestyle as important, (z = -2.145, p >.032; z = -2.581, p .01). spearman correlations indicate participants with the intention to move were weakly associated with educational level, (r = 0.192, p .05). participants with baccalaureate degrees were more likely to move than those with associate degrees, (r=0.264, p .06). feeling prepared in crisis management was negatively associated with the intent to move (r = -0.208, p .03). rural lifestyle perceptions why nurses choose rural lifestyles was addressed with both qualitative and quantitative data and a comparison of the results for new graduates and those employed longer than one year were completed. no significant lifestyle subscale group differences for nurses employed fewer or more than twelve months were found so the data is reported as a whole. the qualitative data consisted of two open-ended questions about how and when nurses were introduced to the rural generalist role. a qualitative analysis asking why individuals choose a rural generalist role produced two themes: proximity and strategic decision making. forty-two responses indicate “proximity” or the closeness of the agency was the motivation for seeking a rural generalist career. participants applied for a job at the closest hospital. people chose to live in rural communities due to birthplace, relocation with a spouse, and relocation for other reasons. examples of responses include: “there is nothing closer for 100 miles,” and “i was born and grew up in a rural community.” few responses indicated that the rural generalist practice was a “strategic decision”. examples of a career move or a lifestyle choice include the following: “i …decided to work in a rural area to accumulate some general nursing experience,” and “i wanted to work in a small rural setting because you know the people that you are caring for.” the main focus of respondents’ decision making was the choice of a community rather than a choice among facilities or employment positions. reasons given for choosing the community provided both specific and general explanations. “we moved to be by my husband’s family” is a specific example for choosing a community. general exemplars pertain to a rural lifestyle such as, “i love rural communities.” online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 nurses were influenced by both people and experiences when choosing a rural nursing career. the types of individuals influencing decisions include: friend, nurse supervisor, hospital director, boss, mother, and preceptor. “i was talked into it.” “my mom was a nurse”. experiences reported as influencing a career choice were either due to exposure to a health care career or a personal health experience. people mentioned as influential in the career choice include: a paramedic, red cross volunteers, certified nurse assistant, and a pharmacist assistant. personal experiences were often family based. “after helping my mom recover from a surgical procedure…” and “after my second son was born…” individuals did not mention preferences for a specific nursing role. their answers were “caring” focused, “i love caring for people i know.” quantitative answers provided more preference data. participants rated the importance of 15 lifestyle variables using a scale of 1-5, where 1 means not important and 5 means important. a rural lifestyle (4), a reasonable cost of living (4), close to family (3.9), opportunities for social relationships (3.9), and employment for spouse (3.9) rated the highest means. the fifteen rural lifestyle variables were moderately associated with demographic variables: marital status, age, and educational level. the variable called “rural lifestyle” was associated with elected leadership (r= 0.499, p<0.001), leadership opportunities (r= 0.456, p <0.001), social relationship opportunities (r=0.223, p0.021), topography (r=0.211, p 0.03), quality of schools (r= 0.209, p 0.032), and cost of living (r=0.195, p 0.045). factor analysis in order to simply data and to identify the nation of lifestyle variables, a factor analysis was performed (fitzpatrick & kazer, 2011). the analysis included: principle component analysis, component rotation using varimax with kaiser normalization and a chronbach alpha. four simple patterns were identified and merged into new variables called: “outdoors”, “living location”, “community leadership”, and “family needs” (table 1). table 1 summary of factor analysis variables outdoors ( =.84) living location ( =.79) community leadership ( =.84) family needs ( =.84) topography cost of living elected leadership quality of schools climate proximity to family opportunities for leadership employment for spouse recreational activities opportunities for professional relationships opportunities to volunteer cultural activities opportunities for social relationships each variable was then compared with the various demographics and the intent to move. the importance of rural lifestyle was kept as a separate variable and compared with others. perceptions of the outdoors were rated as more important to those with baccalaureate degrees or higher degrees (r= 0.227, p 0.014) and associated with family needs (h = 4.739, df 1, p .03). the living location was rated more important as age increased (r = 0.273, p .005). family needs were significantly related with marital status (h=16.241, df 2, p <.001) and having children at home (r= -0.377, p <.001). online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 educational preparation perceptions nurses rated perceptions of preparation for the rural nurse generalist role by addressing the effectiveness of basic education programs. participants used a scale of one to five where one represented totally unprepared and five equaled prepared for the generalist role. nurses addressed 16 nursing educational topics. findings suggest participants felt neither prepared nor unprepared to practice in the following areas: the means for each of the following are placed in order of least to most prepared (table 2). table 2 educational preparation ratings for rural generalist role parameter mean parameter mean trauma 3.05 communication technology 3.45 neurology 3.11 psychiatrics 3.51 pediatrics 3.12 cardiology 3.59 crisis management 3.27 respiratory 3.59 human resource management (hrm) 3.32 leadership 3.72 nursing obstetrics 3.34 pharmacology 3.83 assessment 3.41 critical thinking (rct) 3.98 technology 3.45 geriatrics 4.01 nurses who did not feel prepared in crisis management reported an intention to move (r=0.208, p 0.03). job experience was associated with obstetrics (r= -0.235, p 0.015), crisis assessment (r= 0.203, p 0.04), and communication technologies (r= 0.261, p 0.007) using spearman’s correction. participants who reported feeling supported in the new job position also stated feeling prepared in the following: human resource management (r= -0.238, p 0.014) and cardiac care (r= -0.202, p 0.04). the new lifestyle variables (after factor analysis) were then compared with various educational preparation variables. outdoors was related with feeling prepared in cardiac care (r=0.193, p 0.05). the living location was associated with critical thinking (r=0.227, p 0.02) and cardiac care preparation (r=0.208, p 0.033) and with human resource management (r=0.263, p 0.006). leadership was associated with critical thinking (r=0.198, p 0.041) and cardiac care (r=0.297, p 0.02). discussion the findings of the small convenience sample of novice and expert rural nurses, provides information about nurse perceptions and preferences when choosing a rural generalist position. the sample was drawn from a variety of rural communities and facilities in 22 united states. participants were enrolled in a yearlong residency program either as preceptors or as residents. findings indicate a need for further study with larger samples and a greater diversity a professional development program. respondents were younger in this sample than in previously conducted studies, but the educational levels were similar (park & jones, 2010; molinari & monserud, 2009). online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 intent to move the intent to move was not common among responders but significant. those with fewer than 12 months experience, no preference for a rural lifestyle and an urban birthplace were more likely to intend to move. their reasons for moving according to the data included significant relationships with the lack of educational preparedness and no preference for the rural lifestyle. the importance of educational preparation in crisis assessment and cardiac education were highlighted. further study is suggested. for instance, stress and burnout concepts were not compared with educational preparation or rural lifestyle preferences. future studies about new employee’s intent to move may suggest why baccalaureate nurses are more inclined to move than associate degree nurses. lifestyle preferences employment was related to age and lifestyle preferences. questions arise regarding rural employment, marital status and age. how available are potential rural spouses for young nurses? how is the choice of a rural generalist career impacted by spousal employment? does gender influence the generalist role choice? rural nursing theory supports the findings that lifestyle variables are important when choosing an employer (winters & lee, 2010; lee & winters, 2004; weinert, cudney, & hill, 2008). the theory posits emotional ties to the land, along with strong familial and social networks. people with preferences for the rural lifestyle reported fewer intentions to move; therefore, understanding potential employees’ backgrounds and preferences may impact retention. nurses did not mention the title “rural generalist role” as a career goal in open-ended questions. reasons for the lack of terminology are unknown. several questions arise. is the term widespread as a descriptor of rural nurse practice? how much exposure to rural nursing do students receive? is there a lack of understanding of rural nursing as a specialty? do differences in rural and urban definitions of “generalist” prevent common usage of the term? do rural nurses lack interest in specific role labels like critical care or obstetrics nurse? findings indicate more information is needed about the use and meaning “generalist” before progression towards a national rural generalist certification can proceed. convenience and life experience influenced the choice of a rural generalist role. the finding that early health care exposure and health care professionals’ advice impacted career decisions is similar to other studies (kanto, 2004). few rural nurses discussed career goals suggesting nurses base decisions on accessibility rather than strategic planning. the proximity approach for career choice appears different from processes nurses employ in many urban settings. new graduates in urban settings speak of employment in terms of “becoming” a pediatric or trauma nurse (minnesota department of health, 2007). urban novices expect the new role to take time and experience to accomplish. graduates seek out facilities that offer the position and residencies to aid in the transition-to-practice. in this sample, rural nurses spoke of “caring” rather than becoming a certain type of nurse. do rural nurses seeking to become specialist perceive skill development differently than those who focus on “caring”? according to skillman and associates, an increasing number of rural nurses choose to work in urban sites where specialty employment is more available than in rural settings. are rural nurses who choose to work locally different from those who choose to travel? commuting nurses reduce the rural applicant pool (skillman, et al., 2006). a rural/urban comparative study of new graduates’ job searching strategies is needed. the washington study online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 reported salary as important to nurses who commuted to cities for higher wages. in this study, lifestyle variables were important to participants but salary was not. what is the impact of practice preferences and monetary rewards on the decision of where to work? are there other differences between nurses working in urban and rural settings? how do rural generalists plan for advancement to administrative or specialty roles like cardiac care or oncology? do rural generalists define advancement differently than urban peers? for instance, if few administrative leadership opportunities prevent vertical advancement, do nurses advance laterally by increasing knowledge? how are experts identified and appreciated in rural facilities? education perceptions preparation for practice is often discussed in the literature. in this sample, perceptions of preparedness were measured by the rating of academic education courses. results were similar for both experienced and novice nurses. a lack of preparedness was common to all surveyed. perceptions of preparedness are not as reliable as objective competency measurement according to macleod and associates (2008) so a different measurement approach is suggested for future studies. employee’s lack of preparation perceptions suggests the need for performance-based assessments upon hiring. the lack of preparation also indicates a need for staff development. benner and associates’ and the institute of medicine call for transition-to-practice programs (benner, sutphen, leonard, day, & shulman, 2009; mueller et al., 2006). the national council of state boards suggests using a state regulation strategy to ensure all nurses receive professional development following graduation. conclusion and implications hiring and retaining rural nurses is complicated. many questions are posed and a few trends are noted. the rural applicant pool is small and likely to be drawn from local residents who prefer a rural lifestyle. to further complicate the retaining nurses, the study suggests an intent to move is more likely to occur in new employees with less than one year’s experience and who feel unprepared in crisis assessment and management or cardiac care. individuals reporting an intent to move felt stronger about their lack of preparation than respondents with no such intention. findings suggest academic education programs need to increase the amount of students’ rural exposure and the number of opportunities to practice crisis assessment and management. obstetrical experiences may be infrequent in rural facilities and increase the need for periodic education about at risk births. the need for specialty knowledge in crisis assessment and management and the lower ratings of preparation in these areas is concerning (crooks, 2004; drury, francis, & dulhunty, 2005; rosenthal, 2005). although staff development is costly and difficult, results indicate education cannot be ignored in order to ensure patient safety. feeling unprepared is also related to stress, burnout and turnover and contributes to the high turnover rate of new graduates in rural settings (baernholdt & mark, 2009; jones & gates, 2007; kowalski & cross, 2010). findings suggest interviewing and hiring nurses requires addressing applicant background and lifestyle preferences. interviewers may consider questions about birthplace, nearby family and friends, or spousal employment. results also suggest interviewers can increase the probability of retention by providing local information during the initial interview. new employees want to know about community characteristics and resources such as recreation, and professional relationship opportunities. new residents also want social relationships suggesting mentoring may speed the acclimatization process. a suggest new administrative task is the socialization of new employees into the community. since lifestyle factors influenced job online journal of rural nursing and health care, vol. 11, no. 2, fall 2011 choices, involving community leaders in the hiring process might generate rapid inclusion feelings. data indicate developing a community network approach to hiring might increase employee success. at present, rural nurse employment practices differ from the recruitment strategies of other health care providers (kulig, et al., 2009). including community leaders in the hiring process as do other professions could address local opportunities for: recreation, spousal employment, leadership, and social relationships which were mentioned as important to this sample. involving community leaders in recruitment might increase nurse retention and shorten turnover time (baernholdt & mark, 2009; jones & gates, 2007; rosseter & american association of colleges of nursing, 2010). administrators want more information from both researchers and applicants. researchers will find many workforce questions to ask about the rural generalist role, preparation for the role, and career management over a lifetime. understanding how nurses plan their careers is important for facility management as well as for recruitment and retention. questions about the impact of “convenience” decisions on practice quality and safety outcomes are vital to rural health. the literature does not elaborate on how “convenience” motivations relate to the number of hours worked per week, communication systems, and patient errors. solving the rural nursing shortage begins with more information about why nurses choose the generalist role and the educational preparation needed to be successful. acknowledgement the study was supported in part by a health and human resource services grant d11hp1127, rural nurse residency. references baernholdt, m., & mark, b. a. 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[medline] online journal of rural nursing and health care, 1(2) 74 promoting healthy lifestyles in urban and rural elders linda d. scott, dsn, cfnp1 linda l. jacks, mn, rn2 1 capstone college of nursing, university of alabama, lscott@nursing.ua.edu 2 instructor, nursing and allied health division, western nevada community college, lls@wncc.edu abstract the daily or frequent practice of health promotion activities by elders is critical to maximize health, decrease disabilities, and enhance well-being. the purposes of this descriptive correlational study was to (a) determine differences in 244 urban and rural elders and (b) relationships among health promotion activities, perceived health, functional health, perceived level of social support, and demographic characteristics. data were analyzed using descriptive and linear regression to determine that the perceived level of social support was the significant predictor variable for the overall practice of health promotion. race and functional health were significant predictors of lesser degree. the activities of exercise, nutrition, safety, and substance use were significant to urban and rural elders with different predicator variables for each activity. keywords: health promotion, perceived health, functional health, social support, urban, rural, elders online journal of rural nursing and health care, 1(2) 75 promoting healthy lifestyles in urban and rural elders research studies over the last two decades have shown that elders practice a variety of health promotion activities in varying degrees (brown & mccreedy, 1986; harris & guten, 1979; pender, 1996; potts, hurwicz, goldstein, & berkanovic, 1992; riffle, yoho, & sams, 1989; scott & beare, in press; strawbridge, camacho, cohen, & kaplan, 1993). health promotion activities benefit elders by preventing or controlling health problems, decreasing disabilities, lowering health care costs, and enhancing a sense of well-being (frenn, 1996; harris & guten, 1979; kaufman, 1996; strawbridge et al. 1993). the focus of healthy people 2010 for elders is to increase the quality and years of life by changing risky behaviors into healthy behaviors to decrease health disparities (u.s. department of health & human services, 2000). the identification of variables that influence elders to practice health promotion activities should facilitate the planning and provision of interventions to achieve these goals. health promotion consists of specific behaviors to facilitate health and the wellbeing of an individual on a daily basis (orem, 1991; pender, 1996). the theory of self-care suggests that individuals are autonomous and responsible for self-care and refers to a systematic, deliberate practice of activities that individuals initiate, perform, and regulate on their own behalf to maintain life, promote health, and enhance well-being. an individual's basic conditioning factors, such as age, gender, socioeconomic factors, health state, family system, and patterns of living are internal and external factors that influence self-care and affect one's ability to engage in self-care or health promotion activities (orem, 1991). specific health promotion activities are exercising regularly, refraining from smoking, moderating alcohol consumption, sleeping 7 to 8 hours nightly, maintaining a desirable body weight, observing safety practices, seeking annual medical and dental examinations, performing online journal of rural nursing and health care, 1(2) 76 monthly self-breast examination, and practicing stress management techniques (belloc & breslow, 1972; harris & guten, 1979; pender, 1996). brown and mccreedy (1986) studied the health practices, demographic characteristics, and current health status of 386 elders aged 55 and older to determine that subjects routinely practiced half of the identified health behaviors and that perceived health significantly correlated to the practice of these health behaviors. riffle et al. (1989) studied 113 appalachians with a mean age of 74 years to find significant relationships between perceived health, health promotion activities, and social support with perceived health being the significant predictor for the practice of health promotion activities. other researchers confirmed elders' practice of health promotion (johnson, 1991; potts et al. 1992; strawbridge et al. 1993). perceived health is an individual’s assessment of one's general health and distinguishes between subjective and objective health; demonstrates stability across time, cultures, and age groups; and is congruent with a physician's assessment of general health (maddox & douglas, 1973; magnani, 1990). perceived health is a logical predictor for elders' practice of health promotion activities because elders who believe their health to be better are more likely to perform health promotion activities. speake, cowart, and stephens (1991) studied 580 rural and urban elders to find that perceived health and internal locus of control were the most consistent predictors of health promotion activities. nicholas (1993) found that 72 elders aged 55 to 92 years old who lived with a spouse or others had better perceived health, higher levels of hardiness, and practiced more health promotion activities. duffy (1993) reported that elders with good perceived health, strong internal locus of control, and high self-esteem frequently practiced the health promotion activities of nutrition, stress management, interpersonal support, exercise, and self-actualization. online journal of rural nursing and health care, 1(2) 77 health beliefs of elders vary and encompass functional health. the maintenance of physical functioning was the most frequently cited dimension of physical health (huck & armer, 1996; kaufman, 1996). functional health maintains independence and is defined as the maximum output of an individual to perform the activities of daily living, such as bathing, dressing, toileting, transferring, continence, and ambulation in addition to the complex instrumental activities of daily living, such as using the telephone, cooking, cleaning house, handling money, and shopping (lawton, 1972; linn & linn, 1984; matteson, 1997). functional health was a more absolute and objective measurement than perceived health, more stable over time, and not affected by mood or outlook (litchenstein & thomas, 1987). in 179 elders, duffy and macdonald (1990) found that married elders with more income, younger age, and higher perceived health were more likely to have higher functional health and a moderate practice of health promotion activities, specifically nutrition. a study of 126 elders with a mean age of 78 years found that younger elders with internal locus of control and more education had greater social satisfaction, greater functional health, and practiced more health promotion activities, specifically exercise (hawkins, duncan, & mcdermott, 1988). conversely, other studies concluded that older females with greater functional health practiced more health promotion activities (jensen, counte, & glandon, 1992; martin & panicucci, 1996; strawbridge et al. 1993). scott and beare (in press) supported these findings in 122 elders and determined that perceived health was the significant predictor for health promotion activities; however, functional health was the significant predictor in the practice of exercise, nutrition, substance avoidance, and safety activities. social support serves as a positive feedback mechanism to promote positive adaptive behavior, foster a sense of well-being, and increase resistance to disease (cobb, 1976). online journal of rural nursing and health care, 1(2) 78 continuous changes, such as the aging process, multiple chronic illnesses, physical disabilities, and multiple losses of spouse, family, and friends increase the need for social support in elders (johnson, 1998). social support was described as satisfying relationships, companionship, enjoyment of life, and reciprocal caring (frenn, 1996; huck & armer, 1996). many studies indicated that elders with high levels of perceived social support significantly practiced more health promotion activities and demonstrated positive associations with health, such as lower morbidity and mortality rates (adams, bowden, humphrey, & mcadams, 2000; martin & panicucci, 1996; potts et al. 1992; riffle et al. 1989; schank & lough, 1990; strawbridge et al. 1993). social support is another logical predictor for elders' practice of health promotion activities. diverse definitions, characteristics, and health issues of rural and urban areas have been documented in the literature. for this study, urban was defined as a community with a combined population of at least 50,000 from a central city and contiguous closely settled territory. rural was defined as territories, populations, and housing units not classified as urban generally located 15 to 30 miles from a community with a population no larger than 10,000 residents (u. s. bureau of the census, 1993; u. s. office of management and budget, 1994). rural areas reported more children and elderly residents that consisted of caucasian and native-born residents with few minority residents. rural residents were more likely to have a high school education, experience lower incomes, report lower levels of insurance coverage, perceive lower levels of health (fair to poor), sustain higher trauma mortality rates, specifically in motor vehicle accidents and gun-related incidences, experience higher rates of chronic diseases, report higher infant mortality rates, report less utilization of hospitals and health care providers, and use less preventive health screening than urban residents. comparatively, more elders online journal of rural nursing and health care, 1(2) 79 resided in rural areas (14.6%) than in metropolitan areas (12.6%) and were more likely to receive lower social security incomes, report greater use of medicaid and medicare, own their own home, report poorer health, and experience fewer days of disability with greater levels of perseverance than urban elders. rural elders were less likely to use formal in-home long-term services or long-term care facilities (coburn & bolda, 1999; ricketts, johnson-webb, & randolph, 1999). rural residents were less likely to use seatbelts, exercise, and smoke and more likely to be obese (ricketts et al. 1999). these findings were confirmed by johnson (1991) who found that 250 rural elders inconsistently and infrequently practiced only 7 of 24 health practices. conversely, adams et al. (2000) reported that 102 rural women frequently practiced health promotion activities and social support being the significant predictor variable. few studies have addressed differences in the urban and rural elders' practice of health promotion. speake et al. (1991) studied 343 rural and 232 urban elders to determine that there was no difference in the practice of health promotion in relation to their geographical residence. thornson and powell (1992) studied 200 rural and 196 urban elders to report no differences in their health promotion activities; however, the rural elders were more independent and autonomous in self-care. however, johnson, ratner, and bottorff (1995) determined in 853 subjects (16.5% elderly subjects) that rural canadians engaged in more healthy behaviors than urban residents. more research is needed to determine if differences exist in the practice of health promotion and predictor variables in urban and rural elders. the research questions of this descriptive, correlational study were: online journal of rural nursing and health care, 1(2) 80 1. what are the differences among health promotion activities, perceived health, functional health, perceived level of social support, and demographic characteristics of urban and rural elders living in the community? 2. what are the relationships among health promotion activities, perceived health, functional health, perceived level of social support, and demographic characteristics of urban and rural elders living in the community? a greater understanding of these variables and their influence on each other are needed to develop and implement interventions to maximize elder's health in various geographical areas, especially if differences exist. methodology design a descriptive, correlational design was used to address the research questions. a power analysis was performed to determine a sufficient sample size to reduce the possibility of a type ii error. this study required a sample size of 120 subjects in each geographic location to have a power level of .80. the replicated study with rural elders was completed one year after the completion of the urban study. data were collected using a one-time face-to-face private interview. sample each convenience sample consisted of 122 male and female elders (n = 244) aged 65 years and older who lived in the community and lived alone, with their spouse, or with a relative or friend. the urban subjects lived in a seven-county continuum or contiguously close areas with a population range of 40,000 to 80,0000 and were recruited from a retirement apartment complex, three churches, and a family medical practice located in the southeastern region of the online journal of rural nursing and health care, 1(2) 81 united states. the rural subjects lived in a four-county continuum or contiguously close areas with a population range of 1,500 to 20,000 and were recruited from four nutritional centers located in the western region of the united states. the rural areas were less populated with greater distances between towns or incorporated areas and consisted of fewer shopping opportunities and minimal health care services and providers than the urban areas. the studies were approved at an university's institutional review board in each geographical region and the participating agencies. signed informed consent was obtained from each subject prior to participation in the study. measures health promotion activities. the personal lifestyle questionnaire (plq) measures the frequency that individuals participate in health promotion activities (muhlenkamp & brown, 1983). the plq is a 24-item, 4-point likert scale based on orem's (1991) theory of self-care and delineates specific activities measured by the six subscales of exercise, nutrition, relaxation, substance use, safety, and health promotion or maintenance. the summated score ranges from 24 to 96 with higher scores indicating a greater number of positive health activities practiced. this measure was used in similar groups with reported reliability (alpha = .76, test-retest alpha = .88) and validity (muhlenkamp & brown, 1983). a comparison of the cronbach alpha coefficients for overall health promotion and the subscales of this study with other studies are presented in table 1 and shows a high correlation in overall health promotion and moderate correlation in all of the subscales except nutrition (guilford, 1956). online journal of rural nursing and health care, 1(2) 82 perceived health. the self-rated health (srh) measures an individual's perceived health and is part of the physical domain of the philadelphia geriatric center multilevel assessment instrument. the srh contains four items with a 3or 4-point category response. the summated score ranges from 4 to 13 with higher scores indicating higher levels of perceived health. this health dimension has demonstrated evidence of reliability (alpha = .76, test-retest alpha = .92) and validity (lawton, moss, fulcomer, & kleban, 1982). the urban and rural group's cronbach alpha was equivalent (alpha = .76). functional health. the physical disability domain of the self-evaluation of life function (self) measures an elder's ability to achieve the activities of daily living (adl) and instrumental activities of living (iadl). the measure consists of 13-items on a 4-point likert scale with a summated score ranging from 13 to 52 with lower scores indicating greater online journal of rural nursing and health care, 1(2) 83 functional health. there was reported evidence of reliability (alpha = .96) and validity (linn & linn, 1984). internal consistency for the urban and rural group was lower (alpha = .82). social support. the personal resource questionnaire 85: part ii (prq85: ii) measures an individual's perceived level of social support. it consists of 25 items with a 7-point likert scale and a summated score ranging from 25 to 175 with higher scores indicating higher levels of perceived social support (weinert, 1987). there was reported evidence of reliability (alpha = .89, test-retest alpha = .93) and validity (brandt & weinert, 1981; weinert, 1987). the urban and rural group alpha of .88 provided further support for reliability. demographic characteristics. the demographic questionnaire measures the characteristics of age, gender, race, marital status, educational level, income, living arrangement, and living status for each subject. data analysis data analysis was performed on all study variables by the spss 9.0 for windows using descriptive and inferential statistics. a simple linear procedure was used when only one independent variable correlated with its respective variable. the forward stepwise method was used in the linear regression analysis when more than one variable entered into the equation, and p < .05 was used as the level of significance. multiple regression analysis determined which of the independent variables was most important in explaining the variance in the dependent variables. although the significance level was reported, the standard beta coefficient determined the importance of the variable in its relationship to various health promotion activities subscales. results the majority of the 244 subjects were women, caucasian, and married (table 2). the mean age of the subjects was 74.8 years with ages ranging from 65 to 96 years. significant online journal of rural nursing and health care, 1(2) 84 demographic differences between the urban and rural elders were race (chi-square = 29.88, p < .001) with 88.9% of the subjects being caucasian and in living arrangements (chi-square = 55.52, p < .001) with 63.5% of the subjects living in their own home and 13.5% living in mobile homes, specifically the rural elders. the mean score for the plq was 70.4 with scores ranging from 45 to 96 and indicated a relatively high practice of health promotion activities. the mean score for srh was 9.1 with scores ranging from 4 to 13 to indicate good perceived health. the mean score for self was 15.8 with scores ranging from 13 to 41 to indicate high levels of functional health. the mean score for the prq85: ii was 129.8 with scores ranging from 25 to 223 to indicate moderate perceived levels of social support. significant differences between the urban and rural elders were the overall practice of health promotion (chi-square = 118.73, p .001) and perceived health (chi-square = 25.90, p .002) (table 3). in the health promotion subscales, significant differences were in the practice of nutrition (chi-square = 37.81, p .001), safety (chi-square = 109.61, p .001), and substance use (chi-square = 242.00, p .001). online journal of rural nursing and health care, 1(2) 85 online journal of rural nursing and health care, 1(2) 86 online journal of rural nursing and health care, 1(2) 87 online journal of rural nursing and health care, 1(2) 88 the second research question asked "what are the relationships among health promotion activities, perceived health, functional health, perceived level of social support, and demographic characteristics of urban and rural elders living in the community?" correlations of the variables (table 4) showed statistical significance for rural and urban elders in the overall practice of health promotion (r = -.627, p < .05) and in the activities of exercise (r = .151, p < .05), nutrition (r = -.371, p < .05), safety (r = -.571, p < .05), and substance use (r = -.939, p < .05). online journal of rural nursing and health care, 1(2) 89 multiple regression determined that social support was the significant predictor for the overall practice of health promotion in urban and rural elders and explained 11.5% of the variance (table 5). race and functional health were other significant predictor variables and explained 4.6% and 1.4% of the variance, respectively. discussion the findings of this study provided some important implications for clinical practice even though the study was limited by a convenience sample and did not allow for generalization to the elderly population. the urban and rural elders of this study were more likely to be caucasian, married, females, have completed high school, report an annual income between $3000 to $8999, live in their own home alone, experience greater functional ability, and have similar practices of relaxation activities and health promotion or maintenance activities. similar findings, with the exclusion of perceived health and functional health, were reported as characteristics of rural elders, not urban and rural elders (coburn & bolda, 1999; ricketts et al. 1999). surprisingly, rural elders were more likely to have higher educational levels and perceive their health as better than urban elders. these findings were contrary to those of thorton and powell (1992) who determined no differences in rural and urban elders' perceived and functional health. the differences between urban and rural elders indicated that urban elders were more likely to perceive more positive supportive relationships, practice more overall health promotion activities daily, and practice more nutrition activities, safety activities, and avoid substance use than rural elders. conversely, these findings were not supported by other researchers who compared urban and rural elders (johnson et al. 1995; speake et al. 1991; thornson & powell, 1992). johnson (1991) found that rural elders practiced few health promotion activities while adams et al. (2000) reported that rural females frequently practiced health promotion activities. online journal of rural nursing and health care, 1(2) 90 the conflicting findings strongly suggested that nurses needed to thoroughly assess the characteristics and health practice of elders in their geographical region to determine the strengths and deficits of each elder to practice health promotion, maintain functional health, and enhance perceived social support. the urban and rural elders of this study reported that the perceived level of social support was the significant variable for the overall practice of health promotion activities. it was noted that the greater the practice of health promotion activities, the higher the perceived level of social support. this finding was logical because the opportunities for the enhancement of social support were available as 45.5% of the subjects lived with their spouse and the majority of the subjects routinely participated in activities at nutritional centers and churches. activities included communicating concerns to a confidant, maintaining intimacy, and allotting daily time for self. these findings were confirmed by several studies (adams et al. 2000; martin & panicucci, 1996; potts et al. 1992; riffle et al. 1989; schank & lough, 1990; strawbridge et al. 1993). elders who experienced higher levels of social support reported satisfying relationships that fostered well-being and promoted positive health promotion activities. online journal of rural nursing and health care, 1(2) 91 race was a statistically significant predictor variable for health promotion; however, a limited sample of non-caucasian subjects (11.4%) possibly influenced biased conclusions. the researchers acknowledged the significant relationship and refrained from presenting any conclusions. the majority of health promotion studies had a larger caucasian sample than a non-caucasian sample (belloc & breslow, 1972; brown & mccreedy, 1986; duffy, 1993; harris & guten, 1979; hawkins et al. 1988; nicholas, 1993; riffle et al. 1989). functional health was the third significant predictor of health promotion. even though functional health had a smaller variance than the other predictor variables, the urban and rural elders reported significantly high levels of functional health. elders viewed functional health as independence and physical health (huck & armer, 1996; kaufman, 1996). several studies found that elders with greater functional health and greater social satisfaction practiced more health promotion activities (hawkins et al. 1988; martin & panicucci, 1996; potts et al. 1992; strawbridge et al. 1993). the strong association between functional health and social support sustained elders in their practice of health promotion. the specific health promotion activities significant to urban and rural elders were exercise, nutrition, safety, and substance use. functional health, perceived health, married, higher incomes, and living alone were significant in the practice of exercise activities. functional health and perceived health were logical findings as physical ability was required to perform exercises on a regular basis and feeling healthy encouraged elders to stay active and enhance their well-being. these findings were congruent with other researchers (duffy & macdonald, 1990; hawkins et al. 1988; jensen et al. 1992; riffle et al. 1989; scott & beare, in press) and contrary to other studies (brown & mccreedy, 1986; harris & guten, 1972). elders described their health as activity, exercising, and maintaining independence (kaufman, 1996). online journal of rural nursing and health care, 1(2) 92 social support and living in one's own home were significant in the practice of nutrition activities. all of the rural elders daily or frequently attended a nutritional center and received nutritious food, nutritional education, and social support through positive interactions with others while urban elders frequently participated in church socials. elders who took care of themselves, such as eating three times a day, eating from the five food groups daily, and maintaining one's desired weight attracted and maintained supportive relationships. the greater the social support, the more nutritional practices were reported. similarly these findings were confirmed by riffle et al. (1989) and others (hawkins et al. 1989; martin & panicucci, 1996; potts et al. 1992; schank & lough, 1989; strawbridge et al. 1992). married elders probably combined incomes to purchase healthier foods and promote positive nutritional habits. functional health, social support, race, and living in one's own home were significant in the practice of safety activities. as individuals aged and developed disabilities, they perceived themselves as being more vulnerable and at risk for injuries resulting in a loss of independence; therefore, elders became more diligent and responsible for maintaining health through positive safety practices (duffy & macdonald, 1990; martin & panicucci, 1996; potts et al. 1992). harris and guten (1972) reported that being white, female, and older were the best predictors of safety practices or environmental hazards avoidance. similarly, in this study, 69.3% of the subjects were older females who lived alone or with a spouse in their own home and reported functional health essential to performing safety activities. social support served as an additive to continue positive behaviors, such as wearing seat belts and staying within the speed limit when driving to prevent accidents and physical harm. social support, perceived health, caucasian, and living in one's own home were significant in the practice of substance use. rural elders (m = 6.98, sd 1.57) reported the online journal of rural nursing and health care, 1(2) 93 greater use of alcohol or tobacco than urban elders (m = 15.04, sd 1.38). a bias was probably present in the urban elders as 54% of them were recruited from three churches who advocated no alcohol or tobacco usage. this finding was confirmed in elderly black urban females who attended a baptist church weekly (martin & panicucci, 1996). in comparison, johnson (1991) found that western rural elders reported frequent substance use. hawkins et al. (1988) reported that 87% of the subjects were nonsmokers and 94% were nonalcoholic drinkers; however, these variables were not significant to health promotion activities. schank and lough (1990) reported in frail elderly females that 70% had no alcohol consumption and 50% had smoked in their lifetime and reported high levels of social support. social support and better perceived health combined to influence urban elders to avoid substance use to maintain positive health and sense of well-being. the findings of this study were consistent with orem's (1991) theory of self-care as the elders initiated and practiced health promotion activities with high frequency. the predictor variables of perceived health, functional health, perceived level of social support, age, gender, socioeconomic factors, health state, family system, and patterns of living paralleled the basic conditioning factors and were significant to the practice of health promotion activities. the variables of religion, culture, media, and health care systems of the geographical areas were not addressed in this study and possibly influenced the subjects' responses. interventions are needed to strengthen the elders' current health promotion activities. nurses need to perform a comprehensive health assessment of each elder to identify their participation in health promotion activities, perceived level of social support, functional ability, and any existing health deviations. the nurse focuses the elders on their strengths of perceived level of social support and functional health to encourage them to continue positive health online journal of rural nursing and health care, 1(2) 94 activities, such as continuing a planned exercise program, using seat belts in an automobile, eating a low fat diet, planning periods of relaxation, and visiting family and friends frequently. the nurse performs on-going evaluations of the elder's activities, health outcomes, and health promotion goals to insure progress toward maintaining health, improving functional ability, and enhancing a sense of well-being. modification of the elder's goals and activities are made by the nurse and elder in relation to health outcomes and elder's needs. simultaneously with the comprehensive health assessment, the nurse assists elderly clients to identify any health promotion deficit, such as lack of exercise, poor nutritional habits, poor safety practices, or alcohol or tobacco usage. the nurse encourages elders to determine specific health promotion deficits to change or priority listing of deficits to change over a period of time. the nurse assists the elders to establish specific, realistic goals and develop interventions to change activities and correct identified deficits, such as determining safe, acceptable exercises, teaching daily nutritional needs, eliminating safety hazards in the home, or decreasing alcohol or tobacco usage. on-going evaluations of health outcomes and health promotion goals by the nurse and elders ensure progress toward reducing health promotion deficits and strengthening of positive health promotion activities. the inclusion of the elders' social support system in planning and implementation of these activities provides reinforcement toward goal achievement. nursing referrals to community resources, such as a nutritional center, exercise groups, smoking cessation classes, organizations with monetary resources, and voluntary church groups promote goal achievement. interventions should target elderly men and members of minority groups to increase their participation in health promotion activities, such as seeking annual physical examinations or planning social interactions in diverse cultural groups. these actions by the nurse and elders online journal of rural nursing and health care, 1(2) 95 support orem's (1991) self-care theory that individuals are responsible for self-care and regulate deliberate practice of activities to maintain life, promote health, achieve independence, and enhance well-being for a better quality of life. further research is needed to determine the similarities and differences between urban and rural elders in health promotion. the utilization of larger, random samples with the inclusion of non-caucasian subjects in various geographical regions should promote findings that are applicable to the elderly population and assist in planning intervention studies to enhance social support, functional health, and the practice of health promotion in urban and rural elders. online journal of rural nursing and health care, 1(2) 96 references adams, m.h., bowden, a.g., humphrey, d.s., & mcadams, l.b. 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(1987). a social support measure: prq85. nursing research, 36, 273-277. https://doi.org/10.1097/00006199-198709000-00007 https://doi.org/10.1093/geront/33.5.603 https://doi.org/10.1080/00223980.1992.10543359 https://doi.org/10.1097/00006199-198709000-00007 microsoft word 508-3030-2-ce.docx online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.508 1 editorial see you in nashville for the 2018 international rural nursing conference pamela stewart fahs, phd, rn, editor do you know where you will be july 23 – 26, 2018? i will be in nashville, tn at the international rural nursing conference: advancing rural health through our reach: research, empowerment, academics, clinical practice and health promotion. i certainly hope you will be there! the university of alabama capstone college of nursing; the university of kentucky college of nursing and the rural nursing organization are co-hosting this exciting conference. the conference will at the nashville airport marriott in nashville, tn. this conference will give you the latest information on what is happening in rural nursing and health care. the world of rural nursing and health care is broad, yet like a rural community; it is small enough that there is familiarity. judging from past rural conferences there will be friends, old and new attending. this is a conference for practitioners, educators, and researchers. if you work to ensure the health of rural populations, you do not want to miss this conference. do not delay; the closing date for abstracts submission is january 15, 2018. abstracts will be peer reviewed and acceptance decisions will be made by february 28, 2018. you may submit an abstract at http://training.ua.edu/irnc/abstractsubmissions.php . at least one author from each accepted paper or poster must register for the conference on or before march 31, 2018. to register for the conference, go to http://training.ua.edu/irnc/. see you in nashville! microsoft word weinert_343-1991-2-ed.docx online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 100 a program of nursing research in a rural setting clarann weinert, sc, phd, rn, faan 1 elizabeth nichols, phd, rn, faan 2 jean shreffler-grant, phd, rn 3 1 professor emerita, college of nursing, montana state university, cweinert@montana.edu 2 professor emerita, college of nursing, montana state university, elizabeth59715@gmail.com 3 professor, college of nursing, montana state university, jeansh@montana.edu abstract recounted in this article is the saga of a team’s rural research journey over nearly 20 years. from the outset the overall goal of our research was the promotion of informed health care choices by older rural dwellers. the purpose of sharing our journey story is to illustrate how a program of nursing research can thrive despite being conducted in a low nursing research resource environment, across geographic distances, and with a limited patchwork of funding. this journey began with several collaborative studies on the use of complementary and alternative therapies (cam) by older rural dwellers. a detour in the research journey trajectory occurred with the advent of national recognition of the key role of general health literacy and more specifically the lack of research in the area of health literacy regarding cam. the research team’s journey moved to the conceptualization and development of a model of cam health literacy. this model then served as the basis for creating and the initial testing a measure of cam health literacy. the intention of this article is to be instructive to other research teams as they travel along their own research journeys. keywords: nursing research, rural, cam health literacy online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 101 a program of nursing research in a rural setting sustaining a program of nursing research in a rural setting is a journey with many opportunities and challenges. the purpose of recounting the story of our journey is to share how a program of nursing research can thrive despite being conducted in low nursing research resource environments, across geographic distances, and with a limited patchwork of funding. we attribute our success to an active and astute research team, a topic of interest to all team members, the ability to work across long distances, and a large dose of persistence. in telling this story, only the highlights of our studies are presented. the full descriptions of these studies have been published previously the research team the early phase of this journey was launched by a senior administrator at the university of north dakota (und) and a senior investigator from montana state university (msu), institutions separated by 800 miles. a master’s student and junior faculty member at und rounded out the original team. shortly into the research adventure, these two junior individuals moved on – the master’s student into a doctoral program in another state, the faculty member to clinical practice. to replace the lost team members and enrich this two-institutional research team, the two senior investigators then sought additional members from each institution who were junior in their research roles but interested and competent. a junior investigator from msu with an interest in complementary and alternative therapies (cam) and previous rural research joined and was quickly mentored into the role of principal investigator. in addition, a senior faculty member from und joined the team. these four researchers began a research collaboration that has continued for almost twenty years. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 102 depending on the needs of the research program, other investigators have joined the team for specific tasks. for example, two senior msu investigators were hired: one to conduct interviews in an early study, and one to collect data in a more recent study. graduate and undergraduate students enriched the research team and engaged in library searches, assisted with data collection and management, and helped with the preparation of manuscripts and presentations. a significant challenge to the team was working over long distances-not only across states but also within the state of montana. for example, the principal investigator’s location is 200 miles from the main campus of montana state university (msu) and the second msu investigator. the key to successfully meeting this challenge has been ongoing and frequent communication among the members of the team, utilizing a variety of strategies. the increased ease of electronic and telephone communication facilitated productive meetings. highly important were annual face-to-face meetings that promoted team cohesion, allowed for concentrated group work time, and resulted in the production of grant applications, publications, and presentations. over the course of the journey, the core research team has adapted to a variety of changes: new academic roles/status, the relocation of one of the north dakota team members to montana, and the death of the other north dakota colleague. the remaining three core members continue to work successfully as an engaged research team. identifying the focus of research central to our program of research has been an emphasis on examining strategies for enhancing the health of older rural adults. our early studies on the use of cam by older rural dwellers were driven by the interests of the initial junior team members and that meshed well online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 103 with the broader research endeavors of the senior investigators. further, the cutting edge studies by eisenberg, et al (1993; 1998) on cam use did not differentiate between urban and rural populations, our area of interest. during the late 1990s and early 2000s, several well-known national studies were conducted which demonstrated that the use of cam among the general u.s. population was more common than previously thought. further, researchers found that often there was limited communication between consumers and providers about treatment options and the consumer’s use of cam (astin, 1998; eisenberg, et al., 1993). researchers noted that cam therapies were used more often for chronic than acute health problems. use was more common among women, younger adults, those with higher incomes, more education, and those living in the western united states (astin, pelletier, marie, & haskell, 2000; cherniak, senzel, & pan, 2001; eisenberg, et al. 1998). these investigators tended not to differentiate between rural and urban populations. however, when studies were designed to focus on the use of cam among rural dwellers, the results were inconsistent. vallerand, foulabakhsh, and templin, (2003) found that cam use was less prevalent among rural dwellers than among urban. yet, harron and glasser (2003) reported that the use of cam was more common among rural residents. conversely, other researchers found that the prevalence of use among rural and urban dwellers was similar (arcury, preisser, gesler, & sherman, 2004). initial studies on the research journey the initial research on our journey included a series of studies with older adults living in rural areas to further understand the role of cam in health decisions. the primary purpose was to explore the use of, and satisfaction with, cam from the perspectives of older rural people. the team also sought to gain a better understanding of why cam was used and what sources online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 104 were used to obtain information about cam therapies. throughout these early studies, participants were recruited from counties in montana and north dakota that met the federal definitions for rural and frontier. all studies discussed in this journey were approved by the universities’ institutional review boards for protection of human subjects. in the first study, 325 randomly selected older adults in 19 rural communities were interviewed by telephone. participants had a mean age of 72 years and most (67.7%) reported having one or more chronic illnesses. only 17.5% reported using complementary providers, while 35.7% used self-prescribed cam practices, such as home remedies, nutritional supplements, and herbal products. participants most often learned about the therapies from relatives and friends or consumer marketing rather than from health care professionals. those most likely to use cam were women who were fairly well educated, not currently married, and in their early older years. they had one or more significant chronic illnesses and lower health related quality of life (shreffler-grant, hill, weinert, nichols, & ide, 2007; shreffler-grant, weinert, nichols, & ide, 2005). from this survey, the research team gained an overview of who used cam and what type they used, but it did not provide information about why they used cam, or how much they knew about what they used. to obtain more in-depth information, ten older rural adults with a chronic illness who had reported using cam in the initial interview were re-interviewed. six of the 10 participants were women; eight were between the ages of 70-80; and two were between 60-70 years. their mean education level was 12.5 years. they primarily used self-prescribed cam therapies to compensate for perceived dietary deficiencies. for the most part, they were satisfied with the results they attributed to the cam. it was clear, however, that some participants used the therapies in an inconsistent manner and did not understand the purpose of the products. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 105 participants attempted to use reputable sources for information; yet, few sought information from their allopathic providers due to a perception that the providers were too busy to answer their questions about cam (nichols, sullivan, ide, shreffler-grant, & weinert, 2005). it was of interest to the team that most of the respondents in the original study did not interact with cam providers. the team questioned whether this phenomenon was related to the availability of providers in rural areas and concluded it merited further study. internet and telephone directory searches were used to locate cam resources in 20 small rural communities in montana and north dakota. seventy-three providers, representing a wide variety of cam therapies, were identified in these communities. the team also sought to ascertain the contribution of one type of cam provider, naturopathic physicians to rural health care (nichols, weinert, shreffler-grant, & ide, 2006) through an on-line survey. most naturopaths were located in population centers, but some offered outreach clinics to rural communities. in summary, participants in all of these early studies tended to use self-directed or selfprescribed cam rather than therapies provided by practitioners. local availability of practitioners did not appear to be a factor in the use of cam by older rural residents. the residents gleaned information about the therapies primarily by word of mouth or from the media. some respondents used cam inconsistently; others did not seek information about the effects or risks, and when they did, the information sources used were those generally considered unreliable. cam health literacya detour as on any journey, it is wise to be aware of changing circumstances and respond appropriately. on a road trip, if there is construction indicated ahead, one needs to be prepared to slow, stop, or perhaps take a detour. on our research journey, we became astutely aware of the online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 106 growing national focus on the role of health literacy, that is, “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (u.s. department of health and human services, 2000). creating a health literate populace had become a major priority in the nation’s public health care policy, research, practice, and education arenas. the institute of medicine (iom) included health literacy as one of 20 priority areas and noted that it is fundamental to improving self-management of health conditions (iom, 2004). the iom cited a critical need for more rigorous work to develop appropriate, reliable, and valid measures of health literacy (iom, 2004). more specific to the teams’ program of research, the institute of medicine also noted that there was very little research on how american consumers obtain, understand, and evaluate information about the various cam therapies (iom, 2005). with the advent of these critical documents, there was a clear need for research in the area of cam health literacy. it was evident to our team that a detour from our focus on informed cam use was needed. in order to develop and test an intervention to enhance health decision making related to cam, a measure of cam health literacy was essential. prior to developing a measure, it was critical to have a definition and conceptual model of cam health literacy. cam health literacy model development the team’s working definition of cam health literacy was the information about cam that individuals need to make informed health decisions. the msu conceptual model of cam health literacy was constructed from a comprehensive review of the literature, the team’s prior research, the definition of cam health literacy, and input from national experts (shreffler-grant, nichols, weinert, & ide, 2013). there are three major components to the model: antecedents, structure, and outcome. the primary outcome of the model is informed self-management of online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 107 health. antecedents are factors that can affect the structural component. four concepts, dose, effect, safety, and availability, compose the structural component and were the focus for the subsequent cam health literacy instrument development. the msu conceptual model of cam health literacy is the first known attempt to conceptualize the essential elements of health literacy regarding cam. health literacy, in this model, is expanded in a context different from allopathic health care and goes beyond reading and computational skills. (see figure 1.) the development and refinement of the model was thoroughly discussed in an earlier publication (shreffler-grant, nichols, weinert, & ide, 2013). figure 1. conceptual model figure 1 montana state university (msu) conceptual model of complementary and alternative medicine (cam) health literacy. shreffler-grant, nichols, weinert, and ide (2013), the montana state conceptual model of complementary and alternative medicine health literacy. journal of health communications, 18, 1193 – 1200. doi: http://dx.doi.org/10.1080/10810730.2013.778365 . reprinted with permission of taylor & francis ltd. http://www.tandfonline.com online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 108 instrument development following the articulation of the conceptual model, the next segment of our research journey was the development of a measure of cam health literacy. devellis’ well-established and tested eight-step process for scale development was used to guide our efforts (devellis, 2012). (see table 1.) table 1 devellis’ guidelines for scale development step 1 construct determination step 2 generate item pool step 3 determine measurement format step 4 review of item pool step 5 consider validation items step 6 administer to development sample step 7 evaluate items step 8 optimize scale length the structural component of the newly developed model provided the constructs and concepts necessary to initiate the instrument development process. empirical indicators were identified for each of the four major concepts, and two to seven items for each indicator were generated. a six-point likert scale response format with equally weighted items was selected to allow for a summed single scale score. to ensure that the items were clear and understandable plain language principles (plain language, 2013) were used and medical jargon was avoided. items were written at an 8th grade or less reading level based on the flesch-kincaid grade level (readability formulas, 2013). to refine the item pool, a panel of experts in the areas of tool development and cam therapy generously reviewed the items for consistency with the model and clarity of wording. they also suggested additional items. a revised item pool and response set was reviewed and online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 109 critiqued by four focus groups. two focus groups were comprised of community dwelling senior citizens and two of allopathic and complementary health care providers. recommendations from the experts and the focus groups resulted in the team’s careful re-review of the item pool. at this point in the journey, the initial instrument consisted of 54 items with two versions of the measure. one version had a dichotomous response option of agree/disagree, the other version had a four-point response set with anchors of agree strongly to disagree strongly. refining the instrument a professional research interview company was hired to administer the draft cam health literacy instruments, obtain basic demographic data, including cam use, and a single item health literacy measure included for validity assessment: the participant’s ease of completion of medical forms (chew, bradley, & boyko, 2004). interviews were conducted with a random sample of 1200 adults over the age of 55 from households in non-metropolitan areas of the north-western quadrant of the united states. one half of the sample (n = 600) completed the version with the four-point response set, the other half with the dichotomous response option. decision point the availability of resources required a team decision as to how to proceed with the initial data analysis. we had the skill and statistical programs necessary to analyze the four response data set. however, to appropriately analyze the two-response set required different statistical resources and personnel. in addition, devellis, a consultant on the project, recommended focusing on the four-point response set. thus the decision was made to initially analyze only the four-point response set version. the analysis procedures were conducted on one-half of that sample (n = 300), and then were validated by comparing the results with results of duplicate analyses from the second half of that data set. the procedures were then run on the data from the online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 110 entire sample (n = 600). standard exploratory factor analysis procedures with the number of factors (three) based upon parallel analysis were used. principal components extraction with oblimin rotation was used to determine factors and item loadings. items with weak loadings or that loaded on more than one factor were deleted. the reliabilities of each factor as well as each item’s contribution to that alpha were also examined to determine which items to retain. this process continued until a stable solution with an adequate alpha was obtained. the final 21-item four-response set instrument had a cronbach’s alpha of 0.75. the correlation between the cam health literacy scale and the medical forms completion item was 0.174 (p = .003) (shrefflergrant, weinert, & nichols, 2014). validation study the final leg of the instrument development detour was to conduct a study to further assess validity by comparing cam health literacy scale scores with those on a general health literacy measure. the validation procedures were implemented with a convenience sample of 110 community dwelling older adults (average age 68). the data collection packet included the msu cam health literacy scale and two health literacy measures: the newest vital sign (osborn, et al., 2007) and one question about ease of completion of medical forms (chew et al., 2004). also included were basic demographics, cam use information, and presence of chronic illness. sixtysix percent of the sample was women, 75% had more than a high school education, and 51% were currently married. eighty-two percent indicated that they used cam, and 51% said that they had no significant health problems. the alpha on the cam health literacy scale in this sample was 0.73. the correlation with the newest vital sign was 0.221 (p = .002) and with the single medical forms completion question was 0.277 (p = .004) (shreffler-grant et al. 2014). now, with an instrument in hand, the team was ready to return to the main trail – how to improve online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 111 the cam health literacy of older rural dwellers and thus enhance the information they bring to bear on the management of their health. funding the journey ideally, a program of research is continuously funded; however, life is not always ideal. yet, there are times when the “financial planets” do align! the launching of our journey fortuitously coincided with the national center for complementary and alternative medicine becoming a funding agency. this center funded our first exploratory study and also our most recent work to develop the cam health literacy scale. between the two grants, the research journey was sustained by small intramural grants, investigator dedication, the generosity of time and expertise donated by our nursing and non-nursing research colleagues, and the ongoing commitment of the team members. at times we felt like “the little engine that could!” lessons learned on the journey this research program has been a journey filled with twists and turns that are likely to continue as we travel down the cam health literacy path. the success of this research team can be attributed to active, committed investigators, a topic of interest that has engaged all members, and, at least, occasional funding. maintaining sufficient continuity in the research team while also being open to enlisting help from additional investigators was critical to the development and sustainability of this program of research. the importance of building from one study to the next was an ever-present precept. we invested significant time and energy reflecting, discussing, and “cogitating” about the results of each step of the research program in order to tease out the meaning from the data and identify remaining questions to be answered along with the most appropriate approaches to answering them. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 112 being alert to historical events that have relevance to the program of research is critical. the cam health literacy “detour” was inspired by the iom report which indicated a critical need for more rigorous work to develop appropriate, reliable, and valid measures of health literacy (iom, 2004). in retrospect, what we thought was a detour may have been a main road on the map. from the outset of our research endeavors, the overall goal was the promotion of informed health care choices by older rural dwellers. addressing the definition, model, and measurement of cam health literacy has enlightened and enhanced our research program and is a genuine fit with our goal. this research journey has not been without obstacles. the several definitions of health literacy complicated the task of developing the model of cam health literacy. further, it became clear that there were no markers on the trail, other than our own model, to guide the writing of items and the selection of the response option anchors. an additional challenge was the lack of an appropriate and mature measure of general health literacy against which to validate the msu cam health literacy scale. additional obstacles were the geographic distance between team members along with limited and inconsistent funding. reviewing the journey of a team of researchers over time, including the original intent, of the challenges, and the detours, can be instructive to other teams as they travel on their own research journeys. the way is seldom straight, nor paved with continuous funding, but persistence, a meaningful goal, and good working relationships have kept this team on task and energized. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 113 acknowledgements research supported by: national institutes of health/national center for complementary and alternative medicine r15 at095-01, r15 t006609-01; national institutes of health/national institute of nursing research 1p20nr07790-01; montana state university college of nursing block grant; university of north dakota college of nursing intramural grant. acknowledgement also to bette ide, phd, rn, faan, lompoc, ca, a former research team member (deceased). references arcury, t., preisser, j., gesler, w., & sherman, j. (2004). complementary and alternative medicine use among rural residents in western north carolina. complementary health practice review, 9(2), 93-102. http://dx.doi.org/10.1177/1076167503253433 astin, j. (1998). why patients use alternative medicine: results of a national study. journal of the american medical association, 279 (19), 1548-1553. http://dx.doi.org/10.1001/ jama.279.19.1548 astin, j., pelletier, k, marie, a, & haskell, w. (2000). complementary and alternative medicine use among elderly persons: one-year analysis of a blue shield medicare supplement. journal of gerontology, 55a, 4-9. cherniack, e., senzel, r., & pan, c. (2001). correlates of use of alternative medicine by the elderly in an urban population. journal of alternative and complementary medicine, 7, 277-280. http://dx.doi.org/10.1089/107555301300328160 chew, l. d., bradley, k. a., & boyko, e. j. (2004). brief questions to identify patients with inadequate health literacy. family medicine, 36(8), 588-594. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 114 devellis, r. (2012). scale development: theory and applications. (3rd ed.) thousand oaks, ca: sage. eisenberg, d., kessler, r., foster, c., norlock, f., calkins, d., & delbanco, t. (1993). unconventional medicine in the united states. the new england journal of medicine, 328:246-252. http://dx.doi.org/10.1056/nejm199301283280406 eisenberg, d., davis, r., ettner, s., appel, s., wilkey, s., van rompay, m., & kessler, r. (1998). trends in alternative medicine use in the united states, 1990-1997; results of a follow-up national survey. journal of the american medical association, 280(18), 1569-1575. http://dx.doi.org/10.1001/jama.280.18.1569 harron, m., & glasser, m. (2003). use of and attitudes toward complementary and alternative medicine among family practice patients in small rural illinois communities. the journal of rural health, 19(3), 279-284. http://dx.doi.org/10.1111/j.17480361.2003.tb00574.x institute of medicine (2004). health literacy: a prescription to end confusion. washington dc: the national academies press. institute of medicine (2005). complementary and alternative medicine in the united states. washington dc: the national academies press. nichols, e., sullivan, t., ide, b., shreffler-grant, j., weinert, c., (2005). health care choices. complementary therapy, chronic illness, and older rural dwellers journal of holistic nursing, 23(4), 381-394. http://dx.doi.org/10.1177/0898010105281088 nichols, e., weinert, c., shreffler-grant, j., & ide, b. (2006). complementary and alternative providers in rural locations. online journal of rural nursing and health online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 115 care, 6(2), 40-46 retrieved from http://rnojournal.binghamton.edu/index.php/ rno/index osborn, c.y., weiss, b.d., davis, t.c., skripkauskas, s., rodrigue, c., bass, p.f., wolf, m.s. (2007). measuring adult literacy in health care: performance of the newest vital sign. american journal of health behavior (sept-oct; 31 suppl 1), 36-46. http://dx.doi.org/10.5993/ajhb.31.s1.6 plain language. improving http://www.plainlanguage.gov/ readability formulas, the flesch grade readability formula. retrieved 3/1/13 from http://www.readabilityformulas.com/flesch-grade-level-readability-formula.php shreffler-grant, j., hill, w., weinert, c., nichols, e., & ide. (2007). complementary therapy and older rural women: who uses and who does not? nursing research, 56(1), 28-33. http://dx.doi.org/10.1080/10810730.2013.778365 shreffler-grant, j., nichols, e., weinert, c., & ide, b. (2013). the montana state university conceptual model of complementary and alternative medicine health literacy. journal of health communication, 18(10), 1-8. http://dx.doi.org/10.1080/10810730.2013.778365 shreffler-grant, j., weinert, c., & nichols, e. (2014). instrument to measure health literacy about complementary and alternative medicine. journal of nursing measurement 22(3), 489-499. http://dx.doi.org/1061-3749.22.3.489 shreffler-grant, j., weinert, c., nichols, e., & ide, b. (2005). complementary therapy use among older rural adults. public health nursing, 22(4), 323-3311. http://dx.doi.org/10.1111/j.0737-1209.2005.220407.x online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.343 116 u.s. department of health and human services (2000). healthy people 2010, section 11-2: health communication objective. retrieved july 14, 2005 from http://www.healthypeople.gov. vallerand, a., foulabakhsh, j.,& templin, t. (2003). the use of complementary/ alternative medicine for self-treatment of pain among residents or urban, suburban, and rural communities. american journal of public health, 93, 923-925. http://dx.doi.org/10.2105/ajph.93.6.923 microsoft word editorial completed 12_28_12.docx online journal of rural nursing and health care, 12(2) 1 editorial rural nurse leaders: who are they? what have they done? saying goodbye to one and moving on to honor others pamela stewart fahs, rn, dsn, editor “leader,” such a simple word and such a complex concept. “a person who leads” is the definition found online at http://www.merriam-webster.com/dictionary/leader. as you may remember from those socialization courses in nursing, leaders use various types of power which may be “legitimate”, “referent”, “expert” etc. a true leader goes beyond those rather static definitions; they may at times have used various types of power or none that is recognizable until after their time of leadership has past. they may not even see themselves as leaders yet those in the profession recognize their influence, especially over time as the boundaries of knowledge and the profession change. i believe that one true definition of a leader is that they are the ones that push the boundaries of professional practice, research and / or roles. meleis (1997) noted, visionary members of the discipline also change the domain of knowledge as they posit new or alter theoretical boundaries. they may bring knowledge from other areas or go beyond the current roles, research, and practice of the discipline. these visionary tactics may not always be looked upon in a favorable manner as they are emerging, but when they “lead” to new and often broader boundaries, roles and expectations, eventually the profession “catches up” enough with the leader that we get a vision, even if it is fleeting, of what they see for the future. i believe rural nursing has had many of these visionaries, who have led this “specialty” to not only make rural nursing what it is today, but they are continuing to see “beyond” what most of us see to what we can be tomorrow and in the future. the purpose of this column is two-fold: 1) to recognize one rural nurse leader as she retires from her current role but moves forward and as she, “temporarily” leaves the rural nurse organization (rno) leadership structure to literally take on a new mission in life. 2) to launch, what i hope, is a new column in the online journal of rural nursing and health care, entitled rural nurse leader. the idea for the new column emerged from conversations with professor emeritus deana l. molinari phd, rn, cne. deana has been a nurse for about 46 years, moving from a diploma in nursing in 1966 to completion of her phd in 2003. as with many nurses she furthered her education while simultaneously working at one or more professional positions over the years. not to mention her other life roles that included being a mother to a rather large family, active in her church and community. as with many successful women, she balanced multiple roles with seeming ease but of course, more effort than meets the eye. deana became part of the rno in the early 90’s when it was housed in spokane and created by northwest nurses who wanted more opportunities for professional development. she was part of the creative team and worked on the original issues for the online journal of rural nursing and health care along with dr. jeri dunkin first editor-in-chief of this journal. deana is one of those leaders whose vision goes beyond what most of us “see.” she pushes the boundaries of our profession and certainly has pushed the boundaries of rural nursing through her commitment to several rural health care professional organizations, particularly the rno. dr. molinari has developed and ran nurse residencies to help nurses gain both technical and professional skills, in a supportive environment, as they transition from formal education into practices, particularly in the rural health care arena. she has had two health resources and services administration (hrsa), grants funded for northwest rural residency programs and these are models online journal of rural nursing and health care, 12(2) 2 for the institute of medicine (iom) and robert wood johnson foundation, the future of nursing report (committee on the robert wood johnson foundation initiative on the future of nursing & medicine, 2011). her scholarship has been focused on assisting students with the development of critical thinking skills and various issues around online education and learning, which is touted as one tool for improving not only the quality and accessibility of education to rural nurses but also to improve the health care to rural populations. an area of focus for deana as president of the rno has been to move the organization to the development of competencies for rural nursing and someday a way to credential professionals specifically for rural nursing. another passion for deana is the need to support rural nursing research. she oversaw the development of a research fund, which allowed the organization to give the first $500 research grant in october 2011. there are now guidelines in place for applying for and reviewing the grant application. it is also possible to make a donation to support the rural nurse research grant fund. if you are interested in doing so, please contact karla jordan, rno office manager at rno@bama.ua.edu every once in a while i think i see a glimpse of what dr. molinari envisions for rural nursing and hope she will find a way to continue to enlighten the rest of us even if in the future it is to be from afar. she writes that as health care is changing, “rural health care providers are positioned to lead the inter professional, collaborative, and community skills needed in the new system. study of health will be organized differently. a deep understanding of a body system will not be sufficient for most health providers. new skills to support patients in home, to navigate the health system, and to facilitate self-care will be required of all nurses. nurses will perform more case management and supplement the care given by families. patients and caregivers will lead health teams. providers will aid patients to prevent crises and provide rehabilitate at home. the goal is to cut hospital care by 80%. the change may take time … but the fundamental thinking and philosophy of change is already well underway.” now that she has “officially” retired as a community health cns in oregon and from her position at idaho state university in the summer, she is envisioning new opportunities and is headed off on a new adventure. she notes that she and her husband are preparing to go on a mission for the church of latter-day saints. they have not yet been told what they will be doing or exactly where in the world they will be working but are brushing up on their italian, although they may be on their way to other parts of the world such as africa or south america. they are preparing for some family events, cleaning and packing and helping their adult children with disabilities to transition to their adult living status. deana writes “honestly, we are not interesting people. we are just people trying to live useful lives…” i would agree they are leading useful lives but believe that deana molinari is one of the most interesting people i have had the pleasure to work with in the past few years, and is a true rural nurse leader. if you have a rural nurse leader you would like to recognize please contact me at psfahs@binghamton.edu about writing a column on the work of that individual. i hope you will all wish deana molinari well on her future life adventures and think about others you have known who have led or are currently leaders in rural nursing. references committee on the robert wood johnson foundation initiative on the future of nursing, at the institute of medicine, & medicine, institute of. (2011). the future of nursing: leading change, advancing health: the national academies press. meleis, a i. (1997). theoretical nursing: development and progress (3rd ed.). philadelphia: lippincott. leader . (n.d.). in merriam-webster’s online dictionary. retrieved from http://www.merriamwebster.com/dictionary/leader online journal of rural nursing and health care, 1(1) 3 editorial administrative insights: diversity, chaos, multiplicity beth roder, ma, rn, editorial board member diversity, chaos, multiplicity. these are buzzwords for us as we are moving into the 21st century. we as rural nursing people have unique challenges. as generalists we are given the opportunity and challenge to bring a variety of skills and knowledge to people who are looking to us as their experts. at first glance the diversity we may recognize is color, creed or nationality. we must broaden our scope of diversity beyond racial and ethnic differences. our experience with diversity may lie in the expectations that our clients, patients, families, coworkers and superiors impose on us. and considering the variety of customers each of us deal with daily, that too is diversity. our ruralness sometimes leaves us feeling as if we are not quite in the loop of progress. when i feel this way at times i refer to nelson mendala's 1994 inaugural speech: our deepest fear is not that we are inadequate, our deepest fear is that we are powerful beyond measure. it is our light, not our darkness that frightens us the most. we ask ourselves: who am i to be brilliant, gorgeous, talented, and fabulous? actually, who are you not to be? you are a child of god. your playing small does not serve the world. there is nothing enlightened about shrinking so that other people don't feel secure around you. we are born to make manifest the glory of god that is within us. it is in everyone, and as we let our light shine, we unconsciously give other people permission to do the same. as we are liberated from our fear, our presence automatically liberates others. yes, diversity, chaos, and multiplicity all are a part of each of us. we can live with it, grow with it, or let it diminishes us. let us be liberating to self and those around us. if you have questions or comments, please e-mail me at b_roder10@yahoo.com. microsoft word 248-1346-2-ce.docx online journal of rural nursing and health care, 13(1) a rural community translation of a dementia caregiving intervention leisa r easom, phd 1 gayle alston, ms 2 ryan coleman, mba 3 1 full professor, school of nursing, georgia southwestern state university, leisa.easom@gsw.edu 2 director of community initiatives, rosalynn carter institute for caregiving, georgia southwestern state university, gayle.alston@gsw.edu 3 data manager, rosalynn carter institute for caregiving, georgia southwestern state university, ryan.coleman@gsw.edu abstract purpose: this study explored the impact of the implementation of the ga reach (resources enhancing alzheimer’s caregiver health) a multicomponent, evidence-based, tailored intervention, in eleven rural counties in georgia. methods: utilizing up to nine face-to-face (in the home) and three telephone sessions, tailored education and support was provided to 85 family caregivers over a six month period. a pre-post research design was utilized to measure the impact of the intervention. data was collected on burden, depression, health and healthy behaviors, caregiving frustrations, social support, dementia-related behaviors, and plans for institutionalization. paired sample t-tests were used to analyze the data. results: from baseline to six months, caregivers reported significant (p< 0.05) decreased depression, decreased burden, improved caregiver health, and decreased behavioral problems of online journal of rural nursing and health care, 13(1) the care recipient. caregivers expressed feeling empowered and more capable of addressing the needs of the care recipient. conclusions: findings in this study indicate that the ga reach caregiver support program can sustain the rural caregiver and improve the care environment for the care recipient. hope for the current overburdened health care system includes the incorporation of caregiver support programs and referral to such programs by nursing and other health care providers, especially as the need for family caregivers will increase along with the number of older adults. keywords: rural, translation, caregiving, dementia, aging, evidence-based a rural community translation of a dementia caregiving intervention if family caregivers were no longer available, the cost to our healthcare system would be extremely high and burdensome. family caregivers make up the “backbone” of the nation’s long-term care system for adults with dementia. the need is great for caregiver support for those caring for loved ones with alzheimer’s disease. across our nation, 1 in 8 older adults are living with this disease; especially the oldest old group half of those aged 85 and older have the disease (alzheimer’s association, 2011). georgia (ga) has one of the fastest older adult growth rates in the united states with the oldest age group, 85 and older, increasing rapidly (aoa, 2011). correspondingly, individuals who care for these older adults, caregivers, have also increased. an estimated 11 million caregivers provide 12.5 billion hours of care each year to an estimated 5 million persons with dementia (alzheimer’s association, 2011; hoch, 2009; nichols, martindale-adams, burns, graney, & zuber, 2011). the net worth of the work performed by family caregivers has been estimated at $450 billion annually (feinberg, reinhard, houser, & choula, 2011). these valuable family caregivers need to be viewed as targets for online journal of rural nursing and health care, 13(1) health interventions as well as key participants on the caregiving team for the client with dementia. in the us, approximately 25% of family caregivers live in rural areas which pose unique challenges to caregiving. lack of access for rural residents is a primary concern of state units on aging who are responsible for delivery of services to older adults. specifically, in ga, more than 56% of all counties are classified as “rural”. the georgia statistics system (georgia county guide, 2010) was used to define the rural counties in this study. other considerations of service delivery for the rural resident include distance, transportation, understaffed agencies, high cost of services, and a fragmented service system which lacks coordination and staffing. rural resident self-reliance has also created an attitudinal barrier to acceptance of services (armer & conn, 2001). family caregivers provide a valuable care service; however, the cost to the caregiver may be considerable. research studies have repeatedly shown that family caregivers have an increased risk of experiencing depression, grief, fatigue, and physical health problems secondary to exhaustion and self-neglect (albert, 2004; national alliance for caregiving & american association retired people [aarp], 2009; nichols et al., 2011; sullivan, 2004). the well-being of the caregiver is the key to supporting the care recipient, and also, may determine whether the care recipient can remain safely at home or must be placed in more costly institutionalized care. background ga reach (resources for enhancing alzheimer’s caregiver health) is a 6 month, evidence-based, multicomponent caregiving intervention that targets the well-being of the caregiver. the following narrative provides a brief review of the history of the evolution of the reach intervention. online journal of rural nursing and health care, 13(1) feasibility study reach (burgio et al., 2003) began in 1995, as behavioral research focused on a variety of multicomponent interventions at six sites designed to enhance family caregiving for alzheimer’s disease and related disorders. this first study was designed to examine the feasibility of using multiple different intervention approaches. the interventions were based on diverse theoretical frameworks, all of which are consistent with basic health-stress models. the goals of the healthstress model are to recognize the stressor, change the stressor, and/or change the caregivers’ response to the stressor. results of this first study emphasized the need for further research focusing on a tailored approach which assessed the risk or needs of the caregiver. randomized control trial the follow-up study, reach ii, was a randomized, controlled trial sponsored by the national institute on aging and the national institute on nursing research (belle et al., 2006), and was implemented with caregivers of loved ones with dementia. this multicomponent intervention assessed the risk of the caregiver and based upon the results of this assessment, provided tailored, caregiver specific education, support, and enhancement of stress management skills. delivery of this six month intervention occurred through in-home visits and telephone conversations. the findings of reach ii revealed that hispanic and white caregivers receiving the intervention experienced improvement in burden and depression, but african american caregivers did not. however, when viewed as a group, findings indicated that caregivers demonstrated improvement in caregiver burden, depression, and management of difficult behaviors, social support and self-care, which created a better environment for care for the care recipient. none of these efforts focused solely on the rural population. online journal of rural nursing and health care, 13(1) translational efforts critical is the translation of clinical research into the community setting. translational research facilitates the movement and adoption of clinical research into community settings where families can access and benefit from the program (woolf, 2008). effective implementation of clinical science into service areas is critical so that good effects are achieved with consumers. the bridge from science to service is not always easy, and must continually evolve (fixsen, naoom, blasé, friedman & wallace, 2005). according to rural nursing theory (long & weinert, 1989), a primary concern of rural dwellers is the ability to work and be productive. a secondary concern may be preventive health measures. applying these beliefs to a rural caregiver implies that the caregiver work is primary and care of self is secondary. supports for the rural caregiver are critical. there is limited knowledge about caregiver supports in rural areas where access to care may be limited and community agencies struggling with narrow budgets to provide such supports. in 2004, the administration on aging funded 4 state-based reach translations in california, florida, tennessee, and alabama. of these translational efforts, the alabama reach translation became the reach out model with a shortened intervention series (burgio et al., 2009). in 2007, the department of veterans affairs implemented reach va and became the first national translation of a proven dementia behavioral intervention (reach ii) covering multiple states and facilities (nichols et al., 2011). results from the reach va study included significantly decreased burden, depression, caregiving frustrations and number of troubling dementia-related behaviors. in 2008, the alzheimer disease supportive services program of the administration on aging funded reach translations in several states, including ga. online journal of rural nursing and health care, 13(1) purpose of research this article describes the study and outcomes of a community translation of the reach intervention (modeled from reach va) in rural ga. this translational study involved one group to examine causality in the community setting which is not conducive to experimental controls. the study was conducted by the rosalynn carter institute for caregiving (rci) – an educational, research, advocacy, and service unit of georgia southwestern state university. the mission of the rci is to provide caregivers with effective supports and make investments that promote caregiver health, skills and resilience. this study adds to the knowledge of evidencebased support for rural caregivers to sustain them in their efforts to provide care for their loved ones. method design this study utilized a pre and post research design with baseline assessment of caregivers occurring prior to the introduction of the 6 month intervention program and follow-up assessment at the end of the program. additionally, an overall program evaluation was conducted via telephone with each program enrollee by an independent evaluator to ensure objectivity of program success/failure. sample and participant selection the final convenience study sample included family members (n = 85) who were caring for moderately to severely impaired individuals living with alzheimer’s disease or related dementia in the home setting. caregivers were recruited from eleven rural counties through various means. the counties served in this study had a population density of 40 people per square mile as compared to the state of ga’s 141 people per square mile. employment and poverty levels were online journal of rural nursing and health care, 13(1) less favorable than the state as a whole. the average unemployment rate for the counties served was 11.2% as compared to the state average of 9.8% (u.s. department of labor, bureau of labor statistics, 2012). poverty rates among people aged 65 and over ranged from 16.8% to 25.1% compared to 13.5% for the state as a whole (u.s. department of agriculture [usda], 2011). geographical distances. we considered geographical distances when planning the recruitment process. an outreach plan was created by the investigators and recruitment was continuous over a three year period. flyers and brochures were developed and delivered to aging agencies, faith-based agencies, the medical community, emergency responders, stores, and markets in the rural counties. oral presentations were given at churches, civic group meetings, and health care fairs to advertise the program. inclusion/exclusion criteria. a convenience sample was utilized. referral to the program occurred through self, friends, or agency referral. to be enrolled in the study, each enrollee: 1) was a co-resident caregiver or responsible for daily meal preparation for an individual with alzheimer’s disease or related dementia; 2) verbally expressed that the care recipient has memory problems; 3) provided a minimum of 4 hours of care/day; and 4) rated themselves as having stress at a level of 5 or greater on a scale of 1 to 10. the stress level rating was a verbal rating, not a formal scale. exclusion criteria were limited to the inability to speak the english language. although care receiver dementia severity was not an inclusion/exclusion criterion, this information was collected using the global deterioration scale (reisberg, ferris, de leon, & crook, 1982). the information from this assessment scale provided the interventionists with some knowledge of the intensity of the caregiving situation and assisted them to best plan with the caregiver. care recipients in this study had moderate to severe dementia. the university online journal of rural nursing and health care, 13(1) institution review board provided the human participants oversight for this project and each participant signed an informed consent form (irb #08-019). see table 1 for caregiver characteristics. table 1: demographics of caregivers completing georgia reach demographic frequency (n=85) percentage marital status never married 5 6% married 66 78% widowed 4 5% divorced 7 8% single 3 4% race caucasian 58 68% african american 26 31% not reported 1 1% gender male 19 22% female 66 78% education did not graduate high school 4 5% high school graduate 46 54% at least some college 31 36% not reported 4 5% age (mean = 67) <60 16 19% >60 68 80% not reported 1 1% procedures overview the 6 month intervention program utilized an interventionist manual, a caregiver resource notebook, and a training manual for the certification process. this program included the efforts of both an interventionist and a group leader. the interventionist met with each caregiver in the online journal of rural nursing and health care, 13(1) home while the group leader conducted a telephone support group with small groups of these same caregivers. the manuals (produced in earlier research by nichols et al., 2011) provided scripts to guide both the interventionist and the group leader. the scripts were not read aloud, but provided a consistent base on which to begin conversations with the participants. interventionist. the interventionist met face-to-face with the caregiver for up to nine inhome meetings, approximately 1 ½ hours each and conducted up to three telephone sessions of approximately ½ hour each. a total of twelve contacts, by the interventionist, with each caregiver were desired, but the type of contact could vary. specifically, a caregiver could substitute four of the in-home visits for telephone visits. this adaptation differed from the original reach ii intervention which allowed up to two by phone visits that could be substituted for home visits. at the initial visit, the interventionist collected baseline data on demographics, and conducted a risk appraisal assessment focused on depression, burden, health, social support, selfefficacy, desire to institutionalize and behavioral problems. following the initial meeting, the interventionist met with the caregiver in the home and problem solved to address problems identified in the risk appraisal assessment. the risk assessment guided the focus of each interventionist meeting and tailored support to each family. topics addressed included safety, behavioral issues, and caregiver skills and frustrations. for example, if the assessment revealed sharp or dangerous items in the home upon initial evaluation, a component of the plan for care would include removal of these items creating a less risky and safer environment for the care recipient. a caregiver notebook, with resources and handouts on caregiving topics such as communication and problem solving techniques, was given to each participant and used during the face-to-face meetings and served as a reference for caregivers. educational modules in the online journal of rural nursing and health care, 13(1) notebook targeted the general and specific problems experienced by families living with dementia. each module had a different focus and helped to provide information in a specific area. for example, information dealt with “how to deal with driving” and “how to deal with repeated questions” which are commonly cited issues with dementia. each participant was encouraged to make notes and become familiar with every module of their caregiver notebook. work performance of the interventionists was monitored through monthly audio files of their inhome sessions, weekly review of all documentation, and weekly team meetings with the program manager. close supervision and tracking of interventionist’s interaction was warranted to assess fidelity to the intervention, especially with the staff turnover experienced. at the completion of the program, data was collected by the interventionist to compare to baseline data. while we desired for a third party to collect the post data with each family in the home, the families voiced that they would be uncomfortable with a new person and that they felt this may upset their loved one. individuals with dementia become disturbed when the schedule and familiar routine is disrupted (tabloski, 2010). group leader. as a separate wave of support, the group leader was responsible for the enrollment and scheduling of caregivers, 5-6 caregivers/group, in a telephone support group over the course of the program. the group leader conducted a total of 5 telephone support group sessions, all of which were topic focused and scripted in regard to general information for the topic to be discussed. these calls were in addition to the three interventionist telephone sessions. the script provided a uniform way to introduce topics of general concern to caregivers, and then each group explored and shared among themselves. topics addressed in these sessions included 1) healthy lifestyle; 2) communicating with your loved one; 3) communicating with health care providers; 4) community resources; and 5) financial and legal issues. the calls led by the online journal of rural nursing and health care, 13(1) group leader provided verbal support and allowed caregivers to share with one another. on the telephone calls, caregivers could remain anonymous so as to encourage openness among the group. the program manager monitored fidelity to protocol by listening in on random support group calls. training and certification for staff. required qualifications for the interventionist included an understanding of dementia and related caregiver issues, experience in assessment, care planning and delivery of in-home services, and a high school education. all interventionists had some college education which was above the required qualifications. requiring a minimum of a high school education was planned to minimize the importance of formal college education for this intervention delivery. instead, good communication capabilities and life experiences in assessment or care planning seemed more appropriate skills to the investigators. instruction on alzheimer’s disease was included in the training process. role play was utilized in the interview process with the scoring process heavily related to rapport building skills and ability to adhere to scripts protocol. following hiring, each interventionist and group leader completed a training process, led by the reach va research team, resulting in certification. the training and certification process for the interventionist required two days of instruction followed by a third day of role play with critique and review of skills. the certification process for the group leader was a one day training followed by a day of role play and critique of role play. mastery of learning through demonstration of skills is the goal of the certification process. we had hoped to hire two interventionists and one group leader to implement this intervention. we experienced staff turnover, and over the three year period, six interventionists, 2 african american and 4 caucasian, and one group leader, caucasian, were hired. reasons for high interventionist staff online journal of rural nursing and health care, 13(1) turnover included family relocation and job transfer for better pay. the training and certification process was repeated with each new hire. measures baseline interviews included all major study variables and were conducted in the caregivers’ homes. all measures were utilized pre and post intervention. follow-up interviews occurred at the end of the six month program and also occurred in the home of the caregiver. overall program evaluation was done by a third party via the telephone. the caregiver general questionnaire included 16 items of general demographics with specific questions related to hours/week for caregiving duties and vigilance, as well as selfreported status of caregiver health, caregivers rated health compared to six months ago on a 5point scale where lower scores indicated better health; and well-being, five questions on healthy lifestyles rated as never, sometimes, or often. a risk appraisal assessment consisted of 21 items, adapted from reach ii (czaja et al., 2009), with five questions addressing caregiver safety, five questions assessing caregiver health behavior, three questions of social support, three questions targeting stress, two items on behavioral frustrations i.e. yelling at care recipient, caregiver hitting care recipient; and three questions on advanced planning. in each of these scales, higher scores indicated higher risk in each area that was rated, with the exception of social support (2 items) where higher scores indicated better support. the zarit burden scale (zarit, reever, & bach-peterson, 1980) measured caregiver stress and burden information, 12 item version. for this five point scale, 0 being “never” and 4 being “nearly always”, higher scores indicated greater burden. a score of 17 or higher indicated a “high” level of burden and stress. the center for epidemiologic studies depression scale (ces-d), short form version online journal of rural nursing and health care, 13(1) (andresen, malmgren, carter, & patrick, 1994) is a 10 item, four point scale measuring depression with score of 10 or higher indicating a “high” level of depression. the revised memory and behavior problem checklist (teri et al., 1992) is a scale of 24 items to assess memory, depression, and observable behavioral problems. occurrence of the behavior and caregiver reaction is scored through self-report. the revised scale for caregiving self-efficacy (steffen, mckibbin, zeiss, gallagher-thompson, & bandura, 2002) is a 15 item checklist to assess caregiver confidence in caregiving skills on a scale of 0 to 100. on this scale, higher scores indicated a higher self-efficacy. desire to institutionalize (morycz, 1985) is a six item self-report scale regarding the caregiver intent to place. the program evaluation consisted of 40 items related to aspects of the program including helpfulness of the caregiver notebook; stress management techniques; knowledge, skills, and confidence gained as a caregiver; number length, and quality of in-home visits; value of telephone support group; and overall satisfaction with program participation. higher ratings indicated increased satisfaction. data analysis paired t-tests were employed for data analysis. the t-test is a statistical method for comparing differences between two groups. the two groups being compared, pre and post, were matched. paired samples t-tests were used to determine statistical significance (p ≤ .05) among the group from baseline to follow-up data collection. chi-square tests were utilized to determine statistical differences among demographic segments. frequency distributions were utilized in regard to occurrence of reported behavioral problems. analysis utilized spss version 15.0. online journal of rural nursing and health care, 13(1) results program participants a total of 161 caregivers were enrolled in the program. eighty-five caregivers completed the intervention and all data measurements within 6 months of beginning the program resulting in an attrition rate of 47%. if an enrolled caregiver missed a session: 1) not home when the interventionist arrived for the scheduled visit, or 2) the caregiver did not answer the phone, each called a minimum of twice to make appointment, the caregiver was sent a letter in the mail encouraging them to continue participation. reasons for program drop included the failure to communicate/make appointments after multiple contacts (n = 23), lack of interest to continue program (n = 18); deceased care recipient (n = 13), the lack of time to devote to the program (n = 12), institutional placement of care receiver (n = 6), the caregiver returning to work after hiring agency personnel to provide caregiving services (n = 2), deceased caregiver (n = 1), and the interventionist felt threatened in the home environment (n = 1). using chi-squared tests, we found no statistical differences in baseline demographics (age, education, race, gender, dementia severity of care receiver) and caregiver variables (burden, stress, depression) between participants who dropped out (n = 76) and the remaining participants (n = 85). caregiver variables caregivers participated in nine in-home sessions and three interventionist telephone conversations. additionally, caregivers were invited to participate in 5 telephone support groups with the group leader; however, caregivers chose to participate in an average of two group calls / caregiver. in a comparison from baseline to program end, caregivers showed significant improvements in decreasing burden and depression (see table 2). the group mean burden score of all participants was 19.1 upon entry to the program, compared to 16.3 at program end. fiftyonline journal of rural nursing and health care, 13(1) seven caregivers (67%) scored above the burden benchmark of 17, indicating risk, compared to thirty-nine (46%) caregivers scoring above the benchmark at the end of the program. the group mean depression score was 11.8 upon program entry compared to 9.9 at program end. sixty one caregivers scored above the benchmark, individual score of 10 or higher, for depression upon program entry and only 40 (47%) caregivers above the benchmark upon program exit. table 2: outcome measures paired t-tests from baseline to program end, caregivers reported improvements in their health self-report ratings. the program entry group score was 3.1 and the program exit score was 2.8, lower scores indicated better health ratings. with the caregiver self-efficacy tool, on a scale of 0 – 100, participants rated their confidence in handling fifteen different caregiving situations, with 0 being not at all confident and 100 being totally confident. specifically, confidence in being able to control future problems with the care recipient improved from 58.3% to 78.7% (p = .004). from baseline to program end, overall self-efficacy scores rose from 71.8% to 75.3%, but was not statistically significant (p = .202). caregivers reported being less troubled by problematic behaviors at program end. caregivers responded to twenty four questions regarding occurrence of certain memory and behavior problems in the last week, and if so, how much “annoyance or bother” was experienced. on average, caregivers experienced 15 (41%) of the 24 problem behaviors with the outcome pre scores mean (sd) post scores mean (sd) p value depression 11.8 (6.5) 9.9 (6.1) 0.006 burden 19.1 (8.2) 16.3 (3.0) 0.004 caregiver health 3.1 (.7) 2.8 (.9) 0.023 self-efficacy 71.8 (16.8) 75.3 (17.8) 0.202 online journal of rural nursing and health care, 13(1) care receiver at the beginning of the program with the most frequently reported bothersome behavior being “forgetting what day it is”. the number of behaviors that occurred remained the same over the course of the intervention. when asked to rate how much these behaviors annoyed or bothered the caregiver on a 5-point scale (with 0 being not at all bothered, and 4 being extremely bothered), the mean fell from 1.7 to 1.5, comparison of baseline to program end. the behavior that caregivers showed the most improvement, being less bothered by, and learned to cope with better was “care receiver threatened to hurt themselves”. additionally, there were two caregiver frustration behavior questions in the caregiver questionnaire, administered both pre and post intervention. when asked how often the caregiver felt like screaming or yelling at the care recipient in the past six months, 1 = “never”, 2 = “sometimes”, 3 = “often” due to care recipient behavior, the mean score fell from 2.1 to 1.9. when asked if they felt they had to keep from hitting or slapping the care receiver because of his/her behavior, the mean score fell from 1.2 to 1.1. these scores did not achieve statistical significance, but caregivers did report improvement. finally, caregivers stated they had spoken with the care recipient less often about the possibility of institutional placement after participating for six months in the ga reach program, 28% at program entry compared to 15% at program end. cost analysis. expenses for program implementation were carefully calculated. salary of the pi, office space, telephones, and internet were not included in this calculation as we hoped that agency adoption of this intervention would already have these expenses/services and would not be additional costs. included in the cost analysis was: 1) salaries for the program manager, the interventionists, and group leader; 2) travel expenses for mileage for service delivery, marketing / outreach activities; 3) supplies e.g. training manuals, paper, copying; 4) caregiver online journal of rural nursing and health care, 13(1) notebooks for each client; 5) teleconferencing fees for support groups; and 6) postage for letters sent regarding telephone support group sessions and to remind those clients who had missed an appointment. analysis of the 85 participants completing the study revealed that program implementation involved a cost of $7.00 per day/caregiver. program evaluation. on the overall program evaluation, which was conducted by a third party, who was not involved with the home visits, caregivers shared that the program was beneficial. within two weeks following the completion of the intervention, each participant was contacted via telephone and asked specific questions regarding aspects of the program. caregivers (100%) reported a better understanding of alzheimer’s disease, the caregiving role, and increased confidence in dealing with behavioral problems of the care recipient. table 3: program evaluation program component % reporting benefit overall intervention general benefit 100. better understanding of disease and caregiving role 100. increased confidence in dealing with behavior problems 100. improved ability to care for care recipient 98.50 improvement in care recipient’s life 86.70 individual sessions and home visits improved knowledge 100. increased caregiving skills 97.10 telephone groups improved knowledge 72.70 increased caregiving skills 77.20 discussion georgia reach, a caregiver support program, demonstrates a successful community translation of the reach intervention with a rural population of caregivers caring for individuals with moderate to severe alzheimer’s disease or related dementia. evidence-based caregiver support programs have shown to have positive outcomes for both rural and urban communities (burgio et al., 2009; smith & bell, 2005). online journal of rural nursing and health care, 13(1) in this convenience study, data was collected pre-intervention and post-intervention. positive outcomes were achieved. as with the earlier reach va (nichols et al., 2011) translational study and the reach ii randomized control trial (belle et al., 2006), caregivers experienced statistically significant improvements in both depression and burden. caregivers expressed receiving benefit from all components of the intervention, with telephone support groups receiving a lower rating. the lower rating of the telephone support group was not surprising. this rural population did not seem to value the telephone support and shared that they “did not have time” to spend an hour on a phone call, but preferred the “face to face” contact. perhaps this finding is related to the geographical distances, isolation, and a need for human social interaction experienced by rural caregivers. recruitment issues. in the first year of the project, it became clear that marketing and recruitment efforts would have to be intensified to reach and enroll rural caregivers for the program. rural caregivers are isolated by definition and demonstrate attitudinal barriers such as a deep sense of independence and discomfort with accepting outside help. distrust of a new program also impacted and slowed enrollment. to address this problem, accountability for enrollment was expanded to all team members. marketing and recruitment activities held priority in weekly meetings and interventionists were also utilized to promote the program when not engaged in direct service delivery. interestingly, outreach to social service providers, specifically senior and community centers yielded the greatest return and resulted in an increase in program enrollment. marketing to local retail businesses, posting flyers and leaving brochures, was probably the most ineffective recruitment strategy for the number of participants recruited. for the future, rural agencies and organizations implementing a caregiver support intervention online journal of rural nursing and health care, 13(1) program should begin marketing early and continuously. budget plans should address staff and marketing costs to carry out an intense campaign to enroll caregivers. behavioral problems. management of behavioral problems is a frequent complaint of all caregivers caring for individuals with alzheimer’s disease. the rural caregivers in this study were no different with all reporting care recipient behavioral problems and frustration at managing these troubling behaviors. from baseline to program end, the occurrence of behavioral problems remained consistent and caregivers reported being “less bothered” in their responses to problematic behaviors. we found this finding interesting as behavioral problems usually increase with advancing alzheimer’s disease. caregiver frustration was also reduced after program participation. caregiver confidence, self-efficacy, increased, perhaps indicating that caregivers felt more empowered. through the intervention, caregivers learned new techniques to communicate and problem solve. perhaps this new knowledge and feelings of empowerment had a positive influence on the perception of their ability to address and respond to problematic behaviors. similarly, the reach va (nichols et al., 2011) intervention study indicated significant improvement in caregiver frustration and behavior management as well. decreasing caregiver frustration also has potential for lessening the risk of abuse. these findings may indicate that caregivers can learn to manage troubling behaviors of the care recipient before frustration rises to crisis levels. institutionalization. caregiver stress and burden predict institutionalization (gaugler, kane, clay, & newcomer, 2005). reducing caregiver stress through a caregiver support program may delay or avoid nursing home placement (mittelman, haley, clay, & roth, 2006). in this study, a change was demonstrated in the frequency of conversations between caregiver and care recipient regarding nursing home placement. perhaps the need for such conversations decreased online journal of rural nursing and health care, 13(1) as a result of better behavior management skills, decreased stress, and decreased burden. with institutionalization representing a high cost to both families and the overall healthcare system, more exploration regarding the desire to institutionalize is warranted in future studies. collecting data in this area is clearly indicated. social need in rural areas. caregivers appeared to value the “face to face” contact with the interventionist. a total of twelve contacts by the interventionist with each caregiver were desired. the flexibility of the contact allowed for a substitution of four in-home visits for a telephone visit. most of the caregivers opted for all of the nine in-home visits. perhaps caregiver preference and choice for in-home visits demonstrates the isolation experienced by rural caregivers living in areas where the population is sparse and geographically distanced. application to rural health care and nursing practice. the fabric of rural beliefs will probably not change much over the next decade. nurses practicing in rural health must understand that rural individuals define their health by their ability to work and be productive (long & weinert, 1989). for rural caregivers, their work is the care of their loved one. blending this view of work and care of self is important. as nurses, we must strive to help the rural caregiver to consider that caring for themselves will allow them to continue working and providing that care to the loved one. a seamless nursing referral system for rural caregivers to community caregiving support programs is needed. knowing what community programs are available is an important nursing role in the rural healthcare environment. program cost. analyzing the cost to implement this program was tedious, but important. community agencies hoping to adopt the ga reach program to support the caregivers served need to know anticipated costs. planning well can assist with sustainability of a program. data analysis suggests a cost of $7.00 per day/caregiver. this finding is similar to reach va cost online journal of rural nursing and health care, 13(1) data (l. nichols, personal communication), which reports $5 per day/caregiver with travel to the caregiver home limited to 50 miles, one-way. additionally, the target population in reach va was identified veteran families. in our study, travel costs were higher and impacted by distances of up to 110 miles, one-way, submitted by interventionists traveling to the homes of rural participants and extensive recruitment to these participants. in comparison, the cost per day in a long term care facility is estimated at $215 per semi-private room, inclusive of lodging and meals (prudential research report, 2010). limitations limitations of this translational study include the one group and quasi-experimental design which provide a means for examining causality in situations not conducive to experimental controls. although not the “gold-standard” randomized control trial type of research, translational research focuses on “real-world” effectiveness and thus, has value. the small sample size of mainly caucasian caregivers and limited geographical rural area influence the generalizability of the results. additional research is needed to examine the effect of this program with caregivers of diverse populations. staff turnover of interventionists was a limitation requiring more time for training of new staff. chief reasons for staff turnover were family relocation and/or returning to school. with each new hire, the training and certification process was repeated to ensure intervention fidelity, yet causing a delay or lag in enrolling new participants. data collection in the home was conducted at baseline and program exit by the interventionist, possibly causing a response bias. while we desired to have a third party to collect the data, the families voiced being uncomfortable with a new person and causing possible upset with the care recipient. online journal of rural nursing and health care, 13(1) conclusion program benefit and satisfaction was reported by all caregivers in this study. caregivers shared that the program helped them to understand dementia and increased their knowledge and skills to provide care. caregiver support programs, such as the ga reach program, should be an essential component of rural community agency programs. caregiver support programs also fit well into primary care settings, especially those working with geriatric populations. professional medical and nursing personnel need education regarding these programs and a referral process into these programs is critical. our older adult population will continue to experience growth in coming years and the need for in-home caregiving will increase correspondingly. the findings in this study show great promise for sustaining the rural caregiver and creating an improved caring environment for the care recipient. hope for a positive future for aging individuals demands the incorporation of caregiver support programs into the health care system, especially for rural health. supporting agency this project was supported in part by grant number 90ae0320/01, from the u.s. administration on aging, u.s. department of health and human services. grantees undertaking projects under government sponsorship are encouraged to express freely their finding references administration on aging. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/18182604 http://www.ncbi.nlm.nih.gov/pubmed/7203086 38 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 the clinical nurse leader and rural hospital safety and quality angela jukkala, phd, rn 1 rebecca greenwood, phd, rn 2 kathleen ladner, phd, rn 3 laura hopkins, ms, rn 4 1 assistant professor, school of nursing, university of alabama at birmingham, jukkalaa@uab.edu 2 assistant professor, school of nursing, university of alabama at birmingham, rgreenwo@uab.edu 3 visiting assistant professor, school of nursing, university of alabama at birmingham, kladner@uab.edu 4 clinic administrator, queen of peace clinics, queen of peace hospital key words: rural, hospital, quality, safety, clinical nurse leader abstract rural healthcare organizations face significant challenges when implementing quality and safety initiatives due to limited human and financial resources. the clinical nurse leader (cnl), a new nursing role developed to address the quality and safety concerns of healthcare organizations and providers, may prove to be an exceptionally valuable member of the rural nursing leadership team. educationally prepared to assume nine roles (expert generalist clinician, outcomes manager, advocate, healthcare team leader, information manager, educator, member of a profession, and life-long learner) the cnl is well prepared to function as a valuable member of the rural health care team. through the use of the microsystem assessment process, the cnl can lead quality and safety initiatives specific to meet the unique needs of rural health care organizations, providers, and patients. introduction through hard work and commitment, the quality and safety of care provided in us hospitals has improved over the past 10 years (wachter, 2010). unfortunately, rural applicability of the many quality and safety initiatives that brought this success is unknown as urban initiatives may not be effective and/or relevant to the delivery of care within rural and remote hospitals (coburn, et al., 2004). while initiatives developed for urban and suburban hospitals have been imposed on rural hospitals with varying degrees of success (longo, hewett, ge, & schubert, 2007; westfall, et al., 2004), successful rural hospital quality and safety initiatives are those that can be accomplished with the human, financial, and technological resources available and are relevant to the needs of rural hospitals and populations (klingner, moscovice, tupper, coburn, & wakefield, 2009). rural life and healthcare thoughts of rural living frequently generate pastoral images of healthy farm life; however the reality of life in rural areas is often quite different. in fact, the cultural, social, economic, and geographic characteristics prevalent in rural america actually place rural individuals at high-risk for disease. rural residents are more likely than their urban counterparts to have poorly controlled chronic illness, abuse alcohol and tobacco, and be either underor uninsured (national rural health association (nrha), 2010). poverty is prevalent with high rates of unemployment and limited access to higher education. geographic isolation and http://www.uab.edu/nursing/ mailto:jukkalaa@uab.edu http://www.uab.edu/nursing/ mailto:rgreenwo@uab.edu http://www.uab.edu/nursing/ mailto:kladner@uab.edu http://queenofpeacehospital.com/clinics.html 39 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 virtually nonexistent public transportation exacerbate these problems (agency for healthcare research and quality, 2010). as a result many individuals are not able to effectively manage their health; thus when they do seek care they tend to be quite ill. rural hospitals often function as the primary healthcare provider for a region and may be the sole provider for many individuals (lutfiyya, sikka, mehta, & lipsky, 2009). high quality, safe care that is free from preventable error and harm is an expectation of all patients (blouin, 2010) in all healthcare settings. however, limited resources, lower volumes, small staffs, and inadequate technology (baldwin, et al., 2004; casey & moscovice, 2004) create significant challenges to the development and implementation of quality and safety improvement initiatives in many rural hospitals. nonetheless, to improve quality, rural health care organizations and providers must adopt a comprehensive approach to quality improvement that includes clinical knowledge and the tools necessary to apply this knowledge to practice, including practice guidelines, computer-aided decision support, standardized performance measures, performance measurement and data feedback capabilities, and quality improvement processes and resources (institute of medicine, 2005). thus, organizational, key staff, and hospital leader commitment to advancing patient care quality and safety is critical for success (casey & moscovice, 2004). rural communities and healthcare organizations often have difficulty creating, recruiting, and sustaining an adequate health care workforce (daniels, vanleit, skipper, sanders, & rhyne, 2007). while 20% of the population of the united states lives in rural areas, only 10% of physicians practice in rural areas (nrha, 2010) and the gap between supply and demand is rapidly increasing (rabinowitz, diamond, markham, & wortman, 2008). nursing shortages are prevalent in rural areas as well (cramer, nienaber, helget, & agrawal, 2006), though nurses continue to comprise the largest group of rural healthcare professionals. functioning as generalists, rural nurses provide both routine and emergent care for individuals across the life span (bushy, 1998). the large amount of time spent providing direct patient care and knowledge of the day-to-day issues involved in the delivery of care necessitates that nursing assume a leading role in hospital safety and quality improvement initiatives (gantz, sorenson, & howard, 2003). in fact, no group of rural health care professional providers is better positioned to effect change in the rural care environment than nursing (stanton, 2009). overall, the rural nursing workforce is aging and the impending retirement of large numbers of “baby boomer” nurses is ominous (minnesota department of health, 2007). rural hospital nurse leaders need to ensure that younger, less experienced nurses are educationally and experientially prepared to fill the resulting gaps (squires, 2002). effective strategies to offset the impact from the loss of these expert generalist nurses are urgently needed (montour, baumann, blythe, & hunsberger, 2009) as even one inexperienced nurse can affect patient safety due to the professional isolation inherent in rural practice (hunsberger, baumann, blythe, & crea, 2009). the institute of medicine (iom) has recommended the implementation of safe practices at the delivery level (clinical microsystem) as an effective measure to improve quality and safety (kohn, corrigan, & donaldson, 2000). a clinical microsystem is a small group of people who work together on a regular basis to provide care and the individuals who receive care (nelson, batalden, & godfrey, 2007). regardless of the setting or the population served, knowledge of the clinical microsystems framework can be used to guide and support innovation and reach peak performance (nelson, et al., 2008). utilizing the microsystem assessment framework, the rural cnl is able to identify relevant quality and safety improvement opportunities that reflect the needs of the microsystem and the population it serves (godfrey, 2009). 40 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 clinical nurse leaders the clinical nurse leader (cnl) role was developed in response to concerns about the quality and safety of nursing care in the complex, technologically advanced, ever-changing healthcare system (tornabeni, 2006). as a master’s prepared nurse, the cnl is educationally prepared as an advanced nurse generalist to improve patient care outcomes through use of the microsystem assessment process (rusch & bakewell-sachs, 2007) and managing care delivery for a group of patients (hix, mckeon, & walters, 2009; rusch & bakewell-sachs, 2007; stanley, hoiting, burton, harris, & norman, 2007). as a clinician, the rural cnl would use evidence-based information to design and coordinate the care delivered to individuals and cohorts of patients within the rural hospital microsystem. through the lateral integration of care, the cnl can facilitate and coordinate multiple disciplines and services to ensure the most efficient and goal-directed activities are performed at the right time and in partnership with other disciplines (begun, tornabeni, & white, 2006). reduced fragmentation of care and gaps in communication result in cost-effective efficiency, improved clinical outcomes, and increased patient satisfaction. as an advanced generalist with graduate-level nursing knowledge of illness and disease management, health assessment, and innovative nursing interventions, the cnl bring nursing leadership needed at the point of care to ensure high quality, safe generalist nursing care. comprehensive knowledge of the patient and case management skills, allows the cnl to facilitate patient movement efficiently through the rural healthcare system from the period of acute illness to the patient’s return to the community. efficiency and effectiveness in care delivery is particularly important in critical access hospitals (cah) with programmatic requirements to limit the length of stay to 96 hours and inpatient census no more than 25 inpatients (center for medicare and medicaid services, 2010). as an outcomes manager, the cnl is prepared to lead quality improvement initiatives and design research-based interventions that reduce error, increase patient safety, and stream-line healthcare delivery processes. the cnl evaluates patient health and nursing care process outcomes through the analysis of variance data, communicates findings to the healthcare team, and leads the team in the implementation of initiatives to treat deficiencies within the microsystem. cost benefit analysis is used as a strategy to reduce waste and manage resources. the organizational effectiveness of the cnl is measured by improved clinical, financial, and satisfaction outcomes (harris, tornabeni, & walters, 2006). examples of cnl effectiveness in improving clinical outcomes include improved rates of home health referrals, discharge planning (bowcutt, wall, & goolsby, 2006), improved core measure data, decreased nursing staff turnover (gabuat, hilton, kinnaird, & sherman, 2008), reduced length of stay (los) (tachibana & nelson-peterson, 2007), increased patient satisfaction, a reduction in fall rates, and fewer cardiac arrests (smith, manfredi, hagos, drummond-huth, & moore, 2006). satisfaction outcomes include not only patient satisfaction but nursing staff satisfaction which is demonstrated by increased retention rates, empowerment of nursing staff, and participation in career advancement opportunities. as the interdisciplinary care team manager, the cnl delegates and manages nursing team resources (staff and supplies) (american association of colleges of nursing, 2007). through an understanding of human interactions, communication, problem-solving skills, conflict management, and coalition or team building (harris & roussell, 2010) the cnl is able to advance patient-care delivery through effective team work. 41 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 as a patient advocate, the cnl leads efforts to create and manage a care environment that is responsive to the healthcare needs of diverse rural patients and families. the cnl can include patient preferences and values into the plan of care with patients and families included as partners in care and decision-making. through analysis of differences in clinical outcomes for cohorts of patients in the microsystem, the cnl is able to address health disparities for the most vulnerable including the uninsured, the aged, the less educated, and those with cultural barriers. as an advocate for health care professionals, the cnl promotes practices that are characteristic of healthy work environments. as an educator, the cnl prepares individuals, families, or cohorts of clients for self-care and a maximal level of functioning and wellness (aacn, 2007). to maximize wellness, health promotion, and risk reduction, education programs are designed and implemented, with particular emphasis on those with chronic illnesses. the cnl working at the point of care in the microsystem is able to mentor new members of the nursing staff, promoting evidence-based practice, critical thinking, and sound clinical decision-making. as an information manager, the cnl is able to use information systems and technology that put knowledge at the point of care to improve healthcare outcomes (aacn, 2007). familiarity with the facility’s state of technology and information systems allows the cnl to identify and document internal trends, as well as compare microsystem function to external benchmarks. as a systems analyst/risk anticipator, the cnl participates in the review and evaluation of processes at the system and individual level to anticipate risks to patient safety, prevent medical error, and improve the quality of patient care delivery (aacn, 2007). utilizing tools such as the failure mode effect analysis (fmea) and root cause analysis (rca) allow the cnl to anticipate and respond appropriately to near misses and sentinel events (harris & roussell, 2010). as a member of a profession, the cnl is personally accountable for her/his personal practice; actively engaging in the acquisition of knowledge and skills to effect change in health care practice and outcomes and in the profession (aacn, 2007). as a lifelong learner, the cnl recognizes the need to actively pursue new knowledge and skills as the practice roles and the health care system evolve. discussion rural hospital nursing administrators are responsible for the professional nursing practice environment (ploeg, davies, edwards, gifford, & miller, 2007) and the rural hospital microsystem will ultimately determine the resulting quality and safety of the patient care delivered . successfully implementing evidence-based safety and quality initiatives is challenging and requires strategies that address the complexity of the rural health care system, healthcare providers, and patients to successfully change the culture to one of evidence based practices (institute of medicine, 2004). cnls, through the use of the microsystems assessment framework, are well prepared to lead this process within the rural hospitals. utilization of the best available evidence to inform and guide practice is a critical component of any quality and safety initiative (ahrq, 2008; institute of medicine, 2001). though the vast majority of rural nurses want to include research to inform their practice, they lack the knowledge and skill (bushy, 2004; olade, 2004). as many rural nurses are educated at the associate’s degree (adn) level (omery & williams, 1999), they are not prepared to independently evaluate evidence and implement it into their nursing practice. of interest, rural 42 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 nurses identify the lack of role models as a barrier to evidenced based practice (ebp) and believe that having someone model these behaviors would “boost” their ability to engage in ebp (olade, 2004). the cnl is educationally prepared to lead the development and implementation of evidenced based nursing practice and to mentor rural nurses, increasing the capacity to provide nursing care that is consistent with current best evidence. research specific to inform rural nursing practice is needed (bushy, 2004). providing high quality nursing care for at-risk rural populations requires high-quality rural nursing research as studies conducted by urban nurses in urban settings to guide urban nursing care may or may not be applicable to the delivery of nursing care in the rural setting. finally, the role and effectiveness of the clinical nurse leader has largely been examined from the perspective of large urban health care settings. research to further determine the healthcare outcomes of the cnl role in diverse rural health care settings is needed. partnerships between rural nurses and rural health services researchers to examine rural healthcare structures, processes, and subsequent outcomes are desperately needed. cnls are educationally prepared to participate in the research process and in the development of innovative nursing interventions specific to rural nursing practice. references agency for healthcare research and quality. 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[medline] http://www.health/state.mn.us/divs/orhpc/pubs/retainnurse.pdf http://www.ncbi.nlm.nih.gov/pubmed?term=montour%5bauthor%5d%20and%20changing%5btitle%5d&cmd=detailssearch http://www.nrharural.org/go/left/about-rural-health/what-s-different-about-rural-health-care http://www.nrharural.org/go/left/about-rural-health/what-s-different-about-rural-health-care http://www.ncbi.nlm.nih.gov/pubmed/18677868 http://www.ncbi.nlm.nih.gov/pubmed/15495490 http://www.ncbi.nlm.nih.gov/pubmed?term=omery%5bauthor%5d%20and%20utilization%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=ploeg%5bauthor%5d%20and%20guideline%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=rabinowitz%5bauthor%5d%20and%20widespread%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=rusch%5bauthor%5d%20and%20cnl%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=drummond-huth%5bauthor%5d%20and%20application%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=squires%5bauthor%5d%20and%20graduate%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed/17386309 http://www.ncbi.nlm.nih.gov/pubmed?term=tachibana%5bauthor%5d%20and%20implementing%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed/16404192 http://www.ncbi.nlm.nih.gov/pubmed?term=wachter%5bauthor%5d%20and%20unmistakable%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed/15551852 online journal of rural nursing and health care, 2(1) 6 a comparison of the cardiovascular risks of rural, suburban, and urban women pamela stewart fahs, dsn, rn1 theresa n. grabo, phd, aprn, bc, fnp2 gary d. james, phd3 martha neff-smith, rn4 gale a. spencer, phd, rn5 1 assistant professor, decker school of nursing, binghamton university, psfahs@binghamton.edu 2 associate professor, decker school of nursing, binghamton university, tgrabo@binghamton.edu 3 professor, decker school of nursing, binghamton university, gdjames@binghamton.edu 4 research professor, decker school of nursing, binghamton university, mnsmith@binghamton.edu 5 professor, decker school of nursing, binghamton university, gspencer@binghamton.edu abstract the purpose of this study was to compare the cardiovascular risk factors of women 35 years of age and older with primary residence in rural, suburban, and urban areas. data were collected on 108 women in upstate new york. rural women exhibited higher systolic blood pressure (p = .05) and were older (p=.01) than those living in suburban or urban areas. there were no other statistically significant differences in cardiovascular risk factors among the groups. however, all three groups exhibited levels of total cholesterol, weight, and body mass index that indicate online journal of rural nursing and health care, 2(1) 7 strong cardiovascular risk factors among women in this age group regardless of primary residence. keywords: rural, women’s health, cardiovascular disease (cvd) online journal of rural nursing and health care, 2(1) 8 a comparison of the cardiovascular risks of rural, suburban, and urban women the notion of cardiovascular disease (cvd) as primarily a killer of men is a myth that must be debunked! in 1997, 40% of deaths of women, regardless of age or race, were from cvd. diseases of the heart and cerebrovascular diseases including stroke killed 373,215 women over the age of 40 in the united states (u.s.) in 1997 (hoyert, kochanek, & murphy, 1999). the terminology to indicated diseases pertaining to the cardiovascular system is confusing. the way mortality and morbidity data are analyzed in this country is by disease code. currently in use is the ninth revision of the international classification of disease (icd-9) codes. total cardiovascular disease (cvd) is inclusive of: diseases of the heart, cerebrovascular diseases, and diseases of the vascular system and lymphatics. the codes for categories of cardiovascular disease may be seen in table 1. casper et al. (1999) used the icd-9 codes 390-398, 402, 404-429 (diseases of the heart) to calculated the mortality rate of women 35 years and older on a county level throughout the u.s. the heart disease, age adjusted and spatially smoothed, mortality rate for women 35 years and older residing in new york state at the time of death was 487/100,000 (casper et al. 1999). the two counties where data were collected in this study had mortality rates of 426/100,000 for broome and 431/100,000 in delaware county. on average women are protected from online journal of rural nursing and health care, 2(1) 9 cardiovascular disease for nearly 10 years longer than men, which is thought to be due to the influence of estrogens (stumpf & trolice 1994). however, sixty million american women are expected to be experiencing or have experienced menopause by 2010 (andrews 1995). with increasing life expectancy, women today may expect to live 30 or more years post-menopause, equivalent to a third of their life. according to the u.s. department of agriculture, economic research service, rural people make up 24.8 % of the u.s. population (cited in ricketts iii 1999, p. 8). over 34 million rural women lived in the u.s. according to the 1990 census data. this number represented 52% of the rural population and 30% of america’s women (bushy 1993) in the early 1990s. rural communities often have greater representation of older residents and the female to male ratio is higher than in non-rural locals (coward & krout 1998). healthy people 2010 (u.s. department of health and human services, 2000) notes that heart disease, cancer, and diabetes rates for rural areas exceed those for urban areas. this report also concludes that people living in rural areas are less likely to use preventive screening services or exercise regularly. rural women are considered more likely to experience chronic illnesses such as cardiovascular disease and hypertension (bushy, 1994) and are also less likely to seek treatment for acute illnesses than their urban counterparts. researchers have focused primarily on health issues of more accessible urban groups of women. however, there is a dearth of epidemiological studies on the actual illness and treatment patterns of rural women. literature there is a gap in the literature regarding cardiovascular risks of rural women. only two studies were found comparing cardiovascular risks of rural and non-rural women (broda et al. 1996; edwards et al. 1991) while one study (chapman et al. 1993) compared winter and summer online journal of rural nursing and health care, 2(1) 10 dietary intake and energy expenditures in a sample of rural women. broda et al. (1996) studied women and men in the u.s. and poland. place of residence within each country, rural or urban, was provided although there were no direct rural to urban comparisons. data were extrapolated regarding cardiovascular risk factors in the two groups. subjects ranged from 45 to 65 years of age. this project measured and reported high density lipids (hdl) and two sub-fractions, hdl2 and hdl3. rural u.s. women had lower levels of all types of hdl, which is considered the ‘protective’ cholesterol, than urban u.s. women. lower levels of hdl in both rural and urban u.s. women were significantly associated with cigarette smoking and body mass index (bmi). the authors concluded that low levels of hdl were directly related to heart disease within the populations studied. only one study was found in the literature directly comparing the cardiovascular risk factors of u.s. rural and urban women. this was a descriptive, correlational study of 163 women that examined health risk appraisals on measures of blood pressure, cholesterol, diabetes, and smoking among women ranging in age from 20 – 60 years (edwards et al. 1991). the differences among groups were significant (p = .03), with rural black women being most ‘at risk’ on the measure of elevated cholesterol. cholesterol measures considered at risk were defined as serum cholesterol levels greater than 200 mm/dl. the authors found that 59.4% of the rural black women were at risk on the measure of serum cholesterol compared to 38.3% of the black urban sample. among white women in this study 35.7% urban and 32.6% rural were considered at risk. mean values of serum cholesterol were not included in the report. diabetes and smoking, both known cardiovascular risk factors, were found to be more prevalent in rural than urban women. chapman et al. (1993) completed a prospective study with two measurement points, summer and winter. the sample consisted of 401 women ages 30-50 years, at the beginning of the study with follow-up including 344 of the original sample. the data were online journal of rural nursing and health care, 2(1) 11 descriptive and measured caloric intake, body mass index (bmi), and basal energy expenditure (bee) based on height, weight, a three-day diet history and physical activity record. the rural women in this study ingested fewer total calories, and had lower bee and higher bmi than would be expected given their high activity level. the data collected on dietary intake and physical activity in this study were self report. the lack of research literature specific to cardiovascular risk of rural women in the northeast united states and the high mortality heart disease rates for women in new york state led the women’s health care partnership to formulate the following research questions: 1. what are the cardiovascular risk factors of women living in rural, suburban, and urban areas and attending community screenings in upstate new york? 2. do cardiovascular risk factors vary by area of primary residence (rural, suburban, or urban)? method and design approval for this project was granted from the binghamton university human subjects review committee in july 1999. data were collected during three community screenings held in august 1999 in upstate new york. the screenings were widely advertised within the region. all individuals attending the screening were eligible for a free blood pressure reading and health risk appraisal as well as cholesterol screening at cost ($10). women meeting the inclusion criteria, 35 years of age or older, and willing to participate in the study had the fee for cholesterol screening waived. women interested in participating in the study were given a letter of explanation of risk and benefits and asked to sign an informed consent prior to participation. online journal of rural nursing and health care, 2(1) 12 sample one hundred and eleven women agreed to participate, however three did not complete the screening process leaving a sample of one hundred and eight (n=108) women in the sample. data collection occurred at three places in two counties of upstate new york. participants were asked to complete three questionnaires presented in a single booklet. these three survey instruments took about 15 minutes to complete. in addition each subject had a blood pressure and total cholesterol measurement. instrumentation physiologic measures the joint national committee vi (1997) recommended method of assessing blood pressure was used in this study. this consisted of 3 measurements in the left arm and averaging the last two readings. pre-data collection, inter-rater reliability was established in a session of blood pressure assessments with a consistency of reading within 5mmhg among data collectors. total cholesterol was assessed through a non-fasting, capillary blood test. due to a change in the equipment used by the supporting laboratory services during the study, two types of analyzers were used. the desk top analyzers used in this study, proact™ & cholestech l*d*x™ are typical of analyzers used in community screening because of their portability and ease of testing. a correlation coefficient was run on paired samples using both machines with r = 0.97, indicating a strong positive correlation between readings from the two machines. the laboratory completing the cholesterol test holds a clinical laboratory improvement amendment (clia) certificate from new york state department of health. the individual technicians drawing blood and performing the analysis had undergone competency testing by the supporting online journal of rural nursing and health care, 2(1) 13 laboratory as required by the new york state department of health. serum total cholesterol on capillary blood samples was reported in mg/dl. survey instruments demographic and health history this survey was used to gather information on area of primary residence: rural, suburban, or urban. in addition to the self-report of area of residency, individuals were asked about the presence of three defining characteristics of rural residency. these characteristics included water supply, access to public transportation, and county of residency. the instrument contained questions on status of cardiovascular diseases including myocardial infarction, strokes, hypertension, and dislipidemia. in addition, there were questions about use of medications that might effect cardiovascular risks such as antihypertensives, cholesterol lowering agents, hormone replacement therapy, and over-the-counter or “natural” supplements used to ease symptoms of menopause. health risk appraisal healthier people health risk appraisal© is an educational tool designed by the carter center of emory university. it identifies choices the individual can make to promote good health and describes how to avoid the most common causes of death for a person based on age and gender. this instrument was designed to give an individual some ideas for lowering the risk of lifestyle-affected illnesses or injury in the future. questions on the health risk appraisal included but were not limited to: age, gender, race, years of education, occupation, height, weight, chronic illnesses, and dietary use of grains and fats. online journal of rural nursing and health care, 2(1) 14 hormone replacement profile ali (1998) developed the hormone replacement profile. this fourteen item, likert scale instrument measures self-efficacy and outcome beliefs regarding hormone replacement therapy. the higher the score on the self-efficacy portion of the instrument, the greater the tendency of the individual to be self-efficacious in continued use of hrt. the higher the score on the outcome belief items the greater the tendency to perceive greater positive outcomes to using hrt. results residency using the operational definition of rural residency as living in a county of 50,000 or less or having no access to city water or public transportation there were 33 subjects classified as rural. there were 48 suburban subjects, using self-definition of suburban plus those that selfidentified as rural but did not meet the research definition of living in a rural area. the remainder (n=27) self-selected urban as their place of residency. age and blood pressure mean age for the entire sample (n=108) was 53 years with a range of 35 to 80 years. the mean age for the rural group was 58 years, which was higher than the age of the suburban or urban groups (see table 2 for comparison of mean age and blood pressures by group). there was a statistically significant difference among the three groups f=4.16 (2), p=. 01* on the measure of age. the mean blood pressure for the three groups was 124 mmhg systolic and 77.22mmhg diastolic (n=108). the range on systolic blood pressure was 87 to 169 mmhg and diastolic readings ranged from 58 to 100 mmhg. there was a statistically significant difference among the three groups on systolic blood press with the rural group having the highest systolic online journal of rural nursing and health care, 2(1) 15 readings (f=3.60, df2, p=. 03*). although the average diastolic blood pressure for the rural group was 3 points higher than either the suburban or urban group, differences among the groups did not reach significance (f=1.29, df =2, p=. 28). eight (24% of rural sample) rural women, nine suburban (19%), and six (22%) of urban subjects reported having a history of hypertension on screening. six of the 8 (75%) rural known hypertensive subjects were using antihypertensives compared to 15 (100%) of their more urban counterparts. reasons for not using antihypertensives among the rural women reporting hypertension included: not prescribed, or did not feel medication was needed, concern about side effects, or frequent forgetting to take medication. there was no information collected on level of hypertension for subjects. total cholesterol non-fasting total cholesterol was checked for each subject. rural subjects had higher averages on the total cholesterol levels, 227, s.d. 35 mg/dl than those living in suburban areas 220, s.d. 42 mg/dl, or urban areas 212, s.d. 42 mg/dl. there was no statistically significant difference among groups on the measure of total cholesterol (f = .94, df = 2, p = .39). cholesterol readings were collapsed into normal (² 199mg/dl), borderline (200-239 ml-dl), and high (³240 ml/dl). numbers of individuals and percentage of group with readings in each of these categories can be seen in table 3. online journal of rural nursing and health care, 2(1) 16 in order to assess the “at risk” individuals on the measure of total cholesterol in each group the data were further collapsed into categories of normal (² 199mg/dl) and at risk (³200 ml/dl). twenty-five (76%) of the rural sample were considered at risk on measure of cholesterol. twenty-nine (60%) and 17 (63%) of the suburban and urban sample were placed in the cholesterol at risk category. again the mean number of individuals at risk for heart disease by virtue of their elevated cholesterol levels was highest in the rural sample but significance was not reached (r = .11, p = .27). there was no attempt in these community screenings to measure hdl (high-density lipid) or ldl (low-density lipid) values. prohibitive cost as well as an inability to have participants fast prior to the testing made the measure of hdl and ldl unrealistic for this study. subjects were asked to self-report their hdl if known from previous testing. only one of the 108 subjects reported a previously known hdl. only 6(19%) of the rural women were on medication to lower cholesterol despite 25 (76%) having above normal levels of cholesterol and 15 (46%) self-reporting elevated cholesterol. however there were no significant differences in medication use to lower lipids by rural, suburban, or urban women (table 4). online journal of rural nursing and health care, 2(1) 17 other cardiovascular risk factors weight and smoking are two well-known risks for cardiovascular disease. the mean weight for the entire sample was 158 pounds (lbs.), with a s.d. of 36 lbs. body mass index (bmi) is often a better indicator of cardiovascular risk than weight alone since it considers height in the calculation. bmi of 24 or less is considered within normal limits. bmi of 25-29.9 is considered overweight and 30 or above is categorized as obese. individuals with bmi of above 25 are considered to be at risk for cvd. the average bmi for the sample (n=108) was 28 with a minimum of 19 and a maximum of 109. one outlier with a bmi of 109 in the suburban group was removed for calculating bmi differences among groups. without the outlier, the mean bmi for the sample as a whole was 27 with a range of 19 to 56. without the outlier, there was little variance in mean bmi among the three groups. rural and urban women each had a mean bmi of 27, with sd of 6 and 8 respectively. suburban women had a mean bmi of 26, s.d. 5. however, the group with the largest percent of the sample at risk of cardiovascular disease using bmi as a measure was the rural group. the numbers and percentage of women at risk for cardiovascular disease from above normal bmi can be seen in table 5. online journal of rural nursing and health care, 2(1) 18 rural women self-reported a mean weight of 160 lbs., s.d. 35 pounds, suburban women reported an average 155, s.d. 33 pounds, while urban women reported a mean weight of 160 lbs., s.d. 44 pounds. an anova on differences in weight did not reach a level of significance in this study (f = .29, df = 2, p = .75). only 15 women (14%) in this study reported current smoking. seven (21%) of the rural sample reported current smoking compared to six (13%) suburban women and 2(7%) of the urban group. there was not a significant difference among groups in smoking status (r=3.96, p = .41). those rural women that did smoke reported significantly fewer cigarettes per day (9.60) compared to the non-rural smokers (20.44), t= -2.30, df 17, p=.03. menopause and use of hormone replacement therapy twenty-six (79%) of the rural sample reported having gone through menopause at the time of data collection. only 7 (25%) of the 26 rural women reporting menopause had undergone hysterectomy. although the difference in percentage of surgically induced menopause appears clinically remarkable this difference failed to reach a level of significance. see table 6 for the numbers of women whom reported being menopausal or post menopause and those who had hysterectomy. online journal of rural nursing and health care, 2(1) 19 eleven (35%) of the rural sample reported using hormone replacement therapy (hrt). twenty-nine (37.7%) of non-rural women used hrt. twenty-one (44%) of the suburban women and 7 (26%) of the urban women used hrt. there was no significant difference overall in the use of hrt among women living in rural, suburban, or urban areas (_2 = 2.37, df 2, p = .31). there was a significant difference in both efficacy beliefs in hrt and outcome expectations of hrt between women who reported using hrt and those who did not use hrt (efficacy beliefs t=6.73, df 105, p = .000*; outcome expectations t=6.80, df 104, p=. 000*). users of hrt had higher mean scores on both efficacy beliefs and outcome expectations than non-users. discussion limitations of the study this convenience sample was very homogenous with a primarily caucasian sample. the homogeneity is reflective of the racial makeup of the region where data were collected. only one rural region was represented in the sample. in addition, the non-fasting cholesterol measurements did not provide data on hdl and ldl ratios. the age difference between the rural and non-rural groups could account for the difference in systolic blood pressures. however, this difference is consistent with finding of other studies and needs further study with online journal of rural nursing and health care, 2(1) 20 possible age matched data sets. a power analysis was calculated prior to data collection with an estimated need for 42 subjects per group for a power of .80, a=.05. unfortunately only the suburban group included a large enough sample among the three groups. limited funding prohibited further data collection in this study. future projects need to focus on subject enrollment of assure power and thus avoid the possibility of type ii errors. conclusions this study does provide a description of cardiovascular risks of rural, suburban, and urban women in one region of upstate new york and indicates the need for further study of the health risks of women, particularly those living in rural areas. rural women in this sample were significantly more likely to have elevated systolic blood pressure on screening. however, it is unclear whether this difference is due to lifestyle factors present in rural living or if the age difference between the subgroups accounts for the difference. those rural women self-reporting hypertension were less likely to be using antihypertensive medications than their non-rural counterparts. this rural group also showed tendency toward higher cholesterol, body weight, and bmi yet these measures did not meet levels of significance, indicating the need for a larger rural sample. all groups in this study had a higher mean bmi than found in chapman et al. (1993) sample at either the summer or winter measurement. unlike the edwards et al. (1991) study, these rural women were no more likely to report current smoking than women living in suburban and urban areas and those that did smoke reported approximately half the number of cigarettes per day as the non-rural women in the sample. the edwards et al. (1991) study included black and white low-income women with an age range of 20 to 60 years. the women in this study were primarily white, with ages ranging from 35–80 and data were not collected on income. the differences in racial make-up and age of online journal of rural nursing and health care, 2(1) 21 the samples could account for the differences in findings in the two studies. this work needs to be replicated and extended. future studies of cardiovascular risk of rural women would be enhanced if women from various racial backgrounds and rural regions were included in data collection. online journal of rural nursing and health care, 2(1) 22 references ali, n. (1998). the hormone replacement therapy self-efficacy scale. journal of advanced nursing, 28, 1115-1119. https://doi.org/10.1046/j.1365-2648.1998.00744.x andrews, w.c. (1995). continuous combined estrogen / progestin hormone replacement therapy. nurse practitioner: american journal of primary health care, 20(11 part 2), 1-11. broda, g., davis, c.e., pajak, a., williams, o.d., rywik, s.l., baczynska, e., et al. (1996). poland and united states collaborative study on cardiovascular epidemiology. a comparison of hdl cholesterol and its subfractions in populations covered by the united states atherosclerosis risk in communities study and the pol-monica project. arteriosclerosis, thrombosis, and vascular biology, 16, 339-49. https://doi.org/10.1161/01.atv.16.2.339 bushy, a. (1993). rural women. lifestyle and health status. nursing clinics of north america, 28, 187-97. bushy, a. (1994). women in rural environments: considerations for holistic nurses. holistic nursing practice, 8(4), 67-73. https://doi.org/10.1097/00004650-199407000-00009 casper, m.l., barnette, e., halverson, j.a., elmes, g.a., braham, v.e., majeed, z.a., et al. (1999). women and heart disease: an atlas of racial and ethnic disparities in mortality. morgantown wv: office for social environment and health research, west virginia university. chapman, k.m., misner, j., reber, r., & pankau, j. (1993). cardiovascular risk factors in rural midwestern women. journal of women's health, 2, 373-377. https://doi.org/10.1089/jwh.1993.2.373 https://doi.org/10.1046/j.1365-2648.1998.00744.x https://doi.org/10.1161/01.atv.16.2.339 https://doi.org/10.1097/00004650-199407000-00009 https://doi.org/10.1089/jwh.1993.2.373 online journal of rural nursing and health care, 2(1) 23 coward, r.t., & krout, j.a. (eds.). (1998). aging in rural settings: life circumstances and distinctive features. new york: springer. edwards, k.a., parker, d.e., burks, c.d., west, a.m., & adams, m. (1991). cardiovascular risks among black and white rural-urban low income women. abnf journal, 2(4), 72-6. joint national committee vi. (1998). the sixth report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. archives of internal medicine, 157, 2413-2446. hoyert, d.l., kochanek, k.d., & murphy, s.l. (1999). deaths: final data for 1997. national vital statistics reports, 47(19), 1-104. ricketts iii, t.c. (ed.). (1999). rural health in the united states. new york: oxford university press. stumpf, p.g., & trolice, m.p. (1994). compliance problems with hormone replacement therapy. primary care of the mature woman, 21, 219-229. u.s. department of health and human services. (2000). healthy people 2010. paper presented at the healthy living 2010: understanding and improving health, washington, dc. microsoft word cheshire _439-2644-2-ed.docx online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 73 incorporating clinical experiences at a community-based free clinic to improve nursing students’ understanding of rural, medically underserved populations michelle cheshire, edd, rn 1 michele montgomery, phd, mph, rn 2 paige johnson, phd, rn 3 1 rn mobility coordinator & assistant professor, capstone college of nursing, university of alabama, mcheshire@ua.edu 2 assistant professor, capstone college of nursing, the university of alabama, mmontgomery1@ua.edu 3 assistant professor, capstone college of nursing, the university of alabama, ptjohnso@ua.edu abstract schools of nursing have a responsibility to incorporate content related to social determinants of health and rural health into their curriculum and reinforce this content by providing nursing students with clinical experiences in which they can gain hands on experience providing care to rural residents. free clinics provide a vital service to underserved, rural communities, but often remain an underutilized site for nursing clinical education. the partnership between a free clinic in west alabama and one school of nursing has demonstrated that students gain valuable insight not only into the health care needs of rural populations, but also the value of interprofessional collaboration to provide health services to this population. this clinical experience provided an online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 74 avenue for students to meet their clinical objectives and serve a population of rural residents that were invested in their health but needed the services of this free clinic. senior level bsn students in the community health nursing course assigned to this clinical site reported an intention to serve rural, medically underserved populations after graduation. keywords: rural populations, nursing education, medically underserved populations incorporating clinical experiences at a community-based free clinic to improve nursing students’ understanding of rural, medically underserved populations health is closely associated with economics, education, transportation, and ecology, and many residents of rural communities suffer from poor health due to poor socioeconomic conditions and lack of access to health services. tuscaloosa county, which is home to the university of alabama, is situated in west alabama, and is part of what is considered the black belt region which includes some of the poorest counties in the united states. this region of the state consists of 18 rural counties as defined by the united states department of agriculture (usda) definition using economic research service rural-urban commuting areas (ruca) with codes 4-10 (usda, 2009). the severity of economic struggles places residents of these counties at a great disadvantage when attempting to receive health care. the good samaritan clinic (gsc), which is located in tuscaloosa county, is a free clinic providing care to rural residents of west alabama. in order to increase baccalaureate prepared registered nurses (bsns) an understanding of the unique health needs and health care access of residents living in rural and underserved areas of alabama is needed. educational opportunities must be offered that provide clinical experiences with these populations. faculty in the community health course at the university of alabama online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 75 (ua) capstone college of nursing (ccn) developed a clinical experience designed to allow senior-level bsn students opportunity to provide care to rural residents who receive care at the good samaritan clinic (gsc). this clinical teaching strategy utilizes academic and community partnerships to provide an opportunity for students to work interprofessionally in a primary care setting. the purpose of this article is to provide nurse educators with an understanding of how this type of teaching strategy can be implemented in baccalaureate programs and the benefits provided to bsn students. background rural areas are more likely to lack adequate primary care and mental health care services, and all of alabama’s 67 counties are designated as medically underserved areas (mua) or contain medically underserved populations (mup) (hrsa, 2016). because of high rates of obesity, cardiovascular disease, and diabetes, alabama ranks 46th in the u.s. for overall health and 50th in health outcomes (uhf, 2016). chronic diseases are a serious problem in alabama. cardiovascular disease (cvd), the leading cause of death, kills more alabamians than all forms of cancer combined (arha, 2013). in 2012, alabama adults ranked fifth in the nation in overweight/obesity (arha, 2013). approximately 34% of adults in alabama are obese and 12.9% have diabetes, ranking 4th in the u.s. (arha, 2013), with these rates are even higher in the rural counties. other risk factors for cvd include the lack of physical activity and poor dietary habits. more than half the deaths that occur each year can be attributed to modifiable health risk factors. there is a growing recognition that providing rural health clinical experiences as part of undergraduate nursing education is successful in improving recruitment of nurses to work in rural online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 76 communities. schools that have implemented these types of experiences, both in the united states (u.s.) and abroad, have demonstrated increased interest in careers in rural health (coyle, 2012; lea et al., 2008; richards, o'neil, jones, davis, & krebs, 2011; younge, ferguson & myrick, 2006). other reported benefits of rural health immersion experiences include providing students with the opportunity to develop relationships with patients and to collaborate with other health professionals (casimiro, hall, kuziemsky, o'connor, & varpio, 2015; van hofwegen, kirkham, & harwood, 2005). in addition, students gain an increased understanding of health care delivery from a systems perspective and greater opportunity to experience the realities of life for rural patients including the impact of socioeconomic status, isolation, service gaps, and barriers to care (erkel, nivens, & kennedy, 1995; garner, 2015; van hofwegen et al., 2005). a clinical experience which allows students to gain hands-on experience working with residents of rural counties was implemented in the gsc, which is an interdenominational christian ministry that provides primary health care and referral to outside health services within a network of pro-bono medical providers. the clinic was started in 1999 by a physician who recognized the need for primary care for patients who did not have health care insurance and did not qualify for government assistance. the clinic serves indigent adults of all races, creeds and genders. over 21 % of residents, (estimated at more than 63,370 in 2014) living in the rural counties served by gsc live at or below the federal poverty level (fpl). the affordable care act makes insurance available for indigent adults but does not require individuals to purchase unless their household income is above 200 % of the fpl. clinic patients must have an income less than 185 % of the fpl, and thus are too poor to afford insurance even with assistance. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 77 one aspect of a clinical experience in a community-based free clinic that is particularly beneficial to nursing students is that they gain an understanding that the care must be provided with limited resources and is much different than the acute care setting. care at the gsc clinic is provided by volunteer physicians, nurse practitioners, nurses, phlebotomists, social workers, dietitians and pharmacy technicians. the part-time staff of eight employees is assisted by over 100 volunteers who work in every area of the clinic. also providing care are students earning their degree in healthcare professions including medicine, nursing, pharmacy, nutrition, social work and health promotion. because the clinic does not currently provide routine wellness and preventive care, all clinic patients are sick. the primary chronic medical problems experienced by patients are hypertension, diabetes, high cholesterol, asthma, bone and joint conditions, stress and gastric conditions. patients also are treated with non-emergency acute illness and injuries. if patients need care beyond the scope of the clinic, every effort is made to locate a pro bono medical provider. this includes hospitalization, surgery, physical therapy and specialty physician care. another objective of the clinical experience at the gsc is that students leave with an understanding of how patients access care in a rural community setting and who makes up the patient population in free rural clinics. patients of the gsc are often referred by the hospitals or private physicians but can also self-refer. new patients make an appointment with a clinic social worker to determine eligibility. the gsc serves approximately 550 patients annually. there are roughly 3,000 patient visits per year. the value of donated care provided by the gsc annually is over 3 million dollars and in 2015 the value of medication provided to patients was over 1.5 million dollars. patients served by the clinic are between 18-65 years old, with the majority of patients falling between the ages of 35-60. fifty-one percent of the patients are white, 38 % african online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 78 american and over 10 % hispanic. nine percent of the hispanic patients are spanish speaking and require an interpreter. all care provided at the clinic is free for the patients. the clinic is supported financially by individual donations, area churches, foundations and community grants. this teaching strategy was implemented in the community health nursing course offered in the fourth semester of a five-semester curriculum in the ua ccn. it is a required course for fourth semester students and is offered in the fall and spring semesters. each student is required to complete 46 hours of community health clinical during the semester. the number of students varies each semester, but approximately 100 students each fall and spring are enrolled in community health nursing. because of the large number of students enrolled in the course and the limited number of clinical days, not all students can be scheduled for a clinical day at the gsc. however, approximately 32 students are able to get a clinical day at the good samaritan clinic each semester. the students work closely with a ccn faculty member who spends one day a week at the gsc as a volunteer rn. in addition to time spent with this faculty member, students also work closely with the medical residents, pharmacists, and social workers. this clinical experience substantially benefits the underserved areas of west alabama while providing undergraduate nursing students with an opportunity to learn more about the health care needs of this population. the purpose of incorporating this clinical experience at the gsc is to increase experiential training opportunities for senior-level bsn students in a primary care community-based setting. this clinical experience also expands upon an academic-practice partnership between the capstone college of nursing and a community-based clinical site (good samaritan clinic), while providing senior-level bsn students with a meaningful clinical experience and training in a medically underserved rural community. increasing educational opportunities in rural health in the online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 79 baccalaureate program will address the critical shortage of bsn prepared rns practicing in those areas. teaching strategy implementation in the community health nursing course at the university of alabama capstone college of nursing an overarching goal is to expose students to opportunities to provide care to rural populations in order to gain a perspective on barriers that hinder quality healthcare in vulnerable populations. the theory portion of the community health nursing course includes content related to health risks and health promotion in rural and medically underserved populations. through lecture and class discussion, students are presented with information from the centers for disease control and prevention, the robert wood johnson foundation, the department of health and human services, and the state health department related to the leading causes of morbidity and mortality in rural populations. implementation of this strategy begins by assigning students to clinical at the gsc in pairs. the students arrive at the clinic an hour before the first patient visit is scheduled. they meet the ccn faculty member who is a volunteer rn at the clinic. pre-conference and orientation to the clinic includes a tour of the clinic, a brief history of the clinic and a description of the objectives of the clinical experience. students are given access to the medical records of the patients scheduled that day. the medical residents, pharmacy students and nursing students all have the opportunity to review the patients’ records and ask questions about the plan of care. discussion between the students encourages and strengthens the students’ confidence in interprofessional communication. the nursing students work with the rn to complete an initial assessment of patients including, height, weight, vital signs and physical assessment. the nursing students are online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 80 required to reconcile the patients medications with those listed in the medical record during initial assessment. the nursing students then place the patient in a room and give report to the pharmacy students and medical residents on the initial assessment findings. students are present in the exam room with patients when they are seen by the medical resident. based on the physicians plan of care the nursing student assist with procedures that may include; ekg, venipuncture, pregnancy test, vision screening, diabetic education, and referrals for imaging. the students participate in the discharging of patients, which is done by an rn after all of the services ordered are provided. during the discharge process students learn the importance of ensuring that all orders have been completed, any referrals for outside pro-bono care have been initiated and any new medications or changes to medications is discussed with the patients. after all patients have been discharged the faculty preceptor has a post conference to review the day’s activities and answer any questions that the students have. after each clinical day, students are required to provide narrative evaluations of the experience. the faculty in the community health course developed clinical journals which asks students to address various components of the clinical experience. these clinical journal questions are posted online, and students type their responses and submit them to their clinical instructor. there are three questions the students must respond to. the first question asks, “what happened?” students are told to describe in detail the facts and events of the clinical experience. they are guided further to reflect upon such things as the health problems of the patients of the gsc and how they felt working with this population. the second question asks, “so what?” students are guided to discuss their feelings, ideas, and analysis of the clinical experience. specifically, students are asked to address how the clinical experience at the gsc was different from or the online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 81 same as they expected. finally, they are asked, “now what?” students are instructed to consider the broader implications of the clinical experience and apply learning. for example, they are asked to discuss what they see as the root causes of the health problems or issues in rural patients who sought care at the good samaritan clinic. reflective student feedback results from the clinical journals indicated the majority of students felt better prepared to care for rural patients, as well as developed a better understanding of the unique health needs of this population and the need for free health clinics such as the gsc. in addition, students reported that this experience has increased their desire to work with similar populations after they graduate. some student responses include: • “this population is at risk for poor health due to financial problems…. i loved working with this rural population. the experience was better than i expected…. i am definitely going to take what i learned in this clinical experience and use it to better care for patients in the community.” • “it was my last day of clinical and i am so happy it was at gsc. it was for a great cause and the patients were very grateful…. i will make it a goal of mine, once i graduate with my degree that i will volunteer at a clinic!” • “i really enjoyed working with this population because it was different than any regular hospital setting….. i learned that patient education is critical in this particular rural/vulnerable population. i left the day with a heavy heart over the hurt that was experienced by some patients. they desperately wanted to no longer experience certain health issues but did not have the funds in order to pay for medicine or surgery….this online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 82 clinical rotation confirmed to me that offering health care to those without available resources has a huge impact on that particular population not only in their physical health, but their spiritual and mental health as well.” • “working with this population allowed me to see another side of life and to be less judgmental. it is easy to judge people for being overweight and not making healthy decisions but sometimes it is not easy to make healthy decisions when you are busy with trying to support your family and cannot afford or access the healthier foods. i learned that health care providers have to change the way they diagnose and treat patients based on the population….i always thought that primary care was boring, but i do like that you get to talk to the patients more and really help them. my experience was better than expected. i think this experience will help me to consider my patients’ personal lives more when teaching them. i also think i will be more understanding of noncompliance and be more motivated to delve deeper to determine the patient’s reasons for being noncompliant or having certain problems in the first place.” • “the part that stood out to me as the biggest health concern for the patients was actually these patients’ lack of insurance and their inability to receive the best medical care available…the rural working poor patient population seems to be in a limbo where they need to either fall even lower into poverty in order to qualify for government assistance or find another job with insurance that will cover their medical costs, and neither is an easy option…this clinic opened my eyes to the needs of the less fortunate and it has inspired me to want to find a similar operation to the good samaritan clinic to contribute to wherever i end up after graduation.” online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 83 • “i really liked serving this rural population because i could really sense that good was being done and that these people truly depended on this free rural clinic…i will remember that clinics like this are just as important as the hospital. it taught me the entire community needs to work together to make this happen.” in addition to expressing how much they learned about rural populations and the services provided by a free clinic, students also valued the experience because of the opportunity to work so closely with other professions. many students commented that it was beneficial to see how the interprofessional team conducted the patient assessments and the types of questions that were asked. students were able to see how physicians treat patient conditions when expensive medical tests cannot be ordered or expensive medications prescribed. students stated that in other classes they were not often exposed to other health care providers’ roles in providing patient care or how they interacted as a health care team, so they found this aspect of their clinical day at the good samaritan clinic particularly beneficial. recommendations for nurse educators free clinics are excellent sites for experiential learning opportunities that enable nursing students to gain an understanding of the unique health needs of rural residents, providing primary care with limited resources, and working within an interprofessional team. the main limitation of this clinical experience is that all of the community health students are not able to participate in the gsc clinical experience due to the limited clinic hours and the lack of faculty who are available to instruct them at the clinic. strategies to overcome these barriers include identifying other clinics in a 60-mile radius of the nursing school that provide primary care to rural residents who have online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 84 limited to no ability to pay and to enlist the help of health care professionals in other disciplines to ensure that the maximum number of baccalaureate students an opportunity to participate in this clinical. involving faculty from other disciplines not only increases the opportunity for more students to get clinical experience in a rural setting, it also provides them with valuable interprofessional education and increases their understanding of working within a team. however, the success of this experience is dependent upon faculty providing information about the clients they will see in the clinic, the challenges they face as rural residents in obtaining health care, and how the clinic operates. any faculty working with students in this type of setting must be knowledgeable of rural population health issues. these types of clinical experiences are imperative to prepare nurses in rural states, such as alabama, with a clear understanding of the health care needs in their state. conclusion schools of nursing have a responsibility to incorporate content related to social determinants of health and rural health into their curriculum and reinforce this content by providing nursing students with clinical experiences in which they can gain hands on experience providing care to rural residents. free clinics provide a vital service to underserved, rural communities, but often remain an underutilized site for nursing clinical education. nursing students exposed to underserved, rural populations are able to better understand the health needs of this population and consequently pursue serving this population after graduation. references online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 85 alabama rural health association (arha). (2013). selected health status indicators: pickens county. retrieved from http://www.arhaonline.org/data/health-status-reports/2013county-health-status-indicators-reports/ casimiro, l. m., hall, p., kuziemsky, c., o'connor, m., & varpio, l. (2015). enhancing patientengaged teamwork in healthcare: an observational case study. journal of interprofessional care, 29(1), 55-61. http://dx.doi.org/10.3109/13561820.2014.940038 coyle, s.b., narsavage, g.l.,. (2012). effects of an interprofessional rural rotation on nursing student interest, perceptions, and intent. online journal of rural nursing and health care, 12(1), 40-48. erkel, e. a., nivens, a. s., & kennedy, d. e. (1995). intensive immersion of nursing students in rural interdisciplinary care. journal of nursing education, 34(8), 359-365. garner, l. (2015). reducing barriers to healthcare for rural homeless individuals with families: experiences of community health nursing students. online journal of rural nursing & health care, 15(1), 4-6. http://dx.doi.org/10.14574/ojrnhc.v15i1.377 health resources and services administration (hrsa). (2016). hpsa find. retrieved from http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx lea, j., cruickshank, m., paliadelis, p., parmenter, g., sanderson, h., & thornberry, p. (2008). the lure of the bush: do rural placements influence student nurses to seek employment in rural settings? collegian, 15(2), 77-82. https://doi.org/10.1016/j.colegn.2008.02.004 richards, e.l., o'neil, e., jones, c., davis, l., & krebs, l. (2011). role of nursing students at rural nurse-managed clinics. journal of community health nursing, 28(1), 23-28. http://dx.doi.org/10.1080/07370016.2011.539086 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.439 86 united health foundation, (uhf). (2016). america's health rankings. retrieved from http://www.americashealthrankings.org/al u.s. department of agriculture (usda). (2009). rural definitions based on economic research service rural-urban commuting areas (ruca). retrieved from http://www.ers.usda.gov/datafiles/rural_definitions/statelevel_maps/al.pdf van hofwegen, l., kirkham, s., & harwood, c. (2005). the strength of rural nursing: implications for undergraduate nursing education. international journal of nursing education scholarship, 2(1). http://dx.doi.org/10.2202/1548-923x.1142 younge, o., ferguson, l., & myrick, f. (2006). preceptorship placements in western rural canadian settings: perceptions of nursing students and preceptors. online journal of rural nursing and health care, 6(2), 47-56. microsoft word tran_339-1960-1-ed_1.docx online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 42 do modifiable cardiovascular risk factors differ by rural classification in women who enroll in a weight loss intervention? dieu-my thi tran, phd, bsn, rn 1 carol h. pullen, college of nursing, edd, rn 2 lani m. zimmerman, phd, rn, faan 3 patricia a hageman, phd, pt 4 1 university of nebraska medical center, college of nursing, omaha, nebraska, dttran147@gmail.com 2 university of nebraska medical center, college of nursing, omaha, nebraska, chpullen@unmc.edu 3 university of nebraska medical center, college of nursing, lincoln, nebraska, lzimmerm@unmc.edu 4 university of nebraska medical center, division of physical therapy education, college of medicine, omaha, nebraska, phageman@unmc.edu abstract purpose: if clinicians and researchers are aware of specific cardiovascular risks associated with women's rural status, whether it be large or small/isolated rural areas, it may help in developing more relevant rural resources. the purpose of this study was to examine whether there were differences in modifiable cardiovascular risk factors of overweight and obese rural women living in large or small/isolated rural areas. sample: this secondary analysis examined baseline cross-sectional data from the "web-based weight loss and weight maintenance intervention for older rural women" clinical trial. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 43 analysis included data from 299 rural midwestern women, ages 40-69 years with a baseline body mass index of 28-45 kg/m2, who provided rural classification data and were randomized into groups. methods: demographic and biomarker baseline data were used. chi-square and independent ttests were used for data analyses. findings: there are no significant differences found in overweight and obese women with cardiovascular risk factors when compared to rural classification, with one exception. total cholesterol was associated with rural classification (p=0.047), where women living in large rural areas were more likely to have elevated total cholesterol levels ( 240 mg/dl) compared to women living in small/isolated areas (18.5% vs. 10.0%, respectively). demographic characteristics such as age and education demonstrated no significant differences by rural classification; however, the majority of women in this study were of high socioeconomic status. conclusions: although this secondary analysis found that rural women have similar cardiovascular risk factors and demographic characteristics, this study highlights the need for clinicians to carefully consider the rural community characteristics for primary prevention. keywords: cardiovascular risk factors, rural classification, middle-aged and older women. do modifiable cardiovascular risk factors differ by rural classification in women who enroll in a weight loss intervention? each year, 55,000 more women than men have a stroke (mosca et al., 2011), and the number of cardiovascular (cv) deaths among women continues to exceed those of men (kling et al., 2013). the american heart association (aha) statistics show that coronary heart disease online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 44 (chd) death rates of women in the united states (us) have increased over the past four decades (mosca et al., 2011). one in every four women died from heart disease (centers for disease control and prevention [cdc], 2013; however, women are still less aggressively evaluated and treated than men for cv disease (homko et al., 2010). major modifiable cv risk factors identified that are associated with cv disease mortality and morbidity include cigarette smoking, hypertension, diabetes, high total cholesterol, physical inactivity, and overweight or obesity. each additional risk factor can contribute significantly to the overall risk of chd (framingham heart study, 2013). consequently, evaluating cv risk factors in middle-aged and older women are warranted. rural women are more vulnerable compared to urban women because they have higher incidence of heart disease and diabetes, and their access to preventive health screening and services may be limited (feresu, zhang, puumala, ullrich, & anderson, 2008; hageman, pullen, walker, & boeckner, 2010). rural america is increasingly more reliant on industrialization of agriculture leading to fewer opportunities for physical activity (fahs et al., 2013). limited access and availability of healthcare such as specialty care, are well-documented as a disadvantage for the rural populations (crouch, wilson, & newbury, 2011; fahs et al. 2013; kim, sillah, boucher, sidebottom, & knickelbine, 2013). a large study of women (>10,000) enrolled in the nebraska wisewoman program revealed rural residence (defined as rural vs. urban) and socioeconomic status were factors related to cv disease risk (feresu et al., 2008). the authors jackson, doescher, jerant, and hart (2005) reported that obesity affected some rural residents disproportionately; whereby, the prevalence of obesity was highest in small rural areas while large rural areas’ prevalence of obesity was similar to urban areas. weierbach, yates, hertzog, and pozehl (2013) compared differences in health status and cardiac risk factors online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 45 between cardiac patients living in large and small/isolated midwestern rural areas, with findings that those living in small/isolated rural areas were less likely to participate in regular physical activity compared to those who live in large rural areas. these studies suggest that there may be differences in cv risk among women by rural classification, though the literature on this remains unclear. in addition, rural classification has been defined in these studies using different methods (feresu et al., 2008). there are several taxonomies available for defining rural classification. the rural urban commuting area (ruca) codes that use zip code health-related data are widely used for policy and research purposes (hart, larson, & lishner, 2005). the ruca codes are created in part by the u.s. department of agriculture’s economic research service (hart, et al., 2005). the four category classification of ruca defines urban (> 50,000 residents), large rural (10,000-49,000 residents), small rural (2,5009,999 residents), or isolated rural (< 2,499 residents) based on the us census bureau’s definitions of urbanized areas and urban clusters, which in turn rely on complex criteria, including population density and population work commuting patterns (hart, et al., 2005). knowledge about any cv risks associated with women’s rural status may help nurses and researchers in developing health resources relevant to their rural patients/clients, whether in large or small/isolated areas. weierbach et al. (2013) focused on cv risk factors in patients/clients post-cardiac surgery, noting that future research should focus on an appreciation of cv risk characteristics of rural communities for designing appropriate wellness and cv risk reduction program. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 46 the purpose of this study was to examine the frequency of modifiable cv risk factors of overweight or obese women who volunteered for a web-based weight loss intervention by ruca-defined rural classifications of large rural and small/isolated rural areas. this study holds the following two aims: 1. to describe cv risk factors of overweight or obese rural women. 2. to examine difference in demographics characteristics (age, marital status, education, household income and insurance) and modifiable cv risk factors (total cholesterol, diabetes, physical activity, cigarette smoking, blood pressure, and overweight/obese) by rural classification, either large and/or small/isolated. methods this secondary analysis used baseline data of overweight/obese rural middle-aged and older women, ages 40-69, who consented to participate in the 30-month “web-based weight loss and weight maintenance intervention for older rural women” clinical trial, (clinicaltrials.gov identifier: nct0130766). briefly, the clinical trial was a community-based randomized controlled trial designed to evaluate the effectiveness of three theory-based webdelivered interventions for promoting healthy eating and activity among rural middle-aged and older women in sixteen counties in northeast nebraska, in order to achieve a 5-10% weight loss and weight maintenance over a 30-month period. the rural women in the parent study were randomized into three groups: the interactive website only, interactive website with a peer-led online support group or interactive website with professional weight loss counseling through email. women were included in the clinical trial if they were overweight/obese with a body mass index (bmi) between 28 and 45, committed to losing weight through dietary changes and physical activity, and capable of walking without any assistive device for one mile. women online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 47 were excluded if they had any physical or medical restrictions to perform moderate physical activity. exclusion criteria included women who were diagnosed with type i diabetes mellitus or were insulin dependent with type ii diabetes mellitus. further details of the parent study design and population sample of the clinical trial have been presented elsewhere (hageman, pullen, hertzog, boeckner, & walker, 2011). of 301 women who completed baseline data and were randomized into groups in the clinical trial, 299 women provided information for accurate identification of ruca codes and were included in this analysis. study variables demographic. demographic information collected from women included age, marital status, education, insurance status, household income, and rural classification. age was classified into three categories: 40-49 years, 50-59 years, and 60-69 years. marital status was classified into two groups as married and not married. education was classified into three categories: high school graduate or less, some college or college graduate, and graduate school or greater (completed some or completed graduate or professional degree). insurance status was classified as “yes” or “no.” income was classified into five categories, below $39,999, $40,000 to $59,999, $60,000 to $79,999, $80,000 to $99,999, and $100,000 or more (20 women refused to report). rural status was classified based on the ruca codes, and were categorized into two groups, either large rural or small/isolated rural for this study (hart et al., 2005). modifiable cardiovascular risk factors. this study examined total cholesterol, diabetes, cigarette smoking, overweight or obesity, high blood pressure, and physical activity, all modifiable cv risk factors for cv disease (framingham heart study, 2013; go et al., 2013). after a 12 hour fast, blood specimens were collected from women to determine total cholesterol online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 48 utilizing the laboratory standardization panel recommendations. total cholesterol was defined based on the national cholesterol education program adult treatment panel iii (ncep atp iii) as < 200 mg/dl is desirable, between 200 to 239 mg/dl is borderline high and as ≥ 240 mg/dl is high (2002). diabetes was self-reported by the participants with “yes” or “no” of having diabetes. smoking status was self-reported by the participants with “yes” or “no” if they are current smokers. weight and height data were used to determine bmi defined as kg/m2, where overweight bmi = 25 to 29.9 kg/m2, obese class i = bmi 30 to 34.9 kg/m2, obese class ii = bmi 35 to 39.9 kg/m2 and obese class iii was ≥ 40 kg/m2 (go et al., 2013). blood pressure was measured after 5 minutes of quiet sitting using a standardized method. a minimum of two blood pressure measurements were obtained and the mean of the two measurements were recorded. blood pressure was defined as normal (sbp ≤ 120 mm hg or dbp ≤ 80 mm hg), prehypertension (sbp between 120-139 mg hg or dbp between 80 to 89 mm hg), or hypertensive (sbp ≥ 140 mm hg or dbp ≥ 90 mm hg) (national heart, lung, and blood institute, 2004). women were asked about their participation in physical activity using the behavioral risk factor surveillance system (brfss). the brfss consists of a 7-item selfreport instrument that determines the women’s physical activity participation defined by the u.s. department of health and human services (cdc, 2011). using women’s responses, physical activity was classified as being active ( ≥ 500 met·min·wk-1) or not active ( < 500 met·min·wk-1) from the brfss survey data using the calculation method defined by morrow, bain, frierson, trudelle-jackson, and haskell (2011). the cut score of ≥ 500 met·min·wk-1 was used to distinguish women who were active versus non-active as activity ≥500 met·min·wk-1 has been associated with having substantial health benefits (u.s. department of health and human services, 2008). online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 49 data analysis descriptive data were summarized by rural classification, either large and/or small/isolated. since the small and isolated rural were similar in demographic characteristics along with small sample size individually, they were combined for analysis. the comparison of proportions of modifiable cv risk factors (total cholesterol, diabetes, physical activity, cigarette smoking, blood pressure, and overweight/obese) and demographic characteristics (age, marital status, education, household income, and insurance) were all dichotomized by rural status and analyzed with chisquare tests. independent t-tests were also used to compare mean differences by rural classification with total cholesterol level, blood pressure and age as continuous variables. data were analyzed using ibm spss version 20. the level of significance was established if the p value was < 0.05. findings key findings are included in table 1. of the 299 overweight and obese women in the weight loss study, their mean bmi was 34.8 kg/m2 with 10.7% overweight and 89.3% obese. the majority of these women were married, had some type of college education, had insurance coverage, had a household income between $40,000 to $79,000, and had a mean age (standard deviation) age of 54 (6.8) years. demographic characteristics such as age, education, and household income demonstrated no differences between the two rural classification groups; however, marital status (p = 0.055) and health insurance (p = 0.053) were marginally associated with living in large vs. small/isolated rural for overweight/obese women. overweight/obese women living in small/isolated area were more likely to be married (89.1% vs. 81.5%) and have health insurance (97.3% vs. 92.1%) compared to overweight/obese women living in large rural area. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 50 analysis using the chi-square test revealed no significant differences proportions of modifiable cv risk factors between women from large rural and small/isolated rural areas, with one exception. total cholesterol was associated with rural classification (p = 0.047), where women living in large rural areas were more likely to have elevated total cholesterol levels ( ≥ 240 mg/dl) compared to women living in small/isolated area (18.5% vs. 10.0%, respectively). few women from either rural classification were diabetic or smokers ( < 5%). analysis of mean differences using independent t-tests showed no differences by rural classification for continuous variables. when examining the cv risk profile (elevated cholesterol, diabetes, cigarette smoking, hypertension and overweight/obese), of the 299 rural women, 42.1% (n = 125) had one cv risk factor, 48.8% (n = 146) had two cv risk factors, 7.7% (n = 23) had three cv risk factors, and 1.0% (n = 3) had more than four cv risk factors. table 1 demographic characteristics and cv risk factors in overweight / obese women weight loss study large rural n =189 (%) small/isolated rural n =110 (%) p-value demographic age 0.672 40-49 55 (29.1%) 28 (25.5%) 50-59 98 (51.9%) 57 (51.8%) 60-69 36 (19.0%) 25 (22.7%) marital status 0.081 married 154 (81.5%) 98 (89.1%) not married 35 (18.5%) 12 (10.9%) education 0.853 high school graduate or less 28 (14.8%) 19 (17.3%) some college or college graduate 115 (60.8%) 65 (59.1%) graduate school or greater 46 (24.3%) 26 (23.6%) household income 0.162 below $39,999 31 (16.4%) 20 (18.2%) online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 51 $40,000 $59,999 48 (25.4%) 29 (26.4%) $60,000 $79,999 45 (23.8%) 27 (24.5%) $80,000 $99,999 31 (16.4%) 20 (18.2%) $100,000 or more 24 (12.7%) 4 (3.6%) have insurance 0.053 yes 174 (92.1%) 107 (97.3%) no 15 (7.9%) 3 (2.7%) modifiable cv risk factors total cholesterol 0.047 desirable (<200 mg/dl) 104 (55.0%) 57 (51.8%) borderline (200-239 mg/dl) 50 (26.5%) 41 (37.3%) high (≥ 240 mg/dl) 35 (18.5%) 11 (10.0%) diabetes (yes) 9 (4.8%) 5 (4.5%) 0.932 physical activity (inactive <500 met·min·wk-1) 121 (64.0%) 75 (68.2%) 0.465 cigarette smoking (yes) 8 (4.3%) 4 (3.6%) 0.527 blood pressure 0.486 normal 82 (43.3%) 40 (36.4%) prehypertension 83 (43.9%) 55 (50.0%) hypertension 24 (12.7%) 15 (13.6%) overweight/obese 0.214 overweight (bmi 25-29.9) 17 (9.0%) 15 (13.6%) obese class i (bmi 30-34.9) 86 (45.5%) 56 (50.9%) obese class ii (bmi 35-39.9) 56 (29.6%) 29 (26.4%) obese class iii (bmi over 40) 30 (15.9%) 10 (9.1%) abbreviations: ruca, rural urban commuting area; cv, cardiovascular discussion few studies have examined the frequency of modifiable cv risk factors of healthy overweight or obese women by ruca-defined rural classifications of large rural and small/isolated rural areas. findings revealed that there were no differences in modifiable cv risk factors between the two rural classifications among midwestern women motivated to volunteer for web-based 30-month weight loss and weight maintenance interventions, except in measures of total cholesterol where a higher percentage of women living in large rural areas had an elevated total cholesterol ( ≥ 240 mg/dl) than women living in small/isolated rural areas. while the results were not significant between groups, women from small/isolated rural areas online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 52 were most likely to participate in physical activity compared to women from large rural, 68.2% and 64.0%, respectively. in general, the rural women residing in the two different rural classifications had similar cv risk factors and demographic characteristics. our findings are consistent with weierbach et al. (2013) who compared differences in health status and cardiac risk factors between cardiac patients in large and small/isolated ruca-defined rural areas. weierbach et al. (2013) noted no differences in smoking, blood pressure, diabetes, or overweight/obese between the large vs. small/isolated rural with the exception that physical activity was higher among residents in large rural areas (p = 0.05). our study found that more than 50% of the rural women had more than two cv risk factors. comparison of our findings with those of others is difficult due to the differences in populations, definitions of rural status, and/or methods used. the work of feresu et al. (2008) examined a population of women ages 40 or older, of which 70% were identified as rural and from a similar geographic area to women in our study. the nebraska wisewoman findings showed women having higher baseline percentages of total cholesterol ( ≥ 200 mg/dl), smoking, and diagnosis of diabetes ( > 50%, 26%, and 10%, respectively) than women in this study. our findings on total cholesterol levels in large rural overweight and obese women are similar to feresu et al. (2008), who found 19.8% had elevated total cholesterol. differences between the two studies may be attributed to socioeconomic status, as the women volunteers in this study were of high socioeconomic status whereas the women in nebraska wisewoman had lower socioeconomic status to participate. possible reasons for our findings that few women smoked might be that smokers may be less likely to volunteer for eating and activity interventions. compared to national data, the prevalence of elevated total cholesterol levels in americans greater than or equal to 240 mg/dl is 13.8%, in contrast, our sample of women from online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 53 small/isolated rural had frequency of 10.0%. however, a higher percentage of our women from large rural areas had an elevated total cholesterol compared to the aha statistics (18.5% vs. 13.8%, respectively) (go et al., 2013). only 36.0% of women from large rural areas and 31.8% from small/isolated rural areas in this study were considered active ( ≥ 500 met·min·wk-1). this is in contrast to the work of morrow et al. (2011), who investigated the physical activity levels of community-living women, who were ages 20 and older, mean age of 68, with findings that 63% engaged in sufficient physical activity (≥500 met·min·wk-1), and 64.5% of women reporting engaging in this level of activity in brfss (u.s. department of health and human services, 2008). in addition, it was reported by the cdc (2014) that physical inactivity is higher in women compared to men, ages 18 and older, age adjusted, and women were less likely to meet federal physical activity guidelines compared to men (go et al., 2013). this secondary analysis has several limitations that should be considered. first, the sample is based from sixteen nebraska rural communities; therefore, generalizability is limited. secondly, the rural women participated voluntarily in the web-based weight loss interventions; therefore, they may differ than the general population as they might have been more motivated to lose weight through physical activity and diet modification over a 30 month period. in addition, the overweight and obese rural women in this study were highly educated, they reported a moderate to high household income and reported having health insurance. more than 50% of women citing a household income more than $60,000 per year and more than 80% of women had some type of college education or higher; therefore, these women were not representative of the general populations. socioeconomic status has been raised as an issue by feresu et al. (2008), who noted that even among women of low socioeconomic status, those who were at the online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 54 lowest end were more likely to have high cv risk and were less likely to return for follow-up screenings or counseling. lastly, women with diabetes who were insulin dependent were excluded from the parent study, which may explain our findings of low percentages of women with diabetes. despite these limitations, this secondary analysis provides follow-up to the recommendations of weierbach et al. (2013) for the need to investigate demographic characteristics and cv risk factors of women in large vs. small/isolated areas, to address health promotion such as weight loss. in addition, exploring possible factors that may contribute to cv risk factors in overweight and obese women in different rural areas may assist with tailoring specific interventions that are relevant to rural women. conclusions and implications both large and small/isolated rural women had similar cv risk factors. total cholesterol, hypertension, overweight/obesity, and physical activity were in need of risk factor modification among this well-educated group of women. as the women in this study were not representative of the general population of women from large and small/isolated rural areas, whether differences in the classification of rural exist remains inconclusive. this research reinforces the need for researchers and practitioners to assess the characteristics and the needs of a given community, whether rural or urban in order to tailor appropriate and effective interventions for cv risk reduction. in addition to this research, there are still very few studies examining cv risk factors through rural classification. larger scale research studies are warranted to examine rural women with cv risk factors in different geographic areas with the ability to generalize to the general population as a whole. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.339 55 although, there were only few significant findings in our study, it is important to disseminate these results since so little is known in this area. the value of reporting nonsignificant findings are for the purpose of not wasting the scientific community time and resources repeating the same findings (matosin, frank, engel, lum & newell, 2014). overall, cv disease remains the number one cause of death for women in the us. several programs and initiatives such as the center for disease control and prevention, the million hearts, the american heart association, and the u.s. department of health and human services, set priorities to focus on health promotion, prevention, treatment and management of cv disease. specifically, the healthy people 2020 goal is to “improve cv health and quality of life through prevention, detection and treatment of risk factors for heart attack” (u.s. department of health and human services, healthy people 2020, 2011). in order to move toward better cv health, vulnerable population from rural areas should be targeted using evidence-based practice. nurses who practice in rural communities should include cv risk assessment in their routine care and take an active role in cv health promotion and prevention to reduce cv disease. supporting agencies acknowledgement: the authors extend appreciation to paul dizona, a data analyst at the university of medical center college of nursing, for his guidance with the dataset. this study was funded by nih ninr grant no 1r01nr010589, with supplemental funding from a research support fund from the nebraska medical center and the university of nebraska medical center. references centers for disease control and prevention. 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(2011). heart disease and stroke: overview. retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid=21 weierbach, f. m., yates, b., hertzog, m., & pozehl, b. (2013). differences and similarities in rural residents’ health and cardiac risk factors. online journal of rural nursing and health care, 13(1), 26-49. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 86 rural nursing and evaluation of pediatric outreach program cory risse, mn, rn 1 jo ann walsh dotson, phd, rn 2 denise smart, drph, mph, rn 3 debbie brinker, msn, rn 4 1 instructor, college of nursing, washington state university, risse@wsu.edu 2 assistant professor, college of nursing, washington state university, joann.dotson@wsu.edu 3 associate professor, college of nursing, washington state university, dsmart@wsu.edu 4 clinical assistant professor and director of experiential learning, college of nursing, washington state university, dbrinker@wsu.edu abstract introduction: rural nurses face barriers and challenges in obtaining continuing education, which contribute to the challenge of maintaining competency while working in a setting that expects proficiency in low volume, high risk procedures. purpose: the purposes of this project were to 1) examine the literature related to pediatric care delivery in rural health care settings and continuing education needs of rural nurses and effective education strategies and 2) analyze the effectiveness of a pediatric outreach program’s educational and professional development interventions (transforming inpatient care and culture [ticc]) in a rural hospital in washington state. methods: the literature review employed key words to search databases on the topics of “rural nursing”, “continuing education”, “outreach”, “pediatrics”, and related concepts. evaluation of online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 87 the ticc project consisted of comparing pre and posttest results from a 40 item questionnaire for those who participated in the ticc project following an 8 hour training session. participants included 66 nurses who participated in the training at the hospital and completed the post test. the means of overall and topic specific pre and post test results were examined. results: there was statistically significant improvement in overall pre to post test performance (p = .005) and in one of the three priority areas, synthesis of care decisions (p = .028). there was also improvement in test performance on the two remaining priority areas, knowledge of equipment and interventions and pediatric specific assessment, although the improvement did not reach statistical significance. conclusion: a rural pediatric outreach program can be an efficient and effective way to address the continuing education needs of rural nurses in a hospital setting. the project serves as a guide for identifying and addressing the pediatric educational needs of nurses, while empowering the very nurses who care for patients in the facility to be part of the leadership and innovation process. the implementation of a pediatric outreach program could be instrumental in improving pediatric patient care in the rural setting. keywords: rural nursing, continuing education, nursing competency, pediatrics, change leadership. rural nursing and evaluation of pediatric outreach program significant differences exist between urban and rural communities that have a direct impact on health care. according to the united states (u.s.) census bureau, urban is defined as areas that house populations of 50,000 or more people and urban clusters are described as areas that house populations of at least 2,500 and less than 50,000 people. rural is defined as all population, housing, and territory not included within urban areas (u.s. census bureau, 2010). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 88 approximately 20% of the us working nurse force is employed in rural settings, accounting for more than 2.6 million nursing positions (u.s. bureau of labor statistics, 2011). rural hospital nurses function in a generalist role and require an extensive skill set since they have the potential to work in all healthcare disciplines and provide care for all age groups and acuity levels during a work day (molinari, monserud, & hudzinski, 2008). it is important that hospital nurses in rural settings possess wide-ranging assessment skills, the ability to identify potential issues, and the ability to respond to emergencies with proficiency (jukkala, henly, & lindeke, 2008). hospital nurses in rural settings have the responsibility of maintaining competency while working in an environment that expects proficiency in low volume, high risk procedures (banks, gilmartin, & fink, 2010). continuing education that is accessible and appropriately matched to the health care setting is important for rural nurses (mccoy, 2009). access to educational activities is a crucial element that contributes to nurse retention in remote and rural regions (mbemba, gagnon, pare & cote, 2013; baernholdt & mark, 2009). educational support can cultivate clinical competence and enhanced patient outcomes (schmalenberg et al., 2008). developing and delivering continuing education to the rural nursing community is vital to safe patient care (wolf & delao, 2013). rural nurses face barriers and challenges in obtaining continuing education beyond those facing urban and suburban nurses. recent studies identified (a) long travel times, (b) expense of overnight stays, (c) issues with staff scheduling, and (d) general cost and lack of time for on-site educators to address advanced staff education beyond mandatory agency requirements as barriers to continuing education by nurses in rural hospitals (jukkala et al., 2008; fitzgerald & townsend, 2012; mccoy, 2009). in addition to the barriers inherent to rural nurses’ general educational needs, responsibility of caring for all ages of clients, including infants and children, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 89 adds another competency challenge. pediatric patients have very different diseases, injuries, and distinctive physiologic and emotional responses to illness and injury, requiring unique approaches to care compared with adults. nurses who have the potential to work with pediatric patients must retain an appropriate level of expertise when caring for this unique population. nurses are uniquely positioned to observe and interpret the impact of systems, policies, and practices on patient care. in order for nurses to effectively lead efforts to improve patient care, they need educational opportunities on the topic of change and health care transformation. this type of work requires a new professional skill set that will allow nurses to be effective leaders of change. this skill set requires special training, which poses an issue for rural nurses since they practice in an environment that contains many barriers to educational and professional development. in an attempt to grow staff nurses’ leadership to optimize outcomes in their hospitals in washington state, an initiative, titled “transforming inpatient care and culture” (ticc), was created and piloted in 2011. the project was proposed to the northwest organization of nurse executives (nwone) board by their chief executive officer (ceo). the project was modeled after the transforming care at the bedside (tcab) campaign, which was developed by the robert wood johnson foundation (rwjf) and institute for healthcare improvement (ihi) to support front-line nurses to create and carry out inventive new practices on their units. tcab encourages nurses to identify the needs in their own work units and to create and implement site appropriate solutions. anticipated outcomes of the “bottom up” approach include improved patient safety and nurse job satisfaction (rwjf, 2011). the ceo of nwone worked with representatives from washington state hospital association and formed a partnership with multiple hospitals, including rural, critical access online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 90 hospitals. this partnership created the ticc project, which was formed to evaluate and address priority change initiatives to optimize outcomes in care. the nurses and administrators of one rural hospital identified pediatric care as their priority initiative, since 45% of their patient population were pediatric clients. with the collaboration and guidance of clinical nurse specialist consultants, staff nurses conducted an assessment of their hospital’s policies and procedures and surveyed providers and staff nurses regarding their confidence/comfort in nurses’ abilities. based on findings, they identified the specific educational needs of the staff nurses who care for pediatric patients. the ticc project included an educational needs assessment, development of education interventions based on the results of the needs assessment, and pre and post knowledge testing in order to measure the effectiveness of the educational interventions. integral to the process was engaging and empowering the hospital nurses to be part of the needs assessment process and the creation of educational interventions. this ticc project was piloted with the intention of using lessons learned to create a professional outreach program that could enhance pediatric nursing skills and competency for use in rural healthcare settings in washington state. nwone did not seek human subjects review for the project as it was an evaluation of the transformation project and was not a research project. the evaluation reported here was a secondary analysis of aggregated data with no identifiers or demographic information. purpose statement the purpose of this paper is to analyze the effectiveness of the ticc project’s educational and professional development interventions implemented in the rural hospital setting. conceptual framework the american association of critical-care nurses (aacn) synergy model for patient care is a patient-centered model that concentrates focus on the needs of the patient, the online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 91 competencies of the nurse, and the synergy created when those needs and competencies align (aacn, n.d. a). an important belief of this model is that the patient characteristics are essential to nurses, and nurse characteristics are essential to patients (kaplow, 2003). this model was originally formulated by a group representing the aacn to provide a theoretical framework for certified practice (swickard, swickard, reimer, lindell, & winkleman, 2014). since its inception in the 1990s and publication by dr. martha curley, the model has been applied to a variety of clinical and academic environments and used in various circumstances and for a range of purposes (curley, 1998; kaplow, 2003; swickard et al., 2014). the model seeks to define nursing beyond a set of tasks and instead describes nursing through more complex characteristics and competencies (swickard et al., 2014). synergy is a process that occurs when individuals interact in ways that promote positive outcomes. the core idea involved in the aacn synergy model for patient care is that the needs or characteristics of patients and families inspire and steer the characteristics or competencies of nurses (kaplow & reed, 2008). when the needs of the patient are matched with the characteristics and skills of the nurse, synergy occurs and patient outcomes are optimized. see figure 1 for a visual representation of the rural nurse patient synergy model. search strategies a literature search was conducted by using the computer databases cinahl and pubmed. the key words included “rural nursing”, “continuing education”, “professional development”, and “pediatrics”. the articles were assessed for applicability to the problem statement and purposes of the paper. the search yielded 20 articles from peer reviewed journals, most within the last eight years. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 92 figure 1 rural nurse patient synergy model originally published in: curley, m. a. (1998). patient-nurse synergy: optimizing patients' outcomes. american journal of critical care: an official publication, american association of critical-care nurses, 7(1), 64-72. modified with permission from the american association of critical-care nurses (aacn). literature review issues with pediatric care delivery in rural health care settings equipment and policies. rural health care settings that offer services to pediatric clients must have both adequately trained staff and a work environment that is prepared to meet the needs of pediatric patients. adherence to guidelines for pediatric emergency department online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 93 policies, procedures, supplies, and equipment was evaluated in a survey of 70 urban and rural hospitals in kentucky (costich, fallat, scaggs, & bartlett, 2013). the authors reported that about half of kentucky healthcare facilities had most (≥85%) of the recommended sized catheters and endotracheal tubes. rural facilities did not stock the smallest equipment sizes (i.e. of masks and endotracheal tubes) because of a reportedly low volume of pediatric patients, and less than 25% of responding hospitals had policies in place to guide pediatric emergency department admissions. pain management. another common pediatric issue occurring in rural health care settings is the non-adherence to pain management protocols. the frequency with which evidence-based pediatric pain management (ebppm) is practiced in emergency departments (ed) was evaluated in the rural state of iowa (kleiber, jennissen, mccarthy, & ansley, 2011). kleiber et al. surveyed 259 licensed medical providers and 1,117 nurses from 118 eds to determine the frequency of application of ebppm in emergency departments and differences based on type of facility (critical access (ca), rural, and urban hospitals) across the state. the authors noted that nurses from urban eds used significantly more ebppm (p < .001) than nurses practicing at rural hospitals or critical access facilities. continuing education needs of rural nurses and effective education strategies important continuing education topics. an investigation involving both novice and expert nurses (n = 106) who practiced in a rural setting revealed common feelings of unpreparedness regarding patient care, specifically in the areas of trauma, neurology and pediatrics (molinari, jaiswal, & hollinger-forrest, 2011). in the same study, nurses who felt unprepared to manage crises were also significantly more likely to report planning to move away from the rural setting (an indicator for nurse turnover) (p < 0.03). a similar study found that online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 94 rural hospital nurses (n=302) working in both hospitals and long term care facilities (ltc) in the midwest us reported a need for enhancing their knowledge of commonly treated clinical conditions, including pediatric related conditions such as diabetes, infectious diseases, pulmonary conditions and fluid balance (fairchild et al., 2013). the nurses also identified continuing education topics, including drug therapy, physical assessment, medication administration, mental status assessment, communication skills, environmental safety assessment, and health history. continuing educational delivery strategies. simulation is an increasingly popular mechanism to use in health professional continuing education, and is especially useful in rural settings. an example is the american heart association pediatric emergency assessment, recognition, and stabilization (pears) course. registered nurses (n = 19) working in a metropolitan magnet hospital, who participated in a pears course had a statistically significant improvement (p = .012) in respiratory-focused skill performance using the pears high fidelity simulation modified behavioral check-off tool compared to nurses (n = 14) who participated in the usual pears course (bultas, hassler, ercole, & rea, 2014). another example was a high fidelity simulation developed to increase nursing competency regarding pediatric respiratory distress assessment for nurses in a 58 bed rural hospital. pre and posttest change demonstrated significant improvement in self-reported nursing competence and confidence (p= .000) following nurses’ participation in the simulation exercise (wodrich, gilmartin, & fink, 2013). multifaceted educational intervention, using a combination of didactic and clinical learning methods offers an array of teaching/learning experiences which may better serve individual learning styles. for example, banks et al. (2010) studied 146 nurses who worked in a 58-bed u.s. rural hospital. an educational intervention developed to improve competence with central online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 95 venous access device (cvads) care, utilized: 1) self-study modules; 2) mini lectures and hands on practice in the skills lab; 3) attendance at nursing grand rounds; 4) access to cvad hospital policy and procedure materials; and 5) optional participation in a journal club. performance test scores (higher = better) on the pre-test were 69.83% (sd = 10.91%). the 1st posttest (immediately after the intervention) was 79.93% (sd = 10.19%) and the 2nd posttest (1 month after the intervention) was 84.95% (sd = 8.75). statistically significant improvements in test scores were shown between the pretest and 1st posttest (p < .001) and between the 1st and 2nd posttest (p < .037). educational programs aimed to support rural nurse continuing education evaluating and learning from preexisting educational programs can help us understand how to plan and implement continuing education to most efficiently meet the needs of rural nurses. the emergency nurse partnership program (enpp) of west virginia university (wvu) was created to bring continuing education to rural hospital emergency department nurses (paulson, 1996). enpp program members and wvu hospital leaders collaborated with rural hospital staff and performed a needs assessment of priority staff learning needs, which led to the development and delivery of a specific curriculum for staff nurses on the topics of cardiology, drug calculations, medicolegal, pediatric respiratory disorders, trauma, and triage. pre and posttests were used to assess change in nurse knowledge on the topics; pretest average was 63%, compared to average post test scores of 81%, documenting improved nursing knowledge. another successful program is the partners in nursing (pin) program that was supported by a the rwjf and northwest health foundations grant, intended to address issues related to the nursing shortage in local communities located in maryland (cottingham, dibartolo, battistoni, & brown, 2011). clinical and academic partners created a program that paired new graduates online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 96 with experienced nurse mentors in order to help the new graduate nurse transition to the professional role, as well as to establish leadership training. 100% retention rate of all pin participants in the second year of the program was a positive finding. staff nurses identifying and leading change initiatives to impact patient care staff nurse involvement and leadership is an important component of the synergy that can affect patient outcomes. one example of an effective program is the aforementioned tcab, which was funded by the rwjf and the ihi. through the tcab process, nurses gain the skill set needed to be future implementers of the tcab process, which encourages the sustainability of the program. curriculum is framed in four principles: safe and reliable care, vitality and team work, patient-centered care, and value-added processes. successful projects from tcab hospitals include rapid assessment teams, preceptor programs, and liberalized patient diet plans. tcab inspired change in the university of pittsburgh medical center (upmc) shadyside in pittsburgh, pennsylvania resulted in a ripple effect that spread to other hospital systems (martin et al., 2007). tcab initiatives have focused on improving patient/client/staff communication by writing staff names at the bedside each shift, extending hours/options for dietary services, offering a free discharge van transportation service, and medication room redesigns. these and other tcab initiatives have resulted in documented positive outcomes including reduced voluntary rn and advanced practice nurse turnover, decreased patient harm from falls, and increased direct nursing care to patients. understanding the key learning needs of rural nurses and understanding interventions and approaches to improve nursing care delivery is important for improving patient care. the array of issues with pediatric care delivery in rural health care settings exemplifies the need for educational intervention. identifying effective educational strategies is crucial in order to plan online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 97 meaningful and efficient continuing education activities. educational programs and processes that use nursing staff to identify and lead change initiatives can be helpful to use as a guide to make patient care improvements. the evidence presented in this literature review supports the efforts made by the ticc project in a rural hospital in washington state and will be further discussed. transforming inpatient care and culture (ticc) project as mentioned previously, in 2011, nurses at a rural hospital in washington state voiced their concern about the competence and confidence of nurses caring for pediatric patients. hospital administrators reported that the pediatric population comprised 45% of the total patient population in the prior year, providing evidence for the significant need to assure nursing staff competence with the population. hospital administrators sought guidance from representatives from nwone and the washington state hospital association (wsha) to support the development of pediatric competencies in their nursing staff. the project was supported by grant funding from wsha, nwone, and the washington workforce. a team of pediatric clinical nurse specialists recruited by nwone and wsha collaborated with staff nurses and administrators from the hospital transforming inpatient care culture (ticc) team. the purpose of the team was to assess, design, implement, and evaluate a plan to enhance nurses’ knowledge and comfort with pediatric patients. with guidance from the clinical nurse specialists, the ticc team staff nurses were the unit champions to design, survey, and plan interventions to optimize pediatric care in their areas. setting the 25-bed critical access hospital is located in a town in south central washington, and has an estimated population of 16,140 (u.s. census bureau, 2015). the hospital offers online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 98 emergency care, intensive care, a family birth center, surgical services, magnetic resonance imaging, laboratory, 3-d obstetrical ultrasound, cardiopulmonary services, registered dietician services, and diabetic education services. the hospital accepts pediatric patients aged one day, including newborns, to 18 years of age. pediatric patients are cared for in the emergency department, medical-surgical units, and intensive care unit. approximately 45% of the hospital’s patients were aged 18 or younger during the 2010 year. intervention design and development the ticc team started its work by developing and conducting two surveys. the first assessed provider’s confidence in nurses’ knowledge and competency with specific types of pediatric patient care, and the second assessed staff nurses’ comfort level and knowledge of pediatric care. the ticc team evaluated survey data and identified priority areas of concern including pediatric specific assessment skills, knowledge of equipment and interventions, and synthesis of care decisions (putting it all together). the pediatric basic knowledge assessment test (bkat) and pediatric emergency assessment, recognition and stabilization (pears) tests were revised and combined to create an assessment of nursing knowledge regarding the priority areas (runton & toth, 1998; famolare & romano, 2013). the test consisted of 40 multiple choice questions in the three general areas of focus identified above. examples of test questions by priority area are included in table 1. the test was administered to 44 staff nurses to establish baseline pediatric knowledge and further guide educational intervention development. an 8-hour educational day was constructed and delivered with the assistance of hospital physicians, a medical resident, staff nurses, the nurse educator, pharmacists, respiratory therapists, and external pediatric consultants. the education day consisted of both large group lectures and small group breakout sessions. the large group lectures addressed the topics of online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 99 pediatric assessment, trauma/shock, pain/medications, children with special health care needs, and putting it all together (synthesis). the small group breakout sessions focused on the topics of respiratory, circulation, pain, and trauma issues. table 1 example knowledge test questions priority area test question number and stem text pediatric specific assessment 6. which are components of increased work of breathing in a child with respiratory distress? 23. which of the following signs and symptoms is a possible indication of hypoglycemia in an infant? knowledge of equipment and interventions 10. a child has a 3.0 mm tracheostomy tube in place. what size catheter should be used to suction the tracheostomy tube? 16. which needle and site is recommended for administering intramuscular immunizations to a 4 month old infant? synthesis of care decisions (putting it all together) 29. an infant’s parents tried to treat her gastroenteritis at home by feeding regular tap water before bringing her to the hospital. which associate electrolyte imbalance would most likely be observed in the laboratory analysis? 35. a pale and obtunded 3-year-old child with a history of diarrhea is brought to the hospital, respirations are 45 breaths/min. with no distress and good breath sounds bilaterally. heart rate is 150 bpm and bp is 88/64 mm hg. capillary refill time is 5 seconds, and peripheral pulses are weak. after placing a 10 l/min flow of 100% oxygen and obtaining vascular access, which of the following is the most appropriate immediate intervention for this child? educational approaches in the small group breakout sessions included use of low and medium fidelity simulation scenarios, educational posters, equipment training, and hands-on skill practice. hospital specific equipment and patient scenarios were incorporated into the training sessions. the training was offered two different days, to ensure participation by all the nursing staff. sixty-six attendees completed a post-test at the end of the educational intervention. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 100 the assessment of the educational priorities not only informed the development of the training, but also identified administrative and policy issues. in response, the ticc team purchased the aacn procedure manual for pediatric acute and critical care for each unit and helped the team revise and/or create pediatric policies and procedures, identify equipment needs, and develop recommendations for pediatric quality improvement projects for the rural hospital. some of the recommendations are summarized in table 2. table 2 pediatric quality improvement project recommendations 1. a mandatory skills day to be held twice a year, with one of the stations being related to pediatric competencies. 2. a monthly pediatric competency to be posted on the rural hospital intranet for nursing staff to complete. 3. a pediatric module to be completed on the rural hospital’s computer learning system annually. 4. the emergency nursing pediatric course (enpc) to be required for all intensive care unit, surgical, and emergency department nurses. charge nurses on the medicalsurgical unit will also be required to pass the course. family birth center nurses will be required to complete the neonatal resuscitation program (nrp). 5. pediatric “lunch and learns” to be offered periodically for nursing staff on topics such as asthma management, respiratory disorders, and diabetes. 6. a mandatory skills day to be held twice a year, with one of the stations being related to pediatric competencies. recommendations also included an annual survey of providers and staff nurses which would be used to identify emerging educational topics that would help to sustain staff knowledge, competency, and confidence regarding provision of pediatric patient and family care. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 101 evaluation the goals of the hospital staff and leadership, along with the project partners, were to use the pretest and posttest data to inform immediate education plans and to improve existing policies and future training. the differences between pre and posttest scores were used, along with qualitative data, to assess the effectiveness of training. as stated earlier, the pretest included 40 questions, and was completed by 44 staff nurses prior to the educational intervention. the posttest, consisting of the same questions, was completed by 66 nurses after the educational intervention. analyses were limited to 38 of the 40 questions, as two questions were miscoded. no demographic data or identifiers were collected with the pre or posttest, and only the aggregated data for the number of respondents answering each question correctly were recorded and available for analysis. therefore, the unit of analysis for the comparison of the pre and posttest results was the percentage of respondents who correctly answered each question. averaging across the 38 questions, the percentage of correct responses before and after the intervention was compared. analysis utilized excel and spss version 23. to compare the pretest to posttest change in the average percentage of correct responses for the 38 questions (all questions and by priority area), a paired t-test was used. approximately 55% of the questions were answered correctly on the pretest, and 70% answered correctly on the posttest, constituting a significant difference in the overall pretest mean score (t (78) = -2.89, p = .005). some of the documented improvement was modest; for example, the average response increased by only 2.3 percentage points (from 97.7% to 100%) on a question regarding the nursing assessment of growth and development in an 8-year-old child. another documented improvement was more dramatic, with an increase of 64.2 percentage points (from 19.1% to 83.3%) on a question regarding safe and accurate pediatric administration online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 102 of medication by nurses. the questions with the greatest improvement were primarily from the synthesis or “putting it all together priority area”, which was featured in both the large group lecture and simulation content. the change in scores was also examined based on the three priority areas targeted by the educational intervention. the percent of change between the pre and posttest averages were determined by calculating the difference between the two numbers, then dividing that number by the pretest average and multiplying the answer by 100 (skills you need, 2016). improvement was seen in all three of the priority areas, but only the difference between pretest and posttest scores on the “putting it all together” priority area were significant (t (18) = -2.39, p = .028) with a pretest average of 51% correct to a posttest average of 73%, constituting a 43% improvement. measurement of knowledge regarding pediatric equipment and interventions increased by 33% (p = .128) and knowledge regarding pediatric assessment by 14% (p = .106). see table 3 for a summary of priority area knowledge test scores. limitations to this analysis were the lack of identifiers and demographics on the pre and posttests. due to the unavailability of respondent level data, statistical analyses were based on comparing the average percentage of respondents answering correctly for the 38 questions. we were unable to examine changes in individuals or determine if the training approach benefited any particular subgroups of the participants. since the posttest was conducted immediately after the educational training, it is uncertain how long the educational intervention will be retained. significance the goal of this ticc project was to address the educational needs of nursing staff aimed at improving pediatric care in a rural hospital setting. based on the evaluation of the pre and post knowledge tests, the ticc project succeeded in improving the pediatric nursing knowledge online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 103 in the nurses at this rural hospital. the ticc project eliminated many of the barriers to continued education in rural hospital settings identified in the literature review (jukkala et al., 2008; mccoy, 2009; wolf & delao, 2013). barriers such as long travel distance, professional isolation, lack of educational guidance, and lack of resources to carry out educational activities were overcome through the implementation of the ticc project. the literature review also identified that educational issues facing rural nurses are diverse and plentiful, which was also evident in the ticc project (fairchild et al., 2013; molinari et al., 2011). table 3 summary of priority area knowledge test scores priority area pretest percent (%) of correct answers posttest percent (%) of correct answers overall percentage (%) improvement p value synthesis of care decisions (putting it all together) 51% 73% 43% .028 * knowledge of equipment and interventions 51% 68% 33% .128 pediatric specific assessment 63% 72% 14% .106 a key idea behind this ticc project was the thorough educational needs assessment orchestrated by the ticc team through quantitative and qualitative surveys and knowledge testing that allowed the identification of priority educational topics specific to this rural hospital nursing staff. the ticc project used a variety of educational activities in the 8-hour educational training day to address educational needs, such as lecture, simulation, hands-on skill training, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 104 and equipment practice. the review of literature documents the effectiveness of the educational approaches used in the ticc project (banks et al., 2010; yacoub et al., 2015). the pre and posttest analyses of the ticc project suggest that these educational approaches were effective in the ticc project. the inclusion of hospital nursing staff as integral members of the ticc team provided great insight into the needs of the nurses and facility as a whole and promotes sustainability for continued innovations to improve patient care. the literature supports the use of nurses guiding and being key players in the development of patient care improvement and being progressive leaders of change in their work units (aacn, 2014; dearmon et al., 2013; kliger, lacey, olney, cox & o’neil, 2010; martin et al., 2007). implications for nursing this ticc pediatric project can be used as a template for a continuing education and professional development program at other rural hospitals. it combines evidence-based approaches to address educational needs that aim to ultimately improve patient care. the steps of forming a staff nurse-led team, identifying specific issues and needs, planning educational activities and policy/administrative changes, and evaluating outcomes is well outlined in the ticc project and could be replicated in another facility. while limitations exist in regards to the ticc project, the evaluation showed strong support for the interventions and activities that aim to improve pediatric nursing knowledge in a rural hospital setting. the ticc project can serve as a guide for other rural hospitals wanting to identify and systematically address educational issues, by using a team of clinical nurse specialists, along with front line staff nurses who can be empowered to be the leaders of innovation on their own work environments. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 105 recommendations future project evaluations of ticc like projects should include demographic data and identifiers for participants in order to improve analytics. the ticc project also conducted the posttest immediately after the 8-hour educational training; an additional posttest at a later time could provide valuable data regarding knowledge retention, a practice well documented in cpr demonstration studies (aqel & ahmad, 2014; madden, 2006). additionally, follow-up to address sustainability and redosing of education would enhance staff nurse confidence and promote optimal patient outcomes. further research is also needed to investigate the impact of the business case for quality and to examine cost savings and revenue generation. the tcab is no longer an active rwj program, but a report describing tcab projects, outcomes, and lessons learned is available from rwj, and is available to guide nurses in rural hospitals to envision their own projects (brown, 2011). the american association of criticalcare nurses (aacn) has also developed their csi academy, which is a 16-month nursing program that supports hospital-based nurses as leaders and change agents (aacn, n.d. b). tools like these can help nurses in rural settings be more connected and empowered. conclusion a rural pediatric outreach program, such as the ticc project, can be an efficient and effective way to address the continuing education needs of rural nurses in a hospital setting. the ticc project serves as a guide for identifying and addressing the pediatric educational needs of nurses, while empowering the very nurses who care for patients in the facility to be part of the leadership and innovation process. the implementation of a pediatric outreach program could be instrumental in improving pediatric patient care in the rural setting. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 106 supporting agency washington state university references american association of critical-care nurses (aacn). 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(2013). simulation to the rescue! caring for a pediatric patient in the rural setting. journal for nurses in professional development, 29(4), 197 201. https://doi.org/10.1097/nnd.0b013e31829aebf6 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.411 111 yacoub, m., demeh, w., barr, j., darawad, m., saleh, a., & saleh, m. (2015). outcomes of a diabetes education program for registered nurses caring for individuals with diabetes. the journal of continuing education in nursing, 46(6), 129 133. https://doi.org/10.3928/00220124-20150126-02 microsoft word fahs_373-2005-1-rv.docx online journal of rural nursing and health care, 15(1) 1 http://dx.doi.org/10.14574/ojrnhc.v15i1.373 editorial save the date for the 2016 international rural health and rural nursing research conference pamela stewart fahs, phd, rn, editor july 19 – 21, 2016, do you know where you will be? i will be in rapid city, south dakota at the international rural health and rural nursing research conference and hope to see you there! co-hosting this exciting conference will be south dakota state university, university of south dakota, the rural nurse organization, matson halverson christiansen hamilton foundation (mhch), and the helmsley charitable trust. the conference will be held at the rushmore plaza civic center in downtown rapid city. this conference will give you the latest information on what is happening in rural health care and nursing. the world of rural nursing and health care is broad, yet like a rural community it is small enough that there is a good deal of familiarity. judging from past rural conferences there will be friends old and new attending. this is a conference for practitioners, educators, and researchers. so if you work to ensure the health of rural populations, this is a conference you will not want to miss. details are still being finalized by the committee and we will soon have information regarding abstract due dates etc. i am sure this is a conference that will not only be informative but also fun, and one that the rno is proud to support. please watch the rno.org website for more details as they emerge. online journal of rural nursing and health care, 1(1) 66 student learning in the community promotes maternal health diane helgeson, ms, rn1 elizabeth tyree, mph, rn2 1 associate professor, college of nursing, university of north dakota, diane_helgeson@mail.nodak.edu 2 clinical associate professor, college of nursing, university of north dakota, liz_tyree@mail.und.nodak.edu abstract the university of north dakota college of nursing expectant family program has over a thirty year history of service by upper division nursing students to expectant families in the area of grand forks. a change over time has been in the population of pregnant women who are now more often single and high risk. student learning experiences include home visits, physical assessments, monitoring for danger signs, individualized instruction on prenatal and family health, attending clinic and lamaze classes and support during labor and delivery. anecdotal information consistently reveals positive impact on the family’s birthing experience and on the students’ learning. keywords: education, learning, public health nursing, maternal-child nursing, home care services online journal of rural nursing and health care, 1(1) 67 student learning in the community promotes maternal health various organizations promote community-based models of nursing education to enable graduates to work across various health care settings and provide care which is focused on the needs of particular populations (american association of colleges of nursing, 1993; national league for nursing, 1999; shugars, o’neill, & badger, 1991). the ecological model of urie bronfenbrenner (1979) is useful in characterizing a multilevel approach of care for the individual in the context of their life situation in the home and community (tyree, henly, schauer, & lindsey, 1998). seeing the family in the community, instead of a hospital, helps bridge learning about continuity of care across settings. the hospital is viewed as an institution in the community, supporting family care of the individual. this article describes the expectant family program, a component in the family in the community course at the university of north dakota. the course deals with family-centered, community based care for child-bearing and child-rearing families. home visiting is the primary activity in this clinical experience. support of self-care in the home is fundamental to home visiting programs (rice, 1998). kadner and brandt (1998) describe potential lessons for students from home visiting including comparison of inpatient and home settings, continuity of care across settings, the family as the unit of intervention and the case management process. the impact of home visiting by nurses on improving the outcome of pregnancy has been measured by olds et al. (1999) in randomized trials over twenty years in elmira, new york and memphis, tennessee. in these studies child bearing women and their children were followed with home visits until the children reached two years of age. long term benefit of home visiting was seen when the children reached 15 years of age, most markedly in those families with online journal of rural nursing and health care, 1(1) 68 compounded risk factors of poverty, single mothers, teenagers and lowest psychological resources. the benefits for these children included fewer arrests and convictions, less smoking and drinking and fewer sexual partners. zotti and zahner (1995) evaluated a public health nursing home visiting program for 398 women, infants and children (wic) registrants with high risk status, divided into a group of 301 who received wic services only and a group of 97 who received wic plus public health nurse visits. they found no difference in prenatal care or birth outcomes between the group visited and wic registrants who were not visited. zotti and zahner (1995) reported lessons learned in care-coordination for the population at risk. in reporting on the effects of advanced practice nurses in improving the outcome of pregnancy through home visiting, brooten and naylor (1995), discuss the type of maternal outcomes which are important to measure. brooten, brooks, madigan, and youngbult (1998) looked at "nurse doses" associated with various complicating risk factors. nurse dose refers to the actual amount of nursing contact time which was spent by expert nurses. brooten et al. (1998) highlight the importance of knowing how much time is needed to reach improved outcomes in a health care system unfettered by current financial constraints on home care. program development the expectant family program at the university of north dakota (und) was initiated to provide students home visiting experiences in the community as well as to fill a gap in follow-up of pregnant women. in the fall of 1969, the und college of nursing developed a program that combined learning experiences for two senior nursing classes, community health and maternity nursing, into one clinical. senior nursing students were assigned to follow primigravida women in their homes as part of a requirement for both classes. the development of this program was online journal of rural nursing and health care, 1(1) 69 described in the article by helgeson, and neuberger (1977). in the fall of 1980, the maternity course was relocated to the junior year and the community health course remained in the senior year. in the fall of 1992, after more curriculum modifications to address changes in the health care system toward more community based education, the expectant family program and a counterpart child health program, which links students with families of children with special needs, became a new course entitled family in the community. the course was placed in the eight-semester sequential curriculum in the second semester junior year. the sixteen week family in the community course focuses on family-centered, community based services for expectant families and families caring for children with special needs. emphasis was on standards of prenatal care, risk assessment, parenting children with chronic illness and/or disability and multi-disciplinary services. the purpose of this article is to describe the expectant family portion of the course. program description the family in the community course at und focused on family-centered, communitybased services in an ecological model based on bronfenbrenner (1979). it includes one hour of didactic lecture, two hours of clinical conference and approximately four hours of independently scheduled clinical time per week. about 48 students every semester are involved in the expectant family program. expectant family student encounters included home visits, attendance at prenatal appointments, classes and diagnostic tests such as ultra-sound and, if the timing was right, labor and delivery. the students were expected to make a visit of about an hour in duration every other week. wide variation in frequency and length of visits was accepted depending on the stage of pregnancy and family needs. cases were located by the students themselves, through online journal of rural nursing and health care, 1(1) 70 newspaper announcements and brochures placed in clinic prenatal packets. feature articles in area newspapers that enhanced visibility in the community were published about the program every few years. students received preparation for home visiting from an "expert panel" of home visitors, faculty, and community health nurses, emphasizing safety and the autonomy of families in selecting their own priorities for learning and intervention. a printed learning packet gave students additional guidance for beginning visits. a brochure explaining the purpose of the program and topics the student might discuss on home visits was used as a guide for casefinding. learning experiences a signed consent to participate was requested from the woman on the first contact. the consent also informed the client that a record was kept in the college of nursing which might be used for research purposes. the client’s signed release of information form enabled the student to request health records from other agencies. assessment began with a maternal history. the history was a structured, concrete form which facilitates an easy exchange of information between student and mother and "breaks the ice." hands-on assessments usually began in subsequent visits and included doppler fetal heart tone auscultation, fundal height, dip-stick urine tests, blood pressure, weight and an interview for danger signs. the doppler assessment was usually the most valued by the family. as a sign of well-being, the doppler brought home the reality of a developing fetus to the partner, siblings and other family members. serial assessments were recorded on a maternal flow sheet. danger signs and interventions were documented in nurses notes and students had home and office phone numbers for at least eight faculty members prepared to consult about decision-making in questionable situations such as, online journal of rural nursing and health care, 1(1) 71 absence of fetal heart tones, increased blood pressure and positive results on dip-sticks. other assessments included an ecomap, which is a pictorial constellation of external support of the family identifying associations such as work, church, extended family, social contacts and others; and genogram, which is a pedigree, usually completed with active participation by the family (wong, 1996). prenatal weight-gain grids were available for tracking weight gain. a family roster was completed which notes other agencies or community services involved with the family unit and a home environment assessment. labor and delivery summaries, postpartum progress and infant assessment were also charted. faculty provided written feedback weekly on the case management and the documentation in the health record. learning was mediated in weekly two hour clinical conferences consisting of 12 students and a faculty member during which they reflected on the case assignments. an emphasis was placed on listening to the "family story" in the experience of pregnancy. students shared case stories and discussed approaches to intervention with an emphasis on listening to family members. teaching families about stages of pregnancy, labor and delivery, infant feeding and cares and many other topics of interest was the most frequent intervention. students followed up on specific questions about teratogens and genetics by consulting the nurse geneticist in the und school of medicine and by doing their own research. all the students joined a national maternity care listserv for specific questions requiring expert consultation, for example, breastfeeding following breast reduction surgery. the students also found timely new teaching materials on the internet, especially related to gestational development, work-related exposures, and other individual concerns expressed by the expectant family. they discussed the material found in clinical conference with the supervising faculty member as to the appropriateness and reliability of the information before the information was shared with the family. reinforcing online journal of rural nursing and health care, 1(1) 72 gestational diabetes and pregnancy-induced hypertension management was a common intervention. teen mothers and mothers with mental retardation were given particularly sensitive and individual attention with teaching aids for populations with low literacy which were acquired. working with families collaboratively on the families' priorities was stressed. the expectant family program was seen as particularly valuable to single mothers, who are often abandoned by the significant other or family and whose numbers have grown. social support was recognized as an important factor in the development of comfort in the parental role (daro & harding, 1999). the program looked at the issues of personal and professional boundaries which are so common in real-world work. students were encouraged to bring personal and professional reflections to clinical conferences within the bounds of appropriate levels of self-disclosure. on occasion, the clinical experience touched unresolved memories of abuse in the student him/herself, and a counseling referral was made for the student. when domestic violence or child abuse surfaced in the case family, faculty worked with the student to report the family to social services, as required by north dakota law, and to the local crisis center if appropriate. case-finding was directed toward referrals of well-functioning families. nonetheless, it happens that the student may have been the first person to identify abuse in a family or the first person to whom a history of abuse was confided. grief and loss are ever-present as the students encounter miscarriage, fetal demise, and stillbirths. one clinical section of twelve students suffered the loss of three infants and two miscarriages in one semester time period. at a time like that the whole class and group of faculty grieved together and supported each other. this overt acknowledgment of the impact of online journal of rural nursing and health care, 1(1) 73 loss on a professional may be a result of consciousness-raising over the last three decades about death and dying. graduate students were available for case consultations to undergraduate students. graduate students followed some highly complex cases which were not appropriate for beginning students. graduate students as case managers, consultants and sometimes as faculty moved the program forward in its clinical sophistication. they also brought an energy and excitement to the work which was contagious. they communicated that this work was important and not just another assignment. they were good role models of committed, engaged professionals. if follow-up of the families was needed after the school year had ended, arrangements were made for the family to be followed by the public health department or another appropriate agency. the faculty member and the student discussed the proper referral and proceeded in a team approach for follow-up. some families did not wish to have follow-up after the school year had ended and refused. the wishes of the family were followed unless there was a legal or safety concern that required follow-up. evaluation the number of expectant women visited yearly was about 90, equaling the number of students that participated in the program per academic year. the average number of home visits per family was 11.5. students made an average of 359 contacts with other programs and providers serving the women per year. it is this entry into the service system which illustrated to the students the complex web of community-based services which are available. in the 1995-96 academic year 190 patient satisfaction surveys were sent to individuals who received home visits from nursing students (lindsey, henly, & tyree, 1997). a total of 101 online journal of rural nursing and health care, 1(1) 74 patients returned the survey. the numbers included child nursing visits as well as expectant family visits. a total of 86 expectant families were visited during that academic year. representative comments included:  "it has been a wonderful program and people can benefit from it."  "very informative, reassuring; provided me with information that exceeded lamaze."  "seems really easy to talk to the student nurse about things you maybe wouldn’t bother to talk to the doctor about." respondents remarked in particular that the program can be of most help to a first-time expectant woman. anecdotal information is rich in giving the flavor of the impact of the program on families. one mother who has a developmental disability associated with fetal alcohol exposure called the college two years after participating in the expectant family program and asked to have the opportunity to speak to the current class of students. the students were assembled to hear the woman’s story, and also present was an advocate with the local advocacy resource center (formerly association for retarded citizens) chapter to assist the woman in her presentation. she spoke about how much help the student had been and suggested to the students some activities which she found particularly helpful. the main message was to encourage the students to tell their case mothers not to drink during pregnancy. the woman described problems in her own daily living activities, which she attributed to her mother’s drinking during pregnancy. she also stated that her two-year-old child was just "labeled" developmentally disabled. she thought that perhaps if she herself had not had a development disability, life would be different for her son, and she was visibly aggrieved to have heard him described that way. online journal of rural nursing and health care, 1(1) 75 the students responded with gratitude for her sharing and recognition of her courage in telling her story. they reported to faculty that the mother had a profound impact on their realization of the importance of their work. word about the help the students can be to parents has spread among that population group. the clinical coordinator of the program received a call from a mother in the hospital asking, "is this the program that keeps your baby from being taken away?" sadly, that decision had been made already, and she was to leave the hospital without the baby. written evaluation of the expectant family program was done in 1999 by a sampling of 24 students. the students as a group evaluated the program as a real asset to the curriculum. representative remarks regarding the program were as follows:  "provided us opportunity to do a lot of education, which also helps us learn better."  "i like the independence, our clients regard us as real professionals."  "i like the expectant family program because it forces me to look things up. i have to have a good understanding of the topic to explain to someone else."  "the expectant mom is a very good program. lots of experience is to be gained by educating these women."  "the expectant family program opened my eyes to safety hazards and concerns i wouldn’t ever have thought of for my family."  "i was part of this program when i was pregnant and now as a student. my family has said that they love having a student nurse." the expectant family program is notable for its longevity and deep roots in the regional system of care for pregnant women. the program was evaluated by the students as well as the online journal of rural nursing and health care, 1(1) 76 expectant women as an excellent learning experience. outcomes of pregnancy associated with home visiting programs, based on the work of david olds (1999), dorothy brooten (1995) and others, should be researched further in the evaluation of the expectant family program at und. online journal of rural nursing and health care, 1(1) 77 references american association of colleges of nursing. 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(1999). prenatal and infancy home visitation by nurses: recent findings. in r. e. behrman (ed.), home visiting: recent program evaluations (pp 44-65). los altos, ca: david and lucille packard foundation. rice, r. (1998). implementing undergraduate student learning in home care. geriatric nursing 19, 106-108. https://doi.org/10.1016/s0197-4572(98)90049-0 shugars, d.a., o’neill, e.h., & badger, j.d. (eds.). (1991). healthy america: practitioners for the year 2005. durham, nc: pew health professions commission. tyree, e., henly, s., schauer, j., & lindsey, d. (1998). undergraduate preparation for primary health care roles in an academic nursing center. journal of nursing education, 37, 337 344. wong, d.l. (1996). clinical manual of pediatric nursing. st. louis, mo: mosby. zotti, m.e, & zahner, s.j. (1995). evaluation of public health nursing home visits to pregnant women on wic. public health nursing, 12, 294-304. https://doi.org/10.1111/j.1525-1446.1995.tb00152.x https://doi.org/10.1016/s0197-4572(98)90049-0 https://doi.org/10.1111/j.1525-1446.1995.tb00152.x online journal of rural nursing and health care, 1(3) 26 children with special healthcare needs in the classroom jena clayton barrett, dsn, rn1 1 capstone college of nursing, university of alabama, jbarrett@nursing.ua.edu abstract this research involved 335 teachers in a rural area. their stories of the inclusion of children with special health care needs in the classroom underline the need for healthcare providers to engage in teaching school personnel about issues in child health. the teachers tell stories about their classroom experiences and the medical needs of the children in a rural setting. laws leading to the inclusion mandate are discussed. there is also a description of the medical diagnoses seen in rural classrooms and a discussion about the issues involved in inclusion. keywords: rural health, inclusion, children, special health care needs online journal of rural nursing and health care, 1(3) 27 children with special healthcare needs in the classroom in 1975, the supreme court handed down a decision that began the growth of inclusion. parents of children with disabilities and their children advocated the need for desegregation. the drive for mainstreaming, the inclusion of children with disabilities in the regular classroom, was based on two emotional foundations. first it represented value of the children, and, second, the offense of the stigma of a special class was removed (giangreco, 1996). there was little research conducted to ascertain the impact this decision would have on the educational system. increasing numbers of children with special health care needs are challenging the abilities of our public education system as they attempt to access a free, appropriate public education. the systems often are unprepared for this challenge to its structure. educators do not have the background to deal with many of the health care needs of the children under their care (salend, 1999). rural schools have limited school nurse staffing to handle emergencies or teach about health issues; they lack the resources to educate their teachers about special healthcare. while rural schools have 49% of the nation’s public schools, 41% of its teachers, and 38% of its students, they receive only 22% of federal, state, and local k-12 funding (national education association, 1999). anxiety among teachers is heightened. current regulations mandate health services for children with special needs be provided in the classroom. financially and emotionally the rural educational system is stretched. it is not clear whether congress ever intended or perceived that children with extensive health care needs would seek the public education deemed their right 20 years ago (rapport, 1996). online journal of rural nursing and health care, 1(3) 28 often framed as a civil rights issue, inclusion has been furthered by advocacy, legislation, and litigation. twenty years ago the education for all handicapped children act (p.l. 94-142) and the americans with disabilities act (ada) were passed. the 104th congress reauthorized the education for all handicapped children act and titled it the individuals with disabilities education act (idea). in 1992 third circuit federal judge john f. gerry in oberti versus clementon ruled “inclusion is a right, not a privilege” (smith, 1997). the changing face of the american classroom now mirrors these laws, laws that should assure children with disabilities a free, appropriate public education in the least restrictive educational settings. while school district central office personnel face legal, financial and administrative issues associated with children with disabilities, teachers face additional challenges (knight & wadsworth, 1993). classroom teachers who previously have had little or no interaction with medical or physical disabilities are being required to assume increased responsibilities by including children with special needs in the regular classroom (salend, 1999). in rural communities school systems bear the responsibility for implementing individual health and education plans, funding most of the therapies, and becoming responsible for healthcare to the extent of tracheotomies. the educational authorities are increasingly concerned about the provision of care for these children (committee on children with disabilities, 2000). healthcare providers in rural communities must become resources for these school system personnel. sample following internal review board approval by the university, teachers in rural school systems were contacted about their interest in participating in research about children with online journal of rural nursing and health care, 1(3) 29 special needs. three hundred and thirty five teachers from two rural county school systems responded and gave informed consent to participate in the research. focus groups teachers met with the researcher mondays after school for three mondays. eleven schools were involved. focus group sessions were conducted at each school for three weeks. the sessions lasted an average of an hour and a half. the researcher cultivated rapport with the teachers by sharing with them her work as a nurse with children with special needs. the focus groups were unstructured, allowing the teachers to discuss any topic they found pertinent concerning children with special needs in their classroom. comments from the teachers were transcribed. findings the focus group sessions revealed that a great many children with special health care needs are currently in rural classrooms (see table 1). teachers in the research study shared stories that revealed a treasury of anecdotes concerning children with disabilities and their impact on the classroom. some teachers found that their contact with children with disabilities was heartwarming and evocative; others felt disheartened and frustrated. online journal of rural nursing and health care, 1(3) 30 online journal of rural nursing and health care, 1(3) 31 opportunities arise from fears the first two stories describe situations where teachers and students are both afraid and uncertain of the unknown. children with disabilities enter the classroom setting and the effect these children have on everyone is heartrending. a fifty-year-old fourth grade teacher with thirty years of teaching experience tells the first story. it offers a glimpse of a classroom that faced their fears and embraced a new experience. the stories illustrate the opportunities offered by inclusion: a young man had been a pupil of mine in the fall semester. he was an average grade student, but had a very bright personality. he was very popular with his fellow classmates and a budding sportsman. he was late for class on several occasions because he worked the farm with his father and grandfather. in the late autumn his life and the life of my classroom were altered. in the spring, this young man returned to my classroom much changed, yet much the same. an event in early fall had left him paralyzed from the waist down. a tractor had run over him in a farming accident. the young man, once independent and full of spirit came back to our classroom incontinent, unable to walk, and beginning to atrophy from the waist down. our original reaction was not admirable. we all felt unable to cope with his changed appearance and physical disabilities. what happened next, however, was one of the most remarkable events to occur in my 30 years of teaching, and it brought us a profound sense of reality. online journal of rural nursing and health care, 1(3) 32 the students in my classroom and i began to change our own routines to accommodate this young man's needs. at first, i complained to my husband how much of a disruption to my routine having this child in my class was. a few parents expressed concern over the time their children spent caring for this child's needs. some students were frightened of the wheelchair. the young man recognized this and began letting his fellow students see the world from his perspective, letting them sit in the chair and use it for mobility. the students identified obstacles in the school which made navigation difficult. they then embarked on projects and worked with the parentteachers association to make the school more wheelchair accessible. three times a week a physical therapist came to our school to work with the young man. the students took turns working with the physical therapist and soon learned a great deal about anatomy and body mechanics. since the young man was incontinent, i thought a lesson on spinal cord innervation would help the students better understand the situation. the students worked up a teaching unit and presented their newfound knowledge to other classes. the students said they had a lot to learn from this young man. so did i. what we gained from this experience was invaluable. he taught us more about life than any textbook. the young student has gone to another grade and is doing well. the opportunities gained for all of us will forever change our lives. this child offered us a chance to understand. online journal of rural nursing and health care, 1(3) 33 a third grade teacher in her thirties with ten years of teaching experience tells the second story: i teach third grade. last fall a young girl with cerebral palsy was placed in my class. i wasn’t even sure what cerebral palsy was. we do not have a school health nurse, so i did a lot of research myself. the class and i were unsure about how to treat this stranger. she had been attending a special education center and was equally unsure about us. the child could not walk and was confined to a wheelchair. i thought she was incontinent. her communication was difficult to understand. the month of september was tough on all of us. as october wore on, the young girl began to gain a cadre of friends. the students were eager to be the one who got to push her wheelchair. i saw the girl begin to smile. then we all began to smile. the young girl made close friends with several classmates and they began to interpret for her. one of the special education teachers brought a communication board for us to use. it had pictures and words on it that the young girl could point to. by thanksgiving i could communicate very well with her. she could tell me when she had to go to the bathroom for her stools so that i could take her. her bladder control was a bit more difficult. the entire class began to plan around her routine and needs. we were not doing the same things the other third graders were doing, but we were learning many different and important things. the young girl did not return after christmas break. she was missed by all of us. we called about her and were informed that she was ill and could not come to class. the students immediately volunteered to take her lessons and visit her. the students took online journal of rural nursing and health care, 1(3) 34 turns going with me once a week and visiting. she was happy to see us. we fell into our old routine at school and realized how much we missed her. at a pta meeting that spring, several parents spoke about how much their child had learned from having a friend with a disability. it was a lesson i could not teach. this young girl taught us much about communication, body functions, patience, and love. in early summer, the young girl died. we will always remember and miss her. frustrations the next two stories clearly exemplify the frustrations teachers are experiencing. the teachers are unprepared for the health and behavioral problems they face as a result of inclusion. the need for a school health nurse becomes evident. a teacher in her thirties with ten years teaching experience relates the first story: in my first-grade classroom i have a 7-year-old who functions like a 3-year-old. this situation is impossible. the other students and i are at wits end. i no longer know how to help this child. i no longer have the time to help the other students and i am not sure where i fit in this environment. i want to teach. i consider myself a good teacher, but what am i to do with this child in this environment? the child throws violent temper tantrums, wears diapers, and is absolutely incapable of being left alone. i must take my lunch break and feed this child. my breaks consist of cleaning this child. my every moment is committed to this one child. what about the other 20 children in my class? they try to help me, but i do not see it their responsibility to diaper and control this one child. to complicate things, this child had been diagnosed with attention deficit disorder and i am supposed to deal with him. i’m not even sure about the medicines this child online journal of rural nursing and health care, 1(3) 35 takes for this. this is an impossible situation. his parents tell me he will progress very little beyond this point. i may find another profession. no one helps us. this is not teaching. a story told by a teacher in her forties who had been teaching second grade for two years follows: this is the first year i have had a child that has health and behavior problems diagnosed as linked to a mother who was on crack cocaine when she was pregnant and when she delivered. the child is in my second-grade class, but i think he belongs somewhere other than in the second grade or in this school. the eight-year-old is profoundly mentally retarded and has moments when his tantrums scare the other children and me. the child had not been in any special education class but this year was evaluated and placed in my room. i have no idea why. he has seizures, which are frightening. he will suddenly fall to the floor, sometimes hitting his head, shake all over, vomit, and soil himself. when this occurs my other students quickly go to the other side of the room. i have one student designated to go and get the principal, but he doesn't know what to do either, and, by the time he gets here, the seizure is usually over. we try to call his mother but can never find her. no one has ever taught me how to handle these things. i dread coming to work now. lack of healthcare preparation the last three stories reflect the lack of preparation teachers have in working with children with special healthcare needs. more than anything else, the stories reflect the need of online journal of rural nursing and health care, 1(3) 36 school health nurses. the first of these stories is told by a third grade, sixty-year old teacher with forty years of teaching experience: can you help me? this year a child with a shunt entered my classroom. what is a shunt? should i do anything for it? the child's parents ask me to let them know if i think it is malfunctioning. malfunctioning? how do i know and what do i do if it is? this is a sweet, quiet child who seems to be doing well with her class work but has a profound learning disability. should i make exceptions for her? i have noticed a bulge on the side of her head and a funny line down her neck. she tells me this is normal. i would like to know more about why she has this; the students in the class are eager to learn more about what is going on. i have asked the parents to help. they tell me that it is my job . . . is it? the next story is told by a twenty year-old new to teaching: i have a child in my classroom with severe asthma. the young girl's mother told me about it at the beginning of school, but that is all she said. she then handed me this "tube and can like thing". i asked her to tell me what it was for. she said the young girl, a third grader, would know what to do. i hoped so, because we are a long way from any kind of emergency response people. on the third week of class the young girl had an asthma attack. she was on the playground and began making terrible breathing sounds. i remembered the "thing" her mother had given me and ran to the classroom to get it. i took it to the playground and gave it to the girl, but she was too upset to do anything. fortunately, a fellow teacher had a daughter who had asthma and understood how to use an inhaler. she took it from me and used it with the child, whose breathing got better. i online journal of rural nursing and health care, 1(3) 37 called her mother. what if that other teacher had not been there or had not known what to do? this story came from a first grade teacher in her forties with ten years of teaching experience: i have a child with a severe peanut allergy. i was concerned and took a course at a local emergency medical training center for learning how to do mouth-to-mouth, but i understand that if the child "closes up" there may be nothing i can do. they tell me that it will take almost five minutes for the emts to respond if i call 911. i need more information on foods and substances containing peanuts and peanut oil. the student and i have made a pact to learn together. i am amazed at how much a 6-year-old is capable of learning and teaching other people. discussion these stories reflect both the positive and negative aspects of inclusion. the impact of inclusion on the child with special needs, on the teacher, and on the other children in the classroom is evident. the first two stories illustrate the positive contributions children with special needs in the regular classroom have to offer. the students and teachers were at first wary of their differences then found new opportunities to grow. the second group of stories describes the fear and exasperation teachers face as a result of inclusion. they also evidence the lack of preparation teachers have in the area of children with special needs. the teachers were sometimes unaware of the children’s diagnosis, what it meant, how to implement interventions, what the medications were. online journal of rural nursing and health care, 1(3) 38 teacher job satisfaction has been tied to teacher self-confidence and feelings of professional competence (salend, 1999; tice, 1997). teachers who have little or no knowledge of the health needs of children with disabilities are now being asked to assume responsibility for areas previously the domain of health care professionals. teachers are expressing anxiety, dismay, fear and resistance (tice, 1997; williams, 1990). with the increased numbers of children with chronic illness entering the school environment come many issues and problems (committee on children with disabilities, 2000). there is an outcry for teacher training in health care—not just for children with disabilities, but for all children. special health care needs predispose a child to serious injury and illness. teachers are on the frontline in preventing illness and injury (emergency medical services for children, 1993). childhood accidents are the leading cause of death and disability for children. accidents can occur to any of the children in the school, not just the children with special needs (lewis, 1999). an examination of curricula required for education majors reveals there are no required courses in cpr, health care or first aid. only the state of california requires education majors to complete a course in health education including training in nutrition, effects of alcohol, drugs, and tobacco, and cpr certification. california is one, if the only, state to have an education major credentialing requirement that includes health education (lovado & rybar, 1995). in the classroom teachers dealt with conditions ranging from attention deficit disorder and children born to crack cocaine mothers to children with shunts, asthma, and allergies. teachers were unprepared to handle situations that did or might arise. the need for a school health nurse is evident. since rural school systems have one nurse to an entire county, or no nurse at all, the implications are clear—teachers must form the first line of intervention for online journal of rural nursing and health care, 1(3) 39 emergencies and health maintenance for all children, not just those with special needs. the emergency response time for some of these rural schools was a long as 20 minutes. teachers said that this concerned them, but also made them cognizant of the fact that they were the emergency response for these children. the teachers were willing to learn, they just needed the resources to do so. healthcare professionals in rural areas are the obvious answer for these teachers’ cry for help. the nurse in rural communities has a rare opportunity to engage in interdisciplinary work. implications students are exiting education curricula without any healthcare knowledge. the education of students in education majors and the education of new teachers is certainly pertinent. with the federal mandate for inclusion should come a federal mandate for educator credentialing in health management knowledge …at least in cpr. by learning cpr, the teachers have more confidence in emergency situations. even if cpr is not needed, having a background in emergency procedure will give the teacher a better sense of control. rural educators are in particular need of this because of their distance from response personnel. the down side of mandating cpr, however, is that cpr certification does not begin to address the inclusion issue and its impact on the classroom. legislatures, by mandating cpr certification, may take a "cheap shot" and feel comfortable that they have done a great deal to solve the safety hazards of inclusion. teachers need to be better prepared in the area of special health care needs. undergraduate and graduate programs in education need to begin to incorporate health care in the curriculum. both education and nursing must also educate their professionals on interdisciplinary work (passerelli, 1997). healthcare professionals must become the providers of online journal of rural nursing and health care, 1(3) 40 education for our educators. nurses can work with schools and teach healthcare (first aid, disabilities seen in the classroom, etc.). this opportunity is there with existing teachers and for teachers beginning their teaching internships. nurses must become advocates for the teacher and the child with special needs by becoming active in policy issues and legislature. as a nurse in a rural community, the opportunity is there to ease teacher anxiety and make school a safe haven. by implementing the above recommendations, teacher anxiety will decrease, and their job performance increase. children's healthcare will improve when teachers become knowledgeable of health care management, and children with special health care needs will be in a safer environment. rural health nurses can answer the call of teachers and children. online journal of rural nursing and health care, 1(3) 41 references committee on children with disabilities. (2000). provision of educationally related services for children and adolescents with chronic diseases and disabling conditions. pediatrics, 105, 448-450. https://doi.org/10.1542/peds.105.2.448 emergency medical services for children. (1993). in j. durch & k. lohr (eds.), division of health care services of the institute of medicine. washington, d.c.: national academy press. giangreco, m. (1996). the stairs didn't go anywhere. journal of the council for exceptional children, 14(2), 1-12. knight, d., & wadsworth, d. (1993). physically challenged students. childhood education, 69(4), 211-215. https://doi.org/10.1080/00094056.1993.10520934 lewis, a. (1999). pediatric emergencies. nursing 99, 29(1), 33-39. lovado, c., & rybar, j. (1995). development and dissemination of a manual to promote teacher preservice in health education. journal of school health, 65(5), 172-175. https://doi.org/10.1111/j.1746-1561.1995.tb06224.x national education association. (1999). a raw deal for rural schools. nea today, 17(6), 8-16. passerelli, c. (1994). school nursing: trends for the future. journal of school health, 64(4), 141-149. https://doi.org/10.1111/j.1746-1561.1994.tb03284.x rapport, m. (1996). legal guidelines for the delivery of special health care services in schools. exceptional children, 62, 537-549. https://doi.org/10.1177/001440299606200605 salend, s. (1999). the impact of inclusion on students with and without disabilities and their educators. remedial and special education, 20(2), 114-127. https://doi.org/10.1177/074193259902000209 https://doi.org/10.1542/peds.105.2.448 https://doi.org/10.1080/00094056.1993.10520934 https://doi.org/10.1111/j.1746-1561.1995.tb06224.x https://doi.org/10.1111/j.1746-1561.1994.tb03284.x https://doi.org/10.1177/001440299606200605 https://doi.org/10.1177/074193259902000209 online journal of rural nursing and health care, 1(3) 42 smith, a. (1997). systemic education reform and school inclusion: a view from a washington office window. education & treatment of children, 20, 1, 7-31. tice, t. (1997). research spotlight. education digest, 62(2), 43-47. williams, d. (1990). listening to today's teachers: they can tell us what tomorrow's teachers should know. teacher education and special education, 13, 3-4, 149153. https://doi.org/10.1177/088840649001300302 https://doi.org/10.1177/088840649001300302 online journal of rural nursing and health care, 1(1) 4 editorial educational issues: facing today’s nursing shortage elvira szigeti, phd, rn, editorial board member it is exciting to think of how one can participate in the educational processes of rural nurses. the purpose of this column is to address educational issues related to the "new graduate," the advanced practice nurse, and continuing professional education. i ask you, the reader, to e-mail specific issues that you would like addressed related to these topics and i anticipate having guest authors on a periodic basis. i will conclude each column with my name and e-mail for your convenience. we again are experiencing a nursing shortage, and at the same time, a decrease in numbers of faculty for schools of nursing—all types. this shortage is different from previous ones due to patients being "sicker" and home "quicker." in addition, there are fewer young persons entering colleges today and those that do have many more opportunities for careers other than nursing. schools of nursing have trouble filling nursing classes, and more importantly, have difficulty finding qualified faculty to teach. this is known as the "graying" of the professorate. the average age of nursing faculty is 49.7 years and there are not many potential persons in the pipeline. lack of qualified nursing faculty impacts numbers of students that can be admitted to schools of nursing, further decreasing numbers of nurses. in the rural areas this is extremely critical. the cost of recruiting just one nurse from a small pool of qualified persons is approaching $30,000, and that is if they stay in the position for at least two years. this cost increases dramatically if they leave prior to two years of employment. it is well documented in the literature that if persons are educated in their home online journal of rural nursing and health care, 1(1) 5 communities, they are more likely to stay there. hence, potential nurses, especially from rural areas, ask for nursing classes taught through distance education means. teaching using interactive television has been done for a number of years. newer is the development of web based courses that students can take at their own pace and time. for those who are visual, there even is a television chip that can be used with a home computer so that students/faculty can see one another! use of distance education to prepare nurses in rural areas also addresses the shortage of qualified nursing faculty. one faculty member at a large university can have a class of 20 students, all in rural areas if the course is web-based or via television. what a wonderful way to deal with scarce resources. in conclusion, i ask you to let me know your issues. i will address them in this column with the help of you, our experts. e-mail: szigetie@upstate.edu. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 methodological review of sampling procedures for rural dwelling sexual and gender minority people michael j. johnson, phd, rn1 tricia gatlin, phd, rn, cne2 1 assistant professor, school of nursing, university of nevada, las vegas, michael.johnson@unlv.edu 2 assistant professor, school of nursing, university of nevada, las vegas, tricia.gatlin@unlv.edu abstract purpose: the purpose of this paper was to review the methodological sampling and recruitment decisions of extant studies that included rural dwelling sexual and gender minority populations. design and sample: this review searched pubmed, cinahl, and scopus for papers using the following inclusion criteria: a) english language; b) primary quantitative research published in the last 10 years, and; c) included a rural adult sexual or gender minority sample from the united states. exclusion criteria included: a) duplicate studies; b) datasets older than 10 years; c) secondary data, and; d) did not differentiate between rural and non-rural samples. thirteen articles were included in the final review. results: this review identified the data collection approaches, rural classification systems, recruitment strategies, and sample demographics. five areas were identified as needing further discussion, including the lack of dissimilar research topics, predominant focus on men, missed 65 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 opportunity to identify transgender people, using social networks and smartphone applications as data collection strategies, and inconsistent rural classification systems. conclusions: researchers should capitalize on social networking and smartphone platforms. future research should include sexual minority women, transgender people, more racial and ethnic minorities, and expand beyond sexual health topics. researchers should also use objective rural classification systems. keywords: review, homosexuality, sexual minorities, transgender persons, glbt, rural population 66 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 methodological review of sampling procedures for rural dwelling sexual and gender minority people rural dwelling sexual and gender minority (sgm) people, which includes individuals who identify as lesbian, gay, bisexual, or transgender (lgbt), have unique health needs compared to urban dwellers and to non-sgm people. rural dwelling sgm people lack social support, are more socially isolated, lack access to an lgbt community, and feel less comfortable disclosing their sexual orientation or gender identity (austin, 2013; mccarthy, 2000; m. l. williams, bowen, & horvath, 2005). lack of social support and sense of belonging are heightened especially among rural sgm elders (comerford, henson-stroud, sionainn, & wheeler, 2004; king & dabelkoschoeny, 2009; lee & quam, 2013). various researchers have also found a greater prevalence of negative mental health outcomes and increased risky health behaviors among rural sgm people (horvath, iantaffi, swinburne-romine, & bockting, 2014; mccarthy, 2000; m. l. williams et al., 2005). rural communities usually lack a diverse cadre of qualified and lgbt-affirmative health professionals (institute of medicine, 2005), resulting in a fear being discriminated against in the health care setting. consequently, sgm people may delay seeking care or may hide their sexual orientation or gender identity from healthcare providers (willging, salvador, & kano, 2006). the rural geography and lack of transportation can further compound the wellbeing of sgm people. in general, disparities in health status and life expectancy between urban and rural areas can be partially explained by the fact that rural communities are geographically isolated from the services provided in large, urban areas. moreover, for rural residents without access to or the ability to drive a private car, a lack of reliable transportation options provides significant barriers for people to travel to healthcare offices, which has negative effects on health outcomes (national advisory committee on rural health and human services, 2017). 67 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 rural dwelling sgm individuals tend to lack social support as compared to their non-sgm counterparts. social support is a strong mitigating factor against negative health outcomes though. increased social contacts, social network size, and social support are associated with better health among both the general population and sgm individuals (fredriksen-goldsen et al., 2012; zaninotto, falaschetti, & sacker, 2009). given the breadth of research that has found strong relationships between social support and health outcomes, and given that rural sgm people tend to lack social support systems, more research is needed. despite the growing body of research findings indicating that rural sgm people experience negative health outcomes, more studies need to be conducted to confirm these findings and to elucidate new knowledge and relationships. the findings from additional research could inform the practice of public health nurses and workers. however, conducting research with rural dwelling sgm people can be challenging due to the barriers around sampling and recruiting participants. despite the methodological advancements in sampling sgm people (meyer & wilson, 2009), rural dwelling sgm people remain scare in most research studies. since sgm people are easier to access in urban environments, researchers presumably do not purposefully target or do not use strategies that reach rural sgm people. the lessons learned from recruiting other marginalized rural dwelling populations can be applied to sgm people. for example, younger age and higher income among rural dwelling people are predictors of willingness to participate in research (morgan, fahs, & klesh, 2005). other barriers to recruiting a rural population include uniqueness of the rural culture, necessity for rural-sensitive recruitment materials, over-sampling, and lack of local research infrastructure (cudney, craig, nichols, & weinert, 2004). additionally, research involving other marginalized populations may require recruitment strategies such as spending time in the community and 68 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 distributing flyers to key community stakeholders (i. c. williams et al., 2011). these studies indicate that specific strategies are needed to recruit rural dwelling people. however, the dearth of research and absence of a publication that reviews methodological recruitment strategies from extant studies that included rural dwelling sgm people could impede future researchers who want to include rural sgm people in their study. recruitment and sampling strategies are key methodological factors to the advancement of knowledge around the health and health care needs of rural sgm people. to understand recruitment and sampling of rural sgm people, this paper reviews the methodological decisions of extant studies that included rural sgm populations in their sampling/recruitment frame. the purposes of this project were to: 1) systematically search literature databases to identify and retrieve quantitative research publications that reported on rural or non-urban sgm populations, and 2) review the retrieved publications to identify key methodological information about the recruitment and data collection approaches, conceptual definitions for rural or non-urban, and sample characteristics (sample size, age, race, sex and/or gender, educational level, and income/employment status). methods design this review project was accomplished by adapting the integrative review process described by whittemore and knafl (2005). the overarching goal of this project was to review and synthesize sampling and recruitment methods in extant research, and to report the findings in a useful way for future researchers. the process entailed the following sequential steps: problem identification, systematic literature search, data extraction, data analysis, and report of findings. 69 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 search method a comprehensive search was conducted in the following databases: pubmed, cinahl, and scopus. the databases were searched using both key terms (mesh in pubmed and subject headings in cinahl) and non-key terms. the search terms included rural, non-urban, lesbian, gay, bisexual, transgender, lgbt, homosexual, sexual minority, and gender minority. although homosexual is not a neutral term, it still legitimately used as a keyword in pubmed. the searches were conducted using various combinations of the search terms. the searches yielded a total of 980 articles. the article titles and abstracts were first assessed for inclusion criteria, and if a determination could not be made based on those alone, then the full article was retrieved and reviewed. this resulted in the inclusion of 13 articles (967 were excluded). to be included, the articles must have (a) been published in the english language; (b) been published in the last 10 years; (c) been original quantitative primary research; (e) included a rural or non-urban adult sgm sample from the united states. articles were excluded if they (a) reported the same data from a previously included study (duplicate studies); (b) used datasets that were older than 10 years; (c) used secondary data; (d) did not differentiate the results between rural and non-rural samples (e.g., sample recruited from both rural and urban areas but the results were pooled together). data extraction and analysis a matrix table (table 1) was created with column headers for citation, design, data collection, definition for rural or non-urban, recruitment/sampling approach, and sample characteristics for rural sgm sample. the first author read each article and extracted the data in to the matrix table. both authors then created other tables (not shown) to compare the data, which allowed for easier recognition of patterns across the data. both authors conducted the data analysis 70 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 using certain recommendations from whittemore and knafl (2005), including identifying and counting patterns and themes and making contrasts and comparisons. results the 13 articles that met the inclusion criteria (austin, 2013; barefoot, warren, & smalley, 2015; bennett, mcelroy, johnson, munk, & everett, 2015; fisher, irwin, & coleman, 2014; gilbert & rhodes, 2014; horvath et al., 2014; hubach et al., 2015; li, hubach, & dodge, 2015; mendoza, harner, haseley, & leedy, 2015; preston, d'augelli, kassab, & starks, 2007; rosenberger, schick, schnarrs, novak, & reece, 2014; schnarrs et al., 2010; whitehead, shaver, & stephenson, 2016) were quantitative descriptive. the research topics included sexual health, modifiable health behaviors, mental health, and healthcare utilization. data collection most of the quantitative studies used internet surveys as the primary approach to collect data. one of the studies conducted face-to-face questionnaires (gilbert & rhodes, 2014), and another only used paper surveys (preston et al., 2007). definition of rural or non-urban most of the articles (n = 10) provided clear conceptual or operational definitions for ‘rural’ or ‘non-urban.’ in the other three studies (gilbert & rhodes, 2014; mendoza et al., 2015; schnarrs et al., 2010), the authors only reported that participants were recruited from rural areas and did not provide specific definitions. of the 10 studies that provided definitions, four (austin, 2013; barefoot et al., 2015; horvath et al., 2014; rosenberger et al., 2014) used a categorical question that asked research subjects to self-report geographical location of their residence, such as large city or urban area, suburbs of large city, town or village, or rural area. however, none of those 71 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 studies defined the population size for each geographical location, thus leaving participants to interpret the definitions for each of the geographical locations. the remaining six articles that provided a definition used either self-reported zip codes or county of residence to determine geographical areas; however, the classification systems differed. some researchers classified zip codes using rural-urban community areas (ruca) codes (bennett et al., 2015) or metropolitan statistical areas (msa) (fisher et al., 2014), which are systems used by the federal government. two other studies used the index of relative rurality (irr) to categorize the geographical area based on self-reported county or zip code (hubach et al., 2015; li et al., 2015). the other two studies used a pre-determined population density for rural or non-urban areas. preston and colleagues (2007) classified a county as rural if the population density was fewer than 274 persons per square mile, whereas whitehead and colleagues (2016) used a population density of fewer than 1,000 persons per square mile. recruitment / sampling approach seven recruitment approaches were identified during the review, including print ads (n = 4), electronic ads (n = 8), paper flyers (n = 4), emails (n = 4), respondent driven or snowball sampling (n = 3), community partnerships (n = 2), and participation incentives (n = 6). the number of recruitment approaches per study ranged from one to five (m = 2.4). none of the papers clearly justified recruitment approaches. the print and electronic advertisements were published mostly in lgbt specific publications and websites (social networking and dating). paper flyers were primarily distributed at lgbt-specific events, community centers, and social venues. those studies that used emails as a recruitment approach primarily sent them to lgbt-related organizations and listservs. the studies that used community partnerships worked with hiv agencies. 72 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 three studies used either respondent driven sampling or snowball sampling to recruit participants. gilbert and colleagues (2014) recruited 17 seed participants and then incentivized them to refer other people from their social networks, achieving a final sample size of 190. mendoza and colleagues (2015) distributed 25 paper surveys at lgbt community gatherings and then asked participants to refer their friends to an online survey, yielding a sample size of 41. the third study (fisher et al., 2014) did not report how they accomplished respondent driven sampling and resulted in a sample size of 75. sample characteristics for rural sgm sample key demographic and sample characteristics were reviewed for each study, including sgm sample size (non-sgm sample size not reported), age, race and ethnicity, sex or gender, educational level, and income/employment status. as shown on table 1, numerous studies did not comprehensively report the sample characteristics. the sgm sample sizes ranged from 41 to 5357 (m = 745.15). eleven studies reported the age as either categorically or using the mean. one study (gilbert & rhodes, 2014) had a sample that was 100% latino, and two other studies had diverse samples (barefoot et al., 2015; gilbert & rhodes, 2014), where non-hispanic white made up less than 80% of the total sample. three studies (fisher et al., 2014; horvath et al., 2014) did not report race or ethnicity details. additionally, nine of the studies reported samples that had received at least some college education. two studies reported a mostly high school educated sample (gilbert & rhodes, 2014; horvath et al., 2014; mendoza et al., 2015), and two other studies did not report the educational level for their subjects. overall, most of the studies recruited samples that were college educated. all studies reported the sex or gender of their sample in either the body of the paper or in the title. six studies had male-only samples (gilbert & rhodes, 2014; hubach et al., 2015; li et 73 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 al., 2015; preston et al., 2007; rosenberger et al., 2014; schnarrs et al., 2010) and three had femaleonly samples (austin, 2013; barefoot et al., 2015; mendoza et al., 2015). five studies (bennett et al., 2015; fisher et al., 2014; gilbert & rhodes, 2014; horvath et al., 2014; whitehead et al., 2016) included transgender people in their sample, and one study included intersex people (bennett et al., 2015). the number of transgender people per study ranged from seven to 344. the remaining studies either did not collect gender identity data or did not report it. discussion although there were only 13 articles identified in this project, the results of the review revealed important information. five distinct areas were identified as needing further discussion, including the lack of dissimilar research topics, predominant focus on men, missed opportunity to identify transgender people, using social networks and smartphone applications as data collection strategies, and inconsistent rural classification systems. future studies need to expand beyond the four topics identified in these research studies, which included sexual health, modifiable health behaviors (e.g., smoking and obesity), mental health, and healthcare utilization. although these research studies contributed important findings to the state of science for rural sgm people, a wide research gap remains. for example, researchers have established numerous health and healthcare disparities among sgm people, such as tobacco and alcohol use, breast cancer, lack of preventive screenings, depression and suicidality, and homelessness (institute of medicine, 2011). adding to the concern, many of these areas overlap with health disparities among the general rural population. for instance, rural areas tend to have higher rates of mental health issues and suicidality (centers for disease control and prevention, 2016b) and lack comprehensive healthcare services, such as mental health and disease 74 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 specialists (institute of medicine, 2005). most of these areas are not well understood among rural dwelling sgm people, thus leaving numerous research opportunities. this review revealed that much of the research with rural sgm people heavily focuses on men, which is likely related to the fact that half of the studies focused on sexual health. this is not surprising though, considering that of the 113 studies funded by national institutes of health between 1989 and 2011, over 86% studied sexual minority men and 79% focused on hiv/aids (coulter, kenst, bowen, & scout, 2014). gay men certainly need to be studied given their high rates of depression, anxiety, suicidality (cochran & mays, 2008), alcohol and drug abuse (ostrow & stall, 2008), and hiv (centers for disease control and prevention, 2016a). however, the lack of representation of sexual minority women and transgender people in the already limited body of rural sgm research is concerning. the unique health needs of those other sub-groups remain poorly understood. over half of the studies in this review only reported binary sex/gender (male or female), and thus missed the opportunity to include rural transgender people in their sample, a group that is grossly underrepresented in research. since scientific knowledge about the health, mental health, and social status of people in the u.s. comes from survey data, and because these data are important to assessing the need for public health policies and group disparities, researchers should collect birth sex and gender identity data (american psychological association, 2016). moreover, one of the only known studies that recruited rural and non-rural individuals who were exclusively transgender found higher rates of poverty, depression, and anxiety among rural dwellers (horvath et al., 2014), indicating a need to identify transgender people in research. although there is no consensus on how to ask questions about gender identity, the majority of research supports using a two-step method (capturing assigned birth sex and current gender identity) (office of 75 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 management and budget, 2016). future researchers should collect sexual orientation and gender identity data. although researchers have been using social media to effectively recruit vulnerable populations for many years (uybico, pavel, & gross, 2007), many of the studies in this review successfully capitalized on existing internet platforms that are safe spaces for sgm people. for example, studies used networking sites and smartphone applications meant for social and sexual encounters, such as grindr, craigslist, and facebook. the pew research center (2015) established that nearly 60% of rural residents use social networking websites, which poses an opportunity to use those platforms to recruit for research. although cell phone coverage is limited in some rural areas, future researchers may also reach more rural sgm people by using innovative smartphone applications and/or text messaging to recruit and collect survey data. for example, hofmann and patel (hofmann & patel, 2015) found text messaging as an effective tool for recruitment. another study, conducted by the university of california san francisco (university of california san francisco, 2016), used a novel smartphone application that allows research subjects to enroll and participate in studies using cell phones. clearly defining the target population early in a research study is important for determining the eligibility of individuals for a study, for applying the results to other relevant populations, and for assuring the overall validity of the results (eldredge, weagel, & kroth, 2014). although this issue is not specific to sgm populations, there was no consistency between the studies in how they operationally defined rural, which limits the ability to compare and generalize findings. moreover, numerous studies used a categorical self-report question to identify the rural sample. this type of question requires the research subject to interpret the definition of each geographical category, which could affect the reliability. further psychometric testing should be done to 76 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 establish the test-retest reliability and validity of geographical location questions. researchers could also use a more reliable measure, such as categorizing self-reported zip codes using the u.s. census bureau’s classification system. other more sophisticated methods based on network science and community-level data (wunderlich, 2016) may provide more accurate geographical classifications, but they can be complex and typically require statisticians with specialized knowledge. conclusions one limitation of the review was its focus on the pubmed, cinahl, and scopus databases. the authors did not search other databases or gray literature. thus, it is possible that the authors missed other articles on this topic. additionally, the authors did not include qualitative research because the recruitment approaches are typically less intensive than quantitative studies. despite these limitations, the findings from this review can assist future researchers with their methodological decisions. researchers should take advantage of existing social networking and smartphone application platforms for sgm users, especially considering a large percentage of americans use the internet and have cell phones. this approach should be used in conjunction with collaborations or partnerships with rural community resources. future research needs a more diverse sample and include sexual minority women, transgender people, and more racial and ethnic minorities. additionally, the topics of research need to expand beyond sexual health. finally, researchers could use a more objective rural classification system and not rely on the participants to interpret their geographical location. 77 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 references american psychological association. 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(2009). age trajectories of quality of life among older adults: results from the english longitudinal study of ageing. quality of life research, 18, 1301-1309. http://dx.doi/org/10.1007/s11136-009-9543-6 83 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 table 1: review of studies that included rural dwelling sexual and gender minority people citation design data collection definition for rural or non-urban recruitment / sampling approach sample characteristics for rural sgm sample* austin, e. l. (2013). sexual orientation disclosure to health care providers among urban and non-urban southern lesbians quantitative descriptive online and paper survey self-reported as either large city, suburbs of large city, small city, town or village, or rural area those not living in large city or suburbs were coded as “non-urban” • print and electronic advertisements: lgbt local newspapers and magazines; lesbian-oriented websites; message boards • paper flyers: lgbt events, communityand universitybased enters, support groups, bookstores, and religious organizations • incentive: not offered • n = 309 • age: m = 41.4 years • race/ethnicity: 8.5% non-white • sex and/or gender: 100% female • education: 62.1% college • income: 41.9% above $50k barefoot, k. n., warren, j. c., & smalley, k. b. (2015). an examination of past and current influences of rurality on lesbians’ overweight/obesity risks quantitative descriptive online survey self-reported as either living in a rural or urban area • electronic advertisements: volunteer section of every u.s. municipality on craigslist (477 sites) for a total of 3 times throughout the year because system deleted them every 30 days • emails: over 5,000 sent out to lgbt-related organizations and listservs located in all 50 states • incentive: raffle to win $50 gift card • n = 1,019 • age: m = 32.2 years • race/ethnicity: 74.5% white • sex and/or gender: 100% female • education: 88.5% at least some college bennet, k., mcelroy, j. a., johnson, a. o., munk, n., & everett, k. d. (2015). a persistent disparity: smoking in rural sexual and gender minorities quantitative descriptive online and paper survey self-reported zip code was categorized as either urban or rural using rural-urban commuting area codes (ruca ranges from 1-9 and this study coded 1-3 as urban and 4-9 as rural) • print and electronic flyers: six different missouri pride festival booths • emails: lgbt missouri listservs and organizations • incentive: not offered • n = 353 • race/ethnicity: 91.4% white; 5.1% hispanic • sex and/or gender: 61.1% female; 0.9% intersex; 2% transgender • education: 76.1% at least some college fisher, c. m., irwin, j. a., & coleman, j. d. (2014). lgbt health in the midlands: a rural/urban comparison of basic health indicators quantitative descriptive online survey self-reported zip codes were categorized as either urban (metropolitan statistical areas) or rural (all others) • print advertisements: lgbt publications • paper flyers: lgbt venues; lgbt events and pride celebrations; • email: lgbt community listservs in nebraska • n = 75 • age: 44% (19-29 years); 17.3% (3039); 18.7% (40-49); 14.7% (50-59); 5.3% (60+) • sex and/or gender: 65.3% male; 37.9% female; 10.7% transgender • education: 87.7% at least some college • income: 47.7% less than $25k 84 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 • university press release which was then picked up by newspapers resulting in dramatic increase in participation • respondent-driven sampling • incentive: $5 gift card gilbert, p. a., & rhodes, s. d. (2014). immigrant sexual minority latino men in rural north carolina: an exploration of social context, social behaviors, and sexual outcomes quantitative descriptive face-to-face survey using spanish-speaking male interviewer not reported clearly but participants had to reside in one of seven rural counties in central north carolina to be included in the study • respondent-driven sampling (17 seed participants recruited from community partner social networks) • incentive: $50 for participating and $20 for each referral • n = 190 • age: m = 25.5 years • race/ethnicity: 100% latino • sex and/or gender: 100% male; 16% transgender • education: 32% at least some college • income: 83% less than $29k horvath, k. j., iantaffi, a., swinburne-romine, r., & bockting, w. (2014). a comparison of mental health, substance use, and sexual risk behaviors between rural and non-rural transgender persons quantitative descriptive online survey self-reported residence as rural or small town (coded as “rural”), city, large town or suburban (coded as “non-rural”) • electronic advertisements: transgender community websites; online mailing lists; journals; forums • incentive: $30 online gift certificate • n = 344 (62.2% transwomen and 37.8% transmen) • age: m = 38.7 years (transwomen); 26.2 (transmen) • education: 38.8% at least some college (transwomen); 62.3% (transmen) • income: 28% poverty (transwomen); 46% (transmen) hubach et al. (2015). loneliness, hiv-related stigma, and condom use among a predominantly rural sample of hivpositive men who have sex with men (msm) quantitative descriptive online survey self-reported county of residence was categorized as rural or mixed rural using index of relative rurality • electronic advertisements: social networking websites for gay men • paper flyers: venues for gay men with hiv throughout south central indiana • incentive: $25 retail gift card • n = 100 • age: m = 42.6 years • race/ethnicity: 86% white • sex and/or gender: 100% male • education: 64% at least some college • income: 62% less than $20k li, m. j., hubach, r. d., & dodge, b. (2015). social milieu and mediators of loneliness among gay and bisexual men in rural indiana quantitative descriptive online survey self-reported zip code analyzed using index of relative rurality • electronic advertisements: mobile applications and websites geared toward men who have sex with men (adam4adam, craigslist, grindr); community organizations; college lgbt centers • incentive: not offered • n = 225 • age: m = 30.7 years • race/ethnicity: 84% white; 7.1% asian / pacific islander • sex and/or gender: 100% male • education: 87.6% at least some college • income: 25.33% unemployed 85 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 mendoza, n. s., harner, v., haseley, h., & leedy, g. (2015). the physical self-perceptions of rural lesbians and heterosexual women quantitative descriptive online and paper survey not reported clearly but participants were recruited from rural areas in wyoming • paper advertisements: united gays and lesbians of wyoming newspaper • respondent-driven: twenty-five paper surveys distributed at annual lgbt community social gathering in southeast wyoming and those women were asked to refer lesbian friends to take the online survey • incentive: not reported • n = 41 • age: m = 40.40 years preston, d. b., d’augelli, a. r., kassab, c. d., & starks, m. t. (2007). the relationship of stigma to the sexual risk behavior of rural men who have sex with men quantitative descriptive paper survey self-reported county was classified as rural if population density was fewer than 274 persons per square mile • mailing lists of non-profit political action group and a social group used to mail out surveys • two local aids organizations distributed and collected surveys • surveys distributed at pride festivals, gay bars, social groups, dances, etc. • incentive: not reported • n = 414 • age: m = 40 years • race/ethnicity: 89% white • education: 78% at least some college rosenberger, j. g., schick, v., schnarrs, p., novak, d. s., & reece, m. (2014). sexual behaviors, sexual health practices, and community engagement among gay and bisexually identified men living in rural areas of the united states quantitative descriptive online survey self-reported residence as large city, medium city, small city, small town not close to city, or rural area included if lived in small city or small town not close to city • email: to every account holder on the world’s largest internetbased networking site for men who are seeking social or sexual interactions with other men • incentive: not reported • n = 5,357 • age: m = 40.6 years • race/ethnicity: 90% white • education: 84.4% at least some college • income: 66% full-time job schnarrs, p. w. et al. (2010). sexual compulsivity, the internet, and sexual behaviors among men in a rural area of the united states quantitative descriptive online survey not reported clearly but participants were recruited from the rural midwest u.s. • electronic advertisements: internet forums and local resource websites for msm • paper flyers: local retail stores and venues • face-to-face at community venues for hiv testing and aids organizations • n = 246 • race/ethnicity: mostly white • sex and/or gender: 100% male 86 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.448 • incentive: raffle for 1 of 40 $50 visa gift card whitehead, j., shaver, j., & stephenson, r. (2016). outness, stigma, and primary health care utilization among rural lgbt populations quantitative descriptive online survey self-reported zip code was classified as rural if had a population density of less than 1,000 people per square mile • electronic advertisements: facebook (targeted 18+ year old with lgbt related interests who reported rural zip codes) • incentive: not offered • n = 1,014 • age: m = 32.4 years • race/ethnicity: 88% white • sex and/or gender: 36.3% female; 47% male; 16.7% transgender • education: 77% at least some college * non-lgbt and non-rural sample size not reported 87 1-19 20-23 microsoft word graves_282-1536-2-ed.docx online journal of rural nursing and health care, 13(2) 56 telehealth technologies for heart failure disease management in rural areas: an integrative research review barbara ann graves, phd, rn 1 cassandra d. ford, phd, rn 2 kathryn davis mooney, rn 3 1 associate professor of nursing, capstone college of nursing, university of alabama, agraves@ua.edu 2 assistant professor of nursing, capstone college of nursing, university of alabama, ford039@ua.edu 3 registered nurse, ksdmooney@gmail.com abstract purpose: the purpose of this integrative research review (irr) is to present evidence of the use and effectiveness of telehealth technologies for improving health outcomes in heart failure (hf) disease management in general as well as the use and effectiveness specific to rural populations. background: hf is the most common chronic disease cause of hospitalization in the u.s. with subsequent high admission rates and cost. because many rural areas are designated as medically underserved, disease management for patients with hf living in rural areas is challenging and in need of innovative management strategies. telehealth technologies have capabilities to provide frequent surveillance and improve outcomes in a variety of health conditions. methods: an irr methodology was used to present evidence of the use and effectiveness of telehealth technologies in the provision of disease management to hf patients in both the general and rural populations. online journal of rural nursing and health care, 13(2) 57 findings: results showed five broad themes of effectiveness: improved knowledge, improved self-care behaviors, improved health outcomes, cost reduction and patient satisfaction. telehealth technologies have proven effective in the management of hf patients by detecting changes in health status earlier, decreasing the rates of hospital readmission and emergency department visits, decreasing costs, and improving self-care behaviors and quality of care. conclusion: evidence from clinical trials supports the use of telehealth in disease management in general as well as future development of strategies for management of hf in rural populations. keywords: heart failure, telehealth, rural telehealth technologies for heart failure disease management in rural areas: an integrative research review congestive heart failure (hf) is a major chronic disease in the united states. according to the american heart association ([aha], 2009) it is estimated that approximately 5.8 million americans live with congestive heart failure (hf), leading to approximately 300,000 deaths each year. while hf management can be complex and challenging, there is added level of complexity for rural residents who are known to experience many barriers to health care access and disparities in health status. the role of telehealth technologies in the delivery of health care, improving access and reducing disparities is gaining attention. the purpose of this integrative research review (irr) is to present evidence of the use and effectiveness of telehealth technologies for improving health outcomes in hf disease management. with this purpose in mind, the research questions that guided this irr are as follows: 1.) how have telehealth technologies been used in the management of heart failure patients (in general) and are they effective? 2.) how have telehealth technologies been used in the management of heart failure patients in rural populations and are online journal of rural nursing and health care, 13(2) 58 they effective? 3.) what are the future implications of telehealth technologies in the management of patients with heart failure in rural areas? background heart failure heart failure is the most common disease diagnosis among hospitalized adults age 65 years and older. furthermore, high readmission rates and prolonged length of stay due to hf have contributed to escalating use of resources and health care cost. the estimated cost of hf, direct and indirect, for 2007 in the us was $33.3 billion (aha, 2009). over the next decade it is projected that the number of us adults age 65 and older will double to 70 million. growth of this magnitude will naturally lead to increases in the known risk factors for hf such as atrial fibrillation, sclerotic valvular heart disease, obesity, diabetes mellitus, and renal dysfunction (lui, 2010). clinical implications point toward a need for innovative and strategic responses, creating access to clinical treatment and prevention strategies for hf. rural health disparities the national healthcare disparities report (agency for healthcare research and quality [ahrq], 2010) documents issues within both quality and access in healthcare. from this report it is clear that disparities in healthcare still exist and that many opportunities for improvement remain across racial, ethnic, socioeconomic and geographical groups. one priority population is in rural, medically underserved areas. it is well documented that residents of rural areas experience more health disparities than residents of urban areas (ahrq, 2010; bennett, olatosi, & probst, 2008; u.s. department of health and human services [usdhhs], 2007). patients in rural areas are often challenged and must overcome many obstacles to healthcare access. barriers online journal of rural nursing and health care, 13(2) 59 such as finances, sociocultural issues, structural features and geography are known to decrease access to healthcare services in rural environments leading to poor health outcomes (bennett et al., 2008; usdhhs, 2007). rural areas are more likely than urban areas to have higher rates of uninsured and underinsured populations, higher rates of poverty, greater transportation barriers and limited care providers (usdhhs, 2007). rural populations also experience higher rates of chronic disease and mortality. rural residents are more likely to report deferred care due to cost and are less likely to have recommended preventative health screenings (usdhhs, 2007). it is well documented that poverty and lack of health care are intertwined; persons without resources cannot afford health services, and communities without resources have difficulty attracting and retaining health care providers. inherent in rural environments is the obvious issues of distance and access to health care. transportation also presents as a significant barrier to health care access for rural residents, the poor and other health disparate populations (bennett et al., 2008; usdhhs, 2007). furthermore, it is easy to see how rising gasoline prices can compounded this problem. telehealth telehealth uses communication methods to link patients with health care providers (artinian, 2007; bowles & baugh, 2007). telehealth technologies such as telephone, televideoconferencing, and internet-based applications, have capabilities to provide frequent surveillance of a variety of health conditions (dorrian et al., 2009; spauling, davis, & patterson, 2008; nesbitt, cole, pellegrino, & keast, 2006; givens & elangovan, 2003; glueckauf et al, 2002). online journal of rural nursing and health care, 13(2) 60 telehealth has been used extensively for the management of diabetes (dansky, bowles, & palmer, 2003; davis et al., 2010) and to a lesser degree with other chronic conditions such as chronic obstructive pulmonary disease (copd) (horton, 2008), and hf (chumbler, mann, wu, schmid, & kobb, 2004; gardner, frantz, & pringle-sprecht, 2001; jenkins & mcsweeney, 2001). the remote nature of rural environments is an excellent opportunity for the demonstration of the effectiveness of telehealth in disease management. rural health disparities, heart failure, and telehealth current healthcare disparities noted in rural populations coupled with the burden of hf is one opportunity for the use of advanced technologies such as telehealth management systems. the development and application of telehealth interventions for the treatment and prevention of hf events in rural areas could be one link toward eliminating rural health disparities. heart failure is a widespread cardiovascular disease in the us (aha, 2009). coordination of care and telehealth are two areas critical for quality of life and improved health for individuals with chronic hf living in rural underserved areas. only a small number of clinical trials have been published in the area of hf management using telehealth technologies in rural populations. a significant gap exists in the current knowledge of the effectiveness of hf management using telehealth interventions in rural populations. integrating concepts of hf, rural and telehealth can provide a framework to guide the development of interventions in eliminating rural health disparities. methods the overall goal of conducting any systematic research review (srr) is to bring together studies that answer particular research questions (brown, 2009). integrative research reviews (irr) are one type of srr that are useful to expand understanding for a particular problem or online journal of rural nursing and health care, 13(2) 61 topic therefore generating knowledge. integrative research review methodologies are systematic and use rigorous inclusion and exclusion criteria and repeated sequences to sort research until the highest quality of evidence is found. narrative summaries of existing studies are used in irr to draw conclusions that can guide decision making (brown, 2009; lobiondo-wood & haber, 2010). an irr methodology was used to review past clinical trial research studies in which telehealth technologies were used to provide management to hf patients in both the general and rural populations. a database search of cinahl, pubmed, medline, ebscohost, and proquest was conducted using the keyword integrations: “heart failure and telehealth” and “heart failure, rural and telehealth”. the integrative search inclusion criteria was limited to clinical trial research articles or randomized controlled trials (rct) in the english language published between january 2000 and april 2010. the rct is considered to have a high level of rigor and therefore study results afford a high level of evidence to guide future practice (ahrq, 2002). only articles with the paired keywords were extracted for full review. this strategy resulted in 25 final articles for review; 14 articles were selected based on relevance. articles reporting incomplete clinical research were excluded. results table 1 presents details of the literature search results: author, key words, purpose, sample, outcomes measured, and results. a total of 14 clinical trials were reviewed based on the inclusion and exclusion criteria and relevance (see table 1) online journal of rural nursing and health care, 13(2) 62 table 1 clinical trial research integrating heart failure, rural and telehealth author/ year keywords purpose(s) sample outcomes results caldwell, peters, and dracup, (2005) heart failure, telehealth, rural to determine whether a simplified education program focused on a single component of disease management (system recognition and management of fluid weight) could improve knowledge, patientreported selfcare behaviors, and hf severity in a rural setting. 36 rural hf patients knowledge, self-care behaviors, and hf severity (bnatriuretic peptide [bnp] knowledge levels and self-reported self-care behaviors improved significantly (p = .01 and .03) and the changes in bnp at 3 months was in the hypothesized direction, yet the difference was not significant clark et al. (2007) heart failure, rural, telehealth to determine adherence adaptation and acceptability to a national nursecoordinated telephone monitoring chf management strategy 60 elderly hf patients adherence, adaptation & acceptability elderly chf patients can adapt quickly, find telephone monitoring an acceptable part of their healthcare, and are able to maintain good adherence. dansky, vasey, and bowles (2008a) heart failure, telehealth to determine the effects of telehomecare on hospitalizatio n, ed use, mortality, and 284 patients with hf hospitalizatio n, ed use, mortality, and symptoms on average, patients in the telehomecare groups had a lower probability of hospitalizations and ed visits than did patients in the control group. differences were online journal of rural nursing and health care, 13(2) 63 author/ year keywords purpose(s) sample outcomes results symptoms related to sodium and fluid intake, medication use, and physical activity. statistically significant at 60 days but not 120 days. results show a greater reduction in symptoms for patients using telehomecare compared to control patients. dansky, vasey, and bowles (2008b) heart failure, telehealth the use of telehealth facilitates patient confidence with subsequent effects on patients’ ability to manage their treatment regimen more effectively. 284 home health patients with hf confidence confidence is a predictor of selfmanagement behaviors. patients using a videobased telehealth system showed the greatest gain in confidence levels with time. findings suggest that confidence may be improved by involvement of nurses as part of a telehealth system. dansky and vasey (2009) heart failure, telehealth to determine if the use of a telehealth system after formal home health services would improve clinical outcomes and selfmanagement behaviors. 108 patients with hf respiratory status, activities of daily living, hospitalizatio ns, ed events patients who continued using telehealth beyond the formal episode of care showed greater improvement in respiratory status and activities of daily living. none of the patients who used telehealth during this stage had any hospitalizations or ed events, while 28.3% of the control group patients required hospitalization and 26.1% had at least one ed visit. finkelstein, speedie, and potthoff, (2006) heart failure, rural, telehealth to evaluate patient outcomes, cost, and satisfaction with hhc delivered by telemedicine 53 patients with diagnosis of hf, copd, chronic wound care transfer to higher level care, mortality, cost, & satisfaction discharge to higher level of care (hospital, nursing home) within 6 months of study participation was 42% for c subjects, 21% for v subjects, and 15% for m subjects. no online journal of rural nursing and health care, 13(2) 64 author/ year keywords purpose(s) sample outcomes results or traditional means for patients receiving skilled nursing care at home. difference in mortality between groups. average visit cost = $48.27 for face-to-face home visits, $22.11 for average virtual visits (video group), and $32.06 and $38.62 for average monitoring group visits for hf and copd subjects, respectively. this study demonstrated that virtual visits for chronically ill patients at home can improve patient outcomes at lower cost. laframboise,to dero, zimmerman, and agrawal, (2003) heart failure, telehealth to determine the feasibility of providing a hf disease management program using inhome telehealth devices (health buddy) and to compare the effectiveness with traditional home management strategies. 90 confidence, functional status, depression, & healthrelated quality of life (hrql) those who received telephonic disease management experienced decreased confidence in their ability to manage hf whereas all other groups experienced increased confidence. improvement was noted but no group differences in functional status, depression, or (hrql). noel, vogel, erdos, cornwall, and levin, (2004) heart failure, rural, telehealth to determine whether home telehealth, when integrated with the health facility’s medical record 104 frail elderly veterans with chf, copd, and/or dm. clinic/ed visits, and a1c levels, cognitive status, patient satisfaction, functional levels, and patient-rated health status compared to control, scores for home telehealth subjects showed statistical significance decrease at 6 months for bed-daysof-care, urgent clinic/ed visits, and a1c levels; at 12 months for cognitive status and at 3 months online journal of rural nursing and health care, 13(2) 65 author/ year keywords purpose(s) sample outcomes results system, reduces healthcare cost and improves quality-oflife outcomes relative to usual home healthcare services for elderly high resource users with complex comorbidities. for patient satisfaction. functional levels and patient-rated health status did not show significant differences for either group. radai et al. (2008) heart failure, telehealth to demonstrate feasibility and consistency in lung resistivity measurement s using a new bioimpedanc e telemedicine device for monitoring of chf patients at home. 5 healthy men 10 elderly patients with pulmonary congestion lung resistivity measurement s preliminary results show that measured resistivity values among healthy young patients are consistent and reproducible within. the mean resistivity in patients with pulmonary congestion were lower than those in healthy patients. the system was noninvasive, safe, and portable. this system demonstrated the ability to retrieve unique data correlated with the amount of fluid in the lungs and transmits the data to a medical call center in order to improve treatment and outcomes for chf. wakefield, ward, et al. (2008) heart failure, telehealth evaluated the efficacy of a program for patients upon discharge using telehealth technologies in reducing hf patients readmission rates, time to first readmission, urgent care clinic visits, survival & quality of life comparison of intervention to usual care resulted in a significant increase in the amount of time until readmission. mortality rates, readmission rates, hospital days, and urgent care clinic use online journal of rural nursing and health care, 13(2) 66 author/ year keywords purpose(s) sample outcomes results resource use. remained unchanged. patient stated quality of life improved with telehealth care via telephone lines. there was little evidence to support video-based telehealth as a better alternative to telephone follow-up. wakefield, bylund, et al. (2008) heart failure, telehealth to determine if differences exist in communicati on profiles between telephone and videophone interactions & if communicati on profiles change over time? 28 patients with hf & hospital readmissio n for hf exacerbatio n home based communicati on intervention. results of the study did not support use of videophone over the telephone. wakefield et al. (2009) heart failure, telehealth evaluated the efficacy of 2 telehealth applications, delivered by telephone and videophone, for improving outcomes of patients following hospital discharge for an acute exacerbation of heart failure 148 patients (iowa city veterans affairs medical center) self-efficacy, satisfaction with care, compliance using survey specific to telehealth. no significant differences noted between groups in medication compliance, self-efficacy or satisfaction with care. knowledge scores improved in the intervention group. whitten and mickus (2007) heart failure, telehealth to determine if patient health outcomes are similar when 67 patients with copd or chf self-rated health status, care access, disease self management. addition of telehealth to copd/chf patient care was not a significant predictor of health and wellbeing. online journal of rural nursing and health care, 13(2) 67 author/ year keywords purpose(s) sample outcomes results supplementin g care with telehealth as compared with traditional care only & what is the attitude of patients with copd/chf toward home telehealth after they have experience it? patient satisfaction patients were satisfied with care delivery via this modality. woodend et al. (2008) heart failure, telehealth to test the impact of 3 months of telehome monitoring on hospital readmission, quality of life, and functional status in patients with hf or angina. 249 patients with hf or angina hospital readmission, health care resource use, morbidity, functional & quality of life. telehome monitoring significantly reduced the number of hospital readmissions and days spent in the hospital for patients with angina and improved quality of life and functional status in patients with hf and angina. patients found the technology easy to use and expressed high levels of satisfaction. online journal of rural nursing and health care, 13(2) 68 heart failure and telehealth dansky and vasey (2009) conducted a study to determine the effectiveness of the use of a telehealth system after discharge from home health services. participants with primary or secondary hf were recruited from 10 home health agencies across the u.s. and randomized to either a telehealth or control group upon discharge. the telehealth group received health buddy telehealth system monitoring during and after formal home health while the control group received no further monitoring. results showed that patients who continued using telehealth beyond the formal episode of care showed greater improvement in respiratory status and activities of daily living. none of the patients who used telehealth during this stage had any hospitalizations or emergency department (ed) events, while 28.3% of the control group patients required hospitalization and 26.1% had at least one ed visit. dansky et al. (2008a) conducted a randomized field study with heart failure home health patients. patients in the control group received routine home visits only. at 60 and 120 days, telehomecare patients had fewer hospitalizations; yet, only the 60 day time period was statistically significant. patients in the control group experienced more emergency department visits and hospitalizations versus the telehomecare patients (including the monitor and video groups). telehomecare patients also indicated decreased symptoms (i.e., medication effectiveness and sodium and fluid intake) except in relationship to physical activity. dansky et al. (2008b) conducted a randomized control study with home health patients diagnosed with hf. data was collected at three points by telephone interview. patients were divided into three groups: control, video systems, and asynchronous or monitoring. over time, each group showed improvement; however, the most improvement was noted in the video group. significant differences were not noted between the control and monitoring groups. the majority online journal of rural nursing and health care, 13(2) 69 of patients’ self-management behaviors were predicted by confidence in their self-management of their condition. video group scores showed the most improvement. these findings suggest that confidence levels may be improved by the involvement of nurses and telehealth systems. radai et al. (2008) tested a bioimpendace telemedicine, pulmotrace@home, system to monitor elderly hf patients. the lung resistivity of patients was measured to identify pulmonary edema. preliminary analyses indicated that the system can be useful for measuring lung resistivity and monitoring hf patients. results also showed that the measured resistivity values among healthy young patients are consistent and reproducible within 48 hours. the mean resistivity in patients with pulmonary congestion was lower than those in healthy patients. the system was noninvasive, safe, and portable. this system demonstrated the ability to retrieve unique data correlated with the amount of fluid in the lungs and transmission of the data to a medical call center in order to improve treatment and outcomes for hf. wakefield, ward et al. (2008) conducted a study to evaluate the efficacy of a telehealthfacilitated post discharge support program in reducing resource use in patients with hf. patients with documented hf were eligible if they had a phone line in the home, the absence of significant communication deficit or cognitive impairment, enrollment in the agency’s primary care clinic, and english-speaking abilities. patients were randomized to telephone, videophone, or usual care for follow-up care after hospitalization for hf. outcome measures used in the study included readmission rates, time to first readmission, urgent care clinic visits, survival, and quality of life. the intervention as compared to the usual care resulted in a significant increase in the amount of time until readmission. however, mortality rates, readmission rates, hospital days, and urgent care clinic use remained unchanged. all subjects reported higher quality of life scores at online journal of rural nursing and health care, 13(2) 70 one year. there was no evidence to support video-based follow-up as a better alternative to telephone follow-up. wakefield, bylund et al. (2008) drew from the previous randomized controlled trials of hf management to compare differences in nurse and patient communication profiles between two telehealth modes: telephone and videophone. subjects were enrolled in the study if they met the following requirements: a mini-mental status examination score of greater than 22, phone line in the home, diagnosis of heart failure, hospital admission for heart failure exacerbation. after audiotaping, telephone and videophone interactions were analyzed using the roter interaction analysis system and a likert-type scale was used to analyze quantitative measures. demographics, nurse perceptions, patient perceptions, changes in communication profiles between telephone and video telehealth, and changes in communication profiles over time were all analyzed based on improvements contributed to telehealth. the study found no difference between nurse’s perception of telephone and videophone interventions and no significant difference in patient satisfaction. in conclusion, the study did not support the use of videophone over telephone communication. in a follow-up study wakefield et al. (2009) analyzed data from a previous study to evaluate the efficacy of two telehealth applications, delivered by telephone and videophone, for improving outcomes of patients following hospital discharge for an acute exacerbation of heart failure. participants were screened within 24 hours of admission to the hospital with possible heart failure exacerbation. at hospital discharge patients were randomized to the videophone intervention or telephone intervention. self-efficacy, satisfaction with care and knowledge of and compliance with prescribed medications were all assessed. outcome measures were all evaluated based on the differences between video and telephone telehealth. no significant difference was online journal of rural nursing and health care, 13(2) 71 noted between videophone and telephone telehealth communications in medication compliance, self-efficacy or satisfaction with care. the intervention group showed improved knowledge scores and was more likely to have had medications adjustments during the 90-day intervention period. the researchers concluded that it was possible that the noted delayed time to readmission was due to routine monitoring of hf symptoms which led to medication changes. laframboise (2003) conducted a randomized controlled trial with recently discharged heart failure patients. in this study, researchers found that use of a device such as the health buddy system was feasible for education and assessment in the majority of study participants with heart failure. except in the case of telephonic delivery, the heart failure management program improved participants’ self-efficacy in relation to heart failure management. despite the delivery method, functional status was improved in turn affecting the need for institutional care and mortality. there was also a tendency for improvement in depression over time as well as improved quality of life. whitten and mickus (2007) conducted a study to assess the use of telehealth with chronic obstructive pulmonary disease (copd) and congestive heart failure (chf) home health patients. patients were randomized to a control group or experimental group; and health outcomes and patient perceptions of telehealth were evaluated. the experimental group had visits via videoconferencing and face-to-face interactions. results of the study indicated patient satisfaction with telehealth and care delivery using this mechanism. the majority of participants viewed telehealth as helpful in increasing care access (79%) and improving disease selfmanagement (68%). the findings for the control and experimental groups were similar. the sf36 general health subscale ratings in the experimental group were poorer post-intervention. yet, this finding was significant only when a number of variables in the model were controlled. online journal of rural nursing and health care, 13(2) 72 woodend et al. (2008) conducted a randomized control trial over a three month period to evaluate the effect of telehome monitoring on patients’ hospital readmissions, functional status, and quality of life. improvements were seen in individuals that participated in the intervention in relation to quality of life and functional status. in patients with angina, emergency department visits, readmissions to the hospital, and days in the hospital were lower. however, this was not found in heart failure patients. telehome monitoring patients were able to use the technology and levels of satisfaction were high. angina patients also indicated high levels of satisfaction. heart failure, rural and telehealth caldwell et al. (2005) conducted a randomized control trial to determine whether a simplified education program focused on a single component of disease management (system recognition and management of fluid weight) could improve knowledge, patient-reported selfcare behaviors, and hf severity in a rural setting. usual care was provided to the control group along with written materials. participants in the intervention group received the simplified education program in addition to a counseling session with a non-cardiac registered nurse and a follow-up phone call. study measurements were taken at enrollment and at 3 months and included patient knowledge, self-care behaviors, and hf severity (b-natriuretic peptide [bnp]). for the intervention group, knowledge levels and self-reported self-care behaviors improved significantly and the changes in bnp at 3 months was in the hypothesized direction, yet the difference was not significant. findings indicate that knowledge and self-care behavior for the intervention group improved following completion of a simplified education program, counseling session, and follow-up phone call focused on management of fluid weight and recognition of symptoms. simple education programs with telehealth follow-up can improve outcomes for hf patients in a rural setting. online journal of rural nursing and health care, 13(2) 73 as observed in clark et al. (2007) elderly patients with hf can adjust to telehealth strategies for management of chronic disease. researchers used a mixed methods approach combining quantitative statistics, feedback surveys and qualitative analysis of clinical notes. the purpose was to determine adherence, adaptation and acceptability to a national nurse-coordinated telephone monitoring hf management strategy entitled chronic heart failure assistance by telephone study [chat]. the cohort consisted of standard care plus intervention (chat). study results showed adherence to study protocol was 65.8%. in the 60 participants completing the study 12 months follow-up adherence was significantly higher at 92.3%. only 3% of this elderly group (mean age 74.7 + 9.3 years) was unable to learn or competently use the technology. acceptability rate was 76.45%. elderly chf patients can adapt quickly, find telephone monitoring an acceptable part of their healthcare, and are able to maintain good adherence. comparison of cost, patient outcomes and patient satisfaction between home-based telehealth and traditional skilled nursing home healthcare (hhc) were the focus of a study by finkelstein et al. (2006). the sample consisted of patients with an average age of 74 years, a diagnosis of congested heart failure, chronic obstructive pulmonary disease, or chronic wound care management and recent discharge from hospital care. control group subjects received standard hhc for their underlying condition. subject in the video group received standard hhc plus 2 supplemental virtual visits (vvs) each week and internet access. subjects in the monitoring group received standard hhc, two weekly vvs, and internet access, plus homebased physiologic monitoring and an electronic diary to report monitoring measurements and symptom management. online journal of rural nursing and health care, 13(2) 74 measurements were based on mortality, transfer to differing levels of care, overall satisfaction and cost. no significant difference in mortality was noted between groups. average visit cost was $48.27 for face-to-face home visits, $22.11 for average virtual visits (video group), and $32.06 and $38.62 for average monitoring group visits for chf and chronic obstructive pulmonary disease (copd) subjects, respectively. this study demonstrated improved patient outcomes and lower cost when comparing virtual visits between a skilled healthcare nurse and chronically ill patients at home to traditional face-to-face home healthcare visits. noel et al. (2004) conducted a single-blinded, single-site, randomized study to determine whether home telehealth, when integrated with the health facility’s medical record system, reduces healthcare cost and improves quality-of-life outcomes for elderly high resource users with complex co-morbidities. the target population was frail elderly veterans with hf, chronic obstructive pulmonary disease, and/or diabetes. the control group received usual home healthcare services plus nurse case management. the intervention group received home telehealth plus nurse case management. analyses were performed to compare outcomes at 6 and 12 months for subjective and objective quality-of-life measures, health resource use, and cost. when compared to control, scores for home telehealth subjects showed a statistically significance decrease at 6 months for bed-days-of-care, urgent clinic/ed visits, and a1c levels; at 12 months for cognitive status and at 3 months for patient satisfaction. functional levels and patient-rated health status did not show significant differences for either group. the integration of home telehealth with a healthcare institution’s electronic database was shown to significantly reduce resource use, improve cognitive status, treatment compliance and stability of chronic conditions for homebound elderly with complex health problems. online journal of rural nursing and health care, 13(2) 75 discussion an irr of rigorous research studies (clinical trials) was used to determine the use and effectiveness of telehealth strategies for heart failure management both in the general population as well as in rural populations. from the results of the review future implications and applications are discussed in terms of the research questions. of the 14 clinical trials reviewed, nine studies reported on the use of telehealth for hf management in the general population and five reported for rural populations. in the results five themes of effectiveness were noted: improved knowledge, improved self-care behaviors, improved health outcomes, cost reduction and patient satisfaction. research question 1: how have telehealth technologies been used in the management of heart failure patients and are they effective? a variety of applications of telehealth concepts have been used in the management of heart failure patients across the general population. technologies that have been shown to be effective include telephone interviews; video conferencing; telehomecare systems, one-way and two-way monitoring systems; telephonic devices, health buddy; and a bioimpedance telemedical system, pulmotrace@home and cardioinspect. in the general population two studies demonstrated improved knowledge, two studies showed improved self-care behaviors, four studies found improved health outcomes, and two reported patient satisfaction. no studies reviewed demonstrated reduced cost directly, but four studies indirectly implied potential cost savings based on reduced hospitalizations, hospital readmissions, ed/clinic use, and bed-days (dansk & vasey, 2009; noel, et al., 2004; radai, et al., 2008; wakefield, ward, et al., 2008). one study showed no difference between telephonic and videophone interaction for the management of hf (wakefield, bylund, et al., 2008) and online journal of rural nursing and health care, 13(2) 76 another study failed to support that supplemental care with telehealth improve health outcomes when compared to traditional care (whitten & mickus, 2007). two studies demonstrated the ability of telehealth to decrease emergency department visits and hospitalization for hf patients (dansky & vasey, 2009; dansky et al. 2008a) while four studies showed lower readmission rates with the use of telehealth (wakefield, ward, et al., 2008; wakefield, bylund, et al., 2008; woodend, et al., 2008; noel, et al., 2004). patients utilizing video or interactive systems showed improvement in confidence related to self-care (dansky et al. 2008b). one study demonstrated the ability to remotely obtain lung resistivity information as a measure of fluid in the lungs of hf patients therefore leading to improved treatment and outcomes (radai, et al., 2008). findings from the review indicated that telehealth technologies have been used in varying capacities for the management of heart failure patients and evidence strongly supports the effectiveness of telehealth technologies for improving health outcomes in hf disease management. research question 2: how have telehealth technologies been used in the management of heart failure patients in rural populations and are they effective? only four clinical trial studies using telehealth in the management of heart failure in rural settings were found. studies reviewed were limited to the strategies of telephone follow-up calls and internet-based virtual visits. for rural populations, one study demonstrated improved knowledge, two studies showed improved self-care behaviors, three studies found improved health outcomes, and three studies reported patient satisfaction when telehealth was used. one study demonstrated that a simple educational program delivered by follow-up telephone calls can improve knowledge level and self-care behaviors in hf patients in rural settings (caldwell, peters, dracup, 2005). another study demonstrated that elderly rural hf patients were accepting of telephone monitoring, adapted quickly, and were able to adhere to the telehealth management online journal of rural nursing and health care, 13(2) 77 strategy (clark, et al., 2007). others studies were able to show patient satisfaction, decreased clinic/ed visits, improved outcomes, and reduced cost using telehealth with rural hf patients (finkelstein et al., 2006; noel, et al., 2004). due to the limited number of studies that focused on rural populations, further research is needed to address the unique needs of this population. furthermore, telehealth can be an important tool in the management of hf in rural populations, providing access to resources that patients may otherwise have to travel a great distance to access. research question 3: what are the future implications of telehealth technologies in the management of patients with heart failure in rural areas? utilization of teleheath has been shown to facilitate improvement in self-care behaviors in the general and rural populations (dansky & vasey, 2009; wakefield, holman, et al., 2009; whitten & michus, 2007; caldwell, et al., 2005). evidence supported the use of telehealth technologies to decrease the rates of hospital readmission and emergency department visits in patients with heart failure in rural areas and can lead to reduced cost (dansk & vasey, 2009; noel, et al., 2004; radai, et al., 2008; wakefield, ward, et al., 2008). telehealth increases access to rural populations for the purpose of disease management. increased access using telehealth allows health care providers to detect changes in health status earlier and in turn improve outcomes with subsequent cost savings. evidence provided by this review can inform clinical practice toward improved knowledge, self-care behaviors, health outcomes, patient satisfaction as well as reducing cost. the framework provided can guide the development of interventions toward eliminating rural health disparities in rural hf patients as well as those with other chronic health conditions. internet-based telehealth strategies are an important area where future research is needed. studies are needed to further describe the feasible and potential for improving access for rural online journal of rural nursing and health care, 13(2) 78 populations where specialized services are lacking. implementation of these strategies can be cost and time effective for patients and providers. conclusion an irr methodology was conducted with the integration of key words: heart failure, telehealth and rural populations. review results present evidence of the use and effectiveness of telehealth technologies in hf disease management in the general population as well as in rural populations. the studies reviewed can provide insight into interventions for the delivery of health care, improving access and reducing health care disparities. twelve of the 14 clinical trials reviewed demonstrated that telehealth technology can increase access to and deliver cost-effective healthcare. results further indicate a variety of telehealth technologies have shown to be effective in the management of heart failure patients. these include bioimpedance telemedical systems, such as pulmotrace@home, cardioinspect; telehomecare systems, one-way and two-way monitoring; telephonic devises, health buddy; and video conferencing. drawing from clinical trial research in both general and rural populations, evidence demonstrated the feasibility of telehealth and its potential to provide important healthcare coverage for rural areas where specialized services are lacking. studies showing improved knowledge, improved self-care behaviors, improved health outcomes, cost reduction, and patient satisfaction with the use of telehealth for the management of hf can be used to design intervention for use in rural populations. sufficient evidence is available to support the use telehealth technologies as an effective and efficient approach to improving healthcare access, improving both health outcomes and health status, and reducing overall cost. further research needs to be conducted to gain insight regarding improvements related to telehealth and self-care behaviors in rural populations. the online journal of rural nursing and health care, 13(2) 79 combination of effectively utilizing telehealth and improvement in self-care behaviors and health outcomes can decrease hospital readmission rates and increase quality of care. as limited resources is often an issue in rural settings, additional studies regarding what methods work best would be useful in ensuring cost and time effective methodologies are utilized. references agency for healthcare research and quality (ahrq) (2010). national healthcare disparities report 2010. national center for health statistics. rockville, md. retrieved from http://www.ahrq.gov/research/findings/nhqrdr/nhdr10/chap10a.html agency for healthcare research and quality (ahrq) (2002). system to rate the strength of scientific evidence. ahrq evidence report/technology assessment number 47 (ahrq publication no. 02-e015). rockville, md: author. retrieved from http://archive.ahrq.gov/clinic/epcsums/strengthsum.pdf american heart association (aha) (2009). heart disease and stroke statistics – 2010 update: a report from the american heart association. available at: http://circ.ahajournals.org/content/121/7/e46 artinian, n. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/18337049 http://www.ncbi.nlm.nih.gov/pubmed/19139220 http://www.ncbi.nlm.nih.gov/pubmed/18954244 microsoft word galloway_325-1860-1-ed.docx online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 43 relationships between social connectedness and spirituality and depression and perceived health status of rural residents ann p. galloway, phd, fnp-c, rn 1 melissa henry, phd, fnp-c, rn 2 1 associate professor, loretto heights school of nursing, regis university, agalloway@regis.edu 2 associate professor, school of nursing, university of northern colorado, melissa.henry@unco.edu abstract purpose: a number of factors impact an individual’s health, including the social, economic and physical environments surrounding the individual, as well as their personal characteristics and behaviors (world health organization, 2012a; united states health and human services, 2011). social factors, such as social norms, social support, and social interactions are known to have a strong impact on health, but are often omitted when looking at the overall health of an individual. rural residents are vulnerable to poorer health outcomes because they often lack needed resources and have other risk factors for developing adverse physical and mental health outcomes. lack of social resources in rural areas may lead to social isolation, which may contribute to poorer health outcomes observed in some of these residents. little is known, however about the relationship of social determinants of health in rural residents and overall health outcomes. therefore, the purpose of this research was to examine the relationships between 2 social determinants of health, social connectedness and spirituality, on the level of self-reported depression and perceived health in a rural population. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 44 sample: a convenience sample of rural residents in a western colorado county. method: self-reported survey data collection with hierarchical multiple regression analyses. findings: the more socially connected a person felt, the better they perceived themselves as physically and mentally healthy. additionally, the more socially connected the individual felt the less depressive symptoms they reported. spiritual perspective was not found to correlate significantly with either self-reported depression or perceived health. conclusion: we found that social connectedness is an important factor in the overall wellbeing of rural residents in this small convenience sample. this has significant implications for assessment of the health needs of rural residents and raises awareness of the need to provide opportunities for residents to become more socially active. keywords: social connectedness, spiritual perspective, spirituality, depression, health, rural populations, vulnerable populations, social determinants of health. relationships between social connectedness and spirituality and depression and perceived health status of rural residents determinants of health are factors which affect the health of communities and individuals. according to healthy people 2020, the determinants of health are personal, social, economic and environmental factors that influence health status (united states health and human services [ushhs], 2011). these factors influence health considerably more than commonly thought of impacts on health such as access to health care and quality of health care services (world health organization [who], 2012a). social determinants of health involve the circumstances in which people live, grow, and work. social circumstances are determined by distribution of resources, money and power. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 45 examples of social determinants of health include social norms, socioeconomic conditions, educational and job opportunities, social support and social interactions (ushhs, 2011). the lack of social resources of a population can impact health as much as the lack of environmental or material resources (barr, 2008). investigating the social determinants of health is important in order to gain understanding of disparities in health status (marmot, 2005). according to the world health organization (2012b) social determinants of health are the primary causes of health inequities. health inequities are defined as “avoidable and unfair differences in health status” (who, 2012b, para. 1). the who commission on social determinants of health was created in 2005 to investigate what could be done to foster health equity. one of the conclusions made by the commission was that for health equity to be assured, communities must be socially cohesive, must ensure basic access to goods, be designed to promote physical and psychological well-being, and must protect the natural environment (marmot, friel, bell, houweling, & taylor, 2008). while the commission on social determinants of health primarily focused on urban areas, the authors specifically noted that in order to assure equity between urban and rural areas the “exclusionary policies and processes that lead to rural poverty, landlessness and displacement of people from their homes” must be addressed and “sustained investments must be made in rural development” (marmot et al., 2008, p. 1663). rural public health policies to reduce disease and improve physical, mental, spiritual and social health will only succeed when the social determinants of health in rural areas are addressed as well (marmot, 2005). rural communities in america comprise 19.3 percent of the united states population (united states bureau of census, 2010). these communities are diverse in demographic, economic, environmental and social characteristics. rural populations are different than urban online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 46 areas in population density, cultural norms, and remoteness. rural communities also differ from urban areas in health care needs, resources, and access to health care which can lead to increased vulnerability for developing poorer health outcomes (institute of medicine, 2005). rural areas tend to be composed of older populations with chronic diseases and disabilities and contain populations with higher rates of health risk factors such as obesity, smoking, substance abuse, lack of physical activity and fewer preventative health practices (institute of medicine, 2005; leight, 2003). a majority of rural communities lack vital health care resources due to difficulty recruiting health care professionals, geographic distance which limits access to health care services, and lack of health care insurance. the lack of resources and the number of risk factors in rural communities increase the risk of poor physical, mental, and social health outcomes (aday, 1994, 2003). social resources may also be compromised in rural inhabitants. social determinants of health include support and social interactions (ushhs, 2011). social support and social interactions relate to how connected an individual feels to friends, family and others in the community (ushhs, 2011; lee, dean, & jung, 2008). two social resources shown to positively predict mental, physical and social health in a variety of populations are social connectedness (ashida & heaney, 2008; cacioppo & hawley, 2003; hill, 2006) and spirituality (chester, himburg, & weatherspoon, 2006; jesse & reed, 2004; jesse, walcott-mcquigg, mariella, & swanson, 2005; daaleman, cobb, & frey, 2001). these social determinants have a strong impact on health, but are not often examined when looking at the overall health of an individual, particularly residents of rural communities. little is known about the contribution of social resources, such as social connectedness and spirituality, on u.s. rural residents’ perceived mental and physical health. understanding how online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 47 these social resources impact self-reported depression levels and perceived health of rural residents is an important first step to better understand the full complexity of health and disease of rural individuals and communities. an improved understanding of these complex attributes of health has the potential to allow rural health care providers and community leaders to better identify and address the unique physical, social and psychological health needs of persons within rural populations. social connectedness social connectedness is described as the relationships between an individual and other people, communities and environments which promote a sense of trust, belonging and social identity (hagerty, lynch-sauer, patusky, and bouswema, 1993; lee et al., 2008; mitchinson, kim, geisser, rosenberg, & hinshaw, 2008). social connectedness refers to the overall quantity and quality of relationships that individuals experience (mitchinson et al., 2008) and by influencing their actions in the social world, serves as a resource for physical, psychological and social well-being. the state of connectedness promotes “a sense of comfort, well-being and anxiety-reduction” (hagerty et al., 1993, p. 293). previous research indicates that higher levels of social connectedness is related to higher levels of perceived health in older adults (ashida & heaney, 2008; giummarra, haralambous, moore & nankervis, 2007) and in young women in rural communities (hinton & earnest, 2009; jackson, unruh & donahus, 2011). social isolation, which is the opposite of social connectedness, has been associated with poorer self-reported health in young adults (cacioppo & hawley, 2003) and with increased mortality in men and women age 52 and older (steptoe, shankar, demakakos, & wardle, 2013). individuals with low social connectedness are at higher risk for poor health outcomes due to decrease social resources and lower levels of self-rated online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 48 physical health (aday, 2003; lee & robbins, 1998; flaskerud & winslow, 1998; cornwell & waite, 2009; mitchinson et al., 2008). social connectedness in rural communities has not been studied extensively and some of the literature found negative effects of social connectedness in rural populations (baernholdt, jennings, merwin, & thornlow, 2010; edwards & cheer, 2007; farmer, lauder, richards, & sharkey, 2003; lauder, reel, farmer, & griggs, 2006). the negative aspects of social connectedness include lack of privacy, lack of autonomy and pressure to conform. resistance to conformity can cause others to withdraw social connections from an individual which can lead to social isolation. investigating the social relationships in a vulnerable population such as those living in rural communities can aid in understanding how this resource impacts the health status of the individual and the community. spirituality spirituality is an individual resource that is personal, subjective and unique and includes meaning or purpose of life, transcendence and connectedness to a higher being, self and others (vance 2001). carroll (2001) explains connectedness as a component of spirituality that “is associated with being in touch with self, others, god, and the universe” (p. 89). the connectedness in spirituality relates to a sense of trust in others or in a higher power and belonging (campbell, yoon, & johnstone, 2010; stranahan, 2001; vance, 2001). there are many ways people express their spirituality; individually through personal reflection and total seclusion and corporately through worshiping in faith communities. faith communities afford a sense of belonging to its members and offer many people a sense of identity by providing a safe, loving and trusting environment. however, not all faith communities provide these benefits to their members. some may cause feelings of guilt, online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 49 unworthiness, and isolation if members are unable to conform to the dogma of the religion (krause & bastida, 2011). spiritual perspective. spirituality is a concept that is difficult to understand due to how abstract a concept it is. spiritual perspective is one of many indicators of spirituality which can be used as a means to quantify and qualify it (meyer, 2003). spiritual perspective represents the importance spirituality plays in a person’s life and involves expressions of spirituality such as mentioning spiritual matters, sharing joys and problems, reading spiritually related material, engaging in private prayer or meditation and expressions of spiritual values such as the importance of spirituality, forgiveness and spiritual guidance in decision making (reed, 1987). spirituality, as objectively measured by the spiritual perspective scale (reed, 1987), has been positively correlated to physical, psychological and emotional health in many populations. persons with a high sense of spirituality demonstrate outcomes of a sense of peace, improved quality of life, a sense of well-being, and self-actualization (bolletine, 2001; coyle, 2002; craig, weinert, walton, & derwinski-robinson, 2006; meyer, 2003; mok, wong, & wong, 2009). spirituality research has also shown that a decrease in this attribute leads to depression and a decreased perception of health (dailey & stewart, 2007; jesse et al., 2005; jesse & reed, 2004; gibson, 2003). spirituality has not been extensively studied in rural populations however, the limited literature reveals rural individuals with active spiritual lives had higher levels of hope and lower levels of depression than those without active spiritual lives (craig et al., 2006, hinton & earnest, 2009). these results are consistent with studies done in other populations. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 50 depression according to the world health organization (2012c), depression is a common mental health disorder that negatively impacts physical, mental and social health in all populations. it is characterized by loss of interest or pleasure, depressed mood, low energy, poor concentration, feelings of guilt, disturbed sleep or changes in appetite. depression can be a chronic and recurrent mental health problem which can cause significant impairment in a person’s ability to function in everyday life. depression may lead to suicide which is associated with approximately 850,000 tragic deaths every year (who, 2012c). vulnerable populations, including rural populations, are at increased risk for depressive symptomatology (gam, hutchinson, dabney, & dorsey, 2003). depression is one of the most common mental health problems that occurs in u.s. rural populations. there are an estimated 2.6 million rural adults who are diagnosed with depression at any one time (probst, laditka, moore, harun, powell, & baxlety, 2006). there are fewer resources and greater barriers to mental health care in rural areas (kemppainen, taylor, jackson, & kim-godwin, 2009; institute of medicine, 2005; national rural health association, 2010). rural residents are more likely to experience adverse events that may increase the likelihood of depression than urban residents. in addition, the stigma of mental health disease, cultural beliefs, and the tendency of rural residents to self-treat often prevents proper diagnosis and acceptance of treatment of depression (kemppainen et al., 2009). adherence to treatment for depression is poor in the rural population. because of these barriers, rural residents are at higher risk of undiagnosed and/or self-treated depression than urban populations and mental health outcomes for rural residents are poorer than the outcomes for urban residents (probst et al., 2006). online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 51 perceived health the world health organization defines health as “a state of complete physical, mental, and social well-being” (who, 1948, p. 1). health is not just avoidance of disease or disease-related disabilities but includes cognitive and physical functioning and active engagement in society (aday, 2003). other definitions of health incorporate a more integral worldview about wellbeing and include death as a natural process of life (dossey, 2008). health is a complex concept that can be understood from many different perspectives. the three primary perspectives of health are: (1) the patient’s self-perception of health, (2) a healthcare professional’s judgment, or (3) observed levels of functioning. an individual’s perception of their health is based on their subjective physical, mental and social well-being as well as self-reported symptoms. individuals use a variety of criteria to rate their health such as ability to live independently and the ability to work or perform other activities of daily living (aday, 1994, 2003). conceptual framework this study was guided by the framework for studying vulnerable populations (aday, 1994, 2003). this framework has been used to study vulnerable populations such as homeless persons, refugees and immigrants, high-risk mothers and infants, and the chronically or mentally ill in empirically directed research assessing the relationships between resource availability, relative risk, and health status. the framework is based on the assumptions that increased resource availability and decreased relative risk leads to improved health status and poorer health status is related to lack of resources and increased relative risks (aday, 1994, 2003). individual level resources identified in the framework are social status (i.e. prestige and power), social capital (i.e. social support), and human capital (productive potential). social online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 52 connectedness and spiritual perspectives could be considered types of social capital resources. lack of these resources may increase the vulnerability of an individual to poorer health outcomes. application of the framework suggests that the presence of social connectedness and spiritual perspectives may have a positive impact on individual physical, psychological and social health needs. the ultimate results of the presence of these resources are individual wellbeing, as reflected by decreased depression and improved self-perception of health. depression and an individual’s perception of health reflect the health status of the individual. it is expected that there will be an inverse relationship between both social connectedness and spiritual perspectives and the level of depression in rural inhabitants. increased social connectedness and spiritual perspective is predicted to result in decreased vulnerability, decreased self-reported levels of depression and increase in self-reported health for rural residents. research setting the setting for this study was a rural county located in western colorado. the county met the definition of rural based on the 2010 united states bureau of census’s and the omnibus appropriations bill of 2004 definitions of rural areas (united states department of agriculture economic research service; 2003). the united states bureau of census (2010) identifies urban areas as either 1) urbanized areas of 50,000 or more people or 2) urban clusters of at least 2,500 and less than 50,000 people. rural includes all population, housing, and territory not included within an urban area or cluster. rural is considered open country and settlements of less than 2,500 residents (institute of medicine, 2005). the omnibus appropriations bill of 2004 broadened the rural area definition to “include any incorporated city or town of 20,000 persons or less” in order to increase the eligibility for online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 53 participation in the united states department of agriculture’s rural broadband grant and loan program (institute of medicine, 2005, p. 201). these two definitions allow consideration of cities and towns as well as the vast open areas in the county of interest. the demographics of the county based on the 2010 census show a population estimate of 56,389 residents. this estimate was further broken down into six towns with populations of 9,566 in the most populated town and 1,079 in the least populated town. the population of the six incorporated towns totaled 33,583 residents (59.55%). the population of the unincorporated area of the county was 22,806 residents (40.44%). there were 2,947.56 square miles in the county which equated to 19.1 persons per square miles. there were no designated metropolitan areas in the county (united states bureau of census, 2011; colorado department of local affairs, 2010). method this descriptive, cross-sectional study used standard survey methods of paper and pencil questionnaires for data collection. the two independent variables under consideration in this study were social connectedness and spiritual perspective. the two dependent variables were self-reported depression and perceived health. sampling institutional review board (irb) approval was granted by the irb of university of northern colorado (protocol number 391162-1). convenience sampling was utilized to obtain the sample at three retail stores each in a different area of the county and at two other community events, a local health fair and a 5k run. the retail stores included a locally owned grocery store and two grocery stores that are part of a nationwide chain. each store was located in a different town in the county and the community events were held in two different areas of the county. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 54 inclusion criteria were adults aged 18 years or older who had the ability to understand and read english; excluded were persons residing in nursing homes, prisons, or other non-residential settings. in an effort to avoid selection bias on the part of the researcher, each person who came by the data collection tables was asked to participate by the researcher. the only screening done was to ask if the potential subjects could read and understand english and were over the age of 18 years. subjects were given an informed consent letter describing the purpose of the study, the survey, and directions for completing the survey. a small table and chairs were set up in a quiet, comfortable area at the retail stores and community events for participants to sit while completing the survey. participants were given time to thoughtfully answer the questionnaire without feeling rushed or stressed. a traditional power analysis for regression indicated for an effect size of .20, a p-value of .05, seven regression predictors and power of .80, a sample of 70 was needed. after three months of data collection, 144 surveys were obtained. sample more females (72.9%) than males (27.1%) participated in the study. the age ranges were fairly evenly distributed with younger adults, ages 18 – 50 years, comprised 47.9% of the sample compared with 52.1% of the participants were ages 51 years and older. the income data demonstrated that more than half of the participants (57.67%) reported annual incomes of $51,000 or greater with 16% of the sample reported greater than $100,000 annual incomes. in contrast, only 5% of the sample reported less than $10,000 annual income. of the individuals who participated in the study, 86.81% were white and only 9.72% were hispanic or latino. in fact, the total percentage of non-white participants was only 13.18%. in online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 55 regards to residents of unincorporated and incorporated areas of the county, the sample was more evenly divided with 42.3% of the participants living in unincorporated areas and 57.7% living in incorporated areas. instrumentation the survey consisted of five parts: a demographic questionnaire, the revised social connectedness scale (lee, draper & lee, 2001), the spiritual perspectives scale (reed, 1987), the center for epidemiologic studies depression scale – revised (eaton, smith, ybarra, muntaner, & tien, 2004) and the short form-12 version 2® health survey (ware, kosinski, & keller, 1996). permission was obtained for use of all instruments from the scale developer and/or company except for the center for epidemiologic studies depression scale – revised which is available in the public domain. the cronbach’s α reliability coefficients for the four survey instruments used in the study ranged from .871 to .968 which indicated the instruments were internally consistent using an acceptable level of α = .8 or greater. demographics. demographic variables collected were: 1) age, 2) gender, 3) income level, 4) race/ethnicity, 5) length of time the subject had resided in the county, 6) how many family members lived within 30 miles of the subject, and 7) did the subject live in incorporated or unincorporated areas of the county. these 7 variables were collected to adequately describe the study sample. social connectedness. the social connectedness scale – revised (scs-r) measures social connectedness as a psychological sense of belonging or how the individual rates their closeness with others in the social environment. it reflects an independent sense of self and an individual’s subjective awareness of others. the scs-r does not measure belongingness such as group memberships or loss of specific relationships (lee et al., 2001). online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 56 the scale consists of 20 items on a 6 point likert scale (1 = strongly disagree to 6 = strongly agree). there are 10 positively worded and 10 negatively worded items. examples of negatively worded items are “i feel like an outsider”, “i don’t feel related to most people” and examples of positively worded items are “i fit in well in new situations” and “i see people as friendly and approachable”. the negatively worded items were reverse scored and summed together with the positive items. the item scores were summed and a range of 20 to 120 is possible. a stronger sense of social connectedness is reflected in a higher score (lee et al., 2001). spiritual perspective. the spiritual perspective scale (sps) measures the subjects’ perceptions of the extent to which they hold spiritual beliefs and values and participate in spiritually-related activities. spirituality is defined broadly so organized or non-organized expressions of spirituality can be used (reed, 1987). the sps is a 10-item scale which uses a 6point likert scale. four items relate to the frequency of spiritual behaviors such as “how often do you engage in private prayer or meditation?” two items under the frequency of spiritual behaviors express the social aspect of spiritual perspective. these are “in talking with family and friends, how often do you mention spiritual matters?” and “how often do you share with others the problems and joys of living according to your spiritual beliefs?” these item’s choices range from 1 = ‘not at all’ to 6 = ‘about once a day’. six items relate to spiritual beliefs, such as “my spirituality is a significant part of my life”. the belief items choices range from 1 = strongly disagree to 6 = strongly agree. higher scores indicate a higher level of spirituality or spiritual perspective (reed, 1987). all the responses were summed and the mean calculated for each participant. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 57 depression. the center for epidemiologic studies depression scale – revised (cesdsr) is a revised version of the original scale developed by radloff (1977) and designed to more reliably reflect the nine primary symptoms of a major depressive episode and general dysphoria according to the american psychiatric association’s dsm-iv criteria (american psychiatric association, 2000; eaton et al., 2004). the cesds-r items measure sadness (dysphoria), loss of interest (anhedonia), appetite, sleep, thinking/concentration, guilt/worthlessness, fatigue, movement and suicidal ideation (eaton et al., 2004). examples of items on the cesds-r include “i could not shake off the blues”, “nothing made me happy”, “and i lost interest in my usual activities” as well as symptoms of depression. the cesds-r consists of 20 items on a 5 point likert type scale. respondents are given instructions to identify how often they might have felt and behaved in certain time frames ranging from 0 = ‘not at all or less than 1 day’ to 4 = ‘nearly every day for the past 2 weeks’. the score was obtained by adding each item and calculating the mean. the higher the score is indicative of more frequently occurring depressive symptoms. perceived health. the short form-12 version 2® (sf12v2®) health survey is a 12 item self-reported scale measuring the subject’s perception of their physical and mental health on a 5 point likert scale ranging from “excellent” to “poor” and “all the time” to “never”. it was designed to measure eight domains of health-related quality of life (ware et al., 1996; ware, kosinski, turner-bowker, & gandek, 2002; ware et al., 2010) including: physical functioning, role limitations due to physical functioning, bodily pain, general health perception, vitality, social functioning, role limitations due to emotional problems and mental health. examples of items on the survey include “in general, would you say your health is…” with choices ranging from “excellent” to “poor” and “during the past 4 weeks, how much of the time has your online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 58 physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.?” again with 5 choices ranging from “all of the time” to “none of the time”. the data obtained from the 8 subscales were aggregated to provide summary measures of the respondent’s physical health and mental health (ware et al., 1996; ware et al., 2002; ware et al., 2010). analysis analysis of the data was conducted using the statistical package for the social sciences (spss™). race/ethnicity data were collected using the united states bureau of census categories and included white/non-hispanic, african-american, native american/pacific islander, hispanic or latino, asian, and multi-racial. these categories were coded 1 through 6 for data analysis. however, for statistical purposes the ‘non-white’ groups were clustered together as there were too few participants within each non-white group to perform the regression analyses. descriptive statistics analyzed and reported for the demographic variables were mean, standard deviation, frequencies, percentages and cumulative percentages (see table 1). model testing was conducted using hierarchical multiple regression to determine how much of the variance in the dependent variables (depression and perceived health) were attributable to each of the independent variables (social connectedness and spiritual perspective). a two-step process was followed. a baseline model with the demographic variables entered as a block was conducted with one of the dependent variables. next an independent variable was introduced in the second step of the regression analysis. the unstandardized beta, the standard beta error, the standardized beta and confidence intervals were reported. in addition the f ratio, online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 59 significance (p), variance (r2) and change in variance (∆r2) were reported for each 2-step regression model (see tables 3-6). results demographic characteristics the demographic data from this study are presented in table 1. table 1 demographic characteristics n = 144 n gender female 102 male 38 age 18-30 19 31-40 27 41-50 22 51-60 32 61-70 26 71-80 12 >80 4 income <10,000 7 10,000-20,000 11 21,000-30,000 12 31,000-40,000 13 41,000-50,000 15 51,000-65,000 19 66,000-100,000 38 >100,000 22 race/ethnicity white 125 african american 1 native american 2 hispanic 14 asian 1 multi-race 1 online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 60 n = 144 n area of county unincorporated 58 incorporated 79 m(sd)mdn range (min max) time in county (months) 196.51 (172.66)144 1018(2-1020) family members in county 2.22 (4.8)0 40(0-40) descriptive findings of study variables most people rated themselves high in social connectedness. the sample results for the scale demonstrate that more subjects reported few depressive symptoms. most individuals perceived their physical and mental health in a positive manner. table 2 includes the descriptive statistics for the study variables. table 2 descriptive findings of study variables instrument ∑ m (sd) range social connectedness 93.20 57 – 119 spiritual perspectives 3.63(1.33) 0 – 5 instrument ∑ m (sd) range depression 0.43(0.45) 0 – 2.3 health and well-being 4.14(0.62) 2 – 5 social connectedness and perceived health results of the hierarchical multiple regression analysis for social connectedness on perceived health are found in table 3. approximately 10% of the explained variance of perceived health was attributable to social connectedness. as social connectedness increased, an individual’s perceived health increased. spiritual perspective and perceived health results of the hierarchical multiple regression analysis for spiritual perspective on perceived health is found in table 4. the baseline regression model in step 1 of table 3 is the online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 61 same for this analysis. spiritual perspective was added to that baseline model in step 2 below. spiritual perspective was not a significant predictor of perceived health in this sample. table 3 effects of demographic variables and social connectedness on perceived health step 1 βi b se β 95% cl (ll-ul) intercept 3.95 0.21 (3.53 – 4.37) gender 0.17 0.12 .12 (-0.06 – 0.40) age 0.00 0.04 .00 (-0.07 – 0.08) income 0.04 0.03 .12 (-0.02 – 0.09) time in county 0.00 0.00 .00 (0.00 – 0.00) family member 0.02 0.01 .13 (-0.01 – 0.04) race -0.12 0.17 -.07 (-0.45 – 0.21) area of county 0.03 0.11 .03 (-0.19 – 0.25) f 0.71 p .67 r2 0.01 step 2 βi b se β 95% cl (ll – ul) intercept 2.49 0.39 (1.72 – 3.26) gender 0.19 0.11 .14 (-0.03 – 0.41) age -0.01 0.04 -.03 (-0.08 0.06) income 0.04 0.03 .14 (-0.01 – 0.09) time in county 0.00 0.00 .03 (0.00 – 0.00) family member 0.01 0.01 .11 (-0.01 – 0.04) race -0.05 0.16 -.03 (-0.37 – 0.26) area of county 0.00 0.11 .00 (-0.21 – 0.21) social connect. 0.02 0.00 .35* (0.01 – 0.02) f 3.14 p < .001 r2 0.11 ∆r2 0.10 note: βi = unstandardized beta; b se = beta standard error; β = standardized beta; * p < .05 predictor = social connectedness; outcome = perceived health online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 62 table 4 effects of spiritual perspective on perceived health step 2 βi b se β 95% cl (ll – ul) intercept 4.14 0.28 (3.59 – 4.69) gender 0.15 0.12 .11 (-0.09 – 0.28) age 0.00 0.04 .01 (-0.07 – 0.08) income 0.04 0.03 .12 (-0.02 – 0.09) time in county 0.00 0.00 -.02 (0.00 – 0.00) family member 0.02 0.01 .14 (-0.01 – 0.04) race -0.14 0.17 -.08 (-0.47 – 0.20) area of county 0.04 0.11 .03 (-0.18 – 0.26) spiritual persp. -0.05 0.04 -.10 (-0.13 – 0.04) f 0.78 p .63 r2 0.01 ∆r2 0.00 note: βi = unstandardized beta; b se = beta standard error; β = standardized beta; * p < .05 predictor = spiritual perspective; outcome = perceived health social connectedness and depression the hierarchical multiple regression analysis for social connectedness and self-reported depression can be seen in table 5. social connectedness was a significant predictor of selfreported depression as seen in step 2 and accounted for approximately 17 % of the variance of self-reported depression in this sample. as social connectedness increased, depressive symptoms decreased. several demographic variables predicted depression including female gender, younger age, and white race/ethnicity. however, when social connectedness was added to the model, it appeared to be the strongest predictor of self-reported depression. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 63 table 5 effects of social connectedness on self-reported depression step 1 βi b se β 95% cl (ll--ul) intercept 0.48 0.16 (0.17 0.79) gender -0.17 0.09 -.16* (-0.34 – 0.01) age -0.07 0.03 -.24* (-0.13 – -0.01) income -0.01 0.02 -.03 (-0.05 .003) time in county 0.00 0.00 .00 (0.00 – 0.00) family member -0.01 0.01 -.05 (-0.02 – 0.01) step 1 βi b se β 95% cl (ll--ul) race 0.31 0.12 .22* (0.07 – 0.55) area of county -0.03 0.08 -.03 (-0.20 – 0.14) f 2.10 p .05 r2 0.05 step 2 βi b se β 95% cl (ll--ul) intercept 1.80 0.28 (1.25 – 2.34) gender -0.19 0.08 -.18* (-0.34 – -0.03) age -0.06 0.03 -.20* (-0.11 – -0.01) income -0.01 0.02 -.04 (-0.05 – 0.03) time in county 0.00 0.00 -.04 (0.00 – 0.00) family member 0.00 0.01 -.03 (-0.02 – 0.01) race 0.25 0.11 .18* (0.03 – 0.47) area of county 0.00 0.08 .00 (-0.15 – 0.15) social connect. -0.01 0.00 -.41* (-0.02 – -0.01) f 6.08 p < .001 r2 0.22 ∆r2 0.17 note: βi = unstandardized beta; b se = beta standard error; β = standardized beta; * p < .05 predictor = social connectedness; outcome = depression spiritual perspective and depression the hierarchical multiple regression analysis for spiritual perspective and self-reported depression can be seen in table 6. the baseline regression model in step 1 of table 5 is the same for this analysis. step 2 added spiritual perspective to the baseline model. spiritual online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 64 perspective was not a significant predictor of self-reported depression in this sample. as noted from the r2 values, the baseline model in step 1 explained approximately 5% of the variance in the dependent variable self-reported depression, with younger age being the only significant predictor and the variance in step 2 which included spiritual perspective was virtually the same. this indicates there was no change in the variance of depression when spiritual perspective was added to the analysis. table 6 effects of spiritual perspective on self-reported depression step 2 βi b se β 95% cl (ll--ul) intercept 0.45 0.21 (0.04 – 0.86) gender -0.16 0.09 -.15 (-0.34 – 0.01) age -0.07 0.03 -.24* (-0.13 – -0.01) step 2 βi b se β 95% cl (ll-ul) income -0.01 0.02 -.03 (-0.05 – 0.03) time in county 0.00 0.00 .00 (0.00 – 0.00) family member -0.01 0.01 -.06 (-0.02 – 0.01) race 0.31 0.12 .22* (0.07 – 0.55) area of county -0.03 0.09 -.03 (-0.20 – 0.14) spiritual persp. 0.01 0.03 .02 (-0.06 – 0.07) f 1.84 p .08 r2 0.05 ∆r2 0.00 note: βi = unstandardized beta; b se = beta standard error; β = standardized beta; * p < .05 predictor = spiritual perspective; outcome = depression discussion social connectedness and perceived health and depression our findings are consistent with other studies which suggest that the lack of social connectedness has detrimental effects on physical and mental health. feeling connected to others leads to physical and psychological well-being and has a positive impact on health (lee & online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 65 robbins, 1998; lee, keough, & sexton, 2002; lee et al., 2008; flaskerud & winslow, 1998; mitchinson et al., 2008). in our study we found that social connectedness was a significant, positive predictor of perceived health in the rural residents we surveyed. the more socially connected a person felt, the more they perceived themselves as physically and mentally healthy. this is consistent with other studies’ findings in rural and urban populations (ashida & heaney, 2008; giummarra et al., 2007, hinton & earnest, 2009; jackson et al., 2011). we also found that low social connectedness was a predictor of self-reported depression in the residents surveyed. a significant percentage of the variance of depression was explained by the level of perceived social connectedness. our findings are similar to other studies’ results that indicate the lack of social capital or social connectedness contribute to the overall depression levels in rural residents (probst et al., 2006; fortney, harman, xu, & dong, 2009; kemppainen et al., 2009). spiritual perspective and perceived health and depression we did not find a significant relationship between spiritual perspectives, perceived health or self-reported depression in this sample of rural, colorado residents. our findings contradict previous studies that suggest that spirituality has positive effects on physical, psychological and social health (campbell, et al., 2010; coyle, 2002; mccord, et al., 2004). spirituality, as measured by spiritual perspective, has been seen as a protective factor against depression in many studies (dew et al., 2010; dailey & stewart., 2007; jesse et al., 2005). the lack of relationship between spiritual perspective and both depression and perceived health in our study is unexpected and may relate to the complexity of the concept of spiritual perspective. one study comparing the relationship between spiritual perspective, social support online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 66 and depression in a sample of caregiving wives of dementia victims and non-caregiving wives of healthy adults, had results similar to ours. they found that in the caregiver group spiritual perspective was not significantly related to social support or depression (robinson & kaye, 1994). the impact of spirituality on physical and mental health may be due to the other characteristics of spirituality such as meaning and purpose to life or transcendence that may have not been captured in our survey tool. in addition, not all outcomes of spirituality are positive. some research has found negative outcomes of spirituality including guilt, inner conflicts and beliefs that lack of spirituality lead to misfortunes, negative emotions, and loss of serenity (bolletino, 2001; carson, 2008) which could have led to the conflicting results we observed. the sample of rural residents in our study may perceive spirituality very differently from the other groups of people previously studied. further research might assist in exploring this relationship in greater detail and identify any potential variation this concept may have for different groups of people. limitations using a convenience sample and the lack of random selection may have led to selection bias by those individuals who agreed to participate in the study decreasing the overall generalizability of the findings. the demographic statistics revealed that the sample did not reflect the population statistics. the sample was older, more female, whiter, and had higher income than the average county resident, which could have been due to the sampling technique and location leading to the potential inadvertent oversight of inclusion of some groups of individuals (such as hispanic residents). participants with more social support or less depressive symptoms might have been more willing to participate. also, inability to leave home due to poor health or depressive symptoms might have excluded some individuals from participation. the online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 67 location of the data collection in retail stores and community health events may have limited who was available to be selected for the sample. additionally, the two community events were health related, and may have caused the sample to be skewed toward healthier individuals or individuals with greater interest in their health. there was also the possibility that wealthier individuals attended these community health events and this may explain the data trend toward subjects with higher incomes. our results suggested that there may be some significant differences in how gender, age, and race affect the contribution of social connectedness and spiritual perspective on a person’s overall health and depression, however, we did not have enough participants from the various demographic groups to make any conclusions of these results. additional research specifically examining the effects of gender age, or race on these variables would be very beneficial to see if there is a difference in perspective for people of different backgrounds. a final limitation of this research study was the small sample and corresponding low power on the spiritual perspective analyses. while there was strong power on the analyses where social connectedness was the independent variable, the power was not adequate in the analyses for spiritual perspectives. a sample with more participants would help to increase the power and as a result, the confidence in the findings. recommendations for further research the current study and much of the literature investigated the relationships between the social connectedness and spiritual perspective on physical and mental health from a quantitative viewpoint. a qualitative study could give insights into how rural populations experience social connectedness and spiritual perspective, how social connectedness and spiritual perspective affect their perception of their health specifically, and the level of importance they attach to the online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 68 variables. this would be of particular interest to explore the perspective of spirituality in more depth in rural resident since our data was inconclusive. a qualitative viewpoint would provide more complex data for rural community health care providers to aid in understanding the relationships between social connectedness and spiritual perspectives on perceived physical and mental health. much research has been done on the benefits of social support but little nursing research has been conducted to identify interventions that foster social connectedness (haun, rittman, & sberna, 2008). this is an area where more research by nursing is needed. most of the research that has been conducted on social connectedness has been in the sociology and psychology realm. more quantitative studies by nurse researchers to investigate how and where nursing can intervene and prevent the ill effects of social disconnectedness are needed. identifying methods to improve and increase social connectedness could lead to decreased vulnerability or risk of adverse health outcomes. implications for nursing the social determinants of health can impact an individual’s health status as much as environmental or material resources such as access to and quality of health care services (barr, 2008; who, 2012b; marmot, 2005; marmot et al., 2008). social connectedness and social relationships are essential in the maintenance of health; however in modern societies, the number of people living alone in the united states is increasing according to the most recent census data (united states bureau of census, 2011; steptoe et al., 2013). in many rural areas, there often are few opportunities for social connectedness to develop (barenholdt et al., 2010; edwards & cheer, 2007; cacioppo & hawley 2003). this and other studies suggest that the lack of social connectedness in rural communities has detrimental effects on physical and mental health. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 69 recommendations from the world health organization (2012a), healthy people 2020 (ushhs, 2011) and the institute of medicine’s committee on the future of rural health care (2005) stress each rural community should conduct a health needs assessment, set priorities for addressing the individual and population’s health needs, and develop and implement action plans to address the identified health needs. these entities recommend all determinants of health, including social determinants, be included in the needs assessment. analysis of social determinants, including social connectedness, in a rural community could lead to the development of strategies to address the unique health needs and improve the mental, physical and social health status of rural residents. rural nurses are uniquely situated to conduct these health needs assessments and make recommendations on ways to improve social connectedness in rural communities. the needs assessments may indicate changes in health policies are needed. nursing should be in the forefront of developing local, state and national health policies which take into consideration the social determinants of health. development of evidence-based practices which foster social connectedness in rural communities can be positive outcomes of the needs assessment and policy changes. nurses can also take the leadership role of forming coalitions to work on developing these practices. incorporating already established rural institutions such as churches, schools and athletic events and obtaining buy-in from rural community leaders can help assure the interventions are successful and meets the needs of the residents (who, 2012b). urban planners have discovered the need for social connectedness in many large cities. in these cities, residential areas of apartments, townhomes, or condos along with shops, gyms and other entertainment venues are built clustered together so inhabitants can walk from place to place and meet with other residents of the neighborhood. faith communities are locating more online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.325 70 often in these neighborhood areas to provide closeness and convenience for their members. rural residents tend to be more isolated from each other, however, similar types of neighborhoods could be developed in rural communities to meet the residents’ physical, mental, spiritual and social health needs. this study highlights the importance of understanding a patient’s social connectedness when developing a patient centered care plan. determining social goals of the patient is essential in assisting a patient to reach their functional goals. nurses who care for individual patients and families should always include the social support and spiritual needs of their patients as either problem areas to address or strengths to be sustained for the patient’s return to optimal health. nursing is in a unique position to improve and increase social connectedness for individuals which can lead to decreased vulnerability and risk of adverse health outcomes for these individuals living in rural communities. educating community leaders and organizations, developing health policies at the local, state, and national level to address the need for more social support and social interactions; and forming coalitions to improve rural health are within nurses’ scope of practice. nursing should be at the forefront in the effort to improve health of our communities and individuals by addressing all determinants of health. references aday, l. a. 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(2002). how to score version 2 of the sf-12 health survey (with a supplement documenting version 1). lincoln, ri: qualitymetric inc. world health organization (1948). constitution of the world health organization. handbook of basic documents. geneva: world health organization. world health organization (2012a). health impact assessment: the determinants of health. retrieved from http://www.who.int/hia/evidence/doh/en/index.html world health organization (2012b). social determinants of health. retrieved from http://www.who.int/social_determinants/en/ world health organization (2012c). depression: what is depression? retrieved from http://www.who.int/mental_health/management/depression/definition/en/ microsoft word 456-2989-2-ce.docx online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 126 childhood obesity in a rural community: first steps to cultivating change paige turner johnson, phd, msn, rn1 michele montgomery, phd, mph, rn2 melissa clark, bsn, rn3 caitlin taylor4 1 assistant professor, capstone college of nursing, university of alabama, ptjohnso@crimson.ua.edu 2 assistant professor, capstone college of nursing, university of alabama, mmontgomery1@ua.edu 3 capstone college of nursing, university of alabama, miclark@crimson.ua.edu 4 capstone college of nursing, university of alabama, cbtaylor3@crimson.ua.edu abstract purpose: this article describes how the community readiness model was used to assess stage of readiness for childhood obesity prevention in a southern, rural county. sample: ten key informants were interviewed for the qualitative assessment of community readiness for change and 100 county residents completed the attitudes for health promotion and disease prevention survey. methods: using the community readiness model as a guide, key informant interviews were conducted by the investigators in a rural county in the south located in the underserved area known as the black belt. an interview template that examined community readiness for childhood obesity prevention was used by the investigators. questions focused on attitudes online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 127 towards children’s physical activity and children’s nutrition. in addition, questions regarding confidence in their community’s ability to reduce childhood obesity, their schools and community’s responsibility to address childhood obesity and who they thought might be interested in participating in a coalition to prevent childhood obesity were asked. results: the mean overall community readiness score for the 10 informants was 3.06, which corresponds with the vague awareness stage of readiness. the lowest scores were for knowledge of the issue of childhood obesity, resources available, and community climate in regards to childhood obesity. all of these scored in the denial/resistance stage of change. conclusions: before interventions can successfully be implemented within a community, community readiness for prevention programs and willingness to change must be assessed. the overall crm scores demonstrate that this county ranged from denial/resistance to vague awareness stages of change. these scores indicate that residents of this community may not be aware of the significance of childhood obesity in their community and efforts to move the community to a more active stage of change must be taken. keywords: childhood obesity, rural, community readiness model, obesity prevention, community assessment, rural health disparities childhood obesity in a rural community: first steps to cultivating change childhood obesity is a significant public health concern in the united states, especially in rural areas where rates of obesity are higher than the rest of the country (befort, nazir, & perri, 2012; hill, you, & zoellner, 2014; j. e. jackson, doescher, jerant, & hart, 2005). approximately 17% of children in the u.s. are considered obese (ogden et al., 2016). in alabama, rates of obesity in children are 16.3% for ages 2-4, 18.6% for ages 10-17, and 16.1% online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 128 for high school age children (trust for america's health & robert wood johnson foundation, 2016). when compared to other regions of the state, rates of obesity in adults are significantly higher in the black belt region which runs through alabama and includes some of the poorest counties in the country. this region of the state consists of 18 rural counties as defined by the united states department of agriculture (usda) definition using economic research service rural-urban commuting areas (ruca) with codes 4-10 (u.s. department of agriculture [usda], 2009). for one of these black belt counties childhood obesity rates are not available. however, the rate of obesity in adults in the county (36%) is worse than many other black belt counties (robert wood johnson foundation [rwjf], 2016). this is a troubling trend because obesity is associated with cardiometabolic health conditions such as cardiovascular disease (cvd) and type 2 diabetes (t2d), which are two of the leading causes of death in the united states and the black belt region of alabama (roger et al., 2011). there are racial and income disparities associated with obesity in rural dwellers, with african americans and residents of lower socioeconomic status more likely to be overweight or obese (c.l. jackson et al., 2013; wang, 2011; zhang & wang, 2004). children from lower income households have a greater risk of being obese than children from higher income households (drewnowski, rehm, kao, & goldstein, 2009; singh, siahpush, & kogan, 2010; skelton, cook, auinger, klein, & barlow, 2009), and the rate of obesity in african-american preschool children is double that of white preschool children (ogden, carroll, kit, & flegal, 2012). because childhood obesity is more common among low-income and minority children in rural areas, effective interventions are particularly needed for this group. however, there have been no effective interventions identified to date that have robust and lasting effects, and even fewer have targeted rural children and their families. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 129 before effective interventions can successfully be implemented within a community, a community assessment to determine knowledge and attitudes towards health promotion programs and readiness to change must be conducted. this article describes the use of semi structured qualitative interviews to assess one rural community’s readiness for childhood obesity prevention programs and a quantitative survey to determine residents’ knowledge of and attitudes toward health promotion and disease prevention programs. although the main focus of this article is to discuss one rural community’s readiness for health promotion programs to reduce childhood obesity, key results from the quantitative survey are also presented. methods sample and setting one rural county situated in the black belt region of alabama was chosen for this study. the population of the county is 20,864 and the racial/ethnic breakdown includes 54% white, 39.6% african-american, and 4.9% hispanic (rwjf, 2016). this county ranked 55th out of 67 counties in terms of health outcomes. additionally, 27% of residents in the county report their health to be poor to fair, 30% are physically inactive, and only 1% live reasonably close to a location for physical activity, such as parks and recreational facilities (rwjf, 2016). finally, 14% of residents are uninsured, and 35% of children are in poverty, which increases the risk for obesity in this county. the protocol for this study was approved by the institutional review board at the investigators’ institution. the sample for the qualitative assessment of community readiness for change was comprised of 10 key informants. key informant interviews are qualitative in-depth interviews with people who know what is going on in the community, and the purpose is to collect information from a wide-range of people, including community leaders, professionals, or online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 130 residents who have first-hand knowledge about the community (ucla center for health policy research, n.d.). the key informants for these interviews were individuals who have lived in the county all their life and included the editor of the local paper, the county extension program coordinator, a local business owner, a city government official, school administrators, and school personnel. the sample for the quantitative assessment of knowledge of and attitudes for health promotion and disease prevention was comprised of 100 county residents who were recruited from throughout the county and from a variety of backgrounds to provide insight into countywide activities and attitudes. all participants signed an informed consent before the interviews were conducted. community readiness for change. this study utilized the community readiness model (crm) which was developed at the triethnic center for prevention research at colorado state university (edwards, jumper-thurman, plested, oetting, & swanson, 2000) to assess community readiness for change. this model was originally developed to guide the development of drug and alcohol prevention programs, but has since been applied to other community health problems (findholt, 2007; hull et al., 2008; sliwa et al., 2011; son, shinew, & harvey, 2011). the crm is based on four premises: (a) that readiness is issue-specific, meaning that a community can be at a high level of readiness to deal with one problem and at a low level of readiness for another problem; (b) that the stage of readiness can be accurately assessed; (c) that community readiness can be increased; and (d) that determining a community’s stage of readiness is essential because interventions to move communities to the next stage differ for each stage of readiness and, unless an intervention is consistent with the community’s current stage, it is likely to fail (edwards et al., 2000; plested, edwards, & jumper-thurman, 2005). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 131 there are nine stages of readiness for prevention identified by the model that are based on the transtheoretical model of individual stages of change and theories of community-level processes and social action to measure progress in group change (slater et al., 2005; york & hahn, 2007) (see table 1). these stages of readiness are assessed using structured interviews with key informants to obtain information on six community dimensions that influence the community’s preparedness to address the issue. these dimensions include: (a) existing prevention efforts, (b) community knowledge of existing efforts, (c) leadership, (d) community climate, (e) community knowledge of the issue, and (f) resources available to support prevention efforts (plested et al., 2005). a previously developed interview template used in a study which also examined community readiness for childhood obesity prevention was used by the investigators (findholt, 2007). the questions were divided into two parts. one part focused on attitudes or programs pertaining to children’s physical activity, and the other part focused on attitudes or programs pertaining to children’s nutrition. there were also three additional questions included in the template. one question asked the informants how confident they were in their community’s ability to reduce childhood obesity. a second question asked them if they believed their schools and community had a responsibility to address the problem. the third question asked the informants who they thought might be interested in participating in a coalition to prevent childhood obesity. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 132 table 1 description of the nine stages of community readiness a with corresponding score stage of readiness description score no awareness community: no knowledge of , local efforts to address, and no concern for issue leadership: believes issue is not a concern resources: none available to deal with issue 1 denial community & leadership: issue not a concern and cannot be addressed community: incorrect knowledge of efforts to address issue; only a few members have knowledge of the issue resources: community and leadership do not support using available resources 2 vague awareness community: a few members have heard of local efforts but know little about them; members have only vague knowledge of issue community & leadership: believe that issue may be a concern in the community resources: limited resources have been identified to address the issue 3 preplanning community: some members have heard about local efforts to address issue but know little about them; limited knowledge of issue community & leadership: acknowledge issue is a concern resources: limited resources are available to further efforts to address issue 4 preparation community: most members have heard about local efforts and have basic knowledge of issue; concerned about issue and wants to do something about it leadership: actively supports continuing or improving current efforts resources: some resources have been identified that could be used; community members and leaders are actively working to secure resources 5 initiation community: most members have basic knowledge of efforts; basic knowledge of issue and aware it occurs locally leadership: plays key role in planning efforts to address problem resources: have been obtained and/or allocated to support further efforts 6 stabilization community: most members have more than basic knowledge of local efforts and about issue; have taken responsibility leadership: actively involved in ensuring or improving the long-term viability of efforts resources: resources are from sources expected to provide continuing support 7 confirmation community: most members have considerable knowledge of efforts; more than basic knowledge of issue and have significant knowledge about local prevalence; majority of community strongly supports efforts leadership: plays a key role in expanding and improving efforts resources: considerable part of allocated resources are expected to provide continuous support; community members looking for additional support 8 community ownership community: most members have considerable and detailed knowledge of local efforts; have detailed knowledge about the issue; highly supportive and actively involved leadership: continually reviewing evaluation results and modifying financial support resources: diversified resources and funds are secured; efforts expected to be ongoing 9 a adapted from plested et al., 2005 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 133 interviews were conducted at times and locations convenient to the informant. the interviews lasted approximately one hour. interviews were audio taped, and field notes were also taken to record respondents’ remarks. each interview was transcribed verbatim by a trained transcriptionist. per the community readiness model’s instruction handbook, the transcriber was given a copy of the interview questions. each interview was transcribed word for word, including things such as laughter. knowledge of and attitudes toward health promotion and disease prevention a previously developed survey (pennay, 2007) was used to assess community members’ knowledge of existing health promotion and disease prevention initiatives in the county, as well as their attitudes towards such programs. items in this survey assessed such things as individuals’ perceptions of health promotion and disease prevention, responsibility for population health, government spending priorities, and perceived seriousness of specific health conditions. in order to assess knowledge of health promotion and disease prevention programs, individuals were asked about specific health promotion campaigns. to assess attitudes toward health promotion and disease prevention, they were asked if they approve or disapprove of specific initiatives. the interviewers traveled to various locations throughout the county to recruit participants and to administer the surveys. the surveys were read to individuals, and they were provided a flip chart with the responses so they could read them as they were being read aloud. this was done to ensure that individuals who could not read or did not understand certain terms had the opportunity to complete the surveys. survey administration lasted approximately 30 minutes. analysis online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 134 to determine community readiness for change the transcribed interviews were scored independently by research assistants who were trained to use the procedure specified by the triethnic center (plested et al., 2005). the two investigators also scored the interviews to verify the results. in instances when there was a disagreement in scores, the interviews were rereviewed to reach consensus on scores for each dimension. within each interview, each of the dimensions was rated based on the crm’s rating scales. scores for each dimension range from 1 (no awareness) to 9 (high level of community ownership). the individual dimension scores are totaled for all interviews and then divided by 10 to get the average dimension score. to obtain the calculated scores for each dimension, the total for that dimension is divided by the number of interviews. the total readiness score for each dimension was calculated by averaging the consensus scores for each dimension across all interviews. the average of the five final dimension scores was calculated in order to obtain the overall community readiness score (table 2). the stage of readiness was determined by rounding down the average score to the previous stage. descriptive statistics were utilized to assess knowledge of and attitudes toward health promotion and disease prevention. table 2 county community readiness model consensus scores dimensions interviews 1 2 3 4 5 6 7 8 9 10 average stage of readiness knowledge of efforts 4 2.5 3 3.5 1.5 5 5 4 3.5 5 3.70 vague awareness leadership 4 3.5 3 4 2.5 3 3.25 4 4 3 3.425 vague awareness community climate 3.5 2.5 3 3.5 1.75 3.5 2.5 3 4 2.5 2.975 denial/resistance knowledge of issue 3 2.5 3 2 1.25 2.5 2.25 2 3 3 2.45 denial/resistance resources 3.5 3 3.5 2 1.5 2.5 3.5 2.5 4 1.5 2.75 denial/resistance overall community readiness score 3.06 vague awareness online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 135 results demographics the sample of key informants (n = 10) was evenly split between males and females and african american and white. this is representative of the county, which is 50.6% female, 49.4% male, 39.9% african american, and 54.7% white. the sample that completed the quantitative survey (n = 100) was not as equally split with 91% of respondents being female and only 9% male, and the majority were african-american. age of respondents ranged from 23 to 88 years old. thirty-eight percent of respondents graduated from high school or had a ged, and only 13% were college graduates. almost half of the respondents were employed (48%), and 51% reported an income less than $20,000. community readiness for change the mean overall community readiness score for the 10 informants was 3.06, which corresponds with the vague awareness stage of readiness. scores for each dimension ranged from 2.45 to 3.70. the lowest scores were for knowledge of the issue (mean, 2.45; range, 1.25 3.0; sd, 0.59), resources (mean, 2.75; range, 1.5 4.0; sd, 0.89), and community climate (mean, 2.975; range, 1.75 3.5; sd, 0.67). all of these dimensions corresponded to the denial/resistance stage of change. knowledge of efforts had the highest score with the most variance (mean, 3.70; range, 1.5 5.0; sd, 1.15). both this score and the leadership score (mean, 3.425; range, 2.5 4.0; sd, 0.55) correspond to the vague awareness stage. in addition to scoring the interviews to determine stage of readiness for obesity prevention, the investigators analyzed the responses to determine if there were any consistent themes throughout the interviews. the only community effort to promote physical activity that was named by the majority of the informants was the fitness center in one of the communities in the online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 136 county. few members were aware of any other efforts. those informants that were able to name additional efforts were unclear of their purpose or who was eligible to participate in them. all of the informants agreed that obesity was an issue in their community. however, most felt that other health issues (i.e., cancer), low socioeconomic status of residents, and lack of resources were more pressing concerns. overall, informants felt that there was a need for increased physical activity programs. they also expressed a concern in changes made to the school lunch program in the county. they stated that children did not like the food so much of it was going to waste. finally, the consensus was that although leadership in the county recognized the need to implement programs to address obesity, they were not doing anything about it. knowledge of and attitudes toward health promotion and disease prevention only 17% of those interviewed think health should be a priority for government spending. when asked specifically what they thought the government should focus on, the answer given most was health insurance/making health care affordable. responsibility for population health is seen as shared by the government, individuals, schools, and parents. while 94% agree that individuals do need to take full responsibility for their own health, there is also agreement that the government (57%), schools (98%), and parents (59%) play a role in promoting good health. when asked about health promotion campaigns and activities that come to mind, the most commonly mentioned campaigns and activities included those related to exercise (68%), cancer screening (65%), diet and nutrition (63%), and obesity (52%). the majority of residents approved or strongly approved of spending public money on health promotion (85%), and 84% either agreed or strongly agreed that health promotion was effective in improving population health. however, the majority (49%) either disagreed or strongly disagreed that the government was doing enough in the area of health promotion. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 137 disease prevention was viewed somewhat differently by the residents of the county. residents viewed health promotion in terms of health behavior education and programs. disease prevention was seen as a clinical intervention with most respondents naming screenings and medical tests when asked what comes to mind when they hear “disease prevention.” as with health promotion, most residents (83%) either approved or strongly approved of spending public money on disease prevention, and 90% responded that disease prevention was an effective way to improve population health. unlike in the area of health promotion, more respondents (37%) believe that the government was doing enough in the area of disease prevention as opposed to those who do not (34%). the survey also measured community perceptions of the perceived seriousness of specific health conditions and risk factors. based on mean scores on a 10-point scale, the most serious health conditions were: cancer (8.74), diabetes (8.52), heart disease (8.35), and childhood obesity (7.57). the risk factors perceived to have the greatest influence on health included: the type of food a person eats (8.20), a person’s mental and emotional state (8.16), a person’s level of stress (8.11), and the amount of physical activity a person does (7.85). because this community assessment was conducted to inform the development of interventions to target childhood obesity, the survey also included items to measure support for a range of health promotion initiatives targeting childhood obesity. of the options offered to respondents, those that received the highest levels of support were building more cycling and walking paths (91%), increasing the amount of physical activity in the school curriculum (89%), removing soft drinks from school cafeterias and vending machines (69%), and making the food industry reduce the portion sizes of fast foods (62%). less support was evident for banning television advertising of high fat and high sugar content foods during children’s viewing hours online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 138 (57%) and banning television advertising of high fat and high sugar content foods altogether (47%). in order to assist with targeting health promotion campaigns, this study also addressed how residents obtained health-related information. the majority of residents reported their main source of health-related information comes from their primary care physician (56%). this was followed by television (16%) and the internet (10%). only 48% of respondents reported internet access, and of those with access, half said they do not use it to look for health information. discussion the overall crm scores demonstrate that the rural county assessed ranged from denial/resistance to vague awareness stages of change. these scores, along with the quantitative data, indicate that residents of this community are not aware of the significance of childhood obesity in their community and they perceive other health conditions are currently more pressing issues. few studies have used the crm to assess a community’s readiness for obesity prevention (findholt, 2007; kesten, cameron, & griffiths, 2013; pradeilles, rousham, norris, kesten, & griffiths, 2016; sheldon, lyn, bracci, & phillips, 2016; sliwa et al., 2011), and methods of reporting results varied. our finding that the community assessed in this study was in the vague awareness stage is consistent with two of the communities assessed in georgia (sheldon et al., 2016). however, other communities assessed have been in the no awareness stage (findholt, 2007), the denial/resistance stage (pradeilles et al., 2016; sheldon et al., 2016), the preplanning stage sheldon et al., 2016; sliwa et al., 2011), and the preparation stage (sheldon et al., 2016). residents also are unaware of any prevention efforts that are currently in place or that may be planned for future implementation but believe that health screenings and low-cost health care are two of the most pressing needs. our finding that this community had little online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 139 knowledge of prevention efforts is consistent with other studies as well (pradeilles et al., 2016; sheldon et al., 2016; sliwa et al., 2011). the scores for community climate, knowledge of issue, and resources put these dimensions in the denial/resistance stage of change. this indicates that key informants believe that childhood obesity is a problem in general, but they do not believe that it is a concern among members of the community in general or that it cannot or should not be addressed (plested et al., 2005). additionally, this stage of change indicates that key stakeholders have limited or no knowledge about the issue of childhood obesity, or there may be misconceptions about the issue. the knowledge and attitudes survey, which was administered to residents throughout the county, confirms this belief since most rated cancer, diabetes, and heart disease as more significant health concerns. key informants were not in support of using available resources to address childhood obesity. many of the key stakeholders indicated they were aware that childhood obesity was a national public health problem, but few were aware of obesity among the children in the county because county-level childhood obesity data has not previously been available. they also stated that they believed most residents of the county held the opinion that if they thought their child was overweight or obese he or she would “grow out of it,” and it would not have long-term health consequences. the key informants also indicated that they thought resources should be directed to other health promotion efforts, especially those aimed towards senior citizens, rather than to childhood obesity prevention programs. these key informants may hold these views because of the lack of childhood obesity data for the county and the cultural view that caring for senior citizens in the county is a priority. however, results of the community-wide survey indicated that the majority of residents were in favor of using public spending for health online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 140 promotion and disease prevention programs and would support measures aimed at reducing childhood obesity. knowledge of efforts and leadership fell into the vague awareness stage of change. this stage of change indicates that a few community members have at least heard about local efforts to address obesity, but they know little about them (plested et al., 2005). leadership and community members believe that childhood obesity may be a concern in the county, but they are not motivated to act. many of the respondents indicated that they knew of efforts that were in place or were being planned, but they were not sure when those programs were offered or who was receiving them. they also stated they believed leaders in the community did want to address the problem of childhood obesity, but that they needed outside expertise to assist them with developing prevention programs. because community climate, knowledge of the issue, and resources had the lowest scores, these are the dimensions that need to be addressed first to increase readiness. the crm handbook provides examples of actions and interventions to implement in each stage of readiness (plested et al., 2005). efforts to raise awareness and move the community from denial/resistance to vague awareness should reach various audiences and include: one-on-one visits with community leaders and members to provide information regarding the issue in the community and the health and financial benefits of prevention programs, visiting existing and established unrelated small groups to inform them of the issue, collecting stories of local people who have been affected by this issue in this community and find creative ways to disseminate their stories, and conducting an environmental scan to identify the community’s strengths, weaknesses, opportunities, and threats (plested et al., 2005). various stakeholders, such as schools, youth organizations, county extension offices, health care providers and hospitals, and online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 141 churches, could combine efforts to send a focused and consistent message regarding obesity prevention and health promotion programs (son et al., 2011). based on the information gathered in the knowledge and attitudes survey regarding how residents’ obtain health-related information, health care providers could be encouraged to share more information regarding childhood obesity and its long-term consequences during routine patient visits. few residents reported obtaining health-related information from the internet or local paper. however, if they could get health promotion information that was tailored to their community, they may utilize these sources more frequently. the county has an active facebook page and a local paper, both of which are willing to incorporate county-specific health-related information and articles free of charge. in addition, information could also be disseminated through church bulletins, local newsletters, and television and radio psas. highlighting the problem of childhood obesity in the county to influencers and opinion leaders is also necessary. in order to increase the stage of readiness of knowledge of efforts and leadership from vague awareness to preplanning the actions mentioned above need to be continued and additional actions must be taken. possible strategies can include: presenting information on childhood obesity at local community events and unrelated community groups using visuals and stories; posting flyers, posters, and billboards; initiating events to present information on the issue; and publishing editorials and articles in newspapers and on other media with general information that relates to the local situation (plested et al., 2005). these types of strategies have been shown to be successful in creating awareness of and preventing childhood obesity (bell et al., 2013; evans, christoffel, necheles, & becker, 2010; greenmills, davison, gordon, li, & jurkowski, 2013 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 142 one limitation of this study is the use of a convenience sample for the quantitative data collection. because of this, women and african americans were a large majority of the responses for the quantitative survey. including more men and other races/ethnicities may have elicited different responses. another limitation is the lack of inclusion of economic and social factors in the community readiness model. because of its application in a small, rural county, these factors may be key contributors to the community’s readiness for obesity prevention and the development of obesity prevention programs. other possible limitations may include response bias by the key informants and the transient nature of readiness not being suited to measurement at a single point in time. conclusion results of this study provided significant insight into awareness of childhood obesity in a southern, rural county and provided guidance to the investigators regarding the necessary next steps to increase the community’s readiness for obesity prevention. based on the crm scores and qualitative feedback gathered during the interviews, health education programs aimed at increasing residents’ understanding of cardiovascular risk factors and the impact of childhood obesity on long-term cardiovascular health are currently being developed. members of the community coalition have agreed to post information on their facebook page and in local newsletters, the head start and county preschool programs have agreed to disseminate information to parents and help organize educational events, and the editor of the local paper has agreed to include informational pieces that highlight the issue of obesity in the county. the community readiness model was a useful tool for initiating discussion of the issue of childhood obesity in this county and generating interest in developing prevention programs. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i1.456 143 acknowledgements this research was supported by a grant from the center for community-based partnerships at the university of alabama. we wish to thank all of the community members and organizations who participated in the interviews. references befort, c. a., nazir, n., & perri, m. g. 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(2004). trends in the association between obesity and socioeconomic status in u.s. adults: 1971 to 2000. obesity research, 12(10), 1622 1632. https://doi.org/10.1038/oby.2004.202 online journal of rural nursing and health care, 1(3) 1 editorial letter from the editor: collaboration deana l. molinari, msn, rn, editorial board member jeri w. dunkin, phd, rn, editor most grant applications require several separate organizations contributing to the benefit of the community. the reason is clear, amazing accomplishments occur in communities where collaboration takes place. telemedicine, networked health care, educational opportunities, improved services, and community involvement enrich our daily lives. the sad thing is not every community knows how to collaborate. according to theory, collaboration may prove difficult in rural areas. the theory states that rural people are fiercely independent and mistrust others to meet their needs. i saw this happen. i participated in a rural group that included leaders from nursing homes, the hospital, the home health agency and the public health agency. one nursing home leader leaned over and said," i will not say a word in the meeting. i am going to take back everything i can. we won’t work with these people. they will steal our market share." since the meeting was to define the duplications of effort in the community and to identify needs for new services, she felt threatened. at the same time another theory states that rural folk aid each other as friends and neighbors. this theory should help contradict the force of the first theory. the trick is to remain friends and neighbors in the professional role. professionals can interact with other disciplines so as to learn their viewpoints, language and liability issues. new educational models for health online journal of rural nursing and health care, 1(3) 2 care professionals emphasize group problem solving. the future may find more professional collaboration due to this education. the lack of collaborative patient care generates danger. physicians often work in tandem much as children in parallel play. nurses claim territory for their shifts and even mistrust others caring for the same difficult patient. these attitudes produce isolation for everyone involved. in isolation mistakes thrive. during a recent illness i had fifteen doctors prescribing and "surgerizing" on my body not with me. i noticed they rarely knew what the others were doing. i was the communication point. they contradicted each other’s orders, and plans. i feared for my waning health. therefore, i asked a medical doctor to head up a collaborative team. the doctors resisted at first, thinking i challenged their treatment. when the meeting occurred i asked a nurse practitioner to represent me because i was too ill to understand the ramifications of everything said. amid many pleasantries, my future was planned. each doctor agreed the approach was novel but most effective for the difficult case. i am alive and kicking to prove that they managed to cooperate. their fears dissipated and so did mine. unfortunately, the staff nurses did not feel the meeting was appropriate for them to attend. i remained the communication conduit between doctors and nurses, unless they changed an order. collaboration is the opposite of avoiding and competing. collaborating is a creative process. participants analyze situations and define them at a higher level than where conflict arises. the players identify shared goals and commit to work together. the collaborative process works best when the situation requires creative, integrative solutions. meeting both sides’ goals and needs produces consensual decisions. people learn and grow though online journal of rural nursing and health care, 1(3) 3 cooperative problem solving. another benefit of the process is that it results in understanding and empathy for other’s situation. too often collaboration is the last choice in problem solving instead of the first choice. one watches the situation heat up, like a pot of water on the stove. for a long time the water molecules bounce around in their own spheres. nothing seems to happen. then all of a sudden the molecules align themselves together in a pattern and the water boils. the molecules join in the rise and fall to the surface. the internal organization theory states that separate bodies of cells with different purposes will, when the stimulus is right, join together in a single purpose. vision is a good example of this principle. there are about thirty different systems identified in the brain that work separately on vision problems. but when the stimulus is right they join together to solve the problem. color, motion, spatial, and orientation systems work simultaneously to give the viewer a picture of reality. although scientists haven’t yet identified what catalyst triggers the cooperation or how it works, we can guess what triggers our community collaboration. felt needs seem to produce the best results. the more community groups feeling the same need produce the fastest collaboration. sometimes a catalyst educates and motivates the community. brainstorming and light housing produce thinking in many parts of the community. once all the elements come together, the pot boils. the project proceeds and sooner or later the goals are reached. nurses make great catalysts. nurses know how to work with many professionals and can advocate beautifully. therefore, nurses should involve themselves in community health issues. talking with others about how to solve issues is brainstorming. talking with everyone about an issue is called light housing. just as the light in a lighthouse warns every few seconds, so can the nurse bring up the subject with everyone met. gaining online journal of rural nursing and health care, 1(3) 4 support from all aspects of the community is the beginning of collaboration. meetings to identify the issue and then searching for creative solutions are the heart of collaboration. after all is said and done, the community will feel greater unity and experience understanding for each other. unity and understanding are the basics of power. in the spirit of collaboration the following resources are provided: grants on the internet. send your favorite site to the editors: jdunkin@bama.ua.edu deana_molinari@byu.edu share your collaborative endeavors in the chat room at http://www.rno.org. http://www.rno.org/ online journal of rural nursing and health care, 1(3) 5 references yoder-wise, p.s. (1999). leading and managing in nursing (2nd ed.). st. louis: mosby. grants on the internet  federal funding: lots: http://www.aads.jhu.edu/federal_grants.htm  education resources: http://www.educationworld.com/grants/resources/index.shtml  national science foundation: http://www.nsf.gov/home/grants.htm  national archives and records administration: http://www.nara.gov/nara/grants.html  the chronical of philanthropy: http://philanthropy.com/grants/  us department of education: http://gcs.ed.gov/  nih office of extramural research: http://grants.nih.gov/grants/policy/policy.htm http://www.aads.jhu.edu/federal_grants.htm http://www.educationworld.com/grants/resources/index.shtml http://www.nsf.gov/home/grants.htm http://www.nara.gov/nara/grants.html http://philanthropy.com/grants/ http://gcs.ed.gov/ http://grants.nih.gov/grants/policy/policy.htm online journal of rural nursing and health care, 1(2) 1 editorial letter from the editor: new tools deana l. molinari, msn, rn, editorial board member jeri w. dunkin, phd, rn, editor new tools change lives. people decide how to perform a task, how to judge a completed task, and how to feel about the task, based upon the tool. families usually keep more than one shovel because of this principle. a snow shovel won’t dig up the earth for planting. the same is true in our work. new tools change how we practice and think about our profession. new tools can confuse or enthuse us. we decide and our decision impacts the world. we need to realize that standards shifts with technology development. i heard a dean say that she denied that her school had a web page until it was updated. now she feels proud of it. what she fails to remember is that the previous web page pushed the limits of technology in its day. her standards moved with the developing technology. many people used the tool three years ago in its imperfect state and found satisfaction. the present page also pushes the limits. tomorrow the page will appear crude by the new standards the developing technology sets. how will the developing technology impact client teaching standards? i envision a time when clients are thoroughly taught standard materials from regional centers using technical communication tools while local personnel meet individual concerns. new tools ease or solve old problems in new ways, and promote new ways of reaching new goals. inventors constantly think about how to please, to save resources, and to promote universally recognized values. the tools bring with them new challenges for which no answer or tool is yet available. for instance, just as "outcome measures" becomes buzz words in rural online journal of rural nursing and health care, 1(2) 2 health, the realization that sometimes complexity cannot reduce to simplicity promotes new discussions. someone will offer methods of managing complexity while some of us begin to institute standardized methods of dealing with common hospitalized ailments. where we are in the growth curve matters little. we grow. little efforts may make the difference in the end. individual efforts count. a single child went to school with the marshals in the 1960s. lots of multifaceted actions preceded the single walk up the steps to first grade but we keep working with the same issues today. the internet itself is no longer new. invented during the cuban crisis time, promoted in the 1970’s and made a lifestyle in the 1990’s, some form of the internet will continue to shape our lives. we may not now enjoy the latest wireless body mounted technologies, but we can connect. the internet will shape how we practice and even think about our professions. the best experts in the world are available for consult by going to our computers. we must think about our practice in terms of teamwork even though we may still be the only professional within hundreds of miles. the rural library no longer consists of a few outdated texts but includes literature from around the world. online journals bring the best thinking to individual desktops. the online journal presents new standards for readers, editors, and authors. readers must keep abreast of more literature than ever before. authors must use more resources in their literature review, sort through fast developing theories and recognize their own bias before writing. editors recognize that journals increase knowledge and discussion. publication choices depend on elements of what makes a timely and important discussion as well as what makes a good scientific contribution. online journal editors hope the potential discussion will reach the collaboration online journal of rural nursing and health care, 1(2) 3 level. editors must ask will the discussion serve the readers, and empower them to reach their professional goals? in this quarter’s journal one of the founders of the neuman systems theory discusses how communities of providers can collaborate. most rural providers have experienced barriers to collaboration. when disciplines work together as partners they can look out for each other’s good, share ideas, and take credit for achievements (sullivan, 1999). the eighth international neuman systems symposium will be held in salt lake city, utah march 22-23. visit http://www3.telus.net/neuman for further information. does the neuman system offer methods of overcoming the barriers in your community? the journal offers a chat room feature for your rebuttal. readers must speak. the technology brought a new standard to our practice. another author states there is a need for different assessment tools for different populations. such a statement demands feedback from readers about their experiences with similar assessment tools. the (n) is small and the sample taken from people before they enter and after they enter an intervention. this is typical of rural research (center nursing press, 1997). are the findings appropriate for your region? since the tools are available, another community with similar concerns could reproduce the study and submit new findings on the same subject. authors could compare and contrast two studies for a larger (n), or perhaps several communities could study the same subject and make one report of their findings. in this way both diversity of sample and the number involved are increased. this constitutes the collaboration editors hope result from online journals. the standard for research increases as small numbers no longer seem inevitable. another result of larger samples could be increased attention in the media. the media rarely cites nursing, administrative, or rural based studies. (center nursing press, 1997) online journal of rural nursing and health care, 1(2) 4 a third article describes the funding problems with medicare for rural hospitals. the summary of the development of the prospective payment can help practitioners understand administration policies. this article calls for increased use of grants for new program development and telemedicine to expand outpatient services at lower prices. is the article useful in your search for funding? could you find new resources from other journal readers? community collaboration makes one proposal eligible for larger grants. should communities align themselves with educational and research facilities to get the funding they need? or can small communities find the expertise they need in other small communities? paper based journals stop with the written word. the reader and speaker direct where the online journal moves next. authors, editors and community chat rooms use the article to provide the foundation for discussion. do the readers agree or disagree? has someone written a report on the subjects they wish to share? the rnojhc offers a place for group discussions. your professional participation transforms the research into a seminar or conference-type question and answer session. the journal may tap visionary leaders’ ideas and give individuals with questions a larger platform of expression. perhaps online journals will provide the catalyst to a new order of social interaction. please help the journal overcome a major challenge. new journals lack previous readers. venture an idea. talk back to the authors. submit your reasoned thoughts. with reader participation the online journal of rural nursing and health care will meet the needs for which it was developed. the journal can identify common needs, improve methods discussion, and increase research sample measurement. the journal results in increased professional knowledge, increased community collaboration, increased job satisfaction, increased local funding opportunities, and increased partnerships. as editors of the rnojhc we online journal of rural nursing and health care, 1(2) 5 rejoice in the opportunities the new tool brings as we struggle with its challenges, and try to see its future. today’s journal is a small shadow of things to come. we hope we can always say we bring the best technology and increasingly higher standards to the challenge. the journal needs your participation. contact the editors if you are interested in submitting articles, becoming a reviewer, or giving comment on the format. online journal of rural nursing and health care, 1(2) 6 references center nursing press. (1997). the woodhull study on nursing and the media: health care’s invisible partner. indianapolis, in: sigma theta tau international. sullivan, e.j. (1999). the forum’s purpose. journal of professional nursing, 15(2), 6768. https://doi.org/10.1016/s8755-7223(99)80073-8 https://doi.org/10.1016/s8755-7223(99)80073-8 online journal of rural nursing and health care, 1(1) 8 nursing workforce issues in rural and urban settings: looking at the difference in recruitment, retention and distribution kathleen b. lasala, phd, rn, cs1 1 associate professor and chair, beth el college of nursing, university of colorado, klasala@mail.uccs.edu abstract nursing personnel workforce issues vary depending on geographic and population density of health care settings and the type of agency. the purpose of this investigation was to explore the distribution of registered nurses in rural and urban health care settings (public health departments, long-term care facilities and hospitals); examine recruitment and retention strategies and barriers; and to analyze relationships between distribution of nurses and recruitment and retention. written surveys of 131 rural and urban nursing administrators (response rate 57%) evaluated the quantitative and open-ended responses to questions regarding specific personnel numbers and recruitment and retention strategies and barriers. results revealed that using the fte (full time equivalency) vacancy formula, rural health care settings reported the lowest vacancies; however, when major vacancies did exist, they were greater in the rural settings. salaries, changes in local economies and military closures, and major changes in nursing position allocations had both a negative and positive effect on both the rural and urban health care settings. the findings indicate that numbers alone are not a sufficient means to determine the need for nurses, and shortages can pose a significant threat to quality and access of health care. keywords: nursing workforce recruitment, retention, distribution online journal of rural nursing and health care, 1(1) 9 nursing workforce issues in rural and urban settings: looking at the difference in recruitment, retention and distribution nursing personnel workforce issues vary depending on the rural or urban geographic and population density of the health care setting and the type of agency. there has been a major change in the focus of health care from an acute, in-patient setting, to a broader, communitybased care, resulting in a shift in nursing personnel needs. the distribution of nurses and other health care personnel is a major issue facing many rural and urban areas, and predicting requirements for personnel is a complex process (dumpe, herman & young, 1998; prescott, 1991, 1993). due to vast differences in rural and urban settings, there may be an assumption that nursing personnel issues will be significantly different. the purpose of this investigation was to explore the distribution of registered nurses in rural and urban health care settings; examine recruitment and retention strategies and barriers; and to analyze relationships between the distribution of nurses and recruitment and retention. determination of nurse adequacy levels in either rural or urban settings requires an analysis of a variety of factors beyond counting vacancy rates (brush, 1992; dumpe et al. 1998; prescott, 1991, 1993; lasala, 1995). the federal government designates nursing shortage areas based on numbers (lee, 1991), and although this provides a starting point for investigation, situational analysis of individual settings may reflect multiple factors play into the need and demand for nurses. a non-economic, non-numerical perspective would evaluate the quality of the patient care, rather than the quantity of nurses. significance of the study health professional shortages pose a significant threat to access, quality, and costs of health care (gilliland, 1997; prescott, 1991, 1993). health care spending in the united states is online journal of rural nursing and health care, 1(1) 10 approximately 14% of the gross national product and personnel account for almost 30% of those expenses (sultz & young, 1999). there is a growing body of literature indicating a shift in the distribution of nurses across the nation (buerhaus & staiger, 1996; ketter, 1994; manuel & sorensen, 1995; stratton, dunkin & juhl, 1995; schultz, 1999); however, there is limited data to reflect current differences in rural versus urban settings. this study provides a collective summary of nursing personnel distribution and identifies key recruitment and retention issues. findings may guide nursing leaders in developing their future recruitment and retention efforts and resource allocation, specifically, nursing position allocations in financially tight times. by using an employer-based research survey at the state level, the results can be used to support and direct workforce policy and comparative research studies in other regions (bamberg, malvery, wainwright, fottler & joiner, 1994). review of the literature in the united states there has been a large population identified as medically underserved and geographic regions designated as health professional shortage areas, in both rural and urban areas. the central health care issue for many communities across the nation is the inadequate supply of health care professionals and limited access of residents to health services (sultz, 1999; christianson & moscovice, 1993). the maldistribution of health care professionals has left many areas underserved or without health care services, while other areas deal with surpluses of health care specialists and services. many health care agencies have been dramatically impacted by nursing shortages and cost containment efforts in the health care system, with some forced to close beds to admissions, others have closed altogether (brush, 1992; fuszard et al. 1990; prescott, 1993). the demand for skilled nurses has increased with advances in complex health care and technological services online journal of rural nursing and health care, 1(1) 11 available in the health care settings. patients are discharged from hospitals with more complex health care needs. concurrently, the nursing profession has increased its role in the community, including ambulatory services, home health care and industrial nursing (buerhaus & staiger, 1996; gilliland, 1997). this shift to ambulatory services and home care has decreased the average patient hospital stay, but increased the patient acuity of patients in the hospital and at home (stratton, dunkin, juhl, ludtke & geller, 1992; brewer, 1996). population demographics also have shifted to an increase in the elderly population which tends to put a high demand on health care services at all levels. federal and state health care reform movements call for a shift to a primary care focus, also increasing the demand for more independent, generalist-focused registered nurses (buerhaus, 1995; sultz & young, 1999). the demand for nurses is currently unstable, as health care reform and managed care movements are demanding increased access and quality, while simultaneously insisting on effective cost containment (dumpe, herman & young, 1998). it has become increasingly clear to nursing leaders that the future of nursing will be drastically shaped by the economic pressures, managed care and market-led reforms (coile, 1995; wakefield, 1997). the demand for nurses is heavily influenced by socio-cultural, political and economic factors. the supply factors refer to the number of available nurses, which is influenced by factors such as changes in the health care system, nursing education, economic conditions and nurse demographics (dumpe et al. 1998). using a supply and demand workforce model, dumpe et al. (1998) identify multiple factors influencing the demand for nurses, including: the health care delivery system; the number and types of services provided; the technology and degree of specialization required; the use of employee substitutes; other health care provider status; the economic system; reimbursement availability and restrictions; nursing education system; and demographics. as the need expands online journal of rural nursing and health care, 1(1) 12 for highly skilled nurses in the health care system, demand will overcome the supply. while managed care has reduced the overall demand for hospital nurses, it has increased the need for nurses in community health care settings. unfortunately, hospital wages have historically been higher than salaries in outpatient settings, plateauing salaries at inflation rate since 1991 (buerhaus & staiger, 1996). there is relative consensus that the present nursing shortage is more a result of the changes in utilization of nurses, than in the supply (dumpe et al. 1998; stratton et al. 1995). the regional maldistribution of nurses has not affected all geographic regions or institutional settings equally. rural and inner-city settings seem to be more consistently hard hit. the largest number of shortage areas designated in the u.s. exist in counties non-adjacent to metropolitan areas (stratton et al. 1995; sultz & young, 1999). morris and palmer (1994) compared ten different allied health professions for differences in vacancy rates. significant rates decreases were cited for only two of the professions, nursing and respiratory therapy. when examining the findings for nurses, significant influences were location and size (f = 4.80, p<.05) investigators noted that on average urban hospitals had significantly more rn vacancies than rural hospitals, however, small rural hospitals had greater vacancy rates than large hospitals. the large hospitals in the urban settings had greater vacancy rates than small hospitals in the same cities. the rural nursing workforce has been greatly impacted by the cultural environment in which it is practiced, including some of the broader trends related to rural occupational and economical foundations as well as political influences that have had a significant impact on rural health care (sultz & young, 1999). the decline in the rural occupational foundations of agriculture, mining and forestry has left many rural communities in economic distress. online journal of rural nursing and health care, 1(1) 13 unemployment is high, with growth in the service industry jobs much slower in rural areas than in urban settings. rural settings often have a captive employment base due to geographic and distance factors which isolate them from urban centers (christianson & moscovice, 1993). many nurses are being drawn to urban area salaries and opportunities for themselves as well as family members (lasala, 1995; stratton et al., 1993, 1995). urban settings have a broader population to draw nursing recruits and nursing administrators can use competitive salary options as a recruitment strategy. in urban areas the supply of nurses has been dramatically affected by health care shifts and "downsizing" due to cost containment efforts. fewer patients in hospitals, reduced budgets and cutbacks for personnel, layoffs, and the substitution of lesser-trained workers for registered nurses have all occurred (begany, 1994; betts, 1994; gilliland, 1997; ketter, 1994; manuel & sorenson, 1995, prescott, 1993). mcguckin-smith (1995) reported 48% of over 3,000 nurses surveyed reported their employers had deleted or failed to fill vacant rn positions, 36% cited staff reductions and 25% reported unit closures, and 23% noted reductions in assistive personnel. nurses also documented rn layoffs and an increase in the usage of unlicensed assistive personnel as factors increasing the rn shortages (begany, 1994; gilliland, 1997). inpatient rn staffing was consistently cited as decreasing (45%), while outpatient settings actually reported no change (41%) or increases (41%). when nursing shortages exist, there is a heavier demand on those nurses remaining in the workforce, which in return increases their job dissatisfaction (klemm & schreiber, 1992). in a recent survey of 681 hospitals, 81% cited poor morale as the worst employee problem. workers cited layoffs, ineffective communication and job uncertainty as major causes of these feelings (morale skidding with restructuring, 1996). further online journal of rural nursing and health care, 1(1) 14 recruitment of nurses is hampered due to the image these nurses portray of their job environment and satisfaction (kramer & schmalenberg, 1991). in addition to salary and geographic issues, some blame a shortage of nurses on increasing career options for women, poor economic return for a baccalaureate degree, nursing management’s inflexibility and lack of autonomy, condescending attitude towards nurses, and a poor image of nursing (schneider, 1992; ludwig, 1998). ludwig (1998) asserts that individuals making career choices are focusing on options that enhance overall quality of life issues, looking for job opportunities that support non-work priorities as well. the nursing shortages that have occurred over the past eight decades are not a continuation of the same problem, but a term to describe the perception of an insufficient nursing supply, inadequate control of practice, and professional concerns within a specific time frame (brush, 1992). dumpe et al. (1998) contend shortages could be predicted and understood better if nursing leaders examined the entire context, rather than just numbers. population and sample a convenience population of all hospitals, long-term care agencies and public health departments in both rural and urban virginia was sampled for this study. counties were classified as urban using the u.s. census bureau's classification system of metropolitan statistical area (msa) designations and only agencies in msa counties. the definition of a msa is a county encompassing at least one city of at least 50,000 population or an urbanized area of at least 50,000 with a total metropolitan population of at least 100,000 (office of management and budget, 1990). non-metropolitan statistical areas and those counties nonadjacent to metropolitan areas were classified as rural. the chief nursing administrators from 230 urban and rural settings in 54 counties/cities (31 urban; 23 rural) in the commonwealth of online journal of rural nursing and health care, 1(1) 15 virginia were asked to participate. surveys were completed and returned from 131 administrators, with a response rate of 57%. instrumentation and operational definitions a recruitment and retention survey tool developed by the university of north dakota (und) rural health research center was revised and piloted for use in rural and urban settings. the tool provided quantitative and open-ended questions which explored distribution of nursing personnel, as well as recruitment and retention strategies and barriers. distribution of registered nurses in individual health care settings was calculated using the rn fte (full time equivalency) vacancy rate. the rn vacancy rates were calculated as follows: this method was developed by the bureau of health care delivery and assistance office of shortage designation to identify nurse shortage counties (bureau of health care delivery and assistance, 1990). recruitment and retention strategies include plans of action to attract and retain nurses. recruitment and retention barriers reflect perceptions of things that block or hinder nurses from joining or staying in an agency. methodology and data analysis this research study involved a self-administered, mailed questionnaire survey. the survey included demographic and descriptive items, likert rating scales, and some open-ended questions for non-predictive, individualized answers. both descriptive analysis and inferential techniques were used to analyze the data. the responses were analyzed as a total sample of all health care settings and then as individual sub-samples consisting of public health departments, hospitals and long-term care facilities. the demographic data were based on frequencies and online journal of rural nursing and health care, 1(1) 16 distribution of responses. clustering and content analysis was used for qualitative open-ended questions. the relationship between the variables of distribution and resulting characteristics was analyzed using inferential statistics. chi-square contingency tables were produced and analyzed using correlation coefficients to determine relationships (p <.05) and their linear directions. correlation coefficients to established the significance level (p <.05) of the comparison data were computed. findings the majority of rural hospitals and long-term care (ltc) agencies were small (less than 80 beds), in comparison to those in urban settings, which were large (75% had 120 or more beds). seventy-nine percent of rural settings were 30 to 90 miles from an urban setting. over 90% of both rural and urban settings reported they did not use swing beds to ease staffing and patient loads, nor were they co-located with other agencies (both less than 12%) or coadministered (urban < 32%; rural < 16%). over half of the agencies reported some type of cross-training of nurses, with public health departments reporting the greatest degree of required flexibility between client care specialty areas, administrative responsibilities and quality assurance. using the rn fte vacancy rate formula, rural health care settings reported the lowest vacancies rates. over half (59.6%) of rural settings reported no vacancies, compared to 43.7% of urban settings without vacancies. however, when major vacancies did exist (vacancy percent rates greater than 21%), they were greater in the rural settings (19.2%) than the urban settings (2.7%). nursing administrators were asked to evaluate if their agency vacancy rates had increased, decreased, or stayed the same. the responses varied dramatically depending on the online journal of rural nursing and health care, 1(1) 17 setting. over 80% of both the rural and urban settings reported that vacancy rates had decreased or stayed the same. the health departments reported largest increase in vacancy rates, hospitals reported the largest decrease in vacancies, and the long term care facilities reported that vacancies had remained constant. the nursing administrators shared perceptions of the causes of decreases and increases in vacancy rates. they reported a general shift in health care to ambulatory care thus limiting the number of positions in hospitals and opening up new ones in ambulatory care settings, resulting in a decreased rate in one setting and an increase in the other, respectively. changes in the overall economy were linked with both loss and retention of nurses. some of the administrators viewed the competitive job market as an influence on nurses staying in their present positions, while others indicated the lack of available job openings (especially full time) led nurses to look elsewhere for positions. some of the administrators indicated that positive affiliations with schools of nursing education (student rotations, internships and job promotional activities) helped improve the recruitment and retention of nurses. some attributed the decrease in vacancies to their positive work environment, referring to the "family like atmosphere" of their agency, which was more commonly reported in the rural hospitals and both rural and urban health departments. a small number of agencies reported recent implementation of recruitment plans, and one urban hospital even referenced free parking as a stabilizing factor. approximately 10% of urban sites associated the increase in vacancy rates with either recent military base closures or nurses leaving to pursue their education. approximately 10% of health departments reported recent budget constraints and reductions had drastically affected the position allotment. this lead to the appearance that vacancy decreases existed, when in fact the online journal of rural nursing and health care, 1(1) 18 positions were no longer available. in both rural and urban settings salaries had improved, enhancing both recruitment and retention of nurses, but the rural administrators continue to see the urban areas drawing nurses by offering higher salaries. promotions, transfers and retirements were documented in both the rural and urban settings as the causes of vacancies. rural settings more consistently cited nurses relocating to urban settings due to family needs. when nursing administrators were asked if the rn vacancy rate (either high or low) accurately reflected the status of rn personnel needs in their agency, over half (52%) responded "no". these administrators elaborated with several explanations. they cited new graduates or inexperienced nurses were not able to function as independently or effectively as experienced nurses. vacant positions in an agency with few rn positions reflected inflated vacancy percentages. in addition, rn positions were not in the agency budget, therefore no vacant positions were available to report even though a need for more nursing staff existed. and finally, several of the public health departments reported "atypical" position vacancies due to new positions. nineteen percent of rural settings and twenty-six percent of urban settings reported critical rn vacancies, citing clinical specialty area needs and specific shift or weekend coverage needs. two of the rural settings indicated a critical need for the primary nurse administrator position. the administrators’ responses were varied when asked how long the average rn stayed in their agencies. in both the rural and urban settings, 35% of the nurses stayed less than five years, and 65% stayed greater than five years. however, the urban settings reported greater numbers of turnover staff per year. in ranking acuity of the nursing shortage in their setting, the most administrators (83.5% rural; 70% urban) reflected "no or little shortage", versus an acute nursing shortage (4% rural; 6% urban). long-term care facilities reported the greatest acute online journal of rural nursing and health care, 1(1) 19 nursing shortage, but also reported the smallest number of employed registered nurses. in evaluating the supply of nurses in their region, 45% of rural administrators noted a very limited supply, versus 10% of urban administrators also noting a very limited supply. ratings of a high supply of nurses were reflected by 47% of the rural administrators, versus 66% of the urban administrators. the apparent conflicting reports from almost half the rural administrators may indicate an awareness that although a specific agency is not dealing with a nursing shortage, the administrators are aware of a low supply in their geographic region. a large majority of both the rural (84%) and urban (93%) administrators ranked little difficulty in recruitment, and 16% and 7%, respectively, ranked significant recruitment difficulty. retention difficulty was ranked in a very similar fashion, with ratings of little difficulty at 86% in the rural settings and 93% in urban. long-term care facilities reported more difficulty in both recruitment and retention than in other settings. none of the agencies in rural or urban settings perceived their sites as dependent on temporary nurses, and almost half (47%) reported temporary nurses were not used at all. in both rural and urban settings, nursing administrators perceived salaries, lack of fulltime positions for nurses, and a competitive job market as barriers to both recruitment and retention. rural administrators also reported the local economy and unmet family needs as barriers. the administrators in both areas indicated nurse relationships (with other nurses, administration and physicians) and work related variables (benefits, working conditions, workload) were viewed as positive incentives for retention. geographic location, housing, and community amenities were not significant factors in either the rural or urban settings. online journal of rural nursing and health care, 1(1) 20 conclusions and recommendations this investigation revealed quantitative analysis revealed there is no acute shortage of nurses in rural or urban health settings when measured by the rn fte vacancy rate calculations traditionally used to determine shortages of health care professionals (bureau of health care delivery and assistance, 1990). however, additional qualitative questioning and analysis revealed that there are critical vacancies and staffing needs not reflected in numbers. these findings support the nursing workforce model developed by dumpe et al. (1998), which focuses on the dynamic, interacting factors that affect supply and demand. major changes in the health care delivery system and the impacts of local economies and occupational foundations have altered distribution, recruitment and retention issues in nursing. overall, salaries, lack of full-time positions for rns, local economies and competitive jobs elsewhere remain a recruitment and retention problem, while close relationships and work related variables remain positive incentives. recruitment is viewed as slightly more difficult than retention, but at the present time neither are identified as very difficult. nursing administrators must encourage a more individual assessment of their own communities, agencies and client needs in nursing personnel decisions, and be vocal in policy decisions which are made based entirely on economical or numerical data. online journal of rural nursing and health care, 1(1) 21 references american nurses association. 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(1992). recruiting and retaining registered nurses in rural hospitals and skilled nursing facilities: a comparison of strategies and barriers. nursing administrative quarterly, 16(4), 49-56. https://doi.org/10.1097/00006216-199201640-00009 stratton, t.d., dunkin, j.w., juhl, n., geller, j.m., & ludtke, r.l. (1993). recruiting registered nurses to rural practice settings: an assessment of strategies and barriers. applied nursing research, 6(2), 64-70. https://doi.org/10.1016/s0897-1897(05)80104-1 stratton, t.d., dunkin, j.w., & juhl, n. (1995). redefining the nursing shortage: a rural perspective. nursing outlook, 43, 71-7. https://doi.org/10.1016/s0029-6554(05)80047-8 sultz h.a., & young, k.m. (1999). health care usa; understanding its organization and delivery (2nd ed.). gaithersburg, md: aspen. wakefield, m. (1997). federal funding shapes nursing’s future. nursing economics, 15(2), 110112. https://doi.org/10.1097/00005110-199111000-00008 https://doi.org/10.1097/00006216-199201640-00009 https://doi.org/10.1016/s0897-1897(05)80104-1 https://doi.org/10.1016/s0029-6554(05)80047-8 microsoft word lane_363-2125-2-ed.docx online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 26 ten year profile of a best practice program aimed at rural women adrianne j. lane, bsn, msn, edd, cne 1 madeleine t. martin, bsn, msn, edd 2 1 chair and professor, department of advanced nursing studies, northern kentucky university. lanea6@nku.edu 2 professor emeritus, college of nursing, university of cincinnati, mimiquilts33@gmail.com abstract providing the best evidence available is important to insuring rural health needs are being addressed. a best practice program delivering breast cancer education and screening to rural women was designed to address the three key barriers to healthy barriers of cost, distance and fear. the purpose of this article is to describe findings and implications of a 10 year profile of this best practice program. from 2001 to 2011 over 2300 rural women received breast health education and no cost mammography through this project. data collected in conjunction with the delivery of this best practice program was compared to national indicator data for a ten year period. when reviewing demographic data, the project women were less educated than the women identified in the cdc data. the project and cdc data were similar in terms of poverty and being uninsured. although there were similarities in the two groups (project and cdc) in terms of poverty and lack of insurance, in the last reported year the project women achieved higher levels of mammography within the past two years even though they were overall less online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 27 educated. while such comparisons are useful, of equal significance are the differences that can occur among data sets and the importance of including multiple data sets. forward movement in the overall national healthcare goals can best be enhanced through the dissemination of grassroots data such as found in this project. such data have the potential to be substantially useful when planning primary and secondary care outreach programs consistent with the national healthcare agenda. nurses have the opportunity and responsibility to advocate in the political arena and to be ever cognizant of national healthy behavior goals and objectives. nurses have a key role in assuring optimum health care is available regardless of one’s rurality. keywords: rural health, breast cancer, cancer screening, access to healthcare, health policy ten year profile of a best practice program aimed at rural women health statistics and data sets are important because they can offer insight into a wide range of population based health indicators. community based data sets provide a means to study healthcare use among population subsets and, when considered in aggregate, can assist with resource allocation and policy recommendations at local, regional and national levels. community based data sets can provide baseline data to help providers and community planners identify areas of need. baseline data from prevention programs are important for program planning and evaluation. not all health data sets and statistics are freely or publicly available. our hope is that by dissemination of this 10 year data set, knowledge gained can be reviewed along with other public health data sets to identify shifts in rural community demographics as well as the impact of national programs on rural health care availability and usage. many committed groups, including the national rural health association (nrha), remain concerned that national health policy such as affordable care act (aca) and healthy people 2020 will not online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 28 adequately address critical rural health concerns. providing the best community based evidence available will be important in insuring current rural health needs are voiced. maximizing the percentage of women who overcome breast cancer is dependent on routine breast cancer screening. rural women are particularly at risk because they do not take advantage of screening procedures that are commonly available to their urban counterparts. recognizing that three key barriers to healthy behaviors are distance, fear, and cost, we developed a community oriented breast health program. the goal was to develop a best practice program that provided breast health education and screening to women in five rural, medically underserved counties in southeastern indiana on an annual basis. best practice is an approach to decisionmaking in which the clinician uses the best evidence available, in consultation with the patient and the community, to decide upon the option which best suits that patient (cochrane, 2014). this best practice program focused on addressing the three key barriers to healthy behaviors by partnering with local health departments and other community stakeholders to overcome the barrier of fear, using mobile mammography to overcome the barrier of distance, and securing external funding to offer the service at no cost addressing the barrier of cost. the purpose of this article is to describe findings and implications of a 10 year profile of this best practice program. background in november 1998 an accord was reached, the master settlement agreement (msa), between the state attorneys general of forty-six states and the five largest tobacco companies in america (public health law center, 2010). through this agreement states would receive more than $206 billion over 25 years. indiana was one of these states and received more than $1.9 billion from the tobacco companies. in addition to funding a tobacco settlement fund, money was transferred to other funds for health programs which included initiatives such as cancer online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 29 detection, women’s health, etc. health departments and community health centers across various states became involved in designing health promotion programs to address the identified health needs (public health law center, 2010) in 2000, indiana started making this tobacco settlement money available for cancer detection programs. disbursement of money was in some cases organized through a system of grants which included those for women’s health. three nurse faculty from the university of cincinnati, who also were residents of rural southeastern indiana, became aware of one of the msa grant opportunities funded through the division of women’s health, state of indiana. the grant guidelines identified the purpose as targeting a women’s health promotion issue. this is significant today because: 1) one of these early grants led to the data which will be reported here, 2) this project being reported demonstrates that money did go directly to indiana rural citizens, and 3) long term impact was realized and magnified in an underserved area by leveraging the original success and securing ongoing money from other sources for over the 10 years of 2001 to 2011. for that initial grant the project team elected to focus on breast cancer screening and education in rural medically underserved counties in southeastern indiana. focusing on breast cancer (bc) was supported based on the nurses’ community work with the indiana chapter of the american cancer society (acs) and local health departments. both groups identified that there were limited efforts in the targeted geographic area to promote healthy behaviors of women regarding breast cancer risk factor awareness, early detection and screening. over time a logic model was developed by the project team to serve as the foundation and structure for the best practice program. further, the not-for-profit organization, southeastern indiana cancer health network, inc. (seichn), was formed by the team with the key goals of providing cancer online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 30 education and screening programs, securing funding to support the programming, and sustaining the program overtime. seichn had two primary activities across the ten years. one was a day long education and lunch session for rural county health department nurses on current bc risk factors and current screening guidelines and techniques. this activity also included purchasing breast self-exam (bse) models and educational materials for each health department for ongoing educational use. the second component, which generated the data presented here, was education and breast screening days for rural community women. the full day program, which focused on education and screening, was structured so that the project team was paired with county health department nurses to deliver the programming. these teams work together to provide a breast cancer screening program that included mobile mammography and breast health education. mammography was provided by mobile van that came to a central location in each of the counties. the educational component included teaching breast self-examination technique and providing information on clinical breast exam (cbe) and breast cancer risk factors. the team modeled their definition of rural after the us department of agriculture economic research services (usda, ers) and the us department of veterans affairs (n.d.), office of rural health (usda, ers, n.d.). rural was defined as non-urban, non-metropolitan with open country-sides. rural residents were living in areas of lower population density with some distance between homes and businesses and whose some source of income was based on farming and agriculture. four of the five counties targeted were 60 or more miles from a major city and the nearest medical centers were 50 60 miles away making distance an issue. of the counties targeted, one was fully medically served, one partially underserved and two fully underserved. online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 31 need of the 250 poorest counties in america, 244 are rural (mathis, 2003). economic factors, cultural and social differences, educational shortcomings, lack of recognition by legislators, and isolation of living in more remote areas combined to impede primary screening and health promotion activities for rural populations. demographics for “rural” vary over time, however some representative numbers include that in 2008 an estimated 70.5 million persons lived in rural areas (23 % of the population). indiana was reported to have the 10th highest overall cancer mortality rates among states and d.c. with 4,680 new cases and 900 deaths estimated for 2006 by the acs. during the 10 year period of our project, health care needs in the five counties were met by 2 small community hospitals, 25-30 miles away whose medical staff come primarily from either cincinnati or louisville. as noted, the nearest medical centers are 50-60 miles away. other agencies such as ywca and the indiana rural health initiatives did not provide services to this part of the state. no mobile mammography units were available in the area other than that brought by this project. in two counties, free lunches were reported significantly over the state average rates of 25% (free), and 7% (reduced). free and reduced school lunches are often noted as an acceptable indicator of poverty in an area. switzerland county reported a mean income of 35% below $25,000.00. the major goals of breast education and screening programs remained constant overtime and included: 1) increase the number of resources (personnel and materials) available to provide ongoing breast screening education programs; 2) increase the number of women who attended a program on bc screening and cancer risk factors; 3) increase access to mammography and cbe screening to women in the identified rural counties; and 4) increase linkages among health care online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 32 professional services and community organizations in the southeastern indiana area. recruitment for programs in rural areas differs from recruitment in urban locals. this program was implemented in such a way that a wide “net” was cast to make the program known and appealing to broad cross-section the county populations including appalachian, hispanic and african american residents living within these rural communities. the county health department nurses were included to insure their commitment to the project. churches, post offices, civic organizations and community events such as bingos were used to present publicity and information about these upcoming education programs and mammography opportunities. programs were advertised in the local newspapers and in local restaurants which often serve as communication hubs. those women deciding to participate in the screening were instructed to contact the health department by phone to register. each was screened during the call to insure eligibility for screening mammography. at the predetermined date, women came to the scheduled site, took part in the educational program, and then went on the mobile van for the mammogram. all educational materials were from acs and the acs screening guidelines for mammography were used for determining participant eligibility. in the event that any participant at any point in this project identified a potential breast related condition, a referral was made to an appropriate health care facility in the community. since its beginning, the staff utilized a data collection form to collect demographic information regarding breast cancer risk, personal and family history, and factors influencing breast cancer screening practices. the data form and process were submitted annually to the university of cincinnati research institutional review board. when the woman arrived for screening, she was given forms to complete. the format of the data forms changed over time to incorporate the needs of our various provider and funding partners so that necessary data were online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 33 gathered while minimizing the time spent by the women. following each screening date, the mobile screening provider agency reported the total number of women needing follow-up. since the project team was essentially “brokers “for the services, the team did not receive results for specific women or the names of women needing follow-up. results from 2001-2011 two thousand three hundred and ninety-four women completed a demographic survey as part of the registration for the seichn breast cancer education and screening event. the results, as displayed on table 1, demonstrate that the typical profile of the women served is over age 50 (56%), caucasian (94.5%), married (63%), and living with a partner (71.2 %). nearly 1/2 of the women have either a high school or ged (49.1%), 1/3 work full-time for pay (33.4%), and over 40% are either retired or receiving no income for work. table 2 displays additional characteristics of participants in 2001, 2003, 2005, 2008, and 2011. the women represented in the aggregate data were from dearborn, franklin, ripley, ohio, and switzerland counties. data on those served by seichn in these counties remained fairly consistent over time. when seichn began their breast education and screening programs in 2001, 68% of the women who participated had never had a mammogram. in 2011 this percentage had decreased to 29%. specifically, in 2001 two in three women had never had a mammogram and in 2011 greater than two in three women had received a mammogram. additionally, of the women who reported previously having a mammogram in 2001, 63% reported they had not had one within the past 2 years. by 2011, of the women who reported having previously had a mammogram, only 26% reported not having had one within the past two years. this is in stark contrast to the national rate of 15% during the program period. throughout the program period approximately one half online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 34 of the women served had total family incomes less than $25,000, with a range from 57 to 41 %. table 1 demographics: 2001-2011 (n=2394) characteristics percent (%) age (years) 30-39 40-49 50-59 60-69 over 70 no response 5.8 31.3 27.2 21.9 6.9 6.9 race caucasian african american hispanic native american no response 94.5 0.8 0.2 0.4 4.1 marital status married widowed divorced separated never married no response 63.0 9.8 13.8 1.6 2.5 9.3 living with partner yes no no response 71.2 26.0 2.8 highest education level some grade school some high school high school graduate/ged some college college graduate some graduate graduate/professional education technical school no response 2.2 11.8 49.1 16.7 8.8 0.5 3.1 2.1 5.7 work status working full time for pay working part time for pay not working for pay retired homemaker no response 33.4 15.0 14.6 15.6 12.1 9.3 online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 35 further from 32% to 48 % of the women who participated in the screening program reported having no insurance. over 55% had annual incomes of less than $25,000 and only 60% reported they had health insurance. of those with insurance less than half reported that the insurance paid for mammograms. anecdotal reports from the women indicated that during the 2009 many had lost jobs with the economic downturn. from 2001 to 2011 the screening mammography followup rate decreased from 21% to 4% as compared to a national average of 5-10% during the same period. table 2 characteristics of rural women seeking mammograms 2001 2003 2005 2008 2011 n 141 215 177 221 257 never had mammogram 68% 11% 10% 34% 29% income <$25,000 48% 55% 57% 41% 41% no mammogram in past 2 years (national rate: 15%) 63% 30% 33% 50% 26% no insurance (national rate for women: 11%) n/a 40% 33% 48% 32% insurance pays for mammogram n/a 47% 40% 33% 45% follow up necessary (national norm: 5-10%) 21% 11% 1% 13% 4% top reasons for not getting mammogram n/a cost a lot/no insurance cost a lot/ kept forgetting cost a lot/no insurance afraid to find a problem no insurance/ cost too much never had breast cancer in family/ too busy top reasons for participation time due to get a mammogram free mammo van nearby free mammo van nearby no cost/ free service easy to get to no cost/ free service concern about health online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 36 throughout the years the women reported the number one reason for not seeking mammography was that mammography ‘cost a lot’ and the top reasons for participating in the seichn program was that the program was ‘free or no cost’ and ‘easy to get to’. discussion data set comparisons since 1987, the centers for disease control and prevention (cdc) has collected selected data on the use of mammography for women 40 years of age and older (national center for health statistics [nchs], 2011, 2013; miller, king, joseph, & richardson, 2012). several of the data categories collected by the cdc are similar to those categories addressed in data collected by the seichn. table 3 displays cdc data on similar characteristics as seen in table 4 displaying seichn data for select years. a comparison of the seichn and the cdc data yields a variety of contrasts. according to the cdc in 2000 seventy % of women reported having had a mammogram within the past two years as compared to 37% of the women who participated in the seichn programming (khajuria, 2013). the national rate of mammography dipped to 67% in 2010 compared to the seichn rate increased to 74% in 2011. table 3 cdc use of mammography and selected characteristics in women 40 and over mammogram within last 2 years income <200% poverty level for family of 2 un-insured high school graduate/ged some college education 2000 70% 58% ($22478) 41% 70% 76% 2003 70% 61% ($24030) 42% 68% 75% 2005 67% 55% ($25510) 38% 65% 73% 2008 68% 56% ($28102) 40% 65% 73% 2010 67% 54% ($28432) 36% 64% 72% online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 37 table 4 seichn use of mammography and selected characteristics in women 40 and over mammogram within last 2 years family income less than $25,000/yr un-insured high school graduate/ged some college education 2001 37% 48% n/a 45% 26% 2003 70% 55% 40% 54% (2004) 18% (2004) 2005 67% 57% 33% 51% 33% 2008 50% 41% 48% 43% 29% 2010 44% 50% 37% 56% 36% 2011 74% 41% 32% 49% 44% when looking at demographics, the seichn women were less educated than the women identified in the cdc data. for the cdc group, 64 to 70 % of the women had at least a high school diploma or ged as compared to a range of 43 to 56 % of the seichn women. even though the percent of women having such education decreased over time in the cdc group from 70 to 64%, the 64% was much higher than the highest report for the seichn data at 56%. further the cdc data revealed that over 70% of the women had some college compared to substantially fewer than 50% of the seichn women reporting any college. the seichn and cdc data were similar in terms of poverty and being uninsured: 40 to 60 % of the women lived in households with total incomes less than $30,000 and 32 to 48 % reported being uninsured. although there were similarities in the two groups in terms of poverty and lack of insurance, in the last reported year the seichn women achieved higher levels of mammography within the past two years even though they were overall less educated. ten year span--intervening factors across the ten years of this project, having no insurance or being underinsured remained an issue for the women who participated in the project programming. this was consistent with national reporting. according to the kaiser family foundation “the number of employers who online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 38 offer health insurance has declined and costs for employer-paid health insurance are rising: from 2001 to 2007, premiums for family coverage increased 78%, while wages rose 19% and prices rose 17%. even for those who are employed, the private insurance in the us varies greatly in its coverage; one study by the commonwealth fund published in health affairs estimated that 16 million u.s. adults were underinsured in 2003” (schoen, doty, collins, & holmgren, 2005). interventions that reduce delays in diagnosing and treating illness have been identified as meaningful across both social and political agencies. in 2001, the major federal programs available to address access to healthcare were medicare and medicaid. these two programs address income issues for some but were not designed to impact non-economic barriers to healthcare such as distance and fear. by 2011, national initiatives such as electronic health records were seen as having the potential to improve the delivery of health care services. healthy people to coincide with the seichn data collection period, a look at healthy people criteria related to breast cancer screening for 2000, 2010, and 2020 reveals a number of points of interest for the advanced practice nurse. be aware that healthy people was planned as a nationwide program focusing on health promotion and disease prevention. healthy people goals were first referenced in 1979 in the mmrw which introduced a new series, "health objectives for the nation." for more than 3 decades, healthy people has established benchmarks and monitored progress over time in order to: 1) encourage collaborations across communities and sectors; 2) empower individuals toward making informed health decisions; and 3) measure the impact of prevention activities” (u.s. department of health and human services [usdhhs], n.d.). in the healthy people 2000 (hp) report, the objective specific to breast cancer screening was to “increase the percent of women 50 years of age and older who received a mammogram online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 39 and clinical breast exam within past 2 years with a target of 60%,” noting a 1987 baseline of 25%. the cdc data reveals that the rate of mammography use in women 50 and older “within the past 2 years” in 2000 was 73.6% and 68.8% in 2010 (miller et al., 2012). in this same 2000 report another objective was to “increase to at least 60% women aged 70 and older who have received a cbe and mammogram within past 2 years”. the 2000 cdc data revealed a rate of mammogram within the past 2 years as 74% for women 65-74 and 61.3% for women over 75 years of age and in 2010 was 71.9% and 55.7%, respectively. seichn data showed a reported screening rate of 37% in 2001 and 74% in 2011 for women 40 and over. while specific number comparisons are useful, of equal significance is that this highlights the differences that can occur among data sets and the importance of including as many data sets as possible in national reporting. for healthy people 2010 the 2000 objectives were revised into a single objective, which was to “ increase percent of women receiving mammogram within the past 2 years age 40 and over” with a target of 70%. the 2010 cdc data revealed that the target was not met and the rate for women over 40 was 67.1%. even though the target was not met, the objective was revised in healthy people 2020. to ensure the needs of rural health are represented in national health planning, rural health advocates have worked diligently to outline benchmarks for rural populations in rural healthy people (usdhhs, 2015). rural healthy people documents efforts to address the health needs of rural residents. their most recent strategic plan includes assessment of the extent to which previous rural people objectives were met, engagement of rural stakeholders, work with the cdc’s guide for preventive services, and inclusion of rural health research. health care providers need to be cognizant of how the healthy people goals have been and are being revised overtime as found in healthy people 2000 to healthy people 2020 and the online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 40 direction of rural healthy people 2020. reflecting on the content of the healthy people and the rural healthy people documents, it becomes apparent that forward movement in the overall national healthcare goals can best be enhanced through supportive evidence found in the dissemination of grassroots data. such data have the potential to be substantially useful when planning primary and secondary care outreach programs consistent with the national healthcare agenda. affordable care act the affordable care act (aca) was signed into law by president obama on march 23, 2010. a section of the act reads “through the affordable care act, women’s preventive health care services – such as mammograms, screenings for cervical cancer, and other services – are covered with no cost sharing under some health plans.” as of june 2014 the united states preventive services task force (uspstf) 2002 guidelines, not the 2009, are followed regarding bc screening under the aca. the 2002 uspstf guidelines recommend screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older (uspstf, 2014). in 2009, the uspstf updated their guidelines for breast cancer screening and recommended biennial screening mammography for women 50 to 74 years of age (uspstf, 2009). the 2009 recommendation was met with controversy from numerous groups including the american cancer society (oncology, 2009). by adopting the 2002 guidelines, women 40 and older are eligible under the aca to receive a mammogram every 1-2 years. the aca addresses the barrier of cost by providing payment coverage for preventive services. with the implementation of the aca, the number of uninsured americans has decreased from 16.4% in 2010 to 13.4% in 2014 (levy, 2014). in 2013 health and human services reports that nearly 1 in 5 of those uninsured lived in rural areas (usdhhs, 2013). our data are reflective that one or online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 41 more of uninsured americans were in a rural area. seichn data reveals that 2 in 5 of those served by the project were uninsured. the aca brought an expectation that the ability to compete in the marketplace for healthcare plans would increase for rural americans. as the nation moves forward with aca, it is crucial to know how the numbers of uninsured rural people has changed. such as expectation can only be assessed if data ‘that was’ is available. rural stakeholders have the ability to affect the impact of the aca through the ‘promoting promising practices by sharing successful ideas’ for insuring the aca for rural americans. seichn provided services in five rural counties through the delivery of a best practice program based on a logic model. the seichn program is a ‘promising practice’ that can be adapted to other initiatives for expanding or insuring aca for rural americans. the seichn program was built on addressing barriers of cost, distance, and fear. the primary focus of the aca is ‘affordable care’, providing access to insurance to all americans, i.e. addressing cost. a lesser aca focus is on increasing access to care. the aca does not specifically address the barrier of seeking healthcare from those trusted providers or the factor of fear. healthcare providers must be vigilant when implementing components of the aca and be cautious of possible pitfalls. recall that the aca provision for providing preventive coverage for women is for ‘some health plans’. our appraisal is that the major national initiative, aca, primarily addresses cost and thus will be minimally effective in rural areas if the barriers of fear and distance (accessibility) are not addressed. questions, such as how will access be increased in rural areas, what is the impact for women seeking preventive healthcare such as mammography when monitoring occurs for only those 50 to 75 or what does it mean when preventive services for ‘some health care plans’, need to be asked. addressing healthcare needs is beyond simply providing payment. effective strategies for increasing access, particularly for those in rural areas, online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 42 must be attained. health indicators as found in healthy people and rural healthy people need to be not only be monitored for trends in results, but the verbiage of the indicators need to be closely reviewed to assure that the data being collected is reflective of the information that is truly needed. implications for practicing nurses the obstacles and barriers to proving health care to rural populations are not going away any time soon. rural residents are a minority in the nation reporting only 25% of the us population. rural residents are older (18% / 15% over 65). rural residents are poorer (19k / 26k per capita income). rural residents claim only 10% of the total number of physicians practicing in the us. the aging/retiring rural physician workforce and the growth in the rural elderly population are increasing the demand for primary care services in rural communities (size, 2002). in both rural and urban areas, nurses are often the point of contact between the patient and the health care system. this provides both challenges and rewards for the nurse. in order to maximize what resources exist, the nurse needs to be knowledgeable about availability of services and the processes necessary to access them. one approach to meeting the need for health services is a redefinition, and often expansion, of the scope and standards of practice for nonphysician practitioners. a recent survey found that 41 % of rural medicare beneficiaries saw a nurse practitioner or non md provider for all (17 %) or some (24 percent) of their primary care in 2012 (bloniarz & hayes, 2013). state legislators are increasingly willing to expand scope of practice definitions. in the 2012, national conference of state legislators (ncsl) tracked 827 bills to redefine providers’ scopes of practice in 29 states, 154 of which were enacted in 24 states and the district of columbia (ncsl, 2013). multiple studies have supported that access to and online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 43 the quality of primary care services can be improved and certain costs can be reduced with targeted expansions of scope of practice for non-physician practitioners. “the iom also found that nurses working as care coordinators and primary care clinicians can reduce hospitalization and re-hospitalization rates for elderly patients” (institute of medicine, 2010). data suggest that nurse practitioners were found to spend more time in consultation with patients and generate greater overall levels of patient satisfaction” (ncsl, 2015). based on the results of this project, nurses need to continue to teach the importance of breast cancer screening. teaching women to be familiar with their own breasts and to understand the need for mammography every one to two years results in increased screening. nurses should advocate for services that address cost, distance, and fear. availability of mobile mammography services must be maintained. project results support mobile mammography access increases breast cancer screening for targeted rural women. nurses need to be ever cognizant of national healthy behavior goals and objectives and their relationships to morbidity and mortality trends. nurses need to be aware that depending on the agency, the healthy behavior guidelines including their operationalization and review can vary across both years and agencies. nurses need to advocate for informed trend reporting. the goal of this project was to develop a best practice program to provide one type of health screening to a targeted five county rural health area. a logic model was developed to serve as the foundation and structure for the program. based on ten years of data, the findings support that a best practice program in rural health includes addressing the three key barriers to healthy behaviors of cost, distance, and fear. over time, such programs can continue to teach the value of screening in overall lowering of health care costs. evaluation models such as the logic model are useful in guiding program development, obtaining funding sustainability and defining online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 44 measurable outcomes within community when resources are limited. updates to “best practice” programs can help rural communities provide optimum care while identifying key steps or processes to meet the health needs of their citizens. summary providing the best evidence available is important to insuring rural health needs are being addressed. a best practice program delivering breast cancer education and screening to rural women was designed to address the three key barriers to healthy barriers of cost, distance and fear. from 2001 to 2011 over 2300 rural women received breast health education and no cost mammography through this project. data collected in conjunction with the delivery of this best practice program was compared to national indicator data for a ten year period. according to the cdc in 2000 seventy % of women reported having had a mammogram within the past two years as compared to 37% of the women who participated in the project programming (khajuria, 2013). the national rate of mammography dipped to 67% in 2010 compared to the project rate which increased to 74% in 2011. when looking at demographics, the project women were less educated than the women identified in the cdc data (u.s. census bureau, n.d.). the project and cdc data were similar in terms of poverty and being uninsured. although there were similarities in the two groups (project and cdc) in terms of poverty and lack of insurance, in the last reported year the project women achieved higher levels of mammography within the past two years even though they were overall less educated. while such comparisons are useful, of equal significance are the differences that can occur among data sets and the importance of including multiple data sets. forward movement in the overall national healthcare goals can best be enhanced through the dissemination of grassroots data such as found in this project. such data have the potential to be substantially useful when planning primary and secondary care outreach online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 45 programs consistent with the national healthcare agenda. health indicators such as those found in healthy people and rural healthy people need to be not only be monitored for trends in results, but the verbiage of the indicators need to be closely reviewed and monitored to assure that the data being collected is reflective of the information that is truly needed. in both rural and urban areas, nurses are often the point of contact between the patient and the health care system. multiple studies support that access to quality of primary care services can be improved and certain costs can be reduced with targeted expansions of scope of practice for nurse practitioners. nurses must advocate expansion of scope of practice and seek answers to such questions as: how will access be increased in rural areas? what is the impact for women seeking preventive healthcare such as mammography when monitoring occurs for only those 50 to 75? what are the implications of the aca statement that ‘women’s preventive health care services are covered with no cost sharing under some health plans’? nurses have the opportunity and responsibility to advocate in the political arena and to be ever cognizant of national healthy behavior goals and objectives and their relationships to morbidity and mortality trends. nurses have a key role in assuring optimum health care is available regardless of one’s rurality. supporting agencies greater cincinnati affiliate of susan g. komen foundation, avon foundation breast care fund, indiana breast cancer awareness trust, brookville library foundation, ripley county foundation, health foundation of greater cincinnati, indiana commission for women online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 46 references bloniarz, k., & hayes, k. (2013). assessing payment adequacy: physician and other health professional services. medicare payment advisory commission meeting brief. retrieved from http://www.medpac.gov/documents/jan_physician_meeting_brief.pdf?sfvrsn=0 cochrane, a.l. (2014). evidence-based health care and systematic reviews. retrieved from http://community.cochrane.org/about-us/evidence-based-health-care institute of medicine. (2010). the future of nursing: leading change, advancing health. committee on the robert wood johnson foundation initiative on the future of nursing. washington, dc: national academies press. khajuria, h. (2013). quickstats: percentage of women aged 50–64 years who reported receiving a mammogram in the past 2 years, by health insurance status. morbidity and mortality weekly report, (mmwr): centers for disease control and prevention, 62(32). 651. retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6232a5.htm levy, j. (2014). u.s. uninsured rate drops to 13.4%: uninsured rate down nearly four percentage points since late 2013. gallup. retrieved from http://www.gallup.com/ poll/168821/uninsured-rate-drops.aspx mathis, w.j. (2003). financial challenges, adequacy, and equality in rural schools and communities. journal of educational finance, 29, 119-136. retrieved from http://www.jstor.org/stable/40704199 miller, j.w., king, j. b., joseph, d. a., & richardson, l. c. (2012). breast cancer screening among adult women: behavioral risk factor surveillance system, united states, 2010. morbidity and mortality weekly report (mmwr): centers for disease control and online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 47 prevention, 61(02), 46-50. retrieved from http://www.cdc.gov/mmwr/preview/mm wrhtml/su6102a8.htm?s_cid=su6102a8_w national center for health statistics (2011). health, united states, 2010: with special feature on death and dying. retrieved from http://www.cdc.gov/nchs/data/hus/hus10.pdf national center for health statistics (2013). health, united states, 2012: with special feature on emergency care. retrieved from http://www.cdc.gov/nchs/data/hus/hus12.pdf national conference of state legislatures. (2013). scope of practice legislative database, 2011-2013. retrieved from: http://www.ncsl.org/issues-research/health/scope-of-practicelegislation-tracking-database.aspx national conference of state legislatures (2015). meeting the primary care needs of rural america: examining the role of non-physician providers. retrieved from http://www.ncsl.org/research/health/meeting-the-primary-care-needs-of-rural-america.aspx oncology. (2009, december 15). major cancer agencies respond to uspstf’s new mammography guidelines. retrieved from http://www.cancernetwork.com/oncologyjournal/major-cancer-agencies-respond-uspstf%e2%80%99s-new-mammographyguidelines public health law center. (2010) master settlement agreement. retrieved from: http://publichealthlawcenter.org/topics/tobacco-control/tobacco-control-litigation/mastersettlement-agreement schoen, c., doty, m. m., collins, s. r., & holmgren, a. l. (2005). insured but not protected: how many adults are underinsured? health affairs, 24(4), 289-302. http://dx.doi.org/10.1377/hlthaff.w5.289 online journal of rural nursing and health care, 15(2) http://dx.doi.org/10.14574/ojrnhc.v15i2.363 48 size, t. (2002). rural health can lead the way. retrieved from http://www.rwhc.com/eoh02/september.pdf u.s. census bureau. (n.d.). poverty thresholds. retrieved from http://www.census.gov/hhes/www/poverty/data/threshld/index.html u.s. department of agriculture economic research service. (2013). rural classifications: what is rural? retrieved from http://www.ers.usda.gov/topics/rural-economy-population/ruralclassifications/what-is-rural.aspx u.s. department of veterans affairs (n.d.). what is “rural?” retrieved from: http://www.ruralhealth.va.gov/about/rural-veterans.asp u.s. department of health and human services. (2013, september 20). the affordable care act what it means for rural america. retrieved from http://www.hhs.gov/healthcare/facts/factsheets/2013/09/rural09202013.html u.s. department of health and human services. (n.d.). about healthy people. retrieved from http://www.healthypeople.gov/2020/about-healthy-people u.s. preventive services task force. (2014). final recommendation statement: breast cancer: screening, 2002. retrieved from http://www.uspreventiveservicestaskforce.org/page/ document/recommendationstatementfinal/breast-cancer-screening-2002 u.s. preventive services task force. (2009, november). recommendation summary: breast cancer: screening. retrieved from http://www.uspreventiveservicestaskforce.org/ page/topic/recommendation-summary/breast-cancer-screening microsoft word pahs_416-2373-1-rv.docx online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.416 1 editorial after the discharge pamela stewart fahs, phd, rn, editor i was recently helping out in a family health care crisis and was reminded how difficult it is for someone to navigate the health care system if they are seriously ill, do not know how to access services or are simply overwhelmed with what needs to be accomplished. what do you do if you are frail and sick and need transportation to health care? what if the home health nurse schedules a visit at 10 a.m. does not show until after 11 and you have a radiation treatment 2 hours away scheduled at 1 p.m.? what happens if the doctor says you need physical therapy but you get home and find that the nearest physical therapist is an hour away, you cannot drive, there is no public transportation and you have no idea how you will get to the appointments? these dilemmas happen with elders but can be a problem at any age. they happen in urban areas but are even more difficult to solve if you live in a rural setting. these problems are a lot simpler to deal with if you have adequate financial resources; however, if the service is extremely limited in a rural community it often still requires a lot of planning and knowledge or luck in navigating the system to be able to access the services needed. of course if the service is not available you may not be able to get the service no matter your resources. ancillary needs that go beyond the acute care setting are often some of the hardest to meet. discharge planning helps but in my experience a discharge from an urban facility back to a rural community often does not translate into the services being delivered as planned. in part, the problem is a fragmented health care system. the newly discharged patient is told to schedule an appointment with the surgeon, the oncologist or other specialist yet the treatments and home health or specialty nursing visits also need to take place in that same time online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.416 2 period. the home health nurse has your diagnosis but may not know that you have radiation scheduled every day for a week after your discharge from the hospital and that you have a long travel time to get to that appointment. the home health nurse of course is most likely seeing more patients than optimal and schedules are easily thrown off, delaying the time of their visit. some health care systems do a better job than others at trying to coordinate care, particularly when there are involved treatment plans. when i have assisted family or friends to deal with complex health issues, i often wonder what do people do who do not have a nurse to ask or do not have family who are able to help. even with family and other resources navigating the health care system can be daunting. i think that for those of us who provide health care, research health issues, or work on health policy as part of our professional lives, it is humbling and a bit scary to see the system through the eyes of someone who needs the system but where the system is not meeting the needs of the individual. can we translate these personal experiences into action to help improve the system? clearly communication within the system and discharge planning that incorporates ancillary as well as direct health care needs is a start. some systems have a “nurse navigator” and i have heard that this type of position can be of great help. whoever is navigating the system needs to be aware of some of the unique challenges of accessing services either within or from rural locations. logic would suggest that meeting these ancillary needs has a bearing on the ability for someone to heal at home and avoid re-hospitalization. microsoft word witte_76-2026-2-ed.docx online journal of rural nursing and health care, 2015(1) 2 http://dx.doi.org/10.14574/ojrnhc.v15i1.376 reappraising an innovation in rural nursing education 1984-present presented at the 2014 international rural health & rural nursing research conference cosponsored by the montana state university college of nursing and the rural nurse organization (rn0). alison schell witte, dlitt et phil, gcns-bc 1 1 assistant professor of nursing, glenville state college, alison.witte@glenville.edu reappraising an innovation in rural nursing education 1984-present purpose the purpose of this presentation is to reappraise an innovative approach to nursing education implemented in 1984 in west virginia. a small public college in central west virginia partnered with a large state university to offer a bsn program for a rural, underserved area of the state. background the challenges for the nursing profession in the 1980s are still with us today: shortage of nurses in rural areas, inaccessibility of nursing education for rural residents, limited availability of qualified nursing faculty and limited clinical learning sites. this partnership was conceived as a unique approach to meeting the state’s needs for nurses and nursing education. the challenges encountered have implications for program planning in west virginia and across the nation. brief description of the undertaking the glenville state college (gsc) / west virginia university (wvu) joint nursing program was developed with a title iii grant in 1984. students were recruited from rural west virginia and enrolled in pre-nursing courses at gsc. qualified students were accepted into the joint nursing program in the sophomore year. the sophomore year of nursing was offered on the gsc online journal of rural nursing and health care, 2015(1) 3 http://dx.doi.org/10.14574/ojrnhc.v15i1.376 campus, using the wvu nursing curriculum and was initially taught by wvu faculty. after the sophomore year, nursing students transferred to wvu charleston division in charleston, wv, an urban center 100 miles away. there they completed the junior and senior years of the program, graduating with a bsn. the goal was to graduate approximately 20 students a year, many of whom, it was hoped, would return to central west virginia for employment. outcomes approximately 229 students have graduated from the gsc/wvu joint nursing program since its inception, fewer than anticipated. many graduates have returned to central west virginia and serve as rural nursing leaders. however, the institutional collaboration has not always been smooth. there have been numerous changes in administration and faculty within each institution. in addition, student outcomes have been inconsistent over the years. the inter-institutional agreement has repeatedly been modified so that now, only the freshman pre-nursing year is completed at glenville state. pre-nursing enrollment has declined, and applications to the gsc/wvu joint nursing program are few. glenville state is looking at different options for nursing education. conclusions partnership may be a feasible option for expanding nursing education into rural areas, but attention must be directed to long term implications of the commitment. challenges are inevitable, especially when academic partners have different institutional missions and goals. no external funding was sought or received for this project. microsoft word document1   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 154 qualitative perceptions of opportunity and job qualities in rural health care work rayna amber sage, phd 1 1 clinical assistant professor, washington state university, rsage@wsu.edu abstract with rural health care worker shortages projected to only worsen in the coming decades, many rural communities are attempting to institute local training and education in hopes of retaining a stable local direct care workforce. this study uses qualitative methods to explore how local health care training, education, and employment are perceived by rural residents in one isolated community where most of the local jobs have transitioned from manufacturing and natural resource extraction to health care and education. based on 60 in-depth, semi-structured interviews and 40 hours of participant observation primarily as a volunteer in a long-term care facility, i find that perceptions about the opportunities in health care that remain in “independence creek, washington” are complex and divergent. the majority of participants speak positively of the local trainings for nursing assistants and the innovative on-site two-year nursing program and argue that these opportunities, seen as either a stepping stone for collegebound young adults or a pathway to decent employment for place-bound individuals, are much needed. perceptions of pay for nurses are also favorable. perceptions of pay for nursing assistants are more mixed. respondents consider it better than other service work, but also not a livable wage. job security is perceived as a big plus, as respondents describe the ability to “get a job anywhere” as a nurse or nursing assistant. however, job stability (having regular hours and work place stability) are not described as strong qualities of working in rural health care. despite   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 155 issues with some negative perceptions of rural health care work, this study demonstrates a continuing need for more local training as we work towards higher quality working conditions and compensation. keywords: nursing assistant training, nursing education, pay, job stability, job security qualitative perceptions of opportunity and job qualities in rural health care work for decades, the department of labor has been tracking and predicting the growing need for all types of health care workers, including registered nurses (rns) and direct care workers (dcws) such as certified nursing assistants (cnas) and nursing assistant-certified (nacs) (u.s. department of labor’s education and training administration, 2010). these terms are used interchangeably in this paper. in washington state, demand for nurses is expected to grow from about 35,000 to 60,000 in 2020 (skillman. andrilla, & hart, 2007). however, with current degree programs and student slots, the projected supply of nurses is actually expected to drop to near 30,000 in 2020. this need is even more critical in rural areas of the united states, which are home to about 65% of all health professionals shortage areas (national advisory committee on rural health and human services, 2011). for rural residents the pursuit of college, including nursing education, almost always means leaving their hometowns (mcdonough, gildersleeve, & jarsky, 2010; molinari, 2001). while community colleges have been partnering with rural communities and local institutions for some time, little is known about how increasing local educational and training opportunities is perceived by the individuals who live in the affected communities. this study builds on existing literature regarding access to training and education in rural places and the nature of jobs in rural health care to explore how residents in one rural remote pacific northwest community perceive and integrate opportunities in health care into their own discourses regarding education and work. more specifically, this study examines how   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 156 local training and educational opportunities in health care are perceived and how individuals describe the pay, stability, and security of health care employment. theory and literature review for rural people, the intersection of educational opportunities and the labor market plays an important role in making decisions about employment and career choices. utilizing a grounded theory approach (glaser & strauss, 1967; wuest, 2012), this project focuses on relevant patterns of beliefs about education and employment in health care to illuminate perspectives of direct care workers who occupy a position of lower privilege in the overall health care system compared to others in health care. to follow is a brief summary of what is currently known about rural educational opportunities, the changing rural economic landscape as it relates to opportunities in health care and what makes some jobs more attractive than others. this literature provides a background for understanding how the rural context is currently understood and how perceptions of opportunities in rural health care might be constructed by those in or considering the field. access to post-secondary training and education individuals living in rural communities have significantly less access to local postsecondary educational opportunities than those living in urban or suburban areas (gibbs, 1998; mcdonough et al., 2010). this lack of local opportunity, coupled with more pervasive and longlasting poverty (tickamyer & duncan, 1990; u.s. department of agriculture/economic research service, 2010) helps explain the large gap in college attendance and completion that exists between rural and nonrural young adults (gibbs, 1998; provasnik et al., 2007). previous research suggests that a community’s proximity to urban centers and educational institutions influences the out-migration of young adults through the variation in access to education and employment opportunities within commuting distance (gibbs, 1998; mcdonough et al., 2010).   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 157 community colleges across the united states have recognized this problem and many have taken steps in an attempt to increase access to education for rural individuals (benson et al., 2008; eller et al., 1998; jaeger, dunstan, & dixon, 2015). since the early 1990s, community colleges have stepped up their efforts to reach potential students in economically distressed rural communities by investing in branch campuses, extended campus centers, and/or collaborating with other local institutions to provide on-site training and credentialing that met the communities labor market shortages in fields such education and health care (baldwin, 2001; holly, 2009; proffit, sale, alexander, & andrews, 2004; rubin, 2001; torres & viterito, 2008). for local residents, these new opportunities meant that for some communities, out-migration was not the only way to get an education. however, little is known about the impacts of these changes on communities, families, and individuals. some youth and young adults cannot or do not wish to leave their rural communities. for these individuals, education and training opportunities may be one of the primary ways to stay and be economically secure, although much of the success of retraining in rural places may depend upon what types of jobs are left for adults to fill and how those jobs are perceived. health care work in rural america: good jobs and bad jobs to better understand how local trainings may be perceived and perhaps utilized, it is useful to explore the types of jobs available in rural health care and how they can be assessed in terms of job quality. in a national assessment of in-migration at the county-level, johnson (2006) found that rural communities experiencing the most growth were those where “retirement, service, and recreation” (p. 16) dominated the local economy. for these counties, the impact of in-migration of older and retiring adults changes the demands for services, especially around health care. the growing demand for health care workers has been accompanied by a marked decrease in jobs   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 158 available in other industrial sectors, especially those mostly occupied by men in rural manufacturing, resource extraction, and farming primarily due to technological advances (reducing need for manual labor), changes in industry and trade regulations, and shifting demand for materials produced through natural resource extraction (flora et al., 1992; morris & western, 1999). these economic shifts were most notable in the 1990s and have remained fairly stable since. despite the increased demand for health care workers, there is a growing problem of recruiting and retaining rns and dcws in rural areas which appears to be, among other factors, the result of decreased interest in caretaking and nursing as a profession and job dissatisfaction (aiken, clarke, sloane, sochalski, & silber, 2002; roberge, 2012). unfortunately, decreasing interest and job satisfaction are partially related to the fact that many health care occupations are what mitnik and zeidenberg (2007) would consider bad jobs. to distinguish between bad and good jobs, researchers look at a number of factors. first, to be a good job in the united states, the job must pay a decent wage (mitnik & zeidenberg, 2007). mitnik and zeidenberg (2007) suggest that a good wage is one in which a single full-time earner can support a family of four at higher than 150% of the poverty threshold. in a foundational study of rural families and labor, nelson and smith (1999) found job stability and character of the workplace are also important in identifying a job as bad or good. according to these authors, good jobs are those which are full-time and year round. in turn, bad jobs are those which are temporary, part-time, and/or seasonal. good jobs are also characterized by having a regular schedule which does not vary from day to day or week to week. additionally, workplace characteristics which would imply a good job include benefits and overall workplace stability (few layoffs, little concern about financial stability of the company). finally, good jobs provide   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 159 opportunities for advancement through increased access, skills-training, and education (mitnik & zeidenberg, 2007). by these standards, many of the jobs in the health care field, especially in skilled-nursing facilities and home health care, might be considered bad jobs. although the structure of the health care industry and its dependence on insurance companies and very limited government monies makes it difficult for these types of jobs to move into the status of good jobs, some facilities are attempting to address issues related to the negative qualities of jobs in health care through increased access to training and education which may make upward mobility more possible than in the past. unfortunately, the structure of direct care work in long-term care facilities and in home health care is such that there is a greater need for staff at the bottom of the staffing hierarchy (who provide the direct care of residents and patients) than at the top (mitnik & zeidenberg, 2007). nonetheless, according to this same study, hospitals may actually be places where upward mobility is possible with increased access, training, and education, because of the more balanced distribution of bad and good jobs (although the majority of jobs, especially for those without higher education are bad). the intersection of growing training and educational opportunities, increasing demand for rural health care workers at various levels, and changing rural demographics provides an interesting backdrop for this project. this study explores the following questions regarding the local opportunities for training and education in health care and the nature of the jobs which can subsequently be pursued after completion of local training or education: 1. how do individuals perceive local training and educational opportunities in health care? 2. how do individuals describe the characteristics of local jobs in rural health care?   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 160 the purpose of this study was to explore how local health care training, education, and labor shortages in rural communities are perceived by rural residents and how these perceptions fit in the larger social context. methodology study site names of places, people, and some occupations have been changed to protect the confidentiality of the participants and socio-economic information presented for this study site are based on the 2010 census which occurred just before the collection of this data (unless otherwise noted). independence creek, washington is a small community located in the mountainous country of eastern washington, with a population of about 2,000 people, of which 92% are white. according to the washington department of health (2006), independence creek has a small town/isolated rural designation. independence creek’s population swelled during the early part of the 20th century, because of ample farming, logging, and mining opportunities. however, changing regulations and diminishing resources gradually led to a permanent decline in these industries over the past 40 years. in 1990, 37% of the jobs in harrison county were in farming, natural resources, mining, construction, or manufacturing (office of financial management, 2012). in 2010, these types of jobs made up just 25% of all employment. during this same period jobs in the service and health care sectors increased. the region took a huge economic hit in 2001 when a nearby mineral refinery plant closed, taking 300 of the last wellpaying jobs out of the community in a matter of three months. although the health care sector only grew modestly while the community was losing the majority of its industrial jobs, care work became one of the primary pathways to stable, year-round employment. thus, at the time of this study, the majority of good local jobs were concentrated in health care and education. working   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 161 in these fields was also the primary way to gain access employee benefits. harrison county also has a history of stubbornly high poverty, slightly elevated by the great recession. in 2010, 21% of all individuals living in this community and 24% of families with children under the age of 18 lived in poverty (u.s. census bureau, 2010). after adjusting for inflation, annual wages in this county have remained stagnant since 1987, hovering around $30,000, well below the state average (washington state employment security department, 2010). specific source tables for these figures are not identified to protect the identity of the county and community. harrison county has also experienced a long history of higher-than-average unemployment. in 2010, harrison county had a 12% unemployment rate, while an average of about 9% of those living in washington experienced unemployment that year. thirty-eight percent of men and 50% of women were not currently in the labor market in 2010 (washington state employment security department, 2010). this is compared to 28% men and 40% women at the state level. local health care training and education in general, recruiting and retaining health care workers in rural areas has been a challenge. health care administrators’ attempts to draw in and retain good nursing staff with incentives such as sign-on bonuses and extra vacation time have not been very effective (lemay & campbell, 2010). one of the more successful strategies for recruiting and retaining rural health care providers is to recruit students from rural areas or who have rural connections (molinari & monserud, 2008). physicians from rural areas are, on average, twice as likely to work in rural areas after graduation compared to their urban counterparts (laven & wilkinson, 2003).this is also seen as more ethical, as socialization and training for rural nursing is very different than the socialization process for urban nursing (the frontier education center, 2004).   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 162 independence creek is about an hour from the nearest post-secondary twoand four-year educational institutions. while commuting is possible and definitely done by some, it can be time consuming and dangerous, especially in the winter. some innovative programs have been developed by local health care and educational institutions in independence creek in an attempt to lessen the economic and social impacts of the labor shortages they experience in health care workers. the locally-delivered training and educational opportunities in health care in independence creek mirror many of the recommendations outlined by the department of labor in the allied health access guidebook (u.s. department of labor/employment and training administration, 2010) which are designed to increase access and retention of high quality direct care workers. to follow is a brief discussion of each type of trainings available in or around independence creek. nac/cna certification programs. in independence creek, there is a well-established partnership between the local not-for-profit hospital and the high school. nurse educators from the hospital have been providing an elective course titled “medical careers” for high school juniors and seniors for over 20 years in which the primary purpose is for students to complete all the requirements to become certified as a nursing assistant. although this course is titled “medical careers”, the curriculum primarily focuses on nursing and direct care work, not careers in medicine. in addition to this opportunity in high school, the hospital also offers the traditional adult certification training three times a year. this is also a short course (ten weeks) for adults which focuses solely on completing the requirements for certification. this course and certification costs about $250. for high school students, the cost of the background check and testing fee are waived by the hospital and school. there are also scholarships and some government programs which occasionally help with the costs for both high school and adult   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 163 students. while the high school course is fairly unique, many rural communities have adult certification trainings. on-site associates and bachelors nursing degree programs. independence creek is one of the few isolated rural communities that have opportunities like their on-site associates degree in nursing (adn) and distance degree bachelors of science in nursing (bsn). employees at the independence creek hospital have the opportunity to apply to the associates nursing program which is facilitated by a community college on the western side of washington state. employees may apply to the program after completing 12-15 prerequisite courses in science, math, and general education. prerequisite courses typically take at least a year and are offered to independence creek residents in an online format, at a community college satellite campus about 30 miles away, or at the main campus of the regional community college in appleton (about an hour drive in good weather). once accepted, students complete the rigorous two-year program which includes everything one could expect from a high-quality associates program delivered at a community or technical college. because of the intense nature of this program and limited opportunity to interact with patients and other professionals in this remote rural community, only two students are selected each year. the total cost to the student is about $12,000 in tuition, books, and other additional costs. for nurses who already have associates degrees interested in administration, the hospital has partnered with the university of great falls to provide an online degree program for completing a bachelors. to date, only a few people have taken advantage of this program, but this collaboration reduces the total tuition costs for students from about $27,000 to about $7,000.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 164 research design this study relies on data collected from november 2010 to november 2011, consisting of 60 recorded, in-depth, semi-structured interviews with individuals with ties to health care training and institutions in independence creek and 40 hours of participant observation, primarily spent volunteering in health care settings. these methods allow for an in-depth understanding of how individuals perceive and experience the local health care educational and employment opportunities. the interviews covered a variety of topics related work and education experiences, migration, and perceptions of local employment and educational opportunities (see table 1). interviews lasted about an hour on average and ranged from 35 minutes to 2.5 hours. the bulk of the participant observation was conducted between june and october of 2011 and took place mainly during volunteer shifts at the local long-term care facility. volunteer activities included working with the activity aides to take residents via wheelchair to the local farmers’ market, the thrift store, and other community events, as well as playing cards and visiting with various residents. during these activities, i also interacted with staff and observed how they interacted with residents, patients, and each other. most employees knew i was conducting a research study and were very friendly. several were willing to take moments in their hectic work to explain the work they did and tell me a bit more about themselves, the residents, and patients. because many of the questions asked respondents to talk generally about their experiences, individuals were free to talk about anything they felt was important. interview recruitment and sampling the principal investigator originally made contact with and interviewed key informants in both education and health care. one of these key informants because instrumental in future recruitment of individuals who had participated in the local health care educational programs.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 165 thus, most of the respondents were initially recruited through the health care education coordinator at independence creek hospital. additional respondents were also recruited during participant observation. at the end of each interview, respondents were asked if they knew anyone else who would be interested in participating in this study and this resulted in 65% of the total sample being recruited through snowball methods. purposeful recruitment was also utilized in an attempt to recruit types of individuals who were missing from the sample (such as men). as recommended in grounded theory (wuest, 2012), as interviews revealed additional themes and questions, i specifically recruited individuals who could speak to those experiences or processes. limitations of methods and recruitment strategies while qualitative research provides a rich and in-depth examination of the social experience and environment, there are some limitations related to reliability and generalizability that should be noted. first, the information collected here is assumed to reflect the actual experiences of those involved in the study. while trustworthiness can be an issue in qualitative research, this study focuses on the perceptions of those involved, regardless of their objectivity. when possible, i conducted interviews with multiple people involved in similar events or experiences. this made it easier to see commonalities and differences in their perceptions of the overall process. next, recruitment of men was challenging. as in much of health care, men are very under-represented in health care in independence creek. unemployed men and men in occupations outside of education and health care were difficult to reach and commit to interviews. in a few instances, men canceled and rescheduled more than three times and never actually participated in a formal interview. although gender comparisons are noted in this study, it seems the perspectives and experiences of the 21 men interviewed is more varied than those of the 39 women.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 166 table 1 brief examples of interview questions finally, and perhaps most importantly, the results of this are based on a non-random sample in one rural remote community and cannot be generalized to other communities. it is hoped that the finding here regarding how the magnitude of health care as a primary industry and one community’s attempts at training, educating, and retaining health care workers is perceived and questions section 1: introduction how long have you lived here? what brought you to independence creek? what do you like/dislike about living here? what types of jobs are available in independence creek? section 2: experience in health care, education, and work how did you become interested in health care work? what was your training like? can you tell me about the people in your training/class? the people you work with? for people who did training, but didn’t pursue health care: what made you decide not to pursue health care? section 3: work what kinds of things have you done for work in the past? what did you like most/least? what do you do for work now? probes: how long? how did you get this job? how do you like it? are you looking for something else? is it what you expected you would be doing? what type of work would you like to do in the future? probes: what kinds of training/education/experience would that take? what kinds of opportunities do you have for advancement? would you consider pursuing these? why or why not? section 4: family and current relationship status what is your family/parents like? what did they do for work? are you in a relationship? if yes, when/how did you meet? do you have children? if yes, how old? what are they like? can you tell me about a challenge you and your family have faced? are you where you thought you would be at this point in your life? section 5: wrap up is there anything we haven’t talked about that you would like to share? do you know anyone else who might be interested in talking with me?   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 167 experienced may provide insight for future research and other communities facing similar challenges. data analysis from the onset of this study, data collection and data analysis occurred concurrently (glaser & strauss, 1967; wuest, 2012). interviews and field notes were transcribed and coded for emerging and recurring themes using a grounded theory approach. the principal investigator wrote extensive memos and diagrammed relationships between emerging core concepts. coding schemes were not pre-established and the very open and semi-structured nature of the interviews did not make it possible to specifically code answers to particular questions. initially, open coding was used to review each interview transcript in hyperresearch qualitative data management software (2013). as coding progressed and new codes emerged, earlier transcripts were back-coded. in total, 35 content-specific initial codes emerged. the codes represented in this paper are specific to the research questions outlined previously (which emerged as the study evolved), including participant reflections on the positive and negative characteristics of education and work in local health care, especially those related to availability, upward mobility, pay, stability, workplace qualities, and residential migration. after the initial coding, reoccurring groups of codes were further investigated and theorized as themes regarding perceptions of opportunities, job characteristics, and beliefs about residential migration. this data was entered into excel and then transferred to stata, a quantitative software package (statacorp, 2013), to calculate cross-tabs regarding the occurrences of codes and themes by respondent characteristics (such as gender, education level, and job status) for descriptive purposes. when appropriate, differences in perspectives and responses across categories are also noted.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 168 findings respondent characteristics this project first received exempt status from washington state university’s institutional review board (irb # 11637) in november of 2010 and an approved status (irb number #12016) in june of 2011 when more extensive participatory observation was added to the study. ninety percent of the respondents were white (reflecting the racial make-up of the county) and they ranged in age between 17 and 70. sixty-five percent of those interviewed for this study were women and 55% were either married or cohabitating. sixty-three percent were parents with children ranging in age from birth to 45, and 42% of the parents were either single at the time of the study or had experienced significant periods of single parenthood in the past. aside from the five participants who were still in high school, all respondents had at least completed high school. forty-seven percent had either high school diplomas, geds, or some college. only six respondents had two-year associate degrees, while the remaining 21 (35%) had a four-year degree or higher. this is atypical of the general population in harrison county and reflects the fact that most of the people interviewed were working in a field that usually requires college degrees for any type of upward mobility or status. eighty-two percent of the respondents were employed at least part-time. seventy-six percent of employed respondents worked in health care. eleven respondents (18%) were either full-time students, stay-at-home parents, or retired, thus out of the labor market. opportunities in health care to address the first research questions regarding individuals’ perceptions of the local training and educational opportunities in health care, it is clear that some respondents found the local opportunities in health care training and post-secondary education to be insufficient, while   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 169 others felt they were very advantageous (see table 2). of the 21 respondents working as cnas, 81% (n=17) expressed a desire to gain training and education that would allow for upward mobility in the health care field. forty percent of the respondents (n=24) mentioned the local opportunities were not really effective or ideal, while 55% discussed why they were helpful and important in their community. the unique characteristics of these coding clusters are further detailed below. table 2 count of cases describing themes related to local educational opportunities of the individuals who suggested that they felt the locally-available educationally opportunities were not effective, three related, but distinct themes emerged. first, 54% (13 of 24) discussed the local options being too expensive, time-consuming, and often required burdensome commuting. scott, a 43-year old nurse with a two-year nursing degree who aspires to become a physical therapist, discussed the difficulties he faces in deciding how to complete his prerequisites while living in independence creek. you are currently finishing up your prerequisites how are you doing that? “online. i have weeded out as much as i can do online and then have to go back for anatomy and physiology and one more physics class”. theme case count* local educational opportunities as insufficient because… 24 they are expensive, time-consuming, and require commuting. 13 they do not exist, are extremely limited, and require out-migration. 9 there are too few slots and they are too selective. 8 local educational and employment opportunities in health care are helpful because… 33 they are a stepping stone for those interested in health care. 23 they give place-bound and high school educated people access to training. 24 *some cases mention more than one of the themes presented here.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 170 where do you think you will do those? i am looking to take a little bit of time off and probably finish them up next spring and summer quarter, if they are offered then. probably through [appleton community college] or one of the schools down the way…whichever one is cheaper. in reality, scott’s goals of completing physical therapy school will eventually mean moving, at least for a few years, as the closest school with a program is four hours away, but for now, scott is at least making plans and taking the immediate steps towards his goal. when considering the on-site nursing program, others expressed concern about going into debt to pay for the $12,000 in tuition, fees, books, and supplies. others simply struggled to think about how to finish the prerequisites. for instance, monica, a 27-year old single mother of three had this to say about her hopes of pursuing a nursing degree: i have to do a ton of prerequisites, because i’ve never done any kind of college. i have my ged, that’s it…i think i have two and a half years of prereqs…i don’t know what all kind of classes…there’s [wrightburg] campus and then a couple different colleges in [appleton]…some of it— i would try to purchase a computer first and do on-line, because a lot of the prereqs you can do on-line, ‘cause i don’t want to go to school every day. i mean, if i can do it at home on a computer, then i would rather do that. although the small satellite campus in wrightburg is only about 35 minutes away and offers a limited number of courses for local students, it is still a large commitment for a single mother like monica. also included in this group of individuals who were disappointed with the locally-available education were some who had obtained a degree while commuting to appleton up to seven days a week for several years. while some found commuting an acceptable cost for furthering their education, others felt the price was too high. holly, a 24-year old married mother   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 171 of an infant and part-time nac at the hospital shared this about her experiences with commuting to appleton in an attempt to complete her prerequisites for nursing school: i would commute and it got as bad— ‘cause i tried to take as many classes in [wrightburg] as i could and then about my last year of my prereqs i had to do all of my classes in [appleton] and they would be as bad as five days a week, and then you’d turn around and be like, that’s 10 hours a week just on commuting. in addition to concerns about expenses, time, and travel, nine of the 24 in this coding cluster rejected the feasibility of commuting and argued that local educational opportunities did not really exist or were extremely limited, and therefore, the pursuit of training or education required moving out of town. constance, a 24-year old single woman who moved 65 miles away from her hometown to pursue her dental hygienist certification in appleton had this to say about her experience with nursing assistant work, education, and migration: my last year working there i started school in [wrightburg]…i took as many of the prerequisites as i could, but eventually i ran out—i had to head to [appleton]. so that’s why i ended up putting in my notice so i could just focus completely on school and get into the program…i have moved a few times, but just stayed in [appleton], just getting closer and closer to school. eight of those who felt the local training and educational programs in health care were not useful, argued this was primarily because there were too few slots for students and that the existing programs were too selective. this was especially true about the high school medical careers class and the on-site nursing degree program. while singing praises for the success of the medical careers class, bill, a 52-year old married high school history teacher had this to say: “you can just transfer from the medical careers class to employment— gainful employment   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 172 opportunities…but she only accepts eight kids and so there’s a limit to the amount of opportunity.” martina, a 20-year old single woman who has worked as a full-time nursing assistant in acute care for two years had this to say about her chances of getting into the on-site nursing program: “the people who typically get it first are the ones who have worked here…and it’s basically first come, first serve.” finally, although there was rarely more demand for the adult nac course than could be offered, when asked if the program was capped, meg, the director of education for independence creek hospital had this to say: “i do try to cap that one at eight…because, they’re coming in and they were loggers, you know? are you ready for peri-care?” quality of training is important to meg and she feels this can be partially addressed through small class sizes. she also went on to talk about the increasing demand for the on-site nursing program: we have phone calls about it every week now. [the on-site nursing program] is getting out…in fact, i’m starting a new adult nac class…and probably taking 8 students again, and at least 3 of them are [on-site nursing program] seeking students. i mean, they are right up front with me. while the on-site program is still new, community members are becoming more aware of and interested in pursuing the opportunity. as meg points out, 38% of her incoming adult nursing assistant class are taking the class because they know it is the first step to entering the on-site nursing program. despite some negative comments on the locally-available training and educational opportunities, most of the negative feedback was related to a perceived lack of opportunities, not necessarily that the opportunities are of poor quality or unappealing. in fact, many more individuals felt the training and education in independence creek was very useful for area residents.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 173 fifty-five percent (33 of 60) of the respondents reported that they felt the high school medical careers class, adult nac course, and on-site nursing degree programs are positive assets for individuals and the community. these responses can be categorized into two main themes. some described how individuals who were college-bound used the nac trainings as a way to get medical experience on their way to college. others focused on providing opportunities for place-bound and high school educated people who were not planning on leaving independence creek. a total of 23 people (38% of the respondents) described becoming certified as a nursing assistant as a “stepping stone” or a way to get into the medical or nursing field. while 15 of the 23 currently worked in health care, the remaining supporters did not. this perspective was shared by younger and older respondents, although most respondents in this category discussed these as opportunities for younger adults. leslie, a 17-year old junior at independence creek high school interested in becoming a nurse felt the class was “a way to get your foot in the door…to get exposure in the medical field.” two college-bound young men who became certified within the last two years felt strongly that the class was a very good place to start in their pursuit of higher education in medicine. brent, a 17-year old high school junior noted, in talking to people that are in the medical field, it seems like people are a lot more respected when they’ve worked as a cna. they’ve worked as a nurse. they’ve worked those lower, mid-level jobs in medical before— instead of just going straight and being a doctor and being a doctor who has no point of reference and in their eyes maybe less respect for the jobs that they do just because they didn’t spend an extra four years in medical school.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 174 although these individuals sometimes also expressed distaste for the type of work that was required of nacs (especially in long-term care), they still expressed positive views for the class and work in general. nicole, brent’s 20-year old cousin who works in fast food while being a part-time community college student and who also took the high school class share that while her younger cousin “doesn't necessarily like the cna work, it’s a stepping stone to get to where he wants to be.” while these three respondents were fairly young, this perspective was shared by their old counterparts from the adult nac course. pamela, a 40-year old divorced woman making a career shift out of warehouse work described her enrollment in the class as “a good step” and one that would “open the door” to other opportunities. nurses and administration also described the class as a good place to start for people interested in a career in health care, even though they did not take that route themselves. robin, a 35-year old nurse manager at a local long-term care facility said that although she did not take the class herself, she really felt the individuals who did were “already a step ahead in the nursing field.” four mentioned this work as a good “college” job. meg, the director of education at the hospital nearing retirement told me, “you know, even these kids that are gonna go to four-year school schools, most of them need to have a job, so what’s wrong with being a cna?” finally, an additional ten people in this category expressed interest in the on-site nursing program and identified nac certification as the first step to being accepted. clearly, interest in and awareness of this program is high, especially among lower-status health care workers. although related to the idea of the class being a stepping stone, a second group of coding clusters emerged around the idea that the local trainings were very positive for the community because they give place-bound individuals and those with only high school diplomas the opportunity to complete training that could lead to stable work that pays more than other jobs   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 175 these individuals might be qualified for. a total of 24 individuals either conceptually argued that the training and education were good for other people, or expressed that they themselves had benefited from having these opportunities. the five respondents who discussed how the opportunities are good for others in the community, primarily focused on these jobs as those well-suited for young women, especially those with children. valerie, a 35-year old remarried mother of four teenage children who took the class herself in high school before becoming a dental assistant summed up the sentiments of several respondents regarding the role of these trainings in independence creek: it give a lot of these kids, like there was a pregnant teenage girl, who had a baby and i don’t know if she’s even stayed in or if she’s gone to college or what she’s doing, but it gave her a little bit of hope. i wish they would open more [slots], even just [for] girls who don’t think they’re gonna go anywhere in their lives…it gives these girls something. a job, some training – they’re not gonna go to college. they’re not gonna get out of this town, but at least let’s help them not be on welfare. let’s get them a training before they get too far, where all their doing is living off the system. for women who were not college bound or likely to out-migrate, becoming a direct care worker could provide them with fairly stable employment in an area important to the community. six of the women in the study discussed how the training and subsequent employment helped them get on their feet and establish themselves in the community. these trainings can also be important for those who never want to leave independence creek or find themselves either returning or in-migrating for various reasons. fifty-eight percent (14 of 24) discussed family ties and support as the reason for being place-bound in independence   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 176 creek and all of them were women. dawn, a 25-year old single mother of one moved back to her home town after her father was in a car accident and required extensive rehabilitation. i ended up leaving to come back here after just a couple months because of [my dad’s accident]. so i ended up moving back here because i can’t afford— my mom watched [lenny] for me for free and i can’t afford childcare, so, i just wounded up moving back because mom was here with [my dad]. becoming a cna enabled dawn to both care for her father and support her son, but she could not afford to work if her mother was not providing child care for her while she worked the evening and night shifts. her story was quite similar to three other single mothers in this study. in sum, more individuals saw the local training and educational opportunities in health care in independence creek as more positive than negative. indeed, most of the complaints regarding the local opportunities regarded a need for more slots and variety. those who felt positively about the trainings and education tended to see these as a stepping stone, especially for those who are college bound. on the other hand, several individuals felt the trainings and potential employment provided viable alternatives for individuals, especially young women, who might not otherwise be able to acquire stable employment because of their desire to stay in independence creek, family obligations, or their lack of education. valerie, the 35-year old mother of four summed up what many had to say about the positive impacts of having this type of course in the community by sharing about her own experiences with the high school medical careers class 17 years earlier: “it gave me such a head start, even for my dental assistant class, it gives you such a head start with everything and i think this medical careers class is just the best class to have in this community.”   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 177 perceptions of job characteristics the second research question explores how respondents felt about the available jobs or occupations in local health care. regardless of whether or not the training and education opportunities were seen as negative or positive for the community, many people in this study had something to say about the characteristics of the jobs which local individuals were being trained for (see table 3). when respondents discussed work in health care, pay, security, and stability were topics that came up often, with 67% of respondents (40 of 60) mentioning at least one of these themes. pay as an important consideration. among the 23 respondents who discussed pay for cnas and other dcws, 70% (n=16) felt the pay was not good. four people specifically mentioned that dcws were “overworked and underpaid.” constance, the young woman living in appleton and finishing her dental hygienist certification shared: “the nac work was great but, you know, you max out at $15, anymore. that’s not enough to support yourself.” emily, the mother of three young children and full-time unit clerk expressed her frustration with the differences in pay among low-level positions in the hospital and long-term care facility. “[longterm care] was hard, physical work and you get paid less doing that than just paper work.” rebecca, the married young mother of four girls explained why she is not currently using her certification: it’s important, like i said, for me to stay home with my kids. especially— i mean, i love being a cna, but you don’t make real good money. so, i would be working just to pay for daycare and what’s the point? i would much rather be with them.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 178 table 3 count of cases mentioning themes related to job characteristics theme case count pay 29 for cnas and other dcws 23 for nurses 10 for rural health care, in general 11 job security 21 for cnas and other dcws 7 for nurses 8 for rural health care, in general 6 job stability 19 disliked unpredictability 15 valued flexibility 4 workplace stability 24 unstable funding 6 organizational changes 6 fears of closures, layoffs, and understaffing 4 felt workplace was stable 3 despite what some perceived as very low pay for very difficult work, seven respondents (five of whom were under the age of 25) felt the pay was good, especially compared to other entry-level service jobs. wendy, an 18-year old who landed a home health aide position after taking the medical careers class and who hoped to become a pediatrician someday, had this to say: you actually go into their home and help them. it’s really cool. [my aunt] was really excited when i told her i took this class…‘cause i work at [burger king] and they get significantly a lot better [pay] than you do at fast food— i just like the idea of helping people. that’s always been my kind of thing. three of the seven noted the slightly higher than minimum wage starting pay as a real incentive for entering direct care work, even if the work was not ideal. leslie, the 17-year old high school senior who is interested in dermatology explained how she knows people who were   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 179 making $10 an hour doing this work and how “awesome” that would be. she shares, “you know, you wouldn’t think $2 [an hour] would help that much, but it makes the biggest difference.” hospital and school administration also pointed to the slightly higher than minimum wage pay as a significant incentive for young people to become certified as nursing assistants. compared to the mixed feeling about pay for cnas and other dcws, the ten respondents discussing pay for nurses almost universally agreed the pay was good. the one exception was a well-established nurse who argued that despite the good pay, single mothers who worked as nurses were not able to afford the health insurance premiums to cover their children. finally, among the 11 who discussed pay in rural health care, 73% argued the pay was poor compared to urban health care settings while the other three suggested that the pay was adequate, especially if you considered the cost of commuting to urban places. for these respondents, moving for better employment or pay was generally not something they would even consider. job security as a strength. respondents’ feelings about the ease of locating, securing, and maintaining employment in their field or having a sense of job security, was also important in this study. thirty-five percent of respondents discussed how having skills and training in health care and more specifically, nursing and direct care work, gave either themselves or others in their community security in the local labor market. while six respondents generally considered health care as secure, an additional 13 talked specifically about nurses and cnas (seven and six, respectively). as tina, a 36-year old married mother of two who returned to independence creek after completing her bachelor’s in nursing notes, “not many people can find jobs…unless you have a degree in some education or nursing field or, medical field.” when phillip, the 55-year old logger-turned-nurse, was asked why he decided to go into nursing, he also noted changing demographics. “i think the biggest thing was i knew it was a steady job because baby boomers,   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 180 we’re just getting older— i’m a baby boomer. they need care. you don’t get too many layoffs. and you can find a job.” sherry, a 33-year old married mother of four boys who works nights as a cna in long-term care was well aware of the changing demographics of the nursing population and shared her own experiences with who she saw in classes at the wrightburg satellite campus when she was completing her prerequisites to apply for the on-site nursing program: “it is a good field for younger people to get into because there should be openings in the future as most of the work force is looking to cut back or retire. so a lot of people there were trying to get into nursing programs.” seventy-five percent of those who discussed job security for nurses felt it was very good. opinions regarding job security for cnas and other dcws were similarly positive. all the respondents who discussed job security for cnas and other dcws felt that these occupational lines in health care provided a lot of security. stephanie, an 18-year old cna at a local long-term care facility reported that she regularly encourages her friends to take the nac training because “you always have a job somewhere, because somebody is always gonna get sick.” martina, the young nac in acute care who aspires to become an ultrasound technician, shared a similar perspective, although she was not as enthusiastic as stephanie about her decision to become an nac. “nacs are kind of – i wouldn’t say that they’re in high demand, because for a penny, you can have ten aides, but typically, you can find a job almost anywhere…it was an okay choice.” finally, 100% of the respondents who generally discussed job security in rural health care felt it was strong. with the exception of the two respondents worried about too many nurses entering the current labor market, 90% (17 of 19) of individuals who discussed job security in health care felt it was a reliable field to enter.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 181 job stability as a challenge. the topic of job stability (i.e., consistent hours and schedules) was also a topic that emerged as important to about a third of the respondents. all 19 of those who discussed job security also worked in health care, meaning it was a salient issue for about one in every two health care workers. problems with shift work, being supplemental, on-call, and sent home because of low census were all mentioned. tina, a 36-year old nurse administrator had this to say about her early career in nursing: at that point in my life i…had a small child…and i was going through a divorce and i have a lot of family here and they are a huge support for me, but working evenings, or working nights, it was too hard to leave her at a stranger’s house or find a babysitter for those hours. being supplemental meant holding a position in which workers sign up for as many open shifts as they like at the beginning of the month, as long as they do not exceed full-time or 40 hours a week. these are used primarily for dcw and rn floor positions. while flexible, the drawback of these positions is that sometimes full-time work cannot be obtained, and even when workers sign up for full-time work, supplemental workers are the first ones to go home if there are not enough patients to care for. in general, census remains stable in long-term care, but workers are often called off or sent home early on the hospital’s acute care floor. even for nurses who earn a better wage, this can be problematic. for instance, joe, a 45-year old married nurse supervisor and former marine highlighted the instability of patient census in rural hospitals: you’re already at one or two or three nurses, so if you lose those patients…every other person, you’re going home. verses a large hospital, you might have six or seven nurses per shift, so now you’re one in six to get it…so you may be sent home, and being sent home   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 182 every other day during your cycle of shifts, because they don’t have the patients – who can afford to lose 50% of their pay checks? typically, new cnas start at the hospital or in long-term care as supplemental. while individuals in these positions accrue sick and vacation time, they generally do not have the option of health insurance benefits. seventy-nine percent (15 of the 19) of respondents talking about job stability reported they disliked the unpredictability in their hours, schedules, and subsequent pay. despite being described by others as one of the long-term care facility’s best employees, stephanie, the 18-year old nursing assistant expressed frustration about the stability of her hours: i first started working as supplemental and going to school, and once i got out of doing supplemental i had a lot of hours and then, out of nowhere, they just totally dropped to where i was only getting maybe $300 on a paycheck— that was it. driving back and forth from school from where i was living, that just wasn’t cutting it. still, four individuals did report that they valued the flexibility that came with working supplemental because it was easier to work around a second job, family obligations, and school. debbie, a 30-year old single mother who works supplemental as a nursing assistant while she is completing her prerequisites for the associates degree program in nursing explained that “[they] are really, really willing to work with you. i never know what my schedule is going to be from quarter to quarter, so this helps. i like to keep busy, but i like the flexibility.” those working in acute and er are more susceptible to being sent home because of low patient census or a lack of need. some found that being an rn helped protect against some of the negative aspects related to job stability. for instance, tina, a 36-year old nurse administrator and single mother of two who complained about the unstable schedule eventually pursued her bsn that would allow her to   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 183 demand a more regular schedule. while working in health care was perceived as providing good job security, many respondents found the low pay and job instability frustrating. obtaining bachelor’s degrees allowed some to avoid these negative aspects. work place stability sometimes concerning. finally, although related to pay, security, and job stability, work place stability (i.e., little fear of layoffs, closures, or downsizing) was also a separate topic that emerged in this study. during the time this study took place state support for rural health care facilities, especially those in “critical access areas,” was being considered for reduction because of the massive cuts the washington state legislature needed to make to the annual budget. washington state laws require that the budget be balanced every year, which in lean times puts a lot of pressure on education, health care, and other social services heavily funded by state dollars. jackie, a 37-year old shower aide in long-term care and divorced mother of six expressed her concern about the stability of rural health care and an upcoming vote on budget legislation: “you hear about our financial difficulties and how if this thing passes on the 28th, a lot of rural hospitals will be closing down and it’s scary.” furthermore, the nature of the rural population (older and poorer) means rural hospital and health care systems rely heavily upon government reimbursement for care through programs like medicaid and medicare. independence creek is no exception, with 85% of long-term care residents on state-sponsored health insurance and 60-70% of emergency room, in-hospital and out-of-hospital patients either on state-sponsored health insurance or uninsured all together. during this study, several employee forums were held by hospital administration to discuss the impending budget crunches, shortfalls, and potential cuts. these forums were attended by employees at various levels of service, although those outside of the direct care work delivered in acute and long-term care had more flexibility to leave their offices and current tasks to join the   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 184 discussion. despite the hospital’s attempts to calm employee concerns about potential closures or changes in services and benefits, the threat to rural health care was mentioned by 27% of the respondents (16 of 60) and all but one of these respondents worked in rural health care. debra, a 45-year old married mother of two grown children who works as a paraprofessional at the middle school had this to say about her own concerns: “i’m thankful that we still have a hospital here, [green meadows] closed theirs. they just have an urgent care and so, we’re lucky. i’m hoping that we keep it.” ten of the 19 who mentioned workplace stability issues were primarily concerned about unstable funding, potential closure, layoffs, and understaffing. another six discussed some of the recent organizational restructuring that was occurring to streamline positions and eliminate waste in the labor force. valerie, the 35-year old dental assistant who formerly worked in long-term care as a nursing assistant and has family that works at the hospital explained her perceptions of a growing workload: they don’t want to hear that you don’t have time. you add more, but your room isn’t getting cleaned or your patient was mad, you know…that could just be the economic times, but i feel like it’s just over the past i don’t know how many years, it’s just gotten worse and worse. even before the recession. it’s always been, “do more with less.” not everyone felt rural health care was unstable or that the community was in jeopardy of losing its hospital or the local jobs in rural health care. carolyn, a 53-year old hospital administrator who has worked for independence creek hospital for more than two decades had this to say: “we’ve gone through some changes and had some growing pains, but things seem to be going well.” janis, a 52-year old board member of a local agency which addresses the needs of the elderly within the community discussed the stability of home health care and services:   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 185 i think it will have to become more important. i think with the medicaid cuts and the medicare cuts that are looming and the ones that already happened, homecare is the least expensive alternative if the person is able to be at home without skilled nursing. then any home care agency is able to fill that gap at the least cost. janis is well aware of the budget crunches local health care faces, but feels strongly that the need for care, especially home care will persist and continue to require a local labor force. in the end, community members and those working directly in health care expressed awareness of potential instability in rural health care funding and employment, but health care was still seen as a stable occupational choice by more than a third of the respondents, even if the organizational structure of care delivery changed. discussion this project explored individual perceptions and beliefs about local training, educational, and employment opportunities in health care. more specifically, this study revealed important information about perceptions of opportunity and work characteristics among rural residents in one isolated community where health care is one of the main avenues to local employment. these beliefs and perceptions about education and employment are embedded in larger systems and locally-constructed social hierarchies in independence creek that often support patterns of behaviors that create opportunities for some while limiting opportunities for others (sherman & sage, 2011). in rural communities like independence creek, beliefs about independence and hard work are often incorporated into how individuals are judged by those around them (sherman, 2009). this study illuminates how jobs in health care might provide avenues for some to show their ability to work hard and be independent, depending first on how these opportunities are perceived.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 186 serving dual purposes: local opportunities in health care most people in this study perceived the local training and educational opportunities favorably. in fact, more than half said they were valued and desired to have them in their community. even the respondents who shared negative comments regarding the opportunities felt this way mostly because of the limited nature of what was currently available locally. beliefs about who was best suited for the local trainings fell into two general categories. for 38% of the individuals, local training and educational opportunities in health care provided a jumping off place. most individuals who saw the medical careers class or the adult nac course as a “stepping stone” also performed well in high school and others in the study perceived them as college bound. in general, respondents believed post-secondary education could only be pursued outside of independence creek and therefore, they tended to feel that while the entry level classes were useful in getting exposure to the medical field, the local training and educational opportunities, in general, were insufficient. additionally, family background and social status contributes to the likelihood of college attendance of rural youth (mcgrath, swisher, elder, & conger, 2001; provasnik et al., 2007; sherman & sage, 2011; wilson, peterson, & wilson, 1993) and therefore, this could mean that inequality is being reproduced, at least among the more privileged families in independence creek. alternatively, 40% felt the local training, educational, and employment opportunities in health care provided a suitable alternate route to stable employment either with or without the pursuit of post-secondary education. this is important when considering how non-college educated individuals earn status or respect in the community where most of the good jobs of the past are gone. while some individuals in this group tended to believe the local training and educational opportunities were not sufficient, the majority saw these as good for place-bound individuals who either could not or did not want to   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 187 leave independence creek. they appreciated the local opportunities and a few complained there were too few slots in the on-site nursing program, which they saw as very valuable. the respondents describe the pay for cnas and other dcws as good, or at least better, than other entry-level service jobs. some, like 17-year old leslie, were enthusiastic about the pay, while other like martina, described their decision to go into direct care work as “an okay choice.” these individuals also worried about job and workplace stability, but generally felt they could always find work with their certification. the majority of individuals in this group either forewent college all together in favor of staying in their rural community or managed the difficulties of pursuing post-secondary education without ever leaving. while low pay and a lack of stability make most of the opportunities in rural health care in independence creek bad jobs, participants expressed discourses to justify or explain persistence in these positions. parenthood and other family obligations made staying in independence creek important to these individuals. the slightly higher than minimum wage pay places these positions above other service sector opportunities in the hierarchy of employment in independence creek. others argued that the flexibility of working in supplemental or on-call positions was something that worked well with the other demands in their lives. nevertheless, the majority of respondents who discussed pay for direct care workers agreed that the pay was too low for the level of physical and emotional demands. regardless, for individuals who could not or did not want to leave independence creek, local training, education, and employment provided a much needed opportunity. this was especially important for young women with children. for those who were staying in independence creek, the local pursuit of post-secondary degrees still primarily meant commuting to wrightburg and appleton. it seems that this reality may continue, despite the   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 188 introduction of the on-site nursing program. ten individuals currently working at independence creek hospital and their long-term care facility as nacs expressed interest in the program which can only take two new students per year. while it does not appear that upward mobility is going to be readily available to everyone who enters low-status health care work, for some simply entering this type of work gives them a sense of elevated status. moving beyond this small increase in upward mobility may be difficult. overall, the locally-available trainings and education in health care are desired and valued. although most felt that pay and stability in health care was not very good, it appears that job security tended to out-weight the negative feature of this type of employment. this study builds on what probst, baek, and laditka (2009) found when comparing rural and non-rural respondents in the national nursing assistant study (nnsa) of 2004. these researchers found that while nearly all cnas, on average, noted that they became cnas because they liked taking care of people, when asked to rank their reasons, rural cnas ranked job security or a job close to home as most important, while urban care workers ranked caring for people as most important. having options for staying, even if they are not ideal, appears to also be important for those wishing to remain in independence creek. if washington state wishes to meet the project demands for nurses and other care workers in the future, nursing education will need to be expanded. there are simply too few slots in both campus and off-campus programs to graduate enough nurses to fill the projected needs. this factor is something that state officials and health care administrators have been aware of for some time (skillman et al., 2007), but this study uncovers how potential students view the problem of too few slots and limited access. although this study focuses on how locallyavailable training and education was perceived, 42% also discussed wait lists for adn programs   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 189 in appleton and problems with these programs maintaining their ability to license students. therefore, even those rural residents who are willing to commute or move in order to pursue nursing degrees often run into problems with enrollment. whether it is through on-site rural nursing programs or through expanding traditional campus programs, washington state should set its sights on expanding nursing education. if policy makers are specifically interested in recruiting and retaining quality nurses for rural areas, it seems that recruiting directly from the local community have shown the greatest potential with physicians (laven & wilkinson, 2003), and may be the best option for although much more research is still needed on this subject in relation to on-site programming and nursing. supporting agency department of labor: education and training administration references aiken, l. h., clarke, s. p., sloane, d. m., sochalski, j., & silber, j. h. 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(2004). the appalachian model teaching consortium: preparing teachers for rural appalachia. the rural educator, 26(1), 24–29. retrieved from http://www.ruraleducator.net/archive/26-1/26-1_profitt.pdf. provasnik, s., kewalramani, a., coleman, m. m., gilbertson, l., herring, w., & xie, q. (2007). status of education in rural america (no. nces 2007-040). washington, dc: u.s. department of education national center for educational statistics. roberge, c. m. (2012). who stays in rural nursing practice? an international review of the literature on factors influencing rural nurse retention. online journal of rural nursing and health care, 9(1), 82–93. http://doi.org/10.14574/ojrnhc.v9i1.107 rubin, s. (2001). rural colleges as catalysts for community change: the rcci experience. rural america, 16(2), 12–19.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 193 sherman, j. 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(2010). american factfinder. washington, dc: census bureau.   online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.382 194 u.s. department of agriculture/economic research service (2010). rural income, poverty, and well-being: poverty geography. washington, dc: usda/ers. retrieved from http://www.ers.usda.gov/briefing/incomepovertywelfare/povertygeography.htm u.s. department of labor’s education and training administration. (2010). allied health access guidebook. tatc consulting. retrieved from https://wdr.doleta.gov/directives/attach/ten/ten2010/ten10-10a1.pdf washington state department of health. (2006). rural and urban commuting areas, 2006. olympia, wa: washington state department of health. retrieved from ftp://ftp.doh.wa.gov/geodata/layers/maps/ruca_zip_06.pdf washington state employment security department. (2010). reports, data, and tools. olympia, wa: washington state employment security department. retrieved from https://fortress.wa.gov/esd/employmentdata/reports-publications wilson, s. m., peterson, g. w., & wilson, p. (1993). the process of educational and occupational attainment of adolescent females from low-income, rural families. journal of marriage and the family, 55(1), 158–175. http://dx.doi.org/10.2307/352966 wuest, j. (2012). grounded theory: the method. in p. munhall (ed.), nursing research: a qualitative perspective (5th edition), (pp. 225-256). sudbury, ma: jones & bartlett learning.   online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.442 1 editorial moving forward in rural nursing pamela stewart fahs, phd, rn, editor the editor of the 4th edition of rural nursing: concepts, theory and practice (winters, 2013) and the original editor of that work (lee, 1998) have asked me to reach out to you as readers of the online journal of rural nursing and health care; and as rural nurses in practice, education, and research, to ask for your input regarding this classic text and where you would like to see the focus of a next edition. a short survey that combines needs assessment data for a future text as well as interest in providing material for that future edition can be found at https://www.surveymonkey.com/r/57mx5mn . more about the survey can be found at the end of this editorial. a fairly recent publication noted that there has been little change in the top priorities in rural health in the last decade (brolin et al., 2015). the rural healthy people 2020 study noted that access to care remains a top priority. there is a bit more finesse reported in the brolin and colleagues findings regarding lack of access to health with discussion of necessity beyond access to primary care. the access issue is inclusive of emergency services and insurance concerns. although not mentioned in brolin et al., the issue of access to specialty care also remains an access issue in rural locations. the number of people living in rural areas in the us has shrunk slightly from about 20% in 2000 to 17% according to the 2010 data. this is at a time when about ½ of the world population lives in rural environments. however the need for rural healthcare does not seem to be diminishing and the health priorities identified by key stake holders have not shown much change over the past decade. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.442 2 nurses are providing valuable services within rural communities, yet rural nursing does not always have the same monetary benefits found in more urban areas. a new report on economic and employment data on registered nurses (rns) and advanced practice registered nurses (aprns) pulls from a variety of sources to give a picture of nursing today (mcmenamin, 2016). some of the lowest wages for nurses are in non-metropolitan statistical areas, a disturbing facet of the report, for those living and working in rural nursing. there were 63 substate areas in the us where nurses made on average less than $55,000 per year. over half of these areas (36) were in rural places. although rural nurses are likely to have a lower salary than their more urban counterparts, nursing remains a relatively high paying career within rural communities. nursing remains one of the most trusted professions and most often well respected, particularly in rural communities. the question often arises as to what is rural nursing, what is entailed within the field of rural nursing and how is it the same or different from nursing in non-rural areas? the beginning of a process of developing a theory to guide rural nursing goes back to the 1980’s (lee & mcdonagh, 2013; long & weinert, 1989; winters, 2013). we have come to some agreement about rural nursing in that period of time; with most in the field agreeing that rural nurses are what i term a consummate generalist (fahs, in press). major concepts and themes have emerged and been affirmed over time (lee, winters, broland, raph, & buehler, 2013). however, there remain areas regarding rural nursing that need further exploration. the original work on a rural nursing theory was conducted in the western part of the us (montana) and canada (lee & mcdonagh, 2013). one might ask, do the same concepts and propositions exist in other areas of the us and how does rural nursing differ in terms of providing health to rural populations around the world? is current knowledge of rural nursing sufficient in depth and scope to guide practice? online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.442 3 do the concepts traditionally associated with rural nursing and rural populations still hold true? if there is a need to further the development of rural nursing theory, what are the next steps? is it time to test some of the propositions developed through qualitative methodology in more quantitative studies. what is your opinion about this classic text? do you have expertise that would all you to contribute to future editions of this work. this is needs assessment survey can be found at https://www.surveymonkey.com/r/57mx5mn . drs. winters, lee, and i would appreciate your participation in this survey. survey responses are due by january 15, 2017 and all responses are anonymous. there is an area within the survey where you can provide contact information if you wish. references bolin, j.n., bellamy, g.r., ferdinand, a.o., vuong, a.m., kash, b.a., schulze, a., & helduser, j.w. (2015). rural healthy people 2020: new decade, same challenges. journal of rural health, 31, 326 333. https://dx.doi.org/10.1111/jrh.12116 fahs, p.s. (in press). leading-following in the context of rural nursing. nursing science quarterly, lee, h.j., winters, c.a., boland, r. l., raph, s.j. & buehler, j.a. (2013). an analysis of key concepts for rural nursing. in c.a. winters (ed.), rural nursing: concepts, theory, and practice (pp. 469 – 480). new york: springer. lee, h.j & mcdonagh, m.k. (2013). updating the rural nursing theory base. in c.a. winters (ed.), rural nursing: concepts, theory, and practice (pp. 15 34). new york: springer. long, k.a. & weinert, c. (1989). rural nursing: developing the theory base. scholarly inquiry of nursing practice, 3, 113 – 127. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.442 4 mcmenamin, p. (ed.), (2016). ana’s nurses by the numbers: a synthesis of ana-curated rn/aprn information from federal government sources. winters, c.a. (2013). preface. in c.a. winters (ed.), rural nursing: concepts, theory, and practice (pp. xvii xix). new york: springer. online journal of rural nursing and health care, 1(2) 12 small, rural hospitals: a fight for survival julie w. robinson1 grant t. savage, phd2 1 graduate assistant, culverhouse college of commerce, university of alabama 2 healthsouth chair & professor, culverhouse college of commerce, university of alabama, gsavage@cba.ua.edu* * corresponding author abstract declining reimbursements, resulting from the 1997 balanced budget act (bba), have placed an enormous strain on small, rural hospitals that are typically dependent on medicare patients for the majority of their revenue. under the bba, new managed care and private options are available, payments to hospitals are reduced, part b premiums are increased, and a prospective payment system (pps) is authorized for outpatient, home health, and skilled nursing services. the balanced budget refinement act of 1999 (bbra) attempts to rectify some of the reductions in reimbursement. nonetheless, to take advantage of the bbra and to address declining reimbursements from other sources, rural hospitals should expand outpatient services, embrace telemedicine and telehealth initiatives, and actively seek alternative funding. keywords: medicare reforms, rural health policy, hospital strategy online journal of rural nursing and health care, 1(2) 13 small, rural hospitals: a fight for survival rapid changes in technology, reimbursements, and regulations between 1980 and 1989 resulted in the closure of more than 200 small, rural hospitals (hart, amundson & rosenblatt, 1990). as we enter the 21st century, rural hospitals servicing populations in non-metropolitan counties throughout the u.s. are once again facing immense pressures, especially from aging populations and from public and private payers. these pressures are most intense for small hospitals, with fewer than 100 beds. most rural hospitals are dependent on medicare for the majority of their revenue, and the 1997 balanced budget act (bba) has drastically reduced their medicare reimbursements (coburn, fluharty, hart, mackinney, mcbride, mueller, & wakefield, 1999). rural hospitals cannot continue business as usual, even with the recent relief provided through the 1999 balanced budget revision act (bbra). to reduce the negative impact the bba has had and to take advantage of the provisions in the bbra, small rural hospitals should expand outpatient services, embrace telemedicine and telehealth initiatives, and actively seek alternative funding from foundations and other sources. background medicare was enacted in 1965 as title xviii of the social security act and began in 1966 under president lyndon b. johnson. the program currently is managed by the health care financing administration (hcfa) which was formed in 1977 as an agency of the federal department of health and human services. the social security administration maintains the data that determines medicare eligibility. medicare provides coverage for people aged sixty-five and older, for people who are disabled and eligible for social security, and for people with permanent kidney failure. medicare has two parts, a and b. medicare part a provides hospital insurance and is financed online journal of rural nursing and health care, 1(2) 14 through a 2.9 percent payroll tax. employers and employees each pay half the tax. a premium payment is not required, but beneficiaries do pay a deductible of $764 on hospital stays each year. federal actuaries initially estimated future expenditures for medicare part a so that a payroll tax could be established based on potential costs. however, the government's 1965 estimates were based on a worker to beneficiary ratio of 5:1; in 1995 that ratio was 3:1, and it is projected to be 2.2:1by 2020 as the baby boomer generation matures (barton, 1999). medicare part b is known as supplementary medical insurance (smi). it helps pay the cost of medical equipment and supplies, outpatient hospital services, and physician services. general tax revenues provide 75 percent of the funding, while beneficiaries pay a monthly premium that funds the remaining 25 percent of part b. the smi program covers 80 percent of the allowed charge for health services (barton, 1999; the century foundation, 1999). changes and controversies in medicare in 1997 congress passed legislation signed by president clinton to balance the federal budget, thereby authorizing major reductions in medicare funding. unresolved issues with the bba were the conflicting interests of the small, rural hospitals, the health care financing administration, and congress. rural health care facilities believed the federal government was balancing the budget at their expense. congressional proponents of bba insisted that measures had been taken to reduce the inequalities rural health care facilities historically have experienced. from the small, rural hospitals' perspective, however, the health care financing administration’s implementation of the bba created an expectation gap, and made bba reforms an important issue for hospitals and rural communities. as issue management experts have argued (wartick & mahon, 1994), expectation gaps between "what is" versus "what ought to be" tend to become the focus for conflicts and are the online journal of rural nursing and health care, 1(2) 15 impetus for social and organizational change. indeed, these conflicts were perceived as so severe that lobbying efforts from the health care provider community and other stakeholders in 1999 resulted in revisions to the 1997 legislation (jones, 2000). the major aspects of both the bba of 1997 and bbra of 1999 are discussed below. the balanced budget act of 1997 under the auspices of the balanced budget act of 1997, medicare had drastic budget reductions. measures were enacted to reduce the projected growth of medicare spending by $116.4 billion by 2002. the impact of this funding decline for medicare has been compared to the impact in the 1980s of the prospective payment system (pps) on hospital insurance (arent fox alerts, 1998). many of the provisions were to be phased in through 2002. new managed care and private options, reduced payments to hospitals, increases in part b premiums, and a pps for outpatient, home health, and skilled nursing services were a few of the major changes. managed care and private options managed care is becoming increasingly the norm for employer-based health insurance, according to research conducted by the century foundation. one study notes that in 1993, 78 percent of workers in firms with 1-24 employees, and 65 percent of those with 25-49 employees had access to traditional fee-for-service health insurance. only two years later, both those figures had fallen to 30 percent. (the century foundation, 1999:2). as of october 1999, approximately 16 percent of all medicare beneficiaries were enrolled in managed care plans (shay, mcbride, & mueller, 2000). medicare+choice allows private insurance companies to offer managed care coverage to beneficiaries. everyone who has medicare parts a and b is eligible, except those who have endstage renal disease. managed care plans often encourage preventive health, especially if they are online journal of rural nursing and health care, 1(2) 16 based on a fixed payment per patient. for example, the majority of managed care plans cover annual physicals, eye exams, certain immunizations, ear exams and outpatient prescription drugs. proponents of medicare managed care believe medicare+choice has the potential of cutting costs and perhaps improving the quality of care. however, the savings have yet to be seen. the health care financing administration is taking steps to educate medicare recipients of the benefits of managed care plans. in the medicare & you 2000 (1999) handbook, the hcfa uses easy to read graphs to show the results of a survey it conducted. the survey measured the communication skills of managed care doctors as viewed by a sample of medicare managed care plan members. this booklet is just one of the ways hcfa is attempting to educate beneficiaries about the reform. according to a 1997 u.s. congressional budget office report, medicare paid about 5 percent more for the beneficiaries who enrolled in hmos than it would have spent if the participant had remained with traditional coverage (the century foundation, 1999). one of the reasons for these higher costs was the process of risk selection. this is the practice of managed care plans marketing to healthier beneficiaries who want lower out-of-pocket costs and more benefits. less healthy beneficiaries are more likely to stick with what they know. the possible effects of this selection bias are increased premiums and payroll tax rates for those receiving traditional fee-for-service medicare. in accord with the bba, a new risk adjustment procedure is being instituted during 2000. this adjustment takes into account the prior hospitalization experience of beneficiaries as a factor for determining the per capita payments for medicare+choice plans. another change congress has made under the 1997 bba is to fix the growth rate of managed care plans at a lower rate per capita than in medicare’s traditional feeonline journal of rural nursing and health care, 1(2) 17 for-service section. in the past, the rate had been a percentage of the program's expected fee-forservice costs. this measure is anticipated to save $23.2 billion. these medicare reform proposals that rely on competition among managed care organizations, however, ignore many seniors living in rural areas. for example, according to a study by families usa, a consumer advocacy group, alabama has nearly 240,000 rural medicare beneficiaries, and only participants in walker county have access to a medicare hmo ("rural medicare hmos," 1999). moreover, national data shows slow growth in medicare+choice for rural (2.5%) versus urban (20.3%) communities, with extreme regional variation in the growth and decline in managed care enrollments during 1999 (shay, mcbride, & mueller, 2000). reduced payments to hospitals the second major bba reform reduced payments to hospitals, constituting almost 30 percent of the expected medicare program savings over the next five years (the century foundation, 1999). this reduction is where rural hospitals have suffered the most since they derive the majority of their revenue from these reimbursements (rural policy research institute, 1999). according to robert a. berenson, director of the center for health plans and providers, a division of the health care financing administration, one in four medicare beneficiaries live in rural areas (berenson, 1999). the bba froze payment increases under the prospective payment system for the 1998 fiscal year, while setting rates for 1999 through year 2002 slightly below the expected increases in medical costs (the century foundation, 1999). increase in part b premiums a third bba reform was to increase part b premiums. in 1997, monthly premiums were $45.50. under the bba they increase to $64.00 in 2002. since the elderly spend an average of online journal of rural nursing and health care, 1(2) 18 21 percent of their disposable income on health care (the century foundation, 1999), this increase undoubtedly will place a strain on low-income beneficiaries. according to the century foundation, about 78 percent of medicare beneficiaries have incomes below $25,000. prospective payment system (pps) a pps sets pre-determined rates for different categories of medical services. since 1984, medicare has had pps for inpatient services based on diagnostic-related groups (drgs); the bba authorizes a pps for outpatient services, which is slated for implementation during 2000. the bba of 1997 reduced cost-based outpatient services as conversion was completed to a pps. at the same time, the bba immediately imposed a pps for skilled nursing services and introduced an interim payment system with conversion to a pps after 2000 for home health service payments. taken together, these measures had unforeseen negative impacts on reimbursements for rural hospitals, all which provide outpatient services and 72% of which offer either or both home health and skilled nursing services (coburn et al. 1999). from 1990 to 1996, the rate of medicare spending on home health and skilled nursing services grew at a fast pace. understandably, the pps for skilled nursing services and reductions in home health reimbursements was one of the earliest bba reforms implemented, but with unanticipated adverse results. for example, between mid-1997 and mid-1999 over 2,500 medicare-certified home health agencies were closed, and home health payments decreased 38% from 1997 to 1998 (national association of home care, 1999). indeed, congressional testimony on revisions to the bba in 1999 focused on the hardships such closures have created for the elderly (berenson, 1999). online journal of rural nursing and health care, 1(2) 19 the balanced budget revision act of 1999 the medicare, medicaid, and schip balanced budget refinement act of 1999 was signed into law on november 29, 1999, providing approximately $17 billion in additional funding over the next five years. many of the provisions of the bbra have a direct impact on rural health care delivery and access to services for rural medicare beneficiaries. the following discussion highlights these provisions drawing on analyses from the rural policy research center (mueller, 1999) and reports from the health care financing administration (2000). section 202 in the bbra benefits rural hospitals with 100 or fewer beds by allowing them to receive the same payments for outpatient services as they would have received without the implementation of a pps. this relief extends until january 1, 2004. section 404 extends the medicare dependent hospital program to october 1, 2006, benefiting rural hospitals with fewer than 100 beds which have 60% or more of their inpatient services attributable to medicare. these designated hospitals receive enhanced payments. in addition, the bbra increases the attractiveness of the critical access hospital (cah) designation. the cah designation is appropriate for very small hospitals (15 beds or less) with low daily patient census that provide limited inpatient services for an average of no more than 96-hours per patient. the bbra provides cahs with all-inclusive rates for inpatient and outpatient services and eases their use of swing beds. recommendations clearly, small rural hospitals that depend on medicare patients for the majority of their revenue must take an active role to benefit from the bbra of 1999 and to counter the negative impacts from the bba of 1997. while some rural facilities that are strategically positioned with ample community support may be able to muddle through the changes wrought by the bba and online journal of rural nursing and health care, 1(2) 20 the bbra without major reorganization, other hospitals will have to take radical steps. we suggest that at least three different approaches should help rural hospitals survive: 1. expanding outpatient services 2. embracing telemedicine and telehealth initiatives 3. seeking alternative funding sources. expand outpatient services to address reduced reimbursements from medicare, small rural hospitals may expand outpatient services while cutting back on similar inpatient services. of course, all rural hospitals are already offering some outpatient services. according to a recent study by the project hope walsh center for rural analysis, rural hospitals obtained more than two-fifths of their total revenue from outpatient services in 1995 (center for health affairs, 1998). in the past, medicare paid for hospital outpatient services based on hospital-specific costs. under the 1997 bba, congress has enacted several reforms that authorize the implementation of a hospital outpatient pps. as of august 2000, hospitals will be paid for outpatient services based on their national median costs, and services will be classified into ambulatory payment classification (apc) groups, similar to drgs for inpatient services. fortunately, under the bbra of 1999, all rural hospitals of 100 beds or less are exempt from the outpatient pps until january 1, 2004. moreover, critical access hospitals (cahs) benefit from a pps exemption, and receive all-inclusive rates for inpatient and outpatient services. hence, expanding outpatient services and reducing inpatient beds is definitely advantageous, both for medium-sized rural hospitals with slightly over 100 beds and for small hospitals with daily inpatient census counts close to the cah 15-bed constraint (mueller, 1999). cahs also have advantages since they are not required have the same level of physician staffing online journal of rural nursing and health care, 1(2) 21 as do secondary and tertiary care hospitals, and may rely more heavily on nurse practitioners and physician assistants (hcfa, 2000). for medium-sized rural hospitals, attracting non-medicare as well as medicare patients can help to offset the future possible adverse effects of the pps for outpatient services. outpatient services appear to be ideal niche for small rural hospitals due to their low number of beds and the fact that, when possible, people prefer to drive to larger hospitals for tertiary or quaternary inpatient services (rural policy research center, 2000). embrace telemedicine and telehealth initiatives the 1997 bba includes several new provisions authorizing payment for telemedicine and encouraging telehealth initiatives. the purpose is to bring urban expertise to rural providers, while increasing access to specialist and preventive care for rural populations (berenson, 1999). telemedicine allows for medical consultations and telehealth advice to take place through the internet, via wide-area networks, or over the telephone. as a noted physician and expert on medical monitoring devices notes: during the next decade diseases requiring medical intervention will be much the same as those being treated today. the site of care may, however, be moved away from the community general hospital to a non-hospital site or to a higher order or specialty hospital at a distance (wilson, 1999: 1). the telecommunications act of 1996 includes subsidies to help rural health care providers gain access to a variety of telecommunications services at lower rates. according to the federal communication commission (1997), in addition to discounted services, rural providers located in an area without toll-free access to the internet can receive subsidized tollfree access for up to 30 hours of connection time or $180 a month, whichever is less. as of online journal of rural nursing and health care, 1(2) 22 january 1998, a pool of $400 million a year has been available for funding (american hospital association, 1999). a national survey of telemedicine programs reveals a dramatic growth in telemedicine from 1993 ‚ 1997. the study found a total of 80 active telemedicine programs in 38 states and washington, d.c, as compared to 12 active programs in 1993 (grigsby & allen, 1997). the majority of these programs use broadband technology and are located in academic medical centers or community hospitals; however, after decades of refining, telemedicine is now less expensive and easier to use. new internet-based alternatives have been created for smaller projects, as opposed to the high-end systems used by nasa and in pentagon programs; moreover, ordinary telephone service (pots) is the preferred mode of transmitting voice, video and data. systems that use narrow-band lines have the advantage of being accessible to roughly 99% of the population and are inexpensive to operate. although speed and picture resolution are lower quality than in broadband applications, early reports from the field indicate that pots is a satisfactory method of employing telehealth to deliver healthcare services. the advances in narrow-band technology along with the availability of a national infrastructure to deliver services with this technology create unprecedented opportunities (zajtchuk & gilbert, 1999). radiology for example, is a common application in rural telemedicine (hassol et al. 1997) and its use in emergency departments is expanding (baker & festa, 1999). moreover, it would be advantageous for rural hospitals to adopt telemedicine and telehealth initiatives not only to expand access to health services but also to improve the quality of patient information (shepperd, charnock, & gann, 1999). online journal of rural nursing and health care, 1(2) 23 seek alternative sources of funding small, rural hospitals cannot absorb the medicare cuts in the bba of 1997 for an extended period of time and expect to remain unscathed. these vulnerable facilities must seek federal, community, and private funding in order to remain open. for example, a clinic in bessemer, alabama, staved off closing its doors after an anonymous donor and jefferson county each donated $125,000. the clinic serves more than 2,000 patients. most of these patients are senior citizens with little or no medigap insurance. there are several grant programs specifically targeted at rural areas. in fact, the united states department of agriculture (1999) offers financial support through a program called discover rural development. funding is also available from the health resources and services administration's (1999) federal office of rural health policy through its rural health outreach grant program, which makes funds available to rural facilities to expand existing services and enhance health services delivery. other sources of funding are listed at pennsylvania state university's (1999) office of rural health web site. these types of grants could be used to expand outpatient services and/or adopt a telemedicine or telehealth system. clearly, a grant writer may be a small, rural hospital's best asset. if rural hospitals do not have the staffing and expertise to write grant proposals, they should look toward community volunteers and seek alliances with state and local university programs in health care management. on the one hand, retired and other individuals in the local community may be both experienced and willing to help draft grant proposals. on the other hand, students in health care management undergraduate and graduate programs typically must fulfill internship or other practicum requirements and can be a valuable resource for writing grants, especially when supervised by experienced faculty members and administrators. online journal of rural nursing and health care, 1(2) 24 conclusion clearly, if rural hospitals can implement each of the recommendations they should be able to survive the changes wrought by the bba and the bbra, all other matters being equal. however, reality suggests that none of the proceeding recommendations is equally applicable to every rural hospital; each hospital faces its own unique situation. hospital ceos and their boards should assess their strengths, weaknesses, and resources, and then craft a strategy that best fits their opportunities and goals. it may not be feasible for a small, rural hospital to expand outpatient services or to adopt telemedicine and telehealth systems. grant writers may not already be on staff, easily trained, or available for hire. the money or support may not be there. such barriers, nonetheless, are not insurmountable, and one or more of these recommendations should still be practicable. in any case, these recommendations should help rural hospitals take advantage of the opportunities under the bba of 1997 and the bbra of 1999. even if rural hospitals can only implement one of these recommendations, they should be better able to sustain their mission of providing quality health care to local, and often isolated, communities. online journal of rural nursing and health care, 1(2) 25 references american hospital association. (1999). small or rural hospitals: telehealth and fcc universal service funding. retrieved october 19, 1999, from http://www.aha.org/memberserv/ smallrhtele.html arent fox alerts. (1998, 28 september). hcfa announces a prospective payment system for outpatient services. retrieved october 19, 1999, from http://www.arentfox.com/ alert/hcfa_pps.html baker, s.r., & festa s. (1999). the use of teleradiology in an emergency setting with speculation on the near future. radiologic clinics of north america, 37, 1035-44. https://doi.org/10.1016/s0033-8389(05)70142-1 barton, p. b. (1999). understanding the u.s. health services system. chicago, il: health administration press. berenson, r. a. (1999, 14 july). testimony before senate appropriations subcommittee on agriculture, rural development, and related agencies. retrieved november 12, 1999, from http://www.hcfa.gov/testmony/1999/rural1.htm center for health affairs. 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(1997, 5 september). updated frequently asked questions on universal service for rural health care providers (cc docket no. 96-45). retrieved july 18, 200, from http://www.fcc.gov/bureaus/common_carrier/public_notices/ 1997/da971932.html grigsby, b., & allen, a. (1997, august). telemedicine programs: fourth annual review. telemedicine today, 42(8), 30-38, 42. hart, g., amunndson, b., & rosenblatt, r. (1990). is there a role for the small rural hospital? journal of rural health 6(2), 101-18. https://doi.org/10.1111/j.17480361.1990.tb00194.x hassol, a., irvin, c., gaumer, g., puskin, d., mintzer, c., & grigsby, j. (1997). rural applications of telemedicine. telemedicine journal, 3, 215-225. https://doi.org/10.1089/tmj.1.1997.3.215 health care financing association. (1999). medicare & you 2000. baltimore, md: u.s. department of health and human services. health care financing association. (2000). hi & smi trustees report: medicare amendments since the last report. retrieved july 20, 2000, from http://www.hcfa.gov/pubforms/ tr/hi2000/seciia.htm https://doi.org/10.1111/j.1748-0361.1990.tb00194.x https://doi.org/10.1111/j.1748-0361.1990.tb00194.x https://doi.org/10.1089/tmj.1.1997.3.215 online journal of rural nursing and health care, 1(2) 27 health resources and services administration. (1999). federal office of rural health policy: information on the rural health outreach grant program. retrieved november 22, 1999, from http://pathsrvr.rockford.uic.edu/hrsa/ruralhp.html jones, w.j. (2000). medicare and the rules of national policymaking: if a, then b. journal of healthcare management, 45(2), 84-88. mueller, k. (2000). rural implications of the medicare, medicaid and schip balanced budget refinement act of 1999 (research report p99-11). columbia, mo: rural policy research institute. national association of home care. (1999). hcfa data reflect staggering drop in home health outlays. retrieved november 22, 1999, from http://www.nahc.org/nahc/ newsinfo/99nr/hhout.html pennsylvania state university. (1999). pennsylvania office of rural health: federal grant opportunities relevant to rural health. retrieved october 19, 1999, from: http://www.cas.psu.edu/docs/casdept/aers/porh/federal.html rural medicare hmos are scarce. (1999, september 11). daily mountain eagle, p. a3. rural policy research institute. (1999, 2 november). rural by the numbers: health. retrieved july 18, 2000, from http://www.rupri.org/rnumbers/health/index.html shay, b., mcbride, t., & mueller, k. (2000). a report on enrollment: rural medicare beneficiaries in medicare+choice plans (rural policy brief 5:1). columbia, mo: rural policy research center. shepperd, s., charnock, d., & gann, b. (1999). helping patients access high quality health information. british medical journal, 319, 764-766. https://doi.org/10.1136/bmj.319.7212.764 https://doi.org/10.1136/bmj.319.7212.764 online journal of rural nursing and health care, 1(2) 28 united states department of agriculture. (1999). discover rural development. retrieved october 21, 1999, from http://www.rurdev.usda.gov/rd/index.html wartick, s.l., & mahon, j.f. (1994). toward a substantive definition of the corporate issue construct. business & society, 33, 293-311. https://doi.org/10.1177/000765039403300304 wilson, c.b. (1999). the impact of medical technologies on the future of hospitals. british medical journal, 319, 1287-1289. https://doi.org/10.1136/bmj.319.7220.1287 zajtchuk, r., & gilbert, g.r. (1999). telemedicine: a new dimension in the practice of medicine. disease-a-month, 45, 197-262. https://doi.org/10.1016/s0011-5029(99)90009-3 https://doi.org/10.1177/000765039403300304 https://doi.org/10.1136/bmj.319.7220.1287 https://doi.org/10.1016/s0011-5029(99)90009-3 microsoft word langham_432-2642-1-ed1.docx online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 3 healthy kids: impacting children’s health in rural alabama ginny weldon langham, dnp, msn, rn 1 j kyle taylor, phd 2 allison j terry, phd, msn, rn 3 kathryn dugan, med, mt (ascp) 4 li qian, md, mls (ascp) cm 5 kathy w. jones, ms, mls(ascp) cm 6 ashley miles godwin, aud, ccc-a, f-aaa7 1 assistant professor, school of nursing, college of nursing and health sciences, auburn university montgomery, llangham@aum.edu 2 associate professor/department head, medical & clinical laboratory sciences, college of nursing and health sciences, auburn university montgomery, jtaylor@aum.edu 3 assistant dean, school of nursing, college of nursing and health sciences, auburn university montgomery, aterry@aum.edu 4 instructor, medical & clinical laboratory sciences, college of nursing and health sciences, auburn university montgomery, kdugan@aum.edu 5 associate professor, medical & clinical laboratory sciences, college of nursing and health sciences, auburn university montgomery, lqian@aum.edu 6 assistant professor, medical & clinical laboratory sciences, college of nursing and health sciences, auburn university montgomery, kjones31@aum.edu 7 department head/director, communication disorders, college of nursing and health sciences, auburn university montgomery, agodwin3@aum.edu online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 4 abstract significant changes have occurred in the healthcare community as a result of legislative decisions, the economic downturn, and long range effects of consistent annual reductions in public funding. community partnerships have become vital to the existence of many areas of healthcare delivery, including the alabama state department of education’s school health services program which is charged with the oversight of the health of students while they are enrolled in alabama public schools. this program, along with many state agencies, continues to struggle in finding creative ways to stretch every education dollar in order to adjust to the impact of across the board budget cuts. a decrease in the number of registered nurses and the increasingly complex medical issues of students requiring individualized care have potentially jeopardized the ability of school nurses to adequately monitor and detect changes in the overall health status of children in the alabama school health services program. nursing, medical laboratory sciences, and communication disorder students from the college of nursing and health sciences (conhs) at auburn university montgomery (aum) conducted health screenings for school age children in medically underserved counties of rural alabama. the purpose of this article will be to discuss the collaboration and implementation of an interprofessional, community-based, service-learning project entitled healthy kids. keywords: rural health, interprofessional collaboration, child health, service learning online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 5 healthy kids: impacting children’s health in rural alabama the alabama rural health association (arha), the alabama department of public health office of primary care and rural health (adph-opcrh), and the national organization of state offices of rural health have explored several trends in healthcare which negatively impact the overall health of alabama’s rural population including, but not restricted to, limited availability of local healthcare providers, population growth, inadequate personal and public transportation options to healthcare facilities, and inadequate insurance coverage (adph opcrh, n.d.a.). furthermore, they report that rural populations have less annual income and less education than their urban contemporaries. according to the alabama department of public health (2015a), the health status of african-americans in alabama is not as favorable as the health status of caucasian alabamians as the mortality rate for african-americans is 15% higher related to heart disease and 1.8 times higher from diabetes than for caucasian alabamians. the adph-opcrh (n.d.b.) evaluates communities in the state to determine health professional shortage areas (hpsa) and medically underserved areas/populations (mua/p). if a deficiency is found when comparing the number of healthcare providers (physicians, dentists, and psychiatrists) to the entire population within a specific area, a designation of a geographic hpsa is warranted. when the number of providers accepting medicaid insurance or a sliding fee scale is insufficient in comparison to the low-income population of a service area, the designation of a low-income hpsa is given. within alabama, 27 of 67 counties have been identified as geographic primary care hpsas, and 33 counties as low-income primary care hpsas (adphopcrh, 2015a). low-income dental hpsas have been designated within 66 of alabama’s 67 counties and 43 counties have been identified as geographic mental hpsas, with 23 counties as low-income mental hpsas (adph-opcrh, 2015b, 2015c). medically underserved online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 6 areas/populations (mua/ps) indicate inadequate primary healthcare services as measured by the number of healthcare providers and certain health status indicators that effect a community’s health, including cardiovascular diseases, nutrition and physical activity, obesity, oral health, diabetes, mental health and substance abuse (adph-opcrh, n.d.b.). mua/ps have been categorized within each of alabama’s 67 counties – virtually the entire state (figure 1). figure 1. medically underserved areas/populations in alabama. alabama department of public health, office of primary care & rural health. (n.d.c.). medically underserved areas/populations. retrieved from http://www.adph.org/ruralhealth/assets/muapmap.pdf permission to publish granted from adphopcrh) online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 7 the southern state of alabama is primarily comprised of rural counties with 55 out of 67 being classified as “rural.” rural is defined by arha (n.d.) by analyzing four variables within a county: (a) employment percentages in the local school system, (b) monetary value of agricultural production, (c) total population per square mile, and (d) population of the largest city in the county. lowndes and elmore counties, both rural counties, have been designated as medically underserved areas with a scarcity of primary, dental, and mental healthcare providers (adphopcrh, n.d.c., 2015a, 2015b, 2015c). the united states census bureau (2015a) estimates 10,458 individuals reside in lowndes county with 22.9% under the age of 18 years. of this county’s population, 72.4% is african american compared to 13.3% in the united states (united states census bureau, 2015a). between 2006 and 2011, 52.0% of lowndes county’s population was considered under 200% of the poverty level (arha, 2013). the median household income is $25,678 with 31.4% of residents living in poverty (united states census bureau, 2015a). elmore county’s population is approximately 81,468 with 22.8% persons under 18 years old, and 21.3% of the county’s individuals being african american. the median household income is $54,159 with 14.4% of persons living in poverty (united states census bureau, 2015b). the prevalence of heart disease and diabetes in alabama is significant (adph, 2010a; 2015a; arha, 2013; johnson, peterson, dotherow, & johnson, 2013). these non-communicable conditions can be directly linked to modifiable risk factors including a sedentary lifestyle, obesity, poor nutrition and smoking (adph, 2015b; barlow, 2007; mozaffarian et al., 2016; united states department of health and human services [usdhhs], national institutes of health [nih], national heart, lung, and blood institute [nhlbi], 2005). when these risk factors, along with other key indicators of health outcomes, are examined, the health status of communities can be assessed (cdc, 2015a). since 1926, heart disease has been the primary cause of death in alabama online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 8 with rural counties having a higher rate of heart disease mortality than urban counties (adph, 2015a). furthermore, the 15 counties with the highest heart disease mortality rates are all rural (adph, 2015a). according to the centers for disease control and prevention (cdc, n.d.a), 40.4 % of adult alabamians were diagnosed with hypertension in 2013, 12.9% were diagnosed with diabetes in 2014, and 66.9% had weight classifications of either obese or overweight in 2014. early health screenings, along with health promotion and disease prevention education, have proven to reduce the incidence of these diseases (adph, 2015b; clark, 2008; sidorov & romney, 2016). if fewer children entered adulthood with the challenges posed by obesity, hypertension and/or diabetes, a significant improvement in overall health status could be more likely to be achieved (dick & ferguson, 2015; kelly et al., 2013). according to the nurse administrator of the alabama school health services program, a decrease in the number of registered nurses and the increasingly complex medical issues of students requiring individualized care have potentially jeopardized the ability of school nurses to adequately monitor and detect changes in the overall health status of children in alabama’s public schools (j. ventress, personal communication, august 25, 2016). an ongoing communityacademic partnership between neighboring county school systems and aum’s college of nursing and health sciences has proven to be effective through the utilization of baccalaureate nursing and health sciences students to assist public school nurses in identifying children at risk for health issues. this endeavor offers a proactive approach to address the health disparities existing in the schoolchildren of rural alabama (adph, 2010b) and supports the school-based interventions endorsed by the world health organization ([who], 2005). the purpose of this article is to discuss the collaboration and implementation of an interprofessional, community-based, servicelearning project entitled healthy kids, which provides health screenings to school age children in online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 9 medically underserved counties of rural alabama. the objectives for healthy kids are to (a) partner with schools in the rural alabama counties to provide service-learning experiences that promote health and wellness, (b) assemble interprofessional student health teams to engage in health screenings for children in underserved communities, (c) provide individualized health education to the children being screened to promote health and prevent disease, and (d) identify health concerns that require follow-up attention and notify school officials. methods service learning/interprofessional collaborative practice the american association of colleges of nursing (aacn, 2009) advocates the use of service learning projects as an active learning strategy to promote the core competencies of baccalaureate education. these foundational competencies include critical thinking, creative problem solving, oral and written communication, application of evidence-based practice (ebp) concepts, health promotion teaching skills, and group dynamics. through the development of service learning projects, faculty can structure clinical activities which incorporate the application of classroom theory and promote professional development while meeting community needs. faculty in the college of nursing and health sciences at aum are committed to the integration of service learning experiences throughout the curriculum. service learning activities provide the opportunity for students to apply classroom concepts during a structured activity while providing a service to the community (mueller & norton, 2005; national service-learning clearinghouse, 2016). effective service learning should utilize experiential learning, provide a structured activity that meets a community need, require reflection, and incorporate both the learner’s needs and the community needs to yield positive outcomes for all involved parties (schmidt & brown, 2016). course faculty developed the healthy kids program as an experiential activity and part of the online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 10 clinical requirements for a senior level baccalaureate community health nursing course. the project was designed to assist local school nurses with health screening needs while allowing student nurses the opportunity to develop their professional communication skills, hone their nursing assessment skills, further their understanding and application of classroom concepts such as growth and development and cognitive stages, as well as teach health and wellness concepts. in 2015, the healthy kids program was expanded to include students from the medical laboratory sciences and communication disorders departments. this interprofessional approach is consistent with aum’s core values of community engagement, diversity and collaboration. furthermore, this approach parallels the interprofessional collaborative practice competencies of values and ethics for interprofessional practice, roles and responsibilities, interprofessional communication, and teams and teamwork (interprofessional education collaborative expert panel, 2011). the collaboration is also serving as a basis for research for the entire college while incorporating tenets of the curriculum development guide for health professions faculty (association for prevention teaching and research, 2014). the healthy kids program improves communication and physical assessment skills while allowing them to interact with children at different developmental levels. students become aware of the more common health problems of children while identifying research opportunities to further investigate appropriate preventative approaches. through this endeavor, students from the nursing, medical laboratory sciences and communication disorders departments have hands-on experience in working together to address healthcare needs and consider ways to enhance health maintenance within communities. results the healthy kids project has impacted over 8,000 elementary and middle school-aged children in underserved communities of lowndes and elmore counties in alabama since 2008. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 11 the screenings occurred at eight elementary schools and three middle schools involving numerous faculty and hundreds of health sciences students. bmi referrals when calculating bmi for groups up to 2000 children, the cdc has developed an effective and helpful excel spreadsheet and database. the children’s bmi tool for schools (cdc, n.d.c) was utilized in calculating bmi and bmi-for-age percentiles using height, weight, sex, date of birth, and date of measurement. calculating bmi within the pediatric population differs from the adult population in that bmi fluctuates with age and is gender specific (cdc, n.d.b). therefore, the cdc (n.d.b) recommends the determination of bmi-for-age percentiles to be used in comparison among children of the same sex and age. the weight status categories reflected on the cdc growth charts for children and teens are underweight, healthy weight, overweight, and obese (cdc, n.d.b). for children aged 2-20 years of age, underweight is defined as a bmi less than the 5th percentile; normal or healthy weight is defined as a bmi at or above the 5th percentile and lower than the 85th percentile; overweight is defined as a bmi at or above the 85th percentile and less than the 95th percentile; and obese is defined as a bmi equal to or greater than the 95th percentile for children of the same age and sex (cdc, n.d.b). over 800 abnormal findings of bmifor-age percentiles have been reported to the school nurse coordinators in lowndes and elmore counties since 2008. the referral criteria for bmi-for-age percentiles are based on the cdc’s guidelines of weight status categories (cdc, n.d.b). dental referrals since 66 of alabama’s 67 counties have been identified as low-income dental health professional shortage areas (adph-opcrh, 2015b), the presence of dental issues among school children is not surprising. during the healthy kids screenings, a visual oral inspection is made to online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 12 detect unfilled cavities, discoloration of teeth, and red or swollen gums. the american academy of pediatric dentistry (2013) and the who (2003) advocate dental screenings within the school setting to expedite timely detection and prompt referral for treatment. through the healthy kids program, over 350 dental referrals have been noted. vision referral health professional availability, lack of insurance coverage, and affordability are barriers to receiving appropriate vision care, especially among rural populations and a partnership with community stakeholders is endorsed by the cdc (n.d.d) to promote the understanding of a relationship between vision and overall health. snellen letter and symbol charts were used to evaluate visual acuity. a normal visual acuity evaluation is 20/20; findings of 20/40 or greater were noted as abnormal and referred for follow-up (weber & kelley, 2014a). there have been over 1,200 vision referrals provided to the school nurse coordinators. hearing referrals the american speech-language-hearing association (n.d.) estimates that approximately 391,000 school-aged children in the united states have some form of hearing loss. early detection is necessary to minimize the potential impact in speech development, cognitive development and social development (american academy of audiology [aaa], 2011; cdc, 2016). during the healthy kids screenings, evidence based guidelines are followed in pure tone screenings at 1000, 2000, and 4000 hz to both ears (aaa, 2011), with over 130 hearing referrals having been made. children who were unable to be conditioned or failed pure tone hearing screenings received otoscopy, tympanometry, and distortion product otoacoustic emissions testing to more accurately refer for appropriate follow up. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 13 glucose referrals according to the american diabetes association ([ada], 2016a), nearly 30 million people in the united states, including children, were living with diabetes in 2012 and 1.4 million more americans are diagnosed each year. among school-aged children, diabetes is one of the most common diseases encountered (national diabetes education program [ndep], 2014; imperatore et al., 2012). since comorbidities such as hypertension and obesity may accompany diabetes (ada, 2016a, 2016b; kelly et al., 2013; ndep, 2014; usdhhs-nih-nhlbi, 2005), a comprehensive healthy kids evaluation may reveal significant findings. non-fasting blood glucose levels were obtained via finger stick and results were recorded on the health assessment form. referral criterion was based on ada (2016b) guidelines and hockenberry and wilson’s (2009) pediatric recommendations. over 300 abnormal blood glucose levels have been reported through the healthy kids program. vital sign/assessment referrals a brief head-to-toe examination included temperature, heart rate, respirations, blood pressure, and auscultation of heart and lung sounds. oral temperatures were obtained from digital thermometers. heart rate and respirations were manually calculated. blood pressure readings were obtained with appropriate sized pediatric or adult cuffs and manual sphygmomanometers. questionable readings were verified by nursing faculty. evaluation of vital sign readings were based on hockenberry and wilson’s (2009) pediatric referral criterion. more than 450 abnormal findings of vital signs or assessment results have been reported to the school nurse coordinators. other referrals included within the head-to-toe examination was a visual inspection of the scalp and skin for the presence of pediculosis capitis (head lice), acanthosis nigracans, and tinea corporis online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 14 (ringworm). though not a serious health issue, head lice is easily transmittable from person to person or from contact with infested objects such as combs, brushes, or hats thus necessitating screenings within the school setting (mckinney, james, murray, nelson, & ashwill, 2013; turner, 2014). acanthosis nigracans is a dermatological condition that most often affects body folds and creases such as the neck, armpits, and groin with the skin becoming darkened and thickened, having a velvety texture (mayo foundation for medical education and research, 2016). its presence has been associated with diabetes and indicates a referral for further follow up (american academy of dermatology, 2016; weber & kelley, 2014b). tinea corporis is a fungal infection commonly found on the trunk, face, and extremities. it can be transmitted by person to person contact or by contact with contaminated items and requires medical treatment (mckinney, et al., 2013). over 60 referrals for the above referenced findings have been made to the school nurse coordinators. conclusion community partnerships have become vital to all areas of healthcare delivery. the healthy kids outreach project serves the community by improving the overall health of public school students in rural counties of alabama. by intervening early, healthy behaviors can be learned and the prevalence of adult health issues such as hypertension, cardiovascular disease, obesity, and diabetes can be decreased. it also will continue to solidify a community-academic partnership by allowing collegiate faculty to serve as a resource to the alabama department of education, the individual school nurses, and the personnel of each public school. this interprofessional, community based, service-learning endeavor benefits underserved public school children, provides much needed assistance to public school nurses, assists undergraduate health sciences students in experiential activities, and promotes strategies of population-based healthcare. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 15 the number of referrals, along with stakeholder requests, warrant continued participation in the healthy kids evaluations. over 3,400 referrals have been made in lowndes and elmore counties with approximately 43% of school children identified as being at risk for health issues. as the school nurses provide follow-up attention to these identified health concerns, the overall health status of school children is improved; thereby improving the overall health of the rural populations in which they reside. future studies documenting longitudinal data will allow for ongoing assessments of the health status among children residing in rural communities. innovative approaches to rural healthcare, such as healthy kids, could be replicated to address the continuing challenges of vulnerable populations and to positively impact healthcare delivery systems. additional collaborations among disciplines and communities should be explored to continue the application of evidence-based practice interventions in disease prevention and health promotion. finally, hundreds of health professional students have been impacted by the healthy kids screenings. they enjoy seeing faculty “in action” in the clinical area. the faculty members become part of the healthcare team as active learning takes place within the community. in addition, health professional students from three distinct disciplines work together in teams to assess the children, teach health principles and address health issues among rural communities. the collaboration of students fosters a sense of teamwork that will follow the students into the workplace after graduation. the ultimate result will be healthcare professionals who collaborate more effectively in meeting the healthcare needs of diverse populations. acknowledgements office of research and sponsored programs at auburn university montgomery online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.432 16 references alabama department of public health. 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(2016). the spectrum of care. in d.b. nash, r.j. fabius, j.l. clarke, a. skoufalos, m.r. & horowitz, (eds.). population health: creating a culture of wellness (2nd ed., pp. 19-41). burlington, ms: jones & bartlett learning. turner, l.p. (2014). the nurse in the schools. in m. stanhope & j. lancaster, j. (eds.), foundations of nursing in the community: community-oriented practice (4th ed., pp. 566584). st. louis, mo: elsevier. united states department of health and human services, national institutes of health, national heart, lung, and blood institute. (2005). the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents (nih publication no. 05-5267). retrieved from https://www.nhlbi.nih.gov/files/docs/resources/heart/hbp_ped.pdf united states census bureau. (2015a). quickfacts: lowndes county, alabama. retrieved from http://www.census.gov/quickfacts/ united states census bureau. 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(2005). preventing chronic diseases: a vital investment. retrieved from http://www.who.int/chp/chronic_disease_report/full_report.pdf online journal of rural nursing and health care, 1(3) 6 editorial rural practice forum: mental health services for adolescents bette ide, phd, rn, editorial board member joanne thompson, m.s., rn, a school nurse in roseau, mn, discusses the urgent problem of mental health services for adolescents in rural areas and gives suggestions for ways the rural nurse can deal with them. the acceptability and availability of mental health services for the adolescent population is at crisis levels in northern minnesota and north dakota. adolescents in rural areas face isolation and loneliness, poor access to transportation, and increased economic conflicts (unemployment, divorce, poor housing, and poor nutrition), and lack of specialized mental health services. adolescents in rural areas might respond by increased ‘escape’ risk taking behaviors of alcohol and/or drug abuse and sexual activity. resiliency research has provided some cues to improve future orientation, active skill acquisitions, and positive risk taking behaviors. professionals can assist by always seeking the positive behaviors and reinforcing whenever possible. mentors are critical for all adolescents. most adolescents make excellent mentors themselves if structured to enhance their positive attributes. communities (especially faith communities) can foster resiliency by providing activities with responsible adult supervision. transportation is an issue with the isolated adolescent. activities should be geared to immediately after school or church so transportation is only one occurrence. youth directors or parish workers would increase attendance if transportation is provided. schools need to provide opportunities for transitions to work or post-secondary endeavors. schools also need to offer a variety of activities for non-competitive activities. online journal of rural nursing and health care, 1(3) 7 medical clinics need to provide assessment for mental health with adolescent contacts. opportunities for counseling need to be available. child mental health resources are “few and far between”. an appointment for mental health assessment may involve a 120-mile drive, which means a day without employment for parents. professionals need to be sensitive to distance and attempt to have follow-up via phone or electronic communication. education professionals need to consider a mental health screening when formal assessments are performed for attention deficit disorder and when behavioral indicators point in that direction. school social workers need to be aware of the local resources. all too often, parents dismiss the symptoms of depression as a ‘phase’ or ‘hormones’. school personnel need to advocate for students when appropriate. nurses in the public sector are excellent resources for adolescents. nurses ‘see the whole picture’ of adolescent, family, and community. nurses also need to explore the concept of resiliency for practical applications. adolescents need to be saturated with caring adults. opportunities of “required volunteerism”, mentoring relationships, realistic short and long term goal setting, empowerment of parents, proactive skill building activities (especially refusal skills), consciousness raising community programming, are just a few of options that nurses can initiate or facilitate. for further information, email me at bette_ide@mail.und.nodak.edu. online journal of rural nursing and health care, 1(2) 7 editorial administrative insights: building a strong profession beth roder, ma, rn, editorial board member each nurse, wherever the work may be located, is building a strong tower for health care. many years, many nurses, and through many types of government control, nurses have carried on the work of service and caring to those entrusted to our care. this era, perhaps more than any other we need to build together. we need one another to stand tall as towers for people who are not able to stand for themselves, whatever the reason may be. as i consider how this figurative tower is built i ponder the way each of us build our professional towers. some have laid a strong foundation, having made nursing a choice at a very young age. the foundation has been laid carefully through planning and hard work as education is pursued. others have chosen nursing, but only for a short time, until the role doesn’t fit the life plan that is preferred. the foundation was never quite as secure or able to stand the tests of time. as you are building your tower what elements have you included in the structure. is there a window to let sunlight into your soul when the dark night of sorrow, loss, and despair overcome your spirit? it is important that we let that light shine out as well as into the tower. it is only as you have been illuminated that your light can shine forth. that light may be offering compassion, nursing skills executed with love, or your presence. there is great healing and solace for patients when your presence; body, mind, and spirit are with people. online journal of rural nursing and health care, 1(2) 8 the structure and its material elements such as taking care of yourself to maintain the strength that is needed daily will be a way for these strong towers to stand. the onslaught of managed care, decreasing medicare funding, an aging population, threaten all of us. productivity levels demand more work with less help. each of us is faced with ethical dilemmas as we endeavor to provide the best care possible. but nurses have always held out a torch to lead the way. stand proud and stand tall as we move forward with the changes in health care. help create the change in whatever way you can, in whatever area you work, and where ever you may live. you, as a strong tower stand as a bulwark in the changing times of providing holistic health care. your comments are encouraged. please e-mail me at b_roder10@yahoo.com. microsoft word marthawilliams_51-1288-1-ed.doc journal of rural nursing and health care, 12(2) 3 rural professional isolation: an integrative review martha a. williams, ms, rn, nea-bc, phd student assistant vice president nursing, arnot ogsen medical center; phd student, binghamton university, rural nursing, mwilliams@aomc.org abstract background: chronic nursing shortages have plagued rural communities for many years. it is therefore important to highlight the specific challenges confronting rural areas in regards to recruiting and retaining nurses. one challenging factor associated with recruitment and retention of rural nurses is professional isolation. purpose: this paper reports the findings of an integrative review conducted to analyze and critique recent empirical and theoretical literature on the concept of rural professional isolation. the author explores the ways in which professional isolation has been considered in the multidisciplinary health and nursing literature. methods: a cross-search of three nursing and social science databases located 26 papers, the majority published between 2000 and 2010. in addition, several classic articles dating back to 1989 were included. the articles focused on various aspects of professional isolation in nursing, medical, and allied health literature. whittemore and knafl’s integrative review method guided the analysis. a narrative description of findings and synthesis of data was performed. results: professional isolation appeared in the literature in numerous contexts. as it relates to rural nursing, the concept has often been cited, but remains poorly described. conclusion: professional isolation may be geographic (a distance from), social (a lack of contact with), or ideological (out casted from). however, most of the literature reviewed relates to the geographic or the social aspects of the concept. electronic communication and information technology hold great potential for reducing professional isolation of nurses who practice in rural areas. keywords: integrative review, professional isolation, rural nursing rural professional isolation: an integrative review failure to recruit and retain talented nurses in rural settings is a major concern across north america and abroad (roberge, 2009). to combat this phenomenon, it is vital that we understand the factors that lead to successful retention of rural nurses, and the prevention of high vacancy rates among them. reasons given for shortages and vacancies across rural settings generally relate to the unique boundaries and dimensions of rural nurse practice, but a better understanding of the specific constraints confronting rural nurses is needed (bushy, 2002, 2004). professional isolation (pi) has specifically been cited as an inhibitor to the recruitment and retention of nurses in rural areas; yet even amidst increasing rural nursing literature in the last decade, relatively little has been published about the concept (brown, williams, & capra, 2010; bushy, 2002; stewart & carpenter, 2009; taylor & lee, 2005). this paper is a report of an integrative literature review conducted to summarize and critique the recent empirical and theoretical literature related to pi, and to describe the nature of pi from a rural perspective. a journal of rural nursing and health care, 12(2) 4 better understanding of the concept will assist the nursing community in theory development, and it will have direct applicability to rural nursing practice and policy. the review the purpose of this integrative review is to analyze, critique, and synthesize the recent body of literature on the topic of pi, focusing on the rural aspect. nursing, allied health, and medical literature are included in the review. the author will describe the various ways in which the term is considered in the multidisciplinary and nursing literature. the integrative review has been identified as a robust tool for synthesizing available literature on a given topic. this approach combines data from theoretical and empirical literature, and allows for a full understanding of the topic under investigation (de sousa, da silva, & de carvalho, 2010). whittemore and knafl’s (2005) revised integrative review method guided the author in the identification of published literature related to pi. the design focused primarily on research and theoretical literature in the areas of nursing, allied health, and medicine. search methods to identify the body of relevant literature available on the concept of rural pi, the author performed a cross-search of cinahl, medline, and academic search complete using a combination of the keywords “professional isolation” in title or abstract and “rural” in abstract. the search was designed to expose a large number of results as well as the earliest literature on the concept. therefore, no time limit was applied to the initial search. articles discussing pi in both rural and urban settings were considered. search outcome this approach yielded 222 results from various domains. references were examined in an effort to capture any missing articles authored by rural scholars thought to contribute to the review. this technique produced ten additional articles. next, the search was limited to scholarly (peer reviewed) articles in source type periodicals; this yielded 83 results after duplicates were eliminated. development of inclusion criteria facilitated the final selection of relevant references. articles containing relevant discussions of the concept of pi or any discussion of models or frameworks applied to the pi were considered. any studies that attempted to address pi including quantitative, qualitative, and mixed-method research studies were considered. only articles in english from 2000 to the present were included, unless they were considered classic or seminal articles. studies discussing the concept of pi in disciplines other than nursing were considered to investigate whether or not the concept was described similarly across disciplines. lastly, any piece of writing that specifically mentioned any of the long and weinert (1989) key concepts relevant to the provision of care by rural health care providers was included to assure that the rural perspective was captured. articles were not included in the literature review if their discussion focused specifically on disease or disease management, or isolation experienced by rural residents. any definition of pi was accepted because there is no general agreement on a single definition. any definition of rural was accepted for the same reason. no restriction was placed on geographical regions or place of origin of the article. the final selection included a combination of mixed method, quantitative, qualitative, theoretical, commentary, and reports for a total of 26 articles for review; twenty research and six non-research articles. journal of rural nursing and health care, 12(2) 5 quality appraisal the twenty research articles were then systematically critiqued using the evaluative criteria set forth by fineout-overholt, melnyk, stillwell, and williamson (2010) for quantitative research, or cesario, morin, and santa-donato (2002) for qualitative research. each research study was evaluated for scientific merit, and scored for its level of evidence. the six nonresearch articles were critiqued, and categorized as level vii, or expert opinion. upon completion of the evaluative reviews, all data were entered onto the literature comparison chart (appendix a). though some articles were more robust than others, all had merit, and none were excluded based on methodological quality. data abstraction and synthesis the 26 studies were synthesized under the following subheadings: (a) author/year, (b) definition of rural, (c) definition of pi, (d) design (e) purpose (f) sample, (g) quality score/level of evidence, and (h) findings/conclusions. results publications/clinical domain the reviewed articles were first sorted by publication to identify those journals that published the most articles on the topic. the online journal of rural nursing and health care generated three articles, (conger & plager, 2008; lee & winters, 2004; o’lynn et al., 2009). two publications generated two articles each, australian journal of rural health, (bushy, 2002; rosenberg & canning, 2004), and scholarly inquiry for nursing practice (long & weinert, 1989, 1999). all other publications produced only single articles for inclusion in the final review. the articles were then grouped by clinical domain. those represented were: nursing, 15; medicine, 4; rehabilitation services, 3; nutritional services, 1; mental health, 1; and clinical informatics, 2. geographical distribution the studies originated from united states, 9; canada, 1, australia, 9; united kingdom, 6; and sweden, 1. twenty two articles were specific to rural areas; three described an urban aspect of pi, and only one compared results across both settings. the greater emphasis on rural was an expected finding, and suggests that pi is more commonly reported in rural settings. study designs nine qualitative studies were reviewed: (conger & plager, 2008; courtney & farnworth, 2003; gibb, 2003; gibson & heartfield, 2005; helitzer, heath, maltrud, sullivan, & alverson, 2003; kohlwes, koepsell, rhodes, & pearlman, 2001; lee & winters, 2004; stewart & carpenter, 2009; vimarlund, olve, scandurra, & koch, 2011). of these, the sample sizes ranged from n = 2 to n = 137, and were nursing, medical, or rehabilitation service oriented. all of the studies reported a greater than 95% female subject group, with one exception. gibb (2003) reported a 50% male subject group; however, the sample size was small (n = 5). eight quantitative studies were reviewed: (bowers-ingram & nelson, 2009; kemp, zuckerman, & finlayson, 2008; kurzydlo, casson, & shumack, 2005; o’donnell, jabareen, & watt, 2010; o’lynn et al., 2009; rosenberg & canning, 2004; st. george, 2006; taylor & lee, 2005). all of the quantitative study designs were non-experimental; seven out of eight scored level of evidence vi. only one quantitative study scored level v. kemp et al. (2008) conducted a journal of rural nursing and health care, 12(2) 6 retrospective descriptive comparison of the adoption rate of laparoscopic technique for performing cholecystectomy in small rural versus urban hospitals from 1988 to 1997. the data (n = 4,302,456) was synthesized to answer whether pi was an obstacle in the dissemination of the laparoscopic technique. of the quantitative studies, sample sizes ranged from n = 26 to n = 4,302,456, and those authors who described gender reported > 92% female. three of the research articles reviewed were mixed-method studies: (bedward & daniels, 2005; brown et al., 2010; chapman et al., 2004). of these, bedward and daniels (2005) detailed the development of clinical supervision at several pilot sites. the study scored 20/24 for quantitative, and 22/30 for qualitative. the study had a large sample size, and was the only study to be conducted in two phases (n = 104 in 1999, and n = 95 in 2000). the study was enhanced by collaboration between the school of education and the health trust which made it unique. the authors however, did not report the gender of the study participants. the brown et al. (2010) article was unique in that it was the only article to discuss pi in the context of rural dieticians. the study also possessed merit, scoring 18/24 quantitative, and 20/30 qualitative. the authors described both positive and negative characteristics of a rural role. this study reported a sample size of 140; 98% female. chapman, et al., (2004) scored 17/24 quantitatively, and 18/30 qualitatively. the study was one of the older studies reviewed, making its literature review older as well. a convenience sample was used, and individuals who may not have been specialists may have responded, potentially confounding the results. the sample size was large, 449; gender was not reported. the remaining non-research literature was either theoretical, report, or commentary. each of the three theoretical pieces were classics, and therefore extremely important to this review (lee & winters, 2004; long & weinert, 1989; 1999). the two non-research reports written by well-known rural author angeline bushy (2002; 2004), are important in this discussion because they examine and expand on rural phenomenon in greater depth than is available in previous literature. lewkonia’s (2001) article is the only commentary to be reviewed. it is noteworthy because (a) it is one of only two articles that relate pi to incompetence; the other is courtney and farnworth (2003), and (b) it is the only article to mention a measurement tool to quantify pi, the “social disengagement scale” (lewkonia, 2001, p. 528). defining rural in their classic work on rural nursing, long and weinert (1989) defined rural nursing as “the provision of health care by professional nurses to persons living in sparsely populated areas” (p. 114). it is widely recognized that researchers and policy-makers may apply numerous definitions to the term rural. in the context of this review, any definition of rural was accepted, since there is no universally agreed upon designation. however, unique elements of rural life must be clearly understood by those providing health care to people residing in rural communities. of the 22 articles specific to rural settings, only six of the articles defined rural in precise terms. of these, kemp et al. (2008) described rural in terms of ruca codes; kurzydlo et al. (2005) used the australian definition of rural remote metropolitan areas (rrma); lee and winters, (2004) defined rural as communities less than 1,300 persons; o’lynn et al. (2009) applied the usda 2007 definition; and rosenberg and canning (2004) applied australian health care zones to define rural. the remaining 16 rural-based articles all stated that they were carried out in rural areas, but only provided a narrative description of the term. those descriptive phrases included for example, long and weinert’s (1989) “sparsely populated areas” and “working outside of an urban center” (taylor & lee, 2005). in the studies that did not define the journal of rural nursing and health care, 12(2) 7 term rural, one could usually conclude that the study was carried out in a rural area based on the study’s demographics. a more precise definition of the term is an area of needed improvement. defining professional isolation two articles stood out with respect to defining pi. the first, long and weinert (1989), is significant because it contains the earliest mention of pi from a rural nursing perspective. in their seminal article, the authors describe emerging themes and generated three relational statements from their qualitative data. it is the third relational statement that deals with rural care givers; their lack of anonymity, isolation from professional peers, and sense of role diffusion (long & weinert, 1989, p. 120). however in 1989, the concept was presented as an emerging theme, and a precise definition of pi was not given. a second important article by shreffler (1998) provides more clarity to the meaning of the term than any other piece of literature reviewed. the concept analysis provides dictionary definitions, and summarizes the uses of pi from a rural point of view. the author uses the walker and avant method (as cited in shreffler, 1998) of concept analysis. attributes are summarized, and model, borderline, and contrary cases are proposed. also presented are antecedents, consequences, and empirical referents. these two pieces of work are essential for anyone seeking to fully understand the concept of rural pi. within the remaining body of literature examined, pi was usually portrayed in a negative sense; a lack of some needed resource, or a distance from some needed person, place, or thing. bedward and daniels (2005) described pi in a social context of feeling unsupported, lacking opportunity, and not being recognized or praised for achievements. in a similar way, chapman et al. (2005) used the terms job pressure and feeling undervalued to describe pi. a few authors described pi in the context of being distanced from peer support (bedward & daniels, 2005; brown, williams, & capra, 2010; bushy, 2004; courtney & farnworth, 2003; kohlwes, et al., 2001; kurzydlo, casson, & shumack, 2005; lewkonia, 2001; long & weinert, 1989; o’donnell et al., 2010; o’lynn et al., 2009; st. george, 2006; stewart & carpenter, 2009). others described pi in the context of lacking communication (bowers-ingram & nelson, 2009; bushy, 2002; conger & plager, 2006; vimarlund et al., 2011; taylor & lee, 2005), or lacking proctorship or mentorship (conger & plager, 2006; cumbie, weinert, luparell, conley, & smith, 2005; kemp, zuckerman, & finlayson, 2008; o’lynn et al., 2009; rosenberg & canning, 2004; stewart & carpenter, 2009). the term was often cited as a contributor to inadequate recruitment and retention, or higher than average vacancy rates (brown et al., 2010; bushy, 2002; stewart & carpenter, 2009; taylor & lee, 2005). many authors specifically mentioned a geographic disadvantage (cumbie et al., 2005; gibb, 2003; gibson & heartfield, 2005; kemp et al., 2008; lewkonia, 2001; o’donnell et al., 2010; rosenberg & canning, 2004; st. george, 2006; stewart & carpenter, 2009; taylor & lee, 2005; vimarlund et al., 2011). many articles described specific methods to reduce pi. these included provision of clinical supervision (bedward & daniels, 2005); creating nursing research opportunities (bushy, 2004); development of support groups (cumbie et al., 2005); use of telehealth (helitzer et al., 2003); use of interactive cd-rom (kurzydlo et al., 2005); e-mentoring, i-chat, and e-mail (stewart & carpenter, 2009); and use of information and communication technology (taylor & lee, 2005). one article described a new and emerging theme related to pi; conger and plager’s (2008) article is unique in describing “rural connectedness versus disconnectedness” as it relates to geographic, social, and professional isolation. another unique perspective was offered by kohlwes et al., (2005). their article dealt with physicians’ responses to requests for physicianassisted suicide. the authors described a sort of ideological pi whereby those who participated in journal of rural nursing and health care, 12(2) 8 this unconventional practice were in essence shut off from others by a professional “code of silence” (p.657). discussion in this integrative literature review, 20 research and 6 non-research articles discussing various aspects of pi, both rural and non-rural were reviewed. the focus of the review was to understand what has been written about pi from a rural perspective. a number of themes emerged from the literature, including characteristics and implications of rural pi. the rural nursing and rural medicine professions dominated the literature, with literature from north america and australia prevailing. inherent in the nature of rural pi is the notion of being distanced from some aspect of the profession, either from peers, technology, larger centers, or education. another aspect relevant to rural pi included the idea of working alone; this was characterized by sole or solo practitioners, working in smaller teams, or working in non-urban locations. some writers indicated that the consequences of rural pi could be either positive or negative, depending on the context. for example, familiarity could be positive when the practitioner had close knowledge of the patient and family, leading to well-informed care. it could also have negative effects if either the practitioner or the patient possessed sensitive information about the other that neither wished to share. more frequently however, rural pi was described as a barrier to recruitment, retention, or competence. rural pi was further described as a lack of some element necessary to complete the professional role, such as peer support, mentorship, proctorship, continuing education, or technology, coupled with the practitioner’s perception that the necessary element was missing in his or her professional life. finally, in terms of reducing the ill effects of rural pi, writers often identified communication and information technology as means to reduce pi thus improving recruitment and retention issues. the literature illustrates a sudden increase of information technology in recent years, which holds great promise in combating rural pi. telemedicine, internet, e-learning, online coursework, i-cat and e-mail with professional mentors and peers, has only recently begun to appear in the literature. there were several limitations to this literature review. the depth of pi research in rural health care settings is limited. that which does exist is plagued with imprecise definitions. the existing literature does however add credence to the notion that rural health care environments are unique from their urban and suburban counterparts. the general findings from this literature review are not conclusive due to the small number of articles examined. a thorough and comprehensive review of all sources is greatly needed. other limitations of this review may be attributed to the design and quality of the assessment tools. the interpretative nature of this review involved subjectivity, therefore reliability of the scoring may be questionable. finally, there is a need for further research to complete a more in-depth picture of rural pi. references bedward, j., & daniels, h. r. (2005). collaborative solutions clinical supervision and teacher support teams: reducing professional isolation through effective peer support. learning in health and social care, 4, 53-66. bowers-ingram, l., & nelson, m. r. (2009). surveying general practice nurses’ communication preferences in tasmania. australian journal of advanced nursing, 27, 59-65. brown, l., williams, l., & capra, s. (2010). going rural but not staying long: recruitment and retention issues for the rural dietetic workforce. nutrition and dietetics, 67, 294-302. journal of rural nursing and health care, 12(2) 9 bushy, a. (2002). international perspectives of rural nursing. australian journal of rural health, 10, 104-111. [medline] bushy, a. (2004). creating nursing research opportunities in rural healthcare facilities. journal of nursing care quality, 19, 162-168. [medline] cesario, s., morin, k., & santa-donato, a. (2002). evaluating the level of evidence of qualitative research. journal of obstetric, gynecologic, & neonatal nursing, 31, 708-714. [medline] chapman, j., shaw, s., congdon, p., carter, y. h., abbott, s., & petchey, r. (2004). specialist public health capacity in england: working in the new primary care organizations. public health, 119, 22-31. [medline] conger, m. m., & plager, k. a. (2008). advanced nursing practice in rural areas: connectedness| versus disconnectedness. online journal of rural nursing and health care, 8, 24-38. courtney, m., & farnworth, l. (2003). professional competence for private practitioners in occupational therapy. australian occupational therapy journal, 50, 234-243. cumbie, s., weinert, c., luparell, s., conley, v., & smith, j. (2005). developing a scholarship community. journal of nursing scholarship, 289-293. [medline] de sousa, m. t., da silva, m. d., & de carvalho, r. (2010). integrative review: what is it? how to do it? einstein, 8, 102-106. fineout-overholt, e., melnyk, b. m., stillwell, s. b., & williamson, k. m. (2010). critical appraisal of the evidence: part i. american journal of nursing, 110, 47-52. [medline] gibb, h. (2003). rural community mental health nursing: a grounded theory approach of sole practice. international journal of mental health nursing, 12, 243-250. [medline] gibson, t., & heartfield, m. (2005). mentoring for nurses in general practice. journal of interprofessional care, 19, 50-62. [medline] helitzer, d., heath, d., maltrud, k., sullivan, e., & alverson, d. (2003). assessing or predicting adoption of telehealth using the diffusion of innovations theory: a practical example from a rural program in new mexico. telemedicine journal and e-health, 9, 179-187. [medline] kemp, j., zuckerman, r. s., & finlayson, s. (2008). trends in adoption of laparoscopic cholecystectomy in rural versus urban hospitals. journal american college of surgeons, 206, 28-32. [medline] kohlwes, r., koepsell, t. d., rhodes, l. a., & pearlman, r. a. (2001). physicians’ responses to patients’ requests for physician-assisted suicide. archives of internal medicine, 161, 657663. [medline] kurzydlo, a., casson, c., & shumack, s. (2005). reducing professional isolation: support scheme for rural specialists. australasian journal of dermatology, 46, 242-245. lee, h. j., & winters, c. a. (2004). testing rural nursing theory: perceptions and needs of service providers. online journal of rural nursing and health care, 4, 51-63. lewkonia, r. (2001). educational implications of practice isolation. medical education, 35, 528529. [medline] long, k. a., & weinert, c. (1989). rural nursing: developing the theory base. scholarly inquiry for nursing practice, 3, 113-127. [medline] long, k. a., & weinert, c. (1999). rural nursing: developing the theory base.including commentary by nichols e with author response. originally printed in scholarly inquiry for http://www.ncbi.nlm.nih.gov/pubmed/12047505 http://www.ncbi.nlm.nih.gov/pubmed/14750924 http://www.ncbi.nlm.nih.gov/pubmed/15077834 http://www.ncbi.nlm.nih.gov/pubmed/12465867 http://www.ncbi.nlm.nih.gov/pubmed/15560898 http://www.ncbi.nlm.nih.gov/pubmed/20574204 http://www.ncbi.nlm.nih.gov/pubmed/16235872 http://www.ncbi.nlm.nih.gov/pubmed/15842080 http://www.ncbi.nlm.nih.gov/pubmed/12855040 http://www.ncbi.nlm.nih.gov/pubmed/18155565 http://www.ncbi.nlm.nih.gov/pubmed/11231697 http://www.ncbi.nlm.nih.gov/pubmed/11380853 http://www.ncbi.nlm.nih.gov/pubmed/2772454 journal of rural nursing and health care, 12(2) 10 nursing practice, vol. 3, no. 2, summer, 1989, pp. 113-127. scholarly inquiry for nursing practice, 3, 257-279. o’donnell, c. a., jabareen, h., & watt, g. (2010). practice nurses’ workload, career intentions and the impact of professional isolation: a cross-sectional survey. biomed central, 9(2), 110. [medline] o’lynn, c., luparell, s., winters, c. a., shreffler-grant, j., lee, h. j., & hendricks, l. (2009). rural nurses’ research use. online journal of rural nursing and health care, 9, 34-45. roberge, c. m. (2009). who stays in rural nursing practice? an international review of the literature on factors influencing rural nurse retention. online journal of rural nursing and health care, 9, 82-93. retrieved from http://www.rno.org rosenberg, j. p., & canning, d. f. (2004). palliative care nurses in rural and remote practice. australian journal of rural health, 12, 166-171. [medline] shreffler, m. j. (1998). professional isolation: a concept analysis. in h. j. lee (ed.), conceptual basis for rural nursing (pp. 420-432). new york: springer. st. george, i. m. (2006). professional isolation and performance assessment in new zealand. the journal of continuing education in the health professions, 26, 216-221. [medline] stewart, s., & carpenter, c. (2009). electronic mentoring: an innovative approach to providing clinical support. international journal of therapy and rehabilitation, 16, 199-206. taylor, r., & lee, h. (2005). occupational therapists’ perception of usage of information and communication technology (ict) in western australia and the association of availability of ict on recruitment and retention of therapists working in rural areas. australian occupational therapy journal, 52, 51-56. vimarlund, v., olve, n., scandurra, i., & koch, s. (2011). organizational effects of information and communication technology (ict) in elderly homecare: a case study. health informatics journal, 14, 195-210. [medline] whittemore, r., & knafl, k. (2005). the integrative review: updated methodology. journal of advanced nursing, 52, 546-553. [medline] http://www.ncbi.nlm.nih.gov/pubmed/20205777 http://www.ncbi.nlm.nih.gov/pubmed/15315546 http://www.ncbi.nlm.nih.gov/pubmed/15315546 http://www.ncbi.nlm.nih.gov/pubmed/18775826 http://www.ncbi.nlm.nih.gov/pubmed/16268861 online journal of rural nursing and health care, 2(2) 54 perspectives of the ideal assisted living facilities from depression era nurses jason bischoff, rn, bsn kelly timmer, rn, bsn cindy walton, rn, bsn connie white, rn, bsn karen zulkowski, dns, rn, cws1 1 assistant professor, college of nursing, montana state university, karenz@montana.edu* * corresponding author abstract the diversity of the elderly combined with a prolonged life span means their response to changing care and health is varied. today’s elderly population prefers to stay in their own homes. however, as their health declines they become more dependent. their choice of housing is influenced by age, need for assistance, availability of their children, health care providers, services and facilities. one type of housing choice that has recently become popular for elderly persons is assisted living facilities. little is known about how the rural elderly view what is important in an assisted living setting. the purpose of this qualitative study was to determine qualities of a senior living facility that retired rural elderly nurses would include in their vision of the optimal assisted living accommodations. common themes that emerged were social environment, health and health care, diet and nutrition, exercise and recreation, social systems, and physical environment. keywords: assisted living, rural elderly, health care, elderly housing online journal of rural nursing and health care, 2(2) 55 perspectives of the ideal assisted living facilities from depression era nurses the elderly population in the united states is a diverse group of individuals. each person regardless of their age, gender, race, or ethnic group has distinctive characteristics, and the experience of aging is different for everyone. residing in a rural area may result in characteristics and needs for elderly persons that are different from their urban counterparts. (hobbs & damon 1996). the growth of the population of 65 year olds and older has affected every aspect of society. (stanford 1994, in hobbs & damon, 1996). this creates challenges as well as opportunities for families, health care providers, policy makers, and businesses (federal interagency forum of aging-related statistics— population 2000, p. 1). the diversity of the elderly themselves combined with a prolonged life span means their response to changing care and health is varied. today’s elderly population prefers to stay in their own homes. however, as their health declines they become more dependent. the choice of housing by the elderly is influenced primarily by age, the need for assistance, and the availability of their children, health care providers, services and facilities. location, race and/or ethnicity and marital status also influence decision-making (joint center for housing studies, n.d.). assisted living communities provide some service or assistance to the residents. continuing care communities, a type of assisted living, offer a wide range of services and accommodations for the elderly. continuing care communities are commonly found in metropolitan areas and the residents tend to be over 85 years of age without children living nearby. eighty percent of the communities have a modest size residence with three or less rooms. this living arrangement is more likely to be chosen by the elderly when their household lacks a driver, or they have difficulty climbing stairs (joint center for housing studies, n.d.; u.s. department of commerce, 1995). as the older population becomes larger and more diverse, online journal of rural nursing and health care, 2(2) 56 over the next 50 years programs and services for the elderly will require more flexibility to meet the demands of this changing population (federal interagency forum of aging-related statistics—population 2000, p. 2). problem as the population ages they experience more chronic illnesses or conditions such as diabetes, congestive heart failure and dementia. these conditions contribute to the decreased ability of individuals to perform activities of daily living without assistance and often result in the elderly needing to live in an assisted living or nursing home setting. little is known about how the rural elderly themselves view what is important in an assisted living setting. purpose the purpose of this study was to determine qualities of a senior living facility that retired rural elderly nurses would include in their vision of the optimal assisted living accommodations. relevant background aging population in 2000, the estimate of people aged 65 or older in the united states was 35 million which accounts for almost 13% of the total population (federal interagency forum of agingrelated statistics—population, 2000, p. 2). over the next 30 years, the number of elderly persons is expected to double to 70 million (federal interagency forum of aging-related statistics—population, 2000, p. 2). the population of 85 year olds is currently the fastest growing segment of the older population. in 2000, approximately 2 percent of the u.s. population was 85 years or older and by 2050, this is projected to increase to almost 5 percent. (federal interagency forum of aging-related statistics—population, 2000, p. 2 and u.s. department of commerce, 1995). the increased population of those greater than 85 years old is online journal of rural nursing and health care, 2(2) 57 based on the longer life span of individuals than was seen in previous generations (raymond, 2000, p. 1) and is due largely to advances in medicine, health care, hygiene, disease prevention and nutrition (joint center for housing studies, n.d.). one baby boomer in 9 is expected to live to at least age 90 (raymond, 2000, p. 1). assisted living facilities assisted living facilities date back to the board-and-care home. these facilities developed as the need arose for housing for elderly people that could not live alone but did not have a large income or a family support structure. board and care facilities provided food, shelter and assistance with activities of daily living. the facilities typically were located in large houses constructed in the 1920s and 1930s era. the houses had a large living room, dining room, kitchen and a number of bedrooms and bathrooms to accommodate residents, who commonly shared a bedroom with one other individual. this model provided a means for poor or low-income individuals to live relatively comfortably in an environment that was reminiscent of the type of home they may have been raised in (peskin, 1999). in the early 1980's a different type of assisted living housing became available. the owner/operators rehabilitated older boarding homes or constructed new housing to create a fresher, brighter environment. these new communities were usually decorated professionally and provided areas for activities, sitting, eating, and care. this low-cost model ranged from $1,200 to $1,500 per month (peskin, 1999). it was not long before assisted living communities became diverse, offering a range of services and housing choices. according to an annual study, a 2000 overview of the assisted living industry, today’s assisted living facilities report an average daily room rate of $73.97 in 1999, the highest rate recorded in the survey’s history. prices ranged from a minimum of $39.47 to a maximum of online journal of rural nursing and health care, 2(2) 58 $206.11, with a median room rate of $69.83 daily. the study also indicated that residents in assisted living facilities had an average age of 83, were 75% females and required help with three activities of daily living (blankenheim, 2000, p. 1-2). design this is a qualitative study designed to examine what elderly nurses feel is optimal in an assisted living facility. participants were females, age 70 or older, living in montana, and who previously worked as registered nurses. four individuals were selected and unstructured interviews were conducted using a pre-selected open-ended question with prompts to elicit additional information. data were collected through face-to-face interviews and transcribed verbatim. additional information used by the investigators was participant observation and field notes. the data were then read and reread by all four researchers and coded to select emergent themes. sample four participants were selected based on the criteria of being age 70 or older, living in the great falls, montana area, and previous employment as a registered nurse. procedure informed consent was obtained from each participant prior to the interview. the interviews ranged in time from approximately 45 minutes to one hour. all four of the interviews were in person. one interview was conducted at a coffee shop and one interview was conducted on the great falls campus. two of the interviews took place at the subject’s home. the interview consisted of one pre-selected open-ended question and specific probes were used as needed. a medical transcriptionist transcribed the data from two of the interviews. the other online journal of rural nursing and health care, 2(2) 59 two interviews were transcribed by one of the researchers. the data were then reviewed and coded. as the researchers refined the coding process, themes emerged from the data. analysis of data common characteristics of the participants emerged. these characteristics may be related to aspects of rural dwellers and/or may be related to their occupation as registered nurses, as well as other factors. these characteristics included hardiness, independent, thrifty, resourceful and prudent. all of the participants had the desire to live in a rural area with access to nature, and natural light. additional common themes that emerged were categorized under the identified aspects of the conceptual model. however, some of the categories were blended rather than separate and distinct social environment. identified concepts include independence, choices, personal appearance, pets, lifelong learners, and a common area for socializing with friends and family that come to visit. personal appearance was included in the statement made by participant 03 who said: oh, the hairdressers, for women i think, are very important. they should be available and available close by on the premises or else they should be taken there. participant 02 said this about pets: i would like to have my sister bring my dog out once in a while... i do obviously like animals, and if they had a community pet, why as a lot of the nursing homes do, they are finding out that if they have a resident dog, that it makes a lot of difference to people. participants were identified as lifetime learners. all were concerned with mental stimulation specifically referred to as brain exercise by participant 03. she said: online journal of rural nursing and health care, 2(2) 60 i think people should exercise their brain...there’s certain games they can play. even though i don’t play cards, there are card games you can play. crossword puzzles are supposed to be excellent. many times the elderly have problems with reading, but it’s a good exercise too. there are also certain television shows you know that would exercise your brain a little too. i think too, that when you put people together and socialize, that helps exercise your brain. people can’t always do physical exercise because of their disabilities, but they can always exercise their brain. participant 03 said: i think too, in visiting with your family, you need to have a place to you know, well, whoever your support system is to visit. if you just have one room, then you would have another area that would be homey and you could take your visitors to and you could then get along better. she also stated: i think that would be nice anyway to have areas that you meet in and for the residents to do their socializing and make sure they socialize. get them, get things going you may have to push a little along the way. get them out of their room. health and health care identified concepts were physical exercise, brain exercise, nature, spirituality, holism, choices, and transportation for access to health care providers of their choice. the most preferable unstructured exercise identified was walking. structured exercise classes were also online journal of rural nursing and health care, 2(2) 61 mentioned. mental stimulation or brain exercise was extremely important to all participants. nature and spirituality were intertwined. the concept that indoors = stagnation & outdoors = stimulation were identified as concepts. the participants had a holistic view of health, and wanted to exercise the freedom of health care choices and access to specialty providers (ophthalmologist, rheumatologist, etc.). participant 04 stated: i would like, i think, to have a qualified rn or lpn on site and still use my own providers... transportation was needed by participant 02 who said: well, to get me to my doctor’s appointments... diet and nutrition all participants mentioned choices and appropriate diet for chronic disease as important. the food should also be nutritious. participant 01 said: variety; choices, options. participant 03 said: well, i have to stay on a low salt diet. it’s not my choice, but well, that’s the way it is. participant 04 stated: i am not a huge appetite person but good nutrition, the pyramid thing. online journal of rural nursing and health care, 2(2) 62 exercise and recreation walking was identified as the preferred unstructured exercise activity. participant 02 stated: i’m more into walking than anything else. it just suits me better because i tire pretty easily and i can control that a little bit better. structured exercises were also important as participant 02 pointed out: i think i would like some organized exercise because commitments get a little funny sometimes. transportation is extremely important for residents that do not have a vehicle or are unable to drive. interaction through activities inside and outside of the facility was also important. participant 02 stated: they have lots of activities in town that i would participate in if i had the opportunity. ... church activities, bible studies and things like that. transportation was also identified for access to shopping, dining & entertainment by participant 03 who stated: i suppose too, that you would have something available for transportation. something that could take you if you were able, to go to the mall or something so that you could get out a little bit. those things are important and hard to come by sometimes. mental stimulation – brain exercise was another major theme. participant 02 said: online journal of rural nursing and health care, 2(2) 63 well i love to read by i can’t (due to failing eyesight). i listen to audiotapes quite a bit. i listen to tv quite a bit. i get a good history channel and a learning channel. support systems/family/friends a family space for visitors to stay overnight on the premises was desired, though the participants preferred family and friends close by. pets were acceptable if the housing was individual and if not then a community pet was deemed more appropriate. spirituality was also a theme and participant 03 says this about spirituality: a...the one thing we see and certainly become aware of as we age, is the spiritual thing becomes more important because you’re getting to the area where you know sooner or later that it’s going to be over with. architecture & physical environment all participants preferred a rural environment. there was a desire for a spacious common area for visiting and an area for visitors to stay overnight. personal space and the room to have some of their personal items with them were mentioned. all wanted natural light, access to windows, and sun. outdoor accessfor environmental contact with nature was extremely important as well as outdoor areas for walking. participant 03 said: personally, it would be kind of nice to have some kind of a view, you know, just something you could look out of, and kind of see something in nature. and an area that you can walk around in, feel safe while you’re walking there, that could be outside as long as you could do it. it’s really important. it’s better than just sitting inside. online journal of rural nursing and health care, 2(2) 64 participant 01 stated: i would like lots of light. some place where there is a lawn, a few trees and not all concrete. i do not care for concrete. that does not appeal to me. participant 04 said: ...natural light, windows, sun,. ...gardens, walking, anything so you can be outdoors. conclusions results from this study should guide today’s health care planners in designing the assisted living facilities presently and in the future. the population of elders used in this study was raised in the depression era. therefore, they are thrifty, prudent, and resourceful. they are not dreamers and were very practical about their personal needs, while considering the needs of others at the same time. the subjects did not stop being nurses. according to participant 03: you’re part of the look after everybody sort. and you’re concerned can they really afford it?” there was talking in the third person, which revealed concern regarding others= safety, environmental needs and finances. according to participant 01: money is always a concern. they were familiar with assisted living facilities in the area because they have reached the age when they are approaching the need for assistance because of failing vision and some degree of chronic illness. there was ambivalence toward nurse practitioners. these nurses were raised in online journal of rural nursing and health care, 2(2) 65 an era when physicians were the only primary care providers. only one participant, 03, had a nurse practitioner as one of her specialty providers. we had thought that perhaps religion would be a foremost concern. however, there was no emphasis on religion, but rather indirect conversation about spirituality, which seemed to be connected to nature and the outdoors. the elderly of tomorrow will be the “baby-boomer” generation. their mindset and life experiences will be very different from today’s elderly population. the study has potential to be used with different populations of age groups as well as a random sampling of subjects. examination of the next generation of elderly could revel important differences in needs and expectations of assisted living centers. there do not appear to be similar studies about the opinions of the elderly of assisted living centers that have been completed. therefore, this is an excellent topic for further research to develop nursing knowledge and publishing the data to add to the body of nursing knowledge. however, the population size for this study was small. this study needs to be to be repeated with a larger sample size. the open-ended one-question approach may have revealed additional data if a more structured questionnaire had been developed. online journal of rural nursing and health care, 2(2) 66 references american academy of nurse practitioners. (2001). publication guidelines. blankenheim, t. (2000). report provides insight on state of the industry. mcknight's long-term care news, 21(14):35. federal interagency forum on aging-related statistics (2000). older americans 2000: key indicators of well-being: population. retrieved april 15, 2001, from http://www.agingstats.gov/chartbook2000/population.html hobbs, f., & damon, b. (1996, april). 65+ in the united states. u.s. census bureau. p23-190 current population reports: special studies. retrieved april 15, 2001, from http://www.census.gov/prod/1/pop/p23-190.html joint center for housing studies. (n.d.). housing america's seniors. harvard university. retrieved april 15, 2001, from http://www.gsd.harvard.edu/jcenter/ home%20page/research.html peskin, h. (1999). rediscover your roots. contemporary long term care, 22(9):44. raymond, j. (2000). senior living: beyond the nursing home. american demographics, 22(11):58-63. u.s. department of commerce, economics and statistics administration, bureau of the census. (1995, may). statistical brief. sixty-five plus in the united states (sb/958). retrieved april 15, 2001, from http://www.census.gov/apsd/www/statbrief/sb95_8.pdf microsoft word schulz_330-1881-1-ed3.docx online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 123 physical activity patterns in rural-residing spousal caregivers and cardiac surgery patients in the first 6 months post-surgery paula schulz, phd, rn 1 lani zimmerman, phd, rn 2 patrik johansson, md, mph 3 melody hertzog, phd 4 sue barnason, phd, rn 5 1 associate professor, college of nursing, university of nebraska medical center, pschulz@unmc.edu 2 professor, college of nursing, university of nebraska medical center, lzimmerm@unmc.edu 3 associate professor, college of public health, university of nebraska medical center, pjohansson@unmc.edu 4 assistant professor, college of nursing, university of nebraska medical center, mhertzog@unmc.edu 5 professor, college of nursing, university of nebraska medical center, sbarnaso@unmc.edu abstract background: caregivers (cgs) play a major role in cardiac surgery patients’ adoption of secondary prevention strategies. little research has examined spousal cgs activities to preserve their own health and support patients’ heart-healthy behaviors. purpose: the aims of this descriptive pilot study are to: 1) compare cardiovascular (cv) risk factors and physical activity (pa) levels and 2) examine trajectories of change in pa patterns at 3 and 6 weeks and 3 and 6 months after cardiac surgery. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 124 sample: 28 rural residing adult (> 60 years) cardiac surgery patients and their spousal cgs. methods: pa data was obtained from actigraph® accelerometers mailed to dyads at 4 time points after cardiac surgery. descriptive analyses and multivariate hierarchical modeling were used to describe and identify pa patterns. findings: the dyads were older (cg m = 68.5 ± 6.6, patient m = 70.7 ± 6 years) with primarily female cgs (92%) residing in small rural towns (n=26, 46.4%) or farm/ranch (n=16, 28.6%). cv risk factor concordance was evident particularly for hypertension (60.7%) and hypercholesterolemia (25%). cgs and patients spent the majority of time in sedentary activity. most patients (89.3%) completed cardiac rehabilitation programs and increased their mean minutes/day spent in moderate to vigorous pa over the 4 time points (13.3 ± 15.6 to 22.6 ± 24.4). however, cgs mean minutes/day remained virtually unchanged over time (15.8 ± 20.8 to 12.7 ± 11.7). considered as dyads, 38% (n=8) showed essentially no change for either member, but for 29% (n=6) the caregiver showed no change while the patient activity increased. conclusions: cgs were similar in age and comorbidities to their spouses, however, cgs were less likely to increase their pa levels. health disparities in cvd mortality in the rural population may have additional impact and underscores the need for future targeted interventions addressing cv risk in cgs. keywords: health behavior, cardiac surgery, caregiver, risk factors online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 125 physical activity patterns in rural-residing spousal caregivers and cardiac surgery patients in the first 6 months post-surgery cardiac surgery affects not only the lives of patients, but also their spouses who are typically the primary caregiver. informal caregivers (cg) are relied on by 51% of cardiovascular (cv) patients after hospital discharge (mosca et al., 2011). research has shown that strained cgs for patients with cardiovascular (cvd) disease neglect their own healthy behaviors (burton, newsom, schulz, hirsch, & german, 1997) and have higher risk of mortality (schulz & beach, 1999). little is known about the health of cgs for cardiac surgery patients returning home to rural areas from the urban centers where their surgery was performed. studies have targeted health promotion for family members with cv risks (mosca et al., 2008) but have not specifically focused on those family members with additional cg responsibilities, placing them at even higher risk. therefore, the primary purpose of this descriptive longitudinal pilot study was to compare cv risk and physical activity in rural residing adult (≥ 60 years) cardiac surgery patients and their spousal cgs at the time of surgery and four time points in the first six months following hospital discharge. the specific aims are to: 1) compare cv risk factors and mean minutes spent in moderate or greater physical activity levels at 3 and 6 weeks and 3 and 6 months after cardiac surgery; and 2) examine trajectories of change in physical activity patterns in the first 6 months after cardiac surgery in patients and their spousal cgs. rural residents continue to have known disparities in life expectancy (singh & siahpush, 2014) with a higher prevalence of hypertension, physical inactivity (schiller, lucas, ward, & peregoy, 2012) smoking, obesity, and older persons (o'connor & wellenius, 2012). in fact, a online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 126 study examining trends in rural-urban disparities and cause specific mortality in the us between 1969 and 2009 found that causes of death contributing most to the rural urban disparities included heart disease and stroke (singh & siahpush, 2014). data also reveal that disparities have widened over time; excess mortality from all causes combined and from several major causes of death, including cvd in non-metropolitan areas was greater in 2005-2009 than in 1990-1992 (singh & siahpush, 2014). however, rural patients returning home after surgery in urban centers have reported positive support systems in their communities (pesut, laberge, sawatzky, mallinson, & rush, 2013) and are more likely to enroll in cardiac rehabilitation (cr) programs (adjusted odds ratio 3.30, ci 2.35 – 4.64) (turk-adawi, oldridge, tarima, stason, & shepard, 2014) compared to residents in urban locations. several studies have established the similarities in cv risk factors between patients and their partners (di castelnuovo, quacquaruccio, donati, de gaetano, & iacoviello, 2009; macken, yates, & blancher, 2000; meyler, stimpson, & peek, 2007). however, cgs awareness of their own cv risk is a concern. in spite of shared lifestyle behaviors and cardiac risk factors between family members and cardiac patients, 50% of family members with elevated lipid levels and 59% of those with elevated blood pressure were unaware of their personal risk factors (mosca et al., 2008). healthy behavior in cgs may be abandoned as they focus on their spouses’ recovery from cardiac surgery. secondary prevention targeted for the cardiac patient may be addressed, however, health promotion for the spousal cg with similar cv risks has had limited study. selection of variables for the current study was guided by concepts described in the health promotion model (hpm) (pender, murdaugh, & parsons, 2006). an underlying assumption is that cg and patient variables influence cg health outcomes. the hpm posits that prior health online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 127 related behavior and personal factors are important determinants affecting health-promoting behaviors. prior health related behavior consists of usual “healthy habits” practiced by individuals. physical activity represented the primary behavior of interest in our study. interventions targeted for cr patients have been shown to positively influence the adoption of physical activity (chase, 2011; hall et al., 2010; oliveira, ribeiro, & gomes, 2008). in addition, falba and sindelar (2008) reported that an individual’s physical activity habits positively influence (odds ratio = 1.83 – 1.86) a spouse’s physical activity. perceptions of physical activity have been found to differ between rural and urban settings. rural-living participants indicated summer heat and winter cold as barriers to exercise as opposed to urban participants having more alternatives to exercise (king, thomlinson, sanguins, & leblanc, 2006). rural participants, both men and women, viewed work on the farm as exercise and urban participants reported walking the stairs at work or going to a mall to walk as a form of exercise (king et al., 2006). personal factors are biologic factors such as gender and age which influence the cgs health outcomes. the majority of caregivers for cardiac surgery patients are women as men are approximately three times more likely to have cardiac surgery than women (go et al., 2014). older cgs with chronic disease caring for cardiac surgery patients reported significantly worse health related quality of life (hrqol) compared to younger cgs without chronic disease (rantanen et al., 2008; rantanen et al., 2009a; rantanen et al., 2009b). other personal factors that may influence health outcomes include personal beliefs. rural residents are more likely to believe that health is influenced by fate rather than personal responsibility (mcconnell et al., 2010). online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 128 physical activity levels, specifically moderate or more intense levels, were the health outcomes of interest in this study. less frequent physical activity levels were reported by family members of cv patients with specific caregiving responsibilities and burdens (financial strain and upsetting behavior) (mochari-greenberger & mosca, 2012). cv risk was found to be significantly higher in cgs with low physical activity levels as compared to non-cgs with low physical activity levels (von känel et al., 2011). methods design this descriptive longitudinal pilot study recruited a convenience sample from two midwestern tertiary hospitals. both hospitals provided cardiac surgery patients with similar postoperative hospital care and discharge education addressing incision care, signs and symptoms of infection, activity progression instructions and pain management strategies. this education was provided prior to discharge and similar print materials were sent home with the patients. sample subjects were eligible for the study if they were: a) cardiac surgery patient (cabs and/or valve surgery) and spouse; b) ≥ 60 years of age; c) living together; d) home address in a rural community; c) no serious comorbidities or cognitive impairments. the rural urban commuting area codes (ruca) created in part by the us department of agriculture’s economic research service were used to classify the subject’s residence (hart, larson, & lishner, 2005). ruca codes are assigned at the zip code level and include 33 different categories. the categories of ruca codes selected for this study included those classified as large rural, small rural, and isolated rural. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 129 of the 83 dyads meeting inclusion criteria for the study, 29 consented to participate and 24 completed the study. one dyad declined to participate at baseline and four other dyads declined after beginning the study. two cgs did not meet the age inclusion criteria (57 and 59 years), however were included as their spouses were over 65 years. cgs were primarily female and slightly younger than the patients. the majority (96.4%) of patients were recovering from cabs and one from valve replacement. in this study, 94.6% of the subjects were white. the patients had more comorbidities (m=3.07) compared to the cg (m=2.4). approximately half of the cgs (47.4%) and patients (52.6%) reported being employed. the majority of the patients (89.3%) reported attending a cr program. following cardiac surgery, patients are typically restricted from driving for 6 weeks. patients in our study largely relied on cgs to transport them to cardiac rehabilitation programs. the demographic and clinical characteristics of the sample are depicted in table 1. subjects resided in 24 different towns with a mean of 84 miles from the hospital where their surgery was performed. the majority of subjects (n=26, 46.4%) lived in a small, rural town, 16 resided on a farm or ranch (28.6%) with the remaining subjects reporting living in a small town (n=8, 14.3%) or in a rural area (n=6, 10.7%). they reported traveling .2 to 25 miles (mean = 9.4 miles) to visit their health care provider. measures baseline demographic (age, race, educational level, work status, and income) and clinical variables (co-morbidities and physical activity level) were collected via self-report. selected data (type of surgery and hospital length of stay) were collected from the patient’s medical record. subjects described their residence as a farm/ranch, small rural town, small town, or in a rural area (not a farm/ranch). online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 130 table 1 demographic and clinical characteristics of the sample clinical variables caregivers (n=28) patients (n=28) mean (s.d.) range mean (s.d.) range age 68.5 (6.6) 57-82 70.7 (6.0) 67-83 education (years) 13.6 (2.3) 8 – 17 13.1 (2.3) 8 – 17 bmi 29 (6.1) 20.652.5 31.1 (5.2) 21.338.7 comorbidities 2.4 (1.3) 0-6 3.07 (1.3) 1-6 caregivers n (%) patients n (%) gender (% female) 26 (92.9%) 2 (7.1) cardiac rehabilitation (yes) 25 (89.3) cardiac risk factors both yes hypertension 18 (64.3) 23 (82.1) 17 (60.7) hypercholesterolemia 9 (32.1) 20 (71.4) 7 (25) diabetes 7 (25) 9 (32.1) 4 (14.3) family history of coronary artery disease 4 (14.3) 7 (25) 2 (7.1) tobacco use 2 (7.1) 3 (10.7) 0 body mass index n=28 n = 27 normal weight (18.5 – 24.9) 6 (21.4) 4 (14.8) 1 (3.6) overweight (25 – 29.9) 15 (53.6) 8 (29.6) 4 (14.3) obese (≥ 30.0) 7 (25) 15 (51.9) 5 (17.9) physical activity (pa) was measured objectively using the actigraph® accelerometer (model gt3x: actigraph, pensacola, fl) at 3 and 6 weeks and 3 and 6 months post-surgery. the actigraph® is small (4.6cm x 3.3cm x 1.5cm), lightweight (19g) and worn on an elastic belt with the device positioned over the right hip. reliability and validity of the actigraph® has been reported for older (copeland & esliger, 2009; gardiner et al., 2011; matthews, 2005; miller, strath, swartz, & cashin, 2010) and obese adults (feito, bassett, tyo, & thompson, 2011; lopes, magalhães, bragada, & vasques, 2009). test-retest reliability correlations online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 131 (intraclass correlation coefficient (icc)= 0.7 0.9) were reported in free-living individuals (n = 143) across separate administrations (sirard, forsyth, oakes, & schmitz, 2011). the average daily number of minutes spent in pa of at least moderate intensity was the main variable that was obtained from the actigraph® for this study. time (in minutes) spent in pa were estimated using freedson, melanson, and sirard (1998) cut-points and moderatelifestyle intensity activities were estimated using cut-points proposed by matthews (2005). weekly summary estimates (mean minutes/day) in sedentary, light/lifestyle, moderate/vigorous activity levels were compiled for all participants with at least 5 valid days (worn ≥ 8 hours) of accelerometer data. procedure approval from the institutional review committees (#176-09-ep) for each site was obtained. if both cg and the cardiac surgical patient met inclusion criteria and agreed to participate, written informed consent was obtained. patient clinical data were retrieved from the medical records and spouse data were obtained via self-report. baseline data were obtained from subjects prior to the patient’s dismissal from the hospital. completion of baseline data questionnaires took approximately 45 – 60 minutes. all participants were instructed regarding accelerometer wear, placement, mailing procedures, and schedule. the principal investigator (pi) or research nurse contacted participants by phone at approximately 3 and 6 weeks and 3 and 6 months after discharge to complete follow-up questionnaires and validate that participants had received the accelerometer. data analysis using spss v.21, descriptive statistics (frequencies, means, sds) were obtained for the demographic and clinical variables. data collection was scheduled for 3 weeks, 6 weeks, 3 online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 132 months, and 6 months following hospital discharge. the mean number of days since discharge for each data collection point was approximately as planned (24, 46, 97, and 186 days, respectively). analyses for aim 1 included means and standard deviations for minutes of activity at sedentary, light/lifestyle, and moderate/vigorous intensity levels calculated separately for caregivers and patients at each time point. analyses for aim 2 involved examining plots of the raw data for each dyad. to explore the trajectories of change in moderate or more intense activity while taking into account potential intercorrelation of patterns within couples, we used hlm v.6 (raudenbush, bryk, cheong, & congdon, 2007) to fit a multivariate hierarchical model similar to that presented by raudenbush, brennan, and barnett (1995). this two-level model treats the dyad as the unit of analysis and yields separate population estimates of the curve parameters for cgs and for patients, as well as estimates of the correlations among these parameters. because the sample is small, analysis was confined to linear models (i.e., caregiver intercept and slope and patient intercept and slope). time was computed as days from hospital discharge, and then centered so that model intercepts will estimate the population average minutes of moderate or more intense activity at 21 days after discharge (raudenbush et al., 1995). results cardiovascular risk the cardiac risk factors noted in the majority of subjects included hypertension, hypercholesterolemia, and being overweight or obese (table 1). hypertension was the most common risk factor experienced by both patient and spouse (n=17, 60.7%), followed by hypercholesterolemia (25%). the majority of subjects were either overweight or obese with online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 133 caregivers being more overweight (54%) and patients were more in the obese category (52%). more patients were diabetic (25%) compared to the cg (14%). physical activity accelerometers were worn by caregivers and patients at the four time points with 15 caregivers and 11 patients consistently meeting the desired protocol of at least 10 hours per day, for ≥ 5 days at the four data points. actigraphs® returned with < 5 days of wear were excluded from the analysis (23.4%, n=39). comparison of average minutes spent in the different activity level categories revealed little differences between cgs and patients at each time point. in general, this sample of older adults spent approximately 2 2.5 hours daily in light or lifestyle activity, 10 – 20 minutes in moderate to vigorous physical activity and the remainder of the time in sedentary activity (table 2). table 2 physical activity data caregiver patient daily minutes in physical activity categories (accelerometer) wk 3 n=19 mean (s.d.) wk 6 n=22 mean (s.d.) m 3 n=19 mean (s.d.) m 6 n=22 mean (s.d.) wk 3 n=20 mean (s.d.) wk 6 n=22 mean (s.d.) m 3 n=17 mean (s.d.) m 6 n= 18 mean (s.d.) sedentary 1263 (55) 1258 (64) 1262 (74) 1279 (76) 1297 (68) 1275 (65) 1264 (95) 1271 (75) lifestyle/light 161 (51) 169 (57) 166 (67) 148 (67) 129.8 (60) 148.9 (54) 154.8 (80) 146 (63) moderate/ vigorous 16 (21) 13 (14) 11 (12) 13 (12) 13 (15) 16 (19) 21 (24) 23 (24) pa frequencies accelerometer wk 3 n=21 n (%) wk 6 n=21 n (%) m3 n=19 n (%) m6 n=17 n (%) wk3 n=21 n (%) wk 6 n=22 n (%) m3 n=17 n (%) m6 n=19 n (%) > 30 min/day in pa 3 (15.8) 2 (9.1) 2 (10.5) 3 (13.6) 3 (15) 4 (18.2) 5 (29.4) 6 (33.3) online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 134 to examine the trajectories of change in physical activity level over time, population curves from the multivariate hierarchical linear model were fit to the activity data (figure 1). tests of the estimates of fixed (population) effects suggest that moderate activity is significantly greater than zero at 3 weeks for both caregiver and patient (estimated at approximately 15 minutes). by six months, estimated activity at this intensity level for the patient has on average increased to 25 minutes (slope p = .09), but for the caregiver has remained about the same, decreasing to 13 minutes (slope p = .47). tests of the estimated variance components suggest that there is significant variability of both patient and caregiver intercepts around the population intercept, and significant variability of patient slopes around their population value (all p < .0005). considerable variability was also found in the caregiver slopes (p = .06). figure 1. population curves from multivariate hlm fit to activity data 0 5 10 15 20 25 30 50 days 100 days 150 days 200 days m in ut es days after hospital discharge caregiver patient online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 135 a strong negative correlation of caregiver intercept and slope (-.84) indicates that higher initial activity for a caregiver was associated with smaller increases or even decreases across the first 6 months. in contrast, the patient intercept and slope was less strongly correlated (-.30). patient and caregiver intercepts were positively correlated (.35), but their slopes showed virtually no association (-.04). categorization of trajectory slopes for individuals showed that of 21 caregivers with sufficient data to estimate a trajectory, 2 increased activity, 15 showed essentially no change, and 4 decreased activity. of 21 patients, 7 increased, 10 were unchanged, and 4 decreased. considered as dyads, 38% (n=8) showed essentially no change for either member, but for 29% (n=6) the caregiver showed no change while the patient activity increased. discussion the aim of this pilot study was to provide information about cv risk factors and physical activity patterns in a sample of rural-residing adult cardiac surgery patients and their spouses. a high degree of concordance between these rural patients and their spousal cgs was evident for risk factors particularly hypertension and bmi. similar risk factor prevalence has been documented in cardiac patients and their spouses including diabetes (thomson, niven, peck, & howie, 2013) smoking (di castelnuovo et al., 2009), bmi (di castelnuovo et al., 2009; thomson et al., 2013) and physical activity participation (thomson et al., 2013). these data are consistent with studies reporting significantly more obesity and self-reported coronary heart disease among rural residents (o'connor & wellenius, 2012). clearly, interventions to reduce cardiac risk could be beneficial for both cg and patient. accelerometer data in this study revealed that both cgs and patients spend the majority of their time (21 hours/day) in sedentary activity. copeland and esliger (2009) observed similar online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 136 patterns in healthy older adults (n=38), noting that approximately 14 hours/day were spent in light or sedentary activity. national recommendations for older adults emphasize reducing sedentary behavior in this population to lower risks of cv disease (nelson et al., 2007). with the exception of the 3 week time point, patients consistently spent more time in pa compared to cgs. in our sample, patterns of pa revealed that most patients could increase activity levels to meet the requirements for cv risk reduction, but few sustained this level. the majority of patients appeared to increase their pa, at least initially, which may correspond with their attendance in cr programs. consistent with the hpm, physical activity participation did influence health behavior outcomes in the patients. however, the assumption that behaviors of one spouse may influence the other was not evident in the physical activity participation by cgs. strong evidence has established the effectiveness of cr programs in increasing pa (chase, 2011) but these programs have not routinely included spousal cgs. these results suggest that patients tend to respond to cr and recognize the importance of healthy lifestyle behavior, while the cg was less likely to increase time spent in pa that could impact cv risk. little objective pa measurement in cgs has been documented. however, older adult cgs (n=24) and non-caregivers (n=48) wearing accelerometers in a study by marquez et al. (2012) averaged 8 and 11 minutes per day, respectively in moderate or greater physical activity levels. this is similar to results in the current study where cgs averaged 11 – 16 minutes per day in pa. cgs may need different strategies to enhance their pa within the time constraints of their caregiving responsibilities. for example, shorter, more frequent bouts of activity may be more feasible for cgs to accomplish (marquez et al., 2012). interventions tailored to the cgs individual situation, allowing flexibility while respecting time constraints may be more effective. booster sessions tailored to time points specific to pa patterns could be tested. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 137 although the sample was small, the longitudinal design allowed for examining patterns of pa for both the cgs and patients. pa activity for patients generally increased with no appreciable change noted in cg participation in pa. a few cgs did increase their time spent in pa over the 6 month period, however, this was not consistently correlated with the patient pa. such a finding contrasts with falba and sindelar (2008) who reported that involvement by one spouse in exercise is associated with exercise in the other spouse. further studies are needed to determine barriers such as cg burden or financial considerations which may interfere with adoption of activity behaviors. limitations the findings of this study are subject to several limitations. first, this small convenience sample may not be generalizable to cgs and cardiac surgery patients representing urban and more diverse populations. in addition, only spousal cgs were included in this study. future studies could include caregivers regardless of their relationship to the cardiac patient. although accelerometers are an objective measure of pa, subjects are aware of this measurement which may have potentially influenced their activities. examination of the individual plots for cases having all four observations indicated that about 30% of the cases exhibited some degree of nonlinearity, usually within the first 6-9 weeks after hospital discharge. although our results appear to reflect the overall trend (improvement or decline) even for these cases, the very early recovery period needs further study in order to more precisely model the trajectories and to gain understanding of factors influencing behavior changes during that time. online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 138 implications future longitudinal intervention studies focused on cg health are essential. cgs in this study were similar in age, cv risk, and comorbidities to their spouses. however, focus on the patient’s recovery without acknowledgement of similar risks in the cg may subsequently impact outcomes in both partners. spousal cgs with many of the same risks as patients are in need of interventions which tailor strategies to prevent decline for both cg and patient. lifestyle changes need to occur within the individual but also may be valuable in the overall home environment to impact both the patient and the cg. for example, changing dietary habits in the home and establishing routines including physical activity. changes in cg lifestyle are also preventative strategies to reduce cv risk and avoid undergoing a cardiac intervention, themselves. the goal of the national prevention strategy, a provision in the affordable care act, is to “increase the number of americans who are healthy at every stage of life” (national prevention council, 2011). as health care delivery in this country shifts from a focus on sickness and disease to a focus on prevention and wellness, the need for informal cgs will increase. widening health disparities stemming from cvd mortality in the rural population as compared to urban counterparts (singh & siahpush, 2014) may have additional impact and underscores the need for future targeted interventions addressing cv risk in cgs. preserving cg health is necessary to improve the ability to function as a cg and partner for the patients to whom they provide care. funding funded by p20 nr011404-04, national institute of nursing research online journal of rural nursing and health care, 14(2) http://dx.doi.org/10.14574/ojrnhc.v14i2.330 139 references burton, l. c., newsom, j. t., schulz, r., hirsch, c. h., & german, p. s. 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(2014). widening rural-urban disparities in life expectancy, u.s., 1969-2009. american journal of preventive medicine, 46(2), e19-e29. http://dx.doi.org/10. 1016/j.amepre.2013.10.017 sirard, j. r., forsyth, a., oakes, j. m., & schmitz, k. h. (2011). accelerometer test-retest reliability by data processing algorithms: results from the twin cities walking study. journal of physical activity & health, 8(5), 668-674. [medline] thomson, p., niven, c., peck, d., & howie, k. (2013). coronary heart disease risk factors: concordance between patients and partners before and after bypass grafting surgery. journal of cardiovascular nursing, 28(6), 550-562. http://dx.doi.org/10.1097/jcn.0b013e 31826341ae turk-adawi, k. i., oldridge, n. b., tarima, s. s., stason, w. b., & shepard, d. s. (2014). cardiac rehabilitation enrollment among referred patients: patient and organizational factors. journal of cardiopulmonary rehabilitation and prevention, 34(2), 114-122. http://dx.doi.org/10.1097/hcr.0000000000000017 von känel, r., mausbach, b. t., dimsdale, j. e., mills, p. j., patterson, t. l., ancoli-israel, s., . . . grant, i. (2011). regular physical activity moderates cardiometabolic risk in alzheimer's caregivers. medicine and science in sports and exercise, 43(1), 181-189. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 168 a review of the 2016-2017 flu season: guidelines, costs, and barriers simone chinnis, mba, rn 1 james j. sterrett, pharm d. 2 richetta deas, msn, aprn, anp-bc 3 whitney smith, msn, aprn, anp-bc;gnp-bc 4 ruth conner, phd, fnp-bc 5 1adjunct clinical assistant, college of nursing, medical university of south carolina, chinniss@musc.edu 2 assistant professor, south carolina college of pharmacy, sterrejj@musc.edu 3 nurse practitioner, roper st. francis, deasrg@musc.edu 4 instructor, medical university of south carolina, smithwhit@musc.edu 5 assistant professor, college of nursing, medical university of south carolina, stockder@musc.edu abstract in the united states (us), about 50,000 influenza-related deaths occur annually (centers for medicaid and medicare services [cms], 2014). the most important preventive measure for the influenza virus is for people to obtain the influenza vaccine (varsha et al., 2014; uyeki, 2014). of note, the vaccine is often underutilized; however, the influenza vaccine is recommended as an annual part of preventive care for people who are >6 months of age (united states government of health and human services, 2015; centers for diseases control and prevention [cdc], 2016; world health organization [who], 2016). the under-vaccination of patients with the influenza vaccine is a profound issue, especially in rural communities, which is online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 169 defined as locations populated by fewer than 50,000 people (united states census bureau [u.s. census bureau], 2015). in west virginia, for example, a state where 38% of the population resides in rural areas, people who were insured by medicare and whose insurance records did not manifest that they received the influenza vaccine, possessed a 170% increased risk of death during the influenza season in comparison to those who did receive the influenza vaccine (schade & mccombs, 2000). this literature review discusses the increased need for influenza vaccination in rural communities; reviews the 2016-2017 influenza season's guidelines and costs; and in preparation for the 2017-2018 influenza season, the need to overcome barriers that are associated with influenza vaccination. keywords: rural, influenza, flu, flu shot, flushot, influenza vaccine, guidelines, costs a review of the 2016-2017 flu season: guidelines, costs, and barriers the influenza vaccine, which is colloquially referred to as the “flu shot,” is recommended as an annual part of preventive care for people who are >6 months of age (united states government of health and human services, 2015; centers for diseases control and prevention [cdc], 2016a; world health organization [who], 2016). the under-vaccination of patients with the influenza vaccine is a profound issue, especially in rural communities (united states census bureau [u.s. census bureau], 2015). generally, rural communities may be defined as locations populated by fewer than 50,000 people. of note, a limitation exists within most reviews of literature and national data about rural communities because data are limited about counties populated by less than or equal to 10,000 people (bennett, 2013; u.s. census bureau, 2015). the behavioral risk factor surveillance system (brfss), a national entity that monitors online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 170 the receipt of the influenza vaccine, does not gather data from rural counties populated with <10,000 people (bennett, 2013). keeping in mind these limitations, during the 2009-2010 influenza season, galarce, minsky, and viswanath (2011) found that influenza vaccination uptake occurred in only 47% of the population residing in rural areas. from october to december of the 2015-2016 influenza season, only 20% of the patients who visited a rural federally qualified health center in the southeastern part of the united states, as determined by the center’s former director of quality improvement, received the influenza vaccine (j. brown, personal interview, february 12, 2016). in the united states (us), about 50,000 influenza-related deaths occur annually (centers for medicaid and medicare services [cms], 2014). in west virginia, for example, a state where 38% of the population resides in rural areas, people who were insured by medicare and whose insurance records did not manifest that they received the influenza vaccine, possessed a 170% increased risk of death during the influenza season in comparison to those who did receive the influenza vaccine (schade & mccombs, 2000). in preparation for the next flu season, this literature review discusses issues that impact rural communities and the guidelines, costs, and barriers that are associated with influenza vaccinations during the 2016-2017 influenza season. guidelines the director for the cdc makes the ultimate determination about the governing guidelines for preventive influenza practices in the united states (us). this decision is based on recommendations from who and the advisory committee on immunization practices (acip), an organization composed of both medical and public health personnel responsible for us immunization recommendations. the official cdc influenza guidelines are published annually at some point in august in the mmwr morbidity mortality weekly report. per cdc guidelines, online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 171 healthcare providers should recommend annual influenza vaccines to anyone who does not possess a contraindication for vaccination and is greater than or equal to six months of age from october each year until the government issues a notification that the flu season is over (grohskopf et al., 2015; united states government of health and human services, 2015). the following list consists of groups that are considered a priority for the receipt of the annual influenza vaccination: pregnant women—recognized by the who for being at risk for developing serious complications if they were to become infected with influenza virus — children six to fifty-nine months of age, people greater than 65 years of age, individuals with chronic medical conditions, healthcare workers, and/or people who provide care for those who belong to priority influenza vaccination groups. these conditions include the following: people with pulmonary conditions, people with either suppressed or compromised immune systems, children from 6 months to 18 years of age who possess an increased risk of developing reyes syndrome post influenza infection due to current adherence to an aspirin regimen, individuals residing in group facilities, people with a body mass index greater than 40, native americans and those of alaskan descent, and people suffering from metabolic, renal, hepatic, and/or neurologic dysfunction (cdc, 2016a; who, 2016). the composition of the strains of influenza viruses included in the annual influenza vaccine changes annually (who, 2016). the who performs year-round surveillance of influenza activity and makes recommendation for the strains to be included in the annual vaccine. the who (2016) recommended that the following influenza virus strains be included in the 20162017 trivalent influenza vaccines: a/california/7/2009 (h1n1)pdm09-like virus, a/hong kong/4801/2014 (h3n2)-like virus, and b/brisbane/60/2008-like virus. in addition to these strains, who recommended that quadrivalent vaccines also contain b/phuket/3073/2013-like online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 172 virus. country-specific entities—e.g. the cdc in the united states—make the final determination about the inclusion/exclusion of influenza strains in the annual influenza vaccines. the federal drug administration vaccine and biological products advisory committee, the organization that makes the final determination about the composition of the annual influenza vaccine in the us, endorsed the who’s recommended influenza strains for the 2016-2017 influenza season on march 4, 2016, noting that the same strains will be used for both the northern and southern hemisphere influenza vaccines (federal drug administration [fda], 2016). an additional noteworthy recommendation occurred on june 22, 2016: the acip recommended to the cdc that the live attenuated vaccines not be used during the 2016-2017 influenza season; however , as of when this article was submitted for publication, the cdc had yet to make a final determination (cdc, 2016c). contraindications for the influenza vaccine consist of having a severe reaction to the influenza vaccine in the past, a current state of moderate to severe illness, and/or a history of guillain-barre (grohskopf et al., 2015; acip, 2016). allergies to eggs and/or latex are not contraindications for the receipt of the influenza vaccine; however, additional care needs to be made to discern which vaccine is best for this patient population. also, specific guidelines govern the immunization of children, between the ages of six months and eight years of age, with the influenza vaccine. the acip is responsible for immunization recommendations in the us. as this article is a reflection of the 2016-2017 influenza season, minutes from the acip meeting on february 2016 refer to the 2015-2016 list of fda approved influenza vaccines; therefore, vaccination recommendations in this article only pertain to those vaccines, which are presented in table 1 using the table as published by grohskopf et al. (2015) and acip (2016). online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 table 1 influenza vaccines – us, 2015 -2016 influenza season trade name manufacturer presentation mercury µg/0.5 ml from thimerosal ovalbumin µg/0.5 ml age indications latex route inactivated influenza vaccine, quadrivalent (iiv4), standard dose. contraindications*: severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza vaccine. precautions*: moderate to severe acute illness with or without fever; history of guillain-barré syndrome within 6 weeks of receipt of influenza vaccine. fluarix quadrivalent glaxosmithkline 0.5 ml single-dose prefilled — ≤0.05 ≥3 yrs no im† flulaval quadrivalent id biomedical corp. of quebec (distributed by glaxosmithkline) 5.0 ml multi-dose vial <25 ≤0.3 ≥3 yrs no im† fluzone quadrivalent sanofi pasteur 0.25 ml single-dose prefilled — § 6 through 35 mos no im† 0.5 ml single-dose prefilled syringe — § ≥36 mos no im† 0.5 ml single-dose vial — § ≥36 mos no im† 5.0 ml multi-dose vial 25 § ≥6 mos no im† fluzone intradermal quadrivalent sanofi pasteur 0.1 ml single-dose prefilled microinjection system — § 18 through 64 yrs no id** inactivated influenza vaccine, trivalent (iiv3), standard dose. contraindications*: severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza vaccine. precautions*: moderate to severe acute illness with or without fever; history of guillain-barré syndrome within 6 weeks of receipt of influenza vaccine. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 174 trade name manufacturer presentation mercury µg/0.5 ml from thimerosal ovalbumin µg/0.5 ml age indications latex route afluria biocsl 0.5 ml single-dose prefilled — <1 ≥9 yrs†† no im† 5.0 ml multi-dose vial 24.5 <1 ≥9 yrs†† via needle;18 through 64 yrs via jet injector no im† fluvirin novartis vaccines and diagnostics 0.5 ml single-dose prefilled syringe ≤1 ≤1 ≥4 yrs yes§§ im† 5.0 ml multi-dose vial 25 ≤1 ≥4 yrs no im† fluzone sanofi pasteur 5.0 ml multi-dose vial 25 § ≥6 mos no im† inactivated influenza vaccine, cell-culture-based (cciiv3), standard dose. contraindications*: severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza vaccine. precautions*: moderate to severe acute illness with or without fever; history of guillain-barré syndrome within 6 weeks of receipt of influenza vaccine. flucelvax novartis vaccines and diagnostics 0.5 ml single-dose prefilled syringe — ¶¶ ≥18 yrs yes§§ im† inactivated influenza vaccine, trivalent (iiv3), high dose. contraindications*: severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza vaccine. precautions*: moderate to severe acute illness with or without fever; history of guillain-barré syndrome within 6 weeks of receipt of influenza vaccine. fluzone high-dose*** sanofi pasteur 0.5 ml single-dose prefilled syringe — § ≥65 yrs no im† online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 175 trade name manufacturer presentation mercury µg/0.5 ml from thimerosal ovalbumin µg/0.5 ml age indications latex route recombinant influenza vaccine, trivalent (riv3), standard dose. contraindications*: severe allergic reaction to any vaccine component. precautions*: moderate to severe acute illness with or without fever; history of guillain-barré syndrome within 6 weeks of receipt of influenza vaccine. flublok protein sciences 0.5 ml single-dose vial — 0 ≥18 yrs no im† live attenuated influenza vaccine, quadrivalent (laiv4)**** contraindications*: severe allergic reaction to any vaccine component, including egg protein, or after previous dose of any influenza vaccine. concomitant use of aspirin or aspirin-containing medications in children and adolescents. in addition, acip recommends laiv4 not be used for pregnant women, immunosuppressed persons, persons with egg allergy, and children aged 2 through 4 years who have asthma or who have had a wheezing episode noted in the medical record within the past 12 months, or for whom parents report that a health care provider stated that they had wheezing or asthma within the last 12 months. laiv4 should not be administered to persons who have taken influenza antiviral medications within the previous 48 hours. persons who care for severely immunosuppressed persons who require a protective environment should not receive laiv4, or should avoid contact with such persons for 7 days after receipt. precautions*: moderate to severe acute illness with or without fever; history of guillain-barré syndrome within 6 weeks of receipt of influenza vaccine; asthma in persons aged 5 years and older; medical conditions which might predispose to higher risk for complications attributable to influenza. flumist quadrivalent††† medimmune 0.2 ml single-dose prefilled intranasal sprayer — <0.24 (per 0.2 ml) 2 through 49 yrs no in online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 table 1 abbreviations: acip = advisory committee on immunization practices; id = intradermal; im = intramuscular; in = intranasal. * immunization providers should check food and drug administration-approved prescribing information for 2015–16 influenza vaccines for the most complete and updated information, including (but not limited to) indications, contraindications, warnings, and precautions. package inserts for u.s.-licensed vaccines are available at www.fda.gov/biologicsbloodvaccines/vaccines/approvedproducts/ucm093833.htm. † for adults and older children, the recommended site for intramuscular influenza vaccination is the deltoid muscle. the preferred site for infants and young children is the anterolateral aspect of the thigh. specific guidance regarding site and needle length for intramuscular administration may be found in the acip general recommendations on immunization, available at www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm. § available upon request from sanofi pasteur (1–800–822–2463 or mis.emails@sanofipasteur.com). ¶ quadrivalent inactivated influenza vaccine, intradermal: a 0.1-ml dose contains 9 µg of each vaccine antigen (36 µg total). ** the preferred injection site is over the deltoid muscle. fluzone intradermal quadrivalent is administered using the delivery system included with the vaccine. †† age indication per package insert is ≥5 years; however, acip recommends afluria not be used in children aged 6 months through 8 years because of increased risk of febrile reactions noted in this age group with biocsl’s 2010 southern hemisphere iiv3. if no other ageappropriate, licensed inactivated seasonal influenza vaccine is available for a child aged 5 through 8 years who has a medical condition that increases the child’s risk for influenza complications, afluria can be used; however, providers should discuss with the parents or caregivers the benefits and risks of influenza vaccination with afluria before administering this vaccine. afluria may be used in persons aged ≥9 years. §§ syringe tip cap may contain natural rubber latex. ¶¶ information not included in package insert. estimated to contain <50 femtograms (5x10-8 µg) of total egg protein (of which ovalbumin is a fraction) per 0.5 ml dose of flucelvax. *** trivalent inactivated influenza vaccine, high-dose: a 0.5-ml dose contains 60 µg of each vaccine antigen (180 µg total) ****on june 22, 2016, the acip recommended to the cdc that the laiv vaccine not be used during the 2016-2017 influenza season. during the time that this article was composed, the cdc had yet to make a determination (2016c). ††† flumist is shipped refrigerated and stored in the refrigerator at 35°f–46°f (2°c–8°c) after arrival in the vaccination clinic. the dose is 0.2 ml divided equally betweeneach nostril. health care providers should consult the medical record, when available, to identify children aged 2 through 4 years with asthma or recurrent wheezing that might indicate asthma. in addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving laiv, parents or caregivers of children aged 2 through 4 years should be asked: “in the past 12 months, has a health care provider ever told you that your child had wheezing or asthma?” children whose parents or caregivers answer “yes” to this question and children who have asthma or who had a wheezing episode noted in the medical record within the past 12 months should not receive flumist.**** on june 22, 2016, the acip recommended to the cdc that the flumist vaccine not be used during the 2016-2017 influenza season. the cdc has yet to make a final determination (cdc, 2016). online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 during the 2016-2017 influenza season, in the population who possessed an allergy to eggs, the severity of the allergy served as the determining factor for which influenza vaccine was used (acip, 2016). a mild egg allergy was defined as the development of uticaria postingestion/exposure to eggs. the occurrence of any other symptoms—e.g. urticaria and nausea/vomiting, angioedema, anaphylaxis, etc.—when exposed to eggs, was defined as a severe allergy. based on this stratification, the following guidelines were implemented by the acip (2016) as a determinant about which vaccine should be used for people with egg allergies during the 2016-2017 influenza season. in individuals who possessed a mild egg allergy, providers could use any age and health appropriate influenza vaccine. people who possessed a severe egg allergy could use any age and health appropriate influenza vaccine; however, in this population, any vaccine other than the recombinant influenza vaccine was required to be administered in a medical facility staffed by a physician who specialized in the management of serious allergic reactions (acip, 2016). additionally, everyone, regardless of allergy to eggs, was required to undergo observation for fifteen minutes after receiving the influenza vaccine. per the implementation of these changes by the acip (2016), the algorithm that was used for the selection of an influenza vaccine during the 2015-2016 influenza season was no longer applicable during the 2016-2017 influenza season. specific guidelines, which are presented in figure 1 using the same table from grohskopf et al., (2015), governed influenza vaccine administration to children from six months of age to eight years of age who historically was never inoculated with the influenza vaccine. during the 2015-2016 season, among children who were six months through eight years of age, no preference existed for the use of either the trivalent or quadrivalent vaccine. if children were obtaining the vaccine for the first time, they received two doses, separated by approximately four online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 178 weeks (grohskopf et al., 2015). the quantity of doses administered to children less than or equal to 8 years varies each year based on the strain(s) of the influenza virus that the vaccine protects against. based on the acip’s (2016) recommendations, the guidelines from the 2015-2016 influenza season roughly remained the same for the 2016-17 season. children who received two doses of the influenza vaccine during the same influenza season prior to the most recent influenza season were only to receive one dose of the influenza vaccine during the subsequent season. in reference to the duration of immunity after vaccination, the quantity of antibodies in the body declines within six months after vaccination. in reference to the geriatric population, antibodies to the influenza vaccination decline at a more rapid rate than other age groups (grohskopf et al., 2015). sanofi developed the quadrivalent influenza vaccine to combat this decline. additionally, the vaccine was deemed safe for use in pediatric populations greater than six months of age (sanofi pasteur, 2016). figure 1. fused with implied permission—e.g. materials that are used from public domains are reproducible with reference to the source(s) of origin. influenza vaccine dosing algorithm for children aged 6 months through 8 years — advisory committee on immunization practices, united states, 2015– 16 influenza season from mmwr morbidity mortality weekly report, 64(30), p.821 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 179 cost table 2 vaccines, ages appropriateness, and cost.—based on charts used by the cdc (2016b) information presented in table with implied permission—e.g. materials that are used from public domains are reproducible with reference to the source(s) of origin. centers for disease control and prevention on july 5, 2016 (2016b) vaccine brandname/ tradename cost ($)/ package of 10 doses *values were rounded to the closest number* manufacturer influenza (age 6 months and older) fluzone® quadrivalent 16.62 sanofi pasteur influenza (age 6-35 months) fluzone® quadrivalent pediatric dose no preservative 23.17 sanofi pasteur influenza (age 36 months and older) fluzone® quadrivalent no-preservative 18.23 (average)* *cost is based on how the vaccine is packaged. sanofi pasteur influenza (age 36 months and older) fluarix® quadrivalent preservative free 16.82 glaxosmithkline influenza (age 36 months and older) flulaval quadrivalent 15.77 glaxosmithkline influenza (age 4 years and older) fluvirin® 14.41 novartis influenza live, intranasal (age 2-49 years) ****on june 22, 2016, the acip recommended to the cdc that this vaccine not be used during the 20162017 influenza season. the cdc has yet to make a final determination (cdc, 2016c). flumist® quadrivalent no preservative 23.70 medimmune influenza (age 9 years and older) afluria® no preservative 15.67 biocsl influenza (age 9 years and older) afluria® 14.41 biocsl influenza (age 18 years and older) flublok® no preservative 35.75 protein sciences online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 180 table 2, reflects influenza vaccination prices for providers as reported by manufacturers to the cdc (2016b). the prices were valid until february of 2017. costs for influenza vaccines at publix®, as presented in table 3, were applicable to locations that served dually as a grocery store and pharmacy. such establishments are only located in the southeastern region of the united states—e.g. alabama, florida, georgia, north carolina, south carolina, and tennessee (publix®, 2016). the descriptions used are based on the descriptions that are used by publix® on their website. these descriptions do not contain manufacturer information. table 3 costs for influenza vaccines at publix ® influenza vaccine description of the influenza vaccine approved population cost ($) trivalent trivalent vaccines protect against two influenza a viruses and one influenza b virus recommended for everyone 6 months of age and older 30 flucelvax (preservativefree & egg free) a standard-dose trivalent shot containing virus grown in cell culture instead of eggs recommended for ages 18 years of age and older 38 quadrivalent quadrivalent vaccines protect against two influenza a viruses and two influenza b viruses yearly vaccine for everyone 6 months of age and older 40 high dose trivalent vaccine with a higher dose of antigen acip recommended option for people 65 years of age and older 60 (cdc, 2015; publix, 2016) walgreens, walmart, and cvs offered three different types of influenza vaccines. the costs associated with those vaccines are presented in table 4. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 181 table 4 costs for influenza vaccines at walmart®, cvs®, and walgreens® influenza vaccine description of the influenza vaccine approved population walmart® cost($) cvs® cost ($) walgreens® cost ($) influenza seasonal recommended for everyone 2 years of age and older 25 31.99 31.99 * price in delaware: 35.99 (seasonal and preservative free) fluzone-high dose trivalent vaccine with a higher dose of antigen acip recommended option for people 65 years of age and older 48 54.99 59.99 * price in delaware: 63.99 fluarix quadrivalent vaccines protect against two influenza a viruses and two influenza b viruses. preservative free. yearly vaccine for everyone 3 years of age and older 24 36.99 39.99 (cvs, 2015;walgreens, 2016;walmart pharmacist, conversation, june 28, 2016) barriers the most important preventive measure for the influenza virus is for people to obtain the influenza vaccine (verger et al., 2015; uyeki, 2014); however, the vaccine is often underutilized. the following are potential barriers to obtaining the influenza vaccine: a) cost; b) providers fail to recommend the vaccine to patients; c) patients’ perceived lack of access to vaccine; d) fear of injections; e) beliefs that influenza is not a serious illness, f) lack of time to obtain the vaccine due to other obligations; g) lack of transportation to sites where vaccines are administered; and h) concerns about the safety and efficacy of the vaccine (beel, rench, montesinos, & healy, 2014; mayet, al-shaikh, al-mandeel, alsaleh, & hamad, 2017; yuen & tarrant, 2014). in preparation for the next flu season, healthcare providers need to work diligently to remove online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 182 barriers to the influenza vaccine by implementing evidence-based practices. for example, the provision of opportunities to obtain the influenza vaccine and vaccination education at medical visits results in the removal of several barriers (stinchfield, 2008; verger et al., 2015; grohskopf et al., 2015; chinnis, 2017). healthcare providers need to recognize that rural populations encounter numerous health disparities. providers are members of a diverse interprofessional team; it is imperative that team members work with rural populations to ensure that they receive the best preventive care possible during the next influenza season. healthcare providers are charged with the task to ensure that a flame is forever lit, sparking fervor to administer as many influenza vaccines as possible. with a rejuvenated spirit, healthcare providers need to recommit themselves to increasing influenza vaccine uptake during the 2017-2018 influenza season. this task begins now! references advisory committee on immunization practices. (2016). summary report: february 24, 2016 [meeting minutes]. atlanta, ga: us department of health and human services, cdc; 2016. retrieved from http://www.cdc.gov/vaccines/acip/meetings/downloads/minarchive/min-2016-02.pdf beel, e. r., rench, m. a., montesinos, d. p., & healy, c. m. (2014). acceptability of immunization in adult contacts of infants: possibility of expanding platforms to increase adult vaccine uptake. vaccine, 32(22), 2540-2545. http://dx.doi.org/10.1016/j.vaccine.2014.03.056 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 183 bennett, k. j. (2013). rural population estimates: an analysis of a large secondary data set. journal of rural health, 29(3), 233-238. http://dx.doi.org/10.1111/j.1748-0361. 2012.00446.x centers for medicaid and medicare services. (2014, december). immunizations. retrieved from https://www.cms.gov/medicare/prevention/immunizations/index.html?redirect=/im munizations/ centers for disease control and prevention. (2016a, may). influenza vaccination: a summary for clinicians. professional. retrieved from http://www.cdc.gov/flu/professionals/vaccination/vax-summary.htm centers for disease control and prevention. (2016b, july 5). cdc vaccine price list. retrieved from http://www.cdc.gov/vaccines/programs/vfc/awardees/vaccine-management/pricelist/index.html center for disease control and prevention. (2016c, june 22). acip votes down use of laiv for 2016-2017 flu season [media statement]. retrieved on june 27, 2016, from http://www.cdc.gov/media/releases/2016/s0622-laiv-flu.html chinnis, s. (2017). increasing influenza vaccination uptake (unpublished quality improvement project). college of nursing at the medical university of south carolina, charleston, sc. cvs pharmacy. (2015). price list. minute clinic. retrieved on june 27, 2016, from http://www.cvs.com/minuteclinic/services/price-lists food and drug administration. (2016). 142nd meeting of the vaccines and related biological produces advisory committee, march 4, 2016 [summary minutes]. washington, dc: food and drug administration; 2016. retrieved from http://www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials/blood online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 184 vaccinesandotherbiologics/vaccinesandrelatedbiologicalproductsadvisorycommittee/u cm494071.pdf . galarce, e. m., minsky, s., & viswanath, k. (2011). socioeconomic status, demographics, beliefs and a (h1n1) vaccine uptake in the united states. vaccine, 29(32), 5284-5289. http://dx.doi.org/10.1016/j.vaccine.2011.05.014 grohskopf, l. a., sokolow, l. z., olsen, s. j., bresee, j. s., broder, k. r., & karron, r. a. (2015). prevention and control of influenza with vaccines: recommendations of the advisory committee on immunization practices, united states, 2015-16 influenza season. mmwr morbidity mortality weekly report, 64(30), 818-825. https://doi.org/10.15585/mmwr.mm6430a3 mayet, a. y., al-shaikh, g. k., al-mandeel, h. m., alsaleh, n. a., & hamad, a. f. (2017). knowledge, attitudes, beliefs, and barriers associated with the uptake of influenza vaccine among pregnant women. saudi pharmaceutical journal, 25(1), 76 – 82. http://dx.doi.org/10.1016/j.jsps.2015.12.001 publix. (2016). vaccinations. preventive care. retrieved from http://www.publix.com/ pharmacy-wellness/pharmacy/preventive-care/vaccinations sanofi pasteur. (2016, april 11). 450/477 fluzone quadrivalent highlights of prescribing information. swiftwater, pa: sanofi pasteur, inc. retrieved from https://www.vaccineshoppe.com/image.cfm?pi=fluqiv&image_type=product_pdf schade, c. p., & mccombs, m. a. (2000). influenza immunization and mortality among diabetic medicare beneficiaries in west virginia. west virginia medical journal, 96(3), 444-448. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 185 stinchfield, p. k. (2008). practice-proven interventions to increase vaccination rates and broaden the immunization season. american journal of medicine, 121(7), s11-s21. http://dx.doi.org/10.1016/j.amjmed.2008.05.003 united states census bureau. (2015, july 27). urban and rural classification. geography. retrieved from http://www.census.gov/geo/reference/urban-rural.html united states department of agriculture. (2016, june 3). west virginia. state fact sheets. retrieved from http://www.ers.usda.gov/data-products/state-fact-sheets/statedata.aspx?statefips=54&statename=west%20virginia#.uzp4alxvdms united states government of health and human services. (2015, july). influenza. vaccines. retrieved from http://www.vaccines.gov/diseases/flu/index.html uyeki, t. m. (2014). preventing and controlling influenza with available interventions. new england journal of medicine, 370(9), 789-791. http://dx.doi.org/10.1056/nejmp1400034 verger, p., cortaredona, s., pulcini, c., casanova, l., peretti-watel, p., & launay, o. (2015). characteristics of patients and physicians correlated with regular influenza vaccination in patients treated for type 2 diabetes: a follow-up study from 2008 to 2011 in southeastern france. clinical microbiology and infection, 21(10), 930-e1. http://dx.doi.org/10.1016/j.cmi.2015.06.017 walgreens. (2016). price menu. healthcare clinic. retrieved from http://www.walgreens.com/topic/pharmacy/healthcare-clinic/price-menu.jsp world health organization. (2014, march). influenza (seasonal). fact sheet n2. retrieved from http://www.who.int/mediacentre/factsheets/fs211/en/ world health organization. (2016, february). recommended composition of influenza vaccines for use in the 2016-2017 nothern hemisphere influenza season. influenza. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.428 186 retrieved from http://www.who.int/entity/influenza/vaccines/virus/recommendations/20 1602_recommendation.pdf?ua=1 yuen, c. y. s., & tarrant, m. (2014). determinants of uptake of influenza vaccination among pregnant women–a systematic review. vaccine, 32(36), 4602-4613. https://doi.org/10.1016/j.vaccine.2014.06.067 george_536 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 209 predictors of success in a graduate nurse practitioner program tracy p. george, dnp, aprn-bc, cne 1 allison c. munn, rn, phd 2 sarah h. kershner, phd, mph, ches 3 tiffany a. phillips, dnp, np-c 4 1 assistant professor, school of health sciences, francis marion university, tgeorge@fmarion.edu 2 assistant professor, school of health sciences, francis marion university, amunn@fmarion.edu 3 assistant professor, school of health sciences, francis marion university, skershner@fmarion.edu 4 assistant professor, school of health sciences, francis marion university, tphillips@fmarion.edu abstract background: prior research studies on the predictors of success in nurse practitioner programs have not focused on students in rural areas. purpose: the purpose of this study was to examine factors that influence student success in a rural nurse practitioner program in the southeastern united states. methods: admission data from family nurse practitioner students at a rural university were obtained from a secured drive and transcribed into an excel spreadsheet. bivariate analysis using independent t-tests for continuous variables and chi-square tests for categorical variables was online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 210 conducted to determine group differences between successful and unsuccessful students by demographic and education factors. results: a total of 84 students were enrolled in the family nurse practitioner program, including 70 (83.3%) females and 14 (16.7%) males. student demographics included 15 (17.9%) african american, 67 (79.8%) caucasian, one (1.2%) american indian or alaska native, and one (1.2%) asian, with 67 (80%) residing in the local rural pee dee region. of the 84 students, 49 (58.3%) successfully completed the program and 35 (41.6%) were unsuccessful and either withdrew or were dismissed. african american students had decreased rates of program enrollment and completion compared to caucasian students, with only 3 (20%) of the 15 enrolled students successfully completing the program. conclusions: identification and examination of sociodemographic and education factors influencing student success in southeastern rural nurse practitioner programs may improve overall program completion rates, facilitate program success for minority students, and increase the diversity of the nurse practitioner workforce. keywords: academic success, nursing students, school admission criteria, nurse practitioner predictors of success in a graduate nurse practitioner program nurse practitioners (nps) have been vital in providing healthcare in rural and underserved areas where primary care provider physician shortages are most prevalent (streeter, zangaro, & chattopadhyay, 2017). the united states (u.s.) health resources and service administration (hrsa) recently released primary care physician workforce data for 2013 and projected models for workforce supply for the year 2025. prediction models forecast significant shortages in u.s. midwest and southern regions with an expected deficit of over 700 primary care physicians in the online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 211 state of south carolina (streeter et al., 2017). according to the american association of nurse practitioners (aanp) (n.d.), 86.6% of nps are certified in a primary care area with 77.8% providing primary care. in order to continue to meet the nation’s healthcare needs, nurse practitioner students must successfully complete a graduate nursing program and subsequently pass a certification examination. graduate nurse practitioner students who are from rural areas and attend a local rural-based graduate nurse practitioner program are likely to both reside and practice in the region after completing their program of study (skillman, kaplan, andrilla, ostergard, & patterson, 2014). in order to retain local rural-dwelling students, it is important to understand the factors most important to student success in rural graduate family nurse practitioner programs. the u.s. census bureau (2010) defines rural as the population, housing, and territory not included in an area with at least 50,000 residents. although the county in which the university is located has more than 50,000 residents, the city comprises the majority of the population with approximately 37,778 residents in 2017 (u.s. census bureau, 2017). the remaining residents are spread throughout nearly 800 square miles of small towns and rural farmlands. the graduate program is comprised of both online and on-campus curriculum components, and many commuter students live in surrounding counties that are designated as rural by the federal office of rural health policy (health resources and services administration [hrsa], n.d.a.). the pee dee region that surrounds the university is a largely rural area comprised of 12 counties (hrsa, n.d.b). eight of the 12 counties are designated as rural, with three counties having portions of the counties defined as rural. only one county in the region is not designated as being rural (hrsa, n.d.b). the south carolina department of health and environmental control, bureau of community health and chronic disease prevention ([sc,dhec,bchcdp], 2016) provided statistical information on the population and health rankings for this region. the region online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 212 is 59% caucasian, 35% black, 4% hispanic, and 2%. seven of the 12 counties in this region of the state rank in the bottom third of county health rankings. three counties in the region are designated health provider shortage areas with between 16% and 25% of county residents reporting inability to access a health care provider due to cost. the above data indicates there is a need for more nurse practitioners to meet the healthcare needs of this rural, underserved region. three factors found to predict student success in graduate nursing programs were the admission grade point average (gpa), nursing gpa, and undergraduate science gpa (ortega burns, hussey, schmidt, & austin, 2013; patzer et al., 2017). similarly, undergraduate gpa has been found to be indicative of graduate gpa (el-banna et al., 2015). at a large, public, midwestern urban university, a formula for graduate doctor of nursing practice admissions was developed, which included a weighting of 70% for gpa, 15% for the professional statement, and 15% for the three recommendation letters (creech & aplin-kalisz, 2011). a national investigation of rural nursing programs found barriers to student recruitment included program expense, distance of commute to campus, and work schedule considerations (skillman et al., 2014). however, there is limited data on barriers to program completion or factors contributing to student success in those rural nurse practitioner programs. there is a need for more research on the predictive factors for graduate nursing success. prior research studies on the predictors of success in nurse practitioner programs have not focused on students in rural areas. the purpose of this study was to examine data on the factors that influence student success in a rural nurse practitioner program in the southeastern us. theoretical framework tinto’s model of student departure provides a framework for considering the predictors of student attainment and persistence (tinto, 1993). according to tinto, a student’s decision to online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 213 withdraw from a university occurs due to both student characteristics, including pre-entry attributes and goal commitments, and his or her academic, environmental and social integration in an institution. pre-entry attributes include factors such as family background, abilities, skills, and prior schooling. goal commitments refers to the intentions of the student when entering the program and external commitments by the student to family, friends, work obligations, and others. tinto (1993) identified that african american students, students from low-income families, and adult students required individualized interventions to decrease attrition. although tinto’s model was originally designed for undergraduate students, it may be applicable to graduate nursing students. methods data collection. the study was conducted through academic admission record review of family nurse practitioner students at a rural, public university in the southeastern us with expected graduation dates of december 2016 and december 2017. approval for the study was received from the university’s institutional review board. the protocol approval number is 09-26-2017-008. data were extracted from a secured drive and transcribed into an excel spreadsheet, with the collected data providing program information for the phase i analysis of a multi-phase study. a small sample size was expected due to few cohorts with both program admission and completion information. phase i included extraction of pre-entry attributes data from both successful (program graduate) and unsuccessful (non-program graduate) students and included demographic and education variables (table 1). table 1 study variables online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 214 variable name classification / categories determination variable level dependent outcome variable success success = graduated program completion and exit data nominal non –success = withdrew or dismissed demographic outcome variables gender male self-identified in admission record nominal female race white or caucasian self-identified in admission record nominal black or african american american india or alaska native asian ethnicity hispanic / latino self-identified in admission record nominal non-hispanic latino age n/a represented as mean (sd) birth year in record ratio education independent variables college/university where obtained bsn study site official transcripts nominal other sc college/university i non-sc based college/university ii rn to bsn status previously completed a rn to bsn program (yes/no) official transcripts nominal bsn gpa n/a represented as mean (sd) official transcripts ratio miles from campus n/a represented as mean (sd) permanent address in admission record ratio rurality iii pee dee residents hrsa grant eligibility nominal non-pee dee residents undergraduate course grade point average (gpa) microbiology n/a represented as mean (sd) official transcripts ratio anatomy n/a represented as mean (sd) official transcripts ratio physiology n/a represented as mean (sd) official transcripts ratio science iv n/a represented as mean (sd) official transcripts ratio masters of science of nursing (msn) msn gpa n/a represented as mean (sd) official transcripts ratio i includes 7 south carolina based colleges or universities. ii includes 9 non-south carolina based colleges or universities. iii rurality defined as hrsa grant eligibility (hrsa, n.d.b). ivaverage gpa for undergraduate science courses: anatomy, physiology, & microbiology. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 215 data analysis. data were de-identified in the excel spreadsheet and imported into spss statistics for mac (version 24.0). data were screened for missing values, outliers, potential transcription errors, and normality. descriptive statistics were computed for student demographic variables and education characteristics. independent t-tests and chi-square tests were used to determine differences between successful and unsuccessful students. for the variables of race and location of undergraduate bsn institution (study site or within/outside of the state of south carolina), those categories with very few students were collapsed to strengthen the chi-square analysis. undergraduate anatomy, microbiology, and physiology gpa were combined into an undergraduate science gpa variable. group differences were reported using 95% confidence intervals and alpha was set at 0.05. results during the study time period, 84 students were enrolled in the family nurse practitioner program, including 70 (83.3%) females and 14 (16.7%) males. of these students, 15 (17.9%) were african american, 67 (79.8%) were caucasian, one (1.2%) was american indian or alaska native, and one (1.2%) was asian. eighty percent of these students provided permanent addresses in the admission record that corresponded to a location in the rural pee dee region. bivariate analyses (table 2) revealed that 49 (58.3%) of the enrolled students successfully completed the program, with 35 (41.7%) exiting the program unsuccessfully. of the 15 enrolled african american students, 12 (80%) were unsuccessful in completing the program compared to 23 (34.3%) caucasian students (p = 0.003). additionally, students who were unsuccessful in program completion were older and had a mean age of 38.7 (10.9) years compared to 35.6 (8.7) online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 216 years for successful students (p = 0.2). undergraduate bsn institution was a non-significant factor, as was the mean number of miles students lived away from campus. mean undergraduate bsn gpa was higher for successful students 3.5 (sd = 0.36) when compared to unsuccessful students 3.36 (sd = 0.39) (p = 0.1). although age and bsn gpa were non-significant factors, there are apparent differences between the groups that may be significant in a larger sample size of the population. table 2 student characteristics overall and by level of success (graduated vs. did not graduate) variable n (%) overall (n=84) level of success p-value did not graduate (n=35) graduated (n=49) gender 0.6 male 14 (16.7) 5 (35.7) 9 (64.3) female 70 (83.3) 30 (42.9) 40 (81.6) race 0.003i white or caucasian 67 (79.8) 23 (34.3) 44 (65.7) black or african american 15 (17.9) 12 (80) 3 (20) american indian or alaska native 1 (1.2) 0 (0.0) 1 (100) asian 1 (1.2) 0 (0.0) 1 (100) ethnicity na hispanic/latino 1 (1.2) 1 (100) 0 (0.0) age, mean (sd) 36.9 (1.1) 38.7 (10.9) 35.6 (8.7) 0.2 rurality 0.3 pee dee resident ii 67 (80) 26 (38.8) 41 (61.2) non-pee dee resident ii 17 (20) 9 (52.9) 8 (47.1) bsn college/university 0.3 study site 43 (51.2) 18 (41.9) 25 (58.1) other sc college/university iii 27 (32.1) 9 (33.3) 18 (66.7) non-sc college/university iv 14 (16.7) 8 (22.9) 6 (42.9) rn to bsn 38 (45.2) 16 (45.7) 22 (57.9) 0.9 bsn gpa, m (sd) 3.45 (0.38) 3.36 (0.39) 3.5 (0.36) miles from campus, m (sd) 41.1 (3.2) 42.8 (27.6) 39.9 (30.7) 0.7 undergraduate course / science gpa microbiology 3.0 (0.1) 3.0 (0.8) 3.1 (0.8) 0.6 anatomy 3.1 (0.1) 3.0 (0.9) 3.2 (0.8) 0.2 physiology 3.1 (0.1) 3.1 (0.7) 3.1 (0.7) 0.8 science v 3.1 (0.1) 3.0 (0.7) 3.2 (0.6) 0.4 masters of science degree (msn) gpa online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 217 variable n (%) overall (n=84) level of success p-value did not graduate (n=35) graduated (n=49) msn 3.3 (0.1) 2.2 (0.7) 3.7 (0.2) <0.001 i p-value obtained for 3 categories: white, black, & other (american indian or alaskan native, asian). iidetermined by reviewing student home zip codes and counties listed in “pee dee region” as defined by south carolina department of health and environmental control (n.d.) regional health care coalitions. iii includes 7 south carolina based colleges or universities. iv includes 9 non-south carolina based colleges or universities. v average gpa for undergraduate science courses: anatomy, physiology, & microbiology. discussion analysis of program admission data revealed suboptimal program completion rates for local pee dee residents and african american students. additionally, students with mean undergraduate gpas below 3.5 were less successful in program completion. there were no conclusive demographic or education factors for program success among the students. african american nurse practitioners are underrepresented in the workforce and in graduate nurse practitioner programs despite the need for a more diverse nursing workforce to meet the nation’s healthcare needs (national league for nursing, 2016). membership demographics for the aanp (2010) revealed that 90.3% of members are caucasian. in a 2016-2017 national survey, 13.9% of students who graduated from master’s in nursing np and post-master’s np programs were african american, while 66.0% of students were caucasian (american association of colleges of nursing, 2018). the program completion rates do not correspond with the nearly 40% of ethnic minorities representing the u.s. population and local community (sc, dhec, bchcdp, 2016; u.s. census bureau quick facts, 2017). supporting minority students to successfully graduate nursing programs is of great importance in order to develop nurse practitioners that represents the demographics of the surrounding population and meet the healthcare needs of rural diverse communities. understanding factors that positively and negatively influence minority student success can aid graduate nursing programs to support and respond to the unique needs of rural minority students. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 218 for this phase i analysis, barriers for rural and african american students for successful program completion were not clear given the information available in the academic admission records. thus, a phase ii qualitative study is planned to investigate barriers and facilitators to successful program completion for african american students who have previously been enrolled in the program. phase ii will include focus group sessions led by african american nurse practitioners to interview former african american students to discuss both program and socio-demographic factors that influenced their success in the program. several themes have been cited in the literature as barriers to minority student success. isolation and loneliness, discrimination and a lack of cultural competence by faculty, peers, patients, and staff, and lack of emotional and advisory support have been frequently identified in the literature (loftin, newman, dumas, gilden, & bond, 2012; murray, 2015; veal, bull, & miller, 2012; gardner, 2005). these themes, highlighting a lack of social integration, are consistent with factors identified in tinto’s model of student departure as influencing a student’s decision to depart from an institution (tinto, 1993). factors associated with minority student success includes program and personal factors. the presence of academic support, mentoring, and a minority student association are positive program factors (loftin et al., 2012; murray, 2015; veal et al., 2012). integration and inclusivity within the program and among peers is also very important (murray, 2015; veal et al., 2012). academic progression, defined as successfully obtaining knowledge and proceeding to the next course, helps instill confidence (veal et al., 2012). personal characteristics associated with success include determination, overcoming obstacles, and a resolve to succeed (loftin et al., 2012; gardner, 2005). these factors showing positive social, academic, and environmental integration and positive intentions by students are consistent with the elements of tinto’s model of student departure online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 219 found to support student retention (tinto, 1993). phase ii findings will be analyzed and interventions will be tailored to meet the specific needs of rural and african american students in the program in an effort to increase student success. limitations although the generalizability of the phase i results is limited due to sampling from one rural nurse practitioner program and a small sample size, findings revealed important group differences and warrant further investigation. the limited nature of the information available in the admission record hindered understanding of the influence of programmatic and socio-demographic factors on both overall and african american successful program completion. in response to these limitations, a phase ii qualitative exploration is planned to gain understanding of barriers and facilitators to successful program completion. although location of the institution and distance of student residence from campus were non-significant in this analysis, focus group sessions may reveal additional barriers unique to rural-dwelling students and their access to program support services. additionally, future study phases will include replication of the quantitative analysis and a logistic regression analysis using a larger number of student cohorts to increase power and generalizability of findings. conclusion decreased successful program completion rates overall and for both rural and african american students in a southeastern us rural graduate nurse practitioner program are not well understood by examination of admission factors and criteria. however, understanding barriers and facilitators to successful program completion for african americans is vital to providing tailored support for these minority graduate students. there is a need for more research to better understand the perceived beliefs and barriers experienced by rural minority students and how those beliefs are online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 220 related to successfully completing a family nurse practitioner program. focus groups with successful and unsuccessful nurse practitioner students may provide qualitative data on this population and pathways to support minority student success. by identifying and ameliorating the factors associated with minority student success, it may be possible to increase minority students’ graduation rates and to ultimately see the number of minority advance practice registered nurses increase to be more representative of the population being served. references american association of colleges of nursing. (2018). 2017 2018 enrollments and graduations in baccalaureate and graduate programs in nursing. washington, dc: american association of colleges of nursing. american association of nurse practitioners. (n.d.). np fact sheet. retrieved from https://www.aanp.org/all-about-nps/np-fact-sheet american association of nurse practitioners. (2010, may). 2010 membership demographics. retrieved from https://www.aanp.org/research/10-research/146-member-demographics creech, c. j., & aplin-kalisz, c. (2011). developing a selection method for graduate nursing students. journal of the american association of nurse practitioners, 23, 404 409. https://doi.org/10.1111/j.1745-7599.2011.00626.x el-banna, m. m., briggs, l. a., leslie, m. s., athey, e. k., pericak, a., falk, n. l., & greene, j. (2015). does prior rn clinical experience predict academic success in graduate nurse practitioner programs? journal of nursing education, 54, 276 280. https://doi.org/10.3928/01484834-20150417-05 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 221 gardner, j. (2005). barriers influencing the success of racial and ethnic minority students in nursing programs. journal of transcultural nursing, 16, 155 162. https://doi.org/ 10.1177/1043659604273546 health resources and services administration [hrsa] (n.d.a.). defining rural population. retrieved from https://www.hrsa.gov/rural-health/about-us/definition/index.html health resources and services administration [hrsa] (n.d.b). rural health grants eligibility indicator. retrieved from https://datawarehouse.hrsa.gov/tools/analyzers/geo/rural.aspx loftin, c., newman, s. d., dumas, b. p., gilden, g., & bond, m. l. (2012). perceived barriers to success for minority nursing students: an integrative review. international scholarly research network nursing, 2012, 1 9. https://doi.org/10.5402/2012/806543 murray, t. a. (2015). factors that promote and impede the academic success of african american students in prelicensure nursing education: an integrative review. journal of nursing education, 54(9), s74 s81. https://doi.org/10.3928/01484834-20150814-14 national league for nursing. (2016, february). achieving diversity and meaningful inclusion in nursing education: a living document from the national league for nursing. retrieved from http://www.nln.org/docs/default-source/about/vision-statement-achievingdiversity.pdf?sfvrsn=2 ortega, k. h., burns, s. m., hussey, l. c., schmidt, j., & austin, p. n. (2013). predicting success in nurse anesthesia programs: an evidence-based review of admission criteria. aana journal, 81, 183 189. patzer, b., lazzara, e.h., keebler, j.r., madi, m.h., dwyer, p., huckstandt, a.a., & smithcampbell, b. (2017). predictors of nursing graduate school success. nursing education perspectives, 33, 272 274. https://doi.org/10.1097/01.nep.0000000000000172 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 222 skillman, s., kaplan, l., andrilla, c.h.a., ostergard, s., & patterson, d. (2014). support for rural recruitment and practice among u.s. nurse practitioner education programs. policy brief #147, rural health research & policy centers. retrieved from http://depts.washington.edu/uwrhrc/uploads/rhrc_pb147_skillman.pdf south carolina department of health and environmental control (n.d.). sc dhec hpp regional health care coalitions. south carolina public health region snapshot. counties listed in pee dee region as determine by map retrieved from http://www.scdhec.gov/health/fhpf/ephf/grantrequirements/staffcontacts/ south carolina department of health and environmental control, bureau of community health and chronic disease. (2016). south carolina public health region snapshot. retrieved from http://scaledown.org/pdf/region%20snapshots%202016.pdf streeter, r., zangaro, g., & chattopadhyay, a. (2017). perspectives: using results from hrsa’s health workforce simulation model to examine the geography of primary care. hsr: health services research, 52(1). https://doi.org/10.1111/1475-6773.12663 united states census bureau (2017, july 1). quick facts. retrieved from https://www.census.gov/quickfacts/fact/table/florencecountysouthcarolina,florencecitys outhcarolina,us/pst045217 united states census bureau. (2010). 2010 urban and rural classification and urban area criteria. retrieved from https://www.census.gov/geo/reference/ua/urban-rural-2010.html tinto, v. (1993). leaving college: rethinking the causes and cures of student attrition, 2nd (ed.), chicago: university of chicago press. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.536 223 veal, j. l., bull, m. j., & miller, j. f. (2012). a framework of academic persistence and success for ethnically diverse graduate nursing students. nursing education perspectives, 33, 322 327. https://doi.org/10.5480/1536-5026-33.5.322 thill_545-other-3484-1-9-20190116 online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 89 a reality tour in rural and public health nursing nicole thill, mph 1 laura pettersen, m.s. 2 alana erickson, mph 3 1 executive director, north central wisconsin ahec, nthill@nahec-wi.org 2 executive director, scenic rivers ahec, lpettersen@scenicriversahec.org 3 communication specialist, winnebago county health department, aerickson@co.winnebago.wi.us abstract program purpose: rural areas face unique challenges recruiting and retaining registered nurses. communities and higher education programs must work collaboratively to successfully recruit and retain nurses and other health professionals to rural areas. students who receive firsthand experiences in rural, underserved areas are more likely to work in these areas upon graduation, when compared to students who are not provided with these opportunities. a rural immersion experience, as part of a nursing program, is one strategy to attract nurses to work in a rural area. discussion: students participate in a daylong tour visiting healthcare sites in a rural area. students are exposed to the diversity of rural populations and services, and learn about the unique challenges and rewards of working in those settings. over 700 students have explored a community action agency, county health department, critical access hospital, center for hospice care, and a federally qualified health center through the rural reality tour. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 90 program evaluation: eighty-three percent of participants said the experience had a positive impact on their interest in working in a rural or underserved area. students are asked to rate each partner session on a scale of 1 to 5, with 1 being no learning and 5 being a great deal of learning. for all sessions combined, partner sessions have averaged 4.27. conclusion: this low-cost, high impact program provides an opportunity to further communitybased education and enhance the supply, distribution, diversity, and cultural competence of registered nurses. keywords: nursing education, rural nursing, public health, area health education center (ahec), partnerships a reality tour in rural and public health nursing background the public health system is comprised of “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction” (centers for disease control and prevention, 2017). public health is evolving, and while the scope and complexity of public health nursing responsibilities have expanded (wisconsin department of health services, division of public health, office of health informatics, 2013), the united states has seen a steep decline in the number of trained community and public health nurses (young, acord, schuler & hanson, 2014). the reason for this is multidimensional, and mirrored in the shortage of rural nurses, including: an aging workforce, a poorly funded public health system, inconsistencies in community and public health nursing educational approaches and opportunities, and a shortage of clinical training sites (young et al., 2014). given the shortage of registered nurses and a poorly funded public health system, there is a great need for collaboration and pooling online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 91 of resources among public health departments, healthcare providers, and other organizations in rural communities in order to improve health outcomes. the united states census bureau defines rural as “all population, housing, and territory not included within an urban area.” urban areas fall into two categories, urbanized areas (uas) of 50,000 or more people, and urban clusters, of at least 2,500 and less than 50,000 people (united states census bureau, n.d.-a). the supply of registered nurses in rural communities is lower per capita than urban areas (u.s. department of health and human services, health resources and services administration, national center for health workforce analysis, 2013). the gap in supply and demand for nursing, as well as other healthcare professionals, is also higher in rural areas. rural areas typically have higher proportions of elderly and higher rates of chronic illness, both of which create an increase in demand for healthcare professionals (rural health information hub, n.d.a.). for example, 46 of wisconsin’s 72 counties are classified as rural (see figure 1) (wisconsin office of rural health, 2017). wisconsin’s 65 and older population slightly exceeds the national average of 15.6%, totaling 16.5% of the state population (united states census bureau, n.d.b). figure 1. rural wisconsin facts. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 92 rural communities experience significant health disparities and are more likely to be impacted by social factors impacting health (rural health information hub, n.d.b.). from access to direct medical services, to public health resources like fluoridated water, rural residents are impacted. addressing social determinants of health in curriculum and providing training opportunities in rural and underserved communities provides students with the skills needed to practice in these communities and refer patients to appropriate public and social service resources. it takes a multifaceted approach from multiple sectors to change systems and factors that impact health (advisory committee on training in primary care medicine and dentistry, 2016). it is imperative that communities and higher education programs work collaboratively to successfully recruit and retain health professionals to rural areas. higher education programs can offer, or even require educational training experiences in rural areas. research has shown nurses are more likely to work in a small, rural community if they were provided opportunities to experience a rural environment, and often employers use these experiences as a recruitment tool (hendrickx, mennenga, & johansen, 2013). the rural health tour discussed here does just that, bringing students to rural facilities to hear from practicing professionals and witness the unique structures of rural healthcare systems. a rural immersion experience, as part of an undergraduate nursing program, is one strategy to attract nurses to work in a rural area. a study conducted by coyle and narsavage (2012) evaluated the impact of a senior-level rural rotation on nursing student interest in rural health, changes in beliefs and perceptions related to rural health, and intent to practice in a rural state. of the 248 online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 93 participants who completed a pre and post survey, 53% of students reported an increased interest in rural healthcare. providing opportunities that excite students about public health is important to convey the value of public health nursing (larsen, reif, & frauendienst, 2012). nursing rotations among undergraduate students have expanded from recent norms. non-traditional sites, such as schools, homeless shelters, non-profit agencies, churches, etc., are being used more to reflect diversifying communities and unique social support interaction. this strategy not only benefits students by providing them a well-rounded clinical rotation experience, but combats the shortage issue of traditional clinical nursing sites as well. additionally, the more exposure students get to these non-traditional sites, the more likely they will choose to work in those settings upon graduation (pijl-zieber & grant kalischuk, 2011). along with exposure in undergraduate clinical experiences, healthcare facilities and organizations must have strong recruitment strategies in place to attract students to work in public health and rural areas. daniels, vanleit, skipper, sanders and rhyne (2007) sent a survey to health professional program graduates and found that those who first practiced in rural areas found the following factors important in their decision: community need, financial aid, community size, returning to hometown, and rural training program participation. purpose the goal of the rural health tour is to expose students and teaching staff to the diversity of rural populations and services and create awareness of the unique challenges and rewards of working in those settings. the driving force behind the development of the rural health tour was the desire of the nursing faculty at viterbo university for students to explore rural public health online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 94 service agencies firsthand and expose them to the communities and resources in the region. this complemented the ongoing need for a well-prepared future workforce in rural communities as expressed by community partners. students of this program attend school in a county designated in the 2010 census as 16.8% rural. this experience brings participants to three communities in two neighboring counties, one at 57.7% and the other 85.7% rural. the rural health tour is a daylong program that exposes nursing students to the populations and resources in the communities surrounding their higher education institution, the benefits and challenges of working in rural healthcare, and the professional opportunities available. to keep the program manageable and sustainable for all partners involved, the daylong tour runs a full and tight schedule (see figure 2). students load the bus at 8:00 a.m. and travel over 100 miles throughout the day to visit partner locations. program presenters include: a community action agency, a county health department, a critical access hospital, a center for hospice care, and a federally qualified health center. each site is given the opportunity to present an introduction to their services and their role as part of the public health system, discuss the communities they serve, highlight the benefits and challenges of rural healthcare, and offer a tour. partners highlight their work with unique populations including: spanish-speaking farm workers, amish factions, low-income patients, and many under or uninsured patients that may prolong seeking preventive healthcare services. students are encouraged to ask questions and participate in discussion. question prompts are provided to the students to help them connect the dots, and often students are enthusiastic to inquire from their own perspective. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 95 figure 2. rural health tour schedule used from 2016-2018. the regional area health education center (ahec) is a logical convener of this program because their goal is to improve access to healthcare by improving the number, distribution, and diversity of healthcare providers in the region they serve. for each tour, the regional area health online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 96 education center coordinates partners (who provide in-kind donation of their time), provides funding for lunch ($10.00 per person) and transportation ($350 for school bus rental), and prepares informational folders for the students ($45 for folders and printed copies). folders include an agenda and contact information for sites, information on other ahec programs, health careers websites, rural loan repayment programs, and other items as appropriate for the time and audience participating. the local community action agency sets the stage by discussing poverty in the region and social determinants of health. the presentation provides facts and examples of the struggles local families living in poverty face. health care issues, dental health concerns, housing, homelessness, transportation, and food insecurity are all discussed. students are given information about the services available to low-income individuals and families. this session helps students recognize, “how important it is for me, the nurse, to know these resources [in order to] advocate for my patients.” the next stop on the tour is a visit with public health nurses at the county health department. students learn about the myriad of services provided by the health department and the role of a public health nurse. a participant shared: “it was nice to learn about all the opportunities as a nurse in public health; many roles i didn’t even know existed. it definitely changed my views on public health nursing.” the critical access hospital provides a panel of professionals consisting of registered nurses from various departments, supervisors, and human resource staff. students listen to various perspectives on what it is like to work in a small, rural hospital. the human resource staff provide students resume/interviewing tips and information on the benefits and challenges of working at a online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 97 critical access hospital in a rural area. one student stated: “before this trip i didn’t know what rural hospitals and healthcare facilities had to offer, and now i think that it might be a better fit for me than a big hospital.” students meet with the director of a hospice care center where they learn about what it is like providing end of life care, specifically in a rural setting. the role of the interdisciplinary team and engagement of patients and families is highlighted. this discussion on the history of how and why this facility came to the community exemplifies “how the community [pulls] together to create programs to support people struggling in the community, and the community’s ability to come together to finance” needed resources. the last stop on the tour is a visit to a federally qualified health center (fqhc). exposure to the fqhc helps students see a valuable community-based resource in the region. students learn about the funding sources for fqhc’s, the unique populations served, the services provided, what it is like working in that setting and more. “i especially liked the last stop and scenic bluffs [community health center]. i always wondered what sort of job opportunities there are besides a hospital and i would love to work at a place like that,” is a sentiment shared by many program participants. all bachelor of science in nursing students at viterbo university are required to go on the rural health tour as part of their senior year public health nursing: concepts & clinical applications course. students go on the tour the second day of class, and refer back to the things they learned on the tour throughout the semester and during classroom time and clinical experiences. three of the tour’s sites regularly host students for clinical experiences. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 98 the rural health tour benefits students and partner sites alike. for many students the facilities within the tour offer a new perspective of providing healthcare. students gain a greater awareness of the social aid available and how to advocate for underserved patients. many students consider working in a rural setting, including a public health agency after this experience. the benefit for community partners is the opportunity to recruit future healthcare workers and promote the services they provide. figure 3. rural & health tour program evaluation used from 2013-2017. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 99 discussion all students who participate in the rural health tour are given an opportunity to evaluate their experience to examine whether the program is effectively meeting the goal of exposing students to the diversity of rural populations and services and creating awareness of the unique challenges and rewards of working in those settings. to ensure a high response rate, surveys (see figure 3) are administered in the classroom shortly following the rural health tour experience. data has been collected from 458 nursing student participants. student testimony assures that this program not only serves as a great educational experience, but often a career inspiration as well. students are asked, “has this clinical experience in any way affected your consideration of becoming employed as a nurse in a rural underserved part of the country?” 83.34% of participants responded yes and 16.66% of participants responded no. students are asked to rate each partner session on a scale of 1 to 5, with 1 being no learning and 5 being a great deal of learning. for all sessions combined, partner sessions have averaged 4.27. students also have the opportunity to provide written feedback about their experience. feedback has always been very positive. one student said: “it was a great day that not only oriented us to public health, but it opened my eyes to rural health as well. something i had previously not ever thought about as a nurse.” the impact of this program is apparent as expressed by one student: “i have always considered rural nursing... i feel more comfortable with the decision after this experience...i feel as though i could really make a difference in rural nursing.” to date, at least 12 students have been hired as a registered nurse at a site they visited on the rural health tour upon graduating with a bachelor of science in nursing degree. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 100 conclusion in an effort to support academic and workplace partners alike, the rural health tour program continues to expand by adding additional health profession program tours and sites. the tour began with 14 students per tour, and each year there has been a steady increase in the number of students as a result of class enrollment increases. currently the tour runs three times per year, with the number of students on each tour in the low 50’s, along with two nurse faculty and one scenic rivers ahec staff. since the program started in 2010, there have been over 20 tours, involving 15 community partners, and directly impacting over 500 nursing students. further research may involve a longitudinal study to investigate the number of participants who work in rural or public health shortly following graduation, as well as those participants who are still working in rural or public health years later. although 83% of participants reported this experience has affected their consideration of becoming employed in a rural underserved part of the country, it's unclear whether this tour is reinforcing pre-existing intentions. further research could measure the impact of the tour on students' interest in working at a rural health facility through a pre and post evaluation. the survey has high completion rates, in that completing the rural health tour evaluation is a requirement for the nursing students. the same evaluation was used from 2009-2013 evaluating self-reported student learning at each of the organizations visited. in 2013 the question “has this clinical experience in any way affected your consideration of becoming employed as a nurse in a rural underserved part of the country?” was added (see figure 3). in 2018, the survey was moved online to a qualtrics survey focusing on the outcomes and goals of the public health nursing: concepts & clinical applications course (see figure 4). the evaluation still relies on online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 101 student self-reported learning, but aligns with specific nursing concepts. in order to address the issue of unknown pre-existing intentions, students are asked a before and after question regarding intention to work in a rural setting and intention to work in public health. figure 4. updated rural health tour evaluation used 2018 -present. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 102 the adaptation of this survey demonstrates the quality improvement mindset of this program; continuing to provide a meaningful experience for the students and measure the success of intentions. the rural health tour is a low-cost, high impact program that provides an opportunity to further community-based health profession education and enhance the supply, distribution, diversity, and cultural competence of healthcare professionals in rural and underserved areas. the rural health tour is an effective way to provide nursing students with rural and public healthcare experiences and promote opportunities beyond the traditional clinical setting. this inexpensive program is replicable in other health profession programs in a variety of communities. references advisory committee on training in primary care medicine and dentistry. (2016). addressing social determinants of health: the role of health professions education. retrieved from https://www.hrsa.gov/advisorycommittees/bhpradvisory/actpcmd/actpcmd_13th_report_sd h_final.pdf centers for disease control and prevention. (2017). the public health system & the 10 essential public health services. retrieved from https://www.cdc.gov/publichealthgateway/publicheal thservices/essentialhealthservices.html coyle, s.b., & narsavage, g.l. (2012). effects of an interprofessional rural rotation on nursing student interest, perceptions, and intent. online journal of rural nursing & health care, 12(1), 40-48. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 103 daniels, z., vanleit, b., skipper, b., sanders, m., & rhyne, r. (2007). factors in recruiting and retaining health professionals for rural practice. journal of rural health, 23(1), 62-71. https://doi.org/10.1111/j.1748-0361.2006.00069.x hendrickx, l., mennenga, h., & johansen, l. (2013). the use of rural hospitals for clinical placements in nursing education. in c.a. winters (ed.). rural nursing: concepts, theory and practice. (pp. 293-301). new york: springer. https://doi.org/10.1891/9780826170866.0019 larsen, r., reif, l., & frauendienst, r. (2012). baccalaureate nursing students' intention to choose a public health career. public health nursing, 29, 424-432. https://doi.org/10.1111/j.15251446.2012.01031.x pijl-zieber, e. m., & grant kalischuk, r. (2011). community health nursing practice education: preparing the next generation. international journal of nursing education scholarship, 8(1), 2250. rural health information hub. (n.d.a.). rural healthcare workforce. retrieved from: https://www.ruralhealthinfo.org/topics/health-care-workforce#workforce rural health information hub. (n.d.b.). social determinants of health for rural people. retrieved from https://www.ruralhealthinfo.org/topics/social-determinants-of-health united states census bureau. (n.d.-a). geography: urban and rural. retrieved from https://www.census.gov/geo/reference/urban-rural.html united states census bureau. (n.d.-b). quickfacts: selected: wisconsin; united states. retrieved from https://www.census.gov/quickfacts/fact/table/wi,us/age775217 u.s. department of health and human services, health resources and services administration, national center for health workforce analysis. (2013). the u.s. nursing workforce: trends online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.545 104 in supply and education. retrieved from: https://bhw.hrsa.gov/sites/default/files/bhw/ nchwa/projections/nursingworkforcetrendsoct2013.pdf wisconsin department of health services, division of public health, office of health informatics. (2013). wisconsin public and community health registered nurse workforce report (p00450). retrieved from: https://www.dhs.wisconsin.gov/publications/p0/p00450.pdf wisconsin office of rural health. (2017). rural wisconsin fact sheet. retrieved from: http://worh.org/sites/default/files/rural%20wi%20health%202017_0.pdf young, s., acord, l., schuler, s., & hansen, j. (2014). addressing the community/public health nursing shortage through a multifaceted regional approach. public health nursing, 31, 566573. microsoft word a review of barriers to healthy eating in rural and urban adults.docx online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 122 a review of barriers to healthy eating in rural and urban adults jill r. reed, phd, aprn-np 1 bernice c. yates, phd, rn, faha 2 julia houfek, phd, rn, aprn-cns 3 wayne briner, phd 4 kendra k. schmid, phd 5 carol pullen, edd, rn 6 1 assistant professor, college of nursing, university of nebraska medical center, jrreed@unmc.edu 2 professor, college of nursing, university of nebraska medical center, bcyates@unmc.edu 3 professor, college of nursing, university of nebraska medical center, jhoufek@unmc.edu 4 professor, college of health human services and sciences, ashford university, wayne.briner@ashford.edu 5 associate professor of biostatistics, director of masters programs at the college of public health, university of nebraska medical center, kkschmid@unmc.edu 6 professor, college of nursing, university of nebraska medical center, chpullen@unmc.edu abstract background: people encounter a variety of barriers that impact their ability to eat a healthy diet. because of the higher obesity rates and poorer health status in rural adults, attention is needed on examining the gaps in knowledge about healthy eating barriers in rural adults. purpose: the purpose of this manuscript was to describe what is known about barriers to online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 123 healthy eating in both rural and urban adults. the social ecological model was used as a framework using individual, interpersonal, organizational, and community factors to organize barriers to healthy eating. methods: forty-two studies were found that discussed barriers to healthy eating in adults. of these, 14 were conducted solely in rural settings, 2 in mixed rural and urban settings and the remaining 26 studies done in urban settings. results: the impact of barriers unique to rural settings is not well understood as the majority of studies found were conducted in urban settings. barriers that rural adults face that may contribute to their greater occurrence of obesity were higher cost of healthy foods, lack of time, lack of social support, work issues and lack of access to grocery stores. conclusion: more research is needed to provide a greater understanding of the unique challenges rural people face and how to eliminate barriers to maintaining a healthy diet. keywords: barriers, healthy eating, rural, obesity a review of barriers to healthy eating in rural and urban adults individuals can positively influence their own health and well-being by choosing diets or making food choices based on nutritional recommendations (teixeira, patrick, & mata, 2011). unfortunately, many people encounter a variety of barriers that impact their ability to eat a healthy diet, therefore contributing to the high rates of overweight and obese adults and subsequent chronic medical conditions. background and significance typical attributes of a healthy eating pattern are eating whole fruits and vegetables, low fat dairy products, eating a variety of foods, eating regularly, and eating foods high in vitamins and online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 124 minerals.  (lacaille, dauner, krambeer, & pedersen, 2011). despite the apparent knowledge of the importance of fruits and vegetables in a healthy diet (eikenberry & smith, 2004), one-third of americans report consuming fruits and vegetables less than one time daily (centers for disease control and prevention, 2013). finding ways to increase healthy foods, such as fruit and vegetable intake, as part of a healthy diet, should focus on factors influencing intake, such as eliminating barriers of healthy eating (eikenberry & smith, 2004). the challenge, not only in the united states (us), but globally, is centered on how to help people eat healthy foods and limit intake of unhealthy high-fat, high-calorie, processed, and convenience foods (sassi, 2010). changing eating behaviors and removing barriers for healthy eating is important for all adults at risk for becoming overweight or obese. however, it is even more important for individuals in rural areas because the occurrence of being overweight or obese is significantly higher (befort, nazir, & perri, 2012). not only do rural people experience greater rates of becoming overweight and obese compared to their urban counterparts, but they also have higher dietary fat and calorie consumption and less access to fresh fruits and vegetables (bolin, gellamy, ferdinand, kash, & helduser, 2015; nebraska health and human services system , 2004). the seriousness and magnitude of the obesity problem in rural areas is also a central focus of national initiatives. one goal of healthy people 2020 (n.d.) is to eliminate differences in obesity risk due to geographic location, such as living in rural areas where approximately 20% of the u.s. population lives (united states census bureau, 2010). greater attention should be paid to the problem of obesity in rural areas because these individuals have higher rates of premature death from chronic diseases such as chronic obstructive pulmonary disease, cardiovascular disease and some cancers (befort et al., 2012; eberhardt & pamuk, 2004). online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 125 the purpose of this review was to describe what is known about barriers to healthy eating in both rural and urban adults. since the majority of studies have been conducted in adults living in urban areas with limited information about rural adults, it was necessary to describe what is currently known in both populations. because of higher obesity rates and poorer health status in rural adults, the focus was on examining what is known and not known about barriers to healthy eating encountered by adults living in rural areas. methods a literature review was conducted to identify studies that discussed barriers to healthy eating in adult populations. the databases pubmed, cinahl, cochrane and scopus were searched using the key words “barriers,” “healthful eat*,” “healthy food,” “diet,” “nutrition,” “obesity,” “overweight,” “adults,” “urban,” and “rural” in various combinations. the search was not limited by date of publication but was limited to the english language and adult human subjects. to be included, studies had to discuss barriers of healthy eating in adults as the main focus. if the study examined both barriers to healthy eating and physical activity, the article was included. studies were excluded if they focused on eating disorders, healthy eating behaviors of children or adolescents, or focused solely on barriers to exercise or physical activity. both quantitative and qualitative studies were included in the review. the search for literature revealed a majority of studies being conducted in urban areas compared to rural settings. forty-two studies were found that discussed barriers to healthy eating in adults. of these, 14 were conducted solely in rural settings, 2 in mixed rural and urban settings, and the remaining 26 studies were done in urban settings. sixteen of the twenty-six urban studies (62%) were conducted in international locations such as europe, australia and canada. because the majority of the studies were done outside the us, it was felt these online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 126 international studies should be included to provide a more comprehensive review of the barriers experienced by adults. although rural is defined in a variety of ways, if the investigator asserted or maintained they were studying a rural population, the article was included in the review. in this paper, perceived barriers was defined as an individual's evaluation of the potential obstacles that may lessen the likelihood of engaging in a specific health behavior (glanz, rimer, & viswanath, 2008), in this case healthy eating. the social ecological model (sem) is a systems model with multiple bands of influence that emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem (rimer & glanz, 2005). according to fleury and lee (2006) multilevel perspectives consistent with the sem are useful approaches in health behavior research and health promotion efforts. therefore, the sem was used to organize and examine healthy eating barriers experienced by adults because barriers are multifaceted and function on multiple levels. the following four levels of the sem were used to review barriers to healthy eating: individual, interpersonal, organizational, and community (mcleroy, bibeau, steckler, & glanz, 1988). each level of the sem is first defined followed by a summary of the barriers identified in each level, starting with rural studies followed by a summary of studies conducted in urban settings. each level concludes with a summary of the barriers discovered for that level along with the implications for rural populations. results individual barriers the individual level of the sem includes characteristics of the individual such as knowledge, attitudes, behavior, self-concept, skills, and developmental history (mcleroy et al., online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 127 1988). across various studies, barriers that prevented individuals from participating in healthy eating behaviors included lack of time, cost, taste preferences, lack of knowledge, and lack of motivation or willpower  (biloukha & utermohlen, 2001; eikenberry & smith, 2004; gough & conner, 2006; kearney & mcelhone, 1999; welch, mcnaughton, hunter, hume, & crawford, 2009; welsh et al., 2012; whiting, vatanparast, taylor, & adolphe, 2010). lack of time. the concept of lack of time in relationship to healthy eating is complex (welch et al., 2009). it may reflect an individual’s perception of time available for food shopping and preparation, but may also be associated with their perception of the time demands related to other aspects of life including job, studies or family that may take precedence over healthy eating (gedrich, 2003). research conducted in rural areas was scarce with only two studies found examining lack of time as a barrier to healthy eating. specifically, for rural women, healthier eating occurred more often when time was not seen as a barrier (yates et al., 2012; sequin, connor, nelson, lacroix, & eldridge, 2014). research conducted within urban areas in europe revealed lack of time, specifically lifestyle choices (e.g. leisure activities) and work commitments, as a major perceived barrier to healthy eating (biloukha & utermohlen, 2001; gough & conner, 2006; kearney & mcelhone, 1999; lappalainen, saba, holm, mykkanen, & gibney, 1997). working more than 40 hours per week was associated with a greater number of time-related barriers and behaviors regarding healthy eating in young urban adults from the us. barriers included: (a) being too busy to eat healthy, (b) being too rushed in the morning to eat a healthy breakfast, (c) not enough time to sit online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 128 down and eat a meal, and (d) perceiving eating healthy took too much time (escoto, laska, larson, neumark-sztainer, & hannan, 2012). lack of time was cited as a barrier to healthy eating for australian urban women primarily due to long hours at work (andajani-sutjahjo, ball, warren, inglis, & crawford, 2004; welch et al., 2009). women were significantly less likely to consume portions of a healthy diet (i.e., fruits and vegetables) and more likely to consume portions of an unhealthy diet (i.e., fast foods and energy-dense snack foods) due to time constraints (welch et al., 2009; williams, thornton, & crawford, 2012). older women were less likely to report time pressure as a barrier to healthy eating than younger women, possibly because of decreased demands on their time due to fewer employment or child care responsibilities (welch et al., 2009). cost. the cost of buying healthy foods was another area with limited research findings pertaining to rural adults with only two studies located. these studies found when rural women perceived cost as a minimal barrier to buying healthy foods, they in turn ate a healthier diet (yates et al., 2012; sequin et al., 2014). the cost to purchase healthy foods was cited as a barrier to healthy eating for urban adults living in europe (biloukha & utermohlen, 2001), the us (keim et al., 2011; lucan, barg, & long, 2010; marcy, britton, & harrison, 2011; wolf et al., 2008), and for low-income canadian adults (whiting et al., 2010). not only was current cost of healthy foods an issue, but many urban adults, in the us and globally, reported the rising cost of purchasing healthy foods as an ongoing barrier (biloukha & utermohlen, 2001; eikenberry & smith, 2004; gough & conner, 2006). the reported high cost and lack of access to fruits and vegetables were among the most troublesome for a group of urban adults from the united kingdom (uk) who were actively online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 129 trying to increase fruit and vegetable consumption (john & ziebland, 2004). australian urban women cited the cost of buying healthy foods as the most common barrier to healthy eating and ultimately maintaining weight (andajani-sutjahjo et al., 2004). taste preferences and perceptions. no studies were found explicitly examining taste preferences and perceptions (i.e., healthy eating is boring) in rural adults. in contrast, multiple studies conducted in urban areas were found. the perception of healthy eating as “boring” constituted a major barrier to changing current diets, with taste clearly being presented as a key barrier to the intake of more healthy foods for a group of urban men from the uk (gough & conner, 2006). taste, along with quality and freshness, was also identified as a barrier for european union adults, although this was an issue for more men than women (biloukha & utermohlen, 2001; kearney & mcelhone, 1999). australian women with a taste preference for fruits and vegetables were more likely to consume components of a healthy diet and less likely to consume components of an unhealthy diet (williams et al., 2012). a study of u.s. urban adults found that concerns about the reduction of taste quality of a low-fat, healthy diet was the most important factor affecting food decisions (glanz, basil, maibach, goldberg, & snyder, 1998). lack of knowledge. no studies were found specifically addressing lack of knowledge of healthy eating as a barrier for rural adults. research conducted within urban areas of europe has shown lack of knowledge about what constituted healthy foods to be a barrier for not eating a healthy diet (biloukha & utermohlen, 2001; ziebland, thorogood, yudkin, jones, & coulter, 1998). lowincome canadian adults also reported lack of knowledge as a barrier for healthy eating (whiting et al., 2010). in a study of urban u.s. adults, men rated knowledge as a barrier for healthy eating online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 130 higher than women did (welsh et al., 2012). men’s relative lack of knowledge related to healthy eating may reflect an overall gender difference regarding food behavior as women historically have been more involved in grocery shopping and cooking (welsh et al., 2012). another european study found lack of knowledge was not a major obstacle to healthy eating as these adults already believed their diets were healthy (kearney & mcelhone, 1999). lack of motivation or willpower. lack of motivation as a barrier to healthy eating in rural adults was not found in the existing literature. however, perceived lack of self-control or willpower for eating unhealthy foods was identified as an important barrier to healthy eating in urban adults living in the us (welsh et al., 2012) and in younger adults and in those with higher education living in europe (lappalainen et al., 1997). similarly, lack of motivation for changing their diet and losing weight was one of the greatest barriers for healthy eating in multiple european studies of urban adults (biloukha & utermohlen, 2001; gough & conner, 2006; jones, furlanetto, jackson, & kinn, 2007; kearney & mcelhone, 1999; lappalainen et al., 1997; michaelidou, christodoulides, & torova, 2012; sabinsky, toft, raben, & holm, 2007). australian women cited lack of motivation as the most common perceived barrier to healthy eating and ultimately maintaining weight (andajani-sutjahjo et al., 2004). summary of individual level barriers across studies, lack of time and the cost of purchasing healthy foods were the two most commonly cited and perhaps the two most influential factors that created barriers to healthy eating. because most of the studies were qualitative or self-report, it is difficult to know if the identified barriers were actual barriers or a perception of barriers experienced by the individual. the majority of the studies examining individual level barriers were conducted in urban online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 131 populations with information specific to rural populations being minimal. two studies used mixed samples of rural and urban adults but did not report differences between the groups so it is unknown which barriers were unique or more difficult for rural adults (eikenberry & smith, 2004; jilcott, laraia, evenson, & ammerman, 2009). many of these individual barriers reported by urban adults may be relevant in rural adults as well, but more studies are needed to confirm these findings. more studies are needed in rural adults that examine individual level factors that create unique barriers to healthy eating in rural adults. interpersonal barriers according to the sem, the interpersonal level includes formal and informal social support systems, including family, work group, and friendship networks (mcleroy et al., 1988). barriers at the interpersonal level seem to originate from the lack of support from family and friends and the living situation of the individual (living alone). lack of social support. lack of support and negative support are both barriers to healthy eating and have been reported in both rural and urban low income women. while women tried to prepare healthy meals for the family, lack of encouragement from partners/spouses in rural settings (parker & keim, 2004) and refusal to eat healthy foods by the entire family in urban settings hindered their attempts (chang, nitzke, guilford, adair, & hazard, 2008). another barrier to eating and preparing healthy foods mentioned in mixed rural and urban populations was accommodating food preferences of the entire family, including their preference for unhealthy snack food (chang, baumann, nitzke, & brown, 2005: eikenberry & smith, 2004; jilcott et al., 2009). lack of support was also an issue for women when they felt they had no one to confide in, no online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 132 one to share their healthy eating problems with and no one to simply listen to them (chang et al., 2008). in contrast, the majority of studies examined social support for healthy eating from a positive perspective. in rural southeastern us, family support for healthy eating was significant for men but not women (hermstad, swan, kegler, barnette, & glanz, 2010). it is possible that this greater sense of social support for healthy eating among men is because women often do the food shopping and meal preparation for the family. social support from families was also positively associated with healthy eating in rural women, including an increased consumption of fruits and vegetables (yates et al., 2012). the most commonly experienced support for rural women from both family and friends were compliments on changing eating habits, discussion of eating habit changes, and encouragement not to eat unhealthy foods when tempted which improved healthy eating behaviors (walker, pullen, hertzog, boeckner, & hageman, 2006). one could assume that the lack of these supportive behaviors may have a negative effect on rural individuals’ healthy eating behavior, but more research is needed in this area. in studies involving mixed samples of urban and rural adults, family or living with someone was the most common promoter of healthy eating whereas living alone was a frequent barrier to healthy eating (eikenberry & smith, 2004). for women, their family’s preference for unhealthy snack food was the most prominent influence on shopping and food found in the home (jilcott et al., 2009). women in urban australia who perceived more family support, including family members eating and encouraging them to consume a healthy diet and discouraging eating unhealthy foods, were more likely to consume components of a healthy diet and less likely to consume components of an unhealthy diet (williams et al., 2012). anderson, winett, and online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 133 wojcik (2007) found that higher levels of social support from families for shopping for healthier foods such as fruits and vegetables to bring into the home was related to healthier eating. summary of interpersonal level barriers lack of social support from family members was the most powerful barrier at the interpersonal level that hinders attempts to eat a healthy diet. for many individuals, family members are the people they spend the most time with and consequently who have the most influence on their eating behaviors. because lack of social support as a barrier has not been studied much in populations other than low-income women, regardless of setting, we do not know the impact lack of social support has on healthy eating in other groups. limited studies were found measuring lack of social support. more studies are needed to determine what factors constitute perceived lack of support as a barrier, the obstacles it creates, and how individuals can overcome the challenges for healthy eating created by lack of support. organizational barriers the organizational level of the sem includes worksites which occur and operate under a common set of rules and policies that guide behavior (mcleroy et al., 1988).     the primary organizational factor for adults that may pose a barrier for healthy eating is the work environment. work environment. healthy eating may be challenged in the workplace by societal trends that include (a) longer working hours, (b) compressed work weeks (working a traditional 40-hour week in less than 5 days), (c) shift work, (d) longer distances to travel between work and home, (e) reduced job security, and (f) part-time or temporary work, which are realities of the modern workplace online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 134 (“healthy people 2020”, n.d.; jabs & devine, 2006). longer hours in the workplace are increasingly affecting the health and lives of u.s. adults (“healthy people 2020”, n.d.). research has shown that workers experiencing stressors, both physical and psychological, at work are at increased risk of injuries, heart disease, and digestive disorders (“healthy people 2020”, n.d.). farming is one occupation commonly found in rural areas. befort et al. (2012) found an increased risk of obesity in young rural adults aged 20 to 39. a potential explanation for this is that equipment has become more computerized and mechanized, contributing to the increased prevalence of obesity among younger rural workers compared to the older generation of farmers (befort et al., 2012; bolin et al, 2015). jilcott et al. (2009) found the social environment (presence of "tempting" foods with little nutritional value) at work to be a barrier for healthy eating in a mixed sample of urban and rural women. a qualitative study examining healthy eating behaviors in small, rural worksites (i.e., fewer than 50 employees) found multiple barriers (escoffery, kegler, alcantara, wilson, & glanz, 2011). more than half of respondents identified (a) lack of time, (b) limited selection of healthy food options at work, (c) job stress leading to eating unhealthy foods, and (d) location of their job (e.g. small, rural community), which could limit access to healthy foods, as barriers to healthy eating at work. studies conducted in urban areas have also demonstrated that the worksite creates a potential barrier for healthy eating, specifically because of the amount of time spent in the work environment (welch et al., 2009). australian women reported (a) inflexible hours, (b) unpredictable hours, and (c) shift work including night and weekends as barriers for healthy eating in the work environment (welch et al., 2009).. doctors from the uk perceived their online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 135 employer and work environment as unsupportive of healthy eating due to lack of breaks and unhealthy cafeteria food (winston, johnson, & wilson, 2008). similarly, long work shifts, lack of breaks due to poor staffing and busy workloads were identified as barriers to healthy eating in a study of nurses in the uk (faugier, lancaster, pickles, & dobson, 2001). summary of organizational level barriers at the organizational level, the work environment was the primary influence with similar barriers found in both rural and urban settings. the rural work environment has been studied less than urban workplaces. however, from the available literature, it appears that the setting of the workplace, whether rural or urban, was not the primary reason people experienced barriers to healthy eating. many of the barriers identified at the organizational level were issues uncovered at the individual level as well, such as lack of time. it is difficult to entirely separate these identified barriers because it is the individual at work and their personal perceptions that influenced what was seen as barriers in the work place. while the work environment itself can contribute to these barriers, such as the number of hours spent at work, many of these issues can be attributed to the perception of the individual. more studies are needed focusing on rural worksites with an emphasis placed on decreasing the barrier to eating a healthy diet. community barriers the community level of the sem includes the connections among institutions and informational networks within defined boundaries which collectively comprise the larger societal structure (mcleroy et al., 1988). community can be defined by geographic location, membership in a particular group, or possession of certain beliefs that produce affiliations. the main community barriers identified that impact healthy eating includes lack of access to stores online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 136 selling healthy foods and the media that can give inaccurate nutrition information or glamorize foods. lack of access. lack of access to obtaining food within the community encompasses multiple issues. the primary access issues included (a) geographic isolation, (b) distance to the nearest grocery store, and (c) limited transportation. in addition, quality and cost of available food and access to healthy foods such as fruits, vegetables, low-fat food items and whole grain products created problems for many adults (chang et al., 2008; jilcott et al., 2009; liese, weis, pluto, smith, & lawson, 2007; patterson, moore, probst, & shinogle, 2004; sequin et al., 2014; yousefian, leighton, fox, & hartley, 2011). rural dwellers face barriers to healthy eating because of their physical isolation and lack of access to healthy food sources (befort et al., 2012). food sources in rural areas are not evenly distributed. because of economic considerations, many grocery stores in rural areas are consolidating into fewer but larger stores. generally these larger stores are concentrated in bigger towns in the local areas leading to areas of concentration and areas where few or no grocery stores exist (morton, bitto, oakland, & sand, 2005; sharkey, 2009; sharkey & horel, 2008). these changes in the food environment are adversely affecting those living in rural areas because of cost (sharkey, 2009). without easy access to local grocery stores, individuals either have to pay higher travel costs to reach a grocery store, or pay higher prices for more nutritious foods such as fresh fruits and vegetables at local convenience stores, if those healthier options are even available (liese et al., 2007; sharkey & horel, 2008). another potential source for healthy foods at home is the maintenance of a family vegetable garden. there is some perception that rural areas have better access to fresh online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 137 vegetables because of farming. however kegler, escoffery, alcantara, ballard, and glanz (2008) found most rural people did not have a produce garden because they believed they did not have time, felt they were too old, or thought gardens were too much work and could buy produce cheaper than actually growing it. rural residents felt that having access to local farmers’ markets and having the opportunity to join a community garden was easier than having a garden at home (sequin et al., 2012). research conducted primarily within urban areas has shown that populations with limited or difficult access to a grocery store (supermarket) tend to live in neighborhoods with greater disadvantages and/or with a higher proportion of minority residents (sharkey, 2009). residents of these same neighborhoods tend to consume fewer fruits and vegetables, and often have a higher body mass index (bmi) than do residents of affluent areas (inagami, cohen, finch, & asch, 2006; morland, diez roux, & wing, 2006). the lack of availability of large supermarkets is of concern because large supermarkets tend to offer food at lower prices and provide a wider variety and higher-quality food products than do small grocery stores (horowitz, colson, hebert, & lancaster, 2004). the presence of supermarkets in urban communities was associated with a lower prevalence of obesity (morland et al., 2006). in contrast, the presence of convenience stores was associated with a higher prevalence of obesity in the us (morland et al., 2006). inagami et al. (2006) also found higher bmis in individuals who lived and shopped at grocery stores that were in disadvantaged urban neighborhoods and in those who traveled farther to access a grocery store. media. aggressive marketing of unhealthy foods by the media was seen as a barrier for rural adults (kaiser & baumann, 2010). in addition, the media was found to be a negative barrier in urban online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 138 adults and could influence dietary choices and intake through conflicting dietary information. whiting et al. (2010) found that low-income canadians were influenced negatively by the media as these individuals reported they were not clear on what was accurate information regarding healthy eating despite all the information found in magazines and on television. urban men from the uk did not like the government using the media to tell them what was healthy or unhealthy and ultimately what they should or should not eat (gough & conner, 2006). for college students, a commonly cited barrier regarding advertising was making the food look so enticing that the individual wanted to go buy that food right away, even though they knew it was an unhealthy food (garcia, sykes, matthews, martin & leipert, 2010). another barrier included the economic aspect of advertising campaigns such as buy one, get one free for unhealthy snacks, such as candy bars. the individual sees that buying more is a better value, therefore taking advantage of the better value and thus indulging in more candy (garcia et al., 2010). summary of community level barriers lack of access to healthy foods and the influence of the media were both barriers noted at the community level for rural and urban adults. the amount of time many individuals spend using various sources of media (e.g. tv, internet) could be a possible explanation of the influence media messages have on maintaining a healthy diet. because of advances in technology and improved means of communication, the barriers the media creates seem to affect rural and urban adults in similar ways. more studies are needed to determine how to assist rural residents to overcome the lack of access barrier and to improve the ability to purchase healthier foods easier and cheaper than currently available. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 139 discussion it is imperative that barriers to healthy eating for rural individuals receive more research attention. rural residents experience higher poverty rates (kusmin, 2010) and are less likely to meet recommendations for fruit and vegetable consumption than urban residents (lutfiyya, chang & lipsky, 2012). ver ploeg et al. (2012) found that while the majority of rural residents live within 10 miles of a grocery store, those with lower income tend to live more than 10 miles from a grocery store. unhealthy eating behaviors may lead to the development of obesity and other chronic diseases such as cardiovascular disease, hypertension, diabetes, and several types of cancer (national heart, lung, and blood institute, 2013). despite several national initiatives to eliminate differences in these health issues due to geographic location, few studies have been done examining the unique barriers to healthy eating in adults living in rural areas. based on the studies reviewed, the most common barriers to healthy eating for rural adults included individual-level barriers of lack of time to shop for and prepare healthy meals and the higher cost of healthy foods. lack of social support was the most common barrier at the interpersonal-level. the most frequent organizational-level barrier was time spent at work while lack of access to grocery stores and healthy foods created the most common barrier at the community–level. having access to and availability of healthy foods, the time to prepare healthy meals and social support from family and friends is necessary so adults can follow a healthy diet. better access to retail stores that sell healthier food options may have a positive impact on a person’s diet, yet these locations may be less available in rural neighborhoods (“healthy people 2020”, n.d.). people in rural areas live farther from the nearest supermarkets meaning average distance, time, and out-of-pocket cost to get healthy foods is greater for rural than urban individuals (united states department of agriculture, 2009). given that shopping at online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 140 supermarkets is associated with greater fruit and vegetable consumption and traveling greater distances to grocery shop is associated with higher bmi, the scarcity of supermarkets in rural areas may help explain the increased rates of obesity (inagami et al., 2006). finally, the higher cost of food can impede healthy eating in rural communities (hardin-fanning & rayens, 2014). while the various types of barriers for healthy eating were categorized into different levels based on the sem, in reality they do not work in isolation. the influences on healthy eating behaviors interact across these different levels. a great deal of the literature addressed individual level barriers. lack of time, identified as an individual barrier, has influence on the other levels as well. for example, an individual’s perception of lack of time available to eat healthy was the result of the amount of time spent involved with work and family commitments which took away time to shop and prepare healthy meals. they may also need to travel considerable distances to reach a grocery store which also takes more time. this review uncovered more international studies that examined barriers to healthy eating in urban adults compared to studies conducted in urban u.s. adults. the findings indicated similar barriers to healthy eating in urban settings, regardless of the country the study sample was located in. because of the lack of research in rural adults, both nationally and internationally, more research needs to be conducted to determine if rural adults face similar barriers to what was found in urban adults or if they have other barriers that need to be discovered and addressed. the few studies that were conducted in rural populations consisted primarily of women, so even less is known about the barriers men face. with men being the primary workers in rural occupations, such as farming, and with younger rural adults having increased rates of obesity compared to older rural adults (befort et al., 2012), it is critical to learn more about what barriers online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 141 exist in rural populations and how to intervene to prevent the increasing rates of obesity and comorbid conditions that arise secondary to being overweight and obese. once there is more knowledge about the barriers rural adults face, more intervention studies can be conducted to determine how to effectively help rural adults overcome these barriers to eating a healthy diet and ultimately to lose weight or maintain a healthy weight and decrease the incidence of chronic diseases that arise from being overweight/obese. interventions to reduce the occurrence of overweight and obesity and improve access to healthy foods need a multidimensional approach that focuses on individual behavior change, interpersonal influence, organizational issues, and community influences (gamm, hutchison, dabney, & dorsey, 2003). limitations the broad range of definitions of rural and the variability in rural populations across studies was a concern. only two studies provided the actual population size of the county used in the study to provide evidence of rural status (escoffery et al., 2011; nothwehr & peterson, 2005). casey et al. (2008) was the only study that reported the criteria used to define rural, the u.s. census bureau, which included areas with populations less than 50,000 people. there can be great variability in the population of a community identified as rural along with the actual services offered and availability of food sources. the lack of information about the rural population and disparate definitions of rural complicated the interpretation of results and comparisons across studies. it would help to have the use of a consistent or standard definition to define rural in future studies. nevertheless, there remains inherent value in examining barriers found in urban versus rural populations. it is essential for future research studies to define the rural or urban setting (e.g., rural urban commuting area codes (ruca) codes) so online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 142 comparisons and conclusions can be made more confidently as this line of research needs to continue to ensure the needs of rural and remote populations are understood and met. because of a lack of strategies identified for rural communities to use to overcome barriers, strategies applicable for urban communities are often made to fit rural areas (barnidge et al., 2013). adapting evidence to a rural setting is challenging based on characteristics of the rural environment itself, such as social norms, less access to stores, less people living in the area, fewer health care providers, and cultural practices unique to rural settings (hennessy et al., 2010). in addition, more studies are needed to determine the strategies that work in rural areas to overcome barriers to healthy eating. conclusion more data are needed to know exactly what barriers for healthy eating exist for rural adults so intervention strategies to overcome barriers and increase access to healthy foods can be identified. multilevel interventions that combine both behavioral and environmental components to support healthy eating behaviors are essential. nurses have the knowledge and skills to assess nutritional status and are well positioned to provide leadership at all levels to promote healthy diets and ultimately healthier communities. the importance of understanding the unique challenges that rural adults face in the quest to eat a healthy diet is critical, especially for nurses working in rural settings. this review found multiple barriers to healthy eating in adults. it is essential to explore new pathways to improve the health of rural people and not blindly accept the existing conditions and barriers simply because of their location on a map. significant steps are needed to make healthy food choices available and affordable to all people in all types of geographic locations, including urban and rural (story, kaphingst, robinson-o'brien, & glanz, 2008). from a social ecologic perspective, online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.379 143 the goal should be a to reduce barriers encountered at each level; individual, interpersonal, organizational, and community, in an effort to support healthy eating behaviors in all settings in which people live, work, and play. funding agencies sigma theta tau – gamma pi chapter college of public health, references andajani-sutjahjo, s., ball, k., warren, n., inglis, v., & crawford, d. 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"internal" and "external" barriers to changing diet and exercise in a three year follow-up of participants in a health check. social science & medicine, 46(4-5), 461-465. http://dx.doi.org/10.1016/s0277-9536(97)00190-1   tasseff_528-article text-3491-1-6-20190122 online journal of rural nursing and health care, 19(1) 159 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 exploring perceptions of palliative care among rural dwelling veterans tamara l tasseff, phd, rn 1 susan s. tavernier, phd, aprn-cns, aocn 2 karen s. neill, phd, rn, sane-a, df-iafn 3 paul r. watkins, phd 4 1 jonas veterans healthcare alumna, iowa city va health care system, tamara.tasseff@va.gov 2 assistant professor, college of nursing, idaho state university, tavesusa@isu.edu 3 interim dean & professor, college of nursing, idaho state university, neilkare@isu.edu 4 professor, college of education, idaho state university, watkpaul@isu.edu abstract aim: to explore the palliative care perceptions of rural dwelling veterans in a completely rural area of the united states. background: as a whole, rural dwelling people have reduced access to health care, including palliative care. palliative care can effectively address the distressing physical, emotional, psychological and spiritual suffering related to either serious acute or chronic conditions; additionally, it can be delivered at the same time with usual treatment at any point in the disease trajectory to improve the quality of life for rural dwelling veterans living with serious chronic conditions. however, a significant gap exists in the research pertaining to the perceptions of palliative care among rural dwelling veterans. method: a qualitative study using a descriptive phenomenological approach was conducted as part of a larger mixed methods study. the setting was a geographically defined rural area online journal of rural nursing and health care, 19(1) 160 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 encompassing over 8,500 square miles. rural nursing theory served as the conceptual lens for this study. audio-recorded, semi-structured, face-to-face interviews were conducted with a purposive sample of six male rural dwelling veterans using an interview guide. subsequently, data were analyzed using a thematic analysis process. findings.: four themes were identified: uncertainty about palliative care; where and when; palliative care is not hospice care; and opportunities. rural veterans were found to be unaware of the meaning of palliative care. five of the six veterans did not perceive palliative care to be endof-life. a unique finding, none of the rural dwelling veterans perceived palliative care to be hospice care. conclusions: in this study, rural veterans perceived hospice care and palliative care to be different. veterans in this sample were unable to define palliative care and did not associate it with an improved quality of life. therefore, broad-based palliative care education is needed for rural dwelling veterans and for healthcare professionals providing their care. keywords: rural veterans, palliative care, aging in place, rural nursing theory, hospice exploring perceptions of palliative care among rural dwelling veterans palliative care focuses on improving the quality of life for people and families suffering from serious chronic conditions, such as cancer, multiple sclerosis, rheumatoid arthritis, heart failure, dementia, and diabetes (world health organization [who], 2016). palliative care can be delivered at any stage in the disease course, from initial diagnosis through the end-of-life (who, 2018). additionally, it may be delivered concurrently with usual or curative treatment (hargadon, tran, stephen, & homler, 2017; mor et al., 2016). online journal of rural nursing and health care, 19(1) 161 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 deemed a basic human right to health care, only 14% of people globally receive palliative care to address the physical, psychological, emotional and spiritual suffering that often accompanies a serious illness (who, 2016). the most basic palliative care can generally be administered by families and friends. however, the more specialized palliative care, palliative medicine, is delivered by providers who are trained to manage extremely complex symptoms. somewhere in the middle, the potential does exist for palliative care to be delivered concurrently as a component of comprehensive primary care across rural areas. notably, concurrent palliative care may offer rural dwelling people the opportunity to remain active longer, experience an improved quality of life, and age in place. the number of hospital-based palliative care programs in the united states continues to grow; yet, few outpatient palliative care programs exist outside of urban areas (meier & bowman, 2017). the rural adult population of the united states numbers 47 million and occupies 72% of the land area (cromartie, 2016). rural veterans account for 11% of the rural dwelling adult population (holder, 2017) and roughly 30% of the larger veteran population (u.s. department of veterans affairs [usdva], office of rural health, 2016). rural dwelling adults, when compared with their urban dwelling counterparts, are older, have smaller incomes, are less healthy, and have reduced access to health care services (bolin et al., 2015). on average, veterans who live rurally are older and more disabled than the larger rural population, experience greater healthcare-related disparities than both rural dwelling non-veterans and urban dwelling veterans, and seek healthcare from rural providers and veterans administration (va) providers (tasseff & tavernier, 2018). the veterans administration/veterans health administration (va/vha) has allocated nearly a third of its budget (32%) health care to rural veterans (usdva, office of rural health, 2018). current va/vha programs include community-based palliative care (usdva, office of online journal of rural nursing and health care, 19(1) 162 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 rural health, 2018) and concurrent palliative, in the form of hospice care for veterans who are receiving cancer treatments (mor et al., 2016). the enable iii, a randomized controlled trial involving 207 participants at multiple sites in the united states, including veterans receiving cancer treatments at a va medical center, studied the effects of early versus delayed palliative care and concluded that one-year survival rates were statistically significantly higher (p = .038) for veterans assigned to the early palliative care or concurrent palliative care intervention group (63%) than the delayed palliative care group (48%) (bakitas et al., 2015). earlier enable randomized controlled trials supported that concurrent palliative care, in the form of hospice care, was effective at improving the quality of life for veterans living with cancer (bakitas et al., 2009) and heart failure (dionne-odom et al., 2014). most of what we know about the perceptions of palliative care is based on research studies conducted in urban or rural areas outside of the united states, or research involving veterans who are currently receiving palliative care (mcilfatrick, et al., 2014; golla et al., 2014; dembinsky, 2014;). the complete literature review, conducted as part of the larger mixed methods study was reported in a previous publication (tasseff, tavernier, watkins & neill, 2018). no literature was identified that addressed rural veterans’ perceptions of palliative care prior to enrollment in palliative care services. the lack of published literature about the palliative care perceptions among rural veterans living in the unites states indicates a significant gap in the literature. therefore, the purpose of this research was to explore palliative care perceptions among rural veterans. rural veterans are older and have higher rates of disability than the non-veteran rural population. the incidence of chronic conditions increases with age, and people living with chronic conditions experience a decreased quality of life (centers for disease control and prevention, online journal of rural nursing and health care, 19(1) 163 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 2013). therefore, rural veterans may have the most to gain from concurrent palliative care. understanding the perceptions of palliative care among rural veterans is the first step to implementing concurrent palliative care in rural areas. to the best of our knowledge, the perceptions of palliative care among rural dwelling veterans have not been exclusively studied. against this backdrop, the study provides new knowledge to (1) promote discussions about rural dwelling veterans, chronic disease, and concurrent palliative care; (2) gain insights into the perceptions of palliative care held by rural veterans; and (3) advocate for education and models of care for community and healthcare professionals that include access to culturally sensitive, concurrent palliative care. this article describes the qualitative component of a mixed methods study that explored the perceptions of palliative care among six male rural dwelling veterans. veterans in the rural area where this study was conducted represent 14% of the population (u.s. department of veteran affairs, 2016) which is higher than the national average. methods rural nursing theory served as the conceptual lens throughout the course of this study. specifically, rural dwelling people define health as the ability to do what they want to do (lee & mcdonagh, 2013) while remaining productive and able to work (long & weinert, 2013) as opposed to perceiving health as the absence of disease. this is an important foundational concept as rural dwelling people may not be averse to living with serious chronic conditions if they are able to continue to do the things they want to do, including work. design this was a qualitative study conducted with a descriptive phenomenological approach. basic qualitative descriptive designs seek to describe the phenomena of interest while remaining online journal of rural nursing and health care, 19(1) 164 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 close to the data (sandelowski, 2000). like many other qualitative studies, a specific or true structured approach was not specified in this study, thereby allowing more freedom in the methodological and conceptual decisions (ravitch & carl, 2016). a phenomenological approach in this study was used to explore the meaning of the perceptions of palliative care within the lived experiences of rural veterans by discovering commonalities across participants (polit & beck, 2012). setting a geographically defined area encompassing over 8,500 square miles in four counties located in two western states served as the setting. the area is sparsely populated with an average of 2.5 to 5.3 people per square mile. it is classified as “mostly rural” (50% to 99.9% of the population living in rural areas) and “completed rural” (100% of the population living in rural areas) per the county classification lookup table (united states census bureau, n.d.). rural is defined as areas where people live that are not classified as urban or urban clusters (united states census bureau, n.d.). participants and recruitment the recruitment phase began in september 2017 following approval granted by the human subjects committee (study number fy2018-38) and continued through november 2017. posters with tear-off-tabs containing the primary researcher’s name, telephone number and email address were placed on community message boards in grocery stores, libraries, post offices and gas stations throughout the geographic area of the study. in addition, recruitment posters were placed on rural message boards, usually located near groupings of mailboxes in some of the more remote areas. advertisements were placed in two of the local weekly papers. rural veterans interested in learning more about the study voluntarily contacted the researcher and were screened for inclusion online journal of rural nursing and health care, 19(1) 165 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 by telephone. one rural veteran without a telephone expressed interest in the study after reading about it on one of the rural message boards. this veteran was screened at the location of the mailboxes and rural message board. the inclusion criteria were met if the individual was above 18 years of age, agreed to an audio-recorded interview, was a military veteran, and lived within the geographically defined area of the study. veterans were excluded if a close friend or family member had been diagnosed with a terminal illness or died in the past six months, or if the individual had received a terminal diagnosis. the consent document was read to each veteran during the screening process for consistency. veterans meeting the inclusion criteria and desiring to participate in this study were scheduled for an interview at a mutually agreed upon location. a total of eight rural veterans responded and were screened; six of them met the inclusion criteria, provided consent and were subsequently scheduled for interviews. ethical considerations this study was reviewed and approved by the university’s human subjects committee. prior to the interview, each rural veteran received information about the study during the screening process and consent was documented. each rural veteran was apprised of the voluntary nature of this study, encouraged to ask questions, and reminded that they could refuse to answer or skip any questions, and end the interview at any time. participants were not identified by name on the audio-recordings. electronic data were encrypted, password protected, and stored in a locked file cabinet with the consents. gift cards worth $10 were given to all participants following the interviews as an acknowledgement of their time. participant characteristics rural veteran participant characteristics are reported in table 1. the interviews’ audiorecorded portions ranged from 12 to 24 minutes. of the six male rural veterans who participated online journal of rural nursing and health care, 19(1) 166 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 in the face-to-face interviews, three were air force veterans, two were army veterans, and one was a navy veteran. the age of these rural veterans ranged from 53 to 76 years. military service ranged from three to 21 years. the total amount of time veterans reported living rurally over the course of their lifetimes ranged from three and one half to 76 years. similarly, the mean number of years living in their current zip code or address was 21 years. table 1. rural veterans – participant characteristics _____________________________________________________________________________________ veterans n (%) _____________________________________________________________________________________ males 6 (100) marital status married 5 (83.3) divorced 1 (16.7) race white 6 (100) education hs grad/ged 2 (33.3) some college 1 (16.7) associates 1 (16.7) bachelors 2 (33.3) employment < 35 hours 3 (50.0) not employed 3 (50.0) veteran statusa non-combat 4 (66.7) combat 2 (33.3) military retiree 1 (16.7) branch of service air force 3 (50.0) army 2 (33.3) navy 1 (16.7) era vietnam 5 (83.3) desert storm, oef, oifb 1 (16.7) service connected disability – yes 3 (50.0) disability rating 30 percent 1 (33.3) 70 percent 1 (33.3) 100 percent 1 (33.3) _____________________________________________________________________________________ m (sd) online journal of rural nursing and health care, 19(1) 167 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 _____________________________________________________________________________________ age (years) 66.8 (8.0) length of service (years) 7.9 (7.1) rural (years)c 57.4 (26.9) current (years)d 21.1 (22.7) _____________________________________________________________________________________ note: atotal years, over entire life, living rurally; boef, oif stands for operation enduring freedom, operation iraqi freedom; ctotal years of living rurally, over lifetime; dtotal years lived in the area of current zip code (postal code) data collection one researcher living in the study area conducted all six interviews. data were collected between september and november 2017 using audio-recorded, semi-structured face-to-face interviews. a semi-structured interview guide, comprised of questions that were developed based on the published literature, was reviewed by a panel of experts experienced with qualitative research. a pilot interview was conducted with one rural veteran prior to the expert review of the semi-structured interview guide. results from this pilot interview were neither included in the data analysis nor reported in the results. questions asked of all veterans included: how would you define palliative care, or what is your personal definition of palliative care; where is palliative care delivered; and when is the most appropriate time for palliative care. additional questions were asked based on the individual responses of each participant. demographic data were collected using a short questionnaire and included: gender, marital status, ethnicity, race, birth year, zip codes of home and work, total years of rural living, years lived in current zip code, education, and employment. additional demographic questions which were specific to veterans and included: combat veteran status, branch and duration of service, military retirement, service-connect disability, disability rating, and era of service. field notes and memos were drafted using pen and paper after the interviews. data analysis online journal of rural nursing and health care, 19(1) 168 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 qualitative analysis software, atlas.ti, version 7.5.15 (atlas.ti scientific software development gmbh, 2016) was used to assist with analyzing the data. thematic analysis, with no less than three rounds of coding (charmaz, 2006), was chosen as the method for analyzing the data. the primary researcher listened to each audio-recording following the interview and a second time prior to beginning the preliminary (inductive) coding to identify key phrases or ideas that would be used as initial (deductive) codes during the second round of coding. codes addressing similar thoughts or ideas were merged. after merging, the related codes were grouped together to create code families. themes were then developed based on the frequency of the codes across these six interviews, and exemplar quotes were identified to support each theme. the audiorecordings were revisited multiple times throughout the process of analysis. the first three interviews were coded independently by two researchers. the two researchers met on two occasions via zoom to discuss the initial codes and preliminary findings. theoretical saturation, the point at which collecting new data does not provide any new insights (creswell, 2014), was reached with the sixth interview; thereafter, no further interviews were conducted. quality and trustworthiness to support quality throughout the research process, a positionality statement was drafted by the primary researcher and shared with three, more experienced researchers prior to the commencement of data collection. positionality statements help identify biases, assist with receiving critical feedback, and present key beliefs and ideologies that shape one’s research (ravitch & carl, 2016). the primary researcher engaged in a critical debate and discussion with a more experienced researcher throughout the process of data collection and analysis using webconferencing capabilities, and memos and reflective journaling were also used. exemplar quotes provided a representation of the rural veterans’ lived experiences or realities. online journal of rural nursing and health care, 19(1) 169 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 findings prior to being asked questions about palliative care, each rural veteran was asked for his personal definition of health or how he defined health. how rural veterans define health provides support for the study’s conceptual lens that rural dwelling people define health as the ability to do what they want to do (lee &mcdonagh, 2013) while remaining productive and able to work (long & weinert, 2013). five of the six veterans defined health as being able to do things, which aligns with the lens through which this study was viewed. “being able to do all of the normal things i’ve been able to do since i was 25.” – rv02 “being able to do the things you want to do in your lifewhether its physical, social or whatever. being able to do those things.” rv04 some rural veterans were also asked what a lack of health would entail. rv04 responded, “inability to do the physical activities that i like to dohiking, walking, biking, working. i like doing work [he smiles].” similarly, the oldest among all six veterans, rv06, who still works a couple of days each week, believes he has “fair health” right now. rv06 replied, “i can’t do now what i used to do five years agothat’s a part of health. i can’t do what i used to be able to do. a year ago, i was mowing about five to six yards a week and working four to five days a week.” some of the rural veterans were asked if it is possible to have some degree of illness and still be healthy. this question was asked because the incidence of chronic conditions increases with aging, and chronic conditions are associated with a decreased quality of life (centers for disease control and prevention, 2013). rv05 paused for a moment before sharing a personal example, “i’m sure. i have a prostate condition, an enlarged prostateand it’s never been a problem, but it’s there. i don’t consider it hindering my health at all.” several other veterans shared a list of chronic conditions ranging from online journal of rural nursing and health care, 19(1) 170 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 diabetes to troublesome heart valves and severe arthritis. they stated that if they could continue doing what they want to do, they could have varying degrees of health coexisting with illness or chronic conditions. rv06 talked about fatigue and a problem he was having with his heart, “right now, i don’t have as good of health as i had a year ago. probably on a 1-to-100 basis, i’m a 75.” uncertainty about palliative care five of the six rural veterans did not know what palliative care was. two veterans, rv05 and rv06, had not heard the term palliative care and declined to guess what it might mean. three of the men guessed that it was probably some type of nursing care or home care; care to provide some type of support; care for someone who needed help taking care of himself; or, care rendered for someone who had no one else to take care of him, such as care provided in a nursing home or assisted living facility. “i have heard of palliative care, but i don’t know what it is.” – rv01 rv02 guessed that to receive palliative care, “somebody’s got to be in a real bad shape.” rv04 voiced familiarity with the term palliative care and defined it as, “i guess it’s, i don’t know, it probably isn’t the same as hospice care. palliative care is pretty much just letting someone go [pause] to die.” he described hospice care as occurring before palliative care and happening as a person progressed towards death. where and when the intrinsic lack of clarity about the term palliative care made it difficult for the rural veterans to think about where and when palliative care should be delivered. four veterans guessed about where and when it may be delivered. rv01 speculated that palliative care was possibly offered at home, “maybe coordinated by hospitals or clinics – almost like home health care?” rv02 stated, “nursing homes? icu? i don’t know.” rv03 guessed, “nursing home – assisted online journal of rural nursing and health care, 19(1) 171 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 living?” after thinking about the question for a few moments, rv04 replied, “a hospital or nursing homemaybe at home. i guess i don’t really know.” palliative care is not hospice care none of the veterans associated palliative care with hospice care. participants were asked if palliative care and hospice care were the same. none of them perceived hospice care to be palliative care. all six rural veterans were able to define and describe hospice care accurately. rv04 speculated about palliative care and thought it may occur after hospice care. “[laughs]. i don’t know. i guess it’s – i don’t know, it’s probably not quite the same as hospice care. [pause]. i don’t really – i think palliative care is pretty much just letting someone go [pause], to die. i think. [pause]. and, to be comfortable.” – rv04 rv06 talked about his hospice experience decades ago when his teenage son was dying of cancer. nearly all the veterans shared stories of family members with serious illness, such as cancer, diabetes, dementia, arthritis, and mobility issues. they were able to share personal example of hospice care. opportunities palliative care can be offered at any stage during a serious health condition. the rationale for asking the veterans about serious health conditions was to identify serious chronic conditions and bothersome symptoms for which concurrent palliative care could impart some benefits. rv01 talked about his own mobility issues, neuropathies, and diabetes, and how these ailments had significantly impacted his life: i love to hunt and be out in the woods. last year i did very little huntingi think i got to hunt two days. i was afraid to leave the house, um, i’ve got a glucagon kit in my bag…it does bother me. for me, it could be life-threatening. the biggest fear is that if something online journal of rural nursing and health care, 19(1) 172 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 happensand i’m in the woodsdrop over, go unconscious and no one finds me for three months [laughs]and that is a great fear. rv02 described a long course of suffering for one friend with diabetes and multiple amputations. he further spoke of another friend who battled cancer and fatigue for a year and a half. rv03 talked about his own mobility issues, the challenges of multiple broken bones and arthritis, and his desire to continue living rurally despite coming to terms with the fact that living rurally would end at some point. rv04 shared the example of his brother who has been living with a slowly progressing cancer for a couple of years. rv06 discussed how his teenage son had battled cancer for many years and lived several years beyond the expectations of his physician. two veterans, rv03 and rv05, described how family members provided basic palliative care, although neither of them was able to define palliative care. rv05 did not know what palliative care was, and he was not comfortable guessing about it. this same participant did provide an example of basic palliative care while describing the serious health conditions of his parents: my mother had dementia. she, ah, for several yearswas just classic dementia. we weren’t really sure who she knew at times, and it just wore away at her health, and she finally passed away. my father had a sort of lung cancer. it, ah, originated from black lung disease from working in the underground coal mines. and, ah, he suffered with that before he passed on. dad was always energetiche would walk every day in the hills; a real physical personsports and everything. and, it took all that away from him. he just gradually got to where about the best he could do was just watch tv, hooked up to his tubes…and, my motherit was just the gradual loss of interest in her church; the people she knew. she always liked to visitgossip a lottalk with folksthat gradually went away. it was just a symptom that was building and building until she wasn’t the person she used online journal of rural nursing and health care, 19(1) 173 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 to be…my sisters lived right next door to them, and so they [sisters] were always right there caring for them [parents]. and, also, a friend of the sisters…. they had very little hospital care. they didn’t spend much time in the hospitals at all. they were mostly at home with my sisters watching over themand this friend that would spend nights with them when they [sisters] couldn’t be available… it worked really well for them. it did. her heart just gave out, finallyright at the end, and they took her to the hospital, and she died right there. and, my dad was in the hospital for maybe a week [pause] before he died. discussion this study explored the perceptions of palliative care among six male veterans living in rural areas. although the rural dwelling veterans were unable to define palliative care and were uncertain about its meaning, all of them were able to describe serious chronic conditions that lasted, in some cases, many years. all six rural veterans were familiar with hospice care, although they did not associate palliative care with hospice care. five of the six veterans did not perceive palliative care to be end-of-life care. it is difficult to compare the results of this study with the findings of other published research works. similar to the findings of mcilfatrick et al. (2014) and golla et al. (2014), the lack of understanding about palliative care was found among these rural veterans. however, no previous literature that we are aware of accounts for the fact that five of the veterans who participated in this study were familiar with hospice yet did not associate palliative care with hospice or specialized cancer care, such as reported by golla and colleagues (2014); or end-of-life care, such as reported by mcilfatrick and colleagues (2014). although the rural veterans participating in this study lived in a rural area, they did not share a common condition or experience similar to the rural aboriginal participants (dembinsky, 2014) or adults with multiple sclerosis (golla et al., 2014). similar to golla and colleagues (2014), a online journal of rural nursing and health care, 19(1) 174 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 definition of palliative care was not provided to the rural veterans who participated in this study. if the participants’ perceptions about palliative care had been influenced by the perceptions held by their healthcare providers (golla et al., 2014) or by their experiences with hospice or end-oflife (mcilfatrick et al., 2014), why did these rural veterans (1) have no idea what palliative care is, and (2) why did five of the six rural veterans not perceive palliative care to be, in part, hospice care or end-of-life care? in the region where this study was conducted, few palliative care programs exist. hospice services are available in several of the small towns; however, hospice and home care services were not available in the areas where four of the six veteran participants live. the closest va medical center with palliative care services was located more than 100 miles from where the six veterans live and does not provide home-based palliative care services in the veterans’ area. conclusions concurrent palliative care, when offered as a critical component of primary care across rural areas, has the potential to improve the quality of life and healthcare for rural dwelling veterans with serious chronic conditions who define health as being able to do what they want to do. managing the bothersome symptoms associated with serious chronic conditions may keep rural veterans active for a longer period and allow them to age in place. however, further palliative care education is needed for rural veterans, nurses and other healthcare professionals who provide their care. implications for practice include: educating providers and nurses about the broader scope of palliative care along with the benefits of concurrent palliative care, promoting palliative care education among rural veterans and the communities or regions where they live, and facilitating access to concurrent palliative care throughout rural areas. online journal of rural nursing and health care, 19(1) 175 http://dx.doi.org/10.14574/ojrnhc.v19i1.528 suggested future research should focus on the preparation of professional caregivers and family members in the concept of concurrent palliative care for improving quality of life and exploring implementation and access barriers to this type of care in more remote areas. additionally, future studies should be completed on veteran engagement in palliative care education in rural community-based or small group settings. this future research should focus on outcomes related to basic palliative care knowledge, the location and timing of this type of care delivery, the differences between hospice and palliative care, and identification of serious chronic conditions and bothersome symptoms for which concurrent palliative care could be of benefit. references atlas.ti scientific software development gmbh (2016). atlas.ti (version 7.5.15) [computer software]. berlin, germany: atlas.ti scientific software development gmbh bakitas, m., lyons, k. d., hegel, m. t., balan, s., brokaw, f. c., seville, j., … ahles, t. a. 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(2018, february 19). palliative care. retrieved march 12, 2018, from http://www.who.int/mediacentre/factsheets/fs402/en/ prengaman_514 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 65 diverse stakeholder perspectives on rural health care reform in a u.s. state that rejected the affordable care act: a case study molly vaughan prengaman, phd, fnp-bc 1 dorinda l. welle, phd 2 nancy ridenour, phd, aprn, bc, faan 3 keith j. mueller, phd 4 1 associate professor, school of nursing, boise state university, mollyprengaman@boisestate.edu 2assistant professor, school of nursing, university of new mexico, dwelle@salud.unm.edu 3 dean, goldfarb school of nursing & president, barnesjewish college, nancy.ridenour@bjc.org 4 department head and gerhard hartman professor in health management & policy, university of iowa, keith-mueller@uiowa.edu abstract purpose: this case study identifies rural health care stakeholder perspectives on the affordable care act (aca) and describes the health policy context in idaho, the only state in the united states to reject medicaid expansion yet develop a state-run health insurance exchange. sample: the sample included 20 rural health care stakeholders, including clinicians, elected officials, state agency administrators, health care facility administrators, and interest group leaders. method: a single-case study of stakeholder perspectives on the aca and rural health care access in idaho was conducted from 2014 to 2016. data sources include qualitative interviews with 20 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 66 rural health care stakeholders and public documents relating to the aca and rural health care from idaho governmental and nongovernmental entities’ websites. findings: since the 2010 passage of the aca, opposition to “obamacare” became associated with a conservative stance on health care reform. however, in this case study, diverse health care stakeholders who criticized aspects of the aca identified several components of the policy, including medicaid expansion, as essential in ensuring access to rural health care. some stakeholders called for federal legislation authorizing nurse practitioners to practice as independent primary care providers. however, the politics of medical sovereignty present challenges to this relevant strategy and to full implementation of idaho’s nurse practice act for increasing access to primary care in a rural state. conclusions: the case study approach can be effective in illuminating stakeholder perspectives and policy strategies that may fall outside of polarized health care policy debates. examination of the state-level political context of rural health care must consider concurrent battles about state sovereignty over health care policy and professional-clinical battles about sovereignty over primary care. keywords: affordable care act, case study, idaho, rural health care policy, advanced practice nurses diverse stakeholder perspectives on rural health care reform in a u.s. state that rejected the affordable care act: a case study since the passage of the affordable care act (aca) in 2010, opposition to “obamacare” has become associated with a uniform conservative stance on health care reform. however, in a online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 67 case study conducted in idaho from 2014 to 2016, diverse health care stakeholders who criticized or expressed ambivalence about the aca identified several of its policy components as essential for an effective rural health care system. in idaho, the only state in the united states to reject medicaid expansion yet develop a state-run health insurance exchange (norris, 2017), rural health care stakeholders described medicaid expansion as key to ensuring access to rural health care. some stakeholders called for federal legislation that authorizes nurse practitioners (nps) to practice as independent primary care providers, particularly relevant for rural states that struggle to recruit and retain physicians. here, we present a case study of idaho, a rural, conservative state. two major definitions of rural are used by the federal government (u.s. department of health and human services [usdhhs], 2013). the first, developed by the united states census bureau (2015), identifies urbanized areas (uas) as those with populations of 50,000 or more and urban clusters (ucs) as those with populations of between 2,500 and 50,000. any area not designated as ua or uc is considered rural (usdhhs, 2013). the federal office of management and budget (omb, 2013) designates counties containing at least one city with a population of 50,000 or more as metropolitan and counties with city populations between 10,000 and 50,000 as micropolitan; any counties with city populations outside of those ranges are considered rural (omb, 2013). seventeen of the 20 interviewees in this study reside in areas of idaho that meet the criteria for both of two federal rural definitions. three nonrural residents were included because of their role in rural health policy development in the state of idaho. we identify rural stakeholder perspectives and their policy recommendations on key aspects of the u.s. health care system that are currently under debate. we also discuss the effectiveness of the case study approach in illuminating policy perspectives and policy strategies that may fall outside of polarized political debates. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 68 rural disparities in access to health care in the united states and idaho access to health care resources declines as population density decreases and geographic isolation increases (aylward et al., 2012; jones, parker, ahearn, mishra, & variyam, 2009). rural residents have fewer health care providers, greater health risks, poorer health outcomes, and greater mortality than their urban counterparts (bailey, n.d.; jones et al., 2009; united health group, 2011). rural residents typically must travel further than urban residents to access care, particularly for specialty care (chan, hart, & goodman, 2006). rural ethnic and racial minority residents experience even greater disparities in health care access and health outcomes (rural health information hub, 2014). rural residents are more likely to lack health insurance than urban residents, further contributing to poorer health outcomes and higher mortality than those with coverage (institute of medicine, 2009; kaiser commission, n.d.). rural uninsured individuals are more apt to be hospitalized for preventable conditions than the urban uninsured (zhang, mueller, & chan, 2008). access to health care among the rural uninsured is further constrained by shortages of primary care practitioners (which includes physicians and advanced practice nurses [aprns]), as well as a lack of specialists, pharmacists, dentists, registered nurses, mental health professionals, hospitals and clinics (aylward et al., 2012; bailey, n.d.; chan et al., 2006; united health group, 2011). by 2020, a 36% shortage of nurses is anticipated (usdhhs, 2013). the rural ratio of primary care physicians per 100,000 is less than half that of urban areas (sanders, 2013; united health group, 2011). this ratio is not anticipated to improve because only 3% of medical students plan to practice in rural areas, and only 2% plan to go into primary care (bailey, n.d.). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 69 more than one third of idaho’s population is dispersed across ruraland frontier-designated counties, with nearly 20% of residents located in frontier counties (skillman, patterson, lishner, doescher, & fordyce, 2013). according to the united states census bureau (2015), 93% of idaho’s population reports being white. in idaho, 12% of residents live below the federal poverty level (fpl), and an additional 20% report incomes between 100% and 199% of the fpl (kaiser family foundation, 2015). approximately 11% of idaho’s population is uninsured; this number jumps to 27% among nonelderly with incomes below the fpl (kaiser family foundation, 2015). idaho has a dramatic shortage of health care providers, with 96% of the state being designated a health professional shortage area (idaho department of health and welfare, 2015). furthermore, 100% of idaho is designated a mental health professional shortage area (idaho department of health and welfare, 2015). idaho’s nurse practice act authorizes independent practice and prescriptive authority for aprns, and approximately 20% of aprns in idaho practice in rural settings (wwami rural health research center, 2015). the aca and the politics of federal, state, and medical sovereignty signed into law on march 23, 2010, the aca requires all americans to purchase health insurance or pay a fine; establishes a federal health insurance exchange, which states would default to if they chose not to establish their own exchange; and offers enhanced federal funding for medicaid expansion (affordable health california, n.d.). twenty-six states (including idaho) and the national federation of independent business sued the federal government, arguing that sections of the aca were unconstitutional. the supreme court ultimately upheld federal health insurance subsidies and the individual mandate, while allowing medicaid expansion to be voluntary (kaiser family foundation, 2012). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 70 the aca became a flash point for conservative assertions of state sovereignty against a federal policy advanced by a democratic and african american president. in the federalist papers, james madison (1787) wrote of the necessity for a balance of power that would enable the federal and state governments “to resist and frustrate the measures of each other” (thompson & fossett, 2008). during aca implementation, this “resistance and frustration” intensified, as some states made claims about their own sovereignty over health care. decisions about state-level aca implementation have been at stake in this political battle, with consequences for the number of residents who can acquire insurance and access care. the politics of aca implementation involved a less publicly visible and ongoing struggle over sovereignty within health care. physicians were the first clinicians in the united states to obtain legislative recognition of their practice and for over a century have expanded the reach of their influence well beyond medicine into state and national politics (starr, 1982). since the early 1900s, the medical profession in the united states has controlled the number of available health care providers via restrictive licensing laws and limited medical school seats. organized medicine has exhibited significant influence over both the health care market and the various organizations that govern health care (starr, 1982). starr (1982) notes that the medical profession not only developed extensive cultural and scientific authority, but members of the medical profession extended their power to the “control of markets, organizations, and governmental policy” (p. 580). the medical profession’s control waned somewhat since the 1980s with health care corporations and insurance companies’ widespread efforts to limit physician autonomy, often in the guise of taming health care costs. indeed, as community hospitals began to buy individual physician practices, these acquisitions served to ease individual physicians’ financial strain, yet came with the price of decreased economic autonomy (starr, 1982). this same trend established online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 71 a set of new, less generously paid roles for nurses as members of “clinical teams,” further challenging physicians’ clinical autonomy and instituting well-funded political pushback by nationaland state-level physician organizations (starr, 1982). the aca’s inclusion of incentivized payment plans to improve health care quality and control health care spending (coburn, lundblad, mackinney, mcbride, & mueller, 2010; kaiser family foundation, 2013; mackinney, mueller, & mcbride, 2011) further intensified professional competition between nurse practitioners and physicians who vie for primary care dollars. states have flexibility in their payment models for rural health clinics and community health centers; policies impacting funding of those facilities and their providers vary greatly (health resources and services administration [hrsa], 2006). funding of health care provided by nonphysicians also varies widely among states, within a state depending on the payer, and even among various federal agencies (hrsa, 2006; safriet, 2011; summers, 2011; weiland, 2008). thirty-three percent of health maintenance organizations and 40% of managed medicaid companies recognize nps as primary care providers. of those, only 52% reimburse aprns at the same rate as physicians (hansen-turton, ritter, rothman, & valdez, 2006). medicaid, medicare, or other payers may reimburse aprns at 65%, 75%, or 85% of physician rates for the same care, depending on state-level reimbursement policies (safriet, 2011). these federal, state, and corporate policy variances are “exacerbating the current maldistribution and shortage of providers” (safriet, 2011, p. 6). advanced practice nursing developed in the 1970s to strategically address the primary care provider shortage. aprns are registered nurses with a master’sor doctoral-level nursing education in the assessment, diagnosis, and management of patient problems; they obtain state licensure and national certification in a specific aspect of care, and can order tests and prescribe online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 72 medications (aprn consensus work group & national council of state boards of nursing., 2008). several factors have constrained aprn independent practice. organized medicine has defended primary care as the exclusive domain of physicians and advocated to limit the primary care provision activities of aprns (safriet, 2011; starr, 1982), despite extensive evidence that aprns provide primary care of comparable quality to that of physicians and at a lower cost (kitchenman, 2012; weiland, 2008). some states require aprns to be supervised by a physician or prohibit aprns from prescribing medications (cassidy, 2012; safriet, 2011). in states that do authorize aprns’ independent practice, physician attitudes have hampered independent aprn practice (aquilino, damiano, willard, momany, & levy, 1999; street & cossman, 2010). these politics of medical sovereignty (starr, 1982) and the lack of uniform federal aprn policies have hindered the full roll-out of advanced practice nursing as a solution to mitigate the devastating primary care practitioner shortage in rural areas. methods case studies involve “naturally occurring situations without control of variables” (gomm, hammersley, & foster, 2000, p. 3), collection of multiple types of data, and qualitative analysis with the aim of understanding “a complex entity located in a milieu or situation embedded in a number of contexts or backgrounds” (stake, 2006, p. 449). case studies have examined state policies for informal care providers (ceccarelli, 2010), the politics of national child care policymaking (cohen, 2001), the relationship between education and health policies in elementary schools (seibold, 2006), and nursing workforce issues in mexico (squires, 2007). idaho is the specific unit of analysis for this single-case study of stakeholder perspectives on the aca and rural health care access (gerring, 2004). the time boundary is from the enactment online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 73 of the aca in march 2010 to the conclusion of data collection in december 2015, with historical context provided. institutional review board approval (institution and protocol number blinded for review purposes) was secured and written consent obtained from 20 rural health care stakeholders, including clinicians, elected officials, state agency administrators, health care facility administrators, and interest group leaders. thematic and narrative analyses were conducted on transcripts of semistructured interviews and public documents on governmental and nongovernmental entities’ websites (stake, 2006). patients were not included in the stakeholder sample. a consideration of the indian health service in idaho was beyond the scope of the study. case study: idaho’s health policy context the state of idaho promoted its consistent opposition to the aca using a narrative that pitted federal against state sovereignty. in a march 5, 2010, press release disseminated shortly after the aca was passed by the senate but before it was passed by the house, idaho governor butch otter expressed his frustration over federal health care reform, emphasizing the primacy of state sovereignty: for 35 years now the federal government has been essentially running healthcare in america, masking market signals and supplanting the judgment of patients and physicians with the determinations of politicians, bureaucrats and lawyers....now the federal government is poised to rescue us from the disaster it created, promising “reform” that amounts to little more than increasing government’s already dominant role in the healthcare system and further reducing the role of states like idaho, not to mention individual patients and providers….the public, policy makers and even patients contributed to the problem with their complacence. having been lulled into a false sense of security by the promise of medicaid and medicare, we failed to insist on meaningful change and self-determination. (otter, 2010, p. 1) online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 74 the idaho legislature blocked federal health care reform even before congress passed the aca. on march 17, 2010, the governor signed the idaho health freedom act, ensuring “that the citizens of our state won’t be subject to another federal mandate or turn over another part of their life to government control” (idaho.gov, 2010, p. 1). one week later, idaho became one of 26 states to legally challenge the constitutionality of the aca (kaiser family foundation, 2012). in the 2011 session, the predominantly republican state legislature passed a bill to nullify obamacare; however, the governor vetoed it, instead issuing an executive order prohibiting state agencies from implementing obamacare (state of idaho, 2011). the governor, while stating that “no one has opposed obamacare more vehemently than me,” nevertheless chose to retain the ability to develop a state-run health insurance exchange and avoid “further control over idahoans” in a federally run insurance exchange should the supreme court uphold the aca (state of idaho, 2011, p. 1). after the supreme court upheld the individual mandate and health insurance subsidies of the aca, a governor-appointed task force recommended the establishment of a state-run health insurance exchange. significant outcry ensued among conservative legislators, one even likening a state-run health insurance exchange to the holocaust (russell, 2013). by the time legislation to establish a state-run exchange was passed, the first aca open enrollment period had already begun. therefore, idaho used the federal exchange for the initial open enrollment and then transitioned to its state-run exchange in time for the second open enrollment period in 2015. idaho became the only state in the union to build its own health insurance exchange yet opt out of medicaid expansion (norris, 2016). in 2015, 54,000 idahoans were denied coverage through the state-run exchange. their incomes were too low to qualify for the health insurance premium subsidy via the aca and yet, because idaho had not expanded medicaid, they were ineligible for medicaid (russell, 2016). even though a series of governor-convened health care online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 75 task forces had all recommended expanding medicaid, no bill on medicaid expansion ever made it to the idaho legislature floor for vote (“a true idaho solution,” 2016). stakeholder perspectives on medicaid expansion in qualitative interviews, health care system stakeholders described stymied efforts at statelevel health care reform. several expressed frustration over idaho’s failures to legislate medicaid expansion as part of the aca implementation. one interest group administrator explained: we’ve had three shots at the legislative assembly and failed every time to get them to seriously consider medicaid expansion. idaho you know has its single party system. the numbers of democrats is so small that the republicans can substantially ignore them. you know this antifederal, the “obama is evil” vibe, to where we’re just being senseless and we’re actually causing harm. it’s interesting on medicaid expansion we have 78,000 people that you could help, but you’re choosing not to. that same administrator suggested that health care professionals contribute to the problem by becoming complacent, not with medicaid and medicare, but with state government: at the end of the last session,…the governor…gave the legislature…an “a” in education funding, a “b–” in transportation….in idaho he doesn’t even have to give a letter grade [for] health and social services....in health care we’re having the conversation about to what degree are we contributing to that by not exercising the voice we should be exercising. an elected official noted idaho’s political environment itself as negatively impacting access to health care services in rural idaho: we can’t get medicaid expansion passed yet. and so the politics are profoundly effective simply because it’s pitting a political ideology against…your citizens. and, so far the political ideology is winning. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 76 unlike the unified state government position, stakeholders’ perspectives on the aca and medicaid expansion reflected a spectrum of political opinions not necessarily conforming to political party narratives, illustrated by the comments of two hospital administrators: i don’t believe in taking care of people through government programs, but if we had medicaid expansion in this state it would have resulted in more people having the potential ability to access health care in rural areas. the biggest policy change that’s needed is a redesign of medicaid. the service is so abused;…the use of the [emergency room] for nonurgent care needs to be limited....i hear a lot of people coming in, “well, i’ve got the card, i don’t have to pay for it” when they’re coming in for a cough. that’s abusing the system. and when i see at the grocery store somebody using their card to buy steaks most of us can’t afford i think there needs to be limits put on that. even while arguing against “government programs,” conservative stakeholders proposed retaining, reforming, or expanding medicaid in idaho. the responses described through liberal ideology consistently focused on the lack of medicaid expansion in idaho. one state administrator stated: [repeatedly] the legislature has chosen not to expand medicaid, so we are losing federal dollars into the state, we’re losing the ability to increase medical services for people.…we’re losing money…health care jobs…health care services, and people are losing their lives.…this is not a civil right or a civil liberty, it’s a human right, to be able to be taken care of. across political ideologies, stakeholders associated the loss of federal funding or health care jobs with state restrictions on medicaid. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 77 stakeholder perspectives on the aca interviewees provided multiple viewpoints on the impact that the aca, regardless of medicaid expansion, has had on health care access. hospital administrators in particular argued that the aca had not enhanced access to health care services in rural idaho, due to “extreme compliance requirements” and the “complexity” and “confusion” of assuming that “everybody was getting insurance.” stakeholders also recognized the conflict demonstrated by community members who appreciate the individual benefits from the aca but oppose or demonize the policy. an interest group administrator commented: we’ve been in a lot of community groups where there’s a lot of vitriol against obamacare and how horrible it is, but then when you ask the obvious questions, like does anybody in the room have somebody in the family who is uninsured because they fall into the coverage gap, [then] everybody knows somebody. or, has anybody in the room benefitted because now their kids can be covered under their group coverage to age 26? a lot of hands go up. has anybody benefitted from the no preexisting condition elimination? hands go up. that’s obamacare. in an environment where perspectives on the aca are informed by ideology and highly charged emotions, some stakeholders focused on the observed positive changes the aca has generated in their practices: with the aca i’ve seen a lot more new patients come in for a wellness exam so i was able to provide a lot of good health information and screenings. [the aca] is getting more people access to good information about preventative health care so they can avoid issues 5 to 15 years down the road. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 78 the majority of rural clinicians interviewed indicated that more people were accessing preventive care and seeking care for health issues sooner since aca implementation. stakeholder perspectives on aprns although idaho has a robust nurse practice act authorizing aprns’ full scope of practice independent of physician supervision, few interviewees independently mentioned aprns in their comments regarding the rural provider shortage, and even fewer referenced the state’s nurse practice act. most stakeholders spoke disparagingly of aprns and physician assistants (pas) as a single “mid-level” class of health care provider: if a mid-level doesn’t know when they’re in over their head then that’s dangerous. if they don’t know their limits and don’t ask for help then by the time they get to a physician the patient has been completely mismanaged. they should have a limited role. several rural physicians echoed this perspective. one stated, “aprns and pas are imperative as extenders to the physicians, but without the physicians there to ground and lead the team, then it’s somewhat dangerous.” another physician noted, “in one respect they can improve access to care, but if they’re not part of a physician-led team it can lead to higher costs with unnecessary referrals to specialists.” some stakeholders described aprns as lesser-skilled, mid-level providers with different training than physicians, yet they compared aprns with “their physician counterparts” when discussing their interest in specialization, willingness to practice in a rural locale, and value in generating reimbursement revenue. one rural aprn noted the role of conflicting state and federal policies on conflicted attitudes toward aprn independent practice: online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 79 aprns can practice independently in idaho [but] are required to have all their charts and orders signed off on by a md in a critical access facility or rural health clinics. medicare and medicaid rules are the reason aprns have to have physicians co-sign everything; they overrule state law. some stakeholders distinguished aprns from physician assistants and emphatically valued aprns’ independent role as primary care providers. a rural hospital administrator noted: we should separate out nurse practitioners from physician assistants. nurse practitioners are fully trained and capable of providing a full spectrum of primary care services, whereas physician assistants have to operate under the license of a physician so they are not as valuable in rural care settings where they are required to have a physician quote unquote “supervise” them. nurse practitioners should be more widely utilized and they could answer a lot of the access issues here in idaho. one rural aprn described economic competition between aprns and mds, noting that rural physicians value aprns as a way to increase revenue, but not to provide independent primary care: more aprns would practice in rural settings if [physicians] were more accepting of independent aprns. the doctors like us to work for them, not as competitors, so we aprns sometimes have a bit of a fight on our hands….[one] doctor told my patient that about the only person i’m good to see is one with a runny nose, a bloody nose, or a hang nail, and that he should see a “real doctor.” despite a nurse practice act authorizing full scope, independent practice for aprns in a state that values state-level “self-determination” of health care, aprns described a context of online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 80 economic competition, federal and hospital policy constraints, and everyday workplace opposition to their independent role in rural primary care provision. stakeholder policy recommendations when asked to identify policy changes they saw as crucial to optimizing access to rural health care in idaho, stakeholders prioritized medicaid expansion, enhanced physician reimbursement, and health care payment system revision, and described these policy reforms as economic development strategies. some saw medicaid expansion as a way to address the primary care workforce shortage, “help[ing] with rural physician recruitment and reimbursement,” “bring[ing] jobs and money into idaho,” and enabling states to pay for health care: “medicaid rates…would be better than no reimbursement.” other stakeholders argued for broad reimbursement reform, recommending changing health care payment from a volume-based system to a value-based model that emphasizes holistic, preventive care. enhanced medicaid and medicare reimbursements for physician services were cited as a key incentive to attract physicians to rural idaho. medicaid expansion, advocated using varied rationales even alongside criticisms, was the single most common policy change recommended by interviewees, valued for its role in increasing patients’ access to rural health care, building the primary care workforce, sustaining the state’s health care system, and stimulating state economic development. conclusion this study demonstrates the utility of the case study approach in capturing diverse stakeholder perspectives on rural health care and health care policy in ideologically charged environments. state-level case studies can identify the perspectives of those actually engaged in the rural health care arena and document policy viewpoints ignored or marginalized in public online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.514 81 debate. in the political context of a rural, conservative state, participants who held “opposing” political views surprisingly valued similar aspects of the aca and recommended similar policy changes to enhance access to rural health care services. in addition, the use of governmental and nongovernmental web site sources enables case study researchers to describe state-level policy context, particularly when access to public officials for research interviews may be prohibitive. in a national context where federal sovereignty and state sovereignty are increasingly pitted against each other, a third battle—one over medical sovereignty—significantly shaped the politics of rural health care in idaho. as aprns advocate for federal legislation granting independent practice and equitable reimbursement throughout the united states, public and professional messaging will be essential in countering the medical sovereignty narrative and advancing aprns as an effective strategy to improve access to rural primary care services. state-level case studies can give voice to those who are actually involved in the everyday work of health care, 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(2008). uninsured hospitalizations: rural and urban differences. journal of rural health, 24, 194-202. http://dx.doi.org/10.1111/j.17480361.2008.00158.x microsoft word graves_353-2175-1-ed.docx online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 63 use of community-based participatory research toward eliminating rural health disparities barbara ann graves, phd, msn, rn 1 karl hamner, phd 2 sarah nikles, mph 3 haley wells, mph 4 1 associate professor of nursing, capstone college of nursing, the university of alabama, agraves@ua.edu 2 assistant dean for research, school of social work & director, office of evaluation, college of education , university of alabama , khamner@ua.edu 3 data manager, the emmes corporation, smnikles@gmail.com 4 program coordinator, university of alabama at birmingham, haleywells@gmail.com abstract purpose/aims: rural communities throughout the us continue to sustain disparities in healthcare access and outcomes despite decades of health research and action. community-based participatory research (cbpr) has been successful in empowering communities through research and tailored interventions toward the elimination of health disparities. the purpose of this study was to ascertain the community perspective on health issues within a cbpr project framework. specific goals included identification of county-level key health issues, assessment of health related risk factors, and development of community capacity to deal with significant health challenges while working within a community-university partnership. online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 64 methods: a cbpr needs assessment was conducted using multi-method research through key informant interviews, a telephone survey of community residents and a survey of medical professionals to ascertain the community perspective on health issues. results: findings showed a wide range of health needs. epidemiology assessment of county data revealed excess mortality due to cancer, diabetes, heart disease, chronic respiratory disease, accidents, infant mortality and suicide. key informant interviews showed the top perceived health-related problems to be lack of insurance coverage, obesity, lack of education, and lack of consistency in primary care. telephone survey findings revealed the top perceived health problems were poor quality or insufficient health services, lack of insurance coverage, obesity, lack of education, and lack of consistency in primary care. telephone survey findings revealed the top perceived health problems were poor quality or insufficient health services, lack of insurance, heart disease, cost of care/poverty, cancer, drug abuse, diabetes, lack of senior care, obesity, and pediatric/prenatal care. implications: this study provides a specific application of cbpr to help reduce rural health disparities. data was used to develop a childhood obesity task force summit to combat the local obesity epidemic. a healthy week initiative was also implemented. this research can serve as a model for future research and community engagement scholarship as it relates to cbpr as a paradigm to identify, address and eliminate health disparities. keywords: rural health, healthcare disparities, community-based participatory research online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 65 use of community-based participatory research toward eliminating rural health disparities health disparities afflicting rural communities across the united states are well documented (ahrq, 2008). residents of rural areas experience more health disparities than their urban counterparts. literature supports that they are more likely than urban residents to be poor, elderly, in poorer health, uninsured and have chronic health conditions (bodenheimer, chen & bennet, 2009; u.s. department of health and human services [usdhhs], 2010). addressing ongoing rural health disparities presents a challenge. a growing body of literature has demonstrated that community-based participatory research (cbpr) is one research method that can lead to improved health outcomes in disparate population groups and communities (crosby, wendel, vanderpool, & casey (2012). cbpr is an “approach to health and environmental research meant to increase the value of studies for both researchers and the community being studied” (viswanathan, et al., 2004; p. 3) and thus is defined as a “collaborative research approach that is designed to ensure and establish structures for participation by communities affected by the issue being studied, representatives of organizations, and researchers in all aspects of the research process to improve health and wellbeing through taking action, including social change” (ibid; p. 3). cbpr has further been identified as a promising approach to address rural health disparities through capacity building, establishing trust and information dissemination (newman, et al., 2011). in a seminal summary of 60 cbpr studies for the agency for healthcare research and quality (ahrq), viswanathan et al. (2004) found that the degree of community involvement varied significantly between studies. the authors found 30 studies with interventions focusing on changing individual, community, organizational or environmental factors related to the health online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 66 problems identified. the remaining 30 were non-interventional studies predominantly geared to problem identification, risk factor assessment, capacity development and community empowerment. although arguably the most important aspects of true cbpr, capacity building and community empowerment were the least commonly reported outcomes in the 30 noninterventional studies. however, more recent studies show that cbpr is increasingly being used to build capacity and empower communities to address health disparities in addition to identifying problems and developing interventions across numerous different health issues for diverse rural communities (corbie-smith et al., 2011; gehlert & coleman, 2010; haynes et al., 2011; johnson, bartgis, worley, hellman, & burkhart, 2010; paskett et al., 2011). according to israel et al., (2001), cbpr can be an effective approach in targeting health disparities in specified communities and specific populations. research, jointly conducted by communities and researchers, can assess health problems and design targeted interventions in underserved communities, thereby leading to improved healthcare access and health outcomes. cbpr may be one of the nation’s best options for eliminating health disparities (ahrq, 2002). purpose the walker county area resources & needs (warn) project was the large overarching project designed to address the healthy people 2010 interest areas of health, human services/strengthening families, & supportive communities by connecting indigent rural families in walker county, alabama, a rural community, to affordable quality primary healthcare. the overall aim of the project was to identify the financial, educational, and transportation barriers that engender unemployment, chronic disease, and premature death in the adult population and thereby strengthen healthcare services in rural walker county. the goals of warn were to identify the key health issues facing the county, assess risk factors, and develop online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 67 the community’s capacity to deal with significant health challenges through empowerment resulting from a well-established community-university partnership. specific goals were: goal a: to conduct a needs assessment to identify health resources & needs in walker county through existing data sources, input from social & health services professionals, community leaders & community residents; identify existing services & compile a community resources guide. goal b: to define & formalize the walker area transformational coalition for health (watch) 2010, a rural health network created to improve the health of the uninsured & underinsured residents of walker county. goal c: to convene a health forum for the discussion of community health assets, needs & priorities for action. overall, the warn project utilized a cbpr approach and was designed, funded and implemented in a partnership between a state university and county community members to identify and address rural health disparities for walker county, alabama. local representatives of the walker area transformational coalition for health (watch) (then 2010; now watch 2020), a rural health network formed in 2008 by a range of private and not-for-profit local, regional and state organizations (hamner, kennedy, & wolfe, 2008), were included during the formulation of the purpose and specific aims of the warn project. these representatives were consulted on the most appropriate methods to gain the trust of the residents and were involved in the actual study design, selection of key informants, data collection and analysis. once the study was formulated, the purpose, aims, and methods were presented to the watch 2010 board for final input and approval. community and academic leaders offered support in the acquisition of funds to implement the study. funds were provided by the community foundation of greater online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 68 birmingham, the walker area community foundation, the university of alabama center for mental health and aging, the tuscaloosa veterans affairs medical center and the university of alabama capstone college of nursing. in order to meet goal a, a multi-method cbpr needs assessment was conducted. two nursing faculty members at the university of alabama capstone college of nursing worked with the community partners and two locally employed vista student to identify health resources and needs through existing data sources and input from local social and health services professionals, community leaders, and community residents. using both quantitative and qualitative designs, data were collected for the needs assessment from publicly available state, county, and municipal secondary health and service sources, key informant interviews, a random telephone survey of adult residents, and a survey of healthcare professionals. this article reports the results of the cbpr needs assessment. the community walker county is a mostly rural county located in the appalachian foothills of northwest alabama. this county is defined as predominately rural based on the united states department of agriculture (usda) definition using economic research service rural-urban commuting areas (ruca) with codes 4-10 (usda, 2009). walker county, a full medically underserved area (mua) and a partial health professional shortage area (hpsa) for primary and dental care under federal (health resources & services administration) guidelines, has a critical disparity in healthcare services. sixteen percent of residents live in poverty (national average 12.7%), and 41% of those living in poverty live below 200% of the federal poverty level (alabama department of public health [adph], 2009). the result is a population with uncontrolled chronic illnesses, reflected in a life expectancy of only 70.6 years, among the online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 69 lowest in alabama (compared to 75 years for alabama and 78.2 for the nation as a whole) (adph, 2009; kochanek, xu, murphy, miniño, & kung, 2011). methods sources of data a cbpr needs assessment was conducted to identify health resources and needs through existing data sources and input from local social and health services professionals, community leaders, and community residents. using both quantitative and qualitative designs, data was collected for the needs assessment from publicly available state, county, and municipal secondary health and service sources, key informant interviews, a random telephone survey of adult residents, and a survey of healthcare professionals. procedures an exploratory, multi-method design was used to conduct a community needs assessment consisting of four phases: an epidemiological assessment (phase 1); key informant interviews with county leadership, community, faith and business leaders, and service providers (phase 2); a randomized telephone survey of adult residents based on findings from phase 2 (phase 3); and a healthcare professional survey (phase 4). the study protocol was approved and monitored by the institutional review board (irb) of the university of alabama as exempt (#09-or-188). phase 1. a county epidemiological assessment of selected mortality health status indicators, as identified from the 2009 adph reports, was the preliminary step in the needs assessment. walker county cause of death indicators were compared with state, national, and target indicators to assess excess patterns of disease and health disparities. phase 2. phase 2 of the needs assessment was designed to assess the needs of the community by conducting interviews with key informants living in walker county. community online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 70 partners were asked to identify informants to interview based on their professional exposure to these informants and thus ensuring a sample which contained a variety of occupations and organizations. potential key informants were contacted to obtain permission and set appointments for interviews. nine key informant interviews were conducted. those interviewed included a school vice-principal, a community liaison, a lawyer, a housewife, a businessman, a doctor, a nurse, a case worker, and a social worker. initially ten interviews were planned but one interview with a community minister was not completed due to schedule conflicts. they worked in a variety of fields including the local hospital, the local judicial system, the school systems, the county health department, non-profit assistance services, churches, local businesses, and other county services. all participants were interviewed at their convenience in their personal and private office or space by two researchers. the study was explained, code numbers were assigned, and verbal informed consent was obtained prior to each of the nine interviews. the researchers emphasized that the information obtained would be both anonymous and confidential. in semi-structured interviews, participants were asked exploratory, open-ended questions concerning the health needs of walker county (see table 1). they were encouraged to share their opinions and reactions with follow-up questions from the interviewers. interview questions did evolve somewhat over time in order to obtain as much pertinent information about the phenomenon of health needs in walker county. each interview took approximately 30 to 60 minutes and was followed by debriefing to ensure validity and to provide content to answers where needed. informants were not compensated for their participation. the interviews were audio-taped and transcribed verbatim. notes were taken by the researchers during the interviews to record online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 71 researcher observations of behavior and highlight areas of transcribed interviews on which to focus in greater depth. table 1 key informant interview questions (phase 2). questions 1. what do you perceive to be a health/general problem for walker county 2. how does walker county differ from other counties? 3. what is good here? 4. what is not so good here? 5. what resources are available for improving health? 5a. are they being used effectively? if not, why not? 6. what key things can the community do to improve things locally? analysis and interpretation were ongoing through the data collection stage. consistency was checked as the two researchers discussed and compared results after each interview and made notes. after only nine interviews, a repetition of information was noted, and data collection was terminated. data saturation occurred as evidenced by repetition and confirmation of previously collected data (speziale & carpenter, 2007). both researchers listened to the audio tapes and read and re-read the transcripts to acquire a sense of each interview, extract significant statements and organize into clusters of themes (sanders, 2003). terms, ideas, or quotations from the interviews were identified to help focus on common themes and patterns. findings were used to design a follow-up telephone survey for phase 3. phase 3. phase 3 of the needs assessments used the key informant interview findings to design a follow-up telephone survey. this component was crucial to ensure residents of walker online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 72 county have an active voice in identifying health needs and in establishing priority areas for future community-based health services and research. the survey was developed by the research team with input from researchers who conducted the key informant interviews and community leaders and was submitted for subcontract to the university of alabama institute for social science research (issr). issr is an interdisciplinary organization at the university of alabama with more than 25 years’ experience in designing and conducting research interviews in a wide range of social sciences. the full telephone interview was administered in july and august 2010. it assessed demographics, personal health information, health status, healthcare access, individual satisfaction with available healthcare resources, and caretaking responsibilities. random-digitaldial methodology was used to recruit adults living in walker county with telephones. data were collected from a sample of 774 residents of walker county, alabama, randomly selected from among residential households in walker county with land-line telephone service. in each walker county household contacted, a research assistant attempted to select as the respondent the resident with the next birthday among the residents aged 19 years and older. using the sequence of birthdays in a household was an effective method to approximate randomness in the selection of a population level respondent from each household contacted without the time, complication, and intrusiveness of a kish-based selection. data was collected by research assistants trained in telephone interviewing using cati (computer-assisted telephone interviewing) software from sawtooth systems. verbal consent was obtained from each interviewee prior to administering the survey. the telephone survey tool is available, upon request, from the authors. phase 4. as the study progressed it was decided by the watch 2020 board of directors that an assessment of the health status of walker county from the perspective of the healthcare online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 73 professionals would be beneficial in the planning of future intervention and prevention programs. information obtained from the key informant interviews and the telephone survey was used to guide administration of a needs assessment to healthcare professionals. a questionnaire was compiled and distributed to 150 healthcare professionals in walker county, with a completion rate of approximately 30 percent (45 surveys). the respondents included registered nurses, nurse practitioners, administrators, physicians, dentists, and pharmacists. the six-question survey used open-ended questions allowing for free-response. the healthcare professional survey tool is available, upon request, from the authors. results epidemiological assessment in walker county, about 59% of the population completed high school within four years, compared to 70% in alabama, and less than half of the population of walker county has some college experience, compared with 56% in alabama and 68% in the united states (robert wood johnson foundation [rwjf], 2012). poverty and unemployment are also likely contributors. walker county has a very high unemployment rate (10.6%, as opposed to 5.4 % nationwide) (rwjf, 2012). consequently, walker county is consistently ranked as having some of the poorest health outcomes in the state. rwjf county health rankings (rwjf, 2012) show walker county ranked 67th out of 67 alabama counties in terms of mortality, or years of potential life lost before the age of 75. however, in the same report, walker county ranked 43rd in terms of available health infrastructure (rwjf, 2012). alabama, as a whole, also receives low scores for its healthcare. in the rankings of state healthcare by the united health foundation (uhf, 2012), alabama placed 46th overall in the year 2011. online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 74 health profile mortality by selected cause is presented and compared to state and national mortality data in table 2. table 2 walker county health comparison with state & national mortality data (phase 1). disease walker county state national heart disease 321.5% 254.0% 180.1% cancer 312.8% 217.8% 173.2% stroke 49.5% 56.2% 38.9% accidents 97.5% 49.7% 37.3% chronic lung &respiratory disease 100.4% 58.6% 42.3% diabetes 32.0% 26.3% 20.9% influenza & pneumonia 20.4% 19.8% 16.2% alzheimer’s disease 36.4% 32.1% 23.5% suicide 14.5% 14.2% 11.8% homicide 8.7% 8.7% 5.5% human immunodeficiency virus disease 4.4% 3.6% na *source: adph, 2009 health profiles; usdhhs (national vital statistics (2011) na = not available key informant interviews. the nine key informants perceived the greatest health and general problems in walker county to be the lack of insurance coverage or being underinsured; obesity; a lack of education; and a lack of consistency in primary care. they believed that walker county differed from other counties in the state of alabama by a markedly lower selfesteem in the individual citizens and the county, a lower socioeconomic status (ses), lower levels of education, an increased drug culture, and a lack of local industry. when asked how online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 75 much of a problem alcohol abuse was in walker county, 81% said that it was either an “extreme problem” or “quite a large problem.” some of the perceived disadvantages to living in this area included a lack of discipline in the home, the division of community by the 270 churches within the county, the lack of vision by the county leadership, the high drug and crime rate, the poor education system, the poor literacy rates, the shortages of physicians who accept medicare, and the lack of transportation. also of noted importance was a “crippling sense of tradition” defined by respondents as ongoing poverty and lack of education because what was “good enough for the prior generation was good enough for the next generation.” however, some of the stated benefits of living in walker county included the physical environment, the increased number of physicians, the jasper city school system, the hospital (walker baptist medical center), and the strong sense of community. informants were asked to identify assets available as far as healthcare services for walker county. some of these included: hope clinic (a free clinic for indigent care); walker baptist medical center; federally qualified health centers (the capstone rural health center in parrish and jasper health services clinic in jasper, in particular); walker county public health department (the all kids and women, infants and children [wic] programs, in particular); american red cross; local physicians, nurse practitioners and hospitalists; local urgent care centers; united way; faith-based groups; jasper area family services (including the baby talk program); northwest alabama mental health center; and local drug stores that work with the hospital to make medications affordable. when asked to discuss areas needing improvements within the community, informants identified transportation, affordability of care, more recreational facilities and physical exercise opportunities, partnerships and collaborations among online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 76 the variety of service providers, education and awareness opportunities, and easy access to this information through a website or a network. telephone survey. the survey used a random-digit-dialing sample consisting of 774 participants. the sample was 70% female, 93% white and had an average age of 57 years. highest level of education attained was most often reported as high school diploma (31.9%) or some college or technical training (25.8%). the majority of the survey population had a household income of $39,000 or less. among those surveyed, 12% were veterans. the most significant health concerns in walker county perceived by the general population as identified by the telephone survey are shown in table 3. table 3 important issues in walker county (n = 774) important issues number % of all answers poor quality or insufficient health services 178 23.00 lack of insurance 151 19.51 heart disease 81 10.47 cost of care/poverty 80 10.34 cancer 76 9.82 drug abuse 61 7.88 diabetes 50 6.46 lack of senior care 48 6.20 obesity 46 5.94 pediatric and prenatal care 27 3.48 other reported concerns noted from the surveys included: sexually transmitted infections, alzheimer’s, autoimmune diseases, and teen pregnancy. many of the sample surveyed in the online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 77 needs assessment reported that they did not have a problem reading health materials or understanding written information (39.1%) or understanding verbal information (34.1%). however, 54.7% did not feel comfortable filling out health forms without assistance. most either read the health sections of newspapers and magazines (66.7%) or watched health segments on television (82.6 %). the majority of respondents reported that they are in “very good,” “good,” or “fair” health (79.4%). however, approximately 40% attributed their physical health to not achieving personal goals, and almost 60% said that normal work inside and outside the home caused them physical pain which interfered with that work. survey results showed “poor quality or insufficient health services” as the most significant health concern in walker county. eighty-nine percent of participants said they were “very satisfied” or “somewhat satisfied.” only 9% of those surveyed reported using medicaid, while 41% reported using medicare and 11% reported having no insurance. the majority (74%) reported that they went to a doctor’s office or clinic when they were sick. most (80%) respondents reported that they had visited a health care provider, for any reason, in the last 12 months. however, 51.8% reported that they had not been to the dentist’s office within the last 12 months. the body mass index (bmi) of the population surveyed was calculated using a formula obtained from the national heart lung and blood institute (nhlbi, nd). the average bmi was 28.3 ± 6.2, which is in the overweight range. approximately 32% had bmis above 30, which would categorize them as obese. when asked about how well the people of walker county managed their weight, almost 50% of those surveyed said that the population managed their weight “poorly” or “very poorly.” online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 78 other findings from this survey showed the majority of the participants reported that they never smoked cigarettes (75.2%). when asked a range of questions regarding depression, about 36 to 41% of those surveyed showed some signs of depression. these signs were characterized by feeling little pleasure or interest in daily activities, by feeling nervous or anxious several or more days in a two-week period, and by experiencing uncontrollable worrying several or more days in the past two weeks. healthcare professional survey. the most reported concerns regarding healthcare in walker county, according to resident health care professionals, included no insurance due to lack of jobs (33%), abuse of prescription drugs (15%), obesity (12%), and lack of education among the population (10%). their rationale for the disparity between health factors and health outcomes was largely a lack of responsibility and concern for personal health, as well as the lack of insurance and jobs. diabetes, high blood pressure, and heart disease were identified by health care professionals as the most severe health problems in walker county. the healthcare professionals suggested that health education in schools and adult health education classes would be the best ways to improve health and create healthy lifestyles in walker county. almost 70% of the respondents to the health care professional survey indicated they would be willing to participate in offering health education classes in healthy lifestyle choices, as well as chronic disease management. discussion epidemiological assessment assessment of selected health status indicators as identified from adph (2009) revealed an overwhelming number of disparities for walker county as represented in table 2 and 3. when compared to state and national cause of death indicators, excess mortality was noted online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 79 across many categories including heart disease, cancer, stroke, accidents, chronic respiratory disease, diabetes, influenza and pneumonia, alzheimer’s disease, suicide, and hiv disease. given education and literacy are determinants of health (crosby et al., 2012), documented poverty and lack of educational attainment noted in walker county have contributed to the county’s poor health status. furthermore, poverty is a significant contributor to poor healthcare quality and health outcomes for a variety of diseases and injuries (raffensperger et al, 2010). many of walker county residents are the working poor, which is usually associated with poor access or affordability of quality health services. the current economic environment amplifies the problems in a large population with unmet healthcare needs and poor health outcomes. key informant interviews one overarching common theme was that the invaluable resources identified by key informants are not being used effectively due to a lack of transportation and knowledge of the options available in the county. concern with transportation to healthcare services was also found in a previous study (graves, 2012), where 16% of those interviewed said that they traveled more than 30 miles for healthcare and found this to be a major problem. telephone survey despite the survey population reporting “poor quality or insufficient health services” as the most significant health concern in walker county, when asked to assess their satisfaction with the available health care, 89% said they were “very satisfied” or “somewhat satisfied.” this suggests that individual satisfaction with health services is higher than perceived community satisfaction. while outside data (adph, 2009) indicates that 21.9% of the walker county population was eligible for medicaid assistance, only 9% of those surveyed reported using medicaid. online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 80 approximately 32% had bmis above 30, which would categorize them as obese. this finding corresponds with data from the centers for disease control and prevention (cdc), reporting that 31% of the population of the state of alabama is obese (cdc, 2007) and showing that 30.9% of walker county’s population is obese (2007). graves (2012) found an overwhelming 44% obesity in patients in one local walker county health clinic. furthermore, almost 50% of those surveyed identified that the population did not manage weight well, suggesting that the population of walker county is aware of the county’s obesity epidemic. health care professional survey when asked to describe the most severe health problems in walker county, the answers given by the health care professionals were consistent with those obtained from the random telephone survey of community residents – diabetes, high blood pressure, and heart disease. obesity was identified as a problem but was lower on the list in this group. they did agree that a lack of education among the general population about healthy lifestyles was the greatest obstacle in overcoming those challenges. strength and limitations a particular strength of the study was the use of a multi-method design (lobiondo-wood & haber, 2010). the collection of different types of data related to the complex phenomenon of health and community worked to bring clarity to health disparities present in this rural community. this multi-method approach allowed for the examination of different facets of community health and enriched understanding of the human experience of health in a rural community. the combination of methods not only facilitated instrument development and the accomplishment of the specific project goals, but can now also guide intervention development. online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 81 some complications were noted during the completion of this study. the timeline for accomplishing deliverables had to be extended while the phone survey was finalized. this may have created a slight discrepancy between the responses of the key informants and the telephone survey results. there was also some deviation from the script for the telephone survey, which created obstacles in the interpretation of the results. furthermore, the telephone survey reached a majority white, female, urban population, making it less generalizable to the entire population of walker county. this selection bias is consistent with the trend of younger individuals typically now owning cellular phones only; people who have land-lines are typically older. all participants in the telephone survey had land-line telephone service and therefore it is possible that findings may differ from those with only cell phone service or no telephone service. a limitation of this study is that it drew heavily from active collaboration with partnering agencies, community-based organizations, and community members. the findings may not apply to communities where such collaboration is not present. the generalizability of the study findings to the larger rural population is further limited by the sample size and demographics. the study population or community was located in northwest alabama and was composed of mostly white participants living in poverty situations. findings may differ for other rural communities in other regions. implications the high prevalence of chronic disease seen in walker county shows a high priority need for future research and interventions. this community-based needs assessment can now be used to guide the development of future research as well as treatments and intervention protocols. more research is needed to identify specific burdens within the infrastructure and to place this online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 82 information in a cultural context for designing community-based prevention and intervention strategies. this project has demonstrated the ability to build capacity and empower this rural community. furthermore, the use of a cbpr approach was successful in identifying and assessing health disparities in this county. the data can now be used to work toward the elimination of health disparities. although this research has high relevance to social and health service professionals it is also relevant to other professionals who are interested in the use of cbpr. it can therefore be used by those with an interest in community engagement and scholarly and civic engagement and has pedagogical potential for teaching in these fields. this research can serve as a model for future research and community engagement scholarship as it related to cbpr as a paradigm to identify, address and eliminate health disparities. academic centers can connect with community partners to conduct cbpr. nurse faculty leaders are valuable resources for assessing health problems and designing targeted interventions in underserved communities toward improved healthcare access and health outcomes and ultimately leading to decreased health disparities. conclusions the use of cbpr in this rural community was successful in this community-based need assessment was used to guide the development of intervention strategies within the framework of watch 2020. all results were presented to the watch 2020 board of directors, as well as community leaders, in order to aid in the development of a sustainability plan. dialogues to relate community health experiences provided excellent means to learn about communityspecific needs. watch 2020 was inspired by the results of the needs assessment to host a online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 83 childhood obesity task force summit to determine the most effective way to combat the obesity epidemic in walker county. watch 2020 also planned a healthy week initiative which will take place annually in an attempt to reduce health disparities of walker county. the planning and program efforts of watch were valuable to the county, but in 2012 the watch 2020 leadership reviewed other organizational models to increase community impact. the health action partnership in nearby jefferson county provided the model for a more concrete leadership structure that was better suited to moving prevention strategies forward in walker county. watch transitioned into the walker county health action partnership (wchap) in october 2013 with signed articles of collaboration and committed anchor organizations to support the work, but many partners that participated in watch transitioned as well. additional key community partners have signed on to wchap, increasing the reach and impact of prevention efforts and helping secure funding from three external grants. in summary, the current findings support disparities in healthcare use and health outcomes in this rural community. furthermore, it was determined that walker county community residents do not suffer from a shortage of available healthcare services. these findings show a disconnection between the noted availability of healthcare services and disparities in many health outcomes. further research is needed to identify potential cultural factors and barriers. this study highlights the value of cbpr as a paradigm to address rural health disparities through capacity building, establishing trust and information dissemination. all communities are different and have individual identities; information from one community is not necessarily replicable or transferable. cbpr is an effective approach for the identification of communityspecific health disparities and in the guidance of developing community-specific interventions toward the elimination of health disparities. online journal of rural nursing and health care, 15 (2) http://dx.doi.org/ 10.14574/ojrnhc.v15i2.353 84 supporting agencies as a part of the walker area resources and needs project, this study was funded in part by: the community foundation of greater birmingham ($17,000);the walker area community foundation($10,000); & the university of 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(2004). community-based participatory research: assessing the evidence. summary, evidence report/technology assessment: number 99. ahrq publication number 04e022-1, august 2004. agency for healthcare research and quality, rockville, md. retrieved from http://www.ahrq.gov/clinic/epcsums/cbprsum.htm microsoft word findholt_article 11 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 environmental influences on children’s physical activity and diets in rural oregon: results of a youth photovoice project nancy e. findholt, phd, rn1 yvonne l. michael, scd, ms2 melinda m. davis, phd(c), ccrp3 victoria w. brogoitti, bs4 1associate professor, school of nursing, oregon health & science university, findholt@ohsu.edu 2investigator, octri, oregon health & science university, michaely@ohsu.edu 3research scientist, orprn, oregon rural practice-based research network, davismel@ohsu.edu 4director, union county commission on children & families key words: rural populations, childhood obesity, photovoice abstract little is known about the effect of the rural environment on children’s physical activity and food choices. in this study, six rural adolescents participated in a photovoice assessment to document conditions that influenced children’s activity and diets. physical activity was hindered by inadequate recreational resources, unsafe streets, and distance, but was promoted by the natural environment and support for youth sports. healthy eating was hindered by busy lifestyles, limited access to healthy foods, access to and promotion of unhealthy foods, and social values, but was promoted by the agricultural setting and gardening. while many of these factors occur in non-rural settings, the findings suggest that rural communities have unique strengths and barriers that must be considered when developing interventions. introduction over recent decades, the prevalence of childhood obesity has increased dramatically in the united states. recent results from the national health and nutrition examination survey (nhanes) indicate that nearly 19% of school-age children and adolescents, ages 6 to 19 years, are obese and an additional 16% are overweight (ogden, carroll, curtin, lamb, & flegal, 2010). this epidemic is especially severe in rural parts of the country, where obesity rates among children and adolescents have been shown to be higher than state or national averages and higher than rates among youth in urban areas (joens-matre et al., 2008; king, meadows, engelke, & swanson, 2006; lewis et al., 2006). a recent national study found that rural children were 25% more likely to be overweight or obese than their urban counterparts (lutfiyya, lipsky, wisdombehounek, & inpanbutr-martinkus, 2007). children who are obese are at risk for many serious physical and emotional health conditions, including type 2 diabetes, hypertension, orthopedic problems, low self-esteem, and depression (daniels, 2006; strauss & pollack, 2003; wang & veugeloers, 2008). it is widely believed that environmental factors are at the root of the obesity epidemic (miller & silverstein, 2007). however, research into the links between the environment and children’s physical activity and diets is limited at this time (sallis & glanz, 2006). this limitation is especially true in regard to the rural environment because nearly all of studies exploring the environmental correlates of children’s activity and eating patterns have been conducted in urban or suburban settings (hartley, 2007). 12 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 although research conducted in urban or suburban areas may provide clues as to the factors that affect children’s physical activity and food choices in rural communities, it cannot be assumed that the factors are the same. many rural communities are characterized by vast distances, low socioeconomic status, transportation challenges, and low public funding levels for facilities, programs, and other public amenities (phillips & mcleroy, 2004), and these characteristics may contribute to low levels of physical activity and unhealthy diets among children. on the other hand, it is conceivable that the rural environment may be perceived as safer and that rural children may spend more time outdoors and have more access to fresh fruits and vegetables along with less access to fast food restaurants than their urban and suburban counterparts – factors that have been linked to increased physical activity and healthy eating behaviors (baranowski, thompson, durant, baranowski, & puhl, 1993; french, story, neumark-sztainer, fulkerson, & hannan, 2001; hearn et al., 1998; klesges, eck, hanson, haddock, & klesges, 1990; sallis et al., 1993; timperio, crawford, telford, & salmon, 2004). in this article, we report the findings of a study that explored the perceptions of rural youth concerning the environmental barriers and facilitators of children’s physical activity and healthy eating in their communities. photovoice was utilized as the method for achieving this goal. photovoice is a participatory action research methodology that entrusts cameras to people so they can document and discuss community needs and assets (wang & burris, 1997). this photovoice project was part of a multi-method community assessment conducted by u.c. fit kids (union county fit kids), a coalition of community and academic partners who are engaged in community-based participatory research for childhood obesity prevention in union county, oregon. method setting and participants union county is an isolated agricultural region in northeast oregon that, at the time of the study, had a population of 24,753 people (u.s. census bureau, 2007). most of the residents were caucasian (94.0%) and the median household income was well below the state average ($39,873, compared to $48,735 for oregon). there were six main communities in the county, one with 12,327 residents and five that ranged in size from 290 to 1,961 residents. each community had its own school district with a single high school. a purposive sampling strategy was used to recruit one student from each of the six high schools in the county. to be eligible to participate in the study, a student had to have lived in his or her community for at least eight years and had to have attended the local elementary school. these criteria were established to ensure that the student participants would have an in-depth knowledge of their communities. of the six students who participated in this study, four were females, all were caucasian, three were high school seniors, two were juniors, and one was a sophomore. active parental consent and student assent were obtained at the time of recruitment. photovoice procedure we followed a procedure similar to one delineated by wang (2006) to engage the student participants in data collection and analysis. human subjects approval and study oversight was provided by the oregon health & science university institutional review board. the steps that 13 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 were taken are summarized below. for a detailed description of the study procedure, see findholt, michael, and davis (2010). three 3-hour photovoice sessions and a final 1-hour session took place between july and october 2007. the sessions were facilitated by a team of two investigators and two graduate students. during the first session, the facilitators led an interactive discussion about environmental influences on children’s physical activity and diets, discussed the project goals and ethical issues related to photography, and provided each student with two disposable cameras. a professional photographer provided tips on using the cameras. the students were asked to take pictures of facilitators and barriers to children’s physical activity and healthy eating within their communities. they were given one month to complete their photography and return the cameras for processing. at the second session, the students reviewed their photographs and selected those they thought were most important, wrote captions to explain what the photographs meant, shared and discussed their photographs with each other, and identified themes that arose from the photographs. the following questions were used to facilitate the discussion: what do you see here? what’s really happening here? how does this affect children’s physical activity or food choices? why does this problem, concern, or strength exist? what can we do about it? following this session, the facilitators drafted a computerized slide presentation using the students’ photographs and captions. at the third session, the students made minor changes to the slides, practiced giving the presentation, and brainstormed about steps that could be taken in union county to promote physical activity and healthy food choices among children. finally, at the fourth session, the students presented their findings to members of the u.c. fit kids coalition and other invited guests. at the conclusion of this session, the students received a $100 stipend. results the photographs taken by students revealed several barriers to children’s physical activity and healthy eating in this rural county, but also some assets that promoted healthy behaviors. the following represents the major themes that emerged from the photographs and group discussions. to view a sample of the photographs, go to http://www.eou.edu/ohsu/ photovoice.html. factors influencing physical activity limited availability of recreational facilities and programs was identified as a primary barrier to children’s physical activity. one student photographed her town’s boundary sign showing a population of 1,710 and wrote, “this sign shows that our town is very small. because [it] is so small, the choices for … physical activity are limited.” the perception of having few options for physical activity was widely shared among the students. in addition, existing facilities were frequently described as inaccessible or inadequate. for example, it was noted that: (a) some facilities had not been maintained; (b) few facilities were open after 5 p.m.; (c) some facilities were only available to select groups, such as youth who were involved in sports; (d) some facilities lacked shelter and were too hot to use during summer months; and (e) some parks were perceived as unsafe places for children to play because of the people who might be loitering there. one exception to the theme of limited resources for physical activity emerged in photographs of the natural environment. using pictures of nearby lakes, rivers, and wooded 14 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 areas, the students explained that these natural areas were commonly used by children and their families as places to play and be active. one student photographed a small lake near her community and wrote that when the water level was sufficient “there are kids there every day with their families.” it was also noted that organized youth sports were very popular in union county and provided opportunities for children to be active. for example, one student took a picture of an outdoor basketball court and wrote, “in [my community], sports are extremely supported and inspired. i believe that this sets out a good example for young children to become more active.” another commented that at least three-quarters of the students in her small school participated in sports. however, during the group discussions, several students observed that only traditional sports such as football or soccer were offered and that there were no structured opportunities for youth to participate in non-traditional activities. thus, it was difficult for those who lacked an interest in sports to be active. one student said, “i know that, if i’m going to go out and do something, it’s on my own time. for example, going out and snowboarding on the weekend … i can do that, but it’s not supported by the school. it takes a lot of motivation to go out on your own.” many of the students’ photographs focused on community streets, and their captions revealed that the side streets were a primary location where children played and were active. for example, one student took a picture of chalk drawings on a street and observed that few people drove on the side roads in his community so children often played on these streets. on the other hand, several students emphasized that there were few sidewalks or bike lanes in their communities and that the main streets had much traffic, including oversized trucks. many of the main streets were, in fact, highways, and the students observed that, even when sidewalks or bike lanes were present, it felt unsafe to walk or bicycle on these roads. finally, long distances between home and school or play areas were identified as a factor that hindered children’s physical activity. one student, who lived in union county’s largest community, explained that his home was two miles from school and said, “if we weren’t so sprawled out maybe people would walk more, but most people now just drive.” likewise, a student living in one of the smallest communities used photographs of pasture land within the city limits to show that, even in small towns, people were “spread out”, and he noted that a local playground was rarely used by children because it was “too far to walk.” however, sociocultural factors might also influence the decision to get a ride, rather than walk or ride a bike. at least two students observed that many of their peers drove to school even when they lived nearby because it was “cool to drive a car”. factors influencing food choices a predominant theme in the photographs and stories pertaining to food was that children’s diets were strongly influenced by their home environment (e.g., “whatever the parents serve for dinner is what the child will consume”). however, the students also identified several factors within their communities which they believed had an effect on the food choices made by youth and their parents. busy lifestyles and perceived lack of time emerged repeatedly as significant barriers to healthy eating. the students took pictures of fast food restaurants and prepared foods and explained that parents and youth frequently purchased these foods, even when they knew they 15 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 were unhealthy, because: “when you’re running around trying to get things done, it’s just easier to go to mcdonalds.” in addition, limited access to healthy foods was identified by the students who lived in the smallest communities of union county as a factor that negatively influenced children’s diets. one student, who lived in a town of 490 residents, photographed the produce section of her community’s small market – a single refrigerated shelf holding fewer than two dozen vegetables, such as onions and bell peppers – and noted that, in addition to the limited quantities, these foods were “not what kids would eat anyway [for snacks].” unhealthy foods, on the other hand, were perceived by all of the students as being easy to obtain and heavily promoted. although one student observed that fast food chain restaurants were not common in small communities like her home town, she and other students used photographs of soft drink machines, deli counters, and candy displays to show that high-fat and high-sugar foods were widely available. they also noted that these foods were inexpensive, making them easy for children to access. in addition, the students emphasized that advertisements for unhealthy foods were abundant and that many of the marketing strategies targeted youth. for example, one student took a picture of the breakfast cereals in her local market and pointed out that the heavily sweetened cereals were placed on the lower shelves, where children would easily see them. another photographed a large candy display located adjacent to the entrance of her community’s market and wrote, “this is what kids first see when they walk into this store.” finally, several social values were identified as having a negative effect on children’s diets. one value – that getting a bargain is good – emerged in photographs showing (a) signs advertising a sale on soda and energy drinks, (b) a store refrigerator promoting larger sizes of soda for only 25 cents more, and (c) a large bag of candy with a caption that read, “sometimes getting larger bags of something can be cheaper and much more appealing…. if you purchase bigger bags of something unhealthy, you will consume more of it.” a second value was expressed by a student who said, “bigger is better in america – that’s the problem.” he and others talked about the appeal of over-sized portions and all-you-can-eat buffets. in addition, several students noted that food, particularly unhealthy food, was perceived as a treat or a reward. one student took pictures of a mcdonald’s arch card and a box of fudge brownie mix and explained that these were used by parents as a way to reward or entertain their children. in contrast to these barriers to healthy eating, union county’s agricultural setting and the popularity of gardening were identified as factors that promoted healthy food choices because they increased access to healthy foods and helped people to be more aware of nutrition and where their food comes from. one student photographed a cucumber vine and wrote, “in my town, agriculture is very popular. vegetable gardens and edible crops are a good inspiration to eat organic foods. it’s … fun to watch them grow, and harvest them as well.” unfortunately, however, comments such as this one were greatly overshadowed by the larger themes pertaining to unhealthy foods being fast, cheap and popular. discussion the findings from this study need to be considered in light of the small number of student participants and inclusion of only one rural county. despite this, the students’ photographs and comments add to the knowledge base about environmental influences on children’s physical activity and diets, especially as these pertain to rural communities. 16 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 some of the findings are consistent with previous research. recreational facilities have been found to be less common in low-income neighborhoods than in higher-income neighborhoods (estabrooks, lee, & gyurcsik, 2003; gordon-larson, nelson, page, & popkin, 2006; powell, slater, chaloupka, & harper, 2006), and may also be less common in rural than in urban communities (wilcox, castro, king, housemann, & brownson, 2000). limited access to recreational facilities and programs has been associated with lower levels of physical activity among children and adolescents (romero, 2005; sallis, prochaska, & taylor, 2000). similarly, convenience stores, which offer fewer healthy foods such as fresh fruits and vegetables, are far more common than supermarkets in rural areas and in low-income communities (liese, weis, pluto, smith, & lawson, 2007; morland, wing, roux, & poole, 2002; moore & roux, 2006), and some evidence suggests that consumption of healthy foods is influenced by whether these foods are available in local grocery stores (cheadle et al., 1991; morland, wing, & roux, 2002; rose & richards, 2004). in addition, long distances, traffic-related safety concerns, and lack of sidewalks and bike paths have been identified as barriers to walking and bicycling among children (cdc, 2002; cdc, 2005; ewing, schroeer, & greene, 2004; timperio et al., 2004). also, previous studies have found that what children eat is influenced by what is available in the home (o’dea, 2003; hearn et al., 1998); that less healthy foods are often selected because they are easy and quick (o’dea, 2003); and that aggressive marketing of unhealthy foods toward children is a factor that leads children to consume these products (institute of medicine, 2005; page & brewster, 2007). among the findings that were unique to this study was that the natural environment was extensively used and appreciated as a resource for physical activity. this is an important healthpromoting characteristic because outdoor play has been consistently linked to physical activity among young children (baranowski et al., 1993; klesges et al., 1990; sallis et al., 1993). interestingly, no safety issues were mentioned despite the fact that use of these resources does present some risk. (for example, there are no lifeguards at the rivers and lakes where children swim.) another unique asset that was identified was the popularity of youth sports. in rural communities, youth sports may be particularly popular because there are few other social activities available to the residents. also, children might be encouraged to participate in sports because, without a high level of participation, there would not be enough players to form a team. although a strong focus on sports does promote children’s physical activity, it is not ideal. not all children enjoy or are good at traditional sports. female students, in particular, have reported discomfort in trying out for or participating in sports due to perceived incompetence, perceptions of peer judgments, and the seriousness of participation (bauer, yang, & austin, 2004; hohepa, schofield, & kolt, 2006). also, as one student in our study noted, not all sports require a high level of physical activity. for example, in baseball, children spend much time standing or sitting. finally, many sports, such as football, are not life-long activities. our findings pertaining to rural streets and their influence on children’s physical activity were interesting in that there was a distinct contrast between the perceptions concerning the side streets and those concerning the communities’ main roads. the main connecting roads were described as dangerous and a barrier to walking and bicycling. however, the side streets, which had little traffic, were identified as a primary area where children played. despite low traffic and the perception of safety, the use of side streets as play areas may present safety risks. the findings pertaining to community sprawl were also interesting because sprawl is a concept that is typically associated with urban areas, where homes are widely separated from 17 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 stores and workplaces (ewing, schmid, killingsworth, zlot, & raudenbush, 2003). yet, as our study showed, sprawl is factor that influences physical activity in rural areas as well. people living in the country or on farms have always been spread out, but it was surprising to find that, even in very small communities, sprawl (or the perception of sprawl) was identified as a factor that reduced walking. in regard to dietary influences, the findings of our study suggest that rural communities are not isolated from the trends that have had a profound negative effect on people’s diets in other parts of the country. lack of time to prepare meals, the appeal of fast food and large portions, and exposure to aggressive marketing of unhealthy foods, among other factors, appeared to have an overwhelming influence on children’s diets in union county. in contrast, union county’s agricultural surroundings and vast number of orchards and gardens were perceived as having only a minor positive effect on children’s food choices. some reasons for the limited effect of the agricultural environment on children’s diets were found in other findings from the u.c. fit kids community assessment. these included union county’s limited growing season and the fact that preserving food was uncommon among young families. an important strength of the study was that it engaged adolescents who had grown up in union county and had an in-depth knowledge of their communities in the assessment. this research should be expanded to include adolescent participants from other rural counties. in addition, the participants in the current study suggested that future research allow more photovoice sessions so that students would have more time to research their communities and refine their photographic techniques. in addition, one student suggested that photographs be taken at different times of the year in order to capture environment factors that are important during different seasons. implications for practice while many of environmental factors that were identified in this study as having an influence on children’s physical activity and diets also occur in non-rural settings, our findings indicate that rural communities do have unique strengths and barriers that must be considered in the development of interventions. the findings point to the need to increase access to physical activity opportunities for rural children outside of organized traditional sports. activities that make use of the natural environment may be particularly attractive. there is also a need to increase access to healthy foods, such as fresh fruits and vegetables, especially for children and families who live in small communities that lack supermarkets. in agricultural areas, such as union county, promoting the use and preservation of locally grown products may be helpful. in addition, it is important to provide children and families with ideas about how to prepare quick and healthful meals and snacks. again, promoting the use and preservation of local produce may be a useful strategy. finally, addressing street safety is essential, particularly on the main roads but also on side streets since the streets serve as primary play areas for children. author note this study was funded with a grant from the northwest health foundation. the authors would like to thank jamie peters, rn, mph for her assistance in facilitating the photovoice sessions. 18 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 references baranowski, t., thompson, w.o., durant, r.h., baranowski, j., & puhl, j. 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[medline] microsoft word winton_368-2238-1-ed (2).docx online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 23 korean immigrant’s health and healthcare practices in rural america: a systematic review mary b. winton, phd, rn, acanp-bc assistant professor, department of nursing, tarleton state university, mwinton@tarleton.edu abstract purpose: a systematic review of the literature was conducted to determine korean immigrants’ health and healthcare practices. method: a systematic review of relevant studies was conducted between 2005 and 2013 using cinahl complete and science direct within the ebscohost discovery service and the cochran library as outlined in the preferred reporting items for systematic reviews and metaanalyses. original research articles discussing the health and healthcare among korean immigrants in the united states were reviewed. key terms included korean immigrants, rural, texas, healthcare, research, and koreans. findings: using various combinations of the key terms, the search produced 243 potential relevant records with only 25 being eligible for review. no studies represented rural regions. furthermore, only one study was conducted in texas. twenty-five records described the state of health and healthcare among korean immigrants. topics included socialization, healthcare utilization, cancer screening practices, a prevalence of depression, knowledge of hypertension and stroke, and level of physical activity. conclusions: despite the review, korean immigrant’s health and healthcare are still largely unknown, especially when taking rurality into context. health disparities are more likely to occur in rural medically underserved areas than in urban areas. the presence of such health disparities is even more probable among korean immigrants. an increased knowledge of the online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 24 korean culture is needed among healthcare practitioners to promote health and healthcare among these vulnerable populations. keywords: korean, texas, rural, health, healthcare korean immigrant’s health and healthcare practices in rural america: a systematic review the united states is a multicultural nation with asians being one of the fastest growing minority groups (shive et al., 2007; weir, tseng, yen, & caballero, 2009). according to the 2010 u.s. census bureau (2012), over 14 million residents in the united states (us) are asians, nearly 1.5 million of which are koreans. furthermore, with the continuing immigration of asians, varying locales in the us are experiencing a population boom, especially among younger generations (kandel, 2011). rhoads (2012) reported that of the 50 states, tx had the greatest increase of immigrant koreans. in addition, tx experienced a 22-fold increase in the number of korean immigrants (kis) from 1970 to 2009, most of whom reside in dallas and harris counties. many others reside in bexar county and on military bases (rhoads, 2012). the population growth of kis necessitates a better understanding of kis’ health and healthcare. background and significance federal initiatives continue to focus on decreasing health disparities among all ethnicities, including asian americans and pacific islanders (aapi). healthy people 2020 (u.s. department of health and human services, office of disease prevention and health promotion, n.d.) included 1,200 objectives in 42 topic areas. these areas of focus suggested that improving access to comprehensive, quality healthcare services, enabling patients to locate healthcare providers whom they trust, and promoting and providing health equity will diminish many of the online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 25 existing health disparities. furthermore, the goal of the texas health and human services (thhs, 2010) was to “promote the health, responsibility, and self-sufficiency of individuals and families” (p. 3). despite these initiatives, quality health and healthcare among specific subgroups of aapis such as kis are lacking (han, kang, kim, ryu, & kim, 2007; park & grindel, 2007; weir et al., 2009). furthermore, kis tend to seek social and psychological support as well as healthcare advice from other koreans (lee, hann, yang, & fawcett, 2011; lee, lee, & im, 2011; yang & yang, 2011) rather than from professional healthcare providers of western medicine, potentially contributing to the existing health disparity (sin, fitzpatrick, & lee, 2010). additionally, kis have traditionally defined their health based on quality of life (qol) rather than on quantity of life. a life worth living was a direct function of being in harmony with one’s immediate surroundings (choe, padilla, chae, & kim, 2001) whether at work, school, or home. choe et al. (2001) also reported that factors such as helplessness and powerlessness affected qol and kis’ willingness to seek healthcare. kis viewed their health as “good” when symptom free and consequently did not seek screening and preventive healthcare (han et al., 2007; ihara, 2009; yoo & kim 2008). the general lack of health screening, preventive medicine, and health maintenance among kis potentially increases the incidences of chronic illnesses (frisbie, cho, & hummer, 2001; jang, kim, & chiriboga, 2005; ko et al., 2011). therefore, the purpose of this analysis was to systematically review the evidence on the health and healthcare perceptions, behaviors, and practices among kis. korean immigrants in rural tx according to the migration policy institute (mpi, n.d.) the majority of american kis lived in ca (31%). three other states had five to 10 percent of kis (tx, ny, and va). furthermore, online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 26 the population of kis in tx had increased dramatically since the liberalization of the us immigration law in 1965 (rhoads, 2012). consequently, koreans constituted over one percent of the total population of foreign-born residents in texas. according to zipatlas (2012), the majority of immigrants lived in urban areas; yet five of the top ten tx towns (cresson, coppell, harker heights, campbellton, and copperas cove) with the highest percentage of kis were located in rural tx. the percentage of kis in these locales ranged from 1.11 to 2.17 percentage of the total population per town. rurality and health disparity according to the rural policy research institute (rpri, 2007) health panel, no universal definition for rurality exists. furthermore, the definition for rurality defined by the intended outcomes varied. consequently, multiple definitions for rurality produced some degree of vagueness and ambiguity in relevant research (vanderboom & madigan, 2007). for the purpose of this paper, rurality is defined as, “all population, housing, and territory [that is] not included within an urban area” (u.s. census bureau, 2010, para. 3) and has a population of fewer than 50,000 people (u.s. census bureau: american factfinder2, 2010). optimal healthcare for people living in rural areas can be difficult to obtain because of significant barriers (brems, johnson, warner, & roberts, 2006) such as sociocultural and structural factors (graves, 2008). specific examples included cultural beliefs, language difficulties, financial constraints, and minimal availability of healthcare resources (graves, 2008). additionally, rural healthcare providers faced challenges in delivering appropriate healthcare. such challenges included residents’ unwillingness to participate in health prevention or screening programs (brems et al., 2006; brown, ojeda, wyn, & levan, 2000). without appropriate healthcare, health disparities increased, resulting in a higher morbidity and mortality online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 27 (andrulis, 2003; brown et al., 2000; jones, 2010). the national institutes of health (nih, n.d.) reported that despite the improvement of overall health in america, disproportionate levels of health disparity continue to exist for various ethnic minorities and rural dwellers. for the purpose of this paper, health disparity is defined as “. . . differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups. . . .” (nih, n.d., p. 12). method this literature review was conducted as outlined by the preferred reporting items for systematic reviews and meta-analyses (prisma) to provide a clear path for conducting and reporting literature review (liberati et al., 2009) and guides the process for systematic literature searches. the goal is to assist authors in transparent reporting of systematic reviews and metaanalyses. the process includes a 27-item checklist, and depending on the review objectives, these items may be modified. the cinahl complete, eric, health/psychosocial instrument, health source: nursing/academic edition, socindex with full-text, science direct, and tx reference center databases within the ebscohost discovery service (ebscohost), and the cochran library were searched for articles published between 2005 and 2013 to obtain the most current data on kis using the terms korean immigrants, texas, rural, and health care. additionally, the subject terms koreans, research, and united states were added during the search. the search included three rounds. articles were deemed appropriate when appraised for the relevance and quality of the study. during round one, articles were searched based on the key terms, excluding those that were not original research. during round two, abstracts were screened for eligibility. in round three, full-text articles were obtained for further review. both qualitative and quantitative studies online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 28 were included. during the collection of articles, duplicate records were removed. most of the records were extracted during the perusal of titles and abstracts. the remaining records were obtained by reading the article to ascertain eligibility. findings the selection of records to be reviewed was accomplished during the search process. when all the key terms (korean immigrants, texas, rural, health care) were included in the search, no eligible records were found. therefore, various combinations of the key and subject terms were utilized. two-hundred and forty-three articles were identified. after removing duplicate articles, 216 records were eligible for screening; however, all but 25 articles were excluded due to irrelevance. no articles were discovered with the key terms korean immigrants, rural, and texas. furthermore, no research articles were found on kis’ health and healthcare in rural us. overall, the majority of the records failed to satisfy the basic requirements of relevancy to the key terms and was excluded. more specifically, the excluded records either failed to be exclusive to koreans, did not qualify as original research (editorials, personal commentaries, or newspaper clippings) conducted in the us, were not established within the required time frame, or some combination of the above. of the 25 studies reviewed (appendix), 19 were quantitative (bernstein, park, shin, cho, & park, 2011; choi, wilbur, & kim, 2011; donnelly & kim, 2008; eun, lee, kim, & fogg, 2009; han et al., 2010; hofstetter et al., 2010; hwang & zerwic, 2006; jang et al., 2005; jang, park, cho, roh, & chiriboga, 2012; jo, maxwell, wong, & bastani, 2008; kim, 2011; kim & menon; 2009; kim et al., 2011; kim, kim, & gulick, 2009; lee, eun, lee, nandy, 2011; lee, kim, & han, 2009; lee & yoon, 2011; maxwell, jo, crespi, sudan, & bastani, 2010; shin, 2011; yang, 2007), four were qualitative (jo, maxwell, yang, bastani, 2010; sin et al., 2010; online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 29 sin, jordan, & park, 2011; yoo & zippay, 2012), one was a retrospective analysis (han et al., 2007), and one used mixed-method (yoo & kim 2008). various topics of these 25 articles included hypertension/stroke (han et al., 2010; hwang & zerwic, 2006; kim et al., 2011), tobacco smoking among kis (hofstetter et al., 2010; kim et al., 2009), the perspectives of church leaders in assisting kis with resources for health and healthcare (jo et al., 2010; yoo & zippay, 2012), cancer behaviors and health beliefs among kis (eun et al., 2009; jo et al., 2008; kim & menon, 2009; lee, eun et al., 2011; lee, kim et al., 2009; maxwell et al., 2010), depressive disorders (bernstein et al., 2011; donnelly & kim, 2008; jang et al., 2012; kim, 2011; sin et al., 2011), enabling factors affecting health perceptions (lee & yoon, 2011), and physical activities for promotion of general well-being (choi et al., 2011; shin, 2011; yang, 2007). multi-generational cardiovascular health perceptions (sin et al., 2010) and healthcare utilization (jang et al., 2005; yoo & kim, 2008) among kis were also reported. one retrospective study on the recruitment barriers of kis for health promotion studies was located (han et al., 2007). all studies were conducted in geographic areas where large populations of kis were located and asian grocery stores, and faith and non-faith based organizations were available. only one study was located in central tx (yang, 2007) with a large population of kis. during the analysis, nine major categories emerged that could affect health and healthcare of kis. these categories include (a) health, health perceptions, and healthcare, (b) knowledge of diseases, (c) culturally sensitive educational programs, (d) physical activities, (e) cancer screenings, (f) depression, (g) financial constraints, (h) english language competency, and (i) korean organizations. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 health, health perceptions, and healthcare according to the kaiser family foundation (kff, 2008), koreans tended to be healthier than other asian immigrants. conversely, kis generally considered their own health to be fair to poor (eun et al., 2009; yang, 2007). furthermore, kis who were older, female, and less educated were more likely to view their health as poor (jang et al., 2005). a variety of factors influenced kis’ health perceptions. for example, factors negatively influencing kis’ health perceptions included lower financial status, increased physical disability (jang et al., 2012), lack of english competency, mistrust in the western healthcare system (jang et al., 2005), and length of us residency (lee & yoon, 2011; yang, 2007). conflicting results regarding the length of us residency as it related to kis’ health perceptions were discovered; longer residency both positively (yang, 2007) and negatively (lee & yoon, 2011) correlated with poorer health (yang, 2007), and might be related to the amount of acculturation. poor psychological and physical health negatively impacted kis’ health perceptions; depression, loneliness, and decreased vitality resulted in lower perceived health (lee & yoon, 2011). healthcare satisfaction and subjective perception of health affected healthcare utilization (jang et al., 2005). not surprisingly, kis with more negative health perceptions and higher healthcare satisfaction were more likely to seek healthcare (jang et al., 2005). since migrating to the us, kis experienced increased illnesses such as cancer (jo et al, 2008; mccracken et al., 2009), heart disease (boo & froelicher, 2012; fitzpatrick et al., 2012; jang & kim, 2010), diabetes (jang et al., 2012; so, chin, & lee, 2011), and depression (bernstein et al., 2011; donnelly & kim, 2008; jang et al., 2012; yoo & zippay, 2012). furthermore, diabetes was significantly correlated to negative health perceptions (jang et al., 2012). online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 31 knowledge of diseases kis’ knowledge of risk factors and health promotion activities were varied and some knowledge was inaccurate. knowledge of cardiovascular health (cvh; sin et al., 2010) and strokes (hwang & zerwic, 2006) were different among the younger and older generations. generally, kis considered healthy diet, physical activity, less stress, and clean environment as important in promoting cvh. the younger generation considered walking and being spiritual as beneficial and nonfat food items such as jelly beans as harmful (sin et al., 2010). on the other hand, older people perceived relaxation and laughter beneficial and loneliness and stress harmful (sin et al., 2010). younger kis were more knowledgeable than the older generation on the risk factors for strokes; however, neither generation identified stroke risk factors such as diabetes, hypertension, and cardiovascular disease and non-stroke risk factors such as extreme weather and physical activities (hwang & zerwic, 2006). furthermore, stress, which is not a risk factor for stroke, was incorrectly identified among both generations (hwang & zerwic, 2006). the younger generation was also more knowledgeable of stroke symptoms; however, vision changes and severe headache were least identified while chest pain, dyspnea, and hand tremors were incorrectly construed as stroke symptoms (hwang & zeric, 2006). culturally sensitive educational programs many kis lacked health screenings such as mammograms (kim & menon, 2009; maxwell et al., 2010) and few with chronic medical conditions made lifestyle modifications (han et al., 2010; kim et al., 2011). however, culturally tailored educational interventions increased kis’ participation in health screenings and improved health and healthcare practices. appointment reminders, explanations for mammogram follow-up tests, provisions of health information, and referrals for mammography increased health screenings (maxwell et al., 2010), and bi-monthly online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 32 telephone counseling for medication adherence with hypertension (han et al., 2010; kim et al., 2011). furthermore, telephone counseling decreased alcohol consumption and increased physical activity (han et al., 2010; kim et al., 2011). a stage-based, semi-structured, interactive program was not significant for increasing kis’ readiness for mammography; however, it was effective in increasing knowledge of breast cancer (kim & menon, 2009). physical activities kis did not participate in leisure time physical activity; instead, kis participated in transportation-related physical activity (walking and cycling) and household physical activity (choi et al., 2011). furthermore, kis perceived physical activity positively influenced physical and mental health (shin, 2011; yang, 2007); exercise was a significant predictor for improved health (yang, 2007), and with more vigorous activity, greater health improvement was noted (shin, 2011). cancer screenings the low incidences of cancer screenings among kis was affected by a variety of factors. mammograms (eun et al., 2009; kim & menon, 2009; lee et al., 2009; maxwell et al., 2010), cervical exams (lee, eun et al., 2011), and colorectal exams (jo et al., 2008) were sporadic among kis. several facilitators and barriers for cancer screenings were noted. facilitating factors such as having symptoms, financial means, transportation, and a trustworthy physician significantly increased the likelihood of obtaining cancer screenings (jo et al., 2008). barriers to cancer screenings included being unfamiliar with the process of obtaining mammograms (kim & menon, 2009), english language difficulties (lee et al., 2009; maxwell et al., 2010), and financial constraints (jo et al., 2008; lee et al., 2009; maxwell et al., 2010). additionally, kis’ perceptions for the seriousness and benefits of cancer screenings also influenced screening rates; online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 33 furthermore, age influenced these perceptions (eun et al., 2009; lee et al., 2009; lee, eun et al., 2011). older women perceived significantly more seriousness to having cancer (eun et al., 2009; lee, eun et al., 2011) and potentially more benefits to screenings (lee et al., 2009; lee, hahn et al., 2011) compared to younger women; however, older women had lower screening rates than younger women (eun et al., 2009). furthermore, perceived benefits were greater among those who had mammograms in the past (eun et al., 2009; lee et al., 2009). finally, perceived susceptibility to cancer also influenced screening rates (lee et al., 2009). stress and depression stress and depression are common among kis. in fact, many kis often used the words “depression” and “stress” interchangeably. symptoms were related to feelings of introversion, loneliness, isolation (sin et al., 2011), fatigue, appetite changes, and sleep disturbances (donnelly & kim, 2008). depressive symptoms increased among kis in poor physical health (donnelly & kim, 2008); depression was positively correlated with chronic diseases such as diabetes (jang et al., 2012) and negative health behaviors, such as smoking (kim et al., 2009). depressive symptoms increased hostility and neglect and decreased signs of affection among parents of teenagers; fathers were affected to a greater degree than were mothers (kim, 2011). acculturative stress might affect depressive status (bernstein et al., 2011; sin et al., 2011), and kis were almost twice as likely to experience stress as the general us population (bernstein et al., 2011). in fact, lack of english proficiency and longer length of us residency significantly caused higher anxiety and depression in addition to decreased self-control and vitality (lee & yoon, 2011). additionally, depression and racial discrimination had significant positive correlation (bernstein et al., 2011). one-third of participants in one study (bernstein et al., 2011) and one-fourth in another study (jang et al., 2005) experienced some form of discrimination, online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 34 such as disrespect, due to race or ethnicity. on the other hand, social support and spirituality significantly improved psychological health and general well-being among kis (lee & yoon, 2012). financial constraints another factor influencing health and healthcare was financial constraints. yoo and kim (2008) explored barriers and challenges to health services among insured and uninsured kis. even though most participants had insurance, older ki women’s insurance covered the cost of the mammograms while younger ki’s insurance did not (yoo & kim, 2008). furthermore, no significant differences were found in overall healthcare utilization among the insured and uninsured. high deductibles prevented accessing health services for those with insurance. jo et al. (2008) reported a lack of insurance or inability to afford healthcare were major factors discouraging cancer screenings. english language competency another factor that influenced health and healthcare among kis was lack of english competency. the inability to speak english significantly impacted health perceptions which negatively influenced healthcare utilization (jang et al., 2005; lee et al., 2009). furthermore, poor english speaking abilities were significantly associated with increased depression (bernstein et al, 2011; lee & yoon, 2011). korean organizations korean american churches assisted kis in the promotion of health and healthcare utilization and provided socialization with other kis. churches provided not only spiritual guidance but also a sense of community belonging (jo et al., 2010; yoo & zippay, 2012). additionally, churches tried to meet ki’s physical and mental health needs through health online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 35 promotion clinics, anger management seminars, and smoking cessation programs in addition to preserving korean culture (jo et al., 2010). church attendance was found to be a significant predictor in increasing smoking cessation, in addition to decreased exposure to second hand smoke and smoking in homes (hofstetter et al., 2010). however, korean churches were largely not equipped to provide healthcare advice, did not have the clinical knowledge, and were not aware of available community resources to support ki’s health and healthcare needs (jo et al., 2010). discussion a systematic review of literature on the health and healthcare of kis living in the us revealed 25 records, none of which addressed health and healthcare for rural kis. most studies conducted on asians were done in a locale where a large population of kis resided, such as ca, il, ny, md, and wa. furthermore, studies utilized self-reports and small sample sizes, which prevented generalizing the conclusions to the overall ki population. twenty of the results were self-reports, four were interviews, and one study used retrospective data analysis. nine major categories emerged during the analysis that included health, health perceptions, and healthcare; knowledge of diseases; culturally sensitive educational programs; physical activities; cancer screenings; depression; financial constraints; english language competency; and korean organizations. factors identified that affected or had the potential to impact kis’ health included health perceptions, disease knowledge, financial constraints, english competency, and physical activity. in addition, perceptions, beliefs, age, perceived susceptibility for cancer, knowledge about healthcare system, and benefits of screening impacted cancer screening behaviors. depression was associated with stress, poor health, and feelings potentially exacerbated by immigrant status, namely loneliness, isolation, online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 36 and discrimination. culturally sensitive health promotion programs demonstrated improved health behaviors including cancer screening, medication adherence, decreased alcohol consumption, and increased exercise. additionally, korean churches provided spiritual guidance and promoted health, healthcare, and socialization. conclusions the status and perceptions of health vary among different ethnicities. variables such as race/ethnicity, socio-economic status, level of education, and gender are associated with health outcomes (texas department of state health services, 2010). among the studies on health and healthcare disparities in minority groups, the dominant perception is that disparities continue to exist and no clear solution to the problem has been determined (fowler-brown, ashkin, corbiesmith, thaker, & pathman, 2006). a better understanding of kis’ culture, including health and healthcare needs, is required to decrease health disparities. exacerbations of current chronic health conditions, including mental disorders such as depression, can be reduced or even prevented with appropriate health education and readily available healthcare (jang et al., 2012). further exacerbating health and healthcare disparities is the fact that people living in rural regions tend to be poorer, older, and have poorer overall health than those residing in metropolitan areas (agency for healthcare research and quality, 2011). this would imply that to decrease health disparities among kis living in rural regions, studies are needed. additionally, health resources in rural communities specifically for asian immigrants are desperately needed in order to promote a healthier lifestyle and healthcare utilization among kis. the lack of evidence on kis living in rural america should be a primary focus for future research. furthermore, to achieve federal and state initiatives, a better knowledge of health awareness, health improvement, and health and healthcare among kis is warranted. online journal of rural nursing and health care, 16(1) http://dx.doi.org/10.14574/ojrnhc.v16i1.368 37 references agency for healthcare research and quality. 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(2012). retrieved from http://zipatlas.com/us/tx/city-comparison/percentage-koreanpopulation.htm microsoft word blumling_275-1403-2-ed.docx online journal of rural nursing and health care, 13(2) 122 researching and respecting the intricacies of isolated communities amy a. blumling, r.n., b.s.n. 1 tami l. thomas, phd, cpnp, rnc, faanp 2 dionne p. stephens, phd 3 1 emory university, ablumli@emory.edu 2 assistant professor, nell hodgson woodruff school of nursing and robert wood johnson foundation nurse faculty scholar alumna, emory university, tami.thomas@emory.edu 3 assistant professor, department of psychology, florida international university, dionne.stephens@fiu.edu abstract purpose: conducting research in a rural area can be challenging for nurses for a variety of different reasons. the task at hand can be especially difficult when it involves discussing a sensitive topic, such as human papillomavirus (hpv) vaccination. this study was conducted to describe parental perceptions of the hpv vaccine in rural areas, while simultaneously describing a method for engaging in successful nursing research in rural areas. methods: a team of nurse researchers completed a planned process to first understand rural culture in southeastern georgia, and then more specifically, the families living in these three separate counties. this process initially involved developing a connection and working relationship with key community leaders, such as school principals. following this, researchers worked on establishing rapport and trust with local parents and research participants themselves. online journal of rural nursing and health care, 13(2) 123 qualitative methods were then used to collect focus group and interview data on parental views of hpv, hpv vaccination, and hpv-related cancers. findings: results indicated that parents had little knowledge of the hpv vaccine in rural georgia, including misconceptions that the vaccine is for females only. in addition, many parents continually voiced the concern that the hpv vaccine would promote promiscuity in their children. conclusions: providing consistent, timely, and open communication with the community members was crucial throughout the entire research process. this focused approach with respect to total community, culture, and religious value is essential in conducting research. future studies conducted in rural areas should focus on specific intervention points that improve parental hpv knowledge. keywords: research challenges in isolated communities, cultural competence, educating researchers, parental knowledge of hpv in rural georgia researching and respecting the intricacies of isolated communities conducting research in rural areas poses a number of challenges related to the person, such as a lack of trust in researchers or lack of interest in research topics; to the community, including a lack of connection to the rural population; and diminished access to the rural population due to physical distance. however, overcoming these challenges is essential because of the fact that these groups of individuals continue to suffer higher than normal rates of various morbidities, including cervical cancer. in order to begin to address this concern, a research study was implemented to speak with rural parents about their thoughts on the human papillomavirus (hpv) vaccine. study implementation required educating a research team, and then initiating a working relationship with rural community leaders, school officials, and parents. this paper was online journal of rural nursing and health care, 13(2) 124 then developed to share successful strategies for research implementation in rural areas, while also describing results from a qualitative research project focusing on a sensitive topic: prevention of hpv infection in rural georgia. background working in rural areas rural communities in southern georgia suffer both from health and geographic disparities that are unlike other rural populations in the united states (hart, larson, & lishner, 2005). the rural poor are defined as those often living in isolated communities depending upon the help of the government, such as through welfare services like medicaid or medicare. these groups frequently live longer distances from healthcare services, and have higher costs associated with these services than their larger urban or larger rural counterparts (hart et al., 2005; ryannicholls & racher, 2004). however, many rural georgians are living in extreme poverty, also termed the “extreme poverty experience”, which has been described by researchers as higher unemployment rates, declining or stalled industrial growth, slow or no job growth, and higher populations of children and the elderly (brown & hirschl, 1995). unfortunately, in southern georgia, extreme poverty has been perpetuated by stratified political and economic systems that foster dependency and increase health disparities (tickamyer & duncan, 1990). a life of extreme poverty, which is one result of a state of persistent poverty, is associated with the inability to find employment, limited opportunities to improve and maintain financial independence, and persistent marginalization. consequently, these factors have continually kept african americans, one of the largest groups enduring the extreme poverty experience, in jobs with lower wages, as well as further increasing the overall number of those families living in extreme poverty (williams, 2007; zimmerman & whetten, 1938). in addition, persistent poverty online journal of rural nursing and health care, 13(2) 125 and the extreme poverty experience in rural southern communities have brought unique challenges to rural adolescents and their healthcare providers. the extreme poverty experienced by many adolescents living in rural areas puts them at an increased risk for a variety of negative lifestyle choices, such as dropping out of school and participating in high-risk sexual behavior. this lifestyle thus increases their overall risk for contracting the human papillomavirus (hpv) and other asymptomatic sexually transmitted infections (gottvall, waldenström, tingstig, & grunewald, 2011; "new data show heavy impact of chlamydia on u.s. men and women, particularly young people.," 2005). general challenges for nurse researchers in isolated communities challenges for nurse researchers in isolated, rural communities include understanding the unique culture of rural communities and identifying health care challenges in these individual areas. rural southern culture can vary from county to county, as each one has a social history that may include poverty, segregation, and marginalization. the variation from one county to another might best be viewed or described as a neighborhood effect. a neighborhood effect is the aggregate effect of social determinants of health, such as income, education, employment, and residence (hartley, 2004). when challenged with research in rural communities, it is essential that each specific county be assessed individually and the uniqueness of each neighborhood examined to determine neighborhood effects and specific rural culture for that county. rural culture is also closely linked with family structures, and a common misconception is that all rural families are extended and live in close proximity. however, rural culture also includes teens raised in single parent homes. these teens have demonstrated greater health and geographic disparities than their counterparts raised in traditional nuclear or extended families (mclaughlin & sach, 1988). further evidence of the gap in health and geographic disparities for online journal of rural nursing and health care, 13(2) 126 teens living in persistent rural poverty is seen in research that indicates rural women are less likely to be counseled about stis during pregnancy and to lack a preferred method for sti prevention. furthermore, these women believe that their partners do not carry any stis (crosby, yarber, diclemente, wingood, & meyerson, 2002). this makes transmission of hpv and rates of hpv infection a harsh reality for many women living in rural, isolated communities with limited financial and health resources. the challenge of limited health care resources is also important to address when studying rural communities. when this study was initially being considered in 2008, georgia ranked 41st out of 50 states in overall health rankings, demonstrating a decrease in public health funding by 22%, a decline in immunization coverage by 3%, high rates of infectious disease, and an increasing number of uninsured ("america's health rankings: a call to action for individuals & their communities," 2008). these rankings underline the effects of persistent rural poverty on health issues and define the health and geographic disparities prevalent for the rural poor, including teens. the rural counties selected for study suffered from the economic, public health, and educational challenges that are consistent with the overall, larger healthcare and geographic disparities. finally, geographic disparities compound the problems associated with poor access to care, disinterest in academic achievement, and poverty. percentages of teens, women, and parents living in rural areas below the poverty level continue to increase in southern georgia. the documented rates of poverty for girls and boys 14 to 17 years of age are greater than 26 %, compared to 17% of their urban counterparts (rogers, 2001; rogers & dagata, 2000). african american girls ages 14 to 17 living in rural areas are at an even greater risk, as poverty rates here exceed 22%, which does not include those living in the “near poverty” category, or family online journal of rural nursing and health care, 13(2) 127 incomes only marginally above the poverty line (rogers, 2001). in addition, poverty rates for children under the age of 18 represent a disproportionate percentage of the poor 35.7%, whereas children under the age of 18 represent only 25% of the total us population (proctor & dalaker, 2002). given these challenges, the principal investigator (pi) of this study recognized the need to examine the culture, the health care environment, and the geographic disparities of each selected county to better educate the research team. hpv: a hidden disease in isolated communities hpv is the most commonly occurring sexually transmitted infection in the united states, infecting approximately twenty million people annually (gottvall et al., 2011). half of these infections occur in adolescents and young adults between the ages of 15 to 24 years, with actual rates for this age group projected to be much higher in rural areas due to the asymptomatic nature of the infection in many people (gerund & barley, 2009) hpv infections are transmitted through direct contact during sexual intercourse, including genital-to-genital, manual, and oral sex practices. winer et al. (2006) provide strong evidence that hpv is usually transmitted through penetrative sex; however, transmission rates of 9.7% suggest that skin-to-skin or genital-to-genital contact transmission does occur. it is estimated that in addition to the twenty million people currently infected with hpv through all modes of transmission, another six million infections are newly diagnosed each year (centers for disease control and prevention [cdc], 2012). increasing rates of diagnosed hpv infection in rural communities is a growing concern, as the incidence of hpv-related cervical cancer in these rural communities continues to rise (dempsey, cohn, dalton, & ruffin, 2011; jain et al., 2009). this concerning rise in hpv and hpv-related cancers is the motivation for research in these rural communities. because hpv infection can be a sensitive topic, an extensive review of online journal of rural nursing and health care, 13(2) 128 literature, discussion of culture in rural communities, and a plan to contact and determine the feasibility of research in these isolated, rural south georgia communities were conducted and completed. the principal investigator’s (pi) research proposal was submitted for a descriptive study with a theoretical framework based on the health belief model to examine parental knowledge, attitudes, beliefs, and intent to vaccinate their children, ages 9 to 13, against hpv. after funding was received, a variety of challenges arose for the nurse researchers. community engagement methods pre-proposal planning initially, pre-proposal planning and research team education was essential to build the foundation for successful data collection in new, rural sites. the strategies used during the preproposal phase included: informal phone conversations with community leaders, spontaneous interviews, planned meetings, presentations to school boards and parents, informal windshield surveys, and simple observational field notes. team education when the pi began to strategize on how to best educate the research team, many materials and frameworks were considered. this specific research project required a theoretical framework that would challenge team members, including nursing students and others with health science degrees, and include concepts of cultural competence. campinha-bacote’s model of nursing cultural competence was eventually selected, due to its progressive viewpoint that cultural competence is a working process consisting of five constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire (camphinha-bacote, 2002). online journal of rural nursing and health care, 13(2) 129 the research team was comprised of doctoral and bachelor nursing students. all nursing students had roles in data collection, interaction with community members and parents, and data entry. initially, the research team and the pi reviewed and discussed current literature about persistent poverty and rural health. using the information from the research and the topics from discussions, the research team hypothesized the possible correlations, if any, between hpv vaccine uptake, health disparities, and geographic barriers. in addition, formal and informal discussions occurred about each member’s own cultural awareness and cultural encounters. along with this exercise, additional information about the rural counties, including demographics, unemployment rates, high school graduation rates, and economic impacts from the recession of 2008, increased the team members’ understanding of the culture in these rural communities. these discussions and exercises provided important contextual information needed to prepare for project implementation. the dramatic health and geographic disparities of the focal rural communities, in addition to the importance of consistent communication, were emphasized. communication that was purposefully void of any condescension or bias was essential when working with the various parents, communities, and school leaders throughout the areas. informal discussions among the team members prior to research clarified what the hypothesized concerns and disparities of the study should focus on. this was an additional strategy for educating the research team, and it assisted in dispelling any preconceived ideas or prejudices. each strategy for educating the research team focused on respecting every individual, rural southern community for its own intrinsic value and attributes, whether it was the town’s historic value, community pride, beautiful countryside, or hospitality of the residents. as the research team continued to discuss these issues across the period of data collection, it was clear that online journal of rural nursing and health care, 13(2) 130 framing this project in terms of education and an attention to cultural competence was essential. research team members quickly became aware that the problem of increased hpv transmission and decreased hpv vaccine uptake could be solved only by building a partnership with the residents in these rural southern communities. this process required an unwavering respect for these isolated communities, and the establishment of trust that began with appreciation for everyone involved. strategies for contact efforts were initiated to engage and encourage community members, especially school principals and administrators, to participate in the research process. support from these key community leaders was essential to successful implementation of data collection. once school officials and community leaders agreed upon the aims of the project, these key, influential leaders assisted in developing communication venues with other school officials, parents, and school nurses. a reciprocal wheel of communication among the team members, pi, and community leaders was emphasized, with a focus on communication initiation and followthrough. the methods most commonly used to initiate and maintain contact between the community leaders and the pi included informal phone conversations, spontaneous interviews, planned meetings, and eventually presentations to school boards and parents to ascertain their level of interest in participating in the research process. throughout the entire process, communication was purposefully kept open, honest, and consistent, as well as attentive to community leaders’ and parents’ suggestions and insights. online journal of rural nursing and health care, 13(2) 131 research procedures preliminary participant introduction after community engagement and approval by the university’s institutional review board (irb) and the county school superintendents, parents were recruited through irb approved flyers and word of mouth recruitment by community leaders in the chosen counties of research focus: burke, lincoln, and screven counties, as shown in figure 1. parents were greeted by either the pi or trained research assistant (ra), and screened for eligibility (age 18 or older, had a child between the ages of 9 13, and signed and read the informed consent letter). eligible parents were invited to attend a focus group discussion about sexual health and other health issues in their community through their middle school principals, whom the community views as well-respected and influential leaders. this community organization leader explained that the purpose of the study was to elicit information to inform the development of hpv intervention tools targeting rural areas. parents were also informed that focus groups would last approximately 30 45 minutes, and that they would be reimbursed $50 total for their time spent completing a brief survey and the focus group discussions. contact information was obtained from parents that agreed to participate, and reminder calls were made to participants in the two days before the focus group. varying demographics participants were recruited from september through november 2011, as part of a study to develop a culturally appropriate intervention addressing cancer prevention and hpv education. the counties selected for research included: burke, lincoln, and screven counties of southeast, rural georgia. each county varies in demographic and geographic challenges. online journal of rural nursing and health care, 13(2) 132 figure 1: specific counties of research focus burke county has a population of 23,316 individuals, with a median household income of $33,155, and an unemployment rate of 8.9%. forty-seven percent of the children in this county are living below the poverty line. in terms of race and culture, 43.3% of the individuals here are african american. the closest hospital to these residents is approximately 45 minutes away. lincoln county’s population is smaller, at 7,966 individuals, with a median household income of $36,399. despite this slight increase in household income compared to burke county, the unemployment rate here is 11.2%. thirty-two percent of the children in this county are living below the poverty line. of all the county individuals, 32.1% are african american. a drive from lincoln county to the closest hospital takes approximately 65 minutes. finally, screven county houses 14,593 individuals, with a median household income of $32,155. the unemployment in this area is at 14.8%. in this county, 33.5% of the children are living below the poverty line. in this area, 43.3% of the individuals are african american, as shown in table 1. in addition, the online journal of rural nursing and health care, 13(2) 133 closest hospital to screven county is approximately 90 minutes away (us census bureau, 2011). table 1 summary of demographic data for burke, lincoln, and screven counties, ga counties burke lincoln screven population 23,316 7,996 14,593 population density, per mile2 28.1 37. 22. age statistics median age 35.9 45.0 39.5 percent female 52.0% 51.3% 51.2% under 20 31.1% 23.2% 28.3% between 20 and 39 23.9% 20.4% 22.3% between 40 and 59 27.3% 31.4% 28.1% 60 and older 17.6% 25.1% 21.2% race and culture white 54.6% 65.7% 54.6% black or african american 43.3% 32.1% 43.3% asian 0.4% 0.4% 0.4% american indian 0.3% 0.4% 0.3% pacific islander 0.0% 0.0% 0.0% other races 0.3% 0.4% 0.3% two or more races 1.1% 0.9% 1.1% hispanic or latino culture 1.2% 1.2% 1.2% households and families housing units 9,865 4,786 6,739 housing unit density per mile2 11.9 22.7 10.4 households 8,533 3,281 5,596 mean household size 2.7 2.4 2.5 families 6,110 2,252 3,854 mean family size 3.2 2.9 3.1 households with children under 18 39.0% 23.0% 27.8% households with married couple living together 42.4% 50.3% 45.1% households with no husband present 24.1% 14.2% 18.6% school public school enrollment percent female 47.3% * 50.0% qualify for free or reduced price lunch 83.7% 97.9% 78.1% white 30.5% 58.3% 46.2% online journal of rural nursing and health care, 13(2) 134 counties burke lincoln screven black or african american 66.7% 38.5% 51.9% elementary (pre-k – grade 5) 49.9% 46.7% 44.8% middle (grades 6-8) 21.5% 20.4% 23.2% high (grades 9-12) 28.5% 32.9% 32.0% private school enrollment 582 4 64 (us census, 2011). *data was missing from us census records. one of the most challenging geographic barriers present to both the researchers and the participants was the distance required for both parties to travel in order to meet at a facility such as a school library, school administrative building, or public library that would be an environment conducive to conducting research. the pi and ras traveled approximately 6-8 hours round trip to rural southeastern georgia for most focus groups, while many parent participants were required to travel upwards of an hour themselves. qualitative methods a total of four focus groups were conducted; the size of the groups ranged from three to five participants. before the focus groups began, all participants read a letter of consent and acknowledged their agreement to participate in the study. groups were audio taped using a digital recorder. focus groups were conducted by one of three facilitators with training in qualitative research and issues facing rural and minority populations. facilitators followed a semi-structured focus group guide that included open-ended questions related to hpv vaccine related beliefs and perceptions. participants were asked their thoughts about general health, hpv knowledge, sources of hpv related information, and attitudes toward vaccinating their children against hpv, as seen in table 2. these questions served as an initial stimulus for discussion; facilitators were encouraged to probe responses and ask follow-up questions based on participant responses to the initial questions. throughout the data collection process, evidence for emerging ideas was sought. to do this, the research team online journal of rural nursing and health care, 13(2) 135 listened to the audio recordings after each focus group, and facilitators and project staff discussed topics that merited additional follow-up in subsequent focus groups. focus groups were conducted until content saturation was reached, i.e., until no new ideas or themes emerged during the focus groups. all procedures were approved by the irbs of the participating institutions. table 2 sample hpv focus group questioning route begin focus group 1. pi or group leader introduction 2. icebreaker/parental introduction a. “can you each go around the room and tell me what you enjoy doing during your spare time when you aren’t working?” 3. identification of parents’ children’s ages 4. first question: “have any of you ever known anyone who’s had cancer or died of cancer?” a. probe: “what type of cancer did they have?” 5. second question: “can you tell me what you think ‘good health’ is?” a. probe: “how would you describe someone who you think is in really good health?” 6. third question: “what are some ways you think cancer is preventable?” 7. fourth question: “now i’d like to talk a little bit about hpv. have you heard of it? what do you know about hpv?” a. probe: “does anyone know that hpv causes cancer? what kind of cancers do online journal of rural nursing and health care, 13(2) 136 you think it causes?” 8. fifth question: “did anyone know there’s a vaccine for hpv?” a. probe: “do you know anything about the hpv vaccine?” 9. sixth question: “do you know anyone who’s had their kids vaccinated with the hpv vaccine?” 10. seventh question: “did they talk to you about the benefits? do you think there are any benefits?” a. probe: “can you tell me more about this?” 11. eighth question: “is there any reason you would choose not to get your child vaccinated with the hpv vaccine?” a. probe: “has anyone you know told you a reason why they decided not to get their children vaccinated? did you agree with them? why or why not?” 12. ninth question: “finally, i’d like to ask whether talking about the hpv vaccine here made you change your mind about getting your child vaccinated?” a. probe: “if no, why not?” b. probe: “if yes, what are the reasons?” data analysis thematic coding procedures were used to analyze the qualitative data. first, the digital audio recordings were transcribed and checked for accuracy. transcripts were then preliminarily analyzed by an expert in qualitative analysis (eqa) using the principles of grounded theory (cates, brewer, fazekas, mitchell, & smith, 2009; glaser & strauss, 1967). after familiarizing themselves with the recordings and transcripts, the eqa and an additional coder created broad categories, and each unit of the transcript was assigned to one or more categories. within each online journal of rural nursing and health care, 13(2) 137 broad category, similar data were grouped together, and subcategories were created based on these data groupings. coders discussed categories and subcategories, which were then revised as new data were considered, or as researchers came to new understandings and generated new hypotheses. to optimize the trustworthiness of the results, regular meetings were held with the pi and eqa to discuss results and to develop new understandings and interpretations of the data. results demographics participants included 18 parents (2 men, 16 women) with ages ranging from 35 to 60 years, recruited from burke, lincoln, and screven counties. the majority of participants were african american (n = 12; 67%); while 33% were white. the children of the parents’ being interviewed ranged in age from 3 to 30 years old, with all parents having at least one child 9-13 years old and/or in middle school, as per the study inclusionary criteria. the average number of children per participant was 2.5. the average age of the children was 12.5 years. some parents did not list the gender of their child, but of those who did: male children represented a slight majority at 54% (n=21), while female children represented 46% (n=18) of the child population. qualitative analysis the results presented here are organized around three major themes identified in the analysis: 1) perception that the hpv vaccine is only for females, 2) concerns about the long-term implications of the vaccine, and 3) concerns that the vaccine encourages sexual promiscuity. in addition, many parents brought up the desire for more education on the vaccine, for both their children and themselves. they also felt that greater emphasis should be placed on community involvement and support in protecting children from sexual risks. online journal of rural nursing and health care, 13(2) 138 perception that vaccine is for females. many of the parents in the focus groups expressed that they had heard of the hpv vaccine, but the majority of them believed it was given exclusively to girls. as a result of their belief that the hpv vaccine is made solely for females, many of the parents only listed prevention of cervical cancer as the target for the vaccine. one parent specifically stated that: it is transmitted predominantly through being sexually active…and i’ve always heard it just mostly for girls, as opposed to boys, but then again, i guess if you’re sexually active, anybody can get it… and that it’s very painful. that’s about all i know. concerns on long-term implications of hpv vaccine. initially, parents were open to considering vaccination of their children, despite the fact that many of them voiced concerns regarding the risks associated with the vaccine. the general consensus was that there was a perceived lack of history of the vaccine’s use, and that they were unsure of the possible longterm side effects of the vaccine. throughout the discussion, the parents’ willingness to vaccinate their children decreased. many concerns were shared about the vaccine’s safety, including the comment by one parent: my lack of knowledge about the benefits versus the side effects from vaccinations. what is the probability that it’s going to produce these results if i do expose my child to the vaccination? because, you know, i like children. they can possibly suffer severe effects from the vaccination. so before i expose my child to those harmful side effects, i first need to know the benefits of him getting that vaccination. concerns on giving permission to have sex. parents were also concerned that by having their children vaccinated, it would seem to the child as if the parents were giving them online journal of rural nursing and health care, 13(2) 139 permission to have sex. many parents expressed their beliefs that their children did not need the vaccine because they were raised to not engage in pre-marital sex. one parent explained her rationale by implying that the majority of hpv vaccine implications are directly related to sexual activity: i think if it were strictly for cancer, that’s a different story. but the fact that you get the hpv virus through sexual transmission...that’s when you kind of have to stop and think. it’s almost like...‘ok, son, here’s this to prevent this, here’s this to prevent that’…excuse me, if you didn’t do it, you wouldn’t have to worry about it. discussion implications of thematic analysis data collection identified 3 key themes common throughout the focus groups, including a misconception on who should receive the vaccine, concerns about the safety and history of the vaccine, and a concern that giving the hpv vaccine to children will encourage sexual promiscuity. these findings imply that there is a need for more education about the hpv vaccine, and that the education should be targeted towards parents residing in rural areas, especially african american families who suffer disproportional rates of cervical cancer and deaths related to cervical cancer. in addition to providing basic education on what hpv and the hpv vaccine are, the misconception that the vaccine is explicitly for females needs to be addressed. it is also imperative to discuss parental concerns relating to vaccination in order to increase vaccine uptake. specifically, the history of the vaccine development and the relatively low-risk should be emphasized. finally, it will also be necessary to openly discuss and explore parental concerns about a link between vaccination and sexual promiscuity. if parents see the benefits of the vaccine as outweighing the risks, vaccine uptake rates will likely increase. this is online journal of rural nursing and health care, 13(2) 140 especially crucial in rural areas, where cervical cancer rates are exceptionally high and access to primary care is limited. assessment of knowledge families living in rural areas are known to have less access to healthcare facilities, and consequently the services, such as hpv vaccination, that these facilities provide. in addition to this disparity, cervical cancer mortality is twice as high among african american women than in white women living in rural areas (cates, et. al, 2009). despite this, studies show that african american women are less likely to have heard of hpv than their white counterparts (cates, et. al, 2009) this research conducted in rural georgia supported these findings by discovering that between parents who have not/do not intend to vaccinate their children with the hpv vaccine, and those that do, african americans accounted for over 83% of the former category. however, one distinct difference found in this current research was the overwhelmingly positive support by african americans for vaccines in general. despite some studies implying that african americans are less likely to think that vaccines in general are beneficial and necessary than their white counterparts (cates, et. al, 2009), this study in rural georgia found the opposite results. throughout focus groups, parents were specifically asked whether they approved of vaccines in general, and the vast majority, including mostly african american parents, stated that unless there was some type of allergy or medical contraindication, they were wholly supportive of vaccination. the issue seen with lack of hpv vaccine uptake, therefore, seems to stem from the fact that few of the african american parents interviewed had previously heard of either hpv or the hpv vaccine. despite the majority of the african american parents not having heard of the hpv or the hpv vaccine, there was a general lack of knowledge on the vaccine implications and safety among parents of all races and ethnicities. online journal of rural nursing and health care, 13(2) 141 these findings imply that there is a need for more education about the hpv vaccine, and that the education should be targeted towards parents residing in rural areas, especially african american families who suffer disproportional rates of cervical cancer and deaths related to cervical cancer. in addition to providing basic education on what hpv and the hpv vaccine are, the misconception that the vaccine is explicitly for females needs to be addressed. it is also imperative to discuss parental concerns relating to vaccination in order to increase vaccine uptake. specifically, the history of the vaccine development and the relatively low-risk should be emphasized. finally, it will also be necessary to openly discuss and explore parental concerns about a link between vaccination and sexual promiscuity. if parents see the benefits of the vaccine as outweighing the risks, vaccine uptake rates will likely increase. this is especially crucial in rural areas, where cervical cancer rates are exceptionally high and access to primary care is limited. role of community gate-keepers despite a variety of initial obstacles and challenges, research and community engagement were successfully initiated in multiple rural areas. one of the main reasons that this was possible was due to the support and guidance of key community leaders, or “gate-keepers” into the community. key informers, including school superintendents, principals, and teachers, in the rural counties were fairly agreeable to the idea of conducting research there, and eventually became key proponents of the research project. however, they initially informed the pi that they had experienced some negative interactions with researchers previously, such as a lack of followup when data collection was completed. despite any initial hesitancy or mistrust, the community gatekeepers were willing to organize and promote the research in the community. the pi and research assistants made a point to not only keep the community leaders informed throughout the online journal of rural nursing and health care, 13(2) 142 entire research process, but also to seek their input on what topics should be addressed and how best to reach the parents. in addition, the pi regularly provided the counties with any and all preliminary data collected and plans for implementing interventions in the future. as this rapport and trust were built up, these individuals became indispensible consultants and collaborators for successful research study implementation and data collection. in addition to forming these necessary relationships to allow thorough data collection, the community gate-keepers paved the way to reach a multitude of parents throughout the communities who otherwise might not have been interested or trusting of nurse researchers from outside of town. over the years spent collecting data and focus group information, the pi and research assistants gradually transitioned from the roles of nurse researchers interested in rural health, to identifiable community advocates interested in specifically improving the lives of children in burke, lincoln, and screven counties of georgia. specific challenges for rural nursing research overall, the main challenges encountered by the nurse researchers while working in a rural area centered on establishing rapport and trust with the community leaders and participants, encouraging parent participation, and the physical distances between survey/focus group collection sites. working consistently and honestly with the community gatekeepers was an integral part in not only gaining trust and support among the leaders of the community, but also in gaining interest and participation from various parents. it is nearly impossible to enter into a secluded, rural community and start asking questions about parents’ children and their views on the hpv vaccine without having any sort of rapport established beforehand. building a relationship with community leaders first, who could then reach out to their own community members, was a key component of the successful data collection. not only did having the online journal of rural nursing and health care, 13(2) 143 support from the community leaders give the parents trust in the researchers, it also enabled them to be honest and open in discussing their thoughts on various health topics relating to their children. an additional component of this was the manner in which the pi and research assistants framed their interest in the communities: not just as a scientific matter, but as a personal commitment to enhancing the health and lives of all children living in rural areas, who often lack access to primary care and experience a variety of health disparities. finally, the physical distance between the researchers (atlanta-based) and the counties of interest (southeastern georgia) was also a barrier to overcome each time research was conducted. the pi and research team traveled an average of 3 4 hours, each way, to the communities in rural georgia. in addition, the parents also had to travel upwards of an hour in order to reach a spot conducive to research and data collection. many of the parents who participated in the research came from areas that required over an hour’s drive, which illustrates the geographical vastness in rural communities. this distance from any sort of school or town center in the communities is not only an issue when conducting research in the areas, but it is even more of a concern when the same expanse forces families to travel hours in order to reach the nearest pediatric hospital or healthcare facility. conclusions respect, trust, and communication educating a research team that is charged with work in rural communities must focus on the specific, individual rural culture for study success and community engagement. in addition, consistent communication, respect, and cultural competence are essential to build a foundation of relationships that support the entire research process. the initial pre-planning phase was imperative to understand the varying differences, community concerns, and possible barriers in online journal of rural nursing and health care, 13(2) 144 each individual county. this research team found that this was best accomplished framing the cultural concerns in a specific model of cultural competency. with this information, the research team was then able to begin the process of establishing trust with the community members. one of the key methods to first establishing this respect and trust with the larger community body was building rapport with the specific, individual community gatekeepers, such as school principals or school officials, over a period of time. in addition to providing an avenue for reaching out to other possible parent participants, these types of community leaders can be invaluable resources for assessing the values and needs of the local community. without the support of a key, influential community member, it would have been very unlikely that members of secluded, rural areas would have been willing to participate in nursing research where sensitive topics, such as adolescent sexual health, would be discussed. once it was made clear that the research would be conducted with respect to specific concerns of each community, it was much easier for research participants to feel comfortable and trusting to discuss the topics associated with adolescent hpv infection. in addition to the initial steps of building trust and ensuring respect, it was also essential to incorporate consistent, honest communication with all community members involved. one of the most common complaints and concerns that participants voiced was the lack of continued involvement after data collection was complete. community gatekeepers expressed hesitancy in participating with the research because of past experiences when research was conducted with other groups, but no follow-up was provided with the parents to inform them of results and future actions to address the results found. to avoid this problem, the nursing research team made a point to consistently provide open, honest communication and to return to the communities once results were analyzed. in addition, at the completion of the initial parent online journal of rural nursing and health care, 13(2) 145 surveys and focus groups, the researchers began collaborating with the parents on specific interventions to address the results and improve the overall health and well-being for adolescents living in areas. quick steps to researching in rural communities although any attempt to reach out to a rural community in order to conduct scientific research of them is a unique situation, and should be treated as such, the pi and researchers believe that the following “quick steps” are essential for those fellow researchers interested in accessing rural communities: (a) research and identify the needs of a rural community; (b) discuss these observations with a key community member, and potential liaison, such as a principal or church leader; (c) assess willingness of key community member, or “gatekeeper”, to assess local willingness to participate; (d) throughout this process of building trust and rapport, keep an open line of communication with the community gatekeepers and any parents willing to become involved in the research process; (e) collect data at a time and in an environment that is convenient for the participants; (f) follow up with community leaders and participants to let them know what data analysis shows, and what the implications are for further steps. implications for future rural nursing research this focus on educating the research team and respecting the community has implications far beyond rural, isolated communities in southern georgia. research conducted in isolated areas in other parts of the world similarly requires educating a research team and respecting the community. while this may initially seem like common sense, there are few step-by-step explanations similar to those expressed in this article. this brief guide, or quick reference, can be highly valuable to students who wish to fully understand the intricacies of conducting rural health research. the strategies previously mentioned led to successful data collection, with online journal of rural nursing and health care, 13(2) 146 greater than expected response rates. in addition, the relationships built during the pre-planning phase are ongoing, and have provided the framework for continued research. supporting agencies funding from robert wood johnson foundation nurse faculty scholar program to tami l. thomas, id # 67983 references america's health rankings: a call to action for individuals & their communities. 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(1938). rural families on relief: us government. priningoffice. http://www.ncbi.nlm.nih.gov/pubmed/15882109 http://www.ncbi.nlm.nih.gov/pubmed/16790697 online journal of rural nursing and health care, 1(2) 9 editorial partnerships in nursing education elvira szigeti, phd, rn, editorial board member full text not available. microsoft word schme_289-1545-1-ed.docx online journal of rural nursing and health care, 13 (2) 6 live health assessment in a virtual class: eliminating educational burdens for rural distance learners joann klaassen, rn, mn, jd 1 carol schmer, rn, phd 2 anita skarbek, rn, phd(c) 3 1 associate clinical professor, school of nursing and health studies, university of missouri kansas city, klaassenj@umkc.edu 2 assistant clinical professor, school of nursing and health studies, university of missouri kansas city, schmerc@umkc.edu 3 assistant clinical professor, school of nursing and health studies, university of missouri kansas city, skarbeka@umkc.edu abstract online nursing education presents challenges for educators. demonstrating and testing skills acquisition in a nontraditional face to face format is difficult. the learning exchange reverse demonstration (lerd) model provides a mechanism that allows students in an online setting to demonstrate skills acquisition with real time faculty feedback, increased student satisfaction, and measureable learned outcomes. a sample consisting of online rural rnbsn students who utilized the lerd model was compared to a traditional face to face rn-bsn sample. both groups were completing the same health assessment course. questionnaires distributed to both groups after completion of the health assessment course indicated that the rural students were very satisfied with the lerd model experience, had less travel and time off work expenses, and achievement of learning outcomes was equal to or greater than those in the traditional face to online journal of rural nursing and health care, 13 (2) 7 face format. although initial expenses are required for the lerd model, once instituted this model offers a viable alternative to the traditional face to face format that in today’s world of online learning is not always possible or practical. this method could allow rural students the opportunity to continue their nursing education while remaining in their communities, thus insuring needed health care will continue in rural areas. keywords: online learning, student satisfaction, nursing education, rural nursing innovations live health assessment in a virtual class: eliminating educational burdens for rural distance learners nursing education has always been challenging. in the era of technology-based health care delivery and online education delivery many challenges persist. although the opportunities new technologies provide for distance education are numerous, there continue to be concerns regarding teaching methods, course designs, cost containment for both students and higher education institutions, and learning outcomes. furthermore, the expansion of health information technology and the renewed emphasis on tele-health, raise new challenges related to best practices and instructional methods in the use of emerging technology as a component of online instruction. the purpose of this study was to compare student satisfaction and learning outcomes using a novel, tele-health based, live on-line learning exchange reverse demonstration (lerd) model© for instruction in health assessment skills, versus student satisfaction and learning outcomes in a traditional, onsite health assessment skills lab. background in 2010, over 19 million undergraduate students and nearly three million graduate students were enrolled in federally funded post-secondary schools (national center for educational statistics, 2012). as such, educational institutions are continually challenged to meet the diverse online journal of rural nursing and health care, 13 (2) 8 needs of adult learners who often struggle balancing educational, work, and personal commitments (ross-gordon, 2011). many colleges and universities transitioned to online instruction in order to provide adult learners with greater access to higher education programs (ko & rossen, 2010). research has shown that online educational experiences have demonstrated benefits such as autonomy enhancement, improved cognitive development, and increased problem –solving skills (kocaman, dicle & ugur, 2009). nursing education is one of several disciplines that continue to expand these opportunities for students. literature also illustrates that online education provides an excellent opportunity for rural nurses to continue their education, while living and working in their own communities (bushy, 2006; fairchild, 2012). providing the opportunity for rural nurses to remain in their communities while they are continuing their education is an essential factor in order to meet the urgent need for rural nurses with advanced education and skills (fitzgerald & townsend, 2012). although online instruction is proliferating traditional online instructional methods do not provide a mechanism to teach skill acquisition, such as health assessment skills (gray, 2013). for this reason, many distance education programs require rural distance learners to travel for portions of their educational experience. for example, rural nurses are required to leave their home and work for either a weekend learning experience, or to meet some form of residency requirement. both approaches are burdensome for these rural distance learners in terms of time and costs, and are de-motivating factors to distance nurses desiring to enhance their education. innovative online educational approaches provide opportunities to deliver high-quality education, while eliminating travel requirements and associated costs for distance learners. in addition, being able to deliver high quality skills-based education may allow rural distance nurse learners to be better prepared to meet the recommendations of both the national league for online journal of rural nursing and health care, 13 (2) 9 nursing’s excellence model (2006) and the institute of medicine’s (2011) “the future of nursing.” these recommendations stress the importance of integrating technology utilization as a component of future nursing practice in order to enhance the delivery of optimum health care. educational research ( ruhe & zumbo, 2009) has demonstrated that it is possible to achieve equal or better learning outcomes, manageable costs of instruction, and high student satisfaction rates using an online format as compared to the traditional face-to-face educational format. cobb (2011) and leasure, davis, and thievon (2000) described online students as being satisfied with the online learning environment, and more engaged in the learning process than their face to face counterparts. although studies (billings, 2000; gikandi, morrow & davis, 2011) related to online nursing education have validated online education as a legitimate instructional format, little is known about the effectiveness of using emerging technologies, such as video tele-health, for on-line nursing education. despite the fact that both the commission on collegiate nurse educators (ccne) (2009) and the american academy of colleges of nursing (aacn) (2008) have established student competencies for nursing informatics, measuring the effectiveness of technology application for student learning in the on-line environment is still in its infancy. lamb and shea (2006) contended that even though emerging technologies are being used extensively in the health care setting, “few undergraduate programs expose nursing students to the full range of technologies available” (p. 7). tele-health, the predominant emerging transformative patient delivery technology now at the fore-front of health care, has been largely overlooked by nursing education. a review of united states nursing programs revealed a few certificate programs related to tele-health technology use with only one or two nursing programs emphasizing tele-health in undergraduate pre-licensure nursing education. there is a paucity of online journal of rural nursing and health care, 13 (2) 10 research regarding educating nurses on tele-health best practices and on student learning outcomes related to innovative technology applications. in one of the few studies addressing student learning outcomes with tele-health application, winters and winters (2007) reported increased nursing student satisfaction when using videoconferencing to assess and teach skills to community-based patients. another study by seibert, guthrie and adamo (2008) utilized standard patients via video-conferencing to evaluate health assessment skills of master’s prepared clinical nurse specialists. the distance group members collaborated to conduct an interview and examination of the standard patient by directing an onsite examiner to examine the patient. although student knowledge demonstrably increased, student satisfaction with the experience was low possibly due to lack of familiarity with the technology and lack of student-faculty interaction during the assessment process. nevertheless, seibert, guthrie and adamo concluded that innovative technologies, such as tele-health technology offered promise for the re-design of online nursing education. the authors of this article, seeing the need for research related to tele-health concept application in the online environment, developed a proprietary teaching-learning model designed to blend the virtual classroom platform, best practices in skill acquisition, and tele-health concepts. the model was piloted in an undergraduate health assessment course provided for rnbsn students, comparing a section of totally online rural distance learners using the tele-health based lerd model© to a section of blended onsite online learners. the lerd model© the lerd model© was carefully and systematically designed to combine both best practices for skills instruction and tele-health concepts. as in tele-health, visualization of a standard patient in a live setting is possible when utilizing the lerd model©. distance learners online journal of rural nursing and health care, 13 (2) 11 utilize enhanced tools, such as a video-otoscope and audible stethoscope, streamed through the wimba live classroom™, to assist with their health assessment skill-building learning. the lerd model© blends videoconferencing via the wimba live classroom™ platform, videography, a standard patient model, and an instructor-student interaction communication loop to teach and observe the distance student’s assessment skills (figure 1). similar to tele-health delivery modalities, interaction between end users is live and instant. in tele-health practice, the expert generally guides the distance generalist who completes the assessment or intervention under the expert’s guidance and direction. in contrast, the lerd model© requires the distance student to guide the expert instructor through a health assessment demonstration for skills acquisition (figure 1). this innovative approach allows for immediate feedback and correction of student assessment techniques by the instructor during lab practice sessions, as well as the end-of-the-semester head-to-toe assessment check-off. figure 1. lerd model process educationally, the lerd model© allows students to progress through the steps of instructor demonstration, guided practice, and reverse student demonstration to display achievement of learning outcomes. this progression comports with benner’s (1984) novice to expert framework which has been utilized in clinical instruction for nursing students. unlike other non-traditional health assessment methods, such as student videotaped health assessments                     online journal of rural nursing and health care, 13 (2) 12 or the aforementioned studies, the live lerd© process allows for an interactional approach and immediate instructor feedback to the student (figure 2). figure 2. lerd model methods after obtaining social science institutional review board approval from the affiliated university, an anonymous online survey was offered to registered nurses (rn) who were baccalaureate nursing students nearing the completion of the online health assessment course for clinical practice at a midwestern university. consent was implied if the students participated in the survey. students were assured that participation in the survey would have no impact on their final grade. the health assessment course was offered to local, mostly urban students as an online didactic course combined with a four day onsite face-to-face health assessment lab/skills demonstration. distance learners, who were all rural students, received an online course utilizing the innovative live lerd model© for health assessment lab/skills demonstration. the wimba live classroom™ (n.d.) operating within the blackboard® information management system of the university formed the platform for the online portions of the health online journal of rural nursing and health care, 13 (2) 13 assessment course for both sections of students. wimba™ is a live virtual classroom which permits sharing of audio and visual information through a university web browser to which students has access through the course. didactic lectures for all students were delivered via tegrity©. tegrity© is a class capture web service which allows students to access classes from ipods, mp3 players, a web browser, or mobile device. both the onsite and the online lerd© model sections were taught by the same instructors and completed over the same 16 week semester. survey questions addressed issues such as: a) student satisfaction; b) years of nursing experience; c) level of computer knowledge prior to attending this course; d) technological difficulties encountered and; e) what burden if any, this course imposed on the student. demographic information was collected to allow for comparison of the two groups. in addition, course grades for the two sections were compared for knowledge and skill acquisition. sample/participants for the study, 38 students from the onsite course and 23 students from the distance online course were offered participation in the survey. a total of 42 students completed the survey; onsite students consisted of 54.8% (23) and distance students included 45.2% (19), providing a response rate of 69% a health resources and service administration (hrsa) grant provided us the opportunity to recruit rural nurses wishing to complete their baccalaureate degree. we considered rural as any county with a population of less than 50,000 according to the 2010 us census. as an incentive to return to school, and to help alleviate some of the burden that rural nursing students face returning to school, the grant allowed us to provide a laptop computer and cover the cost of internet for these students while they were enrolled in the nursing program. online journal of rural nursing and health care, 13 (2) 14 self-disclosed demographic data identified that onsite students were 91% female and consisted of white-non-hispanics (87%), african americans (9%), and hispanics (4%). their ages ranged from less than 25 years to 55 years of age with the majority (74%) in the 31 to 45 year old range. english was identified as the primary language by 91% of the onsite students, with spanish or haitian creole each being identified as the primary language by less than 4%. distance students were 84% female. they were 95% white-non-hispanic, and 5% hispanic. distance students ranged in age from under 25 years to over 55 years. the largest group ranged in age from 45-55 years (32%). all of the distance students identified english as their primary language. both quantitative and qualitative data were collected and analyzed by the researchers. participants were given a five point likert scaled instrument with the options of extremely dissatisfied to extremely satisfied, and participants were allowed to explain any answer in a written qualitative format. results student satisfaction study results indicated that 90% (38) of all the students in both sections were satisfied or extremely satisfied with the health assessment course. only 5% (2) students were very dissatisfied with the course. among the onsite students 87% (20) were satisfied or extremely satisfied and 9% (2) were very dissatisfied with the course. distance students identified that 95% (18) were satisfied or extremely satisfied. nursing experience onsite students worked across a variety of specialty areas, while the rural distance students tended to care more generally for adult and older adult client populations. these data reflect the online journal of rural nursing and health care, 13 (2) 15 lack of specialized health care services available in rural areas (skinner, & slifkin, 2007). most students from both groups worked in acute care settings – typical of associate degree rns (mahaffey, 2002). more onsite students indicated that they performed targeted health assessments, while rural students performed head-to-toe health assessments as part of their clinical practice. years of professional nursing experience also varied between the onsite and distance groups as illustrated in figure 3, with the distance nurses having both the least and the greatest years of nursing experience. figure 3. years of nursing experience level of computer skills students self-identifying themselves as beginner computer users prior to taking the health assessment of clinical practice course included 9% of the onsite students and 11% of distance students. the majority of students identified themselves as either intermediate or advanced computer users (91% onsite, 84% distance) prior to the course, with only one student selfidentifying as an expert user. students were asked to rate their computer skills at the conclusion of the course. there were no students who continued to identify themselves as beginner online journal of rural nursing and health care, 13 (2) 16 computer users. while most students again identified themselves as intermediate or advanced computer users, more students shifted from intermediate to advanced users. one onsite and one distance student self-identified as expert users at the conclusion of the course. technological difficulties students reported problems with technology during the health assessment course. technology problems were reported by 65% (15) of the onsite students and 79% (15) of the distance students although, most students experienced low problem frequency, and a significant number 24% (10) reported no problems at all. student comments regarding the nature of technology problems primarily included problems with the quality of tegrity© lectures in the didactic portion of the course and posted online videos which caused lags and pixilization. rural students also reported some problems with connectivity. several students occasionally lost connectivity during the wimba® practice sessions and one student reported problems with audio requiring the student to call in by phone to the wimba classroom. course burden for students students were asked to identify time and cost burdens of the course such as travel, time off work, etc. onsite students reported that 22% (5) took off work four to five times, 22% (5) took off two to three times, 30% (7) took off work once, and 13% (1) never took off work. a number of students reported using vacation time to attend the onsite health assessment skills laboratory. distance students reported that 5% (1) took time off work more than five times, 16% (3) took time off work two to three times, 26% (5) took time off work once, and 42% (8) never took time off work. of the students who took time off from work to attend the class, distance students averaged four to six hours away from work while onsite students reported an average of four online journal of rural nursing and health care, 13 (2) 17 days off work. distance students reported no costs for travel, hotels, etc., while the costs for the onsite students ranged from $10.00 to $2,000 of unreimbursed costs to attend the onsite health assessment skills lab. onsite students found time away from work and the related costs to be one of the most burdensome aspects of the course even though they reported extremely positively on the quality of the experience. rural students reported few burdensome aspects of the course. several students asked for additional practice lab times, but most feedback recommended making no significant changes to the course structure. the problems with tegrity© and video streaming were mentioned as the most burdensome aspect of the course by both groups of students. learning outcomes since both courses were taught by the same instructors it may be assumed that the course outcomes and grading were comparable for each group. final course grades were similar for both sections with the onsite students averaging 95.7%, and the distance students averaging 97.1%. these grades are analogous to grade averages of previous students who had taken the health assessment for clinical practice course. instructor perceptions of student learning and performance of health assessment skills was equal for both sections. limitations a relatively small sample size of student participants from only one course in one university and the fact that all students were practicing rn’s returning to school limits the generalizability of this study. future studies should include a variety of university/college sites, larger sample sizes, and a variety of graduate and undergraduate students. other considerations for study replication include personnel resources, time, and costs for management of the online lerd model© instruction. although students could easily participate online journal of rural nursing and health care, 13 (2) 18 in the course from their personal laptop computers at home or work, the university incurred additional faculty and staff costs as each online instructional/practice session required a faculty member, videographer and standard patient. in addition, the school purchased specialized electronic stethoscopes, video cameras, and computer laptops for the online laboratory instruction, as well as reserved dedicated examination rooms at the school of nursing. using the lerd model© requires small group sizes of 8-10 students per lab session for effective instruction thus requiring 2-3 instruction/practice sessions each week over the 16 week semester to accommodate the 23 online students. in contrast, the onsite laboratory sessions required 2-3 faculty members for four 8-hour days of boot camp to accommodate 38 students. the onsite group incurred no university costs associated with the laboratory space, computer equipment, or standardized patient models, as students conducted the assessments on their peers. however, once the system and equipment were in place, operation costs were only slightly higher for the lerd model© than the traditional boot camp. conclusions both the onsite group and the online rural distance lerd model© group expressed satisfaction with the health assessment for clinical practice course. the group responses and grades demonstrated that learning outcomes were similar and not affected negatively by either learning format. rural students participating in the online format were less burdened with travel cost, time away from work and family thus making their overall satisfaction with the course slightly higher than the onsite group. online rural distance students further benefitted by exposure to tele-health concepts through use of the lerd model© thus, preparing them to utilize tele-health technology and skills in nursing practice. as the lerd model© has been utilized by the university school of nursing undergraduate rn-bsn program for three years, it has become a online journal of rural nursing and health care, 13 (2) 19 sustainable teaching-learning methodology and one that we would like to assess further for its applicability at the graduate level of instruction and for continuing nursing education, especially within rural communities which generally have less convenient access to higher levels of nursing education. the results of this study have positive implications for nursing education and rural nursing education in particular, by providing a means for quality, convenient access to nursing courses that have traditionally required on-site presence. the provision of skills development and enhancement in the on-line environment is an innovative solution to educational barriers that provides cost and time savings for students while increasing student enrollment. early exposure to tele-health concepts prepares nursing students for the highly transformative technological health care environment. finally, although this study was conducted with nursing students, the technology has the potential to be used in multidisciplinary courses for team skills-building. in the era of rapidly expanding technology in health care and an increasing demand for relevant, applied online learning experiences, it is important to develop innovative instructional approaches. it is equally important to evaluate these novel instructional approaches for student satisfaction rates, problem-solving and critical thinking skills, and learning outcomes. references american academy of colleges of nursing, (2008). the essentials of baccalaureate education for professional nursing practice. boston, ma: aacn. benner, p. (1984). from novice to expert: excellence and power in clinical nursing practice. menlo park: addison-wesley. billings, d. (2000). a framework for assessing outcomes and practices in web-based courses in nursing. journal of nursing education 39 (2), 60-67. [medline] http://www.ncbi.nlm.nih.gov/pubmed/10688463 online journal of rural nursing and health care, 13 (2) 20 bushy a. (2006). nursing in rural and frontier areas: issues, challenges and opportunities. harvard health policy review, 9(1), 17-27. cobb, s. (2011). social presence, satisfaction, and perceived learning of rn-to-bsn student in web-based nursing courses. nursing education perspectives, 32 (2), 115-119. [medline] commission on collegiate nurse educators, (2009). standards for accreditation of baccalaureate and graduate degree nursing programs. boston, ma: ccne. fairchild, r. m. (2012). hold that tiger a collaborative service-learning academic-practice partnership with rural healthcare facilities. nurse educator. 37(3), 108-114. [medline] fitzgerald, c. e., & townsend, r. p. (2012). assessing the continuing education needs and preferences of rural nurses. the journal of continuing education in nursing, 43, 420-7. gikandi, j., morrow, d., davis, n. (2011). online formative assessment in higher education: a review of the literature. computers & education 57, 2333 2351. gray, d. (2013). barriers to online postsecondary education crumble: enrollment in traditional face-to-face courses declines as enrollment in online courses increases. contemporary issues in education research (online), 6 (3), 345. retrieved from http://journals.clute online.com/index.php/cier/article/view/7906 institute of medicine. (2011). the future of nursing: leading change, advancing health. washington, dc: the national academies press. kocaman,g., dicle, a., & ugur, a. (2009). a longitudinal analysis of the self-directed learning readiness level of nursing students enrolled in a problem-based curriculum. journal of nursing education 48, 286 290. [medline] ko, s. & rossen, s. (2010). teaching online: a practical guide (3rd ed.). new york, ny: routledge. http://www.ncbi.nlm.nih.gov/pubmed/21667794 http://www.ncbi.nlm.nih.gov/pubmed/22513769 http://www.ncbi.nlm.nih.gov/pubmed/22513769 online journal of rural nursing and health care, 13 (2) 21 lamb, g. & shea, k., (2006). nursing education in telehealth. journal of telemedicine & telecare, 12: 55 – 56. [medline] leasure, a. r., davis, l., & thievon, s. l. (2000). comparison of student outcomes and preferences in a traditional vs. world wide web-based baccalaureate nursing research course. journal of nursing education 39, 149-154. [medline] mahaffey, e., (2002). the relevance of associate degree nursing education: past, present, and future. online journal of issues in nursing, 7 (2). [medline] national center for education statistics (2012). enrollment in post-secondary institutions, fall 2010; financial statistics, fiscal year 2010, and graduation rates, selected cohorts, 20022007. u.s. department of education. national league for nursing. (2006). excellence in nursing education model. new york: author. ross-gordon, j. m. (2011). research on adult learners: supporting the needs of a student population that is no longer nontraditional. peer review, 13(1), 26-29. ruhe, v. & zumbo, b.d. (2009). evaluation in distance education and e-learning. new york, ny: guilford press. seibert, d., guthrie, j. & adamo, g. (2004). improving learning outcomes: integration of standardized patients & telemedicine technology. nursing education perspectives, 25, 232 237. [medline] skinner, a. c. & slifkin, r. t. (2007), rural/urban differences in barriers to and burden of care for children with special health care needs. the journal of rural health, 23, 150–157. [medline] http://www.ncbi.nlm.nih.gov/pubmed/16539749 http://www.ncbi.nlm.nih.gov/pubmed/10782758 http://www.ncbi.nlm.nih.gov/pubmed/12059279 http://www.ncbi.nlm.nih.gov/pubmed/15508562 http://www.ncbi.nlm.nih.gov/pubmed/17397371 online journal of rural nursing and health care, 13 (2) 22 tegrity (n.d.). lecture capture. retrieved from http://www.tegrity.com/?gclid=ci2kw8xb37 acfqln4aodskky0g united states census bureau (2010). 2010 census urban and rural classification and urban area critera. retrieved from http://www.census.gov/geo/reference/ua/urban-rural-2010.html wimba, inc. (n.d). wimba classroom for higher & further education. retrieved from http://www. wimba.com/solutions/higher-education/wimba_classroom_for_higher_education/ winters, j. & winters, j., (2007). videoconferencing and telehealth technologies can provide a reliable approach to distance assessment and teaching without compromising quality, journal of cardiovascular nursing, 22, 51 – 57. [medline] http://www.ncbi.nlm.nih.gov/pubmed/17224698 online journal of rural nursing and health care, 1(3) 43 effect of training program on physicians’ attitude towards knowledge and practice related to assessment and screening of clients with hiv/aids marietta stanton, phd, rn, cm1 paige johnson, rn2 1 professor and graduate coordinator, capstone college of nursing, university of alabama, mstanton@nursing.ua.edu 2 graduate assistant, capstone college of nursing, university of alabama, ptjohnso@bama.ua.edu abstract this is a study which examines the effects of an educational program on hispanic physicians' attitudes towards and knowledge of hiv/aids. the study also examines physicians' practice patterns related to the screening and testing of hispanic patients at risk for the disease. a oneonone educational program was taken to the physician's office at a time convenient to the physician. a preand post-test design is used with questionnaires developed for the study that assess self-reported data related to physicians' attitudes, knowledge and practice patterns. a convenient sample of physicians participated. this limited the generalizability of the results to other groups. however, it does point out that a training program can alter physicians' screening and testing practices as well as their attitudes towards clients with hiv/aids. this has implications for providers in remote rural areas or in medically underserved communities where access to formalized continuing education may be limited or offered at times not compatible with a busy practice. the study may suggest that one kind of training and education need to be online journal of rural nursing and health care, 1(3) 44 planned and developed to facilitate provider participation. perhaps, online courses or programs might be most effective of providing this one on one approach. keywords: hiv/aids, hispanic physicians, practice patterns, physician education online journal of rural nursing and health care, 1(3) 45 effect of training program on physicians’ attitude towards knowledge and practice related to assessment and screening of clients with hiv/aids the purpose of this study was to examine the effects of a training program for hispanic primary care physicians on their resulting knowledge of, practice patterns relating to, and attitudes towards the screening, testing of patients at risk for developing hiv/aids and/or referral of patients who test positive. several studies have examined sexual health risk assessment and counseling in primary care (manheux, haley, rivard & gervais, 1999: haley, manheux, rivard, & gervais, 1999). one study investigated evaluation of sexual health risk behaviors by primary care physicians during general medical examinations. a survey, using a stratified sample of over 1200 physicians, indicated that fewer than half the respondents reported routinely inquiring about condom use and number of sexual partners. educational preparation and extended training of physicians has been shown to have a positive effect on screening, testing and counseling of patients at risk for developing aids. radecki, shapiro, thrupp, ghandi, sangha & miller's (1999) research demonstrated that fear and misgivings concerning hiv and perceived need for screening and testing at risk individuals changed with further education and training of the physicians. although significant changes have been realized in attitudes towards hiv/aids, studies demonstrate that personal prejudices can cause critical delays in testing and screening (chesney & smith, 1999). this delay in screening and testing by physicians occurs in the general population. this delay is also prevalent in the hispanic/latino community (wainberg, 1999). residency training has a profound effect on physicians' screening and testing behaviors. medical programs differ in their preparation of physicians to screen, counsel, refer and/or treat patients with hiv/aids (yedida & berry, 1999). online journal of rural nursing and health care, 1(3) 46 well over a million people in the united states are estimated to be infected with hiv, a national prevalence of 0.3 percent (freedberg & samet, 1999). studies indicate that general practitioners have widespread contact with patients testing positively for hiv (kirkman, scott & bartos, 1999). however, physician's recognition of common symptoms and sequelae in patients who have aids also needs improvement (fontaine, larue & laussauniere, 1999: bach, calhoun & bennett, 1999). preventing transmission of hiv by assessing hiv positive patients for risky sexual and needle-sharing behaviors is also a critical role for general practitioners (gerbert, brown, cooke, caspers, love & bronstone, 1999). a survey by a leading medical society (1998) indicated that physicians were not performing routine counseling, screening and testing of high-risk patients. this study also indicated that physicians were not always knowledgeable about counseling and the referral of patients who tested hiv positive. in conclusion, it is apparent from the literature that physicians have a great deal of contact with potential high-risk patients. the physicians' education and training does not fully prepare them for screening of or testing related to hiv diagnosis. in addition, despite the increasing prevalence of hiv, physicians are not routinely including risk assessment for hiv/aids, nor are they providing counseling to patients testing positive to halt transmission of the disease. education and training have been shown in other disease processes to have a positive effect on the delivery of care. therefore, this particular study evaluated the effect of an educational program on the hispanic physicians' knowledge of, attitudes towards, and practice behaviors with regard to screening, testing and referral of patients at risk for hiv/aids. since learning is comprised of an affective domain (attitudes), cognitive domain (knowledge) and a online journal of rural nursing and health care, 1(3) 47 psychomotor domain (skills/practice), these three areas were used to evaluate changes in physician behaviors as an outcome of the training intervention (mager, 1997). background all hispanic physicians participating in the training practiced in predominantly urban, economically disadvantaged, medically underserved areas (mua's) where the majority of the physicians' clients were hispanic or latino. the training program was developed under the auspices of a national hispanic physician's medical society. a planning committee of hispanic physicians developed the educational program used in the study. program content was developed based on the society's survey results from the approximately 4000 hispanic physicians who are members. based on survey data, a four-part, modular program on screening, testing of high risk and referral of patients testing positive for hiv was developed. the program was implemented on a one-to-one basis at the physician's place of practice. six instructors for the program, all hispanic physicians themselves, trained for six months with an attending at a large teaching hospital. this facility also had an extensive inpatient and outpatient population of clients diagnosed with aids. all of the physician trainers were bilingual. all materials for the program were developed by this newly trained cadre of physician instructors in conjunction with nationally renowned consultants in aids/hiv prevention, detection and treatment. evaluation materials for the program were also developed by the physicians and consultants and will be described in the methodology. course materials included an extensive list of testing, referral, and community support services available to hiv clients. all program materials were printed in spanish and english. all four of the three-hour classes were taught on a one-to-one basis by the physician instructors in spanish or english as the physician learner preferred. classes followed a lesson online journal of rural nursing and health care, 1(3) 48 plan with very specific content for each module. audiovisual materials, references, handouts and other supplementary course materials were all standardized for consistency and uniformity. the modules were scheduled at convenient times for the physician learner. the rationale for one-to-one instruction was based on the physicians' expressed needs indicated in the pre-program survey. this approach allowed the physician instructors to answer questions, clarify areas of content, and discuss issues as the learner needed or desired. methodology the basic design for this study was a non-experimental, pre-test/post-test design to evaluate the effects of the educational intervention on physicians' attitudes towards, practice patterns related to, and knowledge about, the screening, testing and referral process related to hiv detection and treatment. physicians were recruited to attend the actual program through publications distributed to the medical society's membership. physicians called a point of contact at the organization and indicated interest in participating. the point of contact at the society would then contact the interested physician and set up four appointments for the training to be provided at the physician's office. physicians taking the program also referred fellow professionals from other locations to participate in the program. all participants for the program were self-selected. the use of this convenient, self-selected sample population limits the generalizability of results to any other physician group. however, this study may provide insight into methods of providing education to health care providers that may change knowledge, attitudes, and practice with regard to hiv/aids. completion of the tests and instruments before and after the program was voluntary and confidential. participating physicians were advised that data would be examined and discussed in the aggregate and that the instructor would only know their individual identity. online journal of rural nursing and health care, 1(3) 49 the physician trainers in conjunction developed the instruments used to measure attitudes, practice patterns and knowledge with consultants. items requesting demographic data were included with the instruments administered prior to the course. all three instruments were administered before and after the course and were identical. one instrument queried physicians' level of knowledge with regard to screening, testing, referring and treatment of the symptomatic or asymptomatic patient with hiv/aids. the same test was administered preand post-program. this was a standard type of written objective test with 50 multiple-choice questions. the second questionnaire queried physicians' attitudes towards different aspects of screening, testing and treatment specific to hiv/aids. the instrument used a five point likert scale with responses ranging from "not at all" to "all the time". it contained 30 items. the same test was administered to the physicians before and after their training was complete. the practice pattern questionnaire asked physicians to rate the frequency with which they performed screening, counseling, testing of high risk client as well as the frequency of referral and treatment of symptomatic or asymptomatic clients. it contained 20 items. this same questionnaire was administered before and after the educational program. all three instruments were administered to physicians in spanish or english as the physician learner preferred. physicians at the beginning of their first class or module completed pre-program instruments. post-program instruments were administered four to five weeks after the completion of the fourth module or class. the time frame for the course implementation was july 1998 through february 1999. on average it took physicians about two months to complete all four modules. the data was collected during that same time frame. online journal of rural nursing and health care, 1(3) 50 all instruments developed were evaluated for face validity by physician consultants to the project. all instruments were developed for this study therefore no prior reliability scores were available on any of the instruments prior to use within this study. the specific research question for this investigation was: how will physicians' test scores differ on knowledge, attitudes, and practice patterns before and after an hiv/aids training program? data were analyzed using selected descriptive and nonparametric measures. reliability coefficients using cronbach's alpha were determined on the attitude and practice pattern measures. an item analysis was performed on the objective test measuring knowledge. physicians completing the program were also asked to complete a learner evaluation. they were asked to rank order content they found most helpful within the present course. participants were asked to rate their level of satisfaction with instructors, content, materials and logistics of the completed course. physicians were also asked to comment on their selfperceived accomplishment of the behavioral/educational objectives for the program. the evaluation instrument used a five point likerttype scale with five indicating "high satisfaction" down to one indicating "no satisfaction." results approximately 120 physicians completed the training within the july to february time frame. of these 120 physicians, there was complete data for 114 of this group. the demographic information collected on the physician participants indicated that the group was predominantly male (78%) and hispanic (98%). the majority of the group had less than 10 years experience (66%). approximately 51 percent of the group were in private practice with the remainder practicing in hospitalor community-based clinics. almost all the physician's (95%) indicated that they had less than 50 clock hours of training on hiv/aids. the online journal of rural nursing and health care, 1(3) 51 major areas of practice for the group were family or general practice (51%). about 25 percent of the physicians indicated their practice area was pediatrics; 15 percent indicated internal medicine; and, five percent indicated obstetrics and gynecology. the remaining ten percent of the physicians practiced in surgery or urology or geriatrics. the average score on the pre-test assessing knowledge was 80 percent. the average score on the written post-test was 93 percent with a range of 80-100 percent. an objective test item with a reliability of less than 85 percent was not computed into scoring of the preand posttest. two items were discarded and the score on the remaining 48 questions were used in computation of both test scores. an overall reliability of r³ .95 was calculated on the attitude instrument using cronbach's coefficient alpha. t-tests performed on the preand postitems of the attitude scale indicated statistically significant differences on only two of the attitude scale items selected for measurement in this study. results indicated that physicians felt more comfortable discussing sexual issues with their clients after participating in the educational program. there were statistically significant differences preand post-program (p< .10) on the discussion of sexual issues with patients and the physicians' level confidence in assessing hiv risk behaviors. these changes are portrayed in table 1. online journal of rural nursing and health care, 1(3) 52 online journal of rural nursing and health care, 1(3) 53 an overall reliability of r³ .95 was calculated on the practice instrument using cronbach's coefficient alpha. t-tests were also performed on all items in the practice pattern questionnaire. results demonstrated statistically significant changes (p <.10) on specific practice items related to risk assessment and counseling (see table 2). when examining practice patterns for physicians treating all age groups in their practice, statistically significant differences in practice patterns occurred with patients under the age of 20 (see table 3). statistically significant changes occurred with regard to the actual number of patients tested and/or referred to an independent lab for testing (see table 4). statistically significant differences were also indicated with regard to assessment, screening and counseling of patients with high-risk behaviors (see table 5). all of these differences were statistically significant at the p<.10. online journal of rural nursing and health care, 1(3) 54 discussion it is obvious that the program had an effect on the attitudes towards, practice patterns for, and knowledge level of the physicians participating in this educational intervention. online journal of rural nursing and health care, 1(3) 55 the attitudes selected for inclusion in the study indicated that the statistically significant changes for this group of physicians centered on their discussion of sexual issues and their level of confidence in assessing hiv risk behaviors. the frequency of discussion increased as a result of the program. the physicians self-reported level of confidence also increased as an outcome of the educational program. similarly, changes in practice patterns reflect a statistically significant increase in physician's completing risk assessment, pretest counseling, and testing of patients. this of course, is self-reported data but the finding is verified by the changes in the actual numbers of patients tested and/or referred to a lab for testing by this group of physicians. although there were no statistically significant differences in which patients were assessed for hiv and the frequency of that assessment (first visit, every visit), there was a statistically significant changes in the assessment of risk behaviors in patients under 20 years of age. information provided in the program about the increasing incidence of hiv/aids in the adolescent population may have prompted physicians to consider risk behaviors in that group. there were statistically significant increases in the frequency of the physicians' discussions of testing in high-risk groups. this would indicate that physicians, as they become more aware of the high-risk groups, would have a tendency to test or refer those groups with greater frequency. the physicians were asked to evaluate the program. the rank ordering of the most helpful topics indicated that physicians find the information on assessment, screening and testing most helpful to their practice (see table 6). considering that most of this group were primary care or general practitioners, the evaluation seems to indicate that content related to screening and testing rather than treatment of hiv patients fits the physicians' learning and practice needs. online journal of rural nursing and health care, 1(3) 56 most physicians on the final learner evaluation indicated that although they would refer patients for treatment, knowing the treatment protocols helped them in the provision of care for unrelated health problems to symptomatic patients receiving therapy. physicians also indicated that content on treatment was helpful in terms of discussing potential referral and treatment with clients who tested positive. evaluation of the course validated the appropriateness of the one on one teaching. the majority of physicians indicated that this was most beneficial. the majority valued the ability to ask questions and clarify content immediately during the session. as part of the evaluation of this program, the physician instructors were also asked to provide feedback on the process and content of the program in a focus group session. all of the instructors thought that the content was thorough and comprehensive. all the instructors felt that going to physician's office, although labor intensive, was the only practical way to get the amount of content to the learners. there was also a discussion of having the course websupported with some in person instruction or a completely web-based format with chat rooms and bulletin boards to facilitate instructor and learner communication. others thought about videotaped instruction or lectures using a cd-rom format. another recommendation from the physician instructors was to provide the content via videotapes, the internet and/or teleconferencing (where available) with on-site visits to physician offices for clarification of information and questions about materials. this might provide a more cost effective but still convenient approach for the physician learners. however, what would be the availability of facilities where the physicians actually practice. these alternatives require further study. the technology is available to support these other media options. however, it is unclear how the hispanic physicians would respond to or participate in web-based learning or alternatives. online journal of rural nursing and health care, 1(3) 57 conclusions educational programs can alter assessment, screening and testing behaviors of hispanic physicians especially those that are tailored to the individual physician and provided at their place of practice. educational interventions can also alter attitudes towards and knowledge of screening, testing and referral processes. the one on one learning was well received by the physicians. if this program could be offered via the web, the course would have greater availability and accessibility for physicians. it may be more cost effective than the current method of program delivery. in medically underserved and rural areas where physicians do not have access to programs or cannot afford to leave their practices for extended periods, one on one instruction that goes to the physician may be required. it is obvious that the intervention had a positive impact on the knowledge of, attitudes towards, and practice patterns of physicians relating to screening, testing and referral with regard to hiv/aids. using different forms of instructional technology should be compared to one on one instruction in future studies. this present study did demonstrate that one on one instruction at the physician's place of practice enhanced selected aspects related to screening, testing and referral of patients at risk for hiv/aids in the hispanic community. other educational methodologies should be piloted and tested to ascertain if they had equally positive results. online journal of rural nursing and health care, 1(3) 58 implications the implications of this research indicate that an educational program aimed at specific groups of health providers can modify their knowledge, attitudes and practice pattern toward hiv/aids. it also indicates that at times education has to be brought to the provider on their terms rather than in formal programs at a distance from their practice. all of the providers in this study practiced in hispanic or latino communities in predominantly large urban, medically underserved areas along the eastern and southeastern united states. however, there was a small cadre of physicians who dealt with migrant or seasonal farm workers in the southeast. all of them were unfamiliar with the community resources to support screening and testing processes. it was very apparent in this study that physicians do not necessarily receive all the necessary knowledge regarding hiv/aids. they required additional training and education to adequately assess and screen at risk clients. this may indicate that more information and training is required during basic preparation to integrate this knowledge into the curriculum. it may also indicate that other providers also do not receive in depth training on hiv/aids. just as this is critical in the hispanic community in the inner city, it is equally important to those physicians and other primary providers in rural communities. their knowledge, attitudes and practice patterns related to hiv/aids will impact on their assessing risk, screening and/or referral for testing. as hiv/aids becomes more prevalent in rural communities, it is important that the health care providers who are the front line for prevention are more knowledgeable about risk factors and adequate screening and referral. if rural providers can't access important information about hiv/aids, then appropriate methods for bringing it to them must be a priority. online journal of rural nursing and health care, 1(3) 59 limitations this is a self-selected, relatively small group of physicians. responses of this group are certainly not generalizable to other groups of physicians. this intervention was used and evaluated primarily with hispanic physicians practicing in largely hispanic medically underserved communities. physicians practicing in these areas are limited in number and have typically large practices. the size of their practice has a direct bearing on the physician's ability to access other forms of education. therefore, comparisons between this educational approach and others potential programming were not possible for this group of physicians. recommendations it is recommended that other forms of programming be developed and evaluated to ascertain if they achieve similar results with larger more representative physician samples. it is also recommended that this study be replicated with a larger cadre of rural physicians who treat migrant or seasonal workers. the approach used to reach the physicians in this study could be modified and used for other health care providers working in rural or other medically underserved areas. other professional health care provider like their physician colleagues may not receive adequate preparation in terms of hiv/aids screening, testing and referral. hiv/aids is certainly not just a urban problem, the incidence and prevalence of it in all age groups is increasing rapidly in rural areas (bushy, 2000). as the incidence increases, serious plans for the education of rural providers will need to be developed. the approach in this study worked for these physicians perhaps the approach would be appropriate for rural physicians and health care providers as well. online journal of rural nursing and health care, 1(3) 60 references bach, p.b., calhoun, e.a., & bennett, c.l. (1999). the relation between physician experience and patterns of care for patients with aids-related pneumocystis carinii pneumonia— results from a survey of 1,500 physicians in the united states. chest, 115, 1563-1569. https://doi.org/10.1378/chest.115.6.1563 bushy, a. (2000). orientation to nursing in the rural community. thousand oaks, ca: sage. chesney, m.a., & smith, a.w. (1999). critical delays in hiv testing and care—the potential role of stigma. american behavioral scientist, 42, 1162-1174. https://doi.org/10.1177/00027649921954822 fontaine, a., larue, f., & lasssauniere, j.m. (1999). physicians' recognition of the symptoms experienced by hiv patients: how reliable? journal of pain & symptom management, 18, 263-270. https://doi.org/10.1016/s0885-3924(99)00078-0 freedberg, k.a., & samet, j.h. (1999). think hiv—why physicians should lower their threshold for hiv testing. archives of internal medicine, 159, 1994-2000. https://doi.org/10.1001/archinte.159.17.1994 gerbert, b., brown, b., volberding, p., cooke, m., caspers, n., love, c., & bronstone, a. (1999). physicians' transmission prevention assessment and counseling practices with their hiv positive patients. aids education & prevention, 11, 307320. haley, n., maheux b., rivard, m., & gervais, a. (1999). sexual health risk assessment and counseling in primary care: how involved are general practitioners and obstetrician gynecologists? american journal of public health, 89, 899-902. https://doi.org/10.2105/ajph.89.6.899 https://doi.org/10.1378/chest.115.6.1563 https://doi.org/10.1177/00027649921954822 https://doi.org/10.1016/s0885-3924(99)00078-0 https://doi.org/10.1001/archinte.159.17.1994 https://doi.org/10.2105/ajph.89.6.899 online journal of rural nursing and health care, 1(3) 61 herek, g.m., & capitanio, j.p. (1999). aids stigma and sexual prejudice. american behavioral scientists, 42, 1130-1147. https://doi.org/10.1177/0002764299042007006 kirkman, m., scott, m., & bartos, m. (1999). gp's involvement in the management of patients with hiv/aids in australia. venereology, 12(3), 105-110. maheux, b., haley, n., rivard, m., & gervais, a. (1999). do physicians assess lifestyle health risks during general medical examinations? a survey of general practitioners and obstetrician-gynecologists in quebec. cmaj, 160, 1830-1834. mager, r.f. (1997). preparing instructional objectives: a critical tool in the development of effective instruction. atlanta, ga: the center for effective performance, inc. radecki, s., shapiro, j., thrupp, l.d., gandhi, s.m., sangha, s.s., & miller, r.b. (1999). willingness to treat hiv-positive patients at different stages of medical education and experience. aids patient care & stds, 13, 403-414. https://doi.org/10.1089/apc.1999.13.403 wainberg, m.l. (1999). the hispanic, gay, lesbian, bisexual and hiv-infected experience in health care. mount sinai journal of medicine, 66, 263-266. yedidia, m.j., & berry, c.a. (1999). the impact of residency training on physicians' aids related treatment practices: a longitudinal panel study. academic medicine, 74, 532-538. https://doi.org/10.1097/00001888-199905000-00021 https://doi.org/10.1177/0002764299042007006 https://doi.org/10.1089/apc.1999.13.403 https://doi.org/10.1097/00001888-199905000-00021 fahs_597-article text-3745-1-6-20191125 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.597 1 editorial going west: 2020 international rural nursing conference pamela stewart fahs, phd, rn, editor july 27 – 30, 2020, do you know where you will be? i will be in greeley, colorado at the international rural nursing conference and hope to see you there! hosting this conference are the rural nurse organization; university of northern colorado at greeley, boise state university, the university of wyoming; the matson halverson christiansen hamilton foundation (mhch), and the helmsley charitable trust. the conference will be held at the double tree hilton in greeley, co. this conference will give you the latest information on what is happening in rural health care and nursing. the world of rural nursing and health care is broad, yet like a rural community it is small enough that there is a good deal of familiarity. judging from past rural conferences there will be friends old and new attending. this is a conference for practitioners, educators, and researchers. so if you work to ensure the health of rural populations, this is a conference you will not want to miss. abstracts for presentations and posters are due no later than sunday january 26, 2020. call for abstracts page on the conference website www.irnc.ua.edu .suggested topics for abstract submissions include but are not limited to the following as they relate to rural health and nursing: • evidence-based clinical practice • quality improvement • research • education • policy/workforce please watch the rno.org website for more details as they emerge. see you in greeley. 28 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 the prevalence of cardiovascular disease and associated risk factors in the old order amish in northern indiana: a preliminary study deborah r. gillum, rn, phd 1 beth a. staffileno, rn, phd, faha 2 karon s. schwartz, rn, phd 3 lola coke, rn, phd 4 louis fogg, phd 5 1 associate dean, school of nursing, bethel college, contact 2 assistant professor, college of nursing, rush university, beth_a_staffileno@rush.edu 3 associate professor, school of nursing, bethel college, contact 4 assistant professor, college of nursing, rush university, lola_coke@rush.edu 5 assistant professor, college of nursing, rush university, louis_fogg@rush.edu key words: amish, cardiovascular disease, risk factors, indiana abstract background: the amish are a culturally distinct religious sect who are the fastest growing rural group in the u.s. little is known about their prevalence of cardiovascular disease (cvd) and its risk factors of the amish the purpose of this study was to determine the prevalence rates, risk factors, and types of treatments used to prevent and treat cvd among a sample of the adult amish in northern indiana. methods: a randomized retrospective chart review (n = 200) from a primary healthcare clinic in a large amish settlement was conducted. descriptive statistics were used to determine prevalence rates of cvd, risk factors, and types of medical and alternative health treatments. prevalence rates were compared to white prevalence rates of the american heart association (aha) 2009. results: the overall cvd prevalence was higher among amish men (n = 105) and women (n = 95) compared to white men and women (38.1% and 44.2% vs. 37.2% and 35%, respectively). regarding cvd risk factors, there was a higher prevalence of hyperlipidemia when compared to aha prevalence rates (22.9% and 24.2% vs. 16.1% and 18.2%) but a lower prevalence of type ii diabetes mellitus (4.8% and 5.3% vs. 6.7% and 6.0%) and smoking (9.5% and 2.1% vs. 24% and 20%). obesity was prevalent with 73.7% of males (n = 19) and 100% (n = 11) of women were overweight or obese. an additional finding was the high prevalence of depression in both amish genders compared to rural americans (19.0% and 22.1% vs. 6.1% both genders) and anxiety (11.4% and 14.7% vs.3.6% and 6.6%). the amish use a wide variety of vitamins and herbal remedies along with prescription medications to prevent and treat cvd. conclusion: cvd and its associated risk factors are a concerning health problem in the amish of northern indiana. introduction the old order amish are a culturally distinct rural population in which little is known about cardiovascular disease (cvd) prevalence. the old order amish (hereafter referred to as the amish) are the fastest growing rural group in the u.s. (armer & radina, 2002) and at their current growth rate of 5% a year, the amish population is expected to double in 14 years (elizabethtown college, 2010). there are 427 different settlements located in over 28 states and http://www.bethelcollege.edu/academics/catalog/school_nursing.pdf http://www.bethelcollege.edu/contact/default.php?id=22&staffid=233&set=1 http://www.rushu.rush.edu/servlet/satellite?c=rushunivlevel1page&cid=1204497838852&pagename=rush%2frushunivlevel1page%2flevel_1_college_home_page mailto:beth_a_staffileno@rush.edu http://www.bethelcollege.edu/academics/graduate/nursing/ http://www.bethelcollege.edu/contact/?id=22&staffid=97 http://www.rushu.rush.edu/servlet/satellite?c=rushunivlevel1page&cid=1204497838852&pagename=rush%2frushunivlevel1page%2flevel_1_college_home_page mailto:lola_coke@rush.edu http://www.rushu.rush.edu/servlet/satellite?c=rushunivlevel1page&cid=1204497838852&pagename=rush%2frushunivlevel1page%2flevel_1_college_home_page mailto:louis_fogg@rush.edu 29 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 in ontario, canada. the amish population in the u.s. totals over 249,000, with two thirds of all amish living in pennsylvania, ohio and indiana (elizabethtown college, 2010). the amish are a closed religious community who live in church districts closely monitored by the local bishop and community members. they typically do not continue formal schooling after the eighth grade, and those educated in parochial schools do not study science. using natural remedies and seeking care from non-traditional healthcare providers are common in this culture. the amish are more likely to use alternative and complementary medicine as a first attempt at resolving health issues and only seek modern healthcare if initial attempts fail (graham & cates, 2006). they often fall victim to fantastic claims of natural cures by alternative drug companies who target this culture‟s desire to remain as „natural‟ as possible (schwartz, 2002). the amish lifestyle is different from other rural americans due to their resistance to using technology, their reliance on god‟s will above all things, and their use of old world health knowledge and remedies (graham & cates, 2006; kraybill, 2003). as a result of these unique beliefs, behaviors and health care practices, the prevalence of cvd amongst the amish may not be accurately reflected in national statistics. the amish resist the use of technology, and do not have electricity or telephones in their homes. they must rely on telephone booths placed in central locations close to other amish homes to call for assistance. their primary modes of local transportation are the bicycle and the horse and buggy. the „english‟ (their emic term for the non-amish) assist with travel if longer distances are required. the amish do not obtain commercial health insurance and all health care costs are paid in cash by the family. if the costs are more than a single family can afford, the amish church district(s) assist with the medical bills. paying all cvd expenses out-of-pocket can have a significant impact on the health, as well as the finances, of the amish community. improving health and preventing long term complications of cvd can significantly impact the entire amish community. little is known about amish cvd prevalence compared to other rural americans. furthermore, there are no known studies that have specifically examined amish cardiovascular preventative healthcare practices or use of alternative treatments to prevent or treat cvd. there are no known published cardiovascular research studies of the amish in northern indiana. therefore, the primary purpose of this closed retrospective chart review was to determine the prevalence of cvd and its associated risk factors in a sample of amish in northern indiana. a secondary aim was to describe the types of medical and alternative treatments used to prevent and treat cvd. literature review to date, most of the published research on the amish and cvd has been the result of large cross-sectional descriptive studies carried out at the amish research clinic in strasburg, pa (bielak et al., 2008; hsueh, mitchell, aburomia et al., 2000; mitchell et al., 2008). the amish have been an attractive population for genetic studies of cvd. they are similar culturally, intermarriage within the culture is the norm, and their genealogical lines are documented back to the early 1700‟s (platte et al., 2003). they have large families, and have presumably avoided most of the modern day conveniences that have increased cardiovascular risk factors. genetic studies have led to the identification of specific genes that influence blood pressure (hsueh, mitchell, schneider et al., 2000; mcardle et al., 2007; mcardle et al., 2008) and obesity (hsueh, mitchell, schneider, 2001; platte et al., 2003; rampersaud, mitchell et al., 30 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 2008; steinle et al., 2002; steinle et al., 2005; wang et al., 2009). in addition, these primary studies have found that lipid levels (pollin et al., 2008; pollin et al., 2004, roberts et al., 2007), prolonged qt intervals (post, shen et al., 2007) and arterial calcification (post, bielak et al., 2007; rampersaud, bielak, et al., 2008; shen et al., 2007) are heritable in the amish. bielak et al. (2008) compared amish from lancaster county, pa, with a non-hispanic white population and found that the amish, after adjusting for cardiovascular risk factors, had a 66% greater coronary artery calcification than their comparison group. only two studies published in the last ten years examined cvd and its risk factors in the amish outside of pennsylvania. bassett et al. (2004) characterized the level of physical activity in the amish of ontario, canada, and found the population, who were primarily farmers, was very active and had lower rates of being overweight or obese than the general population. ferketich et al. (2008) determined tobacco use in the amish of holmes county, ohio, was significantly lower than the general population as confirmed with salivary cotinine levels (17.6% vs. 38.8%). research examining the amish and cvd is needed to better understand this distinct settlement of amish in northern indiana. previous studies have concentrated on the amish in lancaster county, pa and have primarily examined how genetics affect cvd or its risk factors. there is no known research of the amish located outside of pennsylvania that has explored the prevalence of cvd and its risk factors. it is unknown if the amish in indiana differ significantly from the amish in pennsylvania. furthermore, the types of traditional or alternative treatments used to prevent/treat cvd have not been explored. therefore, the purpose of this retrospective study was to determine the prevalence rate of cvd and its associated risk factors among a sample of amish in northern indiana. in addition, the researchers explored the types of medical and alternative treatments used to prevent and treat cvd. methodology sample this retrospective patient chart review was conducted at a primary health clinic in a large amish settlement in northern indiana. charts were selected for analysis if the client was amish, 18 years or older and was seen within the past two years at the clinic. two hundred charts were selected randomly using an electronically generated random number table. if a chart was designated that did not meet the inclusion criteria, it was replaced and the next chart alphabetically was pulled until all inclusion criteria were met. procedure approval was obtained from the appropriate institutional review board and the medical director of the clinic prior to data collection. all data was collected in december 2008. demographic data collected from the charts included: age; gender; type of employment; selfreported family history of cvd; tobacco use; presence of hypertension, anxiety, depression, hyperlipidemia, angina, peripheral vascular disease, congestive heart failure (chf), and coronary artery disease; history of myocardial infarction, cerebrovascular accidents (cva), and types of cardiovascular surgeries. height and weight were recorded if both were located in the chart. all medications and treatments noted in the chart (traditional and alternative) were recorded. race 31 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 and education data were not collected since all amish in this northern indiana region are caucasian and typically have an eighth grade education. information was self-reported or documented by the health care provider. for classification purposes, cvd included those with a history of cva, chf, hypertension and/or hyperlipidemia, while coronary heart disease (chd) included those with coronary arterial calcification and/or a myocardial infarction. data was collected using an instrument developed by the principal investigator and was later entered into an excel spreadsheet. data was validated by a comparison between the chart data and the spreadsheet to ensure accuracy. data was analyzed using descriptive statistics to quantify the demographic data, prevalence of cvd and its risk factors, and the types and quantity of treatments utilized. results the sampling of 200 charts included 105 males and 95 females ages 18 to 89 years (table 1). the mean age of males was 45.35 ± 18.34 years and females 47.83 ± 20.14 years. the males were primarily employed in manufacturing (33.3%) and small business (40.0%), with only 16.2% with farming as their source of income. the women were mostly homemakers (74.7%). table 1. demographic data n = 105 n = 95 age (yr) 45.35 (sd 18.34) 47.83 (sd 20.14) employment * manufacturing 35 33.3% 5 5.3% sm business 42 40.0% 15 15.8% homemaker 0 0.0% 71 74.7% agriculture 17 16.2% 1 1.1% teaching 0 0.0% 2 2.1% construction 10 9.5% 0 0.0% religion 3 2.9% 0 0.0% body mass index (bmi) was only calculated on 30 of the charts (19 males and 11 females) due to absence of height measurements in the remaining charts (table 2). the bmi for the males ranged from 17.3 to 42.3 kg/m² with a mean of 28.8 kg/m², and the females ranged from 25.1 to 43.2 kg/m² with a mean of 35.1 kg/m². compared to the world health organization guidelines (2009) only 26.3% (5/19) of the males were considered underweight or of normal weight (bmi ≤ 24.9), while 26.3% (5/19) were considered overweight (bmi ≥25 and < 30) and 47.4% (9/19) were considered obese (bmi ≥ 30). the bmi rates for females were even greater, with no females at normal weight, 27.3% (3/11) were overweight and 72.7% (8/11) were considered obese. 32 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 table 2. body mass index characteristics bmi = body mass index a family history of cvd was noted in 34.5% of the charts, hypertension was documented in 32.5% and type ii diabetes mellitus in 29.5%. only 6.5% of the charts documented a family history of hyperlipidemia and another 6% noted a family history of depression, which did not correspond to the actual prevalence rates noted in this sample. when comparing males to females, cvd was in 38.1% and 44.2% (ci 34.2% to 47.8%) of the charts respectively, while chd prevalence was only noted in 1.9% and 4.2% (ci 0.6% to 5.4%). cva‟s were documented in 4.8% of the males and 5.3% of the females (ci 2.0% to 8.0%) while hypertension was noted in 22.9% and 31.6% (ci 20.8% to 33.2%), respectively. hyperlipidemia was reported in 22.9% of the males and 24.2% of the females (ci 17.6% to 29.4%), although chf rates (1.0% and 3.2%, ci 0.1% to 3.9%) and myocardial infarction rates (1.9% and 4.2%, ci 0.6% to 5.4%) were much lower. type ii diabetes mellitus was found to be at 4.8% prevalence in males and 5.3% in females (ci 2.0% to 8.0%), while hypothyroidism was found in 8.6% and 20% (ci 9.2% to 18.8%), respectively. smoking rates were low at 9.5% (males) and 2.1% (females) (ci 2.7% to 9.3%). interestingly, depression was found in 19% of males and 22.1% of females (ci 14.9% to 26.1%), while anxiety was diagnosed in 11.4% and 14.7% (ci 8.3% to 17.7%), respectively. the preliminary prevalence data and comparative statistics are located in table 3. it is unclear if the differences noted between this population and the national data are significant. various cardiovascular surgeries were noted, including two coronary artery bypass grafts, two pacemakers, and a total of six valve replacements in three patients. in addition, one person had been diagnosed with marfan‟s syndrome, one with von willebrand‟s disease and one with factor v gene mutation. this sample of amish used many low cost prescription and alternative medications. the males used 53 different prescription drugs and 73 different alternative drugs, while the females used 67 different prescription medications and 84 different alternative medications. hydrochlorothiazide was the most common anti-hypertensive used by both genders, while both groups also commonly used aspirin for cardiac prophylaxis and levothyroxine sodium for hypothyroidism. many vitamins and herbal supplements were documented without specific purposes noted. the most common taken by males were vitamin c, saw palmetto, flaxseed oil, “body balance” and calcium, while the women most commonly used calcium, vitamin e, a multivitamin, glucosamine and flaxseed oil. male female bmi: kg / m 2 ( n = 30 ) ( n = 19 ) ( n = 11 ) range 17.3 42.3 25.1 43.2 mean bmi 28.8 35.1 median bmi 29.5 36.1 normal wt 5 (26.3%) 0 overweight 5 (26.3%) 3 (27.3%) obese 9 (47.4%) 8 (72.7%) 33 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 table 3 – comparison of amish cvd and cv risk factor prevalence rates to the national average (whites > 20 years) men women amish (n=105) % national average % difference women (n=95) % national average % difference cvd cvd 38.1 37.2 +0.9 44.2 35.0 +9.2 chd 1.9 9.4 -7.5 4.2 6.0 -1.8 chf 1.0 2.8 -1.8 3.2 2.1 +1.1 mi 1.9 9.4 -7.5 4.2 6.0 -1.8 cva 4.8 2.4 +2.4 5.3 2.7 +2.6 htn 22.9 32.5 -9.6 31.6 31.4 +0.2 cv risk factors smoker 9.5 24.0 -14.5 2.1 20.0 -17.9 hypothyroidism 8.6 5.1 +3.5 20.0 5.1 +14.9 hyperlipidemia 22.9 16.1 +6.8 24.2 18.2 +6.0 dm ii 4.8 6.7 -1.9 5.3 6.0 -0.7 depression 19.0 6.1 +12.9 22.1 6.1 +16.0 anxiety 11.4 3.6 +7.8 14.7 6.6 +8.1 cvd = cardiovascular disease chf = congestive heart failure chd = coronary artery disease dm ii = diabetes mellitus type ii cva = cerebrovascular accident htn = hypertension cv = cardiovascular mi = myocardial infarction chf = congestive heart failure discussion the age and gender distribution of this sample were reflective of the general amish population, which typically has a larger distribution of younger individuals (attributed to large families) and a smaller distribution of those over the age of 65 when compared to the non-amish population (hostetler, 1993). with only 16.2% of this sample working in agriculture, which was in contrast to bassett‟s sample (2004) from ontario, it indicated that not all amish communities are homogenous. 34 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 as evidenced in table 3, this study showed cvd is a health concern in the amish of northern indiana. when compared to the 2009 aha prevalence rates for whites greater than 20 years old, the amish cvd prevalence was found to be higher in males by 0.9% and females by 9.2%. chd was found to be lower than national rates (-7.3% in males and -1.8% in females), but this may be due to a lack of receiving expensive diagnostic testing that would accurately diagnose this specific disease. without medical insurance to pay for diagnostic tests, expensive testing which may be considered routine, is cost prohibitive in the amish. additionally, lower than comparative rates of known myocardial infarctions (-7.5% males, -1.8% females) may have represented a lack of diagnosis with electrocardiograms or other diagnostic tests, but may have indicated the possibility that the amish do not arrive at the hospital in time to be treated for myocardial infarctions. their distance from a local hospital, their lack of quick transportation, and lack of easily accessible telephones to call for emergency transport would delay help in reaching someone experiencing signs of an infarct. depression and anxiety rates in this sample were much higher than comparison samples. with depression rates of 19% in males and 22.1% in females, this was much higher than probst et al. (2006) study that reported the prevalence rate of depression in rural americans at 6.11%. anxiety was significantly higher at 11.4% (males) and 14.7% (females) than wittchen (2002) reported as a 3.6% prevalence in males and 6.6% in females; while young et al. (2008) further confirmed that the prevalence rate of persistent anxiety at 4.7%. it is unknown why the depression rates and anxiety levels are so high. these results were collected at the beginning of the economic downturn in the u.s. and this study location was later to have some of the highest unemployment rates in the nation. these results may have indicated the anxiety and concern over possible changes in the economy. study findings indicated that hyperlipidemia was a health concern, but few amish take prescriptive medications to lower their lipid levels. even though the prevalence was higher than national rates by 6.8% in males and 6.0% in females, only 4.5% of the amish were taking prescribed lipid lowering agents. alternative treatments, such as red yeast rice, grape seed, flax seed oil and green tea, which have been reported anecdotally to improve cholesterol levels, were used, but there was little documentation of laboratory follow-up to ensure improvement of lipid levels. documentation was noted of nutritional education that was culturally acceptable, which included instructions on eating more fresh fruits and vegetables, increasing fiber and whole grains, and decreasing oil and butter use when cooking. this education was directed at those with hyperlipidemia and those who were considered overweight. the amish self-prescribe many alternative herbal medications. their medical charts did not indicate the intended purpose for taking the herb, and little is known about the effects of them in the body or its interaction with other prescription or alternative medications. these alternatives ranged from common vitamins to more obscure treatments heavily promoted by alternative drug companies. many amish choose „natural‟ remedies over man-made remedies. smoking prevalence was much lower in the amish than in the general population (centers for disease control, 2009). while this finding may be limited with only having selfreported data, it is consistent with findings from holmes county, oh (ferketich et al., 2008) which confirmed low tobacco use. the low prevalence of smoking may indicate a strict ordnung against the use of tobacco. the amish of northern indiana are primarily employed in small business and manufacturing, not in agriculture, such as in ontario, canada (bassett et al., 2004) which may indicate a less active lifestyle. this shift in type of employment and increased bmi may indicate 35 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 the amish of northern indiana may be more progressive and acculturated to the “english” lifestyle than those who live in more traditional amish communities, which may lead to increased cardiovascular risk compared to traditional settlements. conclusion this preliminary study is unique as prevalence rates of cvd and its associated risk factors have not been previously reported in the amish setting in northern indiana amish. this study indicated that cvd and its risk factors are health concerns. this group of amish selfprescribed many alternative treatments, in addition to using a wide range of prescription medications. while the literature identified gaps in what is known about cvd prevalence data, particularly of the amish of northern indiana, this preliminary study begins to fill the gap and provides direction for research needed in the future. the knowledge of this population‟s cardiovascular health care practices is limited by the data found in the retrospective chart review and that some data was self-reported. in addition, since bmi was only calculable on a small number of charts, this data needs confirmation with a larger sample size. while many alternative treatments were noted in the chart, the anticipated effects of these alternatives were not noted. in addition, it is not known if the amish perceive cvd as a health problem in their culture. the results of this study indicate the need for further qualitative and quantitative studies to thoroughly investigate the cardiovascular health promotion practices of the amish of northern indiana. this knowledge can lead to the development of culturally specific tailored interventions to improve the cardiovascular health of this amish population. references american heart association. 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microsoft word fash_529-3158-1-ed.docx online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.529 1 editorial place represented in the online journal of rural nursing and health care pamela stewart fahs, phd, rn, editor rural is represented in this journal from a variety of places and perspectives. just perusing the articles for the may 2018 issue, i found place represented as rural central appalachia, southeastern ky, al, western states such as co and canada and over the years we have published articles from all over the us as well as globally. of course, just because research occurs in a specific place or has a rural sample does not make the research rural in and of itself. that said, i personally believe that rural nurses can benefit from research that is inclusive of rural populations even if the topic itself is not rural specific. a case may also be made for including research done in none rural venues if the application to rural health, populations or health policy can be made. however, i find there are a variety of opinions on how an argument for including research inclusive of place should be made if the study could have been completed anywhere and “just happens” to have a rural site or rural sample. the authors that are most successful in making this case clearly delineate how they are defining rural and how the research will influence rural health care, rural nursing or rural policy throughout the article, not just in the title, key words or sample. the focus of this journal is rural nursing and all that goes along with that focus. authors should be reading the author guideline prior to submission and writing to the rural nurse audience to make their case of how rural place matters in the work they are disseminating through the online journal of rural nursing and health care. rural places will be amply represented at the 2018 international rural nursing conference co-sponsored by the rno in nashville, tn from july 23-26, 2018 http://www.rno.org/events/international-rural-nursing-conference-2018-2/ . see you there! 563-article text-3669-1-9-20190820 (1) online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 44 a quality improvement endeavor improving depression screening for rural older adults stephanie ann burge, rn, aprn, dnp 1 warseal powell, rn, crnp, dnp 2 linda mazour, md 3 1 instructor, university of nebraska college of nursing, sburge@unmc.edu 2 assistant professor, university of south alabama college of nursing, warsealpowell@southalabama.edu 3 medical director, franklin county medical hospital, lsmazour@fcmh.biz abstract purpose: develop a quality improvement plan to begin a biphasic depression screening process for rural people 65 years and older residing in two counties in south-central nebraska. sample: project initiation involved retrospective chart review of a convenience sample of 50 adults, 65 years or older with a known diagnosis of anxiety or depression residing in south-central nebraska. method: a quality improvement design based on the plan-do-study-act (pdsa) model, charts a prescribed four-stage cyclic learning process while compatible with the promoting action on research implementation in health services framework (parihs) model for evidence-based practice (ebp), emphasizing the significance of organizational culture. an interprofessional (ip) small-team approach provided momentum into full organization expansion through a three-cycle operational plan. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 45 findings: the project used descriptive statistics providing aggregate demographic data while delivering a means to measure progress towards goal acquisition. conclusion: use of the convenience sample indicated the need to standardize secondary depression screening processes within a vulnerable rural population. outcomes demonstrate goal achievement with the consistent use of electronic medical record (emr) supported patient health questionnaire (phq-2) data for the older adult. however, a breakdown occurred when the organization was reliant on face-to-face communication in notifying the healthcare provider when the phq-2 triggered the need for the more detailed phq-9. a gap in primary care for older men discovered with implications for improving the accessibility of healthcare in the future. keywords: rural depression, depression screening a quality improvement endeavor improving depression screening for rural older adults rural people with behavioral and mental health illness receive less psychiatric care compared to people with behavioral and mental illness living in more populated areas. proportionately, more people who are older live in rural populations and encounter a wide range of disease burden. aging and rurality contribute to the susceptibility of those confronting chronic illness (watanabegalloway, madison, watkins, nguyen, & chen, 2015). specifically, long-distance travel to access specialty health care, getting by with not enough available local primary health providers, and experiencing feelings of displacement when engaging in health care from more urban areas adds to vulnerability. moreover, rural elderly have more medical and mental health care needs compared to people residing in urban areas (snyder, jensen, nguyen, filice, & joynt, 2017). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 46 prevalence the known correlation between aging and risk for depression is well studied with current research continuing to indicate an increased incidence of depression with aging (sjöberg et al., 2017; verhoeven et al., 2014). depression prevalence is similar between rural and urban populations; disconcerting is the variance between the amount and quality of mental health care available in rural areas due to a scarcity of resources (watanabe-galloway et al., 2015). additionally, rural populations comprised of higher numbers of geriatric adults indicate people often experience inadequate diagnosis and are under treated for depression. predictions specify that by 2020 depression will be an uppermost component of worldwide disease problems (davidson et al., 2018). presently, 17% of americans are impacted by depression (leblanc et al., 2015). the economic burden for depression in the united states (us) was assessed at 98.9 billion in 2010 rising 27.5% from 2005 measurements (greenberg, fournier, sisitsky, pike, & kessler, 2015). in 2016, an estimated 4.8% of the us adult population above the age of 50 had a major depressive episode with 64% experiencing severe impairment (national institute for mental health, [nimh], n.d.a). risk factors adults at higher risk for depression are female, advancing in age, living alone, or disabled, less educated, experiencing high levels of stress, chronic disease, and use multiple pharmacological agents. additionally, personal or family history of depression and struggles with substance abuse contribute to the risk of depression development (nimh, n.d.b). estimates of major depression in community dwelling older adults are relatively low ranging from <1-5%. unfortunately, the risk for depression increases (11.5%) in the hospitalized elder and (13.5%) for those requiring home health care (centers for disease control & prevention [cdc], n.d.a.). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 47 depression management depression occurring in later life is a severe affliction often accompanied by medical morbidity, mental decline, and risk of suicide (w. taylor, 2015). unrecognized depression contributes to a pattern of impaired activities of daily living and worsens subsequent medical conditions such as diabetes, high blood pressure, heart disease, chronic obstructive pulmonary disease, and chronic pain (choi, kim, marti, & chen, 2014; de groot, doyle, averyt, risaliti, & shubroo, 2015; holt, de groot, & golden, 2014; lin, yen, chen, & chen, 2013; yohannes & alexopoulos, 2014). also, depression in the older adult connects to rising health care costs nationally (egede, bishu, walker, & dismuke, 2016; bock et al., 2016) a practical answer for clinicians caring for older people in primary care is the identification of depression when it presents. secondary prevention strategies seek to find disease while moving towards earlier management, expecting to improve prognosis and give cost-effective care (institute for work & health, 2015). depression screening approaches involve minimal system expenditure capitalizing on the free availability of high-quality depression screening instruments and systemwide technology support. rural central nebraska an operational definition for rural health care is the delivery of services by professionals to people residing in sparsely occupied regions (gessert et al., 2015). the population of interest is 6,850 people living within 1,262 square miles. the counties are defined as frontier (population density of 5.6 6.5 people per square mile) and are made up of individuals who are aging, involved in agriculture, and have a higher than the average number of people dealing with poverty compared to other rural communities in the nation (suburban stats inc, 2014). the population is mostly caucasian (97.8 %) with native american and people of a mixed race making up the small online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 48 minority of non-white. statistics indicate a close divide along gender lines with the number of men in the state at 50.4% compared to the number of women at 49.6%. multiple agri-businesses support the economy of the region where revenue generated based on crop and livestock production with small businesses providing services to the residents, farmers, and ranchers of the community. although largely middle class, 13.6% of the population live in poverty and an equal number (13%) are uninsured (united states census bureau, n.d.). health department data indicate during 2014 nebraska men died from suicide at a rate of 12.8% compared to a rate of 0.02% for women over the age of 65 years (nebraska department of health and human services, 2014). the nebraska behavioral risk factor surveillance system (brfss) data collected during 2010-2014 indicate more days when mental health was not good in the last month contrasted to nebraskans overall. while 10.1% of people in these counties report a diagnosis of diabetes, 6.1% report a diagnosis of cancer, and 4.2% report cardiovascular disease (cdc, n.d.b.). aggregate data including the predominance of chronic disease, rural communities comprised of proportionally higher numbers of geriatric people, and high county rates of suicide in men indicate a gap in care and signifying unidentified adult depression. theoretical framework quality health care includes the use of evidenced-based practice endorsing the benefit of research to resolve problems presenting in day-to-day nursing and advanced practice-nursing clinical work. depression screening guides better diagnosis and treatment resulting in improved quality of life and cost savings (dham et al., 2017; prasad et al., 2014; rhee, capistrant, schommer, hadsall, & uden, 2017). connecting the science to the practice environment is a challenge, a quality improvement (qi) model is critical in extending new ways to support expert clinicians as they take on changing practice patterns. the plan-do-study-act (pdsa), qi model online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 49 charts a prescribed four-stage cyclic learning approach to adopt changes emulating the scientific method of creating a hypothesis, accumulating data to test the hypothesis, examining and deciphering the results while making inferences to repeat the hypothesis. the approach is classic, pragmatic and intentional in fostering small changes to test interventions allowing for rapid change and adaptation according to feedback while generating the freedom to learn and act (m. j. taylor et al., 2013). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 50 figure 1. plan-do-study-act for rural depression screening implementation (m. j. taylor et al., 2013). a common perception now exists signifying that practice change implementation requires complete system alteration implicating both the individual and the organization. the evidencebased practice (ebp) model was chosen for its significant regard of organizational culture and compatibility with the pdsa, qi model is the promoting action on research implementation in health services framework [parihs] (kitson et al., 2008). the parihs theorists endorse a foundational two-phase application progression by first engaging conversation and understanding about scientific evidence and its reliability within professional and patient context. the second phase requires assessment of regional data needed to measure existing practice and oversee future practice (hutchinson, wilkinson, kent, & harrison, 2012). the parihs framework provides a structure for implementation of research into practice bearing in mind the interchange of three core elements, effective implementation signified as a purpose of the nature and type of evidence, the traits and characteristics of the environment in which the evidence is being introduced, and the way the process is expedited. methods design a quality improvement design using descriptive statistics involving retrospective chart review. the institutional review board (irb) at the university of south alabama approved the project as quality improvement (id: 1149283-1). the agency independently has no irb review processes; project approval was sought and issued by the administrator and chief executive officer (ceo) sanctioning the completion of the qi project. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 51 sampling the study consists of a convenience sample involving the medical records of patients age 65 and older with known depression or anxiety receiving primary health care services in a frontier setting. to be included in the study, the participant must be 65 years or older, with known chronic illnesses, and offer consent to participate in the research at the time of clinic sign-in. exclusion criteria include those 65 years and older with no known chronic illnesses or anyone under the age of 65. a total number of 50 participants were involved in the initiation of the project. measures tools the patient health questionnaire phq-9, and the particularly-short phq-2, are used commonly in primary care and community settings (gelaye et al., 2016; kocalevent, hinz, & brähler, 2013; kroenke, spitzer, & williams, 2001; manea, gilbody, & mcmillan, 2015). the phq-2 and phq-9 are available on open access and are extensively studied instruments for screening depression corresponding to the dsm-iv major depressive criteria. evidence as recent as 2013 indorses reliability and validity of the phq-9 for measurement of depression in the general population (kocalevent et al., 2013). the notably brief two item phq-2 also proves reliable and valid with a strong construct and good criterion validity in recent studies (gelaye et al., 2016). operational plan the systematic process from start to conclusion involves three cycles using the pdsa quality improvement model. cycle-one begins with a study using retrospective chart review for 50 clients who met inclusion criteria. a small interprofessional (ip) team was established and comprised of advanced practice nursing, a physician, the director of informatics, the director of nursing, and the chief executive officer. the purpose of the ip team during planning phase is to review cycleonline journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 52 one study results, define problems and barriers, and determine next steps. team action phase involves work to ready system’s electronic medical record (emr) for data collection using depression-screening reports. the aim of the teamwork at this point is to ease provider notification while determining how best to complement nursing workflow patterns learning about the phq-2 and phq-9 use in clinical practice. finally, cycle-one do phase involves the small ip team completing eleven days of depression screening on eligible patients. cycle-two study phase begins with chart review involving all patients screened in the previous eleven days (during cycle-one) for depression. cycle-two planning phase includes small ip teamwork to review cycle-two study results while determining the plan for full implementation of the project. cycle-two action phase encourages the team to remain vigilant with awareness of communication needs for all system stakeholders while activities include educational and team building endeavors supporting the large ip team group formation. finally, the do phase of cycletwo involves the full implementation of depression-screening processes across the system. cycle-three study phase involves completing data analysis on all participants screened during cycle-two. results from the cycle-three study phase provide data while further guiding the large ip team decision-making through remaining cycle-three phases (plan, do, act). cycle-three positions the organization to sustain ongoing secondary prevention interventions that promote early disease identification for depression in a vulnerable rural population. data analysis data analysis using statistical package for the social sciences (spss) was completed. cycleone data analysis involved a randomized retrospective chart review on 50 patients 65 years and older with a known existing anxiety or depression diagnosis and conducted using electronic medical records (emr) reviewed from january 2014 through december of 2017. data collected online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 53 from the convenience sample included age, gender, visit type, primary medical diagnosis, and any evidence indicating prior completion of secondary screening for depression (see table 1 for cycleone characteristics). the majority of patients in the convenience sample were within the age range of 65-74 years (54%) with an appreciable 18% of the patients in the advanced age group of 85-99 years. the convenience sample was comprised of 64% females and 36% males. patients in the sample sought care 48% of the time for chronic disease follow-up, 32% for acute episodic care, 12% for well visits, and 8% for post-hospitalization follow-up. mental and behavioral disorders had the highest occurrence rate at 22.4% for primary medical diagnosis in this sample while disease involving circulation and musculoskeletal problems together tied for second with a 16.3% primary diagnosis occurrence rate. no evidence found indicating documentation of depression screening into the emr was occurring. results a primary care health care system consisting of four rural health clinics (rhcs) staffed by five advanced practice registered nurses (aprns), a physician, six nurses, one medical assistant, three reception staff members, the director of nursing informatics, the director of nursing, and the chief executive officer; were part of a team strategy to implement a biphasic secondary depression screening process for the older adult in rural primary care. all people ages 65 years and over scoring positively on the phq-2 trigger the completion of the phq-9 (while the client is present in the clinic) allowing provider consideration for initiation or furthering of existing depression treatment. the qi project aligns with the organization’s initiation for using the centers for medicare and medicaid services (cms) guidelines ensuring emr based phq-2 screening for all rural people served by the system. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 54 the overarching aim of the project was evaluated by measuring phq-2 and phq-9 screening rates. cycle-two small-team data analysis results show depression screening (using emr supported phq-2 embedded into clinic check-in processes) increased by 92.9 % while provider collected phq-9 screening (triggered by positive phq-2 findings) increased by 42.8%. out of 14 patients participating during cycle-two, seven patients (50%) triggered the need for a complete phq-9 screening, and seven patient (50%) needed no further screening. of the four out of seven patients, (57.1%) who triggered the need for further screening received no additional assessment while the remaining three patients (42.8%) obtained the needed additional screening. demographic data from cycle-one mirrors the characteristics of the data collected within the convenience sample (see table x). (see table 1 for cycle-two characteristics). the largest percentage of the patients (57.1%) seen during cycle-two were between ages 6574 years, 35.7% males and 64.3% females, most people seeking health care needed chronic disease follow-up and the top primary medical diagnosis was disease of the musculoskeletal system at 28.6%. notably, half of the patients in the population of interest entered local primary rural health care having the risk for depression as identified by the phq-2. biphasic depression screening did not significantly affect provider action towards medication management or referral to mental health services. cycle-three full-system implementation results illustrate depression-screening involving the use of the emr embedded phq-2 increased by 84.3%, patients refused by 10.5%, while missed assessment occurred 5.2% of the time. provider collected phq-9 screening (triggered by positive phq-2) findings increased by 15.25%. out of the 153 patients participating during cycle-three, 94 patients (61.4%) required no further phq-9 assessment. fifty-nine patients (38.5%) scored positively on the phq-2 indicating the need for additional screening, however, 48 (81.3%) did not online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 55 receive the additional phq-9 screening, and two patients (3.38%) refused phq-9 screening. (see table 1 for cycle-three characteristics). consistent with cycle-one and cycle-two data, demographic statistics signal the highest percentage of patients seen were between ages 65-74 years (45.7%), males 37.3% and females 62.7%. flu seasons influence on the use of the health care system reflected in cycle-3 findings, 54.2% of patients seen for acute episodic needs with a disease of the respiratory system being the primary reason for seeking care. remaining consistent with cycle-two conclusions biphasic depression screening did not significantly affect provider action towards medication management or referral to mental health services during cycle-three implementation. table 1 characteristics of participants across cycles one, two and three. characteristic cycle 1 n (%) cycle 2 n (%) cycle 3 n (%) age 50 (100) 14 (100) 153 (100) 65-69 years 16 (32) 5 (35.72) 40 (26.1) 70-74 years 11 (22) 3 (21.4) 30 (19.6) 75-79 years 7 (14) 2 (14.3) 39 (25.5) 80-84 years 7 (14) 1 (7.1) 21 (13.7) 85-89 years 4 (8) 3 (21.4) 13 (8.5) 90-94 years 3 (6) 0 (0) 6 (3.9) 95-99 years 2 (4) 0 (0) 4 (2.6) gender 50 (100) 14 (100) 153 (100) female 32 (64) 9 (64.3) 96 (62.7) male 18 (36) 5 (35.7) 57 (37.3) reason for health care 50 (100) 14 (100) 153 (100) well visit 6 (12) 2 (14.3) 6 (3.9) acute episodic visit 16 (32) 5 (35.7) 83 (54.2) post hospitalization follow-up 4 (8) 0 (0) 5 (3.3) chronic disease follow-up 24 (48) 7 (50) 59 (38.6) primary medical diagnosis 49 (98) 14 (100) 153(100) certain infectious and parasitic disease 1 (2) 1 (7.1) 1 (0.7) neoplasms 1 (2) 1 (7.1) 2 (1.3) diseases of the blood 0 (0) 0 (0) 2 (1.3) endocrine, nutritional, metabolic disease 4 (8.2) 1 (7.1) 12 (7.8) mental & behavioral disorders 11 (22.4) 0 (0) 3 (2) online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 56 diseases of nervous system 1 (2) 1 (7.1) 3 (2) diseases of eye & adnexa 2 (4.1) 1 (7.1) 2 (1.3) diseases of the ear & mastoid process 0 (0) 0 (0) 12 (7.8) diseases of circulatory system 8 (16.3) 1 (7.1) 16 (10.5) diseases of respiratory system 7 (14.3) 1 (7.1) 34 (22.2) diseases of digestive system 3 (6.1) 0 (0) 11 (7.2) diseases of skin/subcutaneous tissue 3 (6.1) 2 (14.3) 13 (8.5) diseases of the musculoskeletal system & connective tissue 8 (16.3) 4 (28.6) 33 (21.6) diseases of the genitourinary system 0 (0) 1 (7.1) 9 (5.9) prior emr documentation -depression screening 0 (0) na na phq-2 completion 0 (0) 14 (100) 153 (100) no 0 (0) 1 (7.1) 8 (5.2) yes 0 (0) 13 (92.9) 129 (84.3) refused 0 (0) 0 (0) 16 (10.5) phq-2 score indicating phq-9 need 0 (0) 7 (50) 59 (38.5) need for phq-9, no phq-9 na 4 (57.1) 48 (81.3) need for phq-9, yes phq-9 na 3 (42.8) 9 (15.25) need for phq-9, refused phq-9 na 0 (0) 2 (3.38) provider action based on phq-9 findings medication management for depression na 7 (50) 9 (0.06) no change in medication management na 2 (28.5) 3 (33.3) medication management adjustment na 0 (0) 2 (22.2) no medication for depression initiated na 5 (71.4) 4 (44.4) mental health referrals na 0 (0) 153 (100) referral made na 0 (0) 5 (3.3) no referral made na 0 (0) 43 (28.1) referral not indicated na 0 (0) 105 (68.6) discussion data analysis involving the convenience sample provided compelling evidence reinforcing the need for system change; there were no indications of documentation of depression screening within the emr upon reviewing cycle-one data. recognition of depression in the elderly is complicated by medical conditions and use of pharmacological agents that can mimic symptoms of depression (such as insomnia, confusion, weariness, and nutritional deficient) while often disease such as diabetes, cancer, central nervous system disorders and arthritis are comorbid with depression (groh & dumlao, 2016). research illustrates the burden of identifying depression is online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 57 eased when using an aggressive approach to screening high-risk populations leading to a better patient understanding of disease process and enormous financial savings when depression is recognized and treated where preexisting co-morbid disease already exists (egede et al., 2016). the qi project aim involved the implementation of depression-screening practices where previously no screening practice existed. the characteristics of the convenience sample indicate that over half of the population of interest is between ages 65-74. statistically, the counties of interest demonstrate an average life expectancy for men being 76 years and women 82 years of age (leduc media, 2014b, 2014a). the average client in the population will need health care services for many years; for some people (18%) life will occur into the advancing ages of 85-99 years and could mean decades of needed primary care. an aging population creates a higher risk for depression, the organization positioned for the future using strategies that ease depression diagnosis, encourage meaningful conversation with providers, monitor for disease, and initiate early treatment when disease recognition occurs. a regional gap exists in providing primary health care services for men (who make up half of the population) however, men are seen for health care only one-third of the time compared to the women in the same counties. literature review points to a larger national gap in understanding depression in men. a systematic review examining 20 databases found 16 qualifying studies, but only four studies spoke to depression in men (devries et al., 2013). future consideration involves redesigning health care systems to recognize mental health and engage both men and woman while providing affordable and accessible care. the local health care system is in the fifth year of emr use. a principal finding in a recent study by whitacre (2017) involving over 1,250,000 providers indicates emr implementation rates surprisingly rise with the degree of rurality. the depression screening qi initiative supports the online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 58 advantages of rural adoption of the emr explicitly easing secondary prevention screening efforts for a population of interest. the phq-2 rates improved throughout the change cycle in part by becoming a component of the electronic admission process. the phq-9 rates did not garner significant improvement during pdsa cycle-3. the phq-9 screening process lacked connection to emr use and relied on the phq-2 screening to prompt an in-person communication between nursing and the health care provider; in-person communication often failed to notify the health care provider of the need for further assessment involving the phq-9 during the time the patient was in the clinic. the emr facilitates the qi evaluation processes while sustaining goal driven change initiatives proving to be an invaluable asset to population-based care. implications planning future care for the population involves continuing advocacy for local, state, and federal policy efforts building an increasingly robust network of mental health providers available both in-person and through telehealth services. the pressing need to provide options for patients in search of mental health counseling services creates the opportunity to explore novel business strategies such as outpatient group behavioral health. additionally, future planning includes consideration of how to offer options outside of a clinic setting for depression screening while keeping the needs of men in mind. progress made with emr facilitation of qi endeavors positions rural nursing to continue to define and provide population health while mastering value-based care. limitations the project results are not generalizable to other elderly populations with depression risk due to the small and homogenous sample. regarding representation, an additional qi study occurred at the same time as the depression qi study; asking the patient to answer more questions than online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.563 59 typical may have affected willingness to participate. autonomy is highly valued by rural people and creates an impact on the use of health care services. conclusion promoting the improved quality of life and well-being for rural nebraskans is increasingly vital as rural demographics continue a downward population shift with communities proportionately more comprised of rapidly aging adults. nebraska’s trend shows older adults live in small towns during late-life and subsequently often require more health care and treatment for multiple disease entities. rurality adds to the complexity of care. secondary prevention measures using screening strategies assists health care providers to identify depression when it presents while moving towards the earlier management of disease expecting to improve prognosis and save expense. references bock, j.-o., brettschneider, c., weyerer, s., werle, j., wagner, m., maier, w., … könig, h. 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(2014). pharmacological treatment of depression in older patients with chronic obstructive pulmonary disease: impact on the course of the disease and health outcomes. drugs & aging, 31, 483–492. https://doi.org/10.1007/s40266-014-0186-0 online journal of rural nursing and health care, 1(1) 25 self-care practices of rural people with hiv disease susan gaskins, dsn, acrn1 margaret a. lyons, phd, rncs2 1 associate professor, capstone college of nursing, university of alabama, sgaskins@nursing.ua.edu 2 assistant professor, capstone college of nursing, university of alabama, mlyons@nursing.ua.edu abstract this qualitative study identified and explored the self-care behaviors of individuals with hiv/aids who live in rural areas. four audiotaped focus groups were conducted with nineteen men and eight women in the rural south. participants described activities used to take care of themselves and help them to feel better. data analysis revealed three categories: (1) dealing with rural issues, (2) staying healthy, and (3) ways of taking care of self with hiv. three subcategories illustrated the concept of dealing with rural issues: (a) returning home, (b) disclosing vs. not disclosing hiv status, and (c) obtaining care. the second category, staying healthy, was portrayed by sub-categories of: (a) eating right, (b) exercising, (c) practicing safer sex, (d) discontinuing drug usage, (e) keeping a positive attitude, and (f) staying busy. the third category, taking care of self with hiv disease depicted sub-categories of participants' descriptions of: (a) taking vs. not medications, (b) going to the doctor, (c) educating themselves about hiv/aids, and (d) being involved with hiv/aids. this study has implications for health care providers and community planners. keywords: hiv/aids, self-care, rural, focus group online journal of rural nursing and health care, 1(1) 26 self-care practices of rural people with hiv disease during 1998, 48,269 persons were diagnosed with acquired immunodeficiency syndrome (aids) in the united states, bringing the total number of reported aids cases to 688,200 (cdc, 1998). since 1996 there has been a decrease in deaths among people with aids and in the occurrence of aids-defining opportunistic infections (aids-oi). the decline in aids related morbidity and mortality can be attributed to improved antiretroviral therapies (pelalla et al. 1998). people surviving longer with hiv/aids reflect an increased prevalence of people living with hiv disease. there has not been a decrease in the incidence of hiv infection and increases are reported for minorities, women, and in some geographical areas. the south has experienced the most rapid growth in aids cases and has the highest incidence in the country (cdc, 1998). the prevalence of aids continues to be highest in larger metropolitan areas, but the number of new cases in rural areas is increasing at a rate three times the rate of urban cases (cdc, 1993). the characteristics of exposure categories of rural individuals differ from the urban populations affected by the epidemic. most of the rural cases are likely to be young, nonwhite, female, and live in poverty. the majority of these individuals acquired hiv through heterosexual behaviors (berry, 1993; rumley, shappley, waivers & eisenfant, 1991; sowell & christiansen, 1996). the increase in prevalence of people living with hiv/aids in rural areas underscores the need for rural-based health care and service organizations that will meet growing needs for long-term support and service in this sector of the population (heckman, somlai, kalichmam, franzoi, & kelly, 1998). although medical therapy is a primary mechanism for disease control, many individuals engage in self-initiated behaviors that are useful in maintaining health, quality of life, and online journal of rural nursing and health care, 1(1) 27 perceptions of wellbeing. these self-care practices aid individuals to live with hiv/aids as a chronic, but manageable disease. previous studies have investigated the efficacy of self-care behaviors in samples of long-term survivors, women, and homosexual/bisexual men with hiv/aids. consistently, the self-care activities reported have included health promotion activities, taking responsibility for one's health, and illness management as needed. a common belief that self-care activities positively influence health was identified among study participants (barroso, 1995; sowell, moneyham, guillory, seals, cohen, & demi, 1997; lovejoy, freeman & christianson, 1991; valente, saunders, & uman, 1993). although several studies were found investigating self-care activities in individuals with hiv, none were found related to those people who live in rural areas. the unique purpose of this study was to identify and explore self-care behaviors of individuals with hiv/aids who live in rural areas. participants the sample for this study consisted of nineteen men and eight women who were hiv+ and who resided in the rural south. participants ranged in age from 18-54 years with the majority falling in the 20s (8), 30s (9), and 40s (8) age range. twenty-two were single, two were married, two were divorced and one was separated from his spouse. most participants were unemployed. more than half were receiving some type of public assistance, for example, food stamps, medicaid, or housing. two participants received disability income. four had no income. twenty-two participants were african-american and five were caucasian. participants were recruited from aids service organizations (asos). methodology a focus group approach was used to investigate the shared meaning of the experience of engaging in health care activities. an advantage of this method is the stimulation and synergy online journal of rural nursing and health care, 1(1) 28 created as participants interact, hear other ideas or experiences, and have their own ideas and experiences validated (stewart and stamdasani, 1990; kruger, 1995). four focus groups were conducted with 27 participants in two areas in the rural south. local asos recruited participants after the researchers obtained approval for the study from the aso board of directors and agency personnel. group members met sample criteria of having been diagnosed with hiv/aids and of living in areas with rural zip codes. group sizes ranged from five to eight participants, were racially mixed, and were comprised of both male and female participants. group sessions were held at the asos either during regular clinic hours or on mornings when clinics were not being held. informed consent was obtained prior to each session. participants were told that their participation was voluntary and that data collected, as well as individual identity, would remain confidential. in addition, members agreed to keep other participants’ identities confidential. demographic data were obtained. guidelines for group participation were presented and a semi-structured interview guide (figure 1) was used to facilitate sequencing of questions and discussion regarding participant self-care practices. additional clarifying questions were asked as deemed necessary by the researchers. both researchers conducted audiotaped discussions and observational field notes were taken during the sessions. group sessions lasted approximately 1 1/2 hours and participants were given a $20 honorarium for their participation. online journal of rural nursing and health care, 1(1) 29 demographic data, verbatim transcripts, and field notes provided the data for analysis. content analysis was used to analyze and interpret the data. individual items were coded and categorized independently by each researcher after each group session. major topics and issues related to each research question were identified. this material was coded then categorized independently by each researcher. the researchers then met to identify, discuss, compare, and collapse data into final categories. low inference descriptors or the use of verbatim accounts of participant experiences were used in the description of findings to reduce threats to validity and reliability in this study (field & morse, 1985). findings as part of focus group discussions participants were asked to describe activities they used to take care of themselves and help them to feel better. three categories related to self-care practices consistently emerged during the sessions: (a) dealing with rural issues, (b) staying healthy and (c) ways of taking care of self with hiv (see fig. 2). online journal of rural nursing and health care, 1(1) 30 dealing with rural issues analysis of data by the researchers revealed that dealing with rural issues posed special concerns for the majority of participants. three sub-categories were illustrative of this concept: (a) returning home, (b) disclosing versus not disclosing hiv status, and, (c) obtaining care. returning home. returning home was a theme frequently encountered in the course of data analysis. many individuals had lived in a metropolitan area, but had returned home to their rural areas after receiving a diagnosis of hiv. they returned home to be near their families. one participant stated, "i came home, not waiting to die, but to spend my last moments with my family." some lived with their families, some did not, but all wanted to be in close proximity for emotional support. there was a sense of an overriding concern for later when health declined and they needed to be taken care of by others. even those who had never lived far from home spoke of establishing closer relationships and having more contact with family members. one participant disclosed the importance of family when he said, "once i found out that i had family love, i didn't care what other people said." disclosing vs. not disclosing hiv status. for the majority of participants, not disclosing their hiv status was an important issue. they discussed not being able to tell their friends and relatives because they feared others would not understand and felt that they could not deal with the possible reactions to their revelations. as one participant stated, "no one really knows but my mama, cousin, and just my close friends. my father doesn't even know." they feared losing their relationships, being abandoned, being judged, or having their confidentiality violated. they feared the potentially stigmatizing effects of disclosure that could impact family members and significant others. information shared could result in loss of jobs or housing. there was a real sense that "everyone knows everyone else and their business" in a small town or online journal of rural nursing and health care, 1(1) 31 rural area. some participants voiced being afraid to have prescriptions filled at the local pharmacy because employees would find out about their disease. they discussed hearing how people talked about hiv/aids and about how uneducated most people are in a small town and used this as a basis for the decision not to share their diagnoses. another frequently encountered issue related to disclosure was fear that their partners would leave them when they were informed of the hiv diagnosis. one participant stated: "i was scared to death. i thought for sure he was going to leave when he found out i had hiv...and it was just the opposite.... he said he had always loved me and it didn't make any difference.... i'm fortunate." participants who had known about their hiv status for a longer period of time were frequently more comfortable discussing their disease openly. however, many of these people also had positive experiences from others after disclosure and had made active choices not to deal with negative reactions. obtaining care. the majority of participants had experienced difficulties at some point in obtaining medical care for their disease. lack of transportation, lengthy distances, and time involved, made access to care a hardship. one participant lived 40 miles from the clinic and cared for a disabled sibling. he stated: "to get over here i have to plan a month in advance. from the time i leave today i will have to start planning how i'm going to get here for my next doctor's appointment." at the time of the interview, all of the participants were receiving care at one of two clinics by physicians with expertise in the care of hiv patients. however, to get to one of the clinics, the physician was forced to travel, twice a month, from a city 60 miles away. the other facility held a special hiv clinic where a regular attending physician saw patients. there, online journal of rural nursing and health care, 1(1) 32 patients had the advantage of scheduling appointments between clinic visits as needed. participants were generally pleased with the care they were receiving for their illness. staying healthy the second category that emerged during data analysis was that of staying healthy. this concept was portrayed by individual efforts to engage in a genuinely healthy lifestyle by incorporating health promotion and disease prevention activities. six subcategories were identified from the researchers' interpretation of data. these were: (a) eating right, (b) exercising, (c) practicing safer sex, (d) discontinuing drug usage, (e) keeping a positive attitude, and (f) staying busy. eating right. for the majority of the participants "eating right" meant eating regular meals and a balanced diet. there were no special diets, but rather, they spoke about eating what they enjoyed, such as southern cooked vegetables. although not taken regularly, vitamins, minerals, and herbs were mentioned as being important dietary supplements. they spoke of online journal of rural nursing and health care, 1(1) 33 taking cat's claw, saint john's wort, beta-carotene, vitamin b, garlic, aloe vera juice, mineral water, and multi-vitamins thinking that these preparations would increase their energy, elevate their moods, and increase their t-cell counts. exercising. all of the participants talked about the importance of exercising; however, most were not involved in regular routines. walking was the most common activity engaged in by participants. for many, walking was a necessity because transportation was nonexistent. however, walking was enjoyed and produced added benefits of keeping them "in shape" and reducing stress. a few participants enjoyed other activities such as swimming, weight lifting, sit-ups, push-ups, and getting exercise at work. one participant regularly swam and did aerobics at the local ymca, but he was in the minority as most did not engage in any type of organized exercise. practicing safer sex. participants were all cognizant of the need to protect others from transmission of hiv as well as protecting themselves from acquiring other sexually transmitted diseases (stds). for a few, abstinence was the only acceptable way to be sure of preventing exposure to stds. however, most of them expressed a desire to be in a caring, monogamous relationship. many were already in such a relationship and spoke of how comforting the relationship was to them. some partners refused to practice safe sex. nevertheless, participants cited feeling guilty and worried about exposing their partners to the virus. one, whose husband was hiv negative, and who was pregnant at the time of the interview stated: online journal of rural nursing and health care, 1(1) 34 it's been real difficult because when we do have sex like in the middle of the night, a lot of times i will get woken up.. then he feels kinda bad about it and scared and then he'll try to rationalize it. 'well your t-cells are way up there and you don't have no viral load, so i'm fine and it doesn't make any difference. discontinuing drug usage. several participants admitted to occasional marijuana usage as well as a previous history of cocaine and heroin abuse. they stated that they had discontinued drug use after finding out that they were hiv positive and felt "better since quitting." they discussed the need to take better care of themselves. many participants drank alcohol (beer) and continued to smoke cigarettes in spite of their hiv diagnoses. they viewed these behaviors as social activities enjoyed with others. keeping a positive attitude. participants discussed the importance of maintaining a positive attitude and "to not get depressed." they spoke of accepting the fact that they probably had a terminal illness but expressed the need to live and enjoy their lives within the limitations of the disease. there were many references to living one day at a time and to the importance of not dwelling on their disease. one individual stated: "just because they say you are going to die, you have to look beyond that and live day to day." for some, spiritual practices helped them to keep their disease in perspective and assisted them in maintaining a positive attitude. all participants professed to being christians and spoke of the many spiritual practices that gave them comfort such as praying, meditating, reading the bible, and having faith in a higher power. however, most individuals did not involve themselves in regular church activities in response to their hiv diagnoses. those individuals who engaged online journal of rural nursing and health care, 1(1) 35 in organized religion, for example, attending services or singing in the choir, prior to their diagnoses, continued to do so. staying busy. a strategy most of the participants identified as helping them to feel better was staying busy. a variety of activities were cited as being useful in keeping them from thinking about themselves and their diseases. for some, work was an enjoyable part of their lives. others discussed engaging in activities that they enjoyed such as fishing, dancing, listening to music, going out with friends to parties or bars, or doing volunteer work. whatever the activity, participants stressed the importance of "having fun." taking care of self with hiv disease the third category identified was taking care of self with hiv disease. participants described behaviors used to take care of themselves that were specifically related to their hiv disease. all were under medical care, some for many years. all of them discussed the pros and cons of taking medications. some insisted that not taking their medications helped them to feel better. other self-care activities related to the hiv diagnosis included seeing the doctor, educating themselves about hiv, and becoming involved with hiv/aids activities. taking vs. not taking medications. the third category identified was taking care of self with hiv disease. participants described behaviors used to take care of themselves that were specifically related to their hiv disease. all were under medical care, some for many years. all of them discussed the pros and cons of taking medications. some insisted that not taking their medications helped them to feel better. other self-care activities related to the hiv diagnosis included seeing the doctor, educating themselves about hiv, and becoming involved with hiv/aids activities. online journal of rural nursing and health care, 1(1) 36 only a few spoke of the benefits of taking medications. those individuals had become accustomed to the routine and had been diagnosed longer. they referred to rising t-cell counts and lower viral loads, weight gain, and a general sense of feeling healthier as evidence of the efficacy of medication. however, they were in the minority. going to the doctor. all participants were under the care of a physician and felt good about the care they were receiving. a few saw private physicians but most received care at an hiv care clinic. an overriding concern was the importance of having a physician who was knowledgeable concerning the treatment of hiv. several participants noted that their doctors seemed to be knowledgeable about their disease, but did not seem as concerned about other problems they were experiencing, such as depression. several participants stated that it bothered them to attend the clinic because everyone knew it was an hiv clinic. educating themselves about hiv/aids. participants discussed educating themselves about hiv disease in an effort to understand the disease and take better care of themselves. they acquired knowledge by asking the physician questions, "watching television", getting information at asos, talking to other people with hiv, going to the library, and attending the annual state hiv conference. however, in spite of attempts to educate themselves, most participants were deficient in knowledge related to their medication. they were unsure as to what the medication was, what it was for, why they were taking it or how it worked. they were also unclear about other important aspects of their illness such as t-cell counts, and viral loads. being involved with hiv/aids. being involved with hiv activities, such as attending support groups, serving on the local hiv speakers bureau, and volunteering at the local aso helped rural participants to feel good about themselves while providing needed services. under the direction of aso personnel, support group members met twice a month, planned trips, meals, online journal of rural nursing and health care, 1(1) 37 and other enjoyable activities. participants indicated that their work with the speaker's bureau provided them with enjoyable interactions and essential support from other group members. however, because they lived in a small town they noted the need for caution when doing presentations. even when not active in the speaker's bureau the aso was a positive experience for many participants. one stated, "i come in here in the foulest mood and it is like taking valium...before i leave i either be smiling or in a better mood. the atmosphere here is so uplifting to me." discussion, implications, and recommendations a limitation of this study, common to qualitative research, is the small sample size. however, results from four focus group discussions with individuals living with hiv/aids in a rural area indicate that participants contend with multiple issues consequent to living in a rural area. similar to the findings of heckman et al. (1998) who studied the psychosocial profiles of 276 persons with hiv/aids in both rural and urban areas, the present study found that rural people reported reduced access to care, more community stigma, and increased fear of disclosure of hiv serostatus. congruent with the findings of mainus and matheny (1996), participants were more likely to travel to an urban area for testing and care because of confidentiality issues and a scarcity of physicians knowledgeable about hiv disease. similar to the findings of other investigators, (heckman et al. 1998; davis, cameron, & stapleton, 1992; valente, saunders, & uman, 1993; lovejoy, freeman & christianson, 1991; sowell et al. 1997; barroso, 1995) participants in this study described behaviors that were viewed as having a positive effect on their lives and on the progress of their diseases. these activities included those that were aimed at keeping themselves healthy as well as those targeted at retarding disease progression. rather than viewing the behaviors as general health promotion online journal of rural nursing and health care, 1(1) 38 activities or disease management activities, they viewed these activities as positive actions that helped them to live more fully within the constraints of their illnesses. other researchers also describe differences in self-care activities that are health related versus disease related (gaskins & brown, 1992; barroso, 1995; corbin & strauss, 1985). the migration of people with hiv/aids to rural areas has been described in the literature and has serious implications for funding and planning services. because these individuals are often not included in state case figures, there is a resulting false perception concerning the prevalence of hiv/aids in an area and the extent of the associated problems (davis, cameron, & stapleton, 1992). the community planning process supported by the cdc could be utilized to more accurately assess the hiv/aids epidemic in a particular area (cdc, 1998). access to care issues, such as lack of transportation, can be dealt with at the community level through involvement with local churches and others who are sympathetic to the needs of those with hiv/aids. the asos in this study frequently provided transportation that enabled individuals to participate in support groups. the non-adherence to medical therapy reported by some participants is of particular concern to health care providers and community planners alike because of the consequences of jeopardizing future medical therapies as well as the increased likelihood of resulting resistant strains of hiv. occurrences such as these would greatly increase the cost of health care and the need for community resources. further study is needed to assess how people make decisions about adherence, strategies to enhance adherence, and the consequences of non-adherence on the health of the individual as relates to disease progression. the importance of health care providers involving patients in decisions concerning their care and treatment, while considering their beliefs and lifestyles, cannot be overestimated. online journal of rural nursing and health care, 1(1) 39 the importance of support groups to the participants has implications for rural areas. nationally, asos have been formed to meet the various needs of individuals with hiv, often in a group setting. greene, berger, reeves, moffat, standish, and calabrese (1999) reviewed the literature on alternative and complementary therapies and activities engaged in by individuals with hiv, including attending support groups. the studies reviewed reported improved quality of life, hardiness, and perceived emotional support from individuals who attended support groups. asos and clinics which serve rural areas must be aware of the importance and positive outcomes related to support groups. meetings need to be planned at times and places that rural members will be able to be involved. the participants in this study spoke about how much they enjoyed meeting with the support groups. they had the opportunity to talk openly about issues and to learn from one another. education of rural communities about hiv/aids is critical not only to enhance the lives of infected individuals but also to increase the awareness of the need for prevention of transmission. community planning groups provide vital links that aid in this process (cdc, 1998). sowell and christiansen (1996) view education as the single most important strategy in decreasing the fear and stigma related to hiv in rural areas. education is needed for health care providers practicing in rural areas, for families of hiv infected individuals, and for the general public. the national rural health association (nrha) (1997) concurs that education is fundamental to prevention, control and treatment of rural hiv/aids. online journal of rural nursing and health care, 1(1) 40 references barroso, j. (1995). self-care activities of long-term surviving of acquired immunodeficiency syndrome. holistic nursing practice, 10(1), 44-53. https://doi.org/10.1097/00004650-199510000-00008 berry, d.e. (1993). the emerging epidemiology of rural aids. journal of rural health, 8(4), 293-304. https://doi.org/10.1111/j.1748-0361.1993.tb00525.x center for disease control and prevention. (1998). hiv/aids surveillance report, 10(2), 1-43. center for disease control and prevention. (1998). hiv prevention community planning: share decision making in action. retrieved august 17, 1998, from http://www.cdc.gov/ nchstp/hivaids/pubs/complan2.pdf center for disease control and prevention. (1993). hiv/aids surveillance report: year-end edition. atlanta, ga: author. corbin, j., & strauss, a. (1985). managing chronic illness at home. qualitative sociology, 8(3), 224-247. https://doi.org/10.1007/bf00989485 davis, k.a., cameron, b.c., & stapleton, j.t. (1992). the impact of hiv patient migrate to rural areas. aids patient care, 6, 225-228. https://doi.org/10.1089/apc.1992.6.225 field, p.a., & morse, j.m. (1985). nursing research: the application of qualitative approaches. rockville: aspen. gaskins, s.w., & brown, k. (1992). psychosocial responses among individuals with human immunodeficiency virus infection. applied nursing research, 5(3), 11-12. https://doi.org/10.1016/s0897-1897(05)80025-4 https://doi.org/10.1097/00004650-199510000-00008 https://doi.org/10.1111/j.1748-0361.1993.tb00525.x https://doi.org/10.1007/bf00989485 https://doi.org/10.1089/apc.1992.6.225 https://doi.org/10.1016/s0897-1897(05)80025-4 online journal of rural nursing and health care, 1(1) 41 greene, k.b., berger, m.f, reeves, c., moffat, a., standish, l.j., & calabrese, c. (1999). most frequently used alternative and complementary therapies and activities by participants in the amcoa study. journal of the association of nurses in aids care, 10(3), 60-73. https://doi.org/10.1016/s1055-3290(05)60120-3 heckman, t.g., somlai, a.m., kalichmam, s.c., franzoi, s.l., & kelly, j.a. (1998). psychosocial differences between urban and rural people living with hiv/aids. journal of rural health, 14(2), 138-145. https://doi.org/10.1111/j.1748-0361.1998.tb00615.x krueger, r.a. (1988). focus groups: a practical guide. newbury park, ca: sage. lovejoy, n.c., paul, s., freeman, e., & christiansen, b., (1991). potential correlates of self-care and symptoms distress in homosexual/bisexual men who are hiv seropositive. oncology nursing forum, 18, 1175-85. mainus, a.g., & matheny, s.c. (1996). rural human immunodeficiency virus health service provision. archives of family medicine, 5, 469-473. https://doi.org/10.1001/archfami.5.8.469 national rural health association. (1996). hiv/aids in rural america. an issue paper. missouri: author. pelalla, f.j., delaney, k.m., moorman, a.c., loveless, m.o., fuhrer, j., satter, g.a., et al. (1998). declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. new england journal of medicine, 338, 853-60. https://doi.org/10.1056/nejm199803263381301 rumley, r.l., shappley, n.c., waivers, l.e., & eisenfant, j.d. (1991). aids in rural eastern north carolina—patient migration: a rural aids burden. aids, 5, 13731378. https://doi.org/10.1097/00002030-199111000-00015 https://doi.org/10.1016/s1055-3290(05)60120-3 https://doi.org/10.1111/j.1748-0361.1998.tb00615.x https://doi.org/10.1001/archfami.5.8.469 https://doi.org/10.1056/nejm199803263381301 https://doi.org/10.1097/00002030-199111000-00015 online journal of rural nursing and health care, 1(1) 42 sowell, r.l., & christensen, p. (1996). hiv infection in rural communities. nursing clinics of north america, 31, 107-123. sowell, r.l., moneyham, l., guillory, j., seals, b., cohen, l., & demi, a. (1997). self-care activities of women infected with human immunodeficiency virus. holistic nursing practice, 11(2), 27-35. https://doi.org/10.1097/00004650-199701000-00005 stewart, d.w., & stamdasani, p.n. (1990). focus groups, theory and practice. newburg park: sage. valente, s.m., saunders, j.m., & uman, g., (1993). self-care, psychological distress, and hiv disease. journal of the association of nurses in aids care, 4, 15-25. https://doi.org/10.1097/00004650-199701000-00005 microsoft word fahs_354-1888-1-ed.docx online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.354 1 editorial rural hospitals endangered? pamela stewart fahs, rn, dsn, editor if you were working in health care in the 1980’s and 1990’s the current headlines and webinars on the closures of rural hospitals may give you a sense of déjà vu. a 2014 headline in the usa today read “rural hospitals in critical condition”. o’donnell and ungar went on to report that 43 rural hospitals have closed since 2010 and that that the rate of closure is intensifying. this data comes from the north carolina rural health research program where a national study is being conducted on hospital closures. you can access an archived webinar http://www.ruralhealthresearch.org/alerts/archive/42 on the rural health research & policy center website (holmes, 2014) which includes their research on issue of profitability and closure of rural hospitals. remember why the critical access hospital (chs) program was created? as hospitals began to receive prospective payment vs. reimbursement for cost, there was a rash of hospital closures, and these closures were occurring disproportionately in rural areas. these closures made access to health care in rural populations problematic but were also a financial strain on the rural communities themselves. rural hospitals are often a major employer in rural communities. critical access hospitals have higher reimbursements than usual, which have helped many survive; however, these reimbursement rates are under review. even with the high level of reimbursement cahs are operating on slim profit margins. what these facilities bring to rural communities, is available health care and peace of mind – someone is there to provide care 24 hours per day. they are critical indeed to the rural populations they serve. the care in cahs should be high quality and these hospitals have a responsibility to assess and maintain quality of online journal of rural nursing and health care, 14 (2) http://dx.doi.org/10.14574/ojrnhc.v14i2.354 2 care. there may well be some rural hospitals that need to close but many provide a valuable service and help to meet the basic goal underlying the affordable care act, access to care. references holmes, m. (2014). change in profitability and financial distress of cahs from loss of cost-based reimbursement. retrieved from http: www.ruralhealthreserach.org/alerts/arechive/43 o’donnell, j. & ungar, l. (2010) usa today special report: rural hospitals in critical condition. microsoft word dementia care evidence.docx online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 117 dementia care evidence: contextual dimensions that influence use in canadian northern rural home care centres dorothy forbes, rn, phd 1 laurel strain, phd 2 catherine blake, ma 3 shelley peacock, rn, phd 4 wendy harrison, rn, bn 5 terri woytkiw, rn, mn, chpcn (c) gnc (c) 6 pamela hawranik, rn, phd 7 emily thiessen, rn, mn, gnp 8 amy woolf, bscn rn 9 debra morgan, rn, phd 10 anthea innes, ba, msc, phd 11 maggie gibson, phd 12 1 professor, faculty of nursing, university of alberta, dorothy.forbes@ualberta.ca 2 professor, emeritus, department of sociology, university of alberta, laurel.strain@ualberta.ca 3 research associate, arthur labatt school of nursing, university of western ontario, cmblake@uwo.ca 4assistant professor, college of nursing, university of saskatchewan, shelley.peacock@usask.ca 5 vice president rural, north east operations (retired), alberta health services north zone, wendyjh@shaw.ca online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 118 6 lead-seniors health clinical support, north zone, alberta health services north zone, terri.woytkiw@albertahealthservices.ca 7 professor & dean, faculty of graduate studies, athabasca university, phawranik@athabascau.ca 8 graduate nurse practitioner, research assistant, university of alberta, ejthiess@ualberta.ca 9 mn student, university of alberta, alwoolf@ualberta.ca 10 professor, college of medicine chair, rural health delivery, university of saskatchewan, debra.morgan@usask.ca 11 director, bournemouth university dementia institute professor health and social care research, bournemouth university, ainnes@bournemouth.ac.uk 12 psychologist, veterans care program, parkwood institute, london, on, maggie.gibson@sjhc.london.on.ca abstract living and working in isolated northern communities pose challenges in using evidence to inform dementia care. purpose: to better understand the contextual dimensions of two home care centres in two canadian northern, rural communities that influence the use of evidence from the perspectives of home care providers (hcps). sample: all clinical leaders, managers, and home care providers (n=48 fte) in the two home care centres were sent an information letter outlining the study’s purpose, expectations, and benefits and invited to participate in focus groups conducted in two home care centres. fourteen staff participated in the two focus groups. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 119 method: a qualitative interpretive descriptive approach was used. semi-structured questions were used to guide the audiotape recorded focus groups. transcripts were coded using lubrosky’s thematic analysis. findings: findings are described in broad contextual themes (e.g., challenges in using the raihc, availability of resources, relationships in a rural community, leadership, and evaluation) that included both positive and negative contextual dimensions that influenced the use of evidence. conclusions: most importantly, reallocated resources are needed in northern home care settings. challenges in exchanging evidence related to difficult relationships with physicians, clients, and their family caregivers were identified. leadership and collaboration dimensions were fundamental to establishing a vibrant workplace in which hcps provided and exchanged evidence-based dementia care. keywords: evidence-based dementia care, northern home care, home care contextual dimensions, knowledge exchange. dementia care evidence: contextual dimensions that influence use in canadian northern rural home care centres in 2011, there were 747,000 canadians living with dementia with predictions that this number will increase to 1.4 million by 2031 when the baby boomers (those born between 1947 and 1966) enter the age of greater risk for dementia (alzheimer society of canada, 2012; foot & stoffman, 2004; forbes & neufeld, 2008). dementia is an irreversible syndrome that is characterized by ongoing decline in intellectual functioning sufficient to disrupt physical, social, and/or occupational functioning. for the purpose of this research, dementia is defined as acquired impairment in shortand long-term memory, associated with impairment in abstract online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 120 thinking, judgment, and other disturbances of higher cortical function or personality changes (american psychological association [apa] 1995; mckhann et al. 1984). later onset dementia includes four primary types of dementia: alzheimer’s disease, vascular dementia, dementia with lewy bodies, and frontotemporal dementia. the most common type is alzheimer’s disease. in canada, approximately 30% of canadians live in rural communities, defined by statistics canada as living outside a major urban centre of more than 10,000 (duplessis, beshiri, & bollman, 2001). rural communities, in comparison with urban settings, have a faster-growing proportion of older adults due to the out-migration of youth and the attractiveness of some rural communities for retirees (forbes & hawranik, 2012). in addition, it has been suggested that early life in a rural setting further increases the risk of dementia (russ, batty, hearnshaw, fenton & starr, 2012). the greater proportion of older adults in rural areas and the association of age and alzheimer’s disease present challenges for individuals with dementia and their family caregivers. these challenges include lack of health care services and health care providers, and difficulty accessing available services (forbes & hawranik, 2012; jansen et al., 2009). likewise, in rural areas there are unique challenges for home care practitioners, who are primarily nurses. recruitment and retention of staff, issues of risk and cost related to travel, staff isolation and safety, and access to reliable information can affect the nature and the quality of the care provided to individuals with dementia and their caregivers (canadian home care association [chca], 2008; jansen et al, 2009). the knowledge needed for the provision of care to individuals with dementia and their family caregivers reflects the complex and changing nature of dementia care, for instance managing activities of daily living, behavioural challenges, sleep-wake disturbances, communication and eating difficulties, being depressed, mood swings, aggression, and online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 121 wandering (jansen et al., 2009). the knowledge required to address these needs must include evidence, which is defined as information or facts that are systematically obtained in a manner that is replicable, observable, credible, verifiable, or basically supportable (i.e., research findings; department of health [doh], 2009). knowledge that will inform dementia care decisions also includes clinical experience, professional craft knowledge (tacit “how to” knowledge), care recipient’s preferences and experiences, and local information that enables collaborative care (roumie, arbogast, mitchel, & griffin, 2005). a rural influence may exist regarding care recipient’s preferences and experiences and local information and needs to be better understood. research evidence is often translated into best practice guidelines. dementia care guidelines for healthy eating, keeping physically and mentally active, staying socially engaged, reducing stress, seeking a diagnosis, and help for cognitive and non-cognitive symptoms and behavioural manifestations have been developed (alzheimer society of canada, 2011; cook & rockwood, 2012; hogan et al., 2008; national institute for health and clinical excellence & social care institute for excellence, 2011; rycroft-malone & stetler, 2004). however, there is strong evidence in the literature indicating inadequate use of well-known best practice guidelines (registered nurses association of ontario [rnao], 2012). studies have revealed that 30% to 45% of patients do not receive care according to scientific evidence and 20% to 25% of the care provided is not needed or is potentially harmful (grol, 2001; mcglynn et al., 2003; rnao, 2012). although home care nurses are the most frequent contact within the health care system for individuals with dementia and their caregivers (joint ccac/service provider, 2008), they often lack the current knowledge, skills, and resources necessary to appropriately meet the needs of individuals with dementia and their family caregivers (forbes et al., 2011). online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 122 the context of a health care work setting is widely considered to be an important influence on the use of best available evidence in practice (dopson, fitzgerald, ferlie, gabbay, & locock, 2002; meijers et al., 2006; rycroft-malone, harvey et al., 2004; wallin, estabrooks, midodzi, & cummings, 2006). specifically, contextual dimensions such as culture, leadership, evaluation, and resources have been shown to be important dimensions that influence the use of evidence (estabrooks, squires, cummings, birdsell & norton, 2009; kitson, harvey, & mccormack, 1998). nurses working in acute care settings with a supportive and collaborative culture, strong leadership, and positive evaluation or performance feedback were significantly more likely to participate in more staff development and report more use of research findings that informed their practice than nurses working in settings where these dimensions of the context were lacking. lower rates of patient and staff adverse events (negative physical effects due to care provided) were also reported (cummings, estabrooks, midodzi, wallin, & hayduk, 2007). in terms of a community home care work setting, the authors are unaware of any research that has examined the context of northern, rural home care centres that influence the use of best available evidence. it is timely to examine these contextual dimensions given the increased prevalence of dementia, the unique characteristics of rural and northern communities (dandy & bollman, 2008) and the shift from institutional to home-based care (alzheimer society of canada, 2010). aim and purpose our program of research aims to improve the quality of care and quality of life for individuals with dementia and their caregivers through integrated knowledge translation (ikt) strategies. these strategies will facilitate the exchange and use of best available dementia care knowledge by home care practitioners, individuals with dementia, and their caregivers. however, it is essential that the home care context supports ikt (cummings et al., 2008; mccormack et online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 123 al., 2002). the purpose of this study was to better understand the contextual dimensions of the home care centres in two rural communities in northern alberta, canada that influence the use of best available dementia care evidence from the perspectives of home care practitioners. setting the alberta health services, north zone is 479,509 square kilometres (1,220 kilometres from north to south and 640 kilometres from east to west) and covers 73% of the canadian province of alberta (see http://www.albertahealthservices.ca/north-zone.asp for further information). the 2012 population was 412,081 with 35,402 (8.6%) persons over the age of 65 years (alberta health services, 2012). thirty-eight publically-funded community home care centres servicing a total of 5,659 clients are located in the north zone. sixteen per cent of older adults in the north zone receive home care services (t. woytkiw, clinical lead, personal communication, september 20, 2011). in 2010-11, 2,824 long term home care clients were assessed using the resident assessment instrument-home care ([rai-hc], hirdes et al, 2004) and 862 (30.5%) scored >2 on the cognitive performance scale ([cps], hartmaier et al, 1995), indicating some degrees of cognitive impairment (w. harrison, vp rural health, personal communication august 3, 2011). two publicly funded home care centres were selected based on an administrator’s suggestion and staff’s willingness to participate in the study. due to the large geographical area of the north zone and long travel distances, these two centres were approached to participate as they were within 30 km of each other and had relatively larger numbers of staff. the community characteristics are outlined in table 1 with the centres coded as a and b to protect their identity. both communities meet the statistics canada definition of rural with populations under 10,000; both are located within an hour drive of an urban setting. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 124 table 1 community characteristics of two rural communities (a and b) community a community b population in 2011a nearly 5,000 ~4,500 % 65+ in 2011a 25% 26% median age in 2011a 44.1 45.0 distance to major centre b >80 kms >80km major industryc-d agriculture, followed by retail, oil & gas, lumber & coal agriculture followed by lumber, oil & gas, manufacturing & retail trades 2006 community profile % labour force participation ratee-f 57% 60% % unemployment ratee-f 4% 3% % population aged 15+ reporting hours of unpaid care of assistance to seniorse-f 19% 22% median after-tax income – all census families, 2005e-f ~$43,000 ~$51,000 % member of visible minoritye-f 3% 3% % aboriginal identitye-f 7% 4% health services # of gpsg 15 9 # of active treatment bedsc-d 62 35 # of long-term care bedsc-d 120 100 # of supportive living spaces/roomsc-d 20 40 note: adapted from: a statistics canada (2012). b mapquest.com (2013). c alberta community profiles [centre b] (2013). d alberta community profiles [centre a] (2013). e statistics canada [centre b] (2007). f statistics canada. [centre a] (2007). g alberta health services. (2012). physicians. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 125 in one community the home care centre is located in an acute care hospital and in the other it is in a free standing building. home care practitioners include regulated professionals such as nurses, licensed practical nurses, and allied health professionals, and unregulated workers such as health care aides. nurses make up the largest proportion of personnel. home care services are most commonly delivered in the home but may be delivered in other settings. client and family caregiver needs are assessed by a case manager using the rai-hc (hirdes et al, 2004) that focuses on clients’ cognition, mood, behaviour, physical functioning, continence, nutritional status, health conditions, informal support, use of health services, and environment. based on this evidence, care plans are developed and outcomes monitored to determine the type and amount of services needed. services are provided at no or low cost to the client and family. case managers may also assist clients to access medical supplies or assistive equipment and technology. home care professional services include assessment, treatments and procedures, rehabilitation, medication administration, palliative or end-of-life care, teaching and supervising self-care and care provided by family members and home support service providers. personal care services include assistance with hygiene, oral care, dressing, toileting and incontinence management, mobilization and transferring, and medications. other services include caregiver support and respite services (alberta health services, north zone, 2013). method the promoting action on research implementation in health services (parihs) framework (harvey et al., 2002; kitson et al., 1998; kitson et al., 2008; mccormack et al., 2002; rycroft-malone et al., 2002; rycroft-malone, seers, et al., 2004) was used to inform this research. the parihs framework considers: (i) the evidence and knowledge being used, (ii) the context, and (iii) how use of the information is facilitated. because of the importance of context online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 126 in facilitating the use of research evidence in practice, context is specifically examined in this study. the framework includes the following dimensions as comprising the context of a work setting: culture (kitson et al., 1998; mccormack et al., 2002; rycroft-malone et al., 2002), leadership (mccormack et al, 2002), evaluation (kitson et al., 1998) and resources (rycroftmalone, harvey, et al., 2004). a qualitative interpretive descriptive approach (thorne, reimer kirkham, & o’flynnmagee, 2004) was used and involved focus groups conducted in the two home care centres. ethical approval was received from the university of alberta, health research ethics board, study id pro00035496. all home care clinical leaders, managers, nurses, allied health workers, and health care aides (n=48 full time equivalent positions) in the two home care centres were sent an information letter outlining the study’s purpose, expectations, and benefits. two focus groups (a=6, b=8, total n=14 individuals) were held during working hours. participants were females between the ages of 25 to 61 years. eleven participants had received a diploma in nursing or held a baccalaureate degree in nursing; the group subsequently is described as rural home care nurses while recognizing that three of the 14 participants were not nurses; one was an occupational therapist and two were health care aides. equal numbers of participants worked full time and part time. the number of years working as a nurse and working in the community varied greatly from two months to 35 years, and two months to 33.5 years respectively. most of the participants who worked directly with clients ‘mildly agreed’ that their training adequately prepared them to care for individuals with dementia. this is a concern as participants also reported that 25% to 90% of clients presented with memory problems (table 2). table 2 focus group participants socio-demographic data demographic n online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 127 demographic n gender: female male 14 0 age :1 <40 41-50 51-60 >61 3 5 2 3 education: 1 certificate diploma undergrad degree 1 5 7 current work: health care aide registered nurse case manager/rn occupational therapist director/rn 2 2 7 1 2 employment: 1 full time part time casual no answer 5 5 2 1 online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 128 demographic n how long working in your profession? 1 <5 years 6-10 years 11-20 years 21-30 years >31 years 3 2 4 2 2 how long have you been working in this community? 1 <5 years 6-10 years 11-20 years 21-30 years >31 years 5 3 3 1 1 how many clients currently on your caseload? 1 <20 21-40 41-60 >61 n/a 1 5 1 2 4 approximately what % of your clients has memory problems? 1 <30% 31-50% 51-70% 71-90% 2 1 3 3 online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 129 demographic n n/a 4 my current level of knowledge and training has adequately prepared me to care for persons with dementia: 1 strongly disagree mildly disagree unsure mildly agree strongly agree 1 2 2 7 1 1one participant did not submit the socio-demographic form. semi-structured questions that reflected dimensions of home care context were used to guide the audiotape recorded focus groups. examples of these guiding questions included: leadership questions: • how would you describe your leaders? • do your leaders usually tell you what to do, or did they usually ask you what you thought needed to be done? • do those in leadership positions facilitate your access to dementia care information? culture questions: • how would you describe your work culture, i.e., “the way you do things”? • do you belong to a supportive work group? • are your colleagues receptive to learning about new information on dementia care? • do you have opportunities to attend professional development activities? • would you say that things are continuously improving in your workplace? online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 130 feedback questions: • do you or your team routinely use the rai-hc data or other data to formulate your care plans and to evaluate performances? • how is performance evaluated in your organization? connections questions: • would you say that there is a great deal of open communication and sharing of information in your workplace? • with whom do you have client care related discussions? • are your concerns about client conditions taken seriously by those in positions of authority? structural and electronic resource questions: • what types of information do you find most useful in supporting individuals with dementia and their caregivers? • how do you determine the trustworthiness of this information? • do you have the people, space, time, and money needed to make use of best available dementia care information and/or to make the needed changes? transcripts were coded using lubrosky’s (1994) thematic analysis. main ideas and topics were identified by individual members of the analysis team (principal investigator and her research assistants) and coded using key phrases that emerged from the data. to ensure rigor, these preliminary conceptualizations were shared with the analysis team as a whole for development and refinement of the themes and patterns, to ensure that the conceptualizations reflected the data presented by the study participants and to encourage the emergence of multiple perspectives around the interpretation of data. the codes were grouped into themes (a higher online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 131 conceptual level) and sub-themes. by comparing and contrasting the coded data, sub-themes, themes, interrelationships, and patterns were revealed. to promote trustworthiness, the following criteria were adhered to: credibility (peer sharing during team meetings); confirmability (use of an audit trail); and transferability. transferability refers to the use of “thick description” to enable others to determine whether the concepts are similar enough to make a transfer to other contexts or time (lincoln & guba, 1985). findings the findings are described in eight broad contextual themes. these include both positive and negative dimensions that influenced rural home care nurses’ use of best available dementia care evidence. location of home care centre in the home care centre located in the local acute care hospital, the proximity to other health care practitioners involved with their clients was identified as promoting the sharing of evidence. “we have a much better rapport with the doctors…we communicate with outpatients...now we can walk physically down there and say… we’re sending them to you...it’s a much better open line of communication” (b, p.17). there was no mention of positive or negative aspects of office location by participants from the home care centre in the free-standing building. challenges in using the rai-hc the staff used the rai-hc (hirdes et al, 2004) to assess clients, develop care plans, and monitor outcomes. the rai-hc also assisted in determining case load assignment among staff working in different geographic areas. however, challenges were reported as participants had difficulty completing the rai-hc in a timely manner. one participant explained that she online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 132 developed her care plan and put in the services prior to completing the rai-hc. “well i think it’s backwards…i have to admit them [clients], make the care plan but i’m not obligated to do the rai for two weeks. [by then], my care plan’s done, like i’ve already decided what my service provision issues were” (a, p.27). nurse case managers found that completing the rai-hc took up most of their time. “it just got to the point where i was so upset about the amount of time spent on the computer versus actual patient care that i decided i needed a different job. so now i work casual and it’s wonderful…i get to do all the patient care” (a, p.30). also, the registered nurses were concerned they were being replaced by licensed practical nurses to provide frontline nursing care that involved the exchange of best available dementia care evidence. “they’re keeping our hands away from the patients” (a, p.31). the rns were spending most of their time at their computer completing the required rai-hc. according to participants, in the near future, the rai-hc will be used across the province to determine staffing ratios based on the number and type of clients assessed. one manager explained, “they’re going to start funding us in a year depending on our rai scores and caseloads. it’s the completed up-to-date rai that they look at. so the fact that we’re 100 [assessments] behind, those 100 don’t exist… so we get zero funding for them” (a, p.28). receiving decreased funding will only intensify the perception of unavailable resources. availability of resources the lack of available human resources played a significant role in participants’ ability to access, assess, adapt, and apply best evidence. “we just don’t have enough hands” (b, p.16). “there’s not a lot of time for proactive thinking…it’s reactive” (b, p.15). most home care nurses are generalists, meaning “you can have everybody coming across your radar” making it difficult to stay up-to-date on the latest evidence related to a wide range of conditions. there was a lack online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 133 of access to specialized dementia care knowledge and/or expertise; “we have a specialist team in palliative care but we don’t have a team for dementia” (b, p.4). “our geriatric, psychiatric nurse does some dementia-related things. [however], we have one, for a large area” (b, p.2-3). in addition, “some people [clients], myself included, are not that great at looking things up on the internet, or they don’t have a computer available. we don’t have handouts to give them, or that nice booklet to give them anymore and sometimes i photocopy some of my old information which might not be current” (b, p.37). there was a sense of helplessness among the participants, “we have nowhere to go, you can’t get help from other facilities, there are so many criteria to get people assessed or to get help; once you’ve accepted somebody, it’s your problem; very few resources” (b, p.1). participants also described available educational resources. these included “supportive pathways” (a, p.53) and alberta health services insite (internal website), “although [insite] is better than it used to be, it’s still really hard to find, unless you know exactly the right search words” (a, p.53). in-house, tele-health sessions, and webinars were more accessible to the staff as in-services external to the organization were too costly (a, p.17; b, p.19). face-to-face orientations and practice sessions on how to support individuals with dementia and their caregivers were considered most valuable (a, p. 25; b, p.37, p. 41). participants also tended to seek dementia care advice from more experienced home care nurses (a, p.52). one participant summed up her experience with “we’re resourceful with limited resources” (b, p.11). dementia care community resources, such as support groups and day programs, were also lacking. “what’s also useful is for the caregivers to have some kind of a venue or support group where they can receive support for themselves. there’s nothing here” (a, p.49). “another big resource that’s missing in this town is transportation. if we had a day program, wonderful; how online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 134 do we get people there?” (b, p.43). the lack of formal day programs that provide respite for family caregivers and support for the individuals with dementia, and the lack of public transportation may also limit adherence to practices that reflect best available dementia evidence. relationships in a rural community living and working in a rural community may mean that the home care nurses and other health professionals personally know, or are related to, their clients. close relationships within a small community may enhance the exchange of evidence while at the same time make it difficult for home care nurses to separate their personal lives from their work. “we try to provide equal services…whether it’s your friend’s grandma…it can be tough” (b, p.22). “we’re talking of a rural area where these doctors know these families, know every part of their family and have real relationships…we try to be equal to everybody, but from their end, it doesn’t always work” (b, p.21). in addition, “these relationships are not terminated when the client is discharged from home care. if you’re in the bigger centre, you know you can wash your hands of that person once they’re placed and you’ll never see them whereas here you go to the grocery store, they come to outpatients, and they’re back at you again” (b, p.22). “we keep people in their homes as long as possible” (b, p.1) [by trying] “to let people do what they can [rather than do for clients] and it’s just taking time for the physicians and public to come along” (b, p.24). care is provided based on the evidence rather than solely on clients’, caregivers’, and providers’ wishes. “so we do the best we possibly can and try to be equal to all” (b, p.24). however, the participants’ professional decisions regarding client care were not always to the satisfaction of family members. “people don’t like some of the best practices that we do. we promote independence. if you’re living in a lodge [supportive living] and you’re going out to do your hair or whatever, then if you need wound care, you should come” [to the home care online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 135 office] (b, p.22). “it’s difficult, we do our job… we try to be equal to all… we try to standardize… and it’s hard, i mean we get shouted at and they make us cry” (b, p.22). occasionally, participants perceived little recognition for their contributions to supporting rural families over extended periods of time, perhaps because they were considered a member of the family. “we just kind of fit in so then we’re forgotten about because it’s a natural course…look at what we’ve done, we’ve let this person and his family manage for so long that we’re just kind of a background thing. but on the other hand, that little card of thanks would have been nice” (b, p.14). this excerpt reveals the need for increased attention to the complexity of these relationships and the influence on the use of evidence. an additional challenge for the homecare nurses was feeling that their contributions to the care of individuals with dementia and their families were not respected by physicians. “do they, respect what we do? i would say not, i would say a resounding no, that’s another work in progress” (b, p.34). “due to the lack of respect to our profession…sadly, we are still hand maidens” (b, p.35). one participant explained that the values and goals of physicians and nurses differ. “the doctors don’t work for the organization that we work for, and they may have different ideas as to what best practice is…we’re concerned about sustainability and i don’t think the physicians are, they’re not concerned about cost” (b, p.20). advocating to physicians on behalf of clients also came with some risks: i have a lady that’s been sitting in an acute care bed for almost two months…because the physician will not sign a capacity [cognitive ability] assessment…we have empty beds in the long-term care centre that she could go to immediately…that’s time consuming, trying to hunt down physicians…they don’t want to hear your explanations…i was online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 136 warned to drop it because if not it would affect future interactions. yes, we’re often threatened if we advocate (a, p. 6-7). leadership positive descriptions of the leadership (i.e., directors) that promoted use of evidence within the two home care centres were reported as being: present and approachable, knowledgeable about the topic or willing to find the required information; honest and not micromanaging [staff]; using a positive, supportive approach that encouraged critical thinking; providing a prompt response that may include constructive criticism; providing opportunities for professional growth; and being recognized for a job well done. (a, p.10-12, 17; b, p.6-8, 14, 28) in addition, having a consistent person in charge was also identified as essential as frequent turn-overs in the leadership were disruptive to the staff. having “a manager that is the same discipline is important” (a, p.10, 12, 17; b, p.29) in facilitating sharing of best available evidence. team work within the home care centre participants described their team, which was composed of home care nurses, as “being on the same page, we’re not working against each other” (b, p.24), sharing the workload, freely supporting each other, reassuring, confirming, and “consulting with each other tremendously, and bouncing ideas off of each other” (a, p.14, 16, 18; b, p.11). an additional strength of the team was their perseverance in implementing best practices even when faced with differing practices of other professionals. “we definitely work together to make sure the safety of that client is foremost…we tend to break rules even if we have to sometimes…to keep them safe” (b, p.35). online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 137 one manager credited her team’s functioning to a culture of collaboration that embraced change. “we’ve embraced electronic charting, it’s probably because [name] is so positive as a team lead, embraced a lot of things that many home care teams have been struggling with, and i think we’re kind of a shining star in that way” (b, p.12). interdisciplinary collaborations the participants identified many health care professionals from other disciplines in their community with whom they regularly collaborated (a, p.38-41). in addition, they regularly organized and/or attended family conferences, staff meetings, and meetings with the assistive living staff and other partners. with new or challenging clients, home care nurses would attempt to arrange a family conference to ensure that consistency and best available evidence were incorporated into the care plans. otherwise, “we’re the go-between…you’re talking with the client about physiotherapy and then you’ve got to talk to the physiotherapist and then you’ve got to get back to the occupational therapist and then back to the family…so i find we’re doing a lot of being in the middle to try and coordinate all of this” (b, p.31). evaluations the absence of regular employee performance appraisals was a concern to several participants. “i have to say, i have never had a performance appraisal… i’ve been here for eight [years] and then we’ve had the rotation of managers which has been part of it” (b, p.28). a healthy work environment cannot be promoted when an employee does not receive a regular performance appraisal and the opportunity to explore strategies to improve in applying evidenced-based care (gaitskell, 2004). online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 138 one manager was interested in expanding the use of the rai-hc to evaluate the use of evidence to improve client outcomes. “how we’re doing or what our caseload is like or how we can prioritize…for all the input that you put in, to be able to pull something out that you can use as a grader, a bigger program planning tool...in terms of accreditation and evaluation” (b, p.26 27). practice implications the lack of resources in these two rural home care settings had a significant impact on home care nurses’ ability to access, assess, adapt, and apply best available evidence. funding is a critical issue. the chca (2013) reports that although there was a 55% increase in the number of people who accessed home care from 2008 to 2011, no province has followed through on its commitment to increase home care funding. the chca calls for a reallocation of funds to home care from acute care. reallocated home care funding targeted to dementia care may ensure greater numbers of staff with specialized training in dementia care and knowledge translation skills. home care nurses would be able to provide more preventive and maintenance services to better support family caregivers through the exchange of best available dementia care knowledge and not always be responding to crisis situations that require acute care services. adequately supporting families in keeping the individual with dementia at home for as long as possible is a cost-effective strategy for the health care system. the potential for complex relational issues that emerge when working and living in small northern rural communities needs to be addressed to enhance the exchange of evidence. possible approaches include: (a) exploring the issues through dialogue with rural healthcare professionals (including physicians and discharge staff in acute care) and community members; (b) collaborating to draft guidelines for dealing with common, recurring conflicts; (c) exploring, online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 139 assessing, and proposing models for resolving conflicts in these communities; and (d) developing and implementing knowledge exchange training curricula and other dementia care educational resources for and with rural practitioners, administrators, and policy makers (nelson, pomerantz, howard, & bushy, 2007). opportunities for dialogue among the home care nurses, administrators, and policy makers are needed to address the issues that the home care nurses raised related to the rai-hc. strategies to help staff and leadership build their capacity to effectively complete the rai-hc in a timely manner and to interpret and use all the client and caseload information it generates are needed. the leaders’ positive, supportive approaches, active listening, and willingness to mentor contributed to a vibrant workplace and promoted the use of dementia care evidence. these relational attributes could be described as reflecting ‘emotional intelligence’, which akerjordet and severinsson (2007) defined as “an ability that encompasses personal and social competence, in which the core values of one’s professional identity are reflected by self-awareness, emotional management, responsibility, authenticity, and empathetic understanding” (p. 1411). in addition, promoting a common vision such as “supporting clients to remain at home for as long as possible” is a central element of good leadership (cummings et al., 2008) and closely resembles 'transformational leadership' (mccormack et al., 2002). this form of leadership is reported to be among the most effective because leaders are able to transpose their ideas and beliefs into collective beliefs. these eventually become assumptions and part of a centre’s culture (mccormack et al., 2002) and can positively influence the transfer of best available dementia care knowledge. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 140 teamwork is critical to ensure the use of best practice evidence and reflects components of social capital: bonding, bridging, and linking. bonding refers to sharing information within a work group, bridging implies sharing information between groups, and linking refers to sharing client care issues with leaders. building social capital has been demonstrated to be negatively associated with emotional exhaustion which is a common occurrence in home care (chca, 2008). hofmeyer and marck (2008) encourage leaders to use ecological thinking to build social capital within their organizations by committing the necessary human and material resources to “(1) forge relations to foster bonding, bridging, and linking social capital; (2) build solidarity and trust; (3) foster collective action and cooperation; (4) strengthen communication and knowledge exchange; and (5) create capacity for social cohesion and inclusion” (p.144). evaluation of home care nurses’ evidence-based practice is also a critical domain of the home care context as it is necessary to meet accreditation and continuing care health service standards. it is an expectation that client data be collected annually or sooner if there is a change in client condition, and performance appraisals and team evaluations are expected to be completed on an annual basis. limited resources and isolation in the north zone lead to challenges in providing feedback to staff on an annual basis, and evaluating the processes and outcomes of client care. these important challenges merit further attention. study limitations transferability of the study’s findings may be limited as the data reflect the responses of a convenience sample located in two northern home care centres in alberta, canada. readers must assess the extent to which these findings are transferable to other settings and how applicable they are in other contexts. further research is needed using other approaches and in other settings. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 141 conclusions despite its limitations, this study illustrates how contextual dimensions influence the use of best dementia care evidence in rural home care nursing practice. most importantly, allocation of resources needs to reflect the unique demographic characteristics and pragmatic realities of northern rural home care settings. reallocated resources are needed in these settings. a shift in current resources from acute care to home care is long overdue since without adequate funding it is very difficult for home care nurses to use best available dementia care evidence. providing increased resources could promote further dialogue regarding the value and purposes of the raihc and assist in its timely completion and multiple uses. challenges were evident in exchanging evidence related to occasional difficult relationships with physicians, clients, and their family caregivers. where ubiquitous relationship challenges among stakeholders are exacerbated by environmental and contextual circumstances, there is a need for culturally-sensitive interventions and solutions. solutions may be found through meaningful dialogue and through the development and application of best practice guidelines. leadership and collaboration dimensions are fundamental to establishing a vibrant workplace where home care nurses actively develop and use their skills, knowledge, and abilities to provide and exchange evidence-based dementia care. these findings contribute to our understanding of the availability and less available contextual dimensions within northern rural home care centres that contribute to home care nurses’ ability to use dementia care evidence in these rural settings. online journal of rural nursing and health care, 15(1) http://dx.doi.org/ 10.14574/ojrnhc.v15i1.344 142 supporting agency funding for the study was gratefully received from the nursing research chair in aging and quality of life, university of alberta, edmonton, canada. the supporting sponsor had no involvement with the design, conduct, or writing the article. references akerjordet, k. & severinsson, e. 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(2006). development and validation of a derived measure of research utilization by nurses. nursing research 55(3), 149-160. http://dx.doi.org/10.1097/00006199-200605000-00001 microsoft word baker_505-3061-2-ce.docx online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 63 a bridge to understanding smoking among women in rural central appalachia: qualitative interviews with local nurses cathy jo baker, phd, rn1 sarah-catherine showalter, bsn, rn2 1 assistant professor, school of nursing, ohio university, bakerc2@ohio.edu 2 nurse resident, georgetown university hospital, ss537612@ohio.edu abstract the rural central appalachian area of southeast ohio has a persistently higher rate of tobaccorelated women’s health issues, low birth weight, and preterm birth than other parts of the state and the nation. nurses from appalachia can provide a bridge for health care providers who are not from the region to understand the perspectives of people who reside in central appalachian counties. the purpose of this study was to learn more about the influences and the special needs in central appalachia to inform women’s health promotion and smoking cessation interventions. method: semi-structured small focus group and individual interviews were conducted with 15 nurses working with women in rural central appalachia. participants were asked about smoking and smoking cessation in relation to their knowledge and experience of women in their home county. findings: major themes discovered included reasons for smoking, reasons for quitting, barriers to quitting, and perceptions of current interventions. the influence of the rural social environment on smoking, such as smokers in the social network and ambivalence toward the dangers of smoking, were particularly emphasized. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 64 conclusions: the particularly strong influence of the social environment is a force for change that must be considered in women’s health promotion activities in this area. tips for quitting smoking in public health service guidelines may be more discouraging than helpful for women in the region according to study participants. using the information gathered, smoking cessation interventions for rural women in this region should incorporate salient issues such as the social environment, smokers in the household, and the desire for gradual smoking cessation. the data suggests that the social context of smoking may dramatically affect smoking cessation efforts in this region. keywords: smoking cessation, women’s health, appalachia a bridge to understanding smoking among women in rural central appalachia: qualitative interviews with local nurses cigarette smoking is the leading preventable cause of disease and death in the united states causing 480,000 premature deaths and $170 billion in direct medical costs annually (u.s. department of health and human services [dhhs], 2014). about 40 million people in the united states still smoke (16.8%), with smoking prevalence the highest among those with less education (ged 43.0%) and the lowest among those with a graduate degree (5.4%) (centers for disease control and prevention [cdc], 2015). in the united states, rural tobacco use is generally higher than in urban areas (american lung association, 2012; doescher, jackson, jerant, & hart, 2006; roberts et al, 2016). smoking rates in ohio appalachian counties (35.2%) are significantly higher than in rural non-appalachian ohio counties (23.3%), as well as in urban and suburban counties (ferketich, wang, & sahr, 2012). the central appalachian ohio counties that formed the setting for this study are categorized online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 65 as rural by the us department of agriculture. these counties were given the non-metro county rural-urban continuum codes of either 7-urban population of 2,500 to 19,999, not adjacent to a metro area or 9 -completely rural or urban population of less than 2,500, not adjacent to a metro area (usda, 2013). this region is also considered to be part of central appalachia by the appalachian regional commission [arc], (2015). rural central appalachia has a relatively high rate of tobacco-related women’s health problems, including low birth weight and preterm birth compared to other parts of the state and the nation. most of the counties in this area have 21-40% of the population living in poverty, compared to the national average of 15.4% (appalachian regional commission [arc], 2015), which is of special concern as persons living below the poverty level have a higher smoking prevalence (26.3%) than persons at or above this level (15.2%). prenatal smoking continues to be one of the most common preventable causes of infant morbidity and mortality in the united states, including pre-term birth and low birth weight (dietz, et al., 2010; seybold, broce, siegal, findley & calhoun, 2012). in an analysis of hospital birth data in southern appalachia, bailey and cole (2009) found that women from rural counties had significantly more low birth weight and pre-term infants. further, these negative birth outcomes have been shown to be associated with smoking rather than poverty alone. chertok, luo, and anderson (2011) found in a study with central appalachian women that those who smoked during their first pregnancy, but quit before their second conception, gave birth to a healthier subsequent child. smoking during pregnancy is a particular problem in ohio, with 16.3% of women still smoking in the third trimester (odh, 2012), twice as high as the national rate of 8.4% (curtin & mathews, 2016). ohio has the highest number of women smoking during pregnancy in the nation (curtin & mathews, 2016). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 66 women often are motivated to quit tobacco use during pregnancy out of concern for their health and the health of their fetuses. however, regional differences persist as compared to the national average of 10% of parturient women smokers, the proportion of appalachian ohio pregnant women who continue smoking at time of delivery is as high as 25-35% (odh, 2012: wolfe, 2011). no qualitative studies published in the past 10 years were found regarding smoking during pregnancy in appalachia. in a qualitative study with adult smokers and former smokers in appalachian kentucky, kruger (2012) found a mismatch between perceptions of smoking cessation interventions and standard interventions by healthcare providers. a qualitative study in appalachian ohio among current and former adult smokers found that family and personal independence were especially important factors in this region (ahijevych et al., 2003). outside of appalachia, britton and colleagues (2017) found in a qualitative study with rural pregnant smokers and their health care providers that the women felt the providers were somewhat insensitive to their needs. the providers felt that they were doing their best with the knowledge that they had. a synthesis of eight qualitative studies in english-speaking countries with various types of healthcare providers showed that participants felt that the professional role could act as either a barrier or a facilitator to providing smoking cessation support to pregnant women (flemming et al., 2016). this synthesis also found that the 190 participants across the 8 studies did not think they had adequate knowledge of how to help women in disadvantaged circumstances to quit smoking. a number of published qualitative studies focused on smoking in the perinatal period in nonappalachian populations. a systematic review of 38 qualitative studies with perinatal smokers in english-speaking countries found that the major factors influencing smoking cessation were online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 67 psychological well-being, significant other relationship, connection with the infant, and appraisal of risks of smoking (flemming, mccaughn et al., 2015). a qualitative study with 24 pregnant smokers in scotland found that the social network was an important influence on smoking cessation during pregnancy, but this influence was perceived by the women as providing both facilitators and barriers to quitting (koshy, mackenzie, tappin, & bauld, 2010). a systematic review of nine studies with the partners of perinatal smokers in english-speaking countries showed that the factors affecting the partner to support or hinder the woman’s smoking included similar factors to those found in studies with the women themselves: the couple’s relationship, perception of smoking risks, and thoughts of being a parent (flemming, graham et al., 2015). qualitative interviews with nurses in southeast ohio were conducted to gain their insights on the smoking status of women in this region. nurses are an important bridge for understanding the cultural context and perspective of women in the communities they serve. in this role, nurses can positively impact health behaviors such as smoking cessation among women in central appalachia. this study targets a significant health threat that disproportionally affects rural women (and their offspring) who are poorer socioeconomically, less well educated, and more susceptible, in general, to greater and more adverse health risks. our study is consistent with the national institute of nursing research emphasis on the design of culturally-appropriate interventions to eliminate health disparities and addresses the recommendation by the surgeon general’s clinical practice guideline for treating tobacco use and dependence to increase research on smoking cessation interventions in minority populations, especially women (fiore et al., 2008). this guideline includes the 5as method which is recommended by the american congress of obstetricians and gynecologists (acog). the purpose of this study was to bridge the gap between researchers and online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 68 southeast ohio residents, tapping into the perspective of nurses from southeast ohio on the perceived barriers to quitting, perceptions of interventions, and the influence of location and cultural environment on tobacco use to learn the specific needs in appalachian women. method data collection purposive sampling was used to recruit nurses who are from southeast ohio and who work in this region with women. care was taken that the participants were not from the same social network and to include nurses who represented different counties in the area and different age groups. once identified through community sources, the nurses were sent an informational e-mail offering participation in the study. participants represented 6 counties in the southeast ohio region. semi-structured individual interviews and one small focus group were conducted until saturation of data was reached. participants completed a demographic and smoking history questionnaire prior to being interviewed. an interview guide was used by the interviewer with questions about the nurses’ knowledge and experience related to counseling women about smoking and smoking cessation in general and during pregnancy. participants were also asked about their perceptions and beliefs regarding smoking in their home county. participants received a $5 food gift card as a thank-you gift. interviews were audiotaped with no names or other identifiers used. the university institutional review board approved the study before recruitment began (protocol #13e036). data analysis interviews were audiotaped, then transcribed verbatim. after a comprehensive review of the transcripts, an inductive method was used to code responses with the organizational aid of nvivo 10 qualitative data management software (qsr international, 2012). a southeast ohio online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 69 native who is a nurse was on the analysis team. content analysis involved extraction of major concepts, themes, and patterns. two persons independently analyzed the data. the coding agreement was then compared and differences resolved by consensus of the coding team. the data management software helped to assess how many comments and how many participants were coded under each node to identify the major themes and subthemes. sample study participants were 15 white female nurses who grew up in southeast ohio and still lived in the area. their age range was 21-44 with an average age of 30 years. self-reported smoking history showed that 50% were never smokers, 16% current smokers, and 34% were former smokers. education: 17% associate’s degree, 58% baccalaureate degree; 25% master’s degree. all of the participants were working as a nurse. they were working in or had worked in a women’s health setting within the past 10 years. results themes fell into 4 major categories: reasons women smoke, reasons women quit, barriers to quitting, and perceptions of current interventions. subthemes revealed ambivalence toward tobacco use, the difficulty of quitting tobacco with smokers in the household and social network, and reactions for people in this region to current smoking cessation guidelines. table 1 shows themes, subthemes, and representative quotes. table 1: summary of qualitative themes themes subthemes quotes online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 70 reasons women smoke stress management “that’s what i use for stress relief.” “…because that was my stress release, so i’m like ‘somebody better find me a cigarette before i take this computer out to the highway out here” social environment “and i think it’s a big part of life for a lot of people in this county… that’s just what they do.” addiction “and then they’re addicted and can’t stop even if they wanted to.” “and i would say first and foremost they just want their baby to be healthy. they fight that, between that and the addiction – i think it’s the two directions they are pulled in.” reasons women quit health “we all know it’s bad for you, i learned that in kindergarten! that’s why it surprises me that so many people my age smoke.” financial pregnancy “some say the cost makes them want to quit, but most people seem like they always can get money for cigarettes.” “probably health of their baby” barriers to quitting social environment smokers in the household “they like to know people and those connections are very important to the sense of security and their place in the world.” online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 71 ambivalence about dangers of smoking “being isolated from friends and family that smoke is a very painful experience and may have material consequences, like on living quarters.” “my aunt’s obstetrician told her that after a certain time in the pregnancy the stress of quitting is more harmful than continuing to smoke…she quit anyway.” perception of current interventions quit date “i think setting a goal is helpful, but 2 weeks seems like a very short time to get used to not smoking.” total abstinence “people i know that have quit has done it gradually.” “it wouldn’t be as scary to them to think about extending how many hours they could go. this week you are going to extend it this amount of hours, the next weak or after you will stretch it out a little more. i think it would be less intimidating and they would maybe have more hope that they could do it.” remove tobacco from your environment “my family defined your everything…we grew tobacco on the side, in the 80s we could get a good price. at the age of 15 you were allowed to start smoking, all of us, … smoking at once. still a major part in a lot of my family members’ houses.” online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 72 reasons women smoke in home county it is important to consider the perceived benefits of smoking in interventions so that the benefits of quitting are seen to outweigh the benefits of smoking. stress management. so she stopped both times she was pregnant, but she still smokes now. she smokes more now than she ever has. she says that she likes being able to take, she views it as taking a break, so it’s kind of like – she’s had a stressful day at work, it’s like as soon as she gets in the car she lights up a cigarette and that is an instant relief for her. many of the participants talked about stress relief relating to poverty and smoking being one of the few coping resources: “like being impoverished – it’s harder to be resilient, and harder to have as many coping skills.” a number of quotes also mentioned stress relief as a reason for picking up smoking again after quitting, even when using nrt or other meds. “…so i quit for nine years and then i got divorced and started smoking again” if i don’t have it, then i’m a nervous, yeah, i’m a nervous wreck. so you know i think it’s just the person. it depends on the person, and i think a lot of people use it for that. i mean i don’t know about you guys, but i come from a low socioeconomic background and that’s all we had. coping with the stresses of poverty was frequently mentioned in the context of reasons for smoking, such as the following comment regarding food insecurity: well that’s like for me growing up, though, you know. the only time we had food was the first of every month, and then you had nothing towards the end of the month ‘cause you were hungry. then the first of the month you had food. i have food all online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 73 the time. my cupboards are full all the time because i make sure that my kids are gonna eat, you know. so i don’t have a shutoff valve anymore. and then my cigarettes stopped me from doing that. social environment. “well i think that it’s part of the culture; that people have seen their grandparents, uncles, cousins, friends smoke. and so it is something that i think they have been socialized into for a very long time.” “i am a current smoker… and i think all my kids smoke, so i don’t think it has broke the cycle any, so.” some of the comments coded here fell into more than one of the main codes. that is, many of the quotes about the social environment represented both a reason people smoke and a barrier to quitting. also, many of the quotes show the intertwining of social environment with other reasons for smoking: “and i think it’s a big part of life for a lot of people in this county… that’s just what they do. that’s what i use for stress relief.” a subtheme within the social environment supporting smoking was the tradition of growing tobacco in the region: “we have a lot of farmers, … tobacco is a big crop for some of them. still a lot of people grow tobacco in this area.” “my grandparents grew tobacco on their farm, i remember helping when i was a kid. they were good, hard-working people…tobacco money got them through a lot of hard times you know.” addiction. addiction was recognized by all the participants as a main reason people continue to smoke. their comments reflected a sense of powerlessness over nicotine addiction: “and then they’re addicted and can’t stop even if they wanted to.” questions about the use of nicotine replacement or other medications to aid withdrawal revealed the complicated nature of quitting. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 74 i know i tried the chantix. it worked until i got really stressed out because my computer crashed and i had a paper due and i’m like ‘okay, somebody find me a cigarette,’ because that was my stress release, so i’m like ‘somebody better find me a cigarette before i take this computer out to the highway out here,’ but i mean it did work. it [chantix] worked and so did the patches, but it just seems like that’s just my stress relief. that’s what i do. this comment shows how these three major reasons for smoking are intertwined: …it just seems like it’s so prevalent, but so is poverty; so i don’t see that their poverty is keeping them from smoking. i don’t know why not, because gosh what other things could they do with that money, but i don’t think that they recognize, or it’s just so normal that they think about, or i guess they’re so addicted that they can’t stop if they wanted to. reasons women quit health. health was the first reason everyone gave for reasons that people in their home county want to quit smoking. as a 22-year-old participant put it: “we all know it’s bad for you, i learned that in kindergarten! that’s why it surprises me that so many people my age smoke.” a number of comments pointed to public health information campaigns and individual health care providers as the impetus to change for health reasons: “a respiratory therapist scared my mom. that’s why she quit smoking. and whatever he said to her, she quit smoking and she’s not turned back.” however, just as many participants stated that they have seen many cases where health warnings were ineffective: online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 75 my dad has severe copd and he still smokes despite the oxygen and everything else, so it’s still a big part. my sisters refuse to quit smoking. they say, yeah, just sinus problems. they don’t have copd or lung problems. financial. the cost of cigarettes was the second most common reason given for wanting to quit. however, these comments also noted that finances do not seem to really curtail smoking in this region: “some say the cost makes them want to quit, but most people seem like they always can get money for cigarettes.” “so almost everyone is on some type of [public] assistance and has very little cash, but somehow manage to get those cigarettes, so i don’t know.” pregnancy. pregnancy was brought up by the majority of participants as a reason that some women quit smoking in their county. “probably health of their baby. and i would say first and foremost they just want their baby to be healthy. they fight that, between that and the addiction – i think it’s the two directions they are pulled in.” however, these comments included some doubt: “i would say some quit while they were pregnant, some reduce the amount that they use when they are pregnant, and some it doesn’t affect their use at all.” the participants’ comments pointed to a lack of knowledge among women about the dangers of smoking during pregnancy. the following quote also demonstrates the ambivalence toward smoking: they might not realize it is all the way through, you know you can have effects the entire time, it’s not just in the last trimester. you know things like that, i don’t think that they’re educated on that stuff and i feel like it is kind of okay, because hey you could be doing something much worse around here; there are lots of other things you can get your hands on, and cigarettes are legal. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 76 barriers to quitting social environment. the social environment was mentioned by all the participants not only as generally encouraging smoking, but also as a barrier for those who are motivated to quit. “they like to know people and those connections are very important to the sense of security and their place in the world. being isolated from friends and family that smoke is a very painful experience and may have material consequences like on living quarters.” the cultural value of independence was reflected within the comments on social environment relating to acceptance of advice and help to quit smoking: “they are friendly superficially, but generally want to take care of their own problems and don’t want to let outsiders into their lives.” “and then on top of that i think people are more proud, and so they’re not always accessing help that’s available.” and i don’t know about y’all, but growing up in my county, i was a troublemaker. if you told me i wasn’t gon’ do something, i was gon’ do it, regardless of whether you liked it or not, and i think that’s part of the culture down there: ‘don’t tell me what i’m not gon’ do.’ online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 77 smokers in the household. i see that when i work with women who are pregnant, they might be very motivated to stop smoking, but their environment is one where it’s very difficult not to be smoking. so i’ll have a woman tell me that the people in her household are smoking, or at work, or whenever she wants to take a break, it’s a smoking break, that’s what people are doing on their breaks. so it’s part of this social network of smoking that is going on. so that’s really difficult. some of the women that i work with have pointed specifically to their partner, that their partners smoking habit directly affects them. ambivalence about the dangers of smoking. the majority of participants alluded to an ambivalence in the region, even among healthcare providers, about smoking. “at the hospital, if you smoke you get a break to smoke, it’s understood. my friend lied about being a smoker so she could get a break with the smokers, that’s how she started smoking.” these comments extended to smoking during pregnancy: “my aunt’s obstetrician told her that after a certain time in the pregnancy the stress of quitting is more harmful than continuing to smoke…. she quit anyway. but, i’ve heard a lot of women say that.” many participants talked of the belief that smoking is less harmful than other substances: “i think that the focus in that point in time is getting them off other chemicals; alcohol and the harder drugs, and smoking is not viewed as, as big of an issue. deal with one problem at a time.” perception of current interventions most smoking cessation interventions are based on the united states public health service guidelines and tips for smoking cessation. the major tenets of these guidelines include to set a quit date within two weeks, the need for total abstinence (not even a single puff), and to remove online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 78 tobacco from your environment (fiore et al. 2008). the 5as intervention (ask, assess, advise, assist, arrange) is part of this practice guideline and is widely used in this region. healthcare providers in rural appalachia have to be trained in the five as program. they need to know the practical ways of how to help women stop smoking, and not just telling them “you have to call the quit line”. for some women that’s effective, but some women either can’t afford to call the quit line, even though it’s a free line, because they may not have free minutes on their phones, and then they might not have the time to sit there on the phone, they might want a more personal interaction. and so i really think it’s important to have… and again i think it might be cultural also in rural appalachia that the face-to-face time is important. so i think it’s hard when all your peers and family members tend to be smokers. i think that’s a harder barrier to overcome, because it would be considered the normal. uhm. i think it’s good to anticipate what type of withdrawal symptoms you might have so that they can identify with those, instead of just feeling frustrated. tips for successful quitting: total abstinence is essential – i get the theory behind it. i think smoking is a tough one sometimes, and i would say that that would be the end goal, that would be really great. but if we could get them from a pack a day, down to four cigarettes a day that would be amazing. so setting like obtainable goals for them personally. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 79 positives of region: why do you stay? social connectedness. it is important to remember that the culture of this region has many positives. the final question in the interviews regarded the reasons these nurses stay in the region. all of the participants cited social connectedness. a 22-year-old woman replied: well, i don’t want to put down [big city], but, it’s different there. down here people are nicer, they care about each other. in this county, i’d be hard-pressed to find a part of it that no one would help me if i was in trouble, car broke down, whatever. discussion reasons women smoke stress management is often cited in various cultural and demographic groups as a main reason people continue to smoke despite the health and financial negatives. the many comments in the data that cite stress management as a reason for starting smoking again after long smokefree periods underlines the importance of psychosocial portions of cessation interventions. one would think that once the physical nicotine addiction is overcome, there would be no reason to return to smoking. this issue supports the importance of psychological addiction in smoking behavior (japuntich et al. 2011). the stresses of poverty were included in this category as factors that affect smoking behavior. our participants emphasized the role of the social environment to continue smoking more than as an anti-smoking force. reports of ambivalence toward smoking, even during pregnancy and among some healthcare providers, emphasizes the pervasive acceptability of smoking in this culture. windsor et al. (2014) found low receptivity to trying to quit among appalachian women who smoked during pregnancy. this reluctance to even try to quit during pregnancy seems unusual in our time. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 80 environmental smoking and attitudes of family, friends, and co-workers toward smoking in a cultural group have long been shown to impact individual smoking choices. partner support and availability of general support has been associated with success in smoking cessation, while a social network containing smokers deterred the maintenance of cessation (mermelstein et al., 2000). our results agree with the qualitative findings with pregnant smokers in scotland that the social network was an important influence that was perceived by the women as providing both facilitators and barriers to quitting (koshy, mackenzie, tappin, & bauld, 2010). there are no published research findings that describe potential differences in benefits of smoking, barriers to quitting, or preferences for interventions between appalachian men and women. however, the context of smoking may differ between genders. appalachian women have higher risk of poverty and less educational attainment than men (thorne, tickamyer and thorne, 2005). therefore, the smoking cessation needs of appalachian women may differ from men. reasons women quit our results agree with a synthesis of eight qualitative studies in english-speaking countries with various types of healthcare providers that showed that participants felt that the professional role could act as either a barrier or a facilitator to providing smoking cessation support to pregnant women (flemming et al., 2016). these healthcare providers pointed to the importance of maintaining a positive patient relationship while navigating the complications of the relationship between smoking and social disadvantage. regarding pregnancy as a reason to quit, appraisal of the risks of smoking has been found in a number of qualitative studies with perinatal smokers in english-speaking countries (flemming, mccaughn, et al., 2015). a systematic review of nine studies with the partners of perinatal smokers in english-speaking countries showed that the factors affecting the partner to support or hinder the woman’s smoking included similar factors to those online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 81 found in studies with the women themselves: the couple’s relationship, perception of smoking risks, and thoughts of being a parent (flemming, graham, et al., 2015). barriers to quitting/perception of current interventions. differences in use and beliefs about smoking among appalachian ohio women are associated with family factors, an entrenched cultural use of tobacco, poverty, and other influences associated with health disparities. specifically, rural appalachian women have less access to community services than women who live in metropolitan areas, and frequently lack transportation to the nearest services (wewers et al., 2012). appalachian women seem to have fewer non-smoking role models, and often do not get social support from family members to quit tobacco (thomson et al., 2016). the only qualitative study found that was conducted in appalachian ohio among current and former adult smokers found that family and personal independence were especially important factors in this region (ahijevych et al., 2003). in appalachian ohio, an individual’s change in behaviors seem to be rooted in the home, family, and trusting relationships. these distinguishing characteristics may require a more population-specific model of smoking cessation intervention in central appalachian women. many participants talked about the history of tobacco farming in the region including personal memories of family members’ and ancestors’ involvement in tobacco production. the public health efforts that vilify tobacco and shame smokers may backfire in this region where tobacco is not only a behavioral tradition, but also an agricultural tradition. when tobacco is being depicted as dirty and shameful, many people in this region may be thinking of their grandparents’ or parents’ tobacco farm. some of the tips for quitting smoking given in the public health service guidelines (fiore et al. 2008) may be more discouraging than helpful for people in this region. for example, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 82 financial and social factors in this area may make limited choices for who is in the household. thus, telling a woman to not let anyone smoke around her is putting an impossible expectation on her in many cases. other factors in the guidelines may be less helpful for people in rural appalachia, such as the financial incentive of spending less on cigarettes. this financial incentive seems to be less convincing in an economically disadvantaged population, but the reasons for this are unclear (farrelly & shafer, 2017). our results support a cut-down-to-quit model of smoking cessation, which has shown success in appalachia (windsor et al, 2014). although gradual cessation is not part of the national health service guidelines, seybold (2012) showed that reduction of smoking during pregnancy improved outcomes in a sample of central appalachian women. graham (2014) showed in a meta-synthesis that most of those interviewed found reduction for gradual cessation to be useful among pregnant women in english-speaking countries. self-reported smoking history of the nurses in our sample showed that 50% were never smokers, 16% current smokers, and 34% were former smokers. no data was available regarding the smoking rates among nurses in the region of this study. however, comparison of our sample with national data from healthcare providers reveals that the smoking rate of these local nurses is higher. sarna (2014) found that 7.09% of registered nurses were current smokers, 16.77% former smokers and 76.14% never smokers in a national sample of healthcare providers. there were a number of comments from participants that referred to smoking being a lesser of evils that may decrease illegal drug use. in addition to the recent national focus on opioid addiction, in the last 2 years the region in which this study was conducted has been especially scrutinized. deaths from illegal opiate overdose have increased sharply in this region over the last four years (odh, 2017). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 83 why do you stay? the participants’ answers to this question reveal the positive forces at work in rural areas that could be harnessed for favorable health behavior change. while this region tends to be more challenged regarding material things, it is rich in tradition and wisdom. the participants’ comments revealed a deep connection to their home county and the people of their community. there is hope to change smoking behavior for the better in this region despite its troubling health indicators. while wewers et al (2012) found that younger age (18 years-30 years) was a risk factor for smoking, chertok and haile (2017) found in a representative central appalachian sample that younger women were more likely to engage in positive smoking behavior change. the tight-knit social networks typical of rural areas can be engaged for favorable change in smoking and other health behaviors. limitations limitations of this study include a purposive sample. care was taken in sample selection to include nurses who represented different counties in the area and different age groups. however, the study was conducted from a university setting, which might have biased who was known to the researchers for recruiting purposes. this may have resulted in the participants’ levels of education being higher than expected for nurses in this area. our sample educational breakdown was 17% associate’s degree, 58% baccalaureate degree and 25% master’s degree. in ohio, 2015 rn workforce data showed 52% associate’s degree, 36% baccalaureate degree and 11% master’s degree (ohio board of nursing, 2015). conclusion central appalachian ohio women are among the nation’s highest risk groups for poor health outcomes associated with tobacco use. addressing these challenges in smoking cessation activities with these women is worth the chance to positively impact the increased smoking-related online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 84 morbidity and mortality. according to the information gathered, smoking cessation interventions should particularly incorporate issues salient to this population such as the relative acceptability of smoking in the social environment, smokers in the household, and the desire for gradual smoking cessation. the data gathered suggest that smoking behavior is 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(2017). 2016 ohio drug overdose data: general findings. https://www.odh.ohio.gov/-/media/odh/assets/files/health/injury-prevention/2016ohio-drug-overdose-report-final.pdf?la=en online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 88 roberts, m.e., doogan, n.j., kurti, a.n., redner, r., gaalema, d.e., stanton, c.a., …higgins, s.t. (2016). rural tobacco uses across the united states: how rural and urban areas differ, broken down by census regions and divisions. health & place 39, 153–159. http://dx.doi.org/10.1016/j.healthplace.2016.04.001 sarna, l., bialous, s. a., nandy, k., antonio, a. l. m., & yang, q. (2014). changes in smoking prevalences among health care professionals from 2003 to 2010-2011. journal of the american medical association, 311 (2), 197-199. https://doi.org/10.1001/jama.2013. 284871 seybold, d. j., broce, m., siegel, e., findley, j. & calhoun, b. c. (2012). smoking in pregnancy in west virginia: does cessation/reduction improve perinatal outcomes? maternal child health journal, 16(1), 133-138. https://doi.org/10.1007/s10995-010-0730-4 thomson, t.l, krebs, v., nemeth, j., lu, b., peng, j., doogan, n. j., … wewers, m.e. (2016). social networks and smoking in rural women: intervention implications. american journal of health behavior, 40(4), 405-415. https://doi.org/10.5993/ajhb.40.4.2 thorn, d., tickamyer, a., & thorne, m. (2005). poverty and income in appalachia. journal of appalachian studies, 10, 341-358. u.s. department of agriculture. (2013). documentation of rural-urban continuum codes economic research service. u.s. department of health and human services. (2014). the health consequences of smoking— 50 years of progress: a report of the surgeon general. atlanta, ga: u.s. department of health and human services, centers for disease control and prevention, national center for chronic disease prevention and health promotion, office on smoking and health. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.505 89 wewers, m.e., salsberry, p., ferketich, a., ahijevych, k., hood, n, & paskett, e. (2012). risk factors for smoking in rural women. journal of women’s health, 21(5), 548-556. https://doi.org/10.1089/jwh.2011.3183 windsor, r, clark, j., cleary, s., davis, a., thorn, s., abroms, l., & wedeles, j. (2014). effectiveness of the smoking cessation and reduction in pregnancy treatment (script) dissemination project: a science to prenatal care practice partnership. maternal child health journal 18(1), 180-190. https://doi.org/10.1007/s10995-013-1252-7 wolfe, s.a. (2011). affordable care act maternal, infant and early childhood home visiting program supplemental information request: statewide needs assessment. columbus, oh: ohio department of health division of family & community health services. microsoft word editorial_vol_11_issue_2 final.docx online journal of rural nursing and health care, vol.11, no. 2, fall 2011 editorial the canopy of healthcare for rural and underserved populations strengthening the root system: defining success pamela stewart fahs, dsn, rn funny how a simple concept like success can be difficult to recognize. look up the word, and you find it comes from the latin succeder, which means “1. result; outcome 2a. favorable or satisfactory outcome or result…” (p. 1421). the conference entitled the canopy of health care for rural and underserved populations: strengthening the root system was jointly sponsored by binghamton university, decker school of nursing (dson) and the rural nurse organization (rno). after spending the last two years working on the planning of the conference, i found myself wondering, was it a success? about a month before the conference, this area of upstate new york experienced one of the most devastating floods this region has ever seen. the conference hotel was flooded. the university downtown center that houses the offices of the continuing education and outreach (ceo) of binghamton university had 17 feet of water that has closed the building until at least the next academic year. the server that held the conference webpage was underwater. those of us on the planning committee were asking “should we go forward or postpone the conference”? scheduled presenters were asking if the conference was still on. we knew several of our speakers, both national and international, had flights booked. it was with a sense of relief that we received the word from the hotel that they would be up and functioning in time for the conference, which was now three weeks away. those working in the offices of ceo, as well as myself and the other members of the planning committee, went to work letting everyone know we would be having the conference. there were still many last minute planning details and tasks to be carried out. there were issues with the webpage for registering as well as some delay for those trying to secure a room at the hotel. i felt some sense of success in just being able to bring this conference to fruition despite the obstacles faced by the region after the flood. i was on the planning committee for a similar conference held in binghamton in 2002. the conference had been planned originally in october of 2001 the events of 9-11 delayed the conference a year. still the 2002 conference had around 200 attendees. as we began the planning for the 2011 conference, this number was the target; yet we only had a little over 100 people attending on day 1 and fewer on days 2 and 3. certainly not the outcome numbers we had worked for in planning this conference. it is a good thing that rural nurses have never labeled success as only being about large numbers. this was an international research conference, and indeed, we attracted people from not only the us but also canada, new zealand, the philippines, turkey and indonesia. there were presentations that focused on work done in rural and underserved populations in these areas, as well as in the bahamas. there are many other countries where rural populations dwell. i would have loved to see representation from more areas in asia, africa, and south america, but given the state of the world economy, i can evaluate the international aspect of this conference as a qualified success. the rural regions from this country were well represented with presenters alone coming from 22 different states. there was representation from many schools in this country that focus their research and outreach toward rural populations. programs represented included but were not limited to east tennessee state university; college of nursing at montana state university online journal of rural nursing and health care, vol.11, no. 2, fall 2011 (bozeman), missoula campus; university of central florida; university of nebraska medical center; university of north dakota; university of virginia; and the decker school of nursing, binghamton university. there was a smattering of health care professions beyond nursing attending. those attending the conference included students, faculty, clinicians, and researchers. attracting fields other than nursing is an area where there was limited success but the diversity of the audience in terms of where they practiced, the areas of research, and their educational backgrounds make me believe this was a successful conference. i personally enjoy research conferences since they stimulate my thinking. at conferences over the years, i have met many people who have become friends. i meet nurses and other health care providers, researchers and academics who are interested in similar areas, and i often am able to build bridges regarding future projects with these individuals. our 2011 conference was no different. i had a wonderful time interacting both socially and professionally with people i have known for years and those who i was meeting for the first time. i was able to connect with people and connect people, including doctoral students, with others who had comparable research interests. using these criteria, i would evaluate the conference as a great success. i have received several emails, notes and calls that support this evaluation of a success for professional networking and building bridges for future work. this conference was only possible with the work of many. although those many are too numerous to mention, i do want to acknowledge the phenomenal work of those on the conference planning committee. representing the rno was deana molinari. those on the committee representing the dson, bu included cindy altmansberger, jill andrews, judy kitchin, mary muscari, gale spencer, fran srnka-debnar and karen zanni. representatives for the zeta iota chapter of sigma theta tau, international were also on the committee. i want to thank those from ceo, jennifer lawson, lisa olbrys, and jim scott. the support of dean joyce ferrario made the conference possible. i also want to acknowledge the work of the staff of the dson, who listened, supported, pitched in to fill the gaps, and kept the efforts afloat. cheers, to cindy altmansberger, mary petersen and sharon stiner. finally, there was a cadre of students, without whom i would have been lost. thank you to louis alerte, bioengineering graduate student and eva kamer, linguistics undergraduate student. lastly, i have to recognize the work of jill andrews, phd student and dson faculty. her attention to detail, sense of style, and just plain old hard work were key factors in making this conference a success! as an academic i think of myself as a “tough but fair” in my evaluations of the work of students. it is difficult to know am i applying the same criteria to my own work. in my final analysis, i believe that this conference, focused on rural and underserved populations, was successful. to be sure, there is room for growth. i am hopeful that the next rural conference will not be plagued by disasters, natural or otherwise. i also hope that the next rural nursing conference will be bigger and even more successful. although we may never really be able to evaluate this outcome, the final measure of success of this conference, for those of us in attendance will be asking ourselves did it play some part in helping to strengthen the root system for the canopy of health care for rural and underserved populations. references guralnik, d.b. (ed) (1979). new world dictionary (2 nd ed.). cleveland, oh: collins. 2 editorial spiritual assessment: what is your method? linda l. dunn, dsn, rn, cnl editorial board member in the last four issues of ojrnhc, varying aspects of spirituality have been addressed. the focus moved across a continuum from one’s personal responsibility to a professional responsibility. nurses in practice are mandated by accrediting bodies, such as joint commission on the accreditation healthcare organizations (jcaho) , as well as professional codes, like the american nurses association code of ethics, to ensure that every patient has a spiritual assessment. in this editorial i would like to challenge every nurse to consider his/her own nursing practice and seriously ask yourself “how do i assess the spiritual needs of my patients?” healthcare providers should have in place a tool by which all patients are spiritually assessed. spiritual assessment is similar to the nursing process in that it is a process that begins when the patient is admitted and continues throughout his/her care. once the spiritual assessment screen has been completed, the spiritual care plan is then developed (rumbold, 2007). many spiritual assessments are readily available; however, there is a jcaho template useful to anyone desiring to create their own tool (hodge, 2006). in the college where i teach, the faculty has just adopted the fica spiritual assessment tool (copyright, christine m. puchalski, md, 1996) that the faculty will use in teaching spiritual assessment to our nursing students. the fica is an acronym for faith and belief, importance, community, and address in care. i would suggest you consider using this tool in your nursing program or in your clinical practice. remember, the fica is a guide, not a check-list to be completed. you may access more information regarding the fica by going to http://www.gwumc.edu. at this site, locate the search box and type in “fica tool”; you will see may articles listed that will provide you with valuable information. also, go to http://www.gwish.org at this site, go to right lower web page and you will see “spiritual assessment in clinical practice”; within this section click on “our new multimedia guide”, then click on the picture of dr. puchalski. you will find an abundance of information on spiritual assessment, particularly on the fica. should you have questions or need assistance in locating this tool, email me at ldunn@bama.ua.edu. references american nurses association (ana). (2004). nursing: scope and standards of practice. washington, dc: author. hodge, d.r. (2006). a template for spiritual assessment: a review of the jcaho requirements and guidelines for implementation. social work, 51, 317-326. [medline] puchalski, c.m., & romer, a.l. (2000). taking spiritual history allows clinicians to understand patients more fully. journal of palliative medicine, 3, 129-137. [medline] rumbold, b.d. (2007). a review of spiritual assessment in health care practice. medical journal of australia, 186, s60-s62. [medline] online journal of rural nursing and health care, vol. 10, no. 1, spring 2010  http://www.gwumc.edu/ mailto:ldunn@bama.ua.edu http://www.ncbi.nlm.nih.gov/pubmed?term=17152630%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15859737%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=17516887%5buid%5d&cmd=detailssearch online journal of rural nursing and health care, 2(2) 83 reliability and validity of a revised family disruption from illness scale in a rural sample bette a. ide, phd, rn1 marcia gragert, phd, rn2 1 associate professor, college of nursing, university of north dakota, bette_ide@mail.und.nodak.edu 2 associate professor, college of nursing, university of north dakota, marcia_gragert@mail.und.nodak.edu abstract this study tests the validity and reliability of the 51-item family disruption from illness scale (fdis) in a sample of 569 rural adults. the family apgar, the family discord scale from the family invulnerability test, and the family quality of life scale were used to validate the fdis as a measure of the impact of illness upon family functioning. the alpha coefficient for the fdis was .93, and the fdis correlated significantly in the expected direction with all measures of family functioning: family apgar, r = -.23; family discord scale, r = .32; fqols, r = .28. a maximum likelihood solution with varimax rotation delineated seven interpretable factors. the fdis offers a psychometrically adequate tool that is uncomplicated to administer for the evaluation of a family’s disruption from illness. the study needs to be replicated in other rural settings, urban settings and with more culturally diverse populations. keywords: family functioning, reliability and validity, measure, illness, rural online journal of rural nursing and health care, 2(2) 84 reliability and validity of a revised family disruption from illness scale in a rural sample the family disruption from illness scale emerged because the first author was unhappy with what was available to measure the impact of illness upon the everyday functioning of families. the only measure she had been able to find was the family seriousness of illness scale (bigbee, 1988, 1990), which is 200 items long and involves weighted items. it, in turn, derives from the wyler seriousness of illness scale (wyler, masuda, & holmes, 1968). both scales are complicated to use and the results are difficult to interpret. for example, the weights may not correspond with how the respondent sees the illness. there seemed to be a need for a simpler tool that would measure the burden of illness (stein et al. 1987) for families. the current scale derives from a basic premise from family systems and role theories that illness of a family member disrupts role function within the family system, resulting in perceptions of role insufficiency and conflicts (doornbos, 1993; fawcett, 1975; hobbs, perrin, & ireys, 1985; johnson et al. 1995; testani-dufour, chappel-aiken, & gueldner, 1992; williams, lorenzo, & borja, 1993; see also, kane, 1997, p. 23, on “social functioning” as a domain of health-related quality of life). this has also been supported in the literature on family coping during illness crisis (engli & kirsivalifarmer, 1993; johnson et al. 1995; koller, 1991) and that on the impact of daily hassles on individual functioning (delongis, coyne, dakof, folkman, & lazarus, 1982; kanner, coyne, schaefer, & lazarus, 1982; wagner, 1990; wagner, compas, & howell, 1988). the notion is also inherent in olson’s (1997) work on family stress and coping and the work of mccubbin and mccubbin (1993). this study examines the reliability and validity of a family disruption from illness scale (fdis) that had previously been tested with a small sample of rural residents and revised (ide, online journal of rural nursing and health care, 2(2) 85 1996). the items were drawn from a 30-item symptom list used for older adults in ide’s dissertation (1979). at that time it was scaled in terms of perceived change in symptoms over time. in the mid-80s the symptom list was revised, scaling it according to frequency of difficulty with symptoms, for a study of older widows in tucson, arizona (ide, tobias, kay, monk, & de zapien, 1990; kay et al. 1988). further items were added, and it was recently used for a needs assessment of rural veterans (ide, 1994). the previous versions of the symptom scale had focused on older adults. in order to measure disruption to family routines caused by illness across life stages, it was necessary to add items and change the scaling. faculty in nursing and family & consumer sciences checked the resulting scale for content validity, and the first version was tested with 161 adults in fall 1995 (ide, 1996). this resulted in the current 51-item scale. methods in november 1996, 600 surveys were distributed at the annual flu clinics in laramie, wyoming, a city of about 30,000 population. the final sample consisted of 569 respondents who completed usable questionnaires and were aged 18 and over (out of a total of 583 returns). the age range of the sample was 18-88, 54% were 40-64 years of age, 2/3 were females, 79% had greater than a high school education, and over 1/3 saw their income as inadequate. the latter characteristics were to be expected. it is usually the mother who takes children to a flu clinic, laramie is a college town, and albany county, of which laramie is the largest city, has the second lowest per capita income of wyoming counties (department of administration and information, state of wyoming, 1994). the ethnic makeup of the sample is typical of the area, with 92.4% caucasian and 4% hispanic. online journal of rural nursing and health care, 2(2) 86 instruments used for validation of the fdis three instruments were used in validating the fdis as a measure of the impact of illness upon family functioning. the family apgar (smilkstein et al. 1982) consists of five items that measure a respondent’s perception of family functioning. originally developed as a clinical tool, good, smilkstein, good, shaffer, and arons (1979) noted a split-half reliability coefficient of .93 and a correlation of .80 with the family function index (pless & satterwhite, 1973). moos and moos (1981) reported an alpha coefficient of .84, a correlation of .54 (p. = .01) with the faces iii cohesion sub-scale, and a correlation of -.40 (p. =.01) with family environment scale. we found an alpha coefficient of .80 in this sample. two of the instruments developed by mccubbin and associates were also used. the family discord scale from the family invulnerability test (mccubbin, olson, lavee, & patterson, 1985; mccubbin & patterson, 1987 is a 4item likert scale that assesses the extent to which families worry, have the same problems over and over, are critical of each other, or have difficulty accomplishing what they want to do. previous reported internal reliabilities were .67 (mccubbin et al. 1985) and .75 (ide, carson, & araquistain, 1997). for this sample, the alpha coefficient was .78. the family quality of life scale (fqols), a 10-item self report measure in a likert-type format developed from the original 40-item scale that was part of the family inventories of mccubbin and associates (olson et al. 1985) assesses the degree of satisfaction with various aspects of family life. previous alpha reliability was .76, and its correlation with the original 40-item scale, which had sound psychometrics, was .82. in previous testing, we found an alpha coefficient of .75; internal reliability was .79 for this study. scores were high to medium on the family apgar (range = 5-15; mean = 13.43) and the fqols (range = 22-77; mean= 43.63), and family discord scores were low (range = 4-20; online journal of rural nursing and health care, 2(2) 87 mean = 10.71). over 70% almost always had help from the family, saw the family as helping them solve problems and as expressing a wish to change, and were satisfied with their family and living arrangements. the 65 and over group reported the highest family discord scores but also had the highest scores on the family apgar and fqols. family disruption from illness scale the revision of the fdis tested consists of a 51-item list of common symptoms and health problems. scaling is according to the respondent’s perception of the degree to which a symptom or problem has caused a disruption in the family’s daily or work routines during the past three months: 0 for no difficulty, and 1 to 4 for symptom or problem present and caused no, minor, moderate, or major disruption in routines. respondents are asked to circle 0 if a member of their family had not had any difficulty with a problem. if a symptom or problem had occurred, then they were to circle the appropriate number referring to their perception of the degree of disruption. the most frequently identified symptoms (noted by 30-40% as disrupting routines) were allergies, colds, forgetfulness, headaches, pain, difficulty sleeping, tiring easily, and vision problems. results the overall degree of disruption noted by this community sample was generally low. the range of scores was 0-133 with a mean of 25 and a median of 19. the alpha coefficient for the fdis was .93, which might be partly a function of the length of the scale and partly due to the homogeneity of this rural sample. the latter is a phenomenon we have seen before when testing tools in rural samples. concurrent validity was generally good. although the correlation coefficients were not high, the fdis correlated significantly in the expected direction with all online journal of rural nursing and health care, 2(2) 88 measures of family functioning: family apgar, r = -.23; family discord scale, r = .32; fqols, r = -.28. factor analysis the purpose of the factor analysis was to identify the latent dimensions or constructs represented in the original variables (hair, anderson, tatham, & black, 1998). a 7-factor maximum likelihood solution generated the fewest nonredundant residuals (11% >.05), resulted in a good fit (chi-square = 1903.48; p = .000), and explained 36.3% of the variance. the scree plots confirmed the 7-factor solution. a varimax rotation was chosen because of the need for orthogonal factors in other analyses (tabachnick & fidell, 1990). table 1 shows the loadings for the seven factors, with loadings of .30 or greater considered relevant. factor 1 could be called behavioral symptoms (alpha = .82). the items consistently loaded on one factor, and seemed to consist of “external” rather than “internal” symptoms, referring to actions or behaviors that result from psychological problems. factor 2 we called online journal of rural nursing and health care, 2(2) 89 acute episodic symptoms (alpha = .76), those minor illnesses that are acute and intermittent. the items with high loadings on factor 3 (alpha = .80) were a combination of gastrointestinal and urinary symptoms along with noise in the ear, dizziness, and skin sores. a phrase that seemed to describe the combination was frustrating symptoms. factor 4 (alpha = .80) consists of four symptoms that always loaded on one factor no matter what solution was used. we called it anxiety/depression, although it could also be termed the “worry” factor. factor 5 (alpha = .73) consists of the functional/sensorineural symptoms that often are thought of as problems that could accompany the aging process. factor 6 (alpha = .67) consists of symptoms, some of them relevant for women’s health, that seem to herald the necessity for some type of change in lifestyle. finally, the highest loadings on factor 7 (alpha = .66) were for a combination of cardiovascular and respiratory symptoms. not unexpectedly, there were eight items that loaded across two factors, six with loadings of greater than .30 on the second factor. difficulty communicating loaded across the two psychosocial symptom factors, with a loading of .40 on behavioral symptoms and .35 on anxiety/depression. two items, infection and dizziness, loaded almost evenly across two factors, although the loadings were only in the .30 range; infection had loadings of .31 on acute episodic symptoms and .30 on behavioral symptoms. dizziness loaded at .31 on both frustrating symptoms and behavioral symptoms. two had secondary loadings on the functional/sensorineural (or aging problems) factor, noise in the ears (.36) (which can be a side effect of certain blood pressure medications) and heart trouble (.33). although surgery loaded most clearly on the changes in lifestyle factor (.53), it also had a .33 loading on the frustrating symptoms factor. eight items (seizures, teeth problems, injury, anemia, asthma, illness of a pet, online journal of rural nursing and health care, 2(2) 90 diabetes, and multiple sclerosis) were eliminated by the procedure, resulting in a 43-item final scale. discussion and conclusions family health promotion is a critical element of primary health care. each family system develops its own pattern of problem-solving and decision-making involving health matters. these patterns are seen in the lifestyle of the family and are shaped by the family’s philosophy of health as well as its internal and external environment. given the chronic strains experienced by many families, ways to deal with disruptions caused by the illness of one of its members can be critical in assisting these families to achieve healthy ways of living. a psychometrically adequate tool that is uncomplicated to administer is critical for the evaluation of a family’s disruption from illness. adequate representation of the phenomenon under study requires a sound theoretical model and a match between the statistical procedures and the aim of the analysis. instrument testing, although not the easiest form of research, is essential to advancing the science of nursing. each of these important elements has been addressed in this research and the revision of the original tool. this study should be replicated in other rural settings, urban settings and with more culturally diverse populations. an important extension would be a comparison of the effect of acute and chronic illness disruptions on the family. the instrument tested in this study offers a less complex but reliable tool to measure the disruption to family routines caused by the illness of family members. it is a different approach to measuring health at the “family” level. this approach could be extremely helpful to nurse practitioners as well as nurse researchers. nurses in the practice arena are often reluctant to become involved in research because of the time involved in measuring illness characteristics. online journal of rural nursing and health care, 2(2) 91 they would be more likely to become involved if simple, easy to use instruments such as this were available. online journal of rural nursing and health care, 2(2) 92 references bigbee, j.l. (1988). the family seriousness of illness scale. unpublished manuscript. bigbee, j.l. (1990). family stress, hardiness, and illness: a pilot study. unpublished manuscript. delongis, a., coyne, j.d., dakof, g., folkman, s., & lazarus, r.s. (1982). relationship of daily hassles, uplifts and major life events to health status. health psychology, 1, 119136. https://doi.org/10.1037/0278-6133.1.2.119 department of administration and information, state of wyoming. (1994). equality state almanac: 1994. cheyenne, wy: author. doornbos, m.m. (1993). family health in the families of the young chronically mentally ill. dissertation abstracts international, 55(03), 820. fawcett, j. (1975). the family as a living open system: an emerging conceptual framework for nursing. international nursing review, 22(4), 113-116. good, m.d., smilkstein, g., good, b.j., shaffer, t., & arons, t. 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(1988). daily and major life events: a test of an integrative model of psychosocial stress. american journal of community psychology, 166, 189-205. https://doi.org/10.1007/bf00912522 williams, p.d., lorenzo, f.d., & borja, m. (1993). pediatric chronic illness: effects on siblings and mothers. maternal child nursing journal, 21(4), 111-121. https://doi.org/10.1007/bf00912522 dekeseredy_550-article text-3570-1-6-20190402 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 2 an exploration of work related stressors experienced by rural emergency nurses patricia dekeseredy, mscn, rn 1 christine m. kurtz landy, phd, rn 2 cara l. sedney, md 3 1 clinical research specialist, west virginia university medicine, patricia.dekeseredy@hsc.wvu.edu 2 associate professor, faculty of health-school of nursing, york university, kurtzlcm@yorku.ca 3 assistant professor, school of medicine west virginia university, csedney@hsc.wvu.edu abstract purpose: nursing in a rural emergency department is a physically and emotionally demanding job. the challenges of working under these conditions can be very stressful for nurses. work place stress can result in nurses developing mental health issues with subsequent physical consequences. these mental health issues, when experienced by nurses, can compromise patient care and safety. the consequences of work related mental health challenges are not isolated to the workplace but also have the potential to disrupt and destroy nurses’ careers and family life. this article addresses the following research question: what are the experiences of rural emergency nurses that can contribute to, or leave rural emergency nurses vulnerable to, the development of work related mental health issues? sample: participants were emergency department registered nursing staff from one hospital located in a rural community north of toronto. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 3 method: an exploratory qualitative descriptive study design was chosen, in which rural emergency department nurses were invited to share their stories through face-to-face in-depth interviews. findings: rural emergency nurses are challenged by a lack of resources, anxious about working outside their scope of practice, and are concerned about issues related to patient privacy and their own anonymity in the community. added to this is the emotional impact of caring for young trauma patients, family, and people they know from the community. these experiences also affect their family members and can be expressed by lashing out, impatience, and withdrawing from interactions with them. conclusion: workplace challenges faced by rural emergency nurses can contribute to occupational mental health issues such as compassion fatigue and burnout. managers of rural emergency departments need to acknowledge the unique working conditions of the nurses, improve communication, and tailor support programs to meet the needs of each individual nurse who has experienced an occupational threat to their mental well-being. keywords: rural emergency nurses, mental health, compassion fatigue, stress, burnout, occupational health an exploration of work related stressors experienced by rural emergency nurses the nurses who work in rural emergency departments (ed) care for members of their community during long shifts in a fast-paced environment with limited resources. nursing in a rural ed is a physically and emotionally demanding job. the challenges of working under these conditions can be very stressful for nurses (healy & tyrell, 2011; yuwanich, sandmark & akhavan, 2016). work place stress can result in nurses developing mental health issues and physical consequences (kilic, online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 4 aytac, korkmaz & ozer, 2016; potter et al., 2010; yuwanich et al., 2016). these mental health issues, when experienced by nurses, can compromise patient care and safety (christodoulou-fella, middleton, papathanassoglou & karanikola, 2017; van bogaert et al., 2017). the consequences of work-related mental health challenges are not isolated to the workplace but also have the potential to disrupt nurses’ careers and family life (showalter, 2010; yuwanich et al., 2016). previous studies have focused on ed nurses and stress, however, there is a dearth of research exploring how working in a rural ed may impact the mental health of the nurses who work in this environment. according to the rural and northern health care report executive summary (government of ontario, 2011) “rural communities in ontario are those with a population less than 30,000 that are greater than 30 minutes away in travel time from a community with a population of more than 30,000” (p. 4). being a rural resident means there can be added challenges to access health care. for example, transportation, limited healthcare supply, perceived lack of quality of health care, social isolation and financial constraints can limit health care access (bolin et al., 2015; goins, williams, carter, spencer & solovieva, 2005). mental health issues such as anxiety, depression, compassion fatigue (cf), burnout, and posttraumatic stress disorder (ptsd) have all been identified as a consequence of workplace stress (aycock & boyle, 2009; cocker & joss, 2016; mealer, burnham, goode, rothbaum, & moss, 2009). studies have shown that emergency nurses have a high prevalence of cf (hooper, craig, janvrin, westsel, & reimels, 2010) and symptoms of burnout (harkin & melby, 2014). in addition, one study found that 1 in 3 emergency nurses’ experienced sub-clinical levels of anxiety/depression and 8.5% met clinical levels of ptsd (adriaenssens, de gucht, & maes, 2012) as a result of the work they do. the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5) is the first edition to include a chapter on trauma and stressor related disorders online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 5 acknowledging that work experiences can give rise to mental health problems such as ptsd and cf (american psychiatric association [apa], 2013). understanding how the challenge of rural emergency nurses’ work can contribute to ptsd, cf, and burnout is imperative in order to manage the deleterious effects of these mental health issues for these nurses. this study addresses the following research question: what are the experiences of rural emergency nurses that can contribute to, or leave rural emergency nurses vulnerable to work place stressors? the study design is an exploratory, qualitative descriptive study that aims to (a) explore the experiences of rural emergency nurses that can affect their mental health; (b) give voice to rural emergency nurses regarding the everyday challenges of caring for their patients; (c) contribute to knowledge, that when disseminated amongst nursing and health professionals can inform policy and program development to address rural emergency room nurses’ occupational mental health issues method an exploratory qualitative descriptive study design was chosen, in which rural ed nurses were invited to share their stories through face-to-face in-depth interviews. this approach provided rich data to help illuminate the challenges and multiple influences on the participants’ experiences. the exploratory qualitative descriptive approach is a viable and acceptable research design for qualitative research that seeks to explore a phenomenon where little is known about the topic (sandelowski, 2000). as there is very little research done on work related stressors rural emergency nurses face, an exploratory descriptive approach was chosen. participants participants were 10 ed registered nurse (r.n.) staff. they were located in one canadian hospital located in a rural community north of toronto, in ontario canada. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 6 data collection after ethical approval was received from the york university research ethics board and from the local hospital research ethics board, the nurse manager of the hospital ed provided her nursing staff with verbal information about the study through staff meetings and casual discussions. a semi-structured interview guide was used to guide all the individual in-depth interviews (see appendix). the guide consisted of thirteen open-ended questions and additional probing questions to facilitate elaboration and depth of exploration of the nurses’ experiences working in the ed. the interviews lasted from 30 to 60 minutes and recordings were transcribed verbatim for analysis. demographic data was included, however, any information that could lead to identification of the participants or the hospital was removed and the nurses were given a pseudonym to ensure the anonymity of the nurses and the hospital. data analysis qualitative content analysis as described by hsieh & shannon (2005) was used as the method for analyzing the data. content analysis is the “subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns” (hsieh & shannon, 2015 p.1278). the transcripts were read word-by-word, highlighting exact words that represented key thoughts or concepts (hsieh & shannon, 2015). the emerging themes were organized and entered as nodes (a meaningful cluster) in nvivo computer software (nvivo, 2012). these processes continued (using constant comparison) until themes emerged from the data that were representative of more than one key thought (hsieh & shannon, 2105). during the process of analysis, two overarching themes emerged from the data. these included the working in a rural ed is stressful and work stress in a rural ed broadly affects nurses and patients. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 7 to develop trustworthiness of the findings, the study was guided by lincoln and guba’s (1985, 1994) trustworthiness framework. this framework consists of five criteria, i.e. credibility, dependability, confirmability, transferability, and authenticity (lincoln & guba, 1985, guba & lincoln, 1994). all the interviews were initially coded by one researcher as described above. then, a second experienced researcher independently coded the interviews and results were discussed among the team until a consensus was reached. in addition, the research team kept comprehensive field notes, careful documentation of the research proposal, and tracked any document changes or revisions to any methodological and analytical decisions contributing to the audit trail. findings demographics ten nurses currently working in the ed were interviewed. the participants’ demographic characteristics are presented in table 1. table 1 demographic characteristics of participants demographic variable n % gender female 10 100 marital status married 6 60 divorced 3 30 single 1 10 age 25-29 1 10 30-34 1 10 35-39 1 10 45-49 2 20 50-54 4 40 55-59 1 10 nursing education online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 8 diploma 7 70 university degree 2 20 graduate degree 1 10 years working as an r.n. < 5 2 20 5-9 1 10 10-14 2 20 15-19 2 20 20+ 3 30 years worked in the e.r < 5 1 10 5-9 3 30 10-14 0 0 15-19 3 30 20+ 3 30 lives in community yes 9 90 no 1 10 employment status full-time 6 60 part-time 4 40 note. diploma nursing graduates are those that graduated from a 2-3 year program from a community college, university graduates have a 4-year bachelor degree in nursing, and graduate program nurses have an advanced degree such as a masters or phd in nursing. the nurses were open about their ed experiences caring for patients in their community. they shared stories about the challenges and personal impact of nursing in a small rural ed. two overarching themes as well as multiple subthemes emerged from the data (table 2). table 2 themes and subthemes overarching theme subthemes working in a rural ed is stressful 1. lack of resources 2. scope of practice and liability concerns 3. lack of privacy in the community online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 9 4. personal relationships with patients and/or their families 5. extreme stress in treating young trauma patients 6. feeling trapped in the ed work stress in a rural ed broadly affects nurses and patients 1. results of the emotional stress of working in the ed 2. impact of work stress on home life 3. cf experience and perception 4. machismo as a way to deal with work stress working in a rural ed is stressful the first overarching theme is that working in a rural ed is stressful. subthemes describing specific work stressors included lack of resources, scope of practice and liability concerns, lack of privacy within the community, personal relationships with patients, extreme stress in treating young trauma patients, and feeling trapped in the ed. all the participants believed that working in a rural ed presented challenges that were different than working in a larger or urban center. quotes from the participants representing the subthemes of this overarching theme are presented in table 3. lack of resources. many participants talked about working with a lack of resources in the rural ed that directly affected their workload and quality of patient care. this included both lack of ancillary staff such as technical and clerical support, and mismatched patient to nurse ratios during periods of heavy ed traffic such as summers and weekends. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 10 scope of practice concerns. a few nurses said that they sometimes had to work outside their scope of practice to save patients’ lives. this led some of the nurses to be concerned that they might be endangering their nursing registration. one participant wondered if her patient might have had a better outcome if the treatment had been initiated more quickly. she was concerned this patient’s case would be reviewed by hospital administration or the college of nurses of ontario and the nursing staff would be held legally responsible for the poor outcome. lack of privacy in the community. the nurses identified that working and living in a small community meant they were recognized outside of work by members of the community and sometimes asked about their work and patients they had cared for. this could include inquiries by former patients as well as questions from patients’ friends or family members who heard about an incident at the hospital. these requests for information put the nurses in awkward positions as they had information they could not share. all participants were aware of privacy legislation and had strategies to deal with situations when they were asked by family or friends to disclose personal information about patients. personal relationships with patients and/or their families. for the participants, working in a small community meant they sometimes treated family and friends in the ed. one participant described doing cpr on friends and how it disturbed her that she did not recognize the patients. another said treating family members could be “upsetting and embarrassing”. still another described feeling self-conscious about treating people she knew in the department and how situations at the hospital have the potential to be retold in the community. extreme stress in caring for young trauma patients. one of the most challenging situations discussed by most of the participants was caring for pediatric and young adult trauma patients. during a pediatric crisis, many of the nurses shared that they identified with the distressed online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 11 families and also often thought about their own children. in addition, when the ambulance dispatch called ahead to notify of an incoming child trauma the nurses were sometimes concerned that it could be their own child. one participant described feeling guilty for hoping the incoming trauma was not her child. although she felt relieved that the trauma patient was not her child, she described the ‘relief’ to be short lived because she was overwhelmed by the reality that the trauma was somebody else’s child. the nurses had vivid memories and recalled with great detail the young trauma patients they cared for. the participants specifically discussed how pediatric traumas affected them emotionally and, in turn, their ability to function on the job. one participant candidly about reliving the experience of caring for a pediatric patient that passed away. these thoughts were so intrusive that they kept her awake at night. another shared that after caring for a child experiencing severe pediatric trauma she had difficulty focusing on her work and would have benefited from a day off to recover. feeling trapped in the ed. another subtheme which repeatedly surfaced was that nurses could feel trapped in the ed. this sense of feeling trapped was attributed to living in a small community and therefore, they would be unable to make the same income and maintain the same lifestyle due to a lack of other types of nursing positions. in addition, nurses who had worked for many years in the hospital remained in their jobs because they had built up seniority, vacation time and pensions. this security made it a difficult decision to switch jobs, even if they wanted a different job. when asked where they saw themselves in ten years, most of the nurses said that they would not be working in this ed. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 12 table 3 quotes forming the subthemes of working in a rural ed is stressful subtheme participant quotes lack of resources “as a nurse you are really challenged…you are doing everything, ecgs, iv`s, any sort of procedure that in a teaching hospital the medical students or the interns would be doing” “…you are very restricted in the resources you have…i have to run and phone for x-ray, i have to run and phone for blood work…no security, no registration.” “here we have barebones everything so i think it’s just trying to figure out what you have to do and doing it.” “[patient visits] in key summer months, are similar to the volumes that i saw in downtown toronto emergency with about a third of the staff.” “it`s on the weekends when you are overwhelmed with numbers, because of this [vacation] area and the population…you know doubles, triples, whatever.” “it’s all about the hours and not getting burnt out...i can see why the nurses get grouch[y] here, because it is stressful…almost twelve o`clock and they haven`t been to breakfast yet [the morning break] and i`ve been up since five thirty and didn`t sleep until four fifteen and i`m thinking it is hard to be here for so many hours and not even go pee or have something to eat” scope of practice and liability concerns “sometimes we cross the line, out of the scope of a nurse. but if i don’t cross that line with my physician backing me up in the next room, this person dies. so we do cross the line and it`s not right, but it is what has to be done because it is for the patient” “i worry for my license a lot here. i`ve never done that before.” lack of privacy in the community “privacy is huge, i would say it is a huge issue because people know everybody, people are related to everybody, people are married to everybody it seems. i just don’t say anything about anyone; because …everybody knows somebody to some degree and you are going to say something that will bite you in the ass”. “it’s very difficult because often i am asked were you working. did you see?” personal relationships with patients and/or their families “yeah, so that part is really hard. i did cpr on a woman’s husband once. i knew the woman more than i knew the husband but just, you are getting involved in the, you know, the whole code.” “i’ve done cpr on a couple of friends of mine that have died and i’m (years old). it’s hard in that sense and then my neighbor, who was totally [pulmonary embolus] and purple, couldn’t even recognize her. you know, you are doing cpr on your neighbor and the husband comes in and you’re kind of going, shoot (shakes her head)” extreme stress in treating young trauma patients “well, last night i was up till four in the morning because the last shift i worked i had an eleven month old. we were doing cpr, tubed her everything. she ended up passing away...it was a local family, you kind of know the family and so i was reliving that…and i was reliving till four fifteen in the morning and what you could have done differently, how could we have made that faster, online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 13 what could we have. do you know what i mean? so it has a big impact, it really does, all this stuff and knowing people…. i`m having three hours sleep…i`ve been redoing (reliving over and over) it. you take a lot of it” “i had a 6 year old drowning a few years ago and we did cpr on him for six hours, he`d fallen through the ice and his baby brother sat outside the trauma room on a stretcher, and his dad stood at the end of the bed clapping, you know; come on (name) come on (name) and for six hours we tried to help this little kid and he didn`t make it”. feeling trapped in the ed “and that`s one of the challenges in a smaller community too, is that most, a lot of nurses feel trapped in what they do because you cannot make the same income and maintain the same lifestyle, there`s not too many other opportunities”. work stress in a rural ed broadly affects nurses and patients the second overarching theme that emerged from the data was that work stress in a rural ed broadly affects nurses and patients. this overarching theme pertains to how working in a rural ed affected the ed nurses’ mental health, feelings, awareness and motivation, and thereby patient care and non-work social functioning. the subthemes that explicate the complexity of this overarching theme are: responses to the emotional strain of working in the ed, impact of work life on home life, compassion fatigue experience and perception, and machismo as a method to deal with work stressors. quotes from the participants representing the subthemes of this overarching theme are presented in table 4. results of the emotional stress of working in the ed. many nurses talked about how they reacted to the emotional stress of working in an ed caused by such things as over work, dealing with trauma and a lack of resources. they also discussed the impact this stress had on their mental health. the participants responded to the stress they experienced at work in various ways. half of the nurses described crying about traumatic work events either at home or while still at work. one participant described leaving work and driving to the lake to cry when she recalled the events of the day. another described being angry and frustrated at work because she felt overwhelmed by her work and unable to cope. still others described feeling “burnt-out” and “grouchy”. one online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 14 participant connected the death of a 17 year old patient she cared for to an episode of depression she experienced. in order to cope with the emotional strain, two participants left nursing for a period of time; one for a year and one for three and a half years. both participants indicated that their stressful work environment contributed to this choice. impact of work stress on home life. most of the nurses stated their work impacted their home life in one way or another by this work stress. this was particularly evident after a “bad day”, i.e. one with multiple trauma patients, difficult cases, or working without enough staff and not being able to take breaks. the participants talked about how a bad day at work would negatively impact their family. they described behaving more negatively toward their families by being angry or yelling after a stressful day at work. some participants described emotionally withdrawing after a bad day from family, while others shared that they sought emotional support from their partners. two participants mentioned using alcohol as a coping mechanism. cf experience and perception. most of the participants had heard of cf and agreed it was a real issue, and one many had experienced. the nurses shared how cf in their experience led them to distance themselves from having therapeutic relationships with patients. the nurses also felt there was a connection between cf and the nurses’ feeling numb to emotions. one participant acknowledged the vulnerability of this group of nurses to cf because of the traumatic events they are involved with. some participants indicated the staff had discussed cf in a work setting. some nurses indicated that they would avoid emotionally supporting patients because it was too upsetting to get involved in their problems or they were too busy. the nurses also spoke about guarding their own emotions to avoid distress by becoming hardened, cynical or blocking out situations that would normally be troubling to them. for online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 15 example, several participants coped by using humor or compartmentalization in addition to blocking out events. machismo as a way to deal with work stress. the nurses were very proud of the work they do. they viewed themselves as survivors for continuing to nurse patients in the stressful environment of the emergency room. in addition, they recognized that emergency nursing was unique and saw ed nurses as tough for sticking with it. one participant spoke with a sense of machismo that she was still working in the ed, while another spoke with pride about being a resilient emergency nurse, teamwork was often related as a positive development of the emotional stress. multiple participants noted that they had pride in their nursing colleagues and one participant said that working in a small department meant nurses needed to rely on each other more than at a larger center, and do more with less help. however, both systemic and interpersonal factors which disincentivized demonstrating vulnerability were mentioned, such as nurses’ not generally taking days off after a stressful case while paramedics often would. table 4 work stress in a rural ed broadly affects nurses and patients subthemes participant quotes responses to the emotional stress of working in the ed “…i started having some anxiety issues and i did get medicated…so i came to work and literally, it was like i wasn’t working…and it turned out i had depression and was off for two months” “i took a break for about three, three and a half years…then i came back in.” impact of work stress on home life “it totally bleeds into your home life….so you go home, you vent, you cry, you drink a bottle of wine, you know you cope or whatever and then you get up the next day and you start over.” “i kind of withdraw, which is not necessarily the best thing to do but it is hard for your family to understand because you have to keep confidentiality…and when you come home, and you look like shit and you feel like shit and all you really want to do is snuggle beside your partner …they don’t get it.” online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 16 “work is work, home is home...some nights i probably drink a couple of glasses of wine and that`s how i deal with it.” cf experience and perception “yeah, i definitely have heard of cf, that’s something we definitely face here a lot, because we are such a small center and we’re not really close to anything. we deal with a lot of traumatic stuff, infants, teenagers, adults, very traumatic deaths.” “i block a lot of it out because you have to keep going because i am an emotional person. i actually make jokes out of a lot of stuff so i can keep going.” “okay, compartmentalize it, it’s an accident, you didn’t cause it, you tried to help them, and you go that way.” machismo as a way to deal with work stress “yeah, it was not a nice place to work, but all us old gals are still here, stuck it through.” “ it’s just totally different nursing, and it’s harder nursing because we have to rely on each other and we do really amazing things here that we should be really proud of ...in the city you would have teams of people doing.” discussion this study shows rural emergency nurses are at risk for workplace stress due to a variety of inciting events, and this in turn has a wide ranging emotional impact on the nurses themselves, as well as home life and patient care. it is important to understand those aspects of workplace stress in rural emergency nursing that can leave nurses vulnerable to cf, burnout, and other mental health issues, as well as to acknowledge characteristics unique to the rural ed such as lack of privacy, feeling trapped, and a lack of resources. education and programs to address work related stress and mental health issues the participants had varying degrees of knowledge on coping with workplace stressors. while compassion fatigue and burnout were familiar terms to some participants, the frequency of unproductive coping mechanisms such as use of alcohol indicate need for further education. nursing education programs and hospital orientation should include courses about the impact of cf and burnout on patients, nurses, and home life. ideally, such programs should be easily accessible (in person or on the internet) and emphasize the importance of self-care such as stress management, health maintenance, and professional development. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 17 the occupational health and safety act (section 25(2) (h)) dictates that employers have a duty to protect their workers (government of ontario, 1990), including mental health. therefore, it is important that hospitals provide mental health support for nursing staff, including programs to reduce or mitigate mental health issues as a result of their work. research into the effectiveness of these programs will assist institutions to choose the best fit for the employee who is or could be affected. findings from this study indicate that programs instituted in urban ed are not necessarily transferrable to a rural ed, and within the ed, the nurses had different ideas of how programs could support them personally. practical strategies to minimize workplace stress in the rural ed the nurses in this study gave examples of ways they felt the hospital management could help them cope with the challenges of working in their ed. job sharing, flexible work hours and scheduling were attributed to making the work environment more manageable and satisfying to the nurses, and also as stress management strategies. scheduling is paramount because if nurses are not given enough time to rest and manage stress between shifts, it can lead to the development of mental health issues such as cf (braunschneider, 2013). this type of improved scheduling has been suggested to reduce burnout in nurses (witkoskistimpfel, sloane, & aiken, 2012). the nurses interviewed said they would often miss breaks during their 12-hour shift because they were too busy to take one. this has implications for patient care because working without proper breaks in a 12-hour shift makes it difficult to perform without errors (witkoski-stimpfel, sloan, & aiken, 2012). manageable work hours and nurses getting enough sleep are important for quality patient care (lockley et al, 2004). furthermore, the perception of management support was important to the nurse participants in this study. they described specific examples where what they perceived as lack of management online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 18 support increased their workplace stress, such as blame in patient complaints or scope of practice issues. conversely, they described new management personnel in a positive light if they were indoctrinated to some of the current ed workplace stressors, citing that such familiarity would hopefully lead to more supportive management decisions. limitations this single-center qualitative study has a number of limitations. the generalizability of a single-center canadian study can be questioned, and therefore replicating the study to include a larger scale and more diverse sample would be of benefit. further generalizability issues arise from the sample of nurse participants. a wider age range of participants, recruiting male nurses (to explore gender difference), and nurses from a multicultural background would enhance the sample and provide varying perspectives of mental health issues resulting from work experiences. because the participants volunteered for the study, voluntary response selection bias may play a role, as nurses with differing experiences in a rural ed may have declined participation. conclusion in this research study, we explore what specific workplace challenges rural emergency nurses’ face that can contribute to occupational stresses. this study is noteworthy in that it is believed to be the first to addresses how the stress of working in a rural ed can affect the mental health of the nurses who work there. findings indicate that rural emergency nurses are challenged by a lack of resources (space, r.n.s and support staff), anxious about working outside their scope of practice, and are concerned about issues related to patient privacy and their own anonymity in the community. added to this is the emotional impact of caring for young trauma patients, family, and people they know from the community. additionally, the findings indicate that the experiences of the nurses can also have an impact on their personal life. the participants had online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 19 varied knowledge of support programs available to them, and mixed reviews on the access and effectiveness of such programs. administrators of rural eds should be aware of the unique working conditions of the nurses, improve communication, and tailor support programs to meet the needs of each individual nurse who has experienced an occupational threat to their mental wellbeing. references adriaenssens, j., de gucht, v., & maes, s. (2012). the impact of traumatic events on emergency room nurses: findings of a questionnaire survey. international journal of nursing studies, 49, 1411-1422. https://doi.org/10.1016/j.ijnurstu.2012.07.003 american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). arlington, va: american psychiatric publishing. aycock, n., & boyle, d. (2009). interventions to manage compassion fatigue in oncology nursing. clinical journal of oncology nursing, 13, 183-191. https://doi.org/10.1188/09.cjon.183191 bolin, j. n., bellamy, g. r., ferdinand, a. o., vuong, a. m., kash, b. a., schulze, a., & helduser, j. w. (2015). rural healthy people 2020: new decade, same challenges. journal of rural health, 31, 326-333. https://doi.org/10.1111/jrh.12116 braunschneider, h. 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(2011). stress in emergency departments: experiences of nurses and doctors. emergency nurse, 31-37. https://doi.org/10.7748/en2011.07.19.4.31.c8611 hooper, c., craig, j., janvrin, d. r., wetsel, m. a., & reimels, e. (2010). compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 21 nurses in other selected inpatient specialties. journal of emergency nursing, 420-427. https://doi.org/10.1016/j.jen.2009.11.027 hsieh, h., & shannon, s. e. (2005). three approaches to qualitative content analysis. qualitative health research, 15, 1277-1288. https://doi.org/10.1177/1049732305276687 kilic, s. p., aytac, s. o., korkmaz, m., & ozer, s. (2016). occupational health problems of nurses working at emergency departments. international journal of caring sciences, 9, 1008-1019. retrieved from http://www.interna tionaljournalofcaringsciences.org/default.aspx?page index=1&pagereason=0 lincoln, y. s., & guba, e. g. (1985). naturalistic inquiry. newbury park, ca: sage. lockley, s. w., barger, l. k., ayas, n. t., rothschild, j. m., czeisler, c. a., & landrigan, c. p. (2007). effects of health care provider work hours and sleep deprivation on safety and performance. https://doi.org/10.1016/s1553-7250(07)33109-7 mealer, m., burnham, e., goode, c., rothbaum, b., & moss, m. (2009). the prevalence and impact of post-traumatic stress disorder and burnout syndrome in nurses. depression and anxiety, 26, 1118-1126. https://doi.org/10.1002/da.20631 nvivo 10 (version 10) [computer software]. (2012). qsr international pty ltd. potter, p., deshields, t., divanbeigi, j., berger, j., cipriano, d., norris, l., & olsen, s. (2010). compassion fatigue and burnout: prevalence among oncology nurses. clinical journal of oncology nursing, 14(5), 56-62. https://doi.org/10.1188/10.cjon.e56-e62 sandelowski, m. (2000). whatever happened to qualitative description? research in nursing & health, 23, 334-340. https://doi.org/10.1002/1098-240x(200008)23:4<334::aidnur9>3.0.co;2-g online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 22 showalter, s. (2010). compassion fatigue: what is it? why does it matter? american journal of hospice palliative medicine, 27, 239-242. https://doi.org/10.1177/1049909109354096 van bogaert, p., peremans, l., van heusden, d., verspuy, m., kureckoval, v., van de cruys, z., & franck, e. (2017). predictors of burnout, work engagement and nurse reported job outcomes and quality of care: a mixed method study. bmc nursing, 16(5). https://doi.org/10.1186/s12912-016-0200-4 witkoski-stimpfel, a., sloane, d., & aiken, l. (2012). the longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. health affairs, 31. http://dx.doi.org/10.1377/hlthaff.2011.1377 yuwanich, n., sandmark, h., & akhavan, s. (2016). emergency department nurses’ experiences of occupational stress: a qualitative study from a public hospital in bangkok, thailand. work, 53, 885-897. https://doi.org/http://dx.doi.org/10.3233/wor-15218 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 23 appendix interview guide introductory script: thank you for agreeing to participate in this research study. before we begin, i just want to remind you that you do not have to answer all the questions. if any question makes you feel uncomfortable, we can stop or pause the interview at any time. you are also aware that i am recording this interview and any written notes i make are only to help me understand the content of this interview when i read the transcripts. this interview and my notes will also be kept in strict confidence as indicated on the informed consent form you signed. do you have any questions? can you tell me why you wanted to be a nurse? what is it like working in a rural er? what do you think is unique about rural emergency nursing? can you tell me how it feels to care for someone you know from the community? how do you deal with issues of privacy both for yourself and the patients outside of the hospital? compassion fatigue can be defined as the ``cost of caring``. that is, that care giving can take an emotional and physical toll on providers. this can have negative effects on a nurse’s professional and personal life. have you heard of this and what are your thoughts on the concept of compassion fatigue? working in the emergency department can be a very demanding job and we all feel challenged by our work at times. can you tell me about a particularly challenging patient or situation? can you tell me about a situation where you felt that you were not able to provide the emotional support the patient or family needed at a distressing time and why? online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.550 24 have you ever felt that you needed a break from working in the emergency department? how did you deal with this? can you tell me how a bad day at work affects your home life? can you tell me about the programs your hospital offers to address the mental well-being of the emergency nurses? where do you see yourself working in ten years? is there anything else you would like to share with me about your experiences working in the er that i have not asked about? bayly_509 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 29 development and implementation of dementia-related integrated knowledge translation strategies in rural home care melanie bayly, phd 1 dorothy forbes, rn, phd 2 catherine blake, ma 3 shelley peacock rn, phd 4 debra morgan rn, phd 5 1 postdoctoral fellow, canadian centre for health and safety in agriculture, university of saskatchewan, mke177@mail.usask.ca 2 professor, faculty of nursing, university of alberta, dorothy.forbes@ualberta.ca 3 research associate, university of western ontario, arthur labatt school of nursing, cmblake@uwo.ca 4 associate professor, college of nursing, university of saskatchewan, shelley.peacock@usask.ca 5 professor, canadian centre for health and safety in agriculture, college of medicine, university of saskatchewan, debra.morgan@usask.ca abstract purpose: as the canadian population ages the provision of high quality dementia care may be increasingly challenging, particularly in under-resourced rural areas. researchers have also online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 30 suggested that rural care providers have unmet dementia-related educational needs and would benefit from formal knowledge exchange supports, such as a knowledge broker (kb). the current research aimed to address this issue by employing a kb to facilitate the development and implementation of integrated knowledge translation (ikt) strategies within two rural home care centres. methods: in this longitudinal multiple case study, ikt processes at each site were assessed at baseline, 6 months, and following the termination of kb assistance. data from 38 semi-structured interviews at the latter time points with registered and licensed practical nurses, health care aides, managers, and other care providers (n=19) were analyzed thematically to examine their perceptions of strategy processes and impacts, including the kb role. findings: perceived facilitators of ikt strategy development and implementation included collaborative development by knowledge users, alignment with organizational values and culture, and regular communication. home care providers (hcps) identified the importance of leadership and perceived the kb to be integral for facilitating communication, keeping strategies on track, and brokering information. barriers to strategy implementation also emerged however, including significant time constraints, limited resources, and the variable nature of dementia. hcp reported that the ikt strategies enabled rural/community-specific solutions, enhanced their knowledge and ability to use best practice dementia information, increased their capacity to exchange dementia knowledge, and ultimately enhanced family and client well-being. conclusions: hcps reported professional benefits from their participation in the ikt strategies, and perceived benefits for people living with dementia and their caregivers. findings suggest the utility of such strategies for addressing ongoing education needs of rural care providers. keywords: dementia, integrated knowledge translation, home care, rural online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 31 development and implementation of dementia-related integrated knowledge translation strategies in rural home care dementia is a syndrome with multiple etiologies that affects memory, cognitive function, behaviour, and ability to perform everyday activities (world health organization, 2012). as a neurodegenerative disorder with high incidence and prevalence (hirtz et al., 2007), it is estimated that over 65 million people will be living with dementia worldwide by 2030 (prince et al., 2013). given the prevalence and significant impacts of dementia on individuals, their families, and health care systems, dementia has been identified as a priority health area by the world health organization. since the risk of dementia increases rapidly with age (ferri et al., 2005; viera et al., 2013) the provision of quality dementia-related health care is particularly important for countries with aging populations such as canada, where the number of people aged 85 and older grew by 19.4% from 2011 to 2016 (statistics canada, 2017). the provision of quality dementia care in canada will be increasingly difficult in general as the population ages. rural areas face specific challenges such as shortages of human health resources such as nurses, physicians, and home support workers, few local support resources for persons living with dementia and their caregivers, limited specialist and professional services, and insufficient access to long term care homes, respite, and day programs (canadian home care association, 2006; dal bello-haas, cammer, morgan, stewart, & kosteniuk, 2014; morgan, semchuk, stewart, & d’arcy, 2002; teel, 2004). additionally, poor transportation options and travel requirements can be difficult for both people and families living with dementia. working over long distances and/or in a setting where local resources are limited poses unique challenges for health care providers. the above challenges, coupled with other factors such as lack of family awareness regarding services, can lead to unmet health needs and crises for people living with online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 32 dementia and families (forbes, morgan, & janzen, 2006; morgan et al., 2002). furthermore, when care or services are available and accessible, providers may not be equipped to deliver optimal dementia care and support. researchers have suggested that the educational needs of rural formal care and support providers are often not met, and that continuing education opportunities and access to current dementia-related information and best-practices are required (dal bello-haas et al., 2014; forbes et al., 2012; forbes et al., 2011; morgan, innes, & kosteniuk, 2011). access to evidence-based and current information is important to maximize the quality of care provided to people living with dementia, but also for communication and the exchange of knowledge with families affected by dementia. forbes et al. (2012) explored the knowledge needs and degree of knowledge exchange between rural community-based health care providers, people living with dementia, and their care partners. they found that trusting relationships between health care providers and care partners were important to the successful exchange of knowledge and meeting the needs of care partners. however, health care providers reported that these relationships were difficult to establish in a climate of short-staffing and minimal resources; their own ability to access knowledge was limited given these constraints. working in relative isolation from other health care providers and organizations was also a frequently reported barrier to interprofessional knowledge exchange, which in turn limited the ability of care providers to provide information to people living with dementia and their families. this work suggests that rural dementia health care providers, people living with dementia, and their care partners would benefit from increased and perhaps more formalized knowledge translation supports. one such support is the development of a knowledge brokering (kb) role, which has recently been gaining traction within the health care sector (bornbaum, kornas, peirson, & rosella, 2015). knowledge brokers perform a variety of tasks which can be categorized into the domains of online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 33 knowledge management (facilitating the creation, exchange, and application of knowledge), linkage and exchange (developing or enhancing knowledge exchange and relationships between different knowledge users and creators), and capacity building (strengthening knowledge users’ capacities and skills, evidence-informed decision making, and capacity to access and apply knowledge) (bornbaum et al., 2015; ward, house, & hamer, 2009). while kb is often unplanned and happening on an informal basis as part of professional practice (canadian health services research foundation, 2003; currie & white, 2012; elueze, 2015), formal kb positions and initiatives have been identified within the health sector as a priority in efforts to increase evidencebased decision making (ellen et al., 2014). initial research on the effectiveness of the kb role in a variety of health-based contexts has suggested its utility for the successful exchange of knowledge between individuals and groups, translating research evidence into policy and practice, connecting people to useful knowledge, facilitating optimal patient care and acquisition of knowledge, and enhancing teamwork, relationships, and links between health care players and sectors (elueze, 2015). given the need for increased knowledge translation supports within rural dementia care (forbes et al., 2012), the current project aimed to support the development of integrated knowledge translation (ikt) strategies to facilitate the exchange and use of best available dementia care knowledge by rural home care providers (rhcp), people living with dementia, and their caregivers. ikt strategies refer to those that are developed collaboratively with knowledge users, to ensure that their priority questions or needs are addressed (cihr 2011; bowen & graham, 2013). this research was developed using the promoting action on research implementation in health services (parihs) framework (rycroft-malone, 2004; kitson et al., 2008). the parihs framework posits that for knowledge to be successfully translated and implemented into practice, online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 34 clarity is needed about the type/credibility of evidence or knowledge being shared, a conducive context (i.e. environment or setting), and effective facilitation to support knowledge exchange and changes to practice (rycroft-malone, 2004; kitson et al., 2008). in its most recent iteration, published after the development of the current research, the i-parihs framework has been reconceptualized to more comprehensively address the types of knowledge that are shared/created for implementation into practice, highlight the roles of actors involved in the implementation of knowledge, and explicitly consider the impacts of the wider, external context (e.g. the broader health system and its embeddedness in social, cultural, and economic systems) (harvey & kitson, 2016). facilitation remains central within this modified framework; harvey and kitson (2016) conceptualize the facilitator role and associated activities as the activators of implementation, and therefore critical to its success. this project aims to explore the processes of knowledge exchange as ikt strategies related to dementia care. this was accomplished by examining how ikt strategies were developed and implemented in two rural canadian home care centers with the help of a kb who was hired for this purpose. specifically, the following research questions were posed: a) what are the process and contextual factors which facilitate or hinder the development and implementation of dementia care ikt strategies? b) how is the facilitation role of a kb perceived by knowledge users during these processes? and c) what are the perceived impacts of the developed ikt strategies? rhcp participated in the development of the ikt strategies and represent key knowledge users, who rely on up-to-date knowledge in dementia care in their work and are also important sources of knowledge for family caregivers. the purpose of this article is therefore to explore rhcp perceptions of the development, implementation, and impacts of the ikt strategies, with a focus on the kb role. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 35 methods the current research was designed as a longitudinal multiple case study, in which the design and implementation of ikt strategies at two sites were assessed at multiple time points. participants two home care centres in rural northern prairie communities were selected as the study sites (site a and site b). sites were selected based on the recommendation of a principal knowledge user working in the north zone of alberta health services. both communities have approximately 5000 people, are within 30 km of each other, and a couple of hours drive from a major centre. workshops were initially held in both sites to explore rhcp concerns/challenges in providing best available dementia care, and all rhcp were invited to participate in this process and the larger study. across sites a and b, 36 participants who were involved with providing or receiving home care services agreed to participate. participants included people living with dementia (n = 3), their family caregivers (n =14), and home care professionals (n =19). the sample for the data presented consists of the 19 rhcp (18 female, one male), who occupied diverse occupational roles within the home care setting (see table 1). on average participants had worked within the community for over ten years, within the profession for over twenty years, and most were currently employed part-time. a significant proportion of participants’ current caseloads were comprised of persons with memory problems, indicating the relevance of dementia-focused ikt strategies to this sample. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 36 table 1 participant demographic information rural home care providers site a (n=10) site b (n=9) mean age 52.8 50.9 highest level of education health care aide certificate college diploma undergraduate degree 1 7 2 4 1 4 current work role rn lpn health care aide case manager director/manager other 3 1 1 2 2 1 3 1 4 3 mean number of work hours/week 31.4 29.3 employment status full time part time 4 6 2 7 mean years in profession 22.7 20.2 mean years in current community 10 12.4 mean number of clients on case load 28.7 29.8 percentage of current clients with memory problems 58.4% 41% ikt strategy development and implementation a registered nurse, who had home care managerial experience and was familiar with both home care settings and the communities, was hired and trained by the principal investigator (pi) in knowledge brokering. the pi connected with the kb on a regular basis to discuss approaches, challenges and successes in supporting the home care staff in developing ikt strategies. beginning with facilitated working group sessions to discuss gaps and potential solutions in dementia care, each site planned and implemented their own ikt strategies. site a developed two ikt strategies, although the second strategy (a meeting with senior area managers to discuss issues and needs related to dementia and care provision) was implemented after data collection. their main strategy online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 37 involved the development and implementation of an information/resource booklet for persons living with dementia and their caregivers. this booklet included information about dementia, dementia management and communication strategies, a list of local resources with descriptions (including associated costs) and contact information, and links to other helpful dementia-related resources. after obtaining feedback from families of people living with dementia, the booklet content was finalized, and copies were printed for distribution. site b focused on one ikt strategy that entailed dementia education and skill training. health care aides and a registered nurse (rn) worked through online modules within the u-first program, which was developed as part of the ontario ministry of health and long-term care’s alzheimer’s strategy prior to 2004 (ryan, 2009). u-first is designed specifically for individuals working within community, acute, and long-term care and aims to improve the quality of interaction between the care provider and the person living with dementia. after completing the program modules, rhcp used u-first wheels (a tool summarizing u-first information and tips for quick reference) to apply skills with clients when providing respite and daily care. procedure and data collection rhcp who consented to participate completed three interviews about the development, implementation, and impacts of the ikt strategies (at baseline, 6 months into the process, and a few months following the termination of the kb role). the interview schedules were developed in accordance with the parihs framework (see rycroft-malone, 2004; kitson et al., 2008), and included questions about evidence (e.g., based on what you were trying to achieve by participating in the demonstration project, what type of information was most useful?), context (e.g., in your workplace, was it difficult or easy to use the information you accessed through the demonstration project?), and facilitation (e.g., what strategies used by the knowledge broker facilitated and online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 38 hindered the success of the projects?). at the final interview, participants were also asked questions focused on perceived impacts of the ikt strategies. all interviews were conducted in a private room in the home care office. ethics approval was obtained from the university of alberta, health research ethics board (id pro000048613; amendment pro00048613_ren1). data analyses interviews were transcribed verbatim and subsequently coded using thematic analysis (braun & clarke, 2006). data were organized by question, with key meanings identified and coded, including those that did not match emerging patterns. codes which cohered around a central concept were then organized into themes, which were considered in relation to each other and the overall dataset. themes, along with illustrative quotations from participants, are presented below. findings in line with the foci of this research, themes were organized into three categories: (a) facilitators and barriers of ikt, (b) role of the kb, and (c) perceived impact of the ikt strategies. while rhcps identified several facilitators of effective knowledge translation strategies (i.e., collaborative development by knowledge users, alignment with organizational values and culture, and regular communication), barriers also emerged (e.g., lack of time, limited resources, and the variable nature of dementia). participants felt that leadership was important to the success of the ikt strategies and viewed the kb very positively, specifically regarding facilitating communication, keeping strategies on track, and brokering information. the kb role was perceived as a valuable human resource helpful for continuing knowledge translation. finally, rhcp described how the ikt strategies allowed community-specific solutions, enhanced online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 39 professional knowledge and ability to use best practice dementia information, increased capacity to act as kb with families, and ultimately enhanced family and client well-being. effective knowledge translation strategies: facilitators collaborative development by knowledge users. a facilitator of effective knowledge translation strategies in the current research was having knowledge users themselves (rhcp) develop the strategies by means of a collaborative process. through the facilitated working group sessions participants worked collectively to identify dementia-related issues that were pertinent to their rural community and worksite, and developed strategies to address them: i think the best strategy was the way we came about establishing what the problems were for people. i think the backwards methodology of how we got to what our— what did we think was gonna be the best, how we could help people in the most cost effective, quickest manner, i think that was really cool. -area manager, site a in site a the main issue being addressed was limited and inadequate support for families of people living with dementia and poor awareness/uptake of existing services. in site b the issue was limited rhcp knowledge and opportunities for continuing education on dementia care best practices. being part of the process to determine solutions to problems was rewarding to rhcp and enhanced commitment to the tasks required for successful strategy implementation: everyone was pretty excited about it even though it was a little extra work, but it’s different from the day-to-day routine too. something that’s needed, not really new but yet exciting to be a part of developing something that might actually go somewhere -rn, site a participants found it meaningful to participate in knowledge exchange (ke) efforts they felt would benefit professionals and families dealing with dementia in their communities. one rn from site a stated that even the support for an initiative in their rural community was helpful: “just basically online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 40 the interest and especially in rural because we don’t have anything at rural, and what works and what doesn’t, it’ll be a benefit i thought.” finally, being able to work in a collaborative manner was identified as helpful by participants, as they did not always have opportunities to communicate about issues and work together: well, i really believe that using the [u-first] model and having the home support aides part of the collaborative meeting was just, it’s the only way to go really to get this information out. and to try and focus on specific clients that things may work, you know, the principles are there… the principles are there but you have to change it for each client. and being able to do that, you can’t do that in a vacuum. you have to do that with other people around you and make the decisions that way, i think. -rn, site b participants identified colleagues as important sources of knowledge and found it helpful to apply an inter-disciplinary approach to the development and implementation of ikt strategies. alignment with organizational values and culture. participants felt that the ikt strategies were well-aligned with the priorities and values within their organization, such as helping people living with dementia stay at home longer, supporting clients and caregivers, and educating families: “it’s talking about excellence, right? and that’s what it is for me is enriching the caregiver’s resource space, so that they’re better equipped to meet client needs”. -rn manager, site b. moreover, the strategies were implemented using resources and processes participants reported were already part of the organizational culture, such as regular communication and meetings between staff members. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 41 implementation of ikt strategies was also facilitated by the supportive attitudes of managers, and an organizational culture that was receptive to formal ke efforts. in discussing this culture, one participant remarked: i think we’re like a great group of people that are willing to learn new things, and try new things, and well, provide the best patient care. and we have a really good team lead who likes us to participate in different things because it’s a learning experience. so, we all learn something. -rn, site a participants reported that their superiors did not dictate how the strategies should be developed, but rather interacted collaboratively and supported autonomous efforts. regular communication. rhcp spoke at length about the degree to which ongoing communication and meetings with colleagues facilitated ke. in addition to the collaborative brainstorming meeting, ongoing communication helped keep the ikt strategies on track: i think the idea of getting together originally, which was good, because then you are picking from different areas. you’re not just working as one, like not just community care… i think the best thing that really worked well is getting together with just the meetings afterwards, so we could streamline it together, too. -licensed practical nurse (lpn), site a meetings enhanced the collaborative processes which participants valued, and helped ensure strategy implementation progressed. ongoing communication and meetings also enhanced rhcp ability to learn from their peers’ professional experiences and share new information learned: “i like to have meetings. i like to do a little bit of research on my own and then come, bring it back to the table and discuss it.” – online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 42 rn, site a. participants in site b reported that ongoing communication and meetings with peers encouraged them to use the new information and skills learned: the regular meetings gave me new insight of what we needed to do or what we were trying to accomplish because i found that at first, i was saying we don’t have time for this. we only have a couple of minutes… so, it was hard at the beginning to get into it because this was not our practice. but then, it was kinda like it let you put your guard down and say that i can take this extra five minutes. i can do this with this client. –home care aide (hca), site b site b participants also reported that discussing their experiences working with people living with dementia using the u-first wheel with colleagues helped successfully integrate new strategies into their practice. although regular communication and meetings was a facilitator to implementation of ikt strategies, a minority of participants reported online communication and information to be a barrier: like even like the kb says, ‘oh, i sent this email off to everybody.’ how many people looked? i didn’t. i didn’t go check my emails because i don’t do that very often. so, if there’s stuff happening there, i’m going to miss it. and i think a lot of people would… and then, of course, when i’m looking at it in front of me, it seems to be clearer in my mind… i’m a hardcopy people. not a computer people. –hca, site b while computers were accessible at both sites, some participants (home care aides in particular) were uncomfortable learning and communicating online or did not perceive online activity to be part of their job. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 43 effective knowledge translation strategies: barriers time constraints. time constraints emerged as a significant barrier to the successful development and implementation of ikt strategies. although regular communication and meetings were already part of the organizational culture of both sites, the strategies involved an additional time commitment that people found difficult to meet: it’s just, you know, it’s so hard to pull off a project because it’s not that others didn’t cover for you when you attended. it’s not that best effort forward wasn’t made, and it wasn’t that everyone didn’t try to be there. it’s just that it becomes low on the totem pole. you know, you just got to fit it in. -lpn, site a irrespective of their specific employment role, rhcp were stretched thin and working with high caseloads. participants overwhelmingly indicated that they found it difficult to add additional strategy development and implementation tasks (e.g. searching for information, attending meetings, providing feedback, completing the online modules) to their workload. time was also a barrier to communicating with clients living with dementia and their families and successfully exchanging information. a lpn from site a explained: time, in the sense of taking the time when you make the visit to elaborate or go through or presenting a package is one thing but taking the time to kind of slide through it with the family that’s going through something like that, i think would be more beneficial than just passing it to them. although rhcp ultimately felt better equipped to communicate with people living with dementia and their families following the ikt projects, time remained a barrier to successfully doing it. similarly, some participants reported that time constraints made it difficult to use the information or skills they had learned: online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 44 and then the other thing that frustrated me with this was, okay, let’s do this but you know, in our jobs, we don’t have time for this… you know, like you don’t have the time with our clients to step back, take the time, here you go, let me help you… like i said our job is personal care. so, you’re going in. you have five minutes with the dementia client, you know? -hca, site b limited resources. although most participants reported time was the only significant barrier to ikt, others described how working with limited resources (i.e., human, technological, financial, and programming) made it more difficult to implement strategies. participants felt that more human resources would improve ability do their job as well as access new dementia care information. as noted above, some rhcp found the use of online information difficult as they did not have convenient computer access: the online modules, i did most of them. i did not complete them. i found them repetitious, long for the time that i had because i don’t live in town. i run to town. i have to come, i don’t have a computer at home. hca, site b in site a, several participants felt that they could have done more with more financial resources to be allocated towards staffing, patient care, and knowledge translation. one participant stated: i think we would have been further at producing if we had a little bit of a budget to go with it. so, i would say definitely the financialthat was one of the struggles. how were we going to make a positive impact and a meaningful impact but not have a budget to do it? recreational therapist, site a finally, some rhc described a general lack of resources in their community, which could not be ameliorated by knowledge translation and made it difficult to effectively help clients: online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 45 it’s just disappointing because it’s like, i know what i’m doing is not enough… we could do this better. yeah, working with the group and even some of the families that i’ve given that booklet to and stuff, a lot of it was, well you know it would have been great if we had this earlier. or, you know it’d be wonderful if we could actually have more in-home help which we don’t have right now, so just things that are lacking or such a thing as simple as, you know these families want to go to these support groups, which has started but there’s no resource for them to access to go and somebody’s looking after the person with dementia… the follow through is still missing. the hands-on resources i guess, the physical resources. -rn, site a limited access to services was therefore a barrier to meeting goals (helping families access resources, keeping people living with dementia at home longer) of the ikt strategies in site a. participants described how more resources, especially respite care, were needed to effectively help people living with dementia and families in their community. ultimately, participants felt that more funding for dementia would enhance their ability to hire more staff, increase programming, and engage in more effective knowledge management. the changeable nature of dementia. one of the unique barriers to ikt reported by participants was the variable nature of dementia. rhcp felt while up-to-date information on dementia and best practices was useful, a challenge was that each person living with dementia expressed different needs and behaviour: i honestly kinda run on my shirt tails anyway when i get with people and just try and go live in their world as best as i can and kind of direct them that way. and if we get information passed to us and that sort of thing, i definitely take that in, but i find with people everybody is so different… i mean the information you get is kind of a guideline. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 46 hca, site a rhcp reported that discussing clients with their peers was a helpful source of information, to understand each client as an individual. the nature of dementia could still pose difficulties however as rhcp tried to apply information and strategies, since the behaviour of many clients was variable day-to-day: i think for some, it made a difference for a while but then you must tweak it again because their condition changes or they get… one day, it works. the next day, it doesn’t. you know, when they get a bladder infection or their physical abilities change, that kind of thing, it changes. it’s always a changingit’s a moving target. that’s what it is. -rn, site b rhcp felt that it was crucial to adapt knowledge and resources to clients’ current needs; this reality made it more challenging to apply dementia care information learned though the ikt strategies. the role of the knowledge broker kb as leader. rhcp perceived leadership as important for the success of the ikt strategies, particularly to their development. participants valued the initial working group session and reported that facilitators led them through brainstorming and decision making in a way that fostered ownership and enthusiasm about the project. participants also viewed the kb as a leader, who guided them through ikt strategy implementation: she kept us on track which i feel without her, things will just not— she was the head of that, she was the one who kept all the notes and planned the meetings and stuff and without someone taking the lead role, things may not follow through how they’re supposed to. -rn, site a the kb was perceived as a constant presence who pulled aspects of the ikt strategies together and was available for questions and advice. although rhcp valued their own collective roles in online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 47 developing and implementing the strategies, they reported kb leadership was necessary for success given their busy workloads. kb as communication liaison. one of the most fundamental tasks performed by the kb was facilitating communication. the kb coordinated project-related meetings, emailed meeting minutes, made herself available to rhcp for questions or issues, and checked in by phone or email with individual staff. participants valued the time the kb spent communicating with them and felt that she coordinated communication between rhcp in a way that facilitated knowledge translation: i’d say she did really well with the project. very organized and she was there to kind of, like even in our meetings, she was there asking questions and kind of summing things up for us... -hca, site b given the importance of ongoing communication to the successful implementation of the ikt strategies, participants perceived the kb’s communication efforts as crucial. kb as monitor. in line with her role as communicator and leader, one of the kb’s perceived functions was to make sure that rhcp were continuing to work on the ikt strategies (e.g. finding resources for the booklet, completing the online modules). as an rn from site b commented: well, having a knowledge broker helps to facilitate that you focus on the problem at hand because you can get yourself overwhelmed by going all over the place or… they were very good at making sure we stayed within our boundaries and didn’t go off track too much. participants found it valuable that the kb was overseeing the progress of the projects and able to “keep everybody on track”; this was perceived as necessary to keep them focused on kt and the strategies amidst their other workplace demands. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 48 kb as knowledge resource. finally, rhcp described the kb’s ability to effectively research, identify, and collate up-to-date dementia knowledge, to facilitate ke and the use of best practice information. in site b, the kb engaged in online research and identified the u-first program as a current and useful tool for home care aides: the knowledge broker being able to come in and do some of the education about it or the identification of it… she had to find it for us, right? and so, it was something she learned about and then went and researched it and then sort of came back and said, “this is what i’ve found.” -rn manager, site b as part of her leadership role, the kb was also a source for answers to rhcp questions. in site a, individual rhcp aided the kb with research on dementia and local resources, and the kb collated this information into a coherent and user-friendly package: she’s taken all our information because we’ve given her, and she’s organized it and put it into a package and brought it back to us. and we had say on what we liked and what we didn’t like, and she changed it… we would literally just give her little bits of information and she put it together. -rn, site a participants in both sites emphasized that with their professional demands there was very little time to seek additional research, knowledge, and educational materials; the kb role was therefore important to finding quality information and translating it into an accessible format. kb role as an ongoing human resource. the role of the kb was valued by participants, who felt that the ikt strategies would have been less successful without the kb’s leadership, communication, monitoring, and knowledge brokering. participants spoke about time as an enormous barrier to ke after termination of the kb position: online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 49 time to find it [information]. and there’s no, after the knowledge broker is removed, the onus will be back on us to be trying to find the time to research and find research because there is no current avenue to be able to support frontline workers with easy accessible information. -rn manager, site b participants spoke of difficulties sustaining the current ikt strategies (e.g., updating the resource booklet developed in site a, ensuring that rhcp are kept up to date with best practice information and implementing it with clients), expanding them, or engaging in further coordinated ke efforts. again, time was a major barrier and participants felt they had little access to ongoing education, as noted by an rn from site b: “we don’t see an education person ever, you know, in our office. it’s sad.” many participants identified the desire for a sustained kb role. in speaking about potential changes she would like to see, as a result of the ikt projects, an rn from site a replied: “once again hopefully the staffing, like that one person that maybe is responsible for this, and does it, and gathers all the information and keeps it up to date, not so it’s all old.” participants were aware of the fiscal challenges in sustaining such a role and described how a kb could be part time, apply skills to conditions beyond dementia, or be shared among multiple locations. rhcp reported that this human resource would allow them to better keep up to date with current dementia information, update client resources, seek case-related resources and information, encourage best care practices, and ensure that dementia information is relevant for specific rural areas. perceived impact of ikt strategies community-specific solutions. participants described how the ikt strategies allowed them to address community-specific gaps and solutions. several participants described rural resource gaps or commented that strategies for urban areas cannot necessarily be applied to rural. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 50 since rhcp were involved in strategy development, they could ensure that knowledge was applicable and usable for their community and professional role. this was particularly salient for the booklet developed in site a: we’re looking at community, different points for people who are caregivers, it could be family members that have somebody with dementia… looking at the resources within the community, identifying what is dementia, what are resources. so, we’ve got like the adult day program, respite within our facility, home care resources, meals on wheels, some common contacts for that, how to communicate with people, looking at personal directives, goals of care, how people are placed. so basically, it’s a good workable document and it’s specific, a good workable booklet and it’s specific to the resources in our community. recreational therapist, site a rhcp in site b described a high proportion of older adults and people living with dementia within their community and reported that their ikt project helped ensure staff were knowledgeable and using best practice information with clients. enhanced professional knowledge and skills. participants overwhelmingly indicated that the ikt strategies enhanced professional knowledge about dementia, best practices/skills, and resources within their community: it gave me more information, i feel more, what shall i say? confident, it gave me a lot of confidence and with the information i have it’s solid, it’s legit, it isn’t just me googling whatever. so, with the information that i have, it’s very evidence-based and i appreciated it. -lpn, site b as illustrated above, many rhcp described feeling more confident working with people living with dementia and their families. rhcp in site b reported having more dementia-related online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 51 knowledge and practical skills to apply and found these skills helpful in their everyday work role. the rn manager in site b explained: the aides reported that it was really, really good for them… you could see their excitement as they had been able to study something, go and try it for a month and see what they can do and then come back and report to us, “oh, this changed.” … they felt better equipped to handle difficult behaviours. they reported that they were able to change their own personal approach to the client recognizing that the client’s behaviour was coming from something. so, it reframed the way they were thinking and approaching the client. rhcp in site a also reported greater dementia-related knowledge including resources within their community, which they felt was crucial to supporting people living with dementia and families. a minority of rhcp (primarily in site a) did not feel they learned a lot of new information; however, these participants valued the increased knowledge of peers or families as well as the validation of their own practices: so, i think it also reaffirmed that, you know, the way i was doing my nursing was still okay and still effective and still considered a good practice. so, when i try and coach other staff members or healthcare aides how to approach people, i feel that i am giving them pertinent information and up to date ideas. -rn, site a all participants therefore perceived the ikt strategies to be a professional asset. increased capacity for knowledge translation. another perceived impact of the ikt strategies was increased rhcp capacity to communicate and exchange knowledge with people living with dementia and their families. site a’s resource booklet was a concrete manifestation of ke, but rhcp also felt that it encouraged further conversations: i think because we have a conversation with them, not that we never used to, but we’ve got something concrete to give them online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 52 and to explain to them. (rn team lead, site a). the booklet opened a line of communication between rhcp and families to talk about dementia and resources. in addition to more effective communication with people living with dementia through the u-first strategies, several site b rhcp felt better able to share dementia-related information with their families: i don’t tell them exactly what i’ve learned in the thing but a lot of clients would ask about dementia or the families will have a hard time and i find it sometimes easier now that i can explain things to them. like don’t be afraid, or it’s normal, or before you were kind of, what should i say? should i say anything at all or just stand there and be quiet, you know? where now i find that i can give them a little bit more information or saying that there is help for that or if you need more information, there is more information. -hca, site b this was important to rhcp as most of them identified sharing information and educating families to be part of their professional role. participants also perceived an enhanced capacity for ke with peers. both ikt strategies brought together individuals with different professional roles, and participants reported that it was a benefit to learn from different perspectives and experiences: probably just the conversation because i learned a lot from peers and colleagues that we don’t often talk to. we were involved with the recreation department and listening to their concerns and what they see, you know, it’s sometimes good to be outside of our little box. rn, site a it was also noted that increased ke between peers strengthened inter-professional communication about specific clients and made it easier to provide performance feedback. enhanced well-being for people living with dementia and their families. finally, rhcp perceived benefits to people living with dementia and their families, largely because of online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 53 enhanced knowledge/skills and communication. participants in site a received very positive feedback from families regarding their booklet and perceived families to be more aware of local community resources, which was a goal of this ikt strategy. a registered nurse commented: “they [families] all thought it was a great thing, that it was very useful information.” several rhcp explained that the information met families’ needs and helped them interact more positively with the person living with dementia, as exemplified by an rn: you kind of know when a client’s family comes back, and they say they have read some of those articles and found them very helpful, and that they were going to change some strategies and how they were talking and dealing with their dementia person in their family. so, i thought that was good to know that we had reached our goal. participants also felt that there were better channels of communication and support in place between rhcp and people living with dementia or their families. in site a, the resource booklet helped rhcp offer support and created a space where families felt comfortable approaching them with needs and questions: i mean giving out these packages, one client in particular who sticks in my mind, gentleman looking after his wife, and he phoned me on a regular basis after he got this package to say, “well this is happening, what do i do now?” which was lovely, we had a connection then that he felt he could phone and ask and get more information. -rn, site a in site b, most of the enhanced communication and support centered on more positive interactions with people living with dementia, as illustrated by a rhca: and then i started paying more attention to this gentleman, started listening to him, taking an extra five minutes to pay attention to what he had to say… at the beginning, i found it a little bit difficult because he [has] dementia, right? but the more i used the wheel and online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 54 tried to figure him out, the easier it became; the less i ran in in a hurry and calmed down. and my approach, my attitude, my everything made a difference on how he approached me and how he felt. and then he started to open up and tell me a lot of stuff about his life and about himself and everything else. and then he became more confident and confident in me and trusted me more. overall, participants in both sites perceived positive impacts of the ikt strategies such as enhanced communication, stronger care relationships, and increased access to knowledge and community resources for people living with dementia and their families. discussion findings illustrate how dementia-related ikt strategies were successfully developed and implemented within a rural home care context. with the help of a kb and support from the researchers, home care providers collaborated to identify gaps/issues related to dementia care, developed ikt strategies to address them, and implemented strategies to increase the use of best practice information in dementia care. this process reflected the key steps identified as necessary in translating knowledge to action (see graham et al., 2006). in addition to the above activities, knowledge was identified and adapted to the local context, barriers to the process were assessed, knowledge use was monitored, evaluation of outcomes was undertaken, and discussions around sustainability and expansion occurred. moreover, rhcp perceived strategies to be of benefit for kt within their professional practice, reporting increased collaboration, and sharing of information with colleagues as well as people living with dementia and their families. while some of the information shared was new information from the ikt initiatives, the increased collaboration meant that rhcp also engaged in internal/informal knowledge brokering, where they shared practice-based knowledge (currie & white, 2012). as noted by ward, smith, house, and hamer online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 55 (2012), informal kt is important and integral to change; our findings suggest that it was enhanced through the collaborative aspects of ikt strategy processes and highly valued by rhcp. an important aspect of ikt is the degree to which the knowledge in question is being applied or influencing practice or decision making (see, e.g., cihr, 2011; campbell, mcintrye, & lord, 2013; straus, tetroe, & graham, 2011). in addition to increased professional knowledge (for most participants), rhcp described how they were using the new knowledge to better inform families about dementia (site a) and interact with people living with dementia in more successful ways (site b). these were important benefits described by rhcp, and it was noted by several participants that the new information and its successful use increased rhcp confidence and positive outlook on ikt activities. in accordance with the parihs framework (rycraft-malone, 2004; kitson et al., 2008), contextual factors functioned as barriers and facilitators to the success of ikt strategies. alignment of strategy processes with the values and culture of the home care organization and managerial support were considered facilitators, while limited time and resources (financial, human, and community) emerged as barriers. these facilitators and barriers are like those described by previous researchers in different health-related contexts, where barriers to kt and kt interventions included limited resources such as money, staff, and time, and facilitators included investment from decision makers and managers (e.g., ellen et al., 2014; straus et al., 2011; yost et al., 2015). also, consistent with theory and empirical work on kt is the importance of knowledge user collaboration and ownership in kt strategy development and implementation (bowen & graham, 2013; graham et al., 2006; kothari & wathen, 2013). in the current research, this was particularly salient given the rural settings of both home care organizations. minimal local resources posed challenges for dementia care and participants emphasized the importance of online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 56 rural and community specific solutions to address the gaps within their respective communities. the mixed feedback regarding online communication and information is noteworthy; this emerged as a barrier for some rhcp and is therefore a potential consideration for other ikt or evidencebased practice initiatives. participant descriptions of dementia-specific challenges are also noteworthy, as they highlight the potential for difficulties with knowledge utilization with this population. fluctuations in cognition, attention, arousal, behavioral and psychological symptoms, verbal ability, memory, and ability to perform activities of daily living are common in people living with dementia. fluctuations may differ in kind and frequency of occurrence depending on the individual and their environment, stage of disease, and subtype of dementia (bradshaw, saling, hopwood, anderson, & brodtmann, 2004; lee, taylor, & thomas, 2012; rockwood, fay, hamilton, ross, & moorhouse, 2014; quinn, clare, jelley, bruce, & woods, 2014). interand intra-individual variation in abilities and behaviours posed challenges for rhcp applications of information with clients. successful knowledge implementation in this setting was therefore highly dependent on rhcp ability to constantly reassess the situation and choose useful strategies. rhcp reported the most success when able to apply relational skills, such as listening more to the person living with dementia and trying to understand the underlying causes of problematic behaviours. part of knowledge exchange and utilization for rhcp was therefore recognizing that the usefulness of specific dementia information and strategies was highly situational. similarly, the progressive nature of dementia meant that stage needed to be considered for providing useful information to family caregivers; several rhcp indicated that families needed to receive information on dementia and accessible resources as early as possible during the disease. this is consistent with research suggesting that caregiver information needs vary over the course of dementia and that information online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 57 on resources is particularly important early in the disease trajectory (forbes et al., 2012; zwaanswijk, peeters, van beek, meerveld, & francke, 2013). finally, rhcp perceived the kb to be integral to the development and implementation of the ikt strategies. the parihs and i-parihs frameworks stress the importance of facilitation to the successful implementation of knowledge into practice (harvey & kitson, 2016; kitson et al., 2008). the rhcp saw the kb as an important facilitative resource who was able to manage knowledge and coordinate collaborative processes. in a recent systematic review of knowledge brokering, bornbaum and colleagues (2015) suggested that the activities and tasks carried out by kbs confirm their characterization as knowledge managers, linkage agents, and capacity builders. our rhcp participant descriptions of the kb’s involvement (as leader, monitor, communication liaison, and knowledge manager) aligned with these primary characterizations and were congruent with other descriptions of how kbs facilitate ke processes (bornbaum et al., 2015; conklin, lusk, harris, & stollee, 2013; elueze, 2015; glegg & hoens, 2016; traynor, decorby, & dobbins, 2014). importantly, rhcp also suggested that the kb role was needed to ameliorate barriers (time, accessibility of knowledge) to accessing and implementing best-practice information. in discussions of sustainability, rhcp perceived the termination of the kb role as a threat to continued updating and expansion of the ikt strategies. traynor et al. (2014) noted that once relationships have been built and in-person kb support has been provided, virtual support may be useful; sustainability and the extent of internal capacity building are important considerations for kb initiatives. in the current research study participants’ requests for an ongoing kb role may reflect the limited resources in both of these rural settings, as well as an indication that the ikt strategies needed more of a focus on capacity-building. finding ways to adequately support ongoing kt within a rural context is an important goal for future work in the area. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 58 conclusions this research adds to the literature on ikt and processes of ke; such process-based information is important for the establishment of future ikt initiatives within different contexts. specific to a rural context, findings illustrate the utility of ikt strategies for addressing some unmet, ongoing education needs of rural care providers (dal bello-haas et al., 2014; forbes et al., 2012; forbes et al., 2011; morgan et al., 2011). rhcp reported professional benefits from participation in strategies, as well as improved support and care for people living with dementia and families. including a kb as a facilitator may be crucial for rural and remote communities who often face a shortage of human health resources (canadian home care association, 2006; dal bello-haas et al., 2014), making it difficult to add kt activities to care provider roles. as noted by morgan et al. (2011), rural areas have less capacity than urban settings to develop specialized services for people with dementia; it is therefore important to ensure that rural care providers are capable and comfortable delivering high quality care and support to people living with dementia and their families. while the findings of this research are applicable to ikt more broadly, they provide an illustration of how ikt strategies and the kb role can be successfully applied within a rural setting. references bornbaum, c. c., kornas, k., peirson, l., & rosella, l. c. (2015). exploring the function and effectiveness of knowledge brokers as facilitators of knowledge translation in health-related settings: a systematic review and thematic analysis. implementation science, 10: 162. https://dx.doi.org/10.1186/s13012-015-0351-9 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.509 59 bowen, s. and graham, i. d. 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(2013). informal caregivers of people with dementia: problems, needs and support in the initial stage and in subsequent stages of dementia: a questionnaire survey. the open nursing journal, 7, 6-13. https://dx.doi.org/10.2174/1874434601307010006 microsoft word 42-331-1-ed_coyle.docx online journal of rural nursing and health care, 12(1), spring 2012 40 effects of an interprofessional rural rotation on nursing student interest, perceptions, and intent susan b. coyle, phd, rn 1 georgia l. narsavage, phd, cpnp, faan 2 1 assistant professor, west virginia university school of nursing, robert c. byrd health sciences center, scoyle@hsc.wvu.edu 2 dean and professor, west virginia university school of nursing, robert c. byrd health sciences center, gnarsavage@hsc.wvu.edu abstract rural areas are in critical need of nurses to meet the health needs of their residents. the problem under investigation in this study was whether a semester-long interdisciplinary rural rotation changed nursing students’ interest in rural health, perceptions of their performance of selected nursing skills, and their intention to practice in a rural community. 248 senior level baccalaureate students completed preand post-rotation surveys. 53.6% of students reported an increased interest in rural health. significant differences were found in students’ confidence in aspects of their performance including recognizing cultural differences, community assessment, community participation, meeting the unique needs of rural patients, identifying barriers to care, and identifying the impact of socioeconomic status on health. students who attended high school in a rural community, expressed increased interest in rural health, and evaluated the rotation favorably were more likely to practice in a rural state after graduation (p < .05). the findings have implications for changes in nursing education. a more comprehensive approach to rural health may be needed to attract students to nursing practice in rural communities keywords: rural, nursing education, nursing practice, intention effects of an interprofessional rural rotation on nursing student interest, perceptions, and intent nearly 17 percent of the u.s. population lives in a rural area (u.s. department of agriculture, 2011c). these rural residents depend on local hospitals, clinics, and health departments to provide accessible and affordable health care. the shortage of nurses is intensified in rural areas (van hofwegen, kirkham, & harwood, 2005) and rural areas are consistently challenged to recruit from a smaller employment pool. in times of nursing shortage, rural areas report not only a reduced potential workforce but also a less-educated workforce (cramer, nienaber, helget, & agrawal, 2006). additionally, successful recruitment and retention of nurses in rural communities are challenged by lower salaries, limited employment opportunities for nurses and their spouse, professional isolation and limited resources (bushy & leipert, 2005; lasala, 2000). one strategy to improve recruitment of nurses to rural communities is to provide a rural immersion experience as part of undergraduate nursing education. the purpose of this research was to evaluate the impact of a senior-level online journal of rural nursing and health care, 12(1), spring 2012 41 undergraduate rural rotation on nursing student interest in rural health, changes in beliefs and perceptions related to rural health, and intent to practice in a rural state. introduction over the past decade, there has been a major shift from acute care to community-based care in the united states, resulting in the redistribution of the nursing workforce. as this shift has occurred, rural settings seem to have been impacted more than metropolitan areas. although rural areas may have a dedicated employment base provided by local residents, nurses are often drawn to adjacent metropolitan areas by higher salaries and a broader array of employment opportunities (lasala, 2000). rural nursing can be framed as a specialty with a unique theoretical framework (long & weinert, 1989). the nurse practicing in a rural community is a generalist who embraces autonomy and is able to work in an environment characterized by close relationships and limited resources. nurses practicing in rural areas need skills to respond to diverse patient needs, flexibility, and the ability to multi-task and work independently (hunsberger, baumann, blythe, & crea, 2009; mccoy, 2009). rural health nursing is a specialty for which few educational programs prepare students. nevertheless, over the past decade, the rural setting has been used not only to meet the programmatic need for clinical sites but also to help students experience the unique characteristics and needs of rural populations (yonge, ferguson, & myrick, 2006). rural clinical experiences, important to the translation of theory into practice, provide students with opportunities to learn how to implement nursing interventions in an increasingly diverse world. students working with rural nurse preceptors can experience an increased variety of individual and family situations, health needs, and health beliefs and practices. west virginia is a rural state that is in critical need of health care providers to practice in rural areas. limited health care access, greater health disparity, and quality issues result in this appalachian population having an excess of premature deaths from heart disease, all cancers, chronic obstructive pulmonary disease, diabetes, and motor vehicle accidents, relative to comparable non-appalachian populations (halverson, 2004). fifty one of west virginia’s 55 counties are designated at least partially as medically underserved areas (u. s. department of health and human services, n.d.). one of the continuing challenges in research related to rural health is the definition of rurality. the rural rotation being evaluated in this work was implemented in the state of west virginia, the only state that is fully contained within appalachia. forty-two percent of its counties have a population of less than 20,000 people; forty-five percent of its county seats have a population of less than 2500. forty-seven percent of its counties are designated as non-core counties by the office of management and budget (rural policy institute, 2006) and 53% are assigned urban influence codes of 6 to 12 indicating counties that are adjacent to a small metropolitan area and contain one town with 2500 or fewer residents (u. s. department of agriculture, 2011a). in addition, over half of the counties are assigned rural-urban continuum codes of 6 or higher indicating that they contain urban centers of between 2500 and 20,000 residents or are designated as “fully rural” (u. s. department of agriculture, 2011b). based on these criteria and the instrument used to evaluate the rotation, an area with less than 20,000 residents was considered rural for the purposes of this study. in 1991, west virginia university (wvu) received a grant from the kellogg foundation to develop a community based program for health professions students to address healthcare work force issues in rural and underserved areas of the state. concurrently, the west virginia state online journal of rural nursing and health care, 12(1), spring 2012 42 legislature funded the rural health initiative act to support these new educational opportunities. in 1995, the kellogg community partnerships program and the rural health initiative were combined into the west virginia rural health education partnerships (wvrhep), a statewide system of rural clinical training sites. all health professions students in the university system of west virginia were required to complete a rural health rotation (shannon et al., 2005). for nursing students, this rotation required 225 clinical hours in community and rural health education including 180 hours in an assigned clinical site, 25 hours of health-focused service learning, and 20 hours of interdisciplinary activities. in addition, students completed two didactic community health courses and designed, implemented and evaluated a community-based health promotion or disease prevention project as their capstone experience in the nursing curriculum. rural clinical sites provided baccalaureate and masters prepared nursing preceptors and the wvrhep provided housing, learning resources, and technical assistance for students. rural training sites included critical access hospitals, community health centers, health departments, rural health clinics serving the uninsured or underinsured, home health and hospice programs, and schools. effective july 2011, the wvrhep structure was dismantled but the school of nursing continues to provide rural health clinical experiences. literature review because rural rotations for nursing students are limited, there is little nursing education research examining the affect of rural clinical experiences on students. results from research conducted in australia indicated that rural health rotations increased the likelihood that nursing students would select rural placements after graduation. thirteen of 40 students (33%) responding to a post-clinical placement survey indicated a desire to work in a rural community after graduation (lea et al., 2008). in an earlier study of undergraduate students, 89% of students who selected a rural clinical placement (n=30) expressed an intent to work in a rural community; preand post-test analysis of data indicated a 12% increase post rural placement (courtney, edwards, smith, & finlayson, 2002). neill & taylor (2002) reported that 59% of students participating in rural placements (n=33) chose employment in rural or remote sites after graduation. research examining the impact of rural clinical experiences on students in the united states has focused on interdisciplinary rural rotations. erkel, nivens, and kennedy (1995) found that 72% of students participating in a summer rural practicum (n= 11) indicated that their experience positively influenced them to consider practice in a rural community. oneha, yoshimoto, bell, and enos (2001) reported that 63% of health professions students who took part in a year-long interdisciplinary clinical experience at a rural health clinic reported plans to practice in a rural or underserved area. research results document multiple benefits for students participating in rural rotations. students report having time to develop relationships with patients and to collaborate with other health professionals (van hofwegen et al., 2005; macavoy & lippman, 2001; oneha et al., 2001) as well as the opportunity to work with a broad range of patients and health needs (van hofwegen et al., 2005). additional reported benefits include increased understanding of health care delivery from a systems perspective and greater opportunity to experience the realities of life for rural patients including the impact of socioeconomic status, isolation, service gaps, and barriers to care (erkel et al., 1995; van hofwegen et al. 2005; oneha et al., 2001). increased appreciation for cultural aspects of care has also been a reported benefit of a rural rotation (erkel et al, 1995.; oneha et al., 2001). although the research results are consistently supportive of the potential impact of rural clinical experiences, it is difficult to generalize from these studies with relatively small sample sizes. online journal of rural nursing and health care, 12(1), spring 2012 43 the purpose of this study was to evaluate the impact of an interdisciplinary rural health rotation on nursing students’ interest in rural health, perceptions about nursing practice in rural settings, and intent to practice in west virginia after graduation. the specific questions for this study were: 1. does participation in a rural health rotation change students’ interest in rural health? 2. does participation in a rural health rotation change students’ perceptions of the importance of and level of confidence related to aspects of rural nursing practice? 3. what were the relationships among quality of rotation, interest in rural health, rural “home” community, intent to practice in a rural area, and intent to practice in west virginia? 4. what learning activities were most meaningful to students? methods participant characteristics two hundred and forty-eight senior level undergraduate nursing students enrolled in a rural health rotation participated. eighty percent of respondents were under the age of 25 (mean = 24.18; sd = 5.93) ; 47.6% of respondents reported spending most of their high school years in a community they considered to be rural. 96% of participants were caucasian; 6% of the respondents were male. sampling procedures students enrolled in the senior-level undergraduate rural health nursing course between september 2008 and december 2010 served as a convenience sample. after irb approval was obtained by wvrhep, baseline data questionnaires (bdq) and post-rotation questionnaires (the student evaluation of rural field experience – serfe) were sent electronically to 383 students. two hundred and forty-eight students completed both surveys for a participation rate of 64%. during orientation to the rural rotation, all students were provided with an opportunity to complete the bdq; in addition, the wvrhep staff sent email reminders to the students. at least 12 weeks later and prior to the end of the semester, the rural health course coordinator sent students three reminders to complete the serfe; the survey link and completion instructions were provided to students in an email from the wvrhep staff. student participation and item response were voluntary and not all students answered all questions; responses were captured in a secure electronic database. measures the bdq and serfe were developed by wvrhep staff in 2001 to assess health professions students’ attitudes and career intents over time. included in the bdq were questions to elicit demographic information (whether or not student attended high school in a rural community, year of birth), factors influencing the choice of nursing as a career, perceptions of nursing and nursing practice, preferred specialty, size of community for practice, likelihood of working in west virginia after graduation, and level of confidence and importance related to selected skills (e.g., working collaboratively, recognizing cultural differences, meeting unique needs of rural patients). the same information was collected from the questions on the serfe plus an evaluation of the overall quality of the rotation and the impact of the rotation on a student’s interest in rural health. although an analysis using data collected using the bdq and serfe has been published (shannon et al., 2005), no validity or reliability data are available. online journal of rural nursing and health care, 12(1), spring 2012 44 most responses to items on the bdq and serfe were captured by category or measured on an ordinal scale. pre-post rotation analyses were performed using the wilcoxon signed rank test. analyses of relationships between variables, intent to practice in a rural community, and intent to practice nursing in west virginia were performed using chi-square tests. the level of significance for statistical testing was 0.05. all analyses were conducted using spss, inc. statistics standard gradpack version 17.0 (spss, 2009). results to learn more about the student sample, three factors related to the choice of nursing as a career were analyzed: 1) 74.9% of students rated the opportunity to exercise social responsibility as moderately or very important to their career choice; 2) 78.6% of students rated the high level of public trust as a factor of moderate or high importance in their career selection, and 3) 73.4% of students identified the need for nurses in their home area as a factor of moderate or high importance in their decision to pursue a nursing career. students’ perception of nurses’ obligation to improve quality of life for people in their community was also analyzed; 92.7% of respondents strongly agreed or agreed somewhat that nurses had that obligation. interest in rural health data from the serfe indicated that the rural rotation had a positive influence on students’ interest in rural health: 133 students (53.6%) indicated that their interest had increased; 80 students (32.3%) indicated that their interest was the same; 32 students (12.9%) reported that their interest had decreased. students indicated that the over-all quality of the rotation was high: 87.6% of the students rated the quality as good, very good, or excellent. changes in student perceptions preand post-rotation comparisons did not reveal significant changes in the size of community in which the student intended to practice (z = -.07; p = .943) but did reveal a significant change in students’ likelihood to work in west virginia after graduation (z = -4.25; p = .000). preand post-rotation comparisons were performed for eight areas related to rural nursing practice – interdisciplinary collaboration, cultural influences on communication, community assessment, unique needs of patients living in poverty, unique needs of rural patients, barriers to health care, impact of socioeconomic status on health. students were asked to rate both the importance of the skill and their confidence in performing it. there were no significant pre-post rotation differences in student perceptions of the importance of these areas. however, wilcoxon signed rank test results revealed significant preand post-rotation changes in students’ confidence in six of the eight areas measured. detailed results are presented in table 1. nursing practice intentions post graduation relationships among attending high school in a rural community, quality of rotation, interest in rural health, and the anticipated size of practice population and likelihood of working west virginia were examined. results of the chi-square test for independence revealed that students who identified themselves as coming from a rural community selected smaller communities (< 20,000 residents) as future practice sites and were more likely to remain in west virginia to practice. online journal of rural nursing and health care, 12(1), spring 2012 45 table 1 preand post-rotation differences in perception of importance and confidence in performance of selected skills of rural nursing practice in addition, students who evaluated the quality of the rotation more favorably also identified smaller communities as future practice sites and were more likely to remain in west virginia. finally, students who reported an increased interest in rural health as a result of the rural rotation were more likely to identify a smaller community in which to practice at time of graduation and a greater likelihood to remain in west virginia to practice. detailed results appear in table 2. table 2 relationships between rural residence, quality of rotation, and interest in rural health and size of practice population and intent to remain in wv after graduation value of learning activities students had the opportunity to respond to an open-ended statement: “please describe one experience or activity during this rotation that taught you most about rural practice”. eighty-nine students responded to this question and their responses were categorized using content analysis. four main categories emerged: patient interaction, interdisciplinary opportunities, community service, and addressing system issues. within the patient interaction category, students identified the value of making home visits, working with entire families rather than just individual patients, and seeing patients multiple times across the semester. interdisciplinary opportunities that were identified as valuable included formal activities provided by wvrhep, informal interactions with other health professions students, and opportunities to be a part of an interdisciplinary team in the clinical site. examples of community service that students found valuable were outreach activities to very small communities, participating in health fairs, patient education opportunities, online journal of rural nursing and health care, 12(1), spring 2012 46 conducting the health promotion/disease prevention activity for their capstone project, and participating in a statewide public health initiative (coronary artery risk detection in appalachian communities, 2010). finally, students identified that confronting the social issues of health literacy, poverty, and barriers to health care taught them the most about rural practice. discussion multiple findings of this evaluative study of a large sample of undergraduate nursing students support previously reported findings from the literature. participation in a semesterlong, interdisciplinary rural rotation increased students’ interest in rural health. students reported building confidence in practice areas essential to the rural nursing role, including interprofessional collaboration, increased cultural understanding, and an appreciation for the life realities (barriers to health care, socioeconomic status) of rural residents. in addition, students identified multiple aspects of their rural experience that reflect the benefits of rural experience discussed in the literature. the analysis of the qualitative data collected revealed that students value direct patient contact, opportunities for interprofessional interaction, and community service. the results of this analysis do not provide definitive support for findings in the literature that a rural rotation increases the likelihood of a student selecting a rural placement after graduation. the rural rotation did not influence students’ choice of practice population post graduation. however, students who grew up in rural communities, reported an increased interest in rural health post-rotation, and evaluated their rotation positively were more likely to identify small communities as future practice sites and were more likely to remain in west virginia to practice after graduation. these results have to be interpreted in light of the limitations of the instruments used. community size was the only determinant of rurality and there was no way to validate that student perception of community size was accurate. data were collected primarily at the ordinal level thereby precluding more extensive parametric testing and analysis. in addition, the patterns of employment in nursing changed across the course of this research because of the national economic situation. it is possible that negative economic conditions influenced student selection of community size for practice after graduation, with increased opportunities anticipated in metropolitan settings. multiple barriers to students’ choosing a rural placement have been identified – isolation, lack of privacy, limited resources, and less access to educational opportunity (bushy & leipert, 2005). these barriers are compounded by the fact that nursing students often spend the majority of their clinical hours in acute care settings and are focused on working in high technology, high action intensive care settings. the slower paced rural setting with its focus on chronic disease management and lifestyle behavior change is not always an attractive alternative. nevertheless, significant factors that influence students to select rural nursing practice have been identified: family connection to the community, a desire for rural quality of life, the opportunity to “give back” to the community, and the preference for a small hospital environment (bushy & leipert, 2005). many of these are personal characteristics that may not be influenced by a semester-long clinical placement. implications while this rural health rotation helped to change students’ confidence in key areas of rural practice, it was not clear that it would change students’ intent to practice in rural areas. additional strategies may be needed to increase the likelihood that students will select a rural practice site after graduation. strategies could include integrating rural theory and practice online journal of rural nursing and health care, 12(1), spring 2012 47 opportunities throughout the curriculum so that students have multiple experiences in rural environments. to conserve limited clinical placements, those students who express an interest in rural practice could be offered an intense, elective rural immersion experience to increase their comfort in rural settings and broaden their understanding of the rural nursing role. building linkages between university faculty and rural preceptors could enhance learning opportunities for students. preceptors often need support and assistance as they work to help students appreciate their role in rural health care. community-based participatory research efforts that involve students will demonstrate professional opportunities that might not otherwise be visible. finally, providing opportunities for community service is one strategy for adding value to clinical experiences in rural communities. multiple, rural-based community service activities integrated across the curriculum may help students to envision nursing opportunities available in rural communities. nursing workforce issues will continue to be part of the rural health care system. changes inherent in u.s. health care reform legislation may potentiate the problem as more people in rural communities have access to care through insurance. nursing education programs, especially those serving rural areas, will need to continue to design and evaluate innovative teaching strategies to influence and encourage students to select rural practice settings postgraduation. success in recruiting health care professionals to rural communities is critical to eliminating health disparities and fostering 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(2011c). state fact sheets: united states [data file]. retrieved from http://www.ers.usda.gov/statefacts/us.htm u. s. department of health and human services – health resources and service administration (n.d.). mua/p by state and county [data file]. retrieved from http://muafind.hrsa.gov/ index.aspx van hofwegen, l., kirkham, s., & harwood, c. (2005). the strength of rural nursing: implications for undergraduate nursing education. international journal of nursing education scholarship, 2(1). [medline] yonge, o., ferguson, l., & myrick, f. (2006). preceptorship placements in western rural canadian settings: perceptions of nursing students and preceptors. online journal of rural nursing and health care, 6(2), 47-56. http://www.ncbi.nlm.nih.gov/pubmed/19326820 http://www.ncbi.nlm.nih.gov/pubmed/12230431 http://www.ncbi.nlm.nih.gov/pubmed/14742024 http://www.ncbi.nlm.nih.gov/pubmed/16236587 http://www.ncbi.nlm.nih.gov/pubmed/16646922 microsoft word 385-2329-2-ce.docx online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 76 interprofessional collaborative education for substance use screening: rural areas and challenges kathryn r puskar, drph, rn, faan 1 heeyoung lee, phd, pmhnp-bc 2 ann m mitchell, phd, rn, ahn-bc, fiaan, faan 3 irene kane, phd, msn, rn, cnaa, ep-c 4 susan a albrecht, phd, rn, crnp, faan 5 linda rose frank, phd, msn, cs, acrn, faan 6 holly hagle, phd 7 dawn l lindsay, phd 8 martin p houze, ma, phd 9 1 professor and associate dean for undergraduate education, university of pittsburgh school of nursing, krp12@pitt.edu 2 assistant professor, university of pittsburgh school of nursing, leehee@pitt.edu 3 professor, university of pittsburgh school of nursing, ammi@pitt.edu 4 associate professor, university of pittsburgh school of nursing, irk1@pitt.edu 5 associate professor, associate dean for special projects, university of pittsburgh school of nursing, saa01@pitt.edu 6 associate professor, university of pittsburgh graduate school of public health, frankie@pitt.edu 7 director of the national sbirt attc at ireta, institute for research, education, and training in addictions (ireta), holly@ireta.org online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 77 8 director of evaluation services, institute for research, education, and training in addictions (ireta), lindsayd@ireta.org 9 date analyst, university of pittsburgh school of nursing, houzem@pitt.edu abstract purpose: interprofessional collaborative practice (ipcp) has been advocated to overcome challenges related to rural healthcare and substance abuse. the investigators evaluated the effectiveness of an online interprofessional education (ipe) program to improve healthcare professionals’ perceptions in treating people with substance use and identified the challenges of conducting ipe. sample: sample included 106 healthcare professionals (nurses, behavioral health counselors, and public health workers) from rural areas in pennsylvania, ohio, and west virginia. method: this prospective study utilized a quasi-experimental design with healthcare professionals who received a 6-hour online ipe regarding substance abuse. measures were the alcohol & alcohol problems perception questionnaire (aappq) and the drug & drug problems perception questionnaire (ddppq). findings: perceptions of alcohol (i.e., role adequacy and role support) and drug (i.e., role adequacy, role legitimacy, sole support, and work satisfaction) problems were improved after training (ps < .05). competing priorities, leadership support, technology, rural culture, and fiscal consequences were addressed as challenges during project implementation. conclusion: the ipe program improved the participants’ attitudes and perceptions toward working with patients who struggle with substance abuse. rural nurse managers can influence online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 78 professionals in a range of clinical team settings to improve safety and quality of health care through ipcp. challenges experienced by rural healthcare professionals can be resolved by the leadership support. consequently, the leadership of nurse management can favorably impact patient healthcare outcomes by reinforcing ipe. interprofessional collaborative education for substance use screening: rural areas and challenges background rural areas face specific healthcare challenges such as vulnerable populations, workforce shortages, and poverty. rural populations tend to be older and poorer than the urban population, and exhibit higher rates of chronic diseases (e.g., obesity, diabetes, and hypertension) (ortiz, meemon, zhou, & wan, 2013). the rural healthcare workforce has high turnover rates due to financial and geographical barriers, access to peer support, and limited numbers of healthcare specialist, such as behavioral health (rosenblatt, andrilla, curtin, & hart, 2006). in particular, substance use is a significant and emerging problem in rural areas. for example, in 2013, approximately 8.2% of the population aged 12 or older (i.e., 21.6 million) in u.s. rural areas were substance users (i.e., defined by dependence or abuse) (substance abuse and mental health services administration, 2014). the prevalence rates of using alcohol and tobacco among both adults and youth in rural areas tend to be higher than those of their counterparts in urban areas (gfroerer, larson, & colliver, 2007; rhew, hawkins, & oesterle, 2011). methamphetamine use also is frequently higher in rural areas compared to metropolitan areas (gfroerer et al., 2007; macmaster, 2013). online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 79 substance use, and in particular alcohol consumption, has been associated with various medical conditions and is a leading cause of death (i.e., 1 in 10 deaths among adults aged 20-64 years old), which shortens lives by 30 years (centers for disease control and prevention, n.d.). moreover, substance abuse contributes to over $600 billion per year in crime, lost work productivity, and healthcare costs (national institute on drug abuse, 2015). the consequences of substance use in rural communities may be greater in than in urban areas because of limited access to treatment and resources (lenardson, race, & gale, 2009). interprofessional collaborative practice (ipcp) has been advocated in prior studies (heath et al., 2014; r. mitchell et al., 2013) to overcome such rural healthcare challenges because, through ipcp, multiple healthcare professionals can work in collaboration to strengthen the skills of each, which enhances functioning at the highest capacity (world health organization [who], 2010). stated simply, ipcp is collaborative work among healthcare professionals from different disciplines carried out to improve the quality of care through enhancement of comprehensive care through interprofessional education (who, 2010). interprofessional education (ipe) is an experience that “occurs when students from two or more professions learn about, from, and with each other” (who, 2010). for example, in a systematic review on the topic, (reeves, perrier, goldman, freeth, & zwarenstein, 2013) assert that ipe improved not only quality of care, including diabetes care, collaborative team behaviors in emergency departments and operating rooms, care for domestic violence, and delivery of care in domestic violence, but also mental health clinicians’ competencies to deliver care, despite limited evidence. in order to address the problems related to substance use in rural areas, we developed an online ipe program for healthcare professionals to improve their competencies to identify online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 80 high-risk substance use, and to provide interventions within a collaborative practice model that serves to improve patient outcomes. purpose the purpose of this study was twofold. first, we sought to evaluate the effectiveness of the ipe program in improving the health professionals’ skills to identify, assess, and provide care for people with substance use and co-morbidities. second, we aimed to identify challenges of conducting an ipe program for health professionals in rural areas. the rural area refers to any place that has a population less than 2,500 people (us census bureau, 2011). pennsylvania has 48 out of 67 counties that are considered to be rural areas (center for rural pennsylvania, 2014). methods description of the ipe program this was a division of nursing (dn), bureau of health professions (bhpr), health resources and services administration (hrsa), department of health and human services (dhhs) funded longitudinal project to increase the number of healthcare professionals (i.e., nurses, public health workers, and behavioral health counselors) in primary care, public health, and addictions settings in rural areas who are skilled in ipcp; and to improve the capacity of healthcare teams to screen, briefly intervene, and refer to treatment (sbirt) substance users in rural settings. this short, valid, and reliable evidenced-based model, sbirt, can be used effectively within the time constraints of a health visit in primary care (mitchell et al., 2013). the ipcp competency domains (i.e., values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, and teams and teamwork) (interprofessional education collaborative expert panel [iecep], 2011) guided the project. the ipcp program was delivered as a 6-hour online educational experience that was hosted on a web-based, open-source learning platform (i.e., moodle, moodle hq, perth, australia). the online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 81 ipcp program comprises four components: learning modules, case simulation practice, interprofessional dialogues, and sharing resources. see figure 1 for an example of the appearance and content of one of the ipcp program. figure 1. case simulation practice from the online module. learning modules. six learning modules were delivered via moodle: (a) introduction to ipcp concepts, (b) continuum of substance use, (c) sbirt, (d) motivational interviewing strategies, (e) practicing ipcp with cases, and (f) project evaluation. the modules take about 2.5 hours to complete, and train participants to build their knowledge regarding substance use, interprofessional collaborative practice, screening, and the use of brief interventions using motivational interviewing techniques. moreover, these modules elucidate interprofessional theory through the use of case-simulation imbedded in materials to illustrate roles and responsibilities, discuss common clinical and psychosocial issues associated with the alcohol and other drug using patients, and expand upon the value of interprofessional education and practice to improve patient healthcare outcomes. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 82 case simulation practice. after completing the learning module, participants completed four case simulations, which provide opportunities to practice the application of sbirt. these simulations take 1.5 hours to complete. the ipcp competency domains were incorporated into the case simulations. interprofessional communication was enhanced by providing the participants opportunities to identify instances in practice in which interprofessional care will improve client, patient, and family outcomes (iecep, 2011). the cases emphasized assessment, referral roles of public health, and behavioral health disciplines to improve team care. interprofessional dialogues about cases. this part of the ipe program involved the application of the sbirt model—presented and practiced in the learning modules and case simulations to clinical cases that the participants have encountered during their clinical practice. for example, upon reviewing a case describing a patient recently diagnosed with fibromyalgia, who is incorrectly taking prescribed pain medications and mixing medication with alcohol use, participants were encouraged to review the case with the moderator with and without using the sbirt process to hypothesize patient outcomes. discussing the case elucidated participant realtime roles and responsibilities within their ipcp to illuminate both their knowledge and learning needs as well as what worked well in their ipcp and what changes would enhance their system. the dialogue sessions gave participants the opportunity to actively take part in effective decision-making in an interprofessional team using evidence-based assessment and critical thinking. in addition, these case studies and dialogue sessions allowed practicing healthcare professionals the opportunity to assume diverse roles within this interprofessional group and support others in their roles. resource sharing. the ipe program includes an online blog that contains a variety of postings that highlight (a) relevant information and resources about interprofessional issues, (b) online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 83 new training videos, and (c) emergent topics about interprofessional education and substance use screening. the blog also serves as a dissemination means to access resources created from the project. for example, participants were encouraged to use the blog to obtain updated information on utilizing ipcp, to explore any issues that may have surfaced within their use of ipcp, and to share any novel information or resources with other participants. design, sample, and settings this study used a pre-post design with a convenience sample obtained primarily from rural mental health facilities located in the tristate region of pa, wv, and oh in the eastern united states. the intervention was implemented between 2012 and 2015. initially the research team visited these clinics and institutions to establish buy-in and provide an introduction to the project, which featured an emphasis on its easy access, free continuing education units (ceus), and incentives. the importance of the ipcp project was also emphasized. during this phase, onsite champions (i.e., participants who advocated ipcp and contributed to the project) and local leaders were identified who agreed to facilitate the project at their particular locations. all sites had the opportunity to utilize technical assistance from the project team. the institutional review board at the university of pittsburg approved the project protocol (irb# pro12090365). measures in addition to collecting demographic information (e.g., age, gender, race/ethnicity, and types of healthcare professionals) from the participants with a questionnaire, the alcohol and alcohol problems perceptions questionnaire (aappq) (shaw, cartwright, spratley, & harwin, 1978) and the drug and drug problems perceptions questionnaire (ddppq) (watson, maclaren, shaw, & nolan, 2003) were the instruments used to evaluate the participants’ perceptions of online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 84 working with patients who may have issues with using alcohol and other drugs. the aappq, a 30-item self-report questionnaire, was used to measure the attitudes of healthcare workers about working with patients with alcohol-related problems. these attitudes are rated by reactions to statements (e.g., "i feel i have a working knowledge of alcohol and alcohol-related problems”) from strongly disagree (i.e., 1) to strongly agree (i.e., 5) on a 5-point likert scale. the aappq has demonstrated good reliability and validity (anderson & clement, 1987). the ddppq, a 22item self-report questionnaire, was used to measure healthcare workers’ perceptions of drugproblems. both the internal consistency (cronbach's α = 0.87) and construct and content validity of these measures have been reported as satisfactory (watson, maclaren, & kerr, 2007). participants were asked to complete all questionnaires (i.e., demographic, aappq, and ddppq) via the research electronic data capture (redcap) application, which is a secure, encrypted, web-based application for building and managing online surveys to track participant progress throughout a project (harris et al., 2009). data were collected from participants at two time points: upon project entry (i.e., pre-training) and after training. analysis statistical analyses were performed using spss 21 (armonk, ny: ibm corp.). data were checked for outliers before analysis was conducted. the sample included 106 participants who had completed both preand post-training data collection. descriptive statistics were used to present the participants’ demographic characteristics. the distribution of the sub-scores of the aappq and ddppq were found to be symmetric and approximately gaussian. linear mixed modeling was therefore used to examine possible differences over time. the model contained a time effect, with f-values in ( table 2 ). online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 85 findings table 1 displays the demographic information gathered. the average age of the healthcare providers was 39.9 years (sd = 13.6). participants comprised 37 (34.9 %) nurses, 16 (15.1 %) mental or behavioral health counselors, 11 (10.4 %) substance abuse professionals, and 6 (5.7%) social workers from 10 clinical sites. a total of 240 participants enrolled in the study (i.e., completed the pre-training survey). of these, 106 successfully completed both the educational intervention program and the post-training surveys. table 1 demographic data (n=106) mean (±sd) or n (%) age (years) 39.9 (±13.6) gender women 90 (84.9%) men 16 (15.1%) race/ethnicity white 99 (93.4%) black 5 (4.7%) others 2 (1.8%) healthcare professionals nurses 59 (55.7%) counselors 16 (15.1%) social workers 6 (5.7%) substance abuse professionals 11 (10.4%) other (including pharmacist, health educator) 13 (12.3%) missing 1 (0.9%) changes in drug problem perceptions 106 participants completed these measures at preand post-intervention. the pairs of means of ddppq that had a statistically significant difference (p =.01) were found in terms of role adequacy and role support. role adequacy measured on a scale of 1 to 5 increased during the study, with an average increase of 0.25 (t = 6.56, p = .01) between preand post-training. role online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 86 support also increased, with an average increase of 0.25 (p = .04) between preand post-training (see table 2). changes in alcohol problem perceptions one hundred six participants completed these measures preand post-intervention. the overall estimate of aappq tended to increase after the intervention. sub-scores of the aappq questionnaire increased over time. role adequacy, role legitimacy, and work satisfaction also increased during the study, with an average increase of 0.24 (p = 0.02), 0.22 (p < .01), and 0.16 (p = 0.04), respectively, between preand post-training (see table 2). table 2 changes in alcohol and drug problem perceptions (n=106). challenges to delivering online ipe the online ipe program was effective in changing the perceptions of the participants. during evaluation, several themes were provided as challenges in delivering ipe in rural areas. these included competing priorities, leadership support, technology, rural culture, and fiscal issues. mean (sd) f-value p-value pre-training post-training d d p p q role adequacy 3.47 (0.77) 3.72 (0.67) 6.56 .01 role legitimacy 3.95 (0.71) 4 (0.6) 0.57 .57 role support 3.73 (0.94) 3.98 (0.76) 4.27 .04 motivation 3.75 (0.87) 3.8 (0.89) 0.13 .72 task-specific self-esteem 3.73 (0.78) 3.79 (0.78) 0.3 .58 work satisfaction 3.33 (0.8) 3.43 (0.73) 0.93 .34 a a p p q role adequacy 3.6 (0.81) 3.84 (0.65) 5.81 .02 role legitimacy 3.85 (0.67) 4.07 (0.48) 7.4 <.01 role support 3.77 (0.92) 3.98 (0.72) 3.74 .05 motivation 3.57 (0.69) 3.72 (0.68) 2.51 .12 task-specific self-esteem 3.71 (0.67) 3.77 (0.61) 0.51 .47 work satisfaction 3.42 (0.62) 3.58 (0.57) 4.12 .04 online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 87 healthcare professionals who participated in this project reported (through ipcp dialogues) that the concepts of ipcp and sbirt are indeed essential; however, maintaining these priorities throughout the project was challenging due to competing priorities. additionally, the dynamic circumstances of the busy clinics negatively impacted the ipcp project completion rate recorded for healthcare professionals. examples included practice pressures (e.g., time management, workload, and emergent patient issues taking priority over education). moreover, recruiting nurses to participate in the ipcp project was difficult because the 8–10 hour/day work schedules of many of the nurses hindered both the enrollment and completion rates. during the beginning of the project, enthusiasm and participation were both high, and over 200 participants were initially enrolled in the program. however, participation over the course of the first year gradually decreased. to address this challenge, after the first project year, we elicited participant and healthcare professional’s input and made the following program changes: we (1) decreased the number of evaluation measures (i.e., number of questions and time points of data collection), (2) added incentives (e.g., gift cards and ceus) to encourage participation, (3) provided site champions with a leadership certificate to recognize accomplishments, (4) visited site clinics to encourage continued buy-in of champion leaders, and (5) consulted marketing experts to update and revise website text and presentation. another challenge to implementation was securing “buy-in” from the healthcare leadership within the organizations and agencies targeted. in order to change the manner in which health care is delivered with this ipcp model, the leaders of a particular clinic, organization, or institution must agree to support the change which allows for full commitment to the ipcp project components. challenges also exist for referrals and include (1) acquisition of additional patient services and (2) communication between health professionals, especially if outside their online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 88 system or organization. the hipaa constraints that are inherent with signed consents for referral resulted in limited communication with healthcare professionals making referrals. to address this constraint, ipcp reminds and reinforces the team to communicate within and outside the system for clinical practice. our project used a distance-based approach (i.e., an online educational intervention provided through a website platform) to train health professionals to more effectively identify and treat substance use using ipe. in particular, we provided live webinar sessions for participants to discuss their experiences interactively and collaboratively. however, despite the technical support provided by our team, some participants found it challenging to use the online platform because of their limited technical skills and ability to use (and access) the equipment needed for this type of program. some participants were not familiar with the webinar platform and had difficulty navigating the project due to their lack of knowledge about web-based platforms. in some cases, participants had to use their home computers because work computers were not available. another challenge we faced in conducting this project was the role of the regional and local cultures that are unique to the rural areas of pa, wv, and oh, in the eastern united states. some healthcare professionals and agencies in these rural areas were skeptical of research activities and researchers, and thus reluctant to provide access to their employees for participation in the study. in addition, as this project aimed to reach busy rural health professionals, webinar and discussion times were scheduled over lunch hour or at the end of the work day to accommodate busy office schedules. fiscal concerns also present a challenge. health professionals in these rural areas, regardless of the clinical setting, are being asked to do more for their clients within the same online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 89 clinical time constraints. administrators and other leaders responsible for making decisions regarding the use of paid time including education and training for professional development is another barrier. with additional requirements placed on healthcare systems for lowering costs, administrators and health professionals may be reluctant to increase educational activities as part of ongoing job responsibilities due to the fiscal consequences resulting from potential loss of patient revenue. the need for professional development to increase interprofessional practice within healthcare teams to improve team effectiveness must be considered. discussion/ implication results indicate that the online ipe program improved the participants’ perceptions about individuals with substance use. data from subscales demonstrate role adequacy, role support, role legitimacy, role support, and work satisfaction increased with the online program enhancing overall interprofessional performance. interpretation of this finding of the increase in these subscales suggests that the participants reported more adequacy and legitimacy in their roles to conduct alcohol/drug use screening. research demonstrates that increase role security leads to changes in behavior. in addition, the interprofessional dialogues about universal screening reinforced the components of interprofessional collaboration. prior studies have reported increased knowledge of mental health issues among rural health professionals who have participated in ipe training (church et al., 2010). the diverse group of healthcare professionals who participated in the project benefited from the content discussed and demonstrated which were relevant and useful to their daily clinical practice in mental health care settings. through ipe and sbirt training, healthcare professionals can collaboratively prevent or lower the risks of alcohol and substance use through coordinated and comprehensive patient care interventions, online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 90 which can positively impact engagement of patients in self-care, improve quality, and safety for patients. regarding application to nursing practice and policy, the study addressed the competing priorities and practices that the participants face in the rural healthcare environment. prior research that has implemented ipe faced similar challenges, which included logistic and structural issues (heath et al., 2014; parker et al., 2013). in particular, rural behavioral health professionals have reported chronic role overload, increased job-related stress, and burnout due to rural culture (e.g., lack of resources, training constraints) (heath et al., 2014; parker et al., 2013). the results of this study further demonstrate these trends within this cohort of health professionals. moreover, our results suggest that traditional hierarchies, policies, procedures, and institutional culture may account for the challenge of implementing ipcp (parker et al., 2013). to support the development of collaboration, nurses and other healthcare professionals can be educated about the unique skill sets, competencies, and roles of specific disciplines that can be employed within the context of an interprofessional work environment. additionally, communication, confidentiality, respectfulness, innovation, team building within interprofessional training activities are key factors in ipcp training. according to a review of 44 articles (supper et al., 2014), many of these demonstrated barriers to interprofessional collaboration were addressed in our ipe training. in addition, our team recognized the critical role of policy leaders in clinical and administrative structure within healthcare settings in implementing and sustaining ipcp, which is in agreement with previous studies (priest et al., 2008; spencer, woodroffe, cross, & allen, 2014). many rural health agencies and institutions have no implemented ipcp within clinical settings. nurse managers, clinical educators, and staff trained in ipcp are in a key position to online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 91 assume leadership in promoting and modeling ipcp with rural clinical care settings (spencer et al., 2014). it is important for sustainability to overcome logistic, motivational and financial barriers to ipcp implementation. considerations for specific targeted funding for ipcp implementation and monitoring (supper et al., 2014) would improve sustainability. certainly, leadership support (e.g., nurse managers) for the implementation of icpc within clinical units would enhance uptake of this model as standard practice. our project took advantage of current distance based education technology in delivering the ipe program in rural areas, a choice based on previous studies that emphasized the benefit of technology to overcome limited access to training and educational resources (brems, johnson, warner, & roberts, 2006) and accessibility (skorga, 2002) in rural settings. nonetheless, the use of technology was reported as being a challenge by some participants consistent with similar reports in the literature (church et al., 2010). conclusion the results of this study indicate that the our educational intervention improved the health professional participants’ attitudes and perceptions in working with individuals with alcohol and other substance use, as well as implementing interprofessional principles within their clinical practice. improving the health of individuals and communities requires collaborative engagement of professionals from various disciplines, responsibility levels and roles. thoughtfully planned and coordinated teamwork can improve the delivery, efficiency, and effectiveness of substance use healthcare especially in rural areas. as we have demonstrated, providing ipe shows promise in promoting this interprofessional teamwork. nursing practice and policy implications for rural nurse managers include providing fiscal and operational, support for continuing education programs for nurses. online journal of rural nursing and health care, 16(1) http://dx.doi.org/ 10.14574/ojrnhc.v16i1.385 92 many nurses have limited ipe and evidence-based screening and brief intervention for substance use in the nursing curriculum which this intervention aimed to address. furthermore, nurses may benefit from mentoring support to improve interprofessional collaboration within their clinic settings. integration of ipe into institutional quality management initiatives would also support adoption and sustainability into clinical services. early exposure to the concept of ipcp, such as in nurse orientation sessions and for other health professionals within the clinical team, has the potential to enhance the expansion of interprofessional practice. nurse managers’ active involvement in developing policies to facilitate ipcp for nurses and their senior management of organizations can assist in resolving challenges to sustain ipcp in rural clinical settings, ultimately improving patients’ healthcare outcomes longitudinally. funding agencies the division of nursing (dn), bureau of health professions (bhpr), health resources and services administration (hrsa), department of health and human services (dhhs) under cooperative agreement number ud7hp25060. references anderson, p., & clement, s. 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(2010). framework for action on interprofessional education & collaborative practice. geneva, switzerland: who. akbar584-article text-3883-1-6-20200331 online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 70 investigating relationships between hypertension, sleep, and cognitive risk in an underserved community princess maryam abdul-akbar, b.s.1 lisa wiese, phd, rn, aphn-bc 2 1 undergraduate student, florida atlantic university, pabdulakbar2013@fau.edu 2 assistant professor, christine e. lynn college of nursing, florida atlantic university lwiese@health.com abstract purpose: the aim of this descriptive correlational pilot study was to investigate the relationship between hypertension, sleep deprivation, and risk of alzheimer’s disease in a rural, older, underserved, and ethnically diverse cohort. sample: residents (n = 52) from three independent subsidized housing units for retired farmer workers, located in a rural florida area known as the glades, volunteered for the study. methods: a quantitative descriptive approach using pearson correlations, t-tests, and scatter plot analysis was applied to surveys and mini-cogtm results. findings: about a quarter (23.1%) of the participants were identified as being at risk for cognitive impairment. hypertension risk correlated moderately with cognitive impairment risk (r = 0.40, p = 0.01). however, in this ethnically, diverse cohort, sleep quality did not significantly influence either blood pressure or cognitive status. this is contrary to other studies that have found an increased risk of alzheimer’s disease among persons with hypertension (carnevale, perrotta, lembo, & trimarco, 2015) and insufficient sleep (brzecka et al., 2018). implications: these results suggest that further investigation is needed to examine if rural living or culture moderates alzheimer’s disease risk factors of diminished sleep and hypertension. future online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 71 findings could impact the design of interventions aimed at reducing ad risk in diverse rural settings. keywords: alzheimer's disease, sleep, hypertension, rural, elders, underserved, diverse investigating relationships between hypertension, sleep, and cognitive risk in an underserved community multiple studies have shown that people living in rural, underserved populations with hypertension are at a higher risk for alzheimer’s disease and related dementias (adrd) (paterson, 2018). this population often experiences a lack of education, reduced health care, little income, poor nutrition, insignificant accessibility to primary and specialty providers, shortage of insurance, and low health literacy (wiese, williams, hain, galvin, & newman, 2019; wiese, williams, & tappen, 2014). these factors serve as root causes for increased risk of alzheimer’s disease and for secondary alzheimer’s-related health outcomes (gaugler, james, johnson, marin, and weuve (2019). additionally, there is a lack of studies examining cognitive screening behaviors among ethnically diverse populations, despite the well-documented increased risks of ad in cultural minorities (babulal et al., 2019). within florida, the department of elder affairs purple ribbon task force (prtf) found that 38% of people with ad had been undiagnosed, and the ethnically diverse inhabitants are facing greater disparities (department of elder affairs, 2013). these findings demonstrate the need for a greater awareness of ad risk and detection by both providers and residents (department of elder affairs prtf, 2013). however, there are few studies that address increased ad risk in rural, older, ethnically diverse populations (wiese, williams, & galvin, 2018). the purpose of this pilot study was to examine potent relationships between online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 72 cognitive impairment, hypertension, and sleep deprivation in a cohort of rural, ethnically diverse retired farmworkers. background dementia is a syndrome of cognitive decline that interferes with communication and performance of daily activities, most often characterized by declines in memory, language skills, and problem-solving (gaugler et al., 2019). the most common type of dementia is alzheimer’s disease (ad), associated with disrupted nerve cell function seen in the presence of excess amyloid plaque buildup and neurofibrillary tangles in the brain (selkoe & hardy, 2016). a new case of ad emerges every 65 seconds, and half of adults over age 85 have ad. this illness is the only top-ten cause of death without a cure (gaugler et al., 2019). blood pressure and risk of alzheimer’s disease there are recent studies that portray a pathophysiological connection between hypertension and ad. when blood pressure is normal, the brain can maintain a proper perfusion, which helps to keep steady oxygen levels and a good supply of nutrients throughout the body. elevated blood pressure tends to impose stress on the cerebrovascular beds that may lead to vascular remodeling and dysfunction (tarumi et al., 2015). hypertension or high blood pressure can prevent proper perfusion, leading to stroke, which then increases dementia risk (carnevale, perrotta, lembo, & trimarco, 2015). in contrast, effective management of hypertension aids in decreasing ad risk (ju, lucey, & holtzman, 2013). sleep deprivation and the risk of alzheimer’s disease the presence of a neurodegenerative disease may result in sleep deprivation, and conversely the lack of sleep increases the production of amyloid plaque. deep sleep has been shown to decrease amyloid production. however, sleep and cognitive ability tend to decrease with age. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 73 when elders suffer from sleep deprivation it has a damaging effect on most cognitive domains, such as attention, working memory, processing information, and reasoning, which can exacerbate ad risk (dzierzewski, dautovich, & ravyts, 2018). of importance to this study is that the combination of a reduction of sleep and elevated blood pressure are linked to a greater production of amyloid plaque, thus altering cerebral blood flow regulation in participants with cognitive impairment (ju et al., 2013). the investigation of sleep deprivation and hypertension both show that they influence the accumulation of amyloid plaque in the brain, thus increasing ad risk. materials and methods setting and sample the study was initiated in january of 2018 in a rural florida area known as the glades, comprised of several small towns surrounding lake okeechobee. this region has been designated as a health professional shortage area and medically underserved area as a medically underserved area (mua) and health professional shortage area (hpsa) (rural economic development initiative, n.d.). for purposes for this study, rural was defined as an area outside of a metropolitan statistical area (health resources & services administration, office of management and budget, n.d.). participants. individuals ranging from 65 and older comprise 33.8% of this population, which are less than 25,000 residents. over 20% of inhabitants are living below the poverty level and lack health insurance. employment in glades county is largely agricultural, with a high school graduation rate of 62% (u.s. census bureau, n.d.). the participants for this study (n = 52) were drawn from a subsample of a larger study (n = 139) funded by the florida department of health’s ed and ethel moore alzheimer’s disease online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 74 research program (wiese, williams, & hain, 2017). inclusion criteria were age 65 and older and the ability to speak english, spanish, or creole. exclusion criteria included being previously diagnosed with depression or dementia, and inability to complete surveys and the clock drawing test. visiting friends or family members or persons under 65 were excluded from the study. permission to conduct the study was given through the principal investigator’s university institutional review board, #1064503-5. the research participants in this convenience study subsample were comprised of immigrant and retired farm workers, of which 81% were african american, 10% afro-caribbean, 2% hispanic american, and 7% non-hispanic white. data collection and analysis the data collection consisted of (1) the sociodemographic survey which included four questions regarding sleep patterns and hypertension history, (2) blood pressure measurements conducted at three time points throughout the study (entry, mid-point, and exit), and 3) the minicogtm (borson, scanlan, chen, & gaguli, 2003; morley et al., 2015). instrument: the sociodemographic survey. this measure consisted of 19 questions regarding age, gender, race, ethnicity, health literacy, sleep patterns, history of hypertension, and eight independent variables (sex, gender, race, ethnicity, education, health literacy, sleep patterns, and history of hypertension). additional questions were asked in reference to the years of rural residence and caregiver status, and if the participant’s care provider had previously asked about and/or examined memory during any emergency or office visits. instrument: sleep survey. this instrument measured the participants’ sleep quality through self-rating with the use of questions, such as “within the past month, how would you rate your sleep quality?” this tool has shown acceptable construct validity in addressing relations with one’s mental and physical health (hale, hill, & burdette, 2010). the survey contained a likert-type online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 75 scale with answers consisting of excellent, very good, good, fair, and poor. afterward, the study results were dichotomized into individuals who answered fair or poor sleep versus excellent, very good, and good sleep. instrument: blood pressure screening form. this instrument measured the participants’ family history and risk factors that may increase the likelihood of developing hypertension. the questions contained in this form were influenced by information from the american heart association and the centers for disease control and prevention. the form consisted of a series of closed ended questions such as “has anyone in your family been diagnosed with hypertension?” as well as sections to measure the participants’ blood pressure and pulse rate. instrument: the mini-cogtm. this instrument (borson et al., 2003) helped to detect the risk of cognitive impairment in older adults. it consisted of a three-item recall test for memory and a scored clock-drawing test. the results were based on a point system in which the participants received one point for each word they remembered for the recall section. for the clock drawing section, the participants received two points for drawing a normal clock and zero points for an abnormal clock. these screenings helped to detect patients whose cognitive deficits have gone unnoticed. data analysis descriptive statistics, t-test and pearson correlation were used to analyze findings and exploring relationships between variables. descriptive and frequency statistics were used to summarize sociodemographic characteristics and results of completed measures (the mini-cogtm, blood pressure screening form, sleep survey, & the sociodemographic survey). specifically, the results were analyzed in order to identify if the participants were at risk for hypertension based on the questionnaire, if the current blood pressure reading was within the spectrum of normal blood online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 76 pressure (120/80), and if there were relationships between the dependent variable (dementia risk) and eight independent sociodemographic variables (sex, gender, race, ethnicity, education, health literacy, sleep patterns, and history of hypertension). analyses were conducted using spss v24 (ibm corporation, n.d.). alpha was set at .05 for all statistical tests. results the sample of 52 patients was derived from three independent senior living facilities for persons aged 65 and older in the glades, fl central rural community. the average participant in the public sample was 68 years of age (sd = 8.3), had lived in a rural area 37.5 years (sd = 24.2), and had received 9.9 years of formal education (sd = 3.59). they demonstrated a health literacy score of 3.54 (sd = 2.9), indicating a 4th-6th grade reading level as seen in table 1. table 1 continuous sociodemographic variables (n = 52) variables m sd age 68.9 8.3 years of education 9.9 3.6 years living rural 37.5 24.2 health literacy level* 3.5 2.9 note. *score between 3 – 4 = 4th to 6th grade reading level most of the participants (73.1%) did not report previous cognitive screening by a healthcare provider and had not been treated for adrd (34.6%). the majority of participants were minorities; african american (80.8%) and afro-caribbean (9.6%). non-hispanic whites comprised 7.7% of the cohort, and over half were females (55.8%) as seen in table 2. approximately a third of the participants identified as being married or engaged (9.6%). online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 77 table 2 categorical sociodemographics (n = 52) variables f % live alone* yes 46 88.5 no 5 9.6 marital status* married 5 9.6 single/divorce/separated/ widow 46 88.5 sees provider yes 13 25 no 39 75 gender male 23 44.2 female 29 55.8 treated for adrd* yes 1 1.9 no 18 34.6 ethnicity african american 42 80.8 afro caribbean 5 9.6 white, non-hispanic 4 7.7 hispanic american 1 1.9 cognitive impairment* no risk 38 73.1 risk 12 23.1 note: * indicate n < 52 because some of the participants did not want to disclose that information screening findings showed that the majority of participants were not at risk for hypertension (73%) or cognitive impairment (73.1%) as represented in figure 3. those with hypertension risk correlated significantly with risk of cognitive decline (𝑟 = .40, p = .01). the two scatter plots illustrate blood pressure as the dependent variable, and cognitive impairment and sleep deprivation as the independent variables shown in figure 1 and 2. the t-test data in table 3 shows that the means for each risk factor are significantly larger than 0. most participants have higher blood pressure, which is clear from the larger mean. participants who exhibited sleep deprivation showed a larger mean score as well. furthermore, most subjects did not show cognitive impairment, which is represented in the smallest mean, but it is still significant. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 78 figure 1. scatter plot of relationship between blood pressure and cognitive risk. figure 1 illustrates a moderate positive correlation between blood pressure and cognitive risk, with a pearson correlation of 0.40 (r2 = 0.16). the scatter plot shows that those with higher blood pressure were at greater risk for becoming cognitively impaired. table 3 sociodemographic risk factors – one sample t-test test value = 0 (n = 52) t df sig. (2-tailed) mean difference 95% confidence interval of the difference (lower bound) blood pressure 13.682 47 0.000 1.39583 1.1906 sleep 9.807 45 0.000 1.10870 0.8810 cognitive risk 3.934 49 0.000 0.24000 0.1174 online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 79 figure 2. scatter plot of relationship between blood pressure and sleep. figure 2 illustrates a negligible correlation between blood pressure and sleep. the pearson correlation of 0.05 (r2 = 0.003) between the two variables further demonstrates this weak relationship. this is in contrast to findings in the literature that poor sleep quality can exacerbate hypertension, but this result may be due to the smaller population sample (n = 52). examining these variables in larger studies may yield different results. figure 3 represents the participants who were at risk for high blood pressure or cognitive impairment. the results show that the majority of the participants were not at risk for either biomarker. based on the results, the demographic of the population shows that although they have limited resources (health care, education, income), the chronic disease of blood pressure was being managed effectively within this population. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 80 figure 3. bar chart of hypertension, blood pressure, and cognitive impairment risk in rural cohort discussion findings related to blood pressure the majority (73%) of the participants were not at risk for hypertension based on the study survey results. this was a surprising finding, because 81% of the participants were african americans, which typically face a higher risk for hypertension. deaths due to high blood pressure in the us are the greatest among african americans (spikes et al., 2019). studies have shown that there are genetic and sociocultural risk factors for hypertension (fuller, mccarty, seaborn, gravlee, & mulligan, 2018). these risk factors tend to manifest differently across racial groups. findings related to sleep and cognitive impairment we found that the percentage of participants who had fair to excellent sleep was 65.2%, while 34.8% of the remaining participants indicated poor sleep. about 23.1% were at risk of cognitive impairment based on the mini-cogtm (borson et al., 2003). however, the majority of the participants reported no prior memory testing by their local provider. only one was previously diagnosed with ad. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 81 some studies show that sleep disturbances are common among patients who have some form of dementia, which includes ad (brzecka et al., 2018). deep sleep potentially has the ability to cleanse the brain and prevent the formation of plaques and tangles (tarasoff-conway et al., 2015). when individuals experience poor sleep, they may have a higher chance of obtaining dementia, compared to the individuals who have a normal sleep patterning (ballard et al., 2011). influence of rural farmwork lifestyle the results showed that the majority of individuals were not at risk for hypertension and did not exhibit poor sleep or cognitive impairment. this raised the question that if these individuals lack the basic needs of the average civilian such as proper healthcare, education, and a sufficient income, then how did the majority of individuals maintain such good health? one explanation may be that participants demonstrated and reported fewer problems with blood pressure, sleep, or memory loss because of health-seeking behaviors motivated by relationships with local providers. almost all (98%) were eligible for medicaid/medicare benefits and saw a provider at least annually, and often quarterly. eighty percent of participants reported being on antihypertensives, although half reported that they were not consistent in taking it daily. however, the participants frequently spoke of their attempts to “watch my salt” during monthly blood pressure screenings, and many said that they walked to the nearby store or pharmacy several times a week. the majority of these residents were seen during monthly blood pressure checks, which are offered by the pi as community service, and could state the date of their next provider appointment. we considered that these favorable blood pressure readings, in contrast to the large percentage of reported hypertension diagnoses, may be related to the participants’ status as former farmworkers. their consistent physical activity may have provided an opportunity for increased vascular circulation (bouchard, blair, & katzmarzyk, 2015). furthermore, these retirees still live in close proximity to online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 82 fresh fruits and vegetables, where fresh fruits and vegetables are more readily available in the nearby store for consumption, which can also contribute to improved heart health (borgi et al., 2016). however, these potentially confounding variables would need to be investigated further as a future implication. living alone. the majority of the participants were living alone due to separation, divorce, or spousal death. the percentage of single individuals was 88.5%; the remaining five persons were married and living together. prior work has shown that social and familial support tend to have an influence on an individual’s blood pressure (fuller et al., 2018). for example, family relationships could have a negative impact on someone’s health; therefore, people with many family members living with them tend to have higher blood pressure. fuller and colleagues (2018) found that larger family networks were related to higher diastolic blood pressure. it is thought that this may be related to the underlying stress of having a large family. african americans are more likely to live with their extended families. the emotional labor of giving support to large volumes of family members tends to cause greater social stressors for african americans (fuller et al., 2018). since most of the participants lived alone, this could be a mediating factor on hypertension. although the majority of participants reported having high blood pressure, it was often being managed, according to our screening results. in a different subset of questions in this population, the majority indicated that they indeed were happier living alone (wiese & williams, 2018). limitations the studied was useful in exploring the relationship between hypertension, sleep, and cognitive impairment within subsidized minorities. however, our study was limited by its small sample size of 52 participants. additionally, our study lacked information pertaining to the participant’s diet and exercise, which would be helpful in understanding why the health outcomes online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 83 of blood pressure, sleep quality, and cognitive risk were lower than expected. lastly, the sample collection area was limited to the glades, florida, which limited the opportunity to include participants from varied education, economic, social, and other types of diverse backgrounds. comorbidities may have contributed to the findings, but in-depth medical histories were not included in this study. there were measurements in places during the screenings to exclude participants who were diagnosed with depression, dementia, and certain cognitive inabilities. however, the comorbidity in individuals with some form of dementia is usually greater than in people without it, being that there is a substantial correlation between ad and vascular dementia (ashraf et al., 2016). one of the main differences is that ad is characterized by the buildup of beta-amyloid plaques and neurofibrillary tangles in the brain, while vascular dementia is characterized by ischemic damage due to impaired blood flow to the brain. (kalaria, 2018). these two diseases are independent of each other, although they do overlap in effect on cognitive function (ashraf et al., 2016). the overlap of two chronic diseases is one of the potential confounding factors that contributed to the limitations of this research. conclusion previous research has shown that a diminished sleep quality may increase risk for hypertension and dementia. however, sleep quality in this small cohort of rural, ethnically diverse farmworkers did not significantly influence either blood pressure or cognition. it was encouraging that during anecdotal conversations, these retired migrant farmworkers expressed an overall desire to maintain good preventive medicine and lifestyle habits that contributed to their overall health. these findings suggest that examining potential cultural influences on sleep and hypertension as risk factors for dementia is needed. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 84 about a quarter (23.1%) of the residents identified as being at risk for cognitive decline were not aware that they were at risk for dementia. however, it is inspiring that many (73%) of the subsidized housing residents who were invited (n = 70) chose to participate in follow-up education and research activities, which have been shown to be helpful for improving health in rural settings (fahs et al., 2013). future efforts will concentrate on expanding this work, and providing more education, screening, and services to cohorts of older retired farmworkers. however, without the involvement of providers to participate in focused cognitive care, these efforts will not likely result in assisting older adults to age-in-place. a continuing education program titled “alzheimer’s training for health care providers” available at the sanders-brown center for aging at the university of kentucky (n.d.), is cited by the national institute of aging (n.d.) as a helpful resource for providers in underserved areas. the training program includes nine modules regarding detection, treatment, and management of persons at risk for ad, and can support future efforts to improve the health and wellbeing of this underserved population. references alzheimer's association. 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(2015). amyloid burden and sleep blood pressure in amnestic mild cognitive impairment. neurology, 85, 1922-1929. https://doi.org/10.1038/nrneurol.2015.11910.1212/wnl.0000000000002167 university of kentucky. ce central. (n.d.). alzheimer’s training for health care providers. retrieved from https://www.cecentral.com/dementia u.s. census bureau. (n.d.) quick facts, population estimates, july 1, retrieved from https://www.census.gov/quickfacts/fact/table/bellegladecityflorida/pst045218 wiese, l. k., & williams, c. l. (november, 2018). depression and loneliness in rural older adults living alone. innovation in aging, 2(suppl 1), 632. https://doi.org/10.1093/geroni/igy 023.2359 wiese, l., galvin, j., & williams, c. l. (2018). rural stakeholder perceptions about cognitive screening. journal of aging and mental health., 23, 1616-1628. https://doi.org/10.1080/13607863.2018.1525607 wiese, l., williams, c.l., & hain, d. (2017). facilitating dementia detection in rural areas. today’s geriatric medicine, 14(10), 34. wiese, l.k, williams, c.l., hain, d., galvin, j., & newman, d. (2019). alzheimer’s association international conference. podium presentation: detecting dementia in older, ethnically diverse residents in rural subsidized housing. session: global initiatives to improve assessment, diagnosis and care for cognitive disorders in underserved populations. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.584 89 diversity and disparities professional interest group symposium. july 17, 2019. los angeles. wiese, l. k., williams, c. l., & tappen, r. m. (2014). analysis of barriers to cognitive screening in rural populations in the united states. advances in nursing science, 37, 327-339. . https://doi.org/10.1038/nrneurol.2015.11910.1097/ans.0000000000000049 online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 5 a rural interprofessional educational initiative: what success looks like deirdre jackman, phd, rn 1 olive yonge, phd, rn 2 florence myrick, phd, rn 3 fred janke, md 4 jill konkin, md 5 1 clinical assistant professor, faculty of nursing, university of alberta, deirdre.jackman@ualberta.ca 2 professor, faculty of nursing, university of alberta, olive.yonge@ualberta.ca 3 professor emerita, faculty of nursing, university of alberta, amyrick@ualberta.ca 4 associate professor, department of family medicine; director of rural and regional health, faculty of medicine and dentistry, university of alberta, fjanke@ualberta.ca 5 associate professor, family medicine ; associate dean, division of community engagement, faculty of medicine and dentistry, university of alberta, dkonkin@ualberta.ca abstract the researchers implemented an interprofessional education (ipe) pilot program, wherein final year baccalaureate nursing students and 3rd year medical students undertook preceptorships concurrently in a semi-rural acute care setting. the goal was to emphasize interprofessional (ip) collaboration and team-building. the researchers sought to determine how hands-on, clinically online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 6 based ip experiences could improve classroom-based ipe, and how the rural context might mediate such experiences. this article is an exploration of how participants defined a successful rural ipe experience, and which factors promoted or hindered that success. the definition of rural as used in the context of the research is to live outside of a major city. three nursing and four medical students who agreed to undertake rural preceptorships were recruited through their supervising faculty. upon their placement, three registered nurses and four physicians, assigned to precept the students, also agreed to take part. the researchers collected data through midpoint and endpoint semi-structured interviews, and two focus groups. the data were coded and analysed using glaserian grounded theory. in the participants’ view, successful rural ipe resulted in enhanced knowledge of each others’ scope of practice, firsthand insights into rural ip teamwork and increased confidence in working with other disciplines. authenticity was a key distinguishing rural feature. success moreover depended on buy-in and facilitation by preceptors and staff, and student initiative and selfreliance. hinderances to success were lack of logistical support, professional inertia or turfconsciousness, and student discomfort with ip engagement. over the course of the pilot, the students grew to emulate their rural preceptors’ interprofessional collegiality beyond the clinical setting. the results of this study support the implementation of ipe in clinical rotations as an alternative or an adjunct to classroom-based ipe. the rural context may be particularly advantageous to clinical ipe owing to comprehensive coverage of acute care and holistic, community focus. keywords: interprofessional education, medical students, nursing students, preceptorship, semirural, western canada online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 7 a rural interprofessional educational initiative: what success looks like traditionally, health sciences practica, such as nursing and medical preceptorships, entail a one-to-one relationship between a student and a practitioner in a specific discipline for the express purpose of enhancing the clinical acumen of the student and the professionalism of the preceptor. in this study, however, the researchers sought to pilot an innovative model which emphasized formal, interprofessional education (ipe) collaboration and team-building between nursing and medical students during a senior clinical placement, in addition to instruction pertaining to their respective programs of study the project, which took place in a semi-rural western canadian community, was designed to promote professional confidence and competence, while providing opportunities for regular ipe experiences during the practicum. the researchers sought to investigate the contribution of ipe collaboration to patient care, communication and the working environment. in this article, the researchers explore how participants defined a successful rural ipe, and the factors they identified as promoting or hindering such experiences. over the past decade there have been a variety of new initiatives in relation to ipe in the health sciences, characterized by a general shift away from purely theoretical, classroom-based ipe to practical and experiential learning (bilodeau et al., 2010; brewer & steward-wynne, 2013; mann et al., 2009; medves et al., 2008). related contemporary trends in ipe are simulation and e-learning (cooper, spencer-dawe, & mclean, 2005; hinderer & joyner, 2014; kowitlawakul, 2014; weinstein, 2010) and workshops or collaborative, problem-based modules (cusack & o’donoghue, 2012; eccott, 2012; lumague et al., 2006; meffe, claire moravac, & espin, 2012; o’carroll, baird, & jackson, 2012). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 8 a central theme emanating from ipe studies is the attitudinal stance of key stakeholders— namely students and faculty, health care providers and administrators—towards the implementation of an ipe program. administrators and faculty alike have proven receptive to practice-based ipe in principle (curran, deacon, & fleet, 2005; giordano, umland & lyons, 2012), however, it has been found that turf consciousness/guarding can lead to resistance among health care practitioners (becker, hanyok, & walton-moss, 2014; curran et al., 2005). as well, the persistence of a gendered and hierarchical discourse between nursing and medicine can invariably hinder interprofessional collaboration and education (bell, michalec, & arenson, 2014; curran, sharpe, & forristall, 2007; jacobsen & lindqvist, 2009; jacobsen, fink, marcussen, larsen, & hansen, 2009; price, doucet, & hall, 2014; wilson, fabri, & wolfson, 2012). beyond these psychosocial factors, scheduling and logistics have been found to be the typical challenges in the implementation of an ipe program (margalit et al., 2009). moreover, successful, practice-based ipe requires prior logistical measures in the practice setting (paré maziade, pelletier, houle, & iloko-fundi, 2012). rural clinical settings have proven advantageous to ipe from a variety of perspectives. rural practice is inherently team-based (medves et al., 2008), predominantly consisting of nurses and physicians. immersion in a rural community provides the opportunity for holistic education regarding all aspects of rural life, beyond the clinical setting (charles, bainbridge, copemanstewart, art, & kassam, 2006; deutchman, nearing, baumgarten, & westfall, 2012). health sciences students undertaking rural ipe may be more likely and feel better prepared to choose rural career placements upon graduation (rhyne, daniels, skipper, sanders, & vanleit, 2006). reported outcomes of ipe programs are largely positive. ipe has been shown to promote patient safety and reduce mis/noncommunication among disciplines (baker & durham, 2013; cox et al., online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 9 2009; thibault, 2011; wilson et al., 2012). students have indicated that practice-based ipe actually enabled them to learn directly about each other’s scope of practice, roles and responsibilities (eccott et al., 2012; hanyok, walton-moss, tanner, steward, & becker, 2013; kowitlawakul, 2014; lumague et al., 2006) and clarify their own roles in the context of an interprofessional team (kowitlawakul, 2014). in turn, interprofessional experiences have been found to promote student confidence in communication skills (meffe et al., 2012), professional identity (cooper et al., 2005; eccott, 2012) and collaboration (eccott, 2012). for the current study, the researchers brought together nursing and medical students for a practice-based ip experience in a rural setting, thereby seeking to: 1) innovate an experiential, practical alternative to classroom-based ipe; and 2) maximize the interprofessional team ethos inherent in rural health care settings through the principles of collaboration, communication and teamwork. methods the specific purpose of this study was twofold: 1) to investigate the psychosocial processes underlying an interprofessional preceptorship pilot for nursing and medical students in a rural health care setting; and 2) to promote interprofessional preceptorship development through evidence-based, qualitative findings. owing to the lack of knowledge regarding the psychosocial processes underlying interprofessional learning experiences, the researchers chose to employ glaserian grounded theory. in collaboration with medical and nursing faculty members at a post-secondary institution in western canada, the researchers recruited three senior (final year) undergraduate nursing students, all female, aged 21-23 years; and four medical students, one male and three female, aged 24-29 years, undertaking a third year preceptorship placement. all students affirmed their online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 10 prior clinical rotations had taken place in urban settings, and all volunteered to take part in the researchers’ interprofessional rural preceptorship pilot. a nursing faculty coordinator also agreed to participate. the students were subsequently assigned concurrent placements in a 76-bed acute care setting approximately 90 km from their place of postsecondary study, in a semi-rural community (population 17,000). the three nursing students resided in the community for 10 weeks. two medical students commenced their preceptorships six weeks prior to the other medical students thus their participation in the ipe was limited to two weeks. however the remaining two medical students had an eight week placement concurrent with the nursing student placements. in addition to the acute care setting, the students undertook rounds in the community primary care network (pcn), a long-term care facility, and a medical clinic at which the precepting physicians practiced. once the students were placed, the researchers further recruited the following preceptors working in acute care at the health care setting: three registered nurses (rns), all female, aged 49-55 years, all of whom had precepted students in the past and reported more than 15 years’ rural clinical experience; and four physicians, two female and two male, aged 29-60 years, reporting between one and 27 years’ rural clinical experience. two physicians had not precepted students prior to taking part in the ipe. prior to recruitment, the researchers obtained ethical approval from the human research ethics board of their employer. all participants provided written, informed consent, with the understanding that they would remain anonymous and that they would be entitled to withdraw at any point during the study. participants were informed about the nature and aims of the study through an information sheet and a 90-minute, onsite presentation. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 11 in addition to facilitating the students’ preceptorship placements and orienting all participants, the researchers also engaged in structured teaching and learning sessions with the participants, using four ipe modules which they had developed specifically for this particular educational experience. sessions were conducted over approximately 60 minutes each, and were scheduled over four weeks during the preceptorship. the modules comprised discussion scenarios, video presentations, jeopardy rounds and additional readings. two modules were presented onsite, and two online. the topics presented included teaching and learning; the rural context; ipe communication and collaboration; and roles and responsibilities. these modules constituted an integral component of the students’ formal coursework for their preceptorships. the researchers conducted the first semi structured interviews midway onsite and upon conclusion the second set of interviews via telephone. all participants took part, with the exception of the two male physicians. additionally, the researchers conducted two onsite focus group sessions. the first midpoint session was attended by students and their faculty coordinator; the second session, which took place upon completion of the preceptorship, was attended by the nurse preceptors and their unit managers. all interviews and focus group sessions were audiorecorded and transcribed. the dataset also comprised researcher field notes and memos. to analyze the data, the researchers employed glaserian grounded theory, based on the symbolic interactionist principle of meaning arising from social processes (blumer, 1986; schreiber & stern, 2001; strauss, 1987). analysis consisted of: 1) substantive coding; and 2) theoretical coding, whereby the researchers searched for intrinsic patterns in the data and subsequently gathered these into thematic categories which, in turn, became the basis for a core variable underlying the entire dataset (glaser, 2005). data analysis began as soon as the first online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 12 interviews were completed and transcribed. three researchers carried out this process independently, using both traditional hardcopy and nvivo 10 (qualitative analysis software), to ensure the findings would be triangulated, mutually auditable, and confirmable. the concluding interviews were dedicated to validating the analysis already carried out, by means of participant corroboration and legitimation of the researchers’ theoretical codes, in the form of focused questions. at the concluding focus group, the researchers shared their findings in a powerpoint presentation and poster. through these measures, the researchers achieved a reliable and rigorous account of the psychosocial processes underlying the ipe. ethics approval this research was approved by the research ethics office, with the approval number res0022459. results in this study, the researchers sought to understand the participants’ actual perceptions of an ipe process in a rural setting, and the conditions they perceived as advancing or impeding that process. what emerged from the data was a process of actively ‘committing’ though out the placement to ipe which generated learning outcomes that reflected nursing and medical students’ enhanced knowledge of each other’s scope of practice, firsthand insights into rural interprofessional teamwork, and increased confidence in working with professionals from other disciplines. such a process served to create authenticity, in that the participants were genuinely interacting as team members rather than taking part in a classroom exercise. according to the participants, the success or breakdown of the ipe preceptorship hinged on several conditions. buy-in and facilitation by preceptors and other staff members, in particular, were found to greatly improve the likelihood of successful ipe learning outcomes, whereas online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 13 professional inertia and resistance to change were acknowledged impediments. perhaps the most significant condition for success or failure, however, was student initiative. outgoing, selfmotivated students ‘committing’ to seeking out ipe interactions with each other, without waiting to be placed together or have their time managed by others, were most likely to benefit from the ipe pilot. it was generally agreed that students without such aptitudes would not be ideal candidates for the ipe pilot. the rural context the researchers deliberately chose to implement the interprofessional preceptorship pilot in a hospital located in a semi-rural setting, to capitalize on the interprofessional rapport they had previously observed in rural settings. in taking stock of the setting, one medical student observed, i’m watching interdisciplinary [teamwork]. i’m watching how the nurses and the doctors and the ems are coming into the emergency room; how they talk with the nurse and then the doctor; [how] the rt comes down and assesses as well. i think what’s so nice is it’s on such a micro-scale that it’s possible for someone to assess a patient on a unit, and then go down to the emergency room, and then, oh someone got called in obstetrics—so you see this more tangibly than if you’re in the big city. if you’re on the obstetrics unit [in the city, then] that’s where you’re staying, cause everyone needs to keep tabs on where everyone is, and you have learning objectives just for that. so rural is nice because it’s more flexible, and then there’s the opportunity to see things as they happen organically. from this student’s perspective, then, the rural context provided comprehensive coverage of ipe teamwork in all acute care situations, albeit in a compressed “micro-scale” which nonetheless felt completely authentic. the choice of the word “organic” suggests that the rural online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 14 setting allowed observation of ip teamwork unfolding naturally, across a continuum of care, rather than the snapshot view afforded by a placement in a single unit in an urban setting. “i think that the rural environment will organically just facilitate that interdisciplinary work… the rural setting will do all the authenticity for you,” echoed another medical student. “where you’re gonna have problems is when you’re gonna start making both nursing students and medical students do things that are kind of like, ok go do this together… the interdisciplinary class has kind of a bad reputation amongst all disciplines.” this student drew a contrast between the “organic” experience of rural ipe and the compulsory, classroom-based ipe, notorious amongst the student participants for its theoretical rather than authenticity-based exercises. “everyone felt the classroom setting was a bit artificial,” agreed a nursing student; “you were supposed to be bringing your scope of practice and your knowledge together, but on very fabricated scenarios.” in the early stages of the pilot, the clinical context acted as more of a barrier to ipe; staff members acknowledged that adapting to the new preceptorship model was difficult. the logistical challenge of coordinating students’ schedules, to have them in the same place at the same time, initially fell to staff. “everyone is so busy,” remarked one precepting physician; “if the medical students haven’t already figured out, they certainly become aware quickly that our timeline is very different than the nursing timeline. we’re running in, running out, and [the nurses are] there all day.” participants were largely unanimous in praising the program, but they expressed regret for lost ipe opportunities due to scheduling difficulties. “i believe that [the ipe program] needs to have more structure because [the students are] missing out. they’ve seen some great things but they could see more,” said one registered nurse. the rural context compounded these logistical difficulties insofar as the staff members, as expert generalists, were online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 15 already spread thin. “in my role i’m a mediator, i’m an educator, i’m a facilitator, i’m doing schedules, i’m doing all these other things,” said a nursing unit manager. “some days i feel like i’m not giving the best 100% to the student because my 100% has to be over here somewhere.” staff buy-in one unit manager who assumed the role of nurse preceptor expressed that she had been informed by hospital administration to take part in the pilot without what she perceived as adequate consultation. regardless of the situation, she consented to be part of this research project. furthermore, two of the four physician preceptors did not respond to interview requests from the researchers. while they indicated support of interprofessional practice at the initial orientation presentation, they did not have much involvement in the pilot, except to release the students under their tutelage from certain commitments in order to attend clinical ipe opportunities. another precepting physician, who was more supportive of the project, acknowledged that bridging the divide between nursing and medical rotations was never going to be easy: the two training models are diabolically different in character and structure... whether [we’re] territorial by design, or by default, i’ve never seen a nursing instructor instruct the medical students, and in return i don’t step over the line and take them aside and instruct. there’s been a line there, so not that we’re not friendly or supportive, but there’s a line and it’s been well-defined. and that’s probably what’s perpetuated some of the both positive and negative things between the two professions. it is worth noting that the physicians who did not actively participate in the ipe objectives had both been practicing for over 20 years, and (apart from one medical student) the only males involved in the project. the students also observed some staff members’ resistance to change, online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 16 especially at the outset. “i think maybe there was some wariness of bringing in new things, and ruffled feathers, [through] messing with what people have as established routines,” remarked one medical student. in this student’s experience, not every preceptor was sanguine about “making sure that we have the time to shadow each other as students, and making an effort to make time for the pilot project.” in any event, however, these instances of professional inertia were exceptions rather than the norm. preceptors observed the value of ipe and sought to bring about interprofessional experiences for the students. these preceptors rarely spoke of teaching interprofessional principles, but rather of setting up the students to discover these principles for themselves. “i’ve been the one who’s been doing most of the scheduling on the medical student side of things,” said one precepting physician. “where there’s a nursing student and a medical student involved, [i’m] just trying to find those opportunities, as they arise, for them to work together with a patient.” the phrase “finding opportunities” perhaps best summarizes how preceptors saw their role, as far as the ipe pilot was concerned. they avoided “stepping over the line” of directly instructing each other’s students, preferring instead to point them in the right direction and then step back. the students corroborated this account, praising the efforts of their preceptors in facilitating ipe experiences. one medical student remarked, [the staff has] all of our phone numbers, and[they] would send a text message to the whole group saying, “if you’re available come to the emergency room, there’s an interesting case that you guys might all benefit from, being there”. one day i know they sent out a message saying there was a patient on a given unit that was being cardioverted, so if you were around and you wanted to see that, then you could go take part and be there together–learn from it together. online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 17 as practitioners and former students themselves, the nursing and medical preceptors demonstrated they understood the value of hands-on interprofessional experience with minimal intrusion by instructors. student initiative facilitation of ipe opportunities by preceptors was not enough to produce successful outcomes; the students also had to capitalize on such opportunities. “it has taken effort on everybody’s part to make it happen,” said the medical student quoted above. “all of us [students] have been pretty engaged, so it hasn’t really fallen to one person to make it work. i think everybody’s been pretty proactive in making that happen.” beyond their prior preparation and experience, proactivity was found to be the greatest asset that students brought to the ipe pilot. in the early stages of the rotation, as the staff and students struggled to coordinate schedules, at least one nursing student seemed in jeopardy of becoming marginalized—”struggling to make sure i’m meeting my course expectations… i’ve always gotta introduce myself, explain what the program is, [and] explain what my personal goals are.” the ipe pilot pushed this student outside of a comfort zone (as it did many staff members) but by the end of the rotation the student, like the other students, was fully invested in the interprofessional team ethos. “they pretty much know what they want, and they’re go-getters,” beamed one nurse preceptor. “they don’t sit in a corner somewhere.” at least one nursing student acknowledged that the pilot suited their particular personality type: “somebody who has the aptitudes to be quite independent, [and] selfmotivating, is gonna do better.” the students also capitalized on opportunities outside the clinical setting to build interprofessional rapport. “we talked together [as students] and decided that [telehealth sessions] would be a good opportunity for us to discuss the presentation, and our perspectives online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 18 from nursing and from medical students,” said a nursing student. “we took the initiative as students to organize the[ primary care network] meetings as well… we had to create those, which was a good opportunity.” these instances, together with case-based, ipe instructional modules (also a component of the pilot) became occasions for the nursing and medical students to socialize and compare schedules. the students also made a point of creating their own social occasions, such as an evening out at a local eatery and participating in a zumba class together, as a way of further building interprofessional team ethos. these occasions illustrated that the students were taking their cue from the close-knit, informal camaraderie of the rural staff members. as one nursing student noted: there’s a doctor who just had a baby and everyone’s invited to her baby shower. the nurses are talking about who’s gonna go, and the docs are gonna go. that’s what ended up happening with us [as students], in a sense—we were able to hang out on a social level. that’s what happens here. it’s normal here and i think that the first time, at least for me, that i saw doctors and nurses and rts and whatnot all having that friendship alongside the professional relationship. …you don’t see that anywhere else. the students demonstrated initiative both in capitalizing on ipe opportunities and in emulating their preceptors’ interprofessional collegiality. this aptitude for proactivity, combined with staff buy-in and the rural team ethos, resulted in successful ipe experiences. as the coordinating faculty member observed, “i think a lot of the confidence did have to go back to the students’ own initiative and willingness to try things, and i guess the support that they’re able to get from the staff [as well].” the participants identified authenticity as the quality that set apart the rural ipe practicum pilot from other forms of ipe. authenticity, in their view, implied online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 19 allowing events to unfold naturally, with minimal intervention by preceptors, so that the students might engage in unscripted, mutual reliance and decision-making as a team. discussion the findings corroborate much of what is established in the literature. the students drew a clear distinction between classroom-based ipe and the ipe preceptorship pilot, expressing a strong preference for the latter (bilodeau et al., 2010; brewer & stewart-wynne, 2013; mann et al., 2009; medves et al., 2008). while the pilot did integrate case-based learning modules outside the clinical setting (cusack & o’donoghue, 2012; lumague et al., 2006; meffe et al., 2012; o’carroll, 2012), their value lay primarily in providing the students an additional opportunity to build rapport and coordinate their schedules. gender, discipline, hierarchy and length of practice experience may have been pertinent influences on staff support (bell et al., 2014; curran et al, 2007; jacobsen & lindqvist, 2009; jacobsen et al., 2009; price et al., 2014; wilson et al., 2012). the two physicians who did not actively participate in the project happened to be male, each with over 20 years of practice experience; the two who did were younger, female practitioners. this may not be a significant result in itself, but participants did acknowledge that territoriality and routine were both in play (becker et al., 2014; curran et al., 2005). the greatest number of setbacks to the pilot resulted from scheduling and logistical issues (curran et al., 2005; margalit et al., 2009). the suggestion by paré et al. (2012) of putting thorough logistical measures in place was borne out in the comments of participants. having hospital administration and university faculty directly involved and supportive of the pilot was highly beneficial (curran et al., 2005; giordano et al., 2012). online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 20 the rural context advanced the objectives of the ipe pilot in several ways. the condensed nature of the rural setting provided abundant opportunities for ipe experience across a continuum of care and the informal collegiality of the rural health care team provided a useful model for the students’ own interprofessional rapport (medves et al., 2008). the students’ rotations encompassed both the acute care and community settings including the primary care network (pcn) and the medical clinic, thereby affording them a more holistic perspective of interprofessional teamwork than the confines of the hospital (charles et al., 2006; deutchman et al., 2012). the students were adamant that the rural context played a crucial role in their acquisition of interprofessional experience, knowledge and confidence, but similar initiatives have succeeded in urban settings as well (eccott et al., 2012; hanyok et al., 2013; kowitlawakul et al., 2014; lumague et al., 2006). limitations and further questions in this study the nursing and medical student sample size (n=7) was sufficient to achieve saturation for grounded theory. from the current findings, little can be deduced about the feasibility of implementing an interprofessional preceptorship pilot in an urban center, although the site researched was large by rural standards. the study also engenders further questions about the feasibility of expanding the pilot to include other health disciplines, such as physiotherapy, pharmacy and occupational therapy, but initial enquiries have shown that these student rotations may be more difficult to coordinate with nursing and medicine for onsite ipe experiences. conclusion online journal of rural nursing and health care, 16(2) http://dx.doi.org/10.14574/ojrnhc.v16i2.417 21 this study indicates that successful interprofessional education outcomes—clinical experience, skills, and confidence in an ip team setting—are the product of an authentic teaching and learning process, and that authenticity is engendered by setting, staff facilitation, and student initiative. the findings strongly support the contention that ipe acquired during a clinical rotation, such as a preceptorship, is more highly valued by nursing and medical students than classroom-based ipe. moreover, it is at least plausible that rural settings confer distinct advantages to those undertaking clinical ipe rotations, owing to the comprehensive coverage of an entire acute care setting and the opportunity to follow the continuum of care into a holistic, community context. funding agency funding for the study was provided by alberta agriculture and rural development, rural initiatives and research branch. acknowledgements the authors wish to acknowledge jim cockell, research assistant, for his assistance in writing and editing this article. the authors also wish to acknowledge how leww, nursing faculty coordinator, faculty of nursing and jim cockell, research assistant. references baker, m.j., & durham, c.f. 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(2012). human error and patient safety: interdisciplinary course. teaching and learning in medicine, 24(1), 18 25. https:/doi.org/10. 1080/10401334.2012.641482 hendrickx_603_formatted online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 142 pediatric clinical for nursing students in rural areas: the camp nursing experience lori hendrickx, edd, rn, ccrn, cnl 1 heidi pelzel, msn, rn 2 linda burdette, phd, rn 3 nancy hartung, msn, rn, cde 4 1 professor, college of nursing, south dakota state university, lori.hendrickx@sdstate.edu 2 instructor, college of nursing, south dakota state university, heidi.pelzel@sdstate.edu 3 assistant dean and associate professor, college of nursing, south dakota state university, linda.burdette@sdstate.edu 4 educator, sanford aberdeen diabetes center, south dakota, nancy.hartung@sanfordhealth.org abstract problem: clinical placement for nursing students in pediatrics can be challenging in rural settings. hospitals in rural areas typically do not have the numbers of pediatric patients necessary to provide individual inpatient pediatric experiences for a group of nursing students nor can community settings accommodate a full group of students at once. children’s hospitals or hospitals with pediatric inpatient units are often a significant distance from nursing programs located in rural areas and there is competition among nursing programs for placement in these facilities. a study by the institute of pediatric nursing (ipn) in cooperation with the american association of colleges of nursing (aacn) concluded that nursing schools had challenges finding pediatric clinical sites and that pediatric content was lacking in depth and breadth (mccarthy & wyatt, 2014). online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 143 alternative clinical placement: for one nursing program located in a rural area, nursing students were placed at summer camps for children with various health care needs, including diabetes, developmental delays and special needs. placing nursing students in a pediatric clinical experience at summer camps provided a supervised environment where they interacted with children with a variety of health care needs and provided care that included recognizing signs of diabetic emergencies, working with insulin pumps, administering medications and feedings via gastric tubes, providing basic first aid, health promotion and health teaching, and engaging in therapeutic communication. outcomes: evaluation of the summer camp experience was positive from students, faculty and camp personnel and student learning outcomes for the pediatric clinical course were met. summer camps can provide excellent learning experiences for nursing students and serve as viable alternatives for pediatric clinical sites when inpatient pediatric facilities are not available. keywords: pediatrics, clinical experience, children, nursing education, summer camps pediatric clinical for nursing students in rural areas: the camp nursing experience finding clinical placements for pediatric experiences can be challenging for nursing education programs located in rural settings (hensel, malinowski, & watts, 2015). rural hospitals typically do not have the numbers of pediatric patients necessary to provide individual pediatric experiences for an entire clinical group nor can rural community settings accommodate a full clinical group at one time. additionally, children’s hospitals or hospitals with designated pediatric inpatient units are often a significant distance. while many nursing programs do travel to urban children’s hospitals or hospitals with pediatric units for clinical, there is often competition among nursing schools for clinical placement in these facilities. the competition for clinical placement at children’s hospitals and the distance many programs must travel are barriers for rural nursing online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 144 programs, resulting in lack of exposure to caring for children. this lack of exposure may potentially deter nursing students from pursuing pediatric nursing upon graduation (institute of pediatric nursing [ipn], n.d. across the united states, nursing programs have turned away qualified applicants due in part to a lack of clinical sites (american association of colleges of nursing [aacn], 2017). specifically related to pediatric clinical, the ipn in cooperation with the aacn concluded that nursing schools were challenged in finding pediatric clinical sites and pediatric content was lacking in depth and breadth (mccarthy & wyatt, 2014). these issues have the potential to affect the pediatric nursing workforce at a time when children’s health care is more complex due to challenging chronic health conditions and evolving behavioral health issues. challenges in finding appropriate inpatient pediatric clinical experiences have resulted in the use of alternative sites for the care of children. many nursing programs use home health, ambulatory care settings, schools, clinics and community settings serving children with health care needs. while all of these provide excellent learning opportunities, the settings often restrict the number of students they can accommodate at one time. the ipn has published a list of alternative sites for inpatient pediatric clinical and includes, among others, summer camps for children and adolescents (ipn, n.d.). many camps are designed to offer a camp experience for children with various health care needs, allowing nursing students to provide care in a supervised setting. the possibility of taking nursing students to camps for pediatric clinical placement was initially piloted with one clinical group at a college of nursing located in a rural midwestern state. this nursing program is located 175 miles from the nearest children’s hospital, making clinical placement difficult. the pilot group was successful and led to online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 145 the expansion of all clinical groups being placed at summer camps for their pediatric clinical rotations. review of literature several barriers to providing adequate pediatric clinical experiences have been identified in the literature. challenges include competition for quality acute care clinical sites, inadequate numbers of clinical instructors, fewer direct hands-on pediatric learning opportunities, and limited opportunities for medication administration (evans, 2017; mccarthy & wyatt, 2014). these challenges are more problematic in rural areas where the added issue of distance from pediatric acute care settings is a factor. the movement of pediatric clinical experiences out of the acute care setting has been supported by the ipn (n.d.) and summer camps are prevalent in rural areas. completing pediatric clinical experiences at summer camps for children with health care needs offers a solution to the difficulty finding appropriate acute care pediatric clinical sites. history of camping historically, for children with specialized health care needs, camping was not always considered a viable option. however, organized camping experiences for children with special needs have been documented since 1899, with the establishment of a permanent site in wisconsin in 1901 (gilmore, 2016). eels (1986) published a manuscript describing the history of organized camping and detailed the development of camps for children with health care issues. while the number of camps for children with special needs grew from 200 to 3,200 by 1947, the types of camps also grew. over time, many camps were established that serve children with multiple diagnoses such as diabetes, cancer, hiv/aids, muscular dystrophy, mental health issues and a range of physical and intellectual challenges (gilmore, 2016). many camps for children with special needs use a online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 146 partnership model. these camps partner with a hospital or other agency to develop camps that are accessible for specific campers. clinical placement at camp historically, placing nursing students at camps for children with special health care needs has been reported as a viable option for pediatric clinical (totten & fonnesbeck, 2002). nursing students at ucla served as counselors at a camp for children with cancer and muscular dystrophy where they participated in camp activities and in the infirmary working with the camp nurse. the students had the opportunity to perform specialized skills such as catheterization, injections, and work with central ports. students reported positive learning experiences and camp staff rated the nursing students’ performance as excellent (nash, 1987). praeger (1997) described successful implementation of camps as clinical sites and identified methods for identifying appropriate camps, selecting and confirming a camp, and preparing students for the camp experience. students were given the option of participating in the camp experience, which included caring for children with diabetes, seizure disorders, myelomeningocele, cerebral palsy and traumatic brain injury. in a descriptive study, vogt, chavez, and schaffner (2011) used reflective journaling to describe nursing students’ experience at a camp for children with diabetes. participants (n=26) reported positive reactions, a sense of responsibility toward their assigned cabins, and an increased knowledge of diabetes (vogt et al., 2011). while many camps are weeklong, one nursing program used a weekend, overnight camp for children with special needs for pediatric clinical. through focus groups, a post-conference, and an online forum, students indicated they were able to do a variety of psychomotor skills and learned several key lessons including: 1) that the camp supported patient-centered care, 2) students felt online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 147 supported and relaxed and 3) that scheduling was a barrier. despite the scheduling issues, the authors indicated a desire to continue the camp experience for students as a pediatric clinical option (hensel et al., 2015). evans (2017) used a qualitative narrative design to explore how placing fourth year nursing students in a camp setting met course outcomes. results showed the camp setting provided the opportunity to demonstrate principals of patient safety, critical inquiry, preventative/promotional health, reflective practice and advocacy. alternative clinical experience the pediatric clinical rotation for nursing students varies among nursing programs. according to mccarthy and wyatt (2014), pediatric clinical sites should transition from a focus on primary care or hospital settings to more community, home, and school-based experiences. in order to accommodate the shifting trends of pediatric nursing, one rural midwestern baccalaureate nursing program adapted the pediatric clinical rotation to be a summer camp-based experience. student learning outcomes within the syllabus included goals of providing therapeutic communication; performing developmentally appropriate assessment, interventions, and evaluation; and applying critical thinking/clinical reasoning/clinical judgement skills. student performance standards for evaluation included timeliness, safety and efficiency of care, professional communication, and active engagement with clinical participants. during the clinical rotation, students’ theoretical knowledge was linked to clinical practice through pediatric case conferences, medication review sessions, and daily pre-briefing and debriefing discussions. procedure for camp preparation preparation for the camp clinical experience was key to nursing student success. at the beginning of the semester, the course syllabus was reviewed and students were informed of clinical online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 148 expectations. students were offered the option to travel to a camp location or stay near the university campus for a day camp clinical rotation. students were given the choice because the travel and overnight immersion requirements were difficult for some students. grant funding was obtained to cover the cost of the cabin rentals where applicable. orientation to the camp experience itself was standardized, but supplementary orientation varied by camp. basic camp orientation included performance evaluation procedure, professional communication review, and additional professional nursing student role expectations. supplemental orientation to each specific camp clinical was provided. this supplemental orientation included travel arrangements, camp housing, meal accommodations, appropriate camp nurse attire, anticipated types of cares that would be performed and an overview of the individual camp. camp #1 camp #1 was envisioned through a partnership between a center for the arts and a theater company. this camp is held on a barrier-free modern replica of an 1880s town. the camp provides visual and performing arts opportunities which are modified for individual campers. campers have a summer camp experience while exploring their love of theater and performing arts. campers try out for performance roles and practice for an official performance at the conclusion of camp. while campers practice their performance extensively, the location is completely handicap accessible and affords campers of all abilities and disabilities to participate in many activities, including horseback riding, pontoon rides, fishing, archery, water activities, swimming, and campfire time. camp counselors are responsible for the safety and health care of campers. many of the campers have chronic disease processes requiring specialized healthcare personnel, a need that online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 149 nursing students can fill through clinical placement. nursing students and instructors are present at camp from “check-in” to “check-out”, providing students an opportunity to meet parents/guardians, learn camper names, medication regimens and health care requirements. nursing students perform care for campers with diagnoses such as autism, downs’s syndrome, cerebral palsy, anxiety disorder, depression, celiac disease, epilepsy, fetal alcohol syndrome, and attention deficit hyperactivity disorder, among others. the daily routine starts with morning medication administration for at least 30 of the 40 campers. some campers require gastric tube administration of medications. this routine occurs again at 1100 and at 2000 for bedtime medications. if campers receive medications at additional times throughout the day nursing students have a reminder system to ensure these medications are administered at the camper’s usual time. parental consent allows the student nurse to administer many over-the-counter (otc) medications to campers. these otc medications are administered only after a focused assessment is conducted. safely administering medications to many children over a short period of time can be a challenge for nursing students who are more familiar with the acute care routine; one that includes a bar code scanner and wrist bands. student nurses quickly learn to adapt and develop additional safety checks to accommodate the camp environment. medication administration is not the only task the students complete. nursing students are “oncall” during the theater practice times for camper safety and healthcare needs. during additional camp activities, the student nurses accompany campers to the lake, riding arena, archery range, “old west main-street”, and hiking trails. the role of the student nurse includes treatment of cuts and scrapes, sprains or strains, and other injuries. if a camper suffers a severe injury, nursing students collaborate with camp staff to follow appropriate protocols or procedures, including notifying a camper’s parent of the current concern. the camp nurse day is often 14 hours long by online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 150 the time bedtime cares are completed and the campers are in bed. because the camp accommodates campers of all abilities, challenging situations with campers can be encountered during the clinical rotation. campers with cerebral palsy may be non-verbal and wheelchair bound, require tube feedings, medication administration through a gastric tube, and frequent personal hygiene cares. in partnership with camp counselors, nursing students worked out alternative communication methods and options for getting the campers out of the wheelchair to participate in activities. camp #2 camp #2 is a week-long residential summer camp for children with type 1 diabetes. in 2018, one-hundred-twenty campers attended the camp, along with forty-two staff members. camp staff are volunteers, including pediatricians, pediatric endocrinologists, physician assistants, nurse practitioners, certified diabetes educators, nurses, dietitians, and social workers, as well as nonlicensed personnel. many of the staff have type 1 diabetes themselves and are former campers. this week-long camp began a collaborative partnership with a midwestern, rural college of nursing in 2014, offering a unique pediatric clinical experience for accelerated bsn nursing students. a typical clinical group is 8-9 nursing students. nursing student responsibilities are identical to those of unlicensed camp staff. each carries a fanny pack equipped with a glucometer, test strips, disposable lancets, cotton balls, alcohol preps, hypoglycemia treatment guidelines, documentation slips, and glucose tablets. during staff orientation, the nursing students and faculty member receive instruction and demonstrate competency of skills via the teach back method. each student is assigned to a camper cabin, spending on average 10-12 hours on site daily. while at camp, most campers test blood glucose on average ten times per day, so students become experts with glucose testing by the end of the week. other responsibilities include observing and/or online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 151 assisting campers with carbohydrate counting, insulin injections/insulin pump bolusing and insulin pump site changes, as directed by camp medical and nursing staff. because this is a pediatric rotation, students are encouraged to interact with campers and develop appropriate relationships in order to gain comfort and experience working with children. campers share a unique perspective about living with type 1 diabetes. the same is true for the many staff who also live with type 1 diabetes. nursing students are encouraged to participate in camp activities during the week, giving them additional opportunities to interact with campers and staff. camp activities include swimming, paddle boats, canoes, paddle boards, fishing, basketball, sand volleyball, and crafts. the pediatric clinical rotation provides a unique educational opportunity for complete immersion into the world of type 1 diabetes. students report positive clinical experiences. the camp not only benefits greatly from having the additional staff on site, but a number of students have returned to volunteer as camp nurses after passing the nclex. evaluation at the conclusion of the week-long clinical experience, students have a debriefing session with their clinical group and instructor. students discuss the experience as a pediatric clinical option, giving feedback addressing ways to maximize the experience for future clinical groups. additionally, students complete an evaluation that addresses the following: positive and negative attributes of the experience, suggestions for improvement and how faculty can better prepare the students for the camp experience. comments have been overwhelmingly positive. students shared that they learned a great deal about diabetes or other specific childhood disorders, improved their techniques in communicating with children, got excellent experience in pediatric medication administration and learned more about mental health issues facing children. one student online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 152 commented: “not only did i learn about diabetes, meds, and insulin pumps but i learned about the psychological toll of having diabetes as a kid.” the students often commented about the opportunity for hands-on learning at camp, particularly related to medication administration, diabetes management and psychosocial interaction. another student commented: i had a great experience at camp for my pediatric clinical opportunity. i feel as though we had a great variety of patients and situations. we had some awesome acute care opportunities as well as great interactions with kids of various ability levels. oh, and i got great experience with giving a whole bunch of meds in not a whole bunch of time. students’ suggestions for improvement resulted in increased instruction on the management of insulin pumps and carbohydrate counting. the pre-camp orientation sessions were revised to reflect students’ comments requesting additional preparation for caring for children with special needs. nursing students were able to meet learning outcomes for the pediatric clinical course. they demonstrated integrity and therapeutic communication with children, peers, and staff; promoted health through teaching and managing illness; demonstrated applicable nursing roles; performed developmentally appropriate population-based assessment, intervention, and evaluation, including health teaching, screening, and referral; and applied critical thinking, clinical reasoning, and clinical judgment to patient care. resources numerous resources are available to programs interested in establishing pediatric clinical experiences at camps for children with health care needs. while many are specific to a particular illness, others are for children with a variety of health care needs. the american camp association (aca) has a “find a camp” function that helps identify what type of camp the searcher is online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 153 interested in. additionally, the aca web site allows one to identify camps for children with special needs or for specific populations. the aca site has information on over 3700 camps (aca, n.d.). more specific to nursing is the association of camp nurses, which offers a wealth of information about camp nursing, including education and resources, research, and information about specific states’ programs. it has published the scope and standards of camp nursing and practice guidelines for camp nurses (association of camp nursing, 2017). see table 1 for resources for camps for children with special health care needs. table 1 camp nursing resources name website american camp association https://www.acacamps.org/ association of camp nurses https://www.campnurse.org/ american diabetes association http://www.diabetes.org camp mak-a-dream https://www.campdream.org/ camp quality usa https://www.campqualityusa.org/ camp one step https://camponestep.org/ kidscamps https://www.kidscamps.com/ muscular dystrophy association https://www.mda.org/summer-camp ped-onc resource center http://www.ped-onc.org/ soar https://soarnc.org/ conclusion in rural areas, nursing programs face significant difficulty providing acute care, in-patient pediatric clinical experiences due to distance from children’s hospitals or hospitals with pediatric units, competition for available clinical sites and the changing demographic related to where children with specialized health care needs receive care. while this nursing program is based in a rural setting, camp nursing experiences are valuable for nursing students from all backgrounds. the camp experience has provided a viable alternative to the acute care setting as resources continue to be scarce. camps should be considered when planning pediatric clinical experiences online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 154 for nursing students as a feasible alternative where students can provide care for children in a funfilled learning environment and still meet the curricular requirements of a pediatric clinical course. acknowledgement grant funding provided by a dawley seed grant award references american association of colleges of nursing (2017). 2016-2017 enrollment and \graduations in baccalaureate and graduate programs in nursing. washington, d.c.: author. publication no. 16-17-01 american camp association. (n.d.). find a camp. retrieved from http://find.acacamps.org/ association of camp nursing (2017). scope and standards of camp nursing practice (3rd ed.). retrieved from https://campnurse.org/product/scope-and-standards-of-camp-nursingpractice/ eels, e. (1986). eleanor eels’ history of organized camping: the first 100 years. martinsville, in: american camp association. evans, s. (2017). camp nursing as clinical placements for undergraduate nursing students. [master’s thesis, university of windsor] retrieved from https://scholar.uwindsor.ca/etd/7353/ gilmore, v. (2016). how special needs camping has impacted the camp experience. retrieved from https://www.acacamps.org/resource-library/camping-magazine/how-special-needscamping-has-impacted-camp-experience hensel, d. malinowski, c. & watts, p. (2015). implementing a pediatric camp clinical for prelicensure education. nursing education perspectives, 36, 60-61. http://dx.doi.org/10.5480/12-871.1 online journal of rural nursing and health care, 20(1) https://dx.doi.org/10.14574/ojrnhc.v20i1.603 155 institute of pediatric nursing. (2018, n.d.). innovative clinical rotation sites. retrieved from http://www.ipedsnursing.org/rotation-ideas mccarthy, a. & wyatt, j. (2014). undergraduate pediatric nursing education: issues, challenges, and recommendations. journal of professional nursing, 30, 130-138. https://doi.org/10.1016/j.profnurs.2013.07.003 nash, d. (1987). summer specialty camps: an overlooked site for student nurses’ clinical placement. journal of nursing education, 26, 126-127. praeger, s. (1997). establishing camps as clinical sites. journal of nursing education, 36, 236237. totten, j.k. & fonnesbeck, b. (2002). camp communities: valuable clinical options for bsn students. journal of nursing education, 41, 83-85. vogt, m., chavez, r., & schaffner, b. (2011). baccalaureate nursing student experiences at a camp for children with diabetes: the impact of a service-learning model. pediatric nursing, 37, 69-73. microsoft word document5 a mixed methods analysis of the place-related risk and protective factors for hospital utilization among children with complex chronic conditions shannon m. hudson, phd, rn, alumnus ccrn 1 gayenell s. magwood, phd, rn, alumnus ccrn 2 marilyn a. laken, phd, rn, faan 3 martina mueller, phd 4 susan d. newman, phd, rn, crrn 5 1assistant professor, college of nursing, medical university of south carolina, hudsonsm@musc.edu 2 associate professor, college of nursing, medical university of south carolina, magwoodg@musc.edu 3 professor, college of nursing, medical university of south carolina, lakenm@musc.edu 4 associate professor, college of nursing, medical university of south carolina, muellerm@musc.edu 5 associate professor, college of nursing, medical university of south carolina, newmansu@musc.edu abstract purpose: children with complex chronic conditions (ccc) have high health care needs and utilization. the purpose of this study was to identify place-related risk and protective factors associated with hospital utilization among children with ccc. methods: a mixed methods study was conducted to generate a risk profile of placerelated factors associated with hospital utilization. the quantitative phase of the study consisted of retrospective review of 216 urban hospital medical records of infants and young children with ccc. the qualitative phase of the study included interviews with parents/caregivers and focus groups with health care providers (hcps) of children with ccc. results from multiple regression modeling and directed content analysis were merged using a side-by-side table organized by ecological level. findings: place-related risk and protective factors on multiple ecological levels were identified. key place-related factors associated with hospital utilization were more complex conditions, positive relationships with hcps, more parent/family resources, and having fewer place-related resources. conclusions: the results of this study suggest patterns of health care utilization among infants and young children with ccc are influenced by place-related factors. parent relationships with hcps and comfort with care, hospital resources, and parent resources determine location of care. results of this study also imply place-related disparities in access to care, especially among children in smaller metropolitan areas and ruraldwelling children. keywords: rural population; rural health services; infant; child, preschool; chronic disease a mixed methods analysis of the place-related risk and protective factors for hospital utilization among children with complex chronic conditions children with complex chronic conditions (ccc) are a vulnerable population of children who, with their families, face increased emotional, psychological, physical and financial difficulties. children with ccc form a subpopulation of children with special health care needs (mcpherson et al., 1998), and are described as having a health condition expected to last at least 12 months that substantially affects one or more body systems. these conditions lead to the need for pediatric specialty care and hospitalization (feudtner, christakis, & connell, 2000), resulting in high health care utilization rates and associated health care costs. for example, children with ccc have longer pediatric emergency department (ed) length of stay and higher hospital and pediatric intensive care unit (picu) admission rates (o'mahony et al., 2013). health care utilization rates among children with ccc significantly increased between 1997 and 2006, and in 2006 hospitalizations among children with ccc accounted for 26% of pediatric inpatient days and 41% of pediatric hospital charges (simon et al., 2010). moreover, issues pertaining to location such as geographic proximity to health care, access to care, and availability of resources may influence health care utilization patterns among children with ccc (pollack et al., 2004; yamamoto et al., 1995). identifying place-related factors associated with health care utilization is critical since rural-dwelling children are more likely to have unmet health care needs, at least one ed visit within a year (devoe, krois, & stenger, 2009), higher asthma hospitalization rates (knudson, casey, burlew, & davidson, 2009), higher use of medical settings for dental needs (martin, vyavaharkar, veschusio, & kirby, 2012), and limited access to pediatric subspecialty providers (mayer, 2008). rural areas also see higher infant mortality rates and higher rates of obesity in children (wright et al., 2008). therefore, this study was designed to address the research question: what multi-level place-related factors put children with ccc at risk for or protect them against hospital admissions or ed visits? theoretical framework the risk and protective factors model (hawkins, catalano, & miller, 1992) and social ecological theory (set) (bronfenbrenner, 1994) served as the theoretical frameworks for this study. according to the risk and protective factors model, certain aspects of an individual or the environment lead to an increased likelihood of a particular outcome (risk factors) while other aspects are associated with a lesser likelihood of the outcome (protective factors) (hawkins et al., 1992; nagy & fawcett, 2011). risk factors have varying degrees of modifiability and some, such as race/ethnicity, are impossible to change. according to this model, protective factors mediate or moderate the effect of the risk factor on the outcome (hawkins et al., 1992). in fact, among persons with similar risk factors, those with protective factors have improved outcomes. the domains of factors in this framework are: individual/peer, school, family, and community. the risk and protective factors (rpf) model has been widely used to address drug use and other risk behaviors in adolescents and has guided the development of a community program for addressing adolescent health behavior (hawkins et al., 2008). the model has also been used as the theoretical framework in studies investigating hospital readmission behaviors (bachrach, schwarz, & bachrach, 2003; bulkow, singleton, karron, harrison, & the alaska rsv study group, 2002; garcia-aymerich et al., 2000; garcia-aymerich et al., 2003; garcia-aymerich et al., 2004; garcia-aymerich et al., 2001; guevara, young, & mueller, 2001). however, no study was identified in which the rpf model was used to investigate hospital admissions and ed visits in children with ccc. in this study, aspects pertaining to place, such as rural residence and proximity to care, were assessed as risk or protective factors for hospital admissions or ed visits in infants and young children with ccc. social ecological theory was used in conjunction with the rpf model during the qualitative analysis in this study. according to set, drivers of behavior exist on multiple levels: intrapersonal, interpersonal, family, community, society, and political. additional tenets of set posit that behavioral influences on each level interact and successful behavior change strategies address influences on multiple levels (sallis, owen, & fisher, 2008). interview and focus group questions were formulated using the key concepts of the rpf model and set, and during data analysis, initial coding categories were created using the guiding frameworks. in addition, particular attention was paid during data analysis to quotes and phrases that indicated differences or disparities pertaining to place. methods design a convergent parallel mixed methods study was conducted using simultaneous, independent quantitative and qualitative methods. the quantitative phase of the study was conducted using a retrospective cohort design with medical record review. during the qualitative phase of the study, key informant interviews with parents/primary caregivers (subsequently referred to as “parents”) and focus groups with health care providers (hcps) were conducted using qualitative descriptive design and analyzed using directed content analysis. while the purpose of the larger study was to investigate the risk and protective factors associated with hospital admissions and ed visits in children with ccc, the focus of this sub-study was to identify place-related factors associated with hospital utilization in infants and young children with ccc. findings from the larger study are presented elsewhere; this sub-study was conducted with a focus on the placerelated variables and the place-related qualitative data. the primary objectives were to 1) investigate the role of urban versus rural residence on hospital utilization, 2) explore the perceptions of parents and hcps regarding place-related factors associated with hospital utilization in children with ccc, and 3) organize issues pertaining to location into an ecological risk and protective factors model. setting. the study was conducted at a 453-bed level iii trauma regional hospital that serves a 15-county area of south carolina (mcleod health, 2012) with more than 875,000 residents (united states census bureau [uscb], 2013). the hospital is the main provider of acute care pediatric services in the area, with a pediatric general care floor, a pediatric intensive care unit, and some pediatric specialty providers, such as pediatric intensivists and a pediatric cardiologist. there is no freestanding pediatric hospital in the region. this setting was ideal for assessing the possible effects of location on hospital admissions and ed visits because several community hospitals in surrounding rural counties transfer higher-needs patients to the urban hospital. the us office of management and budget’s (omb’s) definition of rurality was adopted for this study. according to this definition, a metropolitan area has at least 50,000 residents, a micropolitan area has an urban center of at least 10,000 but not more than 50,000 residents, and a non-metropolitan area has fewer than 10,000 residents in a central area (uscb, n.d.). micropolitan and non-metropolitan statistical areas are considered rural, while metropolitan statistical areas are considered urban. this study was conducted in an urban county primarily surrounded by rural counties. sample. medical records of children with ccc born between january 1, 2008 and november 25, 2011 were reviewed. records for children having an index hospitalization with a diagnosis on the list of complex chronic conditions outlined by feudtner and colleagues (2000) along with at least one additional hospital admission or ed visit within 365 days were selected for further analysis. additional details can be found in hudson, mueller et al. (2014a). any parent who was at least 18 years of age and was the caregiver of a child born between january 1, 2008 and november 25, 2011 with a diagnosis that met the definition of complex chronic condition (feudtner et al., 2000) and at least one additional hospitalization or ed visit was recruited to participate in key informant interviews. hcps working locally in pediatric acute care, pediatric primary care, or emergency care were recruited to participate in focus groups. participating hcps included physicians, nurses, ancillary care providers, and other disciplines; each hcp had worked for at least 1 year caring for children with ccc, and directly cared for children with ccc in their current role. data collection. data collection processes are presented in greater detail in the reports of the quantitative (hudson, mueller, et al., 2014a) and qualitative (hudson, newman, et al., 2014b) phases of the larger study. a hand search of the medical records was performed to identify a cohort of children with ccc born between january 1, 2008 and november 25, 2011 (n = 216). the demographic and clinical data collected included: age, sex, race/ethnicity, type of insurance, county of residence, zip code of residence, technological dependence, primary diagnosis for each admission, and number and type of secondary diagnoses for each admission. measures of hospital admissions and ed visits collected were: index (or initial) hospitalization admission date, index hospitalization discharge date, number of additional hospital admissions and/or ed visits, and dates for each subsequent hospitalization or ed visit. qualitative data collection was carried out using key informant interviews and focus groups. questions specific to location such as perceptions of the roles of transportation, distance to health care providers, and community resources were included in the interview and focus group interview guides. the findings from interviews with parents and focus groups with hcps were compared, as were findings from interviews with ruraldwelling and urban-dwelling parents. institutional review board (irb) approval was obtained from the study site and the principal investigator’s (pi’s) institution (pro00016037) prior to data collection. data analysis. data accuracy was ensured by verifying data entry with the source document, and by checking for missing data and outliers. descriptive statistics were calculated to assess the characteristics of rural-dwelling and urban-dwelling children with ccc. linear regression analyses were conducted to examine whether associations were present between urban versus rural residence and measures of hospital utilization. outcome variables were: length of stay (los) during the index hospitalization, number of hospital admissions and/or ed visits (occurrences) following the index hospitalization, number of days between the index hospitalization and the first subsequent hospital admission or ed visit, and mean number of days between all subsequent hospital admissions and/or ed visits. after bivariate analyses between urban versus rural residence and each outcome variable, multiple regression analyses were conducted to determine whether the addition of urban versus rural residence influenced the relationship with predictors and outcome measures. multiple regression analyses were conducted with the set of demographic and clinical variables with and without the residence variable as possible predictors of the outcome variables to evaluate differences. stepwise linear regression modeling with backward deletion was performed with the level of significance for variable entry set at p < .10, and the level of significance for variable removal set at p > .15 to reduce the probability of a type ii error. qualitative data were analyzed using directed content analysis (hsieh & shannon, 2005) guided by an ecological risk and protective factors framework. to begin the analysis, initial coding categories were chosen using the ecological risk and protective factors framework that emerged during the qualitative phase of the larger study (hudson, newman, et al., 2014b). quotes that seemed to fit into a category were highlighted on the interview or focus group transcript. transcripts were reviewed again, and highlighted segments were coded into one or more categories. phrases associated with place, location, or residence were sought. lincoln and guba’s (1985) framework for developing trustworthiness was adopted to enhance the quality of this portion of the study. the pi kept a field journal and recorded personal influences to promote reflexivity. subject checking was conducted to verify findings. results demographic and clinical characteristics of ruralversus urban-dwelling children from the medical record review (n = 216) are presented in table 1. urban-dwelling and rural-dwelling groups differed in hospital utilization. rural-dwelling children had a significantly longer average index hospitalization los than urban-dwelling children but statistically significantly fewer occurrences following the index hospitalization. characteristics of hospital utilization by residence are outlined in table 2. table 1 medical record sample demographic and clinical data by urban versus rural status variable urban n = 144 proportion (n) or mean + sd (range) rural n = 70 proportion (n) or mean + sd (range) p-value age age (in months) 31.5 + 13.1 (7.052.0) 31.9 + 13.8 (6.052.0) .72 gender male 48.6 (70) 52.9 (37) .56 female 51.4 (74) 47.1 (33) .56 race/ethnicity white 31.9 (46) 42.9 (30) .12 black 63.9 (92) 50.0 (35) .05 asian/pacific islander 0.7 (1) 0 .49 native american/alaskan native 0 2.9 (2) .04 hispanic or spanish origin 2.1 (3) 2.9 (2) .73 other 1.4 (2) 1.4 (1) .98 procedures none 79.2 (114) 77.1 (54) .74 tracheostomy 2.8 (4) 2.9 (2) .97 gastrostomy 14.6 (21) 15.7 (11) .83 permanent indwelling catheter 2.1 (3) 1.4 (1) .74 ventriculoperitoneal shunt 5.6 (8) 7.1 (5) .65 index admission primary diagnosis category neuromuscular 6.3 (9) 5.7 (4) .88 cardiovascular 1.4 (2) 2.9 (2) .46 respiratory 11.1 (16) 15.7 (11) .34 renal 0 1.4 (1) .15 hematological/ immunological 2.1 (3) 1.4 (1) .74 metabolic 0 4.3 (3) .01 perinatal/birth 72.0 (105) 67.1 (47) .38 other 6.3 (9) 1.4 (1) .12 index hospitalization number of secondary diagnoses 6.4 + 5.4 (029) median = 5.0 7.5 + 5.9 (021) median = 7.0 .27 per patient mean number of secondary diagnoses (subsequent events) 1.0 + 1.5 (013.5) median = 0.6 1.2 + 1.4 (08) median = 1.0 .16 insurance public 88.2 (127) 91.4 (64) .47 private 15.3 (22) 14.3 (10) .85 self-pay 2.8 (4) 1.4 (1) .54 number of types of insurance one type (or self-pay) 93.8 (135) 92.9 (65) .80 two types 6.3 (9) 7.1 (5) .80 family status (n = 103) (n = 49) single-parent 46.6 (48) 46.9 (23) .95 two-parent 48.5 (50) 49.0 (24) .95 other relative 2.9 (3) 4.1 (2) .73 other non-relative 1.9 (2) 0 .32 number of siblings (n = 95) 1.3 + 1.4 (09) (n = 47) 1.6 + 1.9 (07) .74 the parents of 11 children expressed interest in participating, and the parent(s) of 8 children (n = 13) were enrolled in the study; 27 hcps provided informed consent, and 24 participated in focus groups. the demographic profiles of parents and hcps are presented in hudson, newman, et al. (2014b). the majority of parents resided in an urban county (84.6%, 11/13); however, 36.3% (4/11) of these parents described living in more sparsely populated areas of the county. characteristics of hospital utilization by residence are outlined in table 2. table 2 hospital admissions and ed visits by urban versus rural status variable urban n = 144 proportion (n), or mean + sd (range) rural n = 70 proportion (n), or mean + sd (range) p-value number of occurrences following index hospitalization 3.1 + 2.8 (1-16) median = 2.0 2.2 + 1.9 (1-8) median = 1.5 .02 number of days between index hospitalization discharge and first subsequent occurrence n = 144 115.2 + 100.0 (1-357) median = 75.0 n = 70 106.9 + 98.7 (1-356) median = 73.0 .48 per patient mean number of n = 90 n = 31 .68 days between subsequent occurrences 108.1 + 81.5 (.5 330.0) median = 94.0 117.6 + 87.1 (5.0308.0) median = 88.2 index hospitalization los in days 22.4 + 31.3 (0-117) median = 4.0 37.2 + 43.5 (1-194) median = 14.0 .003 merged findings by ecological level qualitative and quantitative findings were merged using side-by-side analysis for convergence and divergence. merged findings are presented as follows by ecological level. individual child. parents and hcps perceived that the complexity and severity of the child’s condition influenced the location of care. parents also perceived that the complexity of their child’s condition mandated they bring their child to a particular ed or hospital. a father described one of the reasons he chose to bring his daughter to a preferred urban hospital: “i don’t think at [hospital name], i don’t think they have a special floor for pediatrics and taking care of a baby that has [a ccc].” results from multiple regression analyses supported these beliefs. reliance on a technological device (such as a tracheostomy or gastrostomy tube) was included in the prediction models for the number of occurrences that followed the index admission (r2 = .28, f(9, 203) = 8.56, p < .001) (table 3), the number of days between the index admission and the first subsequent occurrence (r2 = .10, f(5, 207) = 4.47, p = .001) (table 4), and the mean number of days between occurrences that followed the index admission (r2 = .16, f(5, 122) = 4.58, p = .001) (table 5). table 3 coefficients for the final model for predictors of the number of occurrences following the index hospitalization predictor b std. error t p bivariate r partial r constant 3.556 0.687 5.173 .022 rural versus urban -0.932 0.329 -2.834 .005 -.158 -.195 other race/ethnicity -1.169 0.707 -1.655 .100 -.088 -.115 neurological diagnosis 1.358 0.659 2.061 .041 .152 .143 cardiovascular diagnosis 2.824 1.130 2.498 .013 .134 .173 other diagnosis -1.119 0.731 -1.530 .128 -.060 -.107 age in months 0.057 0.012 4.913 <.001 .340 .326 no technological device -1.598 0.380 -4.201 <.001 -.269 -.283 private insurance -0.918 0.431 -2.131 .034 -.114 -.148 self-pay 1.646 1.015 1.621 .107 .098 .113 table 4 coefficients for the final model for predictors of the number of days between the index hospitalization and the first subsequent occurrence predictor b std. error t p bivariate r partial r constant 93.327 24.932 3.743 <.001 rural versus urban -6.422 14.020 -0.458 .647 -.037 -.032 hematology/immunology diagnosis -104.215 48.202 -2.162 .032 -.122 -.149 mean number of secondary diagnoses during subsequent occurrences -51.325 30.338 -1.692 .092 -.152 -.117 no technological device 55.753 16.435 3.392 .001 .238 .229 self-pay -66.854 43.674 -1.531 .127 -.062 -.106 table 5 coefficients for the final model for predictors of the mean number of days between subsequent occurrences predictor b std. error t p bivariate r partial r constant 91.780 73.582 1.247 .215 rural versus urban 45.871 27.586 1.663 .099 .091 .149 mean number of secondary diagnoses during subsequent occurrences -135.387 68.912 -1.965 .052 -.203 -.175 age in months 2.443 1.004 2.443 .016 .179 .215 no technological device 54.642 30.493 1.792 .076 .182 .160 public insurance -91.586 40.045 -2.287 .024 -.225 -.203 thus, children with ccc severe enough to require a technological device had more hospital admissions or ed visits (occurrences) and fewer days between occurrences. number of secondary diagnoses was statistically significant in the prediction models for the number of days between occurrences following the index admission and for the index admission los (r2 = .73, f (5, 207) = 113.56, p < .001) (table 6). these results further supported parents’ and hcps’ beliefs by indicating children with a higher number of secondary diagnoses during hospitalizations had fewer days between occurrences and a longer index hospitalization los than those with fewer secondary diagnoses. parent-child relationship. parents and hcps frequently mentioned the influence of parents’ preferences on location of care. according to hcps, this preference can place children at risk for greater utilization because parents spend time driving from distant locations during which the child’s condition deteriorates. but parents believed spending the extra time driving to a preferred hospital protected children because urban centers have needed equipment and personnel with expertise. table 6 coefficients for the final model for predictors of the index hospitalization length of stay predictor b std. error t p bivariate r partial r constant -31.760 5.844 -5.435 <.001 rural versus urban 6.137 2.653 2.313 .022 .169 .159 no technological device 5.754 3.138 1.834 .068 -.108 .126 neurological diagnosis 9.661 5.420 1.783 .076 -.153 .123 number of index hospitalization secondary diagnoses 5.625 0.248 22.663 <.001 .842 .844 age in months 0.247 0.094 2.632 .009 .056 .180 one mother described how she decides whether to travel to a more distant urban center: when i’m in the car with her, i’m, like, ‘can i make it? do i need to go to [the rural ed]?’ i think if it came to the point where i thought, okay, this is enough and i was by [the rural hospital] she would go to [the rural hospital]. so i just feel, i guess, comfortable enough to drive the extra 20 minutes and get to where i know she’ll be seen immediately and get taken care of. many times, parents’ decisions are influenced by their knowledge and experience with taking their child with ccc to particular hospitals. one mother said that because her child’s condition is severe she is taken “immediately back [to be seen], no matter what. soon as i walk in [to preferred hospital’s name], we are back…we don’t even sign in. we go automatically back.” because she does not want her child to wait to be seen, the mother always brings her child to this ed. parents’ access to care and ability to choose a particular hospital is influenced by their available resources. those who have transportation describe weighing the severity of the child’s condition against the time needed to drive to the preferred hospital, whereas the decisions of those without readily available transportation are determined by the proximity of care. parents who lived in close proximity to an ed said they took their children to the ed when they didn’t have the resources, such as a vehicle or bus fare, to take them to see their primary care provider (pcp) across town. similarly, parents stated lacking money or gas influenced their decisions and access to care. a rural-dwelling mother discussed the problems she faced with her husband working out-of-town and her lack of a telephone: “i get worried sometimes because…what if she has a seizure and i can’t get up with my husband. if she has a seizure, do i just let her lay there? is she gonna die or snap to?” parents’ level of comfort with managing the child’s condition was another influence on location of health care. parents and hcps described situations during which parents tried to manage the child’s condition at home before bringing the child to be seen. hcps believed rural-dwelling parents attempted to manage the child’s condition longer than urban-dwelling parents because of the challenges associated with having a child hospitalized far from home. according to one hcp, rural-dwelling parents “know that if my kid really is sick enough to be in the hospital then i’m going to have a problem with my other kids; i’m going to have a problem with my job.” multiple regression analyses of medical record data supported the position that lack of resources is associated with increased hospital utilization. public insurance and/or self-pay status were statistically significantly associated with higher hospital utilization (ie, more occurrences and fewer days between occurrences). public insurance was considered a proxy for lack of resources. although medicaid standards vary by state, child eligibility is based on parents’ income (centers for medicare and medicaid services, n.d.). family relationships and structure. parents and hcps perceived that the proximity of extended family and friends and their availability to provide support influenced location of health care. hcps believed extended family members were essential sources of transportation and influenced parents’ decisions regarding place of care. in addition to providing transportation to parents, extended family members watched siblings so that parents could take children with ccc to out-of-town specialists’ appointments. parents who had available extended family described the importance of this resource while parents who did not have friends or family near expressed frustration with the lack of this resource. heath care provider relationships. parents and hcps frequently mentioned factors pertaining to health care relationships. both ruraland urban-dwelling parents described choosing to take their child to a hospital farther from home because of their personal preferences. one father described the reasons he preferred a particular hospital: “it makes me feel more comfortable…it’s more of a home setting, the doctor’s more friendly.” relationships with hcps were built on previous experiences and were also influenced by the interactions the parents observed between the staff and the child. the parents of a child with frequent hospitalizations said the following: “since we’ve been up here, like we got to know the nurses, the nurses got to know us, so its […] more comfortable. you feel more comfortable, and i guess [the child] feels more comfortable because of the familiar faces.” hcps agreed that familiarity with a child was beneficial. according to one hcp, a lack of familiarity “puts you even further behind [in the child’s care] because you know this child has something, and you just don’t know what it is.” beyond being familiar with individual children, staff’s expertise with caring for children with ccc in general was a perceived benefit. one hcp described the effect of rural staff’s familiarity with children with ccc: …sometimes the comfort level of the physician and the staff, the more complex a child is, they’re very uncomfortable or they may not do everything to begin with that they need to do, and that child continues to deteriorate in the emergency room before they make a phone call [to a more urban hospital]. parents described a lack of satisfaction with some rural hospitals because they believed staff “couldn’t handle” or “didn’t understand” the child’s condition. parents preferred staff members who not only “knew how to handle [the child’s condition] and knew all the medicines to give her” but also interacted with the child through talk and play. parents and hcps believed communication was a factor that influenced health care utilization. according to hcps, effective communication between providers at smaller community hospitals and those at centers capable of providing a higher level of care was essential to optimal care delivery for children with highly complex conditions. through effective communication, hcps in rural areas could discuss conditions with hcps in centers providing higher levels of care who also may be more familiar with the conditions as well as with individual children with ccc. parents also valued effective communication with pcps and were willing to travel an hour or more to find a pcp who “is really listening and valuing what i have to say and taking that into consideration to make the right judgment call for my kids.” health care system environment. parents’ familiarity with the processes at a particular hospital influenced utilization. parents described knowing, for instance, that the wait time at an ed would be longer and deciding to visit another hospital’s ed instead. however, in the case of an emergency, parents abandoned their preferences for a particular location and instead took the child to the nearest hospital. parents perceived, and hcps agreed, that some locations lacked equipment or expertise to adequately treat a child with ccc. one mother relayed her perception of this lack of expertise: basically, i went to the er with her one morning and he [the physician] told me, ‘oh well, you shouldn’t put her through more than what she has to go through, she’s already sick enough, don’t keep running up here every time you feel like something’s wrong.’ so that was the last time i went to [hospital] because something actually was wrong. because we came here [preferred hospital] and she got admitted. parents believed some hospitals lacked trained staff able to care for children with ccc. the lack of local specialists and other health care services needed by children with ccc meant that all parents, including those who reported urban residence, faced access to care issues and were required to travel an hour or more for care. parents also believed the stress of traveling out of town to see specialists would be relieved by the availability of local clinics or home visits. the lack of health personnel in rural locations also included out-of-hospital services. according to one mother, in her community emergency medical service (ems) providers are not located at a central station so ambulances could take an hour to reach the child. when the child had a seizure, the parents “had to go to the ems station” to receive timely treatment. community environment. parents and hcps perceived that a lack of community resources and organizations influenced rural health care utilization. one hcp argued that an absence of resources in rural locations could substantially affect care: the more rural (further out they are), the less resources are available to go out there because there are some places that only have physical therapy that cover this area. so you could be in a spot and have a really chronic child and have no resources available to you because you live there. hcps believed identifying a pcp in each community who was comfortable with caring for children with ccc would benefit these children. parents did not discuss a lack of health care organizations in rural areas, and instead mentioned the lack of community groups. one mother knew of a parents’ support group in a more metropolitan area, but not of a local group. she attested to location-associated limitations when she said, “i can’t go three hours, two and a half hours away every time i feel like i need to have a support group.” rural versus urban residence was statistically significant in the prediction models for index admission los, number of occurrences, and mean number of days between occurrences that followed the index admission. rural residence was associated with fewer occurrences and more days between occurrences. this finding seems to refute parents’ and hcps’ beliefs; however, rural residence was associated with a longer index hospitalization los. discussion the findings led to an ecological model of place-related risk and protective factors for hospital admissions and ed visits among children with ccc (figure 1). hospital utilization differed between ruraland urban-dwelling children with ccc. increased complexity, or severity of the child’s condition, was the only biological risk factor associated with hospital utilization identified in this study. despite participants’ perceptions that increased complexity led to the need for care at urban centers, rural residence was associated with fewer hospital admissions and ed visits and more days between hospitalizations and visits. this finding may result from data being collected solely at one urban hospital. all parent participants reported using other urban or rural hospitals, thus findings from the medical record review most likely underestimate true utilization rates. while rural residence was in some cases associated with lower rates of utilization, it was also associated with a longer index hospitalization los. this finding may suggest ruraldwelling children are sicker on transfer to an urban center, or may suggest more time is needed for rural-dwelling parents to prepare the home environment for children with ccc prior to hospital discharge. park and colleagues found that rural-dwelling children with liver transplant did not have significantly poorer health outcomes, but tended to be sicker at the time of transplantation than urban-dwelling children (park et al., 2011). the lower rates of hospitalizations or ed visits and higher number of days between hospitalizations or visits may also indicate disparities in access to care among ruraldwelling children. access disparities have been discovered between low-income rural and urbandwelling children (devoe et al., 2009). according to laditka and colleagues (2009), rural-dwelling children are more likely to be hospitalized for ambulatory care sensitive conditions, findings which suggest disparities in access to primary care. similarly, roy, mcginty, hayes, and zhang (2010) report rural-dwelling children with chronic illness have higher rates of hospitalization than urban-dwelling children that may be related to environmental, social, or access to care issues. many of the parents in this study resided in an urban county, but nearly all of these parents discussed place-specific issues such as utilization of rural hospital services, choice of one urban hospital over another, or travel to a more metropolitan area for specialty services. although this study was conducted at a hospital in an urban county, many pediatric specialty providers are located in the largest metropolitan areas of south carolina, approximately 80 to 130 miles away. the lack of local specialty providers corresponds with mayer’s (2008) findings that rural and smaller metropolitan areas had poorer geographic access to pediatric specialty providers. the finding that place-related issues were prevalent among both urbanand rural-dwelling participants suggests accessto-care issues are faced not only by the most rural-dwelling children but also by children with complex chronic conditions in smaller metropolitan areas. when considered in conjunction with the rural nursing theory (long & weinert, 1989), findings from this study have particular relevance for nurses in rural-dwelling areas. for instance, according to rural nursing theory, rural-dwelling people equate work with health and are often viewed as postponing health care until the illness has advanced to the point of requiring hospitalization. findings from this study support this statement and may suggest that nurses and primary care providers be more easily accessible to rural-dwelling children with ccc. however, rural nursing theory also posits that rural nurses and other rural hcps may need to have extended time with communities to gain acceptance and trust, which can affect access if no established providers are available. this study suggests that parents and caregivers of children with ccc seek providers with whom they have an established, trusting relationship. when viewed through the lens of rural nursing theory, this need for a trusting relationship may be more critical for ruraldwelling children with ccc and their families. limitations many of the parents who reported living in an urban county also reported using small community hospital services. this finding suggests that classifying rural versus urban residence by county may not accurately reflect rural versus urban utilization. another limitation results from data having been collected only at one urban hospital. nearly all of the interview participants described using other hospitals or eds indicating an underestimation of hospital utilization in the quantitative portion of the study. this limitation may also affect the relationships between rural versus urban status and hospital utilization found in this study. another limitation was that qualitative findings indicated additional quantitative variables should have been collected. for instance, no quantitative variables on the health care provider relationships level were available to compare with qualitative findings. conclusion the results from this study reveal differences in hospital utilization between rural and urban-dwelling children with ccc. the findings provide evidence of access issues and extend the problem beyond rural counties to urban counties with rural communities and smaller metropolitan areas. further study is needed to develop a more comprehensive understanding of patterns of hospital utilization among rural-dwelling children with ccc to include admissions and ed visits at rural and urban hospitals, primary care utilization, and outpatient services utilization. knowledge gained from further study can support and build upon the risk and protective factors model developed in this study and interventions can be designed to minimize risk factors and strengthen protective factors for hospital admissions and ed visits among children with ccc. acknowledgements this study was funded in part by a grant from the sigma theta tau gamma omicron atlarge chapter. this study was supported by the south carolina clinical & translational research (sctr) institute, with an academic home at the 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(1995). characteristics of frequent pediatric emergency department users. pediatric emergency care, 11(6), 340-346. http://dx.doi.org/10.1097/00006565-199512000-00003 7 editorial what’s happening down under! karen francis, rn, phd, mhlth sc, nsg, med editorial board member i would like to take the opportunity to introduce myself and to thank jeri dunkin for asking me to be involved with the journal. my name is professor karen francis and i am a rural nurse located in australia. i am an academic employed by monash university which is located in the state of victoria on the eastern side of the nation. i am the head of the monash rural school of nursing and midwifery, and i am an active researcher who is interested in education, workforce and the management of chronic disease. i have been an advocate for rural nursing and midwifery since the early 1990s when professor desley hegney established the australian association of rural nurses. in this inaugural report i have chosen to report on two major issues that have significant implications for nurses and midwives in australia particularly for those working and living in rural environments. 2010 is a federal election year which may result in a change in leadership and the management of the nation. any change creates levels of tension among the population and within the political parties aspiring for success. government elections provide valuable windows of opportunity for individuals, groups and organisations to influence policy. there is a great deal of political lobbying occurring with stakeholders aligning with political parties and candidates who appear to be paying attention to their vested interests. coupled with the growing frenzy surrounding the lead up the federal election, nurses and midwives are preparing for a monumental change in the regulation of the profession. federal election australians are being bombarded by new and rehashed, controversial and expected policy statements from the current government and shadow government as the country gears up for the federal election that will be held later this year. as usual, health, education and climate control are major agenda items. the current government is introducing what they see as a radical health care reform prior to the election in accordance with an electoral promise made prior to the last federal election: ‘improving the health care system’. this reform involves the transfer of responsibility for funding hospitals from state/territory governments to the federal government. it is expected that this initiative will reduce disparity between the various jurisdictions in terms of the numbers and types of clinical health care services provided and the geographic location of these. there is some concern that rural and remote communities may be compromised if the government adopts a population based formulae to operationalise health care services. professional and industrial organisations including nursing, medicine and allied health are lobbying for ‘rurality’ to be a significant consideration in this initiative and for planning models to be transparent and provided for comment and modification prior to implementation. national regulation and accreditation in australia currently, each state/territory has independent regulatory authorities with jurisdiction based statutory acts that define practice. while nurses and midwives may licence in any jurisdiction other than the one in which they initially licensed there are online journal of rural nursing and health care, vol. 10, no. 1, spring 2010  8 online journal of rural nursing and health care, vol. 10, no. 1, spring 2010  additional associated costs and the process is cumbersome and sometimes quite lengthy. moreover, there are some differences in pre-service curriculum content, registers, expectations regarding currency of practice and scopes of practice. from the 1st july 2010 australian nurses and midwives will licence for practice with a single regulatory authority, the australian nursing and midwifery board. a single regulatory authority will ensure that pre-service curriculum for nursing and midwifery is consistent and that practice is common across the nation. for nurses and midwives who work near jurisdictional boarders the impost of having to licence in two or three jurisdictions will cease. it is anticipated that this initiative will assist the nursing and midwifery workforce to have greater mobility. times, they are a changing! i am extremely supportive of the national regulatory body and have my fingers crossed that the health system reforms will improve service delivery.   saiki_546-article text-3455-1-6-20181208 online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 179 incontinence care needs in a u.s. rural border region: perspectives of promotoras lori s. saiki, phd, rn, cccn 1 martha l morales, phd, rn, lcce, facce 2 1 assistant professor, school of nursing, new mexico state university, lsaiki@nmsu.edu 2 assistant professor, school of nursing, new mexico state university, moralest@nmsu.edu abstract purpose: the purpose of this study was to explore the incontinence care needs of rural, primarily hispanic, community dwelling adults living along the u.s.-mexico border of southern new mexico from the perspective of the community health workers, or promotoras, who serve this community. sample: community health workers (promotoras) attending a regional meeting were invited to participate in a focus group format to discuss their experiences with urinary incontinence; 25 promotoras provided verbal and/or written feedback. method: a participatory action framework guided this focus group session, which followed an outreach presentation on basic concepts of urinary incontinence. participant feedback and discussion solicited following the presentation was used to assess perceived community needs for incontinence care and bladder health promotion. participants’ verbal feedback and written responses to open-ended questions were analyzed by methods of qualitative content analysis for themes depicting perceived needs of their community for bladder health education and behavioral strategies to alleviate incontinence. findings: the following themes were identified: predisposing conditions, treatments tried, home online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 180 remedies, psychosocial effects, and training requested. promotoras’ comments revealed the lack of information regarding the causes and associated factors of urinary incontinence, the lack of understanding of available behavioral treatment options and how to perform behavioral strategies to promote continence. promotoras identified the negative effects of urinary incontinence on psychosocial health and asked for strategies to help rural adults cope with this condition. conclusion: themes identified will guide the content development of future train-the-trainer sessions for community health workers or promotoras in urinary incontinence self-care strategies. train-the-trainer sessions were identified through methods of participatory action to be the preferred strategy for bladder health promotion outreach to rural adults living in areas with limited access to medical services. keywords: incontinence, rural, promotoras, hispanic, qualitative, needs assessment, participatory action, community health worker incontinence care needs in a u.s. rural border region: perspectives of promotoras new mexico is categorized as a rural state with 17.2 people per square mile and only four cities with a population of more than 50,000 people (new mexico department of health, office of health equity, 2018). the southwestern u.s.-mexico border counties are comprised of approximately 65% hispanic residents. approximately 26% of families in these border counties are living below poverty level (new mexico department of health, office of border health, 2013). over 40% of the residents in the southwest health region of new mexico who report an annual income of less than $15,000 and approximately one-third of those with an annual income of $15,000 – 25,000 describe their overall health as fair to poor (new mexico department of health, office of health equity, 2018). in addition, the new mexico department of health, office online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 181 of health equity (2018) reports that more than 40% of the state’s population live in a primary care health professional shortage area. the new mexico department of health, office of border health (n.d.) has identified the lack of healthcare services and specialty services throughout the state as the impetus for development of rural community health centers and a state-wide certification program for community health workers and promotoras, with the goal of providing outreach health promotion services to these medically underserved communities. background and significance urinary incontinence (ui) is a prevalent condition for community-dwelling adults, with incidence rates of up to 66% of adult women and 41.5% of hispanic women reporting any ui symptoms (sampselle, harlow, skurnick, brubaker, & bondarenko, 2002). approximately 16% of hispanic women (nygaard et al., 2008) and 17% of mexican american women (wu et al., 2014) report moderate to severe ui symptoms. among urban community-dwelling latino adults age 60 years and older who were participating in a behavioral intervention to increase physical activity, 29.5% of the women and 18.3% of the men reported living with ui (smith et al., 2010). moderate to severe ui increases the risk of skin maceration, breakdown, and infection (benbow, 2012). medical treatment for ui in the u.s., including pharmacologic treatment, physical therapy, and surgical treatment, is estimated at $12.4 billion annually (wilson, brown, shin, luc, & subak, 2001). depending on frequency, severity, and type of ui, the individual woman’s mean annual expenditures for managing capture and clean-up of urinary leaking range from $550 to $993 (subak et al., 2006). these costs are generally not covered by medical insurance and so represent an out of pocket expense for the rural poor, who also may have limited access to incontinence supplies. chronic ui is associated with depression (dugan et al., 2000). other significant psychosocial sequelae of ui include loss of mobility, impaired social function, online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 182 and risk of social isolation (jamison, weidner, romero, & amundsen, 2007). these findings were supported by theme analysis from focus groups comprised of low-income hispanic women (longworth, davila, & sampselle, 2003). indirect costs of managing ui symptoms are difficult to estimate and may include lost productivity in the workforce (sung & hampton, 2009). although there are significant physical, economic, and psychosocial costs to living with ui, people who have mild to moderate ui symptoms respond well to behavioral interventions that may be taught and performed at home. for example, up to 80% of participants experience complete or significant reduction of symptoms following pelvic floor muscle therapy (pfmt) training (burgio et al., 1998). bladder training and a bladder-friendly diet are also effective interventions that may be performed at home (sampselle, 2000). community-dwelling women demonstrate low knowledge regarding ui causes and treatment options, with hispanic women being reportedly less informed than other u.s. women (mandimika et al., 2014). only four of 31 low-income hispanic women participating in focus groups reported performing recommended pfmt (longworth et al., 2003). development of a community-based, culturally appropriate bladder health promotion educational intervention that may be sustained through nurse partnership with promotoras is needed in southern new mexico. further complicating treatment of ui is the documented phenomenon of non-disclosure of this condition and the effect of symptom management on quality of life. people living with ui tend not to report symptoms to physicians, with hispanic people in particular preferring not to disclose symptoms for fear of being stigmatized (elstad, taubenberger, botelho, & tennstedt, 2010). people live with ui for an average of seven years before reporting symptoms to a health care provider (beji, yalcin, erkan, & kayir, 2005; berglund, eisemann, lalos, & lalos, 1996), waiting until the effect of symptom management on their quality of life becomes more severe online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 183 (melville, newton, fan, & katon, 2006). by the time people with ui are in distress and seek care, the symptoms may be too severe to respond to behavioral intervention. a community-based strategy to improve screening, identification, assessment, and early intervention for ui would be key to improving outcomes for rural hispanic adults living in the u.s.-mexico border region, for whom access to health care providers is limited. participatory action guiding framework this study was guided by persily and hildebrandt’s theory of community empowerment (2008) and follows the community involvement in health (cih) 8-step program development model (hildebrandt, 1994). the theory of community empowerment proposes to improve the health of individuals in the community through involvement of lay community health workers in the reciprocal health processes of teaching community members proactive health promotion behaviors (persily & hildebrandt, 2008). community-based lay health workers such as promotoras are members of the communities they serve. community health workers empower communities through sharing health promotion knowledge in a culturally relevant context (persily & hildebrandt, 2008). in the cih participatory partnership model, a necessary step prior to developing the nurseled educational intervention is to identify the community assets in terms of practices, strategies, strengths, and resources and then identify the community barriers to implementing the health promotion program (hildebrandt, 1994). this study followed hildebrandt’s (1994) step 1: seek information and assess the community needs in bladder health promotion and continence care, from the perspective of southern new mexico promotoras. through implementing this first step, critical information was obtained to assess community health worker knowledge base and concerns. this was a necessary first step in beginning the process of developing trust between the online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 184 nurse researcher and the lay community health workers. open dialogue and trust are essential components of community empowerment. the overall goals of this study were to lay the groundwork for a trusting relationship between the nurse researcher and promotoras and to obtain information useful in guiding development of a nurse-led bladder health/incontinence care educational intervention. the purpose of this research was to perform a continence care needs assessment from the perspective of the promotoras who work in the community along the u.s.mexico border in southern new mexico, as phase 1 of an ongoing outreach program for community health workers to educate and support rural, primarily hispanic, adults living with urinary incontinence. method this study used processes of participatory action and an exploratory, descriptive, qualitative design to contribute information regarding a rural community needs assessment on bladder health and incontinence care from the perspective of community health workers, or promotoras. a onehour focus group was conducted with an opportunity to provide both verbal and written responses to the following questions: what are some examples of people who have asked you about incontinence? what are their concerns? what questions do they ask? what symptoms do they have with leaking urine? when do they leak? what management strategies have they tried? what information about incontinence would you like to have in order to provide care for people with incontinence? what other issues or concerns do you have about incontinence? sample and setting online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 185 following university institutional review board approval (study #14862), methods of purposive convenience and snowball sampling were used to enroll community health workers from rural areas of southern new mexico. inclusion criteria were as follows: self-identified community health worker, promotora, or lay health resource person. exclusion criteria were as follows: unable to speak or write in spanish or english. the target audience was the promotoras attending a regularly scheduled area meeting of the southern new mexico promotora committee, which serves the three southernmost counties of new mexico (luna, dona ana, and otero counties). target sample size was 30 participants, representing community promotoras who work in rural communities along the u.s.-mexico border. data collection the nurse researchers attended a scheduled meeting of the southern new mexico promotora committee, along with a representative from the new mexico department of health office of community health workers as a trusted liaison. a translator was present for simultaneous translation during the meeting and the focus group. all written materials were presented in both english and spanish. a description of the study and purpose of the needs assessment was presented. prior to collecting promotora perspectives, the nurse researcher established a timeline of future communication and workshops, and provided nurse researcher contact information. a brief oral presentation was used to open discussion, along with informational handout with introductory information on the three common types of incontinence (stress, urgency, and functional) found among community-dwelling adults in the rural setting. an outline of possible causes and strategies to lessen symptom impact was provided for the community health workers to take home as a resource. after this information was provided, the promotoras completed written informed consent and were then offered the opportunity to voluntarily share, in focus group format, online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 186 their perceptions and concerns about the people they work with who come to them with concerns about ui. promotoras were offered the opportunity to ask questions and provide feedback and examples of experiences with incontinence. those who did not wish to share in the discussion were offered the opportunity to write their feedback on an anonymous feedback form with the same open ended-questions that were used to guide the focus group discussion. promotoras in attendance chose either to participate or not to participate, without consequence and without affecting their membership. no individual participant identifiers were collected. notes were taken on audience comments. a written feedback form was provided during the meeting for those promotoras who did not wish to verbalize their thoughts on this potentially sensitive topic at a general meeting, or for those who wanted to provide more extensive feedback. stamped return envelopes were provided for those who might take the feedback forms and mail them at a later time, or to increase the feeling of anonymity in response. no participant identifiers were noted on the written feedback forms. data analysis participants’ responses noted during the meeting were combined with written responses from the open-ended feedback form. responses in spanish were translated into english. participant responses were de-identified, edited for spelling, and formatted. participant responses were analyzed for themes by methods of content analysis. researchers performed an independent analysis of the transcripts for themes and then conferred together to reach consensus. results following invitation by the office of border health liaisons, the topic of urinary incontinence was presented during the lunch hour of a regional meeting of the southern new mexico promotora committee in december of 2017. this venue allowed the nurse researchers to online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 187 establish community connections with promotoras and run a focus group session for the needs assessment phase of this participatory action research. this outreach opportunity for the promotoras was advertised through the office of border health, and numerous calls of interest were received prior to the meeting. the topic of urinary incontinence was of interest to the promotoras, several of whom mentioned their attendance was motivated by their interest in learning more about incontinence prevention. this particular monthly meeting of the southern new mexico promotora committee was a 4-hour workshop to promote certification of community health workers, cover state guidelines for certification, and provide information on opportunities available through the new mexico department of health. state, regional, and local leaders were present. more than 50 participants filled the round tables in the conference room and were served lunch during the focus group session, which lasted for one hour. most of the participants were women, and most spoke primarily or exclusively in spanish. simultaneous english-spanish translation through headsets with microphones by an experienced, bilingual interpreter, provided for a lively real-time exchange of ideas and concerns, regardless of spoken language of choice. thirty-four promotaras signed informed consent to participate in the focus group on perceived needs of the promotoras’ community members in the area of urinary incontinence. a total of 25 promotoras provided oral and/or written comments. notes were taken on the verbal feedback provided during the focus group, and translated from spanish to english as needed. discussion was lively. following the focus group session, time was provided to complete the written feedback forms if the participant had more information to share. twelve of the 17 written responses were translated from spanish into english. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 188 promotora’s shared observations and concerns about working with adults in their communities who experience urinary incontinence clustered into the following themes: predisposing conditions, treatments tried, home remedies, psychosocial effects, and training requested (table 1). themes identified in the promotoras’ comments revealed the lack of information regarding the causes and associated factors of urinary incontinence, the lack of understanding of available behavioral treatment options and how to perform behavioral strategies to promote continence, and the negative effects of urinary incontinence on psychosocial health. table 1 themes and subthemes found in promotoras’ comments themes subthemes quotes predisposing conditions pregnancy hysterectomy age “with time have problems holding their urine.” “nervous bladder.” treatments tried surgery medication kegel exercises “didn’t work.” “nothing worked.” home remedies sanitary pads diapers tight stockings restrict water intake “where can i access treatment other than going to the doctor?” “some women do nothing!” psychosocial effects embarrassing feel humiliated annoying bad odor stay home affects sexual activity “nobody wants to talk about it!” “i don’t want to get older and then smell bad.” training requested need information need to train promotoras to provide educational outreach “why does it happen?” “how to keep it from getting worse?” predisposing conditions the promotoras consistently associated development of urinary incontinence with pregnancy and delivery – particularly multiple pregnancies. one noted a common shared experience of online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 189 women she worked with who delivered their babies vaginally during the 1970’s and received episiotomies having ongoing issues with urinary incontinence unresponsive to surgical treatment. promotoras spoke of women who experienced incontinence following a hysterectomy. several asked if urinary incontinence was a normal consequence of aging. one added: “what about men? they have the same problem!” aging was considered a process that worsened or brought on ui, as manifested in the statement, “my concern is the progression of the situation.” treatments tried the promotoras expressed frustration with the lack of teaching and treatment options. several commented that medications, surgery, and kegel exercises were not consistently helping the adults in their rural communities. the promotoras reported not understanding pelvic floor muscle therapy, or kegel exercises, in terms of how they worked and how to perform the exercises. one recounted a personal experience with a rural patient traveling to california for a surgical procedure following unsuccessful treatment in her own community. the promotoras discussed their experiences with reports of doctors who were not responsive to patient concerns about urinary incontinence, or from women who were too embarrassed to talk about ui symptoms with a male physician. home remedies promotoras wrote about the strategies that people used in the rural settings to try to control or hide their ui. often large sanitary menstrual pads were used rather than the more expensive (and more embarrassing) “diapers” to capture urinary leakage. other remedies tried were to restrict fluid intake and to isolate themselves due to fear of the odor of urine being noticed by others in public. the desire to manage symptoms at home without having to resort to medication or surgery was expressed by many of the participants. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 190 psychosocial effects the stigma and embarrassment felt by rural adults living with ui was noted by many of the promotoras. the negative effect of ui on self-identity was evident in the following comment: “they ask do they need to wear diapers already?” promotoras participating in this study reported that their patients were avoiding social settings and intimacy with partners. there was a palpable worry about how bad things could get with ui in terms of symptom progression and a feeling of powerlessness to make things better. training requested the consistent message of the participants in this study was the overwhelming need for information and the desire to help people in their community alleviate or lessen their ui symptoms and effect on quality of life: “take their info into rural areas to help young and over 60.” one expressed concern about the lack of prenatal care affecting the ability to teach women how to do kegel exercises in time to prevent urinary incontinence. one experienced promotora, near the end of the focus group session, emphatically declared: “i see young women here not talking; just laughing! ask questions; need knowledge!” she went on to request help in learning prevention strategies and with strategies to raise awareness of the issues with urinary incontinence. information was requested to help male residents of rural communities who experience ui, as well. as one participant noted, education was requested for “everything possible, and not just for women but for men as well.” the promotoras in this study overwhelmingly voiced a desire for a program of “train-the-trainer” style educational modules to both empower them as a community health resource in evidence-based ui self-care strategies for rural residents and in order to have a more effective outreach to the rural communities they serve than could be achieved through online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 191 occasional offerings of nurse-led ui education programs in traditional community settings, such as a health clinic. discussion the community health workers participating in this study demonstrated a lack of knowledge regarding evidence-based behavioral interventions (e.g., pelvic floor muscle training exercises, bladder calming strategies, and bladder retraining programs) that could resolve or lessen ui symptom impact. the participants did not know what interventions were available other than kegel exercises, how the behavioral interventions worked and how to perform the interventions, including how to perform kegel exercises. more importantly, although the promotoras expressed a lack of faith in the effectiveness of behavioral interventions, they were very receptive to learning about ui self-care management strategies. because rural residents are reluctant to seek medical care for ui and health care services are difficult to access in rural settings, the promotoras were eager to be trained to provide that outreach bladder health promotion education themselves rather than rely on outsider services, such as nurse-led community seminars or clinic office visits, that may not reach rural residents. promotoras are in a unique position to offer the ongoing support that has been demonstrated to increase the effectiveness of behavioral interventions. the request by the participants in this study for “train-the-trainer” educational modules needs to be addressed in order to provide rural residents living with ui much needed educational support to manage ui at home and to improve quality of life. limitations this study was limited by the sensitive nature of the topic and by the large group setting in which the focus group took place. another limitation included the concern expressed by one promotora that the nurse researcher did not take information from the focus group without a plan online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 192 for future outreach education and a follow-up to share findings with the participants. a plan for providing educational programming was agreed to prior to the promotoras feeling comfortable sharing their perceptions and concerns. trust between academic researchers and community health workers must be nurtured and consistently maintained through communication and action. conclusion promotoras participating in the focus group expressed an urgent need for comprehensive nurse-led training in behavioral interventions to support the primarily spanish-speaking women who are living in rural settings, do not have ready access to healthcare services, and who are too embarrassed to bring up the topic of ui to their male physicians. both urinary incontinence symptom severity and the effect of symptoms on quality of life may be improved through nurseled “train-the-trainer” programs to allow for evidence-based and promotora-provided education in ui self-care management strategies. the eventual goal of this research is to develop, through a participatory action framework, a community-based support system to keep rural adults who live with urinary incontinence as active and independent as possible, mitigating through education any negative effect of incontinent episodes on lifestyle or overall quality of life. the information from this community needs assessment regarding the incontinence care needs of adults living along the u.s.-mexico border, evaluated from the shared perspectives of the community health workers who live in the rural communities, will be used to guide development of future nurse-led communitybased continence care educational modules targeted to support the promotoras in outreach services to rural residents. future research includes evaluating outcomes of the educational modules in terms of reducing knowledge deficits of promotoras regarding health promotion strategies for urinary incontinence and in improving quality of life concerns of the rural residents they serve. online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 193 acknowledgements the authors would like to acknowledge frances martinez, ba ed, ms ed, for translation services. we thank our community partners angie sanchez corral, community development coordinator, office of border health, new mexico department of health, freida adams, rn, director, office of border health, new mexico department of health, and the southern new mexico promotora committee. we gratefully acknowledge support for this study from sigma theta tau international, pi omega 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(2010). correlates of urinary incontinence in community-dwelling older latinos. journal of the american geriatrics society, 58(6), 1170-1176. https://doi.org/10.111/j.15325415.2010.02814.x online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.546 196 subak, l. l., brown, j. s., kraus, s. r., brubaker, l., lin, f., richter, h., . . . grady, d. (2006). the “costs” of urinary incontinence for women. obstetrics and gynecology, 107(4), 908916. https://doi.org/10.1097/01.aog.0000206213.48334.09 sung, v. w., & hampton, b. s. (2009). epidemiology of pelvic floor dysfunction. obstetrics and gynecology clinics of north america, 36, 421-443. https://doi.org/10.1016/j.ogc.2009 .08.002 wilson, l., brown, j., shin, g., luc, k., & subak, l. (2001). annual direct cost of urinary incontinence. obstetrics and gynecology, 98, 398-406. https://doi.org/10.1097/00006250200109000-00007 wu, j. m., vaughan, c. p., goode, p. s., redden, d. t., burgio, k. l., richter, h. e., & markland, a. d. (2014). prevalence and trends of symptomatic pelvic floor disorders in u.s. women. obstetrics and gynecology, 123(1), 141-148. https://doi.org/10.1097/aog.00000000 00000057 668-article text-4245-1-11-20201210 online journal of rural nursing and health care, 20(2) https://doi.org/10.14574/ojrnhc.v20i2.668 1 editorial the year of the nurse and covid-19: editorial pamela stewart fahs, phd, rn, editor the american nurses association’s theme for 2020 was the year of the nurse. the experiences of nurses this year, working in a pandemic, certainly adds meaning to the phrase. nurses continue to be highly respected professionals and the resilience and determination of nurses has been readily evident in this pandemic. nurses of course work in many roles including direct patient care, public health and education to name only a few. i cannot think of a nursing role where this pandemic has not had an impact. direct patient care nurses are of course high on the list of those who have been affected. this role also covers a lot of situations, in the ed, icu, on covid units, and non-covid units in direct care. during the early stages of the pandemic some nurses were being furloughed if not reassigned from areas such as outpatient surgery. school nurses are still trying to keep our children safe and provide the care they may need from effects of chronic illnesses such as type i diabetes and asthma to those acute issues that arise. in the spring and summer school nurses wrote contingency plans for dealing with covid-19 if schools were operating face-to-face, hybrid or online. today, those school nurses are administering a covid plan for screening children and teachers in order to keep the school environment as safe as possible. nurse practitioners and nurses working in the area of mental health are also seeing not only an increase in cases but often having to adapt to a new way of practice through telehealth options. public health nursing is a role that has been shrunk overtime, often due to budget issues, and this has weakened our public health system. today those in public health are dealing with testing and contact tracing and preparing for the need to get vaccine into the arms of individuals in communities and counties across this country. nursing faculty are having to devise and adapt their online journal of rural nursing and health care, 20(2) https://doi.org/10.14574/ojrnhc.v20i2.668 2 didactic as well as clinical teaching roles. although many schools of nursing have been ahead of other disciplines on campus in moving to distance learning modalities many are still in that stage of early development but have undergone a massive shift during the last few months. in may i wrote an editorial regarding rural communities, rural nursing, and covid-19 (fahs, 2020). at that time, i discussed the delayed impacts this pandemic might have in rural communities, such as those where meat packing plants and resort areas are located. i also noted that it is hard for people to imagine the devastation of this disease when living in an area that has been somewhat protected during the early month of the pandemic with mandatory shut downs. as of this writing (december, 2020), we are seeing the spread of covid into more rural area after a period of opening up in the summer and the fall. more people are experiencing the effects of covid in their rural communities. for a rural hospital that has no or very limited icu beds this is a crisis that is in the making; transport to a regional medical center may no longer be an option since hospital and icu capacities are being pushed to the maximum during this winter surge. although relief is on the way, with vaccines beginning to get emergency approval in many nations, the speed at which they can be manufactured and the efficiency and fairness of distribution remains a looming problem. whatever your role, i am sure many of you are feeling the stress of nursing in a pandemic. nursing is never an easy job, but the last few months and predictably the next few months are going to bring extra burden and stress to the roles of nurses. nursing in a pandemic has been challenging but also rewarding in that we have adapted and grown in our abilities to deal with the unexpected. online journal of rural nursing and health care, 20(2) https://doi.org/10.14574/ojrnhc.v20i2.668 3 resilience occurs in the face of adversity, and the resilience of nurses everywhere is obvious and greatly appreciated by those we care for on a day-to-day basis. this year of the nurse is one we will never forget. thank you to each and every one of you for what you do! references fahs, p.s. (2020) covid 19 and rural health care: editorial. online journal of rural nursing and health care, 20(1), 1-5. https://doi.org/10.14574/ojrnhc.v20i1.626 graves_575-article text-3678-1-9-20190820 (1) online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 98 access to diabetes self-management education in a rural state: a gis analysis barbara a. graves, phd, rn 1 elena thompson 2 grace liu 3 jane kunberger 4 laura canaday 5 brooke bambis 6 1 professor of nursing, university of alabama, capstone college of nursing, agraves@ua.edu 2 student, university of alabama, ethompson1@crimson.ua.edu 3 student, university of alabama, gsliu@crimson.ua.edu 4 student, university of alabama, jmkunberger@crimson.ua.edu 5 student, university of alabama, lcanaday@crimson.ua.edu 6 student, university of alabama, bkbambis@crimson.ua.edu abstract background: diabetes is a major cause of mortality and morbidity in the state of alabama.research has demonstrated geographical disparities in diabetes outcomes and access to healthcare services. supporting behavior changes through diabetes self-management education (dsme) has been shown to improve diabetes outcomes. purpose: the overall purpose of this study was to empirically measure and display spatial patterns of potential geographical accessibility of the alabama populations to dsme services. geographic information systems (gis) technology was used to empirically and visually examine spatial online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 99 relationships between variables related to diabetes and access to dsme services. the specific aims were to: (1) determine the percentage of the alabama population with geographical access to dsme services within 30 and 60minutes of travel time; (2) determine the percentage of the population with access by age, sex, race, rural status, and ses. method: a retrospective cohort, descriptive quantitative study design was used. gis and u.s.census bureau data provided visual identification and empirical measures of distance and access. findings: gis analysis provided percentages of alabama’s total population with access to dsme at 30 and 60-minute travel time and maps allowed visualization of dsme service coverage areas. analysis showed that 66.3% and 94.1% of the total alabama population were within a 30 and 60minute travel time to a dsme service location, respectively. while ses status had a minor effect on accessibility, the most noticeable disparity in equity of access was for those living in a rural setting. only 44.1% of individuals in rural settings had 30-minute access to a facility, whereas 81.7% of individuals in an urban setting had 30-minute access. discussion: timely access to the best practice of dsme is essential in reducing diabetes mortality and disparities. social justice requires the reversal of healthcare disparities created by geographical and social inequalities through better distribution of resources. healthcare policy can change dsme locations to increase access and decrease mortality. keywords: diabetes, diabetes self-management education, healthcare access, geographic information systems doi: http://dx.doi.org/10.14574/ojrnhc.v19i2.575 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 100 access to diabetes self-management education in a rural state: a gis analysis background/significance diabetes is a major cause of mortality and morbidity worldwide, in the united states (us), and the state of alabama. estimates indicate that 21 million americans have been diagnosed with diabetes and an additional 8.1 million are living with undiagnosed diabetes. currently diabetes is the 7th leading cause of death in the u.s. (centers for disease control and prevention [cdc], n.d.a) and prevalence is highest in the southeast u.s. southern states also have the highest prevalence of undiagnosed diabetes (danaei, friedman, oza, murray, & ezzati, 2009). alabama consistently ranks in the top five states with the highest diabetes rates (robert wood johnson foundation, n.d.). in 2014, 11.9% of the adult population in alabama had been diagnosed with diabetes (cdc, n.d.b). these disparities are attributed to increased obesity rates, poverty, and larger african-american populations, a particularly at-risk group (winerman, 2011). a higher prevalence of diabetes has also been associated with rural areas (o’connor & wellenius, 2012). studies have shown that socioeconomic status (ses) and ethnic inequalities exist in the provision of healthcare to individuals with diabetes (ricci-cabello, ruiz-perez, olry de labrylima, & marquez-calderon, 2010; walker, gebregziabher, martin-harris, & egede, 2014; walker, gebregziabher, martin-harris, & egede, 2015). also, the literature demonstrates that racial/ethnic populations with lower ses are at risk for poor metabolic control and poor emotional functioning (borschuk & everhart, 2015; u.s. department of health and human services [usdhhs], n.d.) and that significant racial differences and barriers exist in diabetes selfmonitoring and outcomes (campbell, walker, smalls, & egede, 2012). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 101 diabetes self-management education diabetes self-management education (dsme) has been shown to improve diabetes outcomes. national dsme standards (brunisholz, 2014) call for an integrated approach that includes clinical content and skills, behavioral strategies (goal setting, problem solving), and engagement with psychosocial concerns (funnell, et al, 2012). high quality dsme, including healthy eating, being active, adhering to medications, monitoring blood glucose, and stress management, can improve clinical outcomes and patient health status (american diabetes association [ada], 2016; powers, et al. 2015). clinical trials have well established the beneficial effects dsme can have on hemoglobin a1c control and complication reduction (brunisholz, 2014; funnell, et al, 2012). in 2012, only 55.7% of adults diagnosed with diabetes in alabama had ever attended a dsme class (cdc, n.d.b). diabetes self-management education programs function to promote informed decisionmaking, effective self-care behaviors, and active collaboration with healthcare teams to improve clinical outcomes, health status, and quality of life (funnell, et al, 2012). but, dsme programs are not uniformly accessible, and lack of access can contribute to disparities in diabetes outcomes. while the amount of research about diabetes and associated risk factors is overwhelming, a greater understanding of specific regional geographical disparities is needed. disparities in healthcare access and health outcomes addressing disparities in access to healthcare services is a major public health priority. the u.s. department of health and human services has the goal of achieving health equity, eliminating disparities, and improving the health of all groups by 2020 (usdhhs, n.d.). variations in access to healthcare are strongly associated with variables such as age, race, ses, and place of residence and have been linked to health outcome disparities (andersen, 1995; online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 102 graves, 2009; shamshirgaran, et al., 2017; spanakis & golden, 2013). geographical accessibility is reduced by distance because the additional time, cost, and effort of long distance travel decreases utilization of service facilities (dal bello-haas, cammer, morgan, stewart, & kosteniuk, 2014). the relationship between the location of health care services and the locations of the populations in need can result is healthcare disparities. many studies have identified differences or gaps in healthcare access and health outcomes. findings of these studies indicate that while most americans have high quality healthcare available, disparities in healthcare access and health outcomes continue to exist. disparities associated with age, race and ethnicity, sex, income and ses, and place of residence or location of healthcare services have been documented. studies also show variation in healthcare access and adverse health outcomes associated with different geographical regions and urbanization levels (gjesfjeld & jung, 2011; graves, 2009; loop, et al., 2017; o’connor & wellenius, 2012). these differences create vulnerable, at-risk populations with excess diabetes related morbidity and mortality. where dsme services are provided has economic, political, ethical, and geographic implications. there is a need for health policy to focus on geographical patterns of adverse disease outcomes and the effect on at-risk populations. access and rural populations merriam-webster (n.d.) defines rural in general as open land but there are many operational definitions of rural. the u.s. department of agriculture economic research service (usdaers) uses rural-urban continuum codes (ruccs) as a measure of rurality of u.s. counties as metropolitan (metro) versus non-metropolitan (non-metro) (usda-ers, n.d.). the 2013 rural-urban continuum codes form a classification scheme that distinguishes metropolitan counties by the population size of their metro area, and nonmetropolitan online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 103 counties by degree of urbanization and adjacency to a metro area. each county in the u.s. is assigned one of 9 codes. this scheme allows researchers to break county data into finer residential groups, beyond metro and nonmetro, particularly for the analysis of trends in nonmetro areas that are related to population density and metro influence (usda-ers, n.d., para 1). many features of the rural environment create barriers to health service access. dunkin (2000) provides a framework for considering financial, sociocultural (or personal), and structural factors as part of the complex web of causation in rural health. financial factors include a lack of health insurance, adequate health insurance, or income or financial resources to personally pay for needed health services. sociocultural factors include cultural and spiritual beliefs, language, education, self-reliance, and concern about confidentiality. structural factors are those factors that relate to physical accessibility to health resources. they include availability of primary care providers, medical specialist (i.e. endocrinologist), or other healthcare professionals (i.e. certified diabetes educators) and health care facilities (i.e. certified ada diabetes centers). these factors affect health-seeking behaviors, health service utilization, and ultimately, health outcomes in rural areas. sociocultural and financial factors that influence health services have received extensive attention (agency for healthcare research and quality [ahrq], 2017; bushy, 2000; folland, goodman, & stano, 2017; usdhhs, n.d.) while geographical factors of healthcare service access have received much less consideration. healthcare policy changes over the past decade have drastically decreased access to health services. the rural health environment has been impacted by these changes in many ways (ahrq, 2012; bushy, 2000; folland et al., 2017). significant decreases in health services to the already vulnerable, at-risk rural underserved populations compounds and increases existing health online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 104 disparities. of noted importance are the drastic cuts in health services created by the chain of events from the medicare prospective payment system of 1983, to the balanced budget act of 1997, and through to the patient protection and affordable care act of 2010. while the patient protection and affordable care act increased the number of individuals covered by insurance overall access to many services was decreased. physicians within the us often prefer to practice in urban communities, rather than rural communities, due to volume. in 2010, only one out of ten physicians provided healthcare services in rural areas allowing for only 10% of the nation’s physicians to provide healthcare to 20% of its population (ahrq, 2012). rural areas also have lower proportions of all healthcare professionals. rural healthcare services often experience diseconomies of scale because long run average cost of operation increases as output increases (folland et al., 2017). providing care becomes too expensive, providers lose money, forcing them to close or merge with other services, thereby decreasing access. rural populations then experience an increase in distance and travel time to access necessary healthcare services. this situation is the greatest in the costly provision of specialized healthcare services. access and distance when considering accessibility of healthcare services, physical proximity is an important enabling factor. structural factors of access are measured in terms of availability and configuration of healthcare services, transportation to them, and distance and travel time to them (cromley & mclafferty, 2011; gatrell & elliott, 2015; hart, 1971; meade & emch, 2010). research demonstrates that provision of healthcare services often does not match need and that the use of services declines as distance increases (cullinan, gillispie, owen, & dunne, 2011; hart, 1971; tompkins, luginaah, booth, stewart, & harris, 2010). studies show patients may forgo free online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 105 healthcare if distance is greater than 20 miles. in response, many state health departments have proposed a standard in which rural residents should not have to travel more than 30 minutes to see a physician (chan, hart, & goodman, 2006). geographical information systems the use of geographic information systems (gis) in healthcare is growing. this growing technology and research methodology is simply an information system that can efficiently capture, organize, store, manipulate, and analyze spatial data. its ability to link geographical features on a map with attribute data is efficient for analyzing health data, revealing trends and determining relationships that might be missed in a strictly tabular format (evans et al., 2016; gjesfjeld & jung, 2011; graves, 2009). gis have demonstrated value in integration of statistical and geographic data and the visualization of the spatial relationship between location and resources (andersen, 1995; chan et al., 2006; cromley & mclafferty, 2011; cullinan et al., 2011; gjesfjeld & jung, 2011; graves,2009; 2011; love & lindquist, 1995) and therefore in health planning and the allocation of healthcare resources. theoretical framework the study used a framework of accessibility, the model for assessment of potential geographical accessibility (graves, 2011), adapted from the behavioral model of health services use developed by r.m. andersen (1995). andersen’s original model (aday & andersen, 1974) was initially developed in the late 1960s to help understand the use of health services, to define and measure equitable access to healthcare, and to assist in health policy development to promote equal access to healthcare. this seminal model has been used both to predict and explain the use of health services. in the revised behavioral model of health services use, andersen posits that online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 106 health service use is a function of people’s predisposition to use services, factors that enable or impede use, and their need for care. predisposing characteristics include demographic factors, social structure factors, and health beliefs. biological imperatives, such as age and sex, are demographic factors that might explain the need for healthcare. measures of social structure are education, occupation, ethnicity, as well as social networks, social interactions, and culture. in the assessment and measurement of enabling resources, andersen challenges researchers to go beyond measures of regular source of care, physician populations, and hospital bed counts. andersen believes that for utilization to happen, it is imperative that both personal enabling resources and community resources be socially and geographically available. the kinds and types of health services available where people live, as well as organizational structure and process, are important factors (andersen, 1995). the model used in this study can show what health services are provided where to whom, and by whom (organization) as well as where health service coverage is lacking. application of concepts of geographical access and the use of gis analysis can visually identify and empirically measure spatial relationships of geographical, environmental, and social influences of health, healthcare access, and healthcare outcomes (andersen, 1995). a more specific model for the assessment of access can help understand the health status of specific populations related to the provision of specific health services graves, 2011). evaluation of specific small-area need and the relationship to that area’s predisposing factors and enabling resources could lead to better understanding of disparities. the assessment of county-level mortality rates and the relationship to location or distance to health services may lead to improved mortality rates (see figure 1). the model for the assessment of potential geographical online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 107 accessibility is presented in this study and offers a replication model for the study of health outcomes by specific geographical areas (graves, 2011). more information about the relationship between social and geographical factors that enable people to obtain education for diabetes is needed. specifically, are dsme services located across alabama in a manner that allows equal access? research linking diabetes health disparities of specific regions of the state to access to dsme services could provide information to assist in the reduction of the excess diabetes mortality. ultimately, this analysis can serve to guide policy deliberations and health resource allocations as well as targeting of major healthcare priorities. figure 1. diabetes education services: model for assessment of potential geographical accessibility adapted from model for the assessment of potential geographical accessibility with permission graves (2009, ) online journal of rural nursing and health care, https://doi.org/10.14574/ojrnhc.v9i1.102 specific aims and objectives the purpose of this study was to empirically measure and display spatial patterns of potential geographical accessibility of the alabama populations to dsme services. gis technology was online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 108 used to empirically and visually examine spatial relationships between variables related to diabetes and access to dsme services. the specific aims were to: (1) determine the percentage of the alabama population with geographical access to dsme services within 30 and 60-minutes of travel time; (2) determine the percentage of the population with access by age, sex, race, rural status, and ses. research design a descriptive, ecological, explorative study design was used in a retrospective cohort. this design allowed description of the particular predisposing characteristics and the enabling resources of the alabama populations. the study was ecological, seeking to analyze the interrelationship of population characteristics and the specific dsme services environment. a gis was used to provide distance data for a descriptive analysis of the potential access of alabama populations to dsme services. a gis-based analysis provided distance measure (estimated network travel time), geographical mapping, and linking of u.s. census data for analyses of distance and other social determinants of health. descriptive statistics and mapping were used to explore and describe geographical access to dsme services. sampling method/subjects/protection of human subjects this was a secondary analysis that used u.s. census bureau aggregate data within a gis system; no individual data was used. data for this study was restricted to analysis and statistical reporting as aggregate data only. due to the nature of the data there are no human subjects, no atrisk populations, and the project was granted exempt status by the university of alabama irb board (irb#ex-17-cm-012-r1). methods/data collection procedures the following were the principle data sources used for this study: online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 109 ● american diabetes association data. street addresses of agencies that provide dsme services to alabama populations were obtained from the american diabetes association directory for each state (alabama, florida, georgia, mississippi, and tennessee). these addresses were geocoded within arcgis and provided a geographical location for the identified services. services in the surrounding four states were also included in the database due to potential to obtain services across state lines. ● tiger® data. zip code cartographic boundary files containing location in terms of latitude and longitude were downloaded from the united states bureau of census 2010 census data (u.s. census data, 2010). these files were used in arcgis to map and analyze characteristics of the alabama population. ▪ distance (network travel time). gis used the street network database within the tiger boundary files to calculate specified travel time from the identified locations of dsme services. from this data, network buffers of travel time were generated to define service areas of dsme services. ● rural status. rural status was determined using the usda-ers (n.d.) ruccs as a measure of rurality of u.s. counties. rurality was classification by a simple metropolitan (metro) versus non-metropolitan (non-metro) dichotomy. codes 1 through 3 distinguish levels of metropolitan counties by degrees of urbanization, while codes 4 through 9 distinguish varying degrees of rurality and metropolitan proximity. ● 2010 u.s. census bureau zip code-level data (u.s. census bureau, 2010): ▪ age. gis calculated proportion of the adult population with access to dsme services by age. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 110 ▪ race. gis calculated the proportions of the population located within each travel time service area to determine the proportion with access to dsme services by race groups (white, black, american eskimo/indian, asian, hawaii/ pacific islander, other, multirace, and hispanic). ▪ sex. gis calculated the total proportions of the population located within each travel time service area to determine population with access to dsme services for biological males and females. ▪ ses. gis calculated the proportions of the population located within each travel time service area to determine access to dsme services by poverty status measured by those at or below poverty level. table 1 selected outcomes measures model category construct specific measures data source phase 1: descriptive analysis health system geographic location gis coordinates gis addresses from american diabetes association directory predisposing characteristics demographic and social structure gis will calculate the total proportions of the population within travel time service areas to determine population with access to des by: gis and u.s. census bureau age age categories (ages 22-29, 3039, 40-49, 50-64, and 65 and greater). gis and u.s. census bureau race race groups (white, black, american eskimo/indian, asian, hawaii/ pacific islander, other, multi-race, and hispanic). gis and u.s. census bureau sex males and females. gis and u.s. census bureau ses poverty status: ses proportions will be reported for those at or below poverty level. gis and u.s. census bureau online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 111 rural status rurality is based on the office of management and budget (omb) classification by a simple metropolitan (metro) versus non-metropolitan (nonmetro) dichotomy. codes 1 through 3 distinguish levels of metropolitan counties by degrees of urbanization, while codes 4 through 9 distinguish varying degrees of rurality and metropolitan proximity. for this study rural status will be defined as either metro or non-metro. u.s. department of agriculture economic research service (ers) rural-urban continuum codes (ruccs) enabling resources distance (network travel time) network buffers of travel time generated to define service areas of diabetes education and provided a measure of access. gis and tiger® data data analysis data were analyzed using the arcgis® desktop, a commercially available gis software produced by environmental systems research institute, inc (esri). a gis-based analysis provided both geographical mapping and analyses of distance as well as social determinants of health. using u.s. census data and gis, maps of alabama zip codes were generated as the first thematic layer. the locations of dsme services across alabama and contiguous states were geocoded by latitude and longitude coordinates as point data on maps. the buffer tool in arcview gis network analysis was used to create network travel time buffer zones (service areas) of 30 and 60-minutes around point locations of dsme services. thematic map layers of dsme point locations and travel time buffer zones were overlaid on a alabama zip code map layer. based on u.s. census data for each zip code the total percentage of the alabama population located within each travel time service area was calculated to describe access to dsme services. the linkage of online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 112 data sets and thematic map layers allowed gis to estimate population characteristics by age, rural status, race, sex, and ses. limitations while the quality and accuracy of the data in this study is believed to be high, it is important to note that the use of aggregated data sets and geospatial manipulations could have introduced bias and may provide limitations to this study. data input, data manipulation, data output, and data interpretation are potential sources of errors or threats to validity and caution should be used when applying these findings to other geographical regions. furthermore, diabetes is a multidimensional disease with a complex web of causation. this study was limited by the use of risk factors measured only at the aggregate zip code-level, creating the modifiable areal unit problem (maup). the maup is a common problem that is encountered with health geography research and occurs when the same data can yield different results when aggregated in different ways. by choosing to aggregate by zip code instead of a different areal unit, such as county or census tract, the distribution of individuals throughout each zip code tabulation area (zcta) is uncertain. this can skew results, as the exact number of individuals within each service area is unable to be calculated and must instead be estimated. by only using alabama zip codes, the generalizability of the findings relating to access to dsme services is limited to geographical regions with similar population and demographic distributions. results access figures 2 and 3 show the service areas surrounding each dsme service location to provide visualization of coverage within alabama at 30 and 60-minutes of travel time. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 113 figure 2. dsme service locations with 30-minute travel service areas online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 114 figure 3. dsme service locations with 60-minute travel service areas online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 115 detailed results of the gis analysis by total population, sex, rural status, race, age, and ses are reported in table 2 by 30 and 60-minute travel networks. analysis showed that 66.3% and 94.1% of the total alabama population were within a 30 and 60-minute travel time to a dsme service location, respectively. table 2 results summary of population percentages with access to dsme centers in alabama 30 min 60 min total census category n % n % n total population 3,214,395 66.3 4,561,424 94.1 4,845,056 sex male 1,555,319 66.1 2,215,730 94.1 2,354,198 female 1,659,076 66.6 2,345,694 94.2 2,490,858 rural status rural 872,849 44.1 1,790,682 90.6 1,977,476 urban 2,341,546 81.7 2,770,742 96.6 2,867,580 race white 2,112,080 63.5 3,131,917 94.2 3,324,389 black/african american 920,599 73.1 1,178,407 93.6 1,258,954 american indian/ alaska native 18,308 64.1 27,225 95.3 28,578 asian 46,282 84.4 52,928 96.6 54,812 hawaiian/pacific islander 2,071 63.5 3,006 92.1 3,263 other 66,192 65.1 98,359 96.7 101,731 multiracial 48,863 66.6 69,582 94.9 73,329 hispanic/latino 129,780 66.6 188,073 96.6 194,720 age 20-29 460,712 69.9 622,333 94.5 658,646 30-39 412,853 67.1 582,375 94.6 615,301 40-49 440,106 66.2 626,931 94.3 664,760 50-59 436,320 65.5 625,203 93.9 665,754 60-64 176,963 63.5 260,248 93.3 278,848 65+ 418,627 62.9 620,515 93.3 665,364 ses status below poverty level 826375 62.0 1186738 92.4 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 116 equity of access demographic and ses data from the 2010 u.s. census were joined to zcta data in order to analyze how dsme service access varies between different demographics. results from the gis analysis are shown in table 2. access did not differ depending on sex (males 66.1% and 94.1%, females 66.6% and 94.2%). increasing age appeared to have a negative correlation with accessibility for ages 30 to 65+ (67.1% to 62.9% in 30-minute access and 94.6% to 93.3% in 60minute access) demonstrating a gradient effect. these results were also comparable to access of the total population of alabama (66.3% for 30-minute networks and 94.1% for 60-minute networks). table 2 compares access to dsme services across eight categories of race, which affected accessibility most noticeably in the 30-minute networks. the asian population had 18% more access (84.4%) compared to the total access of alabama , and the black/african american population access was 6.8% greater than the total access of alabama. the other races had accessibility similar to the total population of alabama. for 60-minute networks, inequality of access between races was less pronounced, with all of the results around alabama’s total access of 94.1% ses had a minor effect on accessibility. sixty-two percent of households living under the poverty line in alabama lived within a 30-minute travel network of a dsme service location, and 92% lived within a 60-minute travel network. these are comparable to the overall accessibility of the total population of alabama. the most noticeable disparity in equity of access was for those living in a rural setting. only 44.1% of individuals in rural settings had 30-minute access to a facility, whereas 81.7% of online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 117 individuals in an urban setting had 30-minute access. the disparity decreases at 60-minute access (90.6% for rural and 96.6% for urban). discussion the purpose of this study was to empirically measure and display the geographical accessibility of the alabama population to dsme services. detailed results of the gis analysis by total population, sex, rural status, race, age, and ses are reported in table 2 by 30-minute and 60-minute travel times. past literature indicates unequal access to healthcare services due to the previously mentioned demographic attributes and geographic location (usdhhs, n.d.; andersen, 1995; gjesfjeld & jung, 2011; graves, 2009; o’connor & wellenius, 2012). while this study demonstrates some variation in access, there are few of significant magnitude and most measured variables have comparable levels of access with the total alabama population. timely access to dsme services is essential in reducing diabetes mortality and disparities, but as previous studies indicate, a patient may forgo free health care if it is greater than 20 miles away. in response, many state health departments have proposed a standard in which rural residents should not have to travel more than 30-minutes to see a physician (chan et al., 2006). however, detailed results of this study indicate that less than half of the rural population (44.1%) in alabama is within a 30-minute service area of a dsme location compared to 81.7% of the urban population. even within a 60-minute service area, a single large geographical area noted in the southern parts of alabama did not have access to dsme services, as shown in figure 3. this region is part of a large crescent-shaped geographic region known commonly as the black belt region, named for its fertile land and, more recently, for higher levels of rural poverty, declining population, and insufficient health resources, including lack of dsme services. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 118 previous studies have shown limited levels of healthcare access for black, hispanic, and asian populations when compared to the white population, with hispanics facing the greatest barriers (usdhhs, n.d.). however, these findings were not seen in this study for dsme services in alabama. instead, the black and asian category demonstrated a pattern of significantly higher access at a 30-minute travel time (73.1% and 84.4% respectively) when compared to the white category, which displayed the lowest level of access along with the hawaiian/pacific islander category, both at 63.5%. the hispanic/latino population had a similar level of access to the total population at 66.6%. these findings at a 30-minute travel network were unexpected given previous research related to race and healthcare access, but become less prominent at a 60-minute travel network. the prevalence of diabetes is highest among native americans, blacks, and hispanics (spanakis & golden, 2013), and this study provides reassuring data that these racial groups have higher level of access to dsme services for diabetes treatment in alabama. however, it is important to note that geographical location and travel time are not the only indicators of healthcare access, but many other social determinates such as transportation methods, finances, health insurance access, and education should be considered. the inverse relationship between age and percentage of the population with 30-minute access supports the previously identified relationship by love and lindquist (1995) with 20-29 year olds having the highest level of access and 65 years and older with the lowest at 62.9%. this finding raises concerns since older age has been found to be associated with a higher prevalence of health complications associated with diabetes despite better glycemic control (shamshirgaran, et al., 2017). however, the percentage differences between age groups were still comparable to that of the total population. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 119 social justice requires the reversal of healthcare disparities created by geographical and social inequalities through better distribution of resources. this study demonstrates visually the spatial relationships between the dsme services, which are not geographically equally distributed, throughout alabama. as mentioned, there is notable lack of dsme services in the region known as the black belt while there are two noticeably denser areas of dsme services in the birmingham and mobile areas. this is most likely due to their urban statuses and provides higher levels of access for urban populations. however, the occurrence of diabetes is higher among rural residents (o’connor, & wellenius, 2012), which makes up over 40% of the alabama population. contrary to previous studies that indicated that people who live in poverty experience lower access to health services and poorer health status than people above the poverty line (shamshirgaran, et al., 2017), ses had a minor effect on geographic accessibility in alabama. this could be due to the fact that rural status is based on low population density and thus contain a lower number of people, whereas there can be a dense group of people living below the poverty line that live within a 30-minute service network. there was also not a difference in geographical access between sex within alabama, because sex within each zcta is about equally distributed. it is important to note that the use of aggregated data sets and geospatial manipulations could have introduced bias and may provide limitations to this study. data input, manipulation, output, and interpretation are potential sources of error, and caution should be used when applying these findings to other geographical regions. by only using alabama zip codes, the generalizability of the findings relating to access to dsme services is limited to geographical regions with similar population and demographic distributions. because diabetes is a multidimensional disease with a complex web of causation, there are potential confounding variables that pose a threat to the validity of this study. while this study online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 120 investigates multiple demographic attributes, these are not the only factors that influence diabetes. other factors, such as education, diet, social influences, and environment play a major role in diagnosis and complications relating to diabetes and provide possible confounding conditions. also, while urban populations may be closer to dsme services it does not mean there are enough certified educators to meet the needs of increasing population sizes. as identified by models of access (andersen, 1995; graves, 2011) accessibility to dsme services does not equate to acceptability of these services. more research is needed to aid understanding of acceptability of dsme education for rural populations, particularly from a cultural perspective. describing the accessibility without including measures of acceptability is an additional limitation of the study. despite the limitations, outcomes of this study can guide policy deliberations and health resource allocations that target major healthcare disparities. healthcare policy can change dsme service locations to increase access and decrease mortality. highlights 1. previous studies have shown a generalized standard of acceptable travel distance to healthcare services of 20 miles or 30-minutes. however, this study indicated that less than half of the rural population in alabama is within a 30-minute travel time to dsme services compared to 81.7% of the urban population. 2. this study showed an inverse relationship and apparent gradient between age and percentage of the population with 30-minute access to dsme services with the oldest adults having the least access. 3. findings provided reassurance that racial groups with known disparities in access to healthcare had higher level of access to dsme services for diabetes treatment in alabama. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.575 121 4. while geographical location and travel time are not the only indicators of healthcare access, place and distance do matter. social justice requires the reversal of healthcare disparities through better distribution of healthcare services. future research should focus on rural and rural age disparities. transportation methods, finances, and health insurance access also need to be considered. references aday, l.a. & andersen, r. 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(2011). diabetes belt encircles southern us. pbs newshour web site: the rundown. retrieved from http://www.pbs.org/newshour/rundown/study-diabetes-beltencircles-southern-us/ u.s. census bureau. 2010 census data. retrieved from http://www.census.gov/2010census/data/ u.s. department of agriculture (usda-ers) (n.d.). rural-urban continuum codes. retrieved from https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx u.s. department of health and human services (2010). healthy people 2020: national health promotion and disease prevention objectives. retrieved from https://www.healthypeople.gov/2020/about-healthy-people. microsoft word casey_457-3074-2-ce.docx online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 2 shared visits for health care consumers in a rural free clinic setting terry casey, msn, aprn1 audrey powell, msn, rn2 patricia calico, phd, rn3 1 education facilitator/nurse practitioner, ephraim mcdowell health, hope clinic and pharmacy, danville, ky, tjgc58@gmail.com 2 executive director community health, ephraim mcdowell health, hope clinic and pharmacy, danville, ky, alpowell70@gmail.com 3 consultant, stanford, ky, patricia.calico@gmail.com abstract background: one of every four adults in the united states lives with two or more chronic diseases. current care delivery models may not adequately address diabetes or hypertension management challenges. shared visits may provide more efficient chronic illness care. purpose: the purpose of this advanced practice registered nurse-led study was to conduct a pilot program to test the effectiveness of shared visits for low-income, uninsured, rural health care consumers who have uncontrolled chronic type ii diabetes or hypertension and who receive care at a rural free clinic. methods: a convenience sample of two groups of adults with diabetes and one group with hypertension engaged in shared health care visits that included shared education and discussion. data were analyzed using descriptive and inferential statistics. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 3 findings: fifty-three percent of diabetes participants had reduced hemoglobin a1c. a statistically significant difference in systolic blood pressure (p= 0.01) was found for the hypertension group. seventy-eight percent of participants had lower diastolic pressure. conclusion: shared visits show good potential for better self-management and improved outcomes among rural, low-income, uninsured health care consumers who have uncontrolled chronic type ii diabetes or hypertension. keywords: advanced practice registered nurses; chronic disease; diabetes mellitus, type 2; primary health care; rural health; self-care shared visits for health care consumers in a rural free clinic setting adults with chronic health conditions encounter multiple challenges. making lifestyle changes to improve long-term health outcomes and accessing person-centered health care providers are particularly challenging (schwartz et al., 2017). individuals and providers who partner in chronic illness care may change the disease process trajectory toward improved outcomes (cabana & jee, 2004; hibbard & greene, 2013; kurek, teevan, zlateva, &anderson (2016; schwartz et al., 2017). current models of primary care delivery often do not adequately address the challenges in such a way that the individual can “take charge” of his or her health. shared visits, also called group visits, shared medical appointments, cluster visits, or centering care are gaining attention as a more efficient model of chronic illness care (burke & o’grady, 2012). “chronic diseases are non-communicable illnesses that are prolonged in duration, do not resolve spontaneously, and are rarely cured completely.” (centers for disease control and online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 4 prevention, [cdc] 2012, para 1). nearly half of all adults in the united states are affected by chronic diseases (cdc, 2009). approximately 75 million (cdc, n.d.) adults in the united states have hypertension and 30.3 million (cdc, 2017) have diabetes. these chronic diseases increase health costs and place individuals at higher risk for co-morbidities such as heart disease, stroke, and kidney failure (cdc, 2009, cdc, 2017). the economic burden for diabetes was $245 billion in 2012 (american diabetes association [ada], 2013). hypertension costs the nation approximately $48.6 billion annually (cdc, n.d.). rural residents have disproportional higher rates of chronic disease than urban residents (zeng et al., 2015; meit et al., 2014). given the personal health effects and the economic burden of chronic diseases, self-management education is critical to improved health outcomes and lower health costs. literature review shared visits from noffsinger’s initial work on the shared visit model (noffsinger & scott, 2000; noffsinger & atkins, 2001) it was suggested that shared visits may be a less expensive way to provide a greater intensity of monitoring and self-care education; of particular importance in rural settings. shared visits are effective as patients experience improved quality of life, more providerpatient satisfaction, and fewer hospitalizations (brennan, hwang, & phelps, 2011). while definitions may vary, shared visits typically consist of several health care consumers with a common chronic diagnosis, such as hypertension, meeting with a licensed independent practitioner (lip), and a multidisciplinary team for monitoring and education regarding management for the chronic condition. shared visits involve a small cohort of health care consumers (8-10) who meet to learn and discuss disease specific self-care management for approximately 90 to 120 minutes per meeting (brennan, et al., 2011; jones, kaewluang, & lekhak, 2014). groups meet regularly, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 5 such as monthly, for on-going support and education to include partnering with providers, selfmanagement skill building, medication management, and decision making (edelman, gierisch, mcduffie, oddone, & williams, 2015). group problem solving, modeling, and peer support may encourage behavior change and enhance self-efficacy for disease management. experiential learning, motivational interviewing, and staff support enhance the effectiveness of the shared visits (jaber, braksmajer, & trilling, 2006; loney-hutchinson et al., 2009; simmons & kapustin, 2011). best practices for shared visits have yet to be fully determined, but the model has been successful within the larger health care systems that have instituted this care approach (burke & o’grady, 2012). diabetes self-efficacy and glycemic control are improved through shared visits and quality of life may also be enhanced (quiñones et al., 2014). australian nurses who led chronic disease selfmanagement groups were satisfied with the intervention, the feasibility of implementation, and the acceptance by patients (hegney, patterson, eley, mahomed, & young, 2013). in another study, patients in advanced practice registered nurse (aprn)-led shared visits had better glycemic control, more disease related knowledge, and experienced higher self-efficacy than the usual care group in an appalachian primary care setting (jessee & rutledge, 2012). underserved patients from a free clinic in a non-rural area who participated in a patient-centered model of care and shared visits for diabetes management were satisfied with shared visits, gained diabetes knowledge, and perceived better self-efficacy (esden &nichols, 2013). american indian adults participated in a quasi-experimental study focused on diabetes self-management. the intervention group partook in diabetes self-management education and culturally appropriate talking circles to discuss diabetes self-management. compared to american indians who had diabetes selfonline journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 6 management education alone the intervention group had better follow-up adherence at six months (p = 0.010) and lower glycated hemoglobin (hba1c), blood pressure (bp), and weight; although there was not statistical significance (wilken & nunn, 2017). hypertension patients with elevated systolic bp who participated in shared medical visits at an urban free clinic and learned self-management behaviors had a decrease in bp following the visits. the decreases were small and not statistically significant, but every patient demonstrated some decrease in systolic bp (dickman, pintz, gold, & kivlahan, 2012). lynch, leibman, ventrelle, avery, and richardson (2014) conducted intensive group interventions among african americans with type ii diabetes and hypertension. the groups included peer support for weight loss and education on diet and physical activity. reductions in both systolic and diastolic bp were found, but they were not statistically significant. in a study designed to promote hypertension control among veterans, shared medical visits were conducted once a month for four months. forty-seven veterans participated in the study, but 34 participants (72.3%) attended only one meeting and were not included in the data analysis. there were no significant differences regarding adherence to medication before and after the shared visits. the number of veterans with adequately controlled hypertension increased significantly (p = .03) and there were reductions in both systolic and diastolic bp (kirk et al., 2017). then himmelfarb, commondore-mensah, and hill (2016) concluded that aprns and registered nurses (rns) are essential to reducing ethnic disparities and quality gaps in hypertension care. hypertension programs led by aprns, rns, and teams of providers promote excellence in hypertension care and control. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 7 rural the body of literature addressing shared visits with rural and/or free clinic health care consumers is small. at this time no rural free health clinics have been identified as using a shared visit model of care in the state where this research was conducted, however, one rural free clinic in a neighboring state provided shared visits for diabetes care (mallow, theeke, whetsel, & barnes, 2013). in a first known randomized clinical trial pilot study in which rural residents participated in diabetes self-management shared visits positive trends in self-care were evident. although the results were not statistically significant, there is promise that patients from federally qualified health centers in rural appalachia may benefit from culturally appropriate shared visits for diabetes care (schoenberg, ciciurkaite, & greenwood, 2017). access to care is often challenging in rural areas due to lack of transportation, distance, and a limited number of health care providers (national rural health association [nrha], n.d.). these barriers are particularly poignant because rural dwelling adults have more poverty, chronic illnesses, and limited access to health promoting activities and social support (united states department of agriculture [usda], 2016; peterson, & cheng, 2013). rural residents are often lacking as participants in health research and better representation is needed (edelman, yang, guymon, & olson, 2013). for the purposes of this study, a rural area is one which encompasses all population, housing, and territory not included within an urban area of 50,000 or more people (united states census bureau [uscb], 2010). the rural-urban continuum code is 7, meaning a non-metro – urban population of 2,500 – 19,999, not adjacent to a metro area (usda, 2013). purpose the purpose of this aprn-led quantitative intervention study was to conduct a pilot program to test the effectiveness of shared visits for low-income, uninsured, rural health care consumers online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 8 who have uncontrolled chronic type ii diabetes or hypertension and who receive care at a rural free clinic. research questions research questions addressed in the study include: • research question # 1: does a shared visit contribute to improved control of diabetes in the low-income, uninsured rural health care consumers? • research question # 2: does a shared visit contribute to improved control of hypertension in the low-income, rural uninsured health care consumers? methodology study design the study design was a pre-post aprn-led intervention study. pre-intervention baseline (bl) biometric data were collected prior to the shared visit intervention. post-intervention (pi) biometric data were collected after the intervention. narrative data are from aprn notes and the final participant evaluation. study sample a non-randomized, convenience sample was selected from a population of community dwelling adults diagnosed with uncontrolled hypertension defined as bp measures above 140/70 millimeters of mercury (mmhg) and/or type ii diabetes (hba1c above 7%). all participants obtained health care at a rural free clinic for individuals between the ages of 18 and 65 who are at 150% of the poverty level in income, uninsured, and not eligible for medical financial assistance such as supplemental security income (ssi), medicaid, or medicare. potential participants who agreed to participate in the shared visits upon verbal invitation by the aprn, were sent a written invitation to attend the shared visit detailing the time and place of the visit. a follow-up phone online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 9 call was made to ensure the individuals had the correct information regarding the date, time, and place for the visit. potential participants were excluded from the groups if they preferred to continue with the usual care individual visits; would not be able to carry out the self-management concepts, as identified by the aprn or self-reported, due to cognitive ability; mental health issues; transportation problems; living situation or housing issues; and other chronic diseases that would impact attendance or follow-through with self-care. data were not included in the study if a participant chose to leave the group, or had unforeseen circumstances preventing participation. while race and ethnicity were not delineated by group, most participants were caucasian and there were also participants from the african american residents within the rural community. this composition is similar to the population in this rural setting which is 88.7% white, 7.9% african american, and 3.3 % hispanic or latino as of july, 2016 (uscb, 2016). groups. two groups were formed at the beginning of the study in september, 2012. clinic patients with a primary diagnosis of diabetes who met the inclusion criterion of uncontrolled type ii diabetes and agreed to participate were assigned to the diabetes group i. patients with a primary diagnosis of hypertension, which was uncontrolled, were assigned to the hypertension group. seven clinic patients volunteered for the diabetes group i and nine volunteered for the hypertension group. three participants in the diabetes group i with a primary diagnosis of diabetes were also hypertensive. the diabetes i and the hypertension groups met between september, 2012 and august, 2013. a second diabetes group was formed when additional funding to support one more group was confirmed. patients who met the same criteria as the diabetes group i were invited to participate. the group was established under the same procedures as the diabetes group i. six clinic online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 10 patients volunteered to participate. the diabetes group ii began in january, 2013 and ended in august, 2013, when the project funding ended. goals were set for each group. the goal for the diabetes groups was to reduce the individual hba1c level by 0.5. the hypertension group goal was to reduce by 10 mmhg the systolic, diastolic, or total blood pressure readings (heart heath study, unpublished data). table 1 groups group number of members gender age group duration diabetes i 7 women = 5 men = 2 mean = 53.8 yrs. range = 34-63 yrs. 12 months diabetes ii 6 women = 4 men = 2 mean = 54.4 yrs. range = 46-62 yrs. 8 months hypertension 9 women = 4 men = 5 mean = 51.8 yrs. range = 38-62 yrs. 12 months ethics the institutional review board of the rural free clinic parent organization approved the research to study the shared visits with the diabetes and hypertension groups (irb00004199). all individuals signed a consent form before participation. participants were informed that no individual data would be identified during the evaluation and reporting process to insure anonymity. both consent and privacy were addressed within the group and participants were encouraged to only speak to the educational topics. they were not required to share any personal information; nevertheless, some individuals may have shared information in or outside the group. there were no monetary or other rewards for participating in the study. however, participants may have benefited by improved disease self-management, chronicity control, enhanced patient experience, and/or fewer emergency room visits (burke & o’grady, 2012). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 11 study procedures the initial shared visits involved group formation and registration, a group orientation that included ground rules for participation, and review and signing of the consent forms. preintervention baseline biometric measures of blood pressure, height, and weight were documented for all participants, and hba1c for participants with type ii diabetes. hypertension group participants received a bp cuff for home monitoring and a log for maintaining bp readings. participants identified educational topics related to self-management of diabetes and/or hypertension and met with the aprn for a brief individual visit. the shared visits were held monthly for approximately 90 minutes per session at the rural free clinic and were facilitated by the aprn and a rn. brief individual visits of 15 to 30 minutes with the aprn were available following the shared visit as needed. criteria for an individual meeting included an emergent health condition, such as an infection; medication adjustment or prescription renewal; review of laboratory data; and/or a participant concern regarding his/her health status or social condition. other professionals contributed in the group sessions as appropriate to the participant needs. pharmacy residents assisted with education on diabetes as well as medications, a local university agricultural extension service agent discussed meal preparation, and a dietitian engaged participants in nutritional topics. a physical therapist and a wellness trainer provided content on exercise and activity. volunteer rns obtained vital signs and reviewed lab work and prescription refills. college students in a scholarship program dedicated to alleviating poverty and improving education through active community service (bonner program, 2017) participated in registration and data management. registered nurses with expertise in cardiovascular health and mental health presented education in their specialty areas. family nurse practitioner students also participated in online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 12 the educational sessions. final measurement included post-study biometric measurements. participant satisfaction was measured by two open-ended questions. data analysis quantitative data were analyzed using microsoft excel data analyzer. demographic data were analyzed with descriptive statistics (mean, range). pre and post-intervention bio-metric data were analyzed with descriptive statistics (mean, range) and inferential statistics (paired t-tests). simple linear regression was used to predict hba1c and bp based on group attendance. a p value of <.05 established statistical significance. narrative data from the two open ended questions are presented in table 5. findings research question i: does a shared visit contribute to improved control of diabetes in the low-income, uninsured health care consumer? diabetes group i and group ii hba1c hba1c data were analyzed for both diabetes group participants. the paired t-test results were not statistically significant for either group i (p = .07) or group ii (p = .81). three individuals (43%) in group i and one individuals in group ii (17%) met the goal of a reduced hba1c level of 0.5. one individual in group i showed a clinically significant change in hba1c from 7.9 to 6.7 and another from 10.5 to 8.6. all group i participants had a lower hba1c except for one person who maintained the same hba1c and another person who increased by 0.2. the group i mean decreased from 8.3 bl to 7.7 pi. activity levels were not measured for all participants, but an increase in hba1c for one person was attributed to a decrease in physical labor (aprn notes). group ii participants also showed clinically significant changes at the end of the collection period. in one case the hba1c was reduced from 6 to 5.7 and in another from 15.8 to 5.7, a online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 13 potentially life-saving change. the other four participants showed slight increases in the hba1c, but the group ii mean decreased from 8.8 bl to 8.3 pi. two of the three participants who had a primary diagnosis of diabetes and had hypertension showed decreased hba1c. one decreased from 15.8 to 5.7 and the other decreased from 10.5 to 8.6. one participant had a slight increase in hba1c from 7.4 to 7.6. in summary, there were no statistically significant differences in hba1c for either of the diabetes groups. there were clinically significant changes in both groups including participants with diabetes and hypertension (see table 2 and table 3). table 2 diabetes group i time diabetes group i weight in pounds hba1c (%) bp (mmhg) range (mean) range (mean) range systolic (mean) range diastolic (mean) baseline september. 2012 182.6 315.2 (238.9) 7.1 10.5 (8.3) 121 168 (141) 73 104 (86.7) post intervention august, 2013 165.4 315.6 (238.5) 6.7 9.8 (7.7) 109 151 (134.5) 72 90 (81.5) p value p = .07 p = .45 p = .12 table 3 diabetes group ii time diabetes group ii weight in pounds hba1c (%) bp (mmhg) range (mean) range (mean) range systolic (mean) range diastolic (mean) baseline january, 2013 130 319.4 (214.9) 6 -15.8 (8.8) 126 168 (146.5) 77 98 (88) postintervention august, 2013 118 298 (207.7) 5.7 -11.2 (8.3) 101 160 (140.5) 71 93 (83) p value p = .81 p = .60 p = .32 online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 14 research question # 2: does a shared visit contribute to improved control of hypertension in the low-income, rural uninsured health care consumers? hypertension group blood pressure paired t-test results were statistically significant between the bl and pi systolic bp (p = 0.01). seventy per cent of participants had a lower systolic bp following the intervention (range = 14-49 mmhg). paired t-test results for diastolic bp readings (table 4) were not statistically significant (p = 0.08). three individuals met the goal of a reduced diastolic bp of 10 mmhg. seventy-eight percent of participants (7) had a reduction in diastolic pressure (range = 3-24 mmhg). diabetes group i and group ii blood pressure the measurement focus of the diabetes groups was hba1c. however, since three participants in diabetes group i were also hypertensive, bp was monitored. a paired t-test analysis of bl and pi systolic bp was not statistically significant for group i (p = .45) or group ii (p = .60). four individuals in group i (65%) and three individuals in group ii (50%) met the goal for reduced systolic bp of 10 mmhg. there were no statistically significant changes in diastolic bp. two individuals in group i reduced diastolic bp by 10 mmhg (29%) and two in group ii (33%) reduced diastolic bp. the p values were (p =.12) and (p = 0.32) respectively. all three participants who had a primary diagnosis of diabetes and had hypertension showed decreased systolic and diastolic bp. one participant’s bp decreased from 168/95 to 160/83, another from 144/91 to 101/71, and the other from 168/104 to 160/83. in summary, within the hypertension group there was a statistically significant difference between bl and pi systolic measurements (p = 0.01), but no significant differences in diastolic measurements. there were no statistically significant differences in systolic or diastolic bp online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 15 measurements for either diabetes group. there were clinically important decreases in bp for several participants. table 4 hypertension group time hypertension weight in pounds bp (mmhg) range (mean) range systolic (mean) range diastolic (mean) baseline january, 2013 133.4 – 341 (213) 134 – 187 (155.3) 84 -118 (93) postintervention august, 2013 127 – 333 (213.5) 115 – 178 (136.3) 72 -118 (86) p value p = .01 p = .08 shared visit meeting attendance the diabetes group i shared visit attendance ranged from 5 to 9 out of 12 shared visits. participants attended a mean of 7.57 (63%) shared visits. two participants attended nine visits (75%), two attended eight visits (67%), two attended seven visits (58%), and one attended five visits (42%). one participant who attended only five shared visits was absent due to a work schedule conflict (aprn notes). diabetes group ii participants attended half or more of the eight shared visits (range = 4-6). participants attended a mean of 5.5 (69%) shared visits. one participant attended four visits (50%), one attended five visits (63%), and four attended six visits (75%). the hypertension group participant attendance ranged from 4 to 10 out of 12 shared visits. the mean number of visits attended was 6.7 (56%). one participant attended 10 visits (83%), two attended eight visits (67%), two attended seven visits (58%), one attended six visits (50 %), two attended five visits (42%), and one participant attended four visits (33%). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 16 a simple linear regression analysis was conducted to predict hba1c or bp (y dependent variable) based on shared visit attendance (x independent variable). there were no statistically significant results for the diabetes or hypertension groups. there was no correlation between the dependent and independent variables. the results for the diabetes group i were (f (1, 5) = 0.0821, p = .7859), with an r2 of 0.0161. the diabetes group ii results were (f (1, 4), = 0.7543, p = .4341), with an r2 of 0.1586. the hypertension group systolic bp results were (f (1, 7), = 2.0974, p = .1908), with an r2 of 0.2305. the diastolic bp results were (f (1, 7), = 0.0114, p = .9179), with an r2 of 0.0016. individual participant and aprn meetings all participants met individually with the aprn during the course of the study. participants met to address emergent health needs such as headache, limited mobility, and infections (aprn notes). a few participants needed referral for medical care. the aprn arranged referrals to health care providers in gastroenterology, neurology, surgery, and the wound center. clinic staff tracked referrals to assure that appointments were kept and that participants received needed medical care (aprn notes). participants who needed prescription refills met once every three months to review medication appropriateness and to receive new prescriptions as needed. a few participants met for approximately 10 minutes following each shared visit attended to discuss challenges in achieving goals (aprn notes). family participation two participants were accompanied by family members to the shared visits. one participant in the diabetes group i accompanied by a spouse attended eight shared visit meetings (67%). the participant’s hba1c increased by 0.2 from bl (6.8) to pi (7.0). one participant in the hypertension online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 17 group accompanied by a spouse attended five (42%) shared visit meetings. this participant’s bp improved from 141/90 mmhg (bl) to 119/80 mmhg (pi). satisfaction with shared visits participants were asked “what did you find most helpful during the first year of shared visits?” and “what would you recommend we change about the shared visit process?” fourteen of 22 participants responded. all 14 reported satisfaction with the shared visits by identifying what was most helpful. eleven participants stated that what they learned was most helpful, for example, “foods that are good for you to eat”, “information about diabetes or hypertension”, and “way to read back of food boxes”. two responded that the questions and answers helped them and one person stated that “the people” were helpful. participants liked the shared visit experience and 12 individuals said “nothing” needed to be changed. one of the 12 said “if it is not broke don't try and fix it. you guys are great!” two individuals did not respond to the question. table 5 shared visit evaluations what did you find most helpful during the first year of shared visits? what would you recommend we change about the shared visit process? 1. it was okay. helped me a lot. nothing. 2. i learned some things about high blood pressure that i wasn't aware of & learned about some food that are good to eat when you are diabetic. i think the process is good as it. no changes needed. 3. discussion of foods that are good for you when you have diabetes. i don't know of anything that needs to be changed. i learned a lot in the group. 4. learning information about diabetes and getting things to help with it. nothing. 5. the people. what i learned. nothing. 6. help me to learn about diabetes and what is good and bad for me. no response. 7. a lot a about stuff like the way to read the back of food boxes. nothing. all is great. 8. questions and answers. nothing. 9. questions and answers. nothing. 10. learning more about what is important for my blood pressure. nothing. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 18 what did you find most helpful during the first year of shared visits? what would you recommend we change about the shared visit process? 11. lot of information on diabetes and high blood pressure. nothing. 12. learned a lot of information. nothing. 13. a lot of info that i didn't know about a lot of different things. nothing at all (if it is not broke don't try and fix it). you guys are great! 14. more of what foods to eat. no response. discussion the purpose of this aprn-led quantitative intervention study was to conduct a pilot program to test the effectiveness of shared visits for low-income, uninsured, rural health care consumers who have uncontrolled chronic type ii diabetes or hypertension and who receive care at a rural free clinic. a small convenience sample of individuals with superimposed self-selection consented to participate in the study. they comprised three study groups; diabetes group i, diabetes group ii, and a hypertension group. research question i: does a shared visit contribute to improved control of diabetes in the low-income, uninsured health care consumer? hba1c there were no statistically significant findings related to the shared visits and hba1c. the lack of significance could be due to the small sample size and/or sporadic meeting attendance. however, there is an encouraging trend of improvements in hba1c in the groups as five out of seven group i participants lowered hba1c. the greatest reduction in hba1c was from 15.8 to 5.7 for one individual in group ii. previous studies also resulted in reduced hba1c values following shared visits. riley (2013) conducted a study with 22 patients with type ii diabetes from a private primary care practice in which self-care education was provided in shared visits over a three month period. reduced hba1c levels were seen in 82% of patients (mean = 1.1). reductions in weight and diastolic bp were also reported. in another study, 76.9% of participants in a four week diabetes online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 19 shared visit program decreased hba1c levels by the end of the program (reitz, sarfaty, diamond, & salzman, 2012). the length of the study groups may have made a difference in the outcomes. group i participants had more time to develop trust with the providers (reitz et al., 2012) and more time to develop a sense of ownership and accountability for self-care management (langford, sawyer, gioimo, brownson, & o’toole, 2007). reports on duration of group visits show mixed results. lin et al. (2014) found that lifestyle counseling was associated with better health outcomes following 12 to 24 months of counseling. in a study of self-management among african americans that included “culturally tailored education, behavioral skills training, and peer support” (lynch et al., p. 1) intense community shared visits over six months were effective in reducing hba1c. group intensity and participant composition may have influenced the group dynamics and could have prompted individuals to better manage their chronic disease. two participants were helped most by the questions and answers in the shared visits (table 5). the consistent aprn and rn presence and/or the participation of other health care providers may have caused participants to closely examine their self-care. for example, the nutritionist and the personal trainer may have provided challenges that led to improved outcomes. a good relationship among providers and patients enhances communication, promotes adherence to care guidelines, and influences health outcomes (schwartz, et al. 2017). the intensity of the shared visits, length of the groups, and the group composition may have empowered participants with education and skills to translate into the future for better health. blood pressure and weight online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 20 patients who have diabetes and hypertension are faced with the additional challenge of trying to manage both chronic diseases at the same time. managing both simultaneously may be overpowering and lead to lack of success in reducing bp and/or hba1c (lynch et al., 2014). in the current study two participants with both diabetes and hypertension diagnoses reduced hba1c and three participants reduced bp. this suggests they may have had better management skills or even a better understanding of how diabetes and hypertension care are synergistic. only one participant lost weight. systolic and diastolic bp and weight reductions were evident in both diabetes groups, although there were no statistically significant differences. even small reductions in hba1c, bp, and weight are clinically important changes for improved health and well-being. blood pressure and weight monitoring should be continued in future studies because better glycemic control and bp control in patients with type 2 diabetes result in fewer complications. weight loss achieved through concentrated lifestyle interventions is associated with better “fitness, glycemic control, and cvd [cardiovascular disease] risk factors in individuals with type 2 diabetes.” (wing et al., 2010, p. 1575). “…each 1 percent reduction in mean hba1c is associated with a 21 percent reduction in diabetes-related death risk…, 14 percent reduction in heart attacks…, and 37 percent reduction in microvascular complications” (stratton et al., 2000, p. 405) such as renal disease, amputations, and vision loss. “each 10 mmhg decrease in updated systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes…15% for deaths related to diabetes…11% for myocardial infarction…and 13% for microvascular complications” (adler et al., 2000, p. 412). the average weight for participants in this study exceeded 200 pounds before and after the intervention. obesity is prevalent in rural areas and clearly represents risk for poor health outcomes (befort, nazir, & perri, 2012). the weight variable might be given more emphasis in online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 21 future studies given the recent recommendation of the united states preventive services task force [uspstf] (lefevre, 2014) of “offering or referring adults who are overweight or obese and have additional cvd risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for cvd prevention” ( p. 1). on-going support and education about diabetes, bp, and weight are critical to reducing risk, but this important recommendation may go unheeded in rural areas because residents may not have access to “intensive behavioral counseling interventions”. physical activity is also a challenge for rural residents because exercise facilities are limited and there are transportation and financial barriers to accessing these services (peterson & cheng, 2013). multiple factors may play a role in managing diabetes, hypertension, and weight in rural america. self-efficacy; age; financial issues; personal and social issues such as homelessness, food insecurity, transportation, and other health issues may affect self-care or even a vision for change (langford, et al., 2007; payne, 2005). shared visits may offer opportunities to challenge the barriers to change and to desire better health. research question 2: does a shared visit contribute to improved control of hypertension in the low-income, uninsured health care consumers? the shared visit experience, self-management education, and bp monitoring may have improved hypertension control for some participants. evidence supports a statistically significant difference in systolic bp (p = 0.01) and improvements in diastolic bp for 78% of participants, although not statistically significant. the findings should be interpreted cautiously because of the small sample size. hypertension is better controlled when patients understand their disease and engage in self-management (bosworth, powers, & oddone, 2010). health literacy is another potential variable in how patients understand hypertension and make care decisions. in a study where patients were interested in decision-making the patients with low health literacy had less online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 22 bp control and asked fewer medical questions in physician-led shared visits than patients with higher literacy (aboumata, carson, beach, roter, & cooper, 2013). health literacy was not measured in the current study, but group presentations were delivered in narrative and graphic forms to promote understanding and to accommodate different learning styles (aprn notes). more information about learning styles and health literacy could possibly improve shared visits. improved bp control may be associated with self-management through home bp monitoring. home monitoring engages patients in their care and may help them to connect health behaviors with improved outcomes of lower bp (bosworth et al., 2010). patients who make these connections may have a better understanding of the disease process and potentially make better care decisions (bosworth, et al., 2010). disease management education is crucial to better health, but having the knowledge does not always assure behavior change for any chronic disease. more study is needed to understand this phenomenon (wang, inouye, davis, & wang, 2013). one premise is that health education coupled with socialization and support in a shared visit may inspire individuals to engage in self-care (yehle, sands, rhynders, & newton, 2009). results from a study conducted at one free clinic with shared appointments for patients with diabetes and/or hypertension showed that attendees increased self-management behaviors and goal achievement. every patient with hypertension had reduced systolic bp, although the results were not statistically significant. the shared appointments also eased the burden of chronic disease for the organization and for the vulnerable clinic population (dickman et al., 2012). shared visit meeting attendance online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 23 patients were excluded from the current study if they had known attributes that would interfere with attending shared visits, but attendance at the shared visits was less than ideal. nationally clinic attendance is sub-optimal (torres et al., 2015) and more than 30 % of patients in appalachia missed diabetes appointments (schoenberg, et al., 2017). the simple linear regression analyses to predict hba1c or bp based on meeting attendance findings were not significant. the results could be related to the small sample size and further studies with more participants are needed for meaningful analysis. dontje and forrest (2011) found that participants who attended more than three group visits compared to those who attended one to two visits showed better adherence to diabetes management goals. edelman et al. (2010) improved shared visit attendance by including an attendance contract and by providing a transportation voucher. stigmatization may also play a role in meeting attendance and chronic disease selfmanagement. individuals who live with chronic illness may experience stigma regardless of whether the illness is visible or invisible. they may be less likely to socialize, to engage in shared visits, and to assume self-care behaviors (engebretson, 2013). however, individuals who do participate in shared visits may find a milieu of acceptance that promotes learning, engagement, and reduces stigmatization. more information is needed on how to improve group attendance and how weight, diabetes, and hypertension relate to stigmatization and group participation. individual participant and aprn meetings all participants attended at least one individual meeting with the aprn throughout the course of the study. perhaps more visits could have been requested, but the rn, pharmacists, or other team members also addressed participant questions and potentially negated a meeting with the aprn. participants in a study of shared visits for diabetes self-management were encouraged to arrange individual meetings with pharmacists, nutritionists, or other presenters (dontje & online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 24 forrest, 2011). there is insufficient information to determine if the individual participant and aprn meetings affected the outcomes of this study. more detailed information could be documented in future studies. family participation two participants were accompanied by spouses at the shared visit meetings. one participant who attended eight shared visits (67%) had a slight increase in hga1c from bl (6.8) to pi (7.0). the other participant had improved bp from 141/90 mmhg (bl) to 119/80 mmhg (pi) and attended five (42%) of the visits. there are too few participants and data to determine whether family participation in the shared visits made a difference in the current study outcomes. however, family dynamics play an important role in chronic disease management. family members may “sabotage” (mayberry & osborn, 2012, p. 1239) self-management or promote a positive experience by supporting and engaging in the challenging process of disease control. there is also evidence that patient experiences are improved when participants are engaged and empowered, their specific needs are addressed, and when families share in the process (institute of medicine [iom], 2003). family members may be under involved in chronic disease management (powers, 2017) and focused study is needed on how they might better contribute to care. patient satisfaction when participants were asked, “what did you find most helpful during the first year of shared visits?” they responded that they had learned to read labels and how to make appropriate food choices. in rural areas where country cooking is highly desired and access to fresh fruits and vegetables may be limited (befort et al., 2012) building skills on how to read labels and how to online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 25 make appropriate food choices is critical to patient activation and disease management for better outcomes (hibbard & greene, 2013). participants were asked, “what would you recommend we change about the shared visit process?” and they responded that the shared visit process did not require any changes. a positive outcome of this study is that participants viewed the shared visits and group processes as good. patients are not always satisfied with their educational experience and more information is needed on the patient and caregiver experience of obtaining education in order to improve educational processes (danzl, et al., 2016). in future studies a valid and reliable evaluation tool specific to satisfaction with the group visit and the educational components would be useful. the response to the satisfaction questions may also indicate that participants learned new skills in an environment that aligned culturally with their needs for better chronic disease management. individuals have remarkable capacity for change given the opportunity for education and support provided by the shared visits. even small successes may be the impetus for a vision of better health, acting on successes, developing self-efficacy, and achieving healthier lifestyles (pender, murdaugh, & parsons, 2006). patient satisfaction is important in today’s health care environment (mehta, 2015) and measurement should be continued. limitations as a pilot study, the sample was small and the participants were self-selected based on their diagnoses of type ii diabetes or hypertension. the study is limited by the small convenience sample and the absence of a control group. participants who agreed to participate may be different from those who preferred not to participate in the shared visits. most of the participants were caucasian and better representation of minority groups would improve the study. the small sample size may have affected the statistical analyses. therefore, the results cannot be generalized beyond the study online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 26 sample. despite the small sample, there were some promising findings for reductions in hba1c and blood pressure indicating that individuals have the potential for health behavior change over time within the caring environment of the shared visit (burke & o’grady, 2012). larger and more diverse rural samples are needed in future studies to determine best practices in shared visits and self-management interventions. another limitation may be the lack of specific measurements for demographic data, for selfefficacy, and other potential variables. however, in this pilot study the researchers sought to provide a non-intrusive, supportive, and culturally appropriate shared visit. rural residents may be hesitant to participate in research studies led by individuals from outside their community, or that require reading questionnaires with unfamiliar language. therefore, “knowing the patients” (kelley, docherty, & brandon, 2013, p. 351), building trust, and including local providers in the shared visit were important. hometown providers use culturally appropriate language and value the community norms that enhance the shared visit experience. therefore, it was decided to not seek specific demographics or use standardized questionnaires (lindberg et al., 2012; young, barnason, & do, 2015). future studies might provide a better balance of measurements and culture. the final evaluation questionnaire was designed specifically for this study by the researchers. reliability or validity data are not available for the questionnaire. recommendations this study focused on a population of patients living with chronic illness and illustrates the multidimensional and complex nature of disease management among low-income, rural individuals with limited social and environmental resources. there are many barriers to chronic disease self-care management in rural areas. individuals may not always be motivated to actively engage in self-care or they may miss visits and compromise quality care. transportation, fuel costs, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 27 work schedules, illness, and lack of insurance are barriers to meeting attendance that need further exploration (jessee & rutledge, 2012; schoenberg et al., 2017; torres et al., 2015), it is recommended that more culturally appropriate longitudinal studies are conducted to better understand how engagement affects costs as well as individual and population health outcomes (hibbard & greene, 2013). given the uspstf (lefevre, 2014) recommendation of offering intensive behavioral counseling to overweight or obese adults for better diet and exercise, communities and providers might seek better telehealth services. where finances allow, telehealth may help to link rural residents with the behavioral counseling, shared visits, and/or other health services unavailable within their communities (win, 2015). it is recommended that more attention be given to better family engagement in chronic selfcare management including home bp monitoring (bosworth, et al.; danzl et al., 2016) and how family engagement affects health outcomes. patient and family satisfaction with health care continue to be important in today’s health environment and need further exploration using valid and reliable tools. population health is receiving renewed attention from health care providers, policy makers, and public health advocates as a promising framework for improving health in the united states. in this approach poverty, social status, stigmatization, and other barriers to good health are critical components to improving well-being (mahony & jones 2013). health care providers could partner with community leaders to increase available housing, improve access to fresh produce venues, improve health literacy, and to address other social determinants of health that create barriers to better care. aprn-led shared visits for chronic disease management are becoming more prevalent and represent another way to address population health. barriers to self-care management could online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 28 be addressed in shared visits. research should be continued in order to develop best practices for shared visits in the unique rural free clinic and for efficient care delivery. rural residents should be encouraged to participate in research and to thereby improve community health. they need adequate support to meet the research requirements and to complete the study (young, et al., 2015). future studies might include a comparison group with randomization, a larger sample, and the inclusion of additional variables such as self-efficacy or barriers within a rural cultural context. measurement limitations may be addressed by using culturally appropriate, reliable and valid tools to measure concepts such as self-efficacy, disease specific knowledge, patient satisfaction, and costs. while cost was not addressed in this rural free clinic setting, future “studies may incorporate cost related variables relevant to economic sustainment of shared visits for chronic disease management (bluecross blueshield of north carolina, n.d.; dontje & forrest, 2011). summary this study is unique in that it addresses salient variables specific to shared visits in a rural free clinic setting. chronic disease management is complex and it is particularly challenging in the face of poverty, limited access to care, and other rural cultural barriers. aprn-led shared visits show particular promise in empowering patients to self-manage chronic diseases and to engage in health promoting behaviors (burke & o’grady, 2012; jessee & rutledge, 2012). the direct and sustained access to health care providers who partnered with participants to acquire selfmanagement skills in a culturally appropriate person-centered environment is key to this study. an aprn-led team engaged participants in education and provided support to prepare them to “take charge” of their health. some rural low-income participants may have lacked education for complex health care decision-making until the shared visits filled a void (schoenberg et al., 2017). patient satisfaction, statistically significant lower systolic bp, and meaningful improvements in online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.457 29 diastolic bp and hba1c are strong incentives for continuing rural shared visits for chronic disease self-management. the findings from this study may be useful to other aprns who provide care to rural health care consumers. in times of turbulence in how health care will be financed and delivered shared visits may gain prominence. conclusion aprn-led shared visits show good potential for better self-management and improved outcomes among rural, low-income, uninsured health care consumers who have uncontrolled chronic type ii diabetes or hypertension. supporting agency the project was partially funded by the good samaritan foundation lexington, ky references aboumatar, h.j., carson, k.a., beach, m.c., roter, d.l., & cooper, l.a. 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(2015). a closer look at the rural-urban health disparities: insights from four major diseases in the commonwealth of virginia. social science & medicine, 140, 62-68. https://doi.org/10.1016/j.socscimed.2015.07.011 microsoft word 450-3035-3-ce.docx online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 88 rural and remote continuing nursing education: an integrative literature review michelle pavloff, bsn, mn, phd(c), rn1 pamela m. farthing, ba, msc, phd student, rn2 elsie duff, bscn, med, phd, rn, np3 1 faculty, saskatchewan collaborative bachelor of science in nursing, school of nursing, saskatchewan polytechnic; undergraduate adjunct professor, university of regina, michelle.pavloff@saskpolytech.ca 2 research chair, diabetes care, saskatchewan polytechnic; faculty, saskatchewan collaborative bachelor of science in nursing, school of nursing, saskatchewan polytechnic; undergraduate adjunct professor, university of regina, pamela.farthing@saskpolytech.ca 3 faculty, saskatchewan collaborative nurse practitioner program, school of nursing, saskatchewan polytechnic; graduate adjunct professor, university of regina, elsie.duff@saskpolytech.ca abstract background: rural and remote nursing has unique practice requirements that create a need for distinct education and practice preparation. preparing registered nurses (rns) to work in rural and remote communities is essential for the support and advancement of rural and remote health, as there is a shortage of rural and remote health care providers. purpose: an integrative literature review was conducted to identify the current continuing education needs of rural and remote rns internationally. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 89 sample: eight studies were included in the integrative review of the literature. countries reported in the literature included canada (n = 2), australia (n = 2), sweden (n = 1) and the united states (n = 3). method: an integrative literature review on rural and remote nursing practice continuing education was conducted using torraco’s (2005) guidelines, in addition to whittemore and knafl’s (2005) methodological strategies. a search strategy was created, tested, and approved by the research team. themes were extracted, collated, analyzed, and knowledge synthesized. findings: rural and remote rns identified areas requiring enhanced ongoing training. the identified training areas were summarized into the following four themes: 1) comprehensive specialized nursing practice for direct patient care, 2) unanticipated events, 3) non-direct patient care, and 4) advanced specialty courses. conclusion: the autonomy, competency, and expertise that is expected of rns working in rural and remote locations requires educational supports. rural and remote nursing continuing education is required in the areas of: comprehensive specialized nursing practice for direct patient care, unanticipated events, non-direct patient care, and advanced specialty courses. keywords: continuing education, integrative review, registered nurse(s), remote, rural rural and remote continuing nursing education: an integrative literature review rural and remote registered nurses’ (rns) unique practice environment necessitates distinctive education and knowledge to perform in their role. rural and remote rns’ scope of practice requires a significant autonomy to fulfill a variety of roles (such as leader, educator, and advocate) to address patient care. addressing professional development competency in rural rn practice is challenging in non-urban areas, as continuing education (post basic education) has online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 90 financial, time, and access implications. for nurses who work in urban centres, access to education resources is greater than for rural nurses (bushy, 2002; kenny & duckett, 2003; macleod et al., 2004); this includes access to continuing education opportunities. rural nursing is unique, given the generalist nursing expertise required for role competency. rural rns often work autonomously and provide care throughout the lifespan in areas such as community health, general practices, hospitals, and long term care. there is complexity and diversity in the nursing care provided to patients in rural and remote areas. rural rns in one work shift can, for example, manage farming accidents, obstetrical care, mental illness, and a variety of other issues (endacott & westley, 2006). thus, the working environments in rural settings are challenging (bish, kenny, & nay, 2012). the rural and remote nursing work environment, complexity and diversity of nursing care necessitates the need for educational opportunities that are designed specifically for rural and remote nurses (bish et al., 2012; eriksson, bergstedt, & melin-johansson, 2015; jacobson et al.2010; molanari, jaiswal, & hollinger-forest, 2011). to address this need, an examination of self-identified continuing education needs of rural and remote rns globally was undertaken to examine the existing evidence. an integrative literature review to enhance the understanding of the unique education needs of rural and remote nurses was completed to inform teaching and learning. method to examine the relevant literature, whittemore and knafl’s (2005) integrative literature review methodological strategies and torraco’s (2005) guidelines were used to search rural and remote nurse’s continuing education needs. databases used included cinahl plus full text (ebscohost), medline (ovid) ®, and scopus®. main subject headings were combined with the operator ‘and’ (e.g., continuing education and rural and nursing). a combination of online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 91 keywords and mesh headings were used to retrieve the relevant articles. from this search, articles were selected based on the inclusion and exclusion criteria. the scope of this integrative search was limited to peer-reviewed journal articles from any country, published in the english language from 2010-2016. qualitative, quantitative, or mixed methods studies were included if the studies were conducted in rural or remote settings and identified continuing education needs of rural or remote rns or rn midwives. exclusion criteria included grey literature, theses, dissertations or editorials, studies focused on program development or evaluation, theoretical studies, studies that did not include rns or midwives, urban based studies, studies that evaluated rn performance, studies that focused on nursing students, and studies on mentoring or patient education. the electronic database search resulted in the retrieval of 40 articles in cinahl, 51 articles in medline and 13 articles in scopus (n = 104). following this, two researchers screened articles that met inclusion criteria through review of title and abstract. conflicts were resolved by a third member of the research team who reviewed of the title and the abstract for inclusion or exclusion. in total, four researchers went through three databases. after duplicate articles were removed, 90 articles remained and were screened further for inclusion and exclusion criteria through a full reading of the text. following this, 82 articles were excluded as they did not meet inclusion criteria, leaving 8 studies to be included in the integrative review of the literature. the quality of the data from the selected studies was evaluated using polit and beck’s (2012) critique guidelines. a range of research methods were used for the inclusion articles: mixed method (n = 2), qualitative (n = 3), quantitative (n = 3). countries reported in the inclusion articles were canada (n = 2), australia (n = 2), sweden (n = 1) and the united states (n = 3). the findings are summarized by defining rural and remote and identifying learning needs. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 92 results definitions of rural and remote the definitions of rural and remote varied throughout the literature in this review. mackinnon (2010) described rural using a statistics canada definition: “populations (of less than 10,000) living in towns and municipalities outside the commuting zone of larger urban centres” (du plessis, beshiri, bollman, & clemenson, 2001, p. 1). another canadian study described rural as hospitals that were located outside of two large tertiary centers and five regional centers (sedgwick & pijl-zieber, 2015). similarly, jacobson et al. (2010) used proximity to a metropolitan area in their american study to define rural. counties’ population, sizes of cities and towns in the county, and the proximity of a county to a metropolitan area was used to define rural, as defined by the u.s. department of agriculture (jacobson et al., 2010). consistently, the definition of rural is conditional upon the population size and proximity to urban centres. accessibility, resources, and staff were also used to define rural and remote. in australia, rural areas were described as having poor access to health care, high staff turnover, and limited professional development (johnston, maxwell, maguire & alison, 2012). molanari et al. (2011) had a similar view of rural to describe american rural areas as being more complex and having long term nurse shortages. further to this, there were differences in definitions of patient health and patterns of health provider use (molanari et al., 2011). jacobson et al. (2010) described rural areas as having different language, cultural needs, resource availability, and public health infrastructure than urban areas. the concept of rural was self-identified by the nurses who worked in a rural or critical access hospital in the united states or canada (wolf & delao, 2013). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 93 identified learning needs a study specific to palliative care competence and educational needs of staff working in home care, nursing homes, and group homes in rural sweden was administered using a 20-item questionnaire (eriksson et al., 2015). of the 1062 staff who participated in the questionnaire, 70 were rns. the researchers found that participants lacked education in palliative care and topics specific to palliative care (eriksson et al., 2015). the education topics identified by rns included: social issues such as relationships and spiritual/ existential issues such as doctrines, life and death. in total, 76% of rn participants identified a need for further education on palliative care needs (eriksson et al., 2015). obstetrical care and support for education were identified in the mackinnon (2010) study. overall, the ethnographic research included 88 interviews with rns and focused on their experiences and concerns in rural hospital settings. part of the data in this study explored nurses’ experiences providing rural maternity care. nurses reported feeling unfairly burdened having to pay for their own continuing education, on their own time, and being required to find their own resources. rural nurses also indicated that they learned maternity nursing from other nurses, on the job, as there was little exposure to this in their education programs (mackinnon, 2010). mackinnon (2010) identified that rural nursing continuing education needs to be supported to protect the public through possible increases in education funding, more transparency in education processes, and flexible staffing processes. bioterrorism-related preparedness and training needs of rural texas rns was examined using a cross-sectional survey of 3,508 rural registered nurses (jacobson et al., 2010). researchers found less than 10% of nurses surveyed were confident diagnosing or treating bioterrorism-related online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 94 conditions. jacobson et al. (2010) also found that respondents were interested in future training opportunities (69%) to address their lack of emergency readiness. an examination of the attitudes, experiences, and beliefs of aboriginal health workers and rns regarding diabetes mellitus (dm) training occurred using a descriptive qualitative design study conducted in australia (king, king, willis, munt, & semmens, 2012). there were 10 rns included in this study. the researchers found that a course in dm is applicable for rural rns and there is a need for special dm training for nurses working rural and with indigenous clients (king et al., 2012). providing a dm course provided support and helped to empower rural nurses and rural patients with dm (king et al., 2012). chronic obstructive pulmonary disease (copd) experience, training, confidence, attitudes, and knowledge of rural and remote healthcare practitioners was examined using a descriptive cross sectional, observational survey of 31 rural and remote health care practitioners, including 13 nurses who worked in community health, public hospitals, or a private practice (johnston et al., 2012). participants’ in this study self-rated training, confidence, and experience of managing patients with copd as low (johnston et al., 2012). additionally, low participant scores for knowledge levels in understanding pulmonary rehabilitation occurred. the relationship between lifestyle preferences, educational preparedness for the rural nursing generalist role, and the intent to move was determined in a descriptive correlational study of 106 novice and expert rural nurses in the united states (molanari et al., 2011). participants indicated they were not prepared to work as a rural rn where there was less preparedness for trauma, neurology, pediatrics, and crises management practice. rns felt slightly more prepared in the areas of geriatrics, critical thinking, pharmacology, and leadership (molanari et al., 2011). this study is important to address topic specific education for rural rns. online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 95 rural nursing is complex and challenging, as indicated in a canadian study to assess the learning needs of new graduate nurses’ preparation for rural nursing practice (sedgwick & pijlzieber, 2015). further to this, inadequate orientations to rural nursing, combined with a lack of continuing education opportunities addressing emergency and critical care, creates problems for maintenance of competence (sedgwick & pijl-zieber, 2015). competency ratings that nurses selfrated as low included: pediatric advanced lifesaving, neonatal resuscitation, trauma nursing core, emergency procedures, medication side effects, medication administration, triage nursing assessments on patients of all ages, dysrhythmia assessment, and general medication knowledge (sedgwick, & pijl-zieber, 2015). thus, this study is useful to identify core topics for continuing education in rural nursing. education needs specific to emergency departments in critical access hospitals in the united states were identified by participants from 23 american states and canada who engaged in focus groups during a national emergency nursing conference. managing critically ill patients, traumatic injuries, patient behavioural problems, obese, pediatric, and obstetrical patients were topics that nurses identified as lacking (wolf & delao, 2013). participants identified educational needs relating to low-volume high stakes patient situations, patients who had special devices, and postoperative patients who had new surgical procedures (wolf & delao, 2013). thus, a common education need for rural nurses is critical or emergency nursing. in this integrative review of the literature, unique education needs of rural and remote nurses were summarized in to four themes: comprehensive specialized nursing practice for direct patient care, unanticipated events, non-direct patient care, and advanced specialty courses. the four themes each encompass specific nursing areas described in the literature (see figure 1). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 96 recommendations one purpose of this integrative literature review of rural and remote rn continuing education needs was to identify needs from various countries. sedgwick and pilj-zieber (2015) offered several recommendations such as tertiary care centers offering refresher shifts for new rural graduate nurses, or schools of nursing sharing simulation lab space to allow rural nurses to refresh their skills. additionally, administrators may provide new graduate nurses access to mentors, purchase online training programs, and lobby politicians for more clinical nurse educator positions (sedgwick & pilj-zieber, 2015). interdisciplinary learning opportunities, orientation to the rural community, and advanced certification programs were also discussed as recommendations to support new graduate nurses (sedgwick & pilj-zieber, 2015). 1. comprehensive specialized nursing practice for direct patient care • palliative (eriksson et al., 2015) • obstetrics (mackinnon, 2010; wolf & delao, 2013) • pediatrics (molanari et al., 2011; wolf & delao, 2013) • mental health/ behavioral (mackinnon, 2010; wolf & delao, 2013) • geriatrics (molanari et al., 2011) • diabetes care (king, et al., 2012) • neurology (molanari et al., 2011) • cardiology (sedgwick & pijl-zieber, 2015) • respiratory (johnston, et al., 2012) • pharmacology (sedgwick & pijl-zieber, 2015) • bariatrics (wolf & delao, 2013) • post-operative/special devices (wolf & delao, 2013) 2. unanticipated events • emergency preparedness (jacobson et al., 2010) • emergency care: trauma/crisis/ triage (mackinnon, 2010; sedgwick & pijl-zieber, 2015; wolf & delao, 2013) 3. non-direct patient care • technology (molanari et al., 2011) • management/leadership (molanari et al., 2011) 4. advanced specialty courses • pediatric advanced life support (pals) • neonatal resuscitation program (nrp) • trauma nursing core course (tncc) • triage canadian triage and acuity scale (ctas) (sedgwick & pijl-zieber, 2015) figure 1. continuing education needs identified by rural and remote registered nurses online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 97 the role of nursing administration is important to advocate for increased funding, transparency on financial resources, and flexible staffing processes to improve access to continuing education for rural nurses (mackinnon, 2010). nursing unions and regulatory bodies must address continuing education issues, as the skills required for rural nursing roles have a direct impact on patient safety and protection of the public (mackinnon, 2010). further to this, collaboration with other regulatory bodies, such as midwifery associations, may support ongoing education for rural nurses in areas such as maternity care (mackinnon, 2010). periodic continuing education for high-risk births must be supported for rural nurses (molanari et al., 2010). nursing education programs must increase nursing student rural experiences and crises assessment/management practice (molanari et al., 2010). access to emergency preparedness (specifically related to bioterrorism related emergencies) was also noted to be an area that rural nurses identified as requiring continuing education (jacobson et al., 2010). further to this, professional organizations, licensing bodies, and communities were identified to play a role in improving the emergency preparedness of rural nurses when managing bioterrorism emergencies (jacobson et al., 2010). short online videos is one strategy to deliver continuing education to rural nurses (wolf & delao, 2013). such videos may focus on areas of knowledge and practice gaps. knowledge gaps that were identified in the literature include: palliative care specific to rns and the organization/facility that they are working in (e.g., home care, long term care) (eriksson et al., 2015); managing patients with copd, specifically pulmonary rehabilitation (johnston et al., 2012); and supporting rural nurses who work with indigenous patients that have diabetes (king et al., 2012). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 98 improving dm continuing education for rural and remote nurses requires a sustainable multifaceted approach. some suggestions to improve and enhance rural remote nurses’ knowledge of dm include financial support for diabetic education course development and delivery; support for access to a diabetes expert mentor; internet access to locate resources and potentially deliver/house courses about diabetes management; providing nurses with time at work to learn and study; collaboration with other health care providers who work with diabetic patients; support from managers; formal acknowledgement, remuneration, and role recognition of diabetes management qualifications; incorporating principles of indigenous culture and learning in diabetes education (king et al., 2012). providing ongoing, supported and easily accessible dm education resources for rural and remote nurses will ensure safe, effective care for diabetic patients in rural and remote areas. limitations to this integrative review included using three databases; this may have restricted access to valuable articles. the search strategy included a date limitation to explore the most recent literature; however, this may have excluded articles. further to this, the role and scope of the rn in various rural and remote areas may differ, thus their identified needs may not reflect those of all rural and remote rns. several single studies examined content specific topics, such as palliative care or copd, and thus may not be generalizable. several studies were cross sectional or descriptive correlational in methodology, thus, the quality of the measurement tools is not known. there was no universal definition of the terms rural or remote, therefore the generalizability of the findings may be limited. conclusion identifying the knowledge gaps of rural and remote nurses to support continued education preparation for nurses as a first point of care to the healthcare system is important. the role online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 99 autonomy, competency, and expertise that is expected of rns in rural and remote areas requires unique entry to practice and ongoing educational supports. globally, rural and remote rns require education to address role competence and scope of nursing practice. initial nursing education preparation and continuing education opportunities are needed to address competency and safety for rural and remote rns and patients. rural and remote nursing continuing education is required in the areas of: comprehensive specialized nursing practice for direct patient care, unanticipated events, non-direct patient care, and advanced specialty courses. the challenge is to develop teaching and learning in rural and remote nurses’ continuing education. areas for further research may include literature reviews on the types of programs currently available for rural and remote rn continuing education, and quality or types of tools to measure rural nurse competency. additionally, research is required to assess the types of educational supports currently offered to rural and remote rns through nursing unions, associations, licensing bodies, and administration. acknowledgements the authors thank saskatchewan polytechnic for partial funding of this review through the seed applied research program. the authors also thank their research team member chau ha and research assistant devendrakumar kanani for their contributions to this integrative review. references bish, m., kenny, a., & nay, r. (2012). a scoping review identifying contemporary issues in rural nursing leadership. journal of nursing scholarship, 44(4), 411 417. https://doi.org/10.1111/j.1547-5069.2012.01471.x online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 100 bushy, a. (2002). international perspectives on rural nursing: australia, canada, usa. australian journal of rural health, 10, 104 111. https://doi.org/10.1111/j.1440-1584.2002.tb00018.x du plessis,v., beshiri, r., bollman, r.d., & clemenson, h. (2001). definitions of rural. rural and small town canada analysis bulletin, 3(3). catalogue #21006-xie. ottawa: statistics canada. endacott, r., & westley, m. (2006). managing patients at risk of deterioration in rural hospitals: a qualitative study. australian journal of rural health, 14, 275 – 279. https://doi.org/10.1111/j.1440-1584.2006.00829.x eriksson, g., bergstedt, t.w., & melin-johansson, c. (2015). the need for palliative care education, support, and reflection among rural nurses and other staff: a quantitative study. palliative & supportive care, 13(2), 265 – 274. http://doi.org/10.1017/s1478951513001272 jacobson, h.e., soto mas, f., hsu, c.e., turley, j.p., miller, j., & kim, m. (2010). self-assessed emergency readiness and training needs of nurses in rural texas. public health nursing, 27(1), 41 – 48. https://doi.org/10.1111/j.1525-1446.2009.00825.x johnston, c.l., maxwell, l.j., maguire, g.p., & alison, j.a. (2012). how prepared are rural and remote health care practitioners to provide evidence-based management for people with chronic lung disease? the australian journal of rural health, 20(4), 200 – 207. http://doi.org/10.1111/j.1440-1584.2012.01288 kenny, a., & duckett, s. (2003). educating for rural nursing practice. journal of advanced nursing, 44(6), 613 622. https://doi.org/10.1046/j.0309-2402.2003.02851.x king, m., king, l., willis, e., munt, r., & semmens, f. (2012). the experiences of remote and rural aboriginal health workers and registered nurses who undertook a postgraduate online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 101 diabetes course to improve the health of indigenous australians. contemporary nurse, 42(1), 107 – 117. http://doi.org/10.5172/conu.2012.42.1.107 macleod, m.l.p., kulig, j., stewart, n.j., pitblado, j.r., banks, k., d’arcy, c., forbes, d., lazure, g, martin-misener, r., medves, j., morgan, d., morton, m., remus, g., smith, b., thomlinson, e., vogt, c., zimmer, l., & bentham, d. (2004). the nature of nursing practice in rural and remote canada. canadian health services research foundation. retrieved from http://www.cfhi-fcass.ca/migrated/pdf/researchreports/ogc/macleod_final.pdf mackinnon, k. 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(2005). writing integrative literature reviews, conceptual frameworks, and theoretical frameworks: terms, functions and distinctions. human resource development review, 4, 356 367. https://doi.org/10.1177/1534484305278283 online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.450 102 whittemore r., & knafl, k. (2005). the integrative review: updated methodology. journal of advanced nursing, 52, 546 553. https://doi.org/10.1111/j.1365-2648.2005.03621.x wolf, l. & delao, a. m. (2013). identifying the educational needs of emergency nurses in rural and critical access hospitals. the journal of continuing education in nursing, 44(9), 424 428. microsoft word mollard_437-2707-2-ed.docx online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 138 rural women’s explanatory models of postpartum depressive symptomatology elizabeth mollard, phd, aprn-np, ibclc 1 diane b. hudson, rn, phd 2 susan wilhelm, phd, rn-c 3 paul r. springer. phd 4 carol pullen, edd, rn 5 1 assistant professor, college of nursing lincoln division, university of nebraska medical center, elizabeth.mollard@unmc.edu 2 associate professor, college of nursing lincoln division, university of nebraska medical center, dbrage@unmc.edu 3 assistant professor & assistant dean, college of nursing western, university of nebraska medical center, slwilhel@unmc.edu 4 associate professor, department of child, youth and family studies, university of nebraska lincoln, pspringer3@unl.edu 5 professor, college of nursing omaha division, university of nebraska medical center, chpullen@unmc.edu abstract purpose: to construct explanatory models of postpartum depressive symptomatology (ppds) from the perspective of rural women and to compare these models to the traditional medical model. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 139 sample: purposive sample of 20 rural women from one midwestern state who self-identified as having had ppds in the past year. methods: this qualitative descriptive study was informed by kleinman’s (1980) explanatory model of illness and used a semi-structured interview guide. telephone interviews were audiorecorded and transcribed verbatim. data analysis included content analysis within the categories of kleinman’s (1980) explanatory model. findings: rural women were more likely to attribute their ppds to nonphysiological causes than physiological causes. rural women reported the onset, duration, and symptomatology of ppds were similar to what is outlined in the fifth edition of the diagnostic and statistical manual of mental disorders (dsm-5). women considered the effects of ppds to be far-reaching and serious. rural women in this study preferred a variety of often nonpharmacological treatment options and care from informal networks to that available from health care providers. although the rural women in this study did not believe ppds could be prevented, they believed women could better prepare themselves for ppds by having a support system in place and by planning for practical life concerns. conclusions: nurses and other health care providers and researchers should consider rural women's explanatory models of ppds when considering interventions and program development for women in rural communities. keywords: postpartum depression, postnatal depression, qualitative, maternal depression, depressive symptoms, rural nursing theory online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 140 rural women’s explanatory models of postpartum depressive symptomatology postpartum depressive symptomatology (ppds) occurs in 8–19% of women and may include symptoms of sadness, anxiety, weight change, sleep disruption, and loss of interest in life, with onset in the weeks and months following the delivery of a baby (american psychiatric association [apa], 2013; centers for disease control and prevention [cdc] (n.d.); o’hara & mccabe, 2013). ppds differs from the “baby blues,” a mood disruption experienced by most women during the first 2 weeks after giving birth, and from postpartum psychosis, a rare and severe condition that may endanger the safety of the mother and child (jones, chandra, dazzan, & howard, 2014). rural women may be at greater risk for ppds (mollard, hudson, ford, & pullen, 2015; villegas, mckay, dennis, & ross, 2011). nurses and other health care providers should understand how a target population views and explains illnesses to relate to patients and to provide the best care (kleinman, eisenberg, & good, 1978; buus, johannessen, & stage, 2012). because ppds is understudied in rural populations, it is unknown how rural women view ppds and what they consider their best treatment options. studies that elucidate how rural women view and explain ppds can help nurses develop appropriate screening, intervention, and treatment plans that will better serve the rural patient population. the purpose of this study was to construct explanatory models of postpartum depression symptomatology from the perspective of rural women and to compare these models to those of the traditional western health care “medical model” of ppds. background ppds is primarily viewed as a medical phenomenon in the united states even though women do not always describe the etiology of their symptoms as medical (abrams & curran, online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 141 2009; ugarriza, 2002). postpartum depression is generally diagnosed based on the criteria listed in the fifth edition of the diagnostic and statistical manual of mental disorders (dsm-5) under major depressive disorder, with a peripartum onset specifier (apa, 2013). to fit into these diagnostic criteria, women must have an onset of symptoms during either pregnancy or the first 4 weeks postpartum. ppds is not a diagnostic term but includes postpartum depressive symptoms whether the women who experience them meet all dsm-5 criteria. traditional western health care practices, to which will now be referred to as the “medical model,” includes views that ppds has an exclusively physiological etiology (beck, 2002; brummelte & galea, 2015). theories of a physiological cause of ppds have included changes in hormone levels, nutritional status, and delivery method, among others. the treatment of choice in the medical model is generally pharmacological antidepressant therapy (brummelte & galea, 2015; o’hara & mccabe, 2013). in previous research, women who had experienced ppds did not describe their experience as corresponding with the medical model (abrams & curran, 2009; ugarriza, 2002). kleinman (1980) developed his explanatory model of illness as a medical anthropologist who noticed cultural variations in the way illness was viewed and explained. kleinman also noted nurses and other health care providers viewed illness differently from the affected patients (kleinman, 1980). an individual’s explanatory model of a particular illness is formed by ethnic and cultural beliefs, personal experiences, and acquired explanations of the illness. kleinman’s (1980) model is based on the idea that by understanding how the patient views her illness, the health care provider will be better able to care for the patient, find treatment methods with which the patient will comply, and discover unrecognized causal or other mechanisms of the illness (kleinman, 1980). online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 142 kleinman’s (1980) explanatory model has been applied in research to several mental health topics in many cultural variations across the world. in the united states, researchers have applied his model to depression in african american women (waite & killian, 2009), depression in older hispanics (sadule-rios, tappen, williams, & rosselli, 2014), and postpartum depression in nonrural women (ugarriza, 2002). ugarriza (2002) found that, unlike the medical literature at the time, her study participants did not provide an exclusively physiological explanation for their experience, and that women felt more public education and support services for new mothers were necessary. ppds has unique considerations when looking at a rural culture as is detailed in long and weinert’s (1989) rural nursing theory. attributes of rural nursing theory include that rural dwellers see health as the ability to work, making them less likely to seek care if they are still able to function in their daily role. thus, a rural woman who is still able to function in the daily tasks of motherhood may not consider herself in need of care despite experiencing ppds. rural dwellers prefer informal networks of care to formal health care, and may face greater stigma in receiving healthcare due to the lack of anonymity in rural communities (long & weinert, 1989). these factors may be more significant when considering mental health problems as in some rural cultures mental health problems are viewed as a personal weakness (lee & winters, 2004). rural women are understudied, but from what is known, rural women may be at greater risk for depression throughout their life span (groh, 2013; simmons, yang, wu, bush, & crofford, 2015) and specifically during the postpartum period (mollard et al., 2015; villegas et al., 2011). due to increased levels of stigma of mental illness in rural communities (robinson et al., 2012; smalley et al., 2010), mental health is especially understudied. these factors, combined with the stigma of ppds which occurs during a time often portrayed as universally online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 143 happy and peaceful for new mothers (pinto-foltz & logsdon, 2008), may leave ppds under recognized in rural women. although ppds may be seen with stigma in rural cultures, rural women experience ppds and therefore need treatment and understanding. the best way to understand a woman’s experience is to ask her about it, because women are the experts on their own lives. to the researchers’ knowledge, there have been no studies using kleinman’s (1980) explanatory model in rural women with ppds. methods research design a qualitative descriptive design was used in this study. qualitative descriptive methodology is naturalistic, and creates a close description of participants’ experiences in their own voice (sandelowski, 2000). qualitative descriptive methods focus on the “what,” “why,” and “how” of human experience and are appropriate methods for understudied areas of research (lambert & lambert, 2012). in this study, ‘rural’ was defined as a nonmetropolitan county (a county with no urban areas ≥ 50,000) (white house office of management and budget [omb], n.d.). this definition of rural was chosen as it is used at the federal level, thus opening up sources of funding and advocacy across many levels to improve programs in rural communities. sample the purposive, criteria-based sample consisted of 20 rural women from one midwestern state who self-identified as having depressive symptoms in the postpartum period. data saturation was reached at 12 participants. data was collected on 8 additional participants to strengthen and confirm findings. to be included in the study, a participant had to be a woman online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 144 who had given birth within the past year; be at least 19 years old (the legal age of majority in this state); and reside in a rural setting. women who were currently pregnant were excluded from this study so possible pregnancy-related depressive symptoms would not be confused with ppds. additionally, due to the interviewer’s language abilities and the conversational nature of qualitative methods, non–english-speaking women were excluded from the study. recruitment after institutional review board (irb) approval (irb #392-15-ep), recruitment materials were distributed through several means in a midwestern state. recruitment materials were posted at rural women, infants, and children (wic) clinics and rural health care providers’ offices. an advertisement was placed on social media, and a recruitment letter was mailed to rural women who had given birth in the past year who were identified through a purchased direct mail list. six women were recruited through wic clinics, five through health care providers, four through social media, four through word of mouth, and one through the letter campaign. women were given the option to call, text, or send e-mail messages to the researcher to screen for eligibility. twenty-three women contacted the researcher. one woman did not meet the inclusion criteria because she had not given birth in the past year. two women were eligible but did not complete the consent form and were lost to follow-up. fifteen participants made initial contact through text message, two through telephone, and three through e-mail message. a $25 gift card was offered as a participation incentive. data collection participants were interviewed by telephone for 30 to 60 minutes using a qualitative interview guide based on kleinman’s (1980) questions that explored the individual’s online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 145 description of what causes ppds (etiology), how it works (time and mode of onset of symptoms, course of illness), how it affects the body (pathophysiology), and how it should be treated (see table 1). interviews were audio-recorded and transcribed verbatim. all participant transcripts were assigned a pseudonym to ensure confidentiality. table 1 interview guide questions interview guide grand tour questions: first, just to get to know you a little better, tell me a little bit more about yourself? tell me about your baby? how would you describe your pregnancy? how would you describe your birth experience? tell me about how it has been since your baby has been born? etiology what do you think causes some new mothers to experience sad or down feelings? why do some women get down and sad feelings after having a baby and others do not? onset of symptoms what makes sad or down feelings start for new moms when they do? tell me about how your sad or down feelings started pathophysiology when a new mother has sad or down feelings—how does that affect her? was that your experience? course of illness when new mothers have sad or down feelings, how long do those feelings last? how long did your sad or down feelings last? what kind of problems do those sad or down feelings cause for a mother who experiences them? tell me more about (insert particular problem). how serious are those problems? treatment what can a new mother do to take care of her sad or down feelings? tell me about what you did to take care of sad or down feelings? what doesn’t work to take care of sad or down feelings for new mother? did you try anything to take care of your sad or down feelings that didn’t work? should a new mother seek help from another person if she has sad or down feelings? who should that person be? did you try to seek help from anyone for your sad or down feelings? is there anyone a new mother should not go to for help when having sad or down feelings? is there any way to prevent a new mother from experiencing sad or down feelings? do you think your sad or down feelings could have been prevented? online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 146 data analysis methods data analysis methods included descriptive statistics for the demographic quantitative component of the study and content analysis for the transcribed qualitative component. descriptive statistics for quantitative data. the variables on the demographic questionnaire that were used in the descriptive statistical analysis included: age of participant, age of infant in months, race, education level, delivery method (cesarean or vaginal birth), infant feeding method (breast-feeding or bottle-feeding), population in participant’s community, and distance in minutes to the participant’s health care provider. the mean and standard deviation, frequency or percentage was calculated on these quantitative variables where appropriate. content analysis for qualitative data. content analysis is a reflexive and interactive form of data analysis that is informational and summarizes the collected qualitative data (sandelowski, 2000). content analysis is an appropriate form of analysis for understudied areas in which a simple reporting of the data and a straightforward description of the phenomena of study are desired (vaismoradi, turunen, & bondas, 2013). the content analysis process began with a mindful strategy to ensure the trustworthiness of the results. the researchers utilized four concepts of trustworthiness as identified by whittemore, chase, and mandle (2001), to guide content analysis: (a) criticality, (b) authenticity, (c) credibility, and (d) integrity. the study maintained criticality by identifying a research analysis process that was detailed and rigorous. to make sure the results were authentic, the voice of each participant was portrayed in a way that was true to her individual experience. to ensure online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 147 credibility, the experiences of the participants were depicted in an accurate and believable way. and finally, to ensure the study’s integrity, the researchers worked as a group to conduct thorough checks of trustworthiness and removal of bias by the researchers. miles and huberman’s (1994) methods of content analysis were employed on the qualitative data in this study with the three main elements of data reduction, data display, and conclusion drawing. two investigators analyzed the data and met over a series of meetings to interpret and discuss findings (figure 1). figure 1. content analysis process the lead investigator had interviewed the study participants, and the second investigator served as the peer reviewer. the role of the peer reviewer was to ask difficult questions, challenge biases, and push the investigation toward the next level in analysis, and interpretation (lincoln & guba, 1985). upon completion of the two investigator’s analysis, the researchers online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 148 compared the explanatory models of the participants with the medical model of ppds. the medical model of ppds used for comparison in this study included the onset, symptoms, and duration listed in the dsm-5 for major depressive disorder with a peripartum onset specifier; a primarily physiological etiology; and pharmacological antidepressants as the treatment of choice (o’hara & mccabe, 2013). three additional peer reviewers verified the results and interpretation of the study. to ensure transparency of the research process an audit trail was kept, and any documentation pertaining to the study, whether private or shared, was saved and securely stored. a member check method outlined by milne and oberle (2005) was used during the participant interview. this process included clarifying and summarizing what the researcher believed were participants’ major points so that, if necessary, participants could clarify and change their accounts to be better understood by the researchers. an example might be, “i am hearing you say you believe your symptoms got better as time went on. do you agree with that?” results demographic statistics the mean age of participants was 27.25 years (sd = 5.55). the mean number of children each woman had was 2.55 (sd = 1.23). the mean age of the infants was 5.2 months (sd = 3.90). fifteen women identified as caucasian, three as hispanic, one as native american, and one as african american/biracial. fourteen women had a high school education, three women had bachelor’s degrees, two had associate degrees, and one woman had not completed high school. eleven women had cesarean births. seventy percent of women were bottle-feeding. the average community size was 14,380 persons (sd = 17,831), and the mean distance from a participant’s home to her health care provider was 21.75 minutes (sd = 18.9). online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 149 etiology the etiology of the explanatory model included what participants believed caused ppds. nearly all participants named multiple causes for ppds. the main categories of etiology included physiological, lack of support, and trouble adjusting to the maternal role. physiological. many women discussed ppds had a physiological component in its etiology. women often mentioned “hormones”, and birth experience, such as having a cesarean section, as related to their ppds. although nicole thought her ppds was multifactorial, physiological changes played the largest part in causing her ppds. i didn’t know why i was feeling like that, and just the hormone side of it . . . especially csections too. you’re pregnant. you go into a room. you come out. you’re not pregnant. so your body just sort of freaks out because it doesn’t know what to do now. it’s just like when somebody gets their leg chopped off and their body doesn’t realize it. it’s kind of similar. support. women in this study often attributed their ppds to a lack of support. natalie said she lacked support from the beginning of her pregnancy. “i felt i had absolutely no help or support at all. like nobody made my experience exciting . . . i felt like it was a bad thing that i got pregnant and was having a baby.” sara believed she was unsupported due to her rural location and that lack of support played a role in her ppds. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 150 if i was living in a bigger town, i think i would feel completely different, you know? but i just don’t have any friends here. i don’t have any family here. i don’t work here. you know, so it’s kind of—for me it’s situational. maternal role. many women attributed their ppds to difficulty in transitioning to the maternal role. women discussed low self-efficacy, feeling overwhelmed with the maternal workload, feeling like a failure as a mother because of problems breast-feeding, or difficulty with the role change that occurs when moving from a professional role to a maternal role. catherine explained, after the birth of her baby, she did not think she was suited to be a mother, and this caused her ppds. i feel like i don’t have that motherly touch. like some moms are excited to have a baby. they’re thrilled. me, i was thrilled, but then as soon as the baby was here, i was scared. i was nervous because i’m like, i’ve never been taught how to take care of a baby. i was never loved like this by my mom. andrea believed being overwhelmed in the maternal role caused her ppds. “you’re bringing another human life into this world, you know? that whole overwhelmed feeling, are you gonna be good enough? are you doing the right thing? are you gonna make it? for me, that’s what it was.” onset of symptoms all but a few women identified their depressive symptoms beginning sometime in pregnancy or during the first month postpartum. most women could not identify exactly when their ppds started. however, some women had a specific moment when they believed their ppds began. steph said, online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 151 i had him on a friday and i went back to school on a tuesday. and i thought i was fine . . . when i came out of my first class and walked outside i felt like the whole world was looking at me and i felt like pure shame and embarrassment that i wasn’t pregnant. pathophysiology the pathophysiology of ppds for this explanatory model included the manifested symptoms. the symptoms reported by participants in this study corresponded closely with those identified in the dsm-5 for major depressive disorder. every woman reported sadness or loss of interest or pleasure. the other most commonly reported symptoms were sleep disruption, eating change, anxiety, and agitation. megan explained her depressive symptomatology included fatigue, feeling down, and lacking motivation. “i would have good days, and then other days where i didn’t feel like even getting myself out of bed. i just felt exhausted, and i just felt degraded…” nicole described how her self-care decreased with the demands of caring for an infant and how it played a part in her ppds. “now that i have the baby to worry about, you forget to eat. you forget to shower. you don’t brush your hair every day, and just everything for yourself kind of goes downhill.” jessica’s ppds included guilty feelings that the reality of her motherhood did not meet the cultural ideal and that she had quit breast-feeding. everyone kind of has this idealistic picture of what it’s like to have a baby. sort of the warm, fuzzy feelings of love and contentment, and when you don’t have that, you feel guilt, and you feel like, “why is my experience not like that? is it something i’m doing, or not doing? is it because i’m not breast-feeding anymore?” online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 152 course of illness the course of illness included the duration, seriousness, and effects of ppds. all but one woman stated the course of illness was greater than two weeks. many women, including natalie, thought ppds was long lasting or were unsure of how long it might last. natalie reflected, “sometimes i think it’s going to last forever, that’s how i feel. like i see the light at the end of the tunnel, but i feel like it’s a far tunnel, like it’s a long tunnel i’m going through.” when asked whether ppds is serious, women often repeated stories they had heard from television or the internet about other women who had hurt their children or committed suicide. one participant attributed the behavior of a woman who robbed a local bank to ppds. lindsey, who had experienced suicidal thoughts, was clear about the seriousness of ppds and the need for resources for women who have suicidal ideation. knowing that with my experience, and with my friend’s experience, that it comes down to wanting to kill yourself or commit suicide, i think it’s very serious, and i don’t think there’s enough information out there that it could happen, or what to do when it does happen. the effects of ppds were seen in almost all aspects of participants’ lives. women described difficulty bonding with their infants, and how their depressive symptoms negatively affected their other children and significant others. christina discussed how having trouble getting out of bed affected her children. “the kids were worried about me. i was worried about them. they thought ‘oh, mom is sick again,’ you know.” elena discussed her husband’s lack of understanding of her feelings and its effect on their relationship. “i started crying over just simple things. i started crying, and i tried to explain to him how i was feeling. but he just took it as being overdramatic.” online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 153 rachel stated she wanted her husband’s support, but, because of her symptomatology, she remained distant. she explained, there’s nothing that your husband can do, but you want your husband or spouse to be there, and they’re not. if they’re not there, then you want them to be home. but when they’re home, it’s almost like sometimes you just don’t want them around. best course of treatment when asked, what is the best treatment for ppds, most women mentioned multiple methods of treatment, most commonly nonpharmacological methods. christina believed the best way to treat ppds was to focus on and care for herself, even if that meant going against medical advice not to bathe after a cesarean birth. i took long baths even though i wasn’t supposed to; i got a cesarean, like, i don’t care. that helped. i got the sleep that i needed after i realized that she’s going to be okay, and i started to force feed myself several women, including steph, expressed the importance of talking to others, especially to women who had experienced ppds. “you have to talk to somebody because just hearing that it happens, and it happens with other people, and other people’s experiences. it resets in you that it’s okay, and that it happens, and it goes away.” many women discussed pharmacological antidepressants as a treatment option for ppds. discussions about antidepressants were polarized between extremely positive, or extremely negative opinions. sara was positive about her experience with antidepressants. before i was on medication, i was sad all the time. i didn’t want to leave the house. and you know, since being on medication, i have energy, i don’t want to sleep all the time, i get things done, i’m productive—you know, it’s like night and day. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 154 in contrast, andrea thought her health care provider’s offer of medication to treat her ppds was dismissive of her experience. i do not agree with a lot of the doctors that for every depression they suggest a pill . . . i literally believe that a pill is gonna make it worse, or just addict you in one way or another to a chemical… and to live, you need to be emotional, you know? women said improving practical life by having either childcare or more spousal and familial support was a way to improve ppds. women mentioned such coping mechanisms as reading books, gathering further information from the internet, or getting out of the house. a minority of women described maladaptive ways to feel better such as isolating oneself or just forcing oneself to “get over it.” autumn had the misinformed view that a woman can willfully stop her depression. “it lasts as long as you want it to last. like, you have to open your eyes and realize that you have a child you need to take care of.” where to seek treatment when asked where a woman should seek treatment for her ppds, the women most often recommended an individual from an informal network, such as a friend or family member. a healthcare provider was generally recommended as a second-choice option after a friend or family member. irene mentioned accessing one’s informal network before considering a health care provider. she said, i’m able to get through it just by talking to family, so that would be my first recommendation, somebody that they trust, and somebody they’re close with. if they don’t have that, i would probably tell them to go talk to a doctor. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 155 after her positive experience with her doctor, autumn recommended seeking help from a health care provider. she would tell me it’s normal for mothers that are like this, even if you’re a young mother, or an older mother. she would say that there are mothers that have had previous kids, and then all of a sudden they get postpartum with the kid they just had…i thought i was the only one that ever felt like that. other mothers, such as laura, explained seeing a health care provider seemed risky because of misconceptions that a health care provider might declare a woman unfit as a mother for having ppds. she said, “i think most people would go to their friends, and i think it’s scary for anyone to reach out to anyone in health care because they are required to report it.” prevention all women in this study believed ppds could not be prevented. lindsey, who had a history of ppds, described how she tried to prevent a subsequent episode. “i actually tried everything this time. i tried being open. i tried talking to people about it before it happened. i don’t know. i feel it’s just either you get it, or you don’t.” christina agreed. “no, i don’t think there’s a way to prevent it at all. i thought i was doing everything perfectly fine, and then it just came out of nowhere . . . i think it just happens.” most women believed although ppds could not be prevented, a woman could prepare herself for the possibility of it by preparing for practical life concerns such as finances and child care. discussion rural women’s explanatory models were different from the “medical model” of ppds in this study. regarding onset, duration, and manifested symptoms, rural women’s explanatory online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 156 models and the “medical model” corresponded. the differences between the medical model and rural women’s explanatory models of ppds were in the etiology, treatment preference, and recommended sources of help for ppds. in the medical model of ppds, grounded in post-positivism, the cause of ppds is considered physiological (brummelte & galea, 2015; o’hara & mccabe, 2013). very few women in this study named physiological factors as the sole cause of their ppds, most attributing ppds to multiple causes. the role physiological factors play in ppds is an example of an incongruity between models and is notable when considering health care practices surrounding ppds. additionally, even if it was discovered ppds was of physiological origin, the patients’ perception of its cause should be addressed. nurses and other health care providers who stay in tune with their patient’s experience and explanatory model will allow for appropriate treatment and improve patient satisfaction (callan & littlewood, 1998). women often discussed their ppds was caused by a lack of support. support, whether it is social or in practical tasks, is a potential target for interventions in rural populations. an example might be targeting support systems with awareness and strategies to support the new mother in rural communities. women commonly discussed struggles in ppds and the maternal role. interventions focusing on improved maternal self-efficacy, breast-feeding support, childcare and practical life support, may alleviate ppds in some rural women. most rural women in this study agreed with the “medical model” regarding onset and believed their ppds had begun in pregnancy or during the first month postpartum. additionally, the rural women in this study reported duration and manifested symptoms that matched the criteria stated in the dsm-5 and medical model. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 157 unlike the medical model, which uses antidepressant therapy as the primary treatment for ppds, most rural women reported a preference for a variety of treatment options. additionally, rural women may prefer alternative and complementary therapies in treating their symptoms (shreffler-grant, hill, weinert, nichols, & ide, 2007; weinert, nichols, & shreffler-grant, 2015). nurses should implement preferred, safe treatment interventions for new mothers in rural communities. when rural providers consider antidepressant therapy, patient beliefs about antidepressants should be discussed and patients should be educated about the expected effects of antidepressant therapy (bauer et al., 2014; fawzi et al., 2012). when appropriate, treatment modalities such as talk therapy, a support group, or other resources that may aid in practical and social support should be offered (hofmann, asnaani, vonk, sawyer, & fang, 2012; uebelacker et al., 2013). most commonly, women in this study recommended some form of self-care as an important element in treating ppds, including attention to necessary self-care, such as eating and bathing, and such suggestions as checking in with oneself and taking time to meditate or relax. the next most common suggestions were talking to someone, and seeking practical and social support. although women universally said ppds could not be prevented, most women thought there were ways one could prepare for the possibility. nurses and other healthcare providers should educate themselves and their patients on behaviors that may alleviate stress and depressive symptoms such as meditation, self-care, and physical activity (cooney et al., 2013; marchand, 2012). additionally, women should be encouraged to plan ways to reduce stressors after their babies are born. childcare options may be limited in rural communities and is a service area that could be increased or improved to support rural mothers and reduce ppds. online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 158 rural women in this study tended to prefer informal networks for advice and care before seeking formal health care services. this finding confirms rural nursing theory that emphasizes the importance of the informal network in rural cultures (long & weinert, 1989). some participants had the misconception that disclosing ppds to a health care provider would result in the loss of custody of their infant. these misconceptions have been reported in the literature (byatt et al., 2013). nurses and other health care providers caring for rural women should focus on making themselves approachable and correcting misconceptions. those nurses planning ppds interventions in rural communities should consider targeting awareness and support campaigns to new mothers’ informal networks. although the seriousness and effects of ppds are not focused on in the medical model of ppds, rural women’s explanatory models of ppds found ppds serious and its effects farreaching. women particularly emphasized how ppds affected relationships with their significant others and older children and impaired bonding with their infants. nurses and other health care providers but should be cognizant that these non-physiological effects may be more distressing for the woman than her depressive symptomatology. taking the relational factors of ppds into account strengthens the argument for creating awareness and intervention campaigns that include or target mothers’ informal networks. limitations using qualitative methods is indicated in baseline research on an understudied area such as the subject of this study, but limits the generalizability of the results. participation did not require a diagnosis of depression, so the experiences of women in this study may not be transferable to women with a diagnosis of major depressive disorder. the use of a postpartum depression screening scale in this study may have strengthened the findings by determining the levels of online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 159 severity of symptomatology for the various participants. the recruitment efforts did not reach all rural women who self-identified as having ppds. the use of a gift card incentive may have influenced recruitment and thus affected the trustworthiness of results. the use of telephone interview limited the interview experience to verbal communication. it is unknown whether the use of telephone as opposed to in-person interviews decreased rapport or trustworthiness of the researcher to the respondents. it is also unknown whether the anonymity provided through telephone interview discouraged or encouraged women’s participation. implications these findings have several important implications with respect to nursing practice and research. nurses should take note of these implications to become leading advocates for rural women with ppds. practice implications first, and most clearly, ppds is prevalent among women in rural communities, and this population tends to understand and explain ppds in ways that diverge from prevailing medical models. rural women’s explanatory models of ppds are not only culturally relevant but also clinically significant insofar as they shape coping behaviors, treatment preferences, patients' openness to health care providers’ explanatory models that often emphasize a physiological etiology, and the likelihood of noncompliance with pharmacological treatment plans. the data supported that rural women seek care from informal networks before formal networks and that they prefer a variety of treatment options. nurses and other health care providers should take a proactive approach in making themselves available as a care source to rural women by discussing ppds during pregnancy and the postpartum time frame. when appropriate, non-medical interventions should be considered first line. when antidepressant online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 160 therapy is prescribed, patients should be educated on the expected effects in order to increase compliance. providing resources for practical life support, such as referrals to social support services, and increasing quality childcare options may decrease ppds for some rural women. research implications perhaps the most important implication from this study is the need for additional research in this area. additional qualitative studies exploring specific aspects of the explanatory model of ppds should be considered. future studies should compare explanatory models of ppds between rural and urban women. the emphasis of this study was rural culture, thus data were not analyzed for race or ethnicity. analysis of this dataset for race and ethnicity should be considered in the future. more comprehensive and robust studies assessing the prevalence of ppds in rural populations are needed. further research about variables such as maternal selfefficacy and social support networks, and their association and interaction with ppds among rural women, are indicated. further study on the relationship between ppds and breastfeeding, as well as ppds and cesarean birth are needed. this study highlighted that rural women have polarized views on pharmacological methods as a treatment for ppds without a strong indication as to why this variation existed. future studies focused on pharmacological treatment for ppds and rural patient opinion on this treatment method are important. additionally, intervention studies focused on preparing for and treating ppds in rural women are needed. studies focused on explanatory models of ppds in rural nurses and other health care providers would add to the findings in this study, and to the overall picture of rural health care practices surrounding ppds. conclusion in this qualitative descriptive study informed by kleinman’s (1980) explanatory model of illness, rural women most often attributed their ppds to multiple causes and reported the onset, online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 161 duration, and symptomatology of ppds were like what is outlined in the dsm-5. the effects of ppds on rural women’s lives were far-reaching and considered serious. rural women in this study preferred a variety of treatment options and care from informal networks to that available from formal health care services. although the rural women in this study did not think ppds could be prevented, they believed women could better prepare themselves for the experience of ppds by having a strong support system and preparing for practical life concerns prior to delivery. nurses, other health care providers, and researchers should take these explanatory models and the use of informal care networks into consideration when evaluating patients, designing treatment plans, formulating policies, and designing community-level interventions, such as education and outreach. apart from these conclusions, it is clear further research on ppds in rural women is strongly indicated. references abrams, l. s., & curran, l. 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(2014). bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. the lancet, 384(9956), 1789 – 1799. https://doi.org/10.1016/s0140-6736(14)61278-2 kleinman, a. (1980). patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. berkeley, ca: university of california press. kleinman, a., eisenberg, l., & good, b. (1978). culture, illness, and care: clinical lessons from anthropologic and cross–cultural research. annals of internal medicine, 88(2), 251 – 258. https://doi.org/10.7326/0003-4819-88-2-251 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 164 lambert, v. a., & lambert, c. e. (2012). qualitative descriptive research: an acceptable design. pacific rim international journal of nursing research, 16(4), 255 256. lee, h. j., & winters, c. a. 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(2015). an integrative literature review of postpartum depression in rural u.s. communities. archives of psychiatric nursing. advance online publication. https://doi.org/10.1016/j.apnu.2015.12.003 o'hara, m. w., & mccabe, j. e. (2013). postpartum depression: current status and future directions. annual review of clinical psychology, 9, 379 – 407. https://doi.org/10.1146/ annurev-clinpsy-050212-185612 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 165 pinto-foltz, m. d., & logsdon, m. c. (2008). stigma towards mental illness: a concept analysis using postpartum depression as an exemplar. issues in mental health nursing, 29(1), 21 – 36. https://doi.org/10.1080/01612840701748698 robinson, w. d., geske, j., backer, e., jarzynka, k., springer, p. r., & bischoff, r. j. (2012). rural experiences with mental illness: through the eyes of patients and their families. families, systems & health: the journal of collaborative family healthcare, 30, 308– 321. https://doi.org/10.1037/a0030171 sadule-rios, n., tappen, r., williams, c. l., & rosselli, m. (2014). older hispanics' explanatory model of depression. archives of psychiatric nursing, 28(4), 242 – 249. https://doi.org/10.1016/j.apnu.2014.03.006 sandelowski, m. (2000). focus on research methods—whatever happened to qualitative description? research in nursing and health, 23(4), 334 – 340. https://doi.org/10.1002 /1098-240x(200008)23:4<334::aid-nur9>3.0.co;2-g shreffler-grant, j., hill, w., weinert, c., nichols, e., & ide, b. (2007). complementary therapy and older rural women: who uses it and who does not? nursing research, 56(1), 28 33. https://doi.org/10.1097/00006199-200701000-00004 simmons, l. a., yang, n. y., wu, q., bush, h. m., & crofford, l. j. (2015). public and personal depression stigma in a rural american female sample. archives of psychiatric nursing, 29(6), 407 – 412. https://doi.org/10.1016/j.apnu.2015.06.015 smalley, k. b., yancey, c. t., warren, j. c., naufel, k., ryan, r., & pugh, j. l. (2010). rural mental health and psychological treatment: a review for practitioners. journal of clinical psychology, 66(5), 479 – 489. https://doi.org/10.1002/jclp.20688 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 166 uebelacker, l. a., eaton, c. b., weisberg, r., sands, m., williams, c., calhoun, d. . . . taylor, t. (2013). social support and physical activity as moderators of life stress in predicting baseline depression and change in depression over time in the women’s health initiative. social psychiatry and psychiatric epidemiology, 48(12), 1971 – 1982. https://doi.org/10.1007/s00127-013-0693-z ugarriza, d. n. (2002). postpartum depressed women's explanation of depression. journal of nursing scholarship, 34(3), 227 – 233. https://doi.org/10.1111/j.1547-5069.2002.00227.x vaismoradi, m., turunen, h., & bondas, t. (2013). content analysis and thematic analysis: implications for conducting a qualitative descriptive study. nursing & health sciences, 15(3), 398 – 405. https://doi.org/10.1111/nhs.12048 villegas, l., mckay, k., dennis, c.-l., & ross, l. e. (2011). postpartum depression among rural women from developed and developing countries: a systematic review. the journal of rural health, 27(3), 278 – 288. https://doi.org/10.1111/j.1748-0361.2010.00339.x waite, r., & killian, p. (2009). perspectives about depression: explanatory models among african-american women. archives of psychiatric nursing, 23(4), 323 – 333. https://doi.org/10.1016/j.apnu.2008.05.009 weinert, s. c., nichols, e., & shreffler-grant, j. (2015). a program of nursing research in a rural setting. online journal of rural nursing and health care, 15(1), 100 116. https://doi.org/10.14574/ojrnhc.v15i1.343 whittemore, r., chase, s. k., & mandle, c. l. (2001). validity in qualitative research. qualitative health research, 11(4), 522 537. https://doi.org/10.1177/ 104973201129119299 online journal of rural nursing and health care, 17(1) http://dx.doi.org/10.14574/ojrnhc.v17i1.437 167 the white house, office of management and budget (n.d.). metropolitan and micropolitan delineation files. retrieved from: http://www.census.gov/population/metro/data/def.html microsoft word francis_column 9   online journal of rural nursing and health care, vol. 10, no. 2, fall 2010  editorial spring time down under karen francis, rn, phd, mhlth sc, nsg, med editorial board member i write this report on the day we australians refer to as ‘the day a horse race stops the nation’. it is the 150th year of our most prestigious horse race, the melbourne cup which will be run at 3pm today. australians everywhere will be watching the national broadcast of this monumental event hoping that the horse they have drawn in the local sweepstake will win the day. people lucky enough to be at the cup will be/are dressed in their finery; unfortunately, it is an overcast, cold and rainy day in melbourne! oh well, the flowing champagne will limit the effect of the cold and wet i am sure! i will be watching the race from canberra, the nation’s capital. like many australians i will join colleagues for a luncheon, and together we will show our support by barracking for a horse/s of our choice throughout the television broadcast. it only happens once a year, but i, and my fellow compatriots look forward to that sense of national pride and camaraderie that the cup inspires! while rain is not the ideal weather condition that race goers wished for today, the unusually high rainfalls experienced across the country in the past few months have resulted in the breaking of the 10 year drought. storage dams are at last refilling, farmers are rejoicing at expected high yield crops and, as is usual at this time of the year, asthma and hay fever suffers are having to manage allergy symptoms resulting from high pollen counts. one in every 10 australians suffers from asthma. this high prevalence rate impacts on the health care system as resources are diverted to prevention and intervention therapies. nurses, particularly those who are employed in rural environments, provide the majority of health care support to local populations. addressing the burden of disease imposed by increasing prevalence of chronic conditions such as asthma, is the cornerstone of the new health priorities established by the australian government (al-motlaq, mills, birks, & francis, 2010; australian institute of health and welfare, 2008, 2007). primary care prevention and intervention initiatives are advocated and resourced as government attempts to enhance the health of the population while reducing health care costs (al-motlaq, et al., 2010). the newly elected australian government is investing in the health care system. funding is being allocated to increase health student’s access to clinical placement and infrastructure grants are currently being provided to enhance clinical practice spaces within academic environments and health care settings (hwa, 2010). projects that support capacity building of nursing and allied health are prioritised for the first time! the australian government has also increased scholarship funding for nurses and midwives to undertake pre-service education specifically targeting students who live in rural environments, specialist post graduate education and are also supporting professional development activities. many nurses are applying for funding through these scholarship programs to upskill their knowledge and practice to better manage the populations growing chronic disease epidemic. nurse practitioners are taking a lead role in managing clients with chronic disease. while these initiatives are welcomed research indicates that retention of nurses and midwives and other health care professions in rural and remote settings in less than optimal adding to a growing disparity in health of these populations compared with metropolitan counterparts (nrha, 2010). government has increased training places for all health care professionals however innovative strategies to improve recruitment and retention of nurses, midwives and 10   online journal of rural nursing and health care, vol. 10, no. 2, fall 2010  other health care providers to rural and remote practice contexts is required if new graduates are to take up these practice opportunities (francis & mills, 2010). monitoring the impact of new initiatives will continue. it is hoped that the lofty goals identified in the raft of recent government reports will address the health needs of australians and support programs to promote health professionals uptake of practice in rural and remote contexts will be achieved. i am off to watch the great race, wish me luck! references al-motlaq, m., mills, j., birks, m., & francis, k. (2010). how nurses address the burden of disease in remote or isolated areas in queensland. international journal of nursing practice, 16(5), 472-477. [medline] australian institute of health and welfare. (2008). australia’s health 2008. retrieved october 20, 2008, from http://www.aihw.gov.au/ australian institute of health and welfare. (2007). rural, regional and remote health: a study on mortality (2nd edition). retrieved october 20, 2008, from http://www.aihw.gov.au/ francis, k., & mills, j. (2010). sustaining and growing the rural nursing and midwifery workforce: understanding the issues and isolating directions for the future. collegian (royal college of nursing, australia). hwa. (2010). health workforce australia annual report 2009-2010. adelaide health workforce australia. nrha. (2010). measuring the metropolitan-rural inequity. retrieved november 2, 2010, from http://nrha.ruralhealth.org.au/ftp/nrha-measuring-the-inequity.pdf fahs_684-article text-4448-1-6-20210412 online journal of rural nursing and health care, 21(1) 1 https://doi.org/10.14574/ojrnhc.v20i2.684 editorial the international rural nursing conference is coming to you in 2021 pamela stewart fahs, phd, rn, editor it is that time again, for the rural nurse organization (rno) international rural nursing conference. as many of you may know, the conference was originally planned for greely, co in 2020; however, the conference was postponed due to the covid pandemic. this year, the conference will be held virtually. there are several reasons for this decision. as nurses, the conference planning committee and rno board of directors realize that it is critical to keep new cases of covid as low as possible; thus, we are following guidance from the centers of disease control and prevention to limit unnecessary travel. furthermore, many of our presenters and those attending the conference have links to academia, where budgets have been stretched. many schools are still not paying travel costs to conferences, which becomes a burden on nurses who want to be part of the international rural nursing conference. although the conference will be different from previous years the planning committee has some exciting events planned and we hope you will attend the conference. the international rural nursing conference will begin with a live, synchronous event on friday, august 6, 2021. this potion of the conference will be a ½ day and our international keynote address will be given by dr. olola oneko. the live event will be followed with several asynchronous concurrent podium sessions and poster sessions, which will be available for a period of time. costs have been lowered this year to encourage as many of you to join us as possible. costs for rno members will be $100, students may attend for $75, and $160 for non-members. if you are not currently a member please join (https://www.rno.org/membership/ ). registration is online journal of rural nursing and health care, 21(1) 2 https://doi.org/10.14574/ojrnhc.v20i2.684 not yet open, but will be coming soon. check for developing details on the rno website (https://www.rno.org/ ). i look forward to seeing you at this year’s international rural conference. microsoft word 445-2749-4-ce.docx online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 2 complexity compression in rural nursing maura c. schlairet, edd, ma, msn, rn, cnl1 1 associate professor of nursing, georgia baptist college of nursing of mercer university, schlairet_mc@mercer.edu abstract a large and increasing body of literature suggests nurses face mounting production pressure related to complexity of patients, systems, and escalating demands from both. this phenomenon is identified as complexity compression and describes an experience wherein nurses are expected to take on additional, unplanned responsibilities while simultaneously satisfying existing responsibilities in a condensed timeframe. rural nursing practice appears as a fitting example of doing more and doing differently in a time-pressured environment. however, the phenomenon of complexity compression has yet to be discussed specifically in relation to rural nursing or from the lens of a rural nursing theory. conceptualization of complexity compression in rural nursing through use of theory may help redefine the true nature of rural nursing practice and promote discussion and collaboration among nurses, administrators, educators, and policy makers in creation of better rural work environments, improved educational opportunities for rural nurses, and robust healthcare outcomes for rural populations. keywords: complexity compression, conceptualization, theory, rural nursing online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 3 complexity compression in rural nursing the work of nursing has been characterized as both ‘doing more with less’ and ‘doing things differently with less’. rural nursing is an apt example of doing more and doing differently in an under-resourced environment. attributes of complexity appear to characterize the nature of rural generalist nursing today (barrett, terry, le, & hoang, 2016). krichbaum et al. (2007) have identified and described production pressure in nursing as complexity compression (cc); but this phenomenon has yet to be explored specifically in relation to rural nursing or from the lens of rural nursing theory (rnt). this discussion explores the phenomenon using long and weinert’s (1989) theory and uses examples from the literature to illustrate the relevance of the phenomenon to rural nursing practice. the purpose is to present a conceptualization of rural nursing practice that more fully captures the realities and challenges of rural practice. although a solution is not the intent of the discussion, it is hoped that this perspective promotes voice and advocacy among rural nurses for improvements in work environments, policy, education, and research to meet the needs of rural residents. the problem and its context rurality nearly half of the global population lives in rural areas (brownlee, 2011). in the united states (us) in 2015, 46.2 million live in nonmetropolitan counties (united states department of agriculture economic research service [usda ers], n.d.). despite these population statistics, no generally accepted definition of rurality exists. moreover, commonly used definitions are imprecise (williams, andrews, zanni, & fahs, 2012). for this discussion, rurality represents an attribute of a place based on individuals’ perceptions of population density, remoteness from urban centers, or abundance of farmland (indiana business research center [ibrc], 2007). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 4 rural nursing rural nursing has been described as fundamentally different from nursing practice in urban settings (jackman, myrick, & yonge, 2012; macleod et al., 2008). long and weinert (1989) define rural nursing as the provision of healthcare by the professional nurse to individuals living in sparsely populated areas. approximately 20% of all nurses live in rural areas. staffing patterns indicate proportionally more licensed practical and vocational nurses are employed per capita in rural settings (rural health information hub, n.d.). complexity compression. there is a large and increasing body of literature suggesting nurses face mounting production pressure related to complexity of patients and systems, and escalating demands from both. evidence of the nursing shortage, an aging population, and increasing numbers of people with chronic illness represent a few of the demands affecting the nursing profession (institute of medicine [iom], 2001; 2004). in the context of nursing care, krichbaum et al. (2007) identify this as cc and describe this as an experience wherein nurses are expected to take on additional, unplanned responsibilities while simultaneously satisfying their existing responsibilities in a condensed time frame. krichbaum et al. (2011) found attributes of cc include: “the work of nursing”, “system factors”, and “personal factors” (p. 19). the work of nursing includes unexpected elements in the workplace directly interfering with the ability of the nurse to carry out her or his work. system factors represent unpredicted elements in the nurses’ work setting, originating in administration/organizational structure affecting the ability to perform nursing responsibilities within a given time period. personal factors are elements emerging from within the nurse’s immediate personal situation (krichbaum et al., 2011). cc in nursing has been recognized as online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 5 important in job satisfaction and patient outcomes (aalto, karhe, koivisto, & valimaki, 2009), patient safety, quality outcomes, and staff satisfaction (schmidt & pinkerton, 2009). in a recent review of the literature, barrett et al. (2016) identified issues in rural nursing practice characterizing attributes of cc as described by krichbaum et al. (2007; 2011). authors suggest these issues result in a need for rural nurses to provide greater complexity of care in community settings. issues included organizational changes, geographic challenges, role definitions, work settings, and human resources. rural nursing theory core concepts and relational statements of long and weinert’s (1989) rnt may provide insight and be useful for nurses reflecting on the attributes of cc in the care of rural populations. a significant assumption associated with rnt is that healthcare needs in rural settings are quite different from those in urban settings. theoretical core concepts identified in relation to health needs of rural residents and rural nursing practice include: “…work beliefs and health beliefs; isolation and distance; self-reliance; lack of anonymity; outsider/insider; and oldtimer/newcomer” (p.113). the theory incorporates three relational statements: “rural dwellers define health as primarily the ability to work, to be productive, and to do usual tasks” (p.120); “…rural dwellers are self-reliant and resist accepting help or services from those seen as outsiders or from agencies seen as national or regional “welfare” programs” (p.120); and “…healthcare providers in rural areas must deal with lack of anonymity and much greater role diffusion…” (p. 120). long and weinert (1989) developed their middle-range rnt based on the belief that needs of rural residents could not be addressed by nursing models developed in urban areas. in a recent integrative review, williams et al. (2012) concluded no one unified theoretic foundation for rural online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 6 research exists to date. rnt allows us to identify specific issues cited in the rural nursing practice literature, consider these through the lens of theoretical core concepts, relational statements, and propositions, and reflect on these as potential exemplars of cc as initially defined by (krichbaum et al., 2007). defensibility the literature provides evidence of cc in rural nursing practice to support a defense of this conceptualization of the realities of the rural work and work setting among nurses. to highlight elements of rural nursing representing cc, this discussion addresses these issues using krichbaum et al, (2007; 2011) attributes of cc. work of nursing the work of nursing includes unexpected elements in the workplace directly interfering with the ability of the nurse to carry out her or his work (krichbaum et al., 2011). the work of nursing across settings has indeed changed with reduced length of stay and increased patient acuity levels (iom, 2011). such change translates to a demand for nurses to take on new and/or expanded roles in care coordination and preventive care (health resources and services administration [hrsa], 2014). examples such as greater variability in patient census and acuity levels in rural healthcare settings can slow the rate at which rural nurse come to recognize patterns and cues for similar caregiving situations (seright, 2011). expert generalist. the scope of rural practice requires nurses to be comfortable within the role of expert generalist (knight, kenny, & endacott, 2016) due to limited resources (chipp et al, 2011), workforce shortages (brewer, kovner, greene, & cheng. 2009), staffing patterns (bonnel alonzo, conejo, & heinze., 2009), slow hiring, and layoffs (american hospital association online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 7 [aha], 2011). in rural nursing the expert generalist must be flexible, possess a broad knowledge base (montour, baumann, blythe, & hunsberger, 2009), assume additional responsibilities that are traditionally beyond the professional role (keane, smith, lincoln, & fisher., 2011), and develop an expanded scope of practice (knight et al., 2016). role diffusion (barrett et al., 2016) of this sort also requires clinicians have a knowledge base and clinical ability applicable to a range of ages, cultures, and pathophysiological conditions that may occur in rural clinical practice encounters. rural nurses must possess unique competencies and expertise to meet the needs of rural populations. among rural patients, the nurse may be the first and only point of contact with the healthcare system (aha, 2011; international council of nurses [icn], n.d.). for example, the preference for independent decision-making about health and healthcare among rural residents’ results in the rural nurse managing more crises than urban peers (bushy & leipert, 2005). rural nurses are forced to function in a more independent generalized fashion when they are required to “float” to a variety of clinical areas representing significant diversity in patient age, acuity, and specialty practice (hurme, 2009; molinari, jaiswal, & hollinger-forrest, 2011). in addition, practicing public health principles is an expectation of rural nursing practice (bennett, 2009). cultural differences. a cultural environment may include differences in traditions, customs, and value/belief systems of the family and community related to health, injury, and illness (world health organization [who], n.d.). values and culture affect illness recognition, healthcare seeking, attitude toward clinicians, and decision-making about health and healthcare (nelson, pomerantz, howard, & bushy, 2007). a larger proportion of patients in rural healthcare settings are affected by regional customs and community practices; thus, cultural health and healthcare values exert a online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 8 more significant influence in rural nursing practice (nelson et al., 2007). as such, rural nurses must possess unique skills to cope with coexisting cultural systems of healthcare (grant, haskins, gaede, & horwood, 2013). although connectedness with community is the foundation for patients’ trust in nurses and nurses’ accountability to patients (baernholdt, mowinski jennings, merwin, & thornlow, 2010; conger & plager, 2008), connections with a community may not be easy for nurses in rural settings. rural populations sometimes view healthcare professionals as ‘outsiders’ (baernholdt et al., 2010; chipp et al., 2011). however, connectedness is an important element in culturally relevant, quality care, and has been identified as a unique, additional quality indicators associated with rural culture (baernholdt et al., 2010). vulnerable population. healthcare providers and policy makers recognize the challenges inherent in providing care to vulnerable populations (aha, 2011) and rural residents meet many of the conditions for vulnerability. rural populations are older, less affluent, less educated, and have less access to social programs and health services (national rural health association [nrha], 2013). health disparities for this population include increased functional limitations, higher mortality rates (agency for healthcare research and quality [ahrq], 2013), poorer health outcomes, and higher morbidity rates (australian institute of health and welfare [aihw], 2012). in the us, this population is at a greater risk of being uninsured or under-insured (us department of health and human services [usdhhs], n.d.,a). rural households have higher rates of chronic disease, disability, and mortality (jones, parker, ahearn, mishra, & variyam, 2009). rural residents more commonly face hazards on a day-to-day basis related to natural hazards, high physical-risk activities, and excessive travel distance (severo, et al., 2012; veitch, 2009). online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 9 professional isolation. professional isolation is a unique challenge in rural nursing (paliadelis, parmenter, parker, giles, & higgins, 2012; williams, 2012). inherent in rural isolation is the notion of being distanced from some aspect of the profession (i.e., technology, expertise, education, etc.) or lacking some element necessary to the professional role. in a review on professional isolation among rural nurses, williams (2012) found the concept of isolation frequently cited. professional isolation contributes to uncertainty/doubt in provision of safe/effective care (petrie, 2011), competence problems (williams, 2012), performance appraisal problems, inability to use training/qualifications to the full extent, and nurse retention problems (o’donnell, jabareen, & watt, 2010). systems system factors represent unpredicted elements in the nurses’ work setting, originating in administration/organizational structure affecting the ability to perform nursing responsibilities within a given time period. evidence suggests up to 40% of the nurse’s time is occupied in satisfying the ever-growing demands of the healthcare delivery system and is not associated with direct care-giving (hurst, 2010; westbrook, duffield, li, & creswick, 2011). institutional work processes burden rural nurses and have negative implications for patient safety and nursing practice (mackinnon, 2010) and problems in nurses’ work environment have been described (robert wood johnson foundation [rwjf], 2009). nurse staffing. a well-known element contributing to cc relates to the current nursing shortage. the ratio of healthcare providers to residents in many rural areas is poor (grobler et al., 2009). this shortage is a significant global issue (campbell et al., 2013) with rural areas in developing online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 10 countries tending to be the most underserved regions (lea et al., 2008). a comparison between per capita rates of nurses to residents shows a shortfall in rural settings (85.3 nurses per 10,000 rural residents vs. 93.5 nurses per 10,000 urban residents). in addition, rural health professions shortage counties outnumber similarly designated urban counties with a similar designation by a ratio of 2 to 1 (usdhhs, 2011). rural healthcare also suffers from problems with staff retention (paliadelis et al., 2012). new nurse turnover rates may be as high as 60% for rural nurses (brewer et al. 2009). professional isolation (williams, 2012), viewing the job as stressful (dotson, dave, & cazier, 2012), and conflicting nurse-hospital values (bragg & bonner, 2015) have been cited as inhibitors to rural nurse retention and recruitment efforts. although the affordable care act created several programs to help address the rural hospital workforce shortage, programs to retain existing nurses in rural areas were not included in the reform effort (aha, 2011). technology and workforce development. technology acumen and an ability to approach nursing practice from an evidentiary basis are essential for autonomous practice, quality patient outcomes, and building the rural healthnursing workforce. yet, nurses in rural settings may experience barriers to technology (fairchild et al., 2013; koessl, 2009). for example, many rural communities have little or no access to the internet and minimal information and communications technology experience (iom, 2005). rural hospitals lag behind urban hospitals in health technology use (iom, 2005; rhrc, 2009). as of 2008, less than 3% used an electronic health record with computerized provider-orderentry capability (mccullough, casey, & moscovice, 2010). despite the push to develop a nursing workforce that assumes individual responsibility to seek out the best available evidence when making clinical decisions, some findings suggests online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 11 novice rural nurses show a preference for collaboration with co-workers over other resources (i.e., policy books, decision trees, etc.) in clinical decision-making (seright, 2011). adherence to evidence-based guidelines is lower in rural hospitals (goldman & dudley, 2008). additionally, nurses in rural settings may experience barriers to evidence-based practice utilization (koessl, 2009). for example, professional development and continuing education opportunities to build the rural health nursing workforce in these areas may be difficult for rural nurses to obtain due to lack of time, a dearth of available programs (jukkala, henly, & lindeke, 2008), and institutional structure and work processes (mackinnon, 2010). in some situations, subsequently, rural nurses may have difficulty meeting state mandated requirements to maintain licensure (mccoy, 2009). along with evidence-based practice, other essential workforce development needs for rural nurses have been identified and include horizontal-violence, self-empowerment, self-reflection, (fairchild et al., 2013). the very nature of these needs may present as barriers as they are sometimes viewed as “intangibles” (fairchild et al., 2013, p. 368) and are dismissed by administration in deference to issues that are more easily tracked in databases (i.e., quality of care). frequently rural nurses believe they are peripheral to the decision-making process that and issues of concern to them are not understood or supported by administrators (miskelly & green, 2014; paliadelis, et al., 2012). administrative disconnect. disconnects between leaders and staff members in healthcare settings have been reported to be associated with unhealthy work environments and perceptions of non-authentic leadership practices (institute for healthcare improvement [ihi], n.d.). evidence suggests a divide between hospital administrators and clinicians related to organizational vision and focus in rural healthcare settings (fairchild, ferng, & zwerner, 2015). mackinnon (2012) used institutional online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 12 ethnography for exploring the social and institutional organization of rural nursing work experiences and identified a disconnect between administrative and nurse emphases in relation to provision of healthcare. findings suggested an institutional or administrative focus on efficiency and cost savings and rural nurses’ focus on ‘safeguarding’ patients assigned to their care (mackinnon, 2012). although rural nurses advocated for safety standards to protect patients, management’s “efficiency discourse” (mackinnon, 2012, p. 264) failed to acknowledge rural nurses’ understanding about local variations in need for nursing care in rural settings. personal personal factors are described as those elements emerging from within the nurse or the nurse’s immediate personal situation (krichbaum et al., 2011). approximately 16% of us nurses live in rural areas (ana, 2014). most nurses working in rural settings report a rural background or upbringing (dalton, routley, & peek, 2008; daniels, vanleit, skipper, sanders, & rhyne, 2007) and almost 92% of nurses in rural work settings are white, compared to 73% of nurses employed in urban settings (ana, 2014). the ana (2014) reports the average age of a rural rn is 44.9 years, compared with 44.6 years for urban rns. compared with urban counterparts in the us, the rural nursing workforce is nearer to retirement (national advisory committee on rural health & human services [nacrhhs], 2010). choice of a rural generalist role is often influenced by life experience and perceptions of convenience (molinari et al., 2011). nurses in rural practice are less likely to work for a hospital (ana, 2014) and more likely to work in community/public health settings, extended care settings/nursing home, or in ambulatory care (skillman, palazzo, keepnews, & hart, 2007). evidence suggests mean annual salaries are higher for rural nurses who commute out to larger rural or urban work settings and this “out-commuting” was seen more frequently among nurses online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 13 living in economically stressed rural communities (skillman, palazzo, doescher, & butterfield, 2012). educational preparation for practices differs between rural and urban nurses with rural nurses significantly less likely to acquire a baccalaureate degree or additional nursing degree (bigbee, otterness, & gehrke, 2010; newhouse & morlock, 2011). role boundary issues. nurses working in rural settings often have deep roots within their communities and multiple levels of personal contact with patients (baca, 2011; barrett, terry, le, & hoang, 2015); thus, boundaries between nurses’ work related roles and personal lives are ill-defined (bushy, 2003). amplified social connections within the community and a perceived high level of visibility within the rural community makes rural nursing different from urban nursing (bushy 2002; scharff, 2010; winters & lee, 2010). this notion of lack of anonymity for nurses in rural practice is well described (swan & hobbs, 2016) and may lead to stress for rural nurses (nelson et al., 2007). advance practice nurses in rural settings report that organizational structure contributes to role boundary concerns (cant, birks, porter, jacob, & cooper, 2011). other dynamics drive boundary issues. baca (2011) describes a dual relationship in rural practice wherein the nurse is both clinician and friend or provider and family member. boundary issues identified in rural settings also comprise threats to confidentiality, resource allocation issues (nelson et al., 2007), and conflicting demands between personal and work requirements (hounsgaard, jensen, wilche, & dolmer, 2013). stress. stress is common among rural healthcare providers (barrett et al., 2015; newman & berens, 2010) and the international literature describes some unique stressors for rural nurses, beyond stressors identified among urban counterparts (lenthall et al., 2009; paliadelis et al., online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 14 2012. occupational stress among rural nurses has been attributed to hazardous situations in the wards (jondhale & anap, 2013), emotional exhaustion (opie et al., 2011), and occupational violence (barrett et al., 2015; lenthall et al., 2009). change process. the change process is rarely easy; but the rural healthcare setting introduces additional challenges for the nurse. change may be viewed by rural residents as imposed from outsiders or as an agenda that is “not for us” (macken-walsh, 2009, p. 15). the importance that rural residents ascribe to the context of the community (i.e., community based networks, conventions, and social norms) can be a barrier to change in rural settings (macken-walsh, 2009; sleet & gielen, 2015). expected challenges inherent to the change process are further heightened in the rural setting due to isolation (farmer, dawson, martin, & tucker, 2007). even the pace of change has been found to be affected by pressures associated with living in smaller communities (farmer et al., 2007). discussion revealing complexity compression through theory key and related concepts of rnt are useful in revealing the phenomenon of cc in rural nursing practice using examples from the literature. rural dwellers view health as the ability to be productive and perform the usual work role (lee & mcdonagh, 2013; long & weinert, 1989; winters, 2013). this functionality perspective (molinari & guo, 2013) may create cc for rural nurses as they work to provide interventions that are unlikely to be embraced such as wellness and health promotion education or preventive treatments (aha, 2011; ahrq, 2013, aihw, 2012; jones et al., 2009; nrha, 2013). downstream, this rural view of health may further contribute to cc in the provision of nursing care if rural dwellers delay needed healthcare or online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 15 arrive with acute illness on initial presentation (aha, 2011; ahrq, 2013, aihw, 2012; jones et al., 2009; nrha, 2013; seright, 2011). the related concept of isolation in rural nursing (long & weinert, 1989; winters, 2013) contributes further to understanding the phenomenon of cc in practice. professional isolation, or reduced communication and interaction (lee, winters, boland, raph, & buehler, 2013), is a unique challenge in rural practice (paliadelis et al., 2012; williams, 2012). professional isolation is associated with a variety of negative outcomes to include feelings of doubt in the provision of care, concerns about professional competence, and failure to retain nurses in the clinical setting (o’donnell et al., 2010; petrie, 2011; williams, 2012). these outcomes would drive cc in rural nursing practice by creating additional, unplanned responsibilities for nurses. one example would be the need for significant network formation (rygh & hjortdahl, 2007) to mitigate issues associated with distance from some needed aspect of the profession or element necessary to the professional role. certainly, this task would be an added, additional, responsibility to be performed by the rural nurse while simultaneously satisfying existing responsibilities. in addition, the recognized shortfall of nurses in rural settings (paliadelis et al., 2012; usdhhs, 2011) could be compounded by a failure to retain nurses in rural practice associated with professional isolation (o’donnell et al., 2010) and worsening cc among those nurses who remain in rural practice. as a construct in the rural setting, ‘distance’ affects healthcare at many levels. for example, distance from the best possible evidence (fairchild et al., 2013; goldman & dudley, 2008) and subsequent clinical decision-making based on proximity and collaboration with rural coworkers (seright, 2011) could lead to cc through unanticipated clinical outcomes. individual efforts of rural nurse to build evidence based practice acumen through continuing education online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 16 could add to cc given a dearth of available resources in rural settings (jukkala et al., 2008; mackinnon, 2010). in rural practice, nurses believe issues of concern to them are distant or peripheral to the administrative decision-making process (miskelly & green, 2014). in such a dynamic, cc can occur when nurses are required to cope with unplanned responsibilities that unfold in settings configured by healthcare administrators that fail to acknowledge nurses’ tacit understandings of rural patients’ needs (mackinnon, 2012). rural residents are self-reliant (long & weinert, 1989) and may turn inward to their own resources for needed healthcare rather than engaging with formal care systems (lee et al., 2013). folk remedies, healing practices, and cultural systems of healthcare exert a significant influence on rural nursing practice (molinari & guo, 2013; nelson et al., 2007). for example, complementary and alternative medicine use among rural dwellers is high and is widely integrated into rural social and health networks (wardle, lui, & adams, 2012). this may have negative ramifications for the provision of care in the form of cc. additional complexity is introduced into the system as the rural nurse needs keen knowledge and unique skill to cope with these additional demands (grant et al., 2013) of these informal systems. rural nurses are often as outsiders or newcomers by rural dwellers (long & weinert, 1989; lee & mcdonagh, 2013). rural dwellers use these views of their environment to guide interactions and relationships (long & weinert, 1989); thus, nurses may not be accepted (baernholdt et al., 2010; chipp et al., 2011). acceptance is an important element in understanding rural community expectations and fulfilling clinicians’ responsibilities to the community (molinari & guo, 2013). such perceptions appear relevant to cc in rural nursing practice. for example, nurses may take on additional, unplanned responsibilities as they attempt to access privileged information and informed networks required in providing care. additional online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 17 effort may be required in situations that necessitate awareness of implicit assumptions and unique lay resources. the rural nurse, in working to earn the power that is embedded in true acceptance, may expend significant effort. a related concept that is part of modern healthcare, change, may also be perceived by rural dwellers as imposed from outsiders (macken-walsh, 2009). recognizing the importance rural dwellers ascribe to community context (sleet & gielen, 2015); nurses could expect to experience cc when implementing change efforts. rural nurses have a limited ability to preserve a private life (long & weinert, 1989) as they embody dual roles (molinari & guo, 2013) of clinician and friend. the loss of anonymity in the rural caregiving dynamic (long & weinert, 1989; swan & hobbs, 2016) may create cc as the nurse manages additional tasks associated with threats to confidentiality, resource allocation among residents meeting criteria for vulnerability (ahrq, 2013; aihw, 2012; nrha, 2013; usdhhs, n.d.,a), managing stress (nelson et al., 2007), and coping with unplanned responsibilities stemming from role boundary issues (cant et al., 2011). stress from other sources among rural nurses (barrett et al., 2015; jondhale & anap, 2013; opie et al., 2011) could further compound cc through nurse turnover, and subsequent burdening of nurses who remained in the rural settings with additional, unplanned responsibilities. rural nursing practice has been described as a generalist role (molinari & guo, 2013) with specialists’ knowledge (molinari & guo, 2013). this expertise is required in rural practice (knight et al., 2016) and is further evidence of nurses assuming additional responsibilities in rural practice (keane et al., 2011) as aligned with notions of cc. the related concept of role diffusion (long & weinert, 1989; 2013; molinari & guo, 2013) in rural practice adds to cc as nurses are expected to possess additional knowledge and skill applicable to a range of populations, cultures, and conditions (barrett et al., 2016) so that they can function online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 18 independently when ‘floating’ to a variety of clinical settings (hurme, 2009; molinari et al., 2011). attributes of complexity compression krichbaum et al. (2011) identified work, system, and personal attributes and noted how these interfered with the ability of the nurse to carry out work and affected the ability to perform nursing responsibilities within a given time period. this was described as cc in nursing and defined as an experience wherein nurses are expected to take on additional, unplanned responsibilities while simultaneously satisfying their existing responsibilities in a condensed timeframe (krichbaum et al., 2007). in the current discussion, use of the key and related concepts of rnt (long & weinert, 1989) to consider examples from the literature promoted identification cc in rural nursing practice that exemplified all three attributes krichbaum et al. (2011) describe as the underlying structure of the experience of cc. this conceptualization of cc in rural practice aligns with findings from a recent review of the literature on issues and challenges experienced by rural generalist nurses (barrett et al., 2016) that describes additional, unplanned responsibilities and pressures on nurses. conclusion rural nursing theory (long & weinert, 1989) did allow for identification of specific issues cited in the rural nursing practice literature, consideration of these through the lens of theoretical key concepts and related statements, and conceptualization of this as cc as defined by (krichbaum et al., 2007). molinari and guo (2013) call for more testing of rnt to understand the rural environment, the work of the rural nurse generalist, and needs of rural online journal of rural nursing and health care, 17(2) http://dx.doi.org/10.14574/ojrnhc.v17i2.445 19 dwellers. consideration of cc in rural nursing in unison with reflection on rnt may ultimately help redefine the true nature of rural nursing practice. certainly, cc affects all nurses (krichbaum et al., 2007). scharff (1987) opined the core of rural nursing practice does not differ from urban nursing. it remains important, nonetheless, to consider rural nursing in particular as potentially consistent with cc based on rnt (long & weinert, 1989) and existing literature. this conceptualization of rural nursing practice has not previously appeared in the literature, although studies suggest a number of unique issues experienced by rural nurses that differ significantly from their urban counterparts (paliadelis et al., 2012) and rural nurses’ consistent description of the complex nature of their work (barrett et al., 2016; knight et al., 2016). cc in nursing practice will not disappear (weydt, 2009). if the realities of rural nursing can be better understood through the lens of cc and a consideration of rnt, what are the implications of this understanding? if cc is consistent with rural nursing practice, an understanding of this should promote significant discussion and collaboration among nurses, administrators, educators, and policy makers in creation of better rural work environments and improved educational opportunities for rural nurses to support delivery of quality services and improvement in health outcomes among rural residents. references aalto, p., karhe, l., koivisto, a.m., & valimaki, m. 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(n.d.). health impact assessment: determinants of health. retrieved at http://www.who.int/hia/evidence/doh/en/ microsoft word 36-709-5-le (2).doc online journal of rural nursing and health care, 12(1), spring 2012 3 my health companion©: a low-tech personal health record can be an essential tool for maintaining health clarann weinert, sc, phd, rn, faan 1 shirley cudney, ma, rn 2 1 professor emerita, montana state university, college of nursing, cweinert@montana.edu 2 associate professor (retired), montana state university, college of nursing, scudney@montana.edu abstract objective: to report the initial evaluation of a personal health record (my health companion© (mhc©) developed to help individuals track, maintain, and appropriately communicate health information. design and sample: data were examined from three rural independent studies in which mhc© was used: women to women (n = 94); enhancing self care (n=41); and health enhancement for rural elderly (n=33). measurements: tools were the perceived self-efficacy in interacting with healthcare providers (peppi) scale and research team-generated questions related to the level of use, helpfulness in health maintenance activities, suggestions for improvement, and whether or not the mhc© would be recommended to others. results: the peppi scores indicated that use of the mhc© contributed to enhanced perceived self-efficacy and answers to questions suggested the mhc© was helpful in promoting health maintenance activities and would be recommended to others. valuable suggestions for improvement were offered by the participants. the ratings of level of use of the mhc© were relatively low. conclusions: by documenting key health information in a relatively simple, organized fashion, individuals can collect, track, and share health information that will promote prevention or early identification of health problems and foster productive partnerships with their healthcare providers. keywords: personal health record, self-care management, chronic illness, client/provider relationships, rural my health companion©: a low-tech personal health record can be an essential tool for maintaining health individuals can take a more active role in the management their healthcare by using personal health records (phr), a type of documentation which allows them to access and coordinate personal health information and share it with those who need it (moreno, peterson, bagchi, & ursin, 2007). the potential impact on one’s healthcare of using a phr is reflected in the following statement of one rural woman’s experience: the [personal health record] was really a great help to me this week. i had an appointment with my medical doctor on monday….i had my book with medications and all in it and added the test results from this visit. for the first time i had my questions ready and noted online journal of rural nursing and health care, 12(1), spring 2012 4 all we discussed. i felt so empowered to be organized and prepared for once.... i love this new feeling of gaining control (weinert, cudney, & kinion, 2010). this explicit description is an example of how one rural woman used a phr and took an active role in monitoring her health and healthcare. by sharing this record, she gave her healthcare providers a valuable insight into her personal health story and became a partner in care with her provider. this partnership is essential for individuals to receive the most effective, efficient care possible (holman & lorig, 2000). an important task is for the individual to assume the responsibility for keeping the phr accurate and complete (american health information management association, 2005). the sense of empowerment the woman felt could be attributed to her acceptance of responsibility for managing her own condition and ability to solve her own problems with information, but not orders, from her healthcare provider. empowerment implies that the choices made in everyday living with chronic illness are informed ones, grounded in the individual’s emotions, thoughts, values, goals, and other psychosocial aspects of living with a chronic condition (funnell et al., 1991). in doing so, chronically ill individuals become experts about their own lives (bodenheimer, lorig, holman, & grumbach, 2002). thus, personal health records combine knowledge and data which help individuals to become active participants in their own care (tang, ash, bates, overhage, & sands, 2006). among the benefits of phrs were the ability to track clients’ health conditions in conjunction with their healthcare providers, and lowered communication barriers between individuals and care providers (tang et al., 2006). the latter is a plus because the role of the healthcare provider becomes that of a teacher and partner, and the role of the individual evolves into that of a reporter of the trends and tempo of his/her health (lorig & holman, 2000). a phr includes health information managed by the individual as opposed to the clinician’s record of patient encounter–related information, such as a paper chart or a computer-based patient record. although there are not good data currently available that quantify the current use of phr systems, tang and colleagues (2006) believed that the majority of consumers using a phr today use one that is integrated with the provider’s electronic health record in some way. over time, the ultimate goal is an electronic environment in which an individual’s health information can flow seamlessly among systems used by authorized health professionals and the individual, when s/he authorizes such sharing (tang et al., 2006). until that time, low-tech approaches to maintaining and utilizing a phr can play an important role in maximizing the communication between individuals and health care providers. this maximum communication is of particular importance in rural areas because accessing quality health care is impacted by scarcity of providers, limited dissemination and application of up-to-date health care information, long distances, and dangerous travel conditions. leaving home to keep a healthcare provider appointment often involves much advance planning to cover farm or ranch responsibilities such as animal care, meal preparation for workers, etc. it is important that such an effort is not wasted by an unproductive office visit such as was reported by this rural woman: the doctor was running behind schedule...my appointment was at 10 a.m. and i saw him at 11:30…but then the doctor (who was seeing me for the first time) was in a hurry to get through my visit. so 10 minutes later i was going out the door (weinert, whitney, hill, & cudney, 2005). online journal of rural nursing and health care, 12(1), spring 2012 5 development of my health companion ® recognizing the merits of phrs and in response to the frustrations related to nonproductive relationships with the health care system and providers, expressed by participants in our program of rural research, a low-tech, paper/pencil personal health record, my health companion © was developed. the development tasks, as described in detail in an earlier article (weinert, cudney, & kinion, 2010) were: defining the content, establishing an appropriate reading level for the mhc © , and planning participant orientation to the mhc © . the resulting mhc © was used in three rural research studies during which we gathered data on its use and utility. purpose the purpose of this paper is to report the results of the initial evaluation of the my health companion © (mhc © ) as evaluated in a rural environment. the questions to be answered were: how much was the mhc © used? did it enhance confidence in communication with healthcare providers? was the use of the mhc © helpful in achieving health maintenance activities? would the mhc © be recommended for use by others? methods evaluation data were gathered from three different rural research studies that utilized three separate populations: women to women (wtw) project; enhancing self care (esc); and health enhancement for rural elderly (here). all three studies were approved by the university institutional review board for the protection of human subjects. women to women project goal. the goal of the women to women (wtw) project was to use telecommunication technology to provide information and mutual support to middle-aged rural women living with chronic illness. it was expected that their adaptation to chronic illness would be enhanced. sample. participants were rural women with a chronic health condition; 93.2 % were caucasian; and 82.2 % were married. the mean age was 56.2 years with an average education of 14.7 years and a modal income of $35,000 to $44,999. they resided in rural areas of: montana, north dakota, south dakota, wyoming, washington, oregon, nebraska, idaho, and iowa. forty-six lived on farms or ranches, 22 lived in rural areas but not on a farm/ranch, and the remaining 50 lived in small rural towns of less than 12,500 population. design. the basic design was to randomly assign participants to either an eleven week computer intervention that provided a virtual support group and health information or to a control group. intervention participants completed online health teaching units and exchanged messages of support and information in asynchronous online forums. these private discussion groups gave the women the opportunity to freely voice their experiences, concerns, and frustrations related to living with chronic illness in relatively isolated situations (weinert, whitney, hill, & cudney, 2006). based on these comments, the my health companion © was developed, placed in a 3-ring binder, and mailed out for use by the participants in the most recent phase of the project (weinert et al., 2010). evaluation. the intervention group (n = 118) had the use of the mhc © for six months. ninety-four (n = 94) provided evaluation information at the end of the intervention (11 weeks) and three months after the completion of the intervention (24 weeks). online journal of rural nursing and health care, 12(1), spring 2012 6 enhancing self care study goal. the enhancing self care (esc) study was designed to reach a group of women who had previously participated in wtw, prior to the development of the mhc © . the aims were to: a) assess the health promotion, risk behaviors, and psychosocial health of rural farm/ranch women and b) assess the long-term efficacy of the women to women intervention, and c) evaluate the mhc © . sample. the 63 women had a mean age of 59.3 years, with 14.7 years of education; 93.7% where caucasian, with 71.4% married, and a modal income of between $25,000 and $34,999. participants resided in idaho, montana, north dakota, south dakota, and wyoming with 36.5 % living in small towns, 33.3% on farms/ranches, and 22.2 % in rural areas. design and evaluation. participants completed an initial mail survey and were sent the mhc © to use for one year—there was no computer component in this study. at the conclusion of the year, forty one (n = 41) of the participants evaluated its usefulness in managing their health conditions in a second mail survey. health enhancement for rural elders goal. the health enhancement for rural elders (here) project was conducted to encourage personal responsibility for overall self-care management by older rural residents. this series of workshops based in four rural senior centers was launched with the goal of improving the health literacy, health care decision making, and self-care management of rural seniors. sample. a total of 54 participants (women 81% and men 19%) had a mean age of 72.5 and average education of 13.6 years, were primarily caucasian (98.5%), with a modal annual income of over $35,000. thirty nine (57.4%) were married, 28 (38.2%) were widowed, and most 48 (70.6%) lived in small rural towns in eastern montana. design and evaluation. individuals participating in the here project were recruited to use the mhc © and completed an initial mail survey. they were sent the mhc © to use for six months, and 33 responded to a second survey drafted to evaluate the value of the personal health record. measures to assess the effectiveness of the mhc © , both quantitative and qualitative data were gathered. quantitative data were in the form of responses to open-ended questions and comment sections in the written questionnaires, as well as unsolicited references to the mhc © in 22 messages exchanged among the women in the wtw online support groups. questions using likert-like scales constituted the quantitative data. it should be noted that each of the three studies were multifaceted and not solely focused on the evaluation of the mhc © . women to women project measures four questions were developed and administered at the end of the 11-week intervention to address the usefulness of the mhc © in managing chronic illness, preparing for visits with healthcare providers, strengthening relationship/partnership with providers, and organizing and tracking personal health information. each was rated on a scale of 1 not useful at all to 6 extremely useful. after the women had the mhc © for six months, a more in-depth evaluation was included in the 24-week questionnaire that included the perceived efficacy in patient-physician interactions online journal of rural nursing and health care, 12(1), spring 2012 7 questionnaire (peppi) (maly, frank, marshall, dimatteo, & reuben, 2003) and 11 investigator developed items. the 10 item peppi is a measure of clients’ confidence in their ability to communicate with physicians, e.g., “how confident are you in your ability to get doctors to pay attention to what you have to say?”, “to make the most of your visits with your doctors?, etc.” the items were scaled from 1 not at all confident to 5 very confident. internal reliability coefficient for the peppi was .91. a set of 11 questions was developed which focused on the helpfulness of the mhc © in achieving health maintenance activities. the stem was, “please rate the helpfulness of my health companion © in achieving the following activities that relate to maintaining your health,” using a scale of 1 not helpful to 5 very helpful. examples of health maintenance activities assessed were: tracking health care visits, engaging in preventive care, tracking laboratory tests and medications, and preparing for health care visits. in addition, the question, “in terms of my health, my health companion © has been” 0 not helpful to 10 very helpful, was asked along with an opportunity to provide written comments. also included was the open-ended question: “we are interested in knowing how women are using mhc © and what suggestions you have for using the booklet.” additional qualitative data were gleaned from unsolicited computer online forum messages posted throughout the intervention period. these messages were examined to determine perspectives on the role of the mhc © in the maintenance of health and client/healthcare provider partnerships. enhancing self care measures after a year of using the mhc © , the women in the esc study evaluated it using the 11 helpfulness questions, the peppi, the 4 usefulness questions, and the suggestions for use and adaptation question. additional questions were: “overall, how much did you use the my health companion © over the past year? scored on a scale of 1 never used it at all to 6 used it a lot, and “would you recommend the mhc © to others?” using a scale of 1 would not recommend to 6 would definitely recommend. health enhancement for rural elders measures participants had the mhc © for six months. they completed an evaluative survey containing all of the questions that were described above for the esc project. for each of the three studies, the mhc © evaluation questions were included within the overall study assessment. the evaluation of the mhc © evolved over time and not all questions were identical across the three studies, (see table 1.) results overall use and helpfulness of the my health companion © of the 118 participants in the women to women project, 93 (71%) reported that they used the mhc © over the six-month trial period. of those who used the mhc © , the overall rating for helpfulness was 7.10 on a scale of 1 to 10. of those who did not use the mhc © , 10 gave their reasons: 5 already had a system of their own; 3 rarely visited a doctor; 1 forgot to use it; and 1 reported her care provider was not interested. the overall helpfulness was not rated in the esc or here studies online journal of rural nursing and health care, 12(1), spring 2012 8 table 1 instruments / questions used for mhc © evaluation with scoring ranges evaluation measures = team-generated questions; peppi = perceived efficacy in patient-physician interactions questionnaire; computer postings = unsolicited comments made related to mhc © in computer support group; months = time point for data collection. in the esc, 41 of 63 participants (65%) reported using the mhc © over the one-year trial. the mean rating by those who used the mhc © for the question, “overall, how much did you use the my health companion © over the past year?” was 2.46 on a scale of 1 to 5. of the 54 participants in the here project, 33 (61%) reported using the mhc © . those who used had a mean rating for amount of overall use of 2.15. perceived self-efficacy in interacting with healthcare providers (peppi) the participants’ confidence in their ability to understand information from, and communicate information to their healthcare providers was measured by the peppi – a higher score indicated higher confidence. in the wtw project, the peppi was administered at baseline to both the intervention and the control groups. the baseline scores for the 94 users of the mhc © was 39.39 (sd = 7.22). the control group’s baseline score was 37.69 (sd = 8.71). after six months, the intervention groups’ confidence score increased significantly (p = .005) to 41.40 (sd = 5.96). the score of the control group increased to 38.71(sd = 8.45), but was not significant. a modified peppi, with a 1 to 4 scoring range, was used in the esc study. the group was divided into those who used the mhc © (n = 41) and those who did not (n = 14). initially, their scores were not significantly different. the scores for those who used the mhc © increased (p = .096) from 33.56 (sd = 6.88) to 34.71(sd = 5.61) and the scores for those who did not use increased (p = .475) from 32.14 (sd = 7.02) to 33.14 (sd = 7.26). the modified peppi was used in the here project. of the 68 people who began the study 54 (79.4%) returned the second questionnaire which contained the mhc © evaluation. scores were divided into those who reported that they used the mhc © (n = 33) and those who did not (n = 21) and were not significantly different initially. the scores for users increased nearly significantly (p = .074) from 33.00 (sd = 5.24) to 34.42 (sd = 4.86), and the scores for those who did not use increased (p = .719) from 35.00 (sd = 5.36) to 35.48 (sd = 4.18). helpfulness in health maintenance activities the wtw data for the 11 questions related to health maintenance activities which may have been influenced by the use of the mhc © were examined. the highest, on a scale of 1-5, were: tracking laboratory tests (4.22), having contact information for your health care provider online journal of rural nursing and health care, 12(1), spring 2012 9 (4.12), preparing questions for health care provider visits (4.11) and reporting symptoms (4.11). when the 11 questions were summed, the overall mean score for those who used the mhc © was 41.63 (sd = 10.50). in the esc study, the health maintenance activities questions were administered at baseline and in the follow-up questionnaire a year later. the three highest were: engaging in preventive care (4.76), reporting symptoms (4.63), and preparing questions for health care provider visits (4.63). at baseline, the mean score for the 11-item total scale for the user group was 48.20 (sd = 6.80), and for the non-user group it was 48.57 (sd = 5.85). the user group scores increased significantly (p = .053) to 49.95 (sd = 4.98) at the one year evaluation. the non-user group scores decreased to 46.57 (sd = 7.23). the same approach was taken with the here study. the highest scores were: reporting symptoms (4.76), keeping track of health visits (4.64), and knowing family history (4.58). at baseline, the mean score on the 11-item total scale for the user group was 43.94, and for the nonuser group, it was 44.24. after six months, the total scale scores for those who used the mhc © increased significantly (p = .000) to 48.67. for those who did not use the mhc © , the scores also significantly increased (p = .001) to 50.24 (sd = 4.52). the rankings given for the relative importance of health maintenance activities by participants in each study (wtw, esc, and here) are shown in table 2. in all three studies, four questions were asked to determine the utility of the mhc © . for wtw, this assessment was made after only three months of exposure to the mhc © , while for the other two studies, this assessment was made following the full use time period. the mean responses on a six-point scale for those who used the mhc © are listed on table 3. table 2 ranks (1, 2, or 3) of importance of health maintenance activities 1 (best) to 3 (least) response to recommendation question participants in the esc and here projects were asked, using a six-point scale, whether they would recommend the mhc © to others. data from only those who used the mhc © were analyzed. the esc women had a mean of 4.88; the here participants had a mean score of 4.48 responses to open-ended questions the responses to the open-ended questions added meaningful insights. suggestions made in response to the question, “do you have changes that you would like to see in the mhc © ?” included a suggestion each from six individuals: (a) addition of a client summary of an annual history of health issues; (b) format changes, e.g., make smaller, add personal sheets; (c) provide convenience items, e.g., envelope for smaller papers, plastic covers for preserving important papers; (d) break down large categories such as hospitalizations into “drs.,” “labs,” “summary of online journal of rural nursing and health care, 12(1), spring 2012 10 last hospital stay”; (e) color code the various segments of the record; and (f) add page for home health care. table 3 score and standard deviation (sd) of usefulness of mhc by project hcp = health care provider, scores range from 1 lowest to 6 highest the value of having all health information in one place was emphasized in the comments as was its acceptance by healthcare providers as an asset in managing treatment. participants cited the mhc © ’s helpfulness: (a) in organizing and tracking health information; (b) as a log for recording symptoms; (c) in formulating questions to ask their healthcare provider; (d) as a resource for care provider visits; and (e) in focusing on their personal health needs rather than on those of others. comments from online messages perspectives on the utility of the mhc © were also seen in the wtw online conversations. women posted 22 unsolicited messages that reflected their views of the mhc © and often validated the questionnaire data. eight mentioned that they were becoming better organized: …the health companion, it's going to help me be more organized too. i learned the hard way many years ago to keep my own records, but this will help me organize them better. a similar number commented on the mhc © as a means of improving communication with their health care providers: just wanted you to know i have been to two doctors (one a heart specialist) and into two hospitals and they were so impressed with my health companion. it is a great asset for doctors and hospitals. thanks. three cited its value in keeping family informed: not only will this all help me, it will help my family if i can't take care of myself. we just have to let those around us know where we are keeping the notebook and we need to keep our information updated. discussion in an effort to determine the efficacy of the mhc © as an aid in helping three populations of rural individuals become more active partners with their healthcare providers in managing their illnesses, various factors were examined. these included level of use: confidence in their ability to communicate information to their healthcare providers; their view of the importance of health maintenance activities and the impact of using the mhc © on these activities; and their perspectives on how the mhc © helped them to manage their health and relate to their providers. online journal of rural nursing and health care, 12(1), spring 2012 11 level of use overall, the mhc © was seen as very helpful by those in the wtw study, but the ratings for level of overall use were relatively low in the esc and here projects. on the surface, this result could seem contradictory. however, it would be helpful in future studies to compare this result with the number of healthcare provider contacts they had during the tenure of the study. a low number of visits could possibly translate into fewer occasions to use the mhc © . should this not be the case, perhaps a closer partnership with and encouragement from one’s healthcare provider and involvement of family would be strategies for enhancing maximal utilization of personal health records. confidence in communicating with health care providers to make the most of their healthcare provider relationships and obtain the necessary information required to maximize their ability to self-manage their illnesses effectively, individuals need a high sense of perceived self-efficacy regarding their ability to do so. therefore, the higher they scored on the perceived efficacy in patient-physician interactions questionnaire (peppi), the higher their perceived efficacy in their partnership with their care provider. the mean peppi score achieved by the rural women in wtw after using the mhc © compared favorably with a group of individuals with peripheral arterial disease (mcdermott et al., 2009). in another study, it was found that women with higher peppi scores were able to benefit more from educational discussions about breast cancer than those with lower scores (thind & maly, 2006) also of interest was the fact that in all three studies reported here, those who used the mhc © increased their peppi scores more than those who did not. based on the peppi data, it was suggested that use of the mhc © contributed to enhanced participant perceived self-efficacy in making the most of their healthcare provider visits. the following comment from one of the women illustrates this capability: i still am soooo thrilled about this health companion! with my short-term memory lapses it comes in handy or when i have troubles finding my words etc., i can just open it up and show it to the doctor. also with all the new people i am seeing now (urologist, pt), i have been just taking the med list out and having the secretary copy it so that i do not have to write it down on the sheet they give me. inherent in this statement is the sense of empowerment that was expressed by another woman earlier in this report. the use of personal health records can empower individuals by helping them become more engaged in their health care through shared information and decision making with their health care providers. the personal health record has the potential to transform the client-health care provider relationship by empowering the individual to play a more central role (ball, smith, & bakalar, 2007). importance in achieving health maintenance activities the responses to the questions related to health maintenance activities that were posed in all three studies (table 2) gave rise to a number of speculations. these are grouped by study. enhancing self care. in the enhancing self care study, prior to and following the year of mhc © use, the top three health maintenance activities as ranked in importance by the participants were engaging in preventive care, reporting symptoms, and preparing questions for healthcare visits. in ranking the engagement in preventive care as the most important factor in online journal of rural nursing and health care, 12(1), spring 2012 12 maintaining and enhancing one’s health, the esc group’s ranking was consistent with walsh and mcphee’s (1992) notion that preventive health behaviors are influenced by the value placed on health by individuals. overall, maintaining and enhancing one’s health was given high priority by the esc group both before and following the use of the mhc © . from these results, it can be concluded that the participants came into the study with a high appreciation for the importance of health maintenance activities that was further enhanced by using the mhc © . as one woman put it, “it [mhc © ] is helpful to remind me i can make a difference and i am in charge of my health.” the low ranking given to building a personal support system was surprising, as this view is contrary to the voluminous psychosocial literature that touts the importance of social support as a key indicator of successful psychosocial adaptation to chronic illness (weinert, cudney, & spring, 2008). one conjecture might be that, as is commonly seen in rural populations, participants may already have developed a support system of family, friends and neighbors (shenk, 1991) and thus put a lower priority on building new networks. health enhancement for rural elderly. the here study responses were consistent with those in the other two studies in rating of reporting symptoms in their top three health maintenance activities, but unique in their other top two choices--keeping track of health visits and knowing family history. as they were an older age group, it is possible that changes in shortterm memory common in the elderly and appreciation for days gone by may have influenced their choices. women to women. for the wtw group, the focus was not on their view of how important each activity was in the maintenance of their health, but upon the helpfulness of mhc © in the achievement of the health maintenance activities. in the rankings of each activity, the three most helped by the mhc © were keeping track of healthcare visits; tracking lab tests, and knowing and having contact information for healthcare providers. given the focus on the utility of the mhc © , these choices could be seen as practical and reasonable in day-to-day encounters with the healthcare system. the relatively high overall mean of the ratings of the 11 activities taken together could indicate that the wtw group considered the mhc © to be very helpful in assisting them to achieve health maintenance/enhancement activities. usefulness of the mhc © participants in the three studies contributed responses to the question, “how useful was the mhc © in managing chronic illness, preparing for healthcare provider visits, strengthening the partnership with healthcare providers, and organizing and tracking health information.” the ratings (table 3) from the wtw participants were notably higher than the responses from the esc and here groups. this may be attributed to the fact that the wtw participants had participated in a health teaching unit focused on the mhc © , as well as having the opportunity to discuss its use and advantages in the online forum. it is of interest to note that, despite the differences in the ratings, the ranking of the usefulness of the four activities was nearly identical for all of the groups. the more specific tasks of organizing and tracking health information and preparing for healthcare provider visits were ranked first and second while the broader implications of using the mhc © , i.e., managing chronic illness and strengthening partnership with healthcare provider, were ranked third and fourth. however, the serviceability of the mhc © as a tool that can be used to help maintain and enhance health was supported by the ratings. further support for the utility of the mhc © was seen in the women’s personal descriptions of their experiences in its use. the following is an online journal of rural nursing and health care, 12(1), spring 2012 13 example of how the mhc © helped one rural woman strengthen her partnership with her healthcare provider: these specific forms really do come in handy....shoot, i have trouble sometimes remembering my meds, that is, to [set] in front of a dr. and spew them out...dah, my mind just flies out the window...but taking this [mhc © ] with me and perhaps making a copy of specific portions to give them, then dating the sheet(s) when given out would be wonderful for both parties. participants’ recommendations participants who were asked whether they would recommend the mhc © to others responded positively, and those invited to offer suggestions for changes offered solid suggestions in the areas of content, format, and presentation. they emphasized the utility of the mhc © as a tool for keeping track of health information and enhancing their shared responsibility for their health with that of their health care providers. limitations and future directions we acknowledge both caveats and strengths. the data came from three different studies, but the sole intent of these studies was not on the evaluation of the mhc © . each was designed to achieve multiple aims in a rural setting, only one of which was an evaluation of the mhc © - which we considered to be important since the personal health record was a new product. further, larger scale focused studies to evaluate the mhc © and the protocol for its use, as well as key factors that may influence the use and efficacy of the mhc © are clearly needed. the three studies were conducted at different time periods and thus the evaluation questions evolved and were worded or focused slightly differently. also, only the esc participants had an entire year to use the mhc ©. likewise, all three studies had relatively small sample sizes. never-the-less, the research team considered the database, from the combined studies, to be rich enough to merit exploration and reporting. further use and evaluation of the mhc © would provide additional essential information that could contribute to determining the mhc © ’s efficacy. conclusion our intent was to report the effectiveness of the my health companion © in helping rural individuals track health information as a means of improving communication with their health care providers, and ultimately, assist them to become active partners in their health care. despite the limitations, it is clear that the health literacy of those who used the personal health record was enhanced as demonstrated in their ability to better self-manage and work with health care providers. it is becoming increasingly clear that assisting individuals in the tracking of their health information is critical. the overall health efficacy of “tracking” behaviors and information has long been demonstrated in programs such as weight watchers. while the mhc © is not the only personal health record available, this beginning evaluation demonstrated that our low-tech personal health record can be an essential tool for maintaining health. the mhc © contributed to the participants’ perceived self-efficacy in becoming active partners in their health care and was a tool that could be used to help them in the maintenance and enhancement of their health, even in a resource-limited rural environment. although more sophisticated e-health records are on the horizon (tang et al., 2006), for the present, this lowtech, paper/pencil personal health record has been shown to be effective. by documenting key health information in a relatively simple, organized fashion, individuals can track and share with their healthcare providers information about their health that will promote prevention or early online journal of rural nursing and health care, 12(1), spring 2012 14 identification of health problems. it behooves healthcare providers to assist clients in their efforts to monitor personal health information by being proactive in showing individuals how to initiate, maintain, and use a personal health record such as the mhc © . acknowledgement women to women project, phase iii: nih/ninr (2r01nr007908-04a1); enhancing self care: nih/ninr (2 r01 nr007908-04a1) and sc ministry foundation; health enhancement for rural elders: usda2008-03860. acknowledgement: elizabeth kinion, edd, rn, apn-bc, faan references american health information management association e-health information management personal health record work group. (2005). the role of the personal health record in the ehr. journal of american health information association, 76(7), 64a-d. [medline] ball, m., smith, c. & bakalar, r. (2007). personal health records: empowering consumers. journal of healthcare information management, 21(1), 76-86. [medline] bodenheimer, t., lorig, k., holman, h., & grumbach, k. (2002). patient self-management of chronic disease in primary care. the journal of the american medical association, 288(19), 2469-2475. [medline] funnell, m., anderson, r., arnold, m., barr, p., donnelly, m., johnson, p., & white, n. (1991). empowerment: an idea whose time has come in diabetes education. the diabetes educator, 17, 37-41. [medline] holman, h., & lorig, k. (2000). patients as partners in managing chronic disease. partnership is a prerequisite for effective and efficient health care. british medical journal, 320(7234), 526-527. [medline] lorig, k., & holman, h. (2000). self-management education: context, definition, and outcomes and mechanisms. palo alto, ca: stanford university. maly, r., frank, j., marshall, g., dimatteo, m., & reuben, d. (2003). perceived efficacy in patient-physician interactions questionnaire. in b. redman (ed.), measurement tools in patient education (2nd ed., pp. 53-55). new york: springer. mcdermott, m., mazor, k., reed, g., pagoto, s., graff, r., merriam, p., & ockene, i. (2010). attitudes and behavior of peripheral arterial disease patients toward influencing their physician's prescription of cholesterol-lowering medication. vascular medicine, 15(2), 83-90. [medline] moreno, l., peterson, s., bagchi, a., & ursin, r. (2007). personal health records: what do underserved consumers want? retrieved from http://www.mathematicampr.com/publications/pdfs/phrissuebr.pdf shenk, d. (1991). older rural women as recipients and providers of social support. journal of aging studies, 5(4), 347-358 tang, p., ash, j., bates, d., overhage, j., & sands, d. (2006). personal health records: definitions, benefits, and strategies for overcoming barriers to adoption. journal of the american medical informatics association, 13(2), 121-126. [medline] thind, a., & maly, r. (2006). the surgeon-patient interaction in older women with breast cancer: what are the determinants of a helpful discussion? annals of surgical oncology, 13(6), 788-793. [medline] http://www.ncbi.nlm.nih.gov/pubmed/16097127 http://www.ncbi.nlm.nih.gov/pubmed/17299929 http://www.ncbi.nlm.nih.gov/pubmed/12435261 http://www.ncbi.nlm.nih.gov/pubmed/1986902 http://www.ncbi.nlm.nih.gov/pubmed/10688539 http://www.ncbi.nlm.nih.gov/pubmed/20118170 http://www.ncbi.nlm.nih.gov/pubmed/16357345 http://www.ncbi.nlm.nih.gov/pubmed/16614883 online journal of rural nursing and health care, 12(1), spring 2012 15 walsh, j., & mcphee, s. (1992). a systems model of clinical preventive care: an analysis of factors influencing patient and physician. health education and behavior, 19, 157-175. [medline] weinert, c., cudney, s., & kinion, e. (2010). development of my health companion© to enhance self-care management of chronic health conditions in rural dwellers. public health nursing 27(3), 263-269. [medline] weinert, c., cudney, s., & spring, a. (2008). evolution of a conceptual model for adaptation to chronic illness. journal of nursing scholarship, 45(4), 364-372. [medline] weinert, c., whitney, a., hill, w., & cudney, s. (2006). chronically ill women's views of health care. online journal of rural nursing and health care,5(2). http://www.ncbi.nlm.nih.gov/pubmed/1618625 http://www.ncbi.nlm.nih.gov/pubmed/20525099 http://www.ncbi.nlm.nih.gov/pubmed/19094152 online journal of rural nursing and health care, 1(2) 29 quality of life, chronic pain, and issues for healthcare professionals in rural communities anita c. all, phd, rn1 juliet h. fried, edd, cve, crc2 debra c. wallace, phd, rn3 1 associate professor, college of nursing, university of oklahoma health sciences center, anita-all@ouhsc.edu 2 professor, department of human services, university of northern colorado, juliet.fried@unco.edu 3 associate professor, college of nursing, university of tennessee abstract the purpose of this pilot study was to examine differences that existed in the perception of individuals with chronic pain concerning quality of life in two groups: (1) a group who had an intervention for chronic pain (2) and a group who had not had any intervention. no existing literature was found that compared any difference in perceptions of quality of life in individuals who had an intervention for chronic pain and those who had not had an intervention for chronic pain. thirty-six individuals' scores on the ferrans and power's quality of life index were analyzed. data analysis revealed that both groups in this pilot study perceived their quality of life as decreased, but no statistically significant differences were found in the perception of either group (t = -1.65, p= .108). although not statistically significant in this sample, the group (n=16) who had received an intervention program reported less perceived quality of life. issues of online journal of rural nursing and health care, 1(2) 30 concern for healthcare professionals in rural communities and ideas for further research are presented. keywords: chronic pain, quality of life, rural healthcare online journal of rural nursing and health care, 1(2) 31 quality of life, chronic pain, and issues for healthcare professionals in rural communities there has been considerable attention paid to understanding the medical, economic, and social effects of chronic pain over the last several years. the complexity of the nature of pain has led to treatment programs that target both the psychological and physical aspects of pain. alternative treatment models that have incorporated behavioral-oriented programs, multidisciplinary pain management programs, and pharmacological and non-pharmacological interventions have been used (tyre, walworth, & tyre, 1994). the purpose of this paper is to present the results of a pilot study on perception of quality of life in individuals with chronic pain, as well as to raise awareness of issues connected to chronic pain and to encourage future research into this area. problem significance chronic pain has affected over 10% of the population worldwide (tota-faucette, gil, williams, keefe, & goli, 1993; williams et al. 1993). clear-cut pathology often cannot be documented (tota-faucette et al. 1993). frequently, causes of pain cannot be fully understood, and this lack of understanding and treatment of chronic pain has continued to be a challenge for healthcare professionals and rehabilitation counselors (ahmedzai, 1995). many sufferers of chronic pain have developed a disabled state characterized by persistent pain that outlasts the normal duration of healing or resolution post injury (williams et al. 1993). approximately 1% of individuals with chronic pain are severely disabled, and have difficulty in coping with the pain and associated psychological and social problems (beck, 1985; jensen & karoly, 1991; jenson, turner, & romano, 1994). online journal of rural nursing and health care, 1(2) 32 definitions of success or failure of treatment have often reflected the agenda and relative values of individuals conducting the evaluation, and not the individual with chronic pain. individuals with pain may define success or failure of the treatment quite differently from program evaluators. an individual may define a substantial reduction in pain severity as success, but a third-party payment source (one type of program evaluation) may choose to focus on whether the individual has returned to gainful employment (turk, rudy, & sorking, 1993). parallels may be drawn when individuals with pain are encouraged only to focus on pain reduction and not take into account any improvements in functional ability, reduction in medication, and mood improvements that have led to greater harmony and satisfaction within the family. no one measure of efficacy is better than another. each measure must be reviewed within the appropriate context. purpose the purpose of this pilot study was to examine differences that exist in the perception of individuals who had received an intervention for chronic pain and those who not in reporting had perceived levels of quality of life. the aim of this pilot study was not to evaluate the type of intervention or the efficacy of the intervention in the treatment of chronic pain. literature review a review of the literature on chronic pain treatment revealed that studies have concentrated on certain types of treatment protocols, return-to-work criteria, and evaluation of outpatient and inpatient programs (cutler, fishbain, lu, rosomoff, & rosomoff, 1994; cutler, fishbain, rosomoff et al. 1994; fishbain et al. 1993; jenson & karoly, 1991; keefe, gill, & rose, 1986; sweet, 1995; turk et al. tyre et al. 1994; williams et al. 1993). no existing literature was found that compared any differences in perception of quality of life between online journal of rural nursing and health care, 1(2) 33 individuals beginning or completing a pain treatment program. the following literature review addressed characteristics of rural communities, characteristics of individuals residing in rural settings, profiles of individuals with chronic pain, treatment of chronic pain, and quality of life. characteristics of rural communities unique to rural communities has been their combination of structural characteristics. structural characteristics have included: (1) population size, (2) population composition, (3) human and economic resources, (4) employment patterns, (5) density norms, and (6) cultural norms (lopez-de fede, 1998; luloff, 1990). it must be remembered that there is no singular rural america. such an assumption would omit important segments of americans. despite a history of dependence on farming and differences in family size, lifestyle and politics; rural communities have changed dramatically over the recent years. changes have occurred due to the influence of increased access to transportation and communication systems, move of rural residents to urban centers, and the move away from an economy based in farming (lopez-de fede, 1998). general disadvantages of living in rural communities have often been centered on lack of access to or isolation from more urban resources. recently, this isolation has been easier to overcome by improved transportation. communities located on or served by high-quality highway systems have better access to healthcare and other services not easily found within the rural community itself (lopez-de fede, 1998; ricketts, johnsonwebb, & randolph, 1999). in addition to differences in rural communities based on the fact of being less populated, the rural population is not evenly distributed across the united states. in 1990 the census reported that the southern region of the united states had the largest proportion of the rural population (29.1%) (bureau of the census, 1994). as reported by online journal of rural nursing and health care, 1(2) 34 ricketts et al. (1999), individuals living in the southern region of the united states are 79.2% non-white (predominately black), 28.9% between the ages of 25-44, 14.6% greater than the age 65, with a median age of 33.8 years, 10.6% female head of households, and with 68.4% children living with two parents. incomes generally in rural communities have been lower, with decreasing dependence on farming incomes. other occupations that have been seen in rural communities (e.g. agriculture, forestry and fishing) have also decreased in recent years (ricketts et al. 1999; lopez-de fede, 1998). a growth of the rural underclass and an increasing population of individuals with disabilities residing in rural communities has also affected employment statistics in these areas. characteristics of individuals residing in rural settings lack of employment opportunities in rural areas has specifically affected young adults and non-minorities, thus resulting in the growth of what has been termed the rural "underclass". these individuals have been described (lopez-de fede, 1998; ricketts et al. 1999) as high school dropouts, on public assistance, unmarried mothers, or males who have suffered long-term unemployment. twenty eight percent of individuals classed as "underclass" have been reported to live in rural communities as compared 3.4% in cities and 1.1% in suburbs (lopez-de fede, 1998). disability has also been reported to be associated with lower incomes and increased chances of living in poverty (smart & smart, 1997). according to lopez-de fede (1998), a higher rate of limitation in activities has existed for individuals residing in rural communities as compared to urban communities. rural areas have also reported higher rates of chronic disease, infant mortality, and injuries related to occupational hazards. almost two-thirds of this rural "underclass" is reported (lopez-de fede, 1998) to be concentrated in the south. online journal of rural nursing and health care, 1(2) 35 an important policy issue has been and continues to be equitable access to healthcare particularly those considered to be vulnerable populations. individuals in rural communities have been considered a vulnerable population in terms of access to healthcare due to poorly developed and fragile structures for development of care in isolated areas, chronic illness and disability, socioeconomic disparities, and physical barriers. these physical barriers have included: (1) distance from high quality care, (2) transportation issues, and or (3) lack of resources for acute, chronic and rehabilitative services (schur & franco, 1999). mortality associated with trauma, specifically motor vehicle accidents and gun-related accidents has also been reported to be higher (chen, b., maio, r. r., green, p. e., & burney, r. e., 1995; ricketts et al. 1999). individuals with chronic pain typical profiles of individuals with chronic pain are similar in all environments, rural or urban. individuals with chronic pain suffer from unremitting pain, overuse of narcotic analgesics, reactive depression, and frequent use of and dependence on the healthcare system (tyre et al. 1994). based on this type of image of a typical individual with chronic pain, literature revealed that a uniform myth existed that presented individuals with chronic pain as homogeneous (tyre et al. 1994). this myth has often caused psychological factors that vary across individuals to be ignored. a strong relationship between psychological factors, pain, and disability was found to exist. improvement in coping strategies after outpatient pain management treatment has been reported to be associated with reductions in pain ratings, and psychological disability (gil, williams, keefe, & beckham, 1990; tota-faucette et al. 1993). generally, neck and back injuries have reportedly accounted for an appreciable proportion of individuals with workers compensation injuries in rural occupations such as online journal of rural nursing and health care, 1(2) 36 logging and other physically demanding occupations (smith, de hoop, marx, & pine, 1999). psychosocial aspects of rehabilitation from these types of injury have greatly affected successful rehabilitation. a major documented factor in the success of treatment (as measured by return to work criteria) has been compensation related pain and non-compensation related pain with soft tissue injuries. this relationship has continued to underscore the strong involvement of nonmedical issues in the onset and outcomes of complaints of a chronic nature. research has and needs to continue to address the nonphysical aspects of chronic pain (smith, 1998; smith et al. 1999). treatment of chronic pain pain has been described as complex in nature, and interdisciplinary treatment programs have been developed to target psychological as well as physical aspects of pain. these programs have included traditional treatments consisting of pharmacological treatment and physical therapy and, recently, programs have added marital and family therapy, cognitive-behavioral strategies, assertiveness and communication skills training, biofeedback and relaxation training, and operant conditioning techniques. comprehensive approaches have gained popularity and are believed to be more effective than the traditional approaches (cutler, fishbain, lu et al. 1994; cutler, fishbain, rosomoff et al. 1994; fishbain et al. 1993; reinking, tempkin, & tempkin, 1995; tota-faucette et al. 1993; tyre et al. 1994). despite changes and increasing awareness of variables in chronic pain treatment, there has been and still is a great variety of individual responsiveness to treatment. improvement in coping strategies after treatment has been associated with reduction in pain ratings, and psychological disability in pain patients (keefe et al. 1986; spinhoven & linssen, 1991; turner & clancy, 1986). conflict and control issues within the family have been online journal of rural nursing and health care, 1(2) 37 reported as related to increased distress and pain ratings (gil, keefe, crisson, & van dalfsen, 1987; flor, turk, & rudy, 1987; payne, & norfleet, 1986). tota-faucette et al. (1993) studied predictors of admission to a pain management program. family environments and patients' cognitive status on admission were reported (tota-faucette et al. 1993) as significant predictors of variability in outcomes. patients with families who were poorly organized, emphasized control and dependence, and had a high amount of conflict with little commitment to and support for each other were at risk for a poorer response to treatment. the second group found to be at risk for less than optimal outcomes included patients who engaged in negative and irrational thinking, and made little effort to control pain through active cognitive and behavioral strategies. complete initial assessment of individuals' psychological factors could lead to strategies that target individuals at risk with different treatment modalities. quality of life pain has traditionally been considered a physical symptom, but it has also been a sensation which can cause a decrease in an individual’s general well-being, overwhelm the individual, and interact with many aspects of daily living. pain has tended to cross cultural boundaries, particularly when connected with cancer (ahmedzai, 1995; ferrell, 1995). the concepts of pain and quality of life (qol) emerged as early as 1982 as central themes in hospice and palliative care in the care of individuals with cancer (flanagan, 1982; guyatt, feeny, & patrick, 1993; moinpour, 1994; sorkness, 1990). literature between 1992 and 1996 revealed more than 4,000 health-related articles focused on quality of life (king et al. 1997). medical and psychological interventions used to treat pain can also impact qol. the social and spiritual aspects of pain have been the least understood (padilla, ferrell, grant, & rhiner, 1990). online journal of rural nursing and health care, 1(2) 38 quality of life, as previously applied in the medical literature, may not have had a distinctive or unique meaning. researchers have appeared to substitute the term quality of life for various terms intended to describe an individual’s health. gill and feinstein (1994) defined quality of life as the reflection of the way that patients' perceive and react to their health status and to nonmedical aspects of their lives. perceptions of and reactions to quality of life were reported (gill & feinstein, 1994) when individuals were asked directly to rate their overall quality of life and the importance of individual items affecting their quality of life. gill and feinstein (1994) stated that overall quality of life included not only health-related factors but also non-health-related elements, such as jobs, family, friends, and life circumstances. ferrans (1990) and ferrell (1995) described models with similar domains that reflect quality of life. both researchers have included physical, psychological, spiritual, and social domains that were reported as influenced by pain and, therefore, affected perception of quality of life. ferrans' (1990) domains of family and socioeconomic status were reflected in ferrell's (1995) domain of social well-being. these researchers (ferrans, 1990; ferrell, 1995) have taken into account the value of perceptions, particularly in individuals dealing with cancer pain. literature (ferrans, 1990; ferrell, 1995; ferrell, rhiner, & ferrell, 1993; padilla et al. 1990) strongly suggested that accurate assessment of individuals' perceptions will assist human service professionals in the development of interventions designed to improve quality of life. methodology methodology used for this pilot study was focused to uncover differences that exist in individuals' perceptions of quality of life. it was designed to reflect individuals’ perception of quality of life who had received an intervention for chronic pain and those who had not received an intervention. since the definitions of success or failure of treatment varied according to the online journal of rural nursing and health care, 1(2) 39 literature (fishbain et al. 1993; jensen et al. 1994; tota-faucette et al. 1993; turk et al. 1993; tyre et al. 1994), this pilot study made no attempt to evaluate or discuss success or failure of the treatment program. additionally, for this particular pilot study, no attempt was made to match individuals’ severity of pain ratings to their perception of quality of life. study design the approach for this pilot study was non-experimental, causal-comparative (gall, borg & gall, 1996). this method of analyzing data was aimed at the discovery of differences that existed between perceptions of quality of life between two groups of individuals with chronic pain. a major advantage of a causal-comparative research design was that it allowed the researchers to study cause and effect relationships under conditions where experimental manipulation was impossible. this method allowed the researchers to study the effects of something that was present with one group and not present in another group (gall et al. 1996). in this particular study, the effects of a pain management treatment program on the perception of quality of life were of interest to the researchers, not the specific intervention program. the major difficulty with this type of design was that determining causal patterns with any degree of certainty was difficult and findings needed to be interpreted with caution (gall et al. 1996). additionally, researchers needed to be constantly aware that data could lead to strong inferences about the perceptions of individuals receiving an intervention for chronic pain. recommendations could result that were not valid. in this particular pilot study, the results statistically support that there was no difference in perception of quality of life, despite an intervention for chronic pain. online journal of rural nursing and health care, 1(2) 40 sample this pilot study's sample consisted of two groups of individuals (n=36), residing in the southeastern area of the united states, who were measured on their perception of quality of life. one group of individuals (n=16) had received an intervention for chronic pain, in this case, enrollment and completion, as document by program staff of a multidisciplinary chronic pain management program. a second group of individuals (n=20) consisted of those who had not received an intervention related to chronic pain, but who had been initially screened and met the criteria for referral to the pain management program. the sample was a convenience sample of individuals with varied diagnosis or causes of chronic pain. this sample was recruited from a multidisciplinary comprehensive pain management program that included pharmacological management, physical therapy, psychological therapy, and family counseling, operating in the southeastern united states. each individual was administered the quality of life index (ferrans & powers, 1985) by the principal investigator or a trained assistant. with the sample size being small, no attempt was made to match diagnosis, gender, or age. results, with a small sample size, must be interpreted carefully, and not generalized to any other groups but the sample (gall et al. 1996). this sample had a mean duration of pain of five years, a mean age of 50 (range 16 to 77 years), and was primarily female. sources of pain varied and included: first, a predominance of back pain; secondly, neck, shoulder and leg pain; thirdly, pain from burns; and least prevalent, pain in feet and abdomen. only 2% of this sample was employed, retirement was an issue for a small number of the participants, with the remainder unemployed due to self-reported inability to work as a result of chronic pain. no mention was made by any study participants of any pending online journal of rural nursing and health care, 1(2) 41 litigation issues. sample reflected many of the characteristics of individuals living in rural communities. instrument the quality of life index (qli) was developed to measure the quality of life of healthy individuals, as well as those experiencing an illness. qli has been reported to measure satisfaction with, and perceived importance of, various domains of life. these domains included healthcare, marriage, children, job, leisure, personal faith, and life goals. it consisted of 64 selfreport items in a 6-point likert like scale format. subscales addressed health and functioning, socioeconomic factors, psychological/spiritual factors, and family factors (ferrans, 1990; ferrans & powers, 1985; oleson, 1990). quality of life scores were determined by an adjustment of satisfaction responses for the importance responses. this adjustment reflected not only satisfaction but the value of a domain for that particular individual. rationale for this adjustment was based on the idea that people who are highly satisfied with important areas of their life perceive a higher quality of life than those who are very dissatisfied with important aspects of their life (ferrans & powers, 1985). ferrans and powers (1985) reported that the content validity of the qli was derived from the subjective judgment that the items were representative of the content area. it was supported by the literature review and reports of individuals who completed the instrument. construct validity was assessed using the known groups technique. standard deviations were reported for pain, depression, and coping with stress. criterion-related validity was reported as a correlation with the assessment of life satisfaction at 0.80. two week test-retest correlations were reported at 0.87 with 0.81 at a one month test-retest correlation. cronbach's alphas were calculated to assess internal consistency reliability. these were 0.95 for the entire instrument, 0.90 for the online journal of rural nursing and health care, 1(2) 42 health and functioning subscale, 0.84 for the socioeconomic subscale, 0.93 for the psychological/spiritual subscale, and 0.66 for the family subscale. hypothesis the research question centered around perceptions. the hypothesis was: individuals who had not received an intervention for chronic pain would report less perceived quality of life than those who had received an intervention for chronic pain. the rationale for this directional hypothesis was based in the literature on comprehensive approaches to pain management being the more effective treatment protocol (cutler, fishbain, lu et al. 1994; cutler, fishbain, rosomoff et al. 1994; fishbain et al. 1993, reinking et al. 1995; tota-faucette et al. 1993; tyre et al. 1994). results since the sample size was small, no attempt was made in the data analysis to separate the participants into any groups except those who had received an intervention and those who had not. data was analyzed using an independent t-test. power of this t-test result rested in the fact that a directional hypothesis was used with the level of significance set at 0.05. with very large samples, the potential exists for misusing the directional hypothesis; a tenable hypothesis can mistakenly be rejected because of the influence of the sample size (glass & hopkins, 1984). in this pilot study, it was expected that the directional hypothesis would increase the usefulness of the results. thirty-six individuals' scores on the ferrans and powers' (1985) quality of life index were analyzed using inferential statistics. data analysis revealed that both groups perceived their quality of life as decreased. the mean overall score for the nonintervention group (n = 20) was online journal of rural nursing and health care, 1(2) 43 18.9 and the mean score for the intervention (n = 16) was 15.6 (t = -1.65, p =.108). the hypothesis was rejected. based on the fact that the sample size was small, it makes it difficult to draw conclusions based on these results. it does appear, although not statistically significant, that individuals measured after an intervention for chronic pain perceived their quality of life (mean score = 15.6) as less than those individuals measured who had not had an intervention for chronic pain (mean score =18.9). reliability analysis using an alpha scale was done for this sample’s (n=36) total qli score and the subscale scores. the reliability alpha score of 0.962 was obtained for the total qli, .900 for the health and functioning subscale, 0.917 for the socioeconomic subscale, 0.891 for the psychological/spiritual subscale, and 0.717 for the family subscale. these are comparable to those cronbach alphas reported by ferrans and powers (1985) which were: (1) 0.95 for the entire instrument, (2) 0.90 for the health and functioning subscale, (3) 0.84 for the socioeconomic subscale, (4) 0.93 for the psychological/spiritual subscale, and (5) 0.66 for the family subscale. discussion questions that arise as a result of this study are varied. first, does an intervention, such as enrollment in a pain management program, actually decrease perceived quality of life immediately and over time? secondly, could this phenomena result from the fact that the individuals who have had an intervention for chronic pain, and in many cases dealt with chronic pain for a longer period of time, given up hope of the pain resolving or abating? finally, could the higher perception of quality of life in the group who had not experienced an intervention for chronic pain be due to hopes of complete or partial recovery? do individuals, who have not yet experienced a chronic pain intervention, believe pain will disappear? examples of additional online journal of rural nursing and health care, 1(2) 44 questions are: (1) what part do coping strategies play in decreased perception of pain and increased perception of being able to cope? (2) does the perception of increased ability to cope increase perceived quality to life? (3) does severity of pain ratings correlate with perceived quality of life? 4) are there gender differences in perceived quality of life in individuals with chronic pain? findings of this pilot study support questions posed by jensen et al. (1994). these questions focused on the concepts that some pain coping strategies, which are frequently encouraged in interdisciplinary pain treatment programs, may not have a direct short-term impact on perceived improvement in chronic pain. longer term follow-up may be needed to perceive the benefits of improved coping with chronic pain. these results may reflect that particular ways of coping may be important to some individuals with particular demographic characteristics but not to others. gender differences in perceived quality of life have been documented in a study with a large sample of individuals with cancer (n=254 females, n=222 males) (dibble, padilla, dodd, & miaskowski, 1998). as a result of a factor analysis procedure, all cancer-specific items were dropped, and the results suggested that the essential dimensions of qol are not different for those with or without a diagnosis of cancer (dibble et al. 1998). factor analysis did suggest that women and men perceived specific items on the multidimensional quality of life scale‚cancer version (mqls-ca) differently and that measurement of quality of life may require gender specific questions to accurately address dimensions of qol in females and males (dibble et al. 1998). this pilot research did not attempt to uncover specific individual characteristics, demographic data, or specific group patterns of response based on the small sample size. weaknesses of this pilot study lie in its lack of generalizability and the comparison of one group online journal of rural nursing and health care, 1(2) 45 immediately preceding the intervention and one group immediately following completion of the intervention. it would be useful to re-measure both groups of individuals three months following completion of a pain management intervention program. in this pilot study that was attempted, but since the principal investigator had geographically relocated, data needed to be completed by mailing the instrument. the return rate (12%) after two mailings was not sufficient for data analysis. issues for healthcare professionals in rural communities barriers to healthcare and rehabilitation have been identified for individuals residing in rural communities. these barriers included poverty, under insurance or lack of health insurance, shortages of health-care providers, inconvenient health services locations and service hours, prolonged waiting times, lack of public transportation, and communication difficulties for those who cannot speak, or write english (center for disease control [cdc], 1998; meert & thomas, 1998; sample & darragh 1998; schur & franco, 1999). women residing in rural areas reported less access to resources, a need to travel for rehabilitative services, and a need to take charge of coordinating their care. this lack of coordination slowed down their rehabilitation, due to the fact that they had to find information about services and rights by relying on friends, family and word of mouth (sample & darragh, 1998), causing gaps in services and use of the individual’s energy. this expenditure of energy for self-coordination of services has the potential to increase recovery time and use energy that could be used in other activities (e.g. child care, activities of daily living, and employment). it has been estimated that a minimum of 125 million americans are affected by acute or chronic pain annually (kubecka, simon, & boettcher, 1996). literature (benesh, szigeti, ferraro, & gullicks, 1997; jones, 1999; kubecka et al. 1996) has reported that healthcare online journal of rural nursing and health care, 1(2) 46 professionals’ lack of knowledge about pain and its treatment may result in a major barrier to achieving comfort for individuals experience pain. fears of healthcare professionals, individuals, and their families concerning addiction, tolerance and respiratory depression related to the use of narcotics has been reported as an additional barrier to effective pain management and may result in pain being severely undertreated or untreated (kubecka et al. 1996; jones, 1999). additionally, cost of medication in rural settings is reported as a concern and barrier to effective pain management (dalton, carlson, mann, blau, & bernard, 1998; meert & thomas, 1998; sample & darragh, 1998). brockopp, warden, colclough, and brockopp (1996) have cited a general agreement that lack of adequate education, fear of narcotic addiction, incomplete or inadequate assessment of pain, and attitudes towards pain often result in practices that are not conducive to good pain management practices. rural subjects in this study reported being more concerned than urban subjects about taking drugs for pain, taking care of themselves should they experience pain, and being hospitalized for testing should they report their pain. on the other side of the coin these same rural subjects reported that they could handle pain better as they got older (brockopp et al. 1996). one particular study (benesh et al. 1997) reported that the traditional visual analog scale may not be the most appropriate scale to utilize with rural dwelling elders, particularly women. this study indicated that nurses more often than other healthcare providers underestimated individuals’ pain intensity. almost 47.5% of the subjects (n=40, gender female, mean age of 80.5) indicated that the pain thermometer was the easiest and most accurate reflection of their pain intensity. healthcare professionals may need to consider different assessment tools with different populations. online journal of rural nursing and health care, 1(2) 47 healthcare professionals have and continue to view counseling as an essential part of the services provided to individuals, both in private and public agencies. professionals in the field of rehabilitation have a need to understand individuals with chronic pain and need to apply counseling strategies to this population of individuals. chronic pain has both somatic and psychological dimensions and, by the time that much of the symptomology associated with chronic pain becomes evident and interferes with daily living, it has become interwoven into the secondary gains associated with illness. secondary gains include such things as reduced work, reduced social and family obligations, and often monetary payments (beck, 1985; cutler, fishbain, lu et al. 1994; cutler, fishbain, rosomoff et al. 1994; fishbain et al. 1993; gil et al. 1990; jensen et al. 1994). healthcare professionals in the field of rehabilitation need to be aware that research indicates that the immediate pain reactions within days of the onset of pain or an associated injury may provide clues to those individuals who will continue to have pain problems posthealing. this certainly speaks to the need for a quick accurate assessment and diagnosis, often difficult in urban areas and very difficult in rural areas. at three months post-injury or development of pain, fairly accurate predictions can be made of individuals who are unlikely to have continuing pain problems or become disabled. this three-month assessment could certainly impact the focus of therapeutic and financial resources (philips, grant, berkowitz, 1991). preinjury factors include: surrounding job satisfaction, pre-pain coping skills, history of psychiatric problems, and litigation involved with the injury play important roles in persistence of chronic pain (philips et al. 1991). one goal of rehabilitation is to enable individuals with disabilities to work and be useful and independent members of the family and community. consequently, who but a rehabilitation online journal of rural nursing and health care, 1(2) 48 healthcare professional is in a better position to provide support for individuals from the beginning of their treatment in a chronic pain treatment program to their discharge. healthcare professionals functioning in a case management role will help to bridge the gap between rehabilitation and return to work and/or a useful active lifestyle (sweet, 1995). vocational healthcare professionals are invaluable in this process. management of chronic pain and counseling by healthcare professionals are appropriate strategies in helping these individuals make career decisions, learn to cope with and adjust to chronic pain, and manage the outcomes of treatment in a pain management program. importance of an individual's belief in his or her ability to maintain some personal control of life and pain cannot be over stressed. strategies that are used to enhance well-being and activity levels are taught in multidisciplinary and/or interdisciplinary pain treatment programs but need constant reinforcement by healthcare professionals as individuals access these services for return to work assistance (jensen et al. 1994). individuals with a sense that they can control their pain are more likely to initiate and persist in the use of adaptive coping strategies (beck, 1985; jensen & karoly, 1991; jensen et al. 1994). healthcare professionals can teach and reinforce these strategies based on their knowledge of counseling theories, such as cognitive behavioral theory, bandura's social learning theory, and reality therapy (beck, 1985; jensen & karoly, 1991; jensen et al. 1994; covington, 1991). healthcare professionals working in the field of rehabilitation can continue to encourage individuals to maintain coping strategies targeted in multidisciplinary and/or interdisciplinary pain treatment programs. this can be done by remembering that not all treatments have a direct impact on short-term improvement (jensen et al. 1994). in relation to this research study, this may partially explain the results. it may take a longer period of time and involvement in aerobic online journal of rural nursing and health care, 1(2) 49 exercise, stretching exercise, keeping busy, muscle strengthening exercise, relaxation and decreases in resting or withdrawing from activity when pain is present or has increased, and decreases in opioid medications before perception of quality of life moves to a level higher than pre-treatment measurements. specific issues for nurses in rural communities advance practice nurses (apn), specifically clinical nurse specialists (cns) and nurse practitioners (np), have been and will continue to assume integral roles in the delivery of healthcare services in rural communities. apns are able to provide primary healthcare services to a wide variety of clients within the constraints often present in rural communities. these primary care providers often require a lower level of capital support and frequently prefer the autonomy this practice environment allows (baer & smith, 1999). educational programs located in or targeted to rural areas foster interdisciplinary, collaborative practice that increases access and quality of care available to individuals in rural communities. evidence-based practice is an approach to clinical practice that the advance practice nurses are familiar with and skilled in utilizing. this approach is useful in rural areas when it is used to define a clinical problem, identify the needed information, conduct a search on appropriate literature, critical appraise the literature, and identify the applicable clinical data. finally the application of this approach to the client could drastically improve the healthcare of individuals residing in rural communities with chronic illnesses (stotts, 1999). evolving roles of the apn in case management will help prevent the fragmentation of healthcare that often occurs when an individual must travel outside his or her community for specialty care. advance practice nurses functioning in the role of case manager will coordinate medical management, social service programs, family and individual counseling, and vocational online journal of rural nursing and health care, 1(2) 50 consultation. nurses in rural communities will be able to utilize their skills at assessment of both objective findings and subjective complaints. nurses practicing with advanced educational preparation in rural setting will be able to intervene early in the rehabilitative process by the use or ergonomic principles and devices. this type of intervention may not only relieve the onset of chronic pain but additionally relieve secondary injury. nurses advocating the early return to normal work duties instead of restricted duties will also facilitate return to work, thus lessening long term disability (smith, 1998; smith et al. 1999). ideas for future research ideas for further research certainly were generated by this research project and the review of literature. implications for future research include correlations of what happens at predetermined intervals (e. g., three months) during an intervention for chronic pain and correlations of differences in perceptions that exist between individuals of different gender, culture, and educational level. additionally, questions could be asked about pain severity ratings, different medical diagnoses, and health, in general, in correlation with perception of quality of life. areas that might be suspected as playing a large part in perceptions of quality of life and investigated in future studies are family and spousal support. finally, qualitative studies could be designed as a passageway to what could be rich data about individuals with chronic pain and their stories of life, medical care, and relationships. online journal of rural nursing and health care, 1(2) 51 references ahmedzai, s. 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(1993). evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain. british journal of general practice, 43, 513-518. https://doi.org/10.1097/00002508-199306000-00006 https://doi.org/10.1016/0304-3959(93)90049-u https://doi.org/10.1016/0304-3959(86)90121-1 mallow_615_formatted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 241 assessment of readmission in a rural medical center jennifer a. mallow, phd, fnp-bc1 andrea bailey, msn, fnp-bc2 karen e. clark, md, facp3 laurie theeke, phd, fnp-bc, gcns-bc, faan4 1associate professor, school of nursing, west virginia university, jamallow@hsc.wvu.edu 2clinical instructor, school of nursing and transitional care coordination team program consultant, school of medicine, west virginia university, anbailey@hsc.wvu.edu 3professor, chief, and medical director of care management, school of medicine, west virginia university, kclark@hsc.wvu.edu 4professor and phd program director, school of nursing, west virginia university, ltheeke@hsc.wvu.edu abstract understanding and predicting hospital readmission has been of interest for more than three decades. to strategically place readmission reduction resources where most beneficial, organizations use readmission risk-stratification tools. however, common tools used to assess 30day risk do not incorporate health disparity and it is unknown how modifying currently validated tools affects their predictive value. the aims of this retrospective study were to describe the population of people who are admitted and re-admitted for hospital care in a rural population and examine the effectiveness of a common risk stratification tool to predict 30-day readmission in a rural population experiencing health disparities. this retrospective cohort study examined data online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 242 from de-identified electronic health record and included adult patients admitted to one general medicine service. the factors identified in this study that influence readmission are also identified in the literature and include number of co-morbid conditions and insurance status. keywords: hospital readmission, care transitions, health disparities, social determinants of health, risk stratification assessment of readmission in a rural medical center understanding and predicting hospital readmission has been of interest for large hospital systems for more than three decades (smith, norton, & mcdonald, 1985; smith, weinberger, katz, & moore, 1988). more recently, in 2012, the centers for medicare & medicaid (cms), as required by the affordable care act (aca), began to penalize hospitals for readmissions considered to be in excess of national averages. thus, hospital systems have begun to refocus on what can be done to identify patients who are at risk of readmission, improve care delivery, and decrease the likelihood of patients returning to an acute care hospital care within 30 days. background to strategically place readmission reduction resources where most beneficial, organizations use readmission risk-stratification tools. one such tool, the lace index, is widely used and predicts death or readmission for patients within 30 days after discharge from an acutecare hospital (van walraven, wong, & forster, 2012). the lace index scoring tool uses the following measures: length of stay of the index hospitalization, acuity of the index admission in terms of emergent versus non-emergent admission, comorbidity of the patient using the charlson comorbidity index, and the number of emergency department visits in 6 months (gruneir et al., 2011; van walraven et al., 2012). the tool was originally developed and validated in canada in a population that is different from many american populations, thus leading to the lace + index online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 243 introduced by van walraven et al. in 2012. modifications to the original lace index in the form of the lace + captured additional variables such as acute diagnoses and procedures during index admission, academic medical center status, and patient age and gender (van walraven et al., 2012). the lace index may not be the best tool to predict readmission in populations experiencing significant health disparities. health disparities are preventable differences in the burden of disease or opportunities to achieve optimal health that are experienced by socially disadvantaged populations (national cancer institute). rural populations are often at risk for these health disparities. socioeconomic and behavioral health factors may exacerbate readmission vulnerability in rural populations experiencing health disparities. as hospital systems begin to examine readmission data and look for interventions that will be beneficial, it is clear the cause of readmissions is likely multifactorial. considering these important patient characteristics is necessary when trying to predict which patients are most likely to experience poor outcomes and readmission. however, common tools used to assess 30-day risk do not incorporate these factors and it is unknown how modifying currently validated tools affects their predictive value. assuming the risk of excess readmissions stems from multiple factors, one rural hospital system further modified the lace tool to include additional parameters to capture socioeconomic and behavioral health factors. based on qualitative nursing assessment and patient reports, the following pieces of functional assessment data were added to the lace index within the electronic health record: lack of permanent address, place of residence is a hotel/motel, living alone, history of substance abuse, self-reported financial concerns, and poor health literacy. the aims of this retrospective study were three-fold: 1) to describe the population of people who are admitted and re-admitted for hospital care in a rural population, 2) to examine the effectiveness of online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 244 the lace index to predict 30-day readmission in a rural population experiencing health disparities, and 3) to begin to examine the impact of adding functional status variables to the readmission index for the purposes of correctly identifying patients at risk for readmission. methods design using a retrospective cohort sample of electronic records to complete the analysis, the sample was obtained from de-identified electronic health record (ehr), obtained from the integrated data repository (idr) (denney, long, armistead, anderson, & conway, 2016). the idr is a validated clinical data warehouse that is maintained by the west virginia clinical and translational science institute. the study included all adult patients that were admitted to a general medicine service at ruby memorial hospital in morgantown, west virginia (wv) between january 1, 2014 and december 31, 2015. the time frame was chosen to obtain baseline data prior to extensive modification of readmission prevention interventions within the institution. exclusion criteria were data from any patients under 18 years old at the time of admission. this study was granted exempt status by the west virginia university (wvu) institutional review board (45 cfr 46.101). setting rural is defined in this study using the census bureau’s urban-rural classification (ratcliffe, burd, holder, & fields, 2016). appalachia is a 13-state region of the eastern united states (u.s.) in which 42% of the region’s population is rural compared with 20 percent of the national population. wv is in the only state that is entirely within appalachia. the rugged terrain and poor condition of roads hinder access to care and are associated with longer times to reach needed medical care (wilson, kratzke, & hoxmeier, 2012). wv is one of the few u.s. states not online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 245 to have a city with more than 100,000 residents and the largest city in the state has less than 50,000 people. hence, even those who are living in areas classified as “urban” experience health disparity such as geographic isolation, lower socioeconomic status, higher rates of health risk behaviors, limited access to healthcare specialists and subspecialists, and limited job opportunities. the majority (42 of 55) of west virginia's counties are designated as rural, with most of the state's population living in a rural area. wvu health system is the only academic medical center in the state and over 85% of the counties in west virginia are considered health professional shortage areas (u.s.health resources & services administration, 2019). wvu medicine includes the physicians, specialists, and sub-specialists of the wvu school of medicine; the affiliated schools of the wvu health sciences center (nursing, pharmacy, dentistry, and public health). the west virginia university health system is the largest health system in the state comprised of 14 hospitals and five institutes. all of these are anchored by a 690-bed academic medical center, ruby memorial hospital (rmh), that offers tertiary and quaternary care. the general medicine service at ruby memorial hospital accepts patients from across the entire state. thus, the data obtained for this study is from individuals living across a rural state. adult patients with a typical range of acute and chronic medical illness are cared for on general medicine floors or stepdown units. intensive care is provided in a closed system with coverage by intensivist. measures thirty-day readmission. all patients in the idr database that had been admitted into the hospital during the timeframe of the study were identified. the first admission within the study timeframe was considered the indexing admission. the 30-day readmission variable was a dichotomous variable, using the indexing admission as baseline. any patient that was readmitted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 246 within 30 days of the indexing admission was coded as a 1 and those who were not readmitted within 30 days of an indexing admission were coded as a 0. lace+ index. the lace+ index scoring tool is an algorithm that quantifies the risk of a patient's hospital readmission within 30 days of discharge. it is comprised of five different variables: length of stay (l), acuity of admission (a), comorbid conditions (c), emergency department utilization (e), and a summed score. each of those variables are calculated independently. length of stay is recorded in days, which includes the day of admission and discharge. therefore, a patient who is admitted in the evening and discharged the next morning would have a length of stay equal to two days. the acuity of admission is determined by the patient class. patients who were admitted as an inpatient score three for the “a” variable while patients classed as observation score a zero. the comorbid conditions of patient as per the charlson comorbidity index (charlson, szatrowski, peterson, & gold, 1994) were collected during the admission. each comorbidity was assigned a weight that factors into a maximum score of six. emergency department (ed) utilization in the six months preceding the index hospitalization adds one point to the “e” variable, up to a maximum of four points. if the patient was admitted via the emergency department for the index admission, this emergency department utilization was included in the score. in addition, the fifth variable was a summed score, obtained from the first four variables, ranging from 0-19 where a score of 10 or greater signifies a high risk of readmission within 30 days. patient characteristics. in addition to the lace+, this health system further modified the lace+ tool to include additional parameters to capture socioeconomic patient characteristics gender was recorded as a dichotomous variable, male or female. race was available in the idr in the following categories: white, black/african american, hispanic/latino, other, or unknown. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 247 for the purposes of the analysis, the unknown responses were combined with the other category. marital status was available in the idr in the following categories: divorced, separated, married, other, significant other, single, unknown, and widowed. for the purposes of the analysis, separated and divorced were combined, and unknown was combined with the other category. age was calculated from date of birth at the indexing admission and recorded as a continuous variable. insurance status was available in the idr in the following categories: medicaid, medicare, private, self-pay, and other. having a primary care provider was obtained and recorded as a categorical variable: yes, no, and unknown. for the purposes of analysis unknown was combined with no. the lace + tool specific following chronic conditions were collected and dichotomized as a patient either having the condition or not: myocardial infarction, congestive health failure, peripheral vascular disease, cardio vascular disease, dementia, chronic obstructive pulmonary disease, rheumatic disease, peptic ulcer, liver disease (mild and severe), diabetes (with and without complications), hemiplegia, renal disease, malignancy, tumor, and acquired immune deficiency syndrome (aids). the total number of chronic conditions was calculated by tallying the total of each of the above conditions. functional status. information related to socioeconomic status and functional health included literacy, history and/or treatment for alcohol, drug or behavioral issues, financial concerns, functional health assessments, and living arrangements. health literacy was measured by the brief health literacy screen (bhls) (sand-jecklin & coyle, 2014). the bhls is a fivequestion tool that measures patient’s ability to understand and remember written and/or verbal health information. the tool results in a summed score from 0 – 25, with scores less than 19 indicating limited health literacy. the tool is relatively new and was developed and tested in the same population. however, cronbach’s alpha for the bhls in this study was .79. inter-item online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 248 correlations ranged from .21 to .60 and exploratory factor analysis indicated that the instrument was measuring one factor, with item loadings of .65 to .84 (sand-jecklin, daniels, & lucke-wold, 2017). living arrangements were available from the data repository in the following categories: apartment, assisted living, condominium, correctional facility, extended care facility, group home, homeless/hotel/motel/shelter/no address, house, independent living facility, mobile home, nursing home, rehab hospital, residential facility, shelter, and skilled nursing unit. the following variables were collected as a dichotomous variable (yes/no) and recorded as past difficulty with one or more of these issues: hearing deficit, visual deficit, ambulation deficit, difficulty performing activities of daily living, difficulty completing errands, memory deficits, financial concerns, and treatment for alcohol, or illicit drugs. also, having a primary care provider was collected as a dichotomous variable as yes, they have a primary care provider listed, or no, they do not have a primary care provider listed. data analysis data were analyzed using statistical package for the social sciences 24. the first review of the data included a comprehensive descriptive analysis of all study variables for participants who have been admitted within 30 days of an indexing admission. next, chi-square test for independence was used to explore the relationships between 30-day readmission status and the following categorical study variables: gender, race, marital status, insurance status, having a primary care provider, each chronic condition, living arrangements, hearing deficit, visual deficit, ambulation deficit, difficulty performing activities of daily living, difficulty completing errands, memory deficits, financial concerns, and treatment for alcohol, or illicit drugs. mean comparisons were conducted using independent-samples t-tests for the dichotomous categorical readmission online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 249 variable and the following continuous variables: age, number of chronic conditions, health literacy, length of stay, emergency department utilization, and lace+ score. results sample descriptors the sample (n = 9,854) included mostly mid-life adults (mean age = 57.5, sd 18.2), was nearly gender equal, included a majority of white, married, insured by the centers for medicaid and medicare services, and chronically ill. the readmission rate within 30 days for the population was 22.3% and the majority of the patients were re-admitted as inpatients (74%) verses those who were in-house and classified as observation patients (26%). the remainder of the demographic information of the sample can be seen in table 1. table 1 demographics for total population demographic n total (9854) % gender female 5018 50.9 male 4835 49.1 race black/african american 304 3.1 hispanic/latino 44 0.4 white 9317 94.6 other 189 1.9 marital status divorced 1392 14.1 married 4109 41.7 significant other 32 0.3 single 2566 26.0 widowed 1370 13.9 other 204 2.1 financial class medicaid 2543 25.8 medicare 4950 50.2 private 1934 19.6 online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 250 self-pay 197 2.0 other 230 2.3 has primary care provider yes 7534 76.5 no 2320 23.5 functional status variable hearing impairment 899 9.1 visual impairment 746 7.6 ambulation difficulty 3527 35.8 adl deficit 2128 21.6 difficulty completing errands 2836 28.8 memory impairment 1919 19.5 history of treatment for substance disorder 1088 11.0 financial concerns 403 4.1 living arrangements independent community dwelling 8417 85.4 assisted community dwelling 295 3.0 unstable or homeless 119 1.2 missing data 1023 10.4 continuous demographic mean sd age 57.53 18.25 # admissions in 1 year 2.19 5.89 # chronic conditions 1.48 2.15 lace+ score 8.42 4.38 health literacy score 17.99 8.20 when exploring demographic characteristics in this sample, chi-square tests for independence indicated significant associations between being admitted within 30 days and gender, race, marital status, financial class and having a primary care provider. as seen in table 2. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 251 table 2 chi-square analysis of demographics and 30-day readmission *denotes significant results the effect sizes of all the associations are very small. regardless of the admission diagnosis, there was an association between all chronic illness except dementia and aids. see table 3 for detailed chi-square results related to 30-day readmission and each chronic illness. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 252 table 3 chi-square analysis of chronic illness type and 30-day readmission. (n= 9854) demographic readmitted, n, (%) not readmitted n, (%) x2, p value phi coefficient myocardial infarction 40.4, 0.000* phi = 0.06 yes 353 (16.1) 847 (11.1) no 1841 (83.9) 6813 (88.9) chf 69.9, 0.000* phi = 0.08 yes 490(22.3) 1135(14.8) no 1704(8.4) 6525 (85.2) pvd 69.9, 0.000* phi = 0.08 yes 337(17.2) 811(10.6) no 1817(82.8) 6848(89.4) cvd 12.6, 0.000* phi = 0.04 yes 350(16.0) 996(13.0) no 1844(84.0) 6664(87.0) dementia 0.001, 0.97 phi = 0.00 yes 89 (4.1) 312 (4.1) no 2105 (95.9) 7348 (95.9) copd 66.2, 0.000* phi = 0.08 yes 292 (13.3) 589 (7.7) no 1902 (86.7) 7071 (92.3) ra 8.22, 0.005* phi = 0.03 yes 93 (4.2) 230 (3.0) no 2101(95.8) 7430 (97.0) peptic ulcer 15.2, 0.000* phi = 0.04 yes 113 (5.2) 257 (3.4) no 2081(94.8) 7403 (96.6) liver disease, mild 89.4, 0.000* phi = 0.09 yes 363 (16.5) 719 (9.4) no 1831 (83.5) 6941 (90.6) diabetes, without complications 53.3, 0.000* phi = 0.07 yes 618 (28.2) 1593 (20.8) no 1576 (71.8) 6067 (79.2) diabetes, with complications 44.9, 0.000* phi = 0.07 yes 284 (12.9) 631 (8.2) no 1910 (87.1) 7029 (91.8) hemiplegia 7.1, 0.008* phi = 0.03 yes 85 (3.9) 221 (2.8) no 2109 (96.1) 7448 (97.2) renal disease 21.9, 0.000* phi = 0.05 yes 326 (14.9) 856 (11.2) no 1868 (85.1) 6804 (88.8) malignancy 15.8, 0.000* phi = 0.04 yes 243 (11.1) 638(8.3) no 1951 (88.9) 7022 (91.7) liver disease, severe 10.2, 0.001* phi = 0.03 yes 91 (4.1) 215 (2.8) no 2103 (95.9) 7445 (97.2) aids 0.54, 0.46 phi = -0.07 yes 5 (0.2) 25 (0.3) no 99.8 (0.7) 7635 (99.7) * denotes significant results online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 253 significant associations were also found between functional status variables and 30-day readmission status. however, there were missing data for each of the functional status variables and cases with missing data were excluded from the analysis. the associations between 30-day readmission showed that the percentage of readmissions was lower for those with hearing, visual and memory deficits. conversely, those with ambulation difficulty, adl deficits, difficulty completing errands and a history of substance abuse treatment had higher 30-day readmission rates than patients without one or more of these characteristics. see table 4 for detailed chi-square results and missing data related to 30-day readmission and functional status variables. table 4 chi-square analysis of functional status and 30-day readmission. (n = 9854) demographic (n = missing data) readmitted, n, (%) not readmitted n, (%) x2, p value phi coefficient hearing deficit (n = 716) 15.1, 0.001* phi = 0.04 yes 173 (7.9) 726 (9.5) no 1893 (86.3) 6346 (82.8) visual deficit (n = 721) 9.2, 0.01* phi = 0.03 yes 157 (7.2) 589 (7.7) no 1907(86.9) 6480 (84.6) ambulation difficulty (n = 725) 22.2, 0.000* phi = 0.05 yes 868 (39.6) 2659 (34.7) no 1197 (54.6) 4405 (57.5) adl deficit (n = 721) 12.6, 0.002* phi = 0.04 yes 515 (23.5) 1613 (21.1) no 1550 (70.6) 5455 (71.2) difficulty completing errands (n = 725) 10.6, 0.005* phi = 0.03 yes 668 (30.4) 2168 (28.3) no 1396 (63.6) 4897 (63.9) memory deficit (n = 729) 9.6, 0.008* phi = 0.03 yes 409 (18.6) 1510 (19.7) no 1652 (75.3) 5554 (72.5) history of substance abuse treatment (n = 8766) 12.49, 0.000* phi = 0.04 yes 288 (13.1) 800 (10.4) no missing missing financial concerns (n = 2766) 4.47, 0.107 phi = 0.02 yes 99 (4.5) 304 (4.0) no 1449 (66.0) 5236 (68.4) *denotes significant results online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 254 statistically significant differences were found related to age, number of chronic conditions, number of ed visits, and lace+ scores between those who were readmitted within 30 days and those who were not readmitted. there was no significant difference in scores for health literacy scores or length of stay. see table 5 for detailed results of independent samples t-tests. table 5 comparisons of continuous variables and 30-day readmission variable mean n sd std. error mean t df cohen’s d p age not re-admitted 57.89 7660 18.6 0.21 3.87 3820.41 0.04 0.000* re-admitted 56.27 2194 17.0 0.36 # of chronic conditions not re-admitted 1.3 7660 2.0 0.02 -10.37 3119.44 0.10 0.000* re-admitted 1.9 2194 2.4 0.05 health literacy not re-admitted 18.0 4464 8.2 0.12 0.49 5277.00 0.00 0.62 re-admitted 17.86 815 8.1 0.28 length of stay not re-admitted 5.0 7660 6.4 0.07 -0.92 9852.00 0.00 0.36 re-admitted 5.1 2194 6.5 0.14 ed visits last 6 months not re-admitted 0.2 7660 0.8 0.01 -14.12 2276.41 0.14 0.000* re-admitted 1.1 2194 3.0 0.06 lace+ not re-admitted 8.1 7528 4.3 0.05 -12.33 3291.91 0.12 0.000* re-admitted 9.5 2143 4.6 0.10 discussion while readmission assessment and prediction has been of interest for three decades, this study is the first to begin examining the relationships between sociodemographic, behavioral and functional status variables in relation to readmission rates in a rural population within the context of validated readmission risk tools. the descriptors of this study sample are of the general population of wv. these results are consistent with knowledge related to determinants of health in rural appalachia (marshall et al., 2017). the residents of wv experience significant health online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 255 disparities including experiencing the highest incidence of uninsured or underinsured status, low high school graduation rates, highest incidence of infectious disease, highest prevalence of low birth-weight infants, and low availability of primary care providers compared to other states. all these factors correspond to the five identified key domains of social determinants of health (department of health and human services, 2019). there was a difference between the lace+ scores of those who were readmitted and those who were not. however, lace+ scores for those who were readmitted were lower than published thresholds (van walraven et al., 2012). hence, the lace+ scores were not effective in predicting those at risk for readmission in this population. in addition, the population readmission rate exceeded the national averages for those with chronic illnesses (fingar, barrett, & jiang, 2006). individual components of the lace+ that were predictive for readmission was co-morbid conditions and ed visits within the last six months. these predictive items probably accounted for the lower threshold for readmission in this rural population. the functional status findings may not be surprising. cornell university’s 2016 disability status report identifies wv as the state with the highest prevalence of disabilities among noninstitutionalized working adults (ward, myers, wong, & ravesloot, 2017). national rates of identified disabilities are 10.9%, with wv at 18.5.% (erickson, 2018). with the patients in this study, ambulatory disability ranked highest among the six types of disabilities identified by the american community survey, at 10.6%, followed by cognitive and independent living (erickson, lee, & von schrader, 2018). as mid-life adults, the population experiences significant ambulation difficulty, adl deficits, difficulty completing errands and memory impairment. it has long been known that ambulation difficulty in people over the age of 65 has been linked to readmissions (marcantonio et al., 1999; navathe et al., 2018). the difficulty with completing adls and online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 256 completing routine errands is likely linked to ambulation difficulty. in addition, ambulatory disability may be more disruptive to adls in rural verses urban areas due to lack of public transportation services and rugged terrain. however, knowing that this rural population may experience ambulation difficulty at a younger age deserves more examination in relation to readmission. the available data related to substance use was collected as a history of receiving treatment for substance abuse and thus does not measure those who have a history of alcohol or drug abuse that are currently using or have not sought treatment in the past from this facility. information about substance use and abuse is often under reported. wv has the highest rate of drug overdoses in the nation and comparison data indicates that approximately one in 10 people in wv battle with addiction (moody, satterwhite, & bickel, 2017). thus, due to the large amount of missing data, it is possible that addiction incidence may be higher than previously believed and certainly would impact readmission rates. recent studies by gerke, et al, find positive screening scores for active alcohol consumption, drinking behavior and alcohol related problems as well as drug use or abuse in the previous 12 months are associated with higher risk for 30-day readmission to general medicine wards (gerke et al., 2018). understanding living arrangements in the context of the available data is also difficult. while the vast majority of the population lives in the community independently, the number of people in the home and amount of informal and formal care-giver support is not routinely assessed or collected. thus, this information is not available in the ehr and not part of this analysis. however, lack of caregiver support for acute illness when discharged and loneliness have been linked to poor physical outcomes for those with chronic illness (greysen et al., 2016; petitte et al., 2015). in addition, those living in assisted community dwellings may receive services that keep online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 257 them in those institutions and out of acute care hospitals. however, understanding people’s preference and amount of support needed to remain in their home in relation to readmission has not been routinely measured in relation to readmission assessment. while there were significant differences in patient characteristics and 30-day readmission rates, effect sizes were very small. readmission rates were higher in males, whites, those that were single or divorced, receive medicaid benefits and have a chronic illness. those who readmitted were younger that those who did not. while contrary to previously reported findings related to age (cooksley et al., 2015), this finding is similar to recent findings that indicate higher readmissions for younger adults with mental health disorders and patients of all ages with multiple chronic conditions (berry et al., 2018). healthcare cost and utilization project (h-cup) data findings are similar in that males receiving medicaid benefits with mental illness admit more frequently (jiang, weiss, barrett, & sheng, 2015). mental health diagnosis is not commonly measured in lace+ assessment and thus, not collected for evaluation in this study. while health literacy was not significant in relation to readmission status in this population, the overall health literacy of all patients was low and there was essentially no variability in the scores between groups. while not significant in relation to readmission, it certainly merits consideration when developing interventions to reduce hospital readmissions in this rural population. limitations the study population was primarily white which may be different in other rural areas of the country. missing data was identified for all functional health variables. this study was a retrospective analysis of a specific appalachian sample located in north central wv. thus, the findings cannot be generalized to other rural populations without replication. in addition, no specific rural status data of individual patients was collected. thus, the findings cannot be online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 258 generalized to all rural populations, the rest of the u.s. or even to all of appalachia. variables regarding substance abuse history and treatment were missing in the data almost completely. missing data could not be analyzed because using imputed means or for the purposes of prediction of readmission could skew the results. further investigation is warranted to related to these patient characteristics in the future. future implications more research is needed to understand the complex nature of readmissions in rural populations. a larger study to further investigate incorporating the social determinants of health into readmission assessment and to automate some type of readmission risk assessment within the ehr is currently being developed. future initiatives should focus on common data elements to collect determinants of health, specifically in rural populations. these efforts will assist in developing clinical, social, and behavioral interventions for the most vulnerable populations. conclusions the lace+ index is not effective in identifying those at risk for readmissions in this rural population. it is likely that functional status and significant health disparities cause of 30-day readmissions in this rural population. however, further research is warranted. the factors identified in this study that influence readmission are also identified in the literature and include number of co-morbid conditions and insurance status. while most individuals had insurance, the majority of those who were readmitted within 30 days had medicaid as their primary insurance. since people with medicaid who live in rural areas face unique needs, future initiatives aimed at assessing and reducing 30-day readmission rates should focus on distinct clinical, social, and behavioral needs for rural populations. before developing customized care transition plans and online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.615 259 precision healthcare approaches to prevent readmissions, system level changes in collecting health determinant data are needed. the authors declare that there is no conflict of interest. references berry, j. g., gay, j. c., maddox, k. j., coleman, e. a., bucholz, e. m., o’neill, m. r., . . . hall, m. 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(2012). predictors of access to healthcare: what matters to rural appalachians? global journal of health science, 4(6), 23. https://doi.org/10.5539/gjhs.v4n6p23 75 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 the relationship between educational attainment and lung cancer mortality in kentucky: implications for nurses david a. gross, ba 1 1 director of research, marketing & community engagement, center for excellence in rural health-hazard, university of kentucky, dagros3@email.uky.edu key words: lung cancer mortality, educational attainment, poverty, adult smoking rates, appalachia abstract context: the professional literature indicates health has a positive correlation with socioeconomic status. more specifically, prior research documents heightened rates of lung cancer incidence and mortality in appalachia, a region plagued by persistent poverty and below-average educational attainment. this study analyzed predictors of lung cancer mortality within kentucky, a predominantly rural state in central appalachia. purpose: to determine whether county-level lung cancer mortality is related to counties’ high school graduation rates, per capita personal income levels and adult smoking rates. also, to test whether significant differences exist among these variables between kentucky’s appalachian and nonappalachian counties. methods: data from the kentucky institute of medicine’s 2007 report the health of kentucky: a county assessment were analyzed using independent samples t tests, bivariate correlations and regression analyses. results: on a statewide basis, inverse associations were found between county-level lung cancer mortality and counties’ graduation rates (p < .001) and per capita personal income (p < .01). statistically significant differences were detected between kentucky’s appalachian and non-appalachian regions for each variable except adult smoking rates. conclusions: in the context of similar adult smoking rates between the state’s appalachian and nonappalachian counties, high school graduation rates showed the strongest statistical association with lung cancer mortality. this indicates that continued improvements in kentucky’s rate of diploma attainment may contribute to future reductions in lung cancer mortality statewide. these findings suggest practice and policy implications for nurses in kentucky and, potentially, other states with low educational attainment and high lung cancer mortality. introduction lung cancer was responsible for an estimated 159,390 deaths during 2009, making it the leading cause of cancer-related death in the united states (lung cancer alliance, 2009). the disease is particularly problematic in kentucky, where a rate of 80 lung cancer-related deaths per 100,000 population is much higher than the national rate of 55 deaths (kentucky institute of medicine [kiom], 2007). in fact, each of kentucky’s 120 counties has a lung cancer mortality rate that exceeds the national average. an obvious research question, then, is what aspects of life in kentucky increase the risk of dying from lung cancer? an additional consideration is the role the state’s nurses can play in mitigating this health disparity. the purpose of this study was to determine whether kentucky’s county-level lung cancer mortality is related to two socioeconomic predictors (high school graduation rates and per capita http://www.mc.uky.edu/ruralhealth/researchinfo.asp mailto:dagros3@email.uky.edu 76 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 personal income levels). lung cancer mortality’s association with a personal behavior, adult smoking rates, also was evaluated. finally, the study was designed to detect the influence of appalachian versus non-appalachian residence (that is, whether significant differences exist among the variables between these two distinct regions of kentucky). tobacco smoking is the primary risk factor for lung cancer and accounts for approximately 87% of lung cancer-related deaths (mannino, aguayo, petty, & redd, 2003; the washington post, 2008). kentucky’s heritage as a tobacco-growing state and continued high level of tobacco production have fostered, to a large degree, a cultural acceptance of smoking among its residents. consequently, kentucky had the nation’s highest rate of adult smokers each year from 2000 to 2007, and again in 2009 (behavioral risk factor surveillance system [brfss], 2010). the state’s first local law to limit indoor smoking in public facilities was not enacted until 2004, and as recently as 2005 kentucky’s cigarette excise tax of 3 cents per pack was the lowest in the nation. since that time, 26 other kentucky communities have adopted smoke-free laws or regulations, and the cigarette excise tax has been raised to 60 cents per pack, which ranks 39 th among the states (kentucky center for smoke-free policy, 2010; national conference of state legislatures, 2009). these developments are credited with helping to reduce kentucky’s adult smoking rate from a high of 32.6% in 2002 to its current level of 25.6% (brfss, 2010). hahn (a university of kentucky college of nursing professor) and other researchers have analyzed smoke-free legislation’s positive effect on smoking cessation behaviors in lexington, ky., and its association with reduced asthma-related emergency department visits (hahn et al., 2008; hahn, rayens, langley, darville, & dignan, 2009; rayens et al., 2008). yet, exposure to secondhand smoke remains a concern in most kentucky localities. this study analyzed lung cancer mortality in kentucky’s 54 appalachian counties (primarily those in the eastern and southern portions of the state, with 94.4% classified rural) (economic research service, 2003) compared to the rates in its 66 non-appalachian counties (those located in the central, northern and western regions, which include the state’s three urban centers). like much of appalachia, kentucky’s mountain counties have long been associated with cultural isolation, limited educational opportunities and heavy reliance on extractive industries such as coal mining. prior research documents heightened rates of lung cancer incidence and mortality in appalachia, with increasing concentrations over time in kentucky and other states in central appalachia (grauman, tarone, devesa, & fraumeni, 2000; lengerich et al., 2005; lengerich et al., 2004). more recent studies suggest lung cancer may be amplified within coal-mining areas of appalachia because of exposure to environmental contaminants (hendryx & ahern, 2008; hendryx, o’donnell, & horn, 2008). lung cancer also has been associated with occupational exposures (engholm, palmgren, & lynge, 1996; the washington post, 2008). most of kentucky’s appalachian counties (38 out of 54, or 70.4%) are labeled as economically “distressed” by the appalachian regional commission (2008) based on their multi-year rates of low per capita income and elevated rates of poverty and unemployment. the area’s pervasive poverty is evidenced by the fact that kentucky accounts for nearly half of the 81 distressed counties within the entire 13-state appalachian region. 77 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 background as a whole, kentucky’s high school graduation rate trails the us average by 8 percentage points, while its per capita personal income level is $6,000 below the national rate (kiom, 2007). a review of previous studies indicates that, regardless of age, socioeconomic status is an important determinant of individuals’ overall health. deaton, for instance, noted that “proportional increases in income are associated with equal proportional decreases in mortality throughout the income distribution” (2002, p. 13). of particular relevance to this project is that smoking rates generally are higher among the poor and less educated. hemminki and lee (2003) documented the association between an individual’s level of education and his/her risk of developing lung cancer. in their study, 760,000 invasive cancer cases from the swedish family-cancer database were analyzed. subjects were identified according to educational attainment and cancers were tracked from 1971 to 1998. while overall cancer risks showed only minimal differences based on education, some site-specific cancers varied significantly depending upon educational group. lung cancer was much less common in those who were university educated (standardized incidence ratio of 0.47) than those with less than nine years of education (standardized incidence ratio of 1.00). previously, gorey and vena (1995) had reported on a cancer incidence study described as the first to examine lung and other site-specific cancers among the poor and what was a new socioeconomic status measure: the near poor, or persons living below 200% of the federal poverty level. by tracking new york state cancer registry data for nearly 42,000 cases from 1979 to 1986, the authors found that near poverty status in and of itself was a cancer risk factor. for instance, the lung cancer rate for women living in high-poverty areas (those with census tracts in which more than half of residents were below 200% of the federal poverty level) was approximately twice that observed among women living in areas with lower poverty rates. gorey and vena did not explicitly discuss why living in impoverished areas increased residents’ susceptibility to lung or other types of cancer, only referencing the “attendant health risks” (1995, p. 363) found within such locations. the authors likely were alluding to the premise that, in general, a high socioeconomic status allows one to make healthier choices, while low education forces geographic and work choices that place one at greater risk of environmental and occupational exposures. indeed, it has been suggested that health may be influenced by multiple “place effects” (macintyre, ellaway, & cummins, 2002, p. 125) (e.g., air and water quality, the availability of non-hazardous employment, access to education, socio-cultural features, and an area’s reputation). hypotheses based on this review of the literature, it was expected that negative relationships would be detected between county-level lung cancer mortality and the independent variables high school graduation rates and per capita personal income levels. therefore, stated hypotheses were that the lower a county’s high school graduation rate and/or per capita personal income level, the higher its lung cancer mortality rate would be. 78 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 methods the primary data source for this study was kiom’s 2007 report the health of kentucky: a county assessment. this document analyzed kentucky counties’ health status based on 25 different health-related measures, which were used to produce a 1 (best) to 120 (worst) ranking of counties’ relative health status. because of variation in the number of county-level deaths each year, data were combined for multiple years (1997-2004) to produce more stable rates for some measures. this study’s dependent variable was county-level lung cancer deaths per 100,000 population, with original data derived from the kentucky cancer registry inquiry system. independent variables were: counties’ per capita personal income levels, or the mean income computed for every man, woman and child in a particular group, from the bureau of economic analysis, u.s. department of commerce; high school graduation (percentage of adults 25 years or older in each county who had graduated from high school), from the u.s. census bureau and kentucky state data center; and prevalence of smoking (percentage of adult population within each county), from the kentucky behavioral risk factor surveillance survey. appalachian counties in kentucky were designated by the appalachian regional commission, a federal-state partnership charged with facilitating community and economic development. this designation is based on geography, certain economic criteria and political considerations. the use of county-level variables is especially appropriate in kentucky, which ranks third among the states for number of counties (national association of counties, 2009). county borders influence personal attributes and behaviors in a number of ways related to this study, including school systems’ dropout rates, employment opportunities and whether indoor smoking bans are in effect. as such, data were not weighted by population in order to more fully reflect the collective, shared experiences of residents within each county. independent samples t tests were conducted to compare the variables’ means within kentucky’s appalachian and non-appalachian counties. correlation coefficients were calculated to determine whether statistical relationships exist between county-level lung cancer mortality and counties’ high school graduation rates, per capita personal income levels and adult smoking rates. finally, regression analyses were carried out to predict lung cancer mortality as a function of each independent variable. these analyses were conducted using spss statistics 16.0. alpha was set at .05 for all tests. results exploration of the data revealed practical differences between kentucky’s appalachian and non-appalachian regions with regard to most of this study’s variables. for example, high school graduation rates ranged from 49% to 80% in appalachian counties, compared to 61% to 87% in non-appalachian counties. yet adult smoking rates had the same range within the two regions (from 20% to 36%). table 1 shows the results of independent samples t tests analyzing the variables’ regional differences. statistically significant differences were detected between the regions’ means for lung cancer deaths, per capita personal income and high school graduation rate. in other words, it is 79 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 table 1. differences between kentucky counties for various health indicators county designation health indicator appalachian non-appalachian p value lung cancer deaths (per 100,000) 86.4 76.8 < .001 per capita personal income $19,693 $25,339 < .001 high school graduation rate 60.1% 74.0% < .001 adult smoking rate 28.9% 27.5% .078 (n = 54) (n = 66) unlikely these samples “could have been drawn from the same population” (meier, brudney, & bohte, 2009, p. 218). the adult smoking rate difference, however, was not significant at the designated .05 level. of note is that appalachian counties had a less favorable rating for each variable. this suggests kentucky’s lung cancer mortality and socioeconomic disparities are more acutely felt in rural areas. the regional and statewide associations between lung cancer mortality rates and each independent variable are presented in table 2. this analysis required the calculation of pearson’s r correlation coefficients with two-tailed tests. within the respective regions, most variables were not significantly related with lung cancer mortality rates. on a statewide basis, however, significant negative associations were found between lung cancer mortality and counties’ high school graduation rates and per capita personal income levels, while adult smoking rates had a significant positive association with lung cancer mortality. these findings are not unexpected, as associations typically become more stable as sample size (in this case, the number of counties) increases. regression analyses were carried out to predict statewide lung cancer mortality as a function of the independent variables. in a multivariate linear regression containing each independent variable and a dummy variable representing counties’ designation as either appalachian or non-appalachian, the variables accounted for 21.4% of explainable variation in statewide lung cancer mortality (table 3). in this model, only one variable (high school table 2. correlation results for predictors of lung cancer mortality in kentucky correlation with lung cancer mortality rates independent variable appalachian counties non-appalachian counties statewide per capita personal income -.185 -.077 -.302** high school graduation rate -.393** -.187 -.470*** adult smoking rate .103 .245* .210* *p < .05; **p < .01; ***p < .001 80 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 table 3. summary of ordinary least squares regression analysis for variables predicting lung cancer mortality in kentucky counties variable b coefficient std. beta coefficient t score p value constant 113.241 9.029 < .001 b1 per capita personal income .000 .157 1.227 .222 b2 high school graduation rate -.685 -.509 -3.231 .002 b3 adult smoking rate .286 .096 1.137 .258 b4 county designation -1.898 -.075 -.621 .536 adjusted r square = .214; f = 9.080 (< .001) graduation rate) remained significantly associated with lung cancer mortality rates. counties’ graduation rates and per capita personal income levels were highly correlated (r = .772), but tests for multicollinearity among the variables were negative (i.e, each had an acceptable variance inflation factor – 3.753 and 2.480, respectively). table 3 can be further interpreted to project that, over time, each 1 percentage point increase in high school graduation rates would produce .685 fewer lung cancer-related deaths per 100,000 population. the somewhat linear association between county-level lung cancer mortality in kentucky and counties’ high school graduation rates is displayed as a scatter plot in figure 1. figure 1. kentucky’s county-level lung cancer mortality as a function of high school graduation rates 81 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 discussion and conclusions limitations of this study include its focus on a single behavioral predictor of lung cancer mortality. this focus on adult smoking rates neglects the possibility of such other causes as occupational and community exposures to additional toxins. these exposures are known to increase health risks. for example, the combination of coal mining and smoking has been shown to increase individuals’ likelihood of developing lung cancer (miyazaki & une, 2001). another possible synergy is the acceptance of high levels of secondhand smoke in areas with elevated smoking rates. this study also did not include counties’ demographic features. the absence of these and other potential variables might have contributed to this study’s underspecified regression model. further evidence that variables beyond the scope of this study affect lung cancer mortality rates can be observed in figure 1, which illustrates the presence of an outlier within the data. gallatin county, located in northern kentucky, had an average high school graduation rate (68%), as well as an average per capita personal income level and a slightly above average adult smoking rate, but had the state’s highest rate of lung cancer mortality (124 deaths per 100,000 population). it should be noted that with a population of barely more than 8,000 (kentucky state data center, 2009), gallatin’s mortality rate would be sensitive to even modest increases in lung cancer-related deaths. still, one-sample t tests found gallatin’s lung cancer mortality to be significantly higher than the means for other non-appalachian counties and kentucky as a whole (p < .001 for both measures). although some researchers support the removal of outliers to avoid inflated error rates and statistical distortions, in this case including gallatin county in the data was the more conservative approach. future research should more closely analyze relationships between lung cancer mortality and its potential causes in this and other counties with significantly high lung cancer death rates. despite its limitations, this study found statewide associations in the hypothesized direction for lung cancer mortality with high school graduation rates and per capita personal income levels, as well as statistically significant differences between kentucky’s appalachian and non-appalachian counties for each variable except adult smoking rates. adult smoking rates were similar in appalachian and non-appalachian counties in kentucky and were not significantly associated with counties’ lung cancer mortality rates in a multivariate linear regression model that included high school graduation rates, per capita personal income and county designation. in the context of similar adult smoking rates, lower high school graduation rates were significantly associated with increased lung cancer mortality. appalachian counties had significantly lower high school graduation rates, and graduation rates showed the strongest statistical association with lung cancer death rates, which might explain higher lung cancer mortality in appalachian counties. in that regard, this study provides support for prior research suggesting that education may be the best socioeconomic predictor of individuals’ disease risk factors and overall health (robert wood johnson foundation, 2009; wamani, tylleskär, åstrøm, tumwine, & peterson, 2004; karlson et al., 1995; ross & wu, 1995; winkleby, jatulis, frank & fortmann, 1992). indeed, level of educational attainment can influence personal and collective social milieu in a number of ways. these include: occupation (e.g., one’s likelihood of working as a coal miner); place of residence (e.g., proximity to coal-mining sites); amount of disposable income; adherence to healthy behaviors (e.g., one’s likelihood of not smoking); and one’s likelihood of participating in health promotion programs. 82 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 these findings suggest that kentucky’s emphasis on improving high school graduation rates, which resulted in a 6.2 percentage point gain during a recent five-year period (jester, 2008), may contribute to future reductions in statewide lung cancer mortality. it also has the potential to address other health disparities between kentucky’s appalachian and nonappalachian counties, provided that graduation rates in appalachian counties catch up with the rest of the state. implications for nurses relevant to this study is that nurses have demonstrated effectiveness as smoking cessation interventionists (rice, 1999; rice & stead, 2006), despite a reported lack of education in treating tobacco dependence (wewers, kidd, armbruster, & sarna, 2004). previous studies, however, indicate that more than one-third of current smokers have not been asked about their smoking status by nurses or other clinicians (fiore et al., 2000). this might be partially attributable to smoking rates among nurses, which are estimated at 18% nationally and up to 25% in kentucky (bialous, sarna, wewers, froelicher, & danao, 2004; adams, 2010). scholars have expressed concern that “nurses who smoke may be less apt to support tobacco-control programs or encourage their patients to quit” (medical news today, 2008, p. 1). these confounders, in combination with this study’s findings, suggest that relying on clinicor hospital-based smoking cessation counseling will not adequately reduce the risk of lung cancer mortality among patients. rather, an approach that encompasses the social determinants of health might be required. stanton (2009) has outlined several rural nurse competencies that would be applicable to such an approach. for instance, she noted that rural nurses should be “acutely aware of disparities;” “have broad clinical skills that ... span all levels of care including health promotion and disease prevention;” and “need to be proficient ... with accessing educational opportunities for themselves and their colleagues” (stanton, p. 8). perhaps an additional rural nurse competency should be proficiency in accessing educational opportunities for patients. whereas dunkin and dunn (2009) suggested that every patient receive a spiritual assessment, this study indicates that a more in-depth evaluation of patients’ educational attainment is warranted. while it is not uncommon at initial check-in for patients to be queried on this topic, the line of questioning often begins and ends with, “what is the highest level of education you have completed?” for adults whose response is “less than high school,” nurses or other clinicians should seek additional information (e.g., the patients’ willingness to pursue a high school diploma or ged, perceived barriers to doing so, interest in receiving further assistance). state-level data suggest it is entirely appropriate for nurses to advocate that such patients advance their education. among the 20 states (plus the district of columbia) that experienced at least a 5 percentage point decline in adult smoking rates between 1999 and 2009, nearly onequarter had a corresponding reduction in the proportion of residents who had not completed high school (brfss, 2010). this study also highlights the ideal position of school nurses to address education-related issues among their patients. school nurses should act as educational encouragers. moreover, advocates have posited that “school nurses promote student success because healthy students are better learners” (kentucky school nurse association, n.d., p. 1). the association between school nurse practice and students’ educational outcomes has been identified as a research priority for school nursing (edwards, 2002). 83 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 yet, the impact of individual interventions on lung cancer mortality rates and other health disparities is modest. to get at the core of such issues, nurses must be willing to embrace the role of community activist. prior research indicates that nurses generally have had limited public policy involvement (whitehead, 2003; peters, 2002; oden, price, alteneder, boardley, & ubokudom, 2000). more recently, however, gangeness (2009) suggested that communityfocused nurses have the capacity “to inform the development of health care policy” (p. 62). the most immediate benefit seemingly could be produced by rural nurses who become involved at the local level. with regard to lung cancer mortality rates, that likely would include advocating for laws or regulations to limit indoor smoking in public facilities. based on this study’s findings, nurses also should urge local school districts to adopt policies that increase student achievement and reduce dropout rates. author note the original version of this study received the national rural health association’s 2009 lavonne straub memorial student research paper award. the author wishes to acknowledge cynthia m. cole, phd, a retired associate professor in the university of kentucky’s department of behavioral science, and jo ann g. ewalt, phd, director of eastern kentucky university’s master of public administration program, for their assistance. references adams, s. 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[medline] http://www.rno.org/journal/index.php/online-journal/article/viewfile/190/237 http://www.ncbi.nlm.nih.gov/pubmed/15482596?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=4 http://www.washingtonpost.com/wp-dyn/content/article/2008/12/12/%0bar2008121203332.html http://www.washingtonpost.com/wp-dyn/content/article/2008/12/12/%0bar2008121203332.html http://www.nursingoutlook.org/article/s0029-6554(04)00008-9/abstract http://www.ncbi.nlm.nih.gov/pubmed?term=%22nurse+education+today%22%5bjour%5d+and+whitehead%5bauthor%5d+and+nurse%2c+policy&transschema=title&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=%22american+journal+of+public+health%22%5bjour%5d+and+82%5bvolume%5d+and+6%5bissue%5d+and+816%5bpage%5d nance_634_formatted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 133 hepatitis c treatment at a rural navajo health clinic using project echo anna r. nance, dnp-c, rn1 lori s saiki, phd, rn, cccn2 elizabeth g kuchler, dnp, aprn, fnp-bc3 conni deblieck, dnp, msn, rn4 susan forster-cox, phd, mph, mches5 1 graduate assistant and dnp candidate, school of nursing, new mexico state university, anance15@nmsu.edu 2assistant professor, school of nursing, new mexico state university, lsaiki@nmsu.edu 3assistant professor, school of nursing, new mexico state university, ekuchler@nmsu.edu 4associate professor, school of nursing, new mexico state university, deblieck@nmsu.edu 5professor and on-line coordinator, department of public health sciences, new mexico state university, sforster@nmsu.edu abstract purpose: hepatitis c incidence is higher among american indian/alaskan native populations than any other racial or ethnic group in the united states. chronic hepatitis c complications include cirrhosis of the liver, end stage liver disease, and hepatocellular cancer. direct acting antiviral treatment taken orally results in > 90% cure, yet rural primary care providers lack the training and confidence to treat and monitor patients with chronic hepatitis c. rural patients are reluctant to travel to urban areas for hepatitis c treatment. project echo is an innovative telementoring program where specialists mentor primary care providers via videoconferencing to treat online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 134 diseases they would otherwise be unable to manage. the purpose of this quality improvement project was to increase hepatitis c treatment at a rural navajo health clinic through partnership with project echo specialists. methods: this quality improvement project was guided by lippitt’s phases of change theory. the systematic process plan included a protocol for roles and expectations of all members of the healthcare team, a documentation and communication plan, and a tracking system for monitoring patient progress through the plan of care. outcomes were analyzed by descriptive statistics. findings: following partnership with project echo, six patients (31.6%) consented to receiving hepatitis c treatment at the rural navajo health clinic. all six were contacted by outreach staff at multiple points during the project. five (26.3%) completed the full course of drug therapy. four (21.1%) completed follow-up lab work, of which three (15.8%) had a documented cure by sustained virologic response. conclusions: hepatitis c care via project echo-rural clinic partnership was affordable, feasible and not excessively time consuming for a facility with substantial patient outreach resources. key words: rural health clinic, hepatitis c, project echo, tele-mentoring, native american hepatitis c treatment at a rural navajo health clinic using project echo the hepatitis c virus (hcv) invades the liver and causes inflammation (american association for the study of liver diseases-infectious diseases society of america [aasldidsa], 2018). according to the centers for disease control and prevention (cdc, 2016), hcv is responsible for more deaths than all other reportable infectious conditions combined. hcv mortality is estimated at 4.45 deaths per 100,000 persons, and an estimated 3.5 million people in online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 135 the united states live with chronic hcv (cdc, 2016). possible consequences of chronic hcv include cirrhosis of the liver, end stage liver disease, and hepatocellular cancer (thornton, 2015). the incidence of hcv is higher in american indian and alaskan native populations than in any other racial or ethnic group (cdc, 2016). american indian and alaskan native populations had a reported hcv incidence of three cases per 100,000 people; while the white, non-hispanic ethnic group had an incidence of one case per 100,000 people (cdc, 2016). there are an estimated 23,000 to 55,000 chronic cases of hcv infection in the state of new mexico (new mexico hepatitis c coalition, 2016). this represents 1.10% to 2.63% of the total population in new mexico, estimated at 2,088,070 (united states census bureau, 2017). given the possibility of grave consequences from untreated hcv, timely expert care is essential in management of this disease (aasld-idsa, 2018). since 2013, direct acting antiviral treatment has been available, which is taken orally and has a cure rate greater than 90% (department of health and human services [dhhs], 2017). with current medications, most cases require eight to twelve weeks of daily medication and few side-effects are reported (dhhs, 2017; project echo, 2018b). the alamo navajo reservation is located in a rural area of socorro county, new mexico. at the most recent census, 2,006 people were living in the alamo chapter of the navajo nation (navajo division of health & navajo epidemiology center, 2013). according to the united states department of agriculture (usda, 2019), the rural-urban commuting area codes (ruca) classify census tracts by population density, commuting patterns, and area urbanization. the census tract that includes the alamo navajo reservation received a 2010 ruca code of 10 and had a calculated population density of 3.3 people per square mile (usda, 2019). to illustrate the online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 136 rural nature of this community, the nearest grocery store is approximately a one-hour drive from the center of alamo. the alamo navajo health center or “alamo clinic” is located at a two-hours’ drive from the nearest healthcare facility currently accepting referrals for hcv treatment. the clinic and community, therefore, are not only rural but also isolated from necessary healthcare services (alamo navajo chapter, 2018). prior to this project, patients had to receive a referral for further care, as there were no providers trained to treat hcv available at the alamo clinic. additionally, the community health nurse at the alamo clinic observed issues with follow through on referred treatment, as evidenced by only one individual in the community having been successfully treated for a chronic hcv infection (t. winchester, personal communication, july 2018). this individual was a pediatric patient taken to the regional health center by a parent. none of the 19 adults in the community who were known by the alamo clinic to have hcv had followed through on receiving treatment with specialists at the regional medical center (t. winchester, personal communication, july 2018). in 2003, dr. sanjeev arora developed project extension for community health outcomes (echo) while working at the university of new mexico health sciences center (unmhsc) to address the needs of rural communities and underserved populations facing growing incidence of hcv infections. project echo has demonstrated efficacy in bringing the necessary level of care to rural areas such as the tribal health clinic for which this project is intended (arora et al., 2014). project echo is an innovative tele-mentoring program where specialists mentor primary care providers via videoconferencing to treat diseases they would otherwise be unable to manage (arora et al., 2010). arora et al. (2010) assert that with the support of project echo, hcv care provided by rural primary care providers has the potential to be equal in quality to the care provided at online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 137 academic medical centers. a systematic review by zhou et al. (2016) assessed patient and provider outcomes of project echo across 39 studies, including four studies on hcv treatment, and concluded that patient outcomes were comparable between facilities using project echo and care provided in a specialist’s office. background two options were available to provide hcv treatment services for the population served by the alamo clinic. one option was to provide patients with a referral to a specialist at a regional medical center located at a minimum of 85 miles and up to 135 miles distance from the clinic, depending on whether the unpaved portion of the shorter route is passable. this option was previously tried and resulted in only one pediatric patient receiving treatment for hcv. no adults travelled to receive treatment. the second option, using project echo, was chosen to support the family practice clinic to provide hcv treatment in this rural setting. project echo established a base of evidence and established tele-mentoring procedures to enable safe hcv care for patients and a positive experience for family practice providers (zhou, et al., 2016). project echo was considered a logical fit for the alamo clinic. a literature review of the available evidence on project echo was conducted and provided an assessment of project echo including valuable evidence on: quality of care provided with the echo model (arora et al., 2011), professional experience of providers using echo (dubin et al., 2015; fisher et al., 2017; pindyck et al., 2015), likelihood patients in rural areas would receive needed care (carey et al., 2016), and financial acceptability of increasing care for hcv (rattay et al., 2017). the strongest single study evidence for project echo’s hcv treatment program was conducted by arora et al. (2011). this study provided the rare example of a control group, as most literature identified on project echo surveyed only one cohort of healthcare providers. this study online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 138 established that care given at echo sites was equal to care given in an academic medical center by comparing patient outcomes such as sustained virologic response (svr) and serious adverse events (sae). rural facilities such as the alamo clinic have recognized the need for an increased specialized care support network for providers. project echo demonstrates decreased professional isolation, increased professional support, increased access to specialty consultation, and resulted in valuable feedback from specialists (dubin et al., 2015; fisher et al., 2017; pindyck et al., 2015). additionally, the program was designed to meet the needs of underserved communities and to address health disparities such as those observed in this tribal health center (project echo, 2018a). at the unmhsc project echo hub, tele-mentoring services are provided at no cost to family practice clinics. no facility agreement is needed, however provider training at the project echo hub is recommended. site visits are available to assess facility needs. though not specifically assessing native american communities, one article identified access to care for individuals in rural areas, which is an accurate descriptor for the alamo navajo reservation. carey et al. (2016) assessed the likelihood a patient would receive needed services based on the distance they had to travel. the authors found that living in a rural area decreased the likelihood a patient would access specialty care by 22%, yet only decreased the likelihood of accessing echo care by 2%. this illustrates patient acceptability of alternative modes of care in rural or remote locations such as the alamo clinic. from an organizational and governmental perspective, a barrier to healthcare is often financial. in the united states the amount government and insurance payors see as acceptable for expensive medical treatments is frequently set at $50,000 to $100,000 per quality adjusted life year (qaly) gained (aasld-idsa, 2017). in other words, an individual must be expected to gain online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 139 one year of life in good health condition (national institute of health and care excellence, 2018). rattay et al. (2017) found that in 95.6% of cases, treatment of hcv costs less than $50,000 per qaly. this indicates that treatment of hcv is of acceptable financial value according to established limits and indicators. purpose and theoretical framework the purpose of this quality improvement project was to develop, implement, and evaluate a systematic process plan for the use of project echo to treat patients for hcv at the alamo navajo health center. lippitt’s phases of change theory (lippitt et al., 1958) was used as a guide to the process of implementing this proposed change in services at the alamo clinic. lippitt’s phases of change theory is a seven-step framework that focuses on the responsibilities of the change agent (kritsonis, 2005). see table 1 for a description of how the framework guided this project through the implementation phases. in this project, the change agent was represented by the quality improvement project manager. table 1 lippitt’s phases of change theory as a guide to the quality improvement process phase of change steps in the quality improvement process 1. diagnose problem problem outline: alamo clinic staff were concerned about the growing number of their patients who were positive for hcv. patients were not choosing to travel for two hours to receive hcv care from the nearest specialist. the alamo clinic wanted to improve access to hcv care by providing treatment onsite with tele-mentoring support of specialists with project echo. 2. assess motivation & capacity for change motivation: alamo clinic management held long-standing discussions about the possibility of connecting with the telementoring services of unmhsc’s project echo for hepatitis c. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 140 the medical director requested a dedicated change agent to develop the process and procedures in order for the alamo clinic to be successful at integrating project echo tele-mentoring with local hcv care. barriers: uncertainties remained about funding clinic support staff and the potential cost of hcv medication. the top two reasons given by stakeholders for lack of progress in integrating hcv care with project echo were unassigned administrative needs for tracking patients and potential breakdown in communication with the high volume of temporary providers in this rural clinic. capacity: project echo was available free of charge. internet access and web cameras were already available onsite. the clinic’s pharmacist was interested in ordering the necessary medication. the chr and bhl were enthusiastic about supporting outreach efforts to provide hcv treatment locally. 3. change agent’s motivation & resources hcv is a disease affecting many patients with whom the project manager has worked for several years. improving access to hcv care in a meaningful way to this rural population by offering treatment at the alamo clinic was the primary motivation. 4. select progressive change objective the overall goal was to improve hcv treatment in the local population. in order to meet this goal, the objective of this quality improvement project was to develop functional processes and procedures to ensure success in integrating project echo telementoring with the needs of the alamo clinic staff. 5. choose appropriate role for change agent the project manager facilitated connection to project echo, use of their resources, and developed the roles and procedures of the clinic healthcare team to begin providing hcv care at the clinic. 6. maintain change after tele-mentoring with project echo, the medical director felt comfortable providing hcv care for patients using the online resources from project echo. tele-mentoring continues to be available for consultation for complicated cases. the chr and bhl continue to contact patients in need of testing and care. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 141 7. terminate the helping relationship the project manager is no longer present at this facility. the pharmacist, chr and bhl continue to coordinate with the medical director to provide hcv care. lippitt’s phases of change theory was chosen as the framework to guide this quality improvement project because it provides a clear, detailed approach to planned change. in a comparable example, manyibe et al. (2015) used this framework in a program to enhance research capabilities of faculty in minority serving institutions through a peer mentorship program. this bears similarity to this project as it did address native american institutions and was a peer mentorship program to enhance skills of those working in underserved areas. the systematic process plan developed in this quality improvement project included a protocol for roles and expectations of all members of the healthcare team, a documentation and communication plan, and a tracking system for monitoring patient progress through the plan of care. the primary objective was for patients to receive hcv treatment at the alamo clinic where they are more likely to complete the course of treatment, rather than by referral to unmhsc that would involve traveling two hours away from home. the systematic process plan was evaluated for success in meeting this primary objective for a period of six months. this project was approved by the new mexico state university institutional review board, study # 17430; the acting health services director of the alamo navajo health center; and by the alamo navajo board president. method this quality improvement project established a process for providing hcv care at the alamo clinic for patients between the ages of 18 and 65. the focus of the intervention was on the workflow for the five healthcare providers, community health representative (chr), behavioral health liaison (bhl), and clinic nurse. a chr is an unlicensed person trained to help with patient online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 142 outreach, education and transportation. a bhl is a licensed or unlicensed person with similar training as a chr, with an additional focus on patients with behavioral or mental health needs. the following protocol was developed in consultation with key stakeholders representing the providers and the staff of the alamo clinic. to provide treatment for these patients in the way that was most efficient yet also ensured quality, all five providers at the clinic were authorized to discuss potential hcv treatment with the patient and order confirmatory hcv testing. managing treatment of hcv, however, was tasked to the medical director. this close monitoring of patients with hcv was considered important in ensuring quality care, as the remainder of the providers on staff were only on short term contracts with the alamo clinic. project steps step 1: december 2018, the chr began contacting patients with active hcv infections for follow-up appointments with the medical director to discuss treatment. step 2: once all pre-treatment lab work was completed, the first two patients were presented to project echo for treatment recommendations. it was initially expected that all patients would need to be presented, but it quickly became apparent to the medical director that he was confident in following the treatment algorithms, which are provided free of charge by project echo, for all patients without complications such as cirrhosis, kidney disease or other special medical concerns. figure 1 outlines the original planned workflow for the project process steps, and the modifications in process steps that were made during the project. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 143 figure 1 project workflow with modifications in practice made during the project. original workflow modifications detectable hcv viral load on quantitative test ↓ positive antibody without confirmatory testing or treatment ↓ all patients with hcv who desire treatment visit with project manager does the patient need confirmatory testing? ↓ ↓ electronic referral to medical director for treatment ↓ chr contacts patient to schedule appointment with medical director ↓ is the patient a candidate for treatment now? no yes no yes ↓ discussion of healthcare plans and potential for treatment at later time ↓ project manager meets with patient obtain hcv viral load and type by standing order. discuss with patient does the patient have a detectable viral load? yes no review and sign informed consent form ↓ follow uspstf guidelines regarding repeat testing schedule appointment with medical director patient case presented to project echo/ modified to present case based on recommendation by medical director ↓ *initiate drug treatment for hcv *obtain lab work monthly during treatment *obtain hcv viral load at completion of treatment *obtain hcv viral load 12 weeks after treatment is complete is the viral load detectable? yes present patient to project echo for recommendation no patient has achieved svr online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 144 note. *indicates points in treatment plan for chr or bhl to contact patient. one additional patient was presented for concerns over comorbid conditions prior to initiation of treatment. after the patient was deemed appropriate for treatment, the pharmacy began the process of ordering medication and obtaining approval from the patient’s insurance carrier. all patients had access to medications without financial burden. step 3: patients were tracked throughout the process of treatment by using the nice hep c patient management tool excel spreadsheet available at the northern tier initiative for hep c elimination (nice) project (gazarian & owen, n.d). once a patient was determined to have a sustained virological response, then they were discharged from the hcv patient cohort (u.s. department of veteran affairs, 2015). patients who did not complete follow-up lab work on schedule were contacted in person and by phone by the chr or the bhl. measures project process measures were chosen to assess both the workflow for hcv care in the primary care clinic and the effectiveness of the workflow in assisting patients to enter and complete hcv treatment. of patients entering hcv treatment, the goal was for 65% to be presented to project echo. most hcv patients were known to the chr or bhl as members of the community and likely to be located, therefore a goal of 75% contact success was set. contact success was defined as achieving direct communication with the patient, either by phone or in person. patient outcome measures included: • evaluation of the percent of hcv patients entering treatment who were presented to project echo, • percent of those who completed the full course of drug therapy, online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 145 • percent who completed lab work at or after 12 weeks post therapy, and • percent of those who achieved a cure. “cure” was defined as a sustained virologic response (svr), determined by lab work as undetectable levels of the hcv in a patient’s blood after a 12-week period following completion of drug treatment (aasld-ida, 2018). results at the outset of this project there were 19 people identified as patients of the alamo clinic who had detectable hepatitis c viral loads. all 19 patients were aware of their disease status and all were contacted by the chr or bhl and offered treatment. thirteen declined to enter the hcv treatment protocol for undisclosed reasons. during the project period, six patients (31.6%) chose to receive treatment for hcv at the alamo clinic. three of these patients (50%) were presented by the medical director at the alamo clinic to project echo for tele-mentoring. the remaining three patients (50%) had no comorbid conditions, and the medical director determined that he was able to follow the project echo treatment algorithms without presenting the patient at a tele-conference. see figure 2 for the flowchart of patient decisions and responses during the project. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 146 figure 2 flowchart of patient decisions and responses to phases of treatment. all six of the patients who consented to treatment were successfully contacted by the chr or bhl for follow-up care on multiple occasions. both the chr and bhl had permission to drive patients to the clinic for lab work, appointments or medication pick-up. of note, five of six patients (83.3%) did pick up all prescribed medication and therefore these five patients completed the full assessed for eligibility (n = 19) declined participation (n = 13) entered into treatment (n = 6) picked up full course of medication (n = 5) “cure” documented by sustained virological response (n = 3) picked up partial course of medication (n = 1) completed follow-up lab work (n = 3) completed follow-up lab work (n = 1) did not complete follow-up lab work (n = 2) unknown virological response (n = 2) did not achieve sustained virological response (n = 1) online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 147 course of drug therapy according to the local pharmacist (t. zemenfes, personal communication, july 2019). one patient completed a partial course of drug therapy. obtaining follow-up lab work was the most challenging aspect of this project. the chr provided in-person reminders at least once to all patients who had lab work due. four of the six patients (67% of the participants) returned for lab work at or after 12 weeks post-treatment and three (50% of the participants) achieved svr. for the three patients whose cases were presented to project echo by the clinic medical director, two achieved svr following a full course of drug therapy. the third patient presented to echo was determined to be a treatment failure. this patient did not complete a full course of drug therapy and declined further care. options presented to the patient included referral to a specialist, or having their case presented to project echo again for follow-up and advice on how to proceed with care through the alamo clinic. all three of the patients whose cases were not presented by the medical director completed their full course of medication. one achieved documented svr. the other two did not complete their lab work and so their virologic response to the full course of medication was unknown. discussion of the 19 positive cases of hcv at the start of this project, we observed completion of treatment for five patients (26.3%) and confirmed “cure” of hcv for three patients (15.8%). while there is clearly a continued need for hcv treatment at this clinic, these results were an improvement over having only one patient treated in the years prior to implementing this quality improvement project. of importance in monitoring the success of future implementation of hcv care in a rural clinic setting, the six patients who entered treatment were motivated to complete drug treatment but not necessarily to complete laboratory testing. this is evidenced by five of six online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 148 patients picking up their medication, but only four patients completing follow-up laboratory testing. to compare these results to those of other facilities, a morbidity and mortality weekly report stated that approximately 46% of all patients seen by a project echo connected provider actually started hcv treatment. in comparison, 14-22% of patients receive treatment for hcv in the absence of project echo’s availability (mitruka et al., 2014). while the treatment rate for this facility was lower than 46%, this may potentially be attributed to a small sample size or to a particular level of privacy and stigma in this community where patients personally know many staff members in the clinic and are hesitant to present for hcv care. lippitt’s phases of change theory was a useful framework to guide this project. having a change agent (project manager) dedicated to developing the workflow and identifying the roles of the support staff was crucial to navigating the challenges that arose in terms of patient contact and follow-up. the alamo clinic faces a constantly changing medical staff, a very busy medical director, and an enthusiastic chr and bhl who are consistent members of the team. having defined roles and a project plan to follow supported the alamo clinic staff in implementing hcv treatment, with project echo as a support for the medical director. although some of the patients in this project entered hcv treatment at their own request, some entered after being contacted by the chr or bhl. following entry into treatment, the chr and bhl contacted people in person or by phone and were able to locate and communicate with patients readily. patients were willing to come in to have visits regarding initiation of treatment and to pick up medications. the availability of the chr and bhl with vehicles to visit patients at home, and offer transportation to the clinic, was a valuable resource that may not be available in all rural clinics. as far as staff time and effort, it was found that it is important to have a champion and “goto” person who acted as the change agent and followed lippitt’s phases of change theory. hcv online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 149 care has not been provided in the primary care setting until very recently, and as such it is intimidating to many at all professional levels. having one licensed person learn the lab requirements, become familiar with medication payment options, and establish a connection with project echo was necessary to bring what used to be a specialty care service into the primary care setting. additionally, patients expressed preference for having someone they knew they could contact, without divulging private details repeatedly, in order to obtain the information that they need. while there were significant concerns at the outset of the project regarding costs of the medications, all patients were able to receive their medications paid for by medicaid. in tribal clinics, patients may have medicaid coverage if they are eligible, and receive care paid for by contract with the indian health service (ihs) as a secondary payor. a tribal clinic receives funds from ihs but makes decisions on how to administer those funds at a local level. notably, in all cases medicaid reimbursed at a higher rate than the cost to the pharmacy of the medication. according to the local pharmacist (t. zemenfes, personal communication, september 2019), the average wholesale price of the medication used to treat five of the six patients was $15,840 per month, but the actual cost billed to the alamo clinic was $4,215.25 per month. medicaid reimbursement reflected the wholesale cost and was paid to alamo clinic as $14,002 per onemonth supply per patient. the bi-weekly conference with project echo was underutilized during the project. more could have been learned about hcv care and associated issues by attending the bi-weekly teleconference. this would be the role of a champion, to have someone learn and share information to elevate the quality of care provided throughout the clinic. the resources of project echo, however, were essential for establishing hcv care at the alamo clinic. project echo provides a online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 150 wealth of free and up-to-date information on essential requirements for appropriate hcv care and medication selection. additionally, the opportunity to present the very first patients who had ever agreed to be treated for hcv at this clinic provided needed support to the alamo clinic providers for expanding to this new domain of primary care services. because the patients who agreed to receive treatment at the alamo clinic were predominantly healthy individuals without any complications of their hcv infections, the treatment guidelines available online were the most used resource and were rigorously followed in all six cases. alamo clinic provider and staff attendance at the project echo tele-conferences would be essential if a patient developed complications related to their hcv progression or treatment. limitations this facility has challenges and needs particular to the reality of having only one full time healthcare provider. having the medical director serve as the hcv provider is not ideal, as this position requires many additional work responsibilities. it would be preferable for a provider to lead this type of project with dedicated time to regularly participate in project echo sessions and manage patient care coordination concerns. lessons learned treating hcv is possible in any rural clinic with the support of project echo. all key information needed is readily available online and consults with a specialist are made accessible through tele-conference, as well as phone or email when appropriate. additionally, connecting with others who are treating hcv in the primary care setting provided further support and resources to allow confidence in the clinical management. in retrospect, more time should have been devoted to attending the bi-weekly echo conferences as there are weekly didactic presentations and case presentations that could have added valuable information to the care online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 151 provided. this could be changed moving forward to provided dedicated time for a project champion to attend these conferences. the challenges faced in this project were related to patient engagement and laboratory testing. thirteen eligible patients did not participate in hcv treatment for unknown personal reasons. it is worth further exploring this issue as the treatment now is highly effective and readily available. it is not clear why some patients did not complete follow-up laboratory testing. possibly more education was needed in this area either directly to the patients or delivered by the chr and bhl. conclusions hepatitis c care has changed significantly with the availability of direct acting antiviral medications and the support of telemedicine such as project echo. primary care providers are now able to diagnose and treat hcv if they are ready to obtain the modest amount of additional education necessary to do so. it is helpful to have clinic staff who are supportive of this treatment endeavor to effectively and efficiently coordinate care for these patients in a way that allows for the best outcomes in a respectful and private setting. overall, hepatitis c care through a rural clinic-project echo partnership was found to be affordable, feasible and not excessively time consuming for a facility that has established patient outreach capabilities. the freely shared treatment guidelines from project echo provide a reference that is always available, while the teleconferences enhance knowledge and provide the opportunity for consultation with a specialist when necessary. references alamo navajo chapter. (2018, september). home. https://alamo.navajochapters.org/ american association for the study of liver diseases-infectious diseases society of america. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 152 (2017). overview of cost, reimbursement, and cost-effectiveness considerations for hepatitis c treatment regimens. https://www.hcvguidelines.org/evaluate/cost american association for the study of liver diseases-infectious diseases society of america. (2018). recommendations for testing, managing, and treating hepatitis c. http://www.hcvguidelines.org/ arora, s., kalishman, s., thornton, k., dion, d., murata, g., deming, p., parish, b., brown, j., komaromy, m., colleran, k., bankhurst, a., katzman, j., harkins, m., curet, l., cosgrove, e., & pak, w. (2010). expanding access to hcv treatmentextension for community healthcare outcomes (echo) project: disruptive innovation in specialty care. hepatology, 52(3), 1124-1133. https://doi.org/10.1002/hep.23802 arora, s., thornton, k., komaromy, m., kalishman, s., katzman, j., & duhigg, d. (2014). demonopolizing medical knowledge. academic medicine, 89(1), 30-32. https://doi.org/10.1097/acm.0000000000000051 arora, s., thornton, k., murata, g., deming, p., kalishman, s., dion, d., parish, b., burke, t., pak, w., dunkelberg, j., kistin, m., brown, j., jenkusky, s., komaromy, m., & qualls, c. (2011). outcome of hepatitis c treatment by primary care providers. new england journal of medicine, 364(23), 2199-2207. https://doi.org/10.1056/nejmoa1009370 carey, e.p., frank, j.w., kerns, r.d., ho, m., & kirsh, s.r. (2016). implementation of telementoring for pain management in veterans health administration: spatial analysis. journal of rehabilitation research & development, 53(1), 147-156. https://doi.org/ 10.1682/jrrd.2014.10.0247 centers for disease control and prevention (2016). surveillance for viral hepatitisunited states, 2016. https://www.cdc.gov/hepatitis/statistics/2016surveillance/pdfs/2016hepsurv online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 153 eillancerpt.pdf department of health and human services. (2017). national viral hepatitis action plan 20172020. https://www.hhs.gov/sites/default/files/national%20viral%20hepatitis%20 action%20plan%202017-2020.pdf dubin, r.e., flannery, j., taenzer, p., smith, a., smith, k., fabico, r., zhao, j., cameron, l., chmelnitsky, d., williams, r., carlin, l., sidrak, h., arora, s., & furlan, a.d. (2015). echo ontario chronic pain & opioid stewardship: providing access and building capacity for primary care providers in underserviced, rural, and remote communities. studies in health technology and informatics, 209, 15-22. https://doi.org/10.3233/978-1-61499-5050-15 fisher, e., hasselberg, m., conwell, y., weiss, l., padrón, n.a., tiernan, e., karuza, j., donath, j., & pagán, j.a. (2017). telementoring primary care clinicians to improve geriatric mental health care. population health management, 20(5), 342-347. https://doi.org/ 10.1089/pop.2016.0087 gazarian, n., & owen, j. (n.d.). nice projectnorthern tier initiative for hepatitis c elimination: nice hep c patient management tool. http://www.npaihb.org/ hcv/#niceproject kritsonis, a. (2005). comparison of change theories. international journal of scholarly academic intellectual diversity, 8(1), 1-7. https://pdfs.semanticscholar.org/2b7c/ 9cfbaa4aae1954522acc75f3e63b0cd3f968.pdf lippett, r., watson, j., & westley, b. (1958). the dynamics of planned change. new york, ny: harcourt, brace, & world. manyibe, e.o., aref, f., hunter, t., moore, c., & washington, a. (2015). an emerging conceptual online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 154 framework for conducting disability, health, independent living, and rehabilitation research mentorship and training at minority serving institutions. journal of rehabilitation, 81(4), 25-37. mitruka, k., thornton, k., cusick, s., orme, c., moore, a., manch, r. a., box, t., carroll, c., holtzman, d., & ward. j. w. (2014). expanding primary care capacity to treat hepatitis c virus infection through an evidence-based care modelarizona and utah, 2012-2014. centers for disease control and prevention, morbidity and mortality weekly report, 63(18), 393-398. https://www.cdc.gov/mmwr/pdf/wk/mm6318.pdf national institute for health and care excellence. (2018, september). glossary. https://www.nice.org.uk/glossary?letter=q navajo division of health, & navajo epidemiology center (2013, december). navajo population profile 2010 u.s. census. https://www.nec.navajonsn.gov/portals/0/reports/nn2010populationprofile.pdf new mexico hepatitis c coalition (2016, june). hepatitis c virus (hcv) in new mexico: statewide comprehensive plan and profile of the epidemic. https://nmhealth.org/publication/view/plan/2219/ pindyck, t., kalishman, s., flatow-trujillo, l., & thornton, k. (2015). treating hepatitis c in american indians/alaskan natives: a survey of project echo utilization by indian health service providers. sage open medicine,3, 1-5. https://doi.org/10.1177/2050312115612805 project echo (2018a, july). about echo. https://echo.unm.edu/about-echo/ project echo (2018b, july). hcv community: hcv treatment resource links; hcv treatment decision trees. https://hsc.unm.edu/echo/_docs/program-docs/hcv_resource_links online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.634 155 _aug2019.pdf rattay, t., dumont, i.p., heinzow, h.s., & hutton, d.w. (2017). cost-effectiveness of access expansion to treatment of hepatitis c virus infection through primary care providers. gastroenterology, 153(6), 1531-1543. https://doi.org/10.1053/j.gastro.2017.10.016 thornton, k. (2015). natural history of hepatitis c infection. https://www.hepatitisc.uw.edu/go/evaluation-staging-monitoring/natural-history/coreconcept/all united states census bureau. (2017, july 1). quickfacts new mexico. https://www.census.gov/quickfacts/nm united states department of agriculture. (2019, november). rural-urban commuting area codes. https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/ united states department of veteran affairs. (2015, october). faqs about sustained virologic response to treatment for hepatitis c. https://www.hepatitis.va.gov/pdf/sustainedvirological-response.pdf zhou, c., crawford, a., serhal, e., kudyak, p., & sockalingam, s. (2016). the impact of project echo on participant and patient outcomes: a systematic review, 91(10), 1439-1461. https://doi.org/10.1097/acm.0000000000001328 online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 105 psychological impact of traumatic events in rural nursing practice: an integrative review sharleen jahner phd(c), rn 1 kelly penz, phd, rn 2 norma j. stewart, phd 3 1 doctoral student, college of nursing, university of saskatchewan, sharleen.jahner@usask.ca 2 assistant professor, college of nursing, university of saskatchewan, kelly.penz@usask.ca 3 professor emerita, college of nursing, university of saskatchewan, norma.stewart@usask.ca abstract background: rural and remote nurses who practice in acute care often deal with traumatic injury and death in isolated practice with limited psychosocial support. the majority of research in this area has been conducted within urban nursing populations or non-nursing disciplines. caring for others who have experienced a traumatic event may place rural and remote nurses at a greater risk of negative psychological effects over time. purpose: this integrative review will explore the evidence related to the potential negative psychological impact of caring for those who have experienced a traumatic event in the context of rural nursing practice. method: an integrative review of four health and social science databases was conducted using the framework by whittemore and knafl (2005). main search terms included rural and remote nursing, vicarious trauma, secondary traumatic stress, post-traumatic stress disorder, compassion fatigue, trauma, and burnout. articles published between 2006 and 2017 were identified and critiqued based on their scientific merit and applicability to rural nursing practice. results: nine publications were found regarding rural and remote nurses’ exposure to traumatic events, and the potential personal and professional impact of exposure. while occupational stress online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 106 was evident within rural and remote practice, there is a lack of clarity on the traumatic stressors of greatest concern. most notable was the limited application of a rural and remote nursing lens to explore specific events linked to trauma, and the diversity of concepts used to describe the impact of these experiences. conclusion: there are few rural or remote studies that have explored the psychological impact of caring for others who have experienced traumatic events. further research is necessary to explore the specific psychological impact experienced by rural and remote nurses being exposed to traumatic events over time and types of programs necessary to better support them to continue in their practice. keywords: rural, remote, nurses, trauma, vicarious trauma, secondary traumatic stress, posttraumatic stress disorder, compassion fatigue, burnout psychological impact of traumatic events in rural nursing practice: an integrative review a traumatic event is defined by health canada (2007) as an extreme event that may occur in any location or form in which a “person is subjected to or witnesses; falls outside the range of normal experience; is life threatening or could result in serious injuries; exposes the person to shocking scenes of death or injuries” and/or “could lead a person to experience intense fear, helplessness, horror or other reactions of distress” (health canada, 2007, p.1). nurses who practice in rural and remote communities may be confronted with a higher incidence of traumatic injuries and death related to the environment (desmeules et al., 2006; peek-asa, zwerling, & stallones, 2004; shah, hagel, lim, koehncke, & dosman, 2011). higher rural-remote mortality rates occur as a result of diverse farming practices (shah et al., 2011), motor vehicle accidents (simons et al., 2010), and delays in response time, incident recovery, and trauma care (gonzalez, cummings, mulekar, & rodning, 2006; simons et al. 2010). there is concern that those who provide care for online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 107 people who have experienced a traumatic event, may themselves be at risk for negative, transformative, and permanent psychological and physical consequences (ford & courtois, 2009; mccann & pearlman, 1990; pearlman & saakvitne, 1995). there are many factors that place rural nurses at a higher risk and potentially make them more vulnerable to the impact of distressing traumatic events over time. nurses in rural practice provide care for a broad range of people living in “sparsely populated areas” which “host most high risk occupations” (winters, 2013a, p.58). they commonly work in isolation with limited support, and are expected to manage a diversity of complex patients across the lifespan (kulig, kilpatrick, moffitt, & zimmer, 2016; lesergent & haney, 2005). dealing with higher rates of trauma and death is also complicated by the fact that many rural nurses both live and work in the same community, where limited anonymity and blurring of personal/professional boundaries is often the case (lauder, reel, farmer, & griggs, 2006; misener et al., 2008). with personal knowledge of their community members, rural nurses are commonly immersed in all aspects of community life and are part of both formal and informal social networks (lauder et al., 2006; nelson, & park, 2012). given these dual or overlapping relationships, rural nurses are more likely to be intimately involved in traumatic events and witness to the suffering of their community members (nelson, pomerantz, howard, & bushy, 2007; winters, 2013b). the literature exploring the potential psychological impact of formal care providers being exposed to trauma describes constructs such as vicarious trauma (beck, 2011; bercier & maynard, 2015; cieslak et al., 2014; cohen & collens, 2013; dominguez-gomez & rutledge, 2009; graham, 2012; hensel, ruiz, finney & dewa, 2015; izzo & miller, 2010; mealer & jones, 2013; sabo, 2008; sinclair & hamill, 2007; von rueden et al., 2010), secondary traumatic stress (adriaenssens, de gucht, & maes, 2015; beck, 2011; bercier & maynard, 2015; cieslak et al., 2014, dominguez-gomez & rutledge, 2009; graham, 2012; hensel et al., 2015; izzo & miller, online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 108 2010; meadors, lamson, swanson, white, & sira, 2010; mealer & jones, 2013; von rueden et al., 2010), compassion fatigue (beck, 2011; bercier & maynard, 2015; cieslak et al., 2014, dominguez-gomez & rutledge, 2009; graham, 2012; hensel et al., 2015; izzo & miller, 2010; meadors et al., 2010; mealer & jones, 2013; sabo, 2008), burnout (adriaenssens et al., 2015; cieslak et al., 2014, graham, 2012; izzo & miller, 2010; meadors et al., 2010; sabo, 2008), and post-traumatic stress disorder (adriaenssens et al., 2015; beck, 2011; cieslak et al., 2014, graham, 2012; hensel et al., 2015; mealer & jones, 2013; von rueden et al., 2010). although distinct from one another, these constructs are at times, used interchangeably, with overlapping conceptual definitions and/or varied use across occupational disciplines in mainly urban populations. integrative review method a review of the published literature related to the psychological impact of exposure to traumatic events among rural nurses was conducted using whittemore and knafl’s (2005) five stages of problem identification, literature search, data evaluation, data analysis, and presentation. this framework was chosen to guide the review as it allows for the incorporation of a variety of research designs including experimental and non-experimental research to develop a more comprehensive understanding of a particular phenomenon (whittemore & knafl, 2005). problem identification stage a key initial aspect of an integrative review is to identify the background problem and the purpose of the review (whittemore & knafl, 2005). as was highlighted earlier, nurses who practice in rural and remote acute care settings may be at a higher risk for exposure to traumatic events in the context of their geographical isolation. given the limited access to psychosocial support within these settings, they may be at risk for negative psychological effects over time. the terms/constructs used to describe the impact of this exposure are varied, with much of the research online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 109 conducted within occupational groups other than nursing, and/or within urban practice settings. the specific research questions that guided this review were: 1. what terms/constructs are used to describe the impact of exposure to traumatic events for rural and/or remote nurses? 2. what are the potential occupational outcomes of experiencing traumatic events for rural and remote nurses? 3. what types of traumatic events are rural and remote nurses being exposed to, and which of these have the greatest impact? 4. what contextual factors are not being addressed in the literature from the perspective of nurses who provide care in rural and remote settings? an additional purpose of this review was to inform key stakeholders regarding the potential occupational consequences of being exposed to traumatic events, which may guide the development of psychosocial and supportive interventions within a rural/remote context. studies for this review were selected that focused on rural and remote nurses, and restrictions were not placed on having a clear definition of rural as a variety of terms have been used to describe the context of rural nursing, such as rural, remote, and isolation (kulig et al., 2008; macleod, kulig, stewart, pitblado & knock, 2004; misener et al. 2008). literature search stage the second stage of the review process is the literature search stage which consists of rigorous, well-defined strategies to ensure that all relevant literature on the topic is included (whittmore & knafl, 2005). search terms were chosen for this review based on those commonly used in the literature to describe the negative psychological consequences of being exposed to trauma (adriaenssens et al., 2015; beck, 2011; bercier & maynard, 2015; cieslak et al., 2014, cohen & collens, 2013; hensel et al., 2015; izzo & miller, 2010; mealer & jones, 2013; sinclair online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 110 & hamill, 2007; von rueden et al., 2010). a comprehensive search of four electronic databases included a) cumulative index to nursing and allied health literature [cinhal], b) medline, c) psychinfo, and d) cochrane library, with articles published between the years 2006 and 2017 targeted to capture the most recent literature. keyword search categories included ‘vicarious trauma’, or ‘post-traumatic stress disorder’, or ‘secondary traumatic stress’, or ‘compassion fatigue’, or ‘burnout’, or ‘nurses’, or ‘rural and remote.’ the terms were combined with ‘and’ for a more comprehensive search. the term ‘nurse(s)’ was then searched against other trauma related terms as major subject headings of ‘post-traumatic stress disorder,’ ‘secondary traumatic stress,’ ‘compassion fatigue,’ and ‘burnout.’ additional search terms were found by harvesting keywords from articles with the major subject headings including ‘trauma,’ ‘psychological stress,’ ‘occupational stress,’ ‘stress disorders,’ ‘mental health personnel,’ ‘psychosocial factors,’ and ‘mental health.’ each were explored using ‘or’ with the search terms ‘vicarious trauma,’ ‘posttraumatic stress disorder,’ ‘secondary traumatic stress,’ ‘compassion fatigue,’ and ‘burnout.’ phrase searches were then explored in pairs with ‘or’ and up to all 5 concepts by title and abstract. finally, to ensure that all considered publications were relevant to rural and remote practice, the search terms ‘rural health care personnel,’ ‘rural nursing,’ ‘rural health nursing,’ ‘rural health care delivery,’ ‘remote nursing,’ ‘rural,’ and ‘remote’ were also explored. to further enhance the search, the subheadings of ‘trauma’ and key word ‘nurse’ were explored using the process of truncation to identify more suffixes. this comprehensive search strategy provided a thorough historical overview and ensured that all relevant literature was retrieved (pluye, gagnon, griffiths, & johnson-lafleur, 2009). articles and literature reviews were included if: (a) they focused on the psychological impact of exposure to traumatic events, (b) included nurses in the sampling frame, (c) included a rural and/or remote focus, (d) the research design was either qualitative, online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 111 qualitative, or mixed method, (e) the language of publication was english, and (f) the publication date ranged from 2006 to 2017. articles were excluded if they were: (a) non-empirical, (b) unpublished dissertations or theses, or (c) focused strictly on urban practice settings. figure 1 outlines the search strategy and screening process where a total of 475 articles were initially identified during the keyword search, with two additional articles discovered through a search of the publication reference lists. following removal of 3 duplicates, 474 abstracts were screened using the established inclusion/exclusion criteria. there were 407 publications that were excluded related to not having a rural/remote focus, not published in english, they focused on traumatized populations (e.g., mothers of sexually abused children), the area of research was not relevant as it had been conducted in unique environmental and socioeconomic conditions (e.g., gaza strip, rwanda genocide), the human service worker did not include or differentiate nurses from other health care practitioners, or they were newsletters/editorials. the remaining 67 articles were read in depth and screened for their applicability, further excluding articles focusing on midwives, coping, or those that employed a weak research design or were of poor quality overall. a total of nine rural nursing focused articles were subsequently selected for final review (see hegney, eley, osseiran-moisson, & francis, 2015; kenny, endacott, botti, & watts, 2007; lenthall et al., 2009; terry, lê, q., nguyen, & hoang, 2015; singh, cross, & jackson, 2015; o'neill, 2010; opie et al., 2010; opie et al., 2011; rose & glass, 2009). data evaluation stage in addition to using whittemore and knafl’s (2005) review method to evaluate the overall quality of each article, the research critique process outlined by loiselle & profetto-mcgrath (2011) was also used to further systematically evaluate the nine articles chosen for review. articles were reviewed based on substantive and theoretical dimensions, methodology, interpretation of findings, presentation, and writing style (loiselle & profetto-mcgrath, 2011). the nine articles online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 112 included in the final review outlined the significance of the problem (i.e., rural nurses may be at risk for negative psychological effects related to trauma exposure) or identified an important issue that was relevant to one or more of the four original research questions outlined. each provided a clear study design that fit well with the research problem or purpose of the study, sound methodological approach, setting, and data collection method. there was congruence between the study purpose/research questions and study designs chosen. the sampling design was consistent with the method chosen and sample sizes and response rates were clearly identified. the use of standardized tools and data collection methods supported the data quality. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 113 figure 1. search strategy research findings, interpretation, implications and recommendations were made explicit. all articles contributed meaningfully to the current body of knowledge on the topic and have the potential to improve nursing practice. of the nine articles, two utilized qualitative methods including an emancipatory methodology (rose & glass, 2009) and a narrative inquiry with a phenomenological approach (terry et al., 2015). five of the studies employed a cross-sectional design with survey questionnaires and use figure 1: search strategy cinahl (n = 57) medline (n = 205) cochrane (n = 59) psychinfo (n = 154) potential articles identified (n = 475) reference lists reviewed to identify additional relevant articles (n = 2) total articles before duplicates removed (n = 477) articles excluded on final appraisal (n = 58) articles read in full and assessed for eligibility (n = 67) abstracts screened using inclusion/exclusion criteria (n = 474) full-text articles excluded with rationale (n = 407) duplicates excluded (n = 3) final sample (n = 9) online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 114 of standardized scales and both univariate and multivariate statistical analyses (opie et al., 2010; opie et al., 2011; singh et al., 2015; hegney et al., 2015). three studies used a thematic approach including a comprehensive literature review that presented patterns using a thematic analysis (lenthall et al., 2009), a review article that outlined themes (although a thematic analysis approach was not made explicit) (o'neill, 2010), and a study that specifically used a thematic analysis (kenny et al., 2007). none of the research was conducted using a mixed method approach or longitudinal design for research over time. despite some limitations, overall inclusion was based on the article strengths, merit, contribution to understanding, and whether they aligned with the aims of this review. data analysis according to whittemore and knafl (2005), the data analysis stage involves the process of categorizing and summarizing the main conclusions identified about the phenomenon being studied. due to the paucity of research in this area, the authors used their research questions to guide the analysis and summarization of content. a rural lens was used in this review with a specific focus on identification of the (a) specific terms used to describe the psychological impact of exposure to traumatic events over time, (b) potential occupational outcomes of experiencing trauma over time, (c) specific types of traumatic events that may be of concern in in rural/remote settings, and (d) gaps in the rural/remote literature and further research directions. review presentation stage the final stage in the review process is data presentation, which involves the provision of explicit details from each of the primary sources summarizing the final conclusions within the review (whittemore & knafl, 2005). table 1 presents the nine relevant articles according to their: (a) author, starting with the most recent year of publication, and country (b) purpose (c) sample, (d) design, (e) data collection method(s), and (f) key findings relevant to the review. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 115 results the review process yielded nine studies which will be presented with headings that represent the four research question. conceptual terms defining the psychological impact of trauma exposure in relation to our first question for this integrative review, the nine articles identified a variety of conceptual terms used to describe the psychological impact of exposure to distressing events on nurses in rural, remote, and isolated nursing practice environments. those identified were diverse in nature and included emotional toil (kenny et al., 2007), emotional strain (rose & glass, 2009), psychological distress (opie et al., 2010; opie et al., 2011), emotional exhaustion (opie et al., 2010; opie et al., 2011; singh et al., 2015), burnout (o'neill, 2010; opie et al., 2010; singh et al., 2015; terry et al., 2015; hegney et al., 2015), compassion fatigue (o'neill, 2010; terry et al., 2015; hegney et al., 2015), secondary trauma or secondary traumatic stress (sts) (o'neill, 2010; hegney et al., 2015), vicarious trauma (lenthall et al., 2009), and post-traumatic stress disorder (ptsd) (lenthall et al., 2009). although these concepts have been measured in studies involving nurses practicing in urban settings (adriaenssens et al., 2015; beck, 2011; bercier & maynard, 2015; cieslak et al., 2014, cohen & collens, 2013; hensel et al., 2015; izzo & miller, 2010; mealer & jones, 2013; sinclair & hamill, 2007; von rueden et al., 2010), they have not commonly been examined in the context of rural and/or remote nursing practice. this was made evident in this review with identification of only one study that referred to the psychological impact of exposure to trauma in the rural environment (hegney et al., 2015), one study that focused on trauma in the remote environment (lenthall et al., 2009) and one that highlighted trauma exposure in circumpolar isolated areas (o'neill, 2010). on review, there was a lack of consistency in the use of terms, with differing conceptual definitions, and/or diverse constructs being used interchangeably. for example, emotional toil was online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 116 described as the result of practicing in an emotionally challenging role that impacts a nurse’s psychological well-being (kenny et al., 2007). it was considered a key issue in providing psychological care to others and influenced by supportive networks, dual relationships, and achieving balance between tasks and care (kenny et al., 2007). emotional strain occurred when opposing social forces created an inner tension or strain between the nurse’s personal expectations of their professional practice and what is valued in the practice setting (rose & glass, 2009), and emotional exhaustion was described as the result of job demands that cause stress when personal energy is expended (opie et al., 2010; opie et al., 2011). although the above concepts each have unique aspects, all are characterized by intense emotional feelings, and suggest the importance of attending to the competing personal and professional demands that many nurses in rural and remote practice may experience. o'neill (2010) described burnout as a gradual process that begins with high levels of job stress in situations that are emotionally demanding, while singh et al. (2015) suggested that burnout involves mental and emotional exhaustion with increasing intensity which results in a sense of a lack of personal accomplishment. burnout was also found to be related to workload fluctuations (terry et al., 2015), limited resources, and lack of support (opie et al., 2010). while burnout was described as the potential outcome of emotional exhaustion (opie et al., 2010; opie et al., 2011; singh et al., 2015), the literature included in this review does not clarify whether exposure to traumatic events may lead to rural nurses experiencing burnout over time due to high levels of stress or emotional exhaustion. one concept identified as a consequence of working empathically with others who have experienced trauma was compassion fatigue, which led to lower work capacity, loss of interest, or intensified emotional responses to being empathetic (o'neill, 2010). compassion fatigue was noted to be commonly experienced by nurses (hegney et al., 2015) and similar to vicarious trauma online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 117 as it results in cognitive changes over time (terry et al., 2015). o'neill (2010) also highlighted the concept of secondary trauma or secondary traumatic stress as having a sudden onset and occurring when there is a connection or engagement between the caregiver and the trauma experience of the client and may result in symptoms of ptsd in the caregiver. lenthall et al. (2009) described ptsd as being influenced by high demands and low resources, which overlaps with the constructs of emotional toil, emotional strain, emotional exhaustion and burnout. lenthall et al. (2009) suggested that remote nurses may be at greater risk for ptsd with increased exposure to traumatic incidents in the workplace. vicarious trauma was also highlighted in the literature, and was viewed as cumulative in nature with gradual and permanent cognitive changes through the incorporation of the client’s traumatic event (o'neill, 2010). the range of effects can be detrimental as changes can be physical and/or psychological such as distortion in the areas of safety, trust, control, self-esteem, and intimacy, and may result in sensory changes (e.g., physical sensations, intrusive imagery) as well as symptoms of ptsd (o'neill, 2010). ptsd and vicarious trauma are both influenced by a high demands and low resource context in the work setting and like emotional toil, emotional strain, emotional exhaustion and burnout; are intensified by competing personal and professional expectations. it is evidence in this review that vicarious trauma, emotional toil, emotional strain, emotional exhaustion, compassion fatigue, and burnout share dimensional aspects, as they all focus on cumulative effects that may occur over time. those concepts that are specifically linked to trauma exposure are ptsd, secondary traumatic stress (sts), compassion fatigue, and vicarious trauma. in regard to viewing the above concepts through a rural lens, we have determined that while they are often described as unique constructs in the literature, they are difficult to distinguish from one another, as all but sts is characterized by gradual onset, creation of internal turmoil, require a considerable amount of online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 118 personal energy to be expended, and become an occupational stressor as a direct result of external job demands. overall, the concepts outlined in the reviewed literature vary from a behavioral, emotional, physical, and cognitive perspective; are not well defined within a rural context; and commonly overlap with each other in terms of conceptual clarity. it is evident that rural and remote nurses may be vulnerable to the detrimental effects of exposure to trauma in their work environment, and there is a need for a higher degree of conceptual clarity to better capture their unique experiences. potential occupational outcomes related to trauma exposure the occupational outcomes explored in the cross-sectional studies were diverse and measured using a variety of standardized scales (hegney et al., 2015; opie et al., 2010; opie et al., 2011; singh et al., 2015) and newly developed scales such as the ran (remote area nurses) specific job demands scale developed by opie et al. (2010). key concepts examined were occupational stress, work engagement, general health and burnout. standardized scales included the nursing stress scale (opie et al., 2010 and opie et al., 2011), general health questionnaire (opie et al., 2010 and opie et al., 2011), maslach burnout inventory (opie et al., 2010 and opie et al., 2011; singh et al, 2015), utrecht work engagement scale (opie et al., 2010 and opie et al., 2011), maslach and jackson burnout inventory (singh et al., 2015), job content questionnaire (opie et al., 2010 and opie et al., 2011) and ran-specific job demands scale (opie et al., 2010). other concepts related to workplace well-being were measured using the depression, anxiety scale and professional quality of life scale, connor-davidson resilience scale, professional practice environment scale, and nursing work index (hegney et al., 2015). five of the publications included in this review focused on the workplace environment (hegney et al., 2015; lenthall et al., 2009; opie et al., 2010; opie et al., 2011; terry et al., 2015) of which three identified stress as a significant occupational issue (lenthall et al., 2009; opie et online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 119 al., 2010; opie et al., 2011), with one suggesting that workplace psychological stress is considered hazardous (terry et al., 2015). other studies explored the potential factors influencing nurse’s health and safety, and emotional well-being (terry et al., 2015; rose & glass, 2009; kenny et al., 2007), and underscored a variety of negative emotional responses experienced by nurses who provide care to others (kenny et al., 2007; rose & glass, 2009; terry et al., 2015), specifically within the context of traumatic events (o'neill, 2010). in addition, a number of work processes within rural geographical settings were identified as unsafe, impractical, or unsustainable, and safety concerns were linked to psychological distress (rose & glass, 2009; opie et al., 2010; opie et al., 2011; terry et al., 2015). overall, the dominant themes surrounding the occupational wellbeing of nurses in rural and remote settings included compromised workplace health and safety, occupational demands and job stress, and a lack of formal psychological support. key areas of concern centered on organizational constraints (e.g., high workloads, burnout, lack of supervision, interprofessional conflict/bullying), the physical work environment (e.g., unsafe or hazardous state of client homes, unpredictable behaviour of animals, exposure to cigarette smoke), challenging client behavior (e.g., abuse, violence), and the geographical challenges of working in remote settings (e.g., travel distance, personal and professional isolation, inconsistent cellular access/communication). traumatic events and related stressors within a rural context unfortunately, this review revealed a clear lack of evidence on the specific types of traumatic events that may impact rural and remote nurses, which is of great concern. psychological distress was linked to the physical, geographic, and organizational environments in which rural nurses work, the emotional demands of working with patients (terry et al., 2015), management of lifethreatening conditions, and challenges of dual relationships (kenny et al., 2007). however, it is difficult to conclude to what degree or severity of exposure to traumatic events rural and remote online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 120 nurses may be experiencing, and what psychological impact these may have on them personally and professionally over time. nurses in rural and remote settings were found to have a broad and complex scope of practice and commonly confronted with job stress, high job demands, and a hazardous work environment as a result of violence, death, and tragedy (terry et al., 2015). in rural settings, personal and professional boundaries were blurred (o'neill, 2010), as individuals commonly knew one another or had personal relationships in the community (kenny et al., 2007). this was supported by terry et al. (2015) who found that workplace health and safety was particularly challenging in rural and remote areas where death and tragedy are common, and burnout or compassion fatigue are seldom identified as areas of concern. for nurses who are embedded in their community, dual relationships were found to have both advantages and disadvantages (kenny et al., 2007). high visibility and community scrutiny were identified as concerns as nurses in these settings are highly invested in the communities they serve. on the flip side, o'neill (2010) suggested that rural nurses' dedication and commitment may act as protective factors. however, there is still concern regarding the opposing risk factors that exist in rural and remote settings such as the lack of access to mental health services, limited collegial support (kenny et al., 2007), and reduced access to relief staffing to be able to participate in debriefing sessions or to take a personal leave of absence for mental health reasons (terry et al., 2015). contextual factors not being addressed in the literature a variety of terms were used in the reviewed literature to discuss the geographical context of rural living or non-urban nursing practice. although geographical terms related to rural, remote, or isolated setting were noted, no study clearly defined ‘rural.’ an article by kenny et al. (2007) categorized hospitals according to their size and range of services from a-e with the large urban hospitals represented as ‘a’ to the smallest hospitals represented as ‘e’. two articles used the australian institute of health and welfare (aria+) score to determine the level of remoteness online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 121 and access to services by applying a range from 0-15 (opie et al., 2010; opie et al., 2011). in a study by hegney et al. (2015), the australian standard geographical classification was used to identify rural, remote, and major cities based on workplace postal code, and a study conducted in the northern isolated wilderness and minimally populated area was described as circumpolar (o’neill, 2010). lastly, lenthall et al. (2009) characterized remote by geography, professional and social isolation, and the remote nature of practice and defined the primary care nurse sample as “specialist practitioners that provide and coordinate a diverse range of healthcare services for remote, disadvantaged or isolated populations” (p. 208). on review of the constructs through a rural lens, it was determined that there was overlap in the terms used to describe the psychological impact of working in rural and remote practice settings. the lack of definition and clarity of the terms related to rural and remote geographical settings to describe their unique nature is concerning. none of the reviewed literature focused solely on the impact of rural nurses being exposed to traumatic events. however, both review articles recognized the impact of exposure to traumatic events on those working in isolated and remote practice settings (lenthall et al., 2010; o’neill, 2010). while several articles focused on the context of rural nursing practice, only two studies discussed the potential impact over time (o'neill, 2010; singh et al., 2015). in addition, information on potential occupational outcomes of experiencing traumatic events for rural and remote nurses was limited although all of the articles noted general occupational health concerns related to working in rural, remote, or isolated settings. overall, a lack of evidence was found relating to the distress experienced by rural or remote area nurses, with the review highlighting concerns that rural, remote and isolated nurses may be at greater risk of experiencing a variety of negative psychological effects as the result of interactions with their work environment, and being exposed to traumatic events. there is a potential negative impact on personal well-being, psychological distress, and compromised psychological safety online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 122 which may develop into conditions such as post-traumatic stress disorder and vicarious trauma (lenthall et al., 2009). in summary, very little rural and remote literature exists, there is a lack of a clear definition of rural, and most of the research to date has been conducted within countries other than north america. to better understand the impact of traumatic events on rural and remote nurses, additional research using interpretive methodologies (e.g., grounded theory, interpretive description, phenomenology) focusing on the meanings and experiences of individuals is necessary. this will assist in determining what specific traumatic events are most impactful within a rural and remote context from a broader perspective (e.g., canadian, north american), and what conceptual outcomes are consistent with these experiences when considering the unique nature of rural and remote nursing practice. discussion in this analysis, diverse terms emerged to describe the negative psychological effects of varied experiences encountered by rural, remote, and isolated nurses in the work setting, and the impact on their sense of personal and professional wellbeing. through this review, it was also determined that much of the research has been carried out in australia and tasmania, with limited study in the context of rural and remote practice in north america (i.e., canada, united states). in addition, it is difficult to determine the relevance of the findings to rural and remote practice settings from a broader, global perspective. this is especially concerning as the majority of rural nurses live in their primary work community (macleod et al., 2017) and experience unique aspects of nursing practice as a result of being embedded as both health care professionals and essential members of their communities (kenny et al., 2007; o'neill, 2010). there is a need to more fully online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 123 explore the potential impact of exposure to trauma on rural and remote nurses, while recognizing the dual personal and professional roles nurses play, and attending to the potential cumulative effects over time. as was noted earlier, vicarious trauma is the only conceptual outcome that captures both the cumulative nature of the impact and results directly from exposure to traumatic events, and as such, may best describe the experiences of nurses who live and work in rural communities and are exposed to trauma over time. the review also highlighted that high levels of psychological distress may have a negative and detrimental impact on the occupational wellbeing of rural and remote nurses, which is a significant workplace health and safety issue. more specifically, there was an impact on a nurse’s sense of safety and well-being, challenges related to job demands and responsibilities, and concerns regarding a lack of availability of and access to formal psychological support. the evidence emphasized the need to develop better management strategies aimed to address more effective organizational support, increased clinical supervision, and implement practice models that include psychosocial interventions to reduce psychological distress and address safety concerns (kenny et al., 2007; rose & glass, 2009; opie et al., 2010). remarkably, only one study suggested the need for an organizational strategy to address workplace stress by developing a support system focused on debriefing (kenny et al., 2007). this review also supported our concern that nurses who practice in rural, remote, and isolated settings are confronted with a variety of traumatic events as a result of their daily work, which may have negative psychological effects. the extensive rural and remote area practice experience of the first author of this review, validates that those events involving serious injury and/or death are often viewed as having a negative impact, especially when considering the personal connections felt through various community ties. while death, dying, tragedy (kenny et al., 2007; terry et al., 2015), and violence (hegney et al., 2015; lenthall et al., 2009; opie et al., 2010; opie et al., online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 124 2011; terry et al., 2015) were commonly noted to have a negative psychological impact, the specific types or nature of the traumatic events or circumstances surrounding events were not described in the reviewed literature. there is concern that the psychological impact of exposure through a single event or through cumulative events was not reported and reflects a lack of awareness about the types of events or circumstances surrounding the traumatic events with the greatest negative impact. overall, this review revealed that exposure to traumatic events has a negative psychological and physical impact on nurses although there is limited research on the impact on nurses from a rural perspective and none on the long-term implications. while there were many parallels in the findings of the studies from the rural, remote, and isolated contexts, none adequately addressed the research questions posed or clarified the terminology used to describe the negative psychological impact of caring for those who have experienced a traumatic event in the context of rural nursing practice over time. in addition, there was minimal discussion on the physical impact or outcomes of exposure to traumatic events with the exception of stress, sensory changes, and fatigue. overall, reports of the specific physical, mental and emotional outcomes of exposure to traumatic events for rural nurses were found to be limited. there is a gap in knowledge regarding this specific topic area and the global extant literature, and more consideration must be given to the complexities of rural nursing practice and the potential impact of exposure to traumatic experiences over time. conclusion in summary, the psychological response of exposure to the trauma of others has been explored from various discipline specific foci within the context of urban health care delivery. however, there is less evidence exploring key issues related to trauma exposure from the perceptive of nurses online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 125 in rural and remote area practice. the limited literature available beyond the context of rural practice in australia or strictly northern settings highlights numerous conceptual gaps in the research. it is clear that further study is necessary to identify the types of traumatic events that rural and/or remote nurses most commonly face in the workplace, the potential psychological and physical effects of exposure over time, and to distinguish between the types of trauma in relation to degree of negative impact on rural nurses in an effort to better support their psychosocial wellbeing and foster healthy rural and remote work environments. references adriaenssens, j., de gucht, v., & maes, s. 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(2013b). the distinctive nature and scope of rural nursing practice: philosophical bases. in rural nursing, concepts, theory and practice (4th ed., p 241 258). new york, ny. springer. 132 table 1 summary of the findings from literature reviewed author year country purpose sample design data collection findings relevant to research questions hegney et al. (2015) (australia) compare the well-being & perception of the practice environment of nurses in community, acute & longterm care across geographical settings registered nurses, enrolled nurses, and assistants n=1608 (urban n=1008; rural n=382; remote n=238) quantitative crosssectional survey method scales measuring depression, anxiety, stress, resilience, professional quality of life, perceptions of the practice environment key terms/constructs: secondary traumatic stress (sts), burnout (bo), compassion fatigue (cf), compassion satisfaction (cs); • sts was associated with burnout; • lower levels of sts in remote nurses, compared to urban or rural; • no differences in stress, anxiety, depression, cs, bo, or resilience across geographic locations; • professional practice environment viewed positively by nurses across geographic settings and urban nurses rated nursing foundations for quality care higher than rural or remote nurses; • overall, 20% of nurses reported cf • contributing factors, such as exposure to trauma, not identified singh et al. (2015) (australia) compare the frequency and intensity of burnout in rural versus urban nurses mental health nurses in rural or urban n=319 quantitative crosssectional survey design scale measuring 3 aspects of burnout (e.g., emotional exhaustion) key terms/constructs: burnout (bo), emotional exhaustion (ee) • no difference in the level of bo in rural or urban nurses; • potential contributing or causal factors were dealing with emotional and behavioural disturbances vs. trauma exposure; • men experienced higher levels of depersonalization than women • higher levels of emotional exhaustion in younger participants online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 133 author year country purpose sample design data collection findings relevant to research questions terry et al. (2015) (tasmania) examine the safety of the workplace processes rural community nurses (n=15) qualitative narrative inquiry with phenomenological approach, thematic analysis semistructured interviews key terms/constructs: burnout (bo), compassion fatigue (cf) • death & tragedy potential contributing factors in bo and cf; • geographical, environmental, and organizational workplace health and safety challenges; • emotional demands, responsibilities and expectations, social issues, and safety concerns are linked to psychological distress and emotional exhaustion; • lack of replacement staff to take leave may influence ability to access debriefing support and time away for psychological support opie et al. (2011) (australia) assess and compare workplace conditions in two nursing populations remote and urban nurses in health centers and hospitals n=626 (remote n=349; urban n=277) quantitative cross sectional survey design questionnaires measuring burnout, work engagement, nursing stress, and job demands & resources key terms/constructs: psychological distress (pd), emotional exhaustion (ee) • higher levels of workplace pd and ee in urban nurses than remote nurses; • high levels of stress in both remote and urban groups; • higher work engagement and job satisfaction in remote nurses; • no difference between groups in job demands, job resources, or pd related to conflict with nursing colleagues; • workload correlated to ee; • contributing factors such as exposure to trauma are not identified online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 134 author year country purpose sample design data collection findings relevant to research questions o'neill et al. (2010) examine mental health service access in northern communities articles on northern isolated circumpolar communities 62 articles and 2 databases included in this review themes are outlined but thematic analysis not explicit literature review key terms/constructs: secondary trauma (st), secondary traumatic stress (sts), vicarious trauma (vt), compassion fatigue (cf), burnout (bo) • empathic engagement with client’s trauma over time may have profound effect on practitioners; • confusion in definition of terms with st and cf emphasizing emotional responses; while vt focuses on changes to the provider’s cognitive schema and perception over time, including sensory experiences; • embedded practitioners identified emotional, cognitive, and sensory disruptions and dedication and commitment were protective factors; • understanding northern cultures essential for competent practice • contextual issues in northern mental health practice include isolation with challenges for both insider and outsider practitioner roles (e.g., visibility, lack of anonymity, exposure to intergenerational trauma) opie et al. (2010) (australia) examine the workplace demands and resources of remote nurses remote and urban nurses in health centers (n=349) quantitative crosssectional survey design questionnaire measuring burnout, work engagement, nursing stress, and job demands & resources key terms/constructs: psychological distress (pd), emotional exhaustion (ee), burnout (bo) • contributing factors were high levels of occupational stress; • pd and emotional ee were linked to emotional demands, staffing, workload, violence, responsibilities, expectations, isolation, intercultural factors, and social issues; • identified need to enhance workplace support and interventions to address stress and bo and reduce turnover such as improving employee assistance programs and debriefing online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.523 135 author year country purpose sample design data collection findings relevant to research questions rose & glass (2009) (australia) explore the emotional wellbeing of nurses who provide palliative care rural and urban community health nurses (n=15) qualitative emancipatory method semistructured interviews purposive sampling reflective journaling • key terms/constructs: emotional strain (es) • workplace not always conducive to healing, increasing emotional strain; • emotional interactions increase risk of harm and strain on a nurses’ well-being; • psychosocial aspects of care have a personal and professional impact; • strategies needed that promote emotional intelligence, foster self-care, and focus on balance lenthall et al. (2009) (australia) explore stressors experienced by remote area nurses remote primary health centers 26 studies included in this review meta databases analyzed: thematic analysis literature review key terms/constructs: post-traumatic stress disorder (ptsd), vicarious trauma (vt) • exposure to violence and traumatic incidents in the workplace increases the risk of developing ptsd and vt; • identified need for education, training and orientation kenny et al. (2007) (australia) identify issues rural nurses face in providing psychological care to patients with cancer rural hospitals (n=19) qualitative descriptive approach thematic analysis focus group interviews field notes key terms/constructs: emotional toil (et) • impact on emotional well-being identified into 3 themes: task vs. care, supportive networks, and having dual relationships; • difficult to achieve balance between tasks vs. care; • support system needed that focuses on debriefing and forum to reflect, discuss, and receive support; • advantages and disadvantages to dual relationships; • fatigue and emotional exhaustion have a major impact on own well-being; • live and work in same community creates a supportive bond jahnar_523-other-3510-1-6-20190213_notables jahner_523-other-3510-1-6-20190213_tables fitton_623-other-4114-1-6-20200806 online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 53 motivation and exercise in rural postmenopausal women lori sue fitton, phd, arnp 1 kim schafer astroth, phd, rn 2 anne e. cox, phd 3 denise wilson, phd, aprn, fnp, gnp 4 caroline mallory, phd, rn 5 sheryl jenkins, phd, rn 6 1 clinical instructor, department of orthopedics & rehabilitation, university of iowa hospitals and clinics, lori-fitton@uiowa.edu 2 director of graduate programs and professor, mennonite college of nursing, illinois state university, kmastro@ilstu.edu 3 associate professor, college of education, washington state university, anne.cox@wsu.edu 4 mennonite college of nursing, illinois state university, ddwilso2@ilstu.edu 5 dean and professor, college of health and human services, indiana state university, caroline.mallory@indstate.edu 6 professor, mennonite college of nursing, illinois state university, sjenkin@ilstu.edu abstract purpose: the purpose of this research is to explore the relationships among psychological needs, motivation regulations, autonomy support, and physical activity (pa) behavior in rural and urban postmenopausal women within the self determination theory (sdt) framework. sample: the convenience sample included 114 rural postmenopausal women (rpmw) and 56 urban postmenopausal women (upmw) recruited from three midwestern states. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 54 method: subjects completed surveys in paper form which included instruments to measure basic psychological needs, motivation regulations, autonomy support, and pa behavior. findings: results indicate a mix of relationships among psychological needs and intrinsic motivation in rural and urban women. there was a significant correlation (r = .274, n = 169, p = 0.04) between intrinsic motivation and relatedness in rpmw, indicating these women find motivation in meaningful relationships. conclusions: the strength of this research exists in the introduction of a significant correlation between intrinsic motivation to exercise and relatedness in rpmw. previous work with sdt has shown autonomy and competence as motivating factors regarding physical activity behavior in women. this research indicates that for rpmw relatedness is also an important determinant of intrinsic motivation. this data suggests that psychological needs and motivational regulations are dissimilar for rpmw and upmw regarding exercise behavior. keywords: motivation, exercise, rural postmenopausal women, self determination theory, osteoporosis awareness motivation and exercise in rural postmenopausal women americans living in rural areas are more likely to die from preventable diseases than their urban counterparts (center for disease control & prevention [cdc], n.d.a.). physical inactivity, a behavior clearly related to many health disorders, is the fourth leading cause of death worldwide (kohl et al, 2012), and found more frequently in rural americans (cdc, n.d.a.). in fact, rural postmenopausal women (rpmw) have the highest inactivity rates (perry, herting, berke et al, 2013; plonczynski, wilbur, larson, & theide, 2008). physical activity (pa) can decrease a person’s risk for several diseases including cardiac disease, diabetes, select cancers and osteoporosis (cdc, n.d.a.). osteoporosis affects 52 million online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 55 americans with estimated annual costs exceeding $23.5 billion (coleman et al., 2014). caucasian postmenopausal women have a 50% lifetime probability of suffering an osteoporotic related fracture (litwic, edwards, cooper, & dennison, 2012). caucasians constitute 77.9% of the rural population (rural health information hub, 2013), with approximately 5 million of those women age 65 or older (bennett, lopes, spencer, & van hecke, 2013). although rpmw have a high chance for an osteoporotic related fracture, many tend to underestimate their osteoporosis related fracture risk (matthews, laya, & dewitt, 2006). exercise, a cost-effective (garrett et al., 2011) and beneficial fracture prevention strategy (howe et al., 2011) is underutilized in the referent population. in a united states study of 61,200 women, moderate levels of exercise reduced hip fracture rates by 55% (feskanich, willett, & colditz, 2002). as the burden of osteoporosis and other non-communicable diseases escalate, risk factors such as physical inactivity become increasingly relevant (durstine, gordon, wang & luo, 2013). review of the literature exercise and pa are terms often used interchangeably. for clarity, exercise is a subcategory of pa. exercise is planned pa behavior that is purposefully focused on improving or maintaining physical fitness, while pa is described as any bodily movement produced by skeletal muscles that require energy expenditure (dasso, 2018). for the purpose of this research pa will be used. despite the well documented benefits of pa, the cdc estimates that only 24% of all adults meet the 2008 pa guidelines as put forth by the us department of health and human services (whitfield et al, 2019). americans remain inactive and rpmw are most sedentary (wilcox, oberrecht, bopp, kammermann, & mcelmurray, 2005). these disparities are concerning as research indicates rpmw have a higher prevalence of osteoporosis-related vertebral fractures online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 56 (gomez-de-tejada romero, 2014), and tend to underestimate their osteoporosis related future fracture risk (matthews et al., 2006). rural population and physical activity culture, a learned system of shared values, is passed on through generations. culture influences how people interpret what is happening and what they express about themselves (vidaeff, kerrigan, & monga, 2015). one known characteristic of rural culture is that rural elderly experience social isolation (baernholdt, yan, hinton, rose & mattos, 2012) and adapt to change slowly (weidinger et al, 2008). they are independent and self-sufficient, displaying a social closeness that leads to distrust of outsiders (dibartolo & mccrone, 2003). rural populations are self-reliant (wells, 2009), and hesitant to seek services (goins, williams, carter, spencer, & solovieva, 2005). there is a higher population of elderly persons found in rural communities (cdc, n.d.b.; united states census bureau, n.d.a.). rural residents often postpone healthcare services until they are acutely symptomatic (peterson, schmer & ward-smith, 2013). rural residency is a predictor of pa level (osuji, lovegreen, elliott, & bronson, 2006), yet there is no clear understanding of motivation as it relates to physical activity level and residency. rural women and physical activity in addition to cultural dynamics researchers report perceived personal barriers to pa participation in rural communities. barriers identified for rural women include being too tired to participate in planned pa (olsen, 2013; peterson et al., 2013), lack of time and motivation (osuji et al., 2006; peterson et al., 2013), family and caregiving commitments (olsen, 2013; paluck, allerdins, kealy & dorgan, 2006, peterson et al., 2013, wilcox, castro, king, houseman, & brownson, 2000), fear of injury (deshpande, baker, lovegreen, & brownson, 2005) fear of “overdoing it” (wilcox, oberrecht et al., 2005), and being “too old” (olsen, 2013). other barriers online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 57 mentioned include “being overwhelmed” (perry, rosenfeld, & kendall, 2008), “being lonely” (paluck et al., 2006), “having no one to exercise with”, lacking confidence in ability to exercise (wilcox, oberrecht et al., 2005), and financial constraints (goins et al., 2005; peterson et al., 2013). rural postmenopausal women and physical activity nursing literature reports demographic and psychosocial variables which correlate with exercise and pa behavior in rpmw (dye & wilcox, 2006: osuji et al., 2006; perry, herting, berke et al., 2013). for example, nursing research suggests demographics such as age negatively correlate with pa (wilcox, oberrecht et al., 2005), while education and health status (perry, herting, berke et al., 2013) positively correlate with pa levels. king and colleague (2005) noted low socioeconomic status (ses) positively correlated with pa levels and suggested that “a visible walking culture may encourage neighborhood residents [regardless of their individual ses] to be more active” (king et al., 2005, p. 466). additionally, king and colleagues (2005) suggest that residents in a low ses neighborhood may have fewer options for transportation and may need to rely on walking for day to day errands. additionally, psychosocial variables such as attitude (osuji et al., 2006), commitment level (perry & butterworth, 2011), self-efficacy (dye & wilcox, 2006), and perception of exercise (goodwin, 2007) influence pa behavior. support from family and friends is important to rpmw (goodwin, 2007; plonczynski, wilbur et al. 2008). theoretical framework self-determination theory (sdt), a recognized motivation theory used in the exercise literature for many years, identifies key psychological constructs that help explain what energizes behaviors such as exercise. self-determination theory has been used to understand interpersonal support and motivation for behavior change in health-related areas such as tobacco cessation online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 58 (williams & deci, 2001; williams, niemiec, patrick, ryan, & deci, 2009) and weight loss (gorin, poweres, koestner, wing & raynor, 2014). this theory examines the effects of qualitatively different types of motivation, which energize behavior. these motivation regulations are measured on a continuum of increasingly internalized reasons for behavior, ranging from extrinsic to intrinsic (table 1). table 1 the self-determination continuum motivation regulations and psychological needs motivation regulations, best visualized along the sdt continuum (table 1) reflect the extent to which one acts with volition. in the exercise literature, intrinsic regulation is associated with higher amounts of pa, identified regulation is predictive of initial short-term pa behavior adoption, and intrinsic motivation is most predictive of long-term exercise adherence (teixeira, carraca, markland, silva, & ryan, 2012). online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 59 within the sdt framework, when three basic psychological needs of autonomy, competence, and relatedness are met, individuals are more likely to act with intrinsic motivation (deci & ryan, 2002). autonomy refers to having a sense of ownership in one’s actions (deci & ryan, 2002). competence is a sense of confidence in effective interactions with the environment (deci & ryan, 2002). relatedness reflects the need and desire to feel connected to important others, while sharing a mutual goal (deci & ryan, 2002). according to sdt, an autonomy supportive environment is needed to fulfill the basic psychological needs. autonomy support provides an environment of encouragement that minimizes control and judgement (deci & ryan, 2002). studies have shown a positive association between autonomous motivation and pa, as well as autonomy supportive health care climates and autonomous motivation (ng et al., 2012). purpose this study explored the levels and relationships among perceived autonomy support, psychological need satisfaction, motivation regulations, and pa behaviors in both rpmw and upmw within an sdt framework. the specific research aims were to determine 1) the relationship among perceived autonomy-support, basic psychological needs, motivation regulations, and pa behavior in rpmw and upmw; and 2) the difference in levels of perceived autonomy-support, psychological need satisfaction, motivation regulations, and pa behavior between rpmw and upmw. for this research, the united states census bureau (n.d.b.) classification of rural was used, which includes all areas outside of urban areas and employs the term rural interchangeably with nonmetropolitan described as populations, housing, and territory less than 50,000. the united states census bureau (n.d.b.) classification of urban was also employed for this study, the definition being “urbanized areas of 50,000 or more people”. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 60 methods design and setting this study used a comparative two-group descriptive correlational design and was conducted in a variety of community settings, such as churches, community centers, and libraries. using gpower analysis for a priori manova, with a medium effect size and alpha of 0.05, sample size estimate was 210. participants were recruited from three midwestern states, illinois, minnesota, and wisconsin. sample this research began after receiving approval from the university institutional review board (irb-2015-905304). inclusion criteria consisted of women who 1) self-reported amenorrhea (natural, surgical or chemotherapy induced), 2) were able to read, speak, and understand english, and 3) were able to take part in pa. research began in east central illinois. after accepting a position at mayo clinic in minnesota, the researcher concluded the study with study participants from minnesota and wisconsin. a convenience sample of 169 rural and urban postmenopausal women participated in the study over an 18-month period. time restrains prevented achieving recommended sample size. procedure the principal investigator contacted rural and urban community centers, libraries, churches, and senior citizen centers, explaining the proposed research project and offering to present an osteoporosis educational session. to publicize the research and recruit participants, announcements were placed in local newspapers, church bulletins, and on library bulletin boards. over the 18-month period, thirteen osteoporosis educational sessions were held in three midwestern states. at each session, a 30-minute osteoporosis presentation was given, followed by online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 61 an opportunity for questions. after the presentation, the research study was explained in detail and attendees were invited to participate. after obtaining informed consent, those who agreed to proceed with the research completed the study measures. measures the study included four instruments to measure basic psychological needs, motivation regulations, autonomy support and pa behavior. demographic information was collected to determine residence, race, ethnicity, age, education, height, weight, and employment status. questions regarding menopause status, past bone health assessment (previous dexa scan and past vitamin d assessment) were included. the psychological need satisfaction in exercise scale. the psychological need satisfaction in exercise scale (pnse) is an 18 -item questionnaire, with subscales assessing each of the three psychological needs perceived competence, autonomy, and relatedness (wilson, rogers, rodgers & wild, 2006). using a likert scale, each item is scored from one to six with one being “not true at all for me” and six being “very true”. each subscale score is obtained by averaging the responses on the corresponding six items. the scores can range from six to thirtysix, with the higher scores reflecting greater need fulfillment. cronbach’s coefficient for the pnse questionnaire for this research was 0.803. behavioral regulation in exercise questionnaire. the behavioral regulation in exercise questionnaire (breq-2) is a 19-item questionnaire that measures motivation regulations in the exercise context (mullan, markland & ingledew, 1997). the breq-2 contains either three or four items measuring each of the following subscales of amotivation, external regulation, introjected regulation, identified regulation, and intrinsic regulation. using a likert scale, each subscale was measured from 0 to 4, with 0 being “not at all true” and 4 being “very true”. a mean score was online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 62 calculated for each set of motivation regulations. cronbach’s for this research were 0.627 for amotivation, 0.752 for external regulation, 0.649 for introjected regulation, 0.707 for identified regulation and 0.653 for intrinsic regulation. the health care climate questionnaire. the health care climate questionnaire (hccq) has 15 items to assess participants’ perception of the degree to which their health care provider is autonomy supportive, and a shortened version (williams, grow, freedman, ryan, & deci, 1996). in this research, the shortened version was used to assess perceived autonomy support from family and friends. the modification for this research was terminology only, using “important others” in lieu of “healthcare provider”. no psychometric testing was done of the shortened hccq using the term “important others” prior to using. each item was scored using a likert scale with 1 being “strongly disagree” and 7 being “strongly agree”. the cronbach’s coefficient for the hccq in this research was 0.899. international physical activity questionnaire. the international physical activity questionnaire (ipaq) measured the dependent variable of exercise. this inexpensive and convenient tool is the most widely used and validated self-report measure of pa (schembre & riebe, 2011). the questionnaire is a seven-day recall tool that assembles information on time spent during the last 7 days sitting, walking, taking part in moderate intensity activity, and taking part in vigorous activity. the data collected from the ipaq is reported in this research as a continuous variable. the volume of activity was computed by weighting each type of activity by its energy requirements defined in mets to yield a score in mets per minute per week. the met value for computation of met-minutes for walking was 3.3*walking minutes*walking days; for moderate intensity activities 4.0*moderate-intensity activity minutes*moderate intensity days; and for vigorous intensity, 8.0*vigorous-intensity activity minutes*vigorous intensity days. the walking, online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 63 moderate intensity, and vigorous intensity met values were totaled yielding a total metminutes/week score. the cronbach’s coefficient for the ipaq in this research was 0.427. data analysis statistical analyses were carried out using ibm spss for macintosh, version 25.0. data analysis proceeded in sequential stages. initially the data was screened for missing data. when more than 50% of the data was missing from any subscale, the case was deleted from further analysis (tabachnick & fidell, 2007). second, if less than 50% of the data was missing from any subscale, missing values were replaced at the item level with the median substitution imputation protocol (tabachnick & fidell, 2007). descriptive statistics characterized the subsamples of women (table 2). table 2 demographic characteristics of study sample factors by residence n mean std. deviation rural age 114 67.62 10.99 education 114 14.41 2.21 bmi 114 28.64 7.77 urban age 55 68.82 8.19 education 55 15.16 2.43 bmi 55 26.37 4.90 bmi = body mass index. results approximately 97% of the rural and urban population of postmenopausal women identified themselves as caucasian. the majority (98%) of women reported ethnicity as other than hispanic. urban postmenopausal women were approximately 1 year older, (m = 68.9, sd = 7.9) than the rural women (m = 67.6, sd = 10.8). the mean age of menopause for rural women (m = 48.2, sd = 5.9) and for urban women (m = 49.6, sd = 5.5) was similar. the upmw had an average of 1 online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 64 more year of education (15.2) compared to the rpmw at (14.4) years. more rural women had unknown osteoporosis status (60.0%) than urban (54.4%). rural women had a higher average bmi at 28.6 compared to upmw at 26.4. residency, psychological needs, motivation regulations, and physical activity behavior a pearson’s correlation coefficient was used to explore the first research aim, determining the relationship among perceived autonomy-support, perceptions of basic psychological needs, motivation regulations, and pa between rpmw and upmw (table 3). table 3 pearson correlation by rural and urban residence residence pa as im c a r rural pa 1 .159 .248** .264** .304** .134 as .159 1 .322** .321** .275** .514** im .248** .322** 1 .556** .428** .274** c .264** .321** .556** 1 .492** .208* a .304** .275** .428** .492** 1 .170* r .134 .514** .274** .208* .179 1 urban pa 1 .087 .249 .196 .028 .050 as .087 1 .247 .236 .328** .400** im .249 .247 1 .694** .562** .021 c .196 .236 .694** 1 .561** .128 a .028 .382** .562** .564** 1 .298* r .050 .400** .021 .128 .298* 1 pa = physical activity; as = autonomy support; im = intrinsic motivation; c = competence; a = autonomy: r = relatedness. * correlation is significant at the 0.05 level (2-tailed); ** correlation is significant at the 0.01 level (2-tailed) for urban women there was positive correlation between autonomy and relatedness (r = .298, n = 169, p = 0.05). this was the only significant finding particular to urban women. rural women had a positive correlation between pa and intrinsic motivation (r = .248, n = 169, p = 0.01), pa and autonomy (r = .304, n = 169, p = 0.01), and pa and competence (r = .264, n = 169, p = 0.01). rural women also had a positive correlation between autonomy support and online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 65 intrinsic motivation (r = .322, n = 169, p = 0.01), and autonomy support and competence (r = .321, n = 169, p = 0.01). rural women had a positive correlation between competence and relatedness (r = .208, n = 169, p = 0.05). there was a positive correlation between intrinsic motivation and relatedness for rural women (r = .274, n = 169, p = 0.01). after performing a fisher’s r to z transformation, to normally distribute the sample data (fisher, 1921), only intrinsic motivation and relatedness in rpmw attained statistical significance (r = .274, n = 169, p = 0.04). residency, intrinsic motivation, and physical activity behavior to answer the second research aim, a one-way manova tested for differences in motivation regulations, autonomy-support, psychological needs, and pa behavior in the postmenopausal women by residency status. six dependent variables were used: autonomy, competence, relatedness, autonomy support, intrinsic motivation, and pa behavior. the independent variable was residency (rural versus urban). there were no significant differences between rpmw and upmw on the set of dependent variables f (6,161) = 1.75, p = 0.112: pillai’s trace = .061: partial eta squared = .06, therefore no further analyses were performed. the overall mets per minute per week average for upmw exceeded that of the rpmw (3302.7 versus 2652.3 mets value). urban women spent more time in minimal walking (1318.2 versus 954.3 mets value) and also in moderate exercise (1318.2 versus 954.3 mets value). rural women exceeded upmw in vigorous activity (889.3 versus 844.9 mets value). there were no statistically significant findings for pa in either group of women. an additional interesting aspect of this study was assessing bone health awareness in this group of women. knowing that rpmw have a higher prevalence of osteoporosis-related vertebral fractures (gomez-de-tejada romero et al., 2014) and tend to underestimate their osteoporosis related future fracture risk (matthews et al., 2006), assessing bone health in this population was online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 66 valuable. many women in this study (57.7%) had never had a bone health (osteoporosis) screening; this percentage was higher for rpmw (60.0%) than for upmw (54.5%). the majority of rpmw had not undergone a vitamin d screening (64.2%), with a smaller percentage of upmw unaware of their vitamin d status (50.9%). discussion the purpose of this research was to examine the association of residency (rural versus urban) on motivation to exercise and pa behaviors in postmenopausal women, and to assess osteoporosis awareness in postmenopausal women. the importance of this study and the overall findings address in part the literature gaps regarding motivation and pa behavior in rural communities. in this research, intrinsic motivation positively correlated with relatedness, autonomy support and pa in rpmw. for the rpmw in this research, an encouraging environment correlated with more autonomous motivation. likewise exercise behavior positively correlated with more autonomous motivation. this is not a surprising finding as previous literature on rpmw found that friends and family, as well as a supportive environment was important. social support was a facilitator of pa in most research done with this population (dye & wilcox, 2006; goodwin, 2007; osuji et al., 2006; perry, rosenfeld, bennett & potempa, 2007; plonczynski, 2003; wilcox, bopp, oberrecht, kammermann & mcelmurray, 2003). the only statistically significant difference in correlations was the stronger relationship between intrinsic motivation and relatedness in rpmw. for rpmw, relatedness, like autonomy support and social support, was positively related to intrinsic motivation. relatedness may impact pa behavior in rural postmenopausal women. although this study did not reveal a significant correlation between pa and relatedness, this research did reveal a significant correlation between intrinsic motivation and relatedness for rpmw. in the sdt literature, intrinsic motivation is online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 67 associated with long-term exercise adherence (teixeira et al., 2012). if rural women are more intrinsically motivated by relatedness, perhaps pa prospects in rural communities could focus on group exercise opportunities in churches, schools, libraries, or “group walks” rather than home based or individual exercise programs, where women can encourage one another, relate to one another, while building healthy exercise habits. family, friends, and social support have been cited as important constructs in earlier work with rpmw and pa. relatedness according to sdt (deci & ryan, 2002) is a sense of being connected, which would include family, friends, and social support. however, the sdt literature has not found relatedness to predict motivation with regards to exercise behavior. teixeira and colleagues (2012) found multivariate results consistently reported an absence of association between relatedness and pa, with findings from correlational analysis similar. the current study demonstrated a significant positive relationship between relatedness and intrinsic motivation, and a strong positive correlation between relatedness and autonomy support. similar findings from dye and wilcox (2006) indicate social influence and emotional support from others were important for rural women. increasing pa can improve bone health (segev, hellerstein, & dunsky, 2018). many women are not aware of the bone benefits of exercise and many are not aware of their risk for osteoporosis and the sequelae of fragility fractures. public awareness of bone health and osteoporosis continues to be low worldwide (harvey et al., 2017). when examining bone health awareness in this group of postmenopausal women, most rpmw (60%) had not had a bone health screening, they were unaware. likewise, 64% of the rpmw were uninformed of their vitamin d status. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 68 limitations and strengths one limitation of this research study is the small sample size (n = 169) and use of a convenience sample. this study was homogeneous with respect to population demographics which limit the generalization to caucasian postmenopausal women. to address the issue of generalization, future research should include a larger sample size with more representation of all postmenopausal women, especially a greater proportion of women who are not caucasian. another limitation is using a self-report 7-day recall tool to measure pa in a sample of older women. the ipaq is available and easy to use but subject to recall bias and measurement error. an issue when working with older adults is accurately recalling activities performed (washburn, smith, jette, & janney, 1993). recall bias may be inflated with the age of the participants. although the median age for this population was 68, many participants were in the eighth and ninth decade of life. using an objective measurement tool such as an accelerometer could supply a more exact measure. an additional weakness to report is that a pilot test was not conducted after the term important others was exchanged for the term healthcare provider on the shortened form of the hccq. the strength of this research is four-fold. first, as far as is known, this is the first study to measure the impact of residency on pa behavior, intrinsic motivation, autonomy support, and the three psychological needs as described in sdt in rural and urban postmenopausal women. although pa has been studied in this population of women in the past, motivation as it relates to pa has not been measured. second, although social support for pa is referenced as important to rpmw in earlier work, this research found a significant correlation between intrinsic motivation and relatedness in rpmw. motivation to engage in health-sustaining behaviors such as pa is incredibly important yet exceedingly difficult to measure. this research study is an effort to introduce sdt to the nursing community and to demonstrate the utility and practicality of this online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 69 conceptual framework in health-related nursing research has demonstrated the utility of measuring motivation. lastly, this research indicates rpmw are unaware of their bone health status conclusion the purpose of this research was to determine if residency influenced motivation to exercise in postmenopausal women. although one cannot conclude a causal effect between residency, motivation, and pa behavior in this population of women, a significant positive correlation was found between intrinsic motivation and relatedness in rpmw. rural postmenopausal women were intrinsically motivated by family and friends (autonomy support). this data suggests correlates are dissimilar in the psychological needs and motivation regulations of rpmw and upmw. future research with both rpmw and upmw must address the complexity involved with decisions that influence health-sustaining pa behavior. rural communities have greater health comorbidities and higher rates of inactivity. rural postmenopausal women have higher rates of vertebral fractures (gomez-de-tejada romero et al., 2014) and in this study, lower rates of bone health assessment. physical inactivity counseling must extend beyond “exercise more”. bone health assessment and education must be part of the discussion. when discussing physical inactivity, advanced practice providers (app’s) working in a rural setting should consider the value of relatedness as it pertains to intrinsic motivation for rpmw. in sdt, relatedness reflects the need and desire to feel connected to important others. as this research confirmed, feeling connected to others is important for rpmw. initiating community-based group exercise programs in a local school, church, or library, may facilitate connectiveness for rpmw, thereby increasing intrinsic motivation and regular pa participation. as the burden of inactivity sequalae escalates, it is important to pursue further research in motivation, pa behavior, and bone health in rural populations. but it is equally important to online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.623 70 translate this research into practice. rural nurses and rural app’s are in an excellent position to make the translation from research to practice. references baernholdt, m., yan, g., hinton, i., rose, k., & mattos, m. 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(2006). the psychological need satisfaction scale. journal of sport & exercise psychology, 28, 231–251. https://doi.org/10.1037/t22103-000 bourke_652-other-4359-1-6-20210212 online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 67 health care experiences in rural, remote and metropolitan areas of australia claire harper 1 sharon l. bourke, rn 2* elianna johnson, rn 3 janet green, rn, phd 4 ligi anish, rn 5 miriam muduwa, rn 6 linda jones, rn, phd 7 1 nursing student, federation university, australia, claireharper@students.federation.edu.au 2 lecturer, school of health, federation university, australia, s.bourke@federation.edu.au, * corresponding author 3 lecturer, school of health, federation university, australia, e.johnson@federation.edu.au 4 lecturer, school of health, federation university, australia, ja.green@federation.edu.au 5 lecturer, school of health, federation university, australia, l.anish@federation.edu.au 6 lecturer, school of health, federation university, australia, m.muduwa@federation.edu.au 7 senior lecturer, school of health, federation university, australia, l.jones@federation.edu.au abstract background: australia is a vast land with extremes in weather and terrain. disparities exist between the health of those who reside in the metropolitan areas versus those who reside in the rural and remote areas of the country. australia has a public health system called medicare; a basic level of health cover for all australians that is funded by taxpayers. most of the hospital and health services are located in metropolitan areas, however for those who live in rural or remote areas the level of health service provision can be lower; with patients required to travel long distances for health care. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 68 purpose: this paper will explore the disparities experienced by australians who reside in regional and remote areas of australia. method: a search of the literature was performed from healthcare databases using the search terms: healthcare, rural and remote australia, and social determinants of health in australia. findings: life in the rural and remote areas of australia is identified as challenging compared to the metropolitan areas. those with chronic illnesses such as diabetes are particularly vulnerable to morbidities associated with poor access to health resources and the lack of service provision. conclusion: australia has a world class health system. it has been estimated that 70% of the australian population resides in large metropolitan areas and remaining 30% distributed across rural and remote communities. this means that 30% of the population are not experiencing their health care as ‘world-class’, but rather are experiencing huge disparities in their health outcomes. keywords: rural and remote, health access, mental health issues, social determinants health care experiences in rural, remote and metropolitan areas of australia geographically, australia is approximately 7.7 million km2 in size, with 70% of the australian population residing in large metropolitan areas. the remaining 30% of the population are distributed across rural and remote communities (mcgrail & humphreys, 2015). in the outback or remote areas, the weather is often extreme, and land is harsh. livelihoods depend on the presence or absence of rain. people are separated by many kilometers requiring long drives or even an airplane trip to see others, purchase supplies or access healthcare and education. these factors make living in a remote community a difficult life, yet many australians find a deep connection to the land through generations of habitation in the same properties and communities and cannot imagine leaving it behind for metropolitan online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 69 life. whilst this can be seen as admirable, aspects of health care differ when comparisons are made between rural and remote life to that of living in a metropolitan area. consequently, there is evidence indicating that those residing in rural and remote locations experience a higher rate of mortality and morbidity from people living in more accessible areas (australian institute of health and welfare [aihw], 2018). functional metropolitan areas can be defined as where a population between 250,000 and 1.5 million resides within a large metropolitan functional urban area. rural and remote regions are those that are outside the metropolitan and major regional cities. generally, a rural region is considered to be accessible or moderately accessible to services. remoteness of areas are centered on the accessibility/remoteness index of australia which is based on the road distances people have to travel for services (aihw, 2019). classifications of 'remoteness' are used for statistical analysis of health, and also for health funding allocations (smith, 2016). methodology an integrative review methodology was utilised for this paper as it enables a broad review and facilitates a comprehensive understanding of the healthcare inequalities. the integrative review has been identified as unique in healthcare because it is a general review of the existing literature in a systematic way (souza et al. 2010). the literature was gathered using a framework outlined as arksey and o’malley’s (2005) 5 step framework, and more recently levac et al.’s (2010) method of synthesizing health evidence. to facilitate an integrative review of the literature, a search of the literature was performed from multiple health-care related databases: including cinahl, google scholar, medline and grey literature. 406 results were found using the search terms: healthcare, rural and remote australia. adding the term “social determinants of health” refined this further. the search was limited to research in english and articles published since 2010. this search, however, was not limited by rigorous study design. each study was screened through the abstract and title for relevance to an online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 70 australian nursing perspective. other resources, including literature and documents, were sourced to provide additional information to ensure the reader understands how vast australia is, and the kinds of distances that patients from remote areas may need to travel in order to gain medical assistance. australia australia – a land of extremes australia is a land of weather and terrain extremes. drought usually occurs every 18 years in australia (anderson, 2014). the south eastern parts of australia have experienced some of the worst droughts in history with the millennial drought from 2003 – 2012. currently this area has been in drought since 2017 (king et al., 2020). the result has been severe water restrictions for private and commercial use, bushfires with significant loss of land, life and wildlife. when the rains finally came many places were flooded (king et al., 2020). demographically, the majority of the australian population live within major cities. of australia’s total population, 28.2% live in regional and rural settings with 18% living in inner regional areas, 8.2% in outer regional areas, 1.2% in remote areas and 0.8% living in very remote areas of australia (aihw, 2019). the geographical distribution of aboriginal and torres strait islanders (referred to as indigenous herein) vary when compared to nonindigenous populations. there is 65% of indigenous australians living in regional and rural settings. half of the total population of very remote people consist of indigenous australians (royal flying doctor service [rfds], n.d.a). there is a disparity in age between metropolitan and rural remote populations. rural populations report more children, fewer young and middleaged adults and a greater density of workers nearing retirement and the elderly (rfds, n.d.a). remote populations consist of more children, more middle-aged adults, greater prevalence of retired people and substantially fewer elderly people (rfds, n.d.a). the health budget in australia online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 71 across the country in 2016–17, health spending was approximately 10% of the gross domestic product. the cost of the health system in australia is complex. this is because the commonwealth, state, territory and local governments all share responsibility for running the health system in australia. the australian government funds most of the spending for medical services and subsidized medicines as well as health research. then the state and territory governments fund most of the spending for community health services and they all share funding of the public hospital system (calder et al., 2019). the primary funding vehicle utilized by the commonwealth government is the universal system of medicare which underpins the health system and financially supports patients to receive primary and specialist medical care. access to services in rural and remote areas, however, is difficult and this affects medicare funding. people in rural and remote areas spend half as much on medical services as people living in major cities as they have limited services to access (rfds, n.d.a). ensuring the maintenance and improvement in a strong medicare system in rural and remote areas will support access to services. medicare services needs to be combined with more flexible funding arrangements for health services that meet the needs of people in rural and remote areas. the royal flying doctors service the rfds of australia, known as ‘the flying doctor’, is an air medical service that is based and operates in australia founded by reverend john flynn in 1928 (rfds, n.d.a). this service has been funded by the australian government since the 1930’s and is a non-profit organisation that is heavily reliant on community support for additional funding (rfds, 2019b). the rfds is considered to be “one of the largest and most comprehensive aeromedical organisations in the world, providing extensive primary health care and 24-hour emergency service to people over an area of 7.69 million square kilometers” (rfds, n.d.a.). medical treatment by the rfds is free, however the ambulance service that retrieve and return patients to the airport are not (rfds, n.d.a.). the rfds provides emergency and primary health care online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 72 services for those living in regional, rural and the vast remote areas of australia for those who cannot access a general practice or hospital (rfds, n.d.b). this emergency service provided by the rfds include primary response to an accident or illness, or the secondary aeromedical evacuation and retrieval service. australia has 6 states and 2 territories, with 45 rfds bases, and 23 air bases scattered throughout the country (rfds, n.d.c). there are 10 rfds bases located in queensland, 8 in new south wales, 16 in victoria, 1 in tasmania, 3 in south australia, 5 in western australia, and 2 in the northern territory. the rfds also provides telehealth and telemedicine services 24 hours per day and seven days per week through radio, telephone or video call. telehealth provides communication, consultation and support for rural and remote medical staff throughout australia. primary health clinics are provided for remote areas. clinics include general medical practice, nursing services, child and maternal health, and indigenous services (rfds, n.d.a.). the statistics related to the rfds are staggering with 38,064 patients transported by air, 335,125 patient contacts, 21,828 dental patients, 88,188 telehealth consultations, 75, 311 patients transported by road and 16,209 clinics (rfds, n.d.a.). the social determinants of health social determinants of health are the conditions in which an individual lives in and are shaped by financial income, education, employment and social support (aihw, 2018). in rural and remote locations these determinants are often defined by the changing weather patterns, creating an unpredictable lifestyle (kennedy et al., 2014). when rain falls, crops succeed, water tanks are full and livestock are able to thrive. this brings with it financial security as farmers can sell their crops and livestock, jobs are created in order to enable stations to continue to function. families are able to afford to send their children to school to receive an education (kennedy et al., 2014). if the periods between rainfalls become longer, drought occurs. income becomes scarce as farmers must pay for feed for their stock, water cartage and may not be able online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 73 to support farmhands due to a lack of financial income and resources. reduced income, increased debt and a loss of hope have led to an increase in reported mental health problems and suicide. there is also an increasing drift of the younger generation from rural communities to metropolitan regions, contributing to population decline in these remote locations (kennedy et al., 2014). it is important to note that in regional and remote areas, the higher proportion of indigenous australians, and the complexity of their health outcomes impacts the negative health reports and statistics of these remote areas (aihw, 2018). australians enjoy one of the longest life expectancies in the world. one of the reasons for this is that the health system in australia is one of the best in the world, providing safe, quality, and affordable health care (cousins, 2020). there are, however, significant challenges that look to continue for coming decades. these include the ageing population, increasing rates of chronic disease, inequality in access to health services, costs of innovation and research and making the best use of emerging health technologies and data. parts of australia have recently experienced the worst drought in a century (hart et al., 2011; king et al., 2020). the impact on rural communities has been immense with those who are the most geographically and socioeconomically vulnerable, the worst affected. during drought and other natural disasters, such as flood and fire, critical social and health resources within communities become depleted when they are needed most. chronic illness chronic illness is considered one of the most dominant contemporary health issues currently experienced by the australian population due to ageing and lifestyle changes (calder et al., 2019). when comparing the statistics between urban centers and remote communities, several issues stand out as being higher among the remote communities (aihw, 2018). alcohol consumption is considered a significant problem, with 24% of the outer regional and remote populations considered to have exceeded the lifetime alcohol risk guideline, as opposed online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 74 to just 16% in major cities (aihw, 2018). the same report states that 22% of outer regional and remote populations are current daily smokers, compared to 13% of major city dwellers. in addition, there are higher numbers of heart disease, obesity and suicide rates among those communities in remote locations. hospitalisations relating to chronic conditions (excluding diabetes) that could have been prevented through appropriate care or early disease management were found to be 19.1 cases per every 1,000 of the population in very remote areas. in comparison, major cities were found to be 9.7 cases per every 1,000 (aihw, 2018). it is interesting to note that the diabetes related complications that resulted in hospitalisation occurred at an alarming rate as the remoteness increased. compared to 1.7 hospitalisations per 1,000 in metropolitan regions, there were 4.6 cases per every 1,000 hospitalisations in very remote areas. diabetes is the second leading cause of death in very remote areas, the fifth leading cause of death in remote areas compared to seventh in major cities. in other words, people living in remote and very remote areas were more likely to die from diabetes (1.8 and 3.5 times respectively), compared with australia overall (aihw, 2018). in addition, there is a particularly high prevalence of diabetes among indigenous australians (hotu et al., 2018). statistics show that with indigenous australians living in remote communities, there is a significantly higher rate of individuals with diabetes (20.8%) than those living in non-remote locations (9.4%) (hotu et al., 2018). it is believed that a significant factor in this increase of diabetes between remote and non-remote populations is the lack of access to services, in particular general medical practitioner’s where there is a significant shortage (kirby et al., 2015). to support people with diabetes in these communities, a study from 2015 reviewed a pilot program involving nurse-led care in the management of diabetes that was undertaken over a period of 12 months. this program revolved around a diabetes nurse travelling out to three different remote locations around new south wales every 3 months. following the 12-month period, each of the participants involved in the study reported feeling increased confidence in online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 75 self-managing their diabetes and had a better understanding of their condition, thanks to the longer consultation times with the nurse (kirby et al., 2015). the success of this program led to it being integrated into the rfds in the south east sector. mental health issues mental health problems have also been shown to have higher rates among those living in remote locations, with 19% of the outer regional and remote population experiencing mental illness, as opposed to 17% of the major city populations (aihw, 2019). within rural and remote communities, there is also a higher risk of mental health being stigmatized as well as confidentiality issues (pierce et al., 2016). whilst communities may be physically further apart, socially the communities are closer than that of many urban communities. this can result in individuals being reluctant to reach out to mental health services due to the fear of being ostracised by their community (pierce et al., 2016). efforts have been made to reduce the stigma surrounding mental health through advertisements and health promotion programs, however the stigma remains. in line with this, there are also increased rates of suicide among those living in remote locations, particularly within farming communities. a report from kennedy et al. (cited in cousins, 2020) suggest that this increased rate of suicide may be related to the lethality and accessibility of means in rural and remote areas (cousins, 2020). the mental health issues around aging population living in rural areas continue to increase as around 36% of the population (approximately 2.5 million people) are aged over 65 and over (pierce et al., 2016). older people can be vulnerable to mental health issues including depression, anxiety disorders, alcohol, and substance abuse and so forth. evidence suggests that there is a significant need for mental health care for older people living in regional, rural and remote areas (jackson et al., 2019). online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 76 health inequalities and inequities a difference in mortality rates can be noted between major city and remote populations in australia. people living in rural areas have been shown to have a life expectancy 4 years shorter when compared to their urban counterparts (bradford et al., 2016). a 2018 health report found that as remoteness increased, so too did the incidence of potentially avoidable deaths (aihw, 2018). potentially avoidable deaths are considered to be those that, with the correct treatment and individualised care, could have been prevented (thomas et al., 2015). between major cities and very remote locations, potentially avoidable deaths occurred at a rate 2.5 times higher in the remote locations (aihw, 2018). people living in very remote areas have hospitalised rates doubled when compared to metropolitan populations. furthermore, the rate of preventable hospitalisations increases with remoteness with very remote areas reporting preventable hospitalisation rates of 2.5 times higher (aihw, 2019). the other area of preventable deaths is those attributed to traumatic accidents (aihw, 2018). these are commonly attributed to farming machinery, possibly contributing to the shorter life expectancy as compared to metropolitan areas (kennedy et al., 2014). one of the major factors in this increased incidence is limited access to tertiary healthcare services. whilst there are organisations such as the rfds that can provide emergency care and transport to those in remote locations, it remains somewhat limited. where rfds are unable to reach a patient, long travel times await those needing to make their own way to a hospital leading to poorer outcomes for these patients. furthermore, often, the closest medical center is not properly equipped to deal with significant trauma and the patient is required to be transferred to a larger tertiary facility which may be some distance away (rfds, n.d.b). the time prior to ambulance arrival is a predictor of the risk of death with pre-hospital time over sixty minutes being a significant contributor to patient mortality (fatovich et al., 2011). this distance to online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 77 travel for pre-hospital care due to geographical size and access issues of australia has contributed to poorer outcomes for rural and remote people (bishop et al., 2016). one of the major factors in the health disparities between remote and metropolitan areas is access to services. as stated by mcgrail and humphreys (2015), geography is acknowledged by many as a critical aspect of health care access. rural and remote populations have poorer access to health services when compared to major cities (aihw, 2019). furthermore, rural and remote health service are generally smaller, have less infrastructure and provide a broader range of services with limited specialist access. rates of individuals reporting barriers to access general practitioner services is 6 times higher for remote and very remote populations when compared to major cities (aihw, 2019). in addition, there is 58% of remote and very remote populations reporting that they do not have a specialist nearby. across australia, there is also a significant lack of consistency in access to services with individuals travelling significant distances to access specialists and specialist clinics (mcgrail & humphreys, 2015). the mental health facilities and access to these services is also limited in regional and rural areas. for example, it is estimated that less than 10% of psychiatrists throughout australia practice in rural areas (rawsthorne et al., 2009). in addition to the physical distance people must travel in order to reach a primary care service, there are also issues surrounding the recruitment and retention of healthcare workers in remote areas (zhao et al., 2019). the health workforce is a major influence on access to services for rural and remote populations. rural and remote areas are disadvantaged due to substantial health workforce shortages. nursing shortages are apparent in rural areas; however, remote areas have a greater access to nursing services then rural populations (aihw, 2019). strategies there are a number of strategies that governments have initiated to help people located in rural and remote areas to access health care services. various state and territory governments online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 78 have introduced patient assisted travel schemes to provide financial assistance to people in rural and remote areas to travel to receive health services. private health insurers also offer travel and accommodation benefits under hospital cover that can assist with the costs of accommodation, fuel for travelling by car, or train, bus or air fares (rfds, n.d.b). in addition, there is telehealth services which saves travel time and costs and can be a less stressful option than travelling a long distance for healthcare. many telehealth services are covered by medicare benefits in eligible areas of rural, regional and remote australia (aihw, 2019). telehealth was successfully observed to replace services to general practitioners, medical specialists, nurse practitioners, mental health treatment, chronic disease management, pregnancy support, counselling, after-hours consultations and indigenous health assessments (pancer et al., 2018). this success could be used to support rural and remote communities in the continuation and improvement of medicare funded telehealth services that could aim to address the lack of locally sourced services. in the longer term, telehealth can also play a part in supporting people with chronic conditions to manage their health. these telehealth services also support a holistic patient and family centered approach to care that enables care providers and interpreters to be involved in health care conversations. in recent times telehealth has been observed to be an effective replacement to face to face healthcare for the whole population during the covid-19 lockdown requirements. in addition to telehealth, and in an attempt to assist in combatting the lack of equipment and services in remote areas to deal with traumatic accidents, rfds have introduced medical chests. there are approximately 3,000 medical chests that have been provided to those living remotely. these chests contain various medications and medical supplies that can be used under the advice of a rfds medical practitioner over the phone (cherry et al., 2018). online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 79 recommendations australian governments agreed that to eliminate health inequalities between metropolitan and rural australia, there is need to enhance disease prevention and health promotion efforts based on a better understanding of the nature of rural and urban inequalities. future effort should acknowledge rural and remote area advantages and build on the strength of rural and remote public health infrastructure, ingenuity and practice. it is also important to continue following a biomedical model, that not only focuses on illness treatment and cure but rather focuses on illness prevention or health promotion is not ideal in rural and remote areas (bourke et al., 2014). in addition, it is highly recommended that rural and remote area healthcare focuses on educating, recruiting and adequate retention of skilled health professionals. this can be achieved by providing a model of mentoring to strengthen and increase rural and remote health workforce, professional development, recognition, empowerment, and cultural integration (thomas et al., 2015). there is also a need to educate local people to become healthcare professionals as they would be more likely to stay in the region. this can be achieved through incentives and support to enable local people to become healthcare workers. it is also worth examining the health access needs of the elderly population particularly residing in rural and remote areas. since there is a considerable population aged over 65 years and above in rural areas more resources and access should be available to address the needs of this population. several recent studies have shown that while rural and remote communities are more prone to natural disasters, elder community have been more resilient and have contributed significantly towards disaster preparedness, response and recovery efforts (rawsthorne et al., 2009). their expertise in assisting the community should be utilised to help give them purpose in contributing to the resilience of the community. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 80 one of the other areas that needs developing more in rural and remote areas is mental health support through targeted programs. there already exist certain programs such as rural minds which provides workshops that discuss information around mental health issues but there needs to be more work done within farming communities. providing information through these workshops can help the community be more receptive to mental health concerns of people and help support people to acknowledge that they are experiencing difficulty and need help. to improve the quality of life and health of rural and remote people, and be comparable to their urban counterparts, there is need to provide improved culture safety. this is because of the increased population of indigenous people in the rural and remote areas. one way that this can be achieved is by increasing the number of indigenous health care workers by supporting the education of local people to undertake these roles. in addition, there is a need to increase the availability of health care facilities that are run by indigenous communities in these remote areas in order to achieve better health outcomes (smith, 2016). conclusion australia is known to have one of the world class health management systems. evidence suggest that 70% of the australian population resides in large metropolitan areas and remaining 30% of the population are distributed across rural and remote communities. life in the remote and rural areas is identified as challenging compared to the metropolitan areas including poor access to health resources and services in rural areas. this paper examined the disparities that exits between the rural and metropolitan populations and discussed some services which are offered across the regional and remote areas like rfds, medical chest and the need for incorporating first aid courses and telehealth services which has proven quite effective and beneficial during the current covid-19 crises. it could be argued that there is a heightened need for addressing the mental health problems and provision of accessible service to the vulnerable population. it may not be possible to mitigate some of the geographical challenges online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.652 81 but strengthening the rural population through education and bolstering 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(2019). cost impact of high staff turnover on primary care in remote australia. australian health review, 43(6), 689-695. https://doi.org/10.1071/ah17262 hardin_568-article text-3661-1-6-20190805 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 25 household food insecurity and dietary saturated fat in rural appalachia frances hardin-fanning, phd, rn 1 debra k. moser, phd, rn, faha, faan 2 mary kay rayens, phd 3 1 professor, powers endowed chair of nursing research, university of louisville school of nursing, fdhard02@louisville.edu 2 professor, assistant dean of phd program & scholarly affairs & linda c. gill endowed chair of nursing, college of nursing, university of kentucky, dmoser@uky.edu 3 professor, college of nursing, university of kentucky, mkrayens@uky.edu abstract purpose: to explore the relationship between food insecurity and dietary saturated fat intake in rural central appalachia. design: cross-sectional analysis of baseline data from a longitudinal interventional study sample: baseline assessment of dietary saturated fat intake and food security in volunteers who had resided in rural central appalachia for at least five years and were enrolled in a cooking skills class. method: volunteers (n=56, 89.3% female) completed the usda household food security survey module (hfssm) and diet history questionnaire-ii. average age was 56.5 (range 18-76) years. average intake of saturated fat was calculated using dietcalc software. food security was measured using the hfssm. descriptive and inferential statistical analyses were conducted using sas, v. 9.3 with an alpha level of .05. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 26 findings: high or marginal food security was experienced by 75% with 25% of participants experiencing low/very low food security. average daily saturated fat was 26 grams. significant findings included greater saturated fat consumption in men; lower saturated fat consumption with older age; older age being associated with lower food insecurity; and no association between food insecurity and saturated fat intake. average daily saturated fat gram intake was significantly lower for females than males; the group means were 23.6 (sd = 12.4) and 49.6 (sd = 15.0) for these two groups, respectively (t = 4.8, p < .001). for every 10-year increase in age, there was a 2.7 gram decrease in daily saturated fat intake. conclusions: historical food traditions and method of food preparation likely contribute to the lack of an association between high food security and saturated fat intake in rural appalachia. food insecurity was not associated with saturated fat intake in our sample. additional research is needed to determine to the full impact of food insecurity on dietary fat intake in appalachia. keywords: food insecurity, appalachian region, fatty acids saturated, poverty household food insecurity and dietary saturated fat in rural appalachia dietary saturated fat intake and household food insecurity (i.e., the condition of being unable to consistently have physical, social and economic access to sufficient safe and nutritious food that meets dietary needs and food preferences for a healthy life) are both independently associated with higher risk of cardiovascular disease (cvd) and other chronic illnesses (abdurahman, chaka, nedjat, dorosty, & majdzadeh, 2018; ford, 2013; cascio, schiera, & liegro, 2012). in rural central appalachia (i.e., kentucky appalachian counties with rural-urban continuum codes of 8[completely rural or less than 2,500 urban population, adjacent to a metropolitan area] or 9 [completely rural or less than 2,500 urban population, not adjacent to a metropolitan area]) (u.s. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 27 department of agriculture, economic research services [usda, ers], n.d.), an area with disproportionately higher rates of cvd, metabolic syndrome, and type 2 diabetes, household food insecurity is higher than in most other areas of the united states (coleman-jensen, rabbit, gregory, & singh, 2017). in this study, we analyzed the relationship between household food insecurity and dietary saturated fat intake in individuals living in rural central appalachia. background dietary saturated fat many factors influence individuals’ dietary habits, including the type and amount of fats typically consumed. higher dietary saturated fat intake is associated with increased cvd risk, particularly when it replaces polyunsaturated fats or whole grain carbohydrates (tapsell, neale, satija, & hu, 2016). while the human body does use saturated fats for physiological and structural functions, it is able to produce what it requires without dietary intake (u.s. department of health and human services, u.s. department of agriculture, [ushhs, usda], 2015). current nutritional recommendations are to limit dietary saturated fat intake to less than 10% of total calories daily. for the average person consuming 1800-2200 daily calories, saturated fat intake should be limited to less than 18-22 grams each day. however, over 70% of americans consume more than the recommended daily limit of saturated fats (ushhs, usda, 2015). saturated fats are dietary fats that are solid (e.g., lard, shortening, butter, and margarine) or semi-solid (e.g., coconut, palm kernel, palm oils) at room temperature (ushhs, usda, 2015). solid/semi-solid fats are abundant in the u.s. diet and reducing dietary solid/semi-solid fat is an important way to reduce saturated fat and excess calories (ushhs, usda, 2015). saturated fat is associated with higher low density lipoprotein (ldl) cholesterol and serum triglycerides, and online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 28 subsequently, greater risk of atherosclerosis (sacks et al., 2018). replacement of 5% of calories from saturated fats with polyunsaturated fats or monounsaturated fats reduces ldl cholesterol and triglycerides, decreases atherosclerosis risk, and is associated with 15-25% overall cvd risk reduction (li et al., 2015). processed food (i.e., food altered from the harvested state in order to lengthen preservation) high in saturated fats is a major source of energy in the united states (floros et al., 2010). processed food is often less expensive than nonor minimally processed food and is consumed more frequently in food insecure households (eicher-miller, fulgoni, & keast, 2015). individuals participating in food assistance programs are likely to purchase most of their monthly food during the earlier days of the month, resulting in a higher likelihood of purchasing processed foods with longer shelf lives (oliveria, 2018). while processed food improves food security, it also contributes 52% of the saturated fat in the american diet (weaver, et al., 2014). therefore, individuals at high risk of food insecurity are likely to be at risk of a socioeconomic-related higher intake of saturated fats from processed foods. conversely, high food security is associated with a higher intake of polyunsaturated fatty acids, which is related to lower cvd risk (mazidi & vatanparast, 2018; coleman-jensen, et al., 2017). household food insecurity in 2016, 15.6 million (12.3%) u.s. households experienced high food insecurity (colemanjensen et al., 2017). nearly 5% of these food insecure households had very high food insecurity (i.e., eating patterns of at least one household member disrupted and food intake reduced because of insufficient money or resources for food). approximately 18% of these food insecure u.s. households are located in rural counties (rabbitt, coleman-jensen, & gregory, 2017). the typical online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 29 food insecure household spends 29% less for food (including federal/state nutritional supplemental funds) than the food secure household of the same size and composition (coleman-jensen et al., 2017). nearly all individuals experiencing food insecurity report worrying that their food will run out before they could afford to buy more (98% of respondents) and that they are unable to afford to eat balanced meals (95% of respondents) (coleman-jensen et al., 2017). more than 17% of kentucky households reported high or very high food insecurity in 2016. rural central appalachia, the majority of which is located in kentucky, has disproportionately higher rates of food insecurity than the state’s non-appalachian counties (average rates: 17.85% vs. 13.97%; ranges 13.3-23.9 vs. 8.0 – 21.6; respectively) (gundersen, dewey, crumbaugh, kato, & engelhard, 2018 ). in addition to higher rates of cvd, metabolic syndrome and type 2 diabetes, food insecurity in appalachia is also associated with higher rates of obesity, poor management of health conditions, and depression (bengle et al., 2011; johnson, sharley, & dean, 2011; porter & johnson, 2011). objective the purpose of this study was to assess the relationship between food insecurity and saturated fat intake among individuals living in rural appalachia, controlling for age and sex. methods this cross-sectional, exploratory analysis was conducted from baseline data of a longitudinal trial in six rural central appalachian counties with similar demographics. participants who were ≥ 16 years old and lived in rural eastern kentucky for a minimum of five years were eligible for the study. children under the age of 16 were excluded because it is unlikely that this age group would online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 30 include the primary household grocery shoppers. individuals who were unable to make decisions about food choices and those with malabsorptive disorders or procedures were also excluded. research ethics medical institutional review board approval was obtained for this study (14-002-p2h). the study was registered with clinical trials.gov: nct02924051. procedure we recruited study volunteers (n=56) via advertisements in county cooperative extension office newsletters printed in local newspapers. informed consent was obtained by a member of the research team at the start of an informational group meeting held at each county extension office. during this meeting, the purpose and protocol of the study were explained to volunteers. to ensure all data collection forms were of appropriate literacy, participants’ literacy levels were assessed using the newest vital sign screening tool prior to data collection. literacy screening was performed by a registered nurse trained in health literacy assessment. scores on the nvs range from 0-6. individuals who score > 4 on the nvs are considered to have adequate literacy (i.e., the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions) when measured by the test of functional health literacy in adults (weiss et al, 2005). following literacy screening, participants completed the usda household food security survey module (hfssm) and demographic questionnaires during the informational meeting. participants then received a packet that included print instructions on completion of the web-based national cancer institute’s (nci) diet history questionnaire-ii (dhq-ii), including individualized access codes. participants were instructed in the completion of the dhq-ii by a online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 31 registered nurse trained by a doctorally-prepared dietitian. participants were also provided print illustrations of serving sizes of commonly eaten foods paired with comparably sized objects (eg, 3 ounces of meat is approximately the size of a deck of playing cards). participants who did not have internet or computer access received a paper version of the dhq-ii, identical to the webbased version and a large postage-paid, pre-addressed envelope to return the completed dhq-ii. data specialists entered the responses into the electronic dhq-ii using the participant access codes. the diet*calc analysis program 1.5.0 was used to determine the average daily grams of saturated fat (nci, 2012). measures demographic variables included age (in years) and sex (male/female). saturated fat (average daily intake). the dhq-ii measures intake frequency of 124 foods over the previous month. the questionnaire includes portion size and supplement questions (nci, 2012). the dhq-ii has higher correlations (0.63–0.65) with multiple-pass 24-hr recalls obtained seasonally over 12 months than the block (0.54–0.58) and willett (0.58–0.63) questionnaires (subar et al., 2001). the diet*calc software calculates average daily intake of saturated fats from reported frequency of the 124 foods in the dhq-ii. food security. the 18-item usda household food security survey module (hfssm) ranks household food security (i.e., having consistent and reliable access to sufficient amount of nutritious food). the hfssm is a valid measure and considered the most authoritative method for differentiating level of food security. responses of “yes,” “often,” “sometimes,” “almost every month,” and “some months but not every month” are coded as affirmative for each item. the sum of affirmative responses to the 10 questions in the scale is the raw score on the scale. the raw online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 32 score is then combined into categories to form the scored version of the hfssm. the resulting ordinal variable ranges from 1 to 4, with higher scores indicting lower food security. a raw score of zero corresponds to a scaled score of 1 (‘high food security’); raw scores of 1-2 are coded as a scaled score of 2 (‘marginal food security’); raw scores of 3-5 correspond to a scaled score of 3 (‘low food security’); and raw scores of 6-10 are coded as a scaled score of 4 (‘very low food security’). given the ordering of these ranks from the greatest security to the least, the interpretation of this variable is actually a food insecurity ranking as the score increases. analysis we summarized study variables using means and standard deviations or frequency distributions. bivariate associations among study variables were assessed using pearson’s product moment correlation or the two-sample t-test. the multivariable association between food security and saturated fat intake, controlling for age and sex, was assessed using multiple linear regression; variance inflation factors were used to assess whether multicollinearity influenced regression parameters. data analysis was conducted using sas, v. 9.3; an alpha level of .05 was used. results all participants recruited for the study tested at literacy levels ≥5 on the nvs, demonstrating adequate literacy for comprehension of the hffsm and dhq-ii. average age of those in the study was 56.5 years (sd = 13.5); the range was from 18 to 76 years. most participants were female (89.3%). the majority of those in the study were either in the high food security (35.7%) or marginal food security (39.3%) categories; 12.5% of participants were in each of the low and very low food security groups. the average saturated fat consumption per day was 26.4 grams (sd = 19.2); the range was from 6.2 to 74.9 grams. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 33 the correlation of age with food security ranking was significant (table 1). this relationship was negative, suggesting that increased age was associated with decreased food insecurity. the other correlations in the bivariate analysis were not significant, as shown in the table. in particular, saturated fat intake was not associated with age or with food security in this sample. the comparisons of study variables between males and females via the two-sample t-test revealed that there was no difference by sex in age (t = 0.10, p = .92) or food security ranking (t < 0.10, p = .96). the average daily saturated fat gram intake was significantly lower for females than males; the group means were 23.6 (sd = 12.4) and 49.6 (sd = 15.0) for these two groups, respectively (t = 4.8, p < .001). table 1 correlations among study variables (n = 56) variables age r (p-value) food insecurity r (p-value) food insecurity -0.35 (.0081) - saturated fat -0.19 (.17) -.097 (.48) the multiple regression of saturated fat intake on age, sex, and food insecurity was significant overall (f = 9.5, p < .001); the r2 for this model was 0.36. age and sex were significantly associated with saturated fat intake in this multivariate analysis (table 2). in particular, for every 10-year increase in age, the model predicted a 2.7 gram decrease in daily saturated fat intake. consistent with the bivariate analysis, the model indicated lower saturated fat consumption among women, with 25.7 fewer grams per day in this subgroup, compared with men. food security was not predictive of saturated fat grams in this model, though the p-value was smaller in this multivariable analysis relative to the bivariate correlation between these two online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 34 variables. all variance inflation factors were < 1.5, suggesting multicollinearity was not likely distorting any regression parameters. table 2 multiple regression model to assess predictors of daily saturated fat grams (n = 56) variable parameter estimate |t| p-value variance inflation factor age -0.27 2.0 .047 1.14 female -25.74 4.8 <.001 1.00 food insecurity -2.67 1.5 .14 1.14 discussion significant findings in this study include greater saturated fat consumption in men than in women; lower saturated fat consumption with older age; older age being associated with lower food insecurity; and the lack of an association between food insecurity and saturated fat intake, even when adjusting for age and sex. average daily saturated fat intake in the united states is 31.3 grams in men and 23.3 grams in women (usda, ars, 2019). reduction in dietary saturated fat intake has a greater response in total cholesterol and low-density lipoprotein cholesterol in males than in females (weggeman, zock, urgert, & katan, 1999). in this study, average daily saturated fat intake was significantly greater for males than females at 49.6 g/day and 23.6 g/day, respectively. the greater impact of ldl-cholesterol reduction in males indicates strategies aimed at reduction of saturated fat intake would likely be effective in reducing cvd risk in males within this population. older age was associated with lower dietary saturated fat in our study. aging is associated with an increased concentration of inflammatory markers and the concentration is influenced by dietary saturated fat (calder et al., 2017). additional research is needed to determine factors that online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 35 contribute to dietary saturated fat intake in older adults. older age was also associated with greater food security in this cohort. in older adults, food insecurity both contributes to and is a consequence of poor health outcomes including mobility limitations, chronic disease burden, limitations in activities of daily living, medication under-use, and depression (afulani, herman, coleman-jense, & harrison, 2015; bishop & wang, 2018; darmon & drewnowski, 2015; ganhao-arranhado, paul, ramalho, & pereira, 2018; jih, et al., 2018; jung, kim, bishop, & hermann, 2018). while poverty and subsequently, food insecurity, contribute significantly to unhealthy diets, it is likely that other factors contribute to the lack of a significant association between dietary saturated fat and food insecurity in this group of rural central appalachian residents. in 2013, we conducted and reported results of focus groups related to barriers to consuming healthy foods in central appalachian (hardin-fanning, 2013). participants reported difficulties in changing personal habits, limited access to a variety of healthy food, difficulty in preparing healthy foods, limited knowledge of the health benefits of foods, family attitudes toward food, and difficulty determining how to incorporate healthy foods into meals as barriers to healthy eating unrelated to economics. potential strategies to address these barriers have been discussed earlier (hardinfanning, 2013). an additional factor that is likely to influence the high dietary saturated fat in this group of appalachian residents is historical food tradition. historical food tradition the combination of saturated fats being a historical part of appalachian cooking and food serving as a means of celebrating family and community contributes to a diet highly conducive to nutrition-related chronic disease. the typical diet of appalachia consists primarily of calorie-dense online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 36 meats, starches, and fats. a principal historic and current source of protein in rural appalachia is pork (miller, 2009; sohn, 2005). pork is used as a primary food, a seasoning for legumes and vegetables, and a source of cooking fat. climate variations in central appalachia necessitated food preservation that included brining or curing pork (sohn 2005). these preserved pork products (i.e., ham, bacon, sausage, cold cuts) are still principal foods in rural appalachia. frying is a common method of food preparation in rural appalachia (sohn, 2005). frying or adding animal fats (e.g., salt pork added to dried legumes), results in even greater amounts of saturated fats than prior to food preparation. the top ten foods identified as important to appalachians are bacon, biscuits and gravy, chicken and dumplings, cornbread, coffee, fried potatoes, green beans, soup beans, stack cakes and vegetable soup (sohn, 2005). several of these foods are high in saturated fats but have cultural foundations that have endured over generations. while the appalachian diet does have a reasonable variety of foods, particularly during summer when produce is available, most meals include gravies, sauces, and foods fried in fat (sohn, 2005). family, including extended kin, is the cornerstone of community life in appalachia. in rural appalachian communities, food has long been a means of celebration and hospitality (usda, ushhs, 1987). celebration dinners (e.g., weddings, homecomings) usually include several different meats, vegetables, breads, and desserts. family reunions, funeral food preparation, dinners on the ground (i.e., pot luck dinners at community churches), and food-related festivals continue to be very common in rural appalachia (miller, 2009). since these events are opportunities to showcase favorite recipes, the foods served are often fried or have fatty meats added for seasoning. the high saturated fat content in rural appalachia’s historical diet persists in the region. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i1.568 37 strengths and limitations the primary strength of this study is the measurement of saturated fat intake and food security in an at-risk population using validated instruments. these findings add to the understanding of how food choices and food availability may be related to demographic factors, and this is crucial information given the strong links between diet and disease. the main limitation of this exploratory study is sample size, but the results underscore the need for further research in this area. conclusion factors unrelated to socioeconomic status, including demographic characteristics and tradition, influence food choice. food insecurity 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(2005). quick assessment of literacy in primary care: the newest vital sign. annals of family medicine, 3, 514-522. https://doi.org/10.1370/afm.405 online journal of rural nursing and health care, 1(1) 43 social support and health promotion lifestyles of rural women marsha h. adams, dsn, rn1 andrea g. bowden, msn, rn, crnp2 debra s. humphrey, msw, rn3 linda b. mcadams, fnp, rn4 1 associate professor, capstone college of nursing, university of alabama, madams@nursing.ua.edu 2 instructor, nursing department, shelton state community college, abowden@sheltonstate.edu 3 instructor, capstone college of nursing, university of alabama, dhumphre@nursing.ua.edu 4 u.s naval reserve nurse corps officer, family nurse practitioner, dch regional medical center, tuscaloosa, al abstract health promotion is presently receiving increased attention regarding the prominent role it plays in the health care arena. the purpose of the study is to ascertain if a relationship exists between social support and health promotion lifestyles of rural women. the organizing framework for the descriptive correlational study is pender’s (1996) revised health promotion model. the study participants are 400 women whose names were obtained by a simple, random sampling of the voter registration list of a rural county in a southeastern state responding to questionnaires. data was analyzed using descriptive and inferential statistics. the data strongly supported pender’s (1996) health promotion model and the significant role that social support plays in promoting a healthy lifestyle. recommendations for further research include examining the relationship of social support and health promotion lifestyles with rural non-caucasian women, online journal of rural nursing and health care, 1(1) 44 replication of the study using participants who live in rural counties farther from metropolitan areas, and intervention development which may further enhance social support and health promoting lifestyles. keywords: health promotion, social support, rural women, healthy lifestyle, rural health, health promoting lifestyle, rural, health, health responsibility, healthy behaviors online journal of rural nursing and health care, 1(1) 45 social support and health promotion lifestyles of rural women health promotion is receiving ever increasing attention regarding the prominent role it plays in health care. the high costs in health care have necessitated a shift in the emphasis of care to the prevention of disease, rather than strictly the treatment of disease. historically, the relationship between health promotion and disease prevention has been the focus of study by nurses since the concept was presented by florence nightingale in the publication, notes on nursing (1859/1992). however, since the late 1980's, when public attention focused more readily on health promotion, the demand for information to explain the factors that motivate people to seek their health potential has risen (pender, 1996). more recently, global attention to the specific components of health behavior and lifestyle that place the emphasis on quality of life, rather than duration of survival, has become the focus of health promotion research. the world health organization contends that health promotion includes encouraging healthy lifestyles, creating supportive environments for health, strengthening community action, reorienting health services, and building public health policy (goeppinger, 1993; pender, 1996). the national institute of nursing research identifies health promotion as a research priority. nurses should explore psychosocial factors underlying health promotion behaviors, the impact of lifestyle on health status, and strategies to develop personal responsibility for health (bushy, 1991). identification of these factors will serve as valuable pieces of information for both the general public and health care professionals. often, however, women are responsible for building and continuing the social networks that both men and women use (rook, 1984). unfortunately, the relationship between physical health and social support for women is complex and not well established (hansen, isacsson, & janzen, 1990; lough & shank, 1996). therefore, due to conflicting results in various studies, online journal of rural nursing and health care, 1(1) 46 pender (1996) called for further investigation of how social support impacts health promoting lifestyles of women. the purpose of the study was to ascertain if a relationship existed between social support and health promotion lifestyles of rural women. organizing framework the organizing framework for the study is pender’s (1996) health promotion model (hpm) that originates from the expectancy-value theory and the social cognitive theory. the hpm was developed to provide a framework for predicting health promoting behaviors. the model seeks to explain individual characteristics and experiences as well as how behaviorspecific cognition and affect influence these behavioral outcomes (pender, 1996). according to pender (1996), there are two types of individual characteristics and experiences that affect behavioral outcomes. the first is prior related behaviors that an individual possesses. the second is personal characteristics that are comprised of biological, psychological, and socio-cultural experiences. these individual characteristics and experiences interact with the interpersonal and situational influences to shape the behavioral outcomes. in addition, there are four behavior-specific variables with equally important influence upon behavioral outcomes. these four variables are the perceived benefits to action, perceived barriers to action, perceived self-efficacy, and activity-related affect. the variables in combination with interpersonal and situational influences are the ingredients for an individual’s commitment to the plan of action. hopefully, an individual's commitment to the plan of action will result in a health-promoting behavior. unfortunately, the resulting health-promoting behavior is dependent upon immediate competing demands, over which an individual has low control, and preferences, over which an individual has a higher level of control. online journal of rural nursing and health care, 1(1) 47 the factors that influence health behaviors are multidimensional. all factors are interrelated and therefore, produce results that exert both direct and indirect influences on health promoting behaviors. these factors cooperatively support the processes that influence individuals to make decisions and participate in health promoting behaviors. identification of the interrelationships and an understanding of the dynamics that facilitate health specific behaviors provide insight to both health compromising and health enhancing behaviors, and is what makes the model useful to researchers (pender, 1996). according to pender (1996), social support is viewed as an interpersonal influence, a cognition focused on the behaviors, beliefs, or attitudes of other individuals. social support is defined as " a subjective feeling of belonging, being loved, esteemed, valued, and needed for oneself, not for what one can do for others" (pender, 1996, p. 256). individuals assess socially supportive resources and then accept or reject them based on perceived societal norms and individual needs. involvement or participation in socially supportive groups is a likely resource of social support for many individuals. often, social support groups serve to assist with personal strengths of members and help in the accomplishment of long-term goals (pender, 1996). social support groups are considered a protective mechanism of health promoting and health maintenance behaviors. conceptually, social groups can create growth promoting environments, decrease stressful life events, provide feedback or confirmation of actions, and buffer the negative effects of stressful life events. when individuals perceive adequate group support, the resulting goals of health promotion, health maintenance, and disease prevention are more likely to be achieved. health promotion must move beyond the individual to families and communities. therefore, identification of the factors that predict positive health outcomes is a valuable piece of online journal of rural nursing and health care, 1(1) 48 information. social support, when perceived as helpful, can enhance individual health and wellbeing (gillis, 1993). the loss of social support, however, is linked to a variety of disease states and indicates that an absence of social support may increase the incidence of illness (pender, 1996). review of literature research concerning the relationship between social support and health promotion lifestyles using pender’s theoretical framework is limited. most recent research has focused on social support and specific health promotion/disease prevention behaviors such as smoking cessation. in this review of literature, research involving health promotion lifestyles, rural health, and social support was examined in regard to the relationship to health and health practices. health promotion lifestyles health promotion lifestyles in relation to a number of variables have been the focus of nursing research in the nineties (ahijevych & bernhard, 1994; duffy, rossow, & hernandez, 1996; gillis, 1993; lusk, kerr, & ronis, 1995). researchers have examined individuals with varying health problems, diverse cultural groups, women, older adults, and health in the workplace (duffy, 1993; frank-stromberg, pender, walker, & sechrist, 1990; stuifbergen & becker, 1994; stuifbergen, 1995;weitzel & waller, 1990; woods, lentz, & mitchell, 1993). gillis (1993) reviewed the research literature from 1983 to 1991 and concentrated on the determinants of a health promoting lifestyle (hpl). self-efficacy, social support, perceived benefits, self-concepts, perceived barriers, and health definitions were found to be the strongest predictors of a health-promoting lifestyle. self-efficacy was found to be an important predictor of a hpl for hispanics, african americans, and caucasians in a study by weitzel and waller online journal of rural nursing and health care, 1(1) 49 (1990). internal and chance locus of control served as stronger predictors for the caucasian group. adults with disabilities were more likely to engage in hpl if perceived self-efficacy was present (stuifbergen & becker, 1994). kerr and richey (1990) investigated the hpl of english and spanish-speaking mexican americans. self-actualization and interpersonal support received the highest scores among both groups with the spanish-speaking group scoring higher. health responsibility and exercise ranked lowest. similar results were found in a study conducted by duffy, rossow, and hernandez (1996) with mexican-american women and other minority groups. the variable pairs of age and educational level and locus of control and current health status provided the strongest differences in scores among the groups. differing results occurred in a study comparing african-americans and other research involving hpl with a primarily caucasian sample (ahijevych & bernhard, 1994). self-actualization and interpersonal support received the highest scores among african-american women. when compared with other groups in the sample, health responsibility ranked the highest. african-american women received the lowest scores on self-actualization, exercise, and nutrition when compared to other groups. woods, lentz, and mitchell (1993) investigated the health promoting and health damaging behaviors of 470 women. access to education, partnership, employment, and exposure to fewer stressors promoted the health behaviors of exercise and nutrition. in the older adult, individuals who were married and had higher incomes were more likely to engage in exercise, health responsibility, and stress management (duffy, 1993). the health-promoting lifestyles of blue-collar, skill trade, and white-collar workers were examined by lusk, kerr, & ronis (1995). white-collar workers scored higher in areas of selfactualization, exercise, and interpersonal support. self-actualization, exercise, and interpersonal online journal of rural nursing and health care, 1(1) 50 support scores ranked higher among younger workers, while older workers scored higher on health responsibility and nutrition. women scored higher on the overall lifestyle profile and in the areas of health responsibility, exercise, and interpersonal support. individuals with higher education levels consistently scored higher particularly in the areas of health responsibility, exercise, nutrition, and stress management. social support ducharme, stevens, and rowat (1994) addressed conceptual and methodology issues relevant to the study of social support. it was suggested that in order to have sound nursing research, a nursing theoretical framework was needed. the review supported the need for using a valid instrument, such as the personal resource questionnaire (prq 85), to measure social support. the majority of research has focused on the relationship of social support and mental health, but there is also evidence that social support influences physical health (dean, holst, kruner, schoenborn, &wilson, 1994). sherbourne and hays (1990) tested the hypothesis that married persons have more favorable health outcomes than unmarried individuals as a result of social support. the sample consisted of individuals with chronic illnesses such as hypertension, diabetes, coronary artery disease, and depression. married persons reported significantly more social support, better physical functioning, fewer feelings of depression and loss of control, and less life stress. social support and health promoting behaviors have been the subject of numerous studies (aaronson, 1989; hanson, isacsson, & janzon, 1990; lough & shank, 1996; morse, 1997; riffle, yoho & sams, 1989). aaronson (1989) found that perceived and received support contributed to a pregnant woman sustaining both good health practices and recommended health online journal of rural nursing and health care, 1(1) 51 behaviors. riffle, yoho, and sams (1989) examined the relationship of health-promoting behaviors, perceived social support, and self-reported health of the older adult. the results revealed a positive correlation of the health promoting behaviors, self-actualization, health responsibility, interpersonal support, and stress management, to perceived social support and self-reported health. there was no relationship between perceived social support and selfreported health. in a study investigating health status and social support of the older adult, the results showed that the perceptions of positive health status and social support do not decline with age (lough & schank, 1996). social support was viewed as beneficial in both smoking cessation programs and decreasing symptoms related to premenstrual syndrome (hanson, isacsson, & janzon, 1990; morse, 1997). rural health mansfield, preston, and crawford (1989) compared the health practices of rural women with those of a large metropolitan area. the results of the study found that rural women adopted more health practices overall than their urban counterparts. younger women in both groups exhibited more awareness of health promotion. an individual's place of residence was not found to be independently predictive of health practices in a study by speake, cowart, and stephens (1991). perceived health status and locus of control were predictive of health practices involving stress management, exercise, nutrition, health responsibility, self-actualization, and interpersonal support. long and weinert (1992) supported the finding when comparing the health descriptions and perceptions of adults with multiple sclerosis living in rural and urban areas. online journal of rural nursing and health care, 1(1) 52 research questions the following research questions were addressed: 1. is there a relationship between social support and health promotion lifestyles of rural women? 2. is there a relationship between social support and spiritual growth of rural women? 3. is there a relationship between social support and health responsibility of rural women? 4. is there a relationship between social support and nutrition of rural women? 5. is there a relationship between social support and physical activity of rural women? 6. is there a relationship between social support and stress management of rural women? 7. is there a relationship between social support and interpersonal relations of rural women? methodology design the study uses a descriptive correlational design. a power analysis was performed to determine a sufficient sample size in order to reduce the possibility of a type ii error. the minimum acceptable power for a study is .80 (burns & grove, 1997). the present study required a sample size of 100 study participants to have a power level of .80. for the study, health promotion lifestyle was defined as a measurement of a positive state that a rural woman pursues in regard to spiritual growth, health responsibility, nutrition, physical online journal of rural nursing and health care, 1(1) 53 activity, stress management, and interpersonal relations as measured by the health-promoting lifestyle profile ii (s. walker, personal communication, april 22, 1997). social support was a positive state a rural woman pursues via interpersonal networks such as family, friends, neighbors, school, church, and various community groups, associations, and organizations. it was measured by using the personal resource questionnaire (prq85), part two (weinert, 1987). rural women were defined as females who resided in a non-metropolitan county without a city of at least 10,000 residents (ghtaelfi & parker, 1995). the study participants were obtained by a simple random sampling of the voter registration list of a rural county in a southeastern state. of the 6,367 registered female voters, 400 women were selected with the inclusionary criteria of the ability to read and write english. instruments the survey instruments consisted of a demographic data form, the health promotion lifestyle profile ii (hplp ii), and the personal resource questionnaire: part ii (prq 85). the demographic data form gathered information about the study participant’s age, educational level, race, religion, lifestyle status, and employment status. walker, sechrist, and pender (1987) developed the health-promoting lifestyle profile to measure current health promoting practices. the hplp ii is a 48-item 4-point likert scale tool which contains the subscales of self-actualization, health responsibility, exercise, nutrition, interpersonal support, and stress management. based on the research and feedback from other users of the instrument, the hplp was revised to reflect current literature, practice, and to achieve balance among the subscales. the hplp ii, developed within the framework of the health promotion model (pender, 1996) measures current health promoting behaviors using a 52-item, 4-point likert scale which contains the six subscales of spiritual growth, health online journal of rural nursing and health care, 1(1) 54 responsibility, nutrition, physical activity, stress management, and interpersonal relations. all items are scored on a scale from 1 to 4; 1 = never, 2 = sometimes, 3 = often, 4 = routinely. a composite score was obtained as well as individual subscale scores. the cronbach alpha for the total hplp ii was .943. alphas for each of the subscales are as follows: spiritual growth (.864), health responsibility (.861), nutrition (.800), physical activity (.850), stress management (.793), and interpersonal relations (.872). in this study, the alpha coefficient for the total hplp ii scale was .9469 and the subscales ranged from .7293 to .8889 (s. walker, personal communication, april 22,1997). the prq85 designed by brandt and weinert (weinert, 1987) was used to measure social support. part one consists of ten life situations in which the individual might be expected to need some assistance and provides information concerning the individual resources and satisfaction received from those resources. part two is a multidimensional measurement of perceived social support. it is based on weiss’s (1974) five dimensions of intimacy, assistance, social integration, affirmation of worth, and nurturance. i t is a 25-item, 7-point likert scale ranging from strongly agree to strongly disagree that measures the individual’s perceived level of support. long and weinert (1992) reported an alpha coefficient of .91 when using the prq85 in a study focusing on the perceptions of health among rural and urban adults with multiple sclerosis. dilorio, faherty, and manteuffel (1992) studied the relationship of self-efficacy and social support to self-management of epilepsy and reported a cronbach alpha of .88. part two of the prq-85 was used in this study. an alpha coefficient of .8197 was obtained in the present study. table 1 is a summary of the cronbach's alpha coefficients for the study. approvals for the use of the prq85 and hplp ii was obtained prior to use. online journal of rural nursing and health care, 1(1) 55 procedures after sample selection and institutional review board approval, the 400 potential participants in the study were sent the instrumentation packet with a returned-addressed stamped envelope. the packet contained a demographic data form, the hplp ii, the prq85, and a cover letter stating the purpose of the study and perceived benefits from participation. each instrumentation packet was coded prior to mailing to enable the researcher to send a follow-up letter and a second instrumentation packet to the participants not initially responding on the first request. consent for study participation was acknowledged by remittance of the instruments in the self-addressed stamped envelope. results demographic analysis descriptive statistics were used to analyze the demographic data. the participants consisted of 102 rural women, one of whom failed to complete the demographic portion of the instrument as instructed. the age range for the participants was from 19 to 86 years, with a online journal of rural nursing and health care, 1(1) 56 mean age of 47.208. the employment status of the sample revealed 61 individuals (59.8 %) were employed full-time and 15 (14.7%) were employed part-time. twenty-six (25.5 %) of the participants reported their employment status as "other". the demographic data indicated that 88.2 percent of the sample were caucasian. the majority of the participants were married and baptist (70.6%). the highest level of education completed was high school (27.5%) with 21.5% of the sample reporting completion of technical or vocational training. there was a statistically significant relationship between both social support (r = .268: p = < .01) and health promotion lifestyles of rural women (r = .288; p = < .01) and health responsibility (r = .222; p = < .05) when correlated with the demographic variable of levels of education. research questions data were analyzed within the spss 7.5.2 statistical package using descriptive and inferential statistics. frequencies, measures of central tendency, and correlation coefficients were used to address the research questions. the first research question stated, "is there a relationship between social support and health promotion lifestyles of rural women?" the correlation coefficient was computed on the prq 85 and the overall hplp ii using the pearson r. there was a statistically significant relationship between social support and health promotion lifestyles of rural women (r = .579; p = < .01). table 2 describes the ranges, means and standard deviations for social support and health promotion lifestyles. online journal of rural nursing and health care, 1(1) 57 the second research question stated, "is there a relationship between social support and spiritual growth of rural women?" the correlation coefficient was computed on the prq 85 and the spiritual subscale of the hplp ii. there was a statistically significant relationship between social support and spiritual growth (r = .469; p= < .01). the third research question stated, "is there a relationship between social support and health responsibility of rural women?" the correlation coefficient was computed on the prq 85 and the health responsibility subscale. the relationship between social support and health responsibility was statistically significant (r = .416; p = < .01). the fourth research question stated, "is there a relationship between social support and nutrition of rural women?" the correlation coefficient was computed on the prq 85 and the nutrition subscale. the relationship between social support and nutrition was statistically significant (r = .398; p = < .01). the fifth research question stated, "is there a relationship between social support and physical activity of rural women?" the correlation coefficient was computed on the prq 85 and online journal of rural nursing and health care, 1(1) 58 the physical activity subscale. the relationship between social support and physical activity was statistically significant (r = .257; p = < .05). the sixth research question stated, "is there a relationship between social support and stress management of rural women?" the correlation coefficient was computed on the prq 85 and the stress management subscale. the relationship between social support and stress management was statistically significant (r = .434; p = < .01). the seventh question was, "is there a relationship between social support and interpersonal relations of rural women?" the correlation coefficient was computed on the prq 85 and the interpersonal relations subscale. the relationship between social support and interpersonal relations was statistically significant (r = .543; p =≤ .01). multiple regression was used to ascertain which independent variables, if any, explained the difference in the variance of the value of the dependent variables (burns & grove, 1997). the individual demographic information and the prq 85 part ii score served as the independent variables. the dependent variable was the overall health promoting lifestyle score. the demographic variable of race showed a relationship with the hplp ii scores. however, social support, using the prq 85 score was the statistically significant predictor of health promoting lifestyles of rural women. table 3 depicts the results of the multiple regression analysis. online journal of rural nursing and health care, 1(1) 59 discussion social support was found to be a strong predictor of whether an individual engaged in health promotion. these findings are supported in the research literature. several studies have identified the positive relationship of social support and health behaviors (gillis, 1993; kerr & richey, 1990). pender's (1996) perspective that social support is directly related to health and well-being was affirmed by this research. in the revised health promotion model (pender, 1996), interpersonal influence is viewed as a behavioral cognition which affects an individual's commitment to a plan of action and therefore, to a health promoting behavior. based on the findings of this study, social support, as a source of interpersonal influence, corroborates one of the basic beliefs proposed by the model. race was initially identified as a demographic variable that predicted health promoting lifestyles. however, the researchers are hesitant to rely on the statistical association. there seems to be a sampling limitation with regard to race. the sample respondents were only 10.8 % non-caucasian. therefore, no conclusions regarding race as a demographic variable that predicts health promoting lifestyle will be drawn. education was one of the factors that showed a statistically significant relationship critical to social support, health promotion lifestyles, and the subscale of health responsibility. the factor of educational preparation was addressed in the research by riffle, yoho, and sams (1989) with similar results. the researchers postulate that one possible explanation for the sample's high level of educational preparation may be the county's close approximation to a major metropolitan area online journal of rural nursing and health care, 1(1) 60 and a major university. in addition, the use of registered voters as study participants may skew the sample in relation to race and education ultimately limiting the generalizability. interestingly, when the demographic data of the sample is compared to the actual population of the rural community, the sample surveyed revealed a mean age of 47.208, whereas, 43.6 percent of the residents in the county are younger than 20 or older than 65 years of age. therefore, 56.4 percent of the sample is between the ages of 20 and 65. the sample reflects the median age of the county surveyed (alabama department of archives and history, 1997). conclusions the study determined that a relationship existed between social support and healthpromoting lifestyles of rural women. the assumption was that by determining if such a relationship exists, further investigation into the elements that enhance social support could be used as predictors for a health promotion lifestyle. there are two additional conclusions that can be drawn from the findings. first, each of the major components of a healthy lifestyle (health responsibility, spiritual growth, nutrition, physical activity, interpersonal relations, and stress management) correlated with the prq 85 part ii score of the sample. secondly, there was a statistically significant relationship between levels of education and the variables of social support, health promotion lifestyles, and health responsibility. implications for nursing practice as a result of the study, it is clear that social support has a strong correlational relationship to the health promoting lifestyles of rural women. based on this correlation, several implications for nursing practice are identified: online journal of rural nursing and health care, 1(1) 61  social support systems for individuals should be assessed and evaluated with the initial health history.  social support interventions should be included in the overall health promotion plan and complement an individual's ability to achieve total wellness.  evaluation of social support interventions using qualitative and quantitative research methodologies should be used to validate strategies that health professionals use to promote wellness for their clients. recommendations based on the findings of the study, a number of recommendations for future research were identified:  research which focuses on the interventions that further enhance social support and health promotion lifestyles.  further research focusing on the relationship between social support and health promotion lifestyles of rural non-caucasian women.  research using study participants who live in rural counties farther from large metropolitan areas. online journal of rural nursing and health care, 1(1) 62 references ahijevych, k., & bernhard, l. 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(1993). the new woman: health-promoting and health damaging behaviors. health care for women international, 14, 389-405. https://doi.org/10.1080/07399339309516067 https://doi.org/10.2307/2136817 https://doi.org/10.1002/nur.4770170103 https://doi.org/10.1097/00006199-198703000-00002 https://doi.org/10.1097/00006199-198709000-00007 https://doi.org/10.1097/00003727-199005000-00005 https://doi.org/10.1080/07399339309516067 styes_647_formatted online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 100 improving rural emergency nurses comfort during palliative and end-of-life communication abbie a. styes, dnp, cnp, fnp-c 1 mary j. isaacson, phd, rn 2 1urgent care nurse practitioner, monument health spearfish clinic, spearfish south dakota, astyes@monument.health 2associate professor, college of nursing, south dakota state university, rapid city, south dakota, mary.isaacson@sdstate.edu abstract background: emergency nurses (ens) often care for patients nearing the end of their lives or with life-limiting illnesses. however, ens are hesitant to initiate palliative or end-of-life (peol) discussions because of a lack of comfort with these topics. many ens have no formal peol communication training which contributes to the lack of comfort with peol discussions in the emergency department (ed). thus, the purpose of this quality improvement project was to determine how peol communication training affected rural ens perceived comfort level during peol conversations. sample/setting: a convenience sample of 14 registered nurses working in a rural northern plains ed. methods: a quality improvement project was implemented where nurses received online education using the end-of-life nursing education consortium critical care communication module. this was followed by communication scenario review and group discussion. changes in nurse comfort with peol communication were evaluated using a pre and post survey and reflective practice in the group discussion. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 101 findings: this quality improvement project demonstrated a statistically significant increased level of comfort (n = 14, p = 0.006) when communicating with peol patients and their families in the ed. qualitatively, the ed nurses expressed fears and challenges specific to peol communication while also identifying new evidence-based strategies they can use during peol conversations. conclusion: communication is vital when caring for peol patients in the ed. formal peol communication training is effective for improving peol communication skills among ens. increasing nurse comfort when communicating with peol patients has the potential to improve quality of care at end-of-life. keywords: emergency nurses, communication, palliative, end-of-life improving rural emergency nurses comfort during palliative and end-of-life communication in rural emergency departments (ed), nurses care for patients throughout the lifespan (emergency nurses association, 2013). emergency nurses (ens) may care for patients with lifelimiting illnesses or at end-of-life. as frontline caregivers, ens must be comfortable communicating with palliative and end-of-life (peol) patients and their families (bodine & miller, 2017; isaacson, minton, darosa et al., 2019). yet ens, especially those working in rural areas, may struggle with peol communication. this is because in addition to caring for strangers, these nurses are often faced with the challenges associated with caring for someone they know personally. these unique circumstances occur more often in rural settings as ens tend to have deep roots within their communities and multiple levels of personal contact with patients and families. the nature of these relationships may contribute to the discomfort and distress rural ens online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 102 often experience when caring for and communicating with peol patients and their families (beckstrand et al., 2017; schlairet, 2017). many ens feel unprepared to facilitate peol discussions; most have no formal peol communication training for these crucial conversations in the ed (anderson et al., 2016; bodine & miller, 2017; coyle et al., 2015; isaacson & minton, 2018; isaacson, minton, da rosa et al., 2019; price et al., 2017; roth et al., 2017). formal peol communication training reduces communication barriers and increases nurse comfort with peol communication (bodine & miller, 2017; coyle et al., 2015; isaacson, minton, da rosa et al., 2019). training such as education provided by the end-of-life nursing education consortium (elnec) critical care communication module has been shown to increase nurse comfort when communicating with peol patients and their families in the ed (bodine & miller, 2017). thus, the purpose of this quality improvement (qi) project conducted with ens in a rural northern plains ed was to determine how peol communication training affected their perceived comfort level during peol conversations. background patients with acute and chronic illnesses often present to the ed. on average, 51% of patients over the age of 65 will seek care in the ed during the last six months of their lives. these visits are often prompted by acute illnesses or exacerbation of chronic illnesses such as heart failure, chronic obstructive pulmonary disease, or cancer. the physical and emotional distress caused by acute illness or exacerbation of chronic illness contributes to the number of patients and families seeking care in the ed (smith et al., 2012; mierendorf & gidvani, 2014). the uncertain outcome of an ed visit stimulates the rapid development of a trusting relationship between patients and nurses. this relationship provides a level of comfort for patients online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 103 to ask nurses difficult questions such as “how long do you think i have to live?” the uncertainty of what to say or how to respond to peol questions often leaves nurses feeling uncomfortable (isaacson, minton, da rosa et al., 2019; mclennon et al., 2013). ens have a unique role in the care of patients and their families because of their ability to recognize the seriousness of the illness, associated needs, and distress. this role places ens in a prime position for peol conversations (american nurses association [ana], 2017). however, initiating peol discussions with patients and families can be an intimidating experience for nurses because of a lack of training in this area (isaacson, minton, darosa et al., 2019). peol communication skills are often learned on the job. yet, nurses feel that these skills are not enough and are requesting formal peol communication training (anderson et al., 2016; coyle et al., 2015). effective peol communication is key because it reduces distress, empowers patients and families, and encourages patients and families to prepare for the peol experience (price et al., 2017; moir et al., 2015). ens must be confident in their ability to communicate with peol patients and their families (bodine & miller, 2017; isaacson, minton, da rosa et al., 2019). therefore, ens would benefit from formal peol communication training. the picot question for this qi project was: among ens in a rural northern plains hospital (p), how does peol communication training (i) compared to current practice of no formal peol training (c) affect ens perceived comfort level when communicating with patients and families about peol care (o) over a two-month time frame (t)? evidence based practice model to guide this qi project, the first author used the johns hopkins nursing evidence-based practice model (dang & dearholt, 2018). this model includes three phases and uses the acronym online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 104 pet: a practice question (p), evidence (e), and translation (t). phase one consisted of identifying the stakeholder, forming the team, and developing the evidence-based practice question (picot). during phase two, the first author conducted a review of the literature guided by the picot question. the literature was then critically appraised for the level and quality of the evidence using the johns hopkins evidence-based practice evidence level and quality guides. the first author then synthesized the evidence, identified recommendations for change, and developed the intervention. the final translational phase consisted of creating a plan in collaboration with the stakeholder and team for implementing and evaluating the intervention. (dang & dearholt, 2018). methodology setting the setting for this project was a 12-bed ed which is part of an 81-bed rural northern plains hospital. this location was identified as rural because the population is less than 50,000 and is a nonmetro county (united states department of agriculture, n.d.). the ed is designated as a community trauma hospital and serves patients of all ages (south dakota [sd] department of health, n.d.). on average, nurses working in this department provide care for 30 patients per day and approximately 11,000 patients per year. annually, nurses in this ed participate in approximately 48 trauma codes and 48-50 resuscitation codes. the actual number of patients receiving care with life-limiting illnesses is not recorded (m. everson, personal communication, june 19, 2019). current practice is to ensure that nurses receive training in life saving measures. the required education courses include trauma nurse core course, basic life support, advanced cardiac life support, and pediatric advanced life support. prior to this qi project, there was no formal peol online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 105 communication training offered to the ed nurses in this facility (m. eversion, personal communication, july 11, 2019). sample twenty-three registered nurses comprised the ed nursing team. inclusion criteria for this qi project included registered nurses that worked a full or part time position in the ed. based on feedback from the ed director (project stakeholder), those with less than part time status were not invited to participate due to minimal hours they may work in the ed. thus, a convenience sample of 18 registered nurses were invited to participate in this project. evidence based practice intervention and instrument the training for this project included a two phased approach. phase one comprised the use of the online elnec critical care module 6: communication through relias academy (2020). this module was designed to improve peol communication for nurses working in critical care and was recommended by one of the designers of elnec (p. malloy, personal communication, december 21, 2018). education from elnec on the topic of peol communication has been provided to over 732,000 nurses (american association of colleges of nursing, 2019). material covered in this module includes an overview of communication such as types of communication, barriers, expectations, attentive listening, mindful presence, and key statements to use. this module also presents communication key phrases such as using “i wish vs. i am sorry.” in addition, there is education on communicating with providers, the interdisciplinary team, and with patients and family members (relias academy, 2020). the comfort with communication in palliative and end-of-life care (c-cope) instrument was used as a pre and post survey to measure the nurses’ comfort level with peol communication (minton et al., 2020). the 26 item c-cope instrument consists of two ranked items and 24 items online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 106 rated on a 5-point likert-type scale (1 = not difficult, 2 = slightly difficult, 3 = uncertain, 4 = difficult, 5 = very difficult) to assess nurse comfort with peol communication. composite scores for the 24 likert-type items range from 24-120 with higher scores indicating less comfort with peol communication. the rated items are categorized according to patient, family, and team communication. the two ranked items encompass six topics of communication that provide a descriptive assessment of the topics and are ranked as more or less comfortable for nurses to discuss with patients and families (isaacson, minton, da rosa et al., 2019). the c-cope has demonstrated satisfactory content validity, and internal consistency (cronbach’s alpha = 0.90) in measuring nurse comfort level with peol communication (isaacson, da rosa, minton et al., 2017). the cronbach’s alpha for the c-cope in this project was good at 0.86. phase two of this project included peol communication scenario reviews and group discussion. the communication scenarios were developed by the first author and approved by the project advisor (the second author). the communication scenarios were tested for face validity and approved by the stakeholder (ed director) and the education director of the hospital. project procedure the first author applied for institutional review board (irb) approval from the university irb. as a qi project, irb oversight was not required. nurses were assured that privacy would be maintained using a pseudo-name on each survey and only the first author had access to the information provided on the surveys. per recommendations from the project stakeholder, an email was sent out to the ed nurses one week before launching the project. the email described the purpose of the project and ascertained the nurses’ willingness to participate. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 107 the project was launched during a monthly staff meeting, where nurses interested in participating registered on the project roster with their name and email address prior to the beginning of the meeting. during the staff meeting project details were introduced and described to the participants by the first author. ens that agreed to participate completed a paper copy of the c-cope as a pre-survey and were informed that they would repeat the c-cope as a post-survey in approximately two months. after determining the number of participants, the first author purchased the elnec critical care communication module for each participant from relias academy (relias academy, 2020). an account created on the relias academy website enabled the first author to assign and deliver the module via email to each participant. the ed nurses accessed the module by using the link provided in the email and were given approximately one month to complete the online module. phase two of this project began approximately one month after the initial staff meeting. during this phase, the first author presented peol communication scenarios for review which were scheduled on two different dates and times to accommodate nurses’ schedules. this review gave the nurses the opportunity to practice the communication skills they had learned from the online module in a safe environment. the ed nurses only attended one session. research demonstrates that the use of scenarios helps solidify understanding (bodine & miller, 2017). following the communication scenarios, the first author lead a group discussion where the nurses freely expressed their concerns and raised questions regarding the topics included in the formal peol communication training. the first author was a coworker of these nurses and because of this relationship wanted the nurses to feel comfortable expressing their personal experiences and knew they would not be comfortable doing so if they were recorded. to help spur conversation, the first author asked the following questions: online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 108 1. during this training, what was the most interesting thing you learned and why? 2. how do you feel this training will help you in your role as an emergency nurse? 3. have you taken care of any peol patients that you knew personally? approximately two weeks after the implementation of phase two, the post c-cope survey was made available. the first author was present in the ed at various times for a period of two weeks to personally provide a paper copy of the c-cope survey for the participating ens to complete. each participant received a copy of the c-cope that was labeled with the number associated with the participant’s name on the project roster. after completing the c-cope, the participants handed the completed survey directly to the first author. to maintain confidentiality, the c-cope surveys were placed in a binder that was only accessed by the first author. findings results the primary aim of this qi project was to investigate differences in ens perceived comfort before and after the peol communication training using the c-cope survey. a total of 14 ens elected to complete the project. this sample included 4 male and 10 female participants whose ages ranged from 21 to 55 years of age. their educational preparation comprised three with an associate’s degree and 11 with a bachelor of science in nursing. nursing experience varied from new graduates to 30 years. a wilcoxon signed-rank test was conducted to compare median scores on the pre and post c-cope. results of the wilcoxon signed-rank test indicated that the c-cope scores were significantly lower at post-test (mdn = 36.5) than at pre-test (mdn = 51.5), z = -2.731, p = .006. thus, after completing the peol communication training participants reported more comfort with online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 109 peol communication. to evaluate the impact of the intervention an effect size was calculated, r = 0.51 indicating a large effect (mcleod, 2019). figure 1 number of rns ranking patient / family communication as difficult / most difficult results from the two ranked items are reported by the number of nurses with rankings of 5 and 6, indicating difficult or most difficult topics. overall, nurses continued to identify the following topics as difficult before and after the intervention: patient/family initial diagnosis, patient/family recurrence of disease, and patient/family end-of-life. summary of reponses to questions from group discussions the questions asked by the first author during phase two provided an opening for rich discussion by the nurse participants. the first author took notes of participants’ comments during these discussions; therefore, a more in-depth content analysis was not possible. below is a summary of these informal discussions. in response to question 1, the participants identified that education regarding the use of key words was the most interesting part of this peol communication training. they reported they had online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 110 not previously considered using phrases like “i wish things were different” versus “i’m sorry.” several of the nurses described being unaware of how phrases such as “i’m sorry” may be taken negatively by family members who had lost a loved one. one nurse mentioned she liked phrases that showed empathy such as “i can’t imagine how overwhelming this is.” for question 2, many indicated the education would help them feel more comfortable communicating in end-of-life situations and they now are equipped with better ways to speak with patients and families in peol circumstances. another nurse identified that after the training she was more aware of how much communication occurs through body language such as leaning in during a conversation. she expressed being more cognizant of how her own body language would help her communicate more sincerely during these difficult conversations. other participants vocalized agreement with her statements. another nurse shared how challenging it is to maintain a poker face with families with whom you are familiar, especially in the event of an unsuccessful resuscitation. she feels that these family members realize the outcome was not ideal as soon as they see your face and body language. overall, the nurses expressed the peol communication training equipped them with the communication skills needed to feel less uncertain of what to say during peol conversations. in response to question 3, many nurses reported caring for someone they knew was more difficult than caring for a stranger. yet, while this is difficult, these nurses also expressed because they already have trust and rapport with the patient and family, that to be the primary nurse is preferable for families. however, several nurses verbalized concern about seeing the family in public at a later time, feeling that this contact may trigger memories of the death of their loved one. one nurse reported avoiding a family member for three years because of that fear, later learning the family member was just so thankful she was there because she trusted her. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 111 the nurses then began a discussion specific to “showing emotions.” death in the ed is often tragic and unexpected. the nurses shared that at times the emotions they experience are like a rollercoaster; one minute they are fighting for a patient’s life and a few minutes later they face the let-down of losing the patient they worked so hard to save. many of the nurses shared prior to the training, they were uncertain if it was acceptable to feel sad or even shed tears around the patient’s family members. instead, they are now aware that their willingness to be vulnerable around patients and family members promotes empathy and a sense of connection during these difficult times. discussion this qi project identified that peol communication training increased nurse comfort with peol communication in this rural ed. communication training can also improve self-assessed competency in palliative care communication as noted in a study conducted by brown and colleagues (2018). their study identified that simulation-based skills-building using codetalk improved self-assessed competency with a large sample of healthcare professional trainees as compared to those receiving usual education. palliative and end-of-life communication training demonstrates great promise for improving self-assessed competency and nurse comfort with these difficult conversations. yet, even with peol communication training, the results of the ranking of difficult topics in this qi project demonstrated that initial diagnosis, recurrence of disease, and end-of-life discussions remain difficult. these results are similar to those reported by bodine and miller (2017). the nurse researchers found that end-of-life training with simulation in the ed improved the nurses’ knowledge of end-of-life care; however, the participants continued to identify that communication online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 112 with patients, families, and physicians remained challenging (bodine & miller, 2017). more research is needed to determine why these topics remain difficult. the qualitative findings of this project demonstrate the importance of reflective practice to the ens. salins (2018) describes reflective practice as a more mindful approach to clinical practice. reflective practice allows healthcare professionals to take a step back or pause from the situation in the hopes of gaining greater awareness and ultimately to improve practice (salins, 2018). moreover, incorporating reflective practice can enhance healthcare professionals’ ability to cope with adverse or difficult situations (mantzourani et al., 2019). in this project, offering the nurses the opportunity to share their personal experiences in a safe environment encouraged them to pause and reflect on their feelings and responses in peol situations. reflective practice encouraged the nurses to acknowledge their own feelings and consider the feelings of those they are communicating with and caring for in peol situations. implications for practice the results of this qi project are specific to the nurses working in this rural northern plains ed. however, ens in other rural facilities may face similar struggles and could benefit from formal peol communication training (beckstrand et al., 2017). beckstrand and colleagues study of rural ed nurses identified three themes: (a) providing care to patients they know; (b) families are challenging during end-of-life care; and (c) not knowing the patients end-of-life wishes. the peol communication training in this project demonstrated great potential toward helping rural ed nurses become more comfortable engaging patients and families at end-of-life. this qi project revealed that implementing formal peol communication training with discussion and reflection can improve nurse comfort with these difficult conversations. targeted communication training provides nurses with tools needed to not only impact their own practice online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 113 but also the lives of patients and families receiving peol care in the ed. peol communication training enhances nurses’ collaboration skills with other members of the interdisciplinary team and increases their comfort in helping patients and families define their wishes and goals of care (ana, 2016). limitations the limitations for this project include gender, ethnicity, sample size, and participation. the sample of ens consisted of all caucasian participants who were predominately female. this composition is similar to registered nurses in the united states, although national statistics indicate the caucasian nurse population is approximately 76%. (minority nurse, 2020). the sample size for this project was initially 18 nurses, however only 14 completed the module. this may be due to the email invitation for the communication module from relias academy to the ens being deferred to their junk mail, which initially caused a delay in the start of the module. in addition, this project was launched close to the holidays potentially impacting full participation. conclusion the peol communication training offered by this qi project significantly improved rural ens’ perceived comfort when communicating with peol patients and their families. rural ens will continue to care for peol patients and families including those they may personally know; therefore, they must be provided with educational opportunities to enhance their level of comfort with peol communication (bodine & miller, 2017). providing targeted education in peol communication and opportunities for reflective practice to rural ens, has the potential to advance and improve peol care for patients and families. rural ens, who are comfortable and skilled in online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 114 peol conversations, serve as key advocates and supporters in addressing patients’ and families’ wishes and goals of care. references american nurses association. 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(2016). icu bedside nurses’ involvement in palliative care communication: a multicenter survey. journal of pain and symptom management, 51(3), 589-596. http://doi.org/10.1016/j.jpainsymman.2015.11.003 beckstrand, r. l., rohwer, j., luthy, k. e., macintosh, j. l. b., & rasmussen, r. j. (2017). rural emergency nurses’ end-of-life care obstacle experiences: stories from the last frontier. journal of emergency nursing, 43(1), 40-48. https://doi.org/10.1016/j.jen.2015.08.017 bodine, j. l., & miller, s. (2017). a comparison of lecture versus lecture plus simulation: educational approaches for the end-of-life nursing education consortium course. journal of hospice and palliative nursing, 19(1), 34-40. https://doi.org/10.1097/ njh.0000000000000302 online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 115 brown, c. e., back, a. l., ford, d. w., kross, e. k., downey, l., shannon, s. e, curtis, j. r., & engelberg, r. a. (2018). self -assessment scores improve after simulation-based palliative care communication skill workshops. american journal of hospice & palliative medicine, 35(1), 45-51. https://doi.org/10.1177/1049909116681972 coyle, n., manna, r., shen, m. j., banerjee, s. c., penn, s., pehrson, c., krueger, c. a., malone, e. k., zaider, t., & bylund, c. l. (2015). discussing death, dying, and end-of-life goals of care: a communication skills training module for oncology nurses. clinical journal of oncology nursing, 19(6), 697-702. http://doi.org/10.1188/15.cjon.697-702 dang, d., & dearholt, s. l. (2018). johns hopkins nursing evidence-based practice: model and guidelines. (3rd ed.): sigma theta tau international. emergency nurses association. (2013). palliative and end of life care in the emergency setting. retrieved from https://www.ena.org/docs/default-source/resource-library/practice-resour ces/position-statements/palliativeendoflifecare isaacson, m. j., & minton, m. e. (2018). end of life communication: nurses cocreating the closing composition with patients and families. advances in nursing science, 41(1), 2-17. http://doi. org/10.1097/ans.0000000000000186 isaacson, m., da rosa, p., minton, m., & harming, s. (2017). psychometric properties of the comfort with communication in palliative and end-of-life care (c-cope) instrument. journal of pain and symptom management, 53(2), 371-372. https://doi.org/ 10.1016/j.jpainsymman.2016.12.137 isaacson, m. j., minton, m. e., da rosa, p., & harming, s. (2019). nurse comfort with palliative and end of life communication: a rural and urban comparison. journal of hospice and palliative nursing, 21(1), 38-45. http://doi.org/10.1097/njh.0000000000000483 online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 116 mcleod, s. (2019). what does effect size tell you? retrieved from https://www.simplypsychology .org/effect-size.html mclennon, s. m., uhrich, m., lasiter, s., chamness, a. r., & helft, p. r. (2013). oncology nurses' narratives about ethical dilemmas and prognosis-related communication in advanced cancer patients. cancer nursing, 36(2), 114-121. http://doi.org/10.1097/ncc.0b013 e31825f4dc8 mantzourani, e., desselle, s., le, j., lonie, j. m., & lucas, c. (2019). the role of reflective practice in healthcare professions: next steps for pharmacy education and practice. journal of social and administrative pharmacy, 15(12), 1476-1479. https://doi.org/10.1016/j.sap harm.2019.03.011 mierendorf, s. m., & gidvani, v. (2014). palliative care in the emergency department. the permanente journal, 18(2), 77-85. http://doi.org/10.7812/tpp/13-103 minority nurse. (2020). nursing statistics. retrieved from https://minoritynurse.com/nursingstatistics/ minton, m. e., isaacson, m. j., & da rosa, p. (2020). psychometric analysis of the comfort with communication in palliative and end-of-life (c-cope) instrument. international journal palliative nursing, 26(8), 334-343. https://doi.org/10.12968/ijpn.2020.26.8.404 moir, c., roberts, r., martz, k., perry, j., & tivis, l. (2015). communicating with patients and their families about palliative and end-of-life care: comfort and educational needs of nurses. international journal of palliative nursing, 21(3), 109-112. http://doi.org/10.12968/ijpn.2015.21.3.109 price, d. m., strodtman, l., montagnini, m., smith, h. m., miller, j., zybert, j., oldfield, j., policht, t., & ghosh, b. (2017). palliative and end of life care education needs of nurses online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.647 117 across inpatient care settings. the journal of continuing education in nursing, 48(7), 329 336. http://doi.org/10.3928/00220124-20170616-10 relias academy. (2020). elnec critical care module 6: communication. retrieved may 12, 2020, from https://reliasacademy.com/rls/store/browse/productdetailsinglesku.jsp? productid=c888669&dc=true roth, r. l., gail, l., o’connor, n., & aseltyne, k. a. (2017). evaluation of comfort in strengthening perceived communication confidence of advanced practice registered nurses. journal of hospice & palliative nursing, 19(1), 59-66. http://doi.org/10.1097/ njh.0000000000000309 salins, n. (2018). reflective practice in palliative care [editorial]. indian journal of palliative care, 24(1), 1-2. http://www.jpalliativecare.com/text.asp?2018/24/1/1/223229 schlairet, m. c. (2017). complexity compression in rural nursing. online journal of rural nursing and health care, 17(2), 1-33. https://doi.org/10.14574/ojrnhc.v17i2.445 south dakota department of health. (n.d.). state designated trauma hospitals. retrieved may 12, 2020, from https://doh.sd.gov/providers/ruralhealth/trauma/designations.aspx smith, a. k., mccarthy, e., weber, e., cenzer, i. s., boscardin, j., fisher, j., & covinsky, k. (2012). half of older americans seen in emergency department in last month of life; most admitted to hospital, and many die there. health affairs, 31(6), 1277-1285. http://doi.org/10.1377/hlthaff.2011.0922 united states department of agriculture. (n.d.). what is rural? retrieved from https://www.ers. usda.gov/topics/rural-economy-population/rural-classifications/what-is-rural/ microsoft word bacsu_52-940-3-ed.docx online journal of rural nursing and health care, 12(2) healthy aging in place: supporting rural seniors’ health needs juanita r. bacsu, ma, phd student 1 bonnie jeffery, phd 2 shanthi johnson, phd 3 diane martz, phd 4 nuelle novik phd 5 sylvia abonyi phd 6 1 community health and epidemiology, saskatchewan population health and evaluation research unit, university of saskatchewan, juanita.bacsu@usask.ca 2 . faculty of social work, university of regina; director, saskatchewan population health and evaluation research unit, bonnie.jeffery@uregina.ca 3 faculty of kinesiology and health studies, saskatchewan population health and evaluation research unit, university of regina, shanthi.johnson@uregina.ca 4 research ethics, saskatchewan population health and evaluation research unit, university of saskatchewan, diane.martz@usask.ca 5 faculty of social work, university of regina, nuelle.novik@uregina.ca 6 community health and epidemiology, saskatchewan population health and research unit, university of saskatchewan, sylvia.abonyi@usask.ca abstract purpose: to examine the key determinants that support healthy aging in rural communities. sample: fortytwo participants aged 65 and older were recruited from two rural communities in saskatchewan, canada. methods: using an ethnographic methodological approach, data was collected through semistructured interviews, field notes and participant observation notes. cantor’s (1989) social care model was used as the theoretical framework for exploring the supports that facilitate rural healthy aging. findings: healthy aging among rural seniors extends significantly beyond access to physicians and formal health care. eight key themes related to healthy aging were identified: housing; transportation; healthcare; finances; care giving; falls; rural communities; and support systems. conclusions: while there is evidence of poor health among rural seniors, little research has examined healthy aging or the determinants that facilitate healthy aging in rural communities. in addressing rural seniors’ health needs, this study provides a fundamental basis for developing effective interventions and innovative public policy options to support rural healthy aging. keywords: rural health, social support, rural aging, public policy, disparities healthy aging in place: supporting rural seniors’ health needs in comparison to urban seniors, rural seniors are often disadvantaged in terms of having lower incomes, less education, a lack of adequate housing, less access to public transportation and poorer access to health services (elnitsky & alexy, 1998; sylvestre, christopher, & snyder, 2006). rural seniors are reported to have poorer mental and physical health status (crowther, scogin, & johnson norton, 2010), a higher prevalence of functional disability, increased sedentary lifestyle, less use of preventative care (kumar, acanfora, hennessy & kalache, 2001), and report more chronic illness online journal of rural nursing and health care, 12(2) than urban seniors (ortega, metroka, & johnson, 1993). in the current literature, there are few studies that directly address both rural senior men and rural senior women’s health needs especially within the canadian and broader north american context (dobbs, swindle, keating, eales, & keefe, 2004). a study by skinner and rosenberg (2006) suggests that governments are failing to recognize the unique challenges of service delivery within the rural context such as geography, lower socio-economic status and widely dispersed populations. accordingly, it is important to note that rural healthy aging is strongly influenced by factors which are unique to the rural context. goins, spencer and williams’ (2011) study, using focus groups and short survey instruments, found that rural seniors’ perceptions of health contained factors which most medical professionals would not take into account such as rural culture, community context and spirituality. a study by kivett, stevenson and zwane (2000) found that reciprocity and mutual support were key to maintaining health among very-old rural adults. kumar et al., (2001) report that rural healthy aging is supported by social engagement, spirituality and physical activity. a study by pierce (2001) found that rural senior women’s perceived health status was strongly connected to their ability to remain within their own homes and rural communities. according to existing literature (cutchin, 2003; tang & lee, 2011), healthy aging in place is not merely about remaining in a location to age but it involves the facilitation of independence through meeting the support needs of an aging population. however, a recent study by davis and bartlett (2008) found that rural seniors’ desire for independence is often hindered by isolation, distance, income and access to services. a study by johnson (1996) using questionnaires with eighty-two rural seniors, reported that one third of the respondents had no one they could depend on in times of need. moreover, there is a rising concern about the capacity of rural communities to address the needs of an aging population (bull, krout, rathbone-mccuan, & shreffleev, 2001). using an ethnographic methodological approach, findings are presented from a study on the health and support needs of rural seniors. cantor’s (1989) social care model was used as the theoretical framework for examining the supports that facilitate rural healthy aging. more specifically, the study’s objectives were to address knowledge gaps in the health service needs of rural seniors, and to identify the supports that enable rural seniors to remain independent. the research is novel in that it sheds light on the key determinants that facilitate healthy aging in rural communities. in addressing rural seniors’ health needs, this study offers a foundational basis for developing innovative interventions and workable public policy options to support healthy aging in rural communities. methods community context the definition of ‘rural’ was based on statistics canada's (1998) rural and small town definition, as a population living outside of large urban centres with fewer than 10,000 people. moreover, ‘rural communities’ were conceptualized as being underserviced, sparsely populated and geographically disperse (kivett et al., 2000). the phrase ‘rural healthy aging in place’ was used by the research team to examine the supports that enable seniors to remain within their rural communities to age (cutchin, 2003). the research was conducted in the two small, rural communities of watrous and preeceville, saskatchewan, canada. the rural town of watrous has an agricultural-based economy, with a population of about 1,743 people; approximately 450 (25.8%) people are 65 years of age or older (statistics canada, 2007b). the rural community of preeceville is also agricultural-based and has a online journal of rural nursing and health care, 12(2) population of about 1,050, 396 (37.7%) of which are 65 years of age or older (statistics canada, 2007a). theoretical framework cantor’s (1989) social care model was used as the theoretical framework for exploring the different types, informalkin, friends and formalsocial agency, of seniors’ support that facilitates rural healthy aging. cantor’s model (1989) suggests that there are different levels of frailty which are primarily age dependent: a) young old (aged 65 and 74), requires assistance during episodes of illness; b) older old (aged 75 to 84), requires help with housekeeping and maintenance; and c) oldest old (aged 85 and over), needs help with personal care tasks. respondents were recruited through convenience sampling which was guided by cantor’s categories of support. however, unlike cantor’s model, our study’s results found that age was not representative of one’s level of frailty and need for support. respondents were recruited with the help of local community partners who were members of the research team. the community partners were in continual communication with the research team and provided a lead role in identifying the respondents who were interested in participating in the study. respondents did not include seniors residing in nursing homes or full care homes. methodological approach an ethnographic methodological approach was used to examine the health and support needs of rural seniors. ethnography is highly relevant for exploring the beliefs, everyday life and the perceptions of a cultural group (creswell, 2007) such as rural seniors. interviews, field notes and participant observation are common methods of data generation used in ethnographic research (savage, 2006). ethnographic research is often challenging as it requires a significant time commitment for trust building, data gathering, and often involves prolonged work in the community (heyl, 2001). accordingly, relationships with community partners who act as gate keepers are vital as they are able to foster trust and provide introduction and acceptance of the researcher into the community (thomson, 2011). accordingly, the research team worked in close and continual collaboration with local community partners throughout all stages of the study. interviews following ethics approval by the university of saskatchewan and the university of regina, a total of 42 semi-structured interviews were completed with 18 men and 24 women aged 65 and older in the rural communities of watrous and preeceville, saskatchewan, canada. participants were enlisted with the help of local community partners and were recruited to be representative of key variables such as age and gender. the interviews were approximately one hour in length and were conducted by members of the research team. the interviews were conducted in the participants’ homes and the spouses were interviewed separately. the interview guide was designed to explore the support systems that exist for rural seniors at both the personal and community level. throughout all stages of data gathering, detailed field notes and participant observation notes were kept to document and record observations i.e., participant behaviour and beliefs, personal reflections and the overall research process (creswell, 2007). the interview data was audiorecorded, transcribed verbatim and analyzed for common themes using the software atlas.ti-6 (2011). online journal of rural nursing and health care, 12(2) data analysis thematic analysis was used to examine the transcripts by identifying, analyzing and describing key themes and patterns within the data (braun & clarke, 2006; gibbs, 2007). thematic analysis was used to analyze the interview transcripts, participant observation notes and field notes through the following four stages. first, six of the transcripts were independently read and reviewed by four of the researchers using an interpretive approach (gibbs, 2007). second, after the initial reading, the four researchers collectively worked to develop a list of emergent codes which were grounded in the data. following this step, the entire research team, including the community partners, met to identify the areas of agreement and disagreement and develop a master code list which was used to code all of the transcripts using atlas.ti 6 (2011). third, throughout the data analysis, full team meetings were held to review the coding progress and resolve any coding issues as they arose. fourth, once the coding was completed, all of the data (field notes, participant observation notes, and interview transcripts) were reviewed to identify and compare key themes from the different data sources. following the analysis of the data, meetings were held with the full team to review the findings of the data. lastly, community workshops were conducted with the participants in the two communities to share the results and ensure that the findings accurately represented their views. to ensure rigor, the following five measures selected from creswell (2007) and richardson (2000) guided the research process. first, prolonged immersion was used by developing extended relationships and working in close and constant collaboration with community partners throughout the entire research process. the relationships with the community partners helped to foster trust and substantiate the researchers’ interpretations of the data. second, triangulation was conducted by using multiple methods of data generation such as field notes, interviews and participant observation notes. third, thick description was facilitated by having a diverse sample of respondents who were representative of gender and age i.e., 65-74, 75-84, 85 years and over. fourth, member checking was employed through participants’ voluntary review of interview transcripts to confirm data accuracy. fifth, peer review from the entire research team was conducted through an examination of the research process, data analysis and the data findings. sixth substantial contribution was facilitated by working with a collaborative and innovative partnership with diverse community stakeholders i.e., health practitioners, academics, community leaders and health region representatives. results in comparison to cantor’s social care model (1989), the study found that age was not indicative of one’s level of support required. seniors’ needs were primarily dependent upon the supports available within their rural communities. moreover, the findings suggest that seniors’ needs extend significantly beyond access to physicians and the formal health care system. in particular, eight key themes were identified in relation to the health determinants and supports of rural seniors. housing many of the participants identified seniors’ housing as a pertinent issue. one woman stated, “my concern is there isn’t a whole lot of spaces available for people who are no longer able to live in their homes… does that mean i have to go out of town, when i can’t manage here.” in particular, rural seniors felt that more affordable housing was needed across the different levels of care, from independent living to full care options. in watrous, several respondents indicated concern with the online journal of rural nursing and health care, 12(2) closure of the existing seniors’ lodge and further expressed their concern that the new lodge would not address the housing needs. one rural senior commented: well i don’t know what’s going to happen when the lodge closes…when they build the new one that will just be all, there won’t be any suites for people that can look after themselves to just be. so we really need something like that. our findings provide significant insight into rural seniors’ housing needs. for example, respondents noted that any future seniors’ housing needs to incorporate a common space for social interaction, as well as supports for meals, cleaning services and transportation. in watrous, respondents (33%) who lived in condominiums felt that their needs were better addressed than seniors who lived in single family houses. condominium living was generally described as meeting seniors’ needs through downsizing, car pooling opportunities, no yard work and social interaction such as card games. existing literature suggests that the demand for rural seniors’ housing will continue to increase from seniors’ desire to age within their communities, in-migration of seniors retiring from urban communities, people moving in from farms and seniors retiring in the towns where they were raised (statistics canada, 2006, p. 10). moreover, a canada mortgage and housing corporation report (2003) found that in comparison to urban seniors, rural seniors’ housing often requires more costly repair and maintenance as 29% of rural canadian housing was built before 1941. accordingly, rural seniors planning to move out of their own homes may experience difficulties in finding appropriate seniors’ housing. transportation the vast majority of the respondents identified a need for formal transportation services within their rural communities such as a taxi service. one woman stated, “little things come up and you put them off or wait until you think someone has time to help or someone comes around.” another woman commented, “i know i miss out on things because i just don’t want to impose on my friends so unless they say “well can we come and pick you up?” something like that it’s like we have no taxi service.” since rural communities do not have well developed transportation systems, seniors’ mobility often depends on one’s ability to drive. the issue of transportation was often addressed in discussions about rural seniors’ independence. more specifically, several participants equated losing their ability to drive with losing their independence. one participant stated, “[i] dread the day i have to give up driving.” participants described how improved transportation could enable independence for rural seniors. moreover, driving was identified in helping to maintain functional independence and was used to compensate for poor mobility. the findings also suggest that rural seniors have self-imposed driving restrictions which often include not driving in urban centres or long distances. in particular, many of the participants identified a need for formal transportation services to urban centres. as one participant commented, “it’s difficult to phone friends to say you have to be in the city at 7 o'clock in the morning when it gets to be more than once or twice.” accordingly, participants described how a lack of transportation services made it difficult for them to access medical specialist appointments in urban centres. a few of the respondents (7%) use the saskatchewan transportation company’s bus service to travel to their medical appointments in urban centres. some of the respondents indicated that online journal of rural nursing and health care, 12(2) their appointments were often too far from the bus depot and they would have to get cabs to take them from the depot to their medical appointments. participants discussed having concerns about missing the bus back to their rural communities once their medical appointments were done. subsequently, our findings suggest that inadequate formal transportation services to urban centres may be an important barrier to rural seniors’ use of medical services, preventative care, health screenings and specialist appointments. healthcare two main issues were identified in relation to healthcare which included a shortage of family physicians, and being moved out of the community to receive care. in watrous, many of the participants indicated that they were concerned that the only family physician in the town was overworked and would suffer exhaustion. a senior man from watrous stated, “well [our doctor] is a damn good one here and there has been times when he has had to carry the entire load himself which is not fair.” another respondent stated, “well, i think there is a problem, we need two doctors, i don’t know how the one doctor can do what he’s doing, it’s so hard, must be very hard.” similarly, a senior woman commented, “i think the fact that we only have one doctor is a little bit of a worry. i’m afraid we’re going to kill him before he gets some help; we really need a second doctor here for his sake.” accordingly, many of the participants described the need for watrous to have at least two working family physicians to share the workload. in the preeceville community, respondents were also concerned about a shortage of family physicians; however, many of these respondents traveled to several towns outside of preeceville to receive medical care. in particular, respondents did not seem to be reliant on a particular location of care and discussed travelling to the towns of canora, norquay, wadena, kamsack, sturgis and swan river. in comparison to watrous, preeceville has both a practicing physician and a nurse practitioner who would travel to some of the participants’ farms. many of the farm residents from the preeceville area commented on their level of satisfaction with the health services provided by the nurse practitioner. the second issue identified related to seniors being moved out of their communities to receive care. many participants reported concerns related to the stress and mental strain related to being moved from one’s community. one participant commented: if you had to go into the lodge, you often can’t get in here because it’s small and you might get sent to lanigan, you might get sent someplace else but then eventually you’d come back and that’s a little bit of a downer. participants described how being moved away from one’s community to receive care often had a detrimental impact on their family members’ and spouses’ health. a senior woman stated, “i know when [my husband] was sick, he was in [another town] and he really, really wanted to be home in watrous or at home. and we got home on a saturday and died on the sunday so.” respondents attributed the shuffle of seniors around to the different communities as a consequence of the continual move towards the centralization of health services to larger more urban centres. finances several preeceville respondents identified future finances as a significant concern. as one preeceville respondent stated, “that’s a big thing, that’s a big thing. and you have to constantly worry about how you’re going to pay your bills this month.” in comparison, fewer watrous participants identified finances as a concern. however, many of the respondents in both preeceville and watrous discussed finances in relation to the high cost of home care and nursing homes. more specifically, seniors described future concerns related to the high cost of nursing home care for online journal of rural nursing and health care, 12(2) themselves or their spouses. many participants were concerned about finances in relation to covering the costs for medications, medical treatment and travel to receive medical services in urban centres. a respondent indicated, “because my pension cheque doesn’t cover itself in the [housing] facility for rent $1059, and drugs are $300 a little over every two months. so yeah it’s about $150 per month [left].” some respondents discussed working odd jobs to help cover the high cost of medication. overall, several of the preeceville respondents were concerned about their finances and were not sure if their pensions would satisfy their future needs. care giving a lack of care giver services was identified as a significant obstacle for rural seniors who provide care giving. care giving respondents indicated that additional support such as senior daycare programs would help to provide much needed relief from their care giving responsibilities. several male respondents provided care for their wives. in watrous, approximately one-half of the senior male respondents provided some form of care giving to their family members or neighbours. as one rural senior man commented, “ever since she’s [his wife] had her stroke, everybody seems to stay away. you don’t have the same-you know-i find even-well, family-they’re away.” this comment is consistent with a study conducted by sanders (2007) on rural men who are caregivers which found that many of the men provided care in isolation because their children, family and friends were unwilling to help. moreover, our study found that many of the respondents, who are receiving care, would like to see their care givers receive a break. in addition, some of the care giving respondents indicated a sense of guilt and did not want to leave their spouse in respite care but would just like an afternoon off. a caregiver stated, “because i just got to get away… i like to golf, i like to fish, but i haven’t got anybody to leave her with-i can’t anymore.” these findings are congruent with a study by cuellar and butts (1999) that found caregivers’ difficulties in meeting their own needs because of restrictions placed on them by their care giving duties. moreover, many of the participants who provided care were unaware of any formal services offered to care givers, which highlights the need for more awareness and information of existing services available. falls falls and fall related injuries were key barriers that emerged from the interviews with the rural seniors. approximately, one-third of women (39%) and men (31%) had experienced falls with injuries which ranged from physical injuries to functional limitations. some of the respondents’ comments made in relation to their injuries included: “i fell on the ice and had a concussion”, “i fell, i tripped over my cane and i fell on the sink but not here in my house, hit my hand here and had two black eyes, that was it.” respondents tended to downplay the severity of injuries. as one respondent commented, “i fell backwards down the steps, and i don’t feel any of the effects of that. … he [doctor] said i cracked a bone in my back here.” none of the respondents identified falls where they did not sustain injuries. the finding to downplay the severity of injuries might be indicative of a larger issue related to seniors underreporting falls (allen, 2004; roe et al., 2009). to date, there is limited research that examines how the rural context influences seniors’ health care decisions especially in relation to reporting fall and fall related injuries. however, within the rural context, cultural values of hardiness, independence and self-efficacy (craig, 1994) may significantly influence older adults’ decision to down-play or not report a fall or fall-related injury. rural communities online journal of rural nursing and health care, 12(2) opportunities for social engagement and large social networks were identified as key strengths of aging in rural communities. many respondents commented on the importance of longterm familiarity and the high level of trust that had developed over the years with their neighbours and friends. moreover, participants often described how people are more willing to help one another in rural communities than urban communities. as one senior participant commented: and i think in a smaller community you know everybody, you know your neighbours and they know you and lots of times there’s help there if you need it, emergency or something they are there to help you, i don’t think this happens in the city. in addition, many participants felt that urban seniors would be lonelier than rural seniors. as one respondent stated, “my opinion would be there’s probably a lot more lonely people in the city than there is in the town.” accordingly, many of the rural seniors discussed the importance of social connectedness and long-term friendships within their rural communities. it is important to recognize that rural seniors are diverse and not all seniors living in rural communities have strong social networks. russell and schofield (1999) note that social isolation is often connected to a death of a spouse, illness, disability, retirement and low income. the results from our study suggest that a driver’s license and one’s level of social interaction are closely linked. a participant who was unable to drive and lived alone on a farm stated, “no, nobody over here does play cards. no, no everything is dead here. (laughter)... and that main road, you know, you see the main road there. there’s nobody there.” accordingly, our findings suggest that social isolation within the rural context may be further compounded by loss of a driver’s license and inability to drive. support systems in comparison to cantor’s social care model (1989), our study found that age was not indicative of the support required by rural seniors. in preeceville, participants who were classified into cantor’s category of ‘oldest-old’, aged 85 and over, were often in better health and required less support than participants who were classified as young old, aged 65 and 74,. in watrous, some of the participants classified as ‘older old’, aged 75 to 84,were in poorer health and required more support than some of the participants categorized as ‘oldest-old’, aged 85 and over. overall, age was not found to be representative of participants’ required level of care. these findings suggest that cantor’s model requires modification to classify seniors’ frailty based on the types of support required rather than their age. the study’s results reveal that informal supports such as spouses, family and friends are accessed more frequently than formal supports such as private service providers. respondents were less likely to identify that they were receiving support if it was provided by a spouse or a family member. informal supports most often provided assistance with transportation, house cleaning and yard work. one respondent stated that, “everybody works so they got to work me in between. i try to get any appointment in, when they can … so, nobody is really right around here that can give me a hand.” another participant commented, “we are lucky we have kids in town but they’ve got their hands full with their own families and their own places.” accordingly, while family and friends provide support, many rural seniors refrain from asking for help in order to avoid being a burden. formal supports accessed included foot care, housekeeping services and home care. formal supports were only accessed if informal supports were unavailable. while homecare provides support, respondents described how more support is required throughout the 24 hour timeframe. one senior man commented: online journal of rural nursing and health care, 12(2) i’m not being critical of the system i mean god bless home care and the people that work there but they come in 3 or 4 times a day and sure they can see that you get your pills and they can see you do little things but people are still basically on their own from 8:00 at night till 8:00 in the morning and that in my opinion is a crying need and yet i’m not sure what the answer is either to tell you the truth. respondents indicated that it would be useful if home care provided more services such as housekeeping and vacuuming; however, many were unaware of the home care services available. home care was usually only accessed for short timeframes such as coping with an illness or for recovery from a surgery. the findings suggest that gender has a crucial role in determining the composition and types of support accessed by rural senior men and women. in particular, there was an indication of a sense of reluctance and guilt in asking for help with tasks related to traditional gender roles among men and women. senior men indicated a sense of reluctance in asking for help with yard work or home repairs. one male respondent stated, “i know this year i couldn’t shovel snow, and a neighbour came over before i could even ask him to do it you know. i kind of feel bad that i can’t do it myself….” senior women were often less sharing regarding their needs for instrumental support associated with housekeeping or meal preparation. discussion the study’s findings indicate that rural seniors’ health determinants extend significantly beyond access to physicians and the formal health care system. while having access to health and medical services was identified by many participants there were aspects of seniors’ support systems that underscore the influence of other health determinants such as housing, care giving and transportation. the research sheds light on the need for more information and awareness of existing services available to rural seniors such as home care and respite care services. in particular, with limited housing options, no formal transportation services, growing financial concerns and inadequate caregiver support, many seniors without family often have to move to care facilities outside of their communities. the results suggest that strategies outside the formal health care system are necessary for addressing rural seniors’ health service needs. the aging demographic has significant implications for policy makers and rural communities across canada. while there is evidence of poor health among rural seniors, little research has examined healthy aging or the key determinants that facilitate healthy aging in rural communities at the population level. moreover, predictions of escalating pressures on health services continue to rise with the anticipated growth of seniors in rural canada. it is, therefore, important to examine the challenges and opportunities that rural seniors experience in order to support healthy aging in rural areas. in order to improve rural seniors’ health, policy makers need to consider not only the traditional healthcare system, but also the other components of rural seniors’ support systems, such as housing, transportation and finances. in addressing rural seniors’ health needs, this study provides a fundamental basis for establishing workable interventions and innovative public policy options to improve healthy aging in rural communities. supporting agencies saskatchewan health research foundation, canadian centre for health and safety in agriculture, and canadian institutes of health research online journal of rural nursing and health care, 12(2) references allen, t. 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(2011). ethnography: a suitable approach for providing an inside perspective on the everyday lives of health professionals. international journal of therapy and rehabilitation, 18, 10-16. http://www.ncbi.nlm.nih.gov/pubmed/19583659 http://www.ncbi.nlm.nih.gov/pubmed/17953064 http://www.ncbi.nlm.nih.gov/pubmed/16959392 older adults and resilience 45 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 resilience in older adults living in rural, suburban, and urban areas margaret wells, phd, rn, anp 1 1 assistant professor, college of nursing, suny upstate medical university, wellsm@upstate.edu key words: resilience, social networks, health status, older adults abstract background: possessing high levels of resilience may be one factor that helps older adults adjust to the hardships associated with aging. residing in a rural, urban, or suburban location may impact the resilience level of older adults. purpose: first, to determine if resilience levels vary in older adults living in rural, urban, or suburban areas. second, to determine if the relationships of socio-demographic factors (age, income, education, marital and employment status), social networks, health status, and resilience vary with the location in which older adults live. methods: using a cross-sectional design, data were collected from 277 registered voters aged 65 years or over who lived in rural, suburban, or urban locations in new york state. the instruments used were the resilience scale, the sf-12v2, and the lubben social network scale-revised. results: no differences were found in resilience levels across the three locations. in regression analysis, stronger family networks, lower household income, and good mental and physical health status were found to be significantly associated with high resilience levels. conclusion: the location in which older adults reside did not affect resilience levels. strong social ties and good mental and physical health were associated with resilience. the surprising association with resilience was low income. mental health status was most strongly associated with resilience in older adults. screening older adults for resilience levels and intervening when low levels are identified by implementing strategies to build resilience may be clinically relevant; however further research is needed. introduction as people age they often encounter challenges such as the development of chronic illness and the emotional stress resulting from the loss of loved ones. resilient older adults are able to adjust to life adversities with little disruption to their lives. resilience is considered a personality characteristic that moderates the negative effects of stress and promotes adaptation (wagnild & young, 1993). in addition to having particular personality characteristics, resilient individuals often rely on protective factors to help adjust to difficult times. according to the resiliency model (richardson, 2002), if individuals experience disruption to their lives when a stressor is encountered, they rely on internal protective factors, such as self-reliance and good health, as well as external protective factors, such as social networks, to restore balance in their lives. this process is referred to as resilient reintegration. in a study of rural community-dwelling older adults, high levels of resilience were found (wells, 2009). in addition, better self-perceived mental and physical health status and stronger social networks, consisting of friends, were found to predict high resilience levels. in general, rural dwellers often have limited access to healthcare resources and are sometimes separated http://www.upstate.edu/con/ mailto:wellsm@upstate.edu 46 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 from younger family members who leave to go metropolitan areas. the location in which older adults live may present challenges or offer benefits that affect their resilience levels; however, this has not been studied. purpose the purpose of this research study was to determine if resilience levels vary among community-dwelling older adults living in rural, suburban, or urban locations. the first aim was to determine if there were differences in resilience levels among community-dwelling adults by location of residence. the second aim was to determine if the relationships of socio-demographic factors (age, income, education, marital and employment status), social networks, physical and mental health status, and resilience vary according to the location in which community-dwelling older adults live. literature review in studies of older adults, strong social networks have been found to be associated with higher resilience levels (adams, sanders, & auth, 2004; easley, 2003; felten, 2000; garmezy, 1991; hinck, 2004; kinsel, 2005; lamond et al., 2009; montross et al., 2006). hardy, concata, and gill (2004) assessed resilience in community-dwelling older adults who experienced a stressful event within the past 5 years and found that strong social support was not associated with resilience; however, living with others was associated with greater resilience. it appears that social networks may serve as a protective factor for individuals when faced with adversity. several studies found a relationship between physical health status and resilience (adams, sanders, & auth, 2004; felten, 2000; hardy, concato, & gill, 2004; hinck, 2004; montross et al., 2006; wagnild, 2003). only one study, which included a sample of 125 swedish adults age 85 years or older, did not find a relationship between physical health status and resilience (nygren, alex, jonsen, gustafson, norberg, & lundman, 2005). in general, better selfreported physical health status was associated with higher levels of resilience. as one ages, functional ability and health status may decline; thus, studying the relationship between health status and resilience in the older adult population is relevant. in several studies of resilience, strong mental health status and high resilience levels were found to be related. wagnild (2003) found a positive relationship between morale, life satisfaction, and resilience. an inverse relationship between mental health disorders, such as depression, and resilience was found (hardy et al., 2004; wagnild & young, 1990). nygren and colleagues (2005) found that mental health was correlated with resilience in women, but not men. mehta et al. (2007) found that age influences the relationship of apathy, resilience, and disability with depression. specifically, mehta et al. (2007) found that with increasing age, resilience seems to lose importance with regard to late life depression. lee, brown, mitchell, and schiraldi (2008) found that optimism and self-esteem were significant predictors of resilience in both korean mothers and daughters who immigrated to the united states. recently, lamond el al. (2009) found that emotional health, self-rated cognitive function, optimism, days spent with family and friends, and self-rated successful aging were most likely to predict resilience levels in a sample of community-dwelling older women. many qualitative studies of older adults found relationships between positive attitudes, such as optimism, and fewer feelings of depression, and 47 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 well-being (easley & schaller, 2003; hinck, 2004; kinsel, 2005; wagnild & young, 1990; yoon & lee, 2007). resilience levels have been found to be associated with incomes levels in some studies. wagnild (2003) compared income and resilience in 3 different samples and found lower income to be associated with lower resilience in two samples, but not the third. hardy and colleagues (2004) found that higher incomes were associated with higher resilience levels. resilience has been studied in community-dwelling older adults and strong physical and mental health as well as strong social networks have been found to be associated with higher resilience levels. no studies have specifically addressed differences in resilience levels among those living in rural, suburban, or urban locations. additionally, studies have not addressed whether the relationship of resilience and protective factors, specifically level of physical and mental health, strength of social networks, and socio-demographic factors, vary according to location. research is needed to determine if the location in which older adults reside affects their resilience levels. method sample and procedure data were pooled from two studies. the first study obtained data from a rural population (wells, 2009). the second study, which was a replication of the first, obtained data from urban and suburban populations. systematic sampling was used to randomly select adults age 65 years and over from voter registration lists of urban, suburban, and rural residents in new york state. the criterion used to determine the degree of rurality was the rural-urban continuum codes developed by the economic research service (ers), united states department of agriculture [usda] (2003). the rural sample was obtained from the central and southern tier areas of new york state which are coded as 6, indicating that the county is non-metropolitan, has an urban population of 2,500 to 19,999, and is adjacent to a metropolitan county. the urban sample was obtained from voter registration lists of older adults who resided in zip codes within a mid-sized city in central new york with a population of approximately 130,000. the suburban sample was obtained from two zip codes that border the city with one on the east side and one on the west side. these cross-sectional studies were initiated after receiving approval from university human subjects review committees. initially, a research packet containing items on demographics, resilience, social networks, and health status were mailed to 300 registered voters in the designated rural areas. in the subsequent study, 600 research packets were mailed to older adults who resided in suburban or urban zip codes. all participants were offered a chance to win a gift card to a retail store as an incentive to complete the forms. in the first study, follow-up postcards were sent to those who did not respond; however, this yielded few responses and was not repeated in the second study. instruments the resilience scale (rs) was used to measure the level of resilience of the participants (wagnild & young, 1993). the rs was developed from the findings of a qualitative study of older women who had successfully adapted to a major loss (wagnild & young, 1990). these 48 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 women were found to have five characteristics which included: equanimity, self-reliance, perseverance, meaningfulness of life, and existential aloneness and the items on the rs address these characteristics. the rs has 25 items which are scored on a 7-point scale from 1, strongly disagree, to 7, strongly agree. scores on the rs range from 25-175 and scores of 147-175 are considered high levels of resilience (wagnild & young, 1993). the cronbach’s alpha of the rs for this study was .94, which indicates strong internal consistency of the items in the scale. the short-form revised (sf-12v2) health survey was used to measure health status (ware, kosinski, turner-bowker, & gandek, 2002). the sf-12v2 is a norm-referenced selfreported measure of health status and a revised version of the original sf-12. the sf-12v2 has two health summary components which include the physical component summary (pcs) and the mental component summary (mcs). in this study, the cronbach’s alpha coefficients for each summary component of the sf-12v2 were as follows: .87 for the mcs and .89 for the pcs, which indicate strong internal consistency. the lubben social network scale-revised (lsns-r) was the instrument used to measure the social networks of community-dwelling older adults (lubben, gironda, & lee, 2002). items on the lsns-r are rated on a scale of 0 to 5 with 0 indicating ‘never’ or ‘none’ and 5 indicating ‘always’ or ‘nine or more’. a total score of the 12 item lsns-r is obtained by summing each of the equally weighted items. the total score ranges from 0-60, and the subscales of friends and family networks each range in scores from 0-30. cut-points for the total score or subscale scores were not identified and higher scores indicate stronger social networks (lubben et al., 2002). in this study, the cronbach’s alpha for the total lsns-r was .90. for the family and friend subscales, the cronbach’s alpha was calculated to be .89 and .88 respectively. the total lsns-r and the subscales demonstrated strong internal consistency in this study. data analysis statistical analyses were carried out using spss ® 14.0 (spss inc., chicago, ill). the level of significance was set at .05. initial descriptive analyses included frequencies, means, and standard deviations. norm-based scoring software was used to calculate the physical component score (pcs) and the mental component score (mcs) of the sf-12v2. chi-square analysis was performed to determine if there were differences between location and categorical data. continuous data were analyzed using t-tests and one-way analysis of variance (anova) to assess differences in resilience across demographic categories, including location as well as in the sf-12v2 subscales, and the lsns-r total score and subscales. pearson product-moment correlation coefficients were calculated to determine if there were associations between resilience and the other continuous variables. multiple linear regression models were built to evaluate independent predictors of resilience with control for demographic factors. initially all the predictor variables were entered into the model and a backward elimination approach was used, removing any variable with α > .15. the final model included the predictors remaining in the first model as well as location. beta coefficients and 95% confidence intervals for the beta coefficients have been shown as well as the coefficient of variance (r 2 ) for this model. power analysis was performed using samplepower v2 (software) using the r 2 from the regression analysis of the rural sample. with 2 covariates (age and gender) and 3 main variables (pcs, mcs and lsns-r), an alpha of 0.05 and an effect size of r 2 =.38, only 30 people were needed for a power of 80%. 49 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 results in total, the sample consisted of 277 participants. the approximate overall return rate was 31%. the majority of participants were female (53%), married (60%), and not employed (80%). the mean age of the participants was 75 years. sixteen participants omitted their income level and three omitted their age. demographic characteristics of participants according location are shown in table 1. table 1. demographic characteristics of participants suburban n (%) urban n (%) rural n (%) pearson chisquare significance location 95 (34%) 76 (27%) 106 (38) gender male female 43 (45%) 52 (55%) 29 (38%) 47 (62%) 57 (54%) 49 (46%) p=.11 marital status single married divorced widowed 5 (5%) 65 (68%) 3 (3%) 22 (33%) 8 (10%) 35 (46%) 15 (20%) 18 (24%) 8 (8%) 67 (63%) 4 (4%) 27 (26%) p=.00 employment status not working part-time full-time 78 (82%) 9 (10%) 8 (8%) 57 (75%) 14 (18%) 5 (7%) 85 (81%) 33 (12%) 10 (10%) p=.35 household income <10,000 10-24,999 25-34,999 >35,000 2 (2%) 18 (20%) 14 (16%) 56 (62%) 15 (21%) 18 (25%) 9 (13%) 30 (42%) 6 (6%) 31 (31%) 23 (23%) 39 (39%) p=.00 education level some hs hs degree college graduate 2 (2%) 34 (36%) 37 (40%) 21 (22%) 8 (11%) 39 (51%) 12 (16%) 17 (22%) 6 (6%) 64 (60%) 14 (13%) 22 (21%) p=.00 the mean resilience level of the entire sample was 148 and no differences were found in location. table 2 contains the results of one-way anova for location with age, resilience, social networks consisting of friends and family, and physical and mental health status. the only statistical difference was found between location and social networks consisting of family. using pearson’s correlation coefficient, none of the socio-demographic factors (age, gender, income, education, marital status, and employment status) were found to be significantly correlated with resilience. the relationship between the family and friend subscales of the lsns 50 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 table 2. anova results for location with age, resilience, social networks, and physical and mental health status suburban urban rural f significance age mean (sd) 76 (7) 74 (8) 75 (6) .73 p=.48 resilience mean (sd) 148 (17) 147 (21) 149 (18) .46 p=.63 social networks (family) mean (sd) 18 (5) 17 (7) 20 (6) 3.62 p=.03 social networks (friends) mean (sd) 16 (6) 17 (6) 17 (6) 1.29 p=.28 physical health (pcs) mean (sd) 44 (13) 43 (13) 42 (11) 1.06 p=.35 mental health (mcs) mean (sd) 54 (8) 53 (8) 54 (9) .30 p=.74 r and resilience levels were both equally and weakly significantly correlated (r=.21, p=.00). both physical (pcs) and mental health (mcs) status were correlated with resilience. the correlation between pcs and resilience was (r=.23), p=.00, while the mcs had a correlation coefficient of (r=.42), p=.00. when all variables were entered into multiple regression models to predict resilience and a backward elimination method was used, four variables remained and included lsns-r family subscale, household income, mcs, and pcs. location was left in the final model because this was a primary variable of interest for the study. the linear combination of location, lsns-r family subscale, pcs, and mcs was significantly related to resilience, f(6,240)=13.9, p=.00. the r 2 was .24 indicating that 24% of the variance of resilience levels can be accounted for by the linear combination of predictors. higher perceived mental health status was the strongest predictor of resilience. the results of the final regression model for predicting resilience are included in table 3. discussion in this cross-sectional study, the process of resilience was not explored; however, the level of resilience and significant associations with protective factors were identified. the mean resilience level of rural, suburban, and urban community-dwelling older adults, as measured by the resilience scale, was found to be 148, indicating high levels of resilience. the resilience level of older adults did not vary if they lived in a rural, urban, or suburban area. although rural 51 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 table 3. final regression model for predicting resilience predictor unstandardized 95% ci p value variables b coefficient of b rural to suburban -1.96 (-6.90, 2.99) .44 rural to urban -3.15 (-8.40, 2.10) .24 lsns family subscale .55 (.19, .92) .00 pcs .35 (.17, .53) .00 mcs .83 (.58, 1.08) .00 income -2.57 (-4.69, -.46) .02 dwellers often face unique challenges related to limited access to healthcare due to distance and isolation (long & weinert, 1989), resilience level of rural dwellers is similar to those living in suburban and urban areas. high levels of resilience have been found in other studies of older adults; however, location in which they resided was not identified (nygren et al., 2005; wagnild, 2003; wagnild & young, 1993). it does not appear that resilience levels decrease as one ages. resilience levels may actually remain steady or increase as older adults gain from the challenges they cope with successfully; however, further research is needed to support this. none of the socio-demographic factors except income were found to be significantly correlated with resilience. in regression analysis, higher income was found to be significantly associated with lower resilience levels. this is an unusual finding that is not supported in the literature (hardy et al., 2004; wagnild, 2003). a possible explanation for the finding in this study may be that data were collected when the economy was taking a downturn. those with higher incomes were losing more money in the stock market than those with lower incomes. this may have affected resilience levels. further research is needed to determine the relationship between income and resilience. while this study did find a relationship between resilience and social networks consisting of friends and family, it was a weak relationship and only social networks consisting of family were found to significantly predict resilience in regression analysis. within the resilience scale, self-reliance is a measure of resilience. thus, those with high resilience levels tend to have high levels of self-reliance. in chi-square analysis there were differences in strength of social networks and location. rural dwellers had the strongest family networks. urban dwellers were more likely to be divorced and not married than rural and suburban dwellers. these differences may partially explain why stronger family networks were found to predict resilience in regression analysis. this finding is somewhat surprising because it indicates that rural dwellers do not have less contact with family members than those living in other locations. wells (2009) found that in rural older adults, high resilience levels were associated with social networks consisting of friends, but not family. this was thought to be due in part, to the fact that many young adults leave rural areas to attend college or find employment in urban areas which causes rural elders to rely on friends for support. this study found that better perceived physical health status was associated with resilience, and this is well supported in the literature (adams, sanders, & auth, 2004; felten, 2000; hardy, concato, & gill, 2004; hinck, 2004; montross et al., 2006; wagnild, 2003). 52 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 resilience and physical health were only weakly correlated in this study, indicating that declining health status may not reduce resilience levels dramatically. nygren et al. (2005) found that physical health status and resilience were not related in swedish adults age 85 years or older. although older adults may experience decline in physical health, resilience does not always decline. better mental health status had the strongest association with high resilience levels, and several studies of older adults support this relationship (easley & schaller, 2003; hardy et al., 2004; hinck, 2004; kinsel, 2005; lamond, 2009; lee, brown, mitchell, and schiraldi, 2008; mehta et al., 2007; nygren et al., 2005; wagnild, 2003; wagnild & young, 1990; yoon & lee, 2007). mental health status appears to be an important aspect of resilience in older adults across rural, suburban, and urban locations. in the future, early identification of mental health problems and timely interventions may assist in building resilience of older adults; however, research is needed to support this. limitations mailed surveys may not have captured the true level of resilience of community-dwelling older adults. using only self-reported measures to obtain data is a weakness of this study. the response rate of 31% is not unusual for mailed surveys; however, the sample may have been biased to those with high resilience levels may have been more likely to respond. because the sample was obtained from areas in new york state, results may not be generalizable to other populations. in order to complete the surveys, subjects had to be able to read and have adequate visual acuity to complete the surveys. this may have excluded those with low literacy skills and poor visual acuity. in addition, the education level of the participants in the sample is higher than those in the population. because participants had high levels of mental health status, those with poor mental health may have chosen not to complete the packets, due to fear of disclosing private information or because of lack of energy. conclusion while the cross-sectional design of this study prohibited the identification of causal relationships, associations among the protective factors and resilience in relation to location were determined. resilience levels were high in older adults despite whether they lived in rural, suburban, or urban areas. strong social networks and good physical and mental health were important protective factors associated with high resilience levels across all locations. resilience is an important concept that needs further study in the older adult population because it focuses on promoting wellness. within the new healthcare reform law, there are provisions in medicare reimbursement to support disease prevention and health promotion. resilience is thought to moderate the negative effects of stress and promote adaptation (wagnild & young, 1993). screening older adults for resilience levels may help identify those at risk for adapting poorly when exposed to stressors and perhaps early interventions can be initiated to help build resilience. steinhardt, mamerow, brown, and jolly (2009) found that using strategies to build resilience along with diabetic education were effective in helping african american adults with diabetes to have positive outcomes. further research is needed to determine if interventions can effectively build resilience in those identified as having low levels to help promote adaptation during times of physical or emotional hardship. 53 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 references adams, k.b., sanders, s., & auth, e.a. (2004). loneliness and depression in independent living retirement communities: risk and resilience factors. aging and mental health, 8(6), 475485. [medline] easley, c., & schaller, j. (2003). the experience of being old-old: life after 85. geriatric nursing, 24 (5), 273-277. [medline] economic research service, us department of agriculture (2003). measuring rurality: ruralurban continuum codes. retrieved december 31, 2006, from http://www.ers.usda.gov/briefing/rurality/ruralurbcon/ felten, b. (2000). resilience in a multicultural sample of community-dwelling women older than age 85. clinical nursing research, 9(2), 102-123. [medline] hardy, s.e., concato, j., & gill, t.m. (2004). resilience of community-dwelling older persons. journal of the american geriatrics society, 52(2), 257-262. [medline] hinck, s. (2004). the lived experience of oldest-old rural adults. qualitative health research, 14(6), 779-791. [medline] kinsel, b. (2005). resilience as adaptation in women. journal of women and aging, 17(3), 2335. [medline] lamond, a.j., depp, c.a., allison, m., langer, r., reichstadt, j., moore, d.j., golshan, s., et al. (2009). measurement and predictors of resilience among community-dwelling older women. journal of psychiatric research, 43, 148-154. [medline] lee, h.s., brown, s.l., mitchell, m.m., & schiraldi, g.r. (2008). correlates of resilience in the face of adversity for korean women immigrating to the us. journal of immigrant minority health, 10, 415-422. [medline] long, k.a., & weinert, c. (1989). rural nursing: developing a theory base. scholarly inquiry for nursing practice: an international journal, 3(2), 113-127. [medline] lubben, j., gironda, m., & lee, a. (2002). refinements to the lubben social network scale: the lsns-r. behavior measurement letter, 7 (2), 2-11. [medline] mehta, m., whyte, e., lenze, e., hardy, s., roumani, y., subahan, p., huang, w., & studenski, s. (2008). depressive symptoms in late life: associations with apathy, resilience and disability vary between young-old and old-old. international journal of geriatric psychiatry, 23, 238-243. [medline] montross, l.p., depp, c., daly, j., reichstadt, j., golshan, s., moore, d., sitzer, d., & jeste, d.v. (2006). correlates of self-rated successful aging among community-dwelling older adults. american journal of geriatric psychiatry, 14(1), 42-51. [medline] nygren, b., alex, l., jonsen, e., gustafson, y., norberg, a., & lundman, b. (2005). resilience, sense of coherence, purpose in life and self-transcendence in relation to perceived physical and mental health among the oldest old. aging and mental health, 9(4), 354362. [medline] richardson, g.e. (2002). the metatheory of resilience and resiliency. journal of clinical psychology, 58(3), 307-321. [medline] steinhardt, m.s., mamerow, m.m., brown, s.a., & jolly, c.a. (2009). a resilience intervention in african american adults with type ii diabetes: a pilot study of efficacy. diabetic educator, 35(2), 274-284. [medline] wagnild, g. (2003). resilience and successful aging: comparison among low and high income older adults. journal of gerontological nursing, 29(12), 42-49. [medline] http://www.ncbi.nlm.nih.gov/pubmed http://www.ncbi.nlm.nih.gov/pubmed?term=14571241%5buid%5d&cmd=detailssearch http://www.ers.usda.gov/briefing/rurality/ruralurbcon/ http://www.ncbi.nlm.nih.gov/pubmed?term=felten%5bauthor%5d%20and%20multicultural%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=14728637%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=hinck%5bauthor%5d+and+lived&transschema=title&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=kinsel%5bauthor%5d%20and%20adaptation%5ball%20fields%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=18455190%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=schiraldi%5bauthor%5d+and+korean&transschema=title&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=2772454%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=lubben%5bauthor%5d%20and%20lubben%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=mehta%5bauthor%5d+and+apathy&transschema=title&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=16407581%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=nygren%5bauthor%5d%20and%20coherence%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=richardson%5bauthor%5d%20and%20metatheory%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=19204102%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=14692243%5buid%5d&cmd=detailssearch 54 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 wagnild, g., & young, h. (1990). resilience among older women. image: journal of nursing scholarship, 22(4), 252-255. [medline] wagnild, g.m., & young, h.m. (1993). development and psychometric evaluation of the resiliency scale. journal of nursing measurement, 1(2), 165-178. [medline] ware, j.e., kosinski, m., turner-bowker, d.m., & gandek, b. (2002). how to score version 2 of the sf-12 health survey (with a supplemental documenting version 1). lincoln, ri: qualitymetric. wells, m. (2009). resilience in rural community-dwelling adults. journal of rural health, 25(4), 416-420. [medline] yoon, d.p., & lee, e.o. (2007). the impact of religiousness, spirituality, and social support on psychological well-being among older adults in rural areas. journal of gerontological social work, 48(3/4), 281-298. [medline] http://www.ncbi.nlm.nih.gov/pubmed?term=2292448%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=wagnild%5bauthor%5d%20and%20psychometric%5btitle%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=19780924%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=17210533%5buid%5d&cmd=detailssearch fahs_another+mortality+penalty+for+rural+populations+final+2022 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.714 1 editoral another mortality penalty for rural populations: covid 19? pamela stewart fahs, phd, rn, editor there is a gap in mortality between rural and urban people. this has been referred to as the rural mortality penalty (alreshidai et al., 2020; james, 2014). there are more deaths in five major areas among rural than urban populations (centers for disease control and prevention [cdc], n.d.). data are now emerging that indicate rural americans are in the unenviable position of being more likely to have died from covid-19 than those in urban areas (marema, 2022; rural health information hub, n.d.). although covid was initially seen more frequently and was the cause of more deaths in urban than rural areas; by august 1, 2020 the mortality rates were equal. rural mortalities became higher than urban in all but three reporting weeks thereafter (cdc embedded data in marema, 2022). in this data, rural was defined using office of management and budget, 2013 criteria for counties outside of a metropolitan statistical area (as cited in marema, 2022). the largest difference in rural/urban covid mortality, occurred december 2020; rural 8.29 vs. urban 4.79, per 100,000 per week. since february 2022, mortality rates have declined in rural and metropolitan areas. starting the week of april 17, 2022, a divergence began and became wider on may 1, 2022, when urban mortality continued to decline while rural mortality began to climb again. more analysis will be needed to better understand why rural people are dying at a higher rate, at 100,000 per week than urban dwellers. vaccinations rates are part of the problem; however, the classic disparities in rural and urban health care may well hold a role in this latest rural mortality penalty. lack of access to health care, especially specialty care, issues of transportation that complicate accessing health care, and underinsured could be part of the problem. additionally, rural populations tend to have higher online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.714 2 risks that contribute to chronic illnesses (cdc, n.d.). nurse scientists focused on rural health should delve into the problem of higher crude covid mortality rates among rural dwellers. those rural nurses providing direct care in both acute and public settings need to redouble efforts toward vaccination and education on mitigating methods and treatments. beyond these roles, work on reducing macro level disparities is one area that needs continued intra-professional attention, if we are ever going to reduce the rural mortality penalty. references alreshidi, b. g., kalman, m., wells, m., & fahs, p. s. (2020). cardiovascular risk reduction in rural women: a literature synthesis. journal of cardiovascular nursing, 35(2). 199-209. https://doi.org/10.1097/jcn.0000000000000622 centers for disease control and prevention (n.d.). about rural health. https://www.cdc.gov/ ruralhealth/about.html james, w. l. (2014). all rural places are not created equal: revisiting the rural mortality penalty in the united states. american journal of public health, 104(11). 2122-2129. https://doi.org/10.2105/ajph.2014.301989 marema, t. (2022, may 5). new covid infections climb 50% over past two weeks in rural communities. the daily yonder. https://dailyyonder.com/ rural health information hub. (n.d.). news headlines. https://www.ruralhealthinfo.org/ reviewing+benefits+and+barriers+ed+dec+2021 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.706 1 editorial reviewing: benefits and barriers pamela stewart fahs, phd, rn, editor i was recently asked to be a panel member for a research lunch and learn along with two other authors. i found the issue of finding quality reviewers and the editor experiences with reviewers was similar across the panel. reviewers are essential to the publication of a quality referred journal. those who review do so for mainly altruistic reasons, primarily to benefit the discipline. however, there are benefits to the individual. first and foremost, reviewing can help you with your own scholarship. you soon get a sense of what constitutes a quality manuscript and what is pertinent to the fit of that journal. you can identify variations in how fit is decided by reviewing for more than one journal. the majority of journals will give you some sort of template or rubric to use as you assess the manuscript. the assessment is likely to include, what is needed for that journal, and these characteristics are often covered in the author guidelines. the review is also an evaluation of the science reported in the article. journal reviewing can have other less direct benefits, such as adding depth to your curriculum vita or resume. in some institutions, reviewing is counted as scholarship on a clinical ladder. finally, reviewing will help you keep abreast in your field. you will be reading what is new and adding to the science in the area in which you practice or do your own research. barriers to reviewing may include a lack of knowledge about where to find the opportunity. this barrier is easily overcome, contact a journal that you read or that covers topics that you are interested in and contact the editor. here at the online journal of rural nursing and health care we are always looking for new reviewers or reviewers with areas of expertise in specific topics within rural health care, education, policy, or research methods and analysis. you will be sent a online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.706 2 form to complete that provides information about yourself such as work affiliation, position, credentials, contact information, and topic areas you would be most interested in reviewing. finally, you list your publications or presentations that may indicate your area of expertise. dr. ann graves, associate editor and myself use these forms to set up your profile in the management software system. then we can search through the system for people whose areas of research or clinical expertise match with the manuscript being submitted. the match may be along the lines of clinical topics but it may also include specific methodology or analysis knowledge. the reviewer knowledge may be on policy in the area if appropriate to the topic. the final barrier is one we all battle, and that is finding the time to conduct a quality review. the more reviewers at the editor’s disposal, the less any one author has to be called upon. reviewing does not take an inordinate amount of time but needs to be done in a timely manner. if something comes up that indicates you will not be able to meet the preset deadline, contact the editor who will most often be able to allow a bit more time for the review. whether you suggest acceptance for publication, revisions, or rejection, one goal is that the authors can use the feedback to improve the quality of their work. giving kind but unbiased feedback is important for the growth of nurse scientists and authors. journals usually have some mechanism for providing this type of feedback. one important element is that the feedback must remain double blinded so the authors do not know who is doing the review, just as they do not get author information. if you are interested in reviewing for the online journal of rural nursing and health care, please contact either dr. pam stewart fahs, editor-in-chief at psfahs@binghamton.edu or dr. barbara ann graves, associate editor at agaves@ua.edu kershner_other,+678-article+text-4497-1-15-202105+final+with+psf+setup+5.19.21 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 69 self-efficacy and concerns of graduate nursing students regarding the covid-19 pandemic sarah kershner, phd, mph1 tracy george, dnp, aprn-bc, cne2 julia marty hucks, mn, aprn-bc, cne3 1 chair, department of healthcare administration and assistant professor, public health, school of health sciences, francis marion university, skershner@fmarion.edu 2associate professor of nursing and coordinator, bachelor of general studies program, school of health sciences, francis marion university, tgeorge@fmarion.edu 3assistant professor of nursing, school of health sciences, francis marion university, jhucks@fmarion.edu abstract purpose: many nurse practitioner students work as nurses while balancing family obligations and graduate school work. the purpose of this project is to learn more about the self-efficacy and concerns of rural graduate nursing students during the covid-19 pandemic. sample: family nurse practitioner students at a rural, public, liberal arts university in the southeastern united states participated in the study. method: demographic information and survey information was obtained from graduate nursing students to assess their self-efficacy and concerns about the covid-19 pandemic, using the 10item general self-efficacy (gse) scale. findings: respondents reported varied effects of the covid-19 pandemic on work schedules. the mean gse self-efficacy score was 3.32 across two-time points (n=67). nine online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 70 qualitative themes were revealed: concerns about contracting and transmitting covid-19, importance of personal protective equipment and hygiene, impacts at home, stress, decreased clinical placements, coping strategies, public health preparedness, future effects of covid-10, and a renewed commitment to nursing. conclusion: this study provides insight into the experiences of rural graduate nursing students caring for patients during the covid-19 pandemic. keywords: graduate nursing education, self-efficacy, pandemic, covid-19 self-efficacy and concerns of graduate nursing students regarding the covid-19 pandemic in december 2019, the coronavirus (covid-19) outbreak occurred in china, and on january 30, 2020, the world health organization (who) declared that covid-19 was a pandemic (who, n.d.). several studies have measured nurses’ perceptions and concerns related to caring for patients during pandemics. however, there is a lack of research on the potential for self-efficacy to be protective against burn-out and stress during the current covid-19 pandemic, especially among graduate nursing students. in a study of chinese singaporean nurses who had cared for patients during the severe acute respiratory syndrome (sars) and influenza a/h1n1 virus outbreaks, three qualitative themes emerged: living with risk; the experience of sars; and the acceptance of risks (koh et al., 2012). nurses perceived that work increased the risk of contracting the viruses but did not impact the willingness to care for patients (koh et al., 2012). nurses voiced concerns about how work could negatively impact family members’ risk of contracting the virus (koh et al., 2012). in a study of new zealand nurses during the 2009 h1n1 pandemic, infection control, high acuity and mortality online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 71 rates of patients, being asked to work additional shifts, and a lack of support were identified as issues (honey & wang, 2012). similarly, in a study of irish nurses’ perceptions about an influenza pandemic, nurses had concerns about a heightened risk of infection, increased workload, stress levels, and concerns about infecting family members (mcmullan et al., 2016). however, nurses felt that working during the h1n1 pandemic improved nursing skills and led to increased job satisfaction (honey & wang, 2012). fernandez et al. (2020) conducted a systematic review to better understand the lived experience of working as a nurse in an acute setting during a pandemic. from this work, three synthesized findings were identified: supportive team work to provide quality care, the physical and emotional impact, and responsiveness of organizational reaction. in an early study that examined the mental health consequences of caring for covd-19 patients on healthcare providers in china, depression, anxiety, and insomnia were identified as prevalent and were more pronounced in women, nurses, those employed in the epicenter (wuhan), and those on the frontline. a large proportion of the nurses in the sample (71.5%) were identified as “junior,” indicating less work experience, which may increase vulnerability to psychological stress. features of the novel coronavirus, including its high communicability, high morbidity and potential fatality rates, as well as a lack of supplies to respond to the epidemic, changes in work, fear of spreading it to others, and isolation may foster a sense of danger (lai et al., 2020). in a study of israeli dentists during covid-19, factors associated with psychological distress included having chronic illness, fear of being infected with covid-19 by a patient, and a higher reported self-overload (shacham, 2020). dentists with higher self-efficacy scores and those in committed relationships had lower psychological distress levels (shacham, 2020). in a study of korean nurses, perceived self-efficacy in providing care for patients was the strongest predictor of online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 72 nurses’ intention to care for patients with an emerging infectious disease (lee & kang, 2019). self-efficacy, the belief that an individual possesses within himself the strength, skills, or traits to persevere in the face of adversity, may be an asset in meeting the demands placed on graduate nursing students who are simultaneously working and enrolled in school during the covid-19 pandemic. the united states census bureau (2010) defines rural as the population, housing, and territory not included in an area with at least 50,000 people. the city in which the university is located had a population of approximately 38,531 residents in 2019 (united states census bureau, 2019). there are several portions of this county designated as rural by the federal office of rural health policy (health resources and services administration [hrsa], 2021). additionally, many students live in surrounding counties that are designated as rural by the federal office of rural health policy and commute to the university for classes (hrsa, 2021). there is a lack of research on the self-efficacy and concerns of rural graduate nursing students regarding the covid-19 pandemic. the purpose of this project is to learn more about the selfefficacy and concerns of rural graduate nursing students during the covid-19 pandemic. methods the study was conducted at a public liberal arts university in the rural, southeast united states. institution review board approval was obtained. this graduate nursing program is a hybrid, master’s degree family nurse practitioner program in which students complete a plan of study over two years. all of the graduate nursing students are registered nurses, and most of them are working full-time or part-time at local healthcare facilities as nurses during covid-19 while balancing family obligations and graduate schoolwork. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 73 an anonymous, online survey was administered to graduate nursing students enrolled in family nurse practitioner courses in the first and second years of the program in the summer of 2020 and then with the same group of students in the fall of 2020. the statewide percent positivity for covid tests was 7.7% on june 1, 2020 and 9.1% on october 12, 2020 when the surveys were deployed (south carolina department of health and environmental control, 2020a, 2020b). the surge in covid cases that begin in late fall and winter of 2020 had yet to affect the area. the web links to the voluntary surveys were placed in the online learning management system, which was used to deliver course content in the two online courses. completion of the surveys was voluntary. students were informed that no incentives or penalties were connected to survey completion. demographic information and survey information was obtained from graduate nursing students to assess their self-efficacy and concerns about the covid-19 pandemic, using the 10-item general self-efficacy (gse) scale (schwarzer & jerusalem, 1995) along with nine qualitative questions. the gse is a freely available scale in which participants self-report their efficacy (schwarzer & jerusalem, 1995). the cronbach’s alpha for the gse ranges between .76 and .90 (schwarzer & jerusalem, 1995). positive coefficients correlated to emotion, optimism, and work satisfaction, while negative coefficients were found for depression, stress, health complaints, burnout, and anxiety (schwarzer & jerusalem, 1995). results demographics a total of 67 graduate nursing students completed the survey at two points in time (47 students out of 68 students at time 1 in june 2020 for response rate of 69.12%; 20 students out of 68 students at time 2 in october 2020 for a response rate of 29.41%). the majority of respondents (87%) were female and almost three-quarters of the respondents (73%) identified as white or online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 74 caucasian with a remaining 21% identifying as black or african american. almost half of the respondents (42%) were between the ages of 26-35 years of age. of the 67 total respondents surveyed across two time points, there was a range of years worked as an rn: 19% reported 1-3 years of experience, 34% reported 4-6 years of experience, 7% reported 7-10 years of experience and 37% reported greater than 10 years of experience. similarly, there was a range of settings in which respondents worked: 18% reported working on the covid-19 floor, 12% reported working in the emergency department, 6% reported working in home health, 27% reported working in the intensive care unit, 12% reported working on the medical surgical floor, 10% reported working in an outpatient clinic and the remaining respondents worked in pediatrics, psychiatric setting, women’s health or other. quantitative of the 67 total respondents surveyed across two time points (47 students at time 1 in june 2020; 20 students at time 2 in october 2020), there were varied effects of the covid-19 pandemic on work schedules: 30% reported working fewer hours due to the pandemic, 27% reported working more hours due to the pandemic, and 34% reported no impact on work schedule. respondents (n=67) were asked to indicate level of agreement with various statements measuring resilience and self-efficacy using the likert scale response options: 1=not at all true, 2=hardly true, 3=moderately true, and 4=exactly true. table 1 shown below shows the average level of agreement for each of the gse scale statements. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 75 table 1 mean self efficacy of graduate nursing students using gse scale average level of agreement with agree/disagree statements (likert scale: 1=not at all true, 2=hardly true, 3=moderately true, 4=exactly true) summe r average (n=47) fall averag e (n=20) total averag e (n=67) i can always manage to solve difficult problems if i try hard enough. 3.28 3.40 3.31 if someone opposes me, i can find the means and ways to get what i want. 2.43 2.50 2.45 it is easy for me to stick to my aims and accomplish my goals 3.40 3.35 3.39 i am confident that i could deal efficiently with unexpected events. 3.43 3.40 3.42 thanks to my resourcefulness, i know how to handle unforeseen situations. 3.34 3.25 3.31 i can solve most problems if i invest the necessary effort. 3.53 3.50 3.52 i can remain calm when facing difficulties because i can rely on my coping abilities. 3.43 3.45 3.43 when i am confronted with a problem, i can usually find several solutions. 3.43 3.35 3.40 if i am in trouble, i can usually think of a solution. 3.51 3.50 3.51 i can usually handle whatever comes my way. 3.43 3.45 3.43 mean gse self-efficacy score 3.32 3.32 3.32 the highest level of agreement was with the statement “i can solve most problems if i invest the necessary effort” (3.52) and the lowest level of agreement was with the statement “if someone opposes me, i can find the means and ways to get what i want” (2.45). overall respondents indicated a “hardly true”, “moderately true” or “exactly true” on each of the gse state statements. the mean self-efficacy score on the gse scale was 3.32 (“moderately true”). qualitative directed content analysis was used to analyze the nine open-ended survey questions from summer and fall 2020 (shown below in table 2). the investigators coded the open-ended survey questions to identify and determine the categories and repetitive themes found, and agreement was reached on any differences. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 76 table 2 open-ended survey items open-ended survey items 1. what concerns did you face in your work as a registered nurse during the covid-19 pandemic? 2. what issues did you have trying to balance your work and home life during the covid-19 pandemic? 3. how was your ability to complete clinical rotations in the nurse practitioner program impacted by the covid-19 pandemic (if applicable)? 4. how did the covid-19 pandemic affect you emotionally? 5. how do you feel that the covid-19 pandemic has changed your outlook professionally? 6. what positive impact has the covid-19 pandemic had on you-personally or professionally? 7. what coping strategies have you used during the covid-19 pandemic? 8. how do you anticipate that your life will be different going forward? 9. any other comments? nine qualitative themes were identified that remained consistent from both time periods. the themes included concerns about contracting and transmitting covid-19, importance of personal protective equipment and hygiene, impacts at home, stress, decreased clinical placements, coping strategies, public health preparedness, future effects of covid-19 and a renewed commitment to nursing. the nursing students had concerns about contracting and transmitting covid-19 in the summer and fall of 2020. one student said “primary concern is getting sick with covid-19, due to underlying health conditions.” another student reported, “i was concerned that i would bring the virus home to my family.” one student stated “more cautious in caring for patients and especially when coming home to my family.” students were concerned about the lack of personal protective equipment and recognized the need for hygiene measures. one student admitted a concern about the “uncertainty of ppe availability while caring for covid patients.” a student reported that there was a “lack of ppe, [and] unknown exposure risk.” another said online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 77 “it has made me become more aware and see the importance of having good hand hygiene and educating patients on proper sanitation techniques.” nursing students were concerned about the impact of covid-19 at home in the summer and fall of 2020. one student said “no daycare center open during pandemic” was an issue. for some students, an impact related to covid was “more family time” and “more at home time.” another student said, “it was horrible between work, school, and family. [i] was unable to see family many weeks at a time due to risk of exposure. it was very difficult and mentally/emotionally exhausting.” some of the students experienced reduced hours as nurses during the summer of 2020. a student said, “i never thought i’d see a day that an er nurse was not needed.” in the fall, many students were asked to work additional hours. one student said, “it's hard to dedicate time to home with extra hours.” another student in the fall relayed they were “required to work extra hours, my husband was laid off requiring me to work more.” another student in the summer said “being financially secure” was a concern. this concern continued into the fall, and one student said covid was “mostly a financial struggle.” the pandemic was stressful for students in the summer and fall. one student in the summer said, “it was stressful and draining between monitoring my own activity, taking care of patients i knew personally with covid, and adapting to the constantly changing environment of care.” in the fall, one student said covid “creates more stress for our occupation.” another student said, “i know it will make me a stronger provider, yet it has been a struggle with all of the extra stress.” the graduate nursing students also had decreased clinical placements. one student in the summer said, “the biggest issue i had during covid was loss of clinical placement.” for another student, the healthcare “organization paused student learning temporarily…having to online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 78 find another preceptor unexpectedly.” this issue continued into the fall. one student said, “it was difficult to locate a provider agreeable to accept students.” another student reported finding clinical placements was “nearly impossible, consumed all of my time trying to find someone who would allow me to complete hours with them. it was emotionally, physically, and mentally draining. coping strategies was another theme in the summer and fall. the students used a variety of strategies including “spiritual renewal,” “praying,” “yoga,” “meditation,” “talking with other co-workers,” “exercise,” “great support of family” and “time outdoors.” the students became aware of the importance of public health preparedness because of the covid-19 pandemic. one student said, “it made me realize we need to be more prepared for things like covid-19 to protect our patients as well as ourselves.” students in the summer and fall felt that there were future effects of covid-19. “i now have some degree of ptsd. you cannot see this many people die and not be affected.” another student reported “everything around me including the healthcare system has changed.” in the fall of 2020, students also expressed uncertainty for their future, with one person saying, “fear is among all americans, things are not the same.” this concern about the future was extended to their profession. one student said, “i feel like i have done all this work over the years and am graduating into a job market that is not there.” another student in the fall said, “i worry it has (sic) effected job availability for myself once i graduate as an np.” students had a renewed commitment to nursing due to covid-19. one student said, “it made me even more motivated to help others and just strengthened my love to be a nurse and future np.” another student reported, “working under stressful and uncertain conditions with difficult patients has improved my critical thinking and nursing skills.” a student said, “it is an online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 79 encouragement to work together with other healthcare professionals to overcome the many obstacles we face to continue to provide the best care for patients while supporting each other.” discussion because the covid-19 pandemic impacted the nurses’ hours in varying ways, it is difficult to generalize the specific impact of the covid-19 pandemic on work schedules. however, 57% of graduate nursing students (n=67) in this study had a change in their working hours, which may have impacted them financially and in their work-life balance. the changes in work schedules may have been particularly stressful due to the constraints that being enrolled in a rigorous curriculum already imposes. it is important to consider the self-efficacy of nurses during a pandemic such as covid-19 because of its relationship to mental health, resiliency, and the intention to care for patients during a pandemic. in the present study, the quantitative results indicated that the graduate nursing students had an overall moderate level of self-efficacy. shacham (2020) found that healthcare providers with higher self-efficacy scores may have lower levels of mental distress, which is important during the stressful conditions of caring for patients with an emerging infectious disease. it is important to maintain an adequate nursing workforce to care for patients with covid-19. research indicates that nurses who have higher self-efficacy levels may be more likely to care for patients during a pandemic (lee & kang, 2019). in fact, willingness to work in any disaster has been found to be related to self-efficacy and was higher in males, those who are young, and those with more education (al-hunaishi et al., 2019). similar to the findings of koh and colleagues (2012), contracting and transmitting covid19 was a concern of the graduate nursing students in this study, but these students also reported a renewed commitment to nursing. the graduate nursing students were concerned about the online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 80 importance of personal protective equipment and hygiene, which is analogous to the findings of honey and wang (2012). stress was a theme reported by mcmullan and colleagues (2016), which is also a theme in this study. this study provides insight into the experiences of rural graduate nursing students who are working as nurses while completing courses in a family nurse practitioner program. one of the themes unique to graduate nursing students included decreased clinical placements, which impacted their ability to complete clinical courses on time in the nurse practitioner program. because of issues with clinical placements during the summer and fall of 2020, nursing faculty reached out to current preceptors, and several preceptors were able to accept multiple students. in addition, some students were able to complete clinical hours at free clinics, which strengthened partnerships with the nursing program. other students completed their clinical hours at urgent care settings, where there were fewer restrictions on students. none of the nurse practitioner students were unable to complete courses due to a lack of clinical placements. completing the survey may have been healing for some of the nursing students. one student said, i am glad i took time to do this survey. i have not put into words what i have been going through enough during this time. this was therapeutic. in 6 weeks, i have seen more people die than i have in three years. some of the limitations of this study include the small number of graduate nursing students in a single nursing program who were surveyed at two points in time (summer and fall 2020) in the middle of the covid-19 pandemic. during both times, cases had not surged to high levels locally, and nursing was yet to lose one of its own to the illness in the local area. since that time, the rural area in which the study was conducted has seen very high cases rates for covid-19. it online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 81 may be interesting to do additional research as the pandemic evolves in other rural areas. the response rate for the surveys may have been lower due to the constraints of the pandemic itself, as well as emotional saturation related to it. conclusion this study provides insight into the experiences of rural graduate nursing students who are caring for patients during the covid-19 pandemic. these findings have implications for nurse educators, nurses, and health care administrators who may have lacked awareness of the issues facing graduate nursing students in rural areas working on the front lines during a pandemic. since self-efficacy can be taught, future research may focus on ways to improve among nurses and nursing students so that they are better prepared for and more willing to work during stressful work situations such as pandemics. in addition, further research may focus on the concerns of graduate nursing students over a period of time during a pandemic. references al-hunaishi, w., hoe, v. c. w., & chinna, k. (2019). factors associated with healthcare workers willingness to participate in disasters: a cross-sectional study in sana’a, yemen. bmj open, 9. article e030547 http://dx.doi.org/10.1136/bmjopen-2019-030547 fernandez, p. r., lord, h., halcomb, p. e., moxham, p. l., middleton, d. r., alananzeh, d. i., & ellwood, l. (2020). implications for covid-19: a systematic review of nurses’ experiences of working in acute care hospital settings during a respiratory pandemic. international journal of nursing studies, 111. article 103637. https://www.doi.org/10.1016/j.ijnurstu.2020.103637 health resources and services administration [hrsa] (2021). rural health grants eligibility analyzer. https://data.hrsa.gov/tools/rural-health?tab=address online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 82 honey, m., & wang, w. y. (2012). new zealand nurses perceptions of caring for patients with influenza a (h1n1). nursing in critical care, 18(2), 63-69. https://www.doi.org/10.1111/j.1478-5153.2012.00520.x koh, y., hegney, d., & drury, v. (2012). nurses' perceptions of risk from emerging respiratory infectious diseases: a singapore study. international journal of nursing practice, 18(2), 195-204. https://www.doi.org/10.1111/j.1440-172x.2012.02018.x lai, j., ma, s., wang, y., cai, z., hu, j., wei, n., wu, j., du, h., chen, t., li, r. tan, h., kang, l., yao, l., huang, m., wang h., wang, g., liu, z., hu, s. (2020). factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. jama network open, 3(3). https://doi.org/10.1001/jamanetworkopen.2020.3976 lee, j., & kang, s. j. (2019). factors influencing nurses' intention to care for patients with emerging infectious diseases: application of the theory of planned behavior. nursing & health sciences, 22(1), 82-90. https://www.doi.org/10.1111/nhs.12652 mcmullan, c., brown, g. d., & o'sullivan, d. (2016). preparing to respond: irish nurses' perceptions of preparedness for an influenza pandemic. international emergency nursing, 26, 3-7. http://dx.doi.org/10.1016/j.ienj.2015.10.004 schwarzer, r., & jerusalem, m. (1995). generalized self-efficacy scale. in j. weinman, s. wright, & m. johnston. measures in health psychology: a user’s portfolio. causal and control beliefs (pp. 35-37). nfer-nelson. shacham, m., hamama-raz, y., kolerman, r., mijiritsky, o., ben-ezra, m., & mijiritsky, e. (2020). covid-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in israel. international journal of online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.678 83 environmental research and public health, 17(8), article 2900. https://www.doi.org/10.3390/ijerph17082900 south carolina department of health and environmental control. (2020a, june 1). south carolina announces latest covid-19 update. https://scdhec.gov/news-releases/south-carolinaannounces-latest-covid-19-update-june-1-2020 south carolina department of health and environmental control. (2020b, october 12). south carolina announces latest covid-19 update. https://scdhec.gov/news-releases/southcarolina-announces-latest-covid-19-update-october-12-2020 united states census bureau (2019). quick facts. https://www.census.gov/quickfacts/fact/table/florencecitysouthcarolina,florencecountysout hcarolina/pst045219 united states census bureau. (2010). 2010 urban and rural classification and urban area criteria. https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urbanrural/2010-urban-rural.html world health organization. (n.d.). rolling updates on coronavirus disease (covid-19). https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen microsoft word booth_506-3098-2-ce.docx online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 90 service learning initiatives in rural populations: fostering cultural awareness leigh booth, edd, msn, rn1 barbara ann graves, phd, rn2 1 assistant professor, capstone college of nursing, university of alabama, labooth10@ua.edu 2 professor, capstone college of nursing, university of alabama, agraves@ua.edu abstract this article focuses on the implementation of service learning initiatives with rural populations to foster cultural awareness within undergraduate nursing students. the results of student reflections and how they relate to increased awareness of global rural health, cultural awareness, and health disparities is presented. objectives: (1) to describe an international service learning project conducted through a shortterm medical mission to the united republic of tanzania for baccalaureate nursing students; and (2) explore student observations and perceptions regarding culture and health in a rural community. overall, we hope to gain information about the impact of student experiences regarding international service learning, rural health, and cultural perspectives and awareness. methods: the study used the qualitative method of reflective journaling to investigate student observations and perceptions during a medical mission trip regarding culture and health in an international rural community. journals were analyzed using content analysis and thematic identification. results: student reflections revealed themes of increased awareness in global cultural differences, interprofessional relationships, compassionate care, and health disparities in a variety of rural online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 91 settings. students who participated in service learning initiatives within these international medical trips stated they were more globally aware and were now more likely to provide services to rural communities in their future nursing careers. conclusions: this sl project effectively evaluated the benefits of a short-term international mission trip. study results showed student benefits of increased awareness of community needs, decreased stereotyping, increased confidence in working with culturally diverse populations, and increased personal and professional growth for cultural competence. we identified a need to include and develop core interprofessional education competencies in future trips. keywords: rural, rural health, service-learning, medical mission, cultural competence service learning initiatives in rural populations: fostering cultural awareness background across the globe there is a growing need for culturally appropriate healthcare. it is important to understand concepts that impact world health from global, rural, and cultural perspectives. therefore, it is imperative to prepare healthcare professionals with global, rural, and cultural awareness. integrative teaching strategies are needed that both educate providers and meet the changing healthcare needs of culturally diverse rural populations around the world. using service learning (sl) within an international medical mission trip can provide students with organized learning experiences directed toward improving the health of communities in underdeveloped rural areas of the world. global awareness relates to understanding of concepts of global and cultural perspectives. these concepts that impact the world include, but are not limited to, environmental, social, cultural, political, and economic relations. cultural differences exist internationally across countries and regions as well as from urban-to-rural areas. rurality is a concept with aspects online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 92 relevant to both global and cultural awareness. aspects of both international and urban/rural cultural differences create barriers to healthcare resources and services. many health disparities exist due to the barriers and lack of healthcare resources and services. service learning, an active learning approach, has been shown to provide students with experiential learning while they provide valuable healthcare services within communities in need. furthermore, sl embedded in study abroad can increase student awareness of global health, rural health as well as cultural differences and offer opportunities to learn and participate in culturally appropriate healthcare. global and cultural rural health awareness “the term rural suggest many things to many people, such as agricultural landscapes, isolation, small towns, and low population density” (crosby, wendel, vanderpool, & casey, 2012). according to the united nations (un, 2017) rural areas are large and isolated areas of open country with low population density. this can vary from remote villages, to non-urban neighborhoods, to countryside. these areas and communities can be exemplified with a low ratio of inhabitants to open space. agricultural activities tend to be prominent in rural areas (un, 2017). rural and remote populations naturally experience reduced access to healthcare. the resulting health disparities are a major source for concern for people living in rural communities and especially in less developed countries around the world. the united nations (un, 2014) reports that around the world more people live in urban areas than in rural areas and a pattern of global urbanization is expected to continue. in 2014, the rural population accounted for almost half (47%) of the total global population (the world bank group, 2016). globally, the rural population has grown slowly since 1950 and could peak in a few years. while urban population growth is nearly universal, rural population change shows wide variation. “around two-thirds of countries are projected to experience reductions in their rural populations online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 93 between 2014 and 2050…” (un, 2014, p.77). a notable problem is that the world’s rural population is increasingly concentrated in the less developed countries (un). what is problematic in regards to this global pattern of urbanization is the potential implication to lead to further reductions in the already inadequate supply of rural healthcare resources and services. therefore, the global challenge is how to deal with these widely varying regional patterns in urbanization and reduced services to rural population. there continues to be a large portion of the world without immediate access to even the most basic of healthcare needs. culturally competent nurses are needed to be provider culturally competent healthcare globally. it is therefore important to develop nurses who are aware of both international and urban/rural differences. there is a need for nurses who are not just culturally aware, but also with cultural sensitivity and the ability to provide global, culturally competent care. teaching strategies that allow for immersion within different populations and cultures can help students identify core values, connect classroom theories with their experience and develop cultural sensitive approaches to care. service learning (sl) for this project (academic) sl is defined as a “subset of service engagement …as a coursebased, credit-bearing educational experience in which students participate in an organized service activity that meets identified community needs, use knowledge and skills directly related to a course or discipline, and reflect on the service activity in such a way as to gain: a further understanding of course content, a broader appreciation of the discipline, an enhanced sense of personal values and civic responsibilities” (purdue center of instructional excellence, n.d., p.1). the idea of experiential learning is a key concept in sl. sl opportunities facilitate students in becoming involved in real world, community focused activities that contribute in meaningful and online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 94 positive ways to their learning in addition to their “academic and social development” (simpson, 1998; mckinnon & fealy, 2011, p. 95). nokes, nickitas, keida, and neville (2005) present that sl is based on the idea that classroom learning alone cannot provide experience that allows students to develop a sense of civic responsibility and cultural awareness. in addition, participation in sl provides the opportunity to prepare future students not only for their role as nurses, but also as citizens. qualitative research has shown that sl can be “eye opening”, “filled with intense emotion”, and “an insight to the common bond between those served and those serving” (stallwood & groh, 2011, p. 299). the real-world experience of participating in sl provides invaluable knowledge that can be used in future nursing careers as well as life in general. kohlbry and daugherty (2013) relate that sl provides students with activities that involve them directly with people in the communities and with meeting health needs of communities. they become directly involved in patient care, assessment of communities, and health education. in addition, the students are encouraged and given time to reflect on their experience and the process of the experience. in addition, many student benefits are associated with sl. some of these include improved cognition, enhancement of the professional nursing role, improved cultural competence, accomplishment of key learning outcomes, increase in the number of globally prepared nurses, improved skills and knowledge level, heightened sense of caring, better overall communication, and even a greater sense of confidence for the student (amerson, 2010; kohlbry & daugherty, 2013; groh, stallwood, & daniels, 2011; green, comer, elliott, & neubrander, 2011). students most often come away from sl projects with more knowledge, a better sense of how to use this knowledge, and what this knowledge meant for their patients and themselves. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 95 students can travel to remote, underdeveloped countries and became actively involved at the community level. they provide direct healthcare as well as community assessment with the goal to improve both health and quality of life within that specific rural population. students are guided to process the learning experience through reflective journaling. the literature shows that student reflections often reveal themes of increased awareness in global cultural differences, interprofessional relationships, compassionate care, and health disparities in a variety of rural settings. students who participate in sl initiatives within these international medical trips stated they were more globally aware and more likely to provide services to rural communities throughout their future nursing careers. riner (2011) notes the importance of both reciprocity and bidirectionality between student and community as the best pedagogy. those involved in sl should gain from each other, one through providing service and gaining knowledge, and the other from being served and gaining needed help. not only are students meeting the needs of underserved populations through service, but they are also learning skills and gaining knowledge in a way that is relevant to their program of study (stallwood & groh, 2011; mckinnon & fealy, 2011). growing evidence supports sl as a strategy that provides students with opportunities to apply academically learned skills in real-world situations (groh, stallwood, & daniels, 2011; gehrke, 2008). sl strengthens leadership skills, social responsibility, and both interpersonal and interprofessional collaboration. dalmida et al (2016) further outline the benefits of sl for students: “(a) improved skills in health education; (b) increased awareness of community needs and empathy; (c) improved abilities to work with divers clients; (d) decreased stereotyping attitudes about disadvantaged populations; (e) increased civic awareness and responsibility; (f) personal and professional growth; (g) greater flexibility, creativity, and innovation that later influenced both online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 96 their personal and professional lives; (h) increased self-efficacy related to cultural competency and a commitment to international service (p. 520). research has clearly shown that sl can help bridge the existing gap between rural populations and the lack of access to basic healthcare. the application of sl strategies within a medical mission trip can enhance experiential learning and expand student perceptions of both cultural competence and global rural health. intentionally structured international sl within a model of a medical missions is one strategy that can provide solutions for the problem of decreased access to healthcare worldwide. short-term medical mission to tanzania short-term medical missions are common and provide a mechanism to address health needs in low-income, underserved countries. international sl trips provide students with real-world learning experiences in a rural, low-resource setting. sl is one strategy used to by our college of nursing to achieve the mission, vision, and values of the program. the strategy of sl is used within a program of study abroad international medical trips. approximately five years ago our university study abroad partnered with a non-profit faithbased organization to provide nursing students with international medical trips to underdeveloped rural areas around the world. the selected faith-based christian organization, with a mission to provide healthcare and compassion in a world of need, focuses on basic health screenings and treatments of health problems as well as support for spiritual growth. as part of a christian worldview, mission organization volunteers work closely with local pastors and community church members, offer prayer, and share their faith with clinic participants. however, professions of faith by recipients are never required to receive care. this organization targets international underserved populations and does not discriminate based on race, background, or religion. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 97 healthcare providers, lay workers, and translators consist of both volunteers from us-based churches as well as from the community. the selected mission organization has worked in tanzania for many years and has longstanding relationships with local churches, community members, and government. they have history collaborating and providing care with each of the two sites and visits these sites yearly to offer education and medical care. typically, residents of these communities do not have yearround access to a local physician and must travel long distances by public transport to reach a clinical facility without the certainty of being seen. students assist based on their skills and experience; for example, university students are involved as general helpers, medical students and nursing students can serve as health educators, and students with language fluency can serve as translators. students provide services under the direct oversight of a licensed clinician or appropriate supervisor. students are actively involved at the community level participating in activities to improve healthcare for individuals and the community. activities includes health assessment, eye clinics, dental clinics, pharmacy, health education, spiritual care, and recreation for the children. the needs of the community are assessed and addressed. there is a true symbiotic relationship where both the community and the student benefits. during this sl mission experience, students participated in four days of clinic caring for people of tanzania living in rural areas. each day, students traveled to villages and set up medical clinics at various community sites such as schools or other community buildings. tables were set up in different stations with medical supplies. individuals would line up outside the buildings in hope of being seen by a medical provider. student triaged patients, obtained basic demographic information, patient complaints and vital signs. patients would be escorted to a physical exam online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 98 area or an eye exam area based on their most important complaint. after their examination, patients would visit a pharmacy station to receive vitamins and any other medications that could potentially help any current ailments. once they received medical attention, patients could sit and speak to a nurse and/or spiritual counselor. students rotated through the various areas and could practice holistic care. the 10-day onsite experience took place during the summer semester in the rural area of mbeya, tanzania. travel to and from villages where services were delivered was provided by local churches. students participated in a sl experience each day and changed locations as well to experience different areas of the community. in collaboration with other team members, local tanzanian doctors and local community leaders, medical clinics were organized at each location. services provided included physical assessment, health teaching, vision screening, dental screening, pharmacy, and even spiritual care. the local churches or community centers provided lunch for those providing services. purpose/objective the purpose of this qualitative study was to (1) describe an international sl project conducted through a short-term medical mission to the united republic of tanzania for baccalaureate nursing students; and (2) explore student observations and perceptions regarding culture and health in an international rural community. overall, we hoped to gain information about the impact of student experiences regarding international sl and cultural perspectives and awareness within a rural population. methods this research used a qualitative approach to capture data about personal perspectives of student participants on a short-term medical mission to tanzania. participants were required to online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 99 keep a journal of the international medical trip. this method allows thematic analysis of daily reflective journals for the emergence of thematic content. analysis of student reflective journals allowed for exploration of student participants observation and perspectives. the journals were photocopied without names or identifiers with originals returned to students. each participant consented for the journal to be used for the study. journals were read and coded to identify emerging themes among the students related to cultural awareness. journaling is often used in both nursing and sl to stimulate critical thinking and allow students to reflect and deepen understanding. educators can use journal writing to encourage reflective learning. reflective journaling is a heuristic teaching strategy that highlights students’ thoughts and perspectives and thereby foster critical thinking. the development of reflective practices can increase student interest and encourage deeper thinking and investigation. most important, reflective journaling plays a major role in transformational learning. thoughtful and deliberative learning allows students to reflect on their beliefs and to change their orientation of redefine their beliefs. students can connect beliefs, feelings, and actions to improve understanding and lead to self-discovery. reflective journaling is based on reflection of actions, beliefs, and feelings and cannot be a simple summary of course content. setting this study used student reflective journal data from a short-term medical mission to the united republic of tanzania. tanzania has a population of approximately 53,470,000 people. total annual per capita health spending in 2014 was $137, compared to $9403 in the us (world health organization, 2017). the leading causes of death among tanzanians are hiv/aids (18.2%), lower respiratory infections (8.7%), diarrheal diseases (5.2%), and malaria (5.2%). in 2012, the greatest burden of disease was caused by the combined hiv, tb, malaria followed by online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 100 maternal, neonatal and nutritional diseases. maternal mortality is high, with 410 deaths per 100,000 live births in 2012, compared to 28 per 100,000 live births in the us (world health organization, 2017). across the country of tanzania significant health disparities exist between urban areas and rural or poorer areas. study participants eleven nursing students, ten females and one male, consented to the use of their reflective journals from the international medical mission trip for the study. all participants were caucasian and between the ages of 20 and 22 years old. the study protocol was reviewed and approved as exempt by the university of alabama institutional review board (#5584). written consent was obtained from all student participants. a total of 11 journals were submitted and reviewed. data collection and analysis throughout the experience, students were required to document their thoughts through reflective journaling. students were asked specific questions about culture and cultural aspects of healthcare in this rural population to help process the experience through reflection. questions provided to guide student reflection included: • what are your general thoughts about culture after initial contact with this population? • how have your preconceptions of this population’s cultural practices and beliefs changed since arriving? • discuss your perceptions of this culture’s value and role of older adults. student journals were thematically analyzed by two nursing faculty (one participated in the tanzania trip and one did not) (sandelowski, 2000). faculty researchers interacted to compare themes. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 101 results the following are comments from student reflective journals based on specific questions regarding cultural awareness: what are your general thoughts about culture after initial contact with this population? • the number of adults with health issues in africa was extremely increased due to america. the adults in africa simply needed patient education teaching about health, hydration, and sleep hours. the preconceptions i had have changed drastically. • the risk factors i observed were high blood pressure due to the foods they ate, obesity due to the increased amount of carbohydrates, and intense labor leading to overworking of the heart. these factors added together lead to the increased number of individuals in tanzania with heart problems. • the individuals are not extremely healthy but at the same time they have never been taught simple patient teaching of hygiene, hydration, nutrition, etc. if they had the same knowledge we did in the states i believe this population would be healthy and much better off. • i was a little scared at first of the large population of african americans that spoke another language. i was so wrong to be frightened! the people of tanzania were amazing and were extremely caring and loving. they outstretched their hands to us and loved on us in a way even americans do not do. • i was amazed by the countries respect for people that were offering them help. this lady did not have a lot to offer however she was so thankful for us coming to tanzania to help her people, that she wanted to give me whatever she had. • i think the health care of these people are not completely in their hands. and there are a few reasons why i think that. number one, they don’t openly have access to health care. reason online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 102 number two, they don’t have a lot of patient teaching. reason number three, is that there is not a whole lot of financial means available. • dehydration, poor nutrient from electrolyte imbalance can play a part in the cardiovascular risk factors. most every patient that came through had high blood pressure. they also are at lack of patient teaching. they don’t understand that certain actions that you take can drastically lower their blood pressure. • i knew it was not going to be the best going into it. i was a little shocked at the lack of patient teaching though. i feel as though this culture is a community health gold mind. i feel like even with minimum amounts of teaching a lot could be prevented such as high blood pressure, uti, and bacterial infections. how have your preconceptions of this population’s cultural practices and beliefs changed since arriving? • i will forever use this experience as a great one to help me in my career when cultural differences arise. you can always smile and make a warm connection. i have learned to be patient through translation and be appreciative of each other’s culture. • i will learn to be more patient and continue to learn about different cultures. culturally competent care is very important in giving total holistic nursing care in the future. • i believe that this trip has enhanced my belief on what it means to offer culturally competent care. respecting certain practices and life style habits is critical when educating a population on healthier habits in order for them to respond well and take the education to heart. • i think this has definitely changed my level of compassion. i have learned to look at situations and say, i have no idea what this person is experiencing or feeling. there are numerous things that could be going on in a person’s life that i wouldn’t know about unless i asked. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 103 • i did not realize the knowledge deficient of their health care but i think that i adjusted well to how they view preventable diseases. • coming to this area and seeing this culture first hand has opened my eyes to a multitude of things that we take for granted in the united states. for example, having a variety of food, hot water, clean water, and nice accommodations. • africa changed the way i view healthcare because i understand that everyone does not have good accommodations to maintain good healthcare. in the united states, we are blessed to have resources readily available to care for ourselves in our own homes. in africa, people cut themselves and don’t have simple analgesics like neosporin or ibuprofen. they do not have things like rubbing alcohol or disinfectants to clean basic scrapes and often end up with serious infections due to lack of resources or poor knowledge. our most beneficial work was probably teaching people simple community health like how to properly wash their hands with clean water, how to brush their teeth, and bathe with running water not stagnant water like they often do. • how this will change how i provide care: i just realized that, in america, we do not realize how fortunate we are to have the medical care that we do. even though our healthcare system is going down the drain, we are still extremely blessed. • how it changed view on culturally competent care: this experience made me realize that with each and every patient that i need to take knowledge base into consideration. i can’t assume that any patient or family member knows anything certain thing. i know i shouldn’t treat them like they are stupid, but i should provide all information know matter how “common sense” it may seem to me. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 104 • culturally, i feel more confident and understanding of the different cultures i may come into contact with in the states. though, i enjoyed the tanzanian culture. • knowing what is acceptable culturally and what someone will be willing to share or do based on their culture is amazingly important for cross culture care. i thought i knew that before this trip, but i learned at a deeper level just how important it is. it goes beyond different languages, if you can properly convey the desire to help in a respectful way and listen to what they convey in their body language, you can connect with the patient in a way they will trust you with their health information and care, no matter your age or credentials. discuss your perceptions of this culture’s value and role of older adults. • this culture values their older adults very much. when they would bring the elders to the clinic it did not matter if they were having to be rolled in by wheelchair or carried in the elder was going to have medical treatment and be seen first. • i think that this country really values its older population. they treat them with respect. at one point in the clinic, there was an older gentleman that could not walk. so the community put him in a plastic chair to carry him from station to station so that he could receive the same care that they did. i think that as an older adult there, they still have a mission to provide for themselves and their family. in america, older adults get an option to retire, however in this culture it’s a ‘work until you can’t move anymore’ culture. they work very hard to make a living for themselves. discussion this study showed themes consistent with current research literature in relation to the benefits of sl such as increase awareness of community needs, increased in working with culturally diverse populations, respect for diversity and decreased stereotyping, personal and online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 105 professional growth for cultural competency (dalmida, et al., 2016). students involved in sl within an international medical mission trip indicated they gained better understanding of health issues of a rural population in tanzania. student reflective comments indicated a change of perceptions of culture and beliefs and an increase in confidence when providing care to diverse cultures and populations. increased awareness of community needs participants were given the opportunity to communicate with local citizens in their rural environment through translators. this gave unique insight into more specific needs of the rural community. in addition, it allowed students the ability to gain communication skills to gather valuable information about the community and their needs. overall, students learned the importance of addressing barriers to communicate and gaining the trust of the local citizens to better care for these individuals. having close contact with the citizens and even having the opportunity to visit the local homes provided a more intimate look at the needs of the individuals and the community. similar to rural areas in the us, many homes lacked clean water sources, adequate cleaning supplies, and adequate protection from weather. in addition, many other safety issues were discovered such as sanitation, plumbing, and resources for storing food. these issues, among others, helped participants gain understanding because these resources are often taken for granted in the urban communities where they live. participants were creative and discovered a number of ways to provided patient education with limited resources. increased confidence in working with culturally diverse populations consistent with sl literature many participants agreed that the experience increased their confidence in all areas: personally, spiritually, mentally, and physically. furthermore, the online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 106 participants anticipated this new confidence would impact their future nursing careers. most participants stated they would be able to care for patients better because of increased confidence and understanding culturally diverse populations. many of the participants voiced concerns of not having the opportunity in past clinical experiences to provide care to individuals from diverse backgrounds and this experience provided that opportunity and in turn allowed for growth in confidence and knowledge. respect for different backgrounds participant’s comments reflect changes in student understanding of a different culture through the experience in the international medical mission trip and that this experience will help them relate better with people from different backgrounds. this was identified through the question regarding culture perceptions of a specific population relative to value of older adults. the theme of increased respect for individuals from different backgrounds was evident in participant responses. many of the participants stated that they went on the international medical trip with certain preconceived notions about the population. student comments indicate that participation in the trip has changed many of their preconceived notions. participants related that they gained respect and appreciate that not everyone is the same. because people and cultures vary in many ways, it is important to respect both individual and cultural differences. in a sense, most of the students understood this, but respecting these differences in patient education is especially crucial for teaching to be effective. many of the participants agreed that this quality would help them throughout their careers when dealing with other cultures and religions and providing holistic care. increased maturity level online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 107 the final theme that emerged from the reflective journals was the increased maturity level from participating in this international medical trip. eight of the 11 participants mentioned how much they have grown or matured because of their participation in the trip. many of the participants voiced how much they had learned about themselves and how differently they viewed things now. one student stated, “the experience will change my views and the way i provide care my knowing that i personally have been very fortunate in the life i have had so far.” another student related, “i was personally surprised at how much i personally grew. i was going to help other people, but i learned so much in the process.” most participants were surprised at how much personal growth they experienced during their participation in the trip. for many of them, the personal growth was felt immediately. however, several of the participants voiced that after their return and approximately two weeks of reflection, they realized how much the experience meant to them and how much they had learned throughout the opportunity. implications nursing education should continue to take advantage of sl strategies to benefit both students and rural communities. although sl is not new in nursing or education, evidence shows it continues to be an effective teaching strategy. when used in a thoughtful and meaning way, sl can reinforce course content and provide a powerful learning experience while increasing student learning in addition to providing a service to an underserved community. educators should continue to take advantage of this powerful tool for learning opportunities. unmet healthcare needs continue to exist in rural communities around the world. healthcare workers are needed to meet these needs. instilling the desire and passion in nursing students for service to both international and rural communities can a difficult task in relation to today’s competition of intensive care units or emergency departments. students that participate in online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 108 international sl experiences can develop into nurses with an increased awareness of global and rural health concerns and disparities. in addition, they will be better prepared to provide more holistic and culturally sensitive care. sl initiatives within international short-term medical mission experiences can provide valuable opportunities to foster greater interest in nurses to become involved in rural areas on local, national, and international levels. interprofessional collaborative practice is key to quality, safe, patient-centered care. service and interprofessional education are inherent in many medical mission trips but was not evaluated in this study. vast opportunities exist to work with rural, international populations when multiple levels of health professional and students serve together. future research for us will addressing selected interprofessional education collaboratives (ipec) as well as deeper perspectives of students’ perceptions of rural populations. sl through medical mission trips can help health professional students develop interprofessional competencies and enter the workforce prepared to provide cultural competent care. conclusions raising awareness of global rural health issues as well as providing culturally appropriate healthcare through service are important components of nursing education. furthermore, research has revealed that academic sl can help bridge the existing gap between rural populations and access to basic healthcare around the world. this sl project has effectively allowed for the evaluation of the benefits of a short-term mission trip and has assisted the generation of important questions for future research. study results indicated our students benefited by increased awareness of community needs, decreased stereotyping, increased confidence in working with culturally diverse populations, and increased personal and professional growth for cultural competence. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.506 109 references amerson, r. 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(2017). global health observatory data repository. retrieved from http://www.who.int/countries/tza/en/ mcclintock-donahue_516-other-3666-2-6-20190813 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 65 non-pharmacological weight loss program in a rural community: feasibility study alea mcclintock-donahue, dnp, crnp, fnp-c 1 1 practicing nurse practitioner, friendville primary care, west virginia university medicine, aleamcclintock@gmail.com abstract background: obesity is a complex health problem that affects over one-third of us adults. obesity rates are higher in rural communities, which may not have the resources to address. a community-based non-pharmacological weight loss program was implemented to address the limitations of managing rural obesity, specifically cost and transportation. methods: a descriptive study was used to explore the feasibility of an 8-week nonpharmacological weight loss program that included nutrition and healthy lifestyle education for overweight or obese adult residents of a rural community in western maryland (n=23). results: the program was low-cost and had high participant satisfaction. participants whom completed the program showed an increase in motivation to making lifestyle changes (p=0.0002); consumed fewer calories from fat (p=0.029); and had a small change in bmi (p=0.0389). the increase in physical activity minutes with program completion was not statistically significant (p=0.2285). weather, family and work obligations were barriers to attendance. conclusions: this rural community-based weight loss program was feasible, addressed the barriers of cost and transportation, and can be adapted to meet the needs of other rural communities. keywords: obesity, obesity intervention, rural, community, feasibility, non-pharmacological online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 66 doi: http://dx.doi.org/10.14574/ojrnhc.v19i2.516 non-pharmacological weight loss program in a rural community: feasibility study more than one-third of adults in the united states (us) are obese, which is approximately 34.9% or 78.6 million adults (ogden, carroll, kit, & flegal, 2014). overweight and obese adults have higher rates of morbidity from conditions such as hypertension, coronary artery disease, dyslipidemia, stroke, type 2 diabetes, sleep apnea, respiratory problems, and endometrial, breast, prostate, and colon cancers (flegal, kit, orpana, & graubard 2013). the number of extremely obese individuals has been steadily increasing (fryar, carroll, & ogden, 2014). there is a direct link between the increased rates of obesity and increased medical spending and costs. according to finkelstein, trogdon, cohen, and dietz, (2009), the estimated annual medical cost of obesity in the us was $147 billion in 2008. moreover, medical costs for individuals who are obese were estimated to be $1,429 higher than those of individuals with a healthy weight. the percentage of adults that are obese is higher in rural areas as compared to urban areas of the us. in a journal of rural health published study, the prevalence of obesity was 39.6 percent for rural adults and 33.4 percent among urban adults between 2005 and 2008. nearly 20 percent of the us population resides in non-metropolitan areas and face barriers to adopting healthy lifestyles and nutritional behaviors (befort, nazir, & perri, 2012). a rural community is defined as “all population, housing, and territory not included within an urban area. the census bureau identifies two types of urban areas: urbanized areas of 50,000 or more people; urban clusters of at least 2,500 and less than 50,000 people” (u.s. department of health and human services [usdhhs, federal office of rural health policy [forhp] , n.d. para 2). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 67 according to rural healthy people 2020, barriers include limited access to supermarkets that provide fresh produce, high poverty rates with lower household incomes, limited transportation, lower education levels, and lack of community based resources and programs that are designed to help facilitate and promote healthy lifestyles. these limitations put the rural populations at greater risk for numerous diseases and health disorders, including obesity. rural healthcare facilities are less likely to have nutritionists, dietitians, or weight management experts available (bolin & bellamy, 2011). this study was completed with consideration of all ethical and legal rights of the participants. the feasibility study proposal was submitted to the pennsylvania state university internal review board for approval prior to implementation, and was approved as exempt. the consent form and research was discussed with all participants prior to the start of the first session. verbal consent was obtained from all eligible program participants before the start of the first educational session and any data collection. literature review the high prevalence of overweight and obese individuals and limitations faced by rural communities leads to an increased need for evidence-based interventions for weight management. the literature search was conducted to obtain relevant research articles regarding the use of weight loss interventions for underserved or rural populations. to guide the development, implementation, and evaluation of an evidence-based non-pharmacological weight loss program for rural communities, a literature review was conducted to answer the research question: what is the feasibility of a non-pharmacological weight loss program that includes nutrition and healthy life style education for overweight or obese adult residents of a rural community? the bibliographic databases used were pubmed (medline), cumulative index to nursing and allied online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 68 health literature (cinahl), cochrane library, and joanna briggs databases. combinations of keywords and subject headings in all databases included “complementary therapies”, “weight loss”, “rural”, “rural population”, “weight loss program”, "weight reduction programs", “physical activity”, “exercise”, “healthy eating”, and “nutrition”. the limiters applied were english language, human subjects, and articles published from january 2000 until february 2016. titles and abstracts containing one or more keywords were reviewed for inclusion. articles that were not original research studies were eliminated. thirty-seven articles were obtained for further review. studies with subjects over the age of 18 with a diagnosis of obesity, residing in a rural or medically underserved community setting, and participated in a non-pharmacological weight loss intervention were included. fifteen of the best-quality articles were included for the purpose of this literature review: five reported randomized control trials (rct); six reported quasiexperimental studies; three reported cohort studies; and one reported telephone questionnaire. the strength of evidence rating pyramid (melnyk,. & fineout-overholt, 2011) was used to score the strength and quality of evidence of the research articles included in this review. the quality rating scores of the fifteen studies included in this review, range from level ii through iv, and include rcts, quasi-experimental, and cohort studies. based on the results of the fifteen studies included in the literature review, evidence suggests that rural weight loss programs focusing on educational and motivational methods at the community level can result in weight loss and/or increased self-efficacy and individual satisfaction. the implementation of a rural weight loss program will help health care providers in rural communities plan an approach to addressing obesity. many factors affect feasibility and should be assessed on an individual basis for each program. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 69 significance many rural communities lack the resources to address the treatment of obesity (bolin, & bellamy, 2011). furthermore, rural communities are less likely to have appropriate facilities and professionals specializing in weight management, such as certified health coaches, wellness counselors, or dietitians. consequently, the responsibility for promoting a healthy life-style and weight may lie with the primary care provider, health practitioners, or health workers within the community. to address the lack of resources, community-based health practitioners can help implement programs and services within the community that focus on weight management. rural communities need to build the capacity to help their residents through an investment in health and fitness programs and in particular, programs designed to guide residents in adopting healthy habits for weight control. in the area of interest for this study, garrett county, md, the adult obesity rate is at 31%, which is higher than the national average. trends show that the obesity rates in garrett county are rising. additionally, the physical inactivity rate in garrett county is 30% and trends show that physical inactivity is rising. the incidence of inactivity is higher than the national average (county health rankings & roadmaps, n.d.). community needs carried out in garrett county, md revealed the prominent barriers and limitations to health within the county are related to factors of nutrition and physical activity. dr. virginia brown, drph, assistant professor at university of maryland school of public health, conducted 17 focus groups, including 175 individuals residing and/or working in garrett county md to assess community needs. the top concerns for participants in the assessment were nutrition (36%) and physical activity (33%). the focus groups included county leaders, residents, health care providers, and social workers. the data results of the study revealed that residents of garrett county md were dissatisfied with online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 70 the current resources available to them for physical activity and healthy eating. according to residents of garrett county, the most prominent barriers are cost and transportation. the proposed practice suggestion was to implement community-based resources to promote physical activity and healthy eating that are affordable and accessible by county residents (argabrite, & brown, 2016). successful weight loss has been seen with the utilization of face-to-face interventions, phone interventions, a combination of face-to-face and phone interventions, and self-monitoring tools for both weight loss (decrease in bmi) and improved self-efficacy and life satisfaction. better success in weight reduction with the completion of a program was seen with group interventions than individual counseling sessions (befort, donnelly, sullivan, ellerbeck, & perri, 2010), possibly due to additional motivation from other group members. the evidence indicates that face-to-face and phone follow-up and weight maintenance interventions can have a positive impact on long-term weight maintenance and decrease the occurrence of weight regain (miedema, reading, hamilton, morrison, & thompson, 2015; milsom, middleton, & perri, 2011; radcliff et al., 2012).. cost and demand are driving factors in rural weight loss interventions, especially in regards to feasibility. evidence suggests that low cost telephone or mobile phone interventions can be cost-effective and acceptable (gorton, dixon, maddison, mhurchu, & jull, 2011; radcliff et al., 2012). a cost-analysis of a program will help determine feasibility, and should be an important part of the implementation of weight loss programs (bowen et al., 2009). participant attendance rates and participant retention rates are important factors in assessing feasibility. attendance and retention can vary for each rural weight loss program and should be assessed for each type of weight loss intervention in rural communities. the rct study by mayer-davis et al. (2004) online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 71 tailored the program to participant needs, such as transportation. participant attendance and retention in a rural weight loss program may be higher if community needs such as transportation are assessed prior to implementing the weight loss intervention. purpose the purpose of this feasibility study was to address the limitations of managing rural obesity by assessing the feasibility of implementing an evidence-based physical activity and nutrition education weight loss program in one rural community for overweight or obese individuals. the research question for this was: what is the feasibility of implementing a non-pharmacological weight loss program that includes nutrition and healthy life style education for overweight or obese adult residents of a rural community? the study included the implementation and feasibility assessment of an evidence-based, non-pharmacological weight loss program in one rural community located in western md. the weight loss program included physical activity and nutrition education to 23 overweight or obese adults over the age of 18. the goal of program implementation was to identify a feasible and sustainable community-based outreach program to promote weight loss by providing education on lifestyle modification, methods to reduce negative health outcomes among overweight and obese individuals, and methods to improve overall quality of life of overweight and obese individuals. theoretical framework this study was guided by two theoretical frameworks: the logic model was used to guide the evaluation and implementation of the community based program and the transtheoretical model (ttm) helped guide the education aspect of the program. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 72 the logic model is a logical framework, or theory of change, that provides a systematic approach to help guide program implementation and evaluate program effectiveness. the logic model is a systematic way to describe logical associations among program resources, activities, outputs, audiences, and outcomes. the model displays the chain of connections showing how a program is anticipated to work to achieve the desired outcomes. a program logic model links both short-term and long-term outcomes with program activities and processes and the theoretical assumptions or principles of the program (w. k. kellogg foundation, 2001). the logic model has been successfully applied to health program planning and evaluation. a program logic model can help public health workers to identify the inputs and activities that will result in the desired health program outcomes. the logic model can also be utilized to engage stakeholders, ensure commitment to the development and evaluation of the health program, and help guide the future direction of the program (longest, & beaufort, 2005). the ttm is a behavioral change model that is based on multiple theories, and accordingly given the name transtheoretical model. the ttm also integrates elements of bandura’s selfefficacy theory. this construct reflects the degree of confidence individuals have in maintaining their desired behavior change in situations that often trigger relapse (prochaska & velicer, 1997). the ttm focuses on the decision-making process of the individual and is a model of intentional change. this model has the assumption that people do not change behaviors quickly and decisively and a change in behavior occurs continuously through a cyclical process. according to prochaska, diclemente and norcross (1992), the ttm interprets behavior change as an intentional process that unfolds over time and involves progress through a series of six stages of change. the logic model for this program is depicted in figure 1. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 73 figure 1. friendsville weight loss program logic model design & methods a descriptive study was used to explore the feasibility of a rural healthy life style education weight loss program for overweight or obese adults. a pre-test, post-test design was used to measure changes in motivation for weight loss with the university of rhode island change assessment scale (urica) weight control: stages of change (short form) (andrés, saldaña, & beeken , 2015; university of rhode island, cancer prevention research center, n.d.), changes in physical activity with the international physical activity questionnaire short for (ipaq-sf) (craig et al., 2013; ipaq-sf, n.d.), changes in dietary habits with the percentage energy from fat screener (thompson, 2007), and changes in body mass index (bmi) (centers for disease control and prevention, n.d.). demographic data and transportation data were collected at the start of the program and a likert-type satisfaction survey developed by the investigator was completed at the end of the program (burns & grove, 2001; likert, 1932). cost and attendance were measured throughout the duration of the program. the educational weight loss program consisted of 8 weekly group sessions providing participants with face-to-face education on physical activity and healthy eating. data collection occurred weekly at each of the 8 educational sessions. resources/in puts identification of stakeholders, equipment, time and money outputs participants that attend and complete the program activities 8-weekly group educational sessions on healthy eating and physical activity outcomes participant changes in motivation, diet, activity, and bmi; program feasibility; sustainability impact changes in longterm health behaviors after the implementation of a sustainable obesity intervention online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 74 the setting for the program was in the community building of a rural community in western md with a population of 484 (us census bureau, n.d.). the educational sessions were held one evening a week from september 13, 2016 through november 1, 2016. twenty-three participants (n = 23) were recruited using a volunteer sampling procedure and met the criteria for inclusion if they were age 18 or older, had a bmi of 25 or greater, and had the ability to attend all of the educational sessions. recruitment strategies included posting flyers around the community, announcements within the rural community of interest, word of mouth, and snowballing. the program was free to participants and consisted of 8 weekly sessions that were adapted from the curriculum for the eat healthy, be active community workshops. the eat healthy, be active community workshops included six 1-hour workshops which included a lesson plan, learning objectives, talking points, hands-on activities, videos, and handouts. the workshops were designed for community educators, health promoters, dietitians/nutritionists, cooperative extension agents, and others to teach adults in a wide variety of community settings. the curriculum was adapted to incorporate and utilize community resources for healthy eating and physical activity to promote weight loss. a cooking demonstration by a registered dietician with the university of maryland was included. all participants were given pedometers and encouraged to track daily steps and calories. data analysis descriptive statistics were used to organize and summarize the data. sas university edition software was used for statistical analysis. the level of significance for all statistical procedures was set at 0.05. a wilcoxon-signed rank test was used to analyze the pre-test and post-test urica, ipaq-sf and percentage energy from fat screener. a paired t-test was used to analyze the pre-test and post-test bmi data. initial analysis of the data was collected and grouped into online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 75 categories based on similarity of responses. common themes among the categories were identified and a thorough review of the data was conducted. to ensure that themes for coding were valid, a second individual reviewed the themes in an external audit. an attendance count was collected at every program session, and entered into an excel spreadsheet where attendance percentage rates were calculated. costs were collected throughout program implementation, entered into an excel spreadsheet and totaled at program completion. the public domain ipaq questionnaire was used to determine participants’ physical activity habits and all data was collected by the program coordinator and entered into excel spreadsheets. data was stored on a password locked laptop computer owned by the program coordinator. only the program coordinator had access to the raw data. participants were given an identification code and no names were associated with the collected data. personal identifiers were kept in a locked filing cabinet in the home of the program coordinator and will be kept for 5 years. after 5 years all documents will be destroyed. results demographics participant age range was 28 years to 86 years, with the majority falling between 50-59 (n = 6). the mean age calculated was 64.85 (sd=15.13). the majority of participants were white (n = 23) females (n = 22). additional demographics can be found in table 1. the average program attendance for all eight sessions was 72.83%. in total, 21.74% of participants (n = 5) attended 100% of the program sessions. conversely, 17.39% of participants (n = 4) did not complete the program. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 76 table 1 participant demographics characteristic n (n) percentage of those reporting (%) age 20 (23) 20 29 1 5% 30 39 0 0% 40 49 1 5% 50 59 6 30% 60 69 3 15% 70 79 5 25% 80 89 4 20% gender 23 (23) female 22 95.65% male 1 4.35% race 23 (23) white, non-hispanic 23 100% marital status 20 (23) divorced 1 5% married 10 50% separated 1 5% single 1 5% widowed 7 35% education 20 (23) < 12th grade 5 25% high school diploma / ged 8 40% trade / technical / vocational training 1 5% some college (no degree) 4 20% bachelor’s degree 1 5% master’s degree 1 5% income 20 (23) less than $20,000 10 50% $20,000 $39,000 3 15% $40,000 $59,000 4 20% $60,000 $79,000 1 5% $80,000 $99,999 2 10% online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 77 attendance barriers to program attendance and completion. the majority of participants responded that they would drive a vehicle they owned (n = 13) and had a travel time of 5 10 minutes (n = 11). the most frequently reported travel issue that could affect this program attendance was weather (n = 9). four participants (n = 4) dropped-out of the program, but one participant that dropped-out could not be contacted. reasons for dropout were family (n = 2) and work obligations (n = 1). barriers and facilitators to physical activity and healthy eating the top barriers to physical activity were weather (n = 6), no one to exercise with (n = 5), and safety concerns (n = 4). the top facilitators to physical activity were internet access as a resource (n = 11), walking trails (n = 10), and parks (n = 9). the top barriers to healthy eating included the need to travel outside of the community to grocery shop (n = 15), no space for a garden at home (n = 7), and the cost of healthy foods (n = 5). the top facilitators to healthy eating included the internet as a resource (n = 11), they felt it was easy to get healthy foods (n = 9), and gardens (n = 6). desired resources for physical activity and healthy eating were church programs (n = 11), monthly group meetings (n = 10), more money (n = 7), a farmers market (n = 4), and workplace programs (n = 4). satisfaction overall, participants were satisfied (n = 2; 10.53%) or very satisfied (n = 17; 89.47%) with the program. the only satisfaction survey response that received a negative response was the statement “as a result of this program my ability to manage my weight has improved”. although the majority of participants agreed (n = 13; 68.42%) or strongly agreed (n = 2; 10.53%) that as a result of this program their ability to manage their weight has improved, three participants online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 78 responded that they were undecided (n = 3; 15.79%) and one disagreed (n = 1; 5.26%). overall, the participants identified the most helpful part of the program to be the nutrition education (n = 9). the most frequently reported hurdle to success was family obligations (n = 9). five participants (n = 5) suggested adding exercise to each session. cost the actual cost of the program was $368.48 dollars and used for purchasing supplies, handouts, and healthy food. all costs were out of pocket. a true cost analysis was calculated to represent the total cost of the program if the labor provided was based on personnel costs at the garrett county health department in november 2016 (personal communication), and also included the cost of materials and healthy snacks. the calculations for true cost were based on 4 hours a week (1 hour per week to conduct the sessions and 3 hours per week for preparation) with a full-time equivalent (fte) of 0.1. the true cost varied based on the qualifications of the instructor and ranged from $738 to $897. participant changes with program changes in readiness or motivation to make a lifestyle change. the urica pre-test mean was 2.84 (sd = 0.7647), indicating that most participants were already in the action stage at the start of the program; the post-test mean was 3.05 (sd = 0.71), indicating an increase in readiness or motivation to make a lifestyle change. there was a statistically significant increase from the pre-test mean urica score to the post-test mean urica score, indicating that there was a change in motivation or readiness to make a change with the completion of the program (p = 0.0002). changes in physical activity. the ipaq-sf pre-test mean was 2954.3 (sd = 3370.3) and the post-test mean was 4534.8 (sd = 3507.6). although there was an increase from the pre-test online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 79 mean met minutes to the post-test mean met minutes, a change in energy expenditure with physical activity was noted, however, this increase was not statistically significant (p = 0.2285). changes in dietary habits (nutrition). the pre-test percentage energy from fat screener mean (n = 19) was 33.81 (sd = 3.90); the post-test mean (n = 19) was 31.04 (sd = 2.59) indicating a statistically significant decrease in estimated percentage of calories from fat in their diets with the completion of the program (p = 0.0291). changes in bmi. the pre-test bmi mean was 35.02 (sd = 8.10) and the post-test mean was 34.73 (sd = 8.07), indicating a statistically significant decrease in the mean bmi with program participation (p = 0.0389). although the change in bmi is statistically significant, it is small and not clinically meaningful to determine the effects of program completion on participant changes in bmi. discussion this feasibility study shows that an 8-week, low-cost, evidence-based physical activity and nutrition education weight loss program can be successfully implemented in a rural community among primarily white, female adult participants. the results are grouped into outcomes of interest and the discussion of the data is grouped in the following categories: program utilization; program barriers; satisfaction; program cost; and participant changes (motivation, physical activity, dietary habits, and bmi). program utilization program utilization was assessed to determine who used the program and what improvements can be made to improve overall participation. according to leroy and menon (2008), research on the utilization of nutritional interventions and programs is needed to help understand the potential of nutrition programs and how they can benefit an individuals’ quality of life. the recruitment online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 80 goal for the study was 10, and the program exceeded that with the recruitment of 23 individuals that participated. in total, four participants dropped out of the program, and program completion occurred more frequently than program dropout. however, only 21.74% of participants (n = 5) attended 100% of the program sessions. program attendance dropped in the middle of the 8-week program but increased at the last program session. further research should be aimed at finding appropriate methods to increase program attendance and assess additional barriers to attendance. this feasibility study shows that an 8-week, low-cost, evidence-based physical activity and nutrition education weight loss program can be successfully implemented and utilized in a rural community among primarily white, female adult participants of varying ages. this program was designed to address the most prominent barriers of cost and transportation (argabrite & brown, 2016); to address these barriers, this program was offered as a free community-based resource. fifty-percent of program participants had an annual household income of less than $20,000, and it is believed that the utilization of this program is dependent upon providing a free resource to community residents at an easily accessible location. although transportation was identified as a prominent barrier to the utilization of resources for physical activity and healthy eating, this program did not offer coordinated transportation. to promote program utilization and reduce the barriers to the utilization of rural resources to promote a healthy lifestyle, specifically transportation, program sessions were held in an area of a community that would permit individuals to walk to the location. although previous research has identified transportation as a limitation in rural communities and can affect obesity care and the success of weight loss interventions (bollin & bellamy, 2011), the primary mode of transportation by participants of this program was by vehicle and the majority of patients had a travel time of less than 10 minutes. participants saw distance, or a long commute time to the program, as a potential online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 81 barrier to participation. programs in rural communities should utilize community resources to reduce these potential barriers and improve program feasibility. additionally, coordination with public transportation should be considered to expand the outreach and participation. in this program, participants did have the option to sign up for reminder calls, emails, or text messages. considering the decrease in program attendance, additional methods to improve program attendance rates at each session should be incorporated. it may be difficult or impossible to determine the true cause of decreased attendance, as program attendance and attrition in weight loss programs is extremely complex. previous research has concluded that this complexity is due to the influence of numerous external variables and pretreatment characteristics of program participants. psychological variables that can affect program attendance and attrition include lack of motivation, stress levels, and self-confidence in the ability to lose weight. other factors include age, bmi dietary restraint, depression, binge eating, and medical comorbidities (grave, suppini, calugi, & marchesini, 2006; grossi et al., 2006). methods to increase program participation should be explored further prior to program modification and further implementation. program modification to increase attendance should look at methods to include family involvement, as family obligations were seen as a reason for program dropout. additionally, 50% of the program participants were married and 60% of participants had a household size that was greater than one. in future program implementation, strategies to improve attendance and encourage more male participants to attend would provide additional moral support. family member involvement, including both spouses and children, has been seen as an effective method for increasing the effectiveness of weight loss interventions (mclean, griffin, toney, & hardeman, 2003). if the program incorporates the needs of the family, including children, a multidisciplinary team approach should be utilized. success with a multidisciplinary team online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 82 approach has been seen in the brenner fit program, which is a family-based pediatric weight loss program (irby, kaplan, garner-edwards, kolbash, & skelton, 2010). a multidisciplinary team for program development and implementation may include primary care providers, pediatricians, behavioral counselors, dieticians, exercise specialists, physical therapists, and social workers. future research is needed to find successful family-based program interventions that would improve program utilization within rural communities. additional feasibility or pilot testing would be needed to evaluate the modified family-based program curriculum. employment status may also impact program utilization and attendance. the largest percentage of program participants were retired or were not employed full-time, indicating that individuals whom work full-time were less likely to utilize the program. furthermore, work obligations were reported as a reason for program dropout. it has been found that some workplace interventions can have health benefits for participants (conn, hafdahl, cooper, brown, & lusk, 2009). in this study, only four program participants reported that their workplace offers programs focused on physical activity and healthy eating. this program could be easily adapted to workplace settings to encourage utilization. barriers to program attendance and participation research by bollin & bellamy (2011), identifies transportation as a barrier to program utilization, which directly correlates to participant feedback on this program. however, the most frequent travel related issue that participants reported would affect their decision to continue the program was weather. depending on the geographical location of the program, weather and climate may need to be considered during program planning and development. in some rural communities, snow may affect program participation. if the program is seasonal, programs may need to be held in the spring, summer, or fall to avoid snow, ice, and dangerous road conditions. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 83 although the findings in this study show that weather is a barrier to physical activity and is consistent with previous research (chan & ryan, 2009), there is currently a gap in the literature reflecting the true effects of weather on rural community-based programs and further research is indicated. in an attempt to find sustainable interventions, it is important to address the needs of program participants and also community members. the most popular resources or services that participants were interested in using were monthly group meetings and support groups (facebook/internet support group). a feasibility study by oʼbrien et al. (2016), found that a free, readily available internet program for the self-monitoring of weight loss was a feasible choice for a group of women living in a region with few resources. a majority of participants in this program reported that they have internet access available to them, suggesting that an internet support group may be a feasible option to incorporate in the program. it was also found that most program participants attend church regularly and reported that they would attend programs held at their church. although this program was implemented at the community building, churches may be an appropriate place for further program implementation. previous research (parker, coles, logan, & davis, 2010), supports that churches are important community-based partners that can serve as the location for successful weight loss interventions. overall, most program participants reported that they already exercised prior to starting the program, and walking was the most frequently reported form of exercise. additionally, the most frequently reported reason for not exercising, and an identified barrier to physical activity, was that participants had no one to exercise with. the results of this study indicate that most participants would prefer partner or group exercise options. previous research also indicates that individuals have better success in weight loss reduction with the completion of group interventions online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 84 versus individual counseling sessions (befort, donnelly et al., 2010). from the results of this study and previous research, it can be concluded that group interventions and group exercise programs improve program feasibility and weight loss success. barriers to physical activity and healthy eating an additional barrier to physical activity that was identified among program participants was safety concerns. identified facilitators include outdoor resources, such as walking trails, the local park, and bike paths. khan et al., (2009) identified in the centers for disease control and prevention community strategies guide, that improving access to outdoor recreational activities, such as parks, walking trails, and bike paths should be targeted to address obesity at the local or community level. additionally, evidence-based physical activity and nutrition education weight loss programs in rural communities should help participants form walking groups or identify walking partners, promote the use of community resources, and should be individualized to adjust for resources available in each community to help encourage physical activity. the barriers to healthy eating among program participants included limited food options and the high costs of healthy eating, which is consistent with the identified barriers in rural healthy people 2020 (bolin & bellamy, 2011). only three program participants reported that they grocery shop within the community, and most participants travel more than 30 minutes due to limited grocery options. according to bolin & bellamy (2011), limited access to supermarkets that provide fresh produce is a barrier to healthy eating faced by rural communities. food voucher programs have been found to be a successful method to improving fruit and vegetable consumption, and paired with nutrition education the effect is improved (an, 2013). to help offset the cost of healthy food items and increase fruit and vegetable consumption, program online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 85 coordinators should partner with federal and state programs that offer food vouchers to program participants to utilize concurrently with program enrollment. a facilitator to healthy eating identified among program participants was having a garden at home, however this only improves access to healthy foods during a limited number of months in this rural community. additionally, not everyone enrolled in the program had the ability to grow a garden to produce fresh produce due to space constraints. participants reported that they would be more enabled to purchase and cook healthy foods if they had the money to spend, if a local farmers market was available, if they had time to do these activities, and if there were more grocery store options. rural communities can utilize the rural health information hub’s (rhihub), rural hunger and access to healthy food guide (n.d.) and its resources to develop strategies to improve access to healthy food within the community. according to the rural hunger and access to healthy food guide , several recommended and successful approaches to address the issue of health food access include: special financing for food retailers through federal and state programs to bring more stores into rural communities; cooperative grocery store models where members can buy shares in the corporation; farmers markets; community supported agriculture programs that allow local residents to purchase part of a local farmer’s crop at the beginning of the year; farmto-school initiatives that help local farmers sell fresh fruits and vegetables directly to public schools or incorporate school gardens in meal programs; food pantries that distribute nutritious food to low-income families; and community education and outreach that is designed to assist lowincome residents in learning about available food assistance programs, social services, and training related to home economics. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 86 satisfaction overall, the program was overwhelmingly well received, and participants were highly satisfied. a study by yeary et al. (2011) showed that another program consisting of eight weekly small groups led by trained community members with an emphasis on healthy nutrition, physical activity, and faith's connection with health had high participant satisfaction. in terms of feasibility, satisfaction determines the acceptability of the program and helps determine areas that may need adaptation (bowen et al., 2009). one area that program participants reported lower satisfaction scores was in response to the statement: “as a result of this program my ability to manage my weight has improved”. program adaptation should focus on incorporating more strategies for weight management to improve program satisfaction. program participants found the nutrition education session to be the most helpful aspect of the program. additionally, program participants reported that the camaraderie in the program was helpful. based on participant evaluation recommendations, program modification should incorporate a longer duration of a class; however, considering the results of this study and the study by yeary et al. (2011), an increase in program duration may not necessarily have a significant impact on satisfaction, because an eight-week program can have high levels of satisfaction. additional participant suggestions were the incorporation of exercise at each session, additional weight management strategies, and increased accountability for methods such as weekly weighins were suggested. according to participant satisfaction, due to the camaraderie in the program and the results of the study by befort, donnelly et al. (2010), it was found that better success with group interventions and group sessions should be continued. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 87 cost the actual cost of the program was relatively inexpensive at 368.48 dollars, which was used for purchasing supplies, handouts, and healthy food. program cost analysis in terms of feasibility is useful to help determine program practicality and cost has been identified as a prominent barrier to participation in the rural community of interest. a previous study by gorton et al. (2011) recommends that programs should be low-cost or free for individuals with low incomes to encourage participation. rural communities should incorporate cost-effective methods of weight loss interventions. this program cost was contained because the labor provided was free, however, the true cost of the program was significantly higher when factoring in paid labor. program coordinators should consider applying for a grant or assistance to carry out the program to provide at no cost to participants. another solution is to partner with public health agencies for program funding. participant changes with program completion participants who completed the program became more motivated to make life style changes. completion of this program proved to be effective in promoting statistically significant changes in motivation or readiness to make a lifestyle change, improvements in dietary habits, and reductions in the participants’ bmi. however, although the change in bmi is statistically significant, it is small and may not be as clinically meaningful to determine the effects of program completion strictly on participant changes in bmi. the program included 8 weekly in-person sessions that included physical activity and nutrition education, a cooking demonstration with a registered dietician, demonstrations of sugar contents in drinks, weekly snacks with nutritional information, and the encouragement of recording calories consumed daily. the findings in this study are consistent with the previous online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 88 literature that supports the use of in-person group physical activity and nutrition education and reductions in bmi (folta et al., 2009; liu et al., 2015; mayer-davis et al., 2004; miedema et al., 2015; rowley et al., 2000; yeary et al., 2011). additionally, a previous study (wang, fetzer, yang, & wang, 2012) supports the use of self-monitoring weight loss diaries for bmi reductions. participants were encouraged to track diet and exercise, but additional reductions in bmi may have been found if participants were provided with a weight loss diary. although program participants did have increases in their self-reported activity level at the completion of the program, these results were not statistically significant. this program encouraged weekly exercise, but it was not incorporated into the overall program curriculum. additional research should be completed after the incorporation of weekly exercise or the formation of a walking group to see if self-reported exercise levels improve among program participants. previous research supports group programs that include exercise interventions can result in weight loss (ely et al., 2008; mayer-davis et al., 2004; rowley et al., 2000), and greater weight loss may have been seen with the incorporation of exercise. limitations although the actual recruitment exceeded the goal for recruitment in this program, the sample size was still relatively small. the sample for this study was obtained by a volunteer sampling procedure in one rural community in western md with a population of 484, and recruitment was a limitation because i, the program coordinator, was the healthcare provider for many of the community members that were being targeted for program recruitment. although this may have helped program recruitment, some participants may not have participated in the program and concurrent research because of privacy concerns. additionally, the sample was predominately female and white. the lack of demographic diversity in the program may have skewed the results online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 89 of this study. future programs and concurrent research should be aimed at including a more diverse population, and should be extended outside the geographical area of this program. self-reported data was used to collect data about participant demographics, dietary habits, physical activity, and motivation. the use of self-reported data increases the risk of measurement errors such as bias (andrés et al., 2015). another limitation was incomplete or missing data. missing data can have a significant impact on the conclusions that are drawn from the study, decreasing the overall validity (graham, 2009). the majority of data collected for this study was in the form of short answer questions due to time constraints, and many of the responses were not rich data. to obtain more rich data from program participants, a future recommendation is to conduct research using interviews or focus group methods. implications the findings of this study contribute to current gaps in rural obesity and weight loss intervention research, policy and practice. this program and feasibility assessment is being utilized to help guide feasible rural weight loss interventions that address the prominent barriers of cost and transportation. future research is needed to find successful family-based program interventions that would otherwise improve program utilization within rural communities. support of this program within the community and by the local health department will allow for continuation and modification of the program based on the data collected from participants. rural health care providers can use this disseminated information to partner with communities and public health officials to help guide future rural obesity interventions. further, the data collected in this program can help guide necessary health policy initiatives at the community level to improve physical activity and healthy eating. rural communities should consider the implementation and upkeep of designated recreational areas that are easily accessible and safe to online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 90 promote increased physical activity. this should be a community priority as parks and walking trails were found to be top facilitators to physical activity, and safety was found to be a top barrier to physical activity. communities should also focus on correcting the barriers of limited healthy food access with strategies such as the incorporation of farmers markets with the use of concurrent voucher programs. summary this study focused on addressing the limitations of managing rural obesity by assessing the feasibility of implementing an evidence-based physical activity and nutrition education weight loss program in one rural community for overweight or obese individuals. the results have implications for future research, practice, and policy. the pilot program has been determined to be feasible, and program modifications and the implementation of a long-term intervention is suggested. this program can be easily adapted for implementation in other rural communities. recommendation based results provide suggestions for improvements at the community level to promote physical activity and healthy eating. future research is indicated and should be aimed at addressing the limitations discussed in this program. despite the limitations, this study illustrated that a community, evidence-based physical activity and nutrition education weight loss program for overweight or obese individuals was feasible in a rural community and found that it can effectively address the barriers of cost and transportation. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.516 91 references an, r. 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(2012). the efficacy of using selfmonitoring diaries in a weight loss program for chronically ill obese adults in a rural area. journal of nursing research, 20(3), 181-188. http://doi.org/10.1097/jnr.0b013e318263d89b w. k. kellogg foundation. (2001). w. k. kellogg logic model development guide. battle creek, mi: w. k. kellogg. retrieved from https://exinfm.com/training/pdfiles/logicmodel.pdf yeary, k. h.., cornell, c. e., turner, j., moore, p., bursac, z., prewitt, t. e., & west, d. s. (2011). feasibility of an evidence-based weight loss intervention for a faith-based, rural, africanamerican population. preventing chronic disease, 8(6), a146. look_at_this712_psf+setup+12.8.22psf online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 3 perceptions about discrimination in a rural, older, racially and ethnically diverse cohort lisa ann kirk wiese, rn, phd1 katie abel, bsn, rn2 juyoung park, msw, phd3 ishan c. williams, phd, fgsa4 1adjunct faculty, community and population health, c.e. lynn college of nursing, florida atlantic university, lwiese@health.fau.edu 2icu registered nurse, university of florida health shands hospital, katieabel98@gmail.com 3professor, school of social work, florida atlantic university, jpark14@fau.edu 4associate professor, school of nursing, university of virginia, icw8t@virginia.edu abstract purpose: the purpose of this pilot study was to examine perceptions of discrimination among a small cohort of rural older, retired minority florida farmworkers. potential sources of discrimination were explored, such as health literacy, age, sex, gender, racial/ethnic background, or rural residency. sample: the study occurred in a rural area that is designated as a “hot zone” due to its hrsa designation as a medically underserved area (mua), health provider shortage area (hpsa), and medically underserved population, despite lying only 50 miles due west of the affluent town of palm beach, florida. more than 40% of residents live below the poverty level, and only 65% have received a high school diploma. method: a descriptive, correlational pilot study was conducted to investigate potential contributors to discrimination. independent variables examined were age, sex, gender, rural online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 4 residency, racial/ethnic background, and health literacy, using the rapid estimate of health literacy in medicine, short form (realm-sf) (arozullah, 2007). the incidence of self-reported discrimination was investigated. chi-square and pearson correlation analysis were employed to examine survey results. findings were supplemented with a brief narrative inquiry, and responses were analyzed using saldaña’s (2015) model of cyclical coding. findings: twenty-five residents in a subsidized housing unit agreed to participate in this study. this convenience sample was 96% racially/ethnically diverse (68% african american, 24% haitian creole, and 4% hispanic american.) most (78%) were retired field workers, and largely self-identified as female (72%). the residents’ average reading level was 4th-6th grade. health literacy (44%) and rural residency (24%) were the greatest sources of discrimination. female gender discrimination was associated with ethnicity discrimination (r = 0.6, p = .002). conclusions: providers are strongly encouraged to assess their patients’ health literacy levels and experiences with discrimination to inform effective care delivery. keywords: rural, older adult, farmworker, discrimination, health literacy, racially and ethnically diverse. perceptions about discrimination in a rural, older, racially and ethnically diverse cohort one in five older adults live in a rural area (smith & trevelyan, n.d.). rural residents face multiple disparities associated with rural settings, such as lower levels of health literacy (christy et al., 2017), older age (rogers et al., 2015), being female (ayalon & tesch-römer, 2017), and/or being racially and ethnically diverse (stepanikova & oates, 2017). however, these factors have not been widely investigated as factors contributing to discrimination in underserved settings (jackson et al., 2019; mouzon et al., 2020). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 5 health literacy is often defined as the ability not just to obtain but also to understand and communicate basic health information and services and apply health information to make wise health decisions (liu et al., 2018). functional health literacy, defined as the ability to obtain and apply health information to decrease disease risk or impact (nutbeam et al., 2018), is recognized as a critical factor in managing chronic illness (hickey et al., 2018). this is concerning for rural residents, as high rates of preventable chronic disease are experienced by vulnerable populations such as older minority farmworker groups (rasmussen et al., 2020). rural communities of color face disparities in achieving health literacy, which could decrease chronic illness burden (poureslami et al., 2017). these disparities are related to limited access to health information (nadimpalli et al., 2015) and historically grounded distrust of health care systems (jaiswal & halkitis, 2019). furthermore, if persons are disadvantaged in accessing or understanding health care information as a result of low levels of education and reading ability stemming from socially constructed categories, then that is discrimination (dovidio & gaertner, 1986; samerski, 2019). it is possible that persons with limited ability to comprehend health care instructions may be treated with impatience or disregard, and this could be considered a form of discrimination. the perception of such treatment as a form of discrimination by rural, older, and racially/ethnically diverse residents is rarely studied. discrimination related to being older (burnes et al., 2019) and african american (nadimpalli et al., 2015) or hispanic american (cano et al., 2016; velascomondragon et al., 2016) has also been recognized as adding to chronic disease burden. recently, researchers asked more than 14,000 persons in a nationally representative ethnically and racially diverse sample, “in your day-to-day life, how often do you feel you have been treated with less respect or courtesy than other people?” (boutwell et al., 2017, “perceived discrimination”). of more than the third who responded yes, the majority (75%) selected other as the form of online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 6 discrimination, rather than race, gender, sexual orientation, or age. ethnicity and education were the other primary reasons given by respondents for perception of discrimination. neither rural residency nor health literacy were examined as potential factors for discrimination. in addition, stressors related to disclosure of sex at birth and sexual orientation have been linked to chronic comorbidities (hoy-ellis & fredriksen-goldsen, 2016). however, sex and gender discrimination studies related to older rural residents who experience high rates of chronic illness (whitehead et al., 2016) are lacking. the purpose of this pilot study was to examine perceptions of discrimination among a small group of rural older, retired minority florida farm workers. potential sources of discrimination were explored, such as health literacy, age, sex, gender, racial/ethnic background, or rural residency. to our knowledge, the intersectionality of these identities has not been captured in other studies. rural was defined for this work as a micro area (population between 10,000 and 49,999 with an urban core), as designated by the office of management and budget (n.d.). theoretical framework the theoretical framework that influenced this study was the sentinel theory of generative quality of life for the elderly (register & herman, 2006). the authors of this theory explained that several forces and processes contribute to an older adult’s quality of life, including socioeconomic status, life satisfaction, cultural dynamics, self-esteem, and optimism. register and herman (2006) suggested that insufficiencies in these factors may result in poor quality of life, including exposure to perceived discrimination, which was the dependent variable in this study. the theory posits a holistic approach in providing a means for improving the quality of life for older adults. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 7 method a descriptive, correlational pilot study was conducted to investigate factors of perceived discrimination among a convenience sample of retired field workers living in rural florida. potential contributors to discrimination that were studied were health literacy, age, sex, gender, rural residency, and racial/ethnic background. the goal was to add to the state of the science regarding factors that potentially impact discrimination risk among rural, ethnically diverse, older adults. institutional review board approval was obtained from the principal investigator’s university prior to initiating recruitment. settings fifty miles due west of palm beach, florida, is the community of belle glade, the largest of four towns comprising the glades communities. this region is designated as a medically underserved area, medically underserved population, and health professional shortage area (florida department of health, n.d.). more than 30% of the 17,000 residents are reported to be migrant or field/farm workers. more than 40% of residents live below the poverty level, and only 65% possess a high school diploma. thirteen percent of the population are over the age of 65. this community is culturally diverse: 78% african american, afro-caribbean, or hispanic, and 31% foreign born. the data show that a large portion of this population is financially disadvantaged, with more than 30% living below the poverty line, and predominantly non-white. the ratio of males and females is evenly balanced (u.s. census bureau, n.d.). sample twenty-eight rural residents in a subsidized housing unit were invited to participate in this research during blood pressure screening, a regularly scheduled monthly event offered by the principal investigator. specifically, residents were asked whether they would like to participate in online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 8 a smaller study asking some basic questions such as age, sex, years lived in the glades, and feelings regarding discrimination, in addition to completing a brief check of reading health terms. they were informed that their responses would remain anonymous (without identification) and that they would receive a $5 appreciation gift card to a local store. twenty-five participants agreed to participate in the research initiative. data collection in addition to collecting sociodemographic data and measuring reading ability based on the rapid estimate of literacy in medicine, short form (realm-sf) score (arozullah et al., 2007), the incidence of self-reported discrimination was investigated. semi structured interviews were conducted to gather further information regarding feelings of discrimination that might be related to reading ability, sex, gender, rural residency, or ethnicity. measures the sociodemographic survey consisted of 13 questions addressing age, sex, race, ethnicity, education, marital status, religion, and years lived in a rural area. all measures were given to participants in their preferred language by a trained health educator. although race and gender pairings of participant and interviewer were not considered, the principal investigator was wellknown through an established program of research during the past seven years in the community. a tri-lingual local, trusted health leader was present during all interviews. the realm-sf (arozullah et al., 2007) was used as a measure of health literacy. participants were asked to read any words aloud that they recognized among seven words: menopause, antibiotics, exercise, jaundice, rectal, anemia, and behavior (stated here in english). a point was assigned for each word read correctly, and the total score was categorized by grade level and functional ability (table1). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 9 table 1 scores and grade equivalents for the realm-sf score grade range 0 third grade and below; will not be able to read most low-literacy materials; will need repeated oral instructions, materials composed primarily of illustrations, or audio or video tapes. 1-3 fourth to sixth grade; will need low-literacy materials, may not be able to read prescription labels. 4-6 seventh to eighth grade; will struggle with most patient education materials; will not be offended by low-literacy materials. 7 high school; will be able to read most patient education materials. scores and grade equivalents for the realm-sf from “development and validation of a short-form, rapid estimate of adult literacy in medicine, by a. m. arozullah, p. r. yarnold, c. l. bennett, r. c. soltysik, m. s. wolf, r. m. ferreira, & f. b. bryant, 2007, medical care, 45(11), 1026-1033. https://www.ahrq.gov/healthliteracy/research/tools/index.html#rapid zero points indicates a reading level of third grade or lower, with the recommendation to offer repeated oral instructions supplemented by audiovisuals and/or illustrated materials. a literacy score of 1 to 3 indicates a fourthto sixth-grade level, in which low-literacy level materials are suggested. persons scoring 4 to 6 (seventh or eighth grade) would most likely be able to read and comprehend patient education material, and perhaps medication labels. a score of 7 indicates a ninth-grade or higher level of health literacy. to investigate perceptions of discrimination, participants were also asked to respond to a series of quantitative questions written at a fifth-grade literacy level and presented in a simple format with yes/no responses (e.g., “have you ever felt you were treated differently because: you live here in the glades” or “of your reading ability?”). see table 2 below. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 10 table 2 interview questions regarding discrimination to a diverse farm worker cohort (n = 25) number prompt if yes. question 1 is there a time you remember when you felt as if you were treated differently because of: your skin color? prompt can you tell me what it was like? did you feel depressed or upset or sad because you were treated differently? 2 is there a time you remember when you felt as if you were treated differently because of: your gender (male or female)? prompt can you tell me what it was like? did you feel depressed or upset or sad because you were treated differently? 3 is there a time you remember when you felt as if you were treated differently because of your: sexual preference? prompt can you tell me what it was like? did you feel depressed or upset or sad because you were treated differently? 4 is there a time you remember when you felt as if you were treated differently related to where you were born? prompt can you tell me what it was like? did you feel depressed or upset or sad because you were treated differently? 5 have you ever felt frustrated because you struggled to read something? prompt did you feel depressed or upset or sad because you were treated differently? at the completion of the brief questionnaire, they were asked whether they would like to answer further discussion questions regarding feelings of being discriminated against due to various factors, such as age, reading ability, sex at birth, sexual orientation (gender), years lived in the glades (rural residence), and ethnicity. due to the participants’ potential sensitivity to being audio recorded, vigorous note taking by both researchers was used to record responses to interview questions. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 11 analysis descriptive statistics were used to summarize sociodemographic data and the number of “yes/no” responses for the types of discrimination (gender, sexual orientation, area of residence, ethnicity, ability to read). chi-square and pearson’s correlations were conducted to investigate potential relationships among variables in the overall sample. specifically, pearson’s correlations were employed to investigate potential relationships among the continuous independent sociodemographic variables of age, years of formal education, and health literacy level. chi-square was used to test for relationships among the independent categorical variables of gender, sexual preference, ethnicity, years lived rural, and health literacy, with health literacy scores recoded as a categorical variable into lower or higher literacy scores: the cut point for health literacy was 4, with scores of 0 to 3 indicating lower health literacy and scores of 4 to 7 indicating higher health literacy. tests were conducted using spss26 (ibm corp., 2016). saldaña’s model of cyclical coding (saldaña, 2015) was used in guiding the investigators during the qualitative analysis of the open-ended responses. after reading the transcripts twice to gain a sense of participant meanings, the investigators read the transcripts again. memoing was used, defined by glaser (1978) as “writing up of ideas about codes and their relationships as they strike the analyst during coding” (p. 3). next, codes were determined using in vivo word coding, which is defined as using the stakeholder’s own keyword or phrase to create a coding category (manning, 2017; saldaña, 2015). using an in vivo method is advantageous because it helps to prevent researchers from infusing their own meaning into the data (saldaña, 2015). finally, the researchers independently looked for recurring themes, using the conventional method of content analysis, in order to elicit, organize, and understand meanings from the data to draw realistic conclusions (bengtsson, 2016). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 12 results of the 25 participants, 72% identified as female and 28% identified as male, and 76% reported prior farm or field work. only one person was married, and 96% identified as non-white (68% african american, 24% haitian creole, and 4% hispanic american). ages ranged from 59 to 84 years (m = 71.6, sd = 6.4). the average number of years of formal education was 8 (sd = 4.4). the average number of years lived in belle glade was 40.7, but with a considerable sd (29 years). the average health literacy score, as measured by the realm-sf (arozullah et al., 2007), was 2.5 (sd = 2.4), indicating that the average participant could read at a fourthto sixth-grade level (table 3). table 3 sociodemographic characteristics sample (n =25) variable f % gender male 7 28 female 18 72 ethnicity african american 17 68 afro-caribbean 6 24 hispanic american 1 4 white, non-hispanic 1 4 marital status married 1 4 single 12 48 widowed 7 28 divorced/separated 5 20 farm/field worker 76 19 variable m sd minimum maximum age (years) 73.1 6.4 59 84 education (years) 8.0 4.4 0 18 online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 13 realm-sv 2.5 2.4 0 7 years rural 40.7 29 0 80 for scoring of the questions regarding perceived discrimination, yes responses were assigned a point value of 1 and no answers were assigned a point value of 0. there were no responses of i’m not sure or i don’t know. affirmative responses were followed by further exploration with open-ended questions. incidence of perceived discrimination when asked about experiencing discrimination due to their health literacy level, 44% (n = 11) reported discrimination and 56% (n = 14) reported nondiscrimination (table 4). table 4 frequency of perceived discrimination reported in a rural older adult subsample (n = 25) discrimination type yes (%) no (%) sex at birth 4 (16%) 21 (84%) ethnicity 5 (20%) 20 (80%) ability to read 11 (44%) 14 (56%) sexual preference 1 (4%) 21 (96%) rural residency 6 (24%) 76 (19%) when asked whether they had experienced gender discrimination, 16% (n = 4) said yes and 84% (n = 21) said no. as for experiencing discrimination due to their ethnicity, 20% (n = 5) said that they had experienced it and 80% (n = 20) said that they had not experienced it. only one participant (4%) reported experiencing discrimination due to sexual preference. when asked about experiencing discrimination due to living in a rural area, 24% (n = 6) said yes and 76% (n = 19) said no. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 14 correlational analyses to conduct a chi-square analysis, the health literacy (realm-sf) score was dichotomized: lower (score 1 to 3) and higher (score 4 to 7). these two groups were compared in a 2x2 table, with the “yes/no” responses to feeling discriminated against due to reading ability as rows and the lower/higher literacy scores as columns. the relationship was significant: x2 (1, n = 25) = 4.9, p = .038. this indicated that participants with the subjective report of feeling discriminated against based on their reading ability scored lower on the objective measure of health literacy. those who felt discriminated against because they were female were more likely to report ethnic discrimination. based on pearson correlational analysis, there was a negative relationship between age and education (r = -.32; p = .01), indicating that, as age increased, the number of years of education decreased (table 5). similarly, a negative correlation was found between age and health literacy (r = -.27; p = .01), indicating that, as age increased, health literacy decreased. there was a positive correlation between education and health literacy (r = .61; p = .01). table 5 pearson correlation analysis in a rural older adult cohort years in rural years of education literacy level (realm-sf) depression risk (ces-d) age in years age in years .145 -.321** -.266** -.232** years in rural .066 -.073 -.025 .145 years of education .606** .065 -.321** literacy level .107 -.266** depression risk -.232** note: ** correlation is significant at the 0.01 level (2-tailed). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 15 age was negatively correlated with perceived health literacy discrimination (r = -0.46, p = .05) and rural residency discrimination (r = -0.43, p = 0.05). this indicated that older residents perceived less discrimination with regard to reading level or rural residence than did younger residents. gender discrimination was strongly associated with ethnicity discrimination (r = 0.6, p = .002). narrative inquiry for the qualitative inquiry (n = 25), perceived discrimination was explored through openended questions after the “yes/no” questions. two researchers read and then analyzed the narrative transcripts prior to meeting to share results of their independent analyses and found that no reconciliation of major differences was needed. to establish trustworthiness and rigor, in addition to bracketing of any preconceived ideas, use of memoing, and review of transcripts independently by two reviewers, member checking was conducted by returning the interview transcript to participants (morse, 2015). this allowed participants to confirm their narrative and prevent researcher bias. enhancing rigor in qualitative research is important because it increases credibility and accuracy of the researcher’s interpretation of phenomena (birt et al., 2016). using in vivo coding (saldaña, 2015), as described earlier, which calls for selecting participants’ own words as codes, two key concepts emerged from analysis. the first major concept was identified by recognizing frequent participant statements such as, “i know a lot of my neighbors,” “many folks like me,” and “here not a problem.” researchers interpreted this finding to be linked to the rural, homogenous area in which the participants resided. these statements alluded to the possibility that they may have experienced discrimination in the past but it was no longer something they needed to worry about in the area where they lived. the resulting in vivo code identified independently by both researchers was “many folks like [similar to] me” (with online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 16 “like” being an adverb, not a verb). the overarching theme that became evident was “belonging” (table 6). table 6 in vivo* coding examples of participant responses regarding perceived discrimination participant statement in vivo coding concept “being alone is peaceful.” “peaceful here.” peace “i don’t let [living alone] bother me.” “i relax, i play music, i read.” “i worry about me.” “i read the bible.” “it is peaceful here.” “i’m more peaceful here.” “every woman needs something and i ain’t got nothing, but i don’t worry about it, if god meant for me to have it, i’ll have it. everything is in his hands.” “i know a lot of my neighbors.” “many folks like me.” belonging “where i lived before there were not many folks like me.” “…here not a problem. many folks like me.” “here, no; not here.” “i just moved here.” “i got involved and serve the lunches down here.” “it wasn’t pleasant. i try to forget about it. but not here; i haven’t felt it.” “sometimes they discriminate against you because you come here from another country.” “i’m treated differently by other women.” “not here, but where i lived before there were not many folks like me.” “if you’re not from here, you are looked at differently.” “i don’t let it [living in the glades] bother me.” online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 17 participant statement in vivo coding concept “sometimes i am treated different because i am from haiti.” *note: saldaña, 2015 the second concept was defined by participants who named religious practices that aided them in coping with feelings of experiencing discrimination. through participant statements such as, “i go to church all the time,” “i read the bible,” and “everything is in his hands,” the importance of spirituality in this sample became clear to the researchers. being involved in local churches appeared to be the most common outlet for these residents to remain active. the in vivo code from participant statements chosen for this concept was, “i go to church” and summarized as “religiosity” by the team (table 6 above). both themes were verified through member checking with five residents, although for the term religiosity, those participants referred to their spiritual practices as “i am religious.” discussion the discussion was guided by the key principle in register and herman’s (2006) theory of generative quality of life for the elderly, in that holistic assessments of health are needed to advance inclusivity among older adults who are experiencing disparities. it is simply not sufficient to measure vital signs. psychosocial assessments are essential to determine gaps in quality of life. in this study, we attempted to do that through assessing for perceived discrimination. the most frequently reported perception of discrimination was that of reading ability. using chi-square analysis, this finding correlated with the participants’ objectively measured level of health literacy. therefore, asking participants to reflect on feelings regarding such discrimination could be an added indicator of low health literacy. in any case, health care providers should consider the health literacy level of older adults and adjust care accordingly by speaking clearly online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 18 and slowly, using brief sentences, and providing visual information when available (geboers et al., 2018; wittenberg et al., 2018). health professionals should take time to ensure that their patients understand information related to their health care experience and the state of their health (mckenna et al., 2017; ratna, 2019). if providers take necessary steps to address this gap in education, patients are more likely to enjoy more autonomy and practitioners are more likely to receive actual informed consent. health care providers may want to assess health literacy with the realm-sf survey (arozullah et al., 2007) as used in this study or seek similar resources. after adjusting health terminology accordingly, providers can confirm that their patients understand by using the teach-back method, a technique endorsed in the literature (farris, 2015). no unique factors in this study were found to be associated with discrimination, which stresses the importance of taking a holistic approach when caring for patients. investigating all aspects of a patient's life may identify multiple factors that inform why some patients experience discrimination. therefore, it is essential for health care providers to ask the “hard questions” when interviewing a client who may be at risk for discrimination due to stigma related to background or preferences. even when persons have less access to health information or services, a provider who addresses socioemotional needs may make a critical difference by listening, demonstrating respect, and decreasing the sense of discrimination (fernández‐gutiérrez et al., 2018). several research areas that were not discussed in this study should be included in future studies. first, we did not include sexual preference in the sociodemographic questionnaire, a variable that would have offered insight into the diversity of the study sample and better determination of the relevance of one of the qualitative questions, “is there a time you remember when you felt as if you were treated differently because of your sexual preference?” even if it had been included in the demographic questionnaire, patients might have hesitated to answer honestly. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 19 the diagnostic and statistical manual of mental disorders (dsm) included homosexuality as a mental illness until 1973 (drescher, 2015), which means that, for a significant portion of our participants’ lives, homosexuality was known as a disorder, a deviance from the norm that should be cured. therefore, if any participants had identified with the lgbtqiap+ community, there would have been an increased likelihood for withholding information. as the average health literacy level for the study sample was a fourthto sixth-grade reading level, we found anecdotally that this question regarding sexuality discrimination was often misunderstood. consequently, we had to rephrase the question as, “has anyone ever treated you differently because of who you love?” reflecting on this rephrased version, it could be interpreted as referring to interracial relationships rather than same-sex relationships. therefore, future research should attempt to clarify sexual preference to participants with a lower health literacy level. only one participant had gone to college and now held a graduate degree. this african american woman was the only participant in the sample to be taken aback by the qualitative interview and ridiculed the researchers for asking what she perceived to be obvious questions. “of course,” she often replied to whether she had experienced various kinds of discrimination. the researchers had to explain to her that, throughout all of our interviews, she was the only one to express such views, which we perceived was surprising to her by her response. reflecting on this particular interaction, we wonder whether education level has an impact on one’s perception of discrimination. unfortunately, because she was the only participant to hold an advanced degree, we were not able to explore this relationship further. therefore, future research should include participants with various levels of education when investigating perceived discrimination. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 20 this study examined data from one rural community in florida, which prevents generalizability and does not offer comparison with urban communities. another limitation was difference in race and gender that sometimes occurred between the interviewer and participant. including urban populations and targeting older adults in various rural communities, and pairing race/ethnicity of interviewers with participants in future studies, could expand understanding of these issues. the sample population was largely homogenous (96% non-white); further research should be conducted to investigate the extent to which–if any–this affects one’s chances of experiencing discrimination. the majority of the participants in this study were at risk for dementia due to the prevalence of dementia risk factors such as age, low education levels, increased rates of cardiovascular diseases and diabetes, air pollution, and smoking history (chen & zissimopoulos, 2018; h. chen et al., 2017; grande et al., 2020; rasmussen et al., 2020). for future studies, including this as a variable and comparing the findings based on cognitive function may yield insightful findings. a researcher could also include a predetermined level of cognitive function as an inclusionary criterion, which would require screening prior to collecting data. finally, data were collected through voluntary, nonrandomized self-report, so, as with all interview-based studies, any dishonesty among the participants would skew the data. dishonesty is particularly a risk in face-to-face interviews because discrimination is a sensitive subject that not everyone may wish to discuss. to improve on this in future studies, randomization would be necessary and single or double blinding the study could encourage openness and honesty. new contributions to the literature in a study conducted among adults in south korea, lower health literacy was associated with older age (lee et al., 2017). this u.s. study echoes their findings of a negative correlation between age and health literacy, indicating that, as age increases, health literacy decreases. cutilli et al. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 21 (2018) offered a discussion of this phenomenon by explaining that older adults in the united states with lower health literacy are more likely to have fewer years of education. the current study supports this explanation through the positive correlation between education and health literacy. another factor of primary concern is that health disparities are often prevalent in underserved older adults and likely to exacerbate discrimination (fernandez et al., 2016). mantwill et al. (2015) conducted a scoping literature review of five databases that showed mixed results regarding the relationship of health disparities and health literacy and called for more research. the current study included an underserved cohort, consisting primarily of retired and ethnically diverse farm workers who scored low on the realm-sf literacy scale (arozullah et al., 2007). there was a mildly significant correlation with perceived discrimination based on reading ability. although we did not identify any factors that uniquely predicted discrimination risk, gender discrimination was strongly associated with ethnicity discrimination. while the literature provides evidence of increased discrimination risk for non-whites (cano et al., 2016; nadimpalli et al., 2015), this study suggests that non-white older women may be at an especially increased risk of experiencing discrimination. the moral and societal imperative to treat persons with respect should never be minimized by ethnicity, place of residence, sex, gender, age, or ability to read. nurses and other health care providers are in a unique position to minimize discrimination by advocating for respectful treatment of all persons. compliance with ethical standards funding: this study was funded by the national institutes of health, national institute of aging, k01ag064047 (wiese, 2019-2022) and by the florida atlantic university office of research and inquiry. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.712 22 references arozullah, a. m., yarnold, p. r., bennett, c. l., soltysik, r. c., wolf, m. s., ferreira, r. m., lee, s. d., costello, s., denwood, c., bryant, f. b., & davis, t. 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(2016). outness, stigma, and primary health care utilization among rural lgbt populations. plos one, 11(1). https://doi.org/10.1371/journal.pone.0146139 wittenberg, e., ferrell, b., kanter, e., & buller, h. (2018). health literacy: exploring nursing challenges to providing support and understanding. clinical journal of oncology nursing, 22(1), 53-61. https://doi.org/10.1188/18.cjon.53-61 key_696_bk+2_revised+panola+manuscript.b-final_setup+psf_4.12.22+arformatted online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 150 utilizing readers theater for health promotion education in a rural setting betty key, ed.d., msn, bsn, ccrn1 lovie burrell parks, ms, bs2 emily gray, bsn, rn3 janiece erskine, msn, bsn4 1 assistant professor, samford university, moffett & sanders school of nursing, bkey@samford.edu 2 founder and president, panola outreach community resource center, parks.lovie@yahoo.com 3 registered nurse, university of alabama, capstone college of nursing, epgray16@gmail.com 4 graduate nursing student, university of north alabama, janieceerskine@gmail.com abstract purpose: the aims of the study were to bring in healthy foods, such as fruits and vegetables, provide cardiac health promotion information, and build a community-based partnership with a rural community in west alabama by soliciting members of the community to participate in and attend a play on cardiovascular health promotion. sample: the sample population was mostly older african american community members from a non-incorporated, rural area along with individuals from surrounding communities in an alabama black belt county. through community collaboration, 67 persons were recruited to participate as actors via reading a script and (n =13) and all remaining persons were audience members for the community play (n = 54). method: this study utilized a community-based participatory research approach with a qualitative, descriptive research design. the farmers theater toolkit, which utilizes a readers online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 151 theater technique was used to bring cardiovascular health promotion information to a rural community setting. findings: the majority of audience participants either strongly or somewhat agreed that what they learned from the community play would help them make better food choices (96.3%). conclusion: utilizing the farmers theater toolkit in a rural community was an innovative, fun way to share health promotion information. the citizens of this community were very welcoming to the researcher and were excited to partner with an academic institution. health promotion education may reduce health risk behaviors such as unhealthy food choices. this type of intervention may serve as an impetus to making better food choices. keywords: rural community, theater, health eating, health promotion utilizing readers theater for health promotion education in a rural setting cardiovascular disease (cvd) is the leading cause of death in the u.s. (american heart association, n.d.; centers for disease control & treatment [cdc], n.d.). the term cvd refers to diseases of the heart as well as the blood vessels (cdc, n.d.). eating healthy foods such as fruits and vegetables have been shown to aid in the prevention of heart disease (aune et al., 2017). educating individuals about modifiable risk factors such as diet is a way to help individuals become proactive in cvd prevention. there have been many initiatives to educate rural dwellers on modifiable risk factors. however, the best strategy is yet to be determined. this study utilized readers theater as a unique health promotion education strategy. readers theater is a community theater concept that allows actors to be familiar with and read from a script rather than memorizing lines or parts (reed & claunch, 2017). the script conveys information you would like the audience to remember. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 152 eating healthy foods such as fruits and vegetables have been shown to help mitigate the risk of cvd, yet recent studies have shown an increase in cvd in women in rural populations (virani et al., 2021). access to healthy foods, even in rural areas, can be a problem (rural health information hub, n.d.) according to the united states census bureau, rural refers to any population that is not in an urban area (united states census bureau, n.d.a). terms such as food deserts, food insecurity, and low access food areas are all used to describe geographical regions that typically rank low on the socioeconomic scale and are made up of a minority population (massachusetts institute of technology, n.d.; u.s. department of agriculture, n.d.a). other factors such as lack of transportation and finances can also be a deterrent to eating healthy. the aims of this descriptive study were to engage in the distribution of health foods, such as fruit and vegetables, provide cardiac health promotion information and build a community-based partnership with a rural community in west alabama through the use of community readers theater. background food deserts are commonly thought of from a geographic perspective, but emphasis has also been placed on the economic and health components of affected communities (karpyn et al., 2019). the area known as the black belt in alabama originally referred to the black soil of the area, however, the term is now associated with areas of low socioeconomic status (university of alabama, n.d.). many counties in alabama’s black belt are persistent poverty counties with low food access areas. persistent poverty areas are counties that have rates of poverty at 20% or more (housing assistance council, n.d.). rates of poverty are higher in the south and in non-metro areas (u.s. department of agriculture, n.d.b). areas of poverty typically are areas of low food access and contribute to poor health conditions (rural health information hub, n.d.; u.s. department of online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 153 agriculture, n.d.a). furthermore, areas with low food access have a higher incidence of older adults who are affected by chronic health conditions (llyod, 2019). therefore, it is not only important to make healthy foods more accessible, but it is also important to educate individuals on the importance of eating healthy to prevent negative health outcomes. presenting health information in a personalized manner that includes social interaction, such as in a community readers theater play has been shown to be an effective teaching tool (mccallum et al., 2021). method this study utilized a community-based participatory research (cbpr) approach with a descriptive research design. in cbpr members of the community work with the researcher throughout the research process and in decision-making, which can create trust among community members (wickman & carbone, 2018). the study was approved by the corresponding author’s institutional review board (irb). in addition to the corresponding author, the research team was comprised of the president of the local non-profit community outreach organization in the community along with two undergraduate students. the president of the outreach is a strong community advocate who is very influential in the community and frequently organizes community events for the seniors of the county. the location of this study was an unincorporated town and census-designated place (cdp) located in sumter county, a black belt county in alabama. the county has nine towns. the town of panola and surrounding towns were the focus of this study. in 2018 heart disease was listed as the number one cause of death in sumter county (alabama department of public health, n.d.). the town of panola has a population of 71 (alabama demographics, n.d.). the racial make-up of the community is 91.5% (n=65) african american or black and 2.8% (n=2) caucasian or white, 1.4% (n=1) hispanic or latino and 4.2% (n=3) two or more races (alabama demographics, n.d.). in 2020, the population of sumter county was 12, 345, online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 154 with a median income of $24, 320 and a poverty rate of 31.8% (united states census bureau, n.d.b). intervention healthy foods were provided to the community monthly for a total of six months. examples of items included in the food pantry were apples, grapes, peanut butter, and frozen cod. the food items were distributed through the food pantry program operated by the local feed america organization. the research team worked alongside community members who volunteer at the nonprofit and assisted with assembling and distributing food boxes and with the distribution of the boxes. in order to qualify for food boxes recipients had to meet feed america qualification guidelines. approximately 90 families from the county met the emergency food assistance program (tefap) certification of eligibility requirements. food box distribution occurred during the covid-19 pandemic, so everyone followed the cdc covid-19 guidelines. recipients drove up, opened their trunks, and a box was placed in the trunk. food box recipients were recruited to participate as the audience for the play and the community volunteers who helped to assemble the food boxes were recruited to participate as actors in the play. the community actors participated in script writing for the play with a focus on the importance of eating fruits and vegetables to help prevent heart disease. the research team reviewed the heart healthy information with the actors. actors and audience were informed of the fact that the play typically would have been a dinner theater type of play, but due to the pandemic the play would be held outside, and a nutritious box lunch would be provided to take home. cardiovascular health promotion brochures were also included in the food box. the brochures were from cardiosmart of the american college of cardiology (n.d.). the study was funded by an internal grant at the researcher’s academic institution and approved by the irb. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 155 procedure for readers theater with a focus on community non-profits and cardiovascular health in the rural setting, the researcher sought a rural non-profit organization to partner with. the goal was to provide access to healthy foods as well as cardiovascular health promotion information to an area that also qualified as a food desert. in addition to the cv brochures and food, the team also wanted to bring the community together in an engaging way at the end of the six-months to showcase the cv information contained in the brochures. hence, the culmination of the study was a community play that stressed the importance of eating healthy to mitigate heart disease. the organizational framework for the play utilized readers theater. readers theater allows the performer to read from a script versus having to memorize lines (mccallum et al., 2021; reed & claunch, 2017). readers theater is a unique, fun way to share health promotion information in a community setting. the university of kentucky’s farmers dinner theater (fdt) toolkit served as a guide for developing the community play and post play evaluation survey. permission to use the toolkit was obtained from the fdt toolkit developer (reed, 2018). an important aspect of the fdt toolkit is that members of the community participate in writing the play and are actors in the play. the idea was to communicate important health promotion information along with local humor as a fun way to learn. due to covid-19 and having to overcome technology challenges in a rural setting, rehearsals were held over the phone on a free conference line. there was one in-person rehearsal held at the outdoor pavilion a week prior to the play. advertising for the play was conducted primarily by word of mouth. the play, which was developed with the help of the community partner and actors, was comprised of two acts, thereby providing more acting opportunities. pleasantly, there were several community members who wanted to participate. the total online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 156 completion time for the play was approximately 45 minutes. the scripts for the play contained a storyline related to information from the brochures such as the importance of eating more fruits and vegetables to help prevent heart disease. in addition to reading the respective scripts and adding humor, singing was also incorporated. popular southern baptist church songs were altered to include lyrics that encouraged the audience to eat more fruits and vegetables. at the end of the play both actor and audience participants completed an evaluation survey. sample the president and founder of the local non-profit works to provide social outlets and opportunities for seniors in the area. therefore, a convenience sample of seniors from the community were chosen. the seniors in the local and surrounding communities were chosen as participants to serve as actors for the play, n = 13. all of the actors in the play ranged in age from 60 to 90 years old and were residents of the county. audience participants were recruited from individuals who came to pick up food boxes, n = 54. in addition to the audience members who were food box recipients, other guests also attended such as grandchildren, nieces and cousins. findings a total of 67 participants (n=67) completed the post play surveys. descriptive analysis was utilized to analyze the data. the surveys consisted of either nine (actor survey) or ten (audience survey) 5-point likert style questions that ranged from strongly disagree to strongly agree. there were three demographic questions, three questions related to heart disease and diabetes and one question that asked participants to list one lesson learned from the play. additional questions were: 1) do you have heart disease, 2) do you have diabetes, 3) what is the number of people in your family with heart disease, 4) list one thing you learned from the play, and 5) additional comments. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 157 some of the comments were “it helps to share health information”, “eat more fruits and vegetables”, and “it is truly necessary to eat healthy”. responses from the surveys were overwhelmingly positive. questions one through three on the actor surveys and question one through four on the audience surveys differed because they were specific to either the actor or the audience. ninety-four percent (n=63) of participants were african american, and 6% (n=4) were caucasian. one hundred percent either somewhat or strongly agreed that the story would encourage them to discuss the importance of healthy eating to prevent heart disease with their family, make better food choices, and eat more fruits and vegetables. findings for questions specific to the actors revealed 100% (n=13) somewhat to strongly agreed that they enjoyed participating in the play. the majority of the actor participants, 84% (n=11), somewhat to strongly agreed to enjoying helping to write the play, while 16% (n=2) neither agreed nor disagreed. findings for questions specific to the audience revealed 98% (n=53) either somewhat or strongly agreed that they enjoyed the play and 98% (n=53) either somewhat or strongly agreed that that the story was easy to follow. discussion the study began amidst the pandemic and many in the community were dealing with stressors such as the loss of family members from covid-19, loss of income from job loss, and a fear of going into town and coming in close contact with others. the monthly food deliveries were seen as a welcome relief for many because it meant residents would not have to go into town to the grocery store and risk possible exposure. the health promotion information was well received as community members drove through the food pick-up line. there was also a sense of excited expectation knowing that a community play was going to be performed in the forthcoming spring months. this was the first time a play had been performed in the community and that members of online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 158 the community had performed for their peers. the survey data indicated that the town is interested in receiving additional health information presented in this format. limitations of the study were that due to covid-19, the play had to be held outside in the hot weather and the actual community dinner piece of fdt was omitted for safety reasons. also, because of the outdoor temperature, the discussion portion after the play was omitted. post play discussions could have provided more in-depth information for the research team regarding planned behavior changes to eat healthy and insight into the understanding of the information. a six-to-eight-week follow-up would have provided insight into behavior changes of fruit and vegetable consumption. implications for future direction are to utilize the fdt concept for sharing health promotion information in different settings such as school and church. conclusion utilizing the fdt toolkit in the rural community was innovative and fun, especially amid a pandemic where community members were not able to attend church or socialize as they were accustomed to. the citizens of this community were very welcoming to the research team and were excited to partner with the academic institution. everyone indicated a willingness to participate in future studies. health promotion education may reduce health risk behaviors such as unhealthy food choices. this type of intervention may serve as an impetus to making better food choices. references alabama demographics. (n.d.). is panola the best alabama city for your business? https://www.alabama-demographics.com/panola-demographics alabama department of public health. (n.d.). county health profiles 2018. https://www.alabamapublichealth.gov/healthstats/assets/chp2018.pdf online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 159 american heart association. (n.d.). health disparities in rural us: higher coronary artery disease death in women under 65 and people with heart failure. https://newsroom.heart.org/news/health-disparities-in-rural-us-higher-coronary-arterydisease-death-in-women-under-65-and-people-with-heart-failure aune, d., giovannucci, e., boffetta, p., fadnes, l. t., keum, n., norat, t., greenwood, d. c., riboli, e., vatten, l. j., & tonstad, s. (2017). fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality—a systematic review and doseresponse meta-analysis of prospective studies. international journal of epidemiology, 46(3) 1029-1056. https://doi.org/10.1093/ije/dyw319 cardiosmart: american college of cardiology. (n.d.). infographic posters. https://www.cardio smart.org/topics/decisions/clinicians-start-a-conversation/posters centers for disease control and prevention. (n.d.). women and heart disease. https://www.cd c.gov/heartdisease/women.htm housing assistance council. (n.d.). persistent poverty. https://ruralhome.org/ourinitiatives/persistent-poverty/ karpyn, a. e., riser, d., tracy, t., wang, r., & shen, y. (2019). the changing landscape of food deserts. unscn nutrition, 44, 46-53. https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc7299236/ lloyd, j. (2019). from farms to food deserts: food insecurity and older rural americans. journal of the american society on aging, 43(2), 24-32. https://www.jstor.org/stable/26760111 massachusetts institute of technology. (n.d.). fresh food for all: improving access to healthy food in alabama. https://dusp.mit.edu/sites/dusp.mit.edu/files/attachments/project/ecn_repor t_5.pdf online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.696 160 mccallum, d. m., reed, d. r., claunch, d. t., davis, c. m., & conway, m. b. (2021). farm dinner theater: testing an innovative health and safety intervention among older farmers and their families. the journal of rural health, 1-9. https://doi.org/10.1111/jrh.12601 reed, d. b. & claunch, d. t. (2017). moving social norms via theater for senior farmers. journal of safety research, 60, 17-20. https://doi.org/10.1016/j.jsr.2016.11.002 reed, d. b. 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(2021). heart disease and stroke statistics—2021 update: a report from the american heart association. circulation, 143(8), e254-e743. https://doi.org/10.1161/cir.0000000000000950 wickman, c. a. & carbone, e. t. (2018). “just say it like it is!” use of community-based participatory approach to develop a technology-driven food literacy program for adolescents. international quarterly of community health education, 38(2), 83-97. https://doi.org/10.1177/0272684x17749572 johansen_540 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 224 experiences of rural nurses who commute to larger communities laurie jo johansen, phd, ms, bsn 1 tracy a evanson, phd, rn, phna-bc 2 jody l ralph, phd, rn 3 cheryl hunter, phd 4 gary hart, phd 5 1 professor and director of nursing, department of nursing, southwest minnesota state university, laurie.johansen@smsu.edu 2 professor and director of phd program, college of nursing and professional disciplines, university of north dakota, tracy.evanson@und.edu 3 associate professor, faculty of nursing, university of windsor, jody.ralph@uwindsor.ca 4 associate professor, college of education and human development, university of north dakota, cheryl.hunter@und.edu 5 professor, school of medicine and health sciences ; director, center for rural health, university of north dakota, gary.hart@und.edu abstract background: healthcare disparities for rural u.s. populations occur in part due to lack of healthcare providers. increasing numbers of registered nurses (rns) commuting away from rural communities for employment contributes to the rural population’s challenges accessing healthcare. it is largely assumed in the literature that wages are the driving force behind rural online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 225 nurses’ commuting decisions. however, the actual experiences of rns living in rural communities who commute to larger communities for employment is absent in the extant literature. purpose: this descriptive, phenomenological study explored the phenomenon of commuting away among rns living in rural communities who commuted to larger communities for employment. methods: participants included currently licensed rns, residing in rural communities with a critical access hospital, that had a population of less than 2,500, who commuted for employment in larger communities. purposeful sampling with snowballing led to 16 rns from two midwestern states, providing rich variations in personal and professional experiences. data were collected via semi-structured interviews. findings: the core meaning, or essence, of the phenomenon of commuting away was found to be “commuting to achieve personal and professional goals while being a nurse in a rural community.” multifaceted reasons surfaced for rns to commute for employment. most noteworthy reasons for employment decisions included opportunities for specialized areas of nursing not available in rural healthcare settings, along with advancement opportunities. additionally, all rns in the study were found to appreciate feeling valued as a nurse by members of their rural communities. conclusion: the multi-faceted reasons for commuting away indicated that “one size fits all” plans for recruitment and retention efforts will not meet the needs of rural nurses, and neither will simply increasing rural nurse wages. study results are relevant to policy development, nursing practice, nursing education, and future development, recruitment, and retention efforts of nurses serving rural populations. keywords: nurses, rural nurses commuting, employment, job online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 226 experiences of rural nurses who commute to larger communities with 46.2 million people in the united states living in rural areas, approximately 14% of the u.s. population lives on roughly 72% of the land (us department of agriculture [usda], 2016). with a relatively small population distributed over such a large landmass, unique challenges are faced by rural populations. rural populations have a higher prevalence of disease and premature death rates compared to the general u.s. population (matthews et al., 2017). healthcare disparities create challenges in meeting rural healthcare needs (national advisory committee on rural health and human services, 2011). the healthy people 2020 initiative has forged a national effort to create health equity for everyone in the united states (us department of health and human services, 2014). yet, the u.s. rural population continues to face challenges resulting in healthcare disparities. rural populations typically have inadequate numbers of healthcare providers (national rural health association, 2016), which limits their access to healthcare. one factor contributing to the lack of nurses practicing in rural settings is the increasing number of registered nurses (rns) who commute away from their rural, home communities to larger communities for employment. a comparison of the 1980 and 2004 national sample survey of registered nurses (nssrn) data found that in 1980, 14% of rns in the rural united states were commuting for employment, but by 2004, the percentage of rural rns commuting had increased to 37% (skillman, palazzo, hart & butterfield, 2007). current commuter trend data for rns are not available, largely because the nssrn survey was discontinued after 2008. however, with increasing rural hospital closures and rn employment opportunities available outside rural areas, it is likely that the increasing outflow rates of rns who live in rural areas to commute to larger communities for employment has continued. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 227 while it is known that rural rns commuting for employment has increased over time, little is known about their actual experiences. it is widely assumed that wages are the primary driving force for commuter trends among these rns (skillman, palazzo, doescher, & butterfield, 2012), but little detailed research has focused directly on specific first-hand reasons rural nurses commute to larger communities for employment. the purpose of this descriptive phenomenology study is to describe the phenomenon of commuting away among rural rns who live that experience. the phenomenon of rural resident rns commuting away was defined as “traveling away from the rural, home community for conventional employment in non-rural settings” (johansen, 2017, p. 5). for this study’s purposes, rural was defined as a community with under 2,500 inhabitants as specified in the u.s. census bureau’s definition (us census bureau, 2015). a qualitative research approach was necessary, in order to understand the phenomenon through the experiences of those who live it. research method design a descriptive phenomenological research approach was employed to describe the experiences of rns living in rural communities who commute away. phenomenology as a research method strives to deeply explore and describe the everyday world of the participants providing a means to understand the complex nature of a phenomenon and those who are experiencing it (dahlberg, nyström, and dahlberg, 2008). focusing on the experiences that make up the everyday world of the rn participants, an open stance was used by the researcher to approach the phenomenon of rural resident rns commuting to larger communities, allowing the many unique meanings of the phenomenon to surface. the researcher sought participant’s descriptions of their experiences, focusing on the rich variations of experiences. consistent with online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 228 descriptive phenomenological methods, the researcher set aside pre-understandings of commuting away to allow the essence (core meaning) of commuting away to surface. sample purposeful sampling with the snowballing method (kleiman, 2004) was used to obtain a sample with rich variation in experiences (dahlberg et al., 2008). inclusion criteria for the participants were: 1. a currently licensed rn in one of three midwestern states; 2. a resident in a defined rural community (population < 2,500) with a critical access hospital (cah); 3. an rn commuting away from his or her home community for employment in a non-rural setting (community with a population of 2,500 or more), and; 4. english speaking. as the sampling process continued throughout the study, purposeful sampling strategies were used to ensure that the sample included a wide variety of experiences that would lead to a rich, full description of the varying aspects of the phenomenon. variations were sought in relation to differing genders, ages, work experiences, work sites, years of experience, and levels of education. in addition, participants who represented varying relationships with their rural community were also sought, including participants who were born and raised in the rural community versus those who recently moved into the rural community, or did so in the last 3-5 years; as well as participants who had always commuted for employment and those who had been previously employed within the rural community. and finally, variations were sought in community size to which the rns commuted, including small rural areas, large rural areas, and urban areas, as classified by ruralurban commuting area (ruca) codes (usda, 2014). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 229 communities with a population of less than 2,500 residents, in which a cah was located, were identified within a tristate midwest region of the united states. lists of rns were received from the boards of nursing within those states. prospective study participants received a letter of invitation through the u.s. postal service. the prospective participants were able to respond via a form and addressed and stamped envelope, or via email. participants were then contacted by phone and/or email to determine eligibility for the study, with the use of a screening tool. once eligibility was determined, a date and time was scheduled for an interview with the selected participants. not all eligible participants were interviewed. rather, only those participants adding to the variability of experiences were included in the study. to determine which participants were included, the population of each of the communities to which participants were commuting to and from were identified and considered, using the ruca classification system (usda, 2014), along with the 2010 u.s. census data (as cited in johansen, 2017). additionally, each of these community’s counties were classified according to the 2013 ruralurban continuum codes (rucc) (usda, 2013) to distinguish counties by degree of urbanization and adjacency to metro areas. to ensure variability in the sample, participants were selected based on variations in the ruca and rucc codes of the communities where they were employed. recruitment continued until there was good variability in the ruca and rucc codes, as well as variation in other factors that could influence differing experiences, and until the researcher was able to identify the essence of the phenomenon and its meaning. the final sample included 16 participants. the rns all held licenses within the tristate region, and one rn was licensed in more than one state. varieties of settings were worked in, and the rn roles included staff nurses, advanced practice nurses, and nurse administrators. practice areas also varied, with areas of specialization including homecare, hospice, medical-surgical units, online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 230 operating rooms, pediatrics, and maternity care. further demographic characteristics are found in table 1. classification of the communities to which the rns commuted are found in table 2. table 1 demographic characteristics of sample variable range mean n % age (years) 24 78 44.6 caucasian race 16 100 years of rn practice 2 57 19.6 hours worked per week 22 44 34.5 gender male 2 12 female 14 88 education associate 8 50 bachelors 6 38 masters 2 13 years residing in rural home community 1 70 23.2 lived in other rural community prior to current community yes 10 62 no 6 38 years commuting for work 1 32 10 work history previously practiced in a rural community 9 56 always commuted 7 44 table 2 classification of communities to which the rns commuted variable n % ruca zip classification small rural (2,500-9,999) 3 19 large rural (10,000-49,999) 9 56 urban (50,000+) 4 25 census classification 2,500-10,000 3 19 10,001-20,000 6 38 20,001-30,000 2 13 30,001-40,000 1 6 50,001-60,000 1 6 60,001-70,000 1 6 200,000-299,999 1 6 >300,000 1 6 rucc county classification rucc 1 4 25 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 231 variable n % rucc 2 0 0 rucc 3 2 13 rucc 4 0 0 rucc 5 2 13 rucc 6 3 19 rucc 7 5 31 protection of human subjects institutional review board approval was obtained from the researcher’s academic setting (irb-201510-107), as well as employment setting (f-15-17). written, signed consent outlining potential risks and benefits of the study was obtained from each of the participants. participant privacy was protected by assigning numeric codes to the participants and removing identifying information from the transcripts. data collection semi-structured interviews, conducted by the first author (lj), were used to obtain descriptions of the rns’ experiences with commuting from their rural residences to workplaces in larger communities (brinkman & kvale, 2015). interview settings were chosen by the rns in order to ensure a comfortable, yet private interview environment. an interview guide was used to direct the interview with a set of primary questions that were asked of each rn. in keeping with a phenomenological approach, an open dialogue evolved during each interview and spontaneous questions were asked to obtain both depth and breadth of each rn’s description of their experience. all interviews were audio-recorded and ranged in length from 27 to 82 minutes with a mean of 50 minutes. following completion of each interview, field notes were created by the researcher, including descriptions of observations that were not captured by the audio recordings, any additional interactions between the rns and researcher, and anything the researcher identified as noteworthy. a reflexive journal was used throughout the study to allow for the expression of researcher feelings, insights, preunderstandings, and reflections, in an attempt to bracket these online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 232 from the data collection and analysis (streubert & carpenter, 2011). audio recordings were transcribed verbatim by a professional transcription service. each transcript was verified for accuracy by the first author (lj) with all identifying information removed from the transcripts. data analysis analysis of participant interviews followed a tripartite structure, moving between the whole of the data, to the parts of the data, and back to the whole (dahlberg et al., 2008). the first author (lj) completed analysis and the software platform, nvivo 10.0™, was employed for data management. in the first step of analysis (whole), the researcher was immersed in the transcripts, reading the transcripts and field notes several times, while being open to new understandings. this immersion continued until an overall summary and broad understanding of each interview was established (dahlberg et al., 2008). during the analysis step, parts of the data became the focus, and the data were broken down into meaning units. “the term meaning units signals that the division of the whole of data into parts is not carried out randomly but with respect to the meaning that one sees” (dahlberg et al., 2008, p. 243). participant words were used, whenever possible, as codes were assigned to the individual meaning units. once all the data were coded, clusters of meaning were identified, again using participant’s words whenever possible. schematic drawings were used as an analytical procedure to help understand the codes and clusters of meaning, and the relationships between them. this led to the final analysis phase (whole), in which all of the individual data parts were reassembled to identify the essence of the phenomenon (or core meaning) that runs throughout all experiences, including the constituents (elements of the essence) and their variations. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 233 findings essence and constituents the core meaning, or essence, of the phenomenon of commuting away was identified as commuting to achieve personal and professional goals while being a nurse in a rural community. the essence of commuting away meant that rns were motivated to commute to an employment setting outside of their rural, home community, in order to achieve personal and professional goals that could not be achieved in their home community. at the same time, they remained a nurse in that community, even if they were not practicing there. as a result of commuting away, they experienced different professional connections. figure 1 displays the constituents that compose the essence of commuting away. figure 1. essence: commuting to achieve personal and professional goals while being a nurse in a rural community with constituents online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 234 the first constituent, being a nurse in a rural community, related to the fact that although the rns were currently commuting away for employment, they were still regarded as a nurse in their home communities. this was true for rns who had worked in their home communities prior to commuting away, as well as those who had never worked locally. the experience of being a nurse in a rural community had varied meaning among the rns, which was influenced by their experiences and/or perceptions of rural nursing practice. the second constituent was personal and professional goals. the rns had a variety of personal and professional goals, but in all cases, they were unable to meet some of those personal and professional goals through employment in their rural home communities. thus, in order to achieve their goals, they made the decision to commute to a larger community for employment. the third constituent, commuting, involved the act of driving to their employment outside of their home community, and involved several unique challenges in the lives of the rns. finally, the last constituent was different professional connections. this means that the connections to coworkers, patients, employers, and home communities was different in their current employment setting than it was (or would have been) in their rural, home communities. for some rns, the change in these connections was viewed positively and even helped them meet their personal and professional goals, but for others, the different connections were challenging. the meanings of each of these constituents are described in the sections that follow. being a nurse in a rural community all rns, regardless of whether or not they had worked in their rural, home community prior to commuting for employment, described both experiences and perceptions of what it meant to be a nurse in a rural community. a full description of this constituent has been described elsewhere (johansen, 2018). being a nurse in a rural community provided the context that the rns online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 235 continued to live in, even though they were not working in that same home community. the rns perceived that they continued to be respected and trusted within their home communities, because of their role as a nurse, and this was highly regarded by the participants. what it meant to be a nurse in a rural community was also shaped by their direct experiences and/or their perceptions of the demands of rural nursing practice. this included being “a jack of trades,” the need to provide care for neighbors, friends, and family members, a lack of boundaries between their personal and professional lives, and a high visibility because of being known as a nurse in their home communities. feelings about these issues ranged from neutral to inconvenient and undesirable. the former included feelings such as being viewed as a normal part of living in a rural community as a nurse. the latter feelings were sometimes contributing factors to the decision to commute to another community for employment. personal and professional goals while being a nurse in a rural community, the rns felt an inability to achieve some of their personal and professional goals within their rural communities. wages, work hours, staffing patterns, benefit packages, job stability, and technology resources available at their current work were described as means to better meet some of their personal goals. professional goals involved opportunities for professional growth, including opportunities for advancement and working in specialty practice areas. pursuit of personal and professional goals were the primary employment considerations that led to the rns seeking employment outside of their rural, home communities. wages were a consideration as part of their personal goals as one participant explained: you get paid more but yet you’ve got to factor all that other stuff in because then are you just coming out even? so then does it really matter what that pay scale is because you have how much more in gas expense, which leads to more oil changes, which leads to more tires. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 236 some rns reported receiving higher wages after they commuted for employment. however, other rns reported receiving wages similar to home, or even lower wages. thus, while the availability of higher wages outside of their rural community was one of the deciding factors for some of the rns, it was not a deciding factor for all of them. while some received higher wages after they left their rural, home communities for employment, many rns had to consider the additional costs of commuting. another personal goal among many rns was the desire for work to interfere less with their personal lives. increased flexibility of scheduled hours, fewer weekend and night shifts, and union regulation of hours were viewed as positive benefits in the larger healthcare settings. the job hours they offered were better than anything else i could have gotten anywhere else at that time in my life that i needed less hours. work hours, together with staffing patterns experienced in larger healthcare settings, were appreciated by many rns. nurses described how in rural hospitals, there would be only one or two nurses on a shift, with ancillary staff, such as lab techs, only available when needed during evening, night, and weekend shifts. one rn shared: [in the rural hospital] at night, you get a four-vehicle accident with four victims coming and you have two nurses on, and those two nurses are doing your secretarial work, they’re caring for the patients already there in the hospital and it’s the middle of the night and now you’ve got to make all these phone calls to try and get people to come in. that would be way too stressful for me. in rural healthcare settings, primary care providers were not on the premises 24 hours a day, and generally available on an on-call basis. thus, high levels of responsibility for patient care fell to the nurse, and several were uncomfortable with the staffing patterns experienced, or perceived to exist, in rural healthcare settings. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 237 benefit packages were also factors considered when making decisions about employment location. one rn explained: i’m the insurance holder, so that’s a huge thing. retirement, 401(k), flex spending, that’s huge. short-term disability, long-term disability – there are so many more compared to what i’ve ever been offered at other [rural] facilities. however, not all of the rns were in agreement that benefit packages were better at larger healthcare facilities. another rn stated: i gave those [benefits] up to have the flexibility to stay employed [while working in a non-rural healthcare setting]. overall, better retirement plans, insurance packages, sick leave, and vacation time were sought by several of the rns. increased availability, and use, of technology resources was considered a benefit for rns seeking employment in larger healthcare settings. one rn described how less available technology in rural healthcare settings was “like everything was backwards.”. lastly, some rns feared a lack of financial stability in their rural, home hospital, and many described feelings of increased job stability in larger healthcare settings, because of the better financial stability of the institution. one rn shared: i would say there is more job security involved being at that organization. it’s a [regional health system] and it’s pretty well run. . . . they’re financing it all. so i would say financially it’s a very secure and stable security blanket, i guess is what i would call it. there’s really no risk of them shutting the place or anything like that. overall, having a consistent, secure source of income was an important personal goal for rns. in relation to professional goals, opportunities for advancement were often a motivating factor for the rns to seek employment outside of their home communities. advancement opportunities related to the ability to practice in specialty areas of nursing, such as maternity care, as well as possibilities to climb the professional ladder, were found when commuting for online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 238 employment in larger communities. as one rn stated: [specialty area] was one of the main things that brought me [to employment away from my home community]. on the other hand, not all rns shared the appreciation of specialty nursing opportunities, and these rns appreciated and even missed the generalist role of the rural nurse. as one rn explained: now there’s so many minute specialties. that’s great but you lose that basic skill set of being a nurse. i think people get lost . . . in larger communities, you have to be a specialty. it was noted that specialized practice was available in their rural communities, but it was largely limited to gerontological nursing, and many were not interested in that type of specialization. just because i’m commuting away from my community doesn’t mean that the opportunities aren’t there [at home]. they’re there but in a different capacity. in the end, rns not only considered their experiences and perceptions of being a nurse in a rural community when making employment decisions, but they also considered their personal and professional goals. decisions to commute for work in larger communities were multifactorial, but the rns determined that the overall opportunities and benefits of commuting outweighed those available to rns in their rural, home communities. commuting when rns determined that some of their personal and professional goals could not be met while being employed in their home community, they chose to seek employment in another location, which required they commute for employment. the constituent of commuting was defined as the act of driving to a larger community for the purpose of employment (this concept differed from, but was part of, the entire phenomenon of commuting away). the act of commuting affected the rns’ personal and professional lives, and many challenges surfaced. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 239 commuting on rural roads created personal safety concerns such as uncontrollable road conditions, irresponsible drivers, and unexpected obstacles while driving. one rn stated: perpetual deer that like to jump out in front of your car at dusk and dawn, that is a very big challenge. commuting also had an impact on the rn’s family. the time spent commuting meant less time available to spend with their families. two of the rns drove to multiple destinations for employment. the remaining rns in this study commuted 20 to 57 miles each way, with an average of 30 miles. one rn lamented: when i’m gone, you just might as well mark me off for the day. i’m not going to see you [family]. for rns with young children, decisions related to childcare also presented challenges. nurses needed to make decisions about where to obtain childcare, whether in their home community or in the community where they were employed. finding childcare that was available during the hours needed for nurse schedules was also challenging. weather related emergency plans for family, and driving distances with children in the car, also distressed some of the rns. no day care takes them that early in the morning. . . . where do you bring your kids when you’re commuting? do you bring them all the way to [the community where you are working] for daycare with you or do you find something somewhere here [in home community]? . . . once they got to school age . . . what if school gets out early? what if they’re snowed in here or there? you’re that much further away. likewise, rns who had responsibilities for adult family members needing assistance shared some of the same concerns. concerns such as weather and alertness were also an issue with commuting. a common expectation of healthcare facilities was for nurses to be at work regardless of weather conditions. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 240 thus, when inclement weather was expected, nurses needed to go to work early to assure they would be available for their scheduled hours. at the end of their shifts, they sometimes could not go home because of weather or the lack of replacement nurses. sometimes nurses remained at work for several days during winter storms. a 3-day blizzard . . . we had small children, and i was stuck away from home. . . winter commuting is challenging. some decisions to commute hinged on whether they knew someone on the commuter route, or in the commuter community, in case they had car troubles or weather challenges. many rns were concerned about the time and money spent driving to work as well as lack of alertness while driving. nurses needed to leave home earlier for work. thus, the time spent driving to work added to the time spent at work, and travel expenses for commuting. [where i work] there’s a lot of things that you have to deal with that you don’t have to deal with in the rural [area], like parking. there’s parking issues and you pay for parking. in the rural, you don’t even realize that that exists . . . [then] gas money, repairs on my car. a lack of alertness while driving was also a concern for rns, with a sense that the lack of alertness spilled over into the patient care setting once the nurse arrived at work. the drive can be kind of tiresome . . . you drive and you’re still kind of tired and you’re kind of groggy, and you get to work and you’re still kind of groggy for the first couple of hours or whatever. professionally i think that can be a factor, especially depending on how far you have to drive. you’re not really tuned in for a while. that’s one thing i did kind of factor in as well, because sometimes when you drive you just kind of zone and when you get to work you still just kind of feel groggy, even though you’ve been up for the last couple of hours, because you get up, you get ready, then you drive to work, but it’s just that drive in the morning. you’re not mentally with it. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 241 concerns with commuting, especially of those related to personal safety and time to commute, posed challenges for rns and even potential challenges for their patients. while rns identified the difficulties faced as they commuted, there was one aspect of the drive that they viewed positively, the ability to have downtime. one rn explained: the 30 minutes are fabulous to and from work when there are not road conditions or deer issues. it’s decompression time for me. in the morning, it’s more eating a little breakfast, listening to the radio, pretty relaxed. but then on the way home, if i’ve had a really stressful day, maybe somebody passed away close to the end of my shift, and i’m still kind of wound up a little bit from that, that 30 minutes before i get home is wonderful, because it’s me and the radio again. i have a thing in my car where i can call from my steering wheel. it’s a bluetooth. i love that. i cannot believe how much time i spend on the 30-minute commute home making phone calls to friends and my parents to catch up. and then when i get home, i’m strictly home with my husband doing our thing. i love that 30-minute commute. many of the rns expressed appreciation of the downtime that they experienced as they drove to and from work, because this provided an opportunity for them to decompress and personally reflect upon their work before they got home. as rns faced the many challenges presented to them while commuting, some of them indicated they would prefer to not commute. however, motivation to achieve their personal and professional goals outweighed the challenges they faced as they commuted to work. different professional connections as rns commuted for employment in larger healthcare settings, they found their connections to patients, coworkers, employment facilities, and home communities to be different than those connections when they had practiced in a rural healthcare setting (for those nurses who had online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 242 previously practiced in their home community); or were different than what they perceived they would face if they were practicing in their rural, home community (for those who had never practiced there). nurses found higher activity levels while working at larger healthcare facilities, along with greater numbers of patients to care for, in comparison to a rural healthcare setting. such practice settings led some nurses to feel less connected to their patients, coworkers, and work environments, with connections feeling less personal, and more distant. the experience of caring for patients in a rural, healthcare facility was different from the experiences found caring for patients in larger facilities. nurses tended to not personally know their patients when they commuted for employment. for some rns, this greater anonymity was appreciated, and was described positively as “a distance” from their patients. that’s one relief. [while commuting,] i don’t really know the people; this is just how it is. . . . in the area of chemotherapy . . . here, they’re my patients for that day. . . . i’m kind of glad i don’t have to do it with somebody that i really. . . like if it was a close friend or a family member. . . . i don’t really know them; just, they’re my patients. i’m their nurse and they’re my patients . . . there’s a distance. additionally, this “distance” allowed the patients the opportunity to feel safer in disclosing sensitive information with the nurse, as one rn described: i think that i was able to approach patients differently as an outsider because i was not so close to their base. confidentiality wasn’t such an issue. they were more likely to open up and talk to me. the element of “distance” in the commuting away experience provided an anonymity of the patient that rns found they appreciated. the rns also experienced different connections to their patients outside of the healthcare setting. nurses generally found it less common to have personal-professional boundary violation issues, compared to what they experienced in their home communities. they were asked about online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 243 confidential patient matters in public settings much less, which was dramatically different from experiences while working in their home communities. nurses were also less likely to encounter their former patients outside of the healthcare setting, compared to when they were in their home communities. for some, this was appreciated, while others missed those dual, close relationships. i about had somebody run into me [shopping] the other day. unfortunately, i always feel terrible because i don’t remember their names. maybe here in our community i know who they are, but we have 500 deliveries every year, and i’m not in on all 500 but i’m in on a lot. when they are coming up to you a year later, they look different and i just don’t remember their names. and so then you feel terrible. i feel bad that way. . . . that’s kind of a negative because i’m like “oh, i wish i could just remember their names, because they obviously remember me.” while boundary issues were less common, the feeling of disconnection from patients when interacting outside the professional sphere was still expressed as a loss for some rns. there were also changes in the connections rns had with their coworkers. in the rural health care setting, the bond between coworkers was viewed as tighter. “the relationship that you had with the rest of your staff, it was a tighter bond, because there were a smaller number of you, and you knew that you needed to be there for each other.” additionally, the rns noted that in practice in their rural, home community, a sense of family developed, with coworkers attending social events together, including special occasions for family members. in the smaller communities you went outside of your job and you went and had supper with them. you went out and your kids played ball together. this relationship did not exist with their coworkers at the employment to which they commuted. nurses had a greater sense of obligation to their rural coworkers and healthcare facilities as a result of these strong connections. in their rural, home communities, this strong connection also online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 244 led to the rns feeling obligated to come in to work when needed and pick up extra hours. it was almost too easy for me to pick up [hours] because i was too convenient. . . . i was way too accessible. thus, when employed in their rural communities, rns felt like they were at work all the time. conversely, while working outside of their rural, home communities, there was more of a distance in the relationships with coworkers, and the rns’ personal lives were less likely to intersect outside of the work setting. in eight hours, i’m there and gone, and i didn’t have any relations with the workers. it was like they weren’t my friends; they were just coworkers, and everybody was there just to put their time in and go home. so it’s a different atmosphere than the rural . . . it’s just not like a family. . . . there’s not a connection. feelings varied in relation to these different connections with coworkers. some rns missed having closer connections to their coworkers, while others really valued the feeling of distance in those relationships. one thing expressed by the rns, regardless of where they worked, was a strong need for peer support in the workplace. the rns desired to have a formal peer support system, because the personal nature of their practices exposed them to joys and sorrows shared with their patients, and these emotional aspects of their jobs often weighed heavily on their minds. formal peer support systems were highly valued, but were generally not present in any employment setting, regardless of where they worked. because of the confidential nature of caring for patients, the rns were unable to decompress with family and friends. thus, the rns were generally not able to find the emotional support needed to meet their needs. along with feeling less connected to coworkers, the rns also felt less connected to their work environments and employment settings, leading to feeling a lower sense of obligation to their online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 245 employer. some valued the actual distance between work and home, feeling less guilty to decline when they were asked to work extra shifts. in eight hours, i’m there and gone. . . . i could walk away. . . . the big thing is i can leave after eight hours, and i don’t even think about it. i don’t think about that place. i walk out the door and that’s it. where i never did that [working in home community]. considering the commuting away experience, rns worried less about work when they were not working. lastly, rns also felt less connected to their home communities, as a whole, after they commuted for employment. some expressed that this change in connection was a relief, as one rn noted: [commuting away] kind of removes you from the community you live in. because when i come home, i’m just busy doing my stuff, and i don’t find myself getting involved hardly at all in the community. so i’ve kind of lost contact with certain things. so kind of like, i don’t really fit anywhere . . . i come home and we watch tv, i go to bed, and i repeat the same thing. it’s like i don’t have a community . . . so life is much easier i think.” conversely, other rns longed for the connections to their home communities that they no longer had. i can certainly think of a lot of disadvantages [to commuting for employment]. one of them is . . . that social disconnect with the people in my own community. that is a very real thing for me.. . . . i used to be invested in this community and i no longer am. . . . every small community probably has cliques of people and i am no longer in it. . . . back in the early days of my life . . . i knew every single person. . . . i grew up here. . . . that would not be the case anymore. i would not know anybody up on main street, nor would i feel connected to them. very different . . . i’m not invested here and i never had been invested in the community where i worked. . . . i never participated in any community events. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 246 in reality, descriptions of the rns experiences encompassing the phenomenon of commuting away show a blending of experiences throughout all of the constituents, rather than a demarcation of experiences within each constituent. this blending of experiences together creates a sum of the parts of data that are, in the end, greater than the whole of the data (dahlberg et al., 2008). discussion the rural rns in this study found importance and respect in being a nurse in a rural community. however, they were unable to meet some of their personal and professional goals, and this led to them commuting for employment in larger communities away from their rural, home communities. this, in turn, led to different professional connections with patients, coworkers, employers, and their home community at large. being a nurse in a rural community was important to every rn, regardless if they were a new member of their rural, home community, or had been a life-long member of the community. many of the findings within this constituent are supported by the rural nursing theory (long & weinert, 1989), including the crossing of personal and professional boundaries, the lack of anonymity/high visibility of rural rns, and the generalist role of nurses. a lack of anonymity in rural work settings was identified as a factor that precedes job dissatisfaction (roberge, 2009). in this current study, “the blurring of professional boundaries and the lack of privacy in rural communities, with everybody knowing everybody, led to decreased satisfaction in some of the nurse’s personal and professional lives” (johansen, 2017, p. 190-191), and motivated them to seek employment elsewhere. the blending of personal and professional boundaries led to anxiety for some rns, as they feared caring for their family and friends. these findings are consistent with other studies of rural nurses (malone, 2012; roberge, 2009; scharff, 2013). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 247 in an ethnographic study describing the type and scope of nursing for rural nurse generalists in 1987, scharff (2013) found that nurses believed their familiarity with the people they cared for improved patient outcomes. additionally, scharff (2013) reported strong connections between rural coworkers, finding the rural nurse to have a personal familiarity with all the workers in the rural employment setting, creating the potential for deeper connections to coworkers, which were unique to rural settings. in this current study, connections to rural coworkers were found to be rewarding, but sometimes created challenges regarding feelings of obligations between coworkers and employers. nurses chose to live in their rural, home communities for many reasons. some of their personal and professional goals were not attainable through the employment opportunities in those communities. the personal and professional goals, and/or combination of goals that led to their decisions to commute to a larger community, were largely varied, and no specific goal was identified as the single factor that led to the rns’ employment decisions. for some, employment benefits, including better health insurance, higher wages, desirable work hours, technology resources, and increased job stability, were factors that contributed to the rns’ decision to commute for employment. using the nssrn data, skillman et al. (2012) found that salary gaps between non-rural and rural healthcare settings have dramatically increased over time. in 2004, wages for nurses working in more urban areas were approximately 22% more than rural areas (skillman et al., 2007). the imerman, orazem, sikdar, and russell project from the iowa state university revealed the iowa rn licensing database found similar salary gaps for years 1994 – 2005 (as cited in johansen, 2017). thus, it has been largely assumed that wages are the driving force among nurses who choose to commute to larger healthcare settings for employment. however, it is important to note that in the current study, wages were not the driving force for all online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 248 the rns. in the current study, while some rns did seek and attain employment with higher wages, others reported that their wages did not increase, and in some cases, their wages even decreased. thus, the assumption that wages are the driving force for why rural nurses leave their home communities for employment elsewhere, was not found to be true in this study for three midwestern states; a finding that has been supported by a few earlier studies (kovner, brewer, wu, cheng, & suzuki, 2006; molanari, jaiswal, & hollinger-forrest, 2011). beyond personal goals for wages and other employment benefits, the rns also had a desire to meet professional goals. professional development opportunities were valued, and rns perceived a greater availability of these opportunities in larger healthcare settings. stewart el al. (2011) researched factors that are predictive of retention issues for nurses in rural healthcare settings and found that desires for advancements in professional careers were predictive of nurses seeking other job opportunities. the findings from this current study support this. nurses in the current study also sought specialized nursing practice opportunities outside of their rural, home communities, as well as means to advance their careers. some rns in this study perceived that the only specialty practice available in rural areas was gerontological nursing, and they specifically desired other specialty nursing opportunities. some clinical areas of practice have been found to have more popularity than others, among nurses as a whole. work environments that are considered dynamic, lifesaving, and highly technical have been found to be preferred, while opportunities to care for mentally ill, or older adult patients, being less desired (wilkinson, neville, huntington & watson, 2016). fewer opportunities for nurses to practice in specialty nursing positions in rural settings have created challenges in retaining nurses in rural healthcare settings (stewart et al., 2011). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 249 the perceived inability to meet some of their personal and professional goals in their rural, home communities led these rns to commute to employment some distance from their homes. commuting for employment is not an uncommon practice among rural nurses. one study found that just over 10% of nurses living in primarily small towns and rural areas outside metropolitan areas traveled at least 50 minutes one way for employment (rosenberg, corcoran, kovner, & brewer, 2011). the rns in this study were somewhat under that average, as they commuted 30 miles one way, on average (although some did commute 50+ miles each way). in the current study, rns voiced appreciation for the downtime while commuting, as it allowed them to decompress and spend time in self-reflection. however, in a study about mind wandering, monotonous driving was found to negatively impact a driver’s performance, especially with the repeated task of driving the same route, unaccompanied, while the driver focused on reflections and inner thoughts that could lead to distracted driving (berthié et al., 2015). such driving practices were found to influence driver safety and the potential for motor vehicle accidents. it is of concern that none of the rns in the current study indicated any awareness of the personal safety risks associated with this kind of distraction while commuting. there is a need to educate nurses who commute for employment about the dangers associated with distracted driving, in the form of a focus on self-reflection and decompression from their previous shift work experiences, and teach them about the importance of and strategies for mindful driving. as a consequence of commuting to employment outside their home communities, rns felt less connected to their work settings, coworkers, and patients, and some reported having diminished feelings of obligation to their employers. this finding is supported by medves, edge, bisonette, and stansfield (2015) in their study of rural ontario nurses. it should be noted that feelings of obligation and feelings of commitment are two different things. a literature review of online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 250 nurse’s employment intentions found that intention to continue employment at a worksite was increased with a relationship that created a sense of dedication and commitment (cowden & cummings, 2012). however, achieving work-life balance has been found to be important among nurses, with appreciation for the ability to feel free from work activities and feelings of obligation on their non-work days (jamieson, kirk, & andrew, 2013). castaneda and scanlan’s (2014) literature review, examining job satisfaction among nurses, found that the social and professional relationships nurses experience in work settings were important to job satisfaction. in fact, social relationships were often a top predictor of nurse’s satisfaction with their jobs. rural employers can strive to foster relationships that nurture nurses’ feelings of dedication and job satisfaction but should not align those feelings with feelings of obligation that can lead to dissatisfaction with employment. in this current study, the rns also felt more disconnected to their home communities after they experienced commuting for employment. nurses had fewer contacts with community members at home, as they spent less time in those communities. richards, farmer, and selvaraj (2005) found similar experiences while researching the retention of healthcare workers from rural communities who commuted. in this current study, rns had varying feelings about the loss of connections to their rural communities. understanding these feelings is important to increase awareness of factors influencing employment decision making. limitations the current study has a number of limitations that need to be recognized. the sample included nurses from a small geographic area in the midwest united states, and lacked racial diversity. additionally, while all of the rns were commuting away from their rural, home communities for employment, many were still working in other rural communities, whether small online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 251 rural or large rural, as defined by ruca codes. only 25% of the rns commuted to urban communities of 49,999 or more people. thus, the experiences of rural nurses who commute to only urban settings may not be fully represented in this study. additional studies with more diverse populations, different geographic rural locations beyond the midwest united states, and with those who only commute to urban employment settings are warranted to determine if the meaning of commuting away is consistent across populations of rural nurses. implications the findings from this study have implications for nursing practice in rural settings and educating nurses about rural employment. results will inform rural healthcare employers about recruitment and retention strategies, as well as implications for future policy development and research. nursing practice the roles of rural rns need to be acknowledged, recognizing the wide knowledge base and level of expertise needed to provide quality healthcare to rural residents. the public commonly does not understand the complexities and responsibilities of the profession of nursing (brewer, zayas, kahn, & sienkiewicz, 2006). it is imperative that, among the profession of nursing, perceptions that rural nurses are less skilled, or less useful, must change to acknowledge their value as professional nurses. rural nursing requires specialized knowledge and skills, and thus, should be considered a specialized practice. perhaps if rural nurses were recognized for this specialized practice, among their peers and the public at large, they would feel less need to seek other types of specialization. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 252 employers of nurses in rural settings the findings from this study can help inform the recruitment and retention efforts of rural healthcare facilities. the general assumption that wages are the primary driving force for rural nurses to seek employment in larger healthcare settings was not substantiated in this study. rather, there were multiple and varied personal and professional goals that were unmet by the employment options in the nurses’ rural, home communities. unique, individualized strategies for the recruitment and retention of nurses in rural healthcare settings should be developed to benefit not only employers of rural nurses, but also the rural population they serve. this current study found that rns’ goals, both personal and professional, were multifaceted. the one-size fits all strategy to recruit and retain nurses in rural healthcare settings will not be efficient or effective. employers of rural nurses need to recognize and support the diverse and complex roles required of their nurses. assessing the comfort levels of nurses, presently employed or being recruited, with the expert generalist rural nurse role, along with the nurse’s connections to patients and community members, could lead to the creation of individually tailored resources for these nurses. by understanding nurse’s needs, comfort levels, and goals, individualized support systems and resources could benefit both the nurses as well as their patients. mentorship programs based on the nurse’s previous exposures to and comfort with rural nursing, along with orientation programs specifically focusing on the creative, and flexible, roles of rural nurses, can help meet the needs of nurses new to the rural healthcare environments. although job satisfaction was not the focus of this study, the complexities of job satisfaction for nurses practicing in rural healthcare settings should be considered in relation to the findings. the herzberg motivation-hygiene theory identifies both motivational factors, and factors that cause dissatisfaction, for employees at work. herzberg found that factors that truly motivated online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 253 people at work were different from factors that led to job dissatisfaction. motivating factors lead to satisfaction and were associated with people’s capability to achieve psychological growth: responsibility, recognition of accomplishments, advancement, and the actual work accomplished. factors leading to dissatisfaction, called hygiene factors, included items such as wages, work conditions, status at work, policies, supervision, and relationships at work (herzberg, 1968). satisfaction and dissatisfaction are not opposites. rather, the opposite of dissatisfaction would be “no job dissatisfaction.” frequently, employment strategies focus on hygiene factors, which can lead to less dissatisfaction. however, herzberg purports that less dissatisfaction is generally temporary, and does not mean there is job satisfaction. motivating factors can create long-term satisfaction by creating a feeling of worth and fulfillment for employees (herzberg, 1968). the herzberg motivational hygiene theory can explain some of factors that caused the nurses to seek employment outside of their home communities. nurses sought work place motivators, such as advancement and growth opportunities, not available in their home communities, in order to achieve a higher level of job satisfaction. hygiene factors were present in their desires for employment benefits and work conditions that they perceived as better than those available to them in their home communities, leading to less dissatisfaction once they commuted. following herzberg’s theory, there were motivating factors that led to job satisfaction, helping explain why hygiene factors, such as wages, were not as notable in the employment decisions for all nurses. hence, motivators need to be prioritized, but both motivators and hygiene factors need to be considered in recruitment and retention strategies for rural healthcare employers to create a balance of motivation and the prevention of dissatisfaction. providing motivating factors for nurses to meet their desires for both advancement and specialization opportunities is key to the successful retention of rural nurses. with rural nurses online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 254 wearing “many hats,” spreading out the “many hats” could create advancement positions for more nurses, increasing their motivation and satisfaction. additionally, specialty knowledge that nurses bring with them from practices in larger healthcare settings could be acknowledged and integrated in the nurse’s roles as rural specialty experts. these nurses could be called upon to utilize their expertise through telehealth mechanisms, or clinical opportunities. for example, perhaps a rural nurse expresses a desire for specialization in obstetrics (ob), but the rural hospital only infrequently does deliveries. these nurses could be offered an opportunity to receive a paid, mentored experience with a nurse at an ob unit of a more urban facility. that nurse could then return to their home community and be a designated ob nurse specialists who responds to and cares for newly admitted ob patients. striving to decrease employee job dissatisfaction, employers need to be attentive to the benefits being offered to their employees. even though wages were not found to be a key to all nurse’s employment decisions, nurses do need to feel a sense of fairness and equity surrounding wage and benefit packages (kovner et al., 2006). rural nurse desires to prevent work schedules from interfering with their personal lives needs to be a consideration. flexible self-scheduling has been found to decrease nurse dissatisfaction with their jobs (leineweber et al., 2016). for healthcare facilities that do not currently have flexible scheduling options, such interventions may be an effective recruitment and retention strategy. connections between nurses and their rural, home communities need to be considered by healthcare employers. understanding the desires for some nurses to feel connected to their communities, with others desiring just the opposite, should lead to individualized employment strategies. for those nurses desiring to be connected to their communities, creating opportunities for the nurse to represent the healthcare facility in community projects may be beneficial. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 255 understanding the lack of boundaries between nurses and their rural community members could also lead to educational interventions at the community level that could decrease the nurse’s concerns about lack of anonymity in the rural communities. an example could be to provide nurses with interpersonal communication training specific to compliance with confidentiality standards, helping provide strategies to nurses when they are approached by community members about confidential matters. community members could also be invited to meetings hosted by the healthcare facility, where discussion about helping nurses to maintain a boundary between their personal and professional life could help to establish new social norms in relation to how rural community members interact with their nurses. the uniqueness of connections between nurses and their coworkers needs to be considered, since rural nurses have been found to have deeper connections to their coworkers when working in rural healthcare settings (scharff, 2013). even with the unique connections between nurses and their coworkers, the need for peer support surfaced in the current study, with a lack of emotional support available to the nurses inside and outside of their employment settings. rural healthcare facilities need to incorporate a healthy work/life balance for their healthcare providers, creating feelings of dedication and commitment, rather than feelings of obligation that can lead to dissatisfaction. creating informal peer support mentors, establishing formal end-of-shift debriefing sessions, and support hotlines could conceivably create an atmosphere of peer support. nurses in this study all experienced a sense of appreciation from feeling valued and respected by their rural community members. given that recognition for accomplishments and work done well was valued, rural employers can capitalize on the rural communities’ respect and trust for nurses in their communities, thereby increasing job satisfaction and potential for improved online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 256 retention. tailored recognition programs, such as monthly or quarterly awards for outstanding nursing practice, published in the local newspaper, could demonstrate this type of appreciation. nursing education the role academic institutions play in preparing nurses for future practice is instrumental in the future of the healthcare provided to rural populations. previous research has found that exposures to clinical opportunities in rural settings are necessary to prepare nurses for future nursing practice in rural settings (molanari et al., 2011). curricular content of nursing programs has been shown to influence the knowledge, skills, and attitudes of nurses. simulation has been effective component of nursing curriculum in producing learning opportunities that address reallife situations (norman, 2012). simulations should be designed to prepare nurses to care for family, friends, and neighbors in rural healthcare settings, and build communication skills needed to converse professionally during public interactions with rural community members (o’hagan et al., 2013). growth of confidence and interest in rural nursing practice may be enhanced with strategies such as simulation. nursing education programs should carefully consider how curricular content is presented to students, in order to avoid an urban bias. mccann, clark, and lu (2010) found nursing program emphasis on healthcare settings, focusing on technical skills and acute care, may coincidentally discourage future career choices of nurses caring for older adults. the future of nursing education should not only focus on acute care and highly technical specializations, but should also include rural clinical experiences, in order to make nursing positions caring for older adults, and rural nursing practice, more desirable. further, rural nursing practice needs to be conceptualized by nursing faculty as a specialized practice, with its own unique knowledge base and skill set, thus online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 257 elevating the perceived status of rural nursing, and perhaps making it more attractive to new graduates who are seeking to “specialize.” policy development state and federal governmental efforts have historically aimed to improve the recruitment of rural healthcare providers. loan repayment programs, and scholarships, were created to recruit healthcare providers to designated healthcare shortage areas, including rural areas. even though financial incentives have historically been part of recruitment packages for some rural healthcare professionals, there is limited evidence that such programs create long-term success (mbemba, gagnon, paré, & côté, 2013). following herzberg’s theory, recruitment and retention incentives should not only include financial incentives, but also motivating factors, such as professional growth and opportunities for advancement. with the inclusion of such strategies, an increased success with the recruitment and retention of rural nurses could be realized. national nurse credentialing agencies, such as the american nurses credentialing center, should expand their credentialing policies to offer certification in rural nursing, as a nursing specialization. research with limited research available specifically addressing rural nurse job satisfaction, further research is needed to understand factors that lead to rural nurse motivation, along with factors that dissatisfy, to create the most effective recruitment and retention strategies. the creation of a balance between strategies to empower motivation, and minimize dissatisfaction, could be guided by the development of an assessment tool which employers could use to assist in creating individualized strategies for rural nurse recruitment and retention strategies. tracking the current, and projected, commuter trends for rural nurses, such as previously possible with the nssrn, would benefit rural healthcare facilities and the rural population they online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 258 serve by understanding how effective recruitment and retention strategies work. an important safety issue identified in this study was the possible distracted driving that may be occurring with rural nurses who commute, while they are engaged in self-reflection and decompression on their drive home. additional research is needed to identify the prevalence of motor vehicle accidents among nurses who commute significant distances and examine the potential association between distracted driving because of decompression from work, and motor vehicle crashes. some rns in the current study also noted that they experienced a lack of alertness on the drive to their work setting, and that lack of alertness sometimes continued into their work. the potential exists for patient safety to be influenced by nurses who commute. research should be conducted to determine if there is any association between commuting and risks to patient safety, because of lack of alertness. conclusion to achieve health equity for the rural population throughout the united states, actions need to address access to healthcare. the gap in knowledge surrounding rns commuting away from rural communities for employment in larger healthcare settings needs to be better understood. the results of this study are critical to future effective recruitment and retention strategies for rural healthcare facilities and for the health of the rural population served. understanding the experiences of nurses living in rural communities, who commute to larger communities for employment outside of their rural, home communities, takes us beyond previous assumptions that wages are a driving factor leading to employment decision of these nurses. rural nurses’ decisions about where to work are multifaceted. creating appropriate, individualized strategies, recognizing, and promoting rural nursing as a specialized practice, could lead to increased numbers of nurses practicing in rural areas. the end result can be the reduction or online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.540 259 elimination of serious rn scarcity within rural communities. this can help rural populations achieve health equity through access to comprehensive and quality healthcare, including an adequate number of rns. supporting agencies this research was supported in part by a grant from sigma theta tau international, phi chapter. references berthié, g., lemercier, c., paubel, p., cour, m., fort, a., galéra, c., . . . maury, b. 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(2016). factors that influence new graduates preferences for specialty areas. nursing praxis in new zealand, 32(1), 8 19. promoting heart health in rural women is a research study funded by the national institute of health 22 strategies to reduce barriers to recruitment and participation margaret pribulick, rn, ms, phd1* ishan canty willams, phd2 pamela stewart fahs, rn, dsn3 1clinical instructor, decker school of nursing, binghamton university, mag419_78@hotmail.com 2research assistant professor, school of nursing, university of virginia, icw8t@eservices.virginia.edu 3professor and decker chair in rural nursing, decker school of nursing, binghamton university, psfahs@binghamton.edu *contact author précis barriers to subject recruitment and participation are explored and solutions used in a phase-ii, nurse-run intervention study are presented. abstract purpose to identify barriers encountered and solutions employed to improve research recruitment and retention of rural subjects for participation in the promoting heart health in rural women (phh) study. methods this article provides an examination of experiences encountered by nurse researchers in recruiting rural women from two locations to a randomized, controlled trial. problem solving through broadening recruitment areas and inclusion criteria, community liaison assistance, identification of ruralspecific strategies in the literature, and perseverance helped to overcome barriers to subject recruitment and retention in this rural phase-ii nurse-run intervention study. clinical relevance research studies need to be conducted in order to build a body of evidence for nursing interventions to reduce cardiovascular disease risk factors in rural women. a study is strengthened by a robust sample that provides power to statistical analysis. without discussion of realworld experiences and appropriate and effective recruitment and retention strategies in nursing research, there is little chance of conducting research with appropriate power to build evidence-based practice. introduction the purpose of this article is to address barriers encountered and strategies used to improve rural research recruitment and participation in the promoting heart health in rural women (phh) study. an essential aspect of research is recruitment. for research to be successful, it is necessary to obtain a sample size appropriate for the design and in large enough numbers to provide adequate power for the study findings to protect against errors in hypothesis testing. sampling for the phh study took place in two locations: a rural county in upstate new york (ny) and one in central virginia (va). using rural urban continuum codes (rucc), both counties scored a 6 on the scale of 1-9 (united states department of agriculture, economic research service [usda, ers], 2004). the rucc system is county based with levels 1-3 indicating metropolitan and levels 4-9 for nonmetropolitan counties (bigbee & lind, 2007). both counties in this study were classified as rural and were chosen based on contacts already established from previous studies. the va site was also chosen in hopes of obtaining a sample representative of african american rural women as approximately 12% of that county is african online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://www2.binghamton.edu/dson/ mailto:mag419_78@hotmail.com mailto:mag419_78@hotmail.com http://www.nursing.virginia.edu/ mailto:icw8t@eservices.virginia.edu http://www2.binghamton.edu/dson/ mailto:psfahs@binghamton.edu 23 american, compared to only 1.4% in the ny rural county. in 2003 cardiovascular disease (cvd) was reported as 44.7% among black females and 32.4% for white females of the total 33.9% total female prevalence (american heart association [aha], 2007), yet black females are often underrepresented in studies of cvd. barriers to participation in research have been reviewed in order to better understand the perspective of an individual’s participation. of specific interest were recruitment of women and ethnic subpopulations, such as african american women that are underrepresented in rural research. understanding the barriers to research study recruitment and participation within a population can assist the researcher in developing tailored recruitment strategies. though recruiting a sample of participants is cumbersome and time consuming, by understanding the population’s barriers to participation in research and carefully planning recruitment efforts, costly obstacles may be circumvented. recruitment and barrier—the literature in reviewing two well-known nursing research textbooks, the discussion of recruiting and retaining subjects is limited to two to three pages (burns & grove, 2005; polit & beck, 2008). textbooks generally incorporate recruitment into a chapter on sampling. searching an online database, however, can produce a plethora of articles on the topic of recruitment. although there is common ground in recruitment and barriers to participation in research, cultural differences may also be a recruitment challenge. dibartolo and mccrone (2003) studied recruitment and barriers to research participation among rural community-dwelling older adults. obvious barriers within this age group are physical and mental changes along with an increase in chronic disease, which dibartolo and mccrone place in two categories: health-related barriers and social barriers. one social barrier seen in rural research is mistrust of outsiders, thus the inclusion of those who are insiders in the community such as health care providers (dibartolo & mccrone) and community-based organizations or involved community members (fahs, findholt, & daniel, 2003) can help in overcoming this barrier to study recruitment. morgan, fahs, & klesh (2005) in a study of 865 randomly chosen rural subjects in upstate ny found that the presence of an illness increased one’s willingness to participate in research, but a hypothetical fatal illness was most often a barrier. other barriers were inconvenience of times or sites for joining a study as well as having to drive more than 30 miles. trust barriers included not knowing the researchers, not knowing others in the study, and not trusting the researchers. however, nurses were identified as a group as trust worthy to conduct research. rural-specific barriers in the morgan et al. study were transportation, work-related, and outsider issues. another study focused on the recruitment of black americans as subjects (brown, 2004a). the recruitment process was qualitatively recorded and was preliminary to the parent study of everyday life for black american adults (brown, 2004b). seven weeks of intensive activities including the distribution of fliers, announcements, seeking referrals, newspaper and internet advertisement were spent in a community recruiting black americans via festivals, community agencies, beauty shops, churches, and senior centers (brown, 2004a). recruitment for this study (brown, 2004b) was attainable demonstrating that black americans were interested in participating in research. the brown (2004b) study included a one-time measurement of blood pressure with the administration of three questionnaires on site. study participation burden was limited to a one-time, on-site data collection without intervention. distance, time, and cost issues online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 24 often influence the intensity of recruitment efforts and study participation burden in rural areas. study participation burden may influence both subject recruitment and retention. linden and colleagues (2007) undertook focus groups with 58 african american women who discussed attitudes toward participation in breast cancer clinical trials. the researchers reported on themes regarding african american women’s concerns about participating in research studies. these women suggested factors that may exclude research participation include: a mistrust of research, “the system” including funding of research, and reliance on religion and god for healing (linden et al.). these researchers had 100% attendance rate for all focus groups, and 80% were at least open to the idea of participating in a hypothetical randomized trial. the study recruitment and focus group sites were located in area african american churches to increase participation convenience for the subjects. this study further suggests that researchers be aware of their own biases and prejudices concerning access to participation and willingness of subjects to participate in research. linden et al. suggest continuously educating the community throughout the duration of the study, reducing logistic barriers to participation, and avoiding prejudice by offering equal treatment options to subjects regardless of race. further information may be warranted to ensure informed consent due to potential misunderstanding of the concept of randomization. this study supports the idea that african american women are willing to participate in research, although barriers do exist. the study included only urban-dwelling african american women. schutta and burnett (2000) also explored participation in a cancer clinical trial for both genders. participation in this study, as in several other oncological studies, was driven by hope for a cure, despite information on the purposes of a phase-i clinical trial which included safe dosing and exploration of potential toxicities, not cures. jones et al. (2006) also believe there is poor understanding of clinical trials, the process of randomization, and distrust of research and researchers among potential subjects. their triangulation study focused on what patients knew about clinical trials, if they ever participated in a clinical trial, and reasons and willingness for or against participation. one hundred patients out of 141 approached at a clinic agreed to complete a survey of 11 quantitative and two qualitative questions. barriers to participation were identified as uncertainty about trials and unwillingness to increase personal risk, standard treatment was working well or treatment would be delayed, possibility of getting a placebo, and unwillingness to endure future tests. interestingly, those people who were younger or more educated were less likely to participate in clinical trials. mann, hoke, and williams (2005) presented an overview of five pilot studies they conducted among rural mexican american women. mann et al. addressed several issues ranging from appropriate compensation to setting time boundaries and noted “…the extensive time, expense, and effort required to conduct research with a rural population experiencing health disparities” (p. 141). issues of recruitment and participation are problematic in research studies regardless of setting. rural recruitment often requires drawing a large number of people from a smaller subset of the population, thus making it more difficult to recruit needed numbers and loss of participants can reduce power of the study. it is essential to have effective recruitment strategies and to maintain subject retention to have meaningful research that can be generalized to the rural population. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 25 promoting heart health statistics from the american heart association (aha, 2007) and center for disease control and prevention (center for disease control [cdc], 2007) show that cardiovascular disease among women is the number one cause of mortality. promoting heart health was a phase-ii study. phase-ii studies may be done to “ascertain the feasibility of launching a more rigorous test…” (polit & beck, 2008, p. 313) and may be used as a pilot study for future clinical trials. a phase-ii study allows the researcher flexibility to refine areas of the process that are not effective or working as efficiently as desired. one advantage of a phase-ii intervention study is that changes can be made since finding the problems and problem solving is one of the reasons for conducting this level of research. therefore, the researchers of the phh study had the ability to address unforeseen barriers to recruitment; however, each protocol change needed to be approved by the funding agency and the appropriate institutional review board (irb) involved. in this study, the protocol was approved through the binghamton university human subjects research review committee (hsrrc) protocol 259-05 and the university of virginia institutional review board for health sciences research (irb-hsr) protocol 12415. polit and beck (2008) believe that researcher’s sampling plans are frequently the weakest portion of the study. promoting heart health began by completing a power analysis based on repeated measures on two groups with an alpha of .05, effect size of .30, and power of .80. this calculation showed a minimum number of 80 subjects in each group (n=160). a sample size of 176 participants was selected to guard the power of the study against attrition. the initial design included two enrollment periods: one before a planned community intervention and one following the community intervention. figure 1. original enrollment design. all subjects were to receive the community intervention. half of the sample was to receive the stage matched nursing and community intervention (smnci) which was to include four nurse visits, half of the experimental group were scheduled to get the nurse visits prior to the community intervention (ci) and the other half, after the ci. after several months of recruitment screenings, it became clear the needed sample size was unattainable using a two-enrollment period model within the projected time frame and cost constraints of the grant funding. consequently, a rolling enrollment strategy was used, and the design of the study was changed to look simply at the effect of smnci versus ci only, on outcome variables as opposed to looking at a combination of effect and time with a repeated measures analysis. a recalculation of the power analysis was conducted which projected a power of .80, but with a reduced target sample of n = 128. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 26 in this study, a thorough cardiovascular screening was used for two purposes: 1) as a participant recruitment tool as suggested by mann et al. (2005) and 2) to provide a service to the rural communities where the research was conducted. screening procedures for the phh included blood pressure, height, weight, waist circumference, nonfasting finger stick total and high-density lipids cholesterol, and an electrocardiogram (ecg). the screenings were offered at no charge and initially advertised as open to women, with no history of diabetes or known heart disease, between 45 and 65 years of age. the costs of the screening for this study was supported through separate funding, that allowed us to offer the screening to women beyond those who strictly met the study inclusion criteria. for example, two of those screened were less than 35 years of age and nine were older than 66 years old. as part of the effort to build trust within the community of interest, the research team did not turn women away from the screening. screened  274 not eligible 81 (29.6%) randomized 167 (60.9%) smnci 85 (50.9%) no initial  questionnaire/labs  7 smnci  74 completed study 60 noncompletion 14 ecg  not released 4 ci 82 (49.1%) ecg  not released 2 no initial  questionnaire/labs  6 ci  74 completed study 57 reenrolled smnci 15 noncompletion 17 eligible, not  enrolled 26 (9.5%) figure 2. promoting heart health screening, enrollment, attrition and completion data figure 2 shows those screened and their disposition through randomization if eligible as well as those completing the study (n = 117) or 79% of those actually receiving an intervention. one of the challenges in setting inclusion and exclusion criteria is creating criteria that are tight online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 27 enough to control extraneous variables, but not so tight that the sample is not representative of the population to which the findings are to be applied. the initial criteria were identified as problematic early in the screening process. the initial exclusion and revised exclusion criteria (table 1) were set based on the literature and interest in a target population of african american and caucasian, rural, women with up to moderate cvd risks. table 1. initial and revised inclusion criteria variable initial inclusion revised inclusion age 45-65 years 35-65 years gender female location rural (≥3 rucc) ecg normal normal or abnormal with release by cardiologist blood pressure ≤160/90 total cholesterol ≤240 ≤240 or release by cardiologist bmi ≤40 ≤40 or release by cardiologist pulse pressure ≥60 mmhg framingham chdrs ≥20% behavioral change need 1 or more of 3 areas: diet, physical activity, or smoking personal health history no diabetes, heart disease or stroke. enrollment through the initial screenings was more limited than anticipated as many women in this age range, particularly the upper limits of 55-65 years of age, had too high a framingham coronary heart disease risk score (chdrs) (>20 points), which was above the moderate risk level targeted in this study, had a history of diabetes, or had an abnormal ecg. originally, any abnormality in the ecg was considered exclusion criteria. approximately 25% of the ecgs had some type of abnormality which would exclude the very women the study sought as the target population. because there is a paucity of statistical data in the literature concerning the number of abnormal ecgs in women and nothing on abnormal ecgs in rural women, this serendipitous finding warrants further analysis. although the researchers found more abnormal ecgs than expected, often the ecg changes were minor in nature. a modification to both irbs allowed a review of abnormal ecg by a cardiologist who functioned as an unpaid consultant for the study. those subjects with minor ecg changes were allowed to participate. those women who had ecg changes that the cardiologist felt merited further medical evaluation were told of this review and follow-up evaluations were strongly encouraged, but they were not allowed to participate in the study. if they had been enrolled prior to review of ecg, they were administratively withdrawn. women were also administratively withdrawn for failing to complete the first questionnaire and fasting blood work, which was needed prior to intervention (n = 13). online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 28 originally, the finger stick screening, non-fasting total cholesterol of ≥ 240 mg/dl was identified as an exclusion criterion. review of the fasting blood work after entry into the study revealed 24 women whose total cholesterol was now > 240 mg/dl, indicating the fasting cholesterol was a more sensitive measure than nonfasting cholesterol levels. twenty-three women had a screening bmi of 40 or higher. obesity is not a factor used in calculating the framingham coronary heart disease risk score. one woman with a bmi of >70 was excluded due to an abnormal ecg that needed further medical evaluation. twelve women were excluded from consideration for the study based on the original exclusion criteria and 10 women with a bmi >40 were randomized into group after irb modification. the ecg, blood pressure, cholesterol, and weight data were reviewed by the cardiologist as needed. modifications approved by both irbs included change in the age range, allowance for inclusion after review of abnormal ecg, elevated cholesterol, or bmi by a cardiologist (table 1). while the aha suggests adults 20 years of age or older establish baseline cholesterol, bmi, and blood pressure, our data supports that at the age of 55, a woman’s risk of a heart attack increases (community memorial hospital, 2000). beginning april 2006, approximately 274 women were screened for possible participation in the phh study. of these, 193 were found to be eligible for the study based on screening data, 26 chose not to enroll, and 167 were randomized to group. eighty-one (29.6%) women were immediately identified as non-eligible. with the revision of protocol, the screening and initial lab data for those with an abnormal ekg or cholesterol >240 were reviewed by the study cardiologist. after review, an additional six subjects--four from the smnci and two from the ci group--were administratively withdrawn from the study. another 13 subjects were administratively withdrawn when they did not return the day after the screening for fasting blood work or submit an initial questionnaire. final exclusion criteria included abnormal ecg or cholesterol >240mg/dl not cleared by a cardiologist, diabetes, history of a myocardial infarction (mi) or stroke, framingham scores of >20 %, or no need of behavioral change. eleven women were excluded because of an abnormal ecg not cleared by the study cardiologist. nine women had a framingham chdrs >20% and were also excluded from participation; only two women had no identifiable need for behavioral change in the areas of diet, physical activity, or smoking cessation. thus, 148 women began the study after being randomized to group, smnci (n = 74) and ci (n = 74). a total of 117 of the initially randomized women finished the study with final lab work drawn 14 months after entry. thirty-one did not complete the study (21%), i.e. 14 from the smnci group and 17 from the ci group. the most frequently cited reasons for dropping out of the study was being too busy (n = 8) and felt the study was not helping (n = 4). with permission from the irb and funding agency, ny state women who had originally been randomized to the ci group and completed the study were offered the opportunity to reenroll for future analysis. from the group that completed the ci, 16 were reenrolled and received nurse visits. this data will be used to analyze specific aim 5 regarding order of intervention at a later date. barriers and solutions every study has specific circumstances that need to be addressed before entering into the recruitment phase. in developing the promoting heart health study, recruitment of rural women was strategically planned yet recruitment and retention for the phh study to reduce cvd risk online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 29 factors in rural women was a relentless task where seeking solutions to barriers was a critical issue. long and weinert (1989) cited concepts such as isolation and distance, insider/outsider, health beliefs including health as the ability to work, self-reliance, and independence as factors in how rural dwellers assess the need for and access health care. morgan et al. (2005) related how some of these rural concepts influence participation in research. transportation in rural areas is often a concern and potential problems may be solved by using informal networks, although this is not always a reliable solution. several of these concepts were apparent to the phh researchers during study recruitment and subject retention. rural women are often self-reliant in meeting their needs. for example a ny participant rode her bike seven miles after milking cows in order to have her fasting blood work drawn for this study. another issue of transportation that arose was the unprecedented rise in the cost of gasoline during the study. at one point, gas prices climbed slightly over $4.00 a gallon in rural ny. the study did offer to transport women to the data collection site for final lab work or reimburse them for the cost of transportation. this strategy, although not frequently requested, may have limited further attrition as women were finishing the study. placing data collection sites in rural communities rather than having subjects commute to urban areas was helpful in recruiting and retaining subjects, since it limited issues of distance and minimized transportation issues for the subjects. distance and isolation not only do the issues of distance and isolation influence the participation of subjects, but these same concepts can influence the efforts and cost of recruiting rural subjects. to reach rural recruitment sites, the study team traveled 4-16 hours, much of this on two lane roads. screening protocols required a large team of faculty and students with equipment these trips were complex and involved renting vans, planning for overnight stays in va, or consecutive very earlymorning to late-evening drives for the ny screenings. planning for trips was tightly scheduled and undertaken with consideration of students’ class and clinical schedules as well as participant’s lifestyles and community events such as health fairs. there are some barriers to recruitment and retention of subjects not discussed in textbooks. natural disasters can occur, regardless of location, without warning halting recruitment efforts and stalling participation while communities recover. rural areas are often slow recovering from these natural disasters where resources for recovery may be limited and focus on recovery is generally centered on the more urban areas affected. the first recruitment screening for phh took place in june of 2006 in delaware county, ny. late that month, the village where screenings occurred, along with several surrounding towns, received record flooding rains, destroying bridges, washing out portions of roads, and heavily damaging local businesses and homes. participants enrolled at this point were contacted and arrangements were made to delay their participation until they had made some dimension of recovery. this 100-year flood also delayed recruitment and reduced attendance at screening sessions for several months. in general, recruiting in rural areas requires a great deal of personal attention as there is not the large pool of potential subjects that is available in more urban centers, and additional care is needed when working in a community that has experienced a natural disaster. perceptions of research in rural communities during the study, education about the problem being studied, in this case, cardiovascular disease in women, is appropriate and may be used as a recruitment strategy. internet usage and online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 30 public awareness campaigns, whether for education or study recruitment may present distinctly different barriers for rural versus more urban areas. rural areas may lag in internet connection. also, public awareness campaigns may not reach rural areas with the same intensity that they do in more urban centers. public health departments (hd) may have lower funding levels and health messaging may be generated in more urban hd and pushed out to rural health districts. the phh study used multiple avenues as well as the availability of no-fee cardiovascular screenings and the opportunity to participate in the study to communicate the message about heart disease in rural women. radio interviews, public service announcements (psa), articles specific to heart disease written for local newspapers, as well as inserts in church bulletins were tools used. using multiple sources of information advertising the study and public screening events for recruitment are crucial in rural area. foresight in anticipating the various means of advertisement and planning for these potential channels of communication including advanced irb approval helps eliminate delays in advertisement and recruitment activities. although the recruitment strategies started in two specific locations, a primarily african american church in va and a critical access hospital in ny, the recruitment plan was broadened in scope and distance to improve recruitment. offering the screening and study enrollment to county employees in both areas and school district employees in ny helped enrollment. other worksite screenings could help improve enrollments but need to be planned with the employee’s scheduling constraints in mind. literature supports that utilizing community liaisons or key informants reduces barriers to participation (burns & grove, 2005). the promoting heart heath team was able to connect with a church in va that held an annual health fair for their community. the research team had previously completed a small descriptive study at this church’s annual health fair. the church health outreach coordinator and health fair organizer served as a community liaison for the study and worked closely with the phh team to present the study to the church leaders and members. providing cardiovascular health screenings broadened the scope of the church health fair while providing a sampling frame of predominantly african american rural women for phh; however, after attending two fairs, the available targeted population had been screened. attempts were made to establish contact with other african american churches in the area for recruitment, but were not successful. more lead time to work with other churches would have been helpful. a second community liaison approached the team after hearing about the project at a research conference. this liaison lived in the area and had many contacts at the community level. she was able to provide support and assistance as phh widened its recruitment strategies and area to the general population of rural women within a one-and-half-hour travel radius of orange county va. the change in recruitment venues and geographic location to include surrounding rural counties also required a protocol change from the appropriate irb. promoting heart health used similar recruitment techniques as brown’s (2004a) study previously discussed; however, time spent in each community in the phh study was limited to no more than two-three days for each recruitment trip. six recruitment trips were made to va and six to ny over a two-year period of time. brown (2004a) describes a community immersion of seven weeks for recruitment into a study. the brown (2004b) study used two blood pressure measures and three questionnaires in a one-time data collection without intervention. promoting heart health used a screening process that generally took at least an hour to complete which included blood pressure, height and weight, bmi, finger stick cholesterol, framingham scale, and ecg. each woman spoke with a researcher, trained in providing informed consent, and, if they agreed to participate, they were asked to return the next day for fasting blood draws with the online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 31 completed first questionnaire. study enrollment was for 14 months. the phh study required more time and effort for both the screening and participation than did the brown (2004b) study; however, the phh screenings provided the community and individuals with a more in-depth cvd risk assessment than that conducted by brown (2004b). efforts were made to accommodate participants to reduce barriers to both study recruitment and retention. for example, screenings were scheduled on weekends unless it was a work site screening which was scheduled during the work week. once enrolled, subjects in the intervention group were offered a choice of where the nurse visits should take place: their home, the work site during breaks, or some common place in the community such as the health department or local diner. this has worked well with many participants as it provided a defined time limit for the visit that the subject could better control. this option also kept their home-life private and separate, if desired. the phh research team had developed a relationship with both rural communities prior to the study. in va, the ny team had supported previous health fairs at one of the primarily african american churches in the area. even so, it was anticipated that the ny team might be perceived as outsiders in rural va. in addition, all of the researchers on the ny team were caucasian, although our undergraduate student population is diverse and many of our african american student nurses were part of the research team, traveling to va and participating in the cardiovascular community screenings. promoting heart health was fortunate to have three uva faculty members on the research team, one of whom was african american. enrollment of african american women (n = 14) and those completing the study (n = 9) remained lower than anticipated. conclusion rural recruitment can be successful, but often means more events or efforts to recruit subjects than would be needed in a more densely populated area. the pool of possible subjects in rural areas is more limited than those in larger population centers. a researcher may need to draw subjects from a wider and more geographically diverse area to recruit an adequate sample size reflective of the rural population of interest. thus barriers that occur but are not particularly related to rurality, including subject burden regarding time commitment, possible pain or discomfort with procedures, and issues of mistrust particularly within minority communities can be more burdensome in rural studies. barriers often recognized as issues in rural areas, such as distance, isolation, transportation, and insider / outsider status need to be addressed in a culturally appropriate manner. each barrier regarding recruitment and participation requires careful planning for possible solutions to conduct a rural study with an adequate sample size and to limit attrition, thus strengthening the science. acknowledgements the promoting heart health (pph) research team would like to acknowledge and thank our community liaisons and agencies that worked with us including the shady grove baptist church in orange, va; county governments of orange and madison county va; the public health nursing service of delaware county, ny; and delaware valley hospital, united health services, walton, ny; nicholas j. stamato, m.d., facc, cardiology associates, johnson city, online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 32 ny; the decker school of nursing; binghamton university faculty and nursing students and, most importantly, the women who participated in the screenings and the phh study. this article is written on behalf of the phh research team: pamela stewart fahs, theresa n. grabo, gary d. james, mary x. britten, alison m. dura, ann e. fronczek, yvonne a. m. johnston, donna m. morgan, mary ann nemcek, judith quaranta, elizabeth reese, gale a. spencer, frances m. srnka-debnar, margaret pribulick, elizabeth austin, and megan wood seymour, former undergraduates joanne brice, orlando harris, jahumi harrigan, and victoria nketiah as well as the over 50 students who participated in some aspect of this study from the decker school of nursing; binghamton university; elizabeth merwin, irma mahone, and ishan c. williams, university of virginia school of nursing; mary hamil parker, palliative and hospice training, inc. orange county, va.; phyllis highland, shady grove baptist church, orange, va. promoting heart health in rural women; funded by nih/ninr & nhbli; nih 1 r15nr009218-01a; january 2005-december 2008 to pamela stewart fahs, rn, dsn, principal investigator: subcontract university of virginia school of nursing, elizabeth merwin, rn, phd, co-principal investigator. references american heart association. (2007). facts about women and cardiovascular disease. retrieved october 8, 2007, from http://www.americanheart.org/presenter.jhtml?identifier=1200000 bigbee, j.l., & lind, b. (2007). methodological challenges in rural and frontier nursing research. applied nursing research, 20, 104-106. [medline] brown, d.j. (2004a). recruitment of black americans for research: a model of success. journal of multicultural nursing & health, 10(3), 19-23. brown, d.j. (2004b). everyday life for black american adults: stress, emotions, and blood pressure. western journal of nursing research, 26, 499-514. [medline] burns, n., & grove, s.k. (2005). the practice of nursing research: conduct, critique, and utilization (5th ed). st. louis: elsevier saunders. center for disease control and prevention (2007). women and heart disease fact sheet. retrieved october 8, 2007, from http://www.cdc.gov/dhdsp/library/fs_women_heart.htm community memorial hospital. 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(2007). attitudes toward participation in breast cancer randomized clinical trials in the african american community: a focus group study. cancer nursing, 30, 261-269. [medline] online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://www.americanheart.org/presenter.jhtml?identifier=1200000 http://www.ncbi.nlm.nih.gov/pubmed?term=17481476%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15359054%5buid%5d&cmd=detailssearch http://www.cdc.gov/dhdsp/library/fs_women_heart.htm http://cardiac.communitymemorial.com/agegender.htm http://www.ncbi.nlm.nih.gov/pubmed?term=12745386%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=11725939%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=17542716%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=17666974%5buid%5d&cmd=detailssearch 33 online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 long, k.a., & weinert, c. (1989). rural nursing: developing the theory base. scholarly inquiry for nursing practice, 3, 113-127. [medline] mann, a., hoke, m.m., & williams, j.c. (2005). lessons learned: research with rural mexicanamerican women. nursing outlook, 53, 141-146. [medline] morgan, l.l., fahs, p.s., & klesh, j. (2005). barriers to research participation identified by rural people. journal of agricultural safety and health 11, 407-414. [medline] polit, d.f., & beck, c.t. (2008). nursing research: generating and assessing evidence for nursing practice (8th ed.). philadelphia: lippincott williams & wilkins. schutta, k.m., & burnett, c.b. (2000). factors that influence a patient's decision to participate in a phase i cancer clinical trial. oncology nursing forum, 27, 1435-1438. [medline] united states department of agriculture, economic research service (2004). measuring rurality: rural-urban continuum codes. retrieved april 14, 2009, from http://www.ers.usda.gov/ briefing/rurality/ruralurbcon http://www.ncbi.nlm.nih.gov/pubmed?term=2772454%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15988451%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=16381161%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=11058975%5buid%5d&cmd=detailssearch http://www.ers.usda.gov/briefing/rurality/ruralurbcon http://www.ers.usda.gov/briefing/rurality/ruralurbcon witt_631_formatted journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 25 predictors of depressive symptoms in rural farm women aged 50 years and older cheryl dean witt, phd, rn 1 deborah b. reed, msph, phd, rn, faaohn, faan 2 mary kay rayens, phd 3 1assistant professor, school of nursing, university of louisville, cheryl.witt@louisville.edu 2 distinguished service professor, college of nursing, university of kentucky, dbreed01@email.uky.edu 3 professor, college of nursing, university of kentucky, mkrayens@uky.edu abstract purpose: aspects of farming and farm life can contribute to higher levels of depressive symptoms resulting in an increased risk for injury and development of chronic disease and a decrease in overall quality of life. rural farm women can be subjected to stressors from farming as an occupation, their role within the agrarian culture, and life in a rural area. the purpose of this study was to examine the associations of demographic characteristics, agricultural occupational factors, and health indicators with depressive symptoms among farm women aged 50 years and older. methods: secondary analysis of cross-sectional data from the sustained work indicators of older farmers study (2002-2006) was used to examine the influence of factors on depressive symptoms of older (> 50 years) female farmers (n= 358) from north carolina and kentucky. the study was framed by a modified version of the biopsychosocial model. logistic regression was conducted to examine the relationships between demographics, perceived health status, active coping score, perceived stress, and factors specific to farm work and depressive symptoms. journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 26 findings: participants’ depressive symptoms status (high vs. low) was predicted by their race/ethnicity, years of education, adequacy of income for vacation, perceived health status, perceived stress, and active coping. conclusion: this study increases our understanding of the factors associated with depressive symptoms in farm women, but also identifies significant gaps in our knowledge of depressive symptoms among this population. the multifaceted dimensions of depressive symptoms revealed indicate a crucial need to more fully explore the interrelationship among the dimensions of the conceptual model and the physical and mental health of farm women. additional knowledge gained from these studies will assist in the development of assessment instruments, skills, and plan of care specific to the needs of farm women; thus optimizing the health care of farm women. keywords: rural women, farm women, depressive symptoms, farm life predictors of depressive symptoms in rural farm women aged 50 years and older the agricultural industry is a high stress environment with unique aspects of rural life and culture that can contribute to elevated levels of stress and depressive symptoms for farm families. overall, the agricultural industry ranks 4th among the five major occupational groups with suicide rates higher when compared to other occupations, particularly among production farmers (burgard & lin, 2013; lunner et al., 2013; peterson, et al., 2020). in addition, higher levels of depressive symptoms can increase an individual’s risk of injury and the likelihood of developing chronic disease, all of which can impact overall quality of life (faragher, cass, & cooper, 2005; world health organization [who], n.d.). multiple studies have shown that women are generally at a greater risk of a major depressive disorder than men and have a higher prevalence of depressive symptoms (angst et al., 2006; kim, cho, hong, & bae, 2015; smith, kyle et al., 2008). this suggests men and women may have journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 27 different responses to stressors and/or different causes of higher depressive symptoms. farm women are subjected to stressors associated with farming as an occupation and potentially further affected by their identity and role within the agrarian culture, adding to increasing their risk of higher depressive symptoms (mcshane, quirk, & swinbourne, 2016; pryor, carruth, & lacour, 2005). stressors of farming include environmental, social, and physical factors. studies have shown that these stressors include: a) uncertainty of economic future, b) burden of physically demanding work, c) long work hours, and d) aspects beyond the farmer’s control such as governmental regulation, climate, insects, and crop disease (guiney, 2012; kearney, rafferty, hendricks, allen, & tutor-marcum, 2014; who, n.d.). occupational stressors can be further complicated since the farm serves as both the work-place and home, where often family members share the burden of the farm work (fraser et al., 2005; mcshane et al., 2016). farm women may be subjected to further distress because the culture is one of strong work ethic, conservative views, and adherence to gender roles (herron & skinner, 2012; weller, 2017). the patriarchal structure of the farm family dictates that farm women accept major responsibility for the housework, child care, and community activities (herron & skinner, 2012; price & evans, 2009; weller, 2017). this may be in addition to unpaid work on the farm and may include an off-farm job (thurston, blundellgosselin, & rose, 2003). the burden of multi-tasking can result in physical and mental stress for farm women, contributing to their risk of having higher depressive symptoms (price & evans, 2009; thurston et al., 2003). a review of the literature specific to farm women and depressive symptoms revealed multidimensional influences from farm women’s social, psychological, biological, environmental, and demographic elements which may increase farm women’s risk for higher depressive journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 28 symptoms. the leading predictors of higher depressive symptoms included increased family conflict, single marital status, poor health, financial hardship, discrimination, lack of social support, and variables associated with farming as an occupation (i.e., exposure to machinery noise, living on the farm but not actively engaged in farm work, and working on the farm but not getting paid) (hanklang, kaewboonchoo, morioka, & plernpit, 2016; rayens & reed, 2014; roblyer et al., 2016;torske, hilt, glasscock, lundqvist, & krokstad, 2016). although the work-family environment of the agrarian culture is intertwined, studies of depressive symptoms among farmers have neglected to investigate the effects of farm life and depressive symptoms among farm women. current research focuses largely on the male farmer. this is despite the increase of female farmers by 26% between 2012 and 2017 (u. s. department of agriculture, national agricultural statistics service, 2019) and the nearly 3.5 million farm women who may be potentially at risk for higher depressive symptoms (hoppe & korb, 2013; united states census bureau [uscb], 2017). the lack of current research, the relationship of chronic depressive symptoms with health and quality of life as well as gender differences in depressive symptoms noted in previous research, emphasize the need for further investigation of factors affecting depressive symptoms in farm women. this study was framed by a modified version of the biopsychosocial model (bpsm) developed by engel (1977). see figure 1. the bpsm has been applied as a theory in other public health studies related to health behavior (hildon et al., 2018; rosenbaum & white, 2016; smith, warne, et al., 2015). similar to the bpsm, variables associated with higher depressive symptoms among farm women were from psychological, social and biological dimensions; however, the journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 29 theory was modified to encompass the environmental and specific demographic variables identified from the review of the literature. figure 1.bpsm conceptual model in relation to farm women and depressive symptoms objective the purpose of this study was to explore the association of social, psychological, biological, environmental and demographic characteristics on depressive symptoms among farm women aged 50 years and older. methods design and sample this cross-sectional secondary analysis of data examined the associations of personal characteristics, farm life, and perceived health status with a high level of depressive symptoms in older female farmers residing in rural kentucky and south carolina between 2002 and 2006. the original (parent) study was a 4-year descriptive cohort study, sustained work indicators of older farmers, and was conducted in kentucky and south carolina (reed, et al., 2008). data on demographic characteristics, farm work exposure, physical and mental health, and sociocultural aspects of agriculture were collected. journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 30 the parent study sample included persons who were primary farmers (the person in charge of the farm’s daily operations) and their spouses (n = 1,022). eligibility for the parent study included: 1) farmer aged 50 or older or spouse of a farmer aged 50 or older enrolled in the study and 2) ability to speak or read english. the participating institutions’ institutional review boards approved the study (#99-5536-1p6) prior to data collection. verbal consent was obtained from each participant at each data collection point. while 1,022 men and women farmers from kentucky and south carolina participated in the initial survey, only women who had complete data on all study variables (n = 358) were included in this analysis. data were collected via mailed surveys and telephone interviews. five surveys were timed to capture the seasonal aspects of farming. for these analyses, data were selected from surveys i and ii, since survey i included the largest number of demographic questions and survey ii included items specific to females. at the completion of each wave, participants received a small monetary award. items for the original study were adapted from questions used in the national institutes of occupational safety and health (niosh) sponsored farm family health and hazard surveillance project (ffhhsp) and then used in the farm health interview survey (fhis) of the kentucky farm health and hazard surveillance project (browning, westneat, reed, & mcknight, 1999). additional items from the national health interview survey (nhis) were used along with other items developed by the investigators of the parent study. application of the bspm model separates the influences affecting depressive symptoms of farm women into five dimensions: demographic, psychological, biological, environmental, and social. based on the review of the literature, items selected from the larger study were those related to ethnicity, age, marital status, income adequacy, journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 31 education, social support, active coping, perceived stress, perceived health, number of farm tasks performed, satisfaction from farm work, and number of hours the woman worked on the farm. demographic demographic characteristics. assessment of age (in years), race/ethnicity, and education (in years) were obtained by standard survey. the distribution of race and ethnic backgrounds were measured on a nominal scale in the parent study. the composition of the racial and ethnic backgrounds indicated a distribution of four categories: 1) white, non-hispanic, 2) african american, 3) hispanic/latino, and 4) american indian; this variable was recoded to a binary variable of “white, non-hispanic” and “non-white” with african american, american indian, and hispanic/latino coded as 1 and white, non-hispanic as the reference category. participants were asked four questions related to income adequacy. “how adequate was your household’s income to: a) meet household living expenses, b) pay for vacations and leisure activities, c) make major household purchases, and d) allow you to save for retirement?” with scaled response (always, usually, usually not, adequate). these items were also recoded to a binary variable of “always” and “usually adequate” as the reference group. psychological depressive symptoms. the 20-item center for epidemiologic studies-depression scale (ces-d) was used to measure depressive symptoms (radloff, 1977). the ces-d was developed to quickly measure depressive symptoms; it is one of the best-known and most widely used measures of depressive symptoms. its reliability and validity have been supported across demographically diverse populations (radloff, 1977; vilagut, forero., barbaglia, & alonso, 2016). participants were asked to report the frequency of their symptoms during the last week on 16 negative and 4 positive items with response options that included ‘less than 1 day,’ ‘1-2 days,’ journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 32 ‘3-4 days’ and ‘5-7 days.’ the items were totaled for a cumulative final score after the four positive items were reverse coded. next, the scores were divided into two groups based the cut-point of 16 or greater to indicate at least mild to moderate depressive symptoms (counselling resource, 2016; lewinsohn, seeley, roberts, & lee, 1997). cronbach’s alpha for the ces-d in this sample was .88. active coping. the 12-item john henry active coping scale (jhac-12) was used to measure active coping. it was developed by james and colleagues (james, hartnett, & kalsbeek (1983) based on the “john henryism” effect which hypothesizes that those who face stressors (i.e., low socioeconomic resources, job insecurity, uncertainty of future) for extended periods of time continue to persist in their day-to-day lives despite their situation. the jhac-12’s three major concepts are applicable to the agrarian culture: 1) mental and physical vigor, 2) a strong commitment to hard work, and 3) a single-minded determination to succeed (james, 1994). responses are scored from 1 (completely false) to 5 (completely true). examples of questions include: a) “i’ve always felt i could make of my life pretty much what i wanted to make of it;” and “it’s not always easy, but i manage to find a way to do the things i really need to get done.” (james, 1994). scores can range from 12 to 48. the higher the score, the greater the john henryism, indicating a stronger coping propensity despite undesirable circumstances (james, harnett, et al., 1983; wiist & flack, 1992). the tool was used in a study of african american farmers (n=156) in which cronbach’s alpha was .81 (maciuba, westneat, & reed, 2013).cronbach’s alpha in the present sample was .80. perceived stress. perceived stress was measured by an abbreviated 5-item version of the 14item perceived stress scale (pss) (cohen, kamarck, & mermelstein, 1983). the questions selected in the original study were those felt to be more closely related to stress within the farm journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 33 culture (rayens & reed, 2014). participants were asked to respond (never, almost never, some time, fairly often, very often) to the five questions regarding the frequency of thoughts and feelings over the last month. the three positive items in this version were reversed coded then summed with the other two items so that a higher score indicated a greater level perceived stress. the range of possible scores was from 5 to 25, with greater values for the total score indicating higher overall stress. cronbach’s alpha for this shortened pss was .75 in this sample. biological perception of health. self-reported health was measured in a single item from the national health interview survey: “how would you rate your health in general? would you say a) excellent (4), b) very good (3), c) good (2), d) fair (1), or e) poor (0).” self-rated health was then recoded as “fair” or better (1) versus “poor” (0), since these descriptors best delineate the division between better and worse perception of health. environmental farm tasks. participants were asked (yes/no) about the types of farm tasks they had completed in the last year. items reflected a broad range of tasks pertaining to crop production and animal care as well as tasks related to managing the farm. sample items included in this list included: ‘mowed fields,’ ‘herded animals,’ and ‘ordered farm supplies.’ the total score was the number of “yes” items. weekly hours worked. a numerical value was placed in the blank regarding the question, “how many hours did you spend doing farm work last week?” considering that the standard deviation (12) was larger than the mean (8), emphasizing the right skew of this variable (with many participants working very few hours and relatively few working a much greater number), this was journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 34 then coded as a binary variable to reflect those women who did not work any hours on the farm in the past week versus those who spent at least one hour on farm work. satisfaction from farm work. participants were asked, “overall, how much personal satisfaction do you get from your farm work?” (no satisfaction, very little satisfaction, some satisfaction, a great deal of satisfaction). given that 87% of the participants in this study chose either the first or second option, this variable was recoded as a binary indicator, with one category comprising those with little to no satisfaction (0) and the other with those with at least some satisfaction (1). social instrumental support. participants were queried (yes/no) regarding the availability of someone to assist with the farm work during an emergency. data analysis descriptive analysis, including means and standard deviations or frequency distributions was used to characterize the sample and summarized the study variables. bivariate analysis was used to compare women with lower ces-d scores (<16) to those women who had higher ces-d scores (>16), including the two-sample t-test or chi-square test of association as appropriate. multivariable binary logistic regression was used to test whether specific demographics, psychological, biological, social, or farm-related environmental factors were associated with higher depressive symptom scores among the farm women. variance inflation factors were used to assess the presence of multicollinearity and the hosmer-lemeshow goodness-of-fit test was used to evaluate model fit. odds ratios (ors) and 95% confidence intervals (ci) were calculated for depressive symptoms (< 16 versus > 16). analysis was performed using ibm spss, v.22 (ibm corp., 2013). alpha was set at .05 for all statistical tests. journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 35 results the sample demographic characteristics with comparison between the women grouped by low versus high ces-d levels are presented in table 1. the sample included 358 women whose mean age was 63.7 years (sd = 7.6). those with high versus low ces-d scores did not differ in mean age. most of the participants were white, non-hispanic (83%) and married (92.5%). their mean education level was 12.5 years (sd = 2.8). most of the women reported their income as adequate for living expenses (82.7%) and major household purchases (87.7%), but fewer reported an income adequate for a vacation (69%) and even fewer reported an income adequate to save for retirement (59.8%). table 1 group differences for demographic characteristics of the total sample with comparison by low versus high ces-d score among farm women (n = 358) variable total sample (n = 358) ces-d score ____________________________ <16 (n = 307) > 16 ces-d (n = 51) n (%) n (%) n (%) p ___________________________________________________________________________________ white/non-hispanic 296 (82.7%) 260 (87.8%) 36 (12.2%) .014* marital status (married) 331 (92.5%) 284 (85.8%) 47 (14.2%) .93 income adequate for living expenses 321 (89.7%) 276 (86.0%) 45 (14.0%) .717 income adequate for saving for major household purchases 314 (87.7%) 273 (86.9%) 41 (13.1%) .086 income adequate for vacation 248 (69.3%) 226 (91.5%) 21 (8.5%) .001* income adequate for retirement 214 (59.8%) 193 (90.2%) 21 (9.8%) .003* ___________________________________________________________________________________ journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 36 variable total sample (n = 358) ces-d score ____________________________ note. significant at the .05 level, *p < .05 further application of the bpsm to include the variables from the biological, psychological, social and environmental categories with comparison between the farm women grouped by low versus high cesd scores are presented in table 2. a large percentage of participants reported their overall health as fair to excellent (95%). the majority of women (85%) scored less than 16 on the ces-d and the remainder scoring greater than 16. overall, perceived stress scores were low. the mean perceived stress score of all participants was 10.7 (sd = 3.7, range 5-24). scores on active coping were high with a mean of 40.8 (sd = 4.4) on the jhac-12 scale of 12-48. table 2 the modified biopsychosocial characteristics of the total sample of farm women by low versus high cesd scores (n = 358) ___________________________________________________________________________________ variable total sample (n = 358) ces-d score ces-d score < 16 (n = 307) ces-d score > 16 (n = 51) n (%) n (%) n (%) p ___________________________________________________________________________________ biological self-reported health rating of good or better 340 (95.0%) 299 (87.9%) 41(12.1%) .001* psychological perceived stress level 10.7 (3.7) 9.9 (3.2) 15.3 (2.8) .001* active coping level 40.8 (4.4) 41 (4.3) 39.6 (4.7) .029* social instrumental support has assistance with farm work during emergency 277 (77.4%) 239 (86.3%) 38 (13.7%) .598 environmental works on farm 210 (58.7%) 185 (88.1%) 25 (11.5%) .131 journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 37 ___________________________________________________________________________________ variable total sample (n = 358) ces-d score number of farm tasks over previous year 5.7 (4.5) 5.2 (4.5) 4.8 (4.1) .495 satisfaction from farm work 312 (87.2%) 273 (87.5%) 39 (12.5%) .014* _________________________________________________________________________________ note. significant at the .05 level, *p < .05 the majority of women had someone to assist with the farm work during an emergency (77.4%). a little over half of the farm women (58.7%) worked on the farm during the previous week and reported a wide variety of weekly hours worked on the farm. the participants reported a range from 0 to 90 hours per week on the farm during the previous week with a mean of 7.4 (sd = 12.1). the number of farm tasks over the past year ranged from 0-20, with a mean of 4.9 (sd = 4.4). the majority of women were satisfied with farm work with 87.2% reporting positively. race/ethnicity years of education, adequate income for vacation and retirement, reported health status of fair or better, perceived stress score, active coping score and satisfaction from farm work differed significantly by ces-d level (low vs. high). a chi-square test for independence (with yates continuity correction) indicated a significant association between race/ethnicity and high ces-d score χ2 (1, n = 358) = 6.074, p < .001). the percentage of non-white americans in the high ces-d group was twice as high as the low ces-d group (24% versus 12%). level of education differed significantly between the groups, with a slightly lower level of education among those in the high ces-d group (mean difference 1.26, 95% ci: .44 to 2.081) and very small effect size. of those participants in the high ces-d group, only 8.5% reported income adequate for vacation and 9.8% adequate for retirement, compared to 91.5% and 90.2%, respectively of those with low ces-d scores. a small effect size was noted for both income adequate for vacation and retirement. journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 38 those with higher perceived stress scores were more likely to be in the high ces-d group (table 2) and the effect size was small (mean difference = -5.41, 95% ci: -6.35 to -4.46, eta squared p = .003). the coping level was high and while the difference between the groups was significant, the variance between groups was small (mean difference 1.45, 95% ci: .15 to 2.75, eta squared p =.003). the participants were mostly satisfied with their farm work, but there was a significant difference between groups χ2 (1, n = 358) = 5.0, phi = -.013). the farm women in this study were less likely to be in the high high ces-d group if they had higher levels of adaptive coping or were satisfied with farm work. predictors of depressive symptoms logistic regression was used to identify predictors of the likelihood of having a high ces-d score (see table 3). the full model contained 15 independent variables and was significant (χ2 = 142.93, p < .001), indicating that the model distinguished between those farm women who had low versus high ces-d scores. the model as a whole explained between 33% (cox and snell rsquared) and 59% (nagelkerke r-squared) of the variance in ces-d scores and correctly classified 91.1% of cases. table 3 logistic regression to assess predictors of the binary ces-d indicator (n = 358) ________________________________________________________________________ variable odds ratio 95% confidence interval for odds ratio age 1.0 0.94-1.06 white, non-hispanic 0.29* 0.10-0.79 years of education 0.84* 0.71-1.0 married 1.34 0.27-6.59 journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 39 variable odds ratio 95% confidence interval for odds ratio income adequate for living expenses 4.60 0.84-25.26 income adequate for major household purchases 0.79 0.19-3.35 income adequate for vacation 0.15** 0.054-0.44 income adequate for retirement 2.02 0.76-5.38 self-reported health level of fair or better 0.96* 0.02-0.45 perceived stress score 1.81** 1.51-2.16 active coping score 0.89* 0.81-0.98 has access to assistance with farm work in an emergency 1.26 0.42-3.81 worked on the farm in the past week 0.60 0.23-1.60 number of farm tasks over previous year 1.05 0.94-1.17 receives satisfaction from farm work 0.60 0.18-2.01 ______________________________________________________________________________ note. *p < .05, ** p < .001. six of the independent variables made a unique statistically significant contribution to the model (race/ethnicity, years of education, income adequacy for vacation, reported health of fair or better, perceived stress score and active coping score). a participant was less likely to have a high level of depressive symptoms if she was white, non-hispanic and had high levels of education. women who reported income adequate for vacation were less likely to have high ces-d scores (1.87, p < .001). those respondents who reported health of “fair” or better were less likely to have high ces-d scores, controlling for all other factors in the model (-2.35, p = .003). although the mean active coping score was high overall, the two groups did differ. those with higher coping journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 40 scores were less likely to have high ces-d scores compared to those with low scores (-.11, p = .021). the strongest predictor of a high ces-d score was perceived stress level, with odds of 1.81 (p < .001), indicating that farm women who had higher perceived stress were almost twice as likely to have a high ces-d score, controlling for all other factors in the model. discussion in this study several factors significantly predicted a score of 16 or above on the ces-d. consistent with the literature review and the bpsm model, factors were identified from specific demographics, biological, and psychological dimensions. no significant factors from either the social or environmental dimensions were noted in this study. this is likely due to having a limited number of questions available from the parent study addressing these areas. consistent with the literature, race/ethnicity, level of education, factors associated with financial adequacy, self-rated health, perceived stress, and active coping were significant predictors of a high level of depressive symptoms among farm women (rayens & reed, 2014; roblyer et al., 2016; torske et al., 2016). however, there are several indicators that the overall mental health of farm women is healthy. this suggests the need for further investigation regarding aspects of farm life that may enhance overall mental wellness and protect farm women from a higher level of depressive symptoms. in this study, race/ethnicity significantly predicted higher depressive symptoms, with twice as many non-white americans as white, non-hispanic in the group with high depressive symptoms. women with high depressive symptoms also had a slightly lower level of education. results are consistent with those of other studies (hanklang et al., 2016; roblyer et al., 2016). specific demographics (race/ethnicity, education, socioeconomic groups) are commonly noted as predictors of depressive symptoms among women and minorities in the general population not journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 41 necessarily living on farms (becares, laia, & jackson, 2014; marshall, hooyman, hill, & rue, 2013). the sample in our study was largely white, non-hispanic but had 17.3% non-white participants, which is a rather large minority subset in farm-based studies. the approximate 500,000 migrant farm women (saf, 2011) in the u.s. leads to questions regarding specific demographics, lack of u.s. citizenship, and their relationship to depressive symptoms among the subset of migrant farm women; these questions should be further investigated. more studies are needed with both african americans and migrant farm women to investigate the relationship between demographic variables and depressive symptoms among farm women. application of the biopsychosocial model includes additional specific demographics associated with depressive symptoms in farm women. financial adequacy is commonly noted as a variable associated with depressive symptoms; the literature supports this association among farm women (roblyer et al, 2016; sanne, mykletun, moen, dahl, & tell, 2004). questions of income adequacy focused on living expenses, retirement, major purchases, and vacation. although income adequacy for vacation and retirement between groups was significant, only income adequacy for vacation was a significant predictor of high a level of depressive symptoms among older farm women. this further supports the findings of chikani, reding, gunderson, and mccarty (2005) study of 1,500 rural women. their hypothesis that women who take vacations are less likely to become depressed. the psychological and physical benefits of a vacation are well documented; however, studies of farm women regarding this subject are limited (de bloom et al., 2009; gump & matthews, 2000). despite trends of increasing leisure time among many occupations and increasing emphasis of work-life balance, farming is a demanding occupation with little attention to intentional leisure (buettner, shattell, & reber, 2011; smit, 2016). leisure time for farm women journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 42 could be problematic as the agrarian culture is one in which many farmers believe leisure time is possible only after all the work is done (bolwerk, 2002). the survey used in our study did not specify other factors related to the benefits of a vacation or barriers other than financial inadequacy; however, even this limited inquiry predicted higher depressive symptoms in the sample. the subject of leisure time and vacation among farm women is large a gap in the exploration of specific demographics and social factors in the research with farm populations. having poor health, higher levels of perceived stress, and lower levels of active coping significantly predicted higher levels of depressive symptoms. while these variables are commonly associated with higher levels of depressive symptoms among farm women within the biological and psychological dimensions of the bpsm (hovey & magana, 2002; rayens & reed, 2014; stallones & beseler, 2002), the farm women in our sample reported overall high levels of active coping, lower levels of perceived stress, and fair to better health. in addition, the majority were largely satisfied with farm work and most had ces-d scores below 16, the standard cutoff for indication of a high level of depression. this suggests that farm women are generally mentally and physically healthy and psychologically secure in their work. this may be a result of “positive affect” effect. the characteristics of “positive affect” effect include confidence, self-efficacy, physical well-being, effective coping, flexibility, optimism, and pro-social behavior. “positive affect” is a result of frequent positive moods and possession of skills and resources developed over time resulting in higher adaptive characteristics (lyubomirsky, king, & diener, 2005). rayens and reed (2014), in their study of 674 older rural couples and predictors of depressive symptoms, suggested a similar term of “healthy worker” effect. their results reported an overall lower depressive symptom level in their sample. the authors suggest that the healthy worker effect on journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 43 the results may be related to many participants in their study who were relatively healthy and actively engaged in farm work, resulting in lower levels of depressive symptoms. the results here are more suggestive of the positive affect effect. while higher numbers of those with lower depressive symptoms reported working on the farm, there is only a slight difference between groups regarding the mean and standard deviation of number of farm tasks over the previous year. however, the majority of women with low ces-d scores did report satisfaction from farm work. results may have been different had those women who did no farm tasks over the past year had been excluded. the favorable levels noted in this study prompt further questions and thought. the bpsm model should be applied in future research with farm women to more fully explore the interrelationship among variables and physical and mental health outcomes. the results indicate a need for more robust investigation of farm women’s activities and work level, health indicators, quality of life, adaptability, social behavior, and perceived health for a better understanding of those variables on depressive symptoms and other outcomes in farm women. several variables identified in the literature were associated with farm women and high depressive symptoms that were not a focus in the original study. the majority of factors were those associated with migrant farm women and a large number of social factors (hanklang et al., 2016; pulgar et al., 2016; roblyer et al., 2016). applying the bpsm, which includes variables from environmental and social aspects, could have provided a more comprehensive insight to the knowledge of depressive symptoms among older farm women but will provide a basis for opportunities for further investigation. this study has several limitations. this is a secondary analysis of a dataset not primarily focused on depressive symptoms. the data were collected by cross-sectional design, reflecting only one moment in time in an occupational culture that is highly seasonal. variables that are more journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.631 44 fluid such as active coping, perceived health, perceived stress, and potentially income, may not be reflective of their effects on depressive symptoms of the farm women over longer periods of time or at times of increased work load. the majority of women in this study were over the age of 50 and married which limits generalizability of results to all farm women. the parent study population purposively sampled from two different geographical areas (north carolina and kentucky) and was composed largely of white, non-hispanic farm couples who may experience different stressors secondary to the type of farming or differences in culture. in addition, the parent study was conducted during a time of greater prosperity for primary farmers. all of these factors make generalizability limited. conclusion considering the large number of farm women, the increasing number of female farmers, and the changing role of farm women, it is imperative that knowledge be increased about this population, particularly as it relates to the mental health of farm women and their overall quality of life. this secondary analysis revealed the multifaceted dimensions of depression among a cohort of farm women and significant gaps in our knowledge of the bpsm dimensions’ and their relationship to the physical and mental health of farm women. the bpsm should be applied in future research with farm women to more fully explore the interrelationship among variables and physical and mental health outcomes. the results of this study indicate a need for more robust investigation of farm women’s activities and work level, health indicators, quality of life, adaptability, social behavior, and perceived health for a better understanding of those variables on depressive symptoms and other outcomes in farm women. results from in-depth studies can provide crucial information needed for the development of journal of rural nursing and health care, 20(2) 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(n.d.). suicide. retrieved from http://www.who.int/mental_health/suicide-prevention/en/ brown_618-article text-4055-1-6-20200713_formatted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 179 collaborating with rural practice partners to address the need for registered nurses in primary care robin brown, phd, rn1 heidi mennenga, phd, rn, cne2 alham abuatiq, phd, rn3 linda burdette, phd, rn4 leann horsley, phd, rn, chse, cne 5 christina plemmons, phd, rn-bc, cne6 1assistant professor, college of nursing, south dakota state university, robin.brown@sdstate.edu 2associate professor, college of nursing, south dakota state university, heidi.mennenga@sdstate.edu 3assistant professor, college of nursing, south dakota state university, alham.abuatiq@sdstate.edu 4assistant dean and associate professor, college of nursing, south dakota state university, linda.burdette@sdstate.edu 5 assistant dean and associate professor, college of nursing, south dakota state university, leann.horsley@sdstate.edu 6assistant dean and clinical assistant professor, college of nursing, south dakota state university, christiana.plemmons@sdstate.edu abstract purpose: primary care in rural areas of the u.s. urgently need competent healthcare providers, especially registered nurses (rns). registered nurses are ideal team members to help meet the online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 180 primary care needs in rural communities, yet rns are underutilized in primary care settings and rarely practice to the full scope of their license in these settings. the purpose of the project was to conduct a needs assessment with rural primary care practice partners to address the need for rns in primary care. sample: a needs assessment was sent to nurse leaders at 13 rural primary care facilities via an online survey in december 2018. methods: this descriptive exploratory study utilized an online needs assessment survey to gather information from 13 rural clinical practice partners regarding their knowledge, interest, and use of rns in primary care. results: twelve of the 13 rural clinical practice partners completed the needs assessment survey. a majority of the clinical partners indicated they felt knowledgeable about the rn full scope of license and expressed a high interest in the expanded role of the rn in primary care. the clinical practice partners reported interest in providing independent rn chronic and acute care visits, care management, medication management, and collaborative provider and rn visits. conclusion: conducting a needs assessment and collaborating with rural primary care practice partners to address the need for rns in primary care is the first step in developing policies and utilizing rns to the full scope of their license. keywords: primary care, rural, registered nurses collaborating with rural practice partners to address the need for registered nurses in primary care healthcare in the united states (u.s.) is constantly changing and primary care is not immune to these changes. there is a growing shortage of healthcare providers and increased online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 181 prevalence of chronic disease (association of american medical colleges [aamc], 2018; bauer & bodenheimer, 2017; flinter et al., 2017). registered nurses (rns) comprise one of the largest segments of the u.s. workforce, with more than 3.2 million rns nationwide employed in nursing (aacn, 2019). only 16% of rns are employed in rural settings (human resources and services administration [hrsa], 2013) and fewer than 10% of rns are employed in primary care (auerbach et al., 2013). primary care in rural areas of the u.s. urgently needs competent healthcare providers, especially rns. registered nurses are ideal team members to help meet the primary care needs in rural communities, yet rns are underutilized in primary care settings and rarely practice to the full scope of their license in these settings. utilizing rns in primary care has a positive effect on patient satisfaction, patient outcomes, and the cost with chronic disease management (borges da silva et al., 2018; smolowitz et al., 2015). academia and clinical partners play a major role in addressing the nursing supply demands to meet the needs of patients in rural primary care. the purpose of the project was to conduct a needs assessment with rural primary care practice partners to address the need for rns in primary care. the primary care partners identified in this project were in rural and medically underserved (mua) areas as defined by the u.s. census bureau. according to the u.s. census bureau, rural is defined as all populations, housing and territory not included within an urban area (50,000 or more people) (hrsa, n.d.). background the demand for primary care is on the rise and the number of primary care providers is declining. by 2030, the estimated shortage for primary care physicians is between 14,800 to 49,300, which will negatively impact primary care (aamc, 2018). sinsky et al. (2013) describe online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 182 the current decade’s practice model in primary care as “unsustainable” (p. 276). inefficiencies in today’s primary care delivery model are fueling burnout amongst primary care physicians (sinsky et al., 2013). access, quality, and affordability of primary healthcare are all negatively impacted by primary care physician burnout and an overall decline in primary care providers. primary care physician burnout may be due to daily performance of clinical tasks that do not require physician training. after observing 23 innovative u.s. primary healthcare practice sites, sinsky et al. (2013) found improved practitioner satisfaction when a “physician-centric model” was replaced by a “shared-care model” (p. 277). the high functioning teams of the shared-care model distributed work and responsibilities according to their professional scope. shared clinical care was accomplished through expanded rooming protocols, standing orders, and panel management. standing orders, for example, empowered rns to independently diagnose and treat “streptococcal throat infections, conjunctivitis, ear infections, head lice, sexually transmitted diseases, uncomplicated urinary tract infections, and warfarin management” (p. 275). in a shared-care model, standing orders can eliminate the need for physician involvement for patients with a variety of problems. by realigning the roles of the healthcare team, innovative primary care clinics can improve capacity, care, and practitioner satisfaction (sinsky et al., 2013). in primary care, rns seldom practice to the full scope of their license (bauer & bodenheimer, 2017; flinter et al., 2017). full scope of practice may include independent rn visits using standing orders for acute or chronic conditions, medication management, leading complex care management teams to help improve care and reduce the cost of care for patients with multiple diagnoses, and coordination of care between hospital, primary care, and home settings (bodenheiner & bauer, 2016; flinter et al., 2017). in a review of 16 u.s. primary healthcare practice sites that utilized team-based care, smolowitz et al. (2015) identified three general patient online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 183 care contexts in which rns collaboratively or independently provided care. these team-based primary care environments utilized rns practicing to the full scope of their license in (a) “episodic and preventive care delivery,” (b) “chronic disease management,” and (c) “practice operations” (p. 133). in all contexts, rn contributions to patient care were notable and positive. rn delivery of episodic and preventive care replaced billable time of primary care providers, increased patient capacity, averted emergency department use, and increased patient satisfaction. rn management of chronic diseases and post hospital care prevented emergency department visits and hospital readmissions and averted hazardous medication interactions. overall, rns practicing to the full scope of their license in these 16 u.s. team-based primary healthcare practices improved capacity, care, patient satisfaction, and practice financial viability (smolowitz et al., 2015). watts and sood (2016) performed a retrospective review of nearly 4,000 veterans who received diabetes care management from specially trained rns in one of 11 team-based primary care clinics. these high-risk patients (all of whom had pre/post-glycosylated hemoglobin [a1c] values documented) had a1c values of at least 9%, with an average value of 10.6% at baseline. systematic rn care management included focused patient education for diabetes selfmanagement, monitoring of patient status/safety, and assessment of blood glucose trends. intensive chronic disease management of this type requires more time than is typically allowed for a primary care visit. for patients receiving rn case management, which lasted between just over one year to two years, average a1c values were lowered to 8.5% a significant reduction (p < 0.001). as soon as the a1c values were stabilized, the patient’s rn diabetes care management ceased. rn case management, provided by specially trained rns, provided benefits to patients by reducing a1c values below 9%; thus, reducing risk of hyperglycemia related microvascular complications and decreasing risk of diabetes related death (watt & sood, 2016). online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 184 innovative primary care models, such as shared care and team-based care are realigning the roles of primary healthcare teams to increase access to and quality of primary care. when rns practice to the full scope of their license in primary care, benefits include increased access to care, improved patient care, increased practitioner satisfaction, improved patient satisfaction, and cost containment (borges da silva et al., 2018; smolowitz et al., 2015; sinsky et al., 2013). in addition, rn certified diabetes educators or rns with care management experience who receive diabetes management training can provide effective intervention and education for high-risk patients with diabetes (watts & sood, 2016). primary care practices need to redesign their delivery models to fully utilize the skills and expertise of rns (josiah macy jr. foundation, 2016). employing rns in primary care and promoting practice to the full scope of their license may assist in meeting the unmet healthcare needs of the millions of people in the u.s. with chronic disease and public health issues (bauer & bodenheiner, 2017; smolowitz et al., 2015). the impact of rns practicing to the full scope of their license in rural and mua primary settings presents an opportunity for further study. more research is needed on the knowledge and use of rns practicing to the full scope of their license in rural primary care. purpose the purpose of the project was to conduct a needs assessment with rural primary care practice partners to address the need for rns in primary care. academic partners developed and distributed an online needs assessment survey to rural clinical practice partners regarding their knowledge, interest, and use of rns in primary care. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 185 methods design this descriptive exploratory study utilized an online needs assessment to gather information from 13 rural clinical practice partners regarding their knowledge, interest, and use of rns in primary care. sample & instrument the project team invited 13 clinical practice partners to complete the needs assessment of healthcare facilities. the 23-item needs assessment survey was developed by the project team based on a review of literature. two questions related to knowledge and confidence of rns practicing to the full scope of license were included from the community academic partnership for primary care nursing transformation (capacity) needs assessment for rns, an existing survey developed and shared by individuals from emory university. the capacity needs assessment is a 36-item instrument asking detailed questions about eight different domains (hillman & amobi, n.d.). the project team did not use the entire capacity needs assessment because of the length and time needed to complete the survey. the 23-item needs assessment survey developed by the project team was reviewed internally. no additional reliability or validity has been established for the needs assessment. the needs assessment was sent to nurse leaders at 13 rural primary care facilities via an online questionpro (questionpro inc., san francisco, ca, usa) survey in december 2018. questions were included regarding (a) current use of rns in primary care, (b) examples of current responsibilities of rns in primary care, (c) desire to use rns in primary care (if not currently utilized), (d) level of knowledge and confidence of rns practicing to the full scope of their license, and (e) educational needs of facility staff or leadership in order to achieve future goals of rns in online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 186 primary care. participants were told the survey would take approximately 15 to 20 minutes to complete. clinic managers, who were rns, or a rn staff member with knowledge about the clinic were asked to complete the survey. researchers wanted to ascertain the level of understanding regarding full scope of license for a rn. a 5-point likert-scale with the following definitions was provided to enhance accuracy in response: novice – minimal or “textbook” knowledge without connecting it to practice; beginner – working knowledge of key aspects of practice; competent – good working and background knowledge in area of practice; proficient – depth of understanding of discipline and area of practice; and expert – authoritative knowledge of discipline and deep understanding of its application to practice. additionally, participants were asked to rate their level of confidence in applying their knowledge of the rns’ full scope of practice within the practice setting. a 4-point likert-scale with definitions for clarity was provided as follows: not confident – i have a hard time seeing the connections between full scope of license; somewhat confident – i have a good awareness of actions and approaches; confident – i usually have a good idea of what actions/approaches to use; and very confident – i know what actions/approaches to use, how and when to use them. the needs assessment survey contained dichotomous questions related to the use of licensed practical nurses (lpns) and rns within the primary care setting followed by items to explore deeper as to their responsibilities and just how their skills are being utilized. one item asked if standing orders were used within the primary care site followed by questions asking for specific examples of standing orders and potential areas to consider for rns to practice at their full scope of practice in the future. final items on the survey were included to rate their interest in exploring the use of rns in primary care practicing to the full scope of their license, perceived online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 187 barriers, potential preceptors and what they would like to learn more about or assistance with at their facility. this research was considered program evaluation by the researchers’ institution so therefore institutional review board approval was not required. results an exploratory data analysis was conducted. twelve of the 13 rural clinical practice partners (response rate= 92%) completed the needs assessment (n = 12). the clinical practice partners were asked about their level of knowledge related to the rn full scope of license. most clinical partners (n= 5) indicated they had a competent level of knowledge (see figure 1). figure 1 level of knowledge related to rn full scope of practice additionally, when asked about their confidence in applying what they know about the full scope of license to their work in practice, most clinical practice partners (n= 5) were confident (see figure 2). clinical partners reported that role descriptions, workflow examples, and processes and policies from agencies currently utilizing rns to the full scope of practice would be helpful. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 188 figure 2 level of confidence related to applying full scope of practice a 10-point likert-scale (1= extremely low interest; 10= extremely interested) was utilized to indicate how interested clinical practice partners were in exploring the expanded use of rns in primary care, they responded with a mean of 8.58 (sd = 2.97). most partners (n= 7) were very interested in expanding the use of rns in primary care; only one partner had extremely low interest (see figure 3). clinical practice partners reported interest in providing independent rn chronic and acute care visits, care management, medication management, and collaborative provider and rn visits. figure 3 interest in expanding use of rns in primary care 6% 1 24% 3 6% 1 6% 1 18% 2 35% 4 1 4 7 8 9 10 c lin ic al p ra ct ic e p ar tn er s likert scale (0-10) interest in expanding use of rns in primary care n=12 online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 189 the project team requested information about staffing and responsibilities of lpns and rns in the primary care setting, to compare similarities and differences. clinical practice partners employed both licensed practical nurses (lpns) (n= 8, 66.7%) and rns (n= 10, 83.3%) in primary care. daily lpn responsibilities include rooming patients, vital signs, medication administration, telephone triage, medication refills, medication reconciliation, assisting providers follow-up calls, patient education, communicating test results, contributing to assessments and coordinating services. daily rn responsibilities were similar except for rns providing case management, intravenous therapy, and wound care. when asked about standing orders, 58.3% (n= 7) of clinical practice partners indicated use of standing orders in primary care. examples of standing orders used by clinical practice partners included orders for vaccinations, anaphylaxis, pain and fever management, and constipation and diarrhea management. in addition, one clinical partner reported standing orders for diabetes, hypertension, and asthma. clinical practice partners provided examples of how rns are currently utilized to the full scope of their license in the primary care settings. one partner had rns performing independent visits, three partners had rn care managers, and three partners utilized collaborative primary care provider/rn visits. in addition, 11 of the 12 clinical practice partners indicated they had future goals to utilize rns to the full scope of their practice. discussion the purpose of the project was to conduct a needs assessment with rural primary care practice partners to address the need for rns in primary care. the two main results revealed from the needs assessment was the high interest in exploring the expanded use of rns in primary care and the underutilization of rns practicing to the full scope of their license in rural primary care online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 190 settings. the rural clinical practice partners identified a need for a better understanding of the rn full scope of practice in order to advance the role in primary care. clinical partners reported that role descriptions, workflow examples, and processes and policies from agencies currently utilizing rns to the full scope of practice would be helpful. in addition, the clinical practice partners reported interest in providing independent rn chronic and acute care visits, care management, medication management, and collaborative provider and rn visits. clinical practice partners also identified potential barriers to utilizing rns to the full scope of their license. the partners were rural health clinics, with specific regulations allowing reimbursement only when a patient had a face-to-face encounter with a provider (physician, nurse practitioner, or physician’s assistant). there were also concerns about potential resistance and difficulties in gaining support from the providers and administration. bodenheimer and mason (2017) reported similar barriers including that public and private insurers are just beginning to pay for services performed by rns and administrators view rn work as an expense rather than a service of revenue. medicare has introduced fee-for-service payments for rns conducting wellness visits and chronic care management services (bauer & bodenheimer, 2016). currently, there is an increase in demand for rns as chronic care managers because of the growing rates of chronic conditions with the aging population (bauer & bodenheimer, 2016). lack of competitive pay for rns in the primary care setting was another barrier identified from the needs assessment. specifically, there was concern that rns can receive higher wages in hospital settings and experience a reduction in pay when transitioning to practice in primary care. to date, this barrier has not been identified in the literature. the second important finding from the needs assessment was the lack of rns practicing to the full scope of their license in primary care in the rural setting. daily rn responsibilities were online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 191 very similar to the lpn, except for a few rns providing case management, intravenous therapy, and wound care. other researchers report similar findings of rns not practicing to the full scope of their license in primary care even though they have been found to improve patient care and reduce costs of care for patients (bauer & bodenheiner, 2017; flinter et al., 2017). conclusion conducting a needs assessment and collaborating with rural primary care practice partners to address the need for rns in primary care is the first step in developing policies and utilizing rns to the full scope of their license. most of the clinical partners who participated in this study expressed a high interest in the expanded role of rns in primary care. utilizing rns in primary care may positively impact patient outcomes, increase patient satisfaction, and decrease overall cost of managing chronic illnesses especially in a rural setting acknowledgement the authors wish acknowledge the other members of the project team: valborg kvigne, beth walstrom, cassy hultman, and marie schmit. references american association of colleges of nursing aacn. (2019). nursing fact sheet. https://www.aac nnursing.org/news-information/fact-sheets/nursing-fact-sheet association of american medical colleges. (2018). new research shows increasing physician shortages in both primary and specialty care. retrieved from https://news.aamc. org/press-releases/article/workforce_report_shortage_04112018/ auerbach, d. i., staiger, d. o., muench, u., & buerhaus, p. i. (2013). the nursing workforce in an era of health care reform. new england journal of medicine, 368(16), 1470-1472. https://doi.org/10.1056/nejmp1301694 online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 192 bauer, l. & bodenheimer, t. (2017). expanded roles of registered nurses in primary care delivery of the future. nursing outlook, 65, 624-632. https://doi.org/10.1016/j.outlook. 2017.03.011 bodenheimer, t. & bauer, l. (2016). rethinking the primary care workforce – an expanded role for nurses. the new england journal of medicine, 375, 1015-1017. https://doi.org /10.1056/nejmp1606869 bodenheimer, t. & mason, d. (2017). registered nurses: partners in transforming primary care. josiah macy jr. foundation: new york, ny. borges da silva, r., brault, i., pineault, r., chouinard, m., prud’homme, a., & d’amour, d. (2018). nursing practice in primary care and patients’ experience of care. journal of primary care & community health, 9,1-7. https://journals.sagepub.com/doi/10.1177/2 150131917747186 flinter, m., hsu, c., cromp, d., ladden, m., & wagner, e. (2017). emerging new roles and contributions to team-based care in high-performing practices. journal of ambulatory care manager, 40(4), 287-296. https://doi.org/10.1097/jac.0000000000000193 hillman, j., & amobi, c. (n.d.). community academic partnership for primary care nursing transformation (capacity) needs assessment for rns-evaluator guide. atlanta, ga: emory nell hodgson woodruff school of nursing. human resources and services administration [hrsa]. (n.d). u.s. census bureau definition. retrieved from https://www.hrsa.gov/rural-health/about-us/definition/index.html human resources and services administration [hrsa]. (2013). the u.s. nursing workforce: trends in supply and education. https://bhw.hrsa.gov/sites/default/files/ bhw/nchwa/projections/nursingworkforcetrendsoct2013.pdf online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.618 193 josiah macy jr. foundation. (2016). registered nurses: partners in transforming primary care. recommendations from the macy foundation conference on preparing registered nurses for enhanced roles in primary care. https://macyfoundation.org/assets/ reports/publications/macy_monograph_nurses_2016_webpdf.pdf sinsky, c. a., willard-grace, r., schutzbank, a. m., sinsky, t. a., margolius, d., & bodenheimer, t. (2013). in search of join in practice: a report of 23 high-functioning primary care practices. annals of family medicine, 11(3), 272-278. https://doi.org/10. 1370/afm.1531 smolowitz, j., speakman, e., wojnar, d., whelan, e., ulrich, s., hayes, c., & wood, l. (2015). role of the registered nurse in primary health care: meeting health care needs in the 21st century. nursing outlook, 63, 130-136. https://doi.org/10.1097/jac.0000000000000193 watts, s. a., & sood, a. (2016). diabetes nurse case management: improving glucose control: 10 years of quality improvement follow-up data. applied nursing research, 29, 202-205. https://doi.org/10.1016/j.apnr.2015.03.011 p03 handley column smoking_6_7_11 
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 editorial smoking in rural pregnant women: a call to action marilyn cooper handley, rn, msn, phd, cne 1 1associate professor, capstone college of nursing, university of alabama at tuscaloosa, mhandley@ua.edu decades of research have documented the effects of cigarette smoking on the general population. smoking is responsible for approximately 20% of deaths in the united states each year (browning baker, mcnally, & wewers, 2009). cigarette smoking is widely accepted as the most prevalent, yet modifiable risk factor to health and well-being (doescher, jackson, jerant, & hart, 2006). it has been linked to increases in morbidity and mortality. primary diagnoses related to the morbidity and mortality includes coronary disease, peripheral vascular disease, stroke, respiratory disorders and cancer. statistics show that male and female smokers die sooner than non-smokers, 14 and 13 years, respectively (wise & correia, 2008). the report from rural healthy people 2010 gives an estimated cost of tobacco mortality and morbidity treatment of 5073 billion dollars in medical costs (stevens, colwell, & hutchison, 2010). the incidence of smoking in america has decreased ever so slightly over the last decade. this decrease is smallest in the younger and rural population groups. doescher, et al. (2006) reported that not a single rural location met the healthy people 2010 goal of less than 12% smokers. findings from the 2007 national survey on drug use and health show the current rate of smokers in the 18-25 year old group of 36.2%. this was only slightly decreased from the 2006 rate of 38.4%. in the age range 15-44, the rate of smoking was lower in pregnant women (16.4%) than those who were not pregnant (28.4%).the report also stated that smoking rates were higher in individuals with lower levels of income and education and those in the midwest and southern portions of the united states. stevens et al. (2010) reported that men and women in rural areas are more likely to smoke than are their urban counterparts. the higher rate of smoking is credited to delayed access to medical and media resources and lower levels of education. smoking is the most common substance used by pregnant women and has the greatest impact on birth weight, a major predictor of poor pregnancy outcomes (bailey & byrom, 2007). it has a significant, negative effect on maternal and infant health. the woman is at increased risk for chronic cardiovascular and respiratory complications, and hemorrhage secondary to placental abruption and placenta previa. the increased risks of poor pregnancy outcomes for the newborn related to smoking include preterm birth, low birth weight, premature rupture of membranes, hypoxia related to placental complications, stillbirths, and neonatal death. martin, et al (2008) cites low-birth weight (lbw), premature birth, and anomalies as negative outcomes at birth. lbw (<2500 grams) has been identified as a leading cause of neonatal morbidity and mortality in the united states (bailey & byrom, 2007). the incidence of lbw has been demonstrated to be positively related to the number of cigarettes smoked (chan & sullivan, 2008). wise and correia (2008) report that 14% of all preterm infants and 20-30% of all low-birth-weight (lbw) infants are born to women who smoke and that 10% of all infant deaths can be linked to smoking during pregnancy. the effects of these conditions are demonstrated in the learning and developmental problems of children who were born preterm or low-birth-weight (wise & correia, 2008). neurological impairments and delays, attention deficit disorders and psychological problems are 
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 associated with lbw infants (bailey & byrom, 2007). gilman, breslau, subramanian, hitsman, & koenen (2008) reported long-term consequences including developmental problems, and general deficits in intelligence, academic skills, and cognitive function in infants whose mothers smoked during pregnancy. there is a direct correlation between healthcare costs for mothers and infants and maternal smoking. the american lung association (2007) reported that the costs related to preterm infants born to women who smoked during pregnancy exceeded $350,000,000 each year. bailey & byrom (2007) reported that the costs of caring for children who were lbw are $5.5-6 billion dollars more for the first fifteen years of life when compared to those born at normal birth weights. additional findings have confirmed the extended damage to not only to the woman and her unborn child but also to other young children in the home. the infant of a mother who smokes is at increased risk for chronic respiratory complications including otitis media, asthma, respiratory infections; and gastrointestinal problems such as acid reflux and colic (gaffney, 2006). an increased risk of sudden infant death syndrome, increased respiratory and ear infections and asthma can be linked with maternal smoking martin (2008). anderson et al. (2006) reported that while the reduction of lbw has been a goal of healthy people 2010, there has been little progress. not surprisingly, this problem is once again a goal of healthy people 2020. this goal is shared by major organizations such as march of dimes, association for womens’ health, obstetrical and neonatal nurses, and the american college of obstetricians and gynecologists. for infants of mothers who smoked during pregnancy, the negative effects are usually present at birth and continue to cause health problems throughout life. smoking cessation is extremely important in pregnancy because pregnancy outcomes related to the newborn improve if the mother stops smoking. this improvement is time-sensitive, with greater improvement in rates associated with cessation prior to or in early pregnancy. pregnant women who stop smoking in the first 3-4 months of pregnancy have newborns with birth weights that are comparable to those born to women who do not smoke. however, smoking cessation, as late as the beginning of the third trimester of pregnancy, has been shown to decrease the rate of low-birth-weight newborns (chan & sullivan, 2008). smoking is a major modifiable risk factor in rural pregnant women (bullock, et al. 2009). lowbirth weight is one of the major indicators of neonatal outcomes. low-birth weight in the newborn has been associated with maternal smoking and low maternal weight gain in rural appalachia. public information programs designed to increase the awareness of the danger of smoking and smoking cessation programs have resulted in decreases in smoking rates in the general population. the effectiveness of smoking cessation programs designed for pregnant women have been limited, especially with women who are heavier smokers, lower educated, lower income levels, and have many smokers in the woman’s social network (bullock et al. 2009). approximately 60% of mothers who smoke prior to pregnancy will continue to smoke during the pregnancy (martin et al. 2008). although pregnancy has been shown to be a time of increased readiness to change, only about 30% of women who smoke will quit when pregnancy is confirmed (wise & correia, 2008). only 18-25 % quit smoking before the first antepartal visit, another 12% will quit later in pregnancy. many relapse later possibly due to the stressors of potential or actual motherhood (maclean et al. 2002). cessations programs targeted to the general population abound with varying degrees of success. commonly used components of the programs may include group and individual 
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 counseling sessions, informational handouts and videos, behavioral reinforcements and pharmacologic therapies. some success has been demonstrated as the percentage of women who smoke during pregnancy has decreased. a review of pregnancy outcomes data from the united states earlier this decade details that while some pregnant women will reduce their risks for poor outcomes by modifying behaviors, a significant percentage do not (anderson et al. 2006). most women who smoked before pregnancy and quit, returned to smoking during the first year postpartum (gaffney, 2006). this places the infant in the home at risk from second-hand smoke and increases the likelihood that the mother will smoke in future pregnancies. the rates of smoking by women living in rural areas are higher than their urban counterparts (browning, 2009; cronk, 1997). women in rural areas are at risk for increased rates of poor pregnancy outcomes associated with smoking. alexy et al. (1997) reported that women in rural areas are more likely to be african-american, single, less educated, with a lower income than women in urban areas. the percentage of teen pregnancies is higher in rural areas. each of these characteristics is associated with increased risk for poor pregnancy outcomes. it has been suggested that rural geographic residence may place a pregnant woman at risk for poor pregnancy outcomes due to the type and extent of services that are available. it has been suggested that lower socioeconomic status places the woman at greater risk for continued smoking in pregnancy due to less information about the health risks, fewer social supports to quit, and less access to cessation services (browning et al. 2009). although the rural population is significantly more economically disadvantaged, the expenditures per capita by the federal government are much less than in urban areas (alexy, 1997). bailey & byrom (2007) reported nearly 40% of rural women in their study had less than adequate prenatal care, compared to a national average of 25%. almost one-half of the pregnant women smoked, more than four times the national average. barriers to smoking cessation, especially during pregnancy, have clustered around several health disparities. smoking during pregnancy is concentrated in women with lower levels of education, especially those with less than a high-school education (gilman, 2008). younger women have a higher rate of lbw and poor pregnancy outcomes (chan & sullivan, 2008). in rural areas, women are more likely to smoke and there are fewer interventions due to decreased access to care and fewer facilities funded to encourage cessation. barriers such as access to care and related health education may be accentuated by cultural and geographical barriers. social support has been shown to be a contributor to successful smoking cessation; however the degree of support for cessation is directly related to whether or not the support person smokes. with the higher rates of smoking among the general population in rural areas, pregnant women in rural areas are at risk for decreased social support to stop smoking (martin, 2008). the incidence of smoking during pregnancy was increased if the woman was not married, was depressed, had lower levels of income or had used other substances including alcohol. some studies have also demonstrated less motivation toward cessation in those women who described their pregnancies as unwanted or mistimed (martin, 2008). anderson et al. reported that the lack of health insurance appeared to be a factor in decreased risk factors in pregnant women (2006). the rural healthy people 2010 report (stevens et al., 2010) cites a lack of resources, transportation, decreased healthcare coverage, less income to pay for care, lack of informational sources related to smoking and cessation programs and decrease access to providers as major barriers to cessation. physicians and nurses are in a unique position to influence smoking rates by addressing prevention, health promotion, and advocacy in women of childbearing age and those who are 
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 pregnant (moore, 2003). for a variety of reasons, neither nurses nor other healthcare providers have consistently addressed smoking cessation with pregnant patients (moore, 2003). the best strategy to improve pregnancy outcomes is to identify and reduce associated risk factors. health care providers must ask women if they smoke, determine readiness to quit, offer educational information and offer cessation programs and encouragement into each visit. smoking cessation programs should be incorporated into routine care along with more emphasis on preconception health promotion strategies. improved cessation rates for women of childbearing age, and women who are pregnant should be priority goals for research and care providers. another needed goal is to reduce the number of women who resume smoking after pregnancy. the time spent in counseling and educational sessions would cost very little compared to the benefits to these women and their infants and families. cigarette smoking has long been recognized as a negative health behavior that results in great cost to the individual, the family and society. the effects are great in the rural areas of our country where smoking rates are higher for both the general population and pregnant women. decreased access to care and health-related information and programs is a major barrier to reversing the damage to this population. healthcare providers must join with others in the community to reach, teach, and help pregnant women in rural areas reduce this risk to the health of them and their families. references american lung association. (2007). smoking 101 fact sheet. retrieved from http://www.lungsusa.org/site/pp.asp?c=dvluk9o0e&b=39853. alexy, b., nichols, b., heverly, m.a., & garzon, l. (1997). prenatal factors and birth outcomes in the public health service: a rural/urban comparison. research in nursing & health, 20, 61-70. [medline] anderson, j.e., ebrahim, s., floyd, l., & atrash, h. (2006). prevalence of risk factors for adverse pregnancy outcomes during pregnancy and the preconception period – united states, 2002-2004. maternal child health journal, 10, s101-s106. [medline] bailey, b.a., & byrom, a.r. (2007). factors predicting birth weight in a low-risk sample: the role of modifiable pregnancy health behaviors. maternal child health journal, 11, 173179. [medline] browning, k.k., baker, c.j., mcnally, g.a., & wewers, m.e. (2009). nursing research in tobacco use and special populations. annual review of nursing research 27, 319-342. [medline] bullock, l., everett, k.d., mullen, p.d., geden, e., longo, d.r., & madsen, r. (2009). baby beep: a randomized controlled trial of nurses’ individualized social support for poor rural pregnant smokers. maternal child health journal, 13, 395-406. [medline] chan, d.l., & sullivan, e.a. (2008). teenage smoking in pregnancy and birthweight: a population study, 2001-2004. medical journal of australia, 188(7), 392-396. [medline] cronk, c.e., & sarvela, p.d. (1997). alcohol, tobacco, and other drug use among rural/small town and urban youth: a secondary analysis of the monitoring the future data set. american journal of public health, 87(5), 760-764. [medline] doescher, m.p., jackson, j.e., jerant, a., & hart, g. (2006). prevalence and trends in smoking: a national rural study. journal of rural health, 22(2), 112-118. [medline] gaffney, k.f. (2006). postpartum smoking relapse and becoming a mother. journal of nursing scholarship, 38(1) 26-30. [medline] http://www.ncbi.nlm.nih.gov/pubmed/9024478 http://www.ncbi.nlm.nih.gov/pubmed/16710762 http://www.ncbi.nlm.nih.gov/pubmed/17091398 http://www.ncbi.nlm.nih.gov/pubmed/20192110 http://www.ncbi.nlm.nih.gov/pubmed/18496746 http://www.ncbi.nlm.nih.gov/pubmed/18393741 http://www.ncbi.nlm.nih.gov/pubmed/9184502 http://www.ncbi.nlm.nih.gov/pubmed/16606421 http://www.ncbi.nlm.nih.gov/pubmed/16579320 
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 gilman, s.e., breslau, j., subramanian, s.v., hitsman, b., & koenen, k.c. (2008). social factors, psychopathology, and maternal smoking during pregnancy. american journal of public health, 98(3), 448-453. [medline] martin, l.t., mcnamara, m., milot, a., bloch, m., hair, e.c., & halle, t. (2008). correlates of smoking before, during, and after pregnancy. american journal of health behavior, 32(3), 272-282. [medline] maclean, l.m., estable, a., sims-jones, n., & edwards, n. (2002). concurrent transitions in smoking status and maternal role. journal of nursing scholarship, 34(1), 39-40. national survey on drug use and health: national findings (2007). department of health and human services. substance abuse and mental health services administration office of applied studies. moore, m.l. (2003) preterm birth. jognn 32(5), 636-637. [medline] stevens, s., colwell, b., & hutchison, l. (2010). tobacco use in rural areas. rural healthy people 2010: a companion document to healthy people 2010, 1. college station, tx: the texas a&m university system health science center, school of rural public health, southwest rural health research center. retrieved december 7, 2010, from http://www.srph.tamhsc.edu/centers/rhp2010/12volume1tobacco.htm wise, l., & correia, a. (2008). a review of nonpharmacologic and pharmacologic therapies for smoking cessation. formulary 43(2), 44-64. http://www.ncbi.nlm.nih.gov/pubmed/17600245 http://www.ncbi.nlm.nih.gov/pubmed/18067467 http://www.ncbi.nlm.nih.gov/pubmed/14565743 microsoft word 22-247-4-ed_gregg1.docx online journal of rural nursing and health care, 12(1), spring 2012 55 reducing rural youth substance abuse by educating parents through nontraditional technology-based methods: a focus on parental acceptance of the online parenting wisely program jason a. gregg, aprn, fnp-c, dnp 1 1 assistant professor of clinical; fnp distance learning program coordinator college of nursing, university of cincinnati, jason.gregg@uc.edu abstract purpose: to examine acceptance of technology-based substance abuse prevention programming involving use of the internet in a rural parent population. methods: rural parents from a southern state in the east central part of the united states were recruited through local advertisements to participate in two study-related tasks: a brief survey and an online parenting skills educational program entitled parenting wisely. findings: recruitment efforts yielded a total of 39 initial contacts. of these potential subjects, 25 completed surveys and five requested online program access. findings demonstrated parents were more likely to indicate a plan to participate in the online program if they cited a primary reason of perceived benefit, whereas parents were more likely to not participate if they selected a lack of time for task commitment as their emphasized motive. of the five participants who requested online program access, only two of them actually attempted any modules. neither of them successfully finished any module. conclusions: while rural parents indicated some degree of acceptance to an online parenting educational program through survey responses, those indications did not translate to actual completion of the parenting wisely program. recruitment methods seemed to be most effective with flyer distribution and word-of-mouth social networking strategies, while the cost of newspaper advertisements seemed to greatly outweigh any perceived benefit. also, the window for potential subject recruitment was most optimal in a four to six week timeline. more research with a larger sample size is needed in order to help identify and validate demographic characteristics leading to increased likelihood of online program participation. in addition, expanded follow-up research is needed to determine as to why parents do or do not complete such programming. keywords: adolescent, access to care, parents, substance abuse prevention, technology, rural reducing rural youth substance abuse by educating parents through nontraditional technology-based methods: a focus on parental acceptance of the online parenting wisely program adolescent substance abuse has been long considered an urban problem in the united states of america, but epidemiological data demonstrates a worsening trend for rural populations which parallels or even surpasses that of their urban counterparts. these numbers indicate both alcohol and illegal drug usage to be an ever increasing challenge in rural areas (schoeneberger, leukefeld, hiller, & godlaski, 2006). alcohol and methamphetamine usage is greater in rural youth when compared to urban adolescents, and this substance usage increases as population decreases (lambert, gale, & hartley, 2008). these findings are consistent with the substance abuse and mental health services administration’s (samhsa) results from the 2008 national online journal of rural nursing and health care, 12(1), spring 2012 56 survey on drug use and health (samhsa, 2009). results from the national survey demonstrated alcohol binge drinking rates for young persons ages 12 to 17 to be greatest in nonmetropolitan areas at 9.8%. in addition, illicit drug usage in completely rural counties rose almost 50% from 4.1% in 2007 to 6.1% in 2008 (samhsa, 2009). an analysis of samhsa’s data also revealed that rural youth were 26% more likely to have abused prescription drugs than teens from urban areas (havens, young, & havens, 2011). clinical evidence in substance abuse prevention efforts indicates best methods to be those which include parents in the education process. petrie, bunn, and byrne (2007) concluded in a systematic review of the literature that substance abuse reduction outcomes were most beneficial when prevention education focused on parental involvement. this finding was also consistent with samhsa’s 2008 national survey on drug use and health (samhsa, 2009). adolescent responses on this national survey demonstrated that adolescents were less likely to use substances if they believed their parents would strongly disapprove of substance usage. on the other hand, those who sensed a lesser degree of parental disapproval were more likely to use substances. in addition, young people ages 12 to 17 were significantly less likely to use substances when parents exhibited more oversight and control of adolescent activities (samhsa, 2009). with this in mind, it is critically important to incorporate parents into rural adolescent substance abuse prevention efforts. research findings demonstrating the beneficial influence of parents in adolescent substance abuse prevention are consistent with the underpinnings of problem-behavior theory (jessor, 2008), a conceptual framework designed to explain why some older children engage in risk behaviors. a major premise of problem-behavior theory is that “all behavior is the result of person-environment interaction” (jessor, 2008, para. 1). such interaction is examined through three systems of explanatory variables: the perceived-environment system (peer and parental influences); the personality system (academic achievement); and the behavioral system (substance abuse and other risk behaviors). “each system is composed of variables that serve either as instigations for engaging in problem behavior or controls against involvement in problem behavior” (jessor, 2008, para. 3). the ability to maintain a balance between instigations and controls determine the likelihood of problem behavior within each system (jessor, 2008). through the application of this theory, positive parenting skills, along with expanded oversight of child activities, help reduce adolescent substance abuse risk within the perceived-environment system. while inclusion of parents in rural adolescent substance abuse prevention efforts is necessary for optimal reduction outcomes, a disparity in resources often suppresses the ability to effectively reach these parents in large numbers (havens, young, & havens, 2011). such geographical disparities include a lack of adequate funding, number of health care professionals, infrastructure, and facilities. cost-effectiveness is further lessened due to decreased access issues resulting from rural populations being less in number and more widely dispersed (samhsa, 2007). in developing and implementing suitable plans to reach parents in rural substance abuse prevention efforts, one may want to consider recommendations from the institute of medicine (iom) (iom, 2001). the iom has identified six core needs in the development and implementation of quality health care interventions: safe, effective, patient-centered, timely, efficient, and equitable. the iom also maintains that these concepts can be satisfied by applying evidence to health care delivery and utilizing information technology (iom, 2001). when online journal of rural nursing and health care, 12(1), spring 2012 57 applying these concepts to prevention strategies, real progress can be made by using technology in the provision of evidence-based substance abuse prevention programming to rural populations. in recent years, the internet has become increasingly popular for its ability to provide evidence-based prevention programming. this growing demand for internet access has led to alternative delivery method considerations for mental health services (calam, sanders, miller, sadhnani, & carmont, 2008). parallel with traditional face-to-face approaches for prevention education, nontraditional web-based prevention methods have demonstrated key abilities to improve child behavior, parenting skills, and cost-effectiveness (feil, baggett, davis, sheeber, landry, carta, & buzhardt, 2008). cost-effectiveness is fostered by making programs more accessible and acceptable along with tailoring them to cultural and community norms by allowing participants to integrate programming into their daily schedule. in addition, web-based methodology helps adapt to financial limitations by utilizing preexisting community assets that are sustainable (samhsa, 2007). expansion of the internet, particularly broadband service, has seen rapid growth in rural populations during recent years. the united states department of agriculture (usda) economic research service (2009) currently estimates that more than 70% of individuals in rural areas use the internet with greater than 50% maintaining home internet service. with this in mind, utilization of web-based substance abuse prevention programming provides a realistic opportunity to reach rural parents in larger numbers through cost-effective, technology-based methods. an advanced search of the samhsa’s national registry of evidence-based programs and practices (nrepp) for evidence-based substance abuse prevention programs meeting basic appropriateness for rural communities (samhsa, 2010) yielded one web-based delivery option with a focus on parents: parenting wisely. parenting wisely (2010) is comprised of eleven interactive modules: helping children to do housework; helping children do better in school; curfew; step-parenting; school, homework, and friends; loud music, chores incomplete; sharing the computer; sibling conflict; getting up on time; finding drugs; and composite skills practice. for each module, parents watch video simulations of situations typically encountered by families. throughout these scenarios, parents are provided with interactive questions and answers along with rationales for both appropriate and inappropriate responses to these situations. at the conclusion of each module, parents answer a brief quiz of approximately five questions to demonstrate knowledge retained. skills learned through successful completion of the aforementioned modules are as follows: active listening, assertive discipline, job compliance, consequences, consistency, point systems, contracting, problem solving, i statements, role modeling behavior, school and homework monitoring, specific commands, and praise (family works, 2010). the parenting wisely program also attempts to satisfy the three systems of explanatory variables comprising problem-behavior theory: the perceived-environment system, the personality system, and the behavior system (jessor, 2008). while all modules within the parenting wisely curriculum are directed at improving parental influence, some of the modules directly impact each of these system domains. for example, the curfew and school, homework, and friends modules focus on limiting negative influence of peers within the perceivedenvironment system. the helping children do better in school and school, homework, and friends modules address academic achievement within the personality system, while the finding drugs module speaks to substance abuse within the behavioral system. online journal of rural nursing and health care, 12(1), spring 2012 58 the question at hand is not focused on whether online programs such as parenting wisely are effective in improving outcomes, as research has already demonstrated the ability of such programming to reduce adolescent substance abuse risk (family works, 2010). instead, attention was given to the determination of how best to apply substance abuse prevention programming through optimal recruitment and implementation strategies. feil, gordon, waldron, jones, and widdop (2011) demonstrated successful recruitment and high satisfaction with an online version of parenting wisely; however, this study was specific to ethnic minority rather than rural populations. due to minimal research in the approval of internet-based substance abuse prevention programming with rural populations, the overall purpose of this research study was to examine rural acceptance of a web-based course in order to identify characteristics which may predict participation status. attention was also given to an analysis of costs related to implementation of the parenting wisely program in this rural population. methods this study used a descriptive research design for the purpose of examining acceptance of technology-based substance abuse prevention programming involving use of the internet in a rural parent population. the study was approved by the relevant institutional review boards at the university of kentucky. sampling eligible subjects were parents or guardians who had a child enrolled for the 2010-2011 academic year in fourth, fifth, and/or sixth grades of a rural county school system in a southern state located in the east central region of the united states. the number of student households encompassing fourth, fifth, and sixth grades of the rural county school system for the 2010-2011 academic year was approximately 600. of these 600 hundred households, the range of homes maintaining internet access is between 62 and 69 percent (m. bromley, personal communication, october 4, 2010). an application of this percentage range finds the estimated number of student households maintaining internet access is between 372 and 414. identification and recruitment of potential study participants was conducted utilizing three primary methods of advertising: flyers, local newspaper advertisements, and word-of-mouth strategies. advertisement flyers were distributed in both public and private places throughout this rural community where contact with the aforementioned subjects was likely to occur (e.g., schools, churches, grocery stores, gas stations). newspaper advertisements were placed weekly over an eight week period in a publication limited to local distribution. word-of-mouth strategies included verbal advertisement through social networking structures. once advertisement began, subjects who desired complete study information contacted the principle investigator (pi) through personal, telephone, or e-mail communication. the pi provided potential subjects with study information via postal delivery to an address provided by these persons. materials provided were as follows: an informed consent letter describing two tasks comprising the study (a survey and web-based educational program), a brief survey focused mostly on demographic data, and a stamped security envelope addressed to the pi for survey return. if the parent or guardian decided to participate in the survey task of the study, they simply completed the form and returned it to the pi via postal delivery in the provided envelope. however, those also desiring to participate in the web-based educational program needed to contact the pi once again via telephone or email in order to request online participation access. the pi then provided through an e-mail address provided by the study subject a web link to the online educational program, an unidentifiable username, and an access code. online journal of rural nursing and health care, 12(1), spring 2012 59 measures in order to satisfy the overall study purpose of determining parental acceptance of webbased programming in a rural population, acceptance is demonstrated by two measures: indication of plan to participate via survey and actual participation in the web-based program entitled parenting wisely (parenting wisely, 2010). in regard to the survey, study subjects completed the form based on whether they planned or did not plan to participate in the online educational program. a plan to participate demonstrates a degree of acceptance thus providing information on the demographic characteristics associated with likely participation. therefore, demographic characteristics (age, gender, race, marital status, educational background, employment status, and computer and/or internet access) were included as components of measure. in addition, reasons (convenience, time commitment, belief of benefit, prior computer and internet experience, and other) for participation designation were included as elements of measure. demographic categories and participation status reason options were selected on the basis of demonstrated influence in the research literature (gordon & rolland-stanar, 2003). in regard to actual participation, measures included total participant numbers along with completion rate of each module in the parenting wisely curriculum. attention was also given to costs associated with implementation of the parenting wisely program. financial measures were in u.s. dollars and broken down into three factors: cost per unit, cumulative unit cost, and percentage of total costs for each study component unit. analysis acceptance was evaluated by examining actual participation numbers including that related to survey completion and online parenting wisely involvement. comparisons were made between those who indicated via survey a plan to participate and those who did not plan to participate. these comparisons included use of descriptive statistics (percentages, median, mean, standard deviation, and range) along with non-parametric evaluation using chi-square test for independence and the mann-whitney u test. also, the number of those participating in this webbased program was analyzed in terms of total participant numbers and completion rate for each of the 11 modules in order to describe partial versus full-program acceptance. in addition, a breakdown descriptive analysis of costs related to implementation of the parenting wisely program in this rural population was examined. results recruitment yielded a total of 39 initial contacts requesting study-related information materials via postal mail. during this initial contact, all potential study participants requested this information through either phone or in-person conversations. these conversations revealed they were aware of the study via flyers and/or word-of-mouth social networking methods with none referring to newspaper advertisements. contacts also trended downward as the study timeline progressed: 21 contacts during the last two weeks of december; 18 contacts during the first three weeks of january; and no contacts throughout the last five weeks of the study. of these 39 initial contacts, 25 returned surveys while five requested online access to the parenting wisely program. acceptance (survey) demographic characteristics of survey respondents are depicted in table 1. the age of survey respondents ranged from 31 to 56 with a mean age of 38.8 years (sd 6.021). these online journal of rural nursing and health care, 12(1), spring 2012 60 respondents also had a range of one to three children enrolled in fourth through sixth grades of the rural county school system with a mean number of 1.44 children (sd 0.651). table 1 demographic characteristics of survey respondents reasons provided by survey respondents for planned participation status are depicted in table 2. in regards to the selection of other as a participation status reason, two respondents specified either slow streaming internet or lack of interest as a reason for their planned participation status designation. non-parametric testing confirmed a statistically significant difference in the primary reason between subjects indicating a plan to participate and those not planning to participate (p = .002). an evaluation of gender and planned participation status also yielded a significant probability (p = .041); however, when applying yates’ correction for continuity, the value changes to a statistically insignificant probability level (p = .106). other categorical variables similarly evaluated with participation status which approached borderline significance included: marital status (p = .075), owning a home computer (p = .071), and age of parent/guardian (p = .066). online journal of rural nursing and health care, 12(1), spring 2012 61 table 2 reasons provided by survey respondents for planned participation status acceptance (parenting wisely intervention) of the 15 subjects who indicated a plan to participate in the online parenting wisely program, five persons including four females and one male requested information to access the course. three of these five parents did not attempt any of the 11 modules in the online educational curriculum for parenting wisely. one parent attempted a single module, helping children to do housework, but the individual did not complete module requirements. another parent attempted two modules, helping children to do homework and helping children do better in school, but this person did not complete module requirements either. cost analysis as depicted in table 3, total costs for implementation of study procedures was slightly less than $1200. advertising was associated with the largest cost component accounting for online journal of rural nursing and health care, 12(1), spring 2012 62 approximately 85% of total study implementation cost. over 75% of these advertising costs were concentrated in local newspaper advertisements. study supplies accounted for eight percent of study-related costs, while the smallest cost factor involved the online parenting wisely intervention which accounted for seven percent of all costs. table 3 costs associated with study implementation discussion a rural parent population demonstrated some degree of acceptance to an internet-based parenting educational program. survey responses strongly indicated a difference in primary reason as to why a parent did or did not plan to participate in the online parenting wisely program. parents who responded positively to planned participation selected a belief in benefit with the study program, while parents who responded negatively to planned participation cited an inability to work the program into their daily schedule due to the 3-3.5 hour time commitment for program completion. in addition, borderline trends were observed with gender (female), marital status (married), owning a home computer (yes), and age of parent/guardian (older) in relation to a positive planned participation response; however, statistical significance was not demonstrated largely attributed to small sample size. based on verbal reports from the initial contact with 39 potential subjects, advertising methods that were most successful were distribution of flyers and word-of-mouth social networking strategies. there is strong indication that newspaper advertisements were not beneficial in attracting subjects to this study. this is important to note because newspaper advertisements accounted for almost 65% of total study-related costs. in addition, the number of initial subject contacts trended downward as the study timeline progressed. in fact, there were no new contacts during the last 5 weeks of the study. this suggests the advertisement window for recruiting subjects in the study population to be shorter in duration (4-6 weeks) than that provided with this study (10 weeks). another interesting note is the demographic makeup of survey respondents in comparison to recorded characteristics of this local population. comparable to census data (u.s. census bureau, 2010), survey respondents were overwhelmingly white; however, there are some noticeable disparities observed. census data demonstrates the percentage of females in this rural online journal of rural nursing and health care, 12(1), spring 2012 63 community to be slightly less than half, but female survey respondents accounted for 64% of those received. census data also finds those with a bachelor’s degree or higher at 9.7%, yet survey respondents demonstrated a 24% rate of holding a bachelor’s degree or higher. in addition, more survey respondents were married and employed than the number in this local segment of the general population. although 60% (n = 15) of survey respondents indicated a plan to participate in the online parenting wisely program, only one-third of these persons requested program access information. of the five persons who requested online access, only two parents attempted any module work. neither of these two parents attempted more than two of the 11 modules nor finished any of the modules attempted. this study is restricted in its ability to determine why survey indications did not translate into actual online program attempt and completion due to a lack of coding survey respondents. in addition, the lack of follow-up ability prohibited the researcher from being able to provide completion reminders to those who requested online program access. it is plausible financial incentives may be beneficial in boosting participation and/or completion rates. limited research has demonstrated the ability to increase participation numbers in rural, appalachian communities through some sort of financial reward. woodruff, gordon, and lobo (1999) found that an increase in completion of the parenting wisely program was observed in home-based methods utilizing the provision of cd-rom software on a laptop computer or written materials by providing a financial incentive to those who followed through on study program participation. rural populations are often disadvantaged primarily due to geographic seclusion. this isolation can create barriers including a lack of fiscal resources (hardy-brown, miller, dean, carrasco, & thompson, 1987). as a result, this population is adversely affected in access to prevention programming due to limitations in dependable transportation and availability of trained professionals (gordon, 2000). while internet-based programming such as parenting wisely affords the benefit of low implementation cost (gordon & rolland-stanar, 2003), it also helps overcome the aforementioned barriers by increasing access to rural persons of interest (gordon, 2000). since parenting wisely requires no specialized training for program content delivery and evaluation (gordon, 2003), healthcare professionals including community health, school, and advanced practice nurses are at the forefront of ability to design and implement effective recruitment strategies for primary prevention education programs. limitations study limitations primarily involved convenience sampling methods and small sample size resulting in a lack of generalizability of study findings. the limitation in sample size may have been most affected by information contained within advertising methods. it was well noted within these advertising methods that one of the major study-related tasks was related to a webbased educational program. it is plausible that this may have limited potential subject contact with those who did not maintain access to an internet subscription. this assumption is further validated with the survey response rate of those maintaining a home internet subscription being significantly greater than those who did not, respectively 84% and 16%. in addition, another hindrance to a larger sample size may have been the attachment of the pi’s name to advertisements. the pi resides within this rural community thus having name recognition with those that live in the area resulting in potential concerns with anonymity. online journal of rural nursing and health care, 12(1), spring 2012 64 conclusion rural parents indicated some degree of acceptance to an online parenting educational program through survey responses. non-parametric testing (chi-square) found parents more likely to indicate a plan to participate in such a program cite perceived benefit as a primary reason, while parents were more likely to indicate a plan to not participate in a similar program if they cited time commitment as an impediment to working the intervention into their daily schedule. other factors which may affect a participation decision include gender, marital status, owning a home computer, and parental age, but due to limited sample size and variability, findings were marginal with borderline statistical insignificance. additional research is needed to expand on findings from this study including validation of demographic characteristics which increase the likelihood of rural participation in an online program. follow-up assessments need to be incorporated in order to determine why an indication of planned participation may or may not translate into actual partaking in such a program. more research is needed on implementation of technology-based prevention methods in rural populations, as this parallels recommendations from the iom (iom, 2001). web-based technology permits communities to utilize preexisting resources (i.e., internet) thus requiring less upfront money for investment, reduced cost of program implementation by lessening laborintensive components and other more costly resources, and increased accessibility to prevention methods. such a call for using technology-based methods in health care prevention efforts is the cornerstone of recent funding initiatives by the u.s. department of health and human services (dhhs) (u.s. dhhs, 2010). the u.s. dhhs recently announced an allocation in millions of dollars for local prevention efforts and health initiatives. with secured funding approved for such efforts, initial parental interest in internet-based education methods demonstrates the need for expanded monies to fund research focused on understanding how to ensure greater participation and program completion rates of rural parents. while findings from this research study are limited, the information provided helps lay the foundation for theoretical testing of the aforementioned conclusions within larger sample sizes along with other methods to increase program participation and completion rates. potential information from this future research recommendation will help identify a marketing schema which optimally attracts program participants in rural populations. as a result, an increase in participation numbers could translate to an improvement in adolescent substance abuse reduction outcomes. acknowledgements sigma theta tau international (stti) nursing honor society references calam, r., sanders, m.r., miller, c., sadhnani, v., & carmont, s.a. 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(2008). problem-behavior theory: a brief overview. retrieved from http://colorado.edu/ibs/jessor/pb_theory.html lambert, d., gale, j.a., & hartley d. (2008). substance abuse by youth and young adults in rural america. the journal of rural health, 24(3), 221-228. [medline] parenting wisely (2010). parenting wisely: a highly interactive program. retrieved from http://www.parentingwisely.com/course/ petrie, j., bunn, f., & byrne g. (2007). parenting programmes for preventing tobacco, alcohol or drugs misuse in children < 18: a systematic review. health education research, 22(2), 177-191. [medline] schoeneberger, m.l., leukefeld, c.g., hiller, m.l., & godlaski t. (2006). substance abuse among rural and very rural drug users at treatment entry. the american journal of drug and alcohol abuse, 32(1), 87-110. [medline] substance abuse and mental health services administration (2009). results from the 2008 national survey on drug use and health: national findings (office of applied studies, nsduh series h-36, hhs publication no. sma 09-4434). rockville, md. substance abuse and mental health services administration (2010). samhsa’s national registry of evidence-based programs and practices. retrieved from http://nrepp.samhsa.gov/advancedsearch.aspx substance abuse and mental health services administration, center for mental health services (2007). promotion and prevention in mental health: strengthening parenting and enhancing child resilience (dhhs publication no. cmhs-svp-0175). rockville, md. united states department of agriculture economic research service (2009). rural broadband at a glance: 2009 edition (economic information bulletin number 47, february 2009). retrieved from http://www.ers.usda.gov/publications/eib47/eib47.pdf u.s. census bureau (2010). state and county quick facts. retrieved from http://quickfacts.census.gov/qfd/states/21/21191.html u.s. department of health and human services (2010). hhs announces $750 million investment in prevention. retrieved from http://www.hhs.gov/news/press/ 2011pres/02/20110209b.html . http://www.ncbi.nlm.nih.gov/pubmed/21041587 http://www.ncbi.nlm.nih.gov/pubmed/18643798 http://www.ncbi.nlm.nih.gov/pubmed/16450645 http://www.ncbi.nlm.nih.gov/pubmed/16857779 online journal of rural nursing and health care, 12(1), spring 2012 66 woodruff, c., gordon, d.a., & lobo t.s. (1999). home delivery of a cd-rom family intervention to high risk families. retrieved from http://www.familyworksinc .com/research_articles/index.html . online journal of rural nursing and health care, 1(2) 58 use of the neuman systems model for interdisciplinary teams rae jeanne memmott, ms, rn1 kevin m. marett, msw2 randy l. bott3 lee duke, rn4 1 associate professor, college of nursing, brigham young university, rae_jeanne_memmott@byu.edu 2 w. eugene gibbons of social work, brigham young university, kevin_marett@byu.edu 3 department of church history, brigham young university 4 nursing consultant abstract the neuman systems model is particularly adaptable to interdisciplinary use. its broadness and systems approach are especially responsive to use in the changing health care delivery system. application to interdisciplinary use is multidimensional. the model has been used as the structural framework for work at administrative, interdisciplinary health care team and nurse/client/community levels. interdisciplinary work at the administrative (management) level can be found in publications by patricia hinton-walker and john walker. nurse/client/community work is demonstrated in the writings of patricia davies, a psychiatric nurse practicing in wales. application to the interdisciplinary health care team will be discussed in this chapter. this article will focus on the interdisciplinary use of the neuman systems model (nsm) in the practice setting. application in education will also be addressed. represented online journal of rural nursing and health care, 1(2) 59 here is a portion of the work of an interdisciplinary team of university faculty who explored the feasibility of interdisciplinary use of the model in both practice and education. members of the team are also clinical practitioners in their respective professions. online journal of rural nursing and health care, 1(2) 60 use of the neuman systems model for interdisciplinary teams brief history for decades, health care professions in the united states have increasingly moved toward specialization (donley, 1991). expansion of knowledge, especially in technical fields, has caused compartmentalized and fragmented care (davis & botkin, 1994) and an increasing inability among health care providers to view the client as a whole and unique individual (clark, 1997). serious concern related to these trends became apparent in the health care literature of the 1970's and 80's. during this time the terms wholistic and holistic emerged. societies, organizations and educational programs were formed to promote care based on a more holistic approach. the hospice movement (stoddard, 1978), the organization of the american holistic nurses' association (ahna, 1994), and increased emphasis of general practice programs in medical schools, are evidence of that concern. against this historical backdrop the nsm was developed. its original purpose was to stimulate graduate nursing students to build their nursing practice on a synthesis of knowledge gained from general education, prerequisite and nursing courses as well as clinical experience. that synthesis of knowledge was viewed as a critical foundation to viewing clients as whole and integrated beings. consequently the first article written about the model was titled in part, "a total person approach to viewing patient problems" (neuman & young, 1972). betty neuman and rae jeanne young memmott, co-authors of the original publication of the model, both believe that their early life experiences in rural communities shaped their view of the world and therefore the model. neuman stated, "my view of the world was shaped by the simple events of farm life and the hardiness of my parents in responding to them. there was reverence, dignity, and respect for all life.... i was aware at an early age of the importance of god online journal of rural nursing and health care, 1(2) 61 in my life and of having my needs met holistically.... an unconscious expectation was patterned for a holistic view of people and environmental influences were seen as manageable" (carson 1996, p.92). description of the model the neuman systems model presents a systems-based framework for viewing individuals, families or communities. it is based on general systems theory with the client viewed as an open system, which reacts and adapts to both internal and external stressors. nsm is based on numerous concepts and sub concepts, some of which are: stress, adaptation, homeostasis, levels of prevention, intra, inter and extra personal factors, optimal wellness and basic structure. the following description of the model is a brief summary of the description found in the original publication (neuman & young 1972) with examples added by the authors. in this explanation of the model the client will be considered to be an individual. the client system is represented by a series of solid and broken circles. the central circle is the basic structure or energy source, which includes basic survival factors common to the species. some examples are genetic response patterns, strengths or weaknesses of body organs and normal temperature range. the basic structure also consists of characteristics which are unique to a given individual or client such as innate musical talent. the outer most solid circle is referred to as the normal line of defense and represents the individual’s normal state of wellness or the usual state of adaptation, which the person has maintained over time. the broken line outside the normal line of defense is the flexible line of defense. it acts as a buffer or protection to the normal line of defense. ideally it will prevent stressors from online journal of rural nursing and health care, 1(2) 62 invading the client system by blocking or defusing stressors before they are able to attack the normal line of defense. the flexible line of defense is accordion like in its function. when it is expanded greater protection is provided. when it is narrowed and therefore closer to the normal line of defense, its ability to protect is diminished. regular exercise, adequate sleep and good nutrition are practices that will expand the flexible line of defense. the broken circles surrounding the basic structure are the lines of resistance, which are defined as the reactions that occur within the client system when a stressor succeeds in penetrating the normal line of defense. their function is to restore equilibrium and protect the basic structure. a familiar example is the body’s increased production of white blood cells in response to the presence of disease-producing bacteria. five variables are seen as overlapping and interacting with and/or influencing all functions of the client system. neuman (1989) stated, "in all lines of defense and resistance are found elements similar, but specific functionally, related to the five client variables" (p.29). all responses of the client systems should be viewed within the context of five variables, which are believed to be present and interactive in all client systems. those variables are: physiological, psychological, socio-cultural, spiritual, developmental. any stressor or reaction to a stressor will fall under one of the five variables. often the variables will overlap. for example, a mother's distress over her child's failure at school may be viewed as socio-cultural if it disrupts her relationship with the child or psychological if the mother experiences a sense of loss of self as a "good mother." another component of the nsm addresses the intra-, interand extra-personal aspects of the system. this component helps the user of the model to recognize that stressors may occur at any of the three levels. online journal of rural nursing and health care, 1(2) 63 the nsm also includes the concept of prevention at the primary, secondary and tertiary levels. this concept is of particular importance to those who work in the helping professions. interventions can occur at a primary level to strengthen the flexible line of defense, at a secondary level to help restore the client system to equilibrium by treating symptoms that occur after penetration of the line of defense by a stressor or a at the tertiary level to prevent farther damage and maintain stability after reconstitution has occurred. interdisciplinary fit although use of interdisciplinary teams is not new to health care industries, it has gained increasing favor in the environment of health care reform as evidenced by governmental recommendations and guidelines (u s bureau of health professions, 1995) and position statements from professional organizations (american association of colleges of nursing, 1995). the trend in nursing is to collaborate with other health care disciplines as well as with clients. use of interdisciplinary health care (ihc) teams can facilitate the emergence of holistic client care goals from teams of diverse health care specialists. upheaval in the health care industry is affecting all health professions. in the movement for health care reform, emphasis is being placed on such things as the need for health promotion, coordinated care, and reduction in cost. some of the watchwords are "prevention", "wellness" and "healthy lifestyles". concepts in the nsm are parallels to those watch words. therefore, it is not surprising that use of the n.s.m. as a framework for interdisciplinary health care practice is increasing, not only in the united states but also around the world. in neuman (1995), lowry, walker and mirenda state the following: "the neuman systems model is clearly poised and ready for the challenges of the future. sometimes characterized in the past as too broad, complex and comprehensive, the model is online journal of rural nursing and health care, 1(2) 64 coming in to its own with the challenges of the 21st century. the complexities of the global society, of crises in health care delivery, and of changing patterns and dangers from the environment provide stimulus for new applications of the neuman systems model. the model is not only broad and comprehensive enough to provide structure for nursing interventions, but also for other disciplines interested in focusing on wellness and holistic care for patients and clients …the ongoing use and scholarly development of the neuman systems model in practice, education, administration and research in domestic and international settings is evidence of this" (pp. 74&75). because the nsm is built on general systems theory with the flexibility which allows identification of the client as an individual, family, group or community, use of the nsm is equally appropriate for an interdisciplinary team in a public health department with client as community, an acute care psychiatric hospital with client as an individual or an adolescent drug rehabilitation center with client as family. this broad range of adaptability facilitates model implementation in many community settings which have increasingly become the location of health care delivery. the literature is rich with examples of adaptation of the model to all of the above client systems. a comprehensive bibliography of publications related to use of the model can be found in neuman, 1995. nsm interdisciplinary practice/education project believing that promotion of an interdisciplinary approach could enhance the quality of services rendered to clients by the helping professions, in 1994 the authors of this article began meeting to explore the use of nsm as the facilitator for interdisciplinary teamwork. the nsm addressed the need for a shared conceptual framework with a common language and a structure for organizing client information. this particular model was chosen because it is a systems online journal of rural nursing and health care, 1(2) 65 model that addresses the interplay of the subsystems within the system as well as their interaction with the environment. the interdisciplinary team is composed of five faculty at brigham university who were interested in exploring the formation of interdisciplinary teams. all have clinical experience in their area of expertise. each member's expertise corresponds with the knowledge base of at least one of the five variables of the model, i.e. a licensed clinical social worker, a religion professor who is a bishop in his congregation, a social worker with doctoral work in human development, a psychiatric nurse and a nurse with expertise in physiological nursing. team members were introduced to nsm by first reading the explanation of the model in the second edition of neuman systems model (neuman, 1989) and then holding a discussion/training session with the psychiatric nurse who was experienced in using the model. the team then agreed to use a case study approach for enhancing learning. client cases were chosen from the clinical experiences of team members. the team reviewed each case and each team member completed an assessment focused on the client domain related to her/his major area of expertise. the assessments were then evaluated by the entire team for completeness, overlap and congruence with the model concepts and purposes. the next step was formulation of a treatment plan. again input was given from each member's expertise, within the framework of the five model variables, with priority given to interventions which addressed the areas of greatest client stress and need. soon after the team began working together, members recognized that their experience could be examined from two different perspectives. one, which they simply labeled "content", was the use of the nsm for assessment and intervention in client cases. the other, labeled "process", was the experience of working together to become a cohesive interdisciplinary team. online journal of rural nursing and health care, 1(2) 66 although some discussion of both is included, the remainder of this article focuses most heavily on illumination of process. factors to consider when incorporating the nsm understanding the model understanding the model is the first step to incorporation of the nsm in any practice setting. there is much flexibility in how this can take place, such as providing classes with an expert lecturing on the model, sending staff to nsm symposiums, holding a series of classes in which lecture and discussion focus on various aspects of the n.s.m. or taking the approach used by the authors in which team members used the model to develop treatment protocols for actual cases. during the practice sessions, cases from team members lived experience quickly and effectively brought the nsm from the level of theory to that of application and allowed the team to experience the fit of the model to their institution and individual philosophies. learning the language of the model learning the language of the model is not a significant problem for most health care professionals. as stated earlier, the model promotes synthesis of knowledge from areas of study which form the matrix for nursing education. that matrix has elements common to the educational foundations of other health care professions. each of the five variables, i.e. physiological, psychological, socio-cultural, developmental and spiritual, is associated with a field of knowledge that forms the base for practice in some health care related profession. for example, medicine, psychology, physical therapy, social work, and marriage and family counseling, share portions of the educational matrix associated with nursing. thus they are able, for the most part, to speak the language of the nsm, and make major contributions to an interdisciplinary health care team which uses the model. however, because of the breadth of the online journal of rural nursing and health care, 1(2) 67 nsm, other theories, some of which are profession specific, can and must be related to the assessment and intervention processes. all team members must be sensitive to the particular language of their discipline (morrissey, 1989) and must clarify to other members where appropriate. a common language will assist in development of unity among team participants. it is helpful to establish as a group norm the expectation that each member is responsible to ask for and expect to receive clarification of all unfamiliar terminology used by any other team member. it is not unusual for clergy to have an educational background dissimilar to that of the health care professions. the spiritual expert on our team, a professor of religion who is also a lay minister, was the team member least familiar with terminology used in the nsm. conversely, other members of the team were at times unfamiliar with certain religious terminology. in those instances when team members have dissimilar backgrounds, extra time and effort may be required for the team to learn to speak a common language. in summary, the primary reason the nsm adapts well to interdisciplinary use is because it was developed on the premise that the practice of holistic health care must be built on a foundation of synthesized knowledge and interdisciplinary cooperation based in a common language and dynamic systems concepts (neuman & young 1972). functioning as a team functioning as a team is always a challenge and may be particularly difficult if members are accustomed to functioning independently. there is a history of literature related to group process and team building (bennis & shepard, 1956; yalom, 1985; toner, miller & gurland, 1994) which can be applied to interdisciplinary health care teams. consideration of issues specific to promoting productive team norms is important. areas that the project team addressed included: online journal of rural nursing and health care, 1(2) 68 1. the client is a member of the team even though (s)he may not be present at team meetings. this viewpoint helps counter feelings of possessiveness which lead to viewing the client as one's personal property. 2. members must be comfortable acting as team players. those who are not committed, having little desire to participate in team activities, will interfere with the development of team cohesiveness and consume inordinate amounts of team energy. therefore, serious consideration should be given to assigning members to an interdisciplinary team who are truly committed. 3. accountability for certain professional activities may, by law, be designated as the domain of a given profession and must be carried out by the person on the team representing that profession. however, such responsibility seldom, if ever, dictates "ownership" of the case by any one professional. 4. except in areas of legal accountability, professional boundaries cannot be rigidly maintained. factors such as the particular talent of a given team member or client trust may be more important to positive client outcomes than strict maintenance of professional boundaries. assignment of the care coordinator assignment of the care coordinator is an especially important issue. the term "care coordinator" defines the professional who has personal contact with the client, primary responsibility for orchestrating client services and, as the role is being defined in this article, leadership responsibility in those client cases. similar titles which have been used are primary therapist, case coordinator, treatment coordinator, case manager and primary care giver. as case assignments are developed, flexibility and cohesion are critical team attributes (morrissey, online journal of rural nursing and health care, 1(2) 69 1989). rewards for team members will not be equal for each client case. this issue needs to be addressed at the time the team is formed and consensus reached regarding resolution of the potentially negative impact. chafetz (1988) emphasized the importance of the team having a designated leader and the challenge of determining who that leader may be. assignment of the care coordinator often is both an agency and a team issue. the infrastructures of some institutions or agencies dictate the assignment of a given team member as the care coordinator. for instance, in the netherlands the psychiatric nurse is the ihc team member who makes home visits and functions as care coordinator for all psychiatric outpatients. even so, assessment and treatment planning is done by an interdisciplinary team (neuman, 1995). in some instances, the care coordinator may be assigned through a simple system of rotating initial assessment of new clients among the various members of the team and assigning the client to the team member doing that initial assessment. in other instances, a given team member is the care coordinator to all clients in a designated geographical area. although a process which is more specific to client needs is preferable, none of the above structures negates the use of an interdisciplinary team. the authors believe that the critical issue for interdisciplinary work is constant input of the expertise of all team members to all cases. in essence, all team members are assigned to all cases. in settings where the role of care coordinator is open to all professionals on the ihc team, careful consideration of all factors relevant to positive client outcomes should direct selection of the care coordinator. some of the questions most important to consider are: a) in whom does the client have the most trust? b) what problems are most troubling for the client? and c) who has expertise to best intervene? logistical questions to be considered include the amount of time the client will need and which member is available to provide the needed time. online journal of rural nursing and health care, 1(2) 70 such issues can easily become the primary consideration in the assignment of care coordinators. reliance on logistics only should be avoided, since consideration of all relevant factors is essential for provision of the quality of care necessary for optimal client health outcomes. cost of care with use of ihc teams cost of care with use of ihc teams is often one of the first objections raised to this treatment approach. initial cost may, indeed, seem high because of staff time consumed in assessment and treatment planning. however, the authors believe when using the nsm as the framework for interdisciplinary work, one of the long term benefits is significant reduction in cost of care. when the client is viewed as a whole and all variables, as well as the interplay of those variables with the environment, are continually assessed, client problems are addressed as a package with chances of readmission for interrelated problems greatly reduced. errors in care protocol are also reduced using team expertise in decision making as opposed to the individual caregiver viewpoint. our team found over time we became much more efficient and effective in assessing client conditions and planning appropriate interventions. we attributed this to increased familiarity with the nsm, greater understanding and trust among members, and an increase in levels of expertise through sharing/processing of information. one way of reducing cost with the ihc team is to streamline the assessment and treatment planning process. to accomplish this, our team developed an interdisciplinary assessment form, iaf, to be used with the nsm. the form facilitates a quick triage of clients by identifying the domain(s) of the five variables which contain the greatest stressors for the client and determining the expertise most needed to intervene. online journal of rural nursing and health care, 1(2) 71 application in education the team member, who represented expertise in human development, has developed and taught an interdisciplinary undergraduate course in general systems theory using the nsm as the main example for application of general systems theory in the clinical setting. using the nsm, a case study and the interdisciplinary assessment form, students assess the client's needs and determine which member of an interdisciplinary health care team would be the most appropriate care coordinator for the client. the team has developed a proposal for an honors course which would be open to any honors student interested in the health care professions or behavioral sciences. the course will be built on the nsm and emphasize use of an interdisciplinary team for assessing and intervening in client problems. a case study approach will be used. all members on the team will participate in teaching with each member presenting information related to his/her major area of expertise. at the administrative and faculty level, interest in this course is generated by a desire for increased interdisciplinary activity on the brigham young university campus. summary this interdisciplinary health care team experience has enhanced the level of our professional expertise and has enriched both our professional and personal lives. the experience of coming together for the good of the client has its own intrinsic value. we believe that, with a history of increasing health care specialization and compartmentalization, the work of interdisciplinary health care teams using a wholistic model of care is one of the few health care options leading toward increased levels of wellness for all people in all countries. online journal of rural nursing and health care, 1(2) 72 references bennis, w., & shepard, h. (1956). a theory of group development. human relations 9, 415 437. https://doi.org/10.1177/001872675600900403 carson, v.b., & arnold, e.n. (1996). mental health nursing: the nurse-patient journey. philadelphia, pa: saunders. chefetz, p., west, h., & ebbs, e. (1988). overcoming obstacles to cooperation in interdisciplinary long term care teams. journal of gerontological social work, 11(3/4), 131-140. clark, p.g. (1997). values in health care professional socialization: implications for geriatric education in interdisciplinary teamwork. gerontologist, 37, 441-451. https://doi.org/10.1093/geront/37.4.441 davis, s., & botkin, j. (1994). the coming of knowledge-based business. harvard business review, 72(5), 165-170. donley, r. (1991). spiritual dimensions of health care: nursing's mission. nursing and health care, 12(4), 178-183. morrissey, s., moore, s., queiro-tajalli, i., & martz, b.l. (1989). building interdisciplinary teams in gerontological education. educational gerontology 15, 385-394. https://doi.org/10.1080/0380127890150406 neuman, b., & young, r.j. (1972). a model for teaching total person approach to patient problems. nursing research, 21, 264-269. https://doi.org/10.1097/00006199-197205000-00015 neuman, b. (ed.). (1989). the neuman systems model (2nd ed.). norwalk, ct: appleton & lange. https://doi.org/10.1177/001872675600900403 https://doi.org/10.1093/geront/37.4.441 https://doi.org/10.1080/0380127890150406 https://doi.org/10.1097/00006199-197205000-00015 online journal of rural nursing and health care, 1(2) 73 neuman, b. (ed.). (1995). the neuman systems model (3rd ed.). san mateo, ca: appleton & lange. stoddard, s. (1978). the hospice movement. new york, ny: vintage books. toner, j.a., miller, p., & gurland, b.j. (1994). conceptual, theoretical, and practical approaches to the development of interdisciplinary teams: a transactional model. educational gerontology, 20, 53-69. https://doi.org/10.1080/0360127940200105 https://doi.org/10.1080/0360127940200105 leimkuhler_663_formatted online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 3 rural populations’ sources of cancer prevention and health promotion information megan e. leimkuhler, ba 1 lindsay hauser 2 noelle voges 3 pamela b. deguzman, phd, mba, rn, cnl4 1 university of virginia school of medicine’s master of public health program, master of public health candidate, mel7sp@virginia.edu 2 director of outreach and engagement, school of medicine cancer center without walls, university of virginia, lh7yn@virginia.edu 3 assistant director of outreach and engagement, school of medicine cancer center without walls, university of virginia, nev6e@virginia.edu 4 assistant professor, school of nursing, university of virginia, prb7y@virginia.edu abstract purpose: rural residents are less likely to engage in cancer risk-reduction behaviors than their urban counterparts. rural cancer disparities may be related to limited access to and comprehension of cancer-related health information. the object of this study was to identify how rural residents access and understand cancer health promotion and prevention information. sample: twenty-seven residents of central virginia methods: we used a qualitative design with semi-structured interviews and a focus group (n=27) with rural and non-rural residents living in central virginia to accomplish the study aim. findings: four themes were identified from the data: 1) non-rural central virginia residents seek health information from a variety of electronic sources, 2) rural central virginia residents typically seek health care information directly from health care professionals, 3) residents throughout online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 4 central virginia encounter confusing health care information, and 4) rural residents report incorrect cancer-related information. conclusions: lack of internet access coupled with healthcare shortages may limit the ability of rural residents to contextualize and verify inaccurate health information. nurses serving a rural population should consider assessing each rural patient’s internet access and disseminating printed cancer health promotion materials to rural clients without internet access. keywords: rural health; healthcare disparities; access to care; cancer health promotion; health literacy; cancer rural populations’ sources of cancer prevention and health promotion information united states cancer mortality is on the decline; however, similar reductions are not equally shared across geographic areas. geographic variations in cancer rates are driven in large part by modifiable factors such as smoking and obesity rates. the largest geographic variation in cancer occurrence is for those cancer types that are amendable to prevention, such as lung cancer (siegel et al., 2020). engaging in health promotion behaviors (avoiding tobacco products, increasing physical activity) can help prevent cancer (american cancer society, 2020a). however, in the u.s., rural residents are more likely to smoke and less likely to maintain normal body weight and meet leisure time physical activity recommendations than their urban counterparts (matthews et al., 2017). cancer health promotion is not only critical to preventing cancer, but also to reduce risk to cancer survivors of recurrent and new cancer (american cancer society, 2020b; ng & travis, 2008). for those with an existing cancer diagnosis, participation in healthy behaviors can reduce recurrence and improve survival (spector, 2018). however, the 2.8 million cancer survivors living online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 5 in the rural u.s. have lower rates of health promotion behaviors than their urban counterparts (weaver et al., 2013). this disparity may explain why survivors living in rural areas have higher cancer death rates, often despite lower cancer incidence rates (henley et al., 2017). in the rural u.s., access to high quality health care information is impacted by several factors, most notably limited access to health care providers and limitations in health literacy. rural residents in the u.s. are more likely to access health information directly from care providers (chen et al., 2019). this difference is related to the digital divide, the gap in access to reliable high-speed internet service (douthit et al., 2015), and is likely a reason why fewer rural residents use e-mail or the internet to connect with their care providers (greenberg et al., 2018). it is widely accepted that access to high speed, reliable internet is problematic in the rural u.s (chen et al., 2019; perrin, 2019; united states federal communications commission, n.d). although access to internet-based cancer information does not ensure that the user will access reputable sources, certain no-cost sources of free reputable health information such as high-quality evidence-based cochrane reviews of randomized control trials are only available to those who have access to the internet (oxman & paulsen, 2019). for rural residents who have the connectivity to access evidence-based cancer information online, health literacy poses an additional barrier (chen et al., 2019; zahnd et al., 2018). one research study conducted among residents of the mississippi delta found a significant correlation between health literacy scores and both healthy eating and consumption of sugary beverages (zoellner et al., 2011). among cancer survivors, rural residents report putting in less effort to obtain health care information, fewer concerns regarding the quality, and greater difficulty understanding cancer health information (katz et al., 2010). online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 6 nurses have a long history of establishing trust in rural communities (chipp et al., 2011; reay et al., 2006), and can positively influence the health promotion behaviors of their clientele (oh et al., 2014; williams et al., 2014). nurses can help rural patients reduce risk of poor cancer outcomes by providing them with evidence-based cancer health promotion information. to address gaps in patient knowledge, nurses may benefit from knowing how rural individuals obtain cancer information, what information they are able to obtain, and how they process the information. thus, the purpose of this research was to identify how rural residents access and understand cancer health promotion and prevention information. method we utilized a qualitative design to address the study purpose. data was drawn from a community-based needs assessment conducted by the cancer center at the university of virginia medical center (uvacc), located in charlottesville, virginia. figure 1: virginia counties categorized by the rural-urban status using national center for health statistics’ rural-urban classification scheme for counties. counties with a blue border indicate the service area of one of two national cancer institute-designated cancer centers in virginia that serves a largely rural catchment area. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 7 the uvacc is one of two national cancer institute (nci)-designated cancer centers in virginia. its catchment area extends from charlottesville to the northern, western, and southern state borders and is made up of small urban and rural areas. the figure presents the counties of virginia classified using the national center for health statistics (nchs) urban-rural classification scheme (ingram & franco, 2014), overlain with the catchment area of the uvacc. the community assessment was conducted in 2017 to better understand the cancer-related needs, barriers to health care access, and need for enhanced cancer-related services and care for residents of central virginia as part of a standard from the commission on cancer. assessment participants included those with and without a cancer diagnosis, and those living in an area of the uvacc catchment area, which includes small urban, suburban, and rural areas in central virginia. all recruitment, data collection, and human subject protections were overseen and approved by the university of virginia institutional review board for social and behavioral sciences. participant recruitment to ensure a broad sample of participants, a venue-based recruitment strategy was utilized. we screened, recruited, consented, and interviewed participants at several clinic waiting areas, public libraries and public health clinics in surrounding rural counties, and at a nationally accredited senior center located in a suburban county. to meet inclusion criteria, participants had to identify themselves as residing in virginia and being at least 18 years of age or older. data collection we utilized semi-structured interviews to determine respondents’ experience with cancer health promotion and prevention. qualitative studies that utilize semi-structured interviews are typically guided by a list of topics to cover, rather than a predetermined, unchangeable series of specific questions to ask (polit & beck, 2012). because our participants included both those with online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 8 and without a history of cancer, and the topics included cancer-related prevention and health promotion behaviors, the interview guide was structured differently for those with a previous cancer diagnosis (i.e., cancer survivors). for participants who had never had a cancer diagnosis (i.e., community members), topics focused on health promotion activities, including exercising regularly, quitting smoking, reducing alcohol intake, and eating a healthy diet. participants were also asked about their access to health care information and resources. cancer survivors were asked to speak about their knowledge of health maintenance behaviors as a cancer survivor, what actions they were currently taking to maintain their health post-treatment completion, and where they sought information about how to stay healthy. all interviews were conducted individually either in-person or over the phone, except for one in-person focus group of all cancer survivors (using the cancer survivor interview guide) conducted at the suburban senior center. demographic information was collected from each participant, including sex, age, county of residence, and lowincome status, which is a pervasive driver of health literacy inequalities (cutilli et al., 2018; michou et al., 2019; sudore et al., 2006; tang et al., 2019). income status was dichotomized as yes or no based on the participant’s answer to the question “do you ever have difficulty meeting the basic financial needs of your household (rent, electricity, etc.)”. data analysis the focus group and interviews were audio recorded and transcribed verbatim. analysis was conducted according to sandelowski’s descriptive content approach. transcripts were analyzed by the research team using a line-by-line approach (sandelowski, 2000). dedoose, a cross-platform application for analyzing qualitative and mixed methods research with text, was used to conduct inductive open coding to generate and organize codes and themes within the interview text data online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 9 (dedoose version 8.3.5, 2020). to reduce bias, two researchers (m.e.l. and p.b.d.) worked in tandem, discussing and each code and theme designation, until consensus was reached. for the purpose of comparative analysis between rural and urban areas, we used the nchs urban rural classification scheme (ingram & franco, 2014). rural and urban status were classified accounting for the unique geography of the cancer center location with a small city surrounded by rural areas. although all areas in the immediate region are classified as either rural or small urban, we considered the small urban and immediately surrounding areas of charlottesville and albemarle county as “urban” and those outside of a 45-minute radius as rural, unless they lived in an area classified by nchs as urban or medium metropolitan. results we collected data from 27 participants. participant details are in the table. table 1 participant characteristics (n = 27) characteristic n (%) interview type one-on-one 21 (77.8%) focus group 6 (22.2%) cancer status cancer survivor 16 (59.3%) community member 11 (40.7%) residence type rural resident 11 (40.7%) non-rural resident 16 (59.3%) sex female 19 (70.4%) male 7 (25.9%) missing data 1 (03.7%) socioeconomic status not low-income 14 (51.9%) low-income 12 (44.4%) age 65 or younger 15 (55.6%) over 65 12 (44.4.5) online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 10 overall, our sample represented both rural and non-rural areas of central virginia, with ages ranging from 21 to 88. eleven of the interviewees were residents who had never received a cancer diagnosis, while 16 were cancer survivors. respondents were split roughly equally between those who self-identified themselves as low-income and those who did not. four themes were identified from the data: 1) non-rural central virginia residents seek health information from electronic sources, 2) rural central virginia residents primarily seek health care information directly from health care professionals, 3) residents throughout central virginia encounter confusing cancer health information, and 4) rural residents report incorrect cancer-related information. of note, we did not discern any unique themes from those who selfreported as low-income; however, we have identified which quotes are from low-income individuals in the following thematic exemplars. non-rural virginians seek health information from a variety of electronic sources residents of non-rural counties in central virginia frequently reported seeking health advice and information predominantly from electronic sources, such as television programming or webbased resources. a 71-year-old cancer survivor from a non-rural county reported primarily seeking health information through internet-based searches and forums such as club red, a local membership-based online community for preventing heart disease: “so, you know, i get information from, as i said, club red [and] from different blogs on the internet.” an 82-year-old female community member from a non-rural county also reported that she utilized club red for health promotion information. a low-income 35-year-old female community member from a nonrural county reported using facebook to connect with organized walking groups within the community: “that’s always a great place to find some support.” she reported using the online community to meet up with walking groups at a local high school track in the evenings, at no cost online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 11 to her. several non-rural community members and cancer survivors reported using the internet, and two members specifically mentioned dr. oz as a source of health information. an 82-yearold female cancer survivor from a non-rural county reported frequent use of online print materials, including newspapers and magazines: well, i use the internet quite a lot… the washington post and health periodicals that come out, like harvard and other teaching hospitals, you know, that are directed… to women’s health. so… i really get a lot of information on that. she also described participating in an online support group for survivors of a rare cancer that she discovered through the washington post: “it has just been wonderful. and these people are all over the world ‘cause it’s so rare. there’s only about a hundred people in the support group.” rural virginians seek health care information directly from health care professionals study participants from rural counties predominantly reported seeking cancer-related health information directly from a health care provider. a 69-year-old female cancer survivor from a rural county reported that her family did not use the internet to look up information on how to maintain her health after cancer treatment, instead seeking information directly from her physician: “we haven’t looked up anything on the internet, ‘cause you know… we can ask [my doctor] when we come [to the clinic], if there is anything we need... he’s really good.” another rural cancer survivor, a 49-year-old male, discussed his difficulty accessing information after treatment and his reliance on medical professionals rather than health care websites on the internet. “where would i get information? i have to ask the doctors or somebody.” when asked if he used the internet for advice on how to take care of his health needs, he said “not really…i go to the medical websites…most of the hospitals have a website.” when asked about what resources she would seek for improving her health, a rural 44-year-old female community member said that she would “probably start with online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 12 the doctor.” similarly, a low-income rural female community member noted that her husband sought out “a nutrition clinic” at the area nci-designated hospital. a rural 79-year-old female community member whose husband is a cancer survivor reported that they sought post-treatment health promotion information from a specialty clinic close to their home. we live about seven miles from [the community hospital-based clinic, and] …they have an ostomy nurse that we can contact that is very knowledgeable. they have a meeting every couple of months for ostomy patients in the area. and she’s available on the phone for information if you want to call her or if you got any questions or anything. residents throughout central virginia encounter confusing cancer health information all participants, from both rural and non-rural areas described several sources of confusion about cancer-related health promotion information. one source of confusion was related to the volume of information available. a rural 65-year-old female community member reported, “well there’s a lot of stuff, i mean just in the health magazines, magazines themselves, you know, for healthy eating that’s out there.” two separate community members from non-rural counties conflated sources for heart health with those aimed at cancer health. when asked specifically about sources of cancer-related health promotion information, they both cited club red as an internetbased source. however, club red is a medical center-affiliated organization dedicated to promoting heart healthy lives by preventing and controlling heart disease, not the prevention of cancer (jump, 2007). another participant reported the frustration of trying to synthesize what seemed like conflicting information about how to maintain cancer-related health. a 66-year-old female cancer survivor, also from a rural county, stated: online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 13 well, it’s ‘you should definitely eat this’ and then a month later, maybe not, you know… or something like drinking coffee. it’s helpful to have two cups of coffee today, but it’s harmful two weeks later, type thing. that’s what sometimes gets frustrating… cancer survivors also experienced confusion about the different places they could seek reputable information about health maintenance. despite living in the same county as an nci-designated cancer center, multiple cancer survivors did not know where to seek cancer-related health information after completing treatment. [when undergoing cancer treatment] i had my consult with the surgeon and his team, [and] they went over everything that was focused on their surgery but in terms of me afterwards, when i leave that office … i had no idea that there were resources available. it’s not evident that there are resources available… i didn’t know there was a resource center until i saw it in the newsletter from the senior center. rural residents report incorrect cancer-related information multiple participants from rural areas of central virginia reported cancer-related health information that was either factually incorrect or incorrectly synthesized. when asked about dietary habits that help prevent cancer, a rural 59-year-old cancer survivor reported that “this girl told me that cancer survives on sugar.” in response to the same question, a rural female participant stated that she heard “some people say that eating a lot of gluten can cause cancer.” though she stated that she was “not sure how true that is,” she noted that she had “heard that said a few times.” when asked about the relationship between alcohol and cancer, a 44-year-old female rural community member conflated liver cancer with cirrhosis of the liver, stating that liver cancer could be contracted “from your diet, what you eat… you don’t have to drink anything.” online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 14 discussion our interviews with central virginia community members and cancer survivors illustrate how rural residents in our region obtain and process cancer-related health information. the results suggest how rural and urban populations can differ in sources and interpretation of cancer-related health promotion information. both rural and urban residents reported difficulty synthesizing information from different sources; however, these groups differed in how they obtained and validated the information. electronic media was reported as a main cancer-related health information source for our non-rural participants. this is not surprising given that the most reported source of health information in the united states is the internet (swoboda et al., 2018). in a few cases, non-rural participants reported using online sources such as those from medical talk shows and a national newspaper. only about half of advice offered on televised medical shows are supported by evidence (korownyk et al., 2014); health professionals have similarly mixed opinions about the benefit of newspapers as sources of cancer-related health information, which likely reflects inconsistent quality of content (mccaw et al., 2014). while information gleaned may not be entirely evidence-based, there may be some benefits. for example, the participant who reported seeking information from a national newspaper health section was looking for information about a rare cancer, and the information led her to join a support group for that specific group. in light of a potentially mixed benefit, nurses should inquire about which electronic sources patients use, and provide an evidence-based context to the information found. although some of our rural participants also reported using the internet, most described that they would seek cancer-related health information directly from care providers. this difference is perhaps not surprising, given that 660,000 homes and businesses across virginia lack broadband internet access, which reflects the state of limited broadband access across rural america online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 15 (“commonwealth connect,” 2019; larose et al., 2007). despite their reported reliance on health care professionals for cancer-related information, several rural residents reported incorrect or incorrectly synthesized information about how to prevent cancer, and when they did, health care providers were not cited as the source. in fact, sources of misinformation were described vaguely, such as information they had “heard.” this finding is perhaps not surprising given both the lack of access to both the internet and to health professionals. while inaccurate health information is found broadly across the internet and use of it certainly does not shield users from finding wrong information (green et al., 2020), the internet also contains many free primary and synthesized sources of evidence (oxman & paulsen, 2019). rural residents also have less access to confirm or contextualize misinformation because there are significant shortages of primary care providers in rural areas of the u.s. compared with urban areas, and rural residents are more likely to delay medical visits due to distress or fear (graves et al., 2016; stephen et al., 2013). thus, we hypothesize that when rural residents receive imprecise or poorly understood information, they are left to synthesize this information on their own, and that when internet access is lacking, rural populations are even more reliant on health promotion education from a health care professional. implications for rural nurses as the role of nurses continue to expand in the u.s., there is an opportunity to impact rural health disparities (owens, 2018). our research suggests that nurses with a rural clientele should prioritize using clear, factual, appropriately-leveled materials to educate patients about health behaviors that prevent cancer. as part of a health literacy assessment, nurses should consider inquiring about the internet access of their patients, with the understanding that it may limit the availability of clear and appropriate health promotion materials. for those clients with internet access, nurses can discuss which electronic sources patients are using, and if necessary, redirect online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 16 them toward evidence-based online sources. for lower literacy populations, it is well accepted that materials should be written at a 6th grade or lower reading level and include illustrations to maximize effectiveness (safeer & keenan, 2005). as such, evidence-based reviews may not be appropriately leveled for many patients. the american cancer society website (www.cancer.org) contains health information written in plain language (merriman et al., 2002). nurses may need to ensure that patients can search and navigate to the appropriate materials. for those patients with limited access to broadband internet, rural nurses should prioritize distribution of appropriate-level printed (i.e., non-electronic) materials. for certain cancers, practitioners can request free printed cancer-related health information materials from the centers for disease control and prevention, and can print health prevention materials from the american cancer society’s website. to supplement these resources, nurses may consider identifying regional cancer centers that serve their geographic areas to develop partnerships in public health education. these centers may have access to additional printed materials that can help maintain the health of those within their service area. care providers and staff of regional cancer centers serving rural communities are also likely to be knowledgeable about the local rural culture, which can vary considerably geographically (morgan & reel, 2003). ultimately improvements in rural electronic communications infrastructure, specifically enhanced broadband internet access to rural areas, would also improve health care providers’ ability to deliver sufficient, easily digestible information to patients. limitations our study was qualitative and thus findings are not generalizable. we recruited a sample from across central virginia, that was intended to represent a diverse background of residents, while venue-based recruitment enabled us to have incorporate a large proportion of cancer survivors and those living in rural areas; however, results should not be interpreted as online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.663 17 representative of the central virginia population or other areas of the united states. rather, these results are intended to inform practice and promote research to reduce rural disparities in cancer outcomes. conclusion rural cancer-related health disparities may be related to limited access to accurate and appropriately-leveled health promotion information. nurses serving rural populations may improve the health knowledge of their clientele by intentionally disseminating appropriatelyleveled print-based information, and inquiring about access to certain internet-based resources. partnering with regional cancer centers whose service area extends to the nurse practice area may be warranted and should be considered to improve access to appropriate cancer health promotion materials. references american cancer society. 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(2011). health literacy is associated with healthy eating index scores and sugar-sweetened beverage intake: findings from the rural lower mississippi delta. journal of the american dietetic association, 111(7), 1012–1020. https://doi.org/10.1016/ j.jada.2011.04.010 terry_589_formatted online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 32 what australian nursing students value as important in undertaking rural practice daniel r. terry1 blake peck, phd 2 andrew smith, mph 3 tyrin stevenson, mhs 4 hoang nguyen, phd 5 ed baker, phd 6 1 senior lecturer and academic integrity officer, school of nursing and healthcare professions, federation university australia, ballarat, australia, d.terry@federation.edu.au 2 senior lecturer and graduate program coordinator, school of nursing and healthcare professions, federation university australia, ballarat, australia, b.peck@federation.edu.au 3 lecturer and undergraduate program coordinator, school of nursing and healthcare professions, federation university australia, ballarat, australia, andrew.smith@federation.edu.au 4 adjunct professor, center for health policy, boise state university, boise, idaho, usa, tyrinstevenson@boisestate.edu 5 lecturer, wicking dementia research and education centre, university of tasmania, hobart, australia, hoang.nguyen@utas.edu.au 6 professor, department of community and environmental health and director, center for health policy, boise state university, boise, idaho, usa, ebaker@boisestate.edu abstract online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 33 background: rural health services in australia are continually challenged by both the recruitment and retention of the nursing workforce. the aim of the study was to examine what nursing students consider the most important factors for undertaking a rural career in australia. methods: nursing students (n=1,982) studying a three-year bachelor’s degree at an australian university were invited to complete an online survey that examined their rural practice intentions. the questionnaire included demographic, rural background and career intentions, and a modified nursing community apgar questionnaire (ncaq). results: the factors identified most important among nursing students when considering rural practice include patient safety and high-quality care, having autonomy and respect from management, the establishment of positive relationships and good communication between different generations of nurses, and the work environment providing job satisfaction with good morale. conclusions: this study provided insight for rural and regional universities and health services to better demonstrate what students indicate is important to take up rural practice, while highlighting unique challenges for the rural nursing workforce. key elements are proposed that may be augmented at the university and health service level to guide recruitment and possibly retention. rural recruitment and retention of new graduate nurses may be better achieved by addressing what nursing students feel are most important to them when considering rural practice, which are focused around management, decision-making, and practice environment factors rather than economic or community-based factors. the greatest importance to students is the ‘fit between’ them and the agency and much less about their ‘fit with’ the community into which they will be entering. keywords: nurses, students, health workforce, recruitment and retention, community apgar online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 34 what australian nursing students value as important in undertaking rural practice along with other healthcare professionals, nurses maintain the viability of rural health services; however, rural communities experience significant challenges recruiting and retaining nurses, which is exacerbated by an aging workforce (cramer, duncan, megel, & pitkin 2009; prengaman, bigbee, baker, & schmitz, 2014; prengaman, terry, schmitz, & baker, 2017). to address this challenge, policy, programs, and research have attempted to promote and enable recruitment and retention of nurses in rural and remote areas (cramer et al., 2009; mbemba, gagnon, pare, & côté, 2013). workforce programs have focused on rural communities growing their own (cramer et al., 2009), while research programs have emphasised increasing students’ rural clinical experiences and community exposure to increase the likelihood of rural employment (prengaman, bigbee, baker et al., 2014; prengaman, terry, schmitz et al., 2017; smith et al., 2018; terry, baker, & schmitz, 2016). numerous studies and programs have demonstrated various approaches to successfully improve rural recruitment and retention of health professionals, such as strategies to improve recruitment, enhancing job satisfaction, financial incentives, and supporting rural health career pathways (fisher & fraser, 2010). some examples from the findings and recommendations include a history of student rural background being a predictor of rural career choice (kondalsamychennakesavan et al., 2015; macqueen et al., 2018); metropolitan and rural students who undertake rural placements are more likely to undertake rural practice (playford, larson, & wheatland, 2006); and having quality clinical placements and high quality clinical supervision impacts rural practice uptake (macqueen et al., 2018; smith et al., 2018) while there has been a number of studies seeking to understand the factors that lead nursing students to have an interest in rural practice, there is limited understanding of how and why nursing online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 35 students choose rural locations to practice (bushy & leipert, 2005; schofield, fletcher, fuller, birden, & page, 2009; trépanier et al., 2013). however, a study by sutton and colleagues (2016) indicated decision-making is influenced by a number of both non-professional and professional elements. it was shown that nursing and allied health students as well as recent graduates suggested that connectedness to people, place and community, seeing a career pathway and having an opportunity to experience living and working in a rural or remote area were vital in the decision making process. despite these key findings, there were only 13 nursing students within the study, and there remains little insight into the specific factors that nursing students consider to be most important when considering a career in rural practice (sutton et al., 2016; trépanier et al., 2013). in an effort to address the knowledge gap pertaining to the matters that nursing students find important in their deliberations about pursuing a rural career, a previously successful approach was used. initially developed to address physician recruitment and retention issues in rural idaho, the application has been shown to be fruitful in identifying what medical students find important when considering rural practice (reed, schmitz, baker, girvan, & mcdonald, 2017; schmitz, baker, nukui, epperly, & schmitz, 2011). the community apgar questionnaire (caq) continues to be commercially used for the recruitment and retention of physicians across the us states of idaho, wyoming, north dakota, wisconsin, alaska, maine, utah, montana, indiana and iowa (national recruitment and retention network, n.d.), and has been piloted in rural australia as both a physician and nursing recruitment strategy (baker, schmitz, epperly, nukui, & miller, 2010; baker, schmitz, wasden, mackenzie, & epperly, 2012; prengaman, terry, schmitz et al., 2017; schmitz, baker, nukui et al., 2011; schmitz, baker, mackenzie, kinney, & epperly, 2015). traditionally, the apgar is used to quantify resources and capabilities of newborns (apgar, 1966), so too the caq and the nursing community apgar questionnaire (ncaq) help to quantify online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 36 resources and capabilities of a rural community to recruit and retain healthcare staff (prengaman, bigbee, baker et al., 2014; schmitz, baker, nukui et al., 2011). the aim of these tools is to provide an evidence base of key strengths, challenges, and the community’s overall capacity to recruit and retain healthcare staff, while supporting health facilities to develop achievable long-term goals to meet the needs of a rural community (prengaman, bigbee, baker et al., 2014; schmitz, baker, nukui et al., 2011). a modified caq has previously been used among medical students to understand their intentions to undertake rural practice after graduation (reed et al., 2017). from the study conducted by reed et al. (2017), it was highlighted that spousal satisfaction, the frequency of oncall, collegiality and competition among colleagues, and how medical students perceive being needed and supported by the community were demonstrated to be important factors to consider rural employment. the study further highlighted there were differences in what was thought important when considering a rural practice among male and female medical students and those students from rural and urban centers (reed et al., 2017). similarly, a modified version of the ncaq could be used to ask nursing students what level of importance they place on geographic, economic, management, scope of practice, and support factors when considering rural employment (prengaman, bigbee, baker, et al., 2014). understanding the internal personal factors that impact the intention of nursing students, including variances among students who are male, female, and have a rural or urban background, to take up rural employment is considered vital. therefore, the aim of the exploratory study is to examine the factors that nursing students consider the most important to undertake a rural career. specifically, the study sought to answer the following questions: online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 37 1. what factors are most important for nursing students to consider contemplating a rural career? 2. does gender, where students grew up, and where students want to work geographically after graduation, have an impact on what factors nursing students consider important in undertaking a rural career? methods a cross sectional design was used to examine the importance bachelor of nursing students place on undertaking careers in rural areas. the study was conducted through an australian university, which has campuses in rural, regional and peri-urban centers, which provides a wide range of views regarding future rural practice. ethical considerations ethical approval was provided by the federation university australia human research ethics committee (approval #18-017). the invitation to participate in the anonymous survey was sent in the mid-year break to reduce bias or impact on students’ studies and reduce the risk of coercion. no incentives were offered to participants. sample all nursing students (n = 1,982) studying the three-year bachelor’s degree at the university were invited to complete an online questionnaire that examined their rural practice intentions. the nursing student cohort consisted of 60.0% (n = 1,189) rural and regional students, 87.8% (n = 1,740) female students, 8.8% (n = 174) international students, 0.8% (n = 16) aboriginal or torres strait islander, and 22.8% (n = 452) entering the program directly from high school. the sample size required (n = 196) was deemed to have power to detect a 5% absolute difference within and between groups, alpha (2 tailed) = 0.05, margin of error = ±5%. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 38 data collection tool data were collected using a questionnaire that included 23 demographic questions including gender, year of birth, past and current place of residence, current employment, possible future work locations, and marital status. rural background was defined by students when asked to indicate if they grew up in a) inner city metropolitan, b) outer suburb metropolitan, c) a large town or regional centre, d) a small town, or e) on a property or farm. responses were coded inline with relevant modified monash model (mmm) geographical classifications as achieved elsewhere (smith et al., 2018). in addition, the questionnaire included a modified version of the ncaq, which included minor wording changes to meet the australian clinical context. the ncaq demonstrates good reliability with a cronbach alpha of .96, and good face and content validity (prengaman, bigbee, baker et al., 2014; prengaman, terry, schmitz, et al., 2017). the ncaq contains 50 factors relevant to nurse practice intentions (recruitment and retention) in rural areas and ascertains the advantages or challenges and the level of importance of working in rural areas for each factor. the 50 factors are classified into five classes, each containing 10 questions, and include: (a) geographic factors, (b) economic and resource factors, (c) management and decision-making factors, (d) practice environment and scope of practice factors, and (e) community and practice support factors (prengaman, bigbee, baker, et al., 2014). the modified ncaq asked students about the level of importance they place on the 50 rural factors, and are measured using a four-point scale (very important, important, unimportant, very unimportant). including the questions concerning the advantages/disadvantages of the 50 factors was deemed irrelevant, as students were not currently working as registered nurses in rural practice. the questionnaire tool took between 15-25 minutes to complete. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 39 data collection data collection occurred between 28 june and 31 july 2018. administration staff were provided with an invitation letter from the researchers to be forwarded to all nursing students via email to maintain anonymity of students. the invitation included a web link to the information regarding student participation, where students gave informed consent, and could then undertake the survey on-line. a follow-up recruitment email was sent from administration staff to nursing students in weeks 1, 2, and 4 post initial invitation until an adequate sample size (n ≥ 196) was obtained to meet 95%ci (moe ±5%). data were excluded if students did not complete the ncaq questionnaire within the survey. data analysis data were cleaned, checked, and analysed using statistical package for the social sciences (spss), version 24.0 (ibm corporation, 2016) and microsoft excel (version 15.25.1). data were then scored by assigning quantitative values to the four-point scale according to the participant’s perceived importance (very important = 4, important = 3, unimportant = 2, very unimportant = 1), as described elsewhere (prengaman, bigbee, baker et al., 2014; prengaman, terry, schmitz et al., 2017). these importance scores for each factor were then divided by the number of participants to give an overall mean score. independent sample t-test and one-way anova were used to analyse data and identify differences according to metropolitan and rural residence, gender, and student intention to practice after graduating from the bachelor degree program. in addition, chi-square tests were used to explore if where students grew up had a correlation with students’ decisions concerning where they would work after graduation. significance was determined at two-tailed p ≤ 0.05. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 40 results the web link survey was sent via email to a total of 1,982 first, second and third-year students undertaking a bachelor of nursing degree. among the nursing students invited to participate, 329 responded, yielding a response rate of 16.6%, with the full completion of 202 ncaq questionnaires (response rate of 10.2%). table 1 outlines the demographics of the participants and highlights that more than half (n = 114) of the participants were between 30 and 49 years of age, with a fifth (19.3%, n = 39) of all participants being born overseas. more than half were married or in a partnered relationship, while just under four fifths (79.1%, n = 159) were in some form of paid employment. further, it was noted that where female students grew up was significantly associated with where they would be likely to take up work following graduation (χ = 15.424, df = 6, p = 0.017), phi = 0.285. among female students, 21.2% (n=12) who grew up in metropolitan, and 50.6% (n = 68) of those who grew up in rural areas indicated they were likely to take up work in rural areas after graduation. on the contrary, where male students grew up was not significantly associated with where they were likely to take up work following graduation (χ2 = 0.480, df = 2, p = 0.787). data, showed there was a tendency for males to want to work in metropolitan areas after graduation. table 1 participant demographics demographic information frequency percentage (%) gender (n=202) female male 181 21 89.6 10.4 year of program (n=202) first year second year third year 61 71 70 30.2 35.1 34.7 online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 41 demographic information frequency percentage (%) aboriginal or torres strait islander (n=202) 3 1.5 age (years) (n=190) under 20 20-30 years 30-39 years 40-49 years 50 years and over 24 55 59 43 9 12.6 28.9 31.1 22.6 4.7 born in australia (n=202) yes no 163 39 80.7 19.3 speak english as a second language (n=200) 24 12.0 marital status (n=201) single married/partnered divorced/separated other 72 112 11 6 35.9 55.7 5.4 3.0 employment status (n=201) not in paid labour force casual employee (no guaranteed hours of work) part-time employee (less than 38hrs week) full-time employee (38hrs a week) other (not adequately specified) 36 57 80 22 6 17.9 28.4 39.8 10.9 3.0 currently an enrolled (division 2) nurse (n=202) 39 19.3 current after tax income a week (n=202) less than $400 $400 $799 $800 $1499 $1500 $3000 do not wish to answer 85 65 26 3 24 42.1 31.7 12.9 1.5 11.9 where participant grew up (n=202) inner city metropolitan outer suburb metropolitan large regional center small town on a property or farm other 10 48 45 60 30 9 5.0 23.8 22.3 29.7 14.9 4.5 first in family to attend university (n=202) 105 52.0 after graduation: (n=202) i see myself practicing in a metropolitan setting i see myself practicing in a rural/remote setting i do not know where i see myself i see myself practicing overseas 85 81 31 5 42.1 40.1 19.6 3.5 when examining mean scores of the five ncaq classes across the student cohort, management and decision-making factors were identified as being of highest importance among online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 42 students (3.53), followed by practice environment/scope factors (3.52), community and practice support factors (3.48), economic and resource factors (3.26), and geographic factors (3.01). factors most important for nursing students to consider a rural career the factors considered most important for students to take up rural practice included emphasis on patient safety/high quality care, autonomy/respect, positive relationships/communication among different generations of nurses, job satisfaction/morale level and effective partnership between medical and nursing staff as outlined in table 2. in addition, those factors considered and ranked the least important, compared to all other factors, included nurses having trained/lived in rural areas, climate, demographics/patient mix, size of the community, availability or accessibility of day care in the rural community. table 2 top and bottom 10 most important factors for nursing students considering rural practice top 10 factors class mean (n=200) emphasis on patient safety/high quality care practice environment/scope 3.79 autonomy/respect management and decisionmaking 3.74 positive relationships/communication among different generations of nurses practice environment/scope 3.69 job satisfaction/morale level practice environment/scope 3.69 effective partnership between medical and nursing staff management and decisionmaking 3.68 positive workplace culture/supportive working environment that fosters mentoring practice environment/scope 3.67 nursing workforce adequacy and stability community and practice support 3.64 emergency medical services community and practice support 3.62 manageable workload/increased time with patients practice environment/scope 3.62 nurse empowerment/nurses involved in design of best practice environment/unit-based decision making/professional collaboration between management and nursing staff management and decisionmaking 3.60 bottom 10 factors class mean (n=200) online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 43 top 10 factors class mean (n=200) compensation provided to nurse employees beyond salary economic or resources 3.07 social networking geographic 3.05 recreational opportunities geographic 3.03 moving allowance economic or resources 3.03 electronic medical record practice environment/scope 2.98 nurses having trained/lived in rural areas geographic 2.92 climate geographic 2.85 demographics/patient mix geographic 2.84 size of community geographic 2.56 day care economic or resources 2.54 factors important, relative to gender, for students to consider a rural career table 3 provides the results of the ncaq factors for nursing students by gender. nine factors were identified to be significantly different between males and females considering rural careers. in all cases, female students rated these factors much higher than male students. factors with the greatest difference between genders included adequacy of schools for children (p = .022), effective partnership between medical and nursing staff (p = .029), teaching/ mentoring opportunities/ administrative role involvement/ challenge of multiple roles (p = .012), and the availability of school nurses, hospice, home health, and public health nursing services (p = .031). table 3 importance of community apgar factors by gender mean score difference p-value females (n=180) males (n=21) adequacy of schools for children. 3.30 2.81 0.490 .022* effective partnership between medical and nursing staff 3.72 3.33 0.383 .029* teaching/mentoring opportunities/ administrative role involvement/ challenge of multiple roles (direct care, leadership, teaching) 3.53 3.19 0.343 .012* availability of school nurses, hospice, home health, public health nursing services 3.46 3.14 0.321 .031* emergency medical services 3.65 3.33 0.320 .012* online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 44 the adequacy of materials and equipment on the nursing units in the hospital 3.59 3.29 0.303 .019* flexible scheduling/optimal shift availability/12hour shifts 3.44 3.14 0.302 .033* welcome and recruitment program 3.40 3.10 0.301 .050* nursing workforce adequacy and stability 3.67 3.38 0.289 .022* *denotes significance using independent sample t-test factors important, relative to growing-up place, for students to consider a rural career in addition to what is considered most important among the genders, table 4 provides insight into the most important ncaq factors for nursing students with regard to where they grew up. seven factors were identified to be significantly different between the metropolitan and rural students when considering rural careers. in all cases, metropolitan students rated factors, mostly economic in nature, much higher than rural students. factors with the greatest difference included the existence and adequacy of internet access and technological equipment (p = .010), receiving compensation beyond salary (p = .010), a welcome and recruitment program (p = .006), and additional monetary compensation to employees who work shifts other than daylight (p = .014). table 4 importance of community apgar factors by where grew up mean score difference p-value metropolitan (n=102) rural (n=90) the existence and adequacy of internet access and technological equipment. 3.64 3.34 0.293 .010* compensation provided to nurse employees beyond salary. 3.21 2.92 0.284 .010* welcome and recruitment program 3.49 3.22 0.268 .006* additional monetary compensation to employees who work shifts other than daylight 3.45 3.21 0.240 .014* salary 3.57 3.34 0.224 .012* recognition/positive feedback 3.58 3.36 0.223 .015* professional development opportunities/career ladders 3.51 3.30 0.210 .027* *denotes significance using independent sample t-test online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 45 factors important for students to consider a rural career beyond the most important factors among metropolitan and rural students, table 5 highlights the factors most important for nursing students by their choice of future practice following graduation. again, seven factors were identified to be significantly different between the students who wanted careers in metropolitan areas, rural areas or among those who were not sure where they would like to practice. factors with the greatest difference occurred between the future geographic locations of metropolitan and rural areas. the factors included access to larger communities (p = .019) and size of the community (p = .004). specifically, students who were metropolitan career focused still felt access to larger communities were vital, whereas students who were rural career focused felt having acknowledgement of nurses’ accomplishments and services was more important. among those students who were unsure about their choice of future practice, it was identified 28.5% (n = 58) grew up in a metropolitan area, while the majority of students 66.9% (n = 135) grew up in a rural or regional area. the most important factors among this cohort regarding future practice were autonomy and respect (3.71), job satisfaction (3.68), effective partnership between medical and nursing staff (3.65), emphasis on patient safety/high quality care (3.65), and a sense of reciprocity between nurses and the community (3.65). table 5 importance of community apgar factors by choice of future practice mean score difference p-value metropolitan (n=84) rural (n=80) unsure (n=31) access to larger community 3.32* 2.99* 3.16 0.334 .019 size of community 2.75* 2.38* 2.55 0.375 .004 moving allowance 3.06 2.88* 3.39* 0.512 .003 autonomy/respect 3.67* 3.86* 3.71 -0.196 .016 recognition/positive feedback 3.58* 3.81* 3.65 -0.229 .010 online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 46 emphasis on patient safety/high quality care 3.77 3.90* 3.65* -0.255 .015 nurse empowerment/nurses involved in design of best practice environment/unit-based decisionmaking/professional collaboration between management and nursing staff 3.57 3.76* 3.39* -0.375 .002 *denotes where significant difference occurs using anova discussion the results show that management and decision-making as well as the practice environment factors were considered most important to students in their considerations of a rural career in nursing. having trust and confidence in an effective executive team and nurse managers, along with having enough variety for graduates to invest their time into practice to gain a certain level of scope of practice is at the forefront of newly graduated nurses’ decision-making and is consistent with other work already conducted by (terry et al. (2016). practice environments, specifically workload and stress levels, have been highlighted to be key factors that students find important and will assist with their decision-making in regard to rural practice. students in this study were conscious of the increasing demands on healthcare staff, which can lead to a reduction in client care, as such are consistent with findings from other studies (prengaman, bigbee, baker, et al., 2014; prengaman, terry, schmitz, et al., 2017) where students carefully examined the practice in rural areas to ensure that it is centered on quality care, and if rural healthcare facilities views concerning patient care are aligned with their own. when considering the differences between female and male students in regard to areas of most importance when selecting rural practice, it was unremarkable that adequacy of schools for children, flexible schedules, and the availability of alternate pathways were considered more important among female nursing students than males nursing students. this is consistent with the online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 47 findings from craig (2006), who posited that this may in fact be due to the additional roles and family responsibilities that females tend to have outside of work hours. in addition, the level of importance that is placed on these key factors may be linked to a necessity of making a career work within the constraints of life commitments and pressures (alazzam, abualrub, & nazzal, 2017). although these differences between females and males were noted, it was also highlighted that children’s day care was the least important factor when considering rural practice. this low level of importance may be due to the age groups or the life-stage of the students, where they may not have children or their children are school aged, as identified elsewhere (skinner, elton, auer, & pocock, 2014) in terms of factors such as professional support, and autonomy and the importance placed upon them by students in their considerations for rural practice, the findings from this study are similar to that identified by schofield and colleagues (2009) and trépanier et al. (2013). however, these findings highlight differences with existing research by bushy and leipert (2005) and adams, dollard, hollins, and petkov (2005), who identify isolation, receiving adequate social support and a focus on the recreational or enjoyable aspects of rural areas as playing central roles in the decisions of students to undertake rural practice in the future. these differences between studies may be related to the variances of the known benefits, perceived challenges, and what are considered the most important factors, when considering rural practice after graduation. in addition, this study focused solely on nursing students, and used a more nursing specific questionnaire, whereas other studies included employed nursing graduates and multi-disciplinary health professional samples (adams et al., 2005; schofield et al., 2009; trépanier et al., 2013). the differences between this study and other studies is further demonstrated in the current study, where many geographic factors were much less important than anticipated and observed online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 48 elsewhere (lea & cruickshank, 2005; lea, cruickshank, paliadelis, et al., 2008; trépanier et al., 2013). the lower emphasis on geographical factors being important for taking up rural practice may be due to the number of nursing students originating from regional or rural backgrounds, which made up of more than two-thirds (66.9.1%, n = 135) of the cohort. this suggests that recreational opportunities, socialising, the climate, and the size of the community are less important as these students are already cognizant of, already living in, or have intentions to return to these rural communities after graduation, a finding consistent with the work of playford and colleagues (2006). in addition, those students who indicated that they intended to work in metropolitan areas, were more likely to rate geographical factors such as access to larger communities and the size of the community as more important than those considering rural practice, which was found in nurses elsewhere (prengaman, terry, schmitz et al., 2017). what is also highlighted is that almost a fifth (19.6%, n = 31) of students were unsure where they would practice after they graduate, which may be a large untapped resource to address workforce deficits among rural health services. it is an opportunity for industry and training bodies to focus their efforts in providing aspirational nursing students, who remain unsure in their decision-making, with greater theoretical context of rural healthcare supported by practical experiences (smith et al., 2018). however, this requires further examination. conversely, there are metropolitan students who may not have fully considered, experienced or had adequate emersion in rural practice, which has been shown previously to be an important factor contributing to a higher tendency to choose rural careers (adams et al., 2005). those key factors that were identified as important by the cohort of students who were unsure of future rural practice include autonomy and respect, job satisfaction, and effective partnership between medical and nursing staff. this would suggest that if these factors were to be adequately addressed and online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 49 promoted when recruiting nurses to rural practice, then an increase in the interest of those applying for employment in rural areas may be seen (trépanier et al., 2013). this study did not seek to specifically illuminate the implications for health services with regard to recruitment and retention of nurses to rural areas. however, the findings from this study enable rural health services to better identify how they are situated with regard to their strengths and challenges in meeting the needs that are unique to the nursing workforce and that can then be augmented to guide nursing recruitment and arguably retention. the findings from this study suggest an emphasis by health services be placed on establishing and making transparent site specific information associated with factors of the practice environment, such as patient safety and quality care measures, staff workloads, indicators of positive staff morale and a sense of cohesion. as well as this, the findings suggest health services will be well served by demonstrating factors associated with management and decision-making such as levels of staff autonomy, and inclusion in decision-making. collectively these findings are supported by the work of others with baernholdt and mark (2009) noticing the value of transparent patient safety and quality data for potential candidates. ragusa and crowther (2012) suggest that demonstrating a positive and cohesive work culture – that is therefore less stressful – to a candidate will have a positive effect on their intention to seek rural employment. these authors make special mention of highlighting the interconnectivity of private and work life as a way of portraying the inherent cohesion of an organisation. terry and colleagues (2016) also suggest strategies for rural institutions to capitalize on their sense of cohesion and suggests an open acknowledgement of the investment that an institution makes towards developing communication skills in their staff in preference to clinical expertise. with regard to management and decision-making, these same authors suggest that health services online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 50 involve the chief executive officer, chief financial officers, chief nursing officers, and nursing managers in an initial recruitment meeting or interview as a means of satisfying the candidate’s preference to be employed in a facility that has stable and cohesive leadership that is inclusive of all levels. limitations this research captures the perceptions of a self-selected sample of nursing students at one point in time. in addition, the university has campuses in rural, regional and peri-urban locations, with a high mature aged student cohort from rural settings, this may limit the ability to generalize the findings as there are a myriad of factors that may have an impact on student responses. further, the questionnaire assumes that the nursing students have context as to what nursing in rural areas involves, therefore this may be problematic; however, this highlights where future iterations of the questionnaire may be improved. in addition, student respondents of the survey may not be representative of the whole student cohort given the low response rate and completing the survey in full. the low response rate may be due to survey being administered in the mid-semester break. to increase response rate without increasing coercion, the survey may be more suited to be administered at the beginning or end of the year and outside the study period. conclusion studies have sought to understand the elements that lead nursing students to have an interest in rural practice, but there remains limited insights into the specific factors that students themselves consider to be important when contemplating a career in rural practice. findings from the modified ncaq relevant to nursing recruitment and retention highlighted that students recruited to this study identify (a) management and decision-making factors; and (b) practice environment and scope of practice factors as the two most important factors. specifically, students prioritized online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 51 patient safety/high quality care, autonomy/respect and matters of staff cohesion/morale well above those factors that one might routinely consider to be most central. students in this study rated compensation beyond salary, social networking, recreational opportunities, community size and having a background in a rural area as the least important factors for influencing their decisions about pursuing a career in a rural area. it is suggested that rural health services use other approaches to recruitment, and the factors identified from this study should be also considered as part of the recruitment process. further, the outcomes suggest rural and regional universities emphasize meeting the key elements that students see as important and that will adequately prepare these future nurses to work in rural settings. while the cohort of students within this study have a higher percentage of individuals with a history of growing up in a regional or rural setting, which might account for a reduced focus upon the factors above, we are suggesting that rural and regional universities turn towards approaches that make transparent the nuanced qualities required among students to meet the specific recruitment and retention challenges among healthcare agencies. therefore, there is a need to find ever better means of providing details about patient safety and quality care as well as ways in which the management of the institution operates to establish and maintain a cohesive workplace, and this would appear, from this study, to be of more central importance. it would be reasonable to conclude that students in this study are not prioritising aspects of rural life outside of work and are instead focused on factors internal to the healthcare agency. instead, of greatest importance to students is the fit between them and the agency and much less about their fit with the community into which they will be entering. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 52 acknowledgments this research has been supported by the australian government through the school of nursing and healthcare professions at federation university australia. initial funding for the development of the critical access hospital community apgar program was provided by the idaho department of health and welfare, bureau of rural health and primary care. we would also like to acknowledge the research assistance provided by the center for health policy, boise state university, boise, idaho, usa. references adams, m. e., dollard, j., hollins, j., & petkov, j. 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(2018). health professional students' rural placement satisfaction and rural practice intentions: a national cross-sectional survey. australian journal of rural health, 26, 26-32 https://doi.org/10.1111/ajar.12375 sutton, k., waller, s., fisher, k., farthing, a., mcannally, k., russell, d., … carey, t. (2016). understanding the decision to relocate rural amongst urban nursing and allied health students online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.589 56 and recent graduates. newborough: monash university department of rural health. retrieved from http://www.rhwa.org.au/client_images/1847271.pdf terry, d., baker, e., & schmitz, d. (2016). community assets and capabilities to recruit and retain gps: the community apgar questionnaire in rural victoria. rural remote health, 16(3990) 1-10. retrieved from http://www.rrh.org.au/publishedarticles/article_print_3990.pdf trépanier, a., gagnon, m.-p., mbemba, g. i. c., côté, j., paré, g., fortin, j.-p., … courcy, f. (2013). factors associated with intended and effective settlement of nursing students and newly graduated nurses in a rural setting after graduation: a mixed-methods review. international journal of nursing studies, 50, 314-325. https://doi.org/10.1016/ j.ijnurstu.2012.09.005 cochran_625_formatted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 194 characteristics of neonatal abstinence syndrome in a rural clinic population: using electronic medical health records for tracking jill d cochran, phd, aprn, cfnp1 traci jarrett, phd, mph2 adam baus, phd, ma, mph3 1associate professor, west virginia school of osteopathic medicine, and nurse practitioner at robert c. byrd clinic, jcochran@osteo.wvsom.edu 2research assistant professor, west virginia university school of public health, wv prevention research center, wvu office of health services research, tjarrett@hsc.wvu.edu 3director, office of health service researcher and research assistant professor, department of social and behavioral sciences, west virginia university abaus@hsc.wvu.edu abstract purpose: the impact of intrauterine exposure of opioids and other addictive substances on pediatric patients is concerning for health care providers in rural wv. nas patients must be identified, screened, and treated during the pediatric years to facilitate improved outcomes. the purpose of this research was to evaluate the ability of rural providers to use ehrs to identify, describe, and monitor aspects of nas across the pediatric health span. methods: the research team used de-identified data of patients that had the nas diagnosis from a rural clinic. one hundred fifty-five charts were evaluated. demographics, clinical characteristics, and developmental milestone status were extracted from charts. results: there were differences in characteristics across age groups. reported secondhand smoke was higher among the 0-3 year olds. normal bmi percentile was highest among 4-5 year olds. the online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 195 ages and stages developmental screening was abnormal more in those aged 6-19 years. foster care was highest among the ages 0-3 years. the 4-12 age groups highest amount of no show visits. respiratory illness was the most frequent diagnosis and was highest in the 4-5 age group. eye and ear diagnosis were noted as a recurrent diagnosis in the 4-5 year old group. diagnosis related to mental health were highest in the 6-18 age group. discussion: the ehr can be used to describe and track special populations such as nas in rural areas. tagging and tacking patients with nas can help primary care providers manage care and anticipate age related health care needs. tracking high risk populations assures that the patient care is maintained. tracking no show rates assists providers in assuring that patient’s caregivers are compliant in necessary treatments and referrals. child protection can also be involved if medical neglect is noted. ehrs are useful in identifying high risk populations such as nas to facilitate treatments and continuity of care. keywords: neonatal abstinence syndrome, electronic medical health records, nas characteristics, tracking pediatric nas characteristics of neonatal abstinence syndrome in a rural clinic population: using electronic medical health records for tracking introduction/problem statement infants regularly exposed to addictive substances in utero may exhibit neonatal abstinence syndrome (nas). nas is usually observed in the newborn nursery within the first few days of life. the symptoms include tremors, irritability, poor feeding, high-pitched cry, and multiple other symptoms depending on the substance used by the mother during pregnancy (mcqueen & murphy-oikonen, 2016). online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 196 the incidence of nas continues to rise in the united states. there was a five-fold increase in the proportion of babies born with nas from 2000 to 2012 (sanlorenzo et al., 2018). according to the health care cost and utilization project (hcup, 2016), the occurrence of prolonged hospital stays for newborns diagnosed with nas increased from 1:1000 to 48:1000 nationally. the proportion of infants diagnosed with nas who were from rural counties increased from 12.9% in 2003/2004 to 21.2% in 2012/2013 (villapiano, et al., 2017). west virginia (wv) increased from 7.4 per 1,000 in 2007 (stabler et al., 2017) to 50.6 per 1000 live births per year in 2017 (umer et al., 2018). this has caused an enormous burden on the wv foster care system (mccormick, 2017). nurse practitioners in rural areas have multiple obstacles in providing care to special highrisk populations such as infants with nas. patients in rural areas face many barriers in health care services related to limited public and person transportation and distance to health care facilities (warshaw, 2017). the difficulty is compounded by shortages of allied health services and specialty care (macdowell et al., 2010). the impact of intrauterine exposure to addictive substances on pediatric patients is a concern for health care providers in wv. rural clinics often lack resources to manage care of highrisk children. poor growth and development (bier et al., 2015; lamy et al., 2015), cognitive issues (jaeger, et al., 2015), and risk for abuse (weberlinget al., 2003) are only a few of the complications that providers must diagnose and treat. nas patients must be identified, screened, and treated during the pediatric years to facilitate improved outcomes (knopf, 2016; lee et al., 2015). the impact of maternal drug use and drugs to prevent withdrawal complications is yet to be fully realized. the purpose of this study is to utilize data obtained from electronic medical records online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 197 (ehr) to identify patients with a diagnosis of nas and describe other clinical and demographic characteristics of this population in a rural clinic. methodology administration of robert c. byrd clinic approved use of data for the study. robert c. byrd clinic is a nonprofit rural health clinic providing primary care to a three-county area in southern wv. the clinic is staffed with over 40 medical staff members including physicians, nurse practitioners, and interns. services provided by the clinic include family practice, osteopathic manipulative medicine, pediatrics, and psychology services. the clinic is in greenbrier county and designated as a health professional shortage area (hpsa) in primary care and mental health. greenbrier county is considered 69.74% rural (am i rural? – report 24901, wv). this project was submitted to the institutional review board of west virginia school of osteopathic medicine for expedited review procedures and given approval to proceed (irb# 20184). a de-identified data sharing agreement was obtained for this project from robert c. byrd clinic. in january 2018, the needed demographic and clinical data were abstracted from the ehr using system-provided data abstraction tools. these data abstractions were completed by trained informatics consultants and clinical staff to help ensure data quality and completeness. the clinic provided the research team with de-identified and validated data of pediatric patients (ages birth 21 years of age) that had nas diagnosis in icd 9 (code 779.5) and icd 10 codes (p 96.1; 96.2) (who icd-10 online versions). hippa compliance was maintained. from the nas data set, demographic data were extracted from the ehr including age, gender, last three digits of the zip code, insurance payer, and ethnic status. we also extracted clinical characteristics including additional diagnosis, chronic medications, referrals to outside online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 198 agencies or providers, immunization status, attritional rate or current patients standing, time of last visit, record of foster care, weight for length or body mass index (bmi) percentile, developmental milestone status ( squires et al., 2009), secondhand smoke exposure, and appointment history. data were analyzed with spss to assess frequency, counts, and means. results to evaluate the population of patients diagnosed with nas, 155 charts with the required icd 9 and icd 10 codes for nas diagnosis were identified and analyzed. the extracted data were entered into the research electronic data capture (redcap) which is a secure data management system hosted at west virginia university. redcap is a web-based software platform designed to support data capture for research studies. from redcap, data were imported into spss. of the 155 chart audits, 45% (n=70) were females and 55% (n=85) were male. ninety-two percent were caucasian (n=142). the majority of patients (57%) used state insured payers (west virginia medicaid, unicare, children’s health insurance program), 43% had private insurance, and <1% were self-pay. most of the population were children in the 4-5-year-old age group (figure 1). most of the charts had a zip code within four miles of the clinic (figure 2). online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 199 figure 1 age groups 0 10 20 30 40 50 0-1 year 2-3 years 4-5 years 6-12 years 13-18 years 19 years and older age groups online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 200 figure 2 robert c. byrd neonatal abstinence syndrome population per 3-digit zip codes contextual factors were assessed within age group in order to understand the potential developmental trajectory of children diagnosed with nas. secondhand smoke exposure was highest among the 0-1and 2-3-year-old groups with each group reporting 60% as having secondhand smoke exposure. child protective services (cps) involvement or foster care was reported in 22% of the total charts with the 2-3-year-old group of children having the higher percent of reports per age group (58%). children in the 4-5-year-old group had the highest number of normal bmi percentile (figure 3). ages and stages developmental (squires et al., 2009) screen was noted as “abnormal” more in the age groups of 6-12, 13-18, and 19-21-year (figure 4). nomap generated by wvu ohsr' online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 201 show rates or missing one or more scheduled appointments were highest in the 2-3 (64%) and 4-5 (77 %) year-old groups. figure 3 body mass index (bmi) percentiles for age groups 0 5 10 15 20 25 30 35 0-1 years 2-3 years 4-5 years 6-12 years 13-18 years 19 and older age bmi percentile by age bmi percentile age normal weight bmi percentile age overweight bmi percentile age obese online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 202 figure 4 results for ages and stages screening tool medical history was analyzed relating to additional diagnosis and medication history. the diagnosis of “well visits” was distributed equally among the ages. respiratory illness was the next most frequent diagnosis with highest number in the 4-5-year-old group. disorders of the eyes and ears were noted as a recurrent diagnosis in the 4-5-year-old group (figure 5). diagnosis related to mental health were highest in the 6-18-year-old group (figure 6). 0 5 10 15 20 25 30 35 40 0-1 years 2-3 years 4-5 years 6-12 years 13-18 years 19 and older developmental screening abn. normal online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 203 figure 5 diagnosis within age groups 0-5 years of age 0 5 10 15 20 25 endocrine, nutritional, metabolic infectious and parasitic diseases respiratory system injury, poisoning, certain other… eye and adnexa, ear and mastoid process musculoskeletal and connective tissue… injury, poisoning, certain other… certain conditions originating in the… genitourinary system neoplasms diagnosis age 0-5 years old 4-5 years 2-3 years 0-1 years online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 204 figure 6 diagnosis within age groups 6-19 years of age the medication prescribed with the highest frequency was allergy type medications in the 4-5 and 6-12-year-old groups. other medications not categorized was next highest in the 6-12year-old group (figure 7). patient groups reporting no regular medications were highest in the 45 and 13-18-year-old groups. 0 5 10 15 20 25 30 35 endocrine, nutritional, metabolic infectious and parasitic diseases respiratory system injury, poisoning, certain other… eye and adnexa, ear and mastoid process musculoskeletal and connective tissue… injury, poisoning, certain other… certain conditions originating in the… genitourinary system neoplasms diagnosis age 6-19 years old 19 and older 13-18 years 6-12 years online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 205 figure 7 reported medication per age groups referrals to outside specialists were grouped by age and specialty as well as miscellaneous and no outside referrals. the majority of those with no referrals noted were in the 4-5-year-old group. referrals to ear, nose and throat specialists were highest in the 6-12 age group. of the dental referrals, the 4-5 age group had the most referrals with ages 6-12-year-old group second highest. of the referrals made to the “in-house” psychologist, the 13-18-year-old group had the greatest number of patients. the 4-5 and 6-12-year-old groups had more referrals than the other groups (figure 8). 0 5 10 15 20 25 gi m ed s r x ot he r m ed s no m ed s all er gy m ed s m ult i-v ita mi n inh ale rs ac et am ino ph en /i bu pr of en pe g/ lax itiv es he rb als an d o tc bir th co nt ro l ep i/i nje cti on co un t o f p at ie nt s medication type by age group 0-1 2-3 4-5 6-12 13-18 19+ online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 206 figure 8 referral type by age group discussion the ehr can assist in describing the nas population in a rural primary care center. while many of the results align with the usual pediatric population, several important points are noted. 0 2 4 6 8 10 12 14 16 bir th to th re e ps yc ho log ist ot he r no re fer ra ls ga str o ne ur o en do cri ne de nt al vis ion de rm at olo gy or th o pu lm o0 log y en t ur olo gy sle ep m ed ici ne om m /o m t co un t o f p at ie nt s referral type by age group 0-1 2-3 4-5 6-12 13-18 19+ online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 207 foster care is highest in the younger population. this could be related to the enormous amount of care any infant requires, especially those with intrauterine exposure to illicit drugs and medications for withdrawal. since infants with nas are usually fussier than infants who do not have nas (finnegan, 1985; mcqueen & murphy-oikonen, 2016), they are at a higher risk for abuse (oldbury & adams, 2015). the decrease of foster care in older children (mccormick, (2017) could be related to the fact that they are placed with a family member or foster care parent that may adopt them if parental rights are terminated. another possible explanation is that the biological family stabilized. current literature (fill et al., 2018) supports the premise that children with nas have a higher risk for issues in school (15.3%) as compared to children without the diagnosis of nas (11.4%). attention deficit disorder/hyperactivity disorder, behavior issues, and learning disabilities may surface in this age group as scholastic challenges are encountered (fill et al., 2018; jaegeret al., 2015; morgan & wang, 2019). in this study the majority of mental health diagnosis started at age 6 years. this may be related to the age required to diagnose attention deficit type disorders. prior to that age, developmental delays may be noted and treated, but not with a specific diagnosis label. pediatric providers can alert families to observe children for any academic issues to provide timely intervention. earlier interventions in school have a higher rate of long-term improvement (majnemer, 1998). patients diagnosed with nas can be identified in the ehr to promote better follow-up and surveillance of care. referrals for specialty care made outside of the clinic can be assessed, however, the ehr does not have a method to note patient/family compliance for the visit. detecting “no show” rates for visits with-in the clinic will alert providers of gaps in medical care. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 208 at that point, the office can contact the family and attempt to facilitate adherence to the medical plan. if they have left the practice, providers can contact the department of health and human resources (dhhr) and alert them that the patient is no longer in the practice. if a record release has not been requested, dhhr can inform the new health care providers of former medical care and expedite record release. cps can also be involved if medical neglect is noted. demographic data, such as zip codes, can be used to identify geographical areas that have a higher percentage of nas children. regions recognized with a higher prevalence of nas can be prepared for upcoming needs in academic support. documentation of nas prevalence can also empower communities to seek additional grants and funding to provide programs for children and families impacted by nas. conclusion rural health care providers are in uncharted territories when caring for exposed nas infants as they progress through the pediatric lifespan toward adulthood. lack of specialty resources and patient/family compliance add to the burden of care. identifying high-risk patients promotes continuity of care and improved oversight. more work is needed to evaluate the ability of replicating the process in a new ehr system in the clinic. although this is the first data pull of the diagnosis of nas, more data over longer periods of time are needed to see the effectiveness of identifying and following the patients with nas as they age through the system. acknowledgements this project was supported by the national institute of general medical sciences, u54gm104942 and the west virginia school of osteopathic. medicine. the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih or wvsom. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.625 209 references am i rural? – report 24901, wv. retrieved from https://www.ruralhealthinfo.org/am-irural/report?lat=37.84327&lng=-80.43734&addr=24901, wv&exact=0 bier, j. b., finger, a. s., 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(2019). international statistical classification of diseases and related health problems 10th revision. retrieved from http://www.who.int/ classifications/icd/icdonlineversions/en/ the focus of this research was an assessment and comparison of the knowledge of stroke warning symptoms, as well as stroke’s risk factors in a rural versus urban midwest general public sample using a self-administered mail survey 9 stroke knowledge: how is it impacted by rural location, age, and gender? kathleen a. ennen, phd, rn1 julie j. zerwic, phd, rn2 1assistant professor, school of nursing, university of north carolina-wilmington, ennenk@uncw.edu 2associate professor, department of biobehavioral health science, university of illinois at chicago, juljohns@uic.edu key words: rural, stroke knowledge, stroke symptoms, stroke risk factors abstract background and research objective stroke, the third-leading cause of americans' deaths, is often not recognized causing fatal or disabling delays in receiving effective, time-sensitive treatment. to understand the delay in seeking treatment, a sample of rural and non-rural adult residents were surveyed using the stroke recognition questionnaire (srq) to assess their level of knowledge of stroke symptoms and risk factors. sample and method five hundred and sixty-six individual (283 rural and 283 non-rural) from six east central illinois counties responded to the self-administered srq mail survey. the five-element design method for mail surveys guided this survey implementation procedure. results rural and younger (20-64 years) respondents had significantly higher stroke symptom knowledge scores (m = 9.32) compared to non-rural and older (> 65 years) respondents (m = 9.0; t =2.181, p <.03). confusion was the most frequently recognized stroke symptom by rural and women respondents. stroke risk factor knowledge scores revealed no significant differences by residence location, age, and gender. younger respondents were more likely than older respondents to identify high blood pressure, smoking, and diabetes as stroke risk factors. conclusions rural respondents were more knowledgeable about stroke symptoms than has been found in other earlier studies. results indicate that stroke educational efforts should target the elderly (> 65 years), who have the greatest stroke risk but who appear to be least informed. educational interventions are needed in both rural and urban settings which improve the general public’s stroke symptom recognition and response, and help the public sort out which symptoms are associated with stroke versus myocardial infarction. introduction despite the fact that from 1996 to 2006, the stroke death rate fell 33.5% and the actual number of stroke deaths declined 18.4%, stroke continues to be the third-leading cause of death in the united states, making stroke knowledge an important public health concern (lloyd-jones et al., 2010). regardless of rural or non-rural residence someone in the united states suffers a stroke every 40 seconds, and on average, dies of one every 4 minutes, accounting for 610,000 new and 185,000 recurrent strokes (national institutes of neurological disorders and stroke [ninds], 2009). the 2010 estimated direct and indirect cost of serious, long-term stroke disability is $73.7 billion (lloyd-jones et al., 2010). increasing the awareness of stroke warning signs and risk factors among the general population and those at highest risk is essential to stroke prevention and treatment. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://www.uncwil.edu/son/ mailto:ennenk@uncw.edu http://www.uic.edu/nursing/about/bhs.shtml mailto:juljohns@uic.edu 10 most americans do not recognize the symptoms of a stroke, causing disabling or even fatal delays in receiving effective, time-sensitive treatment (lloyd-jones et al., 2010). because stroke injures the brain, stroke victims may the have an impaired ability to communicate or to recognize the symptoms they are experiencing as a stroke. the burden for quick, efficient action therefore shifts to an alert bystander (e.g., family, friends, neighbors, coworkers) who must recognize symptoms associated with a stroke (ninds, 2009). rural location the decreased availability and accessibility of health care providers to the 25% of americans who live in rural areas may impact both the dissemination of stroke information and the timely treatment of stroke (united states department of health and human services [usdhhs], 2000). rural populations for this study were defined as those residents living outside an urban area of 2,500 or more people (united states census bureau, 2001). individuals living in rural areas are typically older and earn less than their non-rural counterparts, compounding the issues surrounding stroke recognition, detection, and treatment (redford & cook, 2001). rural residents are less likely to use preventive health services, and when in need of health care, rural elders are more likely to depend on local rural health systems because of the logistics and cost of travel to urban areas for care (redford & cook, 2001). timely access to emergency services and availability of specialty medical care are additional issues of concern for those in rural areas (pierce, 2007). these facts increase the likelihood that rural residents will have less knowledge of stroke symptoms, be less likely to identify symptoms of an impending stroke, and be hindered from receiving timely care or treatment for stroke symptoms. stroke knowledge table 1 shows results of previous stroke knowledge studies. pancioli et al. (1998) reported that, of 1,880 phone interviews, 27% could not name a single stroke symptom and 14% could not identify a single stroke risk factor. similarly, yoon, heller, levi, wiggers, and fitzgerald (2001) reported that 50% of their (n = 822) community-based interviewees were unable to name one stroke symptom and 24% could not list one stroke risk factor. hux, rogers, and mongar (2000) interviewed participants (n = 190) at a regional shopping mall and found that 34% could not name a single stroke symptom and 10% could not identify a single stroke risk factor. goldstein, silberberg, mcmiller, and yaggy (2009) interviewed 76 latino clients of a community-based health program and noted that 29% could not correctly name a single stroke risk factor and 57% could not identify a single stroke symptom. this lack of knowledge of stroke, especially in those most at risk, such as the elderly, could contribute to the delay in seeking health care services. the results of these few studies support the conclusion that the general public’s knowledge of stroke symptoms and risk factors is inadequate. none of these studies addressed variations in the general public’s knowledge of stroke when comparing rural and non-rural residence location. the purpose of this study was to determine a rural midwest sample’s knowledge of stroke symptoms and risk factors using the stroke recognition questionnaire (srq). online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 11 table 1. results of previous stroke knowledge studies study sample % unable to identify any stroke symptom % unable to identify any stroke risk factor pancioli et al. (1998) 1,880 phone interviews 27% 14% yoon et al. (2001) 822 community-based interviews 50% 24% hux et al. (2000) 190 interviews at a regional shopping mall 34% 10% goldstein et al. (2009) 76 interviews in a community health program 57% 29% conceptual model this research is rooted in the work of leventhal, nerenz, and steele (1984) who developed a common-sense model (csm) of illness recognition based on the notion that different types of information are needed to influence a person’s attitudes and actions to a perceived health threat. the key component of the csm is the idea that a lay person wants to make sense of their illness symptoms by labeling them as a specific illness. their reaction to illness symptoms may be by asking themselves questions such as: what do these symptoms mean? how do i feel about them? am i in danger? is there anything i can do about them? how do i make myself feel better? leventhal and colleagues (1984) argue that how a person labels their illness symptoms regulates how they cognitively, emotionally, and behaviorally act in response to the personal experience of these symptoms. thus, the cognitive process of correctly labeling experienced warning symptoms as a stroke and seeking appropriate and timely health care is increased with stroke knowledge, the focus of this research. design and method this descriptive study of stroke knowledge had a non-experimental, quantitative design. the mailed self-administered stroke recognition questionnaire (srq) was used to assess knowledge of stroke symptoms and risk factors. demographic data were also obtained. design we used the tailored design method for mail surveys (dillman, 2000), a general method of survey implementation outlining a set of procedures for conducting successful selfadministered mailed surveys that produces both high-quality information and higher response rates. it consists of five elements that complement each other. these elements include: (1) a respondent-friendly questionnaire (visually appealing, clear and simple instructions, easy response format), (2) up to five contacts with the questionnaire recipient (lead postcard notice, letters, postcard reminder), (3) inclusion of stamped return envelopes, (4) personalized correspondence, and (5) a token financial incentive ( a one dollar bill paper clipped to first letter) sent with the survey request. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 12 setting and participants the researchers selected six east central illinois counties. the u.s. census bureau’s 2000 geographic comparison table for illinois was used to identify rural (population < 2,500) and non-rural communities in the six selected counties. telephone directories for the communities within these six counties provided a frame for the random selection of resident names and addresses (dillman, 2000). the random selection of survey recipients continued until the researchers had identified 400 rural and 400 non-rural community residents. instruments the principal investigator developed the stroke recognition questionnaire (srq) to identify a respondent’s knowledge of stroke symptoms and risk factors. prior to development of this questionnaire, no tool structured for self-administration existed that specifically measured knowledge of stroke symptoms and risk factors. the srq provides lists of 10 stroke and 10 nonstroke symptoms and 10 stroke and 10 non-stroke risk factors taken from the american heart association (aha, 2001; golstein et al., 2001). respondents were instructed to check “yes” or “no” regarding the likelihood of an item being evident in a person experiencing a stroke or putting a person at risk for stroke. respondents were not given any suggestion as to how many of the symptoms or risk factors listed on their survey were “correct.” eight nationally recognized physician and nurse experts specializing in research and care of stroke patients reviewed the srq for content validity. content validity was determined by using the content validity index (cvi) (waltz, strickland & lenz, 1991). the srq was found to have good content validity for both the symptom item list (cvi = .90) and the risk factor item list (cvi = 1.00). the entire questionnaire scored a cvi of .95. the srq’s reliability was initially assessed by administering the srq to a convenience sample of 34 members of the lay public two weeks apart. the test-retest correlations for the subscales of the srq were stroke symptom r = .80, non-stroke symptom r = .75, stroke risk factor r = .44 and non-stroke risk factor r = .44. internal consistency reliability was computed for the srq for stroke symptoms and stroke risk factors in this data set (n = 566) using the kuder-richardson formula 20 (kr20). the stroke risk factor subscale and stroke symptom subscale alphas were .70 and .81, respectively. the kr20 was not calculated for the non-stroke symptom and non-stroke risk factor subscales because these were comprised of distractor items that did not have meaningful connections with each other. procedure the srq was structured for self-administration. a completed returned questionnaire was the respondent’s consent to participate in this research study. response rate for this mail survey was 566 (70.5%) completed questionnaires returned. the initial questionnaire mailing resulted in 517 (64.4%) returned completed questionnaires. the second and third follow-up questionnaire mailings yielded 41 (5.1%) and 8 (1.0%) completed questionnaires returned, respectively. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 13 analysis data were entered into an spss version 11.5 software database. knowledge scores for stroke symptoms and stroke risk factors were obtained by assigning one point for every correct answer, and zero for every incorrect or missing answer. the non-stroke symptoms and nonstroke risk factors were recoded to reflect one point for those correctly identified and zero points for those incorrectly identified. every individual stroke symptom item and individual stroke risk factor item had missing data ranging from 1 (0.2%) to 18 (3.2%) respondents. nineteen (3.4%) respondents did not disclose annual household income. considering the small percentages of missing data, the researchers assumed no overall effect on the stroke knowledge scores obtained in this large data set (tabachnick & fidell, 2001). results demographic characteristics the rural and non-rural mix of respondents was equal at 283 (50%) each. the final pool of 566 respondents consisted of 328 males (58%) and 236 females (42%). respondents’ ages were grouped into two categories: 20 to 64 years of age (77.6%) and over 65 years of age (22.4%), for comparison with results from other published stroke knowledge studies. table 2 provides demographic data on the subjects. stroke symptom knowledge the srq has two ten-item subscales for stroke symptoms and two ten-item subscales for stroke risk factors. the subscale score for the ten stroke symptoms had a possible range of 0 to 10 points (m = 9.2, sd = 1.67). the majority of respondents (93.4%) had a score of 7 or above; 18 (3.3%) had a score of 0 to 4. respondents in rural settings had significantly higher stroke symptom knowledge (m = 9.32, sd = 1.34) than did respondents in non-rural locations (m = 9.01, sd = 1.93; t = 2.18, p < .03). in addition, respondents aged 20 to 64 had significantly higher stroke symptom knowledge (m = 9.29, sd = 1.51) than did respondents 65 years and older (m = 8.84, sd = 1.85; t = 2.67, p < .01). there were no differences in stroke scores between men and women. respondents’ knowledge of individual stroke symptom items was examined (table 3). significantly more rural respondents (96%) recognized confusion as a stroke symptom (non-rural = 89%; x2 = 11.00, p < .01). women were more likely to recognize confusion (women = 96%, men = 91%; x2 = 4.44, p < .03) and double vision (women = 88%, men = 81%; x2 = 5.35, p < .02). respondents aged 20 years to 64 years were significantly more likely to recognize trouble walking (20 to 64 years = 94%, over 65 years = 88%; x2 = 6.30, p < .01), confusion (20 to 64 years = 94%, over 65 years = 89%; x2 = 5.16, p < .02), loss of balance (20 to 64 years = 94%, over 65 years = 86%; x2 = 9.33, p < .01), and double vision (20 to 64 years = 87%, over 65 years = 73%; x2 = 13.04, p < .01). online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 14 table 2. demographic characteristics by residence location variable categories residence location rural (%) nonrural (%) x2 p n=283 n=283 gender male 170 (60%) 158 (56%) .856 .355 female 113 (40%) 123 (44%) age 20-64 years 217 (76%) 219 (78%) .266 .606 65-97 years 66 (24%) 60 (22%) marital status married 197 (70%) 167 (59%) 12.865 .012 never married 22 (8%) 49 (17%) divorced/separated 33 (11%) 35 (12%) widowed 30 (11%) 32 (12%) employment status working 172 (62%) 183 (65%) 4.034 .401 retired 78 (28%) 69 (25%) homemaker 19 (7%) 14 (5%) unemployed/student 10 (3%) 15 (5%) highest education level less than high school 14 (5%) 10 (3%) 30.483 .000 high school/technical school 205 (73%) 151 (54%) four-year degree 38 (13%) 55 (19%) graduate degree 25 (9%) 66 (24%) household annual income < $20,000 37 (14%) 48 (17%) 2.433 .488 $20,001-$39,999 79 (29%) 71 (26%) $40,000-$59,999 70 (26%) 64 (23%) > $60,000 85 (31%) 93 (34%) race white 280 (99%) 250 (89%) 33.698 .000 black 0 (0%) 15 (5%) asian 0 (0%) 10 (4%) hispanic 0 (0%) 6 (2%) other 1 (1%) 0 (0%) the subscale scores for correct identification of the ten non-stroke symptoms had a possible range of 0 to 10 points (m = 7.05, sd = 2.10). the majority (64.6% or 444) of the respondents correctly identified 7 or more symptoms as non-stroke symptoms, while 22.8% or 122 of the respondents had a score of 4 or less. examination of the non-stroke symptom score variations by rural/non-rural location, gender, and age group revealed no significant differences. the four most frequently misidentified non-stroke symptoms were: difficulty breathing, sudden pain in one arm, extreme tiredness, and chest pain (table 4). extreme tiredness was incorrectly identified as a stroke symptom by more rural respondents (30.3%) than non-rural respondents (24.6%) (x2 = 7.031, p < .01). heartburn was more often misidentified as a stroke symptom online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 15 table 3. stroke symptom and stroke risk factor knowledge by residence location stroke symptom residence location rural (%) non-rural (%) χ2 p n=283 n=283 slurred or garbled speech 273 (99%) 264 (96%) 3.41 .065 numbness on one side of face 273 (97%) 267 (95%) 1.57 .211 confusion 272 (96%) 249 (89%) 11.00 .001 weakness on one side of body 269 (95%) 269 (96%) 0.04 .845 trouble with coordination 262 (95%) 254 (92%) 1.45 .229 trouble walking 266 (94%) 257 (91%) 2.13 .144 sudden unexplained dizziness 259 (94%) 248 (90%) 3.51 .061 loss of balance 262 (93%) 257 (91%) 0.39 .530 double vision 244 (86%) 227 (81%) 3.39 .065 sudden severe headache 228 (83%) 218 (79%) 1.35 .245 stroke risk factor high blood pressure 269 (97%) 263 (95%) 1.26 .262 high blood cholesterol 240 (87%) 231 (84%) 0.77 .380 smoking cigarettes 243 (86%) 233 (83%) 1.37 .241 more than 20 pounds overweight 227 (82%) 218 (79%) 0.77 .379 history of neck vein disease 225 (80%) 220 (79%) 0.13 .721 lack of physical activity 198 (72%) 207 (75%) 0.75 .386 diabetes 193 (70%) 187 (68%) 0.24 .625 history of having a heart attack 190 (68%) 195 (70%) 0.27 .603 irregular heartbeat 164 (59%) 155 (56%) 0.60 .438 alcohol use (> 2 drinks per day) 127 (46%) 124 (45%) 0.03 .858 by younger respondents (15.4%) than older respondents (2.5%; x2 = 4.450, p < .03). in addition, swollen ankles was identified as a stroke symptom by more rural residents (21% than non-rural residents (14%; x2 = 4.01, p < .045). online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 16 table 4. non-stroke symptoms and non-stroke risk factors misidentified as stroke symptoms and risk factors by residence location non-stroke symptoms residence location rural non-rural n=283 (%) n=283 (%) χ2 p difficulty breathing 176 (62%) 165 (58%) 0.79 .371 extreme tiredness 167 (60%) 136 (49%) 7.03 .008 sudden pain in one arm 161 (58%) 154 (56%) 0.30 .581 chest pain 113 (40%) 112 (40%) 0.00 .986 leg cramps 83 (30%) 72 (26%) 1.09 .297 swollen ankles 58 (21%) 40 (14%) 4.01 .045 heartburn 50 (18%) 51 (18%) 0.02 .897 fever 28 (10%) 26 (9%) 0.09 .764 cough 21 (8%) 20 (7%) 0.02 .890 diarrhea 16 (6%) 14 (5%) 0.12 .730 non-stroke risk factor hypoglycemia 102 (36%) 92 (33%) 0.74 .391 trouble sleeping 83 (30%) 75 (27%) 0.61 .435 varicose veins 81 (29%) 94 (34%) 1.47 .225 iron deficiency 51 (19%) 39 (14%) 1.91 .166 low levels of calcium in diet 49 (18%) 35 (13%) 3.00 .083 alzheimer’s disease 39 (14%) 31 (11%) 1.05 .306 lyme disease 32 (12%) 23 (8%) 1.64 .201 exposure to too much sunlight 28 (10%) 21 (7%) 1.10 .295 living close to a power plant 14 (5%) 14 (5%) 0.00 1.00 travel to foreign countries 11 (4%) 6 (2%) 1.54 .215 double vision (83.7%) and sudden severe headaches (80.7%) were the stroke symptoms least often identified. however, in previous studies (kothari et al., 1997; pancioli et al., 1998; yoon et al., 2001), double vision and sudden severe headaches were included as the most commonly identified stroke symptoms. women had minimally higher stroke symptom knowledge scores (m = 9.28) compared to men (m = 9.11), which is consistent with past studies (pancioli et al., 1998; yoon et al., 2001). online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 17 stroke risk factor knowledge the subscale score for the ten stroke risk factors had a possible range of 0 to 10 points (m = 7.43, sd = 2.16). while the majority of respondents (87.4%) had a score of 7 or above, 19 (3.6%) respondents had a score of 4 or less. examination of stroke risk factor score variations by rural/non-rural location, gender, and age group revealed no significant differences. the items that respondents were least likely to identify as stroke risk factors were: alcohol use, irregular heartbeat, diabetes, and history of having a heart attack. there were no significant differences in recognition of risk factors by rural/non-rural location and gender. younger respondents (aged 20 to 64) were significantly more likely than older respondents (aged > 65) to recognize as risk factors for stroke: high blood pressure (younger = 97%, older = 93%; x2 = 4.10, p < .04), smoking (younger = 88%, older = 74%; x2 = 13.97, p < .01), diabetes (younger = 73%, older = 56%; x2 = 13.07, p < .01), and alcohol use (younger = 49%, older = 32%; x2 = 11.46, p < .01). the subscale score for the ten non-stroke risk factors had a possible range of 0 to 10 points (m = 8.34, sd = 1.66). the majority (71.8%) of respondents correctly identified 7 or more non-stroke risk factors correctly, while 59 (11.0%) had a score of 4 or less. higher knowledge of non-stroke risk factors was noted in respondents aged 20 to 64 (m = 7.61, sd = 2.09) compared to respondents aged 65 and older (m = 6.83, sd = 2.23; t = 3.47, p < .01). the three non-stroke risk factors most often misidentified by respondents as stroke risk factors were hypoglycemia, varicose veins, and trouble sleeping. there were no significant differences in recognition of non-stroke risk factors by location or gender. younger subjects were significantly more likely to incorrectly identify as risk factors for stroke: varicose veins (younger = 34%, older = 23%; x2 = 4.77, p < .03), iron deficiency (younger = 18%, older = 10%; x2 = 4.02, p < .04), and lyme disease (younger = 12%, older = 2%; x2 = 9.42, p < .01). discussion rural and non-rural respondents’ level of knowledge of stroke symptoms in this community-based sample is much better than that of the few published reports from other studies, while the knowledge level of stroke risk factors is somewhat better or comparable to the findings in those same studies (kothari et al., 1997; pancioli et al., 1998; yoon et al., 2001). in a hospital-based report from 1997 of 163 stroke patient interviews, kothari and colleagues (1997) reported that 40% of interviewees could not name a single stroke symptom or risk factor. in a 1998 report of a greater cincinnati area general public telephone interview of 1,880 persons, pancioli and colleagues (1998) reported that only 8% of participants could list at least three stroke symptoms and only 4% could list at least three stroke risk factors. yoon and colleagues (2001) in a general public telephone interview of 822 persons, reported that 49.8% of subjects identified one stroke symptom and 76% identified one stroke risk factor. compared with these earlier recall surveys, the recognition knowledge of stroke symptoms of the srq respondents was clearly higher, with 93.4% identifying 7 or more of the 10 most common stroke symptoms and 87.4% able to identify 7 or more of the 10 most common stroke risk factors. in completing the srq, respondents were asked to “recognize” stroke symptoms or stroke risk factors from 20-item lists for each. other studies that examined a sample’s stroke knowledge used an interview format, either phone or in-person, and had respondents “recall” stroke symptoms or risk factors in response to open-ended questions (hux et al., 2000; kothari et online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 18 al., 1997; pancioli et al., 1998; samsa et al., 1997; yoon et al., 2001). the use of a recognition methodology may have contributed to the higher stroke knowledge scores in this study. a similar explanation was offered in a study by zerwic (1998) of a general public sample's knowledge of acute myocardial infarction (ami) symptoms. the overall greater knowledge level rural and non-rural respondents of stroke symptoms and risk factors in this study compared with previous surveys may also be related to the characteristics of the respondent population or to methodological differences. in contrast to previous studies (hux et al., 2000; kothari et al., 1997; pancioli et al., 1998; samsa et al., 1997; yoon et al., 2001), this study’s population was mostly white, young (< 65 years), and welleducated. differences in stroke knowledge between a general public sample and a sample of stroke patients may be related to cognitive deficits of the acute brain insult in the latter population. rural respondents (m = 9.32, sd = 1.32) had slightly (but not significantly) higher stroke symptom knowledge than their non-rural counterparts (m = 9.01, sd = 1.93). this was surprising, as the literature leads us to believe that rural residents who are older, less educated, and poorer than the general public would be less knowledgeable (coward, bull, kukulka, & galliher, 2004; racher, 2002). this finding raises questions about reported differences between rural and non-rural residents. perhaps the definition of a rural community as those residents living outside an urban area of 2,500 or more people is not sufficient. there may be a need to expand the definition of a rural community to include a specified number of miles from the nearest metropolitan community. for example, perhaps the rural areas surveyed in this study were actually bedroom communities to non-rural cities where respondents worked, influencing rural respondents’ access to health information. younger (20 to 64 years) respondents had significantly higher stroke symptom knowledge (m = 9.29, sd = 1.93) than did respondents aged 65 and older (m = 8.84, sd = 1.85). the pattern of age-group differences in knowledge of stroke symptoms was somewhat surprising. stroke being a health problem in older adults, older respondents were expected to be more knowledgeable than younger respondents. the basis for this finding is not obvious, but may include differences in education and access to information about health issues such as stroke. in this study, the four non-stroke symptoms most often misidentified as stroke symptoms were difficulty breathing (60.4%), extreme tiredness (54.9%), sudden pain in one arm (57.0%), and chest pain (40%). these symptoms are in fact symptoms that are reported by individuals experiencing an acute myocardial infarction (ami). some individuals in this study appear to have trouble distinguishing between the symptoms of stroke and ami. interestingly, in an earlier study by zerwic (1998) that focused on the knowledge of a community sample about ami symptoms, the sample confused stroke symptoms with ami symptoms. zerwic (1998) concluded that individuals at risk for ami may need education about the symptoms that are not associated with ami as well as those symptoms that are associated with ami. a similar approach may need to be considered with stroke. individuals who have multiple risk factors for stroke are also at risk for ami. education may be needed to help these individuals sort out which symptoms are associated with one health problem versus the other. the most frequently correctly identified stroke risk factors by rural and non-rural respondents were high blood pressure (96.2%), high blood cholesterol (85.3%), smoking cigarettes (84.7%), and being more than 20 pounds overweight (80.5%), and this is comparable online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 19 to findings in previous studies where respondents identified high blood pressure, stress, smoking, and diet (kothari et al., 1997; pancioli et al., 1998; yoon et al., 2001). four stroke risk factors were not recognized by a substantial number of all respondents: alcohol use (53%), irregular heartbeat (42.2%), diabetes (31%), and history of having had a heart attack (31%). this is evidence that there is a need to educate the general public more specifically regarding stroke’s risk factors. implications for nursing practice the forecast of a rising toll of stroke-related deaths and disability with aging of the babyboom generation has brought new urgency to prevention, earlier recognition, and timely treatment of stroke. nurses are in a unique position to provide education for the general public addressing stroke risk factors. stroke screening programs and education in rural as well as urban settings, such as churches, markets, and work sites, are needed; stroke-awareness programs could make a difference in faster stroke treatment (zerwic, ennen, & devon, 2002). although it is important for the public to be aware of stroke’s symptoms and life-saving benefits of immediate treatments, the key to improved public health is prevention. nurses can help individuals understand stroke risk factors related to their lifestyle. community-based screening programs that are accessible to rural populations that address risk-laden lifestyle behaviors and the symptoms of stroke are one way to increase the public’s stroke knowledge and begin to decrease stroke incidence and its devastating consequences. strengths and limitations of the study a strength of this study was the use of the tailored mail survey design method. this method was successful in obtaining a greater than 70% response rate (566 respondents) and an equitable representation of rural and non-rural residents. the opportunity to complete the srq without the influence of an interviewer is a strength of self-administered surveys. the specific assessment of rural residents’ stroke knowledge was an important strength of this study. limitations of the study include possibility that the characteristics and knowledge level of stroke symptoms and stroke risk factors in those individuals who did not return a questionnaire and who were not selected to participate were different than the sample respondents. the sample, though large, was quite homogenous, as they were mostly white, young, and educated. the use of telephone directories to select a sample may have resulted in the underrepresentation of certain populations. the srq was a new measure using specified lists of stroke symptoms and stroke risk factors requiring recognition versus open-ended questions requiring recall. pilot testing showed that risk factor recognition scores were not as stable across time as the symptom recognition scores. this suggests that study subjects may have been guessing on some of the items in the risk factor assessment affecting stability. conclusions education programs in both rural and urban settings must focus on stroke risk factor modification and actions to take if stroke symptoms occur. data indicate that stroke educational efforts should target the elderly, who have the greatest stroke risk, but who appear to be the least online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 20 informed regarding stroke symptoms and stroke risk factors (appel, harrell, & deng, 2002; fontanarosa & winkler, 1998; stephenson, 1998). however, stroke education will not be effective if directed only towards those at greatest risk for stroke. individuals with acute stroke often have impaired ability to communicate or are unable to recognize their symptoms. therefore, people of all ages, whether rural or urban residents, must be able to recognize (label) the symptoms of stroke to facilitate rapid stroke identification and transport of the symptomatic individual to the hospital. public education in rural and urban communities promoting stroke knowledge and modification of risk factors, actions to take when stroke symptoms occur, and differentiating stroke symptoms from those of an acute myocardial infarction seems to be the most needed interventions. as leventhal nerenz, and steele (1984) described, the correct labeling of signs and symptoms as a stroke should translate into changes in behavior. the translation of enhanced knowledge about stroke symptoms can result in the rapid seeking of health care, increasing the number and percentage of individuals with stroke symptoms who receive effective interventions and reducing the disability and mortality currently associated with stroke. references american heart association. (2001). 2002 heart and stroke statistical update. dallas, tx: author. appel, s.j., harrell, j.s., & deng, s. (2002). racial and socioeconomic differences in risk factors for cardiovascular disease among southern rural women. nursing research, 51(3), 140-147. [medline] coward, r.t., bull, c.n., kukulka, g., & galliher, j.m.e. (2004). health services for rural elders. new york: springer publishing. dillman, d.a. (2000). mail and internet surveys: the tailored design method. 2nd ed. new york: john wiley & sons. fontanarosa, p.b., & winkler, m.a. (1998). timely and appropriate treatment of acute stroke: what's missing from this picture? jama, 279(16), 1307-1309. [medline] goldstein, l.b., silberberg, m., mcmiller, y., & yaggy, s.d. (2009). stroke-related knowledge among uninsured latino immigrants in durham county, north carolina. journal of stroke and cerebrovascular diseases, 18(3), 229-231. [medline] hux, k., rogers, t., & mongar, k. 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(2010). heart disease and stroke statistics – 2010 update: a report from the american heart association statistics committee and stroke statistics subcommittee. circulation, 121, e1-e170. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://www.ncbi.nlm.nih.gov/pubmed?term=12063412%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=9565014%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=10706209%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=9341687%5buid%5d&cmd=detailssearch 21 online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 national institutes of neurological disorders and stroke. (2009). stroke: hope through research. bethesda, md: national institutes of health. pancioli, a.m., broderick, j., kothari, r., brott, t., tuchfarber, a., miller, r., … jauch, e. (1998). public perception of stroke warning signs and knowledge of potential risk factors. jama, 279(16), 1288-1292. [medline] pierce, c. (2007). distance and access to health care for rural women with heart failure. online journal of rural nursing and health care, 7(1), 27-34. racher, f.e. (2002). synergism of frail rural elderly couples: influencing interdependent independence. journal of gerontological nursing, 28(6), 3239. [medline] redford, l., & cook, d. (2001). rural health care in transition: the role of technology. the public policy and aging report, 12(1), 1, 3-5. samsa, g.p., cohen, s.j., goldstein, l.b., bonito, a.j., duncan, p.w., enarson, c., … matchar, d. b. (1997). knowledge of risk among patients at increased risk for stroke. stroke, 28(5), 916-921. [medline] stephenson, j. (1998). rising stroke rates spur efforts to identify risks, prevent disease. jama. 279(16), 1239-1240. [medline] tabachnick, b.g., & fidell, l.s. (2001). using multivariate statistics (4th ed.). boston: allyn and bacon. united states census bureau. (2001). census 2000 redistricting data (public law 9-171) summary file. washington, dc: author. united states department of health and human services. (2000). healthy people 2010: tracking healthy people 2010. washington, dc: office of public health and science. waltz, c.f., strickland, o.l., & lenz, e.r. (1991). measurement in nursing research (2nd ed.). philadelphia: f. a. davis company. yoon, s.s., heller, r.f., levi, c., wiggers, j., & fitzgerald, p.e. (2001). knowledge of stroke risk factors, warning symptoms, and treatment among an australian urban population. stroke, 32(8), 1926-1930. [medline] zerwic, j.j. (1998). symptoms of acute myocardial infarction: expectations of community sample. heart lung, 27(2), 75-81. [medline] zerwic, j.j., ennen, k., & devon, h.a. (2002). stroke: risks, recognition, and return to work. aaohn journal, 50(8), 354-359. [medline] http://www.ncbi.nlm.nih.gov/pubmed?term=9565010%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=12071272%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=9158625%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=9564989%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=11486127%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=9548063%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=12227209%5buid%5d&cmd=detailssearch residence location microsoft word brantley_510-3134-2-ce.docx online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 148 nurse executives leading change to improve critical access hospital outcomes: a literature review with research-informed recommendations heather v. nelson-brantley, phd, rn, ccrn-k1 debra j. ford, phd2 karen l. miller, phd, rn, faan3 marjorie j. bott, phd, rn4 1 assistant professor, school of nursing, university of kansas medical center, hnelsonbrantley@kumc.edu 2 associate professor, interdisciplinary leadership doctoral program, creighton university, debraford@creighton.edu 3 professor and former dean, school of nursing, university of kansas medical center, kmiller@kumc.edu 4 associate professor and associate dean for research, school of nursing, university of kansas medical center, mbott@kumc.edu abstract background and purpose: nurses have been called to lead the transformation of health care to provide more efficient, safe, high quality care. however, little is known about how to prepare and enable critical access hospital (cah) nurse executives to lead change. research indicates that magnet®-designated hospitals have significantly better patient and organizational outcomes as compared to non-magnet hospitals. the purpose of this study was to synthesize challenges faced by cah nurse executives and provide research-informed recommendations for leading change to achieve magnet standards in cahs. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 149 sample and methods: a review of the literature was conducted to understand the historical development of cahs and to identify challenges faced by cah nurse executives. cinahl, pubmed, and the rural health information hub databases were searched for relevant peerreviewed studies and expert commentary published in english from 2007 to 2016. thirty-four articles were synthesized. findings: cah nurse executives face significant challenges to ensuring their hospitals are providing high quality care including: (a) recruitment, retention, and appropriate staffing ratios; (b) the need for nursing staff with multispecialist knowledge; (c) fewer baccalaureate-prepared nurses; and (d) lack of financial and human resources to support new graduate nurse transition, continuing education, and evidence-based practice. recommendations for cah nurse executives seeking to achieve magnet standards were developed from interviews with healthcare professionals (n = 27) at the first independent cah to achieve magnet designation. conclusions: cah nurse executives may consider the magnet standards as a blueprint for leading change to improve organizational outcomes. consideration should be given to: (a) securing administrative leadership support; (b) strategically planning for small, incremental change; (c) building shared governance, quality improvement, research, and education; (d) harnessing collective power; and (e) believing and staying committed to the purpose of improving staff and patient outcomes. keywords: critical access hospital, leading change, magnet, nurse executive, quality outcomes nurse executives leading change to improve critical access hospital outcomes: a literature review with research-informed recommendations nurses have been called, in partnership with others, to lead the transformation of health care to provide more efficient, safe, high quality care (institute of medicine [iom], 2011). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 150 approximately 27.7 million people (21% of the u.s. population) live in rural areas (defined as a population of 50,000 or fewer) of the u.s. (united states census bureau, 2014). provider shortages, access limitations, and the inefficient utilization of health care services have been linked to a lack of high quality health care for rural residents (weinhold & gurtner, 2014). these same factors may present significant challenges for rural hospital nurse executives (nes) seeking to transform rural hospital outcomes. evidence indicates that magnet®-designated hospitals are achieving many of the improvements called for by the iom, and thus the journey to magnet designation may serve as a roadmap for rural hospital nes seeking to achieve high quality care. the name magnet originated in 1982 as a way to describe 41 hospitals that were able to attract and retain nurses at a time and in locations where hospitals around them were experiencing nursing shortages and high turnover (mcclure, poulin, sovie, & wandelt, 1983). an analysis of these hospitals revealed that they possessed similar qualities or characteristics that enabled them to attract and retain nurses; these qualities became known as the 14 forces of magnetism (wolf, triolo, & ponte, 2008). in 1993, the magnet recognition program was established by the american nurses credentialing center (ancc) as a mechanism for formally evaluating and recognizing health care organizations for structures and care processes that support nursing practice. in 2007, the 14 forces of magnetism were collapsed into a new magnet model consisting of five domains: (a) transformational leadership; (b) structural empowerment; (c) exemplary professional practice; (d) new knowledge, innovations, and improvements; and (e) empirical outcomes (ancc, 2013). along with the new magnet model came a shift from a focus on organizational structure and care processes to an emphasis on quality outcomes (ancc, 2013). over the past decade, research has linked magnet hospitals to: (a) decreased mortality and failure-to-rescue (aiken, smith, & online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 151 lake, 1994; kutney-lee et al., 2015; mchugh et al., 2013); (b) decreased pressure injuries (bergquist-beringer, dong, he, & dunton, 2013) and patient fall rates (everhart et al., 2014); (c) higher nurse-perceived managerial support (lacey et al., 2007); (d) improved quality of care (stimpfel, rosen, & mchugh, 2014); (e) increased job satisfaction (lacey et al., 2007) and shared governance participation (hess, desroches, donelan, norman, & buerhaus, 2011); (f) decreased nurse burnout (kelly, mchugh, & aiken, 2011) and turnover (gardner, thomas-hawkins, fogg, & latham, 2007); and (g) higher patient satisfaction (smith, 2014). today, magnet designation is used by the u.s. news & world report and the leapfrog hospital survey as a hospital performance indicator of safety, quality, and efficiency (ancc, 2018b). a newly emerging body of evidence suggests that hospitals undergo significant transformations in their journey to magnet designation, and it is this transformation that leads to superior outcomes (hess et al., 2011). when applying for magnet designation, hospitals or health systems must provide evidence that they are achieving superior nurse and patient outcomes, engaging frontline nursing staff in shared decision making, and have nurses who actively are involved in research (ancc, 2013). these standards may appear to be challenging particularly to nes in small rural hospitals with limited resources. however, as one 25-bed independent critical access hospital (cah) learned, the journey to magnet may be a roadmap to finding effective solutions to their most pressing challenges. access to safe, quality, affordable, and efficacious health care is a leadership priority of countries around the world (world health organization, 2014). recent studies indicate that the rate of rural hospital closures in the u.s. is rapidly accelerating with more than double the number closing in 2013 and 2014 than in 2011 and 2012 (kaufman et al., 2016). these closures place an estimated 1.7 million rural residents at an even greater risk of negative health outcomes and online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 152 economic hardship (kaufman et al., 2016). cahs were introduced as a mechanism for ensuring access to health care for rural residents, and while they have provided much needed access, questions remain about the quality of care they provide (casey, burlew, & moscovice, 2011). it is not enough to provide access to care; there also must be a focus on quality. understanding the challenges faced by cah nes and how best to prepare them for leading change to consistently deliver high quality care remains an underexplored area of research. in a recent meeting of national rural health thought leaders, a recommendation was made to identify successful rural health models that could be replicated with the aim of transforming rural health care nationally (gerardi, 2015). to date, only one independent cah has achieved magnet designation (waverly health center, 2018). this cah may serve as a successful model for nes working in cahs seeking to improve quality outcomes. the purpose of this study was to: (a) outline the historical development and performance of cahs; (b) synthesize challenges faced by cah nes; and (c) provide recommendations for leading change to achieve magnet standards to advance cah quality outcomes. methods a review of the literature was conducted to understand the historical development and performance of cahs and to identify challenges faced by cah nes. literature was collected from november 2015 to may 2016 using cinhal, pubmed, and the rural health information hub (rural health information hub, 2018) databases. data sources included primary studies and systematic reviews from peer-reviewed journals, as well as authoritative reports, documents, webpages, and commentaries from leading rural hospital experts. the search was limited to articles published in english between 2007 and 2016. a manual search using google scholar and reference lists of retrieved articles also was performed. search terms included: critical access online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 153 hospital and rural nursing. the following terms were combined with the previous search terms using the “and” operator: leadership development, finance, resources, education, recruitment, retention, research, patient outcomes, and quality. findings an initial search of the literature resulted in 405 abstracts (see figure 1). after screening the abstracts for duplication, retrievability, and relevance, 58 articles were retained for full-text review. thirty articles were excluded after full-text review because they failed to contribute knowledge related to challenges faced by rural hospitals. while reviewing the remaining 28 articles, four additional articles were identified as relevant and were retrieved from the reference list of the respective articles. while retrieving the four articles, two additional articles were identified through google scholar’s ‘related articles’ feature and were retrieved, reviewed, and retained for analysis. in total, 34 articles were included in the final analysis. cah legislative history and performance the balanced budget act of 1997 established the medicare rural hospital flexibility (flex) program with the aim of improving access to emergency and preventative health care for rural populations (rurual health information hub, 2016). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 154 figure 1. literature search and selection process this act enables rural hospitals to seek federal designation as cahs, thus changing their medicare reimbursement structure from a prospective payment system to a cost-based system (li, schneider, & ward, 2007). to qualify, hospitals must be located more than 35 miles (or 15 miles in areas with mountainous terrain or only secondary roads) from any other hospital, or have been certified by january 1, 2006 by the state as being a necessary provider of care services. in addition, cahs must have no more than 25 acute care and swing beds and maintain an average length of stay of ≤ 96 hours, and offer 24-hour emergency care services (casey et al., 2011). the number of cahs has increased from 41 in 1997 to 1,332 as of april 2016 (rural health information hub, 2016). cahs comprise approximately 61% of all hospitals in rural areas and therefore play a major role in ensuring access to care for rural residents (moss, holmes, & pink, abstracts identified through database search (n = 405) articles added after manual search (reference list or google scholar) (n = 6) abstracts retained after screening for retrievability and duplication (n = 203) abstracts screened for relevance (n = 203) abstracts excluded (n = 145) articles retained for full-text review for relevance (n = 58) articles excluded (n = 30) final articles included in the review (n = 34) online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 155 2015). the typical cah employs 127 individuals, has an average service area population of 17,663, and generates $0.4 million to $26.4 million annually in wages, salaries, and benefits. further, for every job in the cah, an additional 0.34 jobs are created in the community, and an average of $1.8 million are generated in local taxable retail sales (doeksen, st. clair, & eilrich, 2016). thus, cahs also play a significant role in maintaining rural community economies. because of the important role cahs play in rural communities, several legislative acts have been passed in an effort to maintain their financial viability (american hospital association, 2010). the medicare prescription drug, improvement, and modernization act of 2003 increased cah payment to 101% of reasonable costs and expanded payment for on-call services to include those provided by physician assistants, nurse practitioners, and clinical nurse specialists. in 2008, the medicare improvements to patients and providers act extended the 101% reimbursement rate to include clinical lab services provided to medicare beneficiaries. in 2009, the american recovery and reinvestment act established payment incentives for cahs to invest in health information technology by allowing cahs to load multiple years of electronic health record depreciation costs into one year (american hospital association, 2010). collectively, these acts have substantially supported the financial viability of rural hospitals (holmes, pink, & friedman, 2013). while conversion to cah designation has contributed to the financial viability of many rural hospitals, cah status does not guarantee a better financial situation (rural health information hub, 2016). a large-scale study recently was conducted to examine differences between rural hospitals (including cahs) that closed from 2010 to 2014 and rural hospitals that remained open (kaufman et al., 2016). factors that were within the hospital’s control (e.g., liquidity, revenue, utilization, and staffing) were found to be better predictors of remaining open than market factors online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 156 outside of the hospital’s control (e.g., population, socioeconomic status, or distance to other hospitals). hospitals that remained open had higher utilization, and thus revenue, generated from outpatient care and health clinic services, and higher full-time equivalents and staffing salaries (kaufman et al., 2016). because cahs frequently offer only limited services, rural residents may bypass them in search of larger hospitals or health clinics that can meet their specific needs (weinhold & gurtner, 2014). however, findings from the kaufman et al. (2016) study suggest that factors associated with cah closure may be modifiable by careful attention to the types of services offered to patients, as well as staffing ratios and salaries. the flex program not only focuses on conversion of eligible rural hospitals into cahs, but also on improving the quality of care provided by cahs (casey et al., 2011). evidence suggests that cah patient outcomes are mixed. in a study of 89 hospitals in rural iowa, cah conversion was associated with better performance on risk-adjusted rates of iatrogenic pneumothorax, hospital acquired infections, and accidental puncture or laceration, but had no significant impact on lowrisk mortality rates, retention of foreign body during surgery, or pressure injury rates (li et al., 2007). a retrospective review of 500 surgical cases in one illinois cah found an overall complication rate of 4%, which exceeded all benchmarks in the surgical literature (rossi, rossi, rossi, & rossi, 2011). however, in a large hospital-compare study, cahs scored lower on most quality patient outcome measures (i.e., pneumonia, heart failure, and myocardial infarction) compared to prospective payment system, rural and urban hospitals (casey et al., 2011). these findings further were supported by a retrospective, comparative analysis of 2,351,701 patient admissions to 4,738 u.s. hospitals (joynt, harris, orav, & jha, 2011). moreover, cahs in this study had significantly higher 30-day mortality rates for patients with pneumonia, heart failure, and myocardial infarction as compared to non-cahs. collectively, these studies indicate that online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 157 while some cahs are performing above established benchmarks, substantial challenges remain for the clear majority of cahs seeking to achieve high quality care. challenges faced by cah nurse executives nes working in cahs face considerable challenges in the management of complex chronic and acute care needs that often extend beyond the facility’s capacity and competency (weinhold & gurtner, 2014). a review of the literature identified four areas that are particularly challenging: (a) recruitment, retention, and appropriate staffing ratios; (b) need for nursing staff who are flexible, confident, and possess multispecialist knowledge (proficiency to care for a variety of patients across the continuum of acute care needs); (c) fewer baccalaureate-prepared nurses; and (d) lack of financial and human resources to support new graduate nurse transition, continuing education, evidence-based practice, and professional development. each of these areas is examined in further detail below. recruitment, retention, and appropriate staffing ratios. nes in cahs and other rural hospitals face extensive challenges in recruiting and retaining nursing staff, physicians, and other care providers (collins, 2016; joynt et al., 2011; world health organization, 2010). although approximately 50% of the world’s population lives in rural areas, only 38% of nurses and fewer than 25% of physicians work in these settings (world health organization, 2010). thus, identifying successful strategies for attracting and retaining nurses is one of the greatest challenges faced by cah nes. factors that contribute to the shortage of nurses and other care providers in rural areas include: resistance within the provider’s family to live in a rural area, long travel distances to work, worries of social isolation, and an unsuitable work-life balance (weinhold & gurtner, 2014). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 158 nes in cahs also face unique challenges related to maintaining appropriate staff-to-patient ratios. cahs maintain 25 or fewer acute care and swing beds and are staffed with few nurses, which leaves them exposed to significant challenges of fluctuations in patient census (hunsberger, baumann, blythe, & crea, 2009). to illustrate, an increase or decrease of four patients to a 28bed obstetrics unit at a large academic medical center would generate a 14.3% fluctuation in unit patient census. yet, the same increase or decrease of four patients to a 4-bed cah obstetrics unit would generate a 100% fluctuation, resulting in either an empty unit or one with patient overflow that may extend beyond the hospital’s ability to provide safe care. to address fluctuating patient census, nes in cahs often hire a large proportion of part-time staff who work on-call, a practice that rural staff nurses report as disruptive to their personal lives (hunsberger et al., 2009). nursing staff with multispecialist knowledge. the skill set needed for nursing practice in rural settings often is underestimated. while staff nurses in rural hospitals frequently are viewed as generalists, they are more accurately described as requiring multispecialist knowledge (macleod, browne, & leipert, 1998) to care for complex, diverse patient populations, often with minimal support or resources (harmon, 2013; hunsberger et al., 2009). as only one of a small staff, each nurse often cares for pediatric, geriatric, emergency, critically ill, and psychiatric patients all in the same shift (harmon, 2013; hurme, 2009; seright & winters, 2015). further, cahs often operate in communities where no mental health services are available, resulting in patients seeking mental health services in cah emergency rooms that are ill equipped to provide them (hartley et al., 2007). these demands require rural nurses to be highly flexible, selfconfident, and proficient in a variety of patient population specialties (keahey, 2008). fewer baccalaureate-prepared nurses. research indicates that hospitals with higher percentages of baccalaureate-prepared (bsn) registered nurses (rns) have better patient outcomes online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 159 and lower mortality rates (aiken, clarke, cheung, sloane, & silber, 2003; estabrooks, midodzi, cummings, ricker, & giovannetti, 2005; friese, lake, aiken, silber, & sochalski, 2008; tourangeau et al., 2007). based on this evidence, the iom (2011) recommended increasing the number of bsn-prepared rns in the workforce to 80% by 2020. rn workforce analyses indicate that rural areas tend to have fewer highly educated rns compared to urban areas (baernholdt & mark, 2009; brewer & watkins, 2011; u.s. department of health and human services, 2010). increasing the number of bsn-prepared rns in cahs poses a significant challenge to nes due to limited educational opportunities in rural areas (baernholdt & mark, 2009). however, evidence suggests that rural rns who can return to school are more likely to complete a bsn than urban-based rns. in a longitudinal study of 917 associate degree-prepared (ad) rns, residing in a rural area was a significant (p = .002, or = 2.46, 95% ci = 1.37-4.39) and positive predictor of completing a bsn or higher degree (kovner, brewer, katigbae, djukic, & fatehl, 2012). kovner et al. (2012) state that the goal of an 80% bsn-prepared workforce by 2020 cannot be attained by increasing the number of bsn graduates alone; transitioning adprepared rns to bsns also will be required. most rns returning to school need to continue to work while they advance their education, placing an even greater demand on cah nes as they look for ways to support an rn’s ability to attend class while also ensuring the hospital is adequately staffed (kovner et al., 2012). financial and human resources. compounding these challenges are lacks of financial and human resources to support new graduate nurse transition and continuing education (ce). new graduate nurses in all settings require sufficient time, training, and support to acquire basic skills in providing safe and competent care (iom, 2011; joint commission on accreditation of healthcare organizations, 2002). hospitals in urban settings commonly provide the new graduate online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 160 with support through nurse residency programs. however, few residency programs exist in rural hospitals (keahey, 2008). cah nes also are challenged to provide access to ce and professional development opportunities due to budgetary constraints and lack of adequate staffing that enable nurses to attend ce offerings (mccoy, 2009). access to and use of research to inform evidence-based practice is another challenge faced by nes in rural areas (jukkala, greenwood, ladner, & hopkins, 2010). staff nurses in a rural u.s. western state reported several barriers in this area including: lack of knowledge of research methods, lack of time and access to computers or the internet, poor computer literacy skills, diminishing financial support from employers, long travel distances to attend conferences, and a lack of research literature specific to rural practice (winters et al., 2007). nurses in this study used the term research to refer to a general gathering of information, and their preferred method of obtaining information was asking a colleague. overall, the lack of financial and human resources may result in nursing staff who lack critical thinking and prioritization skills, patient safety and discharge education concerns, and practice environment issues (e.g., poor communication, lack of professionalism, bullying, and burnout) (fairchild et al., 2013). nurses, including nes working in cahs, are called to lead change to improve care quality (iom, 2011). yet cah nes are faced with significant challenges to doing so, including: (a) recruitment, retention, and appropriate staffing ratios; (b) the need for nursing staff with multispecialist knowledge; (c) fewer baccalaureate-prepared nurses; and (d) a lack of financial and human resources to support new graduate nurse transition, continuing education, evidence-based practice, and professional development. the remainder of this article will offer waverly health center, the first independent cah to achieve magnet designation, as a successful rural health model for cah nes seeking to improve cah quality outcomes. permission to use the cah name online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 161 in this report was obtained from waverly health center’s chief nursing officer (cno). an introduction to the hospital and their journey to magnet designation is provided, followed by a list of measurable outcomes waverly achieved as a result of that journey. finally, we offer recommendations for cah nes seeking to improve quality outcomes using the journey to magnet standards as a blueprint for leading change. these recommendations were developed from interviews with waverly health center clinicians and administrators (n = 27) as part of a larger qualitative, index case study of waverly’s journey to magnet designation (nelson-brantley et al., 2018). the study was approved by the primary author’s academic medical center institutional review board (irb) (protocol #study00003523). waverly health center: a model of success waverly health center is a 25-bed cah located in a rural midwestern u.s. town of 9,874 (waverly health center, 2013). in 2014, the hospital became the first independent cah to achieve magnet designation. waverly health center is one of the top employers in the community. in 2014, waverly had 444 employees, including 131 rns (waverly health center, 2014). that year the hospital cared for a total of 901 inpatients and 55,877 outpatients. daily operations costs averaged $132,003 (waverly health center, 2014). waverly health center has remained independently operated for over 100 years, a factor considered essential to their ability to provide a multitude of health care services (e.g., birthing center, health clinics, cardiac rehabilitation, outpatient surgery, lab services, complementary integrative therapies) that meet the needs of the local community and surrounding areas (waverly health center, 2013). like most cahs, waverly frequently refers patients to other hospitals for services beyond their scope of service. the hospital has used this opportunity to build a strong network of external supports, including a community hospital, a large academic medical center, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 162 and the world-renowned mayo clinic. the relationship with these external supports goes beyond patient referral to include educational opportunities for the staff of waverly. although nurse staffing measures vary greatly (american nurses association, 2017; spetz, donaldson, aydin, & brown, 2008) making comparisons across settings challenging, nurses at waverly health center report better nurse-patient staffing ratios (typically 1:4 on the medicalsurgical unit and 1:2 in the birthing center) than most cahs and other rural hospitals that commonly have fewer nurses per patient (hunsberger et al., 2009). nursing staff and interprofessional care providers alike report that there is true collaboration, mutual support, and a winning mindset that make their jobs truly enjoyable. they can spend sufficient time providing individualized and comprehensive care to all patients. in addition, the hospital is supported by nearly 300 community volunteers. in 2008, waverly began what would become a 6-year journey to magnet designation. table 1 shows the improved nurse, patient, and organizational outcomes that have been achieved because of this journey. the table was constructed from study findings reported elsewhere (nelson-brantley et al., 2018). table 1 waverly health center patient, nurse, and organizational outcomes attributed to the journey to magnet outcome level outcome patient • outperformed ndnqi® mean fall rate in cahs for 8 consecutive quarters. • zero hospital-acquired pressure injuries in 2015. • zero catheter associated urinary tract infections in 2015. • zero restraint usage in 2015. • zero central line associated blood stream infections in 2015. • hcahps patient satisfaction scores above the state and national mean in all 11 categories in 2015. nurse • staff rn participation in shared governance: leadership, professional development, practice, and quality councils. • staff rn increased knowledge, skills, and appreciation for qi, research, and ebp. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 163 • staff rn satisfaction scores above ndnqi mean for all participating hospitals in 2015. • 17 (13%) of rns seeking advanced education (9 bsn; 8 msn) in 2014. • exceeding state average of bsn-prepared nurses in 2016. • 100% bsn-prepared nurse manager staff as of 2016. organization • increased physician, nurse, and student recruitment. • completed and published two research studies; one underway. • qi documentation tool recognized as a best practice. • professional practice model centered on shared decision making, ebp, and patient-centered care. • preferential hiring of bsn-prepared staff rns as of 2016. • tuition reimbursement provided to rns seeking advanced education. • bsn degree added to criteria for reaching level 2 on nursing career ladder in 2016. • nurse residency program for new graduate rns. • leadership development and succession planning through emerging leaders program. note. ndnqi = national database of nursing quality indicators. cahs = critical access hospitals. hcahps = hospital consumer assessment of healthcare providers and systems. rn = registered nurse. qi = quality improvement. ebp = evidence-based practice. bsn = bachelor of science in nursing. msn = master of science in nursing. recommendations for cah nurse executives considering magnet designation as part of a larger study (nelson-brantley et al., 2018), waverly staff rns (n = 5), nurse managers (n = 9), interprofessional care providers (n = 7), and hospital executive leaders (n = 6) were asked what recommendations they would offer to other cahs interested in pursuing magnet designation. five recommendations emerged from those discussions: (a) secure administrative leadership support; (b) strategically plan for small, incremental change; (c) build shared governance structures, quality improvement (qi) capacities, research networks, and highly educated nursing staff; (d) harness collective power through open communication, education, and direct involvement in the change process; and (e) believe and stay committed to the purpose of improving staff and patient care. table 2 provides specific action steps for achieving each of the five recommendations. the recommendations and action steps are further discussed within the context of what worked well for waverly health center. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 164 table 2 recommendations and action steps for cah nurse executives seeking magnet designation recommendation action step 1. secure administrative leadership support. • build a strong case for seeking magnet designation driven by empirical evidence of magnet-hospital outcomes (nurse recruitment, retention, job satisfaction, and patient outcomes). • present hospital board and executive leadership with costs associated with replacing one staff nurse compared to costs of applying for magnet designation. • communicate to hospital board and executive leadership that journey to magnet is a long-term commitment to advancing the organization, not just nursing. 2. strategically plan for small, incremental change. • conduct a thorough gap analysis. • identify and prioritize goals and measurable outcomes. • develop an action plan. • incorporate the plan into the hospital’s 5-year budget. • identify and appoint a strong taskmaster to keep the process organized and hold everyone accountable. • document as you go. • evaluate progress and adjust as needed. 3. build shared governance, qi, research, and education. • explore waverly health center’s professional practice model for developing shared governance; customize to suit your organization’s mission and values. • build nursing councils to: (a) engage staff in shared decision making; (b) increase knowledge, skills, and appreciation for qi, ebp, and research; and (c) promote leadership development. • train and involve frontline nursing staff directly in the collection and analysis of quality outcomes data, and developing qi projects to improve outcomes. • network with larger hospitals to provide research support. • collaborate with others (e.g., physicians) within your hospital to develop mutually-beneficial projects. • work with an external irb, if necessary, to ensure your research will meet all criteria necessary for the protection of human subjects and publication. • support higher levels of education for nursing staff: preferential hiring of bsn-prepared rns, tuition reimbursement, career ladder advancement based on bsn. 4. harness collective power. • focus on culture first. culture must support staff and patient care. • educate nurse managers, staff nurses, and all non-nursing staff about magnet and why it is important to them and the organization. • identify and focus everyone on meaningful intrinsic rewards. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 165 • engage all staff in identifying stories, writing magnet application, and preparing for magnet site visit. • communicate frequently in an open, transparent manner, explaining the rationale, the benefits, and the downfalls/challenges. • consider hiring a magnet consultant who can bring you expertise, knowledge, and coaching during your journey. 5. believe and stay committed. • if after you have completed a thorough gap analysis and have determined your organization can meet the magnet criteria, go for it! • be flexible, but stick to the plan. do not let other priorities creep in. • instill a positive, enduring sense of hope. • do not discount your stories, no matter how small. • do not let others influence your belief that it is possible. • remember why you are doing this. focus on improving staff and patient outcomes, not the ‘plaque on the wall’. note. cah = critical access hospital. qi = quality improvement. ebp = evidence-based practice. irb = institutional review board. bsn = bachelor of science in nursing. rns = registered nurses. secure administrative support. senior leadership and hospital board support are needed to establish and sustain a long-term budget that provides necessary financial and human resources for the journey to magnet designation. the cah ne should present a strong business case for magnet built on evidence of magnet hospital outcomes, including improved patient outcomes and staff nurse retention. the ne then should link the data by comparing the costs associated with nurse turnover to the costs of applying for magnet designation. this information can help senior administrators see that while the journey to magnet designation will require significant resources, the return on investment (e.g., nurse retention) will outweigh the associated costs. further, a strong message should be conveyed through both words and action that magnet is not just about nursing; it is about achieving a desired future for improved staff and patient outcomes. strategically plan for small, incremental change. once senior leadership has given their full support, the cah ne should use the nursing process as a model for strategically planning, implementing, and evaluating the journey to magnet designation. a thorough gap analysis should be performed that includes whether the organization’s values align with the magnet standards, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 166 individuals’ knowledge about magnet, and the organization’s current performance on meeting the magnet standards. the ne should work with nursing and other directors to identify and prioritize goals and measurable outcomes based on the results of the gap analysis. an essential step should be to engage all stakeholders in the planning process. the ne should seek diverse perspectives, including frontline staff, nurse managers, ancillary staff, interprofessional care providers, and executive leadership (e.g., chief executive officer [ceo], chief financial officer [cfo]). engaging all members helps build knowledge, enthusiasm, and commitment to the journey. an action plan that includes who is going to do what and by when is essential. the plan should be reasonable, understanding that the journey to magnet could take five years or more to complete. once the plan is established, it should be incorporated into the hospital’s 5-year budget, specifying both the financial and human resources needed (e.g., magnet application, magnet consultant, flexible scheduling for staff nurses to attend shared governance councils, irb costs, magnet site visit, and time and expenditures for staff to attend magnet workshops or conferences). the ne should identify and appoint a strong taskmaster who can keep the process organized and hold everyone accountable for completing their tasks on time. the magnet application requires that hospitals provide three years’ worth of data (ancc, 2013). as such, it is essential to document qi projects and outcomes as you go; do not wait until you begin to write the application. finally, routinely evaluate the hospital’s progress and adjust as needed. build shared governance, qi, research, and education. to achieve magnet designation, hospitals must present evidence that they have shared governance structures and actively engage nurses in qi and research (ancc, 2013). cah nes can expect to spend considerable time building shared governance councils, qi capacities, and research if none of these structures exist within the organization. waverly health center spent three years of its 6-year journey to magnet online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 167 designation building such structures. the ne should explore various shared governance models, including waverly health center’s professional practice model, and customize them to suit their organization’s mission and values. building nursing councils that engage frontline staff in shared decision making for nursing practice, leadership, professional development, and qi will help increase staff knowledge, skills, and appreciation for the magnet standards. collaborate with others (e.g., physicians) within your hospital to develop mutually-beneficial research projects. network with larger hospitals, or work with an external irb if necessary, to provide research support to ensure that your research will meet all criteria necessary for the protection of human subjects and eventual publication. in addition to shared governance, qi and research, hospitals applying for magnet designation must provide evidence that the ne and all nurse managers hold a bsn or higher degree (ancc, 2018a). the ne should lead by example; they are instrumental in establishing a clear and consistent message that the hospital values education (orsolini-hain, 2012). as was done at waverly health center, the ne should work with the ceo and cfo to develop an incremental plan to add flexible scheduling to support staff returning to school, tuition reimbursement, and eventually moving to a preferential hiring of bsn-prepared rns. a bsn degree should be required for advancement up the career ladder, rather than advancements being based solely on years of experience (orsolini-hain, 2012). harness collective power. while the cah ne may see significant challenges to achieving magnet designation due to limited resources, an open mind will help them recognize and tap into one of their greatest strengths—the strong sense of community that exists within their hospital. similar to other studies of nurses working in rural hospitals (lockhart, 2009), nurses at waverly found their work satisfying because they are part of a close-knit community. they described their online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 168 work environment as less cumbersome because there are fewer hierarchies that interfere with their ability to bring about change. cah nes should use this strength to harness the collective power necessary for achieving magnet designation. unlike larger hospitals that often pay one or more individuals to work full-time on preparing the hospital for magnet, cahs most likely do not have the financial means to take this approach. therefore, engaging all stakeholders in the preparation of applying for magnet designation was essential for success. the benefits of doing so were increased commitment of the entire organization and appreciation for the work that occurs throughout the hospital. it is essential that the ne communicate frequently, openly, and transparently to internal and external stakeholders, explaining the rationale, the benefits, and the downfalls or challenges they encounter along the way. in addition, the ne should consider hiring a magnet consultant who can develop their knowledge and expertise related to the magnet process, and provide coaching to prepare them for the magnet appraisers. believe and stay committed. the ne should anticipate varied levels of skepticism and doubt, both from external and internal stakeholders alike. achieving magnet designation is a difficult prospect for a hospital of any size, but may be particularly difficult for cahs to envision. for waverly health center, skepticism and doubt were replaced with enthusiasm and commitment as the staff interacted with their ne who instilled a consistent, positive, and enduring sense of hope. the waverly ne encouraged other cah nes seeking magnet designation to never let others negatively influence their belief that they can achieve it, to stay committed the purpose of improving staff and patient outcomes, and to be a cheerleader to help others in the organization stay focused on achieving what truly matters. she encouraged others to remember that it is not about the plaque on the wall; it is about providing exceptional patient care. discussion online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 169 nurses have been called to lead change in transforming hospitals to provide more efficient, safe, high quality care (iom, 2011). although cah designation has provided much needed access to care for rural residents, cah nes continue to face significant challenges to ensuring their organizations provide high quality care. these challenges point to the need for nes to identify successful strategies for increasing recruitment and retention of highly educated, flexible, and confident nurses who possess multispecialist knowledge to care for diverse and complex patients. these demands require adequate financial and human resources to support new graduate nurse transition, continuing education, evidence-based practice, and professional development. much may be learned from waverly health center as an example of a cah that successfully led change to achieve improved nurse outcomes and high quality care. waverly health center has taken a multifaceted approach to ensuring their financial viability and advancing nurse and patient outcomes. they have built a strong foundation of care services that extend beyond their 25 inpatient beds and emergency room. in fact, only 901 individuals received inpatient care as compared to 55,877 who received outpatient care services in 2014. offering outpatient surgery and a variety of health clinics (e.g., walk-in, women’s health, and orthopedic) has generated increased liquidity, revenue, and utilization, key factors that have been associated with greater likelihood of remaining open (kaufman et al., 2016). in addition, waverly offers clinical lab services, which enables them to capitalize on government financial incentives (american hospital association, 2010). waverly has developed a strong external network with larger hospitals that provide waverly staff with ce and training. collectively, these approaches help secure the financial stability of a cah; however, additional approaches are needed to attract and retain high quality staff and to ensure patients are receiving high quality care. for waverly online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 170 health center, the journey to magnet designation proved to be an effective approach to meeting these challenges. nes in cahs may consider the journey to magnet designation as a blueprint for attracting and retaining quality staff, increasing the educational preparation of their nursing workforce, engaging frontline staff in shared decision making, and improving patient outcomes. particular consideration should be given to: (a) securing administrative leadership support, (b) strategically planning for small, incremental change, (c) building shared governance, quality improvement, research, and education, (d) harnessing collective power, and (e) believing and staying committed to the purpose of improving staff and patient outcomes. these recommendations are offered for cah nes to consider within the context of their own organizations. we recognize that each cah is unique, and as such there likely are aspects of our recommendations that will not work for every cah. if the cah is part of a larger system, we recommend the cah ne build relationships with other nes in the system that are mutually beneficial. by partnering with nes from larger hospitals, the cah ne may advance their knowledge of evidence-based practice, technology, and research, as well as that of their staff. this will ensure that they are able to meet the increasingly complex health care needs of their community. likewise, nes working in larger hospitals must appreciate that cah nes know best the needs of their community; they should support them in advocating on behalf of the cah to maintain local decision making that includes types of care services provided. this will ensure the long-term viability of the cah and add to the financial wellbeing of the larger hospital system. we recognize that waverly health center may have had advantages in their efforts to lead change due to the additional outpatient services and external networks that they had established. these factors may be beyond the reach of other cahs with even greater resource limitations. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 171 regardless of whether the cah seeks actual magnet designation, we recommend that cah nes carefully consider and work toward leading change to achieve magnet standards. evidence shows that this journey will likely lead to significant improvements for staff, patients, and the organization (hess et al., 2011; nelson-brantley et al., 2018). conclusions cahs are essential to the provision of health care and economic security of rural populations (doeksen et al., 2016; moss et al., 2015). nes, whether leading a 25-bed hospital or a 1,500-bed hospital, are called to lead change to improve patient, nurse, and organizational outcomes. this report offers lessons learned from the journey of the first independent cah to achieve magnet designation, how those lessons can be applied to similar hospitals, and what positive outcomes may be realized from pursuing magnet designation. the pursuit of magnet is a commitment to improving staff and patient outcomes; it is not about the plaque on the wall. regardless of actual designation, magnet standards should be every ne’s goal. supporting agency dr. nelson-brantley received funding for this study from the taunton scholars program and the delta chapter of sigma theta tau international. acknowledgements the authors thank dr. kristin stegenga, dr. robert lee, dr. sally barhydt, and jennifer nelsonbrantley for their review of the manuscript. dr. nelson-brantley obtained written permission from the cno of waverly health center to use the hospital name in this published manuscript. conflicts of interest and source of funding online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.510 172 dr. nelson-brantley received funding for this study from the taunton scholars program and the delta chapter of sigma theta tau international. no conflicts of interest are declared by the authors. references aiken, l. h., clarke, s. p., cheung, r. b., sloane, d. m., & silber, j. h. 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(2014). twelfth general programme of work: not merely the absence of disease. retrieved from http://www.who.int/about/resources_planning/twelfth-gpw/en/ hunt_525 online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 134 using technology to provide diabetes education for rural communities caralise w hunt, phd, rn 1 kendall henderson, msn, rn 2 richard chapman, phd 3 1 associate professor & associate dean for academics, school of nursing, auburn university, huntcar@auburn.edu 2 assistant clinical professor, school of nursing, auburn university, kaw0019@auburn.edu 3 associate professor, college of engineering, auburn university, chapmro@auburn.edu abstract purpose: diabetes self-management education is the cornerstone of type 2 diabetes management. with appropriate education, people living with diabetes can learn to manage their diabetes which could prevent complications. diabetes prevalence is higher in rural areas compared to urban areas. people living with diabetes in rural areas face significant challenges to care including limited access to diabetes education. the purpose of this pilot study was to develop, implement, and evaluate the effectiveness of diabetes self-management educational modules delivered via ipad devices to increase self-management knowledge levels in adults living with type 2 diabetes mellitus in rural areas. online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 135 sample: study participants included 30 adults living with type 2 diabetes who visited health promotion clinics in rural communities. method: this pilot study involved collaboration between nursing and engineering faculty and students. ten diabetes self-management educational modules were developed and delivered electronically on ipad devices. the modules were presented to people living with type 2 diabetes mellitus who attended health promotion clinics in rural communities. participants completed a diabetes knowledge questionnaire before and after educational modules were presented. findings: diabetes knowledge scores showed a statistically significant increase from pre to posteducational intervention. conclusions: diabetes education delivered using modules on ipad devices was effective at increasing knowledge levels of people in rural areas living with type two diabetes. this may be an effective method for people living in rural areas who have limited access to healthcare and diabetes education. keywords: type 2 diabetes, diabetes self-management education, technology, rural using technology to provide diabetes education for rural communities diabetes self-management education (dsme) is the cornerstone of the management of type 2 diabetes mellitus (t2dm). patients who participate in dsme have improved self-management behaviors. these improvements in self-management behaviors lead to improved glycemic control, decreased rates of diabetes-related complications, and reductions in hospitalizations (beck et al., 2017; pereira, phillips, johnson & vorderstrasse, 2015; powers et al., 2017; yuan et al., 2014). online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 136 the american diabetes association ([ada], 2018) recognizes the vital importance of dsme and recommends that every patient receive dsme at the time of diagnosis and as needed thereafter. yet, despite the evidence that dsme improves outcomes, many people living with diabetes do not receive adequate dsme. the centers for disease control and prevention (cdc) reported a median of 54% of adults with diabetes in the u. s. attended self-management classes (2015). the prevalence of diabetes in rural versus urban areas is notably higher (maez, erickson, & naumuk, 2014). people living in these rural areas experience limited access to healthcare and dsme leading to less than optimal diabetes self-management and an increased number of diabetes-related complications (lepard, joseph, agne, & cherrington, 2015; rutledge, masalovich, blacher, & saunders, 2017). alabama ranks among the highest states for incidence of diabetes and is largely comprised of rural areas. of the 67 alabama counties, 55 are considered rural according to the alabama rural health association’s (n.d.) definition of rural. with appropriate dsme, people living with diabetes can learn to manage diabetes which can prevent the development of diabetes-related complications. healthy people 2020 goals include increasing the proportion of persons with diabetes who obtain annual eye, foot, and dental examinations; have a hemoglobin a1c measurement at least twice a year; and self-monitor blood glucose at least once per day (u. s. department of health and human services, 2018). many people living with diabetes are not aware of the need to participate in these and other selfmanagement activities. to facilitate participation in self-management behaviors, people living with diabetes should have access to dsme about these and other topics. diabetes education is especially challenging in primary care and rural areas and technology has been suggested as an online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 137 effective approach to reach rural patients (bolin, schulze, helduser, & ory, 2015; maez et al., 2014; mcilhenny et al., 2011). technology-based education has been effective at improving diabetes knowledge and diabetes self-management (greenwood, gee, fatkin, & peeples, 2017; sperl-hillen et al., 2013). education has been delivered using smartphone applications, laptops, and tablet computers (greenwood et al., 2017) and people living with diabetes are receptive to technology-based education that provides control over the pace of learning (hall, skinner, tilley, & macrury, 2018). technology-based dsme that is tailored and individualized based on the educational needs of each person is recommended and associated with improved diabetes outcomes (ada, 2018; greenwood et al., 2017). studies indicate that implementation of individualized education, goal-setting, and behavioral change strategies leads to better blood glucose control (harris, silva, intini, smith, & vorderstrasse, 2014; pereira et al., 2015). the purpose of this pilot study was to develop, implement, and evaluate the effectiveness of dsme modules delivered via ipad devices to increase self-management knowledge levels in adults living with t2dm in rural areas. methods this pilot study involved collaboration of faculty and students from the school of nursing and the college of engineering. institutional review board approval was obtained from the university for the study (protocol review #15-248 ep 1506). nursing faculty developed ten short educational modules based on american association of diabetes educators (aade) clinical practice guidelines for self-management of t2dm (aade, 2018; beck et al., 2017). after reviewing the aade guidelines, dsme teaching points including blood glucose monitoring, online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 138 eating healthy, taking medications, monitoring for complications, and exercising were chosen to meet the educational needs of people living with diabetes in rural communities. specific examples were given in each module to illustrate the practicality of making positive changes in relation to diabetes self-management. along with broad statements about portion control and healthy eating, modules provided tips including not eating while watching television and trying to avoid buying canned foods containing large amounts of sodium or sugar. pictures were used to provoke interest and provide context for the module. videos were also incorporated when further instruction was needed, such as how to draw up insulin and different types of exercise routines to do at home. illustrations used in the modules were representative of diverse ethnicities and cultural backgrounds. at the conclusion of each module, activities such as selecting a healthy lowcarbohydrate food from a group of images were used to reinforce learning. table 1 provides an outline of the modules with sample module content and description. table 1 diabetes education module outline module title sample module content description healthy eating guide to counting carbohydrates instructions for counting carbohydrates using food labels building a healthy plate different types of foods and portion sizes that constitute a healthy plate healthy fast food alternatives generic food substitutions to use at fast food restaurants carbohydrate counting activity users choose from options of foods with a certain carbohydrate count and receive feedback online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 139 exercise guide to exercise examples of activities for warm-up, aerobic exercise, and cool down blood sugar and exercise suggestions for monitoring blood sugar before, during, and after exercise exercise videos videos of warm-up, aerobic exercise, and cool down activities insulin proper insulin care proper places to store insulin and how to check the expiration date on insulin vial insulin injection sites potential sites for insulin injection drawing up insulin video video of proper technique for drawing up insulin from a vial injecting insulin video video of proper insulin injection technique injection site activity uses select correct sites for injection and receive feedback blood sugar highs and lows of blood sugar examples of situations in which blood sugar could become too high or too low checking blood glucose video video on using glucometer to check blood sugar complications feet care with diabetes instruction on foot care, including wellness check-ups eye care with diabetes instructions on eye care, including wellness check-ups skin care with diabetes instructions on skin care, including wellness check-ups sick days with diabetes guidelines for self-care when feeling ill once the educational modules were developed, a group of undergraduate students from the department of computer science and software engineering in the college of engineering, online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 140 supervised by an engineering professor, assisted with the technical aspects of module development including setup of the modules on the ipad devices. the team of students used an agile software development process to develop the application which was done using apple’s xcode development environment and the swift programming language. the development was organized into four month-long design cycles, with design documentation and code deliverables presented to the investigator for feedback at the end of each cycle. standard software engineering techniques such as unified modelling language diagramming, including system sequence diagramming, and development of requirements in the form of stories told by users were used. time expenditures were tracked in each design cycle in order to better predict levels of effort necessary for timely completion of future design cycles. average reading level, increased font size, and bold fonts were used to display information in an easy-to-view format. each module was assigned a color to help viewers follow along within the modules. navigation within the ipad app was designed to be userfriendly. participants the school of nursing conducts health promotion clinics in surrounding rural counties at senior day care facilities. faculty and students provide health screenings, education, and referral at no cost to patients who visit the clinics. these clinics provide access to care for members of the community who may not access healthcare elsewhere and serve as a community clinical site for second semester nursing students. two of the primary counties where clinics were conducted are classified by the alabama rural health association (n.d.) as heavily rural and moderately rural. the heavily rural county has a population of approximately 18,000 people with 81% being african online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 141 american (u.s. census bureau, 2017a). the moderately rural county has a population of approximately 57,000 with 46% of the population being african american and 50% caucasian (u.s. census bureau, 2017b). community residents presenting to these clinics who were age 19 or older, could read and understand the english language, and had a self-reported t2dm diagnosis were invited to participate in this educational intervention. the majority of participants qualitatively reported they had not been to any formal dsme classes. instruments the diabetes self-management questionnaire (dsmq) is a 16-item instrument that assesses self-management activities in the areas of glucose management, dietary control, physical activity, and healthcare use. participants rate the extent to which each question applies to them using a four-point likert scale. items are summed and converted to scale scores for each of the four subscales and a sum scale with ranges from 0 to 10 with higher scores indicating better selfmanagement behaviors. the instrument has demonstrated adequate reliability (cronbach’s alpha=.84) and convergent and known-group validity (schmitt et al., 2013). diabetes knowledge was measured using the diabetes knowledge questionnaire ([dkq] eigenmann, skinner, & colagiuri, 2011). one question regarding management of type 1 diabetes was not included since the study enrolled only people living with t2dm and the question regarding the national diabetes services scheme was also removed since it is not applicable in the u.s. the instrument included 11 items with an additional two items for those participants taking oral hypoglycemic medications or insulin to manage blood glucose. the total possible score for those not taking diabetes medication was 22 and for those taking medication the possible score was 24. online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 142 higher scores indicate higher levels of diabetes knowledge. the instrument has demonstrated internal consistency (cronbach's alpha=.73), test-retest reliability, and construct validity (eigenmann et al., 2011). procedures the study was explained to community members who presented to health promotion clinics and met the study inclusion criteria. if a community member agreed to participate, informed consent was obtained and the participant then completed baseline demographic, diabetes selfmanagement, and diabetes knowledge questionnaires. random blood glucose and body mass index was also collected as part of the routine health promotion clinic screening. after completion of baseline information, the participant viewed the diabetes education modules. this intervention was delivered in a one-to-one format which allowed for individualized, patient-centered education. a study researcher discussed educational content with the participant using the activities, pictures, and information in the application modules to guide the discussion. as information on each page of the module was reviewed, participants were given the opportunity to ask questions or receive clarification about the topic. participants were able to use the ipad to complete activities within the modules. upon completion of all educational modules, the diabetes knowledge questionnaire was completed again to evaluate changes from preto post-study. data analysis the data were analyzed using descriptive statistics including means for demographic information and to calculate total and subscale scores for the diabetes self-management and online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 143 diabetes knowledge questionnaires. a paired t test was conducted to compare pre and postintervention diabetes knowledge scores. results study participants included 30 adult community members living with t2dm who visited one of the health promotion clinics. of the 30 participants, 19 were female and 11 were male, 21 were african american and nine were caucasian. the mean age was 73 years with a range of 4991. the average duration of diabetes for the sample was 11 years with a range of .5 to 40 years. the mean random blood glucose for participants was 156 and the mean body mass index was 32 with a range of 23-45. the majority (n=27) of participants completed all modules except for the insulin module. the insulin module was only completed by the seven participants who stated they were currently on insulin therapy. the average time for completion of the modules ranged from 30 to 90 minutes. the mean total score on the dsmq was 6.8 (standard deviation (sd) =1.9). mean subscale scores were 6.4 for glucose management; 5.2 for dietary control; 7.0 for physical activity; and 8.6 for healthcare use. the pre-intervention mean score on the dkq was 14.23 (sd=4.9). following the intervention, the mean dkq score was 20.33 (sd=3). a paired t-test was conducted to compare pre and post-intervention knowledge mean scores. there was a statistically significant difference in pre-intervention knowledge and post-intervention knowledge scores (t=10.94, p=<0.0001). conclusions online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 144 the goal of this project was to develop, implement, and evaluate the effectiveness of diabetes self-management educational modules delivered via ipad devices to increase self-management knowledge levels in adults living with t2dm in rural areas. a total of ten educational modules were developed in the areas of blood glucose monitoring, eating healthy, taking medications, monitoring for complications, and exercising and implemented with a rural population in southeast alabama. overall mean scores for the dsmq indicate there are areas for improvement in selfmanagement in the study sample. the healthcare use subscale of the dsmq had the highest mean score while dietary control had the lowest. this may indicate that while participants do utilize healthcare providers, they are not receiving the needed diabetes education. this could be due to multiple factors including the lack of initial and ongoing formal diabetes education, a limited amount of time available for diabetes education during visits, or inability to retain information provided. the lower self-management dietary score is consistent with previous studies which indicate people living with diabetes experience difficulty initiating and maintaining healthy eating habits (booth, lowis, dean, hunter, & mckinley, 2013; majeed-aris, jackson, knapp, & cheater, 2013). the educational app used in this study provided dietary information that reinforced simple concepts including portion control, shopping for healthy foods, and monitoring carbohydrate intake. this is an area that requires not just one-time education, but ongoing education since educational needs may change over time as people living with diabetes are faced with new challenges or development of complications. online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 145 the majority of participant questions during the educational intervention revolved around nutrition. specifically, they had not received previous education regarding carbohydrates and how they affect blood glucose. most did not know how to read a food label, count carbohydrates, and determine appropriate portion sizes. the environment for this project was ideal for discussing these concepts since many of the clinics are held in senior or day centers where lunch is served. this provided an opportunity to discuss the food they were served and immediately apply some of the nutritional educational content. additionally, some of the health promotion clinics were held at a local food bank. although accompanying patients for grocery shopping was not part of the research study, researchers used this opportunity to shop and read labels with participants following the study intervention. diabetes knowledge scores increased significantly after the educational intervention. ideally, every person living with diabetes can participate in formal diabetes self-management education; however, those living in rural areas may not have access or resources needed to participate in an educational program. rural patients visit healthcare providers less frequently, are less likely to report diabetes complications, and are more likely to receive inadequate diabetes care (harris et al., 2014). providing education in the community offers an accessible alternative for the rural-dwelling population. the study did not include questions about the desirability of ipads for presenting diabetes education, but participants qualitatively reported they enjoyed using the ipad. this is consistent with a national survey of people living with diabetes that identified patients are accepting of media sources for education, and strategies that utilize interactive electronic media are likely to be well online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 146 received (peyrot, rubin, funnell, & siminerio, 2009). participants were engaged with the activities built into the application and asked many questions based on the education provided. a few participants had ipads or computer access at home and researchers showed them websites and applications that could be utilized to support diabetes self-management. most of the participants anecdotally stated they had never used an ipad prior to this experience. participant acceptance of the teaching method indicates further implementation and follow-up education could be effective. computerized education using touchscreens or other technological applications could provide a solution to the lack of diabetes education in rural areas (harris et al., 2014). a major study limitation is that the education was presented at one point in time. while post-intervention knowledge scores significantly increased from pre-intervention, retention of the knowledge gained was not measured at later times. while long-term retention of knowledge was not measured in this study, faculty and students return to these same clinics each semester so researchers have the opportunity to follow-up with the patients and provide ongoing education. future implementation is planned with revisions to the educational modules. another limitation is the awareness that increased knowledge does not necessarily lead to changes in self-management behaviors. both of these limitations emphasize the need for follow up and ongoing education with evaluation of self-management behaviors and clinical outcomes including hemoglobin a1c. implications for practice the ada recommends dsme for all patients living with diabetes at diagnosis, annually, when complications arise, and when care transitions occur (ada, 2018). for those living in rural areas, access to dsme is especially challenging. diabetes education delivered electronically can online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 147 offer a source of information about diabetes self-management and has the potential to improve education delivery to people living in rural areas who have limited access to healthcare resources. as healthcare increasingly moves into the community, opportunities for healthcare providers to engage people living with diabetes in their own community increases. education should be delivered in communities where patients have access to churches and community centers. followup should occur to provide reinforcement for diabetes self-management and additional information as new issues related to self-management arise. providing this education can offer patients in rural areas the knowledge and ability needed to implement self-management practices. references alabama rural health association. 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(2017). depression is linked to hyperglycaemia via suboptimal diabetes self-management: a cross-sectional mediation analysis. journal of psychosomatic research, 94, 17-23. http://dx.doi.org/10.1016/j.jpsychores.2016.12.015 online journal of rural nursing and health care,18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.525 151 sperl-hillen, j., beaton, s., fernandes, o., von worley, o., vazquez-benitez, g., hanson, a …. spain, c. v. (2013). are benefits from diabetes self-management education sustained? american journal of managed care, 9, 104-112. u. s. census bureau. (2017a). quick facts macon county, alabama. retrieved from: https://www.census.gov/quickfacts/fact/table/maconcountyalabama/pst045217 u. s. census bureau. 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(2014). the effect of diabetes self-management education on body weight, glycemic control, and other metabolic markers in patients with type 2 diabetes mellitus. journal of diabetes research, article id 789761. http://dx.doi.org/10.1155/2014/789761. chinnis et al_685+asthma+and+telehealth+685_revisions_1.11.2022_psf2.3.22_setup+formatted4.11.22 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 42 a new model of care: pediatric asthma management simone chinnis, dnp, mba, aprn, fnp-c, ae-c1 angela stanley, dnp, ma, aprn-bc, phcns-bc, nea-bc2 1 instructor, doctorate of nursing practice program, medical university of south carolina, college of nursing, chinniss@musc.edu 2 clinical assistant professor, george washington university, school of nursing, astanley75@gwu.edu abstract utilization of telehealth services and the provision of chronic care management in school-based clinics have proven to be successful care models in the management of pediatric asthma. such models of care have also been positively correlated with an improvement in pediatric asthma outcomes. these models of care were historically implemented to improve access to healthcare for patients living in rural populations. during the pandemic, such services were employed to improve access to care to everyone as they practiced social distancing to slow the spread of covid-19. the pandemic leveled the playing field and made access to care a problem for not only rural populations, but a problem for everyone. in order to continue insurer reimbursements for telehealth and school-based healthcare services, research is needed in support of these healthcare models. keywords: rural community, pediatric asthma, telehealth, school-based clinic, new models of care, pandemic, covid-19 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 43 a new model of care: pediatric asthma management prior to the coronavirus (covid-19) pandemic, barriers to care for rural and underserved populations included work conflicts and geographical distance. simply put, parents/legal guardians of working families were unable to obtain time off from work in order to attend asthmarelated healthcare visits and encountered difficulties related to living in rural areas where one had to travel far distances to seek healthcare. barriers to healthcare for patients with asthma did not occur as a result of clinics’ refusal to provide care. in march 2020, covid-19 was identified as a pandemic by the world health organization, and a national emergency was declared in the united states (brown et al, 2021). brown et al. (2021) completed a retrospective chart audit of four medical institutions in north carolina (2,144,207 people living in rural areas) and south carolina (728,561 people living in rural areas)--wake forest baptist health/wake forest school of medicine, university of north carolina at chapel hill health, east carolina university clinics, and prisma health/university of south carolina school of medicine greenville—that manifests there was a decrease of 64.5% in the number of pediatric visits (0 to 18 years old) from 2019 to 2020. by july 2021, the southern region of the united states, which includes north carolina and south carolina, was classified as one of several regions with the highest prevalence of covid-19 (economic research service [ers], 2021). additionally, the ers (2021) noted that farming dependent, nonmetropolitan counties experienced the second highest cumulative cases of covid19 per 100,000 inhabitants. during the pandemic many pediatric primary care clinics were forced to choose which chief complaints to manage in-person (in the office) versus sick visits to manage in makeshift settings outside of clinic areas. the direct and indirect impacts of covid-19 on children are endless—e.g. decreased primary care visits for routine check and chronic disease management of conditions like online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 44 asthma, decreased vaccination uptake leading to an increase risk in the development of infectious diseases, increased number of days missed from school, increased mental health problems like depression and anxiety, etc. providers prioritized visits based upon chief complaint, patient’s age, and risk of morbidity/mortality. additionally, emergency rooms limited the types of patients they were willing to manage. asthma patients who were not in a state of exacerbation were refused routine care in primary care clinics. because asthma patients are at risk for developing severe complications as a result of covid-19, it became imperative for these patients to undergo routine follow up in an attempt to prevent exacerbations and reduce their risk of developing complications if they were to contract covid-19. this led to the implementation of different modes of care to replace in-person visits in an attempt to assess for the presence, and reduce the occurrence, of asthma-related impairment and adverse outcomes. telehealth and school-based clinics are models of care that have historically been explored to provide asthma management to patients in rural communities. this literature review was conducted to gain a better understanding of effective pediatric asthma management interventions in telehealth and school-based settings in the united states in an attempt to provide care for children with asthma during the pandemic and improve access to care in rural communities. information gleaned from this review can be used to supplement the care that is provided to patients with asthma when patients are unable to complete an in-person visit. asthma is a chronic pulmonary condition consisting of hallmark physiologic responses of episodic airway inflammation and constriction as a result of hyperresponsiveness to stimuli (ish et al, 2020). symptoms of asthma consist of difficulty breathing, shortness of breath, dyspnea on exertion, chest pain, nighttime awakening with cough, wheezing and other manifestations of airway constriction. in 2018, 7.5% of the population in the united states possessed a diagnosis of online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 45 asthma (centers for disease control and prevention [cdc], n.d.b.). more specifically, 5,530,131 children, defined by age as anyone less than eighteen years of age, were plagued with this chronic yet manageable condition. the management of asthma consists of two parts: reducing the risk of impairment by preventing asthma-related symptoms and reducing the risk of adverse outcomes that are associated with this condition (ish et al., 2020; national heart, lung, and blood institute [nhlbi], 2007). asthma-related impairment is defined as the inability to participate in daily activities as a result of new or recurring symptoms of asthma, and the prescribed use of a shortacting beta2-agonist more than two times per week. impairment is also defined subjectively as the patient’s perceived asthma-related limitations. the following adverse outcomes indicate poor asthma control: an asthma exacerbation, a reduction in lung function, or the need for medical management in an emergent, urgent, or acute healthcare setting. in pediatric populations, asthma related impairment manifests in numerous ways including missed days from school, and increased expenditures related to the utilization of health care services. the cdc (n.d.a) attested that children with asthma missed approximately 13.8 million school days in 2013. from 2008 to 2013, asthmarelated healthcare costs equated to $50.3 billion per year (kim et al., 2020). in 2019, 178 children died from asthma-related complications (national center for environmental health, 2021). effective asthma management consists of the use of appropriate pharmacologic agents prescribed during scheduled visits, leading to a reduction in impairment and risks of adverse outcomes (kim et. al., 2020). although pharmacologic interventions at various stages of medicinal management has changed, the overall premise of managing asthma in a stepwise manner based on symptom severity and prevention of exacerbations have remained the same for over a decade (ish et al., 2020; nhlbi, 2007). during a pandemic, providers must remain focused on the following pillars of asthma management: 1) the reduction in pulmonary inflammation as a result of reduced online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 46 exposure to irritants and allergens and the employment of asthma medication, 2) scheduled assessments of patients by providers skilled in the management of asthma, and 3) the ongoing monitoring of medication use and provision of patient education (national asthma education and prevention program, 2020; nhlbi, 2007). if there is a breakdown in any of the management pillars, patients are placed at risk for impairment and the occurrence of adverse outcomes. the care received by pediatric patients depends on the involvement of their caregiver in managing the patients’ condition—e.g. the adherence to prescribed medication practices, employment of proper medication administration technique, and the availability of caregivers to ensure that regular follow-ups occur and at appropriate intervals. healthcare teams must ensure that access to care does not serve as a barrier to asthma management in pediatric populations while combating the risks that are associated with social determinants of health and subsequent health disparities. access to care has always been problematic for rural populations and rose to prominence during the pandemic. methods the review for this practice paper was performed with the guidance of a research librarian using scopus and medline as search engines. intervention was used as a wildcard search term to broaden the search to include any article that included intervention as a term in the title, keywords, or abstract; this was coupled using and with several abstract search terms—e.g. outcomes or benefits or impact, or effectiveness and “asthma control.” the search resulted in 650 articles, leading to the addition of pediatric as an abstract search term, which yielded 351 articles. further narrowing of the search by various terms resulted in the seven articles that will be covered in this review of literature about alternative models of care for pediatric patients with asthma and the healthcare needs of this population. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 47 results kim et al. (2020) completed a systematic review of 317 articles, resulting in a review of seven articles, about the impact of telemedicine in school-based clinics on asthma outcomes in pediatric populations. the reviewed articles consisted of the provision of synchronous and asynchronous tele-monitoring of asthma symptoms, paired with in person or online educational sessions, telemedicine provider visits, and/or the administration of asthma medications in a school setting. five out of seven articles included patients with various degrees of asthma severity and two articles pertained to persistent asthma. the outcomes reviewed consisted of: missed school days (absence of significant findings), values from pulmonary function tests (absence of statistical findings), symptom free days (increase average number of days), use of health services (consisting of, but not limited to, an increase in use of prescriptive medications), and improved results from quality of life questionnaires (findings not significant). kim et al. (2020) noted that future opportunities consist of the need to develop randomized control trials to assess the impact of telemedicine in school-based clinics on asthma outcomes. the model of care used by halterman et al. (2017) consisted of school-based asthma management programs that were sponsored by the rochester school-based asthma study. the focal intervention of the article was the direct observation of preventative asthma medication, noting an additional intervention of providing student assessments through the employment of audiovisual remote technology was also implemented. children whose parents agreed to their involvement with the study underwent an evaluation to determine the severity of their asthma, received evidence-based medication management, and were provided with follow up asthma care. the targeted populations were children from lower socioeconomic statuses and those who identified as either hispanic or non-hispanic african americans. halterman et al. (2017) focused online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 48 on the employment of the intervention and the design of the study. the article was not associated with quantitative outcomes, rather based on findings from the rochester school-based asthma study, which manifested interventions like direct observation and the use of remote technology to assess asthma status resulted in a reduction in days missed from work and school for parents and students respectively. anderson et al. (2020) implemented home visits by licensed personnel as a model of care to improve asthma outcomes through the reduction of environmental allergens and providing inhaler use education. the hypothesis behind these interventions was: the current timeframe that is allotted to providers to care for patients does not afford providers with an opportunity to address every aspect of asthma management, especially the provision of education. families completed the national environmental education foundation’s (n.d.) environmental history form for pediatric patients. based on findings, guideline-based interventions were employed. anderson et al. (2020) manifested that home visits were a cost-effective approach to asthma management when compared to the cost of providing emergent, urgent, or acute care to asthma patients. perry and margiotta (2020) discussed implementation of telehealth to improve the management of asthma in the pediatric population and improve access to care for rural populations. targeted asthma education and continuity of care play an integral role in disease control and management (perry & margiotta, 2020). their systematic review demonstrates the effectiveness of school-based telehealth in the delivery of follow-up encounters and implementation of specific interventions, such as remote spirometry, education. more importantly, patients in geographical locations with poor access to specialty care and limited, or lacking, access to internet services have identified school-based telemedicine as a feasible option to improve asthma self-management and asthma outcomes. however, implementation of a telemedicine program yields the significant online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 49 barrier of funding and financial reimbursement. a comprehensive telehealth cart, which can be used during telehealth visits, can range from $10,000 to $35,000 (perry & margiotta, 2020). this cost does not include the purchase of health insurance portability and accountability act compliance software or additional expenses to ensure adequate internet bandwidth to support highquality videoconferencing. additionally, parity in coverage and reimbursement (pre-covid-19) was not federally mandated (perry & margiotta, 2020). provider training, readiness, and accessibility also pose as significant barriers in implementation of telehealth. in response to covid-19, forty-one states implemented waivers to modify the requirements for telehealth (federation of state medical boards, 2021). although barriers to telehealth exist, financial benefits are associated with the employment of telehealth services. perry and margiotta (2020) highlight the potential cost savings associated with conducting follow-up encounters via telehealth. bian et al. (2019) conducted a retrospective analysis to explore the relationship of a schoolbased telehealth program and emergency department (ed) visits made by children in five rural counties in south carolina. the analysis entailed a review of state medicaid claims data from 2012 to 2017. in 2014, a school-based telehealth program was established in seven counties to manage acute and chronic diseases. an asthma specific training program was integrated into the program. study authors created two samples – (1) children (ages 3 to 17 years) enrolled in south carolina medicaid for at least one month, and residing in one of 5 counties, and (2) a subsample of children diagnosed with asthma. children residing in williamsburg county served as the intervention group and the four surrounding counties without a telehealth program served as the control group (bian et al., 2019). in williamsburg county where telehealth services were offered, the mean monthly ed visits for children increased from 3.65% to 3.87%. whereas the mean monthly ed visits for children in the counties with no telehealth services (control) were 3.37% and 3.56%. for the online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 50 children diagnosed with asthma, the mean monthly ed visits increased from 3.16% to 3.38% for those in the intervention county; and, were 3.02% and 3.9% in the counties with no telehealth services. bian et al. (2019) concluded no overall benefit of a school-based telehealth program to those with limited access to care. however, the author did find a strong association between the presence of school-based telehealth programs and the improvement in health outcomes—e.g. 21% reduction in potential ed visits in children residing in rural areas. kakar et al. (2020) conducted participatory research in an attempt to increase the use of asthma action plans in african americans from lower socioeconomic classes. the team met with a community advisory council to discuss the need to improve asthma outcomes and a community decision was reached to employ the use of asthma action plans as a tool to improve asthma selfmanagement. the goal was to change the model of care that was provided to asthma patients by pediatric providers by increasing the use of asthma action plans (aap) through the provision of incentives to providers to encourage the use of aap. updated aaps were provided to practices and those who distributed the aap to patients were provided with free children’s books. the provision of asthma education by providers to patients serves as the cornerstone of understanding the chronicity of asthma, medication management, and recognizing symptoms that indicate when to seek additional care. asthma education is often provided verbally and reinforced in written form through the provision of an asthma action plan. kakar et al. (2020) updated asthma action plans by adding the names and colored pictures of various inhalers to the back of the asthma action plans with the goal of improving communication between providers and patients about various asthma medications. the goal was to provide an intervention that removed the barrier of inadequate provider-patient communication and increased understanding of asthma medications to improve asthma outcomes. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 51 the fact that asthma outcomes are impacted by social determinants of health and health disparities is general knowledge. miadich et al. (2020) contributed to the body of knowledge about asthma outcomes by analyzing the impact of stress on asthma outcomes, focusing on adolescents. stress was defined as growing up in poverty, occurrences of adolescent-caregiver conflict, witnessing or involvement with community or family violence (defined as neighborhood stress), and episodes of social stress in the form of peer-pressure and/or school-related stress. the authors viewed stress through the ecobiodevelopmental and toxic frameworks (miadich et al., 2020). and, the cumulative risk model was used to assess the stressors experienced by the adolescents and information about stressors was collected from questionnaires that were answered during research sessions. the results were then compiled into a cumulative risk score and compared to the patients’ asthma outcomes. asthma outcomes were defined as visits to the emergency department, asthma control, and quality of life. the study found that an increase in cumulative risk score adversely impacts asthma outcomes. future opportunities consisted of the implementation of interventions to reduce stress as a method to improve asthma outcomes. discussion in 2020, over 5.5 million children were diagnosed with pediatric asthma (cdc, n.d.b.). asthma-related healthcare costs over a five-year period were estimated at $50.3 billion per year (kim et al., 2020). these costs reinforce the importance of disease management and utilization of effective care models that have demonstrated success in patient populations adversely affected by asthma. as providers continue their plight to eradicate problems related to access to care, which so often affects rural communities, and navigate a new era of healthcare that was birthed from the pandemic, they should remain grounded in the foundational knowledge of evidence-based asthma management. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 52 asthma is a chronic, but manageable, condition consisting of episodic airway inflammation and constriction due to bronchial hyperresponsiveness (ish et al., 2020). the purpose of asthma management is to decrease risk of 1) impairment by preventing asthma-related symptoms and 2) the occurrence of adverse outcomes (ish et al., 2020; nhlbi, 2007). prior to the covid-19 pandemic, the primary model of care for pediatric asthma management consisted of face-to-face encounters. for those living in rural areas, such encounters were limited as a result of reduced access to healthcare. in 2020, the cdc issued guidance advising healthcare providers to adopt social distancing practices and encouraged the delivery of clinical services via telehealth. this position supported providers in exploring telehealth as a mitigating strategy to deliver healthcare in rural areas, even after the pandemic. although this practice paper is limited by the method used to complete the literature search, information was gleaned about effective methods of asthma management outside of traditional in-office encounters. clinical implications utilization of telehealth services and the provision of chronic care management in schoolbased clinics have proven to be successful care models in the management of pediatric asthma. the employment of these methods is positively correlated with improved pediatric asthma outcomes. such models of care were historically implemented to improve healthcare access to patients living in rural populations. during the pandemic, utilization of telehealth services and the provision of chronic care management in school-based clinics may continue to be employed as a mechanism for improving access to care in the midst of actions to slow the spread of covid-19, i.e. social distancing. the pandemic levelled the field of healthcare and made access to care a problem for not only rural populations, but a problem for everyone. implications for practice online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 53 in order to continue insurer reimbursements for telehealth and school-based healthcare services, research is needed in support of these healthcare models demonstrating their effectiveness on the improvement of 1) clinical outcomes as manifested by a reduction in the frequency and severity of asthma exacerbations and 2) reduction in costs associated with missed days from school and work as a result of asthma exacerbations. the goals of healthcare workers are to prevent a reduction in lung function and impairment in activities of daily living in patients with asthma. health care workers need to generate research and practice articles in support of the effectiveness of telehealth in the management of pediatric asthma. as covid-19 continues to mutate and pose a mortal risk to patients with asthma, providers, nurses, and medical assistants must continue to share ideas as we work towards improving access to care and providing the best care possible to the most vulnerable members of our population, our children. references akinbami l. j., moorman j. e., & liu x. (2011, january 12). asthma prevalence, health care use, and mortality: united states, 2005-2009. national health statistics report, 12(32), 1-14. https://www.cdc.gov/nchs/data/nhsr/nhsr032.pdf anderson, m. e., zajac, l., thanik, e., & galvez, m. (2020). home visits for pediatric asthma-a strategy for comprehensive asthma management through prevention and reduction of environmental asthma triggers in the home. current problems in pediatric and adolescent health care, 50(2), article 100753. https://doi.org/10.1016/j.cppeds.2020.100753 bian, j., cristaldi, k. k., summer, a. p., su, z., marsden, j., mauldin, p. d., & mcelligott, j. t. (2019). association of a school-based, asthma-focused telehealth program with emergency department visits among children enrolled in south carolina medicaid. jama pediatrics, 173(11), 1041–1048. https://doi.org/10.1001/jamapediatrics.2019.3073 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 54 brown, c. l., montez, k., amati, j. b., simeonsson, k., townsend, j. d., orr, c. j., & palakshappa, d. (2021). impact of covid-19 on pediatric primary care visits at four academic institutions in the carolinas. international journal of environmental research and public health, 18(11), article 5734. https://doi.org/10.3390/ijerph18115734 bukstein, d. a., guerra, d. g., jr., huwe, t., & davis, r. a. (2020). a review of shared decisionmaking: a call to arms for health care professionals. annals of allergy, asthma & immunology, 125(3), 273-279. https://doi.org/10.1016/j.anai.2020.06.030 centers for disease control and prevention. (n.d.a.). asthmastats [fact sheet]. u.s. department of health and human services. https://www.cdc.gov/asthma/asthma_stats/aststatchild _missed_school_days.pdf centers for disease control and prevention. (n.d.b.). most recent national asthma data. u.s. department of health and human services. https://www.cdc.gov/asthma/most_recent_ national_asthma_data.htm economic research service. (2021, july 12). the covid-19 pandemic and rural america. u. s. department of agriculture. https://www.ers.usda.gov/covid-19/rural-america/ federation of state medical boards (2021, january). u.s. states and territories modifying requirements for telehealth in response to covid-19. https://www.fsmb.org/siteassets/ advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid19.pdf halterman, j. s., tajon, r., tremblay, p., fagnano, m., butz, a., perry, t. t., & mcconnochie, k. m. (2017). development of school-based asthma management programs in rochester, new york: presented in honor of dr robert haggerty. academic pediatrics, 17(6), 595-599. https://doi.org/10.1016/j.acap.2017.04.008 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 55 ish, p., malhotra, n., & gupta, n. (2020). gina 2020: what's new and why? journal of asthma, 58(10), 1273-1277. https://doi.org/10.1080/02770903.2020.1788076 kakar, r., combs, r., ali, n., muvuka, b., & porter, j. (2021). enhancing the design and utilization of asthma action plans through community-based participatory research in an urban african american community. patient education and counseling. 104(2), 276-281. https://doi.org/10.1016/j.pec.2020.08.032 kim, c. h., lieng, m. k., rylee, t. l., gee, k. a., marcin, j. p., & melnikow, j. a. (2020). school-based telemedicine interventions for asthma: a systematic review. academic pediatrics, 20(7), 893–901. https://doi.org/10.1016/j.acap.2020.05.008 miadich, s. a., everhart, r. s., greenlee, j., & winter, m. a. (2020). the impact of cumulative stress on asthma outcomes among urban adolescents. journal of adolescence, 80, 254-263. https://doi.org/10.1016/j.adolescence.2019.12.007 national asthma education and prevention program. (2020). 2020 focused updates to the asthma management guidelines. u.s. department of health and human services, national institute of health, national heart, lung, and blood institute. https://www.nhlbi.nih.gov/node/90012 national center for environmental health (2021, march 30). most recent national asthma data. centers for disease control and prevention. https://www.cdc.gov/asthma/most_ recent_national_asthma_data.htm national environmental education foundation [neef] (n.d.) environmental history form for pediatric asthma patients [questionnaire]. https://www.neefusa.org/resource/asthmaenvironmental-history-form national heart, lung, and blood institute. (2007). expert panel report 3 (epr 3): guidelines for the diagnosis and management of asthma (nih publication no. 08-5846). u.s. department online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.685 56 of health and human services. https://www.nhlbi.nih.gov/sites/default/files/media/docs /asthsumm.pdf perry, t. t., & margiotta, c. a. (2020). implementing telehealth in pediatric asthma. the pediatric clinics of north america, 67(4), 623–627. https://doi.org/10.1016/j.pcl.2020.04.003 gibson_649__formatted online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 85 anew project to develop and support rural primary practice nicole ann gibson, dnp, cnp, fnp-c 1 brandi pravecek, dnp, cnp, fnp-c 2 linda burdette, phd, rn 3 leann lamb, msn, whnp-c, rn 4 1electrophysiology dnp, north central heart institute, mzmartens24@gmail.com 2clinical assistant professor, college of nursing, south dakota state university, brandi.pravecek@sdstate.edu 3assistant dean and associate professor, college of nursing, south dakota state university, linda.burdette@sdstate.edu 4instructor, college of nursing, south dakota state university, leann.lamb@sdstate.edu abstract south dakota is one of the nation’s most rural and frontier states and has the highest proportion of rural dwellers in the midwest. many of the state’s counties suffer from provider shortages, with nurse practitioners increasingly being called upon to fill the role of the primary care provider in clinics and critical access hospitals. however, family nurse practitioner (fnp) education programs are not required to provide the training and skills necessary to meet the unique challenges of rural practice. an upper midwest land grant university prepares both masters and doctoral fnp students to fill primary care provider needs in south dakota and the surrounding region. the purpose and scope of this two-year advanced nursing education workforce (anew) project was to enhance an existing academic/practice partnership to prepare primary care advanced practice registered nursing (aprn) students for practice in rural and/or underserved settings in the state and region. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 86 the anew project provided fnp students with a longitudinal primary care clinical traineeship experience in rural clinical settings. trainees benefited from traineeship funds, learning advanced procedures and skill concepts through attendance at a series of educational workshops, and job placement efforts post graduation. the anew project also provided for a comprehensive preceptor development collaborative designed to enhance competence and confidence for independent rural practice and facilitate job placement in rural communities after graduation. this project strengthened the quality of fnp education through an academic/practice partnership which resulted in a symbiotic, synergistic relationship to address rural work force supply and the identification of the knowledge and skills needed for current and future rural healthcare providers. keywords: family nurse practitioner, education, preceptor, academic, practice partnership, rural primary healthcare, healthcare provider shortage anew project to develop and support rural primary practice preparing primary healthcare providers for rural practice continues to be difficult with approximately one in five people, or 19% of the us population, residing in rural settings (united states census bureau, 2017). south dakota (sd) has a significant rural population. south dakotans living in rural areas account for over 51% of the state’s population (united states department of agriculture economic research service, n.d.). rural residents face healthcare barriers in terms of limited access to care as well higher rates of advanced age and chronic disease, and decreased income compared to their urban counter parts (holland et al., 2019). current family nurse practitioner (fnp) education programs are not required to encompass the knowledge and skills needed by nurse practitioners (nps) in rural settings. rural patient care online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 87 requires healthcare providers who possess the knowledge and skills of primary care and who can step in as needed and serve as an emergency medicine provider. to bridge this gap, providing comprehensive education for future rural primary healthcare providers is vital. literature review nurse practitioner education is guided by the national organization of nurse practitioner faculties (nonpf) core competencies and applies to all np programs regardless of population focus (nonpf, 2017). these nonpf core competencies are a set of essential standards for all nps preparing for entry into practice (nonpf, 2017). nurse practitioner population-focused curriculum is further guided by nonpf population-focused nurse practitioner competencies for family/across the lifespan, neonatal, acute care pediatric, primary care pediatric, adult-gerontology acute care and primary care, psychiatric mental health, and women's health/gender related population specialties (nonpf, 2013; nonpf, 2016). however, np educational competencies specific to rural practice as a specialty are not available. rural regions often do not have the capacity to support sufficient healthcare services. according to the national rural health association (2012) and the american hospital association (2019), healthcare facilities in rural areas have difficulty recruiting and retaining primary care providers. this deficit has been attributed, in part, to higher death rates in nonmetropolitan areas compared to those in urban areas (garcia et al., 2017; moy et al., 2017). a shortage of providers has the potential to negatively impact rural patients’ access to healthcare services, including primary care. for example, rural residents were more likely to report less access to care as well as lower quality of care than those residents living in metropolitan areas (agency for healthcare research and quality, 2017). online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 88 physician shortages in rural regions have been well documented in the literature; however, nurse practitioners have increasingly been called upon to fill these rural healthcare gaps with 87 percent of the 270,000 nps in the country now trained in primary care (american association of nurse practitioners, n.d.). despite the np role emerging to meet the needs of rural populations, little information is available about the challenges nps face when beginning practice in a rural healthcare facility. in most of these areas, nps typically practice in primary care clinics and have expanded their role to include acute care settings such as the emergency department, inpatient hospital care, long-term care, telehealth, and off-hours on-call schedules. these additional practice settings exceed most standard np educational program requirements and present a gap in education-to-rural practice transitions. economics, education, rural practice characteristics, rural demographics, and health status are often cited as reasons for healthcare provider shortages in rural regions. in addition, training in an urban setting does not necessarily prepare one for practice in rural settings, making transitions from urban to rural settings difficult for providers. residing in a rural area may impact a provider's desire to return to rural practice after graduation (goodfellow et al., 2016). further, associations between having an interest in underserved populations and working in rural areas are supported within the literature (goodfellow et al., 2016; rabinowitz et al., 2000). despite practitioners with rural backgrounds as well as practitioners with an interest in rural areas returning to those types of areas to practice, rural areas remain medically underserved. methods online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 89 the college of nursing (con) at an upper midwest land grant university prepares masters (ms) and doctoral (dnp) fnps to fill primary care needs in sd and the surrounding region. the purpose of a two-year advanced nursing education workforce (anew) project was to enhance an existing academic/practice partnership to prepare primary care fnp students for practice in rural and/or underserved settings. the program partnered with an integrated health system to provide primary care clinical training experience emphasizing rural and/or underserved populations, traineeships, and a comprehensive preceptor program. four objectives addressed the need for developing enhanced rural fnp education with existing clinical partners and expanded academic-practice partnership and increasing partnerships within rural primary care community-based settings throughout the state and region. the anew project was reviewed by the university institutional review board, who determined the project was not human subjects research and was exempt from full review. objective 1: in collaboration with the practice partner, provide an innovative approach to longitudinal, immersive clinical training experiences that includes advanced procedures and skill concepts, with an emphasis on rural and/or underserved populations for graduate nursing students who are specializing as primary care family nurse practitioners. an academic practice partnership created intentional space for dialogue and innovative action leveraging the strengths of academia and practice aimed at building the competence and confidence of the fnp leading to increased work force capacity. the practice partner is headquartered in sd and is the largest not-for-profit healthcare system in the nation, with locations in 126 communities in nine states. practice partner contributions included identification of clinical sites with established clinical intensity for immersive clinical experience, collaboration on preceptor development, trainee workshops, and rural job fairs. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 90 three workshops, “introduction to the rural clinical community culture”, “advanced procedures in the rural community”, and “advanced skill concepts in the rural community”, were developed and conducted during three fnp practicum courses. these workshops were designed to introduce rural culture, build skill intensity and complexity, and close knowledge and skill gaps by the end of each practicum course. the pedagogical approach incorporated experiential learning with a teaching-learning framework of simulated scenarios and structured debriefing. the workshops included content expert lectures, educational stations, and simulation scenarios. the workshops enhanced the rural experience for the trainees by reinforcing specific skills required of rural fnps. other university con graduate students, community stakeholders, practice partners, and preceptors were invited to attend each workshop and received continuing education units (ceus) or continuing medical education (cme) credits. the “introduction to the rural clinical community culture” workshop was conducted, recorded, and professionally edited using videoconferencing, allowing content experts and trainees to remotely attend the workshop at their convenience. the “advanced procedures in the rural community” workshop topics included: wound management with a focus on laceration closure, digital blocks, 12 lead ecg interpretation, stemi protocols, nail removal, and ear, nose, and throat emergencies. participants were provided opportunities for hands-on experience with splinting and casting. the final “advanced skill concepts in the rural community” workshop expanded on topics introduced in the previous workshop, particularly in terms of skill intensity and complexity. examples of topics were slit lamp/woods lamp skill station, de-escalation techniques and personal safety, child abuse recognition and forensics exam, difficult conversation simulation scenarios, sepsis simulation scenario, stop the bleed®, basic x-ray interpretation, and an unfolding simulation scenario. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 91 in addition, an immersion experience occurred in rural and/or underserved clinical sites in the surrounding region to provide trainees with appropriate learning experiences. trainees completed 180-240 practicum hours in their assigned rural and/or underserved clinical setting over a period of three to four months. a two-week intensive experience established foundational knowledge in rural and/or underserved settings. trainees completed a community assessment and developed a specific intervention to address gaps in services or resources. objective 2: provide traineeship funds to enrolled graduate nursing students specializing as family nurse practitioners, who are placed in primary care sites with a focus on rural and/or populations for longitudinal, immersive, clinical training. the objective focused on the creation of a funded traineeship for fnp students dedicated to serve rural and/or underserved populations. trainee applicants were required to commit to exploring an intent to practice primary care for rural and/or underserved populations; complete an immersive clinical experience and a 2-week intensive experience in a rural setting; attend all workshops; conduct a community assessment with a specific intervention; and agree to provide professional activity data following graduation. the selected anew trainees included 34 females and 9 males who ranged in age from 25 to 50 with an average age of 30.07 years. thirty of the trainees were enrolled in the ms program and 13 in the dnp program. the area where a trainee grew up was rural for 25 trainees, urban for 6, suburban for 11 trainees, and 1 unreported. seven of the 43 trainees were from an economically or environmentally disadvantaged background, and all trainees entered the anew traineeship with plans to practice in a rural or underserved area after graduation. traineeship funds were disbursed at the beginning of each academic semester and assisted trainees in paying for tuition, books, and provided a living stipend. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 92 objective 3: recruit, train, develop, and support preceptors, and evaluate preceptor outcomes in rural and/or underserved settings. a key component of the anew project was to focus on the essential functions of the clinical preceptor. the academic/practice partnership engaged in intentional preceptor development strategies to meet the innovative approach to rural fnp education. the con clinical coordinators contacted experienced primary care provider preceptors in rural and/or underserved settings in four midwest states and matched each trainee with a qualified preceptor. to provide access to educational and informational support, a preceptor-specific webpage was developed and shared with all preceptors. the webpage allowed preceptors to easily access the preceptor handbook, links to free ceu/cme opportunities, and links to preceptor vignettes (nonpf, n.d.) to aid in preceptor/trainee development. anew program faculty also created a continuing education session specific for preceptors titled “leading into the future: preceptor development” which was presented at an annual state nurse practitioner association conference. rural health preceptors were provided the opportunity to attend the conference tuition-free, utilizing funds from the anew program. additional support was provided during a one-day preceptor development workshop created in partnership with the university’s practice partner. during the two-week intensive experience, trainees worked full-time alongside their preceptors (including on-call shifts to cover emergency rooms and caring for the emergent needs of long-term care residents). while most trainees were placed in rural towns, several were placed within the indian health service system on rural native american reservations. working in these settings allowed trainees to completely immerse themselves in the process of addressing factors that impact health disparities common in this population (indian health services, 2019). online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 93 objective 4: develop and implement strategies to connect anew program graduates with employment opportunities in rural and/or underserved settings. anew trainees’ enhanced experiences prepared them for rural employment and increased their employment desirability to rural employers. to facilitate trainees’ employment opportunities in rural areas, a university sponsored job fair was held each year. rural employers were invited to showcase their communities, while connecting trainees with employment opportunities. in preparation for the job fair, trainees developed a portfolio illustrating their enhanced rural and/or underserved experiences that qualified them for available positions. in addition to the job fair, con faculty and the academic/practice partners, including the clinical practice preceptors, facilitated employment opportunity searches, applications, and interviews during the rural immersion and intensive experiences to further connect trainees with employment opportunities. ultimately, the overarching goal of the anew project was to increase the number of primary care providers available in these areas and to more fully equip those fnps to respond to the unique challenges that working in the rural and/or underserved communities experience. between fall 2017 and summer 2019, 56% of anew trainees who completed preceptorships accepted employment in a rural and/or underserved setting. evaluation evaluation efforts were grounded in process and outcome evaluation, with a focus on tracking activities contributing to the intended short-term outcomes, providing ongoing feedback with the practice partner, and identifying best practices for disseminating and application in other settings. the evaluation plan utilized rapid cycle quality improvement (rcqi) and plan-dostudy-act to assess and monitor program objectives, make necessary adjustments, and achieve performance improvement (center for health workforce studies, 2016). quantitative and online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 94 qualitative data points were identified for each project objective. to further enhance evaluation efforts and direct the project, an advisory board composed of academic/practice partners and rural and/or underserved community stakeholders was established. the advisory board met each semester to provide feedback and discuss project progress. formative and process evaluations were conducted following each workshop. all participants rated the “introduction to the rural clinical community culture” workshop as “excellent” or “good” overall and agreed the information was applicable to their practice. “advanced procedures in the rural community workshop” evaluations provided qualitative feedback such as the opportunities for kinesthetic learning and the high-quality speakers were much appreciated. one hundred percent of participants rated the workshop overall as “excellent” (78.57%) or “good” (21.43%). the evaluations for “advanced skill concepts in the rural community workshop” rated all topics >4.2/5 except the sepsis scenario. suggested revisions were to pre-assign roles and increase pre-briefing. trainees identified areas for future workshops such as foreign body removal, wound care, sexually transmitted infection treatment, medical coding, and incision and drainage of abscess. trainees evaluated their clinical immersion experience with a quantitative and qualitative measurement likert scale tool (1-5) developed by the project team. one participant identified the strengths of the experience as “the experience is priceless. you get to see first-hand a whole other side of the potential factors that may impact rural care and practice”. another noted, throughout my experience, i was constantly reminded of the importance of establishing rapport and respect within the community. my preceptor was called last minute to come visit a patient in the nearby community nursing home during a shift. she adapted her schedule to online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 95 see the hospice patient in the nursing home and navigate conflicting healthcare decisions with the family. all participants expressed positive feedback. trainees reported the clinical immersion experience positively affected (scale 4 out of 5) their knowledge of the challenges of rural living and medical practice in the areas of underinsurance/lack of insurance; delays in seeking care; lack of anonymity, and distance to care. trainees' knowledge was “greatly impacted” (4) or “extremely impacted” (5) related to the rural and/or underserved culture characteristics of strong work ethic, determination, frugality, selfreliance, and strong social support networks. one trainee commented, during my experience at the clinic, the school bus dropped of a child who was having difficulty breathing. due to his condition, he was taken via ambulance to the local hospital. the fnp rode in the ambulance as the volunteer emergency medical technicians did not feel comfortable with the child and some of the equipment in the ambulance was not working. it was great to see how resourceful and committed the fnp was in this difficult situation. other trainees commented on how astonished they were to witness first-hand the provider shortages and how those shortages affected residents’ access to care. overall, trainee feedback captured the pressing challenges that most rural communities experience in terms of their members’ access to medical care. anew trainees completed a community assessment and developed community-specific interventions. examples of the interventions created by the trainees included community advanced care planning education, bipap simulation, and provision of free parks and recreation prescriptions. these ideas were shared with community members and peer trainees as a voice-over multi-media presentation accessible on the university course management software. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 96 conclusion the np role is emerging to meet the needs of rural populations, however, there is limited information about the challenges nps face when beginning practice in a rural healthcare facility. the anew project strengthened the quality of fnp education through an academic/practice partnership which resulted in a symbiotic, synergistic relationship to address work force supply and the identification of the knowledge and skills needed for rural healthcare practice. the anew traineeship increased participants’ cultural engagement and fostered a desire to launch a career in a rural and/or underserved environment. utilization of workshops to increase the knowledge and skills needed by rural providers was positively evaluated and supports the need to develop rural practice competencies for np education. primary healthcare provider shortages have impacted rural patients’ access to healthcare services. with the literature focusing primarily on physician shortages in rural areas, more knowledge is needed regarding the recruitment and retention of the nps called upon to fill this nationwide primary care gap. the anew project contributed to this knowledge gap and demonstrated the potential for increasing providers as 56% of trainees accepted employment in a rural and/or underserved setting. therefore, implementation of rural preceptorships, such as the anew project, could ultimately decrease the critical shortage of providers in rural and/or underserved settings. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.649 97 references agency for 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(2017). what is rural america? https://www.census.gov/ library/stories/2017/08/rural-america.html united states department of agriculture economic research service; (n.d.). state data: south dakota. https://data.ers.usda.gov/reports.aspx?statefips=46&statename=south%20 dakota&id=17854 running head: the accuracy of portable lipid analyzers 55 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 the accuracy of referral for portable lipid analyzers in an old order mennonite population maria eve main, msn, arnp 1 susan jones, phd, rn 2 cathy abell, phd, rn 3 1 assistant professor, school of nursing, western kentucky university, eve.main@wku.edu 2 professor, school of nursing, western kentucky university, susan.jones@wku.edu 3 associate professor, school of nursing, western kentucky university, cathy.abell@wku.edu key words: cholesterol, lipids, mennonite, portable lipid analyzers, triglycerides abstract the primary purposes of this study were to: 1) examine the accuracy for referral of two portable lipid analyzers (plas) in an old order mennonite population through a comparison to a national standardized reference laboratory, 2) examine the relationship of total cholesterol values with other known cardiovascular risk factors, and 3) foster the continued participatory model of health care service in this community. the self-selected sample was composed of 42 adult members of an old order mennonite community residing in south central kentucky. a descriptive correlational design was used in this study. there were clinically relevant variations in the total cholesterol and ldl-c in both of the analyzers. additionally, there was a correlation between total cholesterol values and age. the study also facilitated the participatory model used with this community previously as the community members assisted in planning, implementing, and evaluating this project. introduction cardiovascular disease is responsible for 35.3% of all deaths in the united states (lloydjones et al., 2009). epidemiological data clearly identify a relationship between elevated lipid levels and cardiovascular disease with a resultant emphasis on hyperlipidemia as a modifiable risk factor (rosamond et al., 2008). the preventive health practices of screening and the early detection of hyperlipidemia are goals for health care providers to eliminate or modify the risks for cardiovascular disease. while venous blood samples analyzed in reference laboratories provide the most reliable measure of blood lipids, portable lipid analyzers (plas) have gained popularity in conducting baseline lipid screening in community type settings (taylor & lopez, 2004). in a lipid management program in rural alabama the provision of lipid testing through a mobile health unit increased the access of community members to lipid screening and improved treatment for hyperlipidemia (donaldson & andrus, 2004). rural residents often lack adequate transportation, financial resources, and a defined primary health care provider (campo et al., 2008). the mennonites and amish are collectively referred to as anabaptists. they are descendents of a group of 100 founders who emigrated from switzerland and germany after http://www.wku.edu/chhs/cms/index.php/departments/nursing-2/ mailto:eve.main@wku.edu http://www.wku.edu/chhs/cms/index.php/departments/nursing-2/ mailto:susan.jones@wku.edu http://www.wku.edu/chhs/cms/index.php/departments/nursing-2/ mailto:cathy.abell@wku.edu 56 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 persecution from the both protestants and catholics during the protestant reformation in the sixteenth century (kraybill & bowman, 2001). members of these old order anabaptist communities use horse and buggy for local transportation and do not have telephones or electricity. additionally, most are only educated through the eighth grade (wenger, 2003). the impetus for most adults in this community for seeking health care is the interference of a current illness with their ability to work (armer & radina 2006; fisher, 2002). conservative mennonite and amish communities are among the most rapidly growing populations in the rural u.s. with the population doubling every 20 years (young center for anabaptist & pietist studies, 2008). their isolation by choice, rejection of technology, and a preference for illness care contribute to a low utilization of preventive screenings. members from such communities are known to consume a high fat diet, have equivalent levels of obesity as the mainstream u.s. population, and avoid traditional health care (fuchs, 1990; glick, 1998; rampersaud et al., 2008); therefore, they could benefit from cholesterol screening. portable lipid analyzers (plas) offer promise as one means to address this challenge of self-imposed isolation. however, it is of utmost importance that accurate information be obtained when using plas to measure lipid profiles in these isolated religious communities as well as any community setting. these devices provide a convenient and economical lipid panel with immediate results for the patient and health care provider. this will increase the patients’ opportunity for faster referral and intervention. in recent years the availability of plas has increased (taylor & lopez, 2004), but the accuracy of the values obtained is inconsistent. stein et al. (2002) found that portable measurements systematically overestimated triglycerides and high-density lipoprotein (hdl-c). low-density lipoprotein-cholesterol (ldl-c) concentrations were underestimated and total cholesterol provided unbiased estimations. bowden et al. (2004) found a false negative rate of 17.21% to 34.4 % in capillary cholesterol measurement as compared with venous measurement. when comparing the cholestech ldx and the cardiochek pa to a laboratory gold standard, the cholestech ldx demonstrated better reproducibility and was more accurate in categorizing the framingham risk score (dale, jensen, & krantz, 2008). purposes of study little is known about the accuracy for referral of plas in amish and mennonite old order communities. the primary purposes of this study were: 1) examine the accuracy for referral of two plas in an old order population through a comparison to a national standardized reference laboratory, 2) examine the relationship of total cholesterol values with other known cardiovascular risk factors and 3) foster the continued participatory model of health care service for this old order community. methods research design and study sample/setting a descriptive correlational design was used in this study. the self-selected sample included 42 adult members of an old order mennonite community residing in south central 57 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 kentucky. this project evolved from a previously established community and academic partnership. one of the investigators has worked with this community for 12 years establishing a monthly community health fair/clinic day with the residents of the community determining the topics for health teaching, preventive screenings, and other interventions. this collaboration has been successful in part due to the trust developed. building trust among partners and obtaining commitment from community partners have been identified as facilitating factors for successful community projects (lantz, et al., 2001). members of the community assisted with locating an appropriate site for the project and recruiting participants. a culturally sensitive flyer was distributed to potential participants through community gatherings one month prior to the date of data collection. the flyers were black and white with a rural image as a background. data were collected during a one-day health fair at a country store on the periphery of the community. the participants were familiar with the store and felt comfortable in the location. this addressed the challenge of identifying a setting, which was convenient and acceptable for the residents of the community while offering the availability of electricity for the blood centrifuge. the institutional review board at western kentucky university approved the study. all participants provided informed consent before participation. adult members of the community were eligible to participate in this study if they were at least 18 years of age and could read and write english. participants were excluded if they were currently taking coumadin, warfarin, or plavix, had a bleeding disorder, were pregnant or receiving chemotherapy treatment. individuals were asked to fast for at least twelve hours before the laboratory tests were performed. as a benefit, participants received free lipid screening with the current recommendations for followup by a health care provider. portable lipid analyzers the accu-chek instant plus was designated as pla1. pla1 yields total cholesterol (tc) results in three minutes from a drop of capillary blood with a range of 149 to 300 mg/dl. this monitor analyzes only the tc (roche laboratories, 2009). the cardiochek pa was designated as pla2 and can be used at home or in an office setting. results are available within three minutes of completing the finger stick. the cardiocheck pa monitor can perform a tc, hdl-c, calculated ldl-c and trig (cardiochek, 2009). both plas are designated as clinical laboratory improvement amendments (clia) waived tests. clia waived tests are defined as simple laboratory examinations that are cleared by the food and drug administration for home or office use and employ simple methodologies that are accurate and are unlikely to render erroneous results (u. s. food and drug administration, 2009). procedures after acquiring consent, a researcher developed questionnaire was administered to collect desired data. the data collected included gender, age, early cardiac death in first-degree relatives, parity, and current intake of medications or herbals for lowering cholesterol, triglycerides or blood pressure. individual participants had their weight and height measured to determine the most accurate body mass index (bmi). bmi was calculated as weight in 58 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 kilograms divided by height in meters squared. blood pressure was measured with an aneroid sphygmomanometer after the participant had rested for 5 minutes. all testing took place between 7:30 and 10:45 am. prior to the capillary blood collection participant’s fingers were cleansed with alcohol swabs and allowed to dry. using lancets, capillary samples were collected and immediately applied to the appropriate test strips of two portable lipid analyzers. following the collection of capillary samples venous samples were obtained by a certified medical technologist and dispensed into an evacuated red-top vacutainer. after the samples were centrifuged for 15 minutes, the tubes were stored at room temperature. research personnel collecting blood samples were certified in occupational health and safety administration blood borne precaution education. data analysis data were analyzed using spss 16. descriptive statistics were employed to analyze demographic data. t-tests were used to compare the means of cardiovascular risk factors between male and female. a pearson product moment correlation (pearson’s r) was used to examine relationships between lipid values from the reference laboratory and known cardiovascular risk factors. cross-tabulations were completed for tc (pla1) and tc, hdl-c, ldl-c, and trig (pla2) and the reference laboratory tc, hdl-c, ldl-c, and trig. findings demographic data from the 42 participants indicated there was a nearly equal gender mix of men and women; however, one male participant’s venous blood sample was lost in transit to the reference lab. the age of the participants ranged from 21 to 88 years with a mean age of 45.1 years for men and 51.4 years for women. none of the participants reported early cardiac death in a first-degree relative. the average number of children of the female participants was 6.5 children. two of the forty-two participants noted taking prescription medicines for high cholesterol and two other participants noted taking prescription medicines for elevated blood pressure. four participants noted taking herbs for elevated cholesterol, one participant noted taking herbs for elevated triglycerides, and one participant noted taking herbs for elevated blood pressure. the cardiovascular risk factors of the study participants are shown in table 1. the lipid values were categorized according to the national cholesterol education program (ncep) adult treatment panel iii guidelines (ncep, 2001, see table 3). based on these predetermined values, the definition of each true positive, true negative, under-referral, and over-referral for tc, hdl-c, ldl-c, and triglycerides are shown in table 3. cross-tabulations of the values (see table 4) revealed that the pla1tc had an under referral rate of 33.3% and an over referral rate of 0%. the pla2tc had an under referral rate of 0% and an over referral rate of 31.7%. for the remaining lipid values the pla2 had an under referral rate of pla2 hdl-c, (14.6%), pla2 ldl-c (0%), pla2 trig (0%) and over referral rates of pla2 hdl-c (4.9%), pla2 ldl-c (30.3%), and pla2 trig (2.4%). 59 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 table 1. cardiovascular risk factors of a south central kentucky old order mennonite community by sex men (n=21) mean (sd) women (n=20) mean (sd) t a age, y 45.1 (15.4) 51.4 (18.0) -1.20 rltc 198.0 (38.8) 202.7 (32.8) -0.42 rlhdl 50.6 (10.5) 58.4 (13.6) -2.06 rlldl 122.2 (35.6) 119.1 (33.2) 0.28 rl triglycerides 126.5 (74.8) 125.3 (68.9) 0.05 pla1 tc 183.8 (26.3) 184.0 (24.5) -.029* pla2 tc 217.6 ( 60.0) 258.8 (43.1) -2.56 pla2 hdl-c 45.6 (15.1) 66.5 (19.2) 2.21 pla2 ldl-c 159.4 (47.9) 172.7 (34.9) 0.08 systolic blood pressure 132.5 (11.7) 136.8 (22.3) -0.78 diastolic blood pressure 77.9 (7.3) 75.3 (7.0) 1.17 body mass index 25.7 (4.3) 28.7 (6.9) -1.68 note. the age range of participants was 21 to 88 years. a men versus women * p < .05 table 2. correlation of reference laboratory tc and bmi, systolic bp, diastolic bp, age, and children _____________________________________________________________________________________ r b r b body mass index -0.01 age 0.37* systolic blood pressure 0.25 number of children 0.19 diastolic blood pressure -0.02 b pearson’s r * p < .05 table 3. atp iii guidelines total cholesterol hdl cholesterol ldl cholesterol triglycerides true positive rl ≥ 200 pla ≥ 200 rl < 40 pla < 40 rl ≥ 100 pla ≥ 100 rl ≥ 150 pla ≥ 150 true negative rl < 200 pla < 200 rl ≥ 40 pla ≥ 40 rl < 100 pla < 100 rl < 150 pla < 150 under referral rl ≥ 200 pla < 200 rl < 40 pla ≥ 40 rl ≥ 100 pla < 100 rl ≥ 150 pla < 150 over referral rl < 200 pla ≥ 200 rl ≥ 40 pla < 40 rl < 100 pla ≥ 100 rl < 150 pla ≥ 150 60 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 table 4. portable lipid analyzer results by true positive, true negative, under-referral, and overreferral as compared to the reference laboratory _____________________________________________________________________________________ pla1 tc (n = 33) pla2 tc (n = 41) pla2 hdl (n = 41) pla2 ldl (n = 33) pla2 trig ( n= 41) true positive 27.3% 48.8% 70.7% 66.7% 22.0% true negative 39.4% 19.5% 9.8% 3.0% 75.6% under referral 33.3% 0% 14.6% 0% 0% over referral 0% 31.7% 4.9% 30.3% 2.4% discussion the primary purpose of this study was to examine the accuracy of plas for referral in an old order mennonite community. there were clinically relevant variations in the total cholesterol and ldl-c in both of the analyzers. pla1 systematically underestimated the tc and pla2 systematically overestimated the tc as compared to the reference lab. additionally, thepla2 systematically overestimated the ldl as compared to the reference lab. the ncep in the adult treatment panel iii has focused on primary prevention in persons with multiple risk factors, specifically aiming to lower the ldl (ncep, 2001). this recommendation supports the use of pla2, which provides a complete lipid panel. however, pla2 is significantly more expensive to purchase and operate. the cost of pla1 is $217.94 for the monitor and $81.52 for 25 strips (roche, 2009). the cost of pla2 is $668.47 for the monitor and $150.00 for 15 strips (cardiochek, 2009). this economic consideration is most important when providing preventive health services to populations with limited resources such as the old order mennonites. a secondary purpose of the study was to examine the relationship of total cholesterol values with other known cardiovascular risk factors. many large studies have indicated strong association of abnormal lipids with hypertension and elevated bmis (brown, et al., 2000; lloydjones et al., 2009). in this sample, the correlation between the reference laboratory (rl) tc and age (r =.37, p =.009) was the only significant correlation. in 2006, among the overall us adult population aged 20 years or older the mean age adjusted serum total cholesterol level was 195 mg/dl for men and 201 mg/dl for women (kilmer et al., 2008). in a study of lipid levels in an old order amish, pollin et al. (2004) found that the mean serum tc was 211.9 mg/dl for men and 212.6 for women. in an old order mennonite community glick et al (1998) found the mean serum cholesterol for men was 174.3 mg/dl and for women was190.8 mg/dl. in this study, the mean rltc for men was 198 mg/dl and the mean rltc for women was 202.7 mg/dl. the prevalence of serum cholesterol values greater than 240 in us caucasians between the ages of 30 to 50 years ranges from 14 percent to 38 percent (pencina et al., 2007). in this sample, the prevalence of the rltc greater than 240 in participants from 30 to 50 years ranged from 3 to 10 percent. in 2006 the national health and nutrition examination survey (nhanes) survey identified the prevalence of hypertension (bp ≥ 140 or diastolic bp ≥ 90) in us adults as 29% 61 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 (ostchega et al., 2007) which was equivalent to this population’s hypertension prevalence of 28.5%. the nhanes also identified the prevalence of obesity (bmi > 30) in the us population 20 years and older in men as 33.3%, and in women 35.3% (centers for disease control and prevention , 2009). in this sample the prevalence of obesity in adults 20 years or older is 24%, in men 9.5 %, and in women 38%. fuchs (1990) found that amish women have higher rates of obesity in comparison to non-amish women. the guiding principles incorporated in this project included the promotion of active collaboration and participation from all partners, the fostering of co-learning, the dissemination of the project results in useful terms, and the use of culturally appropriate interventions (o’fallon & dearry, 2002). initially, during the established community activities, some of the residents posed questions regarding the accuracy of the cholesterol readings obtained from a pla. the researcher involved in working with the community pursued this. again, followingup on concerns/request is one way the researcher established trust and acceptance by the community members. participants received a copy of their reference laboratory tc, ldlc, hdlc and triglycerides by mail. those participants with abnormal results also received a recommendation to visit their local health care providers. the results of this study in aggregate were presented to the members of the community prior to any publication. there were many questions from the community and they voted to continue to use pla1. this model has increased collaboration with community members and providers of services in rural areas. plas offer a method to meet the challenges in many rural populations regarding access, cost, and the lack of a defined primary health care provider however; at present, there are limitations to their use. additionally, the project offered learning opportunities for undergraduate and graduate students. the students were engaged in the process of collecting data and were exposed to the health care beliefs and practices of members of an old order mennonite community. limitations all participants were caucasians from an old order mennonite community in south central kentucky. this limits the generalizability of these results to a larger population. additionally, much of the demographic data were self-reported and may have been inaccurate. all finger stick samples were obtained before the phlebotomy for venous samples, which may have introduced a systematic bias. the small sample size also limits generalization to the larger population. conclusion more research is needed to understand the variances between portable lipid analyzer measurement and venous samples. the recommendations for practice and education include increasing the health care providers’ and students’ awareness concerning the rising use of plas and their potential of inaccuracy for referral. the venous samples avoid both false positives and false negatives that may be obtained with the use of portable lipid analyzers. in summary, accurately measuring lipid values in hard to access populations is important and plas provide an 62 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 easy to use and rapid determination of lipid values. however, plas should not be used to make clinical decisions for diagnosis and management of patients. author note the authors have no conflict of interest to declare. the funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. acknowledgements this study was supported by a grant from the south central kentucky area health education center, which is appreciated. the authors would like to thank those who participated in the study. references armer, j.m. & radina, m.e. 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(2003). unser satt leit: our sort of people health understandings in the old order mennonite and amish community (unpublished master’s thesis). university of waterloo, waterloo, ontario, canada. young center for anabaptist and pietist studies, elizabethtown college (2008). amish population growth 1992-2008. retrieved november 1, 2008, from http://www2.etown.edu/amishstudies/ http://www.ncbi.nlm.nih.gov/pubmed?term=15178733%5buid%5d&cmd=detailssearch http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/ http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/ http://www2.etown.edu/amishstudies/ scheckel_605-formatting online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 90 learning what i need to know: experiences of rural cardiac surgery patients martha m. scheckel, phd, rn 1 jennifer hedrick-erickson, msn, rn 2 debra stieve, dnp, msn, rn, cne 3 1 dean and professor, college of nursing, health, and human behavior, viterbo university, mmscheckel@viterbo.edu 2 chair bsn completion program and associate professor, college of nursing, health and human behavior, viterbo university, jfhedrick@viterbo.edu 3 regional infection control nurse, arkansas regional office, wellpath, destieve@wellpath.us abstract purpose: this hermeneutic study expands understandings of rural cardiac surgery patients’ experiences of their learning needs following cardiac surgery to inform the provision of patient education for this population. sample: eighteen rural residents provided accounts about their experiences. findings: an interpretation as analysis approach revealed three themes: a) learning: family history informing preventive care; b) learning: the notebook, blue’s clues, and explanations; and c) learning: lifestyle changes and confronting mortality. conclusions: the first theme demonstrates needs to ensure patients from rural settings understand that preventing cardiovascular disease is not limited to family members’ experiences with secondary and tertiary prevention. the second theme underscores the importance of providing patient education materials that are readable and useable, and considers existential learning needs. the last theme highlights the importance of patients understanding how lifestyle changes involve online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 91 embracing new ways of living that are enhanced through cardiac rehabilitation, and yet, can be experienced as life limiting. keywords: cardiovascular disease, cardiac surgery, learning experiences, rural, hermeneutics learning what i need to know: experiences of rural cardiac surgery patients cardiovascular disease (cvd) consists of all diseases of the circulatory system, including those that are congenital (mozaffarian et al., 2015). cardiac surgery, such as valve replacement and repair and coronary artery bypass graft (cabg), often repairs damage to cardiac function resulting from cvd. despite the benefits, cardiac surgery is very invasive and has a long and complex recovery process. patients undergoing cardiac surgery have a multitude of learning needs that, when properly addressed, can contribute to an uncomplicated recovery. learning needs range from knowing how to manage incisions, pain, and new diet and exercise regimens, to learning ways to alleviate the stress, anxiety, and depression often associated with this surgery. these latter psychological needs powerfully remind cardiac surgery patients of their mortality (lapum, church, yau, ruttonsha, & david, 2013). although the learning needs of cardiac surgery patients are multifaceted, rural cardiac surgery patients in the us recover from the surgery within an array of health and sociocultural risk factors. compared with their urban counterparts, rural residents are more frequently underinsured or uninsured (newkirk & damico, 2014; mueller, et al., 2018); have higher rates of smoking, obesity, physical inactivity, and chronic health conditions; and are older (> 65 years of age), less educated, and have lower incomes (bushy, 2012; meit et al., 2014; united states department of agriculture, 2017). in addition, lee and mcdonagh (2018) and long and weinert (1989) suggest that rural residents believe health means being productive, and will work even when they are ill. these authors (lee & mcdonagh, 2018; long & weinert, 1989) also report that rural residents online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 92 are self-reliant and will depend upon themselves, family members, or friends before seeking help from formal health care professionals to address their health issues. these unique health and sociocultural risk factors may affect their ability to learn what they need to know to recover from cardiac surgery without complications. despite the risk factors that can impact rural cardiac surgery patients, there is little research about their learning needs. most studies are limited to cabg patients outside of the us and do not indicate whether patients were from rural or urban areas. the majority of studies are limited to descriptive designs where investigators analyzed correlations between perceived learning needs and demographic characteristics. fredericks, guruge, sidani, and wan (2009) suggested that, in a sample consisting of lower and higher-context cultures (e.g., irish, english, and scottish [lower context]; e.g., indian, chinese, and middle eastern [higher context]), members of lower-context cultures had fewer perceived learning needs following a cabg compared with those from highercontext cultures. the authors attributed this finding to theoretical propositions that those from lower-context cultures understand and use health information provided through explicit verbal and written messages (e.g., patient education materials and verbal instructions). conversely, those from higher-context cultures understand health information when it is delivered through nonverbal behaviors and the physical environment. consequently, perceived learning needs may be impacted when health care providers deliver information only in print or through verbal messages. alkubati, al-zaru, khater, and ammouri (2013) found that gender may influence perception of learning needs. these authors reported yemeni women may rely on men to help them understand their learning needs or may draw on knowledge gained from social roles in understanding health information, thus ranking information needs low. similarly, in another study males had greater learning needs compared to females (fredericks, 2009). the author attributed online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 93 this finding to social roles in which females are designated caregivers and better understand the learning needs of those who are ill. another study by omari, al-zaru, and al-yousef (2014) found that, among a sample of syrian patients, age might influence learning. the authors reported that older patients had greater learning needs than younger patients did because family members typically provided them with information about the illness and self-care, however, they do not receive information from family members considered as ‘other pertinent information’ (p. 1714) such as when to contact the health care provider and where to seek resources for families with loved ones who have had an operation. the purpose of our study was to use hermeneutics to expand understandings of rural cardiac surgery patients’ experiences of their learning needs following cardiac surgery to inform the provision of patient education for this population. our study goes beyond the descriptive correlational research described above about relationships between demographic characteristics and learning needs, thus broadening the scope of knowledge about the learning needs of rural cardiac surgery patients living within the us. methods study design we used hermeneutics as described by gadamer (2003/1960), which is the practice of interpreting experiences to understand phenomena (moules, mccaffery, field, & laing, 2015). our interpretative work assumed that “life cannot be adequately described in theoretical terms” (harmon, 2007, p. 25). rather, interpreting experiences reveals “hidden meaning, of bringing what is unknown to light: revelation and disclosure” (palmer, 1969, p. 147). in using hermeneutics, we generated understandings about rural cardiac surgery patients’ learning needs through interpreting their experiences of learning what they needed to know to recover from their surgeries. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 94 participants following institutional review board approval (irb #c12-861), a cardiac clinical nurse specialist (cns) employed at a regional midwestern medical center recruited participants for the study at the time of their pre-admission testing. participants needed to be hospitalized for cardiac surgery (valve replacement and/or repair and/or cabg), rural residing, over the age of 18, english speaking, and able to verbalize their learning needs. we trained the cns to use the am i rural? tool (rural health information hub [rhihub], n.d.a.) to determine if patients were from a rural health clinic (rhc) area. the rhc designation is determined based on the number of people living in a particular area, how many health care providers are in that area, and residents’ distance from medical care (rhihub, n.d.b.). the cns recruited 20 participants. this sample size is sufficient for providing data to interpret the learning needs of rural cardiac surgery patients (moules et al., 2015). the cns informed participants that we would collect data through two audiotaped interviews—the first just prior to discharge (within 24 hours) from the medical center, and the second six weeks following their discharge at their home. participants interviewed at the time of hospital discharge are able to relate learning experiences during the most acute phase of their recovery. this phase of recovery entails the existential meaning of the heart and can influence the extent to which cardiac patients have the capacity to learn what they need to know to recover from cardiac surgery (martinsen & moen, 2010). participants interviewed six weeks following hospital discharge are able to relate learning experiences during the home phase of recovery. this phase often involves introspection on the traumatic, life-changing aspects of cardiac surgery, as well as learning needs pertaining to self-management strategies required for an optimal recovery (e.g., diet, exercise, wound care, pain control and medication, and stress management) (lapum et al., 2013). online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 95 eighteen of the 20 recruited participants agreed to be in the study. ten participants had a cabg, one had a cabg and a valve replacement, and seven had a valve replacement. participants included nine men and nine women, ages 41 to 85. thirteen participants were married and five were single. all participants were white, with 14 identifying themselves as christian and four reporting no religion. four participants had a high school education, ten had some college, one had a college degree, and three had a graduate degree. one participant was unemployed, 10 were retired, and the rest were employed. all but one participant had health insurance. data collection after obtaining written informed consent from participants, data were collected using nonstructured, audiotaped interviews. during the first interview, we asked participants what they were taught about their cardiac surgery prior to and throughout their hospital stay, and how these experiences helped them learn what they needed to know to recover from surgery. during the home interview, we asked them what was most helpful about these experiences in relation to learning what they needed to know to recover from their surgery. in both interviews, we prompted participants to provide detailed accounts of their experiences with questions such as: “what else helped you learn what you needed to know to recover from open-heart surgery?”; “can you give me a ‘for instance?”; and “what did that [experience] mean to you?” after the interviews, the principal investigator assigned identification numbers to the audiotapes and submitted them to a transcriptionist with experience in qualitative studies. to ensure confidentiality, the transcriptionist replaced all identifying information with pseudonyms. after the transcriptionist transcribed the interviews, we verified them for accuracy. data analysis we analyzed the data using the interpretation as analysis approach (moules et al., 2015). online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 96 this approach involved reading the transcripts multiple times and making notes about their content. the notes provided conjectures of meanings, which we used to develop initial interpretations. these conjectures were often something notable, or common experiences among participants. we further developed conjectures into more complete interpretations through discussion and writing, and using quotations and relevant literature to expound them. conducting data analysis in this manner meant our interpretations were not limited to descriptions of participants’ experiences. rather, through using an interpretive process for data analysis, we identified nuances within the data, elucidating understandings about experiences of recovering from cardiac surgery that would not be accessible through description alone. as we interpreted data, we categorized interpretations into themes. we used themes as an approach to organize the interpretive work (moules et al., 2015). throughout the interpretive process, we acknowledged our prejudices as conditions in which understanding occurs (gadamer, 2003/1960): we — the three investigators of this study — were born and raised in rural areas of the us. we considered our upbringing important for understanding and interpreting data in an “informed and committed way” (moules et al., 2015, p. 121). rigor we maintained rigor throughout our study by drawing on madison’s (1988) principles for evaluating interpretive research. these principles included coherence, comprehensiveness, penetration, contextuality, and agreement. consistent with madison (1988), we maintained coherence by presenting data without inappropriate contradictions (e.g., bringing to light and explaining opposing viewpoints) and ensured comprehensiveness by developing interpretations that promoted a unity of meaning. we assured penetration by writing interpretations that made an impact on the reader and were appropriately adherent to the study purpose. we kept contextuality online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 97 at the forefront of our interpretive work by being aware that interpretations were within the context of rurality. we addressed agreement by working to achieve consistency among what we conveyed in the methods, interpretations, and conclusions. madison (1988) contended that good hermeneutics involves creating suggestiveness and potential, which we strove to do by raising new and important questions for future study. results participants’ experiences of learning what they needed to know following cardiac surgery at the time of hospital discharge and six weeks later at home included three themes: a) learning: family history informing preventive care; b) learning: the notebook, “blue’s clues,” and explanations; and c) learning: lifestyle changes and confronting mortality. we led each theme with the word learning because it was the focus of the interview question. in the hermeneutic sense, learning can reflect the fusion between the knowers and what they were learning (grondin, 1995). in our study, the knowers or the participants frequent references to a family history of cardiac disease reflected a fusion of what they believed they knew about the disease (as transmitted to them by family members) and their understanding of how to prevent cardiac surgery or accept having the surgery. what they learned about cardiac care, however, demonstrated their new understandings about the importance of patient education materials and providers’ explanations of what they needed to know to care for themselves following cardiac surgery. they summed up their learning needs through articulating how cardiac surgery meant learning lifelong lifestyle changes, and for some, these changes meant confronting their mortality. despite the interwoven nature of the themes (figure1), it is important to point out that, with the exception of the first theme, there was no clear demarcation of learning needs in the hospital versus the home. however, the first theme emerged from hospital interviews whereas the second and third theme emerged from online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 98 interviews in both settings. figure 1. interwoven nature of themes learning: family history informing preventive care interviews with participants at the time of hospital discharge revealed that they learned what they needed to know to recover from cardiac surgery through family members’ acute cardiac events. participants’ descriptions aligned with secondary and tertiary levels of prevention, which focus on screening for cardiac disease, surgical intervention, and post-surgical convalesce. one participant said that, after his sister died from atrial fibrillation, another sister asked him and his siblings to schedule medical appointments to determine if they had cardiac disease. he said, “i checked out bad, she [my sister] checked out bad, and my brother walked away okay.” in his case, theme 1: family history informs perceptions of preventive care* theme 2: patient education and provider explanations clarifies perceptions/leads to new learning** theme 3: cardiac surgery = lifelong lifestlye changes to preserve life** * emerged from hospital interviews **emerged from hospital and home interviews online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 99 secondary prevention involved a need for him to undergo tertiary prevention through a valve replacement and cardiac bypass to repair damage from cardiac disease. similarly, another participant wanted to undergo cardiac surgery as a mechanism of tertiary prevention. his father died of a myocardial infarction. he looked forward to the surgery viewing it as “the lesser of two evils” through describing cardiac surgery as easier to recover from than a myocardial infarction. he said: i have always wanted to [have a cardiac bypass] because i never had a heart attack and i don’t want to have one. it sets you so far back. i wanted to be younger to recover faster. i wanted to get it over with. i’ve been planning on [cardiac surgery] since my dad died [of a heart attack]. some participants said they had control over the disease by assuming through, witnessing family members with the disease, that they knew when and how they would seek tertiary prevention to avoid mortality from the disease. one participant said at the onset of cardiac symptoms, he drove himself to the emergency room, and when he arrived, he “walked back and forth in front of the emergency room” without going in for care. he said, “i went through a list of 40 things, like don’t do this. what do you want to get cut up for? you’re not that bad.” upon returning to his vehicle to go home, he said he had “the knife in the back.” this participant’s reflection could be interpreted as the pain signifying confrontation with his fate or “a powerless superior power”, creating a readiness for adversity (heidegger, 1962/1927, p. 436), which compelled him to return to the emergency room for treatment where he subsequently underwent cabg surgery. another participant said he had chest pain three months before having a myocardial infarction. he said he knew about cardiac disease from family members’ medical history and their online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 100 experience with the disease. he said: i could tell from the front chest part, there wasn’t a problem, but from the back, as far as moving property and persons [in my job], i’d have to stop and breathe for a little bit. the legs would go numb, i’d have to crack my fingers. but i would overlook the [signs and symptoms] to make sure everything else was in control as far as how much time i have left— sick time. i planned to go out and rest if i was going to have [back pain]. and then finally the day i had [the myocardial infarction], i could feel it right through my legs and my back, but i continued what i was doing. and finally, at a certain point, i said enough is enough. it’s time to get checked out. this participant had a precarious sense of mastery over managing signs and symptoms (gadamer, 1996) of a myocardial infarction. he thought he knew how to manage when he was having a myocardial infarction and when he was not because of witnessing family members with cardiac disease. he subsequently made the determination about how to circumvent medical interventions for as long as possible, assuming he had the ability to control when he needed medical intervention such as through “planning” when he needed to rest and when he needed to seek medical care. learning: the notebook, blue’s clues, and explanations the majority of participants described the patient education materials they received as essential to learning what they needed to know to recover from cardiac surgery. many of them said they thoroughly read the information, sometimes multiple times during their hospital stay, and again when they were at home. one participant said she read the material from “end-to-end many times over” and another said he “read it, absorbed it, and used it.” in discussing patient education materials, participants referenced material they thought online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 101 offered the best source of information. the source they most frequently discussed was titled notebook on heart surgery, which many of them simply called the notebook. the notebook is a three-ring binder containing six sections with information about the health care center where they had their surgery. it contained pre-surgery instructions, cardiac conditions and procedures, postprocedure care, discharge planning, and other resources. some of the content was copyrighted by companies and organizations producing patient education materials (e.g., staywell, the american dietetic association, and pritchett & hull associates). other content was created by the health care facility. the pages in the notebook had large, colorful illustrations, bolded statements, varied font sizes, and short sentences for ease of reading and comprehension. one participant who underwent heart valve replacement referred to the notebook as the blue’s clues of heart surgery. blue’s clues, was a preschool television series in the us from the late 1990s. he said: there was a big binder to read through, which broke [heart surgery] down into some very simple illustrations. that was a lot more helpful for me to read than technical terms. it’s like the blue’s clues of heart valve replacement. the little pictures with captions, which made it simple because most don’t know they have an aortic valve in the heart, let alone what it does and where the blood goes. despite the large binder, this participant seems to convey how the simplicity (e.g., nontechnical terms) of the material provided a “luminous spot” where the unknown could be known (dewey, 2009/1916, p. 260). this luminosity helped him learn what laypersons generally do not know about cardiac surgery. other participants echoed the blue’s clues description by talking about how the information in the notebook was displayed in a manner that facilitated their learning. one participant recounted online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 102 how the material provided her with step-by-step instructions about what to expect, know, and do preand postoperatively. it was also common for participants to comment on the illustrations and white space, with one participant summing up the material by describing it as friendly. while the appearance and readability of the notebook were important to participants, many of them remarked on the value of health care providers’ explanations of learning what they needed to know to recover from cardiac surgery. one participant said, “they explained the [cardiac surgery procedure] to me so well that half the time i didn’t have questions. but if i had a question, i could always ask them later. no problem.” another participant said the nurse “was terrific; i mean, she was explaining stuff to me all this and that.” another said, “they’ve been great explaining different things or why i’m getting certain medicines, or different ways i need to move.” when asked about the meaning of the explanations, some participants said they felt supported, reassured, and confident in knowing what they needed to know to care for themselves postoperatively. participants’ reflections on health care providers’ explanations reveal the importance of the relational aspects of patient education. to the participants, explanation was an act of caring by a provider that exemplified the artful practice of patient education. polkinghorne (2004) writes that practice involves two entities, “the one to whom the practice is directed is a person, and so is the entity who performs the practice” (p. 89). practitioners are not mechanical or formulaic but rather use judgment and improvisation to help others achieve their goals. such practice conveys a caring attitude that promotes participants’ receptivity to patient education (noddings, 2013). despite the quality of the patient education and value of explanations, a few participants said they were initially frightened by the information they received. one participant said that receiving the notebook “scared me to death” to the point it interfered with her sleep. another participant said online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 103 he was frightened that, upon reading the patient education materials, he had a “two to five percent chance you don’t make it,” and “even though it’s only two to five percent, any chance is scary, even if it’s half a percent.” family members tried to decrease participants’ fears by attempting to console them, and health care providers attempted to alleviate their fears with further explanation. nonetheless, these participants’ preoperative learning experiences seemed to involve existential uncertainty and an obvious sense of vulnerability (dahlberg, 2018). learning: lifestyle changes and confronting mortality in nearly all narratives (hospital and home), participants remarked on types of lifestyle changes they needed to make following cardiac surgery, with a number of them indicating they gained the most comprehensive knowledge in cardiac rehabilitation. in some instances, however, their accounts involved deep reflections on the meaning of lifestyle changes in relation to their mortality. regarding types of changes, many participants understood the need to adhere to new regimens that defied habitual ways of living; they had to get used to new things and acquire new habits. merleau-ponty (1962) writes, “[h]abit has been cultivated when it has absorbed a new meaning, and assimilated a fresh core of significance” (p. 146). upon reflecting on integrating new lifestyle habits into her life, one participant said, “it’s just that remembering these little things along the way or the things you just take for granted and are used to.” another participant said she needed to “be careful and take it easy and not be the woman that i am.” she further explained she did “manly chores versus woman chores” and she needed to modify “cutting wood and cutting the grass,” perhaps permanently. for her, cultivating new habits meant yielding to gendered expectations of women’s work, which did not entail strenuous outdoor activities. some participants said they learned they needed to grocery shop around the perimeter of the store where online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 104 healthier foods typically are located. others learned new ways to manage sodium intake, such as draining a can of beans or corn to remove excess sodium. some talked about avoiding particular restaurants, some of which they used to patronize frequently, because, as one participant said, “[name of town] is not the healthiest community in the world by any stretch of the imagination. people love their fried food here.” participants who elaborated on learning what they needed to know in cardiac rehabilitation often reflected on the multifaceted aspects of recovery. this participant explained his experience in cardiac rehabilitation: the first hour of the day is education. it’s all about your heart and your body and what’s happened to you and how to take care of yourself. and then the next hour is your exercise. i’ve done stuff on the treadmill before but i didn’t think i could because i can’t walk very much with my legs. i’m spending fifteen minutes on there at a nice, fast pace for me without my legs killing me. and that makes me feel good. they have a person come and tell you everything you need to know. what’s going on that day, whether it’s about your heart, if it’s about sugar, if it’s about nutrition, or if it’s about exercises you’re going to do or if it’s about whatever. this participant recounts his experience in cardiac rehabilitation as time well spent, reflecting on the many dimensions of recovery and associated benefits, such as improved endurance. his comments on feeling good reflect the essence of recovery as the “miraculous process of convalescence” (gadamer, 1996, p. 42). nonetheless, not all participants were positive about adopting new lifestyles following cardiac surgery. a few participants said that learning what they needed to know meant grieving the loss of previous lifestyles and confronting their mortality. during the home interview, this participant, who developed atrial fibrillation following his surgery, online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 105 reflected on the meaning of lifestyle changes: i was a sixty-five-year-old man who could catch bullets in his teeth. [now] any change, any quirk, any thump. . .is this it? i’ve got to learn [to live] with the fear of this arrhythmia. i’ve got to learn how to re-eat. i’ve got this heart-healthy diet and what that means to me is, if it tastes good, you can’t eat it. and other things i’ve given up or have to change. cardiac rehab. i started out the first day with a seminar and it was sort of like a cold shower. the instructor made a statement that i really didn’t know, hadn’t researched. that these bypasses are only good for 10 to 15 years. and prior to that, i thought a lot of doctors said you have two good decades, three decades, live to ninety. on wednesday’s class, which again, i mean it was a good class, but not one of my favorites. it was on advance directives. we all have to face the inevitable, but that’s hard facing. the instructor did a very good job on that, but i guess it’s boom, boom, boom, and these aren’t the things you want to hear after coming out of cardiac surgery. this participant paints a bleak picture of his perceptions about the realities of learning what he needed to know to recover from cardiac surgery. he reflects on who he used to be—a strong man who was nearly invincible. he lives in fear of unmanaged arrhythmias, and views lifestyles changes following cardiac surgery as a loss. he sees little pleasure, for example, in eating a hearthealthy diet. he laments that doctors misled him about the expected lifespan following cardiac surgery, vividly describing how shocking it was to learn he may not live decades. the session on advance directives intensified his negative learning experiences as it compellingly imposed the need for him to confront his mortality. he cogently summarizes his concerns about learning by emphasizing what he did not want to learn following cardiac surgery. this participant gives voice to learning experiences that can be overlooked in the midst of online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 106 providing patient education. his experience can be interpreted as patient education services acting as oppressor, wherein he experiences some degree of harm in learning what he needs to know and feels repressed and vulnerable through the educational messages he receives (redman, 2002; 2011). he sees no escape from surgical outcomes, using obligatory statements such as “i’ve got to…”, which, in his case, reflect little sense of power and control over learning what he needs to know to recover. patient education is imposed upon him, furthering his suffering from his cardiac condition. discussion in our study, we broadened understandings of rural cardiac surgery patients’ learning experiences following cardiac surgery to inform the provision of patient education for this population. our study extended research that has primarily focused on the correlation between the learning needs of cardiac surgery patients and demographic variables. the first theme, learning: family history informing preventive care, discusses participants learning what they needed to know through witnessing family members’ cardiac events. they used this knowledge to understand their own condition, articulating it within the context of secondary and tertiary prevention, rather than through primary prevention. this finding is consistent with other studies, which demonstrate that rural residents treated for preventable outcomes of chronic disease can rely on knowledge from family members to understand their own condition and its treatments (liu et al., 2018; lohri-posey, 2006). this way of knowing, however, may result in participants’ abdicating their personal role in prevention and perpetuating their understanding that cardiac disease is resolved through medication and surgical intervention alone (king, thomlinson, sanguins, & leblanc, 2006), rather than through preventive health care. nevertheless, participants’ reliance on family online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 107 knowledge must be considered in relation to other factors where research explains rural residents’ lack of primary prevention may be due to insufficient knowledge about primary prevention (hamner & wilder, 2010) and distance decay (access to care impeded by long travel distances to health care providers) (wong & regan, 2009). the lack of primary prevention may also be related to rural primary care providers’ heavy workloads where they are required to spend time addressing acute health care needs, rather than providing primary prevention services (khoong, gibbert, garbutt, sumner, & brownson, 2014). cohen, manuel, and sanmartin (2015), in fact, suggest that rural residents at risk for an acute myocardial infarction are better served by secondary prevention services because cardiac symptoms trigger diagnostic services. the second theme, learning: the notebook, blue’s clues, and explanations, illuminates participants’ health literacy levels. health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (institute of medicine, committee on health literacy, 2004, p. 4). there is a paucity of research about the learning needs of rural cardiac surgery patients in relation to health literacy. there are, however, a few closely related studies about the health literacy needs of surgical patients. one systematic review and meta-analysis reported heterogeneity in health literacy among surgical patients (roy et al., 2019). a qualitative systematic review indicated a possible association between low health literacy and low comprehension of surgical procedures, and poor adherence to preoperative instructions (oliveira, mccarthy, wolf, & holl, 2015). unlike these studies, our study reflects qualitative homogeneity among participants’ reports of health literacy; for example, they commented on the readability of patient education materials and the practice of rereading content numerous times to ensure they understood the information. the practice of rereading is consistent with another qualitative study, which showed that rural online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 108 residents understand patient education materials through frequently referencing and rereading them as an approach to understanding and using health information (scheckel et al., 2012). scheckel et al. (2012) also inferred a possible link between health literacy and the value that rural residents place on self-reliance (e.g., being informed equates to self-sufficiency), which is a concept consistent with literature on rural culture (lee & mcdonagh, 2018). although our study is not consistent with research on health literacy and surgical procedures, it is consistent with practice guidelines and standards on support systems and effective interpersonal communication, which is necessary to facilitate health literacy (brega et al., 2015; office of disease prevention and health promotion health communication activities, n.d.; the joint commission, 2007). in our study, participants said that health care providers’ explanations were an effective form of support and communication, which helped inform their health literacy needs. this finding mirrors another study in which rural participants saw health care providers’ facilitation of health literacy as a caring act, giving participants “know-how to endure their illness, overcome it, and care for themselves once again” (scheckel et al., p. 117). although there is little research about the role of support and effective communication in relation to health literacy for rural cardiac surgery patients, there are a number of studies that suggest empathy (mammen, sano, braun, & maring, 2018) and psychosocial support (hardman, lawn, & tsourtos, 2018), facilitate health literacy for those in rural areas, giving credence to the significance of these dimensions of care in promoting health literacy among rural cardiac surgery patients. despite the positive findings of our study, which indicated that participants understood the information they received and the value of support systems in augmenting health literacy, it is important to address participants’ comments about being frightened by the information, particularly in relation to cardiac surgery mortality rates. some participants thought even a small online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 109 mortality rate was of great concern. this finding differs from a narrative inquiry study about patients’ experiences of technology in open-heart surgery and recovery where participants saw cardiac surgery as a technological fix, which “averted dwelling on the possibilities of death” (lapum, angus, peter, & watt-watson, 2010, p. 757). it also differs from a study showing that cardiac surgery patients did not feel frightened by the education they received (ivarsson, larsson, lührs, & sjöberg, 2005). however, our findings align with a qualitative, descriptive-exploratory study that suggested those undergoing a cabg need more information about the existential needs of recovery (martinsen & moen, 2010). the third theme, learning: lifestyle changes and confronting mortality, discusses participants’ learning about the importance of confidently embracing new ways of living, such as changing dietary and activity regimens, which is consistent with other studies. lapum et al.’s (2010) narrative inquiry study used a metaphor from elbow (2007) to describe how open-heart surgery patients move away from dependence on technology toward being competent and active participants who “began to sing themselves into their recovery” (lapum, et al., 2010, p. 760) by re-engaging in normal activities of daily living. lapum et al. (2013), in using an arts-informed narrative study, portrayed a figure in an open field in the winter with foliage emerging to show how a patient recovering from cardiac surgery “stands with confidence and readiness to move forward” (p. e696). similarly, martinsen and moen’s (2010) descriptive-exploratory study drew on antonovsky’s salutogenic model to understand how “sense of coherence” illuminates cabg patients’ need for support in adopting new lifestyle changes during recovery from cardiac surgery. the third theme also highlights the importance of cardiac rehabilitation when participants described its utility in meeting their learning needs following cardiac surgery. studies about cardiac rehabilitation in rural settings are predominantly limited to investigating barriers to online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 110 accessing services (field, franklin, barker, ring, & leggat, 2018; sangster et al., 2013; shanmugasegaram, oh, reid, mccumber, & grace, 2013). however, a few studies focused on rural populations report findings similar to our study, which indicate positive associations between cardiac rehabilitation and learning about diet and self-management (fletcher, burley, thomas, & mitchell, 2014), achieving a sense of accomplishment and increased understandings about cardiac health (austin, 2013), and understanding cardiac rehabilitation as important for the “evolution and continuity of the educational process” (erdmann, lanzoni, callegaro, baggio, & koerich, 2013, p. 337). in spite of the research on positive experiences of rural cardiac surgery patients’ participation in cardiac rehabilitation, our study brought to light how learning what one needs to know about recovery can be discouraging. this finding is congruent with anderson, mcallister, and moyle’s (2002) discourse analysis of a pacemaker implantation booklet, which conveyed preferred meanings of surgical outcomes such as health and happiness, when in fact such discourse can be misleading through omission of important information about the unanticipated and unpleasant realities of recovery. our findings indicate that some cardiac surgery patients feel ill-informed about the psychosocial impact of lifestyle changes following cardiac surgery. numerous studies support variations of the psychosocial impact of cardiac surgery, such as depression (hwang et al., 2015), anxiety (tully et al., 2011), and quality of life (perrotti et al., 2019). in the context of rural health, rural residents’ disclosure of the psychosocial impact of cardiac surgery is important to consider in relation to the rural health concept of anonymity. rural residents may be reluctant to reach out for psychosocial support for conditions such as depression, because they fear others known to them may see them seeking out mental health services (swan & hobbs, 2018). our study demonstrates the imperative need to ensure patients from rural settings understand online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 111 what preventive health care is and its relation to preventing cardiac disease. it is alarming that participants in this study equate prevention or cure of cardiac disease with surgical intervention. more research is necessary to learn ways to change perceptions of prevention among those from rural areas, including perceptions generated from within families. this research can facilitate ways to increase engagement with and adherence to cardiac disease prevention activities. our study also reinforces the importance of providing patient education materials that are readable and useable. these materials are treasured tools for those recovering from surgery. the materials must be accompanied by the human touch, which is invaluable to rural residents in promoting their understanding of learning needs following cardiac surgery. further research is needed on health literacy, specifically for rural residents undergoing cardiac surgery, to extend understandings about the utility of patient education materials for this patient population. it is also important to consistently address in a person-centered manner the existential needs of those undergoing cardiac surgery. participants’ comments in our study are a significant reminder that a learning need involves the existential experience of the surgery. health care providers can easily overlook this experience as a learning need amid the array of teaching that must occur around lifestyle changes. further research on existential learning needs can supplement existing studies on depression, anxiety, and quality of life following cardiac surgery. in addition, better understanding and knowing how to address existential learning needs has the potential to prevent patients from being frightened by patient education and feeling as though receiving the education resulted in harm through both knowing and not knowing what they needed to learn to recover from cardiac surgery. finally, it is important to study rural health concepts of self-reliance and anonymity in relation to rural cardiac surgery patients. study of self-reliance is important in gaining understanding about motivation for the utilization of patient education online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 112 material, adoption of lifestyle changes, and cardiac rehabilitation use among rural cardiac surgery patients. understanding the need for anonymity is important in identifying ways to ensure these patients receive mental health support when they experience acute or chronic psychosocial problems following cardiac surgery. our study does have some limitations in that the research was based in the us and thus is a lower-context culture (yamazaki, 2005). this lower context culture may explain why patient education materials were so useful to participants, which may not be the case for a similar study in a high-context culture. the education level of our participants suggests that health literacy may not have been a barrier to understanding and using patient education information. thus, it is important to keep in mind avoid assuming those from rural areas have low levels of health literacy. finally, our study is qualitative and has value in conveying experiences, which cannot be generalized. some studies cited in the discussion include quantitative research designs with systematic reviews. these studies provided a benchmark for the usefulness of our findings. however, our findings must be considered in relation to how they resonate with others to improve understandings about learning needs. herein lies the value of qualitative research where the researcher is, according to denzin and lincoln (2008), a bricoleur or quilt maker, providing “a pieced-together set of representations that is fitted to the specifics of a complex situation” (p. 5). our study did indeed piece together rural participants’ representations of the complex trajectory of their learning needs following cardiac surgery. conclusion the participants in our study revealed three important themes underscoring the learning needs of rural cardiac surgery patients: prevention, health literacy, and lifestyle changes. within these themes were important nuances, such as the influence of family knowledge on learning online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.605 113 needs, reported high levels of health literacy and its possible link to the rural concept of selfreliance, and the emergence of existentialism as a learning need. in addition, some participants were keenly aware of the psychosocial impact of patient education, showing clearly how important it is for health care providers to understand how patients experience learning about recovery from cardiac surgery. for rural residents, this experience can either be empowering or 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(2005). learning styles and typologies of cultural differences: a theoretical and empirical comparison. international journal of intercultural relations, 29, 521-548. https://doi.org/10.1016/j.ijintrel.2005.07.006 abstract 70 stress perception among rural and urban perinatal patients barbara zust, rn, phd1* laura natwick, ba, rn2 ashlee oldani, ba, rn3 1associate professor, nursing program, gustavus adolphus college, bzust@gac.edu 2student, nursing program, gustavus adolphus college 3student, nursing program, gustavus adolphus college *contact author key words: stress, rural, urban, pregnancy abstract pregnancy can be a source of both physical and emotional stress for the pregnant woman. stress can greatly impact one's well-being by increasing blood pressure, reducing coping mechanisms, and ultimately threatening one's homeostasis. anecdotal data indicates that urban and rural areas afford different sociocultural stress. there is a dearth of studies that explore perceptions of stress among pregnant women and no known studies that explore the perception of stress among pregnant women who live in different sociocultural areas of the united states. the purpose of this pilot study was to explore perceptions of stress among rural and urban pregnant women. findings indicated that rural participants attended prenatal classes more than urban participants and that urban participants perceived greater overall stress than rural participants. the study lends feasibility to future research exploring perinatal stress as influenced by geographical, sociocultural factors. background numerous studies indicate that pregnancy can be a stressful time for expectant mothers (nierop, wirtz, bratsikas, zimmermann, & ehlert, 2008; orr, reiter, blazer & james, 2007). maternal stress in pregnancy is associated with elevated blood pressure, excessive weight gain, weight loss, sleeplessness, fatigue, and decreased coping skills (hobel, dunkel-schetter, roesch, castro & arora, 1999). chronic maternal stress can lead to cardiovascular issues and increased susceptibility to infectious disease (march of dimes birth defects foundation, 2009). in a meta-analysis of the literature, glover and o’connor (2006) noted that stress in pregnancy has negative implications for the fetus and could have a long-term negative effect on the child’s behavior and neurodevelopment. weinstock (2008) explored the effect of stressinduced levels of cortisol and corticotrophin releasing hormone in pregnancy. based on animal studies, weinstock postulated that increased maternal levels of cortisol and glucocorticoids could cause learning deficits in the child by altering neurological development of the fetus. van den bergh, mulder, mennes, and glover (2005) found that high levels of maternal anxiety caused an increase in adrenaline and a reduction of placental blood flow, exposing the developing fetus to possible hypoxia. nierop et al. (2008) found that complications such as low infant birth weight, gestational complications, postpartum depression and developmental issues in infancy were associated with women who reported high levels of stress throughout pregnancy. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://gustavus.edu/academics/nursing/ mailto:bzust@gac.edu http://gustavus.edu/academics/nursing/ http://gustavus.edu/academics/nursing/ 71 dayan, et al., (2002) studied 634 pregnant women and found that anxiety and depression along with various biomedical risk factors were correlated with premature delivery. this finding was also supported in a study done by dole, et al. (2003). in a convenience sample of 278 pregnant women, oweis (2001) found that stress experienced by women during the birthing process was positively associated with postpartum depression. similar findings were noted by goldbort (2006) in a qualitative study that explored the relationship between unexpected birthing experiences and mood disorders. some researchers have postulated that pregnancy-specific stress may have a stronger impact on a woman’s physical state than stress in general (dipietro, ghera, costigan & hawkins, 2004). pregnancy-specific stress involves stress that pregnant women experience related to their pregnancy such as concerns over labor and delivery, worries about the health of the baby, parenting, etc., according to lobel, et al. (2008). these researchers criticized studies that did not consider the perinatal patient’s perception of pregnancy-specific stress, but instead measured stress in terms of the number of life event stressors such as moving, loss, job change, etc. lobel et al. (2008) studied perceived pregnancy-specific stress in 279 pregnant women and found that there was a positive association between pregnant women who identified significant pregnancyspecific stress and preterm delivery. although there is ample research that links stress and pregnancy, little is known about the perception of stress among pregnant women living in the rural area compared with the perception of stress among pregnant women living in urban areas. hartley (2004) found that rural health care has a notably greater need for improvement and revision compared to health care in the urban setting. hartley argued that rural populations do not have access to the necessary health services, as do populations in urban areas. galambos (2005) found that there are perinatal disadvantages among rural populations including a shortage of medical specialists, physicians and nurses. rosenblatt and hart (2000) noted that only 9% of the physicians in the united states serve rural populations even though 20% of the american people live there. the rural area has a higher infant mortality rate than urban areas (eberhardt & pamuk, 2004). in a study conducted by zust and briggs (2006) findings indicated that problems with staffing labor and delivery nurses in a rural hospital led to a higher interventional and instrumental delivery rate than the national average. in addition to the disparity of resources in the rural area, distance to the limited resources and lack of public transportation compound the problem for people living in the rural area. in some rural areas of the country, inclement weather such as blizzards and ice storms can further impede rural dweller’s access to health care resources. understanding the nature of perinatal stress is important in guiding practice to effectively reduce perinatal stress. however, it cannot be assumed that urban perinatal stress is the same as rural perinatal stress. the purpose of this pilot study was to explore the perception of stress among rural perinatal patients and the perception of stress among urban perinatal patients. methods an exploratory design with a 15-item survey was used for this study. thirteen items required participants to use a 0-10 likert scale to rate their stress in pregnancy related to factors such as support, financial concerns, physical self concerns, physical baby concerns, labor and delivery concerns, and overall stress. the survey also included two open-ended questions. the first question asked participants to suggest what providers, nurses, and other health care online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 72 personnel could have done to help them reduce their stress. the second open-ended question asked participants who had previous pregnancies to comment on their current experience of pregnancy stress in comparison to the stress they experienced in a prior pregnancy. in addition to the 15-item survey, demographic data was requested that included age, geographic location, employment status, income, number of pregnancies (parity), provider, and whether or not the participant attended prenatal classes. following institutional review board (irb) approval, as well as administrative approval from the hospitals involved, perinatal patients in a rural birthing unit and perinatal patients in an urban birthing center were invited to participate in this study. the rural birthing unit was located in a town of 33,000 people and served a large farming community involving five counties in the midwest. the urban birthing center was located in a metropolitan area of 89,000 on the east coast. staff nurses in both settings assisted with data collection by asking their assigned postpartum patients if they would like to participate in the study by completing the survey. patients were told that the surveys were anonymous; that they should not place their names on the survey, and that they had the right to refuse to participate. women who were not able to read and write in english were excluded from the study. women who had a current negative birth outcome were not asked to participate in this study out of respect for their grieving process. data were analyzed using descriptive statistics, simple frequencies, and correlations. narrative data were analyzed using content analysis. results forty-four participants agreed to participate in this study. there were 22 rural participants and 22 urban participants. the rural sample was obtained before the urban sample, although sample collection in both areas was simultaneous. the larger urban staff of nurses needed reminders to invite their patients to participate. it is unknown how many patients chose not to participate in the study. participants ranged in age from 16 to 39 years old. the mean age of the rural participants (28.8 years) was slightly higher than the mean age of the urban participants (26.6 years). more rural participants (81.8%) attended perinatal classes than urban participants (68.2%). half of the rural participants (50%) had just delivered their first baby (primipara) and 40.9% of the urban participants were primipara patients. the rural participants had more income than the urban participants. half of the rural participants (50%) had an income above $60,000 compared to roughly a fourth (27.2%) of the urban participants who had an income above $60,000. income less than $20,000 was reported by 13.6% of the rural participants and 22.7% of the urban participants. a slightly higher percentage of rural participants (54.5%) chose an ob/gyn provider for their perinatal care than urban participants (50%). nurse midwives were chosen by 13.6% of both the rural and urban participants (table 1). using a 0-10 likert scale, urban participants rated their stress higher than rural participants in every category with a few exceptions (table 2). urban participants rated stress over physical concerns for self, for baby, and for the labor and delivery process higher than rural participants. stress over physical concern for self and labor and delivery were rated higher for primipara participants in both urban and rural areas than for multipara participants in each respective area. urban primipara and multipara participants reported a mean rating regarding stress for their physical wellbeing as 7.3 and 4.4, respectively. in comparison, rural primipara online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 73 table 1. demographics of perinatal participants mean age job status income provider prenatal classes urban 26.6 part time: 18.2% full time: 81.8% $0-20,000: 22.7% $20,000-40,000: 13.6% $40,000-60,000: 36.4% $60,000-80,000: 13.6% $80,000-100,000:13.6% ob/gyn 50% family md 36.4% nurse midwife-13.6% yes: 68.2% no: 31.8% rural 28.8 part time: 31.8% full time: 68.2% $0-20,000: 13.6% $20,000-40,000: 13.6% $40,000-60,000: 22.7% $60,000-80,000: 31.8% $80,000-100,000:18.2% ob/gyn 54.5% family md 31.8% nurse midwife-13.6% yes-81.8% no-18.2% and multipara participants reported a mean rating of stress regarding their physical wellbeing as 3.7 and 1.4, respectively. urban primipara and multipara participants reported a mean rating of stress regarding labor and delivery as 8.8 and 7.2, respectively. rural primipara and multipara participants reported a mean rating of stress regarding labor and delivery as 8.1 and 3.5, respectively. stress regarding the wellbeing of the baby was rated higher for urban primipara and multipara participants (at 8.0 and 8.5, respectively) than for rural primipara and multipara participants (6.9 and 6.4, respectively.) rural primipara participants demonstrated more perceived slightly more stress concerning their providers (1.7) than urban primipara participants (0.2). rural multipara participants rated their stress concerning finances on the average of 2.4, while urban multipara participants rated their stress regarding finances 1.8. transportation was perceived to be slightly more stress producing for rural participants (1.0) than for urban participants (0.5). the data showed that transportation stress was higher for multipara participants than for primipara table 2. mean score for perceived stress among urban and rural participants on a 0-10 likert scale response (10=extreme stress). rural primipara rural multipara urban primipara urban multipara overall stress 7.7 4.5 8.9 8.0 stress over self physical concerns 3.7 1.4 7.3 4.4 stress over labor and delivery 8.1 3.5 8.8 7.2 stress over baby’s wellbeing 6.9 6.4 8.0 8.5 stress over provider 1.7 1.0 0.2 1.1 financial stress 1.7 2.4 3.6 1.8 transportation stress 0.3 1.7 0.1 0.8 employment stress 0.1 1.3 2.1 1.1 stress over support 1.6 0.3 3.2 0.9 online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 74 participants in both areas. primipara rural participants rated their transportation stress on the average of 0.3 while rural multipara participants rated their transportation stress as 1.7, compared to their urban counterparts who rated this stress as 0.1 and 0.8, respectively. stress related to employment was rated lower by rural primipara participants (0.1) than by urban primipara participants (2.1). rural multipara participants indicated slightly more stress regarding employment (1.3) than their urban counterparts (1.1). stress regarding their support system was rated higher for primipara and multipara urban participants (3.2 and 0.9, respectively) compared to primipara and multipara rural participants (1.6 and 0.3 respectively). the mean score for overall stress was highest for urban primipara participants (8.9), followed by urban multipara participants (8.0); than rural primipara participants (7.7), and rural multipara participants (4.5). of the urban primipara participants, 100% rated their overall stress greater than or equal to 7 while 72.7 % of the rural primipara participants rated their overall stress greater than or equal to 7. of the urban multipara participants, 84.6% rated their overall stress greater than or equal to 7. in comparison, only 27.2% of the rural multipara participants rated their overall stress greater than or equal to 7 (table 3). using an alpha of .05 to determine significant pearson correlations, findings indicated that overall stress was associated with labor and delivery concerns for both rural (.797) and urban (.573) participants. overall stress was associated with physical concerns for baby among rural participants (.639) but this association was not demonstrated by the pearson correlation for urban participants (.118). however, labor and delivery stress was associated with stress over the physical wellbeing of the baby for both rural (.560) and urban (.635) participants. there was a greater correlation between labor and delivery stress and stress regarding maternal physical wellbeing for urban participants (.712) than for rural participants (.416). stress regarding transportation was associated with stress over providers for urban participants (.600). there was not a significant association found between transportation stress and provider stress among rural participants (.368) (table 4). there was a positive correlation between stress regarding support concerns and financial stress among urban participants (.846). there was not a significant relationship found between stress over support concerns and financial stress among rural participants (.186). a significant negative correlation was found between stress regarding one’s support system and stress over the physical well being of the baby among urban participants (-.565). this correlation was not significant among rural participants (-.167). stress regarding concern over one’s own wellbeing was significantly associated with geographical area (.511) (table 4). overall, 91% of multiparous rural participants and 92.3% of multiparous urban participants reported that they experienced a different kind of stress with their current pregnancy than with a prior pregnancy. narrative data indicated that stress perceived by multiparous table 3. percent of participants in each category who rated their overall stress on a 0-10 likert scale (10= extreme stress). rural primipara rural multipara urban primipara urban multipara rated overall stress 0-3 9.1% 45.5% 0% 7.7% rated overall stress 4-6 18.2% 27.3% 0% 7.7% rated overall stress 7-10 72.8% 27.3% 100% 84.6% online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 75 table 4. significant associations using pearson’s bivariate correlation of stress factors among rural and urban participants. significance determined using .05 alpha. rural participants pearson r urban participants pearson r overall stress associated with stress regarding labor and delivery concerns .797 .573 overall stress associated with stress regarding baby’s wellbeing .639 not significant stress regarding baby’s wellbeing associated with stress regarding labor and delivery concerns .560 .635 stress regarding self wellbeing associated with stress regarding labor and delivery concerns .416 .712 stress regarding provider associated with stress regarding transportation not significant .600 stress regarding support associated with stress regarding finances not significant .846 stress regarding support associated with stress regarding baby’s wellbeing. not significant .565 participants in both rural and urban areas was greater for their current pregnancy than a previous pregnancy due to complications the participants experienced with a prior pregnancy. for example, one participant stated “i’m worried about having another preemie.” another commented, “i’m worried about pain medications because the epidural made me sick last time.” several multiparous participants commented that the fact that they were adding another child to their household increased their stress. the narrative data indicated that both urban women and rural women felt their overall stress could have been decreased if certain interventions by health care providers took place. both urban and rural women voiced that having a nurse explain procedures and remain more present and encouraging during the labor and delivery process, would have reduced stress. numerous participants wrote about how the lack of explanations by the nurse added to their stress as evidenced by the following quotes. “i thought something was wrong. if i had known about being on monitors the whole time it would have helped”; and “i really wish someone would have really taken the time to sit down with me and answer all my questions…. i had no idea what to expect or anything.” participants explained that the nurse could have an impact on creating a calm and supportive environment thereby easing stress as evidenced by the following quotes. “the room was so loud and chaotic; the nurse could have created a quieter environment”; “if only my nurse had been a little supportive”; and “if only my nurse had been more caring”. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 76 discussion participants in the urban area perceived greater overall stress than participants in the rural area. one possible explanation for the higher stress rate in the urban setting might be that some urban participants may have been referred to the urban setting for a high acuity pregnancy. the fact that there was a significant association noted between perceived stress over one’s physical wellbeing and area, with the highest perceived stress regarding maternal physical wellbeing demonstrated in the urban area, lends support to the postulation that the urban participants may have had higher perinatal acuity. unfortunately, acuity was not measured in this study. it is also possible that the noted inequity of perceived stress may be due to the fact that the rural sample represented a wealthier group than the urban sample. in addition to the fact that the urban sample reported an overall lower income than the rural sample, the cost of living is roughly 11% higher on the east coast than in the rural midwest (cost of living calculator, 2010). therefore, a limitation of this study is that there was an economic disparity between the rural and urban sample that may have played a role in the increased overall stress of the urban sample. although the finding of greater stress in the urban sample in comparison to stress noted in the rural sample may be in part due to a higher acuity of patients with less financial resources, the stress differences could also be due to area cultural differences regarding social support. anecdotal data indicates that there is a strong sense of community and close family ties in the rural area. bushy (2000) contended that there is a sense of social connectedness in the rural area. people are considered to be neighbors, even though they live miles apart. this sense of community creates a network of support that may result in reduction of perceived stress. one of the most important findings was that rural participants attended prenatal classes more than urban participants which may have contributed to the higher overall stress level of the urban group. prenatal education is designed to address a knowledge deficit about labor and delivery and breastfeeding, thereby reducing fear and anxiety (lu, et al., 2003; march of dimes birth defects foundation, 2009). segeel and du plessis (2006) argued that education about the birthing process enhances coping skills by reducing fear of the unknown. in a meta-analysis of the literature, beddoe and lee (2008) found that strategies to enhance relaxation, improve selfunderstanding and self-efficacy, and advance education about the birthing process were best done in a group. nierop et al. (2008) contended that psychosocial support is important in buffering stress for pregnant women. prenatal classes present an opportunity for pregnant women to develop peer support among each other while acquiring perinatal knowledge and relaxation skills. one possible explanation for the discrepancy between rural and urban prenatal class participation could be that prenatal class attendance continues to be valued by the rural culture, but has waning importance in the urban setting. morton and hsu (2007) noted that prenatal class attendance has been declining. using an ethnographic study design involving 11 prenatal classes, these researchers found that attendance in childbirth education was a cultural issue and that the classes offered needed to be sensitive to the culture in which they were presented. these researchers found that participants in what they referred to as a “spa culture” (p. 28) were exposed to relaxation techniques through other sources such as yoga and pilates, and therefore did not need to learn relaxation techniques through prenatal classes. the finding that rural participants had an 81.8% participation rate in prenatal classes, suggests that prenatal classes in the rural area still present content that is valued by the rural online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 77 constituency. this finding is noteworthy. although morton and hsu (2007) found a downward trend in childbirth education class attendance in the urban setting, no studies have explored the attendance of prenatal class education in the rural area. unfortunately, morton and hsu’s postulation that the “spa culture” of today have other resources that replace prenatal education, has resulted in the downsizing of prenatal classes in both urban and rural hospitals by some governing health care systems. this downsizing of prenatal classes inherently gives the curriculum an uban focus that lacks sensitivity to the rural area. due to the lack of public transportation in the rural area as well as the significant distance represented by a five county area, it was anticipated that stress over transportation concerns would be an identified stressor in the rural area. however, this was not the case. both rural and urban participants rated their concern over transportation low. primiparous participants in both areas rated their stress over transportation lower than multiparous participants in both areas. this finding may reflect the added stress a pregnant woman has of transporting her other children to a place where they will be cared for while she is hospitalized for labor and delivery. given that this study took place in the summer, rural ratings about transportation stress may have been higher if the study took place in the winter when inclement weather could have been a factor. an interesting finding was that both rural and urban participants had access to the same scope of perinatal providers. approximately half of each group chose ob/gyn specialists over family practice or midwives. this finding may reflect the explosion of specialty physicians in the united states and possibly the growing need for family practice physicians (miller, 2009). the narrative responses in this study did not address how nurses and other health care professionals could reduce pregnancy specific stress during their pregnancy. all of the narrative responses for ways nurses could help reduce their stress pertained to the stress they perceived in labor and delivery. these responses provided a strong universal message from both rural and urban participants that nurses could be key in reducing perinatal stress by being more “present” at the bedside. this finding lends support to research that upholds the importance of nursing presence in birthing suites as a means of reducing perinatal complications (gagnon, waghorn, & covell, 2008) and preventing postpartum mood disorders (goldbort, 2006; halldorsdottir and karlsdottir, 1996; & oweis, 2001).) halldorsdottir and karlsdottir (1996) found that the patients perceived a lack of nursing’s caring presence; the patient’s perceived lack of connection to the nurse; and the patient’s perception of lack of control associated with not knowing what was happening and why, were contributing factors to postpartum mood disorders. the participants’ perception of nursing’s lack of presence at the bedside is of concern and only speculation can provide possible explanations for their perceptions. perhaps nurses assume that they are not needed if a patient is physically comfortable due to the help of today’s effective pain relief interventions. perhaps more patient monitoring is happening from the nurses’ station in front of banks of monitors transmitting fetal heart tracings. perhaps staffing for nursing’s caring and connected presence at the bedside is not considered cost effective by administrations. perhaps nursing time spent with the electronic medical record has compromised time spent with the patient at the bedside. perhaps there are complications due to obstetrical unit census in staffing qualified perinatal nurses in the rural area (zust & briggs, 2006). more research is needed to explore these conjectures and to further establish the need for nurse-patient relationships that convey a caring and empowering presence (halldorsdottir & karlsdottir, 1996; koloroutis, 2004). the convenience sample and the small number of participants are important limitations to this study. the small sample limits the power of this study, rendering the results inconclusive. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 78 however, the findings strongly suggest the rural area has different needs than the urban area concerning prenatal classes and that there is a need for developing nurse-led prenatal classes that are culturally sensitive according to geographic area. the study also lends support for performing a larger, randomized study to explore perinatal stress specific to geographical, sociocultural factors. references beddoe, a.e., & lee, k.a. 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(2006). labor induction practices in a rural, midwestern hospital. online journal of rural nursing and healthcare, 6(2), 29-39. retrieved may 10, 2009, from http://www.rno.org/journal/index.php/online-journal/article/viewfile/3/170 http://www.ncbi.nlm.nih.gov/pubmed?term=18823187%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=12870624%5buid%5d&cmd=detailssearch http://www.marchofdimes.com/printablearticles/681_1158.asp http://www.examiner.com/x-4380-healthcare-reform-examiner%7ey2009m10d5-the-crisis-in-family-practice-doctors http://www.examiner.com/x-4380-healthcare-reform-examiner%7ey2009m10d5-the-crisis-in-family-practice-doctors http://www.ncbi.nlm.nih.gov/pubmed?term=18769518%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=18462859%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=17636150%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=11069878%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15811496%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=18423592%5buid%5d&cmd=detailssearch http://www.rno.org/journal/index.php/online-journal/article/viewfile/3/170 4     editorial spiritual needs: focus on forgiveness linda l. dunn, dsn, rn, cnl editorial board member every time i turn on a newscast or pick up my morning paper, i learn of more heartache caused by hurting people who so selfishly hurt others. in her book, hurt people hurt people, wilson (1993) describes the root of hurting others: unforgiveness. in recent editorials, i have tried to convey that we all have spiritual needs, one of which is forgiveness. every human being needs to give and receive forgiveness from self, others, and the sacred (carson & koenig, 2008). in an effort to better understand the process of forgiveness, i have found it helpful to consider what forgiveness is and isn’t. forgiveness is not pardoning, excusing, condoning, forgetting, or even reconciling. forgiveness is letting go rather than seeking revenge. forgiving is freeing up your energy in order to move on with life. healing enables us to discover renewed meaning and purpose through our experiences. i think a great example is to think about walking outside barefooted on a warm summer’s day when suddenly you step on a thorn…ouch!! what happens if you keep walking? the more you walk, the more if hurts. if the thorn is not removed, your foot will become infected – could even become so badly infected that amputation would become necessary. what should have been done initially? by all means, stop and remove the thorn. the pierced site may bleed or remain sore for a brief time, but it will heal without the adverse effects that result from failure to remove the thorn. therefore, when pierced by “thorns” (hurt from others), stop and begin the healing process. without “removing the thorn” (forgiveness), anger, resentment, bitterness, and depression (infection) will result. these results will rob us of our peace and joy; our body, mind and spirit will suffer. as nurses, we must be holistically well in order to minister to those placed in our care. how can we be instruments of healing if we have not addressed the hurt in our own lives through the process of forgiveness? “forgiveness is the scent that the rose leaves on the heel that crushes it.” anonymous 5   references carson, v.b., & koenig, h.g, (2008). spiritual dimensions of nursing practice. west conshohocken, pa: templeton press. wilson, s.d. (1993). hurt people hurt people. nashville: thomas wilson. swan_533 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 189 querying rural content experts using an online questionnaire marilyn a swan, phd 1 barbara b. hobbs, phd, rn 2 1 assistant professor, school of nursing, minnesota state university, mankato, marilyn.swan@mnsu.edu 2 associate professor and assistant dean, college of nursing, south dakota state university, barbara.hobbs@sdstate.edu abstract purpose: obtaining feedback from rural content experts is critical in developing valid and reliable instruments to advance the science of rural health. however, traditional methods, i.e., focus groups are impractical due to location and distance. using an online questionnaire combined with telephone and email contacts to obtain content experts’ feedback is discussed. item statement analysis and efficiency and effectiveness of the process are presented. methods: the process included the development of an online questionnaire, asking experts to rate 51 item statement for their relevancy, sufficiency of description, and clarity and readability. to increase the response rate, a series of four contacts (one telephone and three email) were planned and implemented. an item content validity index (i-cvi) was calculated for all items. results: distribution of the online questionnaire to rural content experts separated by geographic distance was efficient and effective in gathering feedback on item statements for content online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 190 validity. content experts completed the questionnaire in less than one hour suggesting the overall efficiency of the process; an 84% response rate supports process effectiveness. following i-cvi evaluation, item statements were reduced from 51 to 24. the analysis resulted in retaining, with or without revision, 47% of the item statements. conclusions: the online questionnaire and four-contact strategy were effective in gathering input from a representative sample of rural content experts separated by great distances; thereby, strengthening the content validity of the item statements. the process demonstrates new opportunities for using online technologies to reach rural content experts. keywords: content validity, rural, content experts, instrument development, lack of anonymity querying rural content experts using an online questionnaire feedback from rural experts who live in remote, sparsely populated areas is critical to developing valid and reliable instruments that advance the science of rural health. one challenge reported in the literature when conducting rural health studies is obtaining feedback from a representative sample (mccauley et al., 2006; prinz, kaiser, kaiser, & von essen, 2009). remoteness and rural isolation can be factors when seeking rural content expert’s participation and feedback on rural health issues and research (schlairet, 2017; williams, 2012). identifying and recruiting content experts was necessary as a key component during new instrument development for the rural health concept lack of anonymity. a frequently used method to gather content experts’ input is a focus group; experts can interact and share their knowledge and perspectives on a topic (carter, bryant-lukosius, dicenso, blythe, & neville, 2014). however, the use of focus groups is not practical for gathering feedback from rural experts separated by vast geographic distance. multiple disciplines report using online questionnaires with rural populations for collecting data (dillman, smyth, & christian, 2014; online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 191 smyth, dillman, christian, & o’neill, 2010). although there are no reports of online questionnaires being used to reach content experts, challenges and barriers to using online questionnaires with rural populations have been identified, e.g., lack of internet access, and sampling methodology. additionally, there is an ethical concern related to the importance of establishing a relationship with an individual before sending an online questionnaire (smyth et al., 2010). the lack of a previously established strategy for reaching rural experts resulted in exploring technological options for constructing an efficient and effective process for gathering rural content expert feedback. this paper discusses the development and implementation of a process, using an online questionnaire, to gather rural content expert feedback on item statements for use in a measure on lack of anonymity. the online questionnaire was also used to establish content validity. to strengthen the response rate, a series of four contacts (one by telephone and three by email) were planned (dillman, smyth, & christian, 2009). the effectiveness and efficiency of both the online content expert questionnaire and the contact plan are discussed. the actual instrument items, scoring, pilot testing, and psychometrics are not presented in this article. background rural nursing theory recognizes lack of anonymity as a component of living in rural areas; within the theory, rural is defined as “living in sparsely populated areas” (long & weinert, 2018, p. 1). therefore, for this project, rural was defined as u.s. counties with a population of less than 10,000 (health resources and services administration, 2014). a clear understanding of the concept and establishment of content validity are essential to instrument development (grant & davis, 1997; norbeck, 1985). concept analysis is frequently used to define concept attributes and to determine empirical referents, how the concept is online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 192 experienced in everyday life (walker & avant, 2011). analysis of the concept informs the development of potential item statements that fully represent the concept the researcher is investigating (grant & davis, 1997; lynn, 1986). prior to this project, a concept analysis of lack of anonymity was completed and 51 item statements were generated (lynn, 1986; swan & hobbs, 2017). the next step in the initial instrument development process was to establish content validity (lynn, 1986). establishing content validity ensures that the instrument includes items that accurately represent the intended concept and are relevant to the content domain (houser, 2008; waltz, strickland, & lenz, 2017). an approach to validate content is by asking others, who have experience or knowledge with the concept, for their feedback (lynn, 1986; streiner & kottner, 2014). as such, content expert input and analysis of the individual item statements is essential to establish content validity during instrument development (fehring, 1987; lynn, 1986). the scoring by experts of each item statement relevance is needed to calculate a content validity index (i-cvi) for that item. once the item statements have been analyzed and validated based on the expert feedback, the item statements can be used in the instrument for data collection. method the first step in developing the online questionnaire was to gain a solid working knowledge of the software, qualtricstm. advanced tutorials within the questionnaire software were viewed to learn how to maximize the software capabilities. knowledge acquisition on the questionnaire software was iterative; tutorials were repeatedly viewed to enhance learning that was then applied to designing the questionnaire. a major design consideration was to limit the burden on the rural expert, who would need to review 51 item statements along with related questions. the questionnaire needed to be easy to use and function efficiently to help compensate for the length. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 193 however, the first attempt at designing the questionnaire did not meet these criteria; the layout and appearance of the questionnaire was difficult for users to navigate and it lacked question logic. in the second design, an item structure was developed that incorporated question logic as outlined in figure 1. figure 1. item statement structure for the online questionnaire question logic allows questions to be displayed based on the expert’s answer to the previous question. using the question logic in figure 1, all 51 item statements were listed as individual questions and rated using a four-point likert-type scale, ranging from 4, highly relevant, to 1, not relevant, to evaluate relevancy and adequacy of the statement description (waltz, strickland, lenz, & soeken, 2010). items answered as highly relevant and quite relevant presented the expert with the next question about the item. items answered as somewhat relevant or not relevant advanced to the next item statement to be evaluated. the application of question logic had the potential to reduce the overall number of questions each expert would need to answer. for clarity and readability, experts were asked if the item statement was clear and readable; rating options of yes, no, or yes, but requires revision were used. following the yes, but requires revision option, a text box allowed experts to enter suggested item statement revisions. similar to the qualitative nature online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 194 of focus groups or meetings, the multiple opportunities for written feedback captured the expert’s thoughts on each item statement. at the end of the questionnaire, content experts were asked if the item statements they identified as highly and quite relevant, comprehensively describe the concept of lack of anonymity. this final question was followed by an opportunity for the content experts to share any additional feedback, thoughts, or revisions in a text field. using the process described above, experts could answer as few as 51 or as many as 153 questions. to address the potential time burden, the software allowed experts to enter and exit the questionnaire as needed, saving their answers before exiting. this strategy ensured that data were not lost and reduced expert burden in completing a lengthy questionnaire. questionnaire development following the development of the online questionnaire, a small feasibility test was conducted on the questionnaire and email instructions to ensure that the online questionnaire was efficient and ready for expert use. two colleagues with a background in higher education were asked to complete the questionnaire. each tester brought a different perspective--one as a nurse educator with rural health expertise and the other as a library and information technology expert to inform the questionnaire development process. the testers were asked to review and use the email instructions and provide feedback on the usability of the directions and, online questionnaire, issues they encountered, and the time it took to complete the questionnaire. the testers reported that the online questionnaire functioned as designed and could be completed in approximately one hour. both testers reported that, due to the questionnaire length, they felt lost at times. they felt that having more information about the findings from the concept analysis would have helped them navigate the questionnaire. based on these comments, two documents were sent as email attachments to the content experts: findings from the concept online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 195 analysis, and a list of the 51 item statements. the testers concluded that access to the supporting information, before entering the online questionnaire, would allow for a more comprehensive review of each item statement by the experts. sample and setting rural health experts were identified as best equipped to provide feedback on the rural health concept of lack of anonymity. seventeen rural health and nursing experts from the united states and canada were selected based on recognition as leaders in rural health care, research, or theory. following a review by the south dakota state university internal review board, the project was considered exempt from human subject review and the rural content experts were contacted. recruitment a series of four contacts was used to approach the content experts. the first contact was made by telephone with the principle investigator using a written script to introduce herself and explain the purpose for the expert review. an introduction was necessary as many of the experts were not personally known to the investigators. experts were provided an overview of the online questionnaire, data collection process and timeline, and time commitment. they were subsequently asked if they would be willing to participate. experts who verbally indicated willingness to participate confirmed preferred email address and were told that future communication would occur by email. contacting the experts by telephone provided time to establish a relationship with the experts, served as pre-notice to receiving the online questionnaire, and provided transparency about the time commitment required to participate in the content validity process (dillman et al., 2009). the initial telephone contact was anticipated to last for 15 to 20 minutes. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 196 following the initial telephone call, the second contact (1st email) was an introductory email. a total of three email contacts were made, seven days apart, over the course of three weeks (dillman et al., 2009). consent was implied by questionnaire completion. once an expert completed the online questionnaire, no further emails were sent, and participation was complete. each email contained appreciation and recognition to the content experts about the value of their feedback, and a thank you was sent when the questionnaire was completed. content experts received information regarding the project and questionnaire completion, the defining attributes and empirical referents from the concept analysis, and a link to the online questionnaire. additionally, a document containing the 51 item statements was sent as an email attachment. to ensure consistency of the instructions and information, the content provided by email was the same information as given during the initial telephone contact. emailing consistent information connected the initial telephone call to the online questionnaire, and in turn, promote response (dillman et al., 2009). the third contact (2nd email) served as a reminder about completing the questionnaire and the importance of their feedback. last, the fourth and final contact (3rd email) re-introduced and provided the same information that was sent in the second contact (1st email). the online questionnaire remained open for seven days after the final email. in total, the online questionnaire remained open for data collection for four weeks. results seventeen rural health and nursing experts were initially contacted by telephone and asked to participate in an online process for gathering expert feedback for instrument development. thirteen rural experts agreed to participate as content experts and received the series of three email contacts; the rural experts lived as close as 25 miles to the principle investigator and as far away online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 197 as 1500 miles. at the completion of the series of email contacts, 11 of 13, or 84% of the content experts, completed the online questionnaire. following the initial telephone contact, three email contacts were made over the course of four weeks. one rural expert responded after the 1st email (second contact); 8 responded following the 2nd email (third contact); and, 2 experts responded after the 3rd email (fourth and final contact). effectiveness and efficiency of the process the questionnaire data were downloaded from the software server into a spreadsheet for initial review. all responses were de-identified. analysis required that expert responses to individual item statements be collated for comprehensive review and refinement. additionally, each item was reviewed independently for relevancy, adequacy of description, clarity and readability. the item content validity index was calculated to determine retention, revision, or removal of item statements. the response rate (84%) exceeded the average online response rate of 33% reported by nulty (2008) in a review of face-to-face compared to online survey response rates. furthermore, the 84% response rate is comparable, or exceeds, a face-to-face survey method. response rate is an indirect indicator of the quality of the questionnaire (dillman et al., 2014). additionally, 100% of the participating content experts completed the total questionnaire. no financial incentive was provided to experts for participating. the possible lack of internet access was not a concern for this population, as the rural experts would have internet access through employers, such as a government or educational institution. the total number of questions that each content expert could have answered ranged from 51 to 153. the actual number of questions answered by the content experts ranged from 81 to 153 (m = 126), with only one content expert answering all the questions. nine of the 11 content experts online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 198 (82%) suggested item statement revisions; ten of the 11 content experts (91%) provided written feedback at the end of the questionnaire. the time from when the online questionnaire was entered in the qualtricstm software until the expert exited the questionnaire ranged from 12 minutes to two-hours and 22 minutes. the mean time to complete the online questionnaire was 47 minutes. the software allowed the experts to enter and exit the questionnaire; however, no data were obtained to determine if the experts entered the questionnaire more than once. one expert’s time was not considered in this calculation, as the time exceeded 31 hours, indicating that the link was left open, making it impossible to determine the actual questionnaire completion time. content validity index experts rated the relevancy of each item statement as highly relevant, quite relevant, somewhat relevant, or not relevant using a four-point likert-type scale. an item content validity index (i-cvi) score was calculated based on the relevancy of the item statements. the i-cvi number represents the proportion of experts who agreed with the relevance of the item statement and is calculated by dividing the number of experts who found the item statement to be highly or quite relevant by the total number of content experts (polit & beck, 2012). a value of one indicates complete agreement among the experts (waltz et al., 2010). for rigor in developing a new instrument, an item statement rating of 0.8 or higher is considered acceptable (dillman et al., 2009; polit & beck, 2012; waltz et al., 2010). to help track the 51 item statements, each item statement was assigned a number that was used throughout the analysis. a spreadsheet was developed that listed each item statement by defining attribute and empirical referent and included: the number of experts who rated the item statement as highly and quite relevant; the i-cvi score; a summary of the written comments from the content experts for each item; and, a section for investigator notes and rationale for the online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 199 disposition of an item statement. the spreadsheet document was used to track the overall analysis, however, each round of analysis was recorded and saved in a separate document. saving a document that represented each stage of the analysis ensured that data were not lost and that item statement decisions throughout the analysis process were captured. the i-cvi number was calculated for each of the item statements. the i-cvi numbers ranged from 0.36 to 1; an i-cvi score of 0.8 or higher was considered acceptable. seventeen item statements (33%) had ratings below 0.7 and were deleted. a number of item statements fell just below the acceptable score or 0.8, with an i-cvi score of 0.7 to 0.79 (n = 11; 22%). a total of 23 item statements had an i-cvi score of 0.8 or higher (45%). item statements with an i-cvi score of 0.7 or higher were evaluated further to determine if they should be retained, revised, or deleted. evaluation of item statements following the calculation and interpretation of the i-cvi scores, individual and collective content expert written responses for each item statement were evaluated. also included in the evaluation was a review of the sufficiency of the description, clarity, and readability scores for the item statements from the online questionnaire. the data were analyzed to refine each item statement and to ensure that each item supported the content domain (grant & davis, 1997). for example, expert feedback indicated that one item statement lacked a conceptual link to lack of anonymity, and the item statement was deleted. similarly, expert feedback informed item statement revisions to ensure clarity and proper wording. discrepancies or inconsistencies in content expert feedback were discussed between the investigators, and taken into consideration when making decisions to revise, delete, or retain an item statement. through this interpretive process, the item statements were refined. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 200 item statements with an i-cvi of .8 or higher accounted for 45% of the 51 item statements; the majority (13) of which did not require revision. the evaluation of the remaining 10 item statements with an i-cvi score of .8 or higher resulted in deletion of three item statements with wording and meaning similar to other item statements; the remaining seven item statements were revised. the evaluation of the 11 item statements with an i-cvi score of 0.7 to 0.79 resulted in seven item statements being deleted; four item statements were revised and retained. see table 1 for the complete listing and disposition of the items. table 1. breakdown of items by i-cvi score disposition of item statements i-cvi score # of items % of items no revision revised deleted ≥ .8 23 45 13 7 3 .7-.79 11 22 0 4 7 < .7 17 33 0 0 17 total 51 100 13 11 27 note. n = 51 of the original 51 item statements, 24 (47%) were retained. of the remaining 24 item statements, 13 (55%) required no revision and, 11 (45%) were revised. at the completion of the analysis, the 24 item statements were used in the development of the lack of anonymity instrument (loan-24). at the end of the questionnaire, content experts were asked if the items they rated as highly and quite relevant adequately describe the concept of lack of anonymity. ten of the 11 content experts (91%) agreed that the item statements comprehensively described the concept. for online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 201 example, one expert shared, “i think you have captured the true essence of the concept.” this feedback supported that the content domain was sufficiently covered in the items. before exiting the questionnaire, experts were asked to share any additional feedback, thoughts, or revisions; ten experts (91%) provided written feedback. the written feedback was used to ensure full conceptualization of lack of anonymity in the item statements. discussion the intent of this paper was to discuss a process used to contact rural content experts and the development and use of an online questionnaire to gather feedback on item statements for a new measure. the development of valid and reliable measures on rural health concepts requires feedback from rural experts who live in remote, sparsely populated areas. item statements were evaluated using an i-cvi score. polit and beck (2006, p. 496) suggest that excellent content validity results from a solid understanding of the concept, good item statements, carefully selected content experts, and clear instructions that enable experts to engage in thoughtful rating. effectiveness and efficiency the series of four contacts was effective in achieving an 84% questionnaire response rate. use of a pre-notice telephone call as a first contact to prospective content experts supports the importance of social interaction and personal connection in questionnaire response (dillman et al., 2009). the personal connection made during the pre-notice telephone call between the principle investigator and each content expert may have provided incentive for experts to complete the questionnaire. the significance of the initial telephone call on prompting response increases when considering that most of the rural content experts contacted were not known to the investigators. evidence of the personal connection was revealed in content expert comments, including “i appreciate being asked for my input.”, “thank you for allowing me to comment on the item online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 202 statements.”, and “i will be happy to provide any explanations or discuss my comments for clarification. this will be an interesting and relevant study.” another benefit of the pre-notice telephone call was that the email contacts sent to the content experts were expected. each expert had the option to delete the email or to review and complete the questionnaire. again, the high response rate indicates the importance of making a personal connection before sending out an online questionnaire. questionnaire ethics requires that a relationship be established before sending out an online questionnaire; however, receiving email questionnaires without knowing the investigators is not an uncommon practice (smyth et al., 2010). the process of placing ‘cold’ telephone calls to experts was daunting, but is an ethically sound process (dillman et al., 2009; smyth et al., 2010). the content validity process discussed supports the use of a pre-notice telephone contact and demonstrates the importance of making a personal connection with experts. the use of question logic, within the questionnaire, reduced the overall number of questions each expert needed to answer, suggesting experts moved efficiently through the questionnaire. efficiency was further indicated by the average time experts were in the questionnaire, which was less than the anticipated 60 minutes determined from the feasibility testing (m = 47 minutes). a majority of the questionnaires were completed over a four-day period following the second email contact. it is not known if experts may have used the time after the first email contact to review the attached conceptual information and item statements. thus, attaching informative documents to the email contact may support questionnaire completion and time efficiency. based on this information, the online questionnaire appeared to be an effective tool in reducing content experts’ time. efficiency of time was a key consideration during the development process. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 203 the use of a well-planned online questionnaire was an effective and efficient process to obtaining rural expert feedback. additionally, the online questionnaire was a practical strategy to overcome the issue of accessing content experts in remote areas. content validity the multiple opportunities to provide written feedback allowed the questionnaire to function similarly to a face-to-face focus group; rural experts could provide direct feedback about the concept and item statements to the investigators. the high response rate (91%) for written feedback suggests that online questionnaires should be designed to provide multiple opportunities for content experts to write feedback. revision of the item statements was supported by the rich, insightful feedback from the rural experts. the amount, and quality, of the written feedback was extremely helpful in refining the item statements for the development of a new measure (lynn, 1986). the strong agreement among the experts that the item statements fully covered the domain of content, supports that lack of anonymity was fully conceptualized (grant & davis, 1997; waltz et al., 2017). in turn, this established the conceptual clarity of lack of anonymity for the newly developed instrument. making revisions without the feedback may have limited full conceptualization of lack of anonymity for instrument development. thus, it is possible to capture the knowledge and insight of content experts using an online questionnaire. this is an important finding for investigators who work with rural and remote populations, separated geographically by distance; a planned contact process and well-planned online questionnaire is an effective strategy to obtain detailed feedback from experts. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 204 the i-cvi score is a widely used measure for establishing content validity for specific items (polit & beck, 2006). in this process, the i-cvi score provided information on the relevance of each item statement that served as a basis for evaluation. deleting item statements with a low icvi score, rather than trying to revise and keep them in some way, ensured the relevancy and conceptualization of lack of anonymity was preserved. similarly, grouping the item statements by i-cvi score and reviewing item statements that fell just below the established benchmark of 0.8 provided opportunity to incorporate meaningful expert feedback to refine the item statements. at the outset, the investigators anticipated the content validity process would reduce the number of item statements. in the end, the item statements were reduced by 47%; from 51 potential item statements to a manageable number of 24. the 24 item statements were incorporated into the lack of anonymity measure (loan-24) and prepared for further testing. further testing will include calculating a scale-level content validity index (s-cvi) using two raters to establish content validity for the overall scale, or measure (polit & beck, 2006). importance of planning developing a process to access rural experts, and creating an online questionnaire required a substantial time commitment for the investigators. time spent at the beginning of the project, including planning, developing, and testing the online questionnaire, reduced the burden and time for the content experts. essential to the success of this process was learning the capabilities of the questionnaire software to promote a high expert response rate. learning the questionnaire software took time, as did creating a questionnaire with 153 questions, but the knowledge is transferrable for future use. further, testing the questionnaire prior to sending it to the experts was key in understanding the information needed to complete the online questionnaire. implications for nursing online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 205 given the speed and advances in technology communication, we assert that our process successfully moves existing content expert processes into technology modalities. the success of this project supports the use of online questionnaires as a viable strategy to reach content experts in rural and remote areas. the process could be used in nursing research to support instrument development as a replacement to presence at traditional focus groups. a benefit of the online questionnaire is the ability to gather diverse feedback from individuals separate by geographic distance and time zones. as such, the process has many potential applications to capture individual feedback on issues in rural practice, research and health policy. the use of a series of four contacts demonstrated effectiveness in making a personal connection with rural experts, making the process a viable alternative when face-to-face focus groups are not practical. more research is needed on how to elicit rural content experts’ feedback using online questionnaires. additionally, prompting a response through personal connection to the investigator gathers input about issues affecting rural practice and health policy that may have been missed in more traditional methods. conclusion a series of four contacts, including the use of an online questionnaire, was successful in accessing rural content experts in remote areas across the united states and canada to establish content validity for a new instrument to measure lack of anonymity. developing processes that effectively and efficiently reach rural experts is necessary to ensure that rural expertise is accurately represented in rural research. the findings from this project suggest that a pre-notice telephone call and a well-planned online questionnaire can obtain feedback essential for content validity. finally, the findings suggest that an online questionnaire methodology may be a suitable replacement to focus groups that may be impractical in rural and remote locations. further, testing online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 206 of this approach is needed to demonstrate its generalizability, effectiveness, and efficiency in accessing rural experts when developing measures to improve rural health. references carter, n., bryant-lukosius, d., dicenso, a., blythe, j., & neville, a. j. (2014). the use of triangulation in qualitative research. oncology nursing forum, 41(5), 545-547. https://doi.org/10.1188/14.onf.545-547 dillman, d. a., smyth, j. d., & christian, l. m. (2009). internet, mail, and mixed-mode surveys: the tailored design method (3rd ed.). hoboken, nj: john wiley & sons, inc. dillman, d. a., smyth, j. d., & christian, l. m. (2014). internet, phone, mail, and mixed-mode surveys: the tailored design method (4th ed.). hoboken, nj: john wiley & sons, inc. fehring, r. j. (1987). methods to validate nursing diagnoses. heart & lung, 16(6), 625-629. grant, j. s., & davis, l. l. 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(2018). rural nursing: developing the theory base. in c. a. winters & h. j. lee (eds.), rural nursing: concepts, theory, and practice (5th ed.). new york, ny: springer publishing company, llc. https://doi.org/10.1891/9780826161710.0002 mccauley, l. a., anger, w. k., keifer, m., langley, r., robson, m. g., & rohlman, d. (2006). studying health outcomes in farmworker populations exposed to pesticides. environmental health perspectives, 114(6), 953-960. http://dx.doi.org/10.1289/ehp.8526 norbeck, j. s. (1985). what constitutes a publishable report of instrument development? nursing research, 34(6), 380-382. https://doi.org/10.1097/00006199-198511000-00022 nulty, d. d. (2008). the adequacy of response rates to online and paper surveys: what can be done? assessment & evaluation in higher education, 33(3), 301-314. http://dx.doi.org/10.1080/02602930701293231 polit, d. f., & beck, c. t. (2006). the content validity index: are you sure you know what's being reported? critique and recommendations. research in nursing & health, 29(5), 489-497. http://dx.doi.org/10.1002/nur.20147 polit, d. f., & beck, c. t. (2012). nursing research: generating and assessing evidence for nursing practice (9th ed.). philadelphia, pa: lippincott williams & wilkins. prinz, l., kaiser, m., kaiser, k. l., & von essen, s. g. (2009). rural agricultural workers and factors affecting research recruitment. online journal of rural nursing and health care, 9(1), 69. schlairet, m. (2017, july). complexity compression in rural nursing. online journal of rural nursing and health care, 17(2), 2-33. http://dx.doi.org/10.14574/ojrnhc.v17i2.445 smyth, j. d., dillman, d. a., christian, l. m., & o'neil, a. c. (2010). using the internet to survey small towns and communities: limitations and possibilities in the early 21st century. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.533 208 american behavioral scientist, 53(9), 1423-1448. http://dx.doi.org/10.1177/00027642103 61695 streiner, d. l., & kottner, l. (2014). recommendations for reporting the results of studies of instrument and scale development and testing. journal of advanced nursing, 70(9), 19701979. http://dx.doi.org/10.1111/jan.12402 swan, m. a., & hobbs, b. b. (2017). concept analysis: lack of anonymity. journal of advanced nursing, 73(5), 1075-1084. http://dx.doi.org/10.1111/jan.13236 walker, l. o., & avant, k. c. (2011). strategies for theory construction in nursing (5th ed.). columbus, oh: prentice hall. waltz, c. f., strickland, o. l., & lenz, e. r. (eds.). (2017). measurement in nursing and health research (5th ed.). new york, ny: springer publishing company. waltz, c. f., strickland, o. l., lenz, e. r., & soeken, k. l. (2010). validity of measures. in c. f. waltz, o. l. strickland, & e. r. lenz (eds.), measurements in nursing and health research (4th ed., pp. 163-201). new york, ny: springer publishing company. williams, m. a. (2012). rural professional isolation: an integrative review. online journal of rural nursing and health care, 12(2), 3. 580-article text-3572-1-6-20190416 online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.580 1 editorial where have all the rural hospitals gone? pamela stewart fahs, phd, rn, editor every time i hear about another rural hospital closure it brings to mind a pete seeger classic, thus i am asking where have all the rural hospitals gone? by spring of 2019, there were 104 rural hospital closures since 2010 (university of north carolina [unc], cecil g. sheps center for health services research, n.d.). the unc center keeps a running tab of closures reported on their website (https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/ ). this number is up from 85 closures less than a year ago. an analysis of rural hospital closures (u.s. government accountability office, 2018) showed a national marked increase in the loss of rural hospitals since 2013. the south had the highest number of closures and those states that did not expand medicaid accounted for 63% of the rural hospital closures (holmes, kaufman, & pink, 2017). the difference in closures between those states that expanded medicaid and non-medicaid expansion states reflect only a small difference in operating margins. rural hospitals in medicaid expansion states on average had a slight (~ 1%), yet positive financial picture. non-medicaid expansion states were more likely to report negative operating budgets for rural hospitals, with financial distress being one of the main reasons for closure (kaufman, reiter, pink, & holmes, 2016). one bright spot is that closure does not always mean complete absence of access to care. hospital closure in most reports means no longer offering acute inpatient services and rural hospitals are generally defined as having a rural urban commuting area (ruca) of 4 or higher on the scale of 10 code levels or being a critical access hospital. hospitals that have ceased inpatient acute care services yet offer some type of emergency care or have converted to a clinic online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.580 2 may be counted as closed. (holmes et al., 2017). what is not included in the list of closed hospitals are those that have significantly reduced their number of inpatient acute care beds although these remain classified as open, the situation does negatively affect the ability of rural patients to receive acute care without having to travel a further distance. in addition to the possible negative health care consequences from closed facilities for rural dwellers, rural hospitals are usually a major employer in their communities. one source (freeman, thompson, howard, randolph, & holmes, 2015) noted that there were over 2000 fulltime equivalent (fte) employees in rural hospitals in 2012-2013, with an average of 321 fte employees. this trend of closure and downsizing can have multiple negative outcomes including a decrease in the number of higher paying jobs in a rural community. references freeman, v.a., thompson, k., howard, h.a., randolph, r., & holmes g.m. (2015, march). the 21st century rural hospital: a chart book. retrieved from http://www.shepscenter.unc.edu/wpcontent/uploads/2015/02/21stcenturyruralhospitalschartbook.pdf holmes, g.m., kaufman, b.g., & pink, g.h. (2017). financial distress and closure of rural hospitals. rural health research gateway webinar. retrieved from https://www.ruralhealthresearch.org/assets/540-1584/9212017-financial-distress-closures-ofrural-hospitals-ppt.pdf kaufman, b.g., reiter, k.l., pink, g.h., & holmes, g.m. (2016). medicaid expansion affects rural and urban hospitals differently. health affairs, 35, 1665 1672. http://dx.doi.org/ 10.1377/hthaff.2016.0357 online journal of rural nursing and health care, 19(1) http://dx.doi.org/10.14574/ojrnhc.v19i1.580 3 university of north carolina, cecil g. sheps center for health services research (n.d.) 87 rural hospital closures: january 2010 – present. retrieved from http://www.shepscenter.unc.edu/ programs-projects/rural-health/rural-hospital-closures/ united states government accountability office (2018). report to congressional requesters: rural hospital closures. number and characteristics of affected hospitals and contributing factors. author: gao-18-634 retrieved from https://www.gao.gov/assets/700/694125.pdf summers_638_formatted online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 131 community characteristics and readmissions: hospitals in jeopardy michele summers, phd, rn-bc, fnp-c 1 serdar atav, phd 2 1 clinical associate professor, decker college of nursing and health sciences, binghamton university, msummers@binghamton.edu 2 professor, decker college of nursing and health sciences, binghamton university, atav@binghamton.edu abstract objective: the purpose was to identify community characteristics that contribute to reductions in readmission rates and reimbursement penalties for hospital systems in upstate new york. methods: hospitals in upstate ny were selected (n = 94). using an ex post facto design and the ecological model, community characteristics of hospital systems were analyzed and coded. independent t-tests, anova, and pearson correlation tests were conducted. results: characteristics correlated with reduced hospital readmission rates and reimbursement penalties included hospitals (1) with critical access status; (2) located in counties with a better county health rank; and (3) located in a primary care shortage area that utilized house calls. discussion: implications include supporting policies that increase access to services, improve formulas for reimbursement, and encourage innovation in care delivery models. future research efforts should focus on house calls in primary care shortage areas. keywords: readmission rates, ecological model, house calls, community health online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 132 community characteristics and readmissions: hospitals in jeopardy mandates of the patient protection and affordable care act (aca) require monitoring the quality of care received in hospitals by tracking readmissions. since the passing of this federal law, mandates allow for penalties in the form of reduced hospital reimbursement when medicare patients are readmitted within a 30-day period (jweinat, 2010; u.s. department of health and human services [usdhhs], 2010). nearly 75% of hospitals nationwide were penalized for poor readmission rates between july 2010 and june 2013, and in new york state (nys), 80% of hospitals lost revenue because of readmission rates. well after the rollout of the aca in 2016, nys did even worse with 93% of hospitals penalized by medicare (rau, 2014, 2017). nys ranked 2nd worst (49th) for healthcare costs, and worst (50th) in the nation for readmission rates. nys exceeded one billion dollars in direct costs for heart failure and pneumonia (new york state department of health [nysdoh], n.d. a; nysdoh, n.d. b; new york state health foundation, 2014). these reduced payments threaten hospital viability. rural hospitals have more vulnerability to closure due to reduced revenues. the hill-burton act of 1946 funded the construction of many hospitals in rural areas. within the past five decades many of these hospitals closed as a result of the u.s. congress prospective payment system for medicare, which capped payments to hospitals by a fixed amount based on diagnoses (wishner et al., 2016). in 1997, the clinton administration attempted to address the problem of hospital closures with the medicare rural hospital flexibility program, providing financial relief for rural hospitals with less than 25 beds. however, during the recession of 2008-2009, 42 rural hospitals across the country closed (wishner et al., 2016). more alarming was the closure of another 72 rural hospitals between 2010 and 2016, further jeopardizing patient access to care. most of those closures online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 133 occurred after the implementation of the aca (kaufman et al., 2016; wishner et al., 2016). hospitals are major employers and sources of income for numerous businesses; therefore, hospitals that are weak financially disrupt community well-being (american hospital association, 2017). reduced hospital revenue as a result of high readmission rates threatens nurse staffing. it is well documented that low nurse staffing is related to poor patient health and safety outcomes (agency for healthcare research and quality, 2004; american nurses association, 2014). high readmission rates contribute to a vicious cycle of poor staffing, poor quality of care, and lower reimbursement. since nurses constitute the largest sector of the health care workforce and are responsible for the majority of care given in hospitals (american association of colleges of nursing, 2019), a reduction in this human resource by hospital organizations has not only quality of care implications but economic as well. it is within the scope of nursing practice and shared governance to develop and implement evidence-based solutions that can yield cost savings and improve health outcomes (lundmark, 2008). rationale in response to the mandates of the aca, hospitals across the country have created initiatives to enhance their quality of care to reduce readmission rates, improve health outcomes and maximize reimbursement (linden & butterworth, 2014). little is known, comparatively or cumulatively, about how effective these programs are in bringing improvement to health status and reducing readmission rates in nys. it would benefit healthcare providers working in policy, communities, and organizations to identify community characteristics and readmission reduction initiatives that are successful at improving health status and reducing the burden of disease. it is imperative to identify cost-effective and worthwhile strategies (cohen et al., 2016). strategies can also assist communities to reach two aims of healthy people 2030 developed for older adults, online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 134 which are to “improve the health and well-being for older adults,” and to reduce pneumonia related hospitalizations among the elderly (usdhhs, 2020, older adults section). healthy people 2030 began in 1980, and provides a unifying framework for communities and organizations working on population health in the u.s. purpose and goal the purpose of this study was to identify community characteristics and organizational initiatives that were correlated with lower reimbursement penalties and lower hospital readmission rates for heart failure and pneumonia. as previously stated, the cost of treating heart failure and pneumonia continue to strain the nys budget. this article specifically addresses community characteristics. organizational initiatives are discussed in a separate paper (summers & atav, 2020). the study’s purpose is driven by the overarching goal of improving health quality for the elderly. by building on community characteristics and implementing organizational initiatives that are correlated with reduced readmissions or loss of revenue, improved health quality for the elderly is achievable. framework and review of the literature ecological model this study used the ecological model as a framework and guide for the literature review. for the purposes of this article, policy and community levels of the ecological model (mcleroy, et al., 1988) are discussed. stanhope and lancaster (2020) describe the five levels of the ecological model as individual, interpersonal, organizational, community, and public policy. the institute of medicine has long supported the ecological perspective and its importance in addressing determinants of population health, acknowledging the interchange and impact among various levels (2002). the study specifically applied the ecological model (see figure 1) to examine the online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 135 impact that the levels of policy and community have on hospital quality, namely readmissions, and to identify components that are correlated to lower reimbursement rates and penalties. figure 1 the ecological model (summers, 2018) policy level factors the aca and centers for medicare and medicaid services (cms) regulations represent the policy level because these entities govern quality measures, and they create algorithms for calculating the payment adjustment factor which ultimately determines payment (centers for medicare and medicaid services [cms], 2020). the federal aca authorized the secretary of health and human services to identify measures of quality that include avoidable hospital readmissions and sets guidelines for reimbursement reductions. beginning with the deficit reduction act of 2005, the secretary was mandated to include hospital outcomes such as readmission rates in the hospital inpatient quality reporting program. these legislated outcome measures were expanded with the aca in 2010 and are now included in reports generated by the online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 136 agency for healthcare research and quality (ahrq) and the hospital consumer assessment of healthcare providers and systems (cms, 2020). for the purpose of this study, the outcome for the ecological model was hospital quality (see figure 1) and was represented using (1) hospital 30-day all cause readmission rates, (2) heart failure related readmission rates (rrhf), and (3) pneumonia related readmission rates (rrpn), as reported by the nys department of health. the fourth outcome examined was the payment adjustment factor (paf), which is the reimbursement penalty imposed on hospitals. the paf is calculated using a base hospital operating payment for specific diagnostic related groups, and the local wage index of the hospital’s region. a paf of one is desirable. in the first year of the aca, the paf penalty was capped at 1%, and has incrementally increased to a 3% reduction in reimbursement as of 2016 (cms, 2020; hoffman, 2017). since the paf is calculated using heart failure and pneumonia related data, two additional interval outcomes were included in this study: the excess readmission ratios for heart failure and pneumonia (errhf and errpn, respectively). these two ratios are risk-adjusted measures that compare actual readmission rates to that of expected rates for that hospital based on national rates and hospital and community characteristics. a higher ratio is equated to poorer than expected readmissions related to heart failure or pneumonia (cms, 2020). community level factors community health workers provide care to individuals, families, and groups, with an aim to improve population health. one of the strongest correlations to life expectancy among race, age, and sex, is education and socioeconomic status (olshansky et al., 2012). socio-economic status has a direct influence on life expectancy, and when the distribution of social supports in a community is increased, health status can be improved (marmot et al., 2008; wilkinson & marmot, online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 137 2003). community level variables addressed in this study included characteristics of (a) rural status, (b) critical access hospital status, (c) primary care provider shortage status and (d) county rank for health factors. rural status. the office of management and budget (omb) classification for a core based statistical area (cbsa) was utilized. the omb classification uses three cbsas based on a county geographic unit. the metropolitan area consists of a core urban population of 50,000 or more. the micropolitan area has populations from 10,000 to 50,000. non-metropolitan areas contain a population of less than 10,000, which for this study is termed rural (rural health information hub, 2020). critical access hospital status. another community level factor examined was whether the hospital was classified by cms as a critical access hospital (cah). to qualify as a cah, the hospital must have (1) less than 25 acute care hospital beds, (2) be located greater than 35 miles from another hospital, (3) have an average length of stay of less than 96 hours, and (4) provide emergency care 24 hours daily and seven days a week (rural health information hub, 2019). cahs have provided needed access to healthcare services in otherwise remote geographic areas. cahs are granted more leeway than non-cahs in terms of financial reimbursement. organizations that oversee the administration of cahs often experience an excessive financial burden (bigby, 2014; reiter et al., 2013). baernholdt et al. (2014) found no difference between hospitals with a critical access designation and those without the designation when measuring nurse-rated quality of care and community perceptions. gaps in the literature exist for studies comparing readmission and reimbursement outcomes between cahs and non-cah entities. primary care shortage area status. the health resources and services administration designates health professional shortage areas for regions with shortages of primary care online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 138 providers, dentists, and mental health providers (health resources and services administration, 2020). primary care provider shortages were examined because advanced practice nurses (apns) serve in the role of a primary care provider. primary care providers are a patient’s first contact with the health care system. a lack of providers contributes to decreased access to care and potentially a deterioration of health status. a shortage also creates an environment for overutilization of emergency rooms and increased hospital admissions (commonwealth fund, 2013). county health rank. the health factor rank, developed by the university of wisconsin population health institute, is based on categories that quantify aspects of social determinants contributing to population health including elements of health behaviors, clinical care, as well as social, economic and physical environmental features (university of wisconsin population health institute, 2016). a county with a score of one is better than the other counties in that state. consequently, it was expected that hospitals located in metropolitan communities with a better county health rank and adequate availability of primary care providers would have lower readmission rates and less reimbursement penalties. organizational level factors the authors have discussed in a separate paper the variables at the organizational level of the ecological model. those variables include whether a hospital utilized any hospital readmission reduction programs, as well as the level of nurse competency involved in a hospital’s interdisciplinary discharge planning team. hospital programs that contributed significantly to reductions in readmission rates and payment penalties for hospital systems in upstate new york included an organizational collaboration or utilization of (1) certified home health agencies, (2) telehealth, (3) house calls, (4) apns on interdisciplinary discharge teams, and (5) the utilization of more than one type of hospital readmission reduction initiative (summers & atav, 2020). online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 139 methods design and sample this study incorporated a non-experimental, ex post facto design which is considered another method of determining causal relationships (lord, 1973). ex post facto designs may be categorized as quasi-experimental. in this design, there is neither random assignment nor manipulation. the research is conducted after events have occurred without any intervention by the researcher (ex post facto research design, 2021). the university’s institutional review board (irb) granted an exempt status since no human subjects or populations were under investigation (irb protocol #3891-16). this study included 94 hospitals located in 53 upstate ny counties. hospitals in nine counties with close proximity to the new york city metropolis were excluded in order to fairly represent rural hospitals. hospitals excluded were in the following nine counties: bronx, kings, new york, queens, richmond, rockland, westchester, nassau, and suffolk. five hospitals were excluded due to: (a) closure (n = 1); (b) the facility was either strictly an urgent care or emergency department (n = 3); or (c) the facility was under the organization and data collection of a pennsylvania hospital system (n = 1). six counties in nys did not have any hospitals. rural status was limited to and based on the core-based statistical area as defined by the omb. data were collected from public domain sources including cms, the ahrq, the u.s. census, the rural health information hub, nysdoh, the university of wisconsin population health institute, and specific hospital websites. scope and limitations information was accessed through various government, non-government, and hospital public domain websites. data were collected at the hospital and county levels for 94 hospitals in online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 140 53 counties, then categorized following the ecological model as a framework. this study’s scope is applicable to upstate ny hospitals, and based on the assumption that data sources were correctly collected, analyzed, and reported. one limitation inherent in a quasi-experimental ex post facto design is that it is a weaker level of evidence for establishing causal relationships when compared to a randomized control trial (lord, 1973). outcome measures the outcome of the study was hospital quality. to measure quality, the following variables were used to operationalize hospital quality (see table 1): • hospital readmission rates • readmission rates for heart failure • readmission rates for pneumonia • payment adjustment factor • excess readmission ratio for heart failure • excess readmission ratio for pneumonia table 1 dependent variable measurement and source dependent (outcome) variable name measure sources hospital readmission rate interval 1. nysdoh: health profileshospitals 2. medicare: hospital compare dataset readmission rate for heart failure interval 1. nysdoh: health profileshospitals 2. medicare: hospital compare dataset readmission rate for pneumonia interval 1. nysdoh: health profileshospitals 2. medicare: hospital compare dataset payment adjustment factor interval cms: readmission reduction program excess readmission ratio for heart failure interval cms: readmission reduction program excess readmission ratio for pneumonia interval cms: readmission reduction program online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 141 predictor qualities this study examined several community factors that could possibly impact the outcome measures. 1. was the hospital located in a rural area? the three categories of location included metropolitan, micropolitan, or rural. 2. was the hospital a critical access hospital or not? 3. was the hospital located in a primary care shortage area or not? 4. what was the hospital’s county health rank? the range for this variable was 1 to 62. data analyses analyses were conducted using ibm’s statistical package for the social sciences (spss) version 22, facilitating the completion of statistical tests. descriptive statistics were conducted providing a summary of the data and how often the community characteristic occurred among hospitals in upstate ny. bivariate analyses included independent t-tests to compare the means of outcome variables, and to determine if there was a significant difference in readmission rates and reimbursement penalties for hospitals that were (1) categorized as a critical access hospital and (2) located in a primary care shortage area. for the independent variable of rural status with three groups, the parametric analysis of variance (anova) was utilized providing analysis for differences among the groups’ means in both within-group variance and between-group variance. games-howell post hoc analyses were chosen to determine which groups were statistically different. pearson correlations were also conducted for the county health rank with each of the readmission outcomes. this parametric test is particularly useful in determining if a correlational relationship exists, how strong that relationship is, and if that relationship is direct or inverse (plichta & kelvin, 2013). online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 142 results several significant findings are discussed in this section. community characteristics addressed in this study included (1) rural status, (2) critical access hospital status, (3) primary care provider shortage status, and (4) county health rank. organizational level factors and the type of hospital readmission reduction program employed by the hospital are discussed elsewhere in detail (summers & atav, 2020). since no individuals were studied, and the subjects under consideration were hospitals, the interpersonal and intrapersonal levels of the ecological model were not specifically addressed in this study. of the community characteristics studied, none were associated with significant differences in (1) readmission rates, (2) readmission rates related to heart failure, (3) excess readmission ratios for heart failure, or (4) excess readmission ratios for pneumonia. the hospitals with critical access status, however, had lower readmission rates related to pneumonia compared to non-critical access hospitals. reimbursement penalties based on the payment adjustment factors were lower for hospitals located in counties with a better county health rank and located in primary care shortage areas utilizing house calls. descriptive statistics were calculated for 94 hospitals in upstate ny (see table 2): table 2 descriptive statistics and frequencies for hospitals in upstate ny: community variables characteristics number (%) of hospitals (n = 94) mean (sd) [min. –max. range] community predictor variables county health rank 94 (100%) 32.72 (15.55) [2-61] metropolitan 63 (67%) micropolitan 21 (22.3%) rural 10 (10.6%) primary care provider shortage 58 (61.7%) critical access hospital 12 (12.8%) online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 143 rural status a one-way, between subjects anova was conducted to compare the effect of rural status on readmission rates and reimbursement penalty rates in upstate ny hospitals. there was not a significant effect. results, however, indicated that hospitals located in micropolitan settings trended towards worse outcomes compared to hospitals located in either metropolitan or rural settings, (see table 3). these findings could be explained by a greater source of revenue and economic support in metropolitan areas. likewise, rural areas may receive federal government financial support. it could be argued that micropolitan communities have an economic disadvantage and include many older industrial cities and towns with an aging population and a diminishing workforce (sisson, 2018). table 3 anova for outcomes according to rural status outcome metro mean sd n micro mean sd n rural mean sd n f p rr 15.612 .8166 56 15.845 .7131 20 15.720 .7563 5 .657 .521 rrhf 22.282 1.5567 56 22.570 1.5991 20 21.960 1.1014 5 .410 .665 rrpn 17.679 1.5984 56 17.330 1.2978 20 17.140 1.2361 5 .595 .554 paf .9950 .0054 56 .9926 .0045 20 .9929 .0048 5 1.702 .189 errhf 1.0240 .0687 56 1.0514 .0849 20 1.0216 .0608 5 1.098 .339 errpn 1.0340 .1174 56 1.0159 .0669 20 1.0007 .0791 5 .389 .679 note. rr= readmission rates; rrhf=readmission rates related to heart failure; rrpn= readmission rates related to pneumonia; paf= payment adjustment factor; errhf= excess readmission ratio for heart failure; errpn= excess readmission ratio for pneumonia online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 144 critical access hospital status those hospitals classified as cahs had lower readmission rates related to pneumonia than non-cahs, t (33) = -.171, p = .021 (see table 4). hospitals classified as a cah did not have the same data collection and analysis methods as non-cahs. therefore, independent sample t-tests were only conducted for the three readmission rates. there is limited literature available that examines various readmission rates of cahs, but these findings do not agree with a previous study stating that cah status does not make a difference in readmission rates (lichtman et al, 2012). this research adds new knowledge regarding pneumonia related admissions and cahs. table 4 independent sample t-tests results for the predictor critical access hospital status critical access hospital non-critical access hospital outcome mean sd n mean sd n p t df rr 15.45 .3475 11 15.67 .7833 82 .103 -.919 33 rrhf 21.65 1.1396 11 22.35 1.5317 82 .064 .562 33 rrpn 16.87 .8211 11 17.57 1.4975 82 .021* -.171 33 note. rr= readmission rates; rrhf=readmission rates related to heart failure; rrpn= readmission rates related to pneumonia. p < .05* primary care shortage area status those hospitals located in communities with a shortage of primary care providers had similar readmission rates and reimbursement penalties (no significant difference) compared to hospitals located in non-shortage areas (see table 5). this could be due, in part, to the size of the sample. this adds to the body of literature that medicare hospital readmission and reimbursement online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 145 rates have not been specifically studied in the context of shortage areas; however, it is known that a shortage of providers, among other factors, is predictive of medicaid readmissions (jiang et al, 2016). table 5 independent sample t-tests results for the predictor primary care shortage area shortage area nonshortage area outcome mean sd n mean sd n p t df rr 15.71 .7453 46 15.63 .8464 35 .645 .436 79 rrhf 22.57 1.5641 46 22.02 1.4596 35 .087 1.633 79 rrpn 17.51 1.4432 46 17.63 1.5907 35 .745 -.359 79 paf .9938 .0049 46 .9949 .0056 35 .395 -.941 79 errhf 1.0422 .0751 46 1.0152 .0673 35 .091 1.673 79 errpn 1.0178 .0639 46 1.0402 .1418 35 .418 -.950 79 note. rr= readmission rates; rrhf=readmission rates related to heart failure; rrpn= readmission rates related to pneumonia; paf= payment adjustment factor; errhf= excess readmission ratio for heart failure; errpn= excess readmission ratio for pneumonia. hospital readmission reduction programs and controlling for primary care shortage area status additionally, each hospital readmission reduction program’s effect on hospital readmission rates and reimbursement penalties was examined using independent sample t-tests, while controlling for primary care shortage area. those hospitals located in primary care shortage areas utilizing house calls had lower reimbursement penalties compared to those hospitals not utilizing house calls, t (44) = 1.848, p = .018 (see table 6). hospitals in primary care shortage areas utilizing online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 146 other hospital readmission reduction programs had similar readmission rates and reimbursement penalties compared to those hospitals not utilizing the programs. table 6 independent t-tests results for the predictor variable (house call) in primary care shortage areas house call no house call outcome mean sd n mean sd n p t df rr 15.61 .6875 8 15.73 .7640 38 .673 -.398 44 rrhf 22.41 1.1115 8 22.61 1.6537 38 .671 -.318 44 rrpn 16.88 .8730 8 17.64 1.5231 38 .056 -1.365 44 paf .9967 .0030 8 .9932 .0051 38 .018* 1.848 44 errhf 1.0415 .0836 8 1.0424 .0745 38 .972 -.029 44 errpn 1.0004 .0752 8 1.0215 .0618 38 .477 -.847 44 note. rr= readmission rates; rrhf=readmission rates related to heart failure; rrpn= readmission rates related to pneumonia; paf= payment adjustment factor; errhf= excess readmission ratio for heart failure; errpn= excess readmission ratio for pneumonia p < .05* county health rank the pearson correlation indicated that those hospitals located in communities with a poorer (higher number) county health rank had a negative correlation with the paf (r (79) = -.230, p = .039) (see table 7), meaning that hospitals located in counties with a worse health rank experienced higher reimbursement penalties. county health rank is based on social-economic elements, the environment, certain health behaviors, and the availability and quality of clinical care (university of wisconsin population health institute, 2016). these findings add new online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 147 knowledge to the body of literature since no known previous studies have specifically examined county health rank with reimbursement penalties. table 7 pearson product correlation for community health rankings on readmission outcomes rr rrhf rrpn paf errhf errpn county health rank -.068 .067 -.043 -.230* .086 -.068 p < .05* discussion in light of the significant findings, critical access hospitals play an important part in managing pneumonia. hospitals located in a county with a better county health rank have less reimbursement penalties assessed against them. additionally, hospital organizations located in primary care shortage areas that utilize either physician or apns to conduct house calls benefit financially. they experience lower reimbursement penalties when compared to hospitals in nonshortage areas that utilize house calls. rural status this study demonstrated that hospitals located in micropolitan areas had worse outcomes than hospitals located in metropolitan or rural settings. critical access hospitals have different reimbursement formulas. unlike most hospitals that are under a prospective payment reimbursement, critical access hospitals’ reimbursements are cost based (reiter et al., 2013). these formulas may provide an advantage over micropolitan hospitals. metropolitan hospitals may have the advantage of rich resources in specialists, technology, and a stronger economic base. laws and regulations that govern healthcare and healthcare financing in all settings should be reevaluated. furthermore, expanding the study to include other states may solidify this finding. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 148 critical access hospital status critical access hospitals had lower readmission rates related to pneumonia compared to the rates in non-critical access hospitals. this unexpected finding could be related to the number of hospitals in the study. these favorable findings could be related to the financial leeway and incentives granted to them (bigby, 2014; reiter et al., 2013). why readmission rates for pneumonia were lower, and why readmission rates for heart failure were not lower in critical access hospitals compared to non-critical access hospitals could be explained by the acute nature of pneumonia. patients may have a better chance of resolving the condition without a subsequent hospital readmission compared to the chronic disease of heart failure which frequently entails multiple readmissions (goroll & mulley, 2021). this finding supports the need to implement policies that will help sustain these small rural hospitals. primary care shortage status hospitals located in communities with a shortage of primary care providers had neither better nor worse readmission rates and reimbursement penalties compared to hospitals located in non-shortage areas. communities in non-primary care shortage areas typically have better outcomes (commonwealth fund, 2013). however, when each hospital readmission reduction program was examined while controlling for whether hospitals were located in primary care shortage areas, hospitals that utilized house calls had lower reimbursement penalties. organizations located in primary care shortage areas should consider expanding their services to include the use of house calls. county health rank as expected, hospitals located in counties with a better county health rank had lower reimbursement penalties. there is a need for supportive funding for county policies and programs online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 149 that address specific measures used in the calculation of county health rank. nevertheless, this is an indication of a reciprocal relationship between healthier communities and better hospitals. recommendations policy as previously stated, it is important to promote policies that will add value to the county health rank, and that will financially support successful hospital programs, thus strengthening communities and organizations. although there is much heated debate over reforming the aca, there is no lack of support for continuing efforts to improve both reimbursement and hospital readmission reduction schemes proposed by the aca (network for regional healthcare improvement, 2015; richie et al., 2014). there are several federal bills under consideration in congress that have the potential to enhance population health, and also lend support to the findings of this research. the independence-at-home act moves this model of care delivery from a demonstration status to permanent status. this legislation could ensure that the delivery of health care within the context of patient homes would continue on a larger scale, through funding and expanding medicare benefits (u.s. senate 1202, 2019). another federal bill that directly impacts reimbursement penalties has been introduced calling for reform of the methodology by which reimbursement penalties are calculated, namely the payment adjustment factor. sponsors of the bill state that the calculations do not take into account the chronic illness burden nor the severity of the illness, and thus reform of the reimbursement methodology would lessen the financial strain on the nation’s hospitals (u.s. house of representatives 3611, 2017). similarly, the save rural hospitals act called for reform in reimbursement calculations for rural hospitals and cahs, because current methodologies were not halting the rapid rate of these hospital closures. this online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 150 legislation would eliminate hospital payment reductions for both medicare and medicaid in rural hospitals (u.s. house of representatives 2957, 2017), and ultimately contribute to the strength of rural communities. state policy recommendations include a bill to revise public health law in new york. ny senate bill 1805 proposes funding that would support the development and implementation of collaborative service plans among hospitals, home care, practitioners, and emergency medical services, which in turn, builds community health (ny senate 1805, 2020). other models of care for communities need to be developed. primary prevention strategies must be a priority focus for policymakers and communities such as the recently passed expansion of medicare payment for home health services ordered by a nurse practitioner, clinical nurse specialist, certified nursemidwife, or physician assistant (american association of nurse practitioners, 2020). future research considering the legislative proposals and study findings, future research efforts should be directed towards examining care delivery models that expand the practice of house calls and the role of the advanced nurse practitioner. conducting research in primary care shortage areas on the use of house calls is of particular interest and could prove financially beneficial to hospital organization serving those areas. the house call shows promise in reducing pneumonia related readmissions, and in reducing reimbursement penalties especially in primary care shortage areas. expanding research to explore levels of the ecological model not included in this study, namely interpersonal and intrapersonal levels, could be included in these future research efforts. practice there are numerous and well documented theories and models that believe nursing care is what makes a difference in patient outcomes. the nurse-patient relationship has been a vital factor online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.638 151 in patients reaching optimal health outcomes (bell et al., 2009). when nurse practitioners grow their practice from a nursing theoretical basis advances in nursing theory can be achieved in both organizational and community settings (ackerman et al, 2010). this approach to nursing care is in contrast to the predominant medical framework that is foundational to most hospital administrations (scott, 1982). nurse practitioner competencies include using evidence to shape practice environments, solving practice problems, and ultimately improving outcomes (hamric & tracy, 2019). organizations should employ nurse practitioners to either conduct house calls for each primary care office, or redesign the workflow to allow providers the time to follow-up with house calls when appropriate for their patients in conclusion, this study supports efforts to revise reimbursement formulas to increase fiscal sustainability of hospital systems. it also supports community level workforce development for house calls in primary care shortage areas. with awareness of various community characteristics that affect hospital quality, apns can promote and implement initiatives correlated with reduced readmissions and loss of revenue. in doing so, health quality for the elderly is achievable. compliance with ethical standards declaration of conflicting interest: the authors declare that there is no conflict of interest, financial or otherwise, and have obtained exempt status from binghamton university’s institutional review board. references ackerman, m., mick, d., & witzel, p. 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(2016). county health rankings and roadmaps. retrieved from www.countyhealthrankings.org wilkinson, r. & marmot, m. (2003). social determinants of health: the solid facts (2nd ed.). world health organization. wishner, j., solleveld, p., rudowitz, r., paradise, j., & antonisse, l. (2016). a look at rural hospital closures and implications for access to care: three case studies. kaiser family foundation: medicaid. retrieved from http://kff.org/report-section/a-look-at-ruralhospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/ microsoft word 67-309-2-ed_zimmerman.docx online journal of rural nursing and health care, 12(1), spring 2012 16 rural versus urban comparison: physical activity and functioning following coronary artery bypass surgery lani m zimmerman, phd, rn, faan, faha 1 susan barnason, phd, aprn-cns, cen, ccrn, faha 2 paula schulz, phd, rn 3 janet nieveen, phd, rn 4 chunhao tu, phd 5 1 professor, college of nursing-lincoln division, university of nebraska medical center, lzimmerm@unmc.edu 2 professor, college of nursing-lincoln division, university of nebraska medical center, sbarnaso@unmc.edu 3assistant professor, college of nursing-lincoln division, university of nebraska medical center, pschulz@unmc.edu 4 assistant professor, college of nursing-lincoln division, university of nebraska medical center, jlnievee@unmc.edu 5 chunhao tu, assistant professor; college of pharmacy, university of new england, ctu@une.edu abstract purpose: the purpose of this sub-analysis was to compare the early recovery of elderly patients following coronary artery bypass surgery (cabs) by geographic location (urban/rural) on physical functioning and physical activity. methods: the sample was 124 subjects who had been in the usual care group (or control group) of a randomized controlled trial. subjects were categorized into geographic locales using rural urban commuting area (ruca) codes: urban n=35, large rural n=17, small rural n=23 and isolated rural n=33. measures included the medical outcomes study short-form 36 and the rt3® accelerometer. mixed linear models were used to analyze the data. results: no significant differences were found for physical functioning by ruca group. however, there was a statistically significant difference for physical activity, for average kcals/kg/ per day (f = 3.01, p < .05) and average daily activity counts (f = 3.95, p <.01), with the subjects in large rural communities having significantly (p < 0.05) more average kcals/kg per day than urban subjects (m = 29.04 and m = 27.25 respectively). subjects in the large rural also had significantly (p < .005) more average daily activity counts than urban (m = 216635 and m = 161221 respectively). conclusions: this is the first study to compare early recovery functioning and activity outcomes of cabs subjects by rural/urban locations. additional study is warranted to evaluate why these differences exist and the potential need to tailor interventions for cabs based on geographic location. keywords: rural urban comparison, cardiovascular surgery, physical activity, physical functioning. erushton typewritten text online journal of rural nursing and health care, 12(1), spring 2012 17 rural versus urban comparison: physical activity and functioning following coronary artery bypass surgery health disparities exist in our society and have been associated with geographic place of residence in various chronic diseases, including heart disease. these disparities most often are in reference to access to care as numerous studies (bray et al., 2005; coughlin et al., 2006; larson & fleishman, 2003; rao et al., 2007) have shown that rural patients are less likely to receive optimal treatment and thus have inferior outcomes. other disparities associated with rural geographic location have included rural residents’ presentation for healthcare with more severe disease, and generally poorer health habits e.g. high prevalence of smoking and obesity, lower levels of physical activity (jones, parker, ahearn, mishra, & variyam, 2009). furthermore, there is conflicting data between rural residence and health outcomes (vanderboom & madigan, 2008; wu et al., 2010). it is important for clinicians to understand if geographic locale of patients influences their ability to recover and rehabilitate following a significant cardiac event such as coronary artery bypass surgery (cabs). therefore, this sub-analysis study was undertaken to compare the recovery period of elderly patients following cabs by geographic location (rural, urban) on physical functioning and physical activity (at baseline, 6-weeks, and 3-months after cabs). although, health disparities between urban and rural patients usually favor outcomes for patients in urban areas; the incongruences from study reports reflect the unique variables and definitions of rural and urban. for example, one study (mcconnell et al., 2010) reported unique differences between rural and urban residents that had an impact on reducing cardiovascular (cv) risk; although there were no group differences. for example, they reported the reason for no differences may be due to environmental factors such as in urban areas, factors such as sidewalk conditions, facilities and equipment available may influence a person’s willingness to increase physical activity. mcconnell (2010) also reported those who decreased cvd risk, regardless of rural or urban, had better outcomes related to factors such as walking distance and cvd risk score (p < .05). additionally, there were differences between those with decreased risk versus those who did not decrease risk within the rural and urban groups. triglycerides, c-reactive protein, diabetes knowledge, risk perception, and outcome expectations were greater for the rural group who decreased their cvd risk versus those who did not (all p < .05). for the urban group, for those who decreased cvd risk (p < .05), their locus of control was from more powerful others versus internal control or happening by chance (mcconnell et al., 2010). although there are known disparities in healthcare for rural-dwelling populations (e.g. access to care), only a few studies (k. m. king, thomlinson, sanguins, & leblanc, 2006; mcconnell et al., 2010; saleh, alameddine, hill, darney-beuhler, & morgan, 2010) have been conducted to examine the impact of rurality on cardiovascular (cv) outcomes such as physical activity; and of those the majority are related to heart failure (hf) populations. specifically related to physical activity, perceptions of patients (n = 42) managing coronary artery disease (cad) differed by urban versus rural dwellers in a qualitative study by king (k. m. king et al., 2006). rural-living participants were more vulnerable to summer heat and winter cold as barriers to exercise as opposed to urban participants having more alternatives to exercise. rural participants, both men and women, viewed work on the farm as exercise and urban participants reported walking the stairs at work or going to a mall to walk as a form of exercise. these findings are similar to what was reported in one study (mcconnell et al., 2010). another study examined the effectiveness and cost-effectiveness of six rural employer-based, wellness programs (which included an exercise and physical activity component) with varying degrees of online journal of rural nursing and health care, 12(1), spring 2012 18 intervention intensities (saleh et al., 2010). they concluded the highest intensity group had the most favorable outcomes in several wellness areas and in percentage of employees with good health indicators compared to the control and lower-intensity intervention groups. however, the lower group had more favorable cost-effectiveness ratios. regardless of the intensity of the wellness program, employers and employees could still benefit from these types of programs. this literature review supports the notion that future intervention studies should be tailored by geographic location (rural and urban) factors that promote exercise since we believe they are different. methods design and sample data for this sub-analysis were from a parent study which tested the effect of a symptom management (sm) home communication nursing intervention designed to improve functioning (physical and psychosocial), decrease postoperative problems, decrease health care utilization, and improve patient satisfaction through early symptom evaluation and management, and enhanced self-efficacy in the early discharge period of the elderly patient after cabs. the symptom management (sm) intervention used a device called the health buddy (hb) that was attached to the telephone line. the study used a randomized (assigned by using a previously generated randomization schedule), two-group (n = 284) repeated measures design with measurements at time of discharge, 3 and 6 weeks, and 3 and 6 months postoperatively in elderly patients (65 years or older). one group received usual care (uc) combined with the sm intervention, and the control group received uc. for this paper, only the 124 participants who were assigned to the uc group were included for this sub-analysis. participants in the sm group were excluded because the sm intervention delivered some strategies for increasing physical activity. participants in the uc group were categorized as urban or one of three rural groups (large, small or isolated). there were 43 participants (35%) who resided in an urban area. within the rural subgroup, participants resided in large rural cities/towns (n = 20, 16%), small rural towns (n = 25, 20%), and isolated small rural towns (n = 36, 29%). rural classifications were based on the rural urban commuting area codes (ruca) created in part by the us department of agriculture’s economic research service (hart, larson, & lishner, 2005). the ruca defines urban (> 50,000 residents), large rural (10,000-49,000 residents), small rural (25009999 residents), or isolated (< 2499 residents) based on the us census bureau’s definitions of urbanized areas and urban clusters, which in turn rely on complex criteria, including population density and population work commuting patterns(hart et al., 2005). participants were recruited from four midwestern tertiary hospitals. participants were aged 65 years or older and had undergone cabs, oriented to persons, places, and time; able to hear, see, speak, and read english; been discharged within 7 days after surgery; and had no physical impairments that would limit their physical functioning. variables and measures physical activity. the modified 7-day activity interview (hellman, williams, & thalken, 1996a) was used for reported baseline physical activity measures. participants were asked to recall their activity levels before surgery. specific measures used from the modified 7-day activity interview were total kilocalories/day expended, average kilocalories/kilogram/day expended, and average minutes/day spent in moderate or greater activity (hellman, williams, & online journal of rural nursing and health care, 12(1), spring 2012 19 thalken, 1996b). psychometric properties of this measure have been reported in the literature (barnason, zimmerman, schulz, & tu, 2009; hellman, williams, & thalken, 1996a). for this study, activity and estimated energy expenditure (eee) will be measured physiologically using the rt3 accelerometer (by stayhealthy, inc.) which was originally the tritracr3d (by hermokinetics, madison, wi) used in research since 1992. in addition, a self-report activity diary of activity/exercise was used to average minutes spent in exercising per day and average kcals/kg/day (a measure of daily eee). these data will be collected for three consecutive days (two week days and one weekend day) at each of the following postoperative time periods: 3 weeks, 6 weeks, 3 months, and 6 months. the rt3 accelerometer, is a triaxial accelerometer which uses advanced microcomputers to register body motion (specifically, the electrical energy of acceleration and deceleration) during activities that involve energy cost. in this study, mean daily total activity counts and mean daily activity kcals expended were measured physiologically using the rt3 accelerometer at each of the following postoperative time periods: 3 and 6 weeks and 3 and 6 months. the rt3 combines three independent sensors in orthogonal axes to detect acceleration in the three-dimensional space (a strength over uniaxial accelerometers which tended to be inaccurate in measuring many different types of activities). the three dimensions are: x (anteroposterior axis), y (medial-lateral axis), and z (vertical axis). within the rt3, counts of accelerations in the three-dimensional axes are sampled every second, stored in a buffer, then the average for each axis is calculated and logged once a minute. this produces “activity counts” (similar to the output produced by the actigraph) and thereby produces a measure of amount of activity. for this study, average daily activities were calculated as follows: activity counts will be summed for each of the three consecutive daytime periods. then a mean daily total activity counts variable were calculated by obtaining a mean of the three days. a subject’s physical characteristics (i.e. gender, age, height, and weight) are entered upon initializing the rt3 monitor. this information is used within the rt3 to calculate the subject’s resting eee in kilocalories (kcals) per minute based on established predictive equations for men and women. the rt3 prediction of the eee of physical activity (eee) in kcals is calculated internally every second and logged every minute using an unpublished proprietary regression equation with the use of the vector magnitude of the acceleration registrations from the x, y, and z axes. these measures are then converted into kcals. the rt3 calculates activity kcals expended using the formula (total kcals resting kcals) for each minute. for this study, estimated eee (activity kcals) will be calculated as follows: activity kcals will be summed for each of the three consecutive daytime periods. then a variable of mean daily activity kilocalories expended will be calculated by obtaining a mean of the three days. a teaching booklet was provided that explained and illustrated how to wear the rt3, and a demonstration was done at discharge from the hospital. triaxial accelerometers have established validity with indirect calorimetry resulting in correlations ranging from .48 .92 (baranowski et al., 1999; campbell, crocker, & mckenzie, 2002; hendelman, miller, baggett, debold, & freedson, 2000). reliability has been demonstrated with correlation values of .85 reported between rt3 activity counts and mixed venous oxygen saturation ( svo2), (rowlands, thomas, eston, & topping, 2004) .51 for activity counts and heart rate (devoe & gotshall, 2003)and .32 .91 for energy expenditure with indirect calorimetry (devoe & gotshall, 2003; g. a. king, torres, potter, brooks, & coleman, 2004). generalizability coefficients for the rt3 with 3 days of data at three data collection points were high (.85 .97).(hertzog et al., 2007) a 3-day diary was also used to correlate with the rt3 data. the reliability estimates (interclass correlations) for 3 days of self-reported, recorded data collection of minutes of moderate or higher physical online journal of rural nursing and health care, 12(1), spring 2012 activity in a diary and rt3 ranged from .76 to .84 at 3 weeks, 6 weeks, and 3 months after cabs(hertzog et al., 2007). physical functioning. the mos sf-36 is a multidimensional scale measuring eight health concepts: general health, physical, role-physical, role emotional, social, bodily pain, mental health, and vitality functioning (a. m. jette, 2003). in this study, four subscales (physical, rolephysical, bodily pain, and vitality) were used separately to evaluate physical functioning. standardized response choices were utilized. each of the concepts is scored on a scale of 0 to 100, with a higher score indicating better health. reliability has been satisfactorily estimated by cronbach’s alpha. in studies of job strain and quality of life, cronbach’s alphas on the subscales ranged from .76 -.93, (lerner, levine, malspeis, & d'agostino, 1994) and in cardiac rehabilitation programs from .72 .85 (d. jette & downing, 1994). these studies all refer to work by stewart et al. (stewart, rand, muldoon, & kamarck, 2009) that showed an internal consistency reliability alpha range of .67 .88. cronbach’s alphas for this sub-sample ranged from .69 – .91 at 6 weeks and 3 months for all subscales. procedures approval from the institutional review committees at the facilities was received. every day the research nurse would approach the unit charge nurses to identify patients who met study criteria. the charge nurses then approached patients and if they agreed to talk to the research nurse about the study, the research nurse would then explain the study, invite them to participate, and obtain written, informed consent. each potential subject was randomly assigned to the intervention or usual care group using a previously generated randomization schedule. the research nurse completed the demographic and patient characteristic tool, and at baseline, verbally administered the mos sf-36 and modified 7-day activity recall by asking participants to reflect on their responses to these measures before undergoing cardiac surgery. a demonstration on how to wear and care for the rt3 accelerometer, along with a teaching booklet, was given to the patients. participants were contacted by telephone at 3 and 6 weeks, and 3 and 6 months, after discharge, at which times the mos sf-36 tool was completed by interview. participants were mailed the rt3 to wear and diary to complete at each time frame. data analysis the statistical package, sas version 9.2, was used to analyze the data. data were entered into a secure data base with random data entry checks by the project director. data analyses in this study were conducted using descriptive and repeated-measures analysis of covariance, with the baseline (before cabs) measures of the physical activity and functioning variables as the covariates. the classification variable treated like an independent variable was urban and rural groups (by ruca code). results the sample was composed of 124 participants (83% men and 17% women), and 86% of the sample were married. participants had a mean age of 71.2 (sd 4.7) years. the majority of participants had an average of 13 or more years of formal education, and approximately 80% of participants participated in cardiac rehabilitation (cr) after hospital discharge. there were no statistically or clinically significant group differences on demographic (e.g. age, length of stay, race, and marital status) or baseline clinical variables (e.g. comorbidities, body mass index, erushton typewritten text erushton typewritten text erushton typewritten text 20 erushton typewritten text erushton typewritten text online journal of rural nursing and health care, 12(1), spring 2012 21 discharge hemoglobin, and cr participation) by urban/rural groups. table 1 provides an overview of the participants’ clinical and demographic characteristics. table 1 demographic and clinical characteristics of study participants by rural group (n=124) online journal of rural nursing and health care, 12(1), spring 2012 22 physical functioning. no significant differences were found between rural and urban patients on physical functioning by urban/rural groups (see table 2 for results of rm-ancova). the mean scores for physical, role physical and vitality showed some slight variations over time in scores (see figures 1-3). table 2 rm-ancova for physical functioning and physical activity with sas mixed procedure. online journal of rural nursing and health care, 12(1), spring 2012 23 physical activity. in relation to physical activity, there were significant differences between urban/rural groups for average kcals/kg/day (f = 3.01, p < .03), and average daily activity counts (f = 3.95, p < .01) . specifically for rt3 data, post bonferroni tests showed large rural (m= 29.04) had significantly (p <.05) more average kcals/kg/ day (a measure of daily energy expenditure) than urban (27.25); and large rural (m= 216635) had significantly (p < .005) more average daily activity counts than large urban (m=161221). in relation to diary measures, small rural (m=2462) had more average kcals/kg/ day than urban participants (m=2219). see table 2 for results of rm-ancova by groups. online journal of rural nursing and health care, 12(1), spring 2012 24 discussion there have not been any other direct comparisons in the literature to examine outcomes in the early recovery period after cardiac surgery based on patients’ geographic residence. although, poorer health outcomes in rural areas are not consistently observed across studies, this may be due largely in part to a lack of standardization of definitions of urban/rural geographic locale. there are even fewer research-based articles that have stratified samples based on urban/rural residence. additionally, there were a few studies that were cardiac focused reporting some differences for urban/rural location making it difficult to compare our findings to other studies. online journal of rural nursing and health care, 12(1), spring 2012 25 the results of the sub-analyses did not support the frequently reported conclusion that rural patients have inferior outcomes to urban participants. in fact, this study found that some aspects of physical activity (estimated energy expenditure and average daily activity counts for one large rural participants were superior to those participants in the urban setting. however, not significant, large rural participants had higher physical functioning scores compared to urban participants at six weeks and three months. these findings are not entirely surprising, as age and gender may have influenced the results. a large proportion of the sample were from rural and were men who reported that they were very often still working (even though 65 or older), particularly in their occupation as farmers, and as reported by mcconnell (mcconnell et al., 2010)both men and women rural participants viewed work on the farm as exercise. the incidence of less physical activity in some of the smaller rural locations might further be explained by king (k. m. king et al., 2006) and mcconnell(mcconnell et al., 2010) who reported rural individuals were more affected by weather for exercising as compared to urban individuals who had more options for exercise (out of the inclement weather); and urban residents may also be more concerned about walking late at night or sidewalk conditions. limitations although we had sufficient power to demonstrate significant differences, a larger and more heterogeneous cv sample is needed for a more thorough investigation of possible mechanisms explaining differences in rural and urban patients. for example, would there be similar results when comparing different cv interventions. the original study was not designed to test differences between urban and rural participants. the study also used self-report measures for physical functioning and one of the measures of physical activity (diary). the small sample size limits the generalizability of the findings and requires caution in the interpretation of the findings. since this was a sub-analysis, our study did not include all possible factors that might be related to rurality and outcomes such as gender differences, age, and occupation. a larger sample would also allow determining the influence of other demographic and environmental factors on physical activity in urban and rural participants. online journal of rural nursing and health care, 12(1), spring 2012 26 conclusions the findings from this study warrant further research to help determine how rurality may influence the types of interventions that can promote and facilitate physical functioning and physical activity following significant cardiac events such as cabs. studying additional surgical populations with a goal of increasing physical functioning and physical activity would contribute to the knowledge of providing different strategies based on urban/rural location. increasing physical functioning and activity after a major surgical event is a goal of most discharge planning activities. this would have a major impact on nursing interventions and health care providers caring for patients in different geographic locations. clinicians could then consider how to address alternative behavioral strategies to increase physical activity within the constraints of the rural and urban environment. these limited findings regarding the differences in cv outcomes, based on urban versus rural location, warrant further study to determine if differences in outcomes extend to other cv outcome differences. several reports indicated that rural patients have inferior outcomes to urban patients; yet very few studies actually stratify and power the sample to really test these differences. it should also be considered that there may not be group differences found; but within each group (urban and rural) different strategies were used to enhance outcomes. this too is important for future studies. there may also be different strategies between rural and urban among different age groups and by gender. a mixed method design would allow the researcher to gather some qualitative data that may help explain why sometimes group difference are not found or what unique strategies work to increase physical activity or functioning in urban versus different rural subgroups and what works or does not work in both areas. this is the first study to compare outcomes of cabs participants (physical functioning and physical activity after cabs) by rural/urban locations. many people assume that urban cabs patients would have better functioning compared to rural populations; however this study did not support that premise. we also believe, from the literature reviewed and findings from this study, the belief that tailoring certain strategies based on urban/rural location is important when planning future studies; however, additional research is needed in this area to better assist nursing when planning activities such as increasing physical activity to reduce cv risk in the cardiac population. acknowledgements this study was funded by the national institute of nursing research of the national institutes of health (grant r01 nr07759; l.z., principal investigator) and (grant 1p20nr011404-01; c pullen principal investigator and l zimmerman, co –investigator). references baranowski, t., smith, m., thompson, w. o., baranowski, j., hebert, d., & de moor, c. 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(2007). disparity in survival outcome after hematopoietic stem cell transplantation for hematologic malignancies according to area of primary residence. biology of blood and marrow transplantation : journal of the american society for blood and marrow transplantation, 13(12), 1508-1514. [medline] rowlands, a. v., thomas, p. w., eston, r. g., & topping, r. (2004). validation of the rt3 triaxial accelerometer for the assessment of physical activity. medicine and science in sports and exercise, 36(3), 518-524. [medline] saleh, s. s., alameddine, m. s., hill, d., darney-beuhler, j., & morgan, a. (2010). the effectiveness and cost-effectiveness of a rural employer-based wellness program. the journal of rural health : official journal of the american rural health association and the national rural health care association, 26(3), 259-265. [medline] stewart, j. c., rand, k. l., muldoon, m. f., & kamarck, t. w. (2009). a prospective evaluation of the directionality of the depression-inflammation relationship. brain, behavior, and immunity, 23(7), 936-944. [medline] vanderboom, c. p., & madigan, e. a. (2008). relationships of rurality, home health care use, and outcomes. western journal of nursing research, 30(3), 365-78; discussion 379-84. [medline] wu, j., moser, d. k., rayens, m. k., de jong, m., chung, m. l., riegel, b., et al. (2010). rurality and event-free survival in patients with heart failure. heart & lung, 39(6), 512520. [medline] http://www.ncbi.nlm.nih.gov/pubmed/18022581 http://www.ncbi.nlm.nih.gov/pubmed/15076796 http://www.ncbi.nlm.nih.gov/pubmed/20633094 http://www.ncbi.nlm.nih.gov/pubmed/19416750 http://www.ncbi.nlm.nih.gov/pubmed/20561853 736_hand+hygiene+submission+january+2023final_setup_2_16_23psf+formatted online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 193 improving hand hygiene in a rural critical access hospital katherine miller, dnp, rn, nea-bc1 kathrine jones, dnp, rn2 rhonda johnson, dnp, cne, cnm, facnm3 jodie becker, dnp, mha, rn, ne-bc, ccrn-k4 1 director of quality management, ambulatory lexington health, lexington medical center, west columbia, south carolina, khmiller@lexhealth.org 2 clinical associate professor and director, healthcare leadership and executive healthcare leadership programs, college of nursing, university of south carolina, jones99@mailbox.sc.edu 3 assistant professor, college of nursing university of south carolina, rjohnso2@mailbox.sc.edu 4 division vice president, quality mission health, hca healthcare, jodie.becker@hcahealthcare.com abstract background: hand hygiene adherence is the single most important infection control practice among healthcare workers. hand hygiene is cost-effective and adherence to protocols can reduce hospital-acquired infections. research regarding hand hygiene adherence has been shown to improve patient safety and reduce hospital-acquired infections. adherence to hand hygiene protocols among healthcare workers is poor and improvement efforts lack sustainability. purpose: the purpose of this project is to improve hand hygiene to be at or greater than 90% in acute care areas of a critical access hospital. target population: the target population includes clinical and non-clinical staff working in a 7 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 194 bed emergency department and a 24-bed acute medical-surgical unit of a rural critical care hospital in north carolina. method: the model for improvement was used to guide the aims, measures, and change. process improvement was conducted using plan-do-study-act (pdsa) test cycles method. findings: two acute care units were monitored for 3 months during which interventions occurred over two pdsa cycles. one unit showed steady improvement each month but did not meet its goal. the other unit exceeded goal metrics in the first and third months of the monitoring period. conclusions: surveys, verbal reminders, and interventions created discussions and greater awareness of hand hygiene. keywords: hand washing, compliance, adherence, rural, critical access improving hand hygiene in a rural critical access hospital hand hygiene (hh) is essential for infection prevention (mcfee, 2009). ignaz semmelweis recognized in the nineteenth century the importance of hh when he hypothesized that the lack of hh was causing childbirth fever resulting in maternal death. dr. semmelweis may have initiated the first hh program when he required hand washing at krankenhaus teaching hospital (kadar et al., 2018). poor hh continues to cause hospital acquired infections (hai) (centers for disease control and prevention [cdc], n.d.-a). patients who suffer a hai are less likely to report a satisfactory hospital stay, which can affect a hospital’s reputation and reimbursement. the avoidable costs for hais in the u.s. range between $142 million and $4.25 billion dollars annually (schmier et al., 2016). according to cdc data hais are the most common cause of an adverse hospital event lengthening hospital stays and causing more than 99,000 deaths annually in the us. the pandemic caused by the virus; sars online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 195 cov-2, commonly referred to as covid-19, has hospitals looking more closely at infection prevention including hh (cdc, n.d.-a). background although recommendations for personal protective equipment (ppe) use, inpatient hospital visiting, as well as other foci changed due to the pandemic, hh has been a constant recommendation. over forty years ago handwashing was recommended to improve patient safety and reduce hais (vermeil et al., 2019). with the focus on hh over the years and with a pandemic, one may assume that all healthcare workers (hcws) practice regular hh. however, adherence to hh protocols and policies remains a struggle in healthcare organizations (cdc, n.d.-a). bucher et al. (2015) recognized that emergency care providers working in pre-hospital environments such as homes, public areas or at traffic accidents have increased risks of spreading infections. in critically ill patients where registered nurses are the primary providers of care, poor hh places patients at increased risk of sepsis (fox et al., 2015). in fact, hcws perform hh half the time when presented with a hh opportunity (cdc, n.d.-a). zhou et al. (2020) detail recommendations in their study and include how hcws are observed and assured that the observed practice of hh met all the criteria such as number of seconds cleansing the hands. for this quality improvement (qi) project, the term used for empowering staff to determine to practice hh is adherence, those who practice hh are practicing adherence to infection prevention. compliance could indicate that staff are merely complying with what they have been directed. staff are expected to clean their hands according to policy and in doing so are compliant. adherence indicates they are electing the practice of hh from knowledge of an evidence-based practice. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 196 problem statement this project asks the following clinical question: what is the impact of a hhqi effort on hcws’ hh adherence rates in a rural critical access hospital (cah) comparing pre-intervention and post-intervention data over a three-month monitoring period? the population is defined as hcws in the acute areas of the hospital, two units, the ed and the acute medical-surgical unit, the expected improvement is hh adherence at or greater than 90%, the comparison is the preintervention data and the post-intervention data results. the expected outcome is sustained improvement after interventions. review of the literature the world health organization (who) launched the world alliance for patient safety in 2004 with a campaign of clean care is safe care (who, 2004). a feature in this campaign was promoting hh (vermeil et al., 2019). biddle (2009), in an update on the conditions of nurse anesthetists’ workstations, recognized a connection between nurse anesthetists’ work areas, and infection rates of patients. the cdc has looked closely at hcws barriers to hh practices. barriers include inconvenient or lack of available hh products or stations, a lack of time to perform hh or concern over disease transmission, and the hcw may have skin irritation from frequent hh, or the products used. the lack of knowledge regarding the healthcare organization’s protocols and policies, hh technique, and the belief that wearing gloves prevents disease transmission are other barriers noted (pittet, 2001; marra & edmond, 2014). individual beliefs and behaviors are influenced by education and attitudes within the healthcare setting. there must be minimal effort to perform hh and few barriers to practice for an increase in adherence. the awareness of the importance of hh can be improved through education online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 197 and training in the appropriate methods, location of products and hh stations and skin protection methods is necessary (alemagno et al., 2010). the who (2009) presented a multimodal plan for improving hh, entitled; “5 moments for hand hygiene” listing the moments a hcw should clean their hands. in addition, programs have been designed to increase hh awareness through online learning programs (alemagno, 2010). de wandel et al. (2010) reviewed the behaviors that determined when intensive care unit (icu) nurses were more likely to perform hh. sadule-rios and aguilera (2017) found key barriers to hh were increased workload, reduced staff, lack of time, and inappropriately placed hh equipment. achieving hh adherence to protocols and policies continues to be a key challenge in healthcare organizations (boyce, 2019). the qi project focuses on evidence-based methods to improve hh adherence rates in a rural cah. goals, objectives, and expected outcomes the primary goal of the project was to increase hh adherence in the hospital’s acute care areas and to sustain this improvement. secondary goals included improvement in staff knowledge of the importance of hh, related policies, pandemic safety processes, and improved understanding of perceived barriers to adherence with hh protocols. pre-intervention surveys were used to measure staff hh practice understanding, identify the perceived barriers, and help guide the interventions phase of the project. a post-intervention survey measured whether the interventions were successful. expected outcomes the expected outcome is a documented sustained hh adherence rate of greater than 90% in acute care areas over three months post interventions. interventions began in may 2021 with efforts to capture all members of the population through rounding, posting flyers, staff meetings, and online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 198 online education. a post-intervention survey was performed after the three-month monitoring period. project design project clinical site the project was conducted at a rural cah in north carolina (nc). according to the nc office of rural health (orh) (nc department of health and human services [ncdhhs], n.d.), a rural health facility is one that the nc orh considers to be underserved by healthcare providers and clinicians. nc orh assists hospitals that have this designation with provider recruitment, grant funding and other resources. the clinical site is in a county with no metropolitan area and less than 50,000 residents (ncdhhs, n.d.). in the clinical setting, alcohol-based hand sanitizer is at the entrance to every patient room and inside the door in both the acute medical-surgical unit and the ed. there are soap and water hand washing sinks located throughout both units. in the ed, hand washing sinks are in every room in addition to the alcohol-based hand sanitizer stations. hand hygiene monitoring is done by trained observers who report findings to the hospital’s infection prevention staff. the clinical site employs an infection preventionist (ip) who deploys hh observers who have been trained to use observational techniques to quantify adherence to hh protocols. the ip is shared between three rural cah. hand hygiene should be performed before and after patient contact, before donning and after doffing gloves, before an aseptic procedure, and after any contact with body fluids (cdc, n.d.-b). the clinical site is accredited by the joint commission (tjc) and policies uphold tjc standards. hand hygiene performed with alcohol hand sanitizer is an acceptable practice except in the care of patients infected with clostridioides difficile, which requires soap and water hh (cdc, n.d.-a) online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 199 staff trained as hh observers maintain their positions and, as an additional duty, observe for hho and hh reporting their findings to the hospital's ip. each hho is one data point. data is measured as to the number of observations, the frequency, median, and percentage of hh adherence. collected data for the project has been analyzed with the assistance of intellectusstatistics™ software (n.d.). hand hygiene products the clinical site uses soap and water for debris removal and alcohol-based hand sanitizer to reduce microbe transmission at the entrance and exit to each patient room and in all clinical areas. hand sanitizer dispensers are also placed outside of offices and key departments such as pharmacy, lab, and therapy services. there are signs on each patient’s door reminding those who enter to clean their hands before entering the patient room. population of interest the population of interest is the clinical and non-clinical staff working in acute care areas, which include a 7-bed ed and a 24-bed acute medical-surgical unit. staff in these areas includes registered nurses, healthcare providers, ancillary staff, housekeeping, dietary, therapy, case management, pharmacy, laboratory staff members, and hospital leaders. registered nurses are the largest portion of staff. recruitment, hiring and retention of nurses continues to be a challenge in rural hospitals (adams, 2016). the project focuses on the acute medical-surgical unit and the ed. staff in both areas may also work in the outpatient area, cardiac rehab, or in the long-term care facility that adjoins the hospital. it is likely that practice behaviors seen in the two focus units exist when staff float or work in other areas. observation online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 200 direct observation is considered the gold standard for the collection of hh data (kingston et al., 2015). direct observation is the process for data collection at the clinical site. hand hygiene opportunities are those prior to and post interaction with the patient. method this qi project is designed using the model for improvement developed by the associates in process improvement (apiweb.org, n.d.). this model asks three questions: 1. what are we trying to improve? 2. how will we know that a change is an improvement? 3. what change can we make that will result in improvement? these three questions help guide a project by identifying the aim, measures, and change (apiweb.org, n.d.) process improvement was conducted using plan-do-study-act (pdsa) test cycles method. the pdsa method is a four-step model and commonly used in qi projects. the planning phase includes stating the desired outcomes and predictions. the “do” phase, is the plan implementation. results of the implementation are analyzed in the study phase. step four is the decision to act based on the analysis of data (christoff, 2018). implementation the project began with the project proposal approval from the clinical site’s nursing education and research council. the project was then submitted for institutional review board (irb) approval and was found to be exempt by the irb. a strength, weakness, opportunity, and threats analysis (swot) assessed internal and external conditions to determine readiness for implementation. the pre-implementation survey of staff assisted in understanding reasons why staff decides not to perform hh. a review and synthesis of the literature helped to determine strategies for developing and implementing a sustainable improvement plan. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 201 interventions 1. placement of additional signage in the emergency department with signage obtained from infection prevention. 2. making the hand hygiene policy available on each unit allow staff to reference this material as time allows. this intervention supports a secondary goal of the project to improve staff knowledge. literature links a lack of knowledge regarding healthcare organization policies to poor hand hygiene adherence (pittet, 2001). 3. use of an online training tool on hh and products used at the clinical site. health care workers’ knowledge on when and how to perform hh has been identified as a barrier to greater hh adherence (o'boyle et al., 2001). the online education tool allowed for a video demonstration and convenient learning and is designed to increase hh adherence (alemagno, 2010). 4. placement of a flyer presenting the who’s five moments for hh on each targeted unit (who, 2009). 5. the hh flyer and policy were presented at staff meetings reinforcing evidence-based practice. these verbal presentations were used as a method to promote hh. 6. verbal reminders during daily staff huddles on hh. the online education tool was assigned by clinical education and professional development leadership at the clinical site. clinical education and professional development gave hospital staff through june to complete the online education tool. clinical education reported 100% completion of the education tool by june 30, 2021. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 202 measurement and tools the u.s. department of health and human services (hrsa) (2011) noted that how things are done is the system of processes an organization engages in. to assist organizations in better defining and improving the process, hrsa described four principles needed in qi work, shown in table 1. table 1 principles needed in quality improvement four key principles of quality improvement 1. qi work as systems and processes 2. focus on patients 3. focus on being part of the team 4. focus on use of the data current processes used to improve hh adherence are education, during the orientation period and annually, hh trained observers and re-education. covid-19 brought robust education focused on ppe and hh as a means of reducing the spread of the virus among hcws and patients (moore et al., 2021). the process for education and data collection and analysis at the clinical site has remained consistent to the processes prior to the pandemic. surveys pre-implementation surveys were completed by staff using a modified who hh questionnaire to establish baseline knowledge and perception of hho and hh practices (who, 2009). the results of this survey were used to guide the educational components and interventions of the project. a post implementation survey was completed at the end of the monitoring period and included the same questions as the pre-implementation survey with two additional questions. one question that had been added is whether the person taking the survey completed a survey in the past. the second question evaluates the education and methods to increase hh adherence. data online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 203 files for the pre-intervention and post-intervention surveys were loaded into intellectusstatistics™ project software for data project management. project datasets for both surveys were analyzed using descriptive statistics applications. summary statistics were calculated for each interval and ratio variable. frequencies and percentages were calculated for each nominal variable. the surveys were not numbered, who completed the surveys was not known to the authors. results participation in pre-intervention and post-intervention surveys was voluntary and open to staff members working in either of the acute care areas. clinical education made surveys available to hospital staff, providing instructions to place completed surveys in the mailbox for clinical education. at the end of two weeks, the surveys were collected from the mailbox and reviewed. of the 45 clinical staff members working in the acute medical-surgical unit and the ed during the pre-intervention survey, 27 surveys were returned for a response rate of 60%. in the time from the pre-intervention survey to the post-intervention survey, there was staff turnover. the exact number of staff remained the same, with permanent staff replaced with travel staff as new employees were hired and oriented. travel staff were invited to participate in the postintervention survey. the post-intervention survey was made available during the first whole week in in the month following the three-month monitoring period using the same procedure as the preintervention survey. with the same total number of staff members working in each department, 29 post-intervention surveys were returned for review and analysis. post-intervention surveys had a response rate of 64%. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 204 pre-intervention survey the most frequently observed category of gender was female (n = 19, 70%). the most frequently observed category of profession was nursing (n = 21, 78%). frequencies and percentages of the categories gender and profession are presented in table 2. table 2 frequency table for gender and profession variable n % gender female 19 70.37 male 8 29.63 profession nursing 21 77.78 therapy 5 18.52 respiratory therapist 1 3.70 survey questions 4 through 13 were analyzed, the responses to this group of questions allowed for the identification of barriers and knowledge. the results of questions 4 through 13 are found in table 3. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 205 table 3 frequency table for pre-intervention survey: questions 4 through 13. n=27 variable n % 4 hh training in the last 3 years yes 24 88.89 no 3 11.11 5 use alcohol hand sanitizer? yes 26 96.30 no 1 3.70 6 are unclean hands a route of cross transmission? yes 24 88.89 no 3 11.11 7 are unclean surfaces responsible for hais? yes 13 48.15 no 14 51.85 8 hh before patient contact prevent germ transmission? yes 26 96.30 no 1 3.70 9 hh after patient contact prevent transmission of germs to the hcw? yes 25 92.59 no 2 7.41 10 alcohol based sanitizer is more effective than soap and water? no 22 81.48 yes 5 18.52 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 206 11 hand scrub for 20 seconds? no 4 14.81 yes 23 85.19 12 is alcohol hand sanitizer an acceptable hh after glove removal? no 6 22.22 yes 21 77.78 13 should artificial nails be avoided? yes 26 96.30 no 1 3.70 hand hygiene adherence acute medical-surgical unit the three-month monitoring period began in june 2021. the baseline data for the acute medical-surgical unit was 80% hh adherence. during the three-month monitoring period, the adherence rate never met the baseline of 80%. steady improvement was shown each month, with the highest hh adherence rate achieved of 78% in august of 2021, below the goal of 90%. emergency department the baseline data for the emergency department was 67% hh adherence. the emergency department exceeded goal two of the three months during the monitoring period. during july, the emergency department had a hh adherence rate of 81%, while not meeting the goal of 90%; this rate is improved over the baseline of 67%. in june and august, the emergency department had 100% adherence for all observed hh opportunities. figure 1 illustrates the hh adherence of both units. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 207 figure 1 hand hygiene adherence across both units post-intervention survey a post-intervention survey conducted at the end of the monitoring period included two additional questions. question one asked if the participant had completed a similar survey earlier in the year and online education. the second question asked if they believe the education had increased their hh adherence. additional questions a fisher's exact test was conducted to examine the relationship of the two additional questions in the post-intervention survey. the results of the fisher exact test were significant based on an alpha value of 0.05, p = .003, suggesting that staff members who participated in the project as evidenced by taking the pre-intervention survey, were significantly more likely to report that hh education influenced their hh adherence. the questions: have you completed a similar survey this year and if you completed hh education in 2021 did it influence you to increase your hh pre-intervention june july august med surg 80% 73% 75% 78% ed 67% 100% 81% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% hand hygiene adherence compared to 90% goal med surg ed online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 208 adherence were found to be related to one another. since the fisher's exact test was conducted for a 2x2 contingency table, the odds ratio was calculated, or = 12.77. this indicates that the odds of observing have you completed a similar survey this year (yes) and if you completed hh education in 2021 did it influence you to increase your hh adherence (yes) is 12.77 times as likely as observing have you completed a similar survey this year (no) and if you completed hh education in 2021 did it influence you to increase your hh adherence (yes). frequencies and percentages sixty-six percent (19/29) of the respondents were nurses and female. this finding is consistent with the findings in the pre-intervention survey. table 4 presents the variables gender and profession. table 4 frequency table for gender and profession variable n % gender female 19 65.52 male 10 34.48 profession therapist 6 20.69 technician 3 10.34 nurse 19 65.52 provider 1 3.45 frequency and percentages for questions 4 through 13 statistics are found in table 5. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 209 table 5 frequency table for post-intervention survey: questions 4 through 13. n=29 variable n % 4 hh training in the last 3 years? yes 28 96.55 no 1 3.45 5 use alcohol hand sanitizer? yes 28 96.55 no 1 3.45 6 are unclean hands a route of cross transmission? yes 26 89.66 no 3 10.34 7 are unclean surfaces responsible for hais? yes 24 82.76 no 5 17.24 8 does hh before patient contact prevent germ transmission? yes 28 96.55 no 1 3.45 9 does hh after patient contact prevent transmission of germs to the hcw? yes 28 96.55 no 1 3.45 10 yes/no: alcohol based sanitizer is more effective than soap and water? no 25 86.21 yes 4 13.79 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 210 variable n % 11 hand scrub for 20 seconds? yes 17 58.62 no 12 41.38 12 is alcohol hand sanitizer an acceptable hh after glove removal? yes 23 79.31 no 6 20.69 13 should artificial nails be avoided? yes 29 100.00 no 0 0 discussion the swot provided valuable information for the first pdsa cycle. the swot analysis allowed the author to view the problem and relate the considered interventions to the project's framework. in completing the swot, an immediate opportunity was identified to add additional signage in the ed. the additional signage gave an important reminder to ed staff to perform hh. during pdsa cycle one, staff completed the online hh education module. this education module was specific to the hh products at the clinical site and had not previously been used for training staff. the module was an online tool allowing for pandemic social distancing. the education module included the amount of hand sanitizer needed to cover the hands and the lather created if using a soap and water method for hh. the amount of time needed for hand rubbing was covered. this education module supported the goals of this qi project, the organization's policy, the cdc guidelines, and the hospital's pandemic guidelines. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 211 during this first pdsa cycle, the emergency department exceeded the goal for hh adherence with 100% hh adherence. the acute medical-surgical unit reached 73% hh adherence for the same month. the rise in hh for the emergency department during pdsa cycle one was immediately following the pre-intervention survey and the placement of additional signage. the pre-intervention survey provided awareness of hh for both units. the additional signage in the emergency department and the pre-intervention survey may have created a higher level of awareness than in the acute medical-surgical unit, where additional signage was not placed as already present. the online hh education module provided awareness of hh, and the knowledge needed to perform hh using the products available at the hospital. during the second month of the three-month monitoring period, a second pdsa cycle was developed to improve the acute medical-surgical unit's hh adherence and sustain the emergency department's achievement. clinical leadership included hh adherence as a topic during daily rounds and reviewed hh goals during daily multidisciplinary huddles in the acute medical-surgical unit. other pdsa elements included posting and reviewing the five moments of hh and the organization's policy. to reinforce the elements of pdsas, hh evidence-based practice reminders continued to be presented at staff meetings. in july, hh adherence in the acute medical-surgical unit improved to 75%, and in the ed dropped to 81%. nursing leadership included hh reminders during one-on-one meetings. pdsa cycle two continued through the end of the three-month monitoring period. the final month saw the highest hh adherence for both units. the ed returned to 100% hh adherence, and the acute medical-surgical unit achieved 78% hh adherence. during the second pdsa cycle, the most significant improvement in hh occurred. interventions were continuous in both units. hh continued to be promoted during huddles, clinical online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 212 rounds, staff meetings, and one-on-one meetings with leadership. the hh policy remained posted at each nursing station, along with a poster on the five moments of hh. a post-intervention survey was completed in september 2021 with a higher percentage of participation than the pre-intervention survey, 64% vs. 60% respectively. during the postintervention survey, travel staff members had joined the acute medical-surgical team as permanent staff had resigned or retired. due to the staff turnover, additional questions were added regarding if the survey participant had completed a similar survey and if they had participated in education, had the education improved their adherence to hh. a fisher's exact test was completed on the two additional questions presented to survey participants. the results of the fisher exact test were significant based on an alpha value of 0.05, p = .003, indicating a higher likelihood of hh adherence if the survey participant completed the pre-intervention survey. during the qi project, the pandemic continued. there were frequent reminders at the clinical site regarding hh, and the staff was reminded of the risk of sars-cov-2 virus transmission. despite the awareness of the danger of transmission of this virus, hh adherence achieved in the acute medical-surgical unit never obtained the goal of 90%. pittet et al. (1999) found that lower hh compliance can occur during times of heavy workload. the pandemic created high workload situations globally (grimm, 2021). the institute of medicine [iom] (2004) recommended empowering nurses to speak up when quality is in danger. limitations there were several limitations to the project. the project focused on one clinical site. a larger sample size may have created different focuses for the second pdsa cycle. rural cah staff often wear many hats and participating in a voluntary survey may have been more time-consuming than the staff wished to spend. turnover in staff resulted in a change in participants from the pre online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 213 intervention to the post-intervention survey. it is unknown to what extent the change in participants affected the results. a fisher’s exact test was used to mitigate the change in participants. this examined whether someone completing a survey had completed a similar survey during the calendar year and if they had completed hh education had it influenced them to increase their hh adherence. there were two levels in whether someone had completed a survey earlier in the year: yes and no. there were also two levels in asking if they had completed hh education in 2021 and had the education influenced the participant to increase their hh adherence: yes and no. time was another limiting factor. with a third pdsa cycle, there may have been a more significant improvement. this project took place during a pandemic when everyday processes changed frequently. changes included changes in visiting hours, workload, the method in which staff training and meetings took place, and social distancing, causing decreased contact with colleagues. with staff changes, the project's focus may have had a lower impact on the target population. the outcomes may have differed if this project had been completed outside the pandemic. the pandemic made social interaction, face-to-face discussion, and training more complicated; this may have impacted the results. conclusion this qi project was conducted to improve patient and staff safety, reducing opportunities for hospital-acquired infections by improving hh adherence to 90% or greater at the clinical site. during the covid-19 pandemic, hand hygiene and other infection prevention activities have received much attention (moore et al., 2021). however, the baseline hand hygiene at the clinical site was well below goal metrics. this project was needed to promote safety and health and was timely due to the covid 19 pandemic. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 214 inappropriately placed hh equipment is not a barrier, and the online education was specific to the type of alcohol hand sanitizer at the clinical site. the education did not improve hh adherence in the acute medical-surgical unit. it did not yield sustained results in the emergency department, as evidenced by the second month of the monitoring period's rate dropping to 81%. with the implementation of the pre-intervention survey, there was an immediate rise in adherence in the emergency department. the second cycle pdsa included verbal reminders, these reminders and the pre-intervention surveys raised awareness and created discussions surrounding hh. it is possible that hh was improved through greater awareness and discussion. had the signage, education, flyers, verbal reminders and surveys not taken place the discussion and awareness may not have surfaced. a third cycle pdsa would include plans to place signs in all patient rooms encouraging patients and their families to ask each person if they had cleaned their hands before entering the room. another consideration to encourage hh is a poster presentation on developing a practice discipline for hh. in the iom's (2011) report on the future of nursing, experts comment that the nursing profession can make changes in the practice and delivery of healthcare. nurses have constant contact with patients and their families, along with the scientific knowledge to provide care. nursing and other hcws must decide to incorporate hh as part of their professional practice. references adams, s. l. 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(2001). understanding adherence to hand hygiene recommendations: the theory of planned behavior. american journal of infection control, (29)6, 352-360. https://doi.org/10.1067/mic.2001.18405 pittet, d., mourouga, p., & perneger, t. v. (1999). compliance with handwashing in a teaching hospital. infection control program. annals of internal medicine, 130(2), 126-130. https://doi.org/10.7326/0003-4819-130-2-199901190-00006 pittet, d. (2001). improving adherence to hand hygiene practice: a multidisciplinary approach. emerging infectious diseases, 7(2), 234-240. https://doi.org/10.3201/ eid0702.010217 sadule-rios, n. & aguilera, g. (2017). nurses’ perceptions of reasons for persistent low rates in hand hygiene compliance. intensive and critical care nursing, 42, 17-21. https://doi.org/10.1016/j.iccn.2017.02.005 schmier, j. k., hulme-lowe, c. k., semenova, s., klenk, j. a., deleo, p. c., sedlak, r. & carlson, p. a. (2016). estimated hospital costs associated with preventable health-care online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.736 218 associated infections in health care antiseptic products were unavailable. clinicoeconomics and outcomes research, 8, 197-205. https://doi.org/10.2147/ceor.s102505 u.s. department of health and human services. (2011). managing data for performance improvement. https://cchn.org/wpcontent/uploads/2014/04/managingdataperformanceimprovement.pdf vermeil, t., peters, a., kilpatrick, c., pires, d., allegranzi, b., & pittet, d. (2019). hand hygiene in hospitals: anatomy of a revolution. journal of hospital infection, 101(4), 383-392. https://doi.org/10.1016/j.jhin.2018.09.003 world health organization. (2004). world alliance for patient safety. https://www.who.int/teams/integrated-health-services/patient-safety/about/world-alliancefor-patient-safety world health organization. (2009). who guidelines on hand hygiene in health care. https://www.who.int/publications/i/item/9789241597906 zhou, q.,lai, x., zhang, x., & tan, l. (2020). compliance measurement and observed influencing factors of hand hygiene based on covid-19 guidelines in china. american journal of infection control, 48(9), 1074-1079. https://doi.org/10.1016/ajic.2020.05.043 715telehealthacceptancefinal_setup_9.26.22pfs (1)+formatted online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 43 telehealth acceptance among appalachian respondents during covid-19: a secondary data analysis victoria hood-wells, phd(c), bsn, msn1 florence m. weierbach, phd, bsn, mph2 amy e. wahlquist, bs, ms3 janet keener, ed.d 4 manik ahuja, phd, ma5 hadii mamudu, phd, ma, mpa, faha 6 1instructor, east tennessee state university, college of nursing, hoodwell@etsu.edu 2professor of nursing, east tennessee state university, associate director at the center for cardiovascular risk research, college of public health, weierbach@etsu.edu 3 research associate professor, center for rural health research, college of public health, east tennessee state university, wahlquist@etsu.edu 4research computing consultant, east tennessee state university, research computing and information technology services, janet@etsu.edu 5assistant professor and associate director for the center for cardiovascular risk research, east tennessee state university, college of public health, ahujam@etsu.edu 6full professor, department of health services management and policy, director at the center for cardiovascular risk research, east tennessee state university, college of public health, mamudu@etsu.edu online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 44 abstract purpose: the purpose of this study is to examine the relationship between telehealth use, telehealth satisfaction, and chronic medical conditions among residents living in appalachian and non-appalachian communities. sample: a covid-19 public health survey was distributed via social media and healthcare clinics in the tri-state region of central appalachia. survey responses were limited to adults aged ≥18 years who consented to participate in the survey that self-identified as an individual with one or more chronic medical conditions (n=195). method: simple descriptive statistics including frequencies, percentages, means, and standard deviations (sds) were calculated for variables of interest both overall and by subgroups of interest. chi-squared tests were used to compare categorical outcomes between groups of interest, while two-sample t-tests were used for continuous outcomes. significance for all tests was determined using an α level of 0.05. findings: there is no statistically significant relationship between respondents with regard to using telehealth services, satisfaction rates related to telehealth use, or reasons for electing not to use telehealth services during the covid-19 pandemic. however, there was a trending statistical relationship between county status and the use of telehealth services in appalachia with those counties doing economically better being more likely to use telehealth services as compared to those fairing less well (p=0.053). findings also suggest that people living in urban areas of appalachia were more likely to be satisfied using telehealth services than those living in non-urban areas of appalachia (p=0.01). conclusions: research is still limited as to how the expansion of broadband capabilities during the covid-19 pandemic has benefited those residing in appalachia in terms of managing chronic online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 45 health conditions. future research should focus on expanding participation among appalachian respondents looking for specific differences related to location within appalachia, age, gender, ethnicity, and socioeconomic status. keywords: telehealth, satisfaction, rural, appalachian, covid-19 telehealth acceptance among appalachian respondents during covid-19: a secondary data analysis since january 2020, there have been more than 856,000 covid-19 reported deaths across the united states spanning through both appalachian and non-appalachian communities (centers for disease control [cdc], n.d.). subsequently, providing healthcare services during a global pandemic has been met with unique challenges and often resistance as providers and patients adjust, out of necessity, to a virtual care option of healthcare delivery. those residing in rural appalachian communities are often plagued by lack of access to care, isolation, and well documented health disparities that has only been magnified by the spread of covid-19 at disproportionate rates as compared to their urban counterparts (bauerly et al., 2019; bhopalwala et al., 2022; cortelyou-ward et al., 2020; jukins et al., 2021; vanderpool et al., 2021). although the use of telehealth can play an important role in managing chronic conditions and continuity of care during the covid-19 pandemic, its overall use among various appalachian and nonappalachian communities has resulted in a variable uptake and an even more uncertain future. telehealth, covid-19, & chronic disease management in 2021 and due to the growing concern over the covid-19 pandemic, geographical restrictions were eliminated by the centers for medicare and medicaid services (cms) allowing for expanded reimbursement of telehealth services (cms, 2020a; cms, 2020b). however, its online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 46 incorporation into health care practices from both a provider and patient standpoint was primarily associated with regional location and urbanicity (demeke et al., 2020). of 245 health centers examined, rural areas of the south were consistently found to have the lowest weekly average of telehealth usage (demeke et al., 2021). either directly or indirectly, the covid-19 pandemic has impacted those suffering from chronic disease via social and economic hardship, access to health care, inability to prevent exacerbation, or lack of routine management for their chronic health condition (czeisler et al., 2020; hacker et al., 2021; london et al., 2020). the use of telehealth during a global pandemic could positively impact the health of those managing chronic conditions and the providers caring for them but only if accepted as a viable alternative to in-person provider interaction. upon a review of the literature exploring telehealth use prior to the public health crisis and subsequent mitigation strategies, several major concepts and themes regarding telehealth use and acceptance arose including community support, infrastructure, buy-in, and cost containment. throughout the works reviewed, community support of telehealth appeared to be a vital component holding a key to client utilization with researchers finding that telehealth services supported by a client’s personal healthcare provider, schools of nursing and medicine, or community-based centers were more likely to be well-received (bernstein et al., 2021; office et al., 2020; resnick et al., 2012). according to pierce et al. (2021) increased telehealth use was significantly correlated with training (p=0.002) and organizational encouragement (p=0.003). many of the researchers also stressed the importance of adequate infrastructure in order to have a successful telehealth program suggesting the need for advanced policy and procedure development, software integration, and network capabilities (calyam et al., 2016; gillespie et al., 2019; lindeman, 2011; noel et al., 2018; norman et al., 2018; o’brien et al., 2014; satariano et online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 47 al., 2014; shah et al., 2013). however, findings revealed that attitude of providers and patients can greatly encourage or hinder efforts to implementation and sustainability of telehealth services necessary to manage health and wellness with reluctance identified by not only clients, but also staff and providers (akbar et al., 2020; carolan et al, 2020; shah et al., 2013). telehealth services have been shown to decrease the financial burden associated with managing chronic conditions including ambulance transport, emergency room costs, and potential risks associated with hospitalization (calyam et al., 2016; gillespie et al., 2019; norman et al., 2018; shah et al., 2013), but its utilization and acceptance remains variable. currently, there is a lack of research in the united states on telehealth use during the pandemic or due to the pandemic in terms of client perception, experience, and factors impacting its utilization comparing appalachian and nonappalachian communities. examining these concepts can help providers to identify potential barriers to telehealth success and develop strategies designed to improve overall health of rural appalachian residents using telehealth as a means of managing chronic health conditions. a covid-19 public health survey was distributed to adults aged 18 years and over via social media and healthcare clinics focusing mainly in the tri-state region of central appalachia. the survey received irb approval from a regional university prior to administration. the focus of the survey was on covid-19 mitigation strategies, health literacy, and chronic health conditions. the survey also addressed alternate methods of receiving health care services for those with chronic health conditions which included the use, acceptability, and accessibility of telehealth services. the purpose of this study is to examine the relationship between telehealth use, telehealth satisfaction, and chronic medical conditions among residents living in appalachian and nonappalachian communities. a secondary data analysis was conducted using the covid-9 public health survey results. online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 48 methods and analysis for this study, survey responses were limited to adults aged ≥18 years who consented to participate in the survey that self-identified as an individual with one or more chronic medical conditions and answered two specific questions on the survey: 1) have you ever used telemedicine services? and 2) when the vaccine for covid-19 becomes available to you, will you seek to obtain it?. respondents were classified as being appalachian or non-appalachian based on their self-reported response for county and state where the individual lives, according to appalachian regional commission (arc) designation for the appalachian region (n.d.-a)). county level data was determined using arc’s county economic status and distressed areas by state 2021 report (n.d.-b)), and rural/urban data was determined using the 2013 rural-urban continuum codes (economic research service [ers], n.d.)). when county and/or state was missing or invalid, respondents were excluded from those corresponding analyses. data was analyzed based on telehealth use (independent variable) and dependent variables including age, education level, reasons for not using telehealth, arc designation, and rural-urban continuum codes. simple descriptive statistics including frequencies, percentages, means, and standard deviations (sds) were calculated for variables of interest both overall and by subgroups of interest. chi-squared tests were used to compare categorical outcomes between groups of interest, while two-sample t-tests were used for continuous outcomes. significance for all tests was determined using an α level of 0.05. findings of the original 430 survey participants, 195 responded met all inclusion criteria for this study, with 175 having available data on appalachian (vs. non-appalachian) status. the vast majority of online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 49 participants (n=169) reported female (86.7%) and had at least some degree of post-secondary education (table 1). table 1 demographic data of study population (n=175) mean (sd) demographics appalachian n = 85 nonappalachian n = 90 gender female 71 (84%) 80 (89%) male 12 (14%) 10 (11%) other 2 (2%) 0 (0%) age in years 53.54 (14.18) 54.49 (12.34) education high school graduate/ged 11 (14%) 17 (20%) some college/associate’s/bachelor’s degree 47 (59%) 49 (58%) post undergraduate 22 (28%) 18 (21%) note: percentages are based on non-missing values telehealth use a total of 20 participants were excluded from this analysis due to absence of a valid county on the survey instrument and were therefore unable to determine appalachian or non-appalachian status. based on the remaining data (n=175), the majority of respondents (71.4%) reported using telehealth services sometime during the covid-19 pandemic. the majority of both appalachian (n=61, 72%) and non-appalachian residents (n=64, 71%) reported using telehealth services during the pandemic (p=0.9). respondents that denied use of telehealth services included 24 from appalachia (28%) and 26 non-appalachian respondents (29%). combined, those that answered no to using telehealth services (n=50) accounted for 28.6% of the total population examined. there is no statistically significant relationship between appalachian versus non-appalachian respondents with regard to using telehealth services during the covid-19 pandemic. based on these initial findings, additional subset analyses for appalachian counties examined relationships online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 50 between the arc (n.d.-b)) guidelines for economic and distressed areas and the ers (n.d.) ruralurban continuum codes for appalachian counties. the results for telehealth use accounting for appalachian non-urban versus appalachian urban respondents produced similar results as those found in appalachian versus nonappalachian. of respondents in non-urban appalachian counties (n=11), results in terms of use were almost equally divided with 45% denying use of such services and 55% answering yes to using telehealth services during the pandemic. of the respondents classified as residing in urban appalachian counties (n=73), almost three-quarters (74%) reported using telehealth services, while 26% denied (n=19). there is not a statistically significant relationship between nonurban/urban status and the use of telehealth services in appalachia (p=0.3). one west virginia county was excluded from analysis due to the county being listed as usa. any additional respondents that did not include a county were excluded from analysis resulting in a total of 84 appalachian respondents included in the analysis. using the county economic status as outlined by arc (n.d.-b)), respondents fell into one of two categories: competitive/transitional or at-risk/distressed. of the respondents from competitive/transitional counties (n=78), 74% reported using telehealth services during the covid-19 pandemic. conversely, from atrisk/distressed counties (n=6), 67% denied using such services. there was a trending statistical relationship between county status and the use of telehealth services in appalachia with those counties doing economically better being more likely to use telehealth services as compared to those fairing less well (p=0.053). telehealth satisfaction the incorporation of telehealth services into an individual’s healthcare practices relies upon user satisfaction and confidence with care provided at a distance. of the 125 appalachian versus online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 51 non-appalachian respondents examined, the majority were satisfied with their telehealth visit (n=72, 57.6%). notably, and despite physical location, the use of telehealth services was supported by 62% of appalachian respondents (n=38/61) and by 53% of non-appalachian respondents (n=34/64). a total of 48 respondents reported their experience with telehealth services as neutral (38.4%) and the remaining respondents (n=5, 4%) reported dissatisfaction. findings suggest that there are no differences in satisfaction of using telehealth between appalachian and nonappalachian respondents (p=0.6). similar results were found when examined using competitive/transitional counties as compared to at-risk distressed counties with 61.7% of overall respondents reporting satisfaction with their telehealth experience (table 2). findings once again suggested that there are no differences in satisfaction of using telehealth between competitive/traditional versus at-risk/distressed counties (p>0.9). table 2 telehealth satisfaction (n = 125) unsatisfied neutral satisfied appalachian (n=61) 2 (3%) 21 (34%) 38 (62%) non-appalachian (n=64) 3 (5%) 27 (42%) 34 (53%) appalachian urban (n=54) 0 (0%) 20 (37%) 34 (63%) appalachian non-urban (n=6) 2 (33%) 1 (17%) 3 (50%) appalachian competitive/transitional county (n=58) 2 (3%) 20 (34%) 36 (62%) appalachian at-risk/distressed county (n=2) 0 (0%) 1 (50%) 1 (50%) *participants that reported telehealth use although the initial results did not suggest differences in satisfaction among respondents, additional analysis suggested otherwise when appalachian communities were divided into urban versus non-urban areas. of the 60 appalachian respondents, 37 (61.7%) were satisfied with their overall experience. analysis revealed that 50% (n=3) of non-urban appalachian respondents reported being satisfied with using telehealth as compared to 63% (n=34) of urban appalachian respondents. as such, findings suggest that people living in urban areas of appalachia were more online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 52 likely to be satisfied using telehealth services than those living in non-urban areas of appalachia (p=0.01). potential barriers to telehealth use the use of telehealth services can potentially improve access to care but it can also encounter factors or barriers that hinder overall acceptance and use within communities. within the survey instrument, respondents who did not use telehealth were given a selection of reasons to why telehealth services were not used including: lack of internet access, lack of adequate phone or computer, confusion about how it works, preference for an in-person provider, and medical care not required. analysis of the data strived to understand the relationship between reasons for not using telehealth services and classifications based on appalachian/non-appalachian, appalachian urban/appalachian non-urban, and county economic status. a thorough examination of each factor revealed that there are no differences in reasons for not using telehealth among respondents whether examined as appalachian versus non-appalachian, competitive/transitional versus atrisk/distressed counties, or appalachian urban versus appalachian non-urban (table 3). table 3 reasons for not using telehealth (n=50)* appalachian n=24 nonappalachian n=26 appalachian urban n=19 appalachian non-urban n=5 appalachian competitive/ transitional n=20 appalachian at-risk/ distressed n=4 lack of internet access 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) lack of adequate phone/computer 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) confusion about how it works 2 (8%) 1 (4%) 1 (5%) 1 (20%) 1 (5%) 1 (25%) prefer to visit healthcare provider in person 16 (67%) 17 (65%) 13 (68%) 3 (60%) 13 (65%) 3 (75%) online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 53 appalachian n=24 nonappalachian n=26 appalachian urban n=19 appalachian non-urban n=5 appalachian competitive/ transitional n=20 appalachian at-risk/ distressed n=4 have not required medical care 8 (33%) 9 (35%) 6 (32%) 2 (40%) 6 (30%) 2 (50%) *participants that did not report telehealth use. note that these options are not mutually exclusive, and participants could choose more than one reason impact of age and education level on telehealth use technology acceptance and telehealth use can often be impacted based upon participant characteristics such as the age of those using the services and their level of education. survey data was examined to assess if there was a relationship between using telehealth and age or education level. upon examination, those that had used telehealth had a mean age of 53.9 years (sd=12.6) and those that had not used telehealth had a mean age of 54.9 years (sd=13.9). analysis suggests that there is no statistically significant relationship between age and using telehealth (p=0.7). a total of 193 respondents answered the questions related to education and telehealth use. of those respondents, two were removed from this specific analysis reporting an education level of less than high school and an additional eight were removed for “other” leaving 183 respondents for evaluation. a total of 133 (72.7%) respondents reported ever using telehealth services with the vast majority of total participants having at least some level of post-secondary education. although there was not a statistically significant relationship between education level and use of telemedicine (p=0.1), there did appear to be a trend with respondents of lower education level being less likely to use telehealth services as compared to participants of a higher level of education. online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 54 discussion telehealth use a relationship was determined to exist between county economic status and the use of telehealth services in appalachia with those counties doing economically better being more likely to use telehealth services as compared to those fairing less well. recent research supports this finding suggesting that areas with higher levels of economic distress are less likely to use telehealth services due to their rural nature regardless of the dramatic increases in acceptance nationwide secondary to the effects of covid-19 (patel et al., 2021). research also suggests that those residing in rural communities represent a less significant percentage of users as compared to those living in urban communities, with lowest participation rates occurring in appalachian areas of kentucky, tennessee, and the midwest (friedman et al., 2022; suran, 2022; vanderpool et al., 2021). although often cited as a potential barrier to telehealth use (bauerly et al., 2019; cortelyouward et al., 2020), lack of internet access did not appear to be a contributing factor to telehealth use in this study with all respondents denying problems with broadband capabilities or lack of access to an adequate phone or computer. rural isolation can lead to issues with broadband access. however, these findings are consistent with recent research suggesting that 97% of all americans own a cell phone, approximately 75-85% own either a laptop or desktop computer, and there is an increased reliance among smartphones found among those of lower socioeconomic status and possessing less than a post-secondary education level (pew research center, 2021). however, additional research is warranted to see if these findings are consistent among all rural communities in appalachia. online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 55 the significant differences in sociodemographics, in terms of regionality and the lack of ethnic diversity among research participants, also requires further exploration. telehealth services has the potential to maintain continuity of care in individuals suffering from chronic health conditions in appalachian communities, but those residing in economically distressed areas of appalachia do not appear to benefit from its use. because the sample size was small when looking through the lens of rural-urban continuum codes, a larger sample size from various appalachian communities is warranted. larger studies are needed to allow for not only appalachian versus non-appalachian but also appalachian urban versus appalachian rural comparison. additionally, future research must take a closer examination of reasons why the use of such technologies has not faired well within this specific vulnerable population accounting for differences in gender and ethnicity. telehealth satisfaction satisfaction with telehealth services is a key factor to sustainability in managing chronic health conditions among those living in rural and urban areas along the appalachia. findings in this study found that there are no differences in satisfaction in telehealth use between appalachian and non-appalachian respondents as well as respondents compared by county status. however, findings do suggest that respondents living in non-urban areas of appalachia are less satisfied with telehealth services as compared to those from urban areas of appalachia. prior to the covid-19 pandemic, satisfaction with telehealth use was subject to mixed review with a lack of focus on appalachian communities. the vast majority of research suggested high levels of satisfaction with telehealth use in more urban communities and metropolitan areas across the united states (akbar et al., 2020; calyam et al., 2016; shah et al., 2013). however, research found distinct differences between age groups with those of younger age and higher online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 56 education level reporting more favorably to telehealth use as compared to those of older age and lower education level. results suggested that adults age 55 years and older were less acceptable of receiving medical care via telehealth secondary to inexperience with technology, decreased health literacy, and distrust (akbar et al., 2020). during the covid-19 pandemic, research suggests high levels of satisfaction expanding into various urban and rural communities though not necessarily specific to appalachia (brown et al., 2020; chen et al., 2022; junkins et al., 2021; ramaswamy et al., 2022; silvestrini et al., 2021; thomson et al., 2021). although expanded research has provided valuable data, still little is known about telehealth satisfaction among varying communities within appalachia. future studies are needed to explore telehealth acceptance and satisfaction among various age groups within appalachia. implementation research is also needed to evaluate satisfaction among this population with exploration into guidelines that aid the building of successful telehealth models that are well received within this specific population. furthermore, research should focus on processes needed to increase engagement and satisfaction with identification of factors that may impair attitudes toward telehealth use and community sustainability so that residents of appalachia have the same opportunity to manage their chronic health conditions as their urban counterparts. potential barriers to telehealth use telehealth services has the potential to help manage chronic health conditions among residents of appalachia but has been hampered in the past by a variety of barriers. this study strived to examine potential barriers to telehealth use among this population during the covid19 pandemic including: lack of internet access, phone, or computer; confusion about telehealth; preference for in-person provider interaction; and, medical care not required. findings suggest that there are no differences in reasons for not using telehealth among respondents whether examined online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 57 as appalachian versus non-appalachian, competitive/transitional versus at-risk/distressed counties, or appalachian urban versus appalachian non-urban. according to the population reference bureau (n.d.), the digital divide still exists between regions of the united states and appalachia and within appalachian rural and appalachian urban areas. between the years of 2013-2017 and of the 420 appalachian counties examined, less than 75% of households owned a computer device especially in areas in and around central appalachia. additionally, less than 60% of households in the appalachian counties examined subscribed to broadband internet services (population reference bureau, n.d.). research conducted by o’brien et al. (2014) in the appalachian region of north carolina found that only 79% of the participants in their study owned a cellular phone, however only one of the cell phone owners possessed a smartphone capable of accessing the internet. furthermore, the authors found that a large percentage of the participants (30-50%) either did not own a desktop computer, laptop, or have knowledge as to how to use the internet. similar results were found during the covid-19 pandemic with 22% of north carolina appalachian areas lacking internet connection at rates of 22-40% (engel-smith, 2021). cortelyou-ward et al. (2020) stresses that the limited broadband access found in many rural areas must be considered a social determinant of health impacting both individuals and communities. limitations there are several limitations noted in this study. first, and as a retrospective study, there is no comparison of results prior to the covid-19 pandemic from which to compare. second, the limitation to a web-based survey instrument prevents the recruitment of participants that lack internet access which could lead to potential bias towards participants with a higher level of digital literacy. third, the participants in this study appear to be highly educated and may not be online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 58 representative of all rural appalachian communities. fourth, the sample size specific to rural appalachia was relatively small making generalizability difficult. lastly, the study population lacked ethnic and racial diversity resulting in an inability to capture results from underrepresented minorities living in rural areas of appalachia. implications & future research although broadband capabilities have expanded in response to the covid-19 pandemic, there is limited research as to how the expansion has benefited those residing in appalachia in terms of managing chronic health conditions. research reflects the need for published surveillance and strategies used for telehealth in appalachian communities, as well as qualitative examination to explore potential barriers toward its implementation. research should also be designed to assess the type of training needed to support its use among this population. because sample sizes were relatively small within the sample population of interest and scattered among varying geographical locations of appalachia, future research should focus on expanding participation among appalachian respondents looking for specific differences related to location within appalachia, age, gender, ethnicity, and socioeconomic status. references akbar, a., iqbal, a., gaziano, d., gasior, f., zaidi, a. j., iqbal, a., & silva, a. 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(2022). telemedicine catches on: changes in the utilization of telemedicine services during the covid-19 pandemic. the american journal of managed care, 28(1), e1-e6. https://doi.org/10.37765/ajmc.2022.88771 gillespie, s. m., wasserman, e. b., wood, n. e., wang, h., dozier, a., nelson, d., mcconnochie, k. m., & shah, m. n. (2019). high-intensity telemedicine reduces emergency department use by older adults with dementia in senior living communities. journal of the online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 62 american medical directors association, 20(8), 942–946. https://doi.org/10.1016/j. jamda.2019.03.024 hacker, k. a., briss, p. a., richardson, l., wright, j., & petersen, r. (2021). covid-19 and chronic disease: the impact now and in the future. preventing chronic disease, 18, e62– e62. https://doi.org/10.5888/pcd18.210086 junkins, a., psaros, c., ott, c., azuero, a., lambert, c. c., cropsey, k., savage, r., haberer, j. e., safren, s. a., & kempf, m. c. (2021). feasibility, acceptability, and preliminary impact of telemedicine-administered cognitive behavioral therapy for adherence and depression among african american women living with hiv in the rural south. journal of health psychology, 26(14), 2730-2742. https://doi.org/10.1177/1359105320926526 lindeman, d (2011). interview: lessons from a leader in telehealth diffusion: a conversation with adam darkins of the veterans health administration. ageing international, 36(1), 146– 154. https://doi.org/10.1007/s12126-010-9079-7 london, j. w., fazio-eynullayeva, e., palchuk, m. b., sankey, p., & mcnair, c. (2020). effects of the covid-19 pandemic on cancer-related patient encounters. jco clinical cancer informatics, 4, 657–665. https://doi.org/10.1200/cci.20.00068 noel, k., yagudayev, s., messina, c., schoenfeld, e., hou, w., & kelly, g. (2018). teletransitions of care. a 12-month, parallel-group, superiority randomized controlled trial protocol, evaluating the use of telehealth versus standard transitions of care in the prevention of avoidable hospital readmissions. contemporary clinical trials communications, 12, 9–16. https://doi.org/10.1016/j.conctc.2018.08.006 norman, g. j., orton, k., wade, a., morris, a. m., & slaboda, j. c. (2018). operation and challenges of home-based medical practices in the us: findings from six aggregated case online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 63 studies. bmc health services research, 18(1), 45–45. https://doi.org/10.1186/s12913018-2855-x o’brien, t. r., treiber, f., jenkins, c., & mercier, a. 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(2021). changes in physician telemedicine use during covid-19: effects of practice setting, demographics, training, and organizational policies. international journal of environmental research and public health, 18(19). https://doi.org/10.3390/ijerph 18199963 population reference bureau. (n.d.). as schools close in response to coronavirus, children in rural appalachia may have less access to tools for remote learning. https://www.prb.org/resources/appalachias-digital-gap-in-rural-areas-leaves-somecommunitiesonline journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 64 behind/#:~:text=during%20the%202013%2d2017%20period,60%20percent%20(see%2 0figure) ramaswamy, a., yu, m., drangsholt, s., ng, e., culligan, p. j., schlegel, p. n., & hu, j. c. (2022). patient satisfaction with telemedicine during the covid-19 pandemic: retrospective cohort study. journal of medical internet research, 22(9), e20786. https://doi.org/10.2196/20786 resnick, h. e., ilagan, p. r., kaylor, m. b., mehling, d, & alwan, m. (2012). teahm technologies for enhancing access to health management: a pilot study of communitybased telehealth. telemedicine and e-health, 18(3), 166-174. https://doi.org/10.1089/tmj.2011.0122 satariano, w. a., scharlach, a. e., & lindeman, d. (2014). aging, place, and technology: toward improving access and wellness in older populations. journal of aging and health, 26(8), 1373–1389. https://doi.org/10.1177/0898264314543470 shah, m. n., mcdermott, r., gillespie, s. m., philbrick, e. b., nelson, d., & lang, e. (2013). potential of telemedicine to provide acute medical care for adults in senior living communities. academic emergency medicine, 20(2), 162-168. https://doi.org/10.1111/acem.12075 silvestrini, m., indresano, j., zeliadt, s. b., & chen, j. a. (2021). “there’s a huge benefit just to know that someone cares.” a qualitative examination of rural veterans’ experiences with telepain. bmc health services research, 21(1), 1-8. https://doi.org/10.1186/s12913-02107133-5 suran, m. (2022). increased use of medical telehealth during the pandemic. journal of the american medical association, 327(4), 313. https://doi.org/10.1001/jama.2021.23332 online journal of rural nursing and health care 22(2) https://doi.org/10.14574/ojrnhc.v22i2.715 65 thomson, m. d., mariani, a. c., williams, a. r., sutton, a., & sheppard, v. b. (august 5, 2021). factors associated with use of and satisfaction with telehealth by adults in rural virginia during the covid-19 pandemic. jama network open, 4(8), e2119530. https://doi.org/10.1001/jamanetworkopen.2021.19530 vanderpool, r. c., stradtman, l. r., gaysynsky, a., & chen, q. (2021). access to use of technology for health: comparisons between appalachian kentuckians and the general u. s. population. journal of appalachian health, 3(4), 60-73. https://doi.org/10.13023/ jah.0304.06 626-article text-3913-1-6-20200416 online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v20i1.626 1 editorial covid 19 and rural health care pamela stewart fahs, phd, rn, editor nurses have long been educated about the need to prepare for a possible future pandemic, it seems the future is now. during times of public health or natural disasters people who have the resources have historically fled cities to more rural locations. with this highly contagious covid 19 virus, rural area health resources may soon be stretched to the limit. meit, kennedy, and briggs (2007) wrote about the potential rural population surge during a future pandemic scenario and the problems the burdens this could cause in rural health care systems. those passing through rural areas may unknowingly spread a virus if the stop for fuel, food or temporary lodging. survey data (meit, briggs, & kennedy, 2008) estimated that about 25% of an urban population may evacuate the more urban areas during a pandemic, even when the government is asking them to shelter in place (p.16). the potential for urban evacuation is more likely without any government recommendation. early rural hotspots such as ski areas in colorado saw transmission from both domestic and international visitors before travel bans were put into place. rural areas that are vacation spots are more likely to see earlier covid – 19 cases than more difficult to access or less popular rural places. however, those who think the pandemic will not reach their rural community are most likely mistaken. the surge may be later or smaller than in highly metropolitan areas, but it will take fewer numbers to quickly overtake the capacity of the rural health care system. since 2010 the university of north carolina sheps center for health research (n.d.) have been reporting about the increasing number of closures of rural hospitals. as of 2019 104 rural hospitals had closed in the past decade (fahs, 2019); with eight more closing in the first few months online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v20i1.626 2 of 2020. this means that the communities that have been able to rely on a hospital in the past are less likely to be able to do so today. this has raised many issues from the lack of maternal / child care in rural areas to the negative economic effect from diminished employment opportunities for rural communities. the health care workforce is usually smaller in rural areas. rural health care practices and facilities are known to have difficulty attracting and retaining nurses, nurse practitioners and physicians than the more urban areas (fahs & rouhana, 2020). rural areas generally have more limited access to health care, fewer facilities and many are on the brink of an insufficient health care infrastructure. one positive of rural healthcare facilities is that those in the system consistently report comradery and team work as essential in rural health care. nurses are more likely to practice to the full extent of their licensure, with more skills developed across units and situations than typically seen in large metropolitan hospitals. rural nurses are often cross-trained to have the flexibility they need to care for a wide variety of health situations that can occur in a rural facility. if a rural hospital is big enough to have an icu, when there are no icu patients that nurse may be cross trained for the emergency department (ed) or assigned to another area. rural nurses are the consummate generalist (fahs, 2017). rural areas also have smaller emergency medical systems (ems) and often rely on volunteer ems. critical access hospitals (cah) are among the smallest types of hospitals and may staff the ed with a nurse practitioner (np) or physician’s assistant (pa) rather than a physician. these hospitals (cah) have no more than 25 beds, with the possible extension of 10 beds for rehabilitation or mental health. the cah is also supposed to discharge or transfer a patient within 96 hours according to the funding regulations. a cah is not likely to have icu beds and ventilators are most likely anesthesia machines for needed procedures. this type of hospital is online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v20i1.626 3 designed to treat and release, hold for a short time period or transfer to higher level facilities for serious problems. some areas have rural hospitals with a bit more capacity than cahs; yet these also tend to be smaller than urban facilities and if they do have icu beds the number are significantly fewer than their urban counterparts. thus, it is not hard to imagine the rural health care system being overtaxed from a pandemic even though the population sizes are smaller. for years what is called the rural mortality penalty has been recognized (kalman, wells, & fahs, 2018). for reasons yet to be fully explained all-cause mortality is disproportionally higher in rural or non-metropolitan places. this means that even when controlling for some variables such as age, there are more than expected deaths in non-metropolitan versus metropolitan populations. some of this may be due to difference in access to health care. rural places tend to have a higher population of those 65 years of age and older and rural populations have a high mortality and morbidity rate in many major chronic illnesses such as heart disease, diabetes and chronic obstructive lung disease (alreshidi, kalman, wells, & fahs, 2020). the above types of chronic illnesses coupled with the higher population of elders indicates the rural population may be particularly vulnerable to covid 19 complications. there are several rural concepts that are thought to influence how rural populations may think about health, health care and health crises. among these are familiarity/ lack of anonymity, self-reliance, newcomer/ old-timer, insider/outsider, lack of transportation, as well as distance and isolation. traditionally rural dwellers have defined health as the ability to work or function, (lee & mcdonagh, 2018). this remains true in certain rural populations including those that are older, male or live in areas of extractive industries (e.g. agriculture, mining, forestry, and fishing). in this group many define themselves around their ability to work and will place the need to work higher than the need for health care unless it is a major emergency or children are at a high risk. online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v20i1.626 4 there is less emphasis on prevention in rural populations. familiarity, or conversely, the lack of anonymity, has both positive and negative consequences. neighbor are more likely to know and help neighbor, everybody knows everybody in rural communities. however, if social distancing is the desired behavior this may be more difficult to communicate to those living in rural areas. selfreliance often means rural citizens believe strongly that they can take care of themselves and family without outside interference. there are major problems with transportation in rural areas, particularly for those with lower socioeconomic means. in the east, it is not unusual to have to drive 45 minutes or more to get to a rural hospital or health care provider. in the west, such as places like montana, these distances can be even longer. some people may think it can’t happen here when in fact a disease as contagious as covid-19 will most likely be felt everywhere. some places may be later in the cycle and although one would think this gives an area more time to prepare; in rural areas where access to health care is already limited, the system may be over-run sooner after the presence of the virus is known. references alreshidi, b. g., kalman, m., wells, m., & fahs, p. s. (2020). cardiovascular risk reduction in rural women. a literature synthesis. journal of cardiovascular nursing 35(2), 199-209. https://doi.org/10.1097/jcn.0000000000000622 fahs, p.s. (2019). editorial: where have all the rural hospitals gone? online journal of rural nursing and health care, 19(1). 1-3. http://dx.doi.org/10.14574/ojrnhc.v19i1.580 fahs, p.s. (2017). leading-following in the context of rural nursing. nursing science quarterly, 30(2), 176-178. https://doi.org/10.1177/0894318417693317 online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v20i1.626 5 fahs, p. s. & rouhana, n. (2020). rural health care: workforce challenges and opportunities. (pp. 437-446). in d. j. mason, e. l. dickson, m. r. mclemore, & g. a. perez. (eds.). policy and politics in nursing and health care (8th ed., 437-446). u.s.: saunders. kalman, m. b., wells, m., & fahs, p. s. (2018). educating rural women about gender specific heart attack and prodromal symptoms. online journal of rural nursing and health care 18(2), 113-133. http://dx.doi.org/10.14574/ojrnhc.v18i2.519 lee, h. j. & mcdonagh, m. k. (2018). updating the rural nursing theory base. in c. a. winters & h. j. lee (eds.). rural nursing: concepts, theory, and practice (5th ed., 45-62). new york: springer. https://doi.org/10.1891/9780826161710.0004 meit, m., kennedy, a., & briggs, t. (april, 2007). urban to rural evacuation: policy brief. norc: walsh center for rural health analysis meit, m. briggs, t., & kennedy, a. (2008). urban to rural evacuation: planning for rural surge: final report. rural health research & policy centers and norc walsh center for rural health analysis. retrieved from https://www.norc.org/pdfs/publications/urbanto ruralevacuationplanningforruralpopulationsurge_finalreport.pd f lane_518 online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 88 impact evaluation of nurse advocacy center for underserved on population health adrianne j. lane, edd, msn, rn, cne professor, college of health professions, northern kentucky university, lanea6@nku.edu abstract purpose: the purpose of this article is to describe a project undertaken to measure the impact of an academic/practice partnership, the nurse advocacy center for underserved (nacu), on the population health of the region with a goal to design an impact evaluation to measure outcomes of an academic/practice partnership. sample/method: the sample included clients, staff, students, faculty, and volunteers from nacu sites. data was collected through patient survey, focus groups, check-sheet, and satisfaction survey. analysis was informed by a logic model and the triple aim. findings: results of focus groups identified themes of advocacy, environment, substance abuse, access, and preventative services. check-sheet results revealed useful areas for measuring impact on regional health were perception of health and hepatitis c status. satisfaction survey results demonstrated that the experience in providing services through nacu was rated as good (10%), very good (50%), and excellent (40%) for non-students and good (15%), very good (23%), excellent (42%) for students. findings support that nacu impact measures align with the foci areas identified by regional health department and greater community. conclusions: a comprehensive impact evaluation is effective in measuring impact of the academic/practice partnership nacu on the health of the community and region. dissemination of results will foster similar initiatives that address population health by creating academic/practice online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 89 partnerships that focus on health care disparities among the underserved. academic/practice partnerships can adapt this logic model evaluation strategy for use in determining impact on similar populations, particularly in areas where access is limited such as rural communities. population health capacity will be expanded through the dissemination of evidence related to developing and maintaining community and public health partnerships, building public health competence through such partnerships, and improving the health of target populations in urban, suburban, and rural communities. keywords: health impact assessment, vulnerable populations, population health, program evaluation, health care quality, access, evaluation impact evaluation of nurse advocacy center for underserved on population health the need for healthcare is more evident than ever in the underserved population. according to the us department of health and human services the underserved are those who have “systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” (para 1, 2010). these obstacles lead to gaps in health status between the general population and the underserved; these gaps are called health disparities. with worldwide trends towards increasing urbanization of the population, a widening gap between the rich and the poor, and increasing health disparities between the rich and the poor, a concerted effort by all is required in order to address the health needs of the underserved. this gap is evident in two distinct groups of people: those in rural communities and those who are online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 90 homeless. addressing the medical issues of both groups of people is a health equity challenge (rhihub, n.d.; koh & o’connell, 2016). the health of the underserved is a barometer for the health of the population as a whole; i.e. the health of a region is only as good as the health of its most vulnerable population. the health of a community directly impacts the overall economic strength of a community (blue cross blue shield association, n.d.) https://www.bcbs.com/the-health-of-america/articles/healthycommunities-mean-better-economy. high numbers of underserved in a community burden the health care system by inappropriate use of emergency departments and inability to pay for care. in one study by truven health analytics 71% of all ed visits were avoidable (rodak, 2013). this adds up to more than $18 billion per year spent in the us on avoidable visits to emergency departments (choudhry et al., 2007). the purpose of this article is to describe a project undertaken to measure the impact of an academic/practice partnership, the nurse advocacy center for underserved, on the population health of the region. the goal of the project was to design an impact evaluation that measured outcomes of an academic/practice partnership addressing the needs of the underserved. the academic/practice partnership was between a nurse advocacy center for underserved (nacu) and a regional health department with a goal to build health capacity in the region among the underserved. one of the priorities in achieving improvements in population health is aimed at reducing health disparities in certain groups. this evaluation project benefited the public health community by demonstrating the effectiveness of an academic/practice partnership aimed at addressing health needs in underserved populations. the key objectives of this project were to 1) design a comprehensive evaluation plan based on a logic model, 2) collect and analyze data for identified strategies within the plan, 3) determine the next steps for nacu operations including online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 91 delivery of care, evaluation, advocacy, and sustainability, and 4) disseminate knowledge gained. results of the impact evaluation provided a basis for the nacu to further its mission to improve health of the underserved. this project resulted in a process for ongoing impact evaluation of the nacu aligned with designated regional health outcomes as identified by the regional health department. such ongoing evaluation provides a basis for seeking grants and funding to support collaborative efforts to address key health initiatives in the region. the focused and collaborative process followed can serve as a model for other communities, both urban and rural, to align outcomes measures and data collection to facilitate addressing regional health care needs. other academic/practice partnerships can adapt the nacu logic model driven evaluation strategy for use in determining impact on similar populations. disseminating the results will foster similar initiatives to address population health through creating similar academic/practice partnerships to address the health care disparities among the underserved. background in 2006, a nurse advocacy center for the underserved (nacu) was formed by a group of nursing faculty and students at a midwestern regional university. this university has as a strong mission of community engagement. the university is recognized for its civic engagement and community outreach. it was one of the first universities to be classified as a “community engagement” institution by the carnegie foundation for the advancement of teaching in 2006. a component of the university’s mission is to contribute to the economic, civic, and social vitality of the region. the university identifies community engagement as one of the five goals for achieving their mission. one strategy for working toward such a goal is to apply the talents of online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 92 faculty, staff, and students through research, outreach, partnerships, and other community engagement activities. aligned with the mission of the university, the college of health professions (chp) has a mission to “promote an innovative environment to facilitate excellence in academics, scholarship, engagement, practice, leadership and lifelong learning within a global context to promote health” (2017). this mission is strongly supported and promoted by college of health professions advisory board. the district director of health for the regional health department, is a longtime member of the college advisory board. this relationship has been core to the partnership and collaborative opportunities that college has had and continues to have with the regional health department. the mission of the regional health department has changed little since 2014 and today is to “prevent disease, promote wellness and protect against health threats” (2017). to achieve the mission, the health department provides an array of programming focused on, but not limited to, flu vaccines, hepatitis b vaccines, influenza vaccines, smoking cessation, diabetes management, immunizations, oral care, affordable care act (aca) enrolment assistance, hiv/aids, substance abuse, and maternal-child health. the support of the university, college, and regional health department are at the core of the ongoing services provided by nurse advocacy center for the underserved (nacu). the impetus for the founding of nacu is the recognition of the important role outreach nursing services play on impacting health disparities of the underserved. this center advocates for quality health care for all persons and has a mission to improve the health of the underserved. collaboration, teamwork, and partnering are core to addressing these needs throughout region. nacu is a key partner in providing and supporting program foci in the underserved populations of the area. in 2012 nacu was selected as the recipient of a regional health department award online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 93 of excellence in public health. this award was given in recognition of individuals and organizations within the region that collaborate with the health department to promote public health. nacu was nominated by staff in the clinical services division of the health department. the nomination specifically mentioned nacu efforts to provide flu and hepatitis b vaccine to the homeless population, reduce unnecessary visits to local emergency rooms and other health promotion activities. nacu has numerous partner sites which include, but are not limited to, homeless shelters, recovery centers, crisis centers, and public housing. many nursing students have clinical rotations at one or more of the nacu partner sites. over the years, nacu has been awarded grant money to support the hiring of nurse practitioners on a limited basis at several of the nacu partner locations. in 2008 a church in a nearby area that serves weekly dinners for those who are homeless became a partner of nacu partner. nursing faculty and students provide care at the established nurse clinic for the adults who come to dinners offered twice a week. in the first year alone, there were 469 visits to the nurse clinic run by the faculty and students at the church. the main health care needs for which the individuals sought care were hypertension, respiratory infections, injuries on the job or from assault, pain, depression/anxiety, and dental problems. clients are homeless men, women, and children, women in substance abuse rehabilitation, women in shelters for domestic violence, and individuals and families in public housing. nacu has a proven record of stability in structure, collaboration with community partners, and service learning for students that will allow it to meet the opportunities and challenges of the future central to the nacu model is the delivery of services on site where underserved persons reside, work or congregate. compared to the general population the underserved have greater barriers to health including lack of insurance, inability to pay, and lack of social support networks online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 94 which result in poorer health status. gaps in health status of the underserved versus the general population are defined as health disparities. on-site services eliminate some of the barriers and decrease health disparities. between 2003 and 2014, the number of locations where services have been provided has grown and the number of people with access to a nurse from barely over 100 to several thousand. the organization has continued to grow thanks to committed nacu leadership including the director, assistant director, and faculty and staff of the college, ongoing support and opportunities provided by partnering agencies, particularly the regional health department, and projects led by nursing students. the nacu sites provide health education and health services. specific services provided depend on the needs of that population and funding. nacu incorporates a model of placing faculty, students, and volunteers where the underserved reside, work, or congregate; this model has proven successful. students from the bsn, accelerated bsn, rn-bsn, respiratory therapy, counseling, social work, and public administration have become engaged with the underserved in the region through nacu. characteristics of individuals who receive services at nacu locations include un-insured, underinsured, homeless, low education level, unemployed, or living in public housing. since its very beginning in 2006, nacu has collaborated with the regional health department to provide services to the underserved throughout the region. nacu has proven its ability to work with the regional health department and other community partners in addressing community health care needs by placing faculty, students, and collaborators where the underserved live and congregate. over these years nacu has collected both formative and summative evaluation data through both formal and informal means. examples of formative assessment conducted include evaluation of processes for volunteer recruitment, grant funding, care delivery, care documentation, and flu vaccine administration. changes have been made to the way services have online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 95 been offered based on formative assessments; these have included the addition of hours and/or days at specific locations, the addition of services such as those of a nurse practitioner or social worker counseling students and the addition of undergraduate community nursing clinical groups and bsn capstone students. further, examples of summative assessment have included number of patients per year per site, number of visits per year per site, referrals to providers per year at some sites, number of attendees at health education programs per year at some sites, number of volunteers per year per site, volunteer hours per year, number of health fairs per year, number of foot clinics per year, number of flu vaccines per year, patient satisfaction with services at some sites, and student evaluation of engagement at various points at some sites. this intermittent data collection has been useful to insure good stewardship and determine mechanisms for fine-tuning. an example of such intermittent data collection is that in 2012 data was collected for all locations in which nacu provided services. the results revealed 914 nurse visits, 567 patients seen, approximately 106 students involved, 17 volunteer nurses, 6 paid staff, over 241 volunteer hours, 5 foot care clinics, over 24 health education sessions, 5 major health fairs, 189 flu vaccines, and 32 pneumonia vaccines. the total estimated value of donated services to the community was $61,382 for 2012. even though much data has been collected intermittently, no formal impact evaluation existed to measure the impact of nacu on the overall regional health needs as outlined by the regional health department. the collection of evaluation data has not been consistent, comprehensive, nor focused toward overall impact evaluation. impact is an outcome measure associated with long term changes in health behaviors, health related knowledge, higher levels of motivation related to health care, decreased use of resources, improved feelings of health, and the like. (sharma & petosa, 2014; timmreck, 2003). online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 96 purpose the purpose of this project was to measure the impact of a nurse advocacy center for underserved (nacu) on the population health of the region. the goal of the project was to design an impact evaluation that measured outcomes of an academic/practice partnership addressing the needs of the underserved. another goal was that the impact evaluation developed would serve as a model to evaluate the impact of the academic/practice partnership, nurse advocacy center (nacu) and the regional health department on building population health capacity. one of the priorities in achieving improvements in population health is aimed at reducing health disparities in certain groups (u.s. office of disease prevention and health promotion, n.d.). method the process for development of an impact evaluation began with the creation of a logic model. a logic model was created to guide this impact evaluation (see figure 1). a logic model design works with both process and outcome evaluation and is well accepted as a best practice evaluation strategy for social service programs. such a model provided a simplified account of the program (problem, intervention, goal), intended outputs (objectives), and intended outcomes (outcomes). the nacu logic model was created to coincide with the mission, vision, and goals of the organization. the mission of the nurse advocacy center for the underserved was to improve the health of the underserved in the region by reducing health disparities. the vision was the elimination of health disparities among the underserved with expansion of services to all underserved of the region. the nacu goals were to 1) collaborate with other academic centers and community agencies to identify health needs and resources for the underserved, 2) increase access and decrease barriers to healthcare for the underserved, 3) provide culturally appropriate primary, secondary, and tertiary interventions through nursing care delivered directly to online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 97 underserved populations in their communities, 4) advocate for culturally appropriate health care for the underserved, 5) engage nursing students in the provision of culturally appropriate health care to the underserved, and 6) continually assess trends and changes in other populations and adapt services as needed. figure 1. nacu logic model problem •some adults in this region lack access to healthcare intervention •create an nursing advocacy center for the underserved (nacu) goal •to provide culturally appropriate healthcare services to the underserved in their community by creating a nacu objectives •develop the necessary infrastructure for the nacu •provide ongoing healthcare services by partnering and collaborating with the community •secure funding to sustain ongoing services provided through nacu outcomes •increase collaboration with community partners to identify health needs and resources of the underserved in the region •increase access to healthcare for the underserved in the region •increase numbers of faculty, students, volunteers, and partners in providing healthcare services via nacu •increase nacu involvement in advocacy activities for culturally appropriate healthcare for the underserved •increase satisfaction among patients, faculty, students, volunteers, partners of nacu, and key regional health department stakeholders •stabilize nacu through ongoing funding •track demographics and service-related result •disseminate knowledge gained online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 98 the creation of the logic model provided the basis for designing the comprehensive evaluation. this evaluation was an effort to capture services provided to the underserved population. the care provided to the underserved/the most vulnerable is often not captured. a goal of the comprehensive evaluation was to determine the impact of nacu services on the population health of the region. the question posed was ‘has nacu produced their desired outcomes and addressed other common measures of impact’? this was best addressed via a series of sub-questions, all of which are directly linked to and guided by the nacu logic model. key questions and sub-questions were identified to determine if nacu had an impact on population health in the area served by the regional health department. examples of such questions included: 1. has nacu increased collaboration with community partners to identify health needs and resources of the underserved in region? 2. has nacu increased access to healthcare for the underserved in the region? a. has nacu affected levels of motivation related to health care in the underserved? b. has nacu affected improved feelings of health in the underserved? c. have emergency room visits at the partner sites decreased with nacu presence? 3. has the numbers of faculty, students, volunteers, and partners in providing health care services via nacu increased? 4. has satisfaction increased among patients, academic partner faculty, academic partner students, volunteers, partners of nacu, and key health department stakeholders? the next step was the operationalization of the logic model which included developing a plan for data collection and identifying the sample. the sample varied depending on the data collection and included patients, stakeholders, staff, faculty, students, and volunteers who engaged in providing services at a nacu site. measures were taken to protect the rights of all sample online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 99 participants. institutional review board approval was sought and approved: irb 16-011 approved expedited. the next step in this process was identifying and meeting with the key stakeholders. aligning with the logic model, the data collection tools included a patient survey, focus groups with key stakeholders, a service-results check sheet, and a satisfaction survey. data was collected at the nacu sites, focus groups were conducted, a service-results check-sheet was developed which would be used on an ongoing basis to collect key impact measures, and a satisfaction survey was distributed. the results of data collection and focus groups were analyzed and a comprehensive analyses was conducted informed by the logic model & triple aim: health, healthcare, and costs. the application of the nacu logic model for impact analysis provided a systematic, focused plan for data collection which could (1) determine if the program was being implemented as specified and, if not, how operations differed from those initially planned; (2) identified unintended consequences and unanticipated outcomes; and (3) determined impact of the academic/practice partnership nacu on the community. community meetings were planned for data collection alignment and futures planning of next steps for nacu including delivery of care, partnerships with regional health department and other community agencies, evaluation, advocacy, and sustainability. the last step of the process was dissemination of knowledge gained. data collection the data collection sites for this study included the community partner sites with nacu. these partners have demonstrated ongoing commitment to collaborating with nacu to meet the needs of the underserved within this urban service area. all nacu community partner sites are located in an urban setting. data collection involved a variety of methods and target groups. patient data was collected at each of the partner sites using a written survey distributed to patients. stakeholder data was collected from key stakeholders at each site and from the regional health online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 100 department using focus group format. satisfaction data was collected from patients, academic partner faculty, academic partner students, volunteers, community partners, and key health department stakeholders using a written survey. service–related results data was collected from key stakeholders, health department key stakeholders, and the nacu director using a check-sheet format. the service-results check-sheet was developed as a component of this project based on nacu site and focus group data. further, the ability to collect data as a component of this project allowed an evaluation foundation to be built. this ultimately served as the basis for ongoing comparisons, adjustments to programming, and future planning. for four of the partner sites, survey data was collected in 2012. this project allowed for a second round of data collection. comparative analysis was conducted for those 4 sites. the patient survey was revised to reflect the implementation of the affordable care act (aca). the 2012 survey consisted of 26 questions addressing demographics, healthcare coverage, provider history, purpose of contact, health needs, and satisfaction. the revised 2015 survey of this project kept the first 26 questions exactly the same to facilitate analysis. nine additional items were added that address aca, perceptions of health and future health needs. for the other four partner sites, the collection of patient survey data serves as a baseline for future data collection. the ability to meet with the key partner site stakeholders and the partner health department representatives using a focus group format promoted engagement in participatory evaluation. the findings of the focus group informed future evaluation as well as served for the basis for developing a service-results check-sheet. the results check-sheet is to be used by both the stakeholders, the partner health department, and the nacu director on an annual basis to collect key measures contributing to impact. online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 101 capacity building can only be strengthened by the commitment of those involved. satisfaction is key to commitment. satisfaction data for each of the constituents (patient, student, faculty, volunteer, and partner) and key health department stakeholders provided a barometer for measuring assurance that nacu is meeting its goals. approval to conduct the project was obtained from the university institutional review board. a poster was displayed at each site announcing the purpose of the project, requesting participation in the project, and noting that confidentiality would be maintained and assured. for purposes of patient data collection, an eligible participant was defined as one who met the participant criteria and presented as a patient to a nacu nurse at one of the nacu community locations. these patients were un-insured, under-insured, homeless, low education level, unemployed, or living in public housing. for the purposes of tracking outcomes, an id number was placed on each health form. id numbers were the only identifiers used on the spreadsheets. the participants were asked to complete a nacu health form at their visits to a nacu nurse at a community location. each of the nacu community locations has a separate, private room where patients are seen. if they agreed to participate, the patients completed the form in that private room. each health form took approximately 5 minutes to complete. if the patient had visual or other impairments that make filling out the form difficult, a graduate assistant assisted in reading the form to the patient. no other time or effort was required of participants. when a patient came to a nacu nurse, the nurse explained the services offered and the study. if the patient agreed to participate, the informed consent document was given to the patient for completion. patients were not denied services if they declined to participate in the study. at any time, any participant could decline participation at any time. there was no direct benefit to participants of this study. indirect benefits included online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 102 improved processes for data collection alignment among multiple agencies with the overall goal to improved healthcare to the underserved and others in the region. for purposes of stakeholder data collection, the principal investigator invited the key contact at each of the community partner sites and the regional health department to a focus group session: a second session was offered to allow attendance by all. the script for the focus groups addressed collaboration, health needs, resources, advocacy, and impact measures. the pi facilitated and recorded the focus group sessions. findings from the focus group sessions were used both to guide the development of the outcome check-sheet by the pi and to inform the evaluation. all academic partner faculty, academic partner students, volunteers, and site partners providing services at a nacu location during a patient data collection period were asked to complete a satisfaction survey. the service-related results check-sheet was completed by both partner stakeholders and the nacu director. as part of the comprehensive plan, data collected during this project was compared to data collected in 2012. in 2012 four of the five partner sites participated in a research study conducted by nacu. an aim of the 2012 study was to collect data to determine if nacu services were effective at improving access and decreasing barriers to health care. data collection strategies from clients used in this previous research study were the same as proposed here. analytic approach the data collected through the various methodologies was analyzed in the following manner. demographic variables were analyzed through the use of descriptive statistics. comparative analysis were conducted on the patient survey data for years 2012, 2015, and 2016. this included frequencies, means, ranges, chi square, and t-tests. these analyses addressed changes in participant characteristics between the years. focus groups were conducted in 2015 to collect online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 103 input from partner stakeholders and the regional health department representatives. focus group data was analyzed using thematic analysis. the 2012 and 2015 patient survey data and 2015 focus group results were used to design the service-results check-sheet and inform the evaluation. service-results check-sheet data was analyzed using descriptive statistics: frequencies, means, and ranges. satisfaction survey data was analyzed using frequencies, means, ranges, and anova. the anova calculation answered whether the group means differed from one another. all analyses were informed by the logic model and categorized in terms of the triple aim: health, health care, and costs. results the key objectives of this project include: 1) design a comprehensive evaluation plan based on the logic model (see figure 1), 2) collect and analyze data for identified strategies within the plan, 3) determine the next steps for nacu including delivery of care, partnerships with regional health department and other community agencies, evaluation, advocacy, and sustainability, and 4) dissemination of knowledge gained. a meeting was held with the key stakeholders in each of the project sites for the nacu and the regional health department. all stakeholders were fully engaged. focus groups were held with the key stakeholders. data was collected at all nacu sites in 2015 and 2016. the check-sheet was developed based on nacu and focus group data. data was collected using the newly developed check-sheet in 2016. 2015 and 2016 data was analyzed. 2015 data was compared to 2016 data as well as compared to data collected at all nacu sites in 2012. satisfaction data was collected at each nacu site. the check-sheet was shared with the stakeholders. the nacu patient registration form was the foundation for completing the impact assessment check-sheet. online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 104 key client data included demographics, allergies, insurance, tobacco use, alcohol use, recreational drug use, homelessness, living arrangements, employment, barriers to healthcare, and perceptions of personal health. the results demonstrate both similarities and differences among the nacu participants in 2012, 2015, and 2016. in 2016 as compared to both 2012 and 2015, the nacu participants included more females, fewer of black and hispanic ethnicity, fewer employed, and many fewer uninsured (see figure 2). figure 2. key demographics of participants by year results revealed that a number of participant characteristics changed at various levels of significance between 2015 and 2016 and between 2012 and 2015 (see table 1). barriers to care increased between 2015 and 2016; however, the barrier of transportation was less of a barrier in 2016 as compared to 2015. further, participant use of recreational drugs and drinking reduced in 0 10 20 30 40 50 60 70 80 90 100 fe ma le <3 0 30 -50 >5 0 w hit e bl ac k hi sp an ic ot he r un ins ure d em plo ye d hs /g ed key demographics 2012 2015 2016 online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 105 the same timeframe, with tobacco use increasing. between 2012 and 2015, the characteristics of gender, ethnicity, and status of being uninsured also experienced significant change. results of the stakeholder focus groups identified several themes regarding gaps in services. the themes were awareness of public health services, linking patients to such services, evaluating effectiveness, and lack of documentation on homeless populations. one goal of the focus groups was to serve as the basis for developing a service-related check-sheet. among the various areas identified as useful for measuring impact on regional health by the regional health department stakeholders were the perception of health as well as hepatitis c status. the service-related checksheet was developed based on the focus group input and data was collected using a check-sheet format was collected at each nacu site (see figure 3). the check-sheet was evaluated as reasonable and informative by the nacu director. identified variables included age, sex, ethnicity, insured status, income, living arrangements, alcohol use, tobacco use, recreational drug use, occupation, education level, vaccination history, medical history including hepatitis c, mental health diagnosis, and pain management, barriers to care, perceived health status, referrals, and number of visits to site per year. the check-sheet will serve as the code book for data entry of the variables found on the revised patient registration form. the revised patient registration form informed via the focus groups was implemented without concerns or comments from the nacu site personnel. the regional health department leadership expressed support of the impact assessment via the check-sheet data. online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 106 table 1 variables of significance two-year comparison 2016: 2015 participant characteristics p value for significant change summary no barriers to care <0.0001 barriers have increased transportation <0.0001 transportation remains a barrier but less of a barrier in 2016:2015 tobacco <0.0001 less people who do not smoke more smoking 10 or more cigarettes per day. recreational drugs <0.0001 less use overall heroin, meth, cocaine, marijuana, opiates, crack, xanax drinks <0.0042 more indicating no drinking 2015: 2012 participant characteristics p value summary ethnicity <0.0031 more reporting white with fewer indicating black, hispanic uninsured <0.0001 more reporting insurance gender <0.0001 more responding female results of the satisfaction data collected from academic partner faculty, academic partner students, volunteers, and site partners revealed that the experience in providing services through nacu was rated as good (10%) to very good (50%) to excellent (40%) for the faculty, volunteers and site partners and good (15%) to very good (23%) to excellent (42%) for the students. comments from the students included that more time should be planned for students to participate more fully at the nacu sites. an unanticipated development was the alignment of the nacu impact assessment with the regional gen h goals. a regional health collaborative had been meeting for the two previous years to identify the key health strategies to be addressed in a multi-state region. ultimately, four areas of foci were unveiled. these included healthy behaviors, care delivery, finance and payment, online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 107 and equity. an identified goal related to healthy behaviors is that 70% of the tristate regional residents will report excellent or very good health. one of the nacu impact assessment measures and an item added to the nacu patient registration form is ‘how do you perceive your overall health?’ other nacu impact measures align with the newly released foci areas identified in our greater community beyond the regional health department. patient name date reason for visit: sex male female age dob (reported in intervals) insurance yes no type: barriers to care transportation time work cost other: income under $10,000/ year $10,000-$20,000/year $20,000$30,000/year over $30,000/year living arrangements homeless yes no if yes, how long? home/apt street car hotel shelter rehab other: alcohol use yes no drinks per day tobacco use yes no chew yes no how much? how often? cigarettes yes no cigarettes per day rec drugs yes no type? how often? occupation do you currently work? yes no if yes, type of job: education level less than 8th grade high school grad/ged college ethnicity white black hispanic other: online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 108 vaccinations influenza pneumonia tdap tetanus hepatitis b other medical history diabetes hypertension/heart disease respiratory disease (asthma, copd, bronchitis) hepatitis c mental health diagnosis substance abuse pain management list other: how do you perceive your overall health? excellent good average poor extremely poor referrals (within last year and ongoing) date agency reason number of visits to this site/year figure 3. nacu impact evaluation check-sheet discussion the results of the project support that all outcomes of the project were achieved: 1) academicpractice partnerships were strengthened, 2) a sustainable impact evaluation plan’ including ongoing comparisons/adjustments to programming and future planning for this academic practice partnership, was created, and 3) a plan for the dissemination of the process for designing the impact evaluation. further, a logic model, a service-related check-sheet, and an impact evaluation were developed; baseline and/or comparative data were collected and analyzed; and a plan for ongoing evaluation and dissemination was operationalized. capacity building can best be strengthened by the commitment of those involved. satisfaction is key to commitment. satisfaction provided a barometer for measuring assurance that nacu was and continues to meet its goals. a systematic, focused plan for collecting and analyzing data was developed. results were categorized according to the triple aim: health, health care, online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 109 and costs. using a comprehensive impact evaluation strategy, provided the ability to determine if the program was being implemented as specified and, if not, how operations differed from those initially planned. using an impact evaluation strategy allowed for the identification of unintended consequences and unanticipated outcomes. a comprehensive impact evaluation provided the tools needed to determine the impact of the academic/practice partnership nacu on the community and region. this comprehensive evaluation continues to serve as the basis for evaluation, advocacy, and sustainability. a number of limitations of this project were identified. the major limitation of the project was that all participants were via convenience sample. the patients at the nacu sites, the key stakeholder, and the volunteers could choose to participate or to not participate. the focus of the project was a single academic/practice partnership located in an urban area. the pi was the data collector. another limitation of the project is that the 2012 data was historical data and the newly collected 2015 and 2016 data was matched as best possible. results of the impact evaluation provided a basis for the nacu and the regional health department to further their missions to improve health of the underserved. the dissemination of the results can foster similar initiatives that address population health by creating academic/practice partnerships that focus on the health care disparities among the underserved. academic/practice partnerships, similar to the nacu and the regional health department partnership, can be duplicated in other areas of the country. population health capacity will be expanded through the dissemination of evidence related to developing and maintaining community and public health partnerships, building public health competence through such partnerships, and improving the health of target populations. other academic/practice partnerships can adapt this logic model evaluation strategy for use in determining impact on similar populations. online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 110 further, this process serves as model in developing an impact evaluation for programs or projects related to the health of a region or another entity. this project resulted in the creation of a logic model and an impact evaluation, both of which are key in measuring specific outcomes against global outcomes. developing such a model can be particularly useful in measuring the impact of programs and/or interventions in rural communities with lack of access to needed healthcare services. rural communities are those with open country and settlements with fewer than 2,500 residents (us department of agriculture, n.d.). those people living in rural areas experience significant health disparities, including increased copd, higher rates of risky health behaviors, and increased mortality rates (rhihub, n.d.). this evaluation methodology can be useful for linking rural needs, rural efforts, and rural outcomes with regional and/or state goals and objectives. the process serves as a collaborative pathway for creating effective evaluation between agencies. using an impact evaluation on an ongoing basis can provide the data necessary for grant funding, resource allocation, and sustainability planning. conclusions this project benefited the public health community by demonstrating the effectiveness of an academic/practice partnership aimed at addressing health needs in underserved populations. the nacu impact evaluation keenly aligned with designated regional health outcomes as identified by the regional health department. ongoing evaluation can provide data necessary for seeking grants and funding to support collaborative efforts that address key health initiatives in a region. this process can serve as a model for other communities, both urban and rural, to align outcomes measures and data collection to facilitate addressing regional health care needs in a focused and collaborative approach. online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 111 acknowledgements this project was supported by the aacn/cdc academic/public health impact evaluation projects -small grants, 2016. references blue cross blue shield association, (n.d.) healthy communities mean a better economy. retrieved from https://www.bcbs.com/the-health-of-america/articles/healthy-communities-meanbetter-economy choudhry, l., douglass, m., lewis, j., olson, c.h., osterman, r, & shah, p. (2007). the impact of community health centers & community—affiliated health plans on emergency department use. retrieved from http://www.communityplans.net/portals/0/mmc%20 bibliography/final%20ed%20report%204.07.pdf koh, h.k. & o’connell, j. j. (2016). improving health care for homeless people. jama. 316, 2586 2587. http://dx.doi.org/10.1001/jama.2016.18760 northern kentucky independent district health department. mission. (2017). retrieved from https://nkyhealth.org/about-us/mission-vision-and-values/ northern kentucky university college of health professions. mission (2017). retrieved from https://www.nku.edu/academics/healthprofessions/about.html rodak, s. (2013). study: 71% of ed visits unnecessary, avoidable. becker’s hospital review. retrieved from https://www.beckershospitalreview.com/patient-flow/study-71-of-ed-visitsunnecessary-avoidable.html rhihub. (n.d.). rural health disparities. retrieved from https://www.ruralhealthinfo. org/topics/rural-health-disparities online journal of rural nursing and health care 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.518 112 sharma, m. & petosa, r. (2014). measurement and evaluation for health educators. burlington, ma: jones & bartlett learning. timmreck, t. (2003). planning, program development, and evaluation, (2nd ed.). sudbury, ma: jones and bartlett. united states department of agriculture. (n.d.) what is rural? retrieved from http://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/what-isrural.aspx united states department of health and human services, office of disease prevention and health promotion (n.d.). healthy people 2020 [internet]. washington, dc. retrieved from https://www.healthypeople.gov/ united states department of health and human services national prevention council. (2010). elimination of health disparities. retrieved from https://www.surgeongeneral.gov/priorities/ prevention/strategy/health-disparities.pdf p08 puskar article 6_7_11 8 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 the life events of adolescents: implications for rural school nurses kathryn r. puskar, rn, drph, faan1 beth r. grabiak, phd, crnp, rn2 dianxu ren, md, phd3 1professor, school of nursing, university of pittsburgh, krp12@pitt.edu. 2 adjunct faculty, school of nursing, westmoreland county community college grabiakb@my.wccc.edu 3 assistant professor, school of nursing, university of pittsburgh, dir8@pitt.edu key words: adolescent, community, life events, school nurse abstract the purpose of this study was to describe life events of rural adolescents and their relationship to depression. the design was a cross sectional survey. the sample included 193 students attending three rural high schools in southwestern pennsylvania. measures included the life events checklist and the reynolds adolescent depression scale (rads-2). results showed that the mean number of life events was eighteen. females reported more life events and more negative life events than males. there was a moderate, linear correlation between negative life events and depression (r = .361; p < 0.0001). rural school nurses should include adolescents’ recent life events in the health history. awareness of negative life events as a precipitating factor in depression constitutes appropriate screening and referral by rural school nurses. introduction why is it important to examine the various life events of rural adolescents and their relationship to depression, and what are the implications for rural school nurses? life events are occasions experienced by people throughout their lives (danish, smyer, & nowalk, 1980). they can be positive (achieving a good grade); negative (death of a parent); desirable or undesirable (moving to a new home) (bernardo & sereika, 1998). rural is defined as low population density at less than 2,500 people (u.s. census bureau, 2011). it is important to examine the life events of adolescents in the rural areas of a county, state, or country because of the lack of access to specialized health services, such as mental health care. in addition, high poverty levels in rural areas contribute to the increased number of uninsured, who are less likely to access health care for themselves or their children. depression is a prevalent disorder among american youth. a section of chapter 3 of the u.s. surgeon general’s report on mental health titled depression and suicide in children and adolescents reveals that “between 10-15% of the child and adolescent population has some symptoms of depression (smucker et al., 1986). the prevalence of a diagnosis of major depression among all children ages 9-17 has been estimated at 5% (shaffer et al., 1996c).” (united states department of health and human services, 2008, p. 4). indicators of a serious depressive episode in adolescents are prolonged depressed mood, poor school performance, worsening relationships with family and friends, and 9 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 substance abuse. symptoms may include decreased interest in activity, change in appetite, difficulty concentrating, fatigue and episodes of memory loss (u.s. national library of medicine, 2009). recent evidence indicates that among children and adolescents, “stressful life events often precede a suicide and/or a suicide attempt (de wilde et al., 1992; gould et al., 1996).these stressful life events include trouble at school or with a law enforcement agency; the end of a relationship with a boyfriend or a girlfriend; or a fight among friends. they are rarely a sufficient cause of suicide, but they can be precipitating factors in young people” (united states department of health and human services, 2008, p.9). puskar et al. (1999) screened 846 rural adolescents for depression. significant depressive symptoms were reported by 12.8% of the youth. self reported depressive symptoms were related to being female, a death in the family, and perceived negative life events. the perceived negative life events included losing a close friend, an increase in the number of arguments with parents, trouble with classmates, and trouble with the police. kostelecky (2005) conducted a study of 133 male and female high school students, age 16-19 years, from two rural midwestern communities in the united states. the aim of the study was to investigate the relationships between academic achievement, parental attachment, life events and substance use. a notable finding was that an increase in the number of life events experienced by adolescent was significantly related to the use of alcohol. peden et al. (2005) sampled 299 rural adolescents ages 14-18 years from 5 rural high schools in kentucky and iowa to determine the commonness of depressive symptoms and related social and environmental variables. results showed that the percentage of students with a high level of depressive symptoms (ces-d ≥ 16) in the sample was 34% and 9% had considered suicide in the past year. males reported as many depressive symptoms as females. predictors of depressive symptoms included poor family relationships and poor active coping. risky behavior linked with depressive symptoms in this sample was operating a 4-wheel all-terrain vehicle. ge, natsuaki, and conger (2006), sampled 550 rural adolescents, (mean age = 14 years) and followed them longitudinally for 11 years. the results showed that adolescents who experienced parental divorce by the age of 15 years showed significantly higher levels of depressive symptoms than adolescents from non divorced families. in addition, stressful life events that occurred shortly after divorce significantly increased the vulnerability to depressive symptoms among the adolescent of divorced parents. bouma et al. (2008), collected data as part of a longitudinal cohort study of (pre)adolescents (n=2127). the results implied that (pre)adolescents whose parents had a lifetime depressive episode were more responsive to the effects of stressful life events than adolescents without depressed parents. females were more responsive to the effects of stressful life events than males. leung (2007) conducted a telephone survey with 717 children and adolescents ages 8-18 years to determine the interrelationships between motives for internet use, stressful life events, social support and the internet use. the findings showed that the use of the internet for information seeking and entertainment (mood management) and recognition gaining and relationship maintenance (social compensation motives) was significantly associated with stressful life events. 10 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 in summary, the literature shows that adolescents’ self reported depressive symptoms are related to being female, a death in the family, and perceived negative life events (puskar et al., 1999). predictors of depressive symptoms include poor family relationships and poor active coping (peden et al., 2005). the literature also shows that adolescents who experience parental divorce by the age of 15 show significantly higher levels of depressive symptoms than adolescents from non divorced families (ge, natsuaki, & conger, 2006). (pre) adolescents whose parents have a lifetime depressive episode are more responsive to the effects of stressful life events than adolescents without depressed parents (bouma et al., 2008). in addition, an increase in number of life events experienced by adolescents is significantly related to the use of alcohol (kostelecky, 2005). internet use is significantly associated with stressful life events (leung, 2007). further exploration of the positive and negative life events experienced by rural youth and their relationship to depression may elucidate the importance of school nurses including life events in the health history. purpose of the study the purpose of this paper is to describe life events and explore the relationship between life events and depression in rural adolescents. research questions 1) what are the life events described by rural adolescents? 2) is there a relationship between life events and depression? methods sample as previously presented by puskar et al. (2006), the sample included 193 students in the ninth, tenth, and eleventh grade from three southwestern pennsylvania rural public high schools. inclusion criteria were the ability to read and write english, and enrollment in main stream classes. subjects were mostly white (86.5%, n=167) and ranged in age from 14-17 years (mean=15.57). females (53.4%, n=103) were higher in number than males (46.6%, n=90). the students were in ninth (57%, n=110), tenth (26.4%, n=51), and eleventh grade (16.6%, n=32). the majority were involved in academic programs (88.6%, n=171). the rest of the students were involved in other programs including vocational, business, and remedial. over one fourth of the students (28.5%, n=55), worked an average of 14.1 hours per week. the highest levels of the father’s education, were high school (39.4%) and a bachelor’s degree (9.8%). the highest levels of the mother’s education were high school (35.2%) and a bachelor’s degree (17.1%). the student’s fathers’ jobs varied. the most frequently reported job was a mechanic (6.7%, n=13). other jobs reported were electrician/plumber, mill worker (3.6%, each n=7); construction (3.1%, n=6), dairy, executive, truck driver (2.6%, each n=5); and manager, maintenance, welder, steel worker (2.1%, each n=4). the student’s mothers 11 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 were nurses (10.9%, n=21); secretaries (5.2%, n=14); teachers (5.2%, n=10); in sales (3.6%, n=7); and waitresses (3.1%, n=6) (table 1). table 1. adolescent characteristics design the research design was a cross sectional survey of 193 adolescents in three rural high schools in southwestern pennsylvania. measures the life events checklist (lec) (johnson & mccutcheon, 1980; brand & johnson, 1982) is a self-report scale that measures life events in older children and adolescents ages 13-18 years. it consists of 46 items plus four spaces for indicating significant events experienced but not listed on the scale. the child notes the event as good or bad, and rates the perceived impact of the event on a scale from 0 (no effect) to 3 (great effect) (goodman, gravitt, & kaslow, 1995). the lec lists two values: a positive life change score and a negative life change score. the positive score is calculated by summing the impact ratings (0 to 3) of the events rated as positive and the negative score by summing the impact ratings (0 to 3) of the events rated as negative. a total life change score can also be calculated by summing the impact ratings of all of the events experienced. test-retest reliability is .66 to .72. (compas, 1987) the reynolds adolescent depression scale – 2nd edition (rads-2) (reynolds, 2002) is a brief, self-report measure of depressive symptoms which consists of 30 items on a 4-point likert scale. the total score on the rads-2 can range from 30-120. a cutoff score of 77 on the rads-2 was established to identify adolescents who demonstrate clinical levels of depressive symptomatology (reynolds, 2002). question # 14 “i feel like hurting myself” measures the risk for self injury and if answered positively, requires timely evaluation for suicidal ideation. the rads-2 has been tested on more than 9,000 adolescents. the internal consistency reliability coefficient is 0.93 (strong). over three months, the retest reliability is 0.79 (reynolds, 2002). procedures characteristic adolescent (n= 193) gender male 90(46.6%) female 103(53.4%) race caucasian 167(86.5%) other 26(13.5%) grade 9th 110(57%) 10th 51(26.4%) 11th 32(16.6%) program of studies academic 171(88.6%) others (vocational, business and remedial) 22(11.4%) employment status employed 55 (28.5%) unemployed 138(71.5%) 12 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 approval to conduct the study was obtained from the school administrators and the university of pittsburgh institutional review board. the research staff met with freshman, sophomores, and juniors in the auditorium of three high schools, which were located in rural counties of the state. during this meeting, the purpose of the study, the consent process, and student payment was explained. signed parental consent and student consent was obtained from those who chose to participate. the measures, including two instruments that recorded life events and depression, were administered to a group during school and took approximately two hours to complete. the students were paid $10.00 for completing the measures. analysis descriptive statistics of frequencies, means, and standard deviations were calculated using sas (sas institute. cary, nc). correlation statistics were also used. the level of significance was set at p < 0.05. results the mean number of life events was (m=17.99; sd=11.84; range = 0-77). the three most common positive life events were “making the honor role” (n=117), “special recognition for good grades” (n=108), and “making an athletic team” (n=94). the three most common negative life events were “death of a family member” (n=75), “serious illness or injury of a family member” (n=71) and “increased number of arguments between parents” (n=58). females reported more life events (m=19.806; sd=12.99; range= 0-77) than males (m=15.875; sd=9.99; range= 0-56) (t=2.05; p=0.025). females also reported more negative life events (m=9.39; sd=8.84) than males (m=5.73; sd=5.45) (t=2.82; p=0.005) (table 2). table 2. number of reported negative life events of adolescents 13 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 the most frequent negative life events for females were “serious illness or injury of a family member” (n=48), “death of a family member” (n=43) and “increased number of arguments between parents” (n=40). males reported that “death of a family member” (n=32), “serious illness or injury of a family member” (n=23), and “increased number of arguments between parents” (n=18) as negative life events (table 3). table 3. negative life events female adolescents % n serious illness or injury of a family member 46.60 48 death of a family member 41.75 43 increased number of arguments between parents 38.83 40 trouble with teacher 35.92 37 trouble with brother or sister 29.13 30 male adolescents death of a family member 35.56 32 serious illness or injury of a family member 25.56 23 increased number of arguments between parents 20.00 18 breaking up with a girlfriend 20.00 18 making failing grades on a report card 20.00 18 as previously reported by puskar et al. (2006), 10% (n=19) of the students, reported depressive symptoms and 90% (n=174), were within normal range. members of the research team interviewed the students that reported depressive symptoms (n=19), self harm ideation (n=4), or who requested to see a counselor (n=8). a total of 30 students were interviewed (one who requested to see a counselor was interviewed previously). the pearson correlation coefficient was calculated between negative life 9.39
 5.73
 0
 2
 4
 6
 8
 10
 12
 female
 male
 p=0.005
 14 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 events and depression. there was a moderate, positive correlation between negative life events and depression (r = .361; p<0.0001). discussion our study findings indicate that 10% (n=19) of the students reported depressive symptoms and 90% (n=174) were within normal range. of the 10% requiring follow up evaluation, several were female (n=15). findings from this study support the previous work of puskar et al. (1999) who noted that self reported depressive symptoms were related to female gender and ge et al. (2006) who revealed that females have a greater number of depressive symptoms in adolescence than males. in addition, bouma et al. (2008) documented that females were more responsive to the effects of stressful life events than males. unlike these reports, peden et al. (2005) revealed that male adolescents reported as many depressive symptoms as female adolescents in our study, there was a moderate, linear correlation between negative life events and depression (r = .361; p<0.0001). interestingly, in this study the negative life events for the total sample were related to family. in 1999, puskar et al. documented that self reported depressive symptoms were related to death in the family, and perceived negative life events. peden et al. (2005) noted that predictors of depressive symptoms in rural adolescents included poor family relationships and ge et al. (2006) revealed that children who went through parental divorce by the age of 15 had more depressive symptoms than children from non divorced families. the findings from our study will alert rural school nurses to the negative life events experienced by adolescents and their relationship to depression. in the high schools, if students self-report or are reported by others to school personnel as being depressed, school nurses need to consider that life events may be a contributing to the distress. during the health history, the school nurse should ask questions about past, current, or future (anticipated) stressful life events. implications for rural school nurses the federal grant support for this study enhances the implications of the findings for nurses and other types of mental health professionals. recently, the u.s. preventive services task force recommendations included screening for adolescent depression as a standard recommendation (agency for healthcare research and quality, 2009, p.3). nurses and other mental health professionals working in rural primary care settings and school nurses in rural communities should become aware of the importance of including life events in the health history of an adolescent, particularly the female adolescent. the nurse may use a behavioral checklist as part of the health history and assessment process. the president’s new freedom commission on mental health section 4 titled goal 4: early mental health screening, assessment, and referral to services are common practice (2007) states that “schools are in a key position to identify mental health problems early and provide a link to appropriate services” (p. 2). school nurses in a rural setting need to be aware that stressful life events may have an impact on the mental health of adolescents and “often precede a suicide and/or a suicide attempt” (united states department of health and human services, 2008, p.9). if a student reports or is reported by others as being depressed, as part of the health history, the school nurse should ask about past, current, or future (anticipated) life events. since the data showed that females report more negative life events, a thorough health history, 15 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 and life events history is warranted. when assessing life events in adolescents, it is most important to note not only the life event, but the adolescent’s perception of the event. for example, “moving to a new home” may be perceived as either desirable or undesirable and should be noted as such (bernardo & sereika, 1998). consideration should be given to the development of a reliable screening, diagnostic, and monitoring questionnaire. this questionnaire should include a set of measurable “vital signs” that are suitable for screening and early identification of problems and illnesses (institute of medicine report, 2007). when rural school nurses are cognizant of the life events experienced or being experienced by the adolescent, they should screen for depression and refer the adolescent to the appropriate mental health agency. acknowledgement this article was supported by grant no. ro1 nr008440-01, national institutes of health, national institute of nursing research references agency for healthcare research and quality. 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[medline] u.s. census bureau. urban and rural definitions. retrieved march 13, 2011, from http://www.census.gov/population/censusdata/urdef.txt u.s. department of health and human services. mental health: a report of the surgeon general. retrieved april 4, 2008, from http://www.surgeongeneral.gov/library u.s. national library of medicine/national institutes of health. (2009). adolescent depression. retrieved october 19, 2009, from http://www.nlm.nih.gov/medlineplus/encyclopedia.html http://www.ncbi.nlm.nih.gov/pubmed/16203200 http://www.ncbi.nlm.nih.gov/pubmed/17474837 http://www.ncbi.nlm.nih.gov/pubmed/16294653 http://www.ncbi.nlm.nih.gov/pubmed/17710198 http://www.ncbi.nlm.nih.gov/pubmed/10069097 http://www.ncbi.nlm.nih.gov/pubmed/8634012 http://www.ncbi.nlm.nih.gov/pubmed/3950219 "members of the editorial review board of the perspectives in health information management have reviewed your manuscript enti 4 editorial telehealth for communities: toward eliminating rural health disparities barbara ann graves, phd, rn editorial board member rural health disparities the national healthcare disparities report (nhdr) (2007) documents issues in both quality of healthcare and access to healthcare providing information to policymakers, clinicians, administrators, and community leaders for the improvement of health. from this report it is apparent that disparities in healthcare still exist and that many opportunities for improvement remain across racial, ethnic, socioeconomic and geographical groups. one priority population is the rural, medically underserved areas. residents of rural areas experience more health disparities than residents of urban areas (nhdr, 2007). barriers such as finances, sociocultural issues, structural features and geography are known to decrease access to healthcare services in rural environments leading to poor health outcomes (eberhardt, et al., 2001). rural areas are more likely than urban areas to have higher rates of uninsured and underinsured populations, higher rates of poverty, greater transportation barriers and limited care providers. rural populations also experience higher rates of chronic disease and mortality. rural areas are often identified as medically underserved areas (muas) and medically underserved populations (mups). it is well documented that poverty and lack of health care are intertwined; persons without resources cannot afford health services, and communities without resources have difficulty attracting and retaining health care providers. furthermore, transportation can be a significant barrier to health care access for rural residents, the poor and other health disparities populations. with rising gasoline prices this problem is becoming much more significant (eberhardt, et al., 2001). a disproportionate burden of health disparities is great in terms of cost and disability and wreaks havoc on the infrastructure of communities. because the health of a community is relevant to its own unique strengths and weaknesses, community-specific, disease-specific interventions are needed. communities need to be empowered to generate knowledge and interventions to solve their own health problems and eliminate their own health disparities (israel et al., 2001). heart failure heart failure (hf) is the most common disease diagnosis among hospitalized adults age 65 years and older. it is estimated that about 5.7 million americans live with hf and that there are 670,000 newly diagnosed cases, resulting in approximately 300,000 deaths each year. the estimated cost of hf (direct and indirect) for 2007 in the united states was $33.3 billion (aha, 2010). of concern is the projected increase in the number of us adults age 65 and older to double to 70 million over the next decade, as well as the known increases in risk factor for hf (atrial fibrillation, sclerotic valvular heart disease, obesity, diabetes mellitus, and renal online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 5 dysfunction)(liu et al., 2010). clinical implications point to a need for population based access to clinical treatment and prevention strategies to aid in the control and prevention of hf events. telehealth telehealth technology has been shown to increase access to health care and deliver costeffective health care. evidence from clinical trials have demonstrated the feasibility of telehealth and its potential to provide important healthcare coverage for rural areas where specialized services are lacking (dorrian et al., 2009; givens & elangovan, 2003) other studies have shown the ability of telehealth interventions to improve patient outcomes while lowering cost (young & ireson, 2003; smith et al., 2001). the field of telehealth continues to advance through evidencebased research. sufficient evidence is available to support the use telehealth technologies as an effective and efficient approach to improving healthcare access, improving both health outcomes and health status, and reducing overall cost. rural health disparities, hf, and telehealth viewing this portrait of disparities in rural populations colored by the burden of hf on communities can increase awareness of opportunities for the use of advanced technologies such as telehealth. integration of concepts of rural, hf and telehealth can provide a framework for communities to derive answers for their own individual health disparities. the development and application of telehealth interventions for the treatment and prevention of hf events in rural areas could be one link in a movement toward eliminating rural health disparities. references agency for healthcare research and quality (ahrq) (2001). community-based participatory research: conference summary. retrieved may 11, 2009, from http://.ahrq.gov/about/cpcr/cbpr/cbpr1.htm agency for healthcare research and quality (ahrq) (april 2007) national healthcare disparities report. national center for health statistics. retrieved may 11, 2010, from http://www.ahrq.gov/htm american heart association (aha) (2010). heart failure. retrieved may 11, 2010, from http://www.americanheart.org/presenter,jhtml?identifier=1486 dorrian, c., ferguson, j., ah-see, k., barr, c., lalla, k., van der pol, m., et al., (2009). head and neck cancer assessment by flexible endoscopy and telemedicine. journal of telemedicine and telecare, 15, 118-121. [medline] eberhardt, m.s., ingram, d.d., & makus, d.m., et al. (2001). urban and rural health chartbook. health, united states, 2001. hyattsville, md: national center for health statistics. givens, g. d. & elangovan, s. (2003). internet application to tele-audiology –“nothing” but net. american journal of audiology, 12, 59 – 65. [medline] israel, b.a., schulz, a.j., parker, e.a., becker, a.b., & community-campus partnership for health (2001). community-based participatory research: policy recommendations for promoting a partnership approach in health research. education for health, 14, 182-197. [medline] online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://.ahrq.gov/about/cpcr/cbpr/cbpr1.htm http://www.ahrq.gov/htm http://www.americanheart.org/presenter,jhtml?identifier=1486 http://www.ncbi.nlm.nih.gov/pubmed?term=19364891%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=14964319%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=14742017%5buid%5d&cmd=detailssearch 6 online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 liu, l. (2010). changes in cardiovascular hospitalization and comorbidity of heart failure in the united states: findings from the national hospital discharge survey 1980-2006. international journal of cardiology, [epub ahead of print]. [medline] smith, a.c., isles, a., mccrossin, r., van der westthuyzen, j., willaims, m., woollett, h., et al., (2001). the point-of-referral barrier – a factor in the success of telehealth. journal of telemedicine and telecare, 7, (suppl. 2): s2:75-78. [medline] young, t.l. & ireson, c. (2003). effectiveness of school-based telehealth care in urban and rural elementary schools. pediatrics, 112, 1088-1094. [medline] http://www.ncbi.nlm.nih.gov/pubmed?term=20060181%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=11747668%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=14595051%5buid%5d&cmd=detailssearch 34 putting the pieces together: how public health nurses in rural and remote canadian communites respond to intimate partner violence judy hughes, phd1 1assistant professor, faculty of social work, university of manitoba, hughesj@cc.umanitoba.ca key words: interpersonal violence, victims, women's health, nurses, health care utilization, service delivery, rural and remote communities abstract intimate partner violence (ipv) is a recognized public health problem with direct physical and longerterm psychological health effects. because of these recognized health impacts, women who have experienced ipv are likely to use health care services. research suggests that women want to and will disclose that they have experienced ipv to health care providers. given this, the ability to identify and respond appropriately to women’s disclosures and then support and connect them with needed community services becomes a key responsibility for health care providers. however, much research reports that few health care providers routinely screen their patients for ipv or provide appropriate follow up and referral. through in-depth interviews with six public health nurses (phns) practicing in rural and remote communities, this study documents how these nurses identify female clients who have experienced ipv, how they intervene in these situations, and the challenges of responding in isolated rural practice contexts. the findings demonstrate that although these phns did not have an articulated mandate to screen and intervene in situation where ipv is occurring, they are engaged in this work. recommendations for training and improved practices are included. introduction intimate partner violence is a recognized public health problem with direct impacts, including cuts, bruises, and broken bones as well as longer-term effects, including headaches, insomnia, depression, anxiety, substance abuse, and a greater likelihood of developing posttraumatic stress disorder (ptsd) (dutton, et al., 2006; loxton, scholfield, hussain, & mishra, 2006; plichta, 2004; romito, molzan turan, & muarchi, 2005). as a result, women who experience ipv use a variety of health care services, including emergency departments, primary care physicians, and public health nurses (campbell, 2002; plichta, 2004; van hook, 2000). although rates of ipv identification vary by practice setting, the results suggest that utilization of these services by victims of ipv is common. for example, 13 percent of 1,526 women at 31 outpatient clinics were identified as victims of abuse (wasson et al., 2000), as were 14 per cent of 2,465 women using a variety of obstetrician/gynecologist offices, emergency departments, primary care offices, pediatrics, and addition recovery (mccloskey, et al., 2005), and 44.3 percent of 399 women at one family medicine clinic (peralta & fleming, 2003). given the prevalence of ipv in these settings, health care providers have a central role in dealing with immediate injuries and other health impacts of ipv. however, it is also crucial for these providers to appropriately identify and refer women to much needed community resources which may prevent further injury and support women in working toward reducing and eliminating violence in their lives. for victims of ipv who live in remote and rural communities, support offered by health care providers is more crucial, as there is often few other resources and services. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://www.umanitoba.ca/social_work/ mailto:hughesj@cc.umanitoba.ca 35 the purpose of this qualitative pilot study is to explore and describe the experiences of public health nurses located in rural communities when assessing and intervening on behalf of women experiencing ipv. the project focuses on phns and their nursing practices as the public health mandate, which includes prenatal and postpartum screening, sexual health clinics and education, and home visits brings them into contact with many female clients. this practice area has also been identified as a primary health area where identification and response to ipv can occur (grafton, wright, gutmanis, & ralyea, 2006; webster, sangster bouck, wright, & dietrich, 2006). in addition, phns are recognized as important health resources within rural and remote communities (leipert & reutter, 2005), especially for women who have experienced ipv (cox, cash, hanna, d’arcy-tehan, & adams, 2001; everson, 2006). the research describes the interactions between phns and their female clients during the moments when clients reveal they are victims of ipv. relevant literature universal or routine screening of all women for ipv is controversial. both the canadian and u.s. task forces on preventative health care recommend against the use of routine protocols, as there is currently a lack of empirical evidence linking the use of these screening procedures to positive outcomes, including decreased incidence of physical and psychological abuse and injury (berg, 2004; nelson, nygren, mcinerney, & klein, 2004; wathen & macmillan, 2003). many canadian and american professional organizations recommend screening as a routine part of medical examinations (campbell, 2002; mccloskey, et al., 2005). others, like worster (2004), citing the potentially harmful effects of false positives and false negatives, advocate a case-finding approach in which clinicians are alert for possible signs or symptoms of ipv and then screen or question if clinically relevant. a final approach suggests that health care providers assess for ipv, so that doctors and nurses can open communication channels and provide ongoing support to abused women patients (griffin & koss, 2002; janssen, dascal-weichhendler, & mcgregor, 2006; smith, 2002; wagman borowsky & ireland, 2002; walton-moss & campbell, 2002). in the absence of clear recommendations and guidelines however, health care providers are unsure of when and how they should screen or assess. survey research documents differential rates of routine screening, with 11 percent to 50 percent of nurses and physicians across diverse practice settings reporting that they routinely screen patients (ellis, 1999; glowa, frasier, wang, eaker, & osterling, 2003; gutmanis, beynon, tutty, wathen, & macmillan, 2004; lapidus, et al., 2005). although higher rates of ipv identification have been documented after introduction of a routine screening question (gerber, leiter, hermann, & bor, 2005; scholle, et al., 2003; paschall richter, surprenant, schmelzle, & mayo, 2003), two studies (gerber et al., 2005; paschall et al., 2003) noted there was little evidence of additional follow up or referral. as the majority of research on ipv screening outlined above focuses on institutional or private practice settings, there has been little investigation of the role of phns in providing services to families where ipv is occurring (dickson & tutty, 1996; evanson, 2006; leipert, 1999). a survey of 125 phns in an urban setting revealed that the majority (86 percent) believe that ipv screening is within their public health role and mandate, even if women do not raise the issue, and 71 percent of participants stated that if ipv indicators were present, they would ask screening questions (dickson & tutty, 1996). however, 55 percent of these phns also reported that they were unsure of what to say to women about ipv. through in-depth qualitative interviews, one group of eleven phns (webster, et al., 2006) and another group of six phns online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 36 (jack, jamieson, wathen, & macmillan, 2008) similarly reported that they believed home visits are appropriate settings for screening and responding to ipv; yet, these two groups of phns also reported that they struggle in knowing how to ask about ipv and then intervene. two qualitative studies, evanson (2006), who interviewed seven phns in rural, midwestern u.s., and cox et al. (2001), who interviewed 24 phns in rural victoria, australia, specifically sought to examine how the rural context influences practice with families in which ipv is occurring. both participant groups of nurses reported that their rural locations create multiple opportunities for them in establishing and maintaining relationships with families, especially with women experiencing ipv. the variety of work roles performed by phns, including home visits, immunization clinics, and community health education, as well as their non-work activities in and around the community, provide them with repeated contact through which they become aware of potential risk factors and be witness to incidents of ipv. in these studies, the phns reported that, at times, identification of ipv is easy. other times, however, the participants noted that identification requires intuition. in cox et al.'s (2001) study, one phn described this as “picking up cues” and how she became alerted to the possibility of ipv because of the reaction one of her clients had when asked if she wanted to have her partner in the room. purpose the purpose of this qualitative pilot study is to provide descriptive data about the assessment and intervention practices of phns when working with families experiencing ipv in the context of rural and remote northern canadian communities. we recruited phns located in the communities of prince rupert, terrace, dease lake, and kitimat in northwestern british columbia, canada. these communities are considered isolated because each is located at a distance from neighboring communities—about 150–700 kilometers apart from each other, between 700–1,000 kilometers to the comparatively large, urban center of prince george, and between 1,500–1,700 kilometers from even-larger vancouver. the distances between these rural communities, combined with the winter climate and rugged geography of northern british columbia, uniformly create difficulties for daily living and for the provision of social and health care services (leipert & reutter, 2005). there are differences, however, among these communities in the availability of services. the larger communities of prince rupert and terrace, each with populations of about 15,000, have community networks and resources. dease lake, the smallest community at about 70 families, has more limited services and is also located the farthest from neighboring communities and larger urban centers (6oo kilometers to the nearest community of terrace, bc, and 1,000 and 1,700 kilometers to the larger centers of prince george and vancouver, bc, respectively). within these communities, phns may be one of only a few professional and confidential supports available to women experiencing ipv (leipert, 1999). the research objectives were to: 1) understand how women disclose to phns and how these nurses come to know that ipv is occurring within families; 2) document screening practices used by phns; and 3) identify the responses of phns to women experiencing ipv and how these are influenced by the rural practice context. method a qualitative method was used to study the everyday nursing practices and the interactions phns have had with women who have experienced ipv. a semi-structured question format was used, as it allows the research interview to cover information that is useful for the online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 37 inquiry, and this format also provides opportunities for participants to add to the depth of the information that is collected (fontana & frey, 2003). questions focused first on if and then how participant phns identify abused women among their clients or how women identify to them (do you have a process or protocol for identifying or screening for woman abuse? can you describe this process or protocol?), their responses to ipv (when you have a woman in front of you as a client who discloses that she has experienced intimate/domestic violence, what do you do first?), and the community supports or resources available and what services are lacking (what services, resources, or programs are available for abused women in your community? are these helpful to women? what services or programs are necessary but unavailable?). data collection participants were recruited through the northern health authority in british columbia with the cooperation of the manager of phns who had circulated a research poster describing the study within each of the identified communities. nurses were interviewed as they contacted us and agreed to participate. prior to each interview, participants read an information sheet detailing the purpose of the research and signed an informed consent sheet. honorariums were provided at the beginning of each interview. interviews varied from 45 to 60 minutes in length and were digitally recorded. ethical review for the study was provided by the university of northern british columbia. recruitment was difficult, as phns have many time constraints, and in some of these northern communities there are staff shortages. in the end, six phns with an average of 13.8 years of experience (range between 2.5 to 35 years of experience) were interviewed. these years of experience include public health, as well as practice in emergency/acute care departments and mental health and addiction/detox services. all interviews were conducted by the first author. data analysis each completed interview was transcribed verbatim by the second author. all identifying information was removed, including the names of the interviewees', which were replaced with a non-identifying number (for example, nurse 01). each transcript was read several times by both authors to fully capture the meaning. analysis began with the first two interviews, which were uploaded as transcripts into the nvivo qualitative software program for coding. the second author began this process by generating a list of codes that served as a framework for analyzing the remaining transcripts. where possible, we employed in vivo coding, which uses the participants' words to name the emerging codes. this technique maintains closeness between the data and the developing and final analyses. reports for each code were generated and links between these more specific codes were made where the data contained within them overlapped and connected. for example, specific codes, such as “women’s disclosures,” “remain supportive,” and “routine screening,” were connected together because data contained with each of these codes described how conversations about ipv occurred between phns and women clients. through this process, four broader themes were identified. next, compelling quotations from the interviews that illustrate the processes described or provided context for our analyses were selected. once the analysis was complete, the first author reread the interview transcripts again and compared these to the developed analysis. the dependability of the analysis is established by these multiple processes of coding and the final comparison of the completed online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 38 online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 analysis against the raw data in each interview. as a final step, all of the study's participants were sent a description of the processes by which the phns heard women's experiences and responded to disclosures of ipv. they were asked to review the account and provide comments about the accuracy of the description. two out of the six nurses responded and confirmed that the account matched their experiences. these procedures were recorded in a methodological journal (guba & lincoln, 2004; morrow, 2005). findings three broad themes were identified in the analysis process: 1) the way in which nurses described how women disclosed experiences of abuse to them, 2) how the phns respond, and 3) the challenges of intervening in the rural and northern practice context. each of these themes is described below. a final section outlines the recommendations provided by the phns to improve their own practices. quotations are used to demonstrate the connection between the derived analysis and the raw data and to reveal both the agreement and variability within the phns descriptions of the ways women disclose and how they respond. indirect and direct disclosures: becoming alert to intimate partner violence all interviewed phns described past practice experiences in which women either disclosed ipv to them or they were alerted to the possibility. salient within their descriptions of these various situations is that disclosure occurs in what are the everyday and routine health care services these phns provide, including prenatal and postpartum screening, the well child program and immunization clinics for babies and children, sexual health clinics, and sexual health education provided for youth. a complex pattern emerged of the ways in which phns ask and come to know about ipv and about how women clients directly and indirectly reveal this to them. although all of these phns stated that some women directly stated that their partner abused them, these instances were noted as rare and tended to occur only when injuries were obvious. indirect disclosures were the norm, and all but one of these phns provided examples. disclosures were indirect in that women were not coming to phns directly because of abuse by their partners or immediately after a violent incident. rather, female clients sought advice or inquired about child development, parenting difficulties, sexual health, or the effects of conflict on children and through these questions the phns became alerted to the possibility that ipv may be occurring: “i go in thinking what we are really going to talk about is related to the baby or your birth control and what happens is that’s not the issue for the family or the person at all” (nurse 01); “they don’t come to us directly. if we see them they are usually presenting here worried about other aspects of their health” (nurse 03); and “somehow it comes up through other things so most often when i’ve dealt with this issue they’ve been coming in seeking help for something else and then you sort of delve into it and that’s when you discover those underlying issues” (nurse 04). questions contained within assessment instruments, such as the parkyn postpartum screening instrument and sexual health questionnaires, provided an opportunity for four of the six phns to ask and initiate discussions about ipv. however, it was not necessarily the questions that signaled to these phns that ipv may be occurring. rather, it was the discussion that ensued in response to the questions—collecting information about a woman’s health history or details about past parenting difficulties, for example—that alerted phns to the possibility of ipv: 39 storytelling. so for example a woman talking about years of becoming pregnant because last time she became pregnant her partner got so angry and hit her in the belly and forced her to have a termination. during their personal social history, storytelling like that would come out when i’m trying to get myself into the context of the clients’ life (nurse 06). it will come up in terms of what has parenting been like in the last couple of months and it comes up that there is violence or it was experienced in the household and it’s affecting the kids. it’s initially brought up less about them themselves then it is sort of the family or the kids that they’re concerned about and that’s how we get into the topic and then you know over time we can sort of bring it back to their experience (nurse 01). another practice example provided by four of the six phns involves sexual health education in high-school settings. the nurses described how adolescent girls approach them and ask questions about birth control and sexual health and behaviors. then, through these interactions, the phns explained how they become concerned that these girls may be in abusive relationships: girls who’ll come in for birth control and then come in a number of times for emergency contraceptives and who are quite anxious about their birth control method and quite insecure that they might be pregnant, and sometimes you get that feeling of maybe this person isn’t ready for the sexual life that their involved in (nurse 06). once the connection was made, these phns then stated that they would initiate frank discussions about healthy relationships: i can have a conversation with this person about whether or not she’s ready to be having sex and what kind of power dynamics exist in the relationship; is she able to talk about that with her partner? (nurse 06). in presenting these practice examples, each of the phns was clear in saying that it is she and not the girl who makes the connection between certain types of questions about sexuality and ipv: those questions aren’t ones that they are identifying at all with violence or with controlling behaviors or unhealthy relationships. in their minds those are questions specifically about sex (nurse 01). four of the six phns clearly stated that revelations about ipv did not necessarily occur as the result of a one-time contact in which screening questions were asked. rather, women revealed experiences to them because of the relationships that are established between them as phns follow women through pregnancy, postpartum screening, and then infant and child immunizations, and follow-up home visits with some families. the importance of this relationship is illustrated in the following: online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 40 the women with whom i am doing home visits, they definitely want the relationship first and sometimes it’s three, six months, a year, two years before they’re willing to disclose anything about what’s happening between them and their partner” (nurse 01) it depends on the relationship i think and the rapport that’s built with the practitioner before they trust (nurse 03); and slowly [with] a lot of relationship-building, things like that come up after you see them a few times, they trust you” (nurse 04). the next section describes the responses and the variety of strategies engaged by these phns after ipv is revealed. supporting women and providing referrals although there was consistency in the participants descriptions of how women disclose and how they come to know about the presence of ipv, there was more variability in what they described as their own responses, including: providing information and referrals, assessing immediate risk, safety planning, and offering shortand long-term support. providing information about community services, access to resources, and referrals to these was the most-identified task performed by these phns. three of the six phns reported that after disclosure they engage in assessment of immediate safety concerns, including asking about the presence of guns in the home and if the partner has previously threatened to harm the woman and/or her children. two of these phns said that they extended these discussions to help women develop long-term safety plans, which included strategies such as having a safe place in the home to hide, memorizing telephone numbers of emergency shelters, and asking a family member or neighbor for transportation to community services that could help them. five of the six phns interviewed stated that offering women initial and ongoing support was also a key response after disclosure of ipv. one of these phns said that she keeps women connected either to the public health service she worked for or to other clinics or services in the local community. she said that these connections were crucial in lessening isolation and creating multiples opportunities for women to ask for and receive help. another phn described how keeping women connected to public health services is safe, as women can tell their abusive partners that the appointments are for children’s health: here’s how to reach me, commit this phone number to memory, it’s the health unit’s phone number so you can call me any time and ask for an appointment for your child” (nurse 05). in addition, for two of these five phns, remaining supportive of women meant allowing them to take the lead in decisions about if, when, and how to accept help: i think it’s just trying to remain supportive of where they are at. asking what can i do to assist you, is there anything that would help you to feel better about your online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 41 situation—and i guess what i try to dance around is maintaining my rapport and connection and nonjudgmental approach with them by not assuming that they want to get out of their relationship (nurse 8). the northern and rural practice context all six of the phns spoke of the difficulties of living within rural and northern areas, especially for women. they described this reality, including details on the lack of employment opportunities for women, the high cost of housing, wage disparities between men and women, and lack of childcare spaces. they also noted how all of these factors combined create greater inequality between women and men in heterosexual relationships and how they can become significant barriers to leaving abusive partners. access to community resources was also identified in all interviews as a significant barrier, for a variety of reasons, for example, the number of resources is limited in smaller communities, some are not culturally appropriate for aboriginal and southeast asian women, and there is no anonymity in the use of some services that are located in well-known areas of some communities. transportation to services was also described as a challenge because local, public buses may not reach all the areas where some services are located, or transit is not available on nights and weekends. for women living in more isolated areas outside these small centers or on reserve communities, farms, or islands, transportation on buses, ferries, and float planes can be difficult to obtain and expensive. the difficulties that these various factors create for women in living with and leaving abusive partners, which are specific to the rural context, add weight to the supportive role that these phns take on. despite this, four of the six nurses noted that in rural areas there is little support offered to them in this role, as there are few opportunities for professional development or clinical supervision. recommendations at the end of each interview, we asked all phns for recommendations on how to improve their own practices with women who experience ipv. one phn suggested that a clear mandate and consistent practice guidelines need to be developed so nurses would have a protocol to work with when they suspect ipv or when women disclose ipv to them: the contact we have with these families and women is all through other channels and back channels, and in public health we could have some more clear mandates and guidelines around trying to access these populations (nurse 04). three of the phns noted the contradiction between the practice reality wherein women disclose experiencing ipv during the course of standard nursing activities and the lack of a clear mandate and guidelines to intervene. the following two quotations illustrate these concerns: [we are not] getting to the root or the cause of a lot of that stuff even a lot of the sexual health education that we do in the schools. we spend so much time on sexual health around how to use a condom and are you on birth control and testing for stis and that kind of thing but such a small segment is healthy relationships and how to decide what is acceptable and what is not. we become online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 42 really task focused but we forget that really important piece around the emotional health and relationships (nurse 04). a lot of the intake is focusing, like, on your physical health: do you smoke, do you have a history of cancer in your family, how long are your periods, how many people have you had sex with, and then there’s one question that says do you have any pain during intercourse. which i’ve always thought was an interesting question because the way that i think it was intended on the form was to look at any physical issues that are causing pain during intercourse but certainly there are psychological and emotional variables that can affect the answer to that question (nurse 06). these phns are asking for direct mandates on if, how, and when to ask and respond to ipv. moreover, they seek clear guidelines on how to practice competently to effectively support and intervene with women after they disclose; to do so, they need more training and professional development: i don’t think that we’re trained sort of adequately to address the why and blanket more of the opportunities that we have when we’re interacting with clients, to learn to pick up cues, to have questions, and to know what to do with the answers. i would say that one of the biggest gaps is that we need more professional development and actual hands on practice (nurse 8). limitations although this in-depth account provides insight of the ways in which the phns ask about and hear women’s experiences of ipv, the findings are limited as they only reflect six unique experiences and perspectives. further interviews with nurses in these remote communities are needed to increase the depth and credibility of the findings. discussion this study reveals the complex and multiple ways women disclose and how phns come to know about ipv, the responses that phns offer, and how the northern and rural practice context influences women’s ability to seek help. although identifying and supporting women are a part of the work the phns are doing, it is not a part of their mandate. the findings here demonstrate that they are nevertheless engaged in these practices, as direct and indirect disclosures of ipv emerge from the patient-practitioner discussions about the patient's physical and sexual health – all of which are mandated public health services. although not consistent across all of these interviews, all of these phns stated that they did respond to women’s disclosures, including offering support, safety assessment and planning, and referral to needed services. five of the six interviewed phns not only emphasized detecting ipv but also building relationships with and supporting women. the strategies these phns engaged in reflect best practice recommendations, particularly strategies identified from research conducted with women who have experienced violence in which women suggest that they want health care providers to ask in a nonjudgmental manner, provide validation of their disclosures, online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 43 referral to community services, and respect their decisions about when to seek other help and leave abusive partners (bates, hancock, & peterkin, 2001; dienemann, glass, & hyman, 2005; dowd, kennedy, knapp, & stallbaumer-rouyer 2002; hamberger, ambuel, marbella, & donze,1998; van hook, 2000; wendt mayer, 2000; zink, elder, jacobson, & klostermann, 2004). yet, only two of the phns expressed confidence in their ability to respond effectively, and all them stated that they needed enhanced training and professional development. other qualitative research with phns has found similar results, which shows that although these health care providers believe that identifying and responding to ipv is an important aspect of their practice, they are not confident in their abilities (cox et al, 2001; dickson & tutty, 1996; evanson, 2006; grafton, et al., 2006; webster, et al., 2006). consistent with other qualitative research about the practice of phns in rural areas (cox et al., 2001; evanson, 2006), and as described in all of the interviews, the absence or the inaccessibility of other services in the context of rural communities, creates a crucial role for phns in identifying and supporting women who have experienced violence. although only one of the phns in this sample acknowledged it, the services offered by phns can be a safe place in which women can disclose and seek support, as visits to a phn can be disguised as child health appointments. a similar finding was reported by the cox et al. (2001) study of 24 phns in rural australia. future research as one of the identified limitations of this research and others (cox et al., 2001; evanson, 2006) is small sample sizes, further research with larger numbers of phns is necessary to extend the depth and credibility of the findings. future research must also consider the differences in urban and rural practice contexts, including the different relationships and boundaries between phns and their clients and variations in the availability and accessibility of other health and social services supports for both phns and clients (cox et al., 2001; evanson, 2006). given the close connection between the health care interventions routinely provided by phns and disclosures of ipv, future research also needs to focus on these moments of interaction and be sensitive to specific practice settings and the initial reason for which health care is being sought or a service being performed (rittmayer & roux, 1999; spangaro, zwi, & poulos, 2009). implications for practice the finding that disclosure of ipv is embedded in standard nursing practices is significant. it is clear from the multiple practice descriptions supplied by five of the phns in this study that awareness of ipv is triggered by specific aspects of prenatal and postpartum screening or when concerns about parenting or sexual health are raised. three of the phns in this study noted the need for this form of specific knowledge, which would build their skills in making connections between the pieces of information revealed through questions about women’s physical and sexual health or parenting difficulties and the presence of ipv in women’s lives. specific knowledge about these interactions is crucial to the development of effective training and professional development programs. the variability in interventions offered by this small group of phns suggests the need for a clearly defined mandate and practice guidelines. however, engaging in this work of detecting and responding to ipv is risky as phns are aware of and at times witness to the prevalence of online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 44 ipv in their communities. specific safety protocols in addressing ipv need to be developed, especially when phns are conducting home visits and when these occur in remote communities or isolated private properties (cox et al, 2001). further, support and confidential supervision from other professionals is crucial so that phns can continue to be effective in providing support to women in their communities (cox et al., 2001; evanson, 2006). conclusion the findings identified through this study extend the small but emerging body of research about the practices of phns among families where ipv is occurring (cox et al., 2001; dickson & tutty, 1996; evanson, 2006; grafton, et al., 2006; webster, et al., 2006). the findings are significant in providing needed and specific knowledge about the health care concerns and questions that abused women bring to phns and the ways in which they are alerted to the presence of ipv through their standard nursing practices. ipv is a complex social problem that requires a variety of social and legal remedies that are beyond the ability of any one health care provider or health care setting to effectively address (smith, 2002; rittmayer & roux, 1999; spangaro, et al., 2009). given the significant health impacts of ipv, however, all health care providers are responsible for identifying and supporting women who have experienced ipv. because there may be few other community supports and services available, and because of the multiple public health roles that phns have with women in their communities, phns can be an important resource within rural and northern communities in providing a safe, confidential space for women to disclose and to receive support, as they make difficult decisions to keep themselves and their children safe. acknowledgements the research is supported by the british columbia medical services foundation (bcm07-0024). the researchers would also like to thank the nurses who participated in the study. references bates, l, hancock, l., & peterkin, d. 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(2006). nursing the social wound: public health nurses' experiences of screening for woman abuse. canadian journal of nursing research, 38(4), 136-153. [medline] worster, a. (2004). intimate partner violence against women: to screen or not to screen in the emergency department? canadian journal of emergency medical care, 6(1), 38–39. [medline] zink, t., elder, n., jacobson, j., & klostermann, b. (2004). medical management of intimate partner violence considering the stages of change: precontemplation and contemplation. annals of family medicine, 2(3), 231–239. [medline] http://www.ncbi.nlm.nih.gov/pubmed?term=17290959%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=17433143%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15209200%5buid%5d&cmd=detailssearch putting the pieces together: how public health nurses in rural and remote canadian communites respond to intimate partner violence abstract relevant literature purpose method data collection data analysis findings indirect and direct disclosures: becoming alert to intimate partner violence supporting women and providing referrals the northern and rural practice context recommendations limitations future research implications for practice conclusion acknowledgements references 560-article text-3549-1-6-20190306 online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 43 implementation of a comprehensive diabetic foot exam protocol in rural primary care kathy l. murphy buschkoetter dnp, fnp-bc 1 warseal powell dnp, fnp-bc 2 linda mazour. m.d. 3 1 family nurse practitioner, franklin county memorial hospital and rural health clinics, kathy.murphynp@gmail.com 2 assistant professor, university of south alabama school of nursing, university of south alabama school of nursing, warsealpowell@southalabama.edu 3 medical director, franklin county memorial hospital and rural health clinics lsmazour@fcmh.biz abstract background: patients with type-2 diabetes mellitus have an increased risk for foot ulcerations and lower extremity amputations. evidence-based practice guidelines recommend annual foot screening at least yearly for patients with type-2 diabetes. comprehensive foot exams that include assessments for loss of protective sensation and peripheral artery disease prove beneficial in reducing morbidity and decreasing the incidence of diabetic foot ulcerations. despite the known benefits of preventive screenings, a limited number of rural providers adhere to well-established treatment guidelines for patients with type-2 diabetes. purpose/aim: the purpose of this quality improvement project was to increase the number of comprehensive foot examinations for adults with type-2 diabetes mellitus in rural primary online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 44 care. the overarching aim was that 75% of adult patients with type-2 diabetes would consistently experience a comprehensive foot exam and risk assessment within 15 weeks of project initiation. methods: the quality improvement project design involved the introduction of a comprehensive diabetic foot exam protocol in four rural health clinics. utilizing the plan-study-do-act quality improvement model, retrospective data was collected from 60 patients to evaluate the percent of patients with type-2 diabetes that received a foot exam in 2017. educational programs were presented to primary care providers and clinic nurses to introduce the protocol. the project implementation occurred as a 1-week pilot in one rural health clinic then system-wide for 14 weeks. results: the retrospective data revealed 42% of patients with type-2 diabetes received a foot exam in 2017. all primary care providers and clinic nurses attended educational sessions on screening guidelines and protocol introduction. following the 15-week project, 68% of patients with type-2 diabetes experienced a comprehensive foot exam and risk assessment. conclusions: implementation of a clinically relevant tool in rural primary care resulted in significant improvement in primary care provider adherence to recommended diabetes foot screening guidelines. keywords: type-2 diabetes, rural, adults, foot exam, guidelines implementation of a comprehensive diabetic foot exam protocol in rural primary care diabetic foot ulcers (dfu) are the leading cause of non-traumatic lower extremity amputations in the united states (centers for disease control and prevention [cdc], 2017) and costs related to the treatment of dfus are well over a billion dollars annually (hicks et al., 2016). online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 45 diabetic peripheral neuropathy (dpn) and peripheral artery disease (pad) are directly related to the development of ulcerations of the foot and lower extremity (boulton, 2013). with the loss of protective sensation resulting from peripheral neuropathy, patients with diabetes are increasingly susceptible to injuries and trauma of the foot and ankle enhancing the possibility of developing foot ulcerations (american diabetes association [ada], 2017). in over half of patients with dfu, pad is present further complicating diagnosis and treatment (brownrigg, apelqvist, bakker, schaper, & hinchliffe, 2013). through tertiary prevention in patients diagnosed with type-2 diabetes mellitus (t2dm), assessments for signs of dpn and pad facilitate identification of patients with loss of protective sensation and impaired perfusion that are at risk for developing long-term complications such as foot ulceration and lower limb amputation (boulton, 2013; markakis et al., 2016). comprehensive foot care that includes screening exams and risk assessments (ra) for patients with diabetes reduces the rate of ulcerations nearly 75% and amputation up to 85% (hershey, 2017; pocuis, man-hoi li, janci, & thompson, 2017). in rural health clinics (rhc) located in franklin and webster counties of south-central nebraska, management and treatment of patients with t2dm by primary care providers (pcp) demonstrates significant variability and lack of adherence to well-established evidence-based practice (ebp) screening guideline recommendations for annual foot exams. specifically, providers inconsistently perform and document annual foot exams for adult patients with t2dm. in rhcs, the compliance rate for yearly diabetic foot exams in 2017 was 42% significantly well below the national rate of 68% (cdc, 2017) and nebraska rate of 68% (department of health and human services [dhhs], 2015). although evidence demonstrates the effectiveness of comprehensive foot examinations (cfe) in reduction and prevention of foot ulcers (ada, 2017; oxendine, 2014), pcps identified barriers to annual foot exam recommendations, similar to those online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 46 found in literature review, including lack of adequate knowledge, time constraints, and strongly held negative attitudes and opinions as to the usefulness and practicality of ebp guidelines (bus & van netten, 2016; furthauer, flamm, & sonnichsen, 2013; vigersky, fitzner, & levinson, 2013). the purpose of this quality improvement project was to increase the number of cfe for adults with t2dm in rural primary care. the research question for this project was: in rural adult patients, ages 19 years and older, with t2dm, does the use of a comprehensive foot exam protocol incorporated into existing electronic medical records improve pcp adherence to ebp guideline recommendation for an annual cfe and risk assessment, compared to the non-use of comprehensive foot exam protocol. significance/literature review diabetes in the united states national statistics estimate that over 30 million people in the u.s. have diabetes. while 23.1 million (7.2%) have a diagnosis of diabetes the remaining 7.2 million are undiagnosed and unaware of their disease (ada, 2017). overall, prevalence of diabetes is higher in minority populations of american indians/alaska natives, non-hispanic blacks, and people of hispanic ethnicity (cdc, 2017). however, the percentage of adults of all races with diabetes increases with age reaching 25.2% in those aged 65 and older. geographical patterns indicate the highest incidence of diabetes in the southern and appalachian regions, followed by midwestern states. rural residents experience a 17% higher rate of t2dm compared to urban residents (ross et al., 2014; national rural health association, 2015). diabetes is a leading cause of morbidity and mortality creating a significant public health and economic burden for patients, healthcare systems, and society (ada, 2017). economic online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 47 burden associated with diabetes is primarily related to the cost of preventable diabetes complications (welch et al., 2015). patients with t2dm that developed neuropathy have up to a 20% lifetime risk of developing foot ulceration (pocuis et al., 2017). additionally, the lifetime risk significantly increases to 30-35% with concomitant risk factors such as pad and foot deformity (brownrigg et al., 2013). patients with a dfu have ulcer recurrence rates of 30-40% in the first year after an ulcer episode (bus & van netten, 2016). care of dfus is estimated to cost nearly $1.4 billion/year (hicks et al., 2016) consuming well over a third of total resources allocated for treatment of t2dm and resulting complications. ulcer prevention, however, represents only a small portion of the total expenditures utilized for diabetic foot care. as the incidence and cost of diabetes continue to rapidly rise, providing high quality evidence-based preventive care is vital to reduce diabetes-associated morbidity and lessen the economic burden. burden of diabetes in franklin and webster counties of nebraska according to the cdc (2017), the incidence of diagnosed diabetes in nebraska is 11.6% notably above the national average of 7.2%. similar prevalence rates are found in franklin (10.8%) and webster (11.1%) counties. high rates of obesity further complicate the burden of diabetes for rural nebraskans. in the u.s., the rate of obesity for rural residents is nearly 26% appreciably more than the 20% rate in urban populations. nebraska has experienced a significant increase in obesity rates from 20% to 31% over the past 18 years. in franklin and webster counties, obesity rates average 33% exceeding the state and national average (cdc, 2017). defining rural population and rural health inequities the concepts of rural and urban are complex, multifaceted, and continue to evolve. the u.s. census defines rural as “all population, housing, and territory not included within an urbanized area, population > 50,000, or urban cluster, population of 2500-49,999” (ratcliffe, burd, online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 48 & fields, 2016). similarly, the u.s. department of agriculture defines rural as “areas of open country and settlements with fewer than 2,500 residents” (cromartie & parker, 2017; u.s. department of agriculture, 2016). the number of people living in rural areas is only 16% of the u.s. population however they reside on 75% of the total land mass. nebraska is considered a rural state with over 35% of the population residing in areas with less than 2,500 residents. according to the census bureau (2016), franklin county covers 574 square miles with a population average of 5.6 person per square mile and webster county covers over 577 square miles with a population average 6.6 person per square mile. the rhcs are located in communities within franklin county including franklin (pop. 1000), hildreth (pop. 318), campbell (pop. 347), and red cloud (pop. 1020) in webster county (us census, 2016). rural residents experience significant healthcare disparities related to greater population risk for poor health, limited access to healthcare providers and systems, and reduced life expectancy when compared to urban residents. vulnerability of rural populations is accentuated by isolated geographic locations that intersect with low socio-economic status combined with higher number of unhealthy habits, fewer community resources, and limited employment opportunities (national rural health association, 2015). when comparing rural versus urban statistics, rural residents experience high rates of obesity related to sedentary lifestyles and an elevated burden of chronic disease demonstrated by increased incidence of heart and lung disease, diabetes, cancer and stroke (ross et al., 2014; vigersky et al., 2013). abuse and misuse of alcohol, tobacco, and prescription medications are characteristics of rural populations that also contribute to lower overall life expectancy (cdc, 2017). diabetic peripheral neuropathy identification online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 49 diabetic peripheral neuropathy (dpn), a microvascular complication resulting from diabetes, affects both small and large sensory fibers and is manifested by paresthesia, dysesthesia, and deficits in normal sensations that profoundly impact patient function and productivity (alleman et al., 2015; van netten et al., 2016). approximately half of all patients with diabetes will develop neuropathy (markakis et al., 2016; pocuis et al., 2017). dpn is directly related to the development of foot ulcers and is a leading cause of amputations in the diabetic population (ada, 2017; bus & van netten, 2016). prevalence of dpn is highest in patients with t2dm and often times underreported and undertreated (schaffer, sandau, & diedrick, 2013). screening patients with t2dm for neuropathy is essential for early treatment, reduction of complications, and decreased morbidity (bus & van netten, 2016). key to reducing and preventing foot ulcers and amputations is the identification of those patients at increased risk through a cfe and ra. according to the ada (2017), all adults with t2dm should undergo a cfe at the onset of diabetes diagnosis and continue annually to identify high-risk conditions. those patients identified with loss of protective sensation and impaired perfusion are at higher risk and should have a foot exam at each visit. furthermore, comprehensive foot care programs that include ra based on ebp guidelines demonstrate improvement in diabetes care and patient outcomes (bus & van netten, 2016; oxendine et al., 2014). provider non-adherence to established guidelines the u.s. preventive services task force was created in 1984 to promote development of ebp guidelines for preventive service in primary care (agency for healthcare research & quality [ahrq], 2015). over the last 30 years, clinical preventative guidelines were published by universities, interest groups, and organizations based on overwhelming evidence that demonstrates primary, secondary, and tertiary prevention efforts reduce costs, enhance the quality of care, and online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 50 improve patient outcomes. in 1989, the ada established screening and treatment guidelines for patients with diabetes. highly graded evidence that combines stringent glycemic control, regular preventive screenings, and early detection and treatment of secondary complications demonstrates significant reduction in morbidity and mortality related to diabetes (ada, 2017; khoong et al, 2013). despite the well-established benefit of adhering to screening guidelines, a limited number of rural providers adhere to ebp screening guidelines (jones, crabb, turnbull, & oxlad, 2014; ross et al., 2014; khoong et al., 2013; vigersky, fitzner, & levinson, 2013). theoretical frameworks this project was guided by the health belief model developed by hochbaum (1958) and awareness-to-adherence model developed by pathman et al. (1996). the health belief model (hbm) was developed to integrate stimulus-response theory with cognitive theory in explaining behavior (hochbaum, 1958). influenced by kurt lewin’s (1951) theories that perceptions of reality, rather than objective reality, influence behavior. in hbm, a combination of perceived susceptibility and perceived seriousness of the condition or situation combines into a perceived threat. the perceived threat has a cognitive component that is influenced by weighing the benefits and barriers to the actions. when considering pcp adherence to ebp screening guidelines, provider experience, knowledge, and attitude appear to have greater weight than guidelines based on robust research. benefits and barriers to adherence are considered before action is taken to follow the recommendations. to further address guideline adherence, the theoretical framework, awareness-toadherence, developed by pathman et al. (1996) that focuses on physician non-adherence to national guidelines for childhood immunizations was used. the model describes a progression of steps through awareness, agreement, adoption, and adherence. in 1999, cabana et al. expanded online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 51 the model and added multi-directional flow pathways that described a sequence of behavior change and defined barriers to guideline adherence. since that time, multiple studies utilized the theoretical model to guide research on adherence to evidence-based guidelines (khoong et al., 2013; radwan, akbari, rashidian, anou-dagga, & elsous, 2017; widyahening, van der graaf, soewondo, glasziou, & van der heijden, 2014). purpose/aims the purpose of the qi project was to increase the number of annual foot exams completed in adults, age 19 and older, with a diagnosis of t2dm in rural primary care. the overarching aim of the project was that 75% of all adult patients with t2dm presenting for primary care in four rural health clinics would consistently experience a cfe and ra within 15 weeks of project initiation. methods a letter of approval was obtained from the university of south alabama institutional review board prior to implementation of the quality improvement (qi) project. exemption status was granted (institutional review board irb00000286, dhhs fwa00001602). subjects/participants the participants in the project were the pcps in four rhcs located in franklin and webster counties in south-central nebraska. the pcps included one full-time family practice physician, four full-time family nurse practitioners (np), and one part-time family nurse practitioner. the family practice physician is a medical doctor with over 30 years of experience. all five nps are masters prepared and vary in advanced practice experience from six months to 23 years. the patient population was adults age 19 years and older with a diagnosis of t2dm. setting online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 52 franklin county memorial hospital (fcmh) is a critical access hospital (cah) in franklin, ne with three provider-based rhcs located in franklin county and one-independent rhc in neighboring webster county. the healthcare system serves residents in both counties and surrounding areas including people from north-central kansas. while some patients travel between 40 to 60 miles to receive care, most patients have access to primary care within a 15minute drive from their home. the qi project was conducted in the four rhcs. tools the michigan neuropathy screening instrument (mnsi) is a valid measure of distal peripheral neuropathy in patients with t2dm (herman et al., 2012; university of michigan, 2017). the mnsi includes a two-step process: (1) assess neuropathic symptom history from the patient through a 15-item questionnaire, and (2) a physical examination by providers to evaluate appearance and sensation of the feet. three clinical tests utilizing three different tools are utilized in the neurological ebp screening guidelines recommended (ada, 2017; university of michigan, 2017) for a cfe to identify loss of protective sensation (lops): (1) single-use 10-g/5.07 monofilaments, also known as semmes-weinstein monofilaments, is placed perpendicular to the skin with pressure applied until the monofilament buckles. it should be held in place for approximately one second and then released at the first, third, and fifth metatarsal heads on the plantar surface and dorsal between base digit one and two (ada, 2017). the sensitivity of the monofilament test ranged from 0.41 to 0.93, and specificity ranged from 0.68 to 1.00 (dros, wewerinke, bindels, & van weert, 2009). (2) 128-hz tuning forks used to test vibratory sensation. vibration sensation should be tested by placing the tuning fork over the dorsum of the great toe on the boney prominence of the dip joint. evidence of usefulness is documented in clinical cohort studies (ada, 2017; schaper et al., 2016). (3) tendon hammer is used to assess ankle reflexes. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 53 the achilles tendon should be stretched until the ankle is in a neutral position before striking with tendon hammer. the absence of ankle reflexes is associated with increased risk of foot ulcer (ada, 2017; schaper et al., 2016). intervention implementation and data collection the plan-do-study-act (pdsa) quality improvement model (langley et al., 2009) was used to guide planning and implementation of the qi project. the model provided a construct for designing, implementing, measuring, and distributing a quality improvement study (institute for healthcare improvement [ihi], 2017). in this qi project, the “plan” phase involved focused discussions with stakeholders that included retrospective chart data that further defined the problem as lack of adherence to ebp screening guidelines in patients with t2dm. in the “do” phase, the cfe protocol was developed from ebp guidelines. a template was created in the electronic medical record, and an educational session about the project was developed for providers and staff. in the “study” phase, the template was introduced and discussed with stakeholders and revisions were made to improve the functionality of the protocol. during the “act” phase, a one-week trial of the cfe and ra protocol in one rhc was implemented to determine the functionality of the questionnaire and template. no changes were made, and the project was implemented system-wide. the pdsa cycle was repeated during system-wide project implementation. retrospective chart review was completed by randomly selecting a sample total of 60 adult patients with t2dm from the electronic diabetes registry utilizing t2dm icd10 codes e11-e11.9. the retrospective chart review included demographic data collection and data extraction from dictation, clinic notes, and assessment data to determine if a foot exam was completed and documented over the previous 12 months. process measures included the percentage of adult online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 54 patients, age 19 years and older, with a diagnosis of t2dm receiving a foot exam within the previous 12 months. prior to implementation of the project, educational training sessions were conducted for all pcps and clinic nursing staff on screening guideline recommendation for annual foot exam, demonstration of cfe with ra, and the introduction of the foot exam protocol in the electronic medical record. trial implementation of the foot exam protocol was conducted over a one-week period to evaluate usability and time involvement with no changes recommended. the project was implemented system-wide in four rural health clinics and data collected from all adult patients, age 19 years and older, with t2dm that presented for primary care during the 15-week study period. analysis/evaluation data analysis was completed utilizing spss program (cronk, 2014). baseline process data was collected from 60 random retrospective chart reviews of 2017 data. all pcps and office nursing staff attended the educational session on screening guideline recommendations for patients with t2dm, foot exam and risk assessment demonstration, and introduction of the foot exam protocol in the electronic medical record. data was collected from all adult patients with t2dm presenting to the rural health clinic during the 15-week project and analyzed for the percentage of cfe and ra completed. further analysis was completed for each of the four clinic sites and each of the six pcps identified as either medical doctor or nurse practitioner. the five nurse practitioners were assigned np1through np5 in order of their employment hire dates. results sixty patients were randomly identified in the electronic medical record from icd-10 codes e11-e11.9 indicating diagnosis of t2dm. demographic data was collect ensuring that all patients selected were 19 years and older with a diagnosis of t2dm. included in the 60 patients, 35% online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 55 (n=21) were female ranging from 52-92 years of age, with a mean age of 72, and 65% (n=39) were male, ranging from 38-85 years of age, with a mean age of 62. table 1 shows retrospective data collected from the convenience sample. charts reviewed for 60 patients with t2dm revealed 42% (n=25/60) had received a foot exam in the previous year (2017). the clinic site percentages varied greatly from 52% (n=12/23) at main street clinic, 40% (n=11/29) at pool medical clinic, 29% (n=2/7) at hildreth clinic, to none completed at campbell clinic. data for each pcp was analyzed and reported as percent of patients seen with t2dm receiving a foot exam. percentages varied from np1 42% (n=14/25), md 35% (n=7/20), np2 29% (n=2/7), np 5 33% (n=1/3), np 3 20% (n=1/5), to np4 none completed. table 1 percentage of adult patients with t2dm receiving a foot exam in 2017 clinic site n = number charts reviewed % of total charts reviewed n= number of foot exams completed % of patients receiving foot exam pool medical clinic 29 48% 11 40% hildreth clinic 7 12% 2 29% campbell clinic 1 2% 0 0% main street clinic 23 38% 12 52% total 60 25 42% provider pcp 1 (md) 20 33% 7 35% pcp 2 (np1) 25 42% 14 56% pcp 3 (np2) 7 12% 2 29% pcp 4 (np3) 5 8% 1 20% pcp 5 (np4) 0 0 0 0 pcp 6 (np5) 3 5% 1 33% total 60 25 42% data collection for 2018 was completed 15 weeks post project implementation. eighty adults patients, age 19 years and older, with t2dm presented for primary care. demographic data revealed 52.5% (n=42) were female ranging in age from 26-89 with a mean age of 67 and 47.5% (n=38) were male ranging in age from 47-84 with a mean age of 66. table 2 shows data collected online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 56 from 80 patients with t2dm presenting for primary care during the 15-week intervention. the percentage of patients receiving a cfe and ra was 63% (50/80). clinic site percentages varied from 88% (n=29/33) at main street clinic, 75% (n=3/4) at the hildreth clinic, 43% (n=18/42) at pool medical clinic, to no completions at the campbell clinic (n=0/1). data for each pcp revealed percentage of patients seen with t2dm receiving a cfe and ra. percentages ranged from 88% (n=29/33) for np1, 71% (n=5/7) np2, 60% (n=3/5) np3, 38% (n=11/29) md, and 34% (n=2/6) np5, to none completed by np4. table 2 percentage of adult patients with t2dm receiving a foot exam and risk assessment in 2018 clinic site n = number of patients with t2dm presenting during 15-week project n=number of foot exams completed % of patients receiving a foot exam n= number of risk assessments completed % of patients receiving a risk assessment pool medical clinic 42 18 43% 18 43% hildreth clinic 4 3 75% 3 75% campbell clinic 1 0 0% 0 0% main street clinic 33 29 88% 29 88% total 80 50 63% 50 63% provider pcp 1 (md) 29 11 40% 11 38% pcp 2 (np1) 33 29 88% 29 88% pcp 3 (np2) 7 5 71% 5 71% pcp 4 (np3) 5 3 60% 3 60% pcp5 (np4) 0 0 0% 0 0% pcp 6 (np5) 6 2 34% 2 33% total 80 50 63% 50 63% outcome measure results: (1) the goal to increase pcp and office nursing staff knowledge of ebp guideline recommendations for cfe in patients with t2dm was met. one hundred percent participation by pcps and office nursing staff in educational sessions with demonstration of cfe and ra with an opportunity for return demonstration; (2) cfe were performed and documented on 63% (50/80) of adult patients with t2dm that presented for primary care within the 15-week online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 57 project below 75% completion goal; and (3) ra were performed and documented in 63% (50/80) of adult patients with t2dm within the 15-week project surpassing the 50% goal. discussion/summary this qi project showed overall improvement of documented cfes for patients with t2dm from 42% pre-implementation to 63% post-implementation. three of the four rhcs showed improved percentage of completion of cfe. percentages varied from hildreth clinic (29%/75%), main street clinic (52%/88%), pool medical clinic (40%/43%) to the campbell clinic (0%/0%) that was unchanged. five of six pcps percentage of completion of foot exam improved. percentages varied from np1 (52%/88%), np2 (29%/60%), np3 (20%/40%), md (35%/38%), np 5 (33%/34%) to np4 (0%/0%) who resigned from the practice prior to project completion. improving the quality of care for rural adult patients with t2dm is essential to reducing and preventing long-term complications such as foot ulcerations. this qi project demonstrates the effective use of pdsa qi model in implementing ebp guideline recommendations into rural clinical practice through the use of comprehensive diabetic foot exam protocol. the findings from this qi project support local efforts to improve adherence to ebp screening guidelines with the use of a clinically relevant tool incorporated into the existing emr. through input from pcps in the planning and implementation of the project, the cfe protocol was customized for local provider usability. significant improvement in adherence to ebp screening guideline recommendation for an annual foot exam reveals successful planning and implementation of the qi project. the simple streamlined process of this qi project provides ease in duplicating a similar project in other rural health clinics. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.560 58 limitations the qi project has several limitations including convenience sample, small sample size, and retrospective data collected by reviewing dictated notes in the emr subject to individual interpretation. the administration of the rhcs was very supportive of the qi project and the strong support may have overly influenced the change process. conclusion chronic health conditions such as t2dm provide complex management challenges for rural pcps. the american diabetes association along with other national organizations and educational institutions provide screening and treatment guidelines for patients with t2dm. evidence demonstrates use of evidence based practice screening guidelines improves clinical outcomes and significantly reduces the risk of preventable diabetes complications. however, multiple studies have shown that a limited number of rural pcps utilize ebp screening guidelines in clinical practice. improving rural provider adherence to well-established guidelines is essential to improving the care of rural residents with t2dm. through qi initiatives in rural primary care, clinically relevant tools such as the cfe protocol incorporated into existing electronic medical record resulted in significant improvement in pcp adherence to evidence based practice screening guideline 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(2014). awareness, agreement, adoption and adherence to type2 diabetes mellitus guidelines: a survey of indonesian primary care physicians. bmc family practice, 15(72). https://dx.doi.org/10.1186/1471-2296-15-72 sellers_547-article text-3540-1-6-20190302 online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 4 retention of nurses in a rural environment: the impact of job satisfaction, resilience, grit, engagement, and rural fit kathleen sellers, ph.d, rn 1 moira riley, ph.d 2 danielle denny, ma 3 doreen rogers, dns, rn, ccrn, cne 4 jeanne-marie havener, phd, aprn 5 tassha rathbone, msn, rn-bc 6 caroline gomez-di cesare, md, , phd. faap, facp 7 1 clinical associate professor, suny polytechnic, sellerk@sunypoly.edu 2 research scientist, center for human services research, university at albany, mrriley@albany.edu 3 statistical data analyst, preferred mutual insurance company. danielle.denny@preferredmutual.com 4 assistant professor, health professions and education, utica college dorogers@utica.edu 5 former director, department of nursing, castleton university; associate in nursing education new york state education department-office of professions, jeannemarie.havener@nysed.gov 6 nurse residency coordinatornurse educator, bassett healthcare networkbassett medical center, tassha.rathbone@bassett.org 7 research scientist, bassett research institute, bassett healthcare networkbassett medical center, caroline.gomez-dicesare@bassett.org online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 5 abstract purpose: the purpose of this study is to examine the unique contributions that job satisfaction, resilience, grit, engagement, and rural fit have on nurses’ intention to stay in their unit for the next 6 months and intention to leave the institution in the next 3 years. sample: the data come from a network wide survey of rns and lpns employed by a rural hospital network in the northeast of the united states. just over half (n=436, 55%) of the 797 nurses that were employed by the network responded to the survey. the majority (73%) were registered nurses (rns), worked inpatient (56%) and were female (86%). method: surveys were sent out in paper form and electronically. nurses responded to questions about their intention to leave their unit in the next 6 months or the organization in the next 3 years, job satisfaction/dissatisfaction, resilience, grit, engagement, and rural fit. findings: we found that when considering all factors together, better rural fit predicted less intention of leaving the current unit in the next 6 months and less intent to leave the organization in the next 3 years. the only other predictor of intent to leave the unit in the next 6 months was resilience where nurses who reported themselves as being more resilient were less likely to report intention to leave. the only other predictor of intent to leave the organization in the next 3 years was nurse engagement (i.e., professional growth) where more engaged nurses were less likely to report intention to leave. conclusion: rather than considering variables independently, our multivariate model found that rural fit is paramount in retention of rural nurses. further, clear and accessible opportunities for professional growth may retain nurse over the long-term despite poor fit with the rural environment. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 6 keywords: job satisfaction, resilience, grit, engagement, rural fit, nurse retention. rural nursing retention of nurses in a rural environment: the impact of job satisfaction, resilience, grit, engagement, and rural fit rural nursing practice, in comparison to urban practice, has unique challenges that impact recruitment and retention. these challenges include 1) lower compensation, 2) chronic understaffing, 3) issues with the professional work environment, and 4) lifestyle issues such as lack of adequate housing, employment opportunities for spouses, and childcare options (baernholdt & mark, 2009; jackman, myrick, & yonge, 2012; newhouse, morlock, provonost, & sproat, 2011; roberge, 2009; rohatinsky & jahner, 2016). high rates of turnover and lack of retention for professional nurses in health care services is of great concern in nursing practice, especially in rural areas (adams, 2016; barrett, terry, le, & hoang, 2016; lea & cruickshank, 2014; mbemba, gagnon, paré, & côté, 2013; mbemba, gagnon, & hamelin-brabart, 2016). retention is alternately defined as turnover, intention to stay, or intention to leave (adams, 2016). in the united states efforts to address retention focus both on retaining nurses within an organization and within the profession of nursing (kovner et al., 2016 a, 2016 b). poor retention both within organizations and the nursing profession has consequences on the health and welfare of organizations, patients, and society, while retaining nursing staff improves access to quality care (squires, jylha, jun, ensio, & kinnunen, 2017). given the importance of nursing retention to quality care, it is not surprising that research focused on nursing retention has identified many contributing factors including salary, availability online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 7 of enhanced professional development opportunities, value congruence between the nurse and organization, and flexibility in scheduling and shift patterns (chang et al., 2015; cosgrave, maple, & hussain, 2018; dotson et al., 2011; fitzgerald & townsend, 2012; gutekunst, delucca, & kessler, 2012; halfer, 2011; hayes, bonner, & pryor, 2010; mbemba, gagnon, & hamelinbrabart, 2016; tourangeau, cummings, cranley, ferron, & harvey, 2010). theoretical models often categorize factors related to nursing retention into either job characteristics or nurse characteristics (ellenbecker, 2004). however, in the rural setting, community characteristics, especially how well nurses fit and are engaged in their rural environment, is an important factor for consideration (dotson et al., 2011; kulig et al., 2018). in the following sections we review what is known about the contributions of job satisfaction, resilience, grit, and engagement on nursing retention and then consider the unique contribution of rural fit on nursing retention. background job satisfaction conceptually, job satisfaction is defined as the fulfillment of one’s wishes, expectations or needs with relation to his or her job or the pleasure derived from one’s job (fairbrother, jones, & rivas, 2010). factors which influence job satisfaction for professional nurses are well studied, and include relationships with coworkers and managers, pay and promotion, a perceived ability to ensure patient safety, the availability of support services, autonomy in nursing practice, and workload (baernholdt & mark, 2009; de gieter, de cooman, pepermans, & jegers, 2010; hairr, salisbury, johannson, & redfern-vance, 2014; lu, barriball, zhang, & while, 2012; twibell, st. pierre, johnson, barton, davis, kidd, & rook, 2012; wang, tao, ellenbecker, & liu, 2012). kuo, lin, and li (2014) examined factors that influence nurses’ intention to leave their current positions. their results indicate that higher job satisfaction significantly decreases work stress and intention online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 8 to leave among nurses. similarly, larrabee et al. (2003) reported that job dissatisfaction is a major predictor of intent to leave. this literature corroborates that nurses who derive satisfaction with their current position are less likely to consider leaving their job. resilience nurse resilience is inferred to be an important factor in nurse retention (hodges, keeley, & troyan, 2008; kornhaber & wilson, 2011; rushton, batcheller, schroeder, & donohue, 2015). resilience is defined as the ability to bounce back from a stressful situation (smith et al., 2008). although resilience is not prominent in the discussion of factors related to retention of experienced nurses, the direct role resilience plays in professional nurse retention is important in healthcare settings as nurses experience stressful work environments (happell, et al., 2013). in addition to the external stressors of professional practice (including variables related to continual changes as institutions work to become more competitive and cost-effective) (brown, wey, & foland, 2018) internal effects of job stressors for nurses include psychological emptiness, diminishing inner balance, and a sense of dissonance (hart, brannon, & de chesnay, 2014). given the current evidence that resilience during nursing education engenders strength, focus and endurance (mcallister & mckinnon, 2009), it is posited that resilience will positively influence retention in the face of difficult workplace experiences. brown, wey and foland (2018) found a positive association with job satisfaction and resilience (p < .001) in a descriptive correlational study of 521 hospital staff nurses. using a grounded theory investigation among female critical care nurses, jackson, vandall-walker, vanderspank-wright, wishart, & moore (2018) suggested that resilience and burnout are connected. nurses who are more resilient are better able to bounce back from negative experiences and should be less likely to leave. grit online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 9 grit is thought to be an intrinsic quality that correlates with resilience. robertson-kraft & duckworth (2014) define grit as perseverance and passion towards a goal over long periods of time. however, grit is conceptually different from resilience as grit considers only intrinsic characteristics with no integration of environmental factors. in addition, grit requires sustained effort and interest in goal attainment despite adversity (robertson-kraft & duckworth, 2014). though a considerable amount of research suggests that the presence of grit is a valuable predictor of success in educational and employment opportunities (eskreis-winkler, shulman, beal, & duckworth, 2014; robertson-kraft & duckworth, 2014), findings are contradictory. findings from one study on the effects of grit on physicians’ job satisfaction and retention in rural and nonrural settings found that grit is unrelated to job satisfaction or retention (reed, schmitz, baker, nukui, & epperly, 2012). however, as nurses assume relatively lower positions in the healthcare hierarchy and may be less empowered to address negative work circumstances, grit may exercise more influence on a nurse’s intent to stay despite adversity encountered on the job. additional research is needed to determine the impact of grit on nurse retention in a rural environment. nurse engagement individuals who are more engaged in their work view their work as positive and fulfilling and approach their work with vigor, dedication, and absorption (schaufeli, salanova, gonzálezromá, & bakker, 2002). the value of nurse engagement was brought to the fore when hodges and clifton (2004) published the results of a survey demonstrating a positive relationship between nurses’ work engagement and patient satisfaction. since then nurse engagement has also been positively correlated with positive patient outcomes, patient safety and patient satisfaction with the online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 10 hospital experience (day, 2014; dempsey & reilly, 2016; nishioka, coe, hanita, & moscato, 2014; press ganey, 2013). multiple studies have examined nurse work engagement in relation to burn out, job satisfaction, and retention. on review of the literature, (simpson, 2009) concluded that nurse engagement at work is largely impacted by organizational factors rather than the intrinsic qualities of the professional. organizational factors related to engagement include having greater job resources (versus job demands), better work experiences (particularly more control), empowerment, reward (including money), recognition, and value fit (le blanc, hox, schaufeli, taris, & peeters, 2007). hakanen and roodt (2010) suggest that job resources are the most important contributor to work engagement and, thus, should be the main focus of organizational efforts to increase employee engagement. increasing nurse engagement is a strategy proposed by tillott, walsh, and moxham (2013) to improve nurse retention. lower levels of nurse engagement are associated with higher job turnover and greater intention to leave one’s current position (brunetto et al., 2013; collini, guidroz, & perez, 2015; sawatzky & enns, 2012; tullar et al., 2016). of the different organizational factors closely tied to engagement, a work environment with supportive leadership that promotes professional practice and high quality patient care is associated with less turnover (nei, snyder, & litwiller, 2015; spence laschinger, zhu, & read, 2016). better nurse-physician collaboration, readily available resources, empowerment, recognition, control/responsibility, and autonomy are all associated with less intention to leave (hewko, brown, fraser, wong, & cummings., 2015; blake, leach, robbins, pike, & needleman, 2013; sawatzky, enns, & legare, 2015). in a comprehensive systematic literature review, 77 factors were found to influence nurse work engagement (keyko, cummings, yonge, & wong, 2016). these factors were categorized online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 11 into six themes: organizational climate, job resources, professional resources, personal resources, job demands, and demographic variables. among the many correlates of engagement, keyko, et. al. reported that nurses who were more engaged are less likely to leave or to consider leaving their job. thus, we hypothesized that nurses who view their workplace as promoting engagement, through professional growth opportunities and professional autonomy, may be more engaged in their organization and less likely to intend to leave their position. rural fit this study examined the perceptions of a population of nurses who work in a rural healthcare network. the majority of the nurses employed by the network live in rural communities. as outlined by bealer, willits, and kuvlesky (1965), rurality is a multidimensional construct including ecological (set out by census data), occupational, and sociocultural frameworks. accordingly, rural fit is felt to be an important concept to explore. the retention of professionals in rural areas is impacted by the local economy and the resultant socio-political culture (including attitudes, normative beliefs, sense of volitional control, motivations, and behaviors) and not just impacted by the geography (killam & carter, 2010). hence, while the phenomenon of rural may be narrowly defined according to the specific demographic and geophysical features of place, more aptly rurality is the interactive effect of the human-environmental field that manifests in differences in perceptions, attitudes and normative beliefs, along a rural-to-urban continuum (willits, bealer, & timbers, 1990). understanding the fit between the individual and the context may be critical in understanding nurse retention. features of rural places such as people, organizations, and infrastructures can have both positive and negative effects on the perceptions of rural healthcare providers. in particular, close community ties and intricate webs of relations between lay and professional community members online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 12 may result in greater professional visibility, a lack of anonymity, and a blurring of boundaries among health care providers (mills, birks, & hegney, 2009). rural healthcare providers may also experience opportunities to work in more diverse roles and have more independence and autonomy (penz & stewart, 2012). this can be more professionally stimulating. the downside to rural practice is that there is also a risk for greater role diffusion, professional isolation and a scarcity of resources (conger & plager, 2012). nurses unfamiliar with rural living may have the additional burden of dealing with issues related to distance, isolation, insider versus outsider status, lack of familiarity with the sociocultural milieu and care networks, as well as a lack of anonymity (williams, 2012). these burdens may be compounded by being both a newcomer to the rural culture and the profession (lea & cruickshank, 2014). in a comprehensive review, dotson et al. (2011) identified that individuals who had connections to rural environments through 1) growing up in a rural environment, 2) family connections, and 3) a positive perception of the rural lifestyle were more likely to choose rural nursing practice. nurses who report that the rural lifestyle is not very important to them are more likely to move than those who rate rural lifestyle as being important (molanari, jaiswal, & hollinger-forrest, 2011). in addition to connection to a rural area, nurses were more likely to choose a job in a rural area if they trained at rural facilities and perceived rural workplaces to be supportive environments (bushy & leipert, 2005; lea and cruickshank, 2014). the importance of community is so influential that roberge (2009) reported that nurses were only satisfied with their jobs if they were also satisfied with their community. taken together, the fit between the nurse and the community may play a key role in understanding rural nurse retention. theoretical models of nursing retention online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 13 prominent models of nursing turnover, such as the causal turnover model, (price & mueller, 1981) emphasize individual characteristics along with job characteristics to predict retention. despite the model’s popularity, a meta-analysis completed by irvine and evans (1995) reported that the model only accounted for 12% of the variance in actual turnover. in other words, 88% of why nurses leave their jobs is predicted by something other than their individual characteristics or job characteristics. hence, in rural nursing, fit within the rural environment could be a characteristic that deserves more attention. as an alternative to the causal turnover model, the job embeddedness model views job retention as a function of how much the individual has become embedded, not just in the organization, but also into the community context (mitchell, holtom, lee, sablynski, & erez, 2001; reitz, 2014). the job embeddedness model has three components: links to people in the community, fit with the community, and a sense that the person has a lot to sacrifice if they leave their current job. theoretically, individuals who are more embedded in their communities are less likely to leave their jobs because their community connections make them want to stay. empirical applications have found that job embeddedness is a better predictor of retention than factors like job satisfaction and organizational commitment (halfer, 2011; reitz, anderson, & hill, 2010; vardaman, rogers, & marler, 2018). while stroth (2010) has suggested that the job embeddedness model could be used to develop retention strategies for rural hospitals, no empirical support for the job embeddedness model in rural nursing retention currently exists. in this paper we will consider the role of rural community fit along with individual and job characteristics to identify which factors most strongly predict nursing retention. summary online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 14 this study examined contributions of job satisfaction, resilience, grit, engagement, and rural fit on nurses’ intention to stay in their unit for the next six months and intention to leave the organization in the next three years. given the paucity of research on factors influencing rural nurses’ intent to stay in a practice, applying the job embeddedness model, rural fit is considered as an indicator of community embeddedness. in accordance with the job embeddedness model, it is expected that better rural fit will be associated with less intention to leave. understanding the predictors of intention to leave will inform strategies to improve nurse retention in rural settings. methods participants data for this study came from a network wide survey of registered nurses (rns) and license practical nurses (lpns) employed by a rural hospital network in the northeast of the united states. the network serves a predominantly rural population, located in primarily rural counties defined by the 2010 us census bureau (ratcliffe, burd, holder, & fields, 2016; united states census bureau, n.d.) as “mostly rural” with >50% of the population considered rural). geographically, each of the counties served by this network are > 90% rural with population densities of <75 persons/square mile (us census bureau, 2010). while population density is central to this definition of rural, the authors recognize that rural is really a multidimensional concept and, when it comes to nurse retention in rural practice settings, issues such as geographic, social and professional isolation, insider versus outsider status, limited access to resources, and so forth, are also important factors to consider. the integrated hospital network consists of six corporately affiliated hospitals, as well as skilled nursing facilities, community and school-based health centers, and health partners in related online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 15 fields. nurses throughout the network provide care and services to people living in a 5,600 square mile region. nurses are employed in both inpatient and outpatient settings. of the 797 nurses employed by the network at the time of the survey, 436 of the eligible nurses responded (55%) to the survey. of the nurses that responded, the majority (73%) were rns, worked in acute care settings (56%) , and were female (86%). in addition, 87% were full time, 6% part time, and 7% were per-diem. all rns and lpns employed by the network were included. contract nurses were excluded from the sample. procedures following approval of the study by the network’s institutional review board (irb study 2050), a distribution list of all eligible rns and lpns was obtained from the network human resources department. individuals on the distribution list were sent an electronic version of the instrument through email using a personalized survey monkey link as well as a hard copy with a return envelope through inter-office mail. the electronic and paper survey instruments were linked to the same participant id number in the unlikely event that someone responded twice, then the duplicate response could be eliminated. no duplicate responses were obtained. both the electronic and hard copy surveys included a cover letter explaining the study, the risks and benefits, and a description of measures employed to ensure that participant responses would remain confidential. on average, the survey took 15-20 minutes to complete. measures creating a survey that could be completed in approximately 15 minutes was felt to be critical to encouraging an adequate response rate. given the number of constructs to be included in the survey, it was necessary to shorten some of the validated measures by choosing proxy items to online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 16 represent entire scales. while this method did not allow verification of the validity, it was found that the scales retained their reliability. retention. based on conceptual definitions of retention, retention was measured by two items developed by the study team. one item asked the participants to report the likelihood they would “leave your current unit within the next 6 months,” while the other asked the likelihood they would “leave the organization in the next 3 years.” self-report responses were rated on a fivepoint likert scale ranging from 1 “very unlikely” to 5 “very likely.” on average participants reported being unlikely to leave their current unit in the next six months (m = 2.06, sd = 1.31) or the organization in the next three years (m = 2.52, sd = 1.33). patient type. the healthcare network where the study took place includes both acute care and ambulatory care settings. the ambulatory care nurses work an eight-hour work day, monday through friday while the acute care nurses work a more variable 12-hour shift, three days per week schedule. due to the differences in the types of work environments that acute care and ambulatory care nurses experience, we suspected possible differences in intention to leave between ambulatory and acute care nurses. respondents were not asked to specify clinic versus hospital as some ambulatory services are delivered in the hospital setting. patient type was measured using one question in the survey that asked participants “what population do you work with?” self-report response choices included the option between “outpatient” (n = 236) and “inpatient” (n = 158). outpatient was coded as 0 and inpatient was coded as 1. job satisfaction. job satisfaction was measured using one item that asked participants to indicate the percentage of time they were satisfied, dissatisfied, or felt neutral about their practice. participants were instructed to respond so that the total percentage between the three boxes equal 100 percent (waddimba, scribani, krupa, may, & jenkins, 2016). the higher the percentage of online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 17 time a participant felt either satisfaction or dissatisfaction with their practice, the higher their level of job satisfaction or job dissatisfaction. in general, nurses reported moderately high levels of job satisfaction (m = 68.66, sd = 21.37) and low levels of job dissatisfaction (m = 19.21, sd = 15.73). grit. grit was measured using the short grit scale (grit-s), an 8-item self-report measure designed to assess trait-level perseverance and passion for long term goals (duckworth & quinn, 2009). in comparison to the original scale, the grit-o, the grit-s retains the two factors of consistency of interests and perseverance of efforts, but with four fewer items (duckworth, peterson, matthews, & kelly, 2007). a subset of four items represents the factor of consistency of interest, which include items such as “new ideas and projects sometimes distract me from previous one.” the remaining four items represents the subset that represents the factor of perseverance of efforts, which include items such as “i am diligent.” participants rated each item on a five-point likert scale ranging from 0 “not like me at all” to 4 “very much like me.” negatively worded items were reverse coded. the grit-s is scored by computing the mean of the 8 items. the higher the grit score, the higher the participant’s trait-level perseverance and passion for long term goals, and vice versa. grit-s has established an internal consistency range of α = .73-.83 over the course of testing (duckworth, et al., 2009). in the current study, the cronbach’s alpha is 0.82, which indicates a high level of internal consistency. on average nurses reported a moderately high level of grit (m = 2.81, sd = .51). resilience. resilience was measured using the brief resilience scale (brs), a 6-item selfreport measure designed to measure four components of resilience which include recovery, resistance, adaptation, and thriving (smith et al., 2008; windle, bennett, & noyes, 2011). the scale is meant to assess the ability to bounce back or recover from stress. participant rated each item, such as “i tend to take a long time to get over setbacks in my life” and “i usually come online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 18 through difficult times with little trouble,” on a five-point likert scale ranging from 0 “strongly disagree” to 4 “strongly agree.” negatively worded items were reverse coded. the brs is scored by computing the mean of the six items. the higher the resilience score, the higher the participant’s resiliency, or their ability to bounce back or recover from stress. brs has established an internal consistency range of α = .80-.91 (smith et al., 2008). the cronbach’s alpha for the brs in the current study is 0.83, which indicates a high degree of internal consistency. on average nurses reported moderately high levels of resilience (m = 2.58, sd = .68). nurse engagement. engagement was assessed using a composite self-report measure that included items from scales in the health care advisory board (hcab) online nurse engagement survey tool (ankner, coughlin, & holman, 2010). the scales included were passion for nursing, autonomy and input, nurse staff teamwork, recognition, and professional growth. the passion for nursing scale assessed how participants feel about nursing. three items focus on the pride in being a nurse, belief in the hospital’s mission, and understanding of how one’s daily activities contribute to the hospital’s mission. participants rated each item, such as “i am proud to be a nurse” on a five-point likert scale ranging from 0 “strongly disagree” to 4 “strongly agree.” a passion for nursing score was created by computing the mean of the three items. on average nurses reported moderately high levels of passion for nursing (m = 3.37, sd = .61). cronbach’s alpha for passion for nursing in the current study is 0.82, which indicates a high degree of internal consistency. autonomy and input assessed how much input participants have at work. the six items focus on the perception of decisional control. participants rated each item, such as “my manager is open and responsive to staff nurse input” on a five-point likert scale ranging from 0 “strongly disagree” to 4 “strongly agree.” the scale was computed by taking the mean of the six items. on average online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 19 nurses reported moderately high levels of autonomy and input (m = 2.27, sd = .63). cronbach’s alpha for autonomy and input in the current study is 0.81, which indicates a high degree of internal consistency. the nurse staff teamwork scale assessed participant’s feelings about the team they work with. the seven items focus on the ability to function effectively within nursing and inter professional teams fostering open communication, mutual respect, and shared decision making to achieve quality patient care. the seven items focus on the ability to function effectively within nursing and inter professional teams fostering open communication, mutual respect, and shared decision making to achieve quality patient care. participants rated each item, such as “i have good relationships with nurses on my unit” and “nurses on my unit work toward common goals” on a five-point likert scale ranging from 0 “strongly disagree” to 4 “strongly agree.” a score was computed by taking the mean of the seven items. on average nurses reported moderately high levels of teamwork (m = 2.89, sd = .68). cronbach’s alpha for teamwork in the current study is 0.81, which indicates a high degree of internal consistency. recognition assessed how participants feel about the feedback they receive. the three items focus on the acknowledgement of one’s contribution. the questions were “i receive regular feedback on my performance”, “i received recognition when i provide care above the care standard”, and “i receive positive recognition for providing evidence based care”. participants rated each item, such as on a five-point likert scale ranging from 0 “strongly disagree” to 4 “strongly agree”. a recognition score was created by computing the mean of the two items. on average nurses reported moderately high levels of recognition (m = 2.30, sd = .99). cronbach’s alpha for recognition in this study is 0.81, which indicates a high degree of internal consistency. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 20 professional growth assessed how the healthcare organization supports their professional development. the three items focus on perceived opportunity and support for advancement. participants rated each item, such as “the organization values my professional growth and clinical skill development” on a five-point likert scale ranging from 0 “strongly disagree” to 4 “strongly agree.” the mean of the three items was computed to determine a score. on average nurses reported moderately high levels of professional growth (m = 2.51, sd = .87). cronbach’s alpha for professional growth in the current study is 0.81, which indicates a high degree of internal consistency. the engagement score was computed by taking the mean of the 21 items from the five subscales listed under engagement. on average nurses reported moderately high levels of engagement (m = 2.81, sd = .51). cronbach’s alpha for engagement in the current study is 0.80, which indicates a high degree of internal consistency. rural fit. community embeddedness is conceptualized as fit between the individual and the surrounding rural community. rural fit was measured using three items from the sense of community index ii, a self-report measure designed to assess a sense of community for a given sample (chavis & wandersman, 1990). the items were modified to address the local rural communities associated with this study. participants rated each item, such as “fitting into rural [region name inserted] is important to me” on a four-point likert scale ranging from 0 “not at all” to 4 “completely.” a rural fit score is created by computing the mean of the three items. on average nurses reported moderate levels of rural fit (m = 1.69, sd = .67). cronbach’s alpha for rural fit in the current study is 0.82, which indicates a high degree of internal consistency. data analytic plan online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 21 before testing study hypotheses, preliminary analyses were computed in which all study constructs were checked for violations of the normality assumption. next, correlations across study constructs were evaluated to check assumptions of directionality of expected relationships between variables. two linear regressions were used to examine the impact of job satisfaction and dissatisfaction, grit, resilience, nurse engagement, and rural fit on intention to leave unit within the next 6 months and intention to leave the hospital in the next three years, respectively. if nurse engagement was a significant predictor of intent to leave, a second linear regression was performed using the subscales of engagement. results study constructs were evaluated to ensure that all constructs met normality assumptions. all of the variables met the requirements of normality. correlation analyses. bivariate correlations were computed among study variables. variable descriptive statistics and correlations among variables can be found in table 1 below. patient type demonstrated a weak positive correlation with nurse engagement (r = .14, p < .05), intent to leave the unit in the next 6 months (r = .21, p < .001), and intent to leave the organization in the next 3 years (r = .25, p < .001), indicating that individuals who worked in acute care settings reported more engagement with their job, were more likely to leave their unit within the next 6 months, and more likely to leave the organization in the next three years. job satisfaction demonstrated a moderately positive correlation with grit (r = .30, p < .001) and nurse engagement (r = .36, p < .001), a weak but positive correlation with resilience (r = .21, p < .001) and rural fit (r = .16, p < .01), and a weak, negative correlation with intent to leave the unit in the next 6 months (r = -.25, p < .001) and intent to leave the organization in the next 3 years (r = -.26, p < .001). in short, those nurses in this study who reported greater job satisfaction online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 22 reported greater grit, engagement, resilience, and/or rural fit and reported less intention to leave the unit and/or organization. table 1: descriptive statistics and correlations among study variables m (sd) 1 2 3 4 5 6 7 8 1 patient type 2 job satisfaction 68.66 (21.37) -.10 3 job dissatisfactio n 19.21 (15.73) .01 -.78† 4 grit 2.81 (0.51) -.12 .30† -.23† 5 resilience 2.58 (0.68) -.02 .21† -.21† .42† 6 rural fit 1.69 (.67) -.02 .16** -.14** .13* .05 7 nurse engagement 2.81 (.51) .14* .36† -.38† .18† .19† .20† 8 leave current unit within 6 months 2.06 (1.31) .21† -.25† .23† -.16** -.16† .24† -.22† 9 leave organization in next 3 years 2.52 (1.33) .25† -.26† .25† -.18† -.03 .32† -.25† .49† note. + = p < .10, * = p < .05, ** = p < .01, † = p < .001. grit had a moderately positive correlation with resilience (r = .42, p < .001) and a weak but positive correlation with rural fit (r = .13, p < .05) and nurse engagement (r = .18, p < .001), with a weak negative correlation with intent to leave the unit in the next 6 months (r = -.16, p < .01) and online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 23 intent to leave the organization in the next 3 years (r = -.18, p < .001). this suggests that those nurses who reported greater grit expressed greater rural fit and engagement and less intention to leave the unit and/or organization. resilience demonstrated a weak positive correlation with nurse engagement (r = .19, p < .001), but a weak negative correlation with intent to leave the unit in the next 6 months (r = -.18, p < .001). those who reported a greater sense of resilience tended to report more engagement and less intention to leave their unit within 6 months. rural fit had a weak but positive correlation with nurse engagement (r = .20, p < .001), a weak negative correlation with intent to leave the unit in the next 6 months (r = -.24, p < .001) and a moderate negative correlation with intent to leave the organization in the next 3 years (r = -.32, p < .001), such that nurses with greater feelings of fitting into the local rural community also reported more engagement with their job, and indicated less intention to leave their unit and/or organization within the the next 6 months or 3 years, respectively. nurse engagement was negatively correlated with intent to leave the unit in the next 6 months (r = -.22, p < .001) and intent to leave the organization in the next 3 years (r = -.25, p < .001), such that nurses reporting a higher degree of engagement with their job at the organization also reported less likelihood to leave their unit within the next 6 months or the organization in the next 3 years. finally, intent to leave the unit in the next 6 months (r = -.22, p < .001) was positively correlated with intent to leave the organization in the next 3 years (r = .49, p < .001), such that nurses who are more likely to leave their unit within the next 6 months are also more likely to leave the organization in the next 3 years. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 24 intent to leave unit in six months. linear regression was used to evaluate the relationship between job satisfaction, resilience, grit, engagement, and rural fit on nurses’ reported intention to leave their unit within the next six months. the results predicting intent to leave the unit can be found in table 2. the model was significant, predicting 18 percent of the variance in intent to leave the unit in six months (r2 = .18, f = 10.02, p < .001). the results revealed that when all the variables were considered in a single model, only patient type (t = 4.46, p < .001), resilience (t = 2.69, p < .01) and rural fit (t = -3.14, p < .01) remained significant predictors. table 2: linear regression predicting intent to leave unit within next six months b se t value intercept 3.20 .70 4.54† patient type .63 .14 4.46† job satisfaction .00 .01 -.95 job dissatisfaction .01 .01 1.17 resilience -.30 .11 -2.69** grit .03 .15 .22 nurse engagement -.23 .15 -1.52 rural fit -.32 .10 -3.14** r2 = .18, f = 10.02, p < .001 note. ** = p < .01, † = p < .001. intent to leave hospital in three years. linear regression was used to evaluate the relationship between job satisfaction, resilience, grit, engagement, and rural fit on nurses’ intent to leave the hospital in the next three years. the model was significant, predicting twenty percent of the variance in intent to leave the organization in the next three years (r2 = .20, f = 11.390, p < online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 25 .001; table 3). the results revealed that when all variables were considered in a single model, significant predictors included patient type (t = 4.78, p < .001), nurse engagement (t = -2.34, p < .05), and rural fit (t = -4.72, p < .001). table 3: linear regression predicting intent to leave organization within next three years b se t value intercept 3.60 .70 5.13† patient type .67 .14 4.78† job satisfaction .00 .01 -.26 job dissatisfaction .01 .01 1.54 resilience .11 .11 1.01 grit -.23 .15 -1.56 nurse engagement -.35 .15 -2.34* rural fit -.49 .10 -4.72† r2 = .18, f = 10.02, p < .001 note. + = p < .10. *, † = p < .001. in order to further explore which components of engagement were most predictive of intent to leave the hospital in three years, an additional set of analyses were performed. the results predicting intent to leave the unit in the next three years can be found in table 4. the model was significant, predicting twenty-three percent of the variance in intent to leave the hospital in the next three years (r2 = .23, f = 8.45, p < .001). the results revealed that opportunities for professional growth (t = -3.25, p < .01) was the only sub-scale of engagement that was significant. rural fit (t = -4.05, p < .001) and patient type (t = -4.89, p < .001) remained significant predictors. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 26 table 4: linear regression predicting intent to leave the organization in the next three years b se t value intercept 3.54 .71 5.01† patient type .70 .14 4.89† job satisfaction <-.01 .01 -.05 job dissatisfaction .01 .01 1.71 resilience .11 .11 .98 grit -.23 .15 -1.58 passion for nursing -.10 .12 -.77 autonomy & input .06 .15 .41 teamwork -.01 .13 -.04 professional growth -.32 .10 -3.28* recognition -.05 .09 -.54 rural fit -.45 .10 -4.33† r2 = .23, f = 8.45, p < .001 note. * = p < .05, † = p < .001. discussion this study aimed to examine the unique contributions that job satisfaction, resilience, grit, engagement, and rural fit have on nurses’ intention to stay in their unit for the next six months and intention to leave this rural organization in the next three years. findings suggested that intent to leave the unit in the next six months or the organization in the next three years held a negative relationship to rural fit such that nurses whom felt that they fit in reported less intention to leave. these findings support the job embeddedness model. specifically, the fit between the individual online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 27 and the community context is very influential on nurses’ intention to leave their unit and the organization findings provide additional support for including understanding of how the nurse is embedded in the community context in considerations of models of rural nursing retention and of the development of recruitment and retention plans. the findings underscore the importance of the interactional and cultural dimensions of rurality. the only other predictor of intent to leave the unit in the next six months was resilience. nurses who identified as being more resilient were less likely to report intention to leave. the only other predictor of intent to leave the organization in the next three years was nurse engagement. more engaged nurses were less likely to report intention to leave the organization in the next three years. these findings add to our knowledge of nursing retention by highlighting the importance of fit within the rural community context in models of nursing retention. at the bivariate level, job satisfaction, grit, resilience, nurse engagement, and rural fit were all negatively associated with intention to leave their unit in the next six months, and with the exception of resilience, all variables were also negatively associated with intention to leave the organization in the next three years. however, in the multivariate analyses, rural fit was the strongest predictor. these results mirror those of roberge (2009) who reported that rural nurses were not satisfied with their jobs unless they were also satisfied with the rural environment. the lifestyle supported by one’s job is likely a part of one’s satisfaction with their job. unfortunately, individuals who prefer the recreational activities and lifestyles more typical of urban areas are likely to find the travel to urban centers both time and cost prohibitive, thus decreasing satisfaction with their job, and increasing their intention to leave. resilience was a unique predictor of intention to leave the unit in six months, but not the organization in three years. it is possible that when individuals have a difficult time recovering online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 28 from stressors, that they may see changing units as a solution that may address the problem. if this is true, supporting nurse resiliency may be one strategy to address within organization turnover. it is also possible that poor individual-unit fit may erode nurse resilience. more research is needed to better understand the nature of nurse resilience and within organization turnover overtime. lack of nurse engagement was a unique predictor of intention to leave in the next three years. when deconstructing this finding, the professional growth subscale was driving this relationship. even when considering rural fit, perception of opportunities for professional growth is associated with less likelihood of leaving over the next three years. it is possible that the opportunity to grow professionally through training opportunities and increasing responsibility incentivizes nurses to remain in rural organizations. opportunities for professional growth need to be clearly laid out and accessible to nurses. alternatively, it is also possible that nurses who intend to remain at an organization become more engaged and seek out more opportunities to advance their practice within the organization. limitations several limitations should be considered. first, as a cross-sectional study, the abilty to draw causal conclusions is limited. next, all of the data was collected through self-report which may inflate the relationships found between variables. objective measures of factors like resilience would strengthen the research design. in addition, only partial scales were used to measure nurse engagement. while internal reliability was maintained, the use of partial scales creates some uncertainty regarding the validity of the scales. future research can further explore subscale validity compared with established scales. rather than using an established scale to evaluate retention, we asked respondents to indicate how likely they were to leave. future studies should online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.547 29 consider measuring retention in other ways such as using validated scales or administrative records of turnover. finally, one measure of embeddedness was used (i.e., community fit); future research studies should include measures of community links and the perceived sacrifice one would make if they left their current job in order to investigate the job embeddedness model more comprehensively. conclusions in conclusion, poor rural fit was found to be associated with increased intention to leave one’s unit and the organization. these findings should be interpreted with caution as this is a cross-sectional study and no causal conclusions can be drawn from these findings. however, these finding suggest strategies that rural organizations may employ to both recruit and retain nurses. for example, organizations may work to support interested local rural residents to pursue a nursing career. unfortunately, while rural students are as successful as urban students in nursing programs, they are less likely to be accepted into nursing school (bigbee & mixon, 2013). programs that offer support for prospective rural nursing students, cultivating their interests and assisting in the application process, may be successful in increasing the number of nurses attracted to rural practice. helping nurses to develop a sense of community and supporting activities that are of interest to newly recruited nurses may help new nurses find a better fit with their rural community. despite the limitations, this study provided additional information 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(2011). a methodological review of resilience measurement scales. health and quality of life outcomes, 9(8), retrieved from https://doi.org/10.1186/1477-7525-9-8 3 editorial preventing postoperative nausea and vomiting: is the answer in your hands? angela smith collins, rn, dsn, acns, bc, ccns editorial board member nausea and vomiting are unpleasant and frequent side effect of anesthesia. one complimentary therapy that has minimal side effects and good outcomes is acupressure stimulation therapy to p6 (neiguan point). p6 is located near the wrist. the precise anatomical site is along the median nerve pathway, two finger widths below the wrist crease. acupressure stimulation can be created by needle acupuncture, transcutaneous electrical stimulus, acupressure by manual pressure, and acupuncture stimulation device such as wristbands. a cochrane collaborative report reviewed forty research reports relevant to p6 stimulation (fan, 2009). statistical analysis of the studies demonstrated that p6 stimulation worked as well as current pharmacological antiemetic therapies. the method of stimulation of the acupressure point and the duration of time of the intervention varied with each study. there were no recommendations from this report on the best method of acupressure for optimal results (fan, 2009). a recent study of a patient undergoing cardiac surgery found that one preoperative treatment with acupuncture at this site significantly diminished the sensation of nausea on postoperative day one and day two (korinenko, y, vincent, a, cutshall, s, li, z & sundt,tm, 2009). there are many ways to take these findings from the literature and apply them to clinical practice. the first application would be to read the above documents and lead a discussion with the anesthesia care providers and surgical staff in your care facility. the discussion should focus on the improved patient outcomes associated with decreased ponv. the second application would be to develop a teaching protocol that would incorporate teaching the staff and patients the methods of the technique. the protocol would also strengthen the portion of informed consent for anesthesia which discusses risks, benefits, and alternatives. as a workgroup the healthcare providers would need to choose the procedural aspects such as method of acupressure stimulation, timing of treatments, and duration. what are your clinical experiences with complimentary therapies? references fan, y.a. (2009) stimulation of the wrist acupuncture point p6 for preventing postoperative nausea and vomiting (review) the cochran collaboration. cochran database of systematic reviews. 2. published by wiley & sons, ltd. 1-122. doi:10.1002\14651858. korinenko, y., vincent, a., cutshall, s., zhou, l., & sundt iii, t. (2009). efficacy of acupuncture in prevention of postoperative nausea in cardiac surgery patients. annals of thoracic surgeons, 88, 537-542. [medline]   online journal of rural nursing and health care, vol. 10, no. 1, spring 2010  http://www.ncbi.nlm.nih.gov/pubmed?term=19632409%5buid%5d&cmd=detailssearch smith_690+rural+hosp+closures+and+ems+revision+100921_psf_edits+final+formatted4.11.22 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 26 the impact of rural hospital closures on emergency medical services transport times todd brenton smith, phd, msha, mba, bsn, nea-bc1 thomas macandrew english, phd2 marilyn whitman, phd3 dwight lewis, phd4 abbey gregg, phd5 1 assistant professor, university of alabama, capstone college of nursing, tbsmith3@ua.edu 2 assistant professor, university of alabama, management, tmenglish1@cba.ua.edu 3 professor and healthsouth endowed chair in healthcare management, university of alabama, management, mwhitman@cba.ua.edu 4 assistant professor, university of alabama, management, lewis060@cba.ua.edu 5 assistant professor, university of alabama, college of community health sciences, algregg1@ua.edu abstract purpose: previous studies have found disparities in emergency medical service (ems) transports for rural residents including double the average response time and lower patient survival rates when compared with their urban counterparts. since 2012, the rate of rural hospitals closures has risen alarmingly from previous years. previous studies have linked the closure of rural hospitals to increased ems transport and total activation time. however, data and methods used in previous studies have not included facility-level characteristics, which limits the ability to tease out the nuances of each closure. thus, the purpose of this study is to examine the impact of rural hospital closures on ems travel time, as well as the characteristics of the closed hospitals. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 27 sample: data sources for the study came from a state-level ems database, the cms provider of service files, and state-level hospital data reports. methods: geographic information system software was used to geocode hospital locations and generate service areas based on drive times. we identified rural hospitals that closed in alabama between 2010-2018 and then identified the 911 call data from the state’s ems database that occurred within close proximity of each of the hospitals of interest, resulting in a sample of 120,802 ems calls. findings: we identified five hospital closures within our time period. for one of the five closures, ems transport time to the emergency department increased by thirteen minutes post-closure. in two of the five closures, transport time increased by five minutes or less. in two instances, however, transport time decreased. conclusions: our findings suggest that not all rural hospital closures result in increased ems transport times as rural patients may have already been routinely transported to alternate hospitals. additionally, specific characteristics of a hospital pre-closure may be related to changes in ems travel times that occur post-closure. keywords: rural health, emergency medical services, access, hospital closure, travel distance the impact of rural hospital closures on emergency medical services transport times emergency medical services (ems) are an intricate system of coordinated response that provides emergency medical care (national highway traffic safety administration, n.d.). for rural communities in particular, ems plays a vital role in providing pre-hospital services for individuals suffering from trauma, sudden injuries, or acute illnesses (rural health information hub, n.d.). yet, rural ems must contend with the challenges of serving a geographically large area online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 28 that may negatively impact response or transport times. previous studies have found a number of disparities in trauma care for rural residents (carr et al., 2017), including double the average response time as their urban counterparts (mell et al., 2017) and lower patient survival rates (english, 2008). since 2012, however, physical access to acute care facilities in rural communities across the nation has decreased significantly as rural hospital closures have increased at an alarming rate. undoubtedly, the term rural remains inexact. the u.s. census bureau offers the only official federal definition of rural consisting of all territory, population, and housing units that are located outside of urbanized areas and urban clusters (u.s. census bureau, n.d.). rural hospitals that are located either in a nonmetropolitan country or in an area within a metropolitan county that has a rural urban community area (ruca) code of 4 or greater (freeman et al., 2015). between 2013 and 2017, u.s. rural hospital closures doubled from the prior five-year period (cosgrove, 2018), leaving approximately 1.7 million rural residents without access to nearby acute medical services (kaufman et al., 2016). to date, the total number of rural hospital closures since 2010 now stands at 137, with well over half of all closures occurring in southern states (sheps center for health services research [sheps center], 2019). the consequences stemming from closures are often severe for the communities they serve (kaufman et al., 2016; thomas et al., 2016). unlike urban hospital closures, in which residents are still left with alternative hospitals in the immediate area, rural hospital closures often leave communities without proximal acute medical services (kaufman et al., 2016). already faced with long ems response times (mell et al., 2017), rural residents may also face longer ems transport times as a result of rural hospital closures. recent studies on the impact of rural hospital closures on ems times have been linked to increased transport and total activation time (miller et al., 2020; troske & davis, 2019). online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 29 specifically, troske and davis (2019) estimate that rural patients in the u.s. spend an additional 11 minutes in ems transport a year after the closure of a hospital. in miller et al. (2020), the authors found that rural hospital closures resulted in greater transport and activation times. although these two studies offer valuable insights on the impact of rural hospital closures on ems times, there are a number of limitations that may influence their findings. for example, these studies relied on secondary data from the national ems information system (nemsis), a national database to which states voluntarily submit ems data. nemsis is considered a convenience sample as not all states participate and/or submit complete data. also, nemsis does not release geographic information such as street addresses or the name of the destination hospital, but rather only zip codes, leaving researchers to make a number of assumptions related to travel distance. furthermore, these two studies relied on average transport time for all rural closure areas and euclidean distances rather than driving distances, respectively, which in certain cases may significantly alter conclusions. therefore, the methods in these two studies do not offer an opportunity to tease out the nuances of each rural hospital closure and may result in an inaccurate or oversimplification of the impact of hospital closures. the present study aims to address these limitations. using data from the state of alabama, we offer a more in-depth, and possibly more accurate, investigation of the impact of rural hospital closures on ems transport times. alabama has witnessed a substantial number of closures (sheps center, 2019) and has recently been reported to have the highest percentage of financially distressed rural hospitals in the country (kacik, 2019). moreover, our study addresses an important factor that is often overlooked in studies examining the impact of closures on ems transport times – the utilization patterns of a hospital facility prior to that hospital’s closing. that is, were ems routinely transporting patients to these rural hospitals prior to their closure? to answer this online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 30 question, our study uses several data sources to highlight variations in ems transport times to alternate hospitals as compared with a pre-closure hospital, how closed hospitals varied based on certain characteristics pre-closure, and how these factors may be related. methods we used data from the alabama department of public health’s ems database to examine the impact of rural hospital closures on ems transport times. approval for use of the data for this study was through the university of alabama’s institutional review board (18-01-872, fwa # 00004939). the database contains full details of all ems calls to 911 centers in alabama including the location of each event and the transport destination location. according to the university of north carolina sheps center (2019), five rural hospitals in alabama closed between 2010 and 2018. we extracted 911 calls data from the state ems department that occurred in a zip code within 15 minutes of drive time of each of the five hospitals of interest. we limited our analysis to advanced life support or basic life support services ground transports and excluded transfer calls to capture only unplanned ambulance transports. this resulted in a final sample of 120,802 non-planned ems calls. the amount of time between dispatch notification of a 911 call to the hospital arrival time was considered to be the total transport time. average transport times were then calculated for each of the now closed five rural hospitals one-year pre-closure and one-year post-closure. we used esri arcgis pro v2.1 and streetmap premium data from here© to geocode hospital locations and generate service areas based on drive times. we then spatially joined zip codes that intersected with generated service areas to determine areas potentially affected by a hospital’s closure. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 31 next, we built a linear regression model using spss v27 to look at the impact of hospital closure on ems response times in zip codes within 15 minutes of each hospital that closed. we included direct effects of each hospital, preand post-hospital closure, and interactions for each hospital with preand post. we used hartselle medical center as a comparison for the dummy variables. hartselle medical center did close but is not considered to be located in a rural area. results figure 1 shows the average time from dispatch notification of an event to the arrival time of the ambulance to each hospital one-year pre-closure and one-year post-closure. findings reveal that transport time changed in an inconsistent manner after hospital closure across the six closed hospitals. in the case of three hospitals, transport times to an alternate hospital increased postclosure by 3, 4, and 13 minutes respectively. the hospital with the largest increase in transport time post-closure (13 minutes) had the highest rate of ems transports pre-closure (61.2%). in two closure cases, transport times decreased post-closure by four and five minutes, respectively. in each of these situations, there were relatively low rates of pre-closure ems transports (0.8% and 27.7%). online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 32 figure 1 preand post-closure ems transport time in minutes by hospital our findings suggest that the impact of closure varied based on the hospital. as shown in table 1, the pre/post closure variable was not statistically significant. however, all of the interactions of each hospital. and pre/post times, were statistically significant with only one exception. four of the areas showed a significant increase in transport times post hospital closure. however, the area surrounding southwest alabama medical center did see a decrease in overall transport time. 46 39 56 33 79 44 53 43 58 37 70 44 0 10 20 30 40 50 60 70 80 90 chilton (pre n=3840 post n= 5191) elba (pre n=3037 post n= 6502) florala (pre n=1416 post n= 2320) randolph (pre n=2142 post n= 21822) southwest (pre n=751 post n= 11106) hartselle (pre n=11110 post n= 51565) m in ut es hospital note. n=120,802 transports pre post online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 33 table 1 difference in difference analysis summary b std. error t p-value (constant) 43.772 0.242 180.51 <0.001 area effect chilton 2.348 0.478 4.908 <0.001 elba -4.859 0.523 -9.284 <0.001 florala 12.139 0.721 16.832 <0.001 randolph -10.896 0.603 -18.066 <0.001 southwest 34.819 0.964 36.132 <0.001 time effect post closure 0.426 0.267 1.593 0.111 interaction of area and time chiltonpost 7.382 0.606 12.178 <0.001 elbapost 3.484 0.622 5.601 <0.001 floralapost 1.392 0.902 1.543 0.123 randolphpost 3.641 0.637 5.712 <0.001 southwestpost -8.968 1 -8.967 <0.001 data from the centers for medicare and medicaid services (cms, n.d.) provider of service files and the alabama state health planning and development agency (n.d.) indicates that four of the five closed hospitals had low occupancy rates pre-closure. only randolph medical center, the closure that resulted in the largest increase in transport time, had a relatively high occupancy rate (54.51%). randolph was also the only hospital with a comprehensive emergency department offering physician coverage for medical, surgical, obstetric, and anesthesiology services 24 hours a day. one hospital had a substantially higher number of emergency department visits compared to the other four, but its services were limited. and, only one of these hospitals was designated as a trauma center. with the exception of just one hospital, all reported medicare as constituting half or more of their principal source of payment. finally, the nearest alternative hospitals for two of online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 34 the five hospitals were located over 30 miles away. the other three hospitals have alternate hospitals ranging between 11 to 17 miles away. additionally, we compared the characteristics and services of each closed hospital to the alternate hospital that saw the largest increase in ems transport rates from the service destination area post-closure (see table 2). overall, these alternate hospitals had greater mean occupancy rates and mean emergency departments visits. offering obstetrics services and operating an intensive care unit (icu) for medical and surgical purposes seemed to be the key differences between most alternate and closed hospitals. and finally, none of the five closed hospitals offered obstetrics or icu services pre-closure. table 2 characteristics of and services offered by closed hospitals chilton medical center elba general hospital florala memorial hospital randolph medical center southwest alabama medical center alternative hospital distance via google maps 30.8 miles, 32 minutes 16.9 miles, 22 minutes 31.4 miles, 39 minutes 11.6 miles, 13 minutes 17.3 miles, 20 minutes hospital characteristics ownership llc healthcare authority corporation healthcare authority llc occupancy rate 12.4% 22% 15.4% 54.5% 14.1% licensed capacity 60 20 23 35 49 type of ed limited essentially prompt essentially prompt comprehens ive essentially prompt number of ed visits 14,051 4,984 2,413 5,041 7,087 designated trauma center no no no no yes percent of discharges by principal source of payment % medicare 68.6% 44.8% 73.3% 61.7% 50.5% % medicaid 8.9% 25.4% 2.9% 12.4% 19.5% hospital services online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 35 chilton medical center elba general hospital florala memorial hospital randolph medical center southwest alabama medical center obstetrics no no no no no cardiac catheterization no no no no no inpatient surgery yes no no yes yes psychiatric (inpatient) no no no yes no psychiatric (emergency) no no no no no icu medical/surgical no no no no no neurological no no no no no note. type of ed definitions: comprehensive comprehensive 24 hour hours a day, including in hospital physician coverage for medical, surgical, obstetric, and anesthesiology services; limited limited by lack of immediate coverage in some major specialties, but a physician is always present in the emergency area and a surgeon is immediately available for consultation, other specialists are on call with 5-30 minutes; essentially prompt essentially prompt emergency care available at all times with basic medical and surgical service usually supplied within 30 minutes or less. certain clinical problems are always immediately transferred to another facility, while others may require specific assessment before transfer. discussion although a number of studies have examined the impact of hospital closures on travel times to emergency department services (buchmueller et al., 2006; hsia & shen, 2011; kaufman et al., 2016), few have used data that identifies the address from which the 911 call originated and the destination hospital, allowing for the accurate driving distance calculation. thus, our study offers a more detailed and accurate assessment of actual ems travel times. we believe that in most health policy arenas, the general consensus considers rural hospital closures as detrimental to the residents in the communities they serve, potentially increasing mortality rates from lack of proximal access to emergency services. indeed, in many communities a rural hospital closure may result in residents having to travel greater distances for care. also, greater travel times for ems have been linked to increased deaths from heart attacks and unintentional injuries (sheps center, 2019). accordingly, a recent study investigating rural and urban emergency department (ed) utilization patterns between 2005 and 2016 found a substantial online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 36 increase in rural ed utilization, accounting for nearly one-fifth of all u.s. ed visits (greenwoodericksen & kocher, 2019). however, our analysis of the impact of rural hospital closures on ems transport times in alabama suggests this may not be the case for every rural hospital. some areas may have alternate hospitals within the same distance, or closer, as revealed in the data from two hospitals in our sample. additionally, a recent study examining the impact of hospital closures on geographic access in the southeast u.s. suggests that it is possible to mitigate the adverse effects of hospital closures (burkey et al., 2017). using optimization modeling techniques, the authors analyzed the potential impact of hospital closures and found that using a strategic approach, a limited number of hospital closures in a given state may not adversely affect geographical access or quality of care. our findings also suggest that the impact of rural hospital closures on ems transport times may be related to hospital utilization patterns prior to closure. given this consideration, prospective patients may have preferred to utilize the services of alternative hospitals prior to their local hospital’s closure. only one of the hospitals in our sample had a high rate of ems transports to it pre-closure, and this was the hospital service area that saw a high increase in transport time postclosure. as financial challenges continue to plague rural hospitals, few are able to offer a full array of services (escarce & kapur, 2009), especially compared with larger facilities in more populated areas. consequently, rural residents may prefer to receive care at other facilities, including those at a greater distance to their homes. thus, it is important to consider the types and breadth of services offered by a rural hospital and the ems transfer patterns pre-closure to accurately assess the impact a rural hospital closure may have on future ems transfer times. while our analysis focused on ems transport times, rural hospital closures may impact other ems outcome measures, such as increased demand for transports, changes in waiting times, the online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 37 time spent waiting to transfer care from the ambulance to the ed staff, or the time from the arrival of the ambulance to the hospital to when it leaves to resume service (el sayed, 2012). these time points may be critical to ems agencies as they optimally staff their organizations to provide the timeliest response to patients. therefore, we believe that an in-depth analysis of ems data is critical to providing high quality care to communities. policymakers, planners, and researchers advocating for rural hospitals should consider using ems data, whether from their state (which in our case had richer data) or from the nemsis database, to prioritize efforts to save rural hospitals at risk for closure that are providing emergency care to their communities. ems data could also be used to identify rural hospitals that may need additional support in order to provide emergency care to their communities. as with most studies, ours is not without limitations. first, as with any spatial analysis of this nature, we cannot infer causation. it is possible that other factors coincided with the hospital closures that could have influenced the results generated. second, the service area generated for each hospital was based on the zip code. thus, we were limited by zip code centroid. the area of some zip codes extended beyond the 15-minute service area in analyses due to missing data. data submitted to the state varies a great deal by time and by ems provider, thus, it is unclear how missing data could impact the findings. finally, our findings are limited to rural hospital closures in one state, and thus may not be generalizable to other states, and our sample size was rather small, with only six hospitals under consideration. conclusion for most health emergencies, timely access to medical care is a critical factor in the successful resolution of the medical event. rural hospital closures are often detrimental to the communities they serve, resulting in some residents having to travel greater distances for care. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 38 with an estimated 700 rural hospitals at a high risk of closure (seigel, 2019), the need to understand the impact that these closures may have on ems transport times to an alternate facility is critical. using optimization modeling techniques, the present study suggests that not all rural hospital closures result in adverse effects to the community or its residents. our findings indicate that some rural hospital closures may actually result in a decrease in post-closure ems transport time. thus, the impact that a rural hospital closure may have on its community may depend on several factors, including utilization and ems travel patterns prior to closure. that said, in some communities where a rural hospital has closed, that hospital may not have been a facility of choice pre-closure for many in the community. policymakers should consider the inclusion of this particular factor when determining the effects of hospital closures on the medical and economic well-being of the rural communities they serve. references alabama state health planning and development agency. (n.d.). certificate of need review board. http://www.shpda.state.al.us/datadivision/pricing.aspx buchmueller, t. c., jacobson, m., & wold, c. (2006). how far to the hospital?: the effect of hospital closures on access to care. journal of health economics, 25(4), 740-761. https://doi.org/10.1016/j.jhealeco.2005.10.006 burkey, m. l., bhadury, j., eiselt, h. a., & toyoglu, h. (2017). the impact of hospital closures on geographical access: evidence from four southeastern states of the united states. operations research perspectives, 4, 56-66. https://doi.org/10.1016/j.orp.2017.03.003 carr, b. g., bowman, a. j., wolff, c. s., mullen, m. t., holena, d. n., branas, c. c., & wiebe, d. j. (2017). disparities in access to trauma care in the united states: a population-based analysis. injury, 48(2), 332-338. https://doi.org/10.1016/j.injury.2017.01.008 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 39 centers for medicare and medicaid services. (n.d.). provider of services current files. https://www.cms.gov/research-statistics-data-and-systems/downloadable-public-usefiles/provider-of-services/ cosgrove, j. (2018). rural hospital closures: number and characteristics of affected hospitals and contributing factors. gao reports. https://www.gao.gov/products/gao-18-634 el sayed, m. j. (2012). measuring quality in emergency medical services: a review of clinical performance indicators. emergency medicine international, 2012. article 16. https://doi.org/10.1155/2012/161630 english, f. (2008). improving cardiac survival rates in rural communities by ownership of health: what the evidence shows. journal of emergency primary health care, 6(3). https://ajp.paramedics.org/index.php/ajp/article/download/465/465/0 escarce, j. j., & kapur, k. (2009). do patients bypass rural hospitals?: determinants of inpatient hospital choice in rural california. journal of health care for the poor and underserved, 20(3), 625-644. https://doi.org/10.1353/hpu.0.0178 freeman, v. a,, thompson, k., howard, h. a., randolph, r., & holmes, g. m. (2015). the 21st century rural hospital. north carolina rural health research program, cecil g. sheps center for health services research. https://www.shepscenter.unc.edu/wpcontent/uploads/2015/02/21stcenturyruralhospitalschartbook.pdf greenwood-ericksen, m. b., & kocher, k. (2019). trends in emergency department use by rural and urban populations in the united states. jama network open, 2(4). article e191919. https://doi.org/10.1001/jamanetworkopen.2019.1919 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 40 hsia, r. y., & shen, y. c. (2011). rising closures of hospital trauma centers disproportionately burden vulnerable populations. health affairs, 30(10), 1912-1920. https://doi.org/10.1377/ hlthaff.2011.0510 kacik, a. (2019). nearly a quarter of rural hospital are on the brink of closure. modern healthcare. https://www.modernhealthcare.com/article/20190220/news/190229999/nearly-a-quarterof-rural-hospitals-are-on-the-brink-of-closure kaufman, b. g., thomas, s. r., randolph, r. k., perry, j. r., thompson, k. w., holmes, g. m. & pink, g. h. (2016). the rising rate of rural hospital closures. the journal of rural health, 32(1), 35-43. https://doi.org/10.1111/jrh.12128 mell, h. k., mumma, s. n., hiestand, b., carr, b. g., holland, t. & stopyra, j. (2017). emergency medical services response times in rural, suburban, and urban areas. jama surgery, 152(10), 983-984. https://doi.org/10.1001/jamasurg.2017.2230 miller, k. e., james, h. j., holmes, g. m., & van houtven, c. h. (2020). the effect of rural hospital closures on emergency medical service response and transport times. health services research, 55(2), 288-300. https://doi.org/10.1111/1475-6773.13254 national highway traffic safety administration. (n.d.). what is ems? https://www.ems.gov/whatisems.html rural health information hub. (n.d.). rural emergency medical services (ems) and trauma. retrieved april 16, 2021 from https://www.ruralhealthinfo.org/topics/emergency-medicalservices seigel, j. (2019). rural hospital closures rise to ninety-eight. national rural health association. https://www.ruralhealthweb.org/blogs/ruralhealthvoices/february-2019/rural-hospitalclosures-rise-to-ninety-seven online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.690 41 sheps center for health services research. (2019). rural hospital closures since january, 2005. university of north carolina. https://www.shepscenter.unc.edu/programs-projects/ruralhealth/rural-hospital-closures/ thomas, s. r., holmes, g. m., & pink, g. h. (2016). to what extent do community characteristics explain differences in closure among financially distressed rural hospitals? journal of health care for the poor and underserved, 27(4), 194-203. https://doi.org/10.1353/hpu.2016.0176 troske, s., & davis, a. (2019). do hospital closures affect patient time in an ambulance? rural & underserved health research center publications, 8. https://uknowledge.uky.edu/ ruhrc_reports/8 u.s. census bureau. (n.d.). rural america. https://mtgis-portal.geo.census.gov/ arcgis/apps/mapseries/index.html?appid=49cd4bc9c8eb444ab51218c1d5001ef6 rural nursing in singapore 10   editorial rural nursing in singapore desley hegney, phd, rn editorial board member   greetings to all of you from tropical singapore. many of you will not have realised that i moved from australia to singapore in march this year. in many ways i could no longer consider myself to be ‘rural’ living in a highly urbanised asian city of 4.5million people. it is really every rural nurse’s dream – one huge shopping centre. really there is not much more to do here than shop and eat. exercise is a challenge as it is hot (about 24c in the morning and gets up to 34c in the evening) and humid. but it does rain a lot (which is a refreshing change from australia) and everything is green. no drought or water shortage, though they do not waste water either. of course, we are only a bridge and a causeway from malaysia or a boat ride to indonesia. many singaporeans go to indonesia and malaysia daily to play golf, shop or visit one of the lovely resorts. it is easy to get around. public transport is great and cheap. taxis are also very reasonable (though the government has put on a surcharge during peak times and sometimes the surcharge is higher than the taxi meter). most expats don’t buy a car, but after six months here i decided to buy a second hand one. in singapore the government sells car licenses for 10 years. that is, you pay to buy a license to buy the car and after 10 years the car has to be scrapped (many are sold into malaysia i am told). this can range from a low a couple of years ago of about $10,000 to $50,000 (the price is rising as the government is restricting the cars on the road and therefore releasing fewer licenses). then you buy the car. the new car price is also heavily taxed – so most of the singaporeans buy second-hand cars. that is what i bought – a second hand subaru (though one does wonder what one would need an all-wheel drive for in singapore). mind you i have seen four-wheel drive cars here. i bought the car because i bought my 3 year old black labrador dog with me – angus. angus has taken some time settling in (ear and skin issues due to the heat) but is doing ok now. because we live in an apartment (or condo as they call them here), i wanted to take him out. there is an off-lead beach that we go to on the weekends, so he has a great time with other dogs, swimming, chasing the ball and generally getting lots of exercise. during the week the maid – mira (who is from the philippines and has 5 children and a husband there) walks him when i am at work or out in the evening). the health system is good here. if i go to the doctor it costs me $5 and that includes prescription medication. the pharmacies in singapore do not dispense drugs – the dispensing is done at the doctor’s surgery (strange). there are large primary care clinics (about 20% public and 80% private). you don’t make an appointment – rather you just turn up and wait. they have a good system of nurse-led case management of chronic diseases where registered nurses (not apns) case manage in particular people with diabetes and heart disease. at nus we have a masters apn program and we are slowly increasing the apn role in both hospitals and primary care. what do i see as so different? well, of course it is asia. it is crowded (especially the trains). sometimes i find the crowds rather overwhelming and then i escape back to my apartment. the shops are open all week from about 10.30am to 11pm!!! so one finishes work and goes shopping! the people are very friendly. singapore is very, very safe. while i could not walk around rural australia at night by myself, i can walk anywhere in singapore by myself and feel 100% safe. the food is great. singapore has three cultures – chinese (about online journal of rural nursing and health care, vol. 9, no.2, fall 2009 11   online journal of rural nursing and health care, vol. 9, no.2, fall 2009 80%), malay and indian (about 15%), as well as expats. so there is a great range of food and it is mostly very cheap (like $2-3 for a meal from the hawker stalls). of course if you want to eat in a top restaurant, there are many, and you pay for that. alcohol is expensive. heavily taxed, and most functions are dry (fanta, coke, sprite). drink driving is really ‘no tolerance’ as if you are below the legal limit but have any alcohol in your blood and are driving erratically they can still charge, cane, imprison you (or all of these options) and take your license away for 12 months. there is no graffiti. no road rage. it is very clean. the toilets are also very clean and are both squat (not for me) or ‘western’ (thank heavens). they don’t eat cats or dogs here either (they may on mainland china, but not in singapore). as i said it is not far to malaysia where, of course, there is a large rural population. i have not explored that as yet, but am hoping to once i settle in here as singapore and malaysia nurses have many common ties. so you will not hear from me again. karen francis will take over the australian rural nurse section. but in my heart i am still a rural nurse and still working in the area of primary care. i will keep up my international contacts and friendships that i have made over the years that i have been involved with rural nursing. i hope you all have a great christmas. even though singapore is not really a christian country, they are already putting up all the lovely lights in orchard road and there are things christmassy appearing in all the shops and food places. we have just finished celebrating deepavali, hari raya haji, hari raya puasa, the festival of the hungry ghost, vesak day, and ramadan – so wonderful the way all these festivals and religions mix so well here. if you are in singapore look me up here at the alice lee centre for nursing studies in singapore. best wishes and thank you for all your support over the years. borgos_664_formatted online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 118 navigating public health clinical placements for rural online rn-bsn students jill c. borgos, phd, ms, rn 1 1assistant professor of nursing, school of education, health, and human services, state university of new york at plattsburgh, jcrom007@plattsburgh.edu abstract purpose: in rural settings scarce public health resources potentially limits the opportunities for nursing students living in these areas to participate in traditional one to one precepted experiences with public health agencies. to meet the revised commission on collegiate nursing education standards related to direct clinical practice, creative strategies are needed for online degree seeking rn-bsn students who live in rural areas. this article explores an alternative learning experience by partnering students with a nonprofit healthcare institute to work on state health initiatives in the geographic region where the students reside. process: in the absence of adequate opportunities for one to one precepted clinical experiences, students living in rural areas completing an online rn-bs program were partnered with a nonprofit health organization. the students participate in an experiential learning experience to fulfill clinical hours in a public health setting as required by the commission on collegiate nursing education. in this case a cohort of students worked with a nonprofit healthcare institute on new york state’s t-21 campaign to further advance their knowledge on health initiatives driven by state health reform policy and actively participate in community-based education. conclusion: with a growing focus on population-based care and caring for vulnerable populations, particularly in rural areas, seeking clinical activities through partnerships with nonprofit healthcare institute to improve health outcomes at the community level offers an alternative online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 119 approach to engaging online degree seeking rn-bsn students in experiential clinical learning in communities with limited public health agency placements. keywords: interprofessional learning, nursing accreditation, rural nursing students, servicelearning pedagogy navigating public health clinical placements for rural online rn-bsn students with a growing focus on population-based care, health disparities, health equity, and vulnerable populations in nursing education, registered nurses to bachelor of science in nursing (rn-bsn) students need educational experiences in these areas. however, the scarce resources in public health in some rural areas makes getting these experiences challenging for the online rnbsn student population. while the traditional one to one precepted model may continue to work in some geographic areas, collaborations and partnerships with state level initiatives through nonprofit health institutes may serve as a meaningful alternative experience. delivery models of higher education have been and continue to evolve to provide access and opportunity not previously envisioned. securing traditional one to one precepted clinical placements for rn-bsn students in online degree programs can pose challenges, especially for cohorts of students who live in more rural or remote areas seeking placements in the same region at the same time. finding multiple clinical placements for students in rural settings in the areas of community and public health poses a particular challenge as public health agencies are in some cases understaffed due to limited financial support, and as a result they may be unable to support student learning (pettit, 2019; himmelstein & woolhandler, 2016). in new york state for example, county public health departments are in part funded through local tax dollars and their budgets are managed by a board of locally elected county supervisors (pettit, 2019). during times of economic hardship, funding online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 120 and support for public health services are at risk of being reduced due to competing demands on local budgets (pettit, 2019). in the absence of adequately funded and staffed public health agencies, traditional one to one clinical placement for cohorts of students in rural areas may not be an option. alternative approaches to clinical experiences are needed to meet program outcomes, state department of education guidelines, and the commission on collegiate nursing education (ccne) accreditation standards. defining rural in new york state rural regions of the united states are often categorized as sparsely populated areas where resources are often limited due to the geographic isolation. the definition of rural is not universal, but it is estimated by the us census bureau that approximately 46 million americans or 15% of the u.s. population live in rural areas (centers for disease control and prevention [cdc], 2017). differing definitions of rural can be found across federal and state agency websites. in some cases, the definition of rural is overlapping or used in a similar vein across agencies. a few examples of government agencies using different or overlapping definitions of rural include the us census bureau, the us department of agriculture, the office of management and budget (omb), the centers for disease control and prevention, the health resources & service administration, and the federal office of rural health policy (rural health information hub, 2019; cdc, 2017). some of the common characteristics distinguishing rural regions from urban or nonmetropolitan areas is the size of a population within defined boundaries, land use or how densely settled an area is, and proximity to other more populated regions with economic interests tied to the labor market (us department of agriculture -economic research service [usda-ers], 2020; cromartie & buchlotz, 2008). the usda-ers (2019) notes that the us census bureau differentiates geographic areas “strictly on measures of population size and density” with rural being any area online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 121 with a population measuring 2,500 or fewer residents. in a slightly different statistically measured definition, the health resources & service administration (2020) notes that the omb defines rural as any region that is not classified as either a “metro or micro” metropolitan area or not part of a “metropolitan statistical area” which includes areas with populations under 10,000. this definition by omb expands the estimated number of americans living in rural areas to 17%. states such as new york, with a population in 2010 of 19.58 million and approximately 12% of its population living in rural areas, has further defined rural in order to meet economic needs specific to the distribution of its population within its borders (schultz, 2019). in 2011 new york state concluded that an “one-size fits all” approach did not adequately reflect the economic growth needs of the state (schultz, 2019). the size of new york and its immense diversity required differing needs across the state and these differences created the need to find an alternative way in which to measure the needs of its population from a resource perspective (schultz, 2019). at that time, new york was divided into 10 regional economic development councils which were then further divided into 36 different economic regions with four separate groupings of the 36 economic regions (schultz, 2019). the four economic groupings were identified using omb metropolitan statistical area (msa) framework. the four economic groupings were divided into downstate msa, upstate msa, upstate micropolitan statistical area (sa), and rural counties unaffiliated with a formal msa. for the purposes of this paper discussing rn-bsn students in new york state, rural is defined using the new york state designated definition of rural counties and upstate micropolitan sa collectively which specifies any rural county that is not part of a metropolitan region and does not have a city of 10,000 residents and counties with one city with at least 10,000 residents respectively and not part of a msa. seven online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 122 percent of new york state’s population lives in one of these two statistically defined areas (schultz, 2019). revised accreditation standards in june 2018 revised accreditation standards were released by ccne with the expectation that by january 1, 2019 all programs seeking accreditation needed to be in compliance with the revised standards “regardless of the date of the last or next on-site evaluation” (commission on collegiate nursing education [ccne], 2018, p.1). revisions across parts of ccne’s standards ii and iii elaborate on expectations of clinical experiences for post-licensure baccalaureate distance learning programs. key element ii-b speaks to programs needing to be able to offer sufficient clinical sites and that these clinical sites are able to help students “to achieve the program’s mission, goals, and expected outcomes” (ccne, 2018, p.2). in standard iii, key element iii-g speaks to the importance of using “teaching-learning practices… to expose students to diverse life experiences, perspectives, backgrounds” (ccne, 2018, p. 2). key element iii-h goes on to highlight the need for students to have the opportunity to engage in clinical experiences with “planned clinical activities that…foster interprofessional collaborative practice” (ccne, 2018, p.1). and further, key element iii-h states that all programs, including distance education preparing students for direct clinical roles such as “post-licensure baccalaureate tracks”, must “provide direct care experience designed to advance the knowledge and expertise in a clinical practice” (ccne, 2019, p.2). these revised key elements provide direction and a renewed perspective on ways to deliver direct clinical experiences for rn-bsn students in online programs living in remote or rural areas. in order to meet the current and revised ccne standards related to direct practice experiences and given the ongoing challenges in finding one to one clinical placements in public online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 123 health for rn-bsn students in rural settings, an alternative learning experience was designed. this experience was focused to help students meet the clinical hours required by the new york state department of education in the area of community and public health, meet the ccne standards for clinical practice experience, and achieve the program’s mission, goals, and expected outcomes. the goal was to engage the rn-bsn students in a meaningful direct public health experience by connecting the students with the needs of their community in an interprofessional and evidencedbased setting centered on addressing ongoing state public health policy initiatives. rn-bsn students, as adult learners, often bring a whole host of experiences to the classroom (taylor, et al., 2000). translating these experiences into meaningful contributions to improve the overall health of their communities as future nursing leaders was one part of the overall learning experience. alternative learning experience the strategy used to provide a meaningful learning experience for rural online rn-bsn students was to connect a group of students to an ongoing new york state health initiative which also had significant implications to their local rural setting. this strategy was grounded pedagogically in a service-learning approach. service-learning pedagogy links theory to practice through connecting students with an identified community need for the dual purpose of improving community health outcomes and providing a learning opportunity for students (murray, 2013; marcus et al., 2011). in this case, the students were asked to work as a group with a nonprofit healthcare institute on new york state’s t21 campaign designed to limit tobacco sales to adults 21 and over (new york state governor’s office, 2019; institute of medicine, 2015). some independent nonprofit healthcare institutes focus their efforts and mission on “advancing population health outcomes by connecting healthcare organizations, businesses, payors, and county and state agencies to improve care, increase access, and lower costs” (adirondack health online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 124 institute, 2020). these types of healthcare institutes offer potential opportunities for creative partnerships in working with students in rural settings on healthcare initiatives. by working with the health care nonprofit organization, the goal was to connect the students to an identified community need to address improving health outcomes and providing a learning environment for the students (murray, 2013; marcus et al., 2011). in this same vein, the goal was for students to meet program and course outcomes of using evidence-based practice to address health issues across the health system, exploring relationships between policy and nursing practice, using communication strategies to meet educational needs of a population, and assuming a leadership role in improving quality care at the community level. for this project, under the supervision of a faculty member, eight online rn-bsn students, who lived within a one-hour geographic radius of each other, met with the director of community initiatives and support administrators at the nonprofit health institute focusing on new york state health initiatives, to gain perspective on new york state’s t21 campaign. it was determined through these meetings that one of the ways to communicate with the population in the community most impacted by the t21 campaign was to connect with local high school students, high school administrators, and parents. this connection evolved into a plan for the students to create a visually representative presentation of tobacco sales in the local community tied with evidenced-based data on long term health outcomes related to tobacco use. to do this the students reached out to a local high school health educator to determine interest in partnering with the school to hold an evening presentation for the high school students, high school administrators, and parents. in preparation for the community presentation the students conducted a literature review of the research on the historical development of the tobacco industry, youth behavior related to smoking, long term health outcomes, and tobacco marketing. to illuminate the connection online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 125 between tobacco sales and marketing strategies aimed at youth within the local community the students conducted a comprehensive windshield assessment of tobacco and e-cigarette vendors in the community that included pictures and geographic mapping. the geographic mapping highlighted the proximity of tobacco sales within walking distance to neighborhoods and k-12 schools. the pictures visually highlighted the colorful displays of tobacco products at the height level aimed to attract youth. at the conclusion of their data collection, the students presented on both new york state’s t21 initiative and their findings from the windshield survey of their community to a group of high school health students, parents, high school faculty and administrators, and directors from the nonprofit health institute. the nursing students had the opportunity to field questions from all the audience members. in particular, the geographic mapping visual of tobacco sales and colorful tobacco product displays generated questions from audience members as it created the most relatable connection between the data and community. as students who were also rns working in acute care settings in the surrounding community, they could speak with personal experience to the long-term health outcomes they see every day in the inpatient setting. this served as a touch point for the students in terms of relevance and confidence with the subject matter. given the lack of public health resources in rural areas of new york state and the subsequent lack of learning opportunities at public health agencies, this service-learning activity provided an alternative clinical approach to the one to one precepted clinical experience by directly engaging a group of students in their community. through this experience students gained an appreciation for working as a team with each other on a project, participating in interprofessional collaboration by working with professionals outside of nursing at a nonprofit health organization, engaging in the collection of evidence-based research with the intent to influence decision making, online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 126 and they demonstrated oral presentation skills to a community of interest. the project provided an opportunity for the students to positively affect the population health outcomes in the nearby community where they live and work as health care professionals. in debriefing sessions, the students reported a sense of professionalism, a connection with an important health issue impacting their community, an understanding of how to inform a population at risk, and pride in being able to contribute to a meaningful and impactful experience. the students’ overall reflection of the learning experience aligned with course outcomes and prior surveys on service learning experiences which include “confidence in educating clients”, “the ability to identify needs in a community”, “appreciation for the role of a community -based nurse”, and making the connection between “classroom learning and future clinical practice”(murray, 2013 p.622; bassi, 2011; balakas and sparks, 2010). conclusion the goal of this experience was to provide online rn-bsn students direct engagement in the work of providing valuable education to members of a community and to engender a feeling of professionalism and confidence in the students. the learning experience helped students meet program and course learning outcomes related to interprofessional collaboration and partnership with stakeholders, participate in community assessment, demonstrate effective advocacy within a community, and it helped them to develop communication strategies. meeting these course and program outcomes aligned with ccne key element ii-b. ccne accreditation key elements iii -g and iii-h were also realized, as students were able to complete a direct patient (patient defined here as the community group) experience, a planned activity that involved interprofessional collaboration with professionals working on health care policy initiatives, an exposure to a diverse online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 127 group, and through their research and presentation the students were able to advance their knowledge in clinical expertise in public health (ccne, 2018). just as the “one-size fits all” approach to defining rural does not adequately address the economic needs of new york state given the diversity and expanse of its geography, the same can be inferred about the application of learning activities in a clinical setting for online rn-bsn students. the alternative learning activity discussed in this article may pose limitations in different settings if replicated. not every model, program, and course experience can be duplicated in the same way. variations exist in student populations, geographic locations, institutional mission, student needs, and program requirements. in this case a collective group of students living in rural areas in the same state but in proximity to each other were able to work together despite being in an online program. additionally, the online nursing program had an already established relationship with a k-12 school district and the community in which the students lived, inevitability contributing to the access to opportunities through these relationships. this may not be the case for other programs thinking about ways to connect online students in rural areas to service-learning activities. regardless of the limitations, it is imperative that nursing faculty continue to think creatively and share ideas collaboratively in order to identify ways to provide meaningful alternative clinical experiences, especially for our rn-bsn students living and learning in remote or rural areas. references adirondack heath institute. (2020). bringing comprehensive health care and services to the people of the adirondack regions. http://adirondackhealthinstitute.org/ online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 128 balakas, k., & sparks, l. (2010). teaching research and evidenced-based practice using a service learning approach. journal of nursing education, 49 (12), 691-695. https://doi.org/10. 3928/01484834-20100831-07 bassi, s. (2011). undergraduate nursing students’ perceptions of service-learning through a school-based community project. nursing education perspectives, 32, 162-167. https://doi. org/105480/1536-5026-32.3.162 centers for disease control and prevention. (2017). about rural health. https://www.cdc.gov/ ruralhealth/about.html commission on collegiate nursing education. (2018, november 9). executive summary of changes to the 2018 standards for accreditation of baccalaureate and graduate nursing programs. https://www.aacnnursing.org/portals/42/ccne/pdf/summary-major-revisio ns-to-2018-standards.pdf cromartie, j. & bucholtz, s. (2008, june 1). defining the “rural” in rural america. united states department of agriculture-economic research service. https://www.ers.usda.gov/amberwaves/2008/june/defining-the-rural-in-rural-america/ health resources & service administration. (2020, december). defining rural population. u.s. department of health and human resources. https://www.hrsa.gov/rural-health/aboutus/definition/index.html himmelstein, d.u. & woolhander, s. (2016, january). public health’s falling share of us health spending. american journal of public health, 106 (1), 56-57. https://doi.org/ 10.2105/ ajph.2015.302608 institute of medicine. (2015). public health implications of raising the minimum age of legal access to tobacco products. washington, dc: national academies press. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 129 marcus, m. t., taylor, w.c., hormann, m. d., walker, t., & carroll, d. (2011). linking servicelearning with community-based participatory research: an interprofessional course for health professional students. nursing outlook, 56 (1), 45-54. https://doi.org/10.1016/j. outlook.2010.10.001 murray, b. (2013). service-learning in baccalaureate nursing education: a literature review. journal of nursing education, 52 (11), 621-628. https://doi.org/10.3928/0148483420131014-08 new york state governor’s office. (2019, july 16). governor cuomo signs legislation to raise tobacco and e-cigarette sales age from 18-21. https://www.governor.ny.gov/news/ governor-cuomo-signs-legislation-raise-tobacco-and-e-cigarette-sales-age-18-21 pettit, p.a. (2019). testimony of new york state association of county health officials to the joint legislative committees on health and finance/ways and means regarding the 2019-2020 executive budget proposal. county health officials of new york. https://www.nysacho.org/wp-content/uploads/2019/02/nysacho-testimony-201920-state-health-budget_final.pdf rural health information hub. (2019, april 8). what is rural? https://www.rural healthinfo.org/topics/what-is-rural schultz, l. (2019, october, 11). introducing new york’s rural economies. rockefeller institute of government. https://rockinst.org/blog/introducing-new-yorks-rural-economies taylor, k., marienau, c. & fiddler, m. (2000). developing adult learners: strategies for teacher and trainers. san francisco, ca: jossey-bass. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.664 130 united states department of agriculture-economic research service. (2019, october 23). what is rural? https://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/ what-is-rural/ united states department of agriculture-economic research service. (2020, may 2020). rural economy & population. https://www.ers.usda.gov/topics/rural-economy-population.aspx seibert other,+687-article+text-4494-1-4-20210430+with+psf+setup+6.28.21 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 3 engaging students as ebp ambassadors in a rural hospital susan a. seibert, dnp, rn 1 jennifer l. evans, dnp, rn, nc-bc 2 1 instructor of nursing, college of nursing and health professions, university of southern indiana, saseibert@usi.edu 2 associate professor, college of nursing and health professions, university of southern indiana, jennifer.evans@usi.edu abstract purpose: a regional research consortium provided a forum to optimize resources and fill gaps in services for all stakeholders. through the consortium, an academic practice partnership was formed with a state university’s nursing program to assist a rural, critical access hospital’s nursing staff gain evidence-based practice (ebp) knowledge and skills. the aim of this project was to create, implement, and evaluate the effectiveness of student led workshops to educate and empower critical access hospital staff nurses with ebp knowledge and skills. sample: a convenience sample of staff nurses who attended monthly staff meetings was used. sixteen nurses completed the pre-test, and 19 nurses completed the post-test. method: the ebp implementation scale and ebp beliefs scale was used in a pretest/posttest design to evaluate staff nurse beliefs about ebp and implementation of ebp in their nursing practice. findings: the nurses reported increased knowledge and application of ebp. the students developed professional and leadership skills. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 4 conclusion: a healthcare research consortium provided a forum that connected academia and practice and fostered sharing of expertise and resources. partnerships between nursing programs and rural, critical access hospitals may be an option for optimizing resources. keywords: critical access hospital, rural hospital, evidence-based practice, nursing students, academic-practice partnerships. engaging students as ebp ambassadors in a rural hospital bedside nurses may lack knowledge and confidence with evidenced-based practice (ebp). this gap in knowledge is compounded in rural hospitals because of a lack of robust staff development resources (friesen-storms et al., 2015; stavor et al., 2017). hauck and colleagues (2013) note the necessity for staff nurse education regarding ebp and leadership support of ebp education to build a culture promoting ebp implementation. this manuscript describes an academic practice partnership that engaged bsn students as ebp ambassadors to increase nurses’ knowledge of ebp and promote ebp utilization at a rural, critical access hospital. background a regional healthcare research consortium, under the auspices of the community patient safety coalition, was formed to empower nurses to lead research and utilize research outcomes to improve nursing practice, patient safety, and quality of life for our communities. members of the consortium, including eight heath care organizations and four nursing programs, established a regional nursing research agenda and combined their resources to mentor and educate nurse researchers. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 5 through the consortium, a chief nursing officer of a rural hospital expressed a need for resources to educate the nursing staff regarding evidence-based practice. the hospital lacked resources for extensive staff training. this 25-bed hospital serves a rural, largely agricultural county of around 36,900 residents and meets with the centers for medicare and medicaid services designation of critical access hospital (deaconess, 2021; gibson county, n.d.; rural health information hub, n.d.). to address the gap in resources, nursing faculty suggested using bsn students as evidence-based practice ambassadors. faculty proposed that students were knowledgeable in searching for quality evidence and already had experience with ebp in their first medical -surgical clinical course through a collaborative evidence-based practice project assignment. as a result, an academic practice partnership was established to advance nurse ebp knowledge and skills and promote ebp in the critical access hospital. project overview faculty called for student volunteers to participate in the project. several students used their involvement in the project toward credit for an academic honors diploma. others volunteered out of interest in ebp. the students, under the guidance of faculty, collaborated with the chief nursing officer to create a student-led educational model enhancing and empowering the nursing staff with knowledge about the evidence-based process. over a two-year span, new student volunteers joined the project as seniors graduated for a total involvement of 12 students. the nursing students reviewed the literature for information on utilization of ebp in rural hospitals and on best practices for ebp education. several articles reported that nurses in rural settings were not confident with identifying research gaps or with implementing the ebp process (friesen-storms et al., 2015; lenz & barnard, 2009; stavor et al., 2017). the literature also online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 6 provided evidence of barriers for rural nurses to implement ebp including lack of ebp knowledge and skills, lack of initiative to change current practice, and lack of institutional supports such as databases and journals (friesen-storms et al., 2015; lenz & barnard, 2009; o’ lynn et al., 2009; stavor et al., 2017). studies by friesen-storms and colleagues (2015) and lenz and barnard (2009) demonstrated that with education, rural nurse utilization of ebp improved. the literature review also informed the students of best practices for ebp education in a hospital setting (lenz & barnard, 2009; winters & echeverri, 2012). based upon the literature review, the students opted for an interactive learning approach to ebp instruction to empower the nurses with ebp confidence and skills. topics included the definition of ebp, the process of ebp, how to identify scholarly sources, how to conduct a literature search, and how to appraise the evidence for a total of five educational sessions. each session included a one-page hand out with bulleted summary of information and a brief, studentled overview of the content. after the overview, the students facilitated interactive learning activities that fostered hands on application of content. for example, the session about the process of ebp included an interactive discussion among the nurses as they developed a picot question that applied to nursing practice within their home unit. the session about how to conduct a literature search included a tutorial on how to navigate the hospitals database with each nurse charged with finding one high evidence article for their respective picot question. on another occasion, the students assisted the nurses to conduct a rapid critical appraisal of one of their articles. the five learning sessions were hosted during scheduled staff meetings. students facilitated one or two sessions per semester over a 2-year period. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 7 melnyk, fineout-overholt, and may’s (2008) ebp implementation scale and ebp beliefs scale were selected to evaluate the effectiveness of the interactive learning sessions. these scales contain 16 items assessing the individual’s perceived value of ebp and an 18-item scale (respectively) evaluating their perceived ability to implement ebp. the cronbach alpha for both scales was >.90. in the original study, melnyk et al. (2008) found that education increased both the value and implementation of ebp. faculty maximized student involvement in the project by having them complete human subject’s protection training, apply for the irb approval, gather consents, and administer the surveys. with faculty supervision, one of the students contacted the authors of the ebp survey to seek permission for use, which allowed them to gain experience communicating with researchers and learn about the copyright process. another student was mentored in and assisted with entering the data into a statistical software package. methods upon irb approval, a pretest/posttest evaluation of a convenience sample was planned to assess the effectiveness of the workshops on the nurses’ ebp beliefs and ability to implement ebp. nurses who worked in the medical/surgical, intensive care, and emergency departments were asked to complete the ebp belief and implementation scales before the first education workshop. prior to completing the scales, nurses signed a consent form to allow for data analysis and outcome dissemination. the pre-workshop evaluation was completed in spring 2016. educational workshops were offered during each spring and fall semesters over a two-year period. following the last educational workshop in the spring of 2018, a post-workshop assessment was completed using the same ebp beliefs and ebp implementation scales. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 8 project outcomes sixteen nurses completed the ebp beliefs and implementation scales in the initial session. following the delivery of all the education sessions, 19 nurses completed the ebp beliefs and implementation scales again. there were three nurses who completed the scales for the postworkshop evaluation who were not present during the inaugural session. the workshops were delivered over two years and more nurses attended the workshops as they were offered. because the pre and post samples were not matched, the pre-workshop scale scores were used as a threshold to determine the initial state of ebp belief and implementation among the nurses. to evaluate the impact of the workshops, the pre-workshop threshold scores of the two scales were compared to the post-workshop scores using a one-sample t-test. the p value for statistical significance was set to be less than 0.05. analysis of the data revealed eight statistically significant components suggesting the educational sessions did indeed have an impact on the nurses’ belief and use of ebp. table 1 details the results of the most significant findings. table 1 survey results "in the past 8 weeks, i have . . . " pre (n=16) post (n=19) significance (p) used evidence to change my practice 2.20 2.42 0.036 shared evidence from a study in the form of a report or presentation to 2 or more colleagues 1.69 2.53 0.002 shared ebp guidelines with a colleague 1.81 2.37 0.003 shared evidence from a research study with a client 1.75 2.05 0.027 accessed the cochrane database of systemic reviews 1.19 1.42 0.014 accessed the national guidelines clearinghouse 1.25 1.58 0.002 evaluated a care initiative by collecting client outcome data 1.69 2.32 0.011 promoted the use of ebp to my colleagues 1.88 2.11 0.036 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 9 practice change requires inquiry, investigation, and dissemination. the outcomes that were found to be significant support these elements of ebp. nurses reported they were more likely to participate in the first steps, inquiry and investigation, after the education. nurses indicated on the survey an increase in how often they accessed scholarly databases to search for evidence regarding nursing practice and used this evidence to support practice change. the survey results also suggested that the nurses were more likely to evaluate these changes following implementation. three of the survey elements demonstrated that following the ebp education, nurses were more likely to share evidence with their colleagues or clients. in addition, the survey showed a significant increase in the nurses’ likeliness to promote ebp to their colleagues. sharing of current evidence is at the essence of practice change; therefore, this outcome may foster further ebp development. the students also benefited from the experience of sharing their ebp knowledge. in addition to gaining experience with irb approval, ebp, and research processes, the students developed other professional and leadership skills. students experienced developing, facilitating, and evaluating educational offerings. they honed their collaboration and communication skills and gained confidence with creating and submitting abstracts. consequently, they presented the project’s successful design and findings at international, national, state, regional and local venues, some of which were peer-reviewed. because of their extraordinary leadership with the project, faculty nominated the students as rising stars in nursing through sigma theta tau. remarkably, one cohort of students was featured in sigma’s reflections on nursing leadership online journal (bell et al., 2019). involvement and leadership in this project produced a dissemination history online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 10 that augmented the student’s resumes and was an impressive point of discussion during their interviews for nursing positions. limitations and future research although the project’s outcomes were favorable for all the stakeholders including the research consortium, the rural hospital, and the nursing students, some limitations exist. the number of participants was limited by the small numbers of nurses attending the staff meetings. also, a formal study of participant knowledge, efficacy, and skills with ebp that matched participant pre-test scores with participant post-test scores would have been a more concrete evaluation of effectiveness on the part of the participants. opportunities for further studies may stem from this project. for example, future research is recommended to substantiate the effectiveness of student-led ebp initiatives in rural hospitals as a model to promote ebp. in addition, further development of a shared resource model involving regional research consortiums to assist rural hospitals with ebp and nursing research should be explored. the critical access hospital and the nursing program plan to continue their partnership. the focus will shift to augmenting hospital ebp teams by including students and faculty in the development of picot questions, searching for evidence using university databases, and assisting in appraisal and analysis of findings. this continued partnership will enhance future students’ appreciation for ebp by allowing them to witness and be a part of the ebp process and provide supportive resources to promote ebp utilization in the critical access hospital. implications and conclusion online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 11 because of the successful stakeholder outcomes, this project is an exemplar for other research consortiums, rural hospitals, and nursing programs. the research consortium served as a catalyst for optimizing regional resources in a way that promoted professional growth and development for nurses and future nurses. collaboration across area hospitals and academic programs may be one solution to fill gaps in resources and expertise. in this case, the use of nursing students as ebp ambassadors was an innovative, effective option to optimize resources and enhance ebp knowledge a critical access hospital with limited educational resources. rural hospitals may consider partnering with neighboring nursing programs to leverage faculty and student expertise. furthermore, based on the project, opportunities exist to optimize bsn student knowledge and skills toward projects that may improve the quality of patients. acknowledgements thank you to the staff and administration at gibson general hospital for their cooperation and support of this project. thank you to these former students who demonstrated extraordinary leadership throughout this project: amber parsons, bsn, rn; katie halbig, bsn, rn; rebecca horn, bsn, rn; jenna spiller bsn, rn; kim bell, bsn, rn; rachel goldstein, bsn, rn; lucy hardison, bsn, rn; anne kiboi, bsn, rn; anna heckman, bsn, rn; sarah mehringer, bsn, rn; allison schroering, bsn, rn; and grace voyles, bsn, rn. references bell, k. a., hardison, l. n., kiboi, a. w., & smith, r. r. (2019, march). sigma’s rising stars of research and scholarship shine! reflection on nursing leadership. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 12 deaconess. (2021). gibson general hospital. https://www.deaconess.com/deaconess-gibsonhospital friesen-storms, j. m., moser, a., van der loo, s., beurskens, a. m., & bours, g. w. (2015). systematic implementation of evidence-based practice in a clinical nursing setting: a participatory action research project. journal of clinical nursing, 24(1-2), 57-68. https://doi.org/10.1111/jocn.12697 gibson county (n.d.). about gibson county. http://www.gibsoncounty-in.gov/about/sitepages/ home.aspx hauck, s., winsett, r. p., & kuric, j. (2013). leadership facilitation strategies to establish evidence-based practice in an acute care hospital. journal of advanced nursing, 69(3), 664674. https://doi.org/10.1111/j.1365-2648.2012.06053.x lenz, b. k., & barnard, p. (2009). advancing evidence-based practice in rural nursing. journal for nurses in staff development. 25(1) e14e 19. https://doi.org/10.1097/nnd.0b013e 318194b6d0 o’ lynn, c., luparell, s., winters, c. a., shreffler-grant, j., lee, h. j., & hendrickx, l. (2009). rural nurses’ research use. online journal of rural nursing & health care, 9(1), 34–45. http://doi.org/10.14574/ojrnhc.v9i1.103 melnyk, b. m., fineout-overholt, e., & mays, m. z. (2008). the evidence-based practice beliefs and implementation scales: psychometric properties of two new instruments. worldviews on evidence-based nursing, 5(4), 208-216. https://doi.org/10.1111/j.1741-6787.2008.00126.x rural health information hub. (n.d.). critical access hospitals. https://www.ruralhealthinfo.org/topics/critical-access-hospitals online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.687 13 stavor, d. c., zedreck-gonzalez, j., & hoffmann, r. l. (2017). improving the use of evidencebased practice and research utilization through the identification of barriers to implementation in a critical access hospital. the journal of nursing administration, 47(1), 56-61. https://doi.org/10.1097/nna.0000000000000437 winters, c. a. & echeverri, r. (2012). teaching strategies to support evidence-based practice. american association of critical care nurses, 32(3), 49-54. http://dx.doi.org/10.4037/ccn2012159 723_jan+28+revised+educational+needs+of+rural+nurses+_final_setup_psf_2_26_23+formatted 32 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 educational needs of rural nurses when entering practice stephanie corner, rn, ms np student1 sherry dahlke, phd, rn, gnc(c)2 kathleen hunter, phd, rn, np, gnc(c), nca3 1 master's family all ages nurse practitioner student, university of alberta, corner@ualberta.ca 2 associate professor, faculty of nursing, university of alberta, dahlke@ualberta.ca 3 professor, faculty of nursing, university of alberta, kathleen.hunter@ualberta.ca abstract purpose: the purpose of this integrative review is to identify the educational needs of rural nurses and the strategies that have been effective in meeting those education needs. sample: the literature search yielded 1388 articles to be screened after 930 duplicates were removed. two researchers screened by title and abstract and full-text review, yielding ten articles. four were qualitative, four were quantitative and two studies were mixed methods. method: an integrative review using whittemore and knafl’s method was conducted. cinahl, medline, embase and scopus databases were searched. studies about registered nurses' practice from canada, the united states and australia were included as these countries are geographically large with rural areas at a distance from larger, urban centres. inductive content analysis was used to develop themes. findings: the themes of educational needs, educational delivery, and barriers to education were developed from data analysis. educational needs of rural nurses are well established, although 33 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 multiple barriers impede access to education. various educational delivery methods have been attempted; it is unclear as to which method is most effective. conclusions: rural nurses must continue to advocate for education opportunities specific to their needs and the demands related to working within the rural context. it’s essential employers and accrediting bodies of hospitals work together to ensure that rural and remote nurses have the essential skills to care for rural and remote populations. keywords: rural nursing, educational needs, educational delivery, barriers to education. educational needs of rural nurses when entering practice rural nursing requires a diverse and broad scope of practice which is positively influenced by additional educational preparation tailored to the needs of rural nursing practice. various definitions of rurality or remote areas exist. the variations consider population, geography, and even rural as a socially constructed phenomenon (asad et al., 2021). the united states of america (usa) department of health and human services (2020), define urban areas and urban clusters and conclude rural encompasses all areas that are not urban. canada similarly defines rural as areas outside population centres and specifies that population densities and living condition vary greatly among rural communities (statistics canada, n.d.). in 2016, 11.3% (44,724) of the regulated nurses working in canadian provinces worked in rural or remote areas with 17.3% of the population living in these areas (canadian institute of health information [cihi], 2016). this number is similar in the united states of america (usa), where 16% of registered nurses (rns) work rurally (health resources and services administration [hrsa], 2013). in australia, approximately 19% of nurses work in rural towns and remote communities (commonwealth of australia, 2020). the nature of rural nursing places a greater demand for an expanded role of practice, despite rural nurses having comparatively lower levels of formal education when compared to urban nursing colleagues 34 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 (macleod et al., 2017). moreover, rural nurses may have lower wages and limited funding for professional development (field et al., 2018; skillman et al., 2007). the canadian association for rural and remote nursing [carrn] (2020) explains that rural nurses experience challenges with both having the education needed to meet the challenges of rural settings and accessing continuing education. in australia, discussion about educational preparation has focused on postgraduate study, yet most rural nurses do not have postgraduate qualifications and face significant barriers in obtaining them (kenny & duckett, 2003). this also highlights a conflict of whether preparation to practice should occur prior to entering the practice environment or if it can occur while practicing in the area. educational preparedness is nuanced and often understanding what makes nurses feel unprepared, can help inform how to prepare nurses for practice (garner & bedford, 2021). in a survey of nurses from the usa, when comparing rural to urban, rural nurses were more likely to indicate that inadequate training was a barrier to their work performance. also, they were less likely to report that their nursing education had equipped them for work (probst, mckinney et al., 2019). rural nurses are required to have a wide range of advanced physical assessment skills, triage, emergency, obstetrical and trauma care skills (macleod, kulig et al., 2004; medves et al., 2015). maintaining knowledge to stay up to date with practice in rural communities requires a broad range of continuing education topics (hendrickx & winters, 2017). this paper reports on an integrative review that examined rural nurses learning needs and how best to address them. background rural nursing is a multi-specialty, generalist practice that requires excellent clinical knowledge (registered nurse association of british columbia [bc], 2005; nurses and nurse practitioners of bc, 2018). in addition to a broad scope of practice, in some rural and remote practice, nurses may be the only primary care providers available. in contrast, urban settings often 35 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 have nurses on-site 24/7 with on-call physician support (mccullough et al., 2021). rural nurses are expected to be able to respond to a variety of clinical situations with minimal support and resources. rural citizens in canada, australia and the usa disproportionately suffer from adverse health outcomes, poorer health, and higher age-adjusted mortality (australian government n.d.-b; probst, eberth et al., 2019; subedi et al., 2019). this is related to complex factors such as geographic location, social determinants of health, access to resources and difficult recruitment and retention of healthcare providers (macleod, kulig et al., 2004). systematic change is required to address all these complex barriers and improve health outcomes in rural and remote settings as rural nurses’ lack of educational opportunities could exacerbate the existing poor rural health outcomes. rural nurses who are prepared for rural challenges will be more competent in meeting the healthcare needs of the population they serve. few continuing education or postgraduate certificate specific to rural nursing exist. of the programs and courses that do exist, their efficacy is poorly reported, and there is no standardization of educational expectations for rural practice. yet, rural nurses need additional education to help them be prepared for practice. wolf and delao (2013) highlighted that rural emergency nurses believed that an advanced knowledge base and critical skill application are fundamental to ensuring safe patient care, and continuing education crucial to support this. lea and cruickshank (2015) discussed the transition to rural practice and concluded that mentorship or unit orientations are not often enough. this was related to generally lower staff numbers, limited resources, and senior staff workloads impeding the ability to support incremental learning in rural practice settings. following a scoping review, bish et al. (2012) suggested that rural nurse leaders on a global scale need to create structures and processes to enable excellence in nursing careers of all types. a key structure they identified is the need to create educational pathways specific to rural 36 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 nursing practice. despite the need for educational opportunities, especially those specific to rural practice preparation, access and opportunity remain limited. barriers to continuing education for rural nurses include geographic isolation, limited accessibility, and financial and time constraints (penz et al., 2007; young et al., 2019). regardless of these barriers, meeting rural nurses’ educational needs must be prioritized. however, it is not well understood what educational strategies have been utilized or are effective in preparing rural nurses for their practice. within canada, entry-level nursing competencies developed for provincial and territorial nursing regulatory associations are based on generic requirements and do not address the needs of nursing in rural or remote practice settings (macleod, kulig et al 2004; kulig, 2005). this is echoed by a recent review by the carrn (2020) where they obtained correspondence from the canadian association of schools of nursing (casn) database stating that rural curricular content in schools of nursing is not currently captured by their database. absence of such information lead to less accountability and lack of quality standards. in the usa, each state and territory have laws to govern the practice of nursing, as defined in the nursing practice act (huynh & haddad, 2022). the nursing practice act (npa) is interpreted into regulations by each state and standards on prelicensure nursing education with clinical learning experiences defined and used for accreditation purposes. as each state has a different interpretation, it proves challenging to examine which includes educational requirements specific to rural practice. not all usa nursing regulatory bodies currently require national nursing accreditation (national council of state boards of nursing, n.d.), which may decrease the impetus to include rural nursing educational content. australian nursing programs are approved by the nursing and midwifery board of australia which works with the australian health practitioner regulation agency to regulate the profession 37 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 (australian government, n.d.-a). ralph et al. (2014) reviewed australian undergraduate, preregistration, nursing curricula using a pestel (politics, economics, society, technology, environment, and law) framework. within the politics category targeted priority areas are identified and include rural and remote australians as a health population. although their analysis identified 36% of curriculum targeted priority areas, there was no indication about the amount of curriculum related to rural health. in june of 2022, the australian government released the national rural and remote nursing generalist framework. this document describes rural and remote practice and the core capabilities of nursing practice. its purpose is to act as reflective and supportive tool for educators, employers, and mentors to assist in a pathway of development for the rural nurse and remote nurse. despite the complexity of rural practice within canada, only two institutions have certificate programs focused on rural or remote nursing (carrn, 2020). while some canadian, usa, and australian nursing schools do offer rural preceptor experiences, there is no consistent approach for preparing students for rural placements or consensus as to whether these experiences are adequate (green et al., 2022; gum, 2007; sedgwick & yonge, 2008; yonge et al., 2013; carrn, 2020). the rural nurse organization is a usa-based organization formed to recognize, promote, and maintain the unique specialty of rural nursing practice (rural nursing organization, n.d.). they advocate for the implementation of rural nurse residency programs and transition-to-practice programs. in australia, the council of remote area nurses of australia (crana) is a grassroots, not-for-profit, membership-based organisation that aims to support nurses and other health professional in providing high quality care to remote areas in australia. they offer continuing education programs tailored to remote and rural practice, as well as a rural and remote mentorship program (crana, n.d.). 38 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 we determined conducting an integrative review would enhance understanding of the unique educational needs of rural nurses and educational strategies that have been employed in rural settings. findings would provide insights into the educational needs of rural nurses and perhaps identify successful rural nurse education programs and strategies. supporting ongoing nurse competence would in turn lead to better patient outcomes and better healthcare experiences (molanari et al., 2011). this information could be used by health authorities to enhance the practice and competence of rural nurses. wilson et al. (2020) called upon government leaders to help advance education, policy, practice, and research activities related to rural health care in canada. the purpose of this integrative review is to identify the educational needs of rural nurses and the strategies that have been effective in meeting those education needs. methods design an integrative review of the literature was performed using whittemore and knafl’s (2005) framework of identifying and analyzing relevant studies. this framework has five phases, including 1) problem formation, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation of results. a health sciences librarian helped guide the literature search and development of search terms. search terms were as follows: (rn" or "registered nurse*") and (education or training or "prepared*" or orientation or workshop*) and (rural or "non-urban" or country* or remote) and (need* or necessit* or requirement* or support*). databases that were searched include cinahl, medline, embase and scopus. inclusion criteria for the review were articles in the english language, published within the last 20 years 2002-2022 and articles about rural registered nurses' practice from canada, the united 39 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 states and australia. these countries are geographically large with rural areas at a distance from larger, urban centres. exclusion criteria were articles relating to continuing education that were included in an integrative review by pavloff et al. (2017) as these authors focused only on continuing education for already practicing rural nurses between 2010-2016. non-research, theoretical articles, dissertations and theses were also excluded. results of the literature review were screened utilizing covidence (covidence systematic review software, n.d.) by title, then abstract, and finally reading the full article by two researchers. a preferred reporting items for systematic reviews (prisma) figure (shamseer al., 2015) was created to document the process of article selection (see figure 1). the mixed methods appraisal tool (mmat) was utilized to critically assess the articles – table 1 (hong et al., 2018). after data were extracted into a table (see table 1), it was analyzed using inductive content analysis (hsieh & shannon, 2005) to identify patterns, themes, or relationships in the literature (see table 3). the first and second authors had numerous meetings discussing the data until a consensus about the key concepts, categories and themes were reached. the third author reviewed and provided feedback on the protocol and versions of the findings. 40 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 table 1 integrative review table author, year and origin aim method and sample findings limitations beks, et al. (2018). rural and remote health australia to explore the experience of rural nurses in managing acute mental health presentations within an emergency context. qualitative descriptive. themes are analyzed by an inductive descriptive approach. 13 rural generalist nurses from one rural ed and 2 rural uccs located in elsewhere. four main themes were elicited. we are the frontline; doing our best to provide care; complexities of navigating the system; thinking about change. rural generalist nurses deliver the majority of care to mental health consumers in eds and uccs. small sample size and novice nurses’ perspectives were not captured. bolin et al. (2011). journal of emergency nursing united states to explore the perspective of emergency nurses in rural areas on the impact of continuing education on clinical competency. quantitative, descriptive design. non-probability sampling via survey. data were obtained from 33 nurses, representing 3 different rurally located ed settings. participants, 10 (39%) rated their occupational satisfaction as 10, 19 (58%) rated their occupational satisfaction 7 9, and 1(3%) rated their occupational satisfaction 5. maintaining competencies is perceived as highly important. 23 (70%) rated this as 10; 8 (24%) rated between 7 and 9. maintaining competencies was described as moderately important. 25 (76%) of respondents stated ed specific ceus should be mandatory. 21 (64%) stated that ceus are not a requirement of their job duties. there was no one to serve as nurse educator in ed. orientation programs, using either a preceptor or mentor approach, was available 85% of the time (n = 28). the only significant correlation was a direct correlation between age and occupational satisfaction, which approached significance (p = .072), and age and perception of maintaining competencies, which achieved significance (p = .001). participants were voluntary which may have influenced the findings. the small sample size limits generalizability 41 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 author, year and origin aim method and sample findings limitations chang et al. (2002). nurse education today australia to describe the development, implementation and evaluation of a mental health continuing education program for nurses employed in rural and remote areas of new south wales (nsw), australia. as well as evaluates the efficacy of this program. mixed methods. qualitative survey to determine needs. quantitative surveys + analysis of open-ended questions to determine program effectiveness. needs analysis questionnaire list of mental health topics needing more education included: talking to people/basic communication skills, assessment/correct psychiatric terminology, depression, suicide/prevention, psychosis/schizophrenia, confusion and dementia in the elderly, management of all conditions, especially aggression. evaluation of the course each workshop was evaluated for content, presentation and organization. the median response to every question was 6 (agree), except for q24 (the modules form a convenient resource for future reference) to which the median response was 7 (strongly agree). overall effectiveness: 91% stated the program content assisted them strongly in developing their knowledge and understanding of mental health and psychiatric problems in rural and remote settings. analysis of open-ended questions: most comments were in favour of the program. limited attention given to medications. an educator is necessary to hold this education component. since the course was tailored to participants, it may not be relevant to other groups. fitzgerald & townsend (2012). journal of continuing education in nursing united states to determine needs and preferences for ce topics and delivery for rural nurses. to create a collaborative relationship between the university and rural hospitals and have them work together to plan online ce a quantitative, pilot study. convenience sampling of 27 nurses working at two hospitals. pilot study results: 1) education 48.1% (n=13) adn, 40.7% (n=11) bsn, 7.4% (n=2) mn, and 0 dnp, 0 phd, 3.7% (n=1) no response. 2) experience 48% (n=13) had been working a current education for 16 or more years, and 74% (n = 20) for at least 11 years. approximately 44.4% (n = 11) had been working as a rn in a rural setting for at least 11 years. 3) preference for learning the most preferred (48%, n=13) and most common (70%, n=18) approach to ce was in person. next was “self-study online” (54%; n = 14). 4) topics of interest: cardiovascular, respiratory, geriatric, and diabetes. 5) potential barriers: topic offered, fee pilot study using a small convenience sample limiting the generalizability. requires continued collaboration between rural hospitals and universities. 42 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 author, year and origin aim method and sample findings limitations offerings about topics of interest to these rural nurses. for ce, time away from work, modality of training, distance to training and level of interest in learning. macleod, lindsey et al. (2008). the journal of continuing education in nursing canada to develop a practice-driven, reality-based postrn rural acute care certificate program. qualitative descriptive. in-depth focus group interviews with 236 rural acute care nurses representing 51 different communities. seven major themes identified by rns as core content for a post-basic nursing curriculum; health assessment across the lifespan, chronic disease management, palliative care and wound care, nursing practice with older persons, perinatal care, critical care, emergency & trauma, mental health and addictions and living and working in a rural community. all of participants were from one geographical region. enacting their learning needs may require an educator that is not currently employed macleod, misener et al. (2008). nursing leadership canada to improve the recruitment and retention of nurses in rural communities, a better understanding of what's important to rural and remote nurses is needed. nurses were asked what advice they would have for new nurses, educators, administrators and policymakers. qualitative descriptive. a national survey of 3,933 rns and in-depth interviews with 153 rns from all provinces and territories. advice to new nurses: find and build relationships with colleagues and the multidisciplinary team. advice to educators: educate on the need for rural practice content and make it hands-on, rural-focused and accessible. advice to administrators: provide accessible supports for learning and clinical practice. advice to policymakers and professional practice organizations: acknowledge that rural/remote practice is unique and needs support. involve communities in planning health services. the results of qualitative data are not generalizable. the educational needs over a diverse area to nurses who are geographical distant makes addressing their needs challenging. mccafferty, et al. (2017). to assess the educational needs and quantitative, crosssectional descriptive, non-probability 12-item needs assessment looked at barriers to education, preferred learning methods, the interprofessional education environment and the authors were unable to determine which of the scenarios were top priority. 43 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 author, year and origin aim method and sample findings limitations journal of continuing education in nursing united states barriers identified by rural nurses in two midwestern states. the continuing education needs of rural nurses are not well understood. rural hospitals face special challenges that serve as barriers to the attainment of continuing education. sampling. a survey was sent via forum to nine rural hospitals to 119 nurses. education topic needs. areas identified as the highest need included postpartum hemorrhage, preterm labour, pediatric care, preeclampsia, shoulder dystocia, and embolism. the barriers to obtaining updated education included distance to travel for educational opportunities and lack of staff for coverage while attending the program. pascoe et al. (2007) australian journal of advanced nursing australia describe the educational needs of nurses working in general medical practice in australia mixed methods. combining qualitative and quantitative data (convergent design) via telephone survey. 222 enrolled (rn division 2 in victoria) and registered nurses (rn division 1 in victoria) working in general practice in rural and urban areas of australia. educational areas of high importance including communication skills (94.1%); infection control (93.7%); confidentiality and national privacy legislation (93.7%); legal and ethical issues (91.9%); first aid and cpr (91.4%); wound care (91.0%); cold chain monitoring (90.0%); sterilisation (90.0%); and triage (90%). barriers to education were lack of time due to work (21.9%); costs of courses (17.3%); distance to education (13.9%); and lack of time due to family commitments (13.1%), distance (20.5%). than urban nurses (3.6%). since this study asked urban and rural nurses about their learning needs it is unclear if the barriers were more representative of the rural nurses. it is unknown if this sample is representative of rural nurses. ristevski et al. (2021), to examine rural communityquantitative, nonrandomized. health service managers (n = the questionnaire rated nurses’ knowledge against 6 national palliative care standards and 10 screening and assessment tools. a 5-point scale of the self-rating scale may have contributed to under or over reporting. 44 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 author, year and origin aim method and sample findings limitations palliative and supportive care australia based nurses’ self-reported knowledge and skills in the provision of psychosocial care to rural residing palliative and end-of-life clients and carers. then correlate knowledge gaps to inform workforce education and planning. 19) distributed a link to an electronic questionnaire to eligible staff (n = 165). 122 of 165 nurses (response rate = 74%) completed the survey (1) no experience to (5) can teach others was used to rate knowledge. results were classified into three categories: practice gaps, areas of consolidation, and strengths. the study found formal training and increasing years of experience were most often associated with the absence of knowledge gaps. whiteing et al. (2022). journal of clinical nursing australia to delineate the contemporary practice of registered nurses working in rural and remote areas of australia. qualitative, multiple case study design. nurses were recruited from 240 sites. the study comprised three phases of data collection. first, a content analysis of 42 documents relating to the context of nursing, specifically rural and remote nursing; second, a content analysis of an online questionnaire (n = 75); and third, a thematic analysis of major themes: a medley of preparation for rural and remote work; being held accountable” responsibility and accountability are intrinsically linked when determining the scope of nursing; alone, with or without someone; spiralling wellbeing. nurses reported levels of stress, with many reporting recent burnout due to the many issues, they face in daily practice. the qualitative data are not generalizable. the introduction of the new code of conduct at the beginning of the process may have may have made it challenging for participants to remember it. 45 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 author, year and origin aim method and sample findings limitations semi-structured interviews (n = 20). continuing education (ce), continuing education units (ceus), emergency department (ed), urgent care center (uucs) 46 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 figure 1 prisma diagram 2318 studies imported for screening 1388 studies screened 930 duplicates removed 1287 studies irrelevant 96 full-text studies assessed for eligibility 86 studies excluded 10 studies included 47 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 findings the search yielded 1,388 articles to be screened after having 930 duplicates removed. after the title, abstract and then full-text review, ten articles remained. of those articles, four were qualitative (beks et al., 2018; macleod, lindsey et al., 2008; macleod, misener et al., 2008; whiteing et al., 2022), four were quantitative (bolin et al., 2011; fitzgerald & townsend, 2012; mccafferty et al., 2017; ristevski et al., 2021) and two were mixed methods (chang et al., 2002; pascoe et al., 2007) (see table 2). the five qualitative studies (beks et al., 2018; macleod, lindsey et al., 2008; macleod, misener et al., 2008; ristevski et al., 2021; whiteing et al., 2022) met all the mmat criteria. the two, quantitative, descriptive studies met three out of five criteria (fitzgerald & townsend, 2012; mccafferty et al., 2017; pascoe et al., 2007). for the mixed methods studies, chang et al. (2002) did not meet the criteria and pascoe et al. (2007) met two out of five criteria (table 2). given the few studies, all were included. the included studies represent three different countries, canada (macleod, lindsey et al., 2008; macleod, misener et al., 2008), the united states (bolin et al., 2011; fitzgerald & townsend, 2012; mccafferty et al., 2017) and australia (beks et al., 2018; chang et al., 2002; pascoe et al., 2007; ristevski et al., 2021; whiteing et al., 2022). 48 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 table 2 mmat quality assessment table citation screening questions qualitative studies s1. are there clear research questions? s2. does the collected data allow us to address the research questions? is the qualitative approach appropriate to answer the research question? are the qualitative data collection methods adequate to address the research question? are the findings adequately derived from the data? is the interpretation of the results sufficiently substantiated by data? is there coherence between qualitative data sources, collection, analysis, and interpretation? beks et al. 2018 yes yes yes yes yes yes yes macleod, lindsey et al. 2008) yes yes yes yes yes yes yes macleod, misener et al. 2008) yes yes yes yes yes yes yes ristevski et al. 2021 yes yes yes yes yes yes yes whiteing et al. 2022 yes yes yes yes yes yes yes citation screening questions quantitative descriptive s1. are there clear research questions ? s2. does the collected data allow us to address the research questions? is the sampling strategy relevant to address the research question? is the sample representative of the target population? are the measurements appropriate? is the risk of nonresponse bias low? is the statistical analysis appropriate to answer the research question? fitzgerald & townsend, 2012 yes yes yes no yes can't tell yes 49 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 mccafferty et al., 2017 yes yes yes no no yes yes bolin et al. 2011 yes yes yes yes yes can’t tell yes citation screening questions mixed methods s1. are there clear research questions? s2. does the collected data allow us to address the research questions? is there an adequate rationale for using a mixed method design to address the research question? are the different components of the study effectively integrated to answer the research question? are the outputs of the integration of qualitative and quantitative components adequately interpreted? are divergences and inconsistencies between quantitative and qualitative results adequately addressed? do the different components of the study adhere to the quality criteria tradition of the methods involved chang et al., 2002 yes yes no no no no no pascoe et al., 2007 yes yes no yes yes no no 50 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 the three themes that were developed from these articles include educational needs, educational delivery, and barriers to education (see table 3). table 3 themes table themes categories educational needs tailored education preceptors, interprofessional practice and experience educational delivery delivery methods – collaboration, (preceptors/interprofessional practice/university partnerships), simulation & tailored modules, certificates and programs barriers pursuing continuing education employer/policymaker engagement theme 1: educational needs educational needs for rural nurses broadly included the demand for tailored education. the importance of tailored education to rural practice was present in eight studies (beks et al., 2018; chang et al., 2002; fitzgerald & townsend, 2012; macleod, lindsey et al., 2008; macleod, misener et al. 2008; mccafferty et al., 2017; pascoe et al., 2007; whiteing et al., 2022). in addition, three studies reported that preceptorship, experience and interprofessional practice were other educational needs of rural nurses (beks et al., 2018; ristevski et al., 2021; whiteing et al., 2022). tailored education amongst eight of the studies, the emphasis on ensuring rural/remote education was tailored to the context of rural practice was prevalent (fitzgerald & townsend, 2012; macleod, lindsey et al., 2008; macleod, misener et al. 2008; mccafferty et al. 2017; pascoe et al., 2007; whiteing et al., 2022). there was an overlap in the reported needs of rural nurses. health assessment and triage, living/working in rural communities, care of older persons, perinatal care, critical care/trauma/emergency, chronic disease management/palliative care/wound care, mental health 51 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 and addictions were major areas that rural/remote nurses reported the need for education (macleod et al., 2008; mccafferty et al., 2017; pascoe et al., 2007). mccafferty et al. (2017) also specified perinatal care, emphasizing post-partum hemorrhage, preterm labour, neonatal resuscitation, preeclampsia, and shoulder dystocia as important educational topics. in terms of emergent care, mccafferty et al. (2017) reported the educational needs for diabetic emergencies, cardiac arrest, stroke/cerebral vascular accidents, and behavioural/psychological disorders. fitzgerald and townsend’s (2012) top four areas of interest included cardiovascular, respiratory, geriatric, and diabetes care as priority education topics. educational needs in mental health nursing were identified by chang et al. (2002) and beks et al. (2018). whiteing et al.’s (2022) qualitative study suggested that preparation for practice should be aligned with a generalist role, but also stressed the importance of cultural competence due to 70% of australia’s remote populations being indigenous peoples. cultural competence was not discussed by the other studies, except for a small piece from macleod, lindsey et al. (2008), which mentioned indigenous populations under the umbrella of living/working in rural communities, without further discussion. preceptors, interprofessional practice, and experience experience in both clinical practice and continuing education was seen to be important in rural practice. whiteing et al. (2022) claimed rural/remote nurses argue for experience rather than education as necessary for the transition to rural nursing. however, they also clarify that there is a lack of access to professional support and no legislation identifying the necessary preparation needed to prepare nurses for rural and remote practice. without any legislation for mandatory qualifications, few nurses possess advanced training or certificates and multiple barriers exist to obtaining them. they suggest preparation should be through specialty post-graduate courses. 52 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 ristevski et al.’s (2021) exploration of rural nurses’ self-reported knowledge and skills also seemed to be linked to years of experience and formal training. they found formal training and increasing years of experience were most often associated with the absence of knowledge gaps and suggest that further research may be needed to determine the best educational strategies. this sentiment is reiterated in beks et al.’s (2018) discussion that nurses who receive ongoing mental health training will increase their competence. theme 2: educational delivery educational delivery methods and understanding of nurses’ perceptions of the best educational modalities were examined by six studies (beks et al., 2008, fitzgerald & townsend, 2012; macleod, lindsey et al., 2008; macleod, misener et al., 2008; mccafferty et al., 2017; whiteing et al., 2022). delivery methods when looking at methods of delivery, multiple approaches were reported as being effective or beneficial. two studies' findings agreed that face-to-face workshops were the preferred delivery method. (macleod, lindsey et al., 2008; fitzgerald & townsend, 2012). in contrast, others suggested that interactive, experiential simulation was the most desired learning modality. (mccafferty et al., 2017; beks et al., 2018; macleod, misener et al., 2008; whiteing et al., 2022). however, the studies reporting face-to-face learning as a preferred learning method (macleod, lindsey et al., 2008; fitzgerald & townsend, 2012), didn’t differentiate if that meant simulation, didactic learning or otherwise. whiteing et al. (2022) was the only study to report that rns believed experience to be more relevant than education for a successful transition to rural and remote practice. this finding is similar to the studies that advocated for simulation learning, as some of whiteing et al.’s (2022) 53 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 recommendations included real-world scenarios, 3d technology, and artificial intelligence programs to improve simulation experiences. two researchers highlighted the importance of interprofessional education and achieving positive working relationships with other disciplines through group interactions (macleod, lindsey et al., 2008; whiteing et al., 2022). whiteing et al. (2022) stressed the importance of positive relationships between rns and physicians, as professional development related to accountability. in contrast, macleod, lindsey et al., (2008) discussed nurse-to-nurse interactions as crucial in learning about rural and remote practice. macleod, lindsey et al., (2008) believed in the importance of group interactions and promoting learning through “regional learning circles” with nurses within a geographical location who could interact with rural/remote nurses and learn from one another. included studies used a variety of delivery methods for education. the most common educational delivery methods, and most valued methods by nurses included: collaborative efforts, simulation, and tailored modules/programs and were discussed in six studies. (chang et al., 2002; fitzgerald & townsend, 2012; macleod, lindsey et al., 2008; macleod, misener et al., 2008; mccaffery et al., 2017; whiteing et al., 2022). collaboration (preceptors/interprofessional practice/university partnerships). authors from three studies (mccafferty et al., 2017; macleod, misener et al., 2008; macleod, lindsey et al., 2008) discussed the importance of “finding colleagues” or educational models focused on interprofessional, experiential simulation and learning in collaborative settings. these ideas were based on the idea that care is complex and required a collaborative, team-focused approach to ensure the best possible outcomes. however, mccafferty et al.’s (2017) continuing education needs assessment, highlighted the tension between utilizing simulation for day-to-day 54 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 routine practice or high acuity, infrequent skill sets. they relate this to how the need to provide education to current nursing providers is identified in the literature, but specific scenarios and topic areas are not. partnerships and educational content created through collaboration with universities were examined in three articles. (chang et al., 2002; fitzgerald & townsend, 2012; macleod, lindsey et al., 2008). both chang et al. (2002) and fitzgerald and townsend (2012) claimed their smallscale examples demonstrated how collaborative efforts could unite university nursing programs with rural hospitals to offer educational support to rural nurses. in contrast, macleod, misener et al. (2008) reported that nurses wanted rigorous continuing education that would qualify as academic credit toward a bachelor of science in nursing (bsn) or master of science in nursing (msn) and such education would require university partnership. simulation as previously discussed, five researchers suggested simulations were an important delivery method (mccafferty et al., 2017; beks et al., 2018; macleod, misener et al., 2008; whiteing et al., 2022). task infrequency was a concern highlighted by three authors (macleod, lindsey et al., 2008; mccafferty et al., 2017; whiteing et al., 2022). a common proposal was that this problem could be mitigated by ongoing simulation and skills practice. tailored modules, certificates, and programs two scholars studied tailored certificates or programs for rural nurses. chang et al. (2002) utilized and discussed the efficacy of multiple modalities of mental health education delivery. they explored the use of modules, audiotaped material, sky channel presentations and regional workshops. participants reported the modules were at levels suitable to their individual needs, and audiovisual materials relevant to the topics. the sky channel presentations were the least well 55 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 received with only 48% of participants watching the presentations, due to work, family, or timing of the broadcast. macleod, lindsey et al. (2008) discussed a practice-driven, reality-based program. a post-graduate certificate was developed through collaboration with a course writer, academic advisor and four practice advisors (rural, acute care rns). the curriculum was a blend of workshops and practicum aligned to their needs assessment. although the program's efficacy or nurses’ perceptions of its administration were not measured, it is an example of new possibilities for responsive, relevant curriculum development in rural acute care nursing. theme 3: barriers to education the barriers to pursuing continuing education for rural nurses are vast and were discussed in five different studies (fitzgerald & townsend, 2012; macleod, lindsey et al., 2008; mccafferty et al., 2017; pascoe et al., 2007; whiteing et al., 2022). employer and policy maker engagement was one barrier explored in-depth in four of the studies. (bolin et al., 2011; macleod, misener et al.’s, 2008; ristevski et al., 2021; whiteing et al., 2022) pursuing continuing education barriers to pursuing continued education were discussed in four studies (fitzgerald & townsend, 2012; mccafferty et al., 2017; pascoe et al., 2007; whiteing et al., 2022). all four studies agreed that distance to education could be a barrier. travel, cost and family commitments (fitzgerald & townsend, 2012; mccafferty et al., 2017; pascoe et al., 2007) as well as coverage from missed shifts and institutional support (whiteing et al., 2022). nurses wanted barriers removed so that continuing education was more relevant, more rural-focused, accessible, and included distance delivery. employer/policy maker engagement 56 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 nurses value continuing education (beks et al., 2018; bolin et al., 2011; macleod, misener et al., 2008; whiteing et al., 2022). three studies explained that mandatory continuing education is not universally required by employers. (bolin et al., 2011; ristevski et al., 2021; whiteing et al., 2022). after completing interviews with rns, macleod, misener et al. (2008) urged employers to acknowledge the uniqueness of rural and remote practice, and support nurses’ scope appropriately. study participants suggested that appropriate education is one means of recognizing and supporting the unique role of rural and remote nurses. discussion the findings of this review identified that researchers have developed an understanding of the diversity of rural and remote nurses’ educational needs, which highlight that rural nurses need to be proficient in routine as well as infrequent high-stakes situations, such as labour and delivery, or cardiac arrest. what was not clear in the literature was an understanding as to how best approach such diverse educational needs and nurses reported varied views about how they wanted education to be facilitated. similar to the barriers found in this review, santos’s (2012) integrative review examining both urban and rural nurses’ barriers to learning, found time constraints, financial constraints, workplace culture, access/relevance, and competency in accessing electronic evidence-based practice literature to be issues. penz et al. (2007) specifically assessed what rural/remote nurses perceive as barriers, finding time and financial constraints, lack of employer support, geographical isolation and physical distance from learning opportunities. another challenge to rural nurses is that continuing education is not mandated as something employers need to provide to their employees. however, renewing and enriching knowledge is part of professional identity and an obligation for nurses (lera et al., 2020; rasmussen et al., 2021). thus, nurses’ attitudes and perceptions towards continuing education, as well as organizational 57 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 support and supportive work environments are important in facilitating continuing education. (lera et al., 2020; mlambo et al., 2021) some of the strategies identified in this study to address barriers were collaboration and interprofessional education. walmsley et al. (2020) looked at practical approaches to normalize interprofessional collaboration in rural hospitals, highlighting the importance of positive workplace cultures and understanding of professions’ roles. they suggest the importance of induction processes and informal introductions, formalized interprofessional interactions, interprofessional education and positive leadership. however, they explain that interprofessional collaboration often focuses on urban healthcare systems, where sub-specialized staff and services are often more plentiful than in rural areas. if urban settings were to collaborate with rural sites, it could be an alternate approach to one of the findings of this review which suggested different rural regions develop learning groups to collaborate and support one another in advancing their educational needs. simulations were commonly advocated as an educational delivery method in this review. davies et al. (2021) integrative review about ward-based simulations suggests learners enjoy them and report increased preparation for professional practice. unfortunately, access, technology, and available resources can be a barrier to simulation in rural settings. yet low-tech simulations in rural settings were found to be useful in overcoming barriers that prevent the frequent use of simulation in rural settings (mogler et al., 2020). whiteing et al. (2022) was the only study in this review that stressed the importance of cultural competence, stating that 70% of australia’s indigenous population live in rural areas. in canada, approximately 60% of the indigenous population also live in rural areas (oecd, 2020). with such a high percent of indigenous people living in rural areas, who have poorer health 58 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 outcomes than non-indigenous counterparts in canada, the usa and australia, it is imperative for rural and remote nurses to have education about cultural safety and cultural competence (harfield et al.,2018). this is important because despite cultural safety being taught in health curriculum worldwide, inequity still exists (kaphle et al., 2021). browne et al.’s (2016) ethnographic research describes the importance of the indigenous epistemological lens as a driving force in strategies to enhance health equity. this same approach could be used to provide rural and remote nurses education to foster cultural competence. implications for practice the findings of this study highlight the need for rural education that is tailored to the needs that are well identified by rural nurses (fitzgerald & townsend, 2012; macleod, lindsey et al., 2008; macleod, misener et al., 2008; mccafferty et al., 2017; pascoe et al., 2007; whiteing et al., 2022). further research is needed to understand how best to facilitate educational delivery to rural and remote nurses. this research should also focus on how to facilitate education when there are physical and infrastructural barriers such as challenges with internet delivery and lower wages for rural nursing as well as limited professional development funds that may constrain types of educational delivery and incentives for nurses to pursue education (fields et al., 2018). interventional research could be one tool to explore and compare the efficacy of the various delivery methods. despite uncertainty about the best means to facilitate education, rural nurses still need to advocate and pursue continuing education. delivery of education could be offered through a variety of modalities, such as mentoring programs, online modules, group learning, simulations and interprofessional education. due to the few postgraduate, rural specific programs and the pre-existing difficulties recruiting and retaining nurses to work in rural settings, mandating specific postgraduate education prior to working in a rural setting is unrealistic. working towards 59 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 educational programs that support the needs of rural nurses, that are readily available and accessible is more likely to be beneficial. it is essential employers and accrediting bodies of hospitals work together to ensure that rural and remote nurses have the essential skills to care for the rural population. as the educational needs of rural nurses are clearly identified, standardization of mandatory continuing education could facilitate a more coordinated approach to education delivery. employers need to support their staff in obtaining courses such as advanced cardiac life support, pediatric advanced life support, trauma nurse care courses and other continuing education courses tailored to specific specialty areas, like labour and delivery. unified approaches could help determine strategies to accommodate participation in educational opportunities. frequent course offerings, with on-site nursing staff or clinical educators, as certified instructors for various courses could be an asset. an educator on site would allow for planned and impromptu course offerings, such as when patient censuses are low. if having on-site educators is not feasible, brainstorming between nurses and their managers on how to accommodate learning could facilitate innovative educational strategies. limitations this review is limited by the english language, focusing on three countries, and the inclusion and exclusion criteria used in the databases. studies from other countries and studies in other languages could provide further insights into different contexts and systems of care, particularly on the best way to facilitate educational delivery to rural nurses. conclusion rural nurses have a diverse scope of practice and require a broad skill set to manage patients across their lifespans. the educational needs of rural nurses appear to have been identified yet meeting these needs has proved challenging. tailored education to rural contexts and making 60 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 educational opportunities readily accessible for rural nurses is important. nurses have a professional responsibility to ensure they maintain their fitness to practice, which includes continuing education. supportive workplace cultures and healthcare organizations are critical in helping rural nurses achieve equitable access to educational opportunities when compared to their urban counterparts. discussion between nursing staff and their employers on how to best meet educational needs would improve accountability in practice, competence in practice and potentially improve health outcomes for rural and remote residents. references asad, f., nur, f., morris, j., bobiak, j. 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(n.d.). does geography matter in mortality? an analysis of potentially avoidable mortality by remoteness index in canada. health reports, 30(5), 3-15. https://doi.org/10.25318/82-003-x201900500001-eng u.s. department of health and human services, health resources and services administration (hrsa). (2013). the u.s. nursing workforce: trends in supply and education. https://www.ruralhealthinfo.org/assets/1206-4974/nursing-workforce-nchwa-report-april2013.pdf walmsley, g., prakash, v., higham, s., barraclough, f., & pit, s. (2020). identifying practical approaches to the normalisation of interprofessional collaboration in rural hospitals: a 69 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.723 qualitative study among health professionals. journal of interprofessional care, 35(5), 662-671. https://doi.org/10.1080/13561820.2020.1806216 whiteing, n., barr, j., & rossi, d. m. 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(2013). “you have to rely on everyone and they on you”: interdependence and the team-based rural nursing preceptorship. online journal of rural nursing and health care, 13(1), 4-25. https://doi.org/10.14574/ ojrnhc.v13i1.216 young, t. k., chatwood, s., ng, c., young, r. w., & marchildon, g. p. (2019). the north is not all the same: comparing health system performance in 18 northern regions of canada. international journal of circumpolar health, 78(1), article 1697474. https://doi.org/ 10.1080/22423982.2019.1697474 abstract 65 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 comparison of hospital admissions in two rural greek public hospitals zoe boutsioli, phd, msc 1 1 researcher, health research unit, athens institute for education and research (atiner), zb5@atiner.gr abstract this paper estimates demand variability in two rural hospitals in greece. three effects are tested: the weekend, the summer holiday and the official holiday. the dependent variable is the daily number of total hospital admissions during 2001-2005. we use the method of ordinary least square. both hospitals present lower total admissions during official holidays. the seasonal variations are more visible in trikala, than those in sparta. for sparta, the impact is statistically insignificant, while for trikala is both positive and statistically significant. weekly seasonal effects can also be observed. for both hospitals, daily total admissions decline on weekends compared to the week days. hospital managers could be based on that result in order to make as accurate as possible decisions about the staff, supplies and beds needed. introduction the establishment of the greek national health system (nhs) in 1983 was based upon the exclusively public health care provision (tountas, karnaki, & pavi, 2002). the role of public hospitals, both urban and rural was upgraded. many new hospital units, especially in rural and remote areas of greece were built up. the total health care expenditures (the) increased significantly (oecd, 2006). in spite of the legislative actions for private health care services restriction, nowadays, private health care expenditures are almost half of the total health expenditures (tountas et al., 2005; oecd, 2006). nevertheless, in rural areas the spread of private health care services was to a lower extent compared to that in urban areas of the country (souliotis, 2002). the general regional hospitals that exist, one for each city, still keep a master role in the provision of secondary health care services in the greek population. characteristically, hospital admissions in public hospitals for general medicine accounted for 1.5 million admissions, in 2000 (esye, 2005). the value of equal access for all citizens in the greek territory was one of the main issues raised with the law 1397/1983 (liaropoulos & tragakes, 1998). the issue of economic efficiency was degraded until recently. from the relevant literature becomes clear that ‘failure to account for uncertainty will lead to biased results, suggesting that hospitals are inefficient’ (smet, 1998, p. 15). hence, the way that the number of admissions varies within a certain period of time is very important for hospital managers (abdel-aal & mangoud, 1998; diaz et al., 2001; jones et al., 2002; jones, joy, & pearson, 2002; hussain et al., 2005; upshur, 2005; earnest, chen, & seow, 2006). an accurate forecasting of future daily admissions can provide to hospital managers useful information in relation to staff and beds needs. for example, it is absolute natural for a hospital manager to wait fewer patients for hospitalization during the summer moths, especially in a region that is not a touristic destination or vice versa (bentley et al., 2001), and to anticipate more patients during winter months due to influenza and other respiratory related diseases (fleming, harcourt, & smith, 2003). the purpose of this paper is to compare the number of total admissions in two regional hospitals in greece during the period 2001-2005. i have used a multivariate model with three explanatory variables to better understand the variations in the number of total http://www.atiner.gr/docs/health_unit.htm mailto:zb5@atiner.gr 66 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 daily hospital admissions. these are the weekend, the official holiday and the summer holiday effects. i have found that about half of the variations of total admissions can be explained by the variations in the three explanatory variables. methods data sources daily data on total hospital admissions were collected from two regional public hospitals. the one is located in trikala city, in central greece, and the second one is placed in sparta city, in south part of peloponnesus and in the lower part of continental greece. the time period covers five years, from 1/1/2001 to 31/12/2005. both hospitals are the only providers for secondary health care, and due to lack of a well established and organized primary health care network, they also provide primary health care through their outpatient departments (tountas, karnaki, & pavi, 2002). primary health care is also provided to the rural population through health stations, established in the whole greek region after the 19831984 health reform (who, 1996). based on the data of the last census, took place in 2001, the number of permanent population in the prefecture of trikala is amounted to 132.689 people, and in the prefecture of laconia, including the city of sparta 92,811 people 1 . in 2001, the number of total hospital admissions in trikala reached about 20 thousands admissions, while the same time period, the number of total admissions in the sparta’s public hospital was almost half of that in trikala, slightly more than 9 thousands admissions. total admissions as a percentage of the total population accounted for 15% in the city of trikala, and 10% in the city of sparta, in 2001 (figure 1). figure 1. census and total hospital admissions in trikala and sparta, 2001. source: esye, 2008 and author’s estimations. the model a multivariate model with three explanatory variables was developed. three hypotheses were tested. during weekends the number of total hospital admissions draws down. in months july and august total hospital admissions remain unchangeable for touristic areas and decline for non touristic destinations. in time periods close to official holidays the number of total admissions decreases. 0 20000 40000 60000 80000 100000 120000 140000 sparta trikala census admissions 67 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 for the first hypothesis, i use a dummy variable that takes the value of one (1) when the day is either saturday or sunday, and the value of zero (0) when it is not. similarly, a dummy variable for the summer months is used. it gets the value of one (1) when the month is either july or august and the value of zero (0) when it is not. last, for the third hypothesis, we have counted 15 official holidays that are celebrated by the whole public servants, including hospital staff. these days include both religious festivities and national days. a dummy variable is also used to estimate the impact of that variable on total hospital admissions. it obtains the value of one (1) when the day is one of the 15 official holidays and the value of zero (0) when it is not. i applied the ordinary least square (ols) method to test the above three hypotheses. the e-views econometric package, version 5.1, was used for the analyses. the weekend effect has been extensively used as an explanatory variable in the forecasting of hospital admissions (fullerton & crawford, 1999; baker et al., 2004; earnest, chen, & seow, 2006; jones et al., 2009). it has been found that patient flows are lower during the weekends than the rest of the week. patients in accordance with their doctors decide to be admitted at the beginning of the week and to have their procedures hereafter. mossialos et al. (2005a; 2005b) have approved for greece that in obstetrical services there is great demand for leisure by physicians. in that way patients have the opportunity to be discharged before the weekend, if their clinical conditions permit it. delays that prolong hospitalization due to weekend effect increase the time that patients are exposed to hazards known to occur in hospitals such as medication errors and infection (law 2519, 1997). consequently, during weekends the number of total admissions is expected to be lower. the seasonality in hospital admissions is an important issue (hisnanick, 1994; abdelaal & mangoud, 1998; fullerton & crawford, 1999; jones, joy, & pearson, 2002; cote, 2005; hussain et al., 2005; jones et al., 2009; lee et al., 2005; matter-walstra, widmer, & busato, 2006). hospitals face considerable problems either in summer months (i.e. spain, portugal, and greece) or during the winter (i.e. the uk, switzerland, canada, and finland). the high temperatures during the summer in mediterranean countries deteriorates the healthiness of specific group of the population, such as the children, the elderly, and those suffer from respiratory and co-related illnesses (schwartz, 1996; schwarts, samet, & patz, 2004; linares & diaz, 2008). contrary, in nordic countries the problem of bed availability is more intense during the winter season, where respiratory infections, like influenza are frequently appeared among the population (semenza et al., 1999). another source of seasonality is tourism, i.e. switzerland, where leisure sports, and especially ski/snowboard tourism creates great flexibility in hospital admissions due to orthopedic traumas (cote, 2005). similarly, during the summer months in countries with hot weather and high tourism, like mediterranean countries and new zealand, the development of sea sport activities and other leisure actions creates more demand for hospitalization (mcgregor, walters, & wordley, 1999; bentley et al., 2001). conclusively, i expect a negative impact of summer holiday variable on total hospital admissions in the city of trikala – a non touristic destination. for the city of sparta in laconia prefecture, i expect no impact of the summer months variable on total admissions, due to the conservation of the total population of the city at the same level as it is during the winter months. during the summer months the undergraduates leave for vacations, while both the native and foreign tourists arrive for visiting the city of sparta and around. official holiday days relate to statutory days off and it is expected to have a negative impact on total hospital admissions. during these days there is a supply and demand impact on hospital admissions. patients do prefer to spend these days with their families (the demand effect) which it is also true for all hospital staff as well (the supply effect). the same 68 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 hypothesis has been tested and verified by other researchers as well (fullerton & crawford, 1999; jones, joy, & pearson, 2002; lee et al., 2005). results total admissions the number of total admissions of the two regional hospitals over the five-year period is presented in figure 2. the mean value for daily total admissions in the hospital of trikala is 61 with a standard of 17.16 whilst for daily total admissions in the hospital of sparta the mean is 27 with a standard deviation of 9.43. (a) 0 10 20 30 40 50 60 2001 2002 2003 2004 2005 t o t a d m (b) 0 20 40 60 80 100 120 140 160 2001 2002 2003 2004 2005 totadm figure 2. number of daily total admissions (a) in the general public hospital of sparta, and (b) in the general public hospital of trikala 69 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 it is apparent that there is a seasonal variation for total admissions series in both regional cities. figure 3 shows the mean number of daily total admissions per month. both hospitals present lower number of total admissions in january, april and december, where the two greatest religious festivals – christmas and easter – are celebrated by the greek orthodox. however, as far as the summer months are concerned, the seasonal variations are more visible in trikala, compared to those noticed in sparta. this means that the population in the city of sparta remains unchanged during the summer months. a possible explanation for this is that the prefecture of laconia, including the capital city of sparta, is a famous touristic destination 2 . figure 3. average numbers of daily total admissions per month, 2001-2005 weekly seasonal effects can also be observed (figure 4). the number of total admissions in trikala hospital is at its highest on tuesday, while in sparta hospital it is at its peak on monday. for both city hospitals, daily total admissions decline considerably on weekends compared to the week days. the fact that in public hospitals in trikala there is an increase of total admissions on sunday could be explained by the common practice by doctors to admit their elective patients on sunday in order to be ready for the pre-surgery examination control and their operation thereupon. regression results table 1 shows the regression results of the multivariate model. with this i measure the impact of the three explanatory variables – weekend effect, holiday effect and official holiday effect – on total daily hospital admissions. in the hospital of trikala, the coefficients of the three explanatory variables are negative and statistically significant at 1% level. in the hospital of sparta, the two coefficients -weekend and official holidayare negative and statistically significant at 1% level. the third coefficient of summer holidays explanatory variable is negative but statistically insignificant. during the summer months – july and august – the number of total admissions remains unchangeable, which could be explained from the touristic nature of the city of sparta in laconia prefecture. 70 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 figure 4. average numbers of daily total admissions per day of week, 2001-2005 only slightly over half of the variations in total hospital admissions are explained by the variations in the explanatory variables, as approve the coefficient of determination (r 2 ). table 1. regression results hospital of trikala hospital of sparta coefficient (t-statistic) coefficient (t-statistic) constant 69.19 (190.75) 31.62 (162.75) weekend -25.68 (-41.08) -14.38 (-42.95) official holiday -17.31 (-12.15) -10.69 (-14.01) summer holiday -3.63 (-4.82) -0.10 (0.24)* r 2 0.5072 0.5318 r 2 adjusted 0.5064 0.5310 f-statistic 694.99 689.86 probability 0.0000 0.0000 note: all coefficients are statistically significant at 1% level, apart from those noted with (*). the impact and implications of the results on primary care and rural practice the decline of hospital admissions during weekends, summer and official holidays should be availed by hospital managers. in that way, they have the chance to create small groups of hospital staff, i.e. a nurse and a doctor, who will go around in the city, in remote 71 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 areas and villages and provide primary medicine (i.e. blood tests, heart pressure measurements, urine tests, drugs etc) in old people, people with kinetic problems, and people with special needs. the home based health support for older and other in-need people can reduce mortality and admission to long-term institutional care (elkan et al., 2001). for highrisk patients with congestive heart failure, the home based intervention (hbi) that comprises a single home visit (by a nurse and pharmacist) is associated with reduced frequency of unplanned readmissions plus out-of-hospital deaths within 6 months of discharge from the hospital (stewart et al., 1998, stewart et al., 1999). also, this practice could have a positive acceptance by people, especially after the implementation of the non-obligatory practice by rural doctors, applied in greece in 1997. such a practice could also contribute to the promotion of physical activity (estabrooks et al, 2003), breastfeeding, (morrow et al., 1999) and other healthy activities. in greece, this practice that contributes significantly in primary care and rural practice could be encouraged and applied in many other hospitals in the country, particularly those located close to remote areas and islands that during the summer months face increased demand of patients, most of which are emergency cases (semenza et al., 1999; bentley, et al., 2001). discussion this study compares the total admissions in two regional hospitals in the city of trikala, in thessaly in central greece and in the city of sparta, in peloponnesus in south greece, over the period 2001-2005. three explanatory variables were tested – the weekend effect, the official holiday effect and the summer holiday effect. to my knowledge this issue has not been investigated in greece. it was found that in the general hospital of trikala, the three variables have a negative and strong statistically significant effect on total admissions. however, in the city of sparta, the summer effect has none statistically significant impact on total hospital admissions. the other two variables have a negative sign and are both strongly statistically significant. these results are in the same line with other previous relevant empirical studies, as they discussed earlier (abdel-aal & mangoud, 1998; fullerton & crawford, 1999; jones, joy, & pearson, 2002; hussain et al., 2005; upshur et al., 2005; jones et al., 2009). more that fifty percent of demand variability is explained by variability of the three explanatory variables. hospital managers could easily apply a multivariate model, such as this developed in this paper to forecast the hospital demand variability. the knowledge of the total admissions variations can assist hospital managers to receive as accurate as possible decisions about the staff, supplies and beds needed, in the short-run, and health policy makers to plan a priori, in an efficient way, the allocation of scarce hospital resources, in the longrun (jones, joy, & pearson, 2002; hughes & mcguire, 2003; baker et al., 2004; cote, 2005; upshur et al., 2005; perea-milla, et al., 2007; smet, 2007; jones, et al., 2009). a limitation of this study is that i use the sum of elective and emergency admissions as the dependent variable in the multivariate model. however, the impact of the independent variables used might be different for each category of hospital admissions – elective and emergency (diaz, et al., 2001; jones, joy, & pearson, 2002; perea-milla, et al., 2007; jones, et al., 2009). further research should test separately these effects. emergency admissions might be less sensitive to the independent variable because of their nature. while, elective admissions can be planned ahead. the possible different effects might help hospital managers to plan in a more effective way the schedule of the staff, at the micro-level, and the capacity (bed) needs, at the mediummacro-level (hughes & mcguire, 2003; baker, et al., 2004; perea-milla, et al., 2007; smet, 2007). 72 online journal of rural nursing and health care, vol. 10, no. 2, fall 2010 more extended models have been developed to forecast hospital demand using most commonly, epidemiological data (hussain, et al., 2005), and weather and pollution information (hisnanick, 1994; diaz, et al., 2001; jones, joy, & pearson, 2002). this is a weakness of the study. the application of such data could explain better the variations in total admissions observed in rural greek public hospitals. acknowledgments i am grateful to an anonymous referee for his guidance and support to accomplish this study. all my thanks go to the hospital staff of the two hospitals – trikala and sparta – for their considerable assistance to collect the required data. also, i would like to thank the greek national scholarship foundation (iky) for its financial support to my postgraduate studies. references abdel-aal r.e., & mangoud, a.m. (1998). modeling and forecasting monthly patient volume at a primary health care clinic using univariate time-series analysis. computer methods and programs in biomedicine, 56, 235-247. 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(1996). health care systems in transition – greece. copenhagen: who. 1 see: http://www.statistics.gr/gr_tables/s1101_sap_1_tb_dc_01_01_y.pdf, accessed in february 4, 2009 2 (http://flyradio.gr/index.php?option=com_content&task=view&id=465&itemid=1). http://www.ncbi.nlm.nih.gov/pubmed/9605777 http://www.ncbi.nlm.nih.gov/pubmed/10509499 http://www.ncbi.nlm.nih.gov/pubmed?term=tountas%5bauthor%5d+and+reforming&transschema=title&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=tountas%5bauthor%5d+and+unexpected&transschema=title&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=upshur%5bauthor%5d+and+simplicity&transschema=title&cmd=detailssearch http://www.statistics.gr/gr_tables/s1101_sap_1_tb_dc_01_01_y.pdf http://flyradio.gr/index.php?option=com_content&task=view&id=465&itemid=1 ani-amponsah_other,+654-revised+manuscript+4.20.21with+psf+setup+final+5.18.21+formatted online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 84 midwives’ experiences of rural maternal newborn care in ghana: a phenomenological inquiry mary ani-amponsah, phd, rn1 solina richter, dcur, rn2 1senior lecturer, department of maternal and child health, university of ghana, mnkansah@ualberta.ca 2 dean, professor, college of nursing, university of saskatchewan, solina.richter@usask.ca abstract midwives’ experiences of frontline healthcare delivery in rural maternal and newborn care have been minimally explored over the past two decades in low and middle-income countries but particularly in resource-limited settings, the situation is concerning. understanding the dynamic influences that impact health care delivery in rural and remote settings is important for averting deaths, improving health outcomes and rural health care practice. purpose: this study aimed to understand, unveil the meanings and articulate the experiences of midwives who practice in rural settings in rural ghana. sample: thirteen (13) midwives who voluntarily participated in the study were purposively and conveniently sampled. methods: interpretive phenomenology that integrated african philosophy was used to explore and unveil the meanings embedded in the experiences of midwives practicing in south rural ghana. findings: the findings establish that midwives make sustained serial efforts to save maternal and newborn lives however, midwives’ ethnic background, age, gender and family situation influence their retention in rural health care settings where they work alone under stressful conditions as skilled care birth attendants. community recognition and supportive community participation online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 85 positively impact midwives’ practice in spite of unattractive living and working conditions. future research needs to investigate the dynamic influences of chiefs, queen mothers and community leaders on emergency obstetric and newborn health care service delivery. conclusion: the rural environment poses significant risks and barriers to safe and ethical health care delivery for women and newborns in ghana. the intricate dynamics of midwives’ age and family life, limited support in skilled care delivery and community participation influences midwives’ intention to stay in rural practice. keywords: rural, midwives, pregnant women, labour, newborns, ghana midwives’ experiences of rural maternal newborn care in ghana: a phenomenological inquiry the increasing trend in global neonatal mortality rates over the past decade projects a crisis situation in resource-constrained countries where such deaths predominantly occur. deaths in children under the age of five declined worldwide from approximately 12.7 million in 1990 to about 5.9 million in 2015 (united nations inter-agency group for child mortality estimation [unigme], n.d.). recent evidence establishes that of these under-5-year-old-deaths, neonatal deaths now account for about 46% (un-igme, n.d.) compared to 41% in 2008 (black, et al., 2010). it is concerning that two of the five world health organisation (who) regions bear the greatest burden of neonatal deaths; southern asia (39%) and sub-saharan africa (38%) and rural communities recording most deaths in both regions (un-igme, n.d.). previous data establish that approximately 90% of these global neonatal deaths were concentrated in southern asia and sub-saharan africa (un-igme, n.d.). this concentration portrays a skew in mortality trends towards economicallyconstrained settings where country capacity to implement proven interventions are consistently limited (fehling et al., 2013; partnership for maternal, newborn & child health, 2016; wiseman et online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 86 al., 2016, who, 2020). the factors which have been extensively documented as limitations to maternal and newborn health care include inadequacies in number of required skilled birth attendants (lassi & bhutta, 2015; liu et al., 2015), low skill development and unavailability of essential medical resources (lori et al., 2012; nkwonta, & oyetunde, 2017), poor health referral systems (adanu, 2010; enweronu-laryea, et al., 2008), and lack of involvement with local communities (unigme, n.d.). the inter-related nature of these factors engenders a complex continuum of experiences related to moral distress, job burn out (austin et al., 2013), low staff retention and staff attrition (erim et al., 2018; lori, et al., 2012) of health care workers typically midwives in low and middle-income countries (lmics) who work as front-line health care workers in maternal and newborn care. these factors increase the risk of neonatal death, mostly in the first 24 hours of the newborn’s life (avoka et al., 2018; baqui et al., 2016; welaga et al., 2013); the time of critical vulnerability. to achieve sustainable development goal (sdg) 3.2.i.e., reduce neonatal mortality to at least 12 per 1000 live births (united nations, 2015), concerted efforts that are guided by locally-generated research evidence and supportive policies are recommended (liu et al., 2015; wiseman et al., 2016). the predominant causes of global neonatal mortality, known to be preventable, are established in a global systematic analysis where more than 80% of the neonatal deaths were attributed to three main preventable and treatable conditions, that is; preterm birth complications (15.4%); intrapartumrelated complications, including birth asphyxia (10.5%); and neonatal sepsis (6 .7%) (liu et al., 2015). understanding the factors which account for the prevailing pattern of deaths within the first 24 hours of newborn lives (baqui et al., 2016) and first week of neonatal life (bhutta et al., 2013; engmann, khan, et al., 2016; lawn et al., 2011) is important for informing existing programs and implementing specific measures to address related issues. in this phenomenological research, online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 87 midwives’ work as frontline line health care providers in maternal and newborn health care in ghana was explored in relation to these preventable deaths. it is important to understand that midwives’ optimal engagement with pregnant women within an enabling environment during the antenatal period and labor and delivery is advantageous to the prevention of newborn mortality. in ghana, a sub-saharan african country where this study was conducted, neonatal deaths account for approximately 60% of infant mortality (ghana statistical service (gss), 2011). while the neonatal mortality rate in ghana was as high as 29 deaths per 1,000 live births, the deaths were mainly concentrated in rural areas (gss, 2015). although there has been a reduction to 25 per 1000 live births (gss, 2018), the decline in neonatal deaths have been relatively slow (figure 1). figure 1 child mortality trends in ghana combined data (ghana statistical services [gss], 1989, 1994, 1999, 2004, 2009, 2018) on ghana demographic health surveys [gdhs], 1988; 1994, 1998, 2003, 2008, and ghana maternal health survey [gmhs], 2017 the main causes of neonatal mortality in ghana are preterm birth complications, intrapartum related complications (including birth asphyxia), and sepsis (engmann, walega, et al., 2012; welaga et al., 155 119 108 111 80 60 52 77 66 57 64 50 41 3744 41 30 43 30 29 25 0 20 40 60 80 100 120 140 160 180 gdhs 1988 gdhs 1993 gdhs 1998 gdhs 2003 gdhs 2008 gdhs 2014 gmhs 2017 n um be r o f d ea th s data source child mortality trends in ghana (per 1,000 live births) under-5 mortality rate (per 1000 live births) infant mortality rate (per 1000 live births) neonatal mortality rate (per 1000 live births) online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 88 2013) which are consistent with those of other lmics (baqui et al., 2016; un-igme, n.d.; who, 2015). in ghana, geographical variations influence the prevalence of neonatal deaths in a manner that calls for in-depth exploration into the determining factors (avoka et al., 2018, baqui et al., 2016). lack of civil registration data, poor geographical and financial access to quality health care service (moyer et al., 2012), limited skilled birth attendance (gss, 2015; issah, et al., 2011) and weak referral systems (adanu, 2010; enweronu-laryea et al., 2008) characterise the contextual reality of working in communities, typically rural settings. the ghana national health insurance scheme (nhis) became operational in 2005 as a pro-poor measure to replace the previous ‘cash and carry’ health care system (agyepong & adjei, 2008; national health insurance authority [nhia], 2013). under the nhis scheme, maternal and newborn health care services are free for registered members but mothers need to purchase or pay out of pocket for their own health care supplies when required items are not available. narratives behind the numerical evidence on neonatal deaths are sparse within the extant of literature (heringhaus, et al., 2013) but is critical to developing context-specific data to establish support systems for pregnant women, newborns, and midwives in rural practice. each numerical data point on neonatal deaths encapsulates a story that illuminates the issues surrounding cause of morbidity and mortalityrelated events when audits are done (kerber et al, 2015; mills, 2011). in this phenomenological study, the focus of midwives’ experiences in rural settings is rooted in the fact that, their work as frontline health care providers in maternal and newborn care in ghana have minimally been explored. an interpretive phenomenological approach was used to unveil midwives’ experiences with rural practice to guide current interventions and shape future programmes. the new online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 89 knowledge generated in this study fills a critical knowledge gap in rural health care delivery in southern ghana. methodology interpretive phenomenology (ip) that integrates heideggerian (heidegger, 1927/1962) and african philosophy were used to explore, unveil the meanings and articulate the experiences of midwives in rural clinical and community practice. interpretive phenomenology extends beyond description to unveil the meanings through understandings gained in the art and act of interpretations of human experiences (dreyfus, 1995; gadow, 2000; heidegger, 1927/1962). phenomenological concepts on the person, being, existence, culture, causality and communality were explored within an african context. midwives described their african ontology about newborn lifesaving in a communal and typically, spiritualistic nature that is grounded in the belief that both the spiritual and non-spiritual worlds are real (gyekye, 1995; wiredu, 1996; wiredu & gyekye, 1992). the integration of ip tenets with african philosophy engendered a woven tapestry of unique intersubjective experiences that are unique to the african population (gyekye, 1995; tutu, 2000; wiredu, 1996) specifically midwives engaged in rural practice. through critical reflection on the shared world of the participants and immersion in the spiraling interpretation of the research data, researchers were drawn into a broader pattern of the participants’ lifeworlds (conroy, 2003). ethical and institutional approvals this exploratory study received approval from five review bodies; i.e., the ethical review boards of the university of alberta, canada approval id: pro00044075; noguchi memorial institute for medical research (nmimr) ghana approval id: nmimr irb cpn 108/13-14; and the dodowa health research centreghana (dhrc) -approval id: dhrc/irb/14/11. institutional approval was obtained from the management of the shai-osudoku district health administration; online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 90 and greater accra regional health directorate – ghana. research participants gave written informed consent and were made aware of their rights to privacy, confidentiality and the option to withdraw from the study at any time without penalty. context the study was conducted in ghana, a west african country located in sub-saharan africa. nursing and midwifery personnel constitute the majority of health professionals involved in the care of maternal and newborn health in ghana (gss, 2014). the total population of ghana was approximately 26.8 million in 2014 (world bank, n.d.) of which 47% reside in rural areas (who, 2015). according to the who statistical report, the nurses/midwives’ density ratio per 10,000 population in ghana is 9.3 (who, 2015). approximately 51.8% (30,502) of this district’s population are females living in 167 communities, which are served by only 22 midwives in the shai osudoku district assembly (district planning coordinating unit [dpcu], 2015). this means that the density ratio of midwives to female population in the district is approximately 7.2 midwives per 10,000 females. during 2016, 1,698 births were registered consisting of 885 males and 813 females in shaiosudoku (dcpu, 2017). rural communities in ghana are sparsely populated, people farm for both economic and domestic purposes and primarily depend on natural resources such as lakes and rivers for subsistence living. the study was conducted in the shai-osudoku district in the rural southeastern part of ghana in the greater accra region. this rural district has the largest surface area with a total population of about 58,885 (dpcu, 2015). the primary means of affordable transportation is the trotro (a 1220seater minibus that has a back-storage compartment for carrying goods such as farm produce, food, plastic containers, and clothing). additionally, the okada (local motorcycle with a rider and 2-3 pillion riders) is a faster but relatively expensive means of transportation, which is often used when online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 91 patients need to be referred and transported. traveling on a trotro and okada via the bumpy roads with pot holes, present transportation challenges, which worsen with the onset of tropical rain season. the roads become inaccessible and subsequently complicates transfers in case of referrals during neonatal and obstetric emergencies. population and sampling thirteen midwives (n=13) were purposively and conveniently sampled from eight (8) rural birth settings in the shai-osudoku district to voluntarily participate in the research. the inclusion criteria were midwives who had practiced in the shai-osudoku district continuously for at least three (3) months and were willing to participate in the study. midwives who lived the experience were engaged to develop rich narratives on the phenomenon (munhall, 2012; polit & beck, 2012) of rural maternal and intra-partum care. data generation data were collected using audio-recorded research conversations with the midwives, field notes, and reflective journaling. the research conversations lasted between 35 minutes to 120 minutes. all the midwives were engaged in research conversations at least once; represented as round (r) # 1; and six were interviewed a second time (r# 2) to probe and elucidate meaning and understanding of the shared rural experiences in developing rich narratives. three midwives were engaged in a third conversation (r# 3), to increase in-depth understanding of their rural experiences. emerging themes from the verbal transcripts were synthesized with data from the field notes, reflective journal and commentaries from two independent readers to produce detailed coconstructed understandings of the midwives’ rural birth experiences. data synthesis online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 92 guided by conroy’s interpretive framework (2003), data gathering was concurrent with synthesis. in conroy's analytic framework, the hermeneutic principles of research (hpr) and the hermeneutic development of commentary (hdc) were integrated into the six ‘research aspects' in the hermeneutic spiral (conroy, 2003) to produce a synthesis of the evidence on midwives’ rural birth experiences. conroy’s six research aspects are: (i) attending to footprints and engaging in concurrent preliminary interpretation; (ii) in-depth interpretation; (iii) independent reader introduction to the narratives; (iv) paradigm shift identification; (v) exemplary development; and (vi) principle development (2003). six (6) major themes emerged from the narratives of which three (3) are presented in this study. in research aspect one, the audio-tapes were transcribed and verbal transcripts read and re-read several times to identify threads in the textual data in and across interactive sessions in an iterative manner in an attempt to unwrap ‘background’ meaning of the midwives’ experiences. in ip, our background is the ‘place’ where our mind, coping skills, practices and discriminations into which we are socialized, are situated with an understanding that our practices are influenced by our beliefs and knowledge (dreyfus, 1995). the data from the voice and written text, field notes, reflective journal, were synthesized to produce narratives of midwives’ experiences. in research aspect two, the researchers’ preliminary interpretations of the narratives were given back to the respective midwives for comments on representations of their experiences as expressed. our intuitions and insights on the midwives’ commented narratives were documented in the reflective journal and tentative concepts and categories compiled. in research aspect three, the two second readers’ comments regarding the midwives’ and researchers’ preliminary interpretations were compiled. similarities or differences within the stories and interpretation within and across sessions were synthesised and narratives written. the participants verified the synthesized data before it was finalized to establish confidence online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 93 in the data and its respective interpretations. active dialogue about the interpretive processes engendered opportunities for co-creating new knowledge a paradigm shift (research aspect four) was engendered as the researchers faced the reality of changing ways of ‘seeing’ and coping with the midwives’ world, and making optimal alterations to interact in the future. these shifts were based on the data and its deeper understanding of rural midwives’ as brave, focused, resilient and dedicated skilled care providers who remained committed to saving maternal and newborn lives in resourceconstrained communities. in research aspect five, cases that demonstrated consistencies in knowledge, skills, concerns and meanings, knowledge common to midwives’ experiences in rural practice were established as exemplars to produce a rich description of rural midwifery practice. in the final aspect (six), all the narratives were examined in relation to the literature to establish principles that guide safe rural midwifery practice. the entire data synthesis was an inherently iterative process which required constant reflection, an engagement with our backgrounds (heidegger, 1927/1962), an attitude of openness (conroy, 2003), and self-immersion within the research data (polit & beck, 2012). this immersion impacted fore-understandings (heidegger, 1927/1962) of midwives' life-worlds to produce an understanding of rural birthing experiences. these fore-understanding emphasize the importance of our lived time in our current circumstances in order to gain an explicit understanding of the significance of our backgrounds (heidegger, 1927/1962). conroy’s integrated framework was used to engage researchers, study participants and independent readers in the hermeneutic spiral (2003) to produce an in-depth description and interpretation of midwives’ experiences. the interpretive process is a mutually created data, which supports the synthesized evidence on co-constituted understandings of the meanings embedded in midwives’ lived experiences. methodological rigor online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 94 to establish trustworthiness and integrity within this research process (sandelowski, 1986), munhall's (2007; 2012) evaluation criteria which draw on heideggerian philosophy was adopted. these criteria involve ―one p (meaning a phenomenological nod of agreement when listening to or reading the text) and ten r’s. nodding is done in agreement that the researcher has grasped at least partially the meaning of participants’ experiences. the ten r’s represent; readability, representativeness, resonancy, recognisability, revelations, raised consciousness, relevance, responsibility, reasonableness, and responsiveness. to ensure readability, jargons were avoided in all documentation related to participants. quotes and metaphors expressed by participants were expressed in midwives' own words, thematic titles, and artistic representations to firmly ground the synthesis in the participants' life words to establish resonancy. the participants also verified the synthesized data before it was finalized to establish confidence in the data and its respective interpretations. to establish representativeness, multiple data sources (verbal transcripts from audio recorded conversations, field notes, reflexive journal, and independent reader comments) were used to represent several dimensions of participants' experiences within the research process. drawing on our african backgrounds posited us to recognize and share in participants' experiences. through self immersion in the data, keeping a reflexive journal and entering the hermeneutic spiral with an open and questioning attitude (conroy, 2003), enabled us to see things as they appeared to us, noting what was revealed in order to explore what was being concealed towards a deeper understanding of the midwives' experiences. study findings the major themes, which emerged from the synthesized data provided illuminating evidence on the complex contextual realities that impact midwives’ rural practice in ghana. the three major themes that emerged were: a) relationality in rural midwifery practice; b) hemmed in between online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 95 rural maternal and newborn emergencies; and c) an engagement with equipment in rural birthing spaces. these themes illuminate the loose but knitted context of the complexities that confront midwives in rural practice. an overarching theme was “lone practice”; however, elements of midwives' african cultural values and professional ethics permeated the shared experiences. for ethical reasons, pseudonyms were used for all the midwives involved in this study. relationality in rural midwifery practice in rural ghana, midwives live, work, and interact with pregnant women within co-constructed relational spaces where communal values are respected to maintain harmonious inter-subjective experiences. within the african setting, the natural inclination to assume and exhibit communal values is rooted in the social expectation that others must connect with one another in an extended self, relinquishing self and “beingness alone”, and taking on “beingness with others” to create a flourishing community (menkiti, 2006). this backbone of african ethics emphasizes a “we” thinking rather than an “i” thinking, and the reverse in this philosophical thought creates dismemberment (armah, 2010). in this study, lone practice was a common phenomenon among the rural-based midwives. the midwives often practiced alone as skilled birth attendants with support from auxiliary nursing staff, that is community health nurses [chns], enrolled nurses [ens], and health care assistants [hcas]. one midwife who is the only skilled birth attendant in the rural birth setting discussed her encounter with community members including the chief (head of the community) and elders (r # 1): oh! i have! as for friends in town, hmm… i have p-l-e-n-t-y! [voice emphasis]; and also, sometimes when they organize harvest at their churches, i go there! even sometimes they don't invite me, but i will hear someone is naming her child she delivered here; then i will go, aha! online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 96 so as for a funeral, almost every funeral, i am there with them, ahah! even when i go to amrale [name of midwife’s family residence in the next town], on saturday, i will come to the funeral and go back [to residence]. weddings too, mostly i go! so, it’s like now, i am part of the town, mmhhh [raises the tone of voice, smiling and gesturing in chair]. i am part of the community! they really appreciate the work i am doing. even when i am going on leave, i have to inform the chief and elders and they might not even allow you to go. (ume-a2). in another rural birth setting within the same district, one midwife shared her unique experience of weak community relationships and how losing a baby in rural practice can damage one’s integrity as a health professional: the community is not much involved in the welfare of the clinic; that is what i have experienced so far. there is no interpersonal relationship between health workers and community members…you tend to do everything you can just to save the baby because this mother needs her baby and even you, as a midwife will earn a bad name in the community if you should lose the baby. people will think you are not qualified. (ume-a5, r#1). in lone practice, midwives benefit from traditional health volunteer work schemes. such support enhances community relational experiences and influences intention to stay in rural practice. one midwife shares her relational experience with community volunteers: it is wonderful working in the rural setting and when you relate with them well, you gain their trust, and anything you tell them, they listen and anywhere they see you [smiling], they will call you. they [community health volunteers] are sort of volunteers, but let me say, the backbone of the clinic. they are people in the community who have nominated themselves to help us... [we] have their phone numbers. (ume-a3, r#1). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 97 in another rural health setting, a midwife who is the only skilled birth attendant feels a sense of commitment to the community and subsequently demonstrates her commitment to maintain a harmonious communal relationship (heidegger, 1927/1962) with minimal focus on herself: if you are a midwife and you are in a community and there is a case and they call you, you have to go [nods head affirmatively], and attend to the case. you are not supposed to travel a lot, because they might bring a case whilst you are not around, and they will have to send the case to the hospital. when this happens, your people [community members] will not be happy with you. (ume-a1, r#1). a midwife in lone practice narrates further how a neonatal death at her facility can break the graceful relational ties she has with her community, and this could have a negative lasting effect on her practice within the rural community: …and in a small community like this, immediately one mother loses the baby at your facility and the news gets to the community, you are finished! [increases tone of voice, opens eyes widely, and slaps her palms against each other whilst swinging head side to side]…5secs. they will be saying, ‘as for this facility when you go there to deliver, you wouldn’t come home with your baby’. the news will go all [long stretch on the word ‘all’ as sounding like ‘aaalll’] around. (ume-a2, r#1). the midwives’ report about harmonious relationships with community members served as opportunities for strengthening ties with women, families and local leadership. within the same district however, other midwives shared their experiences about fear of rejection and social stigmatization which were perceived as threats to community bonding and women’s’ optimal healthseeking behaviors. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 98 hemmed in between rural maternal and newborn emergencies in rural spaces, the lack and or/malfunctioning of lifesaving resources such as suction devices, oxygen, self-inflating bags (ambu-bags), and medications impede effective resuscitation; timely referrals are subsequently indicated. however, poor geographical terrain, transportation challenges, and communication barriers delay the smooth transfer of mothers and newborns to the next level of care. the midwife’s only option of transporting the pregnant woman or ill newborn from the rural birth setting to the next rural town may be an okada. these transportation options depend on the level of remoteness, time of day, road terrain and family’s financial capacity to afford the transport charges. the resource-limited contexts pose life threatening situations that unite midwives, pregnant women, new mothers, newborns and their families in vulnerability on a continuum. one midwife explains the means by which pregnant women who are experiencing prolonged labor, travel to the referral center for emergency care; however due to transportation challenges, pregnant women needing close monitoring sometimes travel without healthcare support: she [heavily pregnant woman] has to manage especially at midnight, sometimes on a motorbike when there is no taxi. you [pregnant woman in labor] have no choice than to go on the motor; sometimes we go with them and their relatives on the motorbike. you will pick another motorbike, but in a case where there is only one motorbike, you give them the referral note to go with their support person. i am the only midwife in this birth facility, i was here alone when the baby was birth asphyxiated, unfortunately for me, the mother had post-partum hemorrhage too; there was a tear because she pushed through the cervix. i just had to cork the perineum with a pad, then i had to leave the mother and come to the baby, because already, [intravenous] cannula was in situ. i just had to give normal saline and shift attention to the baby. so, immediately the baby responded, i went back to the mother to care for her. i didn’t alert her online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 99 [mother] because she was already pouring [bleeding], if she [mother] gets to know [that] this is what was wrong with the baby, we may lose her; i just let her lie down to relax. (ume-a5, r#1). in rural health emergencies, midwives in lone practice make sustained efforts to demonstrate professional ethics in critical clinical situations (austin et al., 2013) where communicating health information could potentially create panic and endanger the mother and family. midwives subsequently demonstrate their skilled obstetric activities at birth facilities, in taxis, and in the bush (en-route to referral center). in another facility, one midwife narrated her efforts to transport a mother and her retained second twin to the next level of care for comprehensive emergency obstetric care in order to save their lives: when i delivered the first one, with the second one, i had to do the examination to see whether there was any other second twin. with the second twin…the scan also, emmm, showed one cephalic, one breech. so, the one cephalic [presentation] is the one i delivered first. so, with the second one, i saw it was breech. so when we were transporting [on a motor bike], on the way… ohhh!...5s she said she wanted to push, i told her that she should not. but because i was having the forceps, the cord clamp and everything, i stopped when we were going, and she delivered on the way. (ume-a1, r#3). in a follow up research conversation with one midwife who is in a lone professional practice, she shared her experience of facing a moribund baby with history of birth asphyxia in a geo-social context where poor transportation and communication networks rendered midwives, ill newborns and their families vulnerable to emotional and physical stress: there was one case where the client came in labor. the membrane bulged. that is when i was able to rupture it and saw the baby was in distress. …so, i tried also to resuscitate to see if the online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 100 baby would respond to resuscitation. so, i was cleaning and felt the heartbeat. i proceeded on cleaning fast [demonstrates by hand] to revive the baby. that day… hhhmm, i did all my best to ensure the baby was fine. the baby was gasping [for air] so i had to refer the baby since i didn’t have oxygen. it was during the day, so they went with a taxi. they went with a relative… i was alone and there was another client who was also in labor, so i couldn’t leave that client and go with the relatives. i asked myself – what if something happens to this baby in the car? if i had gone with them at least, i know i will go with my ventilation bag and continue to be bagging [positive pressure ventilation] till we get to the referral center. (ume-a5, r#2). late reporting to the labor ward is a common phenomenon in the rural communities. this poses as a risk to the newborn and makes them vulnerable to respiratory distress as transition is made from intra-uterine to extra-uterine life. one midwife reveals the challenges of caring for a woman who reports late to the birth facility as a first time attendant in labor with a risk of respiratory distress at birth: yes! first time you are seeing her! yes! and she is in labor! and they [pregnant women] come in a critical state, so you can’t send them back. i have two chns and one en, but none of them have midwifery background! i am the only midwife. [having a look of frustration – eyebrows raised]. it is not easy at a-l-l. when you see the baby can’t breathe well, the baby is not crying, the baby can’t move, then you will just be shivering [gesturing with hands and entire body]. this might lead to you losing the baby because what you are expected to do, you may sometimes forget...5s because you are panicking…and the panicking alone will let you lose the baby! (ume-a2, r #1). the urgent need to save newborn lives in emergency situations create fear and panic in midwives that discloses specific events. in a phenomenological sense, the unexpected events can online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 101 potentially occur as we actively let go of ourselves to meet the possibility of that particular occurrence in whatever form (heidegger, 1927/1962). in a follow up research conversation (r#2), one midwife narrates the concerns with late reporting and the advance preparations she makes for such occurrences: “some will come with normal pregnancies; some might come with head in perineum [baby’s head in perineum]. you have to make sure that even after a delivery, you set up your delivery instruments”. (ume-a5). in lone practice, midwives who have community health nurses, enrolled nurses and healthcare assistants in their settings engage their services to save maternal and newborn lives: i call the chns, ens, and hcas because i’m alone in the health centerthe only one midwife in the health center – as for that one ’deƹ’ (akan language used to express emphasis) it’s too much! so, i used to call one to help me. (ume-a1, r#2). having the support of other health staff offered opportunities for midwives to maximise their life saving efforts in rural birth settings. an engagement with equipment in rural birthing spaces as a low middle income country (lmic) (international monetary fund, 2016), ghana has seen the gradual introduction of technology into its health care system particularly in urban health facilities where life support and mobility-assistive devices are available although not very common. in rural health centres or community-based health planning and services (chps) compounds (i.e., local clinics at community levels), it is the inadequate number or lack of equipment in health care delivery and not the domination of technology that is challenging. in this study, midwives related to ambu-bags (self-inflating bags or bag and valve masks for positive pressure ventilation), bulb syringes (for oro-nasal suctioning), deep suctioning devices and electricity supply as basic to lifesaving in maternal and newborn care. with an understanding that the things around us appear as online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 102 ‘ready-to-hand’ (heidegger, 1927/1962), when in close proximity with life-threatening conditions such as birth asphyxia, midwives explored resources and improvised with local tools in the absence of medically approved bulb syringes for saving newborn lives. families residing in rural settings need to purchase an enema syringe (locally referred to as bentoa) from the local market for a price ranging between 13-15 ghana cedis (approximately $ 2 – 3 u.s.) as part of required items on the maternity list for newborn oro-nasal suctioning at birth. in a research conversation, one midwife narrates her experience with available equipment and newborn lifesaving interventions: sometimes you have a case that at the hospital, you would have the equipment to manage, but this facility…[…<3secs], you don't have! [increased tone in voice]. ahah! like you have an asphyxiated eerr, emmm…baby. you have done your resuscitation…you have done your ambubagging [… <3secs], even with the bulb syringe for the suction, it does not go as deep as a suction machine. so, at the chps compound, we only have the bulb syringe so you can’t go far [pharyngeal suctioning], you suck from the mouth and the nose, so you can’t go deeper…you will see that the bulb syringe is not sucking everything. you may need a suction machine, but you don’t have [drops both hands on lap in desperation]. in some places, they don’t even have an ambu-bag or a bulb syringe. but sometimes when there is no bulb syringe, they use enema syringe [locally referred to as ‘bentoa’] to improvise. so, with those basic things, every facility should have, and it should not be [only] one too! (ume-a2, r#2). in health care crises situations, midwives engage in creative solutions. one midwife shares her experience with lack of equipment: when lights go off, i use torch or rechargeable lamps for deliveries…and if the lamps are not working, i use my phone light. when i get a case of a baby who is asphyxiated, i tell the relatives to look for a taxi. i bag [positive pressure ventilation] till the taxi comes and i bag in online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 103 the taxi till i reach the hospital… the bulb syringe cannot go far so when the baby breaths’, you still hear it, so you still have to send the baby to the hospital. (ume-a3, r#1). a midwife expresses concern about the lack of oxygen supply and the need to build her capacity in the use of basic life-saving equipment, specifically, mobile oxygen tank: “no, we don’t have oxygen! but if they [district health authority] bring the oxygen here, i don’t know how to use it, so i will call for them to come and teach me how to use it”. (ume-a1, r #1). in a similar situation, a midwife expressed challenges associated with lack of nasal oxygen prongs which makes the use of oxygen tank impossible, and the need to gain skills in oxygen usage: midwives are assigned to the maternity ward only. sometimes with the use of oxygen like this, we had to call another nurse to come and teach us how to use it. we were recently supplied with one; that is the cylinder but there was no oxygen for about three (3) months before they filled it. but now we lack the neonatal nasal tubethat is what we don’t have. (ume-a7, r #1). another midwife narrates the dependence on family support and expresses the inherent frustrations in labor and delivery service: in our labor ward, most times i use the support persons; those who come with the client. i try to call on one person to come and assist me in the ward in case there is no one to help me. but they too, because they have no idea about the equipment you have to tell them what to pick, which is very stressful. sometimes i ask myself – “am i the only midwife”? because my other colleagues have support from the other midwives who are experienced but i am here alone! it’s very challenging, very scary. (ume-a5, r#1). reminiscing delays in the requisition of medical supplies, one midwife explains how political leaders who traditionally hail from the community demonstrated their willingness to help to equip online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 104 birth facilities in the community. these unique inter-subjective experiences enrich the midwife's community relations, and shape strategic healthcare interventions initiated by indigenous members of the community serving leadership positions at the national level. the midwife explains in r#2: “i think my other colleague has made this requisition [for healthcare supplies], especially the mp [member of parliament], he wants to help us with those things, yeahhhh!], ...10s..so we are still on it. sometimes you write the requisitions and the memo, [but] it takes time.” (ume-13). delays in procuring age-appropriate basic health care supplies such as suction tubes, bulb syringes, nasal prongs and facemasks create challenges for optimal rural practice. discussions the achievement of maternal and newborn health targets in lmics requires a sustained focus on rural, remote and underserved communities. within such places, health care systems need to be strengthened (lassi & bhutta, 2015; sami et. al., 2018; wiseman et al., 2016). a community-based approach that integrates local governance is recommended to improve maternal and newborn survival (save the children, n.d.; unicef, 2014). high rates of rural maternal and newborn deaths compared with urban has been a predominant issue in sub-saharan africa (who, 2015, 2020). the effect of consistent geographical disparities on women and children (avoka et al., 2018) pose as a major challenge to meeting the sdg 3.2 target by 2030. whilst midwives in rural practice experience numerous challenges as frontline health service providers in maternal and newborn health care delivery (issah et al., 2011; lori et al., 2012; nkwonta, & oyetunde, 2017), they make sustained efforts to save lives. in this study, major challenges that impacted midwives’ rural maternal and newborn practice were skilled staff shortage culminating into poor skill mix, lone practice and distressing moments. other areas of concern were late maternal reporting, weak referral systems, lack of basic life-saving resources, practice learning gaps and transportation challenges. in the midst online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 105 of these challenges, midwives made consistent efforts to demonstrate their social competence to increase their bonding with the community in order to gain the trust of the women and community in professional and facility-based health care. to maintain harmonious communal relations, midwives had to express “sorge” – by demonstrating pure concern (dreyfus, 1995) and “paying attention” to that which mattered (heidegger, 1977) to the chief (head of the village), women, their newborns, families and the community. similar to other contextual views, midwives as africans in this interpretive phenomenological study reminisced; “i am because we are”; “you are because we are”; this is the concept of ubuntu (tutu, 2000) that is shaped by past, present, and future events (dreyfus, 1995; heidegger, 1927/1962). the midwives upheld their communal values and deemed harmonious relationships fundamental to their very existence and survival as healthcare providers in the community. strong relational ties with key stakeholders including chiefs, members of parliament, community elders, health volunteers and members influenced midwives’ intention to stay or leave the work setting. however, health care delivery and practice issues which create inter-subjective tensions also generate moral distress among care providers (austin et al., 2013; reiger & lane, 2013). particularly, when called to respond in a morally appropriate way to be present with the ‘other’ (austin et al., 2013; de beauvoir, 1985) it becomes challenging for midwives to do so when in a lone practice or with poor skill mix. lone practice was a common phenomenon for midwives in rural practice, however when an enabling environment is provided, midwives obtain support to deliver safe and competent maternal and neonatal care (engmann, khan, et al., 2016; lassi & bhutta, 2015). this support must be research driven, sustainable and locally informed (save the children, n.d.; wiseman et al., 2016). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 106 in this study, concerns about effective resuscitation and lack of knowledge in oxygen usage establish the need for midwives’ capacity building. research evidence establish that investing in the training of frontline health workforce is a cost-effective approach that strengthens health care systems (floyd, 2013; un-igme, n.d.). moreover, when midwives are educated and regulated to international standards, they build professional competencies to deliver 87% of midwifery service need in maternal and newborn care (united nations population fund, 2014) towards optimal birth outcomes (avoka et al., 2018; enweronu-laryea et al., 2008; sami et al., 2018). the lack of basic life-saving health care resources makes maternal and newborn health care delivery a challenge. however, community members blame midwives for a neonate’s death, and minimal consideration is given to existing contingencies such as skilled staff shortage, late time of the day, and nonavailability of lifesaving resources such as oxygen supply and suction devices. it is important to think through the reality that pregnant women, who cannot afford the bentoa, may be compelled to access traditional birth attendants (tbas) services. besides the bentoa, the other items on the maternity list, which the pregnant women must purchase for labor and delivery, are sanitary pads, chlorine solution, wrap sheets, baby diapers, clothing, toiletries, and antiseptic solution (e.g., dettol or savlon). these health care demands need to be reconsidered to make facility-based delivery attractive to families. the issue of late maternal reporting is not only related to financial limitation but to the cultural expectation that projects african women as enduring and strong. research evidence has established delays in seeking health care (issah et al., 2011; unfpa, 2014) as a major setback to achieving optimal maternal and neonatal health outcomes in ghana. the phenomenon associated with late reporting to the labor ward is a typical cultural sign of endurance amongst pregnant women to demonstrate their physical strength and resistance to labor pain at home prior to moving to the birth online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 107 facility. from a cultural perspective, “strong women” need to endure labor pain until the amniotic sac ruptures, or “show” (operculum release) is observed. new knowledge in this study serves as basis for improving skill mix, directing care capacity building strategies, maternal education, developing policies and implementing research-informed interventions to support rural midwifery practice and improve newborn health outcomes in rural ghana. limitations of the study the shortage of midwives in ghana poses a major challenge not only to pregnant women, newborns, families and clinicians, but also to researchers. due to the limited number of midwives in the district where the study was conducted, researchers had to re-schedule research conversations on several occasions whilst on site, or by telephone where communication network was efficient since midwives had busy work schedules. frequent travels over 80 – 100 km on marshy roads for a scheduled research conversation had to be cancelled on arrival on several occasions because the midwives in lone practice were busy with women in labor. waiting for the midwives on such occasions presented significant challenges with data collection considering the look of exhaustion on midwives’ faces and the need to reschedule interview appointments. the poor road network and inaccessible road terrain during the rainy seasons generally caused transportation barriers, which further limited the ease of access to the midwives. conclusion the care of pregnant women, mothers, and newborns in rural settings engenders stress among midwives in resource-limited practice spaces. addressing birth-related morbidity and mortality is a moral imperative that requires collective responsibility to ensure maternal and neonatal well-being. it is critical that integrated efforts be made to strengthen community-based care in rural communities online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.654 108 using feasible culturally engrained and sustainable approaches that promote midwifery practice and optimal newborn health care. it is expedient that future research explores the experiences of pregnant women and spouses or partners, tbas, stakeholders, and community leaders in birthing in rural communities. references adanu, r. m. k. 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(2020). world health statistics. https://apps.who.int/iris/bitstream/ handle/10665/332070/9789240005105-eng.pdf declaration of conflict of interest: the authors declare that there is no conflict of interest. fahs_editorial_562.pdf online journal of rural nursing and health care, 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.562 1 editorial a new look to an old favorite, online journal of rural nursing and health care pamela stewart fahs, phd, rn, editor i am happy to report that the change from the old to new manuscript management software for the online journal of rural nursing and health care [ojrnhc] is complete! though not without challenges, the process was completed with superb technical assistance from jesse russell, library systems specialist and erin rushton, associate librarian of binghamton university. mr. jesse russell undertook the system upgrade and transfer to a larger more secure server as one of his first projects with binghamton libraries. since the software had not been updated from the version we inherited in 2011, he had to move from a version that was so old he had to complete not one but two conversions to bring us to the current system. i am sure he did not realize exactly how many questions i could have as we worked through the new system. he continues to be a great support as questions arise. thank you jesse. as many of you know, ms. erin rushton continues to serve as the managing editor of ojrnhc and is a driving force in bringing the journal to fruition every six months. she has spearheaded the move to getting a journal digital object indicator (doi), meeting the new standards for open source publishing, and moving the journal to a more secure server within the library system. erin, publication of this journal would not be possible without your efforts. ann graves, phd is the journal associate editor and she has been a big part of the success as we cleared the path for the change, moving manuscripts already in the system through and beyond the upgrades. thank you ann for helping me find some of the right buttons, seeing where the processes were similar and where they differed, and working so diligently to move the backlog of manuscripts through the system. online journal of rural nursing and health care, 18 (2) http://dx.doi.org/10.14574/ojrnhc.v18i2.562 2 i also want to thank the reviewers who continue to do a wonderful job evaluating and providing feedback to those submitting manuscripts. they devote countless hours in support of nursing science and rural nursing with their manuscript reviews. many of our most faithful reviewers and a few new reviewers agreed to quick turn-around times to minimize the down time for accepting new manuscripts. the contributions of the reviewers to the quality of work we publish cannot be under estimated. the online journal of rural nursing and health care is the official organ for the rural nurse organization (rno). what many do not realize is that all the “staff” for the journal volunteer their time and energy. this continues to allow the rno to keep the contents of the journal free for all who wish to access the publication, without charging authors for submission. waiting for reviews and editorial decisions is challenging in the best of times. therefore, i particularly want to thank all those whose manuscripts were caught within the upgrade timeframe for their patience with this process! please note that if you bookmark the online journal of rural nursing and health care, you will need to change the url for your bookmark. you can access the journal at https://rnojournal.binghamton.edu/index.php/rno . i hope you will find the new journal look pleasing as you continue to enjoy an old favorite professional journal. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 112 the healthcare of vulnerable populations within rural societies: a systematic review kattiria m. gonzalez, ms, phd student, rn1 molly j. shaughnessy, bs, mba, phd student, rn2 edwin-nikko r. kabigting, ms, phd candidate, rn3 donna tomasulo west, ms, phd student, rn, np4 jacqueline callari robinson, bs, phd student, rn5 qimin chen, bs, master’s degree student, rn6 pamela stewart fahs, phd, rn7 1 phd student, decker school of nursing, binghamton university, kgonza33@binghamton.edu 2 phd student, decker school of nursing, binghamton university, mshaugh2@binghamton.edu 3 phd candidate, decker school of nursing, binghamton university, ekabigt1@binghamton.edu 4 phd student, decker school of nursing, binghamton university, dwest3@binghamton.edu 5 phd student, decker school of nursing, binghamton university, jcallar1@binghamton.edu 6 master’s degree student, decker school of nursing, binghamton university, qchen20@binghamton.edu 7 associate dean, professor, director of phd programs, and decker chair in rural nursing, decker school of nursing, binghamton university, psfahs@binghamton.edu abstract purpose: to synthesize the recent research on vulnerable populations within united states (us) rural society regarding healthcare, healthcare policy, and health systems. additionally, a online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 113 healthcare disparity model was utilized to organize the findings as a means of evaluating the current state of the science regarding vulnerabilities research in the field of rural health. methods: a systematic review of literature was conducted covering 46 articles published in the last five years on vulnerability within rural populations in the us and its territories. instruments to evaluate both quantitative and qualitative scientific merit were utilized in this review. findings: analysis of the state of the science indicates that studies that scored well on measures of scientific merit were conducted on some of the most vulnerable populations within rural society. most of this work remains at a descriptive level, rural is only operationally defined approximately 1/3 of the time, and seldom is there a clear definition of the term vulnerable. the findings of this review support the model depicting how healthcare accessibility and quality, along with healthcare needs can reflect the level of vulnerability of rural populations. conclusions: using the combination of the search terms “vulnerable” and “rural” failed to produce any studies on the subject of telehealth. telehealth is an area that needs to be specifically studied for vulnerable populations in rural society. there is a need for rural health research that provides interventions and includes measurement of social determinants of health. keywords: rural, vulnerable, social determinants of health the healthcare of vulnerable populations within rural societies: a systematic review the purpose of this literature review is two-fold. the first purpose is to synthesize the findings of research for the past five years related to vulnerable populations within rural society in the us. additionally, the findings will be discussed within the dynamic multi-vulnerability health care disparities model (grabovschi, loignon, & fortin, 2013). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 114 healthcare disparities and vulnerability in rural america healthcare disparities continue to be a significant issue in the us (crosby, wendel, vanderpool, & casey, 2012; penman-aguilar et al., 2016). the inequality that various groups of americans face concerning their ability to access timely, quality healthcare is driven by many individual, societal, and environmental factors such as race/ethnicity, socioeconomic status, level of educational attainment, provider availability, and more. social determinants of health encompass the place in which people live as well as their socioeconomic status and barriers to quality healthcare. the vulnerability of rural dwellers changes in relation to social determinants of health as well as to the extent of the lack of accessibility to healthcare for individuals and communities (fahs, 2017). subgroups within the american population that have an elevated risk for experiencing healthcare disparities are generally described as vulnerable (de chesnay & anderson, 2016; shi & stevens, 2010). rural dwellers, for example, may be considered a vulnerable population due to their increased likelihood of experiencing barriers to accessing quality healthcare. these healthcare disparities are often accentuated by rural dwellers’ geographic isolation and residence in medically underserved areas (mua) (crosby et al., 2012). the centers for disease control and prevention (cdc) announced that “americans living in rural areas are more likely to die from five leading causes than their urban counterparts” (centers for disease control and prevention, n.d., para 1). the basis for this statement was a report focused on the leading nonmetropolitan and metropolitan causes of death in the us (moy et al., 2017). while this literature review will show that much work has been done to advance understanding of healthcare for rural americans, there online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 115 is still much to accomplish. the development of knowledge in the field of rural health should involve an exploration of the dynamics between healthcare needs, access, and vulnerability to healthcare disparities in rural americans. to organize this exploration, a structured approach was used. the dynamic multivulnerability model of healthcare disparities was selected for this application (grabovschi et al., 2013). this model (figure 1) was created based on hart’s oft-cited description of the inverse care law, which states that “the availability of good medical care tends to vary inversely with the need of the population served” (hart, 1971, p. 412). the vulnerability model is a right triangle wherein the horizontal axis (base) represents the degree of healthcare accessibility and quality and the vertical axis represents healthcare needs; the hypotenuse of the triangle reflects the level of vulnerability (grabovschi et al., 2013). according to the model, an individual who experiences multiple vulnerability factors would be more likely to have high healthcare needs and low access to quality care. barriers to healthcare access in rural settings often include lack of insurance coverage and distance from services. rural residents are more likely to be uninsured compared to urban dwellers (barker, londeree, mcbride, kemper, & mueller, 2013; soni, hendryx, & simon, 2017). with regard to distance, “many rural residents must travel more than 30 minutes to access healthcare services, … in a setting where public transportation is not available and poverty is at its peak, travel to prevention and self-management resources can be even more burdensome” (warren & smalley, 2014, p. xiii). while grabovschi and colleagues (2013) acknowledge that the inverse care law (hart, 1971) focuses on vulnerability related to low socioeconomic status, the grabovschi et al. (2013) model includes many other patient related factors that impact vulnerability and may co-exist in a single online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 116 patient. these factors can be categorized into either inborn or acquired individual traits as well as factors related to the physical environment or broader socioeconomic environment (grabovschi et al., 2013). for example, race would be considered inborn, lifestyle would be acquired, pollution would be categorized as a factor from the physical environment, and culture would be related to the broader socioeconomic environment; all of which are social determinants of health. method the search was conducted using ebsco host and included the following databases: medline full text, psycinfo, cinahl complete, and psycarticles. studies were limited to literature published between the dates of january 2012 to march 2017. to meet review criteria, articles had to be written in the english language, peer-reviewed, and based on research conducted in the us and its territories. articles related to healthcare as well as healthcare policy and health systems were reviewed. research that was conducted outside of the us and its territories, those that specifically discussed patient electronic health records (ehrs), systematic reviews, and dissertations were excluded. search terms used were “rural” and “vulnerable”. if both keywords were not expressed in either the title or abstract, the article was reviewed manually to determine inclusion. using the above criteria, journals specific to rural health in the us were also searched. a total of 51 articles were included for review after the exclusion of dissertations, articles that were duplicates, meta-analysis or systematic review and those with topics including ehrs as well as studies conducted outside of the us. a systematic review method was carried out and each article was evaluated for scientific merit. five articles (10%) were excluded from review due to poor scientific merit, leaving a final count of 46 articles (see figure 2). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 117 thirteen healthcare providers planned and conducted the search. each reviewed a subset of up to four articles. one author (blinded) read all articles and the accompanying review forms for detail accuracy. in order to address inter-rater reliability, two additional providers independently reviewed eight of these articles. levels of evidence the level of evidence for each article reviewed was identified using a system that is primarily based on study design (fineout-overholt, melnyk, stillwell, & williamson, 2010). levels of evidence in this system range from i to vii. systematic reviews or meta-analyses are considered the highest level of evidence. expert opinion is the lowest level. levels of evidence considered in this review included level ii randomized-control trials (rct), level iii quasi-experimental studies, level ivcohort or case controlled studies and level vi, descriptive studies using either quantitative or qualitative methods. for this analysis, systematic quantitative or qualitative reviews (level i or v) were excluded since the project is focused on creating a systematic review. additionally, expert opinion pieces (vii) were excluded. scientific merit scientific merit was evaluated using two different tools depending method. studies that were quantitative were evaluated using a system with eight rated areas, with each item scored from 0 – 3 points. the highest possible score on the quantitative scoring grid was 24 points (association of women’s health obstetric and neonatal nurses, 2003). a rating of 18 or higher was considered to be good quality. articles that scored 13-17 were rated as fair. articles that were given a score of 12 or below were rated as poor quality, lacking scientific merit, and were eliminated from the review. the eight areas considered in scoring were: problem/question, sample, literature review, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 118 data collection/method, instrumentation, design validity, statistical analysis, and justification of conclusion. studies that were qualitative were evaluated using a similar scoring system developed specifically to evaluate qualitative work (cesario, morin, & santa-donato, 2002). the highest score that could be given on the qualitative scoring grid was 27. a score of 23 or higher was rated as good quality. scores of 15-22 were rated to be of fair quality. those articles that did not meet the criteria for scientific merit, i.e., scores of 14 or less, were eliminated from the review. five areas considered in scoring included: descriptive vividness, methodological congruence (rigor in documentation, procedural rigor, ethical rigor and confirmability), analytical preciseness, theoretical connectedness, and heuristic relevance (intuitive recognition, relationship to existing body of knowledge, and applicability). there is no scoring system specifically for mixed methods, thus the articles were scored using the method most prevalent in the research report. theory use of theory was evaluated using the guidelines to judge whether there was minimal, insufficient, or adequate use of models for theory testing (silva, 1986). minimal use meant identifying a theoretical framework for a study but not indicating how it was used. insufficient use of theory indicated that a theoretical model was used to organize the research. studies were considered to have adequate use if they explicitly tested theory. findings although factors such as low socioeconomic status, minority race/ethnicity, and advanced age were not always explicitly indicated in the 46 articles reviewed as being linked to vulnerability, the categorization of these factors explicated by grabovschi et al. (2013) aided in determining their online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 119 presence in the various studies. all of the 46 articles investigated an issue in rural healthcare that involved a patient population with at least one vulnerability factor, with one exception. this standalone study focused on provider performance in critical access hospitals, thereby evaluating access to quality acute care in a rural setting (coleman, baker, gallo, & slonim, 2012). in examining the remaining 45 studies, it was clear that certain vulnerability factors, such as low socioeconomic status, received significant attention from rural health researchers, while other factors such as smoking received far less (see table 1). for the sake of concision, only aspects of vulnerability present in three or more studies were included in table 1 in order to illustrate the most highly studied factors. vulnerability factors found in the reviewed articles but not included in table 1 included lack of social connection (baernholdt, yan, hinton, rose, & mattos, 2012; galloway & henry, 2014), unsafe environment (carter-edwards et al., 2015; klein, liber, kauffman, berman, & ferketich, 2014), risky sexual behavior (gullette, booth, wright, montgomery, & stewart, 2014; kogan, cho, & oshri, 2016), uninsured status (buerhaus, desroches, dittus, & donelan, 2015), farm worker status (crain et al., 2012), immigrant status (crain et al., 2012), sedentary lifestyle (pahor et al., 2014), and living in a healthcare provider shortage area (tuefel et al., 2012). overall, low socioeconomic status was the most frequently mentioned aspect of vulnerability; considered in 22 (47.8%) of the studies. many studies (18, 39.1%) also focused on issues in rural healthcare faced by racial/ethnic minority groups. after low socioeconomic status and racial/ethnic minority, the four other aspects of vulnerability that were most often discussed were chronic physical or mental illness (11, 23.9%), low education (11, 23.9%), old age (8, 17.4%), and youth (8, 17.4%). details of each study reviewed may be seen in table 2. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 120 many of the articles reviewed focused on rural populations with multiple vulnerability factors. for instance, wenzel et al. (2012) examined the resource needs of older africanamericans with cancer and wilhelm et al. (2015) studied low-income mexican-american mothers with low educational attainment during the postpartum period. some of these studies appeared to provide support to grabovschi and colleagues’ (2013) dynamic vulnerability model of health care. this model illustrates the relationship between healthcare needs, vulnerability factors, and access to quality care. across all of the research examined, the populations studied involved rural dwellers, who often contend with reduced access to timely, quality healthcare (crosby et al., 2012; fahs, 2017). in many cases the articles reviewed indicated that rural groups with multiple vulnerability factors faced additional barriers to receiving needed care. for instance, crain et al. (2012) discussed the high mental health care needs of immigrant latino farmworkers residing in a rural area described as “poorly equipped to serve [them]” (p. 277). in this example, the population studied had high healthcare needs, multiple vulnerability factors, and poor access to quality care, which corresponds to the relationship illustrated by grabovschi et al.’s (2013) model. banks et al. (2016) described specifically how poverty prevented those with chronic illnesses in central appalachia from keeping extra medication, food, and water on hand in case of emergency, making them particularly vulnerable to environmental disasters. many other articles, however, did not provide enough information to determine the veracity or usefulness of the model. some articles, for instance, focused only on lack of access to care for rural dwellers but did not discuss whether there was any increased need for healthcare services in the population studied (hsia & shen, 2016; jones & jerman, 2013). ultimately though, the literature supported the view that many vulnerability factors constitute barriers to timely, quality healthcare for rural residents. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 121 level of evidence and scientific merit the level of evidence of research for this review ranged from ii (rct) to vi (qualitative or descriptive studies). the majority (37, 80%) of the papers evaluated were quantitative. the predominant design used was descriptive correlational. in this review, the scientific merit for qualitative studies had scores ranging from a high of 22 to a low of 19 points, out of a possible 27. quantitative study merit scores ranged from a high of 22 points to a low of 13, out of a possible 24. the rating ranges for both quantitative and qualitative studies reflect only the 46 articles included after 5 were removed for questionable scientific merit upon review (see figure 2). interrater reliability was affirmed with two additional health care providers, blinded to the initial review, correctly identifying scientific merit categories in their redundant review of 8 of the original 56 articles. those articles rated as having insufficient scientific merit were kept in the pool for testing for inter-rater reliability to assure that the scoring used for scientific merit would be replicable by other reviewers. sample and sample size of studies for all articles, sample sizes ranged from a low of 10 to a high of 30,874. specifically, for quantitative studies, sample size ranged from a low of 28 to the largest study of 30,874 participants. for qualitative studies, the sample sizes ranged from 10 to 48. although sample sizes varied considerably, only one of the articles calculated power analysis (komro et al., 2015). a power analysis is frequently used in well-grounded quantitative research to limit the possibility of error between proposed hypothesis and findings. komro et al. (2015) used power analysis in their study to justify adding towns to their sample size, which were not included in the original research design. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 122 rural factors rural factors were evaluated and subdivided into three criteria: objective measures, implied but not defined, or not specified. approximately ⅓ (33%) of the articles fell into each of these categories. objective measures included identifications by population density and land use such as us census bureau classifications (ratcliffe, burd, holder, & fields, 2016); or measures reflective of municipality boundaries and land use or methods developed for economical purposes such as the rural urban continuum codes (ruccs) or the rural urban commuting codes (rucas) in the articles reviewed (united states department of agriculture, n.d.a., n.d.b.). additionally, rural was used as a location as well as to identify issues of access to healthcare that are prevalent among this population (winters, 2013). table 2 indicates whether a definition of rural was provided in the articles reviewed. health issue examined thirteen primary topics emerged; the most common category was cancer detection and prevention. specifically, studies most frequently addressed colorectal and breast cancer. the next most researched topic was access to healthcare. other issues that were explored in at least three articles included: rural vs. urban differences, mental health, tobacco control and policy, health promotion and wellness, and risky behaviors. topics that were only addressed once included discrimination and medical mistrust, rural coding schemas, rural infrastructures, the role of the provider, hazards, cardiovascular health, pain management, and pregnancy care. theory utilizing the classification system for adequacy of theory (silva, 1986) only one study was identified has having adequate use (lópez-cevallos, harvey, & warren, 2014). lópez-cevallos online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 123 et al. (2014) utilized the behavioral model of vulnerable populations to frame their study, which evaluated the associations between medical mistrust, perceived discrimination, and satisfaction with healthcare. lemasters et al. (2014) used the health belief model to describe and organize their study, which guidelines label as insufficient use of theory. one study developed a new conceptual model from their findings (carter-edwards et al., 2015). based on silva’s (1986) explanation of theory use in research articles, the majority (98%) of articles reviewed were classified as having no or minimal use of theory. limitations limitations were identified during this review. all the reviewed articles were based on research in the us and written in the english language. this deliberate restriction to us studies has the benefit of a clear focus on vulnerable populations within us rural society; however; this may be seen as a limitation as the findings of this review are less generalizable to the global rural healthcare field. furthermore, there may be significant information related to this topic that could be obtained from research in other countries that was not included in the review. only three (6.5%) of the articles reviewed involved true experimental designs. higher levels of evidence often indicate interventions are being conducted and tested. among all articles, the use of theoretical frameworks was limited, thus limiting the contribution to the development of science. two-thirds of the articles did not use objective definitions of “rural”, making comparisons between populations less reliable. only one article defined “vulnerable” operationally, thus in the majority of studies it was the researchers’ interpretation of factors that determined what was vulnerable (horney et al., 2013). this lack of a clear definition adds more subjectivity than online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 124 necessary had operational definitions been provided. rural and vulnerable, as the only two search terms, was a limitation; however, this provided reasonable limits on the numbers of articles identified. additional search terms, such as disparities, social determinants of health and underserved may produce different results. all articles reviewed were published in a peerreviewed journal. risk bias was not assessed across studies. surprisingly, there were no telehealth studies that emerged during the search. discussion the use of theory testing adds to the scientific knowledge base (silva, 1986). thus, the absence of cited theories in most articles may indicate a lack of use or inadequate significance to theory testing. alternatively, the preponderance of atheoretical research could be an indication of journal page limits and the need for concise writing to meet those requirements. the overreliance on descriptive correlational designs also restricts the appropriateness of theory testing. ideally, studies should incorporate theories and theoretical applications pertinent to rural populations. few disciplines have developed a theory to describe, explain and predict how rurality may influence the acceptance of healthcare within rural populations. one exception is the work on rural nursing theory (rnt) that has been in the nursing literature since the late 1980’s (long & weinert, 1989). thus, it was surprising to find that rnt was not mentioned in articles uncovered in this search. conclusion this systematic literature review supports the premise that there are multiple vulnerable populations within rural society. the model used provided a way to view the types of vulnerabilities explored in the rural healthcare literature (grabovschi et al., 2013). some of the identified vulnerability is related to quality and access to care for rural dwellers and offers ideas online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 125 for further research and/or practice. according to the nc rural health research program, since 2010, 81 rural hospitals have closed (north carolina rural health research program, n.d.). the uncertainty in the insurance markets may potentially have a catastrophic effect on the access and quality of healthcare for the vulnerable, particularly within rural communities. thus, there is a risk of increasing the vulnerabilities within rural society in the future if access to healthcare is further compromised for rural dwellers. future research should adequately operationalize the use of the terms rural and vulnerable to ensure that research findings are applicable to the rural community. studies regarding telehealth may want to use a keyword of vulnerable to assure that the research surfaces in reviews for the vulnerable within rural society. rural dwellers who have a chronic illness, are older, disabled, pregnant, smokers, or have substance abuse issues are likely to have increased healthcare needs. the research indicates that when these vulnerabilities combine with barriers to receiving quality care, such as poverty, lack of insurance, minority race/ethnicity, and residence in a medically underserved area, then healthcare disparities are likely to result. the literature on vulnerable, rural populations in the context of healthcare over the past five years has illuminated the extent of the needs of various vulnerable groups. while the bulk of the literature is descriptive rather than aimed at evaluating interventions, it does provide some of the background knowledge needed to move the science closer to addressing the disparities present in healthcare in the united states. future research should be concentrated on intervention development and testing, with high levels of scientific merit, in order to close the gaps in healthcare quality experienced by vulnerable, rural groups. this systematic review provides a clearer understanding of the state of the science on online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 126 vulnerable populations within rural societies. furthermore, the findings of this review support the applicability of the vulnerability model (grabovschi et al., 2013) for use in rural health research focused on vulnerable populations. acknowledgements christopher matthews, rn, ms, fnp, christine fuller, rn, ms, fnp, don hill rn, ms, fnp, margaret decker, rn, ms, and reham yasin, rn, bs who were students in nurs. 621 / nurs 622 at binghamton university in spring 2017. references adams, s. a., choi, s. k., khang, l., campbell, d. a., friedman, d. b., eberth, j. m., . . . yip, m. p. 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(2013). rural nursing: concepts, theory, and practice (4th ed.). new york: springer. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 136 figure 1 reproduced with permission of c. grabovschi (may 2017). grabovschi, c., loignon, c., & fortin, m. (2013). mapping the concept of vulnerability related to health care disparities: a scoping review. bmc health services research, 13(1), 94. https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-13-94 online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 137 figure 2 search terms: rural vulnerable include: published january 1, 2012 to present english language peer-reviewed within us or us territories search engines: medline full text psycinfo cinahl complete psycarticles 86 results search of: rural journals 8 results total 94 articles exclude: 5 poor scientific merit 46 articles reported exclude: 43 outside us or us territories; use of emr literature reviews, or dissertations 51 articles remain 138 online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 138 table 1 vulnerabilities within the literature aspects of vulnerability considered included papers, n (%) low socioeconomic status 22 (47.8%) racial/ethnic minority 18 (39.1%) chronic physical or mental illness 11 (23.9%) low level of education 11 (23.9%) old age 8 (17.4%) youth 8 (17.4%) residence in medically underserved area 6 (13.0%) disability 5 (10.9%) pregnancy 4 (8.7%) smoking 3 (6.5%) substance abuse 3 (6.5%) online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 140 table 2 details of studies from vulnerable populations in rural society systematic review citation findings location scientific merit / design sample defined rural vulnerable factors level of evidence adams et al. (2015) united states 18 quantitative descriptive 7,240 federal qualified health center (fqhc) sites in 1,612 counties yes medically underserved areas (mua), income, minority vi breast, cervical and prostate cancer mir differed significantly across fqhc access. atav and darling (2012) new york 16 quantitative descriptive correlation infants (day of birth, rural nys counties) yes pregnancy, infancy, low birthweight vi rural coding schemas demonstrated variation in results. baernholdt, et al. (2012) united states 19 quantitative retrospective 911 adult (age >65) yes minority, elder, lack of social connectedness, chronic illness iv older adults reported positive health quality of life (hqol). lower social function and hqol was found in rural dwellers. minority made a difference on 2 hqol subscales. banks et al. (2016) appalachia 26 qualitative yes income vi community had instinctive ability to preserve and utilize resources to overcome adversity in their vulnerability. bardach et al. (2012) kentucky 19 quantitative descriptivecorrelation 1,096 (age 50-76) yes income, education vi fewer accurate responses were associated with lower colorectal cancer guidelines and screenings. bernstein et al. (2016) maryland & massachusetts 24 qualitative 39 participants at 6 clinics in 2 states. no income, youth vi significant barriers to integration of oral care with primary care and federal qualified health centers. buerhaus et al. (2015) united states 22 quantitative cross sectional 972 clinicians (random, survey) no minority, uninsured, language vi primary care nurse practitioners are more likely than primary care medical doctors to practice in rural primary care, in a wider range of settings, treat medicaid recipients, and vulnerable populations. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 141 citation findings location scientific merit / design sample defined rural vulnerable factors level of evidence carter-edwards et al. (2015) north carolina 22 qualitative 45 no income, minority, elders, youth, chronic illness, education, disability, unsafe environment, smoking vi identified smoke-free considerations for structural, environmental, and policy health promotion initiatives. coleman et al. (2012) virginia 17 quantitative 10 clinical teams of ed staff yes only rural vi team and clinical scores were not significant between hospitals. significant correlations with team and clinical scores were seen in acute coronary syndrome, abdominal aortic aneurysm, and non-accidental trauma. crain et al. (2012) north carolina 19 quantitative descriptive correlation 69 farmworkers (farm camps) yes minority, chronic illness, farm workers, immigrant status, education iv rural health care providers are likely to confront poor mental health when providing care to latino farmworkers. demattei et al. (2012) illinois 14 quantitative descriptive correlation 234 children (attend special education school) no youth, disability iv positive benefits were found for special needs children and oral health care experiences were found for dental hygiene students. eshofonie et al. (2015) texas 15 quantitative descriptive expost facto 34 cases (2012, pertussis dx) no youth iv pertussis increase in one county in 2012 compared to 2009-2011. all cases were vaccinated; closeness to schedule not examined. fan et al. (2013) washington 13 quantitative cohort 149,110 (work injury) yes disability iv claim rates could improve evaluation of the effect of geographic difference on disability. faul (2014) kentucky 17 quantitative cross sectional 296 adult (>50 yr., lowincome community) no income, elders vi online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 142 citation findings location scientific merit / design sample defined rural vulnerable factors level of evidence major barriers related to access to healthy food and affordability. feltner et al. (2012) kentucky 16 quantitative pre post 637 (age ≥ 50, risk of colorectal cancer yes mua, income vi community health workers are effective at increasing colorectal cancer (crc) screening and knowledge of crc. galloway and henry (2014) colorado 16 quantitative crosssectional 144 yes lack of social connectedness vi social connectedness is important for patient centered care. goldman at al. (2013) north carolina, vermont, california & new hampshire 22 quantitative descriptive correlation 30,874 females (age >65, medicare, abnormal mammogram. rural and urban. yes income, minority, education. iv no differences found in the explanation of false positive mammography results for vulnerable women. goldman et al. (2012) (7 states) seven unspecified states 21 quantitative retrospective observation 139 facilities (women 4080 yr.) yes income, minority, education. iv a higher percentage of women using low-income and rural serving facilities did not undergo recommended follow-up care. gruca et al. (2014) iowa 19 quantitative retrospective observation visiting consultant database (2,172 oncology clinics) yes chronic illness iv visiting consultant clinic days staffed by iowa physicians increased access to cancer care for rural cancer patients. gullette et al. (2014) arizona 19 quantitative non-experimental descriptive 251 yes income, minority, chronic illness, risky sexual behavior vi identified that sexual sensation seeking is associated with transactional sex. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 143 citation findings location scientific merit / design sample defined rural vulnerable factors level of evidence horney et al. (2013) alaska, florida, georgia, north carolina, south carolina & tennessee 13 quantitative descriptive 76 emergency planners in fema region iv yes vulnerability defined by us census vi some vulnerabilities were overestimated by planners and others were not identified or underestimated. hsia and shen (2016) united states 20 quantitative nonexperimental correlation 1,738 pci centers yes income, minority vi timely access to percutaneous coronary intervention (pci), gold standard, a majority (58%) of rural residents live >60 minutes from a pci hospital. jablonski and duke (2012) texas 22 qualitative 10 nurses no elders, chronic illness vi perceived barriers to pain management include judgmental attitudes, lack of knowledge and skills, authoritative boundaries, and fears related pain management. jones and jerman (2013) united states 16 quantitative descriptive correlation 8,338 abortion patients yes mua, pregnancy iv there is a burden on poor rural women to access abortion services. joyce et al. (2013) ohio 16 quantitative retrospective longitudinal cohort 1650 (medicaid, age 5-17, depression treatment) yes income, youth, chronic illness iv inadequate follow-up was associated with being an adolescent, being disabled, and rural. joynt et al. (2013) united states 20 quantitative retrospective observation 3968 us hospitals (acute care, medicare, american hospital association data) yes chronic illness vi online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 144 citation findings location scientific merit / design sample defined rural vulnerable factors level of evidence mortality rates of critical access hospitals (cah) and non-cah were similar in 2002, but cah had higher mortality rate in 2010. klein et al. (2014) appalachia 22 qualitative descriptive design 27 participants yes unsafe environment, smoking vi identified themes on the barriers and facilitating factors in local smoke-free policy adoption. kogan et al. (2016) georgia 20 quantitative descriptive 505 aa men yes minority, adverse childhood experience, risky sexual behavior vi neglect is a predictor for risky behavior. relational schemas predicted the effect of adversity and neglect on risky sexual behaviors. komro et al. (2015) oklahoma 19 quantitative cohort part of rtc 1,562 students (9th & 10th grade) no minority, youth, substance abuse iv indicate a problem with increases in underage drinking and an ease of purchasing alcohol for minority youth. krukowski et al. (2012) arizona 19 quantitative descriptive 48 participants yes minority vi primary food stores are picked based on proximity, food availability and quality of food, and store characteristics. lemasters et al. (2014) west virginia 18 quantitative descriptive correlation 1,182 women 40 yrs. and older using bonnie's bus mammography screening. yes mua, income, education. vi women responding, “don’t know” to 5 yr. risk were more likely to be less educated, lower income, insured by medicaid and less knowledge about breast cancer. lópezcevallos et al. (2014) oregon 20 quantitative cross section latino, 18-25 yr. (387) yes minority vi medical mistrust was significantly associated with satisfaction with health care. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 145 citation findings location scientific merit / design sample defined rural vulnerable factors level of evidence lutfiyya et al. (2012) united states 17 quantitative descriptive correlation 5-17yr, asthma, national survey of child health (68,634) yes income, minority, youth, chronic illness vi hispanic and low-income school-aged children with asthma have greater odds of experiencing health service deficits. oser et al. (2013) kentucky 27 qualitative substance abuse treatment counselor (28) yes substance abuse vi causes, consequences, and prevention of burnout of substance abuse counselors: rural vs. urban comparison. pahor et al. (2014) (multisite) florida, illinois, louisiana, pennsylvania, massachusetts, north carolina, connecticut, california 22 quantitative rct age 70-89, sedentary lifestyle (1,635) no elders, disability, sedentary lifestyle ii persistent mobility was lower in the physical activity (pa) group. more adverse events were reported by those in pa than in higher education group. phillippi and myers (2013) southern united states 25 qualitative women, rural birthing center (29) yes pregnancy vi reasons women did not use centering pregnancy care(cpc): preferred one-on-one care, experienced barriers to cpc participation, and did not know about group care. samra et al. (2013) midwestern 19 quantitative descriptive correlation mother/infant dyads (28) yes mua, postpartum iv remote access to appropriate healthcare services elicits concerns for the late preterm infants. scogin et al. (2016) alaska 17 quantitative retrospective rural adult, ≥ 65 (134) yes minority, elders vi online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 146 citation findings location scientific merit / design sample defined rural vulnerable factors level of evidence engagement in pleasant events and hopelessness mediate how elderly view quality of life. shaw et al. (2015) washington 22 quantitative descriptive correlation women, complete pcap with consent (773) yes substance abuse, pregnancy iv rural dwellers reported more binge drinking and alcohol abuse at intake and program exit. tarasenko et al. (2014) kentucky 19 quantitative cross sectional age 50-75 (1,012) yes income, chronic, low ed. vi those with multiple morbidity (mm) believe comorbidities burdened factors regarding colorectal cancer screenings (crcs). rural residents reported fewer burdens; however, the overall negative association of mm and crcs remained. teufel et al. (2012) illinois 18 quantitative longitudinal cases (1152) yes hpsa & mua, income vi rural medical legal partnerships help eliminate barriers to healthcare of vulnerable and underserved. vyas et al. (2013) west virginia 19 quantitative crosssection female, age 40-88 (2,265) yes income iv bonnie’s bus mammography screening eliminated barriers to screening underserved. wenzel et al. (2012) central virginia and eastern maryland 27 qualitative aa older adults, age 7581(48) no income, minority, elders, chronic, education. vi older african americans’ financial barriers to care are insufficiently addressed even with insurance. wewers et al. (2012) ohio 18 quantitative descriptive correlation rural women (570) yes income, education., smoking vi low socioeconomic position (sep) women were more likely to smoke compared to high sep women. other smoking associated factors included age, depression and early first pregnancy. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.507 147 citation findings location scientific merit / design sample defined rural vulnerable factors level of evidence whitaker et al. (2013) united states 15 quantitative retrospective observation patients, age >40, dx colorectal cancer, had color/rectal surgery (62,206) no income, uninsured vi odds ratio showed vulnerable population 1.4 times more likely to have increased length of stay. wilhelm et al. (2015) nebraska 15 quantitative rct mothers, age 15-50 (53) no income, minority, education, postpartum period ii rural mexican american mothers indicated an intention and confidence in breastfeeding; most did not breastfeed for 6 months. abbreviations: abdominal aortic aneurysm (aaa); african american (aa); appalachian / appalachia (app); centering pregnancy care (cpc); centering pregnancy (cp); critical access hospital (cah); community health workers (chw); colorectal cancer /screenings(crc / crcs);; dental health (dh); federal qualified health center (fqhc); health education program (h.ed); health quality of life (hqol);health professional shortage area (hpsa); length of stay (los); mortality-to-incidence ratio (mir); medically underserved area (mua);medical-legal partnership (mlp); mexican american (ma); multiple morbidity (mm); odds ratio (or); percutaneous coronary intervention (pci); primary care medical doctor (pcmd); primary care nurse practitioner (pcnp), physical activity (pa); quality of life (qoli); randomized-controlled trial (rct) socioeconomic position (sep); visiting consultant clinic (vcc); visiting consultant database (vcd). rural codes 1 = topographical definitions such as rucc, ruca etc.; 2 = conceptual not operational definition; and 3 = no definition. 507_newrural vulnerable march 6 2018_graves edits042618 507_rural vulnerable march 6 2018_graves edits042618-_tables sundeen_602_formatted online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 6 leveraging the annual wellness visit to improve rural depression management emily sundeen, dnp, fnp-bc 1 warseal powell, dnp, fnp-bc2 robert deuell, md3 1 family nurse practitioner, hunt memorial hospital district and hunt regional medical partners, esundeen@huntregional.org 2 assistant professor, community mental health, university of south alabama college of nursing, warsealpowell@southalabama.edu 3 medical director, hunt regional medical partners, rdeuell@huntregional.org abstract purpose: depression is a common condition in rural primary care associated with significant adverse health and quality of life outcomes. despite evidence-based practice recommendations, depression screening and follow-up are inconsistent in practice. the purpose of this quality improvement project was to improve the rate of depression screening and management as a component of the annual wellness visit (awv) in the rural, primary care setting. the overarching project aim was to increase the rate of depression screening and treatment in adult medicare patients by 50% through the implementation of a standardized screening instrument and management plan within eight weeks of project implementation. sample: the sample population included 66 medicare beneficiaries receiving a medicare annual wellness visit at a primary care practice in rural northeast texas. method: the central focus of this quality improvement project was to initiate standardized depression screening and management in the medicare population as a component of the annual online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 7 wellness visit. patients were screened for depression using the patient health questionnaire-9 (phq-9) instrument. an evidence-based depression management plan based on the phq-9 score guided follow-up and management. findings: when depression screening was performed as a component of the awv, 98.5% of patients received depression screening with a validated instrument. 73.3% of patients who had a phq-9 score of five or greater had a documented follow-up plan, and 93.3% had recommended treatment initiated. a strong positive correlation was found among patients who screened positive for depression and received a documented follow-up plan (rho (63) = .993, p <.001) and had treatment plan initiated (rho (63) = .998, p <.001). conclusions: implementing standardized workflows, such as the annual wellness visit, is foundational to consistently identify and treat depression to remission in the rural primary care setting. keywords: depression, screening, preventive services, patient health questionnaire-9, annual wellness visit. leveraging the annual wellness visit to improve rural depression management major depressive disorder (mdd) is the most prevalent psychiatric illness in the united states (u.s.) (akincigil & matthews, 2017). according to the american psychiatric association (apa) (2013), hallmark features of depression persisting for longer than two weeks include a depressed mood, hopelessness, and loss of interest in usual activities. depression is an incapacitating illness linked with multiple adverse outcomes, including higher rates of self-harm, morbidity, mortality, and the inability to manage self-care (kim et al., 2015). depression is often online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 8 a confounding condition in individuals with other chronic diseases and has a substantial impact on the individual’s overall physical health and quality of life (pruchno et al., 2016). only half of individuals in the primary care setting with depression receive treatment and follow-up despite effective treatment options (picardi et al., 2016). to improve depression screening and management in the primary care setting, a quality improvement (qi) project was developed to incorporate depression screening and management as a component of the medicare annual wellness visit (awv). the central focus of this improvement project was to initiate standardized depression screening in the medicare population during the awv to improve rates of depression screening and treatment. the specific aims of the project were to (1) educate clinical staff on depression screening and management, (2) perform the patient health questionnaire-9 (phq-9) (patient health questionnaire screeners, 1999) depression screening as a component of the awv, and (3) initiate an evidence-based depression management plan with patients who screen positive for depression. a directed practice question was developed to address the identified problem as: will the implementation of a standardized depression tool in adult medicare patients at an awv improve early identification and treatment of depression in eight weeks? depression related disparities depression in the united states and texas depression is a chronic condition impacting approximately one in ten individuals in the united states (akincigil & matthews, 2017). the prevalence of depression increases with advancing age and co-occurring chronic conditions, with approximately 25% of adults over the age of 60 experiencing depression (pruchno et al., 2016). national and state aggregate data on the online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 9 scope of depression and mental health disparities illustrate an urgent need for improvement. according to the national alliance on mental health (2018), approximately 7% of americans live with major depressive disorder. texas ranks 39th out of 50 states in mental illness prevalence and 49th in access to mental healthcare (mental health america [mha], 2018). most worrisome, texas ranks first in states with the highest prevalence of adults with serious thoughts of suicide (mha, 2018). depression in hunt county local and practice site-specific data analysis also supports the need for rapid improvement. hunt county is classified as a health professional shortage area and a medically underserved area (u.s. department of health and human services, 2018a and 2018b). according to the university of wisconsin population health institute (uwphi) (2018), hunt county is significantly below the texas average in healthcare providers. the hunt county ratio of patients to primary care physicians is 3,100:1 versus the texas average of 1,670:1 (uwphi, 2018). the hunt county ratio of patients to mental health providers is 1,560:1 compared to the state average of 1,010:1 (uwphi, 2018). additionally, rates of depression in the medicare population in hunt county is 21.5%, significantly higher than the state average of 17% and the u.s. average of 16.7% (dallas fort worth hospital council foundation, 2018). site-specific data obtained from electronic health record data reflects that in 2018, the practice site provided primary care for 6,176 unique patients. of those, 14% of the patient population had an icd-10 code for depression on their active problem list. the payor mix at the practice setting is 26% traditional medicare, resulting in 1,605 medicare beneficiaries eligible for an awv. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 10 defining the rural population approximately 60 million americans or 17% of the country’s population live in a rural area (bolin et al., 2015). the definition of a rural is multidimensional and complex. according to the u.s. census bureau, rural is “what is not urban” (ratcliffe et al., 2016). factors used to classify rural locations include population thresholds, population density, land use, and distance to urban development. more specifically, rural is defined as a geographic area with 50,000 or fewer people and a population density of fewer than 1,000 people per square mile (ratcliffe et al., 2016). according to the national rural health association (2019), rural communities experience significant obstacles to healthcare, including social isolation, poverty, and geographic factors. rural populations also experience healthcare disparities related to the lack of access to mental health providers (mental health america, 2018). rural healthy people 2020 have identified the highest priority health challenges in rural america include (1) access to healthcare, (2) nutrition/obesity, (3) diabetes, (4) mental health disorders, and (5) substance abuse (bolin et al., 2015). the practice setting of the qi project is located in hunt county, which is designated as urban in the dallas-fort worth metropolitan area (texas department of agriculture, 2016). four rural counties border hunt county, none of which have a hospital. as a regionally integrated health system, the system provides care to the population in the four bordering rural counties. the primary care division includes five clinics located throughout hunt county. two of the clinics are certified rural health centers to provide healthcare for the rural and medically underserved population (medicare learning network, 2018). the operational definition of rural for this qi project is a healthcare organization serving a rural population. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 11 review of the literature u.s. preventive services task force recommendations the u.s. preventive services task force (uspstf) was formed in 1984 as an expert, volunteer panel to develop evidence-based recommendations regarding preventive health interventions (u.s. preventive services task force, 2019). the mission of the uspstf is to standardize and disseminate evidence-based preventive services to improve the overall health of the population (kurth et al., 2018). despite extensive dissemination efforts, variations in clinical practice and implementation gaps remain. currently, americans receive only approximately half of the recommended preventive health services, illustrating a significant variation in evidencebased care (kurth et al., 2018). the annual wellness visit over the past decade, the value of an annual physical exam in asymptomatic adults has been called into question. according to gorbenko et al. (2017), multiple professional organizations and payors alike note that an annual physical exam leads to unnecessary diagnostic studies with no associated reduction in morbidity. proponents of an annual preventive visit argue that personalized encounters targeting age and health-status appropriate interventions are associated with improved health outcomes and adherence with recommended preventive services (gorbenko et al., 2017). in response, the centers for medicare and medicaid services (centers for medicare and medicaid services [cms], 2018b), has introduced the awv as a preventative service encounter dedicated to preventive services covered at 100% by medicare. to date, there is little research regarding the effectiveness of the awv to improve adherence with uspstf recommended online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 12 preventive services. a recent retrospective, observational study concluded that patients who receive an awv were 62% more likely than non-recipients to receive recommended cancer screenings (camacho et al., 2017). notably, the study also demonstrated that awvs improved disparities in preventive services in low-socioeconomic and rural populations. depression screening and management best practices a review of the literature revealed evidence-based strategies to improve depression identification and management in the primary care setting including (1) educating and training clinical staff regarding depression, administering the patient health questionnaire-9 (phq-9) screening, and initiating the depression management plan; (2) standardized depression screening; (3) utilizing a validated instrument to identify clinical depression; and (4) integrating depression screening into the electronic health record (ehr). there is widespread, expert consensus in the literature supporting routine depression screening and subsequent ongoing management in the adult, primary care population (american psychiatric association [apa], 2010; trangle et al., 2016; uspstf, 2019). research also supports standardized, routine depression screening utilizing a validated instrument to identify clinical depression in the primary care setting (apa, 2010; picardi et al., 2016; uspstf, 2019). ehr optimization by embedding depression screening into the ehr workflow is associated with improved depression screening consistency (aleem et al., 2015; bajracharya et al., 2016; trangle et al., 2016). the objective of the institute for clinical systems improvement (icsi) health care guideline: depression in primary care is to guide primary care providers in designing systems and processes to detect, treat, and manage depression (trangle et al., 2016). the guidelines focus recommendations on patient-centered care, collaborative multidisciplinary care, care coordination, online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 13 and ongoing outcome evaluation. guideline recommendations include: (1) routinely screening all adults for depression using a standardized instrument; (2) pharmacologic, psychotherapy, and behavioral interventions; (3) arranging treatment and follow-up; and (4) incorporating shared decision-making with the patient. the guidelines also include a depression management plan based on the severity of depression as determined by the apa diagnostic depression criteria and the phq-9 score (trangle et al., 2016). framework quality improvement model the model for improvement methodology incorporating plan, do, study, and act (pdsa) cycles was used as a guide to direct project interventions and accelerated improvement (langley et al., 2009). the first phase, planning, entailed stakeholder engagement to define the practice problem, collecting baseline depression screening and follow-up rates, and developing objectives and associated interventions. the do phase included clinician education, ehr optimization, depression screening utilizing the phq-9, and initiation of the depression management plan. the next study aspect of the cycle encompassed analyzing outcomes and evaluating if the change resulted in the desired state. the final step of the cycle, act, included ongoing evaluation, continued implementation at the pilot clinic, and planning implementation at all system primary care practice sites. evidence-based practice model evidence-based practice (ebp) models provide a framework to translate research into practice (polit & beck, 2017). according to schaffer et al., (2013), the johns hopkins nursing evidencebased nursing (jhnebp) model is beneficial in providing structure to translate best practices into care delivery. the jhnebp model (2017) is formed around the acronym pet, representing the model online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 14 processes: practice question, evidence, and translation. the depression practice question was fully developed by establishing the population, intervention, comparison, and outcomes (pico). evidence processes included critically appraising the evidence and then designing interventions from evidencebased best practices. evidence translation occurred through project implementation to ultimately improve depression-related health outcomes. theoretical underpinnings the neuman systems model (nsm) (neuman systems model, inc., 2005) is a theoretical framework focused on the individual’s relationship with the environment, stressors, lines of defense, and establishing stability. the nsm is especially applicable in mental health because the individual is conceptualized as a unique, dynamic individual responding to internal and external factors to establish and maintain balance (whetsell et al., 2015). the nsm is a useful framework to guide wellness interventions concerning prevention (fawcett & foust, 2017). primary prevention relates to strengthening the lines of defense and reducing the impact of stressors. secondary prevention encompasses screening for depression. tertiary prevention involves treating depression to obtain remission and the return of optimal wellness. project purpose the purpose of this qi project was to improve the rate of depression screening and subsequent management as a component of the awv in the primary care setting. the project aim was to increase the rate of depression screening and treatment in adult medicare patients by 50% through the implementation of a standardized screening instrument within eight weeks of project implementation. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 15 project design and methodology ethical considerations according to the uspstf (2016), routine depression screening is associated with small to no potential for patient harm. no permission is required to reproduce or utilize the phq-9 depression screening instrument (patient health questionnaire (phq) screeners, 1999). prior to implementation, the student researcher received exempt review approval from the university of south alabama institutional review board (assurance number fwa 00001602, irb database #00000286, project #1423485-1). participants the sample population for the project was a convenience sample of readily available patients at the pilot primary care practice site who received an awv. participant inclusion criteria included patients who received an awv, were older than age 18, and were medicare beneficiaries. exclusion criteria were any patient who declined the awv or was not a medicare beneficiary. setting the practice setting was a primary care clinic owned and operated by an integrated health hospital system. the health system includes a regional hospital, five primary care clinics, and multiple specialty clinics in rural northeast texas. the system is in the second year of joining a larger, national accountable care organization (aco). the aco is participating in the medicare shared savings program to improve the quality of healthcare delivery, facilitate population health, and decrease healthcare expenditures (cms, 2018c). the primary care practice sites have implemented awvs as a targeted method to improve health promotion and quality outcomes. the qi project was piloted at the largest primary care site for system-wide implementation. clinical online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 16 staff at the pilot clinic include two family practice physicians, two nurse practitioners, one physician assistant, four medical assistants, and one population health nurse. instrument the qi project utilized the phq-9 instrument to assess and monitor depression. the phq9 is a patient-reported, psychosocial instrument developed to detect the diagnostic symptoms of depression (spitzer et al., 1999). the phq-9 questionnaire consists of nine questions measuring the presence, severity, and frequency of depressive symptoms. the phq-9 can be used for both detecting and monitoring depression severity facilitating consistent and reliable monitoring (kroenke et al., 2001). there is compelling support for utilizing the phq-9 for depression screening and management by practice guidelines (apa, 2010; trangle et al., 2016; uspstf, 2016). endorsement of the phq-9 is primarily due to the instruments reliably reflecting consistency and validity indicating accuracy. according to the instrument’s developers, the phq-9 internal reliability was calculated at 0.89 using cronbach’s alpha coefficient (kroenke et al., 2001). the phq-9 diagnostic validity was evaluated by meta-analysis; it demonstrated a pooled sensitivity of 0.76 and a pooled specificity of 0.92 (moriarty et al., 2015). operational design and interventions using the pdsa methodology, project planning included collaborating with key stakeholders to identify gaps in current practice and gain the support of the change. a gap analysis was then undertaken to differentiate the current state of depression screening and management from the desired future state. a comprehensive review of the literature regarding depression online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 17 screening and management was then undertaken to design the interventions utilizing evidencebased best practices. the operational do phase of the improvement cycle entailed implementing project interventions. preparatory interventions that occurred before implementation included staff education and ehr optimization. education was targeted towards clinical staff regarding depression, administering the phq-9 screening, and initiating the depression management plan. education was conducted by the advanced practice nurse researcher utilizing the montana geriatric education center’s screening for depression in older adults module (2014). knowledge was evaluated with a pretest and posttest. ehr optimization entailed collaborating with the onsite population health nurse (who is also an ehr administrator) to embed the phq-9 screening and depression management plan directly into the ehr. the institute for clinical systems improvement (icsi) health care guideline: depression in primary care depression treatment plan components of (1) pharmacologic, (2) psychotherapy, and (3) behavioral interventions were embedded into the ehr as discrete fields with corresponding orders and referrals. care delivery interventions included: (1) performing standardized depression screening utilizing the phq-9 instrument as a component of the awv; and (2) initiating the icsi depression treatment plan based on the phq-9 score where indicated. patients were scheduled for an awv by clinic staff if an awv encounter had not been provided in the previous 12 months. patients were asked to present to the clinic 30 minutes before their appointment time to complete medical history update forms. the office staff provided the history update forms, including the phq-9 instrument to the patient to be completed in the waiting room. the medical assistant then roomed the patient, reviewed the phq-9 assessment findings with the patient, and entered the phq-9 score online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 18 into the ehr intake section. patients with a phq-9 score of five or greater were then further evaluated by the primary care provider for clinical depression by assessing risk factors, history, the potential for self-harm, and diagnostic criteria. complex decision points were derived from the severity of depression and terminate with treatment and establishing a follow-up plan. data analysis the study phase of the improvement cycle included evaluation of the qi project objectives and associated quality performance measures. quality measures included structural measures reflecting evaluating capacity, process measures evaluating method steps, and outcome metrics indicating the effect of the intervention (donabedian, 2005). structural measures included the presence of the phq9 score and depression management plan embedded in the ehr. process measures included depression screening as a component of the awv, expressed as a percentile rate. the numerator was patients screened for depression with the phq-9 instrument, and the denominator was all patients receiving an awv. adherence with depression management recommendations was measured as a percentile rate where the numerator was patients who score five or greater on the phq-9 who have a management plan initiated and follow-up arranged, and the denominator was all patients with a phq9 score of five or greater. an outcome-based performance measure was selected to evaluate learner knowledge following project education with a pretest and posttest. the qi project included methods to ensure data accuracy to safeguard the integrity of findings. electronic health record documentation facilitated data collection by enabling ehr-generated reports to capture discrete data points, including the phq-9 score, a documented follow-up plan, and treatment. a data abstraction tool was utilized to ensure complete information was collected from the ehr. statistical analysis was performed using ibm spss version 24 software to compute and online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 19 transform the data into interpretive findings (cronk, 2018). descriptive statistics, including frequency distribution and measurements of central tendency, was calculated to summarize ordinal data. a correlational analysis was then performed to identify the strength of the association between patients who had a positive depression screening and received a documented plan for follow-up and had the depression treatment plan initiated. results the first project objective was to educate and train clinical staff regarding depression, administering the phq-9 screening, and initiating the depression management plan as demonstrated by posttest score of 80% or greater within two weeks of project implementation. clinical staff education was conducted utilizing the montana geriatric education center’s screening for depression in older adults module (2014). knowledge was evaluated with a pretest and posttest within the module content regarding depression, administering the phq-9 screening, and initiating the depression management plan. an outcome-based performance measure was selected to evaluate learner knowledge following project education with a pretest and posttest. the sample size included nine clinicians. a paired-samples t-test was calculated to compare the mean pretest and posttest. the mean pretest score was 58.89 (sd = 18.33), and the mean posttest score was 93.33 (sd = 8.66). a significant increase in scores from the pretest and posttest was found (t (8) = -7.750, p <.001). the second project objective was to perform the phq-9 depression screening assessment in 80% of medicare patients in primary care receiving an awv within eight weeks of project implementation. process performance measures included depression screening as a component of the awv, expressed as a percentile rate. the numerator was patients screened for depression with the online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 20 phq-9 instrument, and the denominator was all patients receiving an awv. the sample size included 66 medicare beneficiaries who received an awv during the eight-week implementation period. the sample population gender distribution was 54.5% female and 45.5% male. the participant mean age was 73.77 (sd = 8.927). the median age was 72, with a range of 58 years. of the 66 participants who received an awv, 65 participants (98.5%) received depression screening using the phq-9 tool. the mean phq-9 score was 2.86 (sd = 3.665), and the median was 2.0 with a range of 15 points. the third project objective was to initiate the depression treatment plan in 50% of patients receiving an awv who screen positive for depression as indicated by a phq-9 score of five or greater within eight weeks of project implementation. a phq-9 score of five or greater was considered a positive screening indicating potential depression. of the patients receiving a phq9 screening, 15 patients (23.1%) had a positive screening. crosstabulation analysis was performed to determine the rate of patients who screened positive for depression and received the recommended treatment. eleven (73.3%) of the 15 patients who had a phq-9 score of five or greater had a documented follow-up plan, and 14 (93.3%) had recommended treatment initiated. a spearman rho correlation coefficient was calculated to determine the presence of a relationship between a phq-9 of five or greater and documented follow-up and treatment plan initiated. a strong positive correlation was found with a documented follow-up plan (rs (63) = .993, p <.001) and treatment plan initiated (rs (63) = .998, p <.001), indicating a significant relationship between the variables. patients with a positive depression screening as a component of the awv tended to receive documented plans for follow-up and have a treatment plan initiated. crosstabulation analysis was used to determine the type of depression treatment initiated. of the 15 patients with online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 21 a positive phq-9 screening, 83% received brief counseling, 13.33% received pharmacotherapy, and 6.67% received no treatment. summary the overarching aim of the qi project was to increase the rate of depression screening and treatment in adult medicare patients by 50% through the implementation of a standardized screening instrument within eight weeks of project implementation. performing depression screening and management as a component of the awv was a new process at the practice; therefore, there was no true baseline comparison. to evaluate overall project effectiveness, the 2018 merit-based incentive program (mips) performance on aco-18: prevention care and screening for clinical depression and follow-up plan was used as a comparison (cms, 2018a). in 2018, 34.29% of patients at the practice site received depression screening and a documented follow-up plan. when depression screening and management was performed as a component of the awv, 98.5% of patients received depression screening, 73.3% of patients with a positive depression screening received a plan for follow-up, and 93.3% of patients with a positive depression screening received recommended treatment exceeding the project aim. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 22 table 1 summary of findings summary of findings aim: increase the rate of depression screening and treatment in adult medicare patients by 50% through the implementation of a standardized screening instrument within eight weeks of project implementation. objective 1: educate clinical staff on depression screening and management associated interventions performance measure goal findings achievement educate clinical staff on depression screening and management and evaluate with a pretest and posttest. outcome greater than 80% paired-samples t-test mean pretest score 58.89 (sd = 18.33) mean posttest score 93.33 (sd = 8.66) met a significant increase in scores from the pretest and posttest was found (t (8) = -7.750, p <.001). objective 2: perform the health questionnaire 9 (phq9) depression screening associated interventions performance measures goal findings achievement embed the phq-9 screening into the electronic health record structural present completed met perform depression screening using the phq-9 tool as a component of the awv. process greater than 80% 98.5% (n= 65) the mean phq-9 score was 2.86 (sd = 3.665), the median was 2.0 with a range of 15 points met objective 3: initiate an evidenced-based plan with patients who screen positive for depression associated interventions performance measures goal findings achievement embed the depression management plan into the electronic health record structural present completed met online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 23 initiate the depression management plan in patients who have a positive phq-9 score of 5 or greater process greater than 50% follow-up plan: 73.3% (n= 15) recommended treatment initiated: 93.3% met significant spearman rho correlation coefficient phq-9 of 5 or greater and follow-up plan (rs (63) = .993, p <.001) phq-9 of 5 or greater and treatment plan initiated (rs (63) = .998, p <.001) limitations the project study design included convenience sampling to boost participant accessibility. utilization of convenience sampling may create potential bias, thereby reducing the generalizability of findings (polit & beck, 2017). the relatively small sample size and narrow geographic location were also project limitations that may limit the generalizability of the findings. practice implications qualitative research has demonstrated that healthcare consumers have an overall low-level knowledge of recommended preventive services; however, they have a strong preference for shared decision-making regarding preventive services (lantz et al., 2016). the awv is a dedicated platform to educate patients on preventive services so they can make informed decisions regarding their care. research has also demonstrated that simple, low-cost interventions, such as email reminders, formal education, individual performance feedback, and environmental prompts, when used together are effective at improving guideline adherence (egger et al., 2017). according to mabry-hernandez et al. (2018), implementation and translational research is needed to identify effective processes and workflows to facilitate adherence with uspstf recommendations in primary care. healthcare system barriers related to adherence gaps include the volume of primary care recommendations, time constraints, clinician familiarity with current online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 24 recommendations, and the lack of structured workflows to address preventive services (mabryhernandez et al., 2018). as of 2015, approximately 60% of primary care providers are employed by healthcare systems (american academy of family physicians, 2015). healthcare systemrelated strategies that promote guideline adherence include multilevel review processes, extensive use of health information technology that incorporate electronic templates and prompts, widespread communication, performance-based financial incentives, individual, real-time feedback, and most importantly provider engagement (doherty et al., 2018). primary care providers are uniquely and favorably positioned to detect, diagnose, and manage depression. innovative solutions are needed in the rural population to reduce variation in clinical practice related to depression diagnosis and treatment. incorporating depression screening and management as a component of the awv in the primary care setting is an intervention that will improve access to mental healthcare in rural communities. implementing depression screening and follow-up in tandem with the awv is a structured method to translate evidence into improved outcomes. routine depression screening is not a new intervention; however, utilizing the awv to deliver screening in a more consistent manner is an innovative approach. conclusion depression is a debilitating, chronic illness, which negatively impacts both mental and physical health. depression is a common condition in the primary care setting that often goes undetected. interventions are needed to improve access to healthcare and mental health disparities in the rural population. implementing standardized workflows in the primary care setting, such as the awv, is foundational to consistently identify and treat depression toward remission. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.602 25 references akincigil, a., & matthews, e. b. 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(2 ed., pp. 407-434). burlington, ma: jones & bartlett. grubbs_632_formatted online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 4 prepare-ing south dakota farm and ranch women for advance care planning theresa garren-grubbs, dnp, rn, cmsrn, cnl1 marijo letizia, phd, rn, apn/anp-bc, faanp2 mary minton, phd, rn, cns, chpn3 1 clinical assistant professor, college of nursing, south dakota state university, theresa.garrengrubbs@sdstate.edu 2 professor, marcella neihoff school of nursing, loyola university chicago, mletizi@luc.edu 3 volunteer faculty, south dakota state university, mary.minton@sdstate.edu abstract purpose: evaluate the impact of an advance care planning (acp) educational session utilizing prepare for your care for south dakota farm and ranch women and its ability to increase engagement in acp and documentation of medical wishes in the form of an advance directive. sample: a convenience sample of women (n = 23) represented members of the farm and ranch community in south dakota who were participating in the power of women as agvocates conference. inclusion criteria for this study included being 18 years old or older, female, and conference participation. exclusion criteria included men and those under the age of 18. method: this was a cross-sectional investigation, consisting of three phases, and included comparisons of the same sample population before and after an acp intervention at different time intervals (baseline, 1 week after the educational session and 3 months after the educational session). increased engagement in acp was evaluated using a pre-test, post-test design and utilized online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 5 the 15-item advance care planning engagement survey. demographic information including age and highest level of education completed was collected. findings: in total, 23 women participated in the education session. the median age range was 3544 years of age. there were statistically significant increases in self-efficacy and readiness to complete acp reported by participants. the objectives of this education session were met. per the participants, this was an effective format for acp. advance directive completion rates did not increase. conclusions: the use of prepare for your care during an education session on acp can increase self-efficacy and readiness to engage in acp. the format of this program is appropriate for future use in community settings with the farm and ranch population. keywords: advance care planning, farm and ranch women prepare-ing south dakota farm and ranch women for advance care planning the institute of medicine (iom) recommended that care at the end-of-life (eol) include person-centered, family oriented, and evidence-based approaches (institute of medicine [iom], 2015). to achieve this goal, advance care planning (acp) conversations and written documentation regarding a person’s eol wishes are needed. these acp conversations and associated written documents are imperative in order to avoid costly care inconsistent with the patient’s wishes (heyland et al., 2013). advance directives (ads) are patient-initiated documents and include living wills and documents naming a healthcare agent (iom, 2015). these documents may include an individual’s wishes related to medical treatments and procedures. advanced care planning is an extension of ads and includes the completion of ad documents in combination with discussions of eol care (iom, 2015). conversations involving acp are not a one-time event, but instead a part of a process online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 6 which occurs on a continuum (sudore, lum et al., 2017a). advance care planning provides a focus on preparing patients and decision makers with the skills needed to identify and communicate which treatments align with the patient’s goals of care in relation to the specific circumstances experienced by the patient. importance of acp and ads in south dakota despite national recommendations, a gap exists in establishing and meeting the goals of care of american adults, particularly among ethnic minorities, veterans, the disabled, and those living in geographically isolated regions (wicks et al., 2018). as an example, the number of adults living in south dakota that have an ad reflect the national rates. a statewide sample of 2,533 adults completing a survey in the, “south dakota’s dying to know” initiative, revealed that only 35% had completed some form of ad (schrader et al., 2009). more recently, the south dakota department of health (2015), through the behavioral risk factor surveillance system, also reported that only 31% of south dakotans stated they had an ad. a recent survey conducted by the conversation project indicated that 32% of american adults have had eol conversations (“the conversation project,” 2018). even though 90% of american adults think it is important to have such discussions, 68% of americans have not participated in these conversations (“the conversation project,” 2018). in south dakota, 89% of individuals noted that they were somewhat or very comfortable discussing dying, but preferred the conversations be initiated by family or professionals such as healthcare providers or clergy (schrader et al., 2009). lack of knowledge is a significant barrier to acp for many (rao et al., 2014), thus, education on the topic is one approach to helping people take steps towards engaging in acp. education, online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 7 particularly in the community setting before a crisis, provides an opportunity with minimal capital expenditures. rural context a variety of definitions reflect the diversity of rurality. the u.s. census bureau definition of rural guided this project with rural defined as, “all population, housing, or territory not included within an urban area” (u.s. census bureau, n.d.). in south dakota, approximately 43.3% of the 814,180 residents lived in a rural area in 2010 (u.s. department of commerce, 2012). the number one industry in south dakota is agriculture. of the farms in south dakota, 98% are family owned and operated (sd department of agriculture, n.d.); therefore, changes in health status for farmers and ranchers can impact the sustainability of farm and ranch operations. with the high percentage of south dakotans participating in farming and ranching, the importance of acp is paramount. farming and ranching livelihood increases work hazards related to heavy machinery and livestock (sd safety council, n.d.). this hazardous work environment can lead to life-altering and life-threatening accidents and can increase the need for acp, especially in younger populations. purpose this program evaluation study included the development and implementation of an education session entitled, “conversations that matter: advance care planning for rural women” during a conference for south dakota women in agriculture called the power of women as agvocates conference. the session included the use of the evidence-based program “prepare for your care” (also referred to as “prepare”). the institutional review boards at south dakota state university and loyola university chicago reviewed this project. both institutions deemed the project exempt. online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 8 the purpose of this project was to evaluate the impact of an acp educational session for south dakota farm and ranch women and its ability to increase engagement in acp and increase documentation of medical wishes in the form of an ad. the program was also evaluated for future use with south dakota state university (sdsu) extension for acp. three objectives guided this project: develop and implement an acp educational session with rural farm and ranch women; evaluate the acp educational session for increased engagement in acp and documentation of medical wishes and eol wishes by rural farm and ranch female participants; and, evaluate the educational session at three time points. the power of women as agvocates conference is presented annually by sdsu extension and annie’s project. as a land grant university, south dakota state university’s mission is focused on teaching, research and extension. south dakota state university extension is the link between university researchers and county extension agents to aid in the dissemination of information to the community (national research council, 1995). annie’s projecteducation for farm women, is one of the many educational programs provided through sdsu extension. annie’s project is designed to provide education to strengthen the role of women in modern farm enterprises (“annie’s project,” n.d.). annie’s project provides educational opportunities through 6-week workshops throughout the state as well as this annual conference. theoretical framework the model chosen to guide this project was the transtheoretical model. the model identified behavior change, much like acp, as a process. a person moves through six different stages when attempting to change a behavior: precontemplation, contemplation, preparation, action, termination, and maintenance (national cancer institute, 2005). online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 9 prochaska et al. (2015) identified an individual moves through multiple stages when making a change. initially, an individual does not have enough information to change (precontemplation). as an individual gains information, the process of behavior change begins: the individual acquires information, contemplates the change, prepares for the change, acts, and maintains the change (prochaska et al., 2015). evidence-based intervention prepare for your care prepare for your care is a patient-centered, step-by-step web-based guide that is used to teach people the skills needed to identify life goals and medical care preferences within their current context and communicate these wishes to surrogate decision makers and providers (sudore, knight et al., 2014). the program has five steps: choose a medical decision maker, decide what matters most in life, choose flexibility of your decision maker, tell others about your wishes, and ask doctors the right questions. this program has been used independently and in group settings and includes written and video information and scenarios with interactions between actors demonstrating the steps of acp. for use in group settings, prepare includes a workbook which allows participants to write down their answers to the questions presented within each scenario. previous research has indicated increased engagement in acp overtime along with higher rates of ad documentation with the use of prepare (cresswell et al., 2018; sudore, boscardin et al., 2017b; zapata et al., 2018). advance care planning engagement survey development and documentation of an ad has been the gold standard for determining the success of acp interventions (howard et al., 2016; sudore, stewart et al., 2013). however, acp is a process, meaning ads alone are not enough to evaluate acp interventions. the advance care online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 10 planning engagement survey (acpes) was developed to measure the impact of acp interventions on engagement by measuring changes in behavior (howard et al., 2016). engagement in acp is affected by behavioral change processes. engagement in these processes (knowledge, contemplation, self-efficacy, and readiness) leads to actions in acp. based on this information, the acpes has two sections: process and action measures (sudore, stewart et al., 2013). the original 82-item acpes has demonstrated reliability and validity along with strong psychometric properties, however the length of the survey decreases its utility in research and clinical settings. five shorter versions of the survey were created. each of the shorter versions is focused on process measures only. the 15-item survey, which was used for the current study, had a cronbach’s alpha of 0.92 (sudore, heyland et al., 2017c). responses to questions on the acpes are on a 5-point likert scale and measure readiness for change and self-efficacy. readiness questions correspond to the person’s stage of change in relation to the transtheoretical model. self-efficacy questions measure a person’s confidence in themselves related to certain acp behaviors. scores on the survey are reported as an average for each question, each domain (medical decision maker, what matters most in life, flexibility for surrogate decision making, and asking questions of medical providers), and each process measure (readiness and self-efficacy). design and methods this was a cross-sectional investigation, consisting of three phases, and included comparisons of the same sample population before and after an acp intervention at different time intervals (baseline, 1 week after the educational session and 3 months after the educational session). increased engagement in acp was evaluated using a pre-test, post-test design and utilized online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 11 the 15-item acpes. along with the acpes, participants were asked, “have you signed official papers to put your wishes in writing about the kind of medical care you would want if you were very sick or near the end of life? these forms are sometimes called an advance directive, durable power of attorney for healthcare, or living will.” demographic information including age and highest level of education completed was collected at the education session. the setting for this study was the power of women as agvocates conference held in january 2020 in south dakota. this community setting engages women in agriculture in south dakota who come together to learn about issues including estate and transition planning along with advance care planning. the registration fee for participants was $50. a convenience sample of women (n = 23) represented members of the farm and ranch community in south dakota who were participating in the conference. inclusion criteria for this study included being 18 years old or older, female, and conference participation. exclusion criteria included men and those under the age of 18. this acp education session was a part of a larger conference. recruitment for the conference was completed through sdsu extension. the conference was advertised at different events throughout the state, through e-mail lists of past annie’s project participants, information on the sdsu extension website, and media releases to newspapers and radio stations. the conference was also promoted on the sdsu annie’s project facebook page. as mentioned previously, the study consisted of three phases. phase 1 included the collection of baseline data. after registration ended for the conference, each participant received an e-mail asking her to complete the acpes prior to conference attendance. participants could choose not to complete the survey. participants had four weeks to complete the survey prior to conference. the participants received four reminder e-mails. online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 12 phase 2 consisted of the education session “conversations that matter” at the conference. this session was an hour and a half in length. the participants viewed the videos for steps 1-3 of prepare (choosing a medical decision maker, what matters most in life, choose flexibility for your decision maker). participants were encouraged to write their answers down to each question during each module in the companion workbook to keep for use after the conference. after each step, participants had the opportunity to ask any questions related to the step. upon completion of steps 1-3 participants were introduced to the topics covered by steps 4 and 5 and how to access them online, but they were not covered during the program due to time constraints. sample ad forms were provided for each participant. the process for filling out an ad form was reviewed with participants. participants then had the opportunity to ask any remaining questions. immediately following the completion of the program, participants were asked to complete the educational session evaluation form. phase 3 consisted of data collection after the conference. one week after the education session, participants were e-mailed and asked to complete the acpes. participants had one week to complete this survey and participants received two reminder e-mails. three months after the education session participants were again emailed to complete the same survey. participants had one week to complete this survey and received two reminder e-mails. to encourage participation in each survey, the participants had the opportunity to register for one of two $20 visa gift cards after each survey, with a total of 4 opportunities. when completing the online survey, the last question asked if the participant wanted to be registered for the drawing. if the participant answered yes, she would be taken to a separate survey to complete contact information. this was to ensure anonymity. for the program evaluation survey, participants were online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 13 asked to put their name on an index card and place in a box and two winners were chosen at random. data collection and analysis data collection at baseline, 1 week and 3-month follow-up occurred via the use of questionpro surveys. questionpro is web-based software that is used for the creation and distribution of surveys (questionpro, n.d.). data collection immediately after the educational session occurred using paper and pencil. responses to the questionpro surveys were automatically tabulated and reviewed by the project coordinator. statistics kingdom and spss software were used for analysis for the data from the acpes. for statistical procedures, the level of significance was set at 0.05. a mann whitney test was used to analyze survey results comparing baseline data to one-week after the education, baseline data to 3 months after the education, and one week after to 3 months after the education. participants completed the program evaluation form immediately following the session. participants answered questions regarding if the three program objectives were achieved using a 4-point likert scale (to a great extent = 4, to a moderate extent = 3, to a slight extent = 2, not at all = 1). teaching expertise/effectiveness of the presenter using a 4-point likert scale (excellent = 4, good = 3, fair = 2, poor = 1) was also evaluated. effectiveness of delivery format and relevance of content to the participant and her family was evaluated with yes or no responses. demographic information was collected. participant names were not collected. each evaluation form was given an identification number. program evaluation form data were entered into an excel spreadsheet by the project coordinator. the average and standard error of each of the three objectives and review of the presenter were calculated using excel. responses for the format and content were tabulated. age online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 14 and education level were classified using age range and degree level. the data were stored on a laptop that could only be accessed by the project coordinator via password. the project coordinator is the only one that had access to the raw data. the evaluation forms were stored in a locked filing cabinet and will be kept for five years, after which the documents will be destroyed. results demographics in total, 23 women participated in the power of women as agvocates conference and the conversations that matter session; 22 women answered the demographic questions on the evaluation form. participants ages ranged from the 18-24 years age group to the 65 years and older age group. the median age range was 35-44 years of age. of the participants responding to the demographic questions (n = 22), 95% (n = 21) had completed at least some college. see table 1 for additional demographic information. table 1 demographic characteristics of power of women as agvocates conference participants. age in years n = 22 percent 18-24 1 4.55% 25-34 3 13.64% 35-44 7 31.82% 45-54 3 13.64% 55-64 7 31.82% 65 or older 1 4.55% highest level competed / highest degree less than high school degree 0 0 high school degree or equivalent 1 4.55% some college but no degree 3 13.64% associate degree 3 13.64% bachelor’s degree 9 40.91% graduate degree 6 27.27% program evaluation overall, participants (n = 23) agreed the three objectives of the conference session were met. all participants responded that each objective was either met to a moderate extent or to a online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 15 great extent. see table 2 for additional information. the majority of participants rated the teaching expertise/effectiveness as excellent (n = 22; 96%) while one participant rated teaching expertise/effectiveness as good (n = 1; 4%). the majority of participants agreed the format of the session was effective for acp (n = 18; 78.3%). one participant did not find the format effective (n = 1; 4%) while four participants did not respond (n = 4; 17.4%). the majority of participants found the program relevant for themselves and/or family (n = 21; 91.3%). there were two participants that chose not to respond to the question (n = 2; 8.7%). table 2 achievement of program objectives objective description mean (n = 23) standard error describe the importance of choosing a medical decision maker 3.96 0.043 identify what matters most in life and for my medical care. 3.78 0.879 determine how much flexibility to give my medical decision maker. 3.82 0.080 rating scale used: to a great extent = 4, to a moderate extent = 3, to a slight extent = 2, not at all = 1 advance care planning engagement survey participants were asked to complete the acpes prior to the conference as a baseline, one week after the conference, and three months post-conference. completion rates declined with each survey; 100% (n = 23) of participants completed the baseline survey while 52% (n = 12) and 22% (n = 5) completed the one-week post-conference and three-month post-conference respectively. comparisons were made between the baseline survey and one-week post-conference, baseline and three months post-conference, and one-week post-conference to three months post-conference. individual questions using a mann whitney test, from baseline to one-week after the conference, the question, “how ready are you are talk to your decision maker about how much flexibility you want to give them?” showed statistical significance. at baseline, the average score for this question was 2.8 (n = 20) and the average at one-week was 4.1 (n = 11) (u = 58.5, z-score = -2.1573, p = 0.0155). online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 16 from baseline to 3 months, the question, “how confident are you that today you could talk to your doctor about how much flexibility you want to give your medical decision maker?” showed statistical significance. at baseline, the average score for this question was 3.7 (n = 21) and the average at three months was 5 (n = 3) (u = 12, z-score = -1.7649, p = 0.00388). no questions showed statistical significance when comparing one-week and three-months post-conference. domains and process measures from baseline to one-week post conference, there was statistical significance for the domains of what matters most in life and flexibility. for what matters most in life, the average score for questions in this domain was 3.5 at baseline and at one-week as 3.9 (u = 2754.5, z-score = -1.7655, p = 0.0388). for flexibility, the average score for questions within the domain was 3.2 at baseline and 4.0 at one-week (u = 1472, z-score = -2.5688, p = 0.0051). there was no difference in any domain from baseline to 3 months or one-week post-conference to three months post-conference. the process measures of readiness and self-efficacy were measured by the acpes. there was an increase in self-efficacy from baseline (average = 3.8, n = 23) to one-week post-conference (average = 4.3, n = 12) as well as baseline to three months post-conference (average 4.3, n = 5). these increases were statistically significant (u = 4114.5, z-score = -2.2395, p = 0.0126; u = 1228, z-score = -1.8721, p = 0.0306). an increase in readiness was seen from baseline (average = 3.0, n = 23) to one-week post-conference (average = 3.6, n = 12). this was statistically significant (u = 8181.5, z-score = -2.6984, p = 0.0035). statistically significant differences were not seen for the other time intervals. advance directives along with the acpes, participants were asked if they had completed official paperwork documenting their medical wishes. at baseline, 22 women responded to this question. of the online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 17 respondents, the majority did not have official paperwork (n = 13, 59.1%) while 8 participants stated they had official documents (n = 8, 36.4%), and 1 participant was not sure (n = 1, 4.5%). one week after the education session, of the 12 responses to the survey question, 5 participants had official documents (n = 5, 41.7%) and 7 did not (n = 7, 58.3%). three months after the education session, 4 participants responded to this question on the survey. of the 4 participants, 0 (n = 0, 0%) had official documentation of medical wishes. discussion this project sought to determine if an education session on acp at a conference for women who farm and ranch would increase engagement in acp along with documentation of ads by comparing the results of the acpes at baseline, one-week, and three months after implementation. this study demonstrated the use of prepare during a session of a larger conference has potential to increase self-efficacy and readiness (both parts of engagement), although further studies are needed. increases in self-efficacy and readiness were seen one week after the conference indicating that, at least in the short term, this program increased engagement in acp in terms of process measures. at three months, increases in self-efficacy remained, while increases in readiness did not increase significantly. after the completion of the conference, the only communication with the participants was via e-mail requesting completion of the follow-up surveys. engagement increased in the time shortly after the conference, but then was not maintained three months after the conference. this could indicate the need for continued follow-up with the conference participants. annie’s project, one of the many programs provided through sdsu extension offers 6-week workshops for women in agriculture. participants in these workshops meet weekly for six weeks which would provide more frequent interaction and follow-up with participants. based on the online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 18 program evaluation, participants agreed the format was appropriate for the topic of acp and that the objectives of the session were met. therefore, this is a program that could be implemented through sdsu extension in the future. however, the recommendation would be to include further follow up with participants. while an increase in engagement for readiness and self-efficacy was apparent, there was not an increase in ad completion at either time point after the conference. there could be several reasons for this. first, low response rates to the surveys after the conference could impact results. those that have completed ads might not have completed the follow-up surveys. second, the focus of the prepare steps 1-3 were more focused on process measures (readiness and selfefficacy) rather than taking the action of completing an ad. implications limited research has been conducted on acp in farm and ranch communities. this project sought to add to this body of knowledge and determine if the prepare intervention was an appropriate initiative for a rural population. detering et al. (2010) found those who participate in acp conversations are three times more likely to have their wishes for end-of-life known and followed. improving acp in the rural population has the potential to improve the care provided at the end-of-life and assure the care provided aligns with the patient’s wishes. it is important to note that rural dwellers are considered self-reliant and tend to resist help from “outsiders” and will seek needed healthcare from informal systems instead of formal systems when able (long & weinert, 1989). major sources of support and information in rural communities include family, friends, and neighbors, particularly those with a healthcare background (wathen & harris, 2006). as a trusted source, the rural nurse has an opportunity to online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 19 support community members in the process of acp. prepare is a program that could be used by nurses in rural communities to have conversations related to acp. by providing education in the community setting to a group of women they could participate in patient activation. patient activation is defined as, “patients’ willingness and ability to take independent actions to manage their health and care” (hibbard & greene, 2013, p. 207). as a part of patient activation, the patient understands her role in her care and has the knowledge, skills, and confidence to manage that care. many organizations do not have the resources (financial, time, manpower) to provide detailed acp education to patients and this program is a way to bring this information into the community and support patient activation. with increased patient activation there is potential to improve patient outcomes and healthcare experiences while decreasing the cost of care (hibbard & greene, 2013). limitations although the power of women as agvocates conference had a capacity of 75 participants, only 23 participants signed up for the 2020 conference. while the reason for the small group is not known, it has been suggested that the unpredictable january weather may have kept some participants away. the weaker farm economy has been suggested as a reason for poor attendance as participants paid a registration fee as well as transportation and lodging, if necessary. because of the low conference attendance, there was a small sample size when this study started. while all participants completed the acpes prior to conference attendance, there was limited survey completion one week after the conference (n = 12) and at three months after the conference (n = 5) despite reminder e-mails and the gift card incentive. the three-month post conference follow-up survey occurred in april 2020. during this time, covid-19 was impacting the daily lives of many americans, including those in south dakota. the current literature is sparse online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 20 on the impact of this pandemic on survey response rates, but this could have impacted the survey completion during this time period. within the surveys which were completed, there was missing data which can impact the value and the interpretability of the data (mercieca-bebber et al., 2016). therefore, with such a small sample size, the results should be viewed with caution. conclusion this study focused on the need for acp education for the south dakota farm and ranch population using an evidence-based acp intervention. the use of prepare for your care during programs provided by sdsu extension for women who farm and ranch has potential to increase engagement in acp. the education session was relevant to participants and was an appropriate format for providing information on acp. this program could be easily adapted to other programs offered by sdsu extension, including annie’s project workshops. by providing education in a community setting, acp education and conversations can be initiated and continued in the healthcare setting. further research is needed on this topic and should be focused on evidencebased interventions to continue to increase engagement in acp with the farm and ranch population. even though there were limitations to this study, this education session format provided relevant information to south dakota women who farm and ranch. references annie’s project. 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(2013). failure to engage hospitalized elderly patients and their families in advance care planning. jama internal medicine, 173(9), 778-787. https://doi.org/10.1001/jamainternmed.2013.180 hibbard, j.h., & greene, j. (2013). what the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. health affairs, 32(2), 207-214. https://doi.org/10.1377/hlthaff.2012.1061 howard, m., bonham, a.j., heyland, d.k., sudore, r., fassbender, k., robinson, c.a., mckenzie, m., elston, d., & you, j.j. (2016). measuring engagement in advance care planning: a cross-sectional multicenter feasibility study. british medical journal open, 6(6), e010375. https://doi.org/10.1136/bmjopen-2015-010375 institute of medicine (iom). (2015). dying in america: improving quality and honoring individual preferences near the end of life. the national academies press. https://doi.org/10.17226/18748 long, k.a., & weinert, c. 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(2014). a novel website to prepare diverse older adults for decision making and advance care planning: a pilot study. journal of pain and symptom management, 47(4), 674-686. https://doi.org/10.1016/j.jpainsymman.2013.05.023 sudore, r.l., stewart, a.l., knight, s.j., mcmahan, r.d., feuz, m., miao, y. & barnes, d.e. (2013). development and validation of a questionnaire to detect behavior change in multiple advance care planning behaviors. plos one, 8(9). https://doi.org/10.1371/journal.pone. 0072465 online journal of rural nursing and health care, 2020(2) http://doi.org/10.14574/ojrnhc.v20i2.632 24 the conversation project. (2018). most americans “relieved” to talk about end-of-life care: new survey by the conversation project finds cultural shift over five years. retrieved from https://theconversationproject.org/wp-content/uploads/2018/07/final-2018-keltonfindings-press-release.pdf u.s. census bureau. 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(2018). feasibility of a video-based advance care planning website to facilitate group visits among diverse adults from a safetynet health system. journal of palliative medicine, 21(6), 853-856. https://doi.org/10.1089/jpm.2017.0476 brewer_619_formatted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 108 the lived experience of nursing appalachia: sampling and recruitment evelyn p brewer, phd, msn, rn 1 florence m. weierbach, phd, msn, mph, rn 2 rebecca adkins fletcher, phd 3 katherine c. hall, phd, rn-bc, cne 4 wendy nehring, phd, rn, faan, faaidd 5 1assistant professor, lees-mcrae college, empbrewer@yahoo.com 2associate professor, college of nursing, east tennessee state university, weierbach@mail.etsu.edu 3assistant professor, department of appalachian studies, east tennessee state university, fletcherra1@mail.etsu.edu 4 associate professor and nursing education concentration coordinator, college of nursing, east tennessee state university, hallkc1@mail.etsu.edu 5dean, college of nursing, east tennessee state university, nehringw@mail.etsu.edu abstract purpose: research in rural areas presents special challenges for sampling and recruitment. examples of considerations include smaller sampling population, privacy concerns, and the rural context. the purpose of this article is to discuss the results of sampling and recruitment strategies within this study. sample: nurses form a central hub of health care in rural communities. however, little is known about the lived experience of nurses serving in this capacity. this study explored stories of nurses in a six-county area of three adjoining states in rural south central appalachia. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 109 method: recruitment for the study was completed using state boards of nursing social marketing strategies and snowball sampling. findings: sampling and recruitment efforts enlisted 15 participants. the sample was deemed representative of the population as participants represented diverse employment contexts, education preparation levels, licensure duration, and multiple generations. conclusions: understanding implications of rural setting and cultural context are critical to successful recruitment and sampling. privacy considerations may still be concerning, however, multiple de-identification strategies serve to help lessen this risk. social marketing strategies failed to recruit the needed number of participants secondary to the fact that participants from only one state were recruited in this manner. smaller population pool limitations were eased by snowball sampling, an approved recruitment method in qualitative research. future researchers should be cognizant of the influence of rurality norms and cultural context on recruitment and sampling efforts. social marketing proved less successful than snowball sampling strategies. further research is needed to develop best practice for rural recruitment and sampling via social marketing. finally, time and resource commitment for participation can be a barrier. flexibility in scheduling interviews, location of interview sites, and the availability of audio/phone interviews served to facilitate agreement to participate. keywords: rural, nursing, appalachia, research, sampling, recruitment the lived experience of nursing appalachia: sampling and recruitment the largest body of health care providers is nurses. nurses provide care around the clock in many health care settings. they serve as a source of preventative care and as the primary source of health care information. of all professionals, nurses have been rated highest in ethical standards and honesty for the last 15 years (norman, 2016). they are viewed as advocates and trusted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 110 members of the community “who provide holistic care with empathy, cultural competence, and professionalism” (brewer, 2018, p. 11). their work ethic, leadership, strength, courage, and resilience are widely recognized. however, nurses largely work in the shadows out of the public eye. little is known about the nurse as an individual apart from their role as a nurse. they work independently and in collaborative teams caring for clients across the lifespan in all global settings and all phases of the health and wellness continuum (international council of nurses, n.d.). registered nurses (rns) are described as “determined, willing to work, able to overcome, and willing to assume positions as leaders in the profession, the community, and the region (brewer, 2018, p. 6). nurses’ contribution to improving outcomes for clients and communities are noticeably visible while the nurses themselves remain hidden. the literature demonstrates efforts to improve health of appalachian individuals and communities through focused regional healthcare systems (fletcher, slusher, & hauser-whitaker, 2006; jessee & rutledge, 2012; lee, hayes, mcconnell, & henry, 2013) but rarely through the work of the individual nurses who work in rural appalachia. although registered nurses influence hundreds of lives every day, the story of how individual nurses get up and go to work every day, the personal significance of what a nurse does, and private challenges encountered by the nurse have not been explored this gap in knowledge is significant because nurses are essential to the health of communities and populations. nurses make up the largest group of health care providers, serve as a primary source of preventive care or health care information, and are ever close to clients (menehan, 2011). additionally, nurses encounter multiple challenges inherent to rural practice, the requirement of being an expert generalist, and working in professional isolation (fahs, 2017; luger & ford, 2019; molinari & bushy, 2012). previous research provides descriptions of individual nursing actions but fails to provide integrated, theoretical insight of nursing practice (winters & lee, 2018). using qualitative online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 111 research methodologies of recruitment, nurses were invited to tell their personal story of living and working in rural appalachia. recruitment of participants in rural communities may necessitate use of multiple strategies and pose special challenges for de-identification and anonymity of both participants and research data. the purpose of this article is to discuss barriers and challenges of recruitment processes for the study. rural appalachia appalachia is marked by diversity and contrast--gently sloping hills to fertile valleys, craggy mountain slopes to deep hollows, and urban municipalities to rural regions. the appalachian region follows the appalachian mountain range through 12 states and all of west virginia, covering 205,000 square miles with a population of over 25 million people. the appalachian region is subdivided into regions having similar characteristics of topography, demographics, and economics (appalachia regional commission [arc], n.d.). almost half of the region is rural (arc, n.d.). the focus region for this research study is a six-county area that includes three adjoining states of south-central appalachia. defining rurality depends on the application of the term. quantification of population size and density serves to define rural and urban by the u.s. census bureau (n.d.a.). another definition of rural proposes an aerial view of a rural area denotes a high percentage of open country, population densities of less than 500 people per square mile, and settlements of fewer than 2500 residents (u.s. department of agriculture economic research service [usda ers], n.d.d.). the usda ers incorporates definitions of the office of management and budget into definitions of rural. this strategy takes into consideration the flow of a population’s labor flow as well as population density. the rural-urban continuum codes (rucc) differentiates metropolitan (metro) counties and nonmetropolitan (nonmetro) counties (usda ers, n.d.b.). a nonmetro online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 112 county is considered adjacent if it is physically adjacent to a metro area and at least 25% of its workforce commutes to a metro county with higher code numbers indicating increased rurality (usda ers, n.d.b.). further classification, core-based delineation, reflects the population size of metro areas and nonmetropolitan counties by the size of the largest city or town and the proximity to metro and micropolitan areas with higher numeric values (1-12) representing increased rurality (usda ers, n.d.c.). a final classification is provided through frontier and remote area codes determined using a combination of low population size and higher geographic remoteness as identified by zip code areas with higher numeric levels indicating increased rurality (usda ers, n.d.a). three of the six focus counties in this study have zip codes areas included in the frontier and remote area code designation. since this classification is based on zip codes and multiple zip codes exist within each county, focus counties of this study were identified as dichotomous “yes” or “no” if any of the zip codes in a county are classified as any level of frontier and remote areas. the classification for the six counties of this study is shown in table 1. this study adopted the definitions of the usda, ers as it was anticipated the considerations of workforce flow and proximity to metropolitan centers would be a consideration for some study participants’ perceptions of nursing practice rather than merely population density of the communities where they worked and lived. rural nursing rural health care differs from urban health care in that the health care providers and systems are not the same, the community context changes, access to health care varies, and, importantly, nursing practice is dissimilar. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 113 table 1 county specific data for rural classification county au.s. census bureau population/sq mi busda, ers rucc cusda, ers uif dusda, ers frontier and remote area county a 47.5 9 10 yes county b 35.1 9 12 yes county c 64 7 10 yes county d 163.4 5 8 no county e 91.1 6 3 no county f 61.1 6 6 no note. adapted from county specific data of au.s. census bureau, (n.d.b.), quick facts. bu.s. department of agriculture economic research service (n.d.b.), rural-urban continuum codes (rucc). cu.s. department of agriculture economic research service (n.d.c.), urban influence codes. du.s. department of agriculture, economic research service (n.d.a.), frontier and remote area codes. historically, medical education, medical facilities, and the number of medical providers were more advanced and available in urban areas when compared to rural areas. the low population census in appalachia, as with all rural areas, failed to provide the fiscally stable environment for practice resulting in a shortage of health care services (barney, 2000; behringer & friedell, 2006). rural communities are different. individuals living in rural areas are more likely to experience environmental and social barriers to health and well-being. these obstacles include poverty, educational attainment, health literacy, adequate community infrastructure, access to healthy and affordable food/housing and transportation (rural health information hub [rhihub], n.d.). health care access is different. distance may be a barrier to access for primary health care as rural residents may have to travel long distances that places a considerable drain on time and finances (deskins et al., 2006; lane, et al., 2012). travel across county, or even state, boundaries is common in many areas. most importantly, rural nursing practice is also different. rural nurses typically earn less, frequently work during staffing shortages, encounter professional challenges in the work online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 114 environment, navigate poorly funded public systems, overcome inconsistencies in educational opportunities, and deal with everyday life barriers inherent to rural living such as housing and child care (baernholdt & mark, 2009; jackman, myrick, & yonge, 2012; roberge, 2009; robert wood johnson foundation, 2010; rohatinsky & jahner, 2016; sellers et al., 2019; thrill, pettersen, & erickson, 2019). characteristics of rural nursing and the rural nursing theory reflect many perspectives of nursing in appalachia (brewer, 2018, winters & lee, 2018). professional isolation, leadership, and professional autonomy are expected norms for nursing practice (brewer, 2018; national advisory committee on rural health and human services, 2015; persily, 2004; russ, 2010). examples of nursing leadership are demonstrated by nurses serving as community advocates bringing needed healthcare services to underserved communities (cockerham, 2015; fletcher, slusher, & hauser-whitaker, 2006; huttlinger, schaller-ayers, kenny, & ayers, 2004; mcdaniel & strauss, 2006; snyder & thatcher, 2014; winters & lee, 2018). the literature illustrates how nurses work to improve outcomes for clients and communities, yet little is known about the personal experience of nursing. discovery of these perspectives is challenged by recruitment barriers inherent to the rural context of the study. study inclusion criteria were defined as a registered nurse who works and lives in appalachia, willingness to allow voice recording of the interview, english as the spoken language, and over the age of eighteen years. exclusion criteria included lack of experience working as a registered nurse in appalachia. to answer the research question of the lived experience of the registered nurse in appalachia, careful consideration was given in defining the targeted population. the first decision was in defining a practice and educational level of the nurse participants. licensed practical nurses were excluded from the study as this level of practice and education online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 115 lacks the scope necessary for many leadership and professional roles. however, registered nurses and nurses with graduate degrees and/or advanced practice have the same initial educational preparation and licensing process, with recognition of additional licensing and education for advanced practice, so the both levels were included in the study. increasing the breadth of inclusion criteria for all levels better represented the targeted population (bonevski, et al., 2014). another consideration was the embeddedness in the context of appalachia. selection of only native appalachians would reveal the lived experience through a cultural lens. however, the sixcounty region in appalachia has seen a lot of growth. it contains a large tourism industry, a large retirement population from other areas of the nation, many vacation homes, and a large regional state university. the identification of the nurse to the appalachian culture would be difficult to ascertain. therefore, it was deemed appropriate to include all rns who practice within the sixcounty region. the primary goal was to understand the lived experience of being a registered nurse who lives and works within the defined geographic area. prior to recruitment, the study received approval through irb processes (protocol v10) at the regional university where the study originated. access to participants was somewhat problematic. the researcher is a resident of the region and it was presupposed that she might know or be known by some of the participants. this shared knowledge of each other on a personal basis and lack of anonymity is an established component of rural nursing practice. it was recognized that it was impossible to eliminate this small-town, rural characteristic, and any associated insider implications (lee & mcdonagh, 2018). care was taken to recruit participants as objectively as possible as described in social marketing strategies (bonevski et al., 2014) by asking the state nursing associations of the three states to send an email containing information about the study to regional nursing association members. this social online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 116 marketing strategy was successful in recruiting informants from only one state and snowball recruitment strategies were initiated as approved in the study proposal. when potential participants answered the recruitment email, further details about the purpose of the study, expectations for participating, confidentiality procedures, and use of participant’s data during analysis was given. at that time, the decision for inclusion as a participant was mutually agreed between the researcher and the informant. four participants were recruited using state nursing association emails to regional members explaining the study and study participation. the relatively small number of participants recruited this way limited the potential for the perspectives of all the nurses in the focus area to be represented equally, a decreased representativeness of the sample. additionally, recruitment exclusively through state nursing association emails could produce a sample of upwardly mobile or advanced practice nurses rather than a sample representing all the nurses in the focus region because not all nurses may belong to the nursing association due to barriers of membership such as inability to afford membership fees. final recruitment review identified nurses were recruited from two of the three states. a far more productive and equally acceptable recruitment strategy was snowball sampling. snowball sampling strategies involve informant member identification of other candidates suitable for inclusion (bonevski, et al., 2014; creswell, 2007) although this strategy presented some challenges as well. the researcher has lived in one of the targeted counties for 50+ years. she has worked as a registered nurse in two of the counties for 20+ years. the extended time in the region was challenging with both positive and negative implications. in this case, perceptions of the rural insider served to facilitate recruitment strategies (bonevski, et al., 2014). this could present a threat to representativeness so the researcher was very intentional when discussing snowballing strategies with participants and care was taken to recruit without bias or preference. equal attention online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 117 was given to avoid all sense of pressure for participants to provide additional potential participants. it is possible that some prior association could unintentionally influence recruitment efforts. to lessen this potential, all participants who met the inclusion criteria were interviewed without exception on a first-come, first-interview basis whether they knew the researcher or not, an ethically sound strategy (margolis, 2000; reel, 2011). five of the participants knew the researcher. three additional participants had heard of but did not know the researcher. seven participants had no prior knowledge of the researcher. sampling in qualitative research is cyclical, recurrent, and emergent (higginbottom, 2004; maxwell, 2013; miles & huberman, 1994). the initial effort of recruitment was through the social marketing strategy that produced a sample size far short of the required number. however, during the interviews with these individuals, the snowball recruitment strategy was introduced to informants and a new list of potential participants was created. with each cycle of interviews, new informants were identified until it was determined that no additional interviews were needed. this cyclical pattern facilitated introduction of multiple participants unknown to the researcher. additionally, it supported timing of the interviews so analytic procedures could occur between interviews as befitting qualitative research protocols (maxwell, 2013). sampling outcomes sampling and recruitment for this study produced fifteen participants from two of the three states. all of them have been employed in various positions including school nurse, nursing education, primary care, mental health, hospital staff nurse, skilled nursing facility, university health clinic, home health, and outpatient surgery. all have worked in the hospital setting at some point in their career. half of them still work in the hospital. only two participants did not provide direct patient care in some capacity at the time of study participation. this diversity supports the online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 118 representativeness of the sample. to understand the context of the work environment better, table 2 provides an overview of hospital services in the targeted counties. the researcher resides in county c. she has worked in counties c and d. table 2 hospital health care service for targeted counties hospital qualification county a county b county c county d county e county f cah / acute cah no hospital cah acute acute cah governance / ownership voluntary nonprofit / private no hospital voluntary nonprofit / private government / local government / local voluntary nonprofit / private number of beds 25 no hospital 25 117 120 2 number of rns (ftes) 22.5 no hospital 48.3 114.5 202.5 11 annual total patient days 1,355 no hospital 5,285 14,368 15,145 56 obstetric services no no hospital yes yes yes no surgical services yes no hospital yes yes yes no emergency room services yes no hospital yes yes yes yes intensive care no no hospital no yes yes no note: adapted from information obtained from the following sources: american hospital directory, n.d. free hospital profiles, retrieved from https://www.ahd.com/search.php ; hospital and nursing home profiles, n.d., retrieved from www.hospital-data.com; official u.s government site for medicare, n.d., hospital compare, retrieved from https://www.medicare.gov/hospitalcompare . critical access hospital (cah) demographics of the nursing participants show an older nurse population. this could be an outcome of sampling strategies but, equally possible, the prevalence of older nurses is reflective of the aging nurse workforce (national council of state boards of nursing, n.d.) or as a characteristic of rural populations (winters, 2018). another observation of the demographics online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 119 demonstrates the diverse levels of education even though the nurses were educated in many different sites both inside and outside the focused six-county region. one third of them worked as a licensed practical nurse (lpn) before pursuing additional education. eight have an associate’s degree in nursing (adn). eleven have a baccalaureate degree in nursing (bsn). eight participants have a master’s degree. three of the fifteen have a terminal degree (phd and dnp). one had less than one year of experience as a registered nurse but eleven have over 20 years of experience. a conclusion from analysis of the study data showed that years of practice in appalachia tends to lead nurses to stay in the region for long periods regardless of their place of origin. it is anticipated that younger nurses or nurses who are still in the early years of their career would change jobs, seeking new opportunities as indicated by a lower number of. years at the same place. yet, as illustrated in table 3, the category average years employed at current job indicates that, even with advancing years of age, nurses are open to changing jobs, beginning new experiences, demonstrated by the range of average years in the current job beginning at 1 month for nurses 5060 years of age and at 3 years for nurses 50-59 years of age. table 3 provides an overview of participant demographics. table 3 participant demographics age (10 yr. groups) participants n mean years as rn (range; sd) mean years employed at current job (range; sd) mean years practice in appalachia (range; sd) ed. background / degrees 60-69 5 33.6 23-41; 7.44) 8.82 (.12-20; 7.83) 22 (3-35; 15.07) lpn, adn, bsn, msn, phd 50-59 4 27.75 (25–33; 3.7) 15.75 (3-30; 12.09) 25.25 (15-36; 10.78) lpn, adn, bs, msn, dnp online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 120 age (10 yr. groups) participants n mean years as rn (range; sd) mean years employed at current job (range; sd) mean years practice in appalachia (range; sd) ed. background / degrees 40-49 2 21.25 (20-23; 2.12) 5 (5; 0) 21.25 (20-23; 2.12 adn, bsn 30-39 2 13.5 (11-16; 3.54) 5.25 (5-5.5; .35) 12.5 (11-14; 2.12) lpn, adn, bs, msn, fnp 20-29 2 1.6 (.4-3; 1.94) 1.6 (.4-3; 1.94 3 (5; 0) lpn, adn, bsn note partial years expressed as decimal. abbreviations: associate degree nursing (adn), bachelor's of science degree in nursing (bsn), family nurse practitioner (fnp), licensed practical nurse (lpn), mater’s of science degree in nursing (msn), philosophy of science degree (phd), standard deviation (sd) discussion sampling and recruitment for research in rural areas may present special considerations. researchers should be knowledgeable of and accommodating to rural setting and cultural context prior to attempting recruitment efforts (cudney, craig, nichols, & weinert, 2004; de chesnay, 2015; mccormick et al., 1999; rhihub, n.d.). use of community members, including insiders and local researchers, known to potential participants may increase trust, perceptions of familiarity, and, thereby, agreement to participate in the study (bonevski, et al., 2014). for this study, knowledge of the researcher facilitated recruitment efforts which was a key consideration of potential bias for the researcher during analysis. the balance between ease of recruitment and analysis bias must be considered during the planning phase for qualitative research. travel and time commitment influence agreement to participate in research. rurality implies greater demand on time and resources, including interference with employment responsibilities (morgan, fahs, & klesh, 2005). this study countered these barriers though researcher flexibility in timing, meeting sites, and the ability to do audio/phone interviews. another strategy could be through use of online meeting platforms or a visual/auditory conference such as facetime. when online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 121 considering use of these mediums, privacy would also be of prime consideration. more research is needed to explore security and availability of these modalities in rural populations. the concepts of knowing/being known and the lack of anonymity in rural communities are widely recognized as considerations (lee & mcdonagh, 2018). much of the previous work on anonymity centers on the client as participant (mccormick et al., 1999). however, less information is available on anonymity of the nurse as the participant, an especially concerning problem as nurses are privy to a great deal of restricted information for their clients and institutions of employment. rurality increases the risk due to the increased familiarity not only of people but also of situations even though de-identification processes are enabled (rhihub, n.d.). it was likely that nurse participants might anticipate inadvertent breach of confidentiality, a serious ethical issue. the informed consent was used as a tool to inform participants of the risk and measures to lessen that risk in this study. measures included in the study included requests to participants to refrain from using identifiable statements related to specific occurrences or clients, de-identification of data in the transcripts through removal of identifiable places or groups, destruction of audio recordings to avoid accidental voice recognition of participants, exemption of situations that increased risk of recognition from all transcripts and researcher reflective writings, and a final round of de-identification when reporting results. release of the informed consent document prior to agreement to participate with ample time to understand planned measures and to clarify concerns served to increase recruitment. the population pool is smaller in rural areas so sample sizes may be adversely affected but use of interviews or focus groups may help ease this restriction (rhihub, n.d.). larger geographic areas along with fewer potential participants result in higher costs for recruitment financially and timewise (cudney et al., 2004). however, the barriers of small population pool and higher burden online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 122 of recruitment may be eased by obtaining thick, rich data through purposeful sampling of individuals who have in-depth knowledge of the focused topic (higginbottom, 2004; maxwell, 2013). social marketing recruitment was effective in only one of the three states, leading to snowball sampling which was effective in recruiting participants from a second state. the criteria of inclusion and exclusion for this study led the researcher to participants who directly experienced the phenomena of interest and were able to provide that desired quality of data. another widely used recruitment strategy is through use of incentives (mccormick et al., 1999; singer & couper, 2008) especially when the response rate is low as with the beginning of recruitment in this study. singer and couper (2008) propose three reasons why individuals agree to participate in research: (a) altruism, (b) interest in the survey topic and/or the researcher, and (c) egotistic reasons, i.e. receipt of monies or incentives. undue influence typically is associated with external factors that sway participant decision-making processes, especially when there is a difference in power or authority over another person (resnik, 2015). the rationale for lack of incentive use in this study is related to not wanting to impose undue influence on participant decision-making processes. since the researcher was native to this area, it was decided to not offer incentives so there would not be a sense of undue influence. the researched decided to not offer any incentive outside of the sense of benefit of contributing to the profession of nursing and nursing knowledge which reflects the rationale of altruism (singer & cooper, 2008) and is one of the reasons individuals agree to participate in research. evaluation of the sample provides insight of the body of participants and the effectiveness of the recruitment strategies. participants revealed the full scope of nursing educational preparation. many started their nursing career as lpns but all had pursued additional education with a majority having attained a bsn degree. the high proportion of participants with a bsn online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 123 and/or a master’s degree may reflect the success of distance/online opportunities instituted in response to documented challenges for education opportunity in rural areas (brewer, 2018). this characteristic contradicts findings of newhouse, morlock, provonost, and sproat (2011) who found a majority of nurses practicing in rural areas are educated at the associate level. however, the low number of participants with a terminal degree may question similar effectiveness of education at that higher level of preparation. finally, the majority of the nurses are older and they hold most of the experience for patient care, implying much of the knowledge will leave with them when they retire. it is possible that the sample representativeness did not adequately capture the balance of older to younger nurses. however, the adequacy of this recruitment is supported by other research showing that nurses are indeed growing older. the national council of state boards of nursing (n.d.) and the national forum of state nursing workforce centers (2016) report 50.9% of registered nurses are 50 years old or older and the health resources and services administration estimate that more than 1 million registered nurses will reach retirement age in the next ten to fifteen years (american association of colleges of nursing, n.d.). limitations of the study include use of a single six-county area as the region of focus as it limited the sample to a somewhat homogenous group. although diversity in age, experience, and education was demonstrated, the lack of ethnically or racially diverse participants was a limitation of the study. this was not an intentional action but was a foreseeable result as the region as a whole is highly homogenous. a final limitation of the study was the fact that the researcher was a member of the community. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 124 implications sampling and recruitment strategies in rural areas must be sensitive to and inclusive of the characteristics of the study environment even though the contextual variation may be very subtle. understanding cultural considerations is important but rurality adds an overlay of complexity to the context for research. the fact that the researcher possessed knowledge of the region and culture served to facilitate this study, however, recommendations for future sampling should include knowledge of rural characteristics as well as cultural characteristics. for example, it would be important for the researcher to understand common communication processes across the rural community as well as face-to-face interactions between the researcher and the participant. anonymity and confidentiality are especially problematic in rural research but when coupled with professional ethical standards for nurses, extra caution is required. future efforts should explore how to best overcome those risks and yet produce the highest quality of data. the smaller population pool of a specific region presents challenges. use of multiple sites to explore a phenomenon may increase the population pool as well as the depth of insight about the topic. it also may decrease the likelihood of a homogenous sample as found with this sampling strategy. future efforts to counter the small sample pool and homogeneity may be inclusion of additional regions of both the appalachian region and comparable rural regions across the nation. finally, social marketing produced a smaller number than anticipated. it is unknown if the lack of successful participant buy-in through social marketing via state boards of nursing hindered sampling significantly, however, in this study, the mark of success as a recruitment strategy is limited. additional research is needed to increase the effectiveness of social marketing in this targeted population. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.619 125 conclusion recruitment and sampling in rural research can be problematic. simultaneous use of multiple recruitment strategies and multiple sites can increase the likelihood that an adequate, representative sample is obtained. transparency in strategies for de-identification may ease privacy concerns arising from the lack of anonymity common to rural areas. other strategies to improve recruitment include use of incentives and flexibility in timing or location of interviews. nursing practice is central to 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(2018). rural nursing: concepts, theory, and practice (5th ed.). new york, ny: springer publishing. https://doi.org/10.1891/9780826161710 editorial_save_the+date12.2.22 online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.724 1 editorial save the date: 2023 international rural nurse conference pamela stewart fahs, phd, rn, editor save the date! the 2023 international rural nursing conference (irnc) will be back live and in person in johnson city, tennessee, july 26-28, 2023. east tennessee state university, college of nursing and binghamton university, decker college of nursing and health sciences are co-hosting this important conference. the rural nurse organization (rno) is, as always, the primary sponsor of the conference. in full disclosure, the online journal of rural nursing and health care is the official journal of the rno. if you are a member of the rno or a registered user of the online journal of rural nursing and health care you will be receiving emails with save the date information on the conference as well as the call for abstracts. the 2023 inrc is focused on bringing together rural and remote nurses, other healthcare professionals, educators, and researchers to address the unique and varied health aspects of rural and remote communities focusing on culture/social determinates of health, global health, policy, and interdisciplinary professional issues. the board categories for abstracts include the focus areas of: • culture/social determinates of health, • global health, • policy, • interdisciplinary professional issues, or • other. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.724 2 when submitting your abstract, you can choose to have it reviewed for a podium, poster presentation or both. podium presentations should include information on the finished project. the call for abstracts is open now until january 13, 2023. the url for submitting your abstract is https://etsuredcap.etsu.edu/surveys/?s=3tlyn9ntrwlc44fx or use the qr code to access the abstract submission platform. i look forward to seeing you in beautiful tn in july 2023. taylor_608_formatted online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 121 exploration of rural nurses in decision making of academic progression joyce m. taylor, phd, rn, ccrn-k1 1 associate teaching professor, rn-bsn nursing program, pennsylvania state university, abington campus, jtaylorrn23@gmail.com abstract purpose: to explore the meaning that academic progression has for rural rns and their decision to pursue or not pursue a bsn or higher levels of education. background: mounting evidence has linked a higher educated nurse with improved patient outcomes and decreased patient mortality prompting leaders in healthcare to call for a bachelor of science (bsn) degree as baseline preparation for nursing practice yet, the majority of the nation’s registered nurses (rns) continues to be educated at the associate degree (ad) level. these numbers are even higher in rural areas of the country, where social determinants of health for rural populations places higher demands on rural nurses to provide quality of care. sample: nine (n=9) ad rns from a rural community hospital in pennsylvania who met inclusion criteria were selected. methods: a qualitative phenomenological approach was the research design choice which captured the lived experiences of how rural rns think and feel about pursuing a bsn or higher degree. findings: findings from this study revealed that rural rns are motivated by the need for a bsn specifically in regard to job security, professional identity, professional development, personal enrichment, and career mobility and feeling prepared for the demands of 21st century nursing practice. the participants conveyed they want their voices to be heard regarding the unique challenges that rural nurses face in pursuit of a bsn. online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 122 conclusion: higher education in nursing is now a key imperative. understanding academic progression in relation to rns practicing in rural healthcare institutions should serve to disseminate the identified gaps of knowledge in rural nursing education. this study has direct implications for curriculum development and educational strategies focused on producing a more educated rural nursing workforce to meet the growing needs of rural populations. keywords: academic progression, associate degree, bachelor degree, nursing education, role transition, rural health, rural nursing, rural rn workforce. exploration of rural nurses in decision making of academic progression mounting evidence has linked a higher educated nurse with improved patient outcomes and decreased patient mortality prompting leaders in healthcare to call for a bachelor of science in nursing (bsn) degree as baseline preparation for nursing practice (aiken, clarke, cheung, sloane & silber 2003; harrison et al., 2019; institute of medicine [iom], 2011). yet, the majority of the nation’s registered nurses (rns), approximately 54%, continue to be educated at the associate degree (ad) level (probst, 2019; spetz, 2018). these numbers are even higher in rural areas of the country, which is significant as social determinants of health for rural populations places higher demands on rural nurses to provide quality of care. (amponsah, tabi, & gibbison, 2015; fahs, 2012; molanari, jaiswal, & hollinger-forrest, 2011). this study addressed the following research question, “how do associate degree prepared rns working in a rural facility describe and interpret academic progression and their decision to pursue or not pursue a bsn degree?” understanding academic progression and rural nurses begins to fill the gap of the under researched rural nursing population regarding appropriate educational attainment for rural nursing practice. online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 123 academic progression despite calls for a more educated rn workforce, academic progression has seen slow progress (iom, 2011). it is now widely recognized that the 80% bsn goal by 2020 will most likely not be met as only 66% of rns are projected to have a bsn+ education by 2025 (spetz, 2018). moreover, a huge disparity in educational attainment exists for rural rns. in fact, recent analysis showed only 46% of the rural rn workforce holds a bsn as compared to the 57% of urban rns (national council of state boards of nursing [ncsbn], 2019; probst, 2019). correspondingly, rural nursing students are usually first-generation college students with little or no support or expectations of academic progression (snyder, jensen, nguyen, filice & joynt, 2017). noteworthy, educational levels for most adults in rural areas remain below the national average; the more isolated a rural rn the less likely they will have achieved a bsn degree (medves, edge, bisonette, & stansfield, 2015; molanari et al., 2011; snyder et al., 2017). marilyn chow in the future of nursing education report asserted, “the future is here, it just isn’t everywhere” indicating that the goal of increasing the proportion of bsn rns to 80% by 2020 is particularly challenging for rural healthcare environments where nurses need to be adequately prepared as frontline caregivers (iom, 2011, p. 317). there are a myriad of factors contributing to the undereducated rural rn pipeline such as quality of education, lack of educational access, and return on investment for higher degrees (amponsah et al., 2015; molanari et al., 2011; murray, havener, davis, jastremski, & twitchell, 2011; probst, 2019). understanding rural nursing the uniqueness of rural nursing and nursing education is largely misunderstood (yonge, myrick, ferguson & grundy, 2013). thus, it is important to have a basic understanding to the context of rural, rural health and rural healthcare education. the diversity of rural settings and online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 124 difficulties with definition and measurement of what is deemed rural have contributed to the lack of accurate description and understanding the needs of rural nurses. for the purpose of clarity in this article, rural is defined as located outside a metropolitan statistical area or more geographically remote with a lower population density. rural areas include some combination of: open countryside, rural towns (places with fewer than 2,500 people), and urban areas with populations ranging from 2,500 to 49,999 that are not part of larger labor market (united states department of agriculture economic research service [usda ers], n.d.). rural health refers to a unique combination of socioeconomic and geographic factors that create disparities in health care not found in urban areas (rural health information hub, n.d.). rural nurses are viewed as rural generalists’ who require specific competencies and skillsets for care coordination, assessment and management of at-risk and underserved rural populations often in resource-poor environments (burman & fahrenwald, 2018; medves et al., 2015; molanari et al., 2011; probst, 2019). compared to their urban counterparts, rural rns are challenged with providing care to rural populations who on average are older, sicker, poorer, more isolated and more likely to be uninsured or underinsured. subsequently, rural residents are less likely to seek preventative care therefore experiencing higher rates of chronic illnesses and co-morbidities. collectively, the aforementioned socioeconomics and health disparities among rural populations places higher demands and expectations on rural rns who are often inadequately prepared for their expanded roles in providing healthcare (amponsah et al., 2015; fahs, 2012; molanari et al., 2011; murray et al., 2011; probst, 2019; snyder et al., 2017). methods a qualitative phenomenological approach was the research design choice, and well-suited to capture the intense and often emotional human experience of what it is really like to experience online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 125 the phenomena in question (van manen, 1990, 2014). the research design enabled a rare glimpse of how rural rns really think and feel about their decision in academic progression. the theoretical frameworks of schlossberg’s transition theory and knowles adult learning theory guided this study, specifically, capturing the needs of clinical rns transitioning to the academic environment (anderson, goodman, & schlossberg, 2012; knowles, 2015). ethics approval for the protection of human subjects was received from the capella university institutional review board #2015741 and from the ethics review board at the local hospital where the research occurred. upon approval, the recruitment phase commenced. participants and recruitment sampling was drawn from the target population of rns who were currently working at the rural acute care facility and met the following inclusion criteria. rns who were currently employed at the facility who were actively pursuing a bsn; rns who considered enrolling in a bsn program within the next five years; or rns who were not considering moving beyond an associate degree in nursing. the five-year time frame was selected as it represented the recommended 80% bsn by 2020 (iom, 2011). a final purposive unique sample of nine (n = 9) participants was sufficient in reaching the point of saturation and most benefited results of the study. data collection prior to any further research activity, informed consent was distributed and explained to interested participants who met the inclusion criteria. once informed consent signatures were obtained, the interview process began. the individual in-depth interviews were guided by semistructured, open-ended questions and additional probing questions (see appendix) that addressed the primary research question. the interviews were audio-recorded and lasted from 30 to 60 minutes. recordings were transcribed verbatim within 48 hours of each interview for accurate online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 126 content analysis. the study participants were given a pseudonym to ensure the anonymity of the nurses and the hospital included in the research. the primary concern in phenomenological research is rigor or trustworthiness that the participants’ experiences are accurately represented (lincoln & guba, 1985). therefore, to establish credibility, confirmability, transferability, and dependability, identify potential biases and develop confidence in the researcher’s interpretation of data collected, strategies deployed included: peer debriefing and member checks, audiorecorded and transcribed interviews, with summaries sent to participants for review (polit & beck, 2017). nine (n = 9) nurses currently working at the facility were interviewed. all nine participants were female as no male candidates chose to participate in the study. however, there was variance in other areas, see demographics (in table 1.). although residency was not listed on the survey, the participants volunteered information. seven of the nine participants were local rural residents, while two participants lived outside the rural geographic area. the furthest commute was 60 miles one-way from the hospital. table 1 participant population demographics participant pseudonym gender age ethnicity rn practice years rn specialty area currently enrolled p 1 f 46 caucasian 7 med-surg; ltc no p 2 f 51 native american 29 icu/ccu yes p 3 f 56 caucasian 30 icu/ccu; adm no p 4 f 29 native american 5 med-surg yes p 5 f 29 caucasian 5 telemetry yes p 6 f 45 caucasian 25 ed no p 7 f 44 caucasian 6 telemetry no p 8 f 50 caucasian 27 icu/ccu yes p 9 f 51 caucasian 29 med-surg, telemetry, adm no abbreviations: adm = administration, ed = emergency department; icu / ccu = intensive care unit/ cardiac care unit, med-surg = medical surgical, ltc = long term care; online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 127 findings analysis of the findings revealed four primary themes: need for a bsn degree, challenges with the decision in pursuing a bsn, motivators for rns to pursue a bsn, and support. multiple sub-themes emerged in conjunction with the dominant themes. the themes and subthemes are identified and discussed in the analysis supported by excerpts from participant narratives. table 2 dominant themes, thematic meaning units, and thematic frequencies dominant themes thematic meaning units frequency (n = 9) percentages % need for a bsn feeling unprepared for expanded role 8 89 job security 9 100 entry level into practice 9 100 professional identity 6 67 challenges with the decision in pursuing a bsn finances 8 89 time and competing priorities 8 89 motivators in the decision to pursue a bsn tuition reimbursement 9 100 flexibility 9 100 accessibility and convenience 6 67 career opportunities 5 56 personal enrichment 5 56 support employer support 9 100 peer support 9 100 academic support 5 56 for most of the participants a career in nursing was prompted by altruism. exemplars included “i enjoy caring for people” or “i really just like everything nursing has to offer regarding helping others.” many chose a two-year program due to affordability, a quick timeframe to degree completion, and for some a bsn was not even an option, as the ad program was all that was available, especially in rural areas. the participants described how becoming a nurse, regardless of pathway to licensure, evoked “a sense of pride, a position of honor in their community”, and for most job security. for decades those tenets held true, until recently when mounting pressures to complete a bsn began to erode their sense of value and security. online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 128 theme 1: need for a bsn degree the first and most common theme derived from the data was the need for a bsn. the participants unanimously shared personal views of need to have versus nice to have a bsn. several sub-themes emerged as most prominent: feeling unprepared for expanded role, job security, bsn as entry level into practice, and professional identity. feeling unprepared. magnified by calls from the iom for a more educated nursing workforce, most participants described feeling unprepared for their expanded roles (iom, 2011). specifically, in regard to leadership, managed care, and systems thinking. participants’ comments included, “my nursing program did a wonderful job in preparing for the actual handson, but i don’t think they could have even thought of how to prepare us for today’s role” or “i could see now why schools need to be different, as even my role has expanded. i am a clinical leader and was never prepared for my expanded role” and “i don’t feel the associate program i attended prepared you to be any type of leader.” job security. traditionally, rn positions, regardless of educational pathway were assumed to be recession proof, as one participant commented, “when i was a senior in high school my father said nursing was a stable job, the economy was going to crap and nursing meant job security.” the rns who initially felt secure are finding themselves in a much different predicament, “we were recently notified that a degree would be mandatory in the near future, especially for management positions . . . so to have a job or the job i want in the next few years i will need to go back to school for my bsn.” the participants noted that hospitals are preferentially hiring newly licensed rns with a bsn or if associate degree nurses do get hired, they are usually required to earn a bsn within a specified period. the idea of poor job prospects prompted a sense online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 129 of urgency. several participants shared: “we are literally stuck without a bsn” or “in the bsn program they talk about the future of nursing 80% bsn by 2020 . . . it scared me. i thought, i better get this done because i am not going to have a job”. another nurse shared, “magnet hospitals won’t even interview you unless you have bachelor degree, education is becoming a big deal”. entry level into practice. all of the participants unwaveringly expressed the need for a bsn as the sole entry into practice. the finding was particularly notable as it shed light on recent perspectives of the decades long debate on entry level into practice. participants expressively described how they would advise someone interested in an education in nursing, “i would say a bsn because here i am now at my age trying to get my bsn, it’s challenging. i don’t think i want to see others go through that.” or “do it all now (get a bsn). go all the way.” others described confusion over multiple pathways and being uninformed, one poignant response: they (magnet hospitals) now want a bsn . . . and for the present employees who don’t a have a bsn the hospitals now have a set period of time they want you to continue education, even floor nurses. so why would schools offer two-year programs that are not going to be useful in finding a job” . . . “i believe it will begin to look bad on them (adn programs) because their students won’t be getting hired.” participants expressed feelings of regret and disappointment of not initially pursuing a bsn, “i wish i knew then what i know now, i would have gone all the way.” one participant felt misinformed by the concept of a 2-year program and shared, “by the time i graduated nursing school i almost had four years of training, i could have just went and got a bsn.” professional identity. several participants shared they felt less credible not having a professional degree, “i want us (nurses) to be respected . . . it is important for nursing to be looked at as a profession that is viewed beyond those who are just doing things such as emptying bedpans online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 130 or bathing someone.” another shared, “as community nurses in a small rural hospital, we do so much and are given so much responsibility and frankly, never receive the credit we deserve. to get credit and be recognized we need to have more education.” theme 2: challenges with the decision in pursuing a bsn the rns described overwhelming challenges with their decision in academic progression, especially regarding finances and time commitments. evidenced by one response, “believe me ... i have given this (a bsn) more than a second thought . . . and there is no easy way at this time.” overwhelmingly, financial burdens, i.e. the cost of tuition was a major challenge. adult learners have homes, families, and added responsibilities. participants looked at tuition costs as an additional burden to everyday living expenses, “i have to work 12-hour days. i have three kids, two of them in school, attend classes, affording the classes while having your regular everyday life expenses, i would say these are huge challenges.” another participant reflected, finances is my number one (challenge). and it’s not that i don’t want a bachelor degree … i am a widow with two kids in college . . . the thought of going back to school is difficult for me because i just can’t afford it. i am looking at way too much debt with my own kids’ student loans. several rns did not see the advantage of a bsn when additional remuneration is not offered, “it’s a big financial commitment . . . and unfortunately, you are not guaranteed to make any more money.” older rns do not feel that they will see a return on their investment, “a bsn is not financially feasible” and “cost is a big issue right now, we do get tuition reimbursement, but it is just a fraction of the cost” and a senior nurse noted, “younger nurses can recoup their investment, but will i be able to?” online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 131 time and competing priorities. balancing their personal lives with workplace responsibilities with the challenges of a rn re-entry placed undo pressures on those rns who have or are considering academic progression as described by several nurses, “time was a huge factor in my decision”, “family time is a big challenge” and “as a single mom, time is a big challenge . . . mainly between working full-time and raising my daughter.” another participant articulated, “time is a big challenge. i usually work three to four 12-hour shifts each week . . . i would need eight hour shifts to go to school . . . so time is a huge factor”. theme 3: motivators for rns to pursue a bsn the third theme revealed strong motivators such as employer-based incentives, academic incentives, and personal incentives of career opportunities and personal enrichment. tuition reimbursement. a surprising finding was that when finances were not considered an issue 100% of respondents were prepared to seek a bsn and possibly a graduate degree, “the thought of going back is difficult for me because i just can’t afford it ... if i were offered to go to school for free i would go.” and “the hospital offered some tuition reimbursement so i enrolled ... tuition reimbursement really, really helped.” flexibility. flexible scheduling was significant as several participants described how flexibility has or would influence their decision: “i changed jobs so i could work three 12-hour shifts ... my new schedule will give me more flexibility and time for studying.” or “flexibility is a big deal ... i need a schedule that accommodates my full-time schedule” and “if i would be allowed to have a more flexible schedule, i would be interested in going back.” accessibility and convenience. the nurses acknowledged that they face additional challenges of being rural and long-distance commutes when considering rn re-entry. several participants noted an alternative to travel is distance learning. online options were particularly online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 132 appealing, “i chose an online program ... it’s perfect for me. i am older. i have kids. if i actually went back to school full-time and had to leave home for class, i think my husband would divorce me” and another revealed: “what really attracted me (to enroll in a bsn program) was that the program was entirely online. for me that was huge ... i have three children all still home in various activities. i work full-time. i could just not do it ... sitting in a class even one night a week. however, not all of the participants embraced online learning as one participant shared: convenience is huge! one school conducted on-site classes at the hospital; but they are no longer at our site anymore. i am not sure why ... having classes at the hospital is very convenient ... most of us actually live in the area ... i am not driving 40, 50 or more miles to go to class ... and i am not ready for online learning yet ... i am not computer savvy. conversely, for one participant limited band-width was another obstacle to web-based programs, “i don’t have good internet access at home; being in this rural area i am in a dead zone ... so internet is an issue for me at home”. career opportunities. several of the participants are at the point in their careers where they are evaluating future prospects and responded with an optimistic tone when relating the possibilities of opportunity and options with a higher degree: “having a bsn is a motivator as in when the opportunity comes and i want to do it ... i can!” and “with a bsn you have choices, you’re not limited ... i would like to do clinical teaching with nursing students”, another commented, “i am looking for some type of leadership role ... i want to mentor young nurses in a role that will make a difference.” the participants commented that having a bsn would make it easier for obtaining promotions, leadership positions, and possibly an educator role. several of the older participants talked about career mobility and career options in the context of advancing age online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 133 and the possibility of not being able to continue to physically perform in their current staff positions, “i am close to fifty, and at work, it is becoming physically harder to be on your feet. it is a lot of physical labor in which i am getting too old to do.” another participant shared similar feelings, “will i be able to continue the kind of nursing that i am doing now, it is physically challenging ... lugging, and lifting, and pulling, i am feeling my age ... i will need at a bsn degree to change that.” personal enrichment. several nurses talked about a bsn in terms of personal growth and enrichment as intrinsic incentives that influenced their decision, “i enrolled in a bsn program because it is more of a self-growth type of thing that i feel i need to do this” or “i know that my children are watching me as i go to school and i am hoping they see a good mentor.” other’s shared, “i wanted to pursue my career further just for personal achievement and personal pride” and “since i started the bsn program, i am more open-minded, i am learning to look beyond the obvious simple answers and understand the reasoning that goes into the process of nursing” or “i especially like research and evidence-based practice and i know that i will need additional education to make that happen ... i was never satisfied with just doing!” theme 4: support overwhelming responses expressed the need for some type of support in the decision for academic progression. support ranged from the most basic of how to get started in a bsn program, choosing a program, program availability, and the application process, to other types of support from family, employers, academic advisors, and participants’ peers. professional isolation was of particular concern as the participants reported there are few nurses at the bsn or graduate level at the hospital. the nurses noted they are often self-encouragers since there are few mentors or positive role models and they would like that to change, “that (rnbsn) will be an uphill battle online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 134 for me. i believe we need mentors, which we don’t have at our hospital at this time.” others indicated that they “don’t feel supported” regarding continuing education and strongly expressed the desire for more guidance and support in their decision for rn re-entry. employer support was viewed as encouragement for lifelong learning, one participant noted, “my last employer started asking me when you are going to go back to school ... that actually gave me the confidence that prompted me to eventually start a bsn program.” support and encouragement from contemporaries influenced the final decision to go back to school as one rn recounted: i actually considered going back due to my peers prompting me. i work in such a small little hospital where everyone knows who’s going to school or wants to go to school ... we are all supportive of each other. we all trade textbooks, notes ... there’s not much support from administration so we try to support each other ... we’re all part of the sisterhood. limitations limitations includes participant diversity. the setting was a small rural community hospital which limited the ability to recruit a more diverse participant pool specifically regarding gender differences. discussion academic progression can be a challenge for most associate degree rns (burman & fahrenwald, 2018; molanari et al., 2011; probst, 2019; jones-schenk, leafman, wallace & allen, 2017). the rural nurses in this study felt particularly challenged when considering rn-bsn program reentry. findings revealed that system and community support for educational attainment including tuition reimbursement, mentoring, accessibility and flexible scheduling were key factors in their decision. noteworthy, are rural hospitals who for the most part remain under sourced and understaffed which in turn limits the ability to offer much needed incentives for rural rns to online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 135 engage in higher education (burman & fahrenwald, 2018; jones-schenk et al., 2017; probst, 2019). implications for practice include rural hospitals to seek funding and scholarships from local, regional, and statewide entities in an effort to support rural rns in pursuit of academic progression. the findings also revealed that in comparison to urban areas, rural nurses have limited opportunities for professional development which impedes efforts to remain current. supported by the literature, when interacting with larger, metropolitan facilities, rural rns described feeling that they are perceived as under educated and incompetent as compared to their urban counterparts (medves et al. 2015, p. 24). the study findings indicated that by necessity rural nurses often rely on their colleagues for support and information regarding higher education. likewise, social capital through shared experiences and resilience are perceived as powerful bonds for rural nurses (burman & fahrenwald, 2018; younge, myrick, ferguson & grundy, 2013a). implications for nursing education includes nursing programs to develop or revise curricula making higher education for rural nurses affordable, relevant and accessible. similarly, findings revealed that the rns felt misinformed when initially choosing an associate degree nursing program. early advisement and mentoring would facilitate their educational journey for higher education. current efforts for unique academic partnerships and distance learning options are steps in the right direction but remain isolated and need to expand (burman & fahrenwald, 2018). perhaps findings from this study will provide new developments in bridging the ongoing entry level into practice debate. lastly, it is hoped that these findings send a compelling message to legislative bodies and nursing education policy makers for the need to be cognizant to the realities of rural nursing practice and education. a rural lens can assist in developing relevant policies and practices to promote a higher educated rural nursing workforce. online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 136 conclusion higher education in nursing is now a key imperative. findings from this study revealed rare up close and personal perspectives from rural nurses to the struggles and rewards they experience in their decision in academic progression. clearly evidenced from the findings was rural rns have a strong interest in higher education and are motivated by the need for a bsn specifically in regard to job security, professional identity, professional development, and career mobility. still, they want their voices to be heard regarding the unique challenges that rural nurses face in the pursuit of a bsn, especially regarding the need for mentoring, employer support and financial resources. health care employers and academic administrators have the responsibility to assure that all nurses are prepared for the challenges in healthcare for the 21st century. educating and supporting practicing nurses as well as those entering the profession of the appreciable benefits to higher education is paramount in providing a more qualified rural nursing workforce equipped to meet the growing healthcare needs of rural populations. recommendations for further research this study provided the foundation for further research to quantify and analyze the efficacy of academic progression and the effect on patient outcomes in rural areas. further research is needed on the efficacy of academic progression in increasing the numbers of advanced practice nurses in rural areas. considering the importance of finances, research to explore the relationship between financial assistance for higher education and the impact on 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(2013a). “you have to rely on everyone and they on you”: interdependence and the team-based rural nursing preceptorship. online online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 140 journal of rural nursing and health care, 13(1), 1-23. retrieved from https://rnojournal.binghamton.edu/index.php/rno/article/view/216 online journal of rural nursing and health care 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.608 141 appendix a each interview began with social greetings, which created a warm, friendly atmosphere inviting casual conservation. what followed was a review of the informed consent that had been previously distributed. it was stressed that the interview would be audio-recorded to preserve the integrity of the data and that the interview would last up to one hour; each participant reconfirmed consent to be recorded. 1.“tell me about your decision to choose nursing”. the broad statement was intended to yield rich information on the participants lived experience in the decision to choose nursing as a career. probes, “what influenced your choice on nursing school”? “tell me how you feel the nursing program prepared you for the expanded roles in nursing”? “can you give me a for instance? probing helped unfold implications and dynamics of the initial question. 2. “what are your thoughts on moving forward in your nursing career”? “can you give me an example”? “tell me about where you see yourself as a nurse in the next five years”? 3. “what are your thoughts on furthering your nursing education”? “what does back to school mean for you”? “tell me about your personal view of obtaining a bsn degree”? “how would you describe personal challenges, if any, in pursuing a bsn”? “what would motivate you to go back to school”? can you tell me how you would direct someone interested in a nursing career”? can you explain why? the researcher adjusted throughout the interview process such as “can you tell me more about ... or can you expand on that point?” ending with 4. “is there anything else you would like to share?” participants were invited to share thoughts, reflections, or feelings on nursing. manuscript 1401009 48 deep roots support new branches: the impact of dynamic, cross-generational rural culture on older women’s response to formal health care christine m. eisenhauer, msn, aprn-cns¹ jennifer l. hunter, phd, rn² carol h. pullen, edd, rn³ ¹assistant professor, department of nursing, mount marty college, cme7f6@umkc.edu ²assistant professor, school of nursing, university of missouri-kansas city, hunterj@umkc.edu ³professor, college of nursing, university of nebraska medical center, chpullen@unmc.edu key words: culture emergent, rural, older women, nursing, case study abstract rural, older adults experience marked disparity in access to quality health care when compared to their urban counterparts. one aspect of promoting health access to these individuals that has received little attention is rural cultural competence. semi-structured interviews and review of cultural artifacts informed this case study of a rural, community-dwelling, 83 year old woman who is co-managing her chronic disease with the formal healthcare system. the purpose of the study was to situate the life story of one rural, elderly woman within the context of the rural culture that she has experienced, and, through the application of bonder, martin, and miracle’s (2002) culture emergent theory, illuminated the theoretical and practical aspects of how dynamic culture influences health care practices and nurse-client encounters. recommendations discussed include individual and system level strategies for developing cultural awareness, cultural knowledge, cultural skill, methods for participating in cultural encounters, and considerations for growing cultural desire. these strategies are considered imperative for the promotion of culturally competent rural nursing, nursing education, and rural patient advocacy. introduction the increasing healthcare needs of the growing population of rural, older adults (age 65+) are a primary concern today amidst a rapidly changing rural culture and continued disparity in healthcare quality and service access (cox, mahone, & merwin, 2008). in this case study, the reader will meet “sarah” (a pseudonym), an 83 year old, rural woman who has been a lifelong resident of the midwestern plains. the purposes of this case study were (1) to illustrate evolving rural health beliefs and practices through a case study of an older woman residing on the midwestern plains, (2) to situate this case within a larger, dynamic rural culture by applying bonder, martin, and miracle’s (2002) culture emergent model, and (3) to utilize the case exemplar to elucidate opportunities for integrating culturally competent approaches into nursing care for rural, older adults, both for patient satisfaction and improved healthcare outcomes (bushy, 2008; starr & wallace, 2009). online journal of rural nursing and health care, vol. 10, no.1, spring 2010 http://www.mtmc.edu/academics/majors/nursing/index.aspx mailto:cme7f6@umkc.edu http://nursing.umkc.edu/ mailto:hunterj@umkc.edu http://www.unmc.edu/nursing/ mailto:chpullen@unmc.edu 49 methods this case study was drawn from a larger study of rural healthcare needs done in the fall of 2007. the study was approved by the institutional review board and informed consent was obtained from participants. methods included semi-structured interviews collected through digital recordings and anecdotal notes, all which were transcribed for data analysis. data was also collected through review of participant observation notes and cultural artifacts such as newspapers, photographs, and diaries. data was reviewed by the key informant to verify accuracy three times throughout the analysis process. interviews were conducted with a retired, rural health nurse; a rural clergyman; and the woman in this case study, who had been a longterm resident of a rural, midwestern community. this elderly woman, who will be called sarah, shared many aspects of her life with one of the investigators through multiple interviews in her home, albums of family pictures, and newspaper clippings. excited about being part of this research, sarah voluntarily wrote a reflective health diary in which she recorded memories of significant health and illness events throughout her life course. writing the diary allowed sarah to narrate what she considered to be significant behaviors that contributed to illness and health in her family, her beliefs about the efficacy of chosen treatments, and patterns of health preservation in daily activities. collectively, these documents provided cultural artifacts that helped sarah reproduce an in-depth recollection of her life and health history. she expressed her memories through a poignantly rural perspective of self-reliance and community interdependence. her stories illustrated both the strongholds of rural survival and the changing aspects of rural culture as it is now lived out among her own (now older adult) children and continuing generations. this case study highlights some of the distinct cultural differences across historical cohorts, while enlightening similarities that endure across rural generations. background rural, older adults in the midwest experience vulnerability from multiple demographic effects that must be considered when assessing their health needs. historically, the majority of rural, older adults tend to be widowed females, with up to 27% having less than a ninth grade education (rural assistance center, 2009; smith, 2003). presently, midwestern older men are more likely to have higher educational attainment than women. this gender difference contributes to an educational disparity among elderly women with lower lifetime earnings contributing to rising poverty rates (15.5%) and poorer healthcare access (u. s. department of agriculture economic research service, 2007). many rural landscapes in the midwest have sparse populations scattered across vast territories. neighbors, friends, and family are often geographically distant in proximity from each other in comparison to urban communities, and individual households must be fairly selfsufficient for survival. rural, older adults manage their health care in general isolation, separated geographically from healthcare providers, supportive services, and often emotionally from their community (goins, williams, carter, spencer, & solovieva, 2005). structural factors, such as lack of transportation and long distances to healthcare services staffed with medical specialists, serve as barriers to accessing care. rural, older adults may have other reasons for not seeking formal care, such as mistrust of health providers, fear of hospitals, misunderstanding of program online journal of rural nursing and health care, vol. 10, no.1, spring 2010 50 qualifying guidelines, and failure on part of the healthcare providers to communicate meaningfully with this population (harju, wuensch, kuhl, & cross, 2006; li, 2006). as a result, rural older adults have developed pride in remaining self-sufficient, demonstrating interdependence only with trusted structures within their rural community. there are social, interactional, and cultural dimensions within these rural communities of geographically distant neighbors that involve an emotional closeness, reciprocal giving, and an informal healthcare network (sebern, 2005). related to this informal healthcare network, as well as to families’ limited resources, a cultural norm is that rural, older adults put off seeking formal healthcare until their health needs are no longer manageable through self care efforts and the help of family, friends, and neighbors. formal health care is sought more as a last resort for illness care rather than as an ongoing source of prevention and health promotion (hayes, 2006). this pattern has been observed in other environments of poverty, scarcity and underdevelopment (johansson, 1991). rural, older adults’ historic need for independence has led to self care practices that take advantage of local resources, including the use of and belief in home remedies as fundamental to their healing. herbal medicine is a central strategy for health protection and disease selfmanagement, used by up to 62% of midwestern older adults (shreffler-grant, hill, weinert, nichols, & ide, 2007). midwestern rural elders also use the highest number of the over-thecounter medications in the form of analgesics, laxatives, and nutritional supplements for self care than any other u.s. elder group (hanlon, fillenbaum, ruby, gray, & bohannon, 2001). although effective to an extent, rural dwellers’ familiar and accessible health resources remain limited to herbs and over-the-counter drug store medications due to continued geographic isolation, poor economic conditions, and the accepted norm of self-reliant health seeking patterns (easom & quinn, 2006). with the technological advances in online information sharing, however, rural, older adults are expanding their social networks to include both traditional and online health information sources. up to 41% of american adults, age 65+, report using the internet as a health information source. however, they are most commonly getting their information from family members who are accessing online reviews posted by other healthcare users (fox & jones, 2009). the threads in the patterns of rural life, as discussed above, are clearly illustrated in sarah’s life story, below. sarah’s story sarah was born in 1924 to parents who farmed during the dust bowl era with its windy, sweltering summers and frigid winters. sarah grew up in a small farmhouse without electricity and with a cook stove as the only source of heat. sarah described each family member having a specific role that was necessary for the survival of the household. sarah’s jobs were picking up corn cobs from the pig pens and chopping wood for the family to burn in the cook stove. some routine activities that promoted survival also contributed to health. saturday was bath day, because that evening the family would go to town to sell eggs and milk. a large copper boiler was filled with hot water in the kitchen and towels were draped over the chairs to provide privacy. “mother kept us well by always keeping us clean and warm,” sarah said. while bath day contributed to cleanliness, hot clothes-pressing irons contributed to warmth. the irons were online journal of rural nursing and health care, vol. 10, no.1, spring 2010 51 wrapped in wool socks and placed at the foot of the bed to keep cold feet warm at night. water boiled on the wood cook stove provided humidity to keep everyone breathing well. sarah attributed a great deal of her health as a child to the basic demands of her rural environment. “daily walks to and from country school kept us well; reading by kerosene lamps made my eyes stronger.” sarah also valued the contribution of nutrition to health. “we drank lots of water. we always had fresh eggs and milk and we ate home-raised garden vegetables throughout the year that we preserved by drying or canning.” sarah’s only memories of going to the doctor were in times of emergency, such as her brother’s appendicitis and her mother having all her teeth pulled due to gingivitis. most of the injuries and illnesses that occurred during sarah’s childhood were managed at home or with the help of neighbors. “mother and i would walk a mile to the neighbor’s home to dress her wounds every day. we would also take things along for the neighbors to eat. we work together to get what needs to be done. we never let each other down, we were always willing to help out and work.” upon graduation from school in 1941, sarah married a neighbor boy, dwight, who drove the school bus for her township. they moved in with his mother one month after marrying when, concurrently, dwight’s father died, a drought caused loss of production and income, and foreclosure on his parent’s farm loomed as a threat. sarah described this time as happy, but with lots of hard work milking cows and tending to the animals during the day. she gave birth to the first of her two children two years later, and her mother-in-law helped care for them. in times of injury or illness, sarah treated the family maladies, including both minor and chronic ailments, with supplies from their medicine cabinet. these included common locally known treatments such as mustard plasters for respiratory ailments, vanilla for burns, turpentine for open wounds, alcohol for fever, mentholatum salve applied to the bottom of feet for colds, epson salts for swelling, mercurochrome for infections, aspirin for pain, bag balm for sore breasts, and a hot water bottle for sore throats and ear aches. sarah did not believe in smoking or drinking alcoholic beverages. she valued getting lots of exercise with farming and involving their children with the livestock to decrease stress and maintain her family’s health. in 1948, sarah’s family experienced a series of catastrophes. a blizzard arrived on november 18th that kept them homebound for months and without coal to burn for heat. dwight cut and gathered wood for the furnace, and when wood became impossible to find, the red cross airdropped coal in their front yard. to make matters even worse during this time, sarah’s mother-in-law was dying of cancer and required 24 hour care. “we were both so wore out. he did chores and cut wood all day and then would sit with his mother at night so i could get some rest.” during the last two weeks of her life, her mother-in-law’s pain became so intense that the army flew in the community doctor to provide her with medicine. when she died, the weather required the army to use a bulldozer to transport the family to town so funeral arrangements could be made. “it’s your faith that carries you through the tough times. i am thankful to god for showing me the way to cope with stress.” sarah’s life progressed happily on their farmstead. her children graduated from high school, married, and developed professional careers which moved them to more distant regions of the state. sarah then worked outside the home as a social services advocate in her county, enjoying socialization with new people. sarah and dwight remained on the farm throughout their older adult years. “we rented out the land but kept our cattle. after all, you have to have some work to do on the farm to stay happy.” online journal of rural nursing and health care, vol. 10, no.1, spring 2010 52 sarah survived significant health events during her older adulthood that required functional assistance and emotional support. sarah described losing her functional independence after a stroke in 1993 as her most difficult and stressful life event. she struggled to keep a positive outlook. “it’s strange how sometimes you find out things about your health you didn’t know. you have to be thankful to god for showing you the ways to cope with the stress. you have to have a positive outlook on life. you can’t dwell in the past. you do what you can to change and if you can’t, your faith carries you through the rough times.” sarah described how her life changed as a result of her stroke. her daily routines were disrupted with frequent doctor and physical therapy visits, the need to arrange transportation, traveling long distances, and being away from home for several hours. sarah felt that getting formal medical care, adapting to the new medicines and treatment regimens, including an eventual pacemaker, progressively lessened her autonomy and quality of life. she feared she might not be able to afford these treatments or manage them at home. sarah was frustrated by her inability to comprehend the health information she was given during doctor visits. “they don’t explain things in our language; they don’t give reasons why you need to take the medicine.” sarah said she did not always take her prescribed medication as ordered because she didn’t understand its purpose in treating her ensuing heart failure. sarah commented tearfully that it was nurses’ support and encouragement that helped her get through these tough times. “i had a 1-800 number i could call and ask the nurses questions. they were so nice and always helpful. i don’t know what i would have done without them.” medicare benefits were also difficult for sarah to comprehend and inhibited her desire to seek medical care, specifically when she received letters of non-coverage for healthcare services that resulted in high out-of-pocket costs for her. lacking satisfactory explanations from her physicians about her health, she did not understand what symptoms warranted seeking further care. she felt her physicians did not understand her life or her suffering. “i felt like, oh, you don’t know how much it hurts to do this.” over the years, as sarah watched her children grow up, she saw a change in how this new rural generation approached and managed their health and illness. “my kids are more aware of what services are out there to fulfill their needs. in my days, you were your own boss. now with these government programs, there are a lot of regulations to comply by. these kinds of changes are stressful.” not everything is negative for sarah in spite of the advancement of her chronic illnesses. she reports receiving a sense of love and belonging from her connections with her husband, family, friends, neighbors, their farmland, her dog, and her guinea bird. she continues to reach out and help her children and grandchildren through daily phone calls with them. she also sends cards to and calls homebound friends, as well as sends food and back issues of newspapers and magazines to neighbors. sarah now embraces the improved socialization and independence she is able to maintain as a result of technology. “i do my shopping from home. my daughter is in the city, 70 miles away. she calls me from the store and i tell her what i want. thank god for cell phones.” thus, sarah’s local social interactions, in combination with her embracing of communication technology, form a web of connectedness that bridges sarah with friends and family at a distance while maintaining her sense of rural identity. online journal of rural nursing and health care, vol. 10, no.1, spring 2010 53 application of culture emergent theory bonder, martin, and miracle’s culture emergent theory (2002) posits that individuals undergo changes in their cultural patterns over time through interactions with the environment and society around them. cultural structures learned early in childhood are reinforced and negotiated as individuals experience new encounters over their life course. these cultural configurations influence beliefs and practices regarding health and illness care by creating dynamic decision-making boundaries. five constructs guide the culture emergent process: culture is learned, culture is localized, culture is patterned, culture is evaluative, and culture has continuity with change. culture is learned rural health lore is passed down through generations transmitted through observation and conversation. as new beliefs, values, and behaviors emerge from understanding different interactions, the learned culture is evaluated and subsequent group identity transformations occur (bonder, martin, & miracle, 2002). sarah’s choice to delay seeking formal care is best understood through her cultural history of relying on lay remedies for self-care practices. these patterns over time became her rules for illness behavior, even as other options were becoming available. thus, sarah continued to act on learned culturally-designated decision markers, influenced by geographic isolation, her underinsured status, her historic need to learn and use self-care practices and lay remedies, and her pride in her autonomy and ability to work despite illness. only when sarah’s disease symptoms became debilitating, hindering her ability to accomplish daily household tasks, was the learned decision point on the rural continuum of where “healthy ends” and “ill-begins” triggered (johansson, 1991). accordingly, formal healthcare was sought when sarah had her stroke, but she perceived the ongoing health maintenance care needed after the stroke as a threat to her quality of life through loss of autonomy. she feared she would not be able to afford new treatments or manage at home independently. sarah’s case reflects how poor accessibility and affordability of healthcare for rural dwellers impose a restricted definition of what it means to be “ill”. in other words, rural, older adults are forced culturally and financially to manage their maladies independently without disrupting their task-performing role. it is not until an acute disease crisis forces their seeking of formal help that they consider themselves “ill”. culture is local health information is understood based upon local ideals, traditions, and norms. localizing information is what makes it meaningful to both the nurse and the patient. with each clinical encounter, only part of the older person’s rural norms are revealed based upon the social context and topic of discussion. misunderstanding the rural cultural context can result in missed opportunities for nurses to clarify poorly understood information (bonder, martin, & miracle, 2004). sarah’s frustration with medical encounters, for example, was largely due to receiving communication that was not presented in a localized language or context. the lack of culturally embedded meaning in the medical language coupled with the authoritative social status of the online journal of rural nursing and health care, vol. 10, no.1, spring 2010 54 physicians hindered sarah’s discourse with them. sarah’s poor understanding of the medical language lead to her lack of adherence with illness care instructions, because she did not understand the purpose of the medication or what symptom severity would warrant seeking further assistance. sarah understood lay remedies much better and trusted them more because their purpose and use had been shared over generations in a language common to her community. culture is patterned rural culture is patterned from both individual and social behaviors that become ritualized to the degree they translate into expressions of group affiliation (bonder et al., 2004). sarah’s self care practices are influenced by historic, economic, educational, and environmental factors that have reinforced patterns of use and her belief in home remedies as fundamental to healing (shreffler-grant et al., 2007). sarah reports her basic daily needs for maintaining health as a stable environmental temperature, a balanced diet of home grown foods, daily exercise through work, prayer, “cleanliness” through regular bathing, and stress management through caring for her farm animals. sarah maintains and promotes her health in the same ways as her parents and neighbors had. sarah’s extensive use of home remedies for treatment of illness prior to seeking formal care is reinforced by several factors: (1) the easy accessibility via traveling salesmen, radio, and mail order catalogs; (2) local knowledge about and affordability of the remedies; (3) the marketing of many home remedies as appropriate for use in both animals and humans which promoted understanding of their indications and usefulness; (4) repeated successes in treating illnesses with home remedies and; (5) reinforced confidence in the efficacy of their use. formal healthcare is used sparingly and is perceived to be less effective for the treatment of health problems due to the numerous barriers surrounding its use. while sarah reports using formal care more than her parents had, the use of home remedies for health maintenance is not diminished, for many logical reasons. culture is evaluative rural values are culturally engrained and influence one’s sense of identity and social belonging. however, these values are constantly re-evaluated in terms of their relevance to the specific context (bonder et al., 2002). rural, older adults value a stoic, self-reliant attitude which places emphasis on self-responsibility for health (bushy, 2008). this rural value includes maintaining a positive attitude despite increasing functional limitations. when sarah’s environment changes due to illness demands that challenged and blurred the boundaries of her usual health behaviors, it forced her value system to change. she chose to positively adapt to the changes around her (bonder et al., 2002). sarah’s new values are built upon existing values and knowledge that rural culture had reinforced through social interactions and personal experiences over time (bonder et al., 2004). sarah’s acceptance of her difficult transitions are as always, supported through her strong faith in god and the encouragement of her family and friends. these pillars help sarah maintain a positive attitude, accept her functional limitations, and redefine a satisfactory quality of life, which allowed her to realize new opportunities in life and improve her overall satisfaction with her well being. online journal of rural nursing and health care, vol. 10, no.1, spring 2010 55 culture has continuity with change a culture has aspects that remain stable across time, as well as many aspects that constantly evolve as new generations bring innovative, contemporary ideas to assimilate into their environment (bonder et al., 2004). sarah’s value for self reliance, home remedies, and family care-giving persisted across her life course into her children’s generation. while sarah provided in-home care for her mother-in-law, sarah’s children care for her with the aid of technology that provides immediate accessibility but still supports the rural cultural preference for independence. remaining rooted in her basic rural values has given sarah the stability to reach out and try new things. she has integrated formal healthcare and prescription medications into her illness management and has found that information accessed through the tv and internet (via her children) provide her a large venue by which formal and complementary therapies can be accessed and researched. the new generation of formally educated, technologically savvy older adults serves as a resource to yet older generations (“their parents”) and demand rural healthcare services that both support their preference for independence and provide immediate accessibility. each new generation and each new development in society will influence cultural knowledge and patterns as new experiences and environmental changes are encountered. nurses can play a key role in addressing the needs of both the oldest-old and young-old generations of rural adults by understanding that cultural transitions are continual and normal (hartley, 2004). the dynamic nature of rural culture requires that nurses seek ongoing cultural encounters and continual refinement of cultural awareness, desire, skill, and knowledge toward cultural competence. implications for nursing culture constantly changes as it is created through the burdens of history and then is socially transmitted across generations (pierpont, 2004). the lens through which culture is viewed has shifted from a static image of unchanging rules, beliefs, and behaviors to a dynamic image of continual change and adaption. thus, becoming culturally competent as a health caregiver is not an end point but rather a life-long process. campinha-bacote (2003) theory of cultural competence provides a simple, yet comprehensive framework guiding this ongoing process, which involves five aspects of growth and learning: cultural awareness, cultural knowledge, cultural skill, participating in cultural encounters, and possessing and growing cultural desire. cultural awareness and desire cultural awareness, per campinha-bacote (2003), involves knowing one’s own cultural values, beliefs, lifeways, and practices as well as increasing one’s knowledge and sensitivity to those of others. promoting cultural awareness in nurses who care for rural, older adults requires that nurses take time to reflect on their own place in relation to rural culture, and to become aware of their assumptions about rural elder’s cultural norms and how they think these beliefs and behaviors affect elders’ healthcare. cultural awareness can be greatly expanded by seeking cultural knowledge. online journal of rural nursing and health care, vol. 10, no.1, spring 2010 56 being more culturally aware, gaining more cultural knowledge through literature and cultural assessment of clients, hearing life stories, participating in cultural encounters, all tend to further increase cultural desirethe desire to know and apply even more culturally relevant approaches to nurse care (campinha-bacote, 2003). on an individual level, these five aspects of learning and practice can promote rural nurses’: (1) knowledge and respect for historic methods of survival, including healing ways, passed down through generations, (2) willingness to and skill in being the learner and listener to stories, and (3) ability to create nursing interventions and education that balance and integrate long term cultural norms with ideas that are newly emerging. rural knowledge cultural knowledge is the process of seeking and obtaining a sound educational base regarding various viewpoints of different cultures, and knowledge regarding specific social, biological, and physiological variations among ethnic or other cultural groups (campinhabacote, 2003). knowledge of rural culture, which can be gained from research literature as well as from rural residents themselves, provides nurses a basis for informed critical thinking about the logic of rural elders’ behaviors. it forms a foundation for comparison between often stereotypical “group” cultural norms and the “individual” culture of each client, whose behaviors and beliefs are affected by both group influences and individual experience. this knowledge is important to gain accurate insights into reasons for each person’s health behaviors. seeking such knowledge from individuals requires development of one’s cultural assessment skill. cultural assessment cultural assessment skills greatly improve the ability of nurses to gain individual cultural information. a variety of cultural assessment tools exist (giger & davidhizar, 2004; purnell & paulanka, 2008; spector, 2004) and can be adapted to the situation and time available. these tools provide guidelines for creating questions that, ideally, encourage clients to “tell their story.” liehr and smith’s (2008) story theory, recently described by gobble (2009), offers much guidance regarding dialoguing with rural women and illustrates the power of this approach. this theory is based upon the view that “humans are born into an ongoing story or history (reed, 1995 in gobble, 2009, p.101). stories unfold, as did sarah’s, as individuals interact with each other and their environment. stories, like culture, are dynamic and emerge over time. story theory also “acknowledges that one’s story continues even as it is being told” (gobble, 2009, p.103). maintaining an ongoing dialogue will help understand how the rural, older adult perceives both the communication and assimilation of the nursing intervention into their ever changing cultural context. nurses, as a result, will develop improved listening and observation skills with rural, older adults when attempting to critically assess how their lived experience has shaped their ideals for care support amidst their changing health status (bonder et al., 2004). stories reveal an individual’s deep rooted values and beliefs and how those interact with health and illness decisions. deep roots can be built upon and can support the growth of new ideas as well. online journal of rural nursing and health care, vol. 10, no.1, spring 2010 57 cultural encounters nurses should also create cultural encounters for themselves outside the health care setting to better understand the social aspects that surround rural living. shopping at the local market or dime store, attending a parish soup supper, or having coffee in the small town bakery presents opportunities for learning the local language and understanding the discourse surrounding community living and health. a trip to the local pharmacy will also be valuable to learn about common herbal supplements requested by older adults and the types of home remedies frequently used. gaining understanding of the local cultural context through these experiences will help the nurse incorporate meaningful approaches into client teaching. on a systems level, integrating of rural nursing theory, rural bioethics, and rural clinical practicum into nursing program curricula will not only promote development of rural cultural competence but also promote nursing students’ desire to serve rural communities. finally, cultural understanding of how health and illness behavior is locally defined and morally influenced by rural values and beliefs will assist nurses in surmounting contextual challenges when developing patient advocacy resources (cook & hoas, 2008). conclusion culture is complex, multifaceted, and constantly changing and growing. rural culture is no different. the case study of sarah illustrates the power of story to provide a personalized, contextualized understanding of the influences and logic of both group and individual cultural norms on health and illness. within sarah’s world are others like her, a population of lifelong, rural dwellers who hold and are supported by deep roots: traditional rural beliefs and pride in their independence, self reliance, and community interdependence. younger generations, tomorrow’s older adults, include the more educated, technologically savvy baby boomers who have branched out to value the immediate accessibility of information and services spawned by the internet, but who continue to be rooted in the values of independence and self-reliance learned from their rural upbringing. this pattern continues, with the youngest generations taking for granted that cyberspace can immediately span the distance between households and services within a rural landscape. the simultaneous existing of cross generational cultural worldviews calls for rural healthcare services that nurture the deep rural roots of independence and interconnectedness with community, yet, branch out into the provision of immediately accessible communication, information, and services that technology can now offer. both the roots and the branches must be balanced. growth of new branches will soon topple a tree with weakened, unnurtured roots. references bonder, b., martin, l., & miracle, a.w. 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(2007). rural america at a glance: 2007 edition (report no. 31). washington, d.c.: u.s. department of agriculture. http://www.ncbi.nlm.nih.gov/pubmed?term=16164478%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=17179871%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=19154192%5buid%5d&cmd=detailssearch 716_+concept+analysis+main+document_graves+edits+formatted online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 65 the rural profile: a concept analysis kristin pullyblank, ms, rn, phd candidate student, decker college of nursing and health sciences, binghamton university, kpullyb1@binghamton.edu abstract purpose: it has been well-documented that rural communities experience poorer health outcomes than urban or suburban communities. the contribution of various structural and sociodemographic factors to this disparity has been well studied. however, research on the impact of the rural profile on health outcomes is understudied, in part because what it means to “be rural” has not been well defined nor operationalized. methods: walker and avant’s traditional concept analysis method was used findings: the rural profile was defined as the set of personal attitudes, beliefs and behaviors that are typically informed by the structural and demographic elements found in less densely populated areas. the attributes of the rural profile are self-reliance, close community and family ties, and an emphasis on place. observable indicators for each of these attributes based on previously published research are discussed. conclusions: while conceptualizing the rural profile is challenging, it is imperative to define and operationalize this concept in order to better address the health needs of rural people and communities. keywords: concept analysis, rural, health behavior, rural beliefs online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 66 the rural profile: a concept analysis it is becoming increasingly clear that rural dwellers have distinct definitions of health. their healthcare needs require approaches that differ significantly from urban and suburban populations. subcultural values, norms, and beliefs play key roles in how rural people define health and from whom they seek advice and care. these values and beliefs, combined with the realities of rural living –such as weather, distance and isolation–markedly affect the practice of nursing in rural settings (long & weinert, 2018, p. 28). the above excerpt indicates that nursing and other health professionals cannot dismiss the influence “being rural” has on health outcomes in rural populations. there is a large body of multidisciplinary research that has found rural people have worse health outcomes than their urban counterparts (aggarwal et al., 2021; cosby et al., 2019; moy et al., 2017; yaemsiri et al., 2019). thomas et al. (2014) has highlighted how a lagging rural economy, lack of investment in rural areas, and geographic isolation have all contributed to health disparities. however, there is a lack of research on the role that the rural profile plays in these health outcomes. part of the issue for this gap may be due to the difficulty of defining, operationalizing and measuring the concept. purpose and method the intent of this concept analysis is to uncover the attributes of the rural profile, determine how these attributes may impact health, and examine how the rural profile can be effectively operationalized. in doing so, nurse scientists and other rural health researchers will be able to better understand rural behavior and attitudes as they pertain to health care access and health outcomes. walker and avant’s traditional approach guided this concept analysis. for the purposes of this analysis, the following steps were employed: select a concept; determine the aims or purposes online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 67 of analysis; identify all uses of the concept; determine the defining attributes; identify the antecedents and consequences; and define empirical referents. findings uses of rural profile rural as defined by the oxford english dictionary is “relating to or characteristic of the countryside rather than the town” (oxford english dictionary, n.d.a.). the term has been both conceptually and operationally defined in a myriad of ways. profile is defined as “a record of person’s psychological or behavioral characteristics, preferences, etc.” (oxford english dictionary, n.d.b.). as a phrase, rural profile and its related terms of rural values, rural attitudes, and rural identity have been used in a variety of sociopolitical contexts to help explain differences that are observed along the urban-rural continuum. for example, there is a large body of literature examining how the rural profile or rural values impact politics and society at large (lynch et al., 2018; lyons & utych, 2021; nemerever & rogers, 2021; trujillo, 2022) as well as more discrete issues such as environmental conservation and sustainability (bonnie et al., 2020; brinkman & hirsh, 2017; diamond, 2021; firlein, 2018), and educational attainment (agger et al., 2018). this body of literature largely frames rural communities as struggling to exert their agency and influence in a society that is based on urban policy. in nursing and other health disciplines, the rural profile has been overshadowed by a focus on how the structural elements of living in a rural area lead to health disparities (anderson et al., 2015; behrman et al., 2021; hartley, 2004; matthews et al., 2017; moy et al., 2017). traditionally, many health researchers have emphasized the modifiable risk factors (e.g. higher smoking rates, online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 68 lower physical activity rates) in rural communities, and invariably suggest the correlation between education, income, access challenges, and health outcomes. more recently, there has been a focus on the phenomenon of syndemics (miller & vasan, 2021), which are defined as “clusters of synergistic health problems precipitated by structural inequalities associated with poverty, racism, and other forms of social exclusion, displacement, exploitation, and oppression” (miller & vasan, 2021, p. 6). regardless of the approach in public health, the primary rural discourse in the health disciplines has been deficit-based instead of acknowledging the unique strengths that come from identifying as being rural (afifi et al., 2022; bourke et al., 2010; poulin et al., 2020; simpson & mcdonald, 2017). despite the reference to a unique rural profile in the literature, rural is still predominantly tied to geographic place and the use of various government geographic designations (bennett et al., 2019; brown & schafft, 2019; ratcliffe et al., 2016). the united states census bureau, the united states department of agriculture–economic research services, and the office of management and budget all classify rural slightly differently (fahs & rouhana, 2021). while widely used, these operational designations can be discordant with people’s own identification of “being rural” (onega et al., 2020). mao et al. (2015) described how place-based measures of rurality lead to an ecological fallacy. in other words, while health behavior outcomes (e.g. diet, physical activity, monitoring blood sugar) are measured at the individual level, place-based rural designations cannot practically be smaller than a census tract. yet any associations between these individual outcomes and rurality must be aggregated at the level of place (e.g., county, zip code, etc.) and therefore, by definition, cannot infer individual experiences. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 69 bennett et al. (2019) recognized that these current classification systems are flawed, and argued that not only are the inconsistencies in defining rural confusing, but they may bias interpretation of research findings. bennett and colleagues suggested the necessity of incorporating elements of the natural environment and local residents’ perceptions of rurality when operationalizing rural. however, operationalization of the term cannot occur until what it means to “be rural” is defined. while rural researchers recognize that the structural and demographic characteristics of living in rural places (e.g. older populations, lack of anonymity, limited resources, economic decline) inform the rural profile (brown & schafft, 2019; cheesmond et al., 2019; keller & owens, 2020; molinari & guo, 2018; oser et al., 2022; ulrich-schad & duncan, 2018), more research is needed to address how the rural profile itself can influence health outcomes. therefore, for this concept analysis, the rural profile is defined as a set of personal attitudes, beliefs and behaviors that are typically informed by the structural and demographic elements found in less densely populated areas. defining attributes researchers who study rural populations, regardless of the discipline, consistently described the vast heterogeneity of rural populations (afifi et al., 2022; brown & schafft, 2019; farmer et al., 2012; simpson & mcdonald, 2017) and therefore defining the rural profile is challenging. however, self-reliance, an emphasis on close community relationships, and a recognition of the value of place were constructs that were nearly ubiquitous in the rural literature. self-reliance, as a construct, is related to hardiness, independence, resilience and individualism (bacsu et al., 2017; bernacchi et al., 2021; collins et al. 2009, keller & owens, online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 70 2020; kuntz et al., 2018; wagnild & torma, 2018). numerous studies have explored the concept of self-reliance in rural communities and have identified it as one of the factors that contributes to the differences in health seeking behaviors between rural and urban populations (deguzman et al., 2022; starcher et al., 2017), particularly mental health seeking behaviors (fennell et al., 2018). self-reliance has been characterized as a learned skill that emphasizes autonomous decision making and independence (lee et al., 2022). according to the updated rural nursing theory, the concept of self-reliance pertains to the ability to maintain health without seeking help from others (lee & mcdonagh, 2022). close community relationships includes recognizing the importance of both family and social networks and incorporates the ideas of neighborliness and reciprocity (bonnie et al., 2020; keller & owens, 2020; maclaren, 2018; phillips & mcleroy, 2004; skrocki et al., 2022). simpson and mcdonald (2017) described community as one of three values that must be considered when thinking about the ethics of rural health care. rural communities are tightly knit often because there are fewer opportunities for relationships, and a smaller choice of friends and social networks. maclaren (2018) described how rural populations are shaped by and shape the rural communities in which they live. rural areas should not be dichotomized based on population densities or distances to the nearest metropolitan area. rather, they have to be put into context so that the cultural, socioeconomic, and sociopolitical factors which construct health experiences can be understood (poulin et al., 2020). this idea of understanding how people interact with the space in which they live is also connected to the third construct of the rural profile, which is an emphasis on place. simpson and mcdonald (2017) referred to three understandings of attachment to place: affective, cognitive, and online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 71 behavioral. the affective, or emotional attachment understanding, is evident in the rural literature. while many rural areas’ economies are no longer extraction based, the connection to place and specifically the land as it was traditionally used, was a strong theme in the literature. there is a sense of nostalgia for the “heritage of what used to be” (ulrich-schad & duncan, 2018, p. 76). in a study by bonnie et al (2020), 60% of rural respondents strongly agreed that where they live is an important part of their identity. at a cognitive level, individuals often incorporate thoughts of the place into their identity and the way in which health care decisions are made can be influenced by this value of place (simpson & mcdonald, 2017). antecedents and consequences antecedents to the rural profile include having lived experience within a rural community (either directly or vicariously), and feeling as if one belongs in that community (brown & schaftt, 2019). belonging is necessary because it facilitates the embodiment of place. consequences are the outcomes of the concept (walker & avant, 2019). if a person has a strong rural profile that person typically has substantial social capital (brown & schafft, 2019; mayer & buttler-nelson, 2018; phillips & mcleroy, 2004) as well as substantial mistrust or distrust of outsiders and newcomers (bernacchi et al., 2021; bonnie et al., 2020, brown & schaftt, 2019; lee et al., 2018). both of these consequences are related to the traditional “deficit discourse” of rurality. rural individuals can often feel as if they are not worthy, or are treated as second class citizens. this phenomenon is true for medical practitioners as well. there is an implicit bias that if a practitioner is working in a rural environment, it means the practitioner was not skilled enough to work in an urban environment and therefore the quality of care will be lower in rural areas (simpson & mcdonald, 2017). the implication of these consequences is that individuals with a online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 72 strong rural profile may not seek health care through formal avenues as readily as others (skrocki et al., 2022). when they do seek health care, it is often for acute matters, or matters pertaining to their children, and there is not an emphasis on preventive care (earle-richardson et al., 2015; mize & rose, 2019). empirical referents the last step of walker and avant’s concept analysis method is identifying the empirical referents. these are observable indicators whereby one “can recognize or measure the defining characteristics or attribute” (walker & avant, 2019, p. 180). most of the literature describing the rural profile or similar terms is qualitative in nature. the attributes are named, but they are not typically operationalized. however, there are a few studies that have attempted to define indicators for various attributes of the rural profile. mansfield et al. (2005) developed the barriers to help-seeking scale which contains a “need for control and self-reliance” subscale. items on this scale that are useful observable indicators for the attribute of self-reliance include: “i would think less of myself for needing help”; “i’d feel better about myself knowing i didn’t need help from others”; “i do not want to appear weaker than my peers”; and “i like to make my own decisions and not be too influenced by others.” paskett and colleagues (2020) developed indicators for identifying with community in their study on rural appalachian communities. useful observable indicators for the concept of community cohesion include: “i know most of the people who live around me,” “i feel a sense of loyalty to my community,” “i feel a sense of connection with other people in my community.” other indicators for the construct of community and family cohesion come from oser et al. (2022) where the authors described the development and validation of a rural identity scale. indicators that could be online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 73 used include: “i have weekly dinners with my extended family,” “i go to family reunions,” “everyone knows one another’s business in my county,” “i feel a sense of belonging with people who live in my county,” “family is very important to people in my county,” and “i exchange goods or services with my neighbors.” the rural identity scale also includes observable indicators for the attribute of place and tradition that is affiliated with place. these indicators include: “i grew up learning about my county’s history,” “either my immediate family or i work in land-related production and/or extraction industries,” and “people born in my county tend to stay here.” thus, in recent years, there has been some movement towards operationalizing attributes of the rural profile, although a comprehensive instrument for assessing the rural profile has yet to be developed. conclusion for this concept analysis, the rural profile is defined as a set of personal attitudes, beliefs and behaviors that are typically informed by the structural and demographic elements found in less densely populated areas. antecedents to the rural profile include having the lived experience of being in a rural place, and feeling as if one belongs in that rural place. the attributes include selfreliance, a closeness to family and community, and a strong emphasis on place. the consequences of having a strong rural profile include increased social capital and also a general distrust of newcomers and outsiders. these consequences may lead to unique health seeking behaviors among rural populations. empirical referents or observable indicators of these attributes were identified. there are many opportunities to further explore this concept, due to the heterogeneity of rural populations and the complexity of unraveling the rural profile from the geographic and socioeconomic influences of health. future work could be focused on developing and validating online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.716 74 instruments to quantitatively measure the rural profile. recognizing that “being rural” leads to a different understanding of health, it is also necessary to collaborate with rural populations to develop best practices and policies within the healthcare arena for these communities. this analysis should be considered a starting point. as farmer so eloquently stated, culture or identity becomes ‘the elephant in the room’ – fundamental to health, but ‘too difficult’ to explore” (farmer, 2012, p. 246). it is imperative that nurse scientists and other rural health researchers continue to address this elephant in the room so that the appropriate provision of health care and health promotion interventions can be offered in rural communities. references afifi, r. a., parker, e. a., dino, g., hall, d. m., & ulin, b. 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(2019). healthy people 2020: rural areas lag in achieving targets for major causes of death. health affairs, 38(12), 2027-2031. https://doi.org/10.1377/hlthaff.2019.00915 frie_other,+674-+with+apa+edits+and+set+up+final+6.25.21pfs+formatted online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 117 interprofessional student perceptions of planning and implementing a student-led, faculty-guided rural health clinic kathryn j frie, dnp, aprn, anp-bc, gnp-bc, fnp-bc, phn1 jennifer r timm, dnp, rn, phn2 amy b koehler, phd, rn3 1assistant professor, department of undergraduate nursing, winona state university college of nursing and health sciences, kathryn.frie@winona.edu 2associate professor, department of graduate nursing, winona state university college of nursing and health sciences, jtimm@winona.edu 3professor, department of undergraduate nursing, winona state university college of nursing and health sciences, akoehler@winona.edu abstract purpose: to develop an interprofessional student-led, faculty-guided clinic in a rural, medically underserved area in wisconsin through applying an existing innovative clinical education model. a local university provides a system for training and practice of interprofessional students in a rural community increasing access to preventive health care to individuals and families in rural medically underserved communities. the primary aim of the project was to qualitatively describe perceptions of interprofessional students after completing community assessment, planning, and implementation phases and secondarily to understand student learning experiences in adopting and leading a community model within a rural practice setting. sample: participants were interprofessional undergraduate and graduate students placed within an interprofessional clinical education model for an assigned clinical, field, or practicum rotation (n=64). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 118 methods: institutional review board approval was obtained prior to implementation of the qualitative evaluation of this project. open-ended survey questions were distributed via qualtrics following the student’s experience. thematic analysis was completed identifying themes of learning and perceptions in rural settings. findings: twenty-six anonymous surveys were collected. major themes identified were cultivating patient outcomes, understanding community as the client, leading through community assessment, and improving self-communication and collaboration. conclusion: participants perceived value in learning within rural settings and noted unique learning features of rurality, primarily around access and resources. participants learned the importance of working together across professions to serve rural areas. schools of nursing and health sciences can be an advantageous partner with others to support health needs in rural settings. keywords: community health, interprofessional practice, nurse-led, rural health, student-led interprofessional student perceptions of planning and implementing a student-led, faculty-guided rural health clinic gaps in access to primary preventive health care exist in rural communities and are particularly limiting to underserved groups. primary care settings are facing significant pressure in responding to the growing needs of a population who is aging and with significant chronic illness (josiah macy jr. foundation, 2016). rural communities are particularly challenged with health care inequities as there are not enough clinicians to meet the needs (westfall & byum, 2020). geographic distance to primary care clinics, limited or absent transportation services, a shortage of primary care providers, and higher than average uninsured and poverty rates all online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 119 impact access to health services in the rural setting. leading health indicators demonstrate a strong need for additional accessible primary preventive care options. the impact of social determinants of health increases the need for involvement of primary and preventive health services, when striving for the improved health status of a community (the everyone project, 2021). salmond and echevarria (2017) discuss quality affordable health care should focus on prevention and disease management, including models of care management, care coordination, and patient education. nursing primary care roles, such as managing patients with chronic disease, working in interprofessional teams, and preventing hospital readmissions have demonstrated improved health outcomes and reduction of costs (josiah macy jr. foundation, 2016). yet, a survey administered by experts in primary care reveals only 4% of nursing curricula includes a robust focus on primary care; this includes associate, baccalaureate, and master’s level degree programs. nurse-led initiatives in the primary care setting have consistently been found to be highly effective on patient outcomes (josiah macy jr. foundation, 2016). student-led initiatives in primary care have also been studied and found to increase access to care through providing free help and support, health teaching, and holistic integrated care (stuhlmiller & tolchard, 2015). rural-based student-led clinics developed to meet the needs of the community have produced multifaceted results, including providing an engaged learning environment for students, mechanism to provide access to health services, and cost savings to the community (stuhlmiller & tolchard, 2015). academic student-led clinics have demonstrated an ability to (1) address access challenges in at-risk communities, (2) mitigate clinical placement shortages in academia, and (3) allow practical application of professional competencies in the rural setting, including independent practice, service to the community, care of underserved populations, online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 120 critical thinking, and engagement with other health professionals in the delivery of care (kavanagh et al., 2015). the nursing profession has roots in and future opportunities in leading community and public health systems to mitigate social determinants of health and create health equity for at-risk and underserved populations, including rural individuals and families. the vision for the future of nursing is to achieve health equity through maximizing the capacity and expertise of nurses (national academies of sciences, engineering, and medicine, 2021). nurses must be educated and prepared to enter, practice, and lead efforts toward health equity. to do so, nursing academics must focus on preparing future nurses in delivering care to a diverse and aging population, understanding complex issues, specifically social determinants of health, that impact health, full engagement in the professional role of nursing, and interprofessional collaboration with both health and non-health professionals and sectors (hassmiller, 2021). background schools of nursing are increasingly challenged in providing community clinical education that is both serving the community and meaningful to students. finding and securing enough community clinical sites can be challenging and competitive, as multiple health profession and non-health profession programs are placing students throughout communities. many academic programs have eliminated community health clinical experiences and focused on increasing simulated experiences (weierbach & stanton, 2018) as simulated experiences are increasing in inpatient and acute care areas. yet, the national academies of sciences, engineering, and medicine (2021) strongly emphasize the importance of experiential learning in adequately preparing future nurses to lead efforts in health equity, social determinants of health, and public health crisis, among others. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 121 graduates from health care professions are not prepared to practice in today’s interprofessional practice environments when transitioning from academia to clinical practice (speakman & arenson, 2015). academia struggles to structure interprofessional clinical education models to provide clinical opportunities for students to work alongside other professions. understanding one another’s roles as a student prepares for collaboration in future roles (walker et al., 2019). as inherent interprofessional patient care is, much work is needed to prepare students to work together to provide quality care of multiple populations. this issue could not be more important as practice continues to shift from acute to community-based settings and the availability of primary care providers and trained nurses for today’s primary care needs is lacking (josiah macy jr. foundation, 2016). to design and deliver health care for rural communities, future health professionals must be prepared to enter practice with competencies in interprofessional practice, primary and preventive care, and rural health. the demand for this type of clinical experience cannot be met without creating nontraditional approaches in nontraditional settings (taylor et al., 2017). an existing interprofessional clinical education model launched in 2017 through a university has demonstrated success in increasing access to health promotion, prevention, and early intervention for underserved and marginalized groups among adult and youth populations, while training interprofessional health profession students (timm & schnepper, 2020). the model applies academic-community partnership to bridge the community needs to existing human resources in the academic setting. using multiple community-access sites to reach underserved and marginalized groups across settings, including a warming shelter, food shelf, and senior center, a unique approach to traditional community clinics applies a framework of interprofessional practice and is specifically guided by the local county community needs assessment, in which online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 122 services are developed from. university students who are in health profession academic programs (athletic training, exercise science, nursing, public health, and social work) are deployed into the community in small, interprofessional teams to engage in a student-led, faculty-guided, and clinically supervised preventive health, wellness, and social services. the clinical supervision model is a blend of direct and indirect supervision, specific to the respective profession, services provided, and clinical setting; nursing faculty are on-site providing direct supervision with additional presence of an interprofessional colleague and a team of interprofessional faculty available indirectly to on-site faculty and students. the services rendered are designed by the scope of practice of on-site clinical supervising faculty. this model creates an ongoing pipeline of interprofessional students to assume roles within the program and reach the community with necessary services, filling a gap in the local community (timm & schnepper, 2020). rural community exemplar a rural community located in western wisconsin with a population of 13,975 geographically spanning over 712 square miles was the setting for this project. the county, with 62% of the population ages 25-64 and 100% of residents designated to be living in a rural area, has been designated as a medically underserved area by the health resources and services administration (hrsa, n.d.). according to the county’s 2018 community needs report, the county is indicated as “100%” rural (gromoske, 2018). a ratio of 6,590:1 (residents: primary care providers) exist, 6,600:1 (residents: mental health providers), and 940:1 (residents: dental care), despite 91% of individuals being under the age of 65 having health insurance. many factors were assessed that are considered challenges for this rural community. transportation barriers limit the ability for person’s and families to get healthcare, food, and social interaction. in this rural county, respondents indicated online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 123 that accessibility and convenience to public transportation was “poor to fair” as was the ability to pay for their own vehicle (gromoske, 2018). quality of life is challenged as the top causes of death are heart disease and cancer, and the county has a higher than state average of self-inflicted injury hospitalizations (gromoske, 2018). an increase in drug overdose deaths and illegal drugs is a large concern of the county. the county’s community needs assessment reports a gradual, yet steep, increase in drug overdose deaths from the year 2000 to 2016 by 225%. more than half of drug poisoning deaths (62%) were unintentional. physical activity rates are low, as 25% reported no leisure time physical activity, and the county faces an obesity rate of 30%, higher than the national high rate of 26% (gromoske, 2018). excessive drinking is prevalent (23%), more than the top united states performer (12%), and contributes to other chronic conditions, interpersonal violence, suicide, and sexually transmitted infections (gromoske, 2018). the community needs assessment reports more than one in five people drink excessively, illegal drug use continues to be a top concern, and physical activity is low contributing to the high rates of obesity. vaccination rates may be affected by access to healthcare, along with religious and cultural beliefs; 63% of children in this rural community are receiving the recommended vaccinations. notably, clinical care conditions are a concern as 49% reported experiencing “poor to fair” ability to pay for healthcare and 31-54% of people reported they did not see a doctor in the past 12 months because of the cost burden (gromoske, 2018). overall, community health data reflects ongoing attention is warranted to the unique needs of the rural communities within this county. access to primary healthcare and mental healthcare is much lower than the state average and the top united states performer. there are severe mental health treatment gaps for youth and adults and decreased chance that people will access health care online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 124 when they need it, despite 91% of people in the county under the age of 65 having health insurance. the county has identified the following needs as most significant, guided by the community needs assessment: improved access to public transportation, increased access to mental healthcare services, increased food security, reduced drug and alcohol misuse and abuse, and increased number of volunteer ems and first responder staff. these many factors guided this project’s aim to facilitate interventions to assist in reducing these gaps. figure 1 illustrates location of the target county and proximity to the academic institution leading the project. a nearby academic institution operating an interprofessional clinical education model was sought as one avenue to increase preventive health care to this rural community. figure 1. buffalo county, wi. note. buffalo county, wisconsin. (n.d.b). buffalo county, wisconsin https://en.wikipedia.org/wiki/buffalo_county,_wisconsin online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 125 note. buffalo county wisconsin. (n.d.a). buffalo county visitors guide. https://www.buffalocounty.com/414/buffalo-county-visitors-guide literature review nurse-led health in rural settings the role of the nurse practitioner (np) in medically underserved areas is not new and differs from the role within an urban area (zwilling et al., 2021). while nps are frequently engaging in primary care practice in rural settings, less of this occurs in the urban setting. over half of nps in urban settings are practicing in specialty areas and do not have their own patient panels while in the rural setting, nps are highly likely to practice within primary care and outpatient settings, practice with more authority, and maintain their own panel of patients. this practice autonomy is important as it increases access to providers and care to patient populations in rural medically underserved areas (zwilling et al., 2021). the nursing profession is grounded in providing care considering the social and environmental context. registered nurses practicing to the extent of scope of practice in primary care will expand the ability to achieve equity-oriented care. an array of primary care services is needed to effectively care for today’s populations. care management and coordination, patient online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 126 education, population health approaches, transitional care, rn co-visits, rn-only visits, and health coaching are within that array. preparing future nurses in these areas puts nurses at the forefront ready to address this demand (josiah macy jr. foundation, 2016). kippenbrock et al. (2017) explore nurse practitioner leadership in rural settings specifically in roles of promoting access to preventive care. data collected in twelve states from the nurse practitioner registry in 2000 and 2010 allowed descriptive analysis of nurse practitioner demographics and changes over time. notably, there was a remarkable decrease of nurse practitioners working in rural settings, while urban work locations increased. the number of nurse practitioners had reduced in rural settings from 1,059 in 2000 to 754 in 2010, a 12% change, and increased in urban settings by 12% (kippenbrock et al., 2017). an opportunity exists in nursing education to provide learning experiences and curriculum focused on rural health care needs. the national organization for nurse practitioner faculty (nonpf) identified a core competency in advanced practice nursing as leadership (2014), and political processes, healthcare advocacy, and problem solving are also expected in nurse practitioner curricula (kippenbrock et al., 2017). nurse practitioners have the education and experience to be influential in rural health care. education in these areas will prepare more nurses with the knowledge and skills necessary to provide rural health, in turn increasing numbers of nurses practicing in rural communities and reducing the primary care access barriers in rural america (kippenbrock et al., 2017). the use of the rn in rural settings to lead and deliver care is underutilized (health resources & services administration, 2020). traditional prelicensure nursing programs have historically emphasized acute care nursing in prelicensure programs limiting the practice readiness in primary care and other non-acute care settings. academic-primary care partnerships are posited to benefit online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 127 academic institutions in increasing clinical education experiences for prelicensure students outside of acute care settings (mennenga, 2021). rns leading care initiatives in care coordination, health promotion for at-risk groups, and management of chronic disease allow the rn to practice to the full scope of practice; as a result, augmenting strategies to address primary care shortages and increasing collaborative approaches to responding to rural health access issues (mennenga, 2021). interprofessional student-led learning stuhlmiller and tolchard (2015) found a rural-based student-led clinic developed to meet the needs of the community provides an engaged learning environment for students, a mechanism to provide access to health services, and cost savings to the community. student-led clinics are often a byproduct of lack of clinical placement sites and academia’s response in securing experiential learning experiences for students. additionally, the student-led model increases access to care through providing free help and support, health teaching, and holistic and integrated care. students report value in experiencing patient care and leadership and management of delivering health care (stuhlmiller & tolchard, 2015). an interprofessional clinical education model providing preventive health services through a faculty-guided, student-led clinic in the community setting demonstrates both the community and interprofessional health profession students and their faculty are served simultaneously by creating an environment of teamness, supporting clinical practice hours and student learning outcomes, student growth in interprofessional practice competencies, and ability to reach underserved groups (timm & schnepper, 2020). increased awareness in the difficulty for underserved groups to access necessary health services and the experience of delivering primary and secondary preventive health services in the clinical setting was identified by interprofessional students as new learning. student learning outcomes reported as most exemplified by the online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 128 interprofessional clinical experience included critical thinking, communication, culturally sensitive care, organizational and systems leadership, and engagement with the community (timm & schnepper, 2020). creating meaningful interprofessional community experiences can be challenging and limiting for some academic programs. taylor et al. (2017) found a simulated interprofessional experience focused on rural communities demonstrated improvement of student’s knowledge of the value of interprofessional care and the importance of rural clinical placements in providing ideal opportunities for students to understand the challenges of living and working in a rural setting. specifically, healthcare students’ perception and understanding of the importance of rural and remote complexity of healthcare requires clinical education and training, including teamoriented patient care and understanding interdisciplinary roles (taylor et al., 2017). school-based health centers one of the most effective ways to reach children and adolescents with preventive health may be the school setting. school-based health centers (sbhcs) have been developed in schools to increase access to health care, particularly in low-income communities (o’leary et al., 2014). stunningly, adolescents who have a sbhc in their own school are ten times more likely to seek help for their mental health and substance use concerns compared to other adolescents without a sbhc (child mind institute, 2016) and sbhcs have demonstrated linkage with decreased depressive symptoms, suicide risk, and emotional disturbances (denny et al., 2018). prevention and early intervention are particularly important in sbhcs, as the long-term effects of alcohol, substance use, depression, poor nutrition, physical inactivity, and other mental health concerns can be debilitating on the quality of life and social functioning among children and adolescents (jackson et al., 2012). sbhcs decrease access barriers to healthcare as students miss less school online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 129 time, transportation barriers are avoided, and busy working parents benefit from care in place. additionally, sbhcs often serve more than the student, including reaching the entire family, school staff, non-class-attending students, and community members (dunfee, 2020). while sbhcs decrease health disparities, they also contribute to academic success by decreasing time away from school and increasing attendance (leroy et al., 2017). carr and stewart (2019) found school nurses and sbhc staff most often face adolescent emotional and behavioral health concerns; these are particularly challenging in rural communities because of access to mental health care limitations. school nurses and nurse practitioners can be influential in delivering preventive health care in the sbhc to create early intervention opportunity for such at-risk groups. for example, a nurse practitioner-led intervention, called cope (creating opportunities for personal empowerment), provides cognitive skills training to middle schoolers in a sbhc setting and has clinically demonstrated improvement in anxiety and depression among adolescents (carr & stewart, 2019). many schools of nursing create learning opportunities for nursing students in the school setting. larson et al. (2011) describe service learning within three different sbhcs in which academic students were involved in leading preventive care in the school setting. the guidelines for adolescent preventive services (gaps) assessment tool was used to identify risk between student variables and found that the use of the gaps assessment tool increased prevention strategies for primary and secondary levels among at-risk fifth and six grade students. the authors posit community service learning as a valuable partnership for baccalaureate nursing programs to provide meaningful educational experiences for nursing students (larson et al., 2011). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 130 purpose the purpose of this project was to develop an interprofessional student-led, faculty-guided clinic in a rural, medically underserved area in wisconsin through applying an existing, innovative, interprofessional clinical model. by utilizing the rural community setting, a local university provides a system for training and practice of interprofessional students to bring accessible preventive health care to individuals and families in rural communities. while implementing this clinical model, the authors intended to qualitatively describe the perceptions of interprofessional students after students’ exploration acquired through completing project assessment, planning, and implementation phases of the project. the existing model provides practice in community-based settings and the focus of this project was specifically with a rural community. nurse leadership program the project lead was an advanced practice registered nurse (aprn) leadership fellow through the duke-johnson and johnson nurse leadership program. the program’s requirements included development, implementation, and evaluation of a transformational project with a collaborative sponsorship agency. through leadership development retreats, distance learning education sessions, project coaching circles, and executive leadership coaching, the fellowship program’s intentions were to train aprn’s to innovate by improving health outcomes among populations. to serve the purpose of both the leadership program and community innovation, the fellow from the nurse leadership program sought to initiate academic institution extension into a local, rural area. discussion initiated with current clinical model innovations that provide aprn and rn leadership while allowing experiential learning in nontraditional settings. the project's intention, to develop an interprofessional student-led, faculty-guided clinic in a rural, medically underserved area while creating an environment of experiential learning, was online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 131 commenced in support of evidence-based literature review findings and documented community needs. to guide further partnerships between academic and community organizations, understanding student perceptions and learning is important. taylor et al. (2017) have published survey questions in interprofessional collaboration and knowledge for rural populations and permission for use was granted. method the project was designed from knowledge supported by literature in areas of nurse-led rural health care and interprofessional student-led clinics, along with previous lessons learned from implementing an interprofessional clinical education model in other settings. the project included four phases and an interprofessional team of health profession students across one semester’s time (n=64), led by their supervising clinical faculty (n=2) and an advanced practice registered nurse leadership fellow, serving as the project lead (n=1). the project initiated in august 2019 and extended through february 2020. data were collected via a post-experience anonymous survey. design of project this six-month project followed four phases. phase one involved activities to achieve assessment of need, led by the interprofessional students. students were charged with a large exploration of the rural geographic area, including detailed review of county-level data and current needs assessment reports. this community assessment included seeking out and interviewing stakeholders, including the county health officer, local community organization leaders, and the superintendent of the k12 school. through collaboration with the county public health agency, students engaged the broader community population through educational outreach located throughout the county. students were able to identify gaps in health services and how such gaps could be addressed with the student-led, faculty-guided clinic. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 132 phase two was design and planning, specifically the development of the k12 clinic space. ongoing outreach with stakeholders and the community continued and students surveyed parents and staff of the k12 school system to seek further information on the design of services. important relationships were built with the school principal and school nurse during this time. the faculty leaders developed formal academic-community partnership with the k12 administration and began to further develop mutual vision, goals, and trust, so necessary in the development of academiccommunity partnerships. phase three implemented and launched the student-led, faculty-guided clinic. students were trained and oriented through existing structures of the clinical education model, including orientation to role functions, service provision, documentation, and site-specific work. weekly clinics were initiated providing preventive health and health promotion services to clientele (students, teachers, and classrooms), and interprofessional students further designed and delivered school-based health promotion throughout the k12 building, guided by school stakeholders, capturing both individual and community-level interventions. students were responsible for all aspects of the clinic operations, guided and supervised by clinical faculty. these responsibilities included determining and maintaining inventory, developing new policies and procedures, reaching out to other existing interprofessional clinic sites to seek guidance on operations, and even identifying what was needed on a week-by-week basis, from pens and pencils to alcohol wipes, printer ink, and privacy partitions. the experience put the students in a setting of learning about budgeting and the complexities of limited resources and how to adapt if, what was identified as needs, were not within budget. frequently, clinic operations require application of local and regional grant opportunities and students participated in preparation, writing, and submission of grants. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 133 phase 4 of this project was the evaluation and quality improvement. students led rapid quality improvement processes, under guidance of the faculty and aprn. student's experience learning in sustainability during this phase. since initial implementation, the clinic has had a second cohort of interprofessional students placed at the rural health clinic. each cohort learns from students before them and engages in enhanced operation to continue growth at the site. table 1 displays the activities by phase and table 2 describes the clinical day for the project team. table 1 phases of project phase activities (role) timeline phase 1 assessment of need irb submission, approval number 1472965(pi) community assessment (ip team) county-level data analysis community assessment analysis & exploration identification of stakeholders interviews with stakeholders community outreach (ip team) community partnership development educational outreach at senior meal sites, food shelf, other community settings surveys of community members analysis of findings (ip team) report findings to stakeholders (ip team) approval to continue project (ip team, clinic director) 2 months phase 2 design, planning securement of collaborating partners (ip team) exploration of existing resources (ip team) analysis of financial feasibility (ip team) ongoing engagement/outreach with community, stakeholders, prospective clients (ip team) attendance at county board meetings (ip team) establishment of formal academic-community partnerships with host site, contracts (clinic director) exploration of grant funding (ip team) 2 months phase 3 implementation student training, orientation (faculty) marketing, public relations (ip team) design of site operations, forms, materials, client education, policy, procedures (ip team) design of site services, programs (ip team) weekly clinics launched (ip team) ongoing quality improvement (ip team) explore, write grant funding (ip team) 2 months online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 134 phase 4 evaluation, ongoing quality improvement evaluation of student learning, perceptions (pi) evaluation of site operations, functions, services, student experiences (ip team, faculty, clinic director) rapid quality improvement (ip team) marketing, public relations (ip team) evaluate, implement ebp activities (ip team) ongoing evaluation of community, target population, stakeholder needs (ip team) explore, write grant funding (ip team) training, orienting of new students (ip team) ongoing institutional review board (irb); primary investigator (pi); interprofessional (ip); evidence-based practice (ebp). table 2 schedule for the interprofessional student team during project time activity 0900 ip carpool van to county health department for pre-brief 0930-1030 ip prebrief welcome, introductions review plan for the day, roles, tasks, target outcomes interprofessional role student presentation updates from previous day faculty, director, student updates team specific goals for the day 1030-1230 team one: health promotion outreach in community sites team two: community assessment, stakeholder interviews 1230-1300 lunch and travel to school site 1300-1330 check-in, clinic set-up, pre-clinic huddle 1330-1700 clinic services 1700-1800 tear-down, clean-up, ip debrief in van back to campus interprofessional (ip) online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 135 sample interprofessional students from undergraduate and graduate academic programs participated in this project after being placed into this interprofessional clinical rotation by program faculty. the students participate in the rotation as part of an academic course in which they are required to complete a variety of experiential hours, varying on type of degree seeking. dependent on the semester in which their experiential course is offered, different degree seeking students (public health, psychiatric mental health nurse practitioners, social work, athletic training varying degrees of nursing) can attend clinical sites in certain settings. sixty-four surveys were sent using an anonymous qualtrics link. twenty-six surveys were returned. the survey was voluntary and not required for completion of the clinical or course. one demographic question regarding degree being sought was added to the questionnaire. for this project, participating students reported themselves as undergraduate prelicensure students in their final semester prior to graduation (n=19), undergraduate rn-bs students in their final semester prior to graduation (n=3), social work students in their final semester prior to graduation (n=2), and graduate nursing students with training in advanced health promotion (n=2). student hours designated to the project ranged from 30 to 80 hours per student, per semester. the clinical faculty consisted of a nursing faculty and a social work faculty, both with extensive experience in community work. data collection after participants completed an institutional review board (irb) approved consent, a series of qualitative questions at the end of their clinical experience were administered via a de-identified voluntary and anonymous survey. the survey consisted of eight questions related to interprofessional learning in rural settings and adapted from taylor et al. (2017), with author online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 136 permission. table 3 lists the questions along with additional prompts to stimulate respondent consideration. table 3 survey questions for students’ perceptions of interprofessional learning in rural setting. question 1 what new knowledge about interprofessional practice have you learned? prompt: which disciplines have you been involved with? 2 what have you learned about your own discipline in management of patients in a rural area? prompt: what patient considerations have you recognized importance with addressing? 3 what qualifiers and what barriers to implementing interprofessional care in your practice did you notice? prompt: location, availability, cost. 4 how will what you’ve learned, impact on your practice in a rural setting? prompt: what changes to practice will you make? adapted with author permissions from “simulated interprofessional learning activities for rural health care services: perceptions of health care students” by taylor et al., 2017, journal of multidisciplinary healthcare, 2017(10), 235-241. https://doi.org/10.2147/jmdh.s140989 data analysis data from the survey questions were analyzed using framework analysis. ward et al. (2013) discuss framework analysis as a mechanism to assist nurse researchers with the rigor and structure required of qualitative data analysis. its benefit is to offer nurse researchers themes that can be linked back to original data (ward et al., 2013). two independent researchers applied framework analysis and identified four main themes. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 137 results a total of 26 survey responses were thematically analyzed. comments included much information about the experience in the rural setting being new and challenging and the impactful learning that occurred throughout the project, particularly the importance of working interprofessional. there were four overarching themes: cultivating patient outcomes, understanding community as client, leading through community assessment, and improving their own communication and collaboration. cultivating patient outcomes participants identified outreaching to the community was imperative to meet the target population needs. participants recognized the importance of reflecting on their own biases to provide holistic, quality care thus providing opportunity to improve patient outcomes. participants reported understanding of barriers related to location of healthcare clinics that they could apply to their role within the clinical setting. one student said: i believe there are many barriers when implementing care in a rural clinical setting such as this clinic. finding a location that is accessible to everyone can be challenging. many individuals who may benefit from these services may not have the means to get there. availability of space is also limited. on the other hand, providing services in a rural community can be extremely beneficial to those who utilize it. costs are usually reduced or free, anyone is welcome, and people who cannot afford regular healthcare have a place to be seen. another student emphasized: “i learned how to still give a patient the highest level of care possible with the limited equipment we have in rural areas.” online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 138 support systems and resources were noted: "considerations when working with an interpreter is to still treat the patient as the primary person you are talking to, so they feel validated and important”, and “i have learned a lot about how important it is to assess the support systems of the patient, as well as looking for signs of any potential mental health conditions.” understanding community as the client participants considered broader perspectives with the consideration of community as their client, versus an individual. challenges, such as travel barriers, housing needs, food insecurity, lack of health/mental care services, insurance status, and language barriers were pronounced in responses from students related to their learnings of rural communities. student perceptions of challenges in rural settings were apparent; a student said: “the main enabler i can think of is the willingness for these areas to accept implementation of this care. some of the barriers are the availability of a site/people to work it, also the cost of getting it started.” another student recognized the importance of and challenge when engaging with members of the public: “i have learned that communication with members of the public can be daunting but should not be something that limits you. i have learned to dive in and be open-minded when asking questions about what people want and need.” some students expressed new perspectives in how nurses could become more present in rural settings: “from the clinical experience, i have become passionate about bettering the presence of nurses and healthcare in rural areas. many of the treatments we provide could be easily managed if it weren't for the geographic distance between clients and healthcare.” understanding the community in which the patients live in was important to this student: “i have learned that it's important to find out all aspects of my patients including online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 139 what kind of community they live in. this can have an impact on their health depending on what resources they have available.” leading through community assessment participants identified phase one, the community assessment process initiated with the windshield survey, as having provided an important introductory understanding of the target community and the aim of the project. they observed many barriers that when placing themselves in the shoes of the potential client should be considered when designing the project: i think the biggest thing i have learned about working in a rural area is the logistical difficulties that come with providing care for clients. going to them instead of expecting them to come you is a big thing i have learned. the importance of community outreach cannot be overlooked, and “rural areas have less resources, therefore it is important for us to obtain the best report from them to have the best outcome.” another student recognized the importance of new and different thinking in rural health: “rural healthcare is challenging from many perspectives. affordability, access, and knowledge remain significant barriers in the community today. overcoming these challenges will continue to require new and different thinking.” i will definitely have an appreciation for how difficult it can be for people in rural areas get around and the distance between them and the nearest clinic. providing excellent patient education, specifically when it is making decisions and help them know when to take immediate action. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 140 multiple students commented on the importance of their role in bringing health services to the rural community: “it became extremely important to us to get the healthcare help they were severely lacking. we spent so much time there that we became more invested in their outcomes.” from the bridges health experience, i have become passionate about bettering the presence of nurses and healthcare in rural areas. many of the treatments we provide could be easily managed if it weren’t for the geographic distance between clients and healthcare. improving their own communication and collaboration participants reported communication amongst the interprofessional team as a tool that they would take into future practice. they also reported that by interviewing stakeholders as part of the community assessment they had experienced hands-on practice in professional communication skills. participants particularly emphasized that understanding collaboration within their team, the target community, department of public health of the county, and with the university aided in the success of the project and their learning in the rural setting. a student explained learning in interprofessional teams: my takeaway is that many other disciplines are utilized and necessary in providing patient centered care. as nursing students, we can only provide a certain amount of services, and utilizing other disciplines is necessary when working with clients in a rural area. the social work students and the grad students were particularly helpful when outside resources were needed. team work was a huge component in running this clinic. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 141 “in buffalo county, we learned a lot about government role and legal teams. we worked together to accomplish the goals of the community.” students recognized the need to improve communication with clients and their team. participants also reported that client interviews were assistive in increasing understanding of the target community: “meeting people where they are, is the number one thing i learned.” …"be empathetic of what they are going through and not assume anything.” in my future practice, i will most likely work with a rural population at some point in time and knowing how important it is to not just ask yes and no questions but, instead investigate into why they answered that way, is very important. “i know completely how important communication is. without it things do not get done, people are not on the same page, there is a disconnect between what exactly needs to be done.” another student recognized the importance of interprofessional care and its ability to support individualized care to clients: during the clinical, i have been involved with several disciplines. i worked with rn to bsn students, grad students, social workers, athletic training, faculty, and nurse educators. working with these disciplines has given me the opportunity to better understand the roles of these professions and how to utilize them. i learned to work closely with different members of the interdisciplinary team to provide individualized care to all clients. discussion there is need for nursing and other health profession students to experience clinical training in rural settings. by interprofessional networking, a greater understanding of strengths and challenges within a community can be addressed (taylor et al., 2017). this project demonstrates online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 142 students who were placed in a rural setting and charged with the design and implementation of a student-led, faculty-guided clinic gained knowledge in interprofessional practice and care for rural communities. overall, the students participating in this project expressed understanding that healthcare in the rural setting holds unique challenges and that nurses collaborating with other professions can effectively design and respond to access barriers, particularly in preventive and primary care. despite the importance of health professionals understanding the importance and value of interprofessional collaboration in improving patient outcomes, it is particularly imperative in the rural setting (taylor et al., 2017). such clinical learning not only benefits students, it also benefits community members. in a time when preventive health and primary care are difficult to access in rural communities, there are nontraditional approaches that can augment other available resources and regularity of services is important (taylor et al., 2017). developing partnerships between schools of nursing and health sciences and rural communities and applying nontraditional approaches to preventive health can address community needs. nurse-led clinics have consistently demonstrated effectiveness in delivering preventive care and care for the underserved; a collaboration with a student-led, faculty-guided academic model extends human resources in a way that dually serves community and academia. nursing provides a scope and service to the medical community that can be offered as a strategic response in areas with limited access to healthcare (richards et al., 2011). nursing faculty also benefit from nurse-led clinic partnership with the community as shown in this project. nurse practitioners and nursing faculty remain current in their practice roles through engaging in such a model and benefit from the impact of engaging in practice with students and online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 143 other practitioners (richards et al., 2011). through this project, interprofessional students experienced authentic clinical training through leading a rural-focused health project. faculty role exploring the role of interprofessional faculty in rural settings is needed. this respective interprofessional clinical education model creates opportunity for faculty practice and enhanced mentorship of students. as nurses have an increasing role in improving public health by providing services of prevention and education, the preparation of students through clinical experiences is equally important (farzi et al., 2018). creating a positive clinical environment in which nursing and other health science students have an interprofessional collaboration is grounded in the relationship between faculty and clinical environment (farzi et al., 2018). the role of interprofessional faculty in the clinical setting has the opportunity to, not only provide the faculty with their clinical practice, but also provide role-modeling for students to enhance the learning experience for students (farzi et al., 2018). school nurse role the school nurse role development requires further exploration. as the school-based health alliance (n.d.) indicates, the collaboration between the clinic and school enhances continuity of care and yields many benefits. in our project, the school nurse facilitated appointments and guided students to and from class and collaborated with the coaches and athletic director to offer sports physicals. although the covid-19 pandemic reduced the opportunities for ongoing in-person clinical care, further opportunities exist to collaborate between the school nurse and this program. limitations limitations should be considered when interpreting the results of this work. for data collection, the survey consisted of eight questions asking for qualitative responses. the online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 144 participants were asked to expect 10-15 minutes length of time to complete the questions and this may have resulted in reduced participation and completion of surveys. plans to collect data using a preand post-quantitative survey may be successful in increasing participation in the survey, while quantifying responses. considerations to measure client and community outcomes are also of interest and as a long-term goal measurement of cost effectiveness of the outreach will be beneficial as a mechanism of sustainability. in the latter phase of this project, the clinic was initiated and began to see clients. initial services delivered by the clinic targeted k12 students within the school. the school nurse was a key stakeholder and team member, functioning as a large asset to the overall clinic operations. the clinic had been open for only three weeks when the covid-19 pandemic emerged and unfortunately reduced the number of services the participating students could deliver, and physical in-person services were suspended. in response, students and faculty developed virtual modalities of support that were convened starting april 1st, 2020, and continue to date, in which this rural community has access to throughout the early and ongoing phases of the pandemic. while participating students experienced only three weeks of delivering service directly, they were able to complete both the planning phase and implemented the clinic. we were particularly interested in the perceptions students had of leading the planning and implementation and have gathered such data through this study; future work will further evaluate the implementation and quality improvement initiatives associated with sustaining this program in the rural setting using innovative modalities throughout the covid-19 pandemic. overall, the student learning experiences of the planning and preparation were extensive. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 145 implications as the needs of the populations and communities we serve become more complex, future health professions must be equipped with the skills and knowledge necessary to step into their respective fields and not only deliver care but also be leaders of change. rural community health is one area in which academic programs can intentionally improve the depth of learning experiences students are provided. this is critical as our rural communities continue to face ongoing and complex barriers to accessing healthcare, including preventive and primary care. determining the most effective means to reach individuals and families in rural communities can be guided by the local community needs assessment and individually design programs for the unique needs of the community. this project used the local community needs assessment and public health program planning approaches to design an interprofessional student-led, facultyguided clinic within a public-school setting in a rural community. school based health centers can provide accessible, high-quality, and trusted healthcare. for sbhcs to successfully meet the needs of its target population, it is imperative there is support from the school and community (american public health association, 2018). applying the framework that was used to guide this implementation project, we aim to sustain this clinic site through an avenue most meaningful for the given community. this is dependent on maintaining collaboration with the site, ongoing assessment of community needs, and adaptability (american public health association, 2018). additionally, the interprofessional clinical education model that provides the infrastructure for this rural site requires leadership by interprofessional clinical faculty, university support of its operations, time, effort, and persistence. an interprofessional student-led, faculty-guided clinic can be adopted in a rural setting when applying an existing interprofessional clinical education model. specific attributes of the process online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.674 146 include involving the students in leadership of the assessment, planning, development, and implementation of the site. through that process, students experience hands-on learning in cultivating patient outcomes, understanding community as client, leading through community assessment, and improvement in their own communication and collaborative skills. in turn and over time, students will be equipped with necessary skills to enter practice and serve rural populations. conclusion access to health and mental care in rural settings is limited and often leads to rural individuals and families not seeking health care, particularly preventive and primary care. there is a known shortage in health care professionals in rural communities and as healthcare expands into community-based settings nurses collaborating with other professions are a piece to the solution in this health inequity. schools of nursing are well positioned to design learning opportunities for students in rural settings. this project provides one way an academic-community partnership can support the growing demand for health care in rural settings. acknowledgements this project was supported through collaborative energy and vision by its community collaborators, specifically those in buffalo county and through 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(2021). comparison of rural and urban utilization of nurse practitioners in states with full practice authority. the journal for nurse practitioners, 17(4), 386–393. https://doi.org/10.1016/j.nurpra.2020.12.033 microsoft word stanton_column 2    online journal of rural nursing and health care, vol. 9, no. 1, spring 2009    editorial quality challenges in rural communities marietta stanton, phd, rn, cnaa, bc, ccm, cmac editorial board member in a few short weeks the rural nursing organization will sponsor their annual conference on quality health care in the rural environment. what do we really by the term quality? the u.s. institute of medicine (iom) defines "quality" as: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. iom released the report, "crossing the quality chasm: a new health system for the 21st century" (iom, 2001) calling for fundamental reform of the u.s. health care system. this report identified six aims for health care quality improvement: safe, effective, patient-centered, timely, efficient, and equitable. these six aims are just as appropriate in a rural environment as they are in an urban setting. they are also appropriate across all levels of prevention and across a variety of health care settings. to accomplish these aims in the rural environment the iom in their report, "quality through collaboration: the future of rural health care" (iom, 2004) identified a five point strategy for rural communities: • adopt an integrated, prioritized approach to addressing both personal and population health needs at the community level; • establish a stronger quality improvement support structure to assist rural health systems and professionals in acquiring knowledge and tools to improve quality; • enhance the human resource capacity of rural communities, including the education, training, and deployment of health care professionals, and the preparedness of rural residents to engage actively in improving their health and health care; • monitor rural health care systems to ensure that they are financially stable and provide assistance in securing the necessary capital for system redesign; and • invest in building an information and communications technology (ict) infrastructure, which has enormous potential to enhance health and health care over the coming decades nursing in the rural community is in a integral position to promote interventions that will advance these strategies through research, education, practice and nursing administration. no professional provider is in a better position to effect change in the rural environment than the rural based professional nurses. they may be employed in a variety of roles in a variety of settings but in general they can implement ways to improve the quality of rural care. as nursing administrators, rural nurses do not just coordinate services within a health care institution. they can serve as community health advocates, leaders, policy makers and political leaders in their communities. as educators, they can mentor and teach all levels of health care providers to provide safe effective care. they can support student experiences and encourage ongoing continuing education as well as encouraging career development through academic program completion for other local health care providers. they can provide health care teaching in health 3    online journal of rural nursing and health care, vol. 9, no. 1, spring 2009    promotion, disease prevention and chronic disease management. they can seek training on technologies to increase the efficiency and effectiveness of health care provision. in clinical practice rural nurses can implement evidence based care, address high volume conditions, and monitor outcomes. as researchers, they can test and monitor innovative practice and disseminate findings to encourage excellence. they can focus on performance improvement to enhance quality, increase efficiency and decrease costs. perhaps the most important point is that nurses in the rural setting can provide leadership. as rural nurses, our organization and it constituents can produce change and ensure that rural residents have the best care while providing a responsible stewardship of clinical resources. the challenge is apparent and nurses are the primary element for success. references institute of medicine (iom) (2004). quality through collaboration: the future of rural health. washington, dc: national academy press. retrieved on may 12, 2009, from http://www.iom.edu/?id=29734 institute of medicine (iom) (2001). crossing the quality chasm: a new health system for the 21st century. washington, dc: national academy press. retrieved on may 13, 2009, from http://www.iom.edu/?id=12736 microsoft word forbes_512-3141-2-ed.docx online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 209 integrated knowledge translation strategies that enhance the lives of persons with dementia and their family caregivers dorothy a. forbes 1 catherine blake 2 melanie bayly, phd 3 shelley peacock, rn, bsc, bsn, mn, phd 4 pamela hawranik, rn, b.n, m.n, phd 5 anthea innes 6 1 professor emeritus, school of nursing, western university, dorothy.forbes@ualberta.ca 2 research associate, school of nursing, western university, cmblake@uwo.ca 3 post-doctoral fellow, canadian centre for health and safety in agriculture, university of saskatchewan, melanie.bayly@usask.ca 4 associate professor, college of nursing, university of saskatchewan, shelley.peacock@usask.ca 5 dean, faculty of graduate studies, professor, faculty of health disciplines, athabasca university, phawranik@athabascau.ca 6 professor, salford university, a.innes1@salford.ac.uk abstract purpose: to understand the lived experience of persons with dementia and their family caregivers who receive home care in northern alberta, canada, and to reveal how integrated knowledge online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 210 translation (ikt) strategies influence the uptake of best available dementia care evidence over time. sample: three persons living with dementia and thirteen family caregivers were interviewed at the beginning of the study, nine months after implementation of the knowledge broker (kb), and six months after termination of the kb role (total interviews = 41). method: the parihs framework guided our longitudinal case study that included two rural home care centres. a qualitative interpretive descriptive approach was used. a kb was hired for 12 months to facilitate the development of different ikt strategies with staff. site a developed two strategies: 1) a planning meeting to discuss local needs and suggestions for improving access to dementia care information and community supports; and 2) the development of an information package. site b focused on working through modules of the u-first program that entailed dementia education and training for the home care providers (hcps). they then used the u-first wheels with clients during their home visits. findings: persons living with dementia spoke of both positive and negative aspects of their dementia journey and how they attempted to manage their lives. family caregivers struggled to find the best approaches and supports to use to enable their family member with dementia to remain at home for as long as possible. ikt strategies such as a kb, the information resource package developed by the hcps, use of the u-first modules and wheels, and a support group were examples of effective ikt. conclusion: ikt strategies and projects increased access to dementia care information and supports. these assisted caregivers to better care for their family member for longer periods at home. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 211 keywords: persons living with dementia, family caregivers, integrated knowledge translation strategies, rural, and home care. integrated knowledge translation strategies that enhance the lives of persons with dementia and their family caregivers dementia refers to a group of neurological conditions typified by a gradual deterioration in behaviour, thinking ability, and memory (alzheimer society of canada, 2010). worldwide, the total number of new cases each year is nearly 7.7 million, making it an international health priority (world health organization, 2012). as of 2010, more than 35.6 million people around the world were living with dementia. this number may almost double to 65.7 million by 2030 and 115.4 million by 2050 (batsch & mittelman, prince et al., 2013). canada has an aging population, and the risk of dementia increases with increasing age. the number of canadians aged 85 and older grew by 19.4% from 2011 to 2016, nearly four times the rate for the overall canadian population (statistics canada, 2017). in 2011, there were 747,000 canadians diagnosed with dementia and this number is expected to increase to 1.4 million by 2031 (alzheimer society of canada, 2010; alzheimer society of canada, 2017; forbes & neufeld, 2008; jansen et al., 2009). this increased prevalence of dementia and a movement from institutional to communitybased care (alzheimer society of canada, 2010), will result in a larger proportion of persons living with dementia remaining in their own homes. this can substantially increase community care, home care, and caregiver burden, especially in rural areas (dal bello-haas, cammer, morgan, stewart, & kosteniuk, 2014). the costs of dementia in canada, including the costs of unpaid care, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 212 were $10.4 billion in 2016 and projected to rise to $16.6 billion by 2031 (prince, comas-herrera, knapp, guerchet, & karagiannidou, 2016). in addition, rural communities have a faster-growing percentage of older adults than urban centres (canadian institute for health information [cihi], 2011; forbes & hawranik, 2012). the association of age with alzheimer’s disease and this greater proportion of seniors in rural areas present challenges for both individuals with dementia and their family caregivers. these challenges may include fewer health care services, lack of transportation, longer distances to access care, fewer health care providers, and an increase in the demand for home care services (chca, 2015; di gregorio, ferguson, & wiersma, 2015; forbes et al., 2012; forbes & hawranik, 2012; forbes, morgan, & jansen, 2006; jansen et al., 2009). there are specific challenges faced by persons living with dementia and their caregivers in rural communities. for instance, even when family caregivers seek help, receiving a diagnosis can take as long as two years (morgan et al., 2008). rural seniors may be more likely to try to rely on an informal support network instead of the health care system (morgan, semchuk, stewart, & d’arcy, 2002) and their use of formal supports is low (innes, morgan, & kostenuik, 2011). family caregivers may also be concerned about stigma or lack of privacy and withdraw from social circles (morgan et al., 2002). similarly, persons living with dementia are often excluded from discussions and decisions about their care and treatment because formal and informal caregivers may assume they are not capable of participating. they may also be denied the opportunity to participate in work or social activities because of concerns about safety or stigma. this is often exacerbated in rural areas because of fewer services and fewer qualified home care providers (hcps) (forbes et al., 2011). online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 213 access to current information can be more limited in rural areas. the dementia care information that persons living with dementia, caregivers, and health care providers need changes at each stage of the disease process. caregivers tend to turn to family and friends and assume others have assessed the dependability of the material (di gregorio et al., 2015; forbes et al., 2012). in addition, rural areas may have more limited access to dementia education for both the formal and informal caregivers, leading to a lack of knowledge about dementia and about available services (innes et al., 2011). the purpose of this research was to understand the experiences of rural persons living with dementia and their family caregivers who receive home care services. thus, a better understanding of the approaches that may be supportive and beneficial were revealed as well as sources of information that were the most helpful. research questions • what is the lived experience of persons with dementia and their family caregivers who receive home care in northern alberta, canada? • what integrated knowledge translation (ikt) strategies influence the uptake of best available dementia care evidence over time? methodology the promoting action on research implementation in health services (parihs) framework guided our approach to our research and helped to better explain derived findings (helfrich et al., 2010). the framework considers: (i) the evidence and knowledge being used, (ii) the context, and (iii) how use of the information is facilitated (kitson et al., 2008). these were important considerations for our work, thus parihs is an appropriate approach for the study. all components of this framework are examined in our research although we do recognize that the online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 214 framework has recently been revised as the integrated or i-parihs framework. “the core constructs of the i-parihs framework are facilitation, innovation, recipients and context, with facilitation represented as the active element assessing, aligning and integrating the other three constructs” (harvey & kitson, 2016, p. 8). the research design was a longitudinal multiple case study (yin, 2012). two home care centres in northern alberta, canada were selected as the study sites. due to the large geographical area of the north zone and long travel distances, these two centres were approached to participate as they were within 30 km of each other and had relatively larger numbers of staff compared to other sites. both communities and catchment areas meet the statistics canada (2016) definition of rural as including all territory lying outside population centres. basic health services were available in these communities. however, similar to other rural areas in canada (morgan et al., 2015), dementia-specific services typically were unavailable. further detailed characteristics of the communities can be found in forbes et al. (2015). a knowledge broker (kb) with experience working as a manager in one of the selected home care settings was hired for 12 months to facilitate the development of different ikt strategies with staff at these two sites. consultations with the kb and workshops were held to facilitate this process. site a developed two ikt strategies: 1) a planning meeting with zone and local managers and staff to discuss needs and suggestions for improving access to dementia care information and community supports in their local community; and 2) the development of an information package for persons living with dementia and their family caregivers. this package contained general information about dementia and specific local resources for persons living with dementia and their families, telephone numbers and website links for caregivers, ideas for communicating with the person living with dementia and for responding to responsive behaviours, and suggestions for online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 215 interacting with someone with memory difficulties. site b focused on enhancing the knowledge and skills of the front-line hcps by working through online modules of the u-first program that entailed dementia education and skill training. the hcps then used the accompanied u-first wheels with clients during their home visits which summarized the information and offered tips for quick reference. persons living with dementia and their family caregivers, who consented to participate, were interviewed in person at the beginning of the study (persons living with dementia = 3, caregivers = 11), nine months after implementation of the ikt strategy (persons living with dementia = 2, caregivers = 13), and six months after termination of the kb role (person living with dementia = 1, caregivers = 11; total interviews = 41). field notes explicating subtle nuances of the context and non-verbal content of the interviews augmented the data (schreiber, 2001). the interviews were audio-recorded and transcribed verbatim. a qualitative interpretive descriptive approach (thorne, reimer kirkham, & o’flynnmagee, 2004) was implemented to analyze the interviews. themes and patterns were derived to inform our understanding of the lived experiences of persons living with dementia and their family caregivers. in addition, the knowledge exchanged among rural persons living with dementia and their family caregivers and the uptake of best available dementia care evidence over time were analyzed. ethical approval was received from the university of alberta, health research ethics board (study i.d. pro00048613). to promote trustworthiness of the findings, the following criteria were adhered to: a) credibility, b) dependability, c) confirmability, and d) transferability (lincoln & guba, 1985). credibility included member checking (i.e., sharing interpretations and/or conclusions with select participants in order to determine if their own realities had been adequately represented) and peer online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 216 debriefing (i.e., exposing the research process among the investigators, graduate students, and post-doctoral fellow). dependability was established through the use of triangulation (e.g., diversity of participants, diversity of data collection approaches including interviews, field notes, and memoing). confirmability was achieved through the use of several researchers analyzing the data and then comparing their interpretations. transferability refers to the acquisition of thick description of the findings to enable readers to determine whether the concepts are similar enough to make a transfer to other contexts or time (lincoln & guba, 1985). description of participants persons living with dementia are often excluded from participating in research studies as they are considered non-reliable informants. however, the authors of this study considered the voices and perspectives of persons living with dementia as necessary and important in informing our understanding of how best to support them and their family caregivers in continuing to remain in their home environments. encouraging them to share their perspectives on life assisted us in knowing them as an individual (murphy, jordan, hunter, cooney, & casey, 2015). pseudonyms are used to protect the identities of the participants and other identifying information has been removed. although several persons living with dementia were invited to participate in the study, only three were able to participate in the interviews. those who did not participate had difficulty communicating. the three participants, two females and one male, were all diagnosed with having dementia, however their specific type of dementia was unknown. their ages ranged from 68 to 77 years, two were married and one was separated. the length of time they had lived in their community ranged from 43 to 75 years. all received home care services on average 13 hours per month for assistance with bathing, medication administration, and respite. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 217 the fourteen family caregivers enrolled in the study included eight spouses, three daughters, a grandchild, brother, and brother-in-law. not all of the family caregivers lived with the person living with dementia. those who did live with their relative with dementia (n= 8) were more likely to provide greater amounts of support in activities of daily living and assistance with personal care. further socio-demographic information about the family caregivers is available in table a. table a socio-demographic characteristics of family caregivers family caregivers two communities combined (n=14) gender female 10 male 4 age mean 67 range 33 85 relationship to person living with dementia spouse 8 daughter 3 grandchild 1 other family member 2 do you live with person living with dementia? yes 8 no 6 if no, how far away (kms)? mean 17.8 range 1 82 in which areas do you help? advice or emotional support 13 household tasks 13 personal care 7 number of hours/week helping? mean 46.9 range 2 120 do you receive support/help? yes 11 no 2 specify type of help family 4 online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 218 family caregivers two communities combined (n=14) home care 3 respite 2 take pwd for weekend 1 driving 1 visiting 1 nurses 1 day program 2 support group 1 emotional support 1 bath 1 highest level of education elementary school 1 high school 8 college or trade school 2 university 2 graduate school 1 employment status employed 4 retired 7 homemaker 3 access to computer at home yes 9 no 5 access to internet at home yes 8 no 6 hours/week you use the computer mean 15 range 2 40 where do you go for information about dementia care? internet 3 books 1 home care nurse 1 doctor 3 alzheimer association 3 care centre 2 friends 1 newspapers/tv 2 support group 1 information package 1 self-reported health status poor satisfactory 5 online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 219 family caregivers two communities combined (n=14) good 7 excellent 2 ethnic or cultural group caucasian/white 14 total household income $10,001 20,000 1 $20,000 $30,00 3 $50,001 $60,000 2 greater than $60,000 2 don’t know 3 would prefer not to answer 1 findings first research question what is the lived experience of persons with dementia and their family caregivers who receive home care in northern alberta, canada? perspectives of persons living with dementia. persons living with dementia openly spoke of both positive and negative aspects of their dementia and how they attempted to manage their lives. making the most of his situation, bill (accompanied by a home care aide) was able to continue to go shopping and interact with other community members. p: we’re on a program right now that’s about buying our own food, which is really good because i go with one of our gals [hcp] and we go shopping and it’s great fun, i really enjoy that…i know that guy, and you say hello and you know it really sort of brings you out into the community a bit (a501-2, bill). in the early stages of the disease, persons living with dementia still have goals and projects that they wish to accomplish. p: well i have a couple of projects that i want to do. last winter i shot about 400, online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 220 maybe …1000 shots of film, and i wanted to make a book for my kids so when i pass away there's something there of mine. … the three [sisters] that are older and myself wanted to go to and i think we're gonna try and do that, want to go to iceland (a501-1, bill). another person living with dementia was concerned how individuals in her small community would respond to her if they knew she had dementia. p: i’m a little bit cautious and afraid sometimes … about letting it (having dementia) out (a504-3, mary). however, there comes a time when persons living with dementia and/or their family caregivers recognize that the person living with dementia is no longer able to continue living in his/her own home. p: i don't remember how to wash dishes and …in the last little while i have a certain amount of phobia about fire (a501-1, bill). the resources required to support persons living with dementia to be safe in their own homes often became too costly to maintain. for example, bill eventually required the following services: hcps twice daily for 15 minutes to fill the medication tray, weekly hcps’ assistance with bathing, weekly homemaker, and a volunteer to take him shopping once a week. bill identified himself that remaining in his own home was not healthy and other options, such as assistant living, were required. p: i know there are times i just have to sleep and i can’t because there’s somebody coming through, getting a bath or something…it just becomes, you know you can’t sleep. and if you can’t sleep, you can’t really be healthy in any way (a501-2, bill). family caregivers’ perspectives. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 221 family caregivers, especially those who live with their relative with dementia, know them best and can often be instrumental in ensuring their relative with dementia receives the most appropriate care possible. p: i suggested to the doctor, i said if the medications that he’s on isn’t doing him any good, take him off it. and so there was some that he was on that they decided wasn’t necessary and so they took him off of that (b205-3, anne). the goal for many family caregivers was to keep their relative with dementia at home for as long as possible. p: it just got to the point where he would get up in the middle of the night in the winter and take off out the door and i had to get the rcmp to help find him. and then i wasn’t sleeping. three nights i didn’t have any sleep. i said [to her physician], “i need help,” so he gave me some pretty strong sleeping pills to give to [person with dementia] so at night at 9 o’clock and then he’d sleep until 9 o’clock the next morning. then i could sleep (b205-3, anne). p: our goal is we keep her home until death. if we can’t, if we can do it, i don’t know but this is what we try. i talk to my daughter about it like if it’s too much for you, tell me, we have to find other solution. she said no, we are young, mom did everything for us, we now do everything for her and i think, i hope we can keep her to the end; but maybe not. but we want to (b204-3, tom). however, family members did not always work together to support their relative with dementia. their previous relationships and views on life influenced their involvement and approach taken with the person living with dementia. p: i [husband] says, “in 23 years you [daughter-in-law] come into town probably twice a day,” they live at [location]. i says, “you don't make no room for her then” i says, “what online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 222 are you gonna do, what have you got in mind?” so i got then the answer was i hung up on her (b603-1, scott). p: i have a father who is a stubborn, german man and very set in his ways and mom with the dementia. i have found he is less open to suggestions and help and thinks she can still do everything. it’s kind of day by day, fly by night in getting them to agree. like it took me a year to get them to agree to meals on wheels but they’re enjoying it (b200-1, helen). family members need to find a way to work together in selecting the approach that will have the best outcomes for their relative with dementia. roles may need to be renegotiated or new roles developed. p: if there’s going to be something major, i discuss it with my brothers and i have two of my brothers take it to my dad because i’m here all the time and i’m the one they get mad at. if something’s going to change, i don’t want to be the one that is going to pay the price so to speak (b200-1, helen). in desperation, families may reach out for potential remedies that they feel may improve their relative’s symptoms. p: i go to the health care and food store and i got omega 3 and stuff like that and then lion’s mane and that’s supposed to help the memory... i know the last few days there, maybe i’m just hopeful, but after that lion’s mane, she’s been getting dressed better and maybe it’s just, i’m kind of an optimistic, you know i always look on the bright side (b203-1, david). family caregivers recognized that they needed information and support in meeting all the needs of their relative with dementia and appreciated the information and ideas shared among attendees at a support group. i: what type of information do you expect to be available through the study or your home online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 223 care nurse? p. more insight to the disease and how to cope with it as a family. i think probably the hardest thing is trying to explain to mom why this is happening to her. she [mother with dementia] knows she’s forgetting but to get her to understand why it’s happening and to remember why it’s happening, like it’s short term, right? long term she could tell me what she did when she was 18. so it’d be nice to have more insight on how to explain to them that they are not alone with this disease (b200-1, helen). some family caregivers, however, did not have adequate supports in place and were struggling to provide care for their relative with dementia. linda clearly described her need for additional assistance to care for her husband. p: i would like to see if i can have access to a lift or something to make life a little easier for [name] and myself because he’s always having to strain to help me, and i’m straining to help him get up and sit down… i guess i would like to make sure that you got from our interview that i could use more help. that it’s, for me to be able to help [name], i need a little bit more help (b201-1, linda). linda was not successful in obtaining additional help prior to her second interview and was experiencing difficulty meeting her own needs. p: you know, i probably shouldn’t be looking after anybody because i’m not looking after myself, you know (b201-2, linda). occasionally, a crisis situation resulted in the family members realizing that they could no longer care for the person living with dementia at home. p: well she broke her arm, she fell down the stairs…we went to [location] at the university hospital, had a shoulder transplant. and from there she went to the [location] nursing home online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 224 (b 203-2, david). most family caregivers shared the challenges of caring for someone with dementia and rarely spoke about positive moments. thus, it is especially important to be able to treasure the brief moments of connection and expressions of pleasure. p: even our grandkids, she is 15, she feeds her sometimes and it takes two hours, it is for me, after an hour, i’m fed up. and my granddaughter feeds her…and [she] was eating, eating normally, she is very, you know sad looking. but then she smiled so much and i joked that the food came out again and i thought, [granddaughter] look there’s a life quality for oma (b204-3, wendy). second research question what ikt strategies influence the uptake of best available dementia care evidence over time? a major ikt strategy is having access to, assessing and using relevant and reliable information available on the internet. the younger generations of participants especially found the internet to be a useful resource. p: i’ve actually given some information that i’ve got off the internet or that [name] have given me and i’ve actually made copies and taken it to the doctor… are you aware of this (b204-2, wendy)? however, not all family caregivers were comfortable using information technology such as the internet and cell phones. p: i have a cell phone now. which i didn’t used to have and i have a heck of a time using it because i didn’t really get trained. someone would say, “oh yeah, well do this and that and other” but that’s where i’m at… i: so you’re not familiar with the internet sites? online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 225 p: no, no. i don’t have a, a computer (b201-2, linda). the support group was also seen as a valuable resource of dementia care strategies. for example, janice learned from other family caregivers, strategies that were beneficial to them and also strategies on how to interact with their family member with dementia. i: the project’s been going on for over a year, what have you been learning personally? p: probably how to deal with the stress and day to day, because the support group, those people that ask questions and they have ideas, try this or try that, and this way or try it that way. so i think that’s helpful (b606-3, janice). participants appreciated the resource package developed by the hcps as described above in the methodology section. p: at one time we got a package and there was a lot of excellent websites and i share information and i talk a lot about it with some of the people from the support group that i go to. i find that, sometimes just talking and sharing your frustrations and as well as your positives is always good and i have one lady in particular that i share information with. i always go online if i want to find something in more detail or whatever. i: the information that you’re finding out of the package and online, has it been relevant to your situation? p: i think so, you always find bits and pieces that you can relate to in your own situation, or particularly my situation and i thought it was a very well put together resource and obviously a lot of work went into it (b607-3, marilyn). strategies suggested in the resource package assisted family caregivers in appropriately responding to the persons living with dementia. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 226 p: it was in the resource package, it gave you a list of, you know how to deal with, and i think one of the things that i have learned and think sometimes is hard to do is to be very patient and to accept what this person is telling you. i mean the first instinct is to say, “well you’re wrong,”… and i think that sticks out in my mind, the patience that you have to have and you know, don’t argue with them and yeah that’s always stuck out in my mind because i mean, you know you right away want to say, “well that’s not right, or you’re wrong, this is the way it happened” (b607-3, marilyn). having received information through the resource package, family caregivers felt more comfortable sharing their knowledge with other caregivers and physicians. p: she’s the total caregiver at home and she does need to take care of herself. i can see that she’s frustrated and stressed about a lot of things and just trying to encourage her to do this and yesterday she came out for a bit while her husband went to the day support and i think that’s important for her. i can see she’s made that change, before she didn’t want to do that, she didn’t want to send him there because she felt guilty. and i said, “you do need time for yourself” because it’s a very stressful road at the moment for her (b607-3, marilyn). p: i’ve talked to other people that have patients there and the doc just hadn’t given them any information, you know just that it’s something that happens and you have to deal with it and you know, blah, blah, blah. they’re not giving you any of this background information like some of the people that are coming to these group meetings, i could cry for them. they have no knowledge and it’s like going back 40 years, “if you have a person in your family that’s like that, lock them up in the back bedroom, and forget about it. don’t talk about it, don’t let your neighbours know what’s going on.” and sometimes i think, with medical staff, they still have that same mentality and they’re the ones that have to reach out and say, okay here’s online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 227 this package. i want you to read it and if you’ve got any questions come back and talk to me (b204-3, wendy). the resource package was also found to be useful by staff in other departments. family caregivers valued and expected an open communication and sharing of information with health care personnel. i : do you think that people receiving the package of information find it’s a useful tool? p: i think so, because i know that [rehabilitation administrator] gave those out at [place] to some of the spouses or the brothers, sisters or whatever of clients. and he didn’t just give them the package, when he had time he actually sat down with some of them and went through, which i thought was just terrific (b204-3, wendy). suggestions were also made on how to improve the resource material. specifically, a couple of family caregivers felt that information on who to contact in the event of an emergency or difficult situation would be helpful. p: i think maybe that they could have [included] how do you get hold of something for the person if something happens, say to me, then how do you get hold of somebody…there’s a lot of really good material (b206-2, steve). i: what type of information is the most useful to you in caring for [name]? p: contact information. so i know who is available, when they’re available, and who to contact for different situations. like for example, if she goes missing or something like that, i have an idea of who to call, or if she’s experiencing certain symptoms that i think someone should be aware of, or she might need her medications checked. (b205-2, anne) information about the support group and the resource material, as described in the methodology section, should be distributed more widely to inform other family caregivers about online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 228 the available support and resources. p: just make it [information package] more public, you know. there’s an awful lot of people out there that need assistance and i think from our group meetings, you know we reach out to other people. i see people coming into [place] when i go to visit [name] and i haven’t seen them at any of our meetings, so you know, just saying are you aware that we do have these group meetings and you know, you’re more than welcome to come. i’ve had a couple of ladies that have come and said, you know thanks (b204-3, wendy). discussion involving persons living with dementia in our study provided the opportunity for them to share their perspectives on their daily lives, their needs, wishes, and future plans. hubbard, downs, and tester (2003) described how prior to the 1990s, the perspectives and subjective experiences of people living with dementia tended to be overlooked, as they were perceived to be incapable of verbally communicating their thoughts and feelings. people who are in the early stages of dementia are often capable of expressing their thoughts and experiences in a rich way, although some difficulties with verbal speech may be present as symptoms progress (pesonen, remers, & isola, 2011). it is important to capture these perspectives to better understand persons living with dementia as individuals with hopes and fears (di gregorio et al., 2015; groen-van de ven et al., 2017). moreover, participation in an interview is often a meaningful experience for people living with dementia, allowing them to share their views and experiences with the hope that they will be of benefit to others (pesonen et al., 2011). in the current study, continuing to remain in their own homes and carrying out their normal activities, such as grocery shopping and meeting up with friends, were valued by the persons living with dementia. in this small northern rural community, one of the participants (mary) shared that stigma online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 229 around dementia remains, and she was hesitant to inform her friends and neighbours that she had a diagnosis of dementia. this is very unfortunate as these individuals could be of assistance and support to her in remaining in her own home as informal community support for people with dementia has been identified as a strength of rural communities (blackstock, innes, cox, smith, & mason, 2006). this experience is congruent with previous research suggesting stigma is a salient issue for rural-dwelling persons living with dementia and their caregivers, and may be a barrier to accessing supports (blackstock et al., 2006; forbes et al., 2011; innes et al., 2011; morgan et al., 2002). in addition to stigma, there is a tradition of independence among rural residents which can discourage help seeking to the detriment of persons living with dementia and their caregivers (forbes et al, 2012). much work is needed to better promote the work of the alzheimer societies and other dementia support groups in heightening awareness about dementia and how best to support persons living with dementia in their own homes (world health organization, 2012). occasionally, persons living with dementia require institutional long-term care (ltc) as their symptoms progress and the family members, even with home care assistance, can no longer manage their care needs. one family caregiver could not afford a lift for her spouse to assist her in helping him transfer from a sitting to standing position. thus, placing him into a ltc facility was necessary, at greater cost to the health care system. once in a ltc setting, the continued involvement of their family members is very important as the visits may trigger moments of happier times for both the person living with dementia and family caregiver. although the persons living with dementia may not be able to recall previous visits by family members, their visits mean a great deal to them. family caregivers usually do their very best to support the persons living with dementia to online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 230 remain at home for as long as possible (jennings et al., 2017; lord, livingston, & cooper, 2015), often at the expense of their own health. however, this challenging period frequently puts a strain on family relationships. if family members do not normally get along or agree on what is best for the person living with dementia, it can be a very difficult and trying time. seeking professional advice and consultation may be necessary to ensure that the family members are working together in selecting the approach and medications that will have the best outcomes for their family member with dementia. home care assistance can make an important contribution in supporting and caring for the persons living with dementia and their family members. home care in northern alberta, canada provides a variety of services such as care following surgery, long-term care, palliative care, and respite services (retrieved from https://www.albertahealthservices.ca, nov. 24, 2017). clients within this study received a hcp who completed tasks such as filling a medication tray, bathing assistance, and meal preparation; a homemaker who assisted with cleaning the home; and volunteers who may take the person living with dementia on walks or shopping. however, the long travel distances and lack of funding for rural home care programs has resulted in hcps not having time for non-urgent clients and their families. thus, relationships between the families and hcps cannot be developed and anticipatory guidance and information is not provided (forbes et al., 2012). in addition to accessing home care services, other community supports were utilized such as the support group for family caregivers. most importantly, the family caregivers felt comfortable in acknowledging that their family member has dementia and in sharing their stories of frustration and sadness within an accepting and understanding group. family caregivers shared successes and helpful tips on strategies and supports that facilitated the care of their loved one with dementia. online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 231 this type of support can be especially helpful if run by a trained and knowledgeable facilitator with knowledge about dementia care and the available local supports, treatments, and assisted living institutions. it is then possible to assist the family caregivers in navigating the typical dementia care stages by providing them with anticipatory information and guidance throughout the journey. however, such a person with these required skills and knowledge would not always be available in a northern rural community. the resource package developed by the hcps is an excellent example of an ikt strategy to address gaps in knowledge about dementia and available services. the hcps in this study widely shared the resource package with the persons living with dementia and their family caregivers and encouraged them to use this resource. because of the positive feedback from our family caregivers, the package was distributed to the local long-term care facilities and to other home care centres in the province. unfortunately, due to lack of funding, the knowledge broker is no longer employed with the two home care offices. hopefully, the remaining staff members will be able to keep the resource package current. very positive feedback was also received from the hcp participants who used the u-first modules to guide their client care (bayly et al., under review). it is anticipated that this tool is continuing to be used. limitations to participate in this study, persons living with dementia were required to be willing and capable of responding to the interview questions and sharing their stories. those who were not able to articulate their stories or felt overwhelmed by their symptoms were not included in this study. thus, our findings were unable to represent a wider range of individuals living with dementia, including those who may have been experiencing greater difficulties. this is a drawback of using only interview methods; previous work has suggested the utility of observational methods online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 232 to combine conversation fragments and in-the-moment conversations with nonverbal behavior to obtain the perspectives of persons living with dementia who have difficulties communicating (hubbard et al., 2003). conclusion this research study revealed the lived experience of persons with dementia and their family caregivers who received home care services in northern alberta, canada. when initially diagnosed, persons living with dementia were aware of their symptoms and hesitant to acknowledge that they had dementia due to the negative connotations associated with it. greater acceptance and education about dementia are desperately needed. families attempted to support the person living with dementia to remain at home for as long as possible. home care services may support the family caregiver by assisting with personal care needs of the family member with dementia, housework, meals, medications, and respite. however, there usually comes a time when these services are no longer adequate and the person living with dementia require 24-hour care in a long-term care facility. if family members had a respectful relationship with each other, making the difficult decisions together about placement appeared to be easier. even after placement, it is important for family members to continue to be involved with the person living with dementia as they do experience precious moments where past memories can be shared. this study also revealed the value of the ikt strategies that facilitated the uptake of best available dementia care evidence. the kb was essential in facilitating the staff in developing and continuing to use their ikt strategies and projects. increased access to dementia care information and supports in their local communities were shared through the dementia information package and front-line hcps continued to use the u-first wheels with clients during their home visits. support groups for family caregivers that are facilitated by an experienced moderator who is online journal of rural nursing and health care, 18(1) http://dx.doi.org/10.14574/ojrnhc.v18i1.512 233 knowledgeable about dementia care can provide and encourage the sharing of knowledge about the disease process and strategies that support the person living with dementia and their caregivers are an excellent ikt strategy. acknowledgements 1. covenant health, alberta, 2. alberta health services references alzheimer society of canada (2017). a new way of looking at the impact of dementia in canada. retrieved from http://alzheimer.ca/en/cornwall/awareness/a-new-way-of-looking-atdementia alzheimer society of canada. 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(2012). applications of case study research. thousand oaks: sage publications. isbn 978-1-4129-8916-9. isaacson_542 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 265 native elder and youth perspectives on mental well-being, the value of the horse, and navigating two worlds mary j isaacson, phd, rn, chpn 1 rebecca c bott-knutson, phd 2 mary beth fishback 3 angela varnum 4 shelly brandenburger 5 1 assistant professor, college of nursing, south dakota state university, mary.isaacson@sdstate.edu 2 van d. and barbara b. fishback honors college dean and associate professor, department of animal science, south dakota state university, rebecca.bott@sdstate.edu 3 masters of public health program coordinator, south dakota state university, mary.fishback@sdstate.edu 4 dvm student, colorado state university, agebhart@rams.colostate.edu 5 associate professor, division of health and natural science, presentation college, shelly.brandenburger@presentation.edu abstract purpose: native american youth experience significant challenges to mental well-being. as part of a larger study to evaluate hope and resilience in a plains tribal population, the purpose of this study was to learn from native american elders and youths what they feel is needed to for youth to grow up healthy on the reservation, and to identify connections between horse use and mental well-being. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 266 sample: six native american elders and eight native american youths from the same plains tribe. method: the research team conducted talking circles with youths and elders. during the talking circles, participants identified community-specific questions for inclusion in a resilience measurement and provided personal stories regarding the relevance of the horse to well-being. findings: both groups felt cultural traditions and language, education, relationships, and interactions with horses have significant roles in enhancing identity development and resilience in youth. however, elders indicated that tribal youth seem to struggle in navigating two worlds. elders expressed that for youth to be well, they need to return to traditional ways within the realms of culture, language, education, and relationships. on the other hand, the youths were more confident in their ability to navigate two worlds, and wished to seek opportunities to blend their traditional and contemporary lives. conclusion: the challenges of navigating two worlds for native americans are experienced across generations. both youths and elders said that resilient youth are able to successfully navigate these challenges when they: (a) know their indigenous identity, (b) participate in cultural activities, (c) have strong family ties, and (d) are able to learn in an environment where their culture is championed. we propose that future efforts must include community-based participatory methods in the development of interventions that include use of the horse to strengthen native american youth resilience and foster health and well-being. keywords: american indian health, resilience, identity, mental well-being, horses online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 267 native elder and youth perspectives on mental well-being, the value of the horse, and navigating two worlds historical trauma is the “cumulative and collective emotional and psychological injury both over the life span and across generations, resulting from a cataclysmic history of genocide” (yellow horse brave heart, 1999, p. 2). historical trauma particularly affects native american/american indian (na/ai) populations and through storytelling, the sharing of traditions, and collective memories of the population, traumatic experiences are passed from generation to generation (sotero, 2006). the lasting effects of this intergenerational trauma among na/ais are linked to colonization practices, such as dissolution of traditional ceremonies, practices, and family structure, resulting in significant cultural losses. these losses have continued psychological ramifications across generations of na/ais (garrett et al., 2013). for example, adults whose parents attended boarding school were shown to have higher rates of depression and suicide contemplation, being influenced by their parents' stress through disruptions in parenting behaviors as well as indirectly through disadvantages their parents suffered from being removed from their own families (bombay, matheson & anisman, 2014). the negative psychological effects from historical trauma are especially persistent with na/ai youth (evans-campbell, 2008; whitbeck, adams, hoyt, & chen, 2004). not only do these youth live with historical trauma, but they may also experience original trauma through social inequality, poverty, and discrimination (sotera, 2006). sotera (2006) asserts that this exposure to historical and original trauma, also described as chronic trauma, can have serious negative effects on interpersonal relationships, development of life skills, and the ability to persevere in the face of challenges. na/ai youth, ages 15-24, exhibit more than twice the rate of suicide as the national online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 268 average (maza, 2015) and have a greater prevalence of depression, anxiety, post-traumatic stress disorder, and substance use disorders (cunningham, o’connor, & asch, 2017). moreover, youth represent the largest percentage of the na/ai population (garrett et al., 2013), thus there is an urgent need for culturally appropriate measurements to assess well-being and diverse interventions to improve the health of reservation communities (gone & trimble, 2012). resilience although na/ais experience significant mental health challenges, the persistent portrayal of native health in a negative light can undervalue certain health strengths embedded in their cultures (fast & collin-vezina, 2010). for indigenous communities, well-being is rooted in strengths such as balance, harmony, community connections, and spirituality (rountree & smith, 2016). all of these can lead to resilience, which is a new word for an old idea among native elders. the concept of resilience is deeply ingrained in the history of na/ai peoples; every indigenous language has a word that means resilience (heavyrunner & marshall, 2003). resilience has been described as having internal strength and valor (brokenleg, 2012). it can be also be defined as “the capacity to face challenges and to become somehow more capable despite adverse experiences” (laframboise, hoyt, oliver, & whitbeck, 2006, p. 194). resilience has also been described as a trait that can reduce the impact of negative stress in people's lives, moving people toward a more neutral (less negative) state (van dick, ketturat, hausser & majzisch, 2017). simultaneously, van dick and colleagues (2017) describe strong identity as something that moves people beyond neutral to a more positive state. combined, resilience and identity development can have positive effects on health outcomes and both may be necessary in developing programming which aims to improve mental health of na/ai youth and decrease rates of depression and suicide. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 269 identity resilience is one of many factors influencing identity development in na/ai youth. these factors differ between communities and are grounded in shared cultural traditions (horse, 2005). horse (2005) asserted that crucial to na/ai identity development is the level of grounding in one’s culture. garret et al. (2013) suggested that participation in ceremonies may create a sense of belonging and identity. additionally, a child’s identity development is enhanced through learning his/her native language, as language influences the way a child perceives his/her world and his/her connections within that world (garrett et al., 2013). a particular challenge of identity development for native youth is the concept referred to as ‘walking in two worlds.’ lumbee tribal member andrew bentley (2015) describes this as trying to maintain one’s physical, mental, emotional, and spiritual well-being while maintaining a level of assimilation with the mainstream culture. navigating in two worlds has been described as bicultural efficacy, the ability to navigate the world successfully in the mainstream culture while simultaneously maintaining one’s cultural identity (okagaki, helling & bingham, 2009). for native youth living in more remote reservation communities, exposure to ‘mainstream culture’ is less. thus, when they leave the reservation and experience the dominant culture, a crisis of identity is likely (houghton, 2014; skousen, n.d.; wong, 2017). this crisis of identity may be lessened in those whose ethnic identity is strong. for example, a study conducted with mexican-american and na youth concluded that “ethnic identity development may increase resilience to discrimination and prejudice which are often common and stressful for ethnic minority adolescents” (romero, edwards, fryberg & orduna, 2014, p. 1). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 270 the horse and well-being na/ai youths’ development of ethnic identity is enhanced when they engage in traditional cultural practices. these cultural practices may also improve mental health, especially given the communal aspect of native cultures (smokowski, evans, cotter, & webber, 2014). one such practice, deeply rooted in the na/ai community highlighted in this study, is working with the horse. because of the horse’s historical and present-day connections to many na/ai peoples, it can enhance identity development and thus may have positive health outcomes for native youth. horses historically played a large role in family life, medicine, war, and survival for the plains tribes during the eighteenth and nineteenth centuries (horse capture & her many horses, 2006), and they continue to be used for recreation and work on reservations. although there are no published quantitative studies of the horse’s effects on na/ai youth wellness, case reports and descriptive studies among this population have documented positive results. for example, equineassisted learning has been employed for substance misuse education and gang prevention in first nations youth (adams et al., 2015; dell, 2011; whitbeck, n.d.). organized rides among great plains tribes also emphasize cultural values (whitbeck, walls, & welch, 2012). the beneficial effects of horse-human interaction have been quantified in cultures other than na/ai and can be experienced physically, emotionally, and socially (all, loving, & crane, 1999; klontz, bivens, leinart, & klontz, 2007; pendry, smith, & roeter, 2014; wilkie, germain, & theule, 2016), suggesting equine activities can positively influence mental health. given the role of historical trauma in native health outcomes, traditional cultural values combined with resilience and strong identity development may have potential positive effects on na/ai youth well-being. the purpose of this two-part study was to learn from both native elders online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 271 and youths what these groups feel is needed for youth to grow up healthy on the reservation, and to identify the connections between horse use and mental well-being. methods design this article reports the qualitative findings from a larger multi-method study conducted to evaluate the psychometric properties of the herth hope index [hhi] (phillips-salimi, haase, kintner, monahan, & azzouz, 2007) and the child and youth resilience measure, child version [cyrm-28] (liebenberg, ungar, & van de vijver, 2012) in a plains na/ai adolescent population. protocol for administration of the cyrm-28 recommends the inclusion of site-specific questions, generated from focus groups with community members (resilience research centre, 2016). following the advised protocol for the cyrm-28, the transdisciplinary research team invited na/ai elders and adolescents to participate in two separate talking circles (i.e., focus groups). talking circles provide a culturally sensitive platform for na/ais to openly share their concerns regarding the topic area (lowe & wimbish-cirilo, 2016). the transdisciplinary research team included three doctoral-prepared individuals: (a) registered nurse, (b) registered dietician, and (c) an equine scientist, along with two mastersprepared public health individuals: (d) physician’s assistant/mental health professional and (e) doctor of veterinary medicine student. two of the team members have worked with this na/ai population specific to the health of horses. two other team members have experience with this population in the arena of childhood obesity and risk behaviors. one team member’s area of expertise is mental health. two of the team members are skilled qualitative researchers and provided leadership and guidance throughout analysis of the narratives. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 272 participants and setting in june, 2016, six native elders and eight native youths from the same tribe participated in separate talking circles. following krueger and casey’s (2000) guidelines, the inclusion criteria for this study and the youth talking circle was: a group of eight na/ai between the ages of 1418 years, tribal membership, and past/present experience with horses. inclusion criteria for the elder talking circle was: a group of eight na/ai elders, tribal membership, and past/present experience with horses. elders were purposefully recruited through a researcher’s previously established affiliation with the director of the reservation’s foster grandparent program. purposeful recruitment of youth occurred through two researchers’ contacts with members of the reservation’s horse community. both groups identified site-specific questions for the cyrm-28 and explored native adolescents’ relationships with horses. in addition, youth were to be between the ages of 13 to 18 years. elder talking circle participants included two male and four female elders. youth talking circle participants were between the ages of 13 to 17 years and included seven female participants and one male. the talking circles were held in a centrally-located college center on a reservation in the northern plains. this reservation is in a rural region as defined by the economic research service (n.d.). procedure and data collection after obtaining written elder and parent/guardian consent and youth assent, the talking circles began with introductions of the research team and the participants. following introductions, the research team provided the participants with copies of the interview questions (table 1), the hhi, and the cyrm-28. each talking circle began with the first question noted in table 1. key comments from the participants and the site-specific questions were annotated on a white board, allowing everyone the opportunity to review in real time. each talking circle online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 273 lasted approximately two hours and was digitally recorded. during the talking circles, each researcher kept separate notes, which were then combined after the discussions. the digital recordings were then transcribed verbatim by a qualified transcriptionist. one researcher listened to the recordings while reviewing the written transcriptions, correcting them as needed for accuracy. table 1 talking circle questions 1.) what is needed for youth to grow up well here? 2.) what does it mean to be healthy? 3.) what are challenges faced by youth? 4.) how is the horse important to your community? 5.) describe the role of the horse in your life. ethical considerations the research team obtained approval from the university institutional review board (irb1508004-exp) and the tribal research review board (102). all participants, including parents/guardians, were informed that their participation was voluntary and that they could withdraw from the talking circle at any time. to maintain confidentiality, participants are not named, but referred to as “youth” or “elder”. the participants provided general demographic information to the research team. after each talking circle concluded, each participant received a $25 gift card and shared a nutritious meal with the research team. all participant data was online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 274 maintained in a locked file, with narrative data stored and shared per a secure university-based online storage system. data analysis using braun and clarke’s (2006) method of thematic analysis, each team member independently reviewed the transcripts by reading and rereading the narratives before their initial gathering to discuss the results. during the first meeting, members described their impressions of potential themes. each team member then independently coded the narratives based on these initial themes. later, the team met again and revisited the initial themes alongside each member’s coding. secondary independent coding then ensued, with team members identifying key participant quotes. to solidify the emergent themes, each team member developed and shared a thematic map. further discussion occurred, resulting in the selection of the overarching theme and supporting themes. throughout the analysis, team members openly debated themes and discrepancies until reaching consensus. rigor the research team addressed rigor, dependability, and trustworthiness by their willingness to share, discuss, refute, and revise their interpretations of the narrative data (roberts, priest, & traynor, 2006). the details provided on the study’s design, process, participants, and setting allow the potential for transferability. credibility of the study is noted, as the team diligently reviewed the youth and elder transcripts separately and as a whole, assessing for differences and commonalities (thomas & magilvy, 2011). confirmability is present, as throughout the process the research team addressed individual preconceived notions and biases (thomas & magilvy, 2011). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 275 results the elder and youth narratives resonated with differing perspectives of navigating two worlds: the world of traditional native values and modern white culture. elders felt that this constant balancing act was the main cause of many destructive behaviors prevalent on the reservation. one elder portrayed the two-world phenomenon as a great chasm, where on one side he thought in his traditional ways and on the other, he was forced to think like a white man. the youths’ descriptions of the two worlds were less negative. they shared how they must be futuristic in their thinking and adapt to the white world, while maintaining connections to their cultural roots. they expressed confidence in who they were; however, they noted that many reservation youths lack this confidence and cope in negative ways. in order for adolescents to successfully navigate between these two worlds, it is essential for them to develop their identity, which became the over-arching theme. impacting and shaping their identities are their cultural traditions and language, relationships, and education. interwoven among all of these themes is the influence of the horse, whose historical and cultural significance is deeply embedded in this tribal community. culture elder and youth participant narratives underscored the importance of staying connected to language and cultural traditions. yet the elders and youths described their language and cultural traditions in subtly different ways. the elders emphasized the need for language proficiency and asserted that youth should be able to speak the language. youths said that while they wished to be fluent in the language, they had limited opportunities to attain fluency. in addition, the elders expressed an urgency about maintaining their cultural traditions, while the youths reported that they struggled to find ways to do so. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 276 a need to speak the language for this native tribe, culture is intertwined with language and ceremonies, and is demonstrated in the continued use of the language and participation in these ceremonies. each of the participating elders was a fluent speaker and expressed frustration with the lack of traditional speakers within the tribal government and educational systems. one elder shared his experience as a child learning to speak his native language and his concerns regarding the survival of the language in native youth: when we grew up, we didn’t speak wasicu [white man], we all spoke [our native language], and it was common. when you are speaking [the native language], you have the tendency to have a good memory…it’s inherent in your mind, you just pull it out. today, one of the differences with our children is they go to school, and they have a hard time. they’re not dumb, they’re not naïve, but because of the historical grief and trauma caused by genocide, it’s painful to recall memory. this participant expressed great frustration with the loss of language. he earnestly pleaded that members of the tribal council should all speak the language. furthermore, he added that knowing the language and the culture should be requirements for youth before they are given special honors: this is horrible, it’s bad, it’s ugly, it’s sad, it’s never going to go away unless leaders like the tribal council, they all start speaking [the native language]. there’s other ways… have a pow-wow, have a princess contest. before that little girl applies for princess she has to speak [the native language] and know her culture. before you are a leader you should be a [native language] speaker. another participant shared these concerns. she recalled working with children as a foster grandparent and noticing their lack of engagement with the culture and the language: online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 277 …mostly i observed and watched the children, you know. they really fascinate me, and a lot of them do not care. they don’t care to learn the language, and i always ask them, but why? youth want to speak the language dialogue with the youths identified a desire to learn the traditional language, but limited occasions to do so. many of them attend the local parochial school, where the native language is taught and opportunities to participate in the inipi (sweat) ceremony exist. one youth participant stated: …our [native] language. we’re losing it, and we’re not really speaking it. i barely even know how to speak it…i guess we were supposed to be taught in school, but i guess some of us weren’t paying attention as much as we were supposed to be. it was [emphasized], but it wasn’t as much as what was needed. the youths also stated that knowing their traditional language was vital. if youth cannot speak the language, even in prayer, then they will lose the ability to communicate with the spirits. one youth explained this: the spirits, and without that, because they don’t understand english, and so like when we were taught, we were taught to pray in [our language], and so i’m sure all of us at least know some [traditional] prayers. another youth said that the generalities of the language are taught at school but not sufficiently reinforced at home. this participant shared that there are no fluent speakers in her family: outside of prayer, the most i’ve ever heard anyone, like anyone my age speak was an introduction…[for example, what’s your] name, where you were born, where you live, where you’re from, just things like that…it’s about that big (indicates by making a small space online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 278 between her thumb and index finger), and that’s about all i’ve ever heard someone my age say [in our language], and that’s taught so, i mean, we didn’t come in like that, come in to school knowing how to say that stuff. it was taught [at school, not at home]. the youths acknowledged the importance of their traditional language, especially to speak to the spirits, or to those who have passed on. this connection to the spirit world through the traditional language may be one way of reconnecting the youth with their cultural lifeways. a need to maintain the cultural traditions as a way of returning to their cultural traditions, honoring their ancestors, and providing a process for healing, one of the elder participant’s family members initiated an annual remembrance horseback ride in the 1980s, memorializing those lost in a historic tragedy. pre-reservation, this na/ai culture practiced seven sacred ceremonies. he indicated that in 1985 this had decreased to three. he recalled: the sun dance has always been popular, and they call it the sweat lodge, [the] inipi, and the hunka. those are the only three rituals [that were practiced], and they forgot about the grieving ceremony, the social give-away, the throwing of the ball…[does not name seventh]. nobody knew the songs [that went with the ceremonies], nobody knew how the ritual went, how the procedures go, so in 1986 we started vision quest, [traditional] speakers, how do we bring that hunka, how do we bring…when you make a relative…so today, all the ceremonies are just being done any way. another elder learned how to cook in the traditional way from her family, “i learned to make wasna.” yet another recalled that her mother’s family was very traditional; they practiced the ceremonies. according to these elder participants, the rituals were taught from grandparents and online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 279 parents to the children. they express concern that this art has been lost or is being less vigilantly maintained. an elder also lamented the lack of understanding demonstrated by his tribe today with respect to the appropriate timing of the ceremonies. he expressed frustration that members of his tribe do not know the origins of the rituals and why they are practiced: we try to bring the tiospaye back. a lot of why our ceremonies that we’re practicing today, a lot of the rituals or even pow-wows, they don’t mean nothing because it’s not the tiospaye doing it. it’s just a bunch of people come together, and they put something on, it happens and goes. but when a tiospaye does it, it has meaning. although there are concerns about the loss of understanding on the purpose of the rituals, the elders described their efforts to re-instill the importance of tiospaye and ceremonies into youths’ lives. one elder described how she works with new mothers: i talk to the new mothers about what i know about star knowledge and…who they are, you know…we started with the ceremonies…and so we became stronger spiritually as a family in our little expanding tiospaye. adding to this, an elder related how important it was to listen to his grandparents tell stories at night. he described how the stories reverberated into his soul and became a part of him, “listening to stories in the evening before bed, you go to sleep hearing them and when you wake up in the morning it feels like you can still hear them.” the struggle to maintain cultural traditions the youths seemed to recognize that in their minds they needed to look ahead and away from the reservation to be successful in today’s world. yet, in their hearts, they felt the importance of knowing the language and the traditional ways. one youth’s family carries out many of the online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 280 traditions through continuation of the language and attending the sun dance. she expressed how much she enjoys going with her family to the sun dance: …being able to go out to the sun dance every year and sweat and, you know, it gives us something to look forward to. like us guys, all our older relatives are dancers, so like when we get older we’re most likely going to be dancers too. i just think that traditional ways are a big key to staying positive on the reservation. she was concerned about her peers on the reservation who might not have the strong family connections to their traditional culture that she so freely experiences. she worries that this loss creates many of the issues present on the reservation: i think like someone without the culture would maybe feel a little like lost, because like we were disconnected to all the [traditional] way of life, you know, not so long ago. and then without it there they would feel lost. and i think that’s why like there’s a lot of bad things going on on the reservation now because they don’t know their traditions, and they don’t know how to pray in [traditional language]. this youth was adamant that knowing the traditions is essential. another youth agreed, saying that going to “sweat” helps mentally. she voiced concern with the parochial school’s emphasis on church attendance and not on participation in sweats: at school, we go to church at least once a month, and sweat is offered. you don’t have to go, it’s offered like every two months, so i think that’s a big inequality or something, but they focus on the like christian views more than they do the [tribal] views…[mass is] required…yep, and they don’t make such a big deal out of it [sweat]. it’s like you have to go to mass, you have [to] be there, you can’t chew gum. there’s so many rules, and like, ‘oh, if you want to go to sweat, go ahead.’ online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 281 both youths and elders expressed the value of knowing the language and participating in traditional practices. the elders emphasized the loss of the language and traditions because of forced assimilation practices. they expressed an urgent need to re-establish the tiospaye as a foundation, helping youth to reconnect with who they are. the youths said that learning the native language and having the opportunity to participate in the traditional ceremonies were essential in shaping their identity. however, language acquisition as well as occasions to attend traditional ceremonies were limited. one youth willingly shared that her family has no fluent speakers; learning the language is only obtained through the school system. the remaining seven youths identified fluent speakers in the home, although none were fluent speakers themselves. for these youth, knowing their cultural traditions, including the language, are important for nurturing their physical and mental well-being and strengthening their resilience. relationships integral to native cultures are family/kinship ties. these relationships, whether nuclear or extended, have over the centuries instilled the importance of cultural heritage, traditions, and language in youth. for the elder participants, family disruption occurred when they were forced to attend boarding schools, forever changing the traditional familial roles. elders and tiospaye each elder introduced himself or herself based on his/her role within their family: grandma, grandpa, brother, sister, mother. this demonstrates that a significant component of the elders’ identity is their role within the family: online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 282 i’m a grandpa and a great-grandpa now. i’m just proud of my great-grandpa status. i’m only 65 years old, but i have to take on the role as an old elderly now in my tiospaye as i’m the eldest male… elders learned about their culture and way of life through observing and modeling their own grandparents’ behaviors and stories. the close relationship between elders (as children) and their grandparents may have risen out of a need for connection to the traditional ways of life. close relationships with grandparents could offer youth a way for seeking experience with, and understanding of, their roots and identity. one elder said: i grew up without parents, but my grandmother, my grandparents are always there. that’s how i learned [native language], and i learned how to do mostly everything, what my grandma taught me…my other set on my mother’s side, they were the traditional, and they had ceremony and, you know, did all the traditional things. so i kind of grew up that way. the elders stressed the importance of family, indicating that they feel it has changed over time. today’s elders were removed from their homes as children, disconnecting them from their parent and grandparent role models. this ultimately changed the way they interacted with their children and grandchildren. the elders expressed strong concern about the generational loss of culture and tradition, specifically regret for not having passed traditions to their children. they credit the destructive behaviors of their children to this failure, voicing a strong sense of responsibility for now passing knowledge onto their grandchildren: eventually i began to understand that the switch in culture, the rules and stuff, that happens, and the men were lost. the women started doing the work that the men used to do, start working and earning money, and the men really had no place or anything, you know, that their old roles were gone…we were boarding school parents, we lost our parenting skills. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 283 additionally, the traditional tiospaye suffers in the government-designed reservation housing communities, where neighbors are often not members of the same extended family. the elders voiced concern about the youth not fully understanding or receiving the benefits of tiospaye. they feel family structure has deteriorated and created confusion among youth: we still all live together, and we encourage each other in our ways, and it is difficult for some of our young children that they live in the two worlds, and oftentimes they don’t know the world i knew growing up, and so it’s difficult for them to see and understand, so we’re working hard with them. i try to extend it to other children. youth and tiospaye both elders and youths perceive trans-generational transfer of information as a way of learning. youths articulated the importance of learning the traditions from their elders and expressed that in the future, they intend to disseminate the stories and traditions to their own children, “like i said, it’s important to learn the stories they tell you…and maybe someday you’ll pass it along to your child.” another youth shared, i think it’s really important to be connected to the family because my grandparents were raised like in the old ways, you know… keep to yourselves, worry about your family, things like that. but i think it should extend to like the community and things like that. while the youths understood the need to learn from family members, specifically their grandparents, they also voiced the importance of relying on outside support. they acknowledged that family may not always be available to learn from or family may not be a positive influence. in these circumstances, identifying someone or something else to connect with is a way for them to learn about themselves and their culture: online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 284 …sometimes your family is a bad place, and you find like someone to look up to outside your family, like it could be someone famous. it could be a storybook character. it could be anyone. it don’t necessarily have to be your family… but for some people that’s all they have. the youths said that an important part of growing up healthy and happy on the reservation includes having solid role models: people who are reliable, trustworthy, and whom they wish to emulate. the youths discussed the importance of being encouraged by others and how this encouragement helps them to overcome life’s challenges. they were unanimous in their responses regarding what they need to grow up well on the reservation, with the following comment capturing the group’s sentiments: i think probably like just a good support system like, you know, loved ones there for them and just good role models they can look up to…role models like, you know, maybe it’s an uncle or an older cousin, or maybe it’s like, you know, your teacher. the elders fear that the current reservation-based housing system is a detriment to the maintenance and thriving of the tiospaye. the youths are adapting the traditional concepts of tiospaye by building relationships and seeking support more inclusively. both relationships and culture are key components of identity development and both groups expressed the value of having connections with others from their community. although not explicitly stated by elders or youths, family relationships and the concept of tiospaye were implicated in the wellness of tribal youths. relationships provide a connection within community as well as an avenue through which to develop identity, both are important concepts for supporting healthy perspectives and self-image. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 285 teaching and learning the youth and elder participants portrayed formal education on the reservation and its association with boarding schools, abuse, and disruption of family and cultural ways differently. the elders emphasized the feeling of being torn by the educational system and they assumed that this is a painful division in the youth as well. one elder remembered: as i became more educated, though, i felt like i was missing something, and i remember being away to college in [another state], and i was coming home on a break. i came over that hill by [home] and i stopped, and for some reason i stopped and i just cried. i was so glad to be home, you know. although elders were supportive of teaching and learning (several had teaching certifications and a wealth of formal and informal teaching experiences), most remained reserved toward public education. the elders shared stories of the physical and emotional pain experienced while attending boarding school. “educators” delivered physical pain in the form of hitting, slapping with a ruler, and ear-pulling: we were in boarding school. i went to boarding school until high school, but they were so mean when i was there. they used to, if you were speaking your language, they would say, ‘put out your hands,’ and then they would get a ruler and just really beat our hands. but i never cried. i could feel the tears coming, but i never cried. i was just i just refused to give in. i’m still stubborn like that. while anger and pain were evident in some of the elders’ stories related to education, there remained an underlying agreement about the importance of education for youth. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 286 we have to find a good leader to bring us all together and really work with the school systems and try to turn it around for our children, because they do need that education in order to survive in the future. youths recognized a very similar feeling of being torn between a traditional life on the reservation and a new life provided by education elsewhere. some recounted missing home while away at school in another state, but then looking forward to being back at school when returning home to the reservation during breaks. one individual, who during the school year lives and studies at an out-of-state high school, said, “we have our ties here. twenty years down the road this will always be our home. this is where our ancestors were.” it seemed to be commonly accepted by these youths, however, that truly reaching out and striving for one’s fullest potential involved leaving the reservation: yes, because it’s hard to believe, but there are a lot of people that think they have to stay here forever. like they have to go to high school here, probably go to [the tribal college] and then work at ihs [indian health services] or something like that. there are not a lot of people that think, ‘i can go to harvard and princeton and penn state.’ living far from the reservation for education was commonly recognized by the youth participants as very challenging, “i mean, to even go to high school off the rez, that takes like a lot because for some people the rez is all they’ve known, so it takes all they have to leave.” although elders experienced historical abuses by the educational system against their collective cultural identity, both elders and youths spoke of the importance of receiving an education. youths seemed to understand the gains inherent in attending school, even if it takes them away from the reservation and their cultural groundings. they sensed that the ability to navigate the educational system, like navigating a world apart from their own culture, would be a online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 287 source of well-being. the opportunity to receive a higher education brings both challenges and tools for youths to shape their identities. horse interwoven within the themes of culture, family, and education was the importance of the horse as teacher, friend, and cultural guide. these participants described how the horse traditionally impacted their ancestors’ way of life. horse culture was extremely important to plains indians. the elders revealed the necessity to pass along culture, language, and tradition through their stories, and recognized the horse as a partner in teaching the youth important and basic values. parallels existed between the perceptions of education and the perceptions of the horse by youths and elders. the elders emphasized the horse’s role as a teacher, not unlike the role that grandparents and community elders also have in educating children. one elder stated, “that horse will teach them, teach them to listen if they need to learn respect, self-esteem, and also self-control, you know. an animal teaches you a lot.” the horse’s physical and symbolic presence directs the youth back to traditional ways, which for many elders was the role that they felt education should play in youth’s lives. besides living and interacting with the horse, learning the story of the horse may also help individuals to feel more connected with their cultures and glean strength. an elder shared: because we have to also teach that the genocide committed against us, the same genocide story can be shared with the buffalo, with the bear, with the elk, with the deer, the genocide towards the horses. we share the same story. we are no different from the bear. we are no different from the grass. elders saw the value of the horse as pointing youth back toward traditional ways, and even suggested a wider inclusion of the horse into the educational curriculum. additionally, the horse online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 288 provides opportunities, such as on family rides and horseback events, to engage in the larger tiospaye, especially with the loss of the traditional family structure. while the youths did not voice distress over this loss, they did express deep appreciation for instances which bring extended family together, specifically via the horse. the youth participants tended to think of the horse, like education, as a means of looking forwards, not backwards. just as multiple participants discussed being excited for opportunities to leave the reservation for education, several mentioned that the horse is important to them because they look forward to activities they can do on horseback to release stress. these activities include riding alone, riding with family, and participating in rodeos. a simple trail ride offers an opportunity to engage extended families in a common purpose. one youth said: yeah, my uncle does quite a few trail rides, and it just like feels good to see everyone come and, you know, all my nieces and nephews or even like, you know, friends and family just happy, getting their horse, getting ready. it just brings joy to my heart to see that. while these youth participants identified a strong connection to the horse, they indicated that not all reservation adolescents feel similarly. one participant stated that many of her classmates felt that riding a horse provided a less “cool” alternative to unhealthy habits such as drugs and parties. this participant thought that many youths would perhaps change their views if they had the chance to develop and nurture relationships with horses: …it’s kind of like it’s not cool, or, do you know what i mean? like they’d rather be out drugging and partying and stuff like that…and horses are for hicks and country people. it’s things like that. if they could ride a horse, they would change, i think. horses are credited by youths as having healthy, healing powers. interactions between these adolescents and horses provides a therapeutic release that may or may not be accessible through online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 289 family relationships. as one youth shared, “the horse, it like, it helps you like, if you’re feeling bad you go ride, and it’ll like help you. he has that power to do that, you know, [know] how you’re feeling.” for the youths, the horse was touted as a companion they could look forward to spending time with and a way to take care of themselves. youth seek affirmation and solace from family and friends. when those venues are not available to them, they combat isolation by seeking role models and companionship in other aspects of their lives. therefore, the horse is considered a friend and a helper by them. one youth described, “just like a human friend would, they help you get things.” the horse also transcends friendship and becomes family in the eyes of these youths. perhaps this is a modern anthropomorphic construct of youth living partially in white culture; although, it certainly could be viewed as an example of youth leaning quite literally on their native concept of mitakuye oyasin. one youth described the role of the horse in her life today, “my friend, brother. horses are pretty important in my life.” the youths’ ability to demonstrate resilience by looking ahead and gaining new strengths from the world around them was reflected in their visions of the horse, representative of their ability to navigate in two worlds. the elders’ perceptions of the horse were largely situated around helping youth to choose to walk in the traditional world of their tribe. both elders and youths recognized the value of staying connected to their culture through language, traditions, ceremonies, and even the horse. however, for the youths it seemed that in their hearts they knew traditional ways were important, but that in their heads they knew they also needed to look ahead for success in the world. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 290 discussion these candid narratives shared by native elders and youths provide a view into the landscape of challenges experienced by na/ais in contemporary society. on the surface, there appeared to be a disconnect in opinion between the youths and the elders regarding the need to learn to navigate in two worlds. however, a deeper exploration of the narratives revealed only subtle differences in how to reintroduce and reinforce the traditional way of thinking into youth’s lives. both the youths and the elders agree that each area is essential for improving mental well-being for native children today. because the power of the horse was a recurring theme throughout the focus groups, we discuss potential ways this animal can assist na/ai youths in navigating two worlds. our participants stressed the importance of knowing and participating in traditional cultural activities, including language proficiency, as ways of decreasing adolescent risk behaviors. pu and colleagues’ (2013) study of na/ai adolescents and violence concluded that adolescent interest in tribal lifeways was positively associated with decreased tendencies toward violence. a review of the literature (henson, sabo, trujillo, & teufel-shone, 2017) regarding protective factors and na/ai adolescent health, characterized connection to traditional culture as a multi-level protective factor. this cultural connectedness included language acquisition and participation in cultural activities. further, six studies found that adolescents who were more engaged with their culture had greater resilience, improved school success, and fewer behavioral delinquencies (henson et al., 2017). na/ai youth participation in cultural activities has also demonstrated enhanced ethnic identity when compared to those not participating in these activities (schweigman, soto, wright, & unger, 2011). brown, dickerson, and d’amico’s (2016) study with urban na/ai adults and adolescents found that youth feel disconnected from their cultures and have limited opportunities to discover their cultural roots. adults in that study also expressed concerns for the youth related online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 291 to this disconnect and felt that if youth could rediscover their cultural identities there would be fewer delinquent behaviors (brown et al., 2016). participants in this study characterized family relationships as an important aspect of living and thriving. for elders, the concept of tiospaye came to life as they learned about culture and the world from their own grandparents, and, in turn, sought to pass on their knowledge to their grandchildren. youth participants in the present study echoed the importance of tiospaye and suggested that they too, would one day pass along important information to their grandchildren. it is common practice in this community for grandparents to raise their grandchildren, or community grandchildren, in order to mitigate risks or negative circumstances, despite having little financial means to do so (dennis & brewer, 2016). in some cases, elders become the preservers and teachers of culture, traditions, and societal roles, guiding grandchildren and expanding upon school curriculum (kincheloe & bull, 1982). henson and colleagues (2017) also identified the importance of family connectedness as a protective factor for na/ai youth well-being. the role of elders as conveyors of cultural information demonstrates the importance of teaching and learning to na/ai cultures. however, some youths felt torn between a life on the reservation, surrounded by their families and traditional culture, and pursuing their educational dreams. the educational system often does not support na/ai values such as being part of a clan, generosity, and collaboration (deyhle & swisher, 1997; lópez, schram & vasquez, 2013). thus, na/ai students may feel pressured to sacrifice traditional values while attending high school or striving for a higher education. perceived discrimination against one’s traditions can significantly impact resilience in a negative way (laframboise et al., 2006). conversely, engagement with one’s culture can promote resilience for indigenous individuals (laframboise et al., 2006) and cultivating an ethnic identity can shape minority individuals’ optimism, self-esteem, and mental online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 292 health (smokowski et al., 2014). thus, educational institutions must not only accept, but cultivate, cultural knowledge and viewpoints, or risk performing a grave disservice to their students. there is also compelling evidence for the role the horse plays in helping to live well and to shape identity. horses can help youths become comfortable and confident within themselves. this is accomplished through an activity that means something to them—an activity which can help them to forge their identity and relationships. perhaps out of necessity, due to the loss of traditional structure, or perhaps as a normal path in adolescent development, youth seek relationships and affirmation outside of the family structure. the horse offers such relationship and affirmation. communication with the horse is predicated upon a common unspoken language (brandt, 2004). they rely on sensing and intuiting; or as one youth in the present study stated, “horses can sense the way you feel.” participants shared that horses served at times as opportunities to connect with families, and at others, they served as an opportunity to retreat with a sensing partner. horses have been implicated in cultural healing through the connection of native people to their roots in “indigenous wellness paradigms” (white plume, 2016, para.3). youths provided evidence of the horse providing retreat, strength, and healing within their lives. limitations there are limitations to this study. the purposeful recruitment of the participants through previous contacts resulted in some having a familial relationship, i.e., two elders were married and some of the youths were cousins. these familial ties could have resulted in “like” thinking; however, the youths were quick to respectfully disagree with one another and offer their own opinion versus agreeing with the group. in addition, the purpose of the talking circles was to form context specific questions to include with the cyrm-28. thus, the team did not conduct additional youth or elder talking circles in order to achieve theoretical saturation (krueger & casey, 2000). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 293 a final limitation is that the elder participants offered opinions regarding the importance of the horse to youth well-being; youths were specifically asked about their relationships with horses and were recruited from horse related contacts. implications for future work our study and recent literature demonstrate the value for na/ai youth of knowing and participating in cultural activities. however, for tribal youth, these opportunities may be limited due to a lack of cultural engagement within their family. both youth and elder participants highlighted transgenerational relationships as crucial to the survival of a generation as well as a culture. youths, however, expressed a need to expand their community of support, even including those outside the traditional tiospaye, in order to live well. traditional na/ai education views learning as integrated across all activities, not as a compartmentalized part of a child’s life (lópez et al., 2013). incorporating elders and community activities into a child’s learning has been shown to improve learning outcomes for na/ai students when done with culturally congruent instruction (aronson & laughter, 2016; oakes & maday, 2009). educational and cultural experiences, both within and outside of the classroom, should serve to guide na/ai youth who navigate two worlds, not increase the width of the chasm between the two. finally, we recommend the horse as a potential catalyst to reaffirm important relationships and the tiospaye, while reconnecting youth with their cultures, and ultimately elevating wellness in na/ai youths. the affinity of our youth participants for horses may be an intuitive attempt to preserve native identities while navigating present-day mainstream white culture. additionally, the horse can be an aid in the educational process. within the classroom, the horse offers a unique opportunity to integrate teachings of culture, relationships, and science, technology, engineering, and math fields. at home, the horse may create transgenerational bonds and connections. in online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 294 partnership with the horse, na/ai youth can build upon the foundations of relationship, education, and culture needed to live well while navigating two worlds. further work is necessary to identify ways to incorporate the horse as a partner in the creation of guided, family-centric cultural activities, where families which are uncomfortable about and unfamiliar with cultural traditions feel welcome to attend and reengage. conclusion the current study was developed as a holistic, multifaceted approach to understanding what it takes for na/ai adolescents to be well. our transdisciplinary approach acknowledges that wellness is complex. the participants in our study revealed meaningful connections among culture, families and tiospaye, and teaching and learning in strengthening their identity. interwoven throughout these themes, is the value of the horse, which has the potential to impact the youth’s ability to successfully navigate two worlds. the challenges of navigating two worlds for na/ais are experienced across generations. in our study, both youths and elders said that resilient youth are able to successfully navigate these challenges when they: (a) know their indigenous identity, (b) participate in cultural activities, (c) have strong family ties, and (d) are able to learn in an environment where their culture is championed (dennis & brewer, 2016; henson et al., 2017; lundberg, 2014; schweigman et al., 2011). absent in the literature is the value of the horse toward promoting the aforementioned themes. to address this gap and bridge the two worlds, we propose that future efforts must include community-based participatory methods in the development of interventions that include use of the horse to strengthen na/ai youth resilience and foster health and well-being. acknowledgements online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.542 295 the authors wish to thank our participants for their candor and willingness to share their personal thoughts. we are also grateful for the guidance of the tribal research review board. special thanks to dr. charles woodard for critical review of the manuscript. funding this work was supported by the south dakota state university scholarly excellence fund and the rocky mountain public health training center public health student stipend. references adams, c., arratoon, c., boucher, j., cartier, g., chalmers, d., dell, c. a., . . . wuttunee, m. 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(1999). oyate ptayela: rebuilding the lakota nation through addressing historical trauma among lakota parents. journal of human behavior in the social environment, 2, 109 126. https://doi.org/10.1300/j137v02n01_08 petrucci_571-other-3737-1-6-20191104 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 156 strategies to increase human immunodeficiency virus testing in rural areas of the united states: a systematic review avery petrucci, mpas, pa-c 1 kristen custer, ms, lgpc 2 eric cameron nemec ii, pharmd, mehp, bcps 3 1 physician assistant, um prince george's hospital, ajpetrucci1630@gmail.com (ms. petrucci was a physician assistant student at sacred heart university when this manuscript was originally developed) 2 clinical therapist, kristenmcuster@gmail.com 3 director of research & assessment, clinical associate professor, sacred heart university, sacred heart university, nemece@sacredheart.edu abstract purpose: hiv incidence continues to increase, with a large portion of new diagnoses found in rural areas of the united states. the worsening statistics in rural areas may be attributed to stigma alone and contribute to the lack of testing available for patients. the objective of this systematic review is to identify accessible and feasible strategies to increase hiv testing within the rural communities in the united states. methods: a systematic literature search of cinahl complete, medline with full text, and psycinfo with restrictions of the english language and rural communities outside of the united states through august 2, 2018. two independent investigators screened articles using online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 157 predetermined inclusion and exclusion criteria. this systematic review is registered through prospero: crd42018108637. findings: there were 14 different studies with specific interventions attempting to increase the rate of hiv testing in rural communities in the united states. technology, faith-based stigma reduction, access, and provider interventions emerged as themes regarding hiv testing and stigma improvement. conclusion: there exists a body of literature that supports a number of specific interventions focusing on access, provider and patient perspective, and ways to decrease stigma that improve hiv testing and could be implemented in rural communities. keywords: rural, hiv/aids, hiv testing/screening, stigma strategies to increase human immunodeficiency virus testing in rural areas of the united states: a systematic review introduction the significant advancements of antiretroviral therapy have transformed the approach to caring for patients with human immunodeficiency virus (hiv), into a manageable, chronic disease. for those who are motivated to take therapy and who have access to lifelong treatment, acquired immune deficiency syndrome (aids) related illnesses are no longer the primary threat to mortality (deeks, lewin, & havlir, 2013). the united states (us) hiv epidemic has evolved over the past 30 years and new diagnoses are now found concentrated in socially marginalized and disenfranchised communities across underserved and geographically isolated areas often considered to be rural in nature (behrends et al., 2018; pellowski, kalichman, matthews, & adler, 2013). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 158 defining “rural” is a multifaceted concept that can often be based on individual perceptions, geographic concepts, and population. unfortunately, the definition frequently incorporates both stereotypes and personal experiences (hart, larson, & lishner, 2005). the multidimensional concept of rural with no clear-cut distinction can make defining a rural area difficult. is the concern geographic isolation or population density (macgregor-fors & vazquez, 2019)? the term suggests pastoral landscapes, unique demographic structures and settlement patterns, isolation, low population density, extractive economic activities, and distinct sociocultural milieus (hart et al., 2005). on average, rural populations have relatively more elderly people, more children, higher unemployment and underemployment rates, and lower population density with higher percentages of poor, uninsured, and underinsured residents (hart et al., 2005). for purposes of this review, the use of “rural” is consistent with the us census bureau (ratcliffe, burd, holder, & fields, 2016) definition as an area outside the metropolitan city limits in which residents have limited access to primary care and public health department services because of the distance, lack of transportation, and/or limited availability of services at satellite clinics (hernandez, mata, vasquez, & martinez, 2014). the literature suggests that being a rural resident alone is a significant risk factor for hiv related morbidity and mortality due to lower testing rates, later hiv diagnoses, later initiation of antiretroviral therapy, and consequently, increased hiv related mortality (lopes, eron, mugavero, miller, & napravnik, 2017; ohl & perencevich, 2011; schafer et al., 2017). additionally, rural residents seeking hiv care may face stigma, social isolation, and other barriers to care such as long distances to a provider, limited transportation, and lack of access to providers with hiv expertise (schafer et al., 2017). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 159 stigma, defined as “the dilemma of being different” or a characteristic perceived to be different from the norm of society (phillips, moneyham, & tavakoli, 2011), is a modifiable risk factor for patients with hiv/aids (rueda et al., 2016). stigma regarding hiv has been reported to significantly impact care utilization and health outcomes, which includes perceived quality of life and medication adherence (schafer et al., 2017; sweeney & vanable, 2016; varni, miller, & solomon, 2012). societal stigmatization due to assumption and transmission about hiv/aids and associated behaviors plays a substantial role in the psycho-social well-being of individuals, especially those living in rural and traditionally conservative regions (darlington & hutson, 2017). moreover, stigmatized people may sometimes be thought of as a category that is pejoratively regarded by the broader society and who are devalued, shunned, or otherwise lessened in life chances and in access to the humanizing benefit of free and unfettered social intercourse (phillips et al., 2011). many individuals believe that if one is following the community’s sociocultural expectations (e.g. being in a monogamous relationship or married), then hiv testing is unnecessary or inappropriate as is talking with one’s partner or spouse about hiv testing (de jesus, carrete, maine, & nalls, 2015). unfortunately, many of those disproportionately affected by hiv/aids share these testing perceptions and communication barriers as evidenced by various patient quotes in the literature regarding testing stigma: “getting an hiv test brings shame to the person who got tested and to one’s family; it implies one is engaging in immoral behavior” (de jesus et al., 2015). “it’s still considered to be a gay disease.” “it is lonely, even the most wellintentioned people are afraid of hiv. i feel sorrow, sadness, grief. i think about wanting a companion to grow old with. i am a sexual being. i think about never having sex with anyone again” (zukoski & thorburn, 2009). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 160 hiv impacts rural communities in southern areas of the united states where cultural conservatism and policies such as abstinence-based sex education have contributed to high levels of hiv-related stigma (reif et al., 2015; schafer et al., 2017). rural areas often have other increased risk factors for increased hiv transmission such as higher rates of poverty, opioid abuse, and lower educational attainment (aldous et al., 2012; kinsler, wong, sayles, davis, & cunningham, 2007). furthermore, studies have shown that fear of stigma has deterred individuals from being tested for hiv and from disclosing their seropositive or seronegative status to sexual partners, family, and friends (kinsler et al., 2007). patients with hiv in rural communities have reported perceptions of their health care providers as acting uncomfortable or treating them in an inferior manner, which greatly affects their use of medical services (kinsler et al., 2007). patients with hiv may feel a great deal of pressure, discomfort, and stigma when with a health care provider where they should feel the safest. as of 2006, the centers for disease control and prevention (cdc) recommends that all people ages 13-64 receive an hiv test at least once (center for disease control and prevention [cdc], 2019). it is also recommended that adults and teens who are at higher risk of hiv should be tested at least once per year (cdc, 2019). many healthcare providers are aware of the cdc guidelines but only 8% of providers will screen patients regardless of the risk (korthuis et al., 2011; zheng, suneja, chou, & arya, 2014). lack of time and other priorities at the time of visit were major indicators to not test and ubiquitous challenges to clinical practice (korthuis et al., 2011). other barriers identified by physicians are current hiv-related policies (third party reimbursement, requirement for written consent), stigma, lack of confidentiality in nonurban communities, practice financial environment, physician attitudes, and patient acceptance (schafer online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 161 et al., 2017). this provider stigma can be perceived by patients. “because they won’t touch you. they act scared to touch you. they put on gloves right away-just to touch your skin-like they don’t know hiv is not spread that way” (zukoski & thorburn, 2009). population characteristics can influence testing rates in rural areas also. for example, only 34.6% of men that have sex with men in a hispanic community outside of durham, north carolina reported ever being tested (sena, hammer, wilson, zeveloff, & gamble, 2010). until recently, the persons most affected by hiv/aids in rural areas have been men who have sex with men, many of whom were diagnosed with aids and treated in an urban area before returning to a rural community (castaneda, 2000). in nonurban south florida, an area of high hiv prevalence, only 21% of a population of migrant and seasonal farmworkers have been tested for hiv (schafer et al., 2017). based upon the aforementioned definition of rural, native american communities make up a considerable amount rural medicine and adversities among the united states. additionally, native american tribes, specifically reported by research in alaska, often refuse any open discussion regarding multiple issues their communities face, such as sex, physical and sexual violence against women and children, substance abuse, or fetal alcohol syndrome. mental illness and suicide are also not addressed because it is believed if he/she discusses something bad or taboo then he/she will make it happen (speier, 2005). for example, when discussing the use of condoms as a method of prevention for individuals who choose not to practice a lifestyle of abstinence, one tribal council member exclaimed that “condoms are the government’s way of creating genocide among alaska natives, because if condoms are used young women won’t get pregnant, and if young women don’t get pregnant our people will not survive” (speier, 2005). this is an example of the distrust that is indicative of historical trauma experienced by native americans in the united online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 162 states. hiv can be a daunting, uncomfortable, and at times upsetting, topic to discuss with health care providers, especially, other individuals in communities with specific cultural practices or religions (foster, 2007). there is also stigma surrounding hiv data that is only applied to men that have sex with men. however, the cdc reports that heterosexual contact is the second most common cause of new hiv incidence especially in hispanic and african american populations older than thirteen years old and spanning across states from idaho to texas (linley et al., 2018). hiv stigma, limited access, cultural barriers, and power differentials between relationships, may be a few reasons why rural communities are not improving in hiv infection rate (varni et al., 2012). regardless of the risk factors of a particular patient, testing for hiv should be a discussion, and an option for patients even outside of primary care (korthuis et al., 2011). in 2015, 40,000 people in the us received an hiv diagnosis, one in two people had been living with hiv three years or more, one in four people had been living with hiv seven years or more, and one in five had already progressed to aids (cdc, 2019). of concern, 59% of heterosexual patients, who are at increased risk of hiv, saw a healthcare provider at least once a year and were still not tested (cdc, 2019). despite the difficulty in finding epidemiological information pertinent to hiv/aids in rural areas of the us, available evidence indicates that the incidence and prevalence of hiv/aids have increased in rural areas (castaneda, 2000). there is an increasing need for hiv testing in rural areas of the us as evidenced by 52% of new hiv infections being in the rural south (cdc, 2019; evangeli, pady, & wroe, 2016; korthuis et al., 2011). there are many non-primary care settings in rural areas serving a high number of individuals that do not, but could, routinely offer hiv screening. stigma, in rural areas especially, has hindered proper healthcare interventions and simple conversations shared with online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 163 patients. stigma is not new to public health, nor is it new to hiv/aids (valdiserri, 2002). in rural areas of the us, hiv-related stigma remains a significant barrier for routine hiv testing (weis et al., 2009). due to the rise of new heterosexual hiv infections, rural communities present a different and challenging context, especially for women. moreover, individuals with hiv/aids in rural communities have been exposed to the disease locally and are most likely to be women, people identified as heterosexual, adolescents, those who are non-white, and heterosexual drug users (castaneda, 2000). the levels of at-risk behavior in rural areas are similar to those in urban areas and in many instances, are much higher (mallory, 2008). while there are opportunities to improve hiv screening across all aspects of care, it is imperative to identify barriers of hiv testing that are negatively affecting rural healthcare in terms of patient and provider perceptions, access, and stigma as this population is disproportionally affected by hiv (pellowski et al., 2013). the goal of this systematic review is to identify strategies that increase utilization of hiv testing in rural areas of the us. methodology electronic database search a systematic literature search was completed utilizing ebscohost to search three electronic databases: cinahl complete, medline with full text, and psycinfo. search dates were limited to the past 20 years including publishing dates from 1997-2017. the search was limited to publications in the english language. the key search terms included were ‘hiv testing’, ‘rural communities in the us’, ‘stigma’, ‘hiv screening strategies in the united states’, ‘hiv testing in rural communities’, ‘strategies to improve hiv testing in rural communities. the boolean phrase ‘and’ and ‘or’ was applied between search terms to assist with the inclusion online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 164 criteria of studies. the online systematic review platform, covidence, was used by two reviewers to independently screen, review, and extract data following prisma guidelines. see table 1 for inclusion and exclusion criteria; disagreements were resolved via discussion. this systematic review is registered through prospero; registration number: crd42018108637. table 1 inclusion and exclusion criteria* inclusion exclusion male or female adults 13-85 years old with unknown or no access to a clinic, or office that provided hiv screening and testing individuals living in or receiving healthcare in an urban area of the united states an unknown, positive, or past hiv test infants and children individuals living 60-90 miles from a city or urban area of the united states pregnant women population of 60,000 residents or less in rural areas individuals who are hiv positive with a cd4 count <500 studies providing intervention strategies to improve hiv screening in the rural setting age >85 years old studies within the united states 6 months-1 year of life remaining due to other comorbidities english language studies published prior to 1997 rural areas outside the united states *table defines the inclusion and exclusion criteria used to assist in study validity and data to find interventions to increase hiv testing in rural areas of the united states study selection studies selected for review included a strategy and/or intervention to improve screening for hiv such as reducing stigma, improving access, and education for the individual. the type of study designs included were pilot, observational, qualitative analysis, randomized control trials, and case reports. these studies also had to target a population consistent with the aforementioned definition of a rural community in the us. definition of strategy or interventions studies included were those that directly addressed a different approach to hiv screening in rural communities who face multiple barriers to adequate healthcare including access, poverty, online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 165 and stigma. education approaches with preand post-test results, hiv screening follow-up, and feasible access to hiv screening with competent providers were all consistent themes amongst the included studies. perceived stigma and discrimination that hindered any hiv testing in the past were the comparison. outcomes of interest included reduced stigma regarding hiv screening and education, improved hiv testing rates, and patient/provider attitudes regarding further testing. the last search was performed on august 2, 2018. results a systematic search was conducted and 634 references were identified. after 49 duplicates were removed, 585 titles and abstracts were screened with 546 deemed irrelevant. thirty-nine full-text studies were assessed for eligibility with 25 excluded due to wrong outcomes, wrong interventions, wrong setting, wrong study design, and wrong patient population (see figure 1 for prisma flow diagram). studies were eligible if they met the inclusion and exclusion criteria of the clinical question and reported a strategy to reduce the stigma of hiv testing in a rural area. fourteen studies were included for review. the study designs encompassed two randomizedcontrolled trials, two pilot studies, four qualitative analyses, four observational studies, a crosssectional quasi experimental design study, and a descriptive crosssectional survey. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 166 figure 1. prisma flow diagram literature review the 14 included studies varied based upon demographics, participants, and interventions; however, they all consistently investigated a rural population. the following was organized based on thematic elements (see table 2) identified pursuant to the systematic review such as the ability to increase access or decrease stigma, effect provider or patient perspectives, and access. table 2 online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 167 study characteristics* theme title authors, year intervention outcome patient attitude assessment of hiv/aids prevention of rural african american baptist leaders: implications for effective partnerships for capacity building in american communities payne-foster, cooper, parton, meeks, 2011 eliciting information from baptist leaders about hiv prevention activities in their congregation and influences of hiv activity prevention based on the geographical residence. significant use of faithbased models for hiv/aids prevention and baptist leaders as an influence of hiv prevention in the deep south. patient attitude testing our faithh: hiv stigma and knowledge after a faithbased hiv stigma reduction intervention in the rural south payne-foster et. al, 2017 examine efficacy of faithbased anti-stigma intervention in rural alabama baptist churches. interventions through congregations to address community issues, health concern and stigma pertaining to hiv. no significant reduction in hiv related stigma was observed but increased attitudes about testing was reported in over half that had never been tested. social and structural factors for those not living with hiv was noted. patient attitude recruitment feasibility and hiv prevention intervention acceptability among rural north florida blacks brown, 2010 recruiting black community members in rural florida to participate in hiv testing and return for follow-up results. a community-based intervention worked in this community and could be successful in other rural populations. the hiv test erasure proved feasible in this model. access rural hiv: brief interventions for felony probationers oser, leukefeld, consentinoboehm, havens, 2006 describing an hiv intervention for southern, rural probationers and to profile participants and their demographics and risk behaviors by degree of criminality hiv interventions are needed to target rural probationers, especially those with an extensive arrest history because of high-risk behaviors such as illicit substance abuse and unprotected sex. access culturally specific health care model for ensuring health care use by rural, ethnically diverse families affected by hiv/aids goicoecheabalbona, 1997 indigenous providers, coordinated, and social service methods to formulate preventions strategies for perinatal hiv transmission in primary care. interdisciplinary and indigenous provider use is imperative for striving for equity of all rural and diverse residents to decrease new hiv spread. access a randomized clinical trial of two telephonedelivered, mental heckman, carlson, 2007 two, telephone delivered, mental health interventions to facilitate change the telephone-delivered support groups have potential to increase online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 168 health interventions for hiv-infected persons in rural areas of the united states adjustment for people living with hiv/aids in rural communities. perceptions and support of hiv related issues but practical significance of those not affected by hiv is limited. access effectiveness of healthy relationships videogroup—a videoconferencing group intervention for women living with hiv: preliminary findings from a randomized controlled trial marhefka et. al, 2014 video-conferencing intervention for women living with hiv in low prevalence, rural areas, to compare sexual behaviors and “prevention with positives” to adjust for different sexual behaviors. promising evidence found dissemination of hiv and risk reduction of video groups. subpopulations need to be explored. access a routine hiv screening program in a south carolina community health center in an area of low hiv prevalence weis et. al, 2009 describing a routine hiv screening program in a community health center in south carolina unless patients opt out. predicting acceptance for screening rates and refusals. demonstrates implementation of routine hiv screening may work in smaller health care settings and in rural areas especially in the south. access community outreach along the u.s./mexico border: developing hiv health education strategies to engage rural populations hernandez, marta, vasqeuz, martinez, 2014 applying strategies in disseminating hiv health education information and research in rural areas along the u.s./mexico border. needs assessment conducted in clinics serving rural areas to enhance dissemination and outreach efforts and to inform the development of culturally and linguistically appropriate health education materials. mobile campaigns directly went into communities. these strategies may be useful if there are general providers who understand specific barriers and promote health equity and sexual knowledge and education regarding hiv. provider attitude hiv testing in community pharmacies and retail clinics: a model to expand access to screening for hiv infection weidle et.al, 2014 implementing confidential hiv testing and counseling using pharmacy and retail clinic staff. feasible model for offering rapid, point of care hiv testing. effectiveness could meet the needs of underserved, rural areas. provider attitude a training program for nurses and other health professionals in ruralbased settings on screening and clinical lifson et. al, 2009 program that focused on hiv, stis, and hepatitis and was designed to enhance participants’ ability to conduct sexual histories and risks, educate about risk reduction and prevention, screen for and nurses and other health care professional should be at the forefront for hiv prevention, screening, and clinical online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 169 management of hiv and other sexually transmitted infections diagnose infections, clinically manage clients with positive screening test results, access prevention and other educational materials and conduct other clinical and public health activities in rural settings. management in rural communities and specific training should be a priority in these areas. provider attitude hiv testing and hiv/aids treatment services in rural counties in 10 southern states: service provider perspectives sutton, anthony, vila, mclellanlemal, weidle, 2010 surveys sent to providers of 10 different southern states to understand the barriers of accessibility and prevalence of hiv testing. trusting the providerpatient relationship, inappropriate infrastructure, hiv perception and distance to testing my need to change for states with little access. surveys sent to providers willing to explain the barriers may be useful for change. provider attitude what makes me screen for hiv? perceived barriers and facilitators to conducting recommended routine hiv testing among primary care physicians in the southeastern united states white et. al, 2015 in depth interviews with primary care providers in the southeast as to why or why not recommend a hiv test. some physicians recommended routine hiv testing in their practice to destigmatize hiv testing. multilevel approaches should be done to enhance physician hiv testing in the primary care setting in the rural southeast. physicians also recommended better advertisement in these communities to enhance screening. provider attitude a quality analysis of provider barriers and solutions to hiv testing for substance users in a small, largely rural southern state wright, curran, stewart, booth, 2013 hiv testing program implemented in rural substance abuse treatment centers. identifying barriers to this method from substance abuse providers. not enough funding has been able to actively implement this model and systems must change to prioritize resources for hiv. *general study characteristics with study theme as noted in literature review the first theme encompassed faith-based interventions regarding hiv awareness and screening, likely due to the cultural importance of church attendance, especially in african american communities (payne-foster et al., 2018; payne-foster, cooper, parton, & meeks, 2011). churches have a rich history of driving social change locally, nationally, and being involved in efforts to combat diseases such as breast cancer, diabetes, and cardiovascular disease (paynefoster et al., 2018). tying in recruitment feasibility and intervention location in churches can be online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 170 of use in rural communities (weis et al., 2009). two studies addressed how rural baptist leaders implemented hiv interventions in their congregations to improve hiv knowledge and acceptance (payne-foster et al., 2018; payne-foster et al., 2011). both faith-based interventions demonstrated an increase in hiv education and willingness to screen. one study sought to elicit written surveys with hiv information specifically for baptist pastors to share with their congregation (paynefoster et al., 2011). the other study directly tested an anti-stigma intervention with a preand post-assessment among congregation groups (payne-foster et al., 2018). both appeared to improve the perception of stigma, which should lead to improved hiv testing rates within the community. the sense of community may contribute to intervention success and is specifically an important topic in african american communities (brown, 2010; payne-foster et al., 2018; paynefoster et al., 2011). as mentioned previously, the role of the provider can affect hiv screening. five reports focused on different healthcare provider perspectives and attitudes regarding hiv and screening with different hiv intervention approaches. the key use of culturally specific providers assisting in collaboration and bridging language barriers to target culturally specific communities regarding hiv proved useful (goicoechea-balbona, 1997). a decrease in stigma seems to be rooted in cultural ethos of a rural community, whether it be religious or grass root community providers, for these interventions to be successful. even in rural areas with substance abuse centers, some providers mention that the priority of hiv remains low and institutional silos in healthcare must end (goicoechea-balbona, 1997; wright, curran, stewart, & booth, 2013). specific training models for nurses and other healthcare workers practicing in a rural setting can be simple and affordable with interventions as easy as learning to take a strong sexual online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 171 history and perform hiv risk assessments (lifson et al., 2009). knowledge of when to screen for hiv, addressing specific barriers, such as distrust, and confidentiality for screening have all become interventions themselves, especially in rural communities (lifson et al., 2009; sutton, anthony, vila, mclellan-lemal, & weidle, 2010; white et al., 2015). healthcare providers appear to support the delegations of different hiv interventions regardless of barriers improving outcomes and quality of life (goicoechea-balbona, 1997; lifson et al., 2009; sutton et al., 2010; white et al., 2015; wright et al., 2013). these distinct rural areas promoted what worked regarding culturally specific sexual roles and promoted safer sex practices through community involvement to strengthen hiv awareness and testing (hernandez et al., 2014; oser, leukefeld, cosentinoboehm, & havens, 2006). providing culturally specific care can contribute to improved hiv awareness and screening. apart from provider and patient attitudes, access to care also remains a significant barrier in rural areas. there were a few strategies reported in the literature that focus on improving access to hiv screening through technology and pharmacies. with access being a barrier to proper healthcare in rural areas, technology can promote hiv screening along with better emotional and coping skills, privacy, and quality of life (heckman & carlson, 2007; marhefka et al., 2014). furthermore, other novel approaches to expanding access included offering rapid hiv tests at community pharmacies, which was a beneficial measurement due to public health accessibility and low cost (sutton et al., 2010; weidle et al., 2014). staff willingness, confidentiality, and point of care access allows hiv screening to be a feasible intervention within a community pharmacy (weidle et al., 2014). documented intervention success and site specific feasibility are important factors to consider when identifying strategies to improve access in rural communities. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 172 discussion this review identified a number of strategies that can help decrease the stigma that may be among the primary barriers that prevents optimal care for patients with hiv in rural communities. these interventions have demonstrated the ability to improve hiv testing, access, and education within rural healthcare. throughout the 14 included studies, authors all recognized the challenges in developing interventions that reduce hiv-stigma, increase knowledge, improve risk perceptions, and testing accessibility. these studies also recognized that the study participants in rural communities had limited resources on current up to date hiv information, and were still engaging in relatively high-risk behavior (basta, stambaugh, & fisher, 2015; castaneda, 2000; ohl et al., 2013; payne-foster et al., 2018; relf et al., 2015; speier, 2005; varas-diaz et al., 2013; weidle et al., 2014). socioeconomic factors, geography, cultural context, and evolving epidemics of injection drug use are coalescing to move the hiv epidemic into the populations where people are dispersed and healthcare resources limited (pellowski et al., 2013; schafer et al., 2017). however, whether it be telehealth-based communication and care (marhefka et al., 2014; ohl et al., 2013), church-focused hiv educational groups (payne-foster et al., 2018; payne-foster et al., 2011), healthcare provider education and access (goicoechea-balbona, 1997; lifson et al., 2009; sutton et al., 2010; white et al., 2015; wright et al., 2013), or even hiv testing and screening in the prison system and community pharmacy (oser et al., 2006; weidle et al., 2014), hiv stigma and limited access to care and education will continue to significantly contribute to hiv/aids mortality (payne-foster et al., 2018). an important component of hiv care will also be placed in the hands of nurses. nurses employed in rural communities and remote areas are crucial to the online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 173 delivery of high quality healthcare and can seek to improve hiv care within rural areas by employing the strategies identified in this review (oosterbroek, yonge, & myrick, 2017). there is a need to empower rural communities, healthcare providers, and nurses to increase hiv testing and reduce the stigma of screening. there appears to be a growing concern regarding the epidemiology of women and hiv/aids in rural communities. women in rural areas are often overlooked as their needs remain a low priority at local, state, and national levels (castaneda, 2000). although the prevalence of hiv/aids in women were reportedly lower at the start of the hiv epidemic, the model and implication to deliver service was male-centered (castaneda, 2000). furthermore, shame and stigmatization associated with many co-occurring risk factors facing all rural community natives create taboo topics, which generates another barrier to any future hiv/aids education and system development (speier, 2005; sutton et al., 2010). it is exceedingly difficult to reverse the trends of high-risk behavior and may even be considered “too prohibited to discuss” (speier, 2005; young & zhu, 2012). in regard to all women, every social and physical setting that makes up a rural community will construct women’s day-to-day experiences and their abilities for personal change and self-determination to stay healthy (castaneda, 2000). women, especially those residing in rural areas, should always be encouraged to get tested for hiv regardless of risk status and behavior. there is no single answer that would singularly improve hiv testing in rural communities. a faith-based intervention in rural alabama may not have the same impact in a migrant community in florida. however, the rural community leadership is a highly valuable resource that can help educate community members about hiv risk factors and treatment management due to potential online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 174 trust and confidentiality issues that seem to hinder hiv testing and progress (ohl & perencevich, 2011; payne-foster et al., 2018; weidle et al., 2014). technological advances, such as telehealth communication or video support groups, may improve rates of hiv testing by reducing missed clinic visits and improving medication compliance (schafer et al., 2017). being aware of a community and its specific afflictions is an important component of being an effective healthcare provider to these communities especially in rural areas. since rural communities often have different experiences and adversities, the various ways of care extension should be applied to accommodate the communities’ specific needs. despite tremendous advances in hiv management across the continuum of care, there are considerable opportunities in this non-urban epidemic. these challenges include establishing and using consistent definitions of rurality, contextualizing each phase along the continuum for the local population, and addressing the barriers unique to rural communities that affect every step of care from testing to lifestyle management and compliance with care (basta et al., 2015; castaneda, 2000; schafer et al., 2017; speier, 2005). while there is a paucity of data currently available, researchers with a community focus may find well placed and appropriate contributions to hiv testing in rural areas. regardless of scarce data, interventions should be encouraged in rooted communities to aid in hiv testing and contribution to help make a difference in rural areas. study limitations in order to accurately capture the existing body of literature, authors included a wide variety of study designs, which limited the ability to uniformly assess the risk of bias in individual reports. reporting bias may have been a limitation itself since all the reviewed studies had interventions that improved hiv testing rates with positive outcomes from the authors and the online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 175 feasible, comprehensive and accessible care that was offered. relevant literature may have been missed due to the inclusion criteria of ‘english language’, ‘united states’, and ‘rural communities in the united states’. there were studies evaluated that pertained to the stigma of hiv and hiv testing in rural communities, however, they were not applicable to the clinical question. last, as not all rural communities are the same or experience the same challenges, the studies reviewed may not be directly applicable to all rural communities/populations. conclusion this review identified that interventions focusing on access, provider and patient perspective, and ways to decrease stigma can improve hiv testing in rural communities. stigma remains a considerable problem in rural areas and may be intensified where there is less tolerance of diverse lifestyles, greater fear of hiv and less anonymity (zukoski & thorburn, 2009). this nonurban hiv epidemic poses a challenge for healthcare providers and nurses to increase hiv testing, reduce hiv infections, and improve care. these strategies, along with health provider optimism, creativity, and knowledge of specific communities will enhance hiv patient care. a sustained effort is needed to support research, ultimately, seeking to understand the barriers that exist across the hiv rural continuum and the development of interventions to overcome these barriers. references aldous, j. l., pond, s. k., poon, a., jain, s., qin, h., kahn, j. s., . . . smith, d. m. 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(2002). hiv/aids stigma: an impediment to public health. the american journal of public health, 92(3), 341-342. http://dx.doi.org/10.2105/ajph.92.3.341 varas-diaz, n., neilands, t. b., cintron-bou, f., marzan-rodriguez, m., santos-figueroa, a., santiago-negron, s., . . . rodriguez-madera, s. (2013). testing the efficacy of an hiv stigma reduction intervention with medical students in puerto rico: the spaces project. the journal of the international aids society, 16(suppl 2), 18670. http://dx.doi.org/10.7448/ias.16.3.18670 varni, s. e., miller, c. t., & solomon, s. e. (2012). sexual behavior as a function of stigma and coping with stigma among people with hiv/aids in rural new england. aids and behavior, 16(8), 2330-2339. http://dx.doi.org/10.1007/s10461-012-0239-5 weidle, p. j., lecher, s., botts, l. w., jones, l., spach, d. h., alvarez, j., . . . thomas, v. (2014). hiv testing in community pharmacies and retail clinics: a model to expand access to screening for hiv infection. the journal of the american pharmacists association, 54(5), 486-492. http://dx.doi.org/10.1331/japha.2014.14045 weis, k. e., liese, a. d., hussey, j., coleman, j., powell, p., gibson, j. j., & duffus, w. a. (2009). a routine hiv screening program in a south carolina community health center in online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.571 183 an area of low hiv prevalence. aids patient care and stds, 23(4), 251-258. http://dx.doi.org/10.1089/apc.2008.0167 white, b. l., walsh, j., rayasam, s., pathman, d. e., adimora, a. a., & golin, c. e. (2015). what makes me screen for hiv? perceived barriers and facilitators to conducting recommended routine hiv testing among primary care physicians in the southeastern united states. journal of the international association of providers of aids care, 14(2), 127-135. http://dx.doi.org/10.1177/2325957414524025 wright, p. b., curran, g. m., stewart, k. e., & booth, b. m. (2013). a qualitative analysis of provider barriers and solutions to hiv testing for substance users in a small, largely rural southern state. the journal of rural health, 29(4), 420-431. http://dx.doi.org/10.1111/jrh.12021 young, s. d., & zhu, y. (2012). behavioral evidence of hiv testing stigma. aids and behavior, 16(3), 736-740. http://dx.doi.org/10.1007/s10461-011-0018-8 zheng, m. y., suneja, a., chou, a. l., & arya, m. (2014). physician barriers to successful implementation of us preventive services task force routine hiv testing recommendations. journal of the international association of providers of aids care, 13(3), 200-205. http://dx.doi.org/10.1177/2325957413514276 zukoski, a. p., & thorburn, s. (2009). experiences of stigma and discrimination among adults living with hiv in a low hiv-prevalence context: a qualitative analysis. aids patient care and stds, 23(4), 267-276. http://dx.doi.org/10.1089/apc.2008.0168 1 editorial from the editor jeri w. dunkin, phd, rn, chce editor as we put the final touches to this issue i came to realize that the journal has become quite stable in the number of articles included in each issue as well as the numbers of editorial columns. in reviewing the history i found that we had published 97 articles and 91 editorial columns or between 4 and 5 of each per issue. interestingly enough that number stayed about the same from volume 1 through volume 9. these articles covered a wide range of topics and came from several different countries as well. it clearly demonstrates that while rural nursing is very diverse, it is at the same time the issues across countries remain the same. those of access, resources, and geographic barriers. these are the barriers that all rural nurses face. that commonality of diversity is what moved me to start the journal originally and i hope that it has provided rural nurses throughout the world with a resource to use for comparison of their issues to those of others and examples of approaches taken to mitigate those issues and research on topics pertinent to practice. i would welcome any comments or suggestions on how we might improve the journal and its usefulness to you, the nurse caring for rural populations wherever that may be. i can be contacted by email at rural.nurse.org@gmail.com.   online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 mailto:rural.nurse.org@gmail.com nichols_642_formatted online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 179 where have they gone? recruiting and retaining older rural research participants elizabeth grace nichols, dns, rn, faan 1 jean shreffler-grant, phd, rn 2 clarann weinert sc, phd, rn, faan 3 1 professor emeritus, college of nursing, montana state university, elizabeth59715@gmail.com 2 professor emeritus, college of nursing, montana state university, jeansh@montana.edu 3 professor emeritus, college of nursing, montana state university, cweinert@montana.edu abstract issue: rural-dwelling elderly have been shown to suffer from health disparities when compared to the general population. research involving these individuals is important, and to have meaningful results, sample sizes must be adequate. recruiting and retaining these individuals pose significant challenges. context: nurse researchers in the rural northwestern united states conducted a 4-part educational intervention aimed at increasing general and complementary and alternative health care literacy of older rural dwellers. significant challenges were faced in both recruiting and retaining participants over the 6-month study period. despite careful planning and community selection, the team had to double the number of communities in which they carried out the project to meet recruitment goals. retention was also a challenge. of 127 participants initially enrolled in the study, only 52 remained to the end. lessons learned: challenges of recruiting and retaining are complex and compounded when the target population is rural, older and the study is longitudinal. recruitment challenges included online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 180 reaching older adults, offering a compelling program, and offering it in an acceptable format at a convenient time and place. a variety of outreach activities were conducted including in-person presentations, advertising or public interest stories in local newspapers or radio stations, and flyers on bulletin boards in restaurants, clinics, churches, community centers, and libraries. a project champion, an individual well known and connected within the community and committed to the success of the proposed study, is a major asset. retention strategies included developing relationships with the participants and maintaining contact with them over the course of the study through such mechanisms as appointment cards, e-mail or regular mail, telephone reminders, and thank you cards. oversampling was important as factors beyond the control of the researcher occurred; for example, illness, death, family crises, unexpected relocations, and weather events that prevented travel to scheduled research events. keywords: complementary health, health literacy, participant retention, sampling where have they gone? recruiting and retaining older rural research participants research, with any population, requires adequate samples to determine if findings are truly based on the intervention, or if they are due to chance. further, funding agencies are increasingly concerned about the adequacy of sample sizes involved in research projects as they seek to ensure that funds are being spent on projects with potential to provide significant information. the importance of sample size is a concern for researchers, and it is even coming to the fore in nursing literature aimed at staff nurses (fowler & lapp, 2019). participant recruitment is often challenging, depending upon the specific research question and the target population. approximately 19.3% of americans live in rural or frontier areas (national rural health association, 2020). health research with rural participants is important as rural dwellers have significant health disparities online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 181 when compared to their urban counterparts; they have less access to health care, tend to be older, and have more chronic illnesses (long et al., 2018; national rural health association, 2020; pew research center, 2018.) historically, rural dwellers have also been shown to be more independent in their health care decision-making using home remedies and traditional therapies for health promotion and self-management of their health problems (altizer et al., 2013; arcury et al., 2015; quandt et al., 2015). conducting research with rural populations offers several additional challenges because of the nature of rural communities as they are small, tend to have fewer resources, and the inhabitants are spread out over significant distances. a number of strategies have been suggested to recruit rural residents into health-related research projects (anuruang et al., 2014; cudney et al., 2004; mitchell et al., 2001), yet the problems of recruitment and retention continue to offer challenges to researchers. obtaining, and if the project is one that occurs over time, retaining, an adequate sample is a significant challenge. the purpose of this paper is to discuss the realities of recruitment and retention of older adult participants in research conducted in sparsely populated rural communities. a case study a research project conducted in the rural intermountain west provides an opportunity to examine factors that affected recruitment and retention of elderly, rural-dwelling individuals. a four-part skill-building educational intervention designed to enhance the general health literacy and literacy about complementary and alternative health (cam) amongst older rural-dwelling individuals was conducted over a seven-week period. a before and after design was used with three data collection points: preand post-intervention and a follow up questionnaire five months online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 182 later. the program sessions were approximately one hour in length and offered every other week. program content focused on information needed when considering cam, skills to evaluate that information, partnering with health care providers, and the importance of health literacy (shrefflergrant et al., 2020; weinert et al., 2020). the initial research plan was to recruit and retain 120 individuals from four rural communities with the hope of retaining 80 for the duration of the study. the study was conducted by a team of three nurse researchers and carried out in rural communities in the north-western quadrant of the united states. the study was approved by the montana state university institutional review board for the protection of human subjects. for this study the research team defined rural as a state or region with a population density of less than 11 persons per square mile and an economy centered on agriculture (ranching, farming, timber), extractive industries (oil, gas, mining), and tourism (fishing, hunting, outdoor activities) (cromartie & bucholtz, 2008). further, targeted rural communities were those in montana with populations of less than 10,000 and not adjacent to a metropolitan area. recruitment strategies the project had several levels of recruitment: community, delivery site, and participants. census data and state office on aging data were used to identify potential communities. the biggest challenge in community identification was finding truly rural communities large enough to have a busy senior center or other location where seniors congregate such as congregate living centers. the number of meals served each week was used as an indicator of activity for senior centers, and facility size for living centers. the populations of the four original communities ranged from approximately 4,200 to 7,400. the additional communities ranged from 2,600 population to 72,000 (two sites in this community) and one community of 30,000. these last two online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 183 communities were selected because of accessibility and presence of senior congregate facilities and for the study to be completed within the allocated time and budget. after potential communities were identified, personal visits and telephone conversations with community leaders and senior center directors were held to make the final selections. site selection was based on having the necessary meeting space, a clientele likely to be interested in the program, and availability on the calendar for the program. these site visits were also used to gauge the interest of the center director in serving as a champion for the project and of the members of the community in the topic of presentation. there was grant funding to provide a computer and projection equipment to the initial sites as an incentive for the facility to participate and funds for a small honorarium for the site champion. when it was evident that the project had to involve more than four communities to recruit a sufficient number of participants, the additional sites participated without any incentive, other than the availability of the program to their older adult members or residents. this suggests that compensation was not a major factor in site recruitment. once a community had been selected and a schedule for the program set, numerous methods were utilized in each community to promote local visibility and interest: flyers throughout the community, in such places as restaurants, library, and church bulletin boards, announcements at the senior center or congregate living site, and articles in local newspapers. the timing of the intervention was planned to encourage participation, e.g. avoiding busy times of the year, planning short sessions immediately after congregate meals. the plan was to recruit project champions to promote the study. project champions are individuals who are well known and connected within the community and committed to the success of the proposed study. these individuals actively recruit participants, announce project events, and sustain interest and participation throughout the online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 184 study. this was successful in a few communities; however, most champions did not function as envisioned. recruitment activities in the first four communities were successful in enrolling 73 participants, a number short of the target of 120 participants. in response to this shortfall, four additional communities were recruited. the recruitment activities identified above were repeated in these additional communities and were moderately successful as can be seen by the total number of participants displayed in table 1 (n=127) who completed the time 1 questionnaire. of this 127, only 67 completed the time 2 questionnaire administered at the end of the fourth educational session. table 1 participant enrollment and retention by site. site type time 1 time 2 time 3 1 living center* 20 14 10 2 senior center* 29 14 11 3 senior center* 12 6 4 4 senior center* 12 5 4 5 senior center 6 3 2 6 senior center 16 5 4 7 living center 12 10 8 8 senior center 20 10 9 total 127 67 / 52.7% 52/40.9% online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 185 *original sites fifty-two participants, or 40.9% of the initial 127, remained throughout the study and completed the time 3 questionnaire. while initial recruitment was a challenge, retention posed a greater challenge. retention strategies retention is as important as recruitment, particularly for intervention studies such as this one. for example, if the participants that drop out of a study constitute a particular group, such as race, age, health status, it might have implications for the validity of the study findings. the average attrition rate (the obverse of retention) for clinical trials is 30% (nuttall, 2012). the attrition rate for this study was 59.1%, well above the average. analysis of the demographic characteristics of those who remained in the study and those who dropped out showed that there were no significant differences between the two groups (shreffler-grant et al, op cit.). this is a positive finding for this study, but attrition/retention continues to be a concern. a multi-part intervention in far flung rural communities requires significant commitment by the participants, as well as adequate financing and significant time of the researchers. the program sessions were scheduled every other week spanning seven weeks. to the extent possible, the program was scheduled with consideration given to factors such as likelihood of weather events, holidays, and individual community and rural schedules of planting, harvesting, and vacation times. the center directors were consulted to avoid conflicting with regular center activities. to make the program as appealing and convenient as possible, the intervention sessions were offered right after the congregate lunch time, thus eliminating the need for repeated driving trips for the participants. at the first meeting, participants were asked to provide an e-mail address online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 186 or phone number so that the team could send thank you notes, remind them of upcoming sessions, and alert them to the time 3 data collection. some champions contacted participants to remind them of upcoming sessions; for example, notes under doors in congregate living facilities, notes on bulletin boards, or individual personal reminders. in some communities, however, the champions did not carry out the role as envisioned. factors that affected attendance at the individual sessions included inclement weather, doctor’s appointments, illnesses of the participant or spouse, death and funeral of a prominent community member, and arrival of unexpected guests. for example, in one community with few medical specialists, once a month a van conveyed individuals to the larger medical community 64 miles away. the monthly trip fell on the day of the third intervention session, and pulled several participants away. some participants simply forgot. in another community, the illness and death of a participant excluded both him and his wife from the study. the team had anticipated some of these and so oversampled, but could not predict the multiple factors that impacted retention. to promote completion of the time 3 questionnaire, approximately 1 month in advance of the mailing, a letter was sent to all participants who had completed both the time 1 and time 2 questionnaires. this letter was to alert them to expect the last questionnaire and to encourage them to use the skills and tools given during the program. telephone calls were tried initially, but few people answered their telephones. when possible, voice mail messages were left, but many did not have activated voice mail systems thus the main reminder communication was by mail. the time 3 questionnaire was mailed out approximately one month after the reminder letters. the time 3 mailing included a cover letter, the time 3 questionnaire, and a stamped, return addressed envelope. if it was not returned within two weeks, a postcard was sent urging the individual to online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 187 complete the questionnaire, or, if they had lost it, to request a new one. if there was no response after an additional two weeks, a second time 3 questionnaire and letter were sent. these activities did result in additional responses. challenges to obtaining time 3 questionnaires included incorrect or incomplete addresses, or participants who had moved and not provided forwarding addresses. one participant died before the time 3 questionnaires were distributed. one project champion was helpful in tracking down correct addresses. through this help, and some persistent internet work on the part of the investigators, all but two were located and completed the time 3 questionnaire. the overall result was a 77.6% retention from time 2 to time 3. the final number of participants was short of the team’s target of 80 participants but was sufficient for the planned analysis. lessons learned recruitment in these small rural communities was challenging despite the variety of strategies used. social media might present an additional recruitment opportunity; however, that approach would not have been amenable to the focused recruitment in this project, unless local centers had web-sites or facebook® pages geared towards local residents. increasingly older individuals are using computers and the internet; thus, this is a strategy worth considering. interviews about the program on local radio stations can be a useful approach in rural areas. identifying a convenient place to hold the program is very important, as is scheduling an attractive time. retention of participants was a significantly greater challenge than recruitment. for example, in one site, 15 people attended the first session and all completed the time 1 questionnaire, indicating their intent to participate in the study. at the second session 15 people online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 188 attended, but only about one half of them were the same people who attended the first session. early in the research project, the team had decided that if individuals came early to the second session and completed the time 1 questionnaire before any content was presented, they could be included in the study. the material presented in the first session was explanatory and was not material covered by the questionnaires. the team also decided that attendance at three of the four sessions and completion of the time 1 and time 2 questionnaires made individuals eligible to receive the time 3 questionnaire. these were trade-offs from the original design, but were deemed acceptable to maintain participant numbers. respondent burden, that is how difficult or time-consuming it is to participate in the project, can be a factor in retention. this was a consideration in the selection of instruments used for data collection, particularly those included in the time 3 questionnaires. the goal of the team was to make participation as easy as possible while maintaining scientific integrity. adding communities, the only strategy that was effective in increasing numbers, had time and budget implications. for example, the budget for the study was based on travel of approximately 4800 miles; in actuality, the team drove over 9,000 miles. also, in order to obtain sufficient participants within the budget and time frame for the study, the team ended up recruiting from congregate sites in two communities within the rural states of montana and wyoming that exceeded the target size of 10,000 residents. with a fixed budget, there was no ability to offer incentives to the new sites, although, as noted above, that did not seem to impact the willingness of sites to participate. adding sites lengthened the project beyond the initially projected two years resulting in the investigators “donating” time during the third year, and pushing dissemination activities into a fourth year. shortening the length of the intervention itself, such as holding the online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 189 sessions weekly, or compressing the content into two sessions might help retain participants, although most of the factors that caused attrition were life factors, such as illness or death, not factors that could be scheduled. compressing the intervention would reduce the time allowed for participants to practice and integrate the skills into their own lives, but would reduce the time for adverse events to happen. providing appointment cards, such as are given out by dental or medical offices, indicating the date and time of each session might help those who simply forgot. having the participant write the time and dates on the cards themselves might further embed the appointment time in their minds and on their calendars. offering participants a choice of methods of contact can give them a measure of control over their personal information, and so encourage ongoing participation. having the third questionnaire sent to participants homes to be completed independently and returned, albeit in a stamped and addressed envelope, can be a factor in retention. it is easy to put the packet aside and forget about it. follow-up contact to ensure a maximum rate of return is important. despite the multiple recruitment and retention efforts discussed in this paper, the team struggled to obtain an adequate sample size. a marginally sufficient number was recruited in most communities but was not retained to completion. individuals could attend sessions without being part of the research aspect, and several did, although most individuals who attended the first session also completed the time 1 questionnaire indicating a willingness to be in the study. all individuals who attended the final session completed the time 2 questionnaire, and most completed the final, or time 3, questionnaire. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 190 retention was affected by participants’ health status, inclement weather, forgetfulness, and other factors. to obtain an adequate sample, additional sites were required that had logistical and financial consequences. obtaining and maintaining an adequate rural sample will likely always be challenging due to the limited size of rural populations and the additional challenges of a higher prevalence of chronic health problems, reluctance to travel in poor weather, and other life events common to older adults. it is hoped that the strategies used and lessons learned by this team will be instructive to others planning research projects in rural communities. acknowledgements national institutes of health, national center for complementary and integrative health 1r15at009097-01 references altizer, k.p., quandt, s.a., grzywacz, j.g., bell, r.a., sandberg, j.c. & arcury, t.a. (2013). traditional and commercial herb use in health self-management among rural multiethnic older adults. journal of applied gerontology, 32(4), 387-407. https://doi.org/10.1177/ 0733464811424152 anurauang, s., davidson, p.m., jackson, d., & hickman l. (2014). strategies to enhance recruitment of rural-dwelling older people into community-based trials. nurse researcher, 23(1), 40. https://doi.org/10.7748/nr.23.1.40.e1345 arcury, t.a., nguyen, h.t., sandberg, j.c., neiberg, r.h., altizer, k.p., bell, r.a., & quandt, s.a. (2015). use of complementary therapies for health promotion among older adults. journal of applied gerontology, 34(5), 552-572. https://doi.org/10.1177/ 0733464813495109 online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 191 cromartie, j., & bucholtz, s. (2008). defining “rural” in rural america. amber waves. https://www.ers.usda.gov/amber-waves/2008/june/defining-the-rural-in-rural-america/ cudney, s., craig, c., nichols, e., & weinert, c. (2004). recruiting an adequate sample in rural nursing research. online journal of rural nursing and health care, 4(2), 78-88. https://rnojournal.binghamton.edu/index.php/rno/article/view/201 fowler, b., & lapp, v. (2019). sample size in quantitative research. american nurse today, 14(5), 61-62. https://www.questia.com/magazine/1g1-592663691/sample-size-in-quantitativeresearch-sample-size long, a.s., hanlon, a.l., & pellegrin, k.l. (2018). socioeconomic variables explain rural disparities in us mortality rates: implications for rural health research and policy. ssmpopulation health, 6, 72-74. https://doi.org/10.1016/j.ssmph.2018.08.009 mitchell, g., veitch, c., hollins, j, & worley, p. (2001). general practice research and solutions in participant recruitment and retention. australian family physician, 30(4), 399-406. https://www.researchgate.net/publication/5386613_practice_based_research_lessons_fro m_the_field national rural health association. (2020). about rural health care. https://www.ruralhealthweb.org/about-nrha/about-rural-health-care nuttall, a. (2012). considerations for improving patient recruitment into clinical trials. clinical leader. https://www.clinicalleader.com/doc/considerations-for-improving-patient0001#:~:text=the%20average%20dropout%20rate%20across%20all%20clinical%20trial s,enroll%20one%20or%20no%20patients%20in%20their%20studies online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.642 192 pew research center. (2018). demographic and economic trends in urban, suburban, and rural communities. https://www.pewsocialtrends.org/2018/05/22/demographic-and-economictrends-in-urban-suburban-and-rural-communities/ quandt, s.a., sandberg, j.c., grzywacz, j.g., altizer, k.p., & arcury, t.a. (2015). home remedy use among african american and white older adults. journal of national medical association, 107(2), 121-129. https://doi.org/10.1016/s0027-9684(15)30036-5 shreffler-grant, j., nichols, e., &weinert, c. (2020). community-based skill building intervention to enhance health literacy among older rural adults. western journal of nursing research, 1(9). https://doi.org/10.1177/0193945920958014 weinert, c., nichols, e., & shreffler-grant j. (2020) “be wise”: a complementary and alternative medicine health literacy skill building programme. health education journal, 1(10). https://journals.sagepub.com/toc/hej/0/0 welch et al._id#+701+accepted+revision+setup+1.27.22+psf+formatted4.11.22 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 3 nursing leadership in rural hospitals: a competency needs assessment teresa welch, ed.d, msn, rn, nea-bc1 christina glenn, drph, ms2 1 assistant professor, university of alabama, capstone college of nursing, tdwelch@ua.edu 2 assistant professor, university of alabama, capstone college of nursing, cjglenn@ua.edu abstract purpose: assess competence and competency needs of nursing leadership in rural hospitals located in the alabama black belt region. determine the preferred method of continuing education to meet those identified competency needs. sample: a purposeful sample of registered nurses currently working in leadership roles identified by the chief nursing officer as nurse manager or nursing directors in a participating rural hospital within the alabama black belt region. method: a pilot study using descriptive statistical analysis to assess competency needs of nursing leadership and preferred method of educational delivery through email survey and likert-style questions. for purposes of recruitment, chief nursing officers were personally introduced to the purpose and design of the study and asked to distribute the email survey to their staff. descriptive statistics analysis was used to examine role preparation and experience of nurse managers and mean self-rated competency scores. bivariate correlations were examined exploring relationships between nurse manager experience, education, and competency. findings: statistically significant at p=0.031, participants with <5 years of experience reported non-proficiency in their knowledge of quality improvement strategies and non-proficiency in their online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 4 ability to lead multi-generational work teams as compared to those with > 5 years of experience who reported proficiency, p=0.026. conclusions: in an environment where constant change and quality drive organizational success, nurse leaders with < 5 years of experience are not proficient in managing multi-generational work teams or in understanding or managing focused quality improvement strategies to monitor, analyze, and improve the quality of patient care processes to improve the healthcare outcomes in an organization. realizing that more than 50% of the current nursing leadership has < 5 years of experience, these findings would suggest that leading and managing, striving for clinical excellence in a diverse workforce would be difficult if not impossible to achieve. keywords: rural hospital, competency, leadership, needs assessment, nurse manager nursing leadership in rural hospitals: a competency needs assessment rural hospitals are the cornerstone of economic development in rural communities. they not only provide access to healthcare contributing to the wellness and quality of life for local residents, but they also support the overall strength of the community’s economy. the value of a local hospital cannot be underestimated, yet 87% of alabama rural hospitals are operating in the red, and many others are marginal with razor thin operating margins (alabama hospital association, n.d.; graves et al., 2021). nursing leadership is strategically and uniquely positioned to have a significant impact on controlling the quality and cost of healthcare while meeting operational demands and thin margins. in rural health care settings, the current nursing shortage is compounded by the maldistribution of incoming health care professionals, which disproportionately affect remote online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 5 communities as graduating nurses choose to work in urban areas (johansen et al., 2018; rural health information hub [rhihub], n.d.a). rural communities are especially affected by the provider gap, as 63% of primary health shortages currently exist in rural communities (rhihub, n.d.a.). in rural hospitals where providers are limited nurses play a significant role in the delivery of health care. they must be able to think critically to assist a diverse patient population representing all ages and all complaints. however, there are unique challenges to rural nursing, among them; professional isolation, lack of professional development and continuing education opportunities, that add additional burdens to the recruitment and retention of highly qualified nurses (johansen et al., 2018; jones et al., 2019; smith et al., 2020; spero et al., 2014). the purpose of this pilot study was to assess the competency needs of nursing leadership in rural hospitals located in the alabama black belt region. a secondary aim was to understand the most effective means of delivering continuing education material designed to support them in their role as nurse leaders. findings from this study will be used to guide future research projects on a broader scale aimed at identifying leadership competency needs and the most effective means of providing continuing education units (ceus) designed to meet them. research findings from the broader study will inform the development and delivery of continue education and professional development opportunities designed to address identified nurse leader competency needs. background the definition of urban and rural areas, according the economic research service of the u.s. department of agriculture [usda, ers] (n.d.) are multi-dimensional concepts whose definitions are sometimes based on population size and at others, geographic location. researchers and policymakers alike are required to choose the most appropriate definition for their work. the federal office of rural health policy uses rural-urban commuting area code [ruca] online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 6 methodology to determine rural eligibility for their programs. the ruca methodology uses population data from the census bureau and geographic location, and commuting distance to determine rurality. the rhihub has taken a similar stance using a combination of geographic distance and population size to define rural as open country and settlements with fewer than 2,500 residents (n.d.b.). for the purposes of this pilot study rural was defined based on population size, geographic location, and distance. rural hospitals serve remote and rural areas of the state where individuals living in these rural communities must travel long distances, upwards of 45 minutes one way, to gain access to health care. rural communities typically center around farming and agriculture and rely on the local hospital as the cornerstone of economic support and development in the community. they are often the single largest employer in the community and the wages generated through employment and support services to the hospital underpin local economies (alabama hospital association, n.d.; graves et al., 2021; health resources and service administration [hrsa], n.d.). rural hospitals not only provide access to health care contributing to the overall health and wellbeing of local residents, they also enrich community living and the quality of life for those living in rural areas. since 2013, thirteen alabama hospitals have closed their doors; seven of which were rural. these closures have had significant economic ramifications and loss of access to health care for our rural residents (alabama hospital association, n.d.; rhihub, n.d.a) according to a recent study by the chartis group, a health care analytics research firm, twelve of alabama's 45 rural hospitals are considered most vulnerable to closure while 50% overall are currently considered at high financial risk (rhihub, n.d.a.). the value of a local hospital cannot be underestimated, yet online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 7 the financial outlook is dire without intervention (alabama hospital association, n.d.; graves et al. 2021; rhihub, n.d.a., n.d.b.). rural hospitals and rural healthcare have unique challenges. according to the literature, rural populations have a disproportionate share of the elderly, uninsured and patients with major health challenges (alabama hospital association, n.d.; graves et al., 2021; rhihub, n.d.a). they are more likely to have higher morbidity and mortality rates than those of their urban counterparts. healthcare in rural populations is often covered by programs such as medicaid and medicare and while the average alabama hospital might have half of its patients covered by medicare and medicaid, the rate can be as high as 90% for rural hospitals (alabama hospital association, n.d.). but to the rural resident, preventive care is not a priority, the state of their health is determined by their ability to work and function independently (long et al., 1989). to compound the health disparities noted in the literature regarding rural populations the geographical distance and lack of internet connectivity create unique challenges for nurses and provider as well (rhihub, n.d.b.). rural nurses play an integral role in providing healthcare for rural communities. in fact, it is estimated that at least half the healthcare providers in rural areas are registered nurses. they may be the first and only point of contact for rural healthcare consumers (alabama hospital association, n.d.; rhihub, n.d.b.). many nurses who have chosen to live and practice in rural settings are life-long residents of the community returning to work in the community after graduation (bushy & leipert, 2005). small communities have close ties where everyone knows everyone, and everyone’s business. trust and acceptance are built on longstanding relationships. nurses who were born and raised in the community will have inroads into and understanding of the community that someone relocating or commuting to the area will not. outsiders are not trusted online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 8 and have a difficult time inserting themselves into the community. it takes time to develop those relationships (bushy & leipert, 2005). rural nurses work in smaller healthcare facilities with limited resources and without the benefit of specialty services and specialists. they are expert generalist who must be able to think critically and assist patients of all ages, with all types of complaints in an unpredictable environment (jones et al., 2019; rhihub, n.d.b.; smith et al., 2020). according to pavloff et al. (2017), the unique practice environment of rural nurses and the expectations of the role necessitate a highly specialized generalist nurse who has expertise and integrated competencies in a comprehensive and broad fashion. further, the literature states that the diversity and complexity of rural nursing dictates specialized education to support the on-going competencies of these nurses so that they are able to maintain the high level of care they provide (jones et al., 2019; paré et al., 2017; pavloff et al., 2017; smith et al., 2020). but in rural, oftentimes geographically remote areas, the resources for professional support are lacking. current literature has highlighted the need to support rural nurses by providing adequate professional development opportunities that address competency, competency development and safety for rural nurses. the mechanism for significant impact has not been identified and warrants further investigation. methodology this was a pilot study that used descriptive statistical analysis to determine the efficacy of a larger scale study designed to assess the leadership competency needs and preferred method of continuing education to best meet those needs for nurse leaders in rural hospitals located in the alabama black belt region. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 9 study design the nurse manager competencies self-assessment inventory tool developed by the american organization of nurse executives (aone), american association of colleges of nursing (aacn), and association of perioperative registered nurses (aorn) to assess requisite skills and behaviors of the successful nurse leader were used to examine mean responses from nursing leadership in all three domains of success for nurse leaders: (a) managing the business, (b) leading the people, and (c) creating the leader within yourself (american organization for nursing leadership [aonl], 2015). two research questions were addressed in the pilot study: research questions ● using benner’s (1982) novice to expert continuum as a guide to define your perception of competence, how would you assess your leadership competencies as identified in the nurse manager competency self-assessment tool? ● as nurse leaders in a rural hospital, what is the most effective means of receiving continuing education material? procedure and sampling purposeful sampling of nursing leadership in rural hospitals located in the alabama black belt region. with institutional review board approval, the chief nursing officer (cno) of each hospital was contacted via telephone to schedule a face-to-face appointment. given the exclusive culture of rural communities, the purpose of the meeting was to develop relationships and improve the likelihood of a positive response rate to the study. the principal investigator (pi) introduced the purpose and intent of the study, described plans to develop free continuing education resources based on the findings of the study, and then requested the cno’s support of the study by electronically distributing the anonymous survey to their nursing leadership team. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 10 with their agreement to distribute the electronic survey the pi forwarded the recruitment email containing a brief description of the study and hyperlink to the informed consent and voluntary anonymous survey. inclusion criteria for this pilot study included: 1) nurse leader with formal leadership role, 2) currently working in a rural hospital located in the alabama black belt region. a thank you note was emailed to the cno within 24 hours of the initial meeting to acknowledge appreciation for their support. definitions nursing leadership all nurses can be considered leaders in their field with or without a formal title or leadership role. formal titles may vary by specialization, education, or even healthcare system. nursing leadership roles are determined by the span of control and sphere of accountability and responsibility within the organization. the cno is typically identified as the nurse executive at the top of the organizational chart. the nurse responsible for all daily and long-term nursing operations. the director of nursing (don) is just below the cno on the organizational chart and is generally responsible for balancing staff leadership and broader organizational operations. they are typically responsible for a group of nursing departments. nurse managers considered frontline managers are just below the don on the organizational chart and are generally responsible for the daily operations of a single nursing department within the organization. they coordinate staff training and hiring, design schedules, and manage the direct care of patients (sullivan, 2017). small rural hospitals don’t have the resources to support multiple layers of formal leadership positions on an organizational chart. nurses promoted to formal leadership roles are expected to function at all levels of leadership and have comprehensive responsibilities that span the management of the entire organization. typically, the nurse at the top of the organizational chart online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 11 is known as the don rather than the cno. for the purposes of this study, nurse leaders identified as having legitimate authority in formal leadership roles were given an opportunity to participate in the survey. alabama black belt region the term black belt refers to the region's exceptionally fertile rich, black topsoil that stretches from texas across the southeast through alabama and up to virginia. at one time in alabama history, the area was a thriving prominent and influential financial, political, and agricultural commercial powerhouse for the entire united states. today, the region is povertystricken and economically underdeveloped with the poorest counties in the nation (university of alabama center for economic development, n.d.; university of west alabama, n.d.). according to the university of alabama center for economic development (n.d.), this region is defined by its dire socioeconomic situation. the region was chosen for the pilot study due to the dire socioeconomic and demographic factors plaguing the region and lack of community resources to support rural hospitals in the area. see figure 1. protection of human rights this study received approval from the university of alabama, institutional review board for non-medical review. all participant rights for anonymity, privacy, and voluntary consent were observed. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 12 figure 1 reproduced with permission from the center for nursing leadership and outreach (cber), the university of alabama. instrument nurse leader competency was assessed using an instrument that was adapted from the american organization of nurse leaders (aonl’s) nurse manager self-assessment inventory tool. the electronic survey was developed and tested for research by warshawsky and cramer (2019). the tool was designed to assess essential nursing leadership competencies in three domains of competence as identified by the nurse manager domain framework: ● science: managing the business, ● art: managing the people, and online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 13 ● leader within: creating the leader in yourself (aonl, 2015). benner’s (1982) novice to expert competency development model was used to define the levels of competence on the survey. it contained seven demographic questions, twenty-eight competency-based items, and one open ended question to solicit preferences in continuing education formats. participants the final sample contained responses from 22 nurse leaders from 8 participating rural hospitals in the alabama black belt region. from the estimated 65-70 formal nurse leaders in this region of the state, this was an estimated 31% response rate. demographics of the sample group were 93.7% female and 6.3% male; 46.6% held an associate degree while 53.4% held a bachelor’s degree. 50% of them indicated that they had been in their leadership role at least 5 years while the other 50% had not. it was interesting to note that not all respondents answered the demographic questions. see table 1. table 1 characteristics of nurses in leadership roles in rural alabama hospitals. cohort characteristics, n (%) total* (n = 22) gender female 15 (93.7) male 1 (6.3) highest educational degree currently held associate 7 (46.6) baccalaureate or higher 8 (53.4) title and scope of current management or leadership role nurse manager 12 (75.0) director of nursing 3 (18.8) chief nursing officer 1 (6.2) years in formal leadership role less than 5 years 8 (50.0) 5 or more years 8 (50.0) minimal educational requirement for promotion to management or leadership associate 8 (61.5) online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 14 cohort characteristics, n (%) total* (n = 22) baccalaureate or higher 5 (38.5) preference for continuing education materials resource materials 3 (18.8) just-in-time video vignettes 4 (25.0) informational brochures 3 (18.7) independent study mini courses 4 (25.0) face-to-face seminars 2 (12.5) results fisher’s exact p-value is the preferred method of statistical analysis when working with nominal variables in a small sample size. fisher’s exact p-test for statistical significance is more accurate in small samples because it applies an exact procedure that considers all possibilities when calculating p-values (kim, 2017). research question one assess the competency needs of nursing leadership in rural hospitals. despite the small sample size in this pilot study, two questions on the survey instrument had statistically significant findings measuring below the threshold of significance, identified as fisher’s exact p-value, (pvalues < .05) indicating that the responses to those questions were significantly associated with leadership experience. participants who indicated that they had less than 5 years of experience as a nurse leader reported non-proficiency on question 10, knowledge of quality improvement strategies such as continuous quality improvement, total quality management, six sigma, and balanced scorecards (p = .031); and non-proficiency on question 27, able to lead multigenerational work teams (p = .026). see table 2. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 15 table 2 level of nursing practice proficiency by years of leadership experience leadership experience total (n=22) less than 5 years (n=8) 5 or more years (n=8) **pvalue business-related items*, n (%) 1 knowledge of health care economics and application to the delivery of patient care 0.6 not proficient 9.0 (60.0) 5.0 (71.4) 4.0 (50.0) proficient/expert 6.0 (40.0) 2.0 (28.6) 4.0 (50.0) 2 knowledge of the unit and departmental budgeting processes both capital and operational 0.12 not proficient 9.0 (60.0) 6.0 (85.7) 3.0 (37.5) proficient/expert 6.0 (40.0) 1.0 (14.3) 5.0 (62.5) 10 knowledge of quality improvement strategies such continuous quality improvement, total quality management, six sigma, and balanced scorecards 0.031 not proficient 9.0 (64.3) 6.0 (100.0) 3.0 (37.5) proficient/expert 5.0 (35.7) 0.0 (0.0) 5.0 (62.5) 19 knowledge of basic business skills such as developing a business case and the project planning process 0.2 not proficient 11.0 (78.6) 6.0 (100.0) 5.0 (62.5) proficient/expert 3.0 (21.4) 0.0 (0.0) 3.0 (37.5) people skills-related items* n (%) 6 knowledge of how to manage performance of employees. this includes performance appraisals, goal setting, motivation, and the disciplinary process 0.3 not proficient 6.0 (42.9) 4.0 (66.7) 2.0 (25.0) proficient/expert 8.0 (57.1) 2.0 (33.3) 6.0 (75.0) 27 able to lead multi-generational work teams 0.026 not proficient 6.0 (42.9) 5.0 (83.3) 1.0 (12.5) proficient/expert 8.0 (57.1) 1.0 (16.7) 7.0 (87.5) 28 demonstrates knowledge of evidencebased nursing practice needed to lead the clinical services 0.3 online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 16 leadership experience total (n=22) less than 5 years (n=8) 5 or more years (n=8) **pvalue not proficient 6.0 (42.9) 4.0 (66.7) 2.0 (25.0) proficient/expert 8.0 (57.1) 2.0 (33.3) 6.0 (75.0) *denotes missing participant responses. **fisher’s exact p-value, p-values < .05 considered meaningful. comparing educational preparation of nurse leaders, those with an associate degree versus bachelor’s degree, no significant associations were found between educational degree held and business-related or people-skills related questions on the survey. all exceeded (p ≥ .05) the acceptable threshold of significance as defined by fisher’s exact p-value, (< .05) to be considered meaningful. research question two what is the preferred method of addressing continuing education needs of nurse leaders in a rural organization. just-in-time video vignettes 27.2% and independent study mini course (webinars) 36.37% were identified as the preferred method of education and continuing education. face-to-face seminars were the least preferred method of continue education. limitations limitations of the study are the relatively small sample size as there are only nine rural hospitals located in the alabama black belt region with one hospital declining to participate leaving eight participating hospitals and approximately 70 potential study participants. the culture of rural communities, particularly with outsider engagement could negatively influence recruitment. to improve recruitment and participation, the pi contacted each of the cnos via telephone to schedule an appointment. the face-to-face appointment gave the pi an opportunity to share common experiences as nurse leader/manger and rural residence and introduce the purpose of the study. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 17 all participant responses were self-selected based on their personal perceptions of competence related to their nurse manager/leader role. although this was a small sample size of self-reported competencies, this study does provide insights into nurse manager perceptions of competence related to quality and multi-generational, multi-cultural workforce management. it also highlights the relationship between years of experience and knowledge with perceived competence. discussion this study provides evidence that knowledge of quality improvement strategies and their ability to lead multi-generational work teams; nurses are significantly associated with leadership experience. nurse leaders with less than five years of experience reported non-proficiency in their knowledge of quality improvement strategies and non-proficiency in their ability to lead multigenerational work teams as compared to those nurse leaders with five or more years of experience who reported being proficient. while a multigenerational workforce presents diverse challenges in understanding the nuances of communication style, motivation factors, conflict management, or even work expectations, the rewards of harnessing those diverse viewpoints has the potential to reap exponential reward for the organization when faced with challenges (coulter & faulkner, 2014). five generations of nurses working side by side is not uncommon in today’s healthcare workforce. each generation brings its own perspective. nurse leaders must be skillful at building trusting relationships with the members of their healthcare team. the ability to understand and connect with staff members at any level in their career helps the overall organization navigate constant change and maintain focus on the core values of patient-centered, high quality patient care and performance improvement. it is this sphere of influence that allows leaders to lead with followers online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 18 who respect and trust their leader able to exceed every expectation (graystone, 2019; sullivan, 2017). the centers for medicare and medicaid services, reimbursement models, such as valuebased purchasing and pay-for-performance are focused on quality improvement and nursing excellence and are driving the financial landscape of healthcare delivery today (rome et al., 2016). as a result, the quality and safety of patient care, patient outcomes, and the patient experience along with the associated costs of providing that care are under intense scrutiny. nursing leadership, particularly in rural hospitals are strategically and uniquely positioned to have a significant impact in controlling the cost of healthcare while ensuring the quality of patient care and meeting operational demands with thin margins. their ability to maintain continuous quality improvement in an efficient cost-effective manner is the foundation of economic viability and success for the hospital itself (muller & karsten, 2012; schuettner et al., 2015). rural hospitals provide medical services to residents in small rural communities who otherwise would not have access to healthcare. they are generally small in size with low patient volumes. the remoteness and size of the hospital can present significant financial challenges. they struggle to achieve economies of scale and don’t have the patient volume or revenue from commercial payers in the payer mix to offset lower medicare reimbursements (rhihub, n.d.b.). the success of rural hospitals with limited resources and tight margins depends on quality nursing leadership. individuals whose knowledge and competence goes beyond the daily business of patient care extending into the relationship and impact of quality metrics, costs, and reimbursement (rome et al., 2016; schuettner et al., 2015) and the hospitals financial viability. the findings from this study will help determine competency needs and support strategies to promote nursing leadership within rural hospitals and help them remain viable in the community. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 19 additionally, findings from this study will help guide future research projects aimed at developing and providing the support structures and ceus most needed by rural nurse leaders. rural hospitals need strong effective leadership to be successful and given the challenges of working in rural environments, opportunities for professional support and development are also a challenge. recommendations rural nursing theory applies to nurses who work in rural, sparsely populated areas and who face unique challenges not observed by their counterparts in urban areas. these nurses must possess an independent autonomous spirit and have a strong knowledge base to provide quality care to diverse patient populations. the shear nature of the rural environment creates obstacles and barriers to professional development. according to pavloff et al. (2017) despite the challenges of rural nursing, these professionals must be able to maintain a level of the competency and autonomy to provide quality patient care. the seminal work of long and weinert (1989) outlined the core tenants of the rural nursing theory: 1) rural residents define health in the context of their ability to work, be productive, selfsufficient, and their ability to do usual tasks; 2) rural residents are independent and resist help from others, especially, those seen as outsiders and when necessary, prefer to seek help from their family or neighbors, those seen as insiders; 3) rural healthcare providers cannot separate professional and personal roles and have greater role diversity in the clinical setting than their urban counterparts. it is imperative to understand the culture of the target population and identify potential barriers to success. the resistance and lack of trust that rural residents have for outsiders was an online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 20 important concern to strategically address. the cno of the hospital was identified as a key gatekeeper, someone influential with a prominent and recognized role within the local community (hennink et al., 2011). the initial meeting with the cno gave the researcher an opportunity to develop a rapport and establish interest in the project. consider not only the expense, but the safety and time commitment required to travel and meet with individual cno’s in remote locations. it was also important to establish a measure of reciprocity. while the initial meeting served to introduce the study and build relationships, it was also a recruitment opportunity. in return for their support cno’s will receive an aggregate report of leadership competency needs and free leadership development ceus. the ability to garner community acceptance was important to the success of the project (kirchgessner & keeling, 2014). given the 31% response rate in this pilot study, the investment was worth the effort. before leaving the cno’s office, exchange business cards for future contact information. future studies are recommended to replicate the procedure. the current survey tool did not have hard stops. several questions in the survey were skipped by participants. it is worth considering the option of adding rules to critical questions to encourage participant answers to all questions on the survey. the study also addressed a common evidence-based gap for nursing leadership training. the practice of promoting bedside nurses who excel in interpersonal skill or clinical excellence is common practice in hospitals and is no longer a feasible option in today’s chaotic healthcare environment (rome et al., 2016; schuettner et al., 2015; warshawsky and cramer, 2019). current nurse leaders recognize the importance of transitional support and training to be successful and embraced the opportunity for continuing education opportunities focused on leadership development. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 21 evidence from this pilot study suggests that hospitals struggling to meet quality metrics and maintain workforce morale and motivation may need to consider implementation of a comprehensive leadership orientation program for nurses who transition into management positions. with limited resources, networking with institutions of higher education to provide the needed education would be a viable option. conclusions rural hospitals are the cornerstone of economic development in rural communities. they not only provide access to healthcare contributing to the wellness and quality of life for local residents, but they also support the overall strength of the community’s economy. the value of a local community hospital cannot be underestimated, yet 88% of alabama rural hospitals are operating in the red, and many others are marginal with razor thin operating margins (alabama hospital association, n.d.; graves et al., 2021; rhihub, n.d.a.). nursing leadership is strategically and uniquely positioned to have a significant impact on ensuring the of quality patient care while also controlling the costs of care to meet operational demands with thin margins. although the sample size was small, the findings from this pilot study were statistically significant supporting the need for a broader assessment of rural nursing leadership. findings from these studies will inform the development of support strategies and continuing education opportunities designed to meet the identified leadership competency needs of nurse leaders in rural hospitals promoting strong nursing leadership. in an environment where constant change and quality drive organizational success, nurse leaders with < 5 years of experience are not proficient in managing multi-generational work teams or in understanding or managing focused quality improvement strategies to monitor, analyze, and improve the quality of patient care processes to improve the healthcare outcomes in an online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 22 organization. realizing that more than 50% of the current nursing leadership has < 5 years of experience these findings would suggest that leading and managing, striving for clinical excellence in a diverse workforce would be difficult if not impossible to achieve. references american organization for nursing leadership. 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(2017). introducing nursing management. effective leadership and management in nursing, (9th ed, pp 1-12.). pearson. u.s. department of agriculture, economic research service. (n.d.). what is rural? retrieved september 26, 2021 from. https://www.ers.usda.gov/topics/rural-economy-population/ruralclassifications/what-is-rural/ university of alabama center for economic development. (n.d.). alabama’s black belt counties. about_the_black_belt.pdf (ua.edu) university of west alabama. (n.d.). demographic’s of targeted area. https://www.uwa.edu/uploadedfiles/osp2/stockdemographics.pdf online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.701 25 warshawsky, n., & cramer, e. (2019). describing nurse manager role preparation and competency: findings from a national study. journal of nursing administration, 49(5), 249255. https://doi.org/10.1097/nna.0000000000000746 koenecke_692+newressubmission_maintext_graves+edits+final100821_formatted online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 152 role of nurses in oral cavity and pharynx cancers patricia da rosa, dds, msc1 lori koenecke, ms, rn, cne2 laura gudgeon, ms, rhia 3 whitney keller4 wei gu5 1 research associate, population health evaluation center/office of nursing research, college of nursing, south dakota state university, patricia.darosa@sdstate.edu 2 cancer programs director, office of disease prevention and health promotion, south dakota department of health, lori.koenecke@state.sd.us 3chronic disease epidemiologist, office of disease prevention and health promotion, south dakota department of health, laura.gudgeon@state.sd.us 4research assistant, population health evaluation center/office of nursing research, college of nursing, south dakota state university, whitney.keller@jacks.sdstate.edu 5research assistant, population health evaluation center/office of nursing research, college of nursing, south dakota state university, wei.gu@jacks.sdstate.edu abstract purpose: the incidence of oral cavity and pharynx cancer is rising in the united states and south dakota (sd) (2009-2018). in 2018, it was estimated that 396,937 of americans were living with oral cavity and pharynx cancer. the 5-year relative survival rate for oral cancer is 66.2%, which online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 153 is less than the survival rates for breast, colorectum, and prostate cancers. tobacco and alcohol use and human papillomavirus (hpv16) exposure are some of the risk factors for oral cancer. overall rural populations have higher cancer mortality than no rural population due to higher poverty, lower access to health services, and cigarette use. the purpose of this study is to investigate the prevalence of the oral cancer risk factors (e.g., cigarette smoking), hpv vaccination rates, and to identify the spatial distribution of social and environmental factors (e.g., social vulnerability, dental care access) in sd. finally, this article discusses how nurses can contribute to oral cancer prevention and early detection. methods: this descriptive study used data from multiple data sources (e.g., sd department of health, hrsa, county health rankings). maps were created using arcgis. findings: from the 66 sd counties, nearly 17% presented high-level shortage scores and were also highly socially vulnerable. hpv vaccination among youth was higher than the national average. studies showed that improving nurse’s knowledge by training on oral cancer is needed and this may increase nurses’ practice in oral cancer prevention and control. conclusions: primary care professionals like nurse practitioners can assist in early detection of oral cancer and promote awareness of signs and main risk factors in rural areas. as part of the total patient care, nurses hold a vital role in prevention and early detection of oral cancer. these efforts with referral to oral cancer screening are vital for decreasing oral cancers morbidity and mortality rates primarily. keywords: rural health, nurses, oral cancer, dentalcare access, geographic information systems online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 154 role of nurses in oral cavity and pharynx cancers background and significance oral cancers, including cancers of the mouth and back of the throat (national institute of dental and craniofacial research, 2018), account for 3% of all cancers diagnosed and reported annually in south dakota (sd) and in the united states (u.s.) (u.s. cancer statistics working group, 2021; south dakota cancer registry, 2020). from 2002-2017, the trends in oral cancer incidence rates for all ages in sd rose 1.7% annually (national cancer institute, 2020). a total of 650 new cases (480 male cases and 170 female cases) of oral cancer were diagnosed in sd residents between 2014 to 2018, with 114 oral cancer-related deaths (28 female and 86 male deaths). in the same period, the age-adjusted incidence rate was 12.6 per 100,000 population in sd, a similar rate when compared to the national rate at 12.0 (u.s. cancer statistics working group, 2021). the nonmodifiable risk factors for the development of oral cancer include gender and age. oral cancer diagnoses are significantly higher in men compared to women and most frequently diagnosed among people aged 50–70 years (national cancer institute, 2020). the main modifiable risk factors include heavy tobacco and/or alcohol use (national institute of dental and craniofacial research, 2018). evidence also shows an association of oral cancer with human papillomavirus strain 16 (hpv16) exposure (national institute of dental and craniofacial research, 2018). moreover, studies show that rural populations have an 8% higher cancer mortality due to higher poverty, lower educational attainment, lack of health insurance, public health resources, and access to health services, a higher proportion of elderly, and cigarette use (blake et al., 2017; bolin et al., 2015). when compared to metropolitan areas, oral cancer incidence rates are 10.9 per 100,000 people, compared to 12.7 in rural areas, suggesting living in a rural area increases oral online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 155 cancer risk (blake et al., 2017). a rural area is classified as any area outside of an urban area, which includes urban clusters (2,500 to 50,000 residents) and urbanized areas (50,000 residents or more) (united states census bureau, 2020). in sd just over 50% of residents live in rural areas (rural health information hub, 2018). oral cancer is considered a silent disease and may easily pass undiagnosed since the early signs include ulcerative lesions and red and white patches on the oral mucosal. thus, early detection and referral of oral cancers are crucial to reduce the likelihood of invasive treatments and improve survival. studies have also shown that older populations living in rural areas do not seek dental care at the same rate when compared to their urban counterparts (hamano, et al. 2017). hence due to the dental health professional shortage areas, rural nurses can play an important role in cancer prevention and control during routine medical care by having the opportunity to promote oral cancer awareness among patients at high risk, to identify early symptoms, and to refer patients for further care when symptoms are noted. to better understand the prevalence and distribution of oral cancer risk factor in sd, the purpose of this study was to (i) investigate the overall prevalence of cigarette smoking among sd adults as well as changes in prevalence of cigarette smoking from 2011 to 2020, (ii) examine the latest rates in hpv vaccination rates among youth in sd, and (iii) to identify the spatial distribution of social and environmental factors (social vulnerability and dental care access) related to oral cancer in the state. finally, this article discusses how nurses can contribute to oral cancer prevention and early detection in a largely rural state. methods this descriptive study uses secondary data from multiple data sources. the percentage of the adult population who report current use (every day or most days) of cigarette and have smoked online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 156 at least 100 cigarettes in their lifetime by county was obtained using the 2011-2020 county health rankings estimates (county health rankings, 2020). the 2019 hpv vaccination rates among 13– 17-year-olds in sd were accessed using the sd department of health data (south dakota department of health, 2019). the social vulnerability index (svi) was obtained from the cdc’s agency for toxic substances and disease (centers for disease control and prevention [cdc], 2018). finally, information on the shortage of dental care was obtained from the health resources & services administration (health resources & services administration, 2021). maps were created by the authors using arcgis. results tobacco in 2020, the estimated prevalence of adult residents currently smoking cigarettes in sd was 18% (south dakota department of health, 2019a), a higher prevalence when compared to the national median of 16% (cdc, 2020a). males were more likely to smoke cigarettes (21%) than females (17%) (south dakota department of health, 2019a). the prevalence of smokeless tobacco, which also increases risk for oral cancer, was 6% among adults, a higher rate when compared to the national median of 4% (south dakota department of health, 2019). according to the sd department of health (2019a), 70% or more of individuals who smoke and 47% of smokeless tobacco users have been advised to quit by a healthcare professional. however, geographical disparities on cigarette use among sd residents persist. figure 1 shows county level change in the prevalence of cigarette smoking among adults from 2011 to 2020. counties with an increase in prevalence of cigarette smoking were shaded in orange, and counties with a decrease of cigarette smoking were shaded in blue. comparing the absolute change in prevalence between the two 5-year averages (2011-2015 and 2016-2020), 41% (27 counties) of online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 157 the 66 counties had an increase in the prevalence of cigarette smoking. however, improvements have also occurred in more than half of the counties (39 counties) where the absolute change varied from -0.3% to -8.2% during the same period (county health rankings, 2020). one of the possible contributing factors is the availability of the sd quitline service which provides free service, including counseling and medications, for those aiming to quit cigarette smoking, smokeless tobacco, and vaping products (south dakota department of health, 2021a). figure 1 county level prevalence of cigarette smoking change from 2011-2015 vs. 2016-2020 in south dakota online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 158 human papillomavirus (hpv) in the u.s., incidence rates for oral cavity and pharynx cancers have increased from 2007 to 2016 (ellington et al., 2020). due to the increase in oral cancer cases, specifically oropharyngeal cancers, there is indication that the rising trend of new cases is associated with hpv16. it is reported that 70% of oropharyngeal cancers in the u.s. was associated with hpv infection in patients with previous exposure to the virus (centers for disease control and prevention, 2020b). in sd this 13year period, nearly 5,000 cancers were diagnosed in a location that potentially resulted from hpv infection, with head/ neck and oral cancers accounting for almost 45% of the cases (south dakota department of health, 2019a). thus, the hpv vaccine is crucial in the prevention against hpv infections and reducing the risk to oral cancers (centers for disease control and prevention, 2020b). although the goal of hpv vaccination is 80% in the healthy people 2030, the national average of hpv vaccination among adolescents ages 13 to 15 is only 48% (u.s. department of health and human services, 2020). in sd, more than 2 in 3 adolescents (73.6%) have started the hpv vaccination series, with more than half (61.2%) of adolescents up to date on the hpv vaccination series in 2019, a significant increase from 2016 (figure 2) (south dakota department of health, 2019b). however, despite hpv vaccination protecting individuals from ever developing these cancers, including oral cancer, sd ranked 31st nationally for up-to-date hpv vaccination rates in adolescents in 2019 (south dakota department of health, 2019b). education about healthy lifestyle choices, such as the benefits of hpv vaccination, assists in primary prevention against oral cancer. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 159 figure 2 2016-2019 national hpv immunization survey data for teens (ages 13-17) in south dakota access to healthcare disparities in access to preventive health services and social vulnerability are important factors that contribute to poor oral health outcomes in rural areas. one way of measuring access to dental care is to use the county level health professional shortage area (hpsa) scores (health resources & service administration, 2021). scores range from 1 to 25, and the higher score means the area needs greater priority of dental health care. four criteria are used to evaluate hpsa score: (a) population-to-provider ratio, (b) percent of population below 100% of the federal poverty level (fpl), (c) water fluoridation status, and (d) travel time to the nearest source of care (nsc) outside the hpsa designation area. to investigate the shortage of dental care in sd, we classified three levels of shortage: (a) low shortage with a hpsa score from 4 to 13, (b) median shortage with a hpsa score from 14 to 16, and (c) high shortage with a hpsa score from 17 to 25. these 55.9 63.2 68.7 73.6 38.6 44.8 49.5 61.2 0 20 40 60 80 100 2016 2017 2018 2019 pe rc en t ( % ) > or = 1 up-to-date data source: south dakota department of health (sd doh) online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 160 three categories are depicted in figure 3. counties with a median-level shortage score and a highlevel shortage score are shaded with light blue and dark blue, respectively. the second layer presented in the map is the social vulnerability index (svi). svi is the percentile ranking with values from 0 to 1. higher values indicate greater vulnerability. we considered counties with svi score greater than 0.8 as highly socially vulnerable. as depicted in figure 3, one in four counties are considered median to high shortage areas for dental care in the state. it is important to note that in minnehaha county, the most populated county in the state, only part of the county is considered median shortage area. figure 3 spatial distribution of dental health professional shortage area (2021) and social vulnerability (2018) in south dakota online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 161 the counties with high-level shortage scores and highly socially vulnerable are bennett county, buffalo county, charles mix county, corson county, dewey county, jackson county, lyman county, mellette county, oglala lakota county, todd county, and ziebach county. early detection and role of nurses the 5-year relative survival rate for oral cancer is 66.2%, which is less than the survival rates for breast (90%), colorectal (80%), and prostate cancers (90%) (american cancer society, 2021). although no population-based screening programs exists for oral cancer, early diagnosis of cancer has the potential to lower likelihood of mortality, especially for high-risk populations. often oral cancer screening is performed by dentists; however, primary care providers also play an important role in the early detection of these cancers and subsequent referral of those exhibiting symptoms. in addition, nurses can promote awareness of oral cancer signs and risk factors (e.g., health habits, lifestyle and behaviors) (the united states preventive services task force, 2013; walker et al., 2018). nurses play an important role in prevention and early detection of cancers because health promotion and disease prevention are essential components of nursing education programs (li et al., 2020). a recent study showed that 91.5% of nurses think that oral cancer screening for adults is important and 83% of nurses trusted their ability to perform an oral cancer examination (li et al., 2020). however, the same study suggests that only 39.3% of public health nurses believed nurses have overall sufficient oral cancer education and 46.7% of these nurses believed that sufficient training would increase oral cancer screening by nurses (li et al., 2020). furthermore, only 36.1% of these nurses believe that there is sufficient oral cancer screening training currently available (li et al., 2020). these study results suggest that providing additional training to nurses online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 162 on the detection of oral cancer may increase practice behaviors for oral cancer screenings and awareness. research suggests that additional training improves nurses’ knowledge on oral health care, and oral cancer awareness (maramaldi et al., 2018). in a recent study, 85% of nurses were aware of risk factors of oral cancer, though only 38% regularly informed patients of oral cancer risk factors during hospital admissions (priyadharshni & sivakumar, 2019). training nurses on providing oral screening examinations as part of routine care is also necessary (priyadharshni & sivakumar, 2019). in areas with shortage of dental professionals, rural nurses may have the opportunity to identify high-risk populations (e.g., rural elderly population with long history of tobacco and/or alcohol use) more often than dental professionals. nonetheless, it is also important to recognize that nurses have a busy routine and, thus an oral assessment should not create extra burden to the nurses’ routine. a study carried out by anderson et al. (2001) showed that after a two-hour training, nurses took on average less than five minutes to complete an oral examination. additionally, nurses may assist in the oral cancer prevention efforts by encouraging hpv vaccination (south dakota department of health, 2021b) among adolescents ages 13 to 17. for instance, hpv vaccination is recommended at the same time as other vaccines such as tdap and meningococcal. this vaccine also protects against other cancers such as cervical and anal cancers. finally, by educating about the risks of tobacco and alcohol use and promoting tobacco cessation services, nurses can assist in the reduction of the leading cause of preventable disease, disability, and deaths in rural areas therefore reducing geographical disparities in health. conclusions although oral cavity and pharynx cancers are primarily preventable, the incidence of oral cancer is rising nationally. in sd, where the incidence rate of oral cancer was rising (2002-2017), online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.692 163 we found that five counties showed not only a high prevalence of cigarette smoking but also a high-level of hpsa score and social vulnerability index. additionally, more than half of the counties are considered shortage areas for dental care. in this context, rural nurses have an imperative role in promoting the primary and secondary cancer prevention strategies. reducing the modifiable risk factors (e.g., tobacco use, heavy alcohol consumption, and exposure to hpv16) and promoting prevention efforts (e.g., hpv vaccination among youth and cessation from alcohol and tobacco use) are crucial for oral cancer prevention and control. in addition, nurses are the front-line workers in health care who can provide information on oral cancer screening and referrals of patients who are at higher risk (e.g., males, aged 50 and older, with history of heavy smoking). these efforts are vital for decreasing oral cancer morbidity and mortality rates primarily in rural areas. references american cancer society. 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(2018). hpv and oral cancer: the need to integrate oral health practices into nursing education. clinical journal of oncology nursing, 22, 166-173. https://doi.org/10.1188/18.cjon.e166-e173 cassity_593_formatted online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 57 using compression-only cpr mini-training sessions to address rural bystander care cassity gutierrez, phd 1 eric rupe, mph, nrp 2 cody arlie reed, ma 3 becky wolff, rn, msn, ma4 1 chair & associate professor, college of pharmacy and health sciences, drake university cassity.gutierrez@drake.edu 2 student, university of south dakota, eric.rupe@coyotes.usd.edu 3 phd student, cornell university, car325@cornell.edu 4 instructor, health science major, university of south dakota, becky.wolff@usd.edu abstract purpose: rural populations face vast disparities in out-of-hospital cardiac arrest survival rates when compared with urban populations. furthermore, rural areas have lower cpr training rates. compression-only cpr (cocpr) is a simplified resuscitation method that eliminates the task of rescue breathing. the simplified nature can significantly reduce training times and be more comprehendible and convenient for the general population. the purpose of this study is to assess the change in knowledge and self-confidence of rural college students to administer cocpr as a result of mini-training sessions. sample: purposive sampling was used to focus on the 125 rural college students who received a cocpr mini-training session at the medium sized university located in a rural state with a historically low cpr training rate. method: each participant completed a 14 question pre-survey, the cocpr training, and 13 question post-survey. descriptive statistics on the pre-, post-, and subscale change scores for both online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 58 knowledge and self-confidence were computed and one-way between subjects anovas were conducted to determine differences between group means related to prior cpr training. findings: the training resulted in a positive increase in the participants’ knowledge and confidence to administer care. furthermore, the participants indicated that they would recommend this training to others. conclusions: this study provides insight into the viability of providing cocpr in lieu of conventional cpr, supports having individuals trained at an earlier age to provide bystander care, and supports training individuals in rural areas where response time is delayed. keywords: rural, bystanders, cpr, compression only, cardiopulmonary resuscitation, cardiac arrests using compression-only cpr mini-training sessions to address rural bystander care a recent report from the institute of medicine (2015) claims that out of the approximate 395,000 annual cases of cardiac arrest that occur in the united states outside of a hospital setting, less than 6% survive. in contrast, approximately 200,000 cardiac arrests occur annually in hospitals with overall survival rates of 18% to 20% (merchant et al., 2014). without trained medical staff readily available, out-of-hospital cardiac arrest patients must rely upon immediate action of bystanders. unfortunately, less than half of out-of-hospital cardiac arrest patients receive immediate help from a bystander until emergency personnel can assist (american heart association [aha], 2018). the lack of action may be due to lack of proper cpr training and/or lack of confidence in provision of care. it is thought that improving training and confidence levels of bystanders can significantly improve outcomes for out-of-hospital cardiac arrest patients. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 59 rural populations face disparities in out-of-hospital cardiac arrest survival rates when compared with urban populations (anderson et al., 2014; rivera, kumar, bhandari, & kumar, 2016; fabbri et al., 2006; young, woodall, enraght-moony, tippett, & plug, 2007). consequently, trained bystanders may be even more critical for out-of-hospital cardiac arrest survival in areas with no centralized ambulance dispatch service, limited pre-hospital services, and prolonged call response times (orkin, 2013). the provision of bystander cpr and cpr training vary widely based on geographic and demographic factors. a national study examining county-level training rates found that annual rates of cpr trainings were low and widely varied across different u.s. counties (anderson et al., 2014). counties with training rates that fell in the lower tertile were more likely to have more rural areas, lower population densities, fewer medical facilities/personnel, and higher cardiovascular-related mortality rates; the study attributed low rates of cpr training to lack of knowledge of training opportunities, and unavailability and unaffordability of training in remote locations (anderson et al., 2014). efforts focused on improving cpr education in all regions, especially rural areas, are needed to improve bystander intervention and out-of-hospital cardiac arrest survival rates. efficacy of chest compression only cpr (cocpr) chest compression only cpr (cocpr) is a simplified resuscitation method that eliminates rescue breathing. the simplified nature can significantly reduce training times and be more comprehendible and convenient for the general population. in 2010, basic life support guidelines from the aha and european resuscitation council (erc) introduced cocpr as an alternative to conventional cpr with rescue breathing (ccrb) for untrained and basic responders (koster, baubin, & bossaert, 2010). several studies have been conducted to compare efficacy of cocpr to ccrb and most studies agree that there is not a significant difference of survival rates between online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 60 individuals who receive cocpr vs. ccrb (iwami, kitamura, kiyohara, & kawamura, 2015; riva et al., 2019; bobrow et al., 2010; ogawa et al., 2011; iwami, kitamura, kawamura et al., 2012). a recent nationwide study looking at out-of-hospital cardiac arrest across three periods of different cpr guidelines, found an almost two-fold higher rate of cpr before emergency medical services arrived and a six-fold higher rate of cocpr over time (riva et al., 2019). these studies support the hypothesis that cocpr should be considered as the preferred bystander resuscitation method, as it is associated with higher cpr rates and overall survival in out-of-hospital cardiac arrest. effects of cocpr training as more findings suggest that cocpr is as effective as ccrb, education and training programs require modification to include the simpler and better-retained cocpr. more convenient cpr training may influence more individuals to become knowledgeable and confident in their cpr delivery skills. shorter training times and simpler techniques can increase the convenience of cpr training and increase the confidence levels and skill retention of the general population. a study conducted in korea examined the effect of basic life support training on bystanders’ willingness to perform both cocpr and ccrb. the study found that respondents were more willing to perform cpr if they could perform cocpr; the study also found that the number of respondents willing to perform cocpr increased from 30% before to 72% after training (cho et al., 2010). a randomized control trial comparing the long-term retention of cpr skills by the general public between those receiving cocpr training versus conventional cpr training, found that one year after training the number of total and appropriate chest compressions was significantly higher in the cocpr group (nishiyama et al., 2014). these studies demonstrate that cocpr is a preferred method that is effective at increasing long term retention of cpr skills. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 61 increasing knowledge of and self-confidence with cocpr can increase bystanders’ willingness to initiate resuscitation and increase survival rates for out-of-hospital cardiac arrest. as such, cocpr trainings should be more readily available resulting in more trained individuals, particularly in rural areas. additionally, a study examining the disparities in survival with bystander cpr following cardiopulmonary arrest based on neighborhood characteristics found that neighborhoods with more high school age persons displayed the lowest survival (rivera et al., 2016). targeting high school students, college students, and other young adults to receive training could conceivably change survival outcomes in rural and other neighborhoods facing survival disparities (rivera et al., 2016). the purpose of this study was to assess the change in knowledge and self-confidence of rural college students to administer cocpr as a result of mini-training sessions administered by trained paramedics. the primary research questions consisted of: does the training increase the knowledge and confidence of participants for performing cocpr, and do the participants think this is a valuable program that should continue to be utilized? methods sample purposive sampling was used to focus on 125 rural college students who completed the program. the study submission and written informed consent were approved as an expedited project by the university’s institutional review board (protocol number: 2014.204). materials marketing the cocpr mini-training sessions were distributed across a medium sized university located in a rural state with a historically low cpr training rate. the free training sessions, conducted by students who were also trained paramedics, were delivered at a primary student online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 62 gathering location on campus during the lunch hour and for student organizations upon request. participation was voluntary and uncompensated. data collection a one group pre-test post-test quasi-experimental design was utilized. the participants completed the informed consent, a pre-survey, received the cocpr mini-training sessions, and completed a post-survey. the pre-survey consisted of 14 questions. seven questions assessed self-confidence to provide care to someone in cardiac arrest utilizing a 7-point likert scale ranging from not confident at all to extremely confident. three multiple choice questions assessed knowledge of cocpr; the remaining questions addressed experience with ccrb and cocpr. the cocpr mini-training session was then administered and consisted of education, a demonstration by trained paramedics, and an opportunity for the participants to practice the steps on the manikins. these additional steps to include the live demonstration and practice resulted in a 5-minute training duration. the post-test survey consisted of 13 questions to include the same seven questions assessing self-confidence to provide care to someone in cardiac arrest utilizing a 7-point likert scale and three multiple choice questions assessing knowledge of cocpr. the final questions addressed the program effectiveness utilizing a 7-point likert scale ranging from strongly disagree to strongly agree. data analyses descriptive statistics on the pre-subscale scores, post subscale scores, and subscale change scores for both knowledge and self-confidence were computed. one-way analysis of variances was used to determine the existence of statistically significant differences between group means when comparing the effect of prior cpr training on change in knowledge and confidence. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 63 results of the participants (n = 125), 41% had prior ccrb training in the past two years, 39% had prior ccrb more than two years ago, and 25% had no prior ccrb training. 28% had prior cocpr training in the past two years, 20% had cocpr training more than two years ago, and 52% had no prior cocpr training. only three participants had ever administered care using cocpr and five utilizing ccrb. the mean post-test confidence scores were greater than the pre-test confidence scores resulting in a positive increase in the change in confidence (m = 4.71, sd = 1.26) for: providing care to someone in cardiac arrest (m = 2.13, sd = 1.68), finding the proper hand position placement to deliver chest compressions (m = 1.94, sd = 1.83), administering chest compressions correctly (m=1.80, sd = 1.98), and providing compression only cpr to someone in cardiac arrest (m = 2.28, sd = 1.93). likewise, the mean post-test knowledge scores were greater than the pretest knowledge scores resulting in a positive increase in the change in knowledge scores (m = .87, sd = .93). figure 1. change in confidence of the participants to administer cocpr online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 64 figure 2. change in cocpr knowledge of the participants as determined by a one-way anova, there was no statistically significant differences between group means when comparing the effect of prior ccrb training on change in confidence (f(2, 122) = .36, p = .15) and prior cocpr training on change in confidence (f(2, 122) =. 17, p =. 842). likewise, there was no statistically significant differences between group means when comparing the effect of ccrb training on increase in understanding (f(2, 121) = .30, p = .739) and prior cocpr on increase in understanding (f(2, 121) = 2.61, p = .078). the participants indicated that the training increased their understanding of how to properly provide cocpr (m = 6.43, sd = .86) and increased their confidence in their ability to administer care to someone in cardiac arrest (m = 6.35, sd = .92). they also indicated that they would recommend this training to others (m = 6.73, sd = .53). discussion the purpose of this study was to assess the change in knowledge and self-confidence of rural college students to administer cocpr as a result of mini-training sessions administered by trained paramedics. this study clearly demonstrated that the mini-training sessions were effective at increasing both the knowledge and self-efficacy of the participants to administer care. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 65 limitations limitations exist that may affect the findings of this study. our study focused on college students in one rural state and generalizations to other rural populations should be made with caution. additional research could investigate improvements or declines in the provision of care and outcomes within rural regions. although this study was conducted in a rural area, ems could be accessed in less than 15 minutes. recent studies have demonstrated that people who waited longer than 15 minutes for an ambulance to arrive had a better chance of surviving if ccrb was performed (orkin, 2013). the application of the 2010 aha and erc guidelines might not provide responders from remote areas with the skills needed to optimize out-of-hospital cardiac arrest outcomes in these settings. further research is needed on resuscitations in remote settings to develop appropriate guidelines and training. implications for rural health care practice when compared to ccbr, cocpr seems to be a good alternative for out-of-hospital, bystander witnessed, cardiac arrests. studies have shown cocpr to be just as effective as ccbr in survivability (bobrow et al., 2010; riva et al., 2019; ogawa et al., 2011; iwami, kitamura, kawamura et al., 2012); additionally, controlled studies have shown that shorter cocpr training sessions may be just as effective as longer ccbr training sessions (cho et al., 2010; nishiyama et al., 2014). if there is a public interest in being educated on resuscitation, then cocpr training may be ideal. training sessions can be shorter in duration than ccbr training and therefore be more convenient and affordable for the population to attend. an emphasis should be placed on getting past typical fears of initiating resuscitation in these training sessions (savastano & vanni, 2011). rapid use of an external defibrillator tends to be an important element in resuscitation and online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 66 should also be an emphasis in cocpr training (savastano & vanni, 2011; iwami, kitamura, kawamura, et al., 2012). furthermore, cocpr trainings should still find opportunities for skill demonstration and practice, as evidenced in this study. conclusion cocpr trainings that address resuscitation fears, emphasize the importance of defibrillators, and provide opportunities to practice skills should result in rural populations that are more knowledgeable and confident in regards to resuscitation for out-of-hospital, bystander witnessed, cardiac arrests. ultimately, the goal is to address the disparities in out-of-hospital cardiac arrest survival rates in rural areas. references american heart association. 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(2010). chest compression-only cpr by lay rescuers and survival from out-of-hospital cardiac arrest. online journal of rural nursing and health care, 20(1) http://dx.doi.org/10.14574/ojrnhc.v20i1.593 67 journal of the american medical association, 304, 1447-1454. https://doi.org/10.1001/ jama.2010.1392 cho, g.c., sohyn, y.d., kang, k.h., kee, w.w., kim, k.s., kim, w.,…lim, h. (2010). the effect of basic life support education on laypersons’ willingness in performing bystander hands only cardiopulmonary resuscitation. resuscitation, 81, 691-694. https://doi.org/ 10.1016/j.resuscitation.2010.02.021 fabbri, a., marchesini, g., spada, m., iervese, t., dente, m., galvani, m., & vandelli, a. (2006). monitoring intervention programmes for out of-hospital cardiac arrest in a mixed urban and rural setting. resuscitation, 71, 180-187. https://doi.org/10.1016/j.resuscitation.2006.04.003 institute of medicine. 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(2007). rural and remote cardiac outcomes: examination of a state-wide emergency medical service. alsbury, australia: conference proceedings of the 9th national rural health conference. terry_article+text,+psf+set+up+final+6.2.21+680-article+text-4511-2-15-20210522 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 44 self-efficacy, grit, and perceptions of rural employment: what changes occur after graduation? daniel r terry, phd, rn 1 blake peck, phd, rn 2 ed baker, phd 3 1 senior lecturer, school of health, federation university australia, d.terry@federation.edu.au 2 senior lecturer, school of health, federation university australia, b.peck@federation.edu.au 3 professor, department of public health and population science and director, center for health policy, boise state university, ebaker@boisestate.edu abstract purpose: general self-efficacy, occupational self-efficacy, and grit have a correlation with academic and practical success amongst nursing students. the role of these same characteristics during the first 18-24 months following the transition from student to nurse is poorly understood. in addition, when a nursing graduate begins to consider a career in a rural area is also remains unclear. this study sought to understand the change, if any, in general selfefficacy, occupational self-efficacy, grit, and rural employment importance that occurred during this transition period. sample: nurses after graduating from a three-year bachelor of nursing degree (n=28). method: a follow-up study of a larger longitudinal mixed-methods cohort design used a survey to examine general self-efficacy, occupational self-efficacy, grit, and rural employment importance among novice nurses. participants had agreed when completing the initial study as students to participate in a follow-up study 18-24-months after graduating. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 45 findings: occupational self-efficacy increased as the cohort transitioned from student to professional nurse, while grit was remarkably lower between final year students and novice nurses. no change in earlier measures of general self-efficacy or importance placed on rural careers were detected. conclusions: following graduation, new clinicians are focused on building professional identity and the development of foundational skills for practice. clinical agencies have an opportunity to shift the balance between autonomy and support in order to harness these key characteristics in an effort to improve the longevity and progression of nursing graduates within the nursing profession. keywords: nurses, students, novice, grit, self-efficacy, community apgar self-efficacy, grit, and perceptions of rural employment: what changes occur after graduation? low levels of general self-efficacy have an impact on academic outcomes among higher education students, where lower levels of general self-efficacy lead to increased levels of attrition (bandura & locke, 2003; guarnaccia et al., 2018; luthans et al., 2004; mclaughlin et al., 2008). likewise, lower levels of occupational self-efficacy have led to poorer employee outcomes as a result of or due to workplace stresses, limited coping abilities, and decreased job satisfaction (bandura & locke, 2003; guarnaccia et al., 2018; mclaughlin et al., 2008). however, self-efficacy as a construct remains pliable and open to development and growth (lorenz et al., 2016). individuals have the capacity to improve their self-efficacy, which can lead to improved personal, academic, and occupational outcomes by developing efficacy through major sources such as personal mastery, the vicarious experiences of others, emotional arousal, and verbal persuasion (bandura, 1977; lorenz et al., 2016). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 46 self-efficacy, whether general or occupational specific, is the self-belief that one can perform or undertake difficult tasks and manage difficult challenges (dewitz et al., 2009; schyns, 2004). self-efficacy therefore is an embedded central belief that one has the capacity to achieve a desired outcome where individuals can adapt to change (bandura & locke, 2003; dewitz et al., 2009; schyns, 2004). in this sense, self-efficacy facilitates and promotes goal setting, investing in effort to achieve, and a level of persistence to overcome barriers or to recover from obstacles or disasters (dewitz et al., 2009; pisanti et al., 2008; schyns, 2004). as such, it is regarded as a positive factor that can influence success, employment satisfaction, job performance, and workplace commitment (dewitz et al., 2009; pisanti et al., 2008; schyns, 2004). previous literature is replete with occupational self-efficacy research that demonstrates individual commitment, work values, workplace culture, and management behaviours can influence the development of occupational self-efficacy (pisanti et al., 2008; terry, peck, smith, & nguyen, 2020a). similarly, occupational self-efficacy research in the healthcare setting has also demonstrated that employees with lower levels of self-efficacy are susceptible to poorer coping skills, have a tendency to burnout more rapidly, and are unable to manage emotional distress (pisanti et al., 2008; terry, peck, smith, & nguyen, 2020a). when undertaking their self-efficacy study among nursing students, terry, peck, smith, and nguyen, (2020a), demonstrated that first year nursing students had lower levels of occupational or nursing self-efficacy than their third-year counterparts. it had been suggested that general and occupational self-efficacy have the potential to be further developed among nursing students, leading to greater levels of workplace performance and satisfaction as they enter the nursing profession; however, this hypothesis and outcome currently remains elusive. (terry, peck, smith, & nguyen, 2020a). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 47 in addition to general and occupational self-efficacy and the capacity to undertake difficult tasks, manage difficult challenges, and achieve desired outcomes, grit offers the passion and capacity to persevere in order to meet long-term objectives regardless of adversity (duckworth, 2016). as such, grit is an innate characteristic that challenges both short-term and long-term tasks that may be demanding or difficult. grit is the capacity to continually move forward regardless of the immediate challenge that lay ahead (duckworth, 2016; duckworth, peterson, et al, 2007). as setbacks, poor outcomes, disappointments, or plateaus are experienced, those individuals with higher levels of grit tend to seek other means of understanding the situation differently in order to continually move forward without deviating from goals that have been set (duckworth, 2016; duckworth, peterson, et al., 2007). it has been suggested that grit is more likely to determine success beyond intelligence and physical abilities alone (duckworth, peterson, et al., 2007; eskreis-winkler et al., 2014). for example, previous research indicates higher levels of grit are predictive of academic and non-academic achievements, more so than other innate factors or individual traits. as such, grit has been demonstrated to have a positive impact on school grades, training success, employment retention, and sporting outcomes (duckworth, kirby et al., 2011; duckworth peterson, et al., 2007; eskreis-winkler et al., 2014; kelly et al., 2014; robertson-kraft & duckworth, 2014). developing or increasing grit requires a change and growth in mindset, where self-belief, clear goal setting, improved social connectedness and self-regulation or the ability to control one's behaviours, emotions, and thoughts is essential (credé et al., 2017; duckworth, 2016; terry & peck, 2020b). when growth in mindset occurs, it has been shown that individuals begin to perceive a difficulty as an opportunity for growth rather than a challenge to overcome, and where the response leads to constructive thoughts and persistent behaviours, rather than being conquered (credé et al., 2017; duckworth, 2016; dweck, 2008; terry & peck, 2020a, 2020b). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 48 although widely examined, including among medical students (reed et al., 2017), grit remains a recent construct in both the nursing profession and specifically australia (terry & peck, 2020a, 2020b). nurses, have been shown to develop grit through their professional practice (mccabe, 2016), and among nursing students, significantly higher levels of grit have been observed among third-year students compared to their first-year counterparts (terry & peck, 2020a, 2020b). however, there has been limited examination of grit levels further increasing as third year student’s transition to registered nurses, or if the transition itself has an impact on measures of grit. in addition, to the limited understanding regarding the development of self-efficacy and grit as nursing students transition to registered nurses, there is also limited insight regarding the degree to which the level of importance nursing students place on pursuing rural career changes over time, particularly as they transition from student to registered nurse. to seek to overcome this, the student nursing community apgar questionnaire (ncaq) was used to understand the level of importance nursing students place on geographic, economic, management, practice, and support factors when considering rural employment (prengaman, bigbee, et al., 2014; prengaman, terry, et al., 2017; terry, peck, smith, stevenson, nguyen, & baker, 2020b). within their initial study that focused on exploring the factors that nursing students consider the most important to undertake a rural career, terry, peck, smith, stevenson, nguyen, and baker (2020b) found that patient safety, high-quality care, autonomy or respect, as well as staff cohesion and morale were considered more important than salary, social networking, and recreational opportunities. the ncaq, as an evidence-based tool and program, seeks to provide measurable insights to understand current performance, while better informing nursing recruitment and retention activities in rural areas. overall, the tool seeks to develop a greater understanding of the unique factors that impact rural recruitment and retention of nurses from the perspective of the health online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 49 service and its health professionals (prengaman, bigbee, et al., 2014; prengaman, terry, et al., 2017; terry, peck, smith, stevenson, & baker, 2019; terry, peck, smith, stevenson, nguyen, & baker, 2020b). although the ncaq has been used to understand what students perceive to be important in their decision to uptake rural employment, our understanding of how or if these levels of importance placed on undertaking rural employment changes over time, particularly as students transition to the role of registered nurses. overall, with the limited understanding of general and occupational self-efficacy, grit, and the level of importance placed on pursuing a rural career as students transition to registered nurses, the purpose and aims of the study were to examine: 1. if general self-efficacy, nursing self-efficacy, and levels of grit improved as students transition from student to nurse over an 18 to 24-month period; and 2. if the level of importance placed on rural employment among students changed over 18 to 24 months as they became nurses. therefore, within this context the hypothesis was that general self-efficacy, nursing selfefficacy, and grit would increase over an 18 to 24-month period as individuals transitioned from student to registered nurse. in addition, it was further hypothesised that the level of importance placed on rural careers would demonstrate little change over time. methods this paper reports on an 18 to 24-month follow-up study of a larger longitudinal mixedmethods cohort design that examines bachelor of nursing student’s career choice, career trajectory and longevity within the profession over a 10-year period post-graduation. the longitudinal study collects periodic data about a number of factors including the importance students place on nursing in rural areas, their attitudes towards living and working in rural locations, the student’s exposure to and contact with rural and remote clinical placement, as well as their nursing career pathway. the aim here is to examine self-efficacy, grit, and online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 50 importance placed on undertaking rural employment among former students who had graduated with a bachelor of nursing degree in an australian university in 2018. sample all nursing students (n=62) who had agreed to participate in an 18 to 24-month followup study after completing a three-year bachelor of nursing degree were included. participants were invited to complete an online questionnaire examining general and nursing self-efficacy, passion and perseverance (grit) and the level of importance placed on undertaking rural employment. among participants, 10 were lost to follow-up, while 28 fully or partially completed a questionnaire (response rate 53.8%). data collection tool data were collected using a questionnaire that included 21 demographic items such as gender, year of birth, current and past place of residence, employment status, income, nursing role, and undertaking postgraduate education. the follow-up questionnaire included a number of questions posed to the same group in 2018 (terry, peck, smith, stevenson, & baker, 2019). the same questions were used to detect changes over time. each set of demographic questions was examined for their reliability and validity and used in other student healthcare research previously (smith, et al., 2018; terry, peck, smith, stevenson, & baker, 2019; terry, peck, smith, stevenson, nguyen, & baker, 2020b). in addition to demographic data, the questionnaire included the same scales from the 2018 data collection period. these scales included the general self-efficacy scale (gse-10) used to measure the general belief that an individual has the capacity to succeed, accomplish tasks, and bounce back from setbacks (schwarzer & jerusalem, 2010; terry, peck, smith, nguyen, 2020a); the occupational or nursing self-efficacy scale (nse-8), which is similar to the gse-10, however, measures an individual’s occupation self-efficacy in terms of ability to succeed, meet occupational specific tasks and bounce back (schyns & von collani, 2002; online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 51 terry, peck, smith, nguyen, 2020a); the nursing community apgar questionnaire (ncaq) developed by prengaman, bigbee, et al. (2014), used to measure the level of importance nurses or nursing students place on taking up rural practice (prengaman, terry, et al., 2017; terry, peck, smith, stevenson, nguyen, & baker, 2020b); and the eight-item short grit scale (grits) developed by duckworth and quinn (2009), used to measure trait-level perseverance and passion for long-term goals among participants (duckworth & quinn, 2009). all scales were examined for their reliability and validity and have been used in other student healthcare research previously (terry, peck, smith, stevenson, & baker, 2019; terry, peck, smith, stevenson, nguyen, & baker, 2020b). lastly, additional open-ended questions were included in the questionnaire, which pertained to the benefits and challenges now that the former students were working as registered nurses. overall, the whole questionnaire tool took between 15-25 minutes to complete. data collection data collection occurred between 4 february and 31 march 2020, where all participants were invited via email. the invitation included a web link directing participants to an information statement, outlining the voluntary nature of the study, any associated risks, and a link to the online questionnaire. a follow-up recruitment email was sent in weeks 2, 4, 6 and 8 until adequate response rate (53.8%) was achieved. once collected, data were matched to responses provided by participants in 2018 using birthdate and postcode, if provided. it must be noted the grit-s was not used in the 2018 data collection round; therefore, follow-up data were compared with 3rd-year student grit levels in the 2019 data collection round (terry & peck, 2020a). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 52 ethical considerations ethical approval for the study was provided by the federation university australia human research ethics committee (approval #18-017). no incentives were offered to participants and completing the online questionnaire implied participant consent. data analysis the statistical package for the social sciences (spss, version 25.0) assisted data analysis the data. given the low number of participant data, both parametric and nonparametric tests were performed, which included paired sample t-test and wilcoxon signed rank test to identify differences within the cohort over time. in addition, independent sample ttests and mann-whitney u tests were used to identify differences between groups. significance was determined at two-tailed p≤.05. results responses from the questionnaire identified more than half (n=17) of participants indicated they were female, two-thirds (n=18) were aged between 20 and 39 years, with more than half (n=16) living in a large regional centre. the majority (n=24) were in part-time employment in diverse areas of the nursing profession, and on average spent 25.2 minutes (range 3-60) traveling to work (table 1). table 1 participant demographics demographic information frequency percentage (%) gender (n=28) female male not stated 17 5 6 60.7 17.8 21.4 age (years) (n=23) 20-30 years 30-39 years 40-49 years 50 years and over 9 9 2 5 32.2 32.2 7.1 17.8 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 53 not stated 3 10.7 where currently living (n=28) inner city metropolitan outer suburb metropolitan large regional centre small town 5 6 16 1 17.8 21.4 57.2 3.6 employment status (n=28) casual employee (no guaranteed hours of work) part-time employee (less than 38hrs week) 4 24 14.3 85.7 location of employment (n=28) metropolitan/city urban/suburban rural 11 10 7 39.3 35.7 25.0 length of time to travel to work (n=25) 25.2 minutes (range 3-60 minutes) area of nursing (n=28) acute care aged care emergency care intensive care medical care mental health neonatal care nursing pool oncology not stated 2 5 7 1 5 2 2 1 1 2 7.1 17.8 25.0 3.6 17.8 7.1 7.1 3.6 3.6 7.1 although the majority of participants were working part-time, this was not considered unusual given the average hours work by registered nurses remains at 33.5 hours a week (commonwealth of australia, 2020). when examining the differences between general self-efficacy and nursing self-efficacy, these data suggest that participants had similar levels of general self-efficacy compared to nursing self-efficacy, t(19) =-.335, p=.74. in addition, when examining participant’s general self-efficacy levels as a nursing student, it was found to be at similar levels, now they were working as registered nurses 18 to 24 months after graduation. however, when comparing participant’s levels of nursing self-efficacy as a student with more recent scores now 18 to 24 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 54 months after graduating, levels were indicated to be significantly higher, as outlined in table 2. beyond self-efficacy among participants, a comparison was made between the level of importance placed on taking up rural practice among nurses. it was shown that there was little variation between scores while participants were students compared to now as registered nurses. lastly, a comparison was made among participants regarding the levels of perseverance and passion (grit) for long-term goals. as such, it was indicated that the 18 to 24 months postgraduation participants had significantly lower levels of grit than their 2019 student counterparts, as outlined in table 2. table 2 comparison of mean scale items scale item mean (sd) test (df) statistic p nse-8 (2018) nse-8 (2020) 23.81(1.79) 25.57(2.50) t(15) = -2.673 .017* gse-10 (2018) gse-10 (2020) 32.25(3.51) 31.68(2.82) t(15) = 0.517 .613 ncaq (2018) ncaq (2020) 3.34 (0.27) 3.30 (0.29) t(9) = 0.612 .556 grit (2019) grit (2020) 3.89 (0.59) 3.43 (0.28) t(19) = -7.165 .000** *p<0.05, **p<0.000 many of the open-ended responses from participants related to and were in line with nursing self-efficacy, where it was demonstrated that participants had developed their capacity to succeed, accomplish key tasks, and had the ability to bounce back from a number of setbacks or challenges. for example, seventeen participants had indicated the positives of working as a registered nurse since graduating was the further development of skills since being a student, being challenged, gaining confidence, developing autonomy, and progressing in their careers. many statements were interwoven into a discussion of working with colleagues who facilitated their development as nurses. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 55 one participant indicated a positive aspect of their employment was that they were “consolidating skills learned at university, being able to problem-solve, and critically think independently” (participant 24). another two participants indicated the positives of their experiences were about “improving clinical skills and developing knowledge” (participant 28) and developing their “hands-on experience, exposure, and responsibilities, while working with other registered nurses” (participant 6). in addition, nearly all participants indicated they had developed the capacity to bounce back from the challenges they had experienced since graduation. examples where participants had learned and developed, included recognising their poor acknowledgment and understanding of end of life care, having the capacity to keep moving forward when mentally and physically exhausted after a challenging shift, working through the transition shock experienced as a new graduate, and developing skills to cope with shift work. although experiencing minor setbacks, most remained committed to the nursing profession. however, one participant indicated they were not sure if they would continue in the profession long term. interestingly this participant demonstrated the highest levels of grit and self-efficacy when compared to their counterparts. discussion previous research is awash with evidence that there is a large chasm to a leap as individuals transition from student to registered nurse. this transformation from student to professional within nursing has been widely shown to constitute transition shock and occurs at various stages over an18 to 24-month period which requires both personal and professional adjustments (duchscher, 2009; hoffart et al., 2011). this transition period has been shown to be a challenging time that leads to feelings of self-doubt, fear, confusion, and even the contemplation of leaving the profession altogether (pennbrant et al., 2013). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 56 although transition shock may also be interwoven through participant’s experiences within this study, the focus here, and what has been highlighted is that despite any level of transitional shock the participants may or have experienced since graduating, the level of nursing self-efficacy has increased over this time. this suggests that participants, regardless of other personal or professional factors at play, after they have or as they end traversing their transition experience, have a propensity to experience higher levels of self-belief in terms of performing nursing specific practice or coping with challenges that may arise in the nursing context when compared to their time as students (pennbrant et al., 2013). although this may be considered unremarkable, the significant increase between the period of being a novice student and now a registered nurse requires a level of growth and development. this occurs within the transition period which is a time of great development in self-belief, personal mastery, emotional arousal, and development of self through the vicarious experiences of others (bandura, 1977; lorenz et al., 2016; pennbrant et al., 2013). it is through this transitional period where an individual learns, develops their skills, and masters the profession by undertaking a number of difficult tasks. the individual is also required to manage difficult challenges with the realization that outcomes and adapting to change can be achieved (bandura & locke, 2003; dewitz et al., 2009; schyns, 2004). pennbrant et al. (2013), has indicated that greater development of occupational selfefficacy within nursing is also impacted by supportive co-workers, supervisors, and nurse managers along with a positive workplace environment (gloudemans, 2013; tynjälä, 2008). in addition, duchscher (2009), has also indicated individuals who are more prepared for the professional environment while learning as students have a greater propensity to experience new things and are more prepared for the transition process. overall, as occupational selfefficacy determines job satisfaction, performance within the workplace, with commitment and online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 57 persistence, this would suggest those participants have developed a greater capacity to meet the demands of their workplace than they did as students. it must be noted that over this same time period, the level of general self-efficacy remained relatively unchanged, which suggests that within the personal lives of individuals, beyond their occupational nursing roles, participants did not experience the same levels of challenge that led to growth and development. there was no remarkable development of selfbelief, self-mastery or difficult challenges that would lead to an increase in an individual’s general self-efficacy levels in the 18-24-month post-graduation and through the transition to employment. from current literature, it may be suggested that while fledgling nurses experience transition shock, the demands of clinical practice, learning new clinical skills and knowledge, while juggling new employment schedules has a significant impact on personal lives. for example, the nursing profession and employment for new graduates initially takes precedence or requires greater balance over personal matters such as connection with family, friends, and time for recreation (duchscher, 2009). in the context of the current study, it could be argued that the all-consuming focus of a new nursing role provides the necessary conditions for an expansion of nursing self-efficacy while doing less to build general self-efficacy over the same period due to the emphasis among new nurses needing to develop professionally or where the adaption of the new professional self is most required (bandura & locke, 2003; dewitz et al., 2009; duchscher, 2009; pennbrant et al., 2013; schyns, 2004). in this sense, general self-efficacy is observed not to increase, as there is little need or impetus for self-efficacy growth due to perhaps only incremental change or adaptation that is required. conversely, nursing self-efficacy at this time is observed to increase due to the demand placed on the individual to develop, adapt, and master new skills, roles and understandings. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 58 beyond these findings, it was noted that the current grit levels amongst the participants were significantly lower when compared to the grit levels among their third-year student counterparts from 2019. in their findings, terry and peck (2020b) found that grit levels increased as students moved from first to second years and surmised that grit levels had increased as a function of the challenges encountered as they transition between the first and second year of their nursing program. it was noted grit levels remained relatively similar between secondand third-year students of the program. in the current study, as participants moved from the role of student nurse to nursing professional, it is noted the grit levels comparatively decreased which may suggest the cohort may have lower levels of perseverance and passion to achieving longer-term goals. it is reasonable to assume that the bachelor of nursing qualification represented a long-term goal that had recently been achieved and having done so the individuals may have been ‘content’ in their newfound employment and role without having already re-established new endeavours requiring ongoing higher levels of grit. in addition, duckworth (2016) and terry and peck (2020b) have indicated that grit is forged and developed within a crucible of demand and support; however, what may be observed here is there may be an imbalance of demands required on new graduates in the workplace compared to the level of supports provided to allow them to learn, develop, and reach their goals, having a direct impact on levels of grit. however, given nursing self-efficacy had increased over time, there may be other factors which have an impact on the lower levels of grit. for example, it may be beyond the support provided or the demand required but may be relative to the time period at which the questionnaire was undertaken. most participants had either just completed their graduate year or were only just commencing a new nursing position elsewhere. as such, they were undergoing additional stressors of a new position or navigating new challenges associated with changing workplaces or employment. as such, the capacity to preserve, be passionate and online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 59 remain committed may potentially decreased due to the change in circumstances. participants are now novice nurses, who in most cases were in positions or employment and as such had lesser levels of support available to them when compared to their year as a graduate nurse. alternatively, among participants, nursing self-efficacy questions in the questionnaire may have been viewed as nursing skills, while grit questions were viewed as how participants encountered challenges and setbacks (duckworth, kirby, et al., 2011; duckworth, peterson, et al., 2007). in this sense, participants demonstrated they had improved their occupational skills, work and their identity as a nurse throughout their transition period, however, were encountering ‘new’ challenges which may have brought into question their own level of optimism and resilience. pennbrant et al. (2013) has indicated new nurses feel they need more time to develop their own identity and to meet the demands of their new role, which at the time of the questionnaire, was still in the development. overall, it may be surmised that grit at the time was lower than anticipated. however, is predicted to increase over time, particularly as participants become more settled with current employment arrangements, their identity as a registered nurse, and they set their sights on an area of nursing specialisation. lastly, it was indicated that the level of importance nursing students place on pursuing a rural career over time has not changed from when they were a student nurse. however, given that relatively little time had passed since graduating, it is likely that the personal circumstances of the student may have also only changed very little over this time. this is important because a significant change in life circumstances has been shown to be an impetus for making a change to a rural career. it follows, therefore, that the views of individual students with regard to what they see as important in their future and their subsequent desire to practice in a rural environment remains the same (cosgrave, malatzky, et al., 2019; cosgrave, maple, et al., 2018). this suggests that views of students regarding rural nursing employment or careers will online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 60 change very little in the immediate years following graduation and that views or what is considered important as a student transition into the nursing profession. it may be inferred that if an individual is not ‘sold’ on the idea of a rural career while undertaking training as a student, then the possibility of a rural career after graduation may be an even harder sell, when personal, social, economic circumstances and life stages begin to impact the longer-term decision making (cosgrave, maple, et al., 2018; fisher & fraser, 2010). this is particularly evident among the more mature participants, who may be well established already with financial responsibilities, family commitments, and socially embedded which precludes their capacity to contemplate more rural employment (cosgrave maple, et al., 2018). therefore, it remains vital for rural training experiences to occur while student nurses are in training. it has been indicated that to improve rural career pathway outcomes among health professionals, including recruitment and retention, undergraduate training must focus more closely on developing individuals with an existing rural background, which remains significant a predictor of rural career choice (kondalsamy-chennakesavan et al., 2015; macqueen et al., 2018). in addition, students, regardless of geographical background, who undertake rural placements are also more likely to undertake rural practice after graduating, while high-quality clinical placements and clinical supervision further impact on rural practice uptake (macqueen et al., 2018; playford et al., 2006; smith et al., 2018). limitations a limitation of this study is that student respondents of the survey may not be representative of the whole student cohort. the overall response rate was at 53.8% which is strong for an online survey and across a longitudinal study such as this and supports the ability to generalize the findings beyond this cohort. this round of data collection included the measure of grit. given that we did collect grit measures from this current cohort of now online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 61 practicing nurses when they were students, we used grit measures from the current cohort of final year bachelor of nursing students to provide a comparison which may not be as reliable. conclusion at 18-24 months after graduating from a bachelor of nursing program both general and occupational self-efficacy had changed in the period between being a final year university student and now a professional registered nurse working in clinical practice. the statistically significant change identified in occupational self-efficacy suggests, unsurprisingly, that the clinical environment offers a series of unique contextual challenges and experiences that foster the development of these attributes. given the links that have been shown between higher levels of occupational self-efficacy and performance and satisfaction with a nursing career, it would seem logical that education providers in and outside a health service take opportunities to build this capacity amongst students early within the program. perhaps providing weekly clinical experiences rather than block experiences might help to promote these essential capabilities as one solution. however, there does remain work to be done to understand the essence of what it is in clinical practice that helps or forces the development of occupational self-efficacy. given the strong links between grit and achievement in a multitude of settings and disciplines of study, it makes sense to seek opportunities to harness this characteristic amongst nursing graduates in an effort to improve their longevity and progression within the nursing profession. the results of the present study are suggestive of grit levels significantly waning in the early months and years of the nursing profession. while further research is needed to ascertain the mechanisms that drive this downturn in grit, we have hypothesised some areas that might be valuable to pursue in furthering our understanding. for example, increasing the level of support and feedback across the graduate year, or to provide a formal education program that runs along-side of the graduate program may work to sustain the levels of grit we saw amongst final year students. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 62 there is a growing need to understand the key points across a nurse’s career that will provide both education and clinical provider’s opportunities to capitalise on enticing prospective healthcare workers to a career in a rural area. at the 18-24-month time-point, we have not found any significant difference compared to the same cohort’s final year bachelor of nursing levels of importance placed on a rural career. while there are characteristics that are well recognised as having strong links to a career in rural practice (e.g. living in a rural area, having family in a rural area) there are other less tangible elements that have been shown to yield an influence, such as, opportunities for professional development, staff morale and other factors that are within the direct remit of rural health providers to change and market to potential candidates (terry, peck, smith, stevenson, & baker, 2019). this study has highlighted that at the 18-24-month period of a new graduate’s nursing career, the focus of their attention is on building their identity as a nurse and developing foundational skills required for entry level practice. there are two possibilities as to why graduate grit has reduced. one, to be successful in their graduate programs, individuals may not have the need for high levels of grit. two, the clinical setting, where the graduate first commences, may not afford the support and new-found autonomy required to bring out this key characteristic. while focusing on developing skills that are basic to the nursing profession there is less attention being paid to those other aspects of professional life that we know are attractive in rural areas and will become important as we continue to follow this cohort across their nursing career. references bandura, a. 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(2013). mastering the professional role as a newly graduated registered nurse. nurse education today, 33(7), 739-745. https://doi.org/10.1016/j.nedt.2012.11.021 pisanti, r., lombardo, c., lucidi, f., lazzari, d., & bertini, m. (2008). development and validation of a brief occupational coping self-efficacy questionnaire for nurses. journal of advanced nursing, 62(2), 238-247. https://doi.org/10.1111/j.1365-2648.2007.04582.x playford, d., larson, a., & wheatland, b. (2006). going country: rural student placement factors associated with future rural employment in nursing and allied health. australian journal of rural health, 14(1), 14-19. https://doi.org/10.1111/j.1440-1584.2006.00745.x prengaman, m., bigbee, j., baker, e., & schmitz, d. (2014). development of the nursing community apgar questionnaire (ncaq): a rural nurse recruitment and retention tool. rural and remote health, 14 article 2633. https://doi.org/10.22605/rrh2633 prengaman, m., terry, d. r., schmitz, d., & baker, e. (2017). the nursing community apgar questionnaire in rural australia: an evidence-based approach to recruiting and retaining nurses. online journal of rural nursing and health care, 17(2), 148-171. https://doi.org/10.14574/ojrnhc.v17i2.459 reed, a. j., schmitz, d., baker, e., girvan, j., & mcdonald, t. (2017). assessment of factors for recruiting and retaining medical students to rural communities using the community apgar questionnaire. family medicine, 49(2), 132-136. https://doi.org/10.1177/08948 4530403000402 robertson-kraft, c., & duckworth, a. l. (2014). true grit: trait-level perseverance and passion for long-term goals predicts effectiveness and retention among novice teachers. teachers college record, 116(3), 1-24. https://www.ncbi.nlm.nih.gov/pubmed/2536 4065 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 67 schwarzer, r., & jerusalem, m. (2010). the general self-efficacy scale (gse). anxiety, stress, and coping, 12, 329-345. schyns, b. (2004). the influence of occupational self-efficacy on the relationship of leadership behavior and preparedness for occupational change. journal of career development, 30(4), 247-261. https://doi.org/10.1177/089484530403000402 schyns, b., & von collani, g. (2002). a new occupational self-efficacy scale and its relation to personality constructs and organizational variables. european journal of work and organizational psychology, 11(2), 219-241. https://doi.org/10.1080/13594320244000148 smith, t., sutton, k., pit, s., muyambi, k., terry, d., farthing, a., courtney, c., & cross, m. (2018). health professional students' rural placement satisfaction and rural practice intentions: a national cross-sectional survey. australian journal of rural health, 26(1), 26-32. https://doi.org/10.1111/ajr.12375 terry, d., & peck, b. (2020a). academic and clinical performance among nursing students: what’s grit go to do with it? nursing education today, 88, 104371. https://doi.org/10.1016/j.nedt.2020.104371 terry, d., & peck, b. (2020b). factors that impact measures of grit among nursing students: a journey emblematic of the koi fish. european journal of investigation in health, psychology and education, 10(2), 564–574. https://doi.org/10.3390/ejihpe10020041 terry, d., peck, b., smith, a., & nguyen, h. (2020a). occupational self-efficacy and psychological capital amongst nursing students: a cross sectional study understanding the malleable attributes for success. european journal of investigation in health, psychology and education, 10, 159-172. https://doi.org/10.3390/ejihpe10010014 terry, d., peck, b., smith, a., stevenson, t., & baker, e. (2019). is nursing student personality important for considering a rural career? journal of health organization and management, 33(5), 617-634. https://doi.org/10.1108/jhom-03-2019-0074 online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.680 68 terry, d., peck, b., smith, a., stevenson, t., nguyen, h., & baker, e. (2020b). what australian nursing students value as important in undertaking rural practice. online journal of rural nursing and health care, 20(1), 32-56. https://doi.org/10.14574/ojrnhc .v20i1.589. tynjälä, p. (2008). perspectives into learning at the workplace. educational research review, 3(2), 130-154. https://doi.org/10.1016/j.edurev.2007.12.001 87 online journal of rural nursing and health care, vol. 10, no.2, fall 2010 the rural nurse organization (rno) & decker school of nursing (dson) binghamton university, state university of new york at binghamton announce the bi-annual international rural nursing & rural health conference october 13, 14, & 15, 2011 including a special graduate student research session on october 15, 2011 in binghamton, ny the dson, binghamton university and the rno are seeking abstracts of research, projects, practice and conceptual or theoretical papers that focus on rural nursing or health/health care of rural and underserved populations. this is a broad multidisciplinary conference with a special invitation for interdisciplinary research teams focused on rural or underserved populations. review for podium presentations will require completed work by abstract deadline. symposium presentations may included completed work (desired) or in progress (if slots available). poster presentations and/or symposia may include work in progress with the planned completion date prior to the october 2011 conference. author information sheet and abstract may be downloaded at http://www2.binghamton.edu/continuing-education/non-credit-programs/rural-health.html the abstract title needs to be on both the author fact sheet and abstract form (see link). abstracts should fit into one (1) page, single space in microsoft word, times new roman 12font with 1-inch margins. abstract should include: purpose; type of work (research, program, conceptual analysis etc.); method, process, or procedure; and outcomes (or planned analysis). please note whether work is in progress or completed. at least one presenter must be a member of rno at time of presentation and be registered for the rural nurse conference. submit author fact sheet and abstract form to psfahs@binghamton.edu by january 28, 2011 papers accepted for presentation may be considered for inclusion in the series of rural monographs published by binghamton university. http://www2.binghamton.edu/continuing-education/non-credit-programs/rural-health.html mailto:psfahs@binghamton.edu kalman_519-3113-2-ed online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 113 educating rural women about gender specific heart attack and prodromal symptoms melanie b. kalman, rn, phd 1 margaret wells, rn, phd, anp-bc 2 pamela stewart fahs, rn, phd 3 1 professor, upstate medical university, college of nursing, kalmanm@upstate.edu 2 professor, lemoyne college, wellsmm@lemoyne.edu 3 associate dean ; phd program director ; professor & dr. g. clifford and florence b. decker chair in rural nursing, decker school of nursing, binghamton university, psfahs@binghamton.edu abstract problem: heart disease (hd) remains the leading cause of mortality among women. improvement of outcomes for morbidity and mortality in females with hd has not occurred at the same rate as in males. rural populations often have more barriers to seeking timely intervention than their urban counterparts. purpose: to test the efficacy of using acronyms to educate rural women on female mi and prodromal symptoms as well as the appropriate response to these symptoms and to assess if knowledge gained was sustained for a 2-month period of time. method: a quasi-experimental design with two groups with site randomization of educational intervention with n = 137 rural women (rucc codes of 5 or higher). factor analysis, validity and reliability testing for the 23 item matters of your heart scale (v. 2) are discussed. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 114 findings: comparing the two educational formats of acronym vs. no acronym showed no statistically significant difference on the knowledge score t = .26, df = 134, p = .80 by group. similar non-significant findings occurred for the major subscales. some demographic groups did achieve significantly higher scores on the moyh v. 2. a multiple regression indicated that the final model explained 90% of the variance in the dependent variable of knowledge of female mi symptoms including the appropriate response to those symptoms (r2 = .90, adjr2, se = 1.65). conclusions: educating rural women to recognize gender specific heart attacks symptoms, possible warning symptoms, and the need to respond appropriately is an area where rural nurses can make a difference whether or not an acronym educational approach is used. keywords: female, heart disease, mi, acronym, heart attack, rural educating rural women about gender specific heart attack and prodromal symptoms heart disease (hd) remains the leading cause of mortality among women and is estimated to affect nearly one in two women, and one quarter of all deaths in the united states (us) are from hd (national institutes of health, u.s., n.d.). there is debate about the relationships of rurality and the incidence of cardiovascular disease (cvd), myocardial infarction (mi), and mortality rates. the existence of a phenomena of non-metropolitan mortality penalty has been previously reported and all-cause mortality has been found to continue to be higher in non-metropolitan places compared to those identified as metropolitan (james, 2014). there are multiple systems used to delineate metropolitan versus non-metropolitan areas of the us. the 2013 rural-urban continuum codes (rucc) is one of the most widely used (united online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 115 states department of agriculture [usda], n.d.). this is a county-based classification system with nine levels of which levels 1 – 3 are considered metropolitan. the coding for rucc 4 9 is nonmetropolitan. the rucc considers not only population but also the amount of urbanization, and whether a county is adjacent or non-adjacent to metropolitan counties (usda, ers, n.d.). however, variances in mortality occur even within those communities considered nonmetropolitan. james (2014) found that those living in rucc counties coded as 6 have the highest mortality penalty compared to a more favorable finding for those in the rural counties with rucc codes of 9. whether there are risks in rural living that potentiate cvd, mi, and /or mortality disparities, it is clear that all women, including those who are rural dwellers have increased risk of heart attack as they age. a previous study including rural and urban women explored the effectiveness of an educational program based an instrument to test women’s knowledge of mi symptoms learned in the program (kalman, et al., 2013). the educational program was organized around two acronyms for gender specific prodromal and mi symptoms and the need to call emergency services if symptoms occur. the term” heart attack” rather than mi was used in the educational program since it is the term most frequently used by non-medical personnel. for acute mi symptoms, the acronym curbs was used to highlight chest sensation or pain, unusual fatigue, radiating pain to back jaw or arm, breathing difficulties, and sweating. the acronym factss stands for fatigue, anxiety, chest discomfort, tummy (indigestion), shortness of breath, and sleeping difficulties, which have been identified as prodromal symptoms of mi in women (mcsweeney et al., 2003; morgan, 2005). the acronym factss is ‘misspelled’ intentionally to stress the point of utilizing a mnemonic or acronym to remember a collection of symptoms. women’s knowledge about mi online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 116 symptoms increased after the intervention (kalman, et al., 2013). because the study used a one group only, pre-test, post-test design, a follow-up study was needed to determine if the use of an acronym-based intervention was effective in increasing knowledge or if this was simply a treatment effect. the purpose of the current study was to test the efficacy of using acronyms to educate rural women on female mi and prodromal symptoms as well as the appropriate response to these symptoms. an additional purpose was to test if the knowledge was sustained over two months. finally, the instrument underwent further refinement and validity testing. literature review despite significant improvements in the management of heart disease once a patient is hospitalized, little gain has been made in the pre-hospital delay times with patient decisions having the most significant impact on delayed time to treatment. while delay time is important with both genders, women had a significantly increased delay time compared to men (ladwig, et al. 2017). mi symptoms in older women often differ from those in men and may be vague in nature such as fatigue, nausea, and shortness of breath. these vague and atypical symptoms have been found to attribute to older women’s delay in seeking treatment (ladwig, et al., 2017). in addition, women often experience prodromal symptoms six months to one year prior to having an mi which further adds to dismissal of symptoms (mcsweeney & coon, 2004). albarqouni, et al., (2016) found that even with knowledge of symptoms women delayed longer in getting to the hospital than men with knowledge. timely treatment is important since prompt intervention can reduce mi mortality and morbidity rates (nguyen, saczynski, gore, & goldberg, 2010). mortality rates for women with mi are higher than those for men, possibly because women are not recognizing the symptoms of mi and, therefore, do not seek timely emergency treatment (izadnegahdar et al., 2014). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 117 several public health campaigns have been initiated to raise awareness of women and health disease such as the american heart association initiative called go red for women, the national heart, lung, blood institute of the national institutes of health campaign called the heart truth, and the department of health and human services office of women’s health initiative called make the call, don’t miss a beat (mosca, et al., 2013). while these campaigns have demonstrated some success, more interventions are needed to improve awareness (mosca, et al., 2013). mcdonald, et al. (2006) found that a storytelling versus factual format did not make a difference in women’s knowledge about mi symptoms; however, both groups added to their knowledge of mi symptoms. in women who had been previously hospitalized for an mi, group sessions that allowed for development of connections and sharing of experiences, fears, and concerns, enhanced knowledge about mi symptoms and the need to call 911 if the symptoms occur (perry & rosenfeld, 2005). older women were the less knowledgeable about these symptoms (albarqouni et al., 2016). interventions to educate about mi symptoms, particularly atypical symptoms, should be targeted to older women. before women can respond appropriately, they need to have knowledge about mi symptoms and timely, safe ways to respond if they are experiencing these symptoms. long and weinert (1989) identified key concepts pertinent to rural populations, and these include health beliefs, self-reliance, isolation, and distance. while these concepts were not directly measured in this study of rural women, they do relate to the issue of rural women seeking medical care for mi symptoms with an appropriate response of calling emergency medical services (ems) 911. health to rural women often means that they identify as needing to be functional to carry out their roles (lee & winters, 2004). this is related to their feelings of self-reliance and the ability to continue to care for others, at times putting the care of others above care of self. women, including online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 118 those who live in rural areas may delay seeking treatment when experiencing mi symptoms. while there may be many predictors for the delay, including possible lack of awareness of what female mi symptoms; rural nursing theory (rnt) highlights the influence of cultural components such as the perception of health that focuses on functionality, the need for self-reliance and desire to care for others. isolation and distance, lack of access, and tendency to rely on lay networks versus professional assistance are also factors in seeking professional health care (lee, winters, boland, raph, & buehler, 2018; montgomery, sutton, & paré, 2017). rural women often have further distance to travel, poorer roads or seasonal conditions that can delay or lengthen travel times, and rural communities are more likely to rely on volunteer ems systems. healthcare facilities are often a great distance away and rural women might dismiss vague symptoms as insignificant and not worth the travel. poverty is an important issue in rural populations. according to bolin et al., poverty rates are higher in rural areas compared to urban areas (2015). however, poverty is not the only issue for rural dwellers. lack of access and limitations in access to care, frequently seen in rural communities are further compounded for those in poverty (fahs, 2017). more resources may be needed to access care, particularly specialty care, in rural communities and poverty only heightens the issue. rural dwellers living in poverty are less likely to have means of reliable transportation and resources to cover the cost of seeking care within the area, much less the additional cost associated with seeking care beyond the rural community. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 119 methods design the design used was quasi-experimental with two groups and site randomization. the research questions were: 1. what is the effect of the use of an acronym-based educational intervention on knowledge of female heart attack and prodromal symptoms as well as appropriate response to these symptoms among rural women? 2. what is the effect of the program on knowledge at two-months after the initial presentation? sample & setting institutional review board (irb) approval was obtained from upstate medical university (irb exemption) and binghamton university (1985-12) before recruitment. female subjects were recruited by contacting rural community groups located in churches and agencies. in addition, fliers were posted at local sites. eligibility criteria for this study included women over 18 years of age who reside in rural areas (rucc code 5 or higher). all subjects had to be able to speak and read english. a power analysis indicated a sample size of at least 128 would be needed to assure power to find a statistically-significant difference between two groups in an independent t-test p = .80, alpha = .05. prior to the presentation a site was randomly assigned to the control or experimental treatment group. design contamination between control and experimental participants was the concern that led to the decision to randomize sites, not subjects (macha & mcdonough, 2011). the education was presented in 18 sites including community centers, church basements, schools, and an education center in a critical access hospital. consent was obtained on the day of the presentation but prior to beginning the presentation. this sample included n = online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 120 136 rural women for the immediate posttest measures. the sample size dropped to n = 75 for the 2 – month follow-up testing. instrument the matters of your heart scale version 2 (moyh v. 2) was refined based on an initial instrument that had 26-items and validity and reliability as previously described (kalman, et al., 2013). the original version was developed and tested with rural and urban women. revisions included additional distractors that had similar first letter response so that identify letters for first words in the acronym would not queue the respondent to the correct answer (e.g. sweating and swelling). instrument items had a possible three-point likert scale response (very uncommon, common, or very common or strongly disagree, agree or strongly agree). the questionnaire was identified as usable as long as there were no more than 5 responses missing on the initial 37 items. a score of 0 was imputed if no answer was marked. the current moyh v. 2 was ultimately reduced to 23 items through a factor analysis with principal axis factoring and varimax rotation, producing a kaiser-meyer-olkin (kmo) of sampling adequacy of .78. scree plot and eigenvalues both affirmed the 6 subscales within the instrument (field, 2018). in the final rotation, 53% of the variance of outcomes was explained by this instrument. a factor analysis is often used to address content validity in instrument development and testing. when the items come together to form factors, they should relate conceptually to other items within that factor and pertain to the concepts being addressed. the items in each of the six subscales were clearly related to each other and the concepts within the online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 121 intervention. for example, the curbs scale had items on chest discomfort, unusual fatigue, shortness of breath and sweating. the next step was to test the instrument and subscales for reliability. the cronbach alpha on standardized items of the knowledge scale equaled .88 which is indicative of good reliability. subsequent reliability testing of subscales on the curbs and factss acronyms, the likelihood of women experiencing symptoms, and a subscale on location of symptoms such as jaw/neck, chest and arm had acceptable cronbach alpha scores ranging from .80 to .85. two subscales did not have appropriate reliably and were discarded. thus the 4 subscales were also used in the analysis. after the factor analysis, the total knowledge score on the moyh v. 2 had a possible range of 0 23 points. the curbs subscale included 6 items with possible range from 0 to 18, and focused on the mi symptoms of chest sensation, unusual fatigue, breathing problems and sweating. the factss subscale contained 5 items with a possible score of 0 15 and focused on prodromal mi symptoms. a third subscale had questions that explored the likelihood of women experiencing symptoms and included 4 items with potential scores from 0 – 12, and the final subscale on location of symptoms such as chest, jaw etc. ranged from a possible 0 to 9 points with 3 items. higher numbers indicated more knowledge on all portions of the instrument. the factor analysis was conducted to assess construct validity of the instrument and the output indicated there was strong construct validity. good reliability (a = .80 .88) of the knowledge scale and each of the four retained subscales was found through conducting cronbach alpha. item test – retest reliability was not calculated. the instrument is available upon request. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 122 procedure in the experimental group sites, the information on female mi and prodromal symptoms was presented using two acronyms, curbs and factss, to improve uptake and retention of knowledge. the control group received the same information as the experimental group. however, control group presentations did not include the acronyms but presented the information with symptoms in alphabetical order. prior to the presentation, participants were asked to complete a brief demographic questionnaire that included yes / no questions regarding medical history, age, educational level, ethnicity and zip code. one of the principal investigators (pi) delivered all programs using a powerpoint presentation and a specific script on speaker notes. the predeveloped and rehearsed scripts for both the presentations were an effort to establish intervention fidelity. when the program concluded, the first posttest was completed. for the two-month followup, the same posttest questionnaire was mailed to the subject. the posttest included the subject's study unique id number to allow linking of immediate posttest and two-month follow-up questionnaires. data collection upon entering the site of the presentation each woman received a pretest booklet that consisted of demographic questions and a posttest questionnaire that were color coded to queue the participant as to which booklet to complete before and after the presentation. they also received a copy of the slides to be presented in that session (depending on randomized site, either using the acronym or alphabetical format). each participant received a pre-stamped envelope the day of the presentation to self-address. at the beginning of each of the 14 presentations, subject rights were presented in verbal, visual, and written form. the women were notified that turning in online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 123 their post presentation questionnaire served as informed consent for participation in the initial part of the study and returning the self-addressed envelope, would allow us to contact them with the 2month follow-up questionnaire. returning the final questionnaire would provide consent for participation in that portion of the study. the women in the control and experimental groups received the same instrument for their posttest and 2-month follow-up. findings descriptive analysis of sample one hundred and thirty-six women (n = 136) attending the presentations provided posttest usable data. data were considered usable if no more than 5 responses were missing, zero was imputed for missing items. data were analyzed using ibm spss version 22. a total of 28 different zip codes were represented in this study. all women were living in a rural part of upstate new york or northeastern pennsylvania with rucc codes of 5 or higher, with the mode of a rucc of 6 in this sample. the sample was primarily caucasian (n = 127, 93%) reflecting the racial makeup of the rural areas where the study took place. ages ranged from 25 to 90 years (m = 63.4, sd = 12.75), with a slight majority reporting their age as 64 years or younger (n = 70, 51%). only 4.5% reported less than a high school education or a graduate equivalency degree (ged). the most often reported educational levels included categories of less than a high school education through some college (n = 70, 51%). immediate post presentation findings comparing the two educational formats of acronym vs. no acronym, an independent t-test was computed and indicated there was no statistically significant difference on the knowledge score t = .26, df = 134, p = .80. the mean score for the group receiving the experimental treatment online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 124 of a presentation using the acronyms was 15.19 points (sd = 5.36) out of a possible 23 points vs. a mean of 14.96 (sd = 5.13) for the group receiving the same information without the use of acronyms. similar non-significant results were found on both the curbs (t = -.54, df = 134, p = .59) and factss subscales (t = -.95, df = 134, p = .34) with means of 2.97 (sd 1.86) and m = 3.80 (sd = 2.30) respectively. although being in the experimental vs. control group did not lead to significantly different scores on the knowledge scale or the curbs or factss subscales, some demographic groups did achieve significantly higher scores in the statistical analysis (see table 1). age groupings were established using the cut point of 64 years or younger (n = 70) vs those 65 years of age and older (n = 64) based on the sample descriptive statistics. similarly, educational grouping of less or more education were established using the cut point of some college or less vs. those with a 2-year degree or more based on demographic data. other groupings such as by reported race (caucasian vs. other and no report), self-report of history of cvd and self-reported medication use for those medications designed to treat hypertension (htn) or hyperlipidemia were also used as independent variable groups for this analysis. none of the tests performed for demographic groupings reached statistical significance. table 1 independent t-test scores on knowledge, curbs and factss by demographic groupings demographic scale grouping mean (sd) independent t-test t, df, p knowledge age younger (≤ 64 years) 16.71 (4.36) t = 4.11, df = 134, p = .000* older (≥ 65 years) 13.22, (5.52) education less education (≤ some college) 14.27, (5.56) t = 2.00, df = 134, p = .047* online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 125 demographic scale grouping mean (sd) independent t-test t, df, p more education (≥ 2-year degree) 16.05, (4.63) curbs age younger (≤ 64 years) 15.46, (2.33) t = 1.76, df = 134, p = .082 older (≥ 65 years) 14.67, (2.89) education less ed (≤ some college) 14.85, (2.78) t = -1.16, df = 134, p = .13 more ed (≥ 2-year degree) 15.37, (2.42) factss age younger (≤ 64 years) 13.40, (1.93) t = 3.38, df = 134, p = .001* older (≥ 65 years) 12.16, (2.48) education less ed (≤ some college) 12.53, (2.57) t = -1.52, df = 134, p = .11 more ed (≥ 2-year degree) 13.13, (1.85) follow-up at 2 months just over half (n = 75, 55%) of the women chose to participate in the 2-month follow-up, returning the mailed questionnaire. again, the data were deemed usable if no more than 5 responses were missing and in the case of missing data, 0 was imputed. as in the analysis of the immediate posttest results, being in the experimental acronym group did not significantly improve the 2month follow-up scores on the knowledge or the curbs or factss subscales. in computing the independent t-test on 2-month follow-up scores by demographic groupings, only age and medication use had any influence on outcome scores. the younger age (≤64) group had statistically significant better scores on the 2-month follow-up on total knowledge (p = .005) and the factss subscale (p = .006) but not the curbs subscale (p = .12). these findings mirror those seen in the immediate post-test analysis. a finding that did differ from the immediate posttest results was the statistically significant difference in the curbs 2-month follow-up by history online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 126 of taking a medication (either for htn or hyperlipidemia). in this analysis those taking a medication (n = 30, m = 15.37, sd = 2.25) as described above scored lower than those not taking medication (n = 45, m = 13.60, sd = 3.25) at the time of the presentation. the difference between the two groups was statistically significant only on the curbs subscale (t (73) = 2.58, p = .01). factors predicting knowledge female heart attack symptoms a backward stepwise regression was computed to identify what variables explained the most variance in outcomes. in addition to the main independent variable of experimental vs. control groups, eight other variables were used as potential predictor variables to identify if they had influenced significance in the factor analysis or in the inferential statistical analysis. the initial loading of 9 variables plus the constant provided 10 predictors in the model (field, 2018). the number of predictors was reduced to 7 in the fourth and most robust model. in addition to the constant, the predictors in model 4 included the subscale of location of female symptoms; grouping of caucasians vs. other or no answer; likelihood of women having specific symptoms, the curbs and facts subscales. this model explained 90% of the variance in the dependent variable of knowledge of female mi symptoms including the appropriate response to those symptoms (r = .95, r2 = .90, adjr2, se = 1.65). the adjusted r2 indicates that there is good cross validity of the model (field, 2018). collinearity statistics of tolerance and variance inflation factor (vif) were examined. all vif in the model were below 10 and tolerance as well above .20 indicating there were no issues of multicollinearity for this model. limitations the requirement to speak and read english reduces the generalizability of the findings. also, the lack of a randomized sample of subjects as well as the intervention only attended by rural online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 127 women from upstate new york or northern pennsylvania limits the generalizability to the population of rural women. attempts to correct for the lack of random sampling included the randomization of type of program by site. site randomization was chosen because of previous reports of randomized subjects in rural communities sharing information and, thus, compromising the intervention (fahs, et al., 2013). although the sample size was adequate for analysis of the immediate post-test information, the analysis of the 2-month follow-up data lacked power to rule out the possibility of a type ii error (field, 2018). this study did not measure baseline knowledge of gender specific mi or prodromal symptoms. the decision to only compare groups on the measures immediately after the presentation and at the 2-month follow-up was made for two reasons. the ability of the program using an acronym format had been used successfully in the past to significantly increase knowledge, curbs and factss scores (kalman, et al., 2013). in not measuring pretest knowledge, limitations of time constraints and survey fatigue of the subjects were managed. further testing of the moyh v. 2 should include test-retest reliability. discussion the acronym approach to educating rural women about gender specific heart attack and prodromal symptoms and how to respond appropriately did not result in a difference in knowledge scores on the main instrument nor the curbs or factss subscales. this finding would indicate that either approach (using acronyms or presenting symptoms alphabetically) are equally effective. similar to the findings of mcdonald and colleagues (2006), the delivery method of the content did not matter, but both groups had increased knowledge. during the educational programs, regardless of the delivery method, participants interacted with one another and shared stories, which might online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 128 have affected their knowledge level. perry and rosenfeld (2005) found that group sessions where participants connected and shared experiences, fears, and concerns, increased knowledge about mi symptoms and the need to call 911 if the symptoms occur. several factors need to be considered prior to completely rejecting the use of an acronym approach in providing rural women with knowledge on the issue. first, the acronyms used in this study may be too awkward to have a significant effect on remembrance of complicated symptoms that often present in women who are having a heart attack or experiencing warning signs of heart attack. previous work has supported the use of acronyms in significantly improving knowledge of populations including those living in rural areas for issues such as stroke (kalman, et al., 2013 a). as noted in the literature review (albarqouni et al., 2016) older women in this study scored significantly worse on the outcome measures of knowledge as well as the prodromal symptoms represented in the factss subscale. the difference in the outcome on the mi symptom subscale, curbs, trended in the same direction with older women scoring lower but did not reach statistical significance (p = .08). additionally, the one significant difference in the curbs subscale score was for women taking medications to treat htn or hyperlipidemia. women on these medications scored lower on identification of symptoms of female heart attack, chest discomfort, unusual fatigue, radiating pain, breathing difficulties, and sweating. the interactions of age and the current use of medications was not examined in this analysis but is an area for further analysis. this manuscript adds to the body of knowledge of nurses working with rural women on issues of gender specific mi and prodromal symptoms. the instrument continues to have strong validity and reliability data. a linear multiple regression produced a model that explained most of the variance (90%) seen in the outcome measures without multicollinearity. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 129 conclusion in summary, rural women have no less risk of heart attacks and poor outcomes than those in metropolitan areas, although some rural population studies have indicated that there is unexplained variance in mortality in non-metropolitan populations. women in this study were most often living in counties with a rucc score of 6, the same level of rurality of counties indicated as having the highest non-metropolitan mortality penalty (james, 2014). the work reported here is not meant to argue rurality is a causal factor in gender specific female mis, but rather that this study brings forth information important to rural women and thus adds to the knowledge of the discipline of nursing and others who work with rural dwellers. too little research is conducted in rural populations and this study is designed to look specifically at rural women and their knowledge of gender specific mi symptoms and the appropriate response in utilizing the emergency services system (911) to gain immediate help in this medical emergency. furthermore, the nurse designed program presented as part of this study served to alert women that early warning or prodromal symptoms often occur with increasing frequency, as reported by women who experienced a heart attack and survived (mcsweeney et al., 2003). rural nursing theory (rnt) informed the research team about cultural components of the rural sample (long & weinert, 1989) and prepared the nurses for questions or comments specific to rural dwellers that might arise; for example, the issue of length of time it would take ems to respond in the community was occasionally mentioned as a possible rationale for not calling 911 for heart attack symptoms. knowledge of rnt allowed the nurses to be prepared to provide data about average rural ems length of response time and the dangers that could occur if relying on self or family/friends for transport. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 130 women need to be aware that prodromal symptoms must be taken seriously and that medical attention at that stage is potentially less expensive and may be effective in delaying or reducing the risk of a female heart attack. a primary role and responsibility of the nurse is to be at the forefront of health promotion, counseling, and education (ana, n.d.). what better way to fulfill this mandate than by educating rural women regarding the recognition of female heart attacks, possible warning symptoms and the need to respond appropriately. nurses can make a difference educating rural women about hear disease. references albarqouni, l., smenes, k., meinertz, t., schunkert, h., fang, x., ronel, k., & ladwig, h. 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(2013) education to increase women’s knowledge of female mi symptoms. journal of the new york state nurses association. 43(2), 11-16. ladwig, k., fang, x., wolf, k., hoschar, s., albarqouni, l., ronel, j., & ... schunkert, h. (2017). comparison of delay times between symptom onset of an acute st-elevation myocardial infarction and hospital arrival in men and women < 65 years versus ≥ 65 years of age. findings from the multicenter munich examination of delay in patients experiencing acute myocardial infarction study. the american journal of cardiology, https://doi.org/10.1016/j.amjcard.2017.09.005 lee, h. j. & winters, c. a. (2004). testing rural nursing theory: perceptions and needs of service providers. online journal of rural nursing and health care, (4)1, 5163. lee, h.j., winters, c.a., boland, r.l., raph, s.w. & buehle, j.a. 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(2003). women’s early warning symptoms of acute myocardial infarction. circulation, 108, 26192623. https://doi.org/10.1161/01.cir.0000097116.29625.7c mcsweeney, j.c., & coon. s. (2004). women’s inhibitors and facilitators associated with making behavioral changes after myocardial infarction. medsurg nursing. 13(1) 49-56. montgomery, s. r., sutton, a. l., & paré, j. (2017). rural nursing and synergy. online journal of rural nursing and health care, 17(1), 87 – 99. http://dx.doi.org/10.14574/ojrnhc.v17i1 .431 morgan, d. m. (2005). effect of incongruence of acute myocardial infarction symptoms on the decision to seek treatment in a rural population. journal of cardiovascular nursing, 20, 365-371. https://doi.org/10.1097/00005082-200509000-00011 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.519 133 mosca, l., hammond, g., mochari-greenberger, h., towfighi, a., & albert, m.a. (2013). fifteen-year follow-up of american women's awareness of heart disease in women: results of a 2012 american heart association national survey. circulation, 127, 1254 1263, https://doi.org/10.1161/circ.0b013e318287cf2f national institutes of health, united states library of medicine (n.d.) medlineplus heart disease in women. retrieved from https://medlineplus.gov/heartdiseaseinwomen.html#cat_51 nguyen, h. l., saczynski, j. s., gore, j. m., & goldberg, r. j. (2010). age and sex differences in duration of prehospital delay in patients with acute myocardial infarction: a systematic review. circulation: cardiovascular and quality outcomes, 3(1), 82-92. https://doi.org/10.1161/circoutcomes.109.884361 perry, c.k. & rosenfeld, a.g. (2005). learning through connections with others: women’s cardiac symptoms. patient education and counseling, 57, 143-146. united states department of agriculture, economic research services (n.d.). rural-urban continuum codes. author. retrieved from https://www.ers.usda.gov/data-products/ruralurban-continuum-codes/ swan_651_formatted online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 183 lack of anonymity and secondary traumatic stress in rural nurses marilyn a. swan, phd, rn1 barbara b. hobbs ph.d., rn, nea, bc2 1associate professor, college of allied health and nursing, minnesota state university mankato, marilyn.swan@mnsu.edu 2professor emerita, college of nursing, south dakota state university, bbarb@rushmore.com abstract purpose: the purpose was to determine the prevalence of lack of anonymity (la) and secondary traumatic stress (sts) among nurses; determine if nurses’ la and sts differ by population density and examine the relationship between lack of anonymity and sts. design and method: a descriptive correlational study examined la and sts in a random sample of 271 nurses from counties with differing population densities (rural, micropolitan and metropolitan) of a midwestern us state. a 3-group design was used to examine the relationship between la and sts in nurses, living and working in these counties. data on lack of anonymity, secondary trauma and demographics were collected through online questionnaires. findings: rural nurses had a higher prevalence of la than micropolitan and metropolitan nurses. while the prevalence of sts among rural nurses was higher than either micropolitan or metropolitan nurses; there was no difference in sts among the three population groups. lack of anonymity and sts were related; however, analysis revealed that la and sts are inversely correlated, indicating that as la increases, sts decreases. a majority of rural nurses (90%) reported living in a rural community prior to their 18th birthday. online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 184 conclusions: rural nurses experience sts at similar rates as their metropolitan and micropolitan counterparts, indicating that population density may not be a factor related to the development of sts. la appears to have a positive effect on reducing sts in rural nurses. clinical relevance: the study advanced the understanding of la and sts among nurses who live and work in different population densities. the social support within rural health care facilities and communities may play a role in mitigating the effects of indirect stress. keywords: rural, rural nursing, lack of anonymity, traumatic stress lack of anonymity and secondary traumatic stress in rural nurses nurses and nursing practice often adapt to the location where a nurse lives and works. as such, nurses working in rural settings are influenced by the unique characteristics of rural health care. rural health care is associated with being ‘small’, i.e., small hospitals, small workforces (nurses and providers), small communities, small populations (lee & mcdonagh, 2013) and lower population densities. together with the ‘small’ aspects of rural health care, rural nursing theory identifies common characteristics of rural health, e.g., lack of anonymity, distance between healthcare systems, lower household income, and limited access to health care, that influence nurses and others who live and work in rural settings (long & weinert, 1989). furthermore, rural nursing is embedded within multiple practice settings: a nursing unit or department, a health care facility, and a community, each with its own population density. nurses practicing in rural health care commonly report knowing patients and families who are receiving care (glover, 2019). relatively unexplored in rural literature is the development of secondary traumatic stress (sts) among nurses who care for people with whom they live and work. secondary traumatic stress can result from learning second hand about a traumatic or disturbing event to someone a person knows or cares about. the purpose of the study was to determine the prevalence of lack of anonymity online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 185 (la) and sts among nurses; determine if nurses’ la and sts differ by population density and examine the relationship between lack of anonymity and sts. lack of anonymity nurses who live and work in rural settings experience la (lee, 1998; long & weinert, 1989). rural nursing theorists and rural experts identify la as a concept unique to rural nursing practice (hegney, 1996; lee & mcdonagh, 2013). rural nurse theory defines rural as “living in sparsely populated areas” (long & weinert, 2018, p.18). lack of anonymity is defined as “a condition in which one cannot remain nameless or unknown” (lee, 1998, p. 77), and permeates the life of a rural nurse. rural nurses describe this experience as ‘living in a fish bowl’, where the personal life of the nurse is exposed and observable to others (mills et al., 2010; rosenthal, 2010). it is common for rural nurses to provide care to community members with whom they have personal connections (rosenthal, 2010). because of these connections, e.g., friendships or family relationships, rural nurses have personal or intimate knowledge of people living and working in the rural community. additionally, rural nurses encounter current and former patients while out in the community, and they are readily recognized as a nurse (hegney, 1996). these encounters can blur personal and professional boundaries because rural nurses are often familiar with intimate details of community members (halverson & brownlee, 2010). similarly, a professional identity is visible to many and can place limits on a rural nurses’ ability to maintain a personal, or private self (swan & hobbs, 2017, 2018). while la is not well described in urban or largely populated areas, the authors contend that la may be present in different community environments including urban settings, such as neighborhoods or boroughs, and in online venues. this contention strengthens the connection of la to population density that is explored in this study. online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 186 secondary traumatic stress secondary traumatic stress is a form of indirect traumatic stress and is defined as “…the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other—the stress resulting from helping or wanting to help a traumatized or suffering person” (figley, 1995, p. 7). the actual traumatic event happens to another; however, trauma can occur to an individual when hearing about a disturbing event. this type of exposure may result in indirect traumatic stress, often referred to as sts and is attributed to learning about a violent or traumatic event experienced by someone close to you or having repeated exposure to difficult or upsetting experiences that happen to people you know (figley, 1995). secondary traumatic stress is a component of posttraumatic stress disorder in the diagnostic and statistical manual of mental disorders (american psychological association [apa], 2013). symptoms of secondary traumatic stress mirror those of direct traumatic stress (post-traumatic stress syndrome): thought intrusion, avoidance, and hyperarousal (apa, 2013). direct and indirect traumatic stress are part of the human experience (van der kolk & mcfarlane, 1996/2007); however, little is known about how la may influence the development of sts in nurses. research findings suggest that nurses are at high risk for developing sts due to their level of proximity and frequency of potential exposure to traumatic experiences of patients (figley, 1995; komachi et al., 2012). health care workers with the closest proximity to the patient have higher risk of developing sts; part-time workers demonstrate lower levels of sts when compared to full-time workers (slocum-gori et al., 2011). the actual prevalence of sts among nurses is unknown. nursing research on sts has largely focused on nurses working in densely populated areas who work in high stress units or nursing roles. beck and gable (2012) found that 63% of labor and delivery nurses studied reported at least one sts symptom. similarly, online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 187 dominguez-gomez and rutledge (2009) report that 85% of emergency room nurses had at least one symptom of sts. these findings suggest nurses are at risk of developing sts from occupational exposure encountered when providing nursing care. secondary traumatic stress is closely related to burnout and is often reported as a component of compassion fatigue. the risk of sts in rural nurses, who experience la and have intimate knowledge of people in their community, was not located in the literature reviewed. definitions for this study, population density refers to the number of people, e.g., nurses, providers, patients, in a given unit of space. population density was determined by using the office of management and budget’s (2013) county designation of metropolitan, micropolitan, and other. metropolitan counties have a population of 50,000 or more; and, micropolitan counties have a population of at least 10,000, but less than 50,000 (health resources and services administration, n.d.). the designation of other was used for counties with a population density of less than 10,000. those counties were considered rural. theoretical framework social cognitive theory (sct) and rural nursing theory provided the theoretical framework for the study. bandura (1977; 1986) proposes that reciprocal determinism is the interaction of cognition, behavior and the environment. these three constructs are in relationship with and influence each other. a change in any one construct, will affect the other two. rural nursing theory concepts can be inserted into the framework of reciprocal determinism. for example, la is a component of rural nursing theory and also part of the environment. using this framework, a rural environment, that includes la, influences a nurse’s cognition and behavior. in turn, a nurse adapts to the environmental influence of rural living. when confronted with traumatic stress, a nurse may online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 188 alter their cognition, behavior, and environment to reduce stress (benight & bandura, 2004). this suggests that a nurse’s adjustment to stress may reduce the risk of developing sts. purpose the purpose of this study was to determine the prevalence of la and sts, determine if there was a difference in sts and to determine if there was a relationship between la and sts in metropolitan, micropolitan, and rural nurses. our hypotheses were 1) rural nurses have a higher prevalence of sts related to repeated exposure to traumatic events of patients known to them, and 2) there is a positive relationship between la and sts in rural nurses. methods design the study used a descriptive correlational design to examine the relationship between la and sts in nurses from different population densities. a 3-group design was used to divide nurses into those who lived and worked in metropolitan, micropolitan, and rural locations. the placement into groups was determined by the population density of the county of residence and employment. nurses who traveled to a different population density area for work were excluded. study data were collected from a midwestern plains state in the united states (us). the study procedures were approved for human subject research by the south dakota state university institutional review board. measures lack of anonymity-10 instrument (loan-10) lack of anonymity is measured using a 10-item, self-report instrument (swan, 2015). the 5point likert scale rates agreement with items, ranging from strongly agree (1) to strongly disagree (5). total point range is 5-50 (swan, 2015). based on participant responses, a cumulative score is online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 189 calculated. scores of 10-25 indicate the individual may be experiencing la; scores of 26-34 are indeterminate; and scores of 35-50 indicate the individual may be experiencing greater anonymity. for this study, the instrument’s cronbach’s alpha was .863, indicating internal consistency. secondary traumatic stress subscale secondary traumatic stress was a factor of the compassion fatigue-short scale-adapted (cf-ss-a). burnout (8-item) and sts (5-item) are measured within the 13-item, self-report screening instrument adapted from the cf-ss (bride et al., 2007; adams et al., 2006). the original cf-ss was developed for use with social workers; we were unable to locate a study demonstrating the use of cf-ss with a nursing population. therefore, a convenience sample of registered nurses, familiar with rural nursing, was asked to provide expert review. based on registered nurse feedback, cf-ss statements were modified to ensure clarity for the target nursing population. the modified instrument was renamed the cf-ss-a. the cf-ss-a 10-point likert scale rates occurrence of events, ranging from never or rarely (1) to very often (10) (adams et al., 2008). the two subscale scores are summed separately with possible scores of 8-80 (burnout) and 5-50 (sts) respectfully. a higher score (30 or more) on the burnout subscale indicates burnout may be present, and clinical evaluation may be warranted. likewise, a score of 15 or higher on the sts subscale indicates sts may be present and clinical evaluation may be warranted (boscarino et al., 2010). adams et al. reported an overall instrument cronbach’s alpha of .90, with cronbach’s alpha of .90 for burnout and .80 for sts (2006). for this study, the cronbach’s alpha for the overall instrument was .92. the subscale cronbach’s alpha was .89 for burnout, and .85 for sts. demographics online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 190 the demographic data included information pertinent to understanding la and sts, and to adequately describe the sample. demographic information included age, gender, ethnicity, years licensed as a nurse, current practice setting, county of employment, and whether or not the participant lived in a rural community prior to their 18th birthday, a factor associated with adults living and working in rural areas. study procedures sample study participants needed to be 1) 19 years of age or older, 2) licensed as a registered nurse, 2) working a minimum of 20 hours per week, and 4) employed at their current employer for at least two years. the inclusion criteria were selected to ensure that participating nurses had enough opportunity to experience la or sts in a practice setting. additionally, requiring two years of nursing practice reduced the confounding variable of new nurses transitioning into practice. a county list from a midwestern state was developed, with population designated as metropolitan, micropolitan, or rural, and subsequently provided to the board of nursing. the board of nursing was asked to randomly select 500 registered nurse names for each of the county population designations from the state’s database. this number ensured each population density would be adequately represented in the study. in total, the board of nursing provided a random sample of 1500 registered nurses as prospective participants. the prospective participant list included each registered nurse’s name, email, home address, and county of residence. the list was reviewed to ensure that each county designation was represented as requested. data collection a 5-contact method described by dillman et al. (2009), modified for an online distribution, was used. a pre-notice letter, introducing the study and inviting their participation in the online online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 191 questionnaire that would be sent to their email address, was sent to the homes of the selected registered nurses. the study questionnaire was copied to qualtrics™ software for online distribution. seven days after the pre-notice letter mailing, an email was sent to the registered nurses email address. the online questionnaire included questions on the inclusion criteria, and a consent form for study participation. following consent, participating registered nurses completed online versions of the loan-10, cf-ss-a, and demographic information. seven days after the initial email, a thank-you email containing the link to the study questionnaire was sent to prospective participants. after seven days, a fourth contact was made by email with a link to the online questionnaire. the final contact was sent seven days after the fourth contact. the survey was then left open for one week and then closed. the study procedures considered how to promote the highest response rate possible. the prenotice letter introduced the study and alerted prospective participants to look for the study email. while the pre-notice letter incurred expense, its purpose was to prevent the study email from being deleted before being viewed (dillman et al., 2009). emails were concisely written to communicate the study instructions clearly for quick viewing (dillman et al., 2009). in addition, emails were sent out first thing in the morning allowing the emails to be viewed early in the day, thus promoting participation (dillman et al., 2009). the use of the qualtrics™ software allowed for the development of an email distribution list for the 1500 randomly selected registered nurses. the use of a distribution list allowed us to personalize the email by inserting the nurse’s name into the email salutation (dillman et al., 2009). another benefit of using a distribution list is the link was tied to the email to which it was sent; this means that if the email was forwarded, the survey could not be completed. this provided assurance that only the randomly selected nurses completed the survey. online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 192 data analysis descriptive statistics, including group and aggregate totals, frequency distribution, measures of central tendency, range, and variance were used to report on cf-ss-a. a one-way anova was used to determine differences in sts scores among metropolitan, micropolitan, and rural nurses. a pearson correlation coefficient was used to describe the relationship between la and sts by group and aggregate total. results a total of 340 nurses completed the questionnaires, of which 80% (n = 271) met the threegroup study design requirements; metropolitan (n = 113) nurses had the highest response rate, followed by micropolitan (n = 77), and rural (n = 81). the study sample was predominately white (94.5%) and female (91%). the mean age was 44.5 years. metropolitan nurses had fewer years of licensure (m = 16, sd = 11.39) than rural (m = 17.5, sd = 11.87) and micropolitan (m = 18.3, sd = 12.19) nurses. acute care was the most common practice setting (44.6%). a majority of rural nurses (90%) indicated that they had lived in a rural community prior to their 18th birthday followed by micropolitan then metropolitan nurses (see table 1). table 1 live in a rural community prior to 18th birthday metropolitan micropolitan rural frequency percent frequency percent frequency percent yes 56 49.6 57 74.0 73 90.1 no 57 50.4 26 26.0 8 9.9 data analysis revealed a higher prevalence (85.2%) of la among rural nurses than was indicated by micropolitan or metropolitan nurses (see table 2). online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 193 table 2 loan-10 scores by county group metropolitan micropolitan rural frequency percent frequency percent frequency percent la 15 13.3 46 59.7 69 85.2 indeterminate 44 39.0 26 33.8 10 12.3 anonymity 54 47.7 5 6.5 2 2.5 for the total sample, 39% of the registered nurses had scores indicating sts may be present. the prevalence of sts was highest in rural nurses and lowest in micropolitan nurses (see table 3 and 4). table 3 frequency of sts (subscale) by county group metropolitan micropolitan rural frequency percent frequency percent frequency percent sts present 42 37.2 25 32.5 39 48.1 no sts 71 62.8 52 67.5 42 51.9 table 4 scores for sts (subscale) by county group place n range m (sd) 95% ci metropolitan 113 5-50 15.26 (10.26) [13.34, 17.17] micropolitan 77 5-48 13.25 (7.84) [11.47, 15.03] rural 81 5-41 16.44 (8.92) [14.47, 18.42] note. n = 271. m = mean. sd = standard deviation. ci = confidence interval. a one-way anova was performed and indicated there was no significant difference in sts among metropolitan, micropolitan, and rural nurses. population density was not a factor related to the development of sts for this study (see table 5). online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 194 table 5 analysis of variance of sts for metropolitan, micropolitan and rural nurses ss df ms f p between groups 412.68 2 206.34 2.42 .091 within groups 22819.87 268 85.15 total 23232.55 270 a pearson product-moment correlation coefficient was calculated on the la and sts data and revealed a significant negative correlation between la and sts (r = -.126, p = .038) for the entire sample of registered nurses. as the la increased, sts decreased. when calculated for each of the 3-groups, however, no significant relationship was found between la and sts in metropolitan (r = -.153, p = .105, n = 113), micropolitan (r = -.172, p = .135, n = 77), and rural (r = -.160, p = .153, n = 81) nurses. the loss of significance suggests the sample size was not large enough to maintain statistical power (portney & watkins, 2009). discussion the purpose of the study was threefold: to examine the frequency of lack of anonymity (la) and sts among nurses. to determine if nurses’ la and sts differ by population density and to understand the relationship between la and sts in nurses who lived in different locations. as expected, rural nurses experience more la than their micropolitan and metropolitan counterparts. although la is described in the literature, this study is believed to be the first to measure, or quantify, la in a population. the prevalence of la in this study sample is consistent with descriptions in both rural nursing practice research literature and rural nursing theory (hegney, 1996; lee & mcdonagh, 2013). likewise, findings in this study support previous research on the prevalence of sts in nursing. there was, however, no difference in the development of sts based on population density; thus, the hypothesis that rural nurses would experience higher sts was not supported. online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 195 rural nurses experienced sts at rates similar to their micropolitan and metropolitan counterparts. the overall prevalence of sts in this sample of nurses is consistent with, if not lower, than other studies. studies of sts commonly use a convenience sample from a specific unit or institution and use a variety of instruments. the randomized sample utilized in this study further supports previous findings related to prevalence of sts in nurses. in this study, almost 40% of the overall sample and close to one-half of the rural nurses had scores indicating sts may be present. sts is affecting a large portion of the nursing workforce, particularly the rural workforce. this is an issue that requires further study to fully understand sts development and explore ways to mitigate its effects. the inverse relationship between the study variables of la and sts in the rural nurse group suggests la may have a positive effect on reducing sts in rural nurses. more research is needed to understand the relationship between these two variables as la is generally considered a negative attribute in rural practice (hegney, 1996). social and workplace support in rural areas differs from metropolitan environments. however, the interconnectedness of rural health care communities may provide a social and workplace support system across the institution (hunsberger et al., 2009). as such, support a rural nurse receives may cross professions, inside and outside of the work environment. as described in the literature, social support is linked with lower incidence of psychiatric illness and may be an independent mediator in the development and recovery from sts (shoji et al., 2014; stansfeld et al., 1999; regehr et al., 2013). similarly, brown et al. (2018) found that change fatigue, a form of stress, occurs less frequently in nurses who work in acute care facilities with fewer beds (i.e. smaller facilities). brown et al.’s recent findings suggest that social support in rural health care and stress are linked in some way. the relational quality of both theoretical online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 196 concepts suggests that the interdependent, interprofessional social support in rural environments requires closer examination. these findings highlight the need for future research on the mechanism of influence between environmental context and the inherent social and workplace support in rural health care facilities and how this influences rural nursing practice. a vast majority of rural nurses had childhood experiences with rural living before their 18th birthday and were more likely to stay in a rural location. research evidence supports that a predictive relationship exists between having a rural background and choosing to work in a rural location (cosgrave et al., 2019; woloschuk et al., 2005). this study did not determine if the childhood experiences occurred within the rural community in which the nurse lives and works; however, the study findings appear to support rural workforce recruitment practices of recruiting within rural communities and growing your own (macphee & scott, 2002). the connection between rural childhood experiences and choosing to live and work in a rural community as an adult needs further research. limitations the findings from this study are generalized to a midwestern state in the us. the study inclusion criteria requiring at least two years of nursing experience, reduced the sample size. the small sample size within the 3-group design affected the statistical power to identify significant differences. lack of anonymity is a broad concept that may have confounding variables that are not well understood; thus, bias may have been present. conclusion online journal of rural nursing and health care, 20(1) https://doi.org/10.14574/ojrnhc.v21i1.651 197 nurses live and work in areas with different population densities. this study showed rural nurses are more likely to experience lack of anonymity than nurses working in more densely populated areas. the prevalence of sts for all nurses is considerable and warrants further investigation. no positive relationship between la and sts was found, however, additional research is needed to further understand la within rural nursing environments. references adams, r. e., figley, c. r., & boscarino, j. a. 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(2005). preparedness for rural community leadership and its impact on practice location of family medicine graduates. australian journal of rural health, 13(1), 3-7. https://doi.org/10.1111/j.1440-1854.2004.00637.x 80    theory derivation: adaptation of a contextual model of health related quality of life to rural cancer survivors leli pedro, dnsc, rn c, ocn, cne1 1assistant professor, college of nursing, university of colorado, denver, deirdre.jackman@ualberta.ca key words: contextual, rurality, hrqol, cancer survivorship, theoretical model; theory derivation abstract for the growing population of cancer survivors, an obvious conceptual framework to guide the inquiry of health related quality of life (hrqol) in rural cancer survivors has not emerged. in this paper, walker and avant’s theory derivation procedures are used to adapt ashing-giwa’s contextual model of hrqol, the parent model, to incorporate rurality into the model’s contextual dimensions. rural cancer survivor relevant definitions and refinements are proposed for the macro (system) and micro (individual) level dimensions of the parent model. this adaptation of the ashing-giwa hrqol model identifies concepts and components of a contextual model that must be included, measured, and accounted for to fully and deeply understand the hrqol of rural cancer survivors. introduction the cancer survivor population, defined as individuals who have completed treatment for any type of cancer and currently have no apparent evidence of active disease, now numbers 11 million. a subset of this growing population is rural cancer survivors. with close to 25% of the u.s. population living in rural areas (gamm, hutchinson, dabney, & dorsey, 2003) one can estimate 2.5 million rural cancer survivors in the united states. it has been documented that people living in rural and remote areas suffer from health differentials including higher rates of mortality and morbidity such as poor health related quality of life (hrqol). they are also more likely than urban adults to report having deferred care because of cost, with residents in remote counties least likely to have a personal physician (bennett, olatosi, & probst, 2008; hartley, 2004). economic factors, cultural, social, and educational differences, lack of recognition by legislators and the sheer isolation of living in remote rural areas, impede rural americans in their quest to lead a healthy life. cancer survivors in rural settings report decreased hrqol along with distinct needs linked to consequences of their cancer diagnosis and treatment (aziz & rowland, 2002; weeks, kazis, shen, cong, ren, miller, et al. 2004). despite this documented health differential between rural and urban cancer survivors, an obvious conceptual framework to guide hrqol inquiry of rural survivors has not emerged. consequently, the purposes of this article are to: a) describe ashing-giwa’s contextual model of hrqol (2005) as the parent model in guiding this inquiry and, b) use theory derivation procedures to present an adapted model for use in rural cancer survivorship research. theory derivation procedures theory derivation procedures are useful when related concepts could benefit from a structural way to represent the relationships. it is also useful when insights about a phenomenon online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 mailto:college%20of%20nursing mailto:deirdre.jackman@ualberta.ca 81    have the potential to inspire further research (walker & avant, 2005). the process of theory derivation is iterative. this process involves cognizance of the level of theory development within ones area of interest via a keen knowledge of current literature leading to insights into possible new concepts and structures for theorizing. with the awareness and insight of a certain phenomenon from the literature (i.e. cancer survivorship), a parent theory is selected that as a whole (or in portions), offers a way to explain or predict the phenomenon of interest. finally with creativity and thoughtfulness, the theorist borrows, modifies, and redefines relevant concepts and structures from the parent theory, to become meaningful within the context of the theorist’s area of interest (i.e. rural cancer survivorship). parent model: ashing-giwa’s contextual model of hrqol hrqol is a commonly used framework to assess the impact of cancer and its treatment on cancer survivorship. ashing-giwa’s (2005) contextual model of hrqol (referred to as model) provides a structure that expands traditional hrqol frameworks by adding cultural and socio-ecological dimensions. the model was informed by: 1) traditional hrqol models (cella, tulsky, & gray 1993; gill, & feinstein, 1994), 2) the biopsychosocial model, 3) qualitative and quantitative studies with cancer survivors, 4) the cancer and cancer survivorship literature, and 5) the multicultural and psychological literature. the model is a “work in progress and under development” (ashing-giwa, 2005, p. 298). the model has eight dimensions, four macro or systemic level dimensions and four micro or individual level dimensions (figure 1). the macro or systemic level includes selected contextual dimensions outside the individual, demonstrated to impact the survivorship experience. in contrast, the micro level contextual dimensions consist of individual level attributes and perceptions regarding the experience of cancer survivorship. table 1 lists the corresponding components for each contextual dimension. specifics of the model will be briefly presented as a foundation for subsequent adaptation of the model to rural cancer survivorship. figure 1. the contextual model of hrqol. adapted from ashing-giwa, k. t. (2005). the contextual model of hrqol: a paradigm for expanding the hrqol framework. quality of life research, 14, 297307. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 82    table 1. parent model dimensions and accompanying components level contextual dimensions components macro/systemic socio-ecological socio-economic status (ses), life burden, and social support cultural ethnicity, ethnic identity, acculturation, interconnectedness, worldview, and spirituality demographic chronological age and gender healthcare system access to health care, quality of health care, and quality of relationship micro/individual general health & comorbidities health status cancer specific medical factors cancer characteristics, age at diagnosis health efficacy motivation and know-how macro level dimensions of the parent model socio-ecological. this contextual dimension of the parent model is distinguished by the components ses, life burden and social support. all are implicated to “have more explanatory power” (ashing-giwa, 2005, pg. 299) in affecting hrqol and survivorship outcomes than ethnic status alone. the model proposes that low ses and associated experiences (i.e. diminished access to quality health care, lack of transportation, and unemployment that lead to marital instability and psychological stress) are barriers to health and risk factors for low hrqol. additionally, the life burden component of the socio-ecological dimension (living situation, role or functional strain, neighborhood resources/characteristics as well as overall dayto-day stressors) has been reported to be highly predictive of hrqol (ashing-giwa, ganz, & petersen, 1999; richardson, wingo, zack, zahran, & king, 2008). unlike the first 2 socioecological components that present risks to low hrqol, the component of social support may mitigate the negative impact of cancer. cultural. the parent model’s cultural contextual dimension includes variables linked to culture that cancer survivors may draw from to deal with their cancer. the model proposes that the relationship between culture and hrqol outcomes is explicated via the variables of ethnicity, ethnic identity, acculturation, interconnectedness, worldview, and spirituality. for example, the cancer survivor’s assessment of hrqol is made through the variable of ethnicity (or cultural and ancestral origins) with its accompanying health beliefs and practices. additionally, the variable ethnic identity or the degree to which cultural heritage is defined by the person (i.e. group vs. individual centered orientation in some cultures) influences how one behaves and relates to the environment (or context that they find themselves) and illness such as cancer (ashing-giwa, 2005). level of acculturation describes how factors such as use of language, interaction with the media, and involvement in social networks from the same ethnic group modify behaviors learned in one’s ethnic origin to support adaptation to the host country. the level to which these cultural adaptations occur influences hrqol and survivorship outcomes through care-seeking and treatment decision-making processes (ashing-giwa, 2005). similarly, the components of interconnectedness and how one views their well-being, and their online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22richardson%20lc%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22zack%20mm%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22zahran%20hs%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22king%20jb%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus 83    association with others such as family and social relationships or the more individual focused western view has the potential for both positive and negative influences on health practices and hrqol. in the model’s cultural dimension, for example, a worldview such as fatalism, an outlook that is more common in ethnic minorities, affects both responses to cancer (e.g., treatment choices) and recovery of cancer survivors. furthermore, the cultural factor of spirituality may mediate a worldview of fatalism in the appraisal of the cancer experience and hrqol, if survivors feel strength from a connection to an omnipotent and omnipresent force in their lives (ashing-giwa, 2005). demographic. the variables of age and gender are identified as components in the demographic dimension of the parent model. however, few studies focus on the impact of both variables in survivorship outcomes. in general, it is clear that age is commonly a factor in cancer survivorship. for example, advanced age is associated with an increased incidence and/or severity of disease and thereby is associated with decreased survival rates (resorlu, beduk, baltaci, ergun, & talas, 2009). on the other hand, king, kenny, shiell, hall, & boyages (2000) reported that in a cohort of women undergoing surgery for early stage breast cancer, younger women fared worse than older women on a broad range of quality of life dimensions. health care system. this macro level dimension of the parent model is composed of access, quality of care and quality of the physician-survivor relationship. access to care for underserved persons with low ses is limited by costs, lack of insurance, language barriers and day to day competing demands related to access to care (e.g. transportation and child care). as a result, the quality of care received by minorities and underserved persons may be weakened and different than others. needless to say situations such as these add a level of stress to the experience of cancer survivorship. differences in communication and perspectives of authority related to health care impact the physician-cancer survivor relationship (ashing-giwa, 2005). obtaining health information and expressing concerns are influenced by some components described in the socio-ecological and cultural dimensions of the parent model. although active participation in one’s health is associated with better quality of care and health outcomes (phipps, madison, polansky & tester, 2000; speucha, ozanne, silvia, partirdge & mulley, 2007), ethnic minorities may not participate in their health care, or providers may not encourage their participation based on their perception that they lack interest in the process. quality of care can be influenced by both access and the physician-survivor relationship, and can vary by facility (i.e. cancer center vs. local physician), and location (i.e. frontier vs. rural vs. metropolitan areas). micro level dimensions of the parent model at the micro level of the parent model, individual variables that may predict hrqol include: general health and comorbidities; cancer-specific medical factors; health efficacy and psychological well-being (table 1). in contrast to the macro dimensions of the parent model that have a more global and less direct impact on hrqol outcomes, the micro level dimensions influence hrqol (an individual’s evaluation of their current situation) directly. general health and comorbidities. the general health dimension within the micro/individual level of contextual hrqol can have a negative impact on hrqol and survivorship outcomes. similarly, severity and prevalence of comorbidities (that can vary among different ethnic and ses groups) can have a negative impact on hrqol (brooks, chen, ghosh, mullin, gardner, & baquet, 2000; garman, pieper, seo, & cohenet, 2003; schultz, stava, beck, online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 84    vassilopoulou-sellin, 2003). in a population-based study of 1,823 cancer survivors and 5,469 age-, sex-and education attainment matched control subjects identified from a 2000 national health interview survey (yarbroff, lawrence, clauser, davis & brown, 2004), cancer survivors were more likely to have multiple comorbid conditions than were control subjects. cancer specific disease characteristics. cancer survivors may experience various troublesome and unpleasant consequences stemming from either the type of cancer treatment, or other consequences from the cancer. yabroff and colleagues (2004) reported burden (lost productivity, health and functional limitations, and overall preference or desirability of a state of health) of illness in cancer survivors to be linked with type of cancer (i.e. cancers with poor prognoses such as melanoma, lung, pancreatic cancer or multiple cancers) making them more likely to report fair or poor health and to have both physical and emotional limitations. another example of the impact of cancer specific characteristics, oh (2004) and colleagues found differences between women with recurrent breast cancer and disease-free breast cancer survivors in some areas of psychosocial adjustment. domains that seem to be more directly related to the cancer experience (physical components of quality of life, cancer-specific stress, and vulnerability), comprised the majority of the differences between disease-free survivors and survivors who had a recurrence. thus cancer-specific disease characteristics are relevant as a micro level dimension of hrqol. health efficacy. the parent model proposes hrqol outcomes are linked to health efficacy or one’s ability to advocate on their own behalf by engaging in behaviors and health practices to maintain and promote health (ashing-giwa, 2005). this process is influenced by cultural contextual components at the macro level. these include perceptions of medical care, subjective norms for adhering to medical treatments and perceptions of support, all of which are important determinants of health practice and utilization and overall hrqol for cancer survivors (dimatteo, hays, gritz bastani, 1993). psychological well-being. the last micro level dimension of the parent model is psychological well-being, a well documented component of hrqol. research regarding cancer survivors has examined depression, anxiety, and self-esteem within the psychological well-being dimension (deimling, kahana, bowman, & schaefer, 2002; pedro, 2001). in general, research findings support a positive relationship between psychological well-being and increased hrqol. summary and critique of parent model the contextual model of hrqol provides an organizing structure to explore the complexities associated with understanding and measuring hrqol. by adding cultural and socio-ecological dimensions to traditional multidimensional hrqol frameworks and proposing interaction between macro dimensions and micro dimensions, ashing-giwa’s model provides a comprehensive structure for exploring hrqol for cancer survivors. furthermore, the parent model proposes individual level variables that may be used to measure a specific dimension of hrqol. finally, the 4 macro level and 4 micro level contextual dimensions of the model can be used to measure relevant assessment variables of cancer survivors’ at risk for poor hrqol and potential group disparity in hrqol outcomes. although the parent model provides a comprehensive, practical structure to assist culturally responsive research, in its current developmental state it possesses shortcomings as a framework for research. one drawback of the model is its lack of specificity. for example, an online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 85    operational definition to clearly differentiate the macro from the micro level dimensions of hrqol is lacking. conceptualizations for each dimension are offered, yet not fully validated (ashing-giwa, 2005b, 2007). testing is needed for clarity and specificity of the model. furthermore, the weighted importance of each contextual dimension within the macro and micro level dimensions is lacking. for example, if only one or two of the individual level dimensions are accounted for, how will this impact the macro level dimensions and vice versa? must all four dimensions on either the macro or micro level be included in the measurement of cancer survivor’s hrqol? are some model dimensions essential or core and therefore always measured in the assessment of hrqol? if so which dimensions are they? or can one assume that all eight dimensions have equal weight in the assessment of hrqol in cancer survivors? in spite of these shortcomings, the contextual model of hrqol has organizational merit in integrating knowledge regarding relevant contextual dimensions and specific components that impact cancer survivorship into a single, unified schema. the model is conceptually useful in describing the “lived experience” of cancer survivors by acknowledging the influence of both the external (macro) and internal (micro) contexts on hrqol. the inclusion of culture as a contextual dimension provides a mechanism for examining not only the complex nature of hrqol but also culture in its broadest terms (i.e. rurality as culture) and its relationship to hrqol. the formulation of effective survivorship interventions requires isolation of actual and potential sources of differences and similarities in outcomes of care among survivors. this requires examining multiple influences (i.e. demographics, healthcare context, and cancerspecific medical factors). a model such as the contextual model can advance this objective. further operationalization and specificity of the macro and micro dimensions that comprise the contextual model, as well as alternate conceptualizations of all or selected dimensions, could facilitate the measurement of factors contributing to poor hrqol. adaptation of parent model for rural cancer survivors adaptation of the contextual model of hrqol to rural cancer survivors is conceptualized as a comprehensive, evidence-based framework to guide cancer survivorship hrqol research. adaptations to the parent model offer a framework with rurality as a defining factor. this offers the potential for concept clarification and subsequent standardization of hrqol assessment factors for rural cancer survivors. the adaptation of the parent model will facilitate conducting cancer survivorship research that is theoretically grounded and responsive to cultural and socio-ecological dimensions including survivors living in a rural culture. ashinggiwa’s contextual model of hrqol, the parent model, has at its core three key statements or assumptions. table 2 lists these next to the author’s derivations for rural cancer survivors. conceptually, the parent model views culture as a “way of life”. additionally, the model posits that a relationship exists between hrqol and culture. adaptation of the parent model to a rural setting is proposed by expanding the macro dimension of culture to include rurality, thus making the model relevant to a rural population. the terms rural and rurality have been differentiated by some researchers with rural referring to a particular kind of geographic setting and rurality a particular behavior style associated with an individual from a rural area (hoggart, 1990). if culture is defined as a way of life in a group of people with shared values, behaviors, and meanings that stem from learned and accumulated experiences, rurality could be viewed as culture. for purposes of this paper, rurality will be defined as a culture and the parent model will be adapted to explicate the rural dimension of cancer survivorship to the formerly culturally online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 86    table 2. assumptions of parent model and adaptation for rural cancer survivors assumptions in parent model author derivations the model is trans-ethnic and trans-cultural rurality is a defining factor of hrqol for rural cancer survivors at the macro and micro level predictors of hrqol vary across ethnicities predictors of hrqol may vary across levels of rurality ethnic culture is a mediating variable to negative health outcomes rurality as culture mediates negative and positive health outcomes based model. furthermore, it is postulated that rurality can mediate negative health outcomes and will precipitate variations in predictors of hrqol. for the population of rural cancer survivors, the parent model also adds relevant dimensions to facilitate full exploration of the risk factors for poor hrqol and disparities in rural hrqol outcomes. the remainder of this article illustrates theory derivation by expanding culture to include rurality and adapting concepts from the parent model to add meaningfulness to the inquiry of hrqol and rural cancer survivorship (table 3 and 4). the discussion focuses on the adaptation and/or refinement of components within the macro and micro levels of the parent model based on the derived assumption that rurality as a culture, is a defining factor of hrqol. the focus in the adapted model is on those contextual dimensions that are primarily experiential in rural cancer survivorship and an embodiment of rurality in physical or psychosocial states of health and well-being. concepts or components from the parent model will be evaluated for their value in fully understanding and measuring hrqol for rural cancer survivors, accompanied by documentation from the literature for proposed adaptations of the model. the ultimate goal of the adapted contextual hrqol model for rural cancer survivors is to facilitate development of adaptation of the parent model’s macro level dimensions for rural cancer survivors macro level dimensions consist of contexts primarily outside of an individual and not necessarily manipulable by the individual yet which may directly influence an individual’s hrqol. the following section describes adaptation of the macro level dimensions in the parent model for rural cancer survivors (table 3). socio-ecological. the parent model describes the socio-ecological context using selfreported household income, highest level of education completed, life burden i.e. the level of stress associated with various aspects of life such as finances, employment, family, and community relations (ashing-giwa, 2007), and social support. the following adaptation of the parent model’s socio-ecological context to rural cancer survivors is offered: the rural socioecological context consists of common, shared effects of systems and processes in the rural setting that contributes to social cohesiveness that shapes the hrqol for the cancer survivor. a rural socio-ecological context pertains to the social arrangements and behaviors amongst people distanced from points of concentrated population or economic activity. two studies, one by craig (1994), and another by leiper and reutter (2005), illustrate this proposed definition in the adaptation of the socio-ecological context. in an ethnographic study with rural elders, craig (1994) studied “what is the culture of rural community life for elderly residents?” and “what are online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 87    the dynamic processes of rural community life that have links with health of elderly residents?” the author identified relationships, especially reciprocal relationships, as key in understanding the life of rural elders. reciprocal relationships expressed by elders included: they felt they “belonged” to increased feelings of obligation toward each other and to the community as a whole. for example, when an elder who was well known in the community became terminally ill, the community readily offered emotional and instrumental support, which in turn was received willingly by the rural elder, allowing them to fulfill their desire to die at home. additionally, rural elders in the study were more likely to accept a referral for health care if it came from individuals with whom they had relationships, such as family or older friends in the community with similar health conditions. findings from this study are illustrative of social arrangements and shared effects of systems and processes contributing to social cohesiveness that occur in rural settings. leipert and reutter’s (2005) study using feminist grounded theory methods, examined how women maintained their health in geographical, social, political, and economically challenged contexts in a northern rural region of canada. this study identified components of the socio-ecological context (also found in the parent model) that may be applicable to rural cancer survivors. findings from three separate interviews with twenty five women of diverse backgrounds revealed that the women experienced vulnerability to physical health and safety risks, psychosocial health risks, and risks of inadequate health care. the women addressed their vulnerabilities by developing resilience through “making the best of the north” (leipert & reutter, 2005, p. 57). “making the best of the north” meant that women developed and used resources and opportunities available in the community that enabled them to address and sometimes reduce their vulnerabilities and risks. the decision to use available resources and opportunities was influenced by their economic circumstances, educational backgrounds, interests and values. for example, women with lower income and education used more resources by seeking available (although limited), education and information to manage their vulnerabilities. they sought education and information from community colleges, community education programs, nurses, physicians (although few in number), and distance education. this education helped to change their attitudes and provided additional job opportunities which in turn made them able to manage their vulnerabilities. a secondary benefit of educational opportunities such as classes and seminars was the discovery of other women who shared and appreciated their circumstances and who, over time, provided a rich resource for emotional, instrumental, and affirmational support. similarly, this network of support was seen in the majority of rural breast cancer survivors in heishman’s (1999) study which cited friends as more supportive than family members. these two studies illustrate the impact socio-ecologic components in the parent model and rurality can have on hrqol. socio-economic status, life burden and social support in the context of rurality impacts the hrqol of rural cancer survivors (koopman, angell, turner-cobb, kreshka, donnelly, & mccoy, et. al, 2001). rural women have been reported to be especially concerned about role disruptions as a result of a cancer diagnosis and treatment because their role as caregivers are central to their lives (mcgrath, patterson, yates, treloar, oldenburg, & loos, 1999a; mcgrath et al., 1999b). interruption of this role influences their self-evaluation as valued members in their rural communities (lopez, eng, randall-david, & robinson, 2005) and may be a source of “burden” which in turn impacts hrqol. in contrast with non-rural women, rural breast cancer survivors may need to reside away from home for long and/or multiple periods of time for follow up care which is often not available in the rural communities. this can be disruptive to the family online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 88    unit. in some rural settings services (e.g., community services such as child care or home health care) are limited and/or less accessible; therefore rural women cancer survivors have reported needing help with physical and daily living needs. additionally, rural breast cancer survivors report significant relief when they received help with the demands of their traditional gender roles (bettencourt, schlegel, talley, & molix, 2007). although on the surface this finding may not seem very different from the challenges of any woman, they have implications for the conceptualization and accurate measurement of the socio-ecological dimension in the adapted model that integrates rurality as described in the rural cultural context in the next section. for example rural breast cancer survivors may need to purposely anticipate their needs and requests for help with daily living needs due to geographical distance between other women who could serve as resources as opposed to more spontaneous requests for help and subsequent assistance when the day doesn’t go as planned. these implications can inform rural health research strategies to ensure study approaches are designed to be meaningful and responsive to needs of rural cancer survivors. cultural. culture is the way of life in a group of people with accompanying values, behaviors, and meanings (kagawa-singer, 2000) that stem from individuals learned and accumulated experiences. in the parent model, self-reported ethnicity was utilized as a proxy for the dimension of cultural context (ashing-giwa, 2007). in the adaptation of the model to rural cancer survivors, rurality (a lifestyle associated with people living in a rural region) is added and expands on the cultural components described in the parent model. byrd and clayton (2003) define culture as “the accumulated store of shared values, ideas (attitudes, beliefs, and norms), understandings, symbols, material products, and practices of a group of people. culture has material and non-material aspects” (p. 522). additionally purnell and paulanka (2005) define culture as “the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life ways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making” (p. 2). based on these broad definitions of culture, a conceptualization of the rural cultural context in an adapted model includes a lifestyle with attitudinal and structural elements arising from a rural worldview and leading to a creative, dynamic existence to manage the vulnerability (e.g., dependence on others, geographic inequities) associated with living in a rural setting. as a rural resident, one’s ethnic culture or way of life requires integrating the “life way” of rurality. consequently the interactions between one’s inherent ethnic culture and situational rural culture must be considered in the adaptation of the cultural dimension of the parent model of hrqol for rural cancer survivors. since the 2000 passing of the minority health and health disparities research and education act, federal funding agencies have required that researchers address culture. if meanings of health are contextually constructed, then culture must be defined broader than race and ethnicity. culture mediates health outcomes; therefore the assessment and measurement of hrqol in rural cancer survivors must include rurality or the lifestyle associated with being rural residents as part of the cultural context in an adapted model. rurality as culture within the cultural dimension of hrqol is perhaps indirectly supported and illustrated via the documentation of high rates of accidents and injuries and risk-taking behaviors in rural populations (dixon & welch, 2000; national center for health statistics, 2001). it has been suggested that an attitude that does not encourage preventative health behaviors is prevalent in rural areas, as is the attitude emphasizing independence or self-sufficiency (elliot-schmidt & strong, 1997; leipert & reutter, 2005). attitudes such as self-reliance, independence, and a reluctance to seek help, also are displayed in rural cultures (eberhardt & pamuk, 2004; harju, online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 89    wuensch, kuhl, & cross, 2006). these attitudes are linked to income and educational level described in the socio-ecological context of the model and are purported to impact hrqol. the attitude of preventative health as a low priority juxtaposed with the higher priority of work and stoicism seem at odds with each other yet illustrates the realities of rurality. given this “way of life”, rural cancer survivors and their health care providers face unique challenges related to “culture” that impact rural cancer survivorship and development of cancer survivorship treatment plans. leipert and george (2008) report a study of rural women’s health in canada. according to participants in this study, “rural culture maintains aspects of conventionality expressed in traditional gender roles and circumscribed opportunities for women” (p. 215). the expectations and practices stemming from a rural culture can both hinder and empower rural women. for example, women described how traditional role expectations limited their ability to make decisions and be independent. however, these women also described rural community-oriented culture as positive from the standpoint of familiarity with one another that led to an awareness of each other’s needs. these factors contributed to a culture of support that had the potential of fostering women’s health. a similar phenomenon was reported by leipert & reutter (2005) where the rural culture was supportive of women if they subscribed to cultural norms established within the rural community. implied in these exemplars of rural cultural context are rural community values and processes, both of which are fundamental elements in the concept of culture and more specifically rurality in the adapted model of hrqol. demographic. on the surface, labeling a dimension on the macro level of the model as demographic seems redundant to the concepts embedded at the individual level of the model. however, in the adaptation of the model for rural cancer survivors, two potential macro level demographic components are relevant because of their ability to shed light on, or mediate the relationships among variables impacting hrqol for rural cancer survivors: 1) type of employment and 2) years of residence in a rural setting. leipert and reutter (2005) described rural women “making the best of the north” by coping with financial and work issues that illustrates how the demographic of employment may fit as a macro level component of the demographic context. survival in the north meant these women had to be resilient, and had to have adequate and secure finances which sometimes necessitated full and part-time employment. the women’s choices were restricted by the community’s need to limit the amount, type and quality of work options in order to provide some work to as many as possible. in smaller northern communities, women with advanced education found it difficult to find appropriate employment and would engage in part-time employment in a variety of work situations including farming, ranching, retail, and foster parenting. travel risks going to work outside their communities, were associated with the climate and terrain; therefore, these rural women would assume part-time employment locally to maintain control in their lives, while others started their own businesses or sold produce grown on their farms to remain locally. a second demographic component that may impact the hrqol of rural cancer survivors, and thus the necessary inclusion in an adapted model of hrqol, is years of residence in a rural setting. it stands to reason that choosing to live and remain in a rural setting long-term, contributes to or affirms fundamental values and attitudes of rurality. choice of residence is described in the theme “choice” that emerged from a qualitative analysis in a study by lee and winters (2004). choosing to “come to” live and stay in a rural setting was associated with generational and family ties or choosing to leave a more densely populated area, as stated by one rural resident: “i feel our quality of life here is as good as any place in the state” (lee & winters, online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 90    2004, p. 57). arbuthnot, dawson, and hansen-ketchum (2007) reported on rural older women who desired to remain in their own home and community despite the challenges of rural life. the realities of aging in a rural community (distant family members, loneliness, chronic transportation difficulties, and limited access to social resources) were only one aspect of their life as rural dwellers and “ordinary life circumstances of the women were inextricable from their overall sense of happiness and well-being” (p. 44). health care system. the health care context as adapted for rural cancer survivors can be described as the experience of, and access to a range of healthcare strategies. these include formal and informal providers in collaboration with paid or volunteer rural cancer survivors that facilitate rural health determinants and minimize health risks. this dimension of health care in the parent model includes access and quality of health care. this dimension is not only relevant in the assessment of the rural cancer survivor’s hrqol, but may be more significant than in the non-rural environment. access to health care for rural cancer survivors may mean planning ahead and working with family and individuals in the community to coordinate trips to local or distant specialists or appointment times with the availability of telehealth professionals. the difficulty with healthcare access also may be due to disruption of family life and employment (davis, williams, redman, white, & king, 2003). bettencourt and colleagues (2007) suggested that rural breast cancer survivors have distinct experiences and challenges, some of which may best be addressed by “insiders” or health care providers in the community. bettencourt’s review identified rural (vs. urban) women desirous of greater health related information about breast cancer. this implies the need for information sharing and cooperation among oncologists and general practitioners in rural areas to stay knowledgeable about both the needs of cancer survivors and current recommended treatments. these studies support the adaptations made to the components of the health care system dimension from the parent model. table 3. adaptation of the parent model’s macro level dimensions for rural cancer survivors parent model author derivations contextual dimension components +added component *refined component socio-ecological socio-economic status life burden/stress social support +affirmational support cultural ethnicity ethnic identity acculturation interconnectedness worldview spirituality *prominent ethnicity of rural regions +rural cultural attitudes, resilience, definition(s) of health, community values & processes demographic chronological age gender relationship status +type of employment, years and choice to live in rural setting health care system access to health care quality of health care quality of doctor/patient relationship + use of confidence building strategies * preference for “insiders”, individualized communication style online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 91    adaptation of the parent model’s micro level dimensions for rural cancer survivors the micro or individual level of the parent model includes four contexts: general health, cancer-specific medical factors, health efficacy, and psychological well-being (table 4). these describe individual level attributes and perceptions regarding cancer survivors’ hrqol. general health & comorbidities. within the general health and comorbidities dimension, the addition of number of co-morbidities and level of functional status are essential in the refinement of the parent model for rural cancer survivors. rural survivors in general are less likely to access health care regularly and thus are often diagnosed with later stage cancers (weeks, wallace, wang, lee, & kazis, 2006). additionally they may experience complications or exacerbation of their comorbidities that contribute to decreases in function. as a result, the number of comorbidites and functional status are essential components to add in the adaptation of the model. cancer-specific medical factors. cancer specific characteristics are the distinct cancer diagnosis and treatment related variables that individually or in combination elucidate actual and potential health risks for the rural cancer survivor. with this proposed definition in the adaptation of the parent model, along with the dynamic described in the general health and comorbidities context above, it is important to add three components to this micro level dimension. these are new and/or secondary cancers, recurrence of primary cancer, and type of treatment(s). health efficacy. health efficacy is not a concept confined to individuals in a rural setting, but has implications for health literacy and health promotion practices. the health efficacy micro dimension adapted for rural cancer survivors describes the adaptable state of mind that stems from immersion and identity with a rural lifestyle that informs navigational (i.e. problem-solving, resource assessment/evaluation), relational (i.e. neighbor, family, hcp), and table 4. adaptation of the parent model’s micro level dimensions for rural cancer survivors parent model author derivations contextual dimension components +added component *refined component general health health status (disease status, co-morbid illnesses) role limitations * number of co-morbidities, functional status cancer specific medical factors cancer characteristics age at diagnosis stage of cancer time since diagnosis type of surgery adjuvant therapy + new and/or secondary cancers, recurrence of primary cancer, type of treatment(s) health efficacy motivation and know how health practices utilization perceived health efficacy medical adherence +health promotion practices, health literacy, expectation of ruggedness & self-reliance, resilience *confidence psychological wellbeing level of functioning emotional well-being * self-reliance, positive “can-do” attitude online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 92    personal (i.e. communication, psychomotor) skills necessary to thrive in a rustic, country setting and to create viable solutions in the presence of few resources. in the process of theory derivation this proposed definition of health efficacy for rural cancer survivors can inform the research concerning rural cancer survivors. psychological well-being. psychological well-being in the adaptation of this micro level dimension is an individual’s degree of mental and emotional functioning that facilitates hrqol. refinement of the components of this micro level context would include focusing on selfreliance and a positive attitude (arbuthnot, dawson, & hansen-ketchum, 2007; elliot-schmidt, & strong, 1997). measurement of these two refined components from the parent model must occur to have an accurate and relevant understanding of hrqol for rural cancer survivors. summary using a theory derivation process, the author adapted the macro and micro dimensions of the parent model, ashing-giwa’s contextual model of hrqol, by expanding the model’s cultural contextual dimension and refining and/or adding to all dimensions in order to make the parent model relevant to the rural population. the adapted parent model provides the necessary structure for the design of rural health research regarding the complex, multidimensional nature of hrqol for rural cancer survivors. at the macro level, rurality within the adapted culture and social-ecological dimensions must be included in the assessment and measurement of hrqol in the rural cancer survivor population. additionally at the micro level, all four adapted dimensions are essential to comprehensively address hrqol for rural cancer survivors. the adapted model for hrqol in rural cancer survivors derived from the parent model can serve to identify the factors and mechanisms contributing to rural cancer health disparities. theoretical adaptations have been described in this article with the goal of ensuring a comprehensive, context-relevant approach to the assessment and measurement of hrqol for rural cancer survivors. additionally it is anticipated that a broader knowledge of hrqol that elucidates the macro level rural cultural dimension will facilitate health practitioners’ ability to advocate for the needs of this sub population of cancer survivors. directions for future nursing inquiry and theory development may stem from this initial adaptation of the contextual model of hrqol. ashing-giwa’s research questions in the evolving development of the parent model are: a) what are the predictors of hrqol in a multiethnic sample of breast cancer survivors and b) do predictors have similar associations with hrqol for each ethnic group (african-, asian-, latina-, and european american)? the same questions stemming from the adaptation of the model to rural cancer survivors, might include: a) what are distinctive predictors of hrqol in rural cancer survivors? and b) do predictors have similar associations with hrqol for varying levels of rurality (i.e. rural vs. frontier) or rural geographic regions (i.e. south vs. mid-west)? finally, viewing rural cancer survivorship from the perspective of a contextual model of hrqol holds much promise for future research, practice, and health policy initiatives. there remains a paucity of research on how culture becomes manifest in clinical encounters as experienced by rural cancer survivors. this adaptation of the parent model is a step towards addressing the goal of culturally 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[medline]   http://www.ncbi.nlm.nih.gov/pubmed?term=19110911%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=18990160%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22richardson%20lc%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22wingo%20pa%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22zack%20mm%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22zahran%20hs%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=%22king%20jb%22%5bauthor%5d&itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_discoverypanel.pubmed_rvabstractplus http://www.ncbi.nlm.nih.gov/pubmed?term=18219664%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=14692036%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=17023138%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=16824163%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15339970%5buid%5d&cmd=detailssearch 713+school+vision+screening_with_psf_setup-6.8.22+formatted online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 29 school vision screening data informing a county-based community health needs assessment john a. musser vi, bs, mph roots (rural ophthalmology optometry treatment & screening) 501(c)(3) non-profit, rootsmissions@gmail.com college of medicine, university of arkansas for medical sciences college of public health, university of arkansas for medical sciences abstract purpose: the objective of this study was to (i) analyze arkansas school nurse vision screening data, (ii) provide a county-based pediatric vision care need assessment, and (iii) evaluate eye care provider workforce in both rural and urban settings to overcome the vision screening follow-up care gap. methods: descriptive statistics and paired t-tests (p < 0.05) were calculated for the number of students receiving vision screening, number of students referred to an eyecare provider, number of students receiving follow-up vision care, the vision screening referral rate, and follow-up rate for all public and charter schools in the state of arkansas. findings: the mean number of students screened in rural counties (mean +/sd; 1530.5 +/ 1170.9) was statistically significantly (t-test 2-tail, p = 0.003) lower than the mean number of students screened in urban counties (7301.10 +/7663.45). the referral rate was comparable in rural counties (9.41% +/4.95%), compared to urban counties (9.29% +/5.16%). nearly twothirds of the children who failed their vision screening did not receive a follow-up comprehensive eye exam (rural: 68.26% +/17.48%; urban: 66.30% +/11.91%). rural counties had just 1.03 +/ 0.86 eye care providers per 10,000 people, compared to urban counties which had 1.30 +/1.11 eye care providers per 10,000 people. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 30 conclusions: the purpose of school nurses screening children for vision abnormalities is to recognize and treat ailments early to ensure students have the best opportunity to learn. this study unveiled that rural and urban arkansas school children alike go without follow-up eye care after failing their school vision screening two-thirds of the time. rural areas have less eye care providers per capita and have a greater burden placed on each eye care provider, however, the follow-up care rate is comparable in rural and urban areas. keywords: rural eye care, amblyopia; nurse vision screening school vision screening data informing a county-based community health needs assessment background and significance the leading cause of pediatric vision impairment – lazy eye (amblyopia) – is often fully reversible if detected and treated prior to age 5 (donahue et al., 2013). however, if this condition is not treated the brain develops without learning how to properly utilize both eyes. after age 7, some lazy eye vision impairment can be permanent (holmes et al., 2011). the pooled prevalence of amblyopia is 1.44% (95% ci 1.17% to 1.78%) (fu et al., 2020). prior studies have shown that children in medically underserved areas are at the highest risk for underdiagnosis of amblyopia (simmons, 2005). amblyopia once detected in young children is affordably and effectively treated using an eye patch or atropine eye drops (jefferis et al., 2015). by decreasing stimuli to the stronger eye, the brain is trained to reconnect with the malfunctioning eye and it progressively regains its strength and neural pathways. the outcomes are poor for older children and adults – surgical realignment of ocular muscles may be performed with only partial improvement (koo et al., 2017). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 31 in 2006, the arkansas legislature established code §6-18-1501 specifying a pediatric vision screening procedure to be completed by all public and charter school nurses for children in pre-kindergarten, kindergarten, grade 1, grade 2, grade 4, grade 6, grade 8, and all transfer students. prior to this landmark improvement there was no unified policy preventing arkansas children from going through all of primary education without proper vision care. amblyopia, cataracts, and uncorrected refractive error would not be detected early enough to preserve vision and the opportunity for educational achievement. the school nurse vision screening procedure is regulated to include the assessment of gross eye appearance, visual acuity, visual acuity with a +2.00 lens, color perception, binocular stability, and various instrument tests. students with abnormal eye alignment, frequent head tilt, visual acuity of 20/40 or worse, improvement of 2 eye chart lines with a +2.00 lens, incomplete color perception, unequal eye muscle stability, or failure of an instrument test are registered with the department of education screening registry as having a failing vision screening. fast forward 15 years, arkansas nurses screened a total of 206,338 students for vision abnormalities in the 2020-2021 academic year alone. although only 11.7% (24,107) of students failed their vision screening, 68.0% (16,402) of those students failing their screening went without follow-up care from an ophthalmologist or optometrist. when two-thirds of those at risk do not receive the follow-up eye care they need, the purpose of screening has been squandered. this unfortunate reality has been consistently documented in arkansas annual school vision screening reports for years (follow-up rate 2017: 61.7%, 2018: 64.9%, 2019: 65.0%, 2020: 68.7%, 2021: 68.0%) lindsey, n.d.-a, n.d.-b, n.d.c; mcdonald, n.d.-a, n.d.-b). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 32 prior studies have also noted differences in vision care outcomes for rural school children when compared to those living in urban areas. rural areas generally have fewer eye doctors and thus families may have greater difficulty obtaining care. however, numerous studies have unveiled rural school children have comparatively lower rates of myopia, hypermetropia and astigmatism (he et al., 2007; padhye et al., 2009). grzybowski et al. (2020) posited that high population density might be a surrogate for less time spent outdoors and more hours performing near work tasks (grzybowski et al., 2020). the u.s. census bureau had defined urban clusters as having between 2,500 to 49,999 residents and urbanized areas have 50,000 residents or more, comparatively rural is all that is outside of urban clusters and urban areas (as cited in the rural health information hub, n.d.). more specifically, for the purposes of this study rural counties are those that the federal office of management and budget defines as not containing a core urban area of 50,000+ people or an adjacent county that has a high degree of social and economic integration with the urban core (i.e. commuting to work). the purpose of this manuscript is multipronged. the purpose includes: (i) analyze school nurse vision screening data, (ii) provide a county-based pediatric vision care need assessment, and (iii) evaluate eye care provider workforce in both rural and urban settings to overcome the arkansas school vision screening follow-up gap. methods the university of arkansas for medical sciences institutional review board determined that this study was exempt and not considered human subjects research. deidentified school vision online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 33 screening data from the 2020-2021 academic year was acquired from the arkansas department of education on 3/11/2022. descriptive statistics (average, standard deviation) were calculated for the number of students receiving vision screening, number of students referred to an eyecare provider, number of students receiving follow-up vision care, the vision screening referral rate, and follow-up rate using microsoft® excel (version 16.56, redmond, wa) for all public and charter schools in the state of arkansas. the local education agency (lea) code look-up tool on the arkansas department of education data repository was utilized to determine the county in which each school resided. data were combined for all schools within each respective county and subsequently counties were categorized as rural or urban per the omb classification as pictured in figure 1. figure 1 rural vs. urban county classification federal office of management and budget the ophthalmology and optometry workforce was quantified via the 2020 us federal health resources and services administration records and the 2020 arkansas manpower report. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 34 statistical significance was set at ≤ .05. paired t-tests were performed comparing the number of students screened, school nurse referral rate, and student follow-up rate with an eyecare professional in rural compared to urban counties. results of the 1,050 arkansas public and charter schools analyzed, 1019 (97.0%) reported screening at least one student. for the 31 schools without reported vision screening data, 22 (71.0%) were high schools, 3 (9.7%) were preschools, 2 (6.5%) were elementary schools, 1 (3.2%) was a middle school, 1 (3.2%) was a k-12 integrated program, 1 (3.2%) was a civilian training program, and 1 (3.2%) was an online independent learning platform. a total of 230,578 students were screened and 24,116 were referred to an eye care provider. there were 7,793 (32.3%) students who received follow-up care, whereas 16,323 (67.7%) students did not receive follow-up care. the mean number of students screened in rural counties (mean +/ sd; 1530.5 +/1170.9) was statistically significantly (t-test 2-tail, p = 0.003) lower than the mean number of students screened in urban counties (7301.10 +/7663.45). the referral rate was comparable in rural counties (9.41% +/4.95%) compared to urban counties (9.29% +/5.16%). the follow-up rate was similar between rural (31.74% +/17.48%) and urban (33.70% +/11.91%) counties (t-test 2-tail, p = 0.645). figure 2 graphically depicts each counties vision screening follow-up rate. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 35 figure 2 percentage of students without follow-up care both rural and urban county public and charter schools had nearly two-thirds of the children who failed their vision screening go without follow-up care (rural: 68.26% +/17.48%; urban: 66.30% +/11.91%). rural and urban county vision care data analysis outcomes and capacity are summarized in table 1 below. table 1 comparing rural vs. urban county school vision screening outcomes & eye care capacity school nurse screening vision care outcomes & care capacity rural (55 counties) urban (20 counties) t-test (2-tailed) total number of students receiving vision screening 84,175 146,022 referred to an eyecare provider 8,428 15,663 receiving follow-up vision care 2,651 5,094 not receiving follow-up vision care 5,777 10,569 online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 36 average number of students +/sd receiving vision screening 1530.45 +/1170.86 7301.10 +/7663.45 p = 0.0033 referred to an eyecare provider 153.24 +/151.21 783.15 +/984.84 p = 0.0103 receiving follow-up vision care 48.20 +/54.08 254.70 +/349.44 p = 0.0164 not receiving follow-up vision care 105.04 +/104.05 528.45 +/660.99 p = 0.0102 average percentage of students +/sd vision screening referral rate 9.41% +/4.95% 9.29% +/5.16% p = 0.9290 vision screening follow-up rate 31.74% +/17.48% 33.70% +/11.91% p = 0.6445 vision screening no follow-up rate 68.26% +/17.48% 66.30% +/11.91% p = 0.6445 total number of providers ophthalmologists 20 109 optometrists 114 308 combined eye care providers 134 417 combined eye care providers per 10,000 people 1.03 +/0.86 1.30 +/1.11 average number of providers +/sd ophthalmologists 0.36 +/1.04 5.45 +/14.55 p = 0.1348 optometrists 2.07 +/2.33 15.40 +/19.64 p = 0.0069 combined eye care providers 2.44 +/2.91 20.85 +/31.62 p = 0.01759 relative care capacity ratio number referred / number of eye care providers 62.90 37.56 relative care gap ratio number without follow-up care / number of eye care providers 43.11 25.35 the us federal health resources and services administration reported 129 practicing arkansas ophthalmologists in 2020. the 2020 arkansas manpower report reported that there were 422 practicing optometrists. the total number of eye care providers in arkansas was 551. there were 20 counties found to not have a practicing ophthalmologist or optometrist. of these counties, 15 were rural and 5 were urban. rural counties averaged 0.36 +/1.04 ophthalmologists and 2.07 +/2.33 optometrists, whereas urban counties had greater care capacity averaging 5.45 +/14.55 ophthalmologists and 15.40 +/19.64 optometrists. moreover, rural counties had just 1.03 +/0.86 eye care providers per 10,000 people, compared to urban counties which had 1.30 +/1.11 eye care providers per 10,000 people. an assessment of relative need shows that rural providers areas online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 37 have an average demand for service of 62.90 school nurse screening follow-up referrals per provider, which is 67.5% greater than urban eye care providers who have an average of 37.56 vision screening follow-up referrals. figure 3 provides a breakdown of the ophthalmologist and optometrist availability by county. figure 3 eye care professional workforce map note. ophthalmologists by county per 10,000 population note. optometrists by county per 10,000 population conclusion this study unveiled that rural and urban arkansas school children alike go without followup eye care after failing their school vision screening two-thirds of the time. the purpose of school online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 38 nurses screening children for vision abnormalities is to recognize and treat ailments early, ultimately ensure students have the best opportunity to learn. rural areas have less eye care providers per capita and have a greater burden placed on each eye care provider, however the follow-up rate is comparable between rural and urban areas. further efforts are needed to foster community partnership between school nurses who perform the screenings and eye doctors who conduct the follow-up evaluation and treatment. ultimately educating family members, school administrators, and teachers in a more holistic approach may hold the key to improving follow-up care conversion from screening to treatment. researchers have previously identified barriers to eyecare including transportation, logistics, timing, cost, family awareness, health literacy, and access to an eyecare provider (balasubramaniam et al., 2013; elam & lee, 2014; kimel, 2006). a fish bone diagram graphically depicting the layered factors undermining poor nurse vision screening follow-up rates is shown in figure 4. figure 4 barriers to vision care fish bone diagram online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 39 references balasubramaniam, s. m., kumar, d. s., kumaran, s. e., & ramani, k. k. (2013). factors affecting eye care–seeking behavior of parents for their children, optometry and vision sciences 90(10), 1138-1142. https://doi.org/10.1097/opx.0000000000000010 donahue, s. p., arthur, b., neely, d. e., arnold, r. w., silbert, d., ruben, j. b., & aapos vision screening committee. (2013). guidelines for automated preschool vision screening: a 10year, evidence-based update. journal of american association for pediatric ophthalmology and strabismus, 17(1), 4-8. https://doi.org/10.1016/j.jaapos.2012.09.012 elam, a. r., & lee, p. p. (2014). barriers to and suggestions on improving utilization of eye care in high-risk individuals: focus group results. international scholarly research notices, 2014 article 527831. http://dx.doi.org/10.1155/2014/527831 fu, z., hong, h., su, z., lou, b., pan, c-w., & liu, h. (2020). global prevalence of amblyopia and disease burden projections through 2040: a systematic review and meta-analysis. british journal of ophthalmology, 104(8), 1164-1170. http://dx.doi.org/10.1136/bjopht halmol-2019-314759 grzybowski, a., kanclerz, p., tsubota, k., lanca, c., & saw, s-m. (2020). a review on the epidemiology of myopia in school children worldwide. bmc ophthalmology, 20(1), 1-11. https://doi.org/10.1186/s12886-019-1220-0 he, m., huang, w., zheng, y., huang, l., & ellwein, l. b. (2007). refractive error and visual impairment in school children in rural southern china. ophthalmology, 114(2), 374-382. https://doi.org/10.1016/j.ophtha.2006.08.020 holmes, j. m., lazar, e. l., melia, b. m., astle, w. f., dagi, l. r., donahue, s. p., frazier, m. g., hertle, r. w., repka, m. x., quinn, g. e., & weise, k. k. (2011). effect of age on online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 40 response to amblyopia treatment in children. jama ophthalmology, 129(11), 1451-1457. https://doi.org/10.1001/archophthalmol.2011.179 jefferis, j. m., connor, a. j., & clarke, m. p. (2015). amblyopia. bmj, 351. https://doi.org/10.1136/bmj.h5811 kimel, l. s. (2006). lack of follow-up exams after failed school vision screenings: an investigation of contributing factors. the journal of school nursing, 22(3), 156-162. https://doi.org/10.1177/10598405060220030601 koo, e. b., gilbert, a. l., & vanderveen, d. k. (2017). treatment of amblyopia and amblyopia risk factors based on current evidence. seminars in ophthalmology 32(1), 1-7. https://doi.org/10.1080/08820538.2016.1228408 lindsey, c. (n.d.-a). annual summary report for vision screenings in arkansas public and charter schools: school year 2016-2017. arkansas department of education, division of elementary and secondary education. https://dese.ade.arkansas.gov/ lindsey, c. (n.d.-b). annual summary report for vision screenings in arkansas public and charter schools: school year 2017-2018. arkansas department of education, division of elementary and secondary education. https://dese.ade.arkansas.gov/ lindsey, c. (n.d.-c). annual summary report for vision screenings in arkansas public and charter schools: school year 2018-2019. arkansas department of education, division of elementary and secondary education. https://dese.ade.arkansas.gov/ mcdonald, c. (n.d.-a). annual summary report for vision screenings in arkansas public and charter schools: school year 2019-2020. arkansas department of education, division of elementary and secondary education. https://dese.ade.arkansas.gov/ online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i2.713 41 mcdonald, c. (n.d.-b). annual summary report for vision screenings in arkansas public and charter schools: school year 2020-2021. arkansas department of education, division of elementary and secondary education. https://dese.ade.arkansas.gov/ padhye, a. s., khandekar, r., dharmadhikari, s., dole, k., gogate, p., & deshpande, m. (2009). prevalence of uncorrected refractive error and other eye problems among urban and rural school children. middle east african journal of ophthalmology, 16(2). https://doi.org/10.4103/0974-9233.53864 rural health information hub. (n.d.). what is rural? https://www.ruralhealthinfo.org/topics/whatis-rural simmons, k. (2005). amblyopia characterization, treatment, and prophylaxis. survey of ophthalmology, 50(2), 123-166. https://doi.org/10.1016/j.survophthal.2004.12.005 730_revision_730+zen+manuscript+only+psf_set_up_4_13_23+arformatting online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 131 implementing a zen room to influence well-being in rural hospital employees vicki brockman, dnp, rn, nea-bc1 anne dominguez, rn, bsn, cpan \2 regina w. urban, phd, rn, npd-bc, cne, ma-lpc3 1chief nursing officer, texas health harris methodist hospital cleburne, vickibrockman@texashealth.org 2pacu nurse, texas health harris methodist hospital cleburne, annedominguez@texashealth.org 3nurse scientist, texas health resources, reginaurban@texashealth.org abstract purpose: the covid-19 pandemic significantly increased work-related stress and anxiety in healthcare workers worldwide, increasing their potential for burnout. rural hospitals experienced additional challenges as they often provided care with limited resources and staff. efforts are made by rural hospitals to mitigate employees’ work-related stress and anxiety, but few studies or projects have been published that highlight these efforts. our evidence-based practice project aimed to answer the question, does the use of a “zen” or recovery room influence rural healthcare staff stress and anxiety levels during their shift? sample: the project’s convenience sample included 36 healthcare workers and hospital staff in an acute care facility, solely servicing a rural county in north-central texas. method: following the iowa model, a literature search was conducted, and irb review of the project was obtained. a private, restful space was created in a room with soft lighting, a massage chair, aromatherapy, and other various tools for relaxation. from june 2021 – january 2022, all staff were invited to use the room and complete a brief voluntary anonymous survey when they online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 132 entered and exited the room. an additional short-answer survey was conducted in march 2022 to explore employees’ perceptions of the project. findings: on average, participants reported significantly lower levels of stress and anxiety after using the zen room. pre-room anxiety scores significantly predicted participants’ post-room stress levels. barriers to room use included employee’s perception of available time and enough staff during the shift to step away from their duties. conclusion: the availability of private, uninterrupted space decreased staff stress and anxiety and allowed them to return to work with a renewed sense of energy. rural hospitals would benefit in implementing such a space and conducting further research on the effects of stress and anxiety levels, even as covid-19 shifts to an endemic disease. keywords: evidence-based practice project, rural hospitals, healthcare workers and staff, stress, anxiety. implementing a zen room to influence well-being in rural hospital employees problem over the past two years of the covid-19 pandemic, healthcare professionals in acute care settings have faced high levels of ongoing job-related stress, compassion fatigue, burnout, and even post-traumatic stress as they provided patient care in high-census, high-acuity settings. this type of job-related stress is linked to poor mental health outcomes, decreased job satisfaction, and decreased patient satisfaction (the joint commission, 2021; richards, 2020). initiatives to support the well-being of health workers and to keep them from leaving the workforce due to extreme work-based demands and burnout during the pandemic and beyond are recommended (national academies of sciences, engineering, and medicine [nasem], 2019). online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 133 this situation is even more challenging in rural hospitals who often have limited resources. in these settings, the multi-disciplinary team is essential as staff frequently serve in multiple roles and must flex in unique ways to adjust to rapidly changing staffing and patient needs (rural health information hub, n.d.). while front line nursing staff provide direct care to patients, support staff which include security, maintenance, environmental services, and nurses in non-traditional roles ensure they have everything that is needed. challenges faced by the rural health workforce were compounded during the pandemic and included difficulty maintaining appropriate staffing levels and the shrinking availability of healthcare workers during localized surges of covid-19 variants (oster et al., 2022). available knowledge the impact of covid-19 on the well-being of healthcare workers has been the topic of much research. initial research completed in the first six months of the pandemic with healthcare workers reported the most common experiences included feeling stressed (93%), anxiety (77%), and exhaustion / burnout (76%) (mental health america, n.d.). in a survey of nurses in 2021, the american nurses foundation (anf) found that in the previous two weeks, the top five emotions reported by nurses included stressed (75%), frustrated (68%), exhausted (67%), overwhelmed (62%), and anxious (58%) (anf, n.d.). one-third of respondents (34%) rated their emotional health as not or not at all emotionally healthy and 50% indicated that they “maybe” or did intend to leave their jobs within the next six months (anf, n.d.). as a result of the unprecedented stressors faced by healthcare workers, many are at risk for experiencing moral distress and injury (riedel et al., 2022) burnout (leo et al., 2021) and turnover (sinsky et al., 2021; anf, n.d.). interventions are needed to support healthcare worker well-being. online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 134 one recommendation that exists in the literature is to create a private recovery or “zen” room that is designed to provide healthcare providers with an opportunity to step away from the work area if needed for a protected amount of time so that they can rest and regroup mentally (hoolahan et al., 2012). these rooms are often designed for individual use, located away from the work area, provide a massage chair or other restful option, and may offer water or other pre-packaged snacks (sanders et al., 2013; markwell et al., 2016). a restful environment is created through the use of techniques such as aromatherapy, sound therapy, and / or other relaxing visual cues to encourage a moment of mindfulness and recovery (li et al., 2019; salmela et al., 2020). healthcare providers may self-refer themselves to the room after a stressful event or be referred by a supervisor or manager. it is important that the responsibilities of the individual using the room are covered in their absence and that they cannot be contacted or called back to the work area early unless an emergent event occurs (salmela et al., 2020). this offers protected time in the room to the user and permission to relax without fear of interruption. published literature about recovery rooms have reported measuring vital signs, stress levels, and nursing quality of life levels as related outcomes of room use (engen, 2012; hand et al., 2019). pagador et al. (2022) noted significant reductions in nurses’ self-report of emotional exhaustion and anxiety during covid19 after use of a massage chair located in a serenity lounge. although these rooms are likely offered in rural healthcare settings, little information exists about the outcomes of those who use them. rationale professional well-being is defined as “the experience of positive perceptions and the presence of constructive conditions at work and beyond that enables workers to thrive and reach their full potential” (chari et al., 2018, p. 590). well-being in clinicians is closely connected to the concepts of resilience and burnout (nasem, 2019). when well-being at work is not achieved, healthcare online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 135 staff may experience fatigue, depression, burnout, anxiety/stress, and a decrease in physiological and psychological quality of life. the systems model of clinician burnout and professional wellbeing (nasem, 2019). explains that burnout and professional well-being take place within a broader system that consists of the external environment, the healthcare organization, and frontline care delivery. these three levels within the system contribute to job demands (negative factors) and job resources (positive factors), collectively known as system work factors. system work factors have a bi-directional relationship with healthcare staffs’ individual characteristics (personality, coping strategies, resilience, etc.). the outcome of the influence of system work factors and these individual characteristics can range from well-being to burnout and has implications for patient care, healthcare organizations, and society (nasem, 2019). the zen room initiative was designed to offer a job resource to these rural healthcare staff as a work-based option to support their well-being and resiliency during covid-19. specific project aim the purpose of this pilot evidence-based practice (ebp) project is expressed in the following pico statement: does the use of a recovery room (or zen room) influence rural healthcare staff well-being during their shift? for this project, healthcare staff well-being consisted of measuring perceived levels of stress and anxiety before and after room use. methods project context our hospital is a small, but growing, rural facility located southwest of a large metroplex area in the southwestern us. we are a part of a larger hospital system that includes acute care facilities, urgent care, home care, and primary care. as the only hospital in our county, we see a wide variety of patients, with a large population of older patients with multiple co-morbidities online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 136 including copd, chf, and diabetes. services are provided through our emergency room, med/surg/tele unit, icu and step-down units, and women’s services, in addition to surgical services and various outpatient services. our county is designated as a rural county by the federal office of rural health policy and our project is reported using the squire 2.0 guidelines (ogrinc et al., 2016). the overarching goal of our project was to create a safe rest haven or “zen room” for staff to relax and escape the chaos on the units for a short time. this area, located directly across the hall from our chapel, provided a sanctuary of calm with soft lighting, a massage chair, music if desired, aromatherapy, devotional books, and other forms of relaxation. staff were encouraged to use this space as needed before or after their shifts, or even during their break time. we had been discussing this idea for several months in our shared decision-making councils, based on information from the american hospital association and examples from other hospitals who had implemented such a space. following the iowa model of evidence based practice, a brief literature review of available research, evidence-based practice, and quality improvement reports was completed which supported the project. the chief nursing officer (cno) worked with front-line staff to determine their preferences for the space and then used this information to submit a request to our foundation to support the project. as the covid-19 pandemic evolved and it became evident that this was going be a long-term battle, we accelerated the work and were able to open the room during nurse’s week in 2021. intervention after obtaining irb determination that this ebp project was a non-regulated study, the zen room was created using a private room with soft lighting, aromatherapy, a massage chair and a yoga mat. a reference library was provided with information on breathing exercises, stress online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 137 management techniques, community-based resources, and reminders of the mental health resources available to employees. a portable wrist blood pressure cuff that measured heart rates, massage (foam) roller, gratitude journal, and water were also available in the room. the room was directly across from the hospital chapel, so staff could use that space as well if needed. the front-line nurses determined what the room would contain, based on the employees’ feedback, and decorated the space to ensure a peaceful environment. this included positive, affirming wall sayings, pictures of nature / beaches that give a sense of calm, a sand table, and gratitude journals. many hours were spent cleaning the space, moving furniture, decorating the walls, setting up the music and aromatherapy options, and finally installing a white board for feedback that is checked routinely. health care staff who used the room were encouraged to temporarily hand off their patient care or work-related responsibilities to a co-worker, and their portable communication device as they would do when taking a meal break. rules of the room were posted instructing the user how to use the aroma therapy and how to clean the massage chair when finished. access to the zen room was secured with a pin-code lock and a sign was placed on the door to indicate when it was in use. at the beginning of their zen room experience, the user was invited to complete a brief pencil and paper survey as they entered the room and again after their 15-minute massage session was completed. participation in the survey was voluntary, and healthcare staff could use the room with or without participating in the survey. completed surveys were collected using a locked collection box placed inside the room. study data was collected for an 8-month period from june 2021 – january 2022, during the second year of the covid-19 pandemic. an additional followonline journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 138 up questionnaire was sent to all employees via email at the end of the 8-month project period to explore their perceptions regarding the zen room project. measures demographic data collected on participants included age and gender. participants were asked to identify their work role (registered nurse, pct, etc.), indicate whether this was the first time they had visited the room, and if they were selfor co-worker referred. for this ebp project, the use of the zen room as an intervention is defined as spending time in the room and using the massage chair and any other items in the room as needed (ie. aromatherapy, yoga mat, etc.). healthcare worker well-being consisted of measuring perceived levels of stress and anxiety before and after using the zen room by selecting a number that best fit their current experience from 1 (none) to 6 (highest) scale. these investigator-designed questions were intended to describe participant levels of stress and anxiety pre and post-room use in a quick and non-burdensome way and were not intended to be formal measurements of these constructs. a 4-question follow-up survey was sent via email to all employees after the room had been open for approximately 8 months to explore their perceptions regarding the zen room. employees were initially asked if they had used the zen room. for those who responded that they had used the zen room, the following open-ended questions were asked: 1.) what did they like about using the room, 2.) what barriers existed to using the room, and 3.) what suggestions they had for improving the room. for those employees who indicated that they had not used the zen room, they were asked to identify their barriers to using the room. data analysis continuous parameters are reported as mean and standard deviation, and discrete parameters are reported as n and percent (%). shapiro-wilk tests were computed on the pre and post anxiety online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 139 and pre and post stress scales to assess normality. a wilcoxon signed rank test was conducted to determine the differences between participants’ self-reported stress and anxiety levels, before and after zen room use. spearman rank-order coefficient was computed to identify associations between pre-anxiety and post stress levels. linear regression modeling was used to regress study variables (age, gender, role, pre-stress, and pre-anxiety levels) on post-stress levels. all tests were 2-tailed with a study α of .05. analyses were performed using ibm spss 27.0 for windows. qualitative data were analyzed using content analysis. results thirty-six healthcare personnel chose to complete the pre and post room use surveys during the first 8 months that the room was available for use. of these, 89.9% were female and 63.9% were registered nurses. non-rn healthcare personnel included pharmacy, lab, engineering, and patient care technicians. at the time of data collection, half of the project participants (56.8%) reported that this was the first time for them to use the relaxation room. approximately half of the participants (55.6%) referred themselves to use the room, while the remaining were encouraged to use the relaxation room by a co-worker. all participants reported using the massage chair while in the room. the massage chair has a pre-programmed 15-minute massage setting. participants reported spending an average of 15.7 minutes in the massage chair while in the room (see table 1). online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 140 table 1 sample characteristics sample characteristic n (%) mean, (sd), range age (n=35) x = 45.35, (9.64), 30 – 65 gender (n=36) female = 32 (88.9%) male = 4 (11.1%) job title (n=36) rn = 23 (63.9%) non-rn healthcare workers = 11 (30.6%) no response = 2 (5.6%) referral to room type (n=36) self-referred = 18 (50%) co-worker referred = 18 (50%) first time to use room (n=36) yes = 20 (55.6%) no = 16 (44.4%) chair minutes x=15.7, (4.72), 5 – 30 ebp project questions: 1. was there a significant difference between participants’ pre and post stress and anxiety levels? at the beginning of their time in the zen room, participants reported a mean stress level of 3.25 (sd=1.18) and a mean anxiety level of 2.39 (sd = 1.25) on a 1 (none) to 6 (highest) scale. a wilcoxon signed rank test was conducted to determine the differences between participants’ self-reported stress and anxiety levels before and after zen room use. on average, participants reported significantly lower levels of stress (z = -4.86, p < .001) and anxiety (z = -3.68, p < .001) after using the zen room (see table 2). online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 141 table 2 changes in participant stress and anxiety before and after room use. participant ratings mean, (sd), range p stress self-rating pre-chair: x=3.25 (1.18) 1 5 post-chair: x=1.37 (0.66 1 – 5 p < .001 anxiety self-rating pre-chair: x=2.39 (1.25) 1 3 post-chair: x=1.42 (.72) 1 – 3 p < .001 2. do any study variables predict post zen room self-reported stress levels? linear regression modeling showed that only pre-anxiety scores predicted post-stress levels (t = 2.38, p = .024). participant age, gender, role, and pre-stress levels were regressed on post-zen room self-reported stress levels and did not contribute to a meaningful model. pre-anxiety levels were significantly but only moderately correlated with post-stress levels (rs = .399, p=.024). post-project follow-up survey results. sixty-four employees responded to the follow up survey. of these, 62.5% (n = 40) reported using the zen room at least once in the past 8 months. for these respondents, using the massage chair was identified as the primary benefit of using the room. as described by one respondent: “the massage chair is very relaxing. i thought it was going to make me sleepy, but actually i feel more invigorated afterwards. it is also a quick mental break.” secondary benefits of using the room that were appreciated by respondents included the aroma therapy and availability of yoga mat. the environment of the room was seen as a positive benefit, with respondents using the words: quiet, peaceful, dark, relaxing, and solitude to describe their experiences. another respondent offered: “i loved the massage chair! the dim lights and aromatherapy are very calming.” for some, the zen room also represented having protected time to stop, wind down, or regroup, as online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 142 described by this participant: “i was able to relieve my headache. i have used it several times to for headache and to regroup after a code.” many also expressed their gratitude for the availability of the room. one employee shared: it has truly been a blessing to me in moments of stress or simply just wanting to get some silent time. thank you for thinking of others when you created such a wonderful and such a needed atmosphere of rest, creativity, and mental escape. for these respondents, the biggest barriers to using the room were finding the time to go and having someone available to relieve them temporarily from their patient care duties. suggestions for improving the room included adding a fan to help if the room felt “stuffy”, reminders as you exit the room to change the door sign back to “available”, a phone re-charging station, and consistent availability of water for refreshment and to refill the diffuser. for those survey respondents who had not yet tried the room (n = 24), the following barriers were identified: feeling like there is not enough time to go or no one available to provide a break to go, not knowing the room code, arriving to find the room is already in use, or forgetting that the room is available for use. discussion summary of key findings and strengths of the project implementing a zen room project in a small, rural hospital setting for use of all healthcare workers and staff resulted in several key findings related to well-being in these employees. healthcare workers and staff reported significantly lower stress and anxiety levels after zen room and massage chair use. participants with lower anxiety levels before room use were more likely to report significantly lower levels of self-reported stress levels after room use. a strength of this online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 143 project is that the room was made available to all employees, not just nursing staff, and 30% of the survey respondents described themselves as non-rn healthcare workers. interpretation in our project, participants reported significantly lower levels of stress and anxiety immediately post chair use. this is similar to the findings of engen et al. (2012) who reported reductions in stress and anxiety after experiencing massage therapist-provided chair massages. hand et al. (2019) also reported significant reductions in perceived stress before and after 15minute mechanical chair massage sessions, while pagador et al. (2022) and hand et al. (2019) noted significant reductions in anxiety after chair use. the world health organization (2022) noted that the global prevalence of depression and anxiety increased by 25% during the first year of the covid-19 pandemic. the american nurses foundation noted in2023, that 75% of nurses reported experiencing stress in the last two weeks, while 58% reported feeling anxiety (anf, 2023). a novel and unsurprising finding for this study is that participants with lower anxiety levels before room and / or chair use were more likely to report significantly lower levels of self-reported stress levels at the end of room and / or chair use. when viewed in light of the systems model of clinician burnout and professional well-being (nasem, 2019), the zen room is a job resource that can positively impact the well-being of rural healthcare staff who are provided with opportunities to utilize it while at work which in turn can help to support quality patient care. while previously published research has focused on nursing use of the room, we encouraged all employees to utilize the space when needed, and to participate in the ebp surveys when using the room. in a small rural setting, staff are often like an extended family, and we wanted everyone to benefit from this opportunity. the room has been used by nursing, pharmacy, maintenance, case online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 144 managers, registration, and radiology staff. in addition, the location of the room away from patient care areas was essential, to prevent interruptions and support a quiet environment. the chapel / chaplain office directly across the hall was an added benefit that allowed spiritual support when needed. qualitative data suggested that those who used the room appreciated the protected space and time to relax and refocus that the room offered, while others identified a lack of time as the biggest barrier to room use, consistent with the findings of salmela et al. (2020). initial costs for the zen room were covered by a proposal funded through donation dollars to the healthcare system, reducing the opportunity costs for the rural facility to the time needed to coordinate the initial set-up of the room and data collection. additional opportunity costs to consider include the timing of offering breaks to direct patient care staff to step away from the units while ensuring the coordination of patient care continues smoothly and safely. ongoing ownership and maintenance of the room needs to be determined, which could be an excellent clinical ladder opportunity. it would be beneficial to create a system to track room usage and identify if there is a need for more structured scheduling of the space. this could be done with a manual log, or even a qr code on the door for staff to complete. in addition, staff suggestions for improvement should be solicited and implemented when possible. limitations this was a single-site ebp project conducted in a small, rural hospital using a convenience sample, so generalizability is limited. while the pre-post survey was easy to complete, there was limited data collection due to participants not completing both surveys. findings might not be reflective of non-pandemic or non-rural settings. conclusions online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 145 self-care during a time of stress and uncertainty is vital to ensure individual well-being and to promote resilience. the covid-19 pandemic and subsequent surges resulted in patients with increased acuity and complexity that required staff to continuously wear ppe, learn new patient care interventions and often work with contract staff who were new to the facility. all of these factors accumulate resulting in a very high-stress and at times chaotic work environment. the availability of an area to retreat and relax with either a 15-minute chair massage, meditation, yoga, or simply listening to soft music in an uninterrupted space decreased staff stress and anxiety and allowed them to return to work with a renewed sense of energy and positivity. our findings, while on a smaller scale, were similar to other studies and we recommend the implementation of a zen or relaxation room and a process for determining the use and impact of this type of intervention for hospitals in rural settings using an ebp model. more research is needed to determine what types of additional job resources (system work factors) to support well-being and resilience may be valued by healthcare workers in rural settings. while this project was implemented during a crisis time, the results should be sustainable over time with these additional recommendations. as covid-19 shifts to an endemic disease, we will continue to support the use of the zen room and look for additional ways to support the well-being and resilience of our healthcare staff. funding this project received internal funding ($2,625.00) from our healthcare system foundation. acknowledgements thank you to all the staff who took the time to participate in our surveys, as well as to anne dominguez, rn, bsn who spent many hours preparing and maintaining the room for staff. online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 146 references american nurses foundation. 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(2022). a scoping review of moral stressors, moral distress, and moral injury in healthcare workers during covid-19. international journal of environmental research and public health, 19(3), 1666-1686. https://doi.org/10.3390/ijerph19031666 rural health information hub. (n.d.). rural healthcare surge readiness for inpatient and hospital care. https://www.ruralhealthinfo.org/healthcare-surge-readiness/inpatient-hospital-care salmela, l., woehrie, t., marleau, e., & kitch, l. (2020). implementation of a “serenity room”: promoting resiliency in the ed. nursing, 50(10), 58-63. https://www.doi.org/10.1097/01. nurse.0000697160.77297.06 sanders, c. l., krugman, m., & schloffman, d. h. (2013). leading change to create a healthy and satisfying work environment. nursing administration quarterly, 37(4), 346-355. https://www.doi.org/10.1097/naq.0b013e3182a2fa2d sinsky, c. a., brown, r. l., stillman. m. j. & linzer, m. (2021). covid-related stress and work intentions in a sample of us health care workers. mayo clinic proceedings: innovations, quality & outcomes, 5(6), 1165-1173. https://doi.org/10.1016/j.mayocpiqo.2021.08.007 online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.730 149 world health organization. (2022). covid-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide. https://www.who.int/news/item/02-03-2022-covid-19pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide hewittt_582-other-3717-1-6-20191018 (1) online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 127 barriers to primary care access in rural medically underserved areas suzanne hewitt, dnp, aprn, fnp-c 1 susan mcniesh, phd, ms, rnc-ob 2 lilo fink, dnp, fnp-bc 3 1 consortium doctor of nursing practice program, california state university northern california, suzanne_h_hewitt@hotmail.com 2 professor emerita, the valley foundation school of nursing, san jose state university. susan.mcniesh@sjsu.edu 3 part time faculty, doctoral program school of nursing, walden university, rlilofink@gmail.com abstract purpose: to explore patients’ perceptions of factors that combine to limit or prevent access to primary care in rural medically underserved areas or populations (muaps ). sample: two focus group sessions were conducted with a sample of eight rural community members. participants were identified as having had a minor illness or injury in the previous six months and having been unable to access their primary care provider (pcp) for care. method: this qualitative study used data generated from comments shared by participants of the focus groups in response to a series of open-ended questions designed to promote meaningful dialogue. the sessions were audiotaped and transcribed by a professional transcription service. the transcribed data was then analyzed by the authors using qualitative content analysis methods online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 128 to classify the data into themes. findings: analysis of data generated from the focus groups identified three dominant themes: people living in rural muaps have unique health care needs when compared to residents of urban or metropolitan areas; rural community members perceive an inability to access their pcp for sudden or unexpected illness or injury leading to foregone care, delayed care or seeking care in the emergency department for nonurgent problems; and the same-day, walk-in, immediate care model is meeting the needs of these patients. conclusion: the 20% of the u.s. population living in rural areas who are being cared for by only 10% of the nation’s primary care providers often lack access to safe, timely, effective, efficient, equitable, and patient-centered health care. implementation of care models similar to the immediate care model in this study may offer rural community members prompt, competent, evidence-based treatment from a nurse practitioner in a timely manner. keywords: rural, healthcare, access, barriers, immediate care, nurse practitioner, aprn barriers to primary care access in rural medically underserved areas persons living in rural, medically underserved areas (muas) throughout the united states experience more barriers to accessing healthcare than their urban counterparts (rural health information hub [rhihub], n.d.a.). nationally, 20% of the population lives in rural areas but only 10% of physicians practice in rural areas (hospitals & health networks, 2016). vulnerable populations, including persons living in designated primary care shortage areas, often lack access to safe, effective, timely, equitable, and patient-centered care (mareno, 2016). as more patients have become insured under the affordable care act (aca), providers and health professionals are required to see more patients with less time allotted for the encounter (u.s. health policy online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 129 gateway, n.d.). factors that contribute to the shortage of healthcare providers include: (a) the retirement of practicing providers, (b) inability or unwillingness to accept new patients by aging providers seeking to reduce their workload, (c) difficulty in recruiting and retaining new providers to rural areas, and (d) the fact that fewer medical students are pursuing family practice careers, leaving a smaller pool of physicians to serve in rural areas (ewing & hinkley, 2013). the institute of medicine published a framework for assessment of quality in health care in 2001, which lists six domains for quality measurement. the six domains of health care quality are known by the acronym steeep: safe, timely, effective, efficient, equitable, and patient-centered (agency for healthcare research and quality [ahrq], n.d.). persons in rural, medically underserved areas are frequently unable to access health care in a timely or efficient manner, and may be utilizing the emergency department (ed) inappropriately, which is not equitable, or foregoing care, which is not safe or effective. additionally, these community members often forego routine preventative exams and screening for preventable or treatable conditions. leight (2003) applied the vulnerable populations conceptual model (vpcm) to rural health and noted that patients who are unable to access necessary health care are vulnerable to higher rates of chronic illness and disability and higher morbidity rates because of delayed diagnoses and increased illness (leight, 2003). flaskerud, who along with winslow first described the vpcm, noted in 1999 that “research has shown that lack of resources, rather than the presence of risk factors, is the best predictor of illness and premature death in vulnerable populations” (nyamathi, koniak-griffin, & greengold, 2007, p. 6). compared to urban areas, rural areas have higher ageadjusted rates of death from the five leading causes of death in the united states: heart disease, cancer, unintentional injury, chronic lower respiratory disease, and cerebrovascular accident or stroke (moy et al., 2017). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 130 literature review previous studies of perceived barriers to health care access have been conducted through mail surveys and telephonic follow up and have been largely quantitative. a 2017 study by allen, call, beebe, mcalpine, and johnson, with a sample size of 2,194, looked at barriers to health care among adults with medicaid insurance in the state of minnesota and identified barriers as either patient-related, provider-related, or system-related. patient-related factors included family or work issues and unavailability of childcare. provider-related factors included perceived discrimination based on sex, race, ethnicity, nationality, ability to pay, or enrollment in a public health care program. providers who did not speak the language, understand the culture or understand the religious beliefs of the patient were seen as barriers at this level, as were providers who were not perceived as trustworthy or having a welcoming office. coverage barriers, financial barriers, and access barriers were all identified as system-level factors: lack of knowledge about services covered by the health plan, worrying about the cost of services or medications, inability to get an appointment, inconvenient office hours, problems with transportation, and inability to see the provider of choice. this study also identified three negative outcomes as a result of barriers to accessing health care in this population: (a) delayed care, (b) foregone care, and (c) no preventative care in the past year. a second quantitative study, published in 2015 by hefner, wexler, and mcalearney, used questionnaires administered to a non-random convenience sample of 859 patients who had sought care for non-urgent complaints at one of two urban emergency departments (eds). access was examined using the aday and andersen framework. the researchers concluded that uninsured patients cited income and transportation as the greatest barriers while insured patients reported primary care infrastructure barriers such as waiting times and difficulty being seen during business online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 131 hours due to employment. an unexpected finding of the study was that 25% of insured respondents felt that they had no barriers to receiving health care in a primary care office, although they were still utilizing the ed for non-urgent complaints. mortensen’s 2014 quantitative study of 2,733 medicaid enrollees analyzed the relationship between access to providers and ed utilization and found that age, sex, race or ethnicity, marital status, education and employment status were not predictive of ed utilization but that poor health status, chronic conditions, and the presence of disability were associated with more frequent ed visits. the data showed a correlation between perceived ability to access primary care and the number of ed visits by enrollees. the study reinforces the findings of the later study by hefner et al. (2015) that medicaid enrollees who are unable to readily access primary care will seek care in the ed. few recent qualitative studies using focus groups to generate data on patients’ perceptions of barriers to primary health care access have been published. one very recent study used focus groups to examine the perceptions of 15 socio-economically disadvantaged persons over the age of 65 living in rural england. this study interpreted data in terms of a social contract that the focus group participants expected their practitioners to honor: if the patient didn’t “bother” the provider with minor issues, he or she expected to be accommodated promptly when they needed to be seen for an unplanned illness or malady. patients considered their contract to be breached when they were unable to be seen for episodic illnesses, using the words “unwelcome”, “nuisance,” and “not worth anything” to describe their feelings of marginalization. these focus group participants specifically cited difficulty in getting through on the phone to make an appointment, unfavorable interactions with receptionists, and a lack of available appointments as the greatest barriers to access (ford et al., 2018). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 132 thus, a number of quantitative studies exploring barriers to health care in rural areas were found with the majority of the studies looking specifically at elderly populations. there was only one review article, douthit, kiv, dwolatzky, and biswas (2016) that examined barriers to health care in rural populations before and after passage of the aca. in our review of the literature, there were no recent qualitative studies conducted in the u.s. purpose of the study an evidence-based, qualitative study was designed to increase understanding of the factors that, according to patients’ perceptions, combine to limit or prevent access to primary care in one rural mua in northern california. the question that this qualitative study proposed to answer was “how do patients living in rural, medically underserved areas perceive their ability to access primary care services within their community?” the purpose of the study was to examine perceived access to primary care through data generated from two patient focus groups, and to propose practical solutions to perceived barriers. the study sought to generate data on how patients saw their ability to access primary healthcare, what they perceived as barriers to their ability to access health care, and what they perceived as possible solutions to these barriers. further, the researchers aimed to utilize the data generated to form the basis for a model of care that can be presented to health care professionals and administrators with the purpose of facilitating access to primary healthcare in this and other similar rural communities. methodology this study used qualitative and quantitative methods of research. focus group sessions were conducted to gather qualitative data identifying barriers to healthcare access as perceived by community members. a retrospective review of 1,868 immediate care patient charts was made to extract data on patient insurance type and patient provider type. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 133 sample this evidence-based qualitative research study used data generated through focus group sessions to identify problems with current processes for procuring care in the event of unexpected illness or injury among members of a rural northern california community. purposive, or purposeful, sampling was utilized to identify those patients who live in the community (as opposed to tourists) and had used a walk-in immediate care clinic within the previous six months for minor medical complaints or injuries that were within the common realm of primary care. examples of chief complaints included respiratory infections, influenza, ear infections, urinary tract infections, abscess and cellulitis, sprains and strains, and minor wounds. twenty-four community members were invited, by e-mail, to participate in the focus groups: twelve responded that they would participate, four cancelled on the day(s) of the sessions, and eight participated. the study was approved by the california state university (csu) fresno school of nursing institution review board (irb, protocol number dnp 1825). permission to conduct the study was granted in a letter of approval from the participating institution, which has no irb, deferred to the review and approval by csu. the two focus groups were composed of eight participants: five females and three males. one participant was in the 30-44 years age group and the remaining participants were age 65 or older. one group member had private insurance while the remainder were insured through either medi-cal or medicare. all but one participant were retired or unemployed; five were unmarried whereas three were either married or in a domestic relationship, and all participants identified their race as being white or caucasian. all participants had used the immediate care clinic at least once in the preceding six-month period. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 134 risks associated with the subject’s participation in the study were those inherent in any focus group session: there is always the possibility that a participant will know, or know of, a fellow group member. participants were advised that if they felt the least bit uncomfortable, the participant could join another group at another time or withdraw from the study. an agreement was made, verbally and in the consent form, that group members would not share information with outsiders or talk between each other. any opinions given or suggestions made during the group sessions that were used in the final project remained anonymous and personal information was not published. setting for study the centers for disease control and prevention (cdc), national center for health statistics (nchs) classifies populations into metropolitan (urban) and nonmetropolitan (rural) categories to better monitor the health of urban and rural residents (cdc, ncvs, n.d.). metropolitan, or urban, areas are further categorized as: (a) large central metropolitan areas with populations of 1 million or more, (b) medium metropolitan areas with populations of 250,000-999,999, and (c) small metropolitan areas, small towns or suburbs with populations of 50,000-249,000. nonmetropolitan, or rural, areas include: (a) micropolitan areas, rural counties where there may be a small urban cluster of 10.000-49,999 residents; and (b) noncore areas, counties that did not qualify as micropolitan areas. the county where the study took place is classified as a micropolitan area (hing & hsiao, 2014 ). all of the county in northern california where the study was conducted has been designated a medically underserved population (rhihub, n.d.b.). the county covers nearly 4000 square miles (zip-codes.com, n.d.) with a reported 159 providers for a population of 87,497 or a provider-topopulation ratio of 1:550. there are three hospitals in the county. the specific area of the county online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 135 where this study was conducted was within the primary service area for a 25-bed rural district hospital with critical access status. focus group sessions. the focus group sessions followed a written guideline so that content of the sessions would flow in a similar pattern. the sessions began with a statement of the purpose and goals of the focus group sessions and a brief overview of the project goals. this content was followed by an overview of confidentiality expectations, consent form signatures, and assignment of identifying numbers to members. a number of open-ended questions were asked to move the conversation in a direction that was designed to promote meaningful dialogue. the opening question asked the participant what they would do if they had a minor medical complaint or injury. from there, the conversation was steered toward ease of making appointments, frequency of routine healthcare screening, delayed or foregone care, the need for specialty consults, utilization of the emergency department for non-urgent care, personal barriers to access, barriers related to individual providers or clinics, and systems barriers. transcriptions and analysis. once a paid professional transcriptionist transcribed the data from the recorded sessions, the primary researcher, her chairperson, and her committee members used a qualitative content analysis technique to analyze the content. qualitative content analysis requires review of the transcripts, examining the language within the content of the transcripts, and classifying the data into themes relevant to understanding the phenomena being studied (hsieh & shannon, 2005). qualitative content analysis can be utilized through one of three possible approaches: conventional, directed, or summative. the conventional approach was used for this study as it online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 136 allows for data collection through open-ended questions, or probes, to develop categories, or themes, derived from actual data (hsieh & shannon, 2005). results the results of the retrospective chart reviews, combined with the responses of the focus group participants, yielded three relevant concepts. first, patients with minor illnesses or injuries are choosing to visit the immediate care clinic when they are unable to see their own pcp. second, patients are visiting this clinic whether they are publicly insured, privately insured, or uninsured. and third, patients are visiting the immediate care clinic regardless of whether they have a primary care provider or not. the logical interpretation of these findings is that immediate care is a viable solution to the problem of foregone care, delayed care, and ed utilization for non-urgent problems. during the six-month period from august 1, 2018 through january 31, 2019, a total of 1868 patients were seen in the immediate care clinic between the hours of 9:00 a.m. and 6:00 p.m., monday through friday. ibm spss was used to run frequencies analyses of two demographic variables collected from these 1868 patient encounters. the first variable analyzed was insurance type: medicare, medi-cal, blue cross, blue shield, commercial, government payer, or uninsured. the largest number of patients, over 44%, were covered by medicare or medicare managed care. the next largest group, at 30%, was blue cross or blue shield followed by medi-cal and medical managed care at 14%. six percent of patients were uninsured and six percent were covered by commercial or government payers. the second variable analyzed the provider types. nearly half of the patients seen in the immediate care clinic over this six-month period, almost 48%, reported seeing one of the seven pcps (four physicians, two nurse practitioners, and one physician assistant) who practice in the same rural health clinic where this immediate care practice is located for their primary healthcare. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 137 nineteen percent were regular patients at one of the other two rural health clinics in the area. all three rural healthcare clinics are located within a quarter-mile of the area’s only hospital. just over 17% of patients reported having no pcp. eight percent of patients using the services at the immediate care clinic were established with one of the area’s five providers who are in private practice (three physicians and two nurse practitioners) and the remaining eight percent of patients had providers who were outside the local geographical area. analysis of the transcribed focus group sessions identified three themes. the most prominent theme was that people living in rural areas or communities have unique health care needs when compared to residents of urban or metropolitan areas. a second theme identified a perceived inability by community members to access care through their primary care providers (pcps) for sudden, or unexpected, episodic illness or injury and that the inability to access care leads to foregone care, delayed care, or seeking care in the emergency department for non-urgent problems. the third theme, unexpected at the inception of this project, emerged during the focus group sessions and indicated that the same-day walk-in services provided at a local immediate care clinic were meeting the needs of patients who would otherwise have foregone care, delayed care, or sought care in the emergency department for a non-urgent problem. patients want to be seen as whole and unique individuals focus group participants described several encounters with providers wherein they did not feel that their unique needs were addressed. one participant stated that he and his wife have had issues with some of the providers which necessitated transferring care to a new provider while another participant expressed “disgust” with a provider who “hardly looked at me, i mean literally looking at the computer instead. didn’t touch me. and i felt like a waste of time.” participants in the focus groups interpreted time spent on the computer as time not spent on their care: a third online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 138 group member, noting that the provider spent time on the computer that should have been spent focusing on the patient, suggested the use of an audio-recorder with translation by a scribe. another group member stated that when her regular pcp became ill and cancelled two appointments, she “finally did get an appointment, it was one of the visiting or rent-a-docs, i call it, and he was terrible. he saw me for 15 minutes exactly, all he did was listen to my heart, he didn’t have my lab work, and he didn’t know anything about me.” this particular patient identified three areas of concern in her statement: the length of time the provider spent with her, the brevity of the physical exam, and the fact that the provider did not appear to know her past medical history including most recent lab results. she also stated that she was so disappointed that she changed from her regular pcp at the hospital clinic to another provider in private practice. she also stated that she took this matter to the hospital board. all eight focus group members verbalized concern over the shrinking pool of available local providers and acknowledged that there are challenges in recruiting and retaining quality healthcare providers to the area. they also expressed dissatisfaction with the practice of staffing clinics with locums, or temporary healthcare providers. the participant who rated her care from a locum provider as “terrible” went on to say, “it’s not as if they’ve been here a long time and they’re going to stay. so i think that has a great effect on the way they treat patients. they’re just passing through: i felt totally disrespected. i’m in my 80’s, so i have a few problems and he didn’t deal with even one of them”. this comment is rich in information. it is the perception of the patient that temporary health care providers don’t feel the same connection to, or respect for, the community that a more permanent provider may have. this participant also acknowledges that her age and additional health problems are a real concern. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 139 community members perceive significant barriers to primary care access members of both focus groups, all of whom reported having a regular pcp, were next asked to share their experiences in attempting to make an appointment for an unexpected illness or injury with their pcp. one participant stated “i wouldn’t even bother calling (my pcp) …you call your provider and they tell you that you’re maybe going to see them in two to three weeks, if you’re lucky.” this participant, however, also admitted that he has had some success putting himself on the cancellation list and being seen within 24 hours. other group members did not have experience with the cancellation list. “i normally don’t call a provider for anything other than something i know i can wait two weeks for an appointment.” a third respondent stated that if she needed to be seen “quickly” (which she quantified as being seen in the next week or two), she would not be able to see her regular pcp and would have to see another provider. a fourth group member related being very sick with bronchitis, having trouble breathing and wheezing, and being told she could be seen in a “couple of weeks.” she advised the scheduler that she needed to be seen “now” and “somehow or other they arranged something.” participants were asked if they could give an example of any time that they, or someone they knew, had a significant delay in receiving medical care or had gone without care because they could not get in to see their pcp. the statement, “if i was bleeding but not bleeding badly, i’d probably wait a little bit” was echoed by another group member who said, “if it was a cut or rash, unless it was really scary and went on for days, i would probably deal with it myself. i’m not a medical person, but i’ve been around long enough.” these responses are examples where decisions to delay or forego care for injuries with bleeding are being made by persons with no medical background who make reference to “bleeding – but not bleeding badly” and not seeking care unless the condition “was really scary or went on for days.” another member responded that online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 140 she “would first try massage, or acupressure, or acupuncture, or a chiropractor, or talk to friends and naturalists,” noting that the staff at one local health food store was quite valuable as a source of health care information. the group also shared a mutual respect for the local pharmacists, citing that they are “very, very well-trained and extremely helpful.” one participant mentioned that if she is prescribed a new medication, she will ask her doctor about it, “but then i go to the pharmacy, and i ask them about it. and they’re very knowledgeable.” focus group members were asked if they, or someone they knew, had used the ed for nonurgent problems because they could not be seen elsewhere. several members gave the example of a urinary tract infection (uti) as a minor but time-sensitive illness for which they would seek care in the ed if they were unable to see their pcp. one participant stated, however, that the wait for care in the ed can be quite long, citing the experience of having a five-hour wait. the participants repeatedly mentioned uti, which is a medical diagnosis requiring urine culture, when they likely meant symptoms of uti, which can include dysuria, urinary frequency, urgency and hesitancy. patients are frequently unable to differentiate between symptoms of a generally benign illness and those of a more serious or emergent nature. immediate care is meeting the needs of community members requiring care for unexpected or episodic illness or injury the first question posed to the groups at the beginning of each session was “what would you do if you had a minor medical complaint such as a rash, earache, cough, flu, or urinary complaint, or if you had a minor injury like a sprain or strain, cut or other minor wound, or a back injury?” the unanimous response: “go to immediate care” referring to the immediate care clinicaffiliated with the local critical access hospital (cah). specific comments were, “i would online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 141 probably go to immediate care for that,” and “i wouldn’t even bother calling (my pcp), i’d just go to immediate care.” one participant polled her neighbors prior to coming to the focus group session and presented a list of suggestions to improve health care in the community: topping the list was the recommendation that “immediate care should be available seven days a week from 8:00 a.m. through 8:00 p.m.” other group members commented that it would be helpful if immediate care were available on weekends, even if only for half a day, specifically stating “it would certainly help the community of people who have to work” and that you could “rely on kids getting sick on the weekend.” a participant who had moved here from out of state expressed surprise when he “found out there was nowhere to go on saturday and sunday for immediate care.” access to routine health care screening all participants reported having received regular medical screening for hypertension, diabetes, and depression as well as applicable screenings for cervical, colon, and breast cancers. the reported barriers arose when these same patients sought care for unplanned medical problems. two members of one group noted that they were old enough that they were no longer candidates for routine screening colonoscopies “because of perforation problems”. the youngest participant, who was in the 30-44 year age bracket, stated that he was “about to be in the age bracket where it’ll be worthwhile.” this comment is relevant in that it shows that the patient has been made aware of screening guidelines. participants shared that their providers had regularly discussed with them the recommended clinical preventative services, as identified by healthy people 2020 (n.d.a.). contrary to the findings of the study by allen et al. (2017), which examined barriers to health care among adults with medicaid insurance, the participants of these focus groups did not forego preventative care because of barriers to primary care access. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 142 specialty services rural communities frequently lack specialty services that are common in more urban areas. participants were asked how they felt about their ability to get specialist care if needed. the responses were numerous and emotional. a member of one group started the conversation by stating “i feel like the specialist situation is a disaster, a complete disaster. we live so far from anything else and we don’t have people here that are skilled enough or diverse enough to take care of the needs of the young and of the aging population.” the fact that the next closest town with more expansive medical specialty services is over two hours away was a special concern for one participant who shared that “since i’m in my 80’s, i’ve gotten very anxious about what i feel is a lack of healthcare here. and i even thought about leaving the area and going to another area where i would be closer to a hospital that is solvent, and specialists, and better healthcare although i really don’t want to leave the area.” this sentiment was shared by another member whose mother had a heart condition and, although the woman “would have loved for her to move here … (but) the medical care wasn’t good enough”. for the elderly, proximity to health care services was a significant factor in where they chose to live. the group discussed the fact that, currently, a cardiologist and a urologist travel to the area two days each month to see patients in the community. specialty services were once offered in this rural area, but are no longer available. these services included pulmonology, dermatology, gastroenterology, endocrinology, nephrology, and neurology. one participant, who moved to the area within the past few years, stated that people in this area pay a little extra (by purchasing an annual contract) for air medical transport insurance in the event they need to be transferred emergently from the local critical access hospital to a hospital offering specialty services in another town. another group member mentioned that he had numerous friends who had been hospitalized online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 143 out of the area because they needed specialty care and how this geographical separation is detrimental to the recovery of the sick person who may be hours away from members of his or her support system. discussion focus group participants in this study agreed that they want to be seen as whole and unique individuals by providers they trust, i.e., providers who are permanent, rather than temporary, members of the community and who will spend time listening to them. they understand that living in a rural area presents a unique group of challenges to quality health care including a diminishing number of providers and a lack of local specialty and consult services. while participants stated they were able to access their pcp for routine and preventative care, they unanimously perceived an inability to access primary health care services for sudden, or unexpected, episodic illness or injury which, prior to the establishment of an immediate care clinic, led to foregone care, delayed care, or seeking care in the emergency department for non-urgent problems. all focus group participants stated that their health care needs for these medical conditions had been met by the immediate care clinic. the diminishing numbers of primary care providers is a problem in this, and other, rural areas across the country. as providers retire, their patients are having to see new providers: sometimes locums or temporary providers who are not as familiar with the patient on an individual level. section six of the national clinical guideline centre (ncgc) 2012 publication on the patient experience in adult national health services is titled “knowing the patient as an individual.” this section states that being recognized and treated as a unique individual is an important part of the entire patient experience (ncgc, 2012). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 144 most studies to date cite multiple barriers to primary healthcare access for routine preventative medical care. allen et al. (2017) specifically list: (a) personal issues such as family responsibilities, work responsibilities, or lack of childcare availability, (b) problems with the individual provider including language barriers, cultural or religious lack of understanding, lack of trust in the provider, or an office environment which seemed “unwelcoming,” and (c) systemspecific factors related to coverage, financial barriers, inability to get an appointment, inability to see the provider of choice, inability to be seen during regular office hours, and not being familiar with the location of the office. all focus group participants in this study reported having a primary care provider whom they saw on a regular basis for preventative care and chronic medical problems. all participants reported having had clinical preventive services, including screening for the prevention or early detection and treatment of colorectal cancer, breast cancer, and cervical cancer, which are leading health indicators identified by healthy people 2020 (n.d.) performed where appropriate for age and gender. it was when they sought care for an unplanned or episodic illness or injury that the barriers to care became apparent. every member of the focus groups reported that, prior to the existence of the immediate care clinic, they would have experienced delays in care for unplanned illnesses or injuries, citing delays of up to three weeks. none of the respondents answered that they had experienced personal issues as barriers to care, although one participant noted her daughter works all week and that if she takes time off for a medical appointment “she loses money when she has to see a doctor and that’s not right.” the same woman also stated, “if you’re talking to single parents who are working full-time and raising children, they might lose a job if they’re not on the job from 8:00 – 5:00 every day, or they might not have a car or money for gas. so there are circumstances, i think, that would affect other people differently.” a 2008 study by the national opinion research center at the university of chicago online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 145 found that 16% of workers in low-wage jobs reported that they, or a family member, had been fired, suspended, punished, or threatened with firing for missing work because of personal or family illness (smith, 2008). one participant questioned the practice of parents taking their children to the ed for minor problems on the weekends. however, she quickly acknowledged that the only other option was to wait until monday and run the risk of not being able to get an appointment with the pcp for another two weeks. these reports are consistent with the findings of a study examining ed use for nonurgent complaints resulting from an inability to access primary care published in the american journal of medical quality. the study concluded that both publicly and privately insured patients utilized the ed for minor complaints because they were unable to get an appointment with their provider, they had not been able to establish care with a pcp, or they had difficulty making time for an appointment during traditional business hours (hefner et al., 2015). uninsured patients utilizing the ed instead of a pcp had additional barriers related to financial, insurance, or transportation factors. at the provider level, no discrimination or cultural issues were identified by either group and members specifically stated that they had no knowledge of anyone in the area experiencing discrimination or a lack of cultural respect. however, lack of trust in the provider was cited by half of the group members and their responses indicated that the 15-minute appointment was the reason for this mistrust. they did not feel that 15 minutes was enough time for a provider to properly evaluate and treat them. one patient, who was not a member of the focus groups, presented to immediate care for care of a large second degree burn to her forearm. she stated that she had seen her private physician earlier in the day for a well-women exam. at the end of her 30-minute visit, she attempted to show her pcp the burn and was reportedly told that her visit had online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 146 already “run over-time” and she would need to “go to immediate care” to have the burn looked at. in her visit to the immediate care clinic, the provider spent time getting the history, examining the burn, performing wound care, instructing the patient on home wound care, providing her with the supplies needed for wound care and a prescription for a topical antimicrobial medication, educating her on what to watch for in the event of complications like infection, and giving her follow up instructions. the immediate care clinic profiled in this study is meeting the needs of community members seeking care for unplanned illness or injury, regardless of their insurance or payment type and regardless of their regular pcp assignment. this model of care offers same-day care, with no appointment necessary, for patients experiencing acute, non-emergent medical problems and minor injuries when their pcp is unavailable or if the patient has no pcp. the care provided at an immediate care clinic has been compared to that received from a pcp, but more accessible and convenient for the patient; unlike an urgent care clinic which is generally equipped to handle nonlife-threatening emergencies along with basic health care services (george washington medical faculty associates, 2014). strengths and limitations the most notable strength of the study lies in the analysis of the qualitative content of the focus group sessions which not only echoed many of the barriers to care noted in the literature review, but also identified immediate care as a real solution to the problem of access to healthcare for episodic complaints. focus groups proved to be an effective method to explore the participants’ perceptions of barriers to health care access as it allowed the group members to share their own experiences and build on shared experiences. the strength of the study is further reinforced by the fact that the researcher is also the lead health care provider in the immediate care clinic and is online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 147 involved in direct patient care 32 hours per week, allowing her to integrate the findings of published studies with actual practice. the small sample size, combined with the homogeneity of participants with respect to age, race, ethnicity, and insurance type, was the most notable limitation of the study. although the participants were engaged and enthusiastic, eight is minimal for qualitative research using focus groups (stewart & shamdasani, 2015). additional data may have been gathered from younger participants, participants from more diverse racial and ethnic backgrounds, and more participants who were employed on a full-time basis and faced the challenge of making health care appointments during traditional work hours. nursing implications advanced practice registered nurses (aprn), especially those with family practice and emergency department experience, are in a prime position to provide safe, timely, effective, efficient, equitable, and patient-centered care to community members who would otherwise not receive it. the immediate care model is an easily implemented and cost-effective strategy to provide this care. the aprn is knowledgeable in evidence-based practice and has the clinical expertise and experience to provide care based on best practice. in addition to critical thinking, clinical judgement, and clinical decision-making skills, the experienced aprn has the additional qualities, developed through nursing practice, of strong communications skills with patients and families as well as other health care professionals. as of 2019 there are 34 cahs in the state of california and 1,348 in the entire united states (rhihub, n.d.a.). critical access hospital eds across the country struggle with surges in patient flow. in eds with single physician coverage, one critically ill patient may overwhelm all available resources (e.g., physician, nursing, respiratory therapy, diagnostic imaging, laboratory) for online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 148 prolonged periods of time which results in low-acuity patients having extended wait times (welch, 2017). in facilities where the physical plant cannot accommodate a fast-track or low-acuity throughput process, these patients will continue to wait leading to a delay in care or, if they are unable to keep waiting, foregone care. the immediate care clinic referred to by focus group participants is located within a suite of outpatient clinical offices on the property of a 25-bed cah, but physically separate from the hospital itself. hospital laboratory and diagnostic imaging services are available to immediate care patients. the immediate care practice is open weekdays from 9:00 a.m. until 6:00 p.m. and is closed for one hour at lunch. one aprn sees an average of 20 patients per day. one medical assistant from the outpatient clinic is assigned to the immediate care provider and registration staff is shared with the other outpatient clinics. the four patient exam rooms are in one of the three office suites that also houses seven primary care providers. certain new models of ambulatory care including free-standing urgent care clinics, retail clinics, and electronic visit websites have been seen as threats in continuity of care, a disruptive innovation which may erode the relationship between the patient and the primary care provider (ladapo & chokski, 2014). services provided at this immediate care clinic, frequently not provided in other convenient care or urgent care settings, were developed to enhance communication between health care team members and to improve patient outcomes. these services make this clinic stand out when compared to other immediate or convenient care clinics. for the patient reporting that he or she is already established with a pcp, a copy of the encounter document is faxed to that provider. for patients reporting that they do not have a pcp, they will be given a list of area providers or, if they prefer, an appointment with a pcp in the same practice will be made during the visit. if a patient does not have health insurance, an access coordinator online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 149 will attempt to see if the patient is eligible for any of the public insurance plans and assist with paperwork. if the aprn determines that a patient would benefit from specialty consultation, such as orthopedic surgery or otolaryngology, the referral can be made during the visit rather than sending the patient back to the pcp for referral. conclusions physician supply and demand studies have projected that, by the year 2025, there may be a shortage of as many as 31,000 adult primary care providers in the u.s. (long et al., 2016). reasons for this projected shortage include the fact that: fewer medical residents are planning to go into primary care or internal medicine, opting instead to pursue specialty practices (long et al., 2016), there is a shortage of healthcare providers through attrition of practicing providers, and it is difficult to recruit and retain new providers to rural areas (ewing & hinkley, 2013). permanent solutions to the problem will not come quickly. during the obama administration, the u.s. department of health and human services, recognizing the impending shortage of pcps in rural areas, was tasked with improving recruitment and retention of health care providers in rural areas through the “improving rural health care initiative.” several programs oriented toward this goal were developed by the health resources and services administration (u.s. department of health & human services [u.s.dhhs], n.d.). funding opportunities like the primary care training and enhancement program have become available to hospitals in rural communities and, while these programs may ultimately benefit the rural community, these benefits are not likely to be realized for many years. moreover, many rural hospitals and clinics do not have staff with the grant-writing expertise of experience to apply for these programs (u.s.dhhs, n.d.). online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 150 recruitment and retention of health care providers to rural communities can be further compounded by perceptions of the providers themselves. medical residents have cited professional isolation, lower salaries, the challenges of primary care medicine, and concern for lack of ancillary mental health and social services support in rural communities (long et al., 2016). in a study of primary care medicine residents, a lower salary was one factor that the residents had initially felt was a fair compromise for the benefit of living in a rural area, but by the end of the study, the residents felt that the lower salaries, coupled with the negative elements of rural practice including stress, personal and professional isolation, and fear of burnout expressed by their mentors deterred them from pursuing practices in rural areas (long et al., 2016). a 2013 study by farmer, prior, and taylor used a capitals framework to link rural health services to community sustainability. economic, social and human capitals were analyzed, using measurable indicators, and applied to individuals and institutions to show the added-value contributions of health services. the contributions included jobs for educated, knowledgeable, and skilled community members, a location for people to become skilled, personal and institutional consumption of locally produced goods and services including schools and real estate, attracting new community members while retaining older residents, and helping to maintain a diverse local population (farmer et al., 2013). the use of telemedicine should be considered and may be attractive to the provider with concerns about lack of professional support. other factors include lack of available or affordable housing, few employment opportunities for spouses or partners, limited school options for children, and a lack of cultural outlets (cohen, 1998). some of these factors, such as suitable housing, can be addressed with community leaders while other factors will remain deterrents to providers and their families considering relocation to a rural area. online journal of rural nursing and health care, 19(2) http://dx.doi.org/10.14574/ojrnhc.v19i2.582 151 the 20% of the u.s. population living in rural communities who are being cared for by only 10% of physicians (hospitals & health networks, 2016) need options when they experience minor illness or injuries. delayed care, foregone care, and use of the ed are not efficient or equitable solutions. prompt, competent, evidence-based treatment provided in a timely manner is a solution and immediate care clinics like the one profiled in this study can provide that care: in many cases with resources that are already available. in the words of community member r. l. cizek (personal communication, april 17, 2019), “immediate care is the best thing to happen to health care in this town.” references agency for healthcare research and quality, (n.d.). the six domains of health care quality. retrieved from https://www.ahrq.gov/talkingquality/measures/six-domains.html allen, e. m., call, k. t., beebe, t. j., mcalpine, d. d., & johnson, p. j. 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(n.d.). mendocino county, ca zip codes. retrieved from https://www.zipcodes.com/county/ca-mendocino.asp editorial_final_+4_24_23 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.741 1 editorial back in live action: the 2023 international rural nurses conference pamela stewart fahs, phd, rn, editor for those of you with a history with the rural nurse organization (rno), you will remember pre-pandemic the conferences we had about every two years. as with many activities that nurses enjoyed, the in-person conference was not possible during the covid-19 pandemic. so, we punted, holding a virtual conference last year that went well; however, we are back and meeting in an area close to my heart, johnson city, tennessee. to learn more about the conference and register use this url: https://www.etsu.edu/2023-irnc for the 2023 international rural nurses conference we will be experiencing the best of both worlds. the conference is live; however, if you cannot attend in person, there is an opportunity to register for a virtual version. those who attend the live version will also have access to taped sessions that may have been missed when there was more than one choice during the same time period. this conference is being hosted by two universities, east tennessee state university, school of nursing and the binghamton university, decker college of nursing and health sciences. there is a great line up of keynote speakers as well as very interesting podium and poster presentation that rose to the top during the peer-review process. there will be panels on interprofessional practice and publishing. at the end of the conference, there is an opportunity to take an optional tour of grandfather mountain, a favorite in this area of appalachia. i am looking forward to the conference and the trip to grandfather mountain. i hope to see you all there. spiritual perspectives of ________ in a southern state 23 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 spiritual perspectives and health: a random survey in a southern state jeri dunkin, phd, rn 1 linda l. dunn, dsn, rn, cnl 2 1 saxon chair and professor; capstone college of nursing, university of alabama, jdunkin@bama.ua.edu 2 professor, capstone college of nursing, university of alabama, ldunn@bama.ua.edu* * contact author key words: spirituality, health, rural abstract while multiple studies have shown that there is a relationship between religion/spirituality and self reported health, as well as health and spiritual well-being, no studies could be found that correlated spiritual perspectives with self reported health. this study was a part of a random-digit-dialing telephone poll of 452 adult respondents 18 years of age or older in the state of alabama. the 10-item spiritual perspectives scale (sps) was used to measure participants’ perceptions of the extent to which they hold certain spiritual views and engage in spiritually-related interactions. respondents were also asked to rate their health on a four point likert type scale from poor (1) to excellent (4) (srh). significant differences were found for the sps on age, marital status and rurality. there was a positive correlation between sps and srh. rurality did not show a significant correlation with srh. three variables were significantly different on gender: sps, age and current marital status. however, only three variables were significantly different between men and women: sps, age, and current marital status. this study adds support to the literature that spirituality is positively related to one’s health and brings to focus the need to pursue the study of the spiritual experience and health connection. introduction nursing has historically viewed humans as holistic: body, mind, and spirit. as the united states of america (usa) becomes more diverse in culture, lifestyles, religions, and worldviews, nurses are challenged more than ever before in providing holistic care to patients (fawcett & noble, 2004). religion and spirituality are two important aspects of one’s culture that permeates this holistic view, particularly in the healthcare arena where rs beliefs may determine the patient’s choices for treatment or end-of-life decisions, as well as affect the way one copes with illness or finds sustaining comfort and support in illness (johnson, elbert-avila, & tulsky, 2005). additionally, during physician-patient encounters, patients want physicians to respect their spiritual beliefs (hebert el al., 2001). the spiritual dimension of humans is universal and relative to one’s state of health (miller & thoresen, 2003). health has been defined as a state of holistic well-being, not just the absence of disease or infirmity (venes, 2005). even though selfrated health (srh) is a subjective assessment of one’s health, it has been shown to be a strong predictor of morbidity, mortality, and health care utilization (daaleman, perera, & studenski, 2004; erikson, unden, & elofsson, 2001). reed (1992) defined spirituality as the tendency to make meaning through one’s intrapersonal, interpersonal and transpersonal relationships that empower one to transcend. she further clarified that spiritual perspectives are “the extent to which spirituality permeates their lives and they engage in spiritually-related interactions” (reed, 1987, 337). thus, it is spiritual perspectives that guide choices, provide comfort, formulate personal values/morals, and assist with coping during illness, suffering, grief and loss. background koenig, mccullough, & larson (2001) reviewed more than 1,200 studies and found that religious beliefs/practices were consistently associated with better health. space within this article prohibits specific discussion of the studies they reviewed. however, empirical studies continue to demonstrate a positive relationship between religion, spirituality, and health, albeit most research has focused more on religion than spirituality (ameling & povilonis, 2001; koenig, 2002; mauk & schmidt, 2004). there have been reports that some religious beliefs/practices are harmful and irrelevant to health, such as refusing medical treatment, failure to seek medical care, maladaptive coping practices, and involvement in cults (flannelly, ellison, & strock, 2004; george, larson, koenig, & mccullough, 2000; koenig, mccoullough, & larson, 2001). http://nursing.ua.edu/ mailto:jdunkin@bama.ua.edu http://nursing.ua.edu/ mailto:ldunn@bama.ua.edu 24 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 daaleman, perera, & studenski., (2004) examined the relationship between religion, spirituality and self-reported health (srh). they brought to light that geriatric outpatients who reported greater measure of spirituality, but not greater religiosity, were more likely to rate their health as good. koenig, george, & titus (2004) concluded that patients who considered themselves to be both spiritual and religious were more likely to have more social support and better psychosocial and physical health outcomes than patients who did not consider themselves spiritual and religious. interestingly, one group of investigators found spirituality to be associated with one’s subjective perception of health status (boero et al., 2005). yi, et al., (2007) ascertained that the self-rated health of young, resident physicians was not only lower than expected, but was also positively correlated with current resident placement in internal medicine, higher level of depressive symptoms, and lower level of spiritual well-being. while numerous populations have been investigated, limited spiritual research has been conducted with rural dwellers (craig et al., 2006). several studies have investigated the spiritual perspectives within various populations, such as hospitalized adults, healthy and chronically ill older adults, bereaved adults, homeless substance abusers, chronic mentally-ill, and healthcare providers. for example, reed (1987) reported significantly higher spiritual perspective scores among hospitalized, terminally ill, older adults than for hospitalized, non-terminally ill as well as healthy older adults. martin (1996) confirmed a high level of spiritual perspectives in african american women with arthritis. brush & mcgee (2000) identified spiritual perspectives to be important in the lives of homeless men in substance abuse recovery. walsh et al., (2002) concluded that people who profess stronger spiritual beliefs could more rapidly and completely resolve their grief after the loss of a loved one. johnson, elbert-avila, & tulsky (2005) demonstrated through an extensive literature review that spiritual beliefs strongly direct decisions by african americans on both treatment decisions and end-of-life choices. despite these findings, there continues to be much controversy in how spirituality and religion are defined. the authors of this study distinguish between religion and spirituality as follows: spirituality is more abstract than religion and can be described as that which gives life meaning and purpose and enables one to transcend. religion is an organized system that designates beliefs, values, rituals, practices, behaviors, and symbols that enhance a relationship with god/higher power. we believe that just as each patient has physical needs (air, water, shelter, food), each patient also has spiritual needs: trust, love, hope, peace, forgiveness, connectedness, and meaning/purpose in life. while all humans are born spiritual, religious affiliation is an individual choice. many studies have shown a relationship between spirituality, religion, and self-reported health (srh) as well as health and spiritual well-being (boero, et al., 2005; daaleman, perera, & studenski, 2004; koenig, george, & titus, 2004; reed, 1987; yi, et al., 2007); however, no studies could be found that correlated spiritual perspectives with srh. also, much of the published research on spirituality, religion, and health has focused on older adults, women, endof-life issues, as well as cross-sectional designs (becker et al., 2007; flannelly, ellison, & stock, 2004; george, ellison, & larson, 2002). therefore, the purpose of this study was to investigate the relationship of spiritual perspectives to srh in a sample of adults 18 years and older living in the state of alabama. methodology the purpose of this article is to report the findings related to spirituality from the omnibus poll, an annual statewide telephone survey conducted by the capstone poll of the university of alabama. the omnibus poll, comprised of sets of questions submitted by university of alabama faculty members and other organizations, covers a wide range of topics and differs somewhat from year to year. permission was obtained to include reed’s (1986) spiritual perspective scale (sps) as one set of questions. once irb approval was obtained from the university of alabama, this 1999 omnibus survey was conducted between march 22, 1999 and april 21, 1999 and was based upon a random-digit-dialing (rdd) telephone poll of 452 adult respondents 18 years of age or older in the state of alabama. the survey had a margin error of plus or minus five percentage points for the total sample. the sample of households was drawn by using the three area codes and all of the three-digit telephone exchanges in alabama. random telephone numbers were generated beginning with the specified area codes and exchanges. these numbers were then used to establish house hold contacts. for each house hold contact, a respondent was randomly selected by asking for the adult whose birthday had occurred most recently. if that person was available, the interview was conducted. if the appropriate person was not available, a call back was 25 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 arranged. telephone interviews were conducted by employees of the capstone poll who were trained and experienced in telephone interview techniques. they received additional training specific to the questionnaire for this project. an experienced supervisor was present at all times during the interview process. data for this study were analyzed using the spss. the 10-item spiritual perspective scale (sps) (reed, 1986) was designed to measure participants’ perceptions of the extent to which they hold certain spiritual views and engage in spiritually-related interactions. the sps has been used successfully in a wide variety of adult populations: healthy, terminally ill, chronic mental illness, appalachian pregnant women, substance addiction, and african-americans (brush & mcgee, 2000; conner & eller, 2004; jesse & reed, 2004; reed, 1987). the psychometric properties of the sps are good. criterionrelated validity and discriminant validity have been demonstrated (reed, 1986, 1987). using the cronbach’s alpha, reliability has consistently rated above .90 with very little redundancy among the items. average inter-item correlations range from .54 to .60 across the adult groups. all item-scale correlations have been above .60. women and lower socioeconomic groups tend to score higher on the sps, as they have on similar instruments, and participants who identify no religious affiliation score significantly lower on the sps than participants who identify a religious affiliation. the sps is scored by calculating the arithmetic mean across all items for a total score that ranges from 1.0 to 6.0. each of the 10 items use a 6-point likert-type scale that is anchored with descriptive words (i.e. 1.0=not at all or strongly disagree) (reed, 1986). the chronbach’s alpha for this study (n=452) which included both men and women was .864 which is very close to what reed (1987) reported. self reported health (srh) has most frequently been reported in the literature by asking only one question. this question simply asks patients/participants to rate their overall health on a scale from poor to excellent (fayers & sprangers, 2002). findings the sample for this study included adults who answered a random digit dial survey at their home telephone number. four hundred fifty-two subjects completed the telephone survey. sixty three percent (n=295) of the respondents were female and 67% (n=301) were married. the age of the respondents ranged from 18 years (n=2) to 95 years (n=1), with the mean age being 48.58 years. thirty three percent had completed high school (n=148) and another 29% had some college education (n=131), while 17.5% (n=79) completed college. twenty six percent chose the “don’t know/not applicable” response to the question. interestingly, 46% of the respondents were employed full time and another 41% were not employed. there were approximately 11% who were employed part-time and most surprising was the 26 % who responded that they didn’t know or felt that it was not applicable to them. this is the same percentage that did not provide data in response to the family income question. fully, two-thirds of the sample reported being married (66.6%) with nearly equal distribution of the rest across widowed, divorced/separated, and single. the family income category most frequently chosen was $30-40,000 (14.6%); however, it is interesting to note that the income categories surrounding that were very close with approximately 12% in the three surrounding categories. twenty-six percent of the subjects did not respond to the family income question. see table 1a for all the respondent demographics. chi-square goodness of fit in analyzing the data for this study, we compared age, race, and education to the 2000 alabama census data. as expected with a telephone survey, there was an over representation of caucasian and an under representation of african americans. there was an over representation of higher levels of education in the study sample compared to the 2000 alabama census. there was no significant difference on age. see table 1b. rate your health respondents were asked to rate their health on a likert scale from 1 to 5 with 1 being poor to 5 being excellent. there was also a selection of “don’t know/not applicable”. two respondents chose that response. the mean for rate your health was 3.39 (n=452), with the median and mode both being 3 (good). the standard deviation was 1.135. the details of the responses can be found in table 2. 26 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 table 1a respondent demographics item frequency percent item frequency percent gender family income male 166 36.7 <10,000 33 7.3 female 286 63.3 10 – 20,000 41 9.1 marital status 20 – 30,000 55 12.2 married 301 66.6 30 – 40,000 66 14.6 widowed 41 9.1 40 – 50,000 56 12.4 divorced – separated 49 10.8 50 – 70,000 53 11.7 single 59 13.1 70 – 90,000 11 2.4 dkna 2 .4 >90,000 18 4.0 dkna 9 2.0 race education white 360 79.6 0-8 grade 15 3.3 african american 80 17.7 9-11 grade 44 9.7 other 10 2.2 high school – ged 148 32.7 dkna 2 .4 some college 131 29.0 religion complete college 79 17.5 protestant 356 78.8 graduate / professional 30 6.6 catholic 36 8.0 dkna 5 1.1 jewish 9 2.0 employment christian 6 1.3 full-time 206 45.6 non-denominational 9 2.0 part-time 49 10.8 other 8 1.8 not employed 187 41.4 none 20 4.4 dkna 10 2.2 dkna 9 2.0 table 1b comparison of survey sample and state demograhpics variable study 2000 alabama census chi-square race white = 79.6% black = 17.7% other = 2.2% white = 71.1% black = 26.0% other = 2.9% 17.74, df=2,p<.001 education 0-8 = 3.3% 9-11 = 9.7% hs = 32.7% some = 29.0% coll. = 17.5% grad = 6.6% 0-8 = 8.3% 9-11 = 12.3% hs = 34.5% some = 25.9% coll. = 12.2% grad = 6.8% 28.69, df=5,p<.001 age 20-29 = 19.1 30-39 = 20.1 40-49 = 20.7 50-59 = 16.0 60-69 = 11.2 70-79 = 8.4 80+ = 4.5 20-29 = 14.4 30-39 = 17.7 40-49 = 21.0 50-59 = 21.2 60-69 = 10.9 70-79 = 9.9 80+ = 4.9 1.16, df=6,p=.98 27 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 table 2 rate your health table 3a spiritual perspectives scale: beliefs (n=452) spiritual perspective scale the spiritual perspective scale (psp) consisted of two sections. the first section addressed the frequency of spiritual activities and the second section focused on the role of spirituality in the person’s life. all items were on a 6 item response scale. see tables 3a and 3b for detailed descriptions of the responses to each item. all items were scored with the highest number (6) being the desired response. the mean for the sps was 42.75 (sd= 5.47) (n=452) correlations significant correlations were found between the spiritual perspective scale, rate your health, and each of the three definitions of rurality, employment, religion, race, family income, respondent sex, current marital status, education, and age. this information is displayed on table 4. 28 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 table 3b spiritual perspectives scale: behaviors (n=452) table 4 correlations item sp scale rate your health urban/ rural u/r level u/r north south religion family income employment education age race gend marital status sp scale 1 rate your health -.007 – .887 1 urban/ rural .048 .306 -0.24 .611 1 u/r level .044 .306 -.027 .562 .915** .000 1 u/r north /south 059 .213 -.015 0.751 .857** .000 .842** .000 1 religion -.031 .517 .098 .038 -.094* .046 -.116* .013 -.104* .026 1 family income .120* .011 0.112 0.017 -.068 .148 -.060 .203 -.081 .086 .020 .676 1 employment .091 .052 -262*– 0.000 -.070 .136 -.052 .273 -.025 .593 .027 .570 .068 .146 1 education .116* .013 .286** .000 -.106* .024 -.124** .008 -.121* .010 .060 .203 .196** .000 -.146** .002 1 age .139* .003 -0.272*** 0.000 .048 .309 .044 .347 .097* .039 -.091 .052 .104* .027 .405** .000 -.076 .109 1 race .019 .694 0.001 – 0.983 -.136** .004 -.119* .011 -.095 .044 .091 .054 -.026 .582 -.015 .757 -.041 .387 -.186** 1 gender -.114* .015 0.010 – 0.839 .043 .363 .054 .253 .024 .609 -.015 .748 .053 .264 .208** .000 -.018 .710 .100* .033 -.083 .077 1 current marital status -.124* .015 0.020 – 0.674 -.114* .016 -.119* .011 -.084 .075 .014 .762 -.193** .000 -.014 .774 .081 .084 -.163** .000 .174** .000 -.098* .037 1 *p=.05 **p=.01 ***p=.001 29 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 manova on gender since much of the research on spirituality, religion, and health has been conducted frequently with samples that were mostly women, older adults, and end-of-life issues (becker et al., 2007; flannelly, ellison, & stock, 2004; george, ellison, & larson, 2002), we purposely designed the inclusive sample to be open to all men and women who were 18 years of age or older. to determine whether there were significant differences in the variables of interest in this study, a multiple analysis of variance (manova) was performed between men and women. the group was almost 2 to 1 female (286 to 166). those variables that demonstrated significant correlations were included in the manova. it is interesting to note only three variables were significantly different between men and women: sps, age, and current marital status. table 5 displays the details of this analysis. table 5 manova on gender variable sum of squares df mean square. f sig spscale between groups within groups total 175.486 13330.255 13505.741 1 450 451 175.486 29.623 5.94 .016* age between groups within groups total 1345.668 132504.140 133849.810 1 450 451 1345.668 294.454 4.570 .033* current marital between groups status within groups total 5.488 562.264 567.752 1 450 451 5.488 1.249 4.392 .037* education between groups within groups total .205 667.111 667.316 1 450 451 .205 1.482 .138 .710 race between groups within groups total .783 112.358 113.142 1 450 451 .783 .250 3.137 .077 family between groups income within groups total 9.092 3269.926 3279.018 1 450 451 9.092 7.267 1.251 .264 rate your between groups health within groups total .054 581.849 581.903 1 450 451 .054 1.293 .041 .839 compare between groups yr ago rate within groups your health total .023 338.533 338.555 1 450 451 .023 .752 .030 .862 level of between groups rurality within groups total .978 336.270 337.248 1 450 451 .978 .747 1.308 .253 urban/ between groups rural within groups total .206 111.909 112.115 1 450 451 .206 .249 .830 .363 rural between groups north/ within groups south total .158 271.689 271.847 1 450 451 .158 .604 .262 .609 30 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 spiritual perspective scale patterns of response by gender because there was a significant difference found on the spiritual perspective scale and gender we examined the spiritual perspective sub-scales (beliefs and behaviors) by gender. figure 1 illustrates the significance that was found on the beliefs subscale. no significant differences were found on the behaviors sub-scale. remember that the beliefs subscales measures the role spirituality plays in a person’s life and the behaviors is the activities associated with one’s spirituality. figure 1: beliefs and behaviors by gender limitations since this study utilized a random digit dialed survey methodology, people without home telephones or those persons with unlisted numbers were excluded from possible inclusion in the study. those surveyed were primarily female (63%); however, the methodology was random selection and could not control for gender. the findings from this study cannot be generalized to people in other geographic locations. discussion and conclusions to our knowledge, this was the first study to report on the correlations between spiritual perspectives and self-reported health. significant differences were found for the spiritual perspective scale (sps) on age, marital status and rurality. additionally, there was a positive correlation between sps and self reported health (srh). rurality, however, did not show a 31 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 significant correlation with srh. sps, age and current marital status were significantly different on gender. while this study offers additional support to the literature that spirituality is positively related to one's health, it again brings to focus the need to pursue the study of the “epidemiology of spiritual experience” (george, et al., 2000, 113) since the spiritual experience is perhaps the area in religious and spiritual research that is the least explored. furthermore, this study lends support to the findings of brush & mcgee (2000) who concluded that health care providers should encourage patients to share their spiritual perspectives and spiritual experiences. we believe the findings from this study have major implications for healthcare providers. every patient should receive a spiritual assessment. for the participants in this study, more than half reported that they talk about spiritual matters and read spiritual materials daily while 77% pray daily (see table 3a: beliefs) knowing what is important spiritually to the patient should be incorporated into the treatment plan, particularly in relation to coping with or transcending the illness experience. in addition, each of the spiritual perspectives behaviors (see table 3b) were either scored “agree” or “strongly agree” by 92-97% of the participants. the findings from this study demonstrated that for this alabama sample, spiritual perspectives are valued and correlated with self-reported health. references ameling, a., & pavilonis, m. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed?term=16%5bvolume%5d+and+685%5bpage%5d+and+hebert+r%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=33%5bvolume%5d+and+739%5bpage%5d+and+jesse%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=53%5bvolume%5d+and+711%5bpage%5d+and+johnson+k%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=52%5bvolume%5d+and+554%5bpage%5d+and+koenig+h%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=12%5bvolume%5d+and+430%5bpage%5d+and+martin+j%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=58%5bvolume%5d+and+24%5bpage%5d+and+miller+w%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=10%5bvolume%5d+and+335%5bpage%5d+and+reed+p%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=15%5bvolume%5d+and+349%5bpage%5d+and+reed+p%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=324%5bvolume%5d+and+1551%5bpage%5d+and+walsh+k%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed/17474998?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=1&log$=free tasseff_527 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 152 exploring perceptions of palliative care among rural dwelling providers, nurses, and adults using a convergent parallel design tamara l tasseff, phd, rn 1 susan s. tavernier, phd, aprn-cns, aocn 2 paul r. watkins, phd 3 karen s. neill, phd, rn, sane-a, df-iafn 4 1 jonas veterans healthcare scholar, college of nursing, idaho state university, tasstama@isu.edu 2 assistant professor, college of nursing, idaho state university, tavesusa@isu.edu 3 professor, college of education, idaho state university, watkpaul@isu.edu 4 associate dean and director of graduate studies, college of nursing, idaho state university, neilkare@isu.edu abstract purpose: to explore the palliative care perceptions of rural dwelling providers, nurses, and adults and, to explore the relationship between the knowledge and perceptions of palliative care held by rural providers and nurses, using a convergent parallel design. sample: qualitative (n = 25), quantitative (n = 51) methods: the setting was a geographically defined rural area of 8,500 square miles. following institutional review board approval, providers (n = 5), nurses (n = 7), and adults (n = 13), online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 153 completed a demographic survey and audio-recorded, face-to-face, semi-structured interviews. qualitative data were analyzed using thematic analysis following a loosely grounded theory approach that was comprised of multiple rounds of coding assisted by qualitative analysis software. survey packets were delivered to 19 healthcare organizations in the same geographic study area; 51 participants (providers, n = 7; nurses, n = 44) completed a demographic survey and the 20-item palliative care knowledge test (pckt). both qualitative and quantitative data were analyzed separately before merging and comparing the results in a final analysis. results: six themes were identified: palliative care offers comfort for the dying or end-of-life care; palliative care? never heard of it; uncertainty about the differences between palliative care and hospice; conflicts between theory and practice; timing is everything; and experience is a strong teacher. pckt total scores for the sample of providers and nurses (n = 51) was 10.73 (sd 2.93) which suggested poor palliative care knowledge. after merging the results, the final analysis indicated convergence. two constructs, maturity and rural investment, were identified. conclusion: providers and nurses in rural areas are experienced, having lived and practiced in rural areas for a considerable time; supporting the constructs of maturity and rural investment. misperceptions and poor knowledge related to palliative care likely prevent the broader application of palliative care in rural areas. keywords: palliative care, rural, providers, nurses, perceptions, convergent parallel design online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 154 exploring perceptions of palliative care among rural dwelling providers, nurses, and adults using a convergent parallel design introduction palliative care is focused on improving the quality of life of people suffering from lifethreatening acute or chronic illnesses and is as appropriate for a teenager undergoing cancer treatments as it is a 94-year-old at the end-of-life (meier & bowman, 2017). the world health organization (who) defines palliative care as the following: palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life threatening illness. it prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual. (2018, para. 1) who (2018) has deemed palliative care a basic human right capable of relieving the suffering that accompanies many chronic illnesses, such as multiple sclerosis, rheumatoid arthritis, dementia, and cancer. palliative care can be introduced at any point in the disease trajectory, from diagnosis through the end-of-life. despite advances in the understanding and availability of palliative care, many people who live in rural areas lack access to healthcare services including palliative care (bolin et al., 2015). people living in rural areas experience a shortage of physicians and nurses, have smaller incomes, are less healthy, and have less access to health care services, including palliative care, than those who reside in urban areas (bolin et al., 2015). additionally, rural dwelling people are more likely to be uninsured (bolin et al., 2015) or covered by a by a high online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 155 deductible health plan (leonardson, ziller, & coburn, 2014), which may further limit access to health care services. by 2030, one out of five americans will be 65 years of age or older (centers for disease control and prevention [cdc], 2013), and most of these individuals will be living with multiple chronic conditions (gerteis et al., 2014). adults living with serious chronic conditions often experience a decreased quality of life (cdc, 2013). concurrent palliative care, which is palliative care offered at the same time as usual or curative treatment, has been reported to improve the quality of life for people living with heart failure (dionne-odom et al., 2014) and cancer (doyle, 2017). however, a significant barrier to the implementation of concurrent palliative care may be the perception that palliative care is end-of-life or hospice care held by physicians (leblanc et al., 2015) and nurses (aslakson et al., 2013). although progress has been made in improving undergraduate medical education, teaching around the concept of palliative care is delivered almost exclusively by lectures and seminars, and supported mainly through hospice visits (fitzpatrick, heah, patten, & ward, 2017). the application of the concept of palliative care as a process of improving the quality of life for individuals across the life span, to prevent and relieve suffering given life-threatening illness, is limited. researchers conducting a mixed methods study of 66 oncologists at three academic cancer centers, one of which was in a predominantly rural state in the united states (u.s.), found that the majority of the 23 hematologic oncologists perceived palliative care to be end-of-life care (61%). the study also showed that 43% had never referred a patient with advanced cancer to palliative care (leblanc et al., 2015). authors of a qualitative study that included 38 urban and rural physicians, nurses, and adults in germany reported that palliative care was perceived as end-of online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 156 life care, and inappropriate for conditions with uncertain disease trajectories; furthermore, the adults could not perceive as to how palliative care might be helpful (golla, galushko, pfaff, & voltz, 2014). similar findings were revealed by a qualitative study conducted in the u.s which involved 18 urban and rural providers treating heart failure; palliative care was perceived as endof-life care and unsuitable for conditions with uncertain trajectories (kavalieratos et al., 2014). in a qualitative study conducted in australia involving 94 emergency physicians and nurses, including staff from regional hospitals serving rural areas, researchers reported that participants perceived palliative care to be end-of-life care, appropriate after treatment ends, and to conflict with life-saving measures (weil et al., 2015). upon diagnosis with a serious health condition, patients are informed by providers about future treatment options. according to the authors of a study conducted in the netherlands, 16 nurses perceived that palliative care should start as soon as the treatment ends (verschuur, groot, & van der sande, 2014) and to that end, nurses spend the most time with patients. in rural areas, nurses are often asked for advice outside of working hours (lee & mcdonagh, 2013) and are consulted by families, friends, and community members. one quantitative study of palliative care knowledge among rural nurses (n = 33) at three long-term care facilities in rural kentucky using the palliative care knowledge test (pckt) found low knowledge scores (49% correct). this study concluded that more palliative care education was needed to improve the care and quality of life for rural long-term care residents (evans, 2016). providers’ and nurses’ palliative care perceptions and knowledge when combined with experiences with rural providers and rural nurses, likely impact how adults living in rural areas perceive palliative care. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 157 palliative care, when offered as a critical component of comprehensive primary care in rural areas, may allow rural adults with serious chronic conditions to have an improved quality of life, remain active for a longer period, and possibly age in place. exploring and comparing palliative care perceptions among rural dwelling providers, nurses, and adults is the first step to understanding rural palliative care needs and bringing about transformative change in healthcare delivery models applied to rural areas. a qualitative study conducted in australia involving 20 aboriginal women with breast cancer and their care providers reported negative perceptions of palliative care as isolating, culturally insensitive, end-of-life care, and based on experiences (dembinsky, 2014). correspondingly, a qualitative study involving 50 adults conducted in a largely rural area of northern ireland showed that adult varying perceptions of palliative care were based on several influences, including the media (mcilfatrick et al., 2014). whether positive or negative, perceptions of palliative care are likely to be reinforced by rural adult experiences (dembinsky, 2014; mcilfatrick et al., 2014). however, it is possible to change the perceptions of palliative care with education (kozlov, mcdarby, reid, & carpenter, 2017; mcilfatrick et al., 2014). based on a comprehensive review of current research and related literature, palliative care perceptions have not been exclusively studied in rural dwelling providers, nurses, and adults within the u.s. most of what we know about the perceptions of palliative care is based on research studies conducted in urban or rural areas outside of the u.s. it may be noted that little published research exists related to the perceptions of palliative care among rural adults. therefore, the purpose of this research was to explore the palliative care perceptions among rural dwelling providers, nurses, and adults. a convergent parallel design was used to explore the perceptions of palliative care online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 158 among rural providers, nurses, and adults. a mixed methods research approach combines the strengths of quantitative and qualitative research designs while overcoming limitations, thereby strengthening the analyses (creswell, 2014). study aims this mixed methods study had two specific aims. the primary aim was to explore and compare palliative care perceptions among rural dwelling providers, nurses, and adults. for this study, providers were defined as medical doctors (mds), osteopathic doctors (dos), nurse practitioners (nps), and physician assistants (pas). nurses were defined as licensed practical/licensed vocational nurses (lpns/lvns) and registered nurses (rns) who were not licensed as advanced practice nurses. rural dwelling adults were defined as people, age 18 or older, who were not actively employed as providers or nurses, and who were living in one of the four rural counties where the study was conducted. the secondary aim was to explore the relationship between knowledge and perceptions of palliative care held by providers and nurses practicing in rural areas. the significance of this study for all providers, but specifically to nurses, is in the context of gaining new knowledge to (1) promote outcome-focused discussions about rural dwelling adults and palliative care; (2) assist health service planners and others involved in designing and improving health care for rural dwelling adults; (3) transform palliative care education; and (4) transform practice models. understanding the perceptions of palliative care is the first step to beginning dialogues about improving the access to palliative care, specifically concurrent palliative care, in rural areas. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 159 theoretical framework rural nursing theory provides the conceptual framework for this study. the underlying concepts in rural nursing theory are centered on rural dwelling people and how health is defined as the ability to be productive, to do, and not necessarily as the absence of disease (long & weinert, 2013). rural nursing theory was introduced in 1989 by long and weinert as an outcome of a qualitative exploration of living by rural dwelling people (winters, 2013). other key concepts of rural nursing theory that serve as the premise of this study include self-reliance and autonomy, delayed healthcare seeking behaviors, and healthcare professionals as generalists (lee & mcdonaugh, 2013; scharff, 2013) who experience role diffusion and lack anonymity (lee &mcdonagh, 2013). the way rural dwelling adults define health impacts how they seek health care and prefer to live. similarly, how providers and nurses practice in rural areas, their education, knowledge, and experiences, likely influence their perceptions of palliative care. methods this mixed methods study used a convergent parallel design. qualitative and quantitative data were collected simultaneously, analyzed separately, and merged and compared in the final analysis (clark & ivankova, 2016). the qualitative data were analyzed prior to the quantitative data to avoid introducing bias during the qualitative analysis. setting the setting included four rural counties situated in the western u.s., encompassing over 8,500 square miles. providers and nurses working at 19 healthcare organizations within the same geographic area participated in the quantitative component of the study. the four counties within the geographic area are sparsely populated, ranging from 2.5 to 5.3 people per a square mile and online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 160 are classified as mostly rural and completely rural in accordance to the county classification lookup table (united states census bureau, n.d.). rural is defined as areas that are not classified as urban or urban clusters (ratcliffe, burd, holder, & fields, 2016; united states census bureau, n.d.). sample qualitative component. a purposive sampling scheme was used in this study. newspaper advertisements, word-of-mouth, as well as posters placed on community and rural message boards were used within the defined geographic area to recruit participants who were over the age of 18 years, could speak and understand english, and lived in one of the states/counties of interest. to avoid the possibility of significant emotional distress arising from the interview questions, the study excluded the participation of adults who had experienced the death of a close family member or friend within the past six months, had a close family member/friend diagnosed with a terminal illness in the past six months, or who had received a terminal diagnosis. potential participants were screened using the inclusion/exclusion criteria and read information from the consent form. audio-recorded, semi-structured interviews were conducted at mutually agreed upon locations by one interviewer using a semi-structured interview guide. field notes and memos were completed and labeled with the participants’ assigned number. in this context, notes and memos are helpful in completing thick descriptions and performing qualitative data analysis (glesne, 2016). a total of 29 potential participants were screened, and four were excluded after reporting deaths of family members or close personal friends within the past six months. the final qualitative sample (n = 25) included five providers, seven nurses, and 13 adults. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 161 quantitative component. an a priori sample estimation was conducted using g*power version 3.1.9.2 (faul, erdfelder, lang & buchner, 2007) to determine the total sample size (n = 128) needed based on parameters for a two-tailed t-test, 0.80 power, a medium effect size of 0.50, and two independent groups, rural providers (n = 64) and rural nurses (n = 64). study packets were provided to each of the 19 healthcare organizations. practice organizations included small public and private clinics, hospitals, skilled nursing and assisted living facilities, and home health services. after reading the information sheet contained in the packet, interested providers and nurses completed a short pen-and paper demographic survey in addition to the palliative care knowledge test (pckt). surveys were returned to the researcher using a prepaid, pre-addressed envelope provided within the study packet. ethical considerations ethical approval for this study was obtained from the human subjects committee of the research institution (study #fy2018-38). potential participants were provided information about the voluntary study as part of the screening process. signed consents were obtained prior to the interviews. no identifying information was collected on the quantitative surveys. a subway® gift card worth $10 was offered to all participants as an acknowledgment of their time. instrumentation demographics. thirteen demographic questions were asked of all participants: gender, marital status, ethnicity, race, birth year, zip codes of home and work, total number of years of having lived rurally, total number of years lived in current zip code, education level, employment status, job, and veteran status. providers and nurses were asked additional questions about primary online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 162 practice setting, main area of specialization, years of experience, completion of palliative care training, and palliative care certification. semi-structured interview guide. an interview guide (see figure 1) was developed from a review of the literature and reviewed by an expert panel. questions appropriate for each group, defined by columns, were noted with an “x”. questions that were not applicable to a group were noted by a darkened cell. the interview guide contains the questions asked of all participants (bolded) and sample questions asked of some of the participants based on individual responses to initial interview guide questions (figure 1). palliative care knowledge test (pckt). the pckt is a questionnaire developed by researchers in japan to assess the palliative care knowledge of nurses and providers (nakazawa et al., 2009). use of the pckt was reported in one study conducted with rural nurses in the u.s. (evans, 2016). nakazawa and colleagues (2009) reported validation of the pckt with nurses (n = 940) at two different facilities in japan. the pckt aligns with the who’s current definition of palliative care and consists of 20 questions assigned to one of five domains associated with palliative care: philosophy (2 questions), pain (6 questions), psychiatric problems (4 questions), and gastrointestinal problems (4 questions). three response choices, “true”, “false” and “unsure”, are available to the participants for each question. one point is awarded for each correct response, and the maximum attainable score is 20. higher scores are indicative of greater palliative care knowledge. the instrument has a reported internal consistency of 0.81 with the domain internal consistency ranging from 0.61 to 0.82, and test-retest correlation of 0.88 (evans, 2016; nakazawa et al., 2009). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 163 figure 1. semi-structured interview guide qualitative analysis qualitative analyses addressed the primary aim of the research to explore and compare palliative care perceptions among rural dwelling providers, nurses, and adults. qualitative analysis software, atlas.ti, version 7.5.15 (atlas.ti scientific software development gmbh, 2016) was used to assist with data analysis. the analysis of data was undertaken using thematic analysis, which supported the development of themes while staying grounded in the data. thematic analysis as an independent method of qualitative analysis has been supported by colleagues in field of psychology (braun & clarke, 2008). three rounds of coding were conducted as part of the qualitative analysis. to become immersed in the data, all audio-recordings were carefully listened to following the interviews. the interviews were listened to a second time prior to beginning the preliminary coding process. the online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 164 preliminary coding process involved the identification of key ideas or codes (inductive), to serve as initial codes (deductive) for the remaining interviews. the first three interviews were coded independently by two researchers (tt, sst), who met twice via zoom video conferencing technology to discuss the initial codes and preliminary findings. subsequent interviews were coded by one researcher (tt), adding more codes in the process. the second researcher was available throughout the process to provide the opportunity to critically discuss and debate emerging themes. after all twenty-five interviews underwent preliminary coding, the audio-files were listened to again, and nearly identical codes were merged where appropriate. upon merger, the codes related to a similar idea or experience were grouped together into code families. the final round of coding entailed the use of code families and memos to identify themes and subthemes based on the frequency, the number of times the code/code family appeared across interviews. exemplar quotes were identified to support each key theme. quantitative analysis quantitative analyses served to explore palliative care knowledge among rural providers and nurses in support of the secondary research aim, to explore the relationship between knowledge and perceptions of palliative care among providers and nurses. a total of 53 surveys were received. two surveys were not completed by providers or nurses and were excluded. the results of the remaining 51 surveys met the inclusion criteria and were included in the analyses. data were shared with co-authors and the third author served as the statistical consultant. analyses were performed using spss version 23. data were first reviewed for missing data. missing demographic data were analyzed based on the number of participants who provided a response. in one instance, a response was missed for pckt question 10, and it was determined online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 165 to be missing completely at random; no other questions were skipped. missing data between two and five percent is considered acceptable (meyers, gamst, & guarino, 2013; vogt, vogt, gardner, & haeffele, 2014) and was not exceeded in this study. the decision was made to estimate a response as the missing value accounted for two percent, the sample was small, and lower powered nonparametric tests were used (polit, 2010). after analyzing the remaining responses to question 10 (n = 50), most responses were found to be either incorrect or “unsure” (54%, n = 27). therefore, the value of “unsure”, with no point value, was assigned to resolve the missing datum. categorical level demographic data were analyzed using frequency counts and percentages and scale level data were analyzed using mean, standard deviation (sd), skewness, and kurtosis. statistical significance was set to p < .05 for all tests. effect size, which was calculated using spearman’s rho, was used to explore correlations between pckt total scores and age, years of experience, years lived in the area of current zip code, and the total number of years lived rurally, and to analyze the correlations between the five pckt domains. the use of spearman’s rho is appropriate with ordinal level dependent variables, such as pckt total score, small sample sizes, and in instances when outliers are present (polit, 2010). descriptive statistics, frequency counts and percentages, were used to compare pckt individual question scores between the rural provider group and the rural nurse group. the mann-whitney u test was used to ascertain the differences in the ranks of pckt total scores and pckt domain scores between the rural provider, as well as the rural nurse group and the ranks in pckt total scores and domains scores between respondents who had reported completing some form of palliative care education, and those who had not. using optimal scaling with multiple nominal data, exploratory categorical online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 166 principal components analysis (catpca) was conducted to explore constructs that could explain the total variation (meyers et al., 2013) in pckt scores. convergent analysis qualitative and quantitative results were merged in the final analysis and addressed the secondary study aim to explore the relationship between knowledge and perceptions of palliative care held by providers and nurses practicing in rural areas. notably, the themes identified in the qualitative analysis were used to inform the quantitative pckt results or palliative care knowledge results. the qualitative and quantitative results of convergent parallel design studies are reported in the results section and the convergent analysis, which is the result of merging and comparing both qualitative and quantitative results, is presented in the discussion section (creswell, 2014). results qualitative twenty-five rural dwelling participants, providers (n = 5), nurses (n = 7), and rural adults (n = 13), completed the audio-recorded, face-to-face, semi-structured interviews. sample characteristics are depicted in tables 1 and 2. actual interview times ranging from six to 26 minutes were conducted at a variety of locations, including places of employment, libraries and the homes of participants. six major themes were eventually identified. table 1. rural participants by group: gender, marital status, education, and employment ____________________________________________________________________________________ providers nurses adults n = 5 / n = 7 n = 7 / n = 44 n = 13 n (%) n (%) n (%) ____________________________________________________________________________________ qualitative quantitative qualitative quantitative gender online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 167 males 3 (60) 4 (57) 1 (14) 4 (9) 7 (54) females 2 (40) 3 (43) 6 (86) 40 (91) 6 (46) marital status married 4 (80) 6 (86) 6 (86) 30 (68) 11 (85) education hs graduate/ged 4 (31) some college 1 (14) 3 (7) 1 (8) associates 4 (57) 26 (59) 3 (23) bachelors 1 (14) 2 (29) 11 (25) 4 (31) graduate 5 (100) 6 (86) 4 (9) 1 (8) employment >35 hours per week 5 (100) 7 (100) 7 (100) 41 (93) 2 (15) <35 hours per week 3 (7) 3 (23) not employed 8 (62) primary practice setting hospital 3 (60) 2 (29) 5 (71) 31 (70) clinic 2 (40) 5 (71) 7 (16) snfa 2 (29) 3 (7) home care 3 (7) employed position md/do 2 (40) np 3 (60) 5 (71) pa 2 (29) rn 6 (86) 35 (80) lpn 1 (14) 9 (20) pc training no 4 (80) 5 (71) 6 (86) 36 (82) yes 1 (20) 2 (29) 1 (14) 7 (16) did not answer 1 (2) ____________________________________________________________________________________ note: due to the differences in rounding, percentages may not equal 100. asnf is skilled nursing facility; bpc training is palliative care training. table 2. rural participants by group: age, years of rural living, and provider and nurse years of experience ____________________________________________________________________________________ providers nurses adults n = 5 / n = 7 n = 7 / n = 44 n = 13 m (sd) m (sd) m (sd) ____________________________________________________________________________________ qualitative quantitative qualitative quantitative age (years) 51 (11.9) 50 (12.4) 48 (9.2) 43 (11.4) 65.3 (7.4) rural (years)a 37 (14.0) 41 (16.3) 28 (18.8) 29 (15.9) 49.5 (21.5) current (years)b 15 (12.2) 13 (13.3) 7 (6.4) 14 (13.9) 19.4 (18.7) experience (years) 15 (15.0) 17 (15.1) 14 (10.7) 15 (11.8) online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 168 ____________________________________________________________________________________ note: due to the differences in rounding, percentages may not equal 100. atotal number of years lived rurally over life; btotal number of years lived in current zip code (postal code) a picture of the rural environment. prior to discussing the key themes, it is important to get a picture of the environment and healthcare facilities employing the nurses and providers who were interviewed. the environment is quite rugged, ranging from open, unprotected plains to heavily forested mountainous terrain. unpredictable weather occurs year-round; wind, hail, and fire storms, flash flooding from the occasional torrential rain storms june through august, and unpredictably heavy snowstorms with dangerous wind chills as early as september and as late as mid-may. providers and nurses often care for people they know well; friends, family, and neighbors. the people who call this area home may drive up to two hours for a clinic appointment or a trip to the emergency room. people who live and work in this rural area often know who is at the clinic or hospital by observing the vehicles parked at the facility. ambulance services and fire departments are staffed primarily by volunteers as opposed to full-time employees. the health care services are often limited by resources, expertise, and equipment. ground and air transports to larger medical centers depend on numerous factors, such as extreme weather conditions especially during the winter. even today, providers continue to make house calls when needed, and may drive out to meet an ambulance to allow a patient to receive treatment sooner or check in on a patient who is homebound and cannot visit the clinic. many of the area healthcare facilities are multi-purpose. the small hospital, long-term care facility, and clinic are physically housed in the same complex. it is increasingly common to see pharmacies, home health services, and durable medical equipment sales offices sharing space online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 169 within the hospital building. in these facilities, nurses and physicians are often generalists with additional training in geriatrics and emergency medical care. when an ambulance arrives, nurses may float from the long-term care area to cover hospitalized patients, while acute care nurses float to the emergency department to receive a patient. ambulatory patients awaiting clinic appointments may be delayed as their provider floats to the emergency department or addresses a hospital patient arriving with unexpected complications. for many rural dwelling adults, the drive to get to the emergency room takes longer than the time it takes to be seen. nurses working in one of the rural hospitals commented it is not uncommon for people to telephone the emergency room and provide staff warning of arrivals. the 13 rural adults interviewed were very complimentary of the care received at these rural hospitals and clinics. in fact, a couple of rural adults expressed some disappointment after the interview that no questions were asked about the state of rural healthcare, the high cost of insurance, or their ideas for solving healthcare challenges such as the number of rural people who are unable to afford insurance. most participants appeared to speak freely, and all participants answered all questions that were asked. key themes themes were organized based on code and code family frequency. key themes were determined by the highest number of codes and code families, which supported each theme. six key themes emerged from the data: 1.) palliative care is comfort for the dying or end-of-life care; 2.) palliative care? never heard of it; 3.) uncertainties about the differences between palliative care and hospice; 4.) conflicts between theory and practice; 5.) timing is everything; and 6.) experience is a strong teacher. exemplar quotes provided evidence in support of each key theme. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 170 palliative care is comfort for the dying or end-of-life care. palliative care is about providing comfort at the end-of-life. this theme occurred in 15 of the 25 interviews. codes referencing comfort and end-of-life appeared 89 times throughout the interviews, with the heaviest concentration or density in the rural nurse group. providing comfort at the end-of-life emerged as the predominant theme of the providers (n = 5) and nurses (n = 7). rural nurses often float between the emergency department and the hospital, or between the long-term care facility and the hospital. in some facilities, nurses may split their time between multiple areas. six nurses who talked about palliative care as end-of-life care were asked for a personal definition of palliative care. the following are three exemplar quotes provided by rural nurses: “i would define that [palliative care]as end-of-life care. you’re basically just keeping that person comfortable for end-of-life.” – rn01 “providing nursing and medical care to a person who is terminally ill. that medical and nursing care concentrate on providing comfort to the person who is in the process of dying.” – rn06 “…all the interventions are concentrated on providing the comfort, not the curing.” – rn06 the one nurse who did not define palliative care as end-of-life care was uncertain about the definition of palliative care and thought it was providing nursing care of the body immediately after death and prior to the mortuary coming to pick up the body. apart from nurses, rural providers also defined palliative care as providing comfort at the end-of-life (n = 4). the interviewed providers work at stand-alone primary care clinics across online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 171 small towns and rural hospitals with primary care clinics and long-term care facilities attached to the hospital. “i think it means keeping people comfortable at the end of their life.” – rp05 “helping a person with their end-stage living as best we can.” – rp04 one provider, who practices in multiple settings throughout the day and has made home visits to offer palliation to rural patients at the end-of-life, termed this wide variation in practice as a specialization: “rural medicine”. this provider, had received some informal mentoring from a palliative care physician, and supported having earlier conversations with patients. “palliative care is not necessarily when end-of-life is expected acutely, end-of-life will probably come in the near future. it can start in a primary care provider’s office and continue up through specialists.” this provider discussed having conversations with clinic patients in their 40s, 50s, and 60s even before palliative care concerns are identified.” – rp03 six of the 13 rural dwelling adults who were interviewed view palliative care as keeping someone comfortable who was at the end-of-life. “my definition is probably going to have to be about end-of-life…letting a patient die as comfortably as possible.” – rd04 “to make it so they are not in pain; making them comfortable until they die.” – rd07 palliative care? never heard of it. the majority of interviewed rural dwelling respondents were adults who are uncertain what palliative care may be and what it entails. as many as seven rural dwelling adults reported they were unfamiliar with the term palliative care. meanwhile, four participants speculated about what palliative care may be. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 172 “pail-ee-uh-tiv? the care i would like? i really don’t know. [laughs]” – rd05 “i’m not exactly sure of the definition – it is one of a circle of cares that you can receive when you are sick or injured…curative? i would hope so, but i really don’t know.” – rd02 despite the ambivalence surrounding palliative care, all 13 rural dwelling adults stated they were familiar with hospice care and provided an accurate definition, as did the 12 rural providers and nurses. uncertainties about the differences between palliative care and hospice. four nurses were uncertain about the differences between palliative care and hospice. “i’m not really sure of the difference between hospice and palliative care.” – rn05 “they’re differentthere is a fine linebut i’m not sure.” – rn04 “different protocols and different [governing] body?” – rn06 one provider and two nurses described no differences between hospice and palliative care. “one is the same as the other to me.” – rn01 “i think that hospice provides palliative care, but you don’t necessarily have to be in hospice to receive that because we do that here at our hospital.” – rp05 conflicts between theory and practice. in theory, four of the five rural providers correctly identified that palliative care can be provided for a longer period; they mostly agreed that palliative care could be delivered concurrently with usual treatment. however, conflicting information was evidenced throughout the interviews, suggesting that actual practices might be different. “treating the whole person. any chronic issue that is debilitating.” – rp02 [in response online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 173 to interviewer’s request to provide a personal definition of palliative care.] contrasting statement: “you know, sometimes you start the palliative care and then people do tend to do better and you are still tryingand they are not wanting to stop treatments.” – rp02 “is it reimbursable? there’s a medical-legal issue of, an insurance issue, of reimbursement of what services are available to somebody. can you do it? certainly. is there benefit to it? ...our society has evolved technically much more quickly than it has societally…we can maintain people alive for much longer than they have a quality of life. we’re able to sustain people much longer, but to what end.” – rp01 contrasting statement: “palliative care, to me, is providing comfort to somebody instead of curative measures.” – rp01 timing is everything. most rural providers defined palliative care as occurring over a longer period when compared to hospice care. when nurses were asked about the timing of palliative care, most of them talked about the timing of palliative care as restrictive, such as the medicare hospice certification requirements of a life expectancy of six months or less, or with the finality of life. “when they have come to the decision that is what they wantend-of-life less than six months.” – rn03 “i think at the point that you feel death is imminent from a disease process.” – rn05 “uncertain whether it is three or six months that we do not expect the person to recover online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 174 and all the interventions are concentrated on providing the comfort, not the curing.” – rn06 “i think when end-of-life is ‘there’.” – rn07 rural providers described the timing of palliative care differently based on the individual patients presenting to them. they mostly described palliative care as occurring over a longer period than hospice care. “palliative care, to me, is providing comfort to somebody instead of curative measures. if they choose palliation versus curative interventions…maybe six months, three months, a year…but it is an individual decision.” rp01 “well, everybody is an individual, so there is no real set time.” – rp04 “palliative care is something that we should discuss with patients before they are at that end-stage. guidelineswhen death is expected in the next two years. if you are looking at cms and medicare guidelinesit can be very specific. i just want the patient taken care of.” – rp03 experience is a strong teacher. interviews with rural providers, nurses, and adults revealed a common underlying thread, experience. each respondent cited examples to support their thoughts and most of them were based on personal experiences. rural dwelling adults also shared memories of family members who received hospice care at home, describing palliative care as hospice care. “i would define it [palliative care] as treatment during a stage of life when there aren’t any avenues for complete change to the situation, and you are making that person online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 175 comfortable for as long as possible – until another factor takes over and they pass away.” – rd03 later in the same interview with rd03, “i had a sister20 years agowho we had hospice care for…she had ovarian cancer. it was a lifesaver, a very positive experience.” nearly every participant talked about a family member suffering from a serious condition, and many of these examples included stories of hospice. additionally, a rural provider, rp03 made mention of a mentorship completed with a palliative medicine physician. rp03 then defined the timing of palliative care in terms of palliative medicine, life expectancy less than two years. one rural nurse, rn06, described palliative care training completed as part of the nursing academic preparation. rn06 described a short clinical rotation in a large hospice organization, and subsequently described palliative care as providing comfort at the end-of-life. rn06 described the differences between hospice and palliative care as having different governing structures and policies, albeit sharing similarities in the end-of-life care provided. based on these examples, it can be surmised that experience is a strong teacher which does influence perceptions. quantitative results the internal consistency of the pckt was found to be acceptable (α = .77; tavalok & dennick, 2011). sample characteristics. most participants were female, married, long-time rural residents who were nurses employed in a hospital setting for more than 35 hours a week. additional sample characteristics are outlined in tables 1 and 2. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 176 pckt overall scores. percentages of correct responses to pckt questions are reported in table 3. question 3 and question 15 had the highest number of correct responses (94%, n = 48 for each). on the other hand, question 7 and question 13 had the lowest percentages of correct responses (4%, n = 2; 10%, n = 5). of 20 possible points, the mean pckt total score for the entire sample (n = 51) was 10.73 (sd 2.93). according to the pckt authors, questions 12 and 14 evaluated knowledge that was no longer included in current practice. thus, the mean pckt total score calculated without questions 12 and 14 was lower for the entire sample (n = 51) m = 9.59 (sd 2.73). after review and discussion of the study aims, it was decided to continue the analysis using the data based on the pckt instrument as originally designed with all 20 questions. online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 177 comparing pckt scores between groups. pckt total score and domain scores are illustrated in table 4. a mann-whitney u test was run to determine any differences in pckt total scores between rural providers (n = 7) and rural nurses (n = 44). distributions of the pckt total scores for rural providers and rural nurses were dissimilar, as assessed by visual inspection. pckt total scores for rural providers (mean rank = 35.21) and nurses (mean rank = 24.53) were not statistically different (u = 89.5, z = -1.78, p = .075). a mann-whitney u test was run for each of the five domains to determine the presence of significant differences in pckt domain scores between rural providers and rural nurses. after the visual inspection of the distributions of the five pckt domain scores, all were found to be dissimilar. for the dyspnea domain, rural providers (mean rank = 36.43) scored statistically significantly higher than the rural nurses (mean rank = 24.34, u = 81, z = -2.084, p = .037, d = 0.51). the scores of the four remaining pckt domains were not statistically significantly different (philosophy [mean rank = 27.93, 25.69, u = 140.5, z = -.445, p = .656], pain [mean rank = 28.14, 25.66, u = 139, z = -.430, p = .667], psychological problems [mean rank = 34.50, 24.65, u = 94.5, z = -1.751, p = .08], and gastrointestinal problems [mean rank = 26.00, 26.00, u = 154, z = 0, p = 1]). table 4. pckt total score and domain scores by rural group ____________________________________________________________________________________ providers nurses total n = 7 n = 44 n = 51 m (sd) m (sd) m (sd) ____________________________________________________________________________________ pckt total score 12.29 (2.69) 10.48 (2.91) 10.73 (2.93) domains philosophy 1.71 (0.49) 1.55 (0.70) 1.57 (0.67) pain 2.57 (0.54) 2.55 (1.21) 2.55 (1.14) dyspnea* 3.29 (0.76) 2.32 (1.20) 2.45 (1.19) online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 178 psychiatric problems 2.43 (0.98) 1.75 (0.78) 1.84 (0.83) gastrointestinal problems 2.29 (1.25) 2.32 (1.05) 2.31 (1.07) ____________________________________________________________________________________ * p <.05 palliative care training. eighty-two percent of the providers and nurses (n = 41) responded in the negative when asked if they had completed any form of palliative care training. nine providers and nurses (18%) reported completing some form of palliative care training, while five (56%) reported completing a continuing education course or seminar. providers and nurses who had completed some form of palliative care training (n = 9) scored higher on the pckt total score (m 12, sd 12.25) than those who did not (n = 42, m 52.26, sd 14.87). however, the difference in pckt total scores between those who completed some form of palliative care training and those who had not were nonsignificant (p = .198). categorical principal component analysis (catpca). the model accounted for 34% (d = 0.90) of the variance in the optimally scaled matrix of 20 items, comprising of two constructs; both constructs had eigen values greater than 3. constructs with eigen values of greater than 1.00 are considered appropriate for consideration (meyers et al., 2013). the first construct, maturity, comprised 18% (d = 0.75) of the total variance within the model. meanwhile the second construct, rural investment, accounted for 16% (d = 0.73) of the total variance. the following components were included in maturity (correlations in parenthesis): age (.69), position (.64), experience (.62), education (.60), total years lived rurally (.59). on a similar note, the following components were included in rural investment: specialization (.85), primary practice setting (.70), years lived in the current area (.60). online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 179 power. g*power version 3.1.9.2 was used to conduct the a priori and post hoc power analyses. a post hoc power analysis was calculated using the means: wilcoxon-mann-whitney test (two groups) to compute the actual achieved power with the rural provider group (n = 7) and the rural nurse group (n = 44). the power was determined to be 0.22, critical t = 2.01, df 47.70. in support of the exploratory approach of this study, a post hoc power analysis using the means: wilcoxon-signed rank test (one sample case) was calculated using the obtained sample (n = 51). the actual power was calculated to be 0.96, critical t = 1.20, df 46.70, d = 0.50. discussion the quality of the study was maintained by using two researchers in the analysis process, critical debate and discussion, and a statistical consultant. the research methods, analyses, results, and conclusions were presented, examined, and discussed with a panel of four independent, experienced researchers prior to submitting this manuscript for publication. the purpose of this mixed methods study was to explore the perceptions of palliative care among rural providers, nurses and adults. the primary aim was to explore and compare the palliative care perceptions of rural dwelling providers, nurses, and adults. the secondary aim was to explore the relationship between knowledge and perceptions of palliative care held by providers and nurses practicing in rural areas. both aims were accomplished by this study. the decision to include all 20 pckt questions was based on the specific aims and the exploratory nature of this study. after excluding the two questions, total pckt scores for the sample (n = 51) were found to be lower. the low pckt scores obtained by rural providers and rural nurses, when combined with the key themes that palliative care is perceived as end-of-life care, makes it alarmingly clear that significant changes are needed to improve the quality of online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 180 provider and nurse academic preparation and continuing education related to palliative care. these findings were strengthened using the convergent parallel design. one rural nurse interviewed for this study, rn06, talked about palliative care as end-of-life care, which was reinforced by the wonderful clinical experience of rn06 in a hospice setting. the findings of this study are reinforced by previously published studies, which suggested that providers and nurses are confused about the broader applications of palliative care (golla, galusko, pfaff, & voltz, 2014; weil et al., 2015), and that they largely perceive palliative care to be synonymous with end-of-life or hospice care (golla et al., 2014; kavalieratos et al., 2014; leblanc et al., 2015; weil et al., 2015). the differences between understanding the theoretical value of broad-based palliative care and contradicting statements made during the interviews raise important questions about the influence of reimbursements and experiences when combined with poor palliative care knowledge, as measured by the pckt (providers 61.5% correct, nurses 52.4% correct). overall total pckt scores, which indicate poor knowledge about palliative care in this study, are supported by previously published studies that included providers from rural areas (kavalieratos et al., 2014; leblanc et al., 2015). the perceptions of rural adults in this study range from having no idea about what palliative care is, to perceptions that palliative care is hospice care or end-of-life care. finding from this study related to rural adults are supported by a recent study of community dwelling adults (n = 301) which found relatively poor palliative care knowledge among adults in the u.s. (kozlov, mcdarby, reid, & carpenter, 2017). the exploratory catpca identified two constructs, maturity and rural investment, which assume meaningful significance for providers and nurses practicing in rural areas. many of these providers and nurses are living and working right where they want to be. although exploratory, online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 181 the constructs of maturity and rural investment have been supported by existing research. providers who practice in rural areas are more likely to be from rural areas (lindsay, 2007). the sample characteristics of participants in both components of this study support the viewpoint that providers and nurses who practice in the studied geographic area are experienced and have lived and practiced in rural areas for a considerable time. this supports the construct of maturity and rural investment. rural nurses are generalists with expertise in many areas (lee & mcdonagh, 2013; scharff, 2013), are well-known, and are involved in many aspects of life in the rural area where this study was conducted, which lends additional support to the construct of rural investment. limitations as a study of two independent samples, this study is significantly underpowered. originally, the a priori power analysis was calculated using a two-tailed t-test, difference between two independent means (two groups). based on the level of the data and non-experimental design, a wilcoxon-mann-whitney test (two groups), should have been ideally used to determine the sample size. however, the desired sample size needed in each group increased by only three. a post hoc power analysis using the obtained sample (one group) calculated the power to be 0.96 with a medium effect size (d = .50). threats relating to small sample size and low power are reduced by the mixed methods design (creswell, 2014). similarly, the expansive geographic area of this study posed some challenges. for example, a few face-to-face interviews were extremely short and theoretical saturation was not achieved in the provider group due to recruitment difficulties and a lack of additional time. some rural health clinics were open for very limited hours and were staffed by providers and nurses who also worked at other facilities. furthermore, online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 182 the 19 healthcare facilities initially identified may have given an inaccurate idea of the number of providers and nurses within the study area. visiting each organization and providing sufficient survey packets for the employed providers and nurses (n= 99) provided a better assessment of the study population. the geographic area of this study is sparsely populated, and several organizations employed small staffs with only a provider or two, in addition to a nurse or medical assistant. therefore, despite its limitations, the small sample (n = 51) is a reasonable representation of the population. moreover, the mean pckt total scores were slightly higher, yet comparable, to the total pckt scores reported for a sample of nurses (n = 35) in rural kentucky (evans, 2016). conclusions considering the results of this small-scale study, coupled with the evidence presented by existing research, it can be concluded that the misperceptions and poor knowledge related to palliative care likely prevent the broader application of palliative care in the rural and highly rural areas where this study was conducted. rural and urban health care disparities continue to widen, and the number of rural dwelling adults impacted by serious chronic conditions continues to grow at a worrying pace. concurrent palliative care, when offered as a vital component of comprehensive primary care in rural areas, may provide the best opportunity for rural adults to remain active and age in place. however, the perceptions that palliative care is end-of-life care may serve as a significant barrier for providers and nurses practicing in rural areas, as well as rural dwelling adults who could benefit from concurrent palliative care. future initiatives may include: redesigning medical and nursing education to include broad-based or concurrent palliative care; educating people in rural areas about the broad scope of palliative care; and working with both policy makers and payers on palliative care reimbursement. indisputably, additional research is online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 183 needed on rural populations. to that end, future studies may include: the role of concurrent palliative care within rural primary care, the way experiences influence practice in rural areas, and the economic impacts of broad-based palliative care in rural areas. additional rural research opportunities exist to include certified and unlicensed staff that faithfully support rural health care, but were not included in this study, such as medical assistants, nursing assistants, emergency medical technicians, and first responders. references aslakson, r., koegler, e., moldovan, r., shannon, k., peters, j., redstone, l., … pronovost, p. 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(2014). exploring public awareness and perceptions of palliative care: a qualitative study. palliative medicine, 28(3), 273–280. https://doi.org/10.1177/0269216313502372 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 187 meyers, l. s., gamst, g., & guarino, a. j. (2013). applied multivariate research design and interpretation (2nd ed.). los angeles, ca: sage publications. nakazawa, y., miyashita, m., morita, t., umeda, m., oyagi, y., & ogasawara, t. (2009). the palliative care knowledge test: reliability and validity of an instrument to measure palliative care knowledge among health professionals. palliative medicine, 23(8). https://doi.org/10.1177/0269216309106871 polit, d. f. (2010). statistics and data analysis for nursing research (2nd ed.). upper saddle river, nj: pearson education. ratcliffe, m., burd, c., holder, k., & fields, a. (2016). defining rural at the u.s. census bureau (american community survey and geography brief no. acsgeo-1). washington, dc: u.s. census bureau. retrieved from https://www2.census.gov/geo/pdfs/reference /ua/defining_rural.pdf scharff, j. e. (2013). the distinctive nature and scope of rural nursing practice: philosophical bases. in rural nursing concepts, theory, and practice (4th ed., pp. 241–258). danvers, ma: springer publishing company. tavakol, m., & dennick, r. (2011). making sense of cronbach’s alpha. international journal of medical education, 2, 53–55. https://doi.org/10.5116/ijme.4dfb.8dfd united states census bureau. (n.d.). geography urban and rural. retrieved from https://www.census.gov/geo/reference/urban-rural.html verschuur, e. m., groot, m. m., & van der sande, r. (2014). nurses’ perceptions of proactive palliative care: a dutch focus group study. international journal of palliative nursing, 20(5), 241–245. https://doi.org/10.12968/ijpn.2014.20.5.241 online journal of rural nursing and health care, 18(2) http://dx.doi.org/10.14574/ojrnhc.v18i2.527 188 vogt, w. p., vogt, e. r., gardner, d. c., & haeffele, l. m. (2014). selecting the right analysis for your data: quantitative, qualitative, and mixed methods. new york, ny: the guilford press. weil, j., weiland, t. j., lane, h., jelinek, g. a., boughey, m., marck, c. h., & philip, j. (2015). what’s in a name? a qualitative exploration of what is understood by “palliative care” in the emergency department. palliative medicine, 29(4), 239–301. https://doi.org/10.1177/ 0269216314560801 winters, c. a. (2013). rural nursing: concepts, theory, and practice (4th ed.). new york, ny: springer publishing. world health organization. (2018, february 19). palliative care. retrieved from http://www. who.int/mediacentre/factsheets/fs402/en/ microsoft word collins_column 4   online journal of rural nursing and health care, vol. 9, no. 1, spring 2009  editorial medication errors: resources for practice angela collins, rn, dsn, aprn-bc, ccns editorial board member the process of giving medication in an acute care hospital is an example of chaos principles. each medication order, dispensing, administration and monitoring, and evaluation is unique. each patient situation and concurrent medical problems is unique. each person in the process of dispensing, administering, monitoring, and evaluation is unique. this sets up thousands of variables in interaction with medication administration. because these variables are highly dependent on communication and human behavior, the outcome is that patient deaths occur. these problems were first highlighted by kohn, corrigan, and donaldson (1999) in a report published in the institute of medicine’s (iom). the challenges of making medication administration safer are even more acute in the rural hospital environment because resources are sparse. there are five resources that may assist rural nurses to dissect the processes that contribute to medication errors in their facilities. • the first with the greatest specificity to rural health environments is from the institute for safe medication practice. this program is a summary document of the current research and best practices in medication processes specific to rural environments. the website is http://www.ismp.org/consult/ruralhospital/default.asp. • the second resource is associated located on the jcaho website. jcaho advocates a program called “speak up” where the patient is encouraged to partner in their care to help prevent medication misadventures. a patient informational brochure can be downloaded from http://www.jointcommission.org/nr/rdonlyres/bf7973e4-bcec42e1-bb59-7d7d207d4870/0/speakup_brochure_meds.pdf. additional resources are also located on this site and the website cites that “there are no copyright or reprinting permissions required for the speak up materials or copy. in references to the materials or copy, we do ask that the joint commission be credited as the source for the materials or copy.” • the third resource is the electronic newsletter from the agency for health care policy and research. this newsletter highlights problem areas and reports best practices in medication safety. the link to register for this resource is http://www.ahrq.gov/qual/errorsix.htm. • the fourth resource is from the iom and is a text called quality through collaboration this resource has several chapters specific to quality improvements in rural hospitals. http://www.nap.edu/catalog.php?record_id=11140. • the final resource is specific to medication adverse effects and updated labeling. this resource is from the fda and is a free access website. http://dailymed.nlm.nih.gov/dailymed/about.cfm. 5   online journal of rural nursing and health care, vol. 9, no. 1, spring 2009  access and utilization of these resources can help rural hospitals examine the process of medication use throughout the facility safer. learning from the mistakes of others and incorporating simple measures into clinical practice could diminish the chaos that cost patients their lives. references kohn, l.t., corrigan, j.m., & donaldson, m.s. (eds.). (1999). to err is human: building a safer health system. institute of medicine. washington, dc: national academy press.       microsoft word graves_column 12 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 editorial community-based participatory research: toward eliminating rural health disparities barbara ann graves, phd, rn editorial board member the national healthcare disparities report (nhdr) (2008) tracks and documents access to healthcare as well as quality of healthcare. this report provides information to policymakers, clinicians, administrators, and community leaders for the improvement of healthcare services. from this report it is apparent that disparities in healthcare still exist and that many opportunities for improvement remain across racial, ethnic, socioeconomic, and geographical groups. the health resources and service administration (hrsa) (2009) designates medically underserved areas (muas) and medically underserved populations (mups) as areas or populations having too few primary health care providers, high infant mortality, high poverty, and/or high elderly populations. one underserved and priority population is residents of rural areas. according to the nhdr (2005), “compared with their urban counterpart, rural residents are more likely to be elderly, poor, in fair to poor health, to have chronic conditions, and to die from heart disease”. residents of rural areas experience more health disparities than residents of urban areas. access to quality healthcare is an ongoing problem for rural populations. financial, sociocultural, and structural features of the rural environment create barriers to healthcare. these factors affect health-seeking behaviors, healthcare access, and ultimately health outcomes in rural areas (bushy, 2000; ricketts, 1999; eberhardt, et al., 2001). rural areas are often identified as medically underserved areas (muas) and medically underserved populations (mups). a disproportionate burden of health disparities for rural populations requires attention. because the burden of poor health is great in terms of cost and disability, further research into specific healthcare disparities for specific rural communities is needed. it is important to learn as much as possible about the ecology of health and disease within the context of individual communities. how can this best be accomplished? communities have identities developed from their unique strengths and resources. health is relevant to this identity. communities need to be empowered to generate knowledge and interventions to solve their own health problems. israel et al. (2001) conducted a review of literature regarding community-based research. from this seminal review comes a comprehensive definition of community-based participatory research (cbpr) as a: ….collaborative approach to research that equitably involves, for example, community members, organizational representatives, and researchers in all aspects of the research process. the partners contribute unique strengths and shared responsibilities to enhance understanding of a given phenomenon and the social and cultural dynamics of the community, and integrate the knowledge gained with action to improve the health and well-being of community members (p. 177). 13 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the agency of healthcare research and quality (ahrq), in ongoing initiatives to address health care disparities, promotes the use of cbpr. ahrq defines cbpr as a collaborative process of research involving researchers and community representatives (ahrq, 2001). key principles as identified by ahrq (2001) are that cbpr: • recognizes the community as a unit of identity. • builds on the strengths and resources within the community. • facilitates collaborative, equitable partnerships in all phases of the research and involves an empowering process. • promotes co-learning and capacity building among all partners. • integrates knowledge generation and intervention for the mutual benefit of all partners. • emphasizes the local relevance of public health problems and the multiple determinates of health and disease including biomedical, social, economic, and physical environmental factors. • process is cyclical and iterative, and research goals are not always known at the beginning of work with the community. • can disseminate findings and knowledge gained to all partners and involve them in the dissemination process (ahrq, 2001). as one may see, the benefits of cbpr are multidimensional. cbpr: • enhances the relevance and use of data. • increases the quality and validity of research. • improves intervention design and implementation by facilitating participant recruitment and retention. • benefits the community through knowledge gained and actions taken. • provides resources for communities. • joins partners with diverse expertise to address complex health problems. • increases trust and bridges cultural gaps between partners. • has potential to translate research findings to guide further interventions and policy changes (ahrq, 2001). according to hrsa (2009), cbpr can be an effective approach in targeting health disparities in specified communities and specific populations. research, jointly conducted by communities and researchers, can assess health problems and design targeted interventions in underserved communities, thereby leading to improved healthcare access and health outcomes. cbpr may be one of the nation’s best options for eliminating rural health disparities references agency for healthcare research and quality (ahrq) (2001). community-based participatory research: conference summary. retrieved on may 11, 2009, from http://.ahrq.gov/about/cpcr/cbpr/cbpr1.htm 14 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 agency for healthcare research and quality (ahrq) (april 2008) national healthcare disparities report. national center for health statistics. retrieved on may 11, 2009, from http://www.ahrq.gov/qual/ardr08.htm bushy, a. (2000). special and at-risk populations. in bushy, a. (ed.), orientation to nursing in the rural community (pp. 73-85.). thousand oaks, ca: sage publications, inc. eberhardt, m.s., ingram, d.d., makus, d.m., et al. (2001). urban and rural health chartbook. health, united states, 2001. hyattsville, md: national center for health statistics. israel, b.a., schulz, a.j., parker, e.a., becker, a.b., & community-campus partnership for health (2001). community-based participatory research: policy recommendations for promoting a partnership approach in health research. educ health, 14, 182-97. ricketts, t.c. (1999). rural health in the united states. new york: oxford university press. u.s. department of health and human services. (usdhhs) (april 2009) retrieved on may 11, 2009, from http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm canada’s national belief in equal opportunity and sense of social responsibility to those who are less fortunate reinforces the principle of access to quality health care for all (madore, 2004; canada health act, 1984) 17 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 accessing heart health: a northern experience katherine timmermans, rn, mscn 1 ellen rukholm, rn, phd, fcahs 2 isabelle michel, rn, ma 3 lisa seto nielsen, rn, mn 4 jennifer lapum, rn, phd 5 robert p. nolan, phd, c psych. 6 jan e. angus, rn, phd 7 1 professor, neocnp school of health sciences and emergency services, cambrian college, katherine.timmermans@cambriancollege.ca 2 professor emeritus, school of nursing, laurentian university, senior research fellow, centre for rural and northern health research, erukholm@laurentian.ca 3 director of resources, research evaluation& development division, sudbury & district health unit, adjunct professor, school of nursing, laurentian university, micheli@sdhu.com 4 phd candidate, lawrence s. bloomberg faculty of nursing, university of toronto, lisa.seto@utoronto.ca 5 associate professor, ryerson university, faculty of community services, daphne cockwell school of nursing, jlapum@ryerson.ca 6 director, behavioural cardilogy research unit, university health network, assistant professor, institute of medical sciences and department of psychiatry, faculty of medicine, university of toronto, rnolan@uhnres.utoronto.ca 7 associate professor, lawrence s. bloomberg faculty of nursing, university of toronto, adjunct scientist, toronto rehabilitation institute, jan.angus@utoronto.ca key words: heart health, lifestyles, place, northern, rural abstract background and research purpose: coronary heart disease (chd) continues to be a major cause of death and disability across the globe. regional differences in chd exist throughout canada, including ontario. it is important to explore the complex interplay between geographical regions and individuals‟ efforts at reducing their cardiovascular risk. this study explored barriers and supports to heart healthy lifestyles and associated meanings within various regions of ontario. the focus of this paper is on the northern context to better understand the issues these individuals face when making heart healthy lifestyle changes. sample and method: the study used an ethnographic approach and photo-elicitation interviews. participants took photographs of places that represented the barriers and supports to lifestyle changes for cardiovascular risk modification. these photographs were used as the basis for interview dialogue. twelve informants from a larger study comprised the northern sub-sample considered in this paper. results and conclusions: when the data were analyzed, health care access and access concerns related to heart healthy lifestyles for people in northern ontario emerged as key findings. findings suggest that the concept of place is pivotal to recognizing issues related to health care access, which should be incorporated as part of our understanding of health and cardiovascular risk modification. mailto:katherine.timmermans@cambriancollege.ca mailto:erukholm@laurentian.ca mailto:micheli@sdhu.com mailto:lisa.seto@utoronto.ca mailto:jlapum@ryerson.ca mailto:rnolan@uhnres.utoronto.ca mailto:jan.angus@utoronto.ca 18 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 background coronary heart disease (chd) continues to be a major cause of death and disability in canada (public health agency of canada [phac], 2009). although chd death rates are declining, regional differences exist throughout canada, including ontario. differences in chd rates may be attributed to variances in major risk factors (phac, 2009; tanuseputro, manuel, leung, & nguyen, 2003). there is compelling evidence that certain physiological and behavioural factors place individuals at risk of developing chd. for instance, the prevalence of chd is linked to modifiable risk factors including hypertension, diabetes, smoking, body mass index (bmi) greater than 27, a diet including more than 30% of calories from fat, and a sedentary lifestyle (choiniere, lafontaine, & edwards, 2000; heart and stroke foundation of canada, 2003). these risk factors are also associated with social patterns of advantage and disadvantage; for example, individuals with less dispensable income are at higher risk for chd (choiniere et al., 2000; king & arthur, 2003; potvin, richard, & edwards; sahai et al., 2000). efforts to make healthy lifestyle changes are complicated by contextual barriers and supports (angus et al., 2009). it is important to explore the complex interplay between contextual conditions unique to geographical regions and people‟s efforts to modify cardiovascular risk. this study of barriers and supports to heart healthy lifestyles originated in two geographical regions in ontario. while study participants were recruited in sudbury and toronto, ontario, canada, the focus of this paper is the northern group of participants from sudbury. this mid-sized city is surrounded by a geographically large area of rural and remote communities and is located 400 km north of toronto, an urban metropolitan centre. sudbury is uniquely situated in the north, servicing the health care needs of the vast majority of surrounding communities, where chd rates exceed provincial averages (sahai et al., 2000; ward, 2003). defining the north the boundaries between northern ontario (no) and southern ontario (so) are not firmly fixed because they fluctuate as official electoral boundaries are redefined. recognizing that there is no consensus in the literature on definitions of terms such as rural and/or northern, the research team chose to define no according to the most commonly accepted geographical coordinates so that the data generated on the health of individuals living in this area could be appropriately contextualized. for this study, no was defined as the provincial region that extends north of the district of parry sound, where climatic conditions and population density begin to noticeably differ from those of areas to the south (mcniven & puderer, 2000; meyer, 2010). figure 1 illustrates the large land mass, and the dividing line through the parry sound district that separates no and so. 19 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 figure 1. map of ontario illustrating the divide/land mass of no and so in no, there is a distinct rural-urban mix population with the majority of northern cities situated within a rural context. no includes a large geographical area accounting for 90% of ontario‟s land mass, and is bigger than most provinces in canada (ministry of northern development, mines and forestry, 2010). less than 10% of the provincial population lives in no, and there are large distances between municipalities requiring extensive use of highways for full economic and social participation (sahai et al., 2000). low population density and distance also contribute to patterns of thin resource dispersal that create challenges for no residents, particularly when accessing health care services. geographic location and socio-demographic position form circumstances that support or undermine health. rural and northern populations have poorer health and higher mortality rates attributed to circulatory diseases such as chd (ward, 2003; pong et al., 2006). previous research indicated provincial regional differences in the prevalence of modifiable risk factors for chd, with higher risk, morbidity and mortality in some areas of no (jaglal, bondy & slaughter, 1999; 20 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 ward, 2003). northern and rural residents in some health regions of canada, as well as individuals with low incomes and limited education, are at highest risk for chd (choiniere et al., 2000; king & arthur, 2003; potvin et al., 2000; sahai et al., 2000). many residents of no have lower incomes, work more shift work in primary industry settings, higher unemployment rates, lower levels of education, and are less likely to have university degrees than persons living elsewhere in ontario (ministry of northern development, mines and forestry, 2009). all of these factors have been associated with higher rates of chd (sahai et al., 2000). health and place there are indications that there is a dynamic relationship among individuals, place, and health. further study of this relationship can be enriched by particular attention to the concepts of space and place. the concept of place refers to physical locations on various scales, ranging from geographic region to the various communities within a city to the dwelling that a person occupies (de certeau, 1984). space refers to the way that places are used or the meanings made out of places; as de certeau suggests, “space is a practiced place” (1984, p. 117). different people may do different things in and assign different meanings to the same place. in this way, place is personalized. theoretical understandings of place in this study are informed by the conceptualizations of de certeau (1984), which accounts for health variations across space and place. an individual‟s interactions within social space and material place can create health inequalities and discourage heart healthy lifestyle practices. for instance, the challenges to lifestyle change include time constraints, stress, financial struggles, and lack of health information (angus et al., 2005; 2007). these barriers are particularly common among some groups of people and influence the prevalence of heart disease in certain geographical areas (davey-smith, 1997; raphael, 2001). patterns of cardiovascular risk are identifiable in geographic subpopulations of urban, northern, and rural areas where variations in heart disease rates reflect variance in cardiovascular risk factors (dennis & pallotta, 2001; jaglal et al., 1999). contextual inequities of chd there is growing recognition that individual patterns of health are contextually embedded, meaning they are influenced by the social and material conditions of place (coburn, 2004; frohlich & potvin, 2008; scambler, 2001). currently, research from several disciplines illuminates the relationships among individuals, place, and health (desmeules, luo, wang, & pong, 2007; potvin & hayes, 2007; sullivan & gyorfi-dyke, 2007). place and health research has re-shaped our understanding of health inequalities by reinforcing attention to determinants of health (desmeules et al., 2007). it is now recognized that research should focus on situated patterns of health rather than solely on national population-level data (pong et al., 2006). individuals often face social and material barriers when incorporating new health knowledge and implementing health behaviour change (angus et al., 2009). social and material environments condition people's efforts to overcome health risks. the habitual, context-sensitive nature of some activities may further complicate health behaviour change (angus et al., 2007). for instance, time limitations, stress, financial struggles, and lack of health information can be factors that contribute to the prevalence of heart disease and risk in various groups of individuals while simultaneously acting as barriers to a healthy lifestyle (davey-smith, 1997; raphael, 2001). these understandings draw attention to the places where risk behaviours are created and chd is experienced. these places may vary according to geographic regions, including the rural north. they may be influenced by social locations, such as socioeconomic position. given these 21 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 ideas, the purpose of this study was to explore barriers and supports to heart healthy lifestyles and associated meanings within a mid-sized northern city set in a rural context. research methods approach this qualitative study is based on the tenets of ethnography which aims to understand and contextualize particular facets of social life (hammersley & atkinson, 2007). the research methods are described in greater detail elsewhere (angus et al., 2009). while observational methods are often associated with ethnography, an alternative is to employ visual methods that enable participants to portray their worlds and contribute to data collection (oliffe & bottorff, 2007; radley & taylor, 2003). thus, in this study, individual interviews were supplemented with photo-elicitation. recruitment and sample this qualitative study was linked with a larger trial (nolan et al., in press) that tested a risk reduction telephone counselling intervention for individuals at high risk for chd in three regions of ontario, including toronto and sudbury. trial participants‟ risk for chd was determined based on the framingham algorithm, using a standardized telephone assessment interview and physician referral form (grundy et al., 2000; wilson et al., 1998). individuals at elevated risk for chd (i.e., two or more risk factors) were invited to participate in the trial, including those with an existing diagnosis of atherosclerotic heart disease. the purpose of our associated qualitative study was to understand the social and material conditions of health behaviour change from the perspectives of people who had been made aware of their high risk for chd and had received information about cardiovascular risk modification. criterion sampling was used to select individuals at high risk for chd and who participated in a chd risk modification program with 39 participants recruited, thus assuring access to people who were knowledgeable about making cardiovascular risk modifications. this paper considers the experiences of the 12 english-speaking participants from sudbury. the sample included six males and six females. table 1 provides a demographic profile of the 12 northern participants. data collection procedures data collection occurred simultaneously at the two sites. the first and second authors formed the sub-team that gathered and analyzed data from the english speaking participants in sudbury. regular teleconference meetings were held with the entire research team; electronic exchange of information and in-person site meetings also occurred. data collection involved focus group discussions and individual photo-elicitation interviews. focus groups were held to introduce participants to the study, and to obtain descriptions of their efforts to change health behaviours. upon completion of the focus group discussions, participants were given disposable cameras and asked to take pictures of activities, objects, and places that affected their heart health initiatives. once the photos were developed, individual, in-depth individual interviews were arranged to discuss the photos. images were used as reference points to ground interviewbased discussion of specific places and situations that affect heart health. photographs of 22 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 table 1: sample demographics and profile (n = 12) characteristic m (sd) age, mean (sd) 62 (04.8 ) yrs of education, median (sd) 12 (02.2) n percentage(%) of sample ethnicity caucasian 10 83.3 other 2 16.7 country of birth canada other 10 2 83.3 16.7 language english 11 91.7 french 1 8.3 marital status married 8 66.7 single or living with others 1 8.3 single or living alone 3 25 family income 19,999 or less 3 25 20,000-39,999 2 16.6 40,000-69,999 4 33.3 70,000 or greater 3 25 work status full-time 4 33.3 retired 5 41.7 receiving disability 2 16.7 unemployed 1 8.3 children, mean (sd) 2.6 1.4 locations where significant healthful activities occur as well as barriers to healthy lifestyles take place helped to expand discussion by suggesting topics or examples. they also served to sharpen and focus description of habitual practices and contextual cues. photo-elicitation interviews were conducted with all of the northern participants except with one woman who felt unable to convey in photographs her feelings of stress related to family health issues. instead, she verbally described these issues in an interview. once the photographs were developed, photo-elicitation interviews were scheduled with each participant at the person‟s convenience, usually in the home. during the interviews, participants were asked to explore the significance of the images in relation to maintaining and/or changing health behaviours. interviews lasted 60 to 90 minutes and were audio recorded. ethical approval was obtained from all research ethics boards of all participating facilities in 2005, file # 20050509. signed release of the photos was obtained from all participants. data analysis data collection and analysis were concurrent. interviews were transcribed verbatim and transcripts reviewed to ensure accuracy and enhance credibility. all identifying information on 23 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 the transcripts was replaced with pseudo names unique to participants to ensure their anonymity. for example, each participant quote is identified by gender f or m, and participant number e.g. fp4. transcripts were read carefully and repeatedly by the primary researchers who noted emerging themes, similarities, and differences among the narratives. during full research team meetings, transcripts were shared and emerging themes discussed, affirmed, and/or revised by all members of the group. the process continued until a stable set of codes was established for the study. these discussions led to elaboration of noteworthy issues and themes, resulting in comparison of experiences in toronto and sudbury. access to resources that supported risk modification was a key issue and became one of the dominant topics of these reflexive discussions. during these discussions, sub team members‟ experiences as residents in specific communities served as resources in elaboration of issues. nvivo software was used to manage the data retrieved from the interviews and field notes, to code data, and to compare participants‟ experiences. results in this study, the accounts of the 12 northern english speaking participants revealed both barriers and supports in making lifestyle changes, and these sometimes pointed to the contradictory influences of context. participant dialogue centered on the theme of „access to places that support health‟, including discussion about diet, exercise, distance and travel, health care providers, and finances. within the places or physical locations of everyday life, participants engaged in the spatial practices of diet, exercise, stress reduction, and access to primary health care. these practices, both habitual and personally meaningful, illustrate the complexity of attempts to modify lifestyle and make heart healthy changes. lifestyle changes were attempted in everyday places of work, home, and neighbourhood that called forth and reinforced habitual practices rather than supporting new patterns. these practices were meaningful to participants as well as others who shared everyday places. furthermore, the relationship between the northern context, population density, dispersal of resources, and climate, and individual lifestyle practices created challenges when participants sought access to places that support health. for instance, geographical issues of climate and transportation compounded being unable to draw on health services e.g. primary health care and support facilities like gyms. the idea of access to places that support health was subsequently broken down into five themes including (a) access to healthy foods, (b) access to exercise, (c) access to roads, (d) access to health care providers, and (e) access to sufficient finances. access to healthy foods a dominant theme associated with cardiovascular risk modification was diet. participants seemed to understand the importance of healthy foods and diet. many participants described maintaining a balanced diet, including lean meats, fruits and vegetables, and whole grains. participants explained that meals cooked in their home environment made it easier to follow a healthy diet because they could control the types of foods prepared. however, participants found it difficult to resist food temptations in certain places. several participants described the struggle of healthy eating in restaurants. an illustration of this is noted in a participant‟s description and photograph (figure 2) of her experience eating at a buffet restaurant during a family gathering. she explains: “when i go there, i love it, and i eat too much, too much sweets, and i don‟t think it‟s healthy … i just can‟t control myself” [fp4]. 24 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 figure 2. buffet restaurant. the struggle of healthy eating involves being drawn to places for the pleasure of satisfying a food craving, and for the socialization and connection that occurs when sharing food with friends and family. this is portrayed in a participant‟s description and photograph (figure 2) of gathering at a local coffee shop: we mostly eat at home, especially for suppers, so we usually have a good meal, a balanced meal. once in a while, you like to go out…we have friends that go to the [coffee shop], practically every night, so once in a while we‟ll go there as a group. and that‟s a good experience, because we sit and chat. but if you overdo any of this stuff, that‟s not good [mp6]. figure 3. coffee shop. several participants noted that social gatherings included a sense of well-being as well as unhealthy eating patterns, hence there were mixed meanings associated with these events. 25 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 socializing created a space that was neither inherently unhealthy nor healthy, but that had potential to be both at the same time. in these cases, participants described two options: (a) reverting to previous eating habits, also called “taking a break” from healthy habits during social functions, and (b) requiring family members and/or guests to change their preferences during special holiday meals. participants often sought resources that they could incorporate into their efforts to change everyday patterns, including knowledge, equipment, and new food items. at these points, the notion of access became salient. both southern and northern participants identified these struggles. access to exercise participants described the importance of an active lifestyle and exercise as a way to reduce their cardiovascular risk. activities like gardening, walking, and going to the gym were seen as supports to their heart health efforts. however, exercising with co-morbidities can be difficult, especially for an older population living in the north where there are limited specialized facilities that support their activity level. nearly all participants described the challenge of exercising with co-morbidities. a good illustration is found in the following account: well, i guess more support. like it‟s nice to be able to say that exercise helps with high blood pressure, but i have bursitis in both hips, so i can‟t walk a lot. and there‟s a lot of exercises i can‟t do like swimming, as far as the aquacise, i go into a pool with a lot of chlorine and i‟m scratching, so there‟s really nothing. [fp6] for this participant, being active was complicated by the challenge of exercising with chronic muscle, bone, and joint problems. it was further hindered by a perceived lack of recreational and rehabilitation facilities that accommodate the exercise needs of individuals with co-morbid conditions. although individuals found it difficult to exercise because of co-morbidities, they often found alternate ways to remain active, such as creating a raised garden to limit bending, and using indoor malls for walking in the winter. in the summer months, participants often described easy access to outdoor exercise, such as walking, biking, and gardening (figure 4). this is apparent in one participant‟s description and corresponding photograph: “i would like to join the [gym]…i went a couple of times to do some swimming, especially in the winter time. in the summer, i‟m always doing something... and this [photograph] is when i went for a little stroll” [mp5]. figure 4. outdoor exercise in summer months. 26 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 for this retired participant summer months were filled with outdoor activities, including restoring cars, vacationing, gardening and walking. he contemplated whether he could afford purchasing a gym membership for exercise in the winter months. a corresponding lack of available and affordable fitness facilities compounded the problem of finding a place for exercise. one participant commented: i don‟t belong to the [local fitness centre]…i found their prices were outrageous… i had looked into it and it was almost five hundred dollars a year. i mean, we‟re comfortable but i have to kind of [gauge] where i‟m going to spend five hundred dollars. [fp5]. however, this participant also acknowledged that she could afford to buy exercise equipment to use in her home. this was apparent in the photograph of her living room where she would exercise (figure 5). figure 5. living room scattered with exercise equipment she further explains: i firmly believe you should help yourself, which is what i did. instead of putting the five hundred out for the [gym], i put out eight hundred and i got myself a treadmill…at yard sales, i found an exercise bike and an ab toner…i do my best. and then…we do a lot of outdoor work here [fp5]. this participant was motivated to promote her cardiovascular health, seeking ways to incorporate exercise into her daily routine despite being on a fixed income. in contrast, participants from toronto spoke of being well resourced because there were several fitness facilities nearby that were easily accessible. for example, an urban female participant, who was financially well resourced, described having a support network within walking distance with which she could exercise and socialize. she described the tennis club she belonged to as follows: probably not far enough away from my house [to facilitate added exercise by walking there]. i can get there in five minutes. it‟s very close. the library is very close too. the library and tennis club are all in the same complex….and i meet 27 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 the fitness group there in the morning and i went there and i enjoyed it…. so i only went to one session, but i did enjoy it and there‟s another place that i go, where it‟s very convenient…. [fp3 urban]. similarly, a male participant who lived in the city core described easy walking access to health care, shops, and fitness facilities. this participant commented on easy access to the many specialists who were involved in the care of his heart health. it is important to note that these examples do not reflect the challenges of people who live in the suburbs of the city and have to travel, fighting heavy traffic, before reaching health care services and facilities. access to roads in the north, low population density results in distribution of resources across great distances. participants indicated that they had long distances to travel and faced unpredictable road conditions. a clear representation of the challenges experienced in the north is represented by several participants‟ photographs of icy roads and snow, and this notable example (figure 6). figure 6. snow covered road this photograph represents a road within city limits and its physical nature involves connecting places. while a road is a place, it is also a path to places such as health care facilities, shops, malls, and gyms. its use is often affected by poor weather conditions, especially during the winter when average temperatures are cold, snowfall is heavy, and harsh weather may last for months. several participants acknowledged the challenges associated with transportation and climate in the north. one participant commented: “you see it on tv. it snows almost every day and i am not familiar with this car; it‟s too heavy and i don‟t know how it behaves in the snow. it makes me nervous” [mp4]. another account that exemplifies the challenges of a northern climate was described by a participant who found the winter months in sudbury isolating with snow and poor road conditions keeping her confined at home: 28 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 i have to get out today. if i don‟t i am going to go stir crazy; besides i need to get out…in case we have more snow i need to get some more stuff… i don‟t mind driving on a day like today but i wouldn‟t drive in a snow storm…i wouldn‟t drive on anything icy [fp2]. this illustrates the impact of harsh, winter climates impeding individuals‟ efforts to traverse to places that support their health. participants often described needing a vehicle to access shops and health care services and viewed this as a support to their health. not only is the road a path connecting places; it is also a means for exercise. the natural environment can be an inexpensive choice for exercise but physical limitations including rugged terrain can make walking in the winter difficult and can act as a deterrent. as one participant suggested: “i am not good at getting out and walking particularly in the winter time” [fp3]. the fear of slipping on ice and falling was described as a deterrent to outdoor activity in the winter by several northern participants. although harsh road conditions are not unique to the north, the difference lies in the length of time that outdoor activity is constrained by several months of winter weather. additionally, while road travel may be viewed as a barrier in both the north and the south, its problematic nature may be differently experienced by residents of the two regions because of density and dispersal of populations. for instance, in the north, there is the fear of road conditions because of travel distances, snow, and animal-related traffic accidents, such as collisions with moose. this was evident in a participant‟s photograph of a highway sign (figure 7) and discussion about the fear of driving on this northern road, which she explains: my travel ones...highway 69 bothers me…when i‟ve kids traveling on that highway and i don‟t like traveling it myself… i find it stressful you know if someone isn‟t there when they are supposed to be there like i am vibrating, what is holding you up… that day [my daughter] was coming from [up north] with the two kids and you know it was right at the height of moose season, bear season and… i am sitting watching the clock…yeah that is not good [fp3] figure 7. two separate highways in no. in the south, extremely dense population creates rush-hour traffic jams and accidents that cause lengthy delays, even while traveling short distances. however, in good weather conditions, northern participants described highways access positively because it allowed quick connections 29 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 to places, especially for those individual living outside of the city core. an illustration is represented in one participant‟s description: i find for [an outlying area], we‟re so close. i mean, i can get to new sudbury faster than somebody at the south end… and i‟m not going over the speed limit, i set my [cruise control…and [driving down the highway] i can get to the shopping centre…in ten minutes [fp5] several participants in the north took photographs of roads, some inadvertently, reinforcing the necessity of access to a vehicle, and highway travel and distance in no. the inherent nature of the road and highways presents both challenges and supports to health practices, but was often described as a as barrier in no. access to health care services and professionals access to quality health services and health professionals may be dependent on resources available. northern participants often felt privileged to have access to a primary care physician; yet, they wanted better access to quality health care. this is illustrated in the accounts of several participants who reported poor access to primary health care and specialized medical treatment. one participant described feeling lucky that she had a primary care physician as she explained that her daughter and grandchildren who were moving to sudbury did not have a doctor: i am very fortunate that i have got a doctor…my daughter is moving here and does not have a doctor for her children… that is just not healthy that they don‟t have a family doctor. [fp3] another participant described the challenges of living with chd and limited access to a primary care physician who could monitor her medical care needs: “when all this came about…i had i guess a little bit of a problem because of the doctors are so few and far between” [fp5]. in this case, the participant relied on different physicians at the walk-inclinic for her prescriptions and described limited follow-up care for her medical problems. an interesting account is represented by another participant who associated emotion with limited physician access. she described desire and distress in her hope for improved health services: i wish some of our resources were better... it is kind of sad to see the hospital still not finished, the other day i was going into the pharmacy and the walk in clinic was closed because there wasn‟t a doctor available, it is things like that that you wish were better. [fp3] primary care is a vital source of health information, support, and monitoring; it is also necessary for detection and management of risk factors including hypertension and hypercholesterolemia. participants with access to primary care pointed out the importance of this resource in assisting with risk modification. similarly, several participants described their challenges in accessing specialized health care services. in one account, a participant explained needing a gastric repair of her oesophagus. she described her difficulties in living with symptoms that could be relieved through a surgical intervention, also indicating that the northern specialist following her care had a long wait list. she explained: “the doctor i have…he‟s got a year and a half waiting list, and i‟m not going to put up with all the symptoms i have” [fp4]. the participant ended the discussion by suggesting she would head south to an urban centre to receive care in a more timely fashion. 30 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 participants also described positive relationships with doctors, who provide valuable information and re-assurance about their health concerns. one male participant described: “since my heart attack, i ask my doctors everything and she has been great…she drew me a picture of the heart and explained everything.” [mp2]. another participant explains: “[my doctor] did listen and that she did take the time. i was always so comfortable…she was wonderful” [fp5]. northern participants were confronted by barriers when accessing health care services. however, participants identified primary care providers as a valued resource. access to sufficient finances in the north, access to health supports was further challenged by financial constraints. several of the northern participants spoke of the challenges they faced because of financial difficulty. in particular, three of the northern participants reported low incomes of less than $19,000 per annum, and described stress associated with lack of material resources. one participant who lived on the outskirts of sudbury spoke of the worries of being unable to afford a reliable vehicle to travel into the city to access health care, groceries, and other necessities that supported his health. he explained: i wasn‟t making enough money. there was [too many low paying jobs] and not enough money. i had to make it week by week…since i was living 20 minutes from the nearest shop or repair shop or trucking centre and my car was almost 16 years old and i never took it to the repair shop in 12 years. i did most of the work myself…so it was too much stress [mp4]. other participants spoke about loss of employment, associating such periods with stress and depression. a notable illustration is evident in one of participant‟s photograph of her cheque book. however, the photograph is not presented because the image was unclear. a major factor contributing to this participant‟s health and well-being was balancing her budget, ensuring she had the finances required to survive from month to month. in this case, she described a time when she was an unemployed single mother taking care of two children. she explained that balancing her cheque book was always stressful because it reminded her of past financial instability: one thing that really gets me going is balancing my cheque book! i get angry, i get frustrated… i was laid off from one job and i went into a depression. like, i didn‟t even know what was happening to me. i just realized that i am in a mess…because i didn‟t have a job that meant financial instability…and it took quite a while to get back on track. [fp3] uncovering the meaning behind this statement illustrated a connection between financial insecurity and its associated psychological stress, which then affects self-care in other ways, including being able to afford a healthy diet and full social participation. in summary, access to places that support health was affected by the interplay of several contextually embedded factors that are components of the northern experience. northern participants demonstrated distinct vulnerabilities in relation to efforts to improve and maintain health. these sites of vulnerability involved access to healthy foods and exercise; access to roads and associated climatic challenges, distance factors, and transportation necessities; access to 31 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 primary health care; and access to sufficient finances and affordable options for a healthy lifestyle. discussion canada‟s commitment to equal opportunity and sense of social responsibility to those who are less fortunate reinforces the principle of access to quality health care for all (canada health act, 1984; madore & tiedemann, 2005). ensuring high quality, affordable, and equitable access to health services is a high priority for canadians since lack of access to such services negatively impacts health. thus, over the past 40 years, access to health care services has received attention from the research community and policy makers seeking to improve health outcomes, including health status and morbidity and mortality rates of individuals across the nation (gulzar, 1999; panelli, gallagher & kearns, 2006; racher & vollman, 2002; ricketts & goldsmith, 2005; wilson & rosenberg, 2002). while a major concern of the health care systems across north america is ensuring equal access to services (racher & vollman, 2002; ricketts & goldsmith, 2005); in the past, health care policy has been driven by a narrow interpretation of the concept of access that does not embrace context-specific issues that arise in rural and northern places. the complexity of lifestyle changes extends beyond the individual since efforts to change are “placed” within social and material contexts that actively shape each individual‟s health and health behaviours. the findings of this study illustrate the meaning of place for individuals living in the northern city of sudbury in relation to their experiences of heart health. a major challenge was accessing places that support heart health. limited access to health services (primary health care and preventative support services) can have serious health consequences, including premature cardiovascular morbidity and mortality (dennis & pallotta, 2001; pong et al., 2006). delayed treatment of health problems often results in increased severity and acuity of health problems, increasing the cost to individuals, families, and the health care system. to address the health inequalities of place, research is required on “places of concern” and “populations of concern” to develop an understanding of the elements underlying these differences (pong et al., 2006). rural and northern populations are populations of concern because they are often confronted by the challenge of accessing health care services (curtis & jones, 1998; gulzar; 1999; pierce, 2007; racher & vollman, 2002; strasser, 2003). in the north, access barriers such as geographical distance can act as an important deterrent to participation in risk modification programs (angus et al., 2007; 2009). rural and northern dwellers face challenges in accessing health care because of increasing age, distance and weather conditions that require a vehicle for transportation (pierce, 2007). the findings of this study support the idea that a major issue for individuals living in the north is access to supports which can help mitigate cardiovascular risk. participants indicated that a lack of available health care professionals made it difficult to support their heart health needs. recent study findings support that most communities in no lack a supply of health care professionals to provide conventional medicine (meyer, 2010). however, several factors shaped the ability to access places that support health. access included places that support emotional well-being and provide resources for managing psychosocial factors such as stress and depression that negatively impact heart health. findings highlighted that accessing health supports includes physical and material resources, such as having the finances and being able to afford membership at a fitness facility. access was further connected to the geographical features of place including climate, distance, and transportation and the distribution of physical resources or places that support health. this was particularly relevant for individuals at high risk for chd, 32 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 who reside in no and have to travel greater distances to access the physical locations that support health. to most of the public, policy makers, and practitioners, the notion of access can be obscure (racher & vollman, 2002). it is complicated by the understanding of place because it is not only about physical places or locations; it is also about how people manage place, navigate through to find place, and the meanings people assign to place. access then is not only about physical locations such as fitness facilities and exercise centres, but it includes access to the human health resources that are at the cornerstone of our health care system. in particular, the circumstances in which people are situated can act as barriers and/or supports within everyday life (de certeau, 1984). these circumstances can be social e.g. a person‟s social position in relation to others they interact with or material e.g. a person‟s tangible resources they can utilize which together are strongly intertwined and mutually reinforced. reliance solely on population counts limits access to necessary health services across northern rural areas (desmeules et al., 2007). there are several factors that need to be considered in discussing access issues: (a) people within place, (b) place and environment, (c) sense of place and social attachment, (d) culture of place, (e) infrastructure of place, and (f) transportation. for instance, an individual‟s social support network can influence the health resources he or she chooses to access (desmeules et al., 2007). this discussion then illustrates the complexity of access within the pursuit of a heart healthy lifestyle. access issues are multidimensional and involve linking the notion of place within patterns of diet, exercise, geography, and emotional well-being. implications and recommendations this study extends knowledge of the heart health experiences of individuals living in a mid-sized northern city of ontario. it reinforces that, in the north, communities are not homogenous; rather, they have diverse social, geographic, and place characteristics (ontario hospital association [oha], 2003) where health needs are different from those in urban areas (ministerial advisory council on rural health, 2002). these findings support the idea that northern and rural areas do not have the same range of access to services as their urban counterparts (swindlehurt, deaville, wynn-jones & mitchinson, 2005). given this diversity, the application of uniform models fails to address the health needs of northern residents where flexibility is required to respond to local needs (oha, 2003). although research has illuminated the differences that occur between and among northern, rural, and southern areas, there continues to be a need for specific policies and approaches that reflect health and place as well as access to resources (oha, 2003). as a result, communities may need to design strategies that meet their unique needs (romanow, 2002). additionally, health policy should continue to address access issues of northern and rural communities in the provision and delivery of heart health services. these issues include distance, sparse population patterns, limited infrastructure including transportation and communication, limited health care resources and access to technology, educational preparation for generalist-specialist practice, and recruitment and retention of professionals. overall, there is no simple solution to any of the challenges faced by northern, rural, and southern communities (pong & russell, 2003). policies, however, should take into consideration the effect that place has on access to health supports. they should be flexible enough to accommodate the needs of the people and diversity of the places in which they live. furthermore, research should continue to address information gaps regarding the health status of all residents and the places in which they are situated. within this context, a research priority may include evaluating the effectiveness of a chd risk reduction strategy that broadens the individual‟s 33 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 experience of “place” by means preventive counselling via telehealth or the internet (nolan et al., in press). study limitations a limitation of the study is that participants may have been highly motivated to participate in risk modification because of their involvement in the larger trial. participants were recruited who were interested and had the time, resources, and supports necessary to participate in the study. due to the descriptive nature of the study, results may not be generalizable for all northern or rural populations. it is, therefore, the individual‟s responsibility to consider how these findings may be valuable in similar contexts. replication of the study is recommended. conclusions this article represents a preliminary step in understanding the implications of access within health and place research in its examination of factors that affect utility and availability of heart health supports. in part, it helps to re-shape our understanding of access and place barriers encountered in the achievement of heart health in one community in no. considering that this study took place in a mid-sized northern city where there is, by comparison, reasonable access to resources, the issues that remote areas face may be more complex. understanding what influences cardiovascular risk modification can be considered place-based, including not only the physical location, but also the concentration of the social and material resources, density of populations, different climates and geographical terrains. acknowledgements we would like to thank the participants in this study for their contributions in helping us understand their experiences in making cardiovascular risk modifications. special thanks to geoff kramer of perpetual notion, edmonton, canada. we are grateful for his work in preparing participants‟ photographic images for this publication. special thanks to cartographer dan mccool for his work in preparing the map of ontario illustrating the divide of no and so. the study was funded by the canadian institutes for health research (cihr). references angus, j., evans, s., lapum, j., rukholm, e., st. onge, r., & nolan, r. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/12371434 http://www.ncbi.nlm.nih.gov/pubmed/12564264 http://intraspec.ca/inequalityisbadforourhearts-2001report.pdf http://intraspec.ca/inequalityisbadforourhearts-2001report.pdf http://www.ncbi.nlm.nih.gov/pubmed/16360698 http://dsp-psd.pwgsc.gc.ca/collection/cp32-85-2002e.pdf http://dsp-psd.pwgsc.gc.ca/collection/cp32-85-2002e.pdf http://www.ncbi.nlm.nih.gov/pubmed/11200734 http://www.ncbi.nlm.nih.gov/pubmed/12876121 http://www.ncbi.nlm.nih.gov/pubmed/15885027 http://www.ncbi.nlm.nih.gov/pubmed/9603539 toerber-clark_656_formatted online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 49 workforce demands of rural nurse practitioners: a descriptive study jody toerber-clark, dnp, fnp-bc 1 marian jamison, phd, rn 2 monica scheibmeir, phd, rn 3 1assistant professor, school of nursing, washburn university, jody.toerberclark@washburn.edu 2professor, school of nursing, washburn university, marian.jamison@washburn.edu 3retired dean, school of nursing, washburn university, monica.scheibmeir@gmail.com abstract purpose: nurse practitioners (nps) are rendering health care services in rural areas in increasing numbers, yet little is known about clinical skills and patient care management activities performed by these advanced practice nurses in the rural environment. the purpose of this descriptive study of rural nps was to identify skills and patient care management activities that they have performed and considered critical to kansas rural practice. sample: a convenience sample of 208 nurse practitioners (np) in rural and frontier kansas were emailed a survey that asked about skills and activities they perform in their rural practice. sixtythree responded for a response rate of 30%. findings: the analysis produced a list of 26 skills and 37 patient care management activities critical to kansas rural np practice. most of the skills/procedures were learned after graduation. almost all the respondents reported additional training/certifications in advanced life support and trauma. the majority of respondents were family nurse practitioners who practiced in a variety of rural settings. “i grew up in a rural setting” and “autonomy of practice” were the two top factors that influenced their decision to practice in a rural setting. online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 50 conclusion: the analysis produced a list of skills and patient care management activities critical to rural np practice. schools of nursing may find these lists useful as they prepare nps for the rural workforce. keywords: rural, nurse practitioner, training, education, skills, and patient care management activities workforce demands of rural nurse practitioners: a descriptive study the united states has experienced rapid growth in the nurse practitioner (np) workforce in the last several decades (auerbach et al., 2020). many nps are choosing to practice in rural communities, thus filling the gap created by the shortage of physicians (xue et al., 2019). following a trend analysis of 50 states and washington, dc, from 2010 to 2016, xue, smith et al. reported that the increase in supply of primary care nps in rural areas was greater than the increase in physician supply in rural areas. as such there is a growing presence of nps in rural primary care practice settings (barnes et al., 2018). once np students graduate and begin practicing in an advanced practice role, they not only use the skills they learned in their educational program, they also use additional skills obtained through training programs and activities provided by their employer. over time, the skills performed by nps can become extensive and can vary depending on the type of practice site, needs of patients, and expectations of employers. the increased utilization of nps in rural settings requires a critical examination of skills and patient care management activities that nps are using in those settings. a review of the literature revealed few articles related to rural workforce requirements of nps in the united states. some evidence exists that rural np practice patterns differ from their urban counterparts. rural nps not only provide primary care services, but also manage a variety online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 51 of acute illnesses and injuries while attending to the needs of patients. rural nps, for example, are more likely to practice to the fullest of their scope of practice, have their own patient panels, work longer hours, see more patients, and have hospital admitting privileges (spetz et al., 2017). rural and frontier nps in wyoming practice in a variety of settings, such as primary care, hospital, emergency room (er), acute care, urgent care, nursing home, and mental health (brown et al., 2009). no articles could be found that addressed skills and activities performed by kansas rural nps. faculty and staff at one nursing school in northeast kansas conducted a descriptive study to help them better understand the training needs of np students who plan to live and work in kansas rural settings after graduation. the study was part of a larger project, funded by the health resources and services administration, to improve the np curriculum to ensure that np graduates who desire a kansas rural practice are ready for that practice upon graduation. the investigators sought to answer the following research questions: what are the characteristics of nps who practice in rural kansas settings? what are the characteristics of practice settings of nps who work in kansas rural areas? what skills and patient care management activities are critical to rural nps in kansas? the results of this study were used to inform the faculty about gaps in the curriculum for family nurse practitioner (fnp) students who plan to live and work in rural settings after graduation. methods kansas has a total area of 82,276 square miles. in 2019, kansas had an estimated population of 2.9 million people, with close to 912,000 living in rural areas of the state (united states department of agriculture economic research service, n.d.). of the 105 counties in kansas, the online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 52 kansas department of health and environment (n.d.) has classified 19 as densely-settled rural (20 to 39.9 persons per square mile), 34 as rural (6 to 19.9 persons per square mile), and 36 as frontier (less than six persons per square mile). nurse practitioner practice in kansas requires a collaborative practice agreement with a physician, which can limit full scope of practice in rural and medically underserved areas. the physician need not be present when care is provided by the np. a convenience sample of kansas rural and frontier nps was invited to complete a survey that asked them to identify their skills and patient care management activities performed on a frequent basis or were deemed important to practice. a list of kansas rural and frontier nps with email addresses was obtained from the school of nursing database of alumni, preceptors, and rural organizations. a total of 235 rural and frontier nps from across the state were invited to participate via email. the survey instrument was a modified version of the “clinical skills and procedures used by nps” instrument, which laustsen (2013) developed and used in a study of skills performed by oregon nps who practiced in a variety of settings. permission was granted for the use and modification of the instrument for the current study. consultation with several rural practice providers (which included both nps and physicians) led to several modifications of the survey to include questions specific to rural practice. the revised survey consisted of three parts: (a) demographic and practice questions, (b) clinical skills and patient care management activity questions, and (c) a place for respondents to make written comments. additional demographic and practice questions addressed reasons for practicing in a rural setting, additional training/certifications obtained after graduation, zip code of practice, type of practice, access to telemedicine, and proximity to the collaborating physician. the online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 53 zip code of the practice setting was requested so that the investigators could verify that the practice was located in a rural setting. using the zip code finder (zip-codes.com) the zip codes were matched to the 89 counties that were listed as densely-settled rural, rural, or frontier by the kansas department of health and environment. the list of clinical skills was assessed for applicability to rural nps. skills that are typically delegated to support staff, such as venipuncture and nebulizer administration, were removed. some skills were added and others were condensed. “extremity casting” and “splinting” were replaced with a single entry called “facture care.” patient care management activities were added and limited to urgent, emergent, complex patient scenarios, pain management, and mental health. respondents were asked about the management of patients with specific health conditions (such as diabetes), management of patients with specific symptoms (such as acute stroke symptoms), and management of certain types of patients (such as frail elderly). respondents were asked to select whether the np performed the skill or patient care management activity by answering “yes” or “no.” they were also asked how often the skill or activity was performed by selecting “performed routinely” (once per week or more), “frequently” (more than once per month), “rarely” (less than 3 times per year), or “not applicable.” in addition, respondents were asked to identify the skills and activities as “very important, important, moderately important, minimally important or not important” to their practice. next the respondents were asked to select where they learned the skill or activity (np program, continuing education, colleague training, or on-the-job). skills and patient care management activities were identified as “critical to practice” if they were reported as performed by 50% or more of the respondents or reported as moderately or very important to practice by 50% of respondents. the revised survey was piloted by members of the np faculty, who confirmed face validity, online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 54 ease of use, and an average time of 20 minutes to complete. after university irb approval was granted (irb #17-19), the study commenced march 2018 with the sending of emails which included a link to the survey via a free web-based survey platform. after two weeks an email reminder was sent to the rural nps to remind them of the opportunity to participate. data were analyzed using descriptive statistics. results of the 235 nps who were invited to participate via email, 27 email addresses were identified as undeliverable. of the 208 valid email addresses, 63 surveys were returned for a response rate of 30%. the majority of the 63 respondents self-identified as fnps (61), white (60), non-hispanic (62), female (57), and between 35 and 64 years of age (52). the most frequent response regarding educational program attended was a master’s degree (44) followed by doctorate (11), post-master’s certificate (5), and “other” certificate (3). when the respondents were asked to pick the top three to five reasons that influenced them to practice in a rural setting, the most frequent response was “i grew up in a rural setting.” the second most common response was “autonomy of practice.” other frequent responses are listed in table 1. most of the nps (53, 84%) reported having been a preceptor for np students in the past. almost all the respondents reported additional training/certifications. for example, 61 (97%) reported they were certified in basic cardiac life support (bcls), 55 (88%) in advanced cardiac life support (acls), 40 (63%) in pediatric advanced life support (pals), 30 (48%) in advanced trauma life support (atls), 14 (22%) in neonatal resuscitation, and 10 (16%) in “other” certification. the most common certification in the “other” category was the trauma nursing core course offered through the emergency nurses association. online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 55 table 1 top thirteen factors that influenced rural nps to practice in a rural setting factor number (%) of respondents “i grew up in a rural setting” 49 (78%) “autonomy of practice” 28 (44%) “i trained in a rural setting” 26 (41%) “proximity of friends and family” 22 (35%) “rural way of life” 21 (33%) “a sense of mission to serve in a rural setting” 20 (32%), “better quality of life” 20 (32%), “spouse/significant other from a rural setting and/or willing to live in rural area” 18 (29%) “sense of belonging” 16 (25%) “financial reasons” 14 (22%) “spouse/significant other work opportunities” 9 (14%) “sense of challenge” 8 (13%) “loan forgiveness/scholarship” 7 (11%) “flexible work schedule” 6 (10%) note: % = percentage most of the 63 respondents reported practicing in more than one setting. family practice was the most frequently reported setting (50 nps, 79%), followed by emergency room (36, 57%), inpatient (26, 41%), urgent care (23, 37%), nursing home (19, 30%), and “other” 12, 19%). about a fifth (13, 21%) reported having their own patient panel. when asked about the estimated annual patient visits to their practice, 17 of the 61 rural nps who responded to this question reported 2,500 or less, 21 reported 2,500 to 5,000, 11 reported 5,000 to 10,000, and 12 reported greater than 10,000. more than half of the rural nps (34) reported having a collaborating physician on-site, seven (7) reported a collaborating physician less than five miles away, 15 reported a collaborating physician five to 50 miles away, and six (6) reported a collaborating physician greater than 50 miles away. when asked about the availability of a 24-hour provider-staffed er, 61 nps responded. fifty (50) reported the 24-hour provider-staffed er was available within 5 miles, 10 reported 5 to 50 miles, and one reported greater than 50 miles away. the availability of specialists varied from online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 56 local (< 5 miles) to regional (5 to 50 miles); respondents indicated most specialists travel to their community. access to general surgery services tended to be available locally, whereas access to ophthalmology, dermatology, orthopedic, cardiology, and obstetrics and gynecology services tended to be available regionally. respondent’s reports on the availability of telemedicine were mixed; half (31) of the 62 nps who responded to this question reported it was not available, a fourth (16) reported it was available in the er only, slightly more than a tenth (7) reported it was available both in the er and clinic, a tenth (6) reported it was available in the clinic only, and a small number (2) reported availability as unknown. the analysis produced a list of 26 skills and procedures that the majority of respondents performed and reported as important to their practice. table 2 provides a list of these skills, the percentage of nps who reported having performed them, and the percentages of nps who reported the skill as moderately to very important to their clinical practice. because the respondents did not respond to every question, the total number that responded to each item varied. the skills that most of the respondents identified as performed were treatment of bites (cat, dog, insect, and human; performed by 98% of nps) and incision and drainage of abscess (performed by 95% of the nps). all of the 26 skills and procedures were performed by 50% or more of the nps. of the 26 skills identified as critical to practice, four were reported by the majority of the 63 rural nps as being learned in their educational program. these were breast exam, pap smear, rectal/prostate, and laceration repair. the percentages of nps that reported learning these skills in their educational program were 87%, 87%, 65% and 55% respectively. the other skills identified as critical to practice were reported by most nps as learned after graduation either on the job or at workshops. online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 57 table 2 skills and procedures identified as critical to kansas rural np practice skills and/or procedures percentage of rural nps who reported performing skill (and how it was calculated*) percentage of nps who reported skill as moderate to very important (and how it was calculated*) treatment of bites** 98% (58/59) 88% (49/56) abscess incision & drainage 95% (58/61) 93% (52/56) laceration repair 93% (56/60) 95% (53/36) epistaxis control 93% (40/43) 83% (30/36) electrocardiogram interpretation 93% (40/43) 94% (34/36) papanicolaou (pap) smear 93% (50/54) 91% (41/45) rectal/prostate exam 92% (33/36) 76% (25/33) breast exam 91% (50/55) 91% (41/45) foreign body removal 91% (48/53) 86% (38/44) skin lesion removal 90% (54/60) 84% (47/56) fracture care 86% (51/59) 93% (52/56) x-ray interpretation 85% (46/54) 93% (42/45) fishhook removal 85% (50/59) 73% (41/56) sebaceous cyst removal 83% (50/60) 79% (44/56) nail removal 78% (45/58) 76% (42/55) digital nerve block 76% (45/59) 82% (45/55) ring removal 76% (45/59) 75% (41/55) wood’s light examination 70% (41/59) 71% (39/55) subungual hematoma excision 69% (40/58) 58% (32/55) genital wart treatment 66% (36/55) 56% (25/45) pilonidal cyst drainage 64% (23/36) 47% (15/32) soft tissue aspiration 59% (35/59) 50% (27/54) joint injection 59% (35/59) 62% (34/55) dislocation reduction 57% (33/58) 69% (37/54) bartholin cyst abscess i & d 57% (30/53) 50% (22/44) ulcer debridement 54% (31/58) 52% (29/56) notes: np = nurse practitioner, *each ratio in parentheses was multiplied by 100 to obtain the percentage. **treatment of bites included cat, dog, insect, human, etc. about half of the skills and procedures deemed critical to rural np practice included those that were performed once a month or more; the other half of the items were rarely performed however they were identified as moderately to very important to practice (results not shown). table 3 provides a list of 12 skills and procedures that 50% of nps reported as performed routinely or frequently in their rural clinical practice. electrocardiogram and x-ray interpretation were the two most frequently performed skills. online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 58 table 3 routinely and frequently performed skills by kansas rural nps most frequently performed skills/procedures performed routinely (> once per week) performed frequently (> once per month) performed rarely (few times per year) n/a percentage of nps who performed skill/procedure routinely or frequently ecg interpretation 21 13 2 1 92% x-ray interpretation 32 8 2 2 91% pap smear 22 14 8 0 82% laceration repair 19 20 12 2 74% abscess i & d 14 25 13 2 72% fracture care 16 18 14 4 65% skin lesion removal 13 19 17 2 63% digital nerve block 7 20 14 3 61% breast exam 4 19 21 0 52% foreign body removal 3 20 19 2 52% nail removal 2 22 20 4 50% wood’s light exam 4 20 14 10 50% notes: ecg = electrocardiogram; i & d = incision and drainage; n/a = not applicable. thirty-seven (37) patient care management activities were identified as critical to practice (table 4). thirty-six of these activities were performed by 50% or more of the nps. one practice activity, complex mental health problem, was performed by less than 50% of respondents, however, 55% (18/33) deemed it moderate to very important to practice, thus, it was added to the list of patient care management activities critical to kansas rural np practice. table 4 patient care management activities identified as critical to kansas rural np practice patient care management activities (i.e., management of a patient with the following conditions, symptoms, or characteristics) percentage of rural nps who reported performing activity (and how it was calculated*) percentage of nps who reported skill as moderate to very important (and how it was calculated*) high blood pressure 98% (42/43) 97% (35/36) frail elderly 97% (34/35) 97% (32/33) urinary complaints 95% (40/42) 95% (35/37) chest pain 95% (41/43) 97% (35/36) copd/asthma with/out exacerbation 94% (34/36) 94% (31/33) acute abdominal pain 94% (34/36) 94% (31/33) mental health conditions 94% (34/36) 91% (30/33) diabetes 94% (32/34) 94% (31/33) acute/chronic pain 93% (56/60) 94% (31/33) online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 59 patient care management activities (i.e., management of a patient with the following conditions, symptoms, or characteristics) percentage of rural nps who reported performing activity (and how it was calculated*) percentage of nps who reported skill as moderate to very important (and how it was calculated*) sexual concerns 93% (51/55) 93% (41/44) sexually transmitted infections 93% (51/55) 93% (41/44) acute/chronic arrhythmias 93% (40/43) 94% (34/36) dvt and/or pe 93% (40/43) 92% (33/36) pelvic pain and/or discharge 93% (39/42) 92% (34/37) congestive heart failure 93% (40/43) 94% (34/36) burns 92% (54/59) 91% (51/56) croup and/or bronchiolitis 92% (35/36) 85% (28/33) breast concerns 91% (50/55) 89% (40/45) concussion 91% (32/35) 91% (30/33) weight changes 91% (32/35) 88% (29/33) anaphylaxis 86% (31/36) 85% (28/33) seeking contraception 84% (46/55) 84% (38/45) mental health crisis 83% (30/36) 82% (27/33) acute stroke symptoms 83% (30/36) 82% (27/33) perimenopausal/menopausal symptoms 83% (35/42) 81% (29/36) victim of abuse (or suspicion of) 83% (29/35) 85% (28/33) vision changes 81% (35/43) 81% (30/37) heart murmur 81% (35/43) 83% (30/36) hypertensive crisis 81% (29/36) 85% (28/33) respiratory distress/intubation 81% (29/36) 79% (26/33) delirium and/or intoxication 81% (29/36) 79% (26/33) attention deficit hyperactivity disorder 75% (27/36) 69% (22/32) acute trauma/stabilization 74% (26/35) 79% (26/33) hearing changes 70% (30/43) 69% (24/35) pediatric developmental concerns or fft 69% (24/35) 70% (23/33) substance abuse/addictions 56% (20/36) 61% (20/33) complex mental health problems 47% (17/36) 55% (18/33) notes: chronic obstructive pulmonary disease (copd), deep vein thrombosis (dvt), failure to thrive (fft), pulmonary embolism (pe). *each ratio in parentheses was multiplied by 100 to obtain the percentage some rural nps reported on education and training needs in the comments section of the survey. one respondent made the following comment: an np in a rural setting needs to be an expert generalist…needs to know something about everything, since we treat birth to death, acute and chronic; urgent and emergent. often a collaborative physician is not available in person—so if taking er call, one must be quite confident in skills. a rural np must have expanded training other than is given in typical fnp program. online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 60 another made the following comment: i learned a lot of the “basics” or “fundamentals” in np school, but have expanded on skill sets with on the job training [and] seeking colleague assistance/training in specialty fields. i suggest more specialty clinical hours such as cardiology, ortho, ob/gyn, radiology etc., than just fnp hours. discussion the analysis produced a list of 26 skills/procedures and 37 patient care management activities critical to rural np practice in kansas. only four of the skills (breast exam, pap smear, rectal/prostate, and laceration repair) were reported as learned in the np’s educational program. the other skills identified as critical to practice were learned either on the job or at workshops. the analysis also produced a list of 12 skills and procedures that the majority of kansas rural nps performed routinely or frequently in their clinical practice. few existing studies examined the range, frequency, and critical nature of skills and practice activities performed by nps. laustsen (2013) identified 23 skills that oregon nps performed on a regular basis or deemed critical to their practice, however, the oregon sample included urban and suburban nps in additional to rural and frontier nps. laustsen reported only two critical skills (pap smears and microscopy) as learned in more than 50% of respondent’s np educational programs, however, the survey used in that study did not include breast exam or rectal/prostate exam, which were added to the survey for the current study. the current study did not specifically ask about microscopy. brown et al. (2009) reported that rural and frontier wyoming nps performed procedures such as electrocardiogram interpretation, x-ray interpretation, suturing, casting, incision and drainage, pap smear, and intrauterine device placement/removal. all of these were identified as online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 61 critical skills in the current study, with the exception of intrauterine device placement/removal, which only 16 of 55 nps (29%) reported performing and only 15 of 44 (34%) reported as very important, important, or moderately important to their rural practice. compared to the studies by laustsen (2013) and brown et al. (2009), the results of this study identified similar skills routinely performed by nps or identified as critical to practice. however, this study identified additional skills that were not previously identified. the additional skills or procedures identified as critical to practice include breast exam, fracture care, fishhook removal, sebaceous cyst removal, nail removal, digital nerve blocks, ring removal, subungual hematoma excision, genital wart treatment, pilonidal cyst drainage, soft tissue aspiration, joint injection, dislocation reduction, bartholin cyst abscess incision and drainage, and ulcer debridement. differences in np practice patterns across states and over time may occur in response to variations in patient needs, limited access to care, regional differences in care, and increased experiences and competency in performing skills and procedures by rural nps. no studies were found that specifically identified patient care management activities performed by rural nps. one explanation is that patient care management activities are included in the fnp certification examination test blue prints produced by the american academy of nurse practitioners and the american nurses credentialing center. because knowledge of patient care management activities is required for certification, schools of nursing include them in their curricula to prepare students to pass one of these fnp certification examinations. although half of the rural and frontier nps in the current study reported that telemedicine was not available at their clinical site, that result may be changing rapidly. shortly after data were collected, kansas passed its telemedicine parity law in may of 2018. the law requires private payers to cover telehealth services and allows telehealth coverage under the state online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 62 medicaid program. the kansas telemedicine act, which took effect january 1, 2019, includes nps as eligible providers. with the passage of the act, telemedicine training has become an essential component of np curricula in kansas. because it protects both the patient and provider from physical contact, the growth of telemedicine has been accelerated by the covid-19 pandemic (rengers, 2020). evidence exists that rural medicaid beneficiaries are more likely to utilize telehealth services than urban medicaid beneficiaries, especially for mental health conditions (talbot et al., 2019). although kansas has not yet adopted the medicaid expansion as of may 2020, it has had a lot of expansion activity (medicaid, 2020) and will likely address it again in the 2021 legislative session. this study addressed additional certifications that nps have completed to meet the workforce demands of rural settings. almost all the respondents reported additional training/certifications in bcls, acls, pals, atls, and/or neonatal resuscitation. nurse practitioner educational programs for primary care roles typically do not provide these certifications as a part of the curricula. for the nps who participated in this study, the additional training was obtained through employers. these skills are important for rural practice as most nps work in multiple settings that include emergency and urgent care as well as primary care. the overwhelming majority of rural nps in the current study identified as fnps (96.8%), white (95.2%), non-hispanic (98.4%), female (90.5%), and between 35 and 64 years of age (82.5%). the respondents included a higher percentage of fnps and were somewhat less diverse compared to national data on the np workforce. according to the american association of nurse practitioners (n.d.), for example, 65.4% of nps in the united states are certified as fnps and the average age of nps is 47 years. nurse practitioner schools (2020) reported that nps and nurse midwives in the united states are predominately white (85.7%) and female (89.5%). online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 63 the factors that influenced the respondents to practice in a rural setting were consistent with those identified in a policy brief provided by the national rural health association (2015). these factors included “rural background, family practice specialty, rural training, rural-oriented curriculum, having family in the rural area, professional opportunities, economic incentive, practice relief, interest in working with underserved populations, and opportunities for family members” (p. 3). the finding that autonomy of practice was the second most common factor that influenced practice in a rural setting in the current study suggests that autonomy in practice is an important factor influencing the recruitment of nps into rural kansas settings. spetz et al. (2017), in their national sample of nps, reported that rural nps have greater practice autonomy than urban nps, especially among nps working in small isolated rural settings. the finding that autonomy is important to rural nps is consistent with studies that have focused on the relationships between state regulations regarding np scope of practice and the supply of nps and location of np practices. xue, kannan et al. (2018), for example, reported that full scope of practice regulation was associated with higher np supply in rural counties and those counties designated as primary care health professions shortage areas. neff et al. (2018) reported that restricted np practice limits the ability of nps to provide care in areas that lack access to primary care providers because nps are often providing care in locations that are geographically located within close proximity to supervising physicians. this is consistent with the current study in which over half of the rural nps (34) reported having a collaborating physician on-site with an additional seven reporting a collaborating physician less than five miles away. the generalizability of the results is limited to rural and frontier kansas np practice. the data were based on provider self-report and did not reflect actual numbers of procedures or online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 64 patient care management activities performed. because the original survey developed by laustsen (2013) was modified for this study, direct comparisons should be interpreted with caution. the survey was rather long and several respondents who completed the survey commented on the length of the survey. the authors noted that items nearer the beginning of the survey were more likely to be completed by all participants, whereas items near the end of the survey had more missing data. reliability and validity of the survey was difficult to assess due to the absence of psychometric testing for either the original or modified instrument. in summary, the analysis produced a list of skills and patient care management activities critical to kansas rural np practice. many of the skills and patient care management activities performed by kansas rural nps were learned after graduation. to increase practice readiness of np graduates for the rural workforce, a critical examination of fnp curricula is needed. although the current study is specific to kansas, the results could be used by faculty of other np programs as they prepare graduates for rural practice. references american association of nurse practitioners. (n.d.). np facts. https://storage.aanp.org/www/documents/npfacts__080420.pdf auerbach, d. i., buerhaus, p. i., & staiger, d. o. (2020). implications of the rapid growth of the nurse practitioner workforce in the us. health affairs, 39(2), 273-279. https://doi.org/10.1377/hlthaff.2019.00686 barnes, h., richards, m. r., mchugh, m. d., & martsolf, g. (2018). rural and nonrural primary care physician practices increasingly rely on nurse practitioners. health affairs, 37(6), 908914. https://doi.org/10.1377/hlthaff.2017.1158 brown, j., hart, a. m., & burman, m. e. (2009). a day in the life of rural advanced practice online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 65 nurses. the journal for nurse practitioners, 5(2), 108-114, http://doi.org/10.1016/j.nurpra.2008.10.013 kansas department of health and environment (n.d.). health professional underserved area report. https://www.kdheks.gov/olrh/download/2019_underserved_areas_report.pdf laustsen, g. (2013). what do nurse practitioners do? analysis of a skills survey of nurse practitioners. journal of the american association of nurse practitioners, 25(1), 32-42. http://doi.org/10.1111/j.1745-7599.2012.00750.x medicaid (2020). status of state medicaid decisions: interactive map. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisionsinteractive-map/ national rural health association (2015). quality of life impacts the recruitment and retention of rural health care providers. https://www.ruralhealthweb.org/getattachment/advocate/policydocuments/qualityofliferecruitmentretentionprovidersfeb2015.pdf.aspx?lang=en-us neff, d. f., yoon, s. h., steiner, r. l., bejleri, l., bumbach, m. d., everhart, d., & harman, j. s. (2018). the impact of nurse practitioner regulations on population access to care. nursing outlook, 66(4), 379-385. http://doi.org/10.1016/j.outlook.2018.03.001 nurse practitioner schools. (2020). the lack of diversity in advanced nursing. https://www.nursepractitionerschools.com/blog/diversity-in-advanced-nursing/ rengers, c. (2020). ‘the genie’s out of the bottle,’ and telehealth is on its way to being the new norm. the wichita eagle. https://www.kansas.com/news/business/biz-columnsblogs/carrie-rengers/article242082156.html spetz, j., skillman, s. m., & andrilla, c. h. a. (2017). nurse practitioner autonomy and online journal of rural nursing and health care 21(1) https://doi.org/10.14574/ojrnhc.v21i1.656 66 satisfaction in rural settings. medical care research and review, 74, 227-235. http://doi.org/10.1177/1077558716629584 talbot, j. a., burgess, a. r., thayer, d., parenteau, l., paluso, n., & coburn, a. f. (2019). patterns of telehealth use among rural medicaid beneficiaries. the journal of rural health, 35(3), 298-307. https://doi.org/10.1111/jrh.12324 united states department of agriculture economic research service. (n.d.). kansas. https://data.ers.usda.gov/reports.aspx?statefips=20&statename=kansas&id=17854 xue, y., kannan, v., greener, e., smith, j. a., brasch, j., johnson, b. a., & spetz, j. (2018). full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties. journal of nursing regulation, 8(4), 5-13. https://doi.org/10.1016/s2155-8256(17)30176-x xue, y., smith, j. a., & spetz, j. (2019). primary care nurse practitioners and physicians in lowincome and rural areas, 2010-2016 [research letter]. jama, 321(1), 102-105. https://doi.org/10.1001/jama.2018.17944 oosterbrock_548-article text-3534-1-9-20190228 online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 64 “everybody knows your name”: belonging in rural preceptorship tracy a oosterbroek, rn, phd 1 olive j. yonge, rn, phd 2 florence myrick, bn, mscn, rn, phd 3 1 assistant professor, faculty of health sciences-nursing, university of lethbridge, tracy.oosterbroek@uleth.ca 2 vice dean – professor, faculty of nursing, university of alberta, oyonge@ualberta.ca 3 professor emerita, university of alberta, flo.myrick@ualberta.ca abstract background: inherently, preceptorship, is challenging and stressful for nursing students. to date, there is a dearth of literature concerning the challenges and opportunities experienced by members of the preceptorship triad namely the nursing student, their faculty advisor, and the preceptor. purpose: the purpose of this study was to explore the challenges and opportunities associated with rural preceptorship by nursing students, their faculty advisors and preceptors. method: photovoice was drawn on as a creative approach to participatory action research (par). this method has been found to empower and engage participants as co-researchers with the ultimate goal of implementing change derived from the priorities of the community, in this case, the teaching and learning experiences of nursing students (n=9), their preceptors and their faculty advisors (n=5). findings: as participants described their experiences throughout the rural preceptorship placement, belongingness emerged throughout the data as a predominant theme. moreover, the online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 65 experience of belonging had a significantly positive impact on student learning and overall rural preceptorship experience. conclusions: relationships between the nursing student and members of the health care team were found to be critical to preceptorship success in rural communities and the motivation among new graduates, to seek permanent employment in the rural community post-graduation. keywords: rural nursing education, rural preceptorship, rural preceptorship, photovoice “everybody knows your name”: belonging in rural preceptorship rural communities, home to more than 30% of the total canadian population, face significant barriers to health care access, often relying on registered nurses as the only primary health care providers (kulig & williams, 2012; macleod, browne, & leipert, 1998). it follows that educational initiatives for rural nursing practice are urgently required (jackman, myrick, & yonge, 2012). nurses working in rural settings are well positioned to inform and guide knowledge development in this area of nursing practice. the current study presented in this manuscript was guided by the following, broad question: what are the challenges and opportunities experienced by nursing students, preceptors, and faculty advisors during nursing preceptorship placements in rural communities? additionally, questions addressed connections between rural preceptorship and rural employment factors, particularly recruitment and retention of new nursing graduates in rural settings? literature review socioeconomic status and geographical location are linked to disparities in canadian health outcomes, the poorest of which are to be found in rural and remote areas (shields & tremblay, 2002). while rural nursing research is growing, significant gaps continue to persist (greiner, glick, online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 66 kulbok, mckim-mitchell, 2008). laurent (2002) explains that the recruitment and retention of rural health care providers has focused primarily on physicians; and that long hours and scant resources have influenced, negatively, the work-life balance and employment retention of rural health professionals. specifically, education in rural jurisdictions for most health professionals is insufficient (laurent, 2002). numerous barriers may impede rural health professionals’ ability to attain education, related to time, cost and access to basic and continuing educational programs (francis & mills, 2011; leipert & anderson, 2012). rural recruitment and retention. the influence of rural preceptorship on future employment has yet to be fully understood. on average, 12-50% increased interest has been noted following rural clinical experiences, although this finding encompasses supervised clinical placements and non-nursing, allied health student placements (courtney, edwards, smith & finlayson, 2002; schoo, mcnamara, stagnitti, 2008). while these placements are recognized as a recruitment strategy for nursing units in rural and urban centers, post-preceptorship employment data remains inconclusive (schoo et al., 2008). meyer bratt, baernholdt, and pruszynski (2014) suggest that differences between urban and rural practice settings must be recognized and specifically addressed. to reduce new staff turnover, and preserve operational resources, it must be determined how rural-specific education influences patient and organizational outcomes (meyer bratt et al., 2014). preceptorship immerses nursing students in a particular setting over an extended period of time (jackman et al., 2012); nonetheless, the contextual values and beliefs specific to rural communities are frequently absent from nursing curricula (dowdle-simmons, 2013). a sustainable, rural nursing workforce is dependent upon educational preparation specific to this environment (hunsberger, baumann, blythe, crea, 2009). forbes and edge (2009) point out that online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 67 the challenges of rural nursing education and rural health care are exacerbated by the shortage of nurses and other health care team members. such findings continue to be relevant in 2018, where a national nursing shortage, including specialty nursing, nursing faculty, and nursing leadership, exists in many settings, necessitating continuous exploration of strategies related to recruitment, and retention. edwards, smith, courtney, finlayson and chapman (2004) posit that the shortage of nurses in rural and remote areas is compounded by nursing students’ lack of educational experience in these settings. the failure to adequately prepare nurses for the complexity of rural environments has resulted in poor job satisfaction and poor staff retention (sedgwick & yonge, 2008a). additional research is required to increase understanding of the factors that may contribute to retention challenges, such as lack of support for professional development as well as lack of resources for spouses and partners. it is, therefore, important to identify effective strategies that prepare nursing students for the diversity, acuity, and complexity of rural nursing practice. the findings reported in this manuscript illustrate some of the challenges and opportunities of rural preceptorship that may impact rural recruitment and retention. belonging, and learning. belongingness, while a relatively recent concept in the nursing literature has been conceptualized extensively by social scientists and psychologists (anant, 1967; baumeister & leary, 1995; hagerty & patusky, 1995; leavitt-jones, lathlean, maguire, & mcmillan, 2007). maslow (1987) conceptualized belonging as a basic need, required to progress along the path to self-actualization. others theorized similarly, suggesting that humans are fundamentally motivated to achieve belongingness (buameister & leary,1995). their view differed somewhat from that of maslow, in that lack of belongingness as a fundamental need would result in detrimental health online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 68 effects similar to the consequences of similar unmet basic needs. whether a fundamental basic need or fundamental motivational factor, experiences of belonging has been found by researchers to have a positive impact on student learning, and the lack of belongingness has resulted in detrimental psychological impacts including stress, anxiety, depression, alterations in self-esteem that some authors suggest may impede learning (grobekcer, 2016; levett-jones et al., 2007). while some students undertake final preceptorships in their home communities, they may find themselves inadequately prepared nonetheless, especially in rural settings (sedgwick & yonge, 2008a). a sense of belonging significantly influences the preceptorship experience, for both students and preceptors alike; students who feel supported in their learning, in turn, feel safe to ask questions and make errors (sedgwick & yonge, 2008b). students are empowered by the authentic relationship that develops between teacher and student; in the case of preceptorship, the nursing staff and preceptor assigned to the student. more recently, this authentic relationship has been described as a genuine partnership that facilitates student learning through collaboration and the mutual sharing of ideas (perry, henderson, & grealish, 2018). experiences of belonging to the team has been found to have numerous benefits including self-directed, self-motivated learning, and feelings of empowerment among students. a sense of belonging to the rural community has been associated with increased job satisfaction and the intention to seek employment upon completion of the nursing placement (borrott, day, sedgwick, & levett-jones, 2016; meyer bratt et al., 2014). these findings link successful rural placements with nursing recruitment. in an ethnographic study, sedgwick, yonge, and myrick (2009) examined students’ perceptions of learning in a rural-based hospital. overwhelmingly, the students reported feeling as though they belonged to the team, in contrast to their previous, urban clinical experiences. rural preceptorships engage all members of the health online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 69 care team in supporting student learning. this approach differs from urban settings, wherein the registered nurse is primarily responsible for support and supervision of the student (sedgwick & myrick, 2009). jackman (2011) explored the relational process of teaching and learning during rural preceptorships, from the perspectives of the student, preceptor and faculty advisor. she found that health care staff and community members adopted supportive roles, similar to those of the preceptor and faculty advisor. students who experienced authentic rural experiences were more likely to remain and practice in the rural setting following the preceptorship. negative consequences of social exclusion or absence of belonging, include anxiety or depression, distract the student, while drawing their attention away from learning, hence compromising their learning potential (grobecker, 2016; leavitt-jones & lathlean, 2008). a mixed-method study that examined minority students’ experiences of belonging during clinical experiences found that nursing students avoided nursing staff who were unfriendly, or unwilling to support their learning (sedgwick, oosterbroek, & ponomar, 2014). method participatory action research and photovoice (par) par initially emerged from the discipline of adult education as both a philosophy and an approach to qualitative research, one in which the research participants assume role as coresearcher, one in which they are authentically and actively engaged in the research process and not merely passive contributors to the data (bargal, 2008; cornwall & jewkes, 1995; khanlou & peter, 2005; white, suchowierska, & campbell, 2004). persons living and working in rural communities are best positioned to articulate the strengths and challenges of rural life. nursing preceptorships provide an extended placement in the rural setting that comprises not only day-toonline journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 70 day nursing practice, but the complexity of the work and the unique social environment. nursing students who complete the final preceptorship course in rural settings have the opportunity not only to consolidate their undergraduate of nursing education, but also to develop sophisticated knowledge and skills that are important to the successful navigation of the complex, rural practice environment. par centers on the collaborative determination of goals: what is important, and what requires improvement or change, from the perspective of participants. participants were given inexpensive point-and-shoot digital cameras and instructed by the researcher to take photographs frequently and uncensored throughout that represented a challenge or opportunity associated with rural practice. images could be captured throughout the preceptorship both during clinical time but also during time spent in the rural community separate from the rural preceptorship. participants, as co-researchers, are engaged throughout the research process in the cocreation of knowledge (mctaggart, 1991; hall, 1984). their sustained engagement throughout the duration of the project aims to represent their unique participant perspective with some expectation of benefit from the research activity. the focus of the research activity shifts from researcher to participant; research is conducted by and for the participants, generating knowledge for action rather than understanding (cornwall & jewkes, 1995). using photovoice, the participants in this study provided a photographic representation of the challenges and opportunities they experienced throughout the rural preceptorship. participants were instructed to capture images, frequently, uncensored, that elucidated their experience in terms of the purpose of the research. the images provided a canvas for meaning from the perspective of the participant, authenticating the perspective of the participant experience. this study revealed the ways in which participants addressed the challenges and built on the opportunities of rural practice. online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 71 ethical approval (protocol # 00060961 was granted by the research ethics office (reo) at the academic institution. the criteria of the tri-council guidelines for human subjects research were followed. the right to withdraw at any time, without risk of harm or consequence, was explained to all participants. written, informed consent was obtained from each of the study participants. each participant was required to obtain signed consent from individuals appearing in their photographs, such as community members, patients, families, friends, and colleagues. all participants were assigned pseudonyms; however, anonymity could not be guaranteed in this type of study, as participants may be the subjects of their own photographic data. data collection and analysis were carried out concurrently, throughout the academic semester, in four phases. in keeping with the principles of par, the participants selected their own images to represent the challenges and opportunities they experienced. these images mobilized conversations during one-to-one interviews between the participants and the researcher. setting this study took place in seven rural, southwestern and central regions of a western canadian province, in communities with no more than 50,000 residents, at least 20 km distant from the nearest urban center. the communities provided various levels of care, including inpatient and outpatient community health services. each of the communities were diverse; representing various cultural, religious, and ethnic groups. students were randomly assigned to inpatient or community settings based on preceptorship capacity. inpatient services varied as much as each community offering acute care and long term or continuing care. acute care services equally varied, in some communities including maternal/child, labor and delivery, operating room, intensive care, pediatric, day treatment, and diagnostic imagining services. online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 72 sample the non-probable, purposive sample was comprised of all fourth-year nursing students and their assigned faculty advisor. the fourth year nursing students were in their senior nursing practical, assigned one-to-one with an experienced rn. each student was assigned a faculty advisor who provided support to the student and faculty advisor. often this support was provided remotely, as a result of the distance among practice sites, but faculty advisors were expected to meet with the student and preceptor at least twice throughout the preceptorship for evaluative meetings. initially, the sample also included rn preceptors assigned to support the students throughout the preceptorship, three preceptors initially agreed to participate but withdrew shortly after the study commenced. the remaining sample consisted of nine (n=9) nursing students, and five (n=5) faculty advisors who agreed to participate. data collection and analysis at the commencement of the preceptorship, the researcher oriented the students, preceptors and faculty advisors, explaining the study purpose and data collection process. participants were provided with point and shoot automatic cameras and instructed to record images as frequently as they desired while mindful of the challenges and opportunities they experienced during the preceptorship. the researcher met with each participant midterm. the participants were instructed to selfselect 20-25 photographs that most meaningfully portrayed the challenges and opportunities they had experienced thus far during the rural placement. the participants were asked the following open-ended questions pertaining to; why they photographed a particular image, where they were when they took the image, and; the ways in which the image represented a challenge or opportunity online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 73 for rural practice. in keeping with the par method, the data collection process was driven by the research participants, reflecting their unique perspective relative to the research purpose and research questions. while the researcher facilitated the face-to-face interviews, the participants were encouraged to speak freely and openly about their selected images. at the completion of the preceptorship, the researcher met again with each participant. participants self-selected additional photographs (approximately 20-25) to discuss for a final interview. the researcher asked the original open-ended questions, as well as allowed the participants to direct the interview conversations around the descriptions of their rural preceptorship experience. the final phase of the study involved verification of the data by participants. a slideshow was created by the researcher from amongst participants’ selected images and sent to each participant via email. the participants were invited to add further remarks or final thoughts on their images. thematic data analysis was carried out concurrently with data collection (braun & clark, 2006) commencing during initial data collection and involved searching for themes or patterns of meaning across multiple data sources. additionally, thematic analysis allows for contextual description of experiences, events, and meanings, without attachment to a pre-existing theoretical framework (braun & clark, 2006). nvivo10, qualitative analysis software was used for data management and coding. findings and discussion the challenges and opportunities experienced by participants, were discussed within the context of every photographic image selected. rurality was described by these participants as more than a geographic location (jackman, myrick, & yonge, 2010; kulig et al., 2008; kulig, online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 74 kilpatrick, moffitt & zimmerman, 2015) but as a sense of place, and a way of being and doing, that represented rural life. rurality, relationships, and, belongingness emerged predominantly throughout the data; a sense of belonging to both the rural community and the health care team emerged as both an advantage of rural practice, as well as a strategy for coping or addressing challenges intrinsic to rural practice. recruitment and retention emerged embedded in the predominate themes. previously, researchers have found that extended clinical placements in the rural communities enhanced student learning as they became immersed in the rural community and rural way of life (meyer bratt et al., 2014; sedgwick & rougeau, 2010; webster et al., 2010). connection with the faculty advisor is essential to student success. carol described challenges she experienced as a result of travel required between her community and the various rural communities where students were placed. james emphasized the reliance on technology to facilitate communication and connection with students when face-to-face meetings were not necessary or possible. beth reflected on the opportunities she experienced during her rural preceptorship, recalling an emphasis on “getting together, de-stressing, (going) outside, and enjoying nature. we had a campfire the one day and a crib group…people are more willing to do stuff with you.” claire described a similar experience: “we actually had a staff mixing party and i ended up going…it was out on a farm. there was a campfire…it was super fun (figure 1).” this finding is noteworthy as many precepted students were not themselves from rural communities. welcomed by community members and staff, the students felt supported both personally and professionally throughout their preceptorships, decreasing their sense of isolation in unfamiliar rural settings. such a safe supportive learning environment is conducive to student learning throughout the inherently stressful, high stakes preceptorship (sedgwick & pijl-zieber, 2015). online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 75 figure 1. campfire some students observed that the relationships among staff were closer in the rural setting than in urban centers and these relationships extended to the students as well. said jenn, “it wasn't just one unit, one teacher; you work with the whole team.” while she was initially assigned to three preceptors, she rarely worked solely with them. “everyone just kind of took me on as a student,” she remarked. “if something was happening, they’d say, you’re coming with me and i’ll walk you through it.” claire described the relationship she developed with the staff at the rural hospital, near the completion of her preceptorship (figure 2): this is a card that i got from my preceptor when i finished my hours. i thought it was a good reflection of rural nursing because of the relationships you make and how personable it can be… we got gifts for each other. i thought this was maybe a unique aspect of rural nursing… you really are one-to-one, and everyone knows you; and everyone was sad to see me go. online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 76 figure 2. greeting card becky described how her experience as a student in a rural setting differed from her previous experience in a larger, urban center. “most of the doctors (here) know your name; call you by your name,” she said. “it’s kind of communal; you work together (figure 3).” figure 3. working together (staff and student) online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 77 hannah likewise described how she was supported by the staff throughout the preceptorship, recounting a particular instance during her last week: “i have been super-spoiled here. i scrubbed solo for the first-time last week, so they bought me pizza to celebrate. i don't know if you get that in an urban centre.” she went on to reflect on how consistent staff support impacted her learning throughout the preceptorship: i feel incredibly supported here… even if you do something that is not quite right, they're not yelling at you or making you feel like you're stupid. from the anesthetists to the surgeons… everybody was willing to teach me. everybody taught me a lot, and not just so their job is easier, but so that i know more and i am more informed. it was really great. these findings attest to the nature of professional working relationships in the rural settings. overwhelmingly, the participants in this study agreed they felt supported throughout the preceptorship, thereby benefiting their learning and the overall process. helen, a faculty advisor described it as a “network of support,” integrating students during rural preceptorship placements and differentiating rural from urban practice. in their study, sedgwick and rougeau (2010) found that rural practice relationships are close-knit and complex, presenting a navigational challenge for nursing students and new graduates. however, they found that a supportive learning environment enhanced learning and feelings of belonging which, in turn, have a significant impact on newly graduated nurses’ feelings of confidence and competence. these authentic collaborative experiences are especially important in rural practice settings, where new graduates commonly practice alone or with minimal staff support. it is widely acknowledged that rural practice juxtaposes tight-knit community spirit with social and professional isolation (jackman, 2011; jackman et al., 2012; leipert & anderson, 2012; sedgwick & rougeau, 2010; sedgwick & yonge, 2009; yonge, myrick, ferguson, & grundy online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 78 2013). the students provided detailed descriptions of how each challenge or opportunity influenced their learning and ability to cope with the unexpected, unique to rural practice. for a time, beth struggled to cope with the demands of the preceptorship. she photographed an image of her pet who was left at home in the city for the duration of the preceptorship. she indicated that the image of her pet represented an attachment and connection to home that was missing while living in the rural community (figure 4). figure 4. pet the absence of nearby familial support was particularly painful. “i could call them, i could drive, but when you live in a rural setting, and you don't live near your family because you moved away… you don't have that support available when you want it,” she admitted. “when things were going downhill, i would rather have [had] my family right there. even for a couple of days.” beth’s powerful recollections illustrate the potentially devastating consequences of physical and emotional isolation, and the importance of the faculty advisor in providing both emotional as well as educational support, especially in rural settings. “[you’re] kind of like a lifeline,” said james of online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 79 his role as faculty advisor. “if they're from the city, they are just isolated… and living isolated… may cause students to feel alone, even though we provide support.” daniel completed his preceptorship in his home community, one with less than three hundred residents. he described the dichotomy of rural living, explaining that the aspects of rural living, such as rodeo, bring the community together, and yet the lack of amenities would likely be less appealing to new nurses “who would think there’s nothing to do in the town”. similarly, becky, having lived and worked for many years in the same rural community expressed her concerns recruitment and retention of new staff, stating: “there’s lots of run-down things… and more and more for sale signs”. these findings shared between student and faculty advisors illustrate ongoing issues that may impact rural recruitment and retention. a sense of belonging underlay the supportive faculty and preceptor relationships and learning environment that pervade these findings. faculty and staff support was critical not only to the students’ success, but to their willingness to ask questions and seek out assistance. faculty advisors recognized their primary responsibility was to support students. fittingly, helen (faculty advisor) drew a parallel between her professional role and that of a rural farmer: to nourish and support students to be strong, to produce, and to thrive in the rural setting. limitations inherent in any research activity are certain limitations that reduce transferability of the findings to other settings. this study was limited by the homogeneity of the sample, in spite of the differences that existed among rural communities and the unique nature of the preceptorship. personal judgement and self-censure must be considered when using photographic data, hence the researcher employed multiple, separate data collection times over a three-month period. perhaps the most significant limitation is the lack of preceptor perspective. the inability or lack of online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 80 willingness of preceptors to participate in research may be indicative of underlying issues rns experience in rural practice in relation to preceptorship, including lack of preparation, an already over-taxed workload, and lack of support or recognition for preceptorship service (bowen, 2018; rebholz & baumgartner, 2015). recommendations rurality remains an elusive concept, difficult to define. nevertheless, in this study, the participants’ photographs and comments captured the sense of community spirit, patterns, habits of communication and cultural contexts that comprised the distinct nature of each rural community to which they were assigned. the nature of interpersonal relationships and support, and the inherent challenges and limitations experienced throughout the preceptorship, dominated the findings. the students were surprised by the breadth and unpredictability of practice, which put their clinical skills to the test. they, nonetheless found they were able to adapt to the rapidly changing work environment, aided in no small measure by positive and supportive relationships with their assigned preceptors, faculty advisors, and other health care team members. differences between rural and urban preceptorship may have an impact on students’ sense of belonging, and the efficacy of the interprofessional team. as a result of this study, it is evident that additional research is needed to understand how students experience belonging in rural preceptorship, and how belonging influences interprofessional team effectiveness. interprofessional, experiential learning opportunities aimed at recruitment, retention, and improved patient outcomes, require deliberate planning and implementation. gaps persist in the growing body of knowledge on rural nursing preceptorship. the findings from this study suggest that newly graduated nurses do not lack interest or employment opportunities in rural communities. comparative research in non-rural settings, during online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 81 preceptorship, would extend the findings of this study. moreover, it is unclear whether the challenges and opportunities experienced during supervised, clinical courses in rural settings are comparable to those experienced during the same courses in urban settings and how experiences of belonging between nursing students and their instructor versus nursing staff influence their learning and motivation to seek employment in the clinical area. ineffective transition to practice is an ongoing predicament for newly graduated nurses (meyer bratt et al., 2012; sedgwick & pijl-zieber, 2015), seriously compounding the nursing shortage. previous research supports implementation and maintenance of professional mentoring programs (cochrane, 2017; dowdle-simmons, 2013; sedgwick & pijl-zieber, 2015) to enhance authentic professional relationships and experiences of belonging among newly graduated registered nurses. this study demonstrated that the development of authentic professional relationships and experiences of belonging are vital to successful retention of new staff, especially recent graduates who report high levels of stress throughout the first-year post-graduation. the findings of this study revealed areas of concern for nursing students and newly graduated nurses that potentially compound existing recruitment and retention issues. the student participants were focused on maximizing opportunities for learning and success of the preceptorship. however, many of the students were offered relief employment upon completion of the preceptorship and those offered positions, accepted. however, students from urban centres stated that they would follow the jobs, starting with those closest to home. conclusions the purpose of this study was to explore the challenges and opportunities associated with rural preceptorship from the perspective of the nursing students, preceptors and faculty advisors. preceptorship in rural settings provides nursing students with an introduction to the role of the online journal of rural nursing and health care, 19 (1) http://dx.doi.org/10.14574/ojrnhc.v19i1.548 82 rural nurse. this role is unique in that it affords the nurse the opportunity to develop meaningful connections with the community. numerous challenges were described by the participants. however, in describing the challenges, the participants talked through how they managed and overcame these challenges. a strong sense of belonging experienced both within the rural practice setting and community, contributed to their growing appreciation for rural practice, and their ability to face and conquer challenges, in turn enhancing their learning and empowering their ability to develop independence and confidence. the findings of this study confirm that authentic professional relationships between the nursing student and preceptor and the staff enhance student learning. rural practice placements have the potential to enrich undergraduate nursing education and introduce the role of the rural nurse to undergraduate nursing students. this role is unique in that it affords meaningful connections with the health care team and the rural community at large. students who successfully navigate the close-knit, rural practice community experience were empowered by a sense of belonging that enhanced their learning throughout the preceptorship. experiences of belonging result in numerous benefits to the nursing student including enhanced self-confidence and workplace satisfaction which may positively impact rural recruitment of newly graduated rns. successful rural nursing preceptorships introduce future nurses to the challenges and opportunities of rural practice and may encourage recent graduates to seek out permanent employment in rural settings. references anant, s.s. 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(2013). nursing preceptorship experiences in rural settings: "i would work here for free". nurse education in practice, 13(2), 125-131. https://dx.doi.org/10.1016/j.nepr.2012.08.001 middleton_manuscript_updated+01.26.22-graves+edits+final022122+arformatt online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 128 progression rates among rural junior-i pre-licensure nursing students using a math academic coaching program (macp): a quality improvement project kellie lavaun middleton, dnp-nel, msn-ne, bsn, rn1 tracy p. george, dnp, aprn-bc, cne2 kate jones, dnp, rn, cenp, ccm3 sarah kershner, phd, mph4 robyn morgan5 1 assistant professor of nursing and skills laboratory coordinator, francis marion university, school of health sciences, kellie.middleton@fmarion.edu 2associate professor of nursing, coordinator of bachelor of general studies program and j. l. mason endowed chair, francis marion university, school of health sciences, tgeorge@fmarion.edu 3associate professor, program director for post master's dnp (aprn & nel) and msn nursing administration, and interim program director: msn & cgs nursing informatics, university of south carolina, college of nursing, jones99@mailbox.sc.edu 4 chair of the department of healthcare administration, and associate professor, francis marion university, school of health sciences, skershner@fmarion.edu 5 coordinator of special events and community affairs, francis marion university rdmorgan@fmarion.edu abstract purpose: math competency is a content area in which some rural pre-licensure baccalaureate nursing students struggle, contributing to lower completion rates. the purpose of this project was online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 129 to determine if a math academic coaching program (macp) can increase first semester nursing student success with math proficiency in medication dosage calculations. sample: first semester bachelor of science nursing students at a rural, public university in the southeastern united states participated in this study. method: six online learning modules were provided. a quantitative, quasi-experimental approach was used to measure successful completion of the medication dosage competency exam (mdce) and junior-i progression using frequency distributions and means to compare macp group to the traditional teaching math group. participation was voluntary. findings: the macp improved mdce scores and progression rates compared to previous semesters of students who did not complete the macp. conclusion: the macp was an effective way to teach math skills to rural first-semester nursing students, assist them in success in the mdce, and increase patient safety through proper medication calculations and dosing. keywords: nursing students, drug dosage calculations, academic success, rural nursing education progression rates among rural junior-i pre-licensure nursing students using a math academic coaching program (macp): a quality improvement project student completion rates remain a major concern for many nursing schools or colleges due to the difficult and rigorous curriculum of nursing education (barbe et al., 2018). student completion is defined as the percentage of students who graduate within a defined period of time (barbe et al., 2018). online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 130 background academic coaching is one strategy to assist students in achieving academic success in nursing programs (bumby, 2020; national council of state boards of nursing, 2013). universities and colleges that offer additional academic student support, based on student needs and availability of nursing program services, have shown high satisfaction ratings and positive learning outcomes among student participants (tantillo et al., 2017). student success services, specifically academic coaching, aim to identify and remove obstacles and generate various opportunities that allow advancement in academic development and improved successful student outcomes (university of maryland, 2019). bumby (2020) found that academic coaching along with electronic resources was associated with improved student success. factors that directly influence success or failure in nursing school include age, gender, and ethnicity (lancia et al., 2013). barbe and colleagues (2018) found that students with diverse racial, ethnic, or cultural backgrounds had higher attrition than other groups of students, so academic coaching programs may be beneficial. self-awareness of bias and acknowledging barriers in nursing education with demographic considerations can bridge this gap (bagnasco et al., 2016). by identifying demographic, academic, and social determinant factors that influence student outcomes, attrition rates caused by course failures can improve in first-semester upper-division nursing students (bagnasco et al., 2016). math competency is an area in which some rural pre-licensure students struggle, contributing to low completion rates (bagnasco et al., 2016). rural nursing students often have difficulty with basic math skills like multiplying and dividing fractions and decimals (bagnasco et al., 2016). in the study by bagnasco and colleagues (2016), 22% of students had difficulty completing drug calculations without a calculator and 30% demonstrated poor math skills. to online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 131 assist pre-nursing students in bridging the knowledge gap in mathematical competencies, intervention is needed. problem medication dosage calculation exam (mdce) failure rates have remained consistent for many first-semester junior cohorts using the current in-class review sessions alone at the project site (francis marion university [fmu], 2019). although students are allowed two attempts on the mdce, they cannot score poorly on the second attempt mdce and progress in the program despite earning an overall passing grade in the course. the problem was identified by faculty when reviewing completion data for junior-i nursing students (see table 1). table 1 mcde success and completion rates success and completion rates 2014 2015 2016 2017 2018 mdce success 1st attempt 58% 45% 50% 59% 61% mdce success 2nd attempt 9% 15% 12% 10% 7% program completion rates 85.4% 82.3% 70.17% 68.3% *66.75% “mdce success attempt” defined as earning 90% or greater on the mcde in the first or second attempt and data show % of students not meeting the 90% requirements. “program completion rates” defined as a c or better in all nursing courses; completing all requirements for graduation and data show for each entering cohort, measured by (# of graduates) / (number of program entrants – number of students who electively withdraw). (*) reflects completion rates as of spring 2018. students have 5 years to complete the 2 years of nursing coursework. these findings suggest that proactive math support, in addition to the macp, may be needed. the purpose of this project was to increase first-semester nursing student success with math proficiency in medication dosage calculations using a math academic coaching program (macp). resources the addition of the macp was designed to make the preparation for the mdce more effective and efficient while providing resources for safe medication administration. medication online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 132 administration safety is imperative for nursing students. aggar & dawson (2014) found that nontraditional teaching and learning methods of medication administration may improve the students’ perception of readiness to administer oral medication. hayes and colleagues (2017) concluded that interrupting medication administration simulation improves awareness and management strategies of the nursing student in addition to increasing their confidence. tabassum and colleagues (2015) conducted a retrospective review to identify reported medication errors, their types, and associated factors. the environmental factors reported were increased patient acuity (14.3%), stress due to attendants' shouting (14.3%), and an insistence by staff (14.3%) (tabassum et al., 2015). at this bachelor of science in nursing program, the program completion rate is lower than desired. approximately 15% of students each semester does not progress beyond the fundamentals of nursing course in the first semester, which includes a mdce. failure to meet the required benchmark of 90% on the mdce results in students being withdrawn from the course. these students can re-enroll in a future semester and may be able to progress and complete the program later. literature review medication administration safety is one theme noted within the literature. aggar & dawson (2014) conducted a quasi-experimental study to determine the possible relationship between student demographics and their perceived preparedness for oral medication administration. results suggested that non-traditional teaching and learning methods of medication administration may improve the students' perception of oral medication passes (aggar & dawson, 2014). hayes et al. (2017) conducted a qualitative study to measure undergraduate nursing perceptions to simulated medication administration interruptions. findings concluded that interrupting medication administration simulation improves awareness and management strategies of the nursing student online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 133 in addition to increasing their confidence (hayes et al., 2017). tabassum et al. (2015) conducted a retrospective review to identify reported medication errors, their types, and associated factors. the environmental factors reported were increased patient acuity (14.3%), stress due to attendants' shouting (14.3%), and an insistence by staff (14.3%) (tabassum et al., 2015). the second theme identified within the literature review was teaching strategies. the metaanalysis review conducted by lee & quinn (2019) aimed to identify methods for incorporating medication administration safety into the undergraduate nursing curriculum (lee & quinn, 2019). specifically, research studies in north america have shown that online learning modules are an appropriate method to incorporate medication dosage calculation and competency into the undergraduate nursing curriculum (lee & quinn, 2019). ramjan et al. (2014) suggest that shifting away from traditional methods and implementing contextualized teaching and learning (ctl) engages students in active learning and promotes best-practice teaching. kelly et al. (2018) conducted a quasi-experimental study in which data was collected on the implementation of advanced medication administration through non-traditional learning and educational activities to improve student outcomes with medication administration. results showed higher confidence in identifying and safely implementing the rights of medication administration (kelly et al., 2018). this project was based on the review of multiple studies indicating that academic improvements occur among nursing students who were provided additional learning opportunities in the form of coaching (harris et al., 2014; tantillo et al., 2017). tantillo et al. (2017) suggest that coaching can take the form of providing resources in non-traditional formats, such as e-learning. data also revealed a correspondence between identified student needs and the use of program services together with improved learning outcomes (tantillo et al., 2017). online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 134 researchers have investigated how e-learning platforms foster self-reliance in undergraduate nursing students. one study suggested that cooperative learning that evolves through online resources' interactive nature promotes higher student achievement, self-reliance, collaborative culture, and lifelong learning skills (amandu et al., 2013). literature supported the use of technology in nursing education and supported that the macp is a learning/teaching tool to improve students’ pre-licensure preparation through active and motivational learning. student challenges were addressed in bagnasco et al.'s quasi-experimental study of 726 undergraduate nursing students to explore where students have the most difficulty and find interventions to bridge the gaps (2016). nursing students had difficulty with basic math skills like multiplying and dividing fractions and decimals (bagnasco et al., 2016). of the sample, 22% had difficulty completing drug calculations without a calculator and 30% had a low score showing poor math skills (bagnasco et al., 2016). methods project/study design a quantitative, quasi-experimental approach was used to examine macp effectiveness, successful completion of the mdce, and junior-i program progression using a pre-test/post-test analysis. frequency distributions and paired t-tests were used to compare mean scores among students who completed the macp intervention. coaching was provided in this project through both virtual and face-to-face platforms to include podcasts and voiceover powerpoints that accompanied each online learning module and face-to-face review sessions. one method that was used to promote student success was e-learning. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 135 project site and population this study was conducted at a bachelor of science in nursing program at a rural, public university in the southeastern united states. this unique geographical and educational area has the only pre-licensure bachelor of science in nursing (bsn) nursing program in the pee dee region as defined by the south carolina (sc) office of healthcare workforce analysis and planning (area health education consortium [ahec], 2014). nine out of the 12 counties in this region are classified as rural and medically underserved areas/populations (muas) (u.s. department of health and human resources [dhec], 2018). an area with less than 50,000 residents is considered rural according to the us census bureau (2010). the federal office of rural health policy considers all non-metropolitan counties as rural (hrsa, 2020). the index of medical underservice (imu) is a scale that ranges from 0% to 100%, where zero percent represents the completely underserved. areas or populations with imus of 62.0% or less qualify for designation as a mua/p (hrsa, 2018). the racial demographics of the pee dee region are 53.3% white, 45% black, 2.3% hispanic, 0.5% american indian, 1.3% asian, pacific islander, and mixed-race (u.s. census bureau, 2015b). five of the 12 counties in the pee dee region have minority population levels greater than 50% (u.s. census bureau, 2015b). four of the five counties with the highest minority population are among the lowest in economic standing compared to the state. economic standing is defined as social and economic factors that affect access to education and other crucial resources (american psychological association [apa], 2021). the study was approved by the institution’s institutional review board (irb) (protocol # pro00099952). in this nursing program, students begin their nursing courses at the junior level and online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 136 complete four sequential semesters in the nursing program. junior-i level students have two attempts to achieve 90% or higher on mdce to remain in the fundamentals of nursing course. intervention this project addressed progression rates among first-semester nursing students at a rural public liberal arts state university. although multiple factors contribute to non-progression, this project targeted math competency, a variable that accounts for approximately 10% of the nonprogression rate. the classroom teaching strategy currently used has not met the learning needs of many students who struggle to succeed on the mdce. although students are allowed two attempts on the mdce, they cannot score poorly on the second attempt mdce and progress in the program despite earning an overall passing grade in the course. a macp, designed by the project manager for this study, was added to current in-person teaching/learning methods in the first semester of the nursing program. the intervention included six required learning modules to include: 1) basic conversions; 2) oral medication calculations; 3) weight-based calculations; 4) safe dose range calculations; 5) reconstitutions, and 6) medication labels. each module contained an interactive worksheet, a 10-15-minute podcast recorded by the project manager, and a ten-question knowledge check quiz with unlimited attempts. the podcast included step-by-step instructions and a review of the interactive worksheet. if unsuccessful after the third attempt, an additional exercise was made available to the student. the quizzes were completed following each macp learning module during weeks two through seven. implementation/procedure the macp took place in the summer of 2020 before the students attempted their fundamentals of nursing course in the fall of 2020. students were notified approximately ten weeks before the start of the academic semester of their acceptance into the nursing program. as online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 137 a part of their acceptance package, information outlining pre-entry requirements was provided. beginning in may 2020 information regarding the macp was included in this package. students also received email notifications from the project manager regarding the macp completion requirements. students were automatically enrolled in the macp through the blackboard® learning platform. the informed consent notified students that the macp is a pre-entry resource for the fundamentals of nursing course and is part of a project and research study. by logging into the online learning modules, students consented to participate in the project. the project manager tracked student access and login attempts through blackboard’s® performance dashboard feature. junior-i students were given one attempt to complete a 20-question pre-assessment test to measure baseline knowledge of mathematical skills and medication dosage calculation competency during week one. following this assessment, students completed the required six modules, interactive worksheet, podcasts, and knowledge check quiz. during weeks eight through 11, students attended one-hour in-class review sessions weekly to include a review of math practice questions and rationales. at the start of week 12, students were given a single attempt to complete a 20-question post-assessment proctored test that measured the effectiveness of the macp. the final proctored mdce was administered at the start of week 13. students who failed to meet the benchmark of 90% on the first attempt were allowed a second attempt at the end of week 13. there was a one-on-one remedial review session offered for students before taking the second attempt mdce. the rate of successful students in the fundamentals of nursing course and the percentage of successful students in the junior-i semester were also measured. data collection the control group data from spring 2020 was collected using the grade book function of blackboard learn®. the number and percent of students who achieved a 90% or higher on the online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 138 mdce and the number percentage of students who completed the course were obtained from the fundamentals course. students' names were recorded and deidentified by assigning a code only accessible to the project director. the deidentified student data were placed in an excel® spreadsheet on a password-protected computer. following implementation, the same data were collected from the fall 2020 blackboard learn® platform. data analysis data analysis was conducted to determine macp effectiveness, successful completion of the mdce, and junior-i progression. numbers, percentages, and frequency distributions of unsuccessful students in two junior-i courses were analyzed for both groups and compared. a paired-samples t-test was conducted among students who received the macp intervention to compare pre-macp and post-macp scores. results students enrolled at the project site, and sc’s rn graduates do not reflect the state’s diversity (see table 2). specifically, male rns are underrepresented when compared to females. upon admission into the upper-division nursing program at the project site, students range in age from 18 years to 50+ years. the national league for nursing (nln) reported that 18% of students enrolled in baccalaureate nursing programs were over 30 years (2014). online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 139 table 2 demographics of student population compared to percent of rn graduates & state’s diversity demographics project group comparison group(s) gender sc rn’s sc general population female 88% 93% 49% male 12% 7% 51% other 0% 0% 0% race 2018 sc rn graduates sc general population white 85% 75.6% 63.7% black 11% 14.3% 26.6% hispanic 1% 3.4% 5.8% asian 2% 1.9% 1.7% american indian 1% 0.6% 0.4% pacific islander 0% 0.2% 0.1% two or more races 0% 2.0% 1.7% age at junior-i enrollment national 18-20 61.5% (18-30) 82% 21-22 15.6% 23-25 7.8% 26-30 7.8% 31-40 5.2% (> 31) 18% 41-50+ 2.0% online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 140 students' backgrounds were characterized by exceptionally high levels of poverty, unemployment, health problems, illiteracy, and poor schools. students from the pee dee region comprise the vast majority of the students on the university campus (71%), which is the only state educational institution in the pee dee region (fmu, 2019). ninety-five percent (95%) of students on this campus are drawn from sc, and 34.2% of the total student body are the first in their families to go to college (fmu, 2019). the pee dee region also lags behind state and national statistics for education. across the state, 25.3% of the adult population holds a bachelor’s degree or higher, while nationally, that percentage is 29.3% (u.s. census bureau, 2015a). in the pee dee region, none of the 12 counties meet either the state or national average for college graduates, according to the latest information from the u.s. census bureau (2015a). this below-average level of baccalaureate education is reflected in the background of the nursing students who participated in the project; of the 80 participants, 73.75% were first-generation college students. descriptive statistics were used to show frequency, mean, and percent change on the mdce from time 1 to time 2 to measure change correlated with the implementation of macp. all students participated in the time 1 mdce (n = 69, 100%) and students who did not achieve a 90% or above on the time 1 mdce were then required to complete the time 2 mdce. less than half (41%) of students were required to complete the time 2 implementation of mdce (n = 28). of the 69 students enrolled in the course, 97% of students completed three or more of the six macp modules (n = 67). participation in module 1 was highest (99%) and participation in module 6 was lowest (91%). success on the mdce was measured as a score greater than 90%. more than 75% of the students completing the time 1 mdce achieved a score greater than 80% (n = 53, 77%) and 100% of the students completing the time 2 mdce achieved a score greater than 80% (n = 28, 100%). online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 141 the mean score from time 1 mdce and time 2 mdce of the 26 students who completed 50% or more of the modules and who completed time 2 mdce was 81% and 95%, respectively, yielding a percentage change increase of 16% from time 1 to time 2 mdce. a paired-samples ttest was conducted among students who received the macp intervention, and there was a statistically significant difference in the mean scores from time 1 to time 2, 81.34 compared to 94.6 (p < 0.05). the non-intervention group had a mean score of 93.7 at time 1. results also demonstrated a decrease in course withdrawal rates due to math failures compared to the previous semester. in spring 2020, 12 of 70 students withdrew from the course (17%) compared to eight of the 80 students withdrawing from the course in fall 2020 (10%), resulting in a 32% percent change in the withdrawals. post-intervention data revealed that 84% of students believed the macp made them feel more confident in medication dosage calculations and 89.9% were more confident in medication administration. to further assess this subset, the following data was extracted: 100% (n = 8) were first generation college students; 50% (n = 4) took a major math or science class more than once; 62.5% (n = 5) were aged 18-22, 25% (n = 2) were aged 23-25, and one student (12.5%) (n = 1) was aged 31-34; 87.5% (n = 7) were black, and 25% (n = 2) were males. these findings suggest that proactive math support, in addition to the macp, may be needed. discussion enrollment in pre-nursing is not a challenge at the project site; retaining and graduating students is the issue. math competency is a specific challenge. math competency is an area in which some rural pre-licensure students struggle, contributing to low completion rates (bagnasco et al., 2016). many of the students who apply to the project site’s 2 + 2 baccalaureate nursing program live in rural areas of the sc where basic education in math is lacking. students arrive online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 142 under-prepared in mathematical skills and abilities with nearly 50% of the students enrolled in the fall 2019 semester upper-division nursing program taking remedial math in their prerequisite courses (fmu, 2019). to further assess this subset, the following data was extracted: 100% (n=8) were first generation college students; 50% (n=4) took a major math or science class more than once; 62.5% (n=5) were aged 18-22, 25% (n=2) were aged 23-25, and one student (12.5%) (n=1) was aged 3134; 87.5% (n=7) were black, and 25% (n=2) were males. more students successfully passed after completing the macp compared to students who did not. results indicate a positive correlation between participation in the intervention and increased math competency scores. the impact of the intervention decreases score differences between at-risk students and non-at-risk students. this project assisted rural nursing students to be successful in math calculations, along with improving junior-i completion rates. the macp along with the face-to-face instruction led to a 32.2 % decrease in withdrawals due to math test results. the macp encouraged students to become responsible, self-disciplined, and improve confidence in their math skills through a series of self-paced modules that built on one another. this intense math instruction helped students to have greater confidence in their math calculations and to be successful. in addition, practice partners at local medical centers indicate that new graduate nurses in rural areas often face challenges with medication management and medication dosage calculations, which can impact patient safety. the macp may have a positive impact on medication safety when nurses are in practice at rural hospitals. the impact of this project improved student confidence in math calculations skills and mdce scores were higher than previous student performance. the findings are similar to those of tantillo et al. (2017), who also found that a online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 143 coaching program improved academic outcomes. however, our intervention used online modules combined with traditional instruction, while tantillo et al. (2017) used only an e-learning method. online learning modules are an effective method to incorporate medication dosage calculation and competency into the undergraduate nursing curriculum (lee & quinn, 2019). ramjan and colleagues (2014) suggest that shifting away from traditional methods and implementing contextualized teaching and learning (ctl) engages students in active learning and promotes best-practice teaching. kelly and colleagues (2018) found that non-traditional learning and educational activities improve student outcomes with medication administration. multiple studies indicate that academic improvements occur among nursing students who were provided additional learning opportunities in the form of coaching (harris et al., 2014; barbe et al., 2018); tantillo et al., 2017). tantillo and colleagues (2017) suggest that coaching can take the form of providing resources in non-traditional formats, such as e-learning. data also revealed a correlation between identified student needs and use of program services together with improved learning outcomes (tantillo et al., 2017). coaching was provided in this project through both virtual and face-to-face platforms to include podcasts and voiceover powerpoints that accompanied each online learning module and face-to-face review sessions. this study improved student confidence in math calculations skills, and the mdce scores were higher than previous student performance. the findings are similar to those of tantillo et al. (2017), who also found that a coaching program improved academic outcomes. however, our intervention used online modules combined with traditional instruction, while tantillo and colleagues (2017) used only an e-learning method. this project has implications for other rural areas. bagnasco et al. (2016) found that rural nursing students have difficulty with medication calculations. research by aggar and dawson online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 144 (2014) indicated that non-traditional teaching methods can improve nursing students’ preparation for medication administration (aggar & dawson, 2014). the macp program could be replicated by other rural nursing programs to improve the medication dosage skills of the nursing workforce in rural, underserved areas. the use of non-traditional teaching programs such as the macp program could lead to a decrease in medication errors and improved patient safety. it is important to support rural nursing students who may struggle with medication dosage calculations so that they can have confidence in safely administering medications. strengths of this project include the use of self-paced online modules, along with traditional instruction. this allowed students to work on math before beginning the nursing courses, while still obtaining face-to-face instruction for clarification. limitations to this study include the use of one group of students at a single university in a rural area of the southeastern united states. another constraint included students being admitted at the last minute who could not participate. specifically, 6.25 % of students started the macp late due to delayed program admission. also, because the project was not mandatory, some students did not complete each module, which may have contributed to the results. if it were mandatory in future semesters, there could be fewer math failures. another constraint affected 10% of students who had never participated in online learning and who had difficulty navigating the modules. additionally, students expressed additional stress related to the covid-19 pandemic during fall 2020. another stressor identified was that some students were unable to participate in the face-to-face review sessions due to a covid-19 quarantine. recommendations for education improving the math skills of nursing students is important for prelicensure nurse educators. self-paced online medication math modules along with classroom instruction can be a useful, low online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.688 145 cost approach with students who struggle with math skills. this approach allows students to review the math content at their own pace, while having individualized instruction in the classroom setting. requiring the modules for all prelicensure students in a nursing program may also increase the success rate on students’ math competency tests. providing a tutorial for the online learning modules may be helpful for students who lack experience with online learning. conclusion concern over progression rates of first-semester nursing students prompted a review of the literature and the subsequent development of the macp. this project improved junior-i bsn nursing student success by providing a macp to all first-semester nursing students at a rural, public university. the online learning modules provided additional mathematical support to students, which increased the mdce success rates. there are plans to continue this project in future semesters at the nursing program because of its successful outcomes with the rural nursing students. at this university, 34.2% of the total student body are the first in their families to go to college, and some may lack the necessary preparation and skills for college math (fmu, 2019). it is important to support rural nursing students who may struggle with medication dosage calculations so that they can have confidence in safely administering medications. additionally, macp interventions with nursing students may promote medication safety in the workplace at rural hospitals. references aggar, c., & dawson, s. 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(2018). negotiated rulemaking committee on the designation of mups and hpsas. retrieved from https://www.hrsa.gov/advisorycommittees/shortage/index.html growth and progress 1 editorial growth and progress jeri dunkin, phd, rn editor growth and progress: both words describe development and evolution of a being or thing. and both are very appropriate for the online journal of rural nursing and health care as we bring to close our tenth year of online publication. growth: the readership of the journal has increase dramatically. this is especially true of the last five years. in 2005 there were 63,010 hits on the journal and in the first 10 months of 2009 there were over 12 times that number (7,984,640). that is quite an increase! in examining the data i found that about 65% of the readers are in the united states but the other 35% come from over 90 countries. the articles submitted for review for the journal are also indicative of substantial growth, with only an occasional submission from countries outside the united states to almost a third of the submissions in 2009 coming from authors in other countries. the editorial board and review panel also have members from around the world. in addition the breadth of topics has grown as well. in this spirit of growth this issue has two guest editorials. they are on very different topics and i hope hold interest for our readers. in addition, this issue has more articles included than ever before. it is very exciting to see the response to, and the need for the online journal of rural nursing and health care. progress: at the same time we have made changes occasionally to facilitate the publication as we have progressed through the evolution of the journal. another change will be coming in 2010 as we take the online journal of rural nursing and health care out of the open publication format and put it into the subscription based journal category and move its publication to an established publisher rather than a voluntary process for the editor and managing editor. our promise to you is that we will do our best to keep it as accessible as possible for all our readers. online journal of rural nursing and health care, vol. 9, no.2, fall 2009 choshi_629_formatted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 78 self-care behaviors of rural women post-invasive coronary interventions modjadji mosima choshi, phd, rn 1 anne g. rosenfeld, phd, rn 2 mary s. koithan, phd, rn, cns-bc, faan 3 1assistant professor, school of nursing, james madison university, choshimm@jmu.edu 2 professor emerita, college of nursing, university of arizona, anner@arizona.edu 3 professor and dean, washington state university college of nursing, mkoithan@arizona.edu abstract purpose: self-care is an essential component of secondary prevention of coronary artery disease (cad) for rural women after undergoing invasive coronary interventions (ici). the purpose of the study was to describe self-care behavior experiences of rural women with cad post-ici. the specific aims were: to identify and describe self-care behaviors initiated by rural women post-ici; and to identify and describe barriers to and facilitators of self-care behavior adoption. the language used to describe self-care can be different between health care providers, who are guided by the american heart association (aha), and rural women whose descriptions are based on their life experiences. methods: qualitative descriptive methods were used to purposefully sample women (n=10) from two rural arizona counties. data were collected using semi-structured face-to-face interviews, lasting approximately 25minutes. atlas.ti mac version 1.5.2 (462) was used for data analysis. findings: aim 1: healthy diet was the most common self-care behavior described by rural women. when describing self-care behaviors, rural women used a different language, which was in online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 79 alignment with aha guidelines for self-care behaviors. aim 2: themes identified and described for barriers were: residential environment, health and physical ailments, family conditions, and personal characteristics; and for facilitators were relationships, available resources, and personal outcomes. conclusions: regardless of poor health-promoting environment, such as unavailability of fresh food stores and access to exercise opportunities rural women took advantage of what they had to keep healthy. they performed self-care behaviors that they described as good for their health and made them happy without associating them the expected self-care behaviors to prevent reoccurrences and complications post-ici. rural health care providers must recognize these challenges, acknowledge the positive assets wihin rural women, and incorporate them into the programs for self-care behavior modification strategies. keywords: self-care, rural women, coronary artery disease, invasive coronary interventions self-care behaviors of rural women post-invasive coronary interventions cardiovascular diseases including coronary artery disease (cad), hypertension, and stroke are the leading causes of death in the united states and accounted for one in three deaths in 2015 (benjamin et al., 2017). further, deaths are more frequently attributed to cad with higher numbers and increased burden among rural women (benjamin et al., 2017; havraneck et al., 2015). treatments for cad include: (a) invasive coronary interventions (ici) defined as percutaneous coronary intervention (pci) including balloon angioplasty with or without stent placement, and (b) coronary artery bypass graft (cabg). after undergoing ici, secondary prevention measures are important to avert reoccurrence. many of these measures are not equally accessible to patients, especially to those living in rural areas. self-care is an essential component of secondary prevention of cad post-ici; however, it is often inaccessible for rural women due to geographic online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 80 health disparities and lack of care coordination post discharge (cudney et al., 2005; kim et al., 2013; kitzman et al., 2017; slusher et a., 2010). post-ici rural arizona women in cochise and pinal counties are sent home; which can be 30 miles or more from the nearest cardiology service. there is an assumption that patients will adopt required self-care behaviors according to the american heart association’s (aha) secondary prevention guidelines (smith et al., 2011). health disparities exist related to gender, socioeconomic status, and geographic inequalities and have been documented in the literature (crosby et al., 2012; cudney et al., 2005; lauckner & hutchinson, 2016; ruiz-perez et al., 2019). these inequalities contribute to the lack of opportunities for rural women to engage in disease-specific self-care behaviors essential for secondary prevention post-ici (turnbull et al., 2020). cardiovascular disease risk factors (e.g., high cholesterol, smoking, high blood pressure, obesity, diabetes) are prevalent in rural areas and must be controlled through self-care to prevent adverse cad outcomes (crosby et al., 2012; fahs et al., 2013). distance, for instance, was found to be interwoven in most of the contextual inequalities and to have a negative impact on rural women’s ability to manage chronic illnesses (ruiz-perez et al., 2019; sullivan et al., 2003; winters et al., 2006). despite these well documented health disparities, there are no studies that provide descriptions of rural women’s perspectives on secondary prevention measures for cad; specifically, self-care behaviors post-ici. the purpose of this study was to describe self-care behavior experiences of rural arizona women with cad post-ici. the specific aims were to: (a) identify and describe self-care behaviors initiated by rural women post-ici, and (b) identify and describe barriers and facilitators of self-care behavior adoption. the u. s. census bureau (n.d.) reports that twenty-eight million women age 18 and older live in rural areas or frontier, and an estimated five million of these women are 65 years and older. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 81 the state of arizona’s definition of rural was used for this study. which is a county with a population less than 400,000 persons and a census county division with less than 50,000 persons in a county with a population of 400,000 or more persons according to the most recent united states decennial census (arizona department of health services [adhs], office of health systems development n.d.). most of the small towns within arizona counties have populations less than 50,000 persons, allowing them to qualify as rural for this study. the aha defines cardiovascular health as the absence of clinically manifest cardiovascular disease together with the simultaneous presence of optimal levels of health factors (e.g., lipids, blood pressure, blood glucose) and health behaviors (e.g., healthy diet patterns, physical activity, non-smoking, appropriate energy intake) (eckel et al., 2014). this study was conducted with rural arizona women with cad post-ici. the definition of self-care was derived from aha, which included attending follow-up appointments where their health factors were checked and taking actions if symptoms reoccur. thus, self-care was defined as the ability of rural women to independently and purposefully initiate and adopt the following behaviors to promote and maintain cardiovascular health: cease smoking, adhere to heart healthy diet, incorporate physical activity in their daily routines, monitor their blood pressure and blood glucose levels regularly, adhere to medical regimen, and follow up with their clinician as required or access health care in a timely manner if symptoms reoccur (eckel et al, 2014; smith et al., 2011). the theoretical perspective for this study encompassed dorothea orem’s self-care deficit nursing theory (taylor et al., 2000); rural health theory (long & weinert, 1989) and the social determinants of health framework (havraneck et al., 2015). self-care deficit nursing theory and the rural health theory account for the personal responsibilities individuals have for self-care and human and environmental conditions that exist during the process of caring for self (e.g., self-care online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 82 demands, health beliefs, culture and social networks). the social determinants of health help acknowledge the social and economic systems that are in place for rural women to be successful when taking care of themselves (e.g., available resources and socioeconomic position). methods this study used qualitative description (qd) design, which was the optimal choice for description of behaviors and experiences without making judgement (sandelowski, 2010). qualitative description design allowed straightforward basic descriptions of self-care behaviors as reported by rural women with minimal theorizing compared to other methods such as grounded theory. the study was reviewed and approved by an institutional review board for human subject research at the university of arizona, protocol number 1606621792. settings the state of arizona has 15 counties; 13 are classified as rural and are where 25% of the arizona’s population reside (adhs, 2019). cardiovascular disease was the leading cause of deaths in cochise county (population 129,099) and pinal county (population 430,799). in cochise county 18.1% and in pinal county 15.5% of adults live below the poverty level. in cochise county 18% and in pinal county 20% of residents have no health insurance. travel time by helicopter to the nearest advanced cardiac care setting is 45 minutes to an hour from cochise county and an hour and 15 minutes from pinal county (adhs, 2019). sampling purposeful sampling was used and continued until data saturation occurred. theme saturation was identified through concurrent transcription and review of interview data throughout the data collection phase. women were included in the study if they were: (a) at least 30 days, and no more than six years post procedure; (b) 35 years and older; (c) spoke and understood english; and (d) online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 83 willing to participate in a face-to-face, voice-recorded semi-structured interview lasting for approximately 60 minutes. women were excluded if they: (a) had a cognitive impairment, (b) were dependent on others for their care, or (c) were institutionalized in a long-term care facility. cognition was deemed impaired if the woman was unable to verbalize understanding of the purpose of the study and unable to provide written informed consent (rosenfeld et al., 2015). recruitment and data collection rural women were recruited from the cardiac clinics using direct contact by speaking to them and/or giving them recruitment flyers during office hours. the research team received permission from the office manager for the primary investigator to hang out at the clinics. those who verbally agreed to participate were screened right away. nine of the women who qualified were interviewed immediately in a private room; one woman was interviewed in her homes at her convenience. the study was explained in detail to each prospective study participant, and the consent form was explained line by line. women were given the opportunity to ask questions or withdraw prior to signing the consent. the primary investigator collected both the demographic and clinical information, and conducted face-to-face, semi-structured interviews that were voice recorded. an interview guide was used to conduct the semi-structured interviews. the interview guide was created based on the definition of self-care for the study, which was derived from the aha guidelines to maintain cardiovascular health. the same grand tour opening statement was used with each rural woman: i am interested in how rural women who had some type of cardiac treatment take care of themselves after they return home. please talk freely while you explain to me your self-care experience. after you finish, i may ask questions to clarify some things. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 84 the remainder of the interview flowed freely depending on the responses to this first question. subsequent questions were asked to verify, clarify, and amplify the self-care behavior experiences the rural women described during the interview. the interviews lasted an average of 25 minutes. data analysis strategies demographic and clinical information were transcribed into a microsoft excel spreadsheet, and voice-recorded interviews were transcribed into a microsoft word (ms-word) document within a week after each interview. information obtained during the interview was encrypted and password protected to protect participants’ information. all written memos about the design and analytic coding, categorizing and data comparison decisions were de-identified, then saved as part of an audit trail (lincoln & guba, 1985). lincoln and guba’s criteria to evaluate the scientific rigor and trustworthiness of the study were used. the truth value and credibility were attained through prolonged engagement (six months) in rural arizona with on-site participants interviews, the iterative process between data collection and data analysis, and frequent de-briefings with other research team members with long-standing histories working in small rural and frontier communities in the southwestern u. s. and arizona. (lincoln & guba, 1985). applicability in qd is ensured throughout the process of data collection and data analysis by thick description including sample specifics and characteristics. consistency was ensured by keeping audit trails of the decisions made throughout the study about the design and analytic coding, categorizing, and data comparison, which are available for peer review. neutrality refers to the freedom from bias, which was maintained by bracketing and establishing auditability during data collection and data analysis. confirmability was achieved through truthful representation of rural women’s self-care behavior experiences. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 85 during the semi-structured interview, participants were asked for clarification if there was any misunderstanding. data analysis started with theoretical coding. after the first three interviews were transcribed and a 90 percent of inter-coder reliability was achieved with one other team member, a codebook was established with unique definitions for the identified larger codes. open coding was then done within each of these larger codes. relevant patterns, interactions, and connections emerged in the succeeding interviews to achieve saturation (bell et al., 2005). discussions between the primary investigator and two other team members occurred to verify and validate the themes and categories identified and to also ensure credibility. saturation was achieved with ten interviews. atlas.ti mac (version 1.5.2), qualitative research software was used for data manipulation and management. findings the study was comprised of ten rural women ranging from ages 56 to 88 years, with a mean age of 77.6 years. nine women were from cochise county and one woman was from pinal county. seven women had a stent placement procedure and the other three had coronary artery bypass grafts (cabg). two women were six years post cabg, two were six years poststent. two women were five years poststent, one was three years post cabg, and three were more than three months but a year or less poststent. descriptions of self-care behaviors of rural women the experiences of the study participants with six self-care behaviors were explored: (a) cease smoking, (b) adhere to heart healthy diet, (c) incorporate physical activity in their daily routines, (d) monitor blood pressure and blood glucose levels regularly, (e) adhere to medical regimen, and (f) follow up with their clinician as required or access health care in a timely manner if symptoms reoccur. only two self-care behaviors elicited themes (tables 1 and 2): (a) adhere to online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 86 a heart healthy diet, and (b) incorporate physical activity in their daily routines. table 3 presents the participants’ experiences relative to the remaining four self-care behaviors. adhere to a heart healthy diet four main themes emerged for heart healthy diet: (a) access to heart healthy food, (b) food i am supposed to eat, (c) eating to feel good, and (d) eating for other health issues. see table 1. lack of access to healthy food. all women reported having access issues – both shopping and/or travel challenges. three women reported they had to travel more than 20 miles or 25 minutes to two hours to the grocery store or food market. one woman drove 10 miles every day to the market to buy groceries, and she said she also wanted to get out of the house. some women took trips to the food market or grocery store once or twice week, whereas for others it was once a month to go buy fresh vegetables. some reported waiting for their daughters to go shopping with them or to bring and prepare food for them. eating as i’m supposed to. regardless of poor access to healthy food, rural women in this study continued trying to eat food they thought they were supposed to eat post-ici. they also reported that they ate healthy, watched what they ate, avoided food with fats or a lot of lard, did not eat processed foods, and avoided salt. eating to feel good. whatever rural women chose to eat, even though some of it was considered heart healthy, they mentioned their choice as being for their overall feelings of health and happiness. they ate whatever they liked and whatever made them feel good and happy. eating for other health issues. several women mentioned either avoiding or not following heart healthy diet because it made symptoms of other health conditions worse. the health issues frequently identified by these women were stomach problems (3 women) and diabetes (3 women). online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 87 table 1 themes and participants' quotes representing adhere to a heart healthy diet themes participants’ quotes lack of access to healthy foods “we go to (town) which is 20 miles from our home to buy food from the market. in (nearest town) or (hometown), they don’t have no market. at least one time a week, but we usually go two times a week.” …but i like to eat salads, but i don’t get the opportunity every day to eat salads because i go to the grocery store once a month. either (town) 34 miles or (town) 92 miles, where i get everything i need once a month. so i get all the fresh vegetables, then the first two weeks i got fresh vegetables and then the last two weeks i do not have any. “i go to (town) which is like 10 miles from here, like almost every day to the store to buy meat, lettuce, tomatoes, and all kinds of vegetables and just to get out of the house.” eating as i’m supposed to i am not supposed to eat a lot of carbohydrates; i am not supposed to eat like potatoes. those will kill you, but i like potatoes. i can eat potatoes, but i will eat a little one, not a whole big potato. but if we go out to eat, i will eat half a potato instead of a full serving. i haven’t been watching what i eat lately, because i hardly eat because i am still like i am in a dream. i can’t believe he passed away. well, tacos, tostadas, tortillas, beans and bread. i shouldn’t because i am a diabetic too. but i eat salads, a lot of salads. i make stuffed cabbage, i don’t know if you have ever heard of hamburger pie, i don’t use lard or shortening. now i am using avocado oil. i am supposed to eat one bread or one tortilla a day, but i don’t really follow that well. eating to feel good “i eat everything. my daughter did everything for me. even the cooking, she put me on a diet. good diet.” i was eating very well, very healthy. just to watch my eating habits, and i feel healthy. we, my husband and i, were always watching our food and the way we were eating. when we purchase meat, we look for meat that is not with a lot of fat on it. even if it is a little higher in price, we buy it because we want to buy for our health. we eat a lot of vegetables, some carbohydrates, and no fats. remove all the fats in the meat, even if we eat poultry, we remove all the skin and all the fat that we can see. “generally, at my age i get whatever i want to get. i get one of those chocolate things in a package.” eating for other health issues for stomach problems: i try not to eat like for example, chili. i avoid chili for my stomach. i don’t drink orange juice for example, to avoid acid. i don’t eat lemon. on my own, the doctors haven’t told me not to do that. i do that on my own and it is working fine. but i do not eat bread, just very little bread. because if i don’t do much exercise and i keep eating bread and a lot of carbohydrates, i will be like this. yes, i will gain weight, a lot of weight. so, i try not to eat many or much carbohydrates. for diabetes: today my blood sugar was too high; it was 250. i quit eating stuff that i am not supposed to eat. i don’t eat no more potato chips or candy so it starts coming down. and this morning i only ate one slice of bread and no more. i am supposed to eat one bread or one tortilla a day, but i don’t really follow that well. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 88 incorporate physical activity in daily routines when asked about incorporating physical activity in their daily routines, seven of the rural women in this study reported walking and normal or routine housework as their main form of physical activity and three women mentioned house work as their only form of activity. participants who had open-heart surgery reported having restrictions on physical activity for a few weeks or months; however, those who had stents reported that they rested for few days before resuming their walking or routine housework. although they reported going back to normal housework routines, they could not perform the heavy housework they had done before the procedure. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 89 table 2 themes and participants' quotes for incorporate physical activity in daily routines themes participants’ quotes walking post stent “i just walk. that’s what i do every afternoon, i walk two blocks. i use to do exercises in the house with a walker (demonstrate with her feet kicking forward and moving legs and arms). by that time, i could not walk.” i walked every day, no, almost every day through wal-mart. i walked through that for an hour. yes, that is what i do, at least a mile. i use to do it every day but now i am getting lazy and i got tired of doing it. so, i do it every like twice this week. well, i am old. i am older than dirt. i will be 88 years next month and that is old. but anyway, i enjoy walking most of the time. sometimes i get bored with it. and i will walk when i go grocery shopping with my daughter. it is more like four times a week that i walk. ...i walk to the mail box and back and go shopping, i go to the wal-mart and walk all over that big store. i do not do any regular exercise other than that. but to the store down here, yes, i do a lot of walking around the stores, because i never know where they have everything. “i walk, in the morning i get out and walk and do exercise. once a day i walk in the park.” i live on a hill, and it is really steep. so now every morning and every evening i have to go up and down that hill to close my gate. so, for me that’s exercise because it makes my heart pump really fast and hard. twice in the morning and twice in the evening. post cabg: i just waited for three months, and i started again. working, walking, and doing the best i could. but my exercise at home wasn’t as bad, because i did not do very heavy stuff. i just did my regular normal meals and that’s about it. i did not wash the windows or anything like that. before i was able to do them. normal housework “i clean house, i make beds and clean house, mop, and i only have a little bit to mop the rest is all carpet.” i rested for about two days and then i got back to my normal routine. i usually get up about between six and seven. at that point i let the dogs out, turn off the alarm, and then make my breakfast, turn on the news while i eat my breakfast, read something until eight o’clock when i get my son up. and then if i have to do laundry, i will do laundry and clean. and then i just go on with what i have to do. i crochet, i embroider, and then i have my flowers outdoors. post cabg: “i did not do anything for a couple of months, then i started doing things. not heavy things or anything like that. my housework, everything that a wife does. cooking, vacuuming, laundry and checking stuff.” “i just rest and do not do heavy work now, beside my age, which is now 81 years old; i try not to do heavy work on my own.” online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 90 other self-care behaviors rural women had to be prompted to discuss how they adopted these lifestyles behaviors. themes did not emerge from this questioning; rather participants described their experiences with these recommendations post-ici. cease smoking. seven women had never smoked. three women were former smokers; however, they reported they knew smoking was not good for them. monitor blood pressure (bp) and blood glucose (bg). participants reported that they may or may not check their bp or their bg. all of those with diabetes (five) and some of those without diabetes checked their bg. they reported knowing what to do with the readings, such as eating something sweet or taking a blood pressure pill. some of those with high blood pressure did not check their blood pressure until it was checked during their clinician office visit. adhere to medical regimens. none of the participants reported any problems with their medications. they took their medications as their clinicians required, even though most of them did not remember the name of their medications. follow up with their clinician as required or access health care in a timely manner if symptoms reoccur. all participants had a follow-up appointment scheduled after their procedures. staff at their clinician’s office called to remind them of the appointment the day before. regardless of the distance and travel time to the clinician’s office, which ranged from two miles (5 minutes) to 72.4 miles (1 hour and 20 minutes) drive, all participants kept their appointments. when symptoms reoccurred, most of the women in this study would first call a family member and instruct them to call 911 or to take them to the hospital. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 91 table 3 self-care behaviors and participants' quotes behaviors participants’ quotes cease smoking “….it took me about a year to finally quit smoking. and me quitting smoking was the best thing, and it was hard.” check blood pressure …high blood pressure? i have low blood pressure. i am taking lisinopril. right now, when they checked at the doctor’s office, he said i have 134 over sixty something. so that was good. sometimes i have my husband check. i don’t check it all the times. if it is low, i sit down and take it easy for a little while. if it high, i do the same. you know you just have to take it easy when you get as old as i am. check blood glucose maybe four times a month. it depends on how i feel. if it goes up, i take an extra blood pressure pill. yes, i do. i check it (bg) before breakfast, before lunch, before dinner, and then i check it at bedtime. that way i, because i am on a sliding scale. this morning it was 166, so i took six units. i check my blood sugar, and when it high, i give myself a shot, and it doesn’t bother me…. it just depends on where i shoot it. sometimes it bruises, sometimes it does not. i usually have low blood sugar, so i have to eat a little sweet in the morning to get it high and a little off. yes, in the mornings. this morning it was 74, but one time i had it lower than that. i don’t remember right now, i should have brought my book, but it is usually low and, in the evening, it gets high if i eat anything that i am not supposed to eat. …i check my blood sugar once in a while because for a while they said i had diabetes, i think for about three years i was on metformin and lisinopril. and i took my test every morning, and it was hardly ever 100. it was like in the 80’s and 90’s sometimes in the 70’s. once in a while it will be a little over a 100, maybe a 108 or 107. so, i took that and showed it to my doctor, and he said i don’t need to take medication anymore then. so, but even so, that has been about a year ago i guess, or nine months. but i check it once in a while. i checked it two days ago, and it was a 100. so, i keep track of that. if i eat little sweets, i go check it again. i don’t want to tell you what it is. it was a 120 one day when i had a lot of other stuff, and i said to myself i better not do that. i take care of myself. medical regimen “yes, it is a lot of pills. i take them every day. my daughter fixes everything for me, morning or noon or night.” yes, i take six different pills from my doctor’s prescription, and i feel okay, i feel happy. because i am taking my pills regularly, i feel great. now i am taking two pills of vitamins. before i was taking only one a day. then i read a label and they say two pills a day. now i am taking two, one in the morning and one in the afternoon, and i am feeling much better now. yes, multivitamins because now i am taking two pills a day instead of just one. follow-up i always keep my appointments. but i got late today, and i don’t know why i am late, really. and now we are 15 minutes late he cannot see me. i said i can wait to see if he can take me later right before lunch or right after lunch, but he said no. well there is a (name of clinic) in (town) 20 miles. i have been several times in this (name of clinic) instead of going to see a doctor 20 miles away or 50 miles away. access care “i know when i had my first heart attack, my husband drove from our house to this hospital in 4 minutes. because we knew he would be faster than an ambulance.” “yes, my daughter will take me to the doctor…. an emergency or you have chest pain….i call my daughter.” “i tell my son, he either calls 911 or he takes me to the hospital.” online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 92 self-care behavior barriers and facilitators these were situations that prevented or enabled rural women to perform self-care behaviors. rural women in this study described these conditions as part of their life not as something that will pass and were appreciative of what they had. barriers to self-care barriers were defined as anything that prevented participants from initiating and performing self-care behaviors. four themes where identified: residential environment, health and physical ailments, social conditions, and personal characteristics. see table 4 for themes and participants’ quotes. residential environment. examples of built and natural resources in neighborhoods include safe public spaces for physical activity, affordable housing, and availability of healthy food options, local emergency and health care services (havranek et al., 2015). eight women described unavailability of amenities such as emergency health services and food markets for fresh fruits and vegetables as barriers to self-care behaviors. for example, the ambulance personnel had a hard time finding one woman’s house when she called because of her rural address. also, three women described the distance from healthcare facilities prevents them from participating in selfcare behaviors. food deserts and distance to the market were both identified as barriers to eating fresh fruits and vegetables. health and physical ailments. participants described the physical conditions and health symptoms that prevented their eating a heart healthy diet, taking medications, or engaging in physical activity. specific conditions mentioned as barriers to walking included: five women, tiredness; two women, arthritis; one woman, heart failure; three women, diabetes; and three women, stomach problems. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 93 family conditions. participants reported that relationships with their daughters, husbands, and sons were barriers to self-care. six of the women reported some type of family issue preventing them from doing self-care behaviors. they reported that their family members were watching over them preventing them from doing self-care behaviors or activities they did before the procedure, especially physical activity. personal characteristics. participants reported that their own individual preferences were barriers to self-care. the words participants used towards certain self-care behaviors revealed the attitude they had towards those behaviors and prevented them from doing them. for example, participants reported their age accompanied by forgetfulness as part of why they were not doing certain self-care behaviors, such as forgetting appointments or taking their pills. table 4 themes and participants’ quotes representing barriers to self-care theme participants’ quotes residential environment i know when i had my first heart attack, my husband drove from our house to this hospital in four minutes. because we knew he would be faster than an ambulance. we have a county address, but we are right outside the city limits, and they have had trouble finding us. and we have private health facility that opened there, and they are the ones that are building that emergency. if you get sick between 8 in the morning and 5 in the evening you can go there, but after that forget it. if we need emergency care, we either go to nearest town 25 miles away with emergency health services or the next nearest town about 52 miles away. coming into counseling, which would be (town) 92 miles, we just don’t have the funds to keep driving back and forth. i started rehabilitation on my back, so i can start exercising and all that. i only did it once, and they wanted me to do it three times a week, and i said i couldn’t afford it. i do not get the opportunity every day to eat salads because i go to the grocery store once a month. which is either (town) 34 miles or (town) 92 miles, where i get everything i need once a month. so, i get all the fresh vegetables and the first two weeks, i got fresh vegetables and then the last two weeks i do not have any. health and physical ailments before i used to do more exercise because i was walking, doing the laundry, cleaning, and now i just do a little only because i get tired. this tiredness affected me because i do something i feel like, argh, i am weak and tired. the next thing i cannot do that. i get out of breath very easily, and i get tired very easily and quickly. i was doing a lot then. but i mean i still do, but i do not vacuum anymore, my husband does that. but i still do everything, i just get tired, more tired than i used to. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 94 “it is hard, because i have rheumatoid arthritis, no, osteoarthritis in my back, so my exercise is limited. i am in a lot of pain. i have a lot of issues with my back so my exercise has been limited.” “metformin i take two a day, sometimes i take four because he (the doctor) said my blood sugar was really high. once a week i drink four a day because it gives me diarrhea really bad.” i do not want to eat. there are so many things; i have a problem with diarrhea. and i love different kinds of food, but i cannot have them, they give me diarrhea. i cannot eat green vegetables because they give diarrhea. so, i do not eat healthy. family conditions i have had a lot of problems with my mother and my blood pressure went up. and my son doesn’t like to walk. he cannot walk slowly. he has to walk really fast. i have an artificial ankle, and i do not like to walk fast. “and my husband had a stroke, and i had to take care of him for like 13 years, and lately i could not leave him alone. and that cut into my walking.” …my exercise, but my exercise at home was not as bad because i did not do very heavy stuff. because i had my husband watching over me all the times. but somebody has to tell me what to do with my husband. because he stresses me out…. personal characteristics “i hate them, i hate taking pills because it is a waste of time. just to sit there and pop pills into you. so, i do not like to do that, half the time i do not do it. i am still alive that is all that matters to me.” she gave me something i did not go for, and i told her i will not take that so just do not give it to me. that is the way i am. my husband says i like to talk a lot, but i like to let them know that i am not going to drink anything that i do not like. facilitators of self-care facilitators are defined as anything that enabled study participants to initiate and perform self-care behaviors. three themes were identified: relationships, available resources, and personal outcomes. see table 5 for themes and participants’ quotes. relationships. the participants reported on the behaviors of their family, friends, and neighbors related to their recovery. eight women reported that their family provided the primary support that facilitated self-care behaviors, and friends and neighbors were available to help each other out. six women reported that their daughters and seven women reported that their husbands were especially supportive with dietary adherence, medications, and health care professional’s appointments or calling 911 if symptoms reoccur. in their own words they reported: “my daughter helped me” or “my husband took good care of me” or “i am lucky to have family i have.” available resources. some participants described the structural factors within their neighborhoods that were accessible. four women described how helpful it was that staff at their online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 95 cardiologists’ offices called them the day before their appointment to remind them. three women reported that going to church was helpful, and two women reported that they used department stores for physical activity. personal outcomes. participants described the feelings they had after they did their selfcare behaviors and how these feelings motivated them to do those behaviors again. three of the women reported doing physical activity because they enjoyed doing it. for all other self-care behaviors, three of the women reported feeling good, feeling better, or feeling happy, and four women reported feeling relaxed and stress-free after performing their self-care behaviors. table 5 themes and participants’ quotes representing facilitators of self-care theme participants’ quotes relationships as a matter of fact, i am lucky, i am really lucky to be alive, to have the family that i have, and there was a lot of friends. everybody was great. so, it really helped. my daughter would not let us go to hometown (after the procedure). she said she is one hour away from town with advanced medical care, if something happens, bingo!! they are great. every time i have an appointment in town with advanced medical care, my daughter takes time from work to go with us. i go grocery shopping with my daughter. my daughter helps. my daughter is always there for me. she lives quite a ways from me. my daughter takes me to the doctors all the time. i have good neighbors, they do not bother me, they do not come to my house or anything. well, (name of neighbor) does once in a while, but it is ok. my son comes in from (the city); he is a pharmacist. he comes over and makes me three weeks at a time (of the pills). he fills my little cubbyholes with them. we have good neighbors we help each other, so we just kind of help each other out there. if my neighbor over there needs help, we go and if we need help, they come over. i am very spoiled. the pharmacist that i take my medications from lives out by our house. so, he fills them in (town, 92 miles away), and he drops them off at my house so i do not have to go there. i am just lucky that he is a good friend of us, so he drops them off. available resources they have somebody schedule them for me, and they call the night before to make sure you are here the next day. like (the cardiologist’s) medical assistant called me and told me i have an appointment. i said ‘no i do not.’ she said ‘yes you do.’ because sometimes we forget, i always tell them to call me the day ahead, whoever it is, whether is the dentist or whatever. “i walk a good mile between the (department store) aisles. i chose the ones that people are not in. i walk inside because i use the cart to walk. i have to use that cart now to balance myself.” online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 96 theme participants’ quotes personal outcomes “yes, i take six different pills from my doctor’s prescription, and i feel okay, i feel happy. because i am taking my pills regularly, i feel great.” “it makes me feel really good. i have always ridden, and it just makes me feel like i am free, and i do not worry about nothing except riding my horse. it just clears my mind.” “i eat well, rest well, socialize normal, and i am ok.” discussion for this study, self-care was defined as the ability of rural women to independently and purposefully adopt these behaviors to promote and maintain cardiovascular health based on aha guidelines. these included: adhere to heart healthy diet, incorporate physical activity in their daily routines, cease smoking, monitor blood pressure and blood glucose levels regularly, adhere to medical regimen, and follow up with the health care professional as required or access health care in a timely manner if symptoms reoccur. however, rural women in this study had different descriptions of self-care behaviors and why they did what they were doing when they got home post-ici. understanding the self-care experiences of rural women post-ici is crucial in implementing secondary prevention measures to improve outcomes and reduce the disparities. the american college of cardiology guidelines recommend cad preventive measures and interventions that are culturally acceptable for individuals (eckel et al., 2014; goff et al., 2014). studies have indicated that living in rural areas, plus other sociocultural factors affect rural women’s ability to manage chronic illnesses such as cad. (sullivan et al., 2003; turnbull et al., 2020; weinert et al., 2008). rural women’s clear understanding of the specific actions to take and resources available to promote self-care can have a positive influence on adopting behaviors postici. rural women in this study reported doing everything they did before undergoing treatment for cad post-ici. they reported they were not told to do any specific actions during discharge instructions. when asked what they did to take care of themselves, they discussed what they normally did, especially choosing foods that are good for them and walking plus their normal online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 97 house routines to keep active. they needed to be prompted to talk about taking their medications, checking their blood pressure and blood sugar, and following up with their clinicians. these findings indicate that when working with rural women, the scientific definition of self-care behaviors must be delineated from the perspective of rural women during discharge instructions post-ici. aha defines a heart healthy diet as a daily serving of fruits and vegetables, whole grains, lean meats, and fat-free or low-fat dairy products (van horn et al., 2016). even though these rural women did not mention eating for their heart health, instead for their overall health, the descriptions of their food choices are consistent with aha’s heart healthy diet. these rural women reported eating what they thought they were supposed to eat, not what they knew they were supposed to eat. for example, they reported that they ate low-fat low-salt food choices and ate fresh fruits and vegetables every opportunity they could. these findings are also consistent with the findings from the cudney et al. (2005) and perry et al., (2008) studies. to encourage and motivate rural women with cad post-ici, their dietary programs must be clear and specific, highlighting foods that are culturally acceptable for them and that are heart healthy. researchers reported that geographic location exposed rural dwellers to limited health care services; however, based on their tendency to maintain a positive attitude towards life, they often did not perceive geographic challenges as problematic (brundisini et al., 2013; pierce, 2005; sullivan et al., 2003). rural women in this study traveled an average of 20 miles each way to the grocery store for fresh fruits and vegetables. this travel distance supports the findings from the kim et al. (2013) and slusher et al. (2010) studies that estimated 10 miles or more distance to the grocery store in their studies. regardless of this distance challenge, rural women in this study and online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 98 in the kim et al. and slusher et al. studies did not report distance as a problem or obstacle to eating as they were supposed to eat. rural women in this study indicated that they performed activities that were part of their daily lives, easy, and enjoyable; however, depending on the type of procedure they had, they avoided strenuous chores a few days or a week post-ici. these findings are consistent with what is in the literature (slusher et al., 2010; sullivan et al., 2003). the recommendations for physical activity are that adults should have 150 minutes of moderate activity per week or 75 minutes of vigorous activity per week (u.s. department of health and human services, 2018). walking and returning to normal housework and routines were the most common forms of physical activity for these rural women. also recommended, is that adults with chronic diseases who are unable to meet the activity guidelines must avoid inactivity by engaging in their regular physical activities according to their abilities. rural women in our study reported using department stores like wal-mart as being resourceful for physical activity, especially to walk up and down the air-conditioned aisles during the arizona summer. unlike other women who might have access to the gym, “drive thru” or online shopping, these rural women took advantage of grocery shopping to meet their physical activity needs. kim et al. (2013) found that rural women would go to recreational facilities if they were available or they knew about them. in that study, availability of recreational facilities increased the physical activity of rural women. therefore, to develop secondary preventive physical activity measures for rural women with cad post-ici, it is important to have a clear understanding of rural women’s perspective of physical activity (fahs et al., 2013). it is imperative to know what strenuous chores are for these rural women and how they may or may not be suitable for physical activity to maintain cardiovascular health. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 99 the rural women in our study discussed performing self-care behaviors as part of their daily routine, not as cad secondary prevention post-ici. they stopped smoking because it was not good for them. kim et al. (2013) and slusher et al. (2010) reported a high prevalence of smoking among rural women. in contrast, all rural women in this study were nonsmokers; seven had never smoked, three had quit smoking. all the women in this study, with the help of their families, took their medications regularly. they checked their blood sugar if they were diabetic and went to their health care professionals when they had appointments. the rural women in our study also considered how they felt physically before performing some of their self-care behaviors. for example, they checked their blood pressure and selfmanaged – taking an extra blood pressure pill if blood pressure was high or lying down if blood pressure was low. buehler et al., (2013) reported that, even though rural women self-evaluated and self-treated as part of their daily routine, it was still not clear whether self-care was used only in response to certain symptomatic illnesses. equal distribution of secondary prevention measures for self-care behavior modification strategies can help address the cad disparities. cardiac rehabilitation services, which are almost inaccessible to rural women, can help control the cardiovascular disease risk factors in rural areas and address the disparities. a simple call from the clinician’s office to remind rural women of their appointment was appreciated, because that also helped the rural women in our study plan their trips. appointments to the clinician were clustered with other chores at the cities where the cardiology clinic appointments took place. for example, they went to the bank or to the market for fresh fruits and vegetables. going to the clinician’s appointment involved family and neighbors needed to care for their animals while they were gone for the day. the same support was needed in case of an online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 100 emergency; the rural women in our study would call on their family members or neighbors or drive themselves to the nearest health care service center. studies have reported that relationships individuals have with others (e.g., attending church gatherings) and the trust among community members have an impact on illness management (crosby et al., 2012; winters & sullivan, 2013). most of the rural women in our study expressed their appreciation and highlighted the support that they had received from their daughters, husbands, sons, friends, and neighbors. other studies have found that people living in rural areas do not usually adopt new behaviors as rapidly as their urban counterparts (bennett et al., 2013; fahs & kalman, 2008). this has also been discussed as based on their sense of independence, selfreliance, and community pride and on other factors such as geography, social, cultural, and economic factors (buchanan, 2008; crosby et al., 2012; fahs & kalman, 2008). some of these positive traits could be incorporated into programs for self-care behavior modification strategies to be more effective in rural communities. study limitations the difference in the rural geography within states can pose a transferability issue. although self-care behavior experiences, barriers and facilitators were adequately described, they may be different from one rural area to another or within states and between states. for example, the distance between cities and rural communities in western states and the south eastern states differs. a multi-state qualitative study with a wider range of participants from different cultural backgrounds would enhance the impact of the results. conclusion this qualitative descriptive study focused on self-care behavior experiences of rural women post-ici and identified barriers to and facilitators of these self-care behaviors. this study is online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 101 noteworthy. even though cardiovascular diseases are the number one cause of death among rural women in cochise and pinal counties, in the u.s, and in the world, to our knowledge, there is no study that has specifically focused on the self-care behavior experiences of rural women with cad post-ici. the american college of cardiology guidelines recommend cad preventive measures and interventions that are culturally acceptable for individuals (eckel et al., 2014; goff et al., 2014). the words that rural women in this study used to describe their self-care behaviors, were consistent with the components of aha’s behavioral recommendations for maintaining cardiovascular health. this study’s findings improve our understanding about self-care behaviors among rural women and the most influential aspects of adopting these self-care behaviors. as rural women tend to live well beyond retirement age, their health beliefs may not be associated with their ability to work, rather with their ability to perform housework and normal routines and whatever makes them happy. self-care is an essential component of secondary prevention of cad for rural women who have undergone ici. when developing programs for self-care behavior modification strategies to address cad risk factors, health care providers must incorporate rural women’s individualized daily living experiences for those programs to be successful. acknowledgements we were successful in the research and production of this paper because of the exceptional support of dr. sally reel, at the university of arizona, college of nursing. her knowledge of rural health kept us on track from the beginning of the research to the final paper. we are grateful for the women who participated in this research, and understand it was a privilege to work with them. we are, also, grateful for doctors at the tucson heart group, tucson arizona, for the rides to the rural clinics. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.629 102 references arizona department of health services. 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(2013). chronic illness experience of isolated rural women: use of an online support group interventions. in c.a. winters (ed.) rural nursing: concepts, theory, and practice (4th ed., 159-172). springer. https://doi.org/10.1891/9780826170 866.0011 george_633_formatted online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 156 the use of tweet-format narrative reflections during a service-learning trip to appalachia allison c. munn, phd, rn 1 tracy p. george, dnp, aprn-bc, cne 2 tiffany a. philips, dnp, np-c 3 j. marty hucks, mn, aprn-bc, cne 4 1 assistant professor of nursing, school of health sciences, francis marion university, amunn@fmarion.edu 2assistant professor of nursing and coordinator of the bachelor of general studies program, school of health sciences, francis marion university, tgeorge@fmarion.edu 3assistant professor of nursing, school of health sciences, francis marion university, tphillips@fmarion.edu 4assistant professor of nursing, school of health sciences, francis marion university, jhucks@fmarion.edu abstract background: tweet-format narratives have been used in medical education to capture student experiences. however, there is a lack of research on tweet-format narratives during experiential learning in nursing education. purpose: the purpose of this project was to explore the usefulness of tweet-format narratives to capture nursing student experiences and to elicit reflection during a service-learning trip. methods: eight bachelor of science in nursing (bsn) students participated in a service-learning experience to appalachia. a grounded theory approach with three data collection methods was online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 157 used to determine the usefulness of tweet-format narratives to facilitate student reflection during the event. a free closed text-messaging app was used to house tweet-format narratives. a focus group session and post-survey were conducted at the conclusion of the trip. emergent themes from each data collection method were compared and modified using iterative techniques and constant comparison analysis until the data were saturated. results: focus group responses were reflective in nature and included student elaboration about content themes that were previously identified by the tweet-based narratives. modification of themes resulted in six final themes of improved skills, cultural competence, patient interaction, socioeconomic factors and health, landscape/clinic setting, and impactful shared experiences. conclusions: it is important for nursing students to reflect on their experiences during servicelearning immersion trips, especially as they relate to underserved rural populations and their unique healthcare scenarios. with the growth of social media, more nursing students are accustomed to communicating in a short, text-based format. the tweet-format narratives in the free closed text-messaging app allowed students to reflect on their experiences through open-ended comments and to communicate with other members of the group. short text-based narratives can be an effective narrative medicine technique for nursing students participating in service-learning trips in rural areas. key words: narrative medicine, rural health, service-learning, technology the use of tweet-format narrative reflections during a service-learning trip to appalachia narrative medicine is an approach to care that incorporates patient/provider narratives into clinical practice and includes "recognizing, absorbing, interpreting, and being moved by the stories of illness" (charon, 2006, p. 4). patients desire healthcare providers who listen to them, are online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 158 attentive to their needs, and address their concerns, and these attributes are encouraged with the use of narrative medicine (zaharias, 2018). through narrative medicine, providers become aware of patients’ lived experience of illness, which may foster holistic care and improved health outcomes (remein et al., 2020). some common tools and techniques in the delivery of medical services like short patient consults or visits, electronic charting, and technology may feel impersonal to patients (liao & wang, 2020). in contrast, narrative medicine is consistent with a personalized approach to healthcare that considers each patient’s individuality (fioretti et al., 2016). likewise, cenci (2006) found that narrative medicine, through reflection on patient’s stories, promoted an interdisciplinary, patient-centered approach to delivery of care. narrative medicine serves to elicit reflection, and reflection is an important component of medical/healthcare education, wherein students can reconcile their performance during patient interactions, encounters, and experiences (charon, 2006; dressler et al., 2019). reflection provides the opportunity for students to take a break from what is occurring, allows them to review an experience, and helps them reassess the situation and problem-solve (murphy, franz, & schlaerth, 2018). furthermore, student reflection facilitates improvement in areas such as professionalism, responsiveness, critical analysis, and decision-making (charon, 2006; dressler et al., 2019). the benefits of narrative medicine include improved communication and collaboration skills, empathy, personal growth, patient-centeredness, and job satisfaction (arntfield et al., 2013; small, feldman, & oldfield, 2017; reiman et al., 2020). empathy can be sustained after involvement in narrative medicine. chen, huang, and yeh (2017) found that empathy scores were sustained for 1.5 years after participating in a narrative medicine program. according to reiman et al. (2020), narrative medicine assisted in the detection and reduction of burnout, promoted critical thinking about ethical issues, and improved clinical skills. similarly, tsai and ho (2012) online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 159 found that medical students with experience in narrative medicine performed better on objective structured clinical examination (osce) communication stations. short tweet-format reflections have been used in medical education and residency programs to capture student experiences, and the use of tweet-format narratives may be an effective tool to facilitate reflection in narrative medicine (dressler et al., 2019; liao & secemsky, 2015; wesley, hamer, & karam, 2018). dressler and colleagues (2018) explored the use of tweetformat narratives to document student experiences and found that the tweets elicited reflection and provided richer information about student experiences than standard evaluation tools because students were able to immediately document details of experiences and perceptions of patient encounters. these details may normally get lost due to delays in journaling or having students recall details only on the end-of-semester evaluation tool (dressler et al., 2018). the use of narrative medicine among interprofessional teams has been associated with decreased isolation among health care providers, and it allowed the members to share a variety of perspectives (small et al., 2017). while reflective practice in medical school education has been utilized with success, there is a lack of data on the use of narrative medicine or tweet-format journaling to capture experiences among nursing students (dressler et al., 2019; tsai & ho, 2012). mangino (2014) and yang et al. (2018) discussed the importance of reflective nursing practice and asserted the importance of incorporating narrative medicine into nursing curricula. the us census bureau (2010) identifies an area to be rural if there are less than 50,000 residents. the federal office of rural health policy considers all non-metropolitan counties as rural, and it also looks at the rural-urban commuting area (ruca) codes (health resources services administration [hrsa], 2020). in this study, nursing students participated in a serviceonline journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 160 learning experience in wise county, virginia. wise county has been designated as a rural area by hrsa (2018). this county is in the mountains of central appalachia, with an estimated population of 37,383 in 2019 (us census bureau, 2020). in wise county, 25.4% of residents are in poverty, and wise county ranks 125 out of 133 counties in virginia in health outcomes (county health rankings, 2020). methods the purpose of this research project was to explore the usefulness of tweet-format narratives as a qualitative data collection tool to capture nursing student experiences and a technique to elicit reflection during a service-learning trip into rural appalachia. study design a four-person nursing faculty team from a public, liberal arts university in the southeastern united states secured internal grant monies to guide and accompany senior-level bachelor of science in nursing (bsn) students on a three-day service-learning immersion event in rural appalachia. the nursing students assisted with a free three-day mobile clinic at a local fairground and were exposed to patients and local providers from this rural area of appalachia. the faculty research team utilized a grounded theory approach and three separate data-collection methods to determine the usefulness of tweet-format narratives to capture student experiences and to facilitate reflection among nursing students who participated in the service-learning event (charmaz, 2014, dressler et al., 2019; glasser & strauss, 1999; hesse-biber & leavy, 2011). the study was approved by the university institutional review board (protocol number: 02-26-2019-004). recruitment and participants students were recruited for the service-learning immersion event during classroom visits. the faculty team introduced the nature of the trip and described the opportunity for interested online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 161 students to participate in a mobile clinic involving the delivery of healthcare services to underserved populations. students were also introduced to the concept of narrative medicine and informed of the tweet-format reflective journaling study that would coincide with the servicelearning immersion event. eight students volunteered to attend the trip and to participate in the immersion experience and in the tweet-narrative reflection study. the students provided their signed informed consent to participate in the study and were able to choose to withdraw or not participate in the study at any time. the study and immersion event were not tied to a nursing course, and there was no danger of academic penalty through participation or non-participation in the study. the cost of the trip for students was supported by the grant funding and was nominal. data collection data collection methods included student and faculty tweet-length narratives that were journaled throughout the service-learning immersion event, a post-survey, and focus group session conducted at the conclusion of the trip. closed messaging application (app) students and faculty used a secured and free, closed-messaging app to communicate with each other about status, location, and experiences during the service-learning trip. faculty encouraged student activity within the closed-messaging app throughout the trip to provide avenues for documentation of experiences, communication, and reflection. students were prompted by faculty to write tweet-length narrative journal entries during break periods of each day and a final thought or reflection each night. faculty were also active participants in the closedmessaging app to document experiences during the trip and to encourage student interaction and participation through initial tweet-narrative journal entries, responses to initial journal entries, and comments of support or shared experiences. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 162 post-survey a paper-based post-survey was administered on the final day of the service-learning trip to capture student demographic data and to offer participants an opportunity to provide further detail of their experiences in an anonymous manner. the survey was administered before the focus group session so that individual student feedback would not be influenced by peer responses in the focus group forum. the post-survey was constructed by the research team before the service-learning trip to align with the service-learning trip objectives and included three broad, open-ended questions: 1) how has this service-learning experience impacted you?, 2) what would you change about the experience?, and 3) any additional comments? these questions were constructed using standard post-experience evaluation questions used by the academic department and were tailored for the service-learning experience. the research faculty team member with expertise in narrative medicine reviewed the survey and semi-structured interview questions for appropriateness and content validity. no further measures of reliability or validity were conducted. focus group session when designing the study, the research team constructed a preliminary semi-structured interview guide based on the concepts of experiential learning, narrative medicine and journaling, and reflection (table 1) (mangino, 2014; murphy et al., 2018; remein et al., 2020). table 1 preliminary semi-structured interview guide interview questions what is your overall impression of the service-learning experience? what skills or tools have you gained that will be helpful to you either personally or professionally? how has this experience helped you to relate to your peers? how has the experience impacted your perception of the nursing faculty? with respect to your nursing school curriculum, what about this experience was unique? given your experience with this service-learning experience, if a peer asked you why this is beneficial, what would you say? what do you think is missing or could be better within this service-learning experience? online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 163 how would you describe the use of the purpose of narrative medicine or journaling in nursing education? how did reading the reflections of other students impact your experience? does anyone have any additional comments or thoughts they want to share? a focus group session was conducted using a modified version of the semi-structured interview guide at the conclusion of the trip and provided an opportunity for students to have open-ended discussion of learning encounters and to recall service-learning trip experiences (table 2). table 2 modified semi-structured focus group guide based on tweet-format narratives interview questions what is your overall impression of the service-learning experience? what skills or tools have you gained that will be helpful to you either personally or professionally? how did the setting/landscape influence your experience? how did the experience influence your understanding of the culture and the people of appalachia? how has the experience influenced your understanding of how social and economic factors impact the physical and mental health of patients? how has this experience helped you to relate to your peers? how has the experience impacted your perception of the nursing faculty? with respect to your nursing school curriculum, what about this experience was unique? given your experience with this service-learning experience, if a peer asked you why this is beneficial, what would you say? what do you think is missing or could be better within this service-learning experience? how would you describe the use of the tweet-length narratives in the closed-messaging app? how did reading the reflections of other students impact your experience? does anyone have any additional comments or thoughts they want to share? the researchers read an informed consent statement at the start of the session and moderated the session using the modified semi-structured interview guide and guided probes. the session was audio recorded and transcribed verbatim with no participant identifiers collected. the session lasted approximately 22 minutes. all students actively participated and were engaged in the session, offering their recounts and reflections of their shared experiences. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 164 data analysis the faculty research team collected and analyzed the data utilizing constant comparison and iterative techniques until the data were saturated. the research team included one faculty member with expertise in narrative medicine and service-learning experiences. this faculty member offered limited input in the data analysis process to prevent a priori assumptions and experiences from influencing the coding schema and category formation (charmaz, 2014; glasser & strauss, 1999; hesse-biber & leavy, 2011). the other three faculty researchers used bracketing techniques to limit preconceptions and unintended alterations of the data during the qualitative analysis. the faculty research team extracted the tweet-narratives from the closed-messaging app each night of the trip and explored the data through organization, memo writing, and initial coding (charmaz, 2014; glasser & strauss, 1999; hesse-biber & leavy, 2011). the faculty team reviewed the tweet-narratives and conducted the initial memo writing and coding separately and then discussed as a group to determine agreement. table 3 provides examples of the tweetnarratives, codes, categories, and emerging themes associated with the coding scheme. in accordance with the tenants of grounded theory construction and constant comparison and iterative analysis techniques, the preliminary semi-structured interview guide was modified to incorporate emerging content and themes discovered through initial coding and analysis of the tweet-format narratives (charmaz, 2014, glaser & strauss, 1999; hesse-biber & leavy, 2011). the modified version of the interview guide included open-ended questions to elicit discussion about student experiences with the patients, residents and local culture, landscape, and with other peers and faculty. the modified interview guide was used to conduct the focus group session. online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 165 the research team reviewed open-ended survey responses and transcripts from the focus group session using the same iterative analysis and coding approach that was used for the tweetformat narratives (table 4). online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 166 table 3 tweet-narrative coding scheme student tweet-narrative initial code focused code/category theme “in triage i was taking a patient’s blood pressure and pulse. while checking his pulse, i noticed it was irregular and hard to keep up with…then he stated he stays in constant atrial fibrillation.” opportunities to improve assessment skills improvement of assessment skills, history taking, and medication administration improved skills “in order to get a really a good history it requires patience and a personable attitude (and a little detective work) but it’s all worth it so that the patient can receive the care that they need.” opportunities to improve history taking improvement of assessment skills, history taking, and medication administration improved skills “i got the chance to administer insulin to a female patient who came to get new glasses but she had a honey bun and her sugar rose to 230! but soon after her insulin injection her bgl came down to 90!” opportunities to assessment skills, history taking, and med administration improvement of assessment skills, history taking, and med administration improved skills “i think the areas of va we’ve been to have some of the nicest people…everyone greets you with a smile…i enjoy the vibe that comes from small town places” feeling welcomed by the community interacting with local residents and learning the culture cultural competence “it is humbling to see how badly these people struggle, yet they are still being positive and complimenting us.” feeling appreciated by the community and residents interacting with local residents and learning the culture cultural competence “i love that we were able to help the people of this community, most importantly, but i also enjoyed being able to explore the area and engage in different cultural events.” helping the community and learning the culture interacting with local residents and learning the culture cultural competence “my patient told me she’s been out waiting for 2 days just to get her eyes checked on” underserved population rural and underserved populations patient interaction “almost all of the patients i interacted with today were very pleasant and appreciative of the services offered.” underserved population rural and underserved populations patient interaction “this experience truly opened my eyes to the poverty of the area, online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 167 student tweet-narrative initial code focused code/category theme which i didn’t think about…when i think of medical missions, i think of going out of the country.” poverty of the local residents and need for missions poverty of residents and lack of access to healthcare socioeconomic factors and health “i noticed a lot of people…[on] medication for their anxiety, depression, and other issues. i wonder if it could be because people living in this area don’t have access to certain needs, living situations might not be great, or don’t have access to health care. it makes you wonder.” poverty of local residents, lack of access to needs and healthcare, mental health issues lack of access to basic needs and care and association to mental health socioeconomic factors and health “i was excited to see all of the mountains because i’ve never seen anything like them before.” opportunity for students to see new landscapes new experiences include travel and observation of new landscapes/clinic setting landscape/clinic setting “hiked through the beautiful appalachian mountains today! on the road to becoming more culturally competent.” opportunity for students to see new landscapes new experiences include travel and observation of new landscapes/clinic setting landscape/clinic setting “it was very humbling to see the amount of people that set up camp in order to come to this event. can’t wait for the next few days.” large number of volunteers coming together meeting other volunteers with similar purpose making a difference “i enjoyed seeing all of the volunteers who came from all over to help people in need…i am excited to meet the people of wise the next few days and make a difference.” large number of volunteers coming together meeting other volunteers with similar purpose making a difference “such a memorable experience. glad i was able to get to know ya’ll a little more “this event was not only a great clinical experience, but great personal experience…. getting to know everyone...[creating] some fun memories” getting to know peers and faculty getting to know peers and faculty shared experiences with peers and faculty shared experiences with peers and faculty shared experiences shared experiences online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 168 table 4 focus group and survey response coding scheme student tweet-narrative initial code focused code/category theme “you were left alone a little more. you found out what you knew, not just what you are kinda prompted to do. [in the hospital], they never let us do an admission by ourselves” opportunities to improve assessment skills improvement of assessment skills, history taking, and medication administration improved skills “you really have to dig deeper when asking questions [taking a patient history] …you have to break it down for them ask them is it anything in this category.” opportunities to improve history taking improvement of assessment skills, history taking, and medication administration improved skills “it kinda shows you how close their community is…they were so thankful that people were there doing stuff for their community” feeling welcomed by the community interacting with local residents and learning the culture cultural competence “it made them not just like the patients that we were seeing-going and interacting in the community, made them like people, not just a patient.” feeling appreciated by the community and residents interacting with local residents and learning the culture cultural competence “i thought it was a great experience…it was good to listen to their [patients’] stories, where they traveled from, it was really neat to see how far these people came to get medical care.” helping the community and learning the culture interacting with local residents and learning the culture cultural competence “they put so much effort getting there [patients]…they wanted to better themselves and take care of themselves…this may have been their only opportunity of the year to get medical care.” underserved population rural and underserved populations patient interaction “a lot of people that came for dental… when they were in triage found out they actual medical problems…things that they didn’t know were going on.” underserved population rural and underserved populations patient interaction “when i think of medical missions, i don’t think of stuff here or so online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 169 student tweet-narrative initial code focused code/category theme close…i guess i didn’t think about this being as big of a problem here.” poverty of the local residents and need for missions poverty of residents and lack of access to healthcare socioeconomic factors and health “i noticed there was a big need for it here [behavioral health services]. typically, the people that have those problems are uneducated or lower educated. people that don’t really have good healthcare. it took [the patient] 19 years just to get that problem just starting to be resolved.” poverty of local residents, lack of access to needs and healthcare, mental health issues lack of access to basic needs and care and association to mental health socioeconomic factors and health “it was peaceful…i think it also made the patients feel more comfortable…in their own setting, in their own area.” opportunity for students to see new landscapes/areas new experiences include travel and observation of new landscapes/clinic setting landscape/clinic setting “i had a lot of patients say…that they were terrified of seeing people in their coats and scrubs. that we were in t-shirts and normal clothes helped them not being as nervous out here.” clinic setting was comfortable for patients and students new experiences include travel and observation of new landscapes/clinic setting landscape/clinic setting “reading the groups’ [tweets] that went to triage’s stuff…it kinda made me feel like i was getting that same experience even through i wasn’t there to do that experience.” shared experiences through tweet narratives shared experiences with peers and faculty with a similar purpose impactful shared experiences “it was also nice to do whatever they needed just to help them…we saw everyone walking around with the bags that we made. it made a difference to me.” large number of volunteers coming together shared experiences with peers and faculty with a similar purpose impactful shared experiences “i feel like we just had fun…we came together for a common goal, and that was to help other people, and in the process, we learned more about each other.” “it was cool to see everyone else’s [tweets]. we were split up…in different areas, we might not have gotten the whole story. somebody else may have seen the same patient and tweeted about it.” getting to know peers and faculty shared experiences through tweet narratives shared experiences with peers and faculty with a similar purpose shared experiences with peers and faculty with a similar purpose impactful shared experiences impactful shared experiences online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 170 themes from the tweet-format narratives were compared to those from the focus group session and survey responses to identify similarities or differences in recall or expression of the immersion event experiences. to determine reflection, student responses were examined for statements indicative of introspection, empathy, and critical thought about lessons learned (chen et al., 2017; murphy et al., 2018). statements were examined to determine if students were able to convey understanding of patients’ lives and situations after the immersive service-learning experience. results this experiential learning trip exposed students to many new cultural and patient care situations and elicited opportunity for student reflection through journaling. students and faculty also uploaded photos of trip activities like packing bags of toiletries, electric toothbrushes, electric razors, and children’s books to hand out to patients. students learned about the culture and landscape of the region by visiting scenic mountain trails in the area, viewing a local play about the culture of the appalachian residents, and visiting a venue to hear local musicians and to experience local dance. focus group and survey responses focus group and survey responses allowed students an opportunity to elaborate and reflect upon a variety of trip experiences including peer, faculty, and patient interactions, cultural enrichment, attainment of skills, and lessons learned. student elaboration of experiences allowed researchers to further understand student experiences and to refine and modify themes. the research team collaborated to determine six modified themes of improved skills, cultural competence, patient interaction, socioeconomic factors and health, landscape/clinic setting, and impactful shared experiences (table 4). themes online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 171 improved skills students felt that they learned more history-taking and problem-solving skills during the rural immersion experience than they could have in the traditional clinical setting. one student described history taking as being “like research, like digging deeper, investigation.” another student said she “definitely got to learn a lot more and practice with history taking, the backgrounds and stuff.” cultural competence students enjoyed visiting the local venues and becoming familiar with the culture and daily lives of the local residents. one student commented, “i think the areas of va we’ve been to have some of the nicest people…everyone greets you with a smile…i enjoy the vibe that comes from small town places.” another student added, “it is humbling to see how badly these people struggle, yet they are still being positive and complimenting us.” patient interaction through patient interaction, students were able to improve both their assessment and communication skills. the interaction allowed them to see first-hand the underserved populations that exist in local rural communities. when asked about patient interactions, students responded that “almost all of the patients i interacted with today were very pleasant and appreciative of the services offered,” and that “my patient told me she’s been waiting for 2 days just to get her eyes checked on.” socioeconomic factors and health students focus group responses elaborated on tweet-narratives that documented the extreme poverty of the patients and poor physical and mental health outcomes associated with that poverty and lack of access to services. previously, one student had only associated this degree of online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 172 need with international mission trips. the student stated, “this experience truly opened my eyes to the poverty of the area, which i didn’t think about…when i think of medical missions, i think of going out of the country.” landscape/clinic setting some of the students had never travelled out of state and had never seen the appalachian mountains. the trip offered students an opportunity to see this new landscape and to experience a remote clinic setting. after interacting with patients, students stated that they saw the value of having the clinic in a community setting where the patients were more comfortable. one student stated, “it was peaceful…i think it also made patients feel more comfortable…in their own setting, in their own area.” impactful shared experiences students elaborated on the usefulness of the tweet-narratives to enhance faculty and peer interaction and to facilitate sharing of impactful experiences. students repeatedly talked about “making a difference” and “working together” in all response forums. students felt they attained a level of familiarity with both their peers and nursing faculty through the experience. one student responded, “i feel like we just had fun. and like, we came together for a common goal, and that was to help other people, and in the process, we learned more about each other.” the student also stated, “i don’t really associate with anyone in another class. so, it was nice to get to know people who weren’t in my class. and you get to know professors more.” another student added, “it’s all so serious in class. we got to have fun here, so… like [professors are] normal people.” student responses were overwhelmingly positive in nature. students did express feelings about being overwhelmed the first day of the trip when clinic organization and patient flow were not well-established. students enjoyed using the closed-messaging app and tweet-format online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 173 narratives to communicate with each other during the experience. one student explained, “it was cool to read everyone else’s [tweets]. we were split up…like in different areas, we might not have gotten the whole story. somebody else may have seen the same patient and tweeted about it.” another student stated that through reading her peer’s tweets, “it kinda made me feel like i was getting that experience event though i wasn’t there.” discussion this unique service-learning trip served as a valuable cultural enrichment and skills attainment experience for nursing students, and it provided an opportunity for the research faculty team to explore the usefulness of tweet-format narratives to elicit reflection in nursing students using a narrative medicine approach (chen et al., 2017; murphy et al., 2018). students initiated experiential dialog and responded to each other during the trip with short tweet-format narratives that contained both thoughtfulness and reflection. the tweet-format narratives captured student experiences, elicited reflection, and enhanced students’ experiences and interactions with one another and with faculty. the focus group and surveys allowed for elaboration and refinement of six themes that emerged during the tweet-format narratives. students explained the usefulness of tweet-narratives to facilitate shared experiences and reflection about those experiences. while group elaboration of content themes was important for further understanding of the shared experiences, all relevant content associated with the six themes was accounted for in the tweet-format narratives (glasser & strauss, 1999; hesse-biber & leavy, 2011). additionally, those narratives included both experiences and reflective thought that are important components of narrative medicine (charon, 2006; mangino, 2014). online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 174 the research team could not identify any other nursing studies where tweet-format narratives elicited reflection through shared experiences. thus, this finding warrants further investigation and may show promise to build camaraderie and trust among student peers and between students/faculty in other nursing educational, academic, or clinical settings. the research team was active within the closed-messaging group which likely influenced students to maintain content appropriate comments and to provide reflective thoughts. limitations limitations included a small sample size of students who participated in the servicelearning trip and a short trip duration of three days. students had multiple opportunities for patient triage, vital signs, and history taking at the clinic, but were limited in observations with specialty areas (e.g. dermatology, pediatrics, women’s health) because of a large number of nurse practitioner students at the clinic who had priority placement. future investigations of tweetnarrative journaling with larger number of students including graduate level nurse practitioner students may provide other perspectives on the usefulness of tweet-narrative journaling in educational clinical experiences. conclusion participating in service-learning experiences is invaluable for students. the free three-day mobile clinic in appalachia exposed the nursing students to the unique healthcare needs of rural, underserved patients, which they will take into their careers as registered nurses. the nursing students gained confidence in their clinical skills, while interacting with patients from a rural area. it is important for nursing students to reflect on their experiences, both on service-learning immersion trips, and in other nursing school learning activities. with the growth of social media, more nursing students are accustomed to communicating in a short, text-based format. the tweetonline journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 175 format narratives in the free closed text-messaging app allowed students to reflect on their experiences through open-ended comments and to communicate with other members of the group. short text-based narratives can be an effective narrative medicine technique to encourage reflection, to promote group discussions, and to enhance peer support while on service-learning trips to rural areas, and the rural setting can provide a backdrop that encourages self-reflection among students and faculty and honors the stories of patients, providers, and students. references arntfield, s. l., slesar, k., dickson, j., & charon, r. (2013). narrative medicine as a means of training medical students toward residence competencies. patient education and counseling, 91, 280-286. https://doi.org/10.1016/j.pec.2013.01.014 cenci, c. (2016). narrative medicine and the personalisation of treatment for elderly patients. european journal of internal medicine, 32, 22-25. https://doi.org/10.1016/j.ejim. 2016.05.003 charmaz, k. (2014) constructing grounded theory (2nd ed.). sage charon, r. (2006). narrative medicine: honoring the stories of illness. oxford university press. chen, p. j., huang, c. d., & yeh, s. j. (2017). impact of a narrative medicine programme on healthcare providers’ empathy scores over time. bmc medical education, 17(1), 108. https://doi.org/10.1186/s12909-017-0952-x county health rankings and roadmaps. (2020). virginia health outcomes. retrieved from: https://www.countyhealthrankings.org/app/virginia/2020/rankings/wise/county/outcomes/ overall/snapshot online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 176 dressler, j. a., ryder, b. a., connolly, m., blais, m. d., miner, t. j., & harrington, d. t. (2018). “tweet”-format writing is an effective tool for medical student reflection. journal of surgical education, 75(5), 1206-1210. https://doi.org/10.1016/j.jsurg.2018.03.002 dressler, j. a., ryder, b. a., monteiro, k., cheschi, e., connolly, m., miner, t. j., & harrington, d. t. (2019). “tweet”-format reflective writing: a hidden needs assessment? the american journal of surgery, 217(2), 314-317. https://doi.org/10.1016/ j.amjsurg.2018.09.018 fioretti, c., mazzocco, k., riva, s., oliveri, s., masiero, m., & pravettoni, g. (2016). research studies on patients' illness experience using the narrative medicine approach: a systematic review. bmj open, 6(7). e011220. http://dx.doi.org/10.1136/bmjopen-2016-011220 glaser, b.g. & strauss, a.l. (1999). discovery of grounded theory: strategies for qualitative research. routledge health resources services administration [hrsa]. (2020). defining rural populations. retrieved from: https://www.hrsa.gov/rural-health/about-us/definition/index.html health resources services administration [hrsa]. (2018). list of rural counties and designated eligible census tracts in metropolitan counties. retrieved from: https://www.hrsa.gov /sites/default/files/hrsa/ruralhealth/resources/forhpeligibleareas.pdf hesse-biber, s.n. & leavy, p. (2011). the practice of qualitative research. (2nd ed.). sage. liao, j. m., & secemsky, b. j. (2015). the value of narrative medical writing in internal medicine residency. journal of general internal medicine, 30(11), 1707-1710. https://doi.org/10.1007/s11606-015-3460-x online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 177 liao, h. c., & wang, y. h. (2020). storytelling in medical education: narrative medicine as a resource for interdisciplinary collaboration. international journal of environmental research and public health, 17(4), 1135. https://doi:10.3390/ijerph17041135 mangino, h. (2014). narrative medicine's role in graduate nursing curricula: finding and sharing wisdom through story. creative nursing, 20(3),191-193. https://doi:10.1891/10784535.20.3.191 murphy, j. w., franz, b. a., & schlaerth, c. (2018). the role of reflection in narrative medicine. journal of medical education and curricular development, 5, 1-5. retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6055100/pdf/10.1177238212051878530 1.pdf remein, c. d., childs, e., pasco, j. c., trinquart, l., flynn, d. b., wingerter, s. l., bhasin, r.m., demers, l.b. & benjamin, e. j. (2020). content and outcomes of narrative medicine programmes: a systematic review of the literature through 2019. bmj open, 10(1), e031568. http://dx.doi.org/10.1136/bmjopen-2019-031568 small, l. c., feldman, l. s., & oldfield, b. j. (2017). using narrative medicine to build community across the health professions and foster self-care. journal of radiology nursing, 36(4), 224-227. https://doi.org/10.1016/j.jradnu.2017.10.002 tsai, s. l., & ho, m. j. (2012). can narrative medicine training improve osce performance? medical education, 46(11), 1112-1113. https://doi.org/10.1111/medu .12029 u.s. census bureau. (2010). 2010 census urban and rural classification and urban area criteria. retrieved from: https://www.census.gov/programs-surveys/geography/guidance/geoareas/urbanrural/2010urban-rural.html online journal of rural nursing and health care, 20(2) http://doi.org/10.14574/ojrnhc.v20i2.633 178 u.s. census bureau. (2020). quick facts: wise county, virginia. retrieved from: https://www.census.gov/quickfacts/wisecountyvirginia wesley, t., hamer, d., & karam, g. (2018). implementing a narrative medicine curriculum during the internship year: an internal medicine residency program experience. the permanente journal, 22, 17-187. https://doi.org/10.7812/tpp/17-187 yang, n., xiao, h., cao, y., li, s., yan, h., & wang, y. (2018). does narrative medicine education improve nursing students’ empathic abilities and academic achievement? a randomised controlled trial. journal of international medical research, 46(8), 3306-3317. https://doi.org/10.1177/0300060518781476 zaharias, g. (2018). narrative-based medicine and the general practice consultation: narrativebased medicine 2. canadian family physician, 64(4), 286-290. retrieved from: https://www.cfp.ca/content/64/4/286.abstract p37 leipert article 6_6_11 37 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 canadian rural women’s experiences with rural primary health care nurse practitioners beverly d. leipert phd, rn1 jessican wagner delaney rn, mscn, np-phc2 dorothy forbes phd, rn3 cheryl forchuk phd, rn4 1associate professor, arthur labatt family school of nursing, university of western ontario, bleipert@uwo.ca 2primary health care nurse practitioner, forbes park medical center, cambridge, ontario, canada, jdelaney@tworiversfht.ca 3 associate professor, arthur labatt family school of nursing, university of western ontario dorothy.forbes@ualberta.ca 4professor, arthur labatt family school of nursing, university of western ontario cforchuk@uwo.ca key words: rural women, rural primary health care nurse practitioners, rural health abstract background: in canada, one in five women lives in a rural area. these rural women often experience different health challenges than urban women, including lower life expectancy, higher rates of disability and cancer, fewer available health care resources and greater distances to access health care services. nurse practitioners [nps] provide important primary health care [phc] services to rural women. research objective: the purpose of this research study was to explore rural women’s experiences with primary health care nurse practitioners [phcnps]. method and sample: in-depth, face-to-face interviews using interpretive description methodology were conducted with nine rural women, aged 18-80, who used np services in rural southwest ontario, canada. results: the participants in the study particularly appreciated the nursing knowledge of the np, the time the nps spent with them, and the thoroughness of the care provided by nps. these foundational elements of the participants’ experiences with rural nps created a sense of trust and respect, which lead to a collaborative partnership between the np and the rural women. conclusions: results of this study suggest that these rural women were overwhelmingly satisfied with the care provided by nps. in particular, they valued the collaborative partnership with the np. these findings have important implications for rural health care practice, policy, and education. background and significance in canada, one in five women lives in a rural area (health canada, 2002; sutherns, mcphedran & haworth-brockman, 2004). rural women face unique health challenges, such as a lower than average life expectancy, and higher rates of disability, infant mortality, and deaths from cancer and circulatory diseases compared to their urban counterparts (romanow, 2002; sutherns et al.). these health risks are combined with a lack of access to appropriate primary health care [phc] services, as an estimated 5.5% of 38 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 rural dwellers have no access to phc services compared to 4.5% of urban dwellers (statistics canada, 2004). clearly, rural women’s health is an important area for study (leipert, 2005; sutherns et al.). through the provision of high quality accessible care, nurse practitioners [nps] can play an important role in the delivery of phc services to rural women (canadian nurse practitioner initiative [cnpi], 2006; government of ontario, 2006). the canadian nurse practitioner initiative [cnpi] (2006) recommends that “canadians… should have the opportunity to have nps on their health-care teams” (p.12). however, in canada, despite the proven efficacy of nps (way, jones, baskerville, & busing, 2001), the inclusion of the np on the health care team is in its infancy. because the health of rural women is often overlooked, and because rural women are often the key health care providers in their families (leipert, 2005), it is important to understand rural women’s experiences with rural primary health care nurse practitioners [phcnps]. the purpose of this research study was to explore rural women’s experiences with primary health care nurse practitioners [phcnps]. the findings of this research provide important information with regards to how rural nps can best meet the health care needs of rural women, and can help to inform practice decisions and policy development. review of the literature multiple databases were examined, including the cumulative index to nursing and allied health research© (cinahl); proquest nursing journals ®; pub med; psycinfo©; women’s studies international; and google scholar™. search words included “rural areas,” “rural women,” “rural health,” “farm women,” “geographic isolation,” “women’s health,” “primary health care services,” “primary health care nurse practitioners,” and “advanced practice nurses”. inclusion criteria for the literature review were that articles were: 1) published in the english language; 2) published in the last ten years with the exception of classic articles; 3) research based and focused on rural women, phc services, and phcnps; and 4) reflected research conducted in canada and other developed countries (including the united states, australia, and the united kingdom). exclusion criteria included articles that were not written in english and that focused on an urban setting. additional sources of literature included relevant federal and provincial government and nursing organization reports; these aided in grounding the study within the ontario context as np practice in canada is jurisdictional. accordingly, the literature review addresses the following topics: 1) nps and principles of phc; 2) rural women’s phc needs and expectations; and 3) client-np interactions and outcomes. nurse practitioners and principles of primary health care nps have been practicing in phc in canada since mid-1960s (nurse practitioners association of ontario [npao], 2005; patterson, 2001). however, it has only been within the past ten years that their role has begun to be recognized. recently the provincial government of ontario has started an initiative entitled “grow your own np” (government of ontario, 2006). this initiative is targeted at aiding rural and remote communities in the expansion of phc care services, including nps. primary health care is based on five principles (stewart & langille, 1995): 1) accessibility of care, 2) public 39 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 participation, 3) intersectoral and interdisciplinary collaboration, 4) appropriate technology, and 5) increased health promotion and illness prevention services. primary health care nps are registered nurses with extended authority that allows them to communicate diagnoses, prescribe approved drugs, and order and administer approved diagnostic services and therapies. phcnps provide wellness care, diagnose and treat minor illnesses and injuries, and screen and monitor chronic diseases such as diabetes and hypertension (college of nurses of ontario [cno], 2008; npao, 2005). in an evaluation study at four rural phc sites in ontario, way et al. (2001) compared the roles of nps working directly with a family physician with the roles of nps working autonomously in their own practice. they found that nps in both areas were underutilized in curative and rehabilitative care, and the authors suspected this was likely because of insufficient knowledge amongst family physicians regarding nps’ scope of practice. the authors also found that nps provided more care relevant to disease prevention and support systems than did physicians. reay, patterson, halma and steed (2006) conducted a research study in taber, alberta, to evaluate the integration of nps into rural phc. using a grounded theory methodology, these authors specifically examined the role of nps and explored the meaning of integrating nps to rural physicians in eight family practice clinics. the researchers found that clinic physicians “believed that patients received better health care services because of the np” (reay et al., 2006, p. 103). reasons for this conclusion included: 1) physicians were able to take on a larger client load while working the same number of hours; 2) emergency room visits were decreased due to the educational support provided by the np with clients; and 3) the np initiated a women’s health clinic and asthma services which had great success (measured by the number of clients requesting to see the np). finally, physicians also viewed the role of the np positively due to the overwhelmingly high client satisfaction with the np. in summary, nps can meet the phc care needs of clients including rural women, provided that physicians, patients, and other health care providers are knowledgeable regarding the nature and scope of np practice. rural women’s primary health care needs and expectations the first national study of rural, remote and northern women’s health (sutherns et al., 2004) found that rural women across canada frequently did not have access to primary health care, that they required more diverse health care practitioners, that they often preferred female health care providers, and that rural women often perceived that male physicians lack understanding of rural women’s health care needs and expectations. similarly, in a literature review regarding rural women’s health and implications for policy and research, leipert (2005) found that “women often feel more comfortable addressing sensitive topics with other women and they perceive that female care providers afford more respect, time and care to the women” (p. 111). in a descriptive research study examining nps in ontario, sidani, irvine and dicenso (2000) concluded that 95% of nps in ontario are female, which suggests that the majority of nps in ontario meet rural women’s preferences for care provided by females. paluck, allerdings, kealy and dorgan (2006), in a qualitative study using eight focus groups with 44 women in rural saskatchewan, explored the health promotion needs of rural women. these authors found that rural women’s health promotion needs vary across the lifespan; for instance, younger women have health needs in regards to 40 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 childbearing, whereas older women have health needs in regards to managing chronic health conditions. such findings support the argument that rural women need health care services that are flexible to meet their health care needs. leipert and george (2008) in their study of the determinants of rural women’s health in ontario discovered that rural women require voice, power, and participation in health care and in their communities to advance and support their health. phcnps have the means to meet these varying health care needs by practicing in collaboration with rural women and other rural health care providers, and by having the expertise to meet the holistic health care needs of rural women of all ages (cno, 2008; npao, 2006). additionally, nps have the ability to work in collaboration with the community, help communities mobilize necessary resources, and develop community programs and specialty clinics to meet specific health care needs (cno; npao). in summary, nps as nurses who are predominantly female (sidani et al., 2000) have the ability to meet the health care needs and preferences of rural women. in addition, nps practice within the five principles of phc (cno, 2008; stewart & langille, 1995), the basis of canada’s health care system, and thus can help empower rural women by using a holistic and inclusive approach to primary health care (npao, 2006). client-nurse practitioners interactions and outcomes few researchers in canada have examined client satisfaction and other outcomes with phcnps. however, the ibm business consulting services and mcmaster university (2005) conducted a study examining the integration of phcnps in the ontario health care system as well as patients’ experiences with nps. a total of 260 individuals (73% of whom were women) completed the written survey. overall it was concluded that participants were satisfied with the care provided by the np; this was attributed to the time and the quality of the care the np provided. this finding is supported by roblin, becker, adams, howard and roberts (2004) who conducted a retrospective study related to np practice in metropolitan atlanta, georgia, using a client satisfaction survey. the survey was administered to a random sample of clients of both sexes within two weeks of their phc visit and examined clients’ satisfaction with nps and physicians. the authors concluded that patients were more satisfied with the care provided by nps than with care provided by physicians. this was attributed mainly to the fact that clients could arrange to see the np sooner and the appointment time with the np was longer, which resulted in increased satisfaction of clients. horrocks, anderson and salisbury (2002) conducted a systematic review of the literature to determine whether nps in phc in the united kingdom could provide care comparable to that of physicians. they concluded that clients were more satisfied with the care provided by nps and overall health outcomes were similar. nps communicated in a way that clients found to be empowering and comforting, they tended to be very thorough in their assessments, and they spent time discussing health care concerns with clients, giving them more information than physicians. moreover, these authors suggested that increasing the number of nps in phc would likely increase patient satisfaction and lead to a higher standard of health care. a randomized controlled trial conducted in england comparing cost effectiveness of general practitioners and nps in phc (venning, durie, roland, roberts & lesse, 2000) similarly concluded that clients were more satisfied with the care provided by nps even when the length of appointment 41 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 time was controlled; clients attributed this satisfaction to the amount of information provided by the np. in a study in new england, johnson (1993) used an ethnographic methodology including individual interviews with three nps in a phc setting to examine interactions between nps and female clients to determine factors that contribute to a high level of patient satisfaction. johnson found that nps engaged clients in a meaningful discussion, an essential first step to establish rapport that facilitates subsequent assessment and intervention. nps asked patients open-ended questions, acknowledged their concerns, developed a partnership, and established a holistic plan of care; these approaches facilitated women’s comfort level and trust in their health care provider. in brief, although these studies were all conducted in phc settings, they were not all grounded in rural areas or canadian settings; therefore, the findings may not be transferable to rural areas in canada. this speaks to the urgent need to examine rural women’s experiences with phcnps in canada as the canadian literature on this topic is limited. purpose of the study and research question the purpose of this study was to explore rural women’s experiences with rural phcnps. accordingly, this study sought to address the following research question: what are the experiences of rural women with rural phcnps in southwest ontario, canada? methodology and methods study context this study focused on one rural phc setting located in a small town of 2000 residents in southwestern, ontario, where two rural phcnps work in an autonomous practice and consulted with a local physician as needed. one np was prepared at a baccalaureate level and the other at a masters level; both nurses held extended registration to provide np services. the np office was located in an old building with less than ideal circumstances, for example, very small examining rooms, no air conditioning in summer, and minimal heat in winter. the nps were on salary and offered phc services to the surrounding communities. with some of the most fertile soil in canada, this rural area has abundant agricultural activity. research design researchers use qualitative research methods “when little is known about a topic, [and] when the research context is poorly understood” (morse, 2003, p. 833). thus, qualitative methods are appropriate for research that explores rural women’s experiences with phcnps. the research design of this study used a feminist lens with an interpretive description research methodology (reinharz, 1992; thorne, reimer kirkham & o’flynnmagee, 2004; thorne & varcoe, 1998). interpretive description is “designed to create ways of understanding clinical phenomena that yield application implications” (thorne et al., 2004, p. 1) by capturing themes and patterns within participants’ subjective experiences to inform clinical understanding (thorne, reimer kirkham & macdonald42 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 emes, 1997; thorne et al., 2004). interpretive description lends itself well to experiencebased questions relevant to rural women’s health and the practice-based discipline of nps. the underlying principle of feminism is the belief that all individuals, regardless of class, race and culture, deserve equal value, respect, opportunity and access to community resources (reinharz, 1992; thorne & varcoe, 1998). the overarching goal of feminist inquiry “is to see the world from the vantage point of a particular group of women” (campbell & bunting, 1991, p. 6), in this study, rural women. sample and sampling strategy purposeful sampling (selecting informative participants) was used in this research to gain an in-depth understanding of individual experiences (polit & beck, 2004). inclusion criteria were that women: 1) resided in a rural area in southwestern ontario; 2) were 18 years of age or older, with a minimum of one woman per decade of age; 3) experienced care by a rural np for at least two visits; 4) were able to read and speak english; and 5) were willing and able to articulate their experiences with a rural phcnp. to recruit rural women, posters and letters of information about the study were made available at the nps’ office. recruitment documents invited potential participants to contact the researcher for more information and/or to volunteer for the study. interpretive description research is consistent with smaller scale qualitative research that may include a sample size of 8-10 participants (thorne et al., 2004). sample size was also determined by data saturation, the “point at which no new information is obtained and redundancy is achieved” (polit & beck, 2004, p. 308). data saturation was achieved after interviewing nine participants. data saturation may have been achieved with this size of sample because all study participants came from similar rural backgrounds and they were all patients of the same two phcnps. data collection prior to conducting the study, ethical approval was received from the university of western ontario ethics review board for human subjects, protocol number 12666e. in-depth face-to-face interviews using a semi-structured interview guide were conducted in participants’ homes. in-depth interviews are consistent with a feminist lens and an interpretive description design because they allow participants to openly discuss issues that are important to them (campbell & bunting, 1991; thorne et al., 2004). topics discussed during the interview included: (a) rural women’s overall experiences of phc; (b) rural women’s experiences with their rural np; and (c) rural women’s perspectives of how living in a rural area affected their phc experience. interviews were 1 to 1.75 hours in length and were audio-recorded. throughout data collection, field notes of observations encountered during the interviews, and a reflexive journal which captured the researcher’s perspectives after each interview were completed (morse & field, 1995). data analysis data analysis was guided by the interpretive description research design and used an inductive approach to construct meaning from participants’ experiences (thorne et al., 2004). in interpretive description research, “the researcher constantly explores such questions as: why is this? why not something else? and what does this mean?” (thorne et al., 2004, p. 11). 43 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 data analysis occurred concurrently with data collection; this strategy helped the researchers to make meaning of the interviews and to identify areas for further exploration in subsequent interviews (aryes, kavanaugh & knafl, 2003; thorne et al., 2004). to ensure accuracy and completeness, each interview was transcribed verbatim and the transcript was compared to its audio-recording. in addition, the nine transcripts were reviewed several times to uncover implicit meanings as well as commonalities and variations (aryes et al.; thorne et al., 2004). as common themes emerged, data were recontextualized into smaller meaningful data sets. to assist in data management and coding, nvivo (qsr international, 2006), a qualitative data management computer software program, was used. findings a total of nine caucasian women ranging in age from 18-80 participated in this research study. the employment status of seven women was retired or working part-time, one participant worked full-time and another participant was a full-time university student. study participants reported having a np as their consistent phc provider for diverse periods of time, from two months to four years, and they drove between five and 30 minutes to reach the practitioner’s office. frequency of visits varied between once weekly to twice yearly. the women reported seeking np services for annual physical examinations, management of chronic diseases such as diabetes and hypertension, family planning, and acute episodic illnesses such as earache or sore throat. the women who participated in this research study were all eager to share their personal experiences with their rural phcnp. access study participants spoke about challenges in accessing phc services in their rural communities, such as difficulty in accessing physicians, having to wait up to one-and-ahalf months to get an appointment, and driving up to one-and-a-half hours to obtain services. one elderly woman underscored the extent of access challenges when she noted that she “would be dead and buried before being able to get an appointment [with her prior physician]”. moreover, when participants did manage to get an appointment with their previous physician, they often spoke of how they “felt rushed and didn’t have time to ask questions”; and that “you could only…[address] one thing [per appointment]”. participants discussed many disempowering experiences with physicians and quite frequently throughout the interviews would compare the care received from the np with that of their prior physician. these comparisons seemed to aid the women in articulating their experiences. all participants reported learning about nps through word of mouth as nps provided phc services to women in the local and surrounding communities. the majority of the participants reported having little knowledge of what a np’s role was prior to seeking out services: “no, i hadn’t heard of them [nps] prior [to first seeing one]…so i went in with an open mind…more or less just thinking…i haven’t lost anything, i haven’t gained anything”. the women reported that they requested that their medical records (from their prior physician) be transferred to the np as this provided their medical history and facilitated the transition between phc providers. the study 44 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 informants reported being very satisfied with the care provided by the nps and offered suggestions about how to improve rural women’s knowledge about and access to nps. the findings that emerged from the data can be conceptualized as a triangle (see figure 1). the foundational findings (the base of the triangle) were the nursing knowledge of the np, the time the nps spent with the participants, and the thoroughness of the care provided by nps. these foundational elements of the participants’ experiences with rural nps created a sense of trust and respect, which lead to a collaborative partnership between the np and the rural woman. additional findings that emerged from the data related to barriers and facilitators to rural women’s experience of nps’ practice. nursing knowledge the study participants felt comfortable knowing that the np was a registered nurse with additional educational training. a positive view of nursing facilitated a positive perspective of nps; participants felt that the nursing background contributed to the care that the np provided. a participant commented that: nurses spend more time with the hands on care…in my experience they tend to be more nurturing and more caring…the doctor might come in and say ‘we are going to do this and this’ and then he hands you off to the nurse…i have always found that nurses have given me comfort, they’ve spent the time and they’ve stayed with me. there’s just such a comfort in nursing. study participants also reported that the np explained things in understandable language and sought additional resources when needed. a participant stated, “[the np will] look in books and get on the internet and check-up…the latest thing. they [the nps] keep themselves up to date...i never saw any of my doctors look things up”. in essence, the up-to-date knowledge base of the nps and the women’s ability to understand and assess nps knowledge allowed the women to entrust them with their care. time all participants spoke passionately about the quantity and quality of time that the np spent with them; this made them feel as though they and their health were valued. as one participant described it: she took the time to listen to my concerns, answer my millions of questions…she didn’t rush the appointment, my appointment took longer then it should have…but she gave me that time and attention that i felt i needed…it made me feel good, it made me feel comfortable, safe, and like she had my best interest at heart. it wasn’t about the paycheck, it was about me. several participants commented on how this time provided them with comfort and the ability to discuss all health concerns, as one participated stated: “i feel more comfortable…[as the nps] have the time to spend with you and go through all your 45 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 figure 1. rural women’s experiences with rural nurse practitioners worries”. compared to their experiences with physicians, the increased amount of time spent with the nps afforded participants more time to develop a collaborative partnership with the np, founded on trust and respect. thoroughness several participants discussed the thoroughness of care provided, frequently comparing the care they received from the np to that of their former physician. one woman illustrated this comparison (while also speaking to the nursing knowledge of a np) as follows: the np is a lot more thorough, being a nurse and probably having more experience to ask a lot of questions to see and understand what is going on…and get to the root of the issue. whereas doctors, sometimes they don’t even listen to everything you have to say and once they have made their assessment, they are gone. when the participants discussed the thoroughness of nps, they appeared to be amazed to be receiving this quality of health care and often equated it to the care an ‘old fashioned doctor’ would provide. as one woman aptly put it, “she [the np] even makes house calls…i was amazed ’cause you really don’t get that except back in the horse and 46 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 buggy days”. participants felt that they could go to the np with any health concerns knowing that “…she makes sure that anything i’ve brought to her attention is investigated completelyany kind of test, referral…[and] she has always been prompt”. several participants also spoke of never having had such a thorough annual health exam prior to seeing the np. one woman stated that the np “map[ped] out all of [her] moles…and check[ed] everything”. the thoroughness of the examinations created a sense of reassurance for the women. by valuing their health concerns and making them feel as though their health was important, nps facilitated a sense of trust and respect. trust and respect these three aforementioned aspects of rural women’s experience with np care (nursing knowledge, time, and thoroughness) created a sense of trust and respect with the participants. informants discussed the non-judgmental attitude of the nps, described by one participant as: “they [the nps] wouldn’t bat an eye” to any clients’ health care needs. for example, a participant spoke of her need to lose weight and how the np respected her efforts by “provid[ing] her with information…to incorporate a healthy, lifestyle…and not [passing] judg[ment]”. this attribute of being non-judgmental helped to create a sense of trust and respect for rural women. many participants reported having the ability to talk directly to the np when needed. as one woman stated, “i could call her right now…and if…[the np] isn’t available immediately she will call me back”. another informant remarked, “i could see the np on the street and say ‘did you get my blood work back?’ and she’d say ‘oh yeah i will give you a call tomorrow’”. behaviours such as these created a sense of security amongst the participants, further reinforcing how their health was valued by the np. one participant eloquently captured this vital trust and security, “…i have no problems trusting…[the np] with my care, with my life, with my child’s life, and trusting her to keep everything confidential”. overall, the trust and respect that rural women felt with the np, founded on the basis of nursing knowledge, time and thoroughness, in turn, fostered a collaborative partnership. collaborative partnership collaborative partnership was seen as the overall outcome of the participants’ experiences with rural nps. a collaborative partnership led to a sense of individualized personal care which was seen as important as this allowed the women to feel that they were valued. a participant explained, “the np focuses on me…when i go in, she looks at me, and she studies me. doctors come in…a lot of them don’t even look into my eyes...they’re so busy mumbling at a chart…and then they walk away”. the participants valued this collaborative partnership and personal relationship, as this participant remarked: it is kind of like she [the np] is your mom or your friend and you can just go in and talk to her and she tells you all this information. rather than going to the doctor, she is there…to help and he [the doctor] is there to cure you and move you out. 47 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 another woman suggested that the np “can provide…a hundred percent or a hundred and ten percent personal care”; this totality of care and the way it was provided resulted in participants feeling secure, valued, and included in a collaborative relationship with the np. the respect that nps showed to participants laid the foundation for mutually exploring solutions to a health problem: “i find [the np] gives you a lot of respect, she listens to what i have to say…she asks me questions whether or not i agree with her, so we work together to find a solution”. the feeling of respect the participants felt with the np facilitated the development of a comfort zone so the women could become actively involved in their health care. barriers to the nurse practitioners’ practice participants described barriers surrounding nps practice in rural areas, namely unreliable remuneration, lack of np recognition, and citizen lack of knowledge regarding nps. regarding unreliable remuneration, a participant explained: there was a town council meeting, and they were gonna get rid of one of the nps because of the funding…and i thought, ‘oh my god! please don’t!’ so they decided to try it for another year, so if that funding isn’t there again this year…we’re going to lose a np …then we’re no further ahead than what we were two years ago. this situation demonstrates the need for secure, sufficient, and sustainable funding for nps. participants provided several examples of the limited or lack of recognition afforded to nps. in one instance, the np could not be a signatory to a form required by a woman “to get orthotics…[the insurance form] had to be signed by a doctor…i called the lady at the medical place…she says ‘…you can’t get reimbursement unless a doctor signs [the form]’”. to overcome this barrier, insurance companies and other agencies need to revise their policies to acknowledge nps as phc providers and as legitimate signatories on insurance and other forms. several participants spoke about going to the hospital for diagnostic tests and needing to give a name of a physician instead of the name of their np. they also talked about the repercussions of having to put a physician’s name rather than the np’s name on reports; this policy resulted in the report being sent to a physician who was not involved in their care, rather than to the referring np, and lead to the np having to dedicate precious time to tracking down reports. this is especially problematic for nps who do not have access to the support of administrative personnel. limited or lack of knowledge about nps and their roles was remarked upon by the majority of the participants in this study. recommendations for ways to promote the role of the np in rural areas included presentations at schools, churches, and community groups, and increased use of television, radio, local newspapers, and other media. without exception, all of the women in this study felt that there should be increased knowledge of and access to nps in rural areas. the comment by this participant echoes the perceptions of many in this study: i think everywhere should have them [nps], i think they should be part of the medical system…they should be available just like doctors. i have 48 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 never heard of them before. i didn’t even know what a np was [prior to seeing one]. if i was educated [in regards to] nps i would have been to one ages ago. overall, the participants in this study saw the role of nps as a necessity in every rural community as they identified nps as being critical to their health. the np provided appropriate and respectful access to phc services. furthermore, participants stressed, “nps make it more accessible to get…good healthcare”. facilitators to the nurse practitioners’ practice the main facilitators to nps’ practice that the rural women discussed related to the nps’ ways of practicing, the way that nps are financially remunerated, the gender of the np, and the nursing background of the np. regarding ways of practicing, participants noted that nps in rural areas were taking on new clients and having flexible appointment times. these actions facilitate access to phc services in under-served rural areas. access and quality of care were also enhanced, participants perceived, by the way that nps were remunerated, as this participant noted: …doctors are paid by ohip [ontario hospital insurance plan] per patient…[the np] is on a salary…so she doesn’t get any more money by staying with me for twenty minutes than she would by staying with me for five minutes…where a doctor…they slot people in every fifteen-twenty minutes and the doctor just goes, boom-boom-boom, and tries to see as many [clients] as he can in a shorter period of time. in essence, informants felt that the salary structure of the np supported the time that the np spent with each client, which facilitated access, trust and respect, collaborative partnerships, and quality care. this research supports the findings of others (leipert, 2005: sutherns et al., 2004) that reveal that rural women often prefer female health care providers. participants commented that “…a female is more thorough and she has time to…talk to you…where doctors [males] are too clinical-like”, and “ tend to look down on females ”. participants also felt that a female health care provider is “more in tune with what the female body is doing”. therefore, the participants in this study perceived that the female gender of the nps was a facilitator in their practices and in rural areas, where few female health care practitioners are available. all participants were aware and took comfort knowing that a np was an experienced registered nurse prior to becoming a np. when asked about the importance of nps having a nursing background, a participant commented, “…i definitely think [it is important], most nurses are very caring…we have had a very positive experience”. this relates to the nursing approach and knowledge of nps which facilitate a sense of trust and respect leading to the ultimate collaborative partnership. discussion this study highlighted several key insights regarding rural women’s experience with phcnps. although the majority of participants had no prior knowledge of nps 49 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 before seeking their services, all participants claimed an overwhelming sense of satisfaction with the care provided by the rural np. the foundational findings that emerged from this study were the nursing knowledge of the np, the time the nps spent with the participants, and the thoroughness of the care provided by nps. these foundational elements of the participants’ experiences with rural nps created a sense of trust and respect, which lead to a collaborative partnership between the np and the rural women. study participants remarked extensively on the satisfaction they felt with the comprehensive, collaborative, and quality care provided by the np. this finding supports the findings of others (bigbee, gehrke, & otterness, 2009; leipert , 1999; macleod, kulig, stewart, pitblado, & knock, 2004) that reveal the complex, skilled, and vital care that nurses who practice in rural settings provide. this study also elaborates on the care provided to women in rural settings by rural nps, and draws attention to the need to sustain and further promote the role of nps in rural areas. the np role is still emerging within the ontario, and indeed, the canadian health care system. findings of this research importantly illuminate rural woman’s expectations regarding rural np practice, which in turn provide insight to nps, public health nurses, physicians, and others regarding the nature and expectations of their practices to meet the needs of rural women. in particular, the nursing knowledge, time spent with clients, and thoroughness of assessments which created a sense of trust and respect that lead to collaborative partnerships are noteworthy specifications of the nature of valued health care practice for rural women. thus, this exploratory study provides important new information for effective rural women’s health care and for future research that further elaborates on the nature and value of np practice in rural canadian jurisdictions. participants discussed barriers within the health care system that hindered rural nps, for instance, lack of sustainable remuneration, lack of recognition, and lack of awareness of nps. it is important that these barriers are addressed to ensure that the role of the np becomes pivotal within ontario and canadian health care initiatives. recently, ibm and mcmaster university (2005) and the cnpi (2006) recommended continued support for the inclusion of nps in the canadian health care system; these recommendations are supported by findings in this study. ibm and mcmaster university (2005) and the cnpi (2006) recommended: (a) a common definition of a np be adopted across canada to eliminate misunderstandings of the np’s role. this is supported by the findings of this study as several participants reported little or no prior knowledge of the roles of the np before consulting one; (b) secure and standardized long-term funding. participants discussed issues surrounding lack of secure funding and feared the loss of a np with every funding renewal; (c) consistency and standardization within all np educational programs across canada. rural women in this study were unclear as to the educational background of the np, thus if np education was standardized the public would have a better understanding of the qualifications of nps; and 4) the importance of interprofessional collaboration with the medical profession. although several participants in this study spoke of how the np and the physician seemed to work collaboratively, some participants noted problems in these relationships. recent developments in the ontario health care system, such as the creation of family health teams (fhts), community health centers, and np led clinics (chcs) (ontario ministry of health and 50 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 long-term care [omohltc], 2002, 2006), may help to facilitate an interprofessional collaborative approach to providing health care. this study further highlights the need for the public to be informed about the role of nps, especially as the role of nps is further integrated within the ontario health care system through fhts, chcs, and np led clinics (omohltc, 2002; 2006), and as participants in this study noted having little or no prior knowledge of a np prior to seeking their services. the rural women in this study offered important strategies on how the role of a np could be promoted in rural areas. these are important considerations to inform the public of the value of nps in rural areas. participants also spoke of the lack of recognition of nps; this could be improved by high profile media campaigns that highlight the important work of rural nps, and by advocating for hospital, referral, and other policies that recognize nps as equal members of the interprofessional health care team. the many enhancements to care that salaried, rather than fee for service, remuneration supports, as described by the participants in this study and other research (canadian health services research foundation [chsrf], 2001) suggest that other health care providers, such as physicians, would benefit from this type of compensation. facilitators to rural np practice related to rural women’s ability to access a np. this is an important finding as rural dwellers generally have limited access to primary health care and nursing services (leipert, 1999; statistics canada, 2004). the rural women in this study reported being more comfortable with a female health care provider, a finding that further supports previous research (leipert, 2005; sutherns et al., 2004), and they thought being an experienced nurse first was an asset. in summary, rural women in this study confirmed and elaborated on the importance of and the need for more nps in rural settings. limitations this study included one research site. these nps were not affiliated with a fht or a chc and there may be some uniqueness to this practice setting. therefore, future research should examine rural women’s experiences with rural nps in other practice settings such as fhts and chcs, as well as in np led clinics. in addition, this study focused on the client’s experience; further research should address the rural np experience for their elaboration regarding rural np practice with rural women. it would also be instructive to conduct a similar study in other rural areas that are more remote, and to determine rural women’s health needs from various cultural perspectives, such as with amish, mennonite, hutterite, and aboriginal women. in addition, although participants were probed for negative np experiences, it is possible that they were reluctant to disclose this information as the researcher was a nurse. finally, the participants’ choice to see the np may have positively influenced their np experience. due to the nature of this small exploratory study, findings are not generalizable, although they do provide important considerations for other rural settings. conclusion this study, which explored canadian rural women’s experiences with rural nurse practitioners, revealed that study participants were overwhelmingly satisfied with the care 51 online journal of rural nursing and health care, vol. 11, no. 1, spring 2011 provided by rural phcnps. in particular, they valued the nursing knowledge of the np, the time the nps spent with them, and the thoroughness of the care provided by nps. these foundational elements of the participants’ experiences with rural nps created a sense of trust and respect, which lead to a collaborative partnership between the np and the rural woman. this study, which used an interpretive description methodology to “make sense of something that clinicians ought to understand” (thorne et al., 2004, p. 8), thus, gained insights that are important for nps, nurses, and other rural health care providers to inform their clinical practice. as nps are set to play a pivotal role within the ontario and health care system (omohltc, 2002; 2006), this research provides important information for future health care practice and policy, np education, and rural research. nurse practitioners need to play key roles in determining rural health care policy and practice in the evolving canadian health care system, rural health care issues and expectations need to figure prominently in np education, especially as rural settings are often where nps practice, and further research regarding the collaborative place of np practice with other rural health care providers, such as public health nurses and physicians, should be conducted. references ayres, l., kavanaugh, k., & knafl, k. a. 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(2002). rural and remote communities: in r. romanow, building on values: the future of health care in canada: final report. ottawa: commission of the future of health care in canada. sidani, s., irvine, d., & dicenso, a. (2000). implementation of the primary health care nurse practitioner role in ontario. canadian journal of nursing leadership, 13(3), 13-19. [medline] statistics canada. (2004). canadian community health survey. retrieved august 1, 2006, from http://www.statscan.ca/daily?english?040615?d040615b.htm stewart, m. j., & langille, l. l. (1995). primary health care principles: core of community health nursing. in m. j. stewart (ed.), community nursing: promoting canadians’ health (pp. 62-88). toronto: w. b saunders canada. sutherns, r., mcphedran, m., & haworth-brockman, m. (2004). rural, remote and northern women’s health policy and research directions. winnipeg: prairie centre of excellence for women’s health. thorne, s., reimer kirkham, s., & macdonald-emes, j. (1997). focus on qualitative methods interpretive description: a noncategorical qualitative alternative for developing nursing knowledge. research in nursing and health, 20, 168-177. thorne, s., reimer kirkham, s., & o’flynn-magee, k. (2004). the analytic challenge in interpretive description. international journal of qualitative methods, 3(1), 1-21. thorne, s., & varcoe, c. (1998). the tyranny of feminist methodology in women’s health research. health care for women international, 19, 481-493. [medline] venning, p., durie, a., roland, m., roberts, c., & leese, b. (2000). randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. british medical journal, 320, 1048-2053. [medline] way, d., jones, l., baskerville, b., & busing, n. (2001). primary health care services provided by nurse practitioner and family physicians in a shared practice. canadian medical association journal, 165(9), 1210-1214. http://www.ncbi.nlm.nih.gov/pubmed/15495390 http://www.ncbi.nlm.nih.gov/pubmed/9849194 http://www.ncbi.nlm.nih.gov/pubmed/10764367 "members of the editorial review board of the perspectives in health information management have reviewed your manuscript enti 6 editorial framing cardiovascular health for rural populations: community, innovation, evidence-based practice, and technology barbara ann graves, phd, rn editorial board member cardiovascular disease (cvd) is the leading cause of death in the united states. more than twice as many deaths occur due to cardiovascular disease as for all types of cancers combined. nationally, every year approximately 16 million cases of coronary heart disease are reported (ahrq, 2005). in 2005 the total cost for all forms of cvd was an astounding $448.5 billion. furthermore, cvd is associated with many forms of chronic illness which add to the cost and decrease quality of life (ahrq, 2005). for these reason cvd has received much attention in health research and health policy arenas (krumholz et al., 2009; peterson et al., 2007; yusuf, reddy, & anand, 2002). findings from studies indicate an overall reduction of heart disease risk and mortality in the past three decades (aha, 2005). while the amount of research noted throughout the literature is overwhelming and heart disease mortality has fallen, heart disease continues to be the single largest killer of men and women in the united states with continuing evidence of variations and disparities that are yet unexplained. prevention and treatment of heart disease is currently a major health priority. the agency for health care quality, the center for disease control and prevention, and the united states department of health and human services have identified major strategies in the prevention, risk reduction, and treatment of heart disease. many large national and international health initiatives have been conducted for the purpose of the advancement of these strategies (cdc, 2009; peterson et al., 2007; ahrq, 2005; rickets, 1999). access to quality, evidence-based health care continues to vary across populations. the literature documents inherent variation in cardiovascular health care access as well as adverse cardiovascular outcomes associated with different geographical regions and urbanization levels (eberhardt et al., 2001; ricketts, 1999; ahrq, 2005). disparities in health care access add to vulnerability and increased risk of heart disease in rural populations as well as excess patterns of cardiovascular mortality and morbidity. health care policy and market changes have adversely affected health care in rural america. the rural health environment has felt the impact of hospital closures, loss of community health services, rising cost, and changes in health care delivery and reimbursement systems. as rural communities confront these changes they must also continue to navigate ongoing problems associated with higher poverty rates, a more dispersed, elderly population, fewer doctors, and less access to transportation sources (ahrq, 2008). to meet these challenges new approaches to cardiovascular health care for rural communities are needed. the recipe for moving toward cardiovascular health in rural, underserved areas will need to include a focus on innovation and outcomes using evidence-based practice and technology in the spirit of community. through community empowerment rural populations can solve their own unique cardiovascular health issues through a spirit of inquiry, using creative community partnering and quality health care provided by practitioners who use online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 7 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 the best evidence to guide decisions in practice. therefore, decreasing cardiovascular mortality and morbidity and improving cardiovascular health will need to be framed within the context of community, innovation, evidence-based practice, and technology. references agency for health care research and quality (ahrq) (2005). health care disparities in rural areas: selected findings from the 2004 national health care disparities report. retrieved on november 10, 2009, from http://ahrq.gov/research/rural.htm agency for health care research and quality (ahrq) (2008, april). national health care disparities report. national center for health statistics. retrieved on may 11, 2009, from http://www.ahrq.gov/qual/ardr08.htm center for disease control and prevention (cdc) (2009). national center for health statistics. retrieved on oct. 1, 2009, from http://www.cdc.gov/nchs/data/series.htm eberhardt, m.s., ingram, d.d., makus, d.m., et al. (2001). urban and rural health chartbook. health, united states, 2001. hyattsville, md: national center for health statistics. krumholz, h.m., merrill, a.r., schone, e.m., schreiner, g.c., chen, j., bradley, e.h., et al. (2009). patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. circulation: cardiovascular quality outcomes, 2, 407-413. peterson, e.d., shah, b.r., parsons, l., pollack, c.v., french, w.j., canto, j.g., et al. for the nrmi investigators (2008). trends in quality of care for patients with acute myocardial infarction in the national registry of myocardial infarction from 1990-2006. american heart journal, 156, 1045-1055. [medline] ricketts, t.c. (1999). rural health in the united states. new york: oxford university press. yusuf, s., reddy, s., ounpuu, s., & anand, s. (2002). global burden of cardiovascular diseases. circulation, 104, 2855. [medline] http://ahrq.gov/research/rural.htm http://www.ahrq.gov/qual/ardr08.htm http://www.cdc.gov/nchs/data/series.htm http://www.ncbi.nlm.nih.gov/pubmed?term=1045%5bpage%5d+and+2008%5bpdat%5d+and+peterson+e%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed/11733407?itool=entrezsystem2.pentrez.pubmed.pubmed_resultspanel.pubmed_rvdocsum&ordinalpos=1 the prime directive: editorial for online journal of rural nursing fall 2009 2   online journal of rural nursing and health care, vol. 9, no.2, fall 2009 editorial the prime directive angela collins, rn, dsn, aprn-bc, ccns editorial board member skilled communication is one of the most elusive competencies to master. however, when the focus is patient safety, it is the prime directive for organizational excellence. the two documents that have been personally highly applicable in this author’s clinical practice are the research reports called silence kills (maxfield et al., 2004) and dialogue heals (maxfield et al., 2008). the full reports are available as a pdf download at www.silencekills.com if an email address is registered. these reports focus on seven categories of conversations that are both challenging and perceived by most healthcare professionals as “risky”. these categories represent the problems in communication that lead to poor patient outcomes (maxfield, et.al. 2004). • broken rules • mistakes • lack of support • incompetence • poor teamwork • disrespect • micromanagement maxfield et al., (2004) call the inability to communicate in these circumstances as a choice not to have a crucial confrontation. addressing these problems in rural healthcare environments can present with an additional level of complexity, due to the financial interconnectivity of only a small group of providers. confrontations in communication are paradoxical. handled correctly there can be insights gained, relationships enriched, and problems solved. incorrectly handled confrontations can lead to decrease productivity and job disengagement. the recommendations set forth in the report dialogue heals and the companion book crucial confrontations are to reflect on the essence of the problem, make it safe for the conversation to occur, and to consider scripting the intervention. this author uses the lens of these resources at a starting point for reflection. the suggestions are interventions to improve communication competency based on evidence. recommended interventions include practice, choosing the best timing for a confrontation, words to use, and safe persons with whom to rehearse a confrontation. what is the issue that needs your deliberate decision to make rural healthcare safer for your community of concern? use these resources to take that decision to communicate about an issue to a higher probability of success.   3   online journal of rural nursing and health care, vol. 9, no.2, fall 2009   references maxfield, grenny, mcmillan, patterson, & switzler. (2004). silence kills. retrieved on november 9, 2009, from http://www.silencekills.com/ maxfield, grenny, mcmillan, patterson, & switzler. (2008). dialogue heals. retrieved on november 9, 2009, from http://www.silencekills.com/ http://www.silencekills.com/ http://www.silencekills.com/ microsoft word bushy_column 6    online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 editorial american nurses credentialing center (ancc) pathway to excellence™ program: addressing meeting the needs of small and rural angeline bushy, phd, rn, faan editorial board member recently while attending the national rural health association 32nd annual conference held in miami florida (may 5-8, 2009) i became aware of an important quality initiative offered by the american nurses credentialing center at the organization’s exhibit: http://www.ruralhealthweb.org/.  the program was developed by texas nurses association to address the concerns of rural nurses; but, recently was purchased by the ancc. in 2003, the texas nurses association (tna) began work to positively affect nurse retention by improving the workplace for nurses and established the nursefriendly™ designation of texas nurses association: http://nfp.etxahec.org/. well known name among rural nurses, mary wainwright, msn at the east texas area health education center (etahec) played a leading role in developing, implementing and disseminating information about this texas initiative: http://www.easttexasahec.org/. the nurse friendly program™ was partially funded with a five-year grant from the u.s. health resources and services administration (hrsa). the goal of this program was to improve both the quality of patient care and professional satisfaction of nurses working in rural and small hospitals in texas. the first nurse-friendly™ hospitals were designated in may 2005. from its inception tna received many inquiries from other states about expansion of nurse-friendly hospital designation. tna sought to transfer the program to a robust, collegial organization that could build on the program’s success, while assuring the program’s integrity as it was made available to facilities nationwide. subsequently, from ancc’s perspective, the high quality and superb reputation of the texas nurses association nurse-friendly ™ program made it a perfect addition to ancc’s existing portfolio of credentialing activities and complimented the existing magnet hospital™ program. in 2007 ancc acquired nurse-friendly designation of the texas nurses association. recently, in re-launching the nurse-friendly™ hospital designation to a national audience, ancc renamed the program, as the pathway to excellence program™: http://nursecredentialing.org/pathway.aspx. the pathway to excellence designation is granted to a facility based on the confirmed presence of characteristics known as “the pathway to excellence criteria”. based upon expert input and nursing literature, the pathway to excellence standards represent qualities that both nurses and research evidence support as being important to the provision of the highest quality of patient care, nursing practice, professional development and job satisfaction, thereby encouraging retention of nurses. the following practice standards may be utilized to develop 7    online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 policies and processes that demonstrate a commitment to a practice environment consistent with providing excellent patient c are and raising job satisfaction among nurses (ancc, 2008, p.6). • control of nursing practice • safety of the work environment • systems exist to address patient care concerns • nurse orientation • chief nursing officer • professional development • competitive wages • nurse recognition • balanced lifestyle • exemplary intradiscipline collaboration • leadership accountability • quality initiatives according to susan sportsman phd, rn, president of the texas nurses association and dean of the college of health sciences and human service at midwestern state university (wichita falls, tx) (ancc, 2008, p.6): the practice standards – which include strong nurse leadership, control of practice, and safety in the work environment for nurses and the patients for whom they advocate – are important components in providing quality patient care and nurse job satisfaction. when hospitals utilize the research-identified practice standards in their policies and practices they demonstrate a commitment to a practice environment that is consistent with quality patient care and nurse retention. the above criteria are integrated into operating policies, procedures, and management practices of all pathway to excellence-designated healthcare organizations. for an organization to earn the pathway to excellence designation, it must successfully undergo a thorough review process that documents foundational quality initiatives in creating a positive work environment—as defined by nurses and supported by research. nurses in the organization verify the presence of the criteria in the organization through participation in a completely confidential online survey. recommended preliminary organizational self-assessment the first step in pursuing recognition as a pathway to excellence healthcare organization is an organizational self-assessment. this asessment must be deliberate and honest if it is to serve as an organizational measure of whether or not to pursue the pathway to excellence 8    online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 designation. specific guidance on the following self-assessment checklist can be found in the pathway to excellence manual (ancc, 2008; 2009). are all members of the nursing staff actively engaged in and aware of the pathway to excellence application? are staff nurses involved in decision-making and all phases of projects that affect nursing, including quality processes? is there evidence that a delineated nursing shared governance model is in place and integrated throughout the organization? is the development of policy/procedures evidence–based and are at least two of these being implemented? is there direct care nurse input on staffing plans and do they serve on nursing and hospital committees? are protective security measures in place for patients and staff? are prevention measures in place to decrease injury, illness, stress and accidents? do direct care nurses actively participate on safety committees and in product evaluation? are employee support structures in place for reporting and addressing work environment events or concerns? are supportive processes in the work environment perceived as restorative and/or holistic? are non-adversarial, non-retaliatory, and alternative dispute resolution mechanisms in place to address concerns about the professional practice of healthcare professionals? are there systems to assess quality of patient care as well as rights and culturally sensitive needs of patients? are error prevention and management procedures disseminated to all staff on an ongoing basis? do orientation activities incorporate general and specific mandatory training requirements? does nursing orientation involve a personalized plan with close supervision of the orientee/new nurse by peers and supervisors providing timely feedback. do staffing patterns accommodate the orientation activities of new nurses? is a cross orientation program in place if assigned to multiple staffing areas? are nurses provided education/training to serve as a preceptor and receive feedback? does the cno have a bsn? is the cno one of the following: * master’s prepared in nursing, business or a health related field * certified in management or administration 9    online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 actively progressing under a written plan towards achievement of additional education/course work to meet above criteria? is the cno accessible and an advocate to patients? is the cno accessible and an advocate to nursing staff? is continuing education supported and geared toward the nurse’s roles and responsibilities? are there examples of development opportunities through mentoring of staff in both the clinical and administrative arenas? is there a process for nurses (i.e., nursing clinical ladder) that facilitates the development of competence, recognition and/or advancement. can we demonstrate that nurses’ wages and salaries are competitive, market adjusted and commensurate with education, expertise, experience and longevity? is incentive pay based on performance and goal achievement? are opportunities and rewards or incentives offered to nurses who serve as outstanding role models for exceptional service? do external entities, such as community and nursing organizations, recognize the nurses employed at the healthcare organization for the accomplishments and contribution to the community and/or profession? are flexible staffing options provided? in addition to employee assistance programs, are other health and wellness support services in place? are direct care nurses involved in developing their work schedule to meet organizational and personal needs? are mechanisms in place that foster and support collaborative interdisciplinary initiatives? are established procedures utilized to constructively manage interdisciplinary conflict? does the nurse manager participate in self evaluation, development, and achievement of predetermined goals? is the nurse manager able to describe examples in which s/he has advocated for patients and direct care nurses? do both staff and manager peers have input to manager’s/supervisor’s evaluation? is the nurse manager’s performance evaluated on outcome measures are incentives awards provided for nurse managers achieving outcomes beneficial to the patient and/or organization? is there a current, written nursing quality plan? do direct care nurses actively participate in outcome based quality initiatives? are evidence-based practices utilized by direct care nurses? 10    online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the ancc pathway designation is best suited for small and medium-sized healthcare organizations. however, the designation is attainable by all healthcare facilities around the world that desire to create work environments in which nurses can flourish. the award substantiates the professional satisfaction of nurses and identifies best places to work. an organization with the designation of pathway to excellence is committed to nurses, to what nurses identify as important to their practice, and to valuing nurses' contributions in the workplace. this designation confirms to the public that nurses working in a pathway to excellence organization know their efforts are supported. finally, kudos’s to texas nurses for their efforts in addressing the concerns of rural nurse in providing quality care to patients. (information about the pathways to excellence program can be found in the references.) references american nurses credentialing center. (2008). overview of ancc pathway to excellence program tm. . silver springs, md: author. american nurses credentialing center. ancc pathway to excellence programtm. retrieved on may 10, 2009, from http://nursecredentialing.org/pathway.aspx texas nurses association. nurse-friendly™ designation of texas nurses association. retrieved on may 10, 2009, from http://nfp.etxahec.org/ rural women’s perceptions of availability, development and maintenance of rural built environments 52 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 rural women’s perceptions of availability, development and maintenance of rural built environments jeanine e. gangeness, phd, ms, rn 1 1 associate professor, department of nursing, bemidji state university, e-mail key words: rural, women, built environments abstract background: obesity is a worldwide concern. physical activity is one way to address obesity. the environment surrounding individuals can impact activity choices. design/methods: multiple, description, explanatory case study design, multiple-methods (focus groups, individual interviews, archival data collection, sidewalk maintenance evaluation) findings: women participants perceived community economic resources as an influencing factor for availability, development, and maintenance of rural built environments conducive to physical activity. these women participants also identified women speaking out and „being heard‟ as influencing availability and maintenance of built environments, and advancing age with reduced physical ability influenced the maintenance of resident-owned rural built environments. conclusions: there are many policy indications for local nurses advocating for rural populations including the consideration of built environment as a factor in health promotion and treatment (diabetes, obesity). introduction obesity is a worldwide concern resulting in disease and disability (world health organization, 2003). while the effects of obesity can be seen in all groups of people worldwide, the population that is currently the most profoundly affected is women (james, leach, kalamara, & shayeghi, 2001) residing in rural areas in the united states (jackson, doescher, jerant, & hart, 2005; patterson, moore, probst, & shinogle, 2004). the problems of obesity relate to the built environment of rural communities and the shift in lifestyles of rural women which has led to decreased physical activity, resulting in an increase in morbidity and mortality (e.g. obesity, diabetes, cardiovascular disease). in rural populations in the united states, obesity results primarily from low density nutritional intake (ledikwe et al., 2003) and limited physical activity (eberhardt, ingram, & makuc, 2001; tai-seale & chandler, 2003). this multiple, descriptive, explanatory case study design employed multiple methods of data collection to determine the perceived influences of the availability, development and maintenance of rural built environments by rural women. women participants in this study perceived limited economic resources as restricting availability, development, and maintenance of rural built environments conducive to physical activity. in addition to limited economic resources, speaking out and “being heard” by those in formal power positions influenced availability. finally, women identified that their advancing age and physical ability, or lack of ability, impacted how well they maintained built environments associated with their own property (e.g. sidewalks in front of their homes). following the background and research methods the findings are reported. the findings include reports on the limited economic resources, speaking out and “being heard” by those in formal positions of power, and their age http://www.bemidjistate.edu/academics/departments/nursing/ http://www.bemidjistate.edu/directory/facstaff/jgangeness 53 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 and physical ability as perceived by the rural women participants. in conclusion, case study assertions, implications for nursing practice and policy, and recommendations are made. background rural adults in the united states are disproportionately more likely to be obese than their urban counterparts (grandinetti, chang, theriault, & mor, 2005; jackson et al., 2005; nothwehr & peterson, 2005; patterson et al., 2004; polley, spicer, knight, & hartley, 2005). jackson et al. (2005) analysed data from the behavioral risk factor surveillance system (brfss) in 19941996 (n=342,055) and in 2000-2001 (n=385,384) and found an increase in the prevalence of obesity for rural residents of every state except florida. this study used an expansive definition of rural which includes areas adjacent to metropolitan areas as well as areas with 10,000 or fewer residents (jackson et al. 2005). this self-reported, telephone survey research provided a broadbrush analysis of rural population trends (jackson et al. 2005). patterson et al. (2004) analyzed data from the 1998 national health interview survey (32,440 interviews) and concluded that there was a high prevalence of rural adults who were both obese (20.4%) and inactive (rural 62.8% versus urban 59.3%). furthermore, they concluded that additional research with rural populations addressing interventions for physical inactivity was warranted (patterson et al. 2004). while there are studies that provide important insights into rural communities, patterson et al. (2004) did not identify a definition for “rural” and northwehr and peterson (2005) focused on a very rural county. one intervention to address obesity is to increase physical activity levels. women are less physically active than men and social factors influence their participation in physical activity (swenson, marshall, mikulichgildbertson, baxter, & morgenstern, 2005). women and physical activity physical activity patterns of women influence their health and wellbeing. women tend to be less physically active than men (p < 0.0001) (swenson et al., 2005); furthermore, physical activity levels are known to influence chronic disease progression, treatment, and prevention of both men and women (perdue, gostin, & stone, 2003). numerous studies have focused on women, their lives, physical activity levels, social support, and environmental influences (evenson, eyler, wilcox, thompson, & burke, 2003; evenson, sarmiento, tawney, macon, & ammerman, 2003; eyler, 2003; eyler et al., 2003a, , 2003b; eyler & vest, 2002; mccarthy et al., 2002; sanderson, cornell et al., 2003; sanderson, foushee et al., 2003; thompson, wolfe, wison, pardilla, & perez, 2003). these studies found that when facilities were unavailable both urban and rural populations were less likely to be active, and women were more likely to be influenced by lack of facilities. rural built environment a number of research studies regarding built environment and physical activity have been conducted with rural populations, using varying population definitions. telephone surveys in rural areas (brownson et al., 2000; deshpande, baker, lovegreen, & brownson, 2005; wilcox, bopp, oberrect, kammermann, & mcelmurray, 2003), focus groups with survey design (bopp, wilcox, oberrect, kammermann, & mcelmurray, 2004), and quasi-experimental survey design (brownson et al., 2004) have all provided valuable introductory data for rural populations. 54 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 however, with the exception of eyler et al. (2003), only two studies have specifically addressed the needs of women in relation to physical activity in rural areas (bopp et al. 2004; wilcox et al. 2003). the missing element in these studies is a comprehensive investigation into rural communities and how community members‟ use built environments to achieve physical activity. physical activity and built environment the eyler at al. (2003a) research was important in identifying built environment factors as critical to physical activity among rural women. the rural white female population (n=1,000) that eyler (2003) studied as a subgroup of the larger study (eyler et al., 2003a) identified the top barriers to physical activity as: “(1) the remoteness of the rural environment, (2) lack of recreational facilities, and (3) not enough sidewalks” . specifically, eyler et al, (2003a) suggested that built environment may be a deterrent to or, in reverse, can be a powerful influence to increase physical activity levels. srinivasan, o'fallon, and dearry (2003), defined built environments as “human-modified places such as homes, schools, workplaces, parks, industrial areas, farms, roads and highways” . this study addressed built environments that are conducive to physical activity, such as sidewalks, trails, and community centers. much of the work done around built environments and how these environments encourage physical activity has focused on urban and suburban locations (brownson, baker, housemann, brennan, & bacak, 2001; carnegie et al., 2002; dannenberg et al., 2003; gilescorti & donovan, 2003; leyden, 2003; saelens, sallis, black, & chen, 2003; srinivasan et al., 2003). a great deal of research indicates that built environments contribute to an increase in physical activity, particularly walking (brownson et al.2001; carnegie et al., 2002; giles-corti & donovan, 2003; leyden, 2003; saelens et al.2003). the policy influences on built environments and physical activity are important at all levels of government, addressed below are the local policy considerations. physical activity and local policy local policies at the state, county or municipality levels that have an impact on the health of a community may include school district (physical activity, nutrition), transportation, zoning (land use, design), and funding priorities (hayne, moran, & ford, 2004). research in an australian community found three key actions of local governments that support environments for physical activity (macdougall, wright, & atkinson, 2002): (a) take a strategic versus an operational focus on the issue, (b) “have open organizational structures to allow the various functions of local government to work together” , and (c) have appropriate leadership. two communities on the arizona-mexico border engaged special action groups to identify and guide local policies in a variety of community level interventions which included policy change (meister & guerney de zapien, 2005). the similarities to these two approaches (macdougall wright & atkinson, 2002; meister & guerney de zapien, 2005) were the multifaceted approach to policy work. for example, one australian study with rural local governments found that public health workers collaborating with local government leaders to place supportive environments for physical activity as a high priority increases discussion and policy solutions to health issues (macdougall, wright & atkinson, 2002). further, a review of studies that included policy interventions for adults concluded that physical activity policies that may promote healthy lifestyles included prompts to increase stair use (n=5), access to places and opportunities for physical activity (n=6), and comprehensive 55 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 work-site approaches, i.e. employee/peer support for physical activity, incentives, access to exercise facilities (n=5) (matson-koffman, brownstein, neiner, & greaney, 2005). while policies directed toward physical activity occur on the international, national, and local levels, information on built environment policies and how they influence physical activity of rural residents could not be found. further comprehensive research on current policies that relate to both physical activity and rural built environments warrants attention. research methods this multiple, description, explanatory case study design (gangeness & yurkovich, 2006) included a comprehensive, multiple-method approach which provided a larger view of the communities. in this study two independent rural communities were chosen based on their locations and populations. both communities had a population of less than 1,000 and did not have a community of more than 2,500 people within a 15-mile radius. the defined parameters for these communities addressed the gap in the literature, in which the published studies tended to have varying rural populations of greater than 2,500 within their samples. these methods included women‟s focus groups (4 groups, n = 26), city council focus groups (2 groups, n = 8), city administrator/clerk interviews (n=2), women‟s verification individual interviews (n=2), individuals referred to the researcher as individuals with perceived power (n=7), analysis of documents (3 years/community), and use of the sidewalk maintenance tool. there were two women‟s focus groups in each community, one with women ages 18-50, and the second with women 51 and over. these grouping were set to delineate possible childbearing/rearing and non-child bearing/rearing years. this case study was guided by an ecologic model (biologic, physical, socio-cultural, and politico-economic components) and grounded in critical-feminist theory (anderson & mcfarlane, 2004; campbell & bunting, 1999). approval was obtained from a university irb and each city council prior to data collection. informed consent was obtained from all focus group and individual interview participants. the study was bounded by rural women‟s perceptions of women‟s utilization of built environments to achieve physical activity; the availability, acceptability, and accessibility of built environments (e.g. trails, sidewalks, community centers); the local government‟s decisions and policy making focused on built environments; and the roles power and limited resources have on influencing the local government‟s decisions. data collection the women‟s focus groups, city council focus groups, and individual interviews were central data sources while the other data sources (sidewalk maintenance assessment, archival data, meeting minutes, and policies) were used to augment and triangulate study findings. this triangulation added depth and breadth to the data analysis, and strengthened the interpretation and credibility of findings. the data sources, collection, and interview guides were built and considered by reviewing an ecologic model (biologic, physical, socio-cultural, and politicoeconomic components), ensuring all areas of the community were evaluated. when the individual interviews were completed it was determined that additional individual interviews would only need to be conducted with the key women informants from the women‟s focus groups. there was repetition of data (among focus groups, city council focus groups, city administrator/clerks), and no further need to establish credibility of understanding. 56 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 data analysis all interview and archival data sources of data were analyzed according to recommended qualitative data content analysis methods that coincide with qualitative case study analysis (boyatzis, 1998; miles & huberman, 1994; yin, 2003). a process was established and used for all data sources/files for analysis of qualitative data, nvivo7 (sdg associates, 2006) was employed for data/file organization. each data source was first analyzed independently. a description and summary of each data source included identification and placement into categories or general themes. after each data source was independently analyzed, a matrix of categories was developed to evaluate the support or challenge of each case study proposition. the analysis steps were performed separately for all of the data sources from the two communities. these separate analyses provided separate case descriptions for cross case analysis. the researcher identified themes, patterns, and differences across all data sources. findings there were 26 total participating women in the focus groups (see table 1). women participants perceived community economic resources as an influencing factor for availability, development, and maintenance of rural built environments conducive to physical activity. these women participants also identified women speaking out and „being heard‟ as influencing availability and maintenance of built environments, and advancing age with reduced physical ability influenced the maintenance of resident-owned rural built environments. the findings are reported under economic resources, speaking out and being heard influences availability, advancing age and physical ability influences maintenance, and a summary with assertions based on study findings. table 1 participating women and their ages ________________________________________________________________________________ community a community b group type number average age age range number average age age range 18-50 8 38 26-50 6 40 33-49 51 and over 6 65 *50-77 6 63 51-78 total 14 12 * one woman age 50 signed up and participated in the 51 and over group by mistake economic resources economic resources were perceived as influencing the availability, development, and maintenance of rural built environments by women participants. one woman found the lack of funding impacted the availability, development, and maintenance of built environments used for physical activity. “doesn‟t is always come down to money?” another woman supported the need for additional economic resources in her community by stating, “i think that it‟s just a small community and there are limits. the resources are limited.” economic resources findings and how they influence the availability and development are reported first followed by maintenance findings. 57 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 availability and development women participants in the focus groups perceived economic resources as influencing availability and development of built environments for physical activity. one woman stated, “funding is always the #1 issue in a small community.” when economic resources were available to the communities, opportunities for physical activity were expanded (e.g. fitness centers), however, when resources were limited, this need of the community were not realized, because it was not the top priority. for example, the communities were not able to financially support day care at fitness center, which was a barrier for child rearing women. the women identified ways to increase availability through development of built environments and found that limited economic resources restricted the opportunities to meet all of the population needs. a blue cross blue shield (bcbs) grant funded a developing built environment (fitness center) that opened during data collection in community a. the combination of funding from the bcbs grant obtained by the city, collaboration with the public school (building), city council, and grassroots community support all created an economic package that made it possible to develop the fitness center in the community. the community education director summed up the development process of the fitness center. i believe it was a [tobacco] settlement to blue cross/blue shield…they [bcbs] had this lump sum of money and … people have wanted to add on to our weight room and make it more accessible for women because the weights we have in there right now are for football players and things like that. so when they got this money, there was a group that did go…gung ho. they found a room and they formed this little committee for the equipment. there are still a lot of things to be worked out right now, but for this town, it‟s perfect, it really is. it‟s a start. one city councilor confirmed that funding for the fitness center idea “was offered by bcbs as a grant” which made it possible for this small community to develop their fitness center. the women focus group (18-50) participants identified the economic need for child care in the developing fitness center to expand availability. one woman in the group explored with other group participants “how big would that have to be? what would you think? i mean i‟m just trying to think of the room that it‟s [fitness center] going to be in and i wonder if that‟s not a possibility.” after the focus group, four of the eight women went to the developing fitness center room and explored the possibilities of an on-sight child care area. in a follow-up interview (5 months after the women‟s focus group) one of these women shared that a day care was not within their budget and stated that they “can‟t really hire a babysitter.” focus groups in both communities discussed how community education was part of the public school system and that most activities were organized and funded by community education. as one city councilor stated “you're right, community ed is probably the key because [of] funding.” community education funding included supporting a person to organize physical activity events, using the public school building and grounds, and paying instructors to lead group fitness activities. one community education coordinator confirmed her role in planning physical activities for residents: i‟m the community ed coordinator so i coordinate evening classes, afternoon, and things like that, and you know in a town this size it is so rural…up until our 58 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 fitness center opened a couple months ago these little after school classes were about the only thing that [we had]… we have a weight room in the high school… we have had step aerobics…we offer indoor walking in the school and that actually gets a pretty good turn out in the mornings and the evenings, and things. community education held a central role in physical activity planning and opening the public school facility and grounds to rural women. overall, women participants perceived economic resources like “huge grant” funding, and collaborations with the community education (public school) as being a positive contributor to the availability and development of built environments for physical activity. maintenance economic resources limited the maintenance of rural built environments conducive to women‟s physical activity. one woman (focus group, 18-50) commented on cleaning the weight room in the public school prior to using the space due to the economic status of the public school. i think it‟s just one more thing that the janitors in our public school system have to do and not that they get any more [pay] for it, i‟m sure. it‟s just another added responsibility, so i‟m very sensitive to that and all of us that use the weight room in the morning and that‟s probably why we vacuum it. they let us in there and are very generous with that… another woman in the group commented further about economic resources and maintenance “you‟re talking about [the] whole maintenance issue that the funds are just not even available, or an organization hasn‟t made that their pet project.” sidewalks were also impacted by limited resources and to some degree streets and roads were influenced by the funding restrictions. the women in both communities recognized that the availability of economic resources could negatively influence the maintenance of built environments that they used for physical activity. speaking out and being heard influences availability the rural women participants in this study reported that they spoke out about the development of built environments and felt they were heard by individuals in formal power positions. “it‟s basically one of those [things] if you want to do it or see it get done do it yourself!” furthermore, a woman proclaimed about addressing and sharing development ideas with the city council “it‟s not something they‟re going to come up with on their own. you have to make your voice heard and let them know.” this woman did feel heard by the city council and identified the need to speak up when needed. when addressing the need to meet with the city council or public school board one woman found “i have never felt…it [the city council] was a closed atmosphere,” she perceived it as an open environment. the women participants found that they could be heard by the city council or public school board regarding the development of built environments and indicated that this option for addressing concerns about availability and development of built environments worked for them. 59 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 advancing age and physical ability influences maintenance a topic that was discussed by a women‟s focus group (51-over) participant was age and physical ability. this woman found that age and physical ability influenced the ability of individuals to maintain sidewalks in front of their homes. she stated, “there are lots of elderly people in town… we just can‟t shovel anymore” due to their physical ability and advancing age. although not mentioned in all of the groups, advancing age and physical ability were paramount to this participant. it should also be noted that advancing age and physical ability were not explicitly discussed in the interview questions. discussion rural women perceived limited economic resources; speaking out and „being heard‟; being empowered by those in formal power positions; advancing age; and physical ability as influencing the availability, development, and maintenance of rural built environments. the perceptions of the rural participants are represented by aspects of the ecologic model. limited economic resources influences the decision making process of the politico-economic component of the ecologic model. limited economic resources hamper the supportive interaction which assists with actualization from the politico-economic component to other components. findings related to speaking out and „being heard‟ by those in formal power positions, and being empowered by speaking out are recognized in the socio-cultural and politico-economic components of the ecologic model. the rural women‟s perceptions of being empowered had both social and political ramifications. the women who felt they could access individuals in formal power positions were empowered by this perception and identified changes that they influenced in their communities. this may be unique to rural communities, as the small number of community members enables relationships to already be in place for most of the population with policy makers. furthermore the advancing age and physical ability of rural women resides within the biological component of the ecologic model. further discussion follows the structure of the findings. economic resources women participants in this study perceived limited economic resources as restricting availability, development, and maintenance of rural built environments conducive to physical activity. they perceived grant writing and collaboration with the public school, city council, and city administrator/clerks as the mechanisms for the acquisition of resources to develop and maintain their built environments used for physical activity. however, rural communities (cities with 1,000 or fewer population) have limited financial resources even with collaboration; they have limited tax base, and limited resources for writing grants. as an example of costs related to built environments, wang et al., (2004) analyzed the 2002 costs of bike and pedestrian trails in nebraska and found the cost varied from $5,735 (crushed lime-stone) to $54,017 (concrete with 3 bridges) per mile. compounding the development burden of built environments are the costs to maintain them which wang et al., (2004) estimated at $4,400 to $5,692 per mile depending on type. these are profound budgetary considerations in rural communities where residents are receiving limited incomes (e.g., elderly). the notion of lower socioeconomic status corresponding with less built environments for physical activity is supported in the literature 60 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 (gordon-larsen, nelson, page, & popkins, 2006). they further connect the limitations in number of facilities for physical activity and limited socioeconomic status to obesity patterns (gordon-larsen et al., 2006). therefore it can be asserted that limited economic resources negatively affect the existence, number, and maintenance of built environments used for physical activity in these two rural communities. empowered women this case study sought to decrease isolation and limited power of rural women by giving them voice through focus group interviews and by seeking to understand their perceptions of what influences the development of built environments for physical activity, thus, supporting the feminist underpinnings. the findings revealed that rural women participants spoke out in their communities and were „heard‟ by those in positions of formal power which resulted in them feeling empowered to make changes in their communities (e.g. pta, safety, addressing day-care needs). the perceptions of empowerment from the women in this study were not as well explored as other rural women population studies (leipert & reutter, 2005a, , 2005b) as empowerment was not the primary focus. researchers focusing on rural women, gender, and geography, leipert and reutter (2005b), found that the rural context, which included “isolation, limited options, limited power and being silenced” contributed to the women‟s marginalization . their vulnerability to health risks were addressed by the women through resilience. leipert (2006) further states that “taking a positive attitude” was part of being hardy and self-reliant . the conclusion that rural women were empowered could be associated with the many examples of adapting their physical activity to the available built environments. the women identified and enacted solutions to most of the concerns in their environment. while an outsider may view built environments as lacking in amount and diversity, those within the environment viewed each built environment as an opportunity and identified options to adapt their behavior. spiers (2000) supports this notion and states: emic perceptions of vulnerability are experiential and qualitative, while etic perceptions involve identification of individuals or groups who are at particular risk according to normative standards derived from the general population. those from an outside perspective (etic) may fail to recognize the adaptations taking place and the perceptions of empowerment held by those in the community (emic) who are able to adapt. therefore, it is asserted that empowerment of rural women in these communities was derived from the perceived built environment opportunities, influential roles, women‟s abilities to adapt their physical activity to available built environments, and their insider status in the rural community. maintenance of environment women identified that their advancing age and physical ability impacted the maintenance of their own property (e.g. sidewalks in front of their homes). homeowner maintenance of sidewalks and its affect on physical activity of community members is not discussed in the healthcare literature. however, swenson, marshall, mikulich-gilbertson, baxter, and 61 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 morgenstern (2005) studied age-related physical activity of hispanic and non-hispanic white rural adults ages 55-80 and found that activity decreased with age. the activities most frequently identified by swenson, et al., (2005) were walking and home maintenance/gardening. walking levels stayed stable for non-hispanic white women until they turned 63 when their activity decreased (swenson et al., 2005). this decrease in activity identified by swenson et.al., (2005) could be associated with the advancing age and reduced status of physical ability identified by study participants resulting in poorly maintained city sidewalks on their home property. therefore it can be asserted that rural women who are advancing in age and have reduced physical abilities may impact the maintenance of the sidewalks in front of their homes and negatively influence the activity level of the entire community. furthermore, the local policy makers could address the community needs related to their aging populations by adopting a maintenance plan for sidewalks throughout their community. summary of case study assertions assertions are the summary of the findings based on the researcher reviewing all data sources and identifying the key messages. assertions are unique to case study design. the assertions in this study were identified in the following three bulleted items.  limited economic resources negatively affect the existence, number, and maintenance of built environments used for physical activity in these two rural communities.  empowerment of rural women in these communities was derived from their speaking out and being heard in the development of built environments, having a positive attitude, and adapting to available built environments.  rural women who are advancing in age and have restricted physical abilities may not be able to maintain the sidewalks in front of their homes which could negatively influence the activity levels of the entire community. policy implications ashe et al., (2007) specifically identified five legal and policy strategies for healthy environments related to physical activity and healthy food options. four of the five recommendations were associated with findings from this case study. these focused on policy and financial support for school environments, built environments, community facilities, and earmarking taxes and fees as a way to finance these needed community built environments. future policy considerations for rural communities and nurses serving these communities are listed below. these are based on findings from this case study research and evolved from the assertions.  local policy makers and nurse advocates need to address their aging population‟s limitations for doing physical activity by adopting a maintenance plan for sidewalks and other built environments for physical activities throughout their community.  local officials need to become politically active in advocating for state and federal policies which increase the economic resources available for rural 62 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 communities regarding physical activity infrastructure (e.g., sidewalks, trails) since it is known that physical inactivity causes an increase in both morbidity and mortality.  nurses advocating for rural populations need to consider the built environment as a factor in health promotion and treatment (diabetes, obesity) as they address health policy issues and resource distribution at the local, state, and federal levels. rural nursing practice implications public health nursing is best suited to address the rural environmental issues that consumers of healthcare face. therefore expanding community health nursing to include considerations of built environments used for physical activity by community members of all ages by conducting needs assessments with this focus of health promotion and prevention are paramount (hays, davis, & miranda, 2006). a more comprehensive look at the environments where individuals reside will create information to inform the development of health care policy which will facilitate realistic physical activity recommendations. conclusions women participants perceived community economic resources as an influencing factor for availability, development, and maintenance of rural built environments conducive to physical activity. other than economic resources, women speaking out and „being heard‟ influenced availability and maintenance of built environments, and advancing age with reduced physical ability influenced the maintenance of resident-owned rural built environments. the economic resources needed by the community were identified by participants. they found that grant writing and collaboration with the public school and city officials were avenues for accessing resources for the development and maintenance of environments used for physical activity. policy work for rural communities should address the physical limitations of aging populations and how home maintenance (clearing and cleaning) can impact the built environments of entire communities. health policy work of local nurses advocating for rural populations should consider the built environment as a factor in health promotion and treatment (diabetes, obesity). furthermore, community health nurses need to 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[medline] http://www.ncbi.nlm.nih.gov/pubmed?term=25%5bvolume%5d+and+53%5bpage%5d+and+thompson+j%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=15054000%5buid%5d&cmd=detailssearch http://www.who.int/hpr/gs.consultation.document.shtml#consultation%20speeches%20statements http://www.who.int/hpr/gs.consultation.document.shtml#consultation%20speeches%20statements http://www.ncbi.nlm.nih.gov/pubmed?term=12%5bvolume%5d+and+1622%5bpage%5d+and+zhang%5bauthor%5d luger_544-article text-3552-1-6-20190311 online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 136 a pilot quality improvement project facilitating leadership skills in rural new graduate nurses shelly j luger, dnp 1 debra j ford, phd 2 1 assistant professor & clinical systems administration track lead, college of nursing creighton university, shellyluger@creighton.edu 2 associate professor, interdisciplinary leadership doctoral program, creighton university, debraford@creighton.edu abstract purpose: the purpose of this article is to present findings from a pilot quality improvement evidence-based new nurse transition program that facilitates clinical leadership skills in novice nurses at the point of patient care at a rural critical access hospital. descriptive data from preand post-intervention scores are reported, and the percent change was evaluated. sample: due to the solitary nature of rural nursing, new graduate nurses in rural areas need support in transitioning to their new role as registered nurses. the author designed, and pilot tested a quality improvement evidence-based new nurse transition program in a rural critical access hospital utilizing complexity science as a framework. method: a quality improvement pilot program designed for new graduate nurses was provided at a critical access hospital in a rural midwestern state. data was collected using preand post intervention scores on the leadership characteristics and skills assessment and teamstepps online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 137 teamwork attitudes questionnaire. descriptive data was evaluated. findings: participant posttest percent change scores increased in perceptions of ability to lead but decreased in attitudes about teamwork. observations of participant interactions in the quality improvement project suggested that the new nurses were developing new ideas, patterns and structures regarding their roles as a team member in the healthcare setting. conclusion: in a rural midwestern critical access hospital a quality improvement leadership program that used a complexity science framework was provided to novice nurses in transition. after the program participant total mean post scores increased in perception of what makes a good leader and in the participant’s perception of their ability to lead. an overall mean score decrease in attitudes about teamwork was noted among the small group of rural novice nurses. keywords: rural, frontier, new registered nurse graduate, transition program, complexity science, leadership a pilot quality improvement project facilitating leadership skills in rural new graduate nurses new nurse graduates are now the largest source of registered nurses available for recruitment in the nation (welding, 2011). new graduates face difficult psychological and intellectual challenges as they adapt to new careers (abraham, 2011; al-dossary, kitsanta, & maddox, 2013; anderson, hair, & todero, 2012; chappell, richards & barnett, 2014; clark, & springer, 2012; dyess & parker, 2012; dyess & sherman, 2009; goode, lynn, & mcelroy, 2013; keahey, 2008). in addition, new graduates who chose to work in rural settings must become expert generalists, functioning at a higher level with less support sooner (fahs, 2017). it has been well documented online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 138 that most nursing school faculty feel that upon graduation student nurses are prepared for the first year of work as a generalist (morton & hyrkas (2012). most nurse leaders in health care organizations feel new graduate nurses are not well prepared for the myriad of challenges faced in the first year of practice. organizational leaders struggle with new graduate’s preparedness to practice (welding, 2011). in addition, it is now recognized that a key new nurse competency is leadership. nurses at all levels, whether staff positions or vice presidents, are providing leadership in a complex patient care environment. nurses who are just beginning careers can be excellent leaders (grossman & valiga, 2013). while there is wide anecdotal agreement that new graduate nurses need knowledge and competency beyond those skills developed in nursing school, there is no agreement on the best approach for developing those new nurse competencies in the work setting (al-dossery, kitsanta & maddox, 2013). clark & springer (2012) identified that although clinical content is important for new nurse graduates, greater competencies regarding the leadership skills of prioritizing, communication, professionalism and teamwork are required. developing clinical leadership skills at the point of patient care is a critical skill for new nurses to develop. leadership is an essential nursing role that encompasses managing patient care delivery, resource management, communication, and conflict management (commission on collegiate nursing education [ccne], 2015). therefore, it is imperative that new graduate nurses build skills in selfconfidence, self-esteem and visionary thinking. these strengths will help enable the new nurse to exert leadership in making decisions, facilitate partnerships with patients and other healthcare workers, accomplish goals and reach visions. when each nurse sees leadership as an online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 139 integral component of professional role healthcare will be transformed. the new graduate may find developing required leadership skills more challenging in rural and frontier areas. context of rural for purposes of this paper rural is defined according to the us department of health and human services (n.d.) as a population less than 50,000. according to the united states department of agriculture (n.d.) "frontier and remote" is described as territory characterized by some combination of low population size and high geographic remoteness. the united states census bureau (n.d.) notes that about 60 million people live in rural areas. according to the united states department of health and human services [dhhs] nursing workforce report (2013) a large majority of nurses reside in metropolitan areas and rural areas have a lower per capita supply of registered nurses (rns). in general rns in rural areas are more likely to hold an associate degree or less as their highest degree (dhhs, 2013). this demographic data suggests unique challenges that new graduate nurses could face in rural areas. research suggests that rural nurses face a multitude of challenges related to the rural nature of the job. these challenges include needing to be expert generalist, professional isolation, and new comer tensions (fahs, 2017; molinari & bushy, 2012; schlariet, 2017). in rural and frontier areas there are fewer nurses, scarce professional development resources, and inequitable access to education and training (molinari & bushy, 2012). new graduate nurses in rural and frontier areas face significant challenges in obtaining and developing required leadership skills in new roles as nurses. this quality improvement was designed to benefit rural and frontier regions critical access hospitals. critical access hospitals (cah) are rural small community hospitals that receive cost online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 140 based reimbursement (american hospital association, n.d.). the purpose of this article is to present findings from a quality improvement project that pilot tested an evidence-based new nurse transition program that facilitated clinical leadership skills in novice nurses at the point of patient care in a rural critical access hospital. descriptive data from preand post-intervention scores are reported and the percent change was evaluated. background nurse residency programs are the gold standard of new nurse graduate programs. residency programs include the expertise of faculty steeped in educational modalities and curriculum as well as expert clinical practice nurses (commission on collegiate nursing education [ccne], 2015). there is an accreditation process for nurse residency programs. accreditation assures that high academic standards are being met. unfortunately, small rural health care organizations often do not have affiliations with academic institutions to provide residency programs. therefore, hospital-based residency programs called transition programs have been developed to help meet the needs of new nurses transitioning to practice. one method found in the literature for improving clinical leadership skills of novice nurses is through new graduate nurse transition programs (ngntp) (spector et al., 2015; chappell, richards & barnett, 2014; clark, & springer, 2012; greer-day, medland., watson, & bojak, 2015; dyess & parker, 2012; dyess & sherman, 2011; dyess & sherman, 2009; fiedler, read, & lane, 2014; goode, lynn, & mcelroy, 2013; welding, 2011). the evidence to support nurse transition programs is well documented. however, the evidence identifies little consensus on what determines best practice of transition programs (rush, adamack, gordon, lilly & janke, 2013). online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 141 a literature search of cinahl, pubmed, google scholar, proquest, and ebsco databases was completed. using the search terms nursing transition, nursing residency, leadership, novice nurse, rural new nurse graduate, and new graduate nurse within the date range of 2007-2017, 45 articles were retrieved. articles were further narrowed by applicability to the purpose of this project: facilitating clinical leadership skills in novice nurses. twenty articles where used to support the quality improvement project. the level of the evidence to support leadership development through nurse transition programs ranged from quality improvement initiatives to systematic literature reviews. several qualitative studies were found related to novice nurse leadership skills. fiedler, reed, and lane (2014) examined long term outcomes of a nurse transition programs on new nurse leadership development in a descriptive pilot study. statistical significance was found in that those who completed the transition program were more likely to act as a charge nurse. in a qualitative study, clark and springer (2012) identified that although clinical content is important in nurse transition programs, greater competencies in the leadership skills of prioritizing, communication, professionalism, and teamwork are required. therefore, it is likely that nurse transition programs can influence bedside nurse leadership skills. dyess and sherman (2009) identified seven learning needs of the new graduate. the qualitative study revealed three major themes. first, the program enabled participants to identify a more global and systems perspective of nursing. second, leadership skills were developed and demonstrated. the final theme was that participants identified improved confidence through taking the program. this study suggested a strong need for leadership content in new nurse graduate programs. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 142 dyess and sherman (2011) continued studying transition programs and used a convenience sample of 109 novice nurses who completed a novice nurse leadership program at a hospital in south florida. post transition program evaluation of acquisition of clinical skills, suggested statistically significant increased skill in the areas of planning and evaluation, being a member of the discipline, leading care and patient care. post transition program evaluation of leadership competencies indicated statistically significant improvement in the sub-scales: model the way, inspire a shared vision, challenge the process, and encourage the heart. in another arm of the study (dyess & parker, 2012) post-program evaluation indicated statistically significant increased skill in the areas of planning and evaluation, member of the discipline, leading care, and patient care. these findings provide important grounding for the intervention implemented in this project. several quantitative studies were found that support positive outcomes in nurse transition programs that facilitate leadership skills. a systematic review of the literature by al-dosary, kitsantas and maddox (2013) provided clear evidence of consistent findings that suggest transition programs reduce turnover and promote professional growth of clinical decision making and leadership skills of the new graduate nurse. the researchers also found that inconsistency in methods of program delivery and lack of rigorous evaluation of the impact of transition programs on leadership skills remains problematic. review of the literature suggests that variations and limitations of the current research provides limited evidence from which to identify best practices for new graduate nurse transition programs. in contrast, landmark research supported by the national council of state boards of nursing [ncsbn] and completed by spector and associates (2015) provided convincing evidence to support transition programs. the study found that hospitals who had established transition online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 143 programs had higher nurse retention rates and fewer patient care errors, employed fewer negative safety practices, had higher competency levels, and had lower stress levels and better job satisfaction. structured programs that had at least six of the following elements were found to provide better support for new graduate rns: patient-centered care, communication and teamwork, quality improvement, evidence-based practice, informatics, safety, clinical reasoning, feedback, reflection and specialty knowledge in area of practice. the research by spector (2015) has begun to frame the way to provide consistency of nurse transition programs. the ncsbn recommend that organizations begin transition programs based on current evidence available because waiting for more evidence will only stifle innovation and creativity for the development of nurse transition programs. due to transition program design variability, the evidence does not support one best transition program. several researchers (anderson, hair, & todero, 2012, rush, et al. 2013, goode, et al. 2013, and ulrich et al. 2010) have been able to identify common or best teaching/learning strategies for transition programs. these components include pairing the novice nurse with a trained preceptor, building a cohort of new nurses in transition, time for discussion and reflection, peer support opportunities, functioning as an interdisciplinary team, and complex simulation scenarios. the researchers point out that determining which education program is better than another is difficult due to confounding factors and variation in program curriculum, methods of delivery and qualifications of clinical educators and preceptors. the literature review of new nurse transition programs indicates evidence of positive outcomes for new nurse graduates. however, due to variability and confounding factors of new nurse transition programs, there is not conclusive evidence to support one type of transition online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 144 program over another. new graduate rn competency regarding leadership skills of prioritizing, communication, professionalism and teamwork is required. a leadership development program for new graduates utilizing a non-linear framework such as complexity science is likely to enhance leadership skills of the new nurse graduate. theoretical framework traditional leadership theories are reaching maturity and are insufficient to explain the complex realities of leadership in healthcare settings (bryman, collinson, grint, jackosn & uhlbien, 2012). therefore, for this quality improvement pilot project utilizing a non-linear framework to develop a leadership program for new graduate nurses might be more sufficient. a complexity science approach requires an approach that is intuitive, reflective and relational. a complexity science framework includes the human factor: the importance of relationships and building networks in organizational change. important to this paradigm is also the process of praxis or reflection on action. complexity science models propose that small changes can result in a significant new trajectory (crowell, 2011). using complexity science as a framework for leadership content in a novice nurse transition program allows for change through reflection on practice (praxis). the pilot quality improvement program consisted of sessions on clinical leadership development (chunking) and sessions for reflection, support and relationship building (emergence and self-efficacy). questions this pilot quality improvement project was guided by the following two study questions: online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 145 q i: does a leadership curriculum in a quality improvement pilot novice nurse transition program improve novice rural nurse’s perception of their ability to lead as measured by the leadership characteristics and skills assessment tool (grossman & valiga, 2013)? q ii: does a leadership curriculum in a quality improvement pilot novice nurse transition program improve new rural nurse’s attitudes towards and skills in the areas of leadership, situation monitoring, mutual support and communication as measured on the team stepps attitude questionnaire [t-taq] (2014)? methods based on the available evidence, developing a leadership educational program guided by complexity science could improve outcomes in transition to practice for new graduate nurses. due to the solitary nature of rural nursing, new graduate nurses in rural areas need support in transitioning to the new role as rns. therefore, a quality improvement pilot program designed for new graduate nurses was provided at a critical access hospital in a rural midwestern town. human subjects human subject approval was obtained through kumc human subjects committee (hsc). the risk to subjects is low and exempt irb approval was granted. preand post-surveys were conducted. names were obtained, and numbers were assigned to each participant to promote confidentiality of names. the list of names and identification numbers were kept separate from the data. informed consent was obtained before pre-survey. subject privacy was protected and security of data was maintained through use of kumc secure server. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 146 setting the program was delivered at a critical access hospital in a rural midwestern state as part of the organization’s initial nurse orientation. the hospital chosen was a critical access hospital with 25-beds for all patient types: acute, observation, swing-bed, intensive care and obstetrics. participants novice nurses are nurses who have recently graduated from nursing school and have less than 12 months of experience as a registered nurse. the program was available for all new registered nurses hired for any department of the critical access hospital. both associate degree and baccalaureate degree prepared rns were included in the program. baccalaureate nursing curriculums typically include more leadership content. the teamstepps process of leadership development may or may not be included in baccalaureate nursing programs. the number of novice nurses in the initial quality improvement pilot cohort was five. intervention the intervention was an eight-module leadership program. the concepts in the program included the following (with the complexity concept included): self-evaluation, communication, conflict management, teamwork, management of patient care delivery, safety, systems thinking, and quality improvement. in the self-evaluation module the new graduate nurses completed preassessment tools, identified areas of strengths and areas for improvement in leadership skills, and developed strategies to improve leadership strengths. in the communication module the new graduate nurses demonstrated use of sbar communication in critical scenarios. during the conflict management module, the new nurse identified his/her conflict management style and demonstrated use of the teamstepps desc tool in a conflict scenario (teamstepps pocket online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 147 guide, n.d.). in the teamwork module the participants demonstrated use of temstepps tools of brief, huddle, debrief, situation monitoring and task assistance (teamstepps pocket guide, n.d.). the management of care module assisted new graduate nurses to identify situations in which they would need to prioritize delegate and manage resources. in the safety module the participants reviewed the critical access hospital national safety goals and identified their role in assisting the organization in reaching the national safety goals. the systems thinking and quality improvement module engaged participants in an activity to demonstrate work process and analysis of outcomes. in the final week the participants completed post-program evaluations. every module in the leadership program encouraged self-directed learning and reflection on practice (praxis), and relationship building with the cohort and peer support (emergence and self-efficacy). the modules were delivered in a face-to-face environment; however, modules could easily be adapted for a blended delivery if required by other critical access hospitals. the program was adapted from the standards for accreditation of post-baccalaureate nurse residency programs by the commission on collegiate nursing education (2015) and the national council of state boards of nursing [ncsbn] (n.d.) transition to practice model. the program was adapted because in the ncsbn (n.d.) transition to practice model it was discovered that leadership, a key link to successful transition of new nurses, as identified in the literature review, was missing. data collection two tools were utilized pre-entry into the program and post-completion of the program. permission was obtained to use the leadership characteristics and skills assessment [lcsa] tool developed by grossman and valiga (2013). part i of the two-part lcsa tool includes 20 statements that measure individual participant perception of what makes a good leader using a 5 online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 148 point strongly-agree to strongly-disagree likert scale. part ii of the lcsa has 20 statements that measure the individual’s perception of their own ability to lead using the same strongly agree to strongly disagree likert scale. grossman (2007) evaluated the reliability of the instrument and determined internal consistency. cronbach’s alpha ranged from .77 to .88 suggesting reliability of the tool. paramount to patient safety is the new nurse’s ability to work effectively as a team member. the agency for healthcare research and quality [ahrq] teamstepps suggests that teamwork comprises four core skills: leadership, situation monitoring, mutual support and communication. throughout the new nurse transition program, ahrq teamstepps tools were utilized to improve leadership skills of the new nurse. the ahrq developed a tool called the teamstepps teamwork attitudes questionnaire [t-taq] (n.d.). the t-taq is a 30-statement tool utilizing a strongly-disagree to strongly-agree 5-point likert scale. the t-taq was used preand postprogram to evaluate new nurse’s attitudes towards and skills in the areas of leadership, situation monitoring, mutual support, and communication. baker and associates (2010) validated that the t-taq. cronbach’s alpha reliabilities exceed 0.7 in all 30 items indicating that the t-taq is a useful, reliable and valid tool for assessing individual attitudes related to the role of teamwork in healthcare. data analysis each participant in the new nurse leadership transition quality improvement pilot program was assigned a unique participant identification number. data was collected using pre-intervention score on the lcsa & t-taq and post-intervention score of both tools. only descriptive data is reported due to the small sample size. the percent change was evaluated. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 149 results there were five participants in the new nurse leadership program provided at a small rural critical access hospital. all five participants graduated from nursing school in may 2016 and this was their first employment as rns. all participants were female. there were four baccalaureate prepared new nurses and one associate degree prepared rn. three of the bsn students attended traditional nursing programs and one completed an accelerated bsn program. the participants nursing education programs had diverse learning delivery methods including face to face, online and interactive television (itv) systems. three of the participants had passed nclex, one participant tested during the program, and one was still waiting for authorization to test. all participants lived in the midwest during their nursing education. all the participants had some exposure to the teamstepps program either through previous employment or through nursing programs. results of the lcsa tool, part i measuring perceptions of what makes a good leader (grossman & valiga, 2013), suggest that a score of 50-59 indicates the participant is probably mixing up the difference between management and leadership. on the leadership transition program pre-test four out of five of the new graduate nurses’ scores ranged from 55-58, indicating these participants were probably confusing the concepts of management and leadership. grossman and valiga (2013) suggest that a score of 60-69 indicate a good perception of a good leader. one participant scored 64 which suggests this participant seemed to have a perception of what makes a good leader before the transition program. however, post-program all the participant scores increased. total mean post scores indicated that the group had a 6.8% increase in perception of what makes a good leader (see table 1). online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 150 table 1: results of the leadership characteristics and skills assessment tool part i: perception of what makes a good leader pre-total score part i post total score part i 58 61 55 58 55 63 64 67 56 59 pre-total score mean part i post total score mean part i % change 58 62 6.8% increase results of the lcsa tool, part ii perception of one’s own ability to lead, pre-test suggested that two out of the five participants had a low perceived leadership ability, with three participants having a moderate perceived ability to lead. none of the participants had a high or extremely high perception of their ability to lead. in this small sample post survey three out of five participant’s perceptions of their ability to lead increased, with one participant’s perception of her ability to lead remaining the same and one participant’s perception of her ability to lead decreased. overall a mean 3.9 % increase in the group perception of their ability to lead was noted (see table 2). table 2: results of the leadership characteristics and skills assessment tool part ii: perception of your own ability to lead pre -total score part ii post total score part ii 54 55 47 47 47 59 51 52 57 54 pretotal score mean part ii post total score mean part ii % change 51 53 3.9% increase online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 151 the t-taq (n.d.) measures health professional’s attitudes toward the core components of teamwork. the data revealed interesting results. the descriptive data collected from the quality improvement program indicated attitudes improved in team structure, decreased in leadership and situation monitoring, and did not change in mutual support and communication. the overall mean scores suggest a 1.5 % decrease in attitudes of the new graduates toward teamwork after the program. in the development of the ttaq baker, et al. (2010) made several suggestions on the interpretation and analysis of results of the instrument. first, they suggest little research exists on whether positive attitudes toward teamwork are required for team training to be successful. further the authors cautioned that the relationship between attitude and behavior is not well defined. finally, they also suggested that attitudes about teamwork can be positive without receiving training. this suggests that healthcare workers are likely to have good attitudes but not necessarily the skills required for teamwork (see table 3). table 3: results of the teamstepps t-taq tool measuring health professional’s attitudes toward teamwork team structure team structure pre-test mean 25.6 team structure post-test mean 26 team structure % change 1.5% increase leadership leadership pretest mean 27.8 leadership posttest mean 26.6 leadership % change 4.3% decrease situation monitoring situation monitoring pretest mean 26.6 situation monitoring posttest mean 25.6 situation monitoring %change 3.7% decrease mutual support online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 152 discussion the literature indicates new graduate nurse transition programs can improve clinical leadership skills of novice nurses (spector et al., 2015; chappell, richards & barnett, 2014; clark, & springer, 2012; greer-day, medland., watson, & bojak, 2015; dyess & parker, 2012; dyess & sherman, 2011; dyess & sherman, 2009; fiedler, read, & lane, 2014; goode, lynn, & mcelroy, 2013; welding, 2011). using a complexity science framework to guide a new nurse leadership program in a rural setting allowed participants of a quality improvement project time to learn and reflect on materials. this was evident through personal informal observations of the new nurses in a rural setting beginning to reflect on their experiences as new nurses during the transition program. additionally, through informal observation of interactions that were taking place during the quality improvement project, new nurses in this rural setting were developing a support system with one another. important concepts related to complexity science began to materialize. the overall decrease in attitude about teamwork among these new graduate rns in a rural setting could be the result of many outside influences. crowell (2011) argued that new ideas, structures or patterns may arise from the relationships the participants were building through the nurse transition program. the mutual support pre-test mean 26.8 mutual support post-test mean 26.8 mutual support % change no change communication communication pre-test mean 25.4 communication posttest mean 25.4 communication % change no change pre -total score mean 26.4 posttotal score mean 26 total %change 1.5% decrease online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 153 new attitudes about teamwork after the program could suggest that a new self-organization (zimmerman, 1999) was beginning to take place among the participants. another possible reason for decrease in attitude about teamwork is a possible confounding factor that all the participants had reported having previous exposure to teamstepps either through school or previous employment. an additional confounding factor was that all participants were taking on new work roles during this education. the complex adaptive behaviors suggest a level of change was occurring in the participants. analyzing the results through a complexity science lens leads to the emergence of the need for further quality improvement initiatives, pilot testing and research on the topic. future practical research could examine change in attitudes about teamwork when skills begin to develop. likewise, further research regarding the influence of “reality shock” on new nurse’s attitudes about teamwork would be beneficial. finally, examining teamwork attitudes of others in the organizations influence on the new nurse in transition’s attitude about teamwork would be useful. limitations of the study there are several limitations to this study. first, the small number of participants make it impossible to generalize the results to transition programs for new nurses. second, due to the nursing shortage at this hospital the need to rapidly deploy new hires lead to a rapid presentation of the leadership curriculum. this rapid presentation allowed only limited time for reflection, support, and relationship building. finally, the study did not factor in academic nursing preparation. four of the students were baccalaureate prepared nurses. baccalaureate nursing programs provide nursing leadership courses as part of the curriculum. there was only one graduate from an associate degree program where leadership courses are generally not provided. online journal of rural nursing and health care, 19(1) https://doi.org/10.14574/ojrnhc.v19i1.544 154 limitations to the study include a small number of participants and potentially confounding variables. conclusion this small quality improvement study supports the use of an evidence-based leadership development program, which uses a complexity science framework, for developing leadership skills in new graduate nurses in a rural critical access hospital. the program can easily be incorporated into new nurse graduate transitional programs for rural new graduate nurse hires. the leadership program could be delivered on-site, on-line or in a blended format. references abraham, p.j. 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(1999). complexity science: a route through hard times and uncertainty. health forum journal, 42(2), 42-69. . adynski _other,+666-newarticle+text-4565-2-15-20210716_graves+final+edits071721_formatted_final apa edits online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 167 a systematic review of the strategies to address health worker shortage in rural and remote areas of lowand middle-income countries gillian i. adynski, phd, rn1 leah l. morgan, phd, rn2 1postdoctoral research fellow, national clinician scholars program, duke university, gillian.adynski@duke.edu 2assistant professor, queens university of charlotte, morganl4@queens.edu abstract purpose: the aim of this paper is to examine the literature on strategies to address the maldistribution of health workers between urban and rural and remote areas of lowand middleincome countries. sample: 16 peer-review articles that address strategies to recruit and retain health workers in rural and remote areas of lowand middle-income countries. methods: a systematic literature review was conducted following preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. findings: embase, pubmed and web of science, were searched resulting in 731 articles, 16 articles were included after screening. across the 16 articles, the main categories to address the maldistribution of health workers between urban and rural and remote areas were use of public sector employment, rural and remote employment incentives, student and school based strategies, and health infrastructure and retention. conclusion: there is not just one type of strategy that can successfully address the maldistribution of health workers between urban and rural and remote areas. to address population health in online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 168 countries suffering from maldistribution of health workers use of increasing the availability of public sector employment, increasing incentives for health workers to work in rural/ remote areas, partnering with health worker training programs and schools, and building up high quality infrastructure and other interventions to retain health workers in rural and remote areas are successful. future research should evaluate interventions to recruit and retain health workers in rural and remote areas and look at population health as a result. the ultimate goal for recruitment and retention of health workers in rural and remote areas is improving population health and this has not been considered in past research. a systematic review of the strategies to address health worker shortage in rural and remote areas of lowand middle-income countries skilled health workers (physicians, nurses, and midwives) are necessary for attaining and sustaining universal health coverage worldwide (global health workforce alliance & world health organization, 2013). nearly all countries are challenged by worker shortages, skill mix imbalance, maldistribution, negative work environments and weak knowledge bases. however, these problems are worse in lowand middleincome countries (lmics) who also face high disease burdens and emigration of health workers (chen et al., 2004; world health organization [who], 2015). these lmics are constantly losing the healthcare workers they do have because of low wages, poor working conditions, poor health infrastructure, and high burdens of diseases (lehmann et al., 2008). the shortages of health workers in lmics worsens in rural and remote areas (johnston et al., 2020; lehmann et al., 2008; who, 2016), as they have even less physicians, nurses, and midwives to provide care to residents. this paper defines rural and remote as those areas relating online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 169 to the country, or areas away from cities (merriam-webster dictionary, 2021). in the world health report, it was determined that half of the world’s population lives in rural and remote areas, however only approximately 38% of the world’s nursing workforce and approximately 25% of the world’s physician workforce resides in rural and remote areas (guilbert, 2006). in south africa, 46% of the population lives in rural areas but only 12% of the doctors and 19% of the nurses live there (who, 2010). in contrast in urban areas in bangladesh, 30% of the nurses are in four metropolitan districts where only 15% of the population lives (who, 2010). past research has demonstrated that having higher physician and nurse to population ratios in rural and remote areas leads to better health outcomes (bigbee et al., 2014; fields et al., 2016). the knowledge and evidence to recruit and retain health workers is still low (mbemba et al., 2016) and health workers policy makers are not consistently making evidence-based policy decisions to address this problem (dolea et al., 2010). despite some reviews of the literature (lehmann, et al., 2008; buykx et al., 2010; mbemba et al., 2016; who, 2010) on recruitment and retention of health workers to rural and remotes areas, few have focused on specific interventions that work in lmic countries, which may have less resources to devote to complex policy interventions. the purpose of this review is to focus specifically on lmics to update a review on the evidence to recruit and retain health workers in rural and remote areas of lmics. in order to grow the body of evidence that policy makers can choose from, this paper seeks to systematically explore the literature on recruitment and retention of health workers to rural and remote areas of lmics and provide necessary updates on what is known about rural and remote retention and recruitment of health workers. a better understanding of current and updated recruitment and retention strategies will assist policy makers and key stakeholders in implementing interventions to strengthen the rural and remote health workforces in lmics. while this paper online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 170 does not focus solely on the nursing workforce, nurses work in interdisciplinary teams and it is vital that nurse policy advocates who strive to provide the greatest access to care to rural populations understand the body of evidence about strategies for recruitment and retention of a variety of different healthcare cadres to rural and remote areas of lowand middleincome countries. methods this review is guided by the preferred reporting items for systematic reviews and metaanalyses (prisma) guidelines for conducting systematic reviews. this review searched for articles that reported empirical research to further knowledge about strategies to recruit and retain health workers in rural and remote areas of lmics. to qualify for this systematic literature review, the studies had to consider strategies to address the problem of not enough health workers in rural and remote areas in lmics, such as rural retention initiatives, school-level policies for recruitment for nursing and medical schools, and governmental laws and regulations. articles were excluded if they did not describe or address a strategy or solution to address recruitment and retention of health workers in rural and remote areas. articles were excluded if they did not meet the general definition of rural or remote areas. articles that stated they were looking at rural or remote health workforces were included and their exact definitions of rural or remote were extracted. articles were not included if they generally addressed recruitment or retention in both urban and rural areas, meaning articles were only included if they were addressing specifically the recruitment and retention of health workers serving rural or remote populations. to qualify for this review, an original, peer-reviewed research paper must have addressed a solution to the problem of maldistribution of health workers between rural and urban areas in lmics. for the purpose of this literature review, health worker was defined as physician, nurse or online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 171 midwife, as they are cadres the world health organization (who) and the global health workforce alliance deem as key health workers in achieving universal health coverage (campbell et al., 2013; global health workforce alliance & who, 2013; guilbert, 2006). lmics were defined by the world bank as those who have a gross national income of $12,375 or less in 2019 (world bank, 2019). both quantitative, qualitative and mixed methods articles were included. articles were excluded if they were not in english, did not meet our definition of healthcare workers, were not a peer-reviewed research paper, or did not include an intervention to recruit or retain health workers in lmics. due to the complexity of the search and the large number of synonyms for the included search terms, a simplified version of the search is included in this section, while the full search string with all synonyms is included in appendix a. searches were adjusted for each database. embase, pubmed, and web of science were searched. the search was “middle/low income country” or [list of all middle/low income countries]) and “health worker” and “distribution”. the search covered all years, in order to maximize the included and relevant articles. next, two reviewers screened title, abstract and then subsequently the full text to see if articles were relevant. these reviewers screened texts independently then met together to concur on included articles. covidence software was used to screen articles. this was followed by one reader extracting all articles, with 10% of the articles being extracted by a second extractor to confirm results. articles were extracted for study design, health workers’ type, country, sample size, rural definition, intervention, and intervention evidence. quality of all articles was assessed using the mixed methods appraisal tool (hong et al., 2018). an assessment of quality was conducted in order to interpret the rigor and strength of the literature. however, no articles were excluded based on online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 172 quality in order to maximize the included and relevant articles. after assessing for quality, results of included articles were synthesized to interpret findings to answer the research question. findings database search results after conducting the search, embase resulted in 238 articles, web of science in 288 and pubmed in 390. once duplicates were removed, this resulted in 731 articles. after title, abstract, and full text screening, 16 articles remained. see figure 1 for additional details. figure 1 prisma diagram. records identified through database searching embase (n =238) web of science (n=288) pubmed (n=390) total (n=916) additional records identified through other sources (n =0) records after duplicates removed (n = 731) records screened (n =731) records excluded (n =701) full-text articles assessed for eligibility (n =30) full-text articles excluded, with reasons not in english (n=1) conference poster (n =1) doesn’t meet hcw definition (n=1) thought piece (n=4) no intervention (n=6) not observing distribution (n=1) studies included in scoping review (n =16) online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 173 overview of articles four articles used qualitative methods, 10 articles used quantitative methods, while the remaining two used mixed methods. of the 11 quantitative methods, four used discrete choice experiments as their survey type. most articles (n=10) were focused on countries in sub-saharan africa, as shown in table 1. the articles discussed different types of health workers: 13 discussed physicians, seven discussed nurses, and three discussed midwives. no articles specifically stated how they defined rural or remote for their study. the quality assessment of all articles can be found in appendix b. of the included articles, 15 were of high quality, with only one article not scoring as the others, as the article was not explicitly clear on the details of the intervention they were evaluating online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 174 table 1 overview of included studies study design health worker country sample rural definition intervention type outcomes figueiredo et al. (2019) cross sectional descriptive design physicians brazil 54 medical schools not explicitly defined, generally defined as rural and underserved areas • established health worker recruitment • student recruitment prevalence of health workers in rural/remote areas gross et al (2010) cross sectional descriptive design nurses kenya 18181 nurses not explicitly defined, generally defined at rural or remote areas • public sector employment prevalence of health workers in rural/remote areas hesketh et al. (2017a) quasi experimental study physicians china 104 village physicians not explicated defined, generally stated as rural china • health infrastructure and retention prevalence of health workers in rural/remote areas kiwanuka et al. (2017) qualitative descriptive nurses, midwives uganda 21 hcws not explicitly defined, generally defined as rural districts • health infrastructure and retention prevalence of health workers in rural/remote areas lagarde et al. (2012) cross sectional descriptive design; discrete nurses south africa 377 nursing students not explicitly defined, generally defined at rural areas • established health worker recruitment willingness to accept employment in rural/remote areas online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 175 choice experiment • student recruitment leon et al. (2010) cross sectional descriptive design physicians tanzania 130 medical students not explicitly defined, generally stated as rural area or rural job • established health worker recruitment • student recruitment willingness to accept employment in rural/remote areas meliala et al. (2013) cross sectional descriptive design; qualitative specialty physicians indonesia 149 specials physicians interviewed 15 specialist physicians shadowed not explicitly defined, generally defined at rural or remote areas • public sector employment prevalence of health workers in rural/remote areas munga et al. (2009) qualitative descriptive physicians, nurses tanzania 21 human resource managers and health workforce policy makers not explicitly defined, generally defined as rural districts • established health worker recruitment • public sector employment prevalence of health workers in rural/remote areas nkomazana et al. (2015) qualitative descriptive physicians, nurses botswana 15 focus groups 5-12 policy markers, health workers and community members in each not explicitly defined, generally stated rural or remote rural. • established health worker recruitment • health infrastructure and retention prevalence of health workers in rural/remote areas online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 176 okeke et al. (2016) difference in difference design midwives nigeria 7104 women who gave birth across 12 nigerian states not explicitly defined, generally defined as rural area or community • public sector employment population health in rural/ remote areas robyn et al. (2015) cross sectional descriptive design; discrete choice experiment physicians, nurses cameroon 351 medical students, nursing students and health workers not explicitly defined, generally defined as rural area or remote rural area • established health worker recruitment • health infrastructure and retention • student recruitment willingness to accept employment in rural/remote areas serneels et al. (2007) contingent evaluation physicians, nurses ethiopia 219 nursing students; 90 medical students not explicitly defined, generally defined as rural area • health infrastructure and retention willingness to accept employment in rural/remote areas sirili et al. (2019) qualitative descriptive physicians tanzania 20 recently graduated physicians not explicitly defined, generally defined as rural area • established health worker recruitment • student recruitment willingness to accept employment in rural/remote areas song et al. (2018) longitudinal observation study physician china 796 poor counties not explicitly defined, generally defined as rural counties • public sector employment prevalence of health workers in rural/remote areas thoresen & fielding (2010) cross sectional descriptive physicians; nurses; midwives thailand 93 healthcare students not explicitly defined, generally • established health willingness to accept employment in online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 177 design qualitative defined as rural districts worker recruitment • health infrastructure and retention rural/remote areas vujicic et al. (2011) labor market survey; discrete choice experiment physicians vietnam 292 physicians not explicitly defined, generally defined as rural areas • established health worker recruitment • health infrastructure and retention willingness to accept employment in rural/remote areas online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 178 strategies used the strategies of the included studies fit into four categories developed by the authors for organizational purposes and synthesis of information. the categories were “public sector employment” (n=5), “established health worker recruitment” (n=9), “student recruitment” (n=5) and “health infrastructure and retention” (n=7). studies observed outcomes that fit into the following three categories, again developed by the author for organizational and synthesis of information: “prevalence of health workers in rural and remote areas” (n=8), “willingness to accept employment in rural and remote areas” (n=7), and “population health in rural and remote areas” (n=1). table 2 overviews the results by strategy type and study results. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 179 table 2 strategies to recruit and retain health care workers in rural and remote area’s evidence intervention type interventions evidence public sector employmen t the government used their own funds to hire healthcare workers to rural/remote areas • increasing public sector midwives in rural areas increased use of antenatal care by 7.3 percentage points. however, they found no significant difference in maternal delivery outcomes or skilled birth attendance (okeke et al., 2016) • 12% increase in nursing staff in the public sector • 204 of 2359 health facilities run by only emergency hiring plan nurses • the most remote area province had a 37% increase in nurses (gross et al., 2010) china’s comprehensive health system reform that increased physician was found to increase physicians in rural underserved areas, however the improvement was not distributed between richer and poorer rural areas (song et al., 2018) the government mandated health worker location and public service • very few physicians spend the required time in their public hospitals, some as little as 1.5 hours a week. this was likely because public sector pay was such a little part of the physician’s overall incomes. • physicians were non-compliant with the new licensure regulations, and would practice where they wanted to, whether they had a license to practice at that location (meliala et al., 2013) federal government places health workers in jobs in the district of their choice • federal government was more effective at placing people in highly remote areas, than when the districts published the jobs themselves (munga et al., 2009) establish health worker recruitment car or housing allowance • in a focus group, housing and car allowance were mentioned as a recruitment study they believed would work for them (nkomazana et al., 2015) • lagarde et al (lagarde et al., 2012) found that offering housing and a car allowance as a recruitment strategy both worked as a way to recruit people to a job and was cost effective. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 180 • providing free housing to physicians in rural areas has a low impact and would only increase those willing to accept employment from 7% to 11 % (vujicic et al., 2011) salary increase • medical students (aor=8.27, ci: 5.23-12.96, p<0.001), medical doctors (aor=5.60, ci: 4.12-7.61, p<0.001) and nurse aids (aor=4.29, ci: 3.11-5.93, p<0.001) all reported they would take a rural/remote job for 75% of the base salary as a bonus (robyn et al., 2015) • robyn et al (robyn et al., 2015) they did not find significance for a salary bonus of 75% with nursing students or nurses. • salary increases about 20% were found to be very expensive, and therefore not cost effective (lagarde et al., 2012) • to reach ethiopia’s goal of 80% of health workers in a rural post, you would need to increase physicians’ salaries by 83% and nurses’ salaries by 57% (serneels et al., 2007) guaranteed reassignment to urban areas • nursing students (aor=2.81, ci: 2.22-3.56, p<0.001) were more likely to take a job if they were offered a transfer to an urban area after their service was complete (robyn et al., 2015) • this was supported by munga et al. (2009), who found that many accepted rural positions working for the government with the hope of transferring to an urban area in their governmental job. allow health workers to reside near their families • family and communities’ commitments and social ties and a sense of belong were associated with hcws seeking employment in rural areas, and especially nurses sought employment near their families (thoresen & fielding, 2010) student recruitment recruit students from rural areas to attend medical and nursing schools • graduating medical students over the age of 26 were much more likely to accept a rural by 30 percentage points (p<0.05) (leon & kolstad, 2010) • graduating medical students with rural residing parents were 50 percentage points more likely to take a rural/ remote job (leon & kolstad, 2010) • recruiting students from rural and remote areas is much more cost than any recruitment measures such as salary increase, car bonus, etc. (lagarde et al., 2012) • those with a rural background were less motivated for a medical career at the end of medical school (74% of rural background students reported being less motivated by the end of medical school than before medical school). (leon & kolstad, 2010) online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 181 aor-adjusted odds ratio • urban born are less likely to be willing to take jobs in rural areas (sirili et al., 2019) create medical schools in rural/ remote areas having rotations in rural areas • municipalities with new medical schools had an increase in physicians: inhabitant ratios greater than those in municipalities without a new medical school (figueiredo et al., 2019) • students who have a community health rotation were less likely by 34 percentage points (significance 5%) to accept a job in a rural area than students without a community health rotation (leon & kolstad, 2010) • providing short term training courses in rural areas increased willingness to accept rural employment from 7% to 14% (vujicic et al., 2011) health infrastructur e and retention improve rural/remote health resources and health facilities • medical students, nursing students, medical doctors, and nurses all would take a job in a rural/remote if the facility had good infrastructure (robyn et al., 2015). • the lack of resources in a district when the districts oversee recruiting health workers, also made it very difficult (munga et al., 2009) • improving equipment in rural areas improves a physician’s willingness to take a job in a rural area from 7% to 15% (vujicic et al., 2011) • physicians increased satisfaction with their salaries and other clinic salary changes, decreasing their turnover (hesketh et al., 2017a) • family proximity, community ties, job security and pension enhance retention, while higher cost of living and unpredictable employment increased turnover (kiwanuka et al., 2017) online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 182 public sector employment public sector employment strategies were defined as any studies that included directly hiring health workers into the public sector and deploying and distributing them to rural and remote areas for permanent positions or temporary ones. gross et al. ( 2010) reported on a government intervention, an emergency hiring plan, that used a mix of government and aid organization money to hire nurses into the public sector of employment, allowing the number of nurses hired to be greater in areas of more need. this descriptive comparative study had a sample size of 18,181 nurses. the intervention had many successes such as: a 12% increase in nursing staff employed in the public sector, the nursing staff increased by 7% in hospitals, 13% in health centers and 15% in dispensaries, and 204 of 2,359 health facilities were staffed entirely by nurses hired by the emergency hiring plan. the province with the highest prevalence of remote areas benefited the most with a 37% increase in the number of nurses per 100,000 populations (gross et al., 2010). similarly, in nigeria, the federal and local government partnered together to create the midwives service scheme, which hired midwives who were unemployed, retired or newly graduated to staff underserved communities. in regions that received the intervention, there was a 7.3 percentage point increase in antenatal care visits at clinics (okeke et al., 2016). however, there was no significant difference in maternal delivery complication or use of skilled birth attendance between regions who received the intervention and those that did not (okeke et al., 2016). another intervention found in the literature was also a government-level policy change which compared the use of the federal government for hiring healthcare workers versus the district government having the hiring power. munga et al.(2009) found through qualitative interviews that the centralized federal government was more effective at recruiting highly skilled healthcare online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 183 workers to remote areas. however, when district leadership recruited health workers themselves there was better retention (munga et al., 2009). meliala et al.(2013) evaluated the effectiveness of a government policy that required physicians work in public facilities for a certain number of days per week. in addition, the government awarded only a certain number of physician’s licenses per district, therefore distributing them out further. this policy change was not well enforced, with physicians only working 1-3 days out of the 5 days of work required. additionally, the findings indicated that physicians would just practice where they wanted without being licensed, so this intervention was ineffective in distributing the physician workforce (meliala et al., 2013). finally, another study by song et al. (2018) looked at the chinese comprehensive health system reform, which included training health workers to work in public facilities and requiring physicians to serve in rural areas in order to be eligible for a professional promotion. through this policy change in china, the number of health workers did increase in rural areas. however, the number of health workers did not increase as much in poorer rural counties as in richer rural counties (song et al., 2018). established health worker recruitment established health worker recruitment strategy was defined as any incentive to recruit or encourage more established health workers to work in rural or remote areas. within the literature, this section can be further broken down into the following four categories of established health worker recruitment: car/housing allowance (n=3), salary increase (n=3), guaranteed reassignment back to an urban area (n=2) and allowing health workers to reside near their families (n=1). three studies observed the effectiveness of a car/ housing allowance as a recruitment intervention for health workers to take a job in a rural and remote area (lagarde et al., 2012; online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 184 nkomazana et al., 2015; vujicic et al., 2011). the first was a qualitative study, with participants of both health workers and health policy makers in botswana identifying that they perceived a car or housing allowance to be an effective intervention to recruit health workers to take a job (nkomazana et al., 2015). lagarde et al. (2012) observed the cost effectiveness of a variety of different recruitment interventions, finding that a car allowance in combination with offering study leave sooner was a cost-effective intervention to recruit heath workers to rural areas however, vujicic et al. (2011) found that providing free housing to physicians in rural areas has a low impact and would only increase those willing to accept employment from 7% to 11% . three studies looked at the use of salary increases or bonuses as a means of incentivizing people to take positions. two of those studies used quality methods of a well-appraised measurement tool (araujo & maeda, 2013), a discrete choice experiment, with appropriate sample sizes and low attrition (lagarde et al., 2012; robyn et al., 2015). the third study used observed contingent evaluation to observe how much health workers’ salaries would need to increase for them to be willing to take a job in a rural and remote area (serneels et al., 2007). robyn et al. ( 2015) looked at the odds of a medical student, nursing student, medical doctor, nurse or nurse aid’s willingness to take a position in a rural and remote area based on several incentives. medical students, medical doctors, and nurse aids all reported they would take a rural and remote job for 75% of the base salary as a bonus but salary increases did not increase nursing students or nurse’s willingness to accept a job in a rural area (robyn et al., 2015). similarly, lagarde et al.(2012) found that salary increases of 20% higher than the current salary was found to be an expensive intervention. finally, serneels et al. (2007) found that to reach ethiopia’s goal of 80% of health workers in a rural post, you would need to increase physicians’ salaries by 83% and nurses’ salaries by 57%. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 185 another possible incentive was offering leave sooner to those who are working in rural and remote areas than for those who are not. many governments have an amount of public service time required after graduating before a health worker can choose where they want to work. this was found to be a relatively cheap incentive, compared to incentives like a salary increase. this incentive provided that if workers took a job in a rural and remote area they could leave their position sooner to go to graduate studies. it was even more effective when it is combined with a car or a salary increase, but the costs go up (lagarde et al., 2012). similarly, another intervention was giving a guaranteed reassignment to urban areas, after a mandatory rural time was complete. nursing students were more likely to take a job if they were offered a transfer to an urban area after their service was complete (robyn et al., 2015). this was similar to the findings of munga et al. (2009) who found that many accepted rural positions working for the government with the hope of transferring to an urban area in their governmental job. finally, one study observed placing health workers in jobs near their families who reside in rural areas as an incentive to take a job in a rural area. family and communities’ commitments, social ties, and a sense of belonging were associated with health workers seeking employment in rural areas, and especially nurses sought employment near their families (thoresen & fielding, 2010). student and school-based strategies student and school-based strategies included any intervention that focused on factors of students (i.e. demographics or experiences in school) that increased likelihood of taking a position in a rural and remote area. three studies observed interventions that recruited students to medical or nursing school from rural and remote areas, to see if they are more likely to return to rural and remote areas post-graduation (lagarde et al., 2012; leon & kolstad, 2010; robyn et al., 2015). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 186 health worker students whose families lived in rural districts were 50% more likely to take rural and remote jobs after graduation and students 26 and older were 30% more likely (leon & kolstad, 2010). recruiting students from rural and remote areas is more cost-effective than salary increases or car bonuses (lagarde et al., 2012). although students from rural areas are more likely to be willing to accept rural jobs, 74% of those students from rural areas were found to be less motivated at the end of medical school then their peers (leon & kolstad, 2010). next, the introduction of a community health rotation during medical school was evaluated as a possible way of incentivizing health workers to work in rural and remote areas. leon & kolstad(2010) found that in a study with 130 medical students in tanzania, students who have a community health rotation were 34% less likely to accept a job in a rural area than students without a community health rotation, suggesting that this intervention was ineffective. this may have been because they did not have positive experience in their community health rotations (leon & kolstad, 2010). however, when vujicic et al. (2011) used a discrete choice experiment with 292 physicians, they found that providing short term training courses in rural areas increased willingness to accept rural employment from 7% to 14%. figueiredo et al. (2019) looked at an intervention in brazil which set up medical schools in rural and medically underserved municipalities. when comparing the rural municipalities who received a new medical school and those that did not, they found that those who had a new medical school had a greater increase in physicians to inhabitant ratios, suggesting that locating medical schools in rural areas was a way to increase physicians in rural areas (figueiredo et al., 2019). health infrastructure and retention health infrastructure and health worker retention category included any intervention that worked on retaining health workers in rural and remote areas. five studies observed interventions online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 187 within this category. the main intervention discussed was improving rural and remote health resources and health facilities (nkomazana et al., 2015; robyn et al., 2015; vujicic et al., 2011). a qualitative study of interviews with policy makers and health workers pointed to fixing resource deficits as a possible solution to rural retention (nkomazana et al., 2015). medical students, nursing students, medical doctors, and nurses all would take a job in a rural and remote facility if that facility had good infrastructure (robyn et al., 2015). in addition, improving equipment in rural areas improves a physician’s willingness to take a job in a rural area from 7% to 15% (vujicic et al., 2011). two other studies observed rural retention. physician’s job satisfaction was increased when their salaries increased, which in turn decreased physician turnover (hesketh et al., 2017a). family proximity, community ties, job security and pension enhanced retention while higher cost of living and unpredictable employment increased turnover (kiwanuka et al., 2017). discussion this systematic review explored strategies to address the lack of healthcare workers in rural and remote areas in lmics. the literature was limited due to the lack of randomized controlled trials or quasi experimental research. we used systematic review methods to update past reviews on evidence-based strategies to recruit and retain health workers in rural and remote areas, while focusing on lmics who may face unique resource challenges in creating workforce distribution policy interventions. our results indicate some successful interventions as well as the need for further research to evaluate the implementation across contexts. our results indicate that there is not one solution or perfect strategy that can address the lack of health workers in rural and remote areas of lmics. each strategy had its successes and its shortcomings. the next sections will address the successes and shortcomings of each of the online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 188 following intervention types: public sector employment, rural and remote employment incentives, student and school-based strategies, and health infrastructure and retention. public sector employment policy recommendations the following is a list of important considerations for policy makers considering expanding public sector employment: 1. using the resources of the federal government may be more effective in hiring health workers to rural and remote areas than local resources, as the federal government may have more access to advertising and recruitment strategies (munga et al., 2009). 2. even with public sector employment scale up, it is still necessary to maintain high job satisfaction or retention of these employees (munga et al., 2009). 3. when rolling out increased public sector employment in rural and remote areas, it is important to monitor patient outcomes, since okeke et al. (2016) found that increased midwives at public facilities did not improve maternal outcomes. 4. public sector employment can be expensive on the part of the government and may not have the opportunity to be subsidized by external funding as it was in the kenya’s emergency hiring plan (gross et al., 2010). sustainability of external funding sources should be evaluated. 5. if using required hours per week with health workers in the public sector, it is important to have strict monitoring of these hours in order to ensure compliance (meliala et al., 2013). depending on the financial resources of a government considering addressing the geographical imbalance of healthcare workers, public sector employment could be successful. but online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 189 the government would need to make sure financial support to fund the jobs is available, as well as investing in ensuring good job satisfaction at these rural and remote jobs. establish health worker policy recommendations the following are a list of important considerations for policy makers considering recruiting established health workers to rural and remote posts: 1. increasing salaries were found to be effective by three studies (lagarde et al., 2012; robyn et al., 2015; serneels et al., 2007). however, it should be noted that this was an expensive way to increase willingness to accept employment, compared with other incentives (lagarde et al., 2012). 2. offering a car or housing allowance increased participants’ willingness to accept employment but was much less expensive (lagarde et al., 2012). therefore, these interventions would be more cost-effective choices for policy makers. various incentives to recruit health workers to rural and remote areas may be effective. before implementing policy changes, cost should be considered because a salary increase incentive may be more expensive than other interventions that yield similar results. student recruitment policy recommendations the following are a list of important considerations for policy makers considering recruiting health worker students to rural and remote posts: 1. recruiting and incentivizing student from rural and remote areas to attend medical, nursing, and midwifery schools may be an effective way to increase the health workforce of rural and remote areas, as these students are more likely to be willing to take a job in rural and remote areas (leon & kolstad, 2010). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 190 2. placing medical, nursing, and midwifery schools in rural and remote areas could be an effective way to increase health workforces in rural and remote areas, based on findings that indicated that medical schools located in rural and remote areas increased the number of medical doctors in those regions (figueiredo et al., 2019). 3. policy makers could consider increasing clinical rotations in rural and remote areas; however, these programs should be carefully monitored as the literature was mixed as to the effectiveness of this interventions. one study indicated that a rural clinical rotation increased willingness to accept jobs there (vujicic et al., 2011), while a second indicated students were less likely to accept employment in rural areas after a clinical rotation there (leon & kolstad, 2010). recruiting students from rural areas, locating health worker schools in rural areas and rural clinical rotations may all be effective ways of increasing rural and remote health workforces. these are highly cost-effective interventions in comparison to increasing salaries or creating emergency hiring plans to hire employees into the public sector. however, they will not work if there are no rural or remote job positions to take so they need to be paired with interventions to scale up employment opportunities in rural and remote areas. health infrastructure and retention policy recommendations the following is a list of important considerations for policy makers considering improving health infrastructure and other interventions in order to promote health worker retention: 1. improvements and investments in rural and remote health facilities to support health workers would likely be effective in decreasing health worker turnover (munga et al., 2009; robyn et al., 2015; vujicic et al., 2011). online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 191 2. other factors that decrease turnover are increased salaries (hesketh et al., 2017b), family proximity, community ties, job security and a strong pension (kiwanuka et al., 2017). these factors that relate to retention need to be addressed in conjunction with interventions that recruit health workers to rural and remote areas. implications this literature review supports a comprehensive strategy that addresses one or more of the above facets of recruitment and retention of health workers (public sector employment, established health worker recruitment, student recruitment, and health infrastructure and retention) and will likely be the most successful methods to increase the number of skilled health workers available to deliver care in rural and remote areas of lmics. this review was not the only review that supports multi-faceted strategies that address multiple factors of recruitment and retention. lehmann et al. (2008), after conducting a literature review on recruitment and retention of health worker staff in rural and remote areas in lmics, also concluded that there are many facets of attraction and retention of health workers to rural and remote areas. in a synthesis of literature on retention strategies for health workers in rural and remote areas buykx et al. (2010) also supported that bundles of retention strategies were more effective than single faceted strategies worldwide. this overlapped with the findings of this literature review that supported the importance of addressing multiple facets of recruitment and retention rather than a single intervention. this literature review contributes to the state of the science regarding recruitment and retention of health workers in rural and remote areas by reflecting the need for multiple and integrative intervention approaches. the integration of these strategies can improve the efficacy and financial feasibility of interventions in order to effectively recruit and maintain health care online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 192 workers. the results reflect similar retention strategies from past literature reviews published a decade earlier. the majority of the included articles were published since the previous reviews published in 2010 and earlier indicating that the results have remained true over the last decade. in 2008, lehmann et al. (2008) claimed policy makers are not always making choices based on evidence-based strategies, like the ones reviewed in this systematic review. this review of the literature indicated that since 2008 many researchers are utilizing who’s recommendations to monitor, evaluate, and disseminate recruitment and retention interventions in rural and remote areas (who, 2010). it is important for researchers to continue to publish work related to the outcome of interventions and strategies to recruit and retain health workforces in rural and remote areas so that knowledge can be shared, and evidence-based strategies can be used in more locations. nurses are key policy advocates for rural populations around the world and understanding the need for policy-based strategies are key to developing interventions to support health workforces in rural areas globally. there are many implications for rural healthcare in lmics based on the findings of this literature review. rural healthcare facility managers and policy makers need to utilize the above technique to recruit and retain health workers to their facilities in order to have stronger health systems that can serve rural populations. these manager and policy makers can increase health worker salaries, offer car or housing allowances, encourage local medical, nursing and midwifery schools to complete rotations in their facilities, and invest in good work environments for employees. in resource limited settings and lmics it may be difficult to make these types of investments; however, this paper supports that if these investments are made there is evidence of effectiveness in recruiting and retaining health workers. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 193 in conclusion, an intervention that addresses multiple facets of recruitment and retention is likely to cost a government significant money, but it may improve access to healthcare for the individuals who reside in rural and remote areas. it would be most effective to have seamless and effective coordination between the government, not-for-profit and private sectors in order to create effective interventions. this review supports that there are four facets of recruitment and retention of health workers to rural and remote posts in lmics which are public sector employment, established health worker recruitment, student recruitment and health infrastructure and retention. this review supports multi-faceted interventions that are specifically designed for the settings they are being implemented in. recommendations for future research future research should measure population health indicators as an outcome. only one article addresses population health as an outcome of the interventions discussed (okeke et al., 2016). it should be noted that the goal of increasing the prevalence of health workers in rural and remote areas is to improve the health of populations in rural and remote areas and health care access of the populations of rural and remote areas. nursing research often approaches problems in a patient and people centric way. nursing research could lead the way on developing evaluations of policies and strategies to recruit and retain health workers in rural and remote areas that focus on looking at population health indicators as an outcome of success. many of these studies looked at health workers willingness to accept employment as an outcome. these studies were hypothetically asking health workers and health worker students about their willingness to accept employment. more research needs to be done on the actual effectiveness of these interventions, rather than the hypothetical effectiveness of these interventions. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 194 limitations the articles lacked homogeneity in strategies and geographical locations which made it hard to draw generalizable conclusions about this subject. in addition, these articles did not have specific definitions of rural and remote areas included in them, making it difficult to compare interventions to one another. future research should explicitly define rural and remote areas in research to make research findings generalizable to other locations. to implement any strategies that this review points to, more research needs to be done on the specific area where these strategies are being considered and look toward unique strategies that meet the needs. research will need to focus on region specific strategies that are feasible and cost effective. experimental studies of these interventions will need to be conducted to evaluate if these strategies are effective in getting more health care workers in rural and remote areas, as well as measuring their impact in health outcomes. conclusions this study showed some positives and negatives of different strategies that could address the lack of health care workers in lmics’ rural and remote areas. likely, in order to successfully address the needs of the populations in the world’s rural and remote areas many strategies will need to be implemented simultaneously, including increasing the capacity of public sector employment, increasing recruitment of establish health workers, increasing recruitment of health worker students and building health infrastructure to retain health workers in rural and remote areas. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 195 references araujo, e., & maeda, a. 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(2016). global strategy on human resources for health: workforce 2030. online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 201 appendix a search strategy for pubmed: middle/lo w income country ("deprived countries" or "deprived country") or "deprived nation") or "deprived nations") or "deprived population") or "deprived populations") or "deprived world") or "developing countries") or "developing country") or "developing economies") or "developing economy") or "developing nation") or "developing nations") or "developing population") or "developing populations") or "developing world") or "lami countries") or "lami country") or "less developed countries") or "less developed country") or "less developed economies") or "less developed economy") or "less developed nation") or "less developed nations") or "less developed population") or "less developed populations") or "less developed world") or "lesser developed countries") or "lesser developed country") or "lesser developed economies") or "lesser developed economy") or "lesser developed nation") or "lesser developed nations") or "lesser developed population") or "lesser developed populations") or "lesser developed world") or "lmis") or "lmis") or "low gdp") or "low gnp") or "low gross domestic") or "low gross national") or "low income countries") or "low income country") or "low income economies") or "low income economy") or "low income nation") or "low income nations") or "low income population") or "low income populations") or "lower gdp") or "lower gnp") or "lower gross domestic") or "lower gross national") or "lower income countries") or "lower income country") or "lower income economies") or "lower income economy") or "lower income nation") or "lower income nations") or "lower income population") or "lower income populations") or "middle income countries") or "middle income country") or "middle income economies") or "middle income economy") or "middle income nation") or "middle income nations") or "middle income population") or "middle income populations") or "poor countries") or "poor country") or "poor economies") or "poor economy") or "poor nation") or "poor nations") or "poor population") or "poor populations") or "poor world") or "poorer countries") or "poorer country") or "poorer economies") or "poorer economy") or "poorer nation") or "poorer nations") or "poorer population") or "poorer populations") or "poorer world") or "third world") or "transitional countries") or "transitional country") or "transitional economies") or "transitional economy") or "under developed countries") or "under developed country") or "under developed economies") or "under developed economy") or "under developed nation") or "under developed nations") or "under developed population") or "under developed populations") or "under developed world") or "under served countries") or "under served country") or online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 202 "under served nation") or "under served nations") or "under served population") or "under served populations") or "under served world") or "underdeveloped countries") or "underdeveloped country") or "underdeveloped economies") or "underdeveloped economy") or "underdeveloped nation") or "underdeveloped nations") or "underdeveloped population") or "underdeveloped populations") or "underdeveloped world") or "underserved countries") or "underserved country") or "underserved nation") or "underserved nations") or "underserved population") or "underserved populations") or "underserved world") list of all middle/lo w income countries ((afghanistan or albania or algeria or ñamerican samoaî or angola or armenia or azerbaijan or bangladesh or belarus or byelarus or belorussia or belize or benin or bhutan or bolivia or bosnia or botswana or brazil or bulgaria or burma or ñburkina fasoî or burundi or ñcabo verdeî or ñcape verdeî or cambodia or cameroon or ñcentral african republicî or chad or china or colombia or comoros or comores or comoro or congo or ñcosta ricaî or ñcªte d'ivoireî or cuba or djibouti or dominica or ñdominican republicî or ecuador or egypt or ñel salvadorî or eritrea or ethiopia or fiji or gabon or gambia or gaza or ñgeorgia republicî or georgian or ghana or grenada or grenadines or guatemala or guinea or ñguinea bisauî or guyana or haiti or herzegovina or hercegovina or honduras or india or indonesia or iran or iraq or jamaica or jordan or kazakhstan or kenya or kiribati or korea or kosovo or kyrgyz or kirghizia or kirghiz or kirgizstan or kyrgyzstan or ñlao pdrî or laos or lebanon or lesotho or liberia or libya or macedonia or madagascar or malawi or malay or malaya or malaysia or maldives or mali or ñmarshall islandsî or mauritania or mauritius or mexico or micronesia or moldova or mongolia or montenegro or morocco or mozambique or myanmar or namibia or nepal or nicaragua or niger or nigeria or pakistan or palau or panama or ñpapua new guineaî or paraguay or peru or philippines or phillippines or philipines or phillipines or principe or romania or rwanda or ruanda or samoa or ñsao tomeî or senegal or serbia or ñsierra leoneî or ñsolomon islandsî or somalia or ñsouth africaî or ñsouth sudanî or ñsri lankaî or ñst luciaî or ñst vincentî or sudan or suriham or suriname or swaziland or syria or ñsyrian arab republicî or tajikistan or tadzhikistan or tadjikistan or tadzhik or tanzania or thailand or timor or togo or tonga or tunisia or turkey or turkmen or turkmenistan or tuvalu or uganda or ukraine or uzbek or uzbekistan or vanuatu or vietnam or ñwest bankî or yemen or zambia or zimbabwe)) distributio n title: ((distribution or balance or imbalance or shortage* or inequality or disparit* or supply*)) online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 203 health care worker (("health workers" or "health workforce" or "human resources" or "labor supply" or "healthcare delivery" or "healthcare professionals" or "physician supply" or "labor market")) *modified appropriately for other databases online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 204 appendix b quality assessment of included studies by the mixed methods appraisal tool (hong et al., 2018) screening questions quantitative non-randomized citation are there clear researc h questio ns? do the collecte d data allow to address the researc h questio ns? are the participant s represent ative of the target population ? are the measurem ents appropriat e regarding both the outcome and the interventio n (or exposure) ? are there compl ete outco me data? are the confoun ders accounte d for in the design and analysis ? during the study period, is the interventi on administ ered (or exposure occurred) as intended ? figueire do et al (figueir edo et al., 2019) yes yes yes yes yes yes yes hesketh et al (hesket h et al., 2017a) yes yes yes yes yes yes yes okeke et al (okeke et al., 2016) yes yes yes yes yes yes yes quantitative descriptive online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 205 citation are there clear research question s? do the collected data allow to address the research questions ? is the sample strategy relevant to address the research question? is the sample represen tative of the target populati on? are the measu rement s approp riate? is the risk of nonrespon se bias low? is the statistical analysis appropriate to answer the research question? gross et al (gross et al., 2010) yes yes yes yes yes yes yes lagard e et al (lagard e et al., 2012) yes yes yes yes yes yes yes leon et al (leon & kolstad , 2010) yes yes yes yes yes yes yes meliala et al (meliala et al., 2013) yes yes yes yes yes yes yes robyn et al (robyn et al., 2015) yes yes yes yes yes yes yes serneel s et al (sernee ls et al., 2007) yes yes yes yes yes yes yes song et al (song et al., 2018) unclear intervent ion unclear yes yes yes yes yes online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 206 thores en et al (thores en & fielding , 2010) yes yes yes yes yes yes yes vujicic et al (vujicic et al., 2011) yes yes yes yes yes yes yes qualitative citation are there clear researc h questio ns? do the collecte d data allow to address the researc h questio ns? is the qualitati ve approac h appropri ate to answer the researc h question ? are the qualitat ive data collecti on method s adequa te to addres s the researc h questio n? are the findings adequat ely derived from the data? is the interpreta tion of results sufficientl y sustained by the data? is there coherence between qualitative data sources, collection, analysis and interpretati on? meliala et al (meliala et al., 2013) yes yes yes yes yes yes yes munga et al (munga et al., 2009) yes yes yes yes yes yes yes kiwanuk a et al (kiwanuk a et al., 2017) yes yes yes yes yes yes yes online journal of rural nursing and health care, 21(2) https://doi.org/10.14574/ojrnhc.v21i2.666 207 nkomaza na et al (nkomaz ana et al., 2015) yes yes yes yes yes yes yes sirili et al (sirili et al., 2019) yes yes yes yes yes yes yes thoresen et al (thorese n & fielding, 2010) yes yes yes yes yes yes yes bernacchi_676_formatted online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 159 rural resilience in cancer survivors: conceptual analysis of a global phenomenon veronica bernacchi, rn 1 jamie zoellner, phd, rn 2 jess keim-malpass, phd, rn 3 pamela deguzman, phd, mba, rn, cnl4 1 phd student, school of nursing, university of virginia, vb6u@virginia.edu 2 full professor, department of public health, university of virginia, jz9q@virginia.edu 3 associate professor, school of nursing and school of medicine, university of virginia, jlk2t@virginia.edu 4 associate professor, school of nursing, university of virginia, prb7y@virginia.edu abstract aim: the aims of this analysis are to (1) identify the concept of rural resiliency in cancer survivors in the nursing literature and (2) propose a conceptual framework that may help nurses leverage rural resilience to improve survivorship care. background: rural cancer survivors demonstrate rural resiliency by utilizing aspects of rural culture to improve their psychosocial distress. however, resiliency in rural cancer survivors is poorly understood. design: we used walker & avants’ concept analysis approach to direct article selection, review, and analysis. review methods: we identified a definition, antecedents, consequences, attributes, empirical referents, and related terms, and provide model, contrary, and borderline case examples. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 160 results: we identified 29 articles that met inclusion criteria. we propose a conceptual model of rural resiliency that is grounded in three domains of rural culture: spirituality, cultural norms, and social capital. attributes of rural culture within these domains impact a cancer survivor’s psychosocial health, leading to either negative or positive psychosocial outcomes. conclusion: a better understanding of how rural resiliency impacts cancer survivors can help clinicians and researchers provide culturally-targeted post-treatment interventions. our proposed conceptual framework may guide nurse researchers to develop measurement tools that evaluate rural resilience and its impact on health outcomes. keywords: rural, cancer survivor, resilience, concept analysis, conceptual framework rural resilience in cancer survivors: conceptual analysis of a global phenomenon there are over 43.8 million cancer survivors worldwide (american cancer society, n.d.), and approximately 3.4 billion people living in rural communities (world bank, n.d.). globally, rural cancer survivors may experience greater psychosocial distress (distress due to physical, emotional, or mental pressures that can decrease quality of life in cancer survivors; (national cancer institute, n.d.) compared to urban cancer survivors (butow et al., 2012). in countries such as australia, the us, ireland, and the uk, rural cancer survivors face barriers to psychosocial care such as provider shortages, local hospital closures, and greater travel times to health care facilities (butow et al., 2012; rogers-clark, 2002). additional barriers include low socioeconomic status, lack of health insurance, and mistrust in healthcare providers (rogers-clark, 2002; zahnd, jenkins, et al., 2018). further complicating access to psychosocial care, rural cancer survivors may prefer to seek psychosocial support from informal sources such as family, friends, and community members instead of healthcare providers (pascal et al., 2015). the global body of literature has identified negative outcomes that rural cancer survivors experience, such as decreased quality of online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 161 life (national cancer institute, n.d.), but little is known about how rural cancer survivors make positive adaptations to improve health outcomes (katz et al., 2010). this concept analysis will help introduce the novel phenomenon of rural resilience in cancer survivors by describing how rural survivors adapt their available community resources to obtain psychosocial care and improve their health outcomes (cosco et al., 2017). resiliency in cancer survivorship is poorly understood due to multiple definitions and contexts (molina et al., 2014). the concept of rural resilience is scarce in nursing literature, and in cancer survivorship literature. at this point, resilience is ill-understood in rural communities, likely because of a strong focus on the negative outcomes that cancer survivors experience (rogers-clark, 2002). concepts are dependent on their context (rodgers, 1993) and resiliency in cancer survivors needs to be analyzed from the rural cultural perspective. currently, rural resilience is a developmental concept in ecological literature (heijman et al., 2019) but this concept may not depict how rural cancer survivors make positive adaptations despite poor healthcare access. likewise, resilience has been analyzed as a concept in nursing literature for patients across the age continuum (earvolino-ramirez, 2007) but that model may not capture how rural culture influences resiliency, or how nursing research may utilize resiliency to improve health outcomes for rural cancer survivors. resilience in adult cancer survivors has been conceptualized in a model that explains the continuum of distress-resilience and incorporated individual characteristics (deshields et al., 2016) but does not explain the role of culture. rural culture influences the health behaviors and beliefs of cancer patients, and its role needs to be understood to develop interventions that improve health outcomes (carriere et al., 2018; rogers et al., 2019). developing a conceptual framework of rural resiliency is the first step towards future intervention development. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 162 by understanding the attributes and outcomes of rural resiliency in cancer survivors, clinical nurses and researchers working in a variety of rural settings will be able to better identify how to engage their communities in survivorship care to improve health outcomes. the purpose of this concept analysis is to 1) establish rural resilience in cancer survivors as a global phenomenon of nursing interest, and 2) propose a conceptual framework to guide the development of interventions that promote rural resilience in cancer survivors. the concept of rural resilience in cancer survivors will be analyzed using the walker and avant (2005) method while discussing the challenges of measuring rural resilience, and recommending focus areas for future research (schiller, 2018). methods a clear and rigorous concept analysis is fundamental for future nursing theory and clinical practice changes (schiller 2018). to accomplish this, we selected the walker and avant’s method due to its prevalence in nursing concept literature and clear methodological steps (walker & avant, 2005). the selection of rural resilience in cancer survivors was chosen based on our clinical experiences observing this population’s successful adaptations to meet their post-treatment needs through informal community resources. the literature defines adaptation in the face of adversity as resiliency (cosco et al., 2017). in this analysis, rural resilience is defined as 1) rural cancer survivors facing adversity, and 2) making an adaption, specifically the use of informal community resources to meet post-treatment care needs and overcome structural, social, physical, and cultural barriers to accessing healthcare. the purpose of this concept analysis is to identify the phenomenon of rural resiliency in the cancer survivorship literature. language used to describe resiliency in the literature guided the search in two phrases. the first search phrase used (resilience or self-efficacy or coping or online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 163 resiliency or self-reliance or spirit or strength or "positive adaptation") and rural and cancer and survivor. the second phrase used community and rural and cancer and survivor. databases searched were: pubmed, googlescholar, proquest social sciences, and web of science. one hundred sixty-five (165) studies were retrieved. all studies retrieved by the search phrases were exported to citation manager for title and abstract review. studies that were relevant to the conceptual analysis based on title and abstract review were fully read, and concept uses, antecedents, consequences, and empirical referents were coded and extracted by a single reviewer. 29 studies meet inclusion criteria for this conceptual analysis. analysis concept uses the literature reflects a continuum of positive and negative aspects of rural resilience as it relates to psychosocial outcomes. negative aspects that increased psychosocial distress included: describing inaccurate beliefs about cancer (livaudais et al., 2010); explaining how rurality caused poor health outcomes (katz et al, 2010); describing how rural cancer survivors ended up isolated from their communities (rogers-clark, 2002); and describing a lack of care-seeking behaviors (gunn et al.,2019). positive aspects of the concept included: strong coping strategies (cahir et al., 2017); inner strength (gunn et al.,2019); informal community support systems (allicock et al., 2017); changing negatives into positives (gisiger-camata et al., 2016); improved health outcomes (rogers et al., 2019); buffers to emotional distress (reid-arndt & cox, 2010); reduced distress (angell et al., 2003); maintaining social standing during survivorship (lópez et al., 2005); improved self-efficacy (olson et al, 2014); returning to normalcy (torres et al., 2016) a positive survivorship narrative (allen & roberto, 2014). antecedents online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 164 several antecedents were consistently found during the phenomenon of rural resilience in cancer survivors. these included barriers to health care access and health outcome disparities, unmet needs for caregivers, fear, having a goal of returning to normal, and a lack of survivorship information (deguzman et al., 2017). the dearth of healthcare access caused a cascade of issues such as unmet survivor needs, fear of cancer-related outcomes, and lack of available survivorship information. facing these challenges, rural survivors needed to find survivorship care through the community resources available to them. attributes rural resilience is guided by cultural beliefs and values. resiliency exists on a dynamic continuum of resilience-psychosocial distress (deshields et al., 2016), and culture impacts resilience through subjective norms and health behaviors (carriere et al., 2018). we found the rural cultural domains of spirituality, social capital, and cultural norms have aspects that can positively or negatively impact health along the resilience-psychosocial distress continuum. the attributes are presented here as a dichotomy between those positive aspects (such as seeking support from the community), and related negative aspects (such as mistrust in healthcare). spirituality: faith vs fatalism rural cancer survivors face challenges obtaining information about the survivorship period, including what to expect. rural survivors use faith as a source of cancer knowledge and support, using spiritual explanations such as “god’s will” (livaudais et al., 2010). faith, prayer, and god are linked to strong social networks via local community churches, and this spiritual support can enable rural cancer survivors to remain positive during the survivorship transition (torres et al., 2016). through faith and spiritual knowledge, which supports inner-strength, rural survivors maintain their independence (walker et al., 2015). faith is utilized as a channel for rural cancer online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 165 survivors to return to their community; rural cancer survivors determined they were successfully transitioning back to their normal lives by spending time at church instead of in the hospital (walker et al., 2015). the negative aspect of spirituality was fatalism. with the spiritual knowledge of “god’s will”, rural survivors may accept their pre-determined fate and decide not to seek health care (; torres et al., 2016). through fatalism, spiritual knowledge of cancer is the result of poorly resourced communities and cultural oddities (allen et al., 2014). providers’ own perceptions of spiritual beliefs may result in culturally inappropriate care. social capital: strong community networks vs cultural differences the attribute of strong social networks was frequently used to describe rural communities in research literature. terms used to describe social networks include “support networks”, “community”, and “social support” (olson et al., 2014; rogers et al., 2019; torres et al., 2016). rural cancer survivors utilize their strong social networks as both informal community support systems and caregivers. social networks keep community members closely connected, and therefore survivors’ cancer journeys are often public knowledge, which survivors view both positively and negatively (mcnulty & nail, 2015). despite a loss of privacy, communities support rural cancer survivors to make healthy choices (rogers et al., 2019), and make healthcare related decisions (allen et al., 2014). the presence and role of strong social networks in rural communities positively impact survivors’ health, but cultural differences may transmit false thinking and beliefs about cancer. the term “cultural differences” was used to encompass any cancer-related belief, activity, or value that was not congruent with mainstream medical practice. cultural differences were used to online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 166 explain rural survivors’ inaccurate beliefs about cancer, unhealthy patterns of behavior, and reasons for worse mental health outcomes (andrykowski & burris, 2010; livaudais et al., 2010). cultural norms: seeking community support vs mistrust in healthcare providers rural cancer survivors often prefer to seek support from informal community sources instead of formal health providers (pascal et al., 2015). rural cancer survivors seek the opportunity to connect with community peers, and obtain community support (allicock et al., 2017). rural cancer survivors indicate they trust their community and community leaders and feel a strong desire to reconnect with their community as they transition to back to their normal lives (gunn et al., 2019; mcnulty & nail, 2015). however, seeking community care may also be due to culturally grounded mistrust in healthcare providers, particularly for rural ethnic and minority groups. rural cancer survivors are sometimes unwilling to seek care from providers (rogers-clark, 2002). a negative outcome of seeking survivorship care and information from informal community sources, is that rural cancer survivors learn inaccurate beliefs about cancer (livaudais et al., 2010). minority survivors may face similar challenges to seeking care from providers, although the origins are different (zahnd, murphy, et al, 2021). researchers have shown that inherent bias and racism in the health care system has left many patients from minority cultures mistrustful of the healthcare system (lópez et al., 2005; mcnulty & nail, 2015). there are differences specific to rural minority cultures. for example, rural hispanic communities may not receive the same information as non-hispanic white cancer survivors because of the inherent bias of providers (livaudais et al, 2010). consequences consequences of rural resilience for cancer survivors is associated positive and negative outcomes along the resilience-psychosocial distress continuum. resilient rural cancer survivors online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 167 can leverage self-and community-reliance to their benefit, but limited healthcare facility resources can lead to unmet post-treatment needs. rural cancer survivors who adapted their existing community systems to support their needs experienced positive consequences such as improved quality of life (mcnulty & nail, 2015), improved physical health (rogers et al., 2019), decreased psychological distress (angell et al., 2003), strong coping skills (torres et al., 2016), improved self-efficacy (olson et al., 2014), less emotional distress (reid-arndt & cox, 2016), and post-traumatic growth (andrykowski & burris, 2010). despite the lack of available health care providers and information, rural cancer survivors were able to utilize their informal community resources to improve their health outcomes. when aspects of rural culture impacted health behaviors in a way that decreased rural resiliency and increased psychosocial distress, cancer survivors experienced chronic health crisis (rogers-clark, 2002), lower functionality (reid-arndt & cox, 2010), unmet survivorship needs (katz et al., 2010), worse coping skills (schlegel et al., 2009), and poorer psychosocial health (andrykowski & burris, 2010). in context of these negative attributes, although rural cancer survivors adapt their strong informal community support systems to obtain survivorship care, they experience poorer health outcomes because they lack clinical support (pascal et al., 2015). model, borderline, and contrary cases in a model case of rural resiliency, cancer survivors with poor access to providers obtain survivorship care efficiently using informal community resources. for example, jackie, a 57-year old breast cancer survivor, is six months post treatment. she received her cancer treatment from a nci-designated cancer center that is two hours away from her home. her local hospital does not have an oncologist or social worker, and her primary care physician is not comfortable providing survivorship care. jackie is experiencing high levels of anxiety about her physical and functional online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 168 changes post treatment. she seeks information and support from peers at her church group. using her social network and spiritual knowledge, jackie views her new changes as “god’s will” and experiences reduced levels anxiety. she does not seek clinical support or treatment. at her follow up visit with her oncologist, jackie admits to having anxiety, but declines her oncologist’s offer for a social work referral. a borderline case of rural resiliency would be if a cancer survivor sought information or support from informal community resources, but is unable to efficiently obtain help. using the same situation as described above, a borderline case of resiliency would be if jackie seeks knowledge and support from her local church group, but the church group is difficult for her to connect with. it takes jackie several attempts before she is able to speak with the church group, but once she does, they give her information and support. in a contrary case, consider james, a 70-year old thyroid cancer survivor who has been denied help from an informal community network. james received treatment from an oncologist and surgeon at the nearest cancer center-over 2.5 hours away from his home. he needs to make a follow-up appointment with an endocrinologist, but there is only one provider in his community, and the provider doesn’t have any appointments available for the next three months. james will need to travel back to the cancer center in a week to see the endocrinologist there, but he is unable to drive because of the pain medications he is taking. james needs help with transportation to his appointment. he reaches out to his local community, friends and neighbors, and they tell him they cannot help him. james has to reschedule his appointment. empirical referents although the phenomenon of rural resilience is present in the literature, the conceptual term is not. likewise, there are currently no consistently used empirical referents of rural resilience. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 169 while there are various resiliency measures, the connor-davidson resilience scale and resilience scale for adults were found most frequently in our literature review, and both have higher psychometric ratings when compared to other resilience measures (wells, 2009). the resilience scale has been used to assess resilience in rural cancer survivors, and found that the scale may not show how self-reliance in rural communities is possible due to the presence of strong social networks (wells, 2009). the resilience scale for adults measures resilience through the domains of personal competence, social competence, family coherence, social support and personal structure (wells, 2009). when compared to the domains we found to impact rural resiliency, this scale measured social capital thoroughly. however, it may not measure the rural resilience domains of spirituality and cultural norms. the connor-davidson resilience scale, a reliable and validated scale used to measure resiliency in cancer patients across the care continuum (connor & davison, 2003) has been used to assess resiliency in aging rural populations (mckibbin et al., 2016). this scale measures resilience through the domains of personal competence, trust, acceptance of change and secure relationships, control, and spiritual influence (wells, 2009). when compared to our findings regarding rural resilience, this scale may address the domain of spirituality, and may address social capital through relationship, personal competence and secure relationships. however, the connordavidson resilience scale does not factor in the impact of cultural norms, which we found to be a significant domain of rural resiliency. neither the connor-davidson resilience scale or the resilience scale of adults comprehensively measure the domains of rural resilience found in our literature review. furthermore, it is unknown if these scales are culturally appropriate for rural cancer survivors (wells, 2009). resilience may be understood differently within various cultures (wells, 2009) and online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 170 we have established that rural culture is the foundation of rural resilience for cancer survivors through our analysis. future qualitative research can determine the applicability of current resilience measures, and provide direction for how to improve those measures to be culturally tailored (wells, 2009). discussion we have identified rural resiliency within the literature by discovering how rural cancer survivors achieve health in a limited-resource environment. we found rural survivors experience more cancer-related fears, unmet needs, and higher levels of emotional distress than urban ones (gunn et al., 2019). due to cultural beliefs, personal preference, or lack of resources, rural survivors actively seek survivorship care through informal community systems (pascal et al., 2015). while rural survivors demonstrate resiliency, the unique cultural context makes it challenging to define or measure rural resiliency. rural cancer survivor needs are different from urban ones, and require different interventions (katz et al., 2010). we propose a conceptual framework to aid in understanding the role of rural resiliency when addressing the unique needs of rural cancer survivors. figure 1 depicts a conceptual framework of rural resilience based on the current analysis. this framework depicts attributes of rural resiliency found within the literature, which are represented as three cultural domains on the resiliencepsychosocial distress continuum (deshilds et al., 2016). the domains of spirituality, social capital, and cultural norms can impact resilience in rural cancer survivors. we found that within the domain of spirituality, faith may be used to increase inner-strength (allen & roberto, 2014), while fatalism can hinder coping (schlegel et al., 2009). in the domain of social networks, strong community networks provide and acceptable source of support (allicock et al., 2017), which may help strengthen self-efficacy (olson et al., 2014). however, cultural differences may be contributed to online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 171 the decision not to seek care (gunn et al., 2019), particularly for ethnic and minority cancer survivors (livaudais et al., 2010; lópez et al., 2005; torres et al., 2016). in the domain of cultural norms, the rural cancer survivors often choose to seek information through trusted community knowledge and resources (allicock et al., 2017), rather than from formal healthcare workers due to mistrust of providers (rogers-clark, 2002). the attributes of each domain impact rural resiliency along the resiliency-psychosocial distress continuum (deshields et al., 2016). increased resilience leads to improved psychosocial outcomes, such as quality of life, coping, self-efficacy and posttraumatic growth. less resilience leads to increased psychosocial distress and worse psychosocial outcomes, including poor quality of life, more unmet needs, and poor coping skills. figure 1 conceptual framework for rural resilience in cancer survivors by investigating both positive and negative impacts of rural culture on cancer survivor resilience, nurse scientists can broaden the understanding of how rurality can positively impact health. targeted interventions to strengthen resiliency has led to improved health outcomes for cancer survivors (molina et al., 2014). researchers have already successfully utilized communityonline journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 172 based interventions to improve survivorship care (angell et al., 2003). nurses are ideally positioned to improve psychosocial distress in rural cancer survivors by promoting rural resiliency. rural communities highly value nursing care, and that nurse-driven interventions improve outcomes for rural cancer survivors (schoenberger et al., 2016; american cancer society, n.d.). in fact, some rural cancer survivors have claimed that the ability to speak with their nurse is the most valuable aspect of survivorship care (schoenberger et al., 2016). moving forward, our conceptual framework may be used to help clinicians and researchers support rural cancer survivors by identifying domains that are supporting or detracting from patients’ health and directing patients to community resources that will support health. nurse researchers can use the conceptual framework to develop targeted interventions within the domain areas to support rural cancer survivors, and use the framework to identify measurable variables. nurse researchers can also use the conceptual model to guide future qualitative research that can evaluate the cultural appropriateness of current resilience measures, and to develop and evaluate a comprehensive measure of rural resilience (wells, 2009). references allen, k. r., & roberto, k. a. 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(2018). teaching concept analysis to graduate nursing students. nursing forum, 53(2), 248-254. https://www.doi.org/10.1111/nuf.12233 schlegel, r. j., talley, a. e., molix, l. a., & bettencourt, b. a. (2009). rural breast cancer patients, coping and depressive symptoms: a prospective comparison study. psychology and health, 24(8), 933-948. https://www.doi.org/10.1080/08870440802254613 schoenberger, y. m., benz, r., mcnees, p., & meneses, k. (2016). patient-centered outcome evaluation of the rural breast cancer survivors intervention. supportive care cancer, 24(4), 1841–1848. https://www.doi.org/10.1007/s00520-015-2974-4 torres, e., dixon, c. & richman, a. r. (2016). understanding the breast cancer experience of survivors: a qualitative study of african american women in rural eastern north carolina. journal of cancer education 31(1), 198-206. https://www.doi.org/10.1007/s13187-0150833-0 walker l. o., & avant k. c. (2005). strategies for theory construction in nursing (5th ed.). pearson education, inc. walker, r., szanton, s. l., & wenzel, j. (2015). working toward normalcy post-treatment: a qualitative study of older adult breast and prostate cancer survivors. oncology nursing forum, 42(6), 358-367. https://www.doi.org/10.1188/15.onf.e358-e367 wells, m. (2009) resilience in rural community-dwelling older adults. journal of rural health. 25(4), 415-419. https://www.doi.org/10.1111/j.1748-0361.2009.00253.x online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.676 178 world bank. (n.d.). rural population (% of total population). https://data.worldbank.org/indicator/ sp.rur.totl.zs zahnd, w. e., jenkins, w. d., shackelford, j., lobb, r., sanders, j., & bailey, a. (2018). rural cancer screening and faith community nursing in the era of the affordable care act. journal of health care for the poor and underserved, 29(1), 71-80. zahnd, w. e., murphy, c., knoll, m., benavidez, g, a., day, k. r., ranganathan, r., luke, p., zgodic, a., shi, k., merrell, m. a., crouch, e. l., brandt, h. m., & eberth, j. m. (2021). the intersection of rural residence and minority race/ethnicity in cancer disparities in the united states. international journal of environmental research and public health, 18(4), 1384. https://doi.org/10.3390/ijerph18041384 8   editorial rural nurse competencies: experts, advocates and activists marietta stanton, phd, rn, cnaa, bc, ccm, cmac editorial board member recently, i was contacted by a group of rural nurses asking if i had a set of competencies for nurses working in rural hospital. i have along with my colleague dr. jeri dunkin, investigated competencies for rural community case managers. having worked as a home health nurse in a rural environment and preparing case managers and outreach workers to provide services in the very rural alabama, i believe that i can make a stab at identifying a beginning skill set for nurses who work in this environment. i preface my delineation with the characteristics outlined in (lee & winters, 2006). using these characteristics as a context, it becomes easier to start with identifying a basic skill set. i also have recently experienced the loss of a family member where lack of access to emergency care, hesitation to act in an emergent situation, and lack of knowledge or skill in a rural setting may have caused irreparable harm. i am not implying negligence or malpractice, but i am saying that lack of access, loss of precious time and simply the failure to maintain an airway and oxygenate the brain caused brain death once care was accessed. nurses in the rural area are in a unique position to perhaps change and affect the quality of care received in a geographic ally isolated or rural area in very different ways than their urban counterparts. nurses in a rural environment need to have and maintain a basic competency in emergent care. this may require ongoing training, partnering with trauma and emergency centers for a refresher and continuing education. they may also need to demand that administration of their health care facility partner with colleges or universities so that accessible training is available at no or low cost to all shifts. nurses need to be proficient in the technologies associated with care and with accessing educational opportunities for themselves and their colleagues. rural nurses need to be staunch patient advocates and be proactive in the health policy and political arena. their proactive involvement in local health care quality throughout all phases of care delivery should mobilize communities to examine services and pressure officials to demand resources that fill gaps. rural nurses need strong leadership skills and they should aspire to not only fill the gaps in care within their own agency but also work collectively with other nurses in the community to coordinate quality care at any point in care delivery, in other words, the hospital nurse can and should be proactive in ensuring that a system for accessing emergent care is in place. nurses in the rural community need to have broad clinical skills that encompass all age groups and span all levels of care including health promotion and disease prevention. rural nurses need to be comfortable dealing with farm related accidents and illnesses. they need to be staff developers, patient educators and community health intervention planners. t hey should know their public health counterparts on a first name basis and understand and participate in any disaster planning activities. they should understand concepts associated with health literacy and promote health education for vulnerable groups in the community. rural nurses need to be culturally competent, acutely aware of disparities, knowledgeable regarding vulnerable groups in 9   their geographic area, while valuing diversity in the work force and community. they need to understand the implication for the why, how, when and where of care delivery. rural nurses should use faith-based and community organizations to provide outreach and provide access for vulnerable individuals in their geographic area. they need to be experts on the transportation and services that can be mobilized to help resident’s access services. they must be experts at integration of care and transitions of care. they need case management skills especially if they don’t have access to a trained case manager or social worker. even if they work in an acute care setting, they should be able to advise neighbors and other rural groups on how to access public health plans and free or low cost medications. the real question: how can one person do it all and/or as a group? how do we get there? references lee, h.j., & winter, c.a. (2006). rural nursing: concepts, theory and practice (2nd ed.). new york: springer publishing. 33 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 complementary and alternative medicine use among amish and non-amish residents of ohio appalachia paul l. reiter, phd 1 mira l. katz, phd 2 * amy k. ferketich, phd 3 electra d. paskett, phd 4 steven k. clinton, md 5 clara d. bloomfield, md 6 1 postdoctoral fellow, lineberger comprehensive cancer center, university of north carolina, preiter@email.unc.edu 2 associate professor, college of public health, ohio state university, mira.katz@osumc.edu 3 associate professor, college of public health, ohio state university, ferketich.1@osu.edu 4 professor, college of public health, ohio state university, electra.paskett@osumc.edu 5 professor, college of medicine, ohio state university, clinton.8@osu.edu 6 professor, college of medicine, ohio state university, bloomfield.28@osu.edu * contact author keywords: complementary therapies, rural health, appalachian region abstract the use of complementary and alternative medicine (cam) is common among many rural residents but little is known about its use among the amish. the aim of this study was to determine the prevalence of cam therapy use among an amish community and compare it to a rural non-amish population. data were taken from a cancer-related lifestyle cross-sectional individual interview survey conducted among amish and non-amish residents of ohio appalachia. amish adults (62 males, 72 females) were compared to non-amish adults (64 males, 90 females) in terms of cam therapy use and utilization of mainstream healthcare services. prior use of any cam therapy was highly prevalent among both amish (males: 98%, female: 100%) and non-amish (males: 89%, females: 98%) participants. cam therapies for which the prevalence was significantly higher among amish participants for both genders included chiropractic therapy (males: 84% vs. 61%, p=0.005; females: 90% vs. 57%, p<0.001) and reflexology (males: 35% vs. 5%, p<0.001; females: 53% vs. 13%, p<0.001). few differences in the use of mainstream healthcare services were found between amish and non-amish participants. while cam therapy use was widespread among both amish and non-amish participants, the amish generally reported higher levels of prior use. these findings underscore the importance of physicians and nurses collecting information on cam therapies when treating patients in this region, particularly amish patients. introduction complementary and alternative medicine (cam) is defined as “a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine” (national center for complementary and alternative medicine, 2008). while many types of cam therapy exist, some of the more commonly used therapies include chiropractic therapy, meditation, and massage therapy (barnes et al., 2004). in the united states (u.s.), use of cam therapy is prevalent and increasing in popularity, with 34% to 62% of people reporting use within the last year (barnes et al., 2004; eisenberg et al., 1993; http://www.unclineberger.org/ mailto:preiter@email.unc.edu http://cph.osu.edu/ mailto:mira.katz@osumc.edu http://cph.osu.edu/ mailto:ferketich.1@osu.edu http://cph.osu.edu/ mailto:electra.paskett@osumc.edu http://medicine.osu.edu/ mailto:clinton.8@osu.edu http://medicine.osu.edu/ mailto:bloomfield.28@osu.edu 34 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 eisenberg et al., 1998; wolsko et al., 2002). use of cam therapies tends to be higher among individuals who are female, have higher education levels, higher socioeconomic status, and those in poorer health (astin, 1998; bishop & lewith, 2008; eisenberg et al., 1993; wolsko et al., 2002). some cam therapies, such as chiropractic therapy, have a history of use among residents of rural communities (gesler, 1988), and recent estimates of cam therapy use among rural populations have ranged from 47% to 79% (arcury et al., 2004; barish & snyder, 2008; del mundo, shepherd, & marose, 2002). while these studies varied in the cam therapies examined, results still indicate that cam therapy use among individuals living in rural areas is likely higher than the national rate. the increase may be due to many social determinants of health, including having less access to mainstream healthcare providers, having lower incomes, and having specific cultural attitudes toward health. a unique rural population that has not been examined extensively in terms of cam therapy use is the amish. the amish are a conservative religious group who have strong communal values and try to separate themselves from modern american life. in terms of healthcare, the amish utilize a wide variety of non-mainstream therapies but also remain dependent on the american culture for professionally educated healthcare providers (brewer & bonalumi, 1995). the amish tend not to have commercial health insurance but instead rely on self-pay and community funds for larger healthcare bills (brewer & bonalumi, 1995). the largest amish community in the world is located in the holmes county region of ohio appalachia (donnermeyer, kreps, & kreps, 1999; hostetler, 1995). similar to many parts of appalachia, ohio appalachia lacks healthcare providers and has high rates of residents without health insurance (dorsky, ramsini, & holtzhauer, 2000; halverson, ma, & harner, 2004). because of these conditions, it becomes of interest to examine the use of cam therapies among the residents of this geographic region. the purpose of this study was to determine the prevalence of cam therapy use within the holmes county amish community and compare it with that of rural, non-amish residents of ohio appalachia. to the best of our knowledge, this is the most extensive examination of cam therapy use among the amish and is the first time amish and non-amish individuals living in the same geographic location have been compared regarding cam therapy. the results of this study will provide insight into the use of cam therapy among two distinct rural populations in the u.s. this information may be used in future education interventions aimed at improving the health and health behaviors of amish and rural non-amish populations, and it will be especially useful to physicians and nurses practicing in these rural communities. methods study design we utilized data collected as part of a cancer-related lifestyle cross-sectional individual interview study conducted among amish and non-amish adults living in ohio appalachia. all participants for this study were residents of either holmes county (2005 population=41,567) or tuscarawas county (2005 population=91,944) (u.s. census bureau, 2006a; u.s. census bureau, 2006b). we interviewed amish adults during 2004 and non-amish adults during 2005. amish households used for this behavioral lifestyle study had previously been randomly selected from the holmes county, ohio amish directory for a study focusing on cancer 35 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 incidence among the amish (ohio amish directory, 2000). to recruit participants for the current study, we first mailed a letter explaining the study to each of these amish households. a co-investigator then visited each household to further explain the study and ask each male and female head of household to participate in a face-to-face interview. if individuals in the sampled households had died or moved out of the state, we recruited the current residents, provided they were amish. an attempt was made to locate individuals who had moved within ohio. for households that were no longer amish or refused to participate, we randomly sampled replacement households from within the same amish church district listed in the amish directory to maintain the target sample size. non-amish households were randomly selected from holmes county and tuscarawas county using the publicly available county auditors’ databases. many of the households were located close to the amish, making for an ideal comparison group. the recruitment methods used for non-amish adults were identical to those used for amish adults. after mailing an introduction letter, a co-investigator visited each selected household to further explain the study and recruit each male and female head of household to participate in a face-to-face interview. we only included individuals who were not raised in amish households in the non-amish sample. for individuals who agreed to participate, research staff conducted face-to-face interviews (1.5 to 2 hours on average) in the participants’ homes. if both the male and female head of household agreed to participate, they were usually interviewed at the same time by different interviewers in separate rooms. most of the men were interviewed by male interviewers and women by female interviewers. we provided a $25 gift card to each participant after their interview in appreciation of their time. the study was approved by the institutional review board at the ohio state university. measures we addressed four major domains of cam therapy, as described by the national center for complementary and alternative medicine (nccam), in this study: (1) manipulative and body-based practices: the manipulation or movement of one or more body parts (chiropractic therapy, massage therapy, and reflexology), (2) energy medicine: the use of energy fields (reiki, polarity therapy, and acupuncture), (3) mind-body medicine: a variety of techniques designed to enhance the mind’s ability to affect bodily function and symptoms (meditation, yoga, pow-wow, and prayer for healing purposes), and (4) biologically-based practices: the use of substances found in nature (dietary supplements) (national center for complementary and alternative medicine, 2008). dietary supplements included vitamins, minerals, proteins/amino acids, fatty acids, fiber, botanicals, enzymes, and any other supplements mentioned by participants. we provided participants with a brief definition of each therapy examined and then asked about prior use (if they had ever used it or were currently using it in the case of dietary supplements). response options for each cam therapy included yes, no, or don’t know. since dietary supplement use by these participants has been described in detail elsewhere (carter, 2008), we will only briefly address it in this report. we also documented each participant’s utilization of mainstream healthcare services by collecting information on history of ever seeing mainstream healthcare providers (any healthcare provider, doctor, nurse practitioner, and physician assistant; yes or no for each), type of healthcare professional seen most often (doctor, chiropractor, or other), and hospital care within 36 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 the last three years (yes or no). participants provided a self-assessment of their general health by rating their health compared to people of the same age and gender (poor, fair, good, very good, or excellent). lastly, participants indicated if they had any medical conditions requiring them to see a healthcare provider regularly (yes or no). demographic information collected included age, marital status (married, never married, and other), education level (less than high school, high school graduate, and more than high school), and household income (less than county median and equal to or greater than county median). county median household incomes were from the year prior to the interview and were based on the u.s. census bureau small area income and poverty estimates (u.s. census bureau, 2008). if both a husband and wife reported a household income estimate and they differed, we assigned the husband’s estimate to both individuals and compared it to the appropriate county median. statistical analyses we used chi-square tests to assess associations between group (amish versus nonamish) and each categorical variable and the mann-whitney test to compare the two groups on age. for cam therapies, if a participant responded “don’t know” for a particular therapy, he or she was excluded from that comparison but included in all others for which data were provided. we stratified all analyses by gender since data were clustered in instances where we interviewed both the male and female head of household. statistical tests were two-sided, and the p-values for chi-square tests were from fisher’s exact test. we used spss 16.0 (chicago, il) to conduct all analyses. results demographic characteristics overall, we interviewed 134 amish adults from 75 households (62 males, 72 females) and 154 non-amish adults from 98 households (64 males, 90 females). response rates for the amish and non-amish were 67% and 23%, respectively. when only households that had an adult available during contact attempts were considered for the non-amish (63% of sampled households), the response rate was 37%. amish males tended to be younger (p=0.02), currently married (p=0.009), less educated (p<0.001), and have lower incomes (p=0.02) compared to non-amish males (see table 1). among females, the amish were more likely to be currently married (p=0.004) and less educated (p<0.001) than the non-amish females. cam therapy cam therapy use was highly prevalent among both genders with 94% (118/126) of males and 99% (160/162) of females reporting prior use of at least one type of cam therapy (see tables 2 and 3). when prayer was excluded from the cam definition, as has been done elsewhere (del mundo, shepherd, & marose, 2002; eisenberg et al., 1993; wolsko et al., 2002), these percentages fell slightly to 91% for males and 98% for females. in addition to current dietary 37 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 table 1 demographic characteristics of amish and non-amish participants by gender; ohio appalachia, 2004-2005 males females amish non-amish amish non-amish (n=62) (n=64) p-value (n=72) (n=90) p-value age (years) 0.02 0.07 mean + sd 52.4 + 13.8 58.8 + 15.9 52.9 + 15.1 56.8 + 15.3 range 22-84 24-92 21-89 22-90 marital status 0.009 0.004 married 59 (95) 53 (83) 67 (93) 67 (74) never married 2 (3) 1 (2) 0 (0) 2 (2) other 1 (2) 10 (16) 5 (7) 21 (23) education <0.001 <0.001 < high school 61 (98) 8 (13) 72 (100) 11 (12) high school graduate 1 (2) 30 (47) 0 (0) 47 (52) > high school 0 (0) 26 (41) 0 (0) 32 (36) household income 0.02 0.06 > county median 20 (34) 34 (58) 21 (36) 42 (52) < county median 38 (66) 25 (42) 38 (64) 39 (48) note: table reports n (%) for categorical variables. totals may be less than stated numbers due to missing data. percents may not sum to 100% due to rounding. sd: standard deviation. supplement use, prior use of chiropractic therapy (males=72%, females=72%), prayer for healing purposes (males=63%, females=71%), and massage therapy (males=24%, females=33%) were the most commonly reported cam therapies. few participants reported using reiki therapy, polarity therapy, and pow-wowing. compared to non-amish males, a higher percentage of amish males reported prior chiropractic therapy (84% vs. 61%, p=0.005), reflexology (35% vs. 5%, p<0.001), and prayer for healing purposes (77% vs. 48%, p=0.001). current dietary supplement use was also higher among amish males (82% vs. 64%, p=0.03). a higher percentage of amish females reported previous chiropractic therapy (90% vs. 57%, p<0.001), massage therapy (44% vs. 23%, p=0.007), and reflexology (53% vs. 13%, p<0.001) compared to non-amish females. amish females also had a higher prevalence of current dietary supplement use, though the difference only reached borderline statistical significance (90% vs. 79%, p=0.06). mainstream healthcare and general health almost all participants (males=98%, females=100%) reported having seen a healthcare professional in the past (see table 4). a higher percentage of non-amish females reported having ever seen a nurse practitioner (27% vs. 6%, p<0.001) and going to the hospital for care within the last three years (51% vs. 31%, p=0.02) compared to amish females. non-amish males did not differ from amish males in terms of these mainstream healthcare services. however, compared 38 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 table 2 use of complementary and alternative medicine (cam) among male participants, amish vs. non-amish; ohio appalachia, 2004-2005 amish non-amish (n=62) (n=64) p-value any cam ever a 0.06 yes 61 (98) 57 (89) no 1 (2) 7 (11) any cam excluding prayer ever a 0.009 yes 61 (98) 54 (84) no 1 (2) 10 (16) manipulative and body-based practices chiropractic therapy ever 0.005 yes 52 (84) 39 (61) no 10 (16) 25 (39) massage therapy ever 0.10 yes 19 (31) 11 (17) no 43 (69) 53 (83) reflexology ever <0.001 yes 22 (35) 3 (5) no 40 (65) 61 (95) energy medicine reiki therapy ever 0.06 yes 0 (0) 5 (8) no 62 (100) 59 (92) polarity therapy ever 0.99 yes 1 (2) 1 (2) no 61 (98) 63 (98) acupuncture therapy ever 0.62 yes 2 (3) 1 (2) no 60 (97) 63 (98) mind-body medicine meditation ever 0.99 yes 4 (6) 5 (8) no 58 (94) 59 (92) yoga ever 0.99 yes 0 (0) 1 (2) no 62 (100) 63 (98) pow-wowing ever 0.49 yes 1 (2) 0 (0) no 61 (98) 64 (100) prayer for healing purposes ever 0.001 yes 48 (77) 31 (48) no 14 (23) 33 (52) biologically-based practices current use of dietary supplements 0.03 yes 51 (82) 41 (64) no 11 (18) 23 (36) note: table reports n (%) for all variables. totals may be less than stated numbers due to missing data. percents may not sum to 100% due to rounding. a includes current use of dietary supplements 39 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 table 3 use of complementary and alternative medicine (cam) among female participants, amish vs. non-amish; ohio appalachia, 2004-2005 amish non-amish (n=72) (n=90) p-value any cam ever a 0.50 yes 72 (100) 88 (98) no 0 (0) 2 (2) any cam excluding prayer ever a 0.13 yes 72 (100) 86 (96) no 0 (0) 4 (4) manipulative and body-based practices chiropractic therapy ever <0.001 yes 65 (90) 51 (57) no 7 (10) 39 (43) massage therapy ever 0.007 yes 32 (44) 21 (23) no 40 (56) 69 (77) reflexology ever <0.001 yes 38 (53) 12 (13) no 34 (47) 78 (87) energy medicine reiki therapy ever 0.73 yes 3 (4) 5 (6) no 69 (96) 85 (94) polarity therapy ever 0.17 yes 4 (6) 1 (1) no 68 (94) 89 (99) acupuncture therapy ever 0.22 yes 7 (10) 4 (4) no 65 (90) 86 (96) mind-body medicine meditation ever 0.53 yes 10 (14) 16 (18) no 62 (86) 74 (82) yoga ever 0.99 yes 4 (6) 5 (6) no 67 (94) 85 (94) pow-wowing ever 0.19 yes 2 (3) 0 (0) no 69 (97) 90 (100) prayer for healing purposes ever 0.30 yes 53 (76) 61 (68) no 17 (24) 29 (32) biologically-based practices current use of dietary supplements 0.06 yes 65 (90) 71 (79) no 7 (10) 19 (21) note: table reports n (%) for all variables. totals may be less than stated numbers due to missing data. percents may not sum to 100% due to rounding. a includes current use of dietary supplements 40 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 to the non-amish, higher percentages of both amish males (35% vs. 11%, p=0.002) and females (38% vs. 7%, p<0.001) reported a chiropractor was the healthcare professional they visited most often. the perceived health of amish males did not differ from that of non-amish males, but more non-amish males reported having a medical condition requiring regular visits to a healthcare provider (50% vs. 27%, p=0.02). among females, amish participants perceived themselves to be in poorer general health (p=0.02), but more non-amish women reported having a medical condition requiring regular visits to a healthcare provider (57% vs. 29%, p<0.001). table 4 use of mainstream healthcare services and general health among amish and non-amish participants by gender; ohio appalachia, 2004-2005 males females amish non-amish amish non-amish (n=62) (n=64) p-value (n=72) (n=90) p-value ever seen a healthcare professional 0.99 n/a yes 61 (98) 62 (97) 72 (100) 90 (100) no 1 (2) 2 (3) 0 (0) 0 (0) ever seen a doctor 0.99 0.44 yes 61 (100) 61 (98) 71 (99) 90 (100) no 0 (0) 1 (2) 1 (1) 0 (0) ever seen a nurse practitioner 0.48 <0.001 yes 9 (15) 13 (21) 4 (6) 24 (27) no 52 (85) 49 (79) 68 (94) 66 (73) ever seen a physician assistant 0.83 0.15 yes 12 (20) 14 (23) 3 (4) 10 (11) no 49 (80) 48 (77) 69 (96) 80 (89) healthcare professional seen most often 0.002 <0.001 doctor 39 (65) 53 (85) 40 (56) 83 (92) chiropractor 21 (35) 7 (11) 27 (38) 6 (7) other healthcare professional 0 (0) 2 (3) 5 (7) 1 (1) gone to the hospital for care in last three years 0.57 0.02 yes 17 (28) 21 (33) 22 (31) 45 (51) no 44 (72) 43 (67) 50 (69) 44 (49) general health 0.67 0.02 poor 1 (2) 0 (0.0) 0 (0) 3 (3) fair 9 (15) 11 (17) 20 (28) 12 (13) good 26 (42) 30 (47) 33 (46) 33 (37) very good 17 (27) 18 (28) 15 (21) 30 (34) excellent 9 (15) 5 (8) 4 (6) 11 (12) any medical conditions that require regular visits to a healthcare provider 0.02 <0.001 yes 17 (27) 31 (50) 21 (29) 51 (57) no 45 (73) 31 (50) 51 (71) 39 (43) note: table reports n (%) for all variables. totals may be less than stated numbers due to missing data. percents may not sum to 100% due to rounding. n/a: not applicable, p-value could not be calculated due to multiple cells containing a zero. 41 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 discussion we aimed to determine the prevalence of cam therapy use among an ohio appalachian amish community and compare it to that of non-amish residents of the same geographical region. to the best of our knowledge, the results provide the first comparison of cam therapy use between the amish and non-amish rural communities. overall, the use of cam therapy was found to be highly prevalent among both groups with many similarities between the two groups. amish males and females did, however, report a higher prevalence of prior use of specific cam therapies, mostly involving manipulative and body-based practices, compared to their non-amish counterparts. the observed levels of cam use observed in this study were noticeably higher than previous studies examining lifetime use of cam therapy (52%-75%) (barnes et al., 2004; oldendick et al., 2000). the discrepancy may be attributable to our study focusing on one rural area within ohio appalachia, a region shown to have a shortage of healthcare providers and high percentages of residents without health insurance (dorsky, ramsini, & holtzhauer, 2000; halverson, ma, & harner 2004). these conditions are extremely important to consider when interpreting our findings since individuals who self-pay for medical care or perceive inadequate access to mainstream healthcare services are more apt to seek non-mainstream healthcare providers (martin & long, 2007; ritchie, gohmann, & mckinney, 2005). cam therapy may be used by many residents of ohio appalachia if it is perceived as a less costly and more easily accessible form of healthcare. only one identified study has addressed cam therapy use among the amish community, and it found that 36% of amish women reported prior use of cam therapy (von gruenigen et al., 2001). our results indicate that cam therapy use among the amish is much higher. since the previous study recruited consecutive women, most of whom were young, from one obstetric/gynecology clinic, it may have underestimated the use of cam therapy among this population. we believe our results, using a random selection of participants, may provide a more valid estimate of cam therapy use among the amish. while the amish have been noted to frequently use home remedies and a folk healthcare system (brewer & bonalumi, 1995), they also seem to be utilizing cam therapies requiring a provider, particularly those offering manipulative and body-based practices. past use of reflexology, chiropractic therapy, and massage therapy were widespread among the amish, with reported usage levels much higher compared to the non-amish. furthermore, over one-third of amish participants indicated a chiropractor was the type of healthcare provider seen most often. thus, the amish appear to be using the services of cam providers frequently, in addition to any home remedies. for the most part, amish and non-amish participants did not differ in terms of their use of mainstream healthcare providers. these results suggest that amish residents of this ohio appalachian region are using cam therapy in conjunction with mainstream healthcare services, as found in other national surveys (barnes et al., 2004; eisenberg et al., 1998). since it has been shown that patients do not frequently mention cam therapy use to mainstream healthcare providers (eisenberg et al., 1993), it is extremely important for mainstream healthcare providers (e.g., physicians and nurses) in rural areas to inquire about cam therapy when treating patients, particularly amish patients, to avoid possible negative therapeutic interactions. this study has several strengths. it provides an improvement over previous research concerning cam therapy use in the amish community due to its larger sample size, inclusion of 42 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 male participants, and the presence of a non-amish comparison group from the same geographic region. furthermore, the participants for this study were randomly selected, face-to-face interviews were conducted, a wide range of cam therapies were examined, and descriptions of each cam therapy were provided to increase respondents’ accuracy. in addition to the cross-sectional study design, there were a few limitations to this study. the response rates, particularly among the non-amish, were lower than desired, which is becoming more common in survey research (steeh et al., 2001). reasons for declining response rates to survey studies are numerous and include but are not limited to lack of time, concerns about privacy, and reduced civic participation (groves, cialdini, & couper, 1992). limited study resources allowed for a maximum of only three attempts to contact each household. while the holmes county amish community is the largest amish community in the u.s. (donnermeyer, kreps, & kreps, 1999; hostetler, 1995), the results still may not generalize to all amish communities, and one strict amish order in the region was excluded because its members were not listed in the holmes county amish directory. comparisons were not adjusted for possible confounders (demographic factors and health status) since some cam therapies had very small numbers of participants who reported use. it is believed, however, that adjusting for these variables would not qualitatively change our findings. fewer non-amish participants reported prior cam therapy use despite having more education, higher incomes, and medical conditions that require regular visits to a healthcare provider, which are all characteristics previously associated with increased use of cam therapy (bishop & lewith, 2008). in this study, prior cam therapy use was highly prevalent among both the amish and non-amish, with amish tending to report higher levels of prior use for almost all of the cam therapies examined. the amish also reported using mainstream healthcare services and therefore may be using cam more as complementary therapy. physicians and nurses need to be diligent about collecting information about cam therapy when treating patients in this geographic region, particularly amish patients, to avoid negative therapeutic interactions. the results are also important for future education interventions aimed at improving the health and health behaviors of amish and rural non-amish populations. future research is needed to explore cam therapy use among other amish and non-amish rural communities and confirm these findings. acknowledgements the current research was funded by the national institutes of health p50 ca015632 (edp) and p30 ca016058 (behavioral measurement shared resource at the ohio state university comprehensive cancer center), the national cancer institute k07 ca107079 (mlk), and the coleman leukemia research foundation. references arcury, t.a., preisser, j.s., gesler, w.m., & sherman, j.e. 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(2005). does use of cam for specific health problems increase with reduced access to care? journal of medical systems, 29(2), 143-153. [medline] steeh, c., kirgis, n., cannon, b., & dewitt, j. (2001). are they really as bad as they seem? nonresponse rates at the end of the twentieth century. journal of official statistics, 17, 227247. u.s. census bureau. (2006a). state and county quickfacts. holmes county, ohio. u.s. census bureau. (2006b). state and county quickfacts. tuscarawas county, ohio. u.s. census bureau. (2008). small area income and poverty estimates. available at: http://www.census.gov/hhes/www/saipe/index.html von gruenigen, v.e., showalter, a.l., gil, k.m., frasure, h.e., hopkins, m.p., & jenison, e.l. (2001). complementary and alternative medicine use in the amish. complementary therapies in medicine, 9(4), 232-233. [medline] wolsko, p. m., eisenberg, d.m., davis, r.b., ettner, s.l., & phillips, r.s. (2002). insurance coverage, medical conditions, and visits to alternative medicine providers: results of a national survey. archives of internal medicine, 162(3), 281-287. [medline] http://www.ncbi.nlm.nih.gov/pubmed?term=29%5bvolume%5d+and+2%5bissue%5d+and+143%5bpage%5d+and+ritchie%5bauthor%5d http://www.census.gov/hhes/www/saipe/index.html http://www.ncbi.nlm.nih.gov/pubmed?term=9%5bvolume%5d+and+4%5bissue%5d+and+232%5bpage%5d+and+von+gruenigen%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=162%5bvolume%5d+and+3%5bissue%5d+and+281%5bpage%5d+and+wolsko+pm%5bauthor%5d microsoft word dunn_column 11 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 editorial spiritual nourishment linda dunn, dsn, rn, cnl editorial board member spring is one of my favorite seasons of the year. a new beginning, beautifully sculptured lawns, flowers in colorful array, birds singing, juicy berries to delight the palate, and tax refunds …wow!! despite the beauty of spring, there are things i don’t enjoy, such as pollen, allergy woes, and tornadoes. such is life. everyday can be a new beginning with new opportunities; however, it may also bring unexpected adversities. as nurses, we observe patients who may be experiencing more than one stressor. in addition to family crises, many are also experiencing caregiver stress, grief and loss, newly-diagnosed illnesses, not to mention current economic woes. suddenly that “spring in our step” may be weakened. how can nurses maintain spiritual wellness that will enable us to reach out to help those facing adversity? i have been reading spirituality: living our connectedness by burkhardt & nagaijacobson (2002). these authors suggest some timely activities that integrate the beauty of nature and our gorgeous spring season to nurture the spiritual self. they suggest we give ourselves an hour, or even better, one whole day to attend to self. when did you last take a devotional book outside to read or go outside to meditate or journal? taking a stroll to admire the beauty of nature is not only good for the soul, but great exercise for the body. plant a garden. watch a sunrise or a sunset. run in the rain or just sit still and listen. i know i never take enough time just to be still. healthcare arenas could take this same idea and provide areas to be quiet at the end of a workday. an outside meditation garden with benches, a fountain, and a bird feeder would be restful. just close your eyes and picture it – can you hear the flowing water and hear the sweet melodies? a walking trail could actually rejuvenate spiritual energy. however, we need not wait on healthcare environments to take care of our spiritual nurturance. i challenge you to reconnect with nature, the spring season, and the sacred. the dark winter may have created an emptiness within the spiritual self that requires a “spring” of nourishment. references burkhardt, m.a., & nagai-jacobson, m.g. (2002). spirituality: living our connectedness. united states of america: delmar. running head: rural nuring and marginalization 60 rural nuring in canada: a voice unheard deirdre jackman, rn, mn1 florence myrick, rn, bn, mscn, phd2 olive j. yonge, rn, phd3 1faculty lecturer and phd student, faculty of nursing, university of alberta, deirdre.jackman@ualberta.ca 2professor and associate dean, faculty of nursing, university of alberta, flo.myrick@ualberta.ca 3professor, faculty of nursing, university of alberta, olive.yonge@ualberta.ca keywords: marginalization, the rural setting, rural nursing practice, health care policy abstract historically, in canada, rural nurses provided health care that incorporated not only care of disease processes and acute illness but also care related to social and political aspects of need and advocacy. with the advent of urbanized, acute hospital care and the focus of disease and cure, the role of the rural nurse was diminished. the purpose of this paper is to explore the role of the rural nurse within the context of the canadian rural populations for whom they care and more specifically to examine how the effects of marginalization and health policy and decision making processes contributed and may continue to contribute negatively to marginalization. the implications of not recognizing or marginalizing rural nurses may once again remove or negate their voice, affect their health care influence and impact the central role of the rural nurse in providing holistic care for and with the rural populations they serve. introduction in canada, nursing as a professional practice is often thought of from a collective perspective. invariably, the collective dialogue entails descriptors of nursing as that of nurses providing care for individuals in acute care settings, with an acute disease focus. gortner (2004) states’ nursing has been depicted at various times as a series of tasks and technology. this particular way of thinking can be viewed as a throwback to the medical model, which inhered an overwhelmingly physical focus. the medical model defines health in a physiological way, with physiological characteristics (potter & perry, 2006). nurses were required to adhere to this medical model, predominant in the 1950s during which time medical and, by default; nursing care was transferred from community to hospital settings. in the canadian post war economic growth, increased funding was directed primarily to the building of new hospitals (p.4). this process centralized the care of people to a single setting and institution, for the purpose of efficiency which promoted care in large institutional settings (baumgart & larsen, 1992; canadian nurses association, 2005). the era of the (rural) district nurse or community nurse thus became obsolete. the large hospital institutions were touted as centres for the provision of the most advanced and leading technical care. indeed, the advances in modern medicine allowed enormous progress to be made in treating diseases that were physical and acute in origin. the evolution of modern medicine and the development of antibiotics and other ‘wonder drugs’ contributed to the belief that there would be a cure for every disease/illness, thus shifting the emphasis away from prevention to cure (allemang, 1995; newman, 1975; bramadat, & saydak, 1993; kulig, 2005; reed, 2004). the diminished role of the nurse providing care in the community, however, had an effect on the lives of these people and the nurses who cared for online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 http://www.uofaweb.ualberta.ca/nursing/index.cfm mailto:deirdre.jackman@ualberta.ca http://www.uofaweb.ualberta.ca/nursing/index.cfm mailto:flo.myrick@ualberta.ca http://www.uofaweb.ualberta.ca/nursing/index.cfm mailto:olive.yonge@ualberta.ca 61 them. nurses who were particularly affected were those who provided care for people in rural canadian areas (ross-kerr, 1998; paul, 2005). these nurses not only cared for the rural populations but also lived and experienced rural living in a holistic way (mckay, 2005). the nursing care included a focus on social and political issues in addition to providing care to patients with physical illness (whall, 2004). in some ways, it could be said that this segment of the canadian population, vis a vis the rural nurse and patient became the forgotten element in the name of progress, with their vital role devalued and eroded. the purpose of this paper is to explore the historic and current role of the rural nurse and the contribution of that role in providing health care to rural populations. in this paper the authors further explore how health care delivery, collective thinking and decisionmaking processes incorporating rural nursing affect and continue to affect rural care. they examine how health care decisions and issues have had an impact on the role of the rural nurse. they explore the concept of marginalization and how it may influence the role of the rural nurse and the ability of the rural nurse to provide nursing care. marginalization the concept of marginalization has often been described as one of ‘not belonging’ to the collective majority. hall, stevons & meleis (1994) describe marginalization as a situation or state in which individuals live on the periphery, away from the dominant group. it is not the spatial aspects or geographic distance that causes a sense of isolation but rather the lack of social support and lack of inclusiveness that cause individuals to feel disconnected from the majority (managhan, & lavioe, 2008). they are excluded from the social and political realms which in turn precipitates a sense of powerlessness. this becomes a voice that goes unheard. in the literature it is contended that marginalization is associated with oppression and lack of control or an absence of rights. historically, those who have less economic wealth or who are fewer in numbers can be subject to marginalization. those in rural canadian communities have, at times, expressed feelings of being disassociated from the greater political and social climate. because the rural population represents less in census numbers than its urban counterpart there is a perception and actuality of less power in voicing concerns and less political representation and advocacy (canadian nurses association (cna), 2002, 2005). rural populations often have less economic wealth within their communities, in turn precipitating a devaluing of the peoples’ voice. with social and political isolation emerge health consequences. the evidence would suggest rural populations do not have equitable access to the determinants of health including social, economic, and physical and human resources that in turn would allow them to experience the same health and well being outcomes as those of urban populations (health canada, 2001). so what of those who are responsible and accountable to caring for these rural communities? where does their role lie in providing care for these people or are they themselves subject to marginalization by living and caring within these areas? are rural nurses, by living and working in their rural communities marginalized by their professional and personal experience? historically, canadian rural nurses have provided holistic care to rural communities, an approach that embraced the type of individualized care needed. this care, however, was subject to change, enforced by social and political dominance at particular points in time (eldrige, & jenkins, 2003; elliot, stewart, & toman, 2009). some would argue this approach has been instrumental in creating marginalization for rural communities and those who serve these populations. online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 62 the rural setting the history of the canadian rural nurse in the provision of health care historically, the role of the rural nurse has been one of importance and one that has been essential to the provision of care to the rural population. without nursing, in many rural areas, care would have been compromised or nonexistent (baumgart & larsen, 1992; mcpherson, 2006). this was the case in alberta, as in other canadian provinces. the work and political advocacy of rural nurses with organizations such as the united farmers women’s association in alberta is a case in point (cashman, 1966). in many instances access to physician care was not an option for rural populations. it was the nurses who filled the void for the role of health care provider. many of these nurses lived, worked and raised families in rural settings. they understood the demands of and the type of care required. these nurses provided complete care that included not only treatment of diseases but also encompassed expanded roles such as the delivery of babies. they taught the importance of health promotion and worked with the people in social and political contexts (ross-kerr & wood, 2003). before the expansion of the concept of health many of these nurses were advocating for people in the canadian rural context. they believed that rural populations should be entitled to adequate health care and a social system that provided such care (ross-kerr, 1998; mcpherson, 2006). with the technological advancement of the treatment of acute disease and the transference of care to urban hospital settings, however, the historic role and influence of the rural nurse was significantly diminished (longford, 2000; mckay, 2005). not only had rural nurses been marginalized but they were now removed from their role and rendered powerless to resist. in canada, the then federal health mister lalonde (1974) issued a report that expanded the concept of health to include lifestyle, biology, environment and organizations of health care. disease continued to be the focus of health professionals, in particular the medical profession, but chronicity emerged as being central to that focus. this emphasis on chronicity suggested that acute treatment and cure could not be viewed as a panacea for health care. examination of chronic conditions and the concomitant lifestyles of people living with various diseases had to be explored. in canada, because of influence of the world health organization (who) (1986) and the then minister of health’s report, the concept of health expanded to include more than acute physical disease processes. leading the discussion concerning care were those in the nursing profession. they promoted nursing care as being holistic (george, 1990). nursing scholars and clinicians concurred with the concept of health relating to not only physical aspects but to the psychological and social influences, included in the newly developed who determinants of health (newman, 1972). these determinants stated that health was significantly impacted by socio-economic issues, such as social support and egalitarianism, related to income and place in society (potter & perry, 2006). this type of discussion, at national and international levels, explored factors regarding health and how health could be impacted by positive and negative factors. people were living longer but many were living with chronic conditions that needed to be treated multiple times and in multiple ways. treatments were no longer exclusively related to surgical interventions or drug therapies. even with these interventions, individuals continued to encounter issues concerning their health or well being, social issues such as unemployment, inadequate housing, insufficient income; psychological influences such as stress, including lack of social support from family and community, which all played a role in health. the who endorsed models such as the primary health care model (phc) (1986). in canada, the phc online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 63 model was adopted as being valuable to the provision of health care to all people, in all settings. there was recognition of the limitations of a disease focus for health care. with the advent of the delineation of health determinants for promoting and maintaining a person’s ability to a healthy lifestyle, together with the expansion of the concept of health to encompass well being, a new dialogue of health as a human right was adopted. health determinants were expanded to include social and economic factors as well as employment, physical and social environments, culture and health services (reutter, 1995). principles regarding the phc model included public and community input and participation, intersectoral and interprofessional collaboration, appropriate technology that was affordable and accessibility to health care resources and services. there was a distinct focus on empowering individuals to have control of decisions about their health (roger & gallagher, 1995; petrucka, & smith, 2005). nurses who previously had not been able to influence the discussion regarding health care became advocates of a person’s individual right to health care and all that such rights entailed (doering, 1992). rural health care in alberta, canada, in the 1970s and 1980s the re-evaluation of health care to include individual and community participation in the decision making process suggested that requests for equitable access to health care services in communities, at a cost that was affordable to the community ought be acknowledged. individuals had a right to health care services, regardless of location (kulig, 2000; kulig, 2005). however, rural communities continued to experience an array of health problems that included poverty, unemployment, cardiovascular disease, cancers and hypertension in higher numbers than their urban counterparts (canadian institute for health information, 2002; stewart & langille, 1995; sorenson, & depeuter, 2002). these communities were often left to face their health problems with limited resources and inaccessible or inadequate resources (anderson & yuhos, 1993; thomlinson et al, 2004). in alberta, canada, in the 1970s there was a political climate during which economic growth began to assume a significant impact on the provision of health care services. large acute care urban centres became the focus of technically advanced care. these centres were designated as tertiary care centres, in which those who were the most acutely ill were treated. those individuals who had chronic and less acute episodes, however, also continued to require access to appropriate care. the social and political climate became ripe to allow for the building or re-building of rural hospitals (church & smith, 2008). many small towns received new hospitals and community health care centres. those in the rural settings who had suffered from a lack of access to health care services and care on a daily basis and within a reasonable geographic distance voiced their need for health care services and health care providers. the political climate, will, and economic growth further ensured that some of these needs were met in rural communities. nurses provided rural nursing care within the confines of these settings. physicians began to migrate to the rural settings. where physician shortages existed, these were supplemented with physicians trained in other countries who set up practices in rural towns (tyrell & dauphine, 1999; henry, edwards, & crotty, 2009). rural nurses provided care primarily in rural hospital settings, except for the most remote rural areas, where on-site physician services were not available. it was the nurses who lived in these communities who provided expanded care. the provision of care encompassed more than a medically acute focus. holistic care included social and political activism to allow resources and services to be requested as a need and a right (kulig, nahachewsky, & thomlinson 2004; macleod, 1998; macleod et al, 2008). online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 64 rural nurses by virtue of their geographic location and their experiences embraced the values of primary health care nursing and the role of community in the provision of health care (ross-kerr & wood, 2003). they recognized their role in the provision of acute care, often deemed by government to be the most legitimate care. nurses, however, continued to explore the social aspects of rural care, especially in relation to population health issues such as access to adequate food, water, shelter, education, immunization programs, and health education programs (ross-kerr, 1998; pang, & russel, 2003). health care services and political will dictated the particular types of care the rural nurses provided, but living in the community also influenced rural nurses, as members of that community. they contended that being politically active and voicing the rural needs on behalf of their rural communities ought to be heard and acknowledged (mcintyre, thomlinson, & mcdonald, 2006). in many ways they were obdurate to allowing marginalization to be an accepted or inevitable position. rurality the concept of rurality has been described from many different perspectives (malpas, 1998; pitlado, 2005; racher, vollman & annis, 2004)). it has been described as a geographic location (andrews, 2003). there has been further articulation concerning the terms remote and/or rural as meaning further, or extreme distance from an urban setting (macleod et al. (a), 2004). rural geographic determinations are located, in a physical and verbal sense, around an urban perspective. in relation to health care services, the term rurality has been linked to what is ‘absent’ or ‘missing’ in the services and personnel needed to provide acceptable care. terms such a ‘lack of health services’ or ‘gaps’ in the ability to provide services continue to focus on the negative aspects of rural health care, without acknowledgement of any positive aspects in relation to rural health (thomlinson et al, 2004; stewart et al, 2005. the manner in which language is used to describe rurality may be seen to relegate it to the margins, away from the urban majority, signalling that it may be less important and less powerful. freire (1997) would contend that to exist as humans we name the world, we explore it, we re-name it and we create new meaning. the examination of new names and meaning generates action and transformation. saying or re-saying the ‘word’ is not the privilege of some but the right of everyone. language can influence meaning and can lead to action and necessary change. the ability of rural communities to seek health care for their communities and to voice the rewarding aspects of living in such communities creates a language of pride and positive connotations’ rather than a language of lesser than or inequity. this re-wording of the language in reference to rurality denotes the positive elements of rural living and experiences and not merely the challenges faced. rural nursing in canada historically, or by current standards for that matter, the role of the rural nurse is not a role that has been uniform in its articulation and understanding. at times, the role of the rural nurse is complex and ambiguous (macleod et al (b), 2004; stewart et al., 2005). indeed, the role of the rural nurse differs significantly from the role of a nurse in an acute tertiary care setting. the particular role has, at times, been lost in the assumptions of the majority. assumptions abound regarding urban settings as the best option to access health care. technological, political and social power serve to influence the assumption that care can only adequately occur in urban online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 65 centres. the rural population has experienced a less collective and powerful voice socially and politically and therefore their specific and genuine needs become lost in the powerful collective of the majority. in the 1990s and into the millennium, as a consequence of the powerful influences of globalization and technology, canadian government policy called for an approach to health care that was leaner in its social supports and obligations (saul, 1995). centralization of care to urban settings was the policy of choice. this political development in turn resulted in division within social and cultural communities, including urban and rural communities (pal, 2001). the role of the rural nurse was perceived as less valuable (crooks, 2004). assumptions were made regarding the type of care required, the facility and technical support needed, but from a pre-dominantly urban perspective (shellian, 2002; pitblado, 2005). reed (2004) contends that service needs, physician demands, political interests and employers still generate a proliferation of technical ‘nursing’ that can exploit nursing’s vision. the role of the rural nurse has not been well understood or communicated. this role is both unique and multicentered (macleod et al (a), 2004). without clear and appropriate articulation and understanding of the role of the rural nurse there is a distinct danger that rural nurses, and those for whom they are responsible, becomes marginalized in a geographic, social and political sense. while the role of the rural nurse continues to be vital to the existence of rural communities, it is essential to create dialogue regarding the essence of such a role, in all its complexity (shellian, 2002; managhan, & lavioe, 2008). it is in the language that social connotations are derived in positive or negative way. the language used to describe ‘nursing’ is paramount in creating and influencing who we are as nurses and how we practice and care for people. the term ‘nurse’ itself inheres some essential and collective attributes. nursing is perceived to be concerned with the care of human beings (mitchell & cody, 1999). central to that focus of care is the person receiving the care. nurses must be able to individualize their care for specific populations. it is with this broader understanding of nursing that they can implement and advocate for just and specific care. not all nursing care, for all populations, however, will be a mirror image of replication. only by being connected with and open to specific needs can the nurse come to understand and advocate with those s/he cares about (kulig et al, 2006). if rural nurses were merely described as ‘nurses providing care in rural canadian settings’ this perception could create, distort and distance the essential embodiment of rural nursing ( bowman, & kulig, 2008). the rural location has, at times, been described in a negative fashion. concomitantly, rural nurses have been unacknowledged for their rural nursing role as one of a positive and influential lived experience. their personal/ professional connection to rural nursing gives them an affinity with the rural community that differs from the nursing role in an urban setting. these differences should not allow for marginalization. care in urban settings as opposed to rural settings are distanced by physical space but should not be distanced by lack of understanding or discrimination (macleod et al (b), 2004). nursing care cannot be articulated from a singular perspective. rural nursing has a rightful and much needed role and place in nursing care and should be acknowledged as such. conclusion invariably, canadian nursing, practice, resources and curricula are discussed in terms of urban availability, access and care. such rhetoric does not, however, inform the nursing profession or the public about the true role of the rural nurse. without specificity, these dominant online journal of rural nursing and health care, vol. 10, no. 1, spring 2010 66 urban overtones, regarding the practice, skills and resources necessary, are only vicariously linked to rural nursing. rural nursing has to be perceived and represented as being important and acknowledged as such. rural nurses know the needs of the rural population because they are a part of the population ergot the communities they serve. such recognition of the rural nursing role can provide a critical awareness of kinds of challenged and solutions that are germane to rural nursing (degroot, 1988; macleod et al, 2008). all nurses need to understand the history of rural nursing and how it has in its past, been marginalized. (baumgart & larsen, 1992; rosskerr, 1998; paul, 2005). rural nurses themselves need to articulate what they do that is unique and why their role is so pivotal to rural health care. rural nurses are in the position to politically assume the mantle of nurse and community member. rural nurses can articulate the role of social and economic needs as influencing care. they can highlight the need for equity of the rural populations regardless of geographic location. nurses need to circumvent the dangers of marginalization through dialogue and political advocacy as well as direct nursing care (mcintyre, thomlinson, & mcdonald, 2006). they must create a strong voice to counteract and at times resist what the majority or government, with political power, may insist upon, to effectively eliminate the negative cost to them and their rural communities. rural nurses are in a prime position to create a climate where being on the margin is not an option, where equality of voice regarding health care is an expectation and a reality. references allemang, m. 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(2004). congruence between existing theories of family functioning and nursing theories. in p.g. reed, n.c. shearer, and l.h. nicoll (eds.). perspectives on nursing theory (4th ed.). philadelphia, pa: lippincott williams & wilkins. world health organization. (1986). ottawa charter for health promotion. ottawa, on: canadian public health association. http://www.rno.org/journal/index.php/online-journal/article/viewfile/139/137 http://www.rno.org/journal/index.php/online-journal/article/viewfile/139/137 http://www.ncbi.nlm.nih.gov/pubmed?term=11928217%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15887769%5buid%5d&cmd=detailssearch http://www.ncbi.nlm.nih.gov/pubmed?term=15615579%5buid%5d&cmd=detailssearch introduction rurality rural nursing in canada conclusion microsoft word cochrane_71-1154-2-ed.docx online journal of rural nursing and health care, 12(2) 11 parental perception of their child’s weight status and associated demographic factors jill d cochran, phd, rn-bc, fnp 1 william a. neal, md 2 lesley a. cottrell, phd 3 christa l. ice, phd 4 1 assistant professor, department of clinical science, west virginia school of osteopathic medicine, jcochran@osteo.wvsom.edu 2 md, professor, department of pediatrics, school of medicine, wvu, wneal@hsc.wvu.edu 3 associate professor department of pediatrics, school of medicine, wvu, lcottrell@hsc.wvu.edu 4 assistant professor, department of biostatistics, school of public health, wvu, cice@hsc.wvu.edu abstract the purpose of this cross-sectional descriptive study was to examine the accuracy of parental perception of their child’s weight status and describe characteristics of those who accurately and inaccurately perceive their child’s weight status. this study utilized data from the cardiac project which spanned from 2006-2009. chi-square analysis was used to determine relationships between parental perception of their child’s weight status and the child’s actual weight status. results indicate that parents have a higher level of accurate parental perception of their child’s weight status than in previous studies. keywords: childhood obesity, parental perception, appalachia parental perception of their child’s weight status and associated demographic factors the prevalence of obesity in children suggests that parents should recognize their child as obese. however, the continuing problem of childhood obesity has not significantly decelerated. the most recent data from the national health and nutrition examination survey (nhanes) showed no significant change in the prevalence of overweight children and adolescents between 1999-2000 and 2007-2008 data except for an increase in 6-19 year old males who were ≥97th percentile of body mass index (bmi) for age and gender (ogden, carroll, curtin, lamb, & flegal, 2010). previous studies suggest that parents do not accurately perceive their child as overweight or obese (adams quinn, & prince, 2005; cottrell et al., 2007; west et al., 2008; wake, salmon, waters, wright, & hesketh, 2002; etelson, brand, patrick, & shirali, 2003; myers & vargas, 2000; jain et al., 2001; baughcum, chamberlin, deeks, powers, & whitaker, 2000; baughcum, burklow, deeks, powers, & whitaker, 1998). accurate or inaccurate perception has been studied in special populations related to race, ethnicity and culture with emphasis on overweight or obese children (intagliata, ip, gesell, & barkin, 2008). significantly higher percentages of obese children live in rural areas. the obesity rate in rural areas is 16.5% compared to an urban rate of 14.8% (liu et al., 2007). the clustered states of wv, ky, tn, nc, tx, sc, ms, and la have the highest rate of obesity in the nation (liu et al., 2007). the majority of these states are in the online journal of rural nursing and health care, 12(2) 12 appalachian region (appalachian regional commission, 2012). mothers in wv, which is the only state entirely in the appalachian area reported inaccurate perception of their child’s weight status (cottrell et al., 2007). as studies have evaluated obese and overweight children (adams et al., 2005; cottrell et al., 2007; west et al., 2008; wake et al., 2002; etelson et al., 2003; myers & vargas, 2000; jain et al., 2001; baughcum et al., 2000; baughcum et al., 1998), little emphasis has been placed on accurate or inaccurate perception of normal or underweight children. demographic factors of parents who inaccurately perceived their overweight child’s weight status have been studied, however, demographic factors of parents who are accurate in perceiving their child’s weight status at any weight class has not been investigated in appalachia. accurate perception of their child’s weight status should guide the nutritional environment of families. environmental factors that contribute to obesity, such as overeating and inactivity, are learned in childhood and may contribute to the development of obesity (golan, 2006). families harbor obesity. if one parent is obese, the child has a 50% chance of becoming obese. if both parents are obese, the child has an 80% chance of becoming obese. obese children have a 70% chance of being overweight or obese as adults (u.s. surgeon general, 2001). the eating patterns of the parent are modeled to the child (birch & fisher, 1998). unless the parents perceive their child’s weight status as a health risk, change will not occur (murtagh, dixey, & rudolf, 2006). given the increased prevalence of obese children in rural areas and importance of parental involvement in their children’s health status, the following aims were identified: 1. evaluate accuracy of parental perception of their child’s weight status as compared to their child’s actual body status determined by center for disease control and prevention (national center for health statistics, 2009) of bmi percentiles (age, gender, height, and weight) in a sample of appalachia parents. 2. evaluate the relationship of selected demographic variables (rural designation, education, age, gender, and socioeconomic status) among parents who are accurate and parents who are inaccurate in perceived weight status of their child. review of the literature accuracy of parental perception of their child’s weight status parental perception of their child’s weight status involves body image perception projected to their child’s body shape and habitus. parental perceptions of their child’s body image are reflected in multiple studies. the literature clearly reflects inaccurate parental perceptions when their child is designated as overweight (adams et al., 2005; cottrell et al., 2007; west et al., 2008; wake et al., 2002; etelson et al., 2003; myers & vargas, 2000; jain et al., 2001; baughcum et al., 2000; baughcum et al., 1998). in a study of 622 mothers of overweight children, 79% did not perceive their child as overweight (baughcum et al., 2000). of the group, 99 mothers had overweight or obese children. in a similar wic population of hispanic mothers (olvera-ezzell, power, & cousins, 1990), 38 mothers were assessed for accurate perception of their child’s weight status. sixty-one percent did not recognize their child as overweight. parental perception was evaluated before and after a state-wide screening program in arkansas (west et al., 2008). in this study, 60% of parents underestimated their child’s weight at baseline. parents of younger children were more likely to underestimate (65%) than parents of adolescents (51%). one year after measurement, accurate perception improved to 53% (p <.0001). online journal of rural nursing and health care, 12(2) 13 in a largely hispanic population, myers and vargas (2000) questioned 200 parents of overweight children aged 2-5 years with open-ended questions about the size of their child. using only direct visualization of their child’s body, parents answered questions about weight and health concerns. parents did acknowledge health risks, specifically cardiac risks (72%), however, 35% of parents did not perceive their child as obese. a similar study (etelson et al., 2003) asked 83 parents to assess their 4-5 year old child’s weight status by plotting their perception on a ruler with extremely underweight and extremely overweight at each end point of the scale after viewing standard growth cards (national center for health statistics, 2000). only 10.5% of the parents accurately identified their child as overweight in the overweight group of children. not only was inaccurate perception noted in the obese population, but also only 41% of parents with normal weight children demonstrated accuracy in plotting their child’s weight status. parental perception of their child’s weight status has been studied in vulnerable populations including native-americans and appalachians. three tribes from wisconsin were assessed for accurate perception of their child’s weight status. participants included 366 parent-child dyad participants from kindergarten through second grade. twenty-six percent of children were overweight (≥95th percentile) and 19% were at risk for overweight (≥85th to <95th percentile). caregivers recognized only 15.1% of overweight children. factors predictive of accurate perception included the child having a bmi >99 th percentile (adams et al., 2005). in an additional study, body mass index (bmi) information was collected during the coronary artery risk detection in appalachian communities (cardiac) project. screening procedures revealed that 37 (33.6%), 14 (22.2%), and 23 (32.4%) of the kindergarten, fifth, and ninth grade students were at risk for being overweight or were already overweight. in the group, of at risk for being overweight or overweight, 62.2% of kindergarten parents, 57.1% of 5 th grade parents, and 43.5% of 9 th grade parents perceived their children to be of healthy weight (cottrell et al., 2007). demographic factors related to accurate and inaccurate parental perception educational status. baughcum et al. (2000) identified lower educational status of the mother as an associated factor of inaccurate parental perception of their child’s weight status. forty-five percent of mothers who inaccurately perceived their child’s weight status had lower education, noted in this study. as high school degree or less. obesity (bmi ≥ 30kg/m2) was more common in the lower education group (30% vs. 14%) and children of parents with lower education were more overweight (weight-for height-percentiles ≥90th; 19% vs. 14%). a similar study conducted in milan, italy (genovesi et al., 2005) described an inverse correlation between parental misperception of their child’s weight status and maternal education. a group of 569 mother-child couples were evaluated by questionnaire and anthropometric measures. a significant association was noted between the mother’s educational level and weight status based on bmi. both mothers (p =.002) and children (p =.02) with a higher prevalence of overweight and obesity were in a lower educational class. perception of their child’s obesity (p =.008) was less in the lower educational class. poverty. poverty is associated with poor parental perception of their child’s weight status. six of the previously reviewed studies (etelson et al., 2003; myers & vargas, 2000; jain et al., 2001; baughcum et al., 2000; baughcum et al., 1998; hackie & bowles, 2007) have documented inaccurate parental perception of their child’s weight status using predominately women, infant, and children (wic) families. wic is a federal program. the usual income eligibility requirements state that the recipients be between 100 percent of the federal poverty guidelines, issued each year by the department of health and human services, but cannot be more than online journal of rural nursing and health care, 12(2) 14 185% of the federal poverty income guidelines (united states department of agriculture, 2009). comparable studies were not conducted in populations that were designated as predominately higher income brackets. race, ethnicity, and culture. accurate or inaccurate perception has been studied in special populations related to race, ethnicity and culture. one-hundred and eleven african american families were screened during a diabetes prevention study (intagliata et al., 2008). a substantial number of the children were obese (69%). however, only 44% of the care givers perceived the child’s weight to be a health problem. parental perception of their child’s overweight status has been evaluated in populations that were predominately latino (intagliata et al., 2008) and hispanic (hackie & bowles, 2007). mother-child dyads (n=123) recruited from a latino community were assessed by questionnaires and anthropometric measurements. mothers in wv, which is the only state entirely in the appalachian area, reported inaccurate perception of their child’s weight status in the cardiac study. parents, with children in three age groups, reported inaccurate perception of their child’s weight status (cottrell et al., 2007). age and gender of child. parental inaccuracies have been associated with the age of the child. baughcum et al. (2000), myers and vargus (2000), etelson et al. (2003), adams et al. (2005), carnell, edwards, croker, boniface, and wardle (2005), and hackie and bowles (2007) studied populations of children under the age of 6 years. as previously cited, baughcum et al. reported an inaccuracy rate of 79%, myers and vargus 89.5%, etelson et al. 89.5%, adams, et al. 84.9%, carnell et al. 82.9%, and hackie and bowles 61%. as children age, accurate perception by parents of the child’s weight status improved. eckstien et al. (2006) noted that parents of children age 6 and older had 56% accurate perception, versus 18% of children younger than six years of age, in overweight children. maynard, galuska, blanck, & serdula (2003) studied a large population of 5500 children ages 2-11. significant improvement in accuracy was noted at 7.8 years of age for both boys and girls. in another study by wald et al. (2007) accuracy rates of 17% for parents of children aged 3-5 years and 61.7% for children aged 6-12 were noted. studies of older children and teens demonstrate a better relationship between age and accurate perception. a study of 15,483 teens (goodman, hinden, & khandelwal, 2000) demonstrated parental accuracy of 32% of their teen’s weight status. west et al. (2008) noted parents of older children more prone to correctly estimate their weight status. sixty-five percent of parents with children <13 years of age reported inaccurate weight status perception compared to 51% of parents with children ≥13 years of age. gender has been studied as a modifying factor in parental perception. studies by wake et al. (2002), west et al. (2008) and goodman et al. (2000) did not note a significant difference in parental perception related to gender. however, wald et al. (2007) noted parental perception was more accurate for females at 63% compared to 46% for males. crouch, o'dea, & battisti (2007) noted a near significant level (p =.056) of health concern for parents of females who were overweight. maynard et al. 2003 noted parental perception to be more accurate for females at 29% compared to males at 14.0%. limitations of existing knowledge studies investigating parental perception overwhelmingly support that parents do not see their child as obese (adams et al., 2005; cottrell et al., 2007; west et al., 2008; wake et al., 2002; etelson et al., 2003; myers & vargas, 2000; jain et al., 2001; baughcum et al., 2000; baughcum et al., 1998). five of the studies (etelson et al., 2003; myers & vargas, 2000; jain et al., 2001; baughcum et al., 2000; baughcum et al., 1998) used predominately wic families, online journal of rural nursing and health care, 12(2) 15 representing lower socio-economic status than the general population. lower education as an influence is not consistently defined in the studies. education, socio-economic status, race, ethnicity, and culture have strong associations with inaccurate parental perception of their child’s weight status. studies considering age as a factor in accurate parental perception noted that accuracy is lower in children under six years of age (adams et al., 2005; baughcum et al., 2000; etelson et al., 2003; hackie & bowles, 2007; myers & vargas, 2000) than children aged six and older (eckstein et al., 2006; maynard et al., 2003; wald et al., 2007). tanner staging also distorts perception, however, accuracy in teens was found to be more accurate than children less than six years of age (goodman et al., 2000; west et al., 2008). gender, as a factor in accurate parental perception, is not always noted (goodman et al., 2000; wake et al., 2002; west et al., 2008), although three studies noted that females were more often perceived as overweight by parents that accurately perceived their child as overweight (crouch et al., 2007; maynard et al., 2003; wald et al., 2007). the existing literature provides numerous studies related to accurate or inaccurate parental perception of their child’s weight status. most of the studies were performed in preschool-aged children; few studies used larger populations of school aged children. when compared to urban areas, rural populations have a higher rate of obesity (liu et al., 2007). accurate or inaccurate parental perception of their child’s weight status has not been studied specifically in these populations using normal weight children. within appalachia, demographic factors have not been used in comparing parents who are accurate verses inaccurate in perceiving in their child’s weight status. methodology sample the study used existing data from the coronary artery risk detection in appalachian communities (cardiac) study collected during the years of 2005-2009 from eight counties. cardiac is a cardiovascular screening project for west virginia children in kindergarten (cardiac-kinder), second (cardiac-too), and fifth grade (cardiac-kid). all 5 th graders in west virginia were eligible to participate in the screening program. all kindergarten and second grade students in select counties were also eligible to participate. each screening was conducted within the school setting and was free for all participants. the program continues to be supported by the claude worthington benedum foundation and the west virginia (wv) department of health and human services. parents or legal guardians of all children who participated in the cardiac health screening in eight counties between 2006 and 2009 were eligible to complete a questionnaire related to health behaviors and attitudes titled “environmental determinants of physical activity in children”. data from this questionnaire were used for this study. all procedures for the original study were approved by the institutional review board (irb) for the protection of human subjects at west virginia university. the request for approval of this secondary analysis was added to the original irb application as an addendum and approved. treatment of data cardiac data sets were received from the cardiac project in three age groups: (1) kindergarten, (2) second grade, and (3) fifth grade. data sets for the cardiac project from the 2006 to 2009 time period were used for this study. eight counties in wv were represented in the data. online journal of rural nursing and health care, 12(2) 16 the data sets contained two components of the cardiac project: 1) anthropometric and demographic data measured and recorded by cardiac team members from the cardiac screening that the child participated in, and 2) the questionnaire “environmental determinants of physical activity in children” containing self-reported data completed by parents of children participating in the project during eligible years and from participating counties. specific data from each component were selected and placed in data sets for three cohorts: kindergarten, second grade, and fifth grade. anthropometric measurements used in this study included the child’s bmi percentile. further recoding was necessary to categorize the bmi into categories of underweight, normal weight, overweight, and obese. cardiac team members linked the anthropometric and demographic data for the student and the questionnaire reported by the parent for that child. data sets were received in an spss file and were cleaned, prepped, and deidentified by cardiac team members. cardiac data extraction anthropometric measures. the method for measuring children in the cardiac study has been used for the duration of the project. a child’s weight status was reported as bmi percentiles obtained from measurements taken by cardiac project staff members. height (cm) and weight (kg) were obtained by measuring to the tenth digit using the seca road rod stadiometer (78″/200cm) and the seca 840 personal digital scale. both seca stadiometer and digital scales have been incorporated in national and international measurement studies of children’s obesity for over 5 years (seca seca sensa 804.). standard calculation for each child’s bmi was based on the recommended equation from the cdc (weight (kg)/height (cm) 2 x 10,000) (hammer, kraemer, wilson, ritter, & dornbusch, 1991; pietrobelli et al., 1998). weight percentile categories were based on age-and gender-specific growth charts recommended by the cdc. children’s bmi percentiles are categorized into 4 groups (hammer et al., 1991; pietrobelli et al., 1998): underweight (<5 th percentile), normal weight (from the 5 th to the 84.9 th percentile), overweight (between the 85 th and 94.9 th percentiles) and obese (95 th % and above). for this data, the cardiac project recruited west virginia rural health education partnership (wvrhep) students to assist with measurements. the wvrhep students were health science students from schools of medicine, nursing, dentistry, pharmacy, as well as students of physical therapy. cardiac staff and local school nurses train wvrhep students to conduct anthropometrical testing. parent questionnaire. the questionnaire, “environmental determinants of physical activity in children” was also completed by a sub sample of cardiac participants. one parent or legal guardian of each participating child answered a series of questions exploring their child’s cardiovascular risk. validated questions developed from a previous study (cottrell et al., 2007) assessed parent health knowledge, and parent health attitudes. variables parental perception parental perception of their child’s weight status was evaluated by comparison of the parent’s response to the question, “compared to other children the same age and gender, how would you describe your child’s weight (fill in only one): very underweight, slightly underweight, about the right weight, slightly overweight, and very overweight.” accurate perception was defined as: very underweight or slightly underweight as associated with bmi’s less than the 5 th percentile, about the right weight associated with bmi’s at or above the 5 th online journal of rural nursing and health care, 12(2) 17 percentile to less than the 85 th percentile, slightly overweight associated with bmi’s at or above the 85 th percentile to less than the 95 th percentile, and very overweight associated with bmi’s equal to or greater than the 95 th percentile (u.s. department of health and human services, 2006). demographic factors educational status was assessed using the demographic tool completed by parents. the categories were: 8 th grade education or less, some high school, high school graduate or ged, some college or technical training, college graduate, and completed graduate school. the response is given by filling in the corresponding circle next to the given responses. parents complete the demographic sheet and the tool reflected whether the mother or father is completing the form. the socioeconomic status of the population was determined using the census bureau equation of family size and composition. for this study, the socioeconomic status of the participants and families was described using a proxy measure of poverty level in the county of residence. this was determined by the zip codes taken from the cardiac data which was categorized into counties. the socioeconomic status of the participants was then determined by the zip code of the participant, compared to the county designation of percent of poverty of that county for children ages 0-17 living in poverty as determined by the census bureau (u.s. census bureau, 2012). three categories were designed to describe level of poverty for the county in which the child and family reside: level 1, poverty level 10%-15% of population designated as living in poverty, level 2, 16%-25% of population designated as living in poverty, and level 3, 26% and above of population designated as living in poverty (united states department of agriculture, 2010). race/ethnicity was determined based on the self-report of parents from the cardiac questionnaire completed by the parent. categories on this questionnaire included: black, hispanic, white, asian, bi-racial, and other. since the state of west virginia is entirely in the appalachian area, all participants were assumed to be members of the appalachian culture due to their west virginia residence. counties of residence were classified using rural-urban commuting area codes (ruca) to distinguish rurality (united states department of agriculture, 2009). based on definitions of rural, (ers/usda data rural definitions: data documentation and methods) the economic research service of the united states department of agriculture (usda) defines nine methods of operationalzing rural. ruca codes define rural areas based on the same theoretical principles and information used by the office of management and budget (omb). ruca codes allow rural definitions based on metropolitan, micropolitan, and small town commuting areas. ruca primary codes 4-10 are designated as rural (http://www.ers.usda.gov/data/ruraldefinitions). this designation of rural was used in this study. ruca codes from the three cohorts were categorized as “rural” (ruca codes 4-10) and non-rural (ruca codes 1-3). comparison of responses by parents related to the child’s gender was determined based on answers from the cardiac screening, either male or female. analysis data analysis data were analyzed using the statistical package for social science (spss) graduate pack for windows (2004) computer software program. after data cleaning, and removal of any online journal of rural nursing and health care, 12(2) 18 subjects with impossible values or greater than 10% of the necessary data elements missing, descriptive statistics were used to describe the sample. each group of students from kindergarten, second grade, and fifth grade was evaluated. the bmi of every child in the sample was calculated using their correct weight and height; then compared to the appropriate cdc guidelines for bmi percentiles in children by age. parametric testing was used after meeting all assumptions. all analyses used a level of p < .05 to designate statistical significance. because this study uses previously collected data, a post hoc power analysis was completed, considering the actual number of useable cases available from a larger data set. to analyze parental perception of their child's weight status and the actual weight status, chi-squares were used to determine whether there was a relationship between a child’s weight status and his or her parent’s perception of that weight status. differences in selected demographics between parents who accurately perceive their child's weight status and parents who inaccurately perceive their child's weight status was evaluated by subdividing children into groups where parents accurately and inaccurately perceived their weight status. chi-square analysis was used to compare demographic variables between the groups. results sample description demographics of children and families. race was originally reported in five categories, however, few responses were given in categories of black, asian, hispanic, bi-racial, and other (kindergarten total n = 919; black, asian, hispanic, bi-racial, and other n = 53; second grade total n = 703 black, asian, hispanic, bi-racial, and other n = 133; fifth grade total n = 297, black, asian, hispanic, bi-racial, and other n = 16). therefore, two groups were created: a) caucasian and b) all other races (black, asian, hispanic, bi-racial, or other). this met the assumptions for chi-square. due to the small numbers of responses for level of education below high school for the mothers in all cohorts (kindergarten n= 32; second grade n= 20; fifth grade n= 7), these categories were collapsed for chi square analysis to reflect high school (hs) or less as one category, while other educational categories from the original data set were kept intact. socio economic status was described using county designation of the participant and economic status of that county as given by the u.s. census department and the united states department of agriculture in three levels: level 1, 10%-15% of population designated as living in poverty; level 2, 16%-25% of population designated as living in poverty; and level 3, 26% and above of population designated as living in poverty. demographics of kindergarten cohort. the kindergarten cohort was the largest sample. multiple characteristics of that sample were explored. there were 957 participants in this group. in this cohort, 71.7 % of the children were under or normal weight and gender was almost equally distributed (48.6%; 51.4%). the majority of kindergarten children were caucasian (94.3%). slightly less than one-half (47%) of that population lived in counties with 10%-15% of the populations living in poverty. the majority of their families lived in counties designated nonrural (63.1%). most mothers had post-high school education (57.6%). a detailed description of sample demographics appears in table 1. online journal of rural nursing and health care, 12(2) 19 second grade cohort. the demographic characteristics of the second grade cohort were obtained from 608 participants with 54.2% females and 45.8% males. more than one-half of the second-grade children were under or normal weight (66.4%). caucasian was the predominant race in this cohort. the majority of the mothers reported post high school education. most of the participants (47.3%) lived in counties that contained 10%-15% of the population living in poverty. the majority of the families of the second grade children lived in areas designated as non-rural (72.2%). see table 2 for detailed demographic data. fifth grade cohort. the demographic patterns of the fifth grade cohort were described with 304 participants; 54.8% females and 45.2 % males. in fifth grade children, more than onehalf of the participants were under or normal weight (56.6%). again, the predominant race was caucasian (94.6%). no information was given as to who completed the demographic form in this cohort. the economic composition of the fifth grade cohort was varied. for this group, the percentage living in poverty level 1 (10%-15% of the population designated as living in poverty, 41%), and poverty level 2, (16%-25% of population designated as living in poverty, 42.9%) were nearly equal. the majority of the families lived in areas designated as rural (60.9%). the majority of the mothers reported post high school education. further detailed data are found in table 3. online journal of rural nursing and health care, 12(2) 20 parental responses recoding responses. accurate and inaccurate parental perception of their child’s weight status as related to bmi percentiles was evaluated. to calculate parental perception of their child’s weight status, data were recoded for two categories of perception responses. too few responses were given in perceived categories of underweight and obese to meet chi-square assumptions. therefore, responses that were perceived as “underweight” were combined with perceived “normal weight” and responses perceived as “obese” were combined with perceived “overweight”. to be consistent with the combined categories of perceived weight status, the child’s actual weight status or bmi category was also recoded. thus, the bmi categories for the child’s actual weight were collapsed to reflect under/normal weight as one category and overweight/obese as the second category in the bmi variable. results of analysis kindergarten cohort. in the kindergarten cohort, a significant relationship between accurate parental perceptions of their child’s weight status and the child’s actual weight status (p <.001) was found. among groups of the kindergarten children perceived by their parents to be about the right weight or less, 78.2% of kindergarten children were actually under or normal weight. of the kindergarten children perceived by their parents to be about the right weight or less, 21.8% of the children were actually overweight and obese. of the kindergarten children perceived by their parents to be slightly overweight and overweight, 7.5% of those children were actually underweight or normal weight and 92.5% were overweight/obese (table 4). online journal of rural nursing and health care, 12(2) 21 cohort second grade. in the second grade cohort, a significant relationship was noted between parental perception of the child’s weight status and the child’s actual weight status (p <.001). of the second grade children perceived by their parents to be about the right weight or less, 80.6% were under/normal weight. however, 19.4% of the children perceived as under/normal weight were actually overweight/obese. of the second grade children perceived to be slightly overweight and overweight, 9.3% were under or normal weight children and 90.7% were overweight/obese (table 4). fifth grade cohort. parents of children in the fifth grade cohort also demonstrated a significant relationship between perception of their child’s weight status and their actual weight status (p =.002). in the fifth grade cohort, 44.1% of children perceived by their parents to be about the right weight or less were under/normal weight. in the same group, 55.9% were actually overweight/obese. of the fifth grade group perceived to be slightly overweight and overweight, 24.1% were under/normal weight and 75.9% were overweight/obese (table 4). demographics to determine the possible impact of demographics between parents who accurately and inaccurately perceive their child’s weight status, chi-square analyses were performed. demographic variables consisted of: gender, race, poverty level, child’s bmi category, rurality, and mother’s education. this question did not require recoding of child’s bmi category. online journal of rural nursing and health care, 12(2) 22 kindergarten cohort. for the parents of children in kindergarten, there was a statistically significant relationship between whether or not the parent was accurate in the perception of the child’s weight status and the child’s gender (p <.001). in parents with daughters, 45.7% were inaccurate and 54.3% were accurate in their perception of the child’s weight status. of the parents with sons, 49.1% were inaccurate while 50.9% were accurate in weight perception of their child. there was also a statistically significant relationship between whether or not the parent was accurate in the perception of the child’s weight status and the child’s bmi category (p < .001). in groups of parents of children with bmis categorized as underweight, 68.6% were inaccurate and 31.4% were accurate in perceiving their child’s weight status. in parents of normal weight bmis children, 22.0% were inaccurate and 78.0% were accurate. parents with children having bmis in the overweight category were 95.8 % inaccurate and 4.2% accurate. in parents with children in bmi groups considered obese, 92.9% were inaccurate and 7.1% were accurate in weight perception (table 5). no relationship was found between race, poverty level, rural status, or mother’s education and accurate parental perception of their child’s weight status. second grade cohort. no relationship was found between gender, poverty level, rural designation, or mother’s education and accurate parental perception of their child’s weight status. a significant relationship between whether or not the parent was accurate or inaccurate in the perception of their child’s weight status as related to race (p =.002). parents of caucasian children demonstrated 52.3% inaccuracy and 47.7% accuracy in weight status perception. parents of children categorized as “all other races” had inaccurate perception of 24.2% and accurate perception of 75.8% of their child’s weight status (table 6). a statistically significant relationship was noted in the child’s bmi category (p <.001). online journal of rural nursing and health care, 12(2) 23 in groups of parents whose child’s bmi was categorized as underweight, 35.3% were inaccurate and 64.7% were accurate in perceiving their child’s weight status. in parents of children with bmis categorized as normal, 33.2% were inaccurate and 66.8% were accurate. parents with children having bmis in the overweight category were 77.8 % inaccurate and 22.2% accurate. parents with children in bmi groups considered obese were 89.8% inaccurate and 10.2% accurate in weight perception. in parents whose bmi category was designated as underweight, 56.0% were not accurate and 44.0% were accurate in perceiving their child’s weight. fifth grade cohort. in the 5 th grade cohort there was a significant relationship between whether or not the parent was accurate in the perception of the child’s weight status (p <.001) and the child’s gender (p < .001). in parents with daughters, 38.2% were inaccurate and 61.8% were accurate in their perception of the child’s weight status. of the parents with sons, 61.0% were inaccurate while 39.0% were accurate in their weight perception of their child (table 7). in cases where the child’s bmi was categorized as underweight, 100.0% were accurate in perceiving their child’s weight status. in parents whose children had bmis in the normal weight category, 26.4% were inaccurate and 73.6% were accurate. parents with children having bmis in the overweight category were 61.1 % inaccurate and 38.9% accurate. in parents with children in bmi groups considered obese, 86.8% were inaccurate and 13.2% were accurate in weight perception (see tables 7). no relationship was found between race, poverty level, rural designation, or mother’s education and accurate parental perception of their child’s weight status. online journal of rural nursing and health care, 12(2) 24 discussion limitations of secondary data while secondary data are a valuable resource, use of such data presents certain limitations. the data were collected for defined purposes, not specifically for the aims of this study. therefore, data analysis required redefining variables and re-categorizing of data elements to meet the objectives of this study. these changes resulted in decreased variability of the data potentially impacting the results. re-categorizing the data was performed with vigilance to preserve the original definition of the variables while balancing the need to have adequate responses in each category. parental perception of their child’s weight status was assessed using questions from the study that asked parents to evaluate their child’s appearance to other children of the same age and gender. considering the rate of obesity in the general population of children in wv (neal et al., 2006), this method of questioning and comparison could be limiting. in this study, it could not be determined if the parent was comparing their child to another child in the normal weight category. if comparison of the child’s weight status was to children who were overweight or obese, parental accuracy would naturally be distorted. the secondary data used in this study did not adequately represent the population of west virginia as related to educational status. a higher level of education was noted in the respondents than in the general population of west virginia (west virginia quick facts from the us census bureau). another limitation of this study was the need to use a proxy measure of socioeconomic status of respondents for analyses. this method is not reflective of the individual family. limitations were noted with respect to geographic location in this study. ruca codes were used to classify rural or urban dwelling of the family. lack of representation of every county in the state in the original data set allowed only certain ruca codes to be represented. the location of the data collection sites in the appalachian area suggests a prevalence of appalachian culture in the respondents. however, this study does not account for residents living in the area who would not self-identify as a member of the appalachian cultures by virtue of inmigration or other factors. parental perception of child’s weight status and associated demographic factors parental perception of their child’s weight status was often accurate as compared to the child’s actual bmi category in this sample. accurate parental perception of their child’s weight status was highest among kindergarten children and declined to its lowest rate in parents of fifth grade children. this is in direct contrast to other studies of parental recognition of their child’s weight status. the perceptions of the parents in this study, as compared to other studies, were online journal of rural nursing and health care, 12(2) 25 more accurate than those of parents reported in the literature (baughcum et al., 2000; myers & vargas 2000; national center for health statistics, 2000; hackie & bowles, 2007; west et al., 2008; cottrell et al., 2007). the contrast in results could be explained by the larger sample of children in this study than noted in previous studies, as well as the similarity of ages in each of the cohorts in this study. higher educational level of the parents may have influenced perception of the parents regarding their child’s weight status in this study. also, the time lapse since the previous studies were completed could account for the difference, since education on children’s obesity has been initiated in the media (baughcum et al., 2000; myers & vargas 2000; national center for health statistics, 2000; hackie & bowles, 2007; jeffery, voss, metcalf, alba, & wilkin, 2005; west et al., 2008; cottrell et al., 2007). parental perception of their child’s weight status was related to the child’s bmi category. to further investigate aspects of accurate and inaccurate parental perception of their child’s weight status, bmi categories were re-expanded into the four original categories: a)underweight, b) normal weight, c) overweight, and d) obese and then compared only to established accurate and inaccurate parental perception. when accurate parental perception of their child’s weight status was compared to bmi categories, differences in parental accuracy of their child’s weight status at each bmi category were identified. there was a major decrease in parental accuracy at the obese category in all cohorts. the major decrease in parental accuracy in the obese category is difficult to explain. perhaps the line between overweight and obesity is not clear to parents. one previous study did evaluate parental perception of their child’s weight status and included categories other than overweight and obese. west et al. (2008) noted less than one-half of parents with children having bmis in the underweight category were accurate in weight perception. other studies were conducted primarily with overweight children without a distinction between overweight and obese, and bmi categories were not always used for comparison to parental perception of their child’s weight (baughcum et al., 2000; myers & vargas 2000; national center for health statistics, 2000; hackie & bowles, 2007). differences in accurate parental perception related to the age of the child in this study varied from the literature. accurate parental perception of their child’s weight status appeared to decline as the child got older in this study. other studies in the literature demonstrated lower accuracy in children younger than 6 years of age (west et al., 2008) and higher accuracy in children older than 6 years of age (eckstein et al., 2006; maynard et al., 2003; wald et al. 2007). the influence of appalachian culture and beliefs may be responsible for the discrepancy in agreement of parental perception of their child’s weight status. appalachian culture holds the belief that heavier children are stronger and better equipped for sports. as the child ages, parents may perceive that the size of the child demonstrates sustenance and hardiness. thin, or even normal weight children are often seen as disadvantaged with less ability to withstand illness and other adverse situations. parent’s beliefs that they have performed well in nurturing their child by feeding them adequately are reinforced through having a child who is heavier (cochran, 2005; cochran, 2008; trombini et al., 2003). however, lack of knowledge as to whether the sample would self-identify as an appalachian remains a limitation. in this study, gender of the child was related to accurate parental perception of their child’s weight status in parents of kindergarten and fifth grade children. parents of younger children were more accurate in perceiving their daughter’s weight status than their son’s. this finding is consistent with previous studies that found parental accuracy in perception of their child’s weight status more consistently in daughters than sons (crouch et al., 2007; maynard et al., 2003; wald online journal of rural nursing and health care, 12(2) 26 et al., 2007). society’s generalized acceptance of larger males, while females are expected to be smaller, may explain these findings (cafri & thompson, 2004; mccreary, 2002). other contributing factors for accurate parental perception varied among the cohorts. modifying factors of race, education, and poverty had limited impact on accurate parental perception of their child’s weight in all cohorts in this study. previous studies found high levels of inaccurate perception in wic populations which included homogeneous respondents from lower socioeconomic status and lower educational levels groups (etelson et al., 2003; myers & vargas, 2000; jain et al., 2001; baughcum et al., 2000; baughcum et al., 1998). baughcum et al. (2000) identified lower educational status of the mother as an associated factor of inaccurate parental perception of their child’s weight status. these studies, however, were conducted primarily with lower income families (income at or below 185% of the u.s. poverty income guidelines), making the impact of income versus education is difficult to ascertain. implications for practice. as the growth and development of the child progresses, various age related interventions should be considered. in infancy, nurses can assist parents in perceiving normal weight status for their infant and reinforce that an overweight baby does not imply a “healthy” baby. the infant’s nutritional self-regulation and hunger cues can be taught and reinforced to parents. for children with a bmi status that is overweight or obese, nurses must understand that the literature describes parental perception of their child as personal and subjective. the high prevalence of obesity in second and fifth grade in this sample demonstrates a need for nursing interventions early, preferably prior to second grade. interventions should be targeted in these age groups, especially for parents of male children. programs that emphasize athletes with normal bmis could serve as cues to action in promoting likelihood of change for parents of overweight or obese children. noting that parents recognized their child as overweight when their child was in the obese category promotes targeting this group of parents for intervention, since recognition of the problem has occurred and change may follow. since obesity in children is not a “billable” diagnosis in primary care, repeat visits for this diagnosis may not occur. nurses can lobby to create changes in billing practices to include the diagnosis of obesity for children as well as the associated diagnosis of hypertension and metabolic syndrome, thereby facilitating closer primary care follow-up of these problems for children. opportunities for further study. replication of this study in geographic areas that contain a larger population of racially diverse families should be considered. other age groups of children should be included in the study to evaluate the impact of physical development on parental perception of their child’s weight status. perception of weight status and associated health risks should be expanded and studied in children as well. conclusion it is necessary for a parent to accurately perceive their child’s weight in order for them to take action related to food provision and consumption patterns. some groups may be at a greater risk for inaccurate perception. association of obesity and health risks must be evaluated to determine the meaning of accurate parental perception of their child’s weight status. future research should support the development of childhood obesity tools, parental and family intervention strategies and methods of evaluating change in food provision and consumption patterns in children. online journal of rural nursing and health care, 12(2) 27 references adams, a. k., quinn, r. a., & prince, r. j. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/12032758 http://www.ncbi.nlm.nih.gov/pubmed/17944783 733_qoc+comparison+revised+4+11_accepted_setup_4_13_23psf+ar_formatted (1) online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 150 quality indicators in critical access hospitals and small rural and urban hospitals marianne baernholdt, phd, mph, rn, faan1 nancy dunton, phd, faan2 elizabeth m. grandfield, phd3 emily cramer, phd4 1sadie heath cabaniss professor and dean, school of nursing, university of virginia, mb2vy@virginia.edu 2research professor, school of nursing, university of kansas medical center, ndunton@kumc.edu 3assistant professor, department of methodology and statistics, utrecht university, e.m.grandfield@uu.nl 4research associate professor, school of nursing, university of kansas medical center, ecramer@cmh.edu abstract purpose: critical access hospitals (cahs) have served their rural communities since they were created in the 1990s. cahs have been exempt from the multiple organizational performance-based approaches that use financial incentives and thus quality indicators targeting cahs specifically do not exist. reports have suggested indicators that are appropriate for rural hospitals and cahs but none have included all types of quality indicators structures, work processes, outcomes, and quality improvement (qi) activities. using a subset of the national database of nursing quality indicators® (ndnqi®) we assessed whether existing indicators for the work environment (structure), patient and nurse outcomes are appropriate for cahs. methods: using 2017 ndnqi® data on 16 structure and outcome indicators (8 work environment, 6 patientand 2 nurse outcomes) were extracted. employing bootstrapped online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 151 confidence intervals cahs were compared to other small (less than 50 beds) rural and urban hospitals. findings: 103 cahs, 63 small rural hospitals, and 91 small urban hospitals had data on at least one indicator (range 87-239 for each indicator). there were no differences between cahs and other small rural and urban hospitals for 15 of the 16 quality indicators. cahs had fewer bachelor-prepared nurses compared to urban hospitals. conclusion: our results suggest that quality indicators for structure and outcomes currently used in approximately 2000 hospitals are also applicable for cahs. whether they apply to all 1350 cahs and can be used to guide benchmarking and qi in cahs needs further study. keywords: critical access hospitals, quality indicators, national database of nursing quality indicators® quality indicators in critical access hospitals and small rural and urban hospitals it has been 20 years since the national academy of medicine (nam, formerly institute of medicine (iom)) released crossing the quality chasm iom (us) committee on quality of health care in america (2001). the report made clear that poor quality and safety outcomes were not caused by bad clinicians but rather because of poor systems. subsequently, multiple organizational performance-based approaches with both financial and accreditive incentives using reports of quality indicators were implemented, targeting first hospitals and later all settings of health care (what is pay for performance in healthcare?, 2018). of the approximately 1800 rural hospitals in the united states (american hospital association, n.d.), more than 1300 are critical access hospitals (cahs) certified under the medicare rural hospital flexibility program (the flex program) which was created by congress in 1997 (casey et al., 2012). compared to other hospitals, cahs have no more than 25 beds, receive cost-based reimbursement from medicare and have limited reporting requirements (casey et al., 2015; lahr et al., 2020; quick et al., 2019). thus, quality indicators targeting cahs online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 152 specifically do not currently exist, making it difficult to ascertain how well cahs’ perform including their structures, work processes, outcomes, and quality improvement (qi) activities, all typical quality indicators (agency for health research and qualityahrq, 2015.; mitchell & lang, 2004). several reports have addressed the lack of quality indicators for all rural hospitals and cahs specifically. one example is a national quality forum (nqf) workgroup that addressed which indicators would be appropriate for all rural hospitals (nqf, 2018). the indicators had to be cross-cutting, resistant to low case-volume and address transitions in care. further, the authors recommended the indicators should be a mix of process and outcome measures. in general, health care quality measures are classified as either, structure (what needs to be in place in an organization), process (care to improve outcomes) and outcomes (the result of structure, process and patient characteristics) (ahrq, 2015). twenty core measures were recommended: nine for hospitals and 11 for ambulatory care. among the nine hospital outcome measures were hospital acquired infections including catheter-associated urinary tract infections (cauti) and clostridioides difficile (c. diff) infections; falls with injury; readmissions, and patients’ assessments of care using the hospital consumer assessment of healthcare provider (hcaps), which is a survey with 29 questions developed by ahrq (centers for medicare & medicaid services, 2021). a process measure was emergency transfer communication. another example addressing the gap in rural relevant measures is an earlier study focused only on quality indicators appropriate for cahs. this paper had almost all process indicators related to pneumonia, heart failure, and acute myocardial infarction indicators (casey et al., 2013). in both examples, the recommendations did not include indicators for structures (e.g., staffing), work processes (e.g., collaborations across departments and between employees), or qi activities (e.g., type and content). online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 153 simultaneously with these papers, the medicare beneficiary quality improvement program (mbqip) was established in 2011 to assist cahs with their qi activities. today, through mbqip, cahs voluntary report quality indicators in four domains: patient safety/inpatient, outpatient, patient engagement, and care transitions (lahr et al., 2021; swenson & casey, 2016). in 2019, 94% or 1270 cahs reported on at least one of nine patient safety/inpatient indicators which included six for hospital-acquired infections (outcomes), transfer from the emergency department (ed) to inpatient unit (process), and a set of antibiotic stewardship elements (process) (lahr et al., 2021). in 2018 the federal office of rural health policy started requiring that cahs report antibiotic stewardship data to the center for disease control and preventions national healthcare safety network (nhsn). these data are then included in mbqip. except for the antibiotic stewardship which 1077 cahs reported on, for the other nine indicators the variance in rates was large with only 233-282 cahs reporting on different types of surgical site infections and 621-789 reporting on other infections. a concern is that some indicators are not appropriate for all cahs (i.e., surgical infections) and another concern is that volume is too low to report a rate. therefore, it is difficult to compare cahs performance with that of other hospitals using data from mbqip. looking to other databases with indicators that are appropriate for all hospitals, a prominent example is the national database of nursing quality indicators® (ndnqi®) which includes indicators addressing structure, process and outcomes at the nursing unit level (montalvo, 2007). ndnqi® was established in 1998 by the american nurses association with 30 hospitals submitting data. by 2014 more than 2000 hospitals submitted data to ndnqi®, the same year press ganey acquired ndnqi® (press ganey, 2014). ndnqi® provides participating hospitals quarterly benchmark data at the nursing unit level, so they can follow their own improvements and compare themselves to like units across the nation (duncan et al., 2011). indicators include structural indicators such as unit type and the work environment (i.e., online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 154 staffing, education, and experience), process indicators including prevention interventions for pressure injury and falls, and both patient and nurse outcomes, for example falls and pressure injury for patients and job enjoyment and job plans (intent-to-stay) for nurses. numerous studies have used ndnqi® to establish the importance of structures and process for patient and nurse outcomes (beck et al., 2019; park et al., 2014; waters et al., 2015). a few studies have used ndnqi® to compare rural and urban nursing units. using 2009 ndnqi® data results showed that compared to urban nursing units rural nursing units had less care provided by rns and fewer rns with a bsn or higher, rated their work environment and job satisfaction lower, but had higher intent-to-stay, and lower rates of the patient outcome, pressure injury (baernholdt et al., 2017). in a subsequent study, rural location was not associated with fall rates, but the nurse work environment was: lower ratings of the practice environment, lower staffing, lower percentage of rns with a bachelor of nursing degree, more rns with less experience, and worse nurse outcomes (job satisfaction and intentto stay) were all associated with higher fall rates (baernholdt, hinton, et al., 2018). in a final longitudinal study using 4 years of ndnqi® data results showed lower pressure ulcer rates were associated with an increase in care interventions (risk and skin assessment on admission and any risk assessment before a pressure ulcer was documented), a 10% increase in rn skill mix (percentage of all nursing care hours provided by rns), higher job satisfaction and lower turnover intentions were significant in both rural and urban nursing units (baernholdt et al., 2020). none of the previous studies used cahs as a comparison group. currently more than 100 cahs report one or more quality indicators to ndnqi®. we propose to assess whether ndnqi® indicators are appropriate for cahs. we compare indicators for the nurse work environment (structure), patient and nurse outcomes between cahs and other small rural and urban hospitals. since we are using de-identified data, the study received irb exemption. online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 155 methods data source this cross-sectional study used 2017 data from ndnqi®. hospitals submit data on staffing and clinical quality measures each quarter. participation in measures varies across hospitals and units within hospitals. data submitted by hospitals are collected according to highly standardized protocols and come from a variety of sources including hospital payroll, patient healthcare records, adverse event (incident) reports, special data collection, and for about 35% of hospitals an annual survey of registered nurses (rns). rn surveys are only included if at least five nurses and 50% of the rns have responded. several studies have confirmed the validity and reliability of ndnqi® measures (bergquist-beringer et al., 2011; choi et al., 2014; choi & staggs, 2014; klaus et al., 2013; waugh & bergquist-beringer, 2016). we included cahs and urban and rural hospitals with 50 beds or less which had submitted data in 2017. urban hospitals included metropolitan (a core urban area of 50,000 or more population) and rural hospitals included micropolitan (an urban core population of at least 10,000, but less than 50,000) and neither metropolitan nor micropolitan (office of management and budget, 2010). first, we extracted data from the following hospital units for all three hospital types: eds, medical, surgical and medical-surgical combined (med/surg), and intensive care units (icus) and for cahs we also extracted data from designated critical access units if present. second, data for all quarterly staffing and patient outcomes were annualized by summing numerator values (e.g., number of patient falls) and denominator values (e.g., number of inpatient days) and calculating rates (e.g. falls/patient days x 1000). only indicators with data for at least three quarters were included. third, we created hospital-level scores as cahs typically have less demarcated units and staff that works in all areas of the hospital (cramer et al., 2011). the hospital-level scores for the annualized staffing and patient outcome measures were created using a weighted standardization method to account for differences in online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 156 patient acuity and patient volume across unit types and then scores were averaged for the hospital. standardized scores (z-scores) for each unit were calculated using unit type (e.g., med/surg, eds, icus) mean and standard deviation estimates. for example, the cauti rate for each unit was adjusted for unit type by subtracting the average cauti rate for units of that type and then divided by the standard deviation of the cauti rates for units of that type. the resulting z-score is the difference in standard deviations, of the unit’s cauti rate from the average cauti rate for units of that type. then each z-score was weighted by the patient device days for that unit (e.g. patient days). further, the hospital average was calculated as the average of a hospital’s units weighted z-scores. finally, z-scores were back-translated to their original metric for reporting of results, by multiplying the z-score by the full sample standard deviation and adding the sample mean. sample a total of 253 hospitals had data on at least one measure including 103 cahs, 63 rural hospitals, and 91 urban hospitals (see table 1 below). the five hospital characteristics included were: 1. census division: northeast, north central, south, east south central, west south central, west north central, mountain, and pacific; 2. teaching status: academic medical center and other teaching hospitals versus nonteaching hospitals; 3. ownership: for-profit, not-for profit and government-federal; 4. american nurses credentialing center (ancc) recognition as a magnet hospital or a nursing pathways hospital (hospitals recognized for their nursing excellence) (ancc, n.d.); and 5. average daily census: number of patients in a hospital for part or all of each day, summed for the month and divided by the number of days in the month. online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 157 table 1 hospital characteristics of cahs, other small rural, and small urban hospital characteristic total (n=253) cahs (n=103) rural (n=63) urban (n=91) freq % freq % freq % freq % census division new england 17 6.59 6 5.83 5 7.94 6 6.52 mid atlantic 16 6.20 2 1.94 4 6.35 10 10.87 east north central 82 31.78 37 35.92 23 36.51 22 23.91 west north central 36 13.95 24 23.30 5 7.94 7 7.61 south atlantic 30 11.63 7 6.80 8 12.70 15 16.30 east south central 5 1.94 1 0.97 2 3.17 2 2.17 west south central 30 11.63 5 4.85 9 14.29 16 17.39 mountain 17 6.59 7 6.80 5 7.94 5 5.43 pacific 24 9.30 14 13.59 2 3.17 8 8.70 teaching status teaching 19 7.37 3 2.91 5 7.94 11 11.95 non-teaching 239 92.64 100 97.09 58 92.06 81 88.04 ownership not for profit 237 91.86 98 95.15 61 96.83 78 84.78 government 13 5.04 5 4.85 0 0.00 8 8.7 for profit 8 3.10 0 0.00 2 3.17 6 6.52 ancc accreditation (magnet or pathway) no accreditation 219 85.55 94 91.26 57 93.44 78 84.78 accreditation 37 14.45 9 8.74 4 6.56 14 15.22 mean sd mean sd mean sd mean sd daily census (avg.) 17.52 11.10 8.91 4.37 21.56 8.19 24.40 11.75 variables we extracted and calculated 16 indicators for the work environment, patient, and nurse outcomes. work environment characteristics of the work environment included eight indicators. rn hours per patient day is a standardized measure of the supply of nursing care. on inpatient units, it represents total monthly productive hours worked by rns who have direct patient care responsibilities divided by the total number of patient days for the month. in eds, total productive hours are divided by the total time patients spend in the ed for the month, captured in minutes. rn education is online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 158 measured as the percentage of direct care rns on the unit who hold a bachelors or higher degree. there were five variables from the annual rn surveys. appropriate assignment is rn’s ratings considering their assigned number of patients and the care they require and influence over schedule is rns ratings of how much influence they have over the hours/schedules that they work. both measures have response options ranging from strongly agree (6) to strongly disagree (1). years of nursing experience is how long a nurse has been on their current nursing unit. the next three variables ask about rns’ work experience. rns are asked how often this happens: treated with dignity: “in my job i am treated with dignity and respect by everyone”; meaningful contribution: “i have what i need in my job, so i can make a contribution that give meaning to my life”; recognized and thanked: “i am recognized and thanked for what i do in my job.” responses range from every day (5) to never (1). patient outcomes there were six indicators included for patient outcomes. four were calculated from administrative data. total fall rate is a sudden, unintentional descent, with or without injury, that results in the patient coming to rest on the floor or on or against some other surface or on another person. falls are only counted if they occur on the patient’s unit. for inpatient units, the fall rate is calculated by dividing the number of patient falls by the total number of patient days. injury fall rate is defined as the number of patient falls that result in an injury (mild, moderate, major or death). pressure injury rate is a prevalence on a given day in a quarter and is the number of hospital-acquired pressure injury divided by the number of patients assessed for pressure injuries. cauti rate is hospital-acquired cauti divided by the number of foley catheter days which are the daily count of patients with a catheter summed across all the days in a month, times 1000. from the rn survey there were two patient outcomes. quality of care (qoc) where nurses rate qoc on their unit from excellent (4) to poor (1) and missed care online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 159 where nurses respond to a check-list of 16 activities, they may have left undone on their last shift because of time constraints. nurse outcomes there were two indicators included from the rn survey for nurse outcomes. job enjoyment which has seven items assessing global job enjoyment on a 6-level likert scale (strongly agree (6) to strongly disagree (1)) and job plans where nurses indicate their job plans for the next year ranging from staying in current position to leaving the profession or retire. for this study it is reported as percentage of nurses who will stay on their unit or in the hospital. statistical analysis due to some data having non-normal distributions, statistical assumptions required for traditional parametric group comparisons (e.g., anova, t-tests) were violated. therefore, differences across groups were examined using bias corrected bootstrapped confidence intervals in order to evaluate differences between cahs compared to general hospitals in rural or metropolitan areas (efron & tibshirani, 1993). bootstrapping was performed in spss version 26 using the bias corrected bootstrapping with 95% confidence intervals on 1000 samples. results study hospitals were found in all regions of the united states, with a plurality of all three hospital types in the east north central census region (illinois, indiana, michigan, ohio, and wisconsin) (see table 1). most of the sample was non-teaching hospitals: cahs (97.09%), rural hospitals (92.06%), and urban hospitals (88.04%). similarly, a large majority of all three hospital types were nonprofit facilities (96.83%-84.78%). small percentages of each hospital type were recognized as ancc magnet or pathways hospitals: cahs (8.74%), small rural online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 160 hospitals (6.56%), and small urban hospitals (15.22%). the average daily census was 8.91 patients in cahs, 21.56 in small rural hospitals, and 24.40 in small urban hospitals. the included indicators had rates reported between 87-237 hospitals (see table 2 below). online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 161 table 2 comparisons of work environment, quality and safety indicators, and nurse outcomes total cahs other rural compare to cahs urban compare to cahs variable n mean sd n mean sd n mean sd upper ci lower ci n mean sd upper ci lower ci work environment rn hours / patient day 177 11.07 3.85 66 10.94 4.02 45 11.32 3.75 -10.29 2.85 66 11.01 3.79 -1.17 1.88 % of rns w/ bachelors 118 40.52 16.60 41 36.89 15.93 35 37.55 15.82 -15.23 6.61 42 46.55 16.54 23.96 -0.22 appropriate assignment 87 4.82 0.43 36 4.95 0.45 18 4.78 .41 -.27 .22 33 4.70 0.39 -0.23 0.41 influence over schedule 87 3.53 0.46 36 3.55 0.42 18 3.54 .49 -.31 .23 33 3.50 0.50 -0.16 0.48 years of experience 87 13.34 3.80 36 13.75 3.73 18 12.76 3.82 -2.09 2.12 33 13.20 3.92 -1.76 2.61 treated with dignity 87 4.26 0.30 36 4.28 0.29 18 4.26 0.37 -0.22 0.15 33 4.23 0.26 -0.22 0.16 meaningful contributio n 87 4.18 0.29 36 4.24 0.28 18 4.21 0.35 0.49 -0.31 33 4.10 0.26 -0.10 0.24 recognized and thanked 87 3.68 0.32 36 3.75 0.31 18 3.67 0.29 -0.23 -0.14 33 3.62 0.34 -0.12 0.29 patient outcomes total fall rate* 229 2.73 1.65 96 2.97 1.91 55 2.67 1.42 -1.82 1.14 78 2.48 1.40 -0.60 0.63 online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 162 injury fall rate 229 0.72 0.71 96 0.92 0.86 55 0.68 0.52 -0.18 1.25 78 0.48 0.53 -0.11 0.42 pressure injury rate 191 1.10 2.21 70 0.96 2.04 50 1.38 3.01 -3.48 1.50 71 1.05 1.66 -1.34 0.76 cauti rate 176 0.50 1.19 66 0.48 1.32 47 0.35 0.74 -0.36 1.42 63 0.64 1.32 -1.28 1.05 quality of care 87 3.52 0.23 36 3.55 0.20 18 3.49 0.33 -0.20 0.09 33 3.50 0.19 -0.16 0.12 missed care 87 1.65 0.69 36 1.52 0.79 18 1.65 0.54 -0.49 -3.48 33 1.80 0.62 -0.48 0.37 nurse outcomes job enjoyment 87 4.18 0.39 36 4.20 0.42 18 4.19 0.44 -0.39 0.14 33 4.16 3.50 -0.36 0.15 job plans (% staying) 87 85.36 10.29 36 85.63 10.98 18 85.46 11.64 4.10 -0.49 33 85.02 8.98 -11.12 3.14 results in bold were significant at p<.001, sd=standard deviation, * fall rates for ed units were not included online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 163 work environment. overall, the eight work environment indicators were similar across the 3 hospital types, with the exception of rn education. the 10-point difference in the percent of rns with a bachelor’s degree in cahs (36.89%) and urban hospitals (46.55%) was significant. for the other seven work environment indicators, rn hours per patient day ranged from 10.94 in cahs to 11.32 in other rural hospitals; appropriate assignment was rated 4.95 in cahs to 4.70 in urban hospitals: years of experience was highest in cahs at 13.75 years and lowest in other rural hospitals at 12.76 years. nurses rated whether they felt they were treated with dignity, their work made a meaningful contribution, and were recognized and thanked for their work similarly high, between 3.62 (3 = some days) and 4.28 (4 = most days). patient outcomes. the six indicators were similar. total fall rate ranged from 2.48 in urban hospitals to 2.97 in cahs, injury fall rate from 0.40 in urban to 0.92 in cahs, pressure injury rate from 0.96 in cahs to1.38 in other rural, cauti rate from 0.35 in other rural hospitals to 0.64 in urban hospitals; qoc from 3.49 in other rural to 3.55 in cahs, and missed care from 1.52 in cahs to 1.80 in urban hospitals (so less than 2 out of 16 tasks were not done). nurse outcomes. job enjoyment was rated from 4.16 in urban to 4.20 in cahs indicating that rns had moderate job enjoyment. most rns planned to stay in their current job: 85.6% of nurses in cahs and 85% in urban hospitals planned to stay in their unit or hospital in the next year. discussion our study found no differences between cahs and other small rural and urban hospitals for 15 of the 16 quality indicators across the work environment (structure), patient and nurse outcomes. for the work environment, we found cahs had fewer bachelor prepared nurses compared to urban hospitals (36.9% vs 46.6), but similar rates to other rural hospitals, the latter online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 164 confirms previous findings (baernholdt et al., 2014). the difference in cahs and urban educational levels for rns is similar (baernholdt et al., 2017), higher (jones et al., 2019), or lower (odahowski et al., 2021; probst et al., 2019) compared to results from other studies of rural and urban nurses’ educational levels. however, even our study’s urban rate of 46.55% rns with a bsn is lower than the national 2019 average for all nurses of 59% (campaign for action,n.d.). this is noteworthy because research suggest that a higher percentage of bsn prepared nurses in hospitals is associated with improved patient outcomes including mortality, patient’s experience, qoc and fall rates (iom, 2011; aiken et al., 2017; baernholdt, hinton et al., 2018). in fact, three reports from nam have maintained the recommendation of increasing the rn workforce to 80% with a bachelor degree (iom, 2011; altman et al., 2016; national academies of sciences engineering and medicine, 2021). the reasons are that bsn prepared nurses are better equipped to handle the increasing complex demands of providing care for our aging populations as bsn nurses have more education in leadership, systems thinking, research, teamwork and collaboration, and health policy (iom, 2011). overall strategies to increase educational levels for rns are warranted and especially in rural areas where the level is significant lower. several studies have pointed to reasons for this gap and potential solutions. first, rural nurses earn less that their urban counterparts so pursuing further education may be difficult and the subsequent salary increase for more education not worth it (duffy et al., 2014; girard et al., 2017). increasing salary differential and hiring practices such that organizations have bsn as there preferred or required education entry level are predictors of nurses’ willingness to return to school (warren & mills, 2009). second, there are few programs in rural hospitals that provide financial and/or time support for rns to pursue more education (milone-nuzzo, 2015). organizational incentives such as tuition assistance (reimbursement, forgivable loans for service, paid sabbatical and or educational days) and flexible scheduling are additional predictors of likelihood of nurses returning to school (warren online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 165 & mills, 2009). finally, the lower adoption of broadband in rural areas remains a major problem for rural nurses to access to online learning (perrin, 2019). the federal communications commission in 2018, launched their 10-year phase 2 plan of the connect america fund to expand broadband in the us which should aid in increasing rural communities’ access to broadband (federal communications commission, n.d.). our study found there were no differences in the six patient outcomes between cahs and other small rural and urban hospitals. for the 2 indicators for nurse outcomes, we found no differences, and only the aforementioned difference in educational levels between urban small hospitals and cahs for the eight work environment indicators. limitations the study has several limitations. first, we used a convenience sample of cahs and other small rural and urban hospitals from one database. it is possible that these hospitals, including the 103 cahs are different than other hospitals. second, while ndnqi® data are of very high quality with standardized and robust processes for data collection (guidelines and training), it is possible that data entry was imperfect. however, a strength is that since ndnqi® data are unrelated to any required reporting data or for reimbursement purposes, the data are less likely to have similar risk of bias as other administrative databases (waters et al., 2015). third, we are reporting hospital-level data. this is an advantage for cahs because they often do not distinguish between units (and acuity) (cramer et al., 2011), compared to the larger hospitals with 25-50 beds that might have more distinct units according to acuity. finally, our data are not adjusted for patient characteristics, including acuity. nevertheless, our findings support that there are existing quality indicators that works well in cahs to assess quality and safety for benchmark purposes to guide both quality improvement and policy. conclusion online journal of rural nursing and health care, 2023(1) https://doi.org/10.14574/ojrnhc.v23i1.733 166 overall, our results suggest that quality indicators for structure and outcomes currently used in approximately 2000 hospitals are also applicable for cahs. therefore, administrators and policy makers can consider using ndnqi® indicators for cah benchmarking. as with any quality indicator, before implementation one has to consider whether the act of measuring increases documentation burden, the utility of the indicator for organizations (e.g. guiding qi activities), clinicians (e.g. informing practice) and patients and families (e.g. aid in deciding where to go for care) (baernholdt, dunton, et al., 2018). future studies should address these issues and whether these indicators apply to all 1300 or so cahs. references agency for health research and quality. 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(2016). inter-rater agreement of pressure ulcer risk and prevention measures in the national database of nursing quality indicators ® (ndnqi). research in nursing & health, 39(3), 164–174. https://doi.org/10.1002/nur.21717 harrington_e-ojrnhc.revised+submission.02.22.2022_graves_final+edits+for+copyediting+arformat online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 100 rural family caregivers’ discoveries following a person-in-context dementia simulation candace currie harrington, phd, dnp, aprn, agpcnp-bc, cne1 sonya r. hardin, phd, mba, mha, aprn, ccrn, np-c, faan2 pamela z. cacchione, phd, crnp, gnp-bc, fsga, faan3 donna w. roberson, phd, rn, fnp-bc4 janice a. neil, phd, rn, cne5 1 assistant professor and the trilogy, signature, and elmcroft gerontology nurse practitioner professor, university of louisville, school of nursing, candace.harrington@louisville.edu 2 professor and dean of the university of louisville, school of nursing, sonya.hardin@louisville.edu 3 professor of geropsychiatric nursing, ralston endowed term chair in gerontological nursing at the university of pennsylvania, school of nursing; nurse scientist, penn presbyterian medical center; senior fellow, leonard davis institute of health care economics university of pennsylvania, pamelaca@nursing.upenn.edu 4 associate professor, east carolina university, college of nursing, robersondo@ecu.edu 5 associate professor emerita, east carolina university college of nursing, neilj@ecu.edu keywords: interpretative thematic analysis, dementia simulation, family caregiver, qualitative research, neurocognitive syndrome abstract purpose: the purpose of this qualitative study was to discover rural family dementia caregivers’ lived experience in a virtual dementia simulation and how it affected their understanding of their online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 101 family members’ daily challenges. to our knowledge, this study is the first to document its impact and value in this understudied, under-reported, and under-represented population. sample: a volunteer sample of 10 rural family caregivers of persons with ad/adrd following participation in a rural eastern north carolina community delivered ad/adrd simulation. method: in-depth interviews lasting 45-110 minutes were conducted. the utrecht phenomenology analytic method was used to sort, analyze, and interpret data. richness of data drove the sample size. results: the volunteer participants were female familial caregivers ages ranged from 49 to 81. their care recipients’ ages ranged from 62 to 93 years. eighty percent of the caregivers provided care for their loved ones 6-7 days a week. only one caregiver had formal (paid) assistance for care provision. the themes now i understand, opened my eyes, and making changes emerged from the participants' statements. conclusion: rural family caregivers found the ad/adrd simulation profoundly impacted their perceptions of ad/adrd and expressed new understandings and eye-opening epiphanies about their family members’ daily challenges with dementia and their planned changes to improve their loved ones’ quality of life. the ad/adrd simulated experience provided participants with a unique opportunity for self-discovery about their loved ones’ daily challenges. this original study addresses the paucity of literature and research about ad/adrd simulations for rural caregivers of persons with ad/adrd. this study further demonstrates the value of ad/adrd simulation to rural nursing practice and science. these findings may prompt rural health nurses to encourage family caregiver participation in person-in-context simulations to enhance their understanding of the loved ones’ lived experience. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 102 rural family caregivers’ discoveries following a person-in-context dementia simulation alzheimer’s disease and related dementias (ad/adrd) touch all aspects of life and relationships and most often affect adults older than 65 years of age (langa et al., 2017). ad/adrd is an umbrella term for several neurocognitive syndromes, the majority of which include alzheimer’s disease, vascular cognitive impairment, frontotemporal degeneration, and lewy body dementia (american psychiatric association [apa], 2013). the number of those living with ad/adrd is projected to reach nearly 13 million by 2050, with a higher prevalence in rural areas (alzheimer’s association, 2021). background geographic and population-specific definitions cannot fully describe the holistic meaning of “rural,” which, in addition to widely separated farm towns and communities with small populations, have unique cultures, attributes, and challenges (pennington, 2015). nearly threequarters of the rural older population reside in the southern portion of the united states (u.s.). older adults in rural areas are less likely to live in nursing homes, less likely to have a high school education, more likely to live in poverty, and have higher rates of chronic conditions (national center for chronic disease prevention and health promotion [nccdphp], 2019; smith & trevelyan, 2019). family caregivers in rural communities constitute an informal (unpaid), critical, and valuable workforce for those living with ad/adrd (harrington et al., 2018; nccdphp, 2019). the u.s. healthcare and long-term care systems could not withstand the financial and workforce burden without the capacity for ongoing and long-term care of family members with ad/adrd (harrington et al., 2018). online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 103 female caregivers constitute over 90% of the informal (unpaid) workforce who provide most care for family members living with ad/adrd in the community setting (alzheimer’s association, 2021; jutkowitz et al., 2017). in 2020, family caregivers of persons with ad/adrd provided an estimated 18.6 billion hours of informal assistance valued at $244 billion, 400 million more hours of care than reported in 2017 (alzheimer’s association, 2017, 2021). nursing home space with trained health care workers is insufficient to accommodate the number of individuals with ad/adrd who require placement if not for family caregivers. in the state where this study was conducted, 170,000 individuals have ad/adrd, with only 351 dedicated ad/adrd beds in 17 counties (alzheimer’s association, 2020; north carolina department of health and human services [ncdhhs], 2021; pennington, 2015). since 80 of the state’s counties are considered rural, those with ad/adrd requiring nursing home placement would likely be distantly separated from family caregivers. most rural caregivers of persons with ad/adrd are over 65 and have unique characteristics that warrant special nursing considerations (gibson et al., 2019; greenberg et al., 2020; sheehan et al., 2020). these caregivers tend to be older (m = 71.3 years, sd = 8.3, p = .02), predominantly female (91%), provide significantly more hours of care per week , and manage more complex medical problems compared with those who provided care for persons without ad/adrd ( sheehan et al., 2020). caregivers’ health disparities in rural areas are greater than those in urban settings due to the social determinants of health, environmental risks, poorer health behaviors (smoking and alcohol use), and less physical activity (united health foundation [uhf], 2021). remote residences impact support and resources like primary healthcare services or acute care centers. innovative technology like telehealth and virtual meetings are often not a feasible solution for rural older family caregivers because many older adults neither have nor use online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 104 internet services due to the expense, cost of devices, lack of skill or confidence in their use, or perceived personal irrelevance (huffman, 2018). behavioral risk factor surveillance system data from 2021 showed that north carolinian older adults reported mental distress increased 21% over the past three years, while access to mental health providers and services increased 17% to 227.5/100,000 in the same period (uhf, 2021). the disparities in access to primary care services in rural communities also continue despite an overall increase in north carolina health care providers, where 31/41 eastern counties are designated as medically underserved for primary care services (department of health resources and services administration [hrsa], 2021). north carolinian’s increase in the frequency of reported mental distress by those 65 years and older was greater than the national average (uhf, 2021). the 21% increase in mental health providers in north carolina to 265.5 /100,000 population had no impact on the reported frequency of mental distress in individuals 65 and older, which increased 32% between 2016-2020 (uhf, 2021). family caregivers of persons with ad/adrd cannot fully understand their family member’s subjective experiences; therefore, their perceptions of ad/adrd associated behaviors may be incongruent with their family members’ lived experiences. caregivers’ lack of understanding may trigger unintended relational discord or mistreatment of either care partner due to unrealistic expectations (aspesoa-varano et al., 2015; harrington, et al., 2018; orfila et al., 2018). a person-in-context ad/adrd simulation that mimics some of their family members’ neurocognitive challenges provides an opportunity for family caregivers of those with ad/adrd to re-evaluate their contextual reality, assumptions, and perceptions. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 105 virtual ad/adrd simulation several ad/adrd simulations were found in the literature, including virtual reality experiences (age-u-cate training institute, 2020; ball et al., 2015; second wind dreams, 2020; wijma et al., 2017). only two virtual dementia simulations provided a person-in-context simulated experience, whereby respondents experienced dementia “as if” they had the syndrome (age-u-cate training institute, 2020; harrington, et al., 2018; han & brown, 2019; second wind dreams, 2020). these products were shown to improve awareness, empathic understanding, and sensitization toward people living with ad/adrd for healthcare professionals and students within a variety of health care settings (age-u-cate training institute, 2020; harrington, et al., 2018; ping et al., 2020; second wind dreams, 2020; slater et al., 2017). harrington et al. (2021) conducted a mixed-methods study with interpretative phenomenology to explore primary care nurse practitioner students’ (n = 20) perceptions and understanding of ad/adrd following a person-in-context dementia simulation. a theme “developing empathic understanding” emerged from the verbatim transcript analysis. respondents believed this experience increased the likelihood that these future health care providers would engage in altruistic helping behaviors. two extensive literature reviews yielded one published study exploring ad/adrd simulation with family caregivers of those with ad/adrd (hirt & beer, 2020; yu et al., 2018). dementia live (dl) was used in a qualitative study with formal (n = 12) and informal caregivers (n = 4) (han & brown, 2019). the dl experience was an eye-opening experience with perceived benefits for the participants, who recommended dl to other caregivers (han & brown, 2019). both the dl and the virtual dementia tour use specially designed equipment to simulate agnosia (failure of recognition through the senses), apraxia (loss of coordination), altered online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 106 perception (loss of depth perception), amnesia (loss of short-term memory), apathy (difficulty initiating activities) and attentional deficits (age-u-cate training institute, 2020; harrington et al., 2018); second wind dreams, 2020). both simulations provided family caregivers an opportunity to subjectively experience some of the effects of neurocognitive deficits commonly seen in the daily struggles associated with advancing ad/adrd (age-u-cate training institute, 2020; second wind dreams, 2020). the virtual dementia tour provides a first-person perception of dementia, whereby trained facilitators guide respondents through an 8-minute experience (second wind dreams, 2020). during the simulation, respondents try to perform five ordinary daily activities (e.g., counting change, setting the table, matching socks, or buttoning a shirt) wearing patented equipment that simulates common neurocognitive changes. this equipment includes gloves (loss of fine motor skill), shoe inserts (altered pain perception), glasses (mimic the peripheral, central, and depth perception vision changes), and noise-producing headphones (auditory perceptions that affect one’s ability to concentrate) (second wind dreams, 2020). the purpose of this qualitative study was to discover rural family caregivers’ lived experiences in the person-in-context ad/adrd simulation and its impact on the family caregiver’s perceptions of the person living with ad/adrd. this study was approved by the east carolina university medical center institutional review board (umcirb). two research questions guided this inquiry: • what is a family caregivers' perception of those with ad/adrd following a person-incontext ad/adrd virtual simulation? • how does a person-in-context ad/adrd virtual simulation experience affect family caregivers’ understanding of ad/adrd as a lived experience? online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 107 method design the qualitative study combined descriptive and interpretative thematic analysis to disentangle the meaning of unique human lived experiences (dowling & cooney, 2012; van manen, 1984, 2016). this approach was practical and applicable given the dearth of research to understand rural caregivers’ lived experience in the context of caring for those with ad/adrd (dowling & cooney, 2012; van manen, 2016). the researchers acknowledged their preconceived contextual assumptions and held them in abeyance (van manen, 2016). by doing so, the true nature and meaning of the respondents’ lived experiences in a person-in-context ad/adrd simulation could be revealed in their true nature (van manen, 1984, 2016). sample and setting the sample was drawn from five counties in the upper coastal plain region of north carolina. edgecombe, halifax, nash, northampton, and wilson counties are geographically located in the upper coastal plain area of northeastern north carolina approximately 100 miles from the atlantic ocean (upper coastal plains council of governments, 2012). the region’s area covers 2,707 square miles of landmass of which 1,152 square miles are farmland (upper coastal plains council of governments, n.d.). this region is designated as rural by the north carolina department of commerce because its population density is less than 250 individuals per square mile (pennington, 2015). three rural events where the ad/adrd simulation was offered were chosen for recruitment. ninety caregivers registered for the first community one-day workshop in an eastern north carolina rural community where the ad/adrd simulation was offered. community partners facilitated all aspects of implementing the person-in-context simulation to maintain the online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 108 study’s epistemological integrity. the principal investigator (p.i.) introduced the study at the beginning of the event then remained for those interested in the study. the person-in-context simulation was delivered by certified facilitators affiliated with an event sponsor and were not coinvestigators in this study (second wind dreams, 2020). other than the ad/adrd simulation delivery, the workshop content was not a study component and did not interfere with the study design. the partners included the study flyer in the registration materials. sixteen potential respondents were screened using the umcirb approved electronic survey to establish eligibility. inclusion criteria were adults over 18 who provided caregiving duties for a functionally dependent family member with ad/adrd, participated in the person-in-context ad/adrd simulation, and agreed to be interviewed within two weeks. due to the changing nature of ad/adrd over time, those who had prior experiences in the person-in-context simulation were included. this volunteer sample (n = 10) provided a richness of data that precluded the need to collect further data (sandelowski, 1993, 1995; thorne, 2016; van manen, 2016). procedure researcher-as-instrument facilitated conversational interactions and space where respondents felt safe sharing their lived experiences and meanings (pezalla et al., 2012). all the researchers recognized that their individual experiences with caregiving for those with ad/adrd are just one of infinite realities. the principal investigator (p.i.) had 15 years of experience counseling and managing the care of those with ad/adrd and their caregivers across care settings as an adult-gerontology primary care nurse practitioner in medically underserved rural areas. the research team members each had 30 years of experience as registered nurses caring for older adults. the p.i. and two research team members grew up in rural cultures and online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 109 acknowledged our limited knowledge about ethnic and racial differences in caregiving for those with ad/adrd. prefatory assumptions included (van manen, 2011, 2016): • the person with ad/adrd had cognitive impairment that required supervision and care by a family member for instrumental activities of daily living or activities of daily living. • the family caregivers of those with ad/adrd demonstrated receptivity to a different perception by participating in the person-in-context simulation, had no cognitive impairment, and provided care for altruistic purposes. data collection the interview contexts included the time they entered the simulation until respondents were interviewed within two weeks. ten face-to-face interviews were conducted using a conversational style that were recorded for transcription purposes. conversational interviewing facilitated building a rapport quickly and established authenticity. baseline interview questions provided a uniform guide for the interviewer with variable responses based on the participants’ responses and willingness to share their stories. guiding statements triggered recall and allowed participants the opportunity to reflect on the experience without leading respondents’ answers. for instance, the interviewer asked, “tell me how you felt when attempting to complete the tasks.” four questions guided the semi-structured interviews: 1. let’s go back to the virtual dementia tour®. walk me through your thoughts and feelings as you tried to complete the tasks. 2. what did the virtual dementia tour® mean to you as your (______fill in the blank with the appropriate relative’s) caregiver? 3. how did the virtual dementia tour® impact how you thought about dementia? online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 110 4. is there anything else you would like to share with me about your virtual dementia tour® experience? the p.i. self-transcribed the recorded interviews for data and epistemological integrity. contact information for mental health services was provided in the informed consent to safeguard respondents’ well-being. the semi-structured interviews ranged from 44-110 minutes in length and resulted in 157 pages of transcripts. after the interviews, the investigator gave each respondent a hand-written note of gratitude for their participation, p.i. contact information, a copy of their signed consent, and a gift card to compensate for their time. the research team used several strategies to achieve trustworthiness. the interpretative strategies and analysis of multiple data sources followed logically from the research questions. the provision of believable accounts and analytically logical findings established credibility (koch, 1996; sandelowski, 1993; thorne, 2016). interpretations were grounded in rich verbatim accounts that revealed a vivid and eidetic picture of respondents’ lived experience in the personin-context ad/adrd simulation (van manen, 2016). triangulation and a confirmable audit trail occurred through team members’ individual multiple reviews of transcripts, field notes, memos, and reflective journals. data analysis the researchers used a seven-step systematic approach for data analysis using a stepwise process to understand the meaning family caregivers of those with ad/adrd assigned to a simulated lived experience (colaizzi, 1978; kuckartz, 2014; van manen, 2016). see figure 1. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 111 figure 1 thematic analysis process in step one, the p.i. transcribed all interview recordings verbatim to ensure data integrity. the electronic transcripts were verified for accuracy by repetitive review of the recordings and transcripts. interview recordings were deleted after the transcript content was verified for accuracy. original names were then replaced with pseudonyms in the transcript files and analysis documents. member checking was used to clarify information during the interview and transcription. the research team then independently immersed themselves in the data by reading the transcripts several times for salient or poignant quotations without interpretation or analysis. data were triangulated through multiple reviews and within-subject notations to establish a 1. first pass independent review of transcripts: highlight salient quotations 2. second review of unhighlighted text and begin memos of individual transcripts using nvivo11 and ms word 3. review transcripts across interview to develop main topics incorporating findings from nvivo11® 4. create a profile matrix to compile of aggregate formulated meanings into thematic clusters incorporating field notes, memos, journal entries 6. create an exhaustive description of the respondents’ lived experiences incorporating those in step 4 5. organize thematic clusters into themes using a team approach 7. capture the essence of rural older female caregivers' perception of a person-in-context ad/adrd simulation. research questions online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 112 confirmable auditable decision trail of the vertical (individual transcripts) and horizontal (across transcripts) data with memos from transcript reviews, field notes, and reflective journal entries (colaizzi, 1978; kuckartz, 2014; thorne, 2016; van manen, 2016). step three involved creating case summaries in word and nvivo 11 to describe the nuances of respondents’ relationships with their family members living with dementia. colored flags were used to mark transcripts with similar quotations. in this step, significant statements about the person-in-context ad/adrd simulation were extracted and organized. in steps four through seven, the data analysis team consisted of three researchers. the team began the process of identifying collective meanings, which were compared to the results in the first stage. then, formulated aggregate meanings were created. the team then identified thematic clusters of meanings. findings were organized into three thematic clusters. thematic definitions were derived from the data. results the volunteer respondents were female familial caregivers (m = 63.3 sd = 10.3), ranging from 49 to 81. their care recipients’ ages (m = 82.5 sd = 8.76) ranging from 62 to 93 years (see table 1). online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 113 table 1 table dyad summaries respondent respondent relationship (age) care recipient relationship (age) years of care days of care per week hours of care per day race 1 daughter (70) mother (92) 7-9 6-7 8-12 white 2 daughter-in-law (74) mother-inlaw (93) 4-6 6-7 21-24 black 3 wife (82) husband (72) 4-6 6-7 21-24 white 4 wife (50) husband (79) 13 6-7 8-12 white 5 sister (74) sister (79) 4-6 6-7 <8 black 6 daughter (49) mother (82) 1-3 2-3 <8 black 7 daughter (62) mother (86) father (88) 4-6 6-7 8-12 white 8 daughter (56) mother (78) 7-9 <1 <8 black 9 daughter/wife (63) mother (86) husband (62) >15 6-7 8-12 black 10 daughter (57) mother (91) 10 6-7 21-24 black thematic analysis three themes revealed the essence of the person-in-context ad/adrd simulation experience and its meaning for these rural family caregivers of those with ad/adrd. respondents described their simulated lived experience as intensely and deeply felt. the themes emerged from respondents’ statements and suggested an altruistic desire to better understand their family members’ lived experiences and improve their comfort and quality of life. the emergent themes included now i understand, opened my eyes, and making changes. theme 1: now i understand. the theme now i understand answered research question one: what is a family caregivers' perception of those with ad/adrd following a person-incontext ad/adrd virtual simulation? this theme involved recurrent realizations and expressed recognition of the physical and mental changes seen with progressing ad/adrd. for example, online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 114 two respondents shared that they did not realize their family members’ ad/adrd affected multiple body systems, such as a respondent whose husband had early frontotemporal degeneration. she stated, “i didn’t understand. i thought it was a mental issue and not a [depth] perception issue.” when asked what she was referring to, she responded: when i got home and watched him ever so closely, his hand doesn’t open up. i did not notice it until after the tour. i never thought about it [his dementia] disease] being a physical thing; [i] always just thought it was a mental thing. this respondent’s recognition of her husband’s change in motor function uncovered her false assumption. the simulated experience enlightened her about the sensory and motor changes commonly found and improve her awareness. another family caregiver who worked in social services with older adults shared her reflections and understanding indicative of self-discovery: the virtual [dementia] tour opens up understanding and knowledge [pause] putting yourself outside of who you are and getting inside somebody else’s feet as much as you can of what they are going through, which opens up your sense of empathy, sympathy, the ability to understand so you can do things differently. the youngest respondent related her understanding of her mother’s inability to the difficulty processing information: it was the process that was broken. you can hear, but if you can’t process it, you can’t get from here to here. for me, this [simulation] taught me the processing of information and communication is not getting there. it is not even about remembering it; it is about absorbing it. it can’t come out the same way. themes opened my eyes and making changes emerged from the data and answered research question two: how does a person-in-context ad/adrd virtual simulation experience online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 115 affect family caregivers’ understanding of ad/adrd as a lived experience? these themes revealed the depth of respondents’ self-discovery through reflection. their statements suggested the person-in-context simulation changed their perception of their loved one’s challenges and provided subjective meaning of ad/adrd as a lived experience. theme 2: opened my eyes. opened my eyes described the emotional aspect of selfdiscovery and described how respondents introspectively interpreted their behaviors, thoughts, and feelings in the simulation at a deeper level. the person-in-context simulation experience revealed the complexity of their loved ones’ daily challenges. upon reflection of her simulation experience, one respondent articulated her changed perception, “it [the simulation] opened my eyes that dementia is not just a disease of the mind. it is a disease of the mind, the body, and the heart and soul of an individual.” another respondent revealed how deeply and strongly the simulation impacted her perception of her mother’s ad/adrd, “when you take a step in their shoes, it sets you back, and you quiet yourself [pause]. it was like, wow! it is deep and strong.” theme 3: making changes. respondents shared how they began making changes based on their simulation experience by changing their caregiving approaches, expectations, and living environment. for example, one respondent shared, “i tried to remove; i just started trying to get rid of extras that don’t need to be. magazines, trinkets, just “things” that don’t need to be.” some respondents shared how they changed their emotional responses when communicating with their family members living with ad/adrd. from her experience, a respondent reduced the stress of the day when she practiced doing dressing time in the state of calmness, “if i see she is getting a little confused, i can guide her… start right here just like that…next thing the camisole—less stress on her…. the less stretched [sic] she is, the less stressed we are. it is calm and peaceful.” one respondent who had dual caregiving responsibility for her husband and mother shared that online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 116 making changes meant changing her expectations about how her husband placed linens in the closet, which had a calming effect on him. she explained, “oh, that linen closet. i just leave it. they are just crammed in there. he is a lot calmer, and he doesn’t think i am picking on him.” other respondents shared how their expectations changed and subsequently reduced relational discord. for example, one respondent shared a reflective anecdote about how she provided her husband with one task for the day to keep him occupied while she was away from home: he would put the clothes in the dryer and not cut [turn] it on. when i come home, there is a pile of wet clothes on the bed to be folded. he put them in the dryer and waited and then take them out of the dryer and put them on the bed for me to fold them up. it does make more sense as to why that would happen. it makes perfect sense. so yesterday, instead of being completely aggravated, i just said i don’t think these are quite dry enough [motioned hugging him] and put them back [strong emphasis] in the dryer and cut [turn] it on this time—[chuckling]. this respondent went further to suggest that making changes in her expectations and reaction improved relational harmony with her husband: it has made me less frustrated with him and just let me hug him and say i don’t think these [clothes] got dry enough instead of [yelling], ‘why did you do this when you know they aren’t dry?’ this statement suggested that making changes in her expectations and reaction improved relational harmony with her husband. one respondent's statements supported the a priori assumption that receptivity to a change in perception was critical to self-discovery. this respondent also reinforced how relational context online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 117 and previous familial conflict shape one’s perception of the person with ad/adrd (aspesoavarano et al., 2015). this respondent shared, “dealing with my sister and working with seniors in my work—i was feeling that this is what life is like for them because i see it every day.” she self-excluded from the necessity to acquire caregiving skills due to a perceived lack of need, “i stopped going to the conferences 4-5 years ago [be]cause i was hearing the same thing over and over. i decided to go back and invite one of my friend[s].” this respondent provided insight into a counter experience that was incongruent with others’ experiences. she was her sister’s caregiver, who attended the ad/adrd simulation for continuing education. when asked how this experience impacted her understanding of her sister’s situation, she responded, “no, i already understood [chuckling]” and did not elaborate further. she then volunteered, “you know, i did not buy into this [family caregiving role], i have my own life.” she expressed that she felt an obligation in reciprocity for her sister’s financial support in the remote past and shared that their relationship was contentious before her sister’s cognitive decline. her statements and rationale for participating in the simulation suggested a lack of receptivity necessary for self-discovery and understanding. ultimately, this respondent did not understand her sisters’ lived experience. upon reflection, if an individual does not have openness to discovery (a prefatory assumption) before a person-in-context ad/adrd experience, reflective self-discovery within and following the experience is less likely. discussion respondents’ contextual statements or recurrent phrases guided the identification of aggregate themes. the person-in-context ad/adrd experience provided respondents with an opportunity for reflection, self-discovery, subjective meaning about ad/adrd, and perceptions of their loved ones’ lived experiences. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 118 the theme now i understand substantiated the cognitive aspect of respondents’ selfdiscovery process, which described respondents’ ability to relate to their family members’ experiences, behaviors, perceptions, and emotions following the person-in-context ad/adrd simulation. the theme opened my eyes described respondents’ epiphanies whereby they interpreted personal behaviors, thoughts, and feelings in the simulation at a deeper level compared to observations of their loved ones. making changes explained how some respondents changed their care approaches by simplifying tasks and adjusting their expectations. the time between respondents’ simulation and interview allowed time for self-reflection and discovery. several respondents expressed their intention to continue repetitive participation in community ad/adrd simulations, as they found their subsequent experiences beneficial in understanding their family members’ disease progression. all respondents who experienced the simulation a second time shared that each experience was distinctive and valuable because their loved one’s ad/adrd evolved. the research team was intrigued that several family caregivers changed their care practices within one week after the person-in-context simulation. others with previous experience in the person-in-context ad/adrd simulation reported maintaining the adopted practice changes made then and new changes based on this experience. respondents’ goals to make changes were consistently reported to improve their family members’ comfort and reduce their ad/adrd challenges. most respondents found the ad/adrd simulation provided a unique and personal learning experience allowing them to understand their loved one’s experience to provide the best quality of life possible. most respondents believed that such simulations should become mandatory and repetitive. those experiencing the ad/adrd simulation for a second time felt the second simulation experience provided them with an eidetic perspective of their family members’ evolving disease trajectory. online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 119 those with previous simulation experiences enriched the researchers’ depth of understanding. respondents’ biases and misperceptions toward their family members and their daily challenges with ad/adrd were like other researchers’ findings (han & brown, 2018). this study supports the national institutes of health's strategic plan to increase research in rural caregivers of those with ad/adrd (2021). a longitudinal study may elucidate whether family dementia caregivers’ experiences in the person-in-context ad/adrd simulation have a long-lasting effect and, if so, how long these effects last. reported reductions in frustration, aggravation, and stress voiced by the respondents might improve caregiving longevity and mutually beneficial care for the family dementia dyads. some respondents were unaware that they held unrealistic expectations and verbalized that adjusting their expectations improved relational harmony. these respondents expressed that the experience was extremely valuable to inform positive changes in their loved ones’ lives. based on respondents’ insights about repetitive participation in person-in-context dementia simulations, one area for future research should address the value of repeated exposures to person-in-context simulation as neurocognitive degeneration progresses. nursing implications rural health nurses are uniquely positioned to educate caregivers on critical measures to protect the emotional, mental, and physical well-being of the ad/adrd caregiving dyad. rural health nurses who offer person-in-context ad/adrd to enhance community caregiver education may improve caregivers’ awareness of the need for different communication strategies for expected behavioral changes associated with ad/adrd. area agencies on aging caregiver specialists often offer person-in-context dementia simulations and may be an excellent resource online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 120 for rural nurses and caregivers. anticipatory approaches for managing the inherent frustrating situations in family caregiving of those with ad/adrd are crucial to dyadic harmony and caregiving longevity. although the person-in-context simulation for this study was offered in a community event, the individual family versions of this or similar simulations may be acquired through grant funding as a valuable and feasible option for rural nurses to promote caring behaviors and expectations toward family members with ad/adrd. home delivery may be a safe alternative for those who are wish to practice social distancing and avoid community events. in rural nurses’ role, they connect residents with local resources and procure services (e.g., home health). interprofessional collaboration with the federally supported area agencies on aging in rural nurses’ regions who deliver person-in-context simulations in the community or home environments strengthen the nurses’ collaborative efforts, provide access to caregiver support specialists, and establish the trust needed to build a stronger support network. rural nurses may benefit from participation in person-in-context ad/adrd simulation to guide advocacy for those with ad/adrd and caregiver education. although not intended, these findings may be transferable to other contexts, situations, and settings (van manen, 2016). limitations understandably, the person-in-context ad/adrd simulation is an intense simulation experience (merizzi, 2018). although these respondents reported experiencing negative emotions, all respondents expressed positive impressions of their person-in-context simulation. no adverse outcomes were reported to the p.i. or umcirb. this team would discourage participation in ad/adrd simulations soon after losing a loved one from ad/adrd, which may intensify grief reactions (merizzi, 2018). those who choose to participate soon after the online journal of rural nursing and health care, 22(1) https://doi.org/10.14574/ojrnhc.v22i1.695 121 death of a loved one caused by ad/adrd have no opportunity for positive change, as seen in those who have current caregiving responsibilities. their participation under these circumstances may lead to regret and emotional pain that may be difficult to process without professional bereavement counseling. although adverse outcomes were not seen in the study, safeguards for respondents’ mental and emotional health need to be planned for those who may experience an adverse reaction following any person-in-context ad/adrd simulation. while caregivers planned and reported implemented changes, further study using personin-context ad/adrd simulation is needed to examine if the changes reported bring about better care strategies or changes in caregivers’ health outcomes. the chosen sampling method may have introduced volunteer bias. however, the all-female sample was congruent with the prevalence rates of female caregivers cited in the literature (alzheimer’s association, 2021; jutkowitz et al., 2017). prior exposure to education and previous participation may have biased the respondents’ perceptions. however, those who participated in the person-in-context ad/adrd simulation three years prior vividly recalled their previous experiences and reported maintenance of changes made in care across time, which added to the researchers’ depth of understanding. conclusion rural family caregivers found the ad/adrd 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(2018). unraveling positive aspects of caregiving in dementia: an integrative review of research literature. international journal of nursing studies, 79, 1-26. https://doi.org/10.1016/j.ijnurstu.2017.10.008 microsoft word stedman-smith_99-943-2-ed.docx journal of rural nursing and health care, 12(2) mothers’ concerns about children’s exposure to pesticide drift in the red river basin of the north: a novel application of photovoice maggie stedman-smith, ph.d., m.p.h., m.s., r.n. 1 patricia m. mcgovern, ph.d., m.p.h., r.n. 2 cynthia j. peden-mcalpine, ph.d., r.n. 3 linda r. kingery, m.s. 4 kathryn j. draeger, ph.d. 5 1 assistant professor, kent state university, college of public health, environmental health sciences, mstedman@kent.edu 2 bond professor of environmental and occupational health policy, university of minnesota, school of public health, division of environmental health sciences, pmcg@umn.edu 3 associate professor, university of minnesota, school of nursing, peden001@umn.edu 4 executive director, university of minnesota regional sustainable development partnerships, kinge002@umn.edu 5 statewide director, university of minnesota, regional sustainable development partnerships, draeg001@umn.edu abstract women of childbearing age and children living in agricultural regions are at-risk for pesticide exposure from many pathways, including occupational track-in from parents, residential use, dietary intake, and drift from farming. little is known about mothers’ concerns regarding the potential for their children to become exposed to pesticides in these regions. photovoice was used as a community needs assessment to learn mothers’ perceptions of exposure pathways to pesticides and other environmental health concerns. this article reports the perceptions of women raising children regarding children’s potential for exposure to pesticide drift. recruitment occurred among three distinct groups living in the red river basin of the north: caucasians living adjacent to actively treated farmland, enrolled in the women, infant and children’s nutrition program (wic); native americans surrounded by active farmland, affiliated with a local tribal college; and new american immigrants from east africa affiliated with a local immigrant development center. perceived sources of exposure included agricultural-aerial and tractor spraying, and truck fogging for mosquito control. mothers wanted advanced notice of spraying or fogging so they could take their children and toys indoors as protective measures, and education to prevent pesticide exposure, delivered in tailored formats for each group. the findings provide real-world insights from mothers and prevention strategies that can be utilized by public health professionals, extension educators, and primary care providers with the aim of reducing pesticide exposure to children in agricultural regions. contents are solely the authors' responsibility and do not represent the official views of any funding source. keywords: children, pesticide exposure, pesticide drift, arial spray, photovoice journal of rural nursing and health care, 12(2) mothers’ concerns about children’s exposure to pesticide drift in the red river basin of the north: a novel application of photovoice pesticides are substances that are intended to prevent, destroy, or repel organisms and are classified by the pests they work against, including, herbicides, insecticides, fungicides, rodenticides, nematocides, and biocides. while the benefits of pesticides are well established (united states environmental protection agency, 2009), the potential for adverse effects on human health from chronic exposure is less clear. cancer is currently the leading cause of death by illness for children in the united states (national cancer institute, 2011). numerous studies have examined possible associations between pesticide exposure and the development of childhood cancer, as well as adverse reproductive and developmental effects. no firm conclusions can be drawn because of methodological problems including incomplete exposure assessments, small sample sizes, and the potential for differential recall bias in self-report (daniels, olshan, & savitz, 1997; weselak, arbuckle, & foster, 2007; zahm & ward, 1998). a more recent meta-analysis concluded that an association does exist between pesticide exposure and childhood cancer; however, causation cannot be inferred due to methodological difficulties and a lack of consideration for the role of genetics (infante-rivard & weichenthal, 2007). exposure to pesticides may occur through inhalation, ingestion, or dermal absorption and children have unique exposure vulnerabilities. due to a smaller weight and higher metabolic and respiratory rates, they breathe more air, eat more food, and drink more fluid per pound of body weight than adults. their breathing zones are closer to the floor where pesticide residues may settle. crawling, hand-to-mouth activity, and playing outdoors on contaminated soil may result in greater exposure. a 2-fold increase in skin surface to body weight in children compared to adults creates greater potential for dermal absorption in children versus adults. in acute exposure, children’s immature livers or kidneys may reduce the ability to clear pesticides. since, growth is still occurring, acute exposures may inhibit the development of systems targeted by toxic exposure. lastly, children have more future years of life to develop adverse health outcomes that have long latency periods and are associated with environmental exposures (american academy of pediatrics committee on environmental health, 2003; landrigan, et al., 1998; landrigan, 2011; national research council, committee on pesticides in the diets of infants and children, 1993). pesticide exposure pathways for children include consumption of conventional foods and contaminated well-water (eitzer & chevalier,1999; lu et al., 2006), tracking in pesticide residues from occupational settings into family vehicles and residences by working parents (loewenherz, fenske, simcox, bellamy, & kalman, 1997), residential usage (gurunathan et al.,1998), and proximity to drift (weppner et al., 2006). drift is the “physical movement of a pesticide through the air at the time of application or soon thereafter, to any site other than that intended” (united states environmental protection agency [us epa], 2008). direct exposure may occur in the vicinity of agricultural spraying. all major organs are susceptible to the toxic effects of pesticide poisoning, with symptoms varying by substance and dose from mild to severe (reigart & roberts, 1999). although the us epa receives thousands of complaints annually related to pesticide exposure through drift (us epa, 2008), the magnitude of acute pesticide induced illness from this pathway is unknown. a study using american association of poison control narratives found 46 cases of acute pesticide illness among bystanders from 32 events in four southern states during 2001 (bryden, mcknight & westneat, 2005). sixty-five percent were referred to or examined in a health care facility, and aircraft crop dusters were the source of exposure for 28%. “bystanders” were exposed persons who were not using pesticides. records from three statewide and national journal of rural nursing and health care, 12(2) surveillance systems between 1998-2002 revealed 2,593 workers and children sustained acute pesticide induced illnesses while in school and daycare. of 409 cases with detailed descriptions, 125 were associated with pesticide drift from neighboring farms and 62 were students. the number of persons who develop acute illness from pesticide exposure may be substantially under-estimated for several reasons: non-occupational exposures are not universally mandated for reporting; symptoms can mimic common maladies, including, allergic reactions and gastrointestinal infections, and clinicians typically receive little training for recognition of pesticide induced illnesses (alarcon et al., 2005). this article describes the results of a community-health needs assessment that used photovoice to gain insight into mothers’ concerns about pesticide exposure for themselves and their children in the red river basin (rrb) of minnesota and north dakota. the effort was part of a one-year grant for planning an intervention to prevent pesticide exposure to children. although several pathways to pesticide exposure and other environmental health concerns were identified, this article focuses on perceptions of exposure to pesticides through drift. methods the minnesota segment of the rrb extends over 37,100 square miles in northwestern minnesota and eastern north dakota. the region is one of the nation’s highest producers of wheat, corn, sugar beets, and soy through conventional agricultural practices (minnesota pollution control agency, 2010). a 2004 survey and focus groups found 50% of residents believed that pesticide exposure could cause cancer and birth defects, while 70% reported they did not have enough information to gauge their risks. due to broad concern and lack of knowledge, a collaborative partnership emerged between the university of minnesota regional sustainable development partnerships (umsdp), faculty researchers from the university of minnesota, school of public health, division of environmental health sciences, and local communities to address issues related to pesticide use and potential exposure among women of childbearing age and children. the methodology of photovoice provides cameras to individuals from vulnerable populations and allows them to document experiences in their daily lives. images are shared with key stakeholders to promote dialogue for the purpose of improving local conditions that impact health (wang & burris, 1997). photovoice can be adapted for assessment, evaluation and asset mapping. the approach has effectively engaged women of childbearing age and youth, and has been used by local county public health officials, academics, health care educators, and practitioners (catalani & minkler, 2010). theoretical foundations of photovoice are grounded in freireian education for critical consciousness, feminist theory, and community-based documentary photography. freire promotes experientially-based discussion among members of marginalized groups to analyze root causes of inequities to create social change (freire, 1973). feminism asserts that power accumulates for those who have voice, set the terms of discourse, and participate in decision making, and it seeks inclusion of those left out of policy deliberations (backer, costellonickitas, mason, mcbride, & vance, 1998). community-based documentary photography engages members of disadvantaged groups in visual representation of their daily conditions to increase social awareness (hubbard, 1994). methods from this photovoice are described in detail elsewhere (stedman-smith, mcgovern, peden-mcalpine, kingery, & draeger, 2011). briefly, convenience samples of three groups of six women (n=18) raising children from at-risk populations, who were not represented in past studies were recruited: caucasians residing near the minnesota-canadian border, living journal of rural nursing and health care, 12(2) adjacent to actively treated farmland, and enrolled in the women, infant and children’s nutrition program (wic); native americans living on a reservation near the center of the rrb, surrounded by farms and affiliated with a tribal college; and new american immigrants predominantly from east africa, affiliated with a local immigrant development center in fargomoorhead (see table 1). recruitment was conducted by local stakeholders who were community leaders that had contact with the mothers in these administrative settings. the study was performed in accordance with the university of minnesota institutional review board (irb). mothers from each group attended two, three-hour workshops during the peak growing season. workshop i provided training about pesticides, the method of photovoice, the ethics of taking pictures, and instructions with hands-on-experience in using digital cameras. participants reflected upon and captured images that depicted concerns about how their children may become exposed to pesticides, and other health and safety issues; one month later, they attended workshop ii to share and discuss the meaning of their photos, community assets, and changes they wanted, if any, to better protect their children. major themes were identified with team input; a report was written for funders, and a poster with images and quotes from the mothers was shown at a community stakeholder meeting in the rrb with ensuing dialogue. a three-year intervention to reduce pesticide exposure to families in this region was funded by blue cross and blue shield foundation of minnesota. upon completion of these activities, analysis was conducted to examine deeper themes and meanings, triangulate findings with existing literature, and make further recommendations for public health practice, policy, and research. transcripts were verified with audio tapes and corroborated with photos and field notes; themes and sub-themes were generated within groups using techniques from grounded theory (strauss & corbin, 1998) and across groups using cross-case analysis (miles & huberman, 1994). cross-case analysis reconciles unique and generic processes across cases. since three distinct groups of mothers participated within one large agricultural region, cross-case analysis allowed for similarities and differences within and across cases to be highlighted. trustworthiness was promoted by member checks and peer review prior to, during, and after analysis. data analysis and decisions were documented in memos, thereby, creating an audit trail to enable method replication. table 1. journal of rural nursing and health care, 12(2) results two major themes were identified regarding potential pesticide exposure sources that mothers identified for themselves and their children: agricultural activities and mosquito control. sub-themes were related to the place for potential community exposures and precautions to prevent exposure. potential pesticide exposure to drift from agricultural activities concerns were identified in multiple locations during daily experiences. caucasian and native american mothers identified sources of agricultural drift exposure when at their residences and when traveling on roads. native american’s voiced additional concern about exposure at school and day care. new american immigrants raised concerns about exposure to agricultural drift in the general region, without identifying specific sources and places. agricultural spray. this young mother was concerned about the potential for pesticide exposure to children at school through drift from aerial spraying. she took two photos from different directions while standing on school property. “the school is located across the road from a potato field. my little brother goes to school there and my mom pulls him out on the days that they spray the field. i don’t think it’s fair that parents have to protect their kids from getting contaminated while at school.” (native american mother) apprehension was voiced about children’s pesticide exposure from drift while in daycare on the reservation. “there’s a field right on the other side of their daycare, and when i went to pick them up, you could just smell that. ‘should they be out there? i would get them inside.’” (native american grandmother) this mother snapped a photo of a wet area located on a highway that was surrounded by open farm fields. “[on this stretch of highway] there are always puddles … from the overspray. i was driving through the area. the puddle was all the way across the road and it was spraying our car. i know that you can get chemical burns from this stuff, so i shut my car window, but still, that spray shouldn’t be sprayed on the road or near me or my car.” (native american mother) another mother photographed an expanse of open farm fields with a plane spraying over a community road. “and we were driving and… i’m pregnant and i can smell things, and i’m like—‘what’s that smell?’ we got around the corner and on one side of the road was a farm, then there was the road, and the field right across. and he was swooping right over the road, right journal of rural nursing and health care, 12(2) over the cows and spraying…. i was literally almost holding my nose ‘cause it was so thick.” (caucasian mother) another participant took a picture of a plane flying close to her home. she describes the impact of the noise on her two year old son in terms of interrupting his morning sleeping patterns. “i’m parked at the end of my driveway and he [farmer-neighbor] has just come over my house and that’s him spraying. …cause they go right over the house. zoom…and the kids will [wake up] … and ben will say, ‘it’s scared –it’s scared’”. (caucasian mother) (see figure 1) figure 1. “parked at my driveway” yet another mother took a photo of a large actively treated farm field next door to their home; she described concerns about potential exposure to her son, who plays near or on the field: “that is the closest field. …they [the children] play …on that edge … so they could walk into the field if they wanted to.” (caucasian mother) this mother photographed a large tractor spraying on an expanse of a black-dirt field adjacent to her backyard, and expressed the realization of how frequently her children were playing outdoors while this farmland was being sprayed. “…every time there was a sprayer, we were outside. every time…” (caucasian mother) the same mother expressed a desire for advanced warning before her neighbor sprays. journal of rural nursing and health care, 12(2) “…the kids are outside playing and we have two dogs. there’d be no way of warning that we could get all of our toys in— but just our animals and our kids inside and turn off the air conditioning.” (caucasian mother) a native american mother raising two small grandchildren took a picture of a large tractor spraying on an open field. “just driving down the road and getting exposed to it ‘cause they’re spraying…this happens a lot….since i’ve usually got my babies on board, how do i try to stay away from that stuff? you really can’t get away from it” (see figure 2) figure 2. “just driving down the road” community truck togging. mothers from all three groups discussed the risks of insecticide exposure from community truck fogging to reduce mosquitoes versus the risks of contracting west nile virus. participants wanted their communities to spray, however, with advanced notice so they could take children and toys indoors before fogging to reduce the potential for dermal and inhalation exposure. this mother snapped a picture to document the fog from community truck spraying drifting across the street from her home. “this is in my driveway. the spray for the city had come around. it’s out of the back of a pickup. and that’s the mist after he’s gone by. it lingers, for mosquitoes.” (caucasian mother) (see figure 3) journal of rural nursing and health care, 12(2) figure 3. “it lingers for mosquitoes” yet another mother relays that her son thinks his asthma is becoming aggravated from pesticide fog wafting into the home after community spraying. “… and i see him spray at night… my son he never have asthma. the time he comes to america have very bad asthma my son and my daughter. and the time inside the house, my son tell me, ‘mom i swear to god… i smell the spray of the mosquitoes.’ i tell him, how? you inside the house” (new american immigrant mother) ` this participant expressed concern about children’s exposure to pesticide fogging while at a head start day care. “they sprayed the whole city for mosquitoes and we could smell the pesticides coming in through the screens. and there’s a head start and a day care in our building …. it was like 4:00 in the afternoon. cause they have the playground equipment for the head start and day care right out in back of the apartment building.” (native american grandmother) a mother took a photo of a 12 year old boy next door who was fogging. he was standing in a cloud of fog, wearing shorts, and a short-sleeved tea shirt, without personal protective clothing, a face mask or eye goggles, and asked, “should he be doing this?” mothers from all three groups expressed a desire for a longer period of advanced warning in group discussions. “i’m really worried about the insecticide exposure for my children, but i’m also worried about west nile virus…and i wish there was some way short of just seeing the truck come by to know that they’re going to spray, just to get my kids and my toys in. if your yard is full of toys and they’re all of a sudden coming down the block, you don’t have time to pick up all your toys…..” (caucasian mother) journal of rural nursing and health care, 12(2) discussion this research provided real-world insights into the concerns of mother’s about pesticide exposure. the results generate hypotheses for how children’s pesticide exposure may occur in these groups, and when triangulated with current scientific literature can be used to make recommendations for future research, public health practice, and policy. since, the study employed convenience sampling with a small group of women (n= 16), it cannot be generalized to all mothers in the rrb or elsewhere. however, qualitatively derived findings may be “transferrable” to other like contexts (lincoln, 2001). the type of pesticides used, whether exposure occurred, the amount of exposure, and the impact on health are not known. pesticide exposure through drift was perceived as an important pathway. yet, limited research elucidates this pathway and the health effects in children. weppner et al. (2006) found higher levels of pesticides on playground equipment at six and 11 hours after spraying compared to baseline levels. elevated levels on the hands of children and increased metabolite levels in spot urine samples following spraying indicated that youth were directly exposed. the results lend credence to this study’s findings of mothers’ perceptions of drift on toys and playgrounds as pathways for children’s pesticide exposure, and mothers’ desire for advanced warning to bring children and toys inside before agricultural spraying. while weppner and colleagues did not find pesticide residues in the home, a study in arkansas did (richards et al., 2001). homes that had wind blowing toward them, and were closest to the field had the highest levels of residue; however, biological measures of exposure were not collected, limiting interpretation of health impact. concern about children’s exposure to pesticide drift at school and day care is supported by limited research documenting acute pesticide induced illnesses from national surveillance systems between the years 1998-2002. the school environment protection act (sepa) was introduced by representative rush holt, d-nj12, on march 20, 2012 (h.r., 4225-112 th congress). sepa would amend the federal insecticide, fungicide and rodenticides act to mandate protections at schools including: integrated pest management programs; advanced notice to parents before pesticide usage; identification of sources of pesticide drift; and written plans to develop school environments protected from pesticides. the bill offers minimum uniform protection to exposure from agricultural drift across the states for children at school. successful policies to protect children from exposure to pesticide drift in the school setting have been enacted on the state level. nine states have mandated buffer zones ranging from 300 feet to 2.5 miles around schools during school activities and commuting hours as a prevention strategy, and enactment of these restrictions to control pesticide drift in areas neighboring schools represent a 6% increase since 1998 (kagan, 2009). perceptions of the relative risks of pesticide exposure from fog generated by truck fogging versus contracting wnv were consistent with findings from a human health risk assessment that included children and multiple exposure routes. the risk assessment compared potential chronic and acute residential exposures to toxicological and regulatory effect levels and concluded that the risks of contracting wnv exceeded the risks of pesticide exposure from fogging (peterson, macedo, & davis, 2006). although, mosquito control commonly uses pyrethroid insecticides, which can cause respiratory irritation, studies conducted in new york city found no increases in hospital admissions for asthma exacerbations during local spray campaigns (karpati et al., 2004; o'sullivan et al., 2005). however, these studies did not account for the possibility of milder asthma exacerbations occurring that did not require hospitalization. journal of rural nursing and health care, 12(2) the us centers for disease control and prevention has documented 133 cases of acute insecticide-induced illnesses associated with mosquito control in nine states from 1999-2002. of the assessed cases, 36 were work-related and 96 were non-work related, including one documented illness of high severity in a person with respiratory disease when a pyrethroid insecticide compound passed through operating window fans and an air conditioner during neighborhood spraying (mmwr, 2003). this report supports the question and concern voiced from the new american immigrant mother from somalia about the possibility of fog entering her home and irritating her children’s asthma. in addition, it underscores worry about children conducting fogging without wearing personal protective equipment. implications for professional practice all mothers wanted community education about the health effects of pesticides and how to reduce exposure to develop strategies to protect their children. caucasian mothers wanted written material from primary care practitioners, visiting public health nurses, and wic providers. native american women wanted written and verbal information from wic, head start, the indian health services, and at events where food is served. new american immigrants wanted information delivered verbally by trained and trusted community members in their homes and at church gatherings. recommendations for professional practice, policy, and future research are consistent with the precautionary principle, which states that “when an activity raises threat of harm to human health and the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically” (kriebel et al., 2008, p. 871, citing raffensperger & tickner, 1999). according to the american academy of pediatrics council on environmental health (2012), precaution is an integral aspect of preventive medicine and disease management. in public health, it is seen in primary prevention, such as neonatal screening and childhood immunizations, while in clinical medicine, it is seen in the ethical principle of, “first, do no harm” (p.838). the american nurses association includes policy advocacy to promote the health of populations within the scope and standards for public health nurses (phns). moreover, the precautionary principle has been endorsed as a central tenet for guiding policy advocacy in professional practice for environmental health nursing (american nurses association, 2007). phns are in a unique position to address the environmental health needs of children using the precautionary principle. they are the largest professional group practicing public health (national research council, committee on educating public health professionals for the 21 st century, 2003), and they practice at key places in the community where they can directly assess the potential for adverse environmental exposures and promote salient interventions. consistent with the ecological framework, such approaches may be implemented on multiple levels, including the individual, family, community, population, and systems domains to promote and protect health. children’s heightened vulnerabilities to exposure from pesticides and other environmental agents compels public health nurses to apply the precautionary principle in collaborative multidisciplinary professional practice for the purpose of safeguarding the health status of children and to protect the developmental potential and well-being of future generations. rural phns can collaborate with members of the local multidisciplinary public health team as well as all involved stakeholders on the state level to increase awareness and advocate for policies that protect children from exposure to pesticide drift while at school. in addition, more awareness is necessary for providers in recognizing and reporting pesticide induced illnesses. journal of rural nursing and health care, 12(2) rural health phns can assess the location of a home in relation to actively treated farmland, and ask parents where their children spend most of their time. such information may lead to an opportunity for providing health education about pesticide exposure and developing strategies to better protect the health of children. a toolkit for pediatric environmental exposures, including pesticides, is available from physicians for social responsibility (physicians for social responsibility, 2009), which can be adapted for use in professional practice. phns can take an active role as partners in interdisciplinary research conducted to inform professional practice. specifically, studies are needed to clarify the relationship between pesticide exposures and adverse maternal and child health outcomes; such studies would utilize longitudinal designs, and include samples that mirror the nation’s diversity with data collection of biological specimens, environmental samples, and self-reported data to associate actual and perceived exposures with outcomes. research is also needed to generate evidence-based recommendations for how long children and pets should remain indoors after agricultural aerial and truck spraying, as well as to explore the most effective community approaches for advanced warning before truck fogging. an important role of phns includes performing community health needs assessments, assisting members of the community to voice their perceptions with regard to environmental health advocacy, and utilizing qualitative data (american public health association, public health nursing section [apha], 2012; apha public health nursing section, 2005). as a method, photovoice integrates these activities, and is within the role of the phn. in addition to generating a needs assessment that successfully led to securing funding for a regional intervention to reduce children’s pesticide exposure, other venues for this photovoice project were implemented to promote community awareness and dialogue. the images and voices of the mothers were incorporated into pesticide applicator re-certification courses by a university of minnesota extension educator, and a traveling exhibit of the photos and captions from the mothers was presented at select community events. utilization of approaches that include a consideration of pathways to pesticide exposure in maternal child health needs assessments in conjunction with collaborative methods, such as, photovoice, have the potential to increase awareness among community members and promote local and state measures for reducing pesticide exposure. funding bc / bs foundation of minnesota, the um office of clinical research, medical school’s program in health disparities research; graduate fellowship in environmental health from sophe / atsdr; midwest center for osh (nihosh t420h008434) ruth horton fund, umnrsd partnership. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/11385597 http://www.ncbi.nlm.nih.gov/pubmed/22102604 http://www.ncbi.nlm.nih.gov/pubmed/9158980 http://www.ncbi.nlm.nih.gov/pubmed/16249796 http://www.ncbi.nlm.nih.gov/pubmed/18074304 http://www.ncbi.nlm.nih.gov/pubmed/9646054 smith_psfahs,+682-article+text-4557-1-15-20210628+final_setup_psf+8.30.21 online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 14 strategies for recruiting and retaining nurses for rural hospital closure research jessica g. smith, phd, rn, cne1 kyrah k. brown, phd2 melynda hutchings, dnp, rn-bc, cen3 elizabeth i. merwin, phd, rn, faan4 1assistant professor, college of nursing and health innovation, university of texas at arlington, jessica.smith2@uta.edu 2 assistant professor, department of kinesiology, college of nursing and health innovation, university of texas at arlington, kyrah.brown@uta.edu 3clinical assistant professor, college of nursing and health innovation, university of texas at arlington, melynda.hutchings@uta.edu 4dean and professor, college of nursing and health innovation, university of texas at arlington, elizabeth.merwin@uta.edu abstract purpose: rural hospital closures result in the loss of lifesaving acute care for rural residents and threaten the health of rural communities significantly. understanding shortand longer-term effects nurses experiences related to a rural hospital closure can pose a unique challenge, as nurses may relocate and become difficult to identify. in this paper, the authors describe the strategies used during a pandemic to recruit and retain rural nurse research participants who experienced a rural hospital closure. strategies presented may help nurse researchers recruit a unique and difficult-toreach rural nurse population during a pandemic. online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 15 sample: the sample consisted of nurses who worked in a rural hospital that closed between 2014 to 2020 in one southwestern state. method: the authors describe multiple strategies used to recruit rural nurses such as public outreach, social media outreach, and personal outreach. public outreach was used through professional organization email listservs and printed newspaper advertisements. social media outreach included public posts online. personal outreach to former rural hospital employees who were existing contacts was through personal social media messages, phone calls, and texts. findings: the most effective method for recruitment and retention was personal outreach through rural hospital champions who sent personal messages using social media. the final sample included 10 nurses from two rural hospitals that closed. five nurses reported about a hospital that closed in 2014, while five nurses reported about a hospital that closed in 2015. conclusion: for successful recruitment, future researchers should use a direct, personal recruitment strategy to recruit and retain rural nurse research participants for studies about rural hospital closures. other strategies for successful rural nurse recruitment for research include planning for an extended recruitment timeline, being flexible with participants regarding data collection procedures, cultivating research interest among rural nurses, and building a culture of research in rural settings. keywords: rural, nursing, research, sampling, recruitment, hospital closure, covid-19 strategies for recruiting and retaining nurses for rural hospital closure research rural hospital closures significantly threaten the health of rural communities, as they result in the loss of lifesaving acute care for rural residents. closures of rural hospitals have a disproportionate effect on rural residents who are, on average, older, poorer, and suffer more online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 16 chronic illnesses given their barriers to transportation and adequate health insurance (national academies of sciences, engineering, & medicine, 2018). the closure of rural hospitals also results in imposed mass resignations for trained rural acute care nurses. understanding nurses’ experiences of a rural hospital closure, and its longer-term effects, can pose a unique challenge because nurses relocate and may be difficult to find after the hospital closure because records are not publicly available. in this paper, the authors describe strategies used to recruit and retain rural nurse research participants who experienced a rural hospital closure in one southwestern state. the authors' study was designed during fall 2019, it was funded in january 2020, and data collection occurred in may 2020 amid the covid-19 pandemic. the authors make specific recommendations for nurse researchers aiming to identify, recruit, and retain rural nurse participants for research studies during a pandemic. the strategies and recommendations presented in this paper may help nurse researchers navigate the complexities of recruiting a unique and difficult-to-reach rural nurse population during a pandemic. background over the years, there has been a steady increase in nursing health services research (nhsr) in rural settings conducted by nurse researchers, including nurses as research participants (cohen et al., 2021; greiner et al., 2008; squires et al., 2019). c. b. jones and mark (2005) established nhsr as referring to the subfield of health services research that focuses on the study of health care delivery and systems of care delivery involving nurses, the examination of structures, processes and outcomes of nursing care, and the evaluation of nursing practice innovations and new models of care delivery (cohen et al., 2021, p. 2). online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 17 rural nurses play a critical role as participants in nhsr because of their immense knowledge and experience within the rural hospitals, which are fundamentally different from urban hospital systems in terms of community characteristics and context, human and technological resources, and practice characteristics (jackman et al., 2012; s. n. jones, 2012). in the us, 20% of nurses reside and work in rural communities (health resources and services administration, bureau of health professions, 2013). in general, rural nurses are directly involved in almost every aspect of ensuring hospital care delivery and quality, including the provision of direct patient care and education, data collection and reporting, designing and implementing quality improvement initiatives, and influencing organizational policies and procedures. therefore, rural nurses as research participants can contribute to knowledge generation related to the structure, processes, and effects of rural healthcare services, and strengthen the nhsr literature (squires et al., 2019). previous research has identified psychosocial and work environment factors that may enable or impede nurses’ participation in research (albers & sedler, 2004; björkström & hamrin, 2001; roll et al., 2013; vangeest & johnson, 2011). regarding enabling factors, nurses are more likely to participate in nursing research when the topic under study interests them and when they work in environments where nurse managers and leaders foster a culture that values research (björkström, johansson, & athlin, 2013; higgins et al., 2010; roll et al., 2013). barriers to nurse participation in research include perceptions about research participation being outside the scope of their role as clinicians (bullen et al., 2014) and having a limited understanding of the research process (björkström & hamrin, 2001; björkström, johansson, & athlin, 2013; higgins et al., 2010). rural nurses may be less responsive to individuals who are viewed as ‘outsiders’ such as researchers who live outside of their community (long & weinert, 1989). also, rural nurses are embedded within the cultural context of close-knit rural communities (lee & mcdonagh, 2018; online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 18 long & weinert, 1989). this community context is often characterized by lack of anonymity and extensive familiarity with others in the community (lee & mcdonagh, 2018). therefore, nurses might be concerned about sharing information during the research process for fear of others finding out about the nature of their participation or for fear of inadvertently breaching patient confidentiality (lee & mcdonagh, 2018). finally, rural nurses, especially those working in busy hospital settings, must contend with the mental and physical challenges of a busy workload (björkström, johansson, & athlin, 2013; govasli & solvoll, 2020). consequently, many nurses report having limited time and/or energy to participate in research during or outside work hours (roxburgh, 2006; vangeest & johnson, 2011). understanding the facilitators and barriers to nurses’ research participation is valuable because this information can inform the efficient design of studies seeking to collect primary data from rural nurse research participants. however, there is a need for more studies documenting the efficacy of processes and strategies used by nurse researchers to recruit and retain rural nurses as research participants (broyles et al., 2011; luck et al., 2017). to date, there are 11 published studies that describe and/or evaluate the processes and strategies used to recruit and retain nurses as research participants (brewer et al., 2020; broyles et al., 2011; howerton child et al., 2014; coyne et al., 2016; desroches, 2020; hysong et al., 2013; khamisa et al., 2014; luck et al., 2017; raymond et al., 2018; stokes et al., 2019; vangeest & johnson, 2011). to the best of our knowledge, only one of these studies focuses explicitly on rural nurses as research participants (brewer et al., 2020). much of the literature on recruiting and retaining nurses as research participants describes face-to-face recruitment processes and strategies. in these studies, the research teams reported recruiting nurses from healthcare facilities or other organizational settings (broyles et al., 2011; online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 19 coyne et al., 2016; hysong et al., 2013; khamisa et al., 2014; luck et al., 2017; raymond et al., 2018). few studies in the literature describe recruitment and retention strategies for internet-based studies (howerton child et al., 2014; desroches, 2020; stokes et al., 2019), which are particularly useful in rural nursing research because rural communities tend to have more geographically diffused populations (brewer et al., 2020; cudney et al., 2004). some of the effective recruitment strategies from internet-based studies are similar to those reported in facility-based studies. these strategies include using more than one recruitment mode, identifying champions who have access to and trust with nurses, using snowball sampling techniques, and ensuring that data collection activities are flexible and convenient for nurse participants (brewer et al., 2020; broyles et al., 2011; coyne et al., 2016; hysong et al., 2013; khamisa et al., 2014; luck et al., 2017; raymond et al., 2018). there are, however, some unique considerations for recruiting and retaining rural nurses as participants in internet-based studies. while internet-based studies in general offer the benefits of cost-effectiveness (howerton child et al., 2014), such studies conducted in rural contexts may result in greater costs in terms of time because of longer recruitment periods and fewer potential participants who are spread across vast geographic areas (brewer et al., 2020; howerton child et al., 2014). compared to facility-based studies, researchers conducting internet-based studies have limited control over the study setting (e.g., being readily available to participants as they complete surveys) and depending on the nature of the study may not have access to a pre-existing contact list from which to recruit potential rural nurses (brewer et al., 2020; howerton child et al., 2014; stokes et al., 2019). finally, researchers conducting internet-based studies may encounter unique issues related to technological usability and issues related to spammers accessing and compromising online data collection forms (howerton child et al., 2014; desroches, 2020). online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 20 considering the unique challenges that come with internet-based studies, there are several recruitment and retention strategies have been identified. one effective strategy is the use of social media platforms (e.g., facebook (fb), linkedin) to create targeted ads using demographic data, to send direct messages to potential participants, and to post flyers in online interest groups (howerton child et al., 2014; stokes et al., 2019). nurse researchers have discussed the importance of tracking and reporting the number (and type of people) who see posts/ads, the number who engage with posts (i.e., likes, shares, comments), and the number of people directly recruited from posts/ads to inform modifications to online recruitment (howerton child et al., 2014; stokes et al., 2019). on the other hand, one study focused on recruiting rural nurses across three states indicated that social media recruitment was effective in only one of the three targeted states (brewer et al., 2020). a second effective strategy is testing online data collection tools for errors and usability (i.e., mobile phone viewing) to prevent potential participants from becoming frustrated and dropping out of the study (desroches, 2020; stokes et al., 2019). in response to rural nurses’ potential hesitation to participate in research due to issues related to confidentiality and anonymity, a third recruitment strategy involves using the consent form (and other recruitment materials) as a tool to overemphasize the research team’s plan to minimize risk associated with breach of confidentiality (brewer et al., 2020). while little is known about what processes and strategies work for internet-based studies recruiting rural nurses as research participants (brewer et al., 2020), even less is known about how this works during the covid-19 pandemic, which has created unprecedented challenges. nurses’ work demands have been exacerbated by the covid-19 pandemic. in the case of rural hospitals and communities, available evidence suggests that rural communities are at higher risk for hospitalization and severe illness among rural residents who tend to be older and have more online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 21 chronic conditions (kaufman et al., 2020; segel et al., 2020). during the covid-19 pandemic, rural hospitals have faced financial (i.e., furloughs, reduction of staff hours) and operational (i.e., personal protective equipment shortages) challenges (segel et al., 2020). the covid-19 pandemic’s impact on hospital patient loads, finances, and operations has placed greater strain on nurses in rural communities, and on the limited time and energy that nurses may have had allocated for potential research participation. while internet-based research offers many advantages (howerton child et al., 2014), during the covid-19 pandemic there has been an increase in number of internet-based studies. the potential of research fatigue, or populations growing tired of engaging with research, may present additional challenges for recruitment and retention in rural settings (patel et al., 2020). there is a need for literature that can help guide nurse researchers who have had to adapt their research methodologies in the wake of covid-19. to ensure the continued growth of nhsr in rural settings, further research is needed about strategies to recruit and retain rural nurses as participants (brewer et al., 2020; broyles et al., 2011). the aims of this paper are to (1) describe the process and strategies used to recruit and retain rural nurses in an internet-based study designed to investigate the impact of rural hospital closures on nurses and residents during the covid-19 pandemic and to (2) identify recommended strategies that may be of particular interest to nurse researchers conducting nhsr in rural settings during the covid-19 pandemic. this paper will inform processes and strategies to effectively recruit and retain a hard-to-reach nurse population—rural nurses who worked in a hospital that has since closed. finally, among the studies using social media to recruit nurses, only one of those studies used a qualitative study design (brewer et al., 2020). therefore, this paper will contribute to an understanding of the unique challenges and strategies involved in using social media to recruit rural nurses as research participants in a study using online surveys and qualitative interviewing. online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 22 method the purpose of recruiting rural nurses as research participants was to understand their perceptions about the impact of hospital closures in rural communities. in the paragraphs below, the original study design and method is described first, followed by a description of modifications to the design and method needed to successfully recruit a sufficient sample. original study design for this study, a hospital was classified as rural if it was in at least one of the following categories: (1) a critical access hospital (cah), (2) a sole community hospital (sch), (3) a rural referral center (rrc) in a non-metropolitan statistical area (msa), or (4) location in a county of 60,000 population or less. this classification is consistent with a state professional organization’s definition of rural. the organization is not named here for confidentiality. licensed nurses who experienced a rural hospital closure in one southwestern state between 2016 and 2020 were originally eligible to participate in the original study. initial public outreach strategies included sending study advertisements to professional organizations, local newspapers, and posting advertisements in community settings (e.g., grocery stores, libraries). the original data collection plan was to conduct three focus groups with eight to ten staff nurses in each group, i.e., between 24-30 staff nurses, and five individual interviews with chief nursing officers (cnos). participants were to be asked to complete an online survey including 11 demographic items and 31 items about their perceptions of the rural nurse work environment before the hospital closure. focus groups and interviews were planned to be either via videoconference or telephone conference. participants’ verbal consent was to be obtained through a phone call, after the participant reviewed the consent form received through email. reminder emails were to be sent about participating. the original data collection timeline was to be from may 2020 to august 2020. online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 23 institutional review board (irb) approval from the authors’ academic institution was received in may 2020. results from survey and interview data will be shared in another paper. modifications to the original study design due to challenges related to rural recruitment and covid-19, the authors modified the study design, methods, and recruitment timeline. the authors made 11 modifications to their irb study protocol. this section describes the need for design modifications. the covid-19 pandemic necessitated that all recruitment be online through social media outreach, personal invitations, and email listserv invitations. after starting data collection in may 2020, the authors changed the design from focus groups to individual interviews for staff nurses because of slow recruitment and scheduling challenges due to increasingly busy schedules due to covid-19. after a month of slow recruitment, the authors modified inclusion criteria to include nurses who worked in hospitals that closed between 2014 and 2020, adding two previous years to the original timeframe of 2016-2020. this decision was made after the third author (mh), who had personal connections from a rural hospital closure in 2014, expressed interest in helping our recruitment efforts. mh’s specific role in participant recruitment is described in detail in the description of recruitment strategies section. this authors also reasoned that potential participants who experienced closures in 2014 and 2015 were not vastly different from those who experienced recent closures. the study protocol was also modified to allow for recruitment of nurses from additional hospitals if more closures occurred in 2020, but to our knowledge, there were no additional closures in the one southwestern state in 2020. the authors extended the recruitment period beginning in may to go through january 31, 2021 due to difficulties with participant recruitment and retention (e.g., some participants did not follow-up even after agreeing to participate). online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 24 description of recruitment and retention strategies public outreach due to the pandemic, the authors decided against posting study advertisements in community settings. public outreach involved the research team paying for one email to be sent to a large professional member organization, paying for advertisements in eight different newspapers across seven counties, and sending unpaid emails through three regional professional organizations. social media outreach initial efforts for social media recruitment using fb included unfunded advertising in fb special interest groups and on author’s personal pages. in june 2020, the authors reached out to the leaders of fb interest or cause pages related to nursing or rural health but found that not being their direct friend on fb resulted in our messages being sent to their spam folder rather than be notified of a message at the exact time it is sent. the authors also posted study advertisements on their personal linkedin pages, shared on twitter, and were able to get professional organizations and their academic institution to post the advertisements on their twitter and fbpages. the authors also used an existing research team fb page to pay for boosted advertisements as a strategy to recruit participants. boosted fb ads are advertisements that are paid to be promoted on the newsfeeds of user profiles in a specific geographic area (i.e., counties where rural hospitals closures occurred) and to profiles with specific characteristics (i.e., profile indicates their job is at a hospital or nursing is listed as an interest). boosted fb advertisements were less expensive and provided good reach and leads, while also offering potential participants the option to provide their contact information. however, the authors only requested email addresses in the contact form for the second, third, and fourth boosted fb advertisements. in the third and fourth fb advertisements, the option for those interested to indicate their phone numbers to contact them was added. this online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 25 strategy enabled the authors to text and call potential participants, as otherwise, emails could have been going to spam folders. the fb boosted advertisements settings were also modified to include counties that were adjacent to the counties with hospital closures on the third and fourth advertisements. personal outreach the authors updated the study protocol to include recruitment through personal contacts because of ongoing challenges in obtaining responses from our target population using public advertising outreach strategies. the first author (js) sent personal messages to existing rural nurse or rural hospital contacts from her social media and personal network, which included 19 people. in august 2020, one author (mh) joined the protocol to serve as a champion for the study. this author (mh) posted the advertisement a rural nursing interest groups fb page and her personal fb page. this fb page had former employees of rural hospitals that closed, comprising 200 plus members. there were both nurses and non-nurses as members. the fb page comments were monitored, and the author (mh) personally messaged individuals that responded. the same author sent announcements to local nursing homes and home health agencies in areas local to rural hospital closures to attempt to identify any nurses that went to these facilities for employment after a rural hospital closure. author (mh) sent private messages to members of a rural community (e.g., mayor, nurse leaders), including local government leadership, former rural hospital administrators, former rural hospital personnel, and a healthcare provider in primary practice. retention strategies the authors tested several participant retention strategies. during the initial stages of data collection, the authors experienced challenges in getting participants to return consent documents online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 26 prior to the scheduled interview and online survey. in response to this, the authors obtained irb approval to obtain potential participants consent via email after reviewing the consent form. originally, the authors reserved open time blocks during the work week to schedule interviews. after recognizing just how hectic potential participants’ schedules were, the authors told potential participants that they were open to doing interviews at whatever time they were available, including, in the evening and on the weekends. the authors also noticed that some confirmed participants were forgetting their scheduled interview even after an email reminder and calendar invitation. having to reschedule a missed interview posed the risk of losing the participant to follow-up. therefore, the authors began sending email and text message reminders within an hour prior to their scheduled interview. findings in the sections below, the authors describe results from the study’s recruitment and retention strategies. this section shows tables to reflect more depth of information. recruitment outcomes table 1 displays each of the three recruitment strategies, total costs and number of participants recruited. as shown in table 1, this recruitment strategy was the most expensive and resulted in no participants. see tables 1 and 2 for a detailed description of recruitment efforts throughout the duration of recruitment in chronological order. table 1 overview of recruitment strategies recruitment strategy cost (u.s. dollars) number of participants recruited public outreach 1,686.04 0 social media ads 215 0 personal outreach 0 10 online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 27 as shown in table 2, fb ads resulted in 17 leads (people who see the ad and sign up to be contacted). of the 17 leads, two indicated initial interest in participating and were eligible after initial screening; however, neither followed up to emails reminding them to provide consent to participate. therefore, none of the leads resulted in participation. table 2 facebook (fb) ad campaign statistics fb ad # 1 fb ad # 2 fb ad # 3 fb ad # 4 ad objective boosted post leads leads leads duration 45 days 39 days 15 days 45 days reach total number, n 2,891 2,170 1,911 2,058 age, % 18-24 5 4 1 4 25-34 14 12 7 8 35-44 22 27 20 18 45-54 24 29 27 20 55-64 20 21 28 22 65+ 15 8 17 28 gender, % female 100 100 100 84 number of leads 7 5 5 post engagements, n link clicks 3 57 48 photo clicks 42 comments 1 1 shares 23 12 video views 1,020 total engagements, n 97 1,077 70 note. lead form for fb ad #2 and #3 included name and email. lead form for fb ad #4 included name, email, and phone number. fifty-two potential participants were contacted using the personal outreach approach. the participation rate was 19% for potential eligible participants who were contacted through personal invitation throughout the data collection period (10/52=19%). one person contacted through personal outreach consented to participate but did not respond to scheduling an interview. personal outreach results are presented in table 3. online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 28 table 3 results for recruiting participants by personal outreach to individuals timeline recruitment method total cost ($) contacted participants (n) 7/2020 – 1/2021 personal outreach (js) to nurses from were existing contacts known to js from a rural hospital that closed 0 19 5 8/2020 – 12/2020 personal outreach by a “rural hospital champion” (mh) to nurses from existing contacts known to mh from a community in which a rural hospital closed 0 30** 5 12/2020 personal outreach by 2 rural nurses from 2 different rural hospitals that did not close. these nurses did not have direct nurse contacts who were working at a rural hospital that closed during the 2014-2020 timeframe. 0 4 0 note: *number contacted refers to the number of private messages sent to individuals js or mh knew through facebook messages, phone calls, or text messages. **not all individuals were nurses at the hospital that closed. some were members of the community, stakeholders, or in other healthcare roles. sampling outcomes there were 13 potential participants who communicated interest in the study and were qualified to participate. three individuals did not follow up to emails to proceed with next steps to participate. two of these three individuals were recruited from fb leads and did not answer emails to proceed with consent. the remaining individual was recruited using the personal contact method and consented to participate but did not respond to further reminders. the retention rate was 76.9% (10/13 = 76.9%) and attrition rate was 23% (3/13=23%). the final sample recruited and retained throughout the study duration included 10 participants. the 10 rural nurse participants were from two different rural hospitals that closed between 2014 and 2020. five rural nurse participants were recruited from one hospital that closed online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 29 in 2014, and five from another rural hospital that closed in 2015. one participant was a chief nursing officer. specific strategies were found to be successful to retain this sample, including using multiple methods to obtain consent, planning to be flexible with scheduling interviews, and planning to be flexible with the interview process. these strategies will be discussed further in the recommendations section of the discussion. discussion the purpose of this paper was to describe effective processes and strategies to recruiting and retaining rural nurses as research participants during a pandemic. the study’s target population, rural nurses who experienced a hospital closure, is a unique, difficult to reach population. for example, records about nurses who were hired at a closed rural hospital are not available for retrieval, although names of closed hospitals are available. the challenges associated with the recruitment and retention of this rural nurse population were further worsened by the covid-19 pandemic. the findings presented in this paper contribute to the dearth of literature on strategies and processes in recruiting rural nurses as research participants (brewer et al., 2020). one barrier to rural nurse participation in research included concerns related to colleagues within the small rural hospital community finding out what was shared in the interviews (lee & mcdonagh, 2018; long & weinert, 1989). for instance, some respondents expressed that there could have been concerns from her nursing colleagues about confidentiality even though the research team clearly conveyed confidentiality on recruitment materials. rural networks are small, which is likely to contribute to these concerns. another barrier was rural nurses’ busy workload (björkström, johansson, & athlin, 2013; govasli & solvoll, 2020), but this expected barrier was exacerbated by the covid-19 pandemic. the covid-19 pandemic contributed to a more arduous process for participant recruitment and online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 30 participation. the pandemic required several changes to this study’s design to recruit and retain nurse research participants. this was understandable, as the target population could have been in the field managing patients with covid-19 on the front lines, could have been pre-occupied about the risk of contracting covid-19, and could also have been struggling with any number of situations exacerbated by the pandemic, including but not limited to furloughs, layoffs, and changes in care needs for elders or children under their care. a third potential barrier could have been potential participants being demotivated. several rural nurse participants expressed how traumatizing the closure of their hospital was and it is possible that potential rural nurse participants did not want to relive those negative feelings. the study, described in this paper, was different from most prior studies on this topic because face-to-face or facility-based recruitment was not possible (broyles et al., 2011; coyne et al., 2016; hysong et al., 2013; khamisa et al., 2014; luck et al., 2017; raymond et al., 2018). therefore, some strategies and approaches did not fit the context of the present study. for instance, the covid-19 pandemic prevented the use of other methods that could have been useful for recruiting nurse participants, such as pursuing communications with open hospitals as a method of recruitment. rural hospitals caring for patients were managing already overwhelming circumstances due to covid-19, therefore, we did not pursue communications with these hospitals out of respect for those front-line nurses and administrators who were preparing for a surge in cases or experiencing the challenges of caring for covid-19 patients. in terms of strategies for recruiting rural nurses during a pandemic, the most effective strategies identified from the study described in this paper included identifying champions who have access to and trust with networks of rural nurses and using snowball sampling techniques (brewer et al., 2020; broyles et al., 2011). also, ensuring flexibility and convenience in interview online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 31 scheduling was essential in retaining rural nurse participants (broyles et al., 2011). our findings point to other effective strategies supported by existing literature such as testing online data collection tools or video conference tools to prevention participants from becoming frustrated (desroches, 2020; stokes et al., 2019) and using the consent form to overemphasize the commitment to confidentiality (brewer et al., 2020). in contrast to existing literature (howerton child et al., 2014; stokes et al., 2019), paid social media advertisement was not effective in recruiting and retaining rural nurse participants. social media recruitment using fb posed unique challenges. if one is not a direct contact (friend) on fb with others who own fb groups that could be interested in this study, messages sent to group leaders could get sent to a spam folder and remain unread. this limits possibilities for advertising to other areas in the state with rural hospital closures. the settings are limited to what is posted in public, as well, and some former rural hospital nurses might not have indicators of being a nurse on their fb profile for privacy. therefore, our boosted ad might not have been visible to all the possible nurses who experienced a rural hospital closure in our target population. potential reasons paid fb advertising did not result in participants despite requesting for their contact information could be (1) not entering contact information correctly, (2) not responding to emails (likely because of emails going to spam folders), (3) not responding to phone calls or text messages due to not recognizing the sender, or (4) mistakenly signing up. it is possible that digital recruitment efforts could also have been hampered by other advertising efforts for other causes or campaigns related to covid-19. people could have been suffering from advertising fatigue on a large-scale (patel et al., 2020). the social media platforms were effective as a tool used by the study champion in reaching out to their respective networks of online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 32 rural nurses, however. it is important to note that tracking the social media advertisement metrics was valuable in helping the research team determine the cost-effectiveness of this specific strategy. another important strategy was related to providing multiple modes of providing ‘informed consent’ (verbal consent, text consent) which was especially helpful for rural nurse participants who were too busy to sign and scan a returned consent form. finally, one effective strategy for ensuring that rural nurse participants showed up to interviews was sending text message reminders within one hour of their scheduled interview. again, due to their busy schedules during the pandemic, many rural nurse participants admitted that they almost forgot about their scheduled interviews. recommendations for researchers encountering challenges conducting future research during a pandemic are presented in the following paragraphs. recommendations for recruiting and retaining rural nurses for research based on the findings, the authors share strategies and implications for successful recruitment and retention of rural nurse participants (table 4). benefits for employing these strategies during a pandemic, which is a major unanticipated challenge, are also discussed. table 4 strategies for successful recruitment and retention of rural research participants short-term strategies 1. use a direct, personal recruitment strategy 2. plan for an extended recruitment timeline 3. include multiple methods to obtain consent, 4. plan to be flexible with scheduling interviews 5. plan to be flexible with the interview process long-term strategies 6. cultivate and maintain a network of rural nurses who are interested in research 7. build a culture of research in rural settings 8. identifying and mentoring rural hospital champions for research online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 33 short term strategies use a direct, personal recruitment strategy. personal outreach was the single-most effective strategy for recruiting and retaining rural nurse participants for this study. using personal outreach addressed the high costs of advertising for this project, which was an unanticipated barrier. inviting a rural hospital “champion” with established connections with rural nurses to join our research team was paramount to recruiting participants for our study. our rural hospital champion served as a direct contact with a network of former rural hospital nurses who could participate and attract participants. this more personal approach to recruitment seemed to yield a better response than ads targeted to the broader nurse audience in the state through list servs and newspapers. plan for an extended recruitment timeline. for successful recruitment of nurse participants for research, it is important for researchers to plan for an extended recruitment timeline. our original participant recruitment period was planned to occur during a four-month timeframe. however, it required us nine months to achieve a sample of 10 participants. one other study reported recruiting rural nurses in the appalachia region which consists of three states and six counties (brewer et al., 2020). the authors reported achieving a sample of 15 rural nurse participants during a four month period using a combination of flyers, professional email lists, social media advertisement, and snowball sampling (brewer et al., 2020).the present study’s sample of 10 could have been related to the unique nature of our study (i.e., seeking rural nurses who had experienced a rural hospital closure during a specific timeframe), the smaller population to recruit from given our inclusion criteria, and the conditions we were facing during the pandemic that made face-to-face recruitment not possible, requiring the sole use of online recruitment methods. online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 34 prior to the data collection period, there was only one hospital closure in 2020 in our target state to our knowledge, whereas in previous years there had been multiple closures. there were no additional hospitals at high risk of a closure or in the process of closure, as far as we were aware. one potential future approach for a more successful recruitment phase would be to plan for an extended research participant recruitment timeline and monitor for rural hospital closures in progress, which could be discussed in news sources local to the rural area. it could be possible to collect data from nurses during a rural hospital closure, while it was fresh on everyone’s mind and of interest to everyone before moving on to another job, or before losing hope that a rural hospital could reopen and prosper. include multiple methods to obtain consent. changing the approach from obtaining phone-only consent to offering email consent, i.e., where a participant could email a yes to agree to participate, was helpful in obtaining consent. including the option to obtain consent through email also increased the likelihood that a participant would participate in all phases of the study, including the survey and interview. doing so meant additional considerations regarding the protection of subjects (e.g., having a protocol for permanently deleting email communications). plan to be flexible with scheduling interviews. reminder emails were effective for ensuring participants made it through the entire process of scheduling the interview, taking the questionnaire, and participating in the interview. sending reminder emails and text messages to participants within an hour prior to their scheduled interview was also effective. given the challenges of obtaining a sample from this unique and difficult to reach population, it is important to be more flexible with interview hours, and more flexible with study design, as we changed our initial plan to include focus group to individual interviews only. we were also flexible with the online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 35 time interviews were held to respect participant needs if they worked night shifts, which helped increase the retention of participants throughout the entire study. it was more difficult to schedule an interview than it was for participants to complete the survey. for example, participants would complete the survey and then become hard to contact for scheduling an interview. some potential participants consented to participate but did not respond to follow-up messages about taking the survey and scheduling a time to interview. it was challenging to keep participants engaged in participating or responding to messages related to scheduling and interview. it was also challenging to find a time to schedule for an interview for those who remained interested, although we remained flexible about when interviews were scheduled on our end. the difficulties our nurse participants had with scheduling an interview appeared to be because of having diverse availability and work schedules. nurses from our target population were working at different institutions on different shifts, including night shifts. also, nurses from our target population were especially busy in their current positions responding to patient care needs at the height of the pandemic. in addition, covid-19 vaccinations were in high demand despite a short supply during the last month of our recruitment period, requiring individual efforts to search for a vaccination site and appointment. this was time consuming and high priority for many that could have deterred nurse participation in a research study. plan to be flexible with the interview process. remaining patient, staying on the line, and communicating via email or text was an effective method to managing unanticipated interruptions that occurred during interviews (i.e., call drops, nurse having to leave interview to receive vaccination). this informed participants that the authors were still on and would like to continue the call. sometimes unanticipated interruptions disrupted the flow of the participant’s thoughts as online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 36 they recalled information to share for the study. however, the authors’ method to address this was to continue at the stopping point at the re-scheduled meeting. for difficulties with communication on the phone conference platform (i.e., call drops), it is essential to remain patient and encourage participant to call back when technical difficulties occur and recur. researchers may consider obtaining approval to use another video conference platform if needed. it was helpful to have both phone and video options for the interview, otherwise requiring video-only interviews could have resulted in fewer participants. long-term strategies for strengthening rural nursing health services research for the long-term success of rural nhsr, the authors provide three additional recommendations (with pandemic-related considerations) based on results from this study to recruit and retain more nurses as research participants: (1) cultivate and maintain a network of rural nurses who are interested in research opportunities and (2) build a culture of research in rural settings, and (3) identifying and mentoring rural hospital champions for rural nursing health services research. these recommendations have implications for organizational policies within rural healthcare settings. cultivate and maintain a network of rural nurses for research opportunities for more expedient rural nurse recruitment for research, one idea is to build and maintain research-focused rural nurse networks willing to engage in research and contribute to its continued development. cultivating such a ‘rural research network’ would require formalized partnership among rural health care providers, rural healthcare facilities, and nurse researchers. the rural research network could enable researchers to investigate changes over time due to the phenomenon of interest (i.e., rural hospital closures) and determine its effects. findings could help researchers to design and test clinical, system, and policy interventions to improve patient care. building a online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 37 network of rural nurses interested in research would result in more expedient communication with nurses who may be interested in participating in studies, even during a pandemic. for example, if nurses were part of an email list, opportunities to participate in research could be offered online when face-to-face interaction is not possible. build a culture of research in rural settings it could be beneficial to build a culture of research to include rural nurses in the process of nhsr and educate them about how such research can help improve rural healthcare. this approach would need organizational policies that reward or reinforce nurses’ and nurse leaders’ interest in learning about how to participate in research as an investigator or participant. this could assure that concerns about confidentiality are not a barrier to recruiting and retaining rural nurses as research participants in future studies. developing a culture of research among rural nurses could have broader implications for nhsr and contribute to a sub field of rural nursing health services research (rnhsr). there was not an apparent rural nursing culture of research in place among our selected sample frame, which could have been a barrier to recruiting nurse participants. for example, during the initial phases of the research study, the authors learned that some rural nurses might be hesitant to participate because of concerns about their colleagues learning about their participation and opinions. this lack of understanding could be related to not being familiar with the commitment researchers have regarding confidentiality, and the processes set in place to ensure confidentiality (i.e., the irb). therefore, the authors were certain to overemphasize confidentiality during recruitment, scheduling, and during interviews. online teleconference meeting invitations with toll-free call-in options were used and voice-only interviews were conducted to reduce technological burden and to honor participants’ concerns regarding confidentiality. online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 38 creating and sustaining a culture of research in rural settings could result in greater trust regarding research studies, even during a pandemic. during a pandemic, there is little time for nurses unfamiliar with research to become educated about its purpose. if a culture of research was already established, then nurses would be more comfortable with the idea of participating in research efforts that are confidential and meant to help improve future patient care in rural settings. cultures of research could result in rural healthcare leaders being more receptive to placing nurse researchers on meeting agendas at, for example, local nursing homes or home health agencies, to provide information about opportunities to participate in research. identifying and mentoring rural hospital champions for research identifying a champion to help with recruitment efforts using a personal approach could be useful for future nurse researchers seeking rural research participants. even though there were elements out of our control, such as the occurrence of the covid-19 pandemic, rural hospital champions were effective in personal outreach to recruit and retain rural nurse research participants. rural nursing health services researchers could identify and mentor nurses who are interested in becoming rural research champions to help others understand the research process and make it clear how research could influence future patient care. the benefit of rural nurse research champions, even during a pandemic, is greater interest in nurse participation in research. conclusion recruiting and retaining nurses for a study about rural hospital closures without face-to-face personal contact can be challenging, and more so during a pandemic. the single most effective strategy we employed was harnessing existing social ties with rural nurses through social media, as our sample was derived entirely from personal outreach recruitment efforts by mh and js. it is therefore critical for rural nurse researchers to build and maintain relationships with rural nurse online journal of rural nursing and health care 2021(2) https://doi.org/10.14574/ojrnhc.v21i2.682 39 social networks to help identify, recruit, and retain rural nurses to serve as research participants for rural nursing health services research. acknowledgements our study was supported by the excellence in research award sponsored by the texas organization of baccalaureate and graduate nursing education (tobgne) references albers, l. l., & sedler, k. d. 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(2019). using facebook and linkedin to recruit nurses for an online survey. western journal of nursing research, 41(1), 96-110. https://doi.org/10.1177/0193945917740706 vangeest, j., & johnson, t. p. (2011). surveying nurses: identifying strategies to improve participation. evaluation and the health professions, 34(4), 487-511. https://doi.org/10.1177/0163278711399572 figueroa_658_formatted online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 24 healthcare needs of u.s. rural latinos: a growing, multicultural population cristina maria figueroa, bs 1 alexandra medvin, bs 2 boondaniwon d. phrathep, ms 3 chad w. thomas, bs 4 judith ortiz, phd 5 angeline bushy, phd, rn, faan 6 1student, university of central florida, cristina.figueroa@knights.ucf.edu 2student, university of central florida, anmedvin@knights.ucf.edu 3student, university of central florida, bphrathep@knights.ucf.edu 4student, university of central florida, chadwthomas@knights.ucf.edu 5director, and senior researcher, rural health research group, judy.ortiz@knights.ucf.edu 6professor and bert fish eminent scholar endowed chair in community health nursing, university of central florida college of nursing, angeline.bushy@ucf.edu abstract purpose: from 2000 to 2050, the latino population in the united states (u.s.) is expected to grow by 273%. health outcomes vary widely among latino subgroups and health disparities more adversely affect rural residents. the commonly used “one-size-fits-all” approach assumes that the u.s. latino population is homogeneous. sample, method: rural latinos in four study states: arizona (az), california (ca), florida (fl) and texas (tx) were the focus of this study. this research describes changes in the latino population in rural counties of the u.s. in two dimensions: 1) change in population by number, and 2) change in population by country of origin using data from 2000-2017. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 25 findings: the following themes emerged: 1) the overall latino population grew in each state; 2) rural latino populations in each state also increased but at a higher rate; 3) there is a variety of diversity in the countries of origin of rural latinos based in each state; and 4) a considerable proportion of latinos living in rural areas are of unknown latino origins. conclusions: as the largest racial or ethnic minority in rural populations and as the second largest group in the nation, latino health has a significant influence on the u.s. healthcare system. for nurses, evidence-based strategies can be tailored to address diverse latino subpopulations to reduce specific disparities for various ethnic populations. keywords: nursing, cultural competence, latino health, hispanics, rural health, treatment barriers healthcare needs of u.s. rural latinos: a growing, multicultural population the latino population is projected to make up more than one-quarter of the u.s. population by 2060 (colby & ortman, 2015). from 2000 to 2050 alone, estimates indicate a 273% increase in the proportion of latinos residing in the united states (vega et al., 2009). according to the united states census bureau (2018), by 2017, latinos composed the largest ethnic or racial minority in america, making up 18.1% of the total population, or 58.9 million people. rural areas of the us have also experienced notable trends in growth of their latino populations. as of 2010, latinos became the largest minority group in rural areas, making up 9.3 percent of rural populations (housing assistance council [hac], 2012). while 50% of all latinos indicate that they have no preference for either term, 54% of latinos say they frequently use country of origin terms to characterize their identity by referring to themselves as mexican, puerto rican, cuban, etc. (lopez, 2013). although the terms hispanic and latino may be used interchangeably, for purposes of this research the term latino(s) will be used. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 26 from a historical perspective, as early as the 16th century, latinos began settling in florida, louisiana, and the northern half of mexico (gregory, n.d.). as early as the 1850 census, u.s. citizens of latino origin reported their countries of origin as: mexico, cuba, puerto rico and other countries in central and south america (gregory, n.d.). diversity among latino subgroups is attributed to cultural influences from central america, south america and countries in the caribbean. this diversity includes differences in cultural aspects such as family values, etiquette, spiritual beliefs, holidays, nutritional habits, beliefs about health and teaching or learning implications (clutter & nieto, n.d.). migration of latinos to california, new york, florida, texas and washington, d.c. continued through the 2000’s due to improved job opportunities and as a safe haven from political unrest in their countries of origin (gutiérrez, n.d.; velasco-mondragon et al., 2016). as a result of these migration patterns, high numbers of latinos from a variety of subgroups are now dispersed throughout rural areas of the us in states such as texas, new mexico, north carolina, arizona, colorado, florida and california (saenz, 2008). brown & lopez (2013), found that at least 55% of the latino population in the us identify california, florida and texas as their home state. latinos, as a whole, have a higher probability of experiencing advanced conditions of chronic disease and are more vulnerable to public health crises such as covid-19. as of july 2020, latinos were 4.6 times more likely to be hospitalized with a covid-19 diagnosis compared to non-hispanic whites and made up 33% of all cases in the us (despres, n.d.). rural health care providers, including nurses, are often not aware of the diversity in health risks within their local latino population. according to previous studies from the national council of la raza (2014), the complexity of latinos with regard to country of origin, race and other demographic or cultural components significantly impacted their health. in other words, online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 27 disease prevalence varies among latino subgroups, which can pose a unique barrier for rural primary care providers. it is imperative that rural healthcare providers avoid the traditional one-size-fits-all approach when working with latinos. instead, caregivers must learn how to creatively interact with diverse rural populations to adequately support unique healthcare expectations and needs (national council of la raza, 2014). not only are there differences among rural latinos culturally but there are also variations in respect to their health outcomes from cancer, cardiovascular disease, diabetes and liver disease (centers for disease control and prevention [cdc], 2015). health behaviors can vary by latino subgroup and subsequently screening approaches and treatment plans will be diverse (cdc, 2015). differences in social determinants of health must also be taken into account as these factors contribute to challenges rural latinos may confront when trying to manage chronic disease(s) (cdc, 2015; national council of la raza, 2014). by not acknowledging the health risks among latino subpopulations, inadequate or inappropriate health promotion contribute to less than optimal health outcomes and additional economic burdens on the u.s. health system. by 2050, estimates suggest health disparities among latinos and blacks will lead to an additional $50 billion-dollar economic burden on the u.s. healthcare system (waidmann, 2009). ineffective communication by health care providers contributes to patient misunderstanding. effective communication should take into consideration social determinants including a person’s level of education, language skills, financial situation, social circumstances as well as racial or ethnic identity. when a health care provider is unable to “bridge the gap” and meet the patient’s needs based on their circumstances, it is less likely the patient will engage in long-lasting behaviors to improve their health. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 28 the purpose of this research is to describe the change in the latino population in rural areas of the us in two dimensions: 1) change in population by number, and 2) change in population by country of origin. most studies focus on culturally tailored disease management programs for latinos as a whole while few consider variations among latino subgroups and even fewer examine those living in rural communities. one strategy reported the use of community health workers to extend the service of rural providers outside of the clinical setting, so that latino patients have access to education on managing or preventing health risks (velasco-mondragon et al., 2016). language skills for providers and health literacy workshops for patients have also played roles in increasing healthcare access to latinos, leading to improvements in patient outcomes (velasco-mondragon et al., 2016). these types of initiatives targeting rural latino residents are examples of positive steps towards addressing the healthcare needs of this group. other ideas to increase patient outcomes includes expanding healthcare policy to increase access to health insurance, providing access to medical interpreters, providing access to telehealth services, development of preventive care programs and further research on latino life to better inform healthcare policy and clinical interventions (cdc, 2015). in the first step to improving health outcomes for rural latinos, we will describe the diversity in rural areas, by examining the cultural differences among latinos and discuss possible implications those differences have in the provision of healthcare services. the intent is to provide rural healthcare communities in the us with information on the diversity of the rural latino landscape, and how it impacts the provision of culturally sensitive clinical services. despite their shared histories and commonalities of language, the latino population represents broadly varying cultures, making it essential for nurses and other providers of the healthcare online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 29 team to understand that “one-size-fits-all” treatment interventions may not be as effective as those that are more culturally tailored. in summary, the latino population is projected to grow throughout the us, including in rural areas. the latino population is composed of several subgroups based on country of origin, each of which may have different health behaviors. it is important that healthcare providers develop an appreciation for the growth of the latino population, and an understanding of how latino subgroups may affect prevention and treatment of health conditions. this study addresses the following research questions: 1. over the past decade, how has the total population of latinos in the rural us changed? 2. how has the rural u.s. latino population changed based on countries of origin? methods the study was designed as a comparison of available u.s. population data for three time periods: 2000, 2010 and 2017. for each year, data on the number of latinos in the rural us and the composition of the rural latino population by country of origin were collected, organized, and qualitatively compared. demographic data for u.s. rural latinos were filtered by year, rural county and total population size using the sources provided in data sources section. this information was analyzed by collecting the state and county populations in addition to the previously mentioned filters to better understand how the u.s. latino population composition has changed between 2000-2017. according to the u.s. census bureau, hispanic or latino refers to individuals in the us of “cuban, mexican, puerto rican, south or central american, or other spanish culture or origin regardless of race” (united states census bureau, n.d., para 1). once the population information was collected for latinos overall as well as the main latino subgroups using state and county filters, it was organized into the tables and graphs seen in the results section. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 30 design and measures the study was designed as a comparison of available data for three time periods: 2000, 2010 and 2017. from the dataset of over 6,000 demographic variables provided by the area health resources files (ahrf), four variables were selected and filtered from the population category for the analysis: census population, latino population, percent of latino population, and latino origins. the ahrf defines origins as the “heritage, nationality group, lineage or country of birth of the person or the person’s parents or ancestors before their arrival in the u.s.” (united states census bureau, n.d., para 1) the variables used from the acs 2017 5year estimates included, demographic and housing estimates. in these estimates under race then hispanic or latino and race, information is provided on the number of latinos counted by country of origin (mexican, puerto rican, cuban, other hispanic or latino). in addition, four variables were created for each individual study state. that is, each individual numerator and denominator is a state total. the four constructed variables are as follows: % rural latino population (rural demographic) (equals total number of rural latinos divided by total rural population.), % rural latino population (state demographic) (equals total number of rural latinos divided by the total state latino population), % country of origin (total rural country of origin/total rural latino population), and % other country of origin (total rural latino population minus total latino population in known countries of origin; total rural other country of origin/total rural latino population). this variable was calculated for 2000 and 2010 only; for 2017 the acs survey included an other category for countries of origin which already combined dominican republic and other countries. sample and setting the population of interest includes latinos residing in all rural counties in the us. the sample constitutes rural latinos residing in 229 rural counties of four study statesarizona, online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 31 california, florida and texas (federal office of rural health policy, 2018). these states were chosen based on reports of high-density populations of latinos found in southern and southwestern states. according to the federal office of rural health policy (n.d.), the u.s. census, the data source used, does not specifically define rural and designates rural as all areas not considered to be urban. the u.s. census outlines that urbanized areas (uas) are those with 50,000 people or more and urban clusters (ucs) are those that have populations of at least 2,500 but lower than 50,000 (federal office of rural health policy, n.d.). to designate the counties as rural, the federal office of rural health policy, uses two methods (federal office of rural health policy, 2018). the first uses the office of management and budget’s definition (ombs), which uses metropolitan, micropolitan, or neither to categorize counties of the united states. those that are considered rural are micropolitan or neither. micropolitan areas are those with an urban core containing a population of at least 10,000 but less than 50,0000. neither refers to counties that do not fall under metropolitan or micropolitan. for reference, counties designated as a metropolitan area are those that contain an urban core location that has a population of 50,000 or more. the second method aims to account for overcounts and undercounts by describing rural counties within metropolitan areas using rural urban commuting area codes (rucac) codes. geographical areas known as census tracts with ruca codes 4-10 are designated as rural. this study received ethics approval from a university institutional review board (sbe-17-13475). data sources data were collected from three sources: the health resources & services administration (n.d.), area health resources files (ahrf) for 2014-2015 and 2018-2019; and the united states census bureau’s 2017: acs 5-year estimates data profiles from the american community survey (acs) demographic and housing estimates. the ahrf files are a online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 32 collection of over 50 data sources that provides information on more than 6,000 county-level variables related to demographic and health-related factors. the ahrf data source provides many pre-constructed variables that were used along with variables we constructed to identify and analyze trends of proportions among the latino population in rural counties. the acs, created by the u.s. census bureau, collects information from millions of households across a wide scope of geographic areas to generate data on social, economic, housing and demographic subjects, 48 in total. the acs 5-year estimate is the most reliable compared to the 1-year estimate and provides the largest sample size. this dataset provided the research with county level geographic information of the proportions of latinos by their countries of origin in rural counties of the united states. the information found in the 2017: acs 5-year estimates data profiles in all states are estimates using data collected from u.s. census surveys throughout 5 years, 2013-2017. analysis the analysis was conducted in two stages. in the first stage, summary statistics were calculated to describe how the latino population in rural areas has grown between 2000, 2010 and 2017. for each of the study states, data were captured for counties that were designated as rural by the federal office of rural health policy as of 2018. the latino population in the rural areas was then determined as a percentage of the total rural population for the years 2000, 2010 and 2017. the resulting values and percentages are reported in table 1, figure 1 and figure 2. in the second stage, proportions were calculated from the data collected to illustrate how the composition of the rural latino population has changed based on country of origin. for each of the study states, the percentage of the rural latino population that reported their country online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 33 of origin as being mexico, puerto rico, cuba, or other was calculated. the resulting values and percentages are reported in table 2, figure 3 and figure 4. results data on the latino population in rural counties of arizona, california, florida and texas were examined and compared for 2000, 2010 and 2017. the growth of the latino population, and the change in countries of origin of the population were assessed. the following results emerged: 1) the total latino population grew in each of the study states; 2) rural latino populations in each state also increased but by a higher percentage rate; 3) there is a variety of diversity in the countries of origin of rural latinos based on state; and 4) a considerable proportion of latinos living in rural communities are of unknown countries of origin and are not reported by a single country as of the 2019 acs estimates (table 1, figure 1, figure 2, table 2, figures 3 and 4). table 1 describes the latino population and the rural latino population for each of the study states by number and percentage of the total. each of the four study states experienced at least 5 6% in growth in the latino population from 2000 to 2010 (table 1). from 2010 to 2017, the study states experienced growth in their latino populations as well, but at a slower rate of 1-4%. these population changes for each state are graphically illustrated in figure 1. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 34 table 1 rural latino populations by state 2000, 2010, 2017 variable arizona california florida texas total a2000 a2010 b2017 a2000 a2010 b2017 a2000 a2010 b2017 state population 5,130,632 6,392,017 7,016,270 33,871,648 37,253,956 39,536,653 15,982,378 18,801,310 20,984,400 20,851,820 25,145,561 28,304,596 state latino population 1,295,617 1,895,149 2,202,173 10,966,566 14,013,719 15,477,306 2,682,715 4,223,806 5,370,860 6,669,666 9,460,921 11,158,751 cnumber of rural counties 7 21 23 178 rural population 318,360 346,130 347,797 796,198 845,229 4,158,132 646,744 706,998 965,981 2,896,664 3,048,790 2,995,374 rural latino population 67,836 84,711 87,586 90,875 132,988 1,371,684 68,563 96,995 135,455 779,142 959,835 997,453 percentages state latino population 25% 30% 31% 32% 38% 39% 17% 22% 26% 32% 38% 39% drural latino population (rural demographic) 21% 24% 25% 11% 16% 33% 11% 14% 14% 27% 31% 33% erural latino population (state demographic) 5% 4% 4% 1% 1% 9% 3% 2% 3% 12% 10% 9% note. astate pop., state latino pop., rural pop. & rural latino pop. totals for 2000 and 2010 in all states are actual counts from the u.s. census (2014-2015 area health resources files). bstate pop., state latino pop., rural pop. & rural latino pop. totals for 2017 in all states are estimates from the u.s. census bureau using data from census 2010 (2018-2019 area health resources files). ctotal number of rural counties reported by the u.s. census for 2000 and 2019 are not available. drural latino population (rural demographic) equals total number of rural latinos divided by total rural population. erural latino population (state demographic) equals total number of rural latinos divided by the total state latino population. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 35 rural counties within each state experienced higher rates of growth in their latino populations. there was a total of 229 rural counties throughout the four states. as of the 2010 u.s. census, latinos made up at least 14% of the total rural population in these states. based on 2017 acs estimates, latinos made up between 26-39% of the local rural populations (table 1, figure 1). california had the highest percentage point gain (5%) from 2000 and 2010 in the total rural latino population (table 1). from 2010-2017 california continued to have the highest percentage increases in the total rural latino population (table 1). california’s rural latino population grew by 17% while those in arizona, florida and texas grew by 0-2% during that time period. figure 1 change in total latino population, az, ca, fl, tx: 2000 and 2017 figure 2 illustrates the change in total rural latino population in arizona, california, florida and texas between 2000-2017. the percentages calculated in this graph are weighted population averages, weighted by the population of rural counties. in 2000 and 2010, the study online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 36 states with the greatest proportions of rural latinos were arizona (21%, 24%) and texas (27%, 31%), respectively. the states in the study with the greatest rural latino proportion in 2017 were california and texas, both at 33%. california had the largest change in its rural latino population between 2010 and 2017, at 17%. florida had the lowest proportion of rural latinos between 2000 and 2017 overall, and the lowest rate of growth. figure 2 change in total rural latino population, az, ca, fl, tx: 2000 and 2017 table 2 describes how the composition of rural latino populations has changed based on country of origin. for each state, rural latinos were categorized into one of three countries of origin: mexico, puerto rico and cuba. for 2000 and 2010, a fourth other category was created to classify latinos whose country of origin was the dominican republic or an unspecified country in central or south america. for 2017, the estimates were taken directly from the acs data source. for all the study states, the largest latino subgroup for both 2000 and 2010 continued to be persons of mexican origin. the second most highly represented country of online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 37 origin category for both years was other the subgroup whose countries of origins are not specifically defined. when the other category was not considered, puerto rico was the second most highly represented country of origin, followed by cuba. florida stood out as a state with the most variety of countries of origin represented in rural areas. although rural latinos in florida were mostly from mexico, compared to the other study states, this state had the highest proportion of rural latinos with puerto rican and cuban origin in 2000 and 2010. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 38 table 2 countries of origin for rural latino populations for az, ca, fl, tx, in 2000, 2010, & 2017 origin arizona california florida texas total a2000 a2010 b2017 a2000 a2010 b2017 a2000 a2010 b2017 a2000 a2010 b2017 mexico 54,670 76,160 80,856 74,398 111,578 1,204,497 39,289 57,291 67,344 582,561 838,870 912,775 puerto rico 318 527 645 1,507 2,372 16,056 6,092 8,794 17,246 2,455 4,834 15,712 cuba 88 136 264 528 600 4,781 11,165 15,495 23,212 1,096 1,529 2,774 cother 12,760 7,888 5,221 14,442 18,438 97,912 12,017 15,415 20,769 193,030 114,602 53,307 percentages mexico 81% 90% 93% 82% 84% 91% 57% 59% 52% 75% 87% 93% puerto rico 0% 1% 1% 2% 2% 1% 9% 9% 14% 0% 1% 2% cuba 0% 0% 0% 0% 1% 16% 16% 18% 0% 0% 0% other 19% 9% 6% 16% 14% 7% 18% 16% 16% 25% 12% 5% note. country of origin totals and percentages for 2000 and 2010 in all states are actual counts from the u.s. census (2014-2015 area health resources files). bcountry of origin totals and percentages for 2017 in all states are estimates from the u.s. census bureau using data from census 2010 (acs demographic and housing estimates2017: acs 5-year estimates data profiles). cother includes latinos from the dominican republic as well as unspecified countries in central and south america online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 39 for all the study states, the largest latino subgroup for both 2000 and 2017 continued to be persons of mexican origin (figure 3, figure 4). the state with the highest average proportion of rural latinos identifying mexico as their country of origin was arizona, whereas the state with the lowest average was florida. florida’s rural population has the highest proportion of those from puerto rico and arizona has the lowest. the greatest number of rural latinos reporting cuba as country of origin live in florida. overall, as reported in table 2, the findings indicate that a majority of rural latinos in all study states identify mexico as their country of origin. the second most highly represented country of origin category for both years was other the subgroup whose countries of origins are not specifically defined. the proportions of country of origin in rural latinos living in florida are more varied. florida had the highest proportion of rural latinos with puerto rican and cuban origin in 2000, 2010 and 2017. florida also had the greatest number of rural latinos from unknown countries of origin (figure 3, figure 4). figure 3 countries of origin for rural latino populations of az, ca, fl, tx in 2000 online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 40 figure 4 countries of origin for rural latino populations of az, ca, fl, tx in 2017 discussion as of 2017, latinos made up an average of 33% of state populations in arizona, california, florida and texas compared to average rural latino populations of 26%. although the average state latino population is higher than the average rural latino population across study states, the rate of growth in the rural latino populations was higher than the rate of change in state proportions. state latino populations among the study states between 2000 and 2017 increased by 4-6% while rural latino populations exhibited growth rates of 5-17% within the same time period. there are many factors that may contribute to this continued growth. foreign-born latinos may be drawn to u.s. rural areas by the prospect of finding readily available work so as to earn money to send back to their families. within the us, latinos in urban areas who have limited english fluency, limited work experience, and/or lack of u.s. citizenship may choose to relocate to rural communities in search of a higher quality of living online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 41 (johnson, 2006). yet another factor is that aging rural populations in the us create a demand for laborers skilled in industries common to rural economies such as agriculture, construction, service and food processing (johnson, 2006; parrado & kandel, 2010). the composition of the rural latino population by country of origin varied from state-tostate in the study sample. as in the past, latinos of mexican origin were the largest group in all four study states. however, florida’s rural latino population stood out as having the greatest diversity. this diversity may be explained by florida’s close geographic proximity to the caribbean and its climate being similar to that of latino immigrants’ home countries. in addition to persons of mexican origin, individuals from cuba, puerto rico and other unspecified latin american countries are represented. it is unknown if the proportions of diversity have equal representation from all countries in latin america. what is known, based on growth of latinos in rural areas, is that the varying diversity among latino subgroups is contributing to the cultural identity of those rural communities, each county unique. with the dispersion of latinos in rural as well as urban areas, it becomes more critical that nurses and other members of the healthcare team develop tailored approaches to addressing the variety of cultures they represent. a common misconception is that u.s. latinos share a single identity. on the contrary, they represent a multitude of cultures and express the variety of attitudes and healthcare behaviors that exist in the caribbean and throughout latin america (clutter & nieto, n.d.). while much is known about the healthcare beliefs of latinos as a whole, less is known about the distinctions in health outcomes of subgroups within the latino community. this lack of knowledge may lead to a generalized treatment approach and may diminish the effectiveness of prevention and management of chronic diseases such as diabetes. a 54% increase in the prevalence of diabetes in the us is expected between 2015-2030 (rowley et al., 2017). what’s online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 42 more, it can be expected that a large portion of the persons with diabetes will be latinos, possibly including rural latinos of varying origin subgroups (sadowski et al., 2012). according to previous research, diabetes is a research topic of focus for latino patients in growing rural midwest communities (sadowski et al., 2012). in other reports, health indicators have varied between latino subgroups (cuban, mexican and puerto rican), highlighting the need to acknowledge their differences (hajat et al., 2000). the estimated increase in rural latino residents with chronic conditions such as diabetes prompts the need for culturally conscious clinical services to avoid overwhelming rural health systems and to improve latino health. this expected increase in rural latino residents with diabetes prompts the need for a better understanding of latino subcultures and how they affect health behaviors such as symptom presentation and communication dynamics (fortuna, n.d.). in addition to the barriers faced by patients with chronic disease, large proportions of latinos in rural communities are also diabetic and lack adequate health insurance (sadowski et al., 2012). in exploring the role of culture in lifestyle behaviors of latino patients with type 2 diabetes, researchers have found that mexican-americans were the focus of many studies, and that not enough is known about latino subgroups in regard to lifestyle behaviors, health outcomes and acculturation measures (pérez-escamilla & putnik, 2007). the same study noted that the stark differences in the role of acculturation in dietary intake, physical activity, smoking/alcohol consumption and obesity are largely the result of differences among latino subgroups. in a study examining social support and exercise, it was found that research gaps remain to improve understanding of how healthcare outcomes and socioeconomic factors differ in puerto rican and mexican latino subgroups (craven et al., 2018). another study investigated general diabetes knowledge among rural latinos, finding that levels of diabetes health literacy differed greatly when comparing patients from mexico to online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 43 those from costa rica. this lack of knowledge directly impacted their ability to comply with plans for healthcare treatment (ceballos et al., 2010). nurses and other types of health care providers who are not knowledgeable about cultural differences among latino subgroups may make assumptions about patients that lead to poorer health outcomes. in contrast, when providers address healthcare concerns of latino patients through culturally-sensitive health services and improved provider-patient communication, promising results may be achieved. for example, in a study of patients with diabetes and limited english proficiency, lower blood sugar levels were attained when cultural competency training for providers along with culturally tailored diabetes education for patients were employed (mcelmurry et al., 2009). in this study, patients are more willing to engage in lifestyle behavior changes when they perceive their healthcare providers to be culturally sensitive. while there is much variation within the latino population as related to country of origin, latinos are an ethnic group that places high value on personal connections and relationships, so that cultural mistrust of healthcare providers may easily arise when cultural competency is lacking (juckett, 2013). one limitation of this study was that the available data lacked detail about the composition of the other country of origin category for urban or rural latinos. also, although we used the most recent data available from our u.s. census-based data sources, we were able to compare the years 2000, 2010 and 2017 only. as additional data become available after the 2020 u.s. census, individual time periods would need to be analyzed to reveal patterns of population growth of rural latinos and more detail about the composition of that population. analyzing how regional differences might impact the latino population and barriers faced by latinos when transitioning to non-latino areas would also add to the research gaps on this topic. online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 44 despite the limitations of this research, it has several strengths. it is one of the few studies to describe the diversity within the rural latino population. much of the previous research describes latinos as a whole, without consideration for county-of-origin differences in the provision of healthcare services. secondly, it is one of the few studies to address the rural latino population of florida. creating effective healthcare programs and policy requires an appreciation of the whole spectrum of values, attitudes and beliefs of the u.s. latino population. more culturally nuanced approaches to healthcare for latinos may contribute to improving patient management of chronic diseases and lowering national healthcare spending attributed to chronic diseases. by broadening the knowledge of the diversity within the rural latino population, all healthcare providers may be better prepared to create and deliver tailored interventions for latino patients in the future. funding the analysis for this paper was supported by the national institute on minority health and health disparities of the national institutes of health under award number r15md011663. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. references brown, a., & lopez, m. h. 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(2015, march). projections of the size and composition of the u.s. population: 2014 and 2060. united states census bureau. https://census.gov/content/dam/census/library/publications/2015/demo/p25-1143.pdf craven, m. r., keefer, l., rademaker, a., dykema-engblade, a., & sanchez-johnsen, l. (2018). social support for exercise as a predictor of weight and physical activity status among puerto rican and mexican men: results from the latino men’s health initiative. american journal of men's health, 12(4), 766-778. https://doi.org/10.1177/1557988318754915 despres, c. (n.d.). coronavirus case rates and death rates for latinos in the united states. salud america!. https://salud-america.org/coronavirus-case-rates-and-death-rates-forlatinos-in-the-united-states/ federal office of rural health policy. (2018, december 31). list of rural counties and designated eligible census tracts in metropolitan counties. health resources & services administration. https://www.hrsa.gov/sites/default/files/hrsa/ruralhealth/resources/for hpeligibleareas.pdf federal office of rural health policy. (n.d.). defining rural population. health resources & services administration. https://www.hrsa.gov/rural-health/about-us/definition/index .html online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 46 fortuna, l. (n.d.). working with latino/a and hispanic patients. american psychiatric association. https://www.psychiatry.org/psychiatrists/cultural-competency/education /best-practice-highlights/working-with-latino-patients gregory, j. (n.d.). latinx great migrationshistory and geography. university of washington. https://depts.washington.edu/moving1/latinx_migration.shtml gutiérrez, d. g. (n.d.). a historic overview of latino immigration and the demographic transformation of the united states. national park service u.s. department of the interior. https://www.nps.gov/heritageinitiatives/latino/latinothemestudy/immigration .htm hajat, a., lucas, j. b., & kington, r. (2000). health outcomes among hispanic subgroups: data from the national health interview survey, 1992-95. (no. 310). us department of health and human services, centers for disease control and prevention, national center for health statistics. health resources & services administration (n.d.). area health resources files (ahrf). [data sets 2014-2015; 2018-2019]. https://datawarehouse.hrsa.gov/topics/ahrf.aspx housing assistance council (hac). (2012, april). rural research brief: race and ethnicity in rural america. http://www.ruralhome.org/storage/research_notes/rrn-race-and-ethnicityweb.pdf johnson, k. m. (2006). demographic trends in rural and small-town america. carsey institute, university of new hampshire. https://scholars.unh.edu/cgi/viewcontent.cgi?article= 1004&context=carsey juckett, g. (2013). caring for latino patients. american family physician, 87(1) 48-54. https://www.aafp.org/afp/2013/0101/p48.html online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 47 lopez, m. h. (2013, october 28). hispanic or latino? many don’t care, except in texas. pew research center. https://www.pewresearch.org/fact-tank/2013/10/28/in-texas-itshispanic-por-favor/ mcelmurry, b. j., mccreary, l. l., park, c. g., ramos, l., martinez, e., parikh, r., kozik, k., & fogelfeld, l. (2009). implementation, outcomes, and lessons learned from a collaborative primary health care program to improve diabetes care among urban latino populations. health promotion practice, 10(2), 293-302. https://doi.org/10.1177/ 1524839907306406 national council of la raza (nclr). (2014). an inside look at chronic disease and healthcare among hispanics in the united states of america. latino coalition for a healthy california. http://www.lchc.org/wp-content/uploads/chronic_disease_report_2014.pdf parrado, e. a., & kandel, w. a. (2010). hispanic population growth and rural income inequality. social forces, 88(3), 1421-1450. https://doi.org/10.1353/sof.0.0291 pérez-escamilla, r., & putnik, p. (2007). the role of acculturation in nutrition, lifestyle, and incidence of type 2 diabetes among latinos. the journal of nutrition, 137(4), 860-870. https://doi.org/10.1093/jn/137.4.860 rowley, w. r., bezold, c., arikan, y., byrne, e., & krohe, s. (2017). diabetes 2030: insights from yesterday, today, and future trends. population health management, 20(1), 6-12. https://doi.org/10.1089/pop.2015.0181 sadowski, d., devlin, m., & hussain, a. (2012). diabetes self-management activities for latinos living in non-metropolitan rural communities: a snapshot of an underserved rural state. journal of immigrant and minority health, 14(6), 990-998. https://doi.org/ 10.1007/s10903-012-9602-x online journal of rural nursing and health care, 21(1) https://doi.org/10.14574/ojrnhc.v21i1.658 48 saenz, r. (2008). a profile of latinos in rural america. carsey institute, university of new hampshire. fact sheet 10. https://scholars.unh.edu/cgi/viewcontent.cgi?article=1034& context=carsey united states census bureau. (n.d.). about hispanic origin. https://www.census.gov/ topics/population/hispanic-origin/about.html#:~:text=omb%20defines%20%22 hispanic%20or%20latino,or%20origin%20regardless%20of%20race united states census bureau (2017). american community survey demographic and housing estimates2017: acs 5-year estimates data profiles. [data set]. https://data.census.gov/cedsci/table?tid=acsdp5y2017.dp05&hidepreview=true united states census bureau. (2018, september 12). profile american facts for features: hispanic heritage month 2018. https://www.census.gov/content/dam/census/newsroom/ facts-for-features/2018/hispanic-heritage-fff.pdf vega, w. a., rodriguez, m. a., & gruskin, e. (2009). health disparities in the latino population. epidemiologic reviews, 31(1), 99-112. https://dx.doi.org/10.1093%2fepirev%2fmxp008 velasco-mondragon, e., jimenez, a., palladino-davis, a. g., davis, d., & escamilla-cejudo, j. a. (2016). hispanic health in the usa: a scoping review of the literature. public health reviews, 37(1), 31. https://doi.org/10.1186/s40985-016-0043-2 waidmann, t. (2009). estimating the cost of racial and ethnic health disparities. the urban institute. https://www.urban.org/sites/default/files/publication/30666/411962-estima ting-the-cost-of-racial-and-ethnic-health-disparities.pdf 95 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 culturally sensitive health promotion plan for tuberculosis prevention and treatment in mexican migrant farm worker populations john e. hess, msn, arnp-c 1 1 dnp student, college of nursing, university of south florida, jehess@mail.usf.edu key words: migrant farm worker, tuberculosis, cultural sensitivity, cultural healthcare practices abstract tuberculosis (tb) is re-emerging as a national health priority. healthcare providers have been attempting to address the challenge of providing preventative care as well as addressing tb cases through long-term treatment plans as these cases are identified. the migrant farm worker population has come into the spotlight as highly vulnerable to this disease with highly unsuccessful outcomes in prevention and treatment. many factors contribute to this disturbing trend, including barriers related to a specific lack of cultural competence amongst health care providers for this specific patient population and patient related barriers associated with cultural beliefs, logistics such as transportation and clinic locations, and the transient nature of the farm worker lifestyle. thus innovations to address these barriers to services are needed. there is a need to develop unorthodox service provision locations as well as the provision of appointment times that are suitable to the workers’ needs. interventions such as reducing wait times, providing meaningful incentives and the renovation of disease specific educational approaches may improve outcomes. treatment strategies that incorporate the cultural beliefs and practices of this population may narrow the service gap considerably. the purpose of this case study presentation is to illustrate the issues associated with providing tb treatment to this vulnerable patient population and to discuss possible solutions and interventions to stimulate culturally competent communication and care. introduction two of the many challenges facing rural healthcare providers include the plight of migrant farm workers and the virulent resurgence of tuberculosis. these two challenges have combined to stress an already fragile network of health care systems as providers attempt to meet the problems of identification, treatment, tracking, and prevention in a constantly migrating patient population. cultural sensitivity in health planning, communication and intervention is instrumental in making a meaningful connection with migrant farm worker patients. the following case study will illustrate some of the inherent problems that a health care provider may face when caring for a migrant patient with tb. the problem over the past five decades migrant farm workers have presented quite a complex problem for health officials. villarejo (2003) found that even as late as 2001 there had not been any national statistics gathered on the size of the population, or its chronic health indicators. there are approximately 3-5 million migrant farm workers and their families living in the u.s. it is estimated that fifty percent of them are undocumented. the author also stated that the federal migrant health program was serving only about thirteen percent of workers and their families. migrant workers, mostly comprised of hispanics of mexican descent, struggle with many issues http://health.usf.edu/nocms/nursing/ mailto:jehess@mail.usf.edu 96 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 that contribute to under service, such as: transience, severe financial limitations, illegal immigration status, isolation in their work and home settings, language barriers, and cultural norms and barriers limiting expansion of traditional folk themes (gwyther & jenkins, 1998). the healthcare service organizations also have factors that compound the inadequacy of services. the case jose, a 42-year-old mexican national migrant farm worker, presented to a health department of a rural county with a chief complaint of inability to work up to par due to fatigue and shortness of breath. jose’s inability to function at his previous high level motivated his foreman, raphael, to bring him to the health department. further questioning, with the assistance of raphael acting as an informal translator, revealed that jose has become fatigued, weak, short of breath and has recently developed a blood-tinged productive cough. jose also reports experiencing chills, night sweats, a subjective low grade fever and a loss of appetite. his sputum is reported as thick, cloudy, and most often, bloody. the cough started approximately 6 weeks ago and progressively worsened over time. his weakness and fatigue led to low productivity on the job and ultimately, the visit to the health department. given that jose had the classic symptoms of tb, protective masks were put into use and a certified translator is summoned to the exam room. with the help of an experienced and empathetic medical translator, jose reveals a significant family history of tb and diabetes. jose is single and migrated from a very poor part of southern mexico. his father had recently died from uncontrolled diabetes and had a persistent cough at his time of death. jose, his mother, sister, and brother had all persistent coughs and were supposedly treated for tb approximately 10 years ago. jose is unsure of the medications used and the duration of treatment. jose further reports that he had returned to mexico 3 months ago for a short visit after his father’s death, returning to the us 6 weeks ago to continue working. given this history, the epidemiology department was asked to join in the evaluation. cultural domains five cultural domains were chosen to elaborate on the health problems associated with tuberculosis in the migrant population including communication, workforce issues, high-risk behaviors, healthcare practices, and barriers presented by the healthcare system itself. these domains are interconnected and exacerbate each other, weaving a stranglehold on efforts to stop the transmission and treatment of this deadly disease. mexican migrant farm workers tend to be non-english speaking, extremely poor, and illiterate. guasasco, heuer, & lausch (2002) stated that because of this and the isolation of their work and housing sites, migrant workers tend to have minimal access to media or awareness of health education. the authors explained that communication between these close-knit family groups often lapse for many months with little extra familial contact as well. transmission of health related information is limited, and written materials are useless as most people do not read, or write, at a level to understand health information pamphlets. the family is the center of most farm worker’s life. guasasco, heuer, and lausch (2002) describe the traditional structure of the mexican family system as patriarchal by form, with the family as the focus of work and lifestyle. positive, up-beat relationships and strong relationships 97 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 between extended family members and close friends, along with the strong leadership of the men, give the family its priorities and values. guasaso, heur and lausch describe the roles of men as workers, women as child bearers and caregivers, with a high value placed by both on productive work. men do not seek nonemergent health care, as it takes them away from the fields. women seek healthcare primarily for childbirth or for a sick child. medical appointments can take up to a full day because of the waiting times in clinics. workforce issues are numerous: long hours of backbreaking work in fields; cramped transportation for long hours in trucks to and from fields; heat and exhaustion factors; exposure to agriculture toxins (insecticides, fungicides, herbicides) which may decrease immune function; and seasonal migration between harvests resulting in disruption of healthcare continuity. villarejo (2003) found the above factors to be compounded by a lack of employer-provided health insurance and a lack of worker inservice training on health issues including toxin exposure management or hygiene, as well as language barriers, isolated locations, and an inability of migrants to pay for services. given these factors, it is easy to understand how migrants may view healthcare as a low priority unless it is emergent in nature. many normal daily activities of farm worker families are classified as high-risk behaviors due to their cultural and healthcare practices. transience leads to lack of follow-through and loss of patient contact with healthcare practitioners (department of health and human services [dhhs], 1992; connor, et al., 2007). periods of intense close-quartered communal living with several other families in substandard dwellings can lead to an increase in disease communicability and diminishing hygiene practices (guasaco, heuer, & lausch, 2002). cultural healthcare practices have been identified as contributing factors to the growing epidemic of tb (joseph et al., 2008). tb has an insidious onset of symptoms. a chronic cough does not prevent a worker from being in the fields, a mother from tending to her children, or a child from performing their role in the family. secondly, as previously noted, this culture does not tend to proactively seek preventive care or nonemergent care. they often rely on folk healing remedies (rodriguez, 1998). the early symptoms of tuberculosis would not trigger an emergent need for medical care and, thus, could go untreated for several years before the symptoms drive the patient into the healthcare setting. thirdly, when a person becomes hospitalized due to symptoms, there is loss of contact with family due to transportation and isolation factors. weathers (2003) found that fear of isolation could contribute to a postponing of treatment because the social consequences are so high. the last domain to be explored in this paper is that of the healthcare system itself as a contributing factor. healthcare practices for low-income populations are not geared to be culturally sensitive (rodriguez, 1993; castro & ruiz, 2009). rodriguez found relationships between patient and practitioner to be fraught with difficulties due to language problems, the inflexibility of site-based care provision, lack of childcare at sites, and an environment insensitive in approach to care and treatment or education. castro and ruiz (2009) reported that patient satisfaction has been identified as a key element to increasing a patient’s utilization of medical care. the authors state that the inadequate cultural competence training of providers creates a disparity in the therapeutic provider-patient bond. characteristics reported by both provider and patient are distrust, misperceptions, misunderstanding, and low follow through rates. these issues, compounded by the transient nature of the farm worker’s life, has lead to a lack of successful interjurisdictional care coordination for this patient population which has significantly impaired successful treatment outcomes for tb among migrant workers and their families. 98 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 finally, even the primary health goals of the farm workers and the u.s. government are at odds. healthy people 2010 (u.s. dept. of health and human services, 2000) recommended several goals and priorities for healthcare, including the eradication of tb and a significant decrease in obesity and diabetes rates for all adults. tuberculosis, obesity, and diabetes are all preventable diseases commonly seen in mexican migrant farm worker families. these are not recognized as health priorities among migrants until they trigger a situation that greatly disrupts the family (guasasco, heuer, & lausch, 2002; weathers, 2003; wilson et al., 2000). detecting and preventing tb is difficult in migrant farm workers. the combination of the issues within the five domains makes identification and prevention/treatment a complex and complicated process. its insidious nature contributes to desensitization and discounting of risk factors or symptoms until significant damage is done to the body and there has been long-term transmission of the bacteria to others (wyss & alderman, 2006). the extended course of medication for treatment leads to noncompliance issues, which may be contributing to the increase in antibiotic resistant strains of tb (restrepo et al., 2007). the dhhs conducted a survey over the past fifteen years which revealed that the “risk of tb among farm workers was estimated to be six times that of the general population” (3). their testing showed that 35% of migrant farm workers in north carolina have positive skin tests with 68% being in those over the age of 34. the standard course of treatment for uncomplicated tb is a six-month regimen of an antibiotic cocktail. ongoing tests of sputum and blood draws are required to determine drug resistant strains of tb and hepatoxicity (kandula et al., 2004). kandula, et al. (2004) noted that patients were hesitant to comply with blood draws due to a belief that they would be drained of energy. complicated or advanced tuberculosis requires weeks of isolation in the hospital along with extended courses of medication, increasing patient bias against intervention. healthy people 2010 (u. s. department of health and human services, 2000) prioritized the need for significant gains toward eradication of tb by 2010. this actually complicates intervention further for migrants. the goals outlined in healthy people 2010 require ongoing observed treatment and follow up for patients. it requires preventive care for most farm workers and their families including a six-month regime of antibiotic cocktails for the 2-3 million people who are the most vulnerable to disease transmission. farm workers are in constant motion nationally in the migration streams and transition in and out of multiple jurisdictions annually. there is also a requirement of up to a year of preventive care for those who are hiv positive. healthy people 2010 supported the structure of penalties for medication noncompliance in a population very difficult to track and treat comprehensively with present resources. the case continues on physical exam jose was found to have a low grade fever and several dull areas over the upper lobes of the lungs are percussed. auscultation detects bronchial breath sounds with mild wheezing and crepitant rales. there is no detectable sign of other body part involvement, but to totally rule out this possibility, further evaluation would be needed. the chest x-ray shows nodular lesions with patchy infiltrates in the upper lobes, a few cavitary lesions, hilar adenopathy and diffuse scar tissue. sputum stain revealed nonmotile acidfast bacilli consistent with tb. given this information, a diagnosis of recrudescent tb is made and antitubercular therapy was started. the sputum culture returns with a positive diagnosis of mycobacterium tuberculosis. a tb skin test is planted but never read. blood sugar at the time of 99 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 the exam was 180 postprandial. fasting blood work is ordered including, cbc, cmp, lipid panel, hepatic functions, hepatitis screen and a 2 hour glucose tolerance test. jose did not come in for the appointment and labs were not drawn. the treatment consisted of daily doses of the appropriate antitubercular agents for 9 months. jose was given the first 3-month supply of the medicines and is instructed to return for a follow-up appointment in three months. appropriate teaching is given to jose and raphael stressing the need to be compliant with the medications, have his lab work completed, and the importance of completing the 9 month treatment program. jose never returned after the initial appointment. necessary lab work, primary care, and antitubercular refills were not done. multiple attempts to make contact with jose were made but were unsuccessful. an epidemiology investigator was sent out to the last known residence and found that jose had left shortly after the visit to the health department. a few of jose’s peers reported that jose had left convinced that the epidemiology department was going to turn him in to immigration. jose and his community had the misperception that their health was not the health department’s primary concern. given this information, it would appear that the health department, during this encounter, failed to communicate effectively with jose and his community. jose left with only the initial 3 months of treatment in hand, unless he seeks further health care and completes the 9 month course of treatment, he could be at an increased risk for developing and transmitting a resistant strain of tb. jose’s symptoms likely diminished with the first three months of treatment; allowing the tb to become dormant or resistant. jose was never found but the investigator did find 6 other farmworkers in the camp with a persistent blood producing cough. discussion unless there is a significant change in both the migrant farm worker culture and the culture of the traditional health care system, health outcomes for this vulnerable patient population are unlikely to improve and may actually worsen in the coming decade. addressing the needs of both entities will require a significant redesigning of healthcare’s approach to migrants. issues and barriers that must be addressed include the establishment of realistic revisions in tb care and follow up to address the overwhelming numbers of migrants who should receive treatment and the major barriers inherent to this care. culturally competent changes in the educational and outreach approaches for this patient population must be developed and implemented. redesigning the healthcare system for mexican migrant populations should have two main mandates: 1) modify the system’s structure, and 2) to prioritize adaptations for the migrants (guasasco et al., 2002). the development of interstate/interjurisdictional/ interagency cooperatives that service the geographic streams of migrants needs to be a priority. these cooperatives should have multi-agency releases and case management plans for migrant groups as they transition between work sites. building interagency data banks for charting and follow up care monitoring would give practitioners a concrete way to track, plan, and document healthcare in a centralized format. connecting designated teams of practitioners between sites will enhance continuity of care; decrease patients lost to disparities, and reduce noncompliance due to the lack of cultural priority (guasasco et al., 2002). incorporation of nontraditional supports for funding and service enhancement will enlarge and deepen the healthcare system’s ability to monitor and serve 100 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 migrants in a cohesive and organized manner. these nontraditional supports can be through researchers at universities, utilizing graduate students from several disciplines in healthcare, and by providing a foundation for access to multidisciplinary services such as counseling, education, legal assistance and advocacy organizations. the second mandate required of the healthcare system is to enhance accessibility of healthcare services to migrants. changing the focus of care to that of the needs of the migrant worker and family members will likely increase the numbers of underserved migrants receiving health care. changes may include providing flexible and variable clinic locations for receiving health care. the clinics need to have flexible hours and assist with childcare to meet the needs of workers and their families (weathers, 2003). having access to convenient mobile health care that has regular stops at the migrant community, the work site, and at the cultural gatherings and celebrations would also result in improved health outcomes for this population. connor, rainer, simcox, and thomisee (2007) describe a 13 year model of community interdisciplinary partnership which sends providers of medical and dental services to farmworker families where they live and work. this is a diverse collaboration of disciplines, both clinical and academic, that has a successful sustained history. reducing the wait times for appointments can greatly reduce the stress of utilizing healthcare services. most women bring their children with them for medical visits and extensive wait times can make child management very frustrating for them (castro & ruiz, 2009). moore, saywell, thakker, and jones (2002) reported that the foremost factor in patient dissatisfaction was wait time. for farm workers, time is an essential commodity. it is easy to see the implication: the more time out of the fields, the more income is lost, and the less likely they will utilize services in the future the use of meaningful incentives for participation in educational, preventive, and treatment may increase participation in these high priority activities (kent, 1993). incentives are a long used mechanism to draw and maintain participation in healthcare activities. culturally sensitive, financially beneficial and socially appropriate incentives need to be developed to elicit initiation of services and maintain compliance with service components. cultural congruence will be required to increase the effectiveness of tb care for the migrant farm worker (weathers, 2003). a re-evaluation of treatment methods in light of cultural values and priorities should lead to more effective treatment strategies, and thus reduce noncompliance and other stressors on the healthcare systems. kandula, et al. (2004) report on the exploration of medication delivery options that may decrease the length of treatment and number of doses required for treatment. this would enhance compliance by simplifying treatment and preventive care for those who are identified now, and for the estimated 2-3 million who will need to be treated in the next five years to meet the healthy people 2010 goals. the final piece of the picture is to renovate the educational approaches that have failed over the past few years. the focus should shift to building communication and cultural bridges. guasasco, et al. (2002) reports the utilization of bilingual healthcare outreach workers who come from the traditional cultural background and are trained to provide a variety of services form translation to patient education. developing consistent teams of practitioners to increase continuity and relational aspects of care can improve patient satisfaction and compliance. incorporating the highly valued persons and the community’s leaders in the culture as partners in education and support is important. these stakeholders include clergy, folk practitioners, traditional healers, and men and women in leadership roles in their community. through the combined efforts of stakeholders and culturally competent providers, trust and rapport with the 101 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 health care system may be established and improve health outcomes (pender, murdaugh, & parsons, 2002). it will be important to develop tools and materials for education that are appropriate for the population in form and content will require that the community itself be mobilized as a stakeholder for their own care. evaluation of program effectiveness will take several years to gather data on the ever increasing numbers of mexican migrant farm worker families. given the strict guidelines and high expectations of the federal government for eradication of tb in this population, identification and preventive care strategies will become a tremendous effort to accomplish in the next five years. unfortunately, the migrant populations are not readily identified as priorities and continue to experience multiple barriers to effective health care. it is important that support and funding resources are tied to evidenced-based programs for prevention and treatment to maximize health outcomes for this particularly vulnerable population. references castro, a., & ruiz, e. 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(2002). health promotion in vulnerable populations. in health promotion in nursing practice (4 th ed.). upper saddle river, nj: prentice hall. http://www.ncbi.nlm.nih.gov/pubmed?term=21%5bvolume%5d+and+278%5bpage%5d+and+castro+a%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=%22public+health+nursing+%28boston%2c+mass.%29%22%5bjour%5d+and+24%5bvolume%5d+and+355%5bpage%5d http://www.ncbi.nlm.nih.gov/pubmed?term=41%5bvolume%5d+and+prevention+control+tuberculosis+migrant+farm&transschema=title http://www.ncbi.nlm.nih.gov/pubmed?term=12%5bvolume%5d+and+60%5bpage%5d+and+gwyther+m%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=10%5bvolume%5d+and+177%5bpage%5d+and+joseph+%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=26%5bvolume%5d+and+163%5bpage%5d+and+kandula+n%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=1391%5bpage%5d+and+kent+j%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=8%5bvolume%5d+and+343%5bpage%5d+and+moore+j%5bauthor%5d 102 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 restrepo, b., fisher-hoch, s., crespo, j., whitney, e., perez, a., smith, b., el al. 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(pp. 264-278). philadelphia: f.a. davis company. http://www.ncbi.nlm.nih.gov/pubmed?term=%22epidemiology+and+infection%22%5bjour%5d+and+135%5bvolume%5d+and+483%5bpage%5d http://www.ncbi.nlm.nih.gov/pubmed?term=4%5bvolume%5d+and+437%5bpage%5d+and+rodriguez+r%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=24%5bvolume%5d+and+175%5bpage%5d+and+villarejo%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=14%5bvolume%5d+and+209%5bpage%5d+and+wilson+%5bauthor%5d http://www.ncbi.nlm.nih.gov/pubmed?term=12%5bvolume%5d+and+7%5bpage%5d+and+wyss%5bauthor%5d a medical home for children with special health care needs in rural locations 45 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 a medical home for children with special health care needs in rural locations amy j. mcclune, phd, rn 1 1 assistant professor, department of nursing, edinboro university of pennsylvania, amcclune@edinboro.edu key words: nurse, rural health, children, special health care needs abstract children with special health care needs (cshcn) present a complex challenge to the medical system. the concept of a medical home has been proposed to ensure consistency and continuity of care for cshcn. although it seems to be an easy solution in theory, implementation is complicated especially for the child residing in a rural area. this paper will explore the possibilities to ensure that rural cshcn have access to a medical home. the characteristics of a medical home include continuity, accessibility, coordination and compassion. a comprehensive focus on the family with attention to cultural needs is critical. geography, transportation, and financial barriers are present in rural families of cshcn. in a five-year longitudinal study, adams and colleagues (2006) found unmet dental, visual, and auditory health needs in school-age children in the rural south. primary care in general was also identified as an unmet need. nora pender‟s model of health promotion (2006) provides a strong framework for assessing and implementing the medical home concept for cshcn in rural areas. individual characteristics include the psychological and socio-cultural components of a rural lifestyle. accessibility issues may prevent optimal health promotion and illness prevention in a cshcn in a rural area. using data from the national survey of cshcn, skinner and slifkin (2007) examined barriers faced by rural families of cshcn that fit with the behavior specific cognitions and affect described by pender. using pender‟s model of health promotion (2006) provides a successful template for providing a medical home for cshcn living in rural areas. involving health care providers, home health agencies and community resources under the leadership of an advanced practice nurse could provide the chemistry needed for success. introduction children with special health care needs (cshcn) present a complex challenge to the medical system. by definition, these children require healthcare services beyond those of healthy children presenting difficultiues with consistency and continuity of care. one solution is the creation of a medical home for each child. although it seems to be an easy solution in theory, implementation is complicated. further complications are presented if the child with special health care needs resides in a rural area. this paper will explore the possibilities to ensure that rural cshcn have access to a medical home. the problem and its context children with special health care needs the term „children with special health care needs‟ has been used for the last twenty years to identify infants, children and adolescents who are in need of services due to chronic disability. over the years, as disabilities have become more complex, the term has undergone redefinition. http://www.edinboro.edu/departments/nursing/nursing.dot mailto:amcclune@edinboro.edu 46 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 the current definition was offered from a collaborative effort by the maternal and child health bureau and the american academy of pediatrics. this definition clears the way for consistent service provision through the various government departments and agencies that serve cshcn. the definition presented in 1998 because of these efforts is as follows: children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally (mcpherson et al., 1998 138). children with special health care needs are present in all aspects of society. the national survey of children with special health care needs conducted in 2001 (u.s. department of health and human services) found that 9.4 million (12.5%) of children under the age of 18 fall under the current definition. these children can be found in one out of five (20%) of u.s. households. cshcn are found more predominately in the older ages (8% in ages 0-5; 15.8% in adolescents from 12-17 years) due delayed recognition or presentation of symptoms. fifteen percent (15%) of boys and 10.5% of girls fall within the cshcn definition. prevalence rates do not vary significantly between income levels. concerning race and ethnicity, higher rates are found in native american/alaskan native (16.6%), mixed race (15.1%) and non-hispanic white children (14.2%). children with moderate to severe health problems are more likely to be found in rural areas (9% in large rural areas; 8.1% in small rural/isolated areas) than in urban areas (7.7%). (u.s. department of health and human services, 2005). medical home the concept of a medical home was introduced by the american academy of pediatrics (aap) in 1967 (as cited in sia et al., 2004). the medical home was conceptualized as a central place where all information related to the care of a cshcn could be found. in the late 1970s, the concept of the medical home grew to include more than a repository of information and was retooled to represent a method of community-based primary care focusing on prevention and wellness (sia et al.). in 1992, the aap published a definition of a medical home that included six characteristics. a medical home should be “accessible, continuous, comprehensive, family centered, coordinated, and compassionate” (aap, 774). culturally effective care was added as a component of the definition in a 2002 update (aap). needed healthcare should be available at any time and awareness of available resources assists the child and family meet their healthcare needs. collaboration between schools, community agencies and providers is important to maintain consistency. finally, the centralization of the medical record is crucial to seamless provision of care by all parties. a critical measurement of success of the medical home is the partnership between the family and the provider. according to the national survey of children‟s health, 46.1% of all children are reported to have a medical home. the percentages are evenly split between urban (46.4%), small rural/isolated (45.2%) and large rural (44.7%) areas. (u.s. department of health and human services, 2005). benedict (2008) used data from the 2000-2001 national survey of children with special health care needs. focusing on children requiring therapeutic (n=5,793) and supportive (n=23.376) services, the study evaluated the presence and effectiveness of a medical home. 47 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 occupational, physical and speech therapy and mental and substance abuse services defined therapeutic services. programs that assist in providing care to the child including specialized equipment, transportation, home health and respite care comprised supportive services. the variable of quality medical home was defined as the components of a medical home defined by the aap. unmet therapeutic needs were present in 16.2% of the children while 9.8% lacked needed supportive services. a quality medical home was present for only 23.9% of the children needing therapeutic services and 32.5% those needed supportive services. additionally it was found that the more severe the condition, the more likely the child was to have unmet needs. specific components of a quality medical home including access to preventative care, cultural sensitivity of the care provider and the degree of care coordination were found to be associated with lower unmet needs for services. this nationwide survey of a large sample delineates the key issues facing families of cschn. rural health care geography can impact the accessibility and consistency of healthcare for all ages. access to both primary and specialty care has been identified as a concern for rural children. transportation can be a considerable barrier to accessing the needed care. additionally financial burdens are consistent with the higher poverty that is often present in rural areas. (wright, 2006). a five year longitudinal study focused on school-age children in the rural south identified lack of healthcare in specific areas (adams et al., 2006). children (n=2813) were assessed in a health fair format that incorporated health history, vital signs, vision and hearing screenings, a physical examination and an anemia screening. variables included unmet needs in dental, visual, and auditory health along with referrals based on dental, vision, auditory or primary care needs. results indicated that uninsured or publically insured children were more likely to experience an unmet health care need and receive a referral for follow-up care. unmet dental needs were highest among the elementary students; vision needs were highest among junior high students. unmet auditory needs were highest among middle school students. the findings of this well-designed study with a large sample size can confidently be generalized to other areas suggesting that unmet health care needs can be found throughout the united states. pender’s health promotion model nora pender‟s model of health promotion (2006) provides a strong framework for assessing and implementing the medical home concept for cshcn in rural areas. pender‟s model arose from the early nursing philosophy that focused on promoting health and preventing illness. cshcn require these same interventions – promoting health and preventing illness – to maintain their current level of health and wellbeing. pender‟s health promotion model was developed to identify characteristics that result in health promotion. individual characteristics and experiences impact knowledge and emotions related to a specific behavior. these components result in a behavioral outcome that includes a commitment on the part of the individual to a plan of action focused on a health promoting behavior. (see figure 1). 48 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 figure 1. pender‟s health promotion model (n.d.) in applying pender‟s model to rural cshcn, many of the issues already discussed fit well. personal factors that are included in the individual characteristics might include the psychological and socio-cultural components of a rural lifestyle including family make-up, financial issues, and transportation. perceived benefits of and barriers to action are complicated. accessibility issues from provider-to-population ratio of both primary and specialty care, insurance coverage, and complexity of medical needs of the child may prevent optimal health promotion and illness prevention. using data from the national survey of cshcn, skinner and slifkin (2007) examined barriers faced by rural families of cshcn. these barriers fit well with the behavior specific cognitions and affect described by pender. rural cshcn were found to be more likely to seek care from a clinic or health center (or=1.44, p<.01). they are more likely to be cared for by general practitioners (or=2.12, p<.01) than pediatric specialists. these effects remained between urban and rural children after adjustment for poverty, insurance and maternal education. rural parents delayed seeking care for their cshcn more than urban parents primarily because the needed care was not provided in the geographic area. financial issues were also cited as a factor in the delay in seeking care. unmet healthcare needs in rural cshcn were more likely a result of transportation or lack of service availability than in urban children. skinner and slifkin (2007) reported that rural families bore a greater burden in caring for their cshcn. indicators of that burden included providing care in the home, lower financial status, spending more time arranging and providing care for their children. they were also more likely to require additional income to meet the child‟s healthcare needs. collaboration of healthcare providers, family, school, and community can discover ways to alleviate barriers. this collaboration is at the heart of a medical home. pender believes that nurses are in an ideal position to coordinate this type of collaboration. advanced practice nurses can extend the benefits of nursing to provide needed primary care. 49 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 the solution – a medical home for rural cshcn desired outcome the optimal solution for this problem is to develop a program coordinated by a pediatric nurse practitioner that would provide a medical home for cshcn in rural areas. outcomes would include a reduction in unmet therapeutic and supportive needs, a satisfaction with accessibility of healthcare and related needed information, and a perception of improved selfefficacy on the part of the parents of cshcn. this project is being proposed for erie county, pennsylvania; a primarily rural county in the northwest corner of the state. defensibility and realism the literature provides evidence to support the feasibility of the proposed program. in 2001, the center for medical home improvement was established to promote and support quality primary care medical homes for cshcn. the center acknowledges the importance of parental partnerships with professionals in providing healthcare. (center for medical home improvement, n.d; cooley & mcallister, 2004). the team members for the center include a lead pediatrician or primary care provider, key non-physician office staff/care coordinator, and parent partners. key to success is the investment of time to the needed tasks within a supportive environment. farmer and colleagues (2005) explored the feasibility of a rural medical home demonstration project. participants (n=51 parents of cshcn) were recruited to take part in a program designed according to the aaps components of a medical home. a primary care physician, the child and family, a nurse practitioner (np), office staff, and a parent consultant comprised the healthcare team. care coordination, information, emotional support and empowerment were the components of the intervention. all participants received a detailed assessment of the needs of the child and family completed by a np in the home. individualized health plans were developed for each child with short-term goals that were evaluated at least once during the 12 months of implementation. upon assessment, children were found to require 4 to 5 health related services. after the completion of the demonstration project, mothers reported better access to mental health services as well as a decrease in visits to their primary and specialty care providers. significant improvement in satisfaction with care coordination services was reported by mothers. total family needs were reduced per the mother‟s reports with less social support, financial and family relationship needs. family strain was also found to decrease. school attendance for the children involved significantly improved. of significance for this study is that the “medical home” was not based in one office. the “medical home” was facilitated by the interventions of a project np who was responsible for making contact with each child‟s primary care provider to ensure coordination and collaboration. although this demonstration project was of a smaller scope, it does provide preliminary support for a medical home for rural cshcn. to make this proposal a reality would require numerous resources. funding would need to be secured to provide the np and other staff members. primary care and pediatric practices must buy-in to the concept of a medical home for the proposal to succeed. most importantly, all stakeholders from the healthcare providers to the parents of the cshcn need to value the possibilities of a medical home. 50 online journal of rural nursing and health care, vol. 9, no. 2, fall 2009 although the resources needed to implement a proposal like this seem insurmountable, it would be worth the time and effort. funding is available from the government and community agencies. with successful grants, funding sources could be found. starting with a small nucleus of providers who are committed to the project, a marketing campaign could be launched to communicate to primary care and pediatric providers. collaborating with home health agencies and other community resources would maximize potential. overall, it could become a reality with the right chemistry of those involved. cshcn and their families who live in a rural area are often lacking in the needed services to promote health and prevent illness. the goal for a cshcn is to maintain or improve their health status as they grow and develop. the stress of caring for a cshcn can be frustrating and exhausting to families. the implementation of a medical home for rural cshcn would provide a solution to many of the issues faced by these children and their families. references adams, m.h., carter, t.m., judd, a.h., leeper, j., yu, j., & wheat, j.r. 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(2005). the national survey of children's health 2003. rockville, md: u.s. department of health and human services. retrieved on april 18, 2008, from http://www.mchb.hrsa.gov/ruralhealth/index.htm u.s. department of health and human services, health resources and services administration, maternal and child health bureau. (2004). the national survey of children with special health care needs chartbook 2001. rockville, md: u.s. department of health and human services. retrieved on april 18, 2008, from http://mchb.hrsa.gov/chscn/index.htm wright, m.m. (2006). nursing care of rural children with special health care needs (cshcn) [editorial]. online journal of rural nursing and health care, 6(2), 5-6. retrieved on april 18, 2008, from http://www.rno.org/journal/index.php/onlinejournal/article/viewfile/16/167 http://www.mchb.hrsa.gov/ruralhealth/index.htm http://mchb.hrsa.gov/chscn/index.htm http://www.rno.org/journal/index.php/online-journal/article/viewfile/16/167 http://www.rno.org/journal/index.php/online-journal/article/viewfile/16/167 microsoft word belden_87-1293-1-ed.doc journal of rural nursing and health care, 12(2) 64 the effect of evidence-based practice on workplace empowerment of rural registered nurses catherine v. belden, rn, msn, doctoral student 1 joan leafman, phd 2 guy nehrenz, edd, ma, rrt 3 patricia miller, rn, mn 4 1 adjunct faculty with the department of health sciences, a.t. still university, cbelden@atsu.edu 2 associate professor, arizona school of health sciences, a.t. still university, jleafman@atsu.edu 3 executive associate dean and professor, college of allied health and nursing, nova southeastern university, gnehrenz@nova.edu 4 coordinator, continuing education, college of nursing & allied health professions, university of louisiana at lafayette, plm7210@louisiana.edu abstract through evidence based practice implementation, autonomous practice and innovation strategies can stimulate workplace empowerment, providing a framework for retention and recruitment within rural healthcare organizations. this pilot study determined the relationships that exist between evidence based practice use and workplace empowerment among rural registered nurses. forty-two rural registered nurses completed an online survey examining their level of evidence based practice use and workplace empowerment. a spearman’s rho found a strong, positive correlation between overall evidence based practice use and workplace empowerment (r = 0.648, p< .001). through regression analysis, educational background was determined to be a confounding variable for overall evidence based practice utilization and perceived level of workplace empowerment. while the resultant small sample size negates generalization of this pilot study to a larger population, the results uphold the premise that organizational support of innovation, as evident within the tenets of evidence based practice, can potentially impact nurses’ sense of empowerment in the workplace. the results are valuable to healthcare administrators, quality and risk professionals, professional development educators, and direct care nurses when determining the needs of rns for evidence based practice education, mentorship, and advancement of organizational empowerment structures. future studies should examine rural registered nurses’ workplace empowerment levels as a source of innovation, which can be a direct result of evidence based practice utilization. evidence based practice, in conjunction with similar empowering work structures, can enhance rural nurses’ ability to implement highly reliable, quality healthcare services in an environment conducive to learning, autonomy, productivity, and innovation. keywords: evidence-based practice (ebp), rural, healthcare, empowerment, nursing, workplace journal of rural nursing and health care, 12(2) 65 the effect of evidence-based practice on workplace empowerment of rural registered nurses background, rationale, and significance over the last 20 years, the number of registered nurses (rns) throughout the united states has been in a constant state of flux. the national projected supply and demand of rns in 2000 was 1,889,243 and 1,999,950 respectively (national center for workforce analysis [ncwa], 2002). in 2020, those statistics will be dramatically different, with projections for supply at 2,001,998 and demand at 2,810,414 (ncwa, 2002). many factors have influenced this dramatic shift, including an aging workforce, a reduction in sufficiently prepared nurses ready to enter the workforce, and increasing work role dissatisfaction (ncwa, 2002). these issues directly affect the motivation of rns to continue bedside practice, particularly in rural organizations, culminating in a negative effect on the health and wellbeing of the citizenry (dunkin, juhl, & straton, 1996). rural rns must contend with the complexities of role diffusion, necessitating a robust clinical aptitude to efficiently address a variety of patient care encounters. role diffusion is the need for clinicians to have a diverse knowledge base and clinical proficiency applicable to a range of ages, cultures, and pathophysiological states that may occur in rural healthcare practice (koessl, 2009). the tenets of evidence-based practice (ebp) lessen the challenges associated with role diffusion through the reduction of unscientific, isolated, or ritualistic traditions in patient care. ebp also fosters a sense of autonomous nursing practice; however, rural rns may experience barriers to ebp utilization due to isolation from research mentors and insufficient awareness of relevant resources (koessl, 2009). through targeted training efforts for ebp incorporation in bedside practice, rural rns may develop a heightened sense of autonomy and workplace empowerment in practice. the influence of ebp use on the level of workplace empowerment of rns in rural healthcare organizations has not been widely studied. ebp use can positively affect patient safety through a culture of empowerment and autonomous practice among rns (armstrong & laschinger, 2005; armstrong, laschinger, & wong, 2009). therefore, rural healthcare organizations may experience heightened levels of workplace empowerment among nursing staff through the incorporation of ebp principles. purpose of study the purpose of this correlational exploratory pilot study was to determine levels of comprehension and ebp uses among of rns in rural healthcare organizations and examine the perceived level of workplace empowerment experienced by those nurses. through the conceptual framework of kanter’s theory of organizational empowerment as discussed in the seminal works of laschinger et al., it was hypothesized that rns in rural healthcare organizations who report higher levels of comprehension and use of ebp processes will have correlating higher levels of workplace empowerment within an organization through improved clinical practice opportunities (wilson & laschinger, 1994; laschinger, 1996; laschinger, sabiston, & kutszcher, 1997). journal of rural nursing and health care, 12(2) 66 methods research design this pilot study was a cross-sectional, descriptive, correlation study that sought to answer the following research question: “to what extent do rural rns’ perceptions and their utilization of ebp affect self-reported workplace empowerment levels?” study participants a random, cross-sectional sample of rns from louisiana was recruited for participation. a contact list of actively licensed in-state rns currently practicing in direct patient care (n = 5,980) was purchased from the louisiana state board of nursing (lsbn). the criteria for inclusion in this study were active licensure, residential status, direct patient care practice, and current employment as an rn in the state of louisiana. the criteria for exclusion from the study were nurses who held an active license but resided outside of louisiana, current employment in metropolitan areas as defined by the u.s. office of management and budget (2000), and rns not involved in direct patient care. based on a systematic sampling process, an interval of every 12 th rn actively employed in direct patient care activities in rural areas was invited to participate in the survey (n = 500). if the 12 th rn was known to the principal investigator either by previous or current association or employment, then the 13 th rn was selected as a potential participant to minimize any bias. this selection method ensured a sample of participants who were not known to the principal investigator. the study received approval from the a.t. still university institutional review board – protocol # 2010-86. participation was on a voluntary basis. data collection a notification letter with hyperlink to the online survey was sent to each potential participant explaining the study and instructions. consent was indicated by completion of the online survey. a 20-minute timeframe was anticipated for completion of the three-part online survey. to maximize survey completion rates, multiple mailings were completed. post card reminders were mailed to all potential participants at three weeks following the initial mailing with a reminder of how to access the survey hyperlink. the online survey was open for participant completion from january through march 2011. the benefits of participating in this study included an opportunity to reflect upon a) personal experience with ebp, b) individual empowerment levels within current nursing positions, and c) the potential influence of organizational ebp use on workplace empowerment levels. confidentiality was maintained by storing data in a password protected computer, accessible by the principal investigator only. to reduce risk of employer awareness of participation, the principal investigator recommended that participants complete the survey in a private location, such as their home. demographic data questionnaire. a demographic data questionnaire included general, unidentifiable data grouped into three subsections. section i consisted of gender, age, and population served by participants’ employer. section ii consisted of educational preparation such as basic nursing preparation, highest degree held, and if participants ever completed a statistics and/or research course. section iii consisted of employment status, primary employer type, primary work role, primary area associated with work role, length of time in current work role, current involvement in direct patient care, and magnet designation status of employer. journal of rural nursing and health care, 12(2) 67 evidence-based practice questionnaire. the evidence-based practice questionnaire (ebpq), developed by upton and upton (2006), evaluated rural rns’ attitudes, knowledge, and individual implementation levels of evidence based practice within various practice settings. the ebpq is a 24-item survey, with a 7-item likert scale organized into three separate subscales. in previous reliability testing, all three individual subscales achieved a cronbach’s alpha of .70 or higher and a cronbach’s alpha of .87 for the entire tool, demonstrating a statistically reliable tool for evaluating nurses’ perceptions. construct validity determined a positive but moderate relationship, with correlation coefficients ranging from .3 .4 (p < .001). brown et al. (2010) obtained similar validity and reliability, as the original pilot, in determining implementation of ebp among rns in a southern california medical center. prior approval to use this tool was obtained from the principal developers. psychological empowerment instrument. the psychological empowerment instrument (pei), a seminal work developed by spreitzer (1995), is a valid and reliable tool used to evaluate the perceived level of workplace empowerment in employees. the survey, consisting of 12 selfscored items using a 7-item likert scale, was incorporated in prior studies to evaluate the perceptions of workplace empowerment among nurses, service employees, and industrial workers (spreitzer, 1995; spreitzer, 1996). the pei examined participants’ impressions of empowerment within the workplace, including confidence in ability to perform assigned work, autonomy and control levels, perceived level of organizational impact, and opportunities for independent decision-making (spreitzer, 1995). comprised of four subscales, the pei exhibited an internal reliability via cronbach’s alpha of .72 with validity averages of .80 during pilot study, demonstrating a reliable and valid tool to assess perceptions of empowerment (spreitzer, 1995). prior approval to use this tool was obtained from the principal developer. statistical analysis all data collected from the completed surveys (n = 42) were entered into a microsoft® excel spreadsheet and corresponded to a variable code book which defined each question in a coded format to ensure consistency. the transcribed data were then uploaded into the ibm® statistical package for social sciences (spss, inc. chicago, il) statistics standard gradpack 19 for data analysis. the data were scanned for any transcription or coding errors by calculating and analyzing frequencies along with the maximum and minimum for each variable with no coding errors identified. none of the data were missing therefore all data were useable for analysis. this study was conducted based on the research question to what extent does rural rns’ perceptions and their utilization of ebp affect self-reported workplace empowerment levels. descriptive statistics including frequencies and percentages determined the attributes of the obtained demographic data from the sample population in comparison to the general population of rns in louisiana. chi square tests examined specific attributes of the sample and population demographic means to determine statistical differences between groups. measures of central tendency analyzed collected survey responses to the ebpq and pei. nonparametric correlation analysis (spearman’s rho) was used to identify relationships between ebpq and pei that demonstrated ebp utilization as a predictor of empowerment in the work setting. multiple linear regressions were used to predict workplace empowerment with ebp comprehension and utilization, while controlling for age, sex, educational background, prior research experience, and time in work role. the alpha level for all testing was set at the .05, twotailed. journal of rural nursing and health care, 12(2) 68 results of the 500 potential participants, 42 (8.4%) registered nurses (rns) responded to the survey (table 1). the majority of respondents were female (78.6%), ages 30-39 (26.2%), and employed in a population service area of 25,000-49,999 (33.3%). in terms of basic nursing education, the majority of the sample (76.2%) had baccalaureate level preparation. a bachelor of science in nursing was the highest degree held for 57.1% of the sample. most participants also completed a statistics or research course at some point in their education (92.9%). a majority of respondents were employed full-time (97.6%), within an acute care hospital setting (83.3%), in a medical unit (26.2%), and in their current work role for five to ten years (35.7 %). table 1 sample and population demographics characteristic specific attribute study sample (n=42) a n (%) louisiana rn population (n=46,828) b n (%) p value gender male 9 (21) 5231 (11) .03 female 33 (77) 41597 (89) age range 20-29 9 (21) 10037 (13) .32 30-39 11 (26.2) 12973 (28) 40-49 8 (19) 10648 (23) 50-59 10 (23) 9601 (21) 60-69 3 (7) 3569 (8) population range in work area below 2500 2 (4) na 2500-4999 5 (11) na 5000-9999 4 (9) na 10000-24999 6 (14) na 25000-49999 14 (33) na 50000-99999 6 (14) na 100000-249999 3 (7) na over 250000 2 (2) na preparatory nursing education a.d.n 10 (23) 19021 (41) .00 bsn 32 (76) 22633 (48) highest degree held a.d.n 9 (21) 15853 (34) .01 bsn 24 (57) 18575 (40) bs/ba not nursing 1 (2) 2496 (5) msn 5 (11) 3946 (8) journal of rural nursing and health care, 12(2) 69 characteristic specific attribute study sample (n=42) a n (%) louisiana rn population (n=46,828) b n (%) p value ms/ma not nursing 2 (4) 1545 (3) doctorate in nsg 1 (2) 161 (0) statistics/research course yes 39 (93) na no 3 (7) na employment status full time 41 (98) 35485 (76) .00 part time 1 (2) 6080 (13) primary employer type acute care hospital 35 (83) 28014 (60) .01 cmty/pub health 2 (4) 4545 (10) home health 4 (9) 3751 (8) md office 1 (2) 804 (2) primary clinical area within primary work role anesthesia 1 (2) 1290 (3) .00 case mgmt 1 (2) na ccu/icu 4 (10) 5061 (11) education 1 (2) 199 (0) emergency care 6 (14) 2957 (6) geriatrics 1 (2) 1767 (4) home health 4 (10) 2913 (6) maternal/neonatal 2 (5) 3104 (7) medical 11 (26) 7492 (16) oncology 1 (2) 1014 (2) or/pacu/rr 2 (5) 3345 (4) otpt/ sds 2 (5) na pediatrics 1 (2) 1914 (4) rehab 1 (2) na surgical 3 (7) na utilization review 1 (2) na time in current role under 6 months 3 (7) na 1 year 1 (2) na 2-4 years 13 (31) na 5-10 years 15 (36) na a total study sample (n=42). b total population of rns in louisiana 2009 (n=46,828) note. na = not available, journal of rural nursing and health care, 12(2) 70 in table 1, a representative portion of the larger louisiana rn population was evident in the study sample (louisiana state board of nursing, 2010). through chi square testing, several demographic indicators were compared to the larger population, demonstrating a statistically significant difference, except for age range. outcomes of ebpq and pei surveys measures of central tendency for the ebpq and pei survey outcomes are presented in table 2. the mean of respondents’ opinions of ebp utilization was 4.44 (neutral) with opinions of workplace empowerment at 5.39 (agree). table 3 presents the spearman rho correlations between the ebpq subscales, overall ebp use, and perceived workplace empowerment levels from the pei. respondents’ use of ebp process was moderately correlated to workplace empowerment (r = .421, p = .006). attitudes to ebp did not correlate to workplace empowerment (r = .091, p = .568). respondents’ skill level in ebp demonstrated a high correlation to workplace empowerment (r = .656, p = .000). there was a strong, positive correlation between overall ebp utilization and workplace empowerment (r = .648, p< .001). the coefficient of determination (r squared) for overall ebp utilization and workplace empowerment was .184 (95% ci = .174, .891; p = .005) (figure 1). journal of rural nursing and health care, 12(2) 71 multiple linear regressions controlled the effects of confounding variables such as gender, age, education, prior exposure to statistics or research course work, and time in work role. gender (β = .038, p = .813), age (β = .290, p = .063), prior exposure to a statistics or research course (β = .053, p = .739), and time in work role (β = .117, p = .459) were not related to overall ebp utilization. for workplace empowerment levels, gender (β = .085, p = .592), age (β = .124, p = .435), prior exposure to a statistics or research course (β = .042, p = .793), and time in work role (β = .149, p = .346) did not demonstrate any significant relationships. educational background demonstrated a moderate, positive correlation with overall ebp utilization and workplace empowerment (β = .464, p = .002; β = .332, p = .031 respectively). controlling for educational background, workplace empowerment remained moderately correlated to overall ebp utilization (r = .454, β = .350, p = .036) (tables 4 & 5). journal of rural nursing and health care, 12(2) 72 discussion evidence-based practice is defined, throughout the literature, as the systematic evaluation and implementation of sound scientific research, coupled with clinical expertise and patient preferences, that facilitate optimal health outcomes for patients (melnyk et al., 2004; pravikoff, tanner, & pierce, 2005; neville & horbatt, 2008; lenz & barnard, 2009). the principles of ebp facilitate a sense of motivation, autonomy, expertise, and innovation amongst nursing employees. essential nursing practice concepts, such as accountability and innovation in patient care activities, have a positive correlation to structural empowerment levels when grounded in expertise and clinical judgment (laschinger & wong, 1999; faulkner & laschinger, 2008). as defined by kanter’s (1977) seminal work on the structural theory of organizational behavior, structural empowerment is the process of mobilizing resources as derived from formal and informal power structures that enable employees to achieve work goals (wilson & laschinger, 1994; laschinger, 1996; laschinger et al., 1997). formal power, by definition, facilitates employee discretion, establishes a recognition structure, and is fundamental to achieving organizational goals by the employee (wilson & laschinger, 1994; laschinger, 1996; laschinger et al., 1997). informal power is based upon the generation of interpersonal relationships forged amongst colleagues within an organization and exists vertically as well as horizontally within the hierarchical structure (wilson & laschinger, 1994; laschinger, 1996; laschinger et al., 1997). informal power structures can particularly influence a sense of innovation amongst nurses, evident in interdisciplinary networking, journal clubs, and team building activities (laschinger, gilbert, smith, & leslie, 2010). employees who have access to formal and informal power within the organization generally exhibit higher productivity levels, a journal of rural nursing and health care, 12(2) 73 sense of accomplishment, gravitate towards innovative processes, and share sources of power structures with other less empowered employees (laschinger et al., 1997; knol & von linge, 2009). the data collected in the study are valuable to healthcare administrators, quality and risk professionals, professional development educators, and direct care nurses to determine the needs of rns for ebp education, mentorship, and advancement of organizational empowerment structures. the purpose of this pilot study, therefore, was to investigate what relationships exist between rural rns’ utilization of ebp and their perceptions of workplace empowerment. it was hypothesized that rural rns’ who reported higher levels of comprehension and utilization of ebp processes would have correlating higher levels of workplace empowerment within their healthcare organization. the findings presented in this study support the proposed hypothesis, and establish a parallel with previous studies examining the relationships between empowerment as a predictor for patient safety, climate and autonomous practice environments that fostered innovation in the clinical setting (laschinger & wong, 1999; armstrong et al., 2009). though a small sample size was elicited in this pilot study, the results are reflective of prior findings by laschinger and collegues (1997) seminal work which demonstrated that the precepts of autonomous practice, foundational to ebp utilization, are critical to a sense of workplace empowerment among front-line nursing staff in both urban and rural healthcare organizations. the respondents of this study offered a neutral opinion to ebp comprehension and utilization while demonstrating a higher mean level for workplace empowerment levels (table 2). this finding may be relative to a majority of respondents having worked in a rural population and not within a highly specialized care department (table 1). as discussed by olade (2004), rural nurses frequently regard ebp as an academic or regulatory mandate instead of a means to advance and improve nursing practice. of the potentially confounding variables examined through linear regression, a moderate correlation existed between educational background and overall ebp utilization, as the majority of the respondents had baccalaureates. this correlation is consistent with previous studies that determined nurses’ level of education as a positive contributor to higher levels of ebp utilization in the practice setting, primarily due to the exposure of the baccalaureate prepared nurse to theoretical and research underpinnings (wilson & laschinger, 1994; eller, kleber, & wang, 2003; olade, 2004). in examination of workplace empowerment levels, the resultant higher mean may be a reflection of the sample, which consisted of a majority of rns who had functioned in their current work roles for greater than five years (table 2). longevity within a particular work role can contribute directly to a sense of inclusion and empowerment (wilson & laschinger, 1994; armstrong et al., 2009). using spearman’s rho, a statistically significant correlation between overall level of ebp utilization and workplace empowerment (r = .648, p = .000) was evident. a similar study conducted by olade (2003) demonstrated that, while 76% of nurse respondents had an unfavorable or indifferent attitude towards ebp, they did express an interest in research utilization within their practice setting if barriers were eliminated. additionally, 65% of the respondents reported a heightened curiosity about research with only 20% feeling adequately prepared to analyze and implement research within their clinical practice (olade, 2003). these results demonstrate a concern for rural healthcare organizations, where administrative support, educational resources, and clinician comprehension of ebp principles are potentially ambiguous. as postulated in kanter’s structural theory of organizational behavior, workplace empowerment is driven by a culture of organizational inquiry, supportive structures, interdisciplinary collaboration, clinical autonomy, a spirit of innovation, and a strong learning journal of rural nursing and health care, 12(2) 74 environment irrespective of clinical discipline (wilson & laschinger, 1994; laschinger, 1996; laschinger & havens, 1996; laschinger et al., 1997; van patter gale & schaffer, 2009). while the results of hypothesis testing do not demonstrate a causal effect, there is evidence that a statistically significant positive relationship exists between rural rns’ ebp utilization and their level of workplace empowerment. the results of this pilot study uphold the premise that organizational support of innovation, as evident within the tenets of ebp, can directly impact nurses’ sense of empowerment in the workplace (knol & van linge, 2009). nursing administrators amenable to a work environment grounded in ebp may increase nurses’ empowerment and commitment to the organization as a whole. study limitations the number of returned surveys, only 8.4% of the 500 rns, is a study limitation that impacts generalizability to a larger population. while demonstrating a representative portion of the rns employed in rural louisiana with respect to several of the demographic indicators, the pilot study sample size may impose bias to the overall results. notably, there were a significantly higher percentage of females with baccalaureate preparation employed in a full time position within an acute care setting. chi square testing was statistically significant. a power effect size was not completed within the initial phases of the study design, which could have contributed to uncertainty as to the significance and representation of the sample to the general population. this study was based upon rural rns’ self-reported perceptions of ebp utilization and workplace empowerment via the ebpq and pei surveys. direct measurements through observations of empowerment structures and ebp use were not conducted in this study. despite this limitation, the perceptions elicited in this study demonstrate support of kanter’s organizational empowerment model through a strong correlation of ebp utilization and workplace empowerment levels. practice implications and recommendations for future research although evidence-based practice within the rural healthcare setting remains in its infancy, opportunities may exist to empower professional nurses to employ its tenets within their direct care activities, resulting in positive benefits for both patients and healthcare organizations alike. evidence-based practice, in conjunction with similar empowering work structures, can enhance rural nurses’ ability to implement relevant, high quality healthcare services in an environment conducive to learning, autonomy, productivity, and innovation. organizations that interweave the ideology of innovative and autonomous practice into their culture through workplace empowerment mechanisms will reap administrative, financial, and human capital benefits. a study by knol and von linge (2009) determined empowerment levels directly affected nurses’ sense of innovation and ability to impart behaviors reflective of ebp into their daily practice. a future research opportunity would be the examination of rural rns’ workplace empowerment levels as a source for innovation, which can be viewed as a direct result of ebp utilization. additionally, inclusion of a broader sample would support or refute this initial pilot study’s findings to the rural rn population at large. conclusions evidence-based practice is a foundational component of outcomes-based clinical decisionmaking and individualized care plan development, necessitating a sense of clinical inquiry and innovation within the rural healthcare organization (schoonover, 2009). to effectively journal of rural nursing and health care, 12(2) 75 implement evidence-based practice and facilitate quality services, nurses must have a spirit of clinical inquiry fostered by applicable research utilization techniques, an appreciation of patientcentered care, and sufficient individual clinical expertise (pravikoff et al., 2005; vratny & shriver, 2007; lenz & barnard, 2009). the cumulative effect of evidence-based practice implementation is to progressively stabilize and improve the health of the general public through efficient and equitable utilization of rigorous scientific research through a systematic critical analysis correlated to patient preferences and the clinician’s expertise level. the progressive integration of evidence-based practice structures in various practice settings can reduce barriers to utilization among rural 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/20465724 http://www.ncbi.nlm.nih.gov/pubmed/9256880 http://www.ncbi.nlm.nih.gov/pubmed/19182547 http://www.ncbi.nlm.nih.gov/pubmed/17163896 http://www.ncbi.nlm.nih.gov/pubmed/19057357 http://www.ncbi.nlm.nih.gov/pubmed/15495490 http://www.ncbi.nlm.nih.gov/pubmed/14746103 http://www.ncbi.nlm.nih.gov/pubmed/16138038 http://www.ncbi.nlm.nih.gov/pubmed/19657252 http://www.ncbi.nlm.nih.gov/pubmed/16448488 http://www.ncbi.nlm.nih.gov/pubmed/17413511 http://www.ncbi.nlm.nih.gov/pubmed/8151435 hilborn et al. _703new+a+scoping+review+of+adult+experiences+psf+4.1.22-+final-setup+formatted4.11.22 online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 57 a scoping review of adult experiences of hospital to home transitions in rural settings billie hilborn, rn, cneph(c), bscn, mhsc (bioethics)1 mina singh, med, phd, rn, i-fcnei2 1 ph.d. candidate and faculty of graduate studies, york university, school of nursing, bhil@yorku.ca 2 professor, york university, school of nursing, minsingh@yorku.ca abstract scoping review question: how do adults experience hospital to home transitions in rural settings? background: adequate preparation for transition from hospital to home can ensure continuity of patient care and is important in rural communities, which lack equitable access to healthcare services and professionals. after hospital discharge, rural patients feel unprepared, and have more emergency visits and hospital readmissions than urban patients. methods: the scoping framework designed by arksey & o'malley (2005) guides the methods. eligible papers were published peer-reviewed reports in english of data collected in a rural setting that examined experiences of adults during transition from hospital to home. the search included mesh and keywords and was adapted to fit different databases. screening of titles and abstracts was followed by full text screening and data extraction. results: a total of 1448 papers were accessed, 701 titles and abstracts screened, 68 screened at full text, with 28 meeting inclusion criteria. the two main reasons for exclusion were that the topic was not transition from hospital to home, and the setting was unidentified or not rural. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 58 findings: there was a broad range of geographic distribution, care settings, recipient groups, research designs, and transition experiences. four main factors influenced transitions: communication; continuity of care; variations in patients, healthcare professionals, and/or services; and attention to the rural context. recommendations: based on the review, recommendations were made to improve discharge processes in rural settings. keywords: scoping review, hospital discharge, hospital to home, transitional care, rural, patient experience, nursing a scoping review of adult experiences of hospital to home transitions in rural settings transitional care has been defined as “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations” such as hospital to home (coleman & boult, 2003, p. 556). adequate preparation for hospital to home transition can ensure continuity of patient care, a key quality indicator for maintaining health (fox et al., 2020; holland & harris, 2007; wan et al., 2017;). poorly managed care transitions can result in poor follow-up on tests and results, adverse medication events, and excess emergency visits and rehospitalizations (li et al., 2021) especially in rural areas where health determinants are adversely influenced (subedi et al., 2019) and equitable access to health professionals and services is lacking (canadian institute for health information [cihi], 2018; wilson et al., 2020). rural patients experience significantly more emergency visits and hospital readmissions than urban patients in the first month after hospital discharge (cihi, 2012). rural discharge planning may be more complex (bolch, 2005), especially when patients must rely on informal home caregivers (dellasega & zerbe, 2002), or have no one to rely on (henning-smith et al., 2019). rural patients online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 59 reported inadequate support and felt unprepared to manage their care after hospital discharge, perhaps due to a “pronounced shift” from care provided by professionals to home self-management (fox et al., 2020, p. 2). the aim of this scoping review is to share knowledge of rural hospital to home transitions to inform research, practice, and policy. methods review methods were guided by the work of an international group of methodologists (arksey & o’malley, 2005; daudt et al., 2013; khalil et al., 2016; tricco et al., 2018). a six-stage process is used. stage 1. identify objectives and research question the objective of this scoping review was to examine published literature to determine the extent, range, and nature of knowledge available to answer the research question: how do adults experience hospital to home transitions in rural settings? stage 2. identifying relevant literature the goal was comprehensive identification of studies without having a restricted or excessive number of papers to screen (arksey & o’malley, 2005; daudt et al., 2013; elliot et al., 2019). the search strategy was drafted and refined using variations of mesh terms and key words hospital to home, patient experience, and rural. home was defined as a private or family residence rather than a rehabilitation, long-term or alternate level of care institution (fox et al., 2019). the final search strategy in table a was run in medline, cinahl, embase, proquest, and emcare databases. guided by the research question, papers were included in the review if they met the following criteria: 1. the primary aim was to report adult patient experiences during transition from hospital to home in any type of rural setting identified by the author(s). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 60 2. the paper was a published peer-reviewed report of data collected with any study design. 3. the full-text english version was available. papers were excluded if they were grey literature, opinion piece, editorial, or conference proceedings. table 1 search strategy # searches results 1 "patient acceptance of health care"/ 49,513 2 patient acceptance of health care.mp. 49,604 3 patient participation/ 26,867 4 "patient participation".mp. 28,505 5 patient preference/ 9,239 6 patient preference.mp. 13,117 7 patient satisfaction/ 84,033 8 patient satisfaction.mp. 102,890 9 preference, patient.mp. 62 10 satisfaction, patient.mp. 340 11 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 18,6070 12 health services accessibility/ 78,027 13 health services accessibility.mp. 78,371 14 health services, indigenous/ 3,444 15 health services, indigenous.mp. 3,463 16 hospitals, rural/ 4,958 17 hospitals, rural.mp. 4,993 18 medically underserved area/ 7158 19 medically underserved area.mp. 7225 20 rural health/ 23,590 21 rural health.mp. 39,198 22 rural health services/ 13,110 23 rural health services.mp. 13,522 24 rural nursing/ 111 25 rural nursing.mp. 399 26 rural population/ 61,946 27 rural population.mp. 65,779 28 center*, rural health.mp. 8 29 communit*, rural.mp. 103 30 health, rural.mp. 70 31 health cent*, rural.mp. 17 online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 61 # searches results 32 health service*, rural.mp. 11 33 nonmetropolitan.mp. 730 34 non-metropolitan.mp. 563 35 nonurban.mp. 484 36 non-urban.mp. 604 37 nursing, rural.mp. 8 38 population*, rural.mp. 123 39 reservation.mp. 2,095 40 rural.mp. 172,472 41 rural communit*.mp. 42 rural health cent*.mp. 775 43 rural hospital*.mp. 3,960 44 service*, rural health.mp. 5 45 "small town*".mp. 1,792 46 village*.mp. 31,764 47 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 272,062 48 (continuity of patient care or transitional care or patient discharge or transition or hospital to home or hospital discharge or discharge planning or coordination of care or continuity of care or care coordination or care continuity).af. 435,749 49 11 and 47 and 48 761 50 limit 49 to "all adult (19 plus years)" 479 51 50 and 2021:2021.(sa_year). 3 database(s): ovid medline(r) and in-process, in-data-review & other non-indexed citations 1946 to april 20, 2021 stage 3. selection of sources of evidence final search results were exported into review management software, where duplicates were removed. initial screening of titles and abstracts was completed by the author, acceptable at this stage due to tight guidance by inclusion and exclusion criteria and the reviewer’s broad and deep understanding of the project (van mossel et al., 2012). to ensure accuracy, a second reviewer screened a random 10% of titles and abstracts, with a predetermined interrater agreement level set at a minimum 80% (lim et al., 2012), which was exceeded. this process was repeated for full text screening. reference lists of included articles were reviewed for potential additional articles, which were screened in the same manner. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 62 stage 4. data charting process the word charting refers to extracting and documenting data in scoping reviews (arksey & o’malley, 2005; tricco et al., 2018). two forms of data charting were developed to chart results, which were piloted and adjusted: 1) a tool with detailed information about pre-determined data to extract from each paper, such as author(s), publication information, country, research objectives, study design, and key findings about transition experiences; and 2) a tabular document to provide a cumulative view of results. stage 5, collating, analyzing, applying meaning, and reporting the results data were analyzed and details about transition experiences are reported here in written format (tricco et al., 2018). details are available in supplementary information. stage 6, stakeholder consultation, if applicable. this stage was considered not applicable. results the number of citations retrieved from database searches is shown in figure 1, with exclusion reasons at each stage. there were 1,448 citations; duplicates were removed and 24 were added from other sources, resulting in 701 for title and abstract screening. full-text screening was completed on 68 papers – 28 met inclusion criteria. publication years span 1997 to 2021, with three papers in the 1990’s, six from 2000 to 2009, and 19 from 2010 to 2021. there is no clear reason for research tripling in the last decade but two papers from the united states mentioned a federal program to reduce hospital readmissions (baldwin et al., 2014; kind et al., 2012). this program, the affordable care act (u.s. house of representatives, 2010), adjusts hospital funding if 30-day readmission rates are excessive, which seems a logical reason to increase research on patient transitions at discharge. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 63 figure 1 prisma-scr flow diagram adapted from moher et al., (2009) with permission through open access, please see references for full credit. geographic distribution spanned seven countries: one paper from norway; two each from china, scotland, and sweden; three from canada; four from australia; and 14 from the united states. each paper had one to nine authors, with three the most common, from disciplines in areas such as clinical, public, or rural health. nurses were noticeably prominent as authors on all but three papers. designs were 14 quantitative (three randomized controlled trials [rct], one systematic review), 10 qualitative, and four mixed methods. there was one study each on post online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 64 hospital care of patients with cancer, bariatric surgery, diabetes, pain, and hip surgery; two each for medications, congestive heart failure, and adverse events; three each for post-stroke and postnatal care; four for cardiac care; and seven for discharge or transition processes. time frames varied widely from the first week after discharge to 40 years; the majority covered the first six months. eleven papers described discharge from rural hospitals and 15 from urban. the mean age of participants was 65 years and 40% were female. nine studies reported having only rural participants, and there were 9-708 participants per study with a mean of 123.7. factors affecting transitions reviewed papers described transitions from hospital to home ranging from “smooth” (eassey et al., 2017, p. 1119) to “treacherous” (kind et al., 2012, p. 2659). patient experiences were influenced by four factors: communication; continuity of care; variations in patients, healthcare professionals, and/or services; and attention to the rural context. there were varied degrees of influence, which was compounded if multiple factors were involved. communication. the importance of communication of healthcare professionals with each other and with patients during hospital to home transition was highlighted in most papers. several papers reported positive outcomes from communication that began in hospital and continued postdischarge, such as between hospital-based clinical nurse specialists (cns) and rural patients who had frequent emergency department visits and/or hospital admissions (baldwin et al., 2014). the cns managed phone appointments in a 30-day transitional care program completed by 39 patients with congestive heart failure, diabetes, or chronic obstructive pulmonary disease; patient satisfaction improved, and emergency visits, readmissions, and costs decreased. the three rcts all highlighted communication, which resulted in better self-management and reduced readmissions (cui et al., 2019), promoted collaboration of physicians and patients (askim et al., online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 65 2004), and reduced pain interference with activity (reynolds, 2009). telephone communication made patients feel “humanized” after cardiac revascularization (pesut et al., 2013, p. 93). a study of transitions after hip fracture care drew attention to discharge notes being an endpoint of clinical accountability with a unidirectional flow of patient information received from or provided to health professionals or family caregivers (johnson et al., 2013). research with patients and carers found that a lack of communication at discharge caused confusion, bitterness, resentment, and insecurity, resulting in missed treatments, complications such as wound infections, and increased costs (williams et al., 2006). significant quality and safety problems were related to written and verbal transfer information that was “incorrect, conflicting or missing”, resulting in missed appointments, unmanaged complications, medication changes not implemented, and staff time wasted (bar-zeev et al., 2012, p. 370). ekdahl and colleagues (2012) found that discharge discussions usually involved only physicians and nurses, with decisions made during paper-based rounds, not at bedsides. poor communication between multiple healthcare professionals and a lack of communication to patients contributed to medication-related problems within four months of hospital discharge (eassey et al., 2017). continuity of care. effective and timely communication contributes to continuity of patient care, which is critical during transitions from hospital to home since hospital stays are shorter and patients may be at higher risk if not fully recovered at discharge (dellasega & fisher, 2001). several papers reported that continuity of care through communication that began in hospital and continued during transition to home was successful, such as when a specialized early discharge midwife met with new mothers before they left the hospital to discuss information, and continued support at home via planned telephone follow-up (löf et al., 2006). in another study, rural and urban cardiac patients were met by researchers in hospital and communication occurred by online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 66 telephone for five months post-discharge in an exploration of their recovery and medication use (dellasega et al., 1999). continuity of care was also promoted during development of a transitional care model that resulted in multiple interventions such as medication adjustments by clinical nurse specialists with prescriptive authority (ie. insulin, nebulizers, diuretics) which helped patients manage at home (baldwin et al., 2014). managing at home was also highlighted in a study of cardiac rehabilitation, where patients preferred a home-based program rather than attending a hospital-based one and had better adherence rates in maintaining contact with rehabilitation nurses (blair et al., 2011). continuity of care was promoted in another study when nurse case managers were “tightly integrated with both the inpatient and outpatient teams” of 708 veterans discharged to rural homes (kind et al., 2012, p. 2665). almost half of the veterans needed medication corrections at the first phone call post-discharge despite pre-discharge counselling and medication reconciliation. this example highlights the necessity for continuity of care when transitioning from hospital to home. some studies drew attention to the lack of continuity, such as the discharge process being “fragmented with major discontinuities” due to the frantic hospital setting and lack of a discharge coordinator (bar-zeev et al., 2012, p. 371). in a different study, continuity of care was negatively affected when patients were admitted and discharged “rapidly” and some returned to hospital the next day (ekdahl et al., 2012, p. 3). continuity of care can be negatively affected by poor uptake of cardiac rehabilitation; only 17% of rural patients followed in one study completed the full 36week program (j. e. johnson et al., 1998,), and in another study 16% of patients declined it, 11% were not referred, and none was available for 33% (pesut et al., 2013). variations. three types of variations affected rural transitions home. these variations include patients, healthcare professional practice, and services available. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 67 patients. the earliest paper in the review examined variations in post-hospital health needs of 41 rural and 40 urban patients; the findings revealed no significant functional differences, but significantly more skilled care was needed by rural patients (schultz, 1997). urban patients received more support from family and friends than rural, who had more paid help due to decreasing availability of informal support; this was deemed a “critical concern” (schultz, 1997, p. 33). a similar study found it “troubling” that 57% of rural participants had no home caregiver – effective individual discharge assessment and planning was “critical" (dellasega & fisher, 2001, p. 258). new mothers in a study by löf and colleagues (2006) varied in the amount of support they wanted from family at home after early discharge, with some wanting help and others preferring privacy, while in a different study new mothers varied in the amount of anxiety they felt and preference for type of technology in post-natal care such as video links, emails, text, or digital interactive television (roberts et al., 2009). a feasibility study of telemonitoring for 10 rural patients with lung cancer found variations in patient-reported perceptions of their symptoms (ie. shortness of breath and pain) and physiologic values (ie. blood pressure and temperature), which could impact self-management (petitte et al., 2014). eassey and colleagues (2017) found variations in the amount patients want to be involved in their care; some preferred none while others collaborated with healthcare professionals about medication management. some authors noted variation in patient ages as a factor in hospital to home transition, such as j. e. johnson and colleagues (1998) who noted older age as a significant positive factor for attending a cardiac rehabilitation program, particularly when combined with other factors such as rurality and social support. another study found that patients receiving home care after discharge who were female, lived alone, and older than 60 had more preventable adverse events, primarily with medications and complications from procedures (tsilimingras et al., 2019). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 68 healthcare professional practice. another factor that could affect the transition experience for a patient is variation in the practice of individual health professionals. johnson and colleagues (1998) found that the strongest influence on patient attendance at cardiac rehabilitation after hospital discharge was if a physician recommended it. another study found varying speeds at which patients were discharged from hospital depended on “the doctor in charge and his/her attitude to frail elderly people” (ekdahl et al., 2012, p. 7). patients reported conflicting advice from health professionals, especially when specialist care was required (eassey et al., 2017). one described how some “heart pills were stopped” when he was in hospital, but at a post-discharge visit his cardiologist told him that was “incorrect and put me back on them”, and another had been prescribed a medication by one doctor but a different one said not to take it (p. 1117). morrison and colleagues (2016) found variations in whether a transitional program was led by cns or physicians with palliative care experience – there was significant reduction in emergency room visits in the cns group. services. blair and colleagues (2011) noted rural communities have varied needs and requirements and found that cardiac rehabilitation services showed equal effectiveness of home and hospital-based programs in improving cardiac risk factors and reducing further cardiac events, mortality rates, hospital readmissions, and lengths of stay. askim and colleagues (2004) found access to services supporting early discharge after stroke improved patient quality of life. some rural patients told “difficult stories” of travel to and from an urban cardiac care centre, lack of emergency services, and feeling that cardiac rehabilitation had an urban focus with little relevance to the everyday rural lifestyle (pesut et al., 2013, p. 92). a new “service innovation” in australia was provided by cardiac rehabilitation nurse mentors, who were able to meet rural patients predischarge and provide six weeks of phone contact (frohmader et al., 2018, p. 98). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 69 in a feasibility study, most new mothers approved of service innovation with video support for infant feeding after hospital discharge, but only if it was available “24 h a day, 7 days a week” and did not disrupt existing services (roberts et al., 2009, p. 351). dellasega and fisher (2001) found there was a lack of professionals (i.e. visiting nurse, physiotherapist, or physician) in rural settings, therefore patients relied more on non-professional (i.e. home delivery of meals, transportation services, companionship). bar-zeev and colleagues (2012) described how services in the rural setting were not the same as in urban, although hospital staff may have an unrealistic idea that it is, such as a midwife being available for several visits daily to support a new mother with breastfeeding, not realizing the consequences of their “poor discharge practices” (p. 371). deng and colleagues (2020) highlighted the need for a variety of services in transitional care, particularly due to the complexity of stroke rehabilitation. attention to the rural context. in this review strong attention to the rural context is described as clearly defining the rural setting and addressing the influence of context such as by comparing urban versus rural findings, which could affect the transition experience. several papers were published in journals with rural in the title, suggesting a focus on that setting, which was usually the case but not always. approximately half of the studies paid strong attention to the home destination being rural. an example is a quantitative study about use of cardiac rehabilitation programs, which has the word rural in the title and abstract, defined a locally designed rurality index, and included rural in the results and discussion; 69% of the respondents (175) lived in rural areas and 31% (79) in small towns, and the degree of rurality had no significant influence on attendance (j. e. johnson et al., 1998). two other examples are a comparison of medication use by elderly cardiac patients in rural and urban locations (dellasega et al., 1999) and an examination of post-hospital professional and online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 70 non-professional home care for 70 frail older adults in rural locations (dellasega & fisher, 2001). both identified rural in the title and introduction and compared rural and urban in the results and discussion, drawing attention to the impact of closing rural hospitals (dellasega & fisher, 2001; dellasega et al., 1999). pesut and colleagues (2013) note in their introduction to a study of post cardiac revascularization that lack of a common definition of rurality complicates patient experiences and address it well by providing a definition for their study (two hours distance by car from treatment centre and population less than 10,000) and including the setting in analysis and discussion. the rural context was the reason for a feasibility study of home telemonitoring of patients with lung cancer after discharge from hospital, aimed at promoting self-care, setting the stage for a clinical trial despite some challenges recruiting and retaining patients, and finding patient homes in the mountains for follow-up visits (petitte et al., 2014). several papers missed opportunities to highlight the rural context. bennett and colleagues (2012) include a title describing post-hospital follow-up of rural patients with diabetes however three-quarters of the data is from urban patients. the definition of rurality is clear, results show rural residents had similar rates of follow-up physician visits in the first 30 days post-discharge compared to urban residents, but transition to outpatient care is “not ideal in smaller rural areas” (bennett et al., 2012, p. 7). other studies were much weaker due to a lack of definition and minimal/complete lack of mention to the potential impact it might have during transition from hospital to home. this was surprising if the word rural was in the title of the journal or the paper and/or abstract, indicated some intent at examining the impact of the setting. askim and colleagues (2004) compared patients in three rural communities to evaluate the effect of usual or extended service after stroke; rural was in the title, but there was minimal mention online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 71 in the text, and no definition. similarly, several other papers used rural superficially in titles, abstracts, findings, and discussion, with no clear definition (cui et al., 2019; ekdahl et al., 2012; h. johnson et al., 2013; kitzman et al., 2017; löf et al., 2006; roberts et al., 2009). the title of the baldwin and colleagues (2014) study suggests that development of a transitional program is rural, however the population is 55% urban, rural is not defined, and mentioned minimally in the text regarding patients “geographically isolated from healthcare” (p. 154). discussion the topic of interest for this scoping review was hospital to home transitions in rural settings. findings included a broad range of papers across seven countries with various research aims and designs by individuals or teams from multiple disciplines, primarily nurses, with varying patient populations. although these broad variations created challenges for drawing findings together, and some anticipated information was not reported, some common factors influenced patient transition experiences: communication; continuity of care; variations (patients, healthcare professional practice, and/or services); and attention to the rural context. results of this scoping review give rise to several points of discussion that link with existing literature. the first point is that during transitions from hospital to home in the rural setting, effective communication and continuity of care are vital and reciprocal – one promotes the other and vice versa. patient outcomes were improved when there was timely post-discharge follow-up care that included effective communication especially when it began in hospital and continued throughout the transition process. improved patient outcomes identified in the reviewed papers include reduction in emergency department visits and 30-day readmissions (morrison et al., 2016; muus et al., 2010), improved patient safety due to reduced medication discrepancies post discharge (dellasega et al., 1999; eassey et al., 2017; kind et al., 2012; tsilimingras et al., 2015), improved online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 72 post-natal care (bar-zeev et al., 2012; löf et al., 2006; roberts et al., 2009), and improved patient outcomes from targeted rehabilitation after stroke (deng et al., 2020; kitzman et al., 2017), cardiac events (frohmader et al., 2018; j. e. johnson et al., 1998; pesut et al., 2013), and hip fracture (h. johnson et al., 2013). communication and continuity of care have been the core dimensions in the delivery of patient-centred healthcare since its inception (gerteis et al., 1993). the picker institute in the united states coined the term patient-centered care in 1988 (barry & edgman-levitan, 2012) and it was promoted as a primary health system aim (national research council, 2001). patientcentred care has been adopted globally (world health organization, 2018). patients may require care past the hospital discharge boundary (holland & harris, 2007) however it is unclear if patientcentred care occurs during transitions from hospital to home. although some reviewed papers hinted, only one specifically mentioned it. the cardiac rehabilitation aussie heart guide program supported by nurse mentors was “based on the patient centred care (pcc) approach” (frohmader et al., 2018, p. 94). some nurses had difficulty adopting this “new approach” but gained understanding of the values and benefits with experience and felt more education and organizational support would be helpful. this review found literature that indicates care is still being organized by healthcare professional choices instead of patients (van humbeeck et al., 2020), which does not promote patient-centred care. the second point of discussion is that patient, healthcare professional, and service variations can create challenges during transitions. this is in line with literature, such as pollack and colleagues (2016) who described challenges that patients experienced during transition to selfmanagement after hospitalization related to knowledge, resources, and self-efficacy. there were gaps in system-based self-management support (such as verbal information transfer at discharge online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 73 and inability to integrate the knowledge into their everyday life) and elements of individual selfmanagement (information was provided but hospital staff did not assess if patients had the resources such as money to purchase new medications or provide time for them to learn and practice new skills needed to carry out the plans). patients may be unprepared or unable to process this information when in the hospital, and their needs may be uncertain at the time of discharge – they need tailored individual support as they adjust to home (allen et al., 2002; pollack et al, 2016). findings from the review also support the literature about varying types of transitions. a systematic review found three types: ● pre-discharge interventions with discharge planning, patient education, medication reconciliation, and scheduling a follow-up appointment; ● post-discharge interventions with follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory providers and home visits; and ● bridging interventions with transition coaches, physician continuity across the inpatient and outpatient settings, and patient-centred discharge instruction (hansen et al., 2011). the third point of discussion are the missed opportunities to draw attention to the rural context during transitions. it is particularly important in rural settings that patients and next of kin are included in discharge planning due to their knowledge of potentially accessible local resources (kealy-bateman et al., 2021). a recent canadian model was developed for rural primary health care (phc) management of dementia, noting that rural settings are different than urban, lack adequate services, struggle with physician recruitment and retention, and that there is “tremendous diversity across rural settings and phc teams” (morgan et al., 2019, p. 2). nursing practice in rural settings presents unique ethical challenges, particularly a lack of resources, which is “a major barrier to quality care” (alzghoul & jones-bonofiglio, 2020, p. 1038). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 74 the fourth point of discussion is that one of the main goals of projects to improve transitions from hospital to home is to reduce unplanned trips to the emergency department and hospital readmission, however the 30-day readmission concept has been challenged in the literature. a chosen 30-day time frame makes it more likely that poor outcomes were “related to the index admission or discharge process” (van walraven et al., 2010, p. 553). hansen et al. (2011) noted that “avoiding rehospitalization has captivated policymakers” and suggested “reconsideration of planned penalties” (p. 527). wan and colleagues (2017) examined patterns over six years of rural disparities in hospital 30-day readmissions and found multiple factors to consider, such as variations among county populations, rural health clinics, and patients, echoing the finding that patient and community level factors affect readmission (rennke et al., 2013). the lace index was developed to determine the level of patient risk for unplanned readmission to hospital within 30 days of hospital discharge based on the sum of four variables: ● length of hospital stay; ● acuity of admission; ● comorbidity; and ● emergency room visits in the six months pre-admission, with expected probability increasing at higher scores (van walraven et al., 2010). as noted by morrison and colleagues (2016) included in this review, research on the most effective delivery of transitional care has varied greatly by intensity, healthcare providers involved, services provided, and care approach, with two being the most consistently studied – the care transitions intervention (gardner et al., 2014) and transitional care model (naylor et al., 2014). the care transitions intervention® (cti) was developed by dr. eric coleman at the university of colorado, school of medicine in 2003, and has reduced hospital readmission rates in various online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 75 patient populations who work with a transitions coach® to ensure their needs are met during transition from hospital to home with five encounters over 30 days: a hospital visit, if possible, a home visit, and three follow-up phone calls (care transitions, n.d.). the cti has a “patientcentered focus” to ensure patient care needs are met, with explicit attention to medication reconciliation and enhancing healthcare continuity (coleman et al., 2006, 1827). the transitional care model (tcm) has been tested and refined by a multidisciplinary (doctors, other nurses, social workers, discharge planners, pharmacists, and others) research team at the university of pennsylvania since 1991 (naylor et al., 2009). the tcm provides comprehensive hospital discharge planning and follow-up at home for chronically ill high-risk older adults, led by the transitional care nurse (tcn), who follows patients from hospital to home, providing services designed to streamline care plans, interrupt patterns of frequent acute hospital and emergency department use, and prevent decline in health status. randomized controlled trials of the tcm found significant reduction in rehospitalizations, emergency department visits, and healthcare costs after patient discharge (naylor et al., 2004, 2014). the final point of discussion arises from the noticeable engagement of nurses in most of the reviewed studies (25/28). nursing is important during transitions from hospital to home since little happens in healthcare without going through the hands of a nurse (allen, 2015). an integrative review of 25 studies evaluating transitional care interventions for patients with heart failure (hf) found that the majority (15) were delivered by nurses, which the authors note “confirmed that nurses are the most important healthcare providers of transitional care for patients with hf” (ba et al., 2020, p. 14). the reviewed study by morrison and colleagues (2016) also noted that most transitional care programs in the literature are multidisciplinary teams with care directed by advance practice nurses, although some rely on other professionals. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 76 as noted in mixed methods study comparing outcomes of discharge planning and follow-up care by nurses (apn, expert, and novice) for elders with chronic healthcare conditions, there are ethical limitations to examining care by different providers, making it difficult to assess the effectiveness of different types of transitional care (jeangsawang et al., 2012). in a more recent study, there were difficulties determining causality in a large multi-year multi-phase mixed methods comparison of care transition strategies to improve patient care funded by the patientcentered outcomes research institute (li et al., 2021). key findings include that during care transitions, patients and family caregivers want to feel cared for and cared about by medical providers; a clear understanding of who is responsible for their health care; and to feel prepared to implement their care plan when discharged from the hospital (li et al., 2021). transition care strategies emphasizing “trust, plain-language communication, and tailored care planning” with “bridging activities” preand post-discharge were consistently and strongly associated with reduced health care use and improved patient-reported outcomes and experiences (p. 29). some study sites were identified as rural based on zip code population, health literacy was identified as requiring help filling out medical/hospital forms or survey language being non-english, and some statistics were provided, but there was no discussion of these topics in the lengthy report. recommendations as levine (1998) noted, “… discharge planning should make the hospital-to-home transition a smooth one” (p. 25). drawing from this review, recommendations to promote smooth transitions to reduce return emergency visits and hospital readmissions in rural settings include: ● attention to discharge residential location and availability of supports and services. ● clearly defined standards of discharge care practice, responsibilities, and accountability. ● improved standardized discharge instructions and checklists for specific conditions. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 77 ● improved discharge planning and care coordination with careful consideration to assessing discharge needs from patient perspectives and including carers if possible. ● standardization of hospitaland home-based rehabilitation (i.e. cardiac and stroke). ● written communication such as two-way booklets between care settings and patient journals/logbooks for symptoms such as pain. all verbal and written communication must be clear and understandable in plain language for patients and carers. ● potential role for telehealth, including input via video conference from specialists. ● use of a transitional care model for planning and discharge purposes. ● more engagement of nurses in the planning process. further research is recommended, and in addition to patient-centred care, topics missing from the papers reviewed provide opportunities, such as gender and age differences, financial factors, the acute/primary care disconnection, most effective communication methods to promote quality patient outcomes, variations in programs, and health literacy. in cross-sectional analysis of 384 patients transitioning from hospital to home, findings indicate that those who screened with inadequate basic health literacy had more transitional care needs and were associated with inadequate caregiver support, which increased patient vulnerability (boyle et al., 2017). limitations one limitation is that excluding papers not in english may reduce the findings, and another is that papers in the scoping review primarily represent the western conceptualization of rural. this review may have missed some published work, and a single reviewer of the majority of full-text papers and for data extraction may have missed some information. critical appraisal of papers and instruments used was not completed in this scoping review, consistent with guidance from the literature (arksey & o'malley, 2005; levac et al., 2010; peters et al., 2020). online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 78 conclusion in the first month after discharge patients are at risk for “post-hospital syndrome…(a) transient period of vulnerability” (krumholz, 2013, p. 100), and unplanned readmission may occur, making transition care important as a preventive mechanism. this scoping review was guided by the research question: how do adults experience hospital to home transitions in rural settings? findings about common factors that improve or hinder rural patient transition experiences resulted in several recommendations to improve discharge processes in rural settings. gaps in the evidence base provide information to guide future research opportunities. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 79 references allen, d., lyne, p., & griffiths, l. 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(2017). contextual, organizational and ecological effects on the variations in hospital readmissions of rural medicare beneficiaries in eight southeastern states. health care management science, 20, 94–104. https://doi.org/10.1007/s10729-015-9339-x *wang, c. d., rajaratnam, t., stall, b., hawa, r., & sockalingam, s. (2019). exploring the effects of telemedicine on bariatric surgery follow-up: a matched case control study. obesity surgery, 29, 2704–2706. https://doi.org/10.1007/s11695-019-03930-4 wilson, r. c., rourke, j., oandasan, i. f., & bosco, c. (2020). progress made on access to rural healthcare in canada. canadian journal of rural medicine, 25, 14-19. https://doi.org/10.4103/cjrm.cjrm_84_19 williams, c., thorpe, r., harris, h., dickinson, c., & rorison, f. (2006). going home from hospital: the postdischarge experience of patients and carers in rural and remote queensland. australian journal of rural health, 14, 9–13. https://doi.org/10.1111/j.14401584.2006.00749.x world health organization. (2018). continuity and coordination of care: a practice brief to support implementation of the who framework on integrated people-centred health services. https://apps.who.int/iris/bitstream/handle/10665/274628/9789241514033eng.pdf?ua=1 online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 91 supplementary information: details of papers reviewed # authors/ year/ journal/ place title study design professions, participants key findings 1 askim et al. 2004 clinical rehabilitation, 18, 238-248. norway evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. a randomized controlled trial. randomized controlled trial early d/c with extended support vs. ordinary care ph + cva md researchers 62 rural patients acute cva at 52 weeks post cva: no positive effect on functional outcome but trend toward better quality of life no significant differences in length of stay 2 baldwin et al. 2014 clinical nurse specialist, 28(3), 147 us, tx developing a rural transitional care community case management program using clinical nurse specialists qi project to prevent readmissions of un & under-insured all = cns (rn phd + 2 msn) with rx authority 39 patients were phoned weekly or more multiple timely interventions i.e. insulin readjustment, med refills improved patient satisfaction decreased hospital and ed 30-day visits, decreased costs 3 bar-zeev et al. 2012 midwifery, 28(3), 366373. australia from hospital to home: the quality and safety of a postnatal discharge system used for remote dwelling aboriginal mothers and infants in the top end of australia case study + key informant interviews + observation in regional hospital and two remote health centres rn/midwife researchers remote dwelling aboriginal mothers and infants poor discharge documentation, communication and coordination between hospital and health centre staff. serious risks to safety for mothers and infants due to adverse effects of poor standards of care. 4 bennett et al. 2012 rural and remote health, missing the handoff: posthospitalization follow-up care quantitative analysis of medicare data from chronic mds + researchers 1.4 million medicare residents of smaller rural areas are less likely to obtain f/u care. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 92 # authors/ year/ journal/ place title study design professions, participants key findings 12 article 2097 us, sc. among rural medicare beneficiaries with diabetes conditions warehouse (ccw) beneficiaries with dm urban/rural differences 30 days post discharge of md follow up personal (i.e. age, race, gender) and illness characteristics more predictive than rurality for md follow up. 5 blair et al. 2011 rural and remote health 11, 1532. (online) uk: scotland home versus hospital-based cardiac rehabilitation: a systematic review systematic review 22 articles reviewed rn + university researchers patients had been d/c’d from hospital and had cardiac rehab no clinically significant reduction in mortality or cv events, health costs. some reduced readmissions due to rehab. home rehab helps rural and patients felt in control 6 cui et al. 2019 rural and remote health, 19(5270). china a nurse-led structured education program improves selfmanagement skills and reduces hospital readmissions in patients with chronic heart failure: an rct rct 12-month follow up education + self-mgmt scales rn + mds + researchers 96 patients + some caregivers medication adherence, dietary modifications, social support, symptom control better in intervention group. readmission rate for hf 10.4% vs. 27.1% little rural attention 7 dellasega et al. 1999 journal of gerontology, 54(10), m514m520. us, pa postdischarge medication use of elderly cardiac patients from urban and rural locations. mixed methods phone interviews 2, 4, 12, 20 post d/c + survey np phd md research team 32 patients aged 65+ urban subjects with same illness severity prescribed more drugs + had significantly more drug changes, directly predicted hospital online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 93 # authors/ year/ journal/ place title study design professions, participants key findings readmission + er visits 8 dellasega and fisher 2001 j of community health nursing, 18(4), 247-260 us, pa posthospital home care for frail older adults in rural locations longitudinal baseline in hospital then phone calls after 48 hrs., 2, 4 + 6 weeks 2 np phd 70 patients aged 65+ 57% had no caregiver non-professional services by unpaid family/friends, home meal delivery, transportation services were used most often, most intense use at 2 weeks 9 deng et al. 2020 clinical rehabilitation, 34(4) 524–532 china effects of an integrated transitional care program for stroke survivors living in a rural community: an rct rct rehab research team 98 patients home rehab for intervention group, control had secondary cva prevention intervention group scored significantly better. no significance in caregiver strain index. program is feasible little rural attention 10 eassey et al. 2017 health expectations, 20(5) , 11141120 australia “i have nine specialists. they need to swap notes!” australian patients’ perspectives of medicationrelated problems following discharge from hospital. 506 surveys = 45% (228) rural 174 reported medication related problem when transitioning home pharmacists patient-centred care required for smooth transitions need more communication + collaboration conflicting advice 11 ekdahl et al. 2012 bmj open, 2(6), e002027 sweden 'are decisions about discharge of elderly hospital patients mainly about freeing blocked beds?' a qualitative qualitative observational geriatric md, district rn, + senior medical & palliative rn 9 patient + hcps 6 rns 3 md interviews, observation in patients often excluded by mds + nurses from discharge discussions and very little participation in decision making online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 94 # authors/ year/ journal/ place title study design professions, participants key findings observational study. 2 general rural + 1 urban teaching hospitals preoccupation to free up beds. patients feel unwelcome in hospital 12 frohmad et al., 2018 australian critical care, 31, 93-100 australia structures, processes and outcomes of the aussie heart guide program: a nurse mentor supported home based cardiac rehabilitation program for rural patients with acute coronary syndrome case study all rns 13 patients recovering from acs interviewed and 7 nurse mentors surveyed patients thought the program assisted their recovery therapeutic relationship developed 13 j. e. johnson et al. 1998 public health nursing, 15(4):288-296 nv, us rural residents' use of cardiac rehabilitation programs survey of patients from 4 hospitals of factors affecting participation 3 rn phds 254 patients 28% (72) attended any cr and only 17% (43) completed the full 36 (3xwk. x 12) degree of rurality not significant influence on use but economic adequacy was. hazardous roads, bad weather, lack of public transportation complicated cr utilization. 14 h. johnson et al. 2013 physiotherapy canada, 65(3), 266-275 ontario canada hip fracture care in rural sw ontario: an ethnographic study of patient transitions and patient handoffs rehab network: pt, ot, + researchers 11 patients (3 went home for rehab), 8 family caregivers, 24 hcps + documents information gaps and poorly timed. unidirectional info flow – lack feedback if papers reached intended person information needs to be structured + timely online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 95 # authors/ year/ journal/ place title study design professions, participants key findings important: pt to pt, other hcps, family 15 kind et al. 2012 health affairs, 31(12), 26592668 us, wi low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a va hospital quality improvement project weekly calls x4 md public health, rn on in + outpatient team nurse case manager met 708 veterans + caregiver prior to d/c, phoned within 72 hours, did medication reconciliation c-trac protocol development to improve care transitions 47% had med discrepancy despite pre d/c med rec, was corrected at 1st phone call. lower rates of 30day rehospitalization. net cost avoidance = $1,225 per veteran 16 kitzman et al. 2017 journal of community health, 42, 565-572. us, ky care coordination for community transitions for individuals poststroke returning to low-resource rural communities program assessment researchers from rehab + rural health 30 patients (17 females 13 males) 70% had ≥5 comorbidit ies began monthly support group specially trained community health worker to support transitions contacted participant first time in home then by phone 1x/week first 3 months then every other week for 6 months. mostly education 17 löf et al. 2006 scandinavian journal of caring sciences; 20(3), 323-330 sweden factors that influence firsttime mothers' choice and experience of early discharge qualitative interviews rn midwives 9 first time mothers rural and urban early discharge team provided positive experience – mothers confident and secure mothers well informed about how to get support online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 96 # authors/ year/ journal/ place title study design professions, participants key findings 18 morrison et al. 2016 journal of nursing scholarship, 48(3), 322329. us, vt reducing preventable hospitalizations with two models of transitional care retrospective cohort comparison preand postintervention cns, dnp, rn phd 98 patients from cns 41 patients from mds average 81 years 63% female both programs have value, but cns program patients had significantly fewer ed visits + hospitalizations 4 months after intervention. 19 muus et al. 2010 rural and remote health, 10(1447). no place noted. effect of postdischarge followup care on readmissions among us veterans with congestive heart failure: a ruralurban comparison. analysis of administrative data from veterans affairs rural health researchers 36,566 hospitalizations 1/3 rural 98% male ~17% had potentially preventable readmission; were older, disabled, had longer initial hospital stays due to illness severity. post d/c md or cardiologist visit within 30 days ↓r/a for urban & rural. no ↑ chf readmission risk for rural. 20 pesut et al. 2013 the journal of rural health, 29, 88–96 canada understanding the landscape: promoting health for rural individuals after tertiary level cardiac revascularization pilot mixed methods study with phone survey and interviews rurality = 2 hours by car pop <10,000 1 all are phd rns 24 rural patients (25% of total) age 36-95 average 65 12 were interviewed no significant difference in cr participation. unmet needs = transportation & lifestyle changes. rural patients had few complications. good info flow – printed + f/u phone calls. 21 petitte et al. 2014 feasibility tudy: home telemonitoring for feasibility study using exploratory, rns + some phds no statistical differences online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 97 # authors/ year/ journal/ place title study design professions, participants key findings oncology nursing forum, 41(2), 153-161 us patients with lung cancer in a mountainous rural area descriptive, and observational methods 10 patients lived within 75 miles of hospital. 5 had usual care 5 had telemonitors 14 days + daily nurse phone call challenges = environment, culture, technology, enrolment, retention one home visit to check patient and pick up monitors 22 reynolds 2009 pain management nursing, 10(2), 76-84 us, wa + id postoperative pain management discharge teaching in a rural population rct rn phd 87 patients 10minute intervention and 59 control from two rural hospitals = pop <50,000 intervention = pre d/c education for self-pain management. no statistical difference but intervention group had lower pain scores and less interference with activities due to pain 23 roberts et al. 2009 maternal and child nutrition, 5, 347–357. uk scotland the use of video support for infant feeding after hospital discharge: a study in remote and rural scotland concurrent mixed methods midwives and nursery nurses centre for rural health 20 interviews + 91 surveys (22.6%) from regional maternity + 3 rural midwifery units varied use of video – some enthusiasm but most preferred face-to-face. worry= continuity of care if video replaces current phone & in-person. midwives were preferred over gps 24 schultz 1997 public health nursing, 14(1), 28-36 us, me identification of needs of and utilization of resources by rural and urban elders after hospital discharge to the home descriptive comparative quantitative at 3 days and 3 weeks after discharge rn phd nurse researcher 41 rural (19 female) = <6 people/sq. mile + 40 urban; ¾ had medical dx use of community services + family assistance similar. more paid help in rural – less costly? rural had significantly more skilled care needs, online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 98 # authors/ year/ journal/ place title study design professions, participants key findings complexity, and unmet needs. urban had sig longer los 25 tsilimingras schnipper, et al. 2015 journal of general internal medicine, 30(8), 1164– 71. us, fl. post-discharge adverse events among urban and rural patients of an urban community hospital prospective cohort study md mph, dnp ms 344 rural + 340 urban rural = zip code with density < 100/sq. mile nurse phone interviews + chart review aes similar in both groups = 28% of which 2/3 were preventable different rural/urban risk factors require different interventions to improve patient safety during transitions 26 tsilimingras, zhang, and chukmaitov 2019 home health care management & practice, 31(4), 257-262 us, fl post-discharge adverse events among patients who received home health care services prospective cohort study interviews and extensive chart review md, mph, phd, md phd 39 rural 46 urban patients phoned by research nurses 3-4 weeks after discharge 42.4% rural patients had ae = high due to extensive document review 47% preventable factors = live alone, dm, pneumonia, infection 27 wang et al. 2019 obesity surgery, 29, 2704–2706. twh toronto canada exploring the effects of telemedicine on bariatric surgery follow-up: a matched case control study matched case control contingent on access to appropriate technology bariatric surgery + camh rurality index for ontario 192 patients 96 telemedicine + 96 non up to 5 years f/u post-op = mean of 2.59 no sig difference in appointment attendance between tele (93%) & non-tele (89%) or lost to f/u 20% vs 14% 28 williams et al. 2006 australian journal of going home from hospital: the post discharge experience of patients and 19 patients + carers. pre and post discharge surveys, 12 sw + academics no post discharge plans even for patient with new colostomy. online journal of rural nursing and health care, 22(2) https://doi.org/10.14574/ojrnhc.v22i1.703 99 # authors/ year/ journal/ place title study design professions, participants key findings rural health, 14, 9–13 australia carers in rural and remote queensland post interviews +50km to qualify for subsidy discharge was sudden and confusing no carer needs arrangements the evolution of the online journal of rural nursing and health care 1 online journal of rural nursing and health care, vol. 9, no. 1, spring 2009 the evolution of the online journal of rural nursing and health care jeri dunkin, phd, rn editor it seems like yesterday that i was discussing the need for a accessible source of knowledge for nurses and other health professionals practicing/working in rural areas and/or populations. the year was 1997. i had just begun my tenure at the university of alabama capstone college of nursing, as the saxon endowed chair for rural nursing. the more i discussed this with my colleagues and mentors the more i realized that what was needed was a peer reviewed electronic journal that could be accessed by all rural nurses and that would facilitate the sharing of research and practice knowledge. after some research and more discussion and with the support of the rural nurses association and the university of alabama capstone college of nursing dean, dr. sara barger the first issue of the online journal of rural nursing and health care was posted to the rural nurse organization in 2000 as a fully refereed journal. in those first years we published the journal quarterly but soon realized that that was too fast to be handled by all volunteer time. so the decision was made to back down to two issues a year, spring and fall. that tempo worked well for the amount of personnel and time we had to work with the journal. the next step was to get the journal indexed and through the work of managing editor dr. steven maccall, we were first referenced in cinahl in 2003; however, since that time, the cinahl has indexed all articles and columns of the journal since volume 1, number 1 from 2000, so the complete run of all articles and columns published in the journal is available through a bibliographic search of the primary index to the nursing literature. as time moved on and the amount of articles submitted increased, we realized in 2006 that we needed to evolve the method used to publish the journal, so we moved the journal to a better online publishing environment. we chose (and presently use) one of the top open source ejournal publishing platforms called “open journal systems”. again dr. maccall took the lead and with the help of the rural nurse organization webmaster made the change with all back issues now available in the pdf format. at this same time it became evident that in order to preserve the online journal of rural nursing and health care as the official journal of the rural nurse organization we implemented the policy that at least one author of published articles had to be a member of the rural nurse organization. this has worked well and the number of submissions have continued to grow to the point that additional personnel/resources are needed to manage the journal submissions and reviews in a timely manner so during the next several months the editorial board and staff will be exploring options and strategies to facilitate the continued growth of the journal while having it as accessible to rural nurses and other health professionals as possible. i will update the progress in each issue for the next year as we explore what direction the journal will take and how it will continue to grow. one thing i do know is that there will continue to be a need for manuscri0pt reviewers for our panels so if you are interested in doing that for us please send me an email stating your interest and include your vita. the email is rural.nurse.org@gmail.com http://pkp.sfu.ca/?q=ojs mailto:rural.nurse.org@gmail.com 735_exploration_rural_menstratual_4_24_23_setup_3_psf+arformatting online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 173 exploration of rural adolescent female’s experiences with menstrual health education and knowledge haley townsend, edd, rn, fnp-bc1 sara kaylor, edd, rn, cne2 delaney johnson, rn3 1assistant professor, capstone college of nursing, university of alabama, hmfranklin@ua.edu 2associate professor, capstone college of nursing, university of alabama, skkaylor@ua.edu 3registered nurse, upmc children's hospital of pittsburgh, delaney.johnson97@gmail.com abstract purpose: the purpose of this qualitative study was to explore the experiences of rural adolescent girls surrounding menstrual health knowledge and experiences. sample: twenty-five participants met selection criteria; aged 15-18, enrolled at a high school in rural alabama and willing to share experiences. method: reflective journaling guided by moderator questioning, through a one-hour educational course elicited rich descriptions of lived experiences. data consisted of journal responses to protect the privacy of participant answers. saldana's first cycle/second cycle constant comparative method was used for data analysis. findings: three themes including feelings of isolation, desire for continued and consistent education, empowerment to influence were discovered. one subtheme of increased female involvement was also discovered. overall, participants felt alone in their quest for knowledge concerning menstrual health as they entered adolescence and desired more education as well as discussions and guidance from their female relatives. from their experiences, they wish to empower younger girls with knowledge. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 174 conclusions: participants in this study experienced period poverty, defined as the lack of access to menstrual health knowledge and education, as described in current literature. rural girls may disproportionately experience period poverty due to already present disparities. earlier and consistently timed education should take place in the home and educational setting to empower young girls to equip them with needed knowledge and reduce stigma surrounding their menstrual cycles. keywords: period poverty, women’s health, menstruation, reproductive health exploration of rural adolescent female’s experiences with menstrual health education and knowledge promoting sexual and reproductive health in young women in age-appropriate ways is vital to lifelong holistic wellbeing. one large part of reproductive health in the young woman is menarche and the monthly menstrual cycle. providing instruction in methods to care for their bodies and normalizing the menstrual cycle can improve knowledge, confidence, and self-efficacy in developing females (national association of nurse practitioners in women’s health [npwh], 2021). stigma, a shameful mark setting people apart from others, surrounding the menstrual cycle and sexual health is still present today (krusz et al., 2019). coupled with parents ill equipped or unwilling to provide education surrounding menstruation, many young women are left without information or misinformation. increased reliable and empowering education surrounding the menstrual cycle is needed for young women, optimally prior to the onset of their first menstrual cycle (npwh, 2021). background period poverty, or the lack of access to menstrual health products or education, burdens the united states with up to 25% of women experiencing it at some point in their lives (medley, 2021; online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 175 rossouw & ross, 2021). although widely contributed to low income, period poverty can affect women at any time in their lives (casola et al., 2022). menstrual health needs, including supplies, sanitation, and education, oftentimes go unmet particularly in rural settings (cardoso et al., 2021). unmet needs can lead to fear and embarrassment surrounding menstruation contributing to silencing and subsequent emotional and mental health concerns in women (casola et al., 2022). women are reported to spend on average at least $20 per period on menstrual health products (park, 2022). with one in six women living below the federal poverty line (less than $30,000 for a family of four) in the united states, affording menstrual health products can be an issue for many (alliance for period supplies, n.d.). increased advocacy is needed to combat period poverty and empower young women to reduce stigma and fear surrounding menstruation (zimlich, 2022). methods design this qualitative study was guided by three research questions that enabled us to explore the lived experiences surrounding menstrual health education and knowledge for rural adolescent young women: a.) how do rural adolescent young women attain their knowledge about their period? b.) what feelings do rural adolescent young women have about menstruation? and c.) what support is provided to rural adolescent young women surrounding their period? we used van manen’s (1990) phenomenological approach as a framework for allowing participants opportunity to reflect on their experiences of menstrual health education and knowledge through moderator-guided reflective journaling prompts. one identified challenge of phenomenology is that “common sense” pre-understandings and assumptions tend to predispose us to interpreting the nature of the phenomenon before we have fully explored its significance (van manen, 1990); for a study conducted by an all-female, caucasian research team with two members online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 176 also mothers of pubescent daughters, this notion felt particularly applicable, and we recognize that societal and cultural presumptions likely exist for many people related to our topic of inquiry. van manen’s phenomenology of practice proves useful for nurses in contributing to the body of knowledge of nursing and allows nurses to act in a more reflective manner in their daily practices (errasti-ibarrondo et al., 2018). in following methodological suggestions proposed, the researchers focused on a phenomenon in which we were deeply committed. through community partnerships in the county in which research was conducted, educators in the school sought assistance in providing menstrual health products for the school. in hearing this need, we sought to understand these experiences leading to period poverty in rural settings. second, the focus of the research was solely on the experience itself. we sought to understand how each young woman had experienced their menstrual cycle and knowledge seeking prior to the education we provided. rather than the conceptualization of experiences, we focused on the words of experience each participant provided. through writing and rewriting of themes, and peer consultation the research team extracted rich data from the reported lived experiences of participants. through frequent bracketing interviews, we were able to maintain a strong relationship with the words of the participants and put aside opinions and current knowledge of the research topic. also embedded within a phenomenological design is recognition of the “intentionality of consciousness” (creswell & poth, 2018, p. 76), in that a reality is perceived only within a context of meaning of the experience for an individual. this subsequently generates multiple realities related to the phenomena of interest—not only for participants of the research, but also for the researchers themselves and the readers of this final report (van manen, 1990; creswell & poth, 2018). therefore, bracketing of the researchers’ individual experiences served as an essential online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 177 component of this design to ensure focus remained on the experiences of the participants without bringing ourselves into the work. to combat any potential bias in the study and to provide a true voice of the participants, all researchers utilized bracketing interviews with a colleague who has experience in qualitative analysis. bracketing interviews occurred prior to the onset of research to engage with forgotten personal experiences and clarify any personal bias or feelings that may influence or impact findings from the journaling responses. the research team found this particularly important as we identified three potential areas of bias. first, the entirety of the research team was caucasian, and all participants were african american; considering and acknowledging this power structure in the research was important to ensure validity of the findings. the research team also acknowledged both faculty members involved in the project have female children who are of menstruating age. these experiences were explored and discussed to reduce the chance of bias in analysis. and last, all members of the research team work and practice in healthcare which could lead to bias in findings based on previous experience as well as expert knowledge of the topic being presented. all team members engaged with potential bias and power structures created by race and occupation. theoretical framework this project was guided by the social ecological model to understand potential influential factors and their interactions that may contribute to period poverty in rural adolescent girls. to explain these influences mcleroy et al. (1988) identified five levels of influence including individual, interpersonal, institutional, community and public policy. this project heavily focused on the individual by exploring knowledge and attitudes, the interpersonal level by exploring group interactions with friends and family, and the community by exploring norms and standards which online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 178 exist surrounding menstrual health. to adequately prepare targeted intervention for promoting health, one must assess and utilize findings pertaining to the interaction of factors within this model (rimer & glanz, 2005). sample and setting the sample was drawn from a small rural high school in one of the blackbelt counties of alabama. the blackbelt region stretches along central alabama and is named for its dark, fertile soil. largely rural, the blackbelt houses this study’s setting with a population of 2,037 individuals. this community is designated as rural by the united states census bureau because its population is less than 50,000 individuals and is situated in a county that is designated as a health professional shortage area and a medically underserved area (alabama department of public health, n.d.; united states census bureau, n.d.). this community population is also lower than the 2500 individuals needed to meet the definition of an urban cluster. all participants in this study were african american young women, which is representative of the overall population of the high school and the county in which the study took place. highlighting the experiences and knowledge of african american young women in this study assists in developing an understanding of health inequity and disparity due to social and economic conditions (chinn et al., 2021). currently, there are no qualitative studies explore experiences and knowledge rural, african american young women related to period poverty. procedure data collection the research team consisted of three members, two of which are experts in qualitative research methodology and implemented all aspects of the study to ensure consistency among study procedures. a total of two menstrual health education sessions were held, with each session lasting online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 179 up to 90 minutes. sessions were led and moderated by the third author, who—at the time—was a senior-level nursing student engaged in faculty-mentored undergraduate research with the other two authors. in addition to leadership development for her as an undergraduate student, this meant each session was facilitated by someone closer in age proximity to the participants, thus creating a more open, personable, and relatable environment for everyone in discussing potentially sensitive matters. faculty members were present in a supportive role, however, and aided in each session's overall organization, including obtaining informed consent from participants and assisting with data collection via reflective journaling. the educational sessions were held during the school day in place of an elective course. they began with an icebreaker activity which allowed for the senior-level nursing student to get to know the participants. discussion about menstrual health topics was guided by a colorful powerpoint presentation and hands on activities. topics presented included basic anatomy, hormonal and physiological changes to the body during the menstrual cycle, proper use of menstrual health products including pads, tampons and cups as well as how to care for oneself during bleeding time. care discussion included ways to relieve menstrual cramps and other physical symptoms, proper disposal of care products and how to track menstruation with a period tracker. dedicated time for reflective journaling (lasting fifteen minutes in length) was offered at various timepoints during each session to allow participant expression of thoughts, feelings, and experiences while the content was still fresh on their minds. before each session ended, journals were collected, scanned into a digital format, then returned to the participant for them to keep. in all, the research team collected a total of 125 (# of reflective prompts x # of journals) guided reflective responses from the journals of 25 participants in the menstrual health education sessions. journal prompts included the following questions: 1.) tell us how being on your period makes you online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 180 feel physically and emotionally. 2.) tell us about a time you may have not had access to supplies or knowledge you needed to care for yourself during your period. 3.) tell us how you seek out information regarding your period and your body. and 4.) tell us how this education may have impacted you and how it can impact others around you. ethical considerations institutional review board (irb) approval from the investigators’ university was obtained to provide full disclosure and the protection of the rights of all participants involved in this study. to obtain parental consent, paper packets were sent home to each student’s parent. each packet contained the study description, copies of the questions asked of their child during the research, and any risks and benefits to receiving education about menstruation. the lead investigator’s contact information was provided for any questions parents may have concerning the research. parents were asked to send the completed consent form with signature back to the school before the sessions. the lead investigator and teacher completed quality checks to ensure only those participants who had a signed consent remained present in the classroom during the research. the research took place during the school day, while students were in their health education course. prior to each educational session, the first author explained the purpose of the study and its procedures and obtained child assent detailing participant’s rights. the participant was instructed if they wished to not take part, they could leave the classroom at any time during the research. due to the sensitive nature of the topic being discussed, participants were provided a printed resource guide containing frequently asked questions about puberty, menstrual health, and website information for places to obtain additional, reputable information. data analysis online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 181 analysis of data collected from participants’ reflective journaling prompts began with the organization and review of their digital journal entries obtained during the educational session. the analytic process was guided by saldana’s (2016) constant comparative method for qualitative data analysis; inductive and comparative techniques helped researchers identify similar patterns of ideas and concepts from the derived data. the language and descriptions used by participants guided the first cycle of coding, in which we coded and divided data into subcategories. during second cycle coding, we sought to identify key concepts and relationships that began to emerge from the data using higher-level analytical skills such as classifying, prioritizing, integrating, synthesizing, abstracting, conceptualizing, and theory building to develop a logical, meaningful synthesis of the data (saldana, 2016). the resulting categories were sorted and further classified and became the central themes of this inquiry. all data was stored on a password-protected and encrypted cloud-based platform accessible only to members of the research team. each researcher conducted independent reviews of digital journals, maintained documentation of field notes, and participated in bracketing of personal thoughts, ideas, perceptions, and experiences related to the research. data saturation emerged between the twelfth and sixteenth reflective journal, but all responses to prompts were included in the review to ensure data would not reveal anything new. multiple approaches were employed to validate the data (creswell & poth, 2018). from the very beginning of planning stages, clarification of researcher bias was identified and continued to be reflected upon throughout the study procedures. secondly, we participated in a departmental research support group intended to offer objective peer review, debriefing, and external audit of our research process and findings, with feedback received that helped ensure our interpretations and conclusions were supported by the data. lastly, during data analysis, discrepancies among online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 182 research team members were handled via team meeting to discuss and interpret the issue, reimmerse ourselves in the data via original transcript review, examine the discrepancy for potential meaning and/or biases, and finally, reach a consensus of derived codes, categories, or themes. rigor the research team employed many methods to ensure trustworthiness of the project in four categories including credibility, transferability, dependability, and confirmability. team members have spent an extended time with participants through this work and other community-based projects. in addition, the team sought informant feedback on the words and themes extracted from data analysis. credibility and transferability were ensured by the dense description of the population being studied and detailed descriptions of the research methods. lastly, bracketing interviews with the researchers highlighting feelings, biases and insights during the research process ensured confirmability. results the volunteer participants were female adolescents, ranging from 15 to 18 years. all participants were african american. thematic analysis three themes and one subtheme revealed the experiences and feelings of adolescent females in this rural community in which the study took place. experiences lacked robust knowledge in education received and less than ideal access to hygiene products. knowledge attained by participants came from female friends and family members. through discussion and journaling, it was revealed that participants held ideas about their periods that were inaccurate. the moderator of the session spent time dispelling these myths and used evidence-based information to educate the participants. the community in which the study took place has one dollar general that online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 183 participants reported as their main source of menstrual health products. selection at this store is often limited and many times pricing is higher than urban counterpart stores. themes emerged from the participants’ statements and suggested a desire to provide information to the researchers to empower younger girls with knowledge and support. the emerging themes included feelings of isolation, desire for continued and consistent education, and empowerment to influence. one emerging subtheme was increased female parent/guardian involvement. theme 1: feelings of isolation the theme feelings of isolation answered research question two: what feelings do rural adolescent girls have about menstruation? this theme highlighted recurrent accounts of feeling alone and without physical and emotional support from family and other female authority figures in their lives. feelings of isolation stemmed from not understanding what was happening on a physiological level and not being equipped with knowledge to perform hygiene during one’s period. one participant wrote: i am confused most of the time about what is going on in my body during my period. i have low confidence because i am scared i might smell bad or have blood running through my clothes. i feel sad and depressed during this time...i just don’t know why. in addition to lack of knowledge, lack of available supplies also contributed to feelings of isolation in this group of participants. experience of period poverty can also lead to feelings of shame and other mental and emotional health concerns. one participant described a time in which she was at school left without sanitary supplies: i was at school and my bleeding had come on. i didn’t have anything to put in my underwear to catch it so i went to bathroom and wadded up some tissue and stuck down there. i was so worried my friends could smell it or i would get blood on my clothes. i don’t want anyone online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 184 knowing i’m bleeding. i kept going back to the bathroom all day changing out my tissue. i was so worried. there was a misconception among the group of participants that girls must miss normal daily activities such as sports or after school clubs because of their period. this led to reports of loneliness and frustration on missing things that were important to them. one participant explained her experience: being on my period makes me depressed. i say this because it cuts out some of my weekly activities. i can’t be running around at practice with a bloody pad on. i get real frustrated when i am unprepared because i never really know when it is going to come on. i will call from the office and tell my aunt that i can’t go to practice this afternoon. theme 2: desire for continued and consistent education the theme desire for continued and consistent education answered research question one and described ways in which rural adolescent girls attain information concerning their periods. overall, participants received some information from their female family members; however, some of it was inaccurate. minimal information came from the school or health setting, and most information was supplemented through internet searches. through the shared experiences of participants, there is a desire for more robust discussion and education from reliable and personal sources. one participant stated she asks “my mother and friends first. i don’t also get a good answer from them so i will go and do a google search.” the participants shared they did receive some education from school, but it was a one-time occurrence. one participant wrote: online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 185 in sixth grade they came to us and gave us a talk about our bodies. they told us about our periods, but i was afraid to ask questions. that was the last time i heard anything about it and i had already started my period. i wish the school would give us more chances to learn. feedback and experiences shared by participants surrounding the education provided to them through this project were positive. one participant wrote that “[the education] has really opened my eyes to some things i did not know, but also to some things i thought i knew and were wrong.” another participant shared that, “the information you gave us today increased my knowledge. i feel like from what i learned from you; i can feel more confident about down there.” subtheme 1: increased female parent/guardian involvement. the subtheme increased female parent/guardian involvement provides additional information about the experiences of participants regarding their desire for additional and consistent education concerning their periods. this subtheme shared the same central organization of the theme desire for continued and consistent education but focuses on the notable element of female guardian involvement in that education and knowledge seeking. not only would they prefer more open conversations and education from their female family members, but they also realized during the educational session that some or much of what their family members told them was inaccurate. most common reported inaccuracies involved the physiologic changes occurring in the body during the menstrual cycle and the misconception that period blood signified filth and dirtiness. one participant wrote, “i like talking to my mom and aunt first about these things. i feel comfortable around them.” another participant shared that she, “wished my mom knew more about my period coming on.” although girls want standardized and consistent education from health professionals at school, they also wish more information would come from their female family members. theme 3: empowerment to influence online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 186 the theme empowerment to influence revealed that the girls in the study feel a duty to younger girls in assisting them attain knowledge and access to sanitary products. this theme answered research question three and shed light on the support, or lack thereof, that is provided to girls in this setting. participants felt strongly about having supplies available to all girls at school that are accessible to empower others. when asked if a sanitary product hygiene locker at school would be useful to students one participant wrote: having period products at school would be great. i know some people do not have these resources at home. it can also help those girls who are just unprepared and don’t know when their period will come on. they don’t have to be embarrassed to grab something out of the locker. they also do not have to check out of school or leave school. i see that a lot. in addition to empowering other girls with access to products, it was clear the girls in this study were empowered by the education received and wanted to share it with others. learning of their own experiences highlighted the importance of sharing information with younger girls. one participant wrote: it is so important to educate young girls about their period. you will just know what to expect and what to do for it. i would really like to help other girls to know things i didn’t know. i don’t like that girls feel shame about their period coming on. i want them to know why it’s happening and they don’t have to feel bad about somebody making fun of them about it. discussion this work aimed to explain overall experiences that rural adolescent young women experience surrounding menstrual health education and knowledge. there are currently no known studies that highlight the experiences of rural, african american young women and their periods in the united states, although some similar studies have been implemented internationally. as online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 187 described by participants through reflective journaling, the results of this study provide insights into the lived experiences and feelings of adolescent young women in a rural alabama community concerning their period. nursing implications based on the findings in this project, young women from rural alabama experience forms of period poverty whether that be a lack of education, knowledge, or sanitary supplies. the participants revealed through reflective journaling that an increase in action from adult contacts including female family members and mentors could aid in overcoming knowledge and experience deficit. nurses in rural settings are especially poised to combat this problem by working with school officials, school health educators as well as parents to plan targeted education early and consistently throughout the preteen and teen years. education should start early and then aimed to be reinforced as the female grows in age. this study was implemented in those age 15 to 18 years to gain an understanding of what knowledge and experiences of young women who have mostly likely have already experienced the onset of their first period. with the average age of menarche at 12 years, education should be delivered well before this time (lacroix et al., 2023). nurses should strive to work with health education teachers in primary schools to utilize or develop evidence-based materials about menstrual health to instruct young females in the school setting. in addition, efforts can be made to host educational events for parents led by nurses and health educators to assist in factual and scientific based conversations in the home that are supportive to growth and development. this study’s findings were consistent with casola et al.’s (2022) recommendations to act against period poverty. there are also benefits to providing educational information about menstrual health to those of other genders. this provides the opportunity to supply others with information about the menstrual cycle and normalize it as a part of everyday life as well as provide understanding of the online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 188 experiences females have concerning their period. combating stigma associated with the menstrual cycle can addressed by universal menstrual health education. school and community health center nurses in rural settings can talk openly and honestly with young females in formal and informal settings to increase knowledge and reduce stigma regarding menstruation. this can be done through scheduled classes or open office hours to provide reliable education guided by patient questioning. this education should start early and remain consistent throughout adolescence. in addition to increased education for young women, one recommendation is to increase educational experiences for female guardians. participants expressed a desire for more discussion to occur with their female family members; however, based on data from this study these individuals may lack dependable knowledge concerning menstruation. evidence based education by a nurse can assist women in guiding their young female family members through their period. nurses can also advocate for fair and equitable access to menstrual health products through policy change or community outreach efforts. policy change suggestions include covering menstrual health products under the special supplemental nutrition program for women, infants and children (wic) in all states as well as eliminating the tampon tax, which has already been done in several other countries (casola et al., 2022). one aspect of this project was the provision of pads and tampons collected by university students to stock a menstrual health locker for the young women in the school. efforts like these can easily be organized through organizations and university level partners through community-based efforts. limitations limitations present in this study include the qualitative nature in which the data was collected as well as the nature of the content being discussed with participants. qualitative methodologies online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 189 are commonly used modes of inquiry in the social sciences; however, some limitations still may exist (marshall & rossman, 2016). the investigators intended to give a voice to those participating in the study about their experiences with period poverty that only qualitative data collection methods could achieve. rich experiences were collected through reflective journaling and represented the population within the study. due to the numbers of participants, results are not generalizable but do reflect larger studies situated within current literature. the investigators aimed to explore experiences within the community in which they perform outreach. another limitation is the sensitive and stigmatized nature of answering questions about menstruation. to combat this limitation, the investigators utilized reflective journaling so the participants could freely express their experiences and feelings on paper in a supportive and encouraging environment. participants potentially still left out information in their journaling due to discomfort with the topic. this limitation cannot fully be eliminated with shame and stigma still attached to women’s health topics. conclusion period poverty continues to be an issue for women domestically and globally. although women of all social classes have the potential to experience period poverty at some point in their lives, those in underserved and rural communities are disproportionately affected (cassola et al., 2022). this project highlighted experiences and knowledge of a group of adolescent young women in rural alabama. through the development of three themes and one subtheme, participants offered insight into the degree in which period poverty is experienced in rural alabama. the young women participating in this project expressed they feel isolated due to their period, crave increased education and discussion with their female family members, and have a hope to empower younger women going forward to combat period poverty. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 190 nurses are well equipped with skills to provide education, support, and mentorship to young women to aid in stigma reduction and knowledge attainment. efforts in period poverty mitigation can start in small communities and grow to more regional and nationwide efforts to raise awareness, trigger open discussion, and enact policy engagement. references alabama department of public health (n.d.). medically underserved areas/populations (mua/ps). https://www.alabamapublichealth.gov/ruralhealth/assets/muapmap.pdf alliance for period supplies (n.d.). national fact sheet on period poverty. https://allianceforperiodsupplies.org/wp-content/uploads/2022/05/alabama.pdf cardoso, l. f., scolese, a. m., hamidaddin, a., & gupta, j. (2021). period poverty and mental health implications among college-aged women in the united states. bmc women's health, 21, article 14. https://doi.org/10.1186/s12905-020-01149-5 casola, a. r., luber, k., riley, a. h., & medley, l. (2022). menstrual health: taking action against period poverty. american journal of public health, 112(3), 374-377. https://doi.org/10.2105/ajph.2021.306622 chinn, j., martin, i., & redmond, n. (2021). health equity among black women in the united states. journal of women’s health, 30(2). https//doi.org/10.1089/jwh.2020.8868 creswell, j. w. & poth, c. n. (2018). qualitative inquiry & research design: choosing among five approaches (4th ed.). sage publications. errasti-ibarrondo, b, jordán, j. a., díez-del-corral, m. p., arantzamendi, m. (2019). van manen's phenomenology of practice: how can it contribute to nursing? nursing inquiry, 26, article e12259. https://doi.org/10.1111/nin.12259 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 191 krusz, e., hall, n., barrington, d. j., creamer, s., anders, w., king, m., martin, h., & hennegan, j. (2019). menstrual health and hygiene among indigenous australian girls and women: barriers and opportunities. bmc women's health, 19, article 146. https://doi.org/10.1186/ s12905-019-0846-7 lacroix, a., gondal, h., shumway, k., & langaker, m. (2023). physiology, menarche. statpearls. https://www.ncbi.nlm.nih.gov/books/nbk470216/ marshall, c., & rossman, g. (2016). designing qualitative research (6th ed.). sage publications. mcleroy, k. r., bibeau, d., steckler, a., & glanz, k. (1988). an ecological perspective on health promotion programs. health education quarterly, 15(4), 351–377. https://doi.org/10.1177/ 109019818801500401 medley, l. (2021). covid relief bill was a missed opportunity to address period poverty in america. https://www.nbcnews.com/think/opinion/covid-relief-bill-was-missedopport unity-address-period-poverty-america-ncna1260522 nurse practitioners in women’s health. (2021). position statement: menstrual equity and menstrual health. https://cdn.ymaws.com/npwh.org/resource/resmgr/positionstatement/ npwh-ps-092021-menstrualequi.pdf park, a. (2022). how inflation impacts the pink tax and the period product industry. https://money.usnews.com/money/personal-finance/spending/articles/the-pink-tax-howinflation-impacts-the-period-product-industry rimer, b. k., & glanz, k. (2005). theory at a glance: a guide for health promotion practice (2nd ed.). national institutes of health. https://cancercontrol.cancer.gov/sites/default/files/202006/theory.pdf online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.735 192 rossouw, l., & ross., h. (2021). understanding period poverty: socio-economic inequalities in menstrual hygiene management in eight lowand middle-income countries. international journal of environmental research and public health, 18(5), article 2571. https://doi.org/10.3390/ijerph18052571 saldana, j. (2016). the coding manual for qualitative researchers (3rd ed.). sage publications, inc. united states census bureau. (n.d.). urban and rural. https://www.census.gov/programssurveys/geography/guidance/geo-areas/urban-rural.html van manen, m. (1990). researching lived experience: human science for an action sensitive pedagogy. state university of new york press. zimlich, r. (2022). what clinicians can do to help with period poverty. contemporary ob/gyn. https://www.contemporaryobgyn.net/view/what-clinicians-can-do-to-help-with-periodpoverty c-725+examination+mental_illness+older+pesons+rural_final_psf_4_5_23+arformatted online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 70 strength and vulnerability of mental illness in older persons within the rural context jessica katerenchuk, rn, mn1 sherry dahlke, phd, rn, gnc(c)2 1research assistant, faculty of nursing, university of alberta, jkateren@ualberta.ca 2associate professor, faculty of nursing, university of alberta, sherry.dahlke@ualberta.ca abstract purpose: in this paper we analyzed the complex issue of mental illness in older persons living in rural areas using the strength and vulnerability integration (savi) model as a conceptual framework to bring balance to negative accounts of older persons’ emotional experiences. method: a narrative review was conducted to examine the mental health issues of older persons living in rural areas. three databases were searched for data pertaining to rural mental health and the savi model. theoretical and empirical articles that analyzed the strengths and vulnerabilities in relation to mental illness in older persons living in rural areas were included and analyzed. additionally, policy and position papers were used to interrogate this issue. findings: analysis revealed three themes: individual vulnerabilities, system vulnerabilities and strengths. rural individuals’ struggles with chronic stress, a loss of social belonging, and neurological dysregulation across their lifespans were discussed in how they developed strengths in ageing and overcame vulnerabilities. barriers to accessing mental health services, caregiving respite care, and health promotional services in rural areas included system vulnerabilities that exacerbated the rates of mental illness and poor health outcomes in older persons. strengths included the rural social connection and community engagement that fostered a sense of community. conclusions: research and practice recommendations situated within the savi model include the importance of acknowledging individual differences viewing the strengths of ageing, cultural online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 71 perceptions of time and leveraging community-based strengths to overcome vulnerabilities of ageing in rural areas. these changes will facilitate nurses and other health care providers assess, respond to, and prevent mental illness and poor health outcomes in the diverse ageing population living in rural areas. keywords: mental illness, rural areas, older persons, strength and vulnerability integration model, ageing population strength and vulnerability of mental illness in older persons within the rural context older persons’ mental health is a major health concern and priority for governments and health care organizations globally (canadian mental health association, n.d.; world health organization [who], 2013, 2017). however, rural areas continue to face inequitable rates of mental illness and poor health outcomes in comparison to urban areas (caxaj, 2016; richman et al., 2019). background the who’s (2019a) sustainable development target to prevent mental illness and promote wellbeing in older persons has public health importance (rangarajan et al., 2021; wainberg et al., 2017). one in four older persons currently lives with a mental health problem, a factor that decreases life satisfaction and increases rates of cognitive impairment, medical co-morbidity, and mortality (pan american health organization,n.d.; puvill et al., 2016; who, 2017). unaddressed mental health concerns across demographics continue to cost the global economy over one trillion united states dollars per year when you account for one in five years lived with disability (shim, 2020; who, 2019b). societal repercussions are expected to worsen due to increasing numbers of older persons (parkar, 2015; who, 2017; who, 2022). older persons will increase in numbers from 12 to 22 percent of the total population size (who, 2017). this means a greater number of older persons will experience mental illness and poor health outcomes, including suicide, in the online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 72 next decade (canadian coalition for seniors’ mental health, n.d.; canadian medical association, 2016; richter et al., 2019; statistics canada, n.d.-a). paying attention to mental health issues is important because more than 700, 000 people die every year from suicide globally (who, 2021). older persons, particularly older men, currently experience the highest suicide rates of all age groups (government of canada, 2014; who, 2014). rural residents face a doubled risk of dying by suicide compared to those in urban centres (helbich et al., 2017; statistics canada, n.d.-b). this concern will continue to worsen unless a critical examination of the mental health issues and their contributing factors are identified and addressed (moroz et al., 2020; st. john et al., 2021). although there are vulnerabilities in rural settings, there are also unique strengths. moreover, older persons are very heterogenous and may have strengths as well as vulnerabilities in coping with mental health issues and maintaining their emotional wellbeing (herron et al., 2021). to provide a holistic understanding of mental illness in rural areas, we employed the strength and vulnerability integration (savi) model as a conceptual framework (nosraty et al., 2015), to examine how older persons in rural areas are managing mental health issues within various contexts including their families, communities, and health care systems. the savi model is a multi-dimensional and lifespan-orientated ageing model that includes both assumptions of strengths inherent in aging, as well as vulnerabilities, providing a more balanced perspective. the savi model draws upon early psycho-social theories, primarily the socioemotional selectivity theory (sst), to posit that individuals experience a motivational shift from knowledge acquisition to emotion-related goals as they age (sullivan-singh et al., 2015). this shift is related to the development of a limited time perspective, or the conscious or unconscious perception of time left to live (carstensen et al., 1999; liao & carstensen, 2018). the online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 73 savi model extends the sst, suggesting that time lived also strengthens older persons’ emotional regulation abilities as they develop life experiences and self-knowledge (blanchard-fields, 2007). the savi model suggests that when older persons face sustained exposure to highly arousing or chronic stressors, age-related emotional strengths may disappear, and physiological vulnerabilities may arise (charles, 2010; sliwinski et al., 2021). thus, older persons are at risk of developing physiological instability post-stressors related to age-related changes in their hemodynamic, parasympathetic/sympathetic, and cardio-musculature systems (charles, 2010; ferrari et al., 2003). within the savi model are assumptions that older persons are prone to experiencing adverse outcomes following chronic stressors, such as high basal cortisol levels, increased blood pressure, and premature death (buckley & schatzberg, 2005; ong et al., 2012). another assumption of the savi model is that older persons cope with stressors and maintain their emotional wellbeing by drawing on cognitive-behavioural emotional regulation skills, such as reappraisal of the situation, avoidance of negative circumstances, and reflection on more positive events (mikels & young, 2018). when older persons encounter circumstances where they are unable to draw on these strengths associated with ageing, they may experience a loss of social belonging, chronic uncontrollable stress, or neurological dysregulation, physiological vulnerabilities (zacher & rudolph, 2022). we used the savi model as a conceptual framework to guide our examination of mental health in rural older persons as we believe it offers a balanced examination of vulnerabilities as well as strengths associated with ageing in rural areas. we acknowledge that the savi model has both strengths and limitations in this endeavour and will provide a critical discussion of the model’s holistic strengths and limitations in our discussion of our findings. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 74 methods the purpose of this narrative review was to explore the strengths and vulnerabilities of older persons as they navigate maintaining and improving their mental health, specifically in rural areas, using the savi model as a conceptual framework. the research questions that guided the review included: 1. what factors contribute to mental illness and poor health outcomes in older persons living in rural areas? 2. what strengths within rural communities promote mental wellbeing among older persons living in rural regions? a search of three databases and policy/position papers related to mental health in older persons living in rural areas and the savi model was conducted. the inclusion criteria were empirical and theoretical articles that were: (a) focused on the emotional strengths and vulnerabilities of older adults living in rural areas in the global context, (b) accessible via the online library, (c) online articles published in full, and (d) in english. rural areas were defined as all territory existing outside of urban centres, which included small towns, villages, and other populated places with less than 1,000 persons, agricultural lands, and remote/wilderness areas. the exclusion criteria included dissertations, theses, and articles written in languages other than english. the search process involved a comprehensive computer-assisted search strategy across three databases: medical literature online (medline), the cumulative index of nursing and allied health literature (cinahl), and psychinfo. in april 2022, the researchers consulted with a medical librarian to narrow down the terms for the search. the terms selected were: "mental* health*" or "mental* ill*" or "mental well*" or suicid* or depress* or anxiety or anxious* or "stress disorder*" or ptsd or "emotional well*" or "emotional health"; rural or countryside or "country online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 75 side" or non-urban or "remote* locat*" or "remote area*" or "remote* living"; elder* or "older people" or "older adult*" or "older individual*" or "older person*" or "old age*" or senior* or "older demographic*"; “strength* or vulnerab* or weakness* or advantage*”. data analysis the methodological quality of the articles were assessed using the mcgill mixed methods appraisal tool (mmat) (hong et al., n.d.; pluye et al., 2011). only papers that met 60% of the mmat criteria were included. the first author completed data extraction of the articles by including the title/year, purpose, method, sample size, key findings related to the vulnerabilities and emotional-related strengths of older persons in the rural context, and outcomes. see table one. the second author guided the data extraction and participated in the analysis. the savi model guided our analysis of the data to ensure that we examined both the strengths of ageing, and the circumstances when older persons become vulnerable when unable to draw upon these advantages in the rural context. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 76 table 1 , overview of the included articles authors/locatio n purpose method sample findings outcomes abdul manaf et al. (2016). malaysia to determine the prevalence of mental health problems and their associated factors in a rural community of perak, malaysia. quantitativenon randomized; cross sectional study 230 respondents of malay elderly aged 60 years and older. mental health problems among the malay elderly was identified as a concern. malay elderly who were single (unmarried, divorced, widowed, living with family (i.e., unable to participate in social activities in the community), and having a poor general health status had a higher risk of depression. vulnerabilities related to mental wellbeing in older adults in the rural area of perak were identified as being single, living directly with family, and poor general health status. adjayegbewonyo et al. (2019). africa to determine associations between social capital and depression and assess differences between urban and rural settings. quantitative nonrandomized; cross sectional study 4209 ghanian and 3148 south african adults 50 years of age and older (suitable older adult age based on african countries' perceptions of ageing). south african rural older adults appeared less engaged in community activities but more trusting and socially active informally than older urban residents. community engagement, sociability, and trust were associated with risk of depression in rural ghana. identified perceived support is more strongly associated with depression than received support, and therefore could be identified as a strength of ageing. identified trust could be strengthened as a protective factor against depression in older adults. was unable to determine meaningful urban rural differences in the effects of social capital on depression. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 77 authors/locatio n purpose method sample findings outcomes baernholdt et al. (2012). united states to examine qol (qol) in a nationally representative sample of communitydwelling adults 65 years and older according to geographic region. 3 dimensions of qol were examined. quantitative nonrandomized; cross sectional study 5000 individuals from the civilian, noninstitutionalize d us population 60 years of age and older. older adults in rural regions experienced more vulnerabilities of ageing, including higher rates of chronic conditions, lower adl function, lower social functioning, memory problems, and depression. lower rates on social functioning in rural areas indicate that rural individuals may be socially isolated, and that they need interventions to prevent chronic health conditions, strengthen relationships, and increase their qol in older age. bayly et al. (2020). canada to investigate the support and education needs of people with dementia and their caregivers living in rural areas, the availability and use of support and education services, barriers to access and use of services, and solutions to overcome the identified barriers. scoping review 174 articles (range of the age of subjects in the studies were not specified) were used for full text independent review. limited and insufficient services are available to dementia patients and their caregivers in rural areas. specific gaps in care included day programming and respite care, counselling and support services, early stage support, and services for minority groups. identified several barriers to the use of services including poor knowledge, practicality barriers, values, negative stigma related to dementia, and the inappropriateness of services. a vulnerability of older adults in rural areas is the limited and insufficient services available to dementia persons and their caregivers. also identified geographical and transportation barriers to accessing care as a unique barrier/vulnerably in rural populations. highlighted the importance of informal community support networks in strengthening wellbeing in older age. identified several recommendations to improve rural dementia services (reduce vulnerabilities) including, 1) enhancing the use of information and online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 78 authors/locatio n purpose method sample findings outcomes communication technologies, 2) having a point of entry to service use, 2) accessibility, d) interorganizational collaboration, 5) education, and 6) developing tailored/person centered services. behera et al. (2016). india to estimate the prevalence of depression and to study the association of depression with sociodemographic and clinical variables among elderly persons in a rural community. quantitative nonrandomized; cross sectional study 490 identified elderly (aged 60 years and older) persons. older individuals living in rural regions are at an increased risk of depression. living in a nuclear family, a lack of physical activity, presence of multiple chronic conditions, no role in family decision making, sleep problems in the past year, and bilateral hearing were loss associated with depression in elderly persons. identified that older persons living in the rural community should regularly engage in physical activity (walking), screening for chronic conditions, and in early public health interventions when diagnosed with depression to decrease risk of emotional deterioration. brjoux et al. (2016). germany to investigate whether volunteers with a special qualification for the assistance of families caring for dementia patients can support family members more effectively than conventional care options in rural areas. quantitative; randomized controlled trial 76 families of dementia caregivers (age range of 52-78) were investigated. family support was identified to be an effective intervention for dementia affected families, leading to an improved qol for caregivers. easing the burden for family caregivers of persons with dementia in rural areas is necessary to maintain home care services. to enhance the emotional strengths of ageing, programs and policies should strengthen social cohesion through older adults' community involvement, and parallelly, their qol. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 79 authors/locatio n purpose method sample findings outcomes burnette et al. (2021). china to examine the impact of social cohesion and geographic locale (urban versus rural) on the qol for older adults in china. quantitative nonrandomized; cross sectional study 9663 adults aged 50 years and older. social cohesion contributed to a better qol in older persons. cohesion mediated association of living arrangement (e.g., living alone, versus with family) and qol in urban, but not rural areas. identified that programs that strengthen social cohesion through community involvement (fostering access, inclusion, meaningful participation) will enhance qol and mental wellbeing (strengths of ageing) in both urban, and rural areas. housing and community developments should focus on allowing older adults to live near, but not with adult children, particularly for rural adult women who are predominantly low income and low education. buvneshkumar at al. (2018). india to estimate the prevalence of depression and to assess the factors that are associated with depression amongst the elderly. quantitative nonrandomized; cross sectional study 690 older adults (aged 60 years and older) in kattankulathur, india. low socioeconomic status, a nuclear family, low intensity work, conflicts in the family, and death of family members were identified as associated with depression in older adults. identified that the risk for depression is closely tied with the family. therefore, any changes in a family's equilibrium, including health, conflict, and bereavement must be acknowledged and addressed as they will have an impact on an older persons mental health status. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 80 authors/locatio n purpose method sample findings outcomes carver et al. (2018). canada to examine what factors enhance or detract from the ability of older adults that live in rural areas to socially engage in rural communities. scoping review included 19 articles in the scoping review. the age of “older adults” included in the review was not specified. maintenance of the physical home, assistance with pet care, and transportation to maintain social participation is key to increasing an older adults' ability to successfully age in place and maintain one's emotional wellbeing. highlighted that by providing community supports in doing daily tasks and having basic human contact, older adults can continuously contribute to the community, which creates a sense of belonging and social cohesion in rural areas. coleman et al. (2011). bulgaria to investigate the role of spirituality and religious practice in protecting against depression among older people in rural villages in bulgaria and romania. quantitative nonrandomized; cross sectional study 160 persons 60 years and older. eastern europe displays high rates of depression among its older population. religion is an important, but neglected part of social capital. social support was also identified as correlated negatively with depressive symptoms. highlighted that enhancing older adult's sense of religion may offer protection against depression in older age in rural areas. social support may also be used to enhance the emotional strengths of ageing and prevent vulnerabilities in older age. fastame et al. (2022). italy to investigate whether sociocultural context (urban versus rural) perceived health, marital status, and satisfaction with family ties predicted hedonic and eudemonic wellbeing in late adulthood and to examine the impact quantitative nonrandomized; cross sectional study 101 community dwelling participants aged 68 to 94 enrolled in the sardinian blue zone and in an urban area (cagliari). main health services and a more favorable economic status was easier to access and obtain in urban centers by older adults. however, higher levels of wellbeing were identified among the inhabitants of sardinian blue zone (rural area). interventions that promote maintenance of a positive social status and connection in older age (being useful for others, supported by others, respected) in one's community can be used to promote positive mental health outcomes in rural and urban areas. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 81 authors/locatio n purpose method sample findings outcomes of sociocultural context on wellbeing, physical health, and satisfaction with family. garabrant & liu, 2021). united states to identify the degree of loneliness, depression, and activity engagement among rural homebound older adults and determine differences in loneliness and activity engagement between those with and without selfreported depression. quantitative nonrandomized; cross sectional study 350 homebound older adults (aged 60 years and older) in 2 rural counties in south central indiana. depression was identified as associated with higher degrees of loneliness and low activity engagement in rural older adults. identified that a high proportion of rural homebound older adults had depression. older adults who were dependent on others and had difficulty competing adls were shown to experience higher degrees of loneliness (mobility issues may cause difficulty in leaving houses). rural older adults who reported depression or loneliness engaged less in leisure activities. identified that rural homebound older adults with depression and loneliness must be encouraged to engage in meaningful activities and socially to strengthen their ability to emotionally cope in the community. gong et al. (2012). china to investigate the associations between family characteristics and depressive symptoms and to provide recommendations for the prevention and treatment of depression of older adults. quantitative nonrandomized; cross sectional study 1317 individuals aged 60 years and older in rural china. confirmed that family related life events, family support, family economic status, and perceived physical health status are all independently associated with depressive symptoms. identified a strong correlation between being exposed to harmful family environments and depressive symptoms in the rural elderly. efforts must be made to address family risk factors (negative life events such as the loss of a spouse, bad perceived health statuses) and enhance family cohesiveness to decrease depressive symptoms in older adults. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 82 authors/locatio n purpose method sample findings outcomes hagen et al. (2022). canada to explore perceptions of help seeking for mental health among farmers and people who work with farmers. mixed methods; sequential mixedmethods design 75 farmers (average age 46.6, range 1988) in ontario. identified several themes in their analysis, including 1) the negative impact of financial stress on perceived stress on farmers. identified relationships between gender and perceived stress (increased in females due to multiple roles), 3) perceived industry peer support and perceived stress (require community support), and 4) perceived stress and perceived support from family (farmers require support from family to manage stress). identified a need to provide stress management and resilience building approaches and interventions for farmers, that include social support networks, industry support (i.e., particularly for women). hagen et al. (2021). canada to identify and explore factors associated with perceived stress among canadian farmers. qualitative; descriptive 75 farmers (average age 46.6, range 1988) in ontario were interviewed. help-seeking among farmers were identified as dependent on four factors in five themes including 1) the accessibility for farmers (i.e., based on awareness, 2) physical distance, finances, and gender), 3) stigma surrounding mental health and help-seeking, 4) the anonymity of services, and the 5) farm credibility of services and service providers. identified that all barriers (financial supports, physical accessibility, stigma, anonymity, gender specific services) to mental health in rural areas in farmers must be addressed through taking a farm credible approach, and understanding the lifestyle and needs of rural farming individuals. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 83 authors/locatio n purpose method sample findings outcomes herron et al. (2021). canada to investigate perceptions of isolation and loneliness during the initial states of the pandemic (may to july 2020). qualitative; descriptive 26 community dwelling older adults (65 years of age and over) living in rural manitoba. rural dwelling older adults are a diverse group with different resources influencing their pandemic experience. during the pandemic older adults experienced isolation and loneliness related to 1) a loss of feelings of autonomy, 2) loss of social activities and spaces, and 3) lack of meaningful connection at home (loss of spouses, friends). however, the authors also found that rural 4) older adults had experienced past feelings of isolation living in rural areas related to the tight knit community and lack of services/activities for older adults. therefore, many older adults also had developed strategies to manage isolation, such as 5) adapting one's home environment and 6) negotiating physically distanced visits (meeting outside and connecting via online technology), and keeping busy. identified the need to develop 'place based' social resources in rural areas for older adults to protect against isolation and loneliness, building upon the strategies used by older adults in managing isolation prepandemic. identified the importance of developing remotely delivering social programs, telephone support services, physically distanced outdoor visits, and programs that encourage keeping busy (walking, gardening) to assist older adults in strengthening their emotional wellbeing. house of commons. (2019). canada to identify factors that make farmers vulnerable to mental health problems and to look at initiatives across canada that supports farmers policy paper reports from farmers (aged 18 and over) across canada. rural farmers experience a high prevalence of mental distress. factors identified that contributed to an increased risk of mental illness in farmers were uncertainty and limited control, the isolation and stigmatization of farming, and identified the importance of developing a national coordination of existing initiatives to support farmers' mental health (canadian network for farmer mental health). this would involve online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 84 authors/locatio n purpose method sample findings outcomes facing mental health challenges. the high-risk nature of farming. factors that contributed to barriers in accessing current supports for farmers were the lack of a clear mental health mandate for agriculture, the restricted access to mental health care, and that health care providers had a poor understanding of the needs of farmers. developing tailored easy access, online programs strengthening mental health and resilience in farmers, training and awareness efforts for stakeholders involved with farmers (highlighting the value and importance of farming), and providing adequate economic support to the agriculture sector. howorth et al. (2019). africa to investigate community beliefs surrounding depression in subsaharan africa. qualitative; descriptive 81 participants from rural villages of kilimanjaro, tanzania (60 years of age and older). identified that depression in older people could be described as having "too many thoughts," cognitive symptoms, affective and biological symptoms, a wish to die, and somatic symptoms. identified depression as potentially caused by an inability to work, loss of physical activity and independence (unable to be financially productive), lack of resources, chronic disease, and family difficulties in older adults living in rural areas in tanzania. cognitive impairment was identified as commonly associated with depression in older people. identified that depression was managed through love and comfort, identified that attempts to understand culturally specific concepts of depression may assist us in accurately diagnosing mental illness, improving service use and availability , and reducing stigma surrounding mental illness in older adults. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 85 authors/locatio n purpose method sample findings outcomes providing advice, help, and spiritual comfort. hu et al. (2018). china to investigate the extent to which social supports could explain depression symptom disparity between rural and urban older adults living in china. quantitative nonrandomized; cross sectional study data from 6772 observations (aged 45 and older) from the 2011 china health and retirement longitudinal study. identified rural older adults experienced more depressive symptoms then their urban counterparts. identified that the gap in community support for older adults in rural areas was a prime explanation for depressive symptom disparities between urban and rural older adults living in china. the urban-rural difference in family support also contributed to this disparity. identified that educational level and increased levels of chronic health conditions (decreased physical health status) could contribute to the revealed disparity in depressive symptoms. to decrease the depression rates in rural older adults, social supports should be strengthened (i.e., improving infrastructure construction, strengthen role of social organizations), and community interpersonal interactions should be encouraged. identified that mental health supports must particularly be given to rural older adults with low education level (i.e., to improve their ability to emotionally cope). jones-bitton et al. (2020). canada to examine the prevalence of stress, anxiety, depression, and resilience amongst canadian farmers. quantitative nonrandomized; cross sectional study 1132 farmers (average age 46.6, less than the average age of canadian farmers age 55) participated in the study. identified that the scores of stress, anxiety, and depression were higher and the scores of resilience lower in farmers than normative data. females in particular scored less positively on all mental health outcomes investigated. strategies such as talking with peers (social support), engaging in hobbies, and performing self-care were identified as useful in improving resilience (essential in highlighted mental illness in farmers as a significant public health concern in canada. identified a critical need for research and interventions (policy, mental health training, health service) related to strengthening farms' mental health and resilience. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 86 authors/locatio n purpose method sample findings outcomes safeguarding against the negative impacts of stress in farming). kunde et al. (2018). australia to examine the life and death circumstances of australian male farmers who died by suicide through verbal reports from their significant others. qualitative; ethnography 12 male farmers (average age 60.17) that committed suicide (family members completed the interviewing, average age 63.50). 6 themes were identified that contribute to elevated rates of suicide in farmers including 1) masculinity as a norm, 2) uncertainty and feelings of no control in farming, 3) feelings of failure in farming, 4) escalating health problems (physical and mental), and 5) maladaptive coping mechanisms (drinking, aggressive behaviors, and 6) increased means (firearms). farmers will continue to face uncertainty (weather, negative life events) in their occupation; local service networks must improve access to mental health care and suicide prevention strategies (strengthening farmers' social support networks, coping mechanisms). in these programs, several factors that contribute to mental illness in farmers must be addressed including masculine norms and socialization, expectations of self in maintaining family traditions and occupation, and a male subtype of depression (i.e., aggressive, anxiety driven). li et al. (2022). china to examine the mediating role of sleep quality and psychological distress between the already explored relationship between social quantitative nonrandomized; cross sectional study 2254 rural empty nest older adults (aged 60 years and older) were included in the analysis. identified that sleep quality and psychological distress mediated the relationship between social capital and self-rated health in older adults in rural areas. efforts must be made to improve older persons' mental health through increasing access to social support resources in rural areas. mental health support options (increase the strengths of online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 87 authors/locatio n purpose method sample findings outcomes capital and self-rated health. ageing) must specifically be made for older adults living alone with sleep problems and psychological distress. liang et al. (2020). china to investigate the relationships between social capital and individual health among the elderly in rural china in an effort to improve the health of chinese people. quantitative nonrandomized; cross sectional study selected 3719 respondents (aged 60 years and older) from the 2016 china family panel studies. identified that cognitive social capital (perceptions of accessible social networks) plays a stronger role then structural (actual social activities in formal or informal networks) in promoting individuals' health (including emotional wellbeing) among the elderly. identified that the health status of older adults in rural areas is poor, related to poor health knowledge among older adults in healthy eating and hygiene habits. increased access to primary health care resources must be created in rural areas to decrease chronic health issues in older adults living in rural areas. these resources must be adaptable, as older adults in rural areas are heterogenous and require different supports (social capital via social groups, mental health needs, chronic health needs). lin & chen. (2018). china to examine the connections between intergenerational emotional closeness, location of multiple children, and parental depressive symptoms within a context of out migration in rural china. quantitative nonrandomized; cross sectional study sample of older adults aged 60 living in rural townships in chaohu (agricultural municipal district with massive outmigration). identified that individuals with adult children living in urban areas were not necessarily the most at risk for deterioration in emotional wellbeing. individuals with adult children living closely by could also experience deterioration in psychological wellbeing if the bond is weak. however, identified that collective emotional closeness (social cohesion) and psychological wellbeing is positively intergenerational cohesion and the physical location of children from older adults affects parents' psychological wellbeing in later life. efforts must therefore be made to strengthen social cohesion between families to support older adults' emotional wellbeing in later life. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 88 authors/locatio n purpose method sample findings outcomes associated with each other in older adults. luo et al. (2017). china to examine the association between social activities and depressive symptoms among older adults in china regarding urban-rural differences. quantitative nonrandomized; cross sectional study 8255 respondents (aged 60 years and older) from 2015 china health retirement longitudinal study. identified the prevalence of depressive symptoms was lower in urban older adults compared with rural older adults. identified interacting with friends daily or in hobby groups were inversely associated with depressive symptoms among rural older adults. however, rural older adults had a higher prevalence of depressive symptoms and participated in fewer social activities compared to their urban counterparts. identified related to the high prevalence of depressive symptoms and low social activity participation in rural areas, financial and social supports must be created for older adults. moholt et al. (2018). norway to explore the use and predictors of home based and out of home respite care services available to home dwelling persons with dementia through examining the perspectives of family caregivers. quantitative nonrandomized; cross sectional study included 420 family caregivers (aged 65 years and older) in northern norway. identified that home care services were significantly higher for persons with advanced age, those living in urban areas, persons living in an assisted living facility, persons living alone, and those able to manage being alone for a short period of time. use of out of home respite care services was higher among male persons with dementia and those living in urban areas. higher age, educational level, status as a daughter/son, full time employment predicted greater use of home based services. identified that more efforts must be made to support families who underuse respite/homecare services (older adults in rural areas, with low educational levels) when caring for family members affected by cognitive disability at home. to promote equity, these services must be tailored to all families and groups of persons with dementia and their caregivers (via social online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 89 authors/locatio n purpose method sample findings outcomes supports, emotional supports). nair et al. (2015). india to examine the psychiatric problems faced by the elderly indian population and develop strategies to improve their qol. quantitative nonrandomized; cross sectional study 383 elderly patients (aged 60 years and older) were included. identified that over 33. 9% of the geriatric population in india was above the threshold for mental illness. the most common psychiatric disorder in older adults in rural areas was depression. highlighted that several barriers prevented the use of health facilities by the community, with more faced by the elderly. these included limited mobility, limited information access, inadequate awareness of the treatability of mental conditions, lack of family support, and social isolation. identified efforts must be made to raise awareness of mental disorders and its association with older age to enhance early detection and treatment in rural areas. efforts must also be made to address family and social risk factors for mental illness among older persons living in rural communities (increased social supports, suicide prevention information, family support). neville et al. (2018). new zealand to understand the physical and social factors that enable those aged 85 years and over to remain engaged in a rural community. qualitative; descriptive included 15 people (aged 65 years and older) who lived independently identified that older people aged 85 years and over found challenges in negotiating the physical environment and maintaining social networks due to changing social demographics and the availability of community identified efforts must be made to develop the physical environments in rural areas (age friendly communities) to support older adults in navigating online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 90 authors/locatio n purpose method sample findings outcomes in a rural community. groups. the first theme (negotiating physical environment) identified well designed physical environments could assist older adults in engaging in social/community activities. identified not all individuals had access to a car and public transport operations were minimal (decreasing access to social engaged. the second theme (maintaining social networks) identified the importance of social environments for older persons in maintaining emotional wellbeing. their communities and engaging socially. pérès et al. (2012). france to study health and aging in elderly farmers living in the rural area, with a central focus on dementia. quantitative nonrandomized; cross sectional study 1002 participants (aged 65 years and older) randomly selected from the farmer health insurance rolls. the ageing population and growing burden of chronic disease will increase demand for health and social services for older farmers with dementia. elderly farmers living in the rural area experience increased risk of dementia related to the long term effects of agricultural exposures. however, these work related vulnerabilities were balanced by the advantages of living in rural areas (walking, fishing, gardening, hunting, etc.). an aging populations and increasing burden of chronic diseases in older age will increase the demand for health and social services for older adults. in rural areas, the challenges of agricultural exposures and decreased access to shops, services, and primary care is outweighed by the advantages (protective factors) of the richer social support networks, living environment (greenery, security, spacious online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 91 authors/locatio n purpose method sample findings outcomes accommodations), and access to a healthier lifestyle. roy et al. (2017). canada to understand the social contexts in which farmers engage in health promoting behaviors that may prevent or mitigate mental health problems. qualitative; descriptive 32 farmers (age range of 25 to 64) in quebec. identified that positive coping mechanisms used by farmers did not align with the negative aspects of the traditional hegemonic norms in north america, and that health promotion strategies should be aligned with the positive, more progressive aspects of these norms (e.g., promoting work life balance). coping mechanisms used by farmers currently focus on instrumental action (taking breaks), rather than communicative action (talk) for farmers when dealing with emotional issues. many older adults and younger farmers are questioning the relentless work ethic previously dominant in farming, representing a cultural change across and within age groups. services must be developed that support farmers in managing their mental health problems. this can be achieved through developing services that enhance farmers' resilience and community engagement (taking breaks collectively), and further deconstruct masculine practices that inhibit engaging in mental health supports. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 92 authors/locatio n purpose method sample findings outcomes ruan et al. (2022). china to examine the association between negative life events and depressive symptoms for older adults, and to differentiate the moderating roles of family ties and friendship ties in the perceived association. quantitative nonrandomized; cross sectional study data from 11,471 older adults (aged 60 years and over) in the chinese longitudinal aging social survey. exposure to negative life events is an important risk factor for depression in older adults. older adults with stronger social ties display less severe depressive symptoms than those with weaker social ties when experiencing negative life events (evidence of the moderating role of social ties). both family and friendship ties were directly related to less severe depressive symptoms (friendship ties were stronger). as older adults faced an increased risk of disruptive life events at older age, they are more at risk of depression. therefore, efforts must be made to support older adults in enhancing cohesion among their family network to improve their mental wellbeing (living close, co-residing). also emphasized the importance of developing friendships in older age to enhance their psychological wellbeing through enhancing resilience and positive coping mechanisms. saifullah et al. (2020). indonesia to identify the population's mental health status and factors correlated with mental distress in rural areas of indonesia. quantitative nonrandomized; cross sectional study 1500 residents (aged 75 years and older) from villages in yogyakarta, indonesia. the rural population of indonesia has a higher prevalence of mental distress in comparison to those living in urban areas. sociodemographic status (older age), gender (male), occupation, small size housing, and being chronically ill (2.6 times risk of mental distress) were found to be correlated factors of mental distress in rural indonesia. identified the importance of developing mental distress prevention programs adapted to older adults, those with more chronic conditions, gender, low income, housing situation (enhancing intergenerational support) and occupation (related to psychological and social work demands). online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 93 authors/locatio n purpose method sample findings outcomes scorgin et al. (2016). united states to investigate two contrasting explanations (behavioral versus cognitive) in the relation of emotional distress to qol. or, the mediating role of engagement in pleasant events (behavioral theory) and hopelessness (cognitive) in the relation of emotional distress and qol. quantitative nonrandomized; cross sectional study 134 older adults (aged 65 years and older) with reduced qol and increased psychological symptoms in rural areas. both theoretical approaches of the cognitive behavioral model and theory of emotional distress (combines cognitive approaches with behavioral elements) are important to understanding qol in older adults living in rural areas. the impact of emotional distress on qol in older rural adults is mediated by the feelings of hopelessness and the impact of these feelings on the pursuit of pleasant events. race/ethnicity (caucasian versus african americans) moderated the indirect effect of emotional distress through engagement in pleasant events and feelings of hopelessness. feelings of hopelessness and engagement in pleasant events is useful targets for interventions in rural, older adult populations. interventions aimed at reducing hopeless and increasing pleasant events may assist in increasing older adults' qol. strategies that should be implemented in older adults that enhance qol included cognitive behavioral therapy (reframing negative thoughts) and behavioral activation (enhancing problem solving, communication skills). silverstein & zuo. (2021). china to examine the impact of caregiving for grandchildren on grandparents' mental health. quantitative nonrandomized; cross sectional study constructed 2835 observations (aged 45 years and older) from 1067 grandparents. when older adults experience limited socioeconomic support from adult children, they are more likely to experience mental distress. however, level of engagement with families and other social group is beneficial to cognitive ability, not emotional wellbeing. as economic inequality grows in china and family size continues to decrease, adult children are increasingly unable to provide economic support to parents who are taking care of left behind children. the economic and therefore emotional wellbeing of caregiving parents can be enhanced through online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 94 authors/locatio n purpose method sample findings outcomes strengthening pension programs. silverstein et al. (2020). china to investigate how uncertainty about care may adversely influence mental health in the older adult population in canada by applying social support and control theories. quantitative nonrandomized; cross sectional study based on data from the china health and retirement longitudinal study (multipaned national representative household survey of the chinese population aged 45 years and older). 11, 000 to 14, 000 respondents were used for the final regression panel. identified older adults living in urban areas and with a college education is less likely to expect care and experienced less depression compared to rural older adults and less educated adults. caregiving frequency is not by itself harmful or beneficial to the emotional and cognitive health of older adults in rural china. however, caregiving in older age could be harmful in the context of custodial care that is less economically supported by adult children. identified that elevated emotional distress is common among older adults that have uncertainty about having a future care provider (absence of children, living further away from them). also identified that decreased living standards and adls increase depression in older adults. the rapid ageing of the china population, increases in chronic disease burden, and decreases in family caregiving indicates that older adults in china may face health and social conditions that will deteriorate their mental health (e.g., uncertainty about having a future care provider, financial security, etc.). efforts must be made to financially incentivize adult children in caregiving for older adults, develop community based care for older adults, and low cost housing for older adults without family support. also identified the importance of developing mental health supports for older adults with chronic health conditions and limited family support. sun et al. (2017). china to examine the predictive power of quantitative nondata were drawn from a low self-esteem (from low social supports), severe identified that strengthening family online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 95 authors/locatio n purpose method sample findings outcomes depression on qol after controlling for self esteem. randomized; cross sectional study study of elderly's mental health in rural china. survey used a sample from 5 public nursing homes in xintai county (205 individuals aged 60 years and older). depressive symptoms, and insufficient social support could decrease seniors' qol (mental wellbeing). identified that qol was negatively associated with age and positively affected by visiting frequencies from their relatives, and that widowed/divorced people reported poorer qol then the married. social support moderated the relationship between self-esteem and qol. older adults in nursing homes experienced severe mental health problems and the low self-esteem made them reluctant to ask for help. social support also buffered the effect of depression on qol among older people in chinese rural care homes. (family eased psychological distress) and other social supports could help older adults with low self-esteem improve their qol, particularly in care homes. efforts should also be made to increase the self-esteem of older adults to enhance their qol and serve as a buffer against depression. thapa et al. (2018). australia to examine the association between the left behind or empty nest status and the mental health of older adults. also, to identify risk factors for mental health in older adults living in rural areas. integrative review 25 articles met the inclusion criteria to be reviewed. the age of subjects in the studies ranged from 50-100 plus years. "left behind" older adults had higher levels of mental health problems. they experienced higher depressive symptoms, higher levels of loneliness, lower life satisfaction, cognitive ability, and psychological health. risk factors for mental health disorders in the left behind parents included living arrangements, gender, education, income, physical health status, physical activity, efforts must be made to target social security supports for the older adults left behind, improving their mental health and wellbeing. also identified the importance of developing programs that enhance emotional intimacy (via technology) between older parents and their migrant children, to online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 96 authors/locatio n purpose method sample findings outcomes family and social support, age, rural residence, and frequency of children's visits. reduce risk of mental illness in older adults. identified special attention must be made to support older adults who are unmarried, have lower education, poorer economic background, older, living in rural areas, and with chronic disease in feeling socially connected (via social support programs, physical activities). wang et al. (2001). taiwan to examine the stressors, stress levels, loneliness, and depression experienced by taiwanese rural elders to determine if differences in their levels of stress were associated with person-environmental characteristics. quantitative nonrandomized; cross sectional study 201 older adults rural community members (aged 65 years and older). rural elders experienced a number of different stressors (i.e., physical strength, pain, and discomfort were the most common). few respondents reported high levels of loneliness. rural individuals in taiwan are more interconnected with their neighbors than in the united states (us), and this may account for the decreased rates of mental illness compared to the us. differences in the degree of stressfulness were related to factors of gender, educational level, living arrangement, and socioeconomic status. identified training needs to be created for community health practitioners to recognize changes associated with ageing (loss, family dynamics, social isolation rural areas, and mental health problems). identified also a need for specialized mental health services in rural taiwan, and that mental health care should be provided in addition to routine physical health care to rural elders. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 97 authors/locatio n purpose method sample findings outcomes williams et al. (2016). canada to understand how does social location influence the experience of family caregivers of older adults with multiple chronic conditions. qualitative; constructivist grounded theory included 40 participants from two provinces. the informal caregivers interviewed were aged 18 years and over and the “older adults” were aged 65 years and older. challenges experienced by caregivers for those with multiple chronic conditions were identified in four themes including 1) the caregiving trajectory that contained the three phases of a) initial (challenges managing time, b) middle (adjusting to changes), c) large (growing confidence), 2) balancing work, caregiving, and family, 3) caregiving and health (maintaining one's physical wellbeing), and 4) finding meaning/self in caregivers (developing gratitude, compassion). gender (female), age (older), employment status (part-time), ethnicity (i.e., immigrants were more vulnerable to a loss of social connection), and geographic status (rural areas) negatively affected the wellbeing of caregivers of older adults with multiple chronic conditions and must be supported when developing mental health programs. windley & scheidt. (1983). united states to examine the similarities and differences in service use and frequency of activity participation in the physically and mentally well or at risk older persons in rural areas. quantitative non randomized; cross sectional 989 older adults (specific age was not specified) were selected from 39 counties in the united states. mental health service use was decreased in the rural areas for both well and vulnerable groups (related to decreased access to public transportation). mentally vulnerable individuals were less likely to access basic community resources (e.g., church, volunteer work, restaurants) related to a lack of functional capabilities or they had no one to assist them. use of community services is a necessary part of independent living, and informal helping networks in small towns assist older adults in obtaining these services. tailored services must be created to support older adults in rural areas engage socially. groups including "helping networks" could be expanded and coordinated to assist older adults transport within the communities. other services such as homemaking, nutrition sites, senior centers, and shuttle services must also be coordinated and offer services to older adults living at home. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 98 authors/locatio n purpose method sample findings outcomes yang et al. (2021). china to examine use of community services by the elderly and its association with mental health (comparing gender and mental health differences). quantitative nonrandomized; cross sectional study 687 elderly people (aged 60 years and older) from 7 counties of china were enrolled. medical services utilization by older adults were higher in rural than in urban areas. due to a deficiency of large hospitals and restricted transportation, rural residents had fewer chances to access professional medical resources in bigger medical situations. rural residents experienced slightly worse mental health then urban older individuals. older adults also used social and recreational services more than in urban areas (i.e., rural areas have less entertainment methods), and may access day care services more frequently then urban older people. multigenerational cohabitation must be encouraged to enhance children's sense of family responsibility and to provide support for older adults. efforts must also be made to enhance daily care, social, and recreational services in both urban and rural areas. medical care and spiritual comfort services must be strengthened to support the wellbeing of community dwelling older persons. yazd et al. (2019). australia to identify the potential risk factors affecting farmers' mental health globally. systematic review 167 articles on farmers' (aged 18 plus) mental health. elevated risk of mental disorders in farming populations were related to pesticides exposure, financial problems, unpredictable climate, and past injuries. additional factors were machine breakdowns, hearing loud machines, time pressure, and governmental regulations. these stressful factors resulted in low self-esteem, withdrawal from social activities, relationship breakdown, hopelessness, nervousness, fatigue, and other mental health identified farmers' mental health issues were the result of a complex interplay of social, environmental, and economic factors. social, environmental, financial, and future health policies must be developed to address these risk factors. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 99 authors/locatio n purpose method sample findings outcomes concerns in farmers living in rural areas. yiengprugsawan et al. (2012). australia to examine the characteristics of thai caregivers, the distribution of psychological distress and mental distress among caregivers, and the association between caregiver status and psychological distress. quantitative nonrandomized; cross sectional study 60, 569 thai adult (majority older adults, aged 40 years and older) part time and full time caregivers. early identification of vulnerable caregivers is needed to promote wellbeing. full time caregivers (mostly older adults living in rural areas) were more distressed than non-caregivers. a lack of social contacts (colleagues and friends) contributed to psychological distress among caregivers. also identified women were often assumed to be natural caregivers, but did not find caregiving as rewarding as male caregivers. identified an association between advancing age and lower psychological distress. identified that social supports must be supported for caregivers and care recipients in older age. social support services could also be used to provide respite care, and therefore enable the caring role to be sustained over time in older adults. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 100 authors/locatio n purpose method sample findings outcomes zhang & silverstein (2022). china to examine whether loneliness mediated the relationship between intergenerational emotional cohesion (iec) to psychological wellbeing (pw) and whether friendship ties moderated the strength of the direct and indirect relationships between eec and pw. quantitative nonrandomized; cross sectional study 958 individuals aged 60 years and older from the longitudinal study of older adults in anhui province, china. stronger intergenerational cohesion (with children) was related to reduced depressive symptoms and increased life satisfaction directly and indirectly through reducing feelings of loneliness. intergenerational emotional cohesion and friendship ties were identified as mutually reinforcing with respect to depressive symptoms. identified that efforts should be made to strengthen social relations to improve mental wellbeing in older adults in rural china. these programs could be centered in senior centers that provide structured activities for older adults in service deprived rural areas. identified that these changes may produce wide gains for qol in vulnerable populations experiencing social and family changes. zhang, nazroo, & vanhoutte (2021). china to examine how migration into urban areas in china is related to risk of depression in later life related to the timing and type of migration. quantitative non randomized; cross sectional study 17, 000 chinese residents aged 60 and older from 10, 000 households within 28 provinces. lifelong urban residents had a higher mental health status compared to lifelong rural residents. the mental health advantage of urban residents is explained by a combination of socioeconomic advantage, access to state welfare, and informal social support (from family without co-habituating). also, rural to urban migration at older ages is more beneficial for later life wellbeing then migration earlier in life. intergenerational cohesion does not always enhance the wellbeing of older adults when they are financially secure and independent. therefore, efforts should be made to enhance the ability of older adults in living an independent life in close proximity to their children (through formal social protections in adequate pensions). zhang,wang, & xu (2021). china to identify and examine the social determinants quantitative nonrandomized; 3438 elderly individuals (aged 60 years identified a high prevalence of depressive symptoms amongst the elderly in rural areas. as socially disadvantaged individuals in older age are more online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 101 authors/locatio n purpose method sample findings outcomes contributing to the degree of depressive symptoms in the chinese elderly with chronic conditions. cross sectional study and older) from the china health and retirement longitudinal study. identified that depressive symptoms were more frequently identified in socially disadvantaged populations, and that social/family support and economic support were ideal for reducing the degree of depressive symptoms in this population. vulnerable to depressive symptoms, psychological supports and interventions should support older adults in coping and managing their mental wellbeing. zhou et al. (2019). china to examine the relationship of sociodemographic characteristics including being left behind, mental disorder, depressive symptoms, stressful life events, social support, and completed suicide. quantitative non randomized; cross sectional study a total of 242 suicide victims (aged 60 years and older) and 242 living comparisons were enrolled in the study. interviews were conducted with informants of suicide victims and their living comparisons. unstable marital status, the unemployed, those with depressive symptoms, and mental disorders were independent risk factors for suicide in the rural elderly. being 'left behind' by family can elevate their suicide risk through increasing life stresses, depressive symptoms, mental disorder, and decreasing social support options. identified that health care professionals can buffer the negative impact of being left behind in older age through providing social support, enhancing social connections, and treating/help manage mental conditions and life stresses. zhou et al. (2021). china to investigate the mental health status in the older adult chinese population during covid-19 and to determine influencing factors of psychological symptoms. quantitative nonrandomized; cross sectional study (longitudinal ) online survey to 1501 participants (aged 60 years and older) from 31 provinces in china. health related factors (i.e., having two or more chronic conditions) had the greatest influence on mental status in older age. higher education level, better economic conditions, and having social support were identified as factors that lowered risk of mental illness in older age. rural residence and those that highlighted that suicide in older adults could be prevented through reducing pesticide use (decreasing environmentally related health conditions), and enhancing training for rural physicians in treating mental health disorder in older adults, online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 102 authors/locatio n purpose method sample findings outcomes lived in medium risk or lockdown regions experienced more depressive symptoms. mitigating stresses in older adults, and enhancing social connections (particularly among "left behind older adults"). note. a summary of the purpose statements, samples, findings, and outcomes of the 48 included articles. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 103 results analysis revealed three themes individual vulnerabilities, system vulnerabilities and strengths. individual vulnerabilities three types of vulnerabilities of older persons living in rural areas included chronic stress, a loss of social belonging, and neurological dysregulation. chronic stress sources of chronic stressors included a loss of cohesion in social networks, the death of family members, maintaining financial security, and managing pain/chronic health conditions (behera et al., 2016; gong et al., 2012; howorth et al., 2019; saifullah et al., 2020; scogin et al., 2016; silverstein et al., 2020; wang et al., 2001; williams et al., 2016; zhang, nazroo, & vanhoutte, 2021; zhang, wang, & xu 2021; zhang & silverstein, 2022; zhou et al., 2019; zhou et al., 2021). workers in agriculture, a large industry consisting of primarily older persons, encounter multi-dimensional and pervasive stressors daily (house of commons, 2019; jonesbitton et al., 2020; lin & chen, 2018; roy et al., 2017; wang et al., 2001; yazd et al., 2019). these older farmers experienced ‘chronic’ stress and became unable to draw upon the emotional regulation strengths associated with ageing, resulting in high levels of emotional reactivity and poor health outcomes, including suicide (buvneshkumar et al., 2018; charles, 2010; hagen et al., 2021b; kunde et al., 2018; piazza et al., 2015). see table two for how descriptions of the chronic stress of farmers living in rural areas are similar to the savi model’s definitions of chronic stress (house of commons, 2019; scott et al., 2013). online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 104 table 2 experiences of chronic stress in farmers savi model’s definition of chronic stress (scott et al., 2013) experiences of rural residents no means of escape. individuals are unable to escape from their workrelated stress: “i can’t tell farmers to return home to rest. farmers are home, and that place is the source of their stress” (house of commons, 2019, p. 24). distressing and pervasive. farmers, ranchers and producers come under attack from many different sources: “our ancestors only had to worry about weather and prices. today we farmers have the added worry of being a target of an extreme activist, something that takes a serious toll on me mentally” (house of commons, 2019, p. 57). prolonged circumstances. farming is a high-risk industry filled with volatility and uncertainty: “canadian farmers have endured drought, porcine epidemic diarrhea, and… financial impacts” (house of commons, 2019, p. 57). loss of social belonging the savi model acknowledges the importance of social network’s protective effects against chronic stressors in older age (sun et al., 2017). rural dwelling persons value social participation and develop larger social networks compared to individuals living in urban areas (carver et al., 2018; neville et al., 2018; wang et al., 2001; yang et al., 2021). yet, they also experience logistical barriers to social connections due to low broadband internet, transportation barriers, and diminished education opportunities (abdul manaf et al., 2016; burnette et al., 2021; carver et al., 2018; hu et al., 2018; liang et al., 2020; lin & chen, 2018; slwinski et al., 2021; zhang, wang, & xu , 2021; zhou et al., 2021). these challenges to accessing social connection with community and religious organizations can lead to psychological distress and loneliness, and a risk of mental illness (adjaye-gbewonyo et al., 2019; coleman et al., 2011; fastame et al., 2022; garabrant & liu, 2021; heron et al., 2021; hu et al., 2018; li et al., 2022; luo et al., 2017; ruan et al., 2022; online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 105 saifullah et al., 2020; scott et al., 2013; wang et al., 2001; windley & scheidt; 1983; yiengprugsawan et al., 2012; zhou et al., 2021). a loss of family cohesion (i.e., with partners, children, grandchildren, friends, etc.) in the rural areas can contribute to diminished emotional wellbeing (buvneshkumar et al., 2018; fastame et al., 2022; gong et al., 2012; hogworth et al., 2019; lin & chen, 2018; li et al., 2022; nair et al., 2015; ruan et al., 2022; scorgin et al., 2016; thapa et al., 2018; zhang, wang, & xu, 2021; zhang & silverstein, 2022). younger generations often move to urban centres (burnette et al., 2021; li et al., 2022; zhang, nazroo, & vanhoutte, 2021; zhou et al., 2019) contributing to older persons’ perceptions of being ‘left behind’ (burnette et al., 2021; lin & chen, 2018; zhang, nazroo, & vanhoutte, 2021; zhou et al., 2019). to combat these feelings older persons could focus on nurturing their social support system and trusting others outside of the family (burnette et al., 2021; liang et al., 2020; lin & chen, 2018). social supports nurture feelings of support, trust, and respect and can protect older adults who are living alone from emotional deterioration and poor health outcomes (adjaye-gbewonyo et al., 2019; burnette et al., 2021; sun et al., 2017). neurological dysregulation age-related chronic conditions that cause neurological dysregulation, such as dementia are disproportionately represented as older persons frequently retire into a rural setting (baernholdt et al., 2012; behera et al., 2016; channer et al., 2020; holecki et al., 2020; howorth et al., 2019; lin & chen, 2018; nair et al., 2015; neville et al., 2018; pérès et al., 2012; silverstein et al., 2020; thapa et al., 2018; yang et al., 2021). neurological conditions can dimmish older persons’ ability to maintain their physical and mental wellbeing (howorth et al., 2019; slwinski et al., 2021; yiengprugswan et al., 2012). online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 106 system vulnerabilities system vulnerabilities included gaps in caregiving supports, gaps in mental health supports and barriers to accessing primary care. gaps in caregiving supports the increased rate of neurological disability in rural areas heighten the demand for family caregivers (pérès et al., 2012; williams et al., 2016; yiengprugsawan et al., 2012). although caregiving for a family member can be rewarding (silverstein & zuo, 2021; yiengprugawan et al., 2012), gaps in home care and community resources means that family caregivers are often without any formal supports (gong et al., 2012; hagen et al., 2021b; moholt et al., 2018; pérès et al., 2012; zhang, wang, & xu, 2021). moreover, they are less likely to access respite care and community support, if it does exist, due to the stigma of mental health and wanting to be independent and maintain their privacy (bayly et al., 2020; buvneshkumar et al., 2018; gong et al., 2012; hagen et al., 2021a; morgan et al., 2002; nair et al., 2015; williams et al., 2016). yet family caregivers who are not supported are at risk to experience depleted energy and develop their own age-related emotional vulnerabilities (brijoux et al., 2016; silverstein & zuo, 2021; yiengprugsawan et al., 2012). gaps in mental health supports older persons experiencing chronic stress, loss of social belonging, and neurological dysregulation face barriers in accessing mental health supports (garabrant & liu, 2021; hagen et al., 2021a; house of commons, 2019; hu et al., 2018; thapa et al., 2018; wang et al., 2001; windley & scheidt, 1983; silverstein et al., 2020; zhang, nazroo, & vanhoutte, 2021). this is due to the inequitable distribution of mental health providers across rural regions, resulting in gaps (house of commons, 2019; martin et al., 2018; yang et al., 2021; zhang, wang, & xu, 2021). online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 107 moreover, the mental health services are often not adapted to the unique rural needs (i.e., the lifestyle, stressors, fears, etc.) of farmers and rural community members, leading to a lack of trust and negative perceptions of the health care system (hagen et al., 2021; house of commons, 2019). furthermore, the double stigma that depression is normal in older persons contributes to systemic barriers to mental health services (abdul manaf et al., 2016; roy et al., 2017). table three provides an overview of these physical and systemic barriers farmers face when accessing mental health services in rural areas (hagen et al., 2021a). table 3 challenges of rural residents in accessing mental health services identified barriers description of barriers financial difficulties in financially covering services: “if you don’t have a health plan you don’t get any coverage, and some health plans don’t cover it anyway” (hagen et al., 2021a, p. 116). physical challenges in physically accessing services: “to drive to [a mental health service], it would’ve been over an hour, hour and a half each way… that’s hard. it’s a big commitment” (hagen et al., 2021a, p. 118). stigma-related perception that the stigma surrounding mental illness still remains: “there seems to be still [stigma] despite all the work that’s been done about mental health… there’s still a horrible stigma. and i don’t think farmers would want to see their trucks parked out in front of the doctor’s office where everyone can see” (hagen et al., 2021a, p. 118). barriers to accessing primary care older persons living in rural areas also face barriers to primary and health promotion services throughout their lifespan (baernholdt et al., 2012; behera et al., 2016; garabrant & liu, 2021; yang et al., 2021). globally, primary health care services are inaccessible, unaffordable, and unsustainable in rural and remote areas (hu et al., 2018; nair et al., 2015). therefore, rural individuals are at an increased risk of developing chronic health conditions that contribute to physical and mental health vulnerability (hu et al., 2018; kunde et al., 2018). on the other hand, these vulnerabilities are often counterbalanced by a healthy rural lifestyle (e.g., walking, fishing, online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 108 gardening, hunting, etc.) and living in a peaceful environment (pérès et al., 2012; ruan et al., 2022). developing the strengths although rural norms of stoicism and independence do not support emotional regulation skills throughout the lifespan (hagen et al., 2021a, 2021b; hu et al., 2018; kunde et al., 2018; ruan et al., 2022; roy et al., 2017; scogin et al., 2016), farmers also engage in positive coping mechanisms that increase their resilience during periods of chronic stress, such as taking work breaks and talking amongst their peers, thereby leveraging community supports (hagen et al., 2022; 2021; jones-bitton et al., 2020; roy et al., 2017; yazd et al., 2019). these coping strategies are aligned with traditional agrarian norms that include a sense of belonging and the value of local social supports (hagen et al., 2022, 2021; luo et al., 2017; roy et al., 2017; yazd et al., 2019). rural older persons experience higher levels of trust among community members, engage in informal community activities, and are accustomed to living in isolation, than do their urban counterparts (garagrandt & liu, 2021; herron et al., 2021). these interpersonal and cultural strengths protect older persons from developing mental illness despite periods of prolonged isolation and stress, such as during the covid-19 pandemic (garagrandt & liu, 2021; herron et al., 2021). these strengths must be acknowledged and developed to support rural dwellers as they experience age-related emotional vulnerabilities across their lifespans (hagen et al., 2021; house of commons, 2019; kunde et al., 2018; roy et al., 2017; yazd et al., 2019). discussion key findings are that individual vulnerabilities, such as chronic stress, loss of belonging, and neurological dysregulation combined with system vulnerabilities of reduced access to primary care, mental health services, and respite care contribute to mental health disparities in older rural online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 109 persons. at the same time, the strengths of interconnected social support networks and rural norms of resilience can bolster mental wellness in older persons. in these ways the savi model used as a conceptual framework provides an understanding of both the vulnerabilities and the strengths associated with aging in rural settings. focusing on strengthening the emotionally protective advantages of rural life, such as access to the large community networks (hagen et al., 2021; house of commons, 2019; roy et al., 2017) could facilitate qol and support older persons who are facing losses, neurological dysregulation, and chronic stresses. carefully examining both potential vulnerabilities and strengths within rural communities could be used to plan interventions that would reduce poor mental health outcomes (romans et al., 2011). for example, privacy concerns that cause older persons to not access existing resources could be addressed by developing generic caregiving support systems (hirsch & cukrowicz, 2014). also, the rural norms of protecting one another during crises could be mobilized into crises networks (shucksmith, 2018). analyzing the complex issue of mental illness in rural regions using the savi model as a conceptual framework was a strategic choice related to its holistic and context-orientated perspective (charles & piazza, 2009), to bring balance to negative accounts of older persons emotion experiences (charles, 2010; charles & luong, 2013). the savi model is valuable in analyzing systemic issues and discrediting societal stereotypes (e.g., the “golden years”, grumpy grandparents, etc.) associated with emotional wellbeing in older age (charles & luong, 2013, p. 443; sun & smith, 2017), thus providing a more balanced perspective about aging and older persons. the savi model could be used in nursing education to promote examination of the heterogeneity of older persons and both the strengths and vulnerabilities of aging. we suggest this online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 110 as nurses’ acceptance of negative stereotypes of cognitive and physical decline and beliefs that working with older people is simple could be related to seeing older people at their most vulnerable and dependant (brown et al., 2008; fox et al., 2016) and having their first clinical experiences in nursing home settings without understanding the complexity of these older persons (dahlke et al., 2021). a more balanced approach that presents strengths as well as vulnerabilities of ageing could encourage more positive perceptions of older persons. this is important as nurses who have positive perceptions of older persons are more likely to recognize and appropriately meet their health and social needs of this population (giles et al., 2008; mccarthy, 2003). researchers have thoroughly examined and validated the savi model’s assumptions about the emotion-related strengths of ageing (wrzus et al., 2013; zacher & rudolph, 2022). this strength can be applied as a strategy to balance the vulnerabilities of ageing in rural regions (charles, 2010). for example, blanchard-fields et al. (2007) identified that older persons are more successful in managing interpersonal conflicts and demonstrating flexibility in resolving problems compared to younger adults. there is potential to engage these conflict resolution skills of older persons to mediate challenges within rural communities and enhance health outcomes for all ages (sun & sauter, 2021). although the savi model has many strengths, it is not without limitations. the central limitation is that researchers have not confirmed if the older persons sense of limited time left to live is associated with emotional wellbeing in older age (hoppman et al., 2017). psychologists claim that an extended versus limited future time perspective is more positively associated with subjective wellbeing (demiray & bluck, 2014; kozik et al., 2015). hoppman et al. (2017) highlights that older persons of the same chronological age think differently about whether or not their time is limited. this suggests that being an older age does not always mean you will have a online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 111 limited time perspective, as previously assumed in the savi model (carstensen et al., 2011). more research is needed to investigate individual differences in perceptions of time and identify which perspective (i.e., limited versus extended) is more directly correlated to emotional wellbeing. another limitation of the savi conceptual framework is inaccurate definitions of time boundaries as to when the emotional regulation strengths are employed following a stressor (scott et al., 2013). scott et al. (2013) highlights that the savi model’s assumption that age differences in emotional wellbeing arise ‘immediately’ after the event passes has not been validated, despite replicated attempts (charles, 2010; charles & piazza, 2009). research into age differences of experiencing less of a negative affect up to two days after a stressful event has been inconclusive (johnson et al., 2008; ong et al., 2006; van eck et al., 1998). more research is needed to identify which factors may delay an older person’s ability to rebound emotionally post-stressor (carstensen et al., 2020; isaacowitz & blanchard-fields, 2012). the savi model is also associated with western assumptions, limiting understanding of cultural differences in older persons’ perception of time and ability to employ the strengths of ageing (sigdel, 2021; twigg & martin, 2014). the assumption that emotion-related motivations are tied to a limited time perspective originated on biomedical understandings of death as a lifelimiting process (sircova et al., 2015). other cultures, including indigenous communities, perceive death not as an end but as a transition period (duggleby et al., 2015). to support the wellbeing of the heterogenous ageing population, researchers could consider adaptations to the savi model’s theoretical underpinnings (luijkx et al., 2020; pace & grenier , 2017). implications despite the limitations associated with the savi conceptual framework, it does provide a useful perspective of recognizing the strengths related to ageing as well as the vulnerabilities. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 112 nurses in the practice setting can use this focus to enhance the strengths and mitigate the emotionrelated vulnerabilities of older people in rural areas. future research examining issues affecting older persons in other underserved populations may similarly find the savi model helpful in illuminating vulnerabilities and community-based strengths to mitigate them. this review revealed a lack of mental health and primary care services, specialized care professionals, and supportive resources for caregivers in rural areas for older persons, particularly farmers. health care leaders could address these systemic vulnerabilities by integrating familyorientated, rurally adapted (e.g., to their fears, needs, and skills) mental health services into primary care. the savi model could also guide policymakers in evaluating the vulnerabilities as well as the strengths within existing health care systems and enhance or increase access to already established mental health supports for older persons. review limitations the results of this narrative review may not be generalizable to all countries or cultures. given the nature of a narrative review, our search for relevant literature included research literature in english from three databases and theoretical literature. a systematic review of more databases and including other languages may have promoted the inclusion of perspectives from different countries and cultures. conclusion the complex issue of mental illness and poor health outcomes in older persons living in rural regions were examined using the savi model as a conceptual framework. this provided identification of systemic factors preventing rural individuals from developing the emotional regulation advantages to overcome the physiological vulnerabilities associated with ageing. the savi model also encouraged identification of the strengths within rural communities that could online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.725 113 be leveraged to address emotional-related vulnerabilities of older adults, such as chronic stress, a loss of social belonging, and neurological dysregulation, as well as, systemic vulnerabilities in the rural health care systems. limitations of the model were also identified, to guide future researchers in understanding individual and cultural differences in employing the strengths of ageing and perceptions of time. references abdul manaf, m. r., mustafa, m., abdul rahman, m. r., yusof, k. h., & abd aziz, n. a. 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(2019). being left-behind, mental disorder, and elderly suicide in rural china. a case control psychological autopsy study. psychological medicine, 49(3), 458-464. https://doi.org/10.1017/s003329171800106x microsoft word 92-330-1-rv_trinkley.docx online journal of rural nursing and health care, 12(1), spring 2012 evaluation of domestic violence screening and positive screen rates in rural hospital emergency departments devin k trinkley, rn, fne 1 sandra h. bryan, rn 2 karen gabel speroni, rn, phd 3 ruth ann jones, edd, msn, rn 4 hubert a. allen, scm 5 1 safe coordinator, shore health system, sanedirector@lighthousedc.org 2 clinical research specialist, shore health system, sbryan@shorehealth.org 3 chair, nursing research council, shore health system, kgabelsperoni@smartneighborhood.net 4 director, acute care, shore health system, rajones@shorehealth.org 5 president, hubert allen and associates, hubertallen@comcast.net abstract introduction: although emergency department (ed) patients are to be screened for domestic violence (dv), not all patients are screened. the objectives of this study were to quantify rural community hospital overall ed patient dv screening rates and positive dv screen rates. methods: in this retrospective chart review, a total of 1,200 of 13,336 patient ed visits were randomly selected. patients were excluded who presented with cardiac or respiratory arrest, mental health diagnoses, or major trauma; were transferred or arrived from long term care facilities; or were victims of sexual assault. data was collected on demographics, language, and three key factors for dv per nurse documentation (reported physical or sexual assault, fear, and objective signs). this study was reviewed by an institutional review board. results: eighty-eight percent (n=1,056) of rural ed patients in this study sample had documentation for dv screening being completed. of these, 2% (n=21) had documentation positive for dv. of those positive, the majority were female (62%), english speaking (86%) patients with an average age of 29 years. eighty-six percent reported assault, 33% reported fear, and 19% had objective signs of dv. conclusions: the overall dv screening rate of 88% supports the recommendation that all hospitals should ensure they have 100% dv screening rate compliance. the low 2% positive dv screening rate suggests the need for future research to determine dv screening barriers for both nurses and patients. keywords: domestic violence, screening, rural hospitals, emergency departments evaluation of domestic violence screening and positive screen rates in rural hospital emergency departments domestic violence has been a part of our society for centuries, quietly accepted, even considered legal. according to boyle in approximately 1824, the expression ‘rule of thumb’ was derived from english law and was interpreted based upon a husband being able to legally hit his wife with a stick as long as the stick was no bigger than the diameter of his thumb (boyle, robinson, & atkinson 2004). domestic violence (dv) is defined by the united states (us) department of justice (doj) as a pattern of abusive behavior in any relationship that is used by online journal of rural nursing and health care, 12(1), spring 2012 one partner to gain or maintain power and control over another intimate partner. it can be physical, sexual, emotional, economic, or psychological actions or threats of actions that influence another person and can include any behavior that intimidates, manipulates, humiliates, isolates, frightens, terrorizes, coerces, threatens, blames, hurts, injures, or wounds someone else (doj, 2011). ed admissions related to dv range from 9% (males) to 13% (females) with rates as high as 25.7% (daugherty & houry, 2008; olive, 2007). domestic violence perpetrators include current or former significant others, family members (including in-laws, step-family and foster family members), and caregivers of the elderly or persons physically, cognitively, or mentally disabled (national coalition against domestic violence, 2010). in 2002, 21.5% of all us murders were committed within the family (durose, et al., 2005). more than three women a day are murdered by their husbands or boyfriends in the u.s. and one in three adolescent girls are a victim of physical, emotional or verbal abuse from a dating partner (durose, et al., 2005). associated dv costs are more than $8.3 billion annually, including medical and mental health services and lost productivity (max, rice, finkelstein, bardwell, & leadbetter, 2004). the united states preventive services task force (uspstf) found insufficient evidence to support for or against routine dv screening. however, the joint commission on the accreditation of healthcare organizations (jcaho), american medical association (ama), and international association of forensic nurses (iafn) each have standards, guidelines and / or recommendations for universal dv screening of all patients, especially in the ed (jcaho, 2005; ama, 2008; uspstf, 2004; and iafn, 2009). although these national standards exist for dv screening, it is not consistently completed for all patients. less than 25% of women seen in 11 us eds were asked dv screening questions (glass, dearwater, & campbell, 2001). this dv screening percentage is consistent with other published research (daugherty, & houry, 2008). barriers for nurses regarding dv screening include a scarcity of dv knowledge and education, time constraints, their own personal experience with abuse, and perceptions of patient compliance regarding returning to the violent home (gutmanis, beynon, tutty, wathen, & macmillan, 2007). an inherent barrier for dv screening in a rural community hospital setting serving members of small towns or areas is the familiarity between the health care provider and the patient or the patient’s family or social network. familiarity of the health care provided may be an alienating barrier for the dv victim (annan, 2008; lewis, 2003). additional barriers for patients of dv are lack of trust in the system as well as a lack of available resources to aid dv victims. associated patient factors are lower income and education levels, unemployment, and/or alcohol or drug abuse (boyle et al., 2004; nolan, 2005). the us census bureau (2000) designation for non-metropolitan was used in this study. from an evidence based practice perspective, research was first conducted to determine actual dv ed screening rates being conducted in two rural eds and of those screened, to determine the percent screening positive for dv. thus, the objectives of this study were to quantify rural community hospital overall ed patient dv screening rates and positive dv screen rates. based upon this information, hospital management could determine if procedures should be implemented with the objective of 100% dv screening of ed patients. methods this retrospective chart review study was conducted by nurses in two rural community hospital eds belonging to one hospital system in the mid-atlantic region of the u.s. this study was reviewed by an institutional review board and deemed to be exempt. the objectives of this study were to quantify rural community hospital ed patient overall dv screening rates and online journal of rural nursing and health care, 12(1), spring 2012 positive screen rates. a sample of 1,200 ed patients were identified from 13,336 admissions in a one year period between 2006 and 2007, using a random numbers generator software program. these patient’s electronic medical records (emr) were reviewed to determine if study eligibility criteria were met. patients were excluded for the following reasons: (a) sexual assault or psychiatric emergencies as these patients are automatically screened for dv by specialized response teams; (b) cardiac or respiratory arrest, major trauma, or patients requiring a higher level of care precluding the ability to conduct dv screening; or (c) or long term care facility patients due to the problematic nature of completing subjective screening for this population. data abstracted was as follows: admission related information, demographics, primary language spoken, and nurse documentation of the three key dv screening factors: (a) patient was physically or sexually assaulted in the last year; (b) patient was afraid at home or in their current environment; and / or (c) patient had objective signs, which included avoidance of caretaker, lack of eye contact, injury not consistent with history, multiple injuries in various stages of healing, and pattern injuries. results eighty-eight percent (n=1,056) of rural ed patients in this study sample had documentation for dv screening being completed (see table 1). for those screened, the majority were female (56%), english speaking (98%) patients with an average age of 37 years. for the age group 14 years of age and younger, the dv screening rate was lower (77%) for all other age groups combined (p<0.0001). there were no statistically significant differences in the screening rates for domestic violence by gender. table 1 demographics of screening for dv and outcomes using electronic medical records a total of 21 patients (2%) had documentation positive for dv. the majority were female (62%), english speaking (86%) patients with an average age of 29 years (p<.01; 95% confidence interval [1.2%, 2.8%]). eighty-six percent reported assault, 33% reported fear, and 19% had objective signs of dv, producing a total of 29 key factors in the 21dv positive screen patients. discussion online journal of rural nursing and health care, 12(1), spring 2012 the positive dv screening rate of 2% in this retrospective study is notably lower than other published rates (9 to 25.7%), including rural rates for the prevalence of intimate partner violence between 8% to 22%, with lifetime prevalence of 13% to 30% (krishnan, hilbert, & pase, 2001). a limitation of this study was the retrospective nature of this research. prospective survey research that would allow researchers to objectively evaluate the three key factors for dv screening is recommended. further, prospective research to facilitate evidence based identification of nurse and patient barriers for dv screening and reporting is recommended. research is also recommended that would result in a valid and reliable tool for dv screening in the ed for both adults and adolescents. while there are validated instruments for intimate partner violence, these instruments are not specific to dv screening for adults and adolescents in the ed. research is also needed from rural eds to further understand barriers of dv screening for patients and ed nurses and doctors alike. as a result of this research, modifications to the emr have been recommended to facilitate dv screening of 100% of ed patients. nurses would be required to complete a separate screen in the emr before computerized discharge would be allowed of the ed patient screening positive for dv. in addition, mandatory dv awareness training was completed for ed personnel and dv awareness training for all ed nurses was proposed as part of the annual competency requirements for registered nurses. conclusion the overall dv screening rate of 88% in this rural hospital system supports the recommendation that all hospitals should ensure they have 100% dv screening rate compliance. evaluation of dv screening rates within the hospital may need to be completed to determine compliance. incorporation of dv screening data in the emr would facilitate this initiative. also, availability of open text fields in the emr would facilitate documentation of objective signs of dv. age appropriate dv screening questions should be available, particularly for children. the 2% positive dv screening rate in this study supports the recommendation of other rural hospitals evaluation of their positive dv screening rates. research is warranted to determine barriers to dv screening for both nurses and patients. research is also warranted on the effect of dv screening training programs to increase the overall dv screening rates and the ability to identify victims. it is only when the dv victim is identified that hospital staff can then begin to provide resources to help them. acknowledgements this study was funded by the nursing department of shore health system. there was no external funding received. the authors wish to acknowledge lois sanger, mls, manager, library services, for her help in reviewing this manuscript. references american medical association (2008). national advisory council on violence and abuse policy compendium: h-515.965. retrieved from www.ama-assn.org/ama1/pub/upload/ mm/386/vio_policy_comp.pdf annan, s.l. 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[medline] http://www.ncbi.nlm.nih.gov/pubmed/18953150 http://www.ncbi.nlm.nih.gov/pubmed/11275861 http://www.ncbi.nlm.nih.gov/pubmed/17250771 http://www.ncbi.nlm.nih.gov/pubmed/11275567 http://www.ncbi.nlm.nih.gov/pubmed/15631280 http://www.ncbi.nlm.nih.gov/pubmed/15083858 p54 aylward article 6_6_11 54 online journal of rural nursing and health care, vol.11, no.1, spring 2011 nurse recruitment and retention in rural newfoundland and labrador communities: the experiences of healthcare managers mark aylward, mn, rn1 alice gaudine, phd, rn2 lorna bennett, mn, rn3 1mental health nurse case manager, eastern health, nlmark_aylward@hotmail.com 2 memorial university of newfoundland, agaudine@mun.ca 3 memorial university of newfoundland, lorna@mun.ca key words: rural nurse, recruitment, retention, rural newfoundland and labrador abstract nurse recruitment and retention in rural newfoundland and labrador (nl) can prove to be a challenge for rural healthcare managers due to a variety of issues and factors. the characteristics of rural communities along with vast nursing shortages throughout canada and the world can certainly contribute to those challenges. research on the topic of nurse recruitment and retention in rural nl is limited, particularly from the perspective of rural healthcare managers. the purpose of this study is to explore and describe the experiences of rural nl healthcare managers contending with nurse recruitment and retention by using a qualitative descriptive design and using content analysis to analyze the data. the findings were categorized to outline barriers and facilitators to nurse recruitment and retention. implications for further research on this topic are discussed, as well as implications for nursing practice and education. introduction healthcare systems in rural newfoundland and labrador (nl) and in rural areas around the globe are encountering major challenges. the challenge of nurse shortages is particularly significant as it may have a negative impact on adequate healthcare provision (murray, 2002; newhouse, 2005). the population of nl is aging, particularly within the rural and remote communities that spread hundreds of kilometers around the rugged coastline of the province. the impact of an aging population with increasing health demands and an out-migration of young professionals has created a strain on the rural healthcare systems throughout nl. this increased pressure on rural systems ultimately leads to an increased pressure on the urban tertiary health facilities because of the need for more advanced procedures and treatment. after the 1992 cod fishery moratorium in nl, rural communities that relied heavily on the fishery for economic stability have experienced some hardship. individuals employed in some sectors of the fishery have sought employment elsewhere, or have obtained education for some other trade or profession. this means communities have experienced a vast out-migration of younger inhabitants. because of the lack of opportunity in these communities, a majority of high school graduates and post-secondary graduates have opted for career opportunities outside of their home community, and even outside of their native province. with increased demands for registered nurses (rns) outside of nl, new nurse graduates also opt to leave nl for better incentives elsewhere. as many rns are currently, or soon will be eligible for retirement, nurse recruitment and retention has been a challenging obstacle for rural healthcare managers. the purpose of this study is to explore and describe experiences of rural nl healthcare managers with nurse recruitment and retention. a qualitative descriptive study design using 55 online journal of rural nursing and health care, vol.11, no.1, spring 2011 content analysis to analyze the data was used in this study. healthcare managers not only contend with the urgency of recruiting nurses to their healthcare institutions and community settings, but they must also find creative ways to retain these nurses. by discussing the challenges and successes that these managers experience, valuable information and knowledge can be generated regarding the issue of nurse recruitment and retention in rural and areas of nl. relevance of study and literature review a literature search was conducted to review current information about rural nursing and the associated factors for rural areas around canada and the world. based on this search, there was a dearth of literature specifically related to nursing recruitment and retention in rural nl. there is clearly a need to explore the issue of nurse recruitment and retention in rural nl. in our literature search, some of the issues pertaining to rural nursing in canada that we have found, include the migration of nurses in and out of canada (pitblado, medves, & stewart, 2005; little, 2007), predictors of career satisfaction for rural canadian nurses (penz, stewart, d’arcy & morgan, 2008), and other general issues concerning nurses in rural canada (macleod, browne, & leipert, 1998). the findings of these studies are relevant to recruitment and retention efforts to help us gain insight into the reasons why nurses move away from rural areas. pitblado et al. (2005) used data from a national survey to assess migration patterns of rural canadian rns. this survey reported that nl was the province least likely to attract rns who were educated in another province in canada. in the year 2000 in particular, there were no rns coming into nl from other provinces. at the same time, the rn workforce in the territories relied on attracting rns from other provinces, including 12.8% of its overall rn workforce recruited directly from nl, or nurses who were originally from nl. in a discussion paper, little (2007) noted that canada is facing and will continue to face a major nursing shortage. although canada produces many nursing graduates per year, many of these nurses emigrate to other countries, the united states in particular. with the nursing workforce continuing to age, a net loss of nurses will continue in this country. little (2007) further suggested that immigration of nurses into canada from other countries will unlikely compensate for this loss of nurses. therefore, canada must develop strategies to attract, recruit, and retain more nurses. predictors of job satisfaction for rural canadian nurses were examined in a national survey of 944 registered nurses (penz et al., 2008). penz et al. (2008) examined individual, workplace, and community characteristics that may contribute to job satisfaction in rural health settings. having adequate and up-to-date equipment, good scheduling, and less demanding workloads were workplace related factors associated with greater job satisfaction identified in this study. satisfaction with living in the individual’s home community was also associated with job satisfaction. this suggests that displaying the benefits of rural lifestyle in recruitment and retention approaches could be beneficial. our search for literature specifically addressing nurse recruitment and retention and nurse staffing issues in rural nl yielded limited findings. interestingly, the association of registered nurses of newfoundland and labrador (arnnl) released a position statement pertaining to staffing issues in institutional settings (arnnl, 2006). the statement noted that an important consideration indirectly related to nurse recruitment and retention is the necessity of adequate staffing levels to ensure the provision of safe patient care. thus, the ability to recruit adequate numbers of rns is essential for meeting appropriate standards of care. dyson et al. (2002) also 56 online journal of rural nursing and health care, vol.11, no.1, spring 2011 released a discussion paper that focused on the recruitment and retention of health and education professionals in northern parts of labrador. this document focuses on the many unique challenges to recruiting and retaining professionals in rural areas, emphasizing the need for further research in the development of recruitment and retention strategies specifically designed for rural parts of this province. some of the challenges mentioned in dyson’s et al. (2002) paper include the lack of basic services in some rural areas of labrador, an aging workforce, lack of transportation options, and geographic isolation. other factors noted in the literature that have an influence on rural nurse recruitment and retention include allocation of resources, geographical isolation, full-time employment, available technology, adequate staffing (macleod et al., 1998; murray, 2002; flynn, 2005; lea & cruickshank, 2005; newhouse, 2005), good leadership, interdisciplinary teams (macphee & scott, 2002; kleinman, 2004; flynn, 2005; teasley et al., 2007;), educational opportunities, adequate orientation (kleinman, 2004; flynn, 2005; lea & cruickshank, 2005; salt, cummings & profetto-mcgrath, 2008), having rural connections (lea & cruickshank, 2005), and of course, salaries (murray, 2002; flynn, 2005; newhouse, 2005; teasley et al., 2007;). macleod et al. (1998) discusses the issues and challenges that many rural nurses face such as accessibility to adequate medical resources and geographic isolation. in some northern and coastal communities, the nurse is often the only medical professional available, and thus must take on multiple roles. when communities are widely dispersed, health centres can be hundreds of kilometers away from a patient in need of service. this results in transportation obstacles for the patient getting to a health facility, or for the community-based nurse who must travel to the patient. newhouse (2005) also identified challenges to rural recruitment including geographic isolation, aging populations, and high turnover rates in staffing that lead to inconsistency in care. in newhouse’s (2005) study, focus groups of nurse administrators were utilized to identify issues in rural healthcare settings, and to establish recommendations to address those issues. some recommendations included improving access to care, and using alternative approaches to healthcare provision in rural areas in response to its unique characteristics. however, the study did not provide details as to what these approaches to healthcare provision should entail. although many rural areas experience difficulties with nurse recruitment and retention, there are some positive aspects to rural nursing as well. teasley et al. (2007) identified the managerial support and autonomy in rural nursing as positive factors that often entice nurses to rural settings. providing adequate support to nursing staff can increase job satisfaction and improve workplace morale in any workplace, both rural and urban. macphee and scott (2002) also examined the positive impact that managerial support can have on rural nurse recruitment and retention. these researchers also mention the positive impact that workplace social networks have on nurse retention in many rural settings. flynn (2005) discusses general nurse retention strategies that may be beneficial for rural or urban centres such as having good orientation programs, ensuring adequate staffing levels, maintaining professional competencies, and providing strong managerial support. most of the literature accessed in this search yielded much information pertaining to rural nursing recruitment and retention in general. however, literature specifically pertaining to nurse recruitment and retention in rural nl is very limited. also, there are few studies that look at rural nurse recruitment and retention from the perspectives of healthcare managers. as a result, examining the experiences of healthcare managers in rural nl may contribute to an enhanced understanding of issues that surround rural nurse recruitment and retention in this province. 57 online journal of rural nursing and health care, vol.11, no.1, spring 2011 methodology this study used a qualitative descriptive design to describe the experiences of rural nl healthcare managers contending with nurse recruitment and retention. qualitative descriptive design does not utilize any one particular theoretical context, but commits to providing a descriptive summary of the phenomenon under study (sandelowski, 2000; polit & beck, 2004). to analyze the collected data, content analysis as outlined by graneheim and lundman (2003) and elo and kyngas (2007) was used. content analysis is useful when the intent of the research is to describe a phenomenon, and to gain an understanding of that phenomenon (hsieh & shannon, 2005). qualitative content analysis includes developing categories for the data. this generation of categories involves a process of grouping data into sub-categories, and eventually reducing the number of overall headings by clustering similar sub-categories into broader categories. participants a purposive sample of eight participants was used for this study. nine participants were initially recruited, but one participant excluded herself from the study prior to data collection. we did note a trend of consistent findings from the eight participants, and no new categories were formulated. as such, we felt the number of participants was sufficient to meet the purpose of this study. the criteria for participation in this study included willingness to participate in the study, and current employment as a healthcare manager in a rural nl town or community. rural nl community was not specifically defined in terms of population or geographic size, but could include any town or community other than any of the three cities in nl. the participants for this study were recruited from three different rural towns. all eight participants were female. participant experience as a healthcare manager in rural nl ranged from six months to twentytwo years. procedure a semi-structured interview guide was developed as the means of data collection for this study. each participant was interviewed once and given the opportunity to contact the primary researcher if they later wanted a second interview to share additional experiences relevant to the study. four of the participants were interviewed in person, and four were interviewed via telephone due to travel constraints. participants were asked to select a location for interviewing that was convenient and private. all interviews were audiotaped for transcription purposes. open-ended questions were used during the interview process, and we endeavoured to use minimal directive questioning in order to allow the participants to give their own detailed descriptions about their experiences with nurse recruitment and retention. each interview began with the statement “describe in as much detail as possible, your experiences as a healthcare manager contending with nurse recruitment and retention in your area.” we asked the participants to share specific examples and stories of their encounters with nurse recruitment and retention, and how their experiences with recruitment and retention had evolved throughout their management career. we sought clarification at times to ensure that the message intended by the participant was being received accurately. the participants in this study spoke of their experiences with nurse recruitment and retention in their work areas, including barriers and facilitators to recruitment and retention. at the end of each interview, participants were given the option to contact the primary researcher to schedule another interview if they later thought of experiences that they might have 58 online journal of rural nursing and health care, vol.11, no.1, spring 2011 neglected to share. however, none of the participants opted for a second interview. as indicated to participants prior to the study process, all interviews were then transcribed verbatim into text. ethical considerations this study was approved by the human investigation committee (hic) of memorial university of newfoundland (mun), and by the research proposals approval committee (rpac) of eastern regional health authority. when recruiting participants for this study, a written letter was mailed followed by telephone and/or email correspondence explaining the purpose of the study, and ensuring confidentiality throughout and after the study process. furthermore, potential participants were informed that they could withdraw from the study at any time without prejudice. data collected for this study is stored on password-protected electronic files, and hard data (typed transcripts, audiotapes) is stored in a locked cabinet. any possible identifying information within the typed transcripts has been coded. analysis sandelowski (2000) points out that qualitative content analysis is usually the preferred approach to analyzing the collected data in a qualitative descriptive study. qualitative content analysis is used to summarize the contextual meaning of the data to give a description of the phenomenon under study (sandelowski, 2000; hsieh & shannon, 2005; elo & kyngas, 2008). the audiotaped interviews were listened to repeatedly to accurately transcribe the text verbatim. the researchers reviewed the typed texts for analysis. the transcripts were read repeatedly to identify commonalities and variances. each transcript was read word for word in order to gain an understanding of the participants’ experiences in a context specific way. while immersed in the data, we coded data by making notes throughout each transcription (graneheim & lundman, 2004; elo & kyngas, 2008). during this process, we then categorized data that had some commonality. we coded and categorized barriers or deterrents to nurse recruitment and retention in rural nl, and facilitators or motivators to nurse recruitment and retention in rural nl. initially, there were numerous categories created. we then condensed the categories by placing data into broader categories with the purpose of creating a general description of the phenomenon. this process was carried out until the researchers came to an agreement on the development of the categories. findings through vigorous analysis of the collected data in this study, we were able to obtain rich data specific to nurse recruitment and retention in rural nl. figures 1 and 2 outline the categories of barriers and facilitators to nurse recruitment and retention in rural nl respectively. barriers as shown in figure 1, a number of experiences and observations of barriers to nurse recruitment and retention noted by the managers have been clustered into categories. these barriers have been categorized as undesirable aspects of rural life. this category and its subcategories are described below. 59 online journal of rural nursing and health care, vol.11, no.1, spring 2011 figure 1. barriers to nurse recruitment and retention in rural nl student debt no family ties in area → no employment for spouse individual attitudes → lack of services and resources small institution size diminishing population isolation factors → lack of full-time jobs mainly float positions decreased professional development excessive overtime/workloads lack of nurses in system undesirable aspects of rural life commonalities arose in many of the participants’ experiences in relation to rural nl in general. findings from this study show that decisions not to practice nursing in rural nl may be attributed to more personal reasons. it is also apparent from the findings that some people, including professionals such as nurses, deem rural and remote areas as having unattractive characteristics or an undesirable lifestyle associated with it. sub-categories of this broad category include a) personal factors, b) rural nl characteristics, and c) limiting nature of rural nursing structure. personal factors throughout many of the interviews with participants in this study, it was apparent that personal matters of the individual nurse often play a role in the decision not to practice in rural parts of nl. these characteristics of individual nurses that affect their decision not to practice in a rural setting can include factors such as student loan debt, or their connections to a particular community. one participant made the following observation pertaining to having no family ties in the rural area, “sometimes they move because…. they have family in other areas, it is not always just the big bucks.” according to this participant, money is not always the major factor that may attract or deter nurses, but rather, having no family in the rural area is often a barrier to recruitment and retention. it was also noted that nurses often choose to stay or leave an area based on family commitments or career opportunities rather than monetary incentives. “so a lot of our staff are moving on for personal reasons, financial might not be the big thing. a lot of it is other family commitments, or wanting to move on in their career in areas that we can’t offer.” a constant factor noted by a number of participants in this study, was the lack of employment in rural nl areas for the nurse’s significant other or spouse. these healthcare managers noted that nurses are not enticed to relocate to a rural community when there is no employment opportunity for their spouse. “to attract the nurses to [name of community] they either have to have some family roots here, [be] dating someone, or have work for their spouse.” personal factors rural nl characteristics undesirable aspects of rural life limiting nature of rural nursing structure 60 online journal of rural nursing and health care, vol.11, no.1, spring 2011 this also applies to retention. when the significant other of a nurse has to relocate for employment purposes, the nurse also leaves. with a nation-wide nursing shortage, these nurses are able to be mobile. nurses are commodities in many healthcare organizations throughout the country, thus they have a wide array of choices as to where they work. “they’re coming out pretty mobile and there’s a nursing shortage across the nation.” another participant states, “….right now there’s nurses who are, you know, their spouses are working in alberta and alberta is crying for nurses like we are, you know, they can make more money out there.” another interesting perception identified in this study with respect to personal characteristics was the participants’ reference to the sense of entitlement amongst younger nurses. one participant felt that many young nurses do not have the same work ethic that many seasoned nurses have, and that this attitude may contribute to some of the barriers that rural healthcare is facing. “….young people today grow up with a sense of entitlement…. you know, what does the world offer me? as opposed to, what can i offer the world?” another participant in the study also had a similar opinion of young nurses. ….we’re finding that the attitudes of nurses have changed. it doesn’t seem to be what it was years ago. and nurses now come out with an attitude of, not what i can do for you but what you can do for me. and i’ve even heard [them say] ‘you should be thanking us for coming to rural settings.’ rural nl characteristics many of the barriers to nurse recruitment and retention in rural nl identified in this study were perceived as being related to the structure and characteristics of rural and remote nl communities. some of the participants had talked to nurses, and discovered that it was the limiting characteristics of these rural areas and the nursing position structure within rural health institutions that often deter the nurse from either coming, or staying for any length of time. for example, some of the managers spoke of the geographic isolation of many rural communities, and harsh weather conditions during the winter. these characteristics often dissuade individuals from moving to a rural area unless they have some vested interest in that particular location. “some people just don’t want to live in a rural area. they have no desire to be in that area.” common aspects of rural nl that the participants often referred to are the lack of social activities and services within many rural and remote communities. “the social aspects, there is no movie theatre here and shopping is [limited] here.” other characteristics of rural nl identified by participants include declining populations, and limited availability of certain resources and services. as a result, many younger nurses are not enticed to reside and work in these rural areas. another participant noted, “….we’re in a very rural setting and services are not in the community to keep these young people here.” limiting nature of rural nursing structure the third sub-category developed from the identified barriers to rural nurse recruitment and retention is the limiting nature of rural nursing, or systemic structures. this sub-category encompasses limitations within the healthcare system itself that often deter nurses from practicing in rural and remote areas of nl. a component of the nursing structure referred to by some of the managers in this study relates to the requirements of nursing positions in rural nl. for example, many rural health facilities post nurse float positions, which require the nurse to work on two or more units, or even in different facilities. some rural managers in this study feel that nurses are not attracted to these positions, but would rather work on a specific unit, that they 61 online journal of rural nursing and health care, vol.11, no.1, spring 2011 are familiar and comfortable with. “unless they’re guaranteed a job there, they are not going to take a float position where they could be, you know, they are an o.r. nurse and they don’t want to be down on long-term care.” another example of the limiting nature of rural nursing position structure in rural facilities is the posting of many temporary positions rather than permanent full-time positions. “i’ve found it extremely frustrating hiring people on temporary assignments for so long. i’ve just thought it’s criminal for people to be hired on temporary assignments all the time and have their lives disrupted.” participants noted that some of the more difficult to recruit areas are usually institution-based units such as long-term care facilities or acute medicine units. as a result, when nurses on these units leave their positions to go into more desirable specialty positions such as community health, managers have great difficulty replacing these positions. ….people kind of like community health roles because number one, well not only the job and the skills and those things, but i guess the lifestyle. you know, they’re away from shift work and those types of things, so that in itself is enticing. so it’s not so much a problem getting them but it’s backfilling where they’re coming from… it’s a domino effect. as noted by this manager, when a nurse successfully obtains a more desirable position within the same organization, the manager may have difficulty replacing that nurse. thus, the manager may be unable to allow the nurse to begin in the new position, resulting in the nurse being temporarily detained in his/her original position. many of the managers interviewed also noted that there was a sense of low work satisfaction and low morale in their workplaces resulting from lack of adequate staffing. when replacement staffing is not available, nurses end up working excessive overtime resulting in stress, low job satisfaction, and potential burnout. as one manager pointed out, the cycle of lack of staffing and excessive workload leads to an inability to recruit. “if you don’t have staff, then workloads are bad and you can’t get time off, and that’s the messages that are out there, so nobody wants to come in.” the unavailability of replacement staff not only prevents nurses from obtaining vacation leave, but other forms of leave as well, such as education leave. nurses are sometimes unable to avail of professional development opportunities because managers cannot replace them, or they are just simply tired of working excessively. one participant made note of the difficulty in utilizing professional development opportunities. “but the ability to use some of that [professional development] is often hampered by the fact that now you’re spending a lot of time doing overtime shifts or covering shifts, you know, it’s hard to implement programs when people are that stretched.” facilitators figure 2 gives an outline of facilitating factors to rural nurse recruitment and retention found in this study. the main category developed is the desirable aspects of rural life, which includes three sub-categories a) connection to the community, b) supportive work environment, and c) rural benefits. 62 online journal of rural nursing and health care, vol.11, no.1, spring 2011 figure 2. facilitators to nurse recruitment and retention in rural nl family ties spousal employment → social networking sense of belonging in community full-time employment → variety of experiences professional development opportunity independent practice → opportunity for creativity desirable aspects of rural life this study yielded positive experiences from the participants in relation to nurse recruitment and retention in rural nl. although recruitment and retention can prove to be challenging at times, the managers in this study shared their successes, and their perspectives of how they could improve on recruitment and retention strategies. they described the overall good qualities of rural nursing and rural life. connection to the community some of the facilitating factors to nurse recruitment and retention in rural nl areas are actually two-edged. for example, having family ties and a sense of connection to the area, and having employment for the nurse’s significant other in the area were noted as facilitators to recruitment and retention. on the other hand, having no family connections, or no spousal employment, were identified as barriers to recruitment and retention. one participant made the following observation. “i guess that, to attract the nurses …. they either have to have some family roots here, [be] dating someone, or have work for their spouse.” the sense of connectedness within smaller institutions in rural nl was also identified as a positive factor in recruiting and retaining nurses in these small communities. “everybody in your community and in the place you work, what i find is that everybody works together because that’s all you’ve got, that’s your support.” this sense of connectedness in rural areas creates supportive work environments, which is described in the next section. supportive work environment some of the participants in this study noted that they usually sense a supportive working atmosphere in small rural communities that promotes closeness and teamwork in the nursing workplace. “nurses have been able to find a balance between work life and you know, probably because it’s such a small group they are able to socialize and mingle and become a social network inside and outside of work.” another participant noted the benefit of interdisciplinary teams in rural health centres. having the nurse as part of the interdisciplinary team so they have the support of the team members. i think that’s important and that’s been a very significant piece of retaining community mental health nurses because they do feel they have the support of their counterparts. there’s connection to the community supportive work environment desirable aspects of rural life 63 online journal of rural nursing and health care, vol.11, no.1, spring 2011 only a small group of community-based mental health nurses in rural [nl] but i do feel there is good connectivity and there [are] good networks set up so that they have the support of each other. and again, it’s that working support and also the support of their team. to me that’s a success story. one participant felt that rural nursing often promotes independent practice, but at the same time, the nurse does have a team of professionals that they can connect and consult with. it’s an excellent way to start, you know, you have a certain level of independence that you wouldn’t have in a bigger center. so, that to me is a great benefit. and again, i guess it’s your network both socially and professionally, you know, they will work as part of a team. in this study, managers also identified professional development as being an important component in creating supportive environments for nurses. furthermore, managers in this study realized that it is sometimes just showing respect for nurses that really helps in supporting nurses. “i think we have to be supportive to our staff. we have to be available to them as a manager.” another manager noted, “….for the most part it’s just the little things, the day-to-day little things, you know, appreciating the extra mile that somebody’s gone, you know, just a smile in the morning and a ‘how are you doing.’” as explained by this participant, the little things may include showing signs of gratitude and appreciation for the nurse’s work and dedication. according to this participant, nurses appreciate being respected and thanked, and this may play a role in retention. it was also recognized that another supportive strategy in rural areas is to be competitive in the market for nurses by providing adequate salaries and bonuses, and incentives that recognize and value the work of nurses. “what i do think is positive is the monetary things that they’ve put in place for rural, you know, sign-on bonus, the bursaries while they’re still students which are tax free, and i think we offer relocation, living allowance for the first six months.” another manager noted other support incentives such as housing. a mental health nurse that we had recruited, we arranged housing for her for a short time until she could get settled in and find a place of her own and those kinds of things. sometimes, that’s major because if you are coming into a small rural community and you have no family here or contacts, if you don’t really know where you are going, you know, so if you can give someone a couple of months of housing, i think that works wonders. rural benefits. some managers recommended promoting rural nl as an ideal place to live as a strategy to recruit nurses in their area. one manager gives a description of rural nl. “it’s a beautiful countryside. you’ve got the ocean there, you can leave your house and go on snowmobile in the winter, you know, the recreational aspects of living in [rural] newfoundland are a huge plus that you can’t get in the city.” another participant elaborated on rural nl as being a great place to live despite the lack of some services and resources. 64 online journal of rural nursing and health care, vol.11, no.1, spring 2011 it’s the lifestyle, it’s the pace, you know you’re not stuck in traffic jams and those kinds of things, so it’s that and sometimes rural newfoundland gets a bad rap because there is nothing to do, but i mean there is lots of things to do. it depends on what your interests are, you know. if you are an outdoors person then what better place is there to be, right? but even in terms of a social network, um, like it’s so different in rural newfoundland…. i think sometimes it’s easy to say, ‘well who’s going to come here?’ because there is nothing here and we are our own worst enemies because we all say that, but there is a lot of people here, young couples starting their families and if you talk to some of them they’ll tell you that there’s no better place to be. so, sometimes i think we need to get out there selling the place and celebrating what we have right? there’s history, there’s site-seeing, there’s roots and a sense of belonging that you can’t really compare to anywhere else. so, there’s lots of good things to sell about rural newfoundland. although rural characteristics were found to be barriers to recruitment and retention, the findings of this study suggest some nurses appreciate rural life. therefore, rural characteristics may also be facilitators to recruitment and retention, so promoting these rural characteristics may indeed enable recruitment success. discussion the findings from this study show that there are a variety of experiences amongst healthcare managers in rural nl with nurse recruitment and retention. the data analysis led to the portrayal of nurse recruitment and retention in these rural nl communities from two viewpoints, the barriers or inhibiting factors to rural nurse recruitment and retention, and the facilitators or aiding factors in rural nurse recruitment and retention. some of the facilitators and barriers identified in this study are actually the reverse of each other. for example, spousal employment can be perceived as a facilitator or a barrier to nurse recruitment and retention in rural nl. with a lack of employment in many rural nl communities, many people have sought employment in other places, including places outside of nl. over the past decade, the development of the alberta oil sands has been attractive to many trades-people, including many newfoundlanders and labradorians. unfortunately for the province of nl, many residents of the province have opted to relocate to alberta as a result of better employment opportunities. in some cases, these residents included the spouses of nurses. when spouses of nurses are required to move to other areas for employment, nurses also leave, making it difficult for rural health managers to retain and recruit nurses. on the other hand, when there is employment for a nurse’s spouse in the rural area, retaining the nurse is much easier. another example of a two-edged facilitator/barrier to recruitment and retention identified in this study is having a rural connection. participants in this study pointed out that nurses are easier to recruit and retain when they have family relations in a rural community, whereas it is usually difficult to recruit and retain nurses who do not have any personal connection to the community. from all accounts of the managers’ experiences in this study, it is evident that nurse recruitment and retention in these rural nl communities has proven to be challenging in recent years, which is consistent with many rural and remote areas throughout canada and other 65 online journal of rural nursing and health care, vol.11, no.1, spring 2011 countries. many of the factors identified in this study are consistent with rural factors noted in the literature review. an increasing elderly population and decreasing younger population (roberge, 2009), the isolating nature of rural communities, and a lack of resources and services have been described as challenges for rural nurse recruitment and retention. anonymity and confidentiality in small rural communities also affect rural nurses as these nurses often know residents personally, and are usually active members within the community (mccoy, 2009; roberge, 2009; jackman, myrick, & yonge, 2010). as mccoy (2009) alludes to, this can lead to ethical dilemmas and role strain for the nurse. other factors that have been found to affect rural nurse recruitment and retention in this study include having rural connections, patient workloads, professional development opportunities, adequate orientation, and salaries. it is apparent that many factors affecting nurse recruitment and retention in rural nl are not necessarily unique to rural nl, but also applicable to rural areas throughout canada and the world. salary is a major factor in recruitment and retention of nurses in nl and across canada. at the time of data collection, nurses of nl were negotiating a collective agreement with the provincial government that increased salaries to become the second highest paid nurses in atlantic canada for the next four years. preceding this agreement however, nl nurses were the lowest paid in the country, which was identified in this study as a major disadvantage to recruitment and retention. nurse recruitment and retention in nl was a major topic in the negotiations for that collective agreement, and it is hoped that the new contract will now aid in recruitment and retention efforts. there have been other interesting factors noted in this study that affect nurse recruitment and retention in rural nl that were not identified in the literature review. such factors include spousal employment, sense of belonging in rural communities, social networking, attitudes of younger nurses, and the beauty of rural nl. the attitude of younger nurses was a notable concept mentioned by some participants in this study. it was mentioned that they have a different work ethic than older nurses. this perceived difference in work attitudes among generations of nurses is an interesting finding. young nurses expect to advance in their careers quickly, and feel that their managers and colleagues should be thanking them for working with them. the older nurses, on the other hand, are resentful towards younger nurse graduates who acquire large signing bonuses for short contracts while they do not receive any such bonuses for their loyalty to the workplace. this often causes much tension and conflict between generations of nurses in some workplaces. the attitudes of younger nurses reflected in this study are not specific to rural settings, but may be applicable to other areas as well. the benefits of rural nl were acknowledged in this study. managers talked about the serene lifestyle in rural nl communities. this lifestyle is attractive to many people, and may entice nurses to work in these rural communities. many of the participants in this study felt that the beauty of rural nl should be portrayed in recruitment and retention initiatives. marketing rural nl can be successful in attracting nurses that may not even realize the beauty of these rural communities. thus, it is important that rural administrators consider marketing rural living as a recruitment and retention strategy. the role of managerial support in healthcare settings was also identified as an important component to providing supportive work environments, which is consistent with other research (macphee & scott, 2002; flynn, 2005; salt et al., 2008). nurses want to be appreciated for their work and expertise. managers can show this appreciation through simple gestures of gratitude, or 66 online journal of rural nursing and health care, vol.11, no.1, spring 2011 by other means such as providing professional development opportunities and/or allowing flexible scheduling options. this is important for both rural and urban centres. the managers in this study did not elaborate on the human resources (hr) specialist role in nurse recruitment and retention. two of the participants noted that they must work in constant collaboration with hr personnel while recruiting new nurses, but they perceived recruitment and retention as a dual role of both the hr person and the manager. throughout this study, the participants talked about the importance of providing support to their staff as a retention strategy, and about providing adequate orientation and professional development as recruitment and retention strategies. seven of the eight participants in this study were frontline managers, who were involved directly with nurse recruitment and retention, and throughout this study they have provided ideas for enhancing recruitment and retention strategies. however, these frontline managers are required to abide by organizational policies around recruitment and retention, and they are confined to specific budgets for recruitment and retention. offering monetary incentives such as signing bonuses and bursaries, and the actual act of seeking new nurses, is the responsibility of hr. further consultation between these frontline managers, senior administrators and hr may be necessary to boost recruitment and retention initiatives in rural nl. this study did not obtain the perspectives of nurses themselves as to why they choose not to work in rural areas. however, a probable reason for deciding not to work in rural healthcare may be the lack of opportunity for advancement in their career. many rural settings have only one manager on site. there is usually minimal turnover in rural management, so frontline nurses may have little to no chance of obtaining a management position in a rural area. furthermore, rural nursing mainly consists of clinical nursing. rural settings usually do not have positions for clinical nurse specialists, nurse educators, or nurse researchers. as a result, many nurses may feel stagnant in rural settings because of the lack of opportunity for movement and advancement. to ensure credibility of this study, we remained true to the descriptions given by the participants. according to sandelowski (1986), auditability of qualitative research refers to the consistency of findings when the research method is adhered to. to do this, we attempted to remain true to the method of qualitative descriptive design and qualitative content analysis by reading about this method. limitations & implications for nursing a limitation to this study is the small participant size. although there were no new categories created after analyzing six participant interviews, we would have preferred a larger participant size to ensure that no new themes would arise from the data. a second limitation is the selection of participants from one geographic region. as a result, the findings of the study may not be transferable to other areas. four of the interviews were via telephone, which was more difficult to conduct than the in person interviews. a limitation of telephone interviewing is the inability to see nonverbal cues. we would recommend using in person interviewing and focus groups for future study on this topic. focus groups may have been a useful data collection method for this study in order to allow brainstorming, and sharing thoughts and ideas about rural nurse recruitment and retention. this study has implications for nursing research. we recommend that research on the experiences of healthcare managers contending with nurse recruitment and retention be conducted in other rural areas of the island of newfoundland, rural and remote areas of 67 online journal of rural nursing and health care, vol.11, no.1, spring 2011 labrador, and rural areas throughout canada in order to obtain a broader scope of experiences of canadian healthcare managers contending with nurse recruitment and retention. these studies could then be confirmed with studies of the experiences of healthcare managers living in other countries related to nurse recruitment and retention. we recommend further research on nurse recruitment and retention in rural nl from the perspectives of nurses themselves, as they may contribute more knowledge of the reasons why nurses stay or leave rural areas. future study on the topic of rural nurse recruitment and retention may focus on the perceived and actual roles and responsibilities of hr. studying multi-generational nursing in relation to recruitment and retention is another implication for nursing research. do younger nurses really feel that rural managers should be thankful that they have decided to work in a rural setting? how do the attitudes of younger nurses affect rural nurse recruitment and retention? how do the attitudes of more seasoned nurses affect rural nurse recruitment and retention? this study also has implications for nursing education. macleod et al. (1998) points out that remote nurses often have a multispecialist role in that they tailor their practice to the culture and the needs of the community. thus, nursing education may need to encompass the distinct aspects of rural nursing. in relation to recruitment and retention of nurses in rural areas, nurse educators may play a role in educating nursing students in the field of rural nursing. nursing programs may be modified to allow compulsory rural placements. implications of this research for healthcare administrators are also pertinent. administrators must consider the barriers and facilitators identified in this study when planning and implementing recruitment and retention tactics. conclusion we have described the experiences of eight rural nl healthcare managers contending with nurse recruitment and retention in their settings. we categorized these experiences under the headings of barriers and facilitators to rural nurse recruitment and retention. the participants within this study are experienced in human resource planning and the provision of health services, thus they offered rich information for planning recruitment and retention initiatives. their experiences and perspectives contribute to a better understanding of the unique complexities rural managers often face when attempting to recruit and retain nurses. while discussing some of the barriers to recruitment and retention, it was our impression that the managers in this study at times expressed a sense of discouragement due to the inability to recruit and retain adequate nurse staffing levels to maintain optimal patient/resident care in their facilities. they also observed that these factors usually have a negative impact on the workplace environment. however, they have shared their successful experiences in recruitment and retention as well, giving way to some of the facilitators to recruitment and retention of nurses in rural areas. references association of registered nurses of newfoundland and labrador. 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(2005). for work and for school: internal migration of canada’s rural nurses. canadian journal of nursing research, 37, 102-121. [medline] polit, d.f., & beck, c.t. (2004). nursing research: principles and methods (7th ed.). philadelphia: lippincott, williams & wilkins. roberge, c.m. (2009). who stays in rural nursing practice? an international review of the literature on factors influencing rural nurse retention. online journal of rural nursing and health care, 9, 82-93. salt, j., cummings, g.g., & profetto-mcgrath, j. (2008). increasing retention of new graduate nurses. journal of nursing administration, 38(6), 287-296. [medline] sandelowski, m. (1986). the problem of rigor in qualitative research. advances in nursing science, 8, 27-37. 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(2000). focus on research methods: whatever happened to qualitative description? research in nursing & health, 23, 334-340. teasley, s.l., sexton, k.a., carroll, c.a., cox, k.s., riley, m., & ferriell, k. (2007). improving work environment perceptions for nurses employed in a rural setting. journal of rural health, 23(2), 179-182.[medline] http://www.ncbi.nlm.nih.gov/pubmed/17397376 chapter 1 67 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 competencies for nursing practice in a rural critical access hospital elaine hurme, phd, rn 1 1 chief nursing officer/assistant administrator, pointe coupee general hospital, new roads, la, ehurme@pcgh.org key words: competency, rural nursing, rural competency, critical access hospital, delphi, generalist, rural nursing research abstract rural nurses are expected to demonstrate excellence in clinical decision making and function in a more independent, generalized fashion. identifying those competencies specific to rural practice will provide a framework for nurses and help to ensure safe and quality patient care. this article identifies nursing competencies most associated with good nursing practice in critical access hospitals. introduction rural nursing is considered a demanding as well as rewarding area of nursing practice. one major term that has emerged in the literature as descriptive of rural nursing practice is that the nurse must function as a generalist in the rural setting (bigbee, 1993; bushy, 2000; bushy & bushy, 2001; bushy & leipert, 2005; crooks, 2004; drury, 2005; eldridge & judkins, 2003; huttlinger, schaller-ayers, lawson, & ayers, 2003; kenny & duckett, 2003; kramer, 1996; lasala, 2000; lee & winters, 2004; long, scharff, & weinert, 1997; rosenthal, 2005). in other words, nurses in rural settings must be cross-trained and possess the ability to perform competently in two or more clinical areas. the rural practice environment has many unique characteristics which govern how nurses practice differently from urban nurses (eldridge & judkins, 2003). certain factors inherent in the rural population are a larger number of uninsured, higher rates of poverty, more participation in high risk behaviors such as cigarette smoking and excessive alcohol intake, and more obesity. homicide rates are lower but deaths due to suicide and accidents are higher in rural areas. rural nurses are often faced with working with older and outdated equipment, have to spend more time teaching due to illiteracy problems in the rural community, and have to deal with a lack of patient privacy and confidentiality in the small rural community. rural hospitals also have fewer baccalaureate-prepared nurses and have a lower ratio of registered nurses to licensed practical nurses. competency in practice benner (1984) wrote that expertise in nursing practice develops only after the nurse has tested and refined nursing hypotheses and principles in actual clinical practice settings. she conducted three studies which sought to determine how nurses attain skills and develop knowledge in the clinical area while progressing through the novice, advanced beginner, competent, proficient, and expert levels. benner defined good nursing practice as skilled ethical practice coupled with scientifically based clinical judgment. good clinical judgment and performance requiring a sound educational foundation combined with experiential learning were http://www.pcgh.org/ mailto:ehurme@pcgh.org 68 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 also strong premises of her competency building framework. she believed that clinical research is necessary to ensure best practices in nursing. the origination of the critical access hospital critical access hospitals (cah) became a reality through a federal program designed to address the financial problems of rural hospitals and improve access to health care for those living in rural areas (bushy & bushy, 2001). this federal initiative was entitled the medicare rural hospital flexibility program created by the balanced budget act of 1997. critical access hospitals are cost-based reimbursed on a fee for service rate as opposed to medicare drg pps reimbursed. certain criteria critical access hospitals must meet include limitation of the average length of patient stay to 96 hours, provision of 24 hour emergency services, and an inpatient census that can not exceed 25, excluding patients being cared for in outpatient surgery areas or in the emergency department. problem statement the primary purpose of this study was to identify nursing competencies most associated with good nursing practice in critical access hospitals. the research objective was accomplished utilizing a delphi panel of rural health nurse experts who were currently employed as directors of nursing in a critical access hospital. study design according to linstone and turoff (1975), the delphi undergoes four distinct phases. first of all the participants contribute information to the issue or subject under question. secondly, the group reaches agreement or consensus on the issue. if agreement is not reached then the third phase delineates and evaluates the reasons for the differences of opinion. lastly, all of the information that has been previously gathered from the participants is analyzed and returned to the participants for consideration. according to these authors three rounds is considered sufficient to produce stability in the responses. population and sample the target population for this study consisted of registered nurses who hire, supervise, or manage nurses in critical access hospitals. these registered nurses were subsequently referred to as “experts” in the rural hospital environment. a listing, including electronic mail addresses, of 27 potential panel members was obtained through the state rural health association. the criteria for the selection of the panel members included the number of potential panel members received and the willingness of the potential panel member to participate in the three rounds of the delphi study. seven nurses agreed to participate in this research study. data collection and analysis this delphi study consisted of three rounds of consensus building. each panelist received instructions along with the instrument for each round of the survey process via 69 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 electronic mail. the panelists were directed to address competencies among all nurses without focusing specifically on the new graduate or the experienced nurse. the initial round one survey instrument consisted of two open-ended, probing questions regarding the identification of competencies unique to rural health nursing. the focus questions for this study were:  “what are the job skills/competencies needed by nurses employed in rural critical access hospitals?”  “please indicate whether the competency is considered: a) a clinical/technical skill b) a critical thinking skill c) a communication/interpersonal skill or d) a management/organizational skill?” the round one instrument was divided into four competency headings which included clinical/technical skill, critical thinking skill, communication/interpersonal skill, and management/organizational skill. the seven panelists submitted a total of 149 items. the items were critiqued for repetitiveness and similar competencies were consolidated. special caution was taken to ensure the uniqueness of the competencies that were submitted was preserved. the round two instrument consisted of items extracted from the panelist‟s original responses. the participants rated the job skills/competencies on the round two instrument utilizing an anchored scale. a text box was provided for comments. this second group of responses was analyzed utilizing the descriptive statistics of group median, mean, and standard deviation. competency items were ranked by descending mean scores from the highest importance to the lowest importance. in ranking the information, tied mean scores were ranked by ascending standard deviation scores. a smaller standard deviation indicated more agreement on a particular item. the data obtained from round two was used to develop the round three instrument which completed this delphi study. each panelist was provided with the group median and their own unique score for each individual competency. an asterisk next to the competency indicated that the panelists needed to rank the importance of the competency utilizing the anchored scale. the lack of an asterisk next to the competency indicated group consensus had been achieved and no further action was needed by the panelists. the researcher received the round three instrument results, assembled this information and proceeded with the summation process. a total of 102 unique competencies were consolidated from the original 149 competencies received during the first round. consensus, ranging from 71% to 100%, was achieved on all 102 items at the completion of round three. tables 1 through 4 provide a final listing of the identified competencies. discussion rural nurse managers must ensure that a qualified nursing staff is available to meet the variety of health care needs of the rural community. in order to meet this demand, the manager must evaluate the individual nurse‟s ability to perform competently in the clinical setting. if a nurse demonstrates a deficiency in a certain area of practice, then the nurse manager must 70 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 address these deficiencies and devise a plan for competent performance by the nurse. currently, the majority of research studies related to evidenced-based clinical nursing practice and competency assessment has taken place in the urban setting (olade, 2004). therefore, there exists a true need to further explore research topics particular to rural nursing. rural nurse managers can utilize the information obtained from this research study which identifies rural nurse competencies to evaluate nursing performance. furthermore, findings from this study can serve as a teaching/learning tool that nurse managers can incorporate into the development of facility educational programs. finally, the most important reason for identifying competent nursing practice in the rural setting is to ensure the delivery of optimal patient care. table 1 importance of clinical/technical competencies needed by critical access hospital nurses identified by rural nursing experts rank clinical/technical competency medª x b sd % d 1 possesses the ability to perform a physical assessment on patients across the lifespan. 5 5.00 0 100 2 knowledgeable of emergency procedures in all areas of the hospital, not only those that present to the emergency department. 5 5.00 0 100 3 able to perform basic nursing procedures/treatments appropriate to the patient‟s diagnosis and age group. 5 5.00 0 100 4 possesses the knowledge and ability to perform triage nursing assessments on individuals of all ages. 5 5.00 0 100 5 possesses the knowledge and ability to perform emergency clinical nursing assessments on individuals of all ages. 5 5.00 0 100 6 able to operate equipment utilized in patient care such as infusion pumps, suction apparatus, lifters, telemetry monitors, and defibrillators. 5 5.00 0 100 7 knowledgeable of basic dysrhythmia recognition. 5 5.00 0 100 8 knowledgeable in regards to intravenous therapy and the maintenance of peripheral and central venous catheters. (i.e. the delivery of iv drugs, drips, blood and blood products). 5 5.00 0 100 9 performs nursing procedures based on the standards of care, hospital policies, and medical and nursing protocols. 5 4.86 .38 100 10 possesses a working knowledge and the ability to perform/initiate respiratory therapy and phlebotomy measures so as not to delay patient care and treatment while on call services are being activated. 5 4.86 .38 100 71 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 11 completes a nursing assessment within an established timeframe of admission to serve as a guide for the implementation of the patient‟s care plan. 5 4.71 .49 100 12 knowledgeable of medications action and side effects. 5 4.57 .53 100 13 applies the nursing diagnosis and institutes monitoring nursing interventions to improve patient outcomes. 5 4.57 .53 100 14 is acls and pals certified. 5 4.57 .53 100 15 evaluates patient responses to nursing interventions and communicates responses through legible documentation and reporting. 5 4.57 .79 71 16 knowledgeable of medication administration guidelines for all age groups. 4 4.49 .53 100 17 implements the nursing process to provide quality care based on assessment, diagnosis, planning, intervention, and evaluation. 4 4.43 .53 100 18 completes and continually updates the patient care plan according to the changing patient needs. 5 4.43 .79 71 19 data collection related to the health status of the patient is systematic and continuous. 4 4.29 .49 100 20 goals for nursing care are formulated and stated in terms of observable outcomes. 4 4.29 .49 100 21 evaluation, reassessment, recording of priorities, new goal setting, and revision of the care plan is a continuous process. 4 4.29 .49 100 22 for emergency department purposes, is tnc certified. 4 4.29 .76 71 23 the patient‟s response is compared with observable outcomes, which are specified in the care plan goals. 4 4.14 .69 86 24 the nursing diagnosis is derived from the patient‟s health status data. 4 4.00 .82 71 25 possesses fundamental computer technology skills in order to effectively utilize the computerized medical record in the emergency department. 3 3.29 .76 100 note: mean ratings classified according to the following scale: 5.00 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 1.00 = no importance. a median ratings indicated by delphi panelists b mean rating based on the following anchored scale: 5.00 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 1.00 = no importance. d level of consensus=percentage of panelists within ± 1 of the median. 72 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 table 2 importance of critical thinking competencies needed by critical access hospital nurses identified by rural nursing experts rank critical thinking competency medª x b sd % d 1 possesses the ability to care for a highly varied group of patients with different diagnoses all located in one clinical area. 5 5.00 0 100 2 possesses the ability to recognize any changes in a patient‟s condition and provide the most appropriate care at any given time. 5 5.00 0 100 3 ensures the use of good judgment in clinical decision making. 5 5.00 0 100 4 possesses the ability to recognize and respond to emergency situations occurring in all age groups. 5 5.00 0 100 5 able to meet the needs of patients utilizing limited resources of the rural setting i.e. lack of transportation. 5 4.86 .38 100 6 demonstrates initiative in providing patient emergent or non-emergent care within the scope of nursing practice. 5 4.86 .38 100 7 must have a clear understanding of all disease processes and individualize these processes in planning patient care (i.e. wound care, fall prevention). 5 4.86 .38 100 8 demonstrates the ability to work with minimum supervisory guidance in exercising independent judgment. 5 4.71 .49 100 9 appropriately delegates and prioritizes patient care activities, and implements the nursing process to ensure that each patient is provided quality patient care. 5 4.57 .53 100 10 able to successfully manage the patient‟s medication regimen. 5 4.57 .53 100 11 utilizes broad pharmaceutical knowledge related to the prevention of drug interactions, and medication errors. 5 4.57 .53 100 12 maintains clinical skills necessary to provide safe, effective nursing care without the availability of pharmacy or respiratory therapy 24 hours a day. 5 4.57 .53 100 13 follows organizational policies/plans/procedures for safety, security, hazardous materials and waste, emergency preparedness, fire/life safety, medical equipment management, utility system management, and infection control. 5 4.57 .79 86 73 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 14 identifies specific goals, objectives, and actions designed to meet the patient‟s needs. 4 4.43 .53 100 15 executes specific patient care activities and/or interventions that will lead to accomplishing the goals set forth in the care plan. 4 4.43 .53 100 16 applies cognitive, technical, and interpersonal skills in the overall coordination of patient care. 5 4.43 .79 86 17 knowledgeable of safety, risk management, infection control, and emergency preparedness procedures according to federal and state guidelines. 5 4.43 .79 86 18 able to perform an assessment that collects in depth information about a patient‟s situation and functioning and then develop a plan of care based on this assessment. 4 4.29 .49 100 19 analyzes problems and suggests appropriate solutions, taking action within the limits of authority. 4 4.29 .49 100 20 able to successfully delegate lower level of care activities. 4 4.29 .76 100 21 coordinates, organizes, secures, integrates, and modifies the resources necessary to accomplish the goals set forth in the care plan. 4 4.29 .76 86 22 monitors the results of care provided in order to determine the care plan‟s effectiveness. 4 4.29 .76 86 23 evaluates the care plan at appropriate intervals to determine the plan‟s effectiveness in reaching desired outcomes and goals. 4 4.14 .69 86 24 knowledgeable regarding the discharge process of patients with special needs i.e. home health, hospice, nursing home, patients requiring medical equipment at home, mental health issues, etc. 4 4.00 .82 100 note: mean ratings classified according to the following scale: 5.00 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 1.00 = no importance. a median ratings indicated by delphi panelists b mean rating based on the following anchored scale: 5.00 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 1.00 = no importance. d level of consensus=percentage of panelists within ± 1 of the median. 74 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 table 3 importance of communication/interpersonal competencies needed by critical access hospital nurses identified by rural nursing experts rank communication/interpersonal competency medª x b sd % d 1 possesses the ability to communicate clearly and effectively with other members of the hospital team. 5 5.00 0 100 2 maintains high personal and professional standards. 5 5.00 0 100 3 exhibits a professional image, good work ethics and serves as a positive role model to staff. 5 5.00 0 100 4 gains the patient‟s confidence with professional considerate nursing care. 5 5.00 0 100 5 refers to age specific competencies when teaching the patient and family. 5 5.00 0 100 6 maintains confidentiality of patient, physician and employee information in accordance with standards established by the hospital in compliance with regulatory agency requirements i.e., hipaa regulations. 5 5.00 0 100 7 adheres to regulatory agency documentation requirements. 5 5.00 0 100 8 demonstrates compassion and respect for the staff, patient and patient‟s family. 5 5.00 0 100 9 clarifies unclear, illegible, or non-specific physician orders prior to implementation. 5 5.00 0 100 10 knowledgeable of proper documentation guidelines 5 4.86 .38 100 11 makes a positive first impression a personal priority, and is honest. 5 4.86 .38 100 12 demonstrates positive interpersonal communication skills and projects a positive attitude. 5 4.86 .38 100 13 accepts phone and verbal orders appropriately, transcribing and implementing orders correctly and in a timely manner. 5 4.86 .38 100 14 strives for excellence, demonstrates high performance in all endeavors. 5 4.71 .49 100 15 exhibits a customer-focused attitude toward others 5 4.71 .49 100 16 fosters a team-focused, interdisciplinary approach to all patient care activities. 5 4.71 .49 100 17 utilizes resources available to communicate with hearing/sight impaired individuals. 5 4.71 .49 100 75 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 18 is a patient advocate regardless of the patient‟s age, culture, or religious background. 5 4.71 .49 100 19 acts as a liaison between the patient and physician, and other hospital departments. 5 4.71 .49 100 20 uses good listening skills, and communicates in an open and responsible, professional manner. 5 4.71 .49 100 21 consistently demonstrates interest, caring and consideration in dealing with the patients, significant others, and co-workers. 5 4.71 .49 100 22 possesses the ability to communicate effectively with nurses from other health care institutions that do not appreciate the role of the rural nurse 5 4.57 .53 100 23 possesses the ability to verbally communicate in an unbiased manner with individuals from all socioeconomic and educational backgrounds. 4 4.43 .53 100 24 demonstrates knowledge of information management requirements specific to the department and the hospital. 4 4.43 .53 100 25 develops, initiates, and participates in the process of patient education, discharge instructions, and preparation of the patient/significant other for discharge or transfer. 4 4.43 .53 100 26 cooperates with staff to achieve departmental goals and promote good employee relations, interdepartmental relations and public relations. 4 4.43 .53 100 27 able to communicate with other health care providers in order to coordinate care after the hospital stay. 4 4.29 .49 100 note: mean ratings classified according to the following scale: 5.00 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 1.00 = no importance. a median ratings indicated by delphi panelists b mean rating based on the following anchored scale: 5.00 4.50 = high importance; 4.49 – 3.50 = substantial importance; 3.49 – 2.50 = moderate importance; 2.49 – 1.50 = low importance; and 1.49 1.00 = no importance. d level of consensus=percentage of panelists within ± 1 of the median. 76 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 table 4 importance of management/organizational competencies needed by critical access hospital nurses identified by rural nursing experts rank management/organizational competencies medª x b sd % d 1 demonstrates flexibility and organizational skills in rapidly changing situations. 5 5.00 0 100 2 possesses the ability to manage the care of patients being cared for by different physicians. 5 5.00 0 100 3 possesses the ability to organize the patient care load utilizing the sometimes limited available staff. 5 5.00 0 100 4 demonstrates proper time management skills in order to complete tasks in a timely manner. 5 5.00 0 100 5 demonstrates the ability to function under pressure during a disaster maintaining a calm, controlled demeanor. 5 5.00 0 100 6 makes clinical assignments based on the patient‟s needs and circumstances. 5 5.00 0 100 7 possesses the ability to rapidly shift from one patient care area to another (i.e. operating room to emergency department). 5 5.00 0 100 8 adapts easily to changes in work assignments and environment and is willing to assume additional responsibility and learn new procedures 5 5.00 0 100 9 strives to promote a positive attitude with the team and accepts additional assignments willingly 5 4.86 .38 100 10 possesses the ability to manage ancillary departmental problems after routine office hours. 5 4.71 .49 100 11 knowledgeable of the facilities‟ organizational structure, including policies and procedures. 5 4.71 .49 100 12 assists in the promotion and maintenance of high quality care through the analysis, review, and evaluation of clinical practice. 5 4.57 .53 100 13 delegates needs/tasks appropriately 5 4.57 .53 100 14 demonstrates the ability to multi-task. 5 4.57 .53 100 15 demonstrates the ability and flexibility to recognize and accept changing conditions while continuing to perform to the best of one‟s ability. 5 4.43 .79 86 77 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 16 ensures a high quality of patient care through appropriate human and material resource allocation. 4 4.43 .53 100 17 able to work independently of senior staff. 4 4.43 .53 100 18 effectively utilizes certain key skills, including communication, critical thinking, negotiation, collaboration, as well as patient advocacy and empowerment. 4 4.29 .49 100 19 ensures effective and efficient utilization of all hospital resources, human and material 4 4.29 .49 100 20 demonstrates initiative by active participation in staff meetings, committees, and projects. 4 4.29 .49 100 21 participates in the problem-solving process associated with quality improvement. 4 4.29 .49 100 22 ensures that the services delivered to patients are medically necessary and are appropriate for the diagnosis, condition, or medical problem 4 4.29 .76 100 23 coordinates the individual patients‟ needs within the context of all outside influences, including the health care delivery system, the community, and the payer source 4 4.14 .38 100 24 functions as an integral member of the hospital‟s leadership team. 4 4.14 .38 100 25 aware of professional and personal limitations and how to access assistance when needed. 4 4.14 .69 86 26 considers under-utilization as well as overutilization of resources in the evaluation of patient care. 4 3.86 .90 71 note: mean ratings classified according to the following scale: 5.00 4.50 = high importance; 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nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 2 familiarity: a concept analysis on rural life marilyn a. swan, phd, rn1 barbara b. hobbs, phd, rn2 luke j. gietzen, ma3 1 associate professor, minnesota state university, school of nursing, marilyn.swan@mnsu.edu 2 professor emerita, south dakota state university, college of nursing, bbarbh64@gmail.com 3 clinical psychology phd student, university of north dakota, department of psychology, luke.j.gietzen@und.edu abstract purpose: to fully conceptualize familiarity, delineating it from other rural concepts and understanding its role in rural life. background: rural nurse researchers identify familiarity as a concept found in rural life. familiarity is a term used in rural literature, nursing research, and theory but lacks comprehensive conceptual understanding. to advance rural nursing science, concepts need updating to support rural research and advance theory development. method: a scoping review of the literature was completed using the joanna briggs institute methodology and supported by the seminal work of arksey and o’malley (2005). using walker and avant’s (2019) eight-step method, the scoping review findings informed this familiarity concept analysis. findings: the familiarity analysis revealed three defining attributes, ‘repeated exposure’, ‘knowledge’, and ‘deep understanding’. antecedents which proceed familiarity include: (i) varied contexts; (ii) lack of anonymity; (iii) novelty. consequences which result from familiarity are: (i) online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 3 trust; (ii) vulnerability; (iii) over-familiarity; and (iv) physiologic reactions. model and alternate cases developed are presented along with identified empirical referents. conclusion: this paper presents findings supporting familiarity as a concept in rural life and form a conceptual foundation for future research and further exploration. the findings also provide the components needed when defining familiarity in rural research. understanding familiarity is necessary for recognizing how rural nurses experience familiarity and its influence in their personal and professional lives. keywords: familiarity, scoping review, rural, nursing, theory familiarity: a concept analysis on rural life “small towns are sometimes like that; familiarity runs high, while regard for personal space is low, if nonexistent” (notaro, n.d.). rural, including small towns, means living in sparsely populated locations (lee & winters, 2022). familiarity is a feature of rural living in which individuals come to know and are familiar with details about the people, environment, history, and culture of a community. thus, it makes sense that rural nurse researchers identify familiarity as a concept found in rural life and a concept present in rural nursing research and theory (mcneely & shreffler, 1998; lee & winters, 2022). although the term familiarity is used in rural literature, it lacks comprehensive conceptual understanding and definition. mcneely and shreffler (1998) conducted a partial concept analysis on familiarity, developing a preliminary definition and defining attributes, however, antecedents (what precedes familiarity), consequences (what results from familiarity), and empirical referents (how revealed in everyday life) were not identified (lee et al., 2022; walker & avant, 2019). to online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 4 advance rural nursing science, rural concepts need updating and fully conceptualized to support rural nursing research and advance rural nursing theory (williams et al., 2012; fahs, 2016). beyond mcneely and shreffler’s early work on familiarity, there exists a research gap on familiarity and its role in rural life. this gap was identified when familiarity was determined to be a consequence of lack of anonymity and rural life (swan & hobbs, 2018; swan & hobbs, 2022). an initial literature search, completed with the intent of clarifying familiarity’s meaning, resulted in volumes of literature mentioning familiarity; however, few publications addressed familiarity and rural life. thus, information about familiarity and rural life obtained was insufficient to draw any conclusions (swan & hobbs, 2018; swan & hobbs, 2022). to clarify familiarity as a rural concept, a scoping review of the literature was completed, leading to the following concept analysis. the purpose of this work is to present a concept analysis on familiarity using walker and avant’s (2019) method. the aim is to fully conceptualize familiarity to delineate it from other rural concepts and to understand its role in rural life. background familiarity often has ambiguous meanings. felder (2021) suggests the ambiguity of familiarity is that it “refers to both knowing well and knowing superficially” (p. 180). as such, the word familiarity can imply anything from trivial knowledge to in-depth knowing. the sheer broadness of the definition presents challenges for explaining the word in daily use, let alone nursing practice and research. over time, the perception of familiarity has changed. titchener (1921) described familiarity as a pleasant reaction or feeling. this contrasts with zajonc’s (1968) idea that familiarity results from mere exposure. mandler (1980) expanded further by making the case that familiarity results from repeated exposure. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 5 in their analysis of the term familiarity as a rural concept, mcneely and shreffler (1998) found that familiarity is “…related to informality, friendship, close relationships/acquaintances, and intimacy” (p. 97). they suggest familiarity has an antithetical quality, making it sometimes welcomed, and at other times, unwelcomed (mcneely & shreffler, 1998, p. 97). swan and hobbs (2017) identified familiarity as a consequence of lack of anonymity, describing the interconnectedness in rural communities that leads to the formation of intimate knowledge of people and places. the ongoing evolution of familiarity hampers our ability to fully understand the role of familiarity in rural life. there is a substantial body of research supporting the idea that familiarity has a physiologic component, involving the encoding of memories and experiences in the brain (gimbel et al., 2017; melton, 1963; squire, 1987). exploration into familiarity branches into neurocognitive psychology, specifically into memory storage within the brain (wang et al., 2016; kihlstrom, 2020). memories created by repeated exposure are stored in two areas of the brain, named familiarity and recollection, and have been extensively researched (wang et al., 2016; kihlstrom, 2020). acknowledging the physiologic process supporting familiarity is foundational in exploring the concept. what is familiar, or internally known, may be deeply embedded and surface without conscious recall. internal knowing may be triggered by our senses through complex brain processes of recognition and familiarity (wang et al., 2016). consider the emotional response when smelling freshly baked chocolate chip cookies, hearing a favorite childhood song, or remembering 9/11. the unexpected retrieval of memories is not always positive, welcomed, or expected (iyadurai et al., 2019). online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 6 what is familiar to an individual is observable in everyday life and activities: a commute to work, a walk around the neighborhood, and seeing familiar people and places. driving a familiar route can result in the realization of not remembering the drive. a walk around the neighborhood is made without any conscious thought or plan. riding a regular bus route means encountering familiar strangers—people and faces you see regularly in a specific place but who are not actually known to you (mandler, 1980; mandler, 2008). everyday activities are completed without much thought. method the approach to investigating a topic with the breadth of familiarity drew on the authors’ previous experience in conducting a concept analysis of lack of anonymity in rural life. given the wide use of familiarity and the diverse ways the concept is perceived across disciplines, we expected the search to result in a large amount of literature. the authors gained insight on the quantity of literature on familiarity, and lack of literature of familiarity in rural contexts, when writing for other publications. this awareness identified methodological issues needing consideration. additionally, the wide use of familiarity also presented a challenge in deciding which literature to include. the method would need to support locating a manageable but representative amount of literature. the method selected was a scoping review of the literature. the data collected informed the concept analysis outlined by walker and avant (2019). the scoping review of the literature was completed using the joanna briggs institute (jbi) methodology (aromataris & munn, 2020) supported by the seminal work of arksey and o’malley (2005). the research question guiding the scoping review was, “what is known from the existing literature about the concept of familiarity?” (swan et al., 2022, para. 7). information on the scoping review and concept analysis protocol is online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 7 published in an open access journal and available for review at https://www.research protocols.org/2022/6/e36930/ (swan et al., 2022). the located literature was uploaded into covidencetm software which automatically removed duplicates and provided a platform for the literature review. each article underwent a two-step review process. first, a title and abstract review was conducted to determine if the inclusion criteria were met. inclusion criteria included articles that defined or directly discussed familiarity as a concept, applied to human beings, indicated a study result or finding on familiarity, were published between 2016 to 2022, and were available in the english language. international literature was included in the review. each abstract was reviewed independently by a research pair of the three-member research team based on the defined inclusion/exclusion criteria. disagreements regarding inclusion were resolved in research team meetings. during this step, modifications to the inclusion/exclusion criteria were made as the researchers gained understanding of the literature (swan et al., 2022). iteratively adjusting the inclusion and exclusion criteria is consistent with the method outlined by arksey and o’malley (2005). similarly, the full-text review was independently completed by a research pair of the threemember research team. additional literature was located from two different sources: reference list scanning and the reference list used to write a book chapter on familiarity (swan & hobbs, 2022; swan et al., 2022). following this same process, additional literature underwent a full text review to determine eligibility for inclusion. disagreements regarding inclusion were resolved in research team meetings. once deemed relevant, the full text articles were uploaded into the covidencetm software. data extracted from the scoping review provided the relevant literature for the concept analysis (see swan et al., 2022). this concept analysis was conducted using walker and avant’s online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 8 (2019) eight step method: the concept was selected; the purpose of the analysis was determined; uses of the concept were discovered; defining attributes were established; a model case was written followed by case examples; antecedents and consequences were identified; and empirical referents defined. findings scoping review results following the scoping review protocol (swan et al., 2022), eight databases were searched using 22 search terms. the search resulted in an extensive amount of literature for review (see figure 1). figure 1 prisma flow diagram for scoping review note. from “the prisma 2020 statement: an updated guideline for reporting systematic reviews,” by m. j. page, j. e. mckenzie, p. m. bossuyt, i. boutron, t. c. hoffmann, c. d., online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 9 mulrow, et al., 2021, bmj, 372(71), p. 10 (https://doi.org/10.1136/bmj.n71 ). copyright by the bmj. in total, 6,252 articles were included in the title and abstract review. as expected, and despite efforts to narrow the search, the amount of literature was vast and speaks to the wide use of the word familiarity contained in the literature and across disciplines (see table 1). table 1 disciplines included in scoping review business/management nursing social media/gaming communication studies occupational health social work criminal justice pharmacy sociology education philosophy sports science engineering politics transportation geography psychology travel/tourism history public health urban development medicine public policy urban studies mental health recreation/leisure military religion/spirituality note. disciplines are presented alphabetically. as the team’s knowledge on familiarity in the literature grew, the two exclusion criteria, literature referring to animals or non-humans and genetics, were deemed insufficient. four additional exclusion criteria were added: 1. articles or studies on brand familiarity 2. articles or studies that involve brain dysfunction (e.g., dementia, autism) 3. articles or studies on language development and education 4. articles or studies on brain mapping for recollection and familiarity online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 10 to assess the level of agreement between research pairs, a proportionate agreement calculation was completed as a pilot review prior to the title and abstract and full text reviews. in both review levels, each research pair (rrange = .83-.91) exceeded the protocol minimum of .75 (swan et al., 2022). in total, 186 articles were included in the scoping review analysis and represent a multidisciplinary and international perspective of literature (see table 2). table 2 included literature by continent and country continent and country no. of participatio n continent and country no. of participation africa ireland 1 burkina faso 1 italy 9 rwanda 2 netherlands 7 south africa 1 norway 2 zimbabwe 1 poland 1 asia portugal 2 bangladesh 1 spain 4 china 14 switzerland 3 india 2 united kingdom 26 iran 1 north america israel 2 canada 18 japan 2 united states 67 malaysia 1 oceania south korea 3 australia 11 europe new zealand 3 albania 1 south america belgium 1 argentina 1 denmark 6 brazil 2 finland 2 other france 5 undisclosed 1 germany 7 note. more than one country may be represented in an article. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 11 the large amount of data extracted was analyzed according to the two major categories: familiarity definition/description and relevant findings. the definition data was qualitative in nature and resulted in a content analysis. the relevant findings were specific research findings from studies that involved familiarity. the data was analyzed separately and then together to provide rigor to the analysis. the findings from the data sets matched and aligned. concept analysis familiarity is unique to the individual; what is familiar to one person may be unfamiliar to another. as such, familiarity is relative to the person who is perceiving it. the uniqueness of familiarity is based on the context and a lack of a universal understanding. perhaps this contributes to the ambiguous quality of familiarity and our ability to understand it as a concept. the sheer uniqueness of familiarity can be a limiting factor. therefore, no single definition can be used to describe familiarity in daily life as found in the literature review. the analysis of familiarity revealed three defining attributes that emerged from both the definition and relevant findings data. antecedents, consequences, along with empirical referents were identified. to assist in understanding what familiarity is, and isn’t, borderline, related, contrary, invented, and illegitimate cases will be presented. based on our extensive review of the literature, we believe that this is the first full conceptualization of familiarity. defining attributes the data strongly supports the presence of three defining attributes which include repeated exposure, knowledge, and deep understanding. table 3 presents the defining attributes with definitions developed from the review. these findings are consistent with baloglu (2001) who identified three types of familiarity related to tourism: information, experience, and self-rating. table 3 online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 12 defining attributes and definitions when interacting with the novel stimulus the mere exposure effect starts the process of making the unfamiliar, familiar (zajonc, 1968). this process occurs over time and is a sensory experience, including sight, sound, and smells (felder, 2021). repeated exposures, or the number of times a person is exposed (devue et al., 2019; felder, 2021), can generate a long-term memory from as little as three interactions with a stimulus (larzabal et al., 2018). exposure is augmented when recalling or recognizing a familiar stimulus from memory (mandler, 1980). the memory recognition or recall of a stimulus reinforces the memorable exposure to the stimuli. thus, memory recall contributes to developing familiarity (carr et al., 2017). repeated exposure is linked to our sense of knowing (carr et al., 2017), whether it be recalling a song or when to turn on an unmarked country road. exactly when repeated exposure moves into knowledge is unknown. yet, evidence suggests it happens: the ability to sing lyrics to a childhood song that comes on the radio or knowing the shortest route to a destination. repeated exposure and the knowledge that develops supports improved performance and our ability to anticipate what is coming next (shen et al., 2018). through interactions with others, we gain personal knowledge that increases our familiarity with people, places, objects, and ideas (richaud, 2018). defining attribute attribute definition repeated exposure recollections of and often repeated interactions with people, places, objects, or ideas that makes the unfamiliar familiar. knowledge deep understanding acquiring information through exposure, experience, and nurtured environments with people, places, objects or ideas. intimacy (non-romantic) with people, places, objects, or ideas that prompts interconnectedness and a sense of belonging. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 13 over time, knowledge continues to grow, so much so, that an individual develops deep, intimate understanding with long-term involvement in a community, people, places, objects, and ideas. this intimate familiarity is associated with positive memories and experiences and can be incorporated into an individual’s identity (preston & gelman, 2020). in rural life, a farmer may have generational connection and knowledge with a piece of land, having memories that extend over a lifetime. rural communities share the same social and professional space, which supports the development of common rituals and other cultural elements (mock, 2017). as such, nurses and health care workers who live and work in their community, will have unique insights into the people they care for, and may even be able to predict a course of action (or not) and understand why a decision was made (tonin & lucaroni, 2017). deep understanding of community creates family-like bonds that represent the closeness and shared life of rural relationships (busza et al., 2018). ryan and mckenna (2013) identified that rural families placing an older adult in a local nursing home had “a sense of familiarity” with the nursing home and owners and had “access to the local grapevine” which informed the family’s understanding of the history of the home and the care provided (p. 4). in addition, the family knew many of the staff through social and professional connections. collectively, the unique information rural families had access to informed decision making on nursing home placement (ryan & mckenna, 2013). antecedents and consequences the antecedents are an important component of the analysis as they must be “in place prior to the occurrence of the concept” (walker & avant, 2019, p.178). in turn, consequences occur as online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 14 a result of familiarity (walker & avant, 2019). the results of this analysis identified three antecedents for, and four consequences of familiarity discussed below. three antecedents of familiarity were identified: varied contexts, lack of anonymity, and novelty. a setting or context must exist for familiarity to occur. as such, knowing the context is necessary to recognizing the presence of familiarity. lack of anonymity, defined as “identifiable, establishing boundaries for public and private self, and interconnectedness in the community” (swan & hobbs, 2017, p. 1078), precedes the development of familiarity (hayfield & schug, 2019). lastly, before anything becomes familiar, it is new, or novel. through repeated exposure, novel experiences become encoded into memory transitioning the novel to familiar (duncan & shohamy, 2016). for example, a nurse from a rural farming area moves to a new state and similar community. the rural community feels familiar to the nurse, but being new, the nurse knows no one and is not known to people in the community (anonymity) and is considered a stranger. through repeated exposure, the nurse comes to know people in the community and people come to know the nurse (lack of anonymity). over time, the nurse becomes familiar with the people, history, and culture of the community. the data reveal four consequences of familiarity: trust, vulnerability (risk exposure), overfamiliarity, and physiologic reactions. evidence supports the idea that familiarity must be present for trust to develop (korstjens et al., 2021; theron & pelser, 2020). for example, a well-known nurse living in a rural community may be extended trust by individuals they have never met. in contrast, trust resulting from familiarity is not without risk to the individual; a patient may choose to stay with a trusted rural provider rather than transfer care to an unfamiliar specialist in an urban location. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 15 we may encounter people who are familiar strangers; the individual moves within our daily routines but is a stranger in that we have no knowledge of them (felder, 2021). through repeated exposures, the stranger becomes familiar. familiarity may affect people’s vulnerability and may impair our objectivity or ability to unbiasedly assess potential risks (felder, 2021). for example, a rural elderly couple may trust an unfamiliar workman who is related to a lifelong friend. without knowing the workman, the couple could be vulnerable in ways not fully understood. furthermore, becoming over-familiar may present risks to oneself or another. over-familiarity between two individuals may lead one individual to believe they know the other well enough to speak for them (mapson & major, 2021). team research findings suggest familiarity improves team function, but over-familiarity may have a detrimental effect and impair team performance (parker et al., 2020; sieweke & zhao, 2015). additionally, the individual may see what they want to see without seeing what actually is (harms et al., 2021). for example, care providers familiar with an elderly rural patient might not offer an aggressive procedure, believing the patient would decline, even though the patient is generally healthy and remains active in the community. finally, not all forms of familiarity are welcomed. for example, familiarity is unwelcome when a person feels nervous or uncomfortable around or being with another person, especially if the second person seeks to deepen the relationship. in this case, the over-familiarity is unwelcomed. empirical referents based on this review, six empirical referents associated with familiarity were identified as being present in everyday life (see table 4). online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 16 table 4 empirical referents for familiarity empirical referents sub-category selected citations* security and comfort safety, comfort, culture, sense of belonging, home, like and positivity (carr et al., 2017; hayfield & schug, 2019) connection 1. personal 2. professional 1. relationships, social and family bonds, environment 2. team-familiarity (maynard et al., 2019; rodrigues et al., 2021) (mccullough et al., 2016; rolland, 2017) problem-solving none (noordzij & wijnia, 2020; shen et al., 2020) fixation option generation (schweizer et al., 2016; viswanathan et al., 2016) inattention automaticity, blasé, routines (burdett et al., 2016; felder, 2021) judgement decision making, risk taking (garcia-marques et al., 2016; karabon & steiner, 2020) *note. selected citations are presented; a full list of included citations available on request. familiarity can be observed in everyday experiences in various ways. security and comfort are revealed through the feelings of safety, comfort, a sense of belonging, and a general sense of positivity and liking what is familiar (garcia-marques et al., 2016; lu et al., 2018; sidenius et al., 2017; yoo & kim, 2016). there is a feeling of being at home and having a cultural connection (cosgrave et al., 2019; tong et al., 2019). interpersonal and interprofessional connections are visible through relationships, including social and family bonds, with ties to a place or environment (cosgrave et al., 2019; cranmer et al., 2017). being familiar with people, places or work supports faster problem solving, efficiency, and increased confidence (noordzij & wijnia, 2020; shen et al., 2020). facing a familiar problem may increase one’s confidence in having the ability to solve a problem versus tackling an unfamiliar one (borgonovi & pokropek, 2019). similarly, being familiar with a hard problem supports competence. for example, a student studying math may perform better with problems previously encountered (shen et al., 2020). online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 17 familiarity also brings about unrecognized challenges in everyday life. fixating on what is familiar and comfortable may limit the ability to consider and generate new or different options (viswanathan et al., 2016). when freed from the constraints of the familiar, originality may increase (schweitzer et al., 2016). similarly, familiarity may promote inattention or mind wandering. drivers on a familiar rural road may unintentionally “zone out” when driving (burdett et al., 2016). familiarity with what is well known means we may no longer pay close attention to our actions and environments. this lack of attention may result in ignoring the finer details and simply going with what is familiar (felder, 2021). for example, they may not notice a leaning mailbox until it falls over. familiarity positively and negatively affects how we judge people and situations. information familiarity may result in quickly assessing the accuracy of information and faster decision making (mapson & major, 2021). risk taking behavior may increase in a familiar environment (karabon & steiner, 2020). for example, the rural farmer who disconnects his seatbelt when turning off the highway onto a familiar gravel road adjacent to the family farm. model case susan is visiting her rural high school for her 10th class reunion. the mascot statue by the office door and classroom buildings are all familiar to her. without directions, she walks to the gymnasium where the party is being held. immediately, the gym environment again brings forth memories of playing basketball all four years. susan even remembers the smells. looking around she sees people from her class. she is still familiar and talks regularly with her closest friends; other faces seem familiar, but she cannot freely recall who they are or how she knows them. at the registration desk, she sees a copy of the school newspaper, which she edited during her senior year, and pictures of football games and senior prom night, all bringing back memories of her online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 18 senior year. she reminisces about the connections she had with some teachers, particularly mr. gallagher who mentored her in math. borderline case benjamin has just arrived at stuttgart, germany airport, where he is to meet with professional colleagues for an international conference. although his heritage is german, this is his first time to germany and his first international trip. luckily, stuttgart airport seems familiar because the environment includes restrooms, waiting areas, eating establishments, and so forth; similar to airports he has visited in the past. despite a familiar feeling environment, he feels like a “fish out of water.” he does not speak german and is dependent on strangers to translate signs and information for him. as he sat in a waiting area where he is meeting his colleagues, a stranger approaches him and asks for directions in german. he tries to explain, in english, that he is an american and does not speak german. being a stranger to the area, he thinks this encounter is unusual; however, he is approached by two more german strangers over the next 90 minutes. with three similar experiences, benjamin believes that he may appear as more of a familiar “german” than he thought in the past. related case mildred and bob are having plumbing problems in their rural country home. their longtime plumber just retired, and they called the “new” plumber in town. they met the new plumber at church a few times and heard from a friend that he did good work on their plumbing issues. the new plumber and his assistant are scheduled to do the plumbing work on a day that mildred has a medical test at the city hospital a couple of hours away. similar to their past practice with their long-time plumber, they decide to leave the house unlocked and call the new plumber to let him know they will be gone, but the house is open. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 19 contrary case marge is visiting her elderly aunt who lives a couple of hours from her home. due to her work schedule, marge visits infrequently but tries to help her aunt with errands when able. during this visit, marge’s aunt needs more female incontinence pads that can be purchased at the local pharmacy. marge has never purchased female incontinence pads before. when entering the pharmacy, marge is too embarrassed to ask for guidance on where the pads are located. after some searching, she locates the product and gets in the checkout lane. while waiting for the person ahead of her to check out, she thinks the cashier is someone from her aunt’s church and that they may have met before. when it’s marge’s turn to checkout, she feels embarrassed about the purchase and lets the cashier know that the pads are for her aunt. the cashier looks at her funny and says “okay.” as marge leaves the pharmacy and walks to her car, she realizes that she had never met the cashier before. illegitimate case since retiring ten years ago, hank developed a passion for watching morning television. these shows became a part of his daily activities, such that he schedules all appointments, exercise, and visits around the show times. he is particularly fond of the sportscasting host, a retired professional athlete. hank surfs channels and the internet, following the sportscaster’s specials and personal life. when visiting his friends, hank shares stories and tidbits such as the sportscaster’s birthday, upcoming appearances, even personal tragedies hank learned about. hank views the sportscaster as a personal friend, he feels a connection to the sportscaster and he knows him intimately; however, hank has never met the sportscaster. likewise, the sportscaster has no connection to hank. online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 20 implications for rural nursing this analysis is believed to be the first in-depth examination of the concept familiarity. the findings from this analysis supports familiarity as a concept in rural life and expand the early work of mcneely and shreffler (1998). the identification of defining attributes, antecedents, consequences, and multiple cases provides detail on familiarity that was not previously known. the identification of empirical referents, or how familiarity is revealed in everyday life, is a major contribution to the understanding of rural life (walker & avant, 2019). familiarity is often discussed in rural literature and theory without clear definition. our intention is not to provide one definition but describe this broad concept. as researchers operationalize a definition, the components of familiarity described in this paper should be incorporated. thus, this analysis serves as a foundation for future researchers when defining familiarity in rural life, which requires additional research and exploration. familiarity was found to be a consequence of lack of anonymity (swan & hobbs, 2017). the result of this analysis clarifies the distinction between the closely related concepts (swan & hobbs, 2022). in the presence of familiarity, it is difficult to be completely anonymous (richaud, 2018). as an individual becomes known, their lack of anonymity and familiarity increases (swan & hobbs, 2017). this is a normal relationship between the two concepts. however, overfamiliarity may disrupt this relationship and become a liability to personal and professional life. nurses need to recognize that judgments made in situations where over-familiarity exists may affect professional decision making. further research is needed to understand the connections between the concepts. the complexity of familiarity begins with its uniqueness to everyone. rural nurses experience familiarity in their personal and professional lives, often practicing in communities online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 21 where they have a deep understanding of the people, environment, history, and culture of the community (richaud, 2018). the same is true for patients and families that interact with rural nurses. as such, familiarity, welcomed and unwelcome, may influence rural nurses, patients, and families. rural nurses may want to be mindful that their perceptions of a familiar relationship or connection may not be shared by those assigned to their care. the breadth of literature included in this analysis provides a broad exploration of familiarity as a concept and as a given in the culture of rural communities. it is imperative that rural nurses gain skills in recognizing and understanding the importance of familiarity and consider the associated risks of over-familiarity in rural life. the findings from this concept analysis should serve as a guide for rural researchers as familiarity is further developed. limitations several limitations are identified in completing this concept analysis on familiarity. first, the word familiarity has 50 or more synonyms depending on the source referenced while familiar, has upwards of 100+ (merriam-webster unabridged dictionary, n.d.). as such, familiarities' use is pervasive in the literature and its meaning varies among authors, disciplines, and studies. this being so, we were continually clarifying and revising our preliminary understanding on familiarity which led to this concept analysis. to identify all uses of familiarity, our scoping review was intentionally broad to ensure a deep dive into the literature. therefore, mixing editorials with various mixed research design studies could be considered a limitation. second, multiple search terms related to familiarity were input into eight databases; however, it is possible other relevant literature might be available in other databases. a third limitation may be that since the scoping review of familiarity was limited to papers written in english, papers written in other language were not considered. fourth, is the vast amounts of international and multidiscipline literature online journal of rural nursing and health care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 22 screened, reviewed, and excluded before analyzing the remaining 186 articles. it is feasible that some applicable literature may have been missed. furthermore, it is possible that earlier pertinent literature may have been overlooked. and finally, we found it difficult to complete the comprehensive analysis and synthesize the data due to the large number of articles reviewed, variety of disciplines involved, and inconsistency in how familiarity was described or used with studies and papers. therefore, we may have misinterpreted data through our analysis. conclusion familiarity is a term frequently associated with people, places, and items known, but our understanding of its meaning varies by how the word is used and the context. familiarity is linked to rural nursing research and theory, but inconsistencies in the term’s meaning and use have been noted, resulting in this concept analysis. to identify all uses for the concept, a scoping review of international and multidisciplinary literature was completed. the analysis, leading to identifying all uses of the concept, especially those relating to rural life is described. additionally, three attributes, repeated exposure, knowledge, and deep understanding were identified and defined. furthermore, antecedents, preceding familiarity, and consequences, resulting from familiarity were described. to understand how to apply the concept, a model case example was presented along with borderline, related, contrary, invented, and illegitimate case examples. lastly, six empirical referents were listed. the findings also provide 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(1968). attitudinal effects of mere exposure. journal of personality and social psychology, 9(2p2), 1–27. https://doi.org/10.1037/h0025848 smoking cessation 82 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 coronary artery disease and smoking cessation intervention by primary care providers in a rural clinic jeremy a. kelley, msn, rn, crnp 1 roy ann sherrod, dsn, rn, cne, cnl 2 patsy smyth, dsn, rn 3 1 certified registered nurse practitioner, cardiology consultants, pc, tuscaloosa, al, jkelleynp@gmail.com 2 professor, capstone college of nursing, university of alabama, rsherrod@bama.ua.edu 3 chair, department of gradate nursing, mississippi university for women, psmyth@muw.edu key words: coronary artery disease, quality assurance, smoking cessation, rural clinic abstract among numerous risk factors for coronary artery disease (cad), including family history, hypertension, diabetes mellitus and dyslipidemia, the single most modifiable risk factor is smoking. smoking cessation for known cad patients has recognized immediate and long term benefits, namely reduction in the chance of symptom recurrence and death. this article is a description of an evaluation of smoking cessation intervention by primary care providers for patients who smoke with a known history of cad within 1 year of diagnosis. nola j. pender’s revised health promotion model was the framework for this non-experimental, quality assurance study using descriptive retrospective chart review in a rural family practice clinic in the southern united states. data were collected using a researcher-developed quality assurance tool with a final sample of 150 patient medical records. results indicated that over two thirds (68.7%) of the patient sample received smoking cessation therapy prior to or within 1 year after diagnosis of cad; however, 31.3% of the patient sample received no smoking cessation intervention. although a large percentage of this sample received smoking cessation therapy, the american heart association and american college of cardiology recommend smoking cessation therapy for all smokers with known history of cad at each visit. it is recommended that this guideline be followed in all patients regardless of compliance with smoking cessation therapy, and that this therapy be consistently evaluated in its culturally relevant application to rural populations. introduction globally, cardiovascular disease is, and is projected to remain, the number one cause of death. in 2005, this disease accounted for approximately 30% of all deaths or nearly 17.5 million people worldwide (world health organization, 2007). although these figures are astounding, even more staggering is that one major cause of cardiovascular disease is a modifiable risk factor—smoking. smoking has long been linked to heart disease, so much so that the united states congress passed a bill more than 20 years ago, the comprehensive smoking education act of 1984, requiring tobacco companies to carry a warning label noting this relationship. the heart disease and stroke statistics update (american heart association, 2007b) indicated that except for 1918, cardiovascular disease accounted for more deaths than any other single cause or group of causes in the united states from 1900 to 2007 (american heart association, 2007b). mailto:jkelleynp@gmail.com http://nursing.ua.edu/ mailto:rsherrod@bama.ua.edu http://web2.muw.edu/index.php/en/masters-degree.html mailto:psmyth@muw.edu 83 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 smoking prevalence is highest among those with only nine to 11 years of education (34%) and living at or below the poverty level (29.1%) (american heart association, 2007b). in rural areas, educational levels are lower with almost one third of rural residents 25 years or older having less than a 9 th grade education and unemployment rates are higher contributing to greater poverty (alabama rural health association, 2009). there is also a high rate of deaths from cardiovascular disease for the state that was the setting for this study (united health foundation, 2008). thus, rural populations are more likely to smoke, more likely to have cardiovascular disease and therefore promoting smoking cessation should be an even greater priority of pcps in those areas. limited resources and access to care make promotion of healthy behaviors and preventive measure even more relevant for rural populations (klugman, 2008). smokers have a greater than two-to-four-fold chance of developing cardiovascular disease than nonsmokers partly because of smoking’s contribution to increased atherosclerosis (american heart association, 2007a). development of atherosclerosis, progressive artery hardening, which forms from the deposition of fatty plaques in association with scarring and thickening of the artery walls, is tied to toxins in the blood that come directly from cigarette smoking. these arterial wall changes lead to inflammation and formation of blood clots which can progress to coronary artery disease (cad). cigarette smoking is also linked to sudden cardiac death (scd) in both genders (united states department of health and human services, 2004, pp. 364-365, 387). according to the aha and american college of cardiology (acc) guidelines for care, patients with known cad should be asked about smoking with every visit, advised to quit, and offered options regarding smoking cessation therapy (smith et al., 2006). to adhere to these standards of care, smoking cessation interventions need to be a priority of primary care providers (pcps), especially with cad patients who smoke. furthermore, the overwhelming connection between smoking and cad warrants smoking cessation interventions at every visit with these patients. background there have been a number of researchers looking at compliance, cad, and smoking cessation. for example, lannon (1997) found pender’s hpm framework was useful in a qualitative case study investigating medication compliance in individuals on antiepileptic drugs. a number of relevant concepts from pender’s hpm for the patient were supported including perceived self-efficacy by its similarity to perceived control of health because persons who feel they can accomplish a goal are more likely to achieve this goal. modifying factors were also noted with the most impact from interpersonal characteristics, which include one’s pattern of health and interactions with pcps that are heavily affected by environmental and situational factors. the researchers concluded that study results indicated compliance was associated with strong family beliefs regarding health promoting behaviors; good patient to healthcare provider relationship; and a history of successful personal and professional relationships. in noncompliance, the most important factor to be modified was the patient-healthcare professional relationship (lannon, 1997). there is literature to support use of smoking cessation therapy tools such as counseling, nicotine replacement therapy (nrt) and pharmacotherapy for smokers with cad. reid, pipe, and quinlan (2006) conducted a study of hospital smoking cessation promotion for cad 84 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 patients. the 1164 primarily male patient smokers admitted for cardiac related diagnoses, including acs, were seen and counseled by a trained nurse counselor. patient’s readiness to quit was assessed; if not ready, initial counseling focused on negative outcomes of continued smoking compared to positive outcomes of smoking cessation. for those ready to quit, a quit plan with nrt was carried out. at discharge, patients were given guidelines and responsibility for a ten week nrt program. recommendations were sent by letter to each participant’s pcp. patient follow up telephone calls were made using an interactive voice response system to assess abstinence rate at three, 14, and 30 days and six months post-discharge. six months after discharge, 89% of patients responded to contact; 44% reported no smoking in seven days preceding the phone call; and 35% reported total abstinence since discharge. the authors concluded that an approach including education and pharmacotherapy with follow up beginning prior to hospital discharge can have an impact when the motivation to quit is high. they further noted that the quit rate for this sample was lower than in other studies but attributed it to less sample selectivity and decreased smoking prevalence making those who still smoke more dependent and difficult to treat. recommendations included conducting more studies with newer pharmacotherapy; developing hospital-based smoking cessation programs to easily identify, document, and treat smokers; and exploring use of nrt in a harm reduction approach to assist smokers with cad who are unable to quit (reid et al., 2006). the benefits of smoking cessation in cad patients who smoke has been documented in the literature and adds additional importance for smoking cessation interventions by pcps. for example, goldenberg et al. (2003) conducted a study of current smoking, smoking cessation, and risk of scd in cad patients with moderate hypercholesterolemia to determine, initially, the effectiveness of bezafibrate in reducing cad related mortality and occurrence of nonfatal myocardial infarction (mi). however, data revealed marked results regarding the occurrence of scd related to smoking status, which became the primary study focus. the randomly selected sample of 3122 males and females with a history of cad screened in israeli cardiology departments between february 1, 1990 and october 31, 1992 met certain inclusion criteria such as a history of mi and serum cholesterol, lipoprotein, and triglyceride levels. exclusion criteria included presence of type i diabetes, severe heart failure, unstable angina, hepatic failure, renal failure, allergy to bezafibrate, or current use of drugs to lower lipid levels. the sample was categorized into three groups: 370 smokers, 1821 past smokers, and 931 never smokers. data sources included patient self report, observation, and bio-physiologic markers. follow up visits were scheduled every four months for a mean of 6.2 years (goldenberg et al., 2003). the researchers concluded that: (1) continuing smoking after a cad-related diagnosis incurs a significant increase in chance of scd; (2) the risk of scd for past smokers is markedly lower and comparable to those who have never smoked; and (3) the risk of scd with regards to smoking cessation declines immediately with quitting and is not time dependent. their recommendation was complete abstinence from smoking to avoid the increased risk of scd (goldenberg et al., 2003). purpose of research project the majority of cad patients seen in cardiac intensive care units are smokers (jones, griffiths, skirrow, & humphris, 2001). a major challenge these patients face is the struggle over lifestyle changes such as smoking cessation. subsequently, much of hospitalized treatment 85 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 and recovery phases are spent educating them about lifestyle modifications to avoid recurrence of problems. once patients leave the hospital, these lifestyle modifications must become part of their daily routine. someone needs to continue to stress the importance of and assist them to make these modifications. promoting more healthy behaviors, particularly smoking cessation, is a critical role for the pcp. thus, the purpose of this study was to evaluate whether or not smoking cessation was addressed as stipulated in aha and acc guidelines for standards of care by pcps with patients who smoke with a clinical diagnosis of cad as evidenced by acute coronary syndrome (acs) (american heart association, 2008; anderson et al,. 2007). these standards of care indicated that patients with known cad be asked about smoking with every visit, advised to quit, and offered options regarding smoking cessation therapy (smith et al., 2006). research questions 1. is smoking cessation therapy being implemented with known coronary artery disease patients who smoke with a clinical diagnosis of acute coronary syndrome? 2. within what time frame, from prior to diagnosis up to one year after diagnosis, is smoking cessation addressed with known coronary artery disease patients who smoke with a clinical diagnosis of acute coronary syndrome? definition of terms for the purposes of this study, smoking cessation was defined as absence of smoking since the last quit attempt (kim, lee, hwang, & lee, 2005, p. 54). smoking cessation therapy was defined as provider education about the need to abstain from smoking to known cad patients who smoke and have a clinical diagnosis of acs as charted in the patient’s record every visit after cad diagnosis until abstinence from smoking has been achieved. coronary artery disease was theoretically defined as atherosclerosis, or a build-up of plaque along the inner lining of the coronary arteries, which can significantly reduce blood flow to the myocardium and cause a heart attack if the artery becomes blocked (american heart association, 2007b). coronary artery disease was operationally defined as the presence of a clinical diagnosis of acs. the aha and acc use acs to refer to a host of clinical symptoms compatible with myocardial ischemia secondary to cad that include st-segment elevation myocardial infarction, non-st-elevation myocardial infarction, and unstable angina (anderson et al., 2007). primary care provider was theoretically defined as a physician, physician’s assistant, or nurse practitioner who sees patients for common medical problems (medline plus, 2007). in this study, pcp was operationally defined as a physician or nurse practitioner who provided education, preventive care, or acute care to patients. conceptual framework the study’s conceptual framework was based on selected constructs of nola j. pender’s revised health promotion model (hpm) (pender, murdaugh, & parsons, 2006) that has been used in numerous studies to assess influences on health-promoting behaviors. for general 86 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 background purposes, these influencing factors are individual characteristics and experiences that include prior related behaviors and personal factors. personal factors fall into three categories: biological, psychological, and sociocultural. biological factors include variables such as age and gender. psychological factors include variables such as self-esteem, selfmotivation, and perceived health status. sociocultural factors include such variables as race, educational level, and socioeconomic status (pender et al., 2006). other influences are behaviorspecific cognitions and affect, perceived benefits of action, perceived barriers to action, perceived self-efficacy, and activity related affect. although evaluation of these influences was not the focus of this study, they provide a context for evaluation of another type of influence, interpersonal. specifically, the interpersonal influences of the hpm are cognitions regarding the behaviors, beliefs, or attitudes of others. whether real or not, primary sources of interpersonal influences that affect decisions made regarding health promoting behaviors are family, peers and healthcare providers. in hpm, interpersonal interaction influences health-promoting behavior directly and indirectly through social pressures or encouragement to commit to a plan (pender et al., 2006, p. 55). for the purposes of this study, that plan is commitment to smoking cessation and the pcp can provide the pressure. belief on the part of pcps that they can provide interpersonal influence for compliance with healthy behaviors can serve as a motivator to exert the influence. in this case, the influence is exerted through smoking cessation therapy. methodology setting this study was a chart audit in a small rural family clinic in the west central part of a southern state to establish whether or not patients with known cad were provided a smoking cessation intervention within 1 year of diagnosis. the clinic is located in an area designated as heavily rural based on four variables: percentage of total employment in the county; dollar value of agricultural production per square mile of land; population per square mile of land; and an assigned score considering populations of the county’s largest city, other cities, and cities in more than one county (alabama rural health association, 2009). clinic pcps, two medical doctors and one nurse practitioner, treated approximately 40-50 patients daily. sample the study population consisted of approximately 250 males and females within the clinic patient roster who had a history of smoking and cad as evidenced by a clinical diagnosis of acs. the sample consisted of 150 patient’s charts which met the parameters of the study. procedure written approval was obtained from the human resources institutional review board (irb) at the university. once approved by the irb, a letter of consent was obtained from the physician who operates the clinic granting permission for the chart audit. after consent was obtained, patient’s charts were identified alphabetically by clinic personnel as well as the 87 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 primary researcher and checked to see if the patient met inclusion criteria of a history of smoking and cad as evidenced by a clinical diagnosis of acs. if the patient met inclusion criteria, the chart was included in the sample and audited. each chart was audited for patient’s age; gender; receipt of any type of smoking cessation therapy; time of therapy (prior to or within one year of cad diagnosis); type of pcp providing therapy ( physician or nurse practitioner); and presence of other cad risk factors including family history of cad, patient history of hypertension, diabetes mellitus, or dyslipidemia. this process was systematically continued until a finite number of chart audits (150) were completed. data collection and analysis information was collected and recorded on a researcher-developed smoking cessation chart review form (see table 1). completed chart audit forms were kept at the primary researcher’s home in a locked, fireproof box which only that researcher could access. descriptive statistics were used for data analysis to establish a patient profile and address research questions. chi square independence test was used to compare males to females to provide a further delineated patient profile. data analysis was conducted by a statistician using statistical package for the social sciences data software. limitations of project the major limitation of this study was the small scale on which it was carried out. the results are not generalizable because only one location was studied. the researcher only had access to charted information and there was no interaction with the patient or pcp. also, only 150 charts met the criteria for the study. no assessments were made regarding the quality of smoking cessation therapy and performance of smoking cessation therapy by the pcp was only assessed for a period of up to one year of diagnosis. additionally, the data collection tool was developed by the researcher and no validity or reliability for its usefulness was established. results profile of the study participant additional analysis not specifically related to research questions was conducted to present a profile of the study sample. the patient sample was 69.3% male and 30.7% female with 92.3% of males and 95.7% of females greater than 50 years of age. data revealed that 89.3% of the sample had smoked for more than 10 years with 30% having smoked for more than 30 years. regarding the number of packs per day (ppd), 62.6% of the patient sample smoked 12 ppd for ten years or more and 16.7% smoked less than one ppd. because many cad patients have comorbidities and health promotion behaviors such as smoking cessation will benefit outcomes for them as well (american heart association, 2007), a profile of comorbidities in this sample was assessed and analyzed. data analysis revealed that 74% had a family history of cad; 74% had a history of hypertension; only 26% had a history of diabetes mellitus; and 71.3% had a history of dyslipidemia. 88 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 table 1 chart review form chart #: ________ patient’s gender: (1) male (2) female patient’s age (years): (1) < 30 (2) 31-49 (3) 50-69 (4) > 70 (5) not documented patient’s height (inches): ______ patient’s weight (pounds): ______ body mass index: (1) < 18.5 (2) 18.5-24.9 (3) 25.0-29.9 (4) > 30 (5) insufficient information number of years smoking (circle most appropriate): <5 years (2) 5-10 years (3) 10-20 years (4) 20-30 years (5) >30 years (6) not documented number of packs per day (ppd) smoked (circle most appropriate): <1 ppd (2) 1-2 ppd (3) 2-3 ppd (4) 3-4 ppd (5) >4 ppd (6) not documented smoking cessation therapy of any kind charted (circle most appropriate): prior to initial diagnosis of acs within 1 week of initial diagnosis of acs within 2 weeks of initial diagnosis of acs within 1 month of initial diagnosis of acs within 3 months of initial diagnosis of acs within 6 months of initial diagnosis of acs within 9 months of initial diagnosis of acs within 1 year of initial diagnosis of acs not documented smoking cessation therapy charted by (circle most appropriate): (1) md (2) np (3) not documented family history of cad? (1) yes (2) no (3) not documented history of hypertension? (1) yes (2) no (3) not documented history of dyslipidemia? (1) yes (2) no (3) not documented history of diabetes mellitus? (1) yes (2) no (3) not documented 89 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 research questions research question one was related to whether or not pcps were conducting smoking cessation therapy. the therapy was the only intervention evaluated in this study and was defined as provider education to abstain from smoking to known cad patients who smoked. therapy was provided at every follow up visit until the patient quit. results indicated that 68.7% of the sample received some smoking cessation therapy intervention in the form of education. whether smoking cessation therapy was conducted by a physician or nurse practitioner also was assessed in the chart audit. half (50%) of the patient sample received smoking cessation therapy from a physician and less than a fifth (18.7%) of the patient sample received smoking cessation therapy from the nurse practitioner. it is important to note that the nurse practitioner only worked parttime in the office averaging two days per week and that there are two physicians compared to one nurse practitioner. one third (31.3%) of patients in the sample had no documentation of smoking cessation therapy by neither a physician nor nurse practitioner prior to or within one year of initial diagnosis of cad as evidenced by acs. analysis of data for research question two regarding the time frame for smoking cessation therapy indicated that the largest number, 61(40.7%), of the sample received the intervention prior to initial diagnosis of cad as evidenced by acs. the least frequent time period for smoking cessation therapy was from one day past 6 months up to nine months, 1(0.7%), and was comparable to results for two other time periods, up to 3 months, 5(3.3%), and 6 months, 3(2.0%). additional results regarding these time frames can be found in table 2. table 2 smoking cessation intervention time frames time frame number total sample percentage n=150 intervention subsample percentage n=103 prior to diagnosis 61 40.7% 59.2% from dday of diagnosis up to 1 month 17 11.3% 16.5% from 1 day past 1 month up to 3 months 5 3.3% 4.9% from 1 day past 3 months up to 6 months 3 2.0% 2.9% from 1 day past 6 months up to 9 months 1 0.7% 1.0% from 1 day past 9 months up to 1 year 16 10.7% 15.5% total 103 68.7% 100% 90 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 discussion implications regarding the impact of this study are presented in relation to theory, practice, education, and research. with regard to theory, a construct from nola j. pender’s hpm (pender, et al., 2006) was supported in study findings. there are numerous factors involved in increasing prevalence of smoking cessation therapy by pcps. pender’s hpm addresses many of these factors from the patient perspective by accounting for various characteristics that determine why one person may quit smoking while another will not, even with identical smoking cessation intervention. however, the most relevant hpm construct for this study was interpersonal influences. pcps’ recognition of interpersonal influences in promoting healthy behaviors can be evidenced by them implementing smoking cessation therapy with 68.7% of this sample. patient’s failure to be influenced to change, cease smoking, may have a negative impact on pcps when working with other cad patients who smoke. if appreciation for the importance of interpersonal influence lessens, the pcp’s incentive to continue with or even initiate smoking cessation therapy may cease. there is no way to know if changes in perceptions of interpersonal influence contributed to the 31% of cad patients not having smoking cessation therapy by a pcp in this sample but the possibility is worth noting. although no comparisons of findings were made for this sample with urban samples of cad patients and smoking cessation therapy by pcps, the question of what, if any, sociocultural factors related to this being a rural clinic serving rural citizens may have impacted pcp’s implementation of smoking cessation therapy must be asked. while no qualitative data from pcps were obtained in this study, their perspective on any aspects of patient noncompliance and rurality influencing pcps implementation of smoking cessation therapy with all cad patients could provide some interesting data for refinement of smoking cessation interventions with rural citizens by pcps. practice standards of care set the protocols for treatment and follow up as nationally recognized levels of care that should be received by all individuals with particular conditions. these standards are founded from evidence-based data and support evidence-based practice leading to better patient outcomes. this study’s focus addressed primary prevention with smoking cessation therapy. primary prevention is arguably the most important aspect of an evidenced-based practice, particularly with the nurse practitioner. study results revealed that more than 30% of the patients did not receive smoking cessation therapy of any kind from a physician or nurse practitioner even up to one year after diagnosis of acs. numerous reasons for this lack of preventive teaching come to mind, including lack of documentation, noncompliance, and poor follow through at the level of the pcp. each of these factors related to education will be discussed. primary care providers must be educated regarding related relevant facts for cad patients and smoking cessation. although more patients in this sample may have received smoking cessation therapy, no documentation was charted for some if they did. the old adage, “if you did not chart it, you did not do it,” may be particularly relevant here and should be reinforced in education of pcps. insufficient or lack of documentation is a critical area in healthcare and costs physicians, nurse practitioners, hospitals, and other healthcare agencies millions of dollars each year in lawsuits and lost revenue. for the rural clinic already facing issues related to many patients’ low economic status with no insurance or money to pay for services, instituting measures that could positively affect costs is critical. measures that would 91 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 prevent rural patients from having to come more often for more complex, and therefore more expensive, care because of increasing complications and care needs with their cad must be implemented. moreover, this practice deficit warrants the need for quality assurance projects to ensure accurate, sufficient charting and other standards of practice regarding smoking cessation and cad patients as stipulated by american heart association (2007b). with noncompliance the food and drug administration and the national council on patient information (2002) noted, “14-21% of patients never fill their original prescription”; “3050% of all patients ignore or otherwise compromise instructions”; and “the cost of hospital admission is an estimated $8.5 billion annually just for patients who do not take their medicines as prescribed”. noncompliance by patients is frustrating for all pcps and is costly to the healthcare industry. however, the pcp must maintain self-awareness regarding this frustration and maintain professional awareness that noncompliance results from many factors. first, according to pender, murdaugh, and parsons (2006), the best predictor of future behavior is prior related behavior. if patients have never quit or mastered other health promoting behaviors, then it may be more challenging for them to quit. therefore, pcps must first continue to make patients aware of the dangers of smoking and how it correlates to cad to assist them to make well-informed decisions about smoking. second, pcps must remember that patients may need help to identify perceived benefits of action and perceived barriers to action regarding smoking cessation. in doing so, pcps will help both to avoid common pitfalls that lead to noncompliance with smoking cessation intervention or recurrence of smoking by not addressing specific benefits and barriers for this rural population. the increased compliance will positively enhance the pcp’s perspective and reinforce implementation of smoking cessation therapy. third, the pcp may only be able to get smokers to verbally commit to a plan of action, but it is imperative to do so because even a verbal commitment creates an accountability relationship for follow up between the patient and pcp. in follow up, pcps must reinforce behavior change for those cad patients who quit as lannon’s (1997) suggests that the most important modifiable factor in noncompliance is the patient to pcp relationship. therapy does not need to cease when teaching has been provided only once, and encouragement or other forms of positive feedback for those who have quit should be ongoing as well. therefore, it is the pcp’s professional responsibility to make a consistent effort to form a bond with the patient and increase the patient’s awareness of the dangers of smoking. this bond may be particularly relevant with rural populations. rural citizens, in general, tend to want to be self-sufficient and depend on themselves for care and direction. if they feel they need care, they may go to family or someone in the community before seeking out the pcp. therefore, pcps need to take advantage of opportunities they have when with the patient to increase their bond to the extent that the pcp will be viewed as family or a part of the community (klugman, 2008). studies such as the one by reid, pipe, and quinlan (2006) have shown that persistent follow-up along with the use of nicotine replacement therapy increases rates of smoking cessation, and the burden for informing patients regarding healthmodifying behaviors with follow up is the responsibility of pcps. available research data must be used to increase positive outcomes in this area. in the area of research, evidence-based practices are being enhanced using new research findings as the standard by which pcps deliver healthcare. studies have demonstrated that smoking cessation reduces the risk of heart disease drastically and increases the rate of survival to a level equal to non-smokers (goldberg et al., 2003, p. 2304). this research provides 92 online journal of rural nursing and health care, vol. 9, no.2, fall 2009 evidence that whether patients are compliant or not, lifestyle modifications need to be a number one priority in primary prevention. the evidence should motivate pcps to provide related, culturally relevant interventions at every visit. providing these culturally relevant interventions for rural patients means maintaining an awareness by the pcp that people who live in rural areas define health in large part based on their ability to continue work and activities. this view may make it difficult to modify their lifestyles now based on some future disability or improvement and unique strategies by the pcp may be necessary (klugman, 2008). recommendations regarding small rural clinics, the guidelines set forth by the aha and acc should be followed regardless of the setting and unique values and characteristics of the population served. patients who smoke with a known history of cad need to receive smoking cessation therapy with every visit. doing so and documenting that it was done will provide assurance to pcps that they are following national guidelines and encourage continuation with positive chart audits. when smoking cessation therapy is provided, it needs to be charted. with rural patients, the best therapy must be determined and then used. while teaching sheets may be one educational option for some patients, caution regarding their use with rural patients is advised. lower literacy levels because of generally limited educational preparation in rural populations (alabama rural health association, 2009) may lessen the effectiveness of this strategy. one other consideration is cost of therapy because financial resources may be limited. when and where the therapy is implemented is important too because limited access to formal transportation structures is prevalent in rural communities (klugman, 2008) and these factors should be coordinated to meet patient’s needs in these areas. although this study focused on education as a smoking cessation therapy, other appropriate, culturally relevant strategies for pcps should be explored and used to encourage smoking cessation educators of pcps must reinforce the need for smoking cessation with every patient visit. they must also increase pcp’s awareness of the impact of patient provider relationships, rural cultural and social perspectives, and other noncompliance issues on the success of smoking cessation therapy in cad patients who smoke. further clinical research is needed to expand the evidenced-based literature regarding reasons, conditions, and influences for pcps providing or not providing smoking cessation therapy for every patient, particularly those pcps in rural areas given the higher incidence of death from cardiovascular disease in rural areas (united health foundation, 2008). use of pender’s hpm in research to determine reasons for smoking cessation in some and not others with identical teaching is also warranted. further research tracing smoking cessation therapy in known cad patients prior to diagnosis up to current or smoking cessation date is needed. this time period will assist in verifying that smoking cessation therapy is continuing despite noncompliance even if that time is greater than one year. it may take some patients longer than others to be motivated to quit, and pcps should be vigilant in their emphasis on the patient quitting smoking. research to assess knowledge and influences for quitting or not quitting smoking of patients who received smoking cessation therapy is also an area of importance to provide pcps with data for structuring or restructuring smoking cessation therapy. 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